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The psychology of emotional and cognitive empathy.

The study of empathy is an ongoing area of major interest for psychologists and neuroscientists in many fields, with new research appearing regularly.

Empathy is a broad concept that refers to the cognitive and emotional reactions of an individual to the observed experiences of another. Having empathy increases the likelihood of helping others and showing compassion. “Empathy is a building block of morality—for people to follow the Golden Rule, it helps if they can put themselves in someone else’s shoes,” according to  the Greater Good Science Center , a research institute that studies the psychology, sociology, and neuroscience of well-being. “It is also a key ingredient of successful relationships because it helps us understand the perspectives, needs, and intentions of others.”

Though they may seem similar, there is a clear distinction between empathy and sympathy. According to Hodges and Myers in the  Encyclopedia of Social Psychology , “Empathy is often defined as understanding another person’s experience by imagining oneself in that other person’s situation: One understands the other person’s experience as if it were being experienced by the self, but without the self actually experiencing it. A distinction is maintained between self and other. Sympathy, in contrast, involves the experience of being moved by, or responding in tune with, another person.”

Emotional and Cognitive Empathy

Researchers distinguish between two types of empathy. Especially in social psychology, empathy can be categorized as an emotional or cognitive response. Emotional empathy consists of three separate components, Hodges and Myers say. “The first is feeling the same emotion as another person … The second component, personal distress, refers to one’s own feelings of distress in response to perceiving another’s plight … The third emotional component, feeling compassion for another person, is the one most frequently associated with the study of empathy in psychology,” they explain.

It is important to note that feelings of distress associated with emotional empathy don’t necessarily mirror the emotions of the other person. Hodges and Myers note that, while empathetic people feel distress when someone falls, they aren’t in the same physical pain. This type of empathy is especially relevant when it comes to discussions of compassionate human behavior. There is a positive correlation between feeling empathic concern and being willing to help others. “Many of the most noble examples of human behavior, including aiding strangers and stigmatized people, are thought to have empathic roots,” according to Hodges and Myers. Debate remains concerning whether the impulse to help is based in altruism or self-interest.

The second type of empathy is cognitive empathy. This refers to how well an individual can perceive and understand the emotions of another. Cognitive empathy, also known as empathic accuracy, involves “having more complete and accurate knowledge about the contents of another person’s mind, including how the person feels,” Hodges and Myers say. Cognitive empathy is more like a skill: Humans learn to recognize and understand others’ emotional state as a way to process emotions and behavior. While it’s not clear exactly how humans experience empathy, there is a growing body of research on the topic.

How Do We Empathize?

Experts in the field of social neuroscience have developed  two theories  in an attempt to gain a better understanding of empathy. The first, Simulation Theory, “proposes that empathy is possible because when we see another person experiencing an emotion, we ‘simulate’ or represent that same emotion in ourselves so we can know firsthand what it feels like,” according to  Psychology Today .

There is a biological component to this theory as well. Scientists have discovered preliminary evidence of “mirror neurons” that fire when humans observe and experience emotion. There are also “parts of the brain in the medial prefrontal cortex (responsible for higher-level kinds of thought) that show overlap of activation for both self-focused and other-focused thoughts and judgments,” the same article explains.

Some experts believe the other scientific explanation of empathy is in complete opposition to Simulation Theory. It’s Theory of Mind, the ability to “understand what another person is thinking and feeling based on rules for how one should think or feel,”  Psychology Today says. This theory suggests that humans can use cognitive thought processes to explain the mental state of others. By developing theories about human behavior, individuals can predict or explain others’ actions, according to this theory.

While there is no clear consensus, it’s likely that empathy involves multiple processes that incorporate both automatic, emotional responses and learned conceptual reasoning. Depending on context and situation, one or both empathetic responses may be triggered.

Cultivating Empathy

Empathy seems to arise over time as part of human development, and it also has roots in evolution. In fact, “Elementary forms of empathy have been observed in our primate relatives, in dogs, and even in rats,” the Greater Good Science Center says. From a developmental perspective, humans begin exhibiting signs of empathy in social interactions during the second and third years of life. According to  Jean Decety’s article “The Neurodevelopment of Empathy in Humans ,” “There is compelling evidence that prosocial behaviors such as altruistic helping emerge early in childhood. Infants as young as 12 months of age begin to comfort victims of distress, and 14- to 18-month-old children display spontaneous, unrewarded helping behaviors.”

While both environmental and genetic influences shape a person’s ability to empathize, we tend to have the same level of empathy throughout our lives, with no age-related decline. According to “Empathy Across the Adult Lifespan: Longitudinal and Experience-Sampling Findings,” “Independent of age, empathy was associated with a  positive well-being and interaction profile .”

And it’s true that we likely feel empathy due to  evolutionary advantage : “Empathy probably evolved in the context of the parental care that characterizes all mammals. Signaling their state through smiling and crying, human infants urge their caregiver to take action … females who responded to their offspring’s needs out-reproduced those who were cold and distant,” according to the Greater Good Science Center. This may explain gender differences in human empathy.

This suggests we have a natural predisposition to developing empathy. However, social and cultural factors strongly influence where, how, and to whom it is expressed. Empathy is something we develop over time and in relationship to our social environment, finally becoming “such a complex response that it is hard to recognize its origin in simpler responses, such as body mimicry and emotional contagion,” the same source says.

Psychology and Empathy

In the field of psychology, empathy is a central concept. From a mental health perspective, those who have high levels of empathy are more likely to function well in society, reporting “larger social circles and more satisfying relationships,” according to  Good Therapy , an online association of mental health professionals. Empathy is vital in building successful interpersonal relationships of all types, in the family unit, workplace, and beyond. Lack of empathy, therefore, is one indication of conditions like antisocial personality disorder and narcissistic personality disorder. In addition, for mental health professionals such as therapists, having empathy for clients is an important part of successful treatment. “Therapists who are highly empathetic can help people in treatment face past experiences and obtain a greater understanding of both the experience and feelings surrounding it,” Good Therapy explains.

Exploring Empathy

Empathy plays a crucial role in human, social, and psychological interaction during all stages of life. Consequently, the study of empathy is an ongoing area of major interest for psychologists and neuroscientists in many fields, with new research appearing regularly. Lesley University’s  online bachelor’s degree in Psychology  gives students the opportunity to study the field of human interaction within the broader spectrum of psychology.

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‘I Feel Your Pain’: The Neuroscience of Empathy

• Developmental Psychology
• Forecasting
• Neuroscience
• Sensory Systems

Whether it’s watching a friend get a paper cut or staring at a photo of a child refugee, observing someone else’s suffering can evoke a deep sense of distress and sadness — almost as if it’s happening to us. In the past, this might have been explained simply as empathy, the ability to experience the feelings of others, but over the last 20 years, neuroscientists have been able to pinpoint some of the specific regions of the brain responsible for this sense of interconnectedness. Five scientists discussed the neuroscience behind how we process the feelings of others during an Integrative Science Symposium chaired by APS Fellow Piotr Winkielman (University of California, San Diego) at the 2017 International Convention of Psychological Science in Vienna.

Mirroring the Mind

Cultural emphasis on ingroups and outgroups may create an “empathy gap” between people of different races and nationalities, says Ying-yi Hong .

“When we witness what happens to others, we don’t just activate the visual cortex like we thought some decades ago,” said Christian Keysers of the Netherlands Institute for Neuroscience in Amsterdam. “We also activate our own actions as if we’d be acting in similar ways. We activate our own emotions and sensations as if we felt the same.”

Through his work at the Social Brain Lab, Keysers, together with Valeria Gazzola, has found that observing another person’s action, pain, or affect can trigger parts of the same neural networks responsible for executing those actions and experiencing those feelings firsthand. Keysers’ presentation, however, focused on exploring how this system contributes to our psychology. Does this mirror system help us understand what goes on in others? Does it help us read their minds? Can we “catch” the emotions of others?

To explore whether the motor mirror system helps us understand the inner states behind the actions of others, Keysers in one study asked participants to watch a video of a person grasping toy balls hidden within a large bin. In one condition, participants determined whether or not the person in the video hesitated before selecting a ball (a theory-of-mind task). Using transcranial magnetic stimulation (TMS) in combination with fMRI, Keysers showed that interfering with the mirror system impaired people’s ability to detect the level of confidence of others, providing evidence that this system indeed contributes to perceiving the inner states of others. Performing fMRI and TMS on other brain regions such as the temporoparietal junction (TPJ) further suggests that this motor simulation in the mirror system is then sent onward to more cognitive regions in the TPJ.

“Very rapidly, we got this unifying notion that when you witness the states of others you replicate these states in yourself as if you were in their shoes, which is why we call these activities ‘vicarious states,’” Keysers said.

Studies have suggested that this ability to mentalize the experiences of others so vividly can lead us to take prosocial steps to reduce their pain, but Keysers also wanted to investigate the depth of this emotional contagion — how and to what extent we experience other people’s suffering. To do this, Keysers’ lab studied two very different populations: human psychopaths and rats.

While witnessing the pain of others is correlated with activity in the insula, which is thought to contribute to self-awareness by integrating sensory information, and the anterior cingulate cortex (ACC), which is associated with decision making and impulse control, the researchers found that psychopaths who passively observed an aggressor twisting someone’s hand exhibited significantly less brain activity than their neurotypical peers. When the psychopathic individuals were asked to attempt to empathize with the person in the video, however, their brain activity increased to baseline levels.

This suggests that the current model of empathy as a one-dimensional scale with empathic individuals at one end and psychopaths at the other may be overly simplistic, Keysers said.

“Psychopaths are probably equally high on ability, it’s just that they don’t recruit this spontaneously, so their propensity is modified,” he explained.

These findings could lead to more effective interventions for psychopathic individuals, as well as to future research into where people with autism spectrum disorders may fall on these axes.

Shared Pain

Studies of emotional contagion in animal models have allowed researchers to further examine the role of deep brain activity, which can be difficult to neurostimulate in humans. Keysers’ work with rats has found that these animals are more likely to freeze after watching another rat receive an electric shock if they themselves had been shocked in the past.

Inhibiting a region analogous to the ACC in the rats’ brains reduced their response to another rat’s distress, but not their fear of being shocked themselves, suggesting that the area deals specifically with socially triggered fear, Keysers said.

Claus Lamm, University of Vienna, investigates the processes that regulate firsthand pain and those that cause empathy for pain through numerous studies on the influence of painkillers.

In these experiments, participants who took a placebo “painkiller” reported lower pain ratings after receiving a shock than did those in the control group. When those same participants watched a confederate get shocked, they reported a similar drop in their perception of the actor’s pain.

“If you reduce people’s self-experienced pain, if you induce analgesia, that not only helps people to deal with their own pain, but it also reduces empathy for the pain of another person,” Lamm said.

On the neural level, Lamm said, fMRI scans showed that people in the placebo group displayed lower levels of brain activity in the anterior insula and mid cingulate cortex in both cases. These results were further confirmed in another study that compared participants who received only the painkiller placebo with those who received both the placebo and naltrexone, an opioid antagonist that prevents the brain from regulating pain.

This resulted in a “complete reversal” of the placebo effect, causing participants to report both their own pain and the pain of others at near baseline rates, supporting Lamm’s previous claims about the pain system’s role in empathy.

“This suggests that empathy for pain is grounded in representing others’ pain within one’s own pain systems,” Lamm said.

The Self/Other Divide

Empathy may not give us a full sense of someone else’s experiences, however. When observers in one of Keysers’ studies were given the opportunity to pay to reduce the severity of the electric shocks a confederate was about to receive, on average participants paid only enough to reduce her pain by 50%.

Lamm studied this self/other distinction through a series of experiments that measured people’s emotional egocentricity bias. To do so, participants were presented with visuo-tactile stimulation that was either congruent or incongruent with that of a partner under fMRI. In an incongruent pair, for example, one participant might be presented with an image of a rose and be touched with something that felt like a rose, while the other was shown a slug and touched with a slimy substance.

Participants’ own emotions were found to color their perception of other people’s affect at a relatively low rate — however, when researchers inhibited the right supramarginal gyrus (rSMG), a region of the brain previous associated mainly with language processing, this egocentricity bias increased, suggesting that the rSMG may be responsible for maintaining a self/other divide, Lamm said.

“Empathy not only requires a mechanism for sharing emotions, but also for keeping them separate. Otherwise we are getting ‘contaged,’ emotionally distressed and so on,” he said.

The rate of rSMG activation also changes significantly across a lifetime, Lamm added, with the area’s developmental trajectory causing emotional egocentricity to be more common in adolescents and the elderly.

Developing Division

Researchers are working to unite neuroscientific and psychological perspectives on feelings, empathy, and identity, says Piotr Winkielman .

Rebecca Saxe (Massachusetts Institute of Technology) said her work with developmental psychology confirms this trend. In one series of experiments, Saxe monitored the brain networks that 3- to 5-year-old children used to consider a character’s mind (the temporoparietal junction, posterior cingulate, and prefrontal cortex) and body (the secondary somatosensory cortex, insula, middle frontal gyrus, and ACC) throughout a short film.

Saxe found that while these brain regions may interact with each other, there were no points of overlap between the mind and body networks’ activities.

“When we’re getting information from the same source and about the same people, we still nevertheless impose a kind of dualism where we alternate between considering what their bodies feel like and the causes of their minds,” Saxe said.

Furthermore, Saxe and her colleagues found that while these networks were more distinct in children who were able to pass an explicit-false-belief task (e.g., if Sally puts her sandwich on a shelf and her friend moves it to the desk, where will she look for it?), the division was present in participants of all ages.

“Most people have treated explicit false belief as if it were the milestone,” Saxe said. “Actually, the false-belief task is just one measure of a much more continuous developmental change as children become increasingly sophisticated in their thinking about other people’s minds.”

Next, Saxe scaled this experiment down to test the theory of mind of infants as young as 6 months, this time measuring their response to children’s facial expressions, outdoor scenes, and visual static. This time period may be key to understanding the neuropsychology of empathy because most of the brain’s cognitive development happens within the first year of life, she explained.

“A baby’s brain is more different from a 3-year-old’s brain than a 3-year-old’s brain is from a 33-year-old’s brain,” Saxe said.

Under fMRI, the infants’ brains were found to have many of the same regional responses that allow adults to distinguish between faces and scenes. Their brains didn’t show any regional preferences for objects and bodies, however.

This level of regional specificity suggests that the Kennard Principle, the theory that infants’ brains possess such resilience and plasticity because the cortex hasn’t specialized yet, may be only partially true. There does appear to be some functional organization of social process, Saxe said, with gradually increasing specialization as the child ages.

Empathy in Action

Brian D. Knutson says analysis of individuals’ brain activity when considering a purchase may be predictive of aggregate market choices.

On the surface, neuroforecasting sounds like a concept that would be right at home in the world of Philip K. Dick’s Minority Report — a science fiction thriller about a society that stops crime before it happens based on the brainwaves of three mutant “precogs” — said APS Fellow Brian D. Knutson (Stanford University), but someday it could play a very real role in the future of economics.

Knutson’s research on the brain mechanisms that influence choice homes in on three functional targets: the nucleus accumbens (NAcc) for gain anticipation, the anterior insula for loss anticipation, and the medial prefrontal cortex (mPFC) for value integration.

Using fMRI, Knutson was able to predict participants’ purchases in a simulated online shopping environment on the basis of brain activations in these areas. Before participants chose to buy a product, increased activity in the NAcc and mPFC was paired with a decrease in the insula, while the reverse was true of trials in which participants chose not to make a purchase.

“This was very exciting to me as a psychologist to be able to say, ‘Wow, we can take activity out of the brain and, not knowing anything else about who it is and what product they’re seeing, we can predict choice,’” Knutson said.

His economist colleagues weren’t as impressed: They were interested in market activity, not individual choice. Knutson said he accepted this challenge by applying his neuroanaylsis to large-scale online markets such as Kiva and Kickstarter.

Knutson asked 30 participants to rate the appeal and neediness of loan requests on Kiva and found that posts with photos of people displaying a positive affect were most likely to trigger the increased NAcc activity that caused them to make a purchase — or in this case, a loan. More importantly, the averaged choices of those participants forecasted the loan appeal’s success on the internet. Two similar studies involving Kickstarter campaigns also suggested a link between NAcc activity and aggregate market activity.

While brain activity doesn’t scale perfectly to aggregate choice, Knutson said, some components of decision making, such as affective responses, may be more generalizable than others.

“The paradox may be that the things that make you most consistent as an individual, that best predict your choices, may not be the things that make your choices conform to those of others. We may be able to deconstruct and decouple those components in the brain,” Knutson said.

Global Empathy

The neuroanatomy of our brains may allow us to feel empathy for another’s experiences, but it can also stop us from making cross-cultural connections, said APS Fellow Ying-yi Hong (Chinese University of Hong Kong).

“Despite all these neurobiological capabilities enabling us to empathize with others, we still see cases in which individuals chose to harm others, for example during intergroup conflicts or wars,” Hong said.

This may be due in part to the brain’s distinction between in-group and out-group members, she explained. People have been found to show greater activation in the amygdala when viewing fearful faces of their own race, for example, and less activation in the ACC when watching a needle prick the face of someone of a different race.

The cultural mixing that accompanies globalization can heighten these responses, Hong added. In one study, she and her colleagues found that melding cultural symbols (e.g., combining the American and Chinese flags, putting Chairman Mao’s head on the Lincoln Memorial, or even presenting images of “fusion” foods) can elicit a pattern of disgust in the anterior insula of White Americans similar to that elicited by physical contaminant objects such as insects.

These responses can also be modulated by cultural practices, Hong said. One study comparing the in-group/out-group bias in Korea, a more collectivist society, and the United States, a more individualistic society, found that more interdependent societies may foster a greater sense of in-group favoritism in the brain.

Further research into this empathy gap should consider not just the causal relationship between neural activation and behavior, she said, but the societal context in which they take place.

“What I want to propose,” Hong said, “is that maybe there is another area that we can also think about, which is the culture, the shared lay theories, values, and norms.”

