Socialization and Empathy

**3**

**Chapter 1**

**Abstract**

**1. Introduction**

entities, such as A3ES,1

knowledge.

students.

Training

Critical Thinking in Social Work

It is the look at the that leads us to questioning and the answers guide us to updating and the production of knowledge. There is always, in the debates of social work professionals, the question of the search for an intervention project that gives a new meaning to the profession in order to respond, not only theoretically coherent but also efficiently, to the demands placed upon them. The purpose of this chapter is to highlight the importance of critical thinking in the training of social workers. The research is based on an exploratory study carried out with recently graduated university students, whose results point to the benefits of this soft skill in the ability to analyze, understand interactions, detect inconsistencies, systematic problemsolving, reflect on beliefs and values, and reintegrate information as a whole.

**Keywords:** critical thinking, social work, education, soft skills, knowledge

The development of skills in critical thinking by students of higher education is nowadays, faced by the challenges of society and the job market place, essential for professional and personal success. This theme has been the subject of increasing reflection and encouragement by different national and international bodies and

Forum, etc. However, despite the interest expressed, there is still a long way for critical thinking to be a generalized priority in the pedagogical practices of teachers, promoted in an intentional, systematic, and transversal way to any area of

social work and critical thinking at the LCT, we decided to carry out this exploratory study to understand the impact of this curricular unit on newly graduated

<sup>2</sup> It is a public University with 15 graduations, 49 masters, 22 PhDs, and around 8868 students.

which is critical thinking, was created in our university.<sup>2</sup>

<sup>1</sup> A3ES is our National Accreditation Agency for higher education courses.

Thinking about it, in 2009, the Soft Skills Lab (SSL) with the intention of giving students the possibility of complementing their curriculum with soft skills, among

A partial and non-critical view can compromise the performance of any professional, and it is no different with social workers. Common sense concepts are so embedded in our society that even social work students, most of the time, at the beginning of the graduation have a completely wrong idea about what the profession is. The knowledge provided by common sense lead people to believe that the

the European Commission, OECD, the World Economic

Being both teachers in

*Helena Belchior-Rocha and Inês Casquilho-Martins*

#### **Chapter 1**

## Critical Thinking in Social Work Training

*Helena Belchior-Rocha and Inês Casquilho-Martins*

#### **Abstract**

It is the look at the that leads us to questioning and the answers guide us to updating and the production of knowledge. There is always, in the debates of social work professionals, the question of the search for an intervention project that gives a new meaning to the profession in order to respond, not only theoretically coherent but also efficiently, to the demands placed upon them. The purpose of this chapter is to highlight the importance of critical thinking in the training of social workers. The research is based on an exploratory study carried out with recently graduated university students, whose results point to the benefits of this soft skill in the ability to analyze, understand interactions, detect inconsistencies, systematic problemsolving, reflect on beliefs and values, and reintegrate information as a whole.

**Keywords:** critical thinking, social work, education, soft skills, knowledge

#### **1. Introduction**

The development of skills in critical thinking by students of higher education is nowadays, faced by the challenges of society and the job market place, essential for professional and personal success. This theme has been the subject of increasing reflection and encouragement by different national and international bodies and entities, such as A3ES,1 the European Commission, OECD, the World Economic Forum, etc. However, despite the interest expressed, there is still a long way for critical thinking to be a generalized priority in the pedagogical practices of teachers, promoted in an intentional, systematic, and transversal way to any area of knowledge.

Thinking about it, in 2009, the Soft Skills Lab (SSL) with the intention of giving students the possibility of complementing their curriculum with soft skills, among which is critical thinking, was created in our university.<sup>2</sup> Being both teachers in social work and critical thinking at the LCT, we decided to carry out this exploratory study to understand the impact of this curricular unit on newly graduated students.

A partial and non-critical view can compromise the performance of any professional, and it is no different with social workers. Common sense concepts are so embedded in our society that even social work students, most of the time, at the beginning of the graduation have a completely wrong idea about what the profession is. The knowledge provided by common sense lead people to believe that the

<sup>1</sup> A3ES is our National Accreditation Agency for higher education courses.

<sup>2</sup> It is a public University with 15 graduations, 49 masters, 22 PhDs, and around 8868 students.

social worker is a kind of a *good Samaritan,* and this is only one of the challenges students are going to face.

Over time, reality is altered and new conceptions are incorporated into the way of living, learning, acting, interacting, and thinking. The new resources that are constantly added to the already existing ones have or should have the purpose of better serving the individual and society in general. Dealing with the new and complex situations of the contemporary world requires more and more expertise in ways of thinking and acting and relating. Faced with this reality of constant transformations, how can we find autonomy to decide on what is relevant, important, pertinent, and ethical? Critical thinking fits into this question, when it serves as a filter to select what should be harnessed or discarded in this actual avalanche of instantaneous information.

Reflective analysis on the theoretical foundations and intervention models allows social workers to re-equate the directionality of professional action in the context of critical thinking that frames objectivity and questions the reality where it is intervened, as well as the meaning of this intervention in its micro, meso, and macro levels from local to global and from global to local, an exercise that social works constantly need.

As Granja says:

Knowing in Social Work means understanding the social problems as total social phenomena that arise from the operation of the structures and social relations, without denying the particularity of the individual processes and act with a mission to prevent and repair the structural inefficiencies that prevent the poorest from accessing indispensable resources for building themselves as full citizens [1].

Knowledge about the transformation of social reality requires an investment that results from a reflexive activity involving professionals, in a link between theoretical knowledge and practice, through an interdisciplinary approach that requires a theoretical synthesis built with other areas of social sciences, namely psychology, sociology, anthropology and economics, law, public and social policies, among others, which aims to "change the systems of opportunities, promote social relations dynamics and overcoming the deficit of civic participation" [1].

Social work practice focuses on social problems, that is, lack of income, unemployment, isolation and breakdown of social ties, domestic violence, children and young people at risk, school drop-out and failure, and migrants and refugees, among many others which by their complexity require a multidimensional combination of vulnerability and the articulation with structural phenomena and current social policies.

It is better evident for all the importance that critical thinking has in the education of future professionals, although it is nothing new, given the fact that is always in the debates of social work professionals the question of the search for an intervention project that gives a new meaning to the profession in order to respond, not only theoretically coherent but also efficiently, to the demands placed.

Social work as a profession has always demanded critical abilities and qualities from its practitioners because decisions have to be made "on the spot" and under pressure. With practice situations being so complex, the consequences of any decisions and action are extremely important [2].

A reflexive practice leads to thinking through the mediation of concepts and allows to reconstruct the problems and to construct new ways of solving problems. The ability to select data and identify patterns in the professional activity in order to be recognized and transmissible to become sources of knowledge and to be prepare for lifelong learning. For the development of this reflection, it is necessary to have a structured thought about the phenomena that allow analyzing and constructing operational representations.

**5**

mentioned.

designed to develop it [8, 9].

*Critical Thinking in Social Work Training DOI: http://dx.doi.org/10.5772/intechopen.89538*

reflection and critical action [4].

problems that are dealing with.

This requirement goes beyond "competent practice" and demands "critical practice" [3], and the development of "critical being," that is, a person who not only reflects critically on knowledge but also develops their powers of critical self-

In the research that Ford et al. [5, 6] made on criticality with students in social work education, these ideas have been explored and they conclude that the intellectual resources for critical thinking are: (1) background knowledge; (2) critical concepts; (3) critical thinking standards; (4) strategies; and (5) habits of mind. This allows us to realize that this process has to be permanent and rooted as a mindset. The more we know about a situation and the circumstances that caused it, the better we can articulate with a structural question, be it social, economic, cultural, or political, including beliefs, values in order to clarify the range of available options and solutions, so that the professional can make an informed decision about the

Beginning to deal with this type of "how to" knowledge is where a practitioner's ignorance becomes obvious and can cause anxiety. It may well be the reason why many new qualified workers take a very prescriptive, rule-based approach to try to ensure they do not do anything wrong. In many ways such a focus on detail and correctness ensures that practitioners can be more critically aware of what they are

Gray et al. add that "Social workers need to examine closely the strengths and limitations of research evidence. Regardless of how strong the evidence for a particular intervention might be, social workers are in a position where they must critically reflect on their work in the political, social, organizational, and interpersonal contexts, make professional judgements, engage in debate with decision-makers about resource allocation, negotiate appropriate practices and, when necessary, argue convincingly for the effectiveness of the work that is done. This requires skills in formulating and presenting well-supported arguments and the interpersonal and

Based on these assumptions, we did a review of the literature and developed an exploratory study with the aim of understanding the perception of recent students

According to the literature, the importance of critical thinking skills is recognized in the academic and professional contexts, in which the need to implement measures that facilitate their development and awareness of their usefulness is

We find several approaches to critical thinking, some more vague, others more objective, but we cannot easily find a consensus between them, either in terms of definition, in terms of the terminology used, or in the type of methodology

The scientific areas in which we can find greater literary production and investigation around critical thinking are philosophy, psychology, and education [10–12]. We find different contributions from the disciplinary areas mentioned above in an attempt to define critical thinking, and there are no definitions that fit exclusively in one or another area, since many of these authors cross the areas in terms of the research they develop. It is not our goal to find the best definition of critical thinking, or even the most complete one. The various theories focus on different aspects, put the focus on different circumstances, conceptualized in a way that is not always consensual and sometimes even antagonistic. Despite the differences,

doing than experienced workers who have established routines [2].

written communication skills to convey a position convincingly" [7].

in social work about the importance of critical thinking.

**2. The importance of critical thinking in education**

#### *Critical Thinking in Social Work Training DOI: http://dx.doi.org/10.5772/intechopen.89538*

*Empathy Study*

students are going to face.

instantaneous information.

As Granja says:

social policies.

that social works constantly need.

social worker is a kind of a *good Samaritan,* and this is only one of the challenges

Over time, reality is altered and new conceptions are incorporated into the way of living, learning, acting, interacting, and thinking. The new resources that are constantly added to the already existing ones have or should have the purpose of better serving the individual and society in general. Dealing with the new and complex situations of the contemporary world requires more and more expertise in ways of thinking and acting and relating. Faced with this reality of constant transformations, how can we find autonomy to decide on what is relevant, important, pertinent, and ethical? Critical thinking fits into this question, when it serves as a filter to select what should be harnessed or discarded in this actual avalanche of

Reflective analysis on the theoretical foundations and intervention models allows social workers to re-equate the directionality of professional action in the context of critical thinking that frames objectivity and questions the reality where it is intervened, as well as the meaning of this intervention in its micro, meso, and macro levels from local to global and from global to local, an exercise

Knowing in Social Work means understanding the social problems as total social

Knowledge about the transformation of social reality requires an investment that results from a reflexive activity involving professionals, in a link between theoretical knowledge and practice, through an interdisciplinary approach that requires a theoretical synthesis built with other areas of social sciences, namely psychology, sociology, anthropology and economics, law, public and social policies, among others, which aims to "change the systems of opportunities, promote social relations

Social work practice focuses on social problems, that is, lack of income, unemployment, isolation and breakdown of social ties, domestic violence, children and young people at risk, school drop-out and failure, and migrants and refugees, among many others which by their complexity require a multidimensional combination of vulnerability and the articulation with structural phenomena and current

It is better evident for all the importance that critical thinking has in the education of future professionals, although it is nothing new, given the fact that is always in the debates of social work professionals the question of the search for an intervention project that gives a new meaning to the profession in order to respond, not

Social work as a profession has always demanded critical abilities and qualities from its practitioners because decisions have to be made "on the spot" and under pressure. With practice situations being so complex, the consequences of any deci-

A reflexive practice leads to thinking through the mediation of concepts and allows to reconstruct the problems and to construct new ways of solving problems. The ability to select data and identify patterns in the professional activity in order to be recognized and transmissible to become sources of knowledge and to be prepare for lifelong learning. For the development of this reflection, it is necessary to have a structured thought about the phenomena that allow analyzing and constructing

phenomena that arise from the operation of the structures and social relations, without denying the particularity of the individual processes and act with a mission to prevent and repair the structural inefficiencies that prevent the poorest from accessing indispensable resources for building themselves as full citizens [1].

dynamics and overcoming the deficit of civic participation" [1].

only theoretically coherent but also efficiently, to the demands placed.

sions and action are extremely important [2].

operational representations.

**4**

This requirement goes beyond "competent practice" and demands "critical practice" [3], and the development of "critical being," that is, a person who not only reflects critically on knowledge but also develops their powers of critical selfreflection and critical action [4].

In the research that Ford et al. [5, 6] made on criticality with students in social work education, these ideas have been explored and they conclude that the intellectual resources for critical thinking are: (1) background knowledge; (2) critical concepts; (3) critical thinking standards; (4) strategies; and (5) habits of mind. This allows us to realize that this process has to be permanent and rooted as a mindset.

The more we know about a situation and the circumstances that caused it, the better we can articulate with a structural question, be it social, economic, cultural, or political, including beliefs, values in order to clarify the range of available options and solutions, so that the professional can make an informed decision about the problems that are dealing with.

Beginning to deal with this type of "how to" knowledge is where a practitioner's ignorance becomes obvious and can cause anxiety. It may well be the reason why many new qualified workers take a very prescriptive, rule-based approach to try to ensure they do not do anything wrong. In many ways such a focus on detail and correctness ensures that practitioners can be more critically aware of what they are doing than experienced workers who have established routines [2].

Gray et al. add that "Social workers need to examine closely the strengths and limitations of research evidence. Regardless of how strong the evidence for a particular intervention might be, social workers are in a position where they must critically reflect on their work in the political, social, organizational, and interpersonal contexts, make professional judgements, engage in debate with decision-makers about resource allocation, negotiate appropriate practices and, when necessary, argue convincingly for the effectiveness of the work that is done. This requires skills in formulating and presenting well-supported arguments and the interpersonal and written communication skills to convey a position convincingly" [7].

Based on these assumptions, we did a review of the literature and developed an exploratory study with the aim of understanding the perception of recent students in social work about the importance of critical thinking.

#### **2. The importance of critical thinking in education**

According to the literature, the importance of critical thinking skills is recognized in the academic and professional contexts, in which the need to implement measures that facilitate their development and awareness of their usefulness is mentioned.

We find several approaches to critical thinking, some more vague, others more objective, but we cannot easily find a consensus between them, either in terms of definition, in terms of the terminology used, or in the type of methodology designed to develop it [8, 9].

The scientific areas in which we can find greater literary production and investigation around critical thinking are philosophy, psychology, and education [10–12].

We find different contributions from the disciplinary areas mentioned above in an attempt to define critical thinking, and there are no definitions that fit exclusively in one or another area, since many of these authors cross the areas in terms of the research they develop. It is not our goal to find the best definition of critical thinking, or even the most complete one. The various theories focus on different aspects, put the focus on different circumstances, conceptualized in a way that is not always consensual and sometimes even antagonistic. Despite the differences,

we find, in these definitions, points of convergence that we think allow us to have a perception about what critical thinking might actually be [10, 13].

An argument goes from the premises to the conclusion and is one in which there are good reasons for the assumptions to be true, and in addition, the premises have good reasons to support or support the conclusion.

It is focused initially on the holistic assessment of a situation, not explicit reasoning and analysis. In other words, they establish the inductive or deductive links necessary to bring the different parts of a situation into a meaningful whole, to allow it to make sense. Every situation one experiences and faces may be different, but it is imperative to know enough of the parties to make general sense of the whole in order to start dealing with it.

The foundation for critical thinking defines critical thinking as:

the type of thinking—about any subject, content, or problem—in which the thinker improves the quality of his thinking by competently analyzing, evaluating and reconstructing it. Critical thinking is self-directed, self-disciplined, selfmonitored, and self-corrective. It presupposes consent to rigorous standards of excellence and a conscious control of its use. It implies effective communication and problem-solving skills, as well as a commitment to surpass our natural egocentrism and sociocentrism [14].

According to the Delphi Report, referenced by Facione, in addition to the skills associated with critical thinking, there are still a set of aptitudes, divided into two approaches: one related to life skills in general, and another related to specific issues, doubts, and problems. Regarding the first, the Delphi Report describes the following as critical thinker's skills: (1) curiosity over a wide variety of issues; (2) concern about becoming and staying well informed; (3) alert to opportunities to use critical thinking; (4) trust in the rational research process; (5) confidence in your own reasoning abilities; (6) open mind regarding divergent views about the world; (7) flexibility when considering alternatives and opinions; (8) understanding of the opinions of others; (9) honesty in the evaluation of reasoning; (10) honesty when confronted by our own egocentric and sociocentric prejudices, stereotypes, and tendencies; (11) caution in the suspension, elaboration or alteration of judgments; and (12) predisposition to reconsider and revise viewpoints, where honest reflection suggests change is necessary [15, 16].

Regarding the approach related to specific issues, the Delphi Report refers the following as aptitudes: (1) clarity in affirming an issue or concern; (2) method in dealing with complexity; (3) diligence in searching for relevant information; (4) reasonability in the selection and application of criteria; (5) concern to focus attention on the subject; (6) persistence despite any difficulties that may arise; and (7) accuracy to the level allowed by subject and circumstance.

Critical thinking is multidimensional, encompassing the intellectual (logic, rationality), psychological (self-consciousness, empathy), sociological (in terms of socio-historical context), ethics (norms and moral evaluation), and philosophical (meaning of nature and human life) [17].

It is also due to its characteristics of transversatility and multidimensionality that the authors argue that critical thinking has for centuries been the basis for the creation and maintenance of a democratic and democratically participative society, qualified by an active, pluralistic, and autonomous citizenship [18–22].

In education, we highlight pioneering authors who have emphasized critical thinking (although with other terminologies), from the Greek philosopher Socrates and the concepts of "knowledge" and "maièutica," to the American philosopher, psychologist, and educator John Dewey, and reflection on "thinking" and "reflecting" [23, 24].

Dewey is even considered the "father" of the modern tradition of critical thinking [25] when, in the early twentieth century, he advocated the need for education

**7**

*Critical Thinking in Social Work Training DOI: http://dx.doi.org/10.5772/intechopen.89538*

evaluation of critical thinking as competence.

possibilities that are put to our daily lives.

**2.1 Social work education and critical thinking**

work [26].

saying that:

professional maturity.

to prepare students for the complex demands of citizenship and the world of

The debate about the operationalization of critical thinking, the development and teaching of critical thinking, the skills of critical thinking, and the evaluation of critical thinking, are thus essential topics in education from the last decades of the twentieth century until now, specifically for social work, a recent study in this area recommends a future research agenda for critical thinking [27]. As competence, or set of competencies, critical thinking can be developed and evaluated. In this sense, the exploratory study presented here intends to contribute to the evaluation of the importance that students attribute to critical thinking, as well as to the

The twentieth century imposes on contemporary social work the challenge of establishing theoretical categories and methodologies that broaden its interdisciplinary horizon and stimulate the conception of the human being as a builder of its own reality [28]. The increasing complexity leads us to the search for alternatives, skills, and a competence to manage the theoretical-practical process, related to the attempt to understand the reality in constant movement, the tendencies and the

Social work education in Portugal according to Branco [29] "focuses on the dynamics of break and continuity between its pivotal socio-political periods and international influences" the same author in its latest article marks these periods

The social work education itinerary in Portugal during the period between the Republican Regime foundations (1910), the constitution of Estado Novo (1933–1945), the succession of Salazar (1968), the revolutionary crises associated with the Carnation

Questions related to the production of knowledge and the dissemination of this same knowledge arise later (also for socio-historical reasons), with the affirmation of the profession as a specific area of knowledge. In Portugal, with the development of the academic career in the area of social work, (undergraduate, master, and doctorate), the theoretical and practical dimensions, namely training, intervention, and research, have been developing and, consequently, we have assisted to a greater theoretical production (in the form of theses, dissertations, articles, and books) and an intensification of the research effort and its dissemination, which has given to Portuguese social work a greater visibility among the scientific community [30]. Consequently, the construction of knowledge was imposed as a means of awareness of the subjects involved in the teaching-learning process, in a critical perspective of knowledge as a tool for the realization of the political-professional ethical project and for the transformation of the socio-institutional and political- cultural reality. This awareness has undoubtedly been one of the means for advancing

The experience of this critical thinking course comes from the university, where

the study was done through the creation in 2009 of a Cross Skills Laboratory to give students extra skills with the aim of developing a reflexive practice that, rather than aiming at the constitution of a stabilized knowledge, intends to develop the capacities of reflexivity and action; understand the importance of critical thinking in academic and professional context; identify the elements and analyze simple and complex arguments; recognize errors on daily speech; assess the quality of arguments and argumentative texts; and create simple and complex arguments in oral debates and written texts. The students that successfully complete this curriculum

Revolution of 1974 and the academisation period (1989 to the present) [29].

#### *Critical Thinking in Social Work Training DOI: http://dx.doi.org/10.5772/intechopen.89538*

*Empathy Study*

we find, in these definitions, points of convergence that we think allow us to have a

It is focused initially on the holistic assessment of a situation, not explicit reasoning and analysis. In other words, they establish the inductive or deductive links necessary to bring the different parts of a situation into a meaningful whole, to allow it to make sense. Every situation one experiences and faces may be different, but it is imperative to know enough of the parties to make general sense of the

the type of thinking—about any subject, content, or problem—in which the thinker improves the quality of his thinking by competently analyzing, evaluating and reconstructing it. Critical thinking is self-directed, self-disciplined, selfmonitored, and self-corrective. It presupposes consent to rigorous standards of excellence and a conscious control of its use. It implies effective communication and problem-solving skills, as well as a commitment to surpass our natural egocentrism

According to the Delphi Report, referenced by Facione, in addition to the skills

Regarding the approach related to specific issues, the Delphi Report refers the following as aptitudes: (1) clarity in affirming an issue or concern; (2) method in dealing with complexity; (3) diligence in searching for relevant information; (4) reasonability in the selection and application of criteria; (5) concern to focus attention on the subject; (6) persistence despite any difficulties that may arise; and (7)

Critical thinking is multidimensional, encompassing the intellectual (logic, rationality), psychological (self-consciousness, empathy), sociological (in terms of socio-historical context), ethics (norms and moral evaluation), and philosophical

It is also due to its characteristics of transversatility and multidimensionality that the authors argue that critical thinking has for centuries been the basis for the creation and maintenance of a democratic and democratically participative society,

In education, we highlight pioneering authors who have emphasized critical thinking (although with other terminologies), from the Greek philosopher Socrates and the concepts of "knowledge" and "maièutica," to the American philosopher, psychologist, and educator John Dewey, and reflection on "thinking" and "reflecting" [23, 24].

Dewey is even considered the "father" of the modern tradition of critical thinking [25] when, in the early twentieth century, he advocated the need for education

qualified by an active, pluralistic, and autonomous citizenship [18–22].

associated with critical thinking, there are still a set of aptitudes, divided into two approaches: one related to life skills in general, and another related to specific issues, doubts, and problems. Regarding the first, the Delphi Report describes the following as critical thinker's skills: (1) curiosity over a wide variety of issues; (2) concern about becoming and staying well informed; (3) alert to opportunities to use critical thinking; (4) trust in the rational research process; (5) confidence in your own reasoning abilities; (6) open mind regarding divergent views about the world; (7) flexibility when considering alternatives and opinions; (8) understanding of the opinions of others; (9) honesty in the evaluation of reasoning; (10) honesty when confronted by our own egocentric and sociocentric prejudices, stereotypes, and tendencies; (11) caution in the suspension, elaboration or alteration of judgments; and (12) predisposition to reconsider and revise viewpoints,

where honest reflection suggests change is necessary [15, 16].

accuracy to the level allowed by subject and circumstance.

(meaning of nature and human life) [17].

An argument goes from the premises to the conclusion and is one in which there are good reasons for the assumptions to be true, and in addition, the premises have

perception about what critical thinking might actually be [10, 13].

The foundation for critical thinking defines critical thinking as:

good reasons to support or support the conclusion.

whole in order to start dealing with it.

and sociocentrism [14].

**6**

to prepare students for the complex demands of citizenship and the world of work [26].

The debate about the operationalization of critical thinking, the development and teaching of critical thinking, the skills of critical thinking, and the evaluation of critical thinking, are thus essential topics in education from the last decades of the twentieth century until now, specifically for social work, a recent study in this area recommends a future research agenda for critical thinking [27]. As competence, or set of competencies, critical thinking can be developed and evaluated. In this sense, the exploratory study presented here intends to contribute to the evaluation of the importance that students attribute to critical thinking, as well as to the evaluation of critical thinking as competence.

#### **2.1 Social work education and critical thinking**

The twentieth century imposes on contemporary social work the challenge of establishing theoretical categories and methodologies that broaden its interdisciplinary horizon and stimulate the conception of the human being as a builder of its own reality [28]. The increasing complexity leads us to the search for alternatives, skills, and a competence to manage the theoretical-practical process, related to the attempt to understand the reality in constant movement, the tendencies and the possibilities that are put to our daily lives.

Social work education in Portugal according to Branco [29] "focuses on the dynamics of break and continuity between its pivotal socio-political periods and international influences" the same author in its latest article marks these periods saying that:

The social work education itinerary in Portugal during the period between the Republican Regime foundations (1910), the constitution of Estado Novo (1933–1945), the succession of Salazar (1968), the revolutionary crises associated with the Carnation Revolution of 1974 and the academisation period (1989 to the present) [29].

Questions related to the production of knowledge and the dissemination of this same knowledge arise later (also for socio-historical reasons), with the affirmation of the profession as a specific area of knowledge. In Portugal, with the development of the academic career in the area of social work, (undergraduate, master, and doctorate), the theoretical and practical dimensions, namely training, intervention, and research, have been developing and, consequently, we have assisted to a greater theoretical production (in the form of theses, dissertations, articles, and books) and an intensification of the research effort and its dissemination, which has given to Portuguese social work a greater visibility among the scientific community [30].

Consequently, the construction of knowledge was imposed as a means of awareness of the subjects involved in the teaching-learning process, in a critical perspective of knowledge as a tool for the realization of the political-professional ethical project and for the transformation of the socio-institutional and political- cultural reality. This awareness has undoubtedly been one of the means for advancing professional maturity.

The experience of this critical thinking course comes from the university, where the study was done through the creation in 2009 of a Cross Skills Laboratory to give students extra skills with the aim of developing a reflexive practice that, rather than aiming at the constitution of a stabilized knowledge, intends to develop the capacities of reflexivity and action; understand the importance of critical thinking in academic and professional context; identify the elements and analyze simple and complex arguments; recognize errors on daily speech; assess the quality of arguments and argumentative texts; and create simple and complex arguments in oral debates and written texts. The students that successfully complete this curriculum

unit will be able to analyze arguments regarding their structure and content; argue on an issue; identify the deductive validity on propositions; and question arguments, identifying its weaknesses.

According to Jones "Critical thinking can lead us to open up self-doubt and this is a good thing because it lead us to really examine why we think and act as we do" [31] and "Developing an ability to understand why you react and think as you do is part of a recognition of you own inner resources" [31] this author also argues that:

To be able to think about how we, and others, think—thinking about thinking. In doing this you will be thinking about the reasoning, motives and arguments of others. You will have the ability to see all sides of the question and analyze its strengths and weak-in these [31].

And is corroborated by other authors that alert us by saying that

The technical rationality model also fails to recognize how understanding is developed from the integration of theory and practice (…) Reflective learning incorporates both theoretical and practical themes and issues and seeks to integrate these—to open a dialogue between theory and practice [32].

It is a continuous process of reflection and allows the interveners to develop their theory directly from their experience. In addition, it allows you to "tailor" your intervention to each specific context using a range of non-defined skills and perspectives.

#### **3. Methodology**

The present study is exploratory and quantitative and aims to understand the perception of recent graduate students in social work on the importance of learning critical thinking in higher education and its impact on the labor market.

It aims to identify the potential of learning critical thinking during its formation, including future usefulness in the professional field. Although we do not intend to prove hypotheses, we seek to explore the results based not only on the perception of the respondents, but also to categorize the critical-thinking skills acquired as potentialities in teaching in social work and as knowledge of support to the professional exercise.

In a universe of 154 newly graduated students between 2015 and 2017, whose training integrated the curricular unit of critical thinking in their curriculum, we used an intentional sample of 79 individuals recently graduated in social work.

A bibliographical review was made on the subject and we used as a data collection technician, a questionnaire in which we used a Likert scale of level 5. The Likert scales [33] are widely used to measure postures and opinions with a higher level of a question of "yes" or "no," in this questionnaire was composed of a set of sentences (items) in relation to each one of which the respondents were asked to express the degree of agreement from the non-positive (level 1), until *very positive* (level 5). We also added two questions to understand the degree of satisfaction with the critical thinking training with a scale from 0 to 10, in which 0 was totally dissatisfied and 10 totally satisfied and an open question to perceive the benefits and disadvantages of learning critical thinking.

The questionnaire was divided into two parts: socio-demographic characterization and the identification of the importance of critical thinking contribution as training in its learning.

The age of the participants is between 21 and 45 years, with an average of 24.5 years, mostly females, 87.3, 91.1% Portuguese and 78.5% is inserted in the job market (as social workers) and 94.4% attended this curricular unit in the first year of the degree.

**9**

*Critical Thinking in Social Work Training DOI: http://dx.doi.org/10.5772/intechopen.89538*

• Systematic problem solving

• Reflection on beliefs and values

the participants would be anonymous.

(Portugal-Spain).

market (**Figure 1**).

nor negative.

positive nor negative.

**4. Results**

• Understand interactions and detect inconsistencies

tive in terms of results for our university) and is exploratory.

• The reintegration of information as a whole

questionnaire:

• Ability to analyze

Five categories of analysis were established for the fifteen items of the

We are aware that one of the limitations of this study is that there is no credit for its generalization [34] given the fact that it has a small sample (although representa-

Another limitation is that the respondents themselves may have given skewed responses because they know the purpose of the study, they may want to appreciate the university that formed them and give answers that they consider "correct." It was attempted to overcome this limitation by saying that both the institution and

We intend to continue this study in a first phase at national level with partnerships with other universities and later extend to a study in the Iberian Peninsula

The results show that the majority of respondents considered that the contents seized in their critical thinking training were positive or very positive with Likert scores (1–5) between 4.53 and 3.89. The average of responses in the different categories considered the impact of the contents acquired positive 50.55% and very positive 35.27%, understanding this competence as an active element of learning as students, stimulating a clear, logical, and organized thinking, helping to develop the necessary skills during the frequency of higher education and currently in the labor

According to the results, the greatest impact of learning was reflected in the development of strategies for decision-making and in the capacity to train a rigorous analytical view, both with a mean score in the answers of 4.53 (Likert scale-Ls). These figures translate into the impacts of these two categories, which were considered positive by 36.71% of the respondents and very positive by 58.23%. It is also noted that 5.06% of the respondents consider neither positive

The identification of the barriers to critical thinking obtained the highest percentage of answers with the classification of positives (67.09%) along with the diagnosis in problem solving (63.29%). In the categories of preparation for problem solving and articulation of daily information, there was a balanced preference for

Respondents answered that the impact on the preparation for problem solving was both very positive (44.30%) and positive (44.30%), considering neither positive or negative 10.13% nor negative 1.27%. In the articulation of information with the everyday situations, 46.84% was very positive, 44.30 positive, and 8.86 neither

responses, mainly considering positive or very positive.

#### *Critical Thinking in Social Work Training DOI: http://dx.doi.org/10.5772/intechopen.89538*

Five categories of analysis were established for the fifteen items of the questionnaire:

• Ability to analyze

*Empathy Study*

perspectives.

**3. Methodology**

the professional exercise.

of learning critical thinking.

training in its learning.

of the degree.

ments, identifying its weaknesses.

strengths and weak-in these [31].

unit will be able to analyze arguments regarding their structure and content; argue on an issue; identify the deductive validity on propositions; and question argu-

According to Jones "Critical thinking can lead us to open up self-doubt and this is a good thing because it lead us to really examine why we think and act as we do" [31] and "Developing an ability to understand why you react and think as you do is part of a recognition of you own inner resources" [31] this author also argues that: To be able to think about how we, and others, think—thinking about thinking. In doing this you will be thinking about the reasoning, motives and arguments of others. You will have the ability to see all sides of the question and analyze its

And is corroborated by other authors that alert us by saying that

these—to open a dialogue between theory and practice [32].

The technical rationality model also fails to recognize how understanding is developed from the integration of theory and practice (…) Reflective learning incorporates both theoretical and practical themes and issues and seeks to integrate

It is a continuous process of reflection and allows the interveners to develop their theory directly from their experience. In addition, it allows you to "tailor" your intervention to each specific context using a range of non-defined skills and

The present study is exploratory and quantitative and aims to understand the perception of recent graduate students in social work on the importance of learning

It aims to identify the potential of learning critical thinking during its formation, including future usefulness in the professional field. Although we do not intend to prove hypotheses, we seek to explore the results based not only on the perception of the respondents, but also to categorize the critical-thinking skills acquired as potentialities in teaching in social work and as knowledge of support to

In a universe of 154 newly graduated students between 2015 and 2017, whose training integrated the curricular unit of critical thinking in their curriculum, we used an intentional sample of 79 individuals recently graduated in social work. A bibliographical review was made on the subject and we used as a data collection technician, a questionnaire in which we used a Likert scale of level 5. The Likert scales [33] are widely used to measure postures and opinions with a higher level of a question of "yes" or "no," in this questionnaire was composed of a set of sentences (items) in relation to each one of which the respondents were asked to express the degree of agreement from the non-positive (level 1), until *very positive* (level 5). We also added two questions to understand the degree of satisfaction with the critical thinking training with a scale from 0 to 10, in which 0 was totally dissatisfied and 10 totally satisfied and an open question to perceive the benefits and disadvantages

The questionnaire was divided into two parts: socio-demographic characterization and the identification of the importance of critical thinking contribution as

The age of the participants is between 21 and 45 years, with an average of 24.5 years, mostly females, 87.3, 91.1% Portuguese and 78.5% is inserted in the job market (as social workers) and 94.4% attended this curricular unit in the first year

critical thinking in higher education and its impact on the labor market.

**8**


We are aware that one of the limitations of this study is that there is no credit for its generalization [34] given the fact that it has a small sample (although representative in terms of results for our university) and is exploratory.

Another limitation is that the respondents themselves may have given skewed responses because they know the purpose of the study, they may want to appreciate the university that formed them and give answers that they consider "correct." It was attempted to overcome this limitation by saying that both the institution and the participants would be anonymous.

We intend to continue this study in a first phase at national level with partnerships with other universities and later extend to a study in the Iberian Peninsula (Portugal-Spain).

#### **4. Results**

The results show that the majority of respondents considered that the contents seized in their critical thinking training were positive or very positive with Likert scores (1–5) between 4.53 and 3.89. The average of responses in the different categories considered the impact of the contents acquired positive 50.55% and very positive 35.27%, understanding this competence as an active element of learning as students, stimulating a clear, logical, and organized thinking, helping to develop the necessary skills during the frequency of higher education and currently in the labor market (**Figure 1**).

According to the results, the greatest impact of learning was reflected in the development of strategies for decision-making and in the capacity to train a rigorous analytical view, both with a mean score in the answers of 4.53 (Likert scale-Ls). These figures translate into the impacts of these two categories, which were considered positive by 36.71% of the respondents and very positive by 58.23%. It is also noted that 5.06% of the respondents consider neither positive nor negative.

The identification of the barriers to critical thinking obtained the highest percentage of answers with the classification of positives (67.09%) along with the diagnosis in problem solving (63.29%). In the categories of preparation for problem solving and articulation of daily information, there was a balanced preference for responses, mainly considering positive or very positive.

Respondents answered that the impact on the preparation for problem solving was both very positive (44.30%) and positive (44.30%), considering neither positive or negative 10.13% nor negative 1.27%. In the articulation of information with the everyday situations, 46.84% was very positive, 44.30 positive, and 8.86 neither positive nor negative.

#### **Figure 1.**

*Distribution of respondents' answers on the current impacts of content acquired during their training.*

Regarding the ability to identify argumentation errors, 25.32% of the respondents answered that the impacts were neither positive nor negative. This is the category in which neutrality assumes greater expression, although it continues to be less than the responses that consider the very positive (37.97%) and positive (36.71%).

As for the less-valued aspects, but still with an average that considers these competences as positive, are the dimensions of acquisition of learning strategies through reading (3.89 Ls) and acquisition of learning strategies through listening (3.99 Ls). The responses in these two categories vary in their distribution, and the acquisition of learning strategies through reading 32.91% of the respondents considered that the impact of this competence was neither positive nor negative, while 45.57% considered that it was positive and 21.52% which was very positive.

Regarding the acquisition of learning strategies through listening 20.25% considered that was very positive, 59.49% positive, 18.99% that was neither positive nor negative, and 1.27 responded that the impact was negative.

In the acquisition of research techniques and information systematization, most of the answers were positive 55.23%, positive for 22.78% of the respondents, and 16.46% neither positive nor negative. This competence was the one with a residual value, presented the highest percentage of responses that considered the negative impact (2.53%).

The comprehension of the structure of an argumentative text and the acquisition of competences for an argumentative discourse were both considered 55 by 0.70% of the respondents as having a positive impact. The understanding of the

**11**

*Critical Thinking in Social Work Training DOI: http://dx.doi.org/10.5772/intechopen.89538*

advantages or disadvantages in their training.

with the average rating being 7.57 and 7.67, respectively.

able to perform quality work in their intervention with people.

tion attendance and currently in the labor market.

nor negative.

nor negative, 8.86%.

sources of information.

**5. Discussion**

the job market.

structure of an argumentative text also registered 34.18% of responses that indicate a very positive impact and 10.13% that consider that the impact was neither positive

In the acquisition of competences for a care argumentative discourse 33.91% considered to have had a very positive impact and 11.39% did not have a positive or negative impact. The ability to develop abstract reasoning was for 26.58% of the respondents considered very positive, 53.16% positive, and 20.25% neither negative nor positive. The break with common sense was perceived as a competence with a very positive impact by 53.16% of the respondents, 37.97% answered that the impact on this competence was very positive, and the remaining ones were neither positive

Finally, the acquisition of skills for clear and objective writing had 48.10% considering that the impact of the contents acquired was positive, followed by 26.71% of the responses as very positive and 15.19% which was neither positive nor negative. Other aspects analyzed were the satisfaction with the curricular unit of critical thinking and professional satisfaction, as well as the aspects that were considered as

Using a satisfaction scale of 0–10 in which 0 is totally unsatisfied and 10 is fully satisfied, the highest number of equal answers with the classification 8 regarding satisfaction with the program they had in their training of critical thinking was 32.91% of the respondents and 34.18% with the same classification relative to the importance in the labor market. The answers ranged from 4 to 10 in both questions,

In addition to the satisfaction with critical thinking learning in both academic and professional spheres, among the main advantages, respondents identified the improvement of their attention and observation abilities of the real world, as well as the contribution in the decision-making supported by an exercise of rational discernment. It was also mentioned the improvement of the capacities to identify key ideas avoiding irrelevant elements, the facilitation in the process of transmitting ideas and perspectives, and the development of this competence to various situations and contexts. There were no disadvantages to register except for the reference to the difficulty in interpreting texts and access to scientific

About the importance of critical thinking associated with the issue of values and beliefs and of a more comprehensive thinking, respondents considered the knowledge acquired with critical thinking as extremely important because it allows them to question universal opinions, general judgments, and mind-beliefs, in order to be

This exploratory study gives us the perception that the recent graduate students in social work who attended the critical thinking curricular unit valued this learning in their training, but also in the usefulness and articulation with

Participants' responses show that the majority of respondents considered that the competences learned in their training in critical thinking were positive or very positive, with critical thinking being an active element in their higher education, stimulating reflection and acting capacities in the service domain of a clear, logical and systematized form, helping to develop the skills needed during higher educa-

#### *Critical Thinking in Social Work Training DOI: http://dx.doi.org/10.5772/intechopen.89538*

*Empathy Study*

Regarding the ability to identify argumentation errors, 25.32% of the respondents answered that the impacts were neither positive nor negative. This is the category in which neutrality assumes greater expression, although it continues to be less than the

As for the less-valued aspects, but still with an average that considers these competences as positive, are the dimensions of acquisition of learning strategies through reading (3.89 Ls) and acquisition of learning strategies through listening (3.99 Ls). The responses in these two categories vary in their distribution, and the acquisition of learning strategies through reading 32.91% of the respondents considered that the impact of this competence was neither positive nor negative, while 45.57%

responses that consider the very positive (37.97%) and positive (36.71%).

*Distribution of respondents' answers on the current impacts of content acquired during their training.*

considered that it was positive and 21.52% which was very positive.

nor negative, and 1.27 responded that the impact was negative.

Regarding the acquisition of learning strategies through listening 20.25% considered that was very positive, 59.49% positive, 18.99% that was neither positive

In the acquisition of research techniques and information systematization, most of the answers were positive 55.23%, positive for 22.78% of the respondents, and 16.46% neither positive nor negative. This competence was the one with a residual value, presented the highest percentage of responses that considered the negative

The comprehension of the structure of an argumentative text and the acquisition of competences for an argumentative discourse were both considered 55 by 0.70% of the respondents as having a positive impact. The understanding of the

**10**

impact (2.53%).

**Figure 1.**

structure of an argumentative text also registered 34.18% of responses that indicate a very positive impact and 10.13% that consider that the impact was neither positive nor negative.

In the acquisition of competences for a care argumentative discourse 33.91% considered to have had a very positive impact and 11.39% did not have a positive or negative impact. The ability to develop abstract reasoning was for 26.58% of the respondents considered very positive, 53.16% positive, and 20.25% neither negative nor positive. The break with common sense was perceived as a competence with a very positive impact by 53.16% of the respondents, 37.97% answered that the impact on this competence was very positive, and the remaining ones were neither positive nor negative, 8.86%.

