Chapter 2: Literature Review

Overview of the Chapter

The purpose of this study was to determine the essence of resiliency to compassion fatigue, using paradigms from empathy, emotional contagion, resiliency, and compassion fatigue (CF) theory. The results and implications of the study add to strength- based approaches for avoiding CF. Previous research studies have investigated the risks for developing CF, using a model developed by Figley (2002), shown in Figure 1. Training programs resulting from Figley‘s research focused on ways to avoid the risk factors. Although there are many studies regarding the risk factors for CF, there is little discussion of the interrelation of empathy, emotional contagion, and CF. This literature review presents theories and research regarding empathy, emotional contagion, resiliency, and CF, and discusses the bridges between these factors. The chapter is organized by first discussing theories of empathy, emotional contagion, then CF, and resiliency to CF. The literature review ends with a description of theories of phenomenological research which underlie the methodology chosen for this study.

Search Strategies

Using key words such as empathy and CF, I began finding articles in various databases such as Academic Search Premier. At first I constructed an Excel spreadsheet comparing the bibliographies of leading articles to determine the salient and most frequently cited books and articles. As the number of articles I read grew, I recognized keywords which were most often used, and used these to search for more related literature. These keywords included: burnout, caregiving, emotion regulation, emotional

contagion, empathy, empathic contagion, empathic response, life satisfaction, resilience, secondary trauma, and vicarious trauma. The databases I searched included: Abstracted Business Information (ABI/INFORM) Complete; Academic Search Complete/Premier; Cumulative Index to Nursing and Allied Health Literature (CINAHL) Plus; Education Resources Information Center (ERIC); Health & Medical Complete; Medical Literature Analysis and Retrieval System Online (MEDLINE); American Psychological Association (APA) articles (PsycARTICLES), books (PsycBOOKS), non-peer reviewed scholarly publications, PsycEXTRA, and abstracts (PsycINFO); and sociological professional publications (SocINDEX). I also searched the database of dissertations and theses. In the next sections I discuss the theoretical foundations of empathy, emotional contagion, CF, and resiliency, based on my literature search.

Conceptual Framework

The current model of CF, based on Figley‘s (2002) theory, includes many facets: empathic ability, response, and concern; exposure to clients; degree of life disruption; and traumatic memory. In Figley‘s model being empathic is key to developing CF. This literature review therefore presents theories of empathy such as theory of mind (ToM), simulation theory, mirror neuron theory, as well as neuropsychological bases of empathy. Studies of negative emotional contagion are also presented, indicating its impact in development of stress, depression, and risk for CF. An interpretative or constructivist view of social reality ([Bennett, 1998b; LeCompte & Schensul, 1999a](/dissertation/references)) underlies this study. This point of view emphasizes the importance of knowledge based and maintained on social interaction and reinforcement.

In other words, the phenomena of CF and resiliency to CF arise from interaction between an HCP and patients, coworkers, supervisors, and social contacts. The paradigm of positive psychology based on Seligman (2008) then investigates the phenomenon of resiliency to CF, rather than risk factors, and looks at strength-based approaches to resolving problems. Using Bonanno‘s model of resiliency, and its expansion ([Linley & Joseph, 2005](/dissertation/references)) as another conceptual model, I explored the literature.

Empathy, Part of Compassion Fatigue

Many people are attracted to the healthcare profession due to their empathy and compassion. Unfortunately these abilities, if unsupported, may lead to CF ([Figley, 1995, 2002; Hofmann, 2009; Sabo, 2011](/dissertation/references)). The diverse definitions for empathy, sympathy, and compassion make understanding difficult about how these traits are involved in CF. There is little research to indicate how a person can be empathic or compassionate and resilient to CF. When I informally asked psychologists at a Vancouver, BC 2011 conference about CF and their thoughts about what led to it, many responded as Hofmann (2009) indicated: ―Few healthcare professionals are immune to compassion fatigue‖ (p. 40). New research in psychoneuroimmunology and mirror neurons provides evidence of links between empathy and emotional contagion, and between emotional contagion and CF. Until recently, studies of empathy examined the trait as a social interaction and cognitive skill, with little understood about the biopsychological factors involved. The first physiological theory of emotion, posited by Darwin in 1872 ([Stone, 2006](/dissertation/references)), led to other theories of emotion, from which current theories of biopsychological bases for

empathy have emerged. Appraisals of empathy deficits in people with psychiatric disorders, or brain lesions, as well as brain imaging studies of healthy volunteers, provide evidence that the empathic response system is a complex network using both hemispheres of the brain, and involving more than the amygdala and orbitofrontal cortex ([Shamay- Tsoory, 2011](/dissertation/references)). Before brain imaging was available, most psychologists defined empathy the understanding, even experiencing, of another‘s reactions, emotions, intentions, based primarily on cognitive processes ([Rizzolatti, Fogassi, & Gallese, 2006](/dissertation/references)). The individual empathic response, the knowingness of someone else‘s emotional state, seems to happen with such rapidity and such certainty ([Wolf, Gales, E. Shane, & M. Shane, 2001](/dissertation/references)) however, other processes than cognition must play a part ([Rizzolatti et al., 2006](/dissertation/references)). A broad range of definitions have been proposed for empathy. A recent popular definition of empathy is the ability to see through someone else‘s eyes, to experience another person‘s reality ([Bennett, 1998a; Jahoda, 2005](/dissertation/references)). Various types of empathy may exist, leading to two major theories underlying research: (a) cognitive empathy based on theory of mind (ToM), and (b) affective empathy, based on mirror neurons and simulation ([Langdon, Coltheart, & Ward., 2006](/dissertation/references)). Meta-analysts and theory integrationists propose that numerous areas of the brain are active in empathic response, with linkage and mediation at many points ([Oberman & Ramachandran, 2007; Ramachandran, 2011; Seitz, Nickel, & Azari, 2006; Shamay-Tsoory, Tomer, Goldsher, Berger, & Aharon- Peretz, 2004](/dissertation/references)). Levels of human empathy have a normal distribution, with variance between individuals and within each individual, as seen particularly in people experiencing post- 14 traumatic stress disorder, or burnout. Lack of empathy has been noted in certain groups of people: people having autism spectrum disorders ([Dapretto et al., 2006; Oberman & Ramachandran, 2008; Soderstrom, 2003](/dissertation/references)); Tourette‘s syndrome, disruptive behavior disorders, various other psychopathic and personality disorders ([Soderstrom, 2003](/dissertation/references)); schizophrenia ([Langdon et al., 2006; Shamay-Tsoory, Shur, Harari, & Levkovitz, 2007](/dissertation/references)); and in various types of brain lesions ([Shamay-Tsoory et al., 2003; Shamay-Tsoory, Tomer, Goldsher, Berger, & Aharon-Peretz, 2004](/dissertation/references)). Why these groups of people might have empathy deficits may be understood when compared to Feshback‘s definition of empathy: the capacity to: (a) identify another‘s affective cues; (b) assume the perspective and role of the other; and (c) experience and express emotions, or have affective responsiveness ([as paraphrased by Langdon et al., 2006, p. 135](/dissertation/references)). If empathy were totally based on audio or visual cues, one might expect people with visual or auditory impairments to have empathy deficits, but this is not the case ([Clark, Wantz, & Brey, 2005; Griffin-Shirley & Nes, 2005](/dissertation/references)). Appendix G explores the research and theory on the evolution and development of empathy. Examination of empathy as a social experience of shared states of mind, an internal recollection of similar experiences and mental images, gave rise to theory of mind (ToM) and theory-theory ([Oberman & Ramachandran, 2007](/dissertation/references)). Both ToM and theory-theory focus on the cognitive components and linkages in the brain. Examples are: the temporal region, for access to knowledge of past experience; the superior temporal sulcus, providing information about observed behavior; and the medial prefrontal cortex,

linking cognitive information to affective areas ([Frith, as cited in Seitz, Nickel, J & Azari, 2006](/dissertation/references)).

Theoretical Bases of Empathy

Theory of Mind (ToM). Cognitive and developmental psychologists for decades have studied how humans learn to make analogies between one‘s own experience and observation of another‘s experience, infer the other‘s mental state, and attune one‘s own behavioral response to the situation ([Shamay-Tsoory et al., 2004](/dissertation/references)). Early proponents of ToM were Humphrey in 1976, Premack and Woodruff in 1978, followed by Avenanti, Frith, and Singer. The ToM explanation for empathy is that a person understands another‘s beliefs and intentions in order to predict, explain, and react to the other‘s behaviors. This capacity would include basic social perception skills, such as recognizing facial expression, tone of voice and gestures, as well as retaining cognitive flexibility to change one‘s behavior accordingly ([Langdon et al., 2006](/dissertation/references)). Theory-theory (TT), one type of ToM, has been supported by behavioral observations of children who, by the age of three, seem to have developed a theory of how other people think or will react ([Johnson, Filliter, & Murphy, 2009; Zahavi, 2010](/dissertation/references)). Observed children in several studies seemed to test and interact in an exploratory way, rather than accepting a parent‘s logical definitions, trying to develop a fuller explanation of the objects, including humans, with which they interact ([Johnson et al., 2009](/dissertation/references)). TT varies in concept, depending on which theory-theorist speaks ([Krueger, 2009](/dissertation/references)). Gordon and Hobbs (2011) indicated that a clear definition was needed for the commonsense theory of the mind-body interaction.

Simulation theory. The empathic understanding of human action, emotion, and internal state, according to the simulation theorists, is based on the combined ability to perceive others as if they were ourselves, and simulate these observations into our own neurological systems ([Oberman & Ramachandran, 2007, 2008](/dissertation/references)). Empathy theorists who criticize simulation theory emphasize the difference between perception when one uses one‘s own experience as reference point, and perception through the other person‘s point of view. Milton Bennett (1998a), for example, pointed out that sympathy is when one feels emotion for the other person based on one‘s own experience and a single universal reality. In contrast, empathy embraces the concept of multiple realities, and the other person‘s perception and experience. In simulation theory understanding actions, thoughts, and emotions in others has the same biopsychological bases as for processing and executing similar actions, thoughts, and emotions ([Oberman & Ramachandran, 2008](/dissertation/references)). Multimodal neurons. initially called emulators, a term from motor control research, function as receptors of efferent copies of motor commands. These emulators, now more commonly called mirror neurons ([Rizzolatti & Craighero, 2004](/dissertation/references)), produce simulation of the sensory signals in the same manner as if actual sensorimotor neurons were activated, theoretically aiding in prediction of others‘ behavior, with appropriate motor response. From an evolutionary point of view, this chain of reaction has been critical for survival ([Iacaboni, 2008](/dissertation/references)). ―Imitation has a central role in human development and learning of motor, communicative, and social skills‖ ([Iacoboni et al., 1999, p. 2526](/dissertation/references)).

Emulator cells were first discovered by Rizzolatti and his colleagues at the University of Parma in the early 1990s in their research using macaque monkeys to study the sensorimotor system, observing the F5 cortical area associated with hand and mouth movements ([Iacoboni, 2008; Iacoboni et al., 1999; Rizzolatti & Craighero, 2004; Rizzolatti, Fogassi, & Gallese, 2006](/dissertation/references)). They called these multimodal cells mirror neurons due to comparable activity during both action and the observation of the action. Because, according to their theory, imitation has some need for acquisition of language, this research group and other simulation theorists used brain scanning technology to examine Broca‘s area, a primary language center in the human brain. They found confirmation: activated mirror neurons ([Rizzolatti et al., 2006](/dissertation/references)). Barsalou, in 1999, developed a perceptual symbol system (PSS) theory, an expansion on simulation theory ([Barsalou, 2010](/dissertation/references)). PSS is based on what Barsalou called conjunctive neurons. These neurons receive efferent copies of input from cognitive sources, such as proprioception and introspection, and from all senses, not just sensorimotor. This input is retained in memory, a data bank on which empathy draws. In the PSS theory, simulators are networks of conjunctive neurons, which activate in clusters for each category, allowing inferences to be made ([Oberman & Ramachandran, 2007; Seitz, Nickel, & Azari, 2006 ](/dissertation/references)). Barsalou‘s PSS theory, according to some psychologists, provides a ―unified theory for how humans interpret and interact with their environment‖ ([Oberman & Ramachandran, 2007, p. 311](/dissertation/references)).

