I have recently extended my own experience with books to a certain subgroup of difficult-to-treat children in my practice. These children tend to have neurocognitive issues that burden the unfolding of their emotional lives, including the development of empathy. They may have a nonverbal learning disability, Asperger's syndrome, high-functioning autism, mild retardation or traumatic brain damage. They find it hard to read social cues and to understand the responses of classmates, teachers and family members. For such children, at some point in their treatment, I introduce books and writing exercises that focus on the alternative point of view. I have found, at a minimum, that my patients' increase in intellectual understanding of the alternative viewpoint in the literary realm helps them function better in the real world. I have yet to determine whether such an understanding leads to the capacity for empathy.
Empathy is a complex developmental accomplishment whose origins are not fully understood, but the existing psychoanalytic literature reveals a convergence on the fundamentals of the subject. Heinz Kohut, M.D., and his followers believe that the capacity to empathize begins in early life with adequate mirroring between infant and mother. If the child is not neurocognitively intact, normal development will be challenged. Erna Furman likewise believed that the capacity for empathy is rooted in early childhood. In an article titled "Feeling and Being Felt With," she explained that for empathy to develop, the infant requires a mother who can intuitively sense the child's affective state while maintaining the knowledge that the child's state might be different from her own (Furman, 1992). This experience allows the infant to form a sense of self. Over time, with the ongoing consolidation of the sense of self and neurocognitive maturation, the child can accept the existence of others' alternative viewpoints and feelings. Daniel Stern, M.D., (1985) and Peter Fonagy, M.D., (undated) have each furthered theoretical understanding of the development of self versus other in children.
In the realm of alternative-viewpoint fiction is an array of classic fairy tales retold from another character's perspective. For example, I have used an edition of Jack and the Beanstalk with my patients that, if read right side up and front-to-back, tells the standard tale from Jack's perspective; if read instead upside-down and back-to-front, the book recounts the story as the giant sees it. My patients experience a concrete example of a world turned upside-down: The contemplative giant's household is invaded by a thieving, destructive brat. Other examples of alternative-viewpoint fairy tales include various versions of the lupine perspective on Little Red Riding Hood; The True Story of the 3 Little Pigs! by Jon Scieszka (aka A. Wolf) (1989); also Gregory Maguire's Wicked: The Life and Times of the Wicked Witch of the West (1996) and his Cinderella redux, Confessions of an Ugly Stepsister (2000). Representative of alternative-viewpoint adult fiction are Ahab's Wife (Moby Dick) by Sena Jeter Naslund (2000), John Gardner's Grendel (Beowulf) (1972), Jean Rhys' The Wide Sargasso Sea (Jane Eyre) (1996), Anita Diamant's The Red Tent (the story of Dinah from the book of Genesis) (1998), Rosencrantz & Guildenstern Are Dead (Hamlet) by Tom Stoppard (1991) and The Mists of Avalon (the King Arthur legend) by Marion Zimmer Bradley (2003).
Several journalists have adopted an extreme version of the alternative-viewpoint approach in order to report on societal ills; they "become" one of the afflicted about whom they are writing. In the harrowing Black Like Me, white journalist John Howard Griffin (1996) ingested medication to darken his skin, and then traveled the 1950s South to experience life as a black man. Griffin detailed the slow diminishment of his vitality as he is maltreated by white people he encounters. He wrote:
My deepest shock came with the gradual realization that this was not a matter of inconvenience, but rather a total change in living ... I became two men, the observing one and the one who panicked, who felt Negroid, even to the depths of his entrails.
In the fictional Gentleman's Agreement, by Laura Z. Hobson (1979), magazine reporter Phil Green is assigned to write a piece on anti-Semitism in America. Eager to viscerally understand the experience of discrimination, Green adopted a Jewish identity--Phil "Greenberg"--to powerful effect. Even those closest to him are exposed, often to their own surprise.
Barbara Ehrenreich (2001) used the same journalistic technique in Nickel and Dimed: On (Not) Getting By in America. Here, she attempted to capture the experience of the poor by leaving her home for a year and earning her own way through menial jobs. She worked as a cleaning lady, waitress, nursing home aid, only to realize that a single job does not provide enough money for subsistence. She wrote movingly of her despair in living on the edge in shacks or decrepit motel rooms without money, without health insurance and often hungry. Her sojourn into poverty was at times so unbearable that she contemplated returning home. And that, of course, is the weakness in the "journalistic" approach to the alternative viewpoint: our own awareness that the main character, although profoundly enlightened, can resume a previous, less burdensome life. Such books probably cannot generate empathy in readers who lack the emotion to begin with--like my patient "Suzy."
Suzy is 10 years old, the only child of an interracial couple and severely impaired by Asperger's syndrome. Despite her basic beauty, she has a slovenly appearance, as though some strange magnetism randomly attaches clothes to her body every morning. Watching her play, I'm tempted to infer that she enjoys her weekly sessions with me, but I find it hard to read her emotions. Her affect is flat and reveals little. Several times she has asked me to accompany her to school so that I might witness her frustrations; evidently she cannot believe I can comprehend her plight unless I am there with her. My hope is that through a multi-modal, multi-sensory therapeutic approach--plus a hefty dose of compassion on my part--Suzy will, at a minimum, function better in her daily life.