What is Hostile Empathy?

 

I put up a few posts recently that emphasize empathy and why that is important in psychiatric practice.  I have also posted my favorite definitions by empathy – right out of Sim’s text on psychopathology (1).  I was surprised to see the term hostile empathy being used in social media today and in a publication (2) from the Bulletin of Atomic Scientists.  This post considers the original source, its use, and whether it really has anything to do with the technical definitions in psychiatry.

It turns out that the journey to hostile empathy takes you back.  Not back to the time it was used in psychiatry, but back to a discussion of ethnic violence in Indonesia (4) in the 1990s and before that to the early 1980s when “putting oneself in the shoes of a political adversary” was considered a form of realistic empathy as a possible basis for foreign policy.  That writing was done by military analysts, politicians, and anthropologists rather than psychiatrists.    

The original reason for this post is a paper on the Trump administration’s hostile empathy as evidenced by their reduction in aid to the needy both in the US and abroad (2) and the expected toll in morbidity and mortality. The author lists a source that estimates that 110,772 adults and 231,141 children had already died at the time of the paper’s publication largely through acute cuts in food and medical care needed to treat tuberculosis, HIV, malaria, diarrhea, and pneumonia. That is an obvious large human cost for what represents a tiny fraction of the federal budget. Tens of thousands of deaths are also anticipated from the administration’s cuts to Medicaid.  The bombing of Hiroshima and Nagasaki is given as a comparison where anywhere from 110,000 to 210,000 people are estimated to have died.  How can the intentional and ongoing humanitarian catastrophe by the abrupt cut in aid be rationalized?

The author suggests it is like the work of choosing nuclear targets during the Cold War.  The analysts had to distance themselves from any empathy they might have for their potential victims as they chose targets.  That distancing could be justified by the presence of a crisis and bureaucratization that rewarded people for target selection rather than empathy.  In the case of the Trump administration all the cuts are being rationalized as a crisis – even though they add significantly to the debt and could easily have been made through other mechanisms. The most obvious alternate mechanism would have been to not replace federal workers who were retiring or moving to different jobs. In the two most recent years that would have resulted in a decreased of 7.6% (147,000 positions in 2023) or 5.4% (115,900 in 2024).  It is now well known that despite their lack of transparency the savings from Elon Musk’s Department of Government Efficiency (DOGE) have been scaled back considerably from the original $2T dollar figure to a current $170B ( a 92% reduction).  Even that number is complicated by the costs of defending against several lawsuits and other miscellaneous charges that may have cost the taxpayers another $135B.  In addition, the Trump administration fired 18 Inspector Generals who saved the taxpayers anywhere from $90B to $183.5B without the disruption and compromised security.

Looking at the net effect so far – it seems that empathy is not at play at all.  The people receiving aid and the government employees affected were not consulted or understood at all.  In fact, a top administrator in the Trump cabinet said:

“We want the bureaucrats to be traumatically affected. When they wake up in the morning, we want them to not want to go to work, because they are increasingly viewed as the villains. We want their funding to be shut down … We want to put them in trauma.”  - Russell Vought – Director of the Office of Management and Budget 

This is not empathy or hostile empathy of any sort. This is open hostility to public servants in the service of an intolerant ideology by an administration that has so far shown that they have very few positives for the American people.  This cabinet member is also one of the architects of Project 2025 – a unilateral document designed to treat the Executive branch of government as an autocracy for the benefit of a particular ideology. Again – no empathy involved.    

A couple of issues came up and I made my way through the Bubant paper.  The first was the issue of word meaning for different groups and how language is used. Most people invoke Wittgenstein’s language games to make that point and I will join them.  In this case anthropologists and social scientists are clearly using empathic in a much different manner than psychiatrists. A psychiatrist does an interview seeking a deeper understanding of the person they are talking to.  They are looking for individual specific responses – life experiences, cultural factors, traits, symptoms, preferences, behaviors, and dynamics. The goal is to learn those well enough that the person would recognize them if the psychiatrist describes them (Sims).  Some may be recognizable at the group level. The author in this case is describing group characteristics and responses at a global level.  There is also the implicit understanding that empathy is generally used to assist or help the person who is being understood.  It is not used for hostile or nefarious purposes.   

