research paper topics about empathy

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Empathy articles from across Nature Portfolio

Empathy is a social process by which a person has an understanding and awareness of another's emotions and/or behaviour, and can often lead to a person experiencing the same emotions. It differs from sympathy, which involves concern for others without sharing the same emotions as them.

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Neural mechanisms of costly helping in the general population and mirror-pain synesthetes

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Valeria Gazzola

Diverse adolescents’ transcendent thinking predicts young adult psychosocial outcomes via brain network development

Rebecca J. M. Gotlieb
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The effect of psilocybin on empathy and prosocial behavior: a proposed mechanism for enduring antidepressant effects

Kush V. Bhatt
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A distinct cortical code for socially learned threat

Studies in mice show that observational fear learning is encoded by neurons in the dorsomedial prefrontal cortex in a manner that is distinct from the encoding of fear learned by direct experience.

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Andrew Holmes

Cortical regulation of helping behaviour towards others in pain

A study describes the role of the anterior cingulate cortex in coding and regulating helping behaviour exhibited by mice towards others experiencing pain.

Mingmin Zhang
Ye Emily Wu
Weizhe Hong

Social odor choice buffers drug craving

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News and Comment

Natural primate neurobiology.

A new study captures nearly the full repertoire of primate natural behaviour and reveals that highly distributed cortical activity maintains multifaceted dynamic social relationships.

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Your pain in my brain

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Feeling another’s pain

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Stress and sociability

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Ofer Yizhar

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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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Peer-reviewed

Research Article

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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Introduction: Empathy, Shared Emotions, and Social Identity

Published: 26 February 2019
Volume 38 , pages 153–162, ( 2019 )

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Thomas Szanto 1 &
Joel Krueger 2

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Our social encounters are dizzyingly complex. They not only involve overlapping layers of affective, conative, and cognitive engagements between self and others. They are also deeply embedded in continually-changing environments that shape experiential, emotional, and epistemic forms of sharing distinctive of these encounters—forms of sharing that are, in turn, further modulated by contextual factors such as real or imagined group membership and shifting social identities. Moreover, each of these social processes variously affects and feeds back onto the others . This complex tangle of multi-layered processes supports core social capacities like our capacity for interaction, cooperation, affective sharing, joint agency, and social identification. It also directly impacts our capacity for empathy: our ability to perceive, understand, and respond to the experiences and behavior of others. Empathy is facilitated—but also modulated, biased, or even disrupted by—various aspects of these processes. In other words, empathy is a robustly situated practice, one that is bound up with a rich array of processes that encompass not only the dynamics of our face-to-face engagements but also the complex environments in which these engagements develop and take shape.

To be sure, it is not controversial so say that these fundamental dimensions of our sociality, which can be broadly subsumed under the labels “empathy”, “shared emotions”, and “social identity”, are variously and massively interconnected. Most contemporary philosophers, cognitive scientists, developmental and social psychologists, and social neuroscientists working in these areas will readily subscribe at least to the general contours of this picture. It is all the more surprising, therefore, that little attention has so far been paid to conceptually and systematically clarifying how these different social processes might intersect and impact one another. Instead, most of the relevant philosophical, social-scientific, and empirical work in the past decade has focused primarily on specific aspects of these different dimensions of sociality in isolation, and has not systematically addressed their interconnection.

This special issue shifts the focus of these debates by exploring links between philosophical and psychological research on empathy, shared emotions, and social identity. The individual contributions to this special issue are diverse and cover a range of topics and issues. They cluster around the following sets of questions:

What psychological mechanisms underpin instrumental helping and prosocial behaviour?

To what extent does empathy enable joint agency, emotional sharing, and the emergence and maintenance of group and social identity? What role do pre-reflective or subpersonal process play here? What about narrative practices?

Conversely, how do shared emotions, social identity, or group membership modulate or bias empathic understanding at both the interpersonal and the intergroup level?

What is the nature of social identification, and how does our ability to empathize with a particular other impact our identification with a group?

Do complex forms of social identification (e.g., group-identification) presuppose more basic forms of empathy or other interpersonal processes like joint attention and imitation? What exclusionary and ingroup/outgroup mechanisms are involved?

What role do the interrelated socio-psychological processes of stereotyping, social (self-)categorization, depersonalization, or dehumanization play here, and how does self-alienation factor in?

Before we outline how the nine contributions to this issue address these questions, we will first provide context by sketching the most relevant recent debates at the intersection between social cognition, social ontology, and social psychology. Along the way, we shall point to some unresolved issues, desiderata, and avenues for future research.

1 Research Background and Future Avenues

Consider first recent work on social cognition in philosophy and the cognitive sciences, where we can witness a partial shift of focus away from the more established theory of mind debate to explorations of the relation between empathy and affective sharing. One of the central questions in this area of research is whether empathy amounts to some form of affective sharing—that is, whether the sharing of affective states between the subject and the target of empathy is a necessary requirement for (successful) empathic understanding (cf. Michael 2014 ). According to one trend in current social cognition research, which is gaining increased traction, empathy is conceived in primarily affective terms, rather than as a predominantly cognitive form perspective-taking or mindreading. Footnote 1 Here, empathy is characterized as the “simulation of the feelings of others” or as “caused by sharing the emotions of another person” (Hein and Singer 2008 ; cf. de Vignemont and Singer 2006 ). Relatedly, it has been argued that empathy is itself an affective state, which necessarily requires “interpersonal similarity”: some relevant similarity between the affective state of the subject and the target of empathy (Jacob 2011 ; De Vignemont and Jacob 2012 ). Moreover, according to this view, empathy also entails a “care” for the affective state of the other, which brings it closer to what is usually called sympathy (ibid.) (although none of these authors hold that empathy thereby can be equated with sympathy).

Meanwhile, authors mainly drawing on the phenomenological tradition, and especially on the work of Edmund Husserl, Edith Stein, Max Scheler or Alfred Schütz, have forcefully challenged this assumption. They claim that empathy—viewed in this tradition roughly as a sui generis ability to perceptually access and understand the experiential life of others (Zahavi 2014 ; Jardine and Szanto 2017 ; Krueger 2018 ; cf. also Michael and Fardo 2014 )—is neither itself an affective state nor requires any isomorphism between subjects’ and the targets’ mental or affective states. Empathy does not amount to any form of affective sharing of the relevant states, either. As phenomenologists such as Scheler ( 1913/1926 ) or Stein ( 1917 , 1922 ) have long emphasized, it must be markedly distinguished not only from emotional contagion and forms of ‘feeling- with ’ (as in ‘I feel with your loss’), or sympathy, but also from any form of ‘feeling- together ’ Footnote 2 or forms of emotional sharing that today are discussed in terms collective emotions. Footnote 3

Debates about collective emotions concern whether and in what sense a collection of individuals can properly speaking share an emotional episode. Consider, for example, members of a football team who are collectively (i.e., jointly, as a team) grieving over their deceased teammate, or who are proud of their success in the tournament (‘ We are very happy with the result’).

But apart from the phenomenological accounts mentioned previously, there is very little conceptual precision when it comes to determining the relation between empathy and both interpersonal and collective forms of emotional sharing. Incidentally, this relation has hardly been empirically studied either, and is yet very little understood. However one may decide upon this issue—and the editors, as well as most contributors to this issue, tend to side with the phenomenological line of thought—for the present context it is crucial to note the following. Even if one holds that empathy and emotional sharing are in fact clearly distinct social processes—and that, moreover, the former doesn’t necessarily involve the latter—one can still consistently hold that they are interlinked by various social-psychological dynamics.

In this connection, it’s worth mentioning a bold phenomenologically inspired proposal by Salice and Taipale ( 2015 ) that aims to bridge social cognition and social ontology by developing an original account of group-directed empathy. The authors suggest that it is possible to have an empathic act when the target is not an individual or even individual members of a group, but rather the group itself . This possibility, together with the phenomenological insight that empathy is only possible if the empathic target has a (directly) perceptible body, leads them to the conclusion that groups as such are embodied agents; they may properly be attributed a body of their own, i.e., one that is not reducible to the bodies of their individual members. What is more, in discussing the differences between individual- and group-directed empathy, and in particular different display and vehicles of the expression of (shared) emotions, they argue that for structural and essential reasons our empathic grasp of the affective states of groups is more informative, “more extensive, exhaustive”, and indeed “more adequate”, than in the case of individuals (ibid., p. 166). Similarly, one of us (Szanto 2015 ) has claimed that individual-member-to-group and group-to-individual-member directed empathy might correct for various cases of misidentification regarding shared emotions (even if they are, pace Salice and Taipale, not more reliable or adequate than ordinary interpersonal forms). Such misidentifications include, among others, misidentification what the communities’ standards of emotional sharing are, or whether there are any properly shared emotions between a given member and the group in the first place.

A number of issues, however, remained unresolved with regard to such collective forms of empathy. For example, what is the relation between such collective empathic stances and feelings of group-belongingness, ingroup homogeneity, or favoritism? Presumably, if a group collectively engages in empathy towards outgroups, this will strengthen ingroup cohesion, for instance, by way of social distinction. Furthermore, if individual members empathize with the shared emotions of their ingroup, they may gain additional affective reasons to retain their membership. For example, a member of a political movement may thus learn that certain values or affective concerns are shared by other members, a fact that she might not have realized simply by focusing on some doctrinal propositions of the movement; and this will typically reinforce her attachment. Identifying the norms guiding emotional sharing via group-directed empathy may also facilitate affective conformity, and help maintain the shared emotional patterns of the given group. Finally, group-directed empathy may reinforce a sense of belonging, if, for instance, individuals become aware that they are not empathized with as individuals , but become targets of empathic stances of other groups or third parties, as members of a certain group. This seems especially salient in settings of intergroup antagonism, such as racism, when social cognition towards (and indeed recognition of) one’s own ingroup is biased or disrupted (cf. Ito and Bartholow 2009 ; Xu et al. 2009 ; Losin et al. 2012 ). Even though there has been some related empirical research on the modulatory effects of sociocultural identity and ingroup/outgroup distinctions on interpersonal empathic encounters (see more below), such effects on group-directed or intergroup empathic relations have so far been underexamined.