There is some fantastic research going on in empathy. From an evolutionary point of view however it’s important to distinguish an evolved motivation system from a competency. Empathy is a competency not a motivation. Empathy can be used for both benevolent but also malevolent motives. And psychopaths have a competency for empathy but what they lack is mammalian caring motivation. Insofar as part of the reproductive strategy of the psychopath is to exploit others and even threaten them then having a brain that turns off distress to the suffering they cause would be an advantage to them. Psychopaths are much more likely to be prepared to harm others to get what they want. Mammalian caring motivation, when guided by higher cognitive processes and human empathy gives rise to compassion. Without empathy compassion would be tricky but without compassion you can still have empathic competencies

Gilbert, P. (2017). Compassion as a social mentality: An evolutionary approach. In: P. Gilbert (ed). Compassion: Concepts, Research and Applications. (p. 31-68). London: Routledge

Gilbert. P. (2015). The evolution and social dynamics of compassion Journal of Social & Personality Psychology Compass, 9, 239–254. DOI: 10.1111/spc3.12176

Catarino, F., Gilbert, P., McEwan., K & Baião, R. (2014). Compassion motivations: Distinguishing submissive compassion from genuine compassion and its association with shame, submissive behaviour, depression, anxiety and stress Journal of Social and Clinical Psychology, 33, 399-412.

Gilbert, P., Catarino, F., Sousa, J., Ceresatto, L., Moore, R., & Basran, J. (2017). Measuring competitive self-focus perspective taking, submissive compassion and compassion goals. Journal of Compassionate Health Care, 4(1), 5

Very interesting article. The research behind what links our empathy to our actions determining the agenda is fascinating. As social creatures, we seem to inhibit empathetic tendencies naturally in our genetic makeup when studied. Since we have the highest empathetic behavior compared to other animals, who also show empathetic behavior, I wonder if it falls more on our social norms. What we consider relatable is worthy of our empathy. If we don’t relate, we may be less inclined to put ourselves in the other position.

I have what I call empathy pain. It radiates an aching pain in my legs and I can barely stand it. I’ve googled it in attempts to validate it is real. It seems people either do not believe me or can’t understand stand when I tell them it makes my legs ache. Seeing someone’s cuts, surgical incisions, bloody wounds. I can’t describe all the triggers, but I can 100% say the pain I feel in response is intense, even when they say “oh, it didn’t hurt” or “it’s not hurting”. Well, it hurt ME seeing it.

I am currently writing a literature review for my psychology course in University, based on what I am writing about I believe you may have Mirror Touch Synesthesia. This condition is characterized by viewing others being touched and feeling tactile sensations, and this seems quite similar to what you shared. I would recommend doing a bit of research on MTS, and see if it relates to you.

Since I was 7 years old I felt others pain Then I thought everyone could . I came to realize I feel so much more than most . I feel what I see, I feel what I hear. My sensitive to touch is more like pain but my pain level is very high, I can take a lot of pain.

What about feeling pain or illness without observing it or even having knowledge of someone else’s pain? Such as the phenomenon of twins. I’m looking for research of this outside of the twin sibling relationship.

When carrying out functional mapping of the amygdala cortex by means of electrical stimulation in one of my patients with focal epileptic seizures who was being evaluated for resective epilepsy surgery of the orbitofrontal, opercular, and anterior insular cortex the stimulation caused the patient to reminisce over video films he had seen of cartoons (animaniacs) as a child, at the same time empathizing with the suffering of those characters. I had probably activated a limbic pathway connected to the limen insulae where I was administering electrical stimulation at that time. The visual imagery stopped as soon as the stimulus train was over but the patient still empathized with the cartoon characters for about 20 seconds after the stimulation was over and reported his feelings to me.

Wow… I thought I was alone in the way I feel everyone’s pain and joy. I find that I can not watch scenes of torture or violence on tv, thus I hate most movies, unless it’s a children flick. I get pulled into every story I read. On 911 I thought my heart really was breaking, it consumed my entire body. I can’t watch history shows of Pearl Harbor, or nazis. If I do, sometimes those images stay with me for years and come back as nightmares. It’s not easy living with this in today’s world.

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In a set of articles appearing in Perspectives on Psychological Science, an international array of scientists discusses how the study of neighborhoods, work units, activist groups, and other collectives can help us better understand and respond to societal changes.

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Audio cues can not only help us to recognize objects more quickly but can even alter our visual perception. That is, pair birdsong with a bird and we see a bird—but replace that birdsong with a squirrel’s chatter, and we’re not quite so sure what we’re looking at. 

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Empathy is a social process by which a person has an understanding and awareness of another's emotions and/or behaviour, and can often lead to a person experiencing the same emotions. It differs from sympathy, which involves concern for others without sharing the same emotions as them.

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How to build empathy in research

Brenda Reginatto

Sunetra Bane

Dr Susie Donnelly

About this video

Empathy can help researchers better understand people’s behaviours, values and needs. Through asking effective questions, a researcher can build empathy with research participants.

In this webinar, our experts explain why empathy is important in research and focus on three tools for building empathy in research: interviewing, journey mapping and Photovoice. Also, they discuss ways of adapting these tools across sectors; including academia, industry and clinical settings.

After this webinar, you will learn practical tips on how to ask effective questions for building empathy with research participants, how to leverage journey-maps to understand workflows and stories, identify gaps and needs, and encourage participatory research. Also, you will understand how the use of Photovoice as a methodological tool can promote empathy among policymakers and other stakeholders.      

About the presenters

Independent Consultant to digital health companies in Boston, USA.

Brenda is a gerontologist with expertise in human-centered design and healthcare innovation. Brenda has led user research teams at University College Dublin (Ireland) and Partners Healthcare (USA), where she worked with companies, ranging from early stage start-ups to large multinationals, to bring the voice of the user to the design and development of their digital health products. After obtaining her MSc from King’s College London in 2012, Brenda became interested in the application of human-centred design to create better products and services for older adults. She is currently working as an independent consultant to digital health companies in Boston, USA.

Independent UX consultant with innovation labs and start-ups.

Sunetra is a user-experience researcher and strategist with experience in human-centered design and design thinking for product and service design. She also has a background in global public health in the US and Indian context, earning her MPH from Boston University’s School of Public Health in 2015.

During her time at Partners Healthcare, Sunetra leveraged both those elements of her background, education and experience to lead design projects focused on improving health outcomes and the human journey with illness and wellness. She is interested in bridging the gap between academic and applied user research for product and service design in healthcare. Sunetra is now based in Pune, India, working as an independent UX consultant with innovation labs and start-ups.

Postdoctoral researcher with the School of Nursing, Midwifery and Health Systems and the Centre for Arthritis Research in University College Dublin.

Susie is a postdoctoral researcher with the School of Nursing, Midwifery and Health Systems and the Centre for Arthritis Research in University College Dublin. She joined these teams in 2018 under a Wellcome Trust Medical Humanities and Social Science Collaborative grant to conduct participatory action research with a community of people living with the chronic and invisible illness, rheumatoid arthritis. Building on her background in journalism (BA) and sociology (HDip, MSocSc, PhD), she began to explore innovative participatory methods such as photovoice upon joining the research team at the Centre for Applied Research in Connected Health as ethnographer in 2017. 

Susie’s research career reflects her diverse interests in methodology, communications, power and inequality. She has peer-reviewed publications in the Journal of Medical Internet Research , the Irish Journal of Sociology , and the Journal of Contemporary Religion among others

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Empathy Defined

What is empathy.

The term “empathy” is used to describe a wide range of experiences. Emotion researchers generally define empathy as the ability to sense other people’s emotions, coupled with the ability to imagine what someone else might be thinking or feeling.

Contemporary researchers often differentiate between two types of empathy : “Affective empathy” refers to the sensations and feelings we get in response to others’ emotions; this can include mirroring what that person is feeling, or just feeling stressed when we detect another’s fear or anxiety. “Cognitive empathy,” sometimes called “perspective taking,” refers to our ability to identify and understand other people’s emotions. Studies suggest that people with autism spectrum disorders have a hard time empathizing .

Empathy seems to have deep roots in our brains and bodies, and in our evolutionary history . Elementary forms of empathy have been observed in our primate relatives , in dogs , and even in rats . Empathy has been associated with two different pathways in the brain, and scientists have speculated that some aspects of empathy can be traced to mirror neurons , cells in the brain that fire when we observe someone else perform an action in much the same way that they would fire if we performed that action ourselves. Research has also uncovered evidence of a genetic basis to empathy , though studies suggest that people can enhance (or restrict) their natural empathic abilities.

Having empathy doesn’t necessarily mean we’ll want to help someone in need, though it’s often a vital first step toward compassionate action.

For more: Read Frans de Waal’s essay on “ The Evolution of Empathy ” and Daniel Goleman’s overview of different forms of empathy , drawing on the work of Paul Ekman.

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Why Practice It?

Empathy is a building block of morality—for people to follow the Golden Rule, it helps if they can put themselves in someone else’s shoes. It is also a key ingredient of successful relationships because it helps us understand the perspectives, needs, and intentions of others. Here are some of the ways that research has testified to the far-reaching importance of empathy.

• Seminal studies by Daniel Batson and Nancy Eisenberg have shown that people higher in empathy are more likely to help others in need, even when doing so cuts against their self-interest .
• Empathy is contagious : When group norms encourage empathy, people are more likely to be empathic—and more altruistic.
• Empathy reduces prejudice and racism : In one study, white participants made to empathize with an African American man demonstrated less racial bias afterward.
• Empathy is good for your marriage : Research suggests being able to understand your partner’s emotions deepens intimacy and boosts relationship satisfaction ; it’s also fundamental to resolving conflicts. (The GGSC’s Christine Carter has written about effective strategies for developing and expressing empathy in relationships .)
• Empathy reduces bullying: Studies of Mary Gordon’s innovative Roots of Empathy program have found that it decreases bullying and aggression among kids, and makes them kinder and more inclusive toward their peers. An unrelated study found that bullies lack “affective empathy” but not cognitive empathy, suggesting that they know how their victims feel but lack the kind of empathy that would deter them from hurting others.
• Empathy reduces suspensions : In one study, students of teachers who participated in an empathy training program were half as likely to be suspended, compared to students of teachers who didn’t participate.
• Empathy promotes heroic acts: A seminal study by Samuel and Pearl Oliner found that people who rescued Jews during the Holocaust had been encouraged at a young age to take the perspectives of others.
• Empathy fights inequality. As Robert Reich and Arlie Hochschild have argued, empathy encourages us to reach out and want to help people who are not in our social group, even those who belong to stigmatized groups , like the poor. Conversely, research suggests that inequality can reduce empathy : People show less empathy when they attain higher socioeconomic status.
• Empathy is good for the office: Managers who demonstrate empathy have employees who are sick less often and report greater happiness.
• Empathy is good for health care: A large-scale study found that doctors high in empathy have patients who enjoy better health ; other research suggests training doctors to be more empathic improves patient satisfaction and the doctors’ own emotional well-being .
• Empathy is good for police: Research suggests that empathy can help police officers increase their confidence in handling crises, diffuse crises with less physical force, and feel less distant from the people they’re dealing with.

For more: Learn about why we should teach empathy to preschoolers .

How Do I Cultivate It?

Humans experience affective empathy from infancy, physically sensing their caregivers’ emotions and often mirroring those emotions. Cognitive empathy emerges later in development, around three to four years of age , roughly when children start to develop an elementary “ theory of mind ”—that is, the understanding that other people experience the world differently than they do.

From these early forms of empathy, research suggests we can develop more complex forms that go a long way toward improving our relationships and the world around us. Here are some specific, science-based activities for cultivating empathy from our site Greater Good in Action :

• Active listening: Express active interest in what the other person has to say and make him or her feel heard.
• Shared identity: Think of a person who seems to be very different from you, and then list what you have in common.
• Put a human face on suffering: When reading the news, look for profiles of specific individuals and try to imagine what their lives have been like.
• Eliciting altruism: Create reminders of connectedness.

And here are some of the keys that researchers have identified for nurturing empathy in ourselves and others:

• Focus your attention outwards: Being mindfully aware of your surroundings, especially the behaviors and expressions of other people , is crucial for empathy. Indeed, research suggests practicing mindfulness helps us take the perspectives of other people yet not feel overwhelmed when we encounter their negative emotions.
• Get out of your own head: Research shows we can increase our own level of empathy by actively imagining what someone else might be experiencing.
• Don’t jump to conclusions about others: We feel less empathy when we assume that people suffering are somehow getting what they deserve .
• Show empathic body language : Empathy is expressed not just by what we say, but by our facial expressions, posture, tone of voice, and eye contact (or lack thereof).
• Meditate: Neuroscience research by Richard Davidson and his colleagues suggests that meditation—specifically loving-kindness meditation, which focuses attention on concern for others—might increase the capacity for empathy among short-term and long-term meditators alike (though especially among long-time meditators).
• Explore imaginary worlds: Research by Keith Oatley and colleagues has found that people who read fiction are more attuned to others’ emotions and intentions.
• Join the band: Recent studies have shown that playing music together boosts empathy in kids.
• Play games : Neuroscience research suggests that when we compete against others, our brains are making a “ mental model ” of the other person’s thoughts and intentions.
• Take lessons from babies: Mary Gordon’s Roots of Empathy program is designed to boost empathy by bringing babies into classrooms, stimulating children’s basic instincts to resonate with others’ emotions.
• Combat inequality: Research has shown that attaining higher socioeconomic status diminishes empathy , perhaps because people of high SES have less of a need to connect with, rely on, or cooperate with others. As the gap widens between the haves and have-nots, we risk facing an empathy gap as well. This doesn’t mean money is evil, but if you have a lot of it, you might need to be more intentional about maintaining your own empathy toward others.
• Pay attention to faces: Pioneering research by Paul Ekman has found we can improve our ability to identify other people’s emotions by systematically studying facial expressions. Take our Emotional Intelligence Quiz for a primer, or check out Ekman’s F.A.C.E. program for more rigorous training.
• Believe that empathy can be learned : People who think their empathy levels are changeable put more effort into being empathic, listening to others, and helping, even when it’s challenging.

For more : The Ashoka Foundation’s Start Empathy initiative tracks educators’ best practices for teaching empathy . The initiative gave awards to 14 programs judged to do the best job at educating for empathy . The nonprofit Playworks also offers eight strategies for developing empathy in children .

What Are the Pitfalls and Limitations of Empathy?

According to research , we’re more likely to help a single sufferer than a large group of faceless victims, and we empathize more with in-group members than out-group members . Does this reflect a defect in empathy itself? Some critics believe so , while others argue that the real problem is how we suppress our own empathy .

Empathy, after all, can be painful. An “ empathy trap ” occurs when we’re so focused on feeling what others are feeling that we neglect our own emotions and needs—and other people can take advantage of this. Doctors and caregivers are at particular risk of feeling emotionally overwhelmed by empathy.

In other cases, empathy seems to be detrimental. Empathizing with out-groups can make us more reluctant to engage with them, if we imagine that they’ll be critical of us. Sociopaths could use cognitive empathy to help them exploit or even torture people.

Even if we are well-intentioned, we tend to overestimate our empathic skills. We may think we know the whole story about other people when we’re actually making biased judgments—which can lead to misunderstandings and exacerbate prejudice.

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What Is Empathy?

Kendra Cherry, MS, is a psychosocial rehabilitation specialist, psychology educator, and author of the "Everything Psychology Book."

Amy Morin, LCSW, is a psychotherapist and international bestselling author. Her books, including "13 Things Mentally Strong People Don't Do," have been translated into more than 40 languages. Her TEDx talk,  "The Secret of Becoming Mentally Strong," is one of the most viewed talks of all time.

Verywell / Bailey Mariner

Empathy is the ability to emotionally understand what other people feel, see things from their point of view, and imagine yourself in their place. Essentially, it is putting yourself in someone else's position and feeling what they are feeling.

Empathy means that when you see another person suffering, such as after they've lost a loved one , you are able to instantly envision yourself going through that same experience and feel what they are going through.

While people can be well-attuned to their own feelings and emotions, getting into someone else's head can be a bit more difficult. The ability to feel empathy allows people to "walk a mile in another's shoes," so to speak. It permits people to understand the emotions that others are feeling.

Press Play for Advice on Empathy

Hosted by therapist Amy Morin, LCSW, this episode of The Verywell Mind Podcast , featuring empathy expert Dr. Kelsey Crowe, shares how you can show empathy to someone who is going through a hard time. Click below to listen now.

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Signs of Empathy

For many, seeing another person in pain and responding with indifference or even outright hostility seems utterly incomprehensible. But the fact that some people do respond in such a way clearly demonstrates that empathy is not necessarily a universal response to the suffering of others.

If you are wondering whether you are an empathetic person, here are some signs that show that you have this tendency:

• You are good at really listening to what others have to say.
• People often tell you about their problems.
• You are good at picking up on how other people are feeling.
• You often think about how other people feel.
• Other people come to you for advice.
• You often feel overwhelmed by tragic events.
• You try to help others who are suffering.
• You are good at telling when people aren't being honest .
• You sometimes feel drained or overwhelmed in social situations.
• You care deeply about other people.
• You find it difficult to set boundaries in your relationships.

Types of Empathy

There are several types of empathy that a person may experience. The three types of empathy are:

• Affective empathy involves the ability to understand another person's emotions and respond appropriately. Such emotional understanding may lead to someone feeling concerned for another person's well-being, or it may lead to feelings of personal distress.
• Somatic empathy involves having a physical reaction in response to what someone else is experiencing. People sometimes physically experience what another person is feeling. When you see someone else feeling embarrassed, for example, you might start to blush or have an upset stomach.
• Cognitive empathy involves being able to understand another person's mental state and what they might be thinking in response to the situation. This is related to what psychologists refer to as the theory of mind or thinking about what other people are thinking.

Empathy vs. Sympathy vs. Compassion

While sympathy and compassion are related to empathy, there are important differences. Compassion and sympathy are often thought to be more of a passive connection, while empathy generally involves a much more active attempt to understand another person.

Uses for Empathy

Being able to experience empathy has many beneficial uses.

• Empathy allows you to build social connections with others . By understanding what people are thinking and feeling, you are able to respond appropriately in social situations. Research has shown that having social connections is important for both physical and psychological well-being.
• Empathizing with others helps you learn to regulate your own emotions . Emotional regulation is important in that it allows you to manage what you are feeling, even in times of great stress, without becoming overwhelmed.
• Empathy promotes helping behaviors . Not only are you more likely to engage in helpful behaviors when you feel empathy for other people, but other people are also more likely to help you when they experience empathy.