Biopsychological Factors of Empathy

There is no single, universally accepted definition of human empathy, as noted above. It may take stepping into a higher plane of consideration of all recent empathy studies, with integration of significant findings and thought. Researchers, desiring to know which areas of the brain are key components of the empathic response and how these might be linked, have studied people showing empathy deficit due to psychiatric disorders or lesions of specific brain areas. The interwoven historical nature of philosophy and psychology has been abundant in neuropsychological studies of empathy where the search for the physical loci of the empathic response within the human brain has not been unlike the ancient exploration for the location of the soul within the human body ([Iacoboni, 2007](/dissertation/references)). Proponents of ToM focus on ways to support their philosophical stance, as do those investigating simulation theory and mirror neurons ([Gallese, 2007a, 2007b](/dissertation/references)). As for adoption of an integrated theory of biopsychological factors of human empathy, an expanded model for simulation theory, which gives attention to both cognitive and affective empathy, seems of highest value. Simulation theory, for example, explains how both parity (the meaning of the message being the same for both receiver and sender) and direct comprehension (no previous agreement between receiver and sender) can occur during an empathic interaction ([Rizzolatti, Fogassi, & Gallese, 2006](/dissertation/references)). In reviewing the different studies presented here, researchers may need to pay more attention to meta-analyses, and interlink research of all concepts of empathy— anthropological, developmental, evolutionary, sociological, cognitive, and emotional. The closest to this model is the work being done in Israel by Shamay-Tsoory and

colleagues who have been examining empathy deficits in patients with brain lesions ([Shamay-Tsoory, 2011](/dissertation/references)), research by Singer and colleagues in Great Britain ([Lamm, Decety, & Singer, 2011](/dissertation/references)), and by Ramachandran and colleagues in the United States ([Ramachandran, 2011](/dissertation/references)). Researchers using brain scanning technologies critique each other‘s findings, and when differences occur, they speculate about the differing levels of observation possible, depending on what scanning device was used, how it was used, what stimuli were used, and how these stimuli were used ([Shamay-Tsoory et al., 2003, 2004; Singer & Frith, 2005; Singer et al., 2006; S. Smith, 2007b](/dissertation/references)). Because of the need to focus the scanning technology on selected areas of the brain where the researchers expect empathic activation, it is difficult to develop a composite picture Researchers such as Silbert, Gibbons, Cash, Mastaglia, and Thickbroom (2011) have demonstrated the neuroplasticity of human systems, including the possibility for multimodal neuronal systems to be trained for new functions, and adult neurogenesis ([Adams, 2001; Curtis, Kam, & Faull, 2011](/dissertation/references))). As a result, it may be possible, with intense clinical intervention, to develop empathic responses where deficits now exist ([Wolf et al., 2001](/dissertation/references)). The mirror neuron system is tuned by values and biases, and is itself plastic ([Wolf et al., 2001; Iacoboni, 2008](/dissertation/references)). Research based on studies of patients with brain lesions. Because of prior identification of areas significant to executive functioning and other cognitive processes, sensorimotor, or affective processing, the first areas considered biopsychological sites for empathy were the ventromedial (VM), dorsolateral (DLC), and orbitofrontal (OFC)

regions of the prefrontal cortex ([Shamay-Tsoory et al., 2003](/dissertation/references)). Because the right hemisphere has a significant role in processing emotional and social information, it was assumed it would have a large impact on empathic response, if not be the actual seat of empathy. Various researchers, such as Adolphs, Borod, Damasio, and Shamay-Tsoory, had shown patients with right hemispheric lesions had impairment in recognition and expression of facial expression, affective prosody, mental representation of others‘ mental states, and other components of ToM, so specific right hemispheric areas were targeted for empathy deficit correlation ([Shamay-Tsoory et al., 2004](/dissertation/references)). Shamay-Tsoory and colleagues (2003, 2004) confirmed that although prefrontal structures are important for the empathic response, both hemispheres are involved, perhaps having different functions. The 2003 study by Shamay-Tsoory et al. tested three groups for empathic level: 25 people with acquired, localized lesions in the prefrontal cortex (PFC); 17 people with posterior cortex (PC) lesions; and 19 healthy controls. Prior research, such as Eslinger‘s 1988 study, indicated patients with prefrontal lesions might have impaired empathy, such as loss of self-awareness, loss of insight, impaired judgment about others, and impaired decision-making based on cognitive and emotional processing ([Shamay- Tsoory et al., 2003](/dissertation/references)). Assessments of emotional processing, overall level of intellectual functioning, depression, cognitive empathy and emotional empathy were made, using a battery of psychometric tests adapted for Israeli use. Shamay-Tsoory and colleagues discovered a significant relationship between empathy levels, cognitive performance, and specific regions of the prefrontal cortex. Damage to the frontal regions of both hemispheres was correlated, in addition to expected

empathy deficits, to impaired abstract interpretation and indirect communication. Lesions in the right PFC led to loss of the ability to mediate empathy and express an appropriate response ([Shamay-Tsoory et al., 2003](/dissertation/references)). Patients with VM damage were the most significantly impaired, having deficits of emotional tone, recognition of expression, and ToM task performance, but no impairment in cognitive flexibility, the ability to solve new problems with existing knowledge ([Shamay-Tsoory et al., 2003](/dissertation/references)). Lesions of the OFC region corresponded with losses in mediation of empathy, and emotionally related learning. There were empathic deficits (e.g., lowered ability in cognitive flexibility) in patients having DLC lesions, but not as severe as those with OFC lesions. Differences in the two hemispheres were apparent, but only in comparison of the posterior regions of the PFC—no empathy deficits were observed for patients having lesions in the left PC, but deficits in mediation of empathy and expression of response were seen in patients with right PC lesions ([Shamay-Tsoory et al., 2003](/dissertation/references)). Their conclusion was that the right hemisphere does play an important role in mediation of empathy, as it seems to contain the essential components of systems specialized in emotion processing. All patients with right hemisphere lesions had decreased empathy levels, with the most severely impaired having lesions within the right frontal structures. This coincides with the finding that the right frontal lobe is critical for choosing appropriate emotional response for situations, part of cognitive empathy. The right VM region connects affective information from somatic states with cognitive information in decision making, so damage to this area impairs the convergence zones,

leading to nonintegration of the emotional and cognitive facets of the situation. ―A subject with ventromedial damage may understand a social interaction but might fail to comprehend the emotional outcome of this interaction and as a result respond inappropriately to a given situation, thus displaying lack of empathy‖ ([Shamay-Tsoory et al, 2003, p. 333](/dissertation/references)). As a result of the 2003 research study, Shamay-Tsoory and colleagues suggested that: (a) the posterior right hemisphere processes affective information; ( b) the right PFC retrieves past personal events; (c) the DLC is a convergence area, and mediates executive functions such as cognitive flexibility; and (d) the bilateral VM region is the integration point for these processes with input from other brain areas, such as the amygdala and autonomic nervous system ([Shamay-Tsoory et al., 2003](/dissertation/references)). In a subsequent report (2004), the Shamay-Tsoory research group suggested that empathic ability is mediated by distributed circuits. The 2004 study examined three groups: 36 people with frontal lesions (30 men and 6 women); 16 with posterior lesions (10 men and 5 women); and 19 healthy controls (15 men and 4 women), with an average age of 36.5. The people with posterior lesions were separated into groups having damage in either left or right hemisphere, inferior or superior parietal regions. Testing was conducted at least six months after the brain trauma or surgery, at what is considered the chronic phase of recovery ([Shamay-Tsoory et al., 2004](/dissertation/references)). As in the earlier study, a battery of tests was administered to the 70 participants, using Hebrew versions when appropriate; assessments were made of cognitive empathy, emotional empathy, neuropsychology, and cognitive flexibility. The lesion area where empathic deficits were most severe was the

orbitomedial right prefrontal cortex. This region connects with areas of striatum, mediodorsal thalamus, and limbic structures, therefore impacting both cognitive and affective empathy, as well as the mediation and integration of empathic processes with input from other parts of the brain ([Shamay-Tsoory et al., 2004; Shamay-Tsoory et al., 2007](/dissertation/references)). Empathy deficits were not seen in patients having left PC lesions, but were found for those with left PFC lesions, confirming findings in the earlier study regarding the left and right posterior cortex. Lesions in the right parietal cortex correlated with impairment in being able to identify with others. As before, they found lowered affect processing and social cognition skills in patients having lesions in the right hemisphere. Deficits in episodic retrieval, choice of appropriate emotional response, expression of mood, and tone of mood expressed, occurred for patients with lesions in the right PFC ([Shamay- Tsoory et al., 2004](/dissertation/references)). The wide array of neuropsychological tests led to additional insights about empathy. Significant correlations were seen between cognitive and affective empathy scores for all three groups, but affective empathy was related to only two measures of affect recognition (surprise and sadness). Other emotions, such as happiness or anger, seemed unrelated to affective empathy. Cognitive empathy seemed to rely on executive functions mediated by the dorsolateral PFC. This research group concluded that empathy is a multicomponent mix of cognitive and affective neural mechanisms, and suggested that further study validating these results should be done using empathy assessment in real-life situations ([Shamay-Tsoory et al., 2004](/dissertation/references)).

Research using brain scanning technology. In our evolution it has been critical to be ―attuned to the intentional relations of others‖ ([Gallese, 2007b, p. 131](/dissertation/references)). One of the earliest indications for a neurophysiologic basis for human empathic response was an electroencephalographic (EEG) study by Gastuat and Bert in 1954, which reported neural activity in the sensorimotor cortex when participants observed others performing specific actions ([Oberman, Pineda, & Ramachandran, 2007; Oberman & Ramachandran, 2007](/dissertation/references)). Since then researchers have used brain scanning technology to understand the biopsychological bases for empathy. In 1992, at the University of Parma, Rizzolatti and colleagues were using EEG to study the premotor cortex associated with hand and mouth movements in macaque monkeys, when they discovered the visuomotor neurons in area F5 firing at the perception of someone else‘s action ([Iacoboni, 2008; Rizzolatti & Craighero, 2004](/dissertation/references)). By accident, as the story is told, when the macaque under observation saw a researcher reach for a raisin, the EEG monitor indicated neurons firing in the inferior parietal lobule and the F5 area, the same areas activated when the macaque picked up and ate a raisin ([Iacoboni, 2008](/dissertation/references)). This observation led to further studies of the multimodal emulator neurons in monkeys, and in humans ([Rizzolatti & Criaghero, 2004](/dissertation/references)). In 2000 Wolf and colleagues wrote about the role mirror neurons may have in procedural learning, one of a number of articles at the beginning of this century embracing the concept of mirror neurons within humans ([Iacoboni & Dapretto, 2006; Wolf et al., 2001](/dissertation/references)). Functional MRI has been used to reinforce the mirror neuron theory ([Iacoboni & Dapretto, 2006](/dissertation/references)). Even

so, there are neuroscientists who do not accept this explanation of mimicry in humans ([Hickok, 2009; Rogalsky, Love, Driscoll, Anderson, & Hickok, 2011](/dissertation/references)). In 1992 neuroscientists Hanna Damasio and Thomas Grabowski, using neuroimaging technology and knowledge of neuroanatomy, investigated the landmark neurologic puzzle presented by Phineas Gage. With engineering assistance from Randall Frank, they digitally reconstructed Gage‘s brain in three dimensions from images ([Damasio, 1994](/dissertation/references)). The history of the Gage case is dramatic. Before his accident, Gage was a healthy, well-balanced, and respected man. An explosion sent an iron bar into Gage‘s left check, piercing the base of his skull, and exiting the top of his cranium to fall 100 feet away. After the accident, he seemed to have no disability in body or mind, but his emotional system was changed radically: he became unreliable, profane, and impulsive ([Damasio, 1994](/dissertation/references)). Damasio and colleagues found that ―selective damage to the prefrontal cortices . . . [had] compromised his ability to plan for the future, to conduct himself according to the social rules, . . . and to decide on the course of action . . . most advantageous to his survival‖ ([Damasio, 1994, p. 33](/dissertation/references)). Biopsychologists and other neuroscientists generally use three brain scanning technologies to determine functionality of specific areas of the brain—functional magnetic resonance imaging (fMRI), positron emission tomography (PET), and transcranial magnetic stimulation (TMS)—while the effects of stimuli on emotion, cognition, or behavior, including empathic response, are assessed ([Simon-Dack, Rodriguez, & Teder- Sälejärvi, 2008](/dissertation/references)). Functional MRI measures increased oxygen flow to activated areas; PET measures accumulation of radioactive 2-deoxy-glucose or

radioactive water in various areas of the brain; and TMS creates a magnetic field which temporarily disrupts activity in targeted areas ([Simon-Dack et al., 2008](/dissertation/references)). These scanning methodologies have been used to show that mirror neurons exist in humans ([Rizzolatti & Craighero, 2004](/dissertation/references)). One of the first studies to localize where simulator neurons might reside in human brains was in 1995 when Fadiga, Fogassi, Pavesi, and Rizzolati used TMS to observe neuronal activity in the premotor cortex while participants watched others‘ actions ([Rizzolatti & Craighero, 2004](/dissertation/references)). They determined Brodmann‘s area 44/45 (also called Broca‘s area) corresponded to the macaques‘ F5 area. The following year Grafton and colleagues (1996) used PET scanning to monitor participants observing pantomimed motions, which activated both parietal areas, more in the right hemisphere than the left ([Oberman & Ramachandran, 2007](/dissertation/references)). The parietal region is considered important in being able to identify with others. Decety and colleagues, in 1997, again used PET scan to observe neuronal activity when pantomimed motions were observed, this time finding activity in the left inferior frontal lobe (Broca‘s area 45), where understanding meaning of others‘ expression and actions may occur ([Decety, 2010; Decety & Ickes, 2009; Oberman & Ramachandran, 2007](/dissertation/references)). Iacoboni et al. (1999) used fMRI to scan the left frontal operculum (Broca‘s area 44), the right anterior parietal region, and right parietal operculum while participants observed or executed simple finger movements. Three observation conditions, and three observation-execution conditions, using imitative and nonimitative behaviors, were compared. During all three observation tasks, activity was present in the left frontal operculum, and right anterior parietal region, but not in the right parietal operculum.

