By Kevin McCauley, MD, Senior Fellow at The Meadows
I make this shocking statement in my lectures sometimes: “Heroin addicts are sweet people.” I partly say this because I’m an addict and tend to make hyperbolic statements for their emotional impact—which isn’t my best quality. I also do it to push back against the tired trope that you can reduce addiction to a personality disorder. I was taught in medical school that addicts have a lack of empathy—also known as sociopaths. However, this hasn’t been my experience.
Empathy and Addiction
When I sit down with a person struggling with addiction, I don’t hear the sociopath narrative: a person who doesn’t care about the feelings of those around them. In addicts—heroin addicts especially—I listen to people who are exquisitely sensitive to the feelings of those around them. So, I’ll say it again. Heroin addicts don’t have a lack of empathy.
Different audiences react in different ways. Prosecutors squirm while others roll their eyes. However, if there’s a heroin addict’s mother in the room and the lighting is right, I can see her eyes fill with tears.
She has always known her child to feel deeply, to be capable of a keen empathy. It’s almost a superpower that addicts possess. They’re plugged into the pain of the world and bravely and tragically, they try to take on that pain. As a result, it costs some their lives.
On the other hand, every fifth parent of a heroin addict says quite the opposite: “Uh, no. He’s always been kind of a selfish jerk.” It’s hard to hear but often just as accurate. I can call addicts sweet people as much as I want, but I do them a disservice if I don’t admit that these people can act unfeelingly.
The Three Types of Empathy
Empathy is the ability to understand another person’s thoughts and feelings from their perspective. It differs from sympathy in that sympathy is when someone is impacted by another person’s feelings and emotions but remains emotionally distanced. For many people, developing empathy is embodied over time because society doesn’t encourage us to connect with others. Once you actively choose to practice empathy, it becomes more intuitive. Understanding the three types of empathy allows you to build a stronger trust in your relationships.
1. Cognitive Empathy (Perspective Taking)
Cognitive empathy is when you understand what another person might be feeling or thinking.
2. Emotional Empathy (Empathetic Concern)
Emotional empathy is when you connect with and embody those feelings along with the other person. Emotional empathy also allows you to understand physical sensations by identifying a situation when you felt similar emotions.
3. Compassionate Empathy (Shared Effect)
Compassionate empathy is the balance between cognitive and emotional empathy. You’re able to understand and feel another person’s thoughts and feelings without becoming overwhelmed or attempting to problem solve.
My theory about empathy and addiction is that shared effect and empathic concern is too strong in addicts, and perspective-taking is impaired. Maybe what I’m seeing isn’t as much an enhanced capacity for empathy but a collapse of the construct of empathy.
The brain tries to put all three components of empathy together but fails. We see the classic addict paradox. They are people who see themselves as uniquely sensitive but are blind to how they hurt the people they care about. They can’t see it, and this is the least attractive and most destructive symptom of addiction. It’s also the most repairable, and the task of my recovery is to re-calibrate my capacity for empathy.
The Benefits of Empathy and Addiction Treatment
One contributing factor to a successful recovery process is developing empathy. Overcoming denial is the first step in addiction treatment. If you’re still in denial of your substance abuse, you won’t be able to develop empathy for how your addiction affects the people in your life. During treatment, addicts will learn how to be cognizant of what others say and do to understand their experiences and what their needs are. Family therapy allows you to empathize with fellow addiction clients, therapists, and loved ones. Additionally, they will develop the tools they need to continue being empathetic individuals in recovery.
Developing empathy through addiction treatment will allow you to make amends with the people you have hurt along the way and have less conflict with others in the future. To truly make amends, you must have a deep understanding of how you’ve wronged people in the past. This also allows you to avoid making the same mistakes in the future by understanding how your actions will affect others. Lastly, empathy helps people see more of themselves in others and vice versa.
Reconstructing Empathy Through Recovery
The first step in reconstructing empathy is to stop getting high. Addicts—especially opioid addicts—wreak havoc with empathy because they disrupt my ability to feel pain accurately. The areas of my brain that process the pain I feel are also the ones that are active when I observe other people’s pain. A recent study showed that taking a single Tylenol can decrease one’s capacity for empathy. Therefore, imagine what taking heroin can do.