Potential Pitfalls of Empathy

Having a great deal of empathy makes you concerned for the well-being and happiness of others. It also means, however, that you can sometimes get overwhelmed, burned out , or even overstimulated from always thinking about other people's emotions. This can lead to empathy fatigue.

Empathy fatigue refers to the exhaustion you might feel both emotionally and physically after repeatedly being exposed to stressful or traumatic events . You might also feel numb or powerless, isolate yourself, and have a lack of energy.

Empathy fatigue is a concern in certain situations, such as when acting as a caregiver . Studies also show that if healthcare workers can't balance their feelings of empathy (affective empathy, in particular), it can result in compassion fatigue as well.

Other research has linked higher levels of empathy with a tendency toward emotional negativity , potentially increasing your risk of empathic distress. It can even affect your judgment, causing you to go against your morals based on the empathy you feel for someone else.

Impact of Empathy

Your ability to experience empathy can impact your relationships. Studies involving siblings have found that when empathy is high, siblings have less conflict and more warmth toward each other. In romantic relationships, having empathy increases your ability to extend forgiveness .

Not everyone experiences empathy in every situation. Some people may be more naturally empathetic in general, but people also tend to feel more empathetic toward some people and less so toward others. Some of the factors that play a role in this tendency include:

• How you perceive the other person
• How you attribute the other individual's behaviors
• What you blame for the other person's predicament
• Your past experiences and expectations

Research has found that there are gender differences in the experience and expression of empathy, although these findings are somewhat mixed. Women score higher on empathy tests, and studies suggest that women tend to feel more cognitive empathy than men.  

At the most basic level, there appear to be two main factors that contribute to the ability to experience empathy: genetics and socialization. Essentially, it boils down to the age-old relative contributions of nature and nurture .

Parents pass down genes that contribute to overall personality, including the propensity toward sympathy, empathy, and compassion. On the other hand, people are also socialized by their parents, peers, communities, and society. How people treat others, as well as how they feel about others, is often a reflection of the beliefs and values that were instilled at a very young age. 

Barriers to Empathy

Some people lack empathy and, therefore, aren't able to understand what another person may be experiencing or feeling. This can result in behaviors that seem uncaring or sometimes even hurtful. For instance, people with low affective empathy have higher rates of cyberbullying .

A lack of empathy is also one of the defining characteristics of narcissistic personality disorder . Though, it is unclear whether this is due to a person with this disorder having no empathy at all or having more of a dysfunctional response to others.

A few reasons why people sometimes lack empathy include cognitive biases, dehumanization, and victim-blaming.

Cognitive Biases

Sometimes the way people perceive the world around them is influenced by cognitive biases . For example, people often attribute other people's failures to internal characteristics, while blaming their own shortcomings on external factors.

These biases can make it difficult to see all the factors that contribute to a situation. They also make it less likely that people will be able to see a situation from the perspective of another.

Dehumanization

Many also fall victim to the trap of thinking that people who are different from them don't feel and behave the same as they do. This is particularly common in cases when other people are physically distant.

For example, when they watch reports of a disaster or conflict in a foreign land, people might be less likely to feel empathy if they think that those who are suffering are fundamentally different from themselves.

Victim Blaming

Sometimes, when another person has suffered a terrible experience, people make the mistake of blaming the victim for their circumstances. This is the reason that victims of crimes are often asked what they might have done differently to prevent the crime.

This tendency stems from the need to believe that the world is a fair and just place. It is the desire to believe that people get what they deserve and deserve what they get—and it can fool you into thinking that such terrible things could never happen to you.

Causes of Empathy

Human beings are certainly capable of selfish, even cruel, behavior. A quick scan of the news quickly reveals numerous unkind, selfish, and heinous actions. The question, then, is why don't we all engage in such self-serving behavior all the time? What is it that causes us to feel another's pain and respond with kindness ?

The term empathy was first introduced in 1909 by psychologist Edward B. Titchener as a translation of the German term einfühlung (meaning "feeling into"). Several different theories have been proposed to explain empathy.

Neuroscientific Explanations

Studies have shown that specific areas of the brain play a role in how empathy is experienced. More recent approaches focus on the cognitive and neurological processes that lie behind empathy. Researchers have found that different regions of the brain play an important role in empathy, including the anterior cingulate cortex and the anterior insula.

Research suggests that there are important neurobiological components to the experience of empathy.   The activation of mirror neurons in the brain plays a part in the ability to mirror and mimic the emotional responses that people would feel if they were in similar situations.

Functional MRI research also indicates that an area of the brain known as the inferior frontal gyrus (IFG) plays a critical role in the experience of empathy. Studies have found that people who have damage to this area of the brain often have difficulty recognizing emotions conveyed through facial expressions .  

Emotional Explanations

Some of the earliest explorations into the topic of empathy centered on how feeling what others feel allows people to have a variety of emotional experiences. The philosopher Adam Smith suggested that it allows us to experience things that we might never otherwise be able to fully feel.

This can involve feeling empathy for both real people and imaginary characters. Experiencing empathy for fictional characters, for example, allows people to have a range of emotional experiences that might otherwise be impossible.

Prosocial Explanations

Sociologist Herbert Spencer proposed that empathy served an adaptive function and aided in the survival of the species. Empathy leads to helping behavior, which benefits social relationships. Humans are naturally social creatures. Things that aid in our relationships with other people benefit us as well.

When people experience empathy, they are more likely to engage in prosocial behaviors that benefit other people. Things such as altruism and heroism are also connected to feeling empathy for others.

Tips for Practicing Empathy

Fortunately, empathy is a skill that you can learn and strengthen. If you would like to build your empathy skills, there are a few things that you can do:

• Work on listening to people without interrupting
• Pay attention to body language and other types of nonverbal communication
• Try to understand people, even when you don't agree with them
• Ask people questions to learn more about them and their lives
• Imagine yourself in another person's shoes
• Strengthen your connection with others to learn more about how they feel
• Seek to identify biases you may have and how they affect your empathy for others
• Look for ways in which you are similar to others versus focusing on differences
• Be willing to be vulnerable, opening up about how you feel
• Engage in new experiences, giving you better insight into how others in that situation may feel
• Get involved in organizations that push for social change

A Word From Verywell

While empathy might be lacking in some, most people are able to empathize with others in a variety of situations. This ability to see things from another person's perspective and empathize with another's emotions plays an important role in our social lives. Empathy allows us to understand others and, quite often, compels us to take action to relieve another person's suffering.

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By Kendra Cherry, MSEd Kendra Cherry, MS, is a psychosocial rehabilitation specialist, psychology educator, and author of the "Everything Psychology Book."

Is Empathy the Key to Effective Teaching? A Systematic Review of Its Association with Teacher-Student Interactions and Student Outcomes

• Review Article
• Open access
• Published: 10 March 2022
• Volume 34 , pages 1177–1216, ( 2022 )

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• Karen Aldrup   ORCID: orcid.org/0000-0003-1567-5724 1 ,
• Bastian Carstensen   ORCID: orcid.org/0000-0001-5259-9578 1 &
• Uta Klusmann   ORCID: orcid.org/0000-0002-8656-344X 1  

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Teachers’ social-emotional competence has received increasing attention in educational psychology for about a decade and has been suggested to be an important prerequisite for the quality of teacher-student interactions and student outcomes. In this review, we will summarize the current state of knowledge about the association between one central component of teachers’ social-emotional competence—their empathy—with these indicators of teaching effectiveness. After all, empathy appears to be a particularly promising determinant for explaining high-quality teacher-student interactions, especially emotional support for students and, in turn, positive student development from a theoretical perspective. A systematic literature research yielded 41 records relevant for our article. Results indicated that teachers reporting more empathy with victims of bullying in hypothetical scenarios indicated a greater likelihood to intervene. However, there was neither consistent evidence for a relationship between teachers’ empathy and the degree to which they supported students emotionally in general, nor with classroom management, instructional support, or student outcomes. Notably, most studies asked teachers for a self-evaluation of their empathy, whereas assessments based on objective criteria were underrepresented. We discuss how these methodological decisions limit the conclusions we can draw from prior studies and outline perspective for future research in teachers’ empathy.

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Introduction

Students experience a range of emotions—such as enjoyment, anxiety, and boredom—while they attain new knowledge, take exams, or strive to connect with their classmates (Ahmed et al., 2010 ; Hascher, 2008 ; Martin & Huebner, 2007 ; Pekrun et al., 2002 ). Teachers are confronted with these emotions in the classroom and beyond, and their ability to read their students’ emotional signals and attend to them sensitively is vital to form positive teacher-student relationships (Pianta, 1999 ). Therefore, teachers’ social-emotional characteristics have been suggested as essential for the quality of teacher-student interactions and, in turn, students’ psychosocial outcomes (Brackett & Katulak, 2007 ; Jennings & Greenberg, 2009 ; Rimm-Kaufman & Hamre, 2010 ). Empathy is one component of teachers’ social-emotional characteristics that appears particularly relevant for the quality of teacher-student interactions from a theoretical perspective. First, empathy is considered as the origin of human’s prosocial behavior (Preston & de Waal, 2002 ). Second, in contrast to social-emotional characteristics such as emotional self-awareness or emotion regulation, empathy explicitly refers to other people rather than to the self, more specifically, to the ability to perceive and understand students’ emotions and needs (Zins et al., 2004 ).

Because of these theoretical arguments and a recent increase in empirical studies on this topic, the goal of this article is to review prior research investigating the relationship of teachers’ empathy with the quality of teacher-student interactions and, in turn, with student outcomes (see heuristic working model in Figure 1 ). We use effective teaching here as an umbrella term to refer to both interaction quality and student outcomes. Summarizing the current level of knowledge on this topic appears particularly useful for the following reasons. First, various meanings have been attached to the term empathy, and the diversity of concepts that have been used to refer to concepts closely related to empathy (e.g., emotional intelligence, perspective taking, and emotion recognition; also see Batson, 2009 ; Olderbak & Wilhelm, 2020 ) make it difficult to oversee prior research at first glance. Second, the research field has rapidly grown throughout the last decade. Thus, to understand foci of prior research and widely neglected questions is important; for example, the review will uncover possible specific underrepresented student outcomes (e.g., cognitive vs. psychosocial). Third, researchers have applied different methodological approaches. For example, self-report scales and objective tests are available and it is debatable whether both are equally valid considering the risk of self-serving bias in questionnaires (Brackett et al., 2006 ). Against this background, it is important to summarize not only the results from prior studies but also the assessment methods they applied to inform future studies in terms of which methodological approaches are best suited to obtain valid results.

Heuristic working model on the role of teachers’ empathy in the quality of teacher-student interactions and student outcomes; paths where we expect the closest associations are in bold (also see Brackett & Katulak, 2007 ; Jennings & Greenberg, 2009 )

A General Theoretical Perspective on Empathy

Historically, two distinct lines of research have evolved around empathy (for an overview see, e.g., Baron-Cohen & Wheelwright, 2004 ; Davis, 1983 ). First, from the affective perspective , empathy describes the emotional reactions to another person’s affective experiences. According to Eisenberg and Miller ( 1987 ), this means that one experiences the same emotion as the other person. Hatfield et al. ( 1993 ) described the phenomenon of “catching” other people’s emotions as emotional contagion. Affective empathy can elicit both positive and negative emotions, and because emotions are multi-componential, the subjective feelings, thoughts, expressions, and physiological and behavioral reactions can differ depending on the type of emotion (Olderbak et al., 2014 ; Scherer, 1984 ). Empathy from the affective perspective can also mean to feel something that is appropriate but not identical with the other person’s emotion, for instance, responding with concern and sympathy to another person’s sadness (e.g., Batson et al., 2002 ).

Second, from the cognitive perspective, empathy reflects a person’s ability to understand how other people feel by taking their perspective and reading their nonverbal signals (e.g., Wispé, 1986 ). Baron-Cohen and Wheelwright ( 2004 ) pointed out that theory of mind largely converges with the cognitive definition of empathy. Furthermore, models of emotional intelligence, such as the four-branch-model (Mayer & Salovey, 1997 ), include qualities resembling empathy as defined in the cognitive perspective: the ability to perceive emotions in other people’s faces accurately and to understand emotions, that is, knowing when specific emotions are likely to arise.

In accordance with Baron-Cohen and Wheelwright ( 2004 ), we define empathy as including both affective and cognitive components (for similar approaches, also see Davis, 1983 ; Decety & Jackson, 2004 ; Preston & de Waal, 2002 ). This allows for a more comprehensive understanding of empathy and its consequences because the affective component of empathy explains why we care for other people in need and are motivated to react sensitively, whereas the cognitive component explains what enables people to know and name the feelings of others (Batson, 2009 ). Preston and de Waal ( 2002 ) also support the idea that cognitive and affective empathy are entangled and complement each other in explaining prosocial behavior. They suggest that the development of cognitive empathy promotes the “effectiveness of empathy by helping the subject to focus on the object, even in its absence, remain emotionally distinct from the object, and determine the best course of action for the object’s needs” (Preston & de Waal, 2002 , p. 20).

Considering the central role of empathy in human relationships, which has also been supported empirically (Eisenberg & Miller, 1987 ; Kardos et al., 2017 ; Mitsopoulou & Giovazolias, 2015 ; Sened et al., 2017 ; Vachon et al., 2014 ), its importance in social occupations has been recognized for a long time. For instance, Rogers ( 1959 ) proposed that the therapists’ ability to accurately perceive their clients’ point of view will facilitate the therapeutic process and, in turn, produce change in personality and behavior. In line with this assumption, studies with psychotherapists and also with physicians showed that their empathy predicted their patients’ satisfaction and clinical outcomes (Elliott et al., 2018 ; Hojat et al., 2011 ). Like psychotherapists or physicians and their clients, teachers are in close interpersonal contact with their students. Hence, it seems plausible to assume a central role of empathy in their professional lives as well.

The Role of Teacher Empathy

Caring for students and establishing positive teacher-student relationships are a central part of teachers’ professional roles (Butler, 2012 ; O’Connor, 2008 ; Watt et al., 2021 ). Furthermore, providing high levels of emotional support as indicated by a positive emotional tone in the classroom, sensitive responses to students’ emotional, social, and academic needs, and consideration of their interests is one aspect of high-quality classrooms (Pianta & Hamre, 2009 ). To achieve this, the ability to read students’ (non-)verbal signals—in others words: empathy—is vital (Pianta, 1999 ). For instance, teachers’ cognitive empathy will help them better identify from a student’s facial expressions if he or she is sad about a bad grade, angry about an argument with friends, or bored with specific learning activities. Empathic teachers will know that students may feel anxious when confronted with challenging tasks or embarrassed and frustrated when repeatedly unable to answer the teacher’s questions. Having recognized negative affective states in their students, teachers’ affective empathy should motivate them to react sensitively to their students’ emotional needs, provide comfort, and encouragement (Batson, 2009 ; Weisz et al., 2020 ). The prosocial classroom model (Jennings & Greenberg, 2009 ) also integrates these ideas and further states that teachers’ social-emotional competence, of which empathy is one part, should facilitate classroom management.

Effective classroom management means that teachers establish rules and order, apply appropriate strategies to prevent student behavior problems, and maximize time on task (Emmer & Stough, 2001 ). The ability to understand reasons for classroom disturbances could facilitate behavior management. For example, noticing students’ boredom could initiate teachers to choose a different instructional approach before students start off-task activities (Nett et al., 2010 ). Furthermore, taking the perspective of adolescents, teachers will be able to recognize their need for autonomy, which would collide with a controlling classroom management strategy (Aelterman et al., 2019 ; Eccles & Midgley, 1989 ). Yet, effective classroom management may be less dependent on teacher empathy than emotional support is. After all, classroom management includes several facets that go beyond empathy, for example, productive use of time and establishment of rules. For these tasks, specific classroom management knowledges is a key prerequisite (Kunter et al., 2013 ; Shulman, 1986 ).

Finally, even though not mentioned in the prosocial classroom model, teacher empathy could also play a role in instructional support, which is the third key aspect of high-quality teacher-student interaction in addition to emotional support and classroom management (Klieme et al., 2009 ; Pianta & Hamre, 2009 ). Instructional support comprises clear and engaging instruction that promotes content understanding and presents cognitive challenges. In addition, teachers scaffold learning by providing feedback and initiating content-related class discussions (Pianta et al., 2012 ). To adapt instruction to students’ learning needs and design engaging lessons, it is necessary to recognize when students struggle understanding content and which activities they find particularly interesting or boring (Bieg et al., 2017 ; Parsons et al., 2018 ). However, in addition instructional support requires high levels of (pedagogical) content knowledge so again one could assume that empathy plays a less central role than it does for emotional support (Kunter et al., 2013 ; Shulman, 1986 ).

In summary, from a theoretical perspective, a relationship between teachers’ empathy and the quality of teacher-student interactions, in particular with emotional support, appears plausible. By increasing interaction quality, empathy should also indirectly promote student development. Here, we distinguish between cognitive development, that is, outcomes related to students’ learning of subject matter, and psychosocial development, that is, motivational, emotional, and social variables. Prior research consistently shows that emotional support is positively associated with psychosocial outcomes, such as academic interest, self-concept, peer relatedness, and behavioral engagement, whereas classroom management and instructional support are most closely related to student achievement (Aldrup et al., 2018 ; Downer et al., 2014 ; Fauth et al., 2014b ; Kunter et al., 2013 ; Nie & Lau, 2009 ; Ruzek et al., 2016 ; Scherer et al., 2016 ; Wagner et al., 2016 ; Yildirim, 2012 ). Our heuristic working model in Figure 1 illustrates the hypothesized associations between teacher empathy, the quality of teacher-student interactions, and student outcomes. To test these theoretical assumptions, different methodological approaches are available, which we will explain next.