Finally, the acquisition of skills for clear and objective writing had 48.10% considering that the impact of the contents acquired was positive, followed by 26.71% of the responses as very positive and 15.19% which was neither positive nor negative. Other aspects analyzed were the satisfaction with the curricular unit of critical thinking and professional satisfaction, as well as the aspects that were considered as advantages or disadvantages in their training.

Using a satisfaction scale of 0–10 in which 0 is totally unsatisfied and 10 is fully satisfied, the highest number of equal answers with the classification 8 regarding satisfaction with the program they had in their training of critical thinking was 32.91% of the respondents and 34.18% with the same classification relative to the importance in the labor market. The answers ranged from 4 to 10 in both questions, with the average rating being 7.57 and 7.67, respectively.

In addition to the satisfaction with critical thinking learning in both academic and professional spheres, among the main advantages, respondents identified the improvement of their attention and observation abilities of the real world, as well as the contribution in the decision-making supported by an exercise of rational discernment. It was also mentioned the improvement of the capacities to identify key ideas avoiding irrelevant elements, the facilitation in the process of transmitting ideas and perspectives, and the development of this competence to various situations and contexts. There were no disadvantages to register except for the reference to the difficulty in interpreting texts and access to scientific sources of information.

About the importance of critical thinking associated with the issue of values and beliefs and of a more comprehensive thinking, respondents considered the knowledge acquired with critical thinking as extremely important because it allows them to question universal opinions, general judgments, and mind-beliefs, in order to be able to perform quality work in their intervention with people.

#### **5. Discussion**

This exploratory study gives us the perception that the recent graduate students in social work who attended the critical thinking curricular unit valued this learning in their training, but also in the usefulness and articulation with the job market.

Participants' responses show that the majority of respondents considered that the competences learned in their training in critical thinking were positive or very positive, with critical thinking being an active element in their higher education, stimulating reflection and acting capacities in the service domain of a clear, logical and systematized form, helping to develop the skills needed during higher education attendance and currently in the labor market.

#### **5.1 Ability to analyze**

Among the dimensions analyzed stand the development of strategies to support decision-making and analytical capacity through rigorous and systematized procedures. The development of strategies for decision-making includes efficient, quick, and objective forms of planning in the analysis of situations. Here, it includes the ways of acting in complex situations that aim for more efficient and effective responses through thought patterns that can increase the confidence and assertiveness of the responses when implementing them.

The training capacity of a rigorous analytical vision leads to a cognitive reflection, free of opinions and value judgments, focusing on a critical action of analysis of information, facts and events, and managing to select and systematize what is significant in an idea developed or presented. It also promotes a process of evaluation of evidence and facts at the expense of opinions, as well as a reflection on the issues in a structured, logical, and informed way.

The acquisition of research techniques and systematization of information refers to the training of valid and reliable bibliographic research and the careful use of information sources. It is necessary to establish critical thinking in premises based on evidence, supported by theoretical or empirical data.

Although with a less significant expression, the competences of acquiring learning strategies through reading and listening are also present in the development of this competence. It is important to apply research and information selection processes in written texts, the analysis of written narratives, and documentary information to support the development of critical thinking, as well as the listening of oral, synchronous, or asynchronous narratives that allow the acquisition of information to support the construction of logical and consistent reasoning.

#### **5.2 Systematic problem solving**

It is also highlighted the importance of critical thinking as support for diagnosis and problem solving, focusing on the ability to analyze and evaluate situations, looking at them by different prisms, particularly in relation to issues associated with ideologies, religion, ethics, or human behavior.

The preparation of these professionals for the resolution of problems and for the articulation of daily information promotes competences for an accuracy in the way they reflected and act when facing questions that imply the analysis of a complex situation, dilemmas or unforeseen situations, developing the training for think and anticipate problems critically, generating solutions that are useful in solving problems, in project management or in the way different parts of an activity or task is developed.

In this field, the capacity to observe reality and current analysis through the collection and application of information in plural and multidimensional contexts is highlighted and allows the development of forms of analysis and adaptation in different areas and groups in the face of a diversified reality of constant transformations.

#### **5.3 Understand interactions and detect inconsistencies**

The understanding of the structure of an argumentative text and the acquisition of competences for the construction of a discourse are developed competences that allow the identification of reasons and conclusions, together with the evaluation of the premises that support the presented conclusions.

It encompasses the ability to identify points of view in a clear, systematic, and objective way, identifying simple and complex lines of reasoning. It also contributes to a better communication and interaction with others, achieving through a clearer

**13**

empirically.

*Critical Thinking in Social Work Training DOI: http://dx.doi.org/10.5772/intechopen.89538*

selection about what is more or less relevant.

ment, through precise, specific, and concrete language.

**5.4 Reflection on beliefs and values**

personal life and it's a lifelong tool.

**5.5 The reintegration of information as a whole**

us for review, progress, and evaluate results.

the evidences.

a structured way.

discourse to present convincing quality arguments and reinforcing points of view in

This relates to a process that involves conscious choices, supported by evidence that gives strength to our discourse, be it oral or written, allowing cumulatively to be able to interpret and deconstruct our ideas and others ideas. It also allows for an evolution in the capacities of relationship and communication, making possible the

The ability to detect inconsistencies in performance, through the identification of fallacies, refers to the development of the ability to recognize the most common argumentations failures and to be attentive to failures in the arguments of others. It makes possible to identify errors of argumentation with a competence that contributes to finding weaknesses and strengths in the discourses of others and be able to counteract them, as well as to formulate its own arguments. It also highlights the ability to recognize information manipulation techniques and fallacies and present a well-grounded, clear, and organized perspective in order to convince others. It also promotes a correct grammatical and conceptual use, avoiding abstract, vague or general terms that compromise attention-getting to what is central to the argu-

The importance of overcoming the barriers to critical thinking are recognized as a relevant aspect that refers to the pertinence of the approach of this theme, resulting in the development of skills of conceptualization of criticism and overcoming inhibition to criticism and in the ability to be free of emotional influences or affective, avoiding that they affect the clarity of the reasoning and must be analyzed by

Also, it is recognized that common sense is capable of creating absolutisms all the time and the tendency of the great mass of our society is to absorb them easily; creating a vision of the world capable of guiding our whole existence. We are hardly willing to question what is going on around us and seek a second opinion of the facts. Instead, we prefer the convenience of thinking like others, following the vast majority, prefer superficiality. Because it is hard work creating critical thinking, these students create added value in both professional and

The capacity for development of abstract reasoning aims to identify the positioning of others, arguments, and conclusions, leading to innovation processes. It develops concepts and ideas analysis skills from a more systemic and global perspective. Rupture with common sense contributes to the use of facts as support for action to the detriment of individual knowledge supported by lack of evidence, aiding in the foundation of arguments, and ideas that are proven theoretically or

Some research [35] refers that as they are in control of their thoughts, that is, they are aware, understand, self-direct, and self-evaluate; have "tacit knowledge" groups that form "patterns" and represent the learning and generalization of previous experiences, research, and theory; recognize other significant patterns and principles and irrelevant aspects in a situation and bind to these existing known patterns and thus assess in depth (patterns or contours formed in the mind) that when adapted to the problem suggest solution procedures and periodically checks

#### *Critical Thinking in Social Work Training DOI: http://dx.doi.org/10.5772/intechopen.89538*

*Empathy Study*

**5.1 Ability to analyze**

ness of the responses when implementing them.

issues in a structured, logical, and informed way.

**5.2 Systematic problem solving**

ideologies, religion, ethics, or human behavior.

on evidence, supported by theoretical or empirical data.

Among the dimensions analyzed stand the development of strategies to support decision-making and analytical capacity through rigorous and systematized procedures. The development of strategies for decision-making includes efficient, quick, and objective forms of planning in the analysis of situations. Here, it includes the ways of acting in complex situations that aim for more efficient and effective responses through thought patterns that can increase the confidence and assertive-

The training capacity of a rigorous analytical vision leads to a cognitive reflection, free of opinions and value judgments, focusing on a critical action of analysis of information, facts and events, and managing to select and systematize what is significant in an idea developed or presented. It also promotes a process of evaluation of evidence and facts at the expense of opinions, as well as a reflection on the

The acquisition of research techniques and systematization of information refers

Although with a less significant expression, the competences of acquiring learning strategies through reading and listening are also present in the development of this competence. It is important to apply research and information selection processes in written texts, the analysis of written narratives, and documentary information to support the development of critical thinking, as well as the listening of oral, synchronous, or asynchronous narratives that allow the acquisition of information to support the construction of logical and consistent reasoning.

It is also highlighted the importance of critical thinking as support for diagnosis and problem solving, focusing on the ability to analyze and evaluate situations, looking at them by different prisms, particularly in relation to issues associated with

The preparation of these professionals for the resolution of problems and for the articulation of daily information promotes competences for an accuracy in the way they reflected and act when facing questions that imply the analysis of a complex situation, dilemmas or unforeseen situations, developing the training for think and anticipate problems critically, generating solutions that are useful in solving problems, in project

In this field, the capacity to observe reality and current analysis through the collection and application of information in plural and multidimensional contexts is highlighted and allows the development of forms of analysis and adaptation in different areas and groups in the face of a diversified reality of constant transformations.

The understanding of the structure of an argumentative text and the acquisition of competences for the construction of a discourse are developed competences that allow the identification of reasons and conclusions, together with the evaluation of

It encompasses the ability to identify points of view in a clear, systematic, and objective way, identifying simple and complex lines of reasoning. It also contributes to a better communication and interaction with others, achieving through a clearer

management or in the way different parts of an activity or task is developed.

**5.3 Understand interactions and detect inconsistencies**

the premises that support the presented conclusions.

to the training of valid and reliable bibliographic research and the careful use of information sources. It is necessary to establish critical thinking in premises based

**12**

discourse to present convincing quality arguments and reinforcing points of view in a structured way.

This relates to a process that involves conscious choices, supported by evidence that gives strength to our discourse, be it oral or written, allowing cumulatively to be able to interpret and deconstruct our ideas and others ideas. It also allows for an evolution in the capacities of relationship and communication, making possible the selection about what is more or less relevant.

The ability to detect inconsistencies in performance, through the identification of fallacies, refers to the development of the ability to recognize the most common argumentations failures and to be attentive to failures in the arguments of others.

It makes possible to identify errors of argumentation with a competence that contributes to finding weaknesses and strengths in the discourses of others and be able to counteract them, as well as to formulate its own arguments. It also highlights the ability to recognize information manipulation techniques and fallacies and present a well-grounded, clear, and organized perspective in order to convince others. It also promotes a correct grammatical and conceptual use, avoiding abstract, vague or general terms that compromise attention-getting to what is central to the argument, through precise, specific, and concrete language.

#### **5.4 Reflection on beliefs and values**

The importance of overcoming the barriers to critical thinking are recognized as a relevant aspect that refers to the pertinence of the approach of this theme, resulting in the development of skills of conceptualization of criticism and overcoming inhibition to criticism and in the ability to be free of emotional influences or affective, avoiding that they affect the clarity of the reasoning and must be analyzed by the evidences.

Also, it is recognized that common sense is capable of creating absolutisms all the time and the tendency of the great mass of our society is to absorb them easily; creating a vision of the world capable of guiding our whole existence. We are hardly willing to question what is going on around us and seek a second opinion of the facts. Instead, we prefer the convenience of thinking like others, following the vast majority, prefer superficiality. Because it is hard work creating critical thinking, these students create added value in both professional and personal life and it's a lifelong tool.

#### **5.5 The reintegration of information as a whole**

The capacity for development of abstract reasoning aims to identify the positioning of others, arguments, and conclusions, leading to innovation processes. It develops concepts and ideas analysis skills from a more systemic and global perspective. Rupture with common sense contributes to the use of facts as support for action to the detriment of individual knowledge supported by lack of evidence, aiding in the foundation of arguments, and ideas that are proven theoretically or empirically.

Some research [35] refers that as they are in control of their thoughts, that is, they are aware, understand, self-direct, and self-evaluate; have "tacit knowledge" groups that form "patterns" and represent the learning and generalization of previous experiences, research, and theory; recognize other significant patterns and principles and irrelevant aspects in a situation and bind to these existing known patterns and thus assess in depth (patterns or contours formed in the mind) that when adapted to the problem suggest solution procedures and periodically checks us for review, progress, and evaluate results.

#### **6. Conclusions**

Teaching is a privileged context for the development of critical thinking in individuals, and the teacher plays a fundamental role in the conduct of this complex process with theoretical, practical, and motivational components of active learning [10].

Experts in the area of critical thinking collaborated in the definition of strategies and methodologies of approach for the operationalization of the development of these competences in educational contexts, as in the case of the Delphi Report already mentioned, that resulted from the meeting of a group of experts with the objective, through the Delphi Method, to constitute a set of propositions and recommendations that would act as guiding lines for education agents and other professionals related to this area, regarding teaching, and evaluation of critical thinking.

In pedagogical terms, there are different ways of teaching and exercising critical thinking among students. The two most common approaches are: the creation of a course or program specifically dedicated to the development of critical thinking; and the incorporation of the development of critical thinking in curricular subjects.

Based on the literature, we cannot say that one approach is more effective than the other, but we can say that the perception of the key benefits that our graduated students report in conducting our critical thinking programs refers to ensuring good practice that is already being realized through discussions with others and the link between theory and practice to rethink their practices, allowing them to perceive when they fall into the bureaucratic routine and adopt more appropriate methods and approaches.

An awareness and acceptance of uncertainty in the practice of any professional is an important way to lessen stress. There are no perfect solutions out there to find, so we cannot be called on to work perfectly. If we accept the fact that the things we do or decide on are still dependent on something uncertain or on future happenings, and work in a way that takes account of that (i.e. constantly reviewing the things we deal with, decide on, or do), then this is really what "thinking critically" is all about [2].

The key is to strike a balance between the need for certainty and the need to be aware of other ways of doing or thinking about practice. This is where critical reflection (especially involving others) can play a key role in building trust by analyzing practice based on strengths, but also allows consideration of alternative options, points of view, etc., within a space safe, and where uncritical rigidity is not established.

These characteristics should be present not only in the students but also in the teachers. They must know how to model the learning they want to pass. Is it possible to give classes that do not develop these skills but reach other academic goals? Of course yes. But, it is also possible to achieve academic goals, curricular goals, and programmatic content by developing these skills at the same time.

Not least, we find the evaluation. In order to gauge how the process is going, we must evaluate. It is a great challenge to evaluate these skills, it is true. It will be easier to evaluate if you have memorized dates and locations. But as it is a challenge to know how much a student contributed in a group work and not fail to do so, we cannot give up to train our students in skills that will be valid for the rest of their lives because of the difficulty we encounter in the evaluation and the technology resources that allow new forms of formative and summative evaluation.

It cannot be forgotten that the surprises with which every social worker is confronted in everyday contacts and relationships need to be analyzed not only with common sense look but also with critical thinking and the autonomy of a thought based on solid concepts should be a factor of considerable importance. This will mean that in each complex situation, the values that underpin knowledge are at the service of conscious decision-making.

**15**

**Author details**

*Critical Thinking in Social Work Training DOI: http://dx.doi.org/10.5772/intechopen.89538*

collaboration, so that this study was possible.

ing of the Foundation for Science and Technology.

The authors declare no conflict of interest.

Helena Belchior-Rocha\* and Inês Casquilho-Martins

\*Address all correspondence to: helena\_rocha@iscte-iul.pt

Lisboa (ISCTE-IUL), Lisbon, Portugal

provided the original work is properly cited.

Centre for Research and Studies in Sociology (CIES-IUL), Instituto Universitário de

© 2019 The Author(s). Licensee IntechOpen. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/ by/3.0), which permits unrestricted use, distribution, and reproduction in any medium,

We are grateful and want to thank all the participants for their availability and

The publication of this paper was supported by Portuguese national funds through Foundation for Science and Technology in the scope of the UID / SOC / 03126/2019 project. We appreciate the support given by the CIES-IUL and the fund-

**Acknowledgements**

**Conflict of interest**

### **Acknowledgements**

*Empathy Study*

**6. Conclusions**

methods and approaches.

established.

Teaching is a privileged context for the development of critical thinking in individuals, and the teacher plays a fundamental role in the conduct of this complex process with theoretical, practical, and motivational components of active learning [10].

Experts in the area of critical thinking collaborated in the definition of strategies and methodologies of approach for the operationalization of the development of these competences in educational contexts, as in the case of the Delphi Report already mentioned, that resulted from the meeting of a group of experts with the objective, through the Delphi Method, to constitute a set of propositions and recommendations that would act as guiding lines for education agents and other professionals related to

In pedagogical terms, there are different ways of teaching and exercising critical thinking among students. The two most common approaches are: the creation of a course or program specifically dedicated to the development of critical thinking; and the incorporation of the development of critical thinking in curricular subjects. Based on the literature, we cannot say that one approach is more effective than the other, but we can say that the perception of the key benefits that our graduated students report in conducting our critical thinking programs refers to ensuring good practice that is already being realized through discussions with others and the link between theory and practice to rethink their practices, allowing them to perceive when they fall into the bureaucratic routine and adopt more appropriate

An awareness and acceptance of uncertainty in the practice of any professional is an important way to lessen stress. There are no perfect solutions out there to find, so we cannot be called on to work perfectly. If we accept the fact that the things we do or decide on are still dependent on something uncertain or on future happenings, and work in a way that takes account of that (i.e. constantly reviewing the things we deal with, decide on, or do), then this is really what "thinking critically" is all about [2]. The key is to strike a balance between the need for certainty and the need to be aware of other ways of doing or thinking about practice. This is where critical reflection (especially involving others) can play a key role in building trust by analyzing practice based on strengths, but also allows consideration of alternative options, points of view, etc., within a space safe, and where uncritical rigidity is not

These characteristics should be present not only in the students but also in the teachers. They must know how to model the learning they want to pass. Is it possible to give classes that do not develop these skills but reach other academic goals? Of course yes. But, it is also possible to achieve academic goals, curricular goals, and

Not least, we find the evaluation. In order to gauge how the process is going, we must evaluate. It is a great challenge to evaluate these skills, it is true. It will be easier to evaluate if you have memorized dates and locations. But as it is a challenge to know how much a student contributed in a group work and not fail to do so, we cannot give up to train our students in skills that will be valid for the rest of their lives because of the difficulty we encounter in the evaluation and the technology

It cannot be forgotten that the surprises with which every social worker is confronted in everyday contacts and relationships need to be analyzed not only with common sense look but also with critical thinking and the autonomy of a thought based on solid concepts should be a factor of considerable importance. This will mean that in each complex situation, the values that underpin knowledge are at the

programmatic content by developing these skills at the same time.

resources that allow new forms of formative and summative evaluation.

this area, regarding teaching, and evaluation of critical thinking.

**14**

service of conscious decision-making.

We are grateful and want to thank all the participants for their availability and collaboration, so that this study was possible.

The publication of this paper was supported by Portuguese national funds through Foundation for Science and Technology in the scope of the UID / SOC / 03126/2019 project. We appreciate the support given by the CIES-IUL and the funding of the Foundation for Science and Technology.

### **Conflict of interest**

The authors declare no conflict of interest.

### **Author details**

Helena Belchior-Rocha\* and Inês Casquilho-Martins Centre for Research and Studies in Sociology (CIES-IUL), Instituto Universitário de Lisboa (ISCTE-IUL), Lisbon, Portugal

\*Address all correspondence to: helena\_rocha@iscte-iul.pt

© 2019 The Author(s). Licensee IntechOpen. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/ by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

### **References**

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[2] Brown K, Rutter L. Critical Thinking for Social Work. 2nd ed. Southernhay East: Learning Matters Ltd.; 2008. 3, 42, 47 p. ISBN: 978 1 84445 157 9

[3] Adams R, Dominelli L, Payne M, editors. Critical Practice in Social Work. Basingstoke: Palgrave; 2002

[4] Barnett R. Higher Education: A Critical Business. Buckingham: Society for Research in Higher Education and Open University Press; 1997. ISBN: 0 335 19703 5

[5] Ford P, Johnston B, Mitchell R, Myles F. Social work education and criticality: Some thoughts from research. Social Work Education. 2004;**23**(2):185-198. DOI: 10.1080/0261547042000209198

[6] Ford P, Johnston B, Mitchell R, Myles F. Practice learning and the development of students as critical practitioners: Some findings from research. Social Work Education. 2005;**24**(4):391-407. DOI: 10.1080/02615470500096910

[7] Gray M, Plath D, Webb SA. Evidence-Based Social Work: A Critical Stance. London and New York: Routledge Taylor & Francis Group; 2009. ISBN 0-203-87662-89

[8] Bailin S, Case R, Coombs JR, Daniels LB. Conceptualizing critical thinking. Journal of Curriculum Studies. 1999;**31**(3):285-302. DOI: 10.1080/002202799183133

[9] Washburn P. The Vocabulary of Critical Thinking. New York: Oxford University Press; 2010. ISBN: 0195324803

[10] Almeida LS, Franco AHR. Critical thinking: Its relevance for education in a shifting society. Revista de Psicología. 2011;**29**(1):176-195. ISSN 0254-9247

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[15] Facione PA. Critical Thinking: A Statement of Expert Consensus for purposes of Educational Assessment and Instruction—Executive Summary "The Delphi Report" [Internet]. 1990a. Available from: http://assessment.aas. duke.edu/documents/Delphi\_Report. pdf [Accessed: 02 June 2019]

[16] Facione PA. Critical Thinking: A Statement of Expert Consensus for Purposes of Educational Assessment and Instruction—Research Findings and recommendations (ERIC Report No. ED315423) [Internet]. 1990b. Available from: http://www.eric.ed.gov/PDFS/ ED315423.pdf [Accessed: 23 May 2019]

**17**

*Critical Thinking in Social Work Training DOI: http://dx.doi.org/10.5772/intechopen.89538*

[17] Paul R, Elder L, Bartell T. California Teacher Preparation for Instruction in Critical Thinking (ERIC Report No. ED437379) [Internet]. 1997. Available from: http://www.eric.ed.gov/PDFS/ ED437379.pdf [Accessed: 23 May 2019]

2008;**24**(3 Supplement):S6-S13. DOI: 10.1016/s1607-551x(08)70088-3

[25] Fisher A. Critical Thinking: An intrOduction. Cambridge: Cambridge

thoughts about helping students improve how they think. Teaching of Psychology. 1995;**22**(1):82-83. DOI: 10.1207/s15328023top2201\_24

[27] Verburgh A. Effectiveness of

[28] Belchior Rocha H, Marques Ferreira P, Silva TP, Braz

ALTERN2013.20.05

978-1844452019

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[30] Leitão Ferreira J. Serviço social: Profissão e ciência. Contributos para o debate científico nas ciências sociais. Cuadernos de Trabajo Social. 2014;**27**(2):329-341. DOI: 10.5209/ rev\_CUTS.2014.v27.n2.44782

[31] Jones S. Critical Learning for Social Work Students. Exeter: Learning Matters Ltd; 2009. 93, 109 p. ISBN-13:

[32] Thompson N, Pascal J. Developing critically reflective practice. Reflective Practice. 2012;**13**(2):311-325. DOI: 10.1080/14623943.2012.657795

[33] Lima L. Atitudes: Estrutura e mudança. In: Vala J, Monteiro MB, editors. Psicologia Social. Lisboa:

[26] Halpern D, Nummendal SG. Closing

approaches to stimulate critical thinking in social work curricula. Studies in Higher Education. 2019;**44**(5):880-889. DOI: 10.1080/03075079.2019.1586336

University Press; 2001

[18] Angeli C, Valanides N. Instructional effects on critical thinking: performance on ill-defined issues. Learning and Instruction. 2009;**19**:322-324. DOI: 10.1016/j.learninstruc.2008.06.010

[19] Brookfield SD. Developing Critical Thinkers: Challenging Adults to Explore Alternative Ways of Thinking and Acting. Buckingham: Open University Press; 1991. ISBN: 978-1-555-42356-8

[20] Dewey J. Democracy and Education [Internet]. Penn State Electronic Classics Series Publication; 2001. Available from: https://nsee. memberclicks.net/assets/docs/ KnowledgeCenter/BuildingExpEduc/ BooksReports/10.%20democracy%20 and%20education%20by%20dewey.pdf

[Accessed: 24 May 2019]

Terra; 1967 (Brasilian)

about-critical-thinking#

[21] Freire P. Educação Como Prática da Liberdade. Rio de Janeiro: Editora Paz e

[22] Kuhn D. A developmental model of critical thinking. Educational Research. 1999;**28**(2):16-46. DOI: 10.3102/0013189x028002016

[23] Riddell T. Critical assumptions: Thinking critically about critical thinking. The Journal of Nursing Education. 2007;**46**(3):121-126. https://www.healio.com/journals/ jne/2007-3-46-3/%7Bfd7bf35f-0615-4e21-9291-56bf66297a8f%7D/ critical-assumptions-thinking-critically-

[24] Wang S-Y, Tsai J-C, Chiang H-C, Lai C-S, Lin H-J. Socrates, problembased learning and critical thinking—A

Kaohsiung Journal of Medical Sciences.

philosophic point of view. The

*Critical Thinking in Social Work Training DOI: http://dx.doi.org/10.5772/intechopen.89538*

[17] Paul R, Elder L, Bartell T. California Teacher Preparation for Instruction in Critical Thinking (ERIC Report No. ED437379) [Internet]. 1997. Available from: http://www.eric.ed.gov/PDFS/ ED437379.pdf [Accessed: 23 May 2019]

[18] Angeli C, Valanides N. Instructional effects on critical thinking: performance on ill-defined issues. Learning and Instruction. 2009;**19**:322-324. DOI: 10.1016/j.learninstruc.2008.06.010

[19] Brookfield SD. Developing Critical Thinkers: Challenging Adults to Explore Alternative Ways of Thinking and Acting. Buckingham: Open University Press; 1991. ISBN: 978-1-555-42356-8

[20] Dewey J. Democracy and Education [Internet]. Penn State Electronic Classics Series Publication; 2001. Available from: https://nsee. memberclicks.net/assets/docs/ KnowledgeCenter/BuildingExpEduc/ BooksReports/10.%20democracy%20 and%20education%20by%20dewey.pdf [Accessed: 24 May 2019]

[21] Freire P. Educação Como Prática da Liberdade. Rio de Janeiro: Editora Paz e Terra; 1967 (Brasilian)

[22] Kuhn D. A developmental model of critical thinking. Educational Research. 1999;**28**(2):16-46. DOI: 10.3102/0013189x028002016

[23] Riddell T. Critical assumptions: Thinking critically about critical thinking. The Journal of Nursing Education. 2007;**46**(3):121-126. https://www.healio.com/journals/ jne/2007-3-46-3/%7Bfd7bf35f-0615-4e21-9291-56bf66297a8f%7D/ critical-assumptions-thinking-criticallyabout-critical-thinking#

[24] Wang S-Y, Tsai J-C, Chiang H-C, Lai C-S, Lin H-J. Socrates, problembased learning and critical thinking—A philosophic point of view. The Kaohsiung Journal of Medical Sciences.

2008;**24**(3 Supplement):S6-S13. DOI: 10.1016/s1607-551x(08)70088-3

[25] Fisher A. Critical Thinking: An intrOduction. Cambridge: Cambridge University Press; 2001

[26] Halpern D, Nummendal SG. Closing thoughts about helping students improve how they think. Teaching of Psychology. 1995;**22**(1):82-83. DOI: 10.1207/s15328023top2201\_24

[27] Verburgh A. Effectiveness of approaches to stimulate critical thinking in social work curricula. Studies in Higher Education. 2019;**44**(5):880-889. DOI: 10.1080/03075079.2019.1586336

[28] Belchior Rocha H, Marques Ferreira P, Silva TP, Braz Ramalho V. Serviço social crítico: da modernidade à contemporaneidade. Alternativas: Cuadernos de Trabajo Social. 2013;**20**:79-90. DOI: 10.14198/ ALTERN2013.20.05

[29] Branco F. Social work education: The Portuguese story in a local and global perspective. Practice. 2018;**30**(4):271-291. DOI: 10.1080/09503153.2018.1485144

[30] Leitão Ferreira J. Serviço social: Profissão e ciência. Contributos para o debate científico nas ciências sociais. Cuadernos de Trabajo Social. 2014;**27**(2):329-341. DOI: 10.5209/ rev\_CUTS.2014.v27.n2.44782

[31] Jones S. Critical Learning for Social Work Students. Exeter: Learning Matters Ltd; 2009. 93, 109 p. ISBN-13: 978-1844452019

[32] Thompson N, Pascal J. Developing critically reflective practice. Reflective Practice. 2012;**13**(2):311-325. DOI: 10.1080/14623943.2012.657795

[33] Lima L. Atitudes: Estrutura e mudança. In: Vala J, Monteiro MB, editors. Psicologia Social. Lisboa:

**16**

0195324803

*Empathy Study*

**References**

[1] Granja B, Queirós MC. Problemas e desafios da investigação em serviço social. Intervenção Social. 2011;**38**: 233-251. ISSN: 0874-1611 (Portuguese) [10] Almeida LS, Franco AHR. Critical thinking: Its relevance for education in a shifting society. Revista de Psicología. 2011;**29**(1):176-195. ISSN 0254-9247

[11] Baker M, Rudd R. Relationships between critical and creative thinking. Journal of Southern Agricultural Education Research. 2001;**51**:173-188. http://www.jsaer.org/pdf/vol51Whole.

[12] Lai ER. Critical Thinking: A Literature Review—Research Report [Online]. Pearson Education; 2011. Available from: http://images.

[Accessed: 23 May 2019]

DOI: 10.1002/tl.8005

pearsonassessments.com/images/tmrs/ CriticalThinkingReviewFINAL.pdf

[13] Halpern D. Teaching for critical thinking: Helping college students develop the skills and dispositions of a critical thinker. New Directions for Teaching and Learning. 1999;**80**:69-74.

[14] Foundation for Critical Thinking. Our Concept and Definition of Critical Thinking [Internet]. 2007. Available from: https://www.criticalthinking. org/pages/our-conception-of-criticalthinking/411 [Accessed: 02 June 2019]

[15] Facione PA. Critical Thinking: A Statement of Expert Consensus for purposes of Educational Assessment and Instruction—Executive Summary "The Delphi Report" [Internet]. 1990a. Available from: http://assessment.aas. duke.edu/documents/Delphi\_Report.

[16] Facione PA. Critical Thinking: A Statement of Expert Consensus for Purposes of Educational Assessment and Instruction—Research Findings and recommendations (ERIC Report No. ED315423) [Internet]. 1990b. Available from: http://www.eric.ed.gov/PDFS/ ED315423.pdf [Accessed: 23 May 2019]

pdf [Accessed: 02 June 2019]

pdf

[2] Brown K, Rutter L. Critical Thinking for Social Work. 2nd ed. Southernhay East: Learning Matters Ltd.; 2008. 3, 42,

47 p. ISBN: 978 1 84445 157 9

Basingstoke: Palgrave; 2002

19703 5

[3] Adams R, Dominelli L, Payne M, editors. Critical Practice in Social Work.

[4] Barnett R. Higher Education: A Critical Business. Buckingham: Society for Research in Higher Education and Open University Press; 1997. ISBN: 0 335

[5] Ford P, Johnston B, Mitchell R, Myles F. Social work education and criticality: Some thoughts from research. Social Work Education.

[6] Ford P, Johnston B, Mitchell R, Myles F. Practice learning and the development of students as critical practitioners: Some findings from research. Social Work Education.

[7] Gray M, Plath D, Webb SA. Evidence-Based Social Work: A Critical Stance. London and New York: Routledge Taylor & Francis Group; 2009. ISBN

[8] Bailin S, Case R, Coombs JR, Daniels LB. Conceptualizing critical thinking. Journal of Curriculum Studies. 1999;**31**(3):285-302. DOI:

[9] Washburn P. The Vocabulary of Critical Thinking. New York: Oxford University Press; 2010. ISBN:

10.1080/002202799183133

2004;**23**(2):185-198. DOI: 10.1080/0261547042000209198

2005;**24**(4):391-407. DOI: 10.1080/02615470500096910

0-203-87662-89

Fundação Calouste Gulbenkian; 2000 (Portuguese)

**Chapter 2**

**Abstract**

nursing philosophy

**19**

The Moment of Establishing

Grieving Adolescent Daughter

*Kumiko Morita, Maki Iwamoto and Masako Hosohara*

Evidence-based nursing (EBN) ensures the science of nursing practice, while the philosophical and ethical aspects of nursing practice are based on caring. Caring not only leads to the patient and their family's healing but also to the nurse's professional and personal growth since caring includes mutual approval and reciprocity. In the latter half of the chapter, we explain how to establish Dr. Jean Watson's transpersonal caring using the following two events: ① case study: An expert nurse unintentionally says, "Your mother continues to be near and protect you," to a crying daughter beside her mother's deathbed; and ② our project: sanatorium's

**Keywords:** caring, spirituality, Jean Watson, Hansen's disease, end-of-life care,

The concept of "caring" is significant in nursing practice and characterizes nursing practice philosophically and ethically. We make additions and corrections to the lecture at Okayama Prefectural Nursing Association in Japan: "Caring for nursing practice—Let's reflect our nursing practice philosophically." In this chapter, we first explain about understanding clients based on Holism and the significance of caring in nursing practice. Second, we study why and how to establish our two nursing practices as transpersonal caring using Jean Watson's caring theory, and we discuss the significance of caring. The two cases are (1) a crying adolescent daughter in her mother's deathbed and (2) Hansen's disease survivors sharing about their own life review. Finally, we discuss the significance of caring in medical ethics.

beside Her Mother's Deathbed and

Transpersonal Caring in a

Hansen's Disease Survivors

Sharing Their Life Review

*Makiko Kondo, Sachie Okanishi, Etsuko Arai,*

nurses listen to Hansen's disease survivors' life review.

**1. Understanding clients and nursing practices**

[34] Kates S. A qualitative exploration into voters' ethical perceptions of political advertising: Discourse, disinformation, and moral boundaries. Journal of Business Ethics. 1998;**17**(16):1871-1885. DOI: 10.1023/a:1005796113389

[35] Macaulay C. Transfer of learning. In: Cree VE, Macaulay C, editors. Transfer of Learning in Professional and Vocational Learning. London: Routledge; 2000. pp. 1-26. ISBN: 0415204194

### **Chapter 2**

*Empathy Study*

(Portuguese)

0415204194

Fundação Calouste Gulbenkian; 2000

[34] Kates S. A qualitative exploration into voters' ethical perceptions of political advertising: Discourse, disinformation, and moral boundaries. Journal of Business Ethics. 1998;**17**(16):1871-1885. DOI:

[35] Macaulay C. Transfer of learning. In: Cree VE, Macaulay C, editors. Transfer of Learning in Professional and Vocational Learning. London: Routledge; 2000. pp. 1-26. ISBN:

10.1023/a:1005796113389

**18**

## The Moment of Establishing Transpersonal Caring in a Grieving Adolescent Daughter beside Her Mother's Deathbed and Hansen's Disease Survivors Sharing Their Life Review

*Makiko Kondo, Sachie Okanishi, Etsuko Arai, Kumiko Morita, Maki Iwamoto and Masako Hosohara*

#### **Abstract**

Evidence-based nursing (EBN) ensures the science of nursing practice, while the philosophical and ethical aspects of nursing practice are based on caring. Caring not only leads to the patient and their family's healing but also to the nurse's professional and personal growth since caring includes mutual approval and reciprocity. In the latter half of the chapter, we explain how to establish Dr. Jean Watson's transpersonal caring using the following two events: ① case study: An expert nurse unintentionally says, "Your mother continues to be near and protect you," to a crying daughter beside her mother's deathbed; and ② our project: sanatorium's nurses listen to Hansen's disease survivors' life review.

**Keywords:** caring, spirituality, Jean Watson, Hansen's disease, end-of-life care, nursing philosophy

#### **1. Understanding clients and nursing practices**

The concept of "caring" is significant in nursing practice and characterizes nursing practice philosophically and ethically. We make additions and corrections to the lecture at Okayama Prefectural Nursing Association in Japan: "Caring for nursing practice—Let's reflect our nursing practice philosophically." In this chapter, we first explain about understanding clients based on Holism and the significance of caring in nursing practice. Second, we study why and how to establish our two nursing practices as transpersonal caring using Jean Watson's caring theory, and we discuss the significance of caring. The two cases are (1) a crying adolescent daughter in her mother's deathbed and (2) Hansen's disease survivors sharing about their own life review. Finally, we discuss the significance of caring in medical ethics.

#### **1.1 What is needed for high-quality nursing practice?**

Nursing is, undoubtedly, a science of practice. In practical sciences, we not only analyze and critique the phenomenon, but we also use our body as a tool and intervene in the phenomenon to develop and improve. Therefore, the relationship between clients and nurses is important because nursing interventions involves the relationship between them.

physical, physiological, social, and spiritual pain. On the other hand, although the quality of life (QOL) emphasizes the client's subjectivity over objective indicators, it helps understand not one but multiple aspects. Haas' QOL model [1] states that the QOL includes physical, psychological, social, and spiritual well-being. In other words, experiencing pain in these four aspects (physical, psychological, social, and spiritual) is called total pain, while experiencing well-being in these four aspects is called high-level QOL. The relationship between total pain and the QOL is akin to the two sides of the same coin. Therefore, both total pain and QOL focus on understanding human beings from four aspects (physical, psychological, social, and spiritual). When the nurses decide the goals and direction for nursing intervention, they consider what high-level QOL is for the client and evaluate the effectiveness of nursing practice from the client's QOL. Understanding these four aspects is impor-

*The Moment of Establishing Transpersonal Caring in a Grieving Adolescent Daughter beside Her…*

The second perspective is positioning on the life cycle. In **Figure 2(1)**, the arrow presents the patient's and nurse's lifetime from birth to death. The intersection of the two arrows shows the moment wherein the nurse's life and the patient's life cross, i.e., the moment when the patient–nurse relationship was established. The patient–nurse relationship is maintained for a short time in their lifespan. Therefore, if the nurse wants to understand the client deeply, she/he should endeavor to know how the client has lived until meeting her/him and how the client wants to live in the future. Sometimes, nurses are derided that "she knows only patients wearing pajamas", because her concerns are only about the present and she does not make efforts to understand the client's lifecycle. Especially, in end-of-life care, nurses must understand the client's life deeply and support that the client can live and die in his/her own way. Additionally, a nurse meets a great number of patients during her professional life. Although most patients are forgotten with time, some patients are always remembered (see **Figure 2(2)**). We will explain why the differ-

The third perspective includes the clients'significant others as subjects of nursing practice. The arrows in **Figure 2(3)** show my lifetime, my mother's lifetime, and my daughter's lifetime. I have lived with my mother since my birth; the relationship between my mother and me will continue until her death, although the physical and

The fourth perspective is "disease" and "illness" in medical anthropology. While "disease" shows objective events, "illness" shows subjective experience. For example, "blood vessels nourishing the heart are obstructed, the myocardium is necrosis, and pump function of the heart is decreased" is a "disease"; the communication between various medical staff can be established by using a common language, "myocardial infarction." In contrast, when the attack occurred, "I felt that I will die," "I thought about tomorrow's significant job," and "the face of a young child flashed" are "illness" expressing subjective experiences, and 100 people can have 100 types of experiences. Because the goal of nursing practice is the client's physical, psychological, social, and spiritual well-being, nurses must understand not only the pathophysiology (what occurs in the body) and the effect of the disease in their daily life but also the client's subjective experience. The ability to understand both

psychological distance increases with my growth. Similarly, the relationship between my child and me begins in the middle of my lifetime at my child's birth and would ordinarily end at my death. It is similar to a family's life cycle in the family development theory. As shown in **Figure 2(4)**, when a patient–nurse relationship is established, not only the patient but also his/her significant others (in this case, my mother and daughter) are comprised in circles, because they are living their life

together and are connected through strong bonds.

disease and illness is a strength for nurses.

**21**

tant because QOL is an important concept for nursing practice.

*DOI: http://dx.doi.org/10.5772/intechopen.92641*

ences exist in the next term.

When engaging in high-quality nursing practice, two things are important. First, we must understand the clients deeply in order to decide the direction of the approach. Second, we must identify what and how the practice is building.

#### **1.2 Understanding clients based on holism**

Holism is important in nursing. In natural sciences, the phenomenon is understood by breaking it into elements, based on element reductionism. On the other hand, in holism, we try to understand human beings as a whole, whose existence is greater than the sum of their parts. For example, in **Figure 1(a)** and **(b)**, the threedimensional PET bottle is shown as two-dimensional when perceived from above or below. Many people may be unable to understand the PET bottle by seeing only (a) and (b). Understanding "as a whole" means understanding the PET bottle as threedimensional without dividing it into two dimensions. However, because human beings live in more than four dimensions' world, understanding them "as a whole" is very difficult. Therefore, we attempt to draw a multidimensional image by combining several perspectives.

The first perspective understands human beings from four aspects: physical, physiological, social, and spiritual. The sufferings of cancer patients or patients in the terminal stage are known as total pain, which occurs through the interactions of

#### *The Moment of Establishing Transpersonal Caring in a Grieving Adolescent Daughter beside Her… DOI: http://dx.doi.org/10.5772/intechopen.92641*

physical, physiological, social, and spiritual pain. On the other hand, although the quality of life (QOL) emphasizes the client's subjectivity over objective indicators, it helps understand not one but multiple aspects. Haas' QOL model [1] states that the QOL includes physical, psychological, social, and spiritual well-being. In other words, experiencing pain in these four aspects (physical, psychological, social, and spiritual) is called total pain, while experiencing well-being in these four aspects is called high-level QOL. The relationship between total pain and the QOL is akin to the two sides of the same coin. Therefore, both total pain and QOL focus on understanding human beings from four aspects (physical, psychological, social, and spiritual). When the nurses decide the goals and direction for nursing intervention, they consider what high-level QOL is for the client and evaluate the effectiveness of nursing practice from the client's QOL. Understanding these four aspects is important because QOL is an important concept for nursing practice.

