Review: The Empathy Effect by Helen Riess

By Lou Agosta on January 27, 2019

The force of empathy is strong with Helen Riess, MD, and her team.

In The Empathy Effect: 7 Neuroscience-based Keys for Transforming the Way We Live, Love, Work, and Connect Across Differences(with Liz Neporent, Forward by Alan Alda (Sounds True publishing, 234pp, $22.95)) Riess lays out a program for training medical doctors (and the rest of us) to expand our empathy.

The most important point that Dr Riess makes in the concise opening three chapters is that empathy is learnable. Empathy can be taught. The empathic capabilities of the human being can be expanded by practice and training. This is the set up for the introduction and promotion of the proprietary empathy training program, “E.M.P.A.T.H.Y.”®, offered by the for profit enterprise, Empathetics, of which Riess is the CEO. The training based on intellectual property developed at Massachusetts General Hospital and Harvard University. More on that shortly.

The work contains many personal reflections amid a fully buzz-word compliant narrative on the psychology and neuroscience of empathy. Dr Riess lets slip that she was in second grade when the 1963 Community Mental Health Act set in train consequences, some planned, most unintentional, that resulted in the emptying out of the Psychiatric Institutions (“Asylums”) that served for the long-term incarceration of those diagnosed with severe mental disorders.

This means that Dr Riess was young enough to have benefited from the innovations in empathy of Carl Rogers, PhD, and Heinz Kohut, MD, who, prior to the second psychopharmacological revolution, were responsible for putting the term “empathy” on the treatment intervention map of humanistic and self psychology.

Though not explicitly discussed by Riess, for practical purposes, the “second psychopharmacological revolution” is dated from Peter Kramer’s Listening to Prozac(1993). It took the legs out from under virtually every form of talk therapy then in the market, including Cognitive Behavioral Therapy. (CBT, however, has demonstrated staying power for many reasons, not the least of which is that insurers are willing to reimburse for a dozen (or so) sessions.)

Riess is conversant with Paul Ekman’s innovative research in coding (and decoding) the micro-expressions of the human face, an emotional “hot spot,” to discern what a person is “really” experiencing and feeling. Though Ekman does not use the term “empathy,” his approach to micro-expressions implies a definition of empathy distinct from that of Riess’ proprietary approach, which, in turn, aligns with David Hume’s “delicacy of sympathy and taste” (1741). If one person literally perceives a micro-expression of which another is unaware, then the one person’s “delicacy of empathy” (my term, not Hume’s) is more expansive that the other’s.

Thus, Dr Riess calls out the contributions of Rogers and Kohut such as “unconditional positive regard” and “vicarious introspection,” respectively. She appreciates the deep history of empathy (“Einfühlung”) in German aesthetics, in which empathy emerged from the projection of human feelings onto beautiful nature and art, something we humans seem to be cognitively designed to be unable to stop doing.

Riess appreciates that the distinction “empathy” is significantly different than “compassion,” “sympathy,” or “projection,” and she helps the reader distinguish among them. She “gets it” that empathy, like so many phenomena, is on a spectrum and that some people are naturally endowed with less of the capacity (think: disorders of empathy such as autism or at another extreme psychopathy) and some people have more of it (think: the natural empathy, who is acutely sensitive). Riess understands that empathy can misfire or breakdown: empathy faces obstacles and roadblocks, which, paraphrasing now, extend from sentimentalism, spoiling, codependence, projection, all the way to burnout, compassion fatigue, and empathic distress.

In every case, practice and training can expand the empathic competence of the individual and the empathic response in the face of the challenges of unempathic people and circumstances. Riess refers to turning “the dial on … emotional empathy” (p. 19), which is why training is needed. Thus, empathy is more like a dial or tuner – turn it up or down – rather than an “on-off,” all-or-nothing switch.

This brings the discussion round to the details of Riess and Empathetics, Inc.’s innovative, proprietary empathy training. She begins by citing research that demonstrates medical doctors are often trying to deliver one message and their patient’s are getting another one or nothing at all. The antidote? “E.M.P.A.T.H.Y.”®!

It turns out there is a “secret sauce,” a proprietary application of biofeedback technology. I have a report that if you, as a hospital or medical group practice, actually pay the $50K [I am making this number up] to train your medical doctors en masseat Mass General, then patented biofeedback metrics are used to judge the arousal of the subject and, hence, the effectiveness of the empathy induction. Though I am not sure, it sounds like they put the little Velcro-cuff on one of your fingers to measure the galvanic skin response.