When imitative execution occurred, all three areas were activated, leading to the conclusion that Broca‘s area 44 and the right anterior parietal cortex have imitating neuronal mechanisms ([Iacoboni, 2008; Iacoboni et al., 1999](/dissertation/references)). Subsequent mirror neuron system (MNS) and simulation studies found other brain areas involved, as well confirming earlier results. Wicker, Keysers et al., (2003) used fMRI to investigate which areas were activated when the participant showed disgust from smelling something noxious, or observed the reaction in someone else. They found the anterior insula, and to a lesser amount, the cingulate cortex were implicated. The following year Keysers, Gallese and colleagues used fMRI to study MNS activated locations during the experience or observation of being touched ([Gallese, 2007a](/dissertation/references)). They discovered that the secondary, but not primary, somatosensory cortex was activated ([Gallese, 2007a, 2007b](/dissertation/references)). The secondary somatosensory cortex (S2) is a functionally defined region adjacent to the primary somatosensory cortex (S1). Research studies have found S2 cells are activated for the stimuli of light touch or tactile attention, visceral sensations, and for pain ([Eickhoff, Schleicher, Zilles, & Amunts, 2006](/dissertation/references)). Avenanti, Bueti, Galati, and Aglioti (2005), interested in the cognitive and neurophysiological correlates of empathy to perceived pain and experienced pain, used single-pulse TMS to assess the results of stimuli applies to hands or feet. Before Avenanti‘s 2005 study, only three studies (with fMRI) had been used to explore the neurophysiology of human empathy for pain: Decety and colleagues, Singer and colleagues, and Morrison and colleagues. In the Avenanti et al. 2005 study, volunteers sat in front of a video monitor showing: first, a needle inserted into a muscle in the right

hand of an unknown person (a model) while motor-evoked potentials (MEPs) were monitored from the observer‘s same muscle; second, the same area on the model touched using a Q-tip; then a similar pair of experiments using the model and observer‘s right feet. A fifth experiment used a TMS pulse on the left motor cortex while the participant watched the video, with a post-scan battery of tests for sensory and affective reactions, as well as personal distress and empathic concern. An important part of the post-scan measurements were visual analog scales which measured what the researchers termed state empathy, whether self-oriented (how much the participant simulated the pain; how much aversion the participant had to the observation), or other-oriented (how intense the other‘s pain seemed; how much compassion the observer had for the other). The results for the first experiments were negative correlations between amplitude changes in MEPs in the corresponding muscle with McGill Pain Questionnaire (MPQ) sensory ratings for the model, but no significant correlation with affective qualities of the other‘s pain. During the TMS pulse study, the same correlations were seen ([Avenanti et al., 2005](/dissertation/references)). Additional studies by Jackson and Morrison that same year confirmed these results ([Decety & Jackson, 2006](/dissertation/references)). Singer and Frith (2005) used fMRI in studying empathy of pain, looking for physiological correlates for ToM and other types of cognitive empathy. They concluded that there was shared empathic activity in the affective pain network (including the anterior cingulate cortex and anterior insula), but not in the primary somatosensory cortex. This led them to think empathy for pain involved affective, not sensory components of the pain system, and deduced that ―empathy is associated with activity in

regions concerned with the unpleasantness of the pain rather than with its precise sensorimotor qualities‖ ([Singer & Frith, 2005, p. 845](/dissertation/references)). In this study, while the participant‘s brain was scanned, the person watched a video display (a symbolic arrow) whenever the person‘s partner, who sat next to the observer, received a painful stimulus. The study confirmed the 1981 findings by Roland, who claimed somatotopically organized sensorimotor activity could be elicited by simply paying attention to a body part about to be touched. Therefore mental attitude was one of the likely factors of empathy ([Singer & Frith, 2005](/dissertation/references)). Singer and colleagues in Great Britain also were interested in learning how the brain‘s empathic response is modulated by the affective link between individuals, or influenced by cultural bases or learned preferences ([Lamm, Decety, & Singer, 2011](/dissertation/references)). In one study, 32 participants each played an economic game, Prisoner‘s Dilemma, while two confederates in a separate room played either fairly or unfairly against them ([Singer et al., 2006](/dissertation/references)). Afterward, each participant‘s brain activity was scanned using fMRI, with the two confederates sitting on each side of the scanner. While the participant watched, the confederates received what the participant thought was low or high levels of electronically delivered pain. Each session had ten trials for each of six conditions (pain or no pain, in context with delivery to self, the person who played fairly, or the one who played unfairly). After the scanning session, each participant completed a Davis empathy scale, rating the intensity of pain to self and to others, the likability of each of the confederates, and the participant‘s desire for revenge ([Singer et al., 2006](/dissertation/references)).

For both male and female participants, when a person they considered a fair player was ―shocked,‖ there was activity in the frontoinsular and anterior cingulate cortices. This was considered an empathic response to perception of the other player‘s pain. When the player was considered unfair, this response This effect was accompanied by increased activity in the reward-related areas of the brain, showing significant correlation with the observer‘s expressed desire for revenge. These same areas of the brain were also activated when the participant experienced pain, not simply observed it ([Singer et al., 2006](/dissertation/references)). Rizzolatti, Fogassi, and Gallese (2006) summarized their own and others research, beginning with a description of the original accidental discovery of the MNS in the macaque monkey, leading to their own research on biopsychological bases for empathy in humans. Using PET scans while participants were shown different hand movements and grips, the researchered discovered significant results in three cortical areas: the superior temporal sulcus (STS), known to contain neuron responders which activate when a person observes others‘ moving various parts of the body; the inferior parietal lobule (IPL), which corresponds to the monkey‘s IPL; and the inferior frontal gyrus (IFG), which corresponds to the monkey‘s ventral premotor cortex, including the F5 area. Their research in human empathy continues to explore how mirror neurons play a role in understanding others‘ actions rather than just registering it visually or auditorily ([Rizzolatti et al., 2006](/dissertation/references)). Seitz, Nickel, and Azari (2006) performed a meta-analysis of 80 studies reporting neural correlates of human empathy, and concluded there are six spatially distinct

activation clusters, specifically active during empathic response, in the medial part of the frontal lobe, dorsal to the intercommissural plane, the most dorsal cluster coincident with the left supplementary motor area. The specific location of the six clusters, and the apparent function of each, are:  Left supplementary motor area: attention to action.  Right presupplementary motor area: self-referencing of action.  Left superior dorsomedial area: attention to sensation.  Left mid-dorsomedial area: recognition of alternative actions.  Right mid-dorsomedial area: valuation of thought.  Left anterior dorsomedial area: valuation of types of observed behaviors ([Seitz et al., 2006](/dissertation/references)). In summary, Seitz and colleagues suggested there are a number of cognitive empathy activation areas outside the superior frontal or cingulate gyrus, in other cortical areas of frontal, parietal, and temporal lobes, as well as the amygdala. The model of empathy they used seems limited to ToM and other cognitive empathic functions, such as introspection, understanding others‘ behavior, and valuation of types of observed behaviors. Empathic Response and Emotional Contagion

Emotional Contagion Compared to Empathic Response

Empathy consists of three parts: emotional empathy (also known as emotional contagion), cognitive empathy (ToM and TT explanations of our ability to take another‘s perspective), and self-distinction from the other ([Decety & Jackson, 2004; Hatfield,

Rapson, & Le, 2009; Shamay-Tsoory, 2011](/dissertation/references)). If cognitive empathy and the ability to be self-aware are absent or lowered, negative emotional contagion can lead to distress, and develop into CF and the inability to help ([Fabes, Eisenberg, & Eisenbud, 1993](/dissertation/references)). One definition of empathic response, based on simulation theory, is the physical mirroring of another‘s physioemotional state, which happens without thought ([Iacoboni, 2007](/dissertation/references)). Understanding feelings, emotions, and physical reactions within empathy requires awareness of the neural and endocrine systems needed for both detection and response to bodily states ([Carter, Harris, & Porges, 2009; Porges, 2007](/dissertation/references)). Empathy, emotional contagion, and CF therefore can be viewed in terms of adaptive neuroendocrine and autonomic processes. Emotional contagion theory concerns the automatic and unconscious transferring of emotions from one person to another. This includes subjective feelings, expressions, emotional appraisal as well as patterns of physiological processes. Social information processing involves embodiment ([Niedenthal, Barsalou, Winkielman, Krauth-Gruber, & Ric, 2005](/dissertation/references)). The underlying mechanism of primitive emotional contagion is essentially pre-attentive and unconscious Hatfield, Cacioppo, & Rapson, 1992, 1994; Rothschild, 2006). The somatic aspects of emotional contagion may become part of CF with the psychoneuroimmunological implications of stress and emotional overload.

Psychoneuroimmunological Factors of Emotional Contagion

Hatfield, Cacioppo, and Rapson (1992, 1994) were early researchers into emotional contagion and its components, and defined it as the tendency to mimic and synchronize expressions, postures, gestures, and movements with someone else, and

―consequently, to converge emotionally‖ ([Hatfield et al., 1992, p. 154](/dissertation/references)). This can happen through telecommunication (e.g. chat-rooms), as well as in person, and can occur within a group, where individuals pick up the mood of others ([Bartel & Saavedra, 2000](/dissertation/references)). The parts of the nervous system which activate synchrony and mimicry are involved in emotional contagion, giving feedback to the receiver of the situation, as well as helping to define self-perception within the situation ([Hatfield et al., 1994](/dissertation/references)). Research suggests that the MNS is implicated in emotional contagion, as well as empathic response ([Iacoboni, 2008](/dissertation/references)). Explicit emotional contagion can occur as a result of someone‘s intention of persuasion, or to alleviate negative feelings, as well as intention to influence ([Kelly & Barsade, 2001](/dissertation/references)). Implicit emotional contagion, on the other hand, is less conscious, and relies primarily on nonverbal communication ([Hatfield et al., 1992, 1994; Rothschild, 2006](/dissertation/references)). Individual differences exist in response to positive and negative stimuli. In most cases, however, negative events tend to activate quicker and more intense emotional, behavioral, and cognitive responses, compared with neutral or positive events, leading to negative neural responses typical of negative emotions ([Barsade, 2002](/dissertation/references)). An interesting study by Hietanen (1998) studied facial electromyographic (EMG) responses to angry voices compared with contented voices, and found that anger elicited behavioral withdrawal responses, and increased EMG activity in the subjects‘ brow region. This supported the theory of emotional contagion occurring just from hearing emotion expressed vocally by another human. In any case, emotional contagion is more likely to

occur when attention is allocated to the other person or group ([Barsade, 2002; Hatfield et al., 1992, 1994](/dissertation/references)).

Individual Differences of Emotional Contagion

Cultural as well as individual differences exist in people‘s vulnerability to emotional contagion ([Rothschild, 2006](/dissertation/references)). Western cultures based on individuality generally allow greater freedom in overt expression of negative emotions, compared to community-based Asian cultures ([Matsumoto & Kupperbusch, 2001](/dissertation/references)). In addition, women from Western cultures have more emotional expression freedom. Women generally score higher on empathy, social sensitivity, and emotional recognition tests than men ([Chakrabarti, Bullmore, & Baron-Cohen, 2006; Schulte-Rüther, Markowitsch, Shah, Fink, & Piefke, 2008](/dissertation/references)). The Schulte-Rüther et al. (2008) study used fMRI to investigate gender differences in an emotion attribution task. During cognitive processing related to self, women activated more neural activity in the left temporoparietal junction than men. The data suggested that women elicited higher mirror neuron activity than men, which may underlie increased female vulnerability to emotional contagion. Although men and women‘s outward indication of experiencing negative emotions may vary widely, it is possible that the internal experience of emotion is much more similar between genders, and has similar amplitudes of physiological and psychological arousal ([Rothschild, 2006](/dissertation/references)). Supporting this view, the Lamm, Decety, and Singer (2011) meta-analysis found no consistent gender differences across all 32 studies which used fMRI to investigate empathic pain.

Conscious cognitive processes also can cause individual differences, due to varying degrees of openness to receiving or being aware of emotions. Hatfield and colleagues (1994) delineated six factors of individual susceptibility to emotional contagion: 1. The observer gives attention to the person(s) experiencing emotion. 2. The observer feels some type of connection with the other person or group. 3. The observer is able to mimic and simulate frequently during interpersonal interactions. 4. The observer has ability in reading facial, nonverbal and verbal expressions. 5. The observer has ability to detect his or her own internal states. 6. The observer is particularly reactive to his or her own emotions and feelings. Personality (e.g. being a sensitizer or a repressor), psychological stress loads, as well as physiological differences (e.g. having less mirror neurons than normal) can affect vulnerability to emotional contagion ([Hatfield, 1994](/dissertation/references)).