Rather than empathy – hostile empathy is stereotyping and there is a much greater chance for error.  Further – it is evident that it is a recipe for divisiveness and authoritarianism that requires recognizing stereotypes at the grossest of levels. 

The obvious example in this case is proclivity for violence – especially the severe forms described in the letter.  It is difficult to believe that any significant population would not have groups that would never perpetrate this violence or support it.  This approach to populations always depends on probabilities.  There is a probability that a subgroup will respond to divisive rhetoric in a violent way and produce the desired result. By contrast, a psychiatric interview is focused only on the person in the room and what makes them unique. The intention from that knowledge is focused solely on helping that person at some level.  That renders the concept of hostile empathy meaningless.

One of the thought experiments to figure out what is really going on when people plan to bomb, attack, or otherwise incite violence in a population they dislike is looking at the decision making involved.  From a cognitive behavioral standpoint – it can easily be seen as a case of emotional reasoning.  Emotional bias is needed to some degree for most decisions but a heightened bias – by a crisis or appearance of a crisis – leads to more impulsive decisions.  The United States at the highest levels of government have made several including 3 unnecessary wars during my lifetime and the recent attack on Iran.  All these actions were based on false premises and resulted in significant loss of life, resources, and good will.  Keeley (4) has noted this recurrent pattern since the time of wars between prehistoric villages.  As he reviews the social, economic, and cultural factors associated with warfare empathy is not a factor.  He makes the case that prehistoric wars were as significant as modern warfare and probably more deadly.  On the question of war being common Keeley says this:

“Thus pacifist societies seem to have existed at every level of social organization, but they are extremely rare and seem to require special circumstances….. the idea that violent conflicts between groups is an inevitable consequence of being human or social life itself is simply wrong.  Still, the overwhelming majority of human societies have made war.  Therefore, while it is not inevitable, war is universally common and usual.” (p. 32)

Empathy of any kind is not a factor in war.  I would argue that the absence of any sustained successful peace initiatives in the world is related to two factors – the lack of emphasis on peace (even though the advantages are obvious) and a lack of any institution with the ability to enforce peace through dispute resolutions.  The driving force would appear to be the dispute and jumping to the conclusion that armed conflict is the only possible resolution.  Checks and balances on the decision makers within the country is also a factor.  In the United States, Congress is the only branch of government that has the authority to declare war and yet we have seen two Presidents in recent times start a war without that authorization. 

The lessons for psychiatry are clear.  If you are writing about empathy use the correct definition or at least a definition that is consistent with the psychiatric application.  Secondly, don’t accept loose definitions from other groups or contexts to apply to the field.  The best examples I can think of are epistemic and hermeneutic injustice.  These are non-psychiatric terms that are used to criticize the field. Outside criticism is common in psychiatry – but it does not need to be incorporated into the field particularly when the primary goal of the field is to understand each individual patient and their social and cultural context.   

 

George Dawson, MD, DFAPA

Supplementary 1:  I am of course aware of the fact that the authors of hostile empathy never intended to incorporate it into psychiatric technical jargon.  It merits consideration solely based on how non-technical terms show up in our papers.  I provided the examples of epistemic and hermeneutic but there are many more.  Deprescribing is a good example of a word and the associated rhetoric. Any psychiatrist who prescribes a drug knows how to stop it.  If you were ever an acute care psychiatrist – detoxification from drugs and alcohol is a necessary skill.  Many of those situations involve massive doses and polypharmacy.  And yet deprescribing was introduced a few years ago based on the false premises that psychiatrists do not alter medications (they just add more) and they do not know how to stop drugs. The reality is nobody knows more about it than acute care psychiatrists.  I have been presented with shopping bags full of medications for psychiatric, cardiovascular, endocrine, and neurological indications in the same confused patient who could not tell me what they were taking and I had to decide in the space of a few hours what to continue and what to discontinue. Physicians are not taught to deprescribe.  They are taught to discontinue medications.  I did that and taught people how to do it for over 35 years.  And yet we now find papers using the deprescribe term and writing like they are experts in a newly discovered field.  That is a significant problem with allowing people to invent the language of your profession.

