Zero Degrees of Empathy_ A new theory of human cruelty - Simon Baron-Cohen-pages-4.pdf

schizophrenia). We now know it is really very different to schizophrenia, but what is known about its cause? Blame the parents One of the earliest child psychological theories of borderlines was Object Relations Theory. This argued that, if parents don’t respect their child’s needs, or abuse or negl...

schizophrenia). We now know it is really very different to schizophrenia, but what is known about its cause? Blame the parents One of the earliest child psychological theories of borderlines was Object Relations Theory. This argued that, if parents don’t respect their child’s needs, or abuse or neglect their child, the child will become borderline. Object Relations Theory stems from four important psychodynamic ideas. The first is that of the ‘significant other’ (typically a parent), who is the ‘object’ of a child’s feelings, and to whom the child looks to meet his or her needs. The second is Freud’s notion of stages of development that a child has to successfully negotiate to establish a healthy personality. The third is the Freudian principle of the importance of the earliest relationship influencing all later ones. The fourth idea (stemming back to Hungarianborn New York psychoanalyst Margaret Mahler) is that typical infants start in an ‘autistic phase’ of development, where they feel fused with their mother, and then later separate and individuate. During this ‘separationindividuation phase’, the child establishes their sense of self, crucial for later mental health. This process balances the healthy needs for autonomy and for closeness on the one hand, and the unhealthy fear of ‘engulfment’ and abandonment on the other. Otto Kernberg developed these ideas into an explanation of borderlines. He is a professor of psychiatry at Weill Cornell Medical College and Director of the Personality Disorders Institute at the college, and was born in 1928 in Vienna. xxiii Like Mahler, Kernberg believed infants start off in an autistic state and have to build their first relationship, out of which comes a concept of self. During the phase of separating and individuating, the typical child uses a defence mechanism known as ‘splitting’. Good experiences are split off from bad ones. For Kernberg, the natural process of development is to be able to integrate these splits both into accepting the self as comprising good and bad parts, and into accepting the parent as having both good and bad parts. In Kernberg’s account, a child who gets stuck at the splitting stage and who never achieves that integration enters into a ‘dissociative’ state and is destined to become borderline. It could be because the mother frequently pushed her child away or provided no closeness, or the mother may have made it hard for the child to explore the world by clinging too much to her infant. Therefore the child feared he would be abandoned (if she let go) or engulfed (by her holding him too much). Or a dissociative state could be as a result of more extreme deprivation or maltreatment, such as child abuse. The result is a child who never achieves a sense of being an emotionally secure adult. Being stuck with the split, the good experiences and the good image the child has of the parent can be amplified or exaggerated into idealization of the other and a grandiose view of oneself, while the bad experiences are quarantined into a cesspit of negative feelings (anger and hate). The result is an intense need for attachment, an intense fear of abandonment, and a conflict-ridden relationship with the mother. So much for Object Relations Theory. It is a clever theory, because it makes sense of some central characteristics of borderlines, such as the black and white thinking style and the switching that can occur from extreme love to extreme hate. However, many of its predictions about parenting are quite subtle for scientists to measure. How much is too much – or how little is too little – when it comes to hugging your toddler? And it suffers, like many theories of its day, from a bias towards ‘mother-blaming’ that neglects other potential environmental factors (including abusive fathers, step-parents or others in the caregiver role). An easier way to test Object Relations Theory is to take the clear-cut cases of child physical abuse (when children are identified as having been battered, for example) or child sexual abuse, or child neglect (when children are identified as having been left alone for unusually long periods). When you look at children who have had such experiences, and follow them up, certainly there is plenty of evidence for a link with becoming borderline in adulthood. 101 , 102 Common within families of children who later grow up to become borderline are incest, child abuse, violence and alcoholism. Obviously, the link between child abuse and becoming borderline is not total: not all who are abused go on to become borderline, and not all those who are borderline were abused. In fact, 80 per cent of those with a history of sexual abuse are not borderline. 103 110 – Nevertheless, the link is strong. Between 40 and 70 per cent of borderlines report a history of sex abuse. 