Assessment Approaches in Researching Teacher Empathy

Researchers interested in investigating teacher empathy can choose between different measurement approaches that are distinct in terms of two key dimensions: objective assessment versus self-report questionnaires and general versus profession-specific tools. On the one hand, researchers can apply objective assessments such as the Mayer-Salovey-Caruso Emotional Intelligence Test (MSCEIT; Mayer et al., 2002 ). The MSCEIT comprises subtests measuring a person’s ability to perceive and understand emotions in others. For example, participants see pictures of faces and are requested to select the degree to which it expresses each of five emotions. On the other hand, several self-report questionnaires are available. One prominent scale is the Interpersonal Reactivity Index (Davis, 1980 ) including subscales on empathic concern (“I often have tender, concerned feelings for people less fortunate than me.”) and perspective taking (“I sometimes try to understand my friends better by imagining how things look from their perspective.”). Emotional intelligence questionnaires typically include subscales on empathy as well. For example, the other-emotion appraisal subscale of the Wong and Law Emotional Intelligence Scale (Wong & Law, 2002 ) assesses the ability to perceive emotions in others (“I am sensitive to the feelings and emotions of others.”).

However, it is unclear if people can validly evaluate their own empathy and especially regarding the cognitive component, which consists of knowledge and skills, a performance-based approach seems more valid. In line with these concerns, Ickes ( 2001 ) concluded that performance-based measures of empathic accuracy predict performance in social situations whereas self-report measures do not. Likewise, Brackett et al. ( 2006 ) found no association between undergraduate students’ self-reported emotional intelligence and the extent to which others perceived them as friendly and socially engaged but using an emotional intelligence test yielded statistically significant associations. Self-serving bias could be one issue reducing the validity of people’s self-reported empathy. For teachers, in particular, exaggerating their empathy appears likely because establishing close, caring connections with students is an important aspect of their professional identities (O’Connor, 2008 ; Wubbels et al., 1993 ). Finally, the use of self-report questionnaires not only poses the risk of reduced correlations due to validity issues but also of inflated correlations due to common method bias when participants report on their empathy and the dependent variables at the same time (Podsakoff et al., 2003 ). Thus, whether researchers use an objective empathy assessment or a self-report questionnaire can largely affect the results and the degree to which the findings allow for valid conclusion.

In addition, researchers in teacher empathy have to decide on the context-specificity of their instrument. On the one hand, they can use one of the tools described above that were designed for use in the general population. On the other hand, they can choose profession-specific instruments asking teachers about their empathy for students. A profession-specific assessment has several advantages. Generally, performance in specific contexts is best predicted by variables that refer to the same context (Ajzen & Fishbein, 1977 ; Weinert, 2001 ). Furthermore, in contrast to day-to-day interactions with other social partners, teacher-student interactions are unique and characterized by an asymmetric nature (Pianta, 1999 ). Teachers and students differ substantially in terms of their knowledge and experiences and this lack of similarity may impede empathy (Preston & de Waal, 2002 ). Accordingly, teachers likely require profession-specific knowledge about their students’ developmental needs and concerns to facilitate empathy (Eccles & Midgley, 1989 ; Voss et al., 2011 ).

Present Study

The present study provides a systematic review of prior empirical research on the role of teachers’ empathy in effective teaching, which comprises the quality of teacher-student interactions and student development. The relevance of teachers’ empathy and related qualities has been highlighted from a theoretical perspective for over a decade (e.g., Brackett & Katulak, 2007 ; Jennings & Greenberg, 2009 ; Rimm-Kaufman & Hamre, 2010 ). Therefore, our goal was to gather what we have learned so far and whether the empirical evidence is in line with the theoretical claim that teacher empathy is positively associated with effective teaching. Furthermore, we aimed to identify questions that have remained unanswered to date in prior research on the association between teacher empathy and the quality of teacher-student interactions and student outcomes. For instance, reviewing the literature enabled us to carve out consequences of empathy that have been underrepresented in prior research (e.g., specific domains of teacher-student interaction quality or specific student outcomes) or methodological challenges that still need to be solved for ensuring the validity of results. From our perspective, this is an important step to research that can eventually support teachers, teacher educators, school psychologists, principals, and other stakeholders in the education system in evaluating the benefits of promoting teacher empathy.

The heuristic working model (Fig. 1 ), which is largely based on the prosocial classroom model (Jennings & Greenberg, 2009 ), illustrates the hypothesized role of teachers’ empathy in the quality of teacher-student interactions and student outcomes. As outlined above, we expected to find a positive relationship between teachers’ empathy and the quality of teacher-student interactions, in particular, with emotional support. After all, empathy allows teachers to understand students’ perspectives, read their nonverbal signals, and react with concern to students needing help—these qualities are all indicators of emotional support (Pianta et al., 2012 ). In turn, by promoting high-quality teacher-student interactions, teachers’ empathy can be assumed to foster student development. However, because student outcomes are more distal to teachers’ empathy than teacher-student interactions are, we expected less pronounced associations. Furthermore, because we speculated that empathy plays a role especially in teachers’ emotional support and because prior research revealed more consistent association between emotional support and psychosocial rather than cognitive student outcomes (e.g., Fauth et al., 2014b ; Kunter et al., 2013 ), we hypothesized that empathy would have the weakest relationship with student achievement.

Moreover, we speculated that methodological decisions could affect the magnitude of the relationships between teachers’ empathy, the quality of teacher-student interactions, and student outcomes. Thus, our first goal was to determine which methodological approaches have been applied in the field and consider them in reviewing the results from prior work. Based on the principle of correspondence, we expected particularly close associations when a profession-specific rather than a general assessment tool was used to measure teachers’ empathy (Ajzen & Fishbein, 1977 ). In addition, we hypothesized that the reliance on self-report measures to assess empathy and its consequences leads to larger correlations because of common method bias (Podsakoff et al., 2003 ).

Literature Search

We conducted our literature search in PsycINFO and Web of Science in October 2020 without date restrictions. To identify relevant articles on teachers’ empathy we used the following search terms: empathy OR “ perspective taking” OR compassion OR “ emotion* intelligence” OR “ emotion* knowledge” OR “ emotion* awareness” OR “ emotion* understanding” OR “ emotion* accuracy” OR “ emotion* perception” OR “ emotion* detection” OR “ emotion* identification” OR “ emotion* recognition” OR “ teacher* sensitivity” . Using a broad set of search terms allowed us to capture constructs which show substantial conceptual overlap with empathy and are frequently discussed in independent strands of research using different terminology (Mayer et al., 2008 ; Olderbak & Wilhelm, 2020 ).

In PsycINFO, among others titles, abstracts, heading words, tables of contents, and key concepts were searched for the defined terms. We conducted a thesaurus search using the exp Teachers/ command to limit results to teacher samples. Furthermore, we limited our search to quantitative studies using the quantitative study.md command. In Web of Science, the defined terms were searched in titles, abstracts, and keywords. To limit results to teacher samples, we entered our central search terms in combination with teacher* / professor* / educator* / lecturer* / faculty*. We applied the NEAR/3 command, which identifies studies mentioning two terms close to one another (in our case, three words or less in between empathy and teacher synonyms) in any order. Moreover, we excluded the following publication types: meeting abstracts, reviews, book reviews, editorial material, letters, and biographical items. In both databases, we excluded studies written in a language not based on the Latin alphabet (e.g., Chinese, Hebrew). For studies not written in English, we used Google Translate to retrieve the necessary information. This yielded 533 records from PsycINFO and 474 records from Web of Science, resulting in 931 records in total after removing duplicates.

We pursued two strategies to supplement our database search and to identify relevant articles we may have missed. First, we screened the reference list of all studies identified as eligible for our synthesis after evaluating the full-text. Second, we conducted a Google Scholar search in December 2020 to find articles citing the studies we had identified as relevant. These strategies produced 134 additional records.

Inclusion and Exclusion Criteria

We included studies in our research synthesis if they met the following criteria. First, empathy had to be measured in accordance with our definition of empathy. For instance, we neither included studies measuring empathy in rather broad terms (e.g., teacher sensitivity assessed with the Classroom Assessment Scoring System; Pianta et al., 2012 ) nor did we code effects pertaining to fantasy and personal distress. Fantasy and personal distress are subscales of the frequently used Interpersonal Reactivity Index (Davis, 1980 ). However, Baron-Cohen and Wheelwright ( 2004 ) argued that these scales do not measure empathy. For example, the personal distress scale only partly refers to interpersonal situations (e.g., “In emergency situations, I feel apprehensive and ill-at-ease.”). Second, studies had to measure an outcome relevant to our article, that is, aspects of teacher-student interaction or student outcomes. Third, it was necessary to report the statistical significance of bivariate correlations or another statistic convertible to a bivariate correlation. However, we retained studies that reported that an effect was not statistically significant without providing the exact size of the effect. Fourth, results had to be based on a sample of at least ten teachers. Regular and special education teachers of all grade levels were included (i.e., preschool to tertiary education). Importantly, even though teachers demonstrate different behaviors to realize high-quality teacher-student interactions, the three overarching domains of emotional support, classroom management, and instructional support remain relevant from preschool to tertiary education, making the inclusion of a broad range of education levels possible (Langenbach & Aagaard, 1990 ; Pianta & Hamre, 2009 ; Schneider & Preckel, 2017 ). Fifth, we only retained the study that provided the most information if multiple articles were based on the same sample and variables.

Based on these criteria and as illustrated in the PRISMA diagram (Page et al., 2021 ) in Figure 2 , 768 records were excluded after pre-screening the abstracts of the 931 records obtained through database searching. Pre-screening the abstracts of the 134 records from citation searching and footnote chasing left 61 potentially relevant records. In total, we could not retrieve a full text for six records. Thus, we proceeded screening the full-texts of the remaining 160 records from database searching and 58 records from citation searching and footnote chasing for eligibility. These steps were conducted by the first author, and in addition, the second author read 25% of the records to verify the inter-rater reliability. Cohen’s κ was .81, and we agreed in 98% of the articles regarding the questions of whether none versus any of the exclusion criteria were met. Considering reasons for exclusion via the multiple search strategies jointly, twelve did not include a relevant outcome and 13 were excluded for other reasons (e.g., eight articles did not present quantitative results and one article was based on a duplicate sample). In contrast, a comparably large number of 95 articles did not include a relevant predictor. Most often, this was due to emotional intelligence instruments not including empathy-related subscales (e.g., Trait Meta-Mood Scale, Salovey et al., 1995 ; Emotional Quotient Inventory: Short Form; Bar-On, 2002 ). Similarly, we would have needed to exclude 58 articles because they assessed relevant variables but did not report bivariate correlations or other statistics to estimate the relationship of teacher empathy with the quality of teacher-student relationships and student outcomes. Most often these studies used an emotional intelligence instrument including empathy-related subscales (e.g., Trait Emotional Intelligence Qustionnaire, Petrides & Furnham, 2003 ; MSCEIT, Mayer et al., 2002 ), but the analyses were conducted based on the total emotional intelligence scores. Due to the large number of studies that were relevant for our synthesis but that did not report the necessary statistics, we decided to contact the authors and ask for the correlation coefficients if we considered the study particularly informative for our research questions (i.e., the independent or dependent variable was measured with instruments going beyond teacher self-report). We contacted 15 authors, six responded, and one was able to provide the information we requested. Thus, 57 articles were excluded because no relevant analyses were available. Finally, 31 articles remained after full-text reading and citation searching and footnote chasing yielded ten additional records.

PRISMA diagram of the literature search process

Processing of Search Results

For the final set of records, we extracted information on the authors, the year and type of publication, and the sample (i.e., sample size, teachers’ gender, age, and years of job experience, school level, and country). Regarding our independent variable, teacher empathy, we retrieved information on (1) the components of empathy (i.e., affective, cognitive, composite); (2) the instrument; (3) whether a teacher self-report questionnaire, an objective assessment, or other approaches were used; and (4) whether the instrument took a general, a profession-specific, or a situation-specific perspective. For our dependent variables, teacher-student interactions, and student outcomes, we retrieved information on (1) the components of teacher-student interaction (i.e., emotional support, classroom management, instructional support) and student outcomes (i.e., cognitive, psychosocial) and (2) whether a teacher self-report questionnaire, student questionnaires, student achievement tests, classroom observations, or other measurements were conducted. Again, the first author performed these steps and the second author coded 20% of the records to estimate the inter-rater reliability regarding the coding of the components of empathy and the outcome categories. Both assigned the same category to 89% of the predictor and outcome variables. Finally, we retrieved correlation coefficients and information on statistical significance. To answer our research questions, we primarily relied on vote-counting and determined the number of effects that were statistically significant at α < .05. However, we also wanted to give the reader an impression of the size of the effects. Thus, in the few cases where effect sizes other than correlations were reported, we converted them to allow for between-study comparisons. More specifically, we used the formulas provided by Thalheimer and Cook ( 2002 ) to convert F -statistics and t -statistics to Cohen’s d and the formulas provided by Borenstein ( 2009 ) to convert odds ratios to Cohen’s d and to convert Cohen’s d to r . In addition, we recoded the correlations between empathy and negative qualities of teacher-student interactions and maladaptive student outcomes to facilitate the interpretation of the correlation coefficients. Thus, positive correlation coefficients can now be interpreted as indicative of effects in line with our heuristic working model (Figure 1 ). Tables 1 , 2 , 3 , and 4 provide a summary of the reviewed articles organized depending on the methodological approach that was used. The data and the review protocol are available at PsychArchives (Aldrup et al., 2021 ).

In the following, we will first describe general characteristics of the records included in this article and will then provide details about the methodological approaches used. The main part of this section is dedicated to outlining results from prior research on the relationship of teacher empathy with teacher-student interactions and student outcomes. Table 5 gives a summary of the statistically significant effects and the effect sizes for each dependent variable, and Figure 3 provides an overview of the effect sizes depending on the methodological type of study and the dependent variable.

Overview of all effects depending on the methodological type of study and the dependent variables

General Study Characteristics

This research synthesis is based on 23 journal articles, 15 theses, two proceedings papers, and one book chapter, which were published between 2004 and 2020 ( Md = 2014, M = 2014, SD = 3.92).The 41 included records reported results from 42 independent samples from 12 different countries—mostly the USA ( n = 22), followed by Australia and China ( n = 4). The teacher samples comprised between 11 and 467 teachers ( M = 119.02, SD = 103.10). On average, the teachers were M = 36.12 years old and 76.8% were female. The majority of studies included only in-service teachers ( n = 35), who had M = 9.08 years of job experience on average. Most samples were composed either of only secondary school teachers ( n = 16) or a combination of secondary school, elementary school, and, in some cases, early childhood teachers ( n = 8). Each five to six samples included exclusively early childhood teachers, elementary school teachers, or educators at the tertiary level. Only 14 studies provided information on the school subject the participants taught: seven samples included teachers from different subject domains, three assessed English, two mathematics, one physical education, and one law teachers.

The majority of studies (93%) reported only cross-sectional analyses regarding the link between teacher empathy and teacher-student interactions or student outcomes. However, Franklin ( 2014 ) measured empathy at one time point but included two waves of student outcomes and Aldrup et al., ( 2020 ) used longitudinal data across three time points. We only considered the within-wave correlations to make results from these studies comparable to the majority of articles that were cross-sectional. Finally, using a randomized pre-post-control group design, Okonofua et al. ( 2016 ) investigated the effects of an empathic mindset intervention.

Aspects of Empathy and Measurement

In most samples, the focus was on the cognitive ( n = 28) as opposed to the affective component ( n = 8) of empathy. In five samples, both cognitive and affective empathy were assessed and in one sample, a composite measure was used. In terms of measurement instruments, self-report questionnaires were predominant ( n = 29 samples/studies). In the following, we will list the self-report tools that were used in more than one study. The Interpersonal Reactivity Index (Davis, 1980 ) was applied ten times followed by the Wong and Law Emotional Intelligence Scale (Wong & Law, 2002 ), which was used four times. Three other studies measured the ability to perceive emotions in others as well, but based on the Self-Rated Emotional Intelligence Scale (Brackett et al., 2006 ). Three studies used the BarOn Emotional Quotient-Inventory , which measures the ability to understand and respect other people’s feelings (Bar-On, 1997 ). In contrast to these questionnaires designed for use in the general population, only one study applied a profession-specific instrument asking teachers, for example, “I am happy for students if they enjoy happy moments” (Wu et al., 2019 ). Likewise, the Bullying Attitudes Questionnaire (Craig et al., 2000 ; Yoon, 2004 ), which was employed in seven studies, measures teachers’ self-reported empathic concern for student victims of bullying and is therefore situated in the professional context as well.

Nine studies used approaches based on objective criteria to discriminate between more and less empathic teachers rather than using teacher questionnaires. Four studies employed the MSCEIT (Mayer et al., 2002 ). Similar tests—the Amsterdam Emotion Recognition Test (van der Schalk et al., 2011 ) , the Situational Test of Emotional Understanding (MacCann & Roberts, 2008 ), and the Test of Emotional Intelligence (Śmieja et al., 2014 )—were each used in one study. Friedman ( 2014 ) pursued a slightly different strategy and applied the newly developed Teacher Emotional Intelligence Measure , which asks teachers about their likely response to a hypothetical disciplinary incident in class in an open format. A coding manual is used to determine the teacher’s ability to perceive and understand the disputant’s emotions and to identify how other students in class would feel . Zinsser et al. ( 2015 ) conducted teacher focus groups on the role of emotions in classrooms. Based on teachers’ responses to semi-structured questions, trained coders detected the teachers’ emotion knowledge, that is, their ability to recognize and understand emotions in their students. Moreover, two studies asked students to report on their teachers’ empathy (Aldrup et al.,  2020 ; Latchaw, 2017 ). Thus, like in the studies by Friedman ( 2014 ) and Zinsser et al. ( 2015 ), the focus was on teachers’ empathy in the professional context and even more specifically in the respective subject domain. Finally, one article including two samples (Okonofua et al., 2016 ) reported results from an intervention aimed to induce an empathic mindset in their teacher-student interactions. However, the intervention study did not include a treatment check so it remains unknown whether it actually changed teacher empathy.

Effects on Teacher-Student Interactions

We identified 33 studies (34 samples) investigating the role of empathy in teacher-student interactions: 28 studies measured aspects of emotional support, ten measured classroom management, and six measured instructional support. Five studies applied measures of teacher-student interaction that we could not clearly assign to one of the interaction domains.