Image credit:  My 2010 photo of the Painted Mountains in Denali National Park.  

References:

1:  Sims A.  Symptoms in the Mind: An Introduction to Descriptive Psychopathology. 3^rd ed. London: Saunders; 1995

2:  English E.  The consequences of the Trump administration’s hostile empathy.  Bulletin of the Atomic Scientists.  June 16, 2025   https://thebulletin.org/2025/06/the-consequences-of-the-trump-administrations-hostile-empathy/

3:  Nash HT. The bureaucratization of homicide. Bulletin of the Atomic Scientists. 1980 Apr 1;36(4):22-7.

4:  Bubandt N. From the enemy's point of view: Violence, empathy, and the ethnography of fakes. Cultural Anthropology. 2009 Aug;24(3):553-88. https://anthrosource.onlinelibrary.wiley.com/doi/10.1111/j.1548-1360.2009.01040.x

5:  Keeley LH.  War Before Civilization: The Myth of the Peaceful Savage. Oxford: Oxford University Press. 1994.

 

 

The Freak Show

 

When I was a kid my aunt and uncle took my siblings and me to a multicounty fair about 70 miles from our home town. I was probably about 11 years old at the time and withdrawn and introverted – just trying to make sense of the world. When you live in small towns, fairs are always a big deal. It is a rare approximation of big city life. The only place where you could see that many people in one place. There were the usual carnival rides, carnival food, carnival smells, and carnival people. An odd mix of farm life with the exotic. Felliniesque is a description that comes to mind not so much for the surreal atmosphere but the jarring presentations of unusual appearances and behaviors.  And keep in mind this was all about 40 years before the Internet.  In my town at the time we had 3 very grainy black and white TV networks and on any given day only 2 out of three were working. They all broadcast standard network TV and signed off the air at midnight.

The most Felliniesque location at the fair was the Midway – a long thoroughfare bordered by tents and trailers on each side.  Vendors were selling cotton candy, caramel popcorn, snow cones, and hotdogs and the odor of that food was always in the hot, humid air. It was a noisy place due to the carnival barkers shouting to get people to come to their attraction. My only experience with carnival barkers before that was my well-travelled Grandfather’s imitation of one and he was right on.  There were games of skill that involved tossing rings or baseballs at targets, or shooting air rifles.  In those days it was typically 35 cents to try and if you won – the prize was some sort of stuffed toy animal. The games clearly favored the house.  There was usually an obvious gimmick that made it very difficult to win. It was common to see a young couple at one of these games, with the guy spending a lot of money in order to get one of these prizes for his girlfriend. The idea that these strangers were in town to unfairly take your money added to the excitement of wanting to beat them at their own game. Some of the carnival workers knew how to add commentary to keep people coming back without getting them too excited or angry.  I watched all of that at a distance and did not take a chance on the games.