The second perspective is positioning on the life cycle. In **Figure 2(1)**, the arrow presents the patient's and nurse's lifetime from birth to death. The intersection of the two arrows shows the moment wherein the nurse's life and the patient's life cross, i.e., the moment when the patient–nurse relationship was established. The patient–nurse relationship is maintained for a short time in their lifespan. Therefore, if the nurse wants to understand the client deeply, she/he should endeavor to know how the client has lived until meeting her/him and how the client wants to live in the future. Sometimes, nurses are derided that "she knows only patients wearing pajamas", because her concerns are only about the present and she does not make efforts to understand the client's lifecycle. Especially, in end-of-life care, nurses must understand the client's life deeply and support that the client can live and die in his/her own way. Additionally, a nurse meets a great number of patients during her professional life. Although most patients are forgotten with time, some patients are always remembered (see **Figure 2(2)**). We will explain why the differences exist in the next term.

The third perspective includes the clients'significant others as subjects of nursing practice. The arrows in **Figure 2(3)** show my lifetime, my mother's lifetime, and my daughter's lifetime. I have lived with my mother since my birth; the relationship between my mother and me will continue until her death, although the physical and psychological distance increases with my growth. Similarly, the relationship between my child and me begins in the middle of my lifetime at my child's birth and would ordinarily end at my death. It is similar to a family's life cycle in the family development theory. As shown in **Figure 2(4)**, when a patient–nurse relationship is established, not only the patient but also his/her significant others (in this case, my mother and daughter) are comprised in circles, because they are living their life together and are connected through strong bonds.

The fourth perspective is "disease" and "illness" in medical anthropology. While "disease" shows objective events, "illness" shows subjective experience. For example, "blood vessels nourishing the heart are obstructed, the myocardium is necrosis, and pump function of the heart is decreased" is a "disease"; the communication between various medical staff can be established by using a common language, "myocardial infarction." In contrast, when the attack occurred, "I felt that I will die," "I thought about tomorrow's significant job," and "the face of a young child flashed" are "illness" expressing subjective experiences, and 100 people can have 100 types of experiences. Because the goal of nursing practice is the client's physical, psychological, social, and spiritual well-being, nurses must understand not only the pathophysiology (what occurs in the body) and the effect of the disease in their daily life but also the client's subjective experience. The ability to understand both disease and illness is a strength for nurses.

**1.1 What is needed for high-quality nursing practice?**

relationship between them.

*Empathy Study*

bining several perspectives.

**Figure 1.**

**20**

*Understanding as a whole.*

**1.2 Understanding clients based on holism**

Nursing is, undoubtedly, a science of practice. In practical sciences, we not only

When engaging in high-quality nursing practice, two things are important. First,

Holism is important in nursing. In natural sciences, the phenomenon is understood by breaking it into elements, based on element reductionism. On the other hand, in holism, we try to understand human beings as a whole, whose existence is greater than the sum of their parts. For example, in **Figure 1(a)** and **(b)**, the threedimensional PET bottle is shown as two-dimensional when perceived from above or below. Many people may be unable to understand the PET bottle by seeing only (a) and (b). Understanding "as a whole" means understanding the PET bottle as threedimensional without dividing it into two dimensions. However, because human beings live in more than four dimensions' world, understanding them "as a whole" is very difficult. Therefore, we attempt to draw a multidimensional image by com-

The first perspective understands human beings from four aspects: physical, physiological, social, and spiritual. The sufferings of cancer patients or patients in the terminal stage are known as total pain, which occurs through the interactions of

analyze and critique the phenomenon, but we also use our body as a tool and intervene in the phenomenon to develop and improve. Therefore, the relationship between clients and nurses is important because nursing interventions involves the

we must understand the clients deeply in order to decide the direction of the approach. Second, we must identify what and how the practice is building.

**1.3 Affinity with the qualitative research approach**

*DOI: http://dx.doi.org/10.5772/intechopen.92641*

and can find a new direction for care [2].

continue to change.

**Figure 3.**

**23**

The qualitative research method is highly significant to understand "illness" (client's subjective experiences) (see **Figure 3**). Some readers might investigate whether light affects plant growth as elementary school summer vacation homework. In this case, we identify conditions affecting plant growth, light, temperature, fertilizer, amount of watering per day, species type, etc., and compare the experimental (with light) and control groups (without light) while keeping other conditions constant. This is an experimental research based on element reduction and basic research in natural sciences. On the other hand, the qualitative study analyzes the responses of research participants inductively and performs an abstraction, thereby clarifying the nature of the phenomenon. In other words, the researcher not only describes the subjective experiences but also utilizes a theory or middle-range theory to explain the construction and process of the phenomenon. For example, why does the phenomenon occur? What is the nature of the phenomenon? What is the outcome? If we can identify the construction and process of the phenomenon, we can consider where and how to approach to get good outcomes

*The Moment of Establishing Transpersonal Caring in a Grieving Adolescent Daughter beside Her…*

Understanding the subjects in real clinical settings is very difficult. The first reason is the difficulty in understanding the nature of the phenomenon. **Figure 4** shows blind men evaluating an elephant. Blind man A touches the elephant's nose and feels that it is a tube. Blind man B touches the elephant's ear and feels that it is a big fan. Blind man C touches the elephant's leg and feels that it is a thick pillar. However, no blind man could find the essence (elephant) of the thing they touched. Likewise, we cannot directly touch the essence of the phenomenon and only have partial knowledge in a real clinical setting. Therefore, we must repeat the process of trial and error. The second reason is that we must decide the direction for approach and begin support before clarifying the essence of the phenomenon (we cannot wait until the overall picture and essence are clarified). If we explain using **Figure 1**, we believe the double circle (a) and star shape (b) as truth, and we cannot notice the PET bottle as truth, and then we employ a wrong intervention without knowing the truth. The third reason is that the situation and the phenomenon transform at every moment. In other words, if we can clarify the essence of the phenomenon, we must continue to consider the essence of the phenomenon because the situation would

*Experimental research based on element reductionism. "Does plant growth need light?"*

#### **Figure 2.**

*(1) Intersection of nurse A's life and patient B's life established patient-nurse relationship). (2) A nurse meets many patients during their professional life. (3) My life, my mother's life, and my daughter's life. (4) Not only the patient but also his/her significant others are included in the patient-nurse relationship. (5) Transpersonal caring.*

*The Moment of Establishing Transpersonal Caring in a Grieving Adolescent Daughter beside Her… DOI: http://dx.doi.org/10.5772/intechopen.92641*

#### **1.3 Affinity with the qualitative research approach**

The qualitative research method is highly significant to understand "illness" (client's subjective experiences) (see **Figure 3**). Some readers might investigate whether light affects plant growth as elementary school summer vacation homework. In this case, we identify conditions affecting plant growth, light, temperature, fertilizer, amount of watering per day, species type, etc., and compare the experimental (with light) and control groups (without light) while keeping other conditions constant. This is an experimental research based on element reduction and basic research in natural sciences. On the other hand, the qualitative study analyzes the responses of research participants inductively and performs an abstraction, thereby clarifying the nature of the phenomenon. In other words, the researcher not only describes the subjective experiences but also utilizes a theory or middle-range theory to explain the construction and process of the phenomenon. For example, why does the phenomenon occur? What is the nature of the phenomenon? What is the outcome? If we can identify the construction and process of the phenomenon, we can consider where and how to approach to get good outcomes and can find a new direction for care [2].

Understanding the subjects in real clinical settings is very difficult. The first reason is the difficulty in understanding the nature of the phenomenon. **Figure 4** shows blind men evaluating an elephant. Blind man A touches the elephant's nose and feels that it is a tube. Blind man B touches the elephant's ear and feels that it is a big fan. Blind man C touches the elephant's leg and feels that it is a thick pillar. However, no blind man could find the essence (elephant) of the thing they touched. Likewise, we cannot directly touch the essence of the phenomenon and only have partial knowledge in a real clinical setting. Therefore, we must repeat the process of trial and error. The second reason is that we must decide the direction for approach and begin support before clarifying the essence of the phenomenon (we cannot wait until the overall picture and essence are clarified). If we explain using **Figure 1**, we believe the double circle (a) and star shape (b) as truth, and we cannot notice the PET bottle as truth, and then we employ a wrong intervention without knowing the truth. The third reason is that the situation and the phenomenon transform at every moment. In other words, if we can clarify the essence of the phenomenon, we must continue to consider the essence of the phenomenon because the situation would continue to change.

**Figure 3.** *Experimental research based on element reductionism. "Does plant growth need light?"*

**Figure 2.**

*Empathy Study*

**22**

*(1) Intersection of nurse A's life and patient B's life established patient-nurse relationship). (2) A nurse meets many patients during their professional life. (3) My life, my mother's life, and my daughter's life. (4) Not only the patient but also his/her significant others are included in the patient-nurse relationship. (5) Transpersonal caring.*

as art means understanding clients through humanics (humanities, social sciences,

*The Moment of Establishing Transpersonal Caring in a Grieving Adolescent Daughter beside Her…*

The origin of caring is similar to mothering and parenting, and these had been born into home spontaneously, such as caring for a sick family member by other family members, childbearing by women, etc. Therefore, caring is based on nursing, although only caring is not specific to nursing. Philosopher Milton Mayeroff [5] states that care is established through interactions between the care receiver and caregiver. The essence of care is that both the caregiver and care receiver grow, fulfill self-realization, and find meanings and worth. Caregivers assist the care receiver's self-realization and growth, and they achieve their self-realization through the supporting process. This caring relationship is not one-sided selfsacrifice but involves mutual approval and reciprocity (mutually beneficial). Elements of care include knowledge, changing rhythm, patience, honesty, trust, humility, hope, and courage. Therefore, we consider mutual approval and reciprocity as characteristics of caring and the achievement of self-realization by both

The concept of caring involves deliberation about "being (how we exist?)" against "doing (what we do?)." It means that the nurse's existence itself soothes the patients. O'Brien and Davies [6] demonstrated caring in the end-of-life care by Petal illustration: the nurse respects and connects with the suffering patient, searches what is useful for the patient, empowers and helps unleash the potential of the lethargic patient, helps them search for meaning from their sufferings, and then helps the patient maintain their wholeness. The poet, Tomihiro Hoshino [7], had a cervical spine injury and quadriplegia by falling from a horizontal bar in his first year as a teacher and experienced deep existential suffering. He, then, became a Christian, got married, and drew flowers and wrote poems by having a paintbrush in his mouth. His poems expressed the essence of caring from a care receiver's perspective: "I can be standing, because you are supporting me. I can lean off the cliff, because you are supporting me. I can dream invisible tomorrow, because you are supporting me. Although my lifetime is like walking tightrope, I can alive by

One expertise of nurses caring for dying and death is "enduring to stay with a

**2. The moment of established transpersonal caring by Dr. Jean Watson's**

Nursing theorist Dr. Jean Watson strengthened the philosophical and ethical foundations of nursing practice. She considered caring in nursing and theorized transpersonal caring, which involves resonating with each other at a spiritual level. In this section, after overviewing Dr. Watson's theory, we describe two nursing

practices in which transpersonal caring was established.

patient suffering severe physical pain" [8]. As death approaches, our "doing (problem-solving method)" becomes less and less effective. When the nurse stays with the dying patient suffering bitter pain without an effective support method, the nurse feels their helplessness and pain. Therefore, it is one of the causes of burnout among nurses. Furthermore, when the nurse remains by the patient's side, the nurse's presence brings peace to the patient. The essence of caring in end-of-life care is "being (how the nurse exists)," as opposed to "doing (do something useful)."

art, etc.) and emphasizes the narrative-based nursing and caring.

the care receiver and caregiver as the process of caring.

**1.5 What is caring?**

*DOI: http://dx.doi.org/10.5772/intechopen.92641*

supporting from you."

**theory**

**25**

#### **Figure 4.**

*What is a qualitative study?—Drawing out the essences of the phenomenon.*

Mentioned above are difficulties in understanding human beings as a whole. Unlike the traditional experimental research based on element reductionism, the origin of qualitative research approach is humanics (philosophy, sociology, cultural anthropology), and researchers try to clarify the nature of the relevant phenomenon, i.e., they try to clarify that it is not a tube, a big fan, or a thick pillar, but an elephant. Therefore, the qualitative research approach and nursing practice have high affinity because nursing practice is based on holism. The qualitative approach has taken root not only in nursing but also in the academic area of human support (pedagogy, welfare studies, psychology, etc.). Recently, the business world and mass media use stories as a narrative approach. Specifically, the specialty of qualitative research in nursing is to help understand the patients'subjective experiences, i.e., the description of "illness." Accumulating data using qualitative study is like accumulating knowledge of the "illness" and developing area adhesion-type theory or a middle-range theory to explain and predict the relevant phenomenon. Therefore, it contributes to the development of the academic system of nursing by providing evidence and academic infrastructure.

#### **1.4 Nursing as a science of practice**

The second important thing to enable high-quality nursing practice is clarifying what constitutes the nursing practices. The goals of nursing practices are the client's physical, psychological, social, and spiritual well-being based on Hass' QOL model [1] and health and happiness as a whole person. Dr. Hinohara [3, 4] said, "Nursing is an Art, based on Science," based on Dr. William Osler's quote. Nursing as science means evidence-based nursing (EBN) as one area of natural sciences and emphasizes logical and critical thinking and purposeful actions. On the other hand, nursing as art means understanding clients through humanics (humanities, social sciences, art, etc.) and emphasizes the narrative-based nursing and caring.

#### **1.5 What is caring?**

The origin of caring is similar to mothering and parenting, and these had been born into home spontaneously, such as caring for a sick family member by other family members, childbearing by women, etc. Therefore, caring is based on nursing, although only caring is not specific to nursing. Philosopher Milton Mayeroff [5] states that care is established through interactions between the care receiver and caregiver. The essence of care is that both the caregiver and care receiver grow, fulfill self-realization, and find meanings and worth. Caregivers assist the care receiver's self-realization and growth, and they achieve their self-realization through the supporting process. This caring relationship is not one-sided selfsacrifice but involves mutual approval and reciprocity (mutually beneficial). Elements of care include knowledge, changing rhythm, patience, honesty, trust, humility, hope, and courage. Therefore, we consider mutual approval and reciprocity as characteristics of caring and the achievement of self-realization by both the care receiver and caregiver as the process of caring.

The concept of caring involves deliberation about "being (how we exist?)" against "doing (what we do?)." It means that the nurse's existence itself soothes the patients. O'Brien and Davies [6] demonstrated caring in the end-of-life care by Petal illustration: the nurse respects and connects with the suffering patient, searches what is useful for the patient, empowers and helps unleash the potential of the lethargic patient, helps them search for meaning from their sufferings, and then helps the patient maintain their wholeness. The poet, Tomihiro Hoshino [7], had a cervical spine injury and quadriplegia by falling from a horizontal bar in his first year as a teacher and experienced deep existential suffering. He, then, became a Christian, got married, and drew flowers and wrote poems by having a paintbrush in his mouth. His poems expressed the essence of caring from a care receiver's perspective: "I can be standing, because you are supporting me. I can lean off the cliff, because you are supporting me. I can dream invisible tomorrow, because you are supporting me. Although my lifetime is like walking tightrope, I can alive by supporting from you."

One expertise of nurses caring for dying and death is "enduring to stay with a patient suffering severe physical pain" [8]. As death approaches, our "doing (problem-solving method)" becomes less and less effective. When the nurse stays with the dying patient suffering bitter pain without an effective support method, the nurse feels their helplessness and pain. Therefore, it is one of the causes of burnout among nurses. Furthermore, when the nurse remains by the patient's side, the nurse's presence brings peace to the patient. The essence of caring in end-of-life care is "being (how the nurse exists)," as opposed to "doing (do something useful)."

#### **2. The moment of established transpersonal caring by Dr. Jean Watson's theory**

Nursing theorist Dr. Jean Watson strengthened the philosophical and ethical foundations of nursing practice. She considered caring in nursing and theorized transpersonal caring, which involves resonating with each other at a spiritual level. In this section, after overviewing Dr. Watson's theory, we describe two nursing practices in which transpersonal caring was established.

Mentioned above are difficulties in understanding human beings as a whole. Unlike the traditional experimental research based on element reductionism, the origin of qualitative research approach is humanics (philosophy, sociology, cultural anthropology), and researchers try to clarify the nature of the relevant phenomenon, i.e., they try to clarify that it is not a tube, a big fan, or a thick pillar, but an elephant. Therefore, the qualitative research approach and nursing practice have high affinity because nursing practice is based on holism. The qualitative approach has taken root not only in nursing but also in the academic area of human support (pedagogy, welfare studies, psychology, etc.). Recently, the business world and mass media use stories as a narrative approach. Specifically, the specialty of qualitative research in nursing is to help understand the patients'subjective experiences, i.e., the description of "illness." Accumulating data using qualitative study is like accumulating knowledge of the "illness" and developing area adhesion-type theory or a middle-range theory to explain and predict the relevant phenomenon. Therefore, it contributes to the development of the academic system of nursing by

The second important thing to enable high-quality nursing practice is clarifying what constitutes the nursing practices. The goals of nursing practices are the client's physical, psychological, social, and spiritual well-being based on Hass' QOL model [1] and health and happiness as a whole person. Dr. Hinohara [3, 4] said, "Nursing is an Art, based on Science," based on Dr. William Osler's quote. Nursing as science means evidence-based nursing (EBN) as one area of natural sciences and emphasizes logical and critical thinking and purposeful actions. On the other hand, nursing

providing evidence and academic infrastructure.

*What is a qualitative study?—Drawing out the essences of the phenomenon.*

**1.4 Nursing as a science of practice**

**Figure 4.**

*Empathy Study*

**24**

#### **2.1 Why is a theory needed?**

A theory is the systematic knowledge that explains each phenomenon and fact and has predictive power and a deductive system created by combining hypotheses and laws, which are formulated concepts having clear definitions [9]. **Figure 5** shows the relationship between practice, theory, and research. In nursing, practice is usually the most important. The practice involves using knowledge through which nursing becomes a practical science, enhancing the existence value in society. However, the knowledge supporting practice is not always scientific knowledge; unclear evidence and habits exist, such as "we have been doing it for a long time" or "the matter is common sense in this place."

indispensable for logical thinking. Induction proceeds from the concrete to abstract, and deduction proceeds from abstract to concrete. Examples of deduction include case study (using existing theory, analyzing the difficult case, and identifying a solution) and quantitative study (making a theoretical framework and evaluating its validity by using statistics). Examples of induction include qualitative study (creating abstract concepts from concrete phenomenon) (see **Figure 6**). There are many miscellaneous things: ballpoint pen, frying pan, stethoscope, etc. When we gather them by similarity, the ballpoint pen, pencil case, and eraser are comprised under "things to use when writing"; the frying pan, pot, and spoon are comprised under "things to use when cooking'"; ship, airplane, and electric train are comprised under "things to use when traveling"; and weight scale, stethoscope, and thermometer are comprised under "things to use when diagnosing." These are named "stationery," "cooking utensils," "vehicle," and "medical equipment," respectively. Then, these are gathered and defined as "things people use to do something" and named "tool," which is a more abstract concept. In summary, the goal of the inductive method was to create a highly abstract and explainable concept of "tool." Regarding the concepts' usefulness, if we enumerate "stationery" concretely, we can create a thick catalog containing thousands of concrete examples; however, if we use the concept and definition, we can express thousands of concrete examples in one word "stationery." Therefore, a concept's usefulness is highly explainable and convenient. On the other hand, if we use theory to understand the difficult case (e.g., case study), a deduction is used. Its purpose is to select a suitable theory for the relevant phenomenon. For this, the researchers must study the characteristics of various theories and increase their knowledge, like a sommelier. Additionally, there is one caution; we use theory to analyze the relevant phenomenon. When we use one theory, we naturally understand the phenomenon according to the selected theory, and we cannot understand other perspectives. As a result, we may overlook

*The Moment of Establishing Transpersonal Caring in a Grieving Adolescent Daughter beside Her…*

*DOI: http://dx.doi.org/10.5772/intechopen.92641*

important things and the essence of the phenomenon.

**Figure 6.**

**27**

*Deduction and induction.*

Research is the creation of knowledge, i.e., a process of elucidating various problems arising in nursing practice by using logical thinking and scientific methods and creating evidence for sustaining nursing practices. Therefore, there are research buds (issues to be investigated) in nursing practices.

A theory is systematized knowledge created by research and has established nursing as an academic area. Because nursing had emerged spontaneously like mothering and parenting is based on medical knowledge to perform a medical doctor's supplementary work, has theories and systematized evidence to sustain nursing practice, and has academically systematized theories, nursing becomes nursing science. A theory involves accumulating and systematizing knowledge; it is a sustained practice by giving theoretical and academic foundations.

#### **2.2 Deduction and induction**

When we use a theory for nursing practice or create a theory from nursing practice, understanding deduction and induction becomes important. Deduction and induction are the ladder to move between abstract and concrete and enables logical explanation about this movement. Therefore, these inference methods are

**Figure 5.** *Relevance of practice, research, and theory.*

#### *The Moment of Establishing Transpersonal Caring in a Grieving Adolescent Daughter beside Her… DOI: http://dx.doi.org/10.5772/intechopen.92641*

indispensable for logical thinking. Induction proceeds from the concrete to abstract, and deduction proceeds from abstract to concrete. Examples of deduction include case study (using existing theory, analyzing the difficult case, and identifying a solution) and quantitative study (making a theoretical framework and evaluating its validity by using statistics). Examples of induction include qualitative study (creating abstract concepts from concrete phenomenon) (see **Figure 6**). There are many miscellaneous things: ballpoint pen, frying pan, stethoscope, etc. When we gather them by similarity, the ballpoint pen, pencil case, and eraser are comprised under "things to use when writing"; the frying pan, pot, and spoon are comprised under "things to use when cooking'"; ship, airplane, and electric train are comprised under "things to use when traveling"; and weight scale, stethoscope, and thermometer are comprised under "things to use when diagnosing." These are named "stationery," "cooking utensils," "vehicle," and "medical equipment," respectively. Then, these are gathered and defined as "things people use to do something" and named "tool," which is a more abstract concept. In summary, the goal of the inductive method was to create a highly abstract and explainable concept of "tool." Regarding the concepts' usefulness, if we enumerate "stationery" concretely, we can create a thick catalog containing thousands of concrete examples; however, if we use the concept and definition, we can express thousands of concrete examples in one word "stationery." Therefore, a concept's usefulness is highly explainable and convenient.

On the other hand, if we use theory to understand the difficult case (e.g., case study), a deduction is used. Its purpose is to select a suitable theory for the relevant phenomenon. For this, the researchers must study the characteristics of various theories and increase their knowledge, like a sommelier. Additionally, there is one caution; we use theory to analyze the relevant phenomenon. When we use one theory, we naturally understand the phenomenon according to the selected theory, and we cannot understand other perspectives. As a result, we may overlook important things and the essence of the phenomenon.

**Figure 6.** *Deduction and induction.*

**2.1 Why is a theory needed?**

*Empathy Study*

**2.2 Deduction and induction**

**Figure 5.**

**26**

*Relevance of practice, research, and theory.*

"the matter is common sense in this place."

A theory is the systematic knowledge that explains each phenomenon and fact and has predictive power and a deductive system created by combining hypotheses and laws, which are formulated concepts having clear definitions [9]. **Figure 5** shows the relationship between practice, theory, and research. In nursing, practice is usually the most important. The practice involves using knowledge through which nursing becomes a practical science, enhancing the existence value in society. However, the knowledge supporting practice is not always scientific knowledge; unclear evidence and habits exist, such as "we have been doing it for a long time" or

Research is the creation of knowledge, i.e., a process of elucidating various problems arising in nursing practice by using logical thinking and scientific methods and creating evidence for sustaining nursing practices. Therefore, there

A theory is systematized knowledge created by research and has established nursing as an academic area. Because nursing had emerged spontaneously like mothering and parenting is based on medical knowledge to perform a medical doctor's supplementary work, has theories and systematized evidence to sustain nursing practice, and has academically systematized theories, nursing becomes nursing science. A theory involves accumulating and systematizing knowledge; it is

When we use a theory for nursing practice or create a theory from nursing practice, understanding deduction and induction becomes important. Deduction and induction are the ladder to move between abstract and concrete and enables logical explanation about this movement. Therefore, these inference methods are

are research buds (issues to be investigated) in nursing practices.

a sustained practice by giving theoretical and academic foundations.

#### **2.3 Case analysis method by Dr. Jean Watson's human caring theory**

Dr. Margaret Jean Harman Watson [10–13] considered "what is nursing?" and the essence and universality of nursing and developed the human caring theory, which is philosophical and ethical. On one hand, she is a practitioner and proponent of caring. On the other hand, she emphasizes the worth of healing as an experienced person, because she lost an eye and her husband. She believes that true healing and change cannot occur in the real world by seeking utilitarian success but by spiritual healing. She also emphasizes the essence of nursing in caring, which is healing a human's wholeness and establishing nursing philosophy.

Our understanding of Watson's theory in this section was based on her books (Japanese Version) [10–13], an overview of her theory by Emoto [14, 15], and books about nursing theories and their theorists (Japanese Version) [16, 17]. Therefore, there may be some differences between Watson's original expressions because of back-translation. Additionally, although Dr. Rina Emoto described the case analysis sheet (we describe the following), we modified it to clarify the interaction between nurse and subject.

Important concepts to understand Watson's human caring theory include "human care," "transpersonal," "caritas literacy," and "caritas process/carative factor."

#### *2.3.1 Transpersonal*

Transpersonal is a human-to-human connection beyond the person-body-ego at the moment of care, wherein both persons influence each other and share the same time. If transpersonal caring is established, both persons have deeply connected feelings at the spiritual level. **Figure 8** shows the establishment of transpersonal caring. In the time axis containing past-present-future, nurse's present (left-most in **Figure 7**) and patient's present (middle in **Figure 7**) overlap and share the same time, resonate at a spiritual level, and influence each other's future (right-most in **Figure 7**). **Figures 2–(5)** presents transpersonal caring through the arrows showing the nurse's and patient's life, as explained above. We will explain the following case analysis about what happens at the moment wherein transpersonal caring is established.

When using the arrows showing the nurse's and the patient's life in the above section (in understanding clients based on holism, **Figure 2**), transpersonal caring is shown in **Figures 2–(5)**.

#### *2.3.2 Caritas processes/carative factors and modified case analysis sheet*

The caritas processes/carative factors make the core of human caring. She initially expressed "carative factors" and later changed it to "caritas process." The first three carative factors/caritas processes form the philosophical basis, the next six (4th to 9th) are expressed as a practice of care, and the tenth expresses existential understanding. **Figure 8** shows the construction of caritas processes, and ①–T in **Figure 8** are the number of carative factors (corresponding to the number of caritas processes).

⑧ creates a healing environment at mental, physical, social, cultural, and spiritual levels, while the "patient" acts to ⑨ meet basic needs. "Interaction" between the nurse and patient involves ④ establishing true caring into a helping-trusting relationship, ⑤ facilitating and accepting positive and negative emotions, and ⑦ promoting education and learning in the relationship of caring. From the "interaction," "existential power and energy" is born, which contains T interesting spiritual, mysterious, and incomprehensible dimensions about life, death, and suffering

*Footnotes: Main framework is made from above references, and we modify about following. <sup>①</sup>*<sup>T</sup> *are expressed caritas process or carative factor. Modifying from 'bilateral relationship' to "interaction", adding two "actions" arrows, and adding box in order to write contents of interaction. Changing the line connecting boxes. "Foundation sustaining caring" sustain "interaction", and "patient" and "nurse" connect "existential power and energy". Modifying from "existential and phenomenological power" to "existential power".Actor of ⑨ is not nurse but patient. Therefore, modifying from "supporting" to "meeting", because of selecting the verb for which*

*Case analysis sheet based on transpersonal caring by Jean Watson (partially modified) [10–17].*

*Dynamics of the human caring process. References (created by this paper's author based on the references*

*The Moment of Establishing Transpersonal Caring in a Grieving Adolescent Daughter beside Her…*

*DOI: http://dx.doi.org/10.5772/intechopen.92641*

(recognizing existential and soul dimensions).

**Figure 7.**

**Figure 8.**

**29**

*the patient is the subject.*

*[14, 15, 24, 25]).*

**Figure 8** shows the following: ① putting value in humanistic altruism and practicing affection, kindness, and calmness with self and others; ② being with whole body and whole spirit, respecting and sustaining own and other's subjective worlds and beliefs, and instilling hope and trust; and ③ fostering sensitivity to self and others formed the "foundation sustaining caring" and establishes the "interaction" between "patient" and "nurse." The "nurse" ⑥ solves problems creatively and

*The Moment of Establishing Transpersonal Caring in a Grieving Adolescent Daughter beside Her… DOI: http://dx.doi.org/10.5772/intechopen.92641*

**2.3 Case analysis method by Dr. Jean Watson's human caring theory**

human's wholeness and establishing nursing philosophy.

between nurse and subject.

factor."

*Empathy Study*

established.

processes).

**28**

shown in **Figures 2–(5)**.

*2.3.1 Transpersonal*

Dr. Margaret Jean Harman Watson [10–13] considered "what is nursing?" and the essence and universality of nursing and developed the human caring theory, which is philosophical and ethical. On one hand, she is a practitioner and proponent of caring. On the other hand, she emphasizes the worth of healing as an experienced person, because she lost an eye and her husband. She believes that true healing and change cannot occur in the real world by seeking utilitarian success but by spiritual healing. She also emphasizes the essence of nursing in caring, which is healing a

Our understanding of Watson's theory in this section was based on her books (Japanese Version) [10–13], an overview of her theory by Emoto [14, 15], and books about nursing theories and their theorists (Japanese Version) [16, 17]. Therefore, there may be some differences between Watson's original expressions because of back-translation. Additionally, although Dr. Rina Emoto described the case analysis sheet (we describe the following), we modified it to clarify the interaction

Important concepts to understand Watson's human caring theory include "human care," "transpersonal," "caritas literacy," and "caritas process/carative

Transpersonal is a human-to-human connection beyond the person-body-ego at the moment of care, wherein both persons influence each other and share the same time. If transpersonal caring is established, both persons have deeply connected feelings at the spiritual level. **Figure 8** shows the establishment of transpersonal caring. In the time axis containing past-present-future, nurse's present (left-most in **Figure 7**) and patient's present (middle in **Figure 7**) overlap and share the same time, resonate at a spiritual level, and influence each other's future (right-most in **Figure 7**). **Figures 2–(5)** presents transpersonal caring through the arrows showing the nurse's and patient's life, as explained above. We will explain the following case

analysis about what happens at the moment wherein transpersonal caring is

*2.3.2 Caritas processes/carative factors and modified case analysis sheet*

When using the arrows showing the nurse's and the patient's life in the above section (in understanding clients based on holism, **Figure 2**), transpersonal caring is

The caritas processes/carative factors make the core of human caring. She initially expressed "carative factors" and later changed it to "caritas process." The first three carative factors/caritas processes form the philosophical basis, the next six (4th to 9th) are expressed as a practice of care, and the tenth expresses existential understanding. **Figure 8** shows the construction of caritas processes, and ①–T in **Figure 8** are the number of carative factors (corresponding to the number of caritas

**Figure 8** shows the following: ① putting value in humanistic altruism and practicing affection, kindness, and calmness with self and others; ② being with whole body and whole spirit, respecting and sustaining own and other's subjective worlds and beliefs, and instilling hope and trust; and ③ fostering sensitivity to self and others formed the "foundation sustaining caring" and establishes the "interaction" between "patient" and "nurse." The "nurse" ⑥ solves problems creatively and

*Dynamics of the human caring process. References (created by this paper's author based on the references [14, 15, 24, 25]).*

#### **Figure 8.**

*Case analysis sheet based on transpersonal caring by Jean Watson (partially modified) [10–17]. Footnotes: Main framework is made from above references, and we modify about following. <sup>①</sup>*<sup>T</sup> *are expressed caritas process or carative factor. Modifying from 'bilateral relationship' to "interaction", adding two "actions" arrows, and adding box in order to write contents of interaction. Changing the line connecting boxes. "Foundation sustaining caring" sustain "interaction", and "patient" and "nurse" connect "existential power and energy". Modifying from "existential and phenomenological power" to "existential power".Actor of ⑨ is not nurse but patient. Therefore, modifying from "supporting" to "meeting", because of selecting the verb for which the patient is the subject.*

⑧ creates a healing environment at mental, physical, social, cultural, and spiritual levels, while the "patient" acts to ⑨ meet basic needs. "Interaction" between the nurse and patient involves ④ establishing true caring into a helping-trusting relationship, ⑤ facilitating and accepting positive and negative emotions, and ⑦ promoting education and learning in the relationship of caring. From the "interaction," "existential power and energy" is born, which contains T interesting spiritual, mysterious, and incomprehensible dimensions about life, death, and suffering (recognizing existential and soul dimensions).

#### *Empathy Study*

We modified following five points in order to analyze case: (1) ①–T described the caritas processes or carative factors. (2) We modified "bilateral relationship" to "interaction," and added two "action" arrows and a box to write contents of interaction. (3) We changed the line connecting boxes. "Foundation sustaining caring" sustains "interaction," and "patient" and "nurse" connect "existential power and energy." (4) We modified "existential and phenomenological power" to "existential power." (5) The actor of ⑨ is not the nurse but the patient. Therefore, we modified 'supporting' to 'meeting' to convey the patient as the subject. In the next section, we explain the results using this case analysis sheet.

#### *2.3.3 Caritas literacy*

Caritas means compassion, gratitude, taking special interest and expressing philanthropy, mercy, compassion, and soul generosity. In human caring, the ontological attitude "being here" is considered caritas literacy, which contains 15 actions, such as guessing other's feelings accurately, listening to other's subjective story and its meanings, listening to the truth behind the words, etc.

#### *2.3.4 Human caring*

Human caring, known as care from the moral viewpoint, comprises protecting, maintaining, and enhancing human dignity. If the nurse and patient maintain a relationship with transpersonal caring, two people make one story, and caring and healing occur simultaneously. Transpersonal caring-healing has spatial and temporal spread and is connected with a higher and deeper cosmic energy. Therefore, the ontological attitude "being here" influences the healing process. These interactions are human caring.

#### **2.4 The moment of established transpersonal caring-healing (case 1): interaction between a crying adolescent daughter beside her mother's deathbed and an expert nurse**

In this section, we introduce an expert nurse's experience of the moment of established transpersonal caring. An expert nurse shared this story when we conducted grounded theory about the grieving process of nurses who continued to care for the dying patients [8] and introduced care for withdrawing and enhancing the bereaved family's "grieving ability" in the beginner's book about terminal care [18]. An illustrated explanation from the viewpoint of the bereaved daughter's grieving ability is presented in **Figure 9**, and the analysis of human caring by Dr. Jean Watson is presented in **Figure 10**.

#### *2.4.1 Case overview*

Nurse B (late 40s, female) was in charge of patient C (late 40s, female) on the deathbed. Coincidentally, nurse B was not a primary nurse but a shift nurse. Patient C and nurse B first met when patient C was on her deathbed. When nurse B saw the adolescent daughter A crying heavily beside the mother's (patient C) death bed, nurse B empathized with daughter A's deep sadness and involuntarily said, "your mother is near and protect you." Following is the verbatim account of nurse B.

*When a senior high school girl lost her mother to lung cancer, she told me how hard it was for her and started to cry. At that time, I truly understood how she was feeling, and we cried together. I did not just feel sorry for her, but I understood her deepest darkest feelings and how she had so much to contemplate. Just thinking about it makes me cry. At that time,* *I was able to tell her, 'Look, your mother is up there,' unintentionally. I'd never been able to breathe empty words like that before. I'm not a mystic or someone who believes in spirits. But now I'm confident, because I think that, when a person died, the soul deep within that person shares the same space. Later, when she seemed to have calmed down quite well, she*

*The Moment of Establishing Transpersonal Caring in a Grieving Adolescent Daughter beside Her…*

*DOI: http://dx.doi.org/10.5772/intechopen.92641*

**Figure 9.**

**Figure 10.** *Analysis of case 1.*

**31**

*Introduction case 1 [18].*

*The Moment of Establishing Transpersonal Caring in a Grieving Adolescent Daughter beside Her… DOI: http://dx.doi.org/10.5772/intechopen.92641*

*I was able to tell her, 'Look, your mother is up there,' unintentionally. I'd never been able to breathe empty words like that before. I'm not a mystic or someone who believes in spirits. But now I'm confident, because I think that, when a person died, the soul deep within that person shares the same space. Later, when she seemed to have calmed down quite well, she*

We modified following five points in order to analyze case: (1) ①–T described the caritas processes or carative factors. (2) We modified "bilateral relationship" to "interaction," and added two "action" arrows and a box to write contents of interaction. (3) We changed the line connecting boxes. "Foundation sustaining caring" sustains "interaction," and "patient" and "nurse" connect "existential power and energy." (4) We modified "existential and phenomenological power" to "existential power." (5) The actor of ⑨ is not the nurse but the patient. Therefore, we modified 'supporting' to 'meeting' to convey the patient as the subject. In the next section, we

Caritas means compassion, gratitude, taking special interest and expressing philanthropy, mercy, compassion, and soul generosity. In human caring, the ontological attitude "being here" is considered caritas literacy, which contains 15 actions, such as guessing other's feelings accurately, listening to other's subjective story and

Human caring, known as care from the moral viewpoint, comprises protecting, maintaining, and enhancing human dignity. If the nurse and patient maintain a relationship with transpersonal caring, two people make one story, and caring and healing occur simultaneously. Transpersonal caring-healing has spatial and temporal spread and is connected with a higher and deeper cosmic energy. Therefore, the ontological attitude "being here" influences the healing process. These interactions

**2.4 The moment of established transpersonal caring-healing (case 1):**

**interaction between a crying adolescent daughter beside her mother's**

In this section, we introduce an expert nurse's experience of the moment of established transpersonal caring. An expert nurse shared this story when we conducted grounded theory about the grieving process of nurses who continued to care for the dying patients [8] and introduced care for withdrawing and enhancing the bereaved family's "grieving ability" in the beginner's book about terminal care [18]. An illustrated explanation from the viewpoint of the bereaved daughter's grieving ability is presented in **Figure 9**, and the analysis of human caring by Dr.

Nurse B (late 40s, female) was in charge of patient C (late 40s, female) on the deathbed. Coincidentally, nurse B was not a primary nurse but a shift nurse. Patient C and nurse B first met when patient C was on her deathbed. When nurse B saw the adolescent daughter A crying heavily beside the mother's (patient C) death bed, nurse B empathized with daughter A's deep sadness and involuntarily said, "your mother is near and protect you." Following is the verbatim account of nurse B. *When a senior high school girl lost her mother to lung cancer, she told me how hard it was for her and started to cry. At that time, I truly understood how she was feeling, and we cried together. I did not just feel sorry for her, but I understood her deepest darkest feelings and how she had so much to contemplate. Just thinking about it makes me cry. At that time,*

explain the results using this case analysis sheet.

its meanings, listening to the truth behind the words, etc.

*2.3.3 Caritas literacy*

*Empathy Study*

*2.3.4 Human caring*

are human caring.

*2.4.1 Case overview*

**30**

**deathbed and an expert nurse**

Jean Watson is presented in **Figure 10**.

*told me, 'My mum always follows me.' 'Oh, is that so?' I replied. When She said that, I felt so glad that I'd been involved in that way. (Quoted from Makiko Kondo, Grieving Process of Nurses Continuing to Care for Dying Patients, Horizon Research Publishing, USA, 2017)*.

life-and-death events, in which we must recognize the existence of "something

*The Moment of Establishing Transpersonal Caring in a Grieving Adolescent Daughter beside Her…*

According to Dr. Watson's theory, if one person's present and other person's present overlap and resonate at the spiritual level, it influences each other's subsequent life. In **Figures 2–(5)** and **7**, the arcs show the influence on each other's

Daughter A processed her grief while being watched over by nurse B and overcame the crisis of her mother's death by using her grieving ability. Although the mother's body was lost, she believed that her mother was near and protecting her

Nurse B was convinced that her actions were right when she noticed that daughter A processed her grief and overcame her mother's death. Nurse B also heard daughter A saying, "My mum always follows me." Because nurse B was convinced about the existence of a soul, eternal life, and something greater than self, her spirituality manifested, and she could reach the stage of being able to talk and listen to any patient as much as they liked. Although the expert nurse's ability to care for dying patients was shown as a four-layer structure (foundations for continuing to face issues of life and death and skills and tools for facing issues of life and death, overcoming distress, and actively and willingly continuing to face issues of life and death; see **Figure 11**) [8], these abilities of nurse B were enhanced by experiencing transpersonal caring in this case. Although many patients are forgotten over time, this case remained in nurse B's memory because it evoked the pleasure of being involved in the care of dying and of growth as a nurse and human

and that she could continue her life after her mother's death.

*Capacity to continue facing issues of life and death head-on. Transcription [8].*

greater than self" and "eternal life."

subsequent life.

being (**Figure 2(2)**).

**Figure 11.**

**33**

*2.4.3 After establishing transpersonal caring*

*DOI: http://dx.doi.org/10.5772/intechopen.92641*

#### *2.4.2 The moment of established transpersonal caring*

Although daughter A and her mother C (patient) have lived with each other, bereavement was coming without waiting for the daughter A's nesting. Daughter A, mother C, and nurse B shared the same time due to chance. The life of daughter A and mother C who had walked together in life continuing the "past-presentfuture" and the life of the nurse B who had lived completely separate from them overlapped and made "present." It is the moment of crossing each other's life (**Figures 2–(5)** and **7**).