General Teacher-Student Interaction

Three out of five studies measuring blended aspects of teacher-student interactions found statistically significant associations (57% of the investigated effects were significant and positive; see Table 5 ). Secondary school teachers who rated their own ability to perceive other’s emotions higher evaluated their teaching performance ( r = .26, p < .001) more positively (Wu et al., 2019 ). In addition, in two studies with English as a foreign language teachers at high schools and private language institutes (Ghanizadeh & Moafian, 2010 ; Khodadady, 2012 ), teachers’ self-reported empathy was linked to their students’ ratings of teacher qualification (i.e., knowledge, self-confidence, comprehensibility; r = .10, p < .01) and students’ overall ratings of instruction ( r = .26, p < .05). In contrast, Corcoran and Tormey ( 2013 ) found no, or even counterintuitive associations of teachers’ test scores in perceiving ( r = –.15, p < .01) and understanding emotions ( r = .07, p > .05) with student teachers’ practicum performance evaluations, for example, the use of appropriate pedagogic strategies and material or the quality of teacher-student relationships. Petsos and Gorizidis ( 2019 ) did not find a relationship between secondary school teachers’ self-reported perception of other’s emotions and the extent to which students felt their teacher assigned students responsibility ( r = .08, p > .05).

Emotional Support

The number of studies finding a statistically significantly positive association between teachers’ empathy and their emotional support for students ( n = 15) slightly outweighed the number of studies not supporting this link ( n = 11) or finding mixed evidence ( n = 2). Because a substantial number of studies focused on teachers’ reactions to bullying among students as one specific aspect of emotional support, we will summarize results from this line of research separately after describing the findings for emotional support.

Six studies found statistically significant positive associations with teachers’ empathy but eleven found mixed or no evidence (25% of the investigated effects were significant and positive, 73% were not significant; see Table 5 ). Abacioglu et al. ( 2020 ) revealed that primary school teachers evaluating their perspective taking more positively reported using more culturally ( r = .33, p < .01) and socially sensitive teaching practices ( r = .24, p < .01). Similarly, teachers reporting a greater ability to perceive others’ emotions considered their attention to students needs as more pronounced ( r = .24, p < .01) (Nizielski et al., 2012 ). Furthermore, the theses by Gottesman ( 2016 ) and Metaxas ( 2018 ) showed that teachers reporting more empathy were more likely to choose emotionally supportive strategies in response to a hypothetical student exhibiting challenging behavior ( r = .36 and r = .24, p < .01). In these studies, teachers from different grade levels participated spanning pre- to high school. Finally, there were two studies using not only teacher self-report questionnaires and finding a relationship between empathy and emotional support. Khodadady ( 2012 ) found that high school students perceived better rapport with their teacher ( r = .10, p < .01) and greater teacher fairness ( r = .11, p < .01) when teachers reported greater empathy. Moreover, secondary school students reported more positive teacher-student relationships if their teacher attained higher test scores in perceiving ( r = .50, p = .02) and understanding emotions ( r = .45, p = .04) (Barłożek, 2015 ). However, neither Khodadady ( 2012 ) nor Barłożek ( 2015 ) accounted for the nesting of students in classrooms, which is associated with a higher risk of false positive findings (Snijders & Bosker, 2012 ).

Notably, eleven other studies that were not exclusively using teacher self-report questionnaires provided evidence that was less clear. Hu et al. ( 2018 ) assessed preschool teachers’ self-evaluations of their ability to perceive other’s emotions and asked both teachers and external observers to evaluate the quality of emotional support. Emotional perception was statistically significantly related only to teachers’ self-reported emotional support ( r = .31, p < .001). Swartz and McElwain ( 2012 ) asked pre-service early childhood teachers about their perspective taking and observed their responses to children’s emotional displays. Teachers’ perspective taking was unrelated to their strategies when dealing with positive emotions, but when children displayed anger or sadness, empathic teachers were more likely to show supportive ( r = .52, p < .01) rather than non-supportive behavior ( r = –.44, p < .05). Friedman ( 2014 ) also conducted classroom observations to assess the quality of emotional support. Middle and high school teachers with higher scores in a newly developed emotional intelligence test regarding their awareness, perception, and understanding of students’ emotions did not establish a more positive climate and did not show more sensitivity or regard for students’ perspectives. In addition, preschool teachers demonstrating superior emotion knowledge in a focus group were not observed to show more emotional support in the study by Zinsser et al. ( 2015 ). In a similar vein, Heckathorn ( 2013 ) did not find a statistically significant positive and even one negative correlation between teachers’ perception and understanding of emotions as assessed with the MSCEIT (Mayer et al., 2002 ) and the degree to that nontraditional evening graduate adult master’s level students perceived affiliation among learners, opportunities to influence lessons, and teacher support in terms of sensitivity and encouragement. Furthermore, high school teachers’ tests scores in emotion understanding were unrelated to their self-reported quality of teacher-student relationships (O’Shea, 2019 ) and participation in an empathic mindset intervention did not make middle school students feel more respected by their teacher—however, the intervention had an effect for students with a history of suspension (Okonofua et al., 2016 ). In the thesis by Fults ( 2019 ), there was no association between middle school teachers’ self-reported empathy and students’ perception of proximity and Wen ( 2020 ) did not establish a link between college teachers’ self-reported ability to recognize other people’s emotions and student-reported receptivity and liking of the teacher. Likewise, Petsos and Gorizidis ( 2019 ) found no statistically significant correlation between junior high school teachers’ self-reported emotion perception of others and students’ perceptions of their teachers’ helpful and friendly behavior and their understanding of students as opposed to displaying dissatisfaction and admonishing students. Finally, middle school teachers reporting greater empathy with victims of bullying or general perspective taking and empathic concern were not more likely to perceive their teacher-student relationship as close and free of conflict (Hammel, 2013 ; only empathic concern and closeness: r = .27, p < .05). To summarize, teachers who perceived themselves as empathic reported providing more emotional support. However, this impression was rarely evident in students’ and observers’ perspectives. Furthermore, higher test scores in empathy were unrelated to the quality of emotional support.

Likelihood to Intervene in Bullying

Nine of the twelve studies in this strand of research found an effect (62% of the investigated effects were significant and positive; see Table 5 ). Seven studies, including teachers from preschool to the secondary school level, found that teachers feeling empathic concern for a hypothetical student who was a victim of bullying reported a greater likelihood of intervening in the bullying situation (Byers et al., 2011 ; Dedousis-Wallace & Shute, 2009 ; Hines, 2013 ; Huang et al., 2018 ; Sokol et al., 2016 ; VanZoeren, 2015 ; Yoon, 2004 ). In these studies, the effect sizes were moderate to large (all r s > .30; see Figure 3 ). Likewise, teachers’ self-reported general empathic concern, perspective taking, and tendency to experience the feelings of others were positively associated with their likelihood to intervene in bullying from early childhood to college education (Dedousis-Wallace & Shute, 2009 ; Fifield, 2011 ; Huang et al., 2018 ; Singh, 2014 ). One exception of this pattern was the thesis by Hammel ( 2013 ). Only when the hypothetical student was the victim of social exclusion, but not when students became victims of gossip or when friends threatened to end a relationship, was there a statistically significant correlation between middle school teachers’ empathy with the victim and their likelihood to intervene. Moreover, teachers’ general empathic concern and perspective taking were not statistically significantly related with the likelihood to intervene. Similarly, Garner et al. ( 2013 ) did not find a relationship between prospective teachers’ self-reported cognitive empathy and their likelihood to intervene in bullying scenarios. Finally, when pre-service elementary and secondary teachers did not indicate their likelihood to intervene in bullying via self-report, but when they were asked in an open-format with researchers coding their responses, there was less evidence of a relationship between teachers’ self-reported empathic concern and perspective taking with their responses to bullying (Tettegah, 2007 ; 3 of 12 statistically significant effects).

Classroom Management

In seven of ten studies spanning early childhood to tertiary education, there was no statistically significant relationship between teachers’ empathy and classroom management (Abacioglu et al., 2019 ; Friedman, 2014 ; Fults, 2019 ; Gottesman, 2016 ; Hall, 2009 ; Heckathorn, 2013 ; Petsos & Gorizidis, 2019 ). As Table 5 shows, 83% of the investigated effects were not statistically significant. Except for Gottesman ( 2016 ), these studies used other than teacher self-report measures for either empathy or classroom management. In line with the trend to find an association especially when both predictor and outcome are measured via teacher self-report, Hu et al. ( 2018 ) found no association between preschool teachers’ self-reported emotional perception and observer ratings of their classroom management ( r = .03, p > .05), but they did find a link with teachers’ own perceptions of their classroom management ( r = .38, p < .001). However, two studies revealed a positive association between empathy and classroom management. In her thesis, Metaxas ( 2018 ) showed that primary and secondary school teachers reporting being more empathic were less likely to choose punitive behavior ( r = −.22, p < .01) in response to a hypothetical challenging student. Relatedly, Okonofua et al. ( 2016 ) revealed that middle school teachers participating in an empathic mindset intervention were more likely to consider empathic disciplinary strategies ( r = .40, p < .01) rather than punitive approaches ( r = −.41, p < .01). However, these results are again based on teachers’ evaluations of hypothetical scenarios.

Instructional Support

In three of six studies, all relying not only on teacher self-report questionnaires, there was no evidence (85% of the investigated effects were not significant; see Table 5 ) for a relationship between teachers’ empathy and the levels of instructional support they provide for students in secondary school or for college students (Friedman, 2014 ; Hall, 2009 ; Wen, 2020 ). Even though Heckathorn ( 2013 ) found that adults in an evening master’s program rated those teachers who obtained higher test scores in perceiving emotions as providing more organized and clear instruction ( r = .26, p < .01), there was no statistically significant correlation with understanding emotions. Moreover, neither perceiving nor understanding emotions were associated with personal goal attainment defined as the degree to which the teacher attended to students’ individual learning needs and interests. Notably, these results are based on only N = 11 teachers. Again, Hu et al. ( 2018 ) found a link between preschool teachers’ self-reported emotional perception with their self-reported quality of instructional support ( r = .36, p < .001), but not with observers’ ratings of instructional support ( r = −.03, p > .05). Khodadady ( 2012 ) obtained a small, but statistically significant positive relationship between high school teachers’ self-reported empathy and student-reported facilitation ( r = .05, p < .05). However, the nesting of students within classes was not considered in the analyses so caution is warranted in interpreting this finding.

Effects on Student Outcomes

We identified twelve studies investigating the role of empathy in student outcomes: four studies measured cognitive student outcomes and ten measured psychosocial student outcomes including, for example, student engagement, conduct problems, or prosocial behavior.

Cognitive Student Outcomes

Two of four studies, which assessed teacher empathy via student report and a test instrument, provided less support (64% of the investigated effects were not significant; see Table 5 ) for the role of secondary school teacher empathy in students’ cognitive outcomes in terms of achievement test scores, grades, and students’ self-reported abilities in mathematics (Aldrup et al.,  2020 ; Curci et al., 2014 ). Franklin ( 2014 ) found a positive relationship between elementary school teachers’ self-reported empathic concern and students’ reading ( r = .17, p < .05), but not mathematics achievement growth ( r = .00, p > .05). Latchaw ( 2017 ) revealed that college students rating their teachers’ awareness of others’ emotions higher expected a better end-of-course grade ( r = .22, p < .01).

Psychosocial Student Outcomes

Seven of ten studies found little evidence of a relationship between teacher empathy and students’ psychosocial outcomes (72% of the investigated effects were not significant; see Table 5 ). More specifically, preschool teachers who reported a greater ability in perceiving the emotions of others neither noticed more social skills nor fewer peer problems, general anxiety, emotional problems, aggressiveness, conduct problems, or hyperactivity among their students (Poulou, 2017 ; Poulou et al., 2018 ). Contrary to expectations, students even reported more frequent bullying in middle schools employing teachers who rated their empathic concern and perspective taking higher (Underwood, 2010 ). Moreover, teachers at integrated schools who perceived themselves as more empathic did not rate their students as showing less misconduct in class (Nizielski et al., 2012 ) and students did not indicate greater receptivity and involvement in these teachers’ courses (Wen, 2020 ). Likewise, in two small studies ( N ≤ 12) with teachers at a junior high school and in an adult evening master’s program, respectively, there was no association between teachers’ ability to perceive and understand emotions as measured with the MSCEIT (Mayer et al., 2002 ) and student-reported involvement in class (Heckathorn, 2013 ), their scholastic self-esteem, metacognitive beliefs, and goal setting (Curci et al., 2014 ; one of 14 correlations was statistically significant, but all rs  < .12).

In contrast, Aldrup et al., ( 2020 ) showed that secondary school students who perceived their mathematics teacher as more sensitive reported lower mathematics anxiety and were appraised as less anxious by their parents (−.18 ≤ r ≤ −.07). Okonofua et al. ( 2016 ) found that middle school students’ suspension rates were statistically significantly lower among teachers who had participated in an empathic mindset intervention ( r = –.10, p < .001). Furthermore, Polat and Ulusoy-Oztan ( 2009 ) showed that primary school students rated their emotional intelligence higher when their teachers evaluated their own ability to perceive other people’s emotions more positively ( r = .30, p < .01).

Empathy is considered one factor determining prosocial behavior among all humans (Preston & de Waal, 2002 ) and argued to be relevant for teachers’ professional effectiveness given the high social and emotional demands inherent to daily interactions with students (Brackett & Katulak, 2007 ; Jennings & Greenberg, 2009 ). Against this background, we aimed to review the empirical evidence for these theoretical assumptions and identified 41 journal articles, theses, chapters, and conference papers providing insights to the role of teacher empathy in the quality of teacher-student interactions and student outcomes. To date, most research has accumulated on the relationship between teachers’ empathy and their emotional support for students, whereas we know much less about other domains of teacher-student interactions and student outcomes. Overall, there was limited evidence for a statistically significant positive association between empathy and any of the dependent variables considered in this research synthesis. The exception were studies relying exclusively on teacher self-report for assessing empathy and their own (likely) behavior in terms of quality of teacher-student interactions (e.g., Abacioglu et al., 2020 ). In this regard, the most consistent finding was that teachers reporting greater empathy for a bullied student in a hypothetical scenario indicated a greater likelihood to intervene in the situation (e.g., Sokol et al., 2016 ; Yoon, 2004 ). Even though these studies show that feeling concerned for students in specific situations makes teachers more motivated to help them, it remains unknown whether teachers would actually behave as intended in a real classroom situation and whether they would choose appropriate interventions. Thus, at first glance, these findings do not support the theoretical assumptions of an association of teacher empathy with the quality of teacher-student interactions and student outcomes.

One explanation might be that other social-emotional characteristics are more important for predicting the quality of teacher-student interactions, emotional support in particular, and student outcomes. For example, recent studies linked teachers’ mindfulness—a nonjudgmental awareness and acceptance of one’s present experiences (Brown & Ryan, 2003 )—to higher levels of emotional support for students (Jennings, 2015 ; Jennings et al., 2017 ). Furthermore, there is growing evidence regarding the importance of teacher well-being. Prior studies found a positive association between teachers’ work enthusiasm with emotional support, student motivation, and achievement, whereas the reverse was true for burnout symptoms (Arens & Morin, 2016 ; Klusmann et al., 2016 ; Keller et al., 2016 ; Kunter et al., 2013 ; Shen et al., 2015 ). However, it is also possible that researchers have not been able to discover a relationship between empathy, the quality of teacher-student interactions, and student outcomes because they have not attended to some key methodological and conceptual issues that we consider vital for obtaining valid results in future research.

Avenues for Future Research

Dealing with common method bias and the valid assessment of empathy.

The majority of studies we reviewed applied teacher self-report measures of empathy in combination with self-report measures of interaction quality and student outcomes. This poses the risk of common method bias, which can cause positively biased associations between predictor and outcome variables (Podsakoff et al., 2003 ). Therefore, research can only provide valid conclusions about the role of teacher empathy in the quality of teacher-student interactions and student outcomes if more studies combine different data sources. To achieve this, researchers in the field have pursued different strategies.

One approach is to treat common method bias by measuring the dependent variable via student questionnaires, classroom observations, or achievement tests (e.g., Hu et al., 2018 ). This approach enables researchers to investigate whether teacher empathy becomes manifest in teachers’ actions and whether others notice differences between teachers with higher versus lower empathy. Considering the perspectives of other raters except for the teacher appears particularly important because students and external observers often perceive interaction quality differently than the teachers themselves do (e.g., Fauth et al., 2014a ; Kunter & Baumert, 2006 ). In this review, ten studies combined teacher self-report measures with other sources for assessing the outcome. The evidence in these studies was mixed and some found at least partial support for the hypothesis that empathy is associated with effective teaching (Franklin, 2014 ; Ghanizadeh & Moafian, 2010 ; Khodadady, 2012 ; Polat & Ulusoy-Oztan, 2009 ; Swartz & McElwain, 2012 ) whereas others did not (Fults, 2019 ; Hu et al., 2018 ; Petsos & Gorizidis, 2019 ; Underwood, 2010 ; Wen, 2020 ).

One explanation for the heterogeneous results could lie in the comparably small sample sizes. Only two of the studies were based on more than 100 participants—a sample size that is required for detecting medium effects—and five included 50 or less. Small sample sizes reduce the statistical power to detect meaningful effects. Yet, there is also evidence that effect sizes are larger in small samples, perhaps, because they are less likely to be published when yielding insignificant results than expensive larger studies (Slavin & Smith, 2009 ). Thus, future studies should include a sufficient number of teachers to avoid these issues.

Another reason for the inconsistent findings could be the construct validity of self-report empathy measures. Caring for others is at the core of teachers’ professional identity so self-serving bias could cause teachers to describe themselves more positively in terms of their empathy level (O’Connor, 2008 ; Wubbels et al., 1993 ). Furthermore, the self-assessment of social-emotional abilities is now questioned as correlations with objective tools are rather small but objective tools appear more closely related to social behavior (Brackett & Mayer, 2003 , Brackett et al., 2006 ). Therefore, the use of tests rather than self-report questionnaires (e.g., Hall, 2009 ) could improve the measurement of empathy in future research. At the same time, this strategy provides the opportunity to avoid common method bias. However, the few studies that have pursued this strategy have mostly yielded insignificant results. Again, only two of nine studies included more than 100 participants and five drew on only 32 teachers or less. Thus, studies with appropriate power are needed to evaluate the potential of objective empathy assessments.