Psychological and Neurophysiological Bases of Emotional Contagion

Psychological bases. A recent Swedish study ([Lundqvist, 2008](/dissertation/references)) of the influences of personality on susceptibility to emotional contagion, found that reward dependence correlated with all basic emotional components of the emotional contagion scale: anger, fear, sadness, happiness and love. Harm avoidance correlated significantly with susceptibility to anger and fear. Novelty seeking and persistence, on the other hand, had no correlation to emotional contagion. Self-directness correlated with susceptibility to positive emotions, such as happiness and love. Previous studies had shown that

cooperativeness and self-transcendence are linked with reward dependence. In the Lundqvist 2008 study, however, cooperativeness had no significant correlation with vulnerability to anger or love. Self-transcendence was negatively correlated with sadness contagion. The part of personality which experiences and expresses emotions had high correlation with level of susceptibility to emotional contagion. The regulatory characteristics of the individual‘s emotional system were part of vulnerability to another‘s emotions ([Lundqvist, 2008](/dissertation/references)). It is likely that genetic heritage and early experience predispose a person for emotional contagion vulnerability ([Hatfield et al., 1994; Rothschild, 2006](/dissertation/references)). Neurophysiological bases of emotional contagion. Results of studies of the neurophysiological processes underlying personality and emotion have reinforced results from personality studies of emotional contagion susceptibility. The processes necessary for survival and basic to social behavior are based on the capacity to react to stressors, and yet maintain visceral homeostatic states needed for life processes ([Carter et al., 2009](/dissertation/references)). The neural circuits regulating social behaviors, including empathy, may therefore overlap with those regulating visceral homeostasis. ―The autonomic nervous system is fundamental to affective experience, emotional expression, facial gestures, vocal communication, and contingent social behavior‖ ([Carter et al., 2009, p. 170](/dissertation/references)). Studies of animal brains and lesion studies of human brains have found that social communication is determined by the cortical regulation of medullary nuclei using corticobulbar pathways ([Shamay-Tsoory, 2011](/dissertation/references)). Self-reflection and autobiographical memory, part of cognitive empathy, involve the ventromedial prefrontal cortex (VPC),

the TPJ, and the medial temporal lobe (MTL) ([Shamay-Tsoory, 2011](/dissertation/references)). In the evolution of humans a link developed between the neural regulation of facial muscles and a new vagus nerve which had faster transmission than the unmyelinated vagus nerves of other primates ([Porges, 2007](/dissertation/references)). This connection led to the ability to calm agitated states, dampen sympathetic nervous system (SNS) reactivity, as well as the hypothalamic- pituitary-adrenal (HPA) axis, allowing sociability to overcome fear, and the ability to develop gut reaction and empathic responses, including emotional contagion. Wicker, Keysers, Plailly, Royet, Gallese, and Rizzolatti (2003) conducted an fMRI study of disgust and emotional contagion. The participants inhaled odorants, and later viewed video clips of facially expressed disgust. Both types of stimulant, primary and secondary, activated the same sites in the anterior insula and, to a lesser degree, in the anterior cingulated cortex. Both areas are high in mirror neurons ([Iacaboni, 2008](/dissertation/references)). Less is known about the empathic response to sound or emotional contagion from a sound stimulus, as the majority of empathy and emotional contagion research has been based on visual cues ([Carter et al., 2009](/dissertation/references)). Harm avoidance correlates with variations in the behavior inhibition system which is related to serotonergic activity. Reward dependence correlates with variation in the behavior maintenance system, noradrenergic activity in areas of the body affected by norepinephrine ([Lundqvist, 2008](/dissertation/references)). Using the Temperament and Character Inventory (TCI), Lundqvist found the enzyme, monoamine oxidase A functioned in breaking down serotonin and noradrenaline, and influenced ventromedial prefrontal cortex-amygdala connectivity related to both harm avoidance and reward dependence, although not to

novelty seeking. Self-directedness correlated with activity in the medial prefrontal cortex ([Cloninger, Syrakic, & Przybeck, 2006](/dissertation/references)). These same areas of emotion processing and regulating were related to empathy deficits, social emotional disorders, as well as imitative behavior ([Iacoboni, 2008](/dissertation/references)), an essential component of emotional contagion ([Rothschild, 2006](/dissertation/references)). The neuropeptides oxytocin and vasopressin also play an important role in empathy and emotional contagion ([Carter et al., 2009](/dissertation/references)). Domes, Heinrichs, Glascher, Buchel, Braus, and Herpetz (2007) found that oxytocin attenuates amygdala responses to facial expression, regardless of valence. Oxytocin also appeared to improve ability to infer affective states in others ([Domes, Heinrichs, Michel, Berger, & Herpetz, 2007](/dissertation/references)). Another study found oxytocin blood levels correlated with reward dependence ([Bell, Nicholson, Mulder, Luty, & Joyce, 2006](/dissertation/references)).

Development of Emotional Contagion in the Human Life Span

Emotional contagion occurs in all mammals, including rodents, as well as other types of animals such as birds ([Hatfield et al., 1992](/dissertation/references)). In humans it may take place in utero. It certainly is evident in the first days of an infant‘s life (Iacoboni, 2009; McDonald & Messinger (n.d.), Shamay-Tsoory, 2011). An example is the hospital nursery where infants respond to each other‘s crying with their own wails ([de Waal, 2008](/dissertation/references)). It is possible that in human development, beginning in the fetal stage, there is a separation between emotional and cognitive empathy, resulting in some people having one type of empathy without the other, as in autism spectrum disorders and borderline personality disorder ([Shamay-Tsoory, 2011](/dissertation/references)). An individual‘s capacity for empathy and

emotional contagion is a dynamic characteristic which exists on a continuum. Fortunately, a number of research studies have indicated that both cognitive and affective empathy can be developed later in life ([Rothschild, 2006](/dissertation/references)). For example, a person can be conditioned to respond with an appropriate emotion to a specific stimulus through training in awareness and observation of people with whom he or she is interacting ([Rothschild, 2006](/dissertation/references)). It is possible, therefore, that emotional contagion can also be developed or modified throughout life. The converging evidence from neuroimaging and lesion studies of humans indicates emotion recognition and emotional contagion are based on a neural network including the IFG and IPL, whereas cognitive empathy involves the ventromedial prefrontal cortex (VPC), temporoparietal junction (TPJ), and the medial temporal lobe (MTL) ([Shamay-Tsoory, 2011](/dissertation/references)). A recent study ([Hurlemann et al., 2010](/dissertation/references)) which administered nasal oxytocin found participants increased emotional, but not cognitive empathy. This reinforced the theory of separate neural processes for cognitive and emotional empathy, or emotional contagion, and therefore separate developmental tracks.

Interactive synchrony and mimicry. Interactive mimicry and synchrony were important possibly in human evolution, assisting in facilitation of social activity through feelings of unity and understanding ([Levenson & Ruef, 1997](/dissertation/references)). Spectator-participants altered their breathing patterns and muscular contractions unconsciously to mimic individual athletes they observed in competition ([Paccalin & Jeannerod, 2000](/dissertation/references)). When a person sees someone wince from touching a hot surface, that person usually responds with a similar wince ([Hodges & Wegner, 1997](/dissertation/references)). Preston and de Waal (2002) proposed a perception-action hypothesis: perception of another‘s behavior automatically activated one‘s own representations for the behavior, confirmed by mirror neuron research ([Iacoboni, 2009](/dissertation/references)). Gallese (2007), a simulation theorist, suggested that processing social information involves activating neural states during observation that match observer remembered experiences. It is likely that the MNS provides the basis for motor empathy leading to cognitive empathy, imitation, and emotional contagion ([Shamay-Tsoory, 2011](/dissertation/references)). The MNS has been identified in the IFG, Brodmann‘s Area, and the IPL ([Iacoboni, 2009; Shamay-Tsoory, 2011](/dissertation/references)). Automatic mimicry of facial expression has been observed in infants and young children in numerous research studies ([Hatfield, Rapson, & Le, 2009](/dissertation/references)). As children develop and learn to interact socially in conversation, they automatically and continuously mimic and synchronize their own movements with people close to them, with such subtle moment-to-moment changes that no observable change in facial expression occur, although the changes can be detected using fMRI and EMG

([Lundqvist, 1995; Wild, Erb, Eyb, Bartels, & Grodd, 2003](/dissertation/references)). Although important in human development, interactive synchrony and mimicry can lead also to negative effects. Detrimental effects of emotional contagion. Emotional contagion, as part of empathy, facilitates social interaction. As part of CF, however, emotional contagion can make a person vulnerable to absorbing negative emotions (e.g. fear, anger, sadness) and stress. Negative emotion bombardment over a period of time can lead to the somatic reactions to stress. In a crowd, negative emotional contagion may lead to extreme behaviors, such as mass hysteria ([Rothschild, 2006](/dissertation/references)). Mass hysteria has been defined as numerous people linked by some form of communicative interconnection, who take on the same aversive emotional or psychosomatic symptoms and behaviors ([Hatfield et al., 1994](/dissertation/references)). Even a mild form of chronic emotional contagion can have adverse consequences for an individual. Howes, Hokanson, and Lowenstein (1985) found that college students with mildly depressed roommates were more likely to become depressed than those living with roommates without depression. Therapists and medical practitioners who are exposed repeatedly to emotionally traumatized individuals are in danger of developing adverse emotional contagion affects in forming an empathic bond with patients and clients ([Rothschild, 2006](/dissertation/references)). One study which examined mental health practitioners who worked with populations of trauma victims found that 14% of the practitioners developed symptoms of post-traumatic stress disorder (PTSD) ([Shindul-Rothschild, 2001](/dissertation/references)). When a person develops PTSD through another person who experienced the trauma, this is termed vicarious or secondary trauma.

Another potential risk can occur when clients with high vulnerability of emotional contagion ―catch‖ therapists‘ burnout, stress, or depression, adding to the clients‘ own emotional load ([Linehan, Cochran, Mar, Levensky, & Comtois, 2000](/dissertation/references)). Fortunately, if a person‘s cognitive empathic ability is strong, this can be used, with training, to inhibit emotional contagion ([Rothschild, 2006](/dissertation/references)). Psychoneuroimmunologic implications. More research is needed which directly links emotional contagion with the psychoneuroimmunological system, although studies have been done concerning the interactions between the physioneurological system and various types of empathy ([Avenanti et al., 2005; Carr, Iacoboni, Dubeau, Mazziotta, & Lenzi, 2003; Carter et al., 2009](/dissertation/references)). Studies have also been done on the effects of CF on overall health ([Gordon & Hobbs, 2011](/dissertation/references)). Figley‘s (2002) model of CF (see Figure 1), animal single-cell studies of empathy, as well as human lesion studies ([Decety, 2011; Lamm, Decety, & Singer, 2011; Shamay-Tsoory, 2011](/dissertation/references)) have begun to build a bridge of understanding. Figley‘s (2002) model of compassion stress and fatigue begins with empathic ability, which is affected by amount of exposure and empathic concern for the client or patient, leading to an empathic response. This could be the point at which emotional contagion may occur. If the empathic responder finds satisfaction with work and is able to disengage from emotional contagion, (i.e., has cognitive and self-other empathy intact), the process ends there ([Hatfield, Rapson, & Le, 2009](/dissertation/references)). Otherwise, residual compassion stress builds up. As traumatic memories are evoked and the exposure to the client or environment is prolonged, CF may develop. The risk of CF is increased if there are major life disruptions ([Hatfield et al., 2009](/dissertation/references)).

Negative Factors Positive Factors Figure 1. Figley‘s 2002 Compassion Stress and Fatigue Model. [Adapted from C. Figley, ―Compassion Fatigue: Psychotherapists‘ Chronic Lack of Self Care,‖ p. 1437, in Journal of Clinical Psychology, 58(11).] Permission granted for adaptation. Research has established that the HPA axis is involved in the neurobiology of mood disorders and functional psychopathologies such as anxiety disorders, Exposure to client Disengagement Prolonged exposure Degree of life disruptions Empathic concern Satisfaction and sense of achievement Traumatic memories Empathic Ability Empathic Response Residual Compassion Stress Compassion Fatigue

posttraumatic stress disorder (suggesting secondary and vicarious traumatic stress disorder due to emotional contagion are included), burnout (and possibly CF), and depression ([Fortes et al., 2003; Irwin & Cole, 2007; Miller, Chen, & Zhou., 2007](/dissertation/references)). The amygdala is one part of the brain which underlies empathy, allows for emotional convergence with another being, and therefore the development of emotional contagion ([Rothschild, 2006; Shamay-Tsoory, 2010](/dissertation/references)). A meta-analysis ([Lamm, Decety, & Singer, 2011](/dissertation/references)) of nine independent fMRI studies of empathic pain indicated that the core network, consisting of the bilateral anterior insular cortex and medial/anterior cingulated cortex, was associated with empathic responses to other‘s pain. This network overlaps with the areas activated by actual pain. Cognitive empathy occurred in areas of the brain associated with inference and mental representation about another‘s emotional state: the precuneus, VM, superior temporal cortex, and temporoparietal junction ([Lamm et al., 2011](/dissertation/references)). Shamay-Tsoory (2011) also reported, from lesion studies she and colleagues conducted in Israel, that two distinct areas exist for cognitive empathy and emotional empathy (emotional contagion): ―The inferior frontal gyrus and inferior parietal lobule are necessary for emotion recognition and emotional contagion. On the other hand, the involvement of the ventromedial prefrontal cortex, temporopairetal junction, and the medial temporal lobe‖ are necessary for cognitive empathy ([Shamay-Tsoory, 2011, p. 18](/dissertation/references)). Although there may be two distinct and independent neural bases for empathy, empathic responses probably elicit activation to some degree in both areas. Stress, such as develops with CF and perhaps with negative emotional contagion, elevates the concentration of hormones, such as glucocorticoids and catecholamines