Development tasks of the daughter A at high school include spontaneity, diligence, and working on identity. Because the mother's death is too early before nesting, the bereaved daughter's suffering was like tearing a raw tree and spiritual pain. Likewise, because one of the sufferings of the middle-aged dying mother with cancer (regret that death will separate her from her children) was spiritual pain without a relieving strategy [19], she might also die with existential sufferings.

On the other hand, nurse B coincidentally met mother C on the deathbed. However, she experienced bereavement of the significant family and understood the physical difficulties. She also understood (deeply empathized) and resonated with the daughter's sadness. Additionally, nurse B belonged to the same generation as mother C and had a daughter of the same age as daughter A. Therefore, she could understand mother C's sadness and abandonment of leaving her child as if it was her own. She could empathize with daughter C like her own daughter.

Daughter A, nurse B, and mother C were connected at the spiritual level and shared spiritual pain. Nurse B could deeply empathize with daughter A's spiritual pain and could feel mother C's regrettable sadness of dying and leaving the child as if her own. Spiritual pain is the sufferings in a relationship with something greater than self. Dr. Watson mentioned about the connection with the universe [10] that people resonate at the spiritual level beyond space and time. "Look, your mother is up there" and "your mum always follows you after her death" were the worried words from nurse B to the bereaved daughter. Nurse B's words "unintentionally" and "I'd never been able to breathe empty words like that before" showed that her actions were not deliberate and artificial. Therefore, the thoughts mother C was unable to express might have been conveyed to daughter A through nurse B because the trio was connected at a transpersonal level. It is precisely the moment of established transpersonal caring.

The encounter between nurse B and the mother and daughter was coincidental. Although we mentioned above that regret that death will separate her from her children was spiritual pain without a relieving strategy for the dying mother, the mother's love for her child is deep, and therefore, her concern is strong, like the folktales about "mothering ghost" (after mother's death, a baby is born at the tomb, and the mother's ghost comes to buy candy for her baby) that are prevalent at various places in Japan. By the power of something greater than self, mother C's love for her daughter A might attract nurse B in the form of coincidence, who has the ability to deeply empathize with the mother's and daughter's spiritual pain and support daughter A after her mother's death. The words of nurse B, "I'm not a mystic (spirit medium) or someone who believes in spirits," show that she had awareness of living in the world of positivism that emphasized evidence. Still, nurse B was convinced that the soul remains and protects the significant person after death. It shows that the medical field provides opportunities to encounter

*The Moment of Establishing Transpersonal Caring in a Grieving Adolescent Daughter beside Her… DOI: http://dx.doi.org/10.5772/intechopen.92641*

life-and-death events, in which we must recognize the existence of "something greater than self" and "eternal life."

#### *2.4.3 After establishing transpersonal caring*

*told me, 'My mum always follows me.' 'Oh, is that so?' I replied. When She said that, I felt so glad that I'd been involved in that way. (Quoted from Makiko Kondo, Grieving Process of Nurses Continuing to Care for Dying Patients, Horizon Research Publishing,*

Although daughter A and her mother C (patient) have lived with each other, bereavement was coming without waiting for the daughter A's nesting. Daughter A, mother C, and nurse B shared the same time due to chance. The life of daughter A and mother C who had walked together in life continuing the "past-presentfuture" and the life of the nurse B who had lived completely separate from them overlapped and made "present." It is the moment of crossing each other's life

Development tasks of the daughter A at high school include spontaneity, diligence, and working on identity. Because the mother's death is too early before nesting, the bereaved daughter's suffering was like tearing a raw tree and spiritual pain. Likewise, because one of the sufferings of the middle-aged dying mother with cancer (regret that death will separate her from her children) was spiritual pain without a relieving strategy [19], she might also die with existential sufferings. On the other hand, nurse B coincidentally met mother C on the deathbed. However, she experienced bereavement of the significant family and understood the physical difficulties. She also understood (deeply empathized) and resonated with the daughter's sadness. Additionally, nurse B belonged to the same generation as mother C and had a daughter of the same age as daughter A. Therefore, she could understand mother C's sadness and abandonment of leaving her child as if it was her

Daughter A, nurse B, and mother C were connected at the spiritual level and shared spiritual pain. Nurse B could deeply empathize with daughter A's spiritual pain and could feel mother C's regrettable sadness of dying and leaving the child as if her own. Spiritual pain is the sufferings in a relationship with something greater than self. Dr. Watson mentioned about the connection with the universe [10] that people resonate at the spiritual level beyond space and time. "Look, your mother is up there" and "your mum always follows you after her death" were the worried words from nurse B to the bereaved daughter. Nurse B's words "unintentionally" and "I'd never been able to breathe empty words like that before" showed that her actions were not deliberate and artificial. Therefore, the thoughts mother C was unable to express might have been conveyed to daughter A through nurse B because the trio was connected at a transpersonal level. It is precisely the moment of

The encounter between nurse B and the mother and daughter was coincidental. Although we mentioned above that regret that death will separate her from her children was spiritual pain without a relieving strategy for the dying mother, the mother's love for her child is deep, and therefore, her concern is strong, like the folktales about "mothering ghost" (after mother's death, a baby is born at the tomb, and the mother's ghost comes to buy candy for her baby) that are prevalent at various places in Japan. By the power of something greater than self, mother C's love for her daughter A might attract nurse B in the form of coincidence, who has the ability to deeply empathize with the mother's and daughter's spiritual pain and support daughter A after her mother's death. The words of nurse B, "I'm not a mystic (spirit medium) or someone who believes in spirits," show that she had awareness of living in the world of positivism that emphasized evidence. Still, nurse B was convinced that the soul remains and protects the significant person after death. It shows that the medical field provides opportunities to encounter

own. She could empathize with daughter C like her own daughter.

*2.4.2 The moment of established transpersonal caring*

*USA, 2017)*.

*Empathy Study*

(**Figures 2–(5)** and **7**).

established transpersonal caring.

**32**

According to Dr. Watson's theory, if one person's present and other person's present overlap and resonate at the spiritual level, it influences each other's subsequent life. In **Figures 2–(5)** and **7**, the arcs show the influence on each other's subsequent life.

Daughter A processed her grief while being watched over by nurse B and overcame the crisis of her mother's death by using her grieving ability. Although the mother's body was lost, she believed that her mother was near and protecting her and that she could continue her life after her mother's death.

Nurse B was convinced that her actions were right when she noticed that daughter A processed her grief and overcame her mother's death. Nurse B also heard daughter A saying, "My mum always follows me." Because nurse B was convinced about the existence of a soul, eternal life, and something greater than self, her spirituality manifested, and she could reach the stage of being able to talk and listen to any patient as much as they liked. Although the expert nurse's ability to care for dying patients was shown as a four-layer structure (foundations for continuing to face issues of life and death and skills and tools for facing issues of life and death, overcoming distress, and actively and willingly continuing to face issues of life and death; see **Figure 11**) [8], these abilities of nurse B were enhanced by experiencing transpersonal caring in this case. Although many patients are forgotten over time, this case remained in nurse B's memory because it evoked the pleasure of being involved in the care of dying and of growth as a nurse and human being (**Figure 2(2)**).

**Figure 11.** *Capacity to continue facing issues of life and death head-on. Transcription [8].*

#### *Empathy Study*

We cannot escape speculation about mother C. That daughter A could overcome her mother's death and continue her life brought relief to mother C because mother C had a good relationship with her daughter and worried about leaving her daughter behind and hoped for her daughter's happiness. Folktale "mothering ghost" states that a mother dying with strong concerns in this world becomes a ghost and fosters the child. We think that the daughter believed that overcoming bereavement is the reason for memorial services and brings peace.

#### **2.5 The moment of established transpersonal caring (case 2): listening to Hansen's disease survivors' life review by nurses at leprosarium**

#### *2.5.1 Hansen's disease and life review*

Hansen's disease is caused by *Mycobacterium leprae*, which invades the skin and peripheral nerves (sensory, motor, and autonomic nerves) and can change the patients' appearance. Known as "divine punishment disease," it has been stigmatized since ancient times. Therefore, patients continue to suffer from discrimination and rejection. Some Hansen's disease patients ousted from their hometowns became "wandering lepers" who begged at the gates of temples and shrines and departed on wandering journeys. Silver bullet "promin," discovered in 1943, made it possible to cure Hansen's disease completely.

In Japan, Hansen's disease was regarded as a "national disgrace" around World War II, because "wandering lepers" were a symbol of late civilization in a country. The police authorities forcibly placed them in leprosarium under the Leprosy Prevention Law (1907) passed by the government, and they suffered from lifelong isolation. Hansen's disease patients received inhumane treatment in leprosarium at that time, for example, vasectomy, disciplinary confinement where in the sanatorium direction dicided the punisment; exchanging the sanatorium currency for

preventing runaways; changing patient's name to internal alias; forced labor for maintaining the sanatorium despite doctors, nurses, and other staff; establishment

*The Moment of Establishing Transpersonal Caring in a Grieving Adolescent Daughter beside Her…*

By efforts of the National Hansen's Disease Sanatorium Residents' Council, the Leprosy Prevention Law was abolished in 1996, and at the National Redress in 2001, the government was convicted over their error of the isolation policy and formally apologized. In 2009, the Law on Promoting a Resolution to the Hansen's Disease Problem was established, and the treatment for Hansen's disease survivors

improved drastically. However, many of Hansen's disease survivors residing at the sanatorium have missed the opportunity to return to society because the Leprosy

of diseased/non-diseased boundary and autopsy; etc.

**Figure 13.**

**Figure 14.**

**35**

*Ossuary in leprosarium.*

*Zetsudoku by Hansen's disease patient [21].*

*DOI: http://dx.doi.org/10.5772/intechopen.92641*

#### **Figure 12.**

*The significance of listening to Hansen's disease survivors' life review by leprosarium's nurses. Transcription: [21].*

*The Moment of Establishing Transpersonal Caring in a Grieving Adolescent Daughter beside Her… DOI: http://dx.doi.org/10.5772/intechopen.92641*

We cannot escape speculation about mother C. That daughter A could overcome her mother's death and continue her life brought relief to mother C because mother C had a good relationship with her daughter and worried about leaving her daughter behind and hoped for her daughter's happiness. Folktale "mothering ghost" states that a mother dying with strong concerns in this world becomes a ghost and fosters the child. We think that the daughter believed that overcoming bereavement is the

**2.5 The moment of established transpersonal caring (case 2): listening to Hansen's disease survivors' life review by nurses at leprosarium**

peripheral nerves (sensory, motor, and autonomic nerves) and can change the patients' appearance. Known as "divine punishment disease," it has been stigmatized since ancient times. Therefore, patients continue to suffer from discrimination and rejection. Some Hansen's disease patients ousted from their hometowns became "wandering lepers" who begged at the gates of temples and shrines and departed on wandering journeys. Silver bullet "promin," discovered in 1943, made it possible to

Hansen's disease is caused by *Mycobacterium leprae*, which invades the skin and

In Japan, Hansen's disease was regarded as a "national disgrace" around World War II, because "wandering lepers" were a symbol of late civilization in a country. The police authorities forcibly placed them in leprosarium under the Leprosy Prevention Law (1907) passed by the government, and they suffered from lifelong isolation. Hansen's disease patients received inhumane treatment in leprosarium at that time, for example, vasectomy, disciplinary confinement where in the sanatorium direction dicided the punisment; exchanging the sanatorium currency for

*The significance of listening to Hansen's disease survivors' life review by leprosarium's nurses.*

reason for memorial services and brings peace.

*2.5.1 Hansen's disease and life review*

*Empathy Study*

cure Hansen's disease completely.

**Figure 12.**

**34**

*Transcription: [21].*

**Figure 13.** *Zetsudoku by Hansen's disease patient [21].*

**Figure 14.** *Ossuary in leprosarium.*

preventing runaways; changing patient's name to internal alias; forced labor for maintaining the sanatorium despite doctors, nurses, and other staff; establishment of diseased/non-diseased boundary and autopsy; etc.

By efforts of the National Hansen's Disease Sanatorium Residents' Council, the Leprosy Prevention Law was abolished in 1996, and at the National Redress in 2001, the government was convicted over their error of the isolation policy and formally apologized. In 2009, the Law on Promoting a Resolution to the Hansen's Disease Problem was established, and the treatment for Hansen's disease survivors improved drastically. However, many of Hansen's disease survivors residing at the sanatorium have missed the opportunity to return to society because the Leprosy

Prevention Law was abolished belatedly. Their average age was over 85 years; they did not have families because of the sterilization surgeries (Vasectomies) and had either cut off their families willingly or were cut off from them to prevent their families from being discriminated against and rejected by the society. Currently, an important issue in the sanatorium is how to sustain the purpose of life during their life's last phase and care for peaceful dying and death, i.e., how to practice a high level of end-of-life care (see **Figures 12–14**).

*2.5.2 Transpersonal caring in listening to Hansen's disease survivors' life review*

providing indispensable and high-quality end-of-life care.

*DOI: http://dx.doi.org/10.5772/intechopen.92641*

dementia.

**Figure 16.** *Analysis of case 2.*

**37**

**Figure 16** shows the analysis of listening to Hansen's disease survivors' life review by sanatorium nurses by Dr. Watson's transpersonal caring model. First, for the nurses in the leprosarium, "listening to their life review" raised the nurses' ability to empathize and listen, enhanced their counseling mind, deepened their understanding about Hansen's disease survivors'sufferings, and improved their ability of nursing practice concerning their form of existence and life worth for

*The Moment of Establishing Transpersonal Caring in a Grieving Adolescent Daughter beside Her…*

Second, for Hansen's disease survivors, the opportunity to share their life review promoted attainment of meaning and worth from the tribulation and sufferings because of the disease and had a cathartic effect by purifying bitter experiences. Because they are 85 years old on average, they confront their imminent death, loss of friends who shared a hard time together, and the collapse of the National Hansen's Disease Sanatorium Residents' Council due to decreasing survivors who have been fighting against the nation and promoting autonomous by survivors. Therefore, they experience sufferings and loneliness. However, when they connect with the nurse, grief work (contained anticipatory grief) is processed. Additionally, we know that sharing their life review is effective in preventing

Interaction by the sharing and listening of the life review enhanced mutual understanding and mutual approval and deepened their relationship. A nurse can play the role of pseudo-family and can care for dying and death warmly and peacefully like their real family, which could not be created due to sterilization surgery. The philosophical foundations sustaining these interactions include (1) philoso-

phy of nursing (holism, intention for caring, philanthropy), (2) philosophy of end-of-life care (sustaining and respecting the subject's form of existence and life worth, peaceful death, and care for dying warmly and kindly like family),

In our project, to resolve this issue, the sanatorium nurses listened to life reviews of Hansen's disease survivors at the National Sanatorium Oshima Seisho-en (located in Oshima at Seto Inland Sea, Japan). Because Hansen's disease survivors and sanatorium nurse relationships are difficult to find in general hospitals [20], we could not establish a deep relationship for respecting the survivor's life worth and purpose of life for high-level end-of-life care. We published a book containing 19 Hansen's disease survivors' life reviews [21] (see **Figure 15**), which is also a record of our nursing practice.

**Figure 15.** *Our book on life reviews [21].*

*The Moment of Establishing Transpersonal Caring in a Grieving Adolescent Daughter beside Her… DOI: http://dx.doi.org/10.5772/intechopen.92641*

#### *2.5.2 Transpersonal caring in listening to Hansen's disease survivors' life review*

**Figure 16** shows the analysis of listening to Hansen's disease survivors' life review by sanatorium nurses by Dr. Watson's transpersonal caring model. First, for the nurses in the leprosarium, "listening to their life review" raised the nurses' ability to empathize and listen, enhanced their counseling mind, deepened their understanding about Hansen's disease survivors'sufferings, and improved their ability of nursing practice concerning their form of existence and life worth for providing indispensable and high-quality end-of-life care.

Second, for Hansen's disease survivors, the opportunity to share their life review promoted attainment of meaning and worth from the tribulation and sufferings because of the disease and had a cathartic effect by purifying bitter experiences. Because they are 85 years old on average, they confront their imminent death, loss of friends who shared a hard time together, and the collapse of the National Hansen's Disease Sanatorium Residents' Council due to decreasing survivors who have been fighting against the nation and promoting autonomous by survivors. Therefore, they experience sufferings and loneliness. However, when they connect with the nurse, grief work (contained anticipatory grief) is processed. Additionally, we know that sharing their life review is effective in preventing dementia.

Interaction by the sharing and listening of the life review enhanced mutual understanding and mutual approval and deepened their relationship. A nurse can play the role of pseudo-family and can care for dying and death warmly and peacefully like their real family, which could not be created due to sterilization surgery.

The philosophical foundations sustaining these interactions include (1) philosophy of nursing (holism, intention for caring, philanthropy), (2) philosophy of end-of-life care (sustaining and respecting the subject's form of existence and life worth, peaceful death, and care for dying warmly and kindly like family),

**Figure 16.** *Analysis of case 2.*

Prevention Law was abolished belatedly. Their average age was over 85 years; they did not have families because of the sterilization surgeries (Vasectomies) and had either cut off their families willingly or were cut off from them to prevent their families from being discriminated against and rejected by the society. Currently, an important issue in the sanatorium is how to sustain the purpose of life during their life's last phase and care for peaceful dying and death, i.e., how to practice a high

In our project, to resolve this issue, the sanatorium nurses listened to life reviews of Hansen's disease survivors at the National Sanatorium Oshima Seisho-en (located in Oshima at Seto Inland Sea, Japan). Because Hansen's disease survivors and sanatorium nurse relationships are difficult to find in general hospitals [20], we could not establish a deep relationship for respecting the survivor's life worth and purpose of life for high-level end-of-life care. We published a book containing 19 Hansen's disease survivors' life reviews [21] (see **Figure 15**), which is also a record of our

level of end-of-life care (see **Figures 12–14**).

nursing practice.

*Empathy Study*

**Figure 15.**

**36**

*Our book on life reviews [21].*

#### *Empathy Study*

(3) understanding "illness" (understanding the history of Hansen's disease and its survivors regarding their discrimination and rejection, understanding their changes in appearance (symptoms and sequelae) based on pathophysiology), and (4) philosophy of the Hansen's Disease Prevention Law (the government's promise to take responsibility for the last Hansen's disease survivor's death).

empathizing, comfortable bed baths, etc, and these charitas literacy encourages the patient's natural healing power. In Japanese, there are many ancient unique words for respecting and taking care of someone, for example, "arigato (thank you)," "omotenashi (hospitality)," "ogenkide (take care, see you again)," and "odaijini (I hope you get well)." The medical staff uses "odaijini" for patients in the daily medical field, and "odaijini" shows the way of existence ("being" against "doing," as mentioned above). When nurses sincerely confront and dedicate themselves to the patients and their families, they grow by caring, which is characterized by mutual approval and reciprocity. A nurse, who knows real pleasure increases selfaffirmation, finds value and pride in her/his work, becomes more independent, and searches for patients' happiness and health. Therefore, caring is sustaining a philosophical and ethical foundation for nursing practice and protecting patients' dignity

*The Moment of Establishing Transpersonal Caring in a Grieving Adolescent Daughter beside Her…*

We explain how to establish Dr. Jean Watson's transpersonal caring using two events: ① case study: An expert nurse unintentionally says, "Your mother continues to be near and protect you," to a crying daughter beside her mother's deathbed; and ② our project: sanatorium's nurses listen to Hansen's disease survivors' life review. When the participants (① dying mother, bereaved daughter, and expert nurse; and ② Hansen's disease survivors and sanatorium nurses) shared the same time and place and made one story together (① mother's deathbed and ② life review), they spiritually empathized with each other (① mother and daughter's spiritual pain due to separation by death; and ② difficult life and existential distress due to Hansen's disease) and formed a deeper relationship, thereby influencing each other future lives (① daughter: overcoming mother's death and moving on with life, and nurse: realizing soul's existence and increasing competence in end-of-life care; and ② Hansen's disease survivors: cathartic effect by sharing their bitter past experiences, peaceful death by nurses' care like real family despite inability to have their own children, and nurse: discovering the significance and worth of sustaining Hansen's disease survivor's life, caring for the peaceful death of those who have experienced a

Our gratitude goes to the Okayama Nursing Association for giving us the opportunity of lectures for long-term clinical nurses. This work was supported by JSPS KAKENHI Grant Number 18H03075 and Kagawa prefecture in Japan. We would

like to thank Editage (www.editage.com) for English language editing.

in the daily clinical field.

*DOI: http://dx.doi.org/10.5772/intechopen.92641*

**4. Conclusion**

harsh life).

**39**

**Acknowledgements**

Existential power of the interaction include (1) Hansen's disease survivors healed from their existential sufferings, evoking the purpose of life and peaceful death, and (2) nurse in leprosarium experienced pride and value in work and a deeper view of life.

#### **3. Significance of caring in medical ethics**

When we talk about caring, the significance is ethics finally. The Oath of Hippocrates is the foundation of western medical ethics, and some of them are still widely used. After World War II, the Nuremberg Code was established based on the reflections on the Nazi human experiments. The Nuremberg code contained the subject's rights in a medical experiment. Thereafter, the Nuremberg code became the Helsinki Declaration after the Geneva Declaration.

In nursing, the first ethical guideline is the principle of medical ethics (respect for autonomy, non-maleficence, beneficence, and justice). Therefore, when nurses engage in nursing practice, they decide their actions according to the principle; if they have an ethical conflict, they consider what principle among the four ethical principles is threatened or which principles conflict with which principles and then resolve the ethical conflict. The second ethical guideline for nurses' actions is the ICN Code of Ethics for Nurses [22] and the Code of Ethics for Nurses by the Japanese Nursing Association [23]. The third guideline for medical ethics is caring.

Caring is an interaction based on mutual approval and reciprocity. In the old sanatorium, the treatment of Hansen's disease patients was inhumane. Some medical staff showed philanthropy and mercy and made efforts to help and rescue Hansen's disease patients. However, the government committed mistakes in judgment at that time, which led to the violation of Hansen's disease patients' human rights by many medical staff members. If we, the medical staff, respect the patient as a person with dignity and establish a human-to-human relationship, we will experience resistance and disgust against participating in inhumane treatments. However, if we regard them as materials and not humans, we can engage in inhumane treatment without any sense of resistance. Do not let others do what we cannot do to our family and loved ones. If a caring mind is cultivated, ethical sensitivity is enhanced, and actions based on the medical ethics principle is born spontaneously, the principle of nonmaleficence (do not hurt) would be needless. Therefore, caring functions as a stopper and prevents ethically deviant behavior.

Additionally, one of the issues in the current medical field is how to protect human rights and dignity of vulnerable patients, such as those who cannot express their will or have the power to make decisions. When patients have to rely on other people for daily life activities and cannot express their opinion and wills, the caregivers'state directly influences the patient's quality of life. If the caregiver respects the patient's dignity as an irreplaceable person, the quality of care provided is high. Nevertheless, there are news reports about painful incidents, for example, abuse in care homes. Caring includes strategies for protecting the dignity of weak people in a relationship where power balance exists and avoiding ethical issues.

It is difficult to experience transpersonal caring (resonating with each other at the existential level) frequently in daily life. But there is caring in daily commonplace nursing, for example, nurses'smile, calm and warm talking, listening and

*The Moment of Establishing Transpersonal Caring in a Grieving Adolescent Daughter beside Her… DOI: http://dx.doi.org/10.5772/intechopen.92641*

empathizing, comfortable bed baths, etc, and these charitas literacy encourages the patient's natural healing power. In Japanese, there are many ancient unique words for respecting and taking care of someone, for example, "arigato (thank you)," "omotenashi (hospitality)," "ogenkide (take care, see you again)," and "odaijini (I hope you get well)." The medical staff uses "odaijini" for patients in the daily medical field, and "odaijini" shows the way of existence ("being" against "doing," as mentioned above). When nurses sincerely confront and dedicate themselves to the patients and their families, they grow by caring, which is characterized by mutual approval and reciprocity. A nurse, who knows real pleasure increases selfaffirmation, finds value and pride in her/his work, becomes more independent, and searches for patients' happiness and health. Therefore, caring is sustaining a philosophical and ethical foundation for nursing practice and protecting patients' dignity in the daily clinical field.

#### **4. Conclusion**

(3) understanding "illness" (understanding the history of Hansen's disease and its survivors regarding their discrimination and rejection, understanding their changes in appearance (symptoms and sequelae) based on pathophysiology), and (4) philosophy of the Hansen's Disease Prevention Law (the government's promise to take

Existential power of the interaction include (1) Hansen's disease survivors healed from their existential sufferings, evoking the purpose of life and peaceful death, and (2) nurse in leprosarium experienced pride and value in work and a

When we talk about caring, the significance is ethics finally. The Oath of Hippocrates is the foundation of western medical ethics, and some of them are still widely used. After World War II, the Nuremberg Code was established based on the reflections on the Nazi human experiments. The Nuremberg code contained the subject's rights in a medical experiment. Thereafter, the Nuremberg code became

In nursing, the first ethical guideline is the principle of medical ethics (respect for autonomy, non-maleficence, beneficence, and justice). Therefore, when nurses engage in nursing practice, they decide their actions according to the principle; if they have an ethical conflict, they consider what principle among the four ethical principles is threatened or which principles conflict with which principles and then resolve the ethical conflict. The second ethical guideline for nurses' actions is the ICN Code of Ethics for Nurses [22] and the Code of Ethics for Nurses by the Japanese Nursing Association [23]. The third guideline for medical ethics is caring. Caring is an interaction based on mutual approval and reciprocity. In the old sanatorium, the treatment of Hansen's disease patients was inhumane. Some medical staff showed philanthropy and mercy and made efforts to help and rescue Hansen's disease patients. However, the government committed mistakes in judgment at that time, which led to the violation of Hansen's disease patients' human rights by many medical staff members. If we, the medical staff, respect the patient as a person with dignity and establish a human-to-human relationship, we will experience resistance and disgust against participating in inhumane treatments. However, if we regard them as materials and not humans, we can engage in inhumane treatment without any sense of resistance. Do not let others do what we cannot do to our family and loved ones. If a caring mind is cultivated, ethical sensitivity is enhanced, and actions based on the medical ethics principle is born spontaneously, the principle of nonmaleficence (do not hurt) would be needless. Therefore, caring functions as a stopper

Additionally, one of the issues in the current medical field is how to protect human rights and dignity of vulnerable patients, such as those who cannot express their will or have the power to make decisions. When patients have to rely on other people for daily life activities and cannot express their opinion and wills, the caregivers'state directly influences the patient's quality of life. If the caregiver respects the patient's dignity as an irreplaceable person, the quality of care provided is high. Nevertheless, there are news reports about painful incidents, for example, abuse in care homes. Caring includes strategies for protecting the dignity of weak people in a

It is difficult to experience transpersonal caring (resonating with each other at the existential level) frequently in daily life. But there is caring in daily commonplace nursing, for example, nurses'smile, calm and warm talking, listening and

relationship where power balance exists and avoiding ethical issues.

responsibility for the last Hansen's disease survivor's death).

**3. Significance of caring in medical ethics**

the Helsinki Declaration after the Geneva Declaration.

and prevents ethically deviant behavior.

**38**

deeper view of life.

*Empathy Study*

We explain how to establish Dr. Jean Watson's transpersonal caring using two events: ① case study: An expert nurse unintentionally says, "Your mother continues to be near and protect you," to a crying daughter beside her mother's deathbed; and ② our project: sanatorium's nurses listen to Hansen's disease survivors' life review. When the participants (① dying mother, bereaved daughter, and expert nurse; and ② Hansen's disease survivors and sanatorium nurses) shared the same time and place and made one story together (① mother's deathbed and ② life review), they spiritually empathized with each other (① mother and daughter's spiritual pain due to separation by death; and ② difficult life and existential distress due to Hansen's disease) and formed a deeper relationship, thereby influencing each other future lives (① daughter: overcoming mother's death and moving on with life, and nurse: realizing soul's existence and increasing competence in end-of-life care; and ② Hansen's disease survivors: cathartic effect by sharing their bitter past experiences, peaceful death by nurses' care like real family despite inability to have their own children, and nurse: discovering the significance and worth of sustaining Hansen's disease survivor's life, caring for the peaceful death of those who have experienced a harsh life).

#### **Acknowledgements**

Our gratitude goes to the Okayama Nursing Association for giving us the opportunity of lectures for long-term clinical nurses. This work was supported by JSPS KAKENHI Grant Number 18H03075 and Kagawa prefecture in Japan. We would like to thank Editage (www.editage.com) for English language editing.

*Empathy Study*

#### **Author details**

Makiko Kondo\*, Sachie Okanishi, Etsuko Arai, Kumiko Morita, Maki Iwamoto and Masako Hosohara Kagawa Prefectural University of Health Sciences, Japan

**References**

**21**(6):728-742

2017

143-148

[1] Hass B. A multidisciplinary concept analysis of quality of life. Western Journal of Nursing Research. 2000;

*DOI: http://dx.doi.org/10.5772/intechopen.92641*

[11] Watson J. Human Caring Science: A Theory of Nursing. 2nd ed. USA: Jones & Bartlett Learning; 2011. Japanese Version Translated by Inaoka F, Inaoka M, Tomura M, IGAKU-SHOIN

[12] Watson J. Assessing and Measuring Caring in Nursing and Health Sciences. Springer Pub Co.; 2008. Japanese Version Translated by Tsutsui M, Japanese Nursing Association Publishing

[13] Watson J. Human caring theory-the core of theory and caritas process. Bulletin of the Japanese Red Cross Hiroshima College of Nursing. 2010;**10**:

[14] Emoto R, Jean W. Human caring. In: Tsutsui M, editor. Nursing Theory— Understanding and Application to Practice about 20 Nursing Theories. Tokyo: Nankodo Co., Ltd; 2008

[15] Emoto R. Development and

[16] Martha RA, Ann M. Nursing Theorists and Their Work. 5th ed. USA:

Mosby; 2002. Japanese Version

**44**(2):149-158

Ltd., Tokyo, 2003

pp. 155-158

significance of human caring theory by Dr. Watson. Nursing Research. 2011;

translated by Tsuru N, IGAKU-SHOIN

[17] Gertrude T. Theoretical Foundations of Nursing, Appleton and Lange, USA, 1985. Japanese Version Translated by Yoko K, Tanaka Y, Takata S, IGAKU-SHOIN Ltd., Tokyo, 1992. p. 207

[18] Kondo M. Care for withdrawing grieving ability (Hitanryoku wo hikidasu care). In: Asano M, Reiko S, editors. Terminal Care in Picture-Revised Edition (Ede miru terminal care, Kaitei ban). Tokyo: Gakken; 2015.

Ltd., Tokyo, 2014

*The Moment of Establishing Transpersonal Caring in a Grieving Adolescent Daughter beside Her…*

Company, Tokyo, 2003

77-80

[2] Kondo M. Qualitative Research on the Essence of Phenomena. Handout by Open forum in Graduate School of Health Sciences. Okayama University;

[3] Hinohara S. Science and art in medicine and nursing. Bulletin of St. Luke's College of Nursing. 1982;**8**:1-6

[4] Hinohara S. Science and art in team medical care. Journal of Respiratory Management Society. 2002;**12**(2):

[5] Mayeroff M. On Caring. UK: Harper Collins Publishers; 1971. Japanese version translated by TAMURA Makoto.

Tokyo: Yumiru Publishing; 1987

[6] O'Berle K, Davies B. Support and caring: Exploring the concept. Oncology Nursing Forum. 1992;**19**(5):763-767

[7] Hoshino T. Tomihiro Hoshino Poetry Book. Tomihiro Hoshino, Museum, Japan. Available from https://tomihiro. net/ [Accessed: 20 February 2020]

[8] Kondo M. Grieving Process of Nurses Continuing to Care for Dying Patients. USA: Horizon Research Publishing; 2017

[10] Watson J. Postmodern Nursing and Beyond. Netherlands: Elsevier Health Sciences; 2000. Japanese Version Translated by Kawano M, Hasegawa H. Japanese Nursing Association Publishing

[9] Matsumura A, editor. Theory. Japanese Dictionary. Daijirin. 3rd ed. Sanseido, Tokiyo. Available from: h ttps://kotobank.jp/word/%E7%90%86% E8%AB%96-659842 [Accessed: 20

February 2020]

**41**

Company, Tokyo, 2005

\*Address all correspondence to: mkondo@cc.okayama-u.ac.jp

© 2020 The Author(s). Licensee IntechOpen. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/ by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

*The Moment of Establishing Transpersonal Caring in a Grieving Adolescent Daughter beside Her… DOI: http://dx.doi.org/10.5772/intechopen.92641*

#### **References**

[1] Hass B. A multidisciplinary concept analysis of quality of life. Western Journal of Nursing Research. 2000; **21**(6):728-742

[2] Kondo M. Qualitative Research on the Essence of Phenomena. Handout by Open forum in Graduate School of Health Sciences. Okayama University; 2017

[3] Hinohara S. Science and art in medicine and nursing. Bulletin of St. Luke's College of Nursing. 1982;**8**:1-6

[4] Hinohara S. Science and art in team medical care. Journal of Respiratory Management Society. 2002;**12**(2): 143-148

[5] Mayeroff M. On Caring. UK: Harper Collins Publishers; 1971. Japanese version translated by TAMURA Makoto. Tokyo: Yumiru Publishing; 1987

[6] O'Berle K, Davies B. Support and caring: Exploring the concept. Oncology Nursing Forum. 1992;**19**(5):763-767

[7] Hoshino T. Tomihiro Hoshino Poetry Book. Tomihiro Hoshino, Museum, Japan. Available from https://tomihiro. net/ [Accessed: 20 February 2020]

[8] Kondo M. Grieving Process of Nurses Continuing to Care for Dying Patients. USA: Horizon Research Publishing; 2017

[9] Matsumura A, editor. Theory. Japanese Dictionary. Daijirin. 3rd ed. Sanseido, Tokiyo. Available from: h ttps://kotobank.jp/word/%E7%90%86% E8%AB%96-659842 [Accessed: 20 February 2020]

[10] Watson J. Postmodern Nursing and Beyond. Netherlands: Elsevier Health Sciences; 2000. Japanese Version Translated by Kawano M, Hasegawa H. Japanese Nursing Association Publishing Company, Tokyo, 2005

[11] Watson J. Human Caring Science: A Theory of Nursing. 2nd ed. USA: Jones & Bartlett Learning; 2011. Japanese Version Translated by Inaoka F, Inaoka M, Tomura M, IGAKU-SHOIN Ltd., Tokyo, 2014

[12] Watson J. Assessing and Measuring Caring in Nursing and Health Sciences. Springer Pub Co.; 2008. Japanese Version Translated by Tsutsui M, Japanese Nursing Association Publishing Company, Tokyo, 2003

[13] Watson J. Human caring theory-the core of theory and caritas process. Bulletin of the Japanese Red Cross Hiroshima College of Nursing. 2010;**10**: 77-80

[14] Emoto R, Jean W. Human caring. In: Tsutsui M, editor. Nursing Theory— Understanding and Application to Practice about 20 Nursing Theories. Tokyo: Nankodo Co., Ltd; 2008

[15] Emoto R. Development and significance of human caring theory by Dr. Watson. Nursing Research. 2011; **44**(2):149-158

[16] Martha RA, Ann M. Nursing Theorists and Their Work. 5th ed. USA: Mosby; 2002. Japanese Version translated by Tsuru N, IGAKU-SHOIN Ltd., Tokyo, 2003

[17] Gertrude T. Theoretical Foundations of Nursing, Appleton and Lange, USA, 1985. Japanese Version Translated by Yoko K, Tanaka Y, Takata S, IGAKU-SHOIN Ltd., Tokyo, 1992. p. 207

[18] Kondo M. Care for withdrawing grieving ability (Hitanryoku wo hikidasu care). In: Asano M, Reiko S, editors. Terminal Care in Picture-Revised Edition (Ede miru terminal care, Kaitei ban). Tokyo: Gakken; 2015. pp. 155-158

**Author details**

*Empathy Study*

**40**

and Masako Hosohara

Makiko Kondo\*, Sachie Okanishi, Etsuko Arai, Kumiko Morita, Maki Iwamoto

© 2020 The Author(s). Licensee IntechOpen. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/ by/3.0), which permits unrestricted use, distribution, and reproduction in any medium,

Kagawa Prefectural University of Health Sciences, Japan

provided the original work is properly cited.

\*Address all correspondence to: mkondo@cc.okayama-u.ac.jp

[19] Kondo M, Sato R. The sense of defeat felt by middle-aged dying mother with cancer. Japanese Journal of Clinical Thanatology. 2011;**16**:90-101

[20] Nakayama A, Ishikawa K, Kondo M. Clinical nursing competencies of caring for Hansen's disease survivors during the final career stage of nurses' development in Japan. International Journal of Nursing Clinical Practices. 2015;**2**:132

[21] Kondo M. National Sanatorium Oshima Seishoen: Life Review of Aging Japanese Hansen's Disease Survivors-Deeply Deeply Closing our Eyes in Order to See What we Truly Should See. USA: Horizon Research Publishing; 2019

[22] International Council of Nurses. The ICN Code of Ethics for Nurses. Switzerland: ICN; 2012. Available from: https://www.icn.ch/sites/default/files/ inline-files/2012\_ICN\_Codeofethicsf ornurses\_%20eng.pdf

[23] Japanese Nursing Association. The Code of Ethics for Nurses. 2003. Available from: https://www.nurse.or. jp/nursing/practice/rinri/rinri.html

[24] Schertzberg R, Swanton J, Thornton C. Cindy Thornton. Jean Watoson's Theory. Available from: https:// slideplayer.com/slide/13386456/

[25] Watoson J. Nursing: Human Science and Human Care. A Theory of Nursing. USA: Appleton and Lange; 1985. p. 59

**43**

Section 2

Burden by Empathy

Section 2 Burden by Empathy

[19] Kondo M, Sato R. The sense of defeat felt by middle-aged dying mother with cancer. Japanese Journal of Clinical

[20] Nakayama A, Ishikawa K, Kondo M. Clinical nursing competencies of caring for Hansen's disease survivors during the final career stage of nurses' development in Japan. International Journal of Nursing Clinical Practices.

[21] Kondo M. National Sanatorium Oshima Seishoen: Life Review of Aging Japanese Hansen's Disease Survivors-Deeply Deeply Closing our Eyes in Order to See What we Truly Should See. USA: Horizon Research Publishing; 2019

[22] International Council of Nurses. The

Switzerland: ICN; 2012. Available from: https://www.icn.ch/sites/default/files/ inline-files/2012\_ICN\_Codeofethicsf

[23] Japanese Nursing Association. The Code of Ethics for Nurses. 2003. Available from: https://www.nurse.or. jp/nursing/practice/rinri/rinri.html

[24] Schertzberg R, Swanton J, Thornton C. Cindy Thornton. Jean Watoson's Theory. Available from: https:// slideplayer.com/slide/13386456/

[25] Watoson J. Nursing: Human Science and Human Care. A Theory of Nursing. USA: Appleton and Lange; 1985. p. 59

ICN Code of Ethics for Nurses.

ornurses\_%20eng.pdf

**42**

Thanatology. 2011;**16**:90-101

2015;**2**:132

*Empathy Study*

**45**

**Chapter 3**

*Noriko Okabe*

**Abstract**

Emotional Labor in the Airlines:

Relation between Psychological

With the increasing domination of the service sector in the globalized world economy, this research examines the hypotheses that empathy as emotional labor practiced by human service employees moderate the decreasing propensity of job satisfaction. The background is the changed organizational climate, where the human service employees may perceive a psychological contract violation (PCV). The questionnaire surveys were administered to a total of 827 flight attendants working for two airlines, one is a European and another is an Asian airline. The result shows that, first, for both airlines, PCV perceived by the employees decrease job satisfaction. Second, empathy as emotional labor practiced by the employees moderates the decreasing propensity of job satisfaction. Third, the cross-cultural difference is observed how to moderate or repair the decreasing propensity of job satisfaction between European and Asian airline employees. As a practical implication to discuss, emphatically or emotionally competent employees might harmoniously work with people as well as the automated machines, IT and AI in the stressful workplace, thus, contribute a long-term

**Keywords:** psychological contract violation, emotional labor, airline, flight

managing service providers, organizations, and employees.

The world economy is becoming increasingly dominated by the service sector. For example, the population in professional and business services increased by 11.75% between 2000 and 2010 in the United States [1]. Organizational researchers are increasingly paying attention to the unique problem and issues involved in

In the airline industry, many airlines use information technology (IT) and automated machinery for reservation, airport check-ins, and other operations. While it is important for airlines to adapt the competitive environment, IT and the automated machine perform the work previously achieved by human contact employees. As a result, downsizing and the introduction of early retirement program are a

Contract Violation, Job

growth of the human service organization.

attendant, growth of organization

**1. Introduction**

Satisfaction, and Empathy

#### **Chapter 3**

## Emotional Labor in the Airlines: Relation between Psychological Contract Violation, Job Satisfaction, and Empathy

*Noriko Okabe*

### **Abstract**

With the increasing domination of the service sector in the globalized world economy, this research examines the hypotheses that empathy as emotional labor practiced by human service employees moderate the decreasing propensity of job satisfaction. The background is the changed organizational climate, where the human service employees may perceive a psychological contract violation (PCV). The questionnaire surveys were administered to a total of 827 flight attendants working for two airlines, one is a European and another is an Asian airline. The result shows that, first, for both airlines, PCV perceived by the employees decrease job satisfaction. Second, empathy as emotional labor practiced by the employees moderates the decreasing propensity of job satisfaction. Third, the cross-cultural difference is observed how to moderate or repair the decreasing propensity of job satisfaction between European and Asian airline employees. As a practical implication to discuss, emphatically or emotionally competent employees might harmoniously work with people as well as the automated machines, IT and AI in the stressful workplace, thus, contribute a long-term growth of the human service organization.

