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Why do humans heal one another? Evolutionary psychology has advanced our understanding of why humans suffer psychological distress and mental illness. However, to date, the evolutionary origins of what drives humans to alleviate the suffering of others has received limited attention. Therefore, we draw upon evolutionary theory to assess why humans psychologically support one another, focusing on the interpersonal regulation of emotions that shapes how humans heal and console one another when in psychosocial distress. To understand why we engage in psychological healing, we review the evolution of cooperation among social species and the roles of emotional contagion, empathy, and self-regulation. We discuss key aspects of human biocultural evolution that have contributed to healing behaviors: symbolic logic including language, complex social networks, and the long period of childhood that necessitates identifying and responding to others in distress. However, both biological and cultural evolution also have led to social context when empathy and consoling are impeded. Ultimately, by understanding the evolutionary processes shaping why humans psychologically do or do not heal one another, we can improve our current approaches in global mental health and uncover new opportunities to improve the treatment of mental illness across cultures and context around the world.
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Clinical Psychology Review
journal homepage:
Why we heal: The evolution of psychological healing and implications for
global mental health
Brandon A. Kohrt
, Katherine Ottman
, Catherine Panter-Brick
, Melvin Konner
, Vikram Patel
Division of Global Mental Health, Department of Psychiatry and Behavioral Sciences, George Washington University, Washington, DC, USA
Jackson Institute of Global Affairs, Yale University, New Haven, and Department of Anthropology, Yale University, New Haven, USA
Department of Anthropology, Emory University, Atlanta, USA
Department of Global Health and Social Medicine, Harvard Medical School, Boston, and Department of Global Health and Population, Harvard T. H. Chan School of
Public Health, Harvard University, Boston, USA
Understanding biocultural evolution of psychosocial healing helps improve current practice.
Psychological healing is a component of cooperative processes related to evolutionary fitness.
Social rupture and social repair are features of cooperative social species including humans.
Healing comprises empathy, mirroring, emotional contagion, self-regulation, and mentalizing.
Healing among humans involves symbolic processes requiring shared meanings of symbols.
Mental health
Medical anthropology
Placebo effect
Traditional medicine
Why do humans heal one another? Evolutionary psychology has advanced our understanding of why humans
suffer psychological distress and mental illness. However, to date, the evolutionary origins of what drives hu-
mans to alleviate the suffering of others has received limited attention. Therefore, we draw upon evolutionary
theory to assess why humans psychologically support one another, focusing on the interpersonal regulation of
emotions that shapes how humans heal and console one another when in psychosocial distress. To understand
why we engage in psychological healing, we review the evolution of cooperation among social species and the
roles of emotional contagion, empathy, and self-regulation. We discuss key aspects of human biocultural evo-
lution that have contributed to healing behaviors: symbolic logic including language, complex social networks,
and the long period of childhood that necessitates identifying and responding to others in distress. However,
both biological and cultural evolution also have led to social context when empathy and consoling are impeded.
Ultimately, by understanding the evolutionary processes shaping why humans psychologically do or do not heal
one another, we can improve our current approaches in global mental health and uncover new opportunities to
improve the treatment of mental illness across cultures and context around the world.
1. Introduction
1.1. The need for an evolutionary theory of psychological healing
There are formal and informal methods of psychological healing all
around us: family members consoling children and relatives, neighbors
and peers sharing worries and losses, religious leaders caring for
members of their communities, and mental health specialists and non-
specialists treating their patients. This raises the fundamental question
of why humans provide psychological support to one another. What are
the evolutionary origins of emotional support and consoling behaviors
that are ubiquitous across history and populations and foundational to
psychological healing and psychosocial support? The field of evolu-
tionary medicine has made profound contributions to better under-
standing Why We Get Sick, for both physical and mental illnesses, and
understanding the evolutionary origins of distressful emotions (Nesse,
2019; Nesse & Williams, 1995). However, to date, evolutionary theory
has not been comprehensively applied to understanding the origins of
why and how humans console one another when distressed. Now,
evolutionary medicine, social neuroscience, and medical anthropology
Received 17 March 2020; Received in revised form 2 September 2020; Accepted 13 September 2020
Corresponding author.
E-mail address: (B.A. Kohrt).
Clinical Psychology Review 82 (2020) 101920
Available online 19 September 2020
0272-7358/ © 2020 The Authors. Published by Elsevier Ltd. This is an open access article under the CC BY license
are together well positioned to ask Why We Heal one another when in
emotional distress. Ultimately, understanding the evolutionary origins
of psychological healing—specifically interpersonal regulation of
emotions—can help us to better meet the needs of people in general
psychological distress and people living with common mental disorders
around the world.
1.2. An evolutionary model of psychological healing
Our proposed model of healing involves three premises: 1) emo-
tional distress has evolutionary origins; 2) the regulation of emotions
evolved within a social context; and 3) there are motivators and me-
chanisms of interpersonal regulation of emotion that result in consoling
behaviors. We briefly outline these three premises here, then provide
more detail in subsequent sections.
The first premise is that emotions play a role in the various types of
evolutionary fitness, including group-level processes such a multi-level
selection (Wilson & Wilson, 2007). Emotions are central to how social
groups function. Emotions such as grief, sadness, worry, fear, guilt,
shame, anger, and jealousy are in response to and motivate social be-
haviors (Nesse, 2019). Emotions evolved, in part, in response to inter-
personal processes to approach an opportunity that will enhance sur-
vival, reproductive opportunities, or social status, or to avoid threats to
life, reproduction, or social inclusion.
Second, the evolution of emotions occurred in a social context for
mammals (Shariff & Tracy, 2011; Sutcliffe, Dunbar, Binder, & Arrow,
2012). That is, emotions did not evolve among autonomous isolated
organisms, but rather the selection forces acted upon emotions in the
context of social processes. Therefore, selection operated both on the
expression of emotion and the behavioral response of social group
members to that emotional expression. This parallels language for
which selection operated on both speech production and comprehen-
sion (Glenberg & Gallese, 2012). Because emotions evolved in a social
context, there are multiple response pathways to emotional distress (see
Fig. 1). This means that in addition to individual behaviors to respond
to distress (e.g., behavioral responses of engagement, avoidance, or self-
regulation of emotions), there is interpersonal regulation of emotions, by
which another member of the social group helps reduce emotional
distress through consoling and other behaviors. The most obvious forms
of interpersonal regulation of emotions are related to child and ado-
lescent development when parents, other adults, and peers play a role
in regulation of young group members’ emotions. Interpersonal reg-
ulation of emotions continues as adults through informal relationships
(family, friends, members of one’s social group) and in specialized so-
cial roles (religious leaders, community leaders, mental health profes-
sionals). Because emotions evolved within social systems, emotional
regulation is possible both within an individual and between in-
dividuals (Nesse, 2019).
Third, for interpersonal regulation of emotion to occur, there need
to be motivators and mechanisms in place to facilitate consoling be-
haviors and other responses to group members in distress. These me-
chanisms include emotional contagion, empathy, perspective taking
and mentalization to internalize the emotional experience of the person
in distress (de Waal & Preston, 2017). However, there are also context
and interpersonal relationships where these motivators are not trig-
gered leading to failures of empathy and consoling, which is most likely
to occur when the person in distress is not considered a member of the
same social group.
Working with these three premises, knowledge about how evolution
has shaped facilitators and barriers to interpersonal emotional regula-
tion can improve informal consoling behaviors as well as elements of
psychological services. However, to do so requires acknowledgement
about limits of interpreting causality in evolutionary theory. Although
the ultimate goal of biological evolution is reproductive fitness, i.e., the
dissemination of one’s genes, evolution only works through selecting
proximate mechanisms of biology and behavior driving differential
survival and reproduction, which includes epigenetic mechanisms.
Proximate mechanisms may be beneficial, neutral, or detrimental, de-
pending on social and ecological contexts. There is, therefore, no uni-
versal decontextualized equivalence between reproductive fitness and
physical, medical, or ethical fitness. An ultimate-level explanation of
cooperation, for example, points to its phylogenetic history or the
adaptive problem it solves. A proximate explanation points to the
psychological faculties that underlie or compel cooperative behavior.
Regarding interpersonal regulation of emotions, it is helpful to un-
derstand the ultimate-level explanations for social cooperation, as well
as the proximate mechanisms such as emotional contagion, empathy,
and consoling that make cooperative behaviors possible. All of these
processes are further shaped by cultural evolution, which is not re-
ducible to only reproduction and survival. Therefore, any observed
behavior is multidetermined and any single theory or constellation of
theories invoking evolution will be inadequate to comprehensively
explain or predict human behaviors. The theories, thus, should com-
plement, but not replace, other knowledge generated about psycholo-
gical healing and mental health treatments.
2. Evolution of social cooperation
2.1. Evolutionary theories of social cooperation
The evolution of social cooperation provides the foundation for why
interpersonal regulation of emotion occurs. Social mammals are defined
by the cooperation they demonstrate toward other members of one’s
species, with whom they live and forage (Clutton-Brock, 2009). Social
mammals include wolves, some rodent species, elephants, sea mam-
mals, and non-human primates, as well as humans. A number of in-
terconnected theoretical frameworks have been developed to under-
stand why members of a species help one another. These models
include the evolution of altruism as explained by inclusive fitness
theory (Hamilton, 1964), evolutionary game theory (Axelrod &
Hamilton, 1981; Smith, 1982; Trivers, 1971), multilevel selection
theory (Wilson & Wilson, 2007), and fitness interdependence theory
(Aktipis et al., 2018; Chung, 2016).
Inclusive fitness refers to investment in others because of degrees of
relatedness (e.g., within a group there is some degree of shared genetic
lineage that supports helping others to foster propagation of shared
genes). Evolutionary game theory assumes that exchanges will con-
tribute to reciprocal benefits (e.g., tit-for-tat relationships, symbiotic
relations). Multilevel selection assumes that pressures on survival and
reproduction can occur at the group level, in particular when groups are
competing for resources rather than only individual level competition.
Fitness interdependence assumes that some behaviors may be beneficial
for most group members, (e.g., pooling of resources). Although these
theories were historically developed as alternatives to each other (i.e.,
invoking different causal processes), today they are regarded as largely
accounting for the same causal processes in different ways, a concept
known as equivalence (Wilson, 2015). At the intersection of these
theories are the core drivers of cooperation that extend beyond genetic
relatedness to include reciprocity, affirming the intuitive human notion
of trading favors, and fitness interdependence, affirming the intuitive
human notion of being “in the same boat” and therefore needing to
cooperate even without genetic relatedness or narrow reciprocity.