105 Between 60 and 80 per cent of borderlines also had a history of physical abuse, or early parental separation through divorce, or emotional neglect, indifference, deprivation and rejection. 111 Thus, there is plenty of evidence for early developmental trauma causing a person to lose their empathy in this uniquely borderline way (though this is not a necessary and sufficient cause). The borderline brain Remarkably, despite the unstable behaviour of Type Bs, scientists have managed to study their brains, which are definitely different in much of the empathy circuit. First, there is decreased binding of neurotransmitters to one of the serotonin xxiv receptors. 112 Just as we might expect, these abnormalities occur in brain regions within the empathy circuit: the ventromedial prefrontal cortex (vMPFC) and middle cingulate cortex (MCC), and areas of the temporal lobe, among other areas. 112 , 113 Neuroimaging also reveals abnormalities in the empathy circuit in the Type B brain, particularly underactivity in the orbital frontal cortex (OFC)/vMPFC, and in the temporal cortex, all parts of the empathy circuit. And when reading a script about ‘abandonment’, there is less activity in empathy brain regions such as the amygdala, the vMPFC and MCC, the inferior frontal gyrus (IFG) and the superior temporal sulcus (STS). Other studies have found increased amygdala activity on both sides of the brain during emotionally aversive slides. Similarly, while looking at emotional faces, borderlines show increased left amygdala activity. 114 121 – Finally, a recent study found that when Type B individuals play a ‘trust’ game, they show no signs of being able to maintain or repair broken attempts to co-operate with other individuals. Neural markers related to co-operative and trusting gestures (the anterior insula or AI), active in typical individuals, were completely absent in Type B individuals. 122 A novel approach has been to follow up people who were abused as children and scan their brains. It is novel because it is prospective rather than retrospective: the emotional damage was done in childhood and the scientific question is ‘what happens to their brain?’ Not all of them will be Type Bs, but a significant proportion will be. Such people again have abnormalities in the empathy circuit, such as having a smaller amygdala. This is also true of women who were sexually abused, who later show less grey matter in their left medial temporal cortex, compared to non-abused women. Smaller hippocampal volume is also found in people who experienced a trauma and went on to develop post-traumatic stress disorder (PTSD). 123 – 129 One interpretation of all this evidence is that the early negative experiences of abuse and neglect change how the brain turns out. But the key point is that the zero degrees of empathy in borderlines arises from abnormalities in the empathy circuit of the brain. ZERO-NEGATIVE TYPE P Our next encounter with a form of zero degrees of empathy is the psychopath (or Type P). When we meet the psychopath we see a person who shares that same total preoccupation with oneself as we saw in Type B. But, in this case, there is a willingness to do whatever it takes to satisfy their desires. This might take the form of a hair-trigger violent reaction to the smallest thing that thwarts them. Or it might take the form of cold, calculated cruelty. Sometimes the mindless aggression is not triggered by a perceived threat but by the need to dominate, to get what one wants, a complete detachment from another person’s feelings, and possibly even some pleasure at seeing someone else suffer. (The Germans have a word for xxv this: schadenfreude. ) I think you’ll find it a small step to conceptualize Type P as what some people call ‘evil’, but the questions we keep returning to in this book are whether this is the result of zero degrees of empathy, and if this is in turn the result of the empathy circuit not developing and functioning in the normal way. But first let’s look at a real case of a psychopath. Paul: Type P Paul (not his real name, to protect his identity) is twenty-eight years old and is currently detained in a secure prison after being found guilty of murder. I was asked to conduct a diagnostic interview with him by his lawyer, and, because his violence meant it could have been unsafe for him to come to our clinic, I went to see him in the prison. He told me how he had wound up in jail. He insisted he wasn’t guilty because the man he stabbed had provoked him by looking at him from across the bar. Paul had gone over to the man and said, ‘Why were you staring at me?’ The man had replied, I assume truthfully: ‘I wasn’t staring at you. I was simply looking around the bar.’ Paul had felt incensed by the man’s answer, believing it to be disrespectful, and felt he needed to be taught a lesson. He picked up a beer bottle, smashed it on the table, and plunged the jagged end deep into the man’s face. Like me, the barrister at Paul’s trial was shocked by the apparent lack of remorse and the self-righteousness of his plea of not guilty. In my questioning I probed further for some evidence of moral conscience. Paul was adamant that he had simply defended himself. ‘He humiliated me in public. I had to show him I wasn’t a doormat.’ I asked, ‘Do you believe you did anything wrong?’ Paul replied, ‘People have treated me like shit all my life. I’m not taking it from no one no more. If someone shows me disrespect, they deserve what they get.’ I probed further: ‘Are you sorry that he died?’ I waited to hear Paul’s answer, holding my breath. He replied with anger in his voice: ‘Were the kids at school sorry when they bullied me? Was my boss sorry when he fired me? Was my neighbour sorry when he deliberately hit my car? And you ask me if I’m sorry that that piece of shit died? Of course I’m not sorry. He had it coming to him. No one’s ever been sorry for how they’ve treated me. Why should I give a fuck about him?’ This wasn’t Paul’s first offence. He had been in prison six times since he left school at sixteen, for offences that include shoplifting, drug dealing, rape and violent assault. He’d left school with no qualifications, and his career of criminal behaviour had begun when he was as young as thirteen, when he had set fire to the school gym and sat in a tree across a field to watch it burn. He was expelled and from there went to three more schools, each time being expelled for aggression – starting fights in the playground, attacking a teacher who asked him to be quiet, and even jumping on someone’s head when they wouldn’t let him join the football team. As a very young child, the warning signs had been there. At eight years old, he was cruel to his cat, finding it amusing to tie a brick to her back leg and to film her trying to walk. For as long as his mother could remember, Paul had told lies, about both small things (saying he had done his homework when he hadn’t) and bigger things (saying he had gone to school when he hadn’t). Truanting led to staying out all night, even at twelve years old, without telling his parents or getting their permission. Stepping back from Paul Paul is clearly not the kind of guy you want to live anywhere near. Many would not hesitate to describe him as ‘evil’. He is a psychopath – though to give him the proper diagnostic label, we should say he has Anti-Social Personality Disorder (see Appendix 2 for the list of ‘symptoms’ required for this diagnosis). He earns this label because he shows ‘a pervasive pattern of disregard for and violation of the rights of others that begins in childhood or adolescence, and continues into adulthood’. 131 Anti-Social Personality Disorder is diagnosed if someone is over eighteen years old and if they previously had a different diagnosis, Conduct Disorder, in childhood. In Paul’s case, he clearly did. Not all cases of Conduct Disorder grow up into Anti-Social Personality Disorder, but many do (at least 40 per cent). In the general population, about 3 per cent of males (but only 1 per cent of females) have Anti-Social Personality Disorder. In prison samples, the rates are – perhaps unsurprisingly – much higher: about half of all male inmates would warrant this diagnosis, and a quarter of all female inmates. 132 And some people with Anti-Social Personality Disorder – like Paul – are psychopaths. Psychopaths The full name for Paul’s condition is Psychopathic Personality Disorder – or what I call Zero-Negative Type P. About 15 per cent of prison samples are psychopaths, and just less than 1 per cent of males in the general population. Cleckley’s 133 xxvi The concept of the psychopath goes back to 1941, to Hervey 134 book The Mask of Sanity. As its title suggests, Cleckley was concerned with how to recognize a psychopath if he or she is convincingly pretending to be normal. He argued that psychopaths show: superficial charm a lack of anxiety or guilt undependability and dishonesty egocentricity an inability to form lasting intimate relationships a failure to learn from punishment poverty of emotions a lack of insight into the impact of their behaviour, and a failure to plan ahead. Let’s look at the second of these a little more closely: a lack of anxiety or guilt. To me, these two emotions are connected to Type Ps very differently. Clearly, someone who lacks guilt will be capable of doing bad things without worrying about how they themselves will feel later, let alone worrying how someone else might feel. If you have empathy you will be capable of feeling guilt, while if you lack empathy, you won’t. This might make you think that guilt and empathy is one and the same thing: clearly this cannot be true, since a person can feel guilt (e.g., that they went through a red traffic light) without necessarily feeling empathy. So empathy can give rise to guilt but guilt is not proof of empathy. The relationship between anxiety and psychopathic behaviour is also important, since someone who lacks anxiety will be capable of doing bad things without worrying about being punished. But anxiety by itself is not part of empathy. It merely provides a rationale for why one might not hurt another person. Notice that several of the features in the above list also centre on a lack of empathy: a lack of insight into the impact of his or her