**Keywords:** psychological contract violation, emotional labor, airline, flight attendant, growth of organization

#### **1. Introduction**

The world economy is becoming increasingly dominated by the service sector. For example, the population in professional and business services increased by 11.75% between 2000 and 2010 in the United States [1]. Organizational researchers are increasingly paying attention to the unique problem and issues involved in managing service providers, organizations, and employees.

In the airline industry, many airlines use information technology (IT) and automated machinery for reservation, airport check-ins, and other operations. While it is important for airlines to adapt the competitive environment, IT and the automated machine perform the work previously achieved by human contact employees. As a result, downsizing and the introduction of early retirement program are a

trend [2]. Moreover, the advanced technology made many recent airports possible to operate 24 hours a day and 7 days a week and generate challenges for flight attendants to work in the extended duty periods, highly variable schedule, frequent time changes, and increased passenger load. Thus, the external competitive environment and the internal managerial changes raise a new challenge to employees.

As a result, the professional roles expected of modern flight attendants gradually changed from what they were in past decades. Thus, the service-oriented employees might perceive a psychological contract violation (PCV) in the workplace. PCV is an employee's feeling of disappointment and betrayal arising, when they believe that their organization has broken its work-related promises [3]. Conversely, interest in emotions in the workplace has accelerated rapidly over the past decade (e.g., [4, 5]).

The purpose of the present research is, first, to test the hypothesis that psychological contract violation perceived by the human service employees (flight attendants) decreases their job satisfaction. Second, the present research tests the hypotheses whether empathy as emotional labor practiced by the flight attendants moderates the decreasing propensity of job satisfaction.

#### **2. Literature review**

#### **2.1 Emotional labor**

Emotional labor refers to the process by which workers are expected to manage their feelings in accordance with organizationally defined rules and guidelines [6]. Emotional labor is considered an essential part of service-oriented employees. Hochschild [7] classified occupations requiring a higher degree of emotional labor, which include personal service workers and flight attendant as well as health service workers and some other customer-oriented workers. Hochschild [7] has practiced many fieldworks in an airline in the United States and observed the recruiting, training, and other processes of flight attendant. For example, Hochschild [7] introduced an episode in the training that a pilot spoke of the smile as the flight attendant's assets. According to Hochschild [7], organizations are increasingly willing to direct and control how employees present themselves to others.

Numerous scholars have investigated the role of emotional labor. Emotional labor, which was the idea of managing with others as part of the work role, was proposed in sociology in the 1980s. Slowly, the organizational behavior (OB) and organizational psychology (OP) literature began recognizing the value of understanding emotions at work, and emotional labor became a focal area of study [8].

**Emotional regulation:** Emotional regulation is defined as "the processes by which individuals influence which emotions they have, when they have them, and how they experience and express these emotions" ([9], p. 275). **Figure 1** shows that the consensual process model of emotional regulation described by Gross [10]. This model suggests that emotions may be regulated either by manipulating the input to the system (antecedent-focused emotional regulation) or by manipulating its output (response-focused emotional regulation).

**Antecedent-focused emotion regulation:** Antecedent-focused emotion regulation concerns the manipulation of the input to the system [10]. An example of antecedent-focused emotion regulation is situational selection, in which one

**47**

*Emotional Labor in the Airlines: Relation between Psychological Contract Violation, Job…*

approaches or avoids certain people or situations on the basis of their likely emotional impact [10]. Taking a different route to the store to avoid a neighbor who tells offensive jokes [11] and seeking out a friend with whom one can have a good cry [9] are examples of situational selection. Another example of antecedent-focused emotion regulation is situation modification which is a potentially emotion-eliciting situation, for example, whether a flat tire on the way to an important appointment or loud music next door at 3:00 a.m. does not ineluctably call forth emotion. One may convert a meeting into a phone conference or convince a neighbor to tone down

*Emotional regulation. A consensual process model of based on Gross [10] adapted for human service employees* 

**Response-focused emotion regulation:** Response-focused emotion regulation, in contrast, concerns the manipulation of output from the system [10], that is, response modulation or manipulations of physiology, which include facial expression, behavior, and cognition once an emotion is experienced; for example, subordinates tend to hide their experienced anger from their bosses [12]. Another example of response-focused emotion regulation when individuals exhibit more elevated signs of strain is that individuals try not to show any feelings while watch-

**Emotional regulation in organization:** Emotional regulation involves the employees in displaying the organizationally desired emotion [14] and inducing or suppressing feelings to sustain the outward countenance that produces the proper state of mind in others [7]. For example, flight attendants act cheerfully and friendly (e.g., [15]) and put on a smile while dealing with customers, because it is a part of their job [16]. Emotion regulatory process may be automatic or controlled and conscious or unconscious and may have their effects at one or more points in the emotion generative process [9]. The capacity of emotion to promote or undermine constructive functioning depends on the extent to which emotional arousal is monitored, evaluated, and controlled by the individual [17] or the latency, rise time, magnitude, duration, and offset of responses in behavioral, experiential, or physiological domains [9]. Psychologically, emotional regulation is a painstaking developmental process, because it requires intervening in phylogenetically deeply rooted affect systems with the psychologically complex control mechanism. For this reason, the management of emotion is an important component of "emotional

**Emotional display rules:** Although emotions have long been a topic of interest to sociologists and psychologists [7], the display of emotions in organizations has been

ing a terrifying or sad movie which make people cry (e.g., [13]).

maturity" [18] and "emotional competence" [19].

*DOI: http://dx.doi.org/10.5772/intechopen.82274*

a raucous party [9].

**Figure 1.**

*by the author.*

*Emotional Labor in the Airlines: Relation between Psychological Contract Violation, Job… DOI: http://dx.doi.org/10.5772/intechopen.82274*

**Figure 1.**

*Empathy Study*

past decade (e.g., [4, 5]).

**2. Literature review**

ent themselves to others.

output (response-focused emotional regulation).

study [8].

**2.1 Emotional labor**

trend [2]. Moreover, the advanced technology made many recent airports possible to operate 24 hours a day and 7 days a week and generate challenges for flight attendants to work in the extended duty periods, highly variable schedule, frequent time changes, and increased passenger load. Thus, the external competitive environment

As a result, the professional roles expected of modern flight attendants gradually changed from what they were in past decades. Thus, the service-oriented employees might perceive a psychological contract violation (PCV) in the workplace. PCV is an employee's feeling of disappointment and betrayal arising, when they believe that their organization has broken its work-related promises [3]. Conversely, interest in emotions in the workplace has accelerated rapidly over the

The purpose of the present research is, first, to test the hypothesis that psychological contract violation perceived by the human service employees (flight attendants) decreases their job satisfaction. Second, the present research tests the hypotheses whether empathy as emotional labor practiced by the flight attendants

Emotional labor refers to the process by which workers are expected to manage their feelings in accordance with organizationally defined rules and guidelines [6]. Emotional labor is considered an essential part of service-oriented employees. Hochschild [7] classified occupations requiring a higher degree of emotional labor, which include personal service workers and flight attendant as well as health service workers and some other customer-oriented workers. Hochschild [7] has practiced many fieldworks in an airline in the United States and observed the recruiting, training, and other processes of flight attendant. For example, Hochschild [7] introduced an episode in the training that a pilot spoke of the smile as the flight attendant's assets. According to Hochschild [7], organizations are increasingly willing to direct and control how employees pres-

Numerous scholars have investigated the role of emotional labor. Emotional labor, which was the idea of managing with others as part of the work role, was proposed in sociology in the 1980s. Slowly, the organizational behavior (OB) and organizational psychology (OP) literature began recognizing the value of understanding emotions at work, and emotional labor became a focal area of

**Emotional regulation:** Emotional regulation is defined as "the processes by which individuals influence which emotions they have, when they have them, and how they experience and express these emotions" ([9], p. 275). **Figure 1** shows that the consensual process model of emotional regulation described by Gross [10]. This model suggests that emotions may be regulated either by manipulating the input to the system (antecedent-focused emotional regulation) or by manipulating its

**Antecedent-focused emotion regulation:** Antecedent-focused emotion regulation concerns the manipulation of the input to the system [10]. An example of antecedent-focused emotion regulation is situational selection, in which one

and the internal managerial changes raise a new challenge to employees.

moderates the decreasing propensity of job satisfaction.

**46**

*Emotional regulation. A consensual process model of based on Gross [10] adapted for human service employees by the author.*

approaches or avoids certain people or situations on the basis of their likely emotional impact [10]. Taking a different route to the store to avoid a neighbor who tells offensive jokes [11] and seeking out a friend with whom one can have a good cry [9] are examples of situational selection. Another example of antecedent-focused emotion regulation is situation modification which is a potentially emotion-eliciting situation, for example, whether a flat tire on the way to an important appointment or loud music next door at 3:00 a.m. does not ineluctably call forth emotion. One may convert a meeting into a phone conference or convince a neighbor to tone down a raucous party [9].

**Response-focused emotion regulation:** Response-focused emotion regulation, in contrast, concerns the manipulation of output from the system [10], that is, response modulation or manipulations of physiology, which include facial expression, behavior, and cognition once an emotion is experienced; for example, subordinates tend to hide their experienced anger from their bosses [12]. Another example of response-focused emotion regulation when individuals exhibit more elevated signs of strain is that individuals try not to show any feelings while watching a terrifying or sad movie which make people cry (e.g., [13]).

**Emotional regulation in organization:** Emotional regulation involves the employees in displaying the organizationally desired emotion [14] and inducing or suppressing feelings to sustain the outward countenance that produces the proper state of mind in others [7]. For example, flight attendants act cheerfully and friendly (e.g., [15]) and put on a smile while dealing with customers, because it is a part of their job [16]. Emotion regulatory process may be automatic or controlled and conscious or unconscious and may have their effects at one or more points in the emotion generative process [9]. The capacity of emotion to promote or undermine constructive functioning depends on the extent to which emotional arousal is monitored, evaluated, and controlled by the individual [17] or the latency, rise time, magnitude, duration, and offset of responses in behavioral, experiential, or physiological domains [9]. Psychologically, emotional regulation is a painstaking developmental process, because it requires intervening in phylogenetically deeply rooted affect systems with the psychologically complex control mechanism. For this reason, the management of emotion is an important component of "emotional maturity" [18] and "emotional competence" [19].

**Emotional display rules:** Although emotions have long been a topic of interest to sociologists and psychologists [7], the display of emotions in organizations has been

become a topic of greater interest to organizational scholars [4, 20–22]. Hochschild [7] argued that common expectations exist concerning the appropriate emotional reactions of individuals involved in service transaction. In the emotional labor literature, the focus is customer service, where interactions are less spontaneously "emotional," yet high emotional control is needed to maintain positive emotions with customers across time and situations [7]. Human service employees act as emotional labor in order to conform to the emotional regulation and the display rules required by the organizations (**Figure 2**).

Emotional display for organizational purposes has been referred to as "display rules" [23]. Display rules are standards of behavior that indicate not only which emotions are appropriate in a given situation but also how those emotions should be conveyed or publicly expressed [24]. Thus, display rules are norms and standards of behavior indicating what emotions are appropriate in a given situation (**Figure 3**). For example, flight attendants are encouraged to smile, while lawyers use an aggressive and angry tone to encourage compliance in adversaries [25].

**Affective delivery:** Affective delivery or expressing positive emotions in service interactions promotes customer satisfaction [26]. "Employee affective delivery" refers to an employee's "act of expressing socially desired emotions during service transaction" [15]. An affective service delivery is perceived as friendly and warm, which is related to desirable outcomes [27].

**Emotional strategies:** Hochschild [7] identified two emotional strategies that may be used by employees to manage their emotions: surface acting and deep acting.


#### **Figure 2.**

*Conceptual model of the direct and the moderating effects between psychological contract violation (PCV) and job satisfaction.*

**49**

**Figure 4.**

**Figure 3.**

*Emotional Labor in the Airlines: Relation between Psychological Contract Violation, Job…*

**Contracts:** Contracts are important features of exchange agreements. The contract binds the transacting parties as well as the employer and employees and

**Psychological contracts:** The term psychological contract was introduced in the early 1960s by Argyris [29], Levinson et al. [30] and by Schein [31]. While the economic and legal contract can be explicitly described in formal legal terms, Rousseau [32] defines

*DOI: http://dx.doi.org/10.5772/intechopen.82274*

**2.2 Psychological contract violation**

regulates their activities (**Figure 4**).

*Study 1: interaction of PCV and affective delivery on job satisfaction.*

*Study 2: interaction of PCV and surface acting on job satisfaction.*

*Emotional Labor in the Airlines: Relation between Psychological Contract Violation, Job… DOI: http://dx.doi.org/10.5772/intechopen.82274*

#### **2.2 Psychological contract violation**

*Empathy Study*

by the organizations (**Figure 2**).

which is related to desirable outcomes [27].

in adversaries [25].

acting.

**48**

**Figure 2.**

*job satisfaction.*

*Conceptual model of the direct and the moderating effects between psychological contract violation (PCV) and* 

become a topic of greater interest to organizational scholars [4, 20–22]. Hochschild [7] argued that common expectations exist concerning the appropriate emotional reactions of individuals involved in service transaction. In the emotional labor literature, the focus is customer service, where interactions are less spontaneously "emotional," yet high emotional control is needed to maintain positive emotions with customers across time and situations [7]. Human service employees act as emotional labor in order to conform to the emotional regulation and the display rules required

Emotional display for organizational purposes has been referred to as "display rules" [23]. Display rules are standards of behavior that indicate not only which emotions are appropriate in a given situation but also how those emotions should be conveyed or publicly expressed [24]. Thus, display rules are norms and standards of behavior indicating what emotions are appropriate in a given situation (**Figure 3**). For example, flight attendants are encouraged to smile, while lawyers use an aggressive and angry tone to encourage compliance

**Affective delivery:** Affective delivery or expressing positive emotions in service interactions promotes customer satisfaction [26]. "Employee affective delivery" refers to an employee's "act of expressing socially desired emotions during service transaction" [15]. An affective service delivery is perceived as friendly and warm,

**Emotional strategies:** Hochschild [7] identified two emotional strategies that

1.**Surface acting** is an emotional strategy in which employees modify their behavioral displays without changing their inner feelings and employees conform to the rules to retain their job, not to help the customer or organization [26]. Surface acting corresponds to the managing observable expression (e.g., facial or behavioral expressions) to obey display rules.

2.**Deep acting** is another emotional strategy in which the process of controlling internal thoughts and feelings to meet the mandated display. Emotions involve physiological arousal and conditions, and deep acting works on modifying

arousal or cognitions through a variety of techniques [28].

may be used by employees to manage their emotions: surface acting and deep

**Contracts:** Contracts are important features of exchange agreements. The contract binds the transacting parties as well as the employer and employees and regulates their activities (**Figure 4**).

**Psychological contracts:** The term psychological contract was introduced in the early 1960s by Argyris [29], Levinson et al. [30] and by Schein [31]. While the economic and legal contract can be explicitly described in formal legal terms, Rousseau [32] defines

**Figure 3.** *Study 1: interaction of PCV and affective delivery on job satisfaction.*

**Figure 4.** *Study 2: interaction of PCV and surface acting on job satisfaction.*

the psychological contracts as an individual's belief regarding the term and conditions of a reciprocal exchange agreement between that focal person and another party.

**Psychological contract violation (PCV):** A psychological contract violation occurs when one party in a relationship perceives another to have failed to fulfill promised obligations [33]. Since contracts emerge under assumptions of good faith and fair dealing and involve reliance by parties on the promises of the others, violations can lead to serious consequences for the parties involved. Psychological contract violation is distinct from unmet expectations and perceptions of inequity [33]. Employees initially hold unrealistic expectations, and when these expectations go unmet, employees may become less satisfied, perform less well, and become more likely to leave their employer [34].

#### **3. Research hypothesis construction**

#### **3.1 Direct effects between an antecedent (PCV) and an outcome (job satisfaction)**

**Job satisfaction** is the pleasurable emotional state resulting from appraisal of one's job as achieving of facilitating one's job value [35] and a measure of the employee's evaluation of the job and has often been used as a proxy for employee well-being at work [36]. I suppose the human service employee (flight attendants in this study) may perceive a psychological contract violation in the recent changing industrial climate, and then, the situation may deteriorate the job satisfaction of the employees. Therefore, I propose the following direct effect hypothesis:

**Hypothesis 1**: Psychological contract violation (PCV) perceived by human service employee negatively relates to job satisfaction.

#### **3.2 Moderating effects of emotional labor aspects between an antecedent (PCV) and an outcome (job satisfaction)**

A moderator variable specifies when and under what conditions a predictor variable influences a dependent variable [37]. A moderator variable may reduce or enhance the direction of the relationship between a predictor variable and a dependent variable, or it may even change the direction of the relationship between the two variables from positive to negative or vice versa. I propose the following moderating effect hypotheses:

**Hypothesis 2**: Affective delivery of customer service employees moderates the negative relationship between psychological contract violation (PCV) and job satisfaction.

**Hypothesis 3**: Surface acting of customer service employees moderates the negative relationship between psychological contract violation (PCV) and job satisfaction.

**Hypothesis 4**: Deep acting of customer service employees moderates the negative relationship between psychological contract violation (PCV) and job satisfaction.

#### **4. General methods**

#### **4.1 Participants and procedures**

The questionnaire surveys were administered to a total of 827 flight attendants, 414 flight attendants working for a European airline (Study 1), and 413 flight

**51**

1 2 3

Age 3

3.98 **Variables in psychological contract context**

4 5

Job

4.08

.71

.86

.04

.14\*\*\*

.11\*\*

−.22\*\*\*

—

satisfaction

6

Careerism

2.18

.67

.91

.06

−.10\*\*

−.07

.11\*

−.25\*\*\*

—

orientation

7

Task

4.25

.52

.82

.10\*

.12\*\*

.09

.01

.10\*\*

−.08

—

performance

8

Emotional

3.43

.88

.93

−.16\*\*\*

−.03

.01

.11\*

−.21\*\*\*

−.04

−.17\*\*\*

—

exhaustion

**Variables in empathy as emotional labor**

9

Affective

4.50

.52

.82

−.14\*\*

.14\*\*\*

.22\*\*\*

.06

.04

−.02

.36\*\*\*

−.06

—

delivery

10

Surface

3.90

.68

.89

.13\*\*

.03

.08

.03

.01

.08\*

.26\*\*\*

.07

.19\*\*\*

—

acting

11

Deep acting *Note: \*\*\* p < .001, \*\*p < .01, \*p < .05. N = 414.*

*1Gender: coded as male = 0, female = 1.*

3.65

.90

.91

.01 *2Job tenure: coded as 1 = 0–5 years, 2 = 6–10 years, 3 = 11–15 years, 4 = 16–20 years, 5 = 21–25 years, 6 = 26–30 years, 7 = more than 30 years.*

*3Age: coded as 1 = less than 20, 2 = 21–30, 3 = 31–40, 4 = 41–50, 5 = 51–60, 6 = more than 60.*

*4*

**Table 1.**

*Study 1: descriptive statistics, reliability, and intercorrelations.*

*α***:** *Reliability is denoted by Cronbach alpha coefficients.*

.02

−.02

−.03

.02

.00

−.04\*\*\*

.18\*\*\*

.13\*\*\*

.34\*\*\*

—

PCV

2.50

.76

.84

−.08\*

−.07

−.43

—

.79

.01

.76\*\*\*

—

Tenure 2

4.11

1.51

.13\*\*

—

Gender 1

.75

.44

**Mean**

**SD**

**α4**

**1**

**2**

**3**

**4**

**5**

**6**

**7**

**8**

**9**

**10**

**11**

*Emotional Labor in the Airlines: Relation between Psychological Contract Violation, Job…*

*DOI: http://dx.doi.org/10.5772/intechopen.82274*


**Table 1.**

*Study 1: descriptive statistics, reliability, and intercorrelations.*

#### *Emotional Labor in the Airlines: Relation between Psychological Contract Violation, Job… DOI: http://dx.doi.org/10.5772/intechopen.82274*

*Empathy Study*

more likely to leave their employer [34].

**3. Research hypothesis construction**

service employee negatively relates to job satisfaction.

**and an outcome (job satisfaction)**

moderating effect hypotheses:

satisfaction.

satisfaction.

satisfaction.

**4. General methods**

**4.1 Participants and procedures**

the psychological contracts as an individual's belief regarding the term and conditions of

**Psychological contract violation (PCV):** A psychological contract violation occurs when one party in a relationship perceives another to have failed to fulfill promised obligations [33]. Since contracts emerge under assumptions of good faith and fair dealing and involve reliance by parties on the promises of the others, violations can lead to serious consequences for the parties involved. Psychological contract violation is distinct from unmet expectations and perceptions of inequity [33]. Employees initially hold unrealistic expectations, and when these expectations go unmet, employees may become less satisfied, perform less well, and become

**3.1 Direct effects between an antecedent (PCV) and an outcome (job satisfaction)**

**Job satisfaction** is the pleasurable emotional state resulting from appraisal of one's job as achieving of facilitating one's job value [35] and a measure of the employee's evaluation of the job and has often been used as a proxy for employee well-being at work [36]. I suppose the human service employee (flight attendants in this study) may perceive a psychological contract violation in the recent changing industrial climate, and then, the situation may deteriorate the job satisfaction of the employees. Therefore, I propose the following direct effect hypothesis: **Hypothesis 1**: Psychological contract violation (PCV) perceived by human

**3.2 Moderating effects of emotional labor aspects between an antecedent (PCV)** 

A moderator variable specifies when and under what conditions a predictor variable influences a dependent variable [37]. A moderator variable may reduce or enhance the direction of the relationship between a predictor variable and a dependent variable, or it may even change the direction of the relationship between the two variables from positive to negative or vice versa. I propose the following

**Hypothesis 2**: Affective delivery of customer service employees moderates the negative relationship between psychological contract violation (PCV) and job

**Hypothesis 3**: Surface acting of customer service employees moderates the negative relationship between psychological contract violation (PCV) and job

**Hypothesis 4**: Deep acting of customer service employees moderates the negative relationship between psychological contract violation (PCV) and job

The questionnaire surveys were administered to a total of 827 flight attendants,

414 flight attendants working for a European airline (Study 1), and 413 flight

a reciprocal exchange agreement between that focal person and another party.

**50**

attendants working for an Asian airline (Study 2). A five-point Likert-type scale of questionnaire was developed based on a review of the literature to assess the emotional labor aspects and other variables. The questionnaire was randomly distributed. The researcher explained the purpose of the survey to the participants, emphasizing the anonymity and confidentiality of the data. Participants were asked to complete and return the questionnaire to the researcher directly on the place or by using a provided stamped envelope.

#### **4.2 Measures**

**Affective delivery** (an emotional labor aspect) was measured by using three items (α = 0.82) derived from the bases of Grandey [26]. **Surface acting** (an emotional labor aspect) was measured by using four items (α = 0.89) derived from the bases of Brotheridge and Lee [38]. **Deep acting** (an emotional labor aspect) was measured by using three items (α = 0.91) of Brotheridge and Lee [38]. **Psychological contract violation (PCV)** was measured by using two items (α = 0.84) derived from Robinson and Rousseau [33]. **Job satisfaction** was measured by two items (α = 0.86) derived from Robinson and Rousseau [33]. **Careerism orientation** was measured by using five items (α = 0.91) derived from Robinson and Rousseau [33]. **Task performance** was measured by using three items (α = 0.82) derived from Williams and Anderson [39] and Brown et al. [40]. **Emotional exhaustion** was measured by using four items (α = 0.93) derived from Pines & Aronson [41].

#### **4.3 Data analysis**

Cronbach's α is the most widely used index of the reliability of a scale [42] and is an important concept in the evaluation of assessments and questionnaires. In the descriptive statistics, Cronbach's α and intercorrelations were calculated (**Table 1** for Study 1 and **Table 3** for Study 2). Then, hierarchical regression analyses were conducted to test the study hypotheses, the direct effects of the antecedents (PCV) on the consequence (job satisfaction), and the moderating effects of PCV and emotional labor aspects


**53**

**5. Results**

**Table 4.**

*Study 2: hierarchical regressions analyses.*

**Table 3.**

**5.1 Study 1**

*Emotional Labor in the Airlines: Relation between Psychological Contract Violation, Job…*

(affective delivery, surface acting, and deep acting) on the relations between the antecedents and the consequence (**Table 2** for Study 2 and **Table 4** for Study 2).

The participants of the Study 1 are flight attendants working for a European airline. The participants usually work on the long-haul flights, of which the durations

*DOI: http://dx.doi.org/10.5772/intechopen.82274*

*Study 2: descriptive statistics, reliability, and intercorrelations.*

#### **Table 2.**

*Study 1: hierarchical regressions analyses.*

*Emotional Labor in the Airlines: Relation between Psychological Contract Violation, Job… DOI: http://dx.doi.org/10.5772/intechopen.82274*


#### **Table 3.**

*Empathy Study*

**4.2 Measures**

**4.3 Data analysis**

by using a provided stamped envelope.

four items (α = 0.93) derived from Pines & Aronson [41].

attendants working for an Asian airline (Study 2). A five-point Likert-type scale of questionnaire was developed based on a review of the literature to assess the emotional labor aspects and other variables. The questionnaire was randomly distributed. The researcher explained the purpose of the survey to the participants, emphasizing the anonymity and confidentiality of the data. Participants were asked to complete and return the questionnaire to the researcher directly on the place or

**Affective delivery** (an emotional labor aspect) was measured by using three items (α = 0.82) derived from the bases of Grandey [26]. **Surface acting** (an emotional labor aspect) was measured by using four items (α = 0.89) derived from the bases of Brotheridge and Lee [38]. **Deep acting** (an emotional labor aspect) was measured by using three items (α = 0.91) of Brotheridge and Lee [38]. **Psychological contract violation (PCV)** was measured by using two items (α = 0.84) derived from Robinson and Rousseau [33]. **Job satisfaction** was measured by two items (α = 0.86) derived from Robinson and Rousseau [33]. **Careerism orientation** was measured by using five items (α = 0.91) derived from Robinson and Rousseau [33]. **Task performance** was measured by using three items (α = 0.82) derived from Williams and Anderson [39] and Brown et al. [40]. **Emotional exhaustion** was measured by using

Cronbach's α is the most widely used index of the reliability of a scale [42] and is an important concept in the evaluation of assessments and questionnaires. In the descriptive statistics, Cronbach's α and intercorrelations were calculated (**Table 1** for Study 1 and **Table 3** for Study 2). Then, hierarchical regression analyses were conducted to test the study hypotheses, the direct effects of the antecedents (PCV) on the consequence (job satisfaction), and the moderating effects of PCV and emotional labor aspects

**52**

**Table 2.**

*Study 1: hierarchical regressions analyses.*

*Study 2: descriptive statistics, reliability, and intercorrelations.*


#### **Table 4.**

*Study 2: hierarchical regressions analyses.*

(affective delivery, surface acting, and deep acting) on the relations between the antecedents and the consequence (**Table 2** for Study 2 and **Table 4** for Study 2).

#### **5. Results**

#### **5.1 Study 1**

The participants of the Study 1 are flight attendants working for a European airline. The participants usually work on the long-haul flights, of which the durations

are between 6 and 12 hours. After explaining the confidentiality of data, approximately 500 questionnaires were randomly distributed during the field works (10 times) between 2015 and 2017, and 414 responses were received, resulting in a valid response rate of approximately 82.8%.

**Profile of the respondents:** Regarding gender, 307 respondents were female (74.2%) and 107 respondents were male (25.8%). Regarding tenure, the most frequent respondents answered that their work experience was from 16 to 20 years (26.6%), followed by the respondents who have work experience from 11 to 15 years (19.6%), and from 26 to 30 years (18.6%). Regarding age, the most frequent responses answered that their ages were from 41 to 50 years (53.6%), followed by the respondents aged from 51 to 60 years (22.0%), and from 31 to 40 years (20.0%).

**Table 1** presents the descriptive statistics, reliability, and intercorrelations. **Hypothesis 1** *(study 1)* proposed that psychological contract violation (PCV) perceived by the human service employee is negatively related to job satisfaction. As predicted by Hypothesis 1 (*study 1*), **Table 1** presents that PCV is significantly and negatively relates to job satisfaction (*r* = − .22, *p* < .001), supporting H1 (*study 1*).

**Table 2** presents the summary of the hierarchical regression analyses. In step 1, the control variables, including gender, tenure, age, and the additional independent variables, including PCV, careerism orientation, task performance, and emotional exhaustion, are inserted into the regression equation to eliminate alternative explanations. In the step 2, the independent variables of emotional labor aspects (affective delivery, surface acting, and deep acting) are inserted into the regression equation. **Table 2** presents that PCV is negatively related to job satisfaction (*β* = −.17, *p* < 0.01, both in the step 1 and step 2), also supporting Hypothesis 1 (*study 1*).

**Hypotheses 2** *(study 1)* proposed that affective delivery of human service employees moderates the negative relationship between PCV and job satisfaction. **Table 2** presents that, when the interaction term (PCV × Affective Delivery) is inserted into the regression equation in the step 3, the interaction was significant [*F* (12, 401) = 6.640, *p* < .001, ∆*R2* = −.001], supporting Hypothesis 2. Moreover, while PCV was negative predictor on job satisfaction (*β* = −.17, *p* < 0.001, both in the step 1 and step 2; *β* = −.85, *p* < 0.01 in the basic equation of step 3), when the interaction term (1) (PCV × Affective Delivery) was inserted into the equation in the step 3, significantly positive beta appeared (*β* = .74, *p* < .05), supporting Hypotheses 2 (*study 1*). This interaction term (or moderator variable) changes the relationship between the antecedent (or predictor, PCV) and the outcome (job satisfaction) from negative to positive. Conversely, Hypotheses 3 (interaction term (2) PCV and surface acting) and Hypotheses 4 (interaction term (3) PCV and deep acting) were not supported.

#### **5.2 Study 2**

The participants of the study 2 are flight attendants working for an Asian airline. The participants usually work on the medium-haul flights, of which the durations are between 3 and 6 hours. After explaining the confidentiality of data, approximately 500 questionnaires were randomly distributed during the field works (8 times) between 2015 and 2017, and 413 responses were received, resulting in a valid response rate of approximately 82.6%.

**Profile of the respondents:** Regarding gender, 322 respondents were female (78.0%), and 91 respondents were male (22.0%). Regarding tenure, the most frequent respondents answered that they work less than 5 years (33.7%), followed by the respondents who have work experience from 6 to 10 years (25.2%), and from 11 to 15 years (13.1%). Regarding age, the most frequent responses answered that

**55**

*Emotional Labor in the Airlines: Relation between Psychological Contract Violation, Job…*

their ages were from 21 to 30 years (33.9%), followed by the respondents aged from

**Table 4** presents the summary of hierarchical regression analyses. In the step 1, the control variables, including gender, tenure, age, and the additional independent variables, including PCV, careerism orientation, task performance, and emotional exhaustion, are inserted into the regression equation to eliminate alternative explanations. In the step 2, the independent variables of emotional labor aspects (affective delivery, surface acting, and deep acting) are inserted into the regression

**Hypotheses 3** *(study 2)* proposed that surface acting of human service employees moderates the negative relationship between PCV and job satisfaction. **Table 4** presents that, when the interaction term (PCV × surface acting) is inserted into the regression equation in the step 4, the interaction was significant [*F*(13, 399) = 11.781, *p* < .001,

 = −0.010], supporting Hypothesis 3 (*study 2*). Moreover, while PCV was negative predictor on job satisfaction (*β* = −.46, *p* < 0.001, both in the step 1 and step 2), when the interaction term (2) (PCV × surface acting) was inserted into the equation in the step 4, significantly positive beta appeared (*β* = .88, *p* < 0.05). This interaction term (or moderator variable) changes the relationship between the antecedent (or predictor: PCV) and the outcome (job satisfaction) from negative to positive, also supporting Hypothesis 3 (*study 2*). Conversely, Hypotheses 2 [interaction term (1) PCV and affective delivery] and Hypotheses 4 [interaction term (3) PCV and deep acting] were not

In the recent airline industry, many airlines must reduce their costs in order to adapt to the competitive business environment. As a result, the airlines also change the employment relationships. Security, safety, and customer service are the main tasks for flight attendant; irrespective of the airline company is a low-cost carrier (LCC) or traditional airlines. Although much of the work carried out in an aircraft today is nearly the same concerning security and safety as it was in the past days, the working conditions and the expected customer service roles have changed dramatically. Such might generate psychological contract violation in the workplace. In this research, the self-evaluated questionnaire survey with a five-point Likert-type scale was administered in order to estimate the levels of perceptions of human service employees (flight attendants) concerning PCV-related variables and empathy as emotional labor variables. **Table 5** shows the summary of levels concerning job-related perception and empathy as emotional labor. Concerning jobrelated perception, the level of PCV perceived by the employees is from medium to low (average, 2.79), the level of job satisfaction is from medium to high (average, 3.87), and the level of emotional exhaustion is from medium to high (average, 3.63). Concerning empathy as emotional labor, the level of affective delivery of the employees is high (average, 4.50), the level of surface acting is high (average, 4.05), and the level of deep acting is from medium to high (average, 3.74). In summary,

significant, and not supporting Hypotheses 2 (*study 2*) and 4 (*study 2*).

**Table 3** presents the descriptive statistics, reliability, and intercorrelations. **Hypothesis 1** *(study 2)* proposed that psychological contract violation (PCV) perceived by human service employee is negatively related to job satisfaction. As predicted by **Hypothesis 1** *(study 2)*, **Table 3** presents that PCV is significantly and negatively relates to job satisfaction (*r* = − .45, *p* < .001), supporting **Hypothesis 1** *(study 2)*. **Table 4** also presents that PCV is negatively related to job satisfaction (*β* = −.46, *p* < 0.001, both in the step 1 and step 2), supporting **Hypothesis 1** *(study 2)*.

*DOI: http://dx.doi.org/10.5772/intechopen.82274*

equation.

**6. Discussion**

∆*R*<sup>2</sup>

31 to 40 years (29.1%), and from 41 to 50 years (20.1%).

*Emotional Labor in the Airlines: Relation between Psychological Contract Violation, Job… DOI: http://dx.doi.org/10.5772/intechopen.82274*

their ages were from 21 to 30 years (33.9%), followed by the respondents aged from 31 to 40 years (29.1%), and from 41 to 50 years (20.1%).

**Table 3** presents the descriptive statistics, reliability, and intercorrelations. **Hypothesis 1** *(study 2)* proposed that psychological contract violation (PCV) perceived by human service employee is negatively related to job satisfaction. As predicted by **Hypothesis 1** *(study 2)*, **Table 3** presents that PCV is significantly and negatively relates to job satisfaction (*r* = − .45, *p* < .001), supporting **Hypothesis 1** *(study 2)*. **Table 4** also presents that PCV is negatively related to job satisfaction (*β* = −.46, *p* < 0.001, both in the step 1 and step 2), supporting **Hypothesis 1** *(study 2)*.

**Table 4** presents the summary of hierarchical regression analyses. In the step 1, the control variables, including gender, tenure, age, and the additional independent variables, including PCV, careerism orientation, task performance, and emotional exhaustion, are inserted into the regression equation to eliminate alternative explanations. In the step 2, the independent variables of emotional labor aspects (affective delivery, surface acting, and deep acting) are inserted into the regression equation.

**Hypotheses 3** *(study 2)* proposed that surface acting of human service employees moderates the negative relationship between PCV and job satisfaction. **Table 4** presents that, when the interaction term (PCV × surface acting) is inserted into the regression equation in the step 4, the interaction was significant [*F*(13, 399) = 11.781, *p* < .001, ∆*R*<sup>2</sup> = −0.010], supporting Hypothesis 3 (*study 2*). Moreover, while PCV was negative predictor on job satisfaction (*β* = −.46, *p* < 0.001, both in the step 1 and step 2), when the interaction term (2) (PCV × surface acting) was inserted into the equation in the step 4, significantly positive beta appeared (*β* = .88, *p* < 0.05). This interaction term (or moderator variable) changes the relationship between the antecedent (or predictor: PCV) and the outcome (job satisfaction) from negative to positive, also supporting Hypothesis 3 (*study 2*). Conversely, Hypotheses 2 [interaction term (1) PCV and affective delivery] and Hypotheses 4 [interaction term (3) PCV and deep acting] were not significant, and not supporting Hypotheses 2 (*study 2*) and 4 (*study 2*).

#### **6. Discussion**

*Empathy Study*

(20.0%).

response rate of approximately 82.8%.

[*F* (12, 401) = 6.640, *p* < .001, ∆*R2*

response rate of approximately 82.6%.

are between 6 and 12 hours. After explaining the confidentiality of data, approximately 500 questionnaires were randomly distributed during the field works (10 times) between 2015 and 2017, and 414 responses were received, resulting in a valid

**Profile of the respondents:** Regarding gender, 307 respondents were female (74.2%) and 107 respondents were male (25.8%). Regarding tenure, the most frequent respondents answered that their work experience was from 16 to 20 years (26.6%), followed by the respondents who have work experience from 11 to 15 years

(19.6%), and from 26 to 30 years (18.6%). Regarding age, the most frequent responses answered that their ages were from 41 to 50 years (53.6%), followed by the respondents aged from 51 to 60 years (22.0%), and from 31 to 40 years

both in the step 1 and step 2), also supporting Hypothesis 1 (*study 1*).

**Hypotheses 2** *(study 1)* proposed that affective delivery of human service employees moderates the negative relationship between PCV and job satisfaction. **Table 2** presents that, when the interaction term (PCV × Affective Delivery) is inserted into the regression equation in the step 3, the interaction was significant

while PCV was negative predictor on job satisfaction (*β* = −.17, *p* < 0.001, both in the step 1 and step 2; *β* = −.85, *p* < 0.01 in the basic equation of step 3), when the interaction term (1) (PCV × Affective Delivery) was inserted into the equation in the step 3, significantly positive beta appeared (*β* = .74, *p* < .05), supporting Hypotheses 2 (*study 1*). This interaction term (or moderator variable) changes the relationship between the antecedent (or predictor, PCV) and the outcome (job satisfaction) from negative to positive. Conversely, Hypotheses 3 (interaction term (2) PCV and surface acting) and Hypotheses 4 (interaction term (3) PCV and deep acting) were not supported.

The participants of the study 2 are flight attendants working for an Asian airline. The participants usually work on the medium-haul flights, of which the durations are between 3 and 6 hours. After explaining the confidentiality of data, approximately 500 questionnaires were randomly distributed during the field works (8 times) between 2015 and 2017, and 413 responses were received, resulting in a valid

**Profile of the respondents:** Regarding gender, 322 respondents were female (78.0%), and 91 respondents were male (22.0%). Regarding tenure, the most frequent respondents answered that they work less than 5 years (33.7%), followed by the respondents who have work experience from 6 to 10 years (25.2%), and from 11 to 15 years (13.1%). Regarding age, the most frequent responses answered that

= −.001], supporting Hypothesis 2. Moreover,

**Table 1** presents the descriptive statistics, reliability, and intercorrelations. **Hypothesis 1** *(study 1)* proposed that psychological contract violation (PCV) perceived by the human service employee is negatively related to job satisfaction. As predicted by Hypothesis 1 (*study 1*), **Table 1** presents that PCV is significantly and negatively relates to job satisfaction (*r* = − .22, *p* < .001), supporting H1 (*study 1*). **Table 2** presents the summary of the hierarchical regression analyses. In step 1, the control variables, including gender, tenure, age, and the additional independent variables, including PCV, careerism orientation, task performance, and emotional exhaustion, are inserted into the regression equation to eliminate alternative explanations. In the step 2, the independent variables of emotional labor aspects (affective delivery, surface acting, and deep acting) are inserted into the regression equation. **Table 2** presents that PCV is negatively related to job satisfaction (*β* = −.17, *p* < 0.01,

**54**

**5.2 Study 2**

In the recent airline industry, many airlines must reduce their costs in order to adapt to the competitive business environment. As a result, the airlines also change the employment relationships. Security, safety, and customer service are the main tasks for flight attendant; irrespective of the airline company is a low-cost carrier (LCC) or traditional airlines. Although much of the work carried out in an aircraft today is nearly the same concerning security and safety as it was in the past days, the working conditions and the expected customer service roles have changed dramatically. Such might generate psychological contract violation in the workplace.

In this research, the self-evaluated questionnaire survey with a five-point Likert-type scale was administered in order to estimate the levels of perceptions of human service employees (flight attendants) concerning PCV-related variables and empathy as emotional labor variables. **Table 5** shows the summary of levels concerning job-related perception and empathy as emotional labor. Concerning jobrelated perception, the level of PCV perceived by the employees is from medium to low (average, 2.79), the level of job satisfaction is from medium to high (average, 3.87), and the level of emotional exhaustion is from medium to high (average, 3.63). Concerning empathy as emotional labor, the level of affective delivery of the employees is high (average, 4.50), the level of surface acting is high (average, 4.05), and the level of deep acting is from medium to high (average, 3.74). In summary,


#### **Table 5.**

*Summary of levels concerning empathy as emotional labor and other job-related variables.*

the descriptive statistics show that the level of PCV perceived by the employees is from medium to low and the level of empathy as emotional labor is high.

The result also shows that, first, for both airlines, PCV perceived by the serviceoriented and/or human service employees decreases job satisfaction. Second, empathy as emotional labor practiced by the flight attendant moderates or repairs the decreasing propensity of job satisfaction. Third, while the employees of a European airline who work on the long-haul flights (6–12 hours flights) tend to moderate the decreasing propensity of job satisfaction by practicing "affective delivery" (an aspect of emotional labor), the employees of an Asian airline who work on the medium-haul flights (3–6 hours flights) tend to moderate the decreasing propensity of job satisfaction by practicing surface acting (another aspect of emotional labor). Thus, the cross-cultural difference is observed on how to moderate or repair the decreasing propensity of job satisfaction between the European airline employees and the Asian airline employees.