2.2. Social rupture and repair
Group membership in social species is informed by both phenotypic
cues (visual, olfactory, and auditory) and social behaviors, such as
sharing of resources and reciprocal exchanges (Dunbar, 2010; Nelson &
Geher, 2007). For social behaviors to occur and be sustained, there need
to be mechanisms that drive cooperation as well as mechanisms to
punish violations of cooperation norms. Among primates, a complex
world of emotions underlies motivations for social cooperation and
B.A. Kohrt, et al. Clinical Psychology Review 82 (2020) 101920
reactions to social rupture (Shariff & Tracy, 2011; Sutcliffe et al., 2012).
For example, anger, vengeance, and jealousy precipitate social rupture
(Fehr & Rockenbach, 2004). Anger is a response to violation of one’s
interpersonal norms and expectations, including social standards of
interaction (Elison, Garofalo, & Velotti, 2014). Anger can result in
jeopardizing specific bonds or entire group membership, thus risking
social isolation, which is damaging to survival and hence evolutionary
fitness (Bailey & Moore, 2018). Conversely, guilt and shame are emo-
tions motivating one to abide by social norms (such as cooperation and
reciprocity) to avoid social ruptures (Boyd & Richerson, 2009; Breggin,
2015; Gilbert, 2003; Jaffe, 2008). Fear of loneliness drives individuals
to social engagement. All of these emotions, shaped by their evolu-
tionary backstories, play out in different forms of mental illness (Nesse,
2019). Suicide, in particular, is strongly tied to one’s position vis-à-vis
other group members with the most predictive socioemotional states for
self-harm being ‘perceived burdensomeness’ and ‘thwarted belonging-
ness’ (Joiner, 2007; Van Orden et al., 2010).
Social rupture processes require commensurate restorative me-
chanisms. If trust-or-punish processes were the only mechanisms pro-
moting cooperation, groups would eventually disband or show co-
ordinated behavior without any between-member cooperation, e.g.,
schools of fish. With complex social networks, fluctuating resources,
Fig 1. Role of interpersonal regulation in responding to emotional distress
B.A. Kohrt, et al. Clinical Psychology Review 82 (2020) 101920
and life course challenges such as reproduction and aging, there are
small to large social ruptures happening all the time. This is why social
species also require mechanisms for social repair. Psychological distress
often communicates the need for repairing disrupted social relation-
ships (Breggin, 2015). Social repair behaviors include comforting, dis-
tress reduction, and social accompaniment; all of which are docu-
mented in chimpanzee groups (De Waal, 1989; Goodall, 2010, 2011).
Forgiveness is another important social repair mechanism, rooted in
affective and behavioral processes (Billingsley & Losin, 2017; Will,
Crone, & Güroğlu, 2014).
3. Empathy, compassion, and the foundations of psychological
3.1. Empathy, emotional contagion, and emotion regulation
At the core of most consoling and other social repair behaviors is the
process of empathy. To motivate consoling behaviors and other re-
sponses to distress, empathy is needed to accurately communicate the
distressed state and instigate appropriate responses. Empathy is trig-
gered when witnessing distress in a member of one’s social group.
Empathy is “any process that emerges from the fact that observers
understand each other’s states by activating personal, neural and
mental representations of that state, including the capacity to be af-
fected by and share the emotional state of another; assess the reasons
for the other’s state; and identify with the other, adopting his or her
perspective,” (de Waal & Preston, 2017), see Fig. 2. This involves two
different systems: emotional contagion and cognitive perspective-
taking (also known as mentalizing), which can also be inferred among
some non-human mammals (De Waal, 2008; Shamay-Tsoory, 2011;
Zaki & Ochsner, 2012).
Emotional contagion can be observed in motor mirroring, such as
imitating a distressed facial expression, which is an element of state
matching—sharing the emotional state of another (Webb, Romero,
Franks, & de Waal, 2017). This mechanism may have evolved as a result
of kin selection, reciprocal altruism, and sexual selection because it
favors altruistic and cooperative behavior, supports morality, inhibits
violence, and stimulates group cohesion (Smith, 2006). On the negative
side, state matching and emotional contagion can be the basis of crowd
or mob behavior (Hatfield, Cacioppo, & Rapson, 1994). Cognitive per-
spective-taking, i.e., “knowing what another knows, intends or desires,”
(Gonzalez-Liencres, Shamay-Tsoory, & Brüne, 2013), likely evolved due
to the increasing complexity of hominin groups, associated with ad-
vanced reciprocal exchange and cooperation, including indirect re-
ciprocity (Apicella, Marlowe, Fowler, & Christakis, 2012; Marshall,
1961; Trivers, 1971; Wiessner, 2002). This developed cognition allows
for humans to recognize the distinct lives of others while having the
ability to understand different experiences.
3.2. Consoling behaviors
Once distress has been communicated through emotional contagion
and/or mentalizing, then emotional self-regulation on the part of the
consoling group member is needed. Emotion regulation is the process
by which an individual manages an emotional response through both
intentional and unintentional pathways (Nigg, 2017; Thompson,
Uusberg, Gross, & Chakrabarti, 2019). Emotion regulations is needed to
move from experiencing another’s distress to responding to them with
consoling behavior (de Waal & Preston, 2017). Self-regulation of
emotion transforms the suffering response within the individual feeling
empathy, thus allowing her/him to help another member in distress.
Emotional self-regulation on the part of the consoler precedes inter-
personal emotional regulation with the distressed party. Emotional self-
regulation is needed because the empathic response typically produces
comparable experiences of pain or other distress within the consoler.
Once the consoling party has initiated emotional self-regulation,
then comforting behaviors can be enacted. In most social mammals, the
most common way to achieve this distress abatement is through close
physical proximity and the use of touch (e.g., licking and other
grooming behaviors). Consoling behavior, such as spontaneous affilia-
tion directed by an uninvolved bystander to a recent recipient of ag-
gression or misfortune, can be observed in primates and canines (Webb
et al., 2017). When a person is distressed, lonely, or experiencing fear or
grief, then the presence of a group member in close proximity reduces
sympathetic nervous system responses (Bailey & Moore, 2018; Heatley
Tejada, Montero, & Dunbar, 2017).
An elaborated form of physical presence and touch is allo-grooming,
defined as the grooming of another member of one’s species (also called
social grooming). Allo-grooming predates symbolic communication and
is likely one of the earliest forms of social behaviors that can reduce
psychological distress through prolonged close proximity (a property it
shares with human conversation) and touch. A component of renewing,
maintaining, and strengthening social bonds (Dunbar, 2010), allo-
grooming is involved in reciprocal altruism: the continuous exchange
between roles of “groomer” and “groomed” (Lehmann, Korstjens, &
Dunbar, 2007). Allo-grooming occurs in many human groups, and
serves functions similar to those in other primates (Jaeggi et al., 2017).
The act of being groomed is physiologically relaxing, as shown by a
decrease in heart rate, the reduction of some indices of stress, and
sometimes falling asleep. In primates, social grooming seems to play a
role in facilitating group relationships by providing a psychopharma-
cological environment with the release of oxytocin that enhances
commitment to the relationship, therefore creating a psychological
environment of trust (Dunbar, 2010; Nelson & Geher, 2007).
Considering that empathic responses can transfer negative affect
from the sufferer to another individual, what personal benefit could
arise from helping another in distress instead of avoiding the situation
(Zak & Barraza, 2013)? A neurobiological reward mechanism appears
to foster consoling others in distress even though there is transient
distress on the part of the consoler (Inagaki & Eisenberger, 2012; Moll
et al., 2006; Telzer, Fuligni, Lieberman, & Galván, 2014). This reward
mechanism has been described as a “warm glow” feeling after ameli-
orating the observer’s shared pain and performing a “good deed”, which
includes emotional contagion of the emotional relief felt by the dis-
tressed party; this reinforced healing behavior is referred to as “learned
helping” (de Waal & Preston, 2017). Individuals with a strong reward
response and greater aptitude for emotion regulation, compassion, and
consolation tendencies may be adept at other behaviors (such as
There has been considerable debate in the field over whether there is a
neurological difference between the processes of emotional contagion and
cognitive perspective-taking, whether concepts of empathy and compassion are
distinct, and what roles these processes have in affecting prosocial behaviors
(Jordan, Amir, & Bloom, 2016). However, emotions and associated behaviors
are not rigid distinct mutually exclusive processes, but rather evolution of
particular emotions was influence by different types of situations over time and
in ever-increasing complexity of social relationships (Nesse, 2019). Therefore,
multiple emotions are involved in most situations, and these may be potentially
conflicting, with highly personalized constellation of emotions based on in-
dividual life histories and context. We primarily refer to empathy as linked with
the foundational concept of emotional contagion, or “feeling what another
feels” (Gonzalez-Liencres et al., 2013), as well as being able to view a situation
from the perspective of the individual experiencing the emotion. We agree with
Jordan et al. (2016) that empathy is neither sufficient nor necessary for pro-
social behaviors, which may be motivated by other emotions without experi-
encing empathy. Other factors for prosocial behavior can also include pity,
(footnote continued)
cultural norms, and status pursuits, during which prosocial behavior is per-
formed without empathy. In addition, healing behaviors can be delivered with
or without empathy, such as teaching self-regulation skills or providing in-
strumental support to address the stimulus underlying a distressful emotion.
B.A. Kohrt, et al. Clinical Psychology Review 82 (2020) 101920
sharing, comforting, or helping) that foster successful social relation-
ships and better integration in social networks, ultimately supporting
group-level success (De Waal, 2008; Webb et al., 2017). Internal stress
regulation practiced through frequent caregiving can improve overall
mental well-being (Inagaki & Orehek, 2017; Raposa, Laws, & Ansell,
2016; Tabassum, Mohan, & Smith, 2016) and relationship satisfaction
(Post, 2007), as well as reducing internal inflammation and overall
mortality risk from various diseases (Hilbrand, Coall, Gerstorf, &
Hertwig, 2017; O’Reilly, Rosato, Maguire, & Wright, 2015; Poulin &
Holman, 2013). It is important to keep these benefits of helping in
mind, especially considering that helping others may put one’s own
health, safety, and group membership at risk.