behaviour, and egocentricity. As we discussed in Chapter 2, intrinsic to poor empathy is lack of self-awareness, which is probably synonymous with a lack of insight. Psychiatrists are very fond of the term ‘insight’, and here we see the considerable overlap between these concepts. Take for example a person who hurts someone without meaning to (perhaps by saying the wrong thing). Here, the lack of insight is part and parcel of the lack of empathy. In terms of how willing we are to forgive an unempathic act, one might judge that if we hurt another person without realizing it, this is less bad than if we hurt someone else knowingly. Hurting someone knowingly is sometimes also referred to as ‘premeditated’. From Cleckley’s definition, a psychopath might be capable of both kinds of unempathic act. Lacking any sense of guilt might mean one could hurt a person knowing they would indeed hurt; but lacking any insight into the impact of one’s behaviour means that one might hurt someone without realizing it. Interestingly, Cleckley’s definition of a psychopath makes no mention of physical aggression or of breaking the law, which hints at how psychopaths may not come to the attention of the criminal justice system and may be at large in society. They may be the ‘snakes in suits’ in any workplace. 135 While this phrase has become somewhat clichéd, I know of no better way to convey the idea of how Type P might be camouflaged. Clearly, some psychopaths hurt others through physical aggression, but the breakthrough in Cleckley’s formulation was to extend this concept to those who are aggressive in more subtle, invisible ways. A milder form of Type P might be what is sometimes called the ‘Machiavellian’ personality type, or people who are what Richard Christie and Florence Geis called ‘high Machs’: individuals who use others for their own self-promotion. They will lie to get what they want. 136 We saw that a major risk factor in becoming Type B is one’s experience of parental rejection in childhood. I want to dwell on this a bit longer, because how your mother (or father) treated you turns out to be very important both for the development of healthy empathy, and for the risk of becoming Zero-Negative Type P as well. Parental rejection can lead to a child growing up to become violent or a psychopath. It may not be the only factor, but it can be an important one. One reason why parental rejection might be linked to a child developing aggression in adulthood is that inside – emotionally – the child is quietly raging against the parental rejection and is developing high levels of hate. Such extreme, negative emotions are hard to regulate. The child has to vent their rage somewhere and, if as a child they were unable to express it towards the rejecting parent, it may build up, like steam in a pressure cooker, just waiting to be vented in adolescence and adulthood. The result can be explosive violence. Parental rejection was famously studied by John Bowlby, a psychoanalyst and child psychiatrist at the Tavistock Clinic in London. It was here that he developed his remarkable Attachment Theory that explored (on the negative side) the consequences of parental rejection and (on the positive side) the consequences of parental affection. I say remarkable because the theory made predictions that have been amply proven and are socially extremely important. According to Bowlby, the infant uses the caregiver as a ‘secure base’ from which to explore the world, feeling that, when they move away from their parent, they can also return to him or her for ‘emotional refuelling’. (The caregiver is often but not necessarily the child’s biological mother or father.) By giving praise, reassurance and a feeling of safety, the caregiver’s affection helps the child manage his or her anxiety, develop self-confidence, and trust in the security of the relationship. My paraphrase of Bowlby’s theory is this: what the caregiver gives his or her child in those first few critical years is like an internal pot of gold. The idea – which builds on Freud’s insight – is that what a parent can give his or her child by way of filling the child up with positive emotions is a gift more precious than anything material. That internal pot of gold is something the child can carry inside throughout their life, even if they become a penniless refugee or are beset by other challenges. This internal pot of gold is what gives the individual the strength to deal with challenges, the ability to bounce back from setbacks, and the ability to show affection and enjoy intimacy with others, in other relationships. It overlaps with what London child psychiatrist Michael Rutter refers to as ‘resilience’. 