Another relevant context where the connection between mindreading, simulation, and empathy, on one hand, and forms of collaboration, on the other, has been systematically investigated is the enactivist and so-called “interactionist” paradigm in social cognition research. Different proposals have investigated in what sense social cognition can be viewed as a specific form of (embodied) interaction. From this enactive perspective, the claim is not simply that face-to-face interaction is a contextual factor or an enabling condition for social cognition but rather that is it a constitutive feature of it. Footnote 4 Furthermore, there is a related and rapidly increasing body of work exploring, more specifically, links not just between social cognition and interaction but also between social cognition and joint attention and joint agency. Footnote 5 For instance, it has not only been argued that collaborating agents are better mindreaders, since they can draw on a situational cues afforded by the very interaction, which might be otherwise unavailable (Butterfill 2013 ) Footnote 6 ; moreover, classical and contemporary phenomenologists have suggested that more complex forms of experiential we-intentionality and group agency must in fact be founded upon more basic, embodied forms of interaction and, in particular, face-to-face empathic encounters (Zahavi 2014 , 2015a , b ; León and Zahavi 2016 ; cf. also Szanto 2015 , 2018 ).

Two further topics regarding the relation between interpersonal empathic stances and the broader social and moral context in which they are embedded should be flagged here. The first concerns the role of social typification, an issue that has not been sufficiently recognized in contemporary discussions in social cognition, but that has been explored in great detail in the work of early phenomenological thinkers such as Schütz and Gurwitsch. As they argue, in all interpersonal empathic encounters there is always a more or less explicit and more or less specific typification of the other(s) at play. Others are grasped and recognized as concrete personal individuals in direct face-to-face encounters and, at the same time, as more or less “anonymous” representatives or proxies of ideal social types (e.g., Schutz 1932 ; Schutz and Luckmann 1973 ; cf. Zahavi 2014 and esp. Taipale 2016 ). Moreover, concrete others are always and already given “as bearers of roles”, and in more or less specific and more or less familiar social “situations” (Gurwitsch 1931 , p. 111). Again, others never simply appear in a social void. For instance, when greeting the postman who just handed you a letter, you directly perceive both the charming young man and the anonymous one whom you were eagerly awaiting this morning, and maybe even the surprisingly cheerful representative of the near-bankrupt state-service that is known for how poorly their employees are paid. Current approaches typically don’t pay enough attention to this interplay between social and situational typification, direct perception and empathy.

The second issue concerns the relation between empathy and certain morally relevant stances towards the other, in particular, forms of recognition, social visibility, and respect. For example, it has been argued that early phenomenological conceptions of empathy such as Stein’s and Husserl’s have the resources to clarify the moral and epistemological foundations of recognition. Specifically, they can help to refine notions like the “elementary recognition” of the personhood of others, introduced by critical theorist such as Honneth ( 2001 ), and understood as a process that precedes objectifying judgment or explicit evaluative appraisal of specific characteristics of the other (Jardine 2015 , 2017 ; cf. also Varga and Gallagher 2011 ). At the same time, as Jardine ( 2015 , 2017 ) suggests, the nuanced direct perceptual account of empathy that we find for example in Stein’s work may help clarifying the related issue of “social (in)visibility” of others (Honneth 2001 ). For, such a phenomenological account could specify the interpersonal, affective, and practical contexts in which empathic recognition of others is always embedded, and also account for the empathic grasp of the more complex motivational and rational relations between another’s mental and affective states. Furthermore, as Drummond ( 2006 ) has elaborated, moral responses to others, and in particular, respect, are rooted in empathy, as only the latter provides the means to recognize the radical otherness of the other—a prerequisite for respect for another person as such. Such “recognition respect” (Darwall 2006 ) contrasts with sympathetic affective processes (notably sympathy and compassion), which are rooted not in the other’s otherness, but rather in their sameness or similarity, and the possibility of persons to communalize an share emotional states or values. (On recognition and empathy, see also Fuchs’ and Zahavi’s contributions to this issue).

Finally, turning to empirical research, we find a vast body of evidence that emotional sharing and social identification not only motivates and modulates but indeed variously biases and disrupts empathic encounters. More specifically, neurophysiological data suggests that group and ethnic membership often biases the affective, cognitive, responsive or emotion-regulative components of empathy (for a review, see Eres and Molenberghs 2013 ). For example, it has been shown that empathic and vicarious sensory responses (e.g., vicarious pain) are more likely to be elicited in ingroup than outgroup members (e.g., in ethnic, racial or political conflict settings). Footnote 7 Similarly, it has been shown that the underlying neurophysiological mechanisms of empathy, such as neural activation in mental simulation, is reduced by outgroup prejudices, ingroup favoritism, and sociocultural or ethnic identity in general, but also in certain professional (e.g., medical) contexts (Cheng et al. 2007 ; Decety et al. 2010 ). Furthermore, analyzing collective rituals (e.g., fire-walking spectacles) it has been observed that there is a tight synchronization of cardiovascular arousal patterns between performers and family-members in the audience, which are similar to affective mirroring processes underlying empathy (Konvalinka et al. 2011 ). Social identity related modulations have also been demonstrated regarding the accuracy of perception and prediction of group-level emotions from outgroups (Seger et al. 2009 ). Such biases have even been observed in early-infant imitation (Buttelmann et al. 2013 ; Over and Carpenter 2012 , 2013 ) and learning (Kinzler et al. 2011 ), suggesting that mental simulation or affective mirroring is reduced by outgroup prejudices already at an early phase of personal development (4–5 years of age) (cf. Buttelmann and Böhm 2014 ).

It is not quite clear whether and how these social perception biases challenge or even undermine the baseline phenomenological picture of empathy, according to which empathy is—primarily, at least—based on direct perception of embodied minds or direct embodied interaction. It is not even clear whether further empirical research could possibly settle this issue, or whether we need more conceptual and phenomenologically grounded studies. Gallagher and Varga ( 2014 ), who have endorsed the latter strategy, convincingly argue that far from challenging the idea of direct embodied perception, these findings rather undermine the deeply entrenched view from mainstream social cognition research, according to which there would be some hardwired theory of mind modules.

In a related field of social-psychological research, a number of features regarding group size, structure and ingroup/outgroup dynamics have been studied, in order to investigate how they modulate prosocial responses and, in particular, on the attribution and perception of mental and affective properties, or the “humanness”, of others. Research on the familiar phenomenon of “collapse of compassion” has examined why groups in need are less prone to elicit empathic concern than individuals. Moreover, it has been shown that the increase of the number of suffering individuals, and in particular of outgroup members, decreases prosocial affective responses and behaviour (Cameron and Payne 2011 ). There has been also research on how and which types of group membership diminish the attribution of mental states and emotions to individuals. It has been demonstrated that there are higher thresholds for attributing and perceiving minds in outgroup than ingroup faces—they require for example more salient anthropomorphic characteristics or stronger emotional expressions (Hackel et al. 2014 ; cf. also Epley et al. 2007 ). These effects have been even confirmed in the so-called “minimal group” condition, where the paradigm includes randomized group settings. Thus, even without any relevant prior experiences of intergroup conflicts and the absence of relevant stereotypes, subjects are prone to such social perception biases (Hackel et al. 2014 ). Related studies have focused on the modulation in mind attribution and perception and the issue of “group entitativity” (Campbell 1958 ; Hamilton and Sherman 1996 ; Lickel et al. 2000 ). The entitativity of a group refers to the degree according to which a collection of individuals is subjectively perceived precisely not as a random collection or aggregate but as a coherent social unit. It has been demonstrated that there is a strong negative correlation between the attribution of minds and the degree of group entitativity: subjects tend to attribute less autonomy and less “humanness” features, such as own mental states, intentions, etc., to individuals who are perceived as belonging to highly entitative groups (e.g., tight-knit, homogenous communities) (Morewedge et al. 2013 ). All these depersonalization and infra-humanization effects are consistently heightened by strong ingroup identification of social cognizers. On the other hand, the effects are moderated by (perceived or real) specific threats from outgroup members, which then facilitates mind attribution and the accuracy of social perception. This latter effect seems particularly interesting in political, ethnic or other intergroup conflicts.

Again, neither mainstream work in social cognition research, which till very recently focused mostly on the theory of mind debate and developmental-psychological issues related to it, nor phenomenological, interactionist or direct perception accounts of empathy have so far seriously engaged with these empirical studies. Footnote 8 This oversight represents a significant lacuna, all the more so as a systematic investigation of these and related Footnote 9 social perception biases might offer new avenues to also conceptually investigate the still little understood relationship between empathy, sharedness and group membership.

2 The Papers of the Issue

The papers in this special issue can be divided into three main groups: (1) The first consists of two papers discussing the relationship between empathy, cooperation and prosocial behaviour. (2) The three papers of the second group tackle interpersonal and collective forms of sharing, while (3) the four last papers address the complex, often biased or deviant relationship, between empathy, social and group identification, and the constitution of a ‘we’. Let us now give brief synopses of each of these contributions.

Anika Fiebich’s “Social Cognition, Empathy and Agent-Specificities in Cooperation” begins this special issue by offering a rich three-dimensional characterization of cooperation. Fiebich argues that cooperative behavior lies on continuum of cognitive, behavioral, and affective dimensions, all of which must be accounted for if we are to understand how it is that we successfully do things together. According to Fiebich, current debates about cooperation and joint actions—i.e., actions where two or more social agents share an intention to work together toward a common goal, such as moving a piece of furniture or playing music—are generally framed in folk psychological term. In other words, dominant accounts (e.g., Bratman, Searle) portray joints actions as requiring sophisticated theory of mind capacities that enable individuals to accurately represent the desires and intentions of others in order to integrate these with the individual’s own desires and intentions. Drawing on both developmental and phenomenological research, Fiebich challenges this cognitivist picture. She summons different streams of empirical evidence to argue that children engage in many forms of affectively-guided cooperative activities long before they acquire the metacognitive capacities needed for a theory of mind. And she concludes with a call for a plural approach to cooperation, one which acknowledges the ways that shared affective states and agent-specificities can both supplement and, at times, replace, metacognitive capacities in the realm of cooperative behavior.