(epinephrine or norepinephrine), as well as altering the production of cytokins, lowering defenses against infections ([Rabin, 2007](/dissertation/references)). In people with autoimmune disorders, an exacerbation can be evoked by stress, probably due to alteration of the balance between CD4 Th1 and CD4 Th2 cells (T-cell helpers), increasing the reactivity of the Th1 cells ([Rabin, 2007](/dissertation/references)). Stress also affects the endocrine system. The HPA axis is a major part of the neuroendocrine system. There are a complex set of interactions between the paraventricular nucleus (PVN) of the hypothalamus, the anterior lobe of the pituitary gland, and the adrenal glands ([Kaye & Lightman, 2007](/dissertation/references)). These interactions regulate body processes including the immune system—energy storage and use, mood and emotions, digestion, and sexuality. The HPA axis is a primary interaction mechanism for glands, hormones, and parts of the midbrain which influence the general adaptation syndrome (GAS), originally described by Selye ([as cited in Kaye & Lightman, 2007](/dissertation/references)). Neuroendocrine neurons in the PVN produce vasopressin and corticotrophin-releasing hormone (CRH) peptides. These peptides regulate the anterior lobe of the pituitary gland, stimulating the secretion of adrenocorticotropic hormone (ACTH). ACTH then causes the adrenal cortices to produce glucocorticoid hormones (cortisol in humans). The glucocorticoid hormones then affect the PVN and pituitary to inhibit CRH and ACTH production ([Kaye & Lightman, 2007](/dissertation/references)). The transport systems include both neural and blood pathways. For example, CRH is transported through blood, and vasopressin, the antidiuretic hormone, through the axonal network ([Kaye & Lightman, 2007; Miller et al., 2007](/dissertation/references)). Extremely important to the understanding of the HPA axis is the nature of these

feedback loops, which can be thrown off balance by chronic stress such as negative emotional contagion. Depression, which can also be caused by chronic negative emotional contagion, creates dysregulation of the immune system and activation of the HPA axis ([Irwin & Cole, 2007; Miller, 2007; Miller et al., 2007](/dissertation/references)). In one study ([Miller et al., 2007](/dissertation/references)) uncontrollable stressors that threatened physical integrity and involved trauma elicited a high, flat diurnal profile of cortisol secretion. Patients having various levels of clinical depression have disruption of the adrenal axis, the autonomic nervous system, and overall immunity ([Irwin & Cole, 2007](/dissertation/references)). Studies have contradictory results regarding the complex interaction between depression and the immune system, but overall an impairment of cellular immune response results, particularly in the elderly ([Fortes et al., 2003](/dissertation/references)). The autonomic nervous system influences the immune system through sympathetic fibers which innervate the lymphoid organs, and production of catecholamines in the adrenal medulla within the HPA axis ([Fortes et al., 2003; Irwin & Cole, 2007](/dissertation/references)). When the HPA axis is disrupted by stress or depression, excess cortisol is produced and circulated, leading to cytokine (immune messenger cell) development ([Irwin & Cole, 2007](/dissertation/references)). Another consequence of depression, seen in studies of premenopausal women taking antidepressant medications (not selective serotonin reuptake inhibitors), is bone-thinning ([NIMH, 2007](/dissertation/references)). Blood and urine samples taken every hour for a full day indicated that these depressed women had imbalances in the immune system, including proinflammatory substances such as IL-6, known to promote

bone loss. The NIMH (2007) concluded that excess adrenalin produced in depressed patients led to their immune system imbalances. As these studies have shown, emotional contagion, which may be a significant part of CF, can have serious negative results over time. There are, however, some counterarguments as well as limitations of the studies of emotional contagion, presented later in this chapter.

Compassion Fatigue

Compassion fatigue has been compared to burnout, empathic contagion, secondary stress or trauma disorder, countertransference, and secondary victimization ([Austin, Goble, Leier, & Byrne, 2009](/dissertation/references)). Each of these disorders, however, has different characteristics, and can be based on different types of situational problems ([Aycock & Boyle, 2009](/dissertation/references)). The definition of compassion is not universal, and is frequently merged or confused with empathy. For the purpose of this study, compassion refers to a pro-social emotion, potentially beginning development in infancy ([Stone, 2006](/dissertation/references)). Compassion, in contrast to the various forms of empathy, has two components: (a) the recognition of suffering in another person or object, living or inanimate; and (b) the motivation to alleviate that suffering. Just as empathy is a neurological, affective, and cognitive complex reaction within a person, CF is an equally complex psychological, physiological, and a cultural phenomenon ([Austin et al, 2009; Johnson, 2008](/dissertation/references)). Essentially CF is the reduced ability to feel or convey caring support, empathy, or genuine understanding ([Hofmann, 2009](/dissertation/references)). Some of the symptoms of CF, according to the Compassion Fatigue Awareness Project (2012) are: mental and physical fatigue; not caring about others,

including family; repressed or labile emotions; isolation; compulsive behaviors, including substance abuse to mask feeling; poor self-care; poor sleep patterns; depression; apathy; preoccupation; lowered immunosystem and chronic physiological ailments; difficulty concentrating; and being in denial about problems. Compassion and empathy are key components in a therapeutic relationship with a patient, and yet, if not supported, CF can result ([Figley, 2002; McMullen, 2007](/dissertation/references)). The costs of CF are both financial and psychological ([Austin et al., 2009; Tehrani, 2007; Van Hook, 2008](/dissertation/references)). Palliative care, long-term rehabilitation, cancer care, and various other health providing areas have had increasingly large numbers of people suffering from CF ([Abendroth & Flannery, 2006](/dissertation/references)), leading to loss of quality care, and attrition in nurses and other health providers ([McMullen, 2007; Sprang, Clark, & Whitt-Woolsey, 2007](/dissertation/references)).

Origins of the Concept of Compassion Fatigue

One of the earliest uses of the phrase, compassion fatigue, was in reference to the lack of interest in the homeless problem in 1995 ([Link et al., 1995](/dissertation/references)). Joinson (1992) noted some emergency room nurses lost the ability to nurture. She referred to the condition as compassion fatigue. Figley (1995) used the term in connection with secondary traumatic stress disorder, and later (2002) developed the theory and model of CF which is widely accepted today by healthcare professionals (see Figure 1). Figley‘s 2002 case study presented a theoretical model (see Figure 1) for how CF occurs: Exposure to certain clients and situations, combined with empathic concern leads to an empathic response, a physical reaction in the neuropsychological system. As part of coping, disengagement may occur, and loss of satisfaction in the interaction with the client or patient, leading to

residual compassion stress. Prolonged exposure to the stressful situation, combined with traumatic memories, and the degree of life disruptions, then leads to CF. One of the limitations to Figley‘s model, however, is that it implies causation when none has been clearly indicated. Sabo ([personal communication, January 18, 2012](/dissertation/references)) considered the theory also in need of clear definitions for each of the concepts— empathy, compassion, and fatigue. Several theories and paradigms underlie the present study: (a) the model of CF proposed by Figley (2002), the foundation for most current definitions and studies of CF; (b) positive health, as described by Seligman (2008); and (c) an expansion of Bonanno‘s 2004 model of resiliency proposed by Roisman (2005). Unlike burnout, which often can be alleviated by vacation, or job change, CF is a debilitating condition of over-identification or preoccupation with the suffering of others, and is not easily healed ([Stewart, 2009](/dissertation/references)). Multiple symptoms occur with CF, as described by HCPs: loss of the ability to connect and nurture, fatigue, depression, anger, lowered self-efficacy, apathy, and detachment ([Boyle, 2011](/dissertation/references)). Somatic problems also occur, such as headaches, gastrointestinal difficulties, and insomnia. As stress is prolonged, the symptoms worsen gradually for those HCPs who do not recognize the early warning signs and take care of themselves ([Compassion Fatigue Awareness Project, 2012](/dissertation/references)).

Risk Factors

Factors related to working environment, demographics and health of the HCP, as well as duration and type of interaction with patients and clients may be components in the development of CF ([Abendroth, 2011](/dissertation/references)). People who are low in empathic ability,

including some people with an autistic spectrum disorder, are unlikely to develop CF ([Dapretto et al., 2006](/dissertation/references)). On the other hand, people most at risk are those who are overly empathic, without empathy mediation skills to differentiate between self and other, leading to blurred boundaries ([Abendroth & Flannery, 2006](/dissertation/references)). Risk is increased in situations of negative emotional contagion. Personality factors. Many HCPs begin their careers with an idealistic attitude, even at risk to themselves ([Austin et al., 2009; Johnson, 2008](/dissertation/references)). Due to both personal and environmental factors over time, this desire to help others too often has been replaced by ―efficiency, coping and being knowledgeable‖ ([Johnson, 2008, p. 19](/dissertation/references)). Research has shown relationships between risk for CF, inadequate self-esteem, and lowered career satisfaction ([Alkema et al., 2008; Aycock & Boyle, 2009; Harrison & Westwood, 2009](/dissertation/references)). Other individual factors are: habitual somatization of what others feel (empathic response); lack of self-awareness, and inadequate habits of self-care ([Abendroth & Flannery, 2006; Aycock & Boyle, 2009; Harrison & Westwood, 2009](/dissertation/references)); unhealthy cognitive schema developed from personal experience ([Tehrani, 2007](/dissertation/references)); and self- expectations from social learning. A belief in the value of self-sacrifice due to cultural conditioning can lead to overcommitment toward work and patients ([Aycock & Boyle, 2009; Bride & Figley, 2007; Reid, 2006](/dissertation/references)). As an example of bad self-care habits, burnout, if left unchecked, can lead to CF ([Abendroth & Flannery, 2006](/dissertation/references)). Some attachment styles may heighten risk, particularly people who have ill- defined boundaries. This can be the basis of emotional contagion or unhealthy empathic relationships with patients ([Abendroth & Flannery, 2006; Mikulincer et al., 2005](/dissertation/references)). Future

research may show that people who are resistant to developing CF generally have a secure attachment style. Chronic personal distress, consistently correlated with attachment anxiety, may be one aspect of affective empathy ([Mikulincer et al., 2005](/dissertation/references)), leading to risk of CF. Low self-perception of emotional intelligence (PEI) is another risk factor for CF ([Ramos et al., 2007](/dissertation/references)). PEI includes a person‘s self-perception of ability to cope with acute and chronic stress. In 1995, Salovey, Mayer, Goldman, Turvey, and Palfai developed a model of PEI, with three major perceived abilities: (a) attention to moods and emotions of self and others; (b) distinction between feelings; and (c) self-regulation of emotions and moods ([Ramos et al., 2007](/dissertation/references)). High PEI is positively related with lower incidence of depression, higher satisfaction with life and career, and adequate resolution of emotional sociocognitive dissonance (Ramos et al., 2007. Human service workers who have high empathic concern, plus the ability to avoid emotional contagion, are better able to communicate compassionately ([Miller, 2007](/dissertation/references)). Unfortunately numerous people attracted to the career of palliative caregiving have high levels of empathic concern (feeling ―for‖ the patient), without the ability to block emotional contagion (feeling ―with‖ the patient), which leads to high incidence of CF ([Bride & Figley, 2007; Miller, 2007](/dissertation/references)). Abendroth and Flannery (2006) studied risk levels for CF in people working in hospice organizations. Nurses (N=216) from 22 hospices in Florida responded. The key risk factors exposed were trauma within the HCP‘s life, anxiety, life demands at work and home, and excessive empathy. The other risk factor, continually present, was lack of support.

Situational and occupational factors. Most studies of CF have focused on the complex combination of psychological factors leading to the stress disorder, rather than examining closely the context and work environment. For example, Tehrani (2007) proposed that a pre-conscious set of assumptions and accompanying attitudes occurred due to the health professionals own experience or understanding of trauma and post- traumatic stress disorder. Work environment and lack of social support, however, can increase risk of CF ([Austin et al., 2009; Johnson, 2008](/dissertation/references)). Personal accumulation of stress can be a major factor leading to CF whether the stress occurs at home or in the workplace from issues with management and bureaucracy ([Johnson, 2008](/dissertation/references)). Some social science researchers consider CF to be a culturally specific phenomenon in Western cultures ([Austin et al., 2009](/dissertation/references)). Recent technological changes have led to a human condition Stjepan Meštrović has called postemotional ([as cited in Austin et al., 2009, p. 198](/dissertation/references)). This is due, according to Meštrović to people being overexposed to traumatic situations in news and entertainment venues. Technology advances have led to changes in social interaction patterns, such as the increase of remote over direct communication. Postemotional people separate their emotions from any compassionate reactions. Frequently the experience of emotion is synthetic, manipulated by the media. The postemotional state can be viewed as a precursor to CF. The global cultural development of postemotionality then leads to higher CF occurrence in specialized environments, including health care systems ([Abendroth & Flannery, 2006; Bride & Figley, 2007; Johnson, 2008](/dissertation/references)).

There is no question that the occurrence of CF is more frequent than in past years. A number of factors may be responsible. The number of acute care patients who are living longer is increasing. Emergency rooms are becoming overwhelmed with patients entering the healthcare systems, needing acute care, many uninsured and seeking care nowhere else ([Hooper, Craig, Janvrin, Wetsel, & Reimels, 2010](/dissertation/references)). Too often organizations providing care do not provide sufficient training and support for their staff to help them combat compassion fatigue. Aycock and Boyle (2009) found 45% of their national sample of oncology nurses had not received any training regarding their own coping, adaptation, or emotional self-care.