3.3. When empathy fails
In most social species, “in-group members” are the primary bene-
ficiaries of empathy and compassion. In-group members in distress
trigger more empathic or compassionate responses and associated be-
haviors such as grooming to reduce distress, whereas outgroup mem-
bers do not (Cikara, Jenkins, Dufour, & Saxe, 2014). Moreover, whereas
stimulation with oxytocin (e.g., by intranasal administration of
oxytocin) increases empathic responses to in-group members, oxytocin
stimulations appears to have no empathy effect or possibly reduces
empathy and compassion toward outgroup members (De Dreu & Kret,
2016; Van Ijzendoorn & Bakermans-Kranenburg, 2012). Among hu-
mans and some non-human primates, there are pleasure responses as-
sociated with distress among outgroup members—feeling pleasure
when one’s enemies (competitors) are in pain or distress, i.e., a neu-
robiological basis for schadenfreude (Cikara, Bruneau, Van Bavel, &
Saxe, 2014; Cikara & Fiske, 2013). Relationships established by social
grooming play a crucial role for in-group vs. out-group distinctions. For
example, among wild gelada baboons, the likelihood of a female going
to the aid of another female when the latter is under attack is sig-
nificantly correlated with the amount of time the two spend grooming
each other, which strengthens the in-group tie of that pair (Dunbar,
1980; Dunbar, 2010). Social group members are less likely to feel em-
pathy or compassion toward those further away from their in-group.
Fig 2. Psychological healing in the form of interpersonal regulation of emotion between social group members (adapted from de Waal & Preston, 2017, Fig. 3).
B.A. Kohrt, et al. Clinical Psychology Review 82 (2020) 101920
4. Human cultural evolution
4.1. Cultural evolution and the dual inheritance model
An evolutionary theory of psychological healing among humans is
not complete without addressing the dual inheritance model (Richerson
& Boyd, 2008). In dual inheritance, there are two interacting processes:
biological evolution and cultural evolution. Human evolution is coe-
volution: we inherit a biological set of parameters through genetics; in
addition, there are behaviors, symbols, institutions, and ways of
thinking that are culturally inherited (Durham, 1991). Through con-
cepts of epigenetics and social genomics we know that these two are not
independent processes, but highly interlinked. Because of cultural in-
heritance, behavior cannot solely be attributed to reproductive fitness.
Cultural reproduction (the propagation of cultural units, ‘memes’) also
matters. Relationships, emotion, and mind require an ultimate cause in
evolution, a resulting genetic and maturational plan, a process of so-
cialization we have in common with other social species, and a cultural
process for the individual and the group that is unique to humans
(Konner, 2010).
Cultural evolution played a role in shaping social identity as a
powerful factor governing cooperative behavior. People are willing to
cooperate with and even die for other members of their culturally de-
fined groups, often without genetic relatedness or narrow reciprocity.
This fact is most easily explained from a multilevel selection perspective
(Boyd & Richerson, 2009; Richerson & Boyd, 2008). It is a remarkable
fact that cultural variation exists in abundance for human groups at all
scales, including nations of many millions of individuals. Selection also
operates at these scales, as when large polities compete economically
and militarily. Cultural group selection does not necessarily result in
the replacement of people and their genes, but it does result in the
replacement of cultural practices. In other words, when we consider
dual inheritance theory, group selection can become an even stronger
force with the interaction of the cultural track and the genetic track.
Human evolution further advanced psychological healing through
three domains exemplifying the unique outcomes of cultural and bio-
logical processes interacting. First, symbolic logic, including language,
involves biological evolution and makes cultural transmission possible.
Second, protracted caregiving for offspring who have a long period of
dependency and development allows for a great deal of cultural
knowledge to be instilled in humans, not only language, but also the
formation of cultural identities. Third, increased size and complexity of
groups through symbolic identities allows for humans to be part of
multiple different groups, but also places individuals at risk of exclusion
when perceived as not abiding by cultural norms. Table 1 outlines the
contributions of cultural evolution built onto the processes of biological
4.2. Symbolism and language
Humans possess a distinctive inheritance system for symbolic
thought that rivals the boundless possible combinations of genetic in-
heritance (Penn, Holyoak, & Povinelli, 2008; Wilson, Hayes, Biglan, &
Embry, 2014). A “symbol” can be characterized as an arbitrary nature
of reference (a non-necessary link between a form and its meaning),
with antecedents in other non-human species (Luuk, 2013; Ribeiro,
Loula, de Araújo, Gudwin, & Queiroz, 2007). Human symbolic behavior
has higher-order relations that make spatiotemporally displaced refer-
ences; i.e., they are not necessarily bound to physical properties, and
they form nested systems of symbols (Shore, 1996). Once these rela-
tions are established, they are maintained by their utility, coherence,
and role in the social community (Wilson et al., 2014).
Symbolism sets the stage for language, which is central to most
forms of human consoling behaviors. Language vastly expands the di-
verse ways in which consolation and more formal healing can occur
(Dunbar, 2011). Language mimics effects of consolation through
grooming (calming, time in proximity, reciprocal exchange) without
requiring physical contact, which also enables consolation to a group of
individuals and not just one-on-one physical grooming consolation
(Dunbar, 2004). The same physiological responses to allo-grooming can
be observed after small group verbal engagement (e.g., “gossiping cir-
cles”) with familiar social group members. Therefore, language, along
with other symbol systems, makes collective healing possible.
4.3. Parenting and child care
Among primates, humans have the longest childhood period of
dependency, which coevolved with intensive and dynamic caregiving
and bonding behaviors (Konner, 2010). This required highly co-
operative groups and resources to allow for such prolonged de-
pendency. Humans are the only true cooperative breeders among our
close primate relatives. Collective infant and child care is one ex-
planation for the uniquely high level of cooperation that evolved in our
species, which is characteristic of allo-parenting—it takes a village to
raise a child (Hrdy, 2009). Provision of food by parents and others,
especially after weaning, allowed a great step forward in human evo-
lution by shortening birth spacing and accelerating population growth
(Kaplan, Hill, Lancaster, & Hurtado, 2000). It may not be a coincidence
that the acquisition of language in childhood, which forms the foun-
dation of relationships with non-parents, occurs at the typical weaning
age for hunter-gatherers (Konner, 2010, 2016). Ecological factors pro-
moting the evolution of parental care established a set of coevolu-
tionary feedback loops which resulted in increases in parental effort
and offspring needs, a very prolonged childhood despite earlier
weaning, and the evolution of language. This enhanced the relative
benefits of positive social interactions, catalyzing transitions to sociality
during childhood and puberty (Socias-Martínez & Kappeler, 2019).
Emotion regulation emerges during healthy child development, first
via interpersonal regulation of emotion to, later, achieve more self-
regulation of emotions. Parents and caregivers, other family members,
and other social group members model and reward emotion regulation
techniques. This process begins as early as infancy, where caregivers
respond to infant cries by establishing contact and communication with
the infant (Bornstein et al., 2017). Patterns of oxytocin response, with
its role in social reciprocity and bonding, are transferred from parent to
child through patterns of parental care (Feldman, Gordon, Influs,
Gutbir, & Ebstein, 2013). Brain maturation is critical for emotion reg-
ulation, but children also learn to handle emotional distress and in-
ternalize the regulation process from their caregivers in both universal
and culturally specific ways (Abraham, Raz, Zagoory-Sharon, &
Feldman, 2018; LeVine et al., 1994). The presence and tactics of care-
givers encourage children’s self-regulation of emotions, indicating that
“parents [and caregivers] will not comfort them until they begin to
comfort themselves” (Martini & Kirkpatrick, 1992). Play among juve-
niles is also an important element of rehearsing emotional regulation
(Konner, 2010; Shimada & Sueur, 2018; Sutton-Smith, 1997).
One of the important points to consider is that caregiving behaviors
established foundations for male roles in psychological healing. Social
consolation and support are not activities only performed by mothers
and other women in a social group. Male caregiver behavior is in-
creasingly well studied, including its neurobiological correlates and
cross-cultural variability (Gettler, 2016; Golombok et al., 2014;
Hewlett, 1991; Rilling & Mascaro, 2017). Among other consequences,
male caregiving is associated with psychological development of emo-
tion regulation in children (Cabrera & Tamis-LeMonda, 2013;
Cummings, Merrilees, George, & Lamb, 2010; Gettler, 2016; Golombok
et al., 2014; Hewlett, 1991; Rilling & Mascaro, 2017). Moreover, there
is reciprocal influence between children and male caregivers in devel-
opment of emotion regulation, internalizing and externalizing behavior,
and capacity for empathy (Feldman, Bamberger, & Kanat-Maymon,
2013; Flouri, 2005; Pleck, 2010).
Children with high levels of early adverse events and neglectful or
B.A. Kohrt, et al. Clinical Psychology Review 82 (2020) 101920
abusive environments, however, have this process of learning emotion
regulation disrupted or distorted. For example, children in areas of
conflict with high exposures to violence may be less likely to develop
the capacities and motivation required to be empathetic to the needs of
others, while also being more likely to engage in violent conduct
(Walker et al., 2007) and suffer from other mental health problems
(Kohrt et al., 2008). When these children become parents, their beha-
viors and expectations may shape the thoughts and behaviors that affect
their children’s capacity to act (Leckman, Panter-Brick, & Salah, 2014),
setting up the intergenerational transmission of such behaviors.
4.4. Social complexity and symbolic groups
Human groups are also distinct from other social animals because of
the symbols that define groups, tie members together, and exclude non-
group members (Durham, 1991; Shore, 1996). Individuals who have
very different genotypes and limited relatedness can still cooperate
effectively because of symbolic group identification related to nation,
religion, profession, and other non-biologically shared traits. Although
such cooperation is well-known in large-scale societies, many believe
that hunter-gatherer bands were largely kin groups. In fact, these bands,
because they often included individuals related indirectly through
marriage (i.e., in-laws and the in-laws of those in-laws), had an average
genetic relatedness between any two members that was quite low (Hill
et al., 2011); our hunting-gathering past laid the foundations for later
cooperation by non-kin on a much larger scale.
The complexity in terms of size of social groups, subdivisions within
groups, and membership in multiple groups is predominantly a char-
acteristic of humans. Although other primate groups exhibit different
types of dynamic social roles, their groups tend to be smaller, at a
maximum usually not exceeding about 80 members (Dunbar, 1992).
Studies of hunter-gatherer groups have suggested that while local, face-
to-face bands may consist of approximately 30–40 members, the mating
pool that people are aware of and may choose from can be as many as
500 (Lee, 1979; Lee & DeVore, 1968). Moreover, among human hunter-
gatherers, the groups of people who live and work together are nested
within ethnolinguistic aggregates ranging from several hundred to
several thousand members that share a language, allow for the fission
and fusion of the smaller groups, and increase the number of minds
available to store cultural knowledge (Hill et al., 2011; Hill, Wood,
Baggio, Hurtado, & Boyd, 2014; Marlowe, 2005). Since the agricultural
revolution, stable, largely sedentary human social organizations have
expanded to accommodate hundreds of thousands of people. Advances
in cognition among human beings, including language, were likely
driven by the increasing sociality and cooperation within the species
(Hayes & Sanford, 2014). This also requires socioemotional complexity
to manage social bonds and group membership far beyond what is
observed in other species.