John Michael and Marcell Székely’s “Goal Slippage: A Mechanism for Spontaneous Instrumental Helping in Infancy” continues this developmental focus. They note that developmental psychology has, in recent years, shown increased interest in various forms of prosocial behavior in infants and young children: e.g., comforting, sharing, pointing to provide information, and spontaneous instrumental helping (e.g., helping to retrieve a puzzle piece that’s fallen on the floor, or putting a stack of books back into a cabinet). This ability to spontaneously and flexibly adapt to the intentions and behavior of others, and to integrate our own behavioral responses with theirs, is at the root of our cooperative capacities. Michael and Székely critically evaluate several models that attempt to explain the psychological mechanisms underpinning this ability, highlighting strengths and weaknesses of each. They then propose their own model—the “goal slippage” model of spontaneous instrumental helping—based on the core idea that the identification of an agent’s goal leads infants to take up that goal as though it were their own , since infants lack the internal resources to quarantine others’ goals from their own endogenously generated goals. Michael and Székely develop their view by clarifying the psychological content of others’ goals the infant takes up as though they were her own by developing a “lean” notion of content. They then argue that their goal slippage model is better suited for explaining cognitively undemanding forms of prosocial behavior than other competing models, and they show how it might provide a useful starting point for further research into the ontogeny of the psychological underpinnings of human cooperation.

Anna Ciaunica’s “The ‘Meeting of Bodies’: Empathy and Basic Forms of Shared Experiences” shifts the focus from shared behavior to shared experiences. Ciaunica begins with a seemingly obvious observation that has nevertheless been overlooked in ongoing discussions of empathy and embodiment: we begin our social life within the lived body of another, i.e., our mother. She argues that this observation has explanatory significance for debates about both the development and character of our empathic capacities. This is because most current discussions of empathy, including those drawing upon phenomenologists like Husserl, Sartre, Stein, Scheler, and Schutz, focus primarily on face-to-face encounters in which we see others’ mental states embodied in their expressive and goal-directed behavior. According to these vision-centric approaches, we share others’ experiences insofar as they become perceptual content for our own experience. Ciaunica does not dispute the importance of these phenomenologically motivated accounts. However, she argues that before we visually relate to other subjects as objects, we are already bodily connected with them—as becomes clear when we look at the various ways that we are bodily and experientially bound up with caregivers during pregnancy and early infancy. Citing developmental evidence, Ciaunica argues that these “skin-to-skin” encounters do not disappear following infancy, but rather remain integral to our empathic encounters with others throughout our life. Accordingly, our models of empathy and experiential sharing should begin with a consideration of how these proximal body-based ways of establishing mutual awareness underwrite the visuo-spatial forms of empathy that are often thought to be developmentally primitive.

Alessandro Salice, Simon Høffding, and Shaun Gallagher’s “Putting Plural Self-Awareness into Practice: The Phenomenology of Expert Musicianship” is, like Ciaunica’s contribution, a focused investigation of the character of shared experience. However, whereas Ciaunica focuses on shared experience during pregnancy and early infancy, these authors have a different target: the phenomenology of shared agency when performing music together. They take a careful look at qualitative data drawn from interviews with highly-skilled musicians, The Danish String Quartet; these interviews lend insight into what it’s like to perform music with others at a world-class level of expertise. Based on these interviews, Salice, Høffding, and Gallagher argue that, within this performing experience, the musicians develop a sense of “we-agency”: the experience of performing a single action toward which the individual members enjoy an epistemically privileged access. This “we-agency” involves more than mere motor resonance between the performers or explicit coordination arising from members paying attention to what the others are doing. There is, additionally, an affective, interkinesthetic awareness that one’s individual sense of agency has been drawn up into a group agency—a “we-agency”—in which one’s perception–action loops are responsive to, and modulate by, those of the other members. The authors conclude their rich phenomenological analysis by discussing the significance of this view for thinking about the place of self-knowledge and observational knowledge in collective action.

Shaun Gallagher and Deborah Tollefsen’s “Advancing the ‘We’ Through Narrative” puts narrativity to center stage in the collective intentionality debate. To be sure, it is fairly uncontroversial that narratives play an important role not only in the framing and maintaining, or indeed the establishment of personal identity, but also for collective “we-identities”. Yet, the concept of narrativity has so far been rather sidelined in social ontology. This is all the more surprising given the veritable research industry on the cognate notion of collective memory, and if we consider that narrativity has also been increasingly discussed in the philosophy of personal identity and the philosophy of emotions in the past decades. In the face of this, Gallagher and Tollefsen propose a new account of so-called “we-narratives”. Following the authors, we-narratives can roughly be characterized as joint communicative reflections or stories about a group’s past, present or future actions, intentions, goals or norms. They are typically, though not necessarily, told or expressed in some discursive form from the first-person plural perspective (‘what we were doing’, ‘what we ought to do next’, etc.) (cf. also Tollefsen and Gallagher 2017 ). The authors consider a number of different, more or less ephemeral forms of joint agency and collective experiences (ad hoc, planned, and longer-term, coordinated joint actions), and show how we-narratives not only reflect the structure of the respective dyads or groups and build the typical representation format for a retrospective attribution of shared intentionality and agency; they also argue that we-narratives indeed underpin prospective joint intention formation and practical deliberation. Moreover, Gallagher and Tollefsen demonstrate how we-narratives play key roles in the formation of a robust group identity and thus contribute to groups’ stability over time, beyond discrete collective actions and experiences and across changing individual membership.

Joona Taipale’s “The Structure of Group Identification” presents a comprehensive and original account of group identification. For several decades now, the notion of group identification has been ubiquitous in developmental and social psychology. It has been extensively discussed to elaborate the nature of the affective, psychological and social-ontological relationship between individuals and groups. Curiously, however, a precise conceptual and phenomenological determination of the intentional and experiential structure of the identification at stake is still outstanding. Moreover, the notion is beset by a roaster of conceptual ambiguities, in particular when it comes to the nature of the target and the intentional act of identification. Taipale aims at disambiguating this notion, in order to demarcate it from cognate but different phenomena such as empathy, sympathy, and other relations of identity and similarity. Thus, the paper aims to advance our phenomenological understanding of the very act of identification. Taipale investigates a number or complex and important questions like: are there any relevant experiential, intentional, and structural differences between identifying with particular individuals, others qua group-members, and group as such? What is the nature of the experiential relation that identification with somebody entails for the subject and the target of identification, and what roles (if any) do identity and similarity play here? And is group identification a diachronically enfolding process of establishing a group membership, or is it the realization of an identity or similarity that has already been established? In tackling these fundamental issues, Taipale proposes a fine-grained, multi-dimensional model of group identification, one which can account for different types of establishing and robustly maintaining the social identity of the subjects of identification, depending on the type and nature of their targets. Footnote 10

Casey Rebecca Johnson’s “Intellectual Humility and Empathy by Analogy” addresses the question of how imaginative perspective-taking is possible in cases of interpersonal encounters in which the other person is fundamentally different from or deeply disagreeing with oneself? After all, empathic understanding is crucial precisely when our empathetic target’s intellectual outlook and/or experiential background starkly differ from our own. But some have recently denied that true interpersonal understanding is possible in such cases. In contrast, Johnson argues that defenders of a specific analogical conception of empathy need not recoil in the face of this challenge. Johnson addresses the challenge by bringing the relevant analogical account of empathy into relief against competing accounts, and in particular by drawing on the notion of intellectual humility, discussed in recent philosophical and psychological work. Once we recognize our own epistemic, cognitive and experiential limitations and realize that they are analogous to our empathetic targets, that is, once we exercise intellectual humility, Johnson argues, the way for empathy is paved, even if the barriers of understanding seem initially insurmountable.

Thomas Fuchs’ paper “Empathy, Group Identity, and the Mechanisms of Exclusion: An Investigation into the Limits of Empathy” brings together the issue of group identification with the bounds of interpersonal understanding in the face of potentially insurmountable sociocultural or ethnic barriers. Like Johnson, Fuchs, too, fathoms the limits of empathy, but this time by drawing on historical examples of mass atrocities and genocides, and by discussing the phenomenon of a dissociation of empathy. What is the link between the empirically well-documented tendency to exhibit preferential biases in empathizing with one’s ingroup (see above, Sect. 1 ) to the notorious Nazi perpetrator who, in empathic dissociation, behaves as a fully empathic family member while committing horrific mass executions in concentration camps? Fortunately, there seems to be no direct or short route leading from the former to the latter. However, as Fuchs demonstrates, the two phenomena lie on the same spectrum of empathic bias. In exploring this tendency, Fuchs discusses different forms of empathy and the mutual interconnection between higher-level forms of empathy and recognition. He argues that the mere capacity of empathy is not sufficient to instantiate empathic stances towards all members of the human species. We need, additionally, a basic form of recognition of others as persons to whose claim we have to respond. Such recognition can then serve as a means of “extending” empathy, regardless of whether the empathic targets belong to one’s ingroup or not. By investigating exclusionary and discriminatory mechanisms, and in particular dehumanization, and their impact on neutralizing empathic recognition, Fuchs ultimately argues that extreme dissociations of empathy have also detrimental top-down impact on primary empathy and the very personhood of the perpetrators, who eventually become themselves dehumanized.

Dan Zahavi’s contribution “Empathy, Self-Alienation, and Group Membership” integrates a number of threads of the preceding articles. Zahavi engages in a phenomenological discussion of the ways in which second-personal encounters and empathic stances affect our self-understanding, and how their interconnection plays out in the constitution of plural, or ‘we’-identities. Zahavi first sketches the conceptual terrain by critically comparing Heidegger’s skeptical and deflationary views on empathy’s role for the constitution and understanding of plural identities with other classical phenomenologists, who hold that dyadic-empathic engagements are indeed constitutive of the ‘we’. Drawing chiefly on Husserl’s theory of intersubjectivity and his theory of collective intentionality avant la lettre , but also critically discussing a number of contemporary accounts from philosophy, social and developmental psychology, Zahavi then explores the phenomenological, psychological and intersubjective mechanisms of this constitution, such as reciprocity, recognition, and self-alienation. He argues that they play a fundamental role for the establishment of a first-person plural perspective. Thus, by showing how shared and collective identities, or the ‘we’, require specific forms of self/other-relations, involving specific forms of self-experience and self-alienation, Zahavi demonstrates how the first-person (I) and the second-person singular (I/Thou) and the first-person plural perspective (We) are essentially interlinked.