While galvanic skin response is a blunt instrument and does not distinguish between emotions such as fear, anger, sadness, high spirits, much less subtle states such as envy or indignation, it does provide a measure of physiological stimulus and arousal. Useful. Might be worth a try.

This add something to that old joke that when a therapist meets a new patient, there are two anxious people in the room; and it is the therapist’s job to be the least anxious. It adds something, but what? Still, it might be worth a try, especially given the emotional numbness of the survivors of the boot camp approach to medical school and the sleep deprivation regime of medical residency.

Meanwhile, the technology is wrappered in a conversational training that aims at expanding the empathic capabilities of the trainee. There are seven “keys” to empathy which, of course, occur simultaneously, but have to be presented in sequence for purposes of exposition.

The empathy training works on: (1) Eye contact: the eyes are the window to the soul. Look the other person in the eye to expand connectedness, but do not stare without blinking, which communicates aggression. Riess does not mention, but might usefully have done so, that Simon Baron-Cohen[1]calls out lack of eye contact as one of the indicators of a person being on the autistic spectrum.

Training in making eye contact to expand empathy leads naturally to including: (2) Facial expressions as a whole: the human face is an emotional “hot spot,” and while humans can fake many facial expression, there are some micro-expressions that are disclosive of an emotional depth that cannot be faked.

Here the decisive innovations and work of Paul Ekman and his team are critical path. Ekman spent some seven years mapping all the muscles of the face and their contribution to the expressions of emotions. The bottom line? People can consciously control many of these muscles – but not all of them. The muscle around the eyes participate in an authentic smile, and when they do not do so, the smile is perceived as off – as fake.

Riess says: “You don’t have to be an expert to pick up on the minute micro-expressions described by Ekman and others.” Actually you do. Significant practice and training is required, and even then one may know that the other person is not being entirely straight with you, but the micro expression does notprovide any insight into the underlying motive(s). Is the motive sinister or is the person suffering from shame, guilt, or post trauma upset? One has to have a conversation. The “M” is for “facial expression” – okay, actually “muscles” or “micro expressions” in the face.

The face, in turn, leads to: (3) Body language as a whole. Amy Cuddy’s “power pose” does not increase testosterone in the saliva, but significant anecdotal evidence indicates it does expand a person’s self-confidence. In short, look at how a person is standing or sitting and attend to one’s own posture. It can reveal a lot about how one is feeling. “P” is for “body language,” or, to be exact “posture.”

Riess acknowledges the distinction between cognitive and affective empathy – top down and bottom up empathic understanding and receptivity. A future version of this training might incorporate “perspective taking” or “point of view,” in the place of the “P,” the folk definition of empathy, which is otherwise missing from the list of keys. I make no representation as to how such a gesture would require adjustment or amendment to the intellectual property or whether it is even possible to claim as one’s own property something that is arguably the proper possession of all of humanity. One thinks of Kohut’s notion of empathy as oxygen for the soul. Who owns the oxygen? Presumably, humanity, not Harvard.

Next (4) empathy is all about “affect” and the communication of affect. People are not born knowing the names of their emotions. We have formal training in kindergarten in naming colors and numbers. It is not too late to practice experiencing one’s emotional experience and naming it.

In a separate section, Riess calls out the disorder of “alexithymia,” inability or extreme difficulty in naming and articulating feelings. This is different than “over intellectualization,” but sometimes not by much. This is an occupational hazard of anyone who spends years in graduate or medical training, but other people are seemly hardened against experiencing their feelings due to disposition or adverse life experiences.

(5) The “tone” of voice is richly communicative. If is a person is telling what should be a sad story of loss, injury, or set back, yet the person sounds happy, then something is going on beneath the surface that warrants further inquiry. The pace, rhythm, pitch, delivery, and prosody of a statement make a big difference in its reception and processing. Not to be overlooked: “A surgeon’s voice peppered with dominance and delivered with a lower register of concern was predictive of a malpractice claims history” (p. 54). But if one is only undertaking this training to stay out of legal trouble, that is itself an indication of trouble.