137 Bringing this back to psychopaths (and other forms of Anti-Social Personality Disorder), if you trace backwards, such individuals typically have a higher rate of what Bowlby called ‘insecure attachment’. xxvii 138 , 139 Bowlby’s original study, aptly published in 1944, was a careful look at adolescent delinquency, and was entitled Forty-Four Juvenile Thieves, Their Characters and Home Lives. It was the impetus for his theory. What I find important in this work is that it argues that security of early attachment between an infant and his or her caregiver predicts not just how emotionally well-adjusted an individual turns out as an adult, but also predicts their moral development. (Moral development and empathy are not one and the same thing, since it is possible to develop a strong moral code even in the absence of empathy. We’ll come back to this later.) Bowlby’s forty-four thieves were – in his chilling words – ‘affectionless psychopaths’. They showed shallow relationships, having been in and out of children’s homes or institutions, forming superficial relationships with dozens – if not hundreds – of adults. In Bowlby’s view, deep, trusting relationships with just one or a small number of caregivers are vital. Such secure relationships promote both social development (popularity at school, good social skills, turn-taking, sharing) and language development (better communication). Even more, securely attached infants later also develop better empathy and ‘theory of mind’ (being able to accurately infer others’ thoughts). Those with insecure attachments have a higher rate of social difficulties, including anti-social behaviour, and, later in life, a higher risk of divorce in adulthood. Bowlby studied psychology as part of medicine at my college (Trinity College) in Cambridge. He later forged close links with Cambridge ethologist Robert Hinde, who extended Harry Harlow’s seminal studies of monkeys reared without mothers to see the effects of maternal deprivation. This animal model – while ethically questionable xxviii – has taught us a lot about how, in social primates (whether humans or monkeys), a difficult attachment relationship not only increases the risk of the monkey developing aggression, mistakenly interpreting friendly approaches as aggressive, but also in turn increases the risk of the child growing up to become a parent who is harsh and abusive. 140 Now you can see why I describe Bowlby’s Attachment Theory as remarkable. It predicts trans-generational effects. Astonishingly, it also predicts effects outside the narrow realm of social development, in that securely attached infants grow up to become academically more successful at school. This may be because the ‘internal pot of gold’ gives the child that sense of self-confidence and self-esteem to have the courage to explore new areas of learning, and to persist in the face of failure. It may also be that secure attachment makes the child a better mind-reader, both of someone else’s and of their own mind, so that they can reflect on what they know and don’t know, and therefore can learn how to learn. Following his important study of the forty-four thieves, Bowlby was commissioned by the World Health Organization in 1951 to write a report, Maternal Care and Mental Health, which transformed how we care for young children in both schools and hospitals, making such environments more child-friendly and parentfriendly. impact? xxix What other psychological theory has had such far-reaching 141 Clearly insecure attachment is on a spectrum, and relevant to the development of a psychopath are the negative experiences at the most severe end that may go along with childhood separation, such as inconsistent parental discipline, parental alcoholism, lack of supervision, physical, sexual or emotional abuse, or complete abandonment. 142 The argument – from the ‘internal pot of gold’ – is that insecure attachment of this more extreme form increases your risk of becoming Zero-Negative. 143 My old friend Peter Fonagy is a professor of psychoanalysis at University College London and Director of the Anna Freud Centre in Hampstead in London. He is one of those rare scientists who has taken interesting ideas from psychoanalysis and tried to test them empirically. He argues that during the attachment relationship, the infant tries to ‘mentalize’ their caregiver’s mind. The child’s relationship with his or her parents is the crucible for learning about other people. The child not only imagines what their mother is thinking or feeling about people and things in the immediate environment, but, more importantly, what their mother is thinking or feeling about them. He argues that developing empathy proceeds well only if it is safe to imagine another person’s thoughts and feelings. But if when you mentalize you imagine that your mother hates you or wishes you didn’t exist, this could derail the development of empathy. It is certainly an interesting argument, and there is some evidence that fits the idea that parental behaviour contributes to a child’s empathy. For example, parents who discipline their child by discussing the consequences of their actions produce children who have better moral development, compared to children whose parents use authoritarian methods and punishment. 144 And parents who use empathy to socialize their children also produce children who are less likely to commit offences, compared to the children of parents who use physical punishment. The Psychopathic Mind Moving from the early family environment, we can go a little deeper to probe what is going on within the mind of a psychopath. It will come as no surprise that, on questionnaire measures of empathy, psychopaths score lower than others. This can be seen, for example, on the Interpersonal Reactivity Index (IRI). 