It is our hope that the articles in this special issue will spur further conversations about the underexamined links between empathy, shared emotions, and social identity.

E.g., Gallese ( 2001 ), Decety and Lamm ( 2006 ), Decety and Meyer ( 2008 ), Eisenberg and Eggum ( 2009 ), cf. de Vignemont ( 2009 ).

See Zahavi ( 2014 , 2015a , 2018 ), León and Zahavi ( 2016 ), Szanto ( 2015 ), Szanto and Moran ( 2015 , 2016 ); cf. also Vendrell Ferran ( 2015 ), Svenaeus ( 2016 , 2018 ).

Research on shared or collective emotions is still very recent, but constitutes an already burgeoning interdisciplinary field, including sociologists, social and developmental psychologists (cf., for an overview, von Scheve and Salmela 2014 ) and numerous philosophers (e.g., Gilbert 2002 , 2014 ; Tollefsen 2006 ; Konzelmann Ziv 2007 , 2009 ; Helm 2008 , 2017 ; Schmid 2009 , 2014 ; Huebner 2011 ; Michael 2011 ; Salmela 2012 , 2014 ; Salmela and Nagatsu 2016a , 2016b ; Krueger 2014 , 2015 ; Szanto 2015 , 2018 ; León et al. (forthcoming); Thonhauser forthcoming; for recent review articles, see Schmid ( 2018 ) and Salmela (forthcoming).

Cf. De Jaegher and Di Paolo ( 2007 ), De Jaegher et al. ( 2010 ), Fuchs and De Jaegher ( 2009 ), Gallagher ( 2008a , b ), Gallagher and Varga ( 2014 ), Krueger ( 2011 , 2012 ), Schilbach et al. ( 2013 ), Satne and Roepstorff ( 2015 ), Chemero ( 2016 ), see, critically; Herschbach ( 2012 ), Michael et al. ( 2014 ), Overgaard and Michael ( 2015 ).

E.g., Pacherie and Dokic ( 2006 ), Hobson and Hobson ( 2007 ), Gallotti and Frith ( 2013 ), Tomasello ( 2014 ), Abramova and Slors ( 2015 ), Bianchin ( 2015 ), León ( 2016 ), Martens and Schlicht ( 2018 ).

Incidentally, early phenomenologists such as Gurwitsch ( 1931 ) have already pursued very similar lines of interactionist argument regarding empathy, see Jardine and Szanto ( 2017 ), and more below.

See Xu et al. ( 2009 ), Avenanti et al. ( 2010 ), Chiao and Mathur ( 2010 ), Hein et al. ( 2010 ), Beeney et al. ( 2011 ), Cikara et al. ( 2011 ), Azevedo et al. ( 2013 ), Bruneau et al. ( 2012 ), Gutsell and Inzlicht ( 2012 ); cf. Gallagher and Varga ( 2014 ).

For the only exceptions we are aware of, see again Gallagher and Varga ( 2014 ), Varga ( 2017 ), and Fuchs’s contribution to this issue.

One such related family of social cognition biases comprises recent discussions of so-called ‘implicit’ (mostly racial or gender-related) biases. While psychologists and cognitive scientists have extensively investigated the underlying processes of implicit social cognition (cf. for reviews, see Greenwald and Banaji 1995 ; Frith and Frith 2008 ; Nosek et al. 2011 ), and philosophers have begun to systematically tackle the epistemology, metaphysics and ethics of implicit biases (Brownstein and Saul 2016a , b ; for review articles see: Kelly and Roedder 2008 ; Brownstein 2015 ; Holroyd et al. 2017 ), philosophical, and in particular phenomenological, research on the relationship between social perception, embodiment and empathy on the one hand, and implicit biases on the other is missing.

For a recent discussion of the relation between group identification and collective intentionality, pertinent to the present special issue, see Salice and Miyazono (forthcoming).

Abramova E, Slors M (2015) Social cognition in simple action coordination: a case for direct perception. Conscious Cogn 36:519–531

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Acknowledgements

The guest editors of this special issue are very grateful for the thorough work of a number of experts who have kindly accepted to serve as anonymous referees for the contributions. We would also like to thank the editor-in-chief of Topoi , Fabio Paglieri, for an exceptionally smooth collaboration, his patience, and his willingness to host this issue. Thomas Szanto also wishes to acknowledge generous funding from his European Union (EU) Horizon-2020 Marie Skłodowska-Curie Individual Fellowships Grant SHARE (655067): “Shared Emotions, Group Membership, and Empathy”, as well as from the Academy of Finland research project “Marginalization and Experience: Phenomenological Analyses of Normality and Abnormality” (MEPA).

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Do we have more empathy for people who are similar to us? New research suggests it’s not that simple

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How do people successfully interact with those who are completely different from them? And can these differences create social barriers? Social scientists are struggling with these questions because the mental processes underlying social interactions are not well understood.

One recent concept that has become increasingly popular is the “double-empathy problem”. This draws on research looking at people who are known to experience social difficulties , such as autistic people.

The theory proposes that people who have very different identities and communication styles from each other – which is often the case for autistic and non-autistic people – can find it harder to empathise with one another . This two-way difficulty is what they mean by the double-empathy problem.

This idea is getting a lot of attention. Research on the double-empathy problem has rapidly grown over the past decade. This is because it has the potential to explain why different people in society might struggle to empathise with one another, potentially leading to personal and societal problems; from poor mental health to inter-group tensions and systemic racism.

But is this idea accurate? Our recent paper suggests that things might be much more complicated than that.

Graph showing the number of research papers on Google Scholar including 'double empathy' as a term between 2012-2022.

Our analysis suggests that the double-empathy theory has many shortcomings. It highlights that there is widespread confusion surrounding the very fuzzy concept of double empathy. The research has also narrowly focused on social difficulties in autism without considering other social identity factors that affect empathy between different groups, such as gender.

The theory also fails to incorporate the psychological neuroscience of empathy . Instead, it confuses the concept of empathy – that is, psychologically feeling the emotions that other people are feeling – with similar but different phenomena, such as “mentalising” (understanding what people are thinking from a different perspective).

Graph showing different psychological concepts that are confused with double empathy.

Because the double-empathy theory is not well developed, most experiments testing it are muddled. Many researchers claim to be studying double empathy when they do not measure empathy . Meanwhile, other studies are being used as evidence of double empathy despite never having set out to test this theory.

Double-empathy research has also heavily relied on subjective reports of people’s experiences (rather than evaluation by experts), which may not tell the whole story.

Read more: The science of 'mind-reading': our new test reveals how well we understand others

Altogether, the analysis of existing research indicates that the central claim of the double-empathy theory is not well supported. That is, being similar in identity to other people does not necessarily mean that you have more empathy for them.

This is an important issue that needs urgent attention. There are already signs that the double-empathy theory is being put into practice, despite lacking evidence. Certain researchers and doctors have started claiming that, because there is a double-empathy problem, healthcare professionals are generally unable to understand their patients with social difficulties. But there is no reliable evidence for this.

Looking ahead, there is a need for more neuroscientific research on social interaction . We expect that brain imaging technologies, such as “hyperscanning” – scanning multiple human brains at the same time – will help shed light on how different people’s brains interact with each other. For example, this technique can be used to test how similarity between people who interact may influence their brain activity .

To make breakthroughs in this area, this technique could be used alongside artificial intelligence. Exploring whether machines can truly empathise with humans by seeing if they accurately interpret our brain waves will be of great interest.

Read more: Increasingly sophisticated AI systems can perform empathy, but their use in mental health care raises ethical questions

The benefits of diversity

It is thought that people living in more socially diverse places, such as large cities, tend to be more tolerant of those who are different from them than people who live in socially homogeneous places. They ultimately perceive themselves and others as belonging to the same local community despite ethnic and cultural differences and appear to be better at considering the perspective of others .

This suggests that spending time with people who are different to us can perhaps boost our empathy – something that the double-empathy theory does not predict. Ultimately, empathy is not just down to our ability to understand someone through their similarity. Spending time with those from other social and cultural backgrounds may make us place less emphasis on differences – and discover common ground in other areas.

Human experience is vast and complex. Just because two people come from different cultures or have different communication styles does not mean they cannot be very similar in other ways. Perhaps their values align or they have similar interests. This insight could have the potential to remove some barriers that may otherwise make it difficult to understand and empathise with others.

And, sometimes, people from similar backgrounds struggle to understand each other, yet can have great empathy for people who are completely different from them (for example, refugees fleeing war-torn countries). Why? The double-empathy theory may not be the best way to make progress, but it might serve as a springboard for future research to answer this and other questions.

We could really harness the social science of empathy to understand these incredibly complex social issues. This might ultimately reduce societal conflict and improve social cohesion – but we must get research on the right track to achieve this potential.

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Br J Gen Pract
v.63(606); January 2013

Effectiveness of empathy in general practice: a systematic review

Empathy as a characteristic of patient–physician communication in both general practice and clinical care is considered to be the backbone of the patient–physician relationship. Although the value of empathy is seldom debated, its effectiveness is little discussed in general practice. This literature review explores the effectiveness of empathy in general practice. Effects that are discussed are: patient satisfaction and adherence, feelings of anxiety and stress, patient enablement, diagnostics related to information exchange, and clinical outcomes.

To review the existing literature concerning all studies published in the last 15 years on the effectiveness of physician empathy in general practice.

Design and setting

Systematic literature search.

Searches of PubMed, EMBASE, and PsychINFO databases were undertaken, with citation searches of key studies and papers. Original studies published in English between July 1995 and July 2011, containing empirical data about patient experience of GPs’ empathy, were included. Qualitative assessment was applied using Giacomini and Cook’s criteria.

After screening the literature using specified selection criteria, 964 original studies were selected; of these, seven were included in this review after applying quality assessment. There is a good correlation between physician empathy and patient satisfaction and a direct positive relationship with strengthening patient enablement. Empathy lowers patients’ anxiety and distress and delivers significantly better clinical outcomes.

Although only a small number of studies could be used in this search, the general outcome seems to be that empathy in the patient–physician communication in general practice is of unquestionable importance.