In addition, we expected the closest relationship between empathy and emotional support, but as evident in Figure 3 , many of the methodologically sophisticated studies included either other domains of teacher-student interaction quality or student outcomes (e.g., Corcoran & Tormey, 2013 ; Hall, 2009 ). Thus, it was less likely to find pronounced effects in these studies from a conceptual point of view.

Finally, except for Friedman ( 2014 ), previous work with objective assessments has relied on tools that appear rather distant from teachers’ daily work with students. For example, in one subtest of the frequently used MSCEIT (Mayer et al., 2002 ), participants see images of landscapes and artwork and evaluate the degree to which the pictures express certain emotions. Consequently, it appears necessary to use measurement instruments more closely aligned with teachers’ professional tasks.

A Profession-Specific Perspective on Teacher Empathy

As the findings from our review showed, studies investigating the relationship between empathy with victims of bullying and the likelihood to intervene yielded the most robust and substantial correlations. In addition to the fact that both were assessed from the teacher perspective, one explanation for the close association could be that independent and dependent variable refer to the same situation. Another finding supporting the value of a profession-specific approach is that among the few studies of this kind, which either asked students about their teachers’ sensitivity for their emotions or intervened in teachers’ empathy with students (Aldrup et al., 2020 ; Okonofua et al., 2016 ), found statistically significant associations with interaction quality and student outcomes. However, only a few researchers have adapted and developed empathy questionnaires and tests that explicitly ask teachers to refer to the professional context; hence, more instruments of this kind are needed (Friedman, 2014 ; Wu et al., 2019 ; Zinsser et al., 2015 ). To go beyond paper-pencil formats and for a realistic assessment of cognitive empathy, the dyadic interaction paradigm (Ickes, 2001 ), which is frequently applied in empathic accuracy research, could serve as a guideline. Here, a dyad’s interaction is videotaped and each participant individually writes down their thoughts and feelings during specific episodes. Then, the partner’s task is to indicate what their counterpart experienced. In researching teachers’ empathy, one could videotape teacher-student interactions. Furthermore, teachers’ affective empathy has been only assessed via questionnaires thus far, which appears reasonable because it reflects a person’s subjective experiences. Nonetheless, one could also consider using teachers’ facial expressions in response to students’ emotions as an indicator of their affective empathy (e.g., Marx et al., 2019 ).

Moreover, in developing profession-specific instruments, considering different levels of specificity would allow us to gain additional insights about the degree to which teacher empathy is context-dependent. One option would be a situation-specific assessment as was done in bullying research (e.g., Yoon, 2004 ). Likewise, Friedman ( 2014 ) developed a tool for measuring teachers’ ability to perceive and understand students’ emotions during a hypothetical disciplinary incident in class. Another option would be a class-specific assessment. At the secondary school level in particular, teachers see different groups of students each day and it may be easier for them to empathize with some than with others, for example, depending on the students’ age or the number of lessons they see each other per week. Furthermore, Frenzel et al. ( 2015 ) showed that teachers’ emotions largely depend on the class they teach. Being in a class that elicits enjoyment rather than anger or anxiety could facilitate cognitive empathy because positive emotions promote cognitive processes (e.g., broaden-and-build theory, Fredrickson, 2001 ). Of course, one could think of several other relevant specific situations such as empathy with students struggling with content or with students from specific backgrounds who are at risk of adverse developmental trajectories. For example, Warren ( 2015 ) developed a scale measuring teacher empathy for African American males.

Importantly, when using situation- or class-specific assessments, we suggest aligning the specificity of the empathy measure and the dependent variable of interest. We will give an example to illustrate this point: The instrument developed by Friedman ( 2014 ) measures empathy in a very specific situation, but does not tell us about the teachers’ ability to recognize their students’ emotions and take their perspectives in other contexts. Hence, finding an association with dependent variables closely connected to the specific situation of the empathy measure is most likely, whereas a relationship with broader variables appears less probable. Finding no relationship between Friedman’s ( 2014 ) measure of empathy and classroom observations of teacher-student interactions is in line with this idea. Inversely, this means that one should refrain from using situation- or class-specific instruments when the research interest is in explaining teaching effectiveness more broadly.

Interplay with Other Teacher Characteristics and Students’ Prerequisites

In addition to methodological challenges, our unexpected finding could be because teacher empathy alone is not sufficient to achieve high-quality teacher-student interactions and positive student outcomes. First, a hierarchical organization of social-emotional competence is hypothesized with empathy being a precursor of more advanced abilities such as emotion and relationship management (Joseph & Newman, 2010 ; Mayer & Salovey, 1997 ). From this perspective, it can be argued that teacher empathy can only be effective in combination with knowledge and skills about effective behavior in social situations. In line with this, Aldrup, Carstensen et al. ( 2020 ) showed that teachers with greater knowledge about relationship management reported providing more emotional support and perceived their relationships with students more positively.

Second, it is possible that teacher empathy only shows when teachers are motivated to act accordingly. In other words, they may not always display their full empathic potential. Considering the finding that teachers’ emotions largely depend on the group of students they teach (Frenzel et al., 2015 ), one could speculate that teachers will be more motivated to demonstrate empathic behavior in a class they like, making a class-specific assessment of empathy particularly interesting in this line of research. Further aspects, such as emotional stability, pro-sociality, or self-efficacy, have been suggested as relevant determinants of the degree to which people perform empathic behavior (Cavell, 1990 ; DuBois & Felner, 2003 ; Rose-Krasnor, 1997 ). Furthermore, teacher empathy may interact with their well-being such that burnout and the lack of emotional resources impair teachers’ empathy (Trauernicht et al., 2021 ). Likewise, other teacher characteristics may mask their empathy. For instance, the belief that strict discipline is needed because children are naturally rebellious and lazy could lead teacher to suppress empathic tendencies (c.f., Rimm-Kaufman et al., 2006 ).

Third, empathy may not always be beneficial as is evident in the phenomenon of compassion fatigue. Compassion fatigue denotes a loss of interest in empathizing with others and a lack of energy, which can result from self-giving work with people who are in pressing need for help (Adams et al., 2006 ; Knobloch Coetzee & Klopper, 2010 ). In other words, excessive empathy puts people at risk of suffering themselves. For example, teachers with greater empathy for victims of bullying also feel angrier and sadder when witnessing bullying incidents (Sokol et al., 2016 ). To alleviate negative feelings and protect one’s emotional resources, teachers may eventually distance themselves from their students (for a similar line of reasoning, also see Maslach et al., 2001 ). In line with this, prior research showed that people who feel distressed by seeing other people suffering avoid the situation or even show aggressive reactions (Eisenberg & Fabes, 1990 ). Hence, both low and extremely high levels of teacher empathy might be problematic potentially causing a nonlinear relationship with the quality of teacher-student interactions and student outcomes. Considering this, teachers may only benefit from extremely high levels of empathy if they are able to distance themselves from the emotional demands of their work. Potentially interesting moderators of the empathy-outcome relationship include emotion regulation and mindfulness. Prior research shows that they reduce negative emotions so they could be a protective resource for highly empathic teachers (Klingbeil & Renshaw, 2018 ; Lee et al., 2016 ).

In addition to investigating the interplay between empathy and other social-emotional teacher characteristics, we suggest considering whether students’ prerequisite moderate the role of empathy in the quality of teacher-student interactions and student outcomes. For example, prior research shows that teachers play a more prominent role in the development of students at risk of adverse educational trajectories (Hamre & Pianta, 2005 ; Klusmann et al., 2016 ). Hence, teacher empathy might be particularly relevant for students with a low socioeconomic status or with cognitive or social-emotional difficulties. Another important aspect might be students’ age. On the one hand, one could assume that teacher empathy is particularly relevant for young students, for example, because they are still more dependent on adult support to regulate their emotions (Calkins & Hill, 2009 ). On the other hand, student disengagement represents a particular challenge during adolescence and teachers often struggle to meet adolescents’ developmental needs (Eccles & Midgley, 1989 ; Wang & Eccles, 2012 ). Thus, teachers who consider adolescents’ perspectives and care for their feelings might be particularly important during this phase. In line with this assumption, meta-analytic evidence shows that the association between the teacher-student relationship and student engagement and achievement gets closer for older students (Roorda et al., 2017 ).

Limitations

In this article, we aimed to provide the first comprehensive overview of prior research on the relationship between teacher empathy, teacher-student interactions, and student outcomes. Therefore, we included studies from different lines of research that diverge in their operationalization of empathy. For example and as outlined in the Results section, even though both the Interpersonal Reactivity Index (Davis, 1980 ) and the MSCEIT (Mayer et al., 2002 ) were designed to measure whether one is able to consider other’s perspectives, the types of questions/tasks differ substantially. Thus, it is unclear whether all studies actually measured the same underlying construct. A similar problem applies to our dependent variables where there was large heterogeneity in terms of the instruments.

Furthermore, we decided to consider theses, proceedings papers, and book chapters in addition to studies from peer-reviewed journals. Almost half of the studies were not from journal articles. Thus, our approach allowed for a more exhaustive overview of the field and helped to reduce the risk of publication bias. The large number of studies with insignificant results let us conclude that our strategy for reducing publication bias was successful. However, it may have reduced the quality of the included studies. Even though follow-up analyses revealed no differences between the publication types in terms of sample size or the avoidance of common method bias, we cannot rule out other potential limitations such as lower quality of data collection, preparation, and analyses in studies from sources other than journals.

In addition, a large number of studies assessed constructs relevant for our review without reporting correlation analyses. Due to our concerns about the reliance on teacher self-report measures for assessing the independent and dependent variables, we decided to contact the authors only when they had pursued a different methodological approach. Because studies that included only teacher questionnaires typically found closer associations, we should note that our decision might have reduced the number of statistically significant results.

Finally, a meta-analytical analysis would have been ideal to investigate the extent to which methodological study characteristics moderate the size of effects (Borenstein, 2009 ). Nonetheless, we decided against this approach as we identified only a relatively small number of relevant studies for most dependent variables. In addition, we had the impression that computing an overall effect size was not appropriate because of the huge heterogeneity in the research field. The different methodological approaches are not equally valid for assessing empathy and sophisticated studies typically included small samples reducing their weight in meta-analyses.

Theoretical models (e.g., Jennings & Greenberg, 2009 ) emphasize the relevance of teachers’ empathy for high-quality teacher-student interactions and positive student outcomes, but to date, only limited evidence supports this claim. Nonetheless, rather than abandoning the idea that teacher empathy is a relevant construct, we call for methodologically sophisticated studies that go beyond teacher self-report and allow for robust conclusions. Perhaps, we would otherwise overlook an important social-emotional teacher characteristic, where there is an urgent need for action given that teachers frequently struggle to recognize student emotions (Karing et al., 2013 ; Spinath, 2005 ).

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Aldrup, K., Carstensen, B. & Klusmann, U. Is Empathy the Key to Effective Teaching? A Systematic Review of Its Association with Teacher-Student Interactions and Student Outcomes. Educ Psychol Rev 34 , 1177–1216 (2022). https://doi.org/10.1007/s10648-021-09649-y

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Published : 10 March 2022

Issue Date : September 2022

DOI : https://doi.org/10.1007/s10648-021-09649-y

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Empathy is the most important leadership skill according to research.

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Leading with empathy is good for people and organizations.

Empathy has always been a critical skill for leaders, but it is taking on a new level of meaning and priority. Far from a soft approach it can drive significant business results.

You always knew demonstrating empathy is positive for people, but new research demonstrates its importance for everything from innovation to retention. Great leadership requires a fine mix of all kinds of skills to create the conditions for engagement, happiness and performance, and empathy tops the list of what leaders must get right.

The Effects of Stress

The reason empathy is so necessary is that people are experiencing multiple kinds of stress, and data suggests it is affected by the pandemic—and the ways our lives and our work have been turned upside down.

• Mental Health. A global study by Qualtrics found 42% of people have experienced a decline in mental health. Specifically, 67% of people are experiencing increases in stress while 57% have increased anxiety, and 54% are emotionally exhausted. 53% of people are sad, 50% are irritable, 28% are having trouble concentrating, 20% are taking longer to finish tasks, 15% are having trouble thinking and 12% are challenged to juggle their responsibilities.
• Personal Lives. A study in Occupational Health Science found our sleep is compromised when we feel stressed at work. Research at the University of Illinois found when employees receive rude emails at work, they tend to experience negativity and spillover into their personal lives and particularly with their partners. In addition, a study at Carleton University found when people experience incivility at work, they tend to feel less capable in their parenting.
• Performance, Turnover and Customer Experience. A study published in the Academy of Management Journal found when people are on the receiving end of rudeness at work, their performance suffers and they are less likely to help others. And a new study at Georgetown University found workplace incivility is rising and the effects are extensive, including reduced performance and collaboration, deteriorating customer experiences and increased turnover.

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Best 5% interest savings accounts of 2024, empathy contributes to positive outcomes.

But as we go through tough times, struggle with burnout or find it challenging to find happiness at work, empathy can be a powerful antidote and contribute to positive experiences for individuals and teams. A new study of 889 employees by Catalyst found empathy has some significant constructive effects:

• Innovation. When people reported their leaders were empathetic, they were more likely to report they were able to be innovative—61% of employees compared to only 13% of employees with less empathetic leaders.
• Engagement. 76% of people who experienced empathy from their leaders reported they were engaged compared with only 32% who experienced less empathy.
• Retention. 57% of white women and 62% of women of color said they were unlikely to think of leaving their companies when they felt their life circumstances were respected and valued by their companies. However, when they didn’t feel that level of value or respect for their life circumstances, only 14% and 30% of white women and women of color respectively said they were unlikely to consider leaving.
• Inclusivity. 50% of people with empathetic leaders reported their workplace was inclusive, compared with only 17% of those with less empathetic leadership.
• Work-Life. When people felt their leaders were more empathetic, 86% reported they are able to navigate the demands of their work and life—successfully juggling their personal, family and work obligations. This is compared with 60% of those who perceived less empathy.

Cooperation is also a factor. According to a study published in Evolutionary Biology , when empathy was introduced into decision making, it increased cooperation and even caused people to be more empathetic. Empathy fostered more empathy.

Mental health. The study by Qualtrics found when leaders were perceived as more empathetic, people reported greater levels of mental health.

Wired for Empathy

In addition, empathy seems to be inborn. In a study by Lund University , children as young as two demonstrated an appreciation that others hold different perspectives than their own. And research at the University of Virginia found when people saw their friends experiencing threats, they experienced activity in the same part of their brain which was affected when they were personally threatened. People felt for their friends and teammates as deeply as they felt for themselves. All of this makes empathy an important part of our human condition—at work and in our personal lives.

Leading with Empathy

Leaders can demonstrate empathy in two ways. First, they can consider someone else’s thoughts through cognitive empathy (“If I were in his/her position, what would I be thinking right now?”). Leaders can also focus on a person’s feelings using emotional empathy (“Being in his/her position would make me feel ___”). But leaders will be most successful not just when they personally consider others, but when they express their concerns and inquire about challenges directly, and then listen to employees’ responses.

Leaders don’t have to be experts in mental health in order to demonstrate they care and are paying attention. It’s enough to check in, ask questions and take cues from the employee about how much they want to share. Leaders can also be educated about the company’s supports for mental health so they can provide information about resources to additional help.

Great leadership also requires action. One leader likes to say, “You’re behaving so loudly, I can hardly hear what you’re saying.” People will trust leaders and feel a greater sense of engagement and commitment when there is alignment between what the leader says and does. All that understanding of someone else’s situation should turn into compassion and action. Empathy in action is understanding an employee’s struggles and offering to help. It is appreciating a person’s point of view and engaging in a healthy debate that builds to a better solution. It is considering a team member’s perspectives and making a new recommendation that helps achieve greater success. As the popular saying goes, people may not remember what you say, but they will remember how you made them feel.

Empathy contributes to positive relationships and organizational cultures and it also drives results. Empathy may not be a brand new skill, but it has a new level of importance and the fresh research makes it especially clear how empathy is the leadership competency to develop and demonstrate now and in the future of work.

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Why Trait Empathy Is the Wrong Measure

Empathy is best measured in interactions and it's a skill we can all develop..

Posted April 1, 2024 | Reviewed by Jessica Schrader

• The Importance of Empathy
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• Empathy has been treated as an individual trait that can be measured.
• Empathy is fragile and can fall away no matter how much trait empathy people allegedly possess.
• A better and more empathic model locates empathy in interactions instead of limiting it to individuals.

Is empathy a trait—or is it an interaction?

I've been studying empathy for most of my life. I write about empathy in books and studies and teach it across the world, and I developed a unique "big tent" model of empathy that helps people access, increase, or decrease their empathic capacities at any stage in their lifespans.

But the more I think about empathy, the more I question the concept of trait empathy. I question whether we can say that this person has this amount of empathy, and that person has that amount: she’s at 92, they're at 70, those people are at 6.5 …

Instead, I’m now observing empathy as something that exists in interactions , rather than merely in individuals.

Because your empathy can fall away in 3, 2, ...

We've all experienced the sudden loss of our empathy in interactions. For instance, if I forcefully make a statement that you don’t agree with, your empathy may fall away.

Imagine that you and I are committed vegetarians, and that's one of the ways we empathize with each other. If I suddenly glorify the health benefits of meat, it’s very likely that your empathy for me would fade or even disappear. If empathy were a trait that lived entirely within you, that wouldn’t happen.

In fact, empathy can be a very fragile thing. We've all seen that empathy can decrease in the presence of:

• Communication barriers.
• Difference (in age, cultural expectations, group membership, gender expression, body types, neurodivergence, etc.).
• The presence of an emotion you don't know how to work with.
• Fatigue and overwhelm.

Empathy isn't a stable trait; it's something that appears in interactions, and often only when all the conditions are just right.

In my work, I help people develop robust emotional and empathic skills so that they can choose to empathize even when it's difficult. I also help people learn how to turn down specific aspects of their empathy when it's hyper-activated.

If empathy were a trait, we couldn't do that, but because empathy exists in interactions, we can work with our empathy and decide how and when to use it.