#### **7. Practical implication**

The practical implication is, first, about the duration of duty and the amount of tasks. When the duration of the duty of human contact is long enough to treat people, the employees might use affective delivery (an aspect of emotional labor) to moderate or repair the decreasing propensity of job satisfaction. Conversely, when the employees have to do many tasks and treat people in short/medium time, the employees might use surface acting to moderate or repair the decreasing propensity of job satisfaction.

Second, the result of this study may apply to the occupations classified by Hochschild [7] requiring a higher degree of emotional labor, which include flight attendant as well as health service workers, including physicians, nurses, therapists, dentists, dental hygienists, and any other customer-oriented workers, including teachers and lawyers.

Third, empathy affects a wide range of work behavior such as teamwork and helps the employees keep hold their job satisfaction in the organizational changes.

Finally, emotionally competent human service employees might harmoniously work with people in a specific environmental workplace, thus, contributing a longterm growth of the organization.

#### **8. Limitations**

In the cross-sectional design, the use of only the self-evaluated responses of emotional labors may be considered the first limitations of this research. However,

**57**

provided the original work is properly cited.

© 2018 The Author(s). Licensee IntechOpen. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/ by/3.0), which permits unrestricted use, distribution, and reproduction in any medium,

Yokohama National University, Center for Economic Growth Strategy, Japan

\*Address all correspondence to: okabe-noriko-ts@ynu.jp

*Emotional Labor in the Airlines: Relation between Psychological Contract Violation, Job…*

employees perceive a certain emotion and psychological aspects.

self-reports of these psychological variable provide accurate measurement, since it would be difficult for a co-worker or supervisor to accurately estimate whether the

Another limitation may be that individual characteristics may also account for alternative explanations. For example, employees with some characteristics (e.g., a frank and open character versus a timid and close character), employees with any ability (high/low cognitive ability or high/low self-evaluation), employees with some physical ability (physical fitness), as well as employees' gender (female versus male), tenure, age (experienced versus novice), culture, and nationality may also

In addition, the present research exclusively focused on flight attendants and limits the generalizability of the findings. For example, the duration and/or frequency of contact with customers would be comparatively shorter for flight attendants than the duration and/or frequency of contact with hospitalized patients for physicians and nurses in the hospital. It limits the generalizability of the findings.

A suggestion for future research direction would be an investigation of empathy as emotional labor in the different organizations. Another future research direction would be exploring the optimal level of moderating or repairing effect by empathy as emotional labor. Though this research showed that empathy as emotional labor could moderate or repair the decreasing propensity of job satisfaction, it is uncer-

In addition, the future research direction could be exploring how to improve the empathic competence in an organization. Finally, empathy as emotional labor may evoke a new stream of explanation for the effectiveness of human service employees

*DOI: http://dx.doi.org/10.5772/intechopen.82274*

account for alternative explanations.

**9. Suggestion for future research**

in the organization.

**Author details**

Noriko Okabe

tain the optimal level of moderation or repair.

#### *Emotional Labor in the Airlines: Relation between Psychological Contract Violation, Job… DOI: http://dx.doi.org/10.5772/intechopen.82274*

self-reports of these psychological variable provide accurate measurement, since it would be difficult for a co-worker or supervisor to accurately estimate whether the employees perceive a certain emotion and psychological aspects.

Another limitation may be that individual characteristics may also account for alternative explanations. For example, employees with some characteristics (e.g., a frank and open character versus a timid and close character), employees with any ability (high/low cognitive ability or high/low self-evaluation), employees with some physical ability (physical fitness), as well as employees' gender (female versus male), tenure, age (experienced versus novice), culture, and nationality may also account for alternative explanations.

In addition, the present research exclusively focused on flight attendants and limits the generalizability of the findings. For example, the duration and/or frequency of contact with customers would be comparatively shorter for flight attendants than the duration and/or frequency of contact with hospitalized patients for physicians and nurses in the hospital. It limits the generalizability of the findings.

#### **9. Suggestion for future research**

*Empathy Study*

**Table 5.**

**PCV Job** 

**satisfaction**

*The questionnaire was developed with a five-point Likert-type scale.*

and the Asian airline employees.

**7. Practical implication**

of job satisfaction.

teachers and lawyers.

**8. Limitations**

term growth of the organization.

the descriptive statistics show that the level of PCV perceived by the employees is

**Emotional exhaustion**

Study 1 2.49 4.08 3.45 4.50 3.92 3.65 Study 2 3.09 3.66 3.81 4.49 4.17 3.83 Average 2.79 3.87 3.63 4.50 4.05 3.74

The result also shows that, first, for both airlines, PCV perceived by the serviceoriented and/or human service employees decreases job satisfaction. Second, empathy as emotional labor practiced by the flight attendant moderates or repairs the decreasing propensity of job satisfaction. Third, while the employees of a European airline who work on the long-haul flights (6–12 hours flights) tend to moderate the decreasing propensity of job satisfaction by practicing "affective delivery" (an aspect of emotional labor), the employees of an Asian airline who work on the medium-haul flights (3–6 hours flights) tend to moderate the decreasing propensity of job satisfaction by practicing surface acting (another aspect of emotional labor). Thus, the cross-cultural difference is observed on how to moderate or repair the decreasing propensity of job satisfaction between the European airline employees

**Job-related perception Empathy as emotional labor**

**Affective delivery**

**Surface acting**

**Deep acting**

The practical implication is, first, about the duration of duty and the amount of tasks. When the duration of the duty of human contact is long enough to treat people, the employees might use affective delivery (an aspect of emotional labor) to moderate or repair the decreasing propensity of job satisfaction. Conversely, when the employees have to do many tasks and treat people in short/medium time, the employees might use surface acting to moderate or repair the decreasing propensity

Second, the result of this study may apply to the occupations classified by Hochschild [7] requiring a higher degree of emotional labor, which include flight attendant as well as health service workers, including physicians, nurses, therapists, dentists, dental hygienists, and any other customer-oriented workers, including

Third, empathy affects a wide range of work behavior such as teamwork and helps the employees keep hold their job satisfaction in the organizational changes. Finally, emotionally competent human service employees might harmoniously work with people in a specific environmental workplace, thus, contributing a long-

In the cross-sectional design, the use of only the self-evaluated responses of emotional labors may be considered the first limitations of this research. However,

from medium to low and the level of empathy as emotional labor is high.

*Summary of levels concerning empathy as emotional labor and other job-related variables.*

**56**

A suggestion for future research direction would be an investigation of empathy as emotional labor in the different organizations. Another future research direction would be exploring the optimal level of moderating or repairing effect by empathy as emotional labor. Though this research showed that empathy as emotional labor could moderate or repair the decreasing propensity of job satisfaction, it is uncertain the optimal level of moderation or repair.

In addition, the future research direction could be exploring how to improve the empathic competence in an organization. Finally, empathy as emotional labor may evoke a new stream of explanation for the effectiveness of human service employees in the organization.

#### **Author details**

Noriko Okabe Yokohama National University, Center for Economic Growth Strategy, Japan

\*Address all correspondence to: okabe-noriko-ts@ynu.jp

© 2018 The Author(s). Licensee IntechOpen. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/ by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

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**58**

pp. 3-52

*Empathy Study*

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1995;**48**(2):97-125

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Psychology and Behavior. 2000;**21**(2):123-129

Sociology. 2009;**35**:147-165

California Press; 1983

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**61**

Section 3

Psychopathology

and Empathy

Section 3

Psychopathology and Empathy

*Empathy Study*

1986;**51**(6):1173

1991;**17**(3):601-617

2002;**39**(1):110-119

Free Press; 1989

[37] Baron RM, Kenny DA. The moderator–mediator variable distinction in social psychological research: Conceptual, strategic, and statistical considerations. Journal of Personality and Social Psychology.

[38] Brotheridge CM, Lee RT. Development and validation of the emotional labour scale. Journal of Occupational and Organizational Psychology. 2003;**76**(3):365-379

[39] Williams LJ, Anderson SE. Job satisfaction and organizational commitment as predictors of

organizational citizenship and in-role behaviors. Journal of Management.

[40] Brown TJ, Mowen D, Donavan T, Licata JW. The customer orientation of service workers: Personality trait effects on self-and supervisor performance ratings. Journal of Marketing Research.

[41] Pines A, Aronson E. Career Burnout: Causes and Cures. New York:

[42] Streiner DL. Starting at the beginning: An introduction to coefficient alpha and internal consistency. Journal of Personality Assessment. 2003;**80**(1):99-103

**60**

**63**

**Chapter 4**

**Abstract**

*and Vanda Franco Simão*

Prevention of Deviant Pathways

"O Companheiro" Providing an

Alternative to the Prison System

*José de Almeida Brites, Américo Baptista, Catarina Abrantes* 

The association "O Companheiro" is a Portuguese social solidarity institution

which intends to provide an integrated response for the needs of inmates, ex-inmates, and their families. The Social School was established as part of the "O Companheiro," providing one possible alternative to the prison system. The Social School has two main aims: the prevention of deviant pathways and the rehabilitation of those who have entered into criminal activities, promoting their successful integration. Several programs were designed according to a life span perspective, which focuses on the personal development from conception to old age. A core assumption of this perspective is that maturity and development are not completed at any specific

moment but result from an ongoing adaptative continuous lifelong process.

**Keywords:** O Companheiro, social school, crime, rehabilitation, life span

The sparse investment in the prison system, reflected in the few psychologists and specialists working between walls, threatens the rehabilitative and reeducational role of imprisonment. Furthermore, the conventional approaches to criminology and the justice system currently underway, focused mainly on the punishment of deviant behavior, have proven to be unsatisfactory because they are associated with high recidivism rates in criminal behavior. The intervention programs developed in the Portuguese prisons do not cover most of the individuals, adding the fact that they lack a scientific validated evaluation [1]. They usually follow a cognitive behavioral theoretical basis, and the main goal is the behavior control, but they are

An alternative to this view could be the one proposed by positive psychology [4] adapted by criminologists as positive criminology [5]. Whereas the conventional approaches target mainly the elimination of deviant behaviors, this new approach focuses mainly on the development of a new positive lifestyle. The positive

**1. Introduction: the structure of Social School programs**

not responsive to offenders' individual skills and interests [2, 3].

Activities: Social School by

and Rehabilitation from Criminal

#### **Chapter 4**

## Prevention of Deviant Pathways and Rehabilitation from Criminal Activities: Social School by "O Companheiro" Providing an Alternative to the Prison System

*José de Almeida Brites, Américo Baptista, Catarina Abrantes and Vanda Franco Simão*

#### **Abstract**

The association "O Companheiro" is a Portuguese social solidarity institution which intends to provide an integrated response for the needs of inmates, ex-inmates, and their families. The Social School was established as part of the "O Companheiro," providing one possible alternative to the prison system. The Social School has two main aims: the prevention of deviant pathways and the rehabilitation of those who have entered into criminal activities, promoting their successful integration. Several programs were designed according to a life span perspective, which focuses on the personal development from conception to old age. A core assumption of this perspective is that maturity and development are not completed at any specific moment but result from an ongoing adaptative continuous lifelong process.

**Keywords:** O Companheiro, social school, crime, rehabilitation, life span

#### **1. Introduction: the structure of Social School programs**

The sparse investment in the prison system, reflected in the few psychologists and specialists working between walls, threatens the rehabilitative and reeducational role of imprisonment. Furthermore, the conventional approaches to criminology and the justice system currently underway, focused mainly on the punishment of deviant behavior, have proven to be unsatisfactory because they are associated with high recidivism rates in criminal behavior. The intervention programs developed in the Portuguese prisons do not cover most of the individuals, adding the fact that they lack a scientific validated evaluation [1]. They usually follow a cognitive behavioral theoretical basis, and the main goal is the behavior control, but they are not responsive to offenders' individual skills and interests [2, 3].

An alternative to this view could be the one proposed by positive psychology [4] adapted by criminologists as positive criminology [5]. Whereas the conventional approaches target mainly the elimination of deviant behaviors, this new approach focuses mainly on the development of a new positive lifestyle. The positive

psychology focuses on the healthy and adaptive functioning of the human being and values positive psychological traits and experiences such as optimism, satisfaction, well-being, happiness, gratitude, hope, resilience, and empathy. Therefore, positive criminology is based on the perspective that integration and positive life influences that help individuals develop personally and socially will lead to a reduced risk of criminal behavior and better recovery of offenders [6]. An example of related work is done by the Good Lives Approach to the rehabilitation of sex offenders [7, 8].

This new perspective encompasses the Social School, which is a project developed in the facilities of our institution "O Companheiro" and in some prisons. Traditionally, our institution works with ex-prisoners or inmates in a post-reclusion phase, providing various facilities (men's residence, canteen, clothing bank, legal support, and psychological support), but since the Social School was created, our work is not limited to rehabilitation, having an important role in prevention as well. The programs developed by the Social School can be an alternative to effective detention. There are many cases of individuals to whom the court proposes to attend the Social School in a pre-sentential phase as an alternative to prison. Others are released from prison before the end of the sentence (e.g., probation) because they agree to attend Social School programs. Finally, the family, especially the descendants, can integrate the Social School to prevent them from initiating a deviant pathway.

Several programs were developed targeting children and adolescents, the adult population, and the elderly. Research was conducted to establish their efficiency. The following programs were (and are) implemented, encompassing the life cycle; for children and adolescents—enjoying study, learning with sports, dating and the sexual life, and a reward program assisted by animals; for the adult population positive parenting, anger management, learning with sports, life without drugs, pleasant and healthier marital and sexual life, and a reward program assisted by animals; and for the elderly—the well-being and happiness program.

All the programs have a similar structure composed by a specific part, unique in each program, and a general part common to all programs. In the specific part, the skills taught are those that have been assessed as deficient in each age group. For instance, children with poor learning skills or school problems are referred to the enjoying study program, adolescents charged for downloading child pornography or sexual abuse are referred to the program dating and the sexual life. Adults are referred to the positive parenting program if they report difficulties dealing with their child's behavior or if they are charged for some form of child abuse. Finally, the elderly population is referred to the well-being and happiness program to improve both their cognitive functioning and their quality of life.

The general part has four modules: emotional literacy, empathy training, virtue and strength development, and promotion of well-being and happiness. In the emotional literacy module, clients are trained on how to accurately identify and understand the functions of their expressions, as well as having them regulated. Emotions are portrayed as psychological resources that are predominantly processed automatically generating varied behaviors and decisions [9]. In the emotional literacy component, the experience of the awareness of six basic emotions, happiness, surprise, anger, disgust, fear, and sadness is addressed [10]. The same procedure is applied for raising awareness of 10 positive emotions, joy, gratitude, serenity, interest, hope, pride, amusement, inspiration, awe, and love [11]. The second component, the teaching or the awareness of empathy will be described later on in this chapter. The third component involves the knowledge and the new application of character strengths and virtues. These are organized in six classes of core virtues and twenty-four-character strengths [12]. The fourth module is related

**65**

*Prevention of Deviant Pathways and Rehabilitation from Criminal Activities: Social School…*

to the promotion of well-being and happiness, namely changes in focus of attention from the negative to positive events and the promotion of pro-social activities [13]. This part, common to all programs, reflects our approach on both prevention and rehabilitation. It has two simultaneous aims: decreasing the risk factors for deviant pathways and eliminating the negative characteristics. Also, it aims to develop or improve the qualities that will be helpful regarding a successful return into society. Our program of interventions is influenced by the developments on positive psychology [4], positive clinical psychology [14], and positive criminology [5, 6]. A Positive psychology approach is taken because the "O Companheiro" association assumes that a person with a happy and meaningful life has a decreased need to resort to a deviant pathway or crime. Positive clinical psychology since our interventions aim to reduce a person's distress and the negative characteristics which led him/her to a deviant pathway. At the same time, they promote the well-being and a meaningful life. Finally, the interventions are used to assist both the prevention of entering deviant pathways and the rehabilitation and integration in society of individuals who have previously adopted deviant behaviors, as it is underlined by

In this sense, a person is not looked at as an individual who has a set of problems that need to be fixed and a set of risks that need to be managed, but as having quali-

In our programs, empathy training follows the emotional literacy. Empathy is conceptualized as having three components: motor, cognitive, and emotional. Adequate empathy skills in children are related to social competence and popularity amongst peers [15]. Empathy deficit disorder in children is considered a risk for committing crimes [16], and children and adolescents with psychopathic traits and conduct problems showed reduced affective responses to inflicting pain in others [17].

Early manifestations of empathy were observed in infants from 8 to 16 months in response to maternal and peer distress [18]. The more children become proficient and sophisticated, with the significant help of others and contextual factors, in understanding the emotions, desires, and intentions of each one, the better they can achieve their goals and improve proper social interactions with peers and adults. Pro-social and empathic tendencies emerge in childhood and continue to develop through adolescence. From 12 to 18 years, their presence was associated with a pro-social attitude and inversely, their absence was related to antisocial behaviors [19]. In a 23-year follow-up study, empathy assessed in adolescence, between 12 and 16 years, and when the participants were adults at 35 years, was a predictor of empathy, communication skills, social integration, relationship satisfaction, and conflicts in relationships [20]. A generalized lack of empathy is characteristic of adolescents who fulfill the category of conduct disorder with a

In adults, an adequate or high empathy facilitates social behavior, establishes priorities in social interactions, and underlies various forms of helping others or pro-social behavior. Also, it constitutes a motivation to care for the well-being of others [22]. The absence of empathy or low empathy is related to aggression tendencies and the capacity to ignore or inflict suffering on others [23–25]. Empathic adults playing economic games showed more pro-social behaviors, higher levels of cooperation, and more generosity towards their opponents and were able to treat them more fairly [26, 27]. Incarcerated individuals with high levels of psychopathy showed a stronger affective response when imagining inflicting pain in themselves,

*DOI: http://dx.doi.org/10.5772/intechopen.82163*

positive criminology.

ties, strengths, or potentials yet to be developed.

specifier of limited pro-social emotions [21].

**2. Empathy across the life span**

*Prevention of Deviant Pathways and Rehabilitation from Criminal Activities: Social School… DOI: http://dx.doi.org/10.5772/intechopen.82163*

to the promotion of well-being and happiness, namely changes in focus of attention from the negative to positive events and the promotion of pro-social activities [13]. This part, common to all programs, reflects our approach on both prevention and rehabilitation. It has two simultaneous aims: decreasing the risk factors for deviant pathways and eliminating the negative characteristics. Also, it aims to develop or improve the qualities that will be helpful regarding a successful return into society.

Our program of interventions is influenced by the developments on positive psychology [4], positive clinical psychology [14], and positive criminology [5, 6]. A Positive psychology approach is taken because the "O Companheiro" association assumes that a person with a happy and meaningful life has a decreased need to resort to a deviant pathway or crime. Positive clinical psychology since our interventions aim to reduce a person's distress and the negative characteristics which led him/her to a deviant pathway. At the same time, they promote the well-being and a meaningful life. Finally, the interventions are used to assist both the prevention of entering deviant pathways and the rehabilitation and integration in society of individuals who have previously adopted deviant behaviors, as it is underlined by positive criminology.

In this sense, a person is not looked at as an individual who has a set of problems that need to be fixed and a set of risks that need to be managed, but as having qualities, strengths, or potentials yet to be developed.

#### **2. Empathy across the life span**

*Empathy Study*

offenders [7, 8].

deviant pathway.

psychology focuses on the healthy and adaptive functioning of the human being and values positive psychological traits and experiences such as optimism, satisfaction, well-being, happiness, gratitude, hope, resilience, and empathy. Therefore, positive criminology is based on the perspective that integration and positive life influences that help individuals develop personally and socially will lead to a reduced risk of criminal behavior and better recovery of offenders [6]. An example of related work is done by the Good Lives Approach to the rehabilitation of sex

This new perspective encompasses the Social School, which is a project developed in the facilities of our institution "O Companheiro" and in some prisons. Traditionally, our institution works with ex-prisoners or inmates in a post-reclusion phase, providing various facilities (men's residence, canteen, clothing bank, legal support, and psychological support), but since the Social School was created, our work is not limited to rehabilitation, having an important role in prevention as well. The programs developed by the Social School can be an alternative to effective detention. There are many cases of individuals to whom the court proposes to attend the Social School in a pre-sentential phase as an alternative to prison. Others are released from prison before the end of the sentence (e.g., probation) because they agree to attend Social School programs. Finally, the family, especially the descendants, can integrate the Social School to prevent them from initiating a

Several programs were developed targeting children and adolescents, the adult population, and the elderly. Research was conducted to establish their efficiency. The following programs were (and are) implemented, encompassing the life cycle; for children and adolescents—enjoying study, learning with sports, dating and the sexual life, and a reward program assisted by animals; for the adult population positive parenting, anger management, learning with sports, life without drugs, pleasant and healthier marital and sexual life, and a reward program assisted by

All the programs have a similar structure composed by a specific part, unique in each program, and a general part common to all programs. In the specific part, the skills taught are those that have been assessed as deficient in each age group. For instance, children with poor learning skills or school problems are referred to the enjoying study program, adolescents charged for downloading child pornography or sexual abuse are referred to the program dating and the sexual life. Adults are referred to the positive parenting program if they report difficulties dealing with their child's behavior or if they are charged for some form of child abuse. Finally, the elderly population is referred to the well-being and happiness program to

The general part has four modules: emotional literacy, empathy training, virtue and strength development, and promotion of well-being and happiness. In the emotional literacy module, clients are trained on how to accurately identify and understand the functions of their expressions, as well as having them regulated. Emotions are portrayed as psychological resources that are predominantly processed automatically generating varied behaviors and decisions [9]. In the emotional literacy component, the experience of the awareness of six basic emotions, happiness, surprise, anger, disgust, fear, and sadness is addressed [10]. The same procedure is applied for raising awareness of 10 positive emotions, joy, gratitude, serenity, interest, hope, pride, amusement, inspiration, awe, and love [11]. The second component, the teaching or the awareness of empathy will be described later on in this chapter. The third component involves the knowledge and the new application of character strengths and virtues. These are organized in six classes of core virtues and twenty-four-character strengths [12]. The fourth module is related

animals; and for the elderly—the well-being and happiness program.

improve both their cognitive functioning and their quality of life.

**64**

In our programs, empathy training follows the emotional literacy. Empathy is conceptualized as having three components: motor, cognitive, and emotional. Adequate empathy skills in children are related to social competence and popularity amongst peers [15]. Empathy deficit disorder in children is considered a risk for committing crimes [16], and children and adolescents with psychopathic traits and conduct problems showed reduced affective responses to inflicting pain in others [17].

Early manifestations of empathy were observed in infants from 8 to 16 months in response to maternal and peer distress [18]. The more children become proficient and sophisticated, with the significant help of others and contextual factors, in understanding the emotions, desires, and intentions of each one, the better they can achieve their goals and improve proper social interactions with peers and adults.

Pro-social and empathic tendencies emerge in childhood and continue to develop through adolescence. From 12 to 18 years, their presence was associated with a pro-social attitude and inversely, their absence was related to antisocial behaviors [19]. In a 23-year follow-up study, empathy assessed in adolescence, between 12 and 16 years, and when the participants were adults at 35 years, was a predictor of empathy, communication skills, social integration, relationship satisfaction, and conflicts in relationships [20]. A generalized lack of empathy is characteristic of adolescents who fulfill the category of conduct disorder with a specifier of limited pro-social emotions [21].

In adults, an adequate or high empathy facilitates social behavior, establishes priorities in social interactions, and underlies various forms of helping others or pro-social behavior. Also, it constitutes a motivation to care for the well-being of others [22]. The absence of empathy or low empathy is related to aggression tendencies and the capacity to ignore or inflict suffering on others [23–25]. Empathic adults playing economic games showed more pro-social behaviors, higher levels of cooperation, and more generosity towards their opponents and were able to treat them more fairly [26, 27]. Incarcerated individuals with high levels of psychopathy showed a stronger affective response when imagining inflicting pain in themselves, but a smaller response when they imagined inflicting pain on others [28]. Lack of empathy is associated with narcissistic personality disorder [29] and antisocial personality disorder [30].

Empathy continuously changes through the adult years. In the elderly, empathy seems to improve, even though the nature of these changes is a matter of research. In the elderly, decreases in cognitive empathy were found whereas affective empathy increased. The age changes in affective empathy were related with the emotional valence of the stimuli used. Older participants showed more empathic concern and less personal distress in situations that presented negative emotions, whereas for situations that presented positive emotions, older participants demonstrated more empathic concern and personal distress [31]. This dissociation between cognitive aspects of others' understanding and affective aspects, in which the first showed a decrease and the second presents no change or increases with age, is confirmed in other independent studies [32, 33]; the following are some conflicting results [34, 35].

#### **2.1 Empathy training**

The empathy training in our programs is based on the three components of empathy [23, 25], the empathy model developed by Marshall et al. [36] and Marshall and Marshall [37] and the life span perspective applied to empathy [34].

Empathy encompasses a variety of processes that can be considered to be part of three categories: motor, cognitive, and emotional. Motor empathy is described by Hatfield et al. [38] as a primitive emotional contagion or perception-action. The model of empathy advanced by Preston and De Waal [39] projects the tendency to mimic or synchronize the vocalizations, the facial expressions, the postures, and movements with another person. An observer automatically imitates the facial, postural, or vocal expressions of another person. This observation activates the observer's somatic, autonomic, and motor responses, which rely on the discovery of mirror neurons, which show the same activity during the execution and the observation of an action. Rizzolatti et al. [40] demonstrated that the same neurons were activated when a monkey grasped food or when they watched an experimenter grasp food.

In a simple way, the perception of another individual's actions automatically activates similar somatic, autonomic, or motor responses in an attentive observer. Perception and action share some underlying mechanisms of representation, and the perceptual information automatically prepares for action without the need for any intervening cognitive processes. For example, if someone displays a body posture or a facial expression indicating pain, suffering, sadness, anger, or joy, the nervous structures in an observer's brain that represents these movements or postures are automatically activated, and a corresponding part of the behavior is involuntarily emitted, an overt response. This frequently happens in spectators of movie theaters or in sports arenas. For instance, videos were shown resulting in people imitating what they saw, even though they were unaware of it, for example, videos showing people laughing, which automatically induced the observers to laugh. One of the main purposes of this first step is to make people aware of this process.

Cognitive empathy is the second component of empathy training. It encompasses the capacity to take others' perspectives, allowing one to make inferences about their mental or emotional states and understanding their viewpoints or the internal states. It concedes too, the ability to imagine others' thoughts and feelings without confusing each self. Additionally, it includes also the capacity to consciously understand others' thoughts, intentions, emotions, and beliefs and predict their behavior. This is known as the theory of the mind [23, 25, 41]. These capacities allow us to adopt another person's point of view, enabling the possibility of making inferences regarding their cognitive mental states as well as affective states. Such

**67**

**Table 1.** *Program results.*

*Prevention of Deviant Pathways and Rehabilitation from Criminal Activities: Social School…*

capacities are improved during cognitive development [42], and they involve higher cognitive functions that allow perspective taking, self-regulation, and mind percep-

Empathy's final training component is focused on emotional empathy, the capacity to have feelings that reflect what others feel and the ability to share the emotional experiences of another person. We feel joy when our friends succeed; our own emotions are affected by the emotions of others. Consider, for instance, your emotional reaction during a horror or thrilling movie. The person's feelings evoked by the feelings of another person are considered the essence of empathy [45]. Emotional empathy has at least two components: the affective sharing, which reflects the capacity to share or become affectively activated by the emotional states of other persons, and the empathic concern, which reflects the motivation to care for another's welfare. Affective empathy was found to be the main predictor of

The empathy training for each of these three components follows the four steps described by Marshall et al. [36] and Marshall and Marshall [37], both for positive and negative events. Several scenarios were used, with the help of videos and written descriptions. The first scenario is to recognize others' cognitive or emotional state. The second is to be able to see things from another's perspective. The third is to be aware of his/her behavior, thoughts, and emotions, in the case of positive events of his/her joy and in the case of negative events of his/her distress and compassion. Finally, the fourth is taking steps to share the joy of success in positive events, and

altruistic behavior in an experimental game, the dictator game [46].

ameliorating others' distress and suffering, in the case of negative events.

Thirty-five children and adolescents, mean age 12.29 (SD = 2.79), 76 adults, mean age 36.42 (SD = 10.46), and 6 elderly, mean age 65.00 (SD = 3.09), were included in our programs. The dropout rate or program noncompleters were 22.9%, N = 8, for children and adolescents, 22.4%, N = 17, for adults, and 50%, N = 3, for

For those who completed the program, the results were assessed by their therapists according to the following criteria: first, those who have worsened their status during the program; second, those who presented no changes; third, those who improved slightly; fourth, those who improved moderately; fifth, those who improved a lot; and finally, those who attained an excellent status and exceeded the expectations for improvement. For children and adolescent programs N = 1, 2.9% was classified as having deteriorated, N = 2, 5.7% as having no changes during the program, N = 10, 28.6% as improving slightly, N = 12, 34.3% as improving moderately, and N = 2, 5.7% as improving a lot. For adults who entered the programs N = 1, 1.3% were assessed as having deteriorated, N = 10, 13.2% presented no changes, N = 17, 22.4% improved slightly, N = 27, 35.5% improved moderately,

Deterioration during the program 2.9 1.3 33.3 No changes during the program 5.7 13.2 — Improved slightly 28.6 22.4 33.3 Improved moderately 34.3 35.5 33.3 Improved a lot 5.7 5.3 —

**Children and adolescents (%) Adults (%) Elderly (%)**

*DOI: http://dx.doi.org/10.5772/intechopen.82163*

**2.2 Results of the Social School programs**

tion [43, 44].

the elderly.

*Prevention of Deviant Pathways and Rehabilitation from Criminal Activities: Social School… DOI: http://dx.doi.org/10.5772/intechopen.82163*

capacities are improved during cognitive development [42], and they involve higher cognitive functions that allow perspective taking, self-regulation, and mind perception [43, 44].

Empathy's final training component is focused on emotional empathy, the capacity to have feelings that reflect what others feel and the ability to share the emotional experiences of another person. We feel joy when our friends succeed; our own emotions are affected by the emotions of others. Consider, for instance, your emotional reaction during a horror or thrilling movie. The person's feelings evoked by the feelings of another person are considered the essence of empathy [45].

Emotional empathy has at least two components: the affective sharing, which reflects the capacity to share or become affectively activated by the emotional states of other persons, and the empathic concern, which reflects the motivation to care for another's welfare. Affective empathy was found to be the main predictor of altruistic behavior in an experimental game, the dictator game [46].

The empathy training for each of these three components follows the four steps described by Marshall et al. [36] and Marshall and Marshall [37], both for positive and negative events. Several scenarios were used, with the help of videos and written descriptions. The first scenario is to recognize others' cognitive or emotional state. The second is to be able to see things from another's perspective. The third is to be aware of his/her behavior, thoughts, and emotions, in the case of positive events of his/her joy and in the case of negative events of his/her distress and compassion. Finally, the fourth is taking steps to share the joy of success in positive events, and ameliorating others' distress and suffering, in the case of negative events.

#### **2.2 Results of the Social School programs**

Thirty-five children and adolescents, mean age 12.29 (SD = 2.79), 76 adults, mean age 36.42 (SD = 10.46), and 6 elderly, mean age 65.00 (SD = 3.09), were included in our programs. The dropout rate or program noncompleters were 22.9%, N = 8, for children and adolescents, 22.4%, N = 17, for adults, and 50%, N = 3, for the elderly.

For those who completed the program, the results were assessed by their therapists according to the following criteria: first, those who have worsened their status during the program; second, those who presented no changes; third, those who improved slightly; fourth, those who improved moderately; fifth, those who improved a lot; and finally, those who attained an excellent status and exceeded the expectations for improvement. For children and adolescent programs N = 1, 2.9% was classified as having deteriorated, N = 2, 5.7% as having no changes during the program, N = 10, 28.6% as improving slightly, N = 12, 34.3% as improving moderately, and N = 2, 5.7% as improving a lot. For adults who entered the programs N = 1, 1.3% were assessed as having deteriorated, N = 10, 13.2% presented no changes, N = 17, 22.4% improved slightly, N = 27, 35.5% improved moderately,


**Table 1.** *Program results.*

*Empathy Study*

personality disorder [30].

**2.1 Empathy training**

but a smaller response when they imagined inflicting pain on others [28]. Lack of empathy is associated with narcissistic personality disorder [29] and antisocial

The empathy training in our programs is based on the three components of empathy [23, 25], the empathy model developed by Marshall et al. [36] and Marshall and Marshall [37] and the life span perspective applied to empathy [34]. Empathy encompasses a variety of processes that can be considered to be part of three categories: motor, cognitive, and emotional. Motor empathy is described by Hatfield et al. [38] as a primitive emotional contagion or perception-action. The model of empathy advanced by Preston and De Waal [39] projects the tendency to mimic or synchronize the vocalizations, the facial expressions, the postures, and movements with another person. An observer automatically imitates the facial, postural, or vocal expressions of another person. This observation activates the observer's somatic, autonomic, and motor responses, which rely on the discovery of mirror neurons, which show the same activity during the execution and the observation of an action. Rizzolatti et al. [40] demonstrated that the same neurons were activated when a monkey grasped food or when they watched an experimenter grasp food. In a simple way, the perception of another individual's actions automatically activates similar somatic, autonomic, or motor responses in an attentive observer. Perception and action share some underlying mechanisms of representation, and the perceptual information automatically prepares for action without the need for any intervening cognitive processes. For example, if someone displays a body posture or a facial expression indicating pain, suffering, sadness, anger, or joy, the nervous structures in an observer's brain that represents these movements or postures are automatically activated, and a corresponding part of the behavior is involuntarily emitted, an overt response. This frequently happens in spectators of movie theaters or in sports arenas. For instance, videos were shown resulting in people imitating what they saw, even though they were unaware of it, for example, videos showing people laughing, which automatically induced the observers to laugh. One of the

main purposes of this first step is to make people aware of this process.

Cognitive empathy is the second component of empathy training. It encompasses the capacity to take others' perspectives, allowing one to make inferences about their mental or emotional states and understanding their viewpoints or the internal states. It concedes too, the ability to imagine others' thoughts and feelings without confusing each self. Additionally, it includes also the capacity to consciously understand others' thoughts, intentions, emotions, and beliefs and predict their behavior. This is known as the theory of the mind [23, 25, 41]. These capacities allow us to adopt another person's point of view, enabling the possibility of making inferences regarding their cognitive mental states as well as affective states. Such

Empathy continuously changes through the adult years. In the elderly, empathy seems to improve, even though the nature of these changes is a matter of research. In the elderly, decreases in cognitive empathy were found whereas affective empathy increased. The age changes in affective empathy were related with the emotional valence of the stimuli used. Older participants showed more empathic concern and less personal distress in situations that presented negative emotions, whereas for situations that presented positive emotions, older participants demonstrated more empathic concern and personal distress [31]. This dissociation between cognitive aspects of others' understanding and affective aspects, in which the first showed a decrease and the second presents no change or increases with age, is confirmed in other independent studies [32, 33]; the following are some conflicting results [34, 35].

**66**

and N = 4, 5.3% improved a lot. For the elderly we have finished one group with 3 participants classified as having deteriorated, N = 1, as improving slightly, N = 1, and as improving moderately, N = 1 (**Table 1**).

#### **3. Conclusions**

With exception of the elderly, in which we have only the results of one small group, the results showed that our interventions are effective for children, adolescents and adults. The ending status of the participants is attributed to the effects of the whole program, in which the module for empathy training is only one component. It is important, though, to reflect about the significative number of dropouts. We believe that one possible reason might be the fact that many participants are volunteers without court injunctions and free to leave the programs without any legal consequences. This is even more salient with the elderly population, some of them with mobility constraints that prevented them from continuing to go to the institution.

Due to the nature of our social solidarity institution and for ethical reasons, a control group was not included. A better understanding of our programs, set to improve efficacy and the nature of our results, could be obtained by comparing other participants in different institutions using our programs. Furthermore, the efficacy assessment of the several components of our programs (the specific part and the general part composed by the emotional literacy, the empathy, the strengths and virtues and the well-being and happiness) should be conducted.

In relation to the empathy training, improvements in empathy should not be considered equivalent to improvements in morality or pro-social behavior [47], especially in people who portrayed antisocial behaviors. Our results showed improvements in trained skills, but our goal is to prevent entry into deviant pathways and/or reduce criminal behavior recidivism rates. Larger samples and extended follow-up periods are needed in order to answer these fundamental questions.

#### **Acknowledgements**

We have written this chapter hoping that more specialists will be able to recognize our approach as a good alternative to the punitive system implemented in the Portuguese prisons. The Social School is a result of 31 years of working with inmates, ex-mates, and their families. Our first acknowledgment is to them and a very special acknowledgment to the colleagues of "O Companheiro" and all the participants who were so supportive and cooperative. Their graciousness, enthusiasm, and competence truly overwhelmed us.

#### **Conflict of interest**

The authors declare no conflicts of interest with respect to the authorship and/or publication of this chapter.

**69**

**Author details**

Portugal

José de Almeida Brites1

and Vanda Franco Simão2

provided the original work is properly cited.

2 "O Companheiro", Lisbon, Portugal

© 2019 The Author(s). Licensee IntechOpen. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/ by/3.0), which permits unrestricted use, distribution, and reproduction in any medium,

, Catarina Abrantes2

\*, Américo Baptista1

\*Address all correspondence to: j.brites@companheiro.org

1 "O Companheiro", School of Psychology and Life Science, ULHT, Lisbon,

*Prevention of Deviant Pathways and Rehabilitation from Criminal Activities: Social School…*

*DOI: http://dx.doi.org/10.5772/intechopen.82163*

*Prevention of Deviant Pathways and Rehabilitation from Criminal Activities: Social School… DOI: http://dx.doi.org/10.5772/intechopen.82163*

### **Author details**

*Empathy Study*

**3. Conclusions**

institution.

questions.

**Acknowledgements**

**Conflict of interest**

publication of this chapter.

asm, and competence truly overwhelmed us.

and N = 4, 5.3% improved a lot. For the elderly we have finished one group with 3 participants classified as having deteriorated, N = 1, as improving slightly, N = 1,

With exception of the elderly, in which we have only the results of one small group, the results showed that our interventions are effective for children, adolescents and adults. The ending status of the participants is attributed to the effects of the whole program, in which the module for empathy training is only one component. It is important, though, to reflect about the significative number of dropouts. We believe that one possible reason might be the fact that many participants are volunteers without court injunctions and free to leave the programs without any legal consequences. This is even more salient with the elderly population, some of them with mobility constraints that prevented them from continuing to go to the

Due to the nature of our social solidarity institution and for ethical reasons, a control group was not included. A better understanding of our programs, set to improve efficacy and the nature of our results, could be obtained by comparing other participants in different institutions using our programs. Furthermore, the efficacy assessment of the several components of our programs (the specific part and the general part composed by the emotional literacy, the empathy, the strengths

In relation to the empathy training, improvements in empathy should not be considered equivalent to improvements in morality or pro-social behavior [47], especially in people who portrayed antisocial behaviors. Our results showed improvements in trained skills, but our goal is to prevent entry into deviant pathways and/or reduce criminal behavior recidivism rates. Larger samples and extended follow-up periods are needed in order to answer these fundamental

We have written this chapter hoping that more specialists will be able to recognize our approach as a good alternative to the punitive system implemented in the Portuguese prisons. The Social School is a result of 31 years of working with inmates, ex-mates, and their families. Our first acknowledgment is to them and a very special acknowledgment to the colleagues of "O Companheiro" and all the participants who were so supportive and cooperative. Their graciousness, enthusi-

The authors declare no conflicts of interest with respect to the authorship and/or

and virtues and the well-being and happiness) should be conducted.

and as improving moderately, N = 1 (**Table 1**).