The most disquieting aspect of the carnival was the Freak Show. At the time – I am sure the term had fallen out of favor replaced by “human oddities” or similar terms, but everybody still called it The Freak Show.  In just a few years it would be appropriated by the hippie generation and reinvented as a positive social term as in “let your freak flag fly.”  Those attractions had colorful and primitive graphics adding to the bizarre cartoon like appearance.  “Man-eating Amazon rats” displayed 7 or 8 rats chewing on a horrified man. Similar signs proclaimed significant alterations in appearance or deformities. Superlatives were everywhere as the “World’s tallest, fattest, strongest, shortest….”  In order to get people to pay the price of admission to the trailer there was typically stage with an introduction where you could get a glimpse of the attraction. I remember watching a middle-aged man extrude his eyeballs out at the crowd to a mixed reaction of amazement and disgust.  He was the most animated and expressive.  All the other human oddity performers seem bored and they were expressionless. I listened to the local people coming out of the attractions talking about how they were disappointed that the part human, part canine man was just a paper mâché creation in a glass case or that the bearded lady was just a short obese man wearing a dress.

I found the entire Freak Show atmosphere very unsettling. It just seemed wrong to me. I was always taught to mind my own business and treat everybody the same no matter what their appearance. In a Freak Show – those norms go out the window.  The social norm suddenly becomes excitement, excessive commentary, and mixed derision some due to people feeling like their expectations for the unusual were not met and some feeling like they were ripped off. It was an embarrassing display of a lack of empathy and I was embarrassed to be there.  In today’s parlance some might say I was traumatized by the event but I won’t go that far. I went home and thought about it for a long time.  What that lifestyle would be like. What it is like to consent to participate. I would see occasional TV shows with similar themes about these potential conflicts.  Workers were who coerced into these positions based on their appearance  and overworked, but I never saw any real-life stories where that was true. Eventually the memory faded.

As a freshman in a liberal arts college, English literature and composition was a year long required course. Kafka’s A Hunger Artist was one of many required readings. In this short story Kafka describes a man who is basically a side show attraction based on his skill in fasting. He sits in a cage on straw and fasts initially to the accolades of an observing public who admired him at a distance.  He is managed by an impresario who limits the fast to 40 days based on entertainment rather than health concerns – public interest fades at that point. Eventually public interest fades altogether and he signs on with a circus where he is eventually ignored during his fasting.  Even though he always knew he could fast much longer than 40 days and was past that point - both he and the circus staff stopped counting.  He was eventually discovered near death when the apparently empty cage was inspected. He speaks briefly about wanting to be understood and how his fasting was easy because he never found a food that he liked. A definitive interpretation of Kafka’s essay is not available and there are multiple interpretations.  Food seems like a metaphor for the attention of others and that we need more than literal food for sustenance. It speaks to the general case of people who are marginalized in society and may need to take desperate measures for social contact. In the end the Hunger Artist rejects food/social contact.  He dies and is buried with the rotten straw in his cage.

Was a Freak Show a similar attempt to establish social contact? A more typical interpretation is the practical one – it is just a way to make money or more commonly a way for these people to make money. If there were societal safety nets, would these shows need to exist?  It seems that there is a top-down way to deal with the problem and that is just banning these venues or making them so culturally unacceptable that they would not exist.  A societal safety net would be the bottom-up approach - adequate income, housing, medical care, and empathic support.  The reality today is that I don’t see either of those approaches happening.

I have not been to a fair in at least 10 years.  The last one I attended was the second largest state fair in the country.  There were no Freak Shows or human oddities, but they still exist, usually on television where much more biographical content is provided.  The sensationalism associated with them has been taken over by the Internet where any observer can basically see whatever they want ranging from 3 minutes clips of soft (or hard) core pornography to watching Komodo dragons swallow livestock whole headfirst to watching someone split firewood.  

Various authors have suggested the dopaminergic effects of watching sensational videos and the importance of taking a break from all that dopamine. Like most neuroscience in the popular press that is undoubtedly an oversimplification.  Flashing back to my childhood experience – there is a right and a wrong way to do things.  Even as a kid I did not need to be shamed into avoiding freak shows, but one of my colleagues assures me that some people need to be and that shame is not necessarily a bad thing.  