With chronic opioid use, you make the pain worse. They trade analgesia for hyper-algesia. Everything hurts, and the brain doesn’t distinguish well between physical and emotional pain. If pain’s purpose is to guard against further injury, an opioid addict is also hypersensitive to emotional pain.
The eminent neuroscientist George Koob even coined a new word for this phenomenon—hyperkatifeia. The residual hypersensitivity to emotional distress, including an increase in the intensity of emotional distress, can persist long into abstinence.
Perhaps hyperalgesia and hyperkatifeia represent an overdrive of empathy’s shared affect component. To cope with this increased pain sensitivity, I might resort to increased opioid use or simple avoidance strategies. It might be that empathic concern isn’t so much an enhanced empathy as it’s an attempt to avoid intensely felt pain where you compromise your ability to distinguish yourself from others. It’s less about compassion and more about codependency.
If shared affect and empathic concern are too strong in addicts, then perspective-taking is the component that isn’t strong enough.
Empathy and the Mind-Body Connection
Over the last two decades, one of the significant neuroscience discoveries is that much of what we call “mood” starts as signals sent to the brain by a myriad of systems in the body–also known as interoception—the awareness of signals coming from my body.
Heartbeat, breathing, digestion, and blood glucose level send information to the brain. This information usually falls outside conscious awareness. However, I can train myself to become aware—or mindful—of these signals.
The second thing that I can do to recalibrate my capacity for empathy is to improve my interoceptive awareness. Interoceptive signaling undergirds emotion, and improved interoceptive understanding improves emotional regulation and the quality of decision-making.
When interoceptive awareness fails—known as alexithymia—my feelings become muddled in emotional synesthesia. Sadness becomes anger. I mistake hunger, anger, and sleepiness for drug craving. If I suffer from alexithymia, my emotions and choices suffer. This is common with several mental health disorders: schizophrenia, autism spectrum disorders, and addiction.
The part of my brain that coordinates interoceptive awareness is known as the Insular Cortex (IC). This is where I attach my body to my consciousness. Intense interest in the IC began after Naqvi published a case series of heavy smokers who sustained damage in this part of the brain, forgetting they were smokers. It was easy for them to quit because they didn’t even go through nicotine withdrawal. Today, the IC is believed to be critical in craving brain states.
Another part of my brain—the Anterior Cingulate Cortex (ACC)—links interoception to self-awareness and social cognition. The ACC serves as an error detection system sensitive to social context. It feeds errors I make back to me, telling me, “You did that wrong,” and helps me correct my behavior.
One kind of error the ACC picks up on is social cues, so this is where I see myself from other people’s perspectives. If my ACC fails, I won’t be able to see how my addiction hurts those around me. My capacity for perspective-taking is shot. This is a petrifying impairment for someone who considers themselves sensitive to other people’s feelings. Yet, I’m patently and blindly insensitive.
If confronted with the discrepancy between the way I see myself and how others see me, this might precipitate a crisis that can lead to a “moment of clarity” or a flood of shame that powers further retreat into intoxicated avoidance. It takes a skilled therapist or wise sponsor to deftly negotiate this crisis—hold up the mirror at the right time and angle.
Developing empathy and proper boundaries between yourself and others depend on good interoceptive awareness and properly calibrated social functioning. Presently, there’s great excitement surrounding the research into the power of contemplative practices and mindfulness-based therapies such as Dialectical Behavioral Therapy (DBT) and Acceptance and Commitment Therapy (ACT) to improve empathy and recovery from addiction.
It’s also clear how techniques such as Neurofeedback and Somatic Experiencing can improve interoceptive awareness, thus improving emotional regulation and decision making. These therapies and techniques play a role in recovery in ways that mere opioid substitution may never be able to achieve.
Empaths and Addiction
Empaths and addiction might not go hand-in-hand, but addicts are sensitive in ways that the casual observer might not appreciate. If part of the recovery process were to learn how to control this capacity, sensitivity and empathy would be valuable to others. Addicts can become some of the most gifted therapists, nurses, and doctors you’ll ever meet once we understand where the world’s pain ends and our pain begins and the wisdom to know the difference.