Coping Strategies to Avoid Developing Compassion Fatigue

There are, however, people who have developed effective coping strategies, the focus of this study. In addition to healthy habits of self-care, the positive reinforcement of watching patients recover, feeling effective, and being able to interact compassionately with patients helps HCPs avoid CF. Even without specific support from the organization, HCPs seek and receive support from coworkers, family, and friends ([Abendroth & Flannery, 2006; Aycock & Boyle, 2009; Alkema, Linton, & Davies, 2008; Luquette, 1995](/dissertation/references)). In the past, the remedy of ―detached concern‖ ([Miller, 2007, p. 226](/dissertation/references)) has been promoted for professional emotional control. HCPs make an effort to distance themselves from clients, patients, and patients‘ families. With detached concern they consider situations objectively, and yet with caring. This strategy, however, does not appear to be successful in guarding against compassion fatigue, particularly for people with high

empathic concern and codependency issues ([Aycock & Boyle, 2009; Bride & Figley, 2007; Miller, 2007](/dissertation/references)). Although a person may have a detached but compassionate attitude for a familiar set of clients and patients, when a certain incident or trait occurs, it can trigger a CF reaction. For example, a highly competent and empathic physician lost her memory, compassion, and ability to work with patients over a 24 hour period after 9/11 due to her empathic response to the children who lost their parents in the disaster ([personal observation, 2001](/dissertation/references)). She had lost her own father when she was 11. The heightened stress of the situation added to a triggered recall of her own experience combined quickly to develop into CF. Although training programs may emphasize the need to remain objective, the display of compassion is not a commodity which can be controlled and dispensed as needed ([Miller, 2007](/dissertation/references)). For example, in one quantitative study of Hospice nurses, 80% (N = 216) demonstrated moderate to high risk of compassion fatigue ([Abendroth & Flannery, 2006](/dissertation/references)), a finding repeated in numerous studies. Other programs and coping strategies being used successfully to counter CF are explored in [chapter 4](/dissertation/chapter-4) and [chapter 5](/dissertation/chapter-5). Differentiation between CF, Burnout, Secondary Trauma, and Vicarious Traumatic Stress An overlap exists between the definitions and occurrences of CF, burnout, secondary trauma, and vicarious traumatic stress. At first Figley (1995) discussed CF as secondary traumatic stress disorder. Many people even now do not see a difference between burnout and CF ([personal communication, C. Maslach, April 27, 2012](/dissertation/references)). Van Hook (2008) described CF as having a rapid onset, but Stewart (2009) said that

symptoms of CF develop gradually, unnoticed, leading to a critical breakdown. CF and burnout can occur simultaneously, separately, or one followed by the other ([Compassion Fatigue Awareness Project, 2012](/dissertation/references)). Burnout. In contrast to CF, burnout has a gradual onset of emotional exhaustion, hopelessness, and lowered self-efficacy, and is frequently associated with work environment ([Van Hook, 2008](/dissertation/references)). Maslach and Jackson (1985) defined burnout as a ―syndrome of emotional exhaustion, depersonalization, and reduced personal accomplishment that can occur among individuals who do ̳people-work‘ of some kind‖ (p. 837). A callousness may develop, leading HCPs to change from compassionate care for patients and clients to the negative view that these people somehow deserve their problems ([Maslach & Jackson, 1985](/dissertation/references)). Many of these traits overlap with those in CF. The differences lie in type of onset. Presence of work environment issues, which if resolved, can lead to easing burnout, but not necessarily CF. In early studies of burnout it was generally assumed that women would be more prone to developing burnout than men. This may have been due to the prevalence of women in caring positions, in subordinate positions, and in being expected to care for people both at home and at work. The Maslach Burnout Inventory (MBI) was developed in order to empirically research the commonly held theories. Two surveys which used the MBI found no consistent difference between genders, except with regard to which aspect of burnout was salient ([Maslach & Jackson, 1985](/dissertation/references)). Men were more likely to develop depersonalization and callousness, whereas women were more likely to experience

emotional exhaustion and lower self-efficacy. No studies at that time distinguished between heterosexual and homosexual personalities. A Swedish study ([Rudman & Gustavsson, 2011](/dissertation/references)) studied development of burnout symptoms in nurses, and found that initial exhaustion generally develops into burnout, due to dysfunctional coping. In their study a number of different trajectories occurred, with changes in burnout levels, depressive symptoms, and desire to leave nursing. The nurses most at risk for burnout were newly qualified and inexperienced. Kuhn, Goldberg, and Compton (2009) conducted a study of emergency room physicians, assessing the role of uncertainty tolerance in predicting career burnout. Almost a third of the physicians disclosed having experienced burnout at some level. The largest risk factor was high anxiety from concern for unsatisfactory outcomes. Secondary trauma. Primary trauma occurs as actual experience of adversity. Secondary trauma, related to vicarious trauma ([Stewart, 2009](/dissertation/references)), can occur as a response to extensive media coverage of violence and disaster. It is more frequently related to work, such as being a counselor for veterans and other military personnel ([Gregerson, 2007](/dissertation/references)). By definition secondary trauma is due to exposure to someone else‘s extremely stressful events, such as working in an emergency room. The symptoms are similar to CF, rapid in onset, but associated with a particular event. They may include being afraid, avoidance behaviors, having interruptive images of the upsetting event, and difficulty sleeping. Secondary trauma occurs throughout our culture, and may be a primer for developing CF ([Stewart, 2009](/dissertation/references)).

Vicarious traumatic stress. The concept of vicarious traumatization (VT), or vicarious traumatic stress, as Figley (1995) termed it, developed as a type of countertransference when there is repeated ―empathic engagement with trauma survivors and associated cognitive, schematic, and other psychological effects‖ ([Sprang, Clark, & Whitt-Woosley, 2007, p. 260](/dissertation/references)). For mental health professionals, VT can disrupt feelings of safety and trust, power and control, self-efficacy and self-esteem, and intimacy ([Sprang et al., 2007](/dissertation/references)). Using narrative analysis, Harrison and Westwood (2009) studied how master mental health therapists countered developing VT while working with seriously traumatized clients. Nine themes emerged: creating meaning; developing mindful self- awareness; determining to embrace complexity and multiple realities; reinforcing professional satisfaction; maintain clear boundaries; finding ways to avoid isolation; and practicing active optimism ([Harrison & Westwood, 2009](/dissertation/references)). Resiliency Resiliency, the ability to spring back and recover from adversity, is not a fixed personality trait ([Greene, 2002a](/dissertation/references)), although there are standardized tests to measure it. One measurement instrument, used in management training, is the personal stress assessment inventory ([PSAI, Kindler, 1981-1993](/dissertation/references)). The youth risk and resilience inventory (YRRI) developed by Brady in 2006, is a more robust test used to screen for risk factors including bullying and victimization and to identify adolescent resilience assets ([Huebner, 2003](/dissertation/references)). Resiliency, like empathy, is a multifaceted response, dependent on environment, personality, situation, and cultural point of view, not easily assessed as a static trait. Each

discipline studying resiliency has a different definition for it. In order to understand the phenomenon of resiliency to compassion fatigue, a multisystem view is needed ([Greene, 2002b](/dissertation/references)).

Basic Assumptions and Theory

Components of resiliency include self-efficacy, adaptation, healing, wellness, and competence, all factors which can disappear in compassion fatigue. Recent studies of resiliency, part of the positive psychology movement, have examined people who do not become symptomatic ([Linley & Joseph, 2005](/dissertation/references)). Early in the 1980s a longitudinal study, the St. Louis Risk Research Project, investigated the resilience of children who lived in risk-laden circumstances. This led to similar studies in numerous American cities. From these studies researchers determined risk factors and protective factors. In 1993 Benard suggested that resiliency in children correlated highly with the ability to form relationships, solve problems, develop a sense of identity, and the ability to plan and to hope ([as cited in Greene, 2002a](/dissertation/references)). Causative factors, however, were not established. Although most studies of the time investigated resiliency in children and adolescents ([Grotber, 1998](/dissertation/references)), in 1983 Moskovitz studied adult Holocaust survivors and found their resiliency had ―a high degree of ethical and spiritual involvement, social responsibility, and a strong desire to establish a family and a home‖ ([Greene, 2002a, pp 7-8](/dissertation/references)). One of the earliest social psychologists interested in resiliency, Bandura has researched self-efficacy, as part of social learning theory ([Bandura, 1977a, 1982b](/dissertation/references)).

At the time of the International Resilience Project ([Grotberg, 1998](/dissertation/references)) there were two primary ways to study resilience, either retrospective or concurrent studies. The emphasis was on psychopathology rather than on positive situations or attributes. Retrospective studies analyzed factors and traits from a large sample. Concurrent studies tended to focus on children and adolescents in school, or in detention ([Grotberg, 1998](/dissertation/references)). At this time a shift in focus was occurring: more attention was given to the developmental aspects of resiliency. Research participants were usually children and adolescents, but in a social context rather than in a laboratory. In the late 1990s the ecological perspective brought a new dimension to resiliency theory, focusing on resiliency embedded within person-environment interaction at various levels ([Grotberg, 1998](/dissertation/references)). Saleebey‘s life course concept stated that transitions in life are ―both expected and unexpected‖ and have a sense of ―variety and evanescence through time and culture‖ ([Saleebey, 1993, p. 204](/dissertation/references)). Although there is no unified resiliency theory, there are some basic assumptions. Protective factors exist in childhood, such as: (a) a child‘s personal disposition, responsiveness, and self-esteem; (b) the child‘s family milieu being cohesive and supportive; and (c) a social environment and culture which reinforces healthy behaviors, and supports belief systems ([Greene & Conrad, 2002; Grotberg, 1998](/dissertation/references)). Another assumption about resiliency is that it exists along a continuum and is dynamic, rather than a fixed individual trait. Palmer (2000) outlined levels of resilience: 1. Anomic survival, resilience to a continual state of disruption or chaos. 2. Regenerative resilience.

3. Adaptive resilience. 4. Flourishing resilience.

Resiliency as Part of Physical Health

Abundant research on physical resiliency has been done in medical studies demonstrating psychological that resiliency is a basic part of well-being and physical health. ―Optimum health requires balance in all aspects of our existence—maintaining hope, optimism, and a positive attitude‖ ([Riley, 2002, p. 171](/dissertation/references)). Without hope and a positive belief system, physical resiliency plummets. The opposite of a placebo effect can happen due to various factors: the nocebo effect can occur when a person finds some benefit or secondary gain to prolonging illness or disability ([Riley, 2002](/dissertation/references)). In other words individuals can choose whether to engage their resiliency strengths, or not. Individuals use their assumptions, beliefs, knowledge, and fears to arrange, rearrange, and interpret events to develop a story line through which day to day living is perceived. Imagination reflects the operation of the brain–mind. Body sensations caused by events outside and inside the body signal upward to the brain. Conversely, thoughts and feelings that the brain generates move downward to influence the body. ([Spiegel, 1997, p. 617](/dissertation/references)) Coping, part of resiliency, can help regulate distress and management of the distress-causing problem, including physical health ([Riley, 2002](/dissertation/references)). On the other hand, an attitude can be too positive, distorted beyond being helpful, leading to unrealistic expectations that one can cure oneself without medical assistance.

Development of Resiliency

―Resilience is developmental. Being successful strengthens a person‘s competence‖ ([Greene & Conrad, 2002, p. 37](/dissertation/references)). The development of resiliency is described byWolin and Wolin (1995) in Table 1. They examined seven factors of resiliency across the lifespan, within substance-abusing families. Recent studies of how resiliency may be developed Table 1 Developmental Phases of the Seven Resiliencies __________________________________________________________________ Seven resiliencies Child Adolescent Adult __________________________________________________________________ Insight Sensing Knowing Understanding Independence Straying Disengaging Separating Relationships Connecting Recruiting Attaching Initiative Exploring Working Generating Creativity Composing Playing Shaping Humor Laughing Morality Judging Valuing Serving __________________________________________________________________ From ―Resilience among Youth Growing Up in Substance-Abusing Families,‖ by S. Wolin and S. Wolin, 1995, Pediatric Clinics of North America, 42, p. 425. Philadelphia, PA: W. B. Saunders. Reprinted with permission.