Symbolic identity is often mapped onto family relatedness termi-
nology such as kinship networks. Language and other symbolism make
it possible to have ‘fictive’ kin identification, wherein non-related group
members refer to one another by familial terms: e.g., brother, sister,
father, mother, uncle, aunt. Many forms of traditional or religious
healing use fictive kin terms. For example, a priest or a guru refers to
the person suffering as “my child, my son, my daughter, sister, brother,”
and may themselves be called “father” or “brother.” These fictive kin
terms are important because they symbolize being within the same
social group (Griffith, 2010). As such, those relationships that mirror
the close interactions shared between those smaller, local bands are
more likely to trigger empathy and compassion. This increased com-
plexity and size of social groupings elaborated the roles and mechan-
isms for social repair to bring individuals or groups back into society,
under certain conditions (see Fig. 3).
From the perspective of empathy, the ability to form symbolic ties
even beyond one’s immediate social group introduces tremendous po-
tential for consoling behaviors. However, symbolic identities also create
more opportunities for more narrowing of group identities and defining
of out-groups. This places a major threat on empathic and consoling
behaviors. The processes of stigma and discrimination are extensions of
in-group vs. out-group delineations. Members of one’s own social group
can be stigmatized, and thus simulate out-group status, which inter-
rupts the flow of empathy and compassion. Stereotypes of mental illness
trigger stigmatizing reactions around the world (Pescosolido, Medina,
Martin, & Long, 2013). For example, persons with markers of aggres-
sion or violence are stigmatized and isolated and may not receive
compassion or psychological healing. Also, some forms of mental illness
may affect hygiene and self-care that trigger evolutionary-rooted dis-
gust reactions (Brewis & Wutich, 2019). These forms of stigma are also
Table 1
Evolutionary framework of psychological healing
Domains related to evolutionary
Components of biological evolution contributions of cultural evolution
Mechanisms associated with cooperative
behaviors Inclusive fitness – investment based on degree of relatedness
Reciprocal altruism – investment in others with likelihood of returned
Fitness interdependence – benefits of pooled resources
Multi-level selection – competition between groups
Symbolic associations among group members (fictive
kin, tribal, national, or other group symbolic
Propagation of symbols
Defining outgroups (potentially as threats)
Mechanisms associated with responding
to others in psychological distress Mirroring, emotional contagion, and mentalizing – experiencing of others’
distress motivates behaviors to alleviate that distress
Emotion regulation – secondary experience of distress by the healer
triggers responses to reduce that internalized distress through cognitive-
emotional processing (frontal lobe executive functions)
Psycho-neuroendocrinological reinforcement – alleviation of distress in
others yields positive, reinforcing responses (oxytocin, dopamine, and
endorphin release, shift from sympathetic to parasympathetic nervous
Learning helping – increasing efficacy of consoling others facilitates
emotional reward and increased engagement in the behavior
Association with symbolic roles of high status
Material reward through reciprocity or payment
Factors associated with healing Instrumental support (protection from danger, provision of basic needs)
Physical proximity
Touch and allo-grooming
Symbolic healing (transformation of suffering
through attachment to symbols)
Presence of symbols for support, care, protection
Symbolic reintegration to social groups
Costly displays of commitment by healers
Risk-taking by healers
Expert care yielding real and imagined results
Communal commitment and support for healing
B.A. Kohrt, et al. Clinical Psychology Review 82 (2020) 101920
‘communicable’ in that spending time with a person with mental illness
may threatens one’s social status, sometimes referred to as courtesy or
affiliative stigma. This threatens one’s social standing just by spending
time with someone who has a mental illness, and impedes the flow of
empathy (Griffith & Kohrt, 2016).
Symbolic group identification may lead to social norms that dis-
courage empathy and consoling, and replace this with other forms of
coping such as substance use. Moreover, unregulated emotions (e.g.,
emotional outbursts) and lack of interpersonal regulation by other
members of the social group (e.g., allowing the emotional outburst
without consoling or consequences) can be used as a form or display of
dominance in social hierarchies (e.g., political groups) (McIntyre, von
Hippel, & Barlow, 2016). Scientific and technological innovations can
increase exposure to these challenges related to the dual biological and
cultural inheritance, and exploitations of systems may overwhelm the
foundational processes of social healing. Therefore, symbolic group
identification, added to other phenotypic cues of group membership,
leads to complex and dynamic in-group vs. out-group distinctions that
have powerful positive potential as well as major barriers to empathy
and consoling.
5. Specialization of psychological healing
The preceding sections suggested why we psychologically heal others
Fig 3. Psychological healing associated
with social groups based on human dual
inheritance model of biological evolution
(a) and cultural evolution (b). a. Social
cooperative groups are selected for in
evolutionary history based on inclusive
fitness, reciprocal altruism, fitness inter-
dependence, and multi-level selection.
Based on affective processes, a group
member undergoes minor and major
forms of social rupture. Another group
member experiences the suffering of the
isolated group member through empathy
and/or compassion, then provides con-
solation and facilitates social repair. b.
Through additional contributions of cul-
tural evolution, symbols allow for in-
creased group size, complexity, and in-
clusion of non-kin. Group members
experience rupture from the group with
associated affective states (guilt, shame,
anger, loneliness, etc.). Through emo-
tional contagion and mentalization,
other group members feel the pain of the
isolated individual and provide psycho-
logical comfort, facilitating social repair.
Those providing psychological comfort
may use professionalized identities and
symbols (e.g., shamans, religious leaders,
and healthcare workers).
B.A. Kohrt, et al. Clinical Psychology Review 82 (2020) 101920
in the context of social cooperation and how this social healing occurs via
empathy, emotional contagion, emotion regulation, compassion, and
consoling behavior in the form of interpersonal regulation of emotion. As
we introduced in the prior section, cultural evolution allows healing to
take on diverse forms. In this section, we review how interpersonal
regulation of emotions has played out through specialization of psy-
chological healing roles throughout history.
5.1. Shamanism
The archeological record and anthropological research with hunter
gatherer societies over the past century suggest that shamanic practices
likely represent the first formal social role related to specialized
healing. Shamanic practices continue to play a major role in mental
health in many societies today (Gureje et al., 2015). The near ubiquity
of shamanism across historical cultures suggests that this may reflect a
common strategy to deal with distress and misfortune (Eliade, 2004,
orig. 1951; Sidky, 2010; Singh, 2017a). In shamanic healing, the suf-
ferer is generally passive throughout the process, but the healer will
extract something from the sufferer, attach it to a symbol, then trans-
form the symbol (Winkelman, 2001, 2010), which is a form of inter-
personal regulation of emotions because of the emotional transforma-
tion the distressed person experiences (Dow, 1986; Levi-Strauss, 1949).
The symbol transformation of emotional distress could be extracting an
offending spirit from an anxious, distressed, or grieving person by
placing the offending spirit in a chicken, goat, or egg before killing
(cracking) the animal (or egg) to banish the spirit. These types of me-
taphysical spirits can be observed across cultures as a way to externalize
psychological distress, and likely reflect similar mechanisms to the idea
of an unconscious self. These processes of healing are about trans-
forming, removing, destroying, and in other ways altering the offending
spirit and its tie to the suffering individual.
This emotional transformation for the individual can be framed as
moving through a liminal state—a transitory state typically involved in
rituals for life-stages or disease to health (Kohrt, 2015; Turner, 1969).
Moving through the liminal state also changes one’s social standing,
thus accomplishing social repair. On a social level, collective healing
has strong implications for communal bonding and group strengthening
related to social repair: “collective social integration produced by
shamanistic healing practices through the participation of the local
community strengthens group identity, exerting an influence on well-
being by enhancing community cohesion through reintegrating patients
into the social group” (Winkelman, 2010). Social support thus does not
only have therapeutic and prophylactic effects on the healed individual,
but on those involved in the healing process as well.
In addition, the moral authority given to the healer and the belief
system associated with the healing practice are important. Across
healing practices, it is important for the sufferer to believe that the
healing practice will work and that the healer is uniquely suited to
administer that healing practice (Luborsky et al., 1996). The healer and
the sufferer should have either shared or overlapping models of illness
and recovery, or at a minimum must understand each other’s models
and participate intersubjectively in both (Kleinman, Eisenberg, & Good,
1978; Pachter, 1994). Ideally, the sufferer needs to believe that the
specific healer can access that special power or authority (Winkelman,
2002), but it is equally accepted that when a mainstream medical
professional understands the patient’s view, healing is facilitated. Ec-
static states, including altered forms of consciousness, can be used for
symbolic transformation (Eliade, 2004, orig. 1951; Singh, 2017a). This
could also be understood as trusting that the shaman has the emotion
regulation capabilities to successfully alleviate the distress. (Textbox 1
is an example of hunter-gatherer healing with a shamanic healer and
collective ritual process.)
5.2. Organized religion and medicine
The independent development of organized religions in disparate
cultures around the world suggests that a major function of these sys-
tems is to grapple with the human need to make sense of suffering. Most
organized religions are distinguished in specifically defining an in-
group and an out-group. From a social species perspective, if empathy
and compassion are strongest within one’s social group, then organized
religions provide fertile ground for interpersonal regulation of emotion
including consolation and healing. Many organized religions have
common elements including empathy, compassion, emotion regulation,
and consolation for suffering and loss to ease the negative affect asso-
ciated with these experiences (Solomon, Greenberg, & Pyszczynski,
2015). Engaging in a symbolic network of spiritual belief can ease ne-
gative affect.
The earliest written medical writings of psychological distress were
often intertwined with religious, philosophical, and political text. It is
striking that from the earliest days of medical writing, there were de-
scriptions of psychological distress around the world. The texts that
formed the Vedhas and Ayurvedic medicine in South Asia written first
written between the 6
Century BCE–6
Century CE describe humoral
and lifestyle imbalances leading to psychological distress (Jaiswal &
Williams, 2017; Madhavi & Savitha, 2017). Early Chinese medical texts
(Huangdi Neijing, Suwen, Lingshu Jing) written between the 2
BCE and 8
Century CE describe imbalance and disturbances of ‘wind’
associated with a variety of psychological distress symptoms (Lin,
1981). Similar descriptions of distress can be found in Greek writings of
Classical Antiquity (Sadeghfard, Bozorgi, Ahmadi, & Shojaei, 2016),
Q’uranic medical text in the Islamic Golden Age (Haque, 2004), and the
Four Tantras of Tibetan Medicine (Jacobson, 2007).