Your empathy can also rise and fall at the exact same moment

The idea that empathy is a stable trait can easily be shown to be incorrect. In my book The Art of Empathy , I write about something I call “three-party empathy," 1 which is an everyday empathy-bending behavior that you may miss if you assume that empathy is a trait.

We've been surrounded by three-party empathy throughout our lives: it's a situation in which people want us to join them in taking sides. When we take sides, we are of course on the right side, and the people who disagree with us are (of course) on the wrong side. This is an everyday behavior, but when you observe it empathically, you can see what's happening to people's empathic abilities.

Three-party empathy is especially visible on social media , where people fight for your attention and attempt to manipulate your emotions and your empathy. For instance, my activist friends on social media often create forceful and melodramatic posts about their most pressing political concerns; they clearly want me to believe as they do, be on their side, and share all of their emotions and attitudes.

They especially want me to look down on, distrust , or even despise the people on the other side of their issues. Liberal versus conservative, vegan versus carnivore, anti-abortion versus pro-choice, Israelis versus Palestinians, and on into infinity.

If I can't see the ways that my friends are trying to manipulate my empathy, I'll become entrapped in three-party empathy. I'll strongly increase my empathy for my friends and their crusades and enter into enmeshed hyper-empathy with them. But at the same time, I'll decrease my empathy for the enemies of my friends, and drop into hypo-empathy that may even degrade into dehumanization of entire groups or ideologies.

So in my single brain at a single moment in time, I'll be simultaneously at empathy 100 and at empathy 0.

This couldn't happen if empathy were an individual trait.

And there's another problem with the idea of trait empathy

The very idea of trait empathy invites a tragic game of comparisons, where we are free to exile the people we call unempathic .

Some of these exiles are boys and men, who are wrongly called out as constitutionally unempathic, even though socialization is the culprit in teaching males different forms of empathic interactions. Autistic people are also exiled, even though they often deal with uncontrolled hyper-empathy that makes them uncomfortably hyper-sensitive to their environment.

People dealing with sociopathy , psychopathy , and narcissistic traits are also exiled from empathy, even though people in each of these groups can and do empathize. And women and girls are required to be empathic (or even hyper-empathic), which places a tremendous burden on them as "natural" caregivers and loads them up with unpaid emotional labor throughout their lives.

It is unempathic to exile people from empathy, and it is also unempathic to grade empathy as if it's a stable trait instead of a situation-dependent and socialization-dependent interactional behavior.

Reframing empathy

When I did the research for my book on empathy in 2011 and 2012, researchers were fighting over the definition of empathy. Mistakenly framing it as a trait was one reason they couldn't come to any agreement, but there were many other fights that also got in their way. I walked away from their fruitless arguments and built a definition of empathy that focused on skills and interactions rather than mere traits:

Empathy is a social and emotional skill that helps you feel and understand the emotions, circumstances, thoughts, and needs of others, such that you can offer sensitive, perceptive, and appropriate communication and support.

In my model, there are no exiles and no magical people who are unfailingly empathic. Instead, there are imperfect people working to develop the skills they need to interact perceptively and empathically.

The traits of self-development and skill-building are the traits we want to support. The concept of trait empathy is a questionable measure that invites exiling and also erases the social skills, emotional awareness, and empathic labor that are the true measures of healthy empathic interactions.

1 My three-party empathy model is a nod to Fritz Breithaupt’s concept of three-person empathy ; however, my terminology refers to more complex group-level behaviors.

de Waal, F. (2010). The Age of Empathy: Nature's Lessons for a Kinder Society . New York, NY: Crown.

McLaren, K. (2013). The Art of Empathy: A Complete Guide to Life’s Most Essential Skill . Boulder, CO: Sounds True.

McLaren, K. (2014). Interrogating Normal: Autism Social Skills Training at the Margins of a Social Fiction .

Breithaupt, F. (2012). A Three-Person Model of Empathy. Emotion Review, 4: 84.

Hochschild, A. R. (2003). The Managed Heart: Commercialization of Human Feeling. Berkeley, CA: UC Press.

McLaren, K. (2021). The Power of Emotions at Work: Accessing the Vital Intelligence in Your Workplace . Boulder, CO: Sounds True.

McLaren K. (2023). The Language of Emotions: What Your Feelings Are Trying to Tell You . Boulder, CO: Sounds True.

Karla McLaren, M.Ed., is an author, educator, workplace consultant, social science researcher, and emotions and empathy innovator.

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Increasingly sophisticated AI systems can perform empathy, but their use in mental health care raises ethical questions

by A.T. Kingsmith, The Conversation

In a world where technology is increasingly intertwined with our feelings, emotion-AI harnesses advanced computing and machine learning to assess, simulate, and interact with human emotional states.

As emotion-AI systems become more adept at detecting and understanding emotions in real-time , the potential applications for mental health care are vast .

Some examples of AI applications include: screening tools in primary care settings , enhanced tele-therapy sessions and chatbots offering accessible 24/7 emotional support . These can act as bridges for anyone waiting for professional help and those hesitant to seek traditional therapy.

However, this turn to emotion-AI comes with a host of ethical, social and regulatory challenges around consent, transparency, liability and data security.

My research explores these potentials and challenges of emotion-AI in the context of the ongoing mental health crisis in the years since the COVID-19 pandemic .

When emotional AI is deployed for mental health care or companionship, it risks creating a superficial semblance of empathy that lacks the depth and authenticity of human connections.

What's more, issues of accuracy and bias can flatten and oversimplify emotional diversity across cultures , reinforcing stereotypes and potentially causing harm to marginalized groups. This is particularly concerning in therapeutic settings, where understanding the full spectrum of a person's emotional experience is crucial for effective treatment.

Age of emotional AI

The global emotion-AI market is projected to be worth US$13.8 billion by 2032 . This growth is driven by the expanding application of emotion-AI across sectors ranging from public health care and education to transportation .

Advancements in machine learning and natural language processing allow for a more sophisticated analysis of people's emotional cues using facial expressions, voice tones and textual data.

Since its release in early 2023, OpenAI's generative-AI chatbot ChatGPT-4 has been leading the charge with human-like responses across a broad spectrum of topics and tasks. A recent study found that ChatGPT consistently scored higher on " emotional awareness "—identifying and describing emotions accurately—than general population averages.

While OpenAI dominates North American and European markets, Microsoft's chatbot Xiaoice is more popular in the Asia-Pacific region. Launched in 2014 as a "social chatbot" aimed at establishing emotional connections with users, Xiaoice is capable of sustained empathetic engagement , remembering past interactions and personalizing conversations.

In the coming years, a mix of productivity and emotional connection will transform mental health care and redefine how we interact with AI on an emotional level.

Future risks

The rapid rise of emotion-AI raises profound ethical and philosophical questions about the nature of empathy and emotional intelligence in machines.

In The Atlas of AI , AI Scholar Kate Crawford questions the accuracy of systems that claim to read human emotions through digital cues. She raises concerns about the process of simplifying and decontextualizing human emotions .

Digital scholar Andrew McStay further explores the implications of attributing empathy to emotion-AI systems. In Automating Empathy , McStay warns of "synthetic empathy," highlighting a key distinction between simulating a recognition of human emotions and truly experiencing empathy.

Additionally, emotion-AI's ability to analyze emotional states opens avenues for surveillance, exploitation and manipulation . This raises questions about the boundaries of machine intervention in personal and emotional domains.

Rethinking human-AI relations

The widespread application of AI in therapy, counseling and emotional support holds the potential to revolutionize access to care and alleviate pressures on overworked and overburdened human practitioners. However, the personification of emotion-AI creates a paradox where humanizing AI might lead to the dehumanization of human beings themselves.

At the same time, attributing human-like qualities to AI risks making mental health care less interpersonal. The potential for AI chatbots to misinterpret cultural and individual emotional expressions could lead to misguided advice or support . This can further complicate or exacerbate mental health issues, especially where the nuances of human empathy are essential .

These tensions underscore the need for the careful, ethically informed integration of emotion-AI in mental health treatment and care.

These technologies need to complement, rather than substitute, the human elements of empathy , understanding and connection. This requires rethinking human-AI relations, particularly around empathy .

By ensuring the ethical development of emotion-AI, we can aspire to a future where technology enhances mental health without diminishing what it means to be human.

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Effectiveness of empathy in general practice: a systematic review

Empathy as a characteristic of patient–physician communication in both general practice and clinical care is considered to be the backbone of the patient–physician relationship. Although the value of empathy is seldom debated, its effectiveness is little discussed in general practice. This literature review explores the effectiveness of empathy in general practice. Effects that are discussed are: patient satisfaction and adherence, feelings of anxiety and stress, patient enablement, diagnostics related to information exchange, and clinical outcomes.

To review the existing literature concerning all studies published in the last 15 years on the effectiveness of physician empathy in general practice.

Design and setting

Systematic literature search.

Searches of PubMed, EMBASE, and PsychINFO databases were undertaken, with citation searches of key studies and papers. Original studies published in English between July 1995 and July 2011, containing empirical data about patient experience of GPs’ empathy, were included. Qualitative assessment was applied using Giacomini and Cook’s criteria.

After screening the literature using specified selection criteria, 964 original studies were selected; of these, seven were included in this review after applying quality assessment. There is a good correlation between physician empathy and patient satisfaction and a direct positive relationship with strengthening patient enablement. Empathy lowers patients’ anxiety and distress and delivers significantly better clinical outcomes.

Although only a small number of studies could be used in this search, the general outcome seems to be that empathy in the patient–physician communication in general practice is of unquestionable importance.

INTRODUCTION

Patients consider empathy as a basic component of all therapeutic relationships and a key factor in their definitions of quality of care. 1 , 2 One hundred years ago, Tichener introduced the word ‘empathy’ into the English literature, based on the philosophical aesthetics concept of ‘Einfühlung’ of Theodor Lipps. 3 Another important historical moment is the way Rogers speaks about empathy in 1961 in his book: On Becoming a Person: a Therapist’s View of Psychotherapy. 4 Since then, various authors have written about empathy in the setting of psychotherapy and about its functionality in patient–physician communication. Neuroscientific research of recent decades has achieved significant progress in establishing the neurobiological basis for empathy, after discovering the mirror neuron system (MNS) 5 , 6 as probably being related to people’s capacity to be empathic. 7 Scientists have now added new insights, based on functional magnetic resonance imaging (fMRI) experiments. They have discovered that the MNS consists of mirror neurons in the ventral premotor cortex and the parietal area of the brain and neurons in the somatosensory areas and in limbic and paralimbic structures. 8 The insula plays a fundamental role in connecting these regions. 9 fMRI experiments have shown that individuals who score higher in a questionnaire measuring their tendency to place themselves in the other person’s shoes activate their MNS more strongly while listening to other people’s problems. 10 , 11 These results draw the ‘soft’ concept of empathy into ‘hard’ science, which opens a challenging new field of research with potentially important clinical implications. 12 However, these neurobiological studies do not give information about the impact of empathy in clinical care. Within the current opinion of ‘evidence-based health care’, it is important also to get evidence about the effectiveness of empathy in the daily practice of GPs.

To assess the effectiveness of empathy, it is necessary to define what authors mean when using the term ‘empathy’. Although many authors experience difficulties in giving a clear definition, 1 , 2 , 13 – 20 a number of core elements can be identified. In general, authors consider empathy as the competence of a physician to understand the patient’s situation, perspective, and feelings; to communicate that understanding and check its accuracy; and to act on that understanding in a helpful therapeutic way. It has an affective, a cognitive, and a behavioural dimension. 1 , 21 – 24

Empathy can therefore be defined at three levels: as an attitude (affective), 25 , 26 as a competency (cognitive), 2 , 15 and as a behaviour. 2 , 16

Attitude is based on moral standards in the mind of the physician; such as respectfulness for the authenticity of the other person, interest in the other person, impartiality, and receptivity. These standards are formed by a physician’s own human development, their socialisation process, their medical training, their personal experience with patients; by reading professional literature; and by watching movies and reading books. 13 , 15 , 22 , 27 – 29

How this fits in

Empathy is seen, as well as by patients as by physicians, as the base of good patient-physician communication. Despite these opinions one can see a decrease of interest in good patient-physician communication. There is an increase of technological aspects of care and of a prevalence on productivity in general practice. This systematic review shows that also a “soft” skill like empathy has its effectiveness on patient satisfaction, adherence, decrease of anxiety and stress, better diagnostics and outcomes and patient enablement. Physicians should be more aware of this. In the near future it is a challenge to draw the attention of policy makers and health insures on these aspects of empathy.

Competency can be subdivided into empathic skill, a communication skill, and the skill to build up a relationship with a patient based on mutual trust. Empathic skill is the approach by which the physician can elicit the inner world of the patient and get as much information as possible from the patient, while at the same time recognising the patient’s problem. 2 , 30 , 31 Communication skill is used to check, clarify, support, understand, reconstruct, and reflect on the perception of a patient’s thoughts and feelings. 15 , 23 The skill to build up a trusting and long-standing patient–physician relationship encourages physicians to resonate with the patient emotionally. These long-term relationships are important for telling and listening to the stories of illness. 32 , 33

Behaviour has a cognitive and an affective part. The cognitive part includes verbal and/or non-verbal skills. 14 , 15 , 22 , 25 , 26 The affective part includes recognition of the emotional state or situation of the patient, being moved, and recognising a feeling of identification with someone who suffers with anger, grief, and disappointment. After this recognition, the physician, in their behaviour, reflects on and communicates their understanding to the patient ( Figure 1 ). 20 , 23

Subdivisions of empathy.

Both patients and physicians mention empathy as the basis for a humane patient-centred method in general practice, and as an important component of professionalism. 1 , 17 , 34 A large number of patients, nearly 80%, would recommend an empathic physician to other individuals. 35

Despite these opinions, one can see a decrease of interest in good patient–physician communication. Reynolds et al report a low level of empathy in professional relationships. 34 In their view, this is widespread in modern medicine and many recipients of professional help may not feel that their situation is understood by professionals. 34 A study by Kenny et al suggests that physicians and patients have a different perspective on physicians’ communication skills: the perceptions of the medical encounter have been characterised as being so different that they appear to be from ‘different worlds’. 36

Moreover, different authors report a rising prevalence in the last decade of technological and biomedical aspects of care and of more emphasis on effectiveness and productivity in family care. 17 , 20 , 37 Peabody proved to be prophetic when, in 1927, in his lecture The Care of the Patient, he expressed concern that rapidly growing scientific technology was crowding out human values in the management of patients. 38 Just as Spiro asks attention for the ‘unseen and unheard’ patient in these developments, 20 it is important to pay attention to the effectiveness of empathy in patient–physician communication.

The purpose of this literature review is to get a clear view on the proven effectiveness of empathy in patient–physician communication, in particular in general practice.

A search was undertaken of PubMed, EMBASE, and PsychINFO databases, between July 1995 and July 2011, with the support of a professional librarian, to identify studies of general practice, empathy, and effectiveness or outcome of empathy. The search terms used are shown in Box 1 . The search was performed using major medical subject heading (MeSH) terms in titles and/or abstracts ( Box 1 ). After removal of duplicate studies, titles and abstracts were assessed as to whether the articles were pertinent to this literature review and whether they dealt with general practice. Potentially relevant articles were read in full text. Further papers were sought by checking references and citation searches of included and other leading articles (snowball method). After this selection, articles were assessed as to whether or not they fitted within the inclusion criteria.

Box 1. Database search terms used

((empathy[MeSH] OR empath*[tiab])) AND (Physicians, Family[MeSH] OR Primary Health Care[MeSH] OR Family Practice[MeSH] OR “General Practice”[MeSH] OR “General Practitioners”[MeSH] OR Family Physician*[tiab] OR Primary Health Care[tiab] OR Primary Healthcare[tiab] OR Primary Care[tiab] OR Family Practice*[tiab] OR General Practice*[tiab] OR General Practitioner*[tiab] OR Family Medicine[tiab]) AND outcome*[tw]

To fulfil the inclusion criteria, articles had to detail original and empirical studies, published in English. Studies had to contain patient experience, and outcome measures of empathy and measures of GPs’ empathy. Exclusion criteria were: reviews, guidelines, and theoretical or opinion articles. In the last selection, the studies were evaluated by the criteria of quality developed by Giacomini and Cook ( Box 2 ). 39 From the initial 964 papers, seven meeting the inclusion and qualitative criteria were identified ( Figure 2 ).

Selection process for papers on the effectiveness of empathy in general practice.

Box 2. Giacomini and Cook’s criteria 39

• The participant selection is well reasoned and the inclusion is relevant to the research question; the population is representative.
• The data-collection methods are appropriate for the research objectives and setting; the data collection is valid and reliable.
• The data-collection process, which includes field observation, interviews, and document analysis, must be comprehensive enough to support rich and robust description of the observed events.
• The data must be appropriately analysed and the findings adequately corroborated by using multiple sources of information.

Seven studies were found ( Table 1 ). 40 – 46 The effectiveness of empathy in patient–physician communication in the studies included is described as improvement of patient satisfaction and adherence, decrease of anxiety and distress, better diagnostic and clinical outcomes, and more patient enablement. Patient outcomes were measured by questionnaires and laboratory tests, and by analysing audio- and videotapes.

Summary of included articles

CARE = the Consultation and Relational Empathy measure. HbA1c = gylcosylated haemoglobin. JSPE = Jefferson scale of Physician Empathy. JSPPPE = Jefferson Scale of Patient Perception of Physician Empathy. LDL-C = low-density lipoprotein cholesterol. RCT = randomised controlled trial. RIAS = Roter Interaction Analysis System. TAR = Tape Assistance Recall method.