(6) Listening to the whole person is the point at which the training has to go beyond the tips and techniques that have dominated this list. This one is easier said than done and may require a deep engagement with spiritual disciplines of mindfulness, Tai Chi, or a couple of years of one’s own therapy in order to be available to the other person. “H” is for listening to the whole person – and hearinghim or her – presumably within the fifteen minute encounter that is budgeted for the initial medical inquiry.

(7) Empathy without responsiveness is like a tree that falls in the forest without anyone being there. It does not make a difference. Regarding empathic responsiveness, I would have appreciated an example of giving the other person’s experience back to her in a form of words that demonstrate that one “got it” without the exchange being so explicitly compassionate.

Recognition, acknowledgement, and alignment are ways of responding that do not require agreement or altruistic intervention. Yes, of course, it is helpful to be appreciated in one’s struggle and effort, and that is different than having someone jump in and actively provide compassionate support.

By all means, if someone is bleeding, apply a tourniquet while awaiting emergency services. But here one has actually to “dial down” one’s empathy in order to be effective. The point is that both empathy and compassion are often in short supply in the world and the world needs both more compassion and expanded empathy. However, empathy and compassion are distinct.

I may have misread Dr Riess if she wants to build into the human capacity for empathy, a compassionate response – whether her own proprietary version or empathy writ large. I offer this caveat because the vast majority of the examples of empathic response she gives are instances of pro-social helping, altruism, charity, or other aspects of being a Good Samaritan.

Once again, the world needs more Good Samaritans. The world needs both more compassion and expanded empathy; but the two are distinct. The exceptions in the text to examples of compassion are largely those of being over-whelmed or nearly over-whelmed by trauma and counting one’s breaths in order to stay centered in the face of hospital emergency room style dismemberment.

The irony of this book, which promotes linking empathy to its underlying neuroscience, is that the empathy is strong but the neuroscience, weak. Since this is not a “softball review,” a few examples will make this clear.

For example: “Scientists can see the electrical impulses spread through the brain using fMRI (functional magnetic resonance imaging) brain scanning technology” (p. 28). False.

The fMRI makes visible the blood oxygenation level data (BOLD) of between five thousand and fifty thousand neurons in its unit of measure, the voxel (depending on the variable size of the neuronal cells). The inference is: when the neurons get active, because the person is having an experience such as thinking a thought or attending to an event, then the neurons require more blood-rich oxygen to do their job.

In no way, does the fMRI monitor individual neurons or even a small number of them. The fMRI is a powerful tool for imaging soft tissue disorders, but it does not provide visibility down to the level of granularity of anything like individual neurons.

Perhaps Riess was thinking of the EEG: The spread of “electrical impulses through the brain” can indeed be monitored by an electro encephalogram (EEG), a fundamental tool for evaluating disorders of consciousness such as epilepsy and sleep disturbances, but even with an EEG the overall, high level activity of the brain is what is being monitored not individual or even small numbers of neurons.

A similar slip occurs early on: “Scientists first viewed the brains of their subjects in a brain scanner as the subjects had their fingers stuck by needle to determine the precise neurons involved in pain perception” (p. 17). Here “precise” would mean between five thousand and fifty thousand neurons, which is not my definition of “precise”. The level of granularity of the fMRI is an order of magnitude off from that required to “see” an individual neuron. Thus, fMRIs do not see or monitor mirror neurons (if they exist). Period. Once again, the fMRI does provide evidence that the parts of the brain that are busy processing experience receive enhanced blood oxygenation level data (BOLD), and that is the data captured by the fMRI.

Another problem item: “Mirror neurons are specialized brain cells in specific areas of the brain called the premotor cortex, known as the F5 area…” (p. 18). The problem is that the F5 area is part of the brain of the macaque monkey. There is no F5 area in the human brain. Thus, the battle is joined, whether mirror neurons even exist in human beings.

The neurohype around mirror neurons is well represented; but what about the alternative point of view that such an entity as a mirror neuron does not even exist in humans and that the neurological infrastructure has a different configuration and explanation?[2]

How do we advance from synchronization and mirroring (Riess’ big idea of “shared mind intelligence”) to understanding of another person or the person’s mindedness? There are several questions of representation and functional analysis between which scientists and researchers are still working to “connect the dots.” Riess represents this all as a “done deal” with the answer being “mirror neurons,” but she is oversold and fails to connect the dots.

Mirror neurons are one hypothetical explanation for such a phenomenon as “low level (empathic) affective resonance” in human beings. However, so are reflex-like mechanisms such as associations of actions, impressions, and ideas—known to the British empirical philosopher David Hume (1711–1776) as “habits” or “customary conjunctions.”