All of these traditions include components of healing related to
prescribed types of social interactions and emotion regulation. For ex-
ample, Buddhist principles promote boundless compassion for the self
and for others, encouraged through internal engagement with one’s
own emotions (i.e., emotion regulation) and followed by practicing
sympathy and kindness to both in-group and out-group members (Peng
& Shen, 2012). Along with the multitude of Buddhist Zen, Vipassana,
and Tibetan practices, components of this internal “focusing” can be
found in Christian, Jewish Hasidic, and Sufi mystical traditions (in-
cluding prayer, contemplation, and meditation), and secular mind-
fulness practice (Kristeller, 2011). Internal focusing to cultivate positive
affect toward others is a tenet of these practices.
Organized religions provide a linkage between social healing of
others and inward focused self-healing. Growing bodies of research
indicate that religious beliefs and participation of many kinds promote
resilience during illness as well as preventive health, and that healing
and other altruistic acts often rest on religious foundations and are
primed by reminders of faith (Konner, 2019; Rosmarin, Pargament, &
Koenig, 2020). Some aspects of religion teach how to apply consolation
to oneself, either through an anthropomorphized external power such
as a god, or through techniques learned in religious practice, as de-
veloped in Buddhism and other traditions.
In Afghanistan, where longstanding conflict has affected the lives
and livelihoods of local populations for decades, interventions in-
corporating introspective elements of Sufi Islamic practice and en-
hancement of social support has demonstrated positive impacts on
participants’ psychosocial wellbeing. One such intervention is a col-
lective group practice of “Balancing the Blessings” among Afghan
women. In a group setting, one woman is asked to place one bean or
pebble on a side of a scale to symbolize each sad or difficult situation in
her life. Then, the rest of the group helps her to find positive “pebbles”
to place on the opposing side, to symbolically demonstrate the bene-
ficial situations in her life (Omidian & Miller, 2006). The practice en-
ables the participant to feel emotional and social support from the
group leading to a reframing of everyday experiences (Omidian &
Panter-Brick, 2015). The Western urging to “count your blessings,” if
B.A. Kohrt, et al. Clinical Psychology Review 82 (2020) 101920
less dramatic, has a similar function.
5.3. Psychological healing
Anthropologists have compared how shamanic healing shares ele-
ments with psychological therapies (Rivers, 1924). Symbolism and
mythic transformation are central to both practices (1949). In tradi-
tional healing, the shaman provides a publicly salient narrative or myth
to which the sufferer can attach her personal conflict. The shaman
draws the sufferer along the mythic transformation and resolution so
that the sufferer’s affliction is also transformed and resolved in front of
one’s social group. Whether it is a spirit or the unconscious, the healer is
able to access this separate force and transform it to alleviate suffering.
One anthropological framework of universal symbolic healing pro-
cess to explain both shamanism and psychotherapy has 4 stages (Dow,
1986): (1) the healing begins with a set of generalized symbols in a
cultural framework salient to healer and sufferer; (2) the healer per-
suades the attendant sufferer that the framework defines the affliction;
(3) the healer particularizes the framework to the sufferer whose af-
fliction becomes attached to transactional symbols; (4) through the
manipulation of transactional symbols, the sufferer’s emotions are
transformed to produce healing (see Fig. 2). The essential elements of
healing in this process are suggestion, catharsis, social-cognitive re-
structuring, and psychobiological responses. This “universal structure
of symbolic healing is a result of the way that human communication
has been biologically organized by evolution” (Dow, 1986). The
person in distress needs to be invested in the healer’s symbols and the
healing symbols. Hope, or the expectation that the future will be better
than the present, is the primary mechanism of change in folk traditions
of healing and in psychotherapy—and that hope is tied to the faith in
the symbols of the healer and healing (Frank, 1974 [1961]; Frank and
Frank, 1991).
Aspects of this have been referred to as the placebo effect. The
placebo effect works via symbolic healing, with the ritual of the ther-
apeutic act having a tangible effect on the sufferer’s physical and
mental state (Winkelman, 2010). This occurs via symbols imbued with
meaning, prior knowledge and experiences, prior expectations, and via
the perceived level of empathy displayed by the provider (Meissner
et al., 2011). When a medical treatment, which is iteself a ritual of
healing, is administered to an individual, the complex set of psycho-
social stimuli that form the healing context shapes the therapeutic
outcome. These range from the treatment characteristics (e.g., the sight
of a syringe or the script of a prayer) to the sufferer’s and healer’s
characteristics (treatment and illness beliefs, status, gender), and from
the sufferer-healer relationship (suggestion, reassurance, and compas-
sion) to the treatment setting (home or clinic, and room layout)
(Benedetti, Mayberg, Wager, Stohler, & Zubieta, 2005; Di Blasi,
Harkness, Ernst, Georgiou, & Kleijnen, 2001). These contextual factors
generate both a conscious and unconscious biological response to the
therapeutic ritual by activating endogenous opioid and nonopioid
networks within the brain, as well as additional immune system and
hormonal responses (Colloca, 2018; Peciña et al., 2015; Pecina &
Zubieta, 2018). These opioids, such as oxytocin and vasopressin, are
widely distributed neuropeptides in the brain that have prosocial effects
(Andari et al., 2010; Benedetti, 2011; Riem, Bakermans-Kranenburg,
Huffmeijer, & van IJzendoorn, 2013; Yamasue et al., 2012). A large
component of this effect is the individual’s expectation of benefit from
the therapeutic encounter—i.e., the expectation that the treatment will
Textbox 1
A hunter-gatherer model for healing.
Anthropologists look to hunter-gatherer societies for clues to our basic human adaptation during the many thousands of years that modern
Homo sapiens, our species, was developing its fundamental social and cultural forms. While all hunter-gatherers are biologically and psy-
chologically very similar to ourselves, they live in ecological and cultural circumstances resembling those of our ancestors. All hunter-gatherer
groups have healing models and practices of some kind, but one in particular exemplifies many of the points we are trying to make about the
human inclination and capacity for healing. That model and practice is the healing trance dance of the Kalahari San, or Bushmen, of Botswana
and Namibia (Katz, 1982; Konner, 1985; Lee, 1968; Marshall, 1969; Marshall, 1981).
The San healing dance is the central religious ritual of this hunter-gatherer group, as well as their main method of healing. During the
ceremony, which ordinarily starts in the evening and may last all night, women gather in a circle around a fire and clap in complex rhythms
and sing traditional songs that have a quality partly resembling yodeling. If the singing and clapping gather energy, healers—mostly men but
also some women—approach with dance rattles around their ankles and make another circle around the women. They dance monotonously
staring into the fire until some of them fall out and are attended by other healers. Spectators sit in a third circle around the singers and dancers,
and all who attend—essentially everyone in the small village—will be healed, whether ill or not (Lee, 1968; Marshall, 1981).
The healer lying on the ground will be vigorously rubbed by other healers not yet in trance until he is able to be pulled up to a standing-
dancing position and go around laying hands on each person attending, in succession. Because of the extremely kinetic state the healers are in,
it has not yet been possible to study brain activity, but all observers over many decades agree that the healers are in a profoundly altered state
of consciousness. They say that they leave their bodies temporarily and visit the world of the spirits; they may put their heads in the fire or run
into the bush at high speed, not avoiding trees or other obstacles. Other healers have to bring them out of the moribund state, called “like
death,” and protect them from themselves when they are active again. They take grave risks, both spiritual and physical, to gain the power to
With each person, the healer lays both hands on the shoulders and chest, trembles audibly, the tremulous sound increasing in volume as the
moaning sound repeats, until a sharp shriek completes the healing process. At this moment, San believe, the “particles” causing or likely to
cause illness travel up through the touching hands and arms of the healer and shoot out through the nape of the healer’s neck, back into the
world of the spirits where they came from. Periodically, during the circular round of the dance, a healer will stop, face outward toward what is
believed to be a fourth circle consisting of visiting spirits, and shout deprecations at them for causing illness. There is little or no reverence
here, only castigation for bad use of supernatural power.
It is interesting that if the trance-dance fails to gather momentum, fingers point in all directions; the women did not sing strongly enough,
the healers with their dance rattles didn’t dance vigorously enough, the whole village didn’t participate as they should. This strongly un-
derscores the conclusion that the healers’ power derives from the community (Lee, 1968). Very experienced older healers may go into trance
alone, but only after a long apprenticeship in this densely social context (Katz, 1982).
Thus this ritual, observed over many generations in a hunting-gathering society representing one of the environments of human evolu-
tionary adaptedness (EEAs), illustrates the following points: 1) people in general, not just healers, are inclined to help others in need and will
expend energy doing that; 2) healers make particularly costly displays of commitment in order to heal, accumulating specialized knowledge,
taking risks, and investing great personal resources; 3) healing power, although channeled through individual healers, derives from the
community as a whole; 4) healing relies on shared models of the causes and effective remedies for illness; and 5) healing power often requires
healing touch and other close personal contact.
B.A. Kohrt, et al. Clinical Psychology Review 82 (2020) 101920
be effective (Benedetti, 2011; de la Fuente-Fernandez, Schulzer, &
Stoessl, 2002; Scott et al., 2007).
The very fact that good medical and surgical studies require placebo
controls reflects the acceptance by biomedical scientists that symbols as
simple as sugar pills can have positive effects on illness (Harrington,
1999), and the ritual of surgery has a healing effect even when the
actual surgery is not performed (Moseley et al., 2002). One study that
administered a placebo pill to cancer survivors experiencing fatigue
reported a 29% greater improvement in fatigue severity than their
treatment-as-usual counterparts (Hoenemeyer, Kaptchuk, Mehta, &
Fontaine, 2018). Another study randomized osteoarthritis patients into
arthroscopic debridement, arthroscopic lavage, and “sham” arthro-
scopy (where the entire procedure was convincingly replicated without
the actual insertion of the arthroscope). Outcomes were assessed mul-
tiple times over the course of 24 months with the use of five self-re-
ported scores—three on scales for pain and two on scales for func-
tion—as well as one objective test of walking and climbing. The study
found that there was no meaningful difference between the placebo
arm, debridement, or lavage groups both in terms of the self-reported
scales as well as the objective test of walking and climbing at any as-
sessment point during the trial (Moseley et al., 2002). A more recent
systematic review and meta-analysis on “sham” surgical procedures for
pain interventions further indicated that these procedures are asso-
ciated with a large improvement in pain and other subjective patient-
reported outcomes, with relatively small effect on objective outcomes
(Gu et al., 2017).
Another classic study showed that patients who see a natural scene
through their hospital room window recover more quickly from surgery
and request less pain medication than those whose view is a brick wall
(Ulrich, 1984), and this general effect is confirmed in recent studies
(Huisman, Morales, van Hoof, & Kort, 2012). Stress and its alleviation
affect physical healing from surgical wounds and burns (Gouin &
Kiecolt-Glaser, 2011; O'Brien & Lushin, 2019; Robinson, Norton,
Jarrett, & Broadbent, 2017). Why doubt that compassion, meditation, a
collective communal ritual, or a costly display of commitment such as a
shaman’s ecstatic state might have a similar influence? Given these
findings, it is worth recalling Arthur Kleinman’s statement from more
than three decades ago: One would think that every medical student
should be trained to elicit the highest rates of placebo effects through mastery
of nonspecific symbolic techniques” (1988, p. 140).