**68**

José de Almeida Brites1 \*, Américo Baptista1 , Catarina Abrantes2 and Vanda Franco Simão2

1 "O Companheiro", School of Psychology and Life Science, ULHT, Lisbon, Portugal

2 "O Companheiro", Lisbon, Portugal

\*Address all correspondence to: j.brites@companheiro.org

© 2019 The Author(s). Licensee IntechOpen. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/ by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

#### **References**

[1] Gonçalves RA. Delinquência, crime e adaptação à prisão. Coimbra: Quarteto editora; 2008

[2] Baltes PB, Staudinger UM, Lindenberger U. Lifespan psychology: Theory and application to intellectual functioning. Annual Review of Psychology. 1999;**50**:471-507. DOI: 10.1146/annurev.psych.50.1.471

[3] Heard C. Alternatives to Imprisonment in Europe: A Handbook of Good Practice. Rome: Antigone Edizioni; 2016

[4] Seligman MEP, Csikszentmihalyi M. Positive psychology. An introduction. American Psychologist. 2000;**55**:5-14. DOI: 10.1037/0003-066X.55.1.5

[5] Ronel N, Segev D. Positive Criminology. New York: Routledge; 2015

[6] Ronel N, Elisha E. A different perspective: Introducing positive criminology. International Journal of Offender Therapy and Comparative Criminology. 2011;**55**:305-325. DOI: 10.1177/0306624x093577

[7] Fortune C, Ward T, Mann R. Good Lives and the Rehabilitation of Sex Offenders. Positive Psychology in Practice: Promoting Human Flourishing in Work, Health, Education, and Everyday Life. 2015;**37**. https://doi. org/10.1002/9781118996874.ch37

[8] Ward T. Good lives and the rehabilitation of offenders: Promises and problems. Aggression and Violent Behavior. 2002;**7**:513-528. DOI: 10.1016/ S1359-1789(01)00076-3

[9] Ford BQ, Gross JJ. Emotion regulation: Why beliefs matter. Canadian Psychology. 2018;**59**:1-14. DOI: 10.1037/cap0000142

[10] Ekman P, Friesen WV. Unmasking the Face: A Guide to Recognizing Emotions from Facial Clues. Englewood Cliffs, NJ: Prentice-Hall; 1975

[11] Fredrickson B. Groundbreaking Research Reveals How to Embrace the Hidden Strength of Positive Emotions, Overcome Negativity, and Thrive. New York: Crown; 2009

[12] Peterson C, Seligman MEP. Character Strengths and Virtues: A Handbook and Classification. Oxford: Oxford University Press; 2004

[13] Aknin LB, Barrington-Leigh CP, Dunn EW, Helliwell JF, Burns J, Biswas-Diener R, et al. Prosocial spending and well-being: Cross-cultural evidence for a psychological universal. Journal of Personality and Social Psychology. 2013;**104**:635-652. DOI: 10.1037/a0031578

[14] Wood A, Tarrier N. Positive clinical psychology: A new vision and strategy for integrated research and practice. Clinical Psychology Review. 2010;**30**:819-829. DOI: 10.1016/j. cpr.2010.06.003

[15] Warden D, Mackinnon S. Prosocial children, bullies and victims: An investigation of their sociometric status, empathy and social problem-solving strategies. British Journal of Developmental Psychology. 2003;**21**:367-385. DOI: 10.1348/026151003322277757

[16] Van Zonneveld L, Platje E, De Sonneville L, Van Goozen S, Swaab H. Affective empathy, cognitive empathy and social attention in children at high risk of criminal behaviour. Journal of Child Psychology and Psychiatry. 2017;**58**:913-921. DOI: 10.1111/jcpp.12724

[17] Cheng Y, Hung A-Y, Decety J. Dissociation between affective sharing and emotion understanding in juvenile

**71**

*Prevention of Deviant Pathways and Rehabilitation from Criminal Activities: Social School…*

Psychopathology. Washington, DC: American Psychological Association;

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[26] Barraza JA, Zak PJ. Empathy toward strangers triggers oxytocin release and subsequent generosity. Annals of the New York Academy of Sciences. 2009;**1167**:182-189. DOI: 10.1111/j.1749-6632.2009.04504.x

[27] Singer T, Steinbeis N. Differential roles of fairness- and compassionbased motivations for cooperation, defection, and punishment. Annals of the New York Academy of Sciences. 2009;**1167**:41-50. DOI: 10.1111/j.1749-6632.2009.04733.x

[28] Decety J, Chen C, Harenski CL, Kiehl KA. An fMRI study of affective perspective taking in individuals with psychopathy. Imagining another in pain does not evoke empathy. Frontiers in Human Neuroscience. 2013;**7**:489. DOI:

[29] Baskin-Sommers A, Krusemark E, Ronningstam E. Empathy in narcissistic personality disorder: From clinical and empirical perspectives. Personality Disorders. 2014;**5**:323-333. DOI: 10.1037/

[30] Goldstein RB, Grant BF, Huang B, Smith SM, Stinson FS, Dawson DA, et al. Lack of remorse in antisocial personality disorder: Sociodemographic correlates, symptomatic presentation, and comorbidity with Axis I and Axis II disorders in the National Epidemiologic

Survey on Alcohol and Related

2006;**47**:289-297. DOI: 10.1016/j.

comppsych.2005.11.002

Conditions. Comprehensive Psychiatry.

10.3389/fnhum.2013.00489

per0000061

Evidence from the study of psychopathy and other psychiatric disorders. In: Decety J, Ickes W, editors. The Social Neuroscience of Empathy. Cambridge, MA: MIT Press; 2009. pp. 139-152

2010. pp. 97-114

*DOI: http://dx.doi.org/10.5772/intechopen.82163*

Psychopathology. 2012;**24**:623-636. DOI:

[18] Roth-Hanania R, Davidov M, Zahn-Waxler C. Empathy development from 8 to 16 months: Early signs of concern for others. Infant Behavior & Development.

[19] Thompson KL, Gullone E. Prosocial and antisocial behaviors in adolescents: An investigation into associations with attachment and empathy. Anthrozoös. 2008;**21**:123-137. DOI:

psychopaths. Development and

2011;**34**:447-458. DOI: 10.1016/j.

10.2752/175303708X305774

[20] Allemand M, Steiger AE, Fend HA. Empathy development in adolescence predicts social competencies in adulthood. Journal of Personality. 2015;**83**:229-241. DOI:

[21] Eisenbarth H, Demetriou CA, Kyranides MN, Fanti KA. Stability subtypes of callous-unemotional traits and conduct disorder symptoms and their correlates. Journal of Youth and Adolescence. 2016;**45**:1889-1901. DOI:

10.1007/s10964-016-0520-4

[22] Telle NT, Pfister HR. Positive empathy and prosocial behavior: A neglected link. Emotion Review. 2016;**8**:154-163. DOI: 10.1177/1754073915586817

[23] Blair RJR. Responding to the emotions of others: Dissociating forms of empathy through the study of typical and psychiatric populations. Consciousness and Cognition. 2005;**14**:698-718. DOI: 10.1016/j.

[24] Blair RJR. Empathy, moral development, and aggression: A cognitive neuroscience perspective. In: Arsenio WF, Lemerise EA, editors. Emotions, Aggression, and Morality in Children: Bridging Development and

concog.2005.06.004

infbeh.2011.04.007

10.1111/jopy.12098

10.1017/S095457941200020X

*Prevention of Deviant Pathways and Rehabilitation from Criminal Activities: Social School… DOI: http://dx.doi.org/10.5772/intechopen.82163*

psychopaths. Development and Psychopathology. 2012;**24**:623-636. DOI: 10.1017/S095457941200020X

[18] Roth-Hanania R, Davidov M, Zahn-Waxler C. Empathy development from 8 to 16 months: Early signs of concern for others. Infant Behavior & Development. 2011;**34**:447-458. DOI: 10.1016/j. infbeh.2011.04.007

[19] Thompson KL, Gullone E. Prosocial and antisocial behaviors in adolescents: An investigation into associations with attachment and empathy. Anthrozoös. 2008;**21**:123-137. DOI: 10.2752/175303708X305774

[20] Allemand M, Steiger AE, Fend HA. Empathy development in adolescence predicts social competencies in adulthood. Journal of Personality. 2015;**83**:229-241. DOI: 10.1111/jopy.12098

[21] Eisenbarth H, Demetriou CA, Kyranides MN, Fanti KA. Stability subtypes of callous-unemotional traits and conduct disorder symptoms and their correlates. Journal of Youth and Adolescence. 2016;**45**:1889-1901. DOI: 10.1007/s10964-016-0520-4

[22] Telle NT, Pfister HR. Positive empathy and prosocial behavior: A neglected link. Emotion Review. 2016;**8**:154-163. DOI: 10.1177/1754073915586817

[23] Blair RJR. Responding to the emotions of others: Dissociating forms of empathy through the study of typical and psychiatric populations. Consciousness and Cognition. 2005;**14**:698-718. DOI: 10.1016/j. concog.2005.06.004

[24] Blair RJR. Empathy, moral development, and aggression: A cognitive neuroscience perspective. In: Arsenio WF, Lemerise EA, editors. Emotions, Aggression, and Morality in Children: Bridging Development and

Psychopathology. Washington, DC: American Psychological Association; 2010. pp. 97-114

[25] Blair RJR, Blair KS. Empathy, morality, and social convention: Evidence from the study of psychopathy and other psychiatric disorders. In: Decety J, Ickes W, editors. The Social Neuroscience of Empathy. Cambridge, MA: MIT Press; 2009. pp. 139-152

[26] Barraza JA, Zak PJ. Empathy toward strangers triggers oxytocin release and subsequent generosity. Annals of the New York Academy of Sciences. 2009;**1167**:182-189. DOI: 10.1111/j.1749-6632.2009.04504.x

[27] Singer T, Steinbeis N. Differential roles of fairness- and compassionbased motivations for cooperation, defection, and punishment. Annals of the New York Academy of Sciences. 2009;**1167**:41-50. DOI: 10.1111/j.1749-6632.2009.04733.x

[28] Decety J, Chen C, Harenski CL, Kiehl KA. An fMRI study of affective perspective taking in individuals with psychopathy. Imagining another in pain does not evoke empathy. Frontiers in Human Neuroscience. 2013;**7**:489. DOI: 10.3389/fnhum.2013.00489

[29] Baskin-Sommers A, Krusemark E, Ronningstam E. Empathy in narcissistic personality disorder: From clinical and empirical perspectives. Personality Disorders. 2014;**5**:323-333. DOI: 10.1037/ per0000061

[30] Goldstein RB, Grant BF, Huang B, Smith SM, Stinson FS, Dawson DA, et al. Lack of remorse in antisocial personality disorder: Sociodemographic correlates, symptomatic presentation, and comorbidity with Axis I and Axis II disorders in the National Epidemiologic Survey on Alcohol and Related Conditions. Comprehensive Psychiatry. 2006;**47**:289-297. DOI: 10.1016/j. comppsych.2005.11.002

**70**

*Empathy Study*

**References**

editora; 2008

Edizioni; 2016

2015

[1] Gonçalves RA. Delinquência, crime e adaptação à prisão. Coimbra: Quarteto [10] Ekman P, Friesen WV. Unmasking the Face: A Guide to Recognizing Emotions from Facial Clues. Englewood

[11] Fredrickson B. Groundbreaking Research Reveals How to Embrace the Hidden Strength of Positive Emotions, Overcome Negativity, and Thrive.

MEP. Character Strengths and Virtues: A Handbook and Classification. Oxford:

[13] Aknin LB, Barrington-Leigh CP, Dunn EW, Helliwell JF, Burns J, Biswas-Diener R, et al. Prosocial spending and well-being: Cross-cultural evidence for a psychological universal. Journal of Personality and Social Psychology. 2013;**104**:635-652. DOI: 10.1037/a0031578

[14] Wood A, Tarrier N. Positive clinical psychology: A new vision and strategy for integrated research and practice. Clinical Psychology Review. 2010;**30**:819-829. DOI: 10.1016/j.

[15] Warden D, Mackinnon S. Prosocial children, bullies and victims: An investigation of their sociometric status, empathy and social problem-solving strategies. British Journal of Developmental Psychology. 2003;**21**:367-385. DOI: 10.1348/026151003322277757

[16] Van Zonneveld L, Platje E, De Sonneville L, Van Goozen S, Swaab H. Affective empathy, cognitive empathy and social attention in children at high risk of criminal behaviour. Journal of Child Psychology and Psychiatry. 2017;**58**:913-921. DOI: 10.1111/jcpp.12724

[17] Cheng Y, Hung A-Y, Decety J. Dissociation between affective sharing and emotion understanding in juvenile

cpr.2010.06.003

Cliffs, NJ: Prentice-Hall; 1975

New York: Crown; 2009

[12] Peterson C, Seligman

Oxford University Press; 2004

Lindenberger U. Lifespan psychology: Theory and application to intellectual functioning. Annual Review of Psychology. 1999;**50**:471-507. DOI: 10.1146/annurev.psych.50.1.471

Imprisonment in Europe: A Handbook of Good Practice. Rome: Antigone

[4] Seligman MEP, Csikszentmihalyi

Psychologist. 2000;**55**:5-14. DOI:

[2] Baltes PB, Staudinger UM,

[3] Heard C. Alternatives to

M. Positive psychology. An introduction. American

10.1037/0003-066X.55.1.5

10.1177/0306624x093577

[5] Ronel N, Segev D. Positive Criminology. New York: Routledge;

[6] Ronel N, Elisha E. A different perspective: Introducing positive criminology. International Journal of Offender Therapy and Comparative Criminology. 2011;**55**:305-325. DOI:

[7] Fortune C, Ward T, Mann R. Good Lives and the Rehabilitation of Sex Offenders. Positive Psychology in Practice: Promoting Human Flourishing

in Work, Health, Education, and Everyday Life. 2015;**37**. https://doi. org/10.1002/9781118996874.ch37

[8] Ward T. Good lives and the rehabilitation of offenders: Promises and problems. Aggression and Violent Behavior. 2002;**7**:513-528. DOI: 10.1016/

[9] Ford BQ, Gross JJ. Emotion regulation: Why beliefs matter. Canadian Psychology. 2018;**59**:1-14.

S1359-1789(01)00076-3

DOI: 10.1037/cap0000142

[31] Sun B, Luo Z, Zhang W, Li W, Li X. Age-related differences in affective and cognitive empathy: Self-report and performance-based evidence. Journal Aging, Neuropsychology, and Cognition. 2017;**25**(5):655-672. DOI: 10.1080/13825585.2017.1360835

[32] Khanjani Z, Jeddi EM, Hekmati I, Khalilzade S, Nia ME, Andalib M, et al. Comparison of cognitive empathy, emotional empathy, and social functioning in different age groups. Australian Psychologist. 2015;**50**:80-85. DOI: 10.1111/ap.12099

[33] Reiter AMF, Kanske P, Eppinger B, Li SC. The aging of the social mind: Differential effects on components of social understanding. Scientific Reports. 2017;**7**:11046. DOI: 10.1038/ s41598-017-10669-4

[34] Grühn D, Rebucal K, Diehl M, Lumley M, Labouvie-Vief G. Empathy across the adult lifespan: Longitudinal and experience-sampling findings. Emotion. 2008;**8**:753-765. DOI: 10.1037/a0014123

[35] O'Brien E, Konrath SH, Grühn D, Hagen AL. Empathic concern and perspective taking: Linear and quadratic effects of age across the adult life span. The Journals of Gerontology, Series B: Psychological Sciences and Social Sciences. 2013;**68**:168-175. DOI: 10.1093/ geronb/gbs055

[36] Marshall WL, Hudson SM, Jones R, Fernandez YM. Empathy in sex offenders. Clinical Psychology Review. 1995;**15**:99-113. DOI: 10.1016/0272-7358(95)00002-7

[37] Marshall LE, Marshall WL. Empathy and antisocial behaviour. The Journal of Forensic Psychiatry & Psychology. 2011;**22**(5):742-759. DOI: 10.1080/14789949.2011.617544

[38] Hatfield E, Cacioppo JT, Rapson R. Emotional Contagion. New York: Cambridge University Press; 1994

[39] Preston SD, De Waal FBM. Empathy: Its ultimate and proximate bases. Behavioral and Brain Sciences. 2002;**25**:1-71. DOI: 10.1017S0140525X02000018

[40] Rizzolatti G, Fogassi L, Gallese V. Neurophysiological mechanisms underlying the understanding and imitation of action. Nature Reviews Neuroscience. 2001;**2**:661-670. DOI: 10.1038/35090060

[41] Shamay-Tsoory SG. The neural bases for empathy. The Neuroscientist. 2011;**17**:18-24. DOI: 10.1177/1073858410379268

[42] De Waal FB. Putting the altruism back into altruism: The evolution of empathy. Annual Review of Psychology. 2008;**59**:279-300. DOI: 10.1146/annurev. psych.59.103006.093625

[43] Decety J. Dissecting the neural mechanisms mediating empathy. Emotion Review. 2011;**3**:92-108. DOI: 10.1177/1754073910374662

[44] Zaki J. Empathy: A motivated account. Psychological Bulletin. 2014;**140**:1608-1647. DOI: 10.1037/ a0037679

[45] Wondra JD, Ellsworth PC. An appraisal theory of empathy and other vicarious emotional experiences. Psychological Review. 2015;**122**:411-428. DOI: 10.1037/a0039252

[46] Edele A, Dziobek I, Keller M. Explaining altruistic sharing in the dictator game: The role of affective empathy, cognitive empathy, and justice sensitivity. Learning and Individual Differences. 2013;**24**:96-102. DOI: 10.1016/j.lindif.2012.12.020

[47] Decety J, Cowell JM. Friends or foes: Is empathy necessary for moral behavior? Perspectives on Psychological Science. 2014;**9**:525-537. DOI: 10.1177/1745691614545130

**73**

psychopathy.

**Chapter 5**

**Abstract**

**1. Introduction**

research to be done in this area.

**2. Definition of empathy**

*Michael Fitzgerald*

Empathy: Autism and Psychopathy

This chapter examines empathy from a number of angles, especially autism and psychopathy. It is an overarching phenomenon. It is a central factor in interpersonal psychiatry and psychology. The definition of empathy is extremely complex, and multifaceted. It is necessary to be aware of the massive variability and heterogeneity in considering empathy, autism and psychopathy. An example of this is the new concept of autism called criminal autistic psychopathy. To understand this is, to understand lethal dangerousness. This is described in two school shootings with many deaths; Columbine and Sandy Hook. Neurobiology plays a major role in understanding empathy, autism and psychopathy. Early intervention is described and is of critical importance.

Empathy is one of the most important concepts in psychiatry and psychology, particularly in the interpersonal domain. It is central to the neurodevelopmental disorders, autism, learning disability, bipolar disorder and schizophrenia as well as closely associated conditions like psychopathy and personality disorder. Indeed, treating empathy deficits is central to psychiatry and psychology. In the conditions described above, there is so much overlap and empathy deficits of various kinds are critical to understanding these conditions. Because of the serious long-term outcomes, early treatment is critical, even if there is a need for a great deal of extra

The relationship between empathy, autism and psychopathy is insufficiently appreciated. While it is very complex, this chapter tries to explain the relationship. It reviews the relationship between these concepts in the psychiatric literature and also builds on the author's 45 years of clinical experience, dealing with these patients. Fundamental criticism of the American Psychiatric Association [1] DSM 5. Now psychology and neuropsychiatry are intimately entwined. This chapter aims to elucidate the neuropsychology and neuropsychiatry of empathy, autism and

Empathy is a spectrum concept. It is an overarching phenomenon. Batson [2] describes many, "phenomena" in relation to empathy, ranging from (1) "knowing another person's internal state, including his or her thoughts and feelings"; (2) "adopting the posture or matching the neural response of an observed other"; (3) "coming to feel as another person feels"; (4) "intuiting or projecting oneself into another's

**Keywords:** autism, psychopathy, criminality, empathy, alexithymia

#### **Chapter 5**

*Empathy Study*

[31] Sun B, Luo Z, Zhang W, Li W, Li X. Age-related differences in affective and cognitive empathy: Self-report and performance-based evidence. Journal Aging, Neuropsychology, and Cognition. 2017;**25**(5):655-672. DOI: 10.1080/13825585.2017.1360835

[39] Preston SD, De Waal FBM. Empathy: Its ultimate and proximate bases. Behavioral and Brain Sciences. 2002;**25**:1-71. DOI: 10.1017S0140525X02000018

10.1038/35090060

[41] Shamay-Tsoory SG. The neural bases for empathy. The Neuroscientist. 2011;**17**:18-24. DOI:

10.1177/1073858410379268

psych.59.103006.093625

10.1177/1754073910374662

a0037679

[42] De Waal FB. Putting the altruism back into altruism: The evolution of empathy. Annual Review of Psychology. 2008;**59**:279-300. DOI: 10.1146/annurev.

[43] Decety J. Dissecting the neural mechanisms mediating empathy. Emotion Review. 2011;**3**:92-108. DOI:

[44] Zaki J. Empathy: A motivated account. Psychological Bulletin. 2014;**140**:1608-1647. DOI: 10.1037/

[45] Wondra JD, Ellsworth PC. An appraisal theory of empathy and other vicarious emotional experiences.

DOI: 10.1037/a0039252

[46] Edele A, Dziobek I, Keller

Psychological Review. 2015;**122**:411-428.

M. Explaining altruistic sharing in the dictator game: The role of affective empathy, cognitive empathy, and justice sensitivity. Learning and Individual Differences. 2013;**24**:96-102. DOI: 10.1016/j.lindif.2012.12.020

[47] Decety J, Cowell JM. Friends or foes: Is empathy necessary for moral behavior? Perspectives on Psychological

Science. 2014;**9**:525-537. DOI: 10.1177/1745691614545130

[40] Rizzolatti G, Fogassi L, Gallese V. Neurophysiological mechanisms underlying the understanding and imitation of action. Nature Reviews Neuroscience. 2001;**2**:661-670. DOI:

[32] Khanjani Z, Jeddi EM, Hekmati I, Khalilzade S, Nia ME, Andalib M, et al. Comparison of cognitive empathy, emotional empathy, and social functioning in different age groups. Australian Psychologist. 2015;**50**:80-85.

[33] Reiter AMF, Kanske P, Eppinger B, Li SC. The aging of the social mind: Differential effects on components of social understanding. Scientific Reports. 2017;**7**:11046. DOI: 10.1038/

[34] Grühn D, Rebucal K, Diehl M, Lumley M, Labouvie-Vief G. Empathy across the adult lifespan: Longitudinal and experience-sampling findings. Emotion. 2008;**8**:753-765. DOI: 10.1037/a0014123

[35] O'Brien E, Konrath SH, Grühn D, Hagen AL. Empathic concern and perspective taking: Linear and quadratic effects of age across the adult life span. The Journals of Gerontology, Series B: Psychological Sciences and Social Sciences. 2013;**68**:168-175. DOI: 10.1093/

[36] Marshall WL, Hudson SM, Jones R, Fernandez YM. Empathy in sex offenders. Clinical Psychology Review. 1995;**15**:99-113. DOI: 10.1016/0272-7358(95)00002-7

[37] Marshall LE, Marshall WL. Empathy and antisocial behaviour. The Journal of Forensic Psychiatry & Psychology. 2011;**22**(5):742-759. DOI: 10.1080/14789949.2011.617544

[38] Hatfield E, Cacioppo JT, Rapson R. Emotional Contagion. New York: Cambridge University Press; 1994

DOI: 10.1111/ap.12099

s41598-017-10669-4

geronb/gbs055

**72**

## Empathy: Autism and Psychopathy

*Michael Fitzgerald*

#### **Abstract**

This chapter examines empathy from a number of angles, especially autism and psychopathy. It is an overarching phenomenon. It is a central factor in interpersonal psychiatry and psychology. The definition of empathy is extremely complex, and multifaceted. It is necessary to be aware of the massive variability and heterogeneity in considering empathy, autism and psychopathy. An example of this is the new concept of autism called criminal autistic psychopathy. To understand this is, to understand lethal dangerousness. This is described in two school shootings with many deaths; Columbine and Sandy Hook. Neurobiology plays a major role in understanding empathy, autism and psychopathy. Early intervention is described and is of critical importance.

**Keywords:** autism, psychopathy, criminality, empathy, alexithymia

#### **1. Introduction**

Empathy is one of the most important concepts in psychiatry and psychology, particularly in the interpersonal domain. It is central to the neurodevelopmental disorders, autism, learning disability, bipolar disorder and schizophrenia as well as closely associated conditions like psychopathy and personality disorder. Indeed, treating empathy deficits is central to psychiatry and psychology. In the conditions described above, there is so much overlap and empathy deficits of various kinds are critical to understanding these conditions. Because of the serious long-term outcomes, early treatment is critical, even if there is a need for a great deal of extra research to be done in this area.

The relationship between empathy, autism and psychopathy is insufficiently appreciated. While it is very complex, this chapter tries to explain the relationship. It reviews the relationship between these concepts in the psychiatric literature and also builds on the author's 45 years of clinical experience, dealing with these patients.

Fundamental criticism of the American Psychiatric Association [1] DSM 5. Now psychology and neuropsychiatry are intimately entwined. This chapter aims to elucidate the neuropsychology and neuropsychiatry of empathy, autism and psychopathy.

#### **2. Definition of empathy**

Empathy is a spectrum concept. It is an overarching phenomenon. Batson [2] describes many, "phenomena" in relation to empathy, ranging from (1) "knowing another person's internal state, including his or her thoughts and feelings"; (2) "adopting the posture or matching the neural response of an observed other"; (3) "coming to feel as another person feels"; (4) "intuiting or projecting oneself into another's

situation," (a simulation phenomenon); (5), "imagining how another is thinking and feeling," (a theory phenomenon); (6), "imagining how one would think and feel in the other's place," (a simulation phenomenon). Erickson [3], points out that to simulate is to put oneself in the shoes of another and that a simulation theory is sometimes called empathy theory; (7), "feeling distress at witnessing another person's suffering"; (8), "feeling for another person who is suffering" [2]. There will be further elaborations of these phenomena in the years to come, with further research on empathy. Chialant et al. [4], defines empathy as, (a), "an affective state that is (b) "isomorphic to another person's affective state" and (c) "is elicited by observing or imagining another person's affective state," and (d) "is experienced while remaining cognisant that the other person's affective state is the source of one's own affective state." Chialant et al. [4], also note that, "our capacity to distinguish whether the source of an affective experience is triggered by another or lies within ourselves is part of the broader capacity for perspective taking." This chapter will start with a discussion of neuropsychology.

### **3. Neuropsychology**

#### **3.1 Understanding mentalization, theory of mind and empathy**

Swan and Riley [5] note that "how we understand another person's mind and reflect on our own mental states, or, 'mentalize', [6], is the basis of empathy." There are two different views on the mechanism that puts us in the "shoes," (the mind) of another person: (a) "thinking or mind-reading, and (b) feeling or empathy." One way to provide empathy is to share another person's feelings in an emotive manner, defined as, "affective response more appropriate to someone else's situation than to one's own" [7]. Various alternative forms, each based on cognitive theories infer the state of another mind through theory of mind, [8]. This definition [5] involves, "the ability of humans and some animals to ascribe unique mental states to others and to use those mental state attributes during social interactions." Swan and Riley [5], also note the, "theory-theory of [9], which means that, "we attribute mental states to others on the basis of a theory of mind that is constructed in early infancy and subsequently revised and modified or else is the result of maturation of innate mind-reading modules" [10]. Assimilation theory of the mind, [11, 12], is described by Swan and Riley [5], as stating that, "simulation theorists deny that our understanding of others is theoretical and maintain that we use our mind as a model when understanding the mind of others." Finally, Swan and Riley note that mind-reading, [13, 14], note that, "ascribed to the target is ascribed as a result of the attributors instantiating, undergoing or experience that very state." Mind-reading involves attributing a mental state to another. "It is the ability to detect the intentions and predict the behaviours of other individuals." Swan and Riley ([5], page 13), point out that, "it has been argued that empathy is extended to include mentalizing. Mentalization embodies the capacity to include a sense of the actions of oneself and other people on the basis of desires, feelings and beliefs." It is a big issue in autism and Decety and Michalskak Lahey [15] points out that, "empathic perspective taking also partially differs from mentalizing and theory of mind functions, which involve taking another person's perspective and attributing to them particular cognitive states, in that it is more involved in attributing emotional states."

#### **3.2 Empathy and theory of mind**

Research suggests a sharp distinction between autism and psychopathy. Persons with autism are described as having problems with theory of mind and persons

**75**

*Empathy: Autism and Psychopathy*

*DOI: http://dx.doi.org/10.5772/intechopen.82886*

some persons with autism have theory of mind problems.

with autism and callous, unemotional traits.

with psychopathy having intact theory of mind attributes [16], but when one is dealing with neuropsychology and the brain, the situation is rarely so clear cut, so black and white. There is continuous heterogeneity and variability. In the clinical world, these issues are almost always on a spectrum with greater or lesser theory of mind problems. Indeed, some high-functioning autism persons can pass theory of mind tests [10, 17]. Blair [18] points out that "cognitive empathy or theory of mind is profoundly impaired in individuals with autism." These theories have been very seriously undermined by research on high-functioning autism and Scheeren et al. [17], points out that, "counter to what theory of mind theory of ASD would predict, school age children and adolescents with high-functioning ASD seem to be able to master the theoretical principals of advanced mental state reasoning." This is a warning to absolutism in neuropsychology and neuropsychiatry. In short, only

**4. Clinical perspective—variability, heterogeneity and dimensionality**

From a clinical perspective, the author, having diagnosed over 4500 persons with autism sees these overlapping features all the time. It is not rare to see children

clinical patients and this is most clearly seen in those who have criminal autistic psychopathy, [19]. The empathy spectrum, the autism spectrum and psychopathy spectrum are almost infinite in terms of severity and variability, [20]. There is an empathy spectrum from high empathy to no empathy. In actual fact, the idea of zero empathy, [21], is something that is a theoretical concept and that does not occur in the real world. We need to think in dimensional perspective, not categorical perspectives. We need to think in terms of non-specificity rather than absolutely specificity. In the vast majority of these situations we are dealing with multiple genes of small effect interacting with the environment. This gives us almost unlimited variability and heterogeneity in the concept of empathy, autism and psychopathy.

**5. Diagnosis, empathy and neurodevelopmental psychiatry/psychology**

In relation to diagnosis, there is massive overlap between psychiatric diagnostic categories, [22], and there is equally massive overlap between degrees of empathy in many diagnostic categories. Indeed, an over-arching neurodevelopmental category makes more sense than individual diagnostic categories because there is so much overlap in neurodevelopmental psychiatry, [20]. According to Scull [23], Steven Hyman, the former director of NIMH stated that DSM 5, "was totally wrong in the way its authors could not have imagined. So in fact, what they produced was an absolute scientific nightmare. Many people who got one diagnosis got five diagnoses, but they didn't have five diseases – they have one underlying condition." Insel [23, 24], who was also the director of the NIMH stated that DSM 5 showed, "a lack of validity … as long as the research community takes DSM 5 to be a bible, we will never make progress. People think that everything has to match DSM 5 criteria, but what you know … biology never read the book, and he went on to point out that in future the NIMH would be, re-orientating into research away from DSM 5 categories … patients with mental illness deserve better." Clearly, Hyman and Insel were absolutely correct. He, Insel [24], proposed Research Domain Criteria to collect, "genomic, cellular, imaging, social and behavioural information," and he also recommended focusing on the brain and, "connectopathies." Thomas Insel noted that

There is massive variability in the, "real world," that is clinical work with routine

#### *Empathy: Autism and Psychopathy DOI: http://dx.doi.org/10.5772/intechopen.82886*

*Empathy Study*

**3. Neuropsychology**

situation," (a simulation phenomenon); (5), "imagining how another is thinking and feeling," (a theory phenomenon); (6), "imagining how one would think and feel in the other's place," (a simulation phenomenon). Erickson [3], points out that to simulate is to put oneself in the shoes of another and that a simulation theory is sometimes called empathy theory; (7), "feeling distress at witnessing another person's suffering"; (8), "feeling for another person who is suffering" [2]. There will be further elaborations of these phenomena in the years to come, with further research on empathy. Chialant et al. [4], defines empathy as, (a), "an affective state that is (b) "isomorphic to another person's affective state" and (c) "is elicited by observing or imagining another person's affective state," and (d) "is experienced while remaining cognisant that the other person's affective state is the source of one's own affective state." Chialant et al. [4], also note that, "our capacity to distinguish whether the source of an affective experience is triggered by another or lies within ourselves is part of the broader capacity for perspec-

tive taking." This chapter will start with a discussion of neuropsychology.

**3.1 Understanding mentalization, theory of mind and empathy**

Swan and Riley [5] note that "how we understand another person's mind and reflect on our own mental states, or, 'mentalize', [6], is the basis of empathy." There are two different views on the mechanism that puts us in the "shoes," (the mind) of another person: (a) "thinking or mind-reading, and (b) feeling or empathy." One way to provide empathy is to share another person's feelings in an emotive manner, defined as, "affective response more appropriate to someone else's situation than to one's own" [7]. Various alternative forms, each based on cognitive theories infer the state of another mind through theory of mind, [8]. This definition [5] involves, "the ability of humans and some animals to ascribe unique mental states to others and to use those mental state attributes during social interactions." Swan and Riley [5], also note the, "theory-theory of [9], which means that, "we attribute mental states to others on the basis of a theory of mind that is constructed in early infancy and subsequently revised and modified or else is the result of maturation of innate mind-reading modules" [10]. Assimilation theory of the mind, [11, 12], is described by Swan and Riley [5], as stating that, "simulation theorists deny that our understanding of others is theoretical and maintain that we use our mind as a model when understanding the mind of others." Finally, Swan and Riley note that mind-reading, [13, 14], note that, "ascribed to the target is ascribed as a result of the attributors instantiating, undergoing or experience that very state." Mind-reading involves attributing a mental state to another. "It is the ability to detect the intentions and predict the behaviours of other individuals." Swan and Riley ([5], page 13), point out that, "it has been argued that empathy is extended to include mentalizing. Mentalization embodies the capacity to include a sense of the actions of oneself and other people on the basis of desires, feelings and beliefs." It is a big issue in autism and Decety and Michalskak Lahey [15] points out that, "empathic perspective taking also partially differs from mentalizing and theory of mind functions, which involve taking another person's perspective and attributing to them particular cognitive states, in that it is more involved in attributing emotional states."

Research suggests a sharp distinction between autism and psychopathy. Persons with autism are described as having problems with theory of mind and persons

**74**

**3.2 Empathy and theory of mind**

with psychopathy having intact theory of mind attributes [16], but when one is dealing with neuropsychology and the brain, the situation is rarely so clear cut, so black and white. There is continuous heterogeneity and variability. In the clinical world, these issues are almost always on a spectrum with greater or lesser theory of mind problems. Indeed, some high-functioning autism persons can pass theory of mind tests [10, 17]. Blair [18] points out that "cognitive empathy or theory of mind is profoundly impaired in individuals with autism." These theories have been very seriously undermined by research on high-functioning autism and Scheeren et al. [17], points out that, "counter to what theory of mind theory of ASD would predict, school age children and adolescents with high-functioning ASD seem to be able to master the theoretical principals of advanced mental state reasoning." This is a warning to absolutism in neuropsychology and neuropsychiatry. In short, only some persons with autism have theory of mind problems.

#### **4. Clinical perspective—variability, heterogeneity and dimensionality**

From a clinical perspective, the author, having diagnosed over 4500 persons with autism sees these overlapping features all the time. It is not rare to see children with autism and callous, unemotional traits.

There is massive variability in the, "real world," that is clinical work with routine clinical patients and this is most clearly seen in those who have criminal autistic psychopathy, [19]. The empathy spectrum, the autism spectrum and psychopathy spectrum are almost infinite in terms of severity and variability, [20]. There is an empathy spectrum from high empathy to no empathy. In actual fact, the idea of zero empathy, [21], is something that is a theoretical concept and that does not occur in the real world. We need to think in dimensional perspective, not categorical perspectives. We need to think in terms of non-specificity rather than absolutely specificity. In the vast majority of these situations we are dealing with multiple genes of small effect interacting with the environment. This gives us almost unlimited variability and heterogeneity in the concept of empathy, autism and psychopathy.

#### **5. Diagnosis, empathy and neurodevelopmental psychiatry/psychology**

In relation to diagnosis, there is massive overlap between psychiatric diagnostic categories, [22], and there is equally massive overlap between degrees of empathy in many diagnostic categories. Indeed, an over-arching neurodevelopmental category makes more sense than individual diagnostic categories because there is so much overlap in neurodevelopmental psychiatry, [20]. According to Scull [23], Steven Hyman, the former director of NIMH stated that DSM 5, "was totally wrong in the way its authors could not have imagined. So in fact, what they produced was an absolute scientific nightmare. Many people who got one diagnosis got five diagnoses, but they didn't have five diseases – they have one underlying condition." Insel [23, 24], who was also the director of the NIMH stated that DSM 5 showed, "a lack of validity … as long as the research community takes DSM 5 to be a bible, we will never make progress. People think that everything has to match DSM 5 criteria, but what you know … biology never read the book, and he went on to point out that in future the NIMH would be, re-orientating into research away from DSM 5 categories … patients with mental illness deserve better." Clearly, Hyman and Insel were absolutely correct. He, Insel [24], proposed Research Domain Criteria to collect, "genomic, cellular, imaging, social and behavioural information," and he also recommended focusing on the brain and, "connectopathies." Thomas Insel noted that

*Empathy Study*

psychiatrists, "actually believe, (that their diagnoses) are real, but there's no reality. They are just constructs." The first step is to analyse the huge spectrum of empathy and diagnosis. This chapter elucidates the divergence between "laboratory" (research) findings using rarefied, (autism diagnostic interview), instruments [25]. In the clinical world, research findings have to be modified when they do not take into account the complex, "real," clinical world. The autism diagnosis interview misses out three quarters of persons with autism spectrum disorders.

#### **6. Autism, aggression and criminal autistic psychopathy—dangerously low levels of empathy**

The vast majority of persons with ASD show a failure to orientate to other's distress, have difficulty understanding intentions and attributing thoughts to others and appear to respond emotionally, "in a limited way," according to Rogers et al. [26]. They have problems with social relationships, reduced eye contact, problems understanding social know-how, problems sharing thoughts, problems seeing things from other people's perspectives, preservation of sameness, narrow interests and sensory issues. Most are highly moral, but many can show aggression in a non-lethal way and then there are those who are highly dangerous with criminal autistic psychopathy, [19]. Indeed, aggression was well recognised by Asperger [27], Frith [28]. Asperger [27] described Fritz V. as, "aggressive and lashed out with anything he could get hold of, (once a hammer)." Asperger [27] also described autistic acts of malice, sadistic traits, "typically calculated," which suggested an understanding of other minds and suggesting the overlap here between autism and psychopathic traits. One boy, according to Asperger [27], stated, "mummy, I shall take a knife one day and put it into your heart, then blood will spurt out and this will cause a great stir." This suggests a sadistic pleasure characteristic of both psychopathy and autism, (criminal autistic psychopathy) again showing the overlap. The author of this chapter is suggesting that we bring back the diagnosis of autistic psychopathy for those with autism and Asperger syndrome, who engage in criminal activities with a new diagnosis of criminal autistic psychopathy [19]. These persons have the dual features of autism and psychopathy. There are overlapping features, but also differences from psychopathy.

#### **7. School shooting—Sandy Hook**

In relation to the school shooting at Sandy Hook School, Solomon [29], noted that from his conversation with Peter Lanza, the father of Adam who shot 26 people at this school, that he showed poor eye contact, problems with social relationships, preservation of sameness, narrow interests, poor communication skills and sensory issues. These are all classic features of Asperger syndrome, DSM 4, or of the sub-group of Asperger syndrome, called criminal autistic psychopathy, [19]. He had major empathy deficits in relation to other people. According to Solomon [29], when his mother asked Adam whether he would feel sad if anything happened to her, he replied "no." He found it much easier to communicate online. It's online that the true state of affairs of people with dangerous thoughts and fantasy, particularly those with Asperger syndrome, are best seen. The potential for criminal autistic psychopathy can be noticed in very early life with callous traits. Adam felt hostile to people, particularly females and he wrote online, "why females are inherently selfish." Solomon [29], pointed out that, "misogynism is very common in these conditions." His father [29] stated that "Adam would have killed me in a heartbeat, if he'd had the chance." He shot his mother "four times," Solomon [29].

**77**

*Empathy: Autism and Psychopathy*

*DOI: http://dx.doi.org/10.5772/intechopen.82886*

The school shooter Eric Harris at Columbine also had criminal autistic psychopathy, [19]. Cullen [30], described him as, "painfully shy," and that he was hypersensitive to criticism or rejection. Cullen [30], pointed out that he stated that, "I hate almost everyone," and, "I wanna rip his head off, and eat it," in a flat voice. Cullen [30], stated that Eric, "described going to some random, downtown area … and blowing up and shooting up everything he could, and that, he would feel no remorse, no shame. He would make them pay". Cullen [30], went on to point out that he was, "egotistical, empathy-free" and, "egocentric with appalling failure of empathy." Cullen [30], also described him as being, "callous and cunning." Here again, we see the overlap between psychopathy and autism. In the real world, people do not fit into neat categories or

Blair [16] points out that callous, unemotional people show a lack of empathy and remorse, despite perfectly good understanding of thoughts and feelings. He emphasises "lack of empathy, poor processing or distress cues in other people, lack of remorse, but good mentalizing." Blair [16] points out that, "the naming of emotional expressions recruits the neural architectures involved in the processing of these, (emotional), expressions." Blair [16] also pointed out that these persons, "do not present with impaired responding to angry, happy or surprised facial or vocal expressions." Herpers et al. [31], point out that, "deficits in emotional recognition are thought to play an important role in impaired, empathic function in psychopathy. It has been suggested that impaired functioning of the amygdala leads to impaired recognition of facial expressions of distress, specifically fear." Blair [18] notes out that, "there is selective impairment for the processing of fearful and to a lesser extent, sad expressions in individuals with psychopathy." Clinically, the author sees these features commonly in persons with autism. The impairment of processing of fearful expressions was most seriously undermined when Dadds et al. [32]; Dadds and Rhodes [33], suggested that, "facial fear recognition may not be impaired when participants are instructed to look at the eyes." Empathy deficits and theory of mind deficits are partly caused by reduced eye contact, which is evident in clinical practice with persons with autism every day. This reduces their capacity to understand how

people, "tick." One cannot read a face emotionally if one does not look at it.

Blair [16], points out that, "individuals with autism show indications of an aversive response to the distress of others." The problem is that the author sees this clinically all the time in patients with autism and it is not specific to psychopathy. There is huge variability and heterogeneity in autism and this does not take into account the phrase that persons with autism show an aversive response to the distress of others. Indeed, I see many persons with autism who show no aversive response to others. Of course, there is a large gap between what happens in rarefied research studies and how people present in the real world. This is mostly seen in this discussion of empathy, autism and psychopathy. Blair [18], points out that, "it is uncertain whether there is impairment in processing emotional expressions in individuals with autism." Working with persons with autism, as the author does every day, shows this clearly, that there are huge problems in processing emotional expressions in persons with autism. The findings in the research lab do not always

**8.2 Empathy and autism—the clinical perspective**

mirror the "real-life" situation of clinical practice.

boxes. There is a massive overlap between diagnostic categories.