Improvement of patient satisfaction and adherence

Hojat et al found a good correlation between patients’ satisfaction and their perceptions of physicians’ empathic engagement. 40 Corrected item–total score correlations of the patient satisfaction scale ranged from 0.85 to 0.96; correlation between patient satisfaction scores and patient perception of physician empathy was 0.93. 40

Decrease of anxiety and distress

In the study by van Dulmen et al it was found that the more anxious patients were, the more adequately their GPs tended to respond. Patients who perceived their GP as empathic reported lower levels of anxiety. 41

Better diagnostics and clinical outcomes

Levinson and Roter confirm that communication between physicians and patients is associated with underlying physician attitudes. 42 Specifically, physicians with positive attitudes towards psychosocial issues make more statements expressing concern and empathy. The patients of these physicians offer relatively more information about psychological and social issues. These patterns of communication are associated with improved patient satisfaction and patient outcomes. 42 An underlying attitude of genuine interest and empathy, within a continuing relationship, was highly valued. Patients described how the GP’s attitude helped or hindered them in discussing their problems. Patients also described how the GP helped them make sense of, or resolve, their problems and supported their efforts to change. 43

Hojat et al found a positive relationship between physician empathy and patients’ clinical outcomes. Patients with diabetes had their glycosylated haemoglobin (HbA1c) and low-density lipoprotein (LDL) cholesterol levels checked. Both tests showed significantly better results in patients with a more empathic physician. It is suggested that more empathy in the physician–patient relationship enhances mutual understanding and trust between the physician and patient, which in turn promotes sharing without concealment, leading to a better alignment between patients’ needs and treatment plans, and thus more accurate diagnosis and greater adherence. 44

Even the most common infectious disease on earth, a common cold, is shown to last for significantly less time and to be less severe in cases where there is good physician–patient empathy. A ‘physician empathy perfect group’ was associated with the shortest cold duration (5.89 days versus 7.00 days). The amount of change of interleukin-8 and neutrophil level was greater for the ‘physician empathy perfect’ group. Interleukin-8 and neutrophil counts were obtained from nasal wash at baseline and 48 hours later. 45

More patient enablement

There is a direct positive relationship between GP empathy and patient enablement, as well as between enablement and changes in main complaint and wellbeing. 46 Patient enablement was measured by the Patient Enablement Instrument (PEI), with questions on topics such as: ability to cope with life and illness, and patients’ confidence about their health and their ability to help themselves. 46

This review investigates the relationship between GP empathy and patient outcomes. A GP’s daily practice involves many elements that are not evidence based. The existence and use of empathy in communication is one of these ‘soft’ elements. However, this review shows that there is empirical evidence for effects of human aspects in patient–physician interaction. There is a relationship between empathy in patient–physician communication and patient satisfaction and adherence, patients’ anxiety and distress, better diagnostic and clinical outcomes, and strengthening of patients’ enablement.

As mentioned in the introduction, there are different levels of empathy. Authors used different types of tests to measure these different levels, such as the Jefferson Scale of Patient Perceptions of Physician Empathy (JSPPPE), a self-report measuring scale for cognitive and attitude factors; the Consultation and Relational Empathy Measure (CARE), a patient rating system that measures physicians’ communication skills and attitudes; the Roter Interaction Analysis System (RIAS), an observer rating system that measures empathy skills; and the Tape Assisted Recall method (TAR), which measures the development of a long working relationship. 47

Strengths and limitations

A previous review by Beck et al mentioned that actual empirical data were relatively scarce. 48 With the inclusion criteria used in this review, seven articles were found with a bearing on general practice.

This study has a potential cultural bias in interpreting and judging phenomena by standards inherent to European culture. General practice in Europe is most commonly delivered by GPs. In the US, primary care includes both general internists and paediatricians, as well as GPs.

A possible limitation of this review is the underexposure of ‘the danger of empathy’, such as a physician losing their professional distance, which, in certain situations, might make empathy a less desirable aspect of patient–physician communication. 16 , 49

In focusing on empathy, the effects of contextual factors on specific health outcomes are possibly underexposed, such as intrinsic and/or extrinsic factors, healthcare setting, access to care, GP’s workload or pressure, and sociocultural factors. 50

General limitations of this review are that only articles written in English are included. Furthermore, the existing measures of empathy have been taken as presented in the literature; no critical reflection of the validity of these measures has taken place.

Comparison with existing literature

The results of the studies seem to be supported by other authors. For patient satisfaction and adherence, Neumann et al , 21 Kim et al , 51 and Lelorain et al 52 confirm the data; they found links between physician empathy and patient satisfaction, in various clinical settings. Mercer et al have shown that patients view quality of consultation in general practice as related to both the GP’s competence and the GP’s empathic care. 53 Further, Neumann et al argue that affective-oriented effects of empathy are related to more satisfaction, adherence, and trust. 16 Indirectly, patients who are more satisfied with the care received exercise greater adherence to agreed and recommended treatment regimens and courses of action. 3

In relation to decrease of anxiety and distress, in experimental research in which a GP was trained in special communication styles, Verheul et al found that combining a warm and empathic communication style with raising positive expectations leads to positive effects on the patient’s anxiety. 12

In relation to better diagnostics and clinical outcomes, authors have shown that empathic communication achieves the effect that patients talk more about their symptoms and concerns, enabling the physician to collect more detailed medical and psychosocial information. This leads to more accurate medical and psychosocial perception and ultimately to more accurate diagnosis and treatment regimens. 13 , 22 Neumann et al based their ‘effect model of empathic communication in the clinical encounter’ on this evidence. 16 It has also been mentioned that patients’ overall satisfaction with healthcare services, adherence to medical regimens, comprehension, and perception of a good personal relationship are positively related with interpersonal communication between the patient and care provider and are particularly related to the physician’s empathic behaviour. 24 , 48 , 51 , 54 – 57 However, physician-perceived stress has also been shown to correlate negatively with enablement. 57

Implications for practice and research

Empathy is a familiar term in the helping and caring literature. In 2008, the World Health Organization (WHO) reaffirmed the importance of primary health care with its report Primary Health Care Now More Than Ever. 58 The key challenge was ‘to put people first, since good care is about people’. 58 Rakel said that good medical care will continue to depend on care by concerned and compassionate family physicians who can communicate with patients, understand them, know their families, and see them as more than a case. 59

Qualitative studies show that physicians link empathy to fidelity, prosocial behaviour, moral thinking, good communication, patient and professional satisfaction, good therapeutic relationships, fewer damage claims, good clinical outcomes, and building up a trusting relationship with the patient. 15 , 24 , 25 , 60 , 61 In her study, Shapiro explored how primary care clinician-teachers actually attempt to convey empathy to medical students; they argued that the moral development of the GP, their basic willingness to help, their genuine interest in the other, and an emphasis on the other’s feelings are basic principles for acceptance of the empathic approach to the patient. 25

In GPs’ views, limiting factors during consultation are: time pressure, heavy workload, a cynical view on the effectiveness of empathy, and a lack of skill. 13 , 51 , 62 Neumann et al have shown that patients also see time pressure and busyness on the physician’s part as a limiting factor. 21

Thus empathy can be seen as a part of patient–GP communication, characterised by feelings such as interest and recognition and the physician remaining objective. However, barriers exist for implementation in general practice. 13 , 14 , 24 , 30 , 31 , 47 , 63 , 64

Another finding of this review is that some studies suggest that the degree of empathy shown by medical students declines over the course of their training. 20 , 65 , 66 Empathy appears to increase during the first year of medical school, but decreases after the third year and remains low through the final year of medical school, measured using the Jefferson Scale of Physician Empathy–Student Version (JSPE-S). 17 , 66 , 67 In the study by Hojat et al , 66 there are no sex differences. On the other hand, Quince et al discovered that among males during medical education, in both the bachelor and clinical phases, affective empathy slightly but significantly declined and cognitive empathy was unchanged. Among females, neither affective nor cognitive empathy changed. 68 It is ironic that there are indications that when students can finally begin doing the work they came to medical school to do (that is, taking care of patients) they seem to begin losing empathy. 69 Possible explanations of the decline are: a lack of good role models and changes in general cultural and ethical views on illness, health, and portrayals of mankind. Interviews with physicians show that they think that, in current western society, it has become less a part of human nature to be interested in another person and to be affected by someone else’s misery. 17 In their study of American college students, comparing the temporal changes between 1979 and 2009, Konrath et al showed that this development has social roots. 65 Considering these possible tendencies in education and the above-mentioned technological changes within the healthcare system, which probably influence the patient–physician alliance negatively and could undermine empathy in these relationships, it makes sense to emphasise the results of the present review. The evidence of a correlation between empathy and clinical outcomes should be made widely known, especially among medical students and physicians. Some authors already believe empathy can be improved by targeted educational activities and they indicate opportunities to enhance empathy during education. 16 , 17 , 26 , 38 , 69 – 71

It should be mentioned that, until now, the widely acclaimed benefits of empathy only have a small empirical base. Although a few studies of sufficiently high quality show promising results, much more research is needed to claim the effectiveness of empathy in clinical practice on evidence-based grounds. Neumann et al have already highlighted the need for an examination of the cost-effectiveness of empathy in the light of the recent focus of policy makers and health insurers on the efficiency of health care. 16 It is a challenge to draw the attention of policy makers to empathy as an effective and efficient way of delivering health care. A vast majority of patients want empathic physicians, particularly, but not exclusively, in general practice. 72 Indirectly, authors suppose empathic behaviour improves the physician–patient relationship and causes satisfaction for the patient but also for the physician, 1 , 13 , 22 resulting in fewer cases of compassion fatigue or burn out.

Further research is needed on the practical use of empathy in general practice, with a focus on the effects and side effects of empathy and the expectations of patients and GPs. In this context, it is important to take account of how researchers have measured empathy. Measuring empathy is often based solely on self-reports and is therefore often remote from patients’ and physicians’ concrete feelings, experiences, and interpretations in practice. Only patient-perceived empathy is significantly related to patient outcomes. Therefore, it appears best to use a patient-perceived empathy scale to measure physician empathy in practice. 47 , 48 , 63 , 65 , 73

It is remarkable that empirical studies on physician empathy are still relatively scarce. According to the results of the studies included in this systematic review, empathy is an important factor in patient satisfaction and adherence, in decreasing patients’ anxiety and distress, in better diagnostic and clinical outcomes, and in strengthening patient enablement. Thus, physician empathy seems to improve physical and psychosocial health outcomes.

Acknowledgments

I am most grateful to E Peters, specialist librarian of the medical library, for her help with the database searches.

The study was not funded.

Freely submitted; externally peer reviewed.

Competing interests

The authors have declared no competing interests.

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5 Wildlife-Friendly Native Shrubs To Plant

There’s no shrub-stitute for native plants to make your home landscape more welcoming to wildlife. Native shrubs can provide a place for bees, butterflies, birds and other wildlife to rest and refuel, says Charlotte Glen , native plants expert and program manager for the NC State Extension Master Gardener SM program.

Many native plants also add a splash of color or an interesting texture to your landscape.

“Within native shrubs, you have some varieties with great ornamental attributes, that as well as supporting wildlife, are just good functional landscape plants,” Glen says. Because native shrubs are well-adapted to North Carolina’s climate, they typically thrive when planted in the right site.

Picking out a new native shrub for your yard is a fitting way to celebrate National Native Plant Month in April. To help you get started, Glen has created a list of five wildlife-friendly native shrubs to choose from.

One word of advice: Keep a close eye on shrubs planted in the spring or summer to ensure they get enough water through their first growing season to become established.

Browse this list of native shrubs for inspiration.

Spicebush ( Lindera benzoin )

The spicebush gets its name from its aromatic properties. Glen says if you scratch the stems, they give off a wintergreen smell. Pollinators are drawn to the spicebush because it flowers early in spring, when few other plants are in bloom. It is also a larval host plant for two species of swallowtail butterflies. 

Spicebush will produce red fruit in late summer that wildlife enjoy, provided that you have a few of the plants in the vicinity. 

“This is one of those species that has separate male and female plants,” Glen explains. “You get the berries on the female plants, but you need some male plants nearby to pollinate.”

Spicebush foliage turns a bright yellow later in autumn.

What to know about spicebush :

• Works best in landscapes with space and moist soil
• Produces early spring flowers for pollinators
• Supports swallowtail butterflies
• Bears red fruit in late summer
• Adds a pop of color with yellow fall leaves
• Has a low flammability rating and is a good choice for fire resistant landscaping

“Spicebush blooms very early in the spring before the leaves come out. It has yellow flowers that are small but cover the stems. It’s subtle but pretty at the same time. So you get pollinators visiting it, and then you get the berries, which ripen in August and September, that are an important food source for migrating songbirds.” — Charlotte Glen

Serviceberry

Serviceberry (Genus: Amelanchier )

Befitting its name, serviceberry is eager to make itself useful in your landscape. Serviceberry species come in multiple sizes to fit your needs, from treelike A. arborea to shrubby A. spicata, Glen says.

As one of the earliest native plants to bloom, serviceberry produces white flowers that attract pollinators, though North Carolina’s state flower often eclipses it. 

“I think one of the reasons serviceberry hasn’t gotten quite the attention it could have is because it tends to bloom at a similar time to dogwood trees, and dogwood trees are so spectacular,” Glen says. 

In late spring, serviceberry makes a splash with edible berries that are among the first native fruits to ripen, and are favorites with birds, she adds. “The minute the berries are ripe, the birds swoop in and get them.”

The serviceberry’s foliage turns yellow, orange and burgundy in autumn.

What to know about serviceberry

• Looks best in an open, natural home landscape setting
• Has some of the earliest flowers for pollinators
• Attracts native bees
• Provides food for caterpillars 
• Produces fruit that’s irresistible to birds
• Gives landscapes a splash of yellow, orange or burgundy fall color 

“The serviceberry itself is edible for humans. It’s an interesting taste, often described as a cross between a cherry and a blueberry. You can get notes of both. Some people don’t like the sensation of eating it and feeling the seeds. But honestly, often you don’t get any of the fruits because the birds absolutely love them.” — Charlotte Glen

Rabbiteye blueberry

Rabbiteye blueberry ( Vaccinium corymbosum, formerly Vaccinium virgatum )

Interested in a shrub that beautifies your yard and supports native pollinators? Consider planting a native rabbiteye blueberry bush. 

“We have a native bee called the Southeast blueberry bee, which specializes in blueberries and other early spring blooming natives,” Glen says. “If you have a blueberry bush, you may have native blueberry bee nests near you. They’re a type of bee that lives in the ground, and only forages within a couple of miles of where their nest is. Their life cycle revolves around the time when blueberries flower.” Another reason to plant a rabbiteye blueberry is its spectacular foliage in late fall. “Often it’s not until Thanksgiving that they reach the peak in their fall color,” Glen says. “You can have beautiful reds, sometimes a darker burgundy, sometimes a more brilliant orange, and that foliage and color can hang on into December. I think if it wasn’t so popular as a fruit production plant, it would have its place as a landscape plant.” 

If you plant a rabbiteye blueberry, expect to share most or all of the fruit with your animal neighbors. “A lot of the fruits do get eaten by birds. There are also some interesting caterpillars that’ll feed on the foliage and then provide food for birds as well.” As long as they’re planted in acidic soil, native blueberries can adapt to a variety of landscape conditions, needing only an occasional pruning, Glen says. There are varieties adapted to each region of our state – mountains, Piedmont and coastal plain. Your county Extension center can help you do a soil test and determine which varieties will grow best in your area. What to know about the rabbiteye blueberry

• Requires acidic soils–test your soil before planting
• Needs little maintenance except occasional pruning
• Serves sharp-eyed birds first – if you only have a few bushes, don’t expect to have many blueberries left
• Provides sumptuous late fall color, peaking around Thanksgiving

“Most of the blueberry varieties that grow well in home landscapes are in a group called rabbiteye because their berries start off pink, like rabbits with pink eyes, and then turn blue.” — Charlotte Glen

Beautyberry

Beautyberry ( Callicarpa americana )

The stunning beautyberry lives up to its name, bearing magenta fruit. 

“I don’t know of any other plant in nature, especially in the Southeast, that has fruits in this color, ” Glen says. 

Clusters of beautyberry fruits are borne along the stems in early fall, attracting songbirds, which gobble them up. The plant’s less showy flowers, which appear before the fruits, also play an important role: attracting small native bees. “Bees in general kind of match to flower size,” Glen says. “You tend to see smaller bees visiting the smaller flowers. You’ll see a lot of little sweat bees on the beautyberry flowers. You have to look closely.” 

Another feature of the plant is its adaptability. In a sunny spot, the plant has a more compact shape. In shade, the shrub is more open and lanky, Glen says. For best results, the beautyberry needs an annual pruning. “In late winter — February or March — cut the whole thing back to about two feet tall, so that it pushes out the strong new growth. You’ll get more flowers and fruits with more new growth.”

What to know about the beautyberry

• Produces clusters of magenta fruit
• Adapts to sunny or partially shaded spots
• Looks best with an annual pruning in late winter

“The beautyberry’s scientific name is Callicarpa and is an apt descriptor for this native shrub: ‘Calli’ means beautiful and ‘carpa’ means fruit.” — Charlotte Glen

• Possumhaw Viburnum

Possumhaw Viburnum ( Viburnum nudum )

If you’re looking for a color-changing native shrub, Glen recommends the Possumhaw Viburnum, which is native to North Carolina.

In spring, it produces white blooms that attract butterflies and moths. In autumn, it’s dramatic.

“In the fall it has clusters of berries, and they really give you a wonderful show. Initially they’re green, and then they turn pink, and then they turn blue, and then they end up a darker kind of purplish blue. You get this kaleidoscope of color change over the season.“

In late fall, Possumhaw Viburnum leaves turn red and wine-colored hues.

“From Thanksgiving into December, it can look very attractive with the fall color and any remaining fruit. The contrast of the blue to purplish fruits with the burgundy leaves can be quite striking.”

A number of bird species savor the fruits.

Possumhaw Viburnum is adaptable but prefers sunny locations with acidic soils that are moist but well-drained.

What to know about the Possumhaw Viburnum

• Suitable for butterfly, native, pollinator, rain or wetland gardens
• Likes sunny spots with moist, well-drained acidic soils
• Grows up to 12 feet tall and wide
• Produces fruit for birds
• Has wavy-edged leaves that provide texture

“There’s plenty of opportunity to add shrubs to the landscape, beyond the foundation of your house. Consider having some natural areas or beds that include trees and shrubs further out from your home. Think a little bit beyond a cookie-cutter approach.” — Charlotte Glen

• CALS Weekly
• beautyberry
• Charlotte Glen
• National Native Plant Month
• native plants
• native shrubs
• NC State Extension Master Gardener program
• rabbiteye blueberry
• serviceberry

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