Macaque monkeys (the original subjects in the research done by Rizzolati, Gallese, and others (1996)) have a community and social order for which mirror neurons are sufficient to provide monkey interaction in the monkey community; buthuman behavior, action, and emotion involve more complex meanings, which human mirror neurons (if they exist) do notexplain—do not explain by means of language, social institutions, cultural practices, or tradition—because meaning is more than matching. As a mere mechanism of matching, mirror neurons struggle to explain the meaning created and deployed in minded actions and emotions.[3]

In humans and the human species, the macaque mirroring mechanism has been elaborated in evolutionary time into expanded behavioral, emotional, and cognitive capabilities useful for interrelating in significantly more complex human communities. Once prehistoric humans acquired language and used it to expand group solidarity in building communities with tools, art, stories, religious practices, social rituals, and the description of regularities in behavior of the stars and other human beings, diverse pathways opened up for creating and communicating meanings, emotions, projects, and thoughts between individuals.

The neurohype continues as the author moves from the neurologically misleading and false to the superficial. Using the example of addiction to alcohol: “New findings in Neuroscientific studies have redefined addiction from a condition of flawed character to a model of biology and disease. We now know that the brains of people who become addicted are different from those who do not” (p. 174). The brains of people who study French are different than those who do not, so we are on thin ice here in terms of a compelling analogy or contribution.

The good news? If a person has a disease such as pneumonia, modern medicine can cure him even if he is in a coma. That is not the case with the “disease” of addiction. In contrast, overcoming addiction requires the participation of heart and mind – and conscious commitment. The choice between a “moral flaw” and “neuroscience” is a false one once any physical dependency on the abused substance has been attenuated.

Riess recommends the empathic practice of perspective taking is key to shifting out of addictive stuckness – and gives a “shout out” to the program at the Hazelden Betty Ford Foundation; and, no doubt, getting a good listening is highly beneficial to any person, including addicts. However, the contribution of empathy is unwittingly weakened by making it seem like empathy is the answer to overcoming the conflict between the nucleus accumbens, a pleasure center in the brain, and the frontal lobe responsible for decision making.

This brings us to the mereological fallacy, which is pervasive in Riess as indeed in many works of this kind. The mereological fallacy attributes the function of the whole to the part (and vice versa). Brains are a part of a person; and neurons are a part of the brain. Brains are all about neurons; and, in so far as neurons are a necessary condition for the functioning of the embodied person, persons are neurons “all the way down.” But the neurons then start generating phenomena such as consciousness, meaning, language, intentions, joint intentionality, personality, community, and culture.

Thus, social neuroscience is born. Yet brains do notthink; people think. Brains do not express emotions; people express emotions. Brains do not intend this-or-that; people intend this-or-that. Brains do not become addicts; people become addicted. Brains do not empathize; people empathize. The mereological fallacy is a growth industry in social neuroscience. My brain made me do it? Hmmm. Human choice and commitment suggests your brain was definitely participating, but it is far from the whole narrative. The task is to avoid or contain the mereological fallacy, even while allowing social neuroscience to make its contributions in the areas of its strengths. This has not happened in this text.

Another problem? The number of variables changing simultaneously for a person lying still in a fMRI (functional magnetic resonance imaging) machine is large, very large. What worries me is that in an attempt to capture a response in the brain to interesting events experienced by the subject, the researchers, including Helen Riess, have created a brain in a vat. The vat is the fMRI.[4]

What then do brains do when viewed in an fMRI? They “light up.” They discharge neuro-correlates of consciousness (NCCs) in patterns of activation, as indicated in the form of blood oxygenation level data. The empathy circuit “lights up” when people lie back and view “empathy cues,” “empathy triggers,” or “empathy inducers.” We enjoy punishing cheaters—when apprehended and subjected to sanctions, the nucleus accumbens—a pleasure center of the brain—“lights up.” It gets busy. Empathic cruelty? Of course, there are many things that cause the nucleus accumbensto light up, implying the hazards of backwards inference. If it doesn’t light up, you are dead, or in serious neural trouble.