**8.1 Empathy, callous unemotional traits and psychopathy**

**8. School shooting—Columbine**

### **8. School shooting—Columbine**

*Empathy Study*

**low levels of empathy**

psychiatrists, "actually believe, (that their diagnoses) are real, but there's no reality. They are just constructs." The first step is to analyse the huge spectrum of empathy and diagnosis. This chapter elucidates the divergence between "laboratory" (research) findings using rarefied, (autism diagnostic interview), instruments [25]. In the clinical world, research findings have to be modified when they do not take into account the complex, "real," clinical world. The autism diagnosis interview

**6. Autism, aggression and criminal autistic psychopathy—dangerously** 

The vast majority of persons with ASD show a failure to orientate to other's distress, have difficulty understanding intentions and attributing thoughts to others and appear to respond emotionally, "in a limited way," according to Rogers et al. [26]. They have problems with social relationships, reduced eye contact, problems understanding social know-how, problems sharing thoughts, problems seeing things from other people's perspectives, preservation of sameness, narrow interests and sensory issues. Most are highly moral, but many can show aggression in a non-lethal way and then there are those who are highly dangerous with criminal autistic psychopathy, [19]. Indeed, aggression was well recognised by Asperger [27], Frith [28]. Asperger [27] described Fritz V. as, "aggressive and lashed out with anything he could get hold of, (once a hammer)." Asperger [27] also described autistic acts of malice, sadistic traits, "typically calculated," which suggested an understanding of other minds and suggesting the overlap here between autism and psychopathic traits. One boy, according to Asperger [27], stated, "mummy, I shall take a knife one day and put it into your heart, then blood will spurt out and this will cause a great stir." This suggests a sadistic pleasure characteristic of both psychopathy and autism, (criminal autistic psychopathy) again showing the overlap. The author of this chapter is suggesting that we bring back the diagnosis of autistic psychopathy for those with autism and Asperger syndrome, who engage in criminal activities with a new diagnosis of criminal autistic psychopathy [19]. These persons have the dual features of autism and psychopathy. There are

misses out three quarters of persons with autism spectrum disorders.

overlapping features, but also differences from psychopathy.

In relation to the school shooting at Sandy Hook School, Solomon [29], noted that from his conversation with Peter Lanza, the father of Adam who shot 26 people at this school, that he showed poor eye contact, problems with social relationships, preservation of sameness, narrow interests, poor communication skills and sensory issues. These are all classic features of Asperger syndrome, DSM 4, or of the sub-group of Asperger syndrome, called criminal autistic psychopathy, [19]. He had major empathy deficits in relation to other people. According to Solomon [29], when his mother asked Adam whether he would feel sad if anything happened to her, he replied "no." He found it much easier to communicate online. It's online that the true state of affairs of people with dangerous thoughts and fantasy, particularly those with Asperger syndrome, are best seen. The potential for criminal autistic psychopathy can be noticed in very early life with callous traits. Adam felt hostile to people, particularly females and he wrote online, "why females are inherently selfish." Solomon [29], pointed out that, "misogynism is very common in these conditions." His father [29] stated that "Adam would have killed me in a heartbeat,

if he'd had the chance." He shot his mother "four times," Solomon [29].

**7. School shooting—Sandy Hook**

**76**

The school shooter Eric Harris at Columbine also had criminal autistic psychopathy, [19]. Cullen [30], described him as, "painfully shy," and that he was hypersensitive to criticism or rejection. Cullen [30], pointed out that he stated that, "I hate almost everyone," and, "I wanna rip his head off, and eat it," in a flat voice. Cullen [30], stated that Eric, "described going to some random, downtown area … and blowing up and shooting up everything he could, and that, he would feel no remorse, no shame. He would make them pay". Cullen [30], went on to point out that he was, "egotistical, empathy-free" and, "egocentric with appalling failure of empathy." Cullen [30], also described him as being, "callous and cunning." Here again, we see the overlap between psychopathy and autism. In the real world, people do not fit into neat categories or boxes. There is a massive overlap between diagnostic categories.

#### **8.1 Empathy, callous unemotional traits and psychopathy**

Blair [16] points out that callous, unemotional people show a lack of empathy and remorse, despite perfectly good understanding of thoughts and feelings. He emphasises "lack of empathy, poor processing or distress cues in other people, lack of remorse, but good mentalizing." Blair [16] points out that, "the naming of emotional expressions recruits the neural architectures involved in the processing of these, (emotional), expressions." Blair [16] also pointed out that these persons, "do not present with impaired responding to angry, happy or surprised facial or vocal expressions." Herpers et al. [31], point out that, "deficits in emotional recognition are thought to play an important role in impaired, empathic function in psychopathy. It has been suggested that impaired functioning of the amygdala leads to impaired recognition of facial expressions of distress, specifically fear." Blair [18] notes out that, "there is selective impairment for the processing of fearful and to a lesser extent, sad expressions in individuals with psychopathy." Clinically, the author sees these features commonly in persons with autism. The impairment of processing of fearful expressions was most seriously undermined when Dadds et al. [32]; Dadds and Rhodes [33], suggested that, "facial fear recognition may not be impaired when participants are instructed to look at the eyes." Empathy deficits and theory of mind deficits are partly caused by reduced eye contact, which is evident in clinical practice with persons with autism every day. This reduces their capacity to understand how people, "tick." One cannot read a face emotionally if one does not look at it.

#### **8.2 Empathy and autism—the clinical perspective**

Blair [16], points out that, "individuals with autism show indications of an aversive response to the distress of others." The problem is that the author sees this clinically all the time in patients with autism and it is not specific to psychopathy. There is huge variability and heterogeneity in autism and this does not take into account the phrase that persons with autism show an aversive response to the distress of others. Indeed, I see many persons with autism who show no aversive response to others. Of course, there is a large gap between what happens in rarefied research studies and how people present in the real world. This is mostly seen in this discussion of empathy, autism and psychopathy. Blair [18], points out that, "it is uncertain whether there is impairment in processing emotional expressions in individuals with autism." Working with persons with autism, as the author does every day, shows this clearly, that there are huge problems in processing emotional expressions in persons with autism. The findings in the research lab do not always mirror the "real-life" situation of clinical practice.

#### **9. Alexithymia, empathy and anterior insula**

Bernhardt and Singer [34], pointed out that, "alexithymia is sub-clinical phenomena related to difficulties in identifying and describing feelings and in distinguishing feelings from bodily sensations," [35]. Bernhardt and Singer [34], also point out that there was a modulation observed, "by the degree of alexithymia in controls and individuals with ASD, [36]. Indeed, the greater the participant's deficits in understanding their own emotions, regardless of whether they were control subjects or patients, the less activation they showed in anterior insula, while empathising with people present in the same room undergoing painful experiences. These results confirmed the hypothesis that representations in anterior insula underly representations of our own feeling states, which in turn form the basis for understanding the feelings of others. Thus, understanding your own feeling states may be a prerequisite to engage in vicarious simulation for a better understanding of other people's states." This means self-empathy is necessary for other empathy. If one cannot identify one's own emotions, one will not be able to identify other's emotions. "This is necessary for authentic simulation," [37].

#### **10. Empathy, morality, autism and psychopathy**

Blair et al. [18], noted that children with autism show, "relatively preserved moral judgement, as long as the judgement does not require representation of the interest of the perpetrator." Blair [18] also points out that, "empathic responding is necessary for successful moral judgement," but again, there is massive variability. It's not so much that there's a double hit, there may be 100 genetic hits and more impacting on interacting on autism and psychopathy. Rogers et al. [26], pointed out that, "boys with co-occurring ASD and CU tendencies share some of the behaviours and aspects of cognitive profile with boys who have psychopathic tendencies alone. Callous/psychopathic acts in a small number of individuals with ASD probably reflect a 'double hit', involving an additional impairment of empathic response to distress cues, which is not part and parcel of ASD itself." This so called double hit should be hundreds of hits.

In relation to cognitive empathy and theory of mind, Blair [18] stated that, "cognitive empathy or theory of mind is intact in individuals with psychopathy."

#### **10.1 Automatic perspective taking**

These ideas have been very seriously undermined by Drayton et al. [38] in relation to automatic perspective taking. Previous research did not take the complexity of cognitive empathy into account and this led to serious misunderstandings of cognitive empathy. Drayton et al. [38] points out that automatic theory of mind processes are engaged when an individual unintentionally represents the perspective of another person, also called, "altercentric interference." Drayton et al. [38], suggest that "psychopathic individuals have a diminished propensity to automatically think from another's perspective, which may be the cognitive root of their deficits in social functioning and moral behaviour." Drayton et al. [38] raise for this author, the possible failure of previous research on theory of mind and psychopathy, failing, "to tap into a critical component of normal theory of mind processing; or tendency to take other's perspective automatically." Drayton et al. [38], defined, "automatic theory of mind processes," as an individual representing, "the thoughts and feelings of another person without intending to do so." They also point out that

**79**

*Empathy: Autism and Psychopathy*

their own egocentric desires met.

**10.2 Altercentric interference**

emerge equally in social and non-social conditions."

struct in children with ASD as in previous samples" [40].

**10.3 Autism/psychopathy overlapping**

**10.4 Fearlessness and morality**

most contradictory condition.

*DOI: http://dx.doi.org/10.5772/intechopen.82886*

psychopathic individuals have a previously unobserved cognitive deficit that might explain their patterns of destructive and antisocial behaviour, that is … failure, "to automatically take the perspective of others, but can deliberately (controlled), take the perspective of others." These findings suggest that psychopathic individuals have the ability to take the perspective of others, but lack the propensity to do so. It seems they can pass theory of mind tasks in the research situation but fail to do so in the real world situation. This is one of the endless problems of laboratory research not translating into the, "real world," that is the clinical world. This lack of generalisation can be a serious flaw in academic psychological research. Drayton et al. [38], notes that, "psychopathic individuals do show deficits in their ability to understand what others are feeling but this capacity to represent other feelings appears to be distinct from capacity to represent what others see and believe." They also point out that, "psychopathic individuals appear to represent other's perspective in a relatively typical manner when doing so. It is goal-conducive and yet, are able to ignore other's perspective when it is not conducive." This means that all previous theory of mind research on psychopathy missed the fundamental point of the deficit of automatic perspective of others. Drayton et al. [38], point out that, "this combination of relatively intact deliberative theory of mind but impaired spontaneous theory of mind may allow psychopathic individuals to use information about others' mental states to achieve their own ends, while at the same avoid the, 'cost', of automatically representing other's mental states, results in callous and chronic criminal behaviour." They have no empathic interest in other minds, except getting

Of course, there has been debate about altercentric interference. Marshal et al. [39], noted that, "considerable debate has focused on whether adults possess an implicit system for representing others' mental states. Some argue that people automatically represent the perspective of others using evidence from altercentric interference - cases in which another agent's perspective affects the speed with which one can report one's own perspective. Others have argued that altercentric interference is not always specific to social stimuli and thus, may represent a simpler process such as submentalizing." Marshal et al. [39] conclude that, "participants experience both egocentric and altercentric interference, and these effects

Rogers et al. [26], pointed out that ASD plus callous, unemotional traits, "shared some behaviours and aspects of cognitive profile with boys who have psychopathic tendencies alone," and that, "anti-social personality tapped the same latent con-

Fearlessness is not rare in autism, indeed, is a major concern for children with autism in schools and is also seen in psychopathy. They both have emotional processing deficits and indeed, they both, particularly criminal autistic psychopathy can show moral deficits. Of course, many persons with autism have very high moral standards. Shame and embarrassment can be absent in both conditions. Autism is a

#### *Empathy: Autism and Psychopathy DOI: http://dx.doi.org/10.5772/intechopen.82886*

*Empathy Study*

**9. Alexithymia, empathy and anterior insula**

emotions. "This is necessary for authentic simulation," [37].

**10. Empathy, morality, autism and psychopathy**

should be hundreds of hits.

**10.1 Automatic perspective taking**

Bernhardt and Singer [34], pointed out that, "alexithymia is sub-clinical phenomena related to difficulties in identifying and describing feelings and in distinguishing feelings from bodily sensations," [35]. Bernhardt and Singer [34], also point out that there was a modulation observed, "by the degree of alexithymia in controls and individuals with ASD, [36]. Indeed, the greater the participant's deficits in understanding their own emotions, regardless of whether they were control subjects or patients, the less activation they showed in anterior insula, while empathising with people present in the same room undergoing painful experiences. These results confirmed the hypothesis that representations in anterior insula underly representations of our own feeling states, which in turn form the basis for understanding the feelings of others. Thus, understanding your own feeling states may be a prerequisite to engage in vicarious simulation for a better understanding of other people's states." This means self-empathy is necessary for other empathy. If one cannot identify one's own emotions, one will not be able to identify other's

Blair et al. [18], noted that children with autism show, "relatively preserved moral judgement, as long as the judgement does not require representation of the interest of the perpetrator." Blair [18] also points out that, "empathic responding is necessary for successful moral judgement," but again, there is massive variability. It's not so much that there's a double hit, there may be 100 genetic hits and more impacting on interacting on autism and psychopathy. Rogers et al. [26], pointed out that, "boys with co-occurring ASD and CU tendencies share some of the behaviours and aspects of cognitive profile with boys who have psychopathic tendencies alone. Callous/psychopathic acts in a small number of individuals with ASD probably reflect a 'double hit', involving an additional impairment of empathic response to distress cues, which is not part and parcel of ASD itself." This so called double hit

In relation to cognitive empathy and theory of mind, Blair [18] stated that, "cognitive empathy or theory of mind is intact in individuals with psychopathy."

These ideas have been very seriously undermined by Drayton et al. [38] in relation to automatic perspective taking. Previous research did not take the complexity of cognitive empathy into account and this led to serious misunderstandings of cognitive empathy. Drayton et al. [38] points out that automatic theory of mind processes are engaged when an individual unintentionally represents the perspective of another person, also called, "altercentric interference." Drayton et al. [38], suggest that "psychopathic individuals have a diminished propensity to automatically think from another's perspective, which may be the cognitive root of their deficits in social functioning and moral behaviour." Drayton et al. [38] raise for this author, the possible failure of previous research on theory of mind and psychopathy, failing, "to tap into a critical component of normal theory of mind processing; or tendency to take other's perspective automatically." Drayton et al. [38], defined, "automatic theory of mind processes," as an individual representing, "the thoughts and feelings of another person without intending to do so." They also point out that

**78**

psychopathic individuals have a previously unobserved cognitive deficit that might explain their patterns of destructive and antisocial behaviour, that is … failure, "to automatically take the perspective of others, but can deliberately (controlled), take the perspective of others." These findings suggest that psychopathic individuals have the ability to take the perspective of others, but lack the propensity to do so. It seems they can pass theory of mind tasks in the research situation but fail to do so in the real world situation. This is one of the endless problems of laboratory research not translating into the, "real world," that is the clinical world. This lack of generalisation can be a serious flaw in academic psychological research. Drayton et al. [38], notes that, "psychopathic individuals do show deficits in their ability to understand what others are feeling but this capacity to represent other feelings appears to be distinct from capacity to represent what others see and believe." They also point out that, "psychopathic individuals appear to represent other's perspective in a relatively typical manner when doing so. It is goal-conducive and yet, are able to ignore other's perspective when it is not conducive." This means that all previous theory of mind research on psychopathy missed the fundamental point of the deficit of automatic perspective of others. Drayton et al. [38], point out that, "this combination of relatively intact deliberative theory of mind but impaired spontaneous theory of mind may allow psychopathic individuals to use information about others' mental states to achieve their own ends, while at the same avoid the, 'cost', of automatically representing other's mental states, results in callous and chronic criminal behaviour." They have no empathic interest in other minds, except getting their own egocentric desires met.

#### **10.2 Altercentric interference**

Of course, there has been debate about altercentric interference. Marshal et al. [39], noted that, "considerable debate has focused on whether adults possess an implicit system for representing others' mental states. Some argue that people automatically represent the perspective of others using evidence from altercentric interference - cases in which another agent's perspective affects the speed with which one can report one's own perspective. Others have argued that altercentric interference is not always specific to social stimuli and thus, may represent a simpler process such as submentalizing." Marshal et al. [39] conclude that, "participants experience both egocentric and altercentric interference, and these effects emerge equally in social and non-social conditions."

#### **10.3 Autism/psychopathy overlapping**

Rogers et al. [26], pointed out that ASD plus callous, unemotional traits, "shared some behaviours and aspects of cognitive profile with boys who have psychopathic tendencies alone," and that, "anti-social personality tapped the same latent construct in children with ASD as in previous samples" [40].

#### **10.4 Fearlessness and morality**

Fearlessness is not rare in autism, indeed, is a major concern for children with autism in schools and is also seen in psychopathy. They both have emotional processing deficits and indeed, they both, particularly criminal autistic psychopathy can show moral deficits. Of course, many persons with autism have very high moral standards. Shame and embarrassment can be absent in both conditions. Autism is a most contradictory condition.

#### **10.5 Attachment and empathy**

Blair [16], is correct to point out that, "some forms of empathic responding occur independently of attachment style." The causality of attachment research is often deeply flawed. Indeed, Bowlby [41], discussed, "inappropriate mothering," as a cause of autism. Indeed, the causality here is in the opposite direction. Blaming the mother, suggesting that mothers caused autism or psychopathy was totally inaccurate.

#### **10.6 Neurobiology and empathy**

Chialant et al. [4] pointed out that deficiencies in the prefrontal cortex and limbic system are associated with both violent behaviour and empathy. They also pointed out that empathy comes out of a, "brainstem-mediated mimicry," and, "mirror neuron mediated emotional resonance which emerges in the very first months of life." Shamay-Tsoory et al. [42], point out that, "recent evidence suggests that there are two possible systems of empathy: a basic emotional contagion system and a more advanced cognitive perspective-taking system. It is not clear whether these two systems are part of a single, interacting empathy system or whether they are independent. Additionally, the neuroanatomical bases of these systems are largely unknown." They found nevertheless that, "a remarkable behavioural and anatomic double dissociation between deficits in cognitive empathy (ventromedial prefrontal), and emotional empathy (inferior frontal gyrus). Furthermore, precise anatomical mapping of lesions revealed Brodmann area 44 to be critical for emotional empathy, while areas 11 and 10 were found necessary for cognitive empathy." This supports the notion that the inferior frontal gyrus is involved in emotional empathy and the ventromedial prefrontal, in cognitive empathy, and that, "these two neural networks with two core components which are triggered and operate independently."

#### **11. Callous and unemotional traits (CU), fear and neurobiology**

Herpers et al. [31], note that, "youths with CU traits show lower levels of prosocial reasoning," and, "lower emotional responsibility," with, "reduced response of the amygdala and a weaker functional connectivity between the amygdala and the ventromedial prefrontal cortex." Glenn and Raine [43], point out that, "poor autonomic fear conditioning - the ability to learn associations between neutral cues and aversive stimuli – is another well replicated correlate of adult criminal and psychopathic adult offending, conduct disorder in children and adolescents, and juvenile offending. A review of forty-six human brain imaging studies suggests that deficits in fear conditioning may reflect abnormalities in a common core fear network, that consists of the amygdala, insula and anterior cingulate." Indeed, as Linden [44], points out, the brain is a, "rather weird agglomeration of adhoc solutions that have been piled on through millions of years of evolutionary history." No wonder there is so much overlap.

#### **12. Treatment and intervention**

Blair [16], points out that, "moral socialisation is better achieved through the use of induction," (reasoning that draws children to the effects of their misdemeanour on others). Blair [16], also stated that children with, "emotional difficulties of a lack of guilt/remorse linked to psychopathy," then parental socialisation has no effect, i.e., "no statistical bearing." This is a recipe for hopelessness and abandonment

**81**

**Author details**

Michael Fitzgerald

provided the original work is properly cited.

Department of Psychiatry, Trinity College, Dublin, Ireland

\*Address all correspondence to: profmichaelfitzgerald@gmail.com

*Empathy: Autism and Psychopathy*

unemotional behaviour pathway."

emotional recognition.

present with needs treatment.

**14. Conclusion**

**13. Treatment of psychopathic traits**

*DOI: http://dx.doi.org/10.5772/intechopen.82886*

of these children. Indeed, new research does not support that view. Clearly, these children from a very young age, even before the second year, need help in relation to empathy. I see these children from about one and a half years upwards, and they can be helped, as I will show shortly. Waller et al. [45], points out that, "heritable fearlessness and low interpersonal affiliation traits contribute to the development of callous/unemotional behaviours. Positive parenting can buffer these risky pathways," and that, "mother positive parenting moderated the fearlessness to callous-

Taubner et al. [46], pointed out that, "psychopathic traits alone only partially explain aggression in adolescents. Mentalization may serve as a protective factor to prevent the emergence of proactive aggression in spite of psychopathic traits and may provide a crucial target for intervention." Viding [47], points out that, "callous/ unemotional traits are malleable," "respond to warm parenting" and that Dadds et al. [40] showed that they might benefit from training in emotional literacy and

Empathy effects a whole variety of psychiatric disorders to a greater or lesser degree. There is particular emphasis on psychopathy here, but psychopathy and autism are on a neurodevelopmental mental spectrum and they do overlap. A whole range of neurodevelopmental disorders are on this neurodevelopmental spectrum including learning disability, schizophrenia, bipolar disorder, ADHD, autism, psychopathy. It was an error in DSM 5 [1] to separate neurodevelopmental disorders from schizophrenia. In clinical practice, patients are often on more than one points of this neurodevelopmental spectrum and each aspect of the spectrum that they

© 2019 The Author(s). Licensee IntechOpen. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/ by/3.0), which permits unrestricted use, distribution, and reproduction in any medium,

*Empathy: Autism and Psychopathy DOI: http://dx.doi.org/10.5772/intechopen.82886*

*Empathy Study*

inaccurate.

**10.5 Attachment and empathy**

**10.6 Neurobiology and empathy**

Blair [16], is correct to point out that, "some forms of empathic responding occur independently of attachment style." The causality of attachment research is often deeply flawed. Indeed, Bowlby [41], discussed, "inappropriate mothering," as a cause of autism. Indeed, the causality here is in the opposite direction. Blaming the mother, suggesting that mothers caused autism or psychopathy was totally

Chialant et al. [4] pointed out that deficiencies in the prefrontal cortex and limbic system are associated with both violent behaviour and empathy. They also pointed out that empathy comes out of a, "brainstem-mediated mimicry," and, "mirror neuron mediated emotional resonance which emerges in the very first months of life." Shamay-Tsoory et al. [42], point out that, "recent evidence suggests that there are two possible systems of empathy: a basic emotional contagion system and a more advanced cognitive perspective-taking system. It is not clear whether these two systems are part of a single, interacting empathy system or whether they are independent. Additionally, the neuroanatomical bases of these systems are largely unknown." They found nevertheless that, "a remarkable behavioural and anatomic double dissociation between deficits in cognitive empathy (ventromedial prefrontal), and emotional empathy (inferior frontal gyrus). Furthermore, precise anatomical mapping of lesions revealed Brodmann area 44 to be critical for emotional empathy, while areas 11 and 10 were found necessary for cognitive empathy." This supports the notion that the inferior frontal gyrus is involved in emotional empathy and the ventromedial prefrontal, in cognitive empathy, and that, "these two neural networks

with two core components which are triggered and operate independently."

**11. Callous and unemotional traits (CU), fear and neurobiology**

Herpers et al. [31], note that, "youths with CU traits show lower levels of prosocial

Blair [16], points out that, "moral socialisation is better achieved through the use of induction," (reasoning that draws children to the effects of their misdemeanour on others). Blair [16], also stated that children with, "emotional difficulties of a lack of guilt/remorse linked to psychopathy," then parental socialisation has no effect, i.e., "no statistical bearing." This is a recipe for hopelessness and abandonment

reasoning," and, "lower emotional responsibility," with, "reduced response of the amygdala and a weaker functional connectivity between the amygdala and the ventromedial prefrontal cortex." Glenn and Raine [43], point out that, "poor autonomic fear conditioning - the ability to learn associations between neutral cues and aversive stimuli – is another well replicated correlate of adult criminal and psychopathic adult offending, conduct disorder in children and adolescents, and juvenile offending. A review of forty-six human brain imaging studies suggests that deficits in fear conditioning may reflect abnormalities in a common core fear network, that consists of the amygdala, insula and anterior cingulate." Indeed, as Linden [44], points out, the brain is a, "rather weird agglomeration of adhoc solutions that have been piled on through millions of years of evolutionary history." No wonder there is so much overlap.

**80**

**12. Treatment and intervention**

of these children. Indeed, new research does not support that view. Clearly, these children from a very young age, even before the second year, need help in relation to empathy. I see these children from about one and a half years upwards, and they can be helped, as I will show shortly. Waller et al. [45], points out that, "heritable fearlessness and low interpersonal affiliation traits contribute to the development of callous/unemotional behaviours. Positive parenting can buffer these risky pathways," and that, "mother positive parenting moderated the fearlessness to callousunemotional behaviour pathway."

#### **13. Treatment of psychopathic traits**

Taubner et al. [46], pointed out that, "psychopathic traits alone only partially explain aggression in adolescents. Mentalization may serve as a protective factor to prevent the emergence of proactive aggression in spite of psychopathic traits and may provide a crucial target for intervention." Viding [47], points out that, "callous/ unemotional traits are malleable," "respond to warm parenting" and that Dadds et al. [40] showed that they might benefit from training in emotional literacy and emotional recognition.

#### **14. Conclusion**

Empathy effects a whole variety of psychiatric disorders to a greater or lesser degree. There is particular emphasis on psychopathy here, but psychopathy and autism are on a neurodevelopmental mental spectrum and they do overlap. A whole range of neurodevelopmental disorders are on this neurodevelopmental spectrum including learning disability, schizophrenia, bipolar disorder, ADHD, autism, psychopathy. It was an error in DSM 5 [1] to separate neurodevelopmental disorders from schizophrenia. In clinical practice, patients are often on more than one points of this neurodevelopmental spectrum and each aspect of the spectrum that they present with needs treatment.

#### **Author details**

Michael Fitzgerald Department of Psychiatry, Trinity College, Dublin, Ireland

\*Address all correspondence to: profmichaelfitzgerald@gmail.com

© 2019 The Author(s). Licensee IntechOpen. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/ by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

### **References**

[1] American Psychiatric Association. DSM 5. Washington DC: APA; 2013

[2] Batson C. These things called empathy: 8 related but distinct phenomenon. In: Decety J, Ickes W, editors. The Social Neuroscience of Empathy. Cambridge: MIT Press; 2009

[3] Erickson TH. Do not let us be confused: Psychopathy, mind reading and moral responsibility. 2010. http:11. Do not let us be confused. Blogspot. com-2010-05-psychopathy-mind reading–and–moral.html

[4] Chialant D, Edersheim J, Price B. The dialectic between empathy and violence: An opportunity for intervention? The Journal of Neuropsychiatry and Clinical Neurosciences. 2016;**28**:273-285

[5] Swan P, Riley P. Mentalization: A tool to measure teacher empathy in primary school teachers. The Joint AARE APERA International Conference, Sydney; 2012. pp. 1-20

[6] Fonagy P, Steele H, Moran G, Higgitt A. The capacity for understanding mental states: The reflective self in parent and child and its significance for security of attachment. Infant Mental Health Journal. 1991;**12**:201-217

[7] Hoffman M. The contribution of empathy to justice and moral judgement. In: Eisenberg N, Strayer J, editors. Empathy and its Development. Cambridge Studies in Social and Emotional Development. New York: Cambridge University Press; 1987

[8] Premack D, Woodruff G. Does the chimpanzee have a theory of mind? Behavioral and Brain Sciences. 1978;**1**(4):515-526

[9] Gopnik A, Wellman H. The theory theory. In: Hirschfield L, Gelman S,

editors. Mapping the Mind: Domain Specificity in Culture and Cognition. New York: Cambridge University Press; 1994

[10] Baron-Cohen S. Mindblindness: An Essay on Autism and Theory of Mind. Cambridge: MIT Press; 1995

[11] Gallese V, Goldman AI. Mirror neurons and simulation theory of mind Reading. Trends in Cognitive Sciences. 1998;**2**:493-501

[12] Gordon R. Folk psychology assimilation. Mind & Language. 1986;**1**:158-171

[13] Goldman A, Sripada C. Simulationist models of face-based emotional recognition. Cognition. 2005;**94**:193-213

[14] Goleman D. Social Intelligence: Beyond IQ. Beyond Emotional Intelligence. New York: Bantam; 2006

[15] Decety J, Michalskak Lahey B. Atypical empathic responses in adolescents with aggressive and conduct disorder. Biological Psychiatry. 2009;**30**:303-211

[16] Blair R, Mitchell D, Blair K. The Psychopath: Emotion and Brain. Oxford: Blackwell; 2005

[17] Scheeren AM, De Rosnag M, Kootha M. Re-thinking theory of mind of ASD. The Journal of Child Psychology and Psychiatry. 2013;**6**:628-635

[18] Blair R. Fine cuts of empathy and the amygdala: Dissociable deficits in psychopathy and autism. Quarterly Journal of Experimental Psychology. 2008;**61**(1):157-170

[19] Fitzgerald M. Young, Violent and Dangerous to Know. New York: Nova Science; 2010

**83**

*Empathy: Autism and Psychopathy*

[20] Fitzgerald M. The Future of Psychiatry is Neurodevelopmental. Hospital Doctor of Ireland; 2017

[21] Baron-Cohen S. Zero Degrees of Empathy. London: Allen-Lane; 2011

[23] Scull A. Madness in Civilisation. London: Thames & Hudson; 2015

[24] Insel T. A different way of thinking.

[25] Lord C, Rutter M, Le Couteur A. Autism diagnostic interview-revised. Journal of Autism and Developmental

Disorders. 1994;**24**(5):659-685

[26] Rogers J, Viding E, Blair J, Frith U, Happe F. Autism spectrum disorder and psychopathy: Shared cognitive underpinnings or double hit? Psychological Medicine.

[27] Asperger H. Die "Autistischen Psychopathen", im Kindesalter. Archiv Fur Psychiatrie und Nervenkrankheiten.

[28] Frith U, editor. Autism and Aspergers Syndrome. Cambridge: Cambridge University Press; 1991

[29] Solomon A. The Reckoning. New York: The New Yorker; 2014.

Olds T Publishing; 2009

[30] Cullen D. Columbine. Devon UK:

[31] Herpers P, Scheepers F, Bons D, Buitelaar J, Rommelse N. The cognitive and neural correlates of psychopathy and especially callous-unemotional traits in youths: A systematic review of the evidence. Development and Psychopathology. 2013;**26**:245-273

[22] Fitzgerald M. Schizophrenia and autism: Clinical overlap and difference. Clinical Neuropsychiatry.

2012;**10**(4):171-176

New Scientist. 2015:3

2006;**36**:1789-1798

1944;**117**:76-136

pp. 36-45

*DOI: http://dx.doi.org/10.5772/intechopen.82886*

[32] Dadds M, Perry Y, Hawes D, Merzs DJ, Riddell AC, Haines D. Attention to the eyes and fear recognition deficits in child psychopathy. British Journal of

Psychiatry. 2006;**189**:280-281

2008;**363b**:2567-2576

2010;**133**:1515-1525

2006;**36**(4):575-576

Neuroscience. 2012;**35**:1-23

[33] Dadds M, Rhodes T. Aggression in young children with concurrent callous-unemotional traits: Can neurosciences inform progress and innovation in treatment approaches. Philosophical Transactions of the Royal Society of London.

[34] Bernhardt BC, Singer T. The neural basis of empathy. Annual Review of

[35] Nemiah J. Alexithymia. Theoretical considerations. Psychotherapy and Psychosomatics. 1977;**28**:199-206

[36] Bird G, Silani G, Brindley R, White S, Frith U, Singer T. Empathic brain responses in insula or modified by level of alexithymia. Brain.

[37] Fitzgerald M, Bellgrove M. The overlap between alexithymia and Aspergers syndrome. Journal of Autism and Developmental Disorders.

[38] Drayton L, Santos L, Baskin-Sommers A. Psychopaths fail to automatically take the prospective of others. PNAS. 2018;**115**(3):3302-3307

[39] Marshall J, Gollwitzer A, Santos LR. Does altercentric interference rely on mentalizing. PLoS One. 2016;**13**(3):e0194101. DOI:

10:1371-Journal.pone.0194101

2012;**199**:201-207

[40] Dadds M, Cauchi A, Wimalaweerg S, Hawes D, Brennan J. Outcomes, moderators, mediators of empathicemotion recognition training for complex conduct problems in childhood. Psychiatry Research.

*Empathy: Autism and Psychopathy DOI: http://dx.doi.org/10.5772/intechopen.82886*

[20] Fitzgerald M. The Future of Psychiatry is Neurodevelopmental. Hospital Doctor of Ireland; 2017

[21] Baron-Cohen S. Zero Degrees of Empathy. London: Allen-Lane; 2011

[22] Fitzgerald M. Schizophrenia and autism: Clinical overlap and difference. Clinical Neuropsychiatry. 2012;**10**(4):171-176

[23] Scull A. Madness in Civilisation. London: Thames & Hudson; 2015

[24] Insel T. A different way of thinking. New Scientist. 2015:3

[25] Lord C, Rutter M, Le Couteur A. Autism diagnostic interview-revised. Journal of Autism and Developmental Disorders. 1994;**24**(5):659-685

[26] Rogers J, Viding E, Blair J, Frith U, Happe F. Autism spectrum disorder and psychopathy: Shared cognitive underpinnings or double hit? Psychological Medicine. 2006;**36**:1789-1798

[27] Asperger H. Die "Autistischen Psychopathen", im Kindesalter. Archiv Fur Psychiatrie und Nervenkrankheiten. 1944;**117**:76-136

[28] Frith U, editor. Autism and Aspergers Syndrome. Cambridge: Cambridge University Press; 1991

[29] Solomon A. The Reckoning. New York: The New Yorker; 2014. pp. 36-45

[30] Cullen D. Columbine. Devon UK: Olds T Publishing; 2009

[31] Herpers P, Scheepers F, Bons D, Buitelaar J, Rommelse N. The cognitive and neural correlates of psychopathy and especially callous-unemotional traits in youths: A systematic review of the evidence. Development and Psychopathology. 2013;**26**:245-273

[32] Dadds M, Perry Y, Hawes D, Merzs DJ, Riddell AC, Haines D. Attention to the eyes and fear recognition deficits in child psychopathy. British Journal of Psychiatry. 2006;**189**:280-281

[33] Dadds M, Rhodes T. Aggression in young children with concurrent callous-unemotional traits: Can neurosciences inform progress and innovation in treatment approaches. Philosophical Transactions of the Royal Society of London. 2008;**363b**:2567-2576

[34] Bernhardt BC, Singer T. The neural basis of empathy. Annual Review of Neuroscience. 2012;**35**:1-23

[35] Nemiah J. Alexithymia. Theoretical considerations. Psychotherapy and Psychosomatics. 1977;**28**:199-206

[36] Bird G, Silani G, Brindley R, White S, Frith U, Singer T. Empathic brain responses in insula or modified by level of alexithymia. Brain. 2010;**133**:1515-1525

[37] Fitzgerald M, Bellgrove M. The overlap between alexithymia and Aspergers syndrome. Journal of Autism and Developmental Disorders. 2006;**36**(4):575-576

[38] Drayton L, Santos L, Baskin-Sommers A. Psychopaths fail to automatically take the prospective of others. PNAS. 2018;**115**(3):3302-3307

[39] Marshall J, Gollwitzer A, Santos LR. Does altercentric interference rely on mentalizing. PLoS One. 2016;**13**(3):e0194101. DOI: 10:1371-Journal.pone.0194101

[40] Dadds M, Cauchi A, Wimalaweerg S, Hawes D, Brennan J. Outcomes, moderators, mediators of empathicemotion recognition training for complex conduct problems in childhood. Psychiatry Research. 2012;**199**:201-207

**82**

*Empathy Study*

**References**

[1] American Psychiatric Association. DSM 5. Washington DC: APA; 2013

editors. Mapping the Mind: Domain Specificity in Culture and Cognition. New York: Cambridge University Press;

[10] Baron-Cohen S. Mindblindness: An Essay on Autism and Theory of Mind.

Cambridge: MIT Press; 1995

1998;**2**:493-501

1986;**1**:158-171

2005;**94**:193-213

2009;**30**:303-211

Blackwell; 2005

2008;**61**(1):157-170

Science; 2010

[11] Gallese V, Goldman AI. Mirror neurons and simulation theory of mind Reading. Trends in Cognitive Sciences.

[12] Gordon R. Folk psychology assimilation. Mind & Language.

[13] Goldman A, Sripada C.

Simulationist models of face-based emotional recognition. Cognition.

[14] Goleman D. Social Intelligence: Beyond IQ. Beyond Emotional Intelligence. New York: Bantam; 2006

[15] Decety J, Michalskak Lahey B. Atypical empathic responses in adolescents with aggressive and

conduct disorder. Biological Psychiatry.

[17] Scheeren AM, De Rosnag M, Kootha M. Re-thinking theory of mind of ASD. The Journal of Child Psychology

[16] Blair R, Mitchell D, Blair K. The Psychopath: Emotion and Brain. Oxford:

and Psychiatry. 2013;**6**:628-635

[18] Blair R. Fine cuts of empathy and the amygdala: Dissociable deficits in psychopathy and autism. Quarterly Journal of Experimental Psychology.

[19] Fitzgerald M. Young, Violent and Dangerous to Know. New York: Nova

1994

[2] Batson C. These things called empathy: 8 related but distinct phenomenon. In: Decety J, Ickes W, editors. The Social Neuroscience of Empathy. Cambridge: MIT Press; 2009

[3] Erickson TH. Do not let us be confused: Psychopathy, mind reading and moral responsibility. 2010. http:11. Do not let us be confused. Blogspot. com-2010-05-psychopathy-mind

[4] Chialant D, Edersheim J, Price B. The dialectic between empathy and violence: An opportunity for intervention? The Journal of Neuropsychiatry and Clinical Neurosciences. 2016;**28**:273-285

[5] Swan P, Riley P. Mentalization: A tool to measure teacher empathy in primary school teachers. The Joint AARE APERA International Conference, Sydney; 2012.

[6] Fonagy P, Steele H, Moran G, Higgitt A. The capacity for understanding mental states: The reflective self in parent and child and its significance for security of attachment. Infant Mental Health Journal. 1991;**12**:201-217

[7] Hoffman M. The contribution of empathy to justice and moral judgement. In: Eisenberg N, Strayer J, editors. Empathy and its Development. Cambridge Studies in Social and Emotional Development. New York: Cambridge University Press; 1987

[8] Premack D, Woodruff G. Does the chimpanzee have a theory of mind? Behavioral and Brain Sciences.

[9] Gopnik A, Wellman H. The theory theory. In: Hirschfield L, Gelman S,

1978;**1**(4):515-526

reading–and–moral.html

pp. 1-20

#### *Empathy Study*

[41] Bowlby J. Attachment and loss. In: Separation. Vol. 2. London: Hogarth Press; 1973

[42] Shamay-Tsoory S, Aharon-Peretz J, Perry D. Two systems for empathy: A double dissociation between emotional and cognitive empathy in inferior frontal gyrus versus ventromedial prefrontal lesions. Brain. 2009;**132**:617-627

[43] Glenn A, Raine A. Neurocriminology: Implications for the punishment, prediction and prevention of criminal behaviour. Nature Reviews. 2014;**15**:54-63

[44] Linden DJ. The Accidental Brain. Cambridge Mass: H.U.P; 2007

[45] Waller R, Trentacosta C, Shaw D, Neiderhiser J, Ganiban J, Reiss D, et al. Heritable temperament pathways to early callous-unemotional behaviour. British Journal of Psychiatry. 2016;**209**:475-482

[46] Taubner S, White L, Zimmermann J, Fonagy P, Nulty T. Attachment– related mentalization moderates the relationship between psychopathic traits and proactive aggression in adolescents. Journal of Abnormal Child Psychology. 2013;**41**(6):929-938

[47] Viding E. Callous and Unemotional Traits in Children. Washington: Association for Psychological Science; 2013. pp. 1-5

*Empathy Study*

Press; 1973

2009;**132**:617-627

2016;**209**:475-482

2013;**41**(6):929-938

2013. pp. 1-5

[41] Bowlby J. Attachment and loss. In: Separation. Vol. 2. London: Hogarth

[42] Shamay-Tsoory S, Aharon-Peretz J, Perry D. Two systems for empathy: A double dissociation between emotional and cognitive empathy in inferior frontal gyrus versus

ventromedial prefrontal lesions. Brain.

[43] Glenn A, Raine A. Neurocriminology:

[44] Linden DJ. The Accidental Brain.

[45] Waller R, Trentacosta C, Shaw D, Neiderhiser J, Ganiban J, Reiss D, et al. Heritable temperament pathways to early callous-unemotional behaviour. British Journal of Psychiatry.

[46] Taubner S, White L, Zimmermann J, Fonagy P, Nulty T. Attachment– related mentalization moderates the relationship between psychopathic traits and proactive aggression in adolescents. Journal of Abnormal Child Psychology.

[47] Viding E. Callous and Unemotional

Traits in Children. Washington: Association for Psychological Science;

Implications for the punishment, prediction and prevention of criminal behaviour. Nature Reviews. 2014;**15**:54-63

Cambridge Mass: H.U.P; 2007

**84**

## *Edited by Makiko Kondo and Bala Nikku*

Empathy, as it relates to behavioral counseling, is the ability of the counselor to get into the client's phenomenological world and experience it as if it is one's own while putting aside one's own feelings and accepting the client's thoughts and feelings unconditionally. Empathy is indispensable not only for forming good relationships but also for healing hurt persons. Especially now, empathy is the essence of care. This book contains chapters that cover transpersonal caring, learning to be empathic in social school, autism and psychopathy, emotional labor, and critical thinking in social work training from a variety of different perspectives.

Published in London, UK © 2020 IntechOpen © hyejin kang / iStock

Empathy Study

Empathy Study

*Edited by Makiko Kondo and Bala Nikku*