145 However, self-report is notoriously unreliable with psychopaths, since they typically lie to hide their true nature. To avoid this, researchers have resorted to physiological measures of autonomic arousal – how stirred up you become when you hear or see emotional material. 146 , Typically what is measured is galvanic skin response (GSR) – how much 147 you sweat on the palms of your hands when shown emotionally charged material. This reveals that psychopaths have reduced autonomic responsiveness (they are less aroused) while looking at pictures of individuals in distress. Psychopaths are also worse at naming fearful emotional expressions. 149 148 , This suggests that people who are Type P have difficulty with both of the two major components of empathy (recognition and response). Another clue that psychopaths are not processing emotional material in the normal way is that, whereas most people are faster to judge ‘is this a word?’ when they are shown emotional words (relative to their speed at judging neutral words), psychopaths do not show a difference between emotional and neutral words. A method to measure how aroused you are by emotional material is to use event-related potentials (ERP). These show electrical activity in the brain measured by placing electrodes on your scalp. Psychopaths do not show the usual increase in brain activity over the central and parietal regions of the brain in response to emotional words. 150 , 151 As we saw with Paul, one other difference in those who are aggressive is the tendency to interpret ambiguous situations as if the other person has hostile intent. This has been found in children with conduct disorder, some of whom go on to become psychopaths, and is referred to as an ‘attributional bias’, 152 a clear example of the cognitive aspect of empathy not working accurately. One view of the psychopathic mind is that they are simply amoral. The classic test of morality was developed by Kohlberg: you are asked to read a story and judge the morality of the story’s character. The famous example is of the husband who breaks into the chemist shop to steal an anti-cancer drug for his wife, who is dying of cancer, because the chemist refuses to sell the drug for less than $2000 (even though it cost the chemist only $200 to make). You are asked to judge if the husband was wrong or not. The more complex your ability to reason about such moral dilemmas, the more advanced your moral reasoning is judged to be. If you can see two sides of an argument, or that context might change the rights and wrongs of an act, this is taken as a sign that you have a subtler mind than someone who simply reasons on the basis of rules. Contrary to what one might expect, psychopaths do not necessarily score lower on such tests. 153 This may be because psychopaths can say one thing, even though in their day-to-day life they will do another. Kohlberg’s method of measuring moral reasoning is not the only approach. On Elliot Turiel’s tests of moral reasoning, the stories describe not just moral transgressions – acts that violate human rights (e.g., hurting another person) – but also conventional transgressions – acts that violate social conventions (e.g., talking in a library). You are asked to judge how bad an action was, and whether it would still be wrong if there was no rule banning it. By four years old most children can tell the difference between these two types of transgressions, and recognize that while you can change the rules for conventional transgressions so that the act is no longer a transgression (you can announce that in this particular library, talking is allowed), if you modify the rule for a moral transgression (announcing it is now legal to hurt others) that doesn’t make the act any less bad than before. 154 Psychopaths have trouble with this kind of distinction, as do children with anti-social behaviour. 148 , 155 So this tells us that, as well as not showing emotional reactions to others’ distress in the normal way, psychopaths are also blunted in their moral development. But is this simply because psychopaths are less intelligent? There is a clear link between low IQ, low socio-economic status (SES), and anti-social behaviour. The link between low IQ and low SES could be because in poorer neighbourhoods there is a greater likelihood of poorer education. But why should low IQ and low SES increase your risk of developing anti-social behaviour? One reason could be because, without educational qualifications or a job, crime may be a way to make a living. Low IQ may also make it harder for someone to imagine the consequences of getting caught. But the fact that intelligent psychopaths exist shows that low intelligence cannot explain everyone who becomes a psychopath, and the fact that empathic individuals with low IQ also exist, proves that empathy and IQ must be independent. Jeffrey Gray was a professor of psychology in London’s Institute of Psychiatry who I had the pleasure of working with in the early 1990s. He