have indicated that learning self-regulation is a key element ([Hofer, Eisenberg, & Reiser, 2010](/dissertation/references)). Self-regulation and effortful control may have biological bases within temperament ([Hofer et al., 2010](/dissertation/references)). As a healthy person grows from childhood to young adulthood, the executive function in the prefrontal lobes presumably develops. In this process effortful control underlies self-regulation ([Hofer et al., 2010](/dissertation/references)). Studies by Eisenberg, colleagues, and other researchers, have indicated that self-regulation positively correlates with social competence ([Eggum et al., 2011](/dissertation/references)). In contrast, children with lower self-regulation ―exhibit more externalizing and/or internalizing problems. . . . Children who display externalizing problems tend to be more impulsive, spontaneous children, which might make them appear somewhat more resilient than they really are when dealing with a stressful situation‖ ([Hofer et al., 2010, pp. 556-557](/dissertation/references)). Ego resiliency is another factor of personality which should develop as a person matures. Being ego resilient means being flexible in response and need to control one‘s environment ([Hofer et al., 2010](/dissertation/references)). Effortful control is a strong component of this type of resiliency. Another aspect of the development of resiliency is socialization, the ability to find healthy support and maintain positive relationships. A key developmental component of socialization is familial expressiveness, both verbally and nonverbally ([Hofer et al., 2010](/dissertation/references)). In a healthy family situation, instead of repressing negative emotions, or having chaotic expression of them, children with parents may learn to express negative emotion in a beneficial manner, rather than have to regulate it by repression. Power (2004) found a high relationship between quality of a person‘s parenting and quality of a person‘s ability to cope, as well as high correlation between

resilience and high effortful control. In the Hofer et al. (2010) cross-sectional study of French adolescents, a few limitations existed: (a) no causal relationships between parenting and development of resiliency were made; and (b) no peer responses were included, despite the importance of peers during adolescent development. Other contributors to resiliency. Over the past 30 years of research into resiliency, a number of factors contributing to development of resiliency have been posited: trusting relationships, emotional support outside the family, hope, responsible risk taking, sense of being lovable, unconditional love from someone, a sense of mortality, as well as spiritual belief ([Grotberg, 1998](/dissertation/references)). The International Resilience Project ([Grotberg, 1998](/dissertation/references)) found that genetic makeup and temperament in childhood were important components. At the time of Grotberg‘s study, Erikson‘s theories of development were used internationally without distinguishing gender or cultural/ethnic differences, limiting the study‘s generalizability. Another limitation, typical of that period of child-focused resiliency research, the participants were young children, from birth to eleven years of age. Conditions of the environment during development have also been found important to resiliency growth. Less researched, but perhaps as important, are factors of the environment at the time of the adversity, and how they support or detract from resilient reactions. The cultural context, use of humor, and foundation of spirituality are part of the climate in which resiliency can be developed. Environment and Culture. Antonovsky (1987) spoke of salutogenic factors of resiliency which could be developed in a biopsychosocial environment. The seven

elements of salutogenic resiliency are mastery, self-directedness, cooperativeness, optimism, humor, and a sense of coherence ([Hansson et al., 2008](/dissertation/references)). Working with veterans and service members when they have just returned from armed duty presented clinicians with an immediate environment of chaos and post-traumatic stress disorder ([Voss Horrell, Holohan, Didion, & Vance, 2011](/dissertation/references)). Restoration of coherence was essential for both the clinicians and their patients. If the working environment for the clinicians was not supportive, CF, secondary traumatic stress (STS), VT, or some combination of stress conditions developed. On the other hand, resiliency to these serious conditions could be developed within a caring workplace culture. This supportive culture could even lead to positive change for the clinicians, such as vicarious posttraumatic growth, and compassion satisfaction ([Voss Horrell et al., 2011](/dissertation/references)). Having support from coworkers and administration is key to positive results from coping with traumatized people. Voss Horrell et al. (2011) presented a number of preventive measures (seen in Table 2) which can be taken by an organization and its clinicians. In their summary, Voss Horrell et al. (2011) spoke of the urgent need for clinicians to work within a supportive environment, and welcome assistance from trusted colleagues. ―Working with victims of trauma fundamentally and unavoidably changes the way you see the world‖ ([Voss Horrell et al., 2011, p. 85](/dissertation/references)). In a very different environment and culture, Borofsky and Fox (2009) investigated resiliency among Hawaiian youth who had attended culture-based schools. In 2000 the first Native Hawaiian charter school opened, followed by 11 more. The goal of these schools was ―to bring ancient wisdom to modern life‖ ([Borofsky & Fox, 2009, para 3](/dissertation/references)).

Table 2 Suggested Preventive Measures Against Vicarious Trauma, Burnout, and Compassion Fatigue ________________________________________________________________________ Organizational Clinician ________________________________________________________________________ Reduced clinicians‘ caseload size Engage in leisure activities outside work Divide responsibility for trauma Balance caseload with variety of patients patients between multiple providers Allow clinicians autonomy in Create a strong support system outside scheduling of work Provide appropriate resources (e.g., Be aware of PSTD [CF, STS, or VT] in manuals, test materials, etc.) self Provide support staff to manage Seek therapy if necessary administrative issues Encourage discussion and healthy Seek support from other colleagues debate among team members Offer peer-support groups for staff Nurture one‘s spiritual self Provide training related to trauma- Keep abreast of current research on specific issues and evidence-based practices evidence-based practices Provide supervision opportunities for all Seek supervision as needed clinicians (regardless of licensure) Encourage diversity in staff responsibilities Maintain a balanced workload (e.g., (e.g., supervision, research, etc.) engage in activities other than clinical duties, such as research and teaching) (continued on next page)

(Table 2 continued) ________________________________________________________________________ Organizational Clinician ________________________________________________________________________ Provide opportunities for staff development Participate in professional development activities and continuing education Regularly reward staff successes Maintain good physical health (e.g., sleep, hygiene, exercise, healthy eating) Encourage intake interviews prior to clinician assignment ________________________________________________________________________ From ―Treating Traumatized OEF/OIF Veterans: How Does Trauma Treatment Affect the Clinician?,‖ by S. C. Voss Horrell, D. R. Holohan, L. M. Didion, & G. T. Vance, 2011, Professional Psychology: Research and Practice, 42(1), p. 81. Reprinted with permission. Being surrounded by a supportive culture with familiar values led to an increase of resiliency in the young people. Another study of correlation between culture and resiliency was conducted in 2010 by Thomas, who was interested in indigenous children in British Columbia. The Métis Nation, known for their ability to resist colonization, developed a code of ethics with conceptual similarities to good social work practice: children are sacred, and deserving of love and compassion. Familial bonds, identity, and spirituality are integrated parts of the Métis tradition ([Thomas, 2010](/dissertation/references)). Using a transcendental social paradigm, Thomas studied the Métis traditions as another valid reality, a social environment in which resiliency was developed naturally. Aspects of this supportive culture include ―intention, naming, tradition, play, and ritual‖ ([Thomas, 2010, p. 94](/dissertation/references)). Another indigenous

aid to developing and maintaining resiliency is humor as part of the healing process ([P. Carmoney, personal communication, March 28, 2012](/dissertation/references)). Humor. Having a sense of humor has been considered a favorable personality trait underlying resiliency ([Veselka, Schermer, Martin, & Vernon, 2010](/dissertation/references)). There are several types of humor, according to Veselka et al. (2010):  Affiliative humor: Joking in order to strengthen interpersonal bonds.  Self-enhancing humor: Using humor to bolster outlook and cope with stress.  Self-defeating humor: Remarking in a self-disparaging way in order to create interpersonal bonds.  Aggressive humor: Using sarcasm and ribbing to demean others and rise above them. The Veselka et al. (2010) study examined what they termed mental toughness, using the MT48, a Big Five factors of personality standardized test, and the Humor Styles Questionnaire (HSQ), developed by one of the study authors. Their theory, based on common sense, was that positive humor (affiliative or self-enhancing) aids in resilience, but negative humor (self-defeating or aggressive) does not. The study report did not indicate validity or reliability factors of either test. Both tests have been used, however, by other researchers, including Hampes (2010). Using the HSQ and the Interpersonal Reactivity Index (IRI), Hampes studied the relationship between humor styles and empathy. A high positive correlation between self- enhancing humor and perspective-taking empathy resulted, as well as a negative

correlation with personal distress. Affiliative humor did not have these correlations, although it was positively correlated with measures of empathic concern. A strong negative correlation existed, as might be expected, between aggressive humor and all types of empathy—cognitive, perspective-taking, and emotional ([Hampes, 2010](/dissertation/references)). Coping with traumatic events, particularly for first responders, frequently leads to what is known as gallows humor ([Alvarado, Scott, S. T., Scott, R., & Bledsoe, 2011](/dissertation/references)). In a 2003 study, Haslam and Mallon found gallows humor was the most commonly cited coping strategy ([Alvarado et al., 2011](/dissertation/references)). This type of humor is based on either the immediate event, or the ongoing stress of jobs and life situations, and is considered by some to be crass and untasteful. In fact, however, a few studies have shown that satirical treatment of a serious or frightening event has the benefits of increasing positive relationships within a cohort, providing a sense of belonging to a supportive team, and acting as a release valve for accumulation of stress ([Alvarado et al., 2011](/dissertation/references)). Although gallows humor can help strengthen resiliency for first responders, other characteristics need to be present to help find meaning in the violence and chaos of their work ([Green & Conrad, 2002](/dissertation/references)). Strengthening an individual‘s resilience by any means, from use of humor to attention to spirituality, can lead to personal transformation ([Canda & Furman, 1999, Joseph, 2005](/dissertation/references)). Spirituality. Religion and spirituality overlap, but they are different concepts. Canda and Furman (1999) defined spirituality as ―an aspect of a person or group dealing with a search for meaning, moral frameworks, and relationships with others, including ultimate reality‖ (p. 44). Religion, which can be an important element in a person‘s

resiliency, is a concrete, organized expression of spirituality. ―Spirituality can exist without religion and religion can exist without spirituality‖ ([Farley, 2007, p. 3](/dissertation/references)). Table 3 Spiritual Components that Enhance Individual Resiliency ________________________________________________________________________ Trait Spiritual/religious components that support ________________________________________________________________________ Insight Mechanism for explaining the world: Spiritual nature may provide drive to find meaning. Independence Transcendence of daily living through various rituals and experiences Relationships Caring, compassionate, affirming community alternatives comparable to family. Initiative Transforming self and the world: Service to help, heal, save and reconcile. Creativity/humor Spiritual source, inspiration to create beauty: Transformation. Morality Multiple systems for integrity with values, ethics and social justice. ________________________________________________________________________ From ―Making the Connection: Spirituality, Trauma and Resiliency,‖ by Y. R. Farley, 2007, Journal of Religion & Spirituality in Social Work, 26(1), p. 6. Reprinted with permission.

Spirituality can help, as part of resiliency, to provide structure for interpretation, definition of identity, and help in forgiveness ([Greene & Conrad, 2002](/dissertation/references)). Through spirituality an individual can look beyond a personal reality, and experience something greater ([Farley, 2007](/dissertation/references)). This part of resiliency has been difficult to assess, although future qualitative studies may may describe more fully how spirituality aids in resiliency. Farley (2007) suggested spiritual components which could enhance resiliency (see Table 3). Having hope and finding reassurance during stressful experiences are part of the development of resiliency ([Williams, 2002](/dissertation/references)). ―Spirituality deepens and expands a person‘s values and perspectives, allowing for the possibility of viewing adversity as an opportunity for personal growth and development‖ ([Williams, 2002, p. 205](/dissertation/references)). Transformation of stressful life experience into something in which one can find meaning, heightened self-value, and increased connection with one‘s universe, has often been seen in healthcare and psychological professions. Posttraumatic growth and vicarious resiliency. According to traumatic stress researchers, resiliency involves more than resisting maladaptation ([Roisman, 2005](/dissertation/references)), and may lead to actual growth, what Linley and Joseph (2005) termed adversarial growth. Some nurses have experienced this, rather than developing CF: They actually feel stronger because of their satisfaction in being able to help ([Abendroth & Flannery, 2006](/dissertation/references)). 71 Vicarious resiliency, appreciating what one has learned from stressful experience, may strengthen the sense of well-being. HCPs may be able to incorporate what they learn from their clients and patients healing processes ([Hernández, Engstrom, & Gangsei, 2010](/dissertation/references)). This strengthener of resiliency can counteract deterioration toward CF, increase motivation, and find new ways the HCPs can take for healing themselves. Figley‘s (2002) model (see Figure 1) demonstrates that compassion and empathy relate to finding self- satisfaction in stressful or traumatic work; prolonged exposure to the client‘s trauma can cause CF. Posttraumatic growth is a phenomenon where trauma survivors find positive transformation from the traumatic experience ([Hernández et al., 2010](/dissertation/references)). A new point of view occurs, ―the recognition of new possibilities for one‘s life, a greater appreciation of life and personal strength, and spiritual development‖ ([Hernández et al., 2010, p. 71](/dissertation/references)). A form of altruism may develop, a wider view of the larger community, as well as increased compassion. The difference between vicarious resilience and posttraumatic growth is the point of focus: vicarious resilience is within the HCP; posttraumatic growth takes this new resiliency outward to clients, patients, and community ([Hernández et al., 2010](/dissertation/references)). Removal of risk factors may help reduce CF, but developing positive health beyond resiliency, as described by Seligman (2008) and others ([Cameron & Brownie, 2010; Linley & Joseph, 2005; McMullen, 2007; Roisman, 2005](/dissertation/references)) may be possible based on the findings of the present study and related research into the people who do not develop CF. Developing resiliency, without attenuating compassion, is necessary in order to provide quality care. If the characteristics leading to resilience and positive health are

determined, creative treatment and training methods could encourage health practitioners to strengthen them in each other ([Gregerson, 2007; Seligman, 2008](/dissertation/references)).