Widespread acceptance of high frequency and indiscriminate sensationalism does not seem like a good development for society. Instead of attending a rare annual event - people can engage in this activity all day long and every day.  It has occurred with the expansion of exploitation from just the marginalized to everyone and resulted in a much coarser general audience for public discourse. There is some discussion about the lack of critical thinking skills - but that critical thought starts upstream from the cognitive processes with emotion and some clearcut ethical rules and knowing that your excitement may be clear violation of those rules.

We need to figure out ways to move beyond the Freak Show existence.  We already know some of those rules. We need to do it before AI makes things a lot worse. 

 

George Dawson, MD, DFAPA  

 

 

 

Image Credit:

Jack Delano, Public domain, via Wikimedia Commons https://commons.wikimedia.org/wiki/File:Freak_show_1941.jpg "Freak show 1941" https://upload.wikimedia.org/wikipedia/commons/thumb/1/19/Freak_show_1941.jpg/512px-Freak_show_1941.jpg

Compassion Fatigue? Or Sometimes You Eat The Shark And Sometimes The Shark Eats You

I passed a pamphlet for a conference on Compassion Fatigue today and thought to myself: "Why haven't I ever encountered the term compassion in medical school or at any point in my medical or professional training?"  If you look it up in a real dictionary there seems to be multiple meanings ranging from:  "A feeling of wanting to help someone who is sick, hungry, in trouble, etc."  to "a feeling of deep sympathy and sorrow for another who is stricken by misfortune, accompanied by a strong desire to alleviate suffering."  None of these definitions seems to capture what happens in medicine and how physicians are trained.  It seems like an undisciplined emotional reaction to human suffering.  That may seem a bit calloused to someone outside the field but would you want your surgeon operating on you in the throes of an emotional reaction?  Would you want your internist or psychiatrist recommending  medication for you during an emotional episode?  On the other hand, depending on what part of the definition I focus on,  I have already pointed out that in my opinion the overprescribing of medications is motivated at some level by "a strong desire to alleviate suffering."  More evidence that compassion may not be the best basis for medical decisions.

I can still recall the first patient that I was responsible for.  The very first patient I evaluated on Internal Medicine as a third year medical student.  He was not much older than me, but at that point he had a much harder life.  As he explained his symptoms to me and we did the examination, I found myself getting more and more anxious.  I realized that he had a very serious illness that he was not going to recover from.  I pulled all of the test results and x-rays together so I could present it in our team meeting in the morning.  I could barely get the information out to my chief resident and attending.  I was overcome with emotion.  My voice cracked.  I was tearing up.  My head was spinning.  I was focused on how unfair life was.  He was a young guy, just like me with the usual hopes, dreams, and relationships that we all have and through no fault of his own, he had developed a terminal illness.  I certainly wanted to help him, but there was nothing that could be done.  That happens so frequently in medicine, using the most emotional definition of compassion would render most physicians nonfunctional.  It tends to alter your focus.  The focus has to be on what is happening right here and right now and not the unfairness of the process.  The focus needs to be on the technical details or you can't provide competent care and tell people what they need to know.  As I have gotten older, I have an image for the process of unpredictable disease and death.  It reminds me of the war movie where the fleet is sunk and everyone is bobbing in the Pacific Ocean wearing life preservers.  Suddenly the sharks appear and people start to die on a random basis.  Whoever the sharks decide to kill.  A random horrific process.  That is my image.

It may explain the reaction of one of my attendings when I was a resident on a busy inpatient psychiatric unit.  I was reading the description of one of our consultants to him and the consultant used the adjective "unfortunate" to describe all of the medical problems the patient had sustained.  My attending glared at me and said: "Why is he unfortunate?"  It seemed like an obvious descriptor to me.  Anyone with all of these severe medical problems could be described as unfortunate, but I could not respond to him at the time.  It seems to me if the sharks get you or there is a near miss, unfortunate in the bad luck sense may be a good description.  He may have been thinking of another definition.  But I think he was most likely giving me the message that it is best to not even recognize the random walk through life and the fact that the shark can eat you at any time.  Without that element of denial, how can you function?  How can you function as a physician?