In addition to the placebo effect, it is also worth noting the field of
study of common factors in psychological treatment research, which
has relevance to consoling behaviors and interpersonal regulation of
emotion. Common factors are those elements of psychological treat-
ment that are shared among diverse types of treatment such as colla-
boration, empathy, alliance, and affirmation are examples of common
factors (Wampold, 2015). Common factors are important alongside
treatment specific factors, which are elements of treatments that are
specific to the type of intervention, such as problem solving, motiva-
tional interviewing, etc. Because common factors are often intertwined
with treatment specific factors in treatment delivery, it is difficult to
disentangle the relative contribution (Cuijpers, Reijnders, & Huibers,
2019; Mulder, Murray, & Rucklidge, 2017), but both are assumed to be
important (Karson & Fox, 2010). Thus, evolutionary mechanisms of
mirroring, positive emotional contagion, and mentalizing are central to
enabling healing, and they form the basis of being able to collaborate,
empathize, form an alliance, and affirm the person in distress. Ulti-
mately, from a biocultural evolutionary perspective, this calls for at-
tention to both the symbolic process of healing and the foundational
processes of empathy, emotion regulation, and consolation. Based on
what we have reviewed, we can predict from an evolutionary per-
spective that there are conditions that favor psychological healing and
conditions under which it is less likely to occur (See Fig. 4).
Psychological healing has also seen the specialization and devel-
opment of healing approaches some of which draw upon consoling, but
many elements which are also different processes. Therefore, it is
important to point out that we are not suggesting that all formal psy-
chological treatments can be traced to foundations of interpersonal
regulation of emotion. The interpersonal regulation of emotion is more
related to common mental disorders, and would not be sufficient to
develop interventions for specific neuropsychiatric disorders, such as
PICA in a child with developmental delays. Moreover, some manualized
treatments, such as Acceptance and Commitment Therapy (ACT), are
informed by other aspects of evolutionary theory (Hayes, 2019).
6. Implications for global mental health
Global mental health is an “an area for study, research and practice
that places a priority on improving mental health and achieving equity
in mental health for all people worldwide” (Patel & Prince, 2010). The
field of global mental health is dedicated to addressing the disparity
that 90% of research is done with samples representing only 10% of the
global population. Mental health research is dominated by high re-
source, English-speaking populations (Patel & Sartorius, 2008) also
characterized as WEIRD populations (Western Educated Industrialized
Rich Democratic societies) in psychological research (Henrich, Heine, &
Norenzayan, 2010). The attention in recent years on low- and middle-
income countries (LMICs) has also coincided with a growing recogni-
tion that most high-income countries also have large swaths of the
population who go without treatment, especially in rural areas and
among cultural and ethnic minorities (Alonso et al., 2018; Degenhardt
et al., 2017; Hoeft, Fortney, Patel, & Unützer, 2018; Thornicroft et al.,
There has been a concerted effort to evaluate and expand psycho-
logical interventions globally (Fairburn & Patel, 2014). These psycho-
logical interventions use non-specialists as the cadre of trainees (Kohrt
et al., 2018; Singla et al., 2017), who are typically community health
volunteers, teachers, nurses, lay persons in refugee camps, informal or
traditional birth attendants, religious leaders, and family members.
Community health workers and other cadres are trained on average for
5 days to 2 weeks to deliver psychological interventions. These inter-
ventions are designed using core components of psychological treat-
ment classes, such as interpersonal psychotherapy, cognitive behavioral
therapy, behavioral activation, motivational enhancement, and trauma-
focused techniques. As of 2017, there were 25 RCTs of psychological
interventions with a pooled moderate effect size (0.49) for common
mental disorders (Singla et al., 2017). We offer propositions for global
mental health informed by an evolutionary theory of psychological
healing (see Table 2). These propositions are in the spirit that global
mental health reflects inequities around the world—including in high-
income countries—and therefore, these recommendations are also ap-
plicable to improving care in the U.S. and other high resource settings.
6.1. Who delivers psychological support?
6.1.1. In-group members
When taking the evolution of interpersonal regulation of emotion
into account, who should be providing psychological support? The
general answer is an easy one: everyone. As a species we are designed to
do this, and we all probably are already doing this in many aspects of
our lives in terms of consoling children, other family members, and
other members of our social groups. Evolutionary theory also suggests
that interpersonal emotional regulation will be more likely to happen
with certain types of persons—most specifically, with social in-group
members. Emotional contagion and perspective taking are more likely
to happen with in-group members, and that is reflected in the neuro-
biology of empathy studies. This suggests that initiatives should be
taken to create a diverse mental health workforce so that everyone has
access to persons in their communities with shared life experience and
social group membership who can provide psychological support. In the
current political moment, there has been a global response to the
Movement for Black Lives Matter to create a more representative
B.A. Kohrt, et al. Clinical Psychology Review 82 (2020) 101920
society across professional disciplines, and the same has been stated for
a more representative global mental health workforce (Weine et al.,
2020). It is also important to have a developmentally diverse approach
with, in particular, the need for peer mentors and peer helpers of
adolescents and young adults to foster emotional contagion and per-
spective taking to support consoling behaviors.
Cultural, racial, and other attitudes about perceived group differ-
ences can therefore moderate empathic responses, with individuals
more likely to empathize with or demonstrate compassion towards
those within their close relationships or in-group (Decety, Echols, &
Correll, 2010; Hein, Silani, Preuschoff, Batson, & Singer, 2010; Xu, Zuo,
Wang, & Han, 2009). For example, recent studies have indicated that
physician-patient racial-matching in the United States results in a 13%
reduction in hospital mortality rates in one analysis (Hill, Jones, &
Woodworth, 2018) and a 19% reduction in cardiovascular mortality
(Alsan, Garrick, & Graziani, 2018) for Black men being treated by Black
doctors. This suggests that culturally constructed social divisions, such
as race, class, and religion, may impact the human connection, the flow
of empathy and compassion, and the therapeutic alliance.
One of the advocated strategies in global mental health is to train
community health workers. Training community health workers, who
are likely to share identity characteristics with the populations they
serve, would have massive global reach. It could also be consistent with
theories of in-group emotional contagion—given that there is not a
Fig 4. Evolutionary understandings of psychological healing predict conditions under which psychological healing is more likely or less likely to occur effectively.
B.A. Kohrt, et al. Clinical Psychology Review 82 (2020) 101920
large social distance (i.e., a perceived difference between groups of
people as defined by social categories) between the person providing
and receiving care. This increases the likelihood that in-group vs. out-
group differences will be minimized, thus optimizing the conditions
under which empathy via emotional contagion occurs.
6.2. Promoting in-group identification (reducing stigma and discrimination)
That said, exclusively pursuing identity matching of helpers and
beneficiaries is not feasible given the range of different identity mar-
kers. For example, matching on gender, age, and race may not be the
most important identity markers. Instead, religion, sexual orientation,
and other factors may be equally or more important in some contexts.
Moreover, even for community health workers who have a ratio of
1:1000, there will be differences in caste, language, religion, and so-
cioeconomic status within a single community. Therefore, effective
training of empathy, especially mentalizing (or compassion), will be
crucial in any context—even when working with community-based
Social neuroscience theories of stigma are consistent with evolu-
tionary theories of social groups and call for ways to reduce threat and
foster markers of shared identify and experience. Social contact inter-
ventions from the field of social psychology have a potential role here.
Social contact uses the principle of trying to reduce in-group vs. out-
group distinctions by having group members work together (Pettigrew,
Tropp, Wagner, & Christ, 2011). This is done by demonstrating that
individuals have a shared goal of some kind. It involves reducing ne-
gative emotions, such as anxiety, and promoting hope. This has been
used to reduce racial/ethnic barriers, and is also effective in reducing
the stigma against persons with mental illness (Corrigan, Morris,
Michaels, Rafacz, & Rusch, 2012). When anxiety is high, amygdala
activation is increased and there is likely less empathy (Amodio, 2014).
Similarly, in socially stressful situations, there is less positive emotional
contagion, i.e., less shared emotional experience (Martin et al., 2015).
After hurricane Katrina, social out-group members were perceived to be
in less need of emotional and instrumental support despite comparable
levels of trauma (Cuddy, Rock, & Norton, 2007). When anxiety can be
decreased and frontal lobe activities for planning are activated, how-
ever, these differences can be mitigated. There are currently studies
underway examining these social contact approaches in global mental
health (Kohrt et al., 2018). Other alternatives to reduce in-group vs.
out-group differences and promote empathy can involve social contact
interventions (see Textbox 2).
6.2.1. Care from out-group members
Given this evolutionary perspective, it is also important to consider
when in-group membership may not be desirable and why out-group
members may also be needed. Given that emotions—especially sha-
me—may impede consoling from an in-group member, then it is also
important to consider the role of potential out-group members. In ad-
dition, if shame is experienced due to a presumed social norm (e.g.,
homophobic beliefs, anti-religious or political beliefs, etc.) then it may
be important to have support from someone thought to not be part of
the social group. In some cases, anonymity, may be vital for emotional
disclosure and opening up about interpersonal conflicts driving the
emotional distress.
In a comprehensive, evolution-informed perspective, it is important
to both have support available from in-group members, but also access
to out-group members who may not share (or believed to share) beliefs
and values associated with the origins of distress. Technology increas-
ingly makes this possible both with regard to meeting in-group mem-
bers (who may be halfway around the world) as well as accessing out-
group members. The epitome of anonymity in interpersonal regulation
of emotion may not be with a person at all, but with a chatbot that
serves some of the distress regulation roles without the perceived risk of
judgement or violating confidentiality. Technologies such as chatbots
may be able to mimic empathic and compassionate responses. Whereas
chatbots may not have the identity markers to facilitate emotional
contagion, it may be more important that they do not have identity
markers of a particular ethnicity, age, or social status. The wiping away
of these social stimuli may ultimately reduce the impediments when a
person in distress mentalizes about their helper. A person in distress
may not worry ‘what does the chatbot think about me’, which is
something that may hold them back when speaking with other helpers.
Table 2
Application of evolutionary lessons to providing psychological support
Domain Components Descriptions
A. Who should deliver psychological
A1. In-group members Emotional contagion will be more effective when delivered by in-group members; approaches
are needed to reduce discrimination and stigma to foster feelings of in-group membership
A2. Out-group members Engage out-group members (or tools such as chatbots) in context where anonymity is desired or
where distress arises from judgement about in-group social norms
A3. Persons with emotional self-
regulation skills
Persons with strong self-regulation skills will be more effective at interpersonal regulation of
B. What should be delivered in
psychological support?