INTRODUCTION

Patients consider empathy as a basic component of all therapeutic relationships and a key factor in their definitions of quality of care. 1 , 2 One hundred years ago, Tichener introduced the word ‘empathy’ into the English literature, based on the philosophical aesthetics concept of ‘Einfühlung’ of Theodor Lipps. 3 Another important historical moment is the way Rogers speaks about empathy in 1961 in his book: On Becoming a Person: a Therapist’s View of Psychotherapy. 4 Since then, various authors have written about empathy in the setting of psychotherapy and about its functionality in patient–physician communication. Neuroscientific research of recent decades has achieved significant progress in establishing the neurobiological basis for empathy, after discovering the mirror neuron system (MNS) 5 , 6 as probably being related to people’s capacity to be empathic. 7 Scientists have now added new insights, based on functional magnetic resonance imaging (fMRI) experiments. They have discovered that the MNS consists of mirror neurons in the ventral premotor cortex and the parietal area of the brain and neurons in the somatosensory areas and in limbic and paralimbic structures. 8 The insula plays a fundamental role in connecting these regions. 9 fMRI experiments have shown that individuals who score higher in a questionnaire measuring their tendency to place themselves in the other person’s shoes activate their MNS more strongly while listening to other people’s problems. 10 , 11 These results draw the ‘soft’ concept of empathy into ‘hard’ science, which opens a challenging new field of research with potentially important clinical implications. 12 However, these neurobiological studies do not give information about the impact of empathy in clinical care. Within the current opinion of ‘evidence-based health care’, it is important also to get evidence about the effectiveness of empathy in the daily practice of GPs.

To assess the effectiveness of empathy, it is necessary to define what authors mean when using the term ‘empathy’. Although many authors experience difficulties in giving a clear definition, 1 , 2 , 13 – 20 a number of core elements can be identified. 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

Empathy can therefore be defined at three levels: as an attitude (affective), 25 , 26 as a competency (cognitive), 2 , 15 and as a behaviour. 2 , 16

Attitude is based on moral standards in the mind of the physician; such as respectfulness for the authenticity of the other person, interest in the other person, impartiality, and receptivity. These standards are formed by a physician’s own human development, their socialisation process, their medical training, their personal experience with patients; by reading professional literature; and by watching movies and reading books. 13 , 15 , 22 , 27 – 29

How this fits in

Empathy is seen, as well as by patients as by physicians, as the base of good patient-physician communication. Despite these opinions one can see a decrease of interest in good patient-physician communication. There is an increase of technological aspects of care and of a prevalence on productivity in general practice. This systematic review shows that also a “soft” skill like empathy has its effectiveness on patient satisfaction, adherence, decrease of anxiety and stress, better diagnostics and outcomes and patient enablement. Physicians should be more aware of this. In the near future it is a challenge to draw the attention of policy makers and health insures on these aspects of empathy.

Competency can be subdivided into empathic skill, a communication skill, and the skill to build up a relationship with a patient based on mutual trust. Empathic skill is the approach by which the physician can elicit the inner world of the patient and get as much information as possible from the patient, while at the same time recognising the patient’s problem. 2 , 30 , 31 Communication skill is used to check, clarify, support, understand, reconstruct, and reflect on the perception of a patient’s thoughts and feelings. 15 , 23 The skill to build up a trusting and long-standing patient–physician relationship encourages physicians to resonate with the patient emotionally. These long-term relationships are important for telling and listening to the stories of illness. 32 , 33

Behaviour has a cognitive and an affective part. The cognitive part includes verbal and/or non-verbal skills. 14 , 15 , 22 , 25 , 26 The affective part includes recognition of the emotional state or situation of the patient, being moved, and recognising a feeling of identification with someone who suffers with anger, grief, and disappointment. After this recognition, the physician, in their behaviour, reflects on and communicates their understanding to the patient ( Figure 1 ). 20 , 23

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Subdivisions of empathy.

Both patients and physicians mention empathy as the basis for a humane patient-centred method in general practice, and as an important component of professionalism. 1 , 17 , 34 A large number of patients, nearly 80%, would recommend an empathic physician to other individuals. 35

Despite these opinions, one can see a decrease of interest in good patient–physician communication. Reynolds et al report a low level of empathy in professional relationships. 34 In their view, this is widespread in modern medicine and many recipients of professional help may not feel that their situation is understood by professionals. 34 A study by Kenny et al suggests that physicians and patients have a different perspective on physicians’ communication skills: the perceptions of the medical encounter have been characterised as being so different that they appear to be from ‘different worlds’. 36

Moreover, different authors report a rising prevalence in the last decade of technological and biomedical aspects of care and of more emphasis on effectiveness and productivity in family care. 17 , 20 , 37 Peabody proved to be prophetic when, in 1927, in his lecture The Care of the Patient, he expressed concern that rapidly growing scientific technology was crowding out human values in the management of patients. 38 Just as Spiro asks attention for the ‘unseen and unheard’ patient in these developments, 20 it is important to pay attention to the effectiveness of empathy in patient–physician communication.

The purpose of this literature review is to get a clear view on the proven effectiveness of empathy in patient–physician communication, in particular in general practice.

A search was undertaken of PubMed, EMBASE, and PsychINFO databases, between July 1995 and July 2011, with the support of a professional librarian, to identify studies of general practice, empathy, and effectiveness or outcome of empathy. The search terms used are shown in Box 1 . The search was performed using major medical subject heading (MeSH) terms in titles and/or abstracts ( Box 1 ). After removal of duplicate studies, titles and abstracts were assessed as to whether the articles were pertinent to this literature review and whether they dealt with general practice. Potentially relevant articles were read in full text. Further papers were sought by checking references and citation searches of included and other leading articles (snowball method). After this selection, articles were assessed as to whether or not they fitted within the inclusion criteria.

Box 1. Database search terms used

((empathy[MeSH] OR empath*[tiab])) AND (Physicians, Family[MeSH] OR Primary Health Care[MeSH] OR Family Practice[MeSH] OR “General Practice”[MeSH] OR “General Practitioners”[MeSH] OR Family Physician*[tiab] OR Primary Health Care[tiab] OR Primary Healthcare[tiab] OR Primary Care[tiab] OR Family Practice*[tiab] OR General Practice*[tiab] OR General Practitioner*[tiab] OR Family Medicine[tiab]) AND outcome*[tw]

To fulfil the inclusion criteria, articles had to detail original and empirical studies, published in English. Studies had to contain patient experience, and outcome measures of empathy and measures of GPs’ empathy. Exclusion criteria were: reviews, guidelines, and theoretical or opinion articles. In the last selection, the studies were evaluated by the criteria of quality developed by Giacomini and Cook ( Box 2 ). 39 From the initial 964 papers, seven meeting the inclusion and qualitative criteria were identified ( Figure 2 ).

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Selection process for papers on the effectiveness of empathy in general practice.

Box 2. Giacomini and Cook’s criteria 39

The participant selection is well reasoned and the inclusion is relevant to the research question; the population is representative.
The data-collection methods are appropriate for the research objectives and setting; the data collection is valid and reliable.
The data-collection process, which includes field observation, interviews, and document analysis, must be comprehensive enough to support rich and robust description of the observed events.
The data must be appropriately analysed and the findings adequately corroborated by using multiple sources of information.

Seven studies were found ( Table 1 ). 40 – 46 The effectiveness of empathy in patient–physician communication in the studies included is described as improvement of patient satisfaction and adherence, decrease of anxiety and distress, better diagnostic and clinical outcomes, and more patient enablement. Patient outcomes were measured by questionnaires and laboratory tests, and by analysing audio- and videotapes.

Summary of included articles

Author	Country	Quality assessment score	Measure/empathy level	Design	Method	Sample size	Research question	Key findings
Hojat , 2011	US	6	JSPE/physician rating/cognitive and attitude	Quantitative/RCT with statistical controls	Laboratory results	891 patients/31 GPs	To test the hypothesis that physician empathy is associated with positive clinical outcomes for patients with diabetes.	Patients of physicians with high empathy scores were significantly more likely to have good control of HbA1c (56%) than were patients of physicians with low empathy scores (40%). Similarly, the proportion of patients with good LDL-C control was significantly higher for physicians with high empathy scores (59%) than for patients of physicians with low scores (44%).
Rakel , 2011	US	5	CARE/patient rating/skill and attitude	Quantitative/RCT	Questionnaire and laboratory results	348 patients/6 GPs	To evaluate the effects of patient–physician interaction on the severity and duration of the common cold.	The ‘physician empathy perfect’ group was associated with the shortest cold duration (5.89 days versus 7.00 days). The amount of change of interleukin-8 and neutrophil level was greater for the ‘physician empathy perfect’ group.
van Dulmen et al, 2004	Netherlands	4	RIAS/observer rating/skills	Quantitative	Questionnaire and analysis of video consultations	698 patients/142 GPs	To examine the physicians’ responses to patients’ concerns in relation to the patient’s empathic preference and perception and the level of anxiety provoked by the medical visit.	95% of the patients reported that they have perceived their GP to be empathic. The patients who had perceived a more empathic GP reported lower levels of anxiety.
Mercer , 2008	Scotland	5	CARE/patient rating/skill and attitude	Qualitative/prospective	Questionnaires	323 patients/5 GPs	To investigate the relationships between GPs’ empathy, patient enablement and patient-assessed outcomes in primary care consultations in an area of high socioeconomic deprivation in Scotland.	There is a direct relationship between physician empathy and patient enablement.
Hojat , 2011	US	6	JSPPPE physician rating cognitive and attitude	Qualitative/RCT	Questionnaires	535 patients	To develop and examine an instrument to measure patients’ overall satisfaction with their GP.	A large correlation between the perception of physician empathy and patient satisfaction.
Buszewicz , 2006	UK	6	TAR/patient rating/long working relationships	Qualitative	Patient interviews	20 patients/12 GPs	To identify which aspects of GP consultations patients presenting with psychological problems experience as helpful or unhelpful.	Genuine interest and empathy, within a continuing relationship, was highly valued both for psychological and non-psychological problems.
Levinson and Roter, 1995	US	6	RIAS/observer rating/skills	Qualitative	Analysis of audiotapes	412 patients/29 GPs	To assess the relationship between physicians’ beliefs about the psychosocial aspects of patient care and their routine communication with patients.	Physicians who had positive attitudes used more statements of emotions, such as empathy, reassurance, and fewer closed-ended questions than did their colleagues who had less positive attitudes. The patients of these physicians offer more information about psychological and social issues.