Nevertheless, in spite of weakness in the main selling point promoted in the subtitle and that of which the author is most proud – neuroscience – the force of empathy is strong in this text. If one can survive the neurohype of Part I, the reader is rewarded in Part II – presumably the nucleus accumbens is lighting up like a Christmas tree at this point (but so what?) – with applications of empathy to early child development, education, the hazards of social networking, art and literature as ways of expanding empathy, leadership and politics (and the lack of empathy in them), tough issues in mental illness, criminality, sexual identity, and so on, as well as the benefits of empathy for self-soothing, distress tolerance, and emotional regulation.

Now take matters up several levels from neurotransmitters to two human beings interacting in a conversation in a would-be community. Though Riess does not explicitly say it, the solution to the limited empathy of parochial, biased in-group thinking and behavior is straight-forward: expanded empathy. The person on the street thinks of empathy as an “on off” switch. “On” for the in-group. “Off” for everyone else – the “out group.”

However, practice and training enable a person to relate to empathy as a dial or tuner that can be adjusted to the situation. If I am experiencing empathic distress, dial empathy down. If I just do not “get” the other person, dial the empathy up. This does not come naturally to most people – so, once again, the case is made for practice and training, including Riess’ particular solution.

As a critical reader, I would have appreciated a statement that many ways are available to learn and practice empathy. Every mother, parent, teacher, business person with customers, doctor with patients, therapist with clients practices empathy on a good day and already knows a lot about what works and what doesn’t. Thus I imagine Riess saying: “While you, dear reader, do not need a psychiatrist to tell you about empathy [whose training regime since the early 1990s has overwhelmingly consisted in psychopharmacology], nevertheless let me tell you about the advantages of my proprietary way offered by my company Empathetics.” Perhaps Dr Riess thought such a statement was implied, and I can appreciate that point of view, but I still would have welcomed the clarification that it is not the only empathy game in town.

In a separate communication (10/31/2019), Helen Riess wrote to me: “…[P]art of empathy training is modeling respect for others in the field of empathy education, research ad [sic] training.” Agree. Respect, dignity, empathy, and related belong on a short list of phenomena, which, when the person does not believe she is receiving them, the person tends to get stressed, angry, even enraged. Sounds like the individual in question could use expanded empathy.

I hasten to add that, to her great and unconditional credit, Riess is decisively in action against the appalling scandal that empathy peaks in the third year of medical school (Hojat 2009; see also Halpern 2000) and that since the 1990s psychiatric training has overwhelming emphasized psychopharmacology. Meanwhile, the rate of the disabled mentally ill has doubled between 1987 and 2007 and is now six times the rate as in 1955.[5]Hmmm.

In the final ten pages of her work, Dr Riess calls out the “cytokine theory of depression” (and related mental disorders). I assert that she ought to have begun the book with it.

The cytokine theory of depression (see Maes 1995, 1999) is the approach that emerged in the mid 1990s – about the same time that Prozac was disrupting mourning and melancholy paradigms of mental illness with its serotonin chemaical imbalance theory of depression – that emphasizes the role of chronic social stress (divorce, finances, business travel, bullying bosses, misbehaving teenagers, and so on) in kindling long-term inflammation of major organ systems resulting in “sickness behavior.”

Such sickness behavior looks a lot like major depression yet, at least initially, it lacks the melancholic, negative self-talk. Riess highlights treatment options – and life style adjustments – such as mindfulness, yoga, Tai Chi, exercise, diet, alone and in combination, that emphasize stress reduction, self soothing, emotional regulation, and empathy for oneself.

Naturally, the brain participates in all these activities, but reducing stress and expanding distress tolerance through empathy is also a function of the adrenal-hormonal system. It’s just that neurology has the buzz this season, not endocrinology or psychotherapy. Never was it truer that empathy guides us in engaging with and treating the human being as a whole – not a mere amygdala hijack or frontal lobe disinhibition. So the stress reduction paradigm, which is at right angles to and arguably does not contradict the neurotransmitter imbalance paradigm, was pushed to the margins and hardly heard of again until recently (e.g., Segerstron and Miller 2004).

Perhaps after the boot-camp of medical school, the rigors of residency, and the corporate transformation of American medicine (relying as it does on “hitting the numbers”), empathy is at such a low water mark in the medical doctor’s consciousness that “tips and techniques” are the best we can do. Indeed the “H” stands for “listening to the whole person and hearing the individual,” so the intention is present.