B1. Consoling Interventions should include consoling behaviors as a fundamental component of psychological
B2. Touch and collective movement Based on its role in interpersonal alleviation of distress, touch should be explored as an
intervention component ranging from massage to acupuncture; as well as collective movement
such as dance, yoga, and other group physical activities
B3. Social inclusion Interventions should provide the skills and opportunities for people to (re)integrate into social
groups and activities
B4. Emotional self-regulation skills Emotional self-regulation skills should be taught to respond to current distress and improve
responses to future difficulties
B5. Helping others Because of the benefit for self-regulation and the psychophysiological benefits to the helper,
interventions should include skills and opportunities to help others
C. How should psychological support be
C1. Shared cultural symbols and
explanatory models
For symbolic healing to be effective, shared symbols and explanatory models are needed to
attach distress to a symbol and transform that symbol to alleviate the distress
C2. Group delivery To promote social inclusion and opportunities to help others, group delivery formats should be
C3. Delivery tailored to child and
adolescent development
Peers and peer mentor programs with youth at a similar life stage can facilitate emotional
contagion and empathy, as well as foster skill development in emotional regulation and other
areas through scaffolded learning
C4. In systems preventing empathy
fatigue and burnout
To encourage emotional contagion and promote empathy, institutions (e.g., health, education,
and other social services) should have resources to promote helper wellbeing and assure that
support can be delivered effectively to sustain learned helping and avoid learned helplessness
and burnout
B.A. Kohrt, et al. Clinical Psychology Review 82 (2020) 101920
A chatbot version of the Thinking Healthy Program is now being piloted
in Kenya (Green et al., 2019). In addition, technology could be used to
monitor emotion regulation skills among persons trained to be helpers
and their beneficiaries.
6.2.2. Persons with self-regulation skills
Although everyone should be able to provide consolation, the evo-
lutionary perspective highlights the need for emotional self-regulation
skills to be effective at this. Therefore, individuals should be supported
in developing self-regulation skills, and selection of specialized psy-
chological healers (whatever the specific discipline) should include
assessment of self-regulation skills in some manner. This would suggest
expanding scalable reliable techniques for assessing self-regulation of
emotion, as well as using this as a selection criterion for specialists and
non-specialists delivering psychological intervention. Currently in
global mental health, we typically broadly recruit to increase access,
but we could consider culturally valid ways to assess emotional self-
regulation when selecting persons to provide psychosocial services.
Promoting self-regulation skills among helpers is also important to
reduce secondary traumatization and burnout. Burnout threatens the
mental health of providers and impede the care they can provide to
their clients. In conflict-affected areas of Afghanistan and Pakistan,
interventions incorporating mindfulness techniques as part of “fo-
cusing” emotions for humanitarian aid workers have shown improve-
ment in their measures of resilience, notions of service and faith, and
reduction in overall burnout (Miller, Omidian, Rasmussen, Yaqubi, &
Daudzai, 2008; Omidian & Panter-Brick, 2015). Mindfulness practice
encourages awareness and being in the present moment, internally
acknowledging one’s own experience and facilitating critical examina-
tion of personal biases while withholding judgment (Dean et al., 2017).
6.3. What should be delivered in psychological support?
6.3.1. Consoling
From an evolutionary perspective, consoling is a central behavior.
This is consistent with common factors of psychotherapy including
normalization and validation of emotions, and the associated verbal
and non-verbal communication skills that go along with this. Consoling
also involves providing hope that the distress will abate in some way.
One can imagine that consoling is central to emotions such as grief and
guilt. This would not change current practice considerably as most
treatment manuals in global mental health include these elements, but
it reinforces the attention to being sure these competencies are achieved
(Pedersen et al., 2020).
6.3.2. Touch
As a form of consoling, we have also seen how touch is so important
from the physiological response associated with it. This is something
that is radically missing from psychotherapies, and it is important to
consider how that can better be integrated. There may be differences in
the physiology when touch is or is not possible (possibly even a
handshake) as a physical human connection. To date, there has been
limited clarity or advocacy for the role of touch in global mental health
and how it should be incorporated as an element of healing. This should
be remedied, as touch is a foundational component according to evo-
lutionary theory. Touch is likely important for trauma healing in many
cultures, and the prominence of pain interlinked with psychological
distress as a public health crisis highlights this as a gap to be filled
(Kohrt, Griffith, & Patel, 2018).
Specific practitioners such as masseuses, chiropractors, bonesetters,
acupuncturists, and some practices in Ayurveda, Chinese medicine, and
other forms of healing have touch as a healing component. In addition,
touch plays a role in some collective movement such as ecstatic rituals,
dance therapy, somatic therapy, and other practices (Csordas & Lewton,
1998; Monteiro & Wall, 2011). In charismatic religions, touch is a
healing component such as through the laying of hands (Csordas, 1994,
2001). However, it is considered taboo or against professional stan-
dards in most current mental health training. This can be due in part to
the risk of institutions and individuals imbued with symbolic power
(e.g., a religious leader, a practitioner, etc.) using such power to emo-
tionally, physically, or sexually exploit individuals entrusted to their
care. The re-incorporation of touch into mainstream practice therefore
comes with the caution of ensuring safeguards against such exploitative
6.3.3. Social inclusion
Another element that comes up is that social inclusion is a crucial
element from an evolutionary perspective. Social stressors are a major
trigger of emotional distress (Nesse, 2019), thus psychological support
should involve a component of social inclusion. This can take many
forms. It could simply be a positive interaction between an individual in
distress and another person. Social inclusion also can be enhanced by
developing skills to facilitate social interaction, such as through inter-
personal psychotherapy. An evolutionary perspective suggests that
Textbox 2
Reducing in-group vs. out-group differences to promote empathy in health services.
From an evolutionary perspective, in-group vs. out-group divisions are one of the major barriers to empathic, compassionate exchanges. When
a health worker or other person providing psychological support perceives someone in distress to not be part of their group, they are less likely
to experience emotional contagion, and therefore do not engage in consoling behavior. People with mental illness often trigger this out-group
response because they are perceived as unproductive members of the social group, a burden to families and other group members, and
potentially unpredictable or violent. From an evolutionary perspective, interventions are needed that help health workers to see that people
with mental illness are “like me” in many ways.
One example of this in global mental health, is the Reducing Stigma among HealthcAre ProvidErs (RESHAPE) program in which people
with mental illness are trained deliver photographic narratives describing their lives, experiences of mental illness, and experiences in recovery
(Kaiser et al., 2019; Rai et al., 2018). When people with mental illness present these narratives to health workers, it creates a social connection
and reduces the in-group vs. out-group biases. The program has been piloted in Nepal where it resulted in reduced social distance between
health care workers and people with mental illness, less stigmatizing attitudes, and more empathy and other positive therapeutic engagement
(Kohrt et al., 2020).
A medical doctor in southern Nepal reported how interacting with people with mental illness at a RESHAPE training affected his attitudes
and beliefs:
“I think we became more optimistic [after the training]. Before we used to have psychiatry posting while doing [medical training], I used to doubt if
the patients will really get well, if their condition would improve. So, when seeing those people who have recovered, we got the proof that their condition
can improve if they get timely treatment and timely counseling… We got to know how the patients feel and what drives them to do certain things, what
triggers depression. We got to interact with patients who previously had postpartum depression and postpartum psychosis… I felt really bad to know
about the challenges they face in society. I could empathize with them and realize how they might have felt. So, I felt happy to be able to provide service to
people with such problems.” (Kohrt et al., 2020)
B.A. Kohrt, et al. Clinical Psychology Review 82 (2020) 101920
practical skills to make this inclusion work would be vital (e.g., role
plays on communication skills). Moreover, given that themes such as “I
am unlovable” are at the core of cognitive behavioral therapy, ther-
apeutic techniques in cognitive behavioral therapy should focus on this
theme as it is central to social relations.
6.3.4. Emotional self-regulation skills
In therapeutic engagements teaching self-regulation skills for the
person distressed can immediately be helpful, e.g., teaching a relaxation
exercise such as deep breathing, to calm one down in the moment. And,
teaching self-regulation skills can help improve long-term emotion
regulation. There are diverse models of self-regulation and associated
symbols and rituals across cultures (Hinton & Kirmayer, 2013). These
cultural models are part of ethnopsychology, or local psychological
models of how emotions are categorized and experienced (White,
1992). Tibetan, Mongolian, and Chinese medicine all incorporate
practices of self-regulation tied to balancing of humors in the body.
Because of stressful life experiences, constitution and temperament,
diet, environment, or other factors, humors can become unbalanced.
For example, traditional Buddhist practices to regulate wind humors,
khii, qi, rlung, and khyal, and are recommended to persons experiencing
distress (Hinton, Pich, Marques, Nickerson, & Pollack, 2010; Janes,
1995; Kohrt, Hruschka, Kohrt, Panebianco, & Tsagaankhuu, 2004). In
Nepali ethnopsychology, the brain-mind (dimaag) is expected to reg-
ulate the functioning of the heart-mind (man). When the sensations,
memories, or desires become too strong for the brain-mind, or when the
brain-mind becomes weakened by stress, alcohol, or head injury, then
self-regulation is lost and one is distressed and unable to think or be-
have appropriately (Kohrt & Harper, 2008). Self-regulation can build
upon these models in global mental health. For example, local cultural
models were incorporated into self-regulation skills in dialectical be-
havior therapy (Ramaiya et al., 2018; Ramaiya, Fiorillo, Regmi, Robins,
& Kohrt, 2017; Tol et al., 2018). Guided Self Help Plus, a form of Ac-
ceptance and Commitment Therapy developed by the WHO, has been
further adapted and translated for use in global settings (Tol et al.,
2018). This has a strong focus on emotion regulation, and similar in-
itiatives are underway for adolescent mental health promotion.
6.3.5. Supporting treatment beneficiaries to help others
A part of social inclusion is also the idea of reciprocity, as illustrated
by helping others. Helping others contributes to self-regulation. In ad-
dition, helping others alleviates distress (physiologically), and it pro-
motes engagement with one’s social group, and increases the likelihood
of reciprocity in the future. Helping others in itself is a physically and
psychologically healing activity, despite its costs and risks (Fredrickson
et al., 2015; Rilling et al., 2002). Helping others improves development
of self-regulation skills, which then makes one better able to help
oneself and to help others (de Waal & Preston, 2017). The experience of
liberating another or relieving pain reinforces these helping behaviors
(Brown, Nesse, Vinokur, & Smith, 2003). For community health
workers, peers, and other non-specialists, there are qualitative accounts
of feelings of fulfillment, or the “afterglow” of healing, and other po-
sitive responses to the experience of providing psychological services
(Atif et al., 2017; Kohrt & Mendenhall, 2015; Mutamba et al., 2018).