CARE = the Consultation and Relational Empathy measure. HbA1c = gylcosylated haemoglobin. JSPE = Jefferson scale of Physician Empathy. JSPPPE = Jefferson Scale of Patient Perception of Physician Empathy. LDL-C = low-density lipoprotein cholesterol. RCT = randomised controlled trial. RIAS = Roter Interaction Analysis System. TAR = Tape Assistance Recall method.

Improvement of patient satisfaction and adherence

Hojat et al found a good correlation between patients’ satisfaction and their perceptions of physicians’ empathic engagement. 40 Corrected item–total score correlations of the patient satisfaction scale ranged from 0.85 to 0.96; correlation between patient satisfaction scores and patient perception of physician empathy was 0.93. 40

Decrease of anxiety and distress

In the study by van Dulmen et al it was found that the more anxious patients were, the more adequately their GPs tended to respond. Patients who perceived their GP as empathic reported lower levels of anxiety. 41

Better diagnostics and clinical outcomes

Levinson and Roter confirm that communication between physicians and patients is associated with underlying physician attitudes. 42 Specifically, physicians with positive attitudes towards psychosocial issues make more statements expressing concern and empathy. The patients of these physicians offer relatively more information about psychological and social issues. These patterns of communication are associated with improved patient satisfaction and patient outcomes. 42 An underlying attitude of genuine interest and empathy, within a continuing relationship, was highly valued. Patients described how the GP’s attitude helped or hindered them in discussing their problems. Patients also described how the GP helped them make sense of, or resolve, their problems and supported their efforts to change. 43

Hojat et al found a positive relationship between physician empathy and patients’ clinical outcomes. Patients with diabetes had their glycosylated haemoglobin (HbA1c) and low-density lipoprotein (LDL) cholesterol levels checked. Both tests showed significantly better results in patients with a more empathic physician. It is suggested that more empathy in the physician–patient relationship enhances mutual understanding and trust between the physician and patient, which in turn promotes sharing without concealment, leading to a better alignment between patients’ needs and treatment plans, and thus more accurate diagnosis and greater adherence. 44

Even the most common infectious disease on earth, a common cold, is shown to last for significantly less time and to be less severe in cases where there is good physician–patient empathy. A ‘physician empathy perfect group’ was associated with the shortest cold duration (5.89 days versus 7.00 days). The amount of change of interleukin-8 and neutrophil level was greater for the ‘physician empathy perfect’ group. Interleukin-8 and neutrophil counts were obtained from nasal wash at baseline and 48 hours later. 45

More patient enablement

There is a direct positive relationship between GP empathy and patient enablement, as well as between enablement and changes in main complaint and wellbeing. 46 Patient enablement was measured by the Patient Enablement Instrument (PEI), with questions on topics such as: ability to cope with life and illness, and patients’ confidence about their health and their ability to help themselves. 46

This review investigates the relationship between GP empathy and patient outcomes. A GP’s daily practice involves many elements that are not evidence based. The existence and use of empathy in communication is one of these ‘soft’ elements. However, this review shows that there is empirical evidence for effects of human aspects in patient–physician interaction. There is a relationship between empathy in patient–physician communication and patient satisfaction and adherence, patients’ anxiety and distress, better diagnostic and clinical outcomes, and strengthening of patients’ enablement.

As mentioned in the introduction, there are different levels of empathy. Authors used different types of tests to measure these different levels, such as the Jefferson Scale of Patient Perceptions of Physician Empathy (JSPPPE), a self-report measuring scale for cognitive and attitude factors; the Consultation and Relational Empathy Measure (CARE), a patient rating system that measures physicians’ communication skills and attitudes; the Roter Interaction Analysis System (RIAS), an observer rating system that measures empathy skills; and the Tape Assisted Recall method (TAR), which measures the development of a long working relationship. 47

Strengths and limitations

A previous review by Beck et al mentioned that actual empirical data were relatively scarce. 48 With the inclusion criteria used in this review, seven articles were found with a bearing on general practice.

This study has a potential cultural bias in interpreting and judging phenomena by standards inherent to European culture. General practice in Europe is most commonly delivered by GPs. In the US, primary care includes both general internists and paediatricians, as well as GPs.

A possible limitation of this review is the underexposure of ‘the danger of empathy’, such as a physician losing their professional distance, which, in certain situations, might make empathy a less desirable aspect of patient–physician communication. 16 , 49

In focusing on empathy, the effects of contextual factors on specific health outcomes are possibly underexposed, such as intrinsic and/or extrinsic factors, healthcare setting, access to care, GP’s workload or pressure, and sociocultural factors. 50

General limitations of this review are that only articles written in English are included. Furthermore, the existing measures of empathy have been taken as presented in the literature; no critical reflection of the validity of these measures has taken place.

Comparison with existing literature

The results of the studies seem to be supported by other authors. For patient satisfaction and adherence, Neumann et al , 21 Kim et al , 51 and Lelorain et al 52 confirm the data; they found links between physician empathy and patient satisfaction, in various clinical settings. Mercer et al have shown that patients view quality of consultation in general practice as related to both the GP’s competence and the GP’s empathic care. 53 Further, Neumann et al argue that affective-oriented effects of empathy are related to more satisfaction, adherence, and trust. 16 Indirectly, patients who are more satisfied with the care received exercise greater adherence to agreed and recommended treatment regimens and courses of action. 3

In relation to decrease of anxiety and distress, in experimental research in which a GP was trained in special communication styles, Verheul et al found that combining a warm and empathic communication style with raising positive expectations leads to positive effects on the patient’s anxiety. 12

In relation to better diagnostics and clinical outcomes, authors have shown that empathic communication achieves the effect that patients talk more about their symptoms and concerns, enabling the physician to collect more detailed medical and psychosocial information. This leads to more accurate medical and psychosocial perception and ultimately to more accurate diagnosis and treatment regimens. 13 , 22 Neumann et al based their ‘effect model of empathic communication in the clinical encounter’ on this evidence. 16 It has also been mentioned that patients’ overall satisfaction with healthcare services, adherence to medical regimens, comprehension, and perception of a good personal relationship are positively related with interpersonal communication between the patient and care provider and are particularly related to the physician’s empathic behaviour. 24 , 48 , 51 , 54 – 57 However, physician-perceived stress has also been shown to correlate negatively with enablement. 57

Implications for practice and research

Empathy is a familiar term in the helping and caring literature. In 2008, the World Health Organization (WHO) reaffirmed the importance of primary health care with its report Primary Health Care Now More Than Ever. 58 The key challenge was ‘to put people first, since good care is about people’. 58 Rakel said that good medical care will continue to depend on care by concerned and compassionate family physicians who can communicate with patients, understand them, know their families, and see them as more than a case. 59

Qualitative studies show that physicians link empathy to fidelity, prosocial behaviour, moral thinking, good communication, patient and professional satisfaction, good therapeutic relationships, fewer damage claims, good clinical outcomes, and building up a trusting relationship with the patient. 15 , 24 , 25 , 60 , 61 In her study, Shapiro explored how primary care clinician-teachers actually attempt to convey empathy to medical students; they argued that the moral development of the GP, their basic willingness to help, their genuine interest in the other, and an emphasis on the other’s feelings are basic principles for acceptance of the empathic approach to the patient. 25

In GPs’ views, limiting factors during consultation are: time pressure, heavy workload, a cynical view on the effectiveness of empathy, and a lack of skill. 13 , 51 , 62 Neumann et al have shown that patients also see time pressure and busyness on the physician’s part as a limiting factor. 21

Thus empathy can be seen as a part of patient–GP communication, characterised by feelings such as interest and recognition and the physician remaining objective. However, barriers exist for implementation in general practice. 13 , 14 , 24 , 30 , 31 , 47 , 63 , 64

Another finding of this review is that some studies suggest that the degree of empathy shown by medical students declines over the course of their training. 20 , 65 , 66 Empathy appears to increase during the first year of medical school, but decreases after the third year and remains low through the final year of medical school, measured using the Jefferson Scale of Physician Empathy–Student Version (JSPE-S). 17 , 66 , 67 In the study by Hojat et al , 66 there are no sex differences. On the other hand, Quince et al discovered that among males during medical education, in both the bachelor and clinical phases, affective empathy slightly but significantly declined and cognitive empathy was unchanged. Among females, neither affective nor cognitive empathy changed. 68 It is ironic that there are indications that when students can finally begin doing the work they came to medical school to do (that is, taking care of patients) they seem to begin losing empathy. 69 Possible explanations of the decline are: a lack of good role models and changes in general cultural and ethical views on illness, health, and portrayals of mankind. Interviews with physicians show that they think that, in current western society, it has become less a part of human nature to be interested in another person and to be affected by someone else’s misery. 17 In their study of American college students, comparing the temporal changes between 1979 and 2009, Konrath et al showed that this development has social roots. 65 Considering these possible tendencies in education and the above-mentioned technological changes within the healthcare system, which probably influence the patient–physician alliance negatively and could undermine empathy in these relationships, it makes sense to emphasise the results of the present review. The evidence of a correlation between empathy and clinical outcomes should be made widely known, especially among medical students and physicians. Some authors already believe empathy can be improved by targeted educational activities and they indicate opportunities to enhance empathy during education. 16 , 17 , 26 , 38 , 69 – 71

It should be mentioned that, until now, the widely acclaimed benefits of empathy only have a small empirical base. Although a few studies of sufficiently high quality show promising results, much more research is needed to claim the effectiveness of empathy in clinical practice on evidence-based grounds. Neumann et al have already highlighted the need for an examination of the cost-effectiveness of empathy in the light of the recent focus of policy makers and health insurers on the efficiency of health care. 16 It is a challenge to draw the attention of policy makers to empathy as an effective and efficient way of delivering health care. A vast majority of patients want empathic physicians, particularly, but not exclusively, in general practice. 72 Indirectly, authors suppose empathic behaviour improves the physician–patient relationship and causes satisfaction for the patient but also for the physician, 1 , 13 , 22 resulting in fewer cases of compassion fatigue or burn out.