Yet using empathy to “dial down” stress, aggression, and narcissistic injuries, does not map in any obvious way to “E.M.P.A.T.H.Y.”®, which becomes a pair of golden hand-cuffs for the trainer. The ultimate irony is that the only obstacle in the way of expanding empathy – the distinction, not the propriety gimmick – is precisely “E.M.P.A.T.H.Y.”®.

References

Agosta, Lou. (2018). Empathy Lessons. Chicago: Two Pairs Press.

Decety, Jean, Chenyi Chen, Carla Harenski, and Kent A. Kiehl. (2013).An fMRI study of affective perspective taking in individuals with psychopathy: Imagining another in pain does not evoke empathy, Frontiers in Human Neuroscience, 2013; 7: 489; published online 2013 September 24. DOI: 10.3389/fnhum.2013.00489.

Halpern, Jodi. (2001). From Detached Concern to Empathy: Humanizing Medical Practice. Oxford: Oxford University Press.

Hojat, Mohammadreza, M. J. Vergate, K. Maxwell, G. Brainard, S.K. Herrine, and G. A. Isenberg. (2009). The devil is in the third year: A longitudinal study of erosion of empathy in medical school, Academic Medicine84 (9): 1182–1191.

____________________, Daniel Z. Louis, Fred W. Markham, Richard Wender, Carol Rabinowitz, and Joseph S. Gonnella. (2011), Physicians empathy and clinical outcomes for diabetic patients, Academic MedicineMar, 86(3): 359–64. DOI: 10.1097ACM.0b013e3182086fe1.

Hume, David. (1741). Of the delicacy of taste and passion in Of the Standard of Taste and Other Essays, Indianapolis: Bobbs-Merrill: 1965.

Hickok, Gregory. (2014). The Myth of Mirror Neurons. New York: W. W. Norton.

Maes, M. (1995). Evidence for an immune response in major depression: A review and hypothesis, Progress in Neuro-Psychopharmaclogy and Biological Psychiatry19: 11–38.

_______. (1999). Major depression and activation of the inflammatory response system, Advances in Experimental Medicine and Biology461: 25–46.

Riess, Helen. (2013). The power of empathy, TEDxMiddlebury: https://www.youtube .com /watch?v=baHrcC8B4WM [checked on 03/23/2017].

____________, John M. Kelley, Gordon Kraft-Todd, Lidia Schapira, and Joe Kossowsky. (2014). The influence of the patient-clinician relationship on healthcare outcomes: A systematic review and meta-analysis of randomized controlled trials, PLOS, Vol. 9, No. 4 | e94207: 1–7: https://doi.org/10. 1371/journal.pone.0094207.

____________, John M. Kelley, Robert W. Bailey, Emily J. Dunn and Margot Phillips. (2012). Empathy training for resident physicians: A randomized controlled trial of a neuroscience-informed curriculum,Journal General Internal Medicine, 2012 Oct; 27(10): 1280–1286. DOI: 10.1007/s11606-012-2063-z.

Rizzolatti, G., L. Fadiga, V. Gallese, and L. Fogassi. 1996. Premotor cortex and the recognition of motor actions, Cognitive Brain Research 3: 131–41.

Satel, Sally and Scott O. Lilienfeld. (2013). Brainwashed: The Seductive Appeal of Mindless Neuroscience. New York: Basic Books (Perseus).

Segerstrom, Suzanne C. and Gregory E. Miller. (2004). Psychological stress and the human immune system: A meta-analytic study of 30 years of inquiry, Psychol Bulletin. 2004 July; 130(4): 601–630.

FOOTNOTES

[1]Simon Baron-Cohen. (1995). Mindblindness. Cambridge, MA: MIT Press.

[2]For example, see Gregory Hickok. (2014). The Myth of Mirror Neurons. New York: W. W. Norton. For further debunking of the neurohype see Decety et al. 2013, Vul et al. 2009, and Satel and Lilienfeld 2013.

[3]The following paragraphs are adapted from the section “Your brain on empathy” in Lou Agosta 2018: 171–172.

[4]Presumably this is notwhat the late Hilary Putnam meant when he wrote his prescient article of the same name, since the fMRI had not yet been invented, but who knows for sure? See Hilary Putnam. (1981). Brains in a vat, in Hilary Putnam. (1981). Reason, Truth and History. Cambridge: Cambridge University Press: 1–21.

[5]Robert Whitaker, (2010), The Anatomy of an Epidemic. New York: Broadway Paperbacks (Random House), 2010: p. 7.