Approaches in which one can go from a beneficiary of support to a
helper is valuable. For example, in Alcoholics Anonymous, one begins
in a dependent position and then takes on more of a supportive and
mentoring role.
The content of psychological treatments could potentially be aug-
mented to include more approaches for building the beneficiary’s psy-
chological helping skills, while building her or his own psychological
strength. There are examples of contexts in which there have been more
engagements with helping others in the design of therapies, such as in
parenting or other family-focused therapies. Interpersonal elements are
potentially the most effective elements across interventions (Singla
et al., 2017). In Uganda, caregivers of children with the rare and
disabling neuropsychiatric condition Nodding Syndrome participated in
12 weeks of group interpersonal therapy. After completing the pro-
gram, the caregivers reported that they taught the skills to others in the
community (Mutamba et al., 2018). They also supported one another in
their interpersonal therapy groups by continuing to meet and starting
their own microfinance program. In humanitarian emergencies, there
has been concern about psychosocial support programs that frame
beneficiaries as passive victims (Cherepanov, 2015; McCormack &
Joseph, 2013). Instead, the preference in most communities has been
that psychosocial support programs should be designed with active
beneficiaries in mind who will apply the care they receive to then help
others. In response to the Iraq and Syria crisis, many humanitarian
psychosocial programs explicitly draw on notions of service and com-
munity engagement to alleviate profound stress in refugee and war-
affected youth.
It is important to consider caveats when considering the emphasis
on psychologically supporting others and how empathic career roles are
highly gendered. Many social and professional roles for women build
upon caregiving expectations, and health promotional activities often
target women specifically as caregivers responsible for the welfare of
the entire household (Daykin & Naidoo, 2003). Gender theory from
social science and humanities can be a useful lens to engage with when
considering the potential of reinforcing this (George, 2008). To date,
one of the challenges in global mental health is that women make up
more than two-thirds of those delivering psychological interventions,
often in unpaid positions (Singla et al., 2017). A recent report by the
WHO further indicated that women comprise approximately 70% of the
healthcare workforce but only occupy 25% of the senior roles (World
Health Organization, 2019). With the aim of extending equitable,
quality care to the most vulnerable populations, there is a delicate
balance between empowering women within their own communities
and exploiting their work due to gendered expectations of care. It is
important that encouraging psychological support not be framed or
implemented in a way that is expecting women to take on greater
burden of care in families or other social domains, and gendered power
dynamics must be considered when advocating for policies to train a
community health worker labor force. If it is necessary for practical
reasons to lean more on women as caregivers, they should at least be
properly compensated.
6.4. How should psychological support be delivered?
6.4.1. Shared cultural symbols and explanatory models
The symbols of professionals that are associated with healing are
active ingredients of the healing process—for example, the white coat
and stethoscope of physicians operate as symbols that influence
healing, just as shamans use symbols (Dow, 1986; Helman, 2007). Both
the healer and sufferer need to come to a collaborative explanatory
model and shared emotional investment in symbols for healing to be
effective. There are also examples where professional symbols and ex-
planatory models can be harmful. Leaders in global mental health have
already pointed out that “depression” explanatory models are poten-
tially harmful for engagement with services (Patel, Chowdhary,
Rahman, & Verdeli, 2011). Explanatory models refer to how a cultural
group defines the symptoms, causes, and help-seeking associated with a
particular illness. Biomedical explanatory models focus on psychiatric
symptoms, pathology rooted in genetics and brain function, and help-
seeking for psychopharmaceuticals and sometimes psychological
treatments. Other cultural explanatory models may focus more on so-
cial stress and tension, have vague or often somatic symptoms, and
focus on help-seeking with religious leaders, traditional healers, or
other trusted individuals. For example, in Zimbabwe, using social suf-
fering language is more effective for psychoeducation and engagement
than biomedical psychiatric jargon because that latter is often mis-
understood or equated with a permanent genetic condition that cannot
be improved (see Textbox 3).
B.A. Kohrt, et al. Clinical Psychology Review 82 (2020) 101920
6.4.2. Group delivery
There is also an argument for group-based delivery where this is
possible and group inclusion is recommended. Groups allow for re-
ciprocal support, as well as exchanging of practical solutions being
shared. Another question regarding format and content is the role of
groups. In part, groups have been used in global mental health because
they are pragmatic. One person can be trained to deliver services to
greater numbers of beneficiaries through groups, which leads to greater
dissemination and reach. However, evolutionary theories raise other
potential added value. For example, group formats offer a built-in op-
portunity for helping other members. With multiple other group
members, there are also more options for positive emotional contagion,
empathy, and compassion. Therefore, group therapy compared to in-
dividual formats may be advantageous for emotion regulation skill
6.4.3. Delivery tailored to child and adolescent development
There is a natural evolutionary call for starting early and fostering
empathy among children in schools and other settings. Children should
be taught both self-regulation skills as well as consoling skills to support
others. For adolescents, working with peers could reduce social distance
and thus facilitate positive emotional contagion and the likelihood of
shared explanatory models. Vygotsky’s (2006) studies of child devel-
opment advanced the concept of scaffolding, in which children learn
best when taught at a level just ahead of where they are, suggesting that
one good way to learn is from other children who are only a few de-
velopmental stages ahead of them. Mixed-age play groups facilitate
such learning in hunter-gatherer and other traditional societies
throughout the world (Konner, 2010, 2016). Interest in peer programs
for mental health and psychosocial support has gained momentum in
recent years, especially for addressing the significant need in adolescent
mental health care. The foci of such programs have been mental health
first aid, mental health literacy, anti-stigma, and education around
accessing proper referral mechanisms for peers in need. These programs
have reported overall positive outcomes (Hart et al., 2018; Parikh et al.,
2018; Pinto-Foltz, Logsdon, & Myers, 2011; Wyman et al., 2010). Thus,
peer and near-peer mentoring and peer counseling—with appropriate
supervision—could be ideal to optimize empathic exchange and reduce
youth psychological distress.
A developmental approach is also important to consider for self-
regulation. As children and adolescents are in the process of developing
self-regulation skills, school-based interventions to promote self-
regulation could be an ideal platform to intervene during this critical
period. Given the importance of self-regulation in psychologically
supporting others, self-regulation could be taught alongside behavioral
health promotion—including helping others. Some schools in high-in-
come countries are already conducting mindfulness programs. These
programs aim to improve cognitive performance, stress responses, re-
silience, and coping with emotional disress. While a recent systematic
review of the efficacy of mindfulness programs in schools suggested
promising results, the authors recommended that the significant gap in
rigorous trials need to be addressed for further evidence in the field
(Hermosilla, Metzler, Savage, Musa, & Ager, 2019). Newer trials have
aimed to address this methodological weakness, and have reported
positive outcomes (Quach, Jastrowski Mano, & Alexander, 2016;
Sibinga, Webb, Ghazarian, & Ellen, 2016). Recent studies expanding
into evaluating resilience among youth in LMIC settings have reported
positive outcomes (Dajani, Hadfield, & van uum, Greff, & Panter-Brick,
2018; Panter-Brick et al., 2018), but there is still a significant gap for
further research.
6.4.4. Strengthening health systems to prevent loss of empathy through
The settings in which healers work may lead to a loss of empathy
and compassion. This is most notable in studies of burnout. In these
situations, healers feel less able to support another person because of
feelings of powerlessness. Structural issues influence lack of medica-
tion, lack of space for therapy, and lack of time. Healers may stigmatize
people with mental illness to protect their own self-image rather than
confront feelings of professional incompetence, e.g., it is the patient’s
fault they are not getting better. In high-income settings, surgeons,
other health workers, and even mental health specialists show declines
in empathy over training and years of practice (Han & Pappas, 2018;
Henderson et al., 2014). This blunting of empathy goes hand in hand
with stigmatization, which is an outcome of burnout (Taylor & Barling,
2004), and, in a negative cycle, working with stigmatized groups may
increase burnout. Burnout contributes to empathy fatigue among
healthcare providers (Dugani et al., 2018; Selamu, Thornicroft, Fekadu,
& Hanlon, 2017). Humanitarian workers also demonstrate empathy
fatigue with 50% endorsing experiencing burnout after deployment
(Lopes Cardozo et al., 2012; Strohmeier, Scholte, & Ager, 2018).
Therefore, the context of providing care influences empathy, compas-
sion, therapeutic alliance, and other elements of the human connection
in social healing.
Textbox 3
The Friendship Bench
Florence Manyande, a 50-year old woman in Zimbabwe, was having financial problems and could not afford to pay school fees for her children.
She had numerous other stressors and also had recently been hit by a car. She described that “Even my relatives were shunning me. They couldn't
take me in because they said, 'We have our own problems.'" Then Manyande was referred by a local health worker to the Friendship Bench program
at a nearby clinic (excerpt from Singh, 2017b).
The Friendship Bench is an example of psychological treatment that echoes many of the principles described in an evolutionary framework
of psychological healing (Chibanda et al., 2016). The Friendship Bench was developed in Zimbabwe as treatment for common mental dis-
orders. The concept is to engage non-specialists as psychological helpers, mimicking the relationship with a consoling relative, such as wise and
supportive grandmother. There is low social distance in life experience between the person in distress and the person consoling them. The
Friendship Bench dedicates almost 40% of the training content to common factors rather than treatment specific factors of cognitive behavioral
therapy or other specialized techniques. (Pedersen et al., 2020) In Friendship Bench, the non-specialists are expected to be “able to understand
what the client feels and why they feel this way.”
Concepts are used that are culturally relevant and not stigmatizing. Use of local ethnopsychology and concepts such as “thinking too
much”—in place of psychiatric terminology—is helpful for engaging and investing in treatment (Chibanda, Weiss, & Verhey, 2016; Kaiser
et al., 2015). Moreover, problem solving therapy concepts are integrated into local cultural psychological concepts such as kuvhura pfungwa
("opening of the mind"), kusimudzira ("uplifting"), and kusimbisa ("strengthening"). The Friendship Bench emphasizes and facilitates social
inclusion by having group components of the treatment and by helping patients engage with their families and productive roles in society.
For Florence Manyande, at least, beyond helping her quell suicidal thoughts, the Friendship Bench has helped her build the sort of community she had
been craving. At a group therapy session, Manyande says, "I made a friend who introduced me to a sister who had accommodation." No longer homeless,
Manyande learned to crochet bags, which she now sells to make money until she can