Phenomenological Methodology

Studies of phenomena which affect people subjectively, and which occur outside of controlled environments, do not lend themselves to the objectivity, experimental control, and exact measurement of positivist, quantitative methods ([Davis, 1998](/dissertation/references)). Because the research questions of the present study examine subjective perceptions, values, and meanings ascribed by health professionals to CF resiliency, qualitative research was most appropriate. The qualitative methods which could have been used were case study, narrative analysis, ethnography, grounded theory, and phenomenology. Case study, as used by Figley (2002) in providing foundational research into CF, is appropriate for holistic, intensive inquiry into one or several individuals‘ experience. A limitation of case study is that findings cannot be generalized until additional research is performed ([Creswell, 2007](/dissertation/references)). Narrative analysis is pertinent for exploring one or several individuals‘ life history, but does not have a narrow focus on a single type of event or phenomenon ([Creswell, 2007](/dissertation/references)). Ethnography describes a group experience shared through a culture, and may be used in a study of resiliency within the medical profession, but would not have the depth of investigation found in phenomenology ([Creswell, 2007](/dissertation/references)). For the research questions of this study, phenomenology was particularly suited for discovering the essence of an experience or recurring situation and the meanings people ascribe to it ([Moustakas, 1994; van Manen, 1990](/dissertation/references)). Several forms of

phenomenological study exist in the social sciences. These are explored in the next section, with an explanation of why I chose to base my methodology on a combination of the research methods of van Manen and Moustakas. The strength of phenomenology lies in the possible development of a rich, poignant description of lived experience ([Finlay, 2009](/dissertation/references)). In contrast to quantitative research, using methodology paradigms based on the physical sciences, phenomenology allows deeper penetration into the meanings ascribed to a situation, such as resiliency to CF ([Moustakas, 1994; van Manen, 1990](/dissertation/references)). Various forms of phenomenology have been used increasingly in studies of medical concerns, due to the ability to explore the ambiguity present in the subjective experience of illness or wellness ([Finlay, 2009; Rapport & Wainwright, 2006](/dissertation/references)).

Approaches to Phenomenology

The philosophical phenomenology of Edmund Husserl, Maurice Merleau-Ponty, and others influenced the development of methodological phenomenology used in the human sciences. It was not intended as a procedural model to be used in research ([Earle, 2010](/dissertation/references)). Basically phenomenology studies how we experience life ([D. Smith, 2008](/dissertation/references)). For Husserl, intentionality referred to the structuring of forms of experience, a conscious directedness of experience through concept, thought, and image, a type of mindfulness ([D. Carr, 1977; Husserl, 1931, 1970a; D. Smith, 2008](/dissertation/references)). From the philosophical foundations of phenomenology seven traditions developed ([D. Smith, 2008](/dissertation/references)), each leading to a variation of research methodology:

1. Transcendental constitutive phenomenology: the study of experience of objects and events within pure or transcendental consciousness, without regard to the natural world. Moustakas was interested in this, as will be discussed later in this section. 2. Naturalistic constitutive phenomenology: the study of conscious experience of situations in the natural world. 3. Existential phenomenology: the study of human experience in concrete situations, with a focus on free will. 4. Generative historicist phenomenology: the study of how experiential meaning is generated over time as collective experience. 5. Genetic phenomenology: the study within an individual‘s experience of the development of meanings of experiences and objects. 6. Hermeneutical, or interpretative, phenomenology: the study of how we interpret readings, works of art, our interactions with others. Heidegger (1968) was heavily instrumental in developing this. Van Manen (1990) used it as foundation for his research methodology in pedagogy. 7. Realistic phenomenology: the study of human conscious interaction with external reality. Inherent in these different methodological processes is the iterative process of gathering information, engaging with the participants. In contrast to content analysis, where the researcher knows beforehand what is to be discovered, phenomenological methods aim at having no presuppositions or specific expectations ([van Manen, 1990](/dissertation/references)).

Van Manen

In 1990 van Manen proposed specific guidelines for studying a single event or recurring episodes from first person points-of-view, based on Heidegger‘s hermeneutical phenomenology. Van Manen (1997) believed that memory and reflection of experience is based on language. Therefore phenomena can be understood through the structure of language: ―All experience, all human interactions, as some kind of text‖ ([van Manen, 1997, p. 39](/dissertation/references)). Language itself, in both creation and interpretation, deepens understanding of the phenomenon. Writing and research are part of retrospective, rather than introspective, reflection in phenomenological analysis. Three paramount guidelines van Manen proposed were: (a) reflect on essential themes, the essence of the lived experience; (b) maintain a strong, oriented focus; and (c) balance the research context by considering both components and whole ([van Manen, 1990, pp. 30-34](/dissertation/references)). Writing and rewriting is a key element of the process of hermeneutical phenomenology. The treatment of redundant information, not necessarily important philosophically, may be significant psychologically ([Giorgi, 2006](/dissertation/references)). In other words, instead of omitting similar statements, the researcher will create a composite statement indicating the general frequency or value placed on the theme by the participants. The holistic nature of phenomenology is therefore preserved, revealing meaning units, and values, as well as context.

Moustakas

The transcendental phenomenological approach developed by Moustakas was based on a dynamic model which evolved as the essence of the phenomenon was

uncovered ([Davis, 1998](/dissertation/references)). Moustakas‘s term ―transcendental‖ referred to a methodology which included the process of Epoché, acknowledging the presence of the researcher in the study ([Giorgi, 2006; Moustakas, 1994](/dissertation/references)). In this interpretation, Epoché refers to putting away previous knowledge, schema, and suppositions while gathering the new data, but retaining within the researcher a transcendental consciousness ([Moustakas, 1994](/dissertation/references)). Moustakas (1994) used systematic phases in collecting and analyzing data, with iteration of any phase as new information arose. In addition to the textural description of the phenomenon which van Manen focused on, Moustakas believed a structural description should also be developed ([Moustakas, 1994; van Manen, 1990](/dissertation/references)). The textural description of the experience ―includes [the] thoughts, feelings, examples, ideas, [and] situations‖ each individual has had with regard to the phenomenon ([Moustakas, 1994, p. 47](/dissertation/references)). The structural description of an experience provides the ―underlying and precipitating factors that account for what is being experienced,‖ and ―the conditions that must exist‖ ([Moustakas, 1994, pp. 97-98](/dissertation/references)). Part of the phenomenological process is to decrease any barriers to participation in research, to increase the autonomy of participants, and to validate the individuals‘ experiences ([Creswell, 2007](/dissertation/references)). Both van Manen and Moustakas found the researcher‘s field journal useful as part of the paradigm, encouraging humanistic considerations of the participants and the phenomenon. In the field journal a researcher includes her own experiences, feelings, thoughts, as well as field data ([Moustakas, 1994](/dissertation/references)). Moustakas, in addition, advised the use of an interview worksheet to guide the process, maintain focus, and prevent side excursions which may tempt the researcher

([Creswell, 2007](/dissertation/references)). In Moustakas‘ heuristic process the self of the researcher is present throughout the study, incorporating self-discoveries into the findings. While gathering information, however, the interviewer should bracket her own attitudes and assumptions, and remain as quiet as possible in order not to bias the descriptions and explanations of the participants. Combining heuristic phenomenology with the hermeneutic approach in considering the life experiences of the participants, it is possible to elicit new ideas, feelings, and points of view. For example, the interviewer uses a reductive process to describe what is perceived beyond the words.The interview and analysis phases generally require iteration, obtaining new views, and continuing until there is saturation of information. A third phase in Moustakas‘s phenomenological process is imaginative variation. During this phase various positions, roles, or points of view which might occur with regard to the phenomenon are imagined. The purpose is to develop structural descriptions, the foundational and precipitating factors which account for the participants‘ experiences ([Moustakas, 1994, pp. 97-98](/dissertation/references)). The specific steps for imaginative variation are presented later in [Chapter 3](/dissertation/chapter-3) within the section, Data Analysis. Gaps in Knowledge

Counterarguments and Limitations of Prior Research

A convergent definition of empathy does not yet exist, although increased attention to the neural underpinnings of various aspects of empathy are bringing better understanding. There is no consensus about the distinctions between CF, secondary

trauma stress, vicarious trauma, and similar difficulties. Insufficient research exists into the interaction between emotional contagion and the psychoneuro-immunological system. The contradictory results of studies of the affects of stress or depression on the immune system may have been due to differences in duration and style of the methodology, cross- sectional rather than longitudinal, as well as due to not controlling for confounding variables such as chronic disease, disability, nutritional status, obesity, marital changes, psychotropic drugs, smoking, and alcohol consumption ([Fortes et al., 2003](/dissertation/references)). Other studies did not take consideration of within-individuality variations of immunity or depression levels over time ([Fortes et al., 2003](/dissertation/references)). The presence of mirror neurons as explanation for sensorimotor simulation and mimicry is strong, but it is not universally accepted as explanation for empathy or emotional contagion ([Thioux, Gazzola, & Keysers, 2008](/dissertation/references)). Due to the automatic and unconscious nature of emotional contagion, it is difficult to make conscious attempts to regulate it ([Williams, Bargh, Nocera, & Gray, 2009](/dissertation/references)). The Williams et al. (2009) study was based on the hypothesis that nonconscious self-regulatory processes, which are not subject to the same limitations as conscious processes, would help. They found that in the complexity of real-world environments, this hypothesis could be successful. Another area where studies may be limited is in the measurement of empathic accuracy ([Zaki, Bolger, & Ochsner, 2009](/dissertation/references)). Empathic accuracy occurs when the perceiver is able to correctly identify the internal state of the person observed. Little research has yet been done in examining the specific types of information which support empathic accuracy. As more research is done on empathy, a growing number of psychologists

favor a combination of ToM, TT, simulation theory, and PSS as an explanation. Various studies of empathy and emotional contagion differ concerning which explanation of empathy is a subset of which, or whether everything is linked in a complex network of multifunctional brain sources of empathy. Understanding how to intervene with negative emotional contagion, as part of CF, could help reduce the occurrence of this debilitating syndrome. More in-depth neuroscience research relating emotional contagion to the psychoneuroimmunological system is greatly needed. In addition, the use of qualitative research methodologies like phenomenology may give more depth of definition to CF, empathy, emotional contagion, and resiliency.

Areas for Future Investigation

Too little is known about the positive outcomes from dealing with trauma, such as posttraumatic growth and vicarious resilience. Most of the studies about CF have been correlative, quantitative, based on limited populations, and focused on risk factors, rather than resiliency strengths. Little is known about what contributes to resiliency to CF ([Cameron & Brownie, 2010](/dissertation/references)). No research has yet been done on the outliers, the people who are empathic, yet resilient, and do not develop CF in situations where most others do. Although an increasing amount of research is being done studying the neural links of empathy, there are no apparent studies of the connection between chronic negative emotional contagion and the psychoneuroimmunological system. It would be interesting to know what specific immune reactions occur to any type of emotional contagion.

Although Hatfield and her colleagues (1992, 1994, 2009) have studied the ―what‖ of emotional contagion, and Rothschild (2006) has presented ways to circumvent negative reactions from emotional contagion, more research is needed into the effectiveness of these interventions, and what actually happens neurologically if emotional contagion is interrupted or stopped. Other areas of research which need to be studied:  How does emotional contagion occur when a person has limited sensory input?  Who is most vulnerable? And when?  What are the social implications if a person has more ability to ―infect‖ others with emotional contagion, or if a person has a lower or higher ability for healthy emotional contagion?  Are there other explanations of emotional contagion (e.g., morphic field theory) which are valid?  What happens if someone consciously tries to imitate (e.g. neuropsychological programming) another‘s emotion?  What are the most effective ways to teach people to be more adept in understanding others‘ emotions, and improving their own emotional intelligence, and yet retain resiliency to CF?

Summary of Chapter

This chapter began with the mechanics and organization of the literature review. Empathy was demonstrated as a necessary capability in order to have compassion, as well as CF ([Figley, 2002](/dissertation/references)). Emotional contagion, particularly negative emotional contagion

due to continued contact with patients and their families, also can lead to CF ([Grafton et al., 2010](/dissertation/references)). Resiliency based on insight, balance of control and independence, strong relationships, initiative, humor,creativity and flexibility, is needed to cope with CR ([Alkema et al., 2008; Wolin & Wolin, 1995](/dissertation/references)). Because phenomenology is the method used in this study, the chapter ended with an overview of the phenomenology of Moustakas (1994) and van Manen (1997) which I will use in the study. The purpose of the chapter was to provide a foundation of what has been researched and written about these elements—empathy, emotional contagion, CF, and resiliency—and also to indicate what limitations and gaps exist in this knowledge. The following chapter will discuss in detail the methodology used, and its rationale. In reviewing the different studies presented here, researchers may need to pay more attention to meta-analyses, and interlink research of all concepts of empathy— anthropological, developmental, evolutionary, sociological, cognitive, and emotional. As a result, it may be possible, with intense clinical intervention, to develop empathic responses where deficits now exist ([Wolf et al., 2001](/dissertation/references)). The neural circuits regulating social behaviors, including empathy, may therefore overlap with those regulating visceral homeostasis. An individual‘s capacity for empathy and emotional contagion is a dynamic characteristic which exists on a continuum. Emotional contagion, as part of empathy, facilitates social interaction. As part of CF, however, emotional contagion can make a person vulnerable to absorbing negative emotions (e.g. fear, anger, sadness) and stress. Fortunately, if a person‘s cognitive empathic ability is strong, this can be used, with training, to inhibit emotional contagion ([Rothschild, 2006](/dissertation/references)). There is, however, no single composite theory of resilience ([Greene & Conrad, 2002](/dissertation/references)).