After you have talked with thousands of people about their traumas and adversities, you realize that most people suffer.  Personal biases make some people want to alleviate the suffering of some more than others.  Nobody wants to see children suffer.  There are some people who attract the ill wishes of others.  They are generally unlikable or they have perpetrated some kind of shocking crime.  There seems to be a likeability bias with compassion and that also makes it less useful for physicians.  Physicians are obliged to perform competent medical care irrespective of how well the person is liked.  There are often errors on the side of people who are very likeable.  Sometimes physicians and medical staff get very attached to  person based on their personality, physical characteristics, or demeanor.  You may want to help that likeable person more, but that doesn't translate into whether you can or not.

If you are trained to render assistance, save lives when you can and alleviate suffering where does the compassion that you had before medical school go?  Without invoking defense mechanisms it gets converted to other things that are adaptive in the profession.  Empathy and technical skill are good examples.  Empathy is probably a more accurate emotional appreciation of what is occurring in a person you are trying to help.  It is focused on that person and their emotional state and if reflected back to that person they would agree with the observations.  A better measure of burnout for physicians especially psychiatrists would be empathy fatigue rather than  compassion fatigue.  Seeing people as collections of symptoms and having no appreciation for the emotional side of their experience would be one example.  Seeing patients as an endless stream of problems that you need to fix rather than unique individuals would be another.  As the days get longer there are also the comparisons physicians make about how much time they spend taking care of others compared to how much time they spend with their families.  As the family time gets shorter it may be harder to empathize with increasing numbers of patients.

Whether it is compassion fatigue or burnout, these seminars all seem to teach the same things.  It is fashionable to refer to the skills as "tools".  Mindfulness techniques, cognitive behavioral therapy. relaxation techniques, meditation, diet, sleep, and exercise are all parts of the "toolkit."  Nobody ever seems to address the severely deteriorated work environment as a cause and ongoing factor.  Productivity demands on physicians in terms of the number of patients seen, the amount of documentation that needs to be done and the other aspects of being a good corporate citizen are a recipe for burnout and that is probably the most common job scenario for physicians these days.  Professional organizations seem to ignore that fact that if physicians are going to function the way they should and treat the whole person, a work environment without adequate time to talk with patients in one of the fast paths to burnout.

No amount of "tools" can reverse that.

George Dawson, MD, DFAPA

Supplementary 1:  In talking with people over the years and trying to help them stay on the job, the most significant problem is unreasonable employers.  People work in jobs where the job directly impacts their health.  The best example is alternating shifts and never being able to establish a regular sleep routine.  Hospitals are some of the worst offenders.  They have adopted policies that allow them to tell nursing staff that they need to work "mandatory doubles" when there are shortages.  The policies that have hospitalists working 7 days on and 7 days off are no better.  I have interviewed hospitalists about their cognitive efficiency on day 6 and 7 and have been told that it generally plummets.  They are taking twice as long to do the documentation and it is difficult to think.  I was in a similar position one year when I was running a 20 bed inpatient service with assistance of a physician's assistant.  I had to see everyone, everyday and managed both the medical and psychiatric diagnoses.  When I decided to stop doing that, I was replaced by two full time psychiatrists and an internal medicine specialist to take care of all of the medical problems.  Eventually those two psychiatrists felt it was too much work and a third psychiatrist was added to cover 4 of the 20 patients.  The adverse effect of a business model on employee health that operates on personnel expenses cut to the bone can not be overemphasized.  Hospitals and clinics will happily work medical staff to the point that it adversely impacts their health and lifestyle, adversely impacts their cognitive abilities at work, leads to burnout, and leaves them in a state where empathy is a thing of the past.

The only reason I quit running a 20 bed inpatient unit by myself was a colleague of mine who told me he did it for years - right up to the point he had his first heart attack.