Further research is needed on the practical use of empathy in general practice, with a focus on the effects and side effects of empathy and the expectations of patients and GPs. In this context, it is important to take account of how researchers have measured empathy. Measuring empathy is often based solely on self-reports and is therefore often remote from patients’ and physicians’ concrete feelings, experiences, and interpretations in practice. Only patient-perceived empathy is significantly related to patient outcomes. Therefore, it appears best to use a patient-perceived empathy scale to measure physician empathy in practice. 47 , 48 , 63 , 65 , 73

It is remarkable that empirical studies on physician empathy are still relatively scarce. According to the results of the studies included in this systematic review, empathy is an important factor in patient satisfaction and adherence, in decreasing patients’ anxiety and distress, in better diagnostic and clinical outcomes, and in strengthening patient enablement. Thus, physician empathy seems to improve physical and psychosocial health outcomes.

Acknowledgments

I am most grateful to E Peters, specialist librarian of the medical library, for her help with the database searches.

The study was not funded.

Freely submitted; externally peer reviewed.

Competing interests

The authors have declared no competing interests.

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Published: 30 May 2024

Effectiveness of empathy portfolios in developing professional identity formation in medical students: a randomized controlled trial

Munazza Baseer 1 ,
Usman Mahboob 2 na1 ,
Neelofar Shaheen 3 na1 ,
Bushra Mehboob 4 na1 ,
Ayesha S Abdullah 5 na1 &
Uzma Siddique 5 na1

BMC Medical Education volume 24 , Article number: 600 ( 2024 ) Cite this article

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Medical education requires innovative strategies to enhance empathic skills and the formation of professional identities among students. However, evidence-based teaching of empathy and professional identity formation is inadequately represented, particularly in medical curricula. This study investigated the effectiveness of empathy portfolios in developing Professional Identity Formation (PIF) among medical students and the correlation between empathy and PIF. The objectives of this study were to determine the effectiveness of empathy portfolios for teaching and nurturing PIF in medical students and to investigate the correlation between empathy and PIF.

A randomized controlled trial was conducted at Peshawar Medical College, Pakistan. The protocol adhered to CONSORT guidelines. A total of 120 students participated in the study. Empathy and PIF were assessed using two validated questionnaires JSPE-S and PIQ before randomization. The participants were randomized in a stratified fashion into the experimental ( n = 60) and control ( n = 60) groups. The Participants in the intervention group attended a training workshop on portfolio use. Students maintained their portfolios and wrote reflections on incidents that evoked empathy. Independent t-tests were performed to determine whether the control and experimental groups differed in terms of mean empathy and PIF scores, and Pearson’s correlation analyses were used to investigate the relationships between pre- and post-empathy, and pre-post-PIF.

The mean post-test scores on the Empathy and PIF showed a statistically insignificant difference of 0.75 +-17.6 for empathy and 0.45 ± 8.36 for PIF. The intervention had little influence on empathy and PIF scores, as evidenced by nonsignificant effect sizes of 0.32 and 0.36 for empathy and PIF respectively.A strong positive correlation was found between Pre-Empathy and the PIF-Total score (0.519), and between Post- empathy and the PIF-Total score (0.395) ( p < 0.001).

Conclusions

Empathy had a positive linear correlation with PIF; however, the use of empathy portfolios as a three-week single-point intervention was ineffective at nurturing PIF.

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One of the goals of medical education is to assist students in developing a professional identity that is well-formed and mature [ 1 , 2 ]. In recent years, professional identity formation (PIF) has received much attention in the medical education literature since it establishes the moral foundation for one’s medical practice by ensuring that everyone has acquired a professional identity to “think, act, and feel like a physician” [ 3 , 4 , 5 ]. PIF is a complex process involving internalising professional values, roles, and behaviours and shaping how healthcare professionals perceive themselves and their interactions with patients and colleagues [ 5 ]. However, medical schools have struggled to develop effective strategies to promote PIF [ 6 ]. Professional identity development in medical students can be impeded by factors such as bias, disregard for humanistic elements, and the process of dehumanization [ 6 ].

When considering what qualities make a good physician, the literature and related research support the importance of cognitive aspects such as knowledge and professionalism, and emotional elements such as empathy and compassion [ 7 ]. Empathy is a valuable attribute in the medical field since it plays a critical role in building a solid and meaningful relationship between physicians and their patients [ 8 ]. Several studies have reported decreased empathy levels in the later stages of medical professionals’ training programs [ 9 ]. Multiple factors contribute to this decline; doctors prioritize medical skills over humanistic understanding owing to high patient loads and a tendency to create distance from patients [ 10 ].

Despite its significance, insufficient consideration has been given to the role of empathy in developing students’ professional identity. The absence of empathy in the existing models of professional identity requires further probing [ 11 ].

Medical education struggles to promote empathy due to workload, emotional exhaustion, desensitization, and hidden curriculum [ 12 , 13 ]. Zhou et al. [ 14 ] suggested employing portfolios for nurturing empathy and recommended exploring empathy’s potential link with PIF. The purpose of this study is to investigate the effectiveness of empathy portfolios in developing PIF among medical students. In particular, it investigates if there is a correlation between empathy and PIF and evaluate the impact of empathy portfolios on the development of students’ professional identity. Given this context, our study aimed to answer the following research questions:

Would Empathy portfolios prove to be an effective intervention for nurturing medical students’ professional identity formation?

Is there a correlation between empathy and PIF among medical students?

The study duration ranged from April 2023 to September 2023. A randomized controlled trial (Fig. 1 ) was designed and conducted at Peshawar Medical College, Peshawar, Pakistan. The intervention primarily involved the use of major hospitals attached to the medical college which served as the educational environment for developing PIF for the students who participated in this educational trial. These hospitals provide a clinical environment where medical students interact with patients, allowing them to apply and refine their PIF. The consolidated standards of reporting trials (CONSORT) guidelines for Randomized Control Trials were followed to ensure the quality of the study [ 15 ]. Our study is an educational intervention that does not involve any patients or health outcomes and does not fall under the criteria of a clinical trial as defined by the International Committee of Medical Journals Editors (ICMJE) [ 16 ] Therefore, we did not register it in any clinical trial registry.

Ethical approval

was obtained from the Advanced Study Research Board, Khyber Medical University Peshawar, approval number DIR/KMU-AS&RB/EE/002050 meeting held on 31/05/2023, and the Institutional Review Board, Peshawar Medical College, Peshawar, approval number PRIME/IRB/2023 − 532, meeting held on 31/05/2023.

Study design: Effectiveness of empathy portfolios in developing PIF in undergraduate medical students

Sample size and sampling technique

A total of 120 third year MBBS students who had spent at least three months in a hospital setting (clinical clerkships) were included in the study. Stratified random sampling was employed to draw a sample with a probability proportional to the size of the stratum (male and female students) using Open Epi. With a 95% two-sided confidence interval, the sample size for the control and experimental groups was calculated as 60 for each group. A pre-test was taken as a baseline for empathy, using the.

Jefferson Scale of Physician Empathy (JSPE) for Medical Students and Professional Identity Questionnaire (PIQ) for PIF [ 17 , 18 ].

Clinical rotations, normally started in the third year of medical school are a critical shift from theoretical knowledge gained in the classroom to real-world application in healthcare settings. Therefore, during this time, when students are navigating the complexities of patient care for the first time, interventions aimed at developing professional identity, like empathy portfolios, may have a significant impact. Third-year medical students grapple with issues of professionalism, empathy, and their changing role as healthcare providers as they engage more towards the clinical environment. At this point, interventions aimed at helping them develop their professional identities can help set the groundwork for their future practice. Even though third-year students might not have much experience in clinical settings, their involvement in the research offers a chance to evaluate the initial impacts of interventions on the development of professional identities.

Control Group

The control group included 60 medical students who did not maintain their empathy portfolio during the study period. Instead, they followed the traditional routine curriculum without specific empathy-focused activities.

Experimental/trial group

The experimental group consisted of 60 students who were exposed to an educational intervention that included empathy triggers and reflective practices. Participants were introduced to empathy portfolios and given comprehensive instructions on how to use and maintain them effectively. Participants signed the confidentiality agreements as they were informed about the necessity of respecting group boundaries and confidentiality, emphasising the potential impact on the intervention’s success. The randomly selected students were exposed to clinical rotations for the first time, but consideration of empathy triggers and knowledge of PIF was never part of their curriculum. For this reason, previous clinical rotations might have minimally influenced the PIF of participants as a confounding variable.

Data collection procedure

Sixty students of the experimental group participated in a 2.5-hour training workshop where they learned how to create electronic portfolios on Google sites and document guided reflections on experiences that made them feel empathetic. Participants were trained by two experienced facilitators by demonstrating examples of how to collect artefacts (picture/ video/ audio) of any interaction or events that made them feel empathetic and reflect on them. After the workshop, participants were required to maintain their portfolios and record their interactions with patients, colleagues, and healthcare professionals for a duration of three weeks. During post-clinical hours, participants used their user-specific login credentials to access their electronic portfolios and compose guided reflections. Although the risk of potential data contamination was there, user-specific log-ins, along with supervised monitoring and a confidential intervention space served as measures to minimize the risk. Following three weeks of portfolio engagement, the participants again filled out Jefferson’s Scale for Empathy and the PIF Questionnaire post-test using Google Forms.

Instrumentation

Professional identity questionnaire.

Brown et al. created the PIQ (Professional Identity Questionnaire) to measure an individual’s level of social affiliation with a given group. It has been used to assess the level of professional identity among nurses working in several South English hospitals. The questionnaire has ten items that are scored on a 5-point Likert scale from 1 (never) to 5 (often). To guarantee uniformity, items F through J are negatively written, and their scoring is inverted. The PIQ gives a quantitative measure of professional identity by producing a total score. The PIQ has been validated by Daan et al. (2021) as a quantitative measure of professional identity formation among medical students in medical educational settings. Internal consistency analysis showed a Cronbach’s alpha value of 0.82.

Jefferson scale of empathy medical student version (JSPE -Sversion)

The JSPE questionnaire uses a self-report style to test empathy levels. It consists of 20 items scored on a 7-point Likert scale, with 1 being strongly disagree and 7 being strongly agree. The JSPE has a score range of 20 to 140, with higher scores suggesting stronger levels of empathy. The JSPE-S version has 10 items that are positively phrased and pertain to “perspective taking,” whereas the other 10 items are negatively worded and pertain to topics such as “compassionate care” and “standing in the patient’s shoes.” On a Likert scale of 7 to 1, the negatively phrased items were reverse rated. It is worth noting that the JSE-MS was not translated in this study because all participants were fluent in English and had acquired their education in English.

Data analysis

Quantitative data collected from both the pre-test and post-test questionnaires were compiled and organized for analysis. Independent t-tests were performed to determine whether the control and experimental groups differed in terms of mean empathy and PIF scores; paired sample t-tests were used for pre- and post-empathy; and pre- and post-PIF. Pearson’s correlation analyses were used to investigate relationships between pre- and post-empathy and pre- and post-PIF scores. Cohen’s d effect sizes were calculated to measure the effect of intervention.

Participants in the study comprised 120 third year MBBS students. 62.5% ( n = 75) of them were male, and 37.5% ( n = 45) were female. The students who took part in the study ranged in age from 20 to 22 years old, with an average age of 21 years.

The intervention had little influence on empathy and PIF scores, as evidenced by the minor differences and nonsignificant effect sizes (0.32 and 0.36 for empathy and PIF respectively). The study was unable to find statistically significant differences in post-test scores for PIF or empathy between the experimental and control groups or between participants, regardless of gender, as shown in Table 1 .

The Pre-Empathy-Total score showed a strong positive correlation with the Pre-PIF-Total score (0.519), and this correlation was statistically significant ( p < 0.001). Post-PIF-Total showed a strong positive correlation with Post-Empathy-Total (0.395), and this correlation was statistically significant ( p < 0.001). Table 2 is given below.

The current study is the first experimental study to examine the efficacy of an intervention promoting professional identity through empathy portfolios during medical school. One possible explanation for these nonsignificant results could be related to the complexity of Professional Identity Formation. According to Sarraf-Yazdi et al. [ 19 ]. , professional identity in the medical field is influenced by many factors, including personal values, experiences, and role modelling by established professionals. Although a well-intentioned intervention was used, the empathy portfolios might not have adequately addressed all these factors. Moreover, the duration of the intervention may not have been long enough to manifest substantial changes. Research by Fathi et al. (2023) indicated that interventions spanning a more extended period tend to yield more profound effects on professional identity [ 20 ].

The results of this study on the effectiveness of empathy portfolios in developing PIF among medical students offer several important insights. This study revealed slight improvements in the measured variables (empathy and PIF) both before and after the intervention. The results of this study showed that the structured empathy portfolio and routine hospital clerkships did not differ significantly from each other in the development of empathy and PIF. However, the experimental group performed slightly better on empathy and PIF than the control group. Since PIF is a more complex process, a 3-week period may not have been sufficient to demonstrate any significant difference; however, this study provides insight into whether this approach is sufficient to observe any change in empathy or PIF. Furthermore, the nonsignificant differences between the control and experimental groups underscore the importance of considering diverse teaching methods. According to Hookmani [ 21 ], combining empathy training with interactive workshops, reflective practices, and mentorship programs has shown promising results in enhancing PIF. Thus, future interventions might benefit from a multifaceted approach that incorporates various teaching strategies and integrates empathy development into the broader context of medical professionalism and PIF. The lack of gender differences in the outcomes aligns with previous research by Oosterhoff & Yunus [ 22 ], suggesting that gender does not significantly influence the development of empathy or professional identity in medical students. Regarding the second research question, the pre-PIF total score strongly correlated with the pre-empathy total score and post-empathy post-PIF score.

The study by Artioli et al. [ 23 ] showed that interventions incorporating reflective practices, such as journaling and debriefing sessions, can lead to profound self-awareness, skills development, professional growth, empathic attitudes and sensitivity towards emotions.

Given the dynamic nature of identity and the significant impact of informal interactions outside the classroom on PIF among medical students, educational institutions must offer sufficient network and institutional support to develop PIF [ 24 ]. This can be achieved by facilitating casual interactions in diverse learning environments to promote successful transformations.

This study has significant implications for medical education and the professional growth of medical students. The process of self-regulation, known as PIF, is characterized by ongoing and deliberate efforts to manage and influence internal and external influences [ 25 ]. This process necessitates a certain level of motivation to effectively govern the conversation between these factors. Hence, medical schools should have student-centred and individualized learning experiences augmented by reflection. These measures are essential for fostering motivation and facilitating a positive PIF process. Furthermore, medical students need to consider their professional trajectory and current stage of development. Therefore, using a questionnaire to quantify PIF, as implemented in this research, could be a valuable tool for evaluating PIF among medical students.

In summary, although empathy portfolios did not demonstrate significant effectiveness in our study, their investigation provided valuable insights into the complex process of professional identity formation in medical education. By using innovative teaching methods and continually developing educational interventions, educators can better prepare medical students for the challenges and responsibilities of modern healthcare practice.

Strengths and limitations

This study forges the use of empathy portfolios as a tool to help develop Professional Identity Formation (PIF) among medical students. The strength of the study lies in its RCT design, enhancing the credibility of the findings, deepening understanding of the interplay between the constructs, and potentially informing future educational interventions. While the study demonstrates a positive effect of the intervention, the effect size is small. The study’s timeframe of three weeks might underestimate the full potential of the effect of empathy portfolios on PIF as portfolios are typically intended for longer-term use. Conducting the study within a single institution limits the generalizability of the findings. Replicating the study across multiple institutions would enhance the validity of the results. Various measures were adopted to minimize contamination between groups, but the inherent risk of data contamination in a single-institution study remains.

Future directions

Further studies might examine whether more prolonged exposure to portfolios, as recommended, may result in greater effect sizes and whether sustained effects could be observed over an extended period. Future research might also explore the potential difficulties and impediments to successfully integrating empathy portfolios into the medical curriculum.

Data availability

The datasets generated in response to filling the questionnaire are available from the corresponding author on request.

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Acknowledgements

We are thankful to all the study participants, who took part in this study. We are grateful to Dr Mifrah Rauf Sethi, Mr Ehtisham ul Haq and Miss Alia Nosheen for all the support they provided during the process.

This research has received no specific grant from any funding agency in the public, commercial or not for profit organizations.

Author information

Usman Mahboob, Neelofar Shaheen, Bushra Mehboob, Ayesha S Abdullah, Uzma Siddique these authors contributed equally to this work.

Authors and Affiliations

Department of Health Professions Education and Research, Peshawar Medical College, Riphah International University, Peshawar, Pakistan

Munazza Baseer

Institute of Health Professions Education & Research, Khyber Medical University, Peshawar, Pakistan

Usman Mahboob

Neelofar Shaheen

Department of Oral and Maxillofacial Surgery, Peshawar Dental College, Riphah International University, Peshawar, Pakistan

Bushra Mehboob

Ayesha S Abdullah & Uzma Siddique

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MB designed the study, collected the data, and analyzed the data. UM Conceptually designed the study, revised the manuscript, and gave final approval of the manuscript. NS designed the study, analyzed the data and revised the manuscript. BM Substantially reviewed and revised the manuscript. ASA analyzed the data and substantially reviewed and revised the manuscript. US collected and analyzed the data. All the authors read and approved the final manuscript.

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Correspondence to Munazza Baseer .

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Ethical approval was obtained from the Advanced Study Research Board, Khyber Medical University Peshawar, approval number DIR/KMU-AS&RB/EE/002050 meeting held on 31/05/2023, and the Institutional Review Board, Peshawar Medical College, Peshawar, approval number PRIME/IRB/2023 − 532, meeting held on 31/05/2023. Informed consent from the participants was also obtained.

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Baseer, M., Mahboob, U., Shaheen, N. et al. Effectiveness of empathy portfolios in developing professional identity formation in medical students: a randomized controlled trial. BMC Med Educ 24 , 600 (2024). https://doi.org/10.1186/s12909-024-05529-5

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Do we have more empathy for people who are similar to us? New research suggests it's not that simple

by Luca Hargitai, Lucy Anne Livingston and Punit Shah, The Conversation

One recent concept that has become increasingly popular is the "double-empathy problem." This draws on research looking at people who are known to experience social difficulties, such as autistic people.

The theory proposes that people who have very different identities and communication styles from each other—which is often the case for autistic and non- autistic people —can find it harder to empathize with one another . This two-way difficulty is what they mean by the double-empathy problem.

This idea is getting a lot of attention. Research on the double-empathy problem has rapidly grown over the past decade. This is because it has the potential to explain why different people in society might struggle to empathize with one another, potentially leading to personal and societal problems; from poor mental health to inter-group tensions and systemic racism.

But is this idea accurate? Our recent paper suggests that things might be much more complicated than that.

The theory also fails to incorporate the psychological neuroscience of empathy . Instead, it confuses the concept of empathy—that is, psychologically feeling the emotions that other people are feeling—with similar but different phenomena, such as "mentalising" (understanding what people are thinking from a different perspective ).

Double-empathy research has also heavily relied on subjective reports of people's experiences (rather than evaluation by experts), which may not tell the whole story.

This is an important issue that needs urgent attention. There are already signs that the double-empathy theory is being put into practice, despite lacking evidence. Certain researchers and doctors have started claiming that, because there is a double-empathy problem, health care professionals are generally unable to understand their patients with social difficulties. But there is no reliable evidence for this.

Looking ahead, there is a need for more neuroscientific research on social interaction . We expect that brain imaging technologies, such as "hyperscanning" —scanning multiple human brains at the same time—will help shed light on how different people's brains interact with each other. For example, this technique can be used to test how similarity between people who interact may influence their brain activity .

To make breakthroughs in this area, this technique could be used alongside artificial intelligence. Exploring whether machines can truly empathize with humans by seeing if they accurately interpret our brain waves will be of great interest.

The benefits of diversity

This suggests that spending time with people who are different to us can perhaps boost our empathy—something that the double-empathy theory does not predict. Ultimately, empathy is not just down to our ability to understand someone through their similarity. Spending time with those from other social and cultural backgrounds may make us place less emphasis on differences—and discover common ground in other areas.

We could really harness the social science of empathy to understand these incredibly complex social issues. This might ultimately reduce societal conflict and improve social cohesion—but we must get research on the right track to achieve this potential.

Journal information: Psychological Review

Provided by The Conversation

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Do we have more empathy for people who are similar to us? New research suggests it’s not that simple

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Effectiveness of empathy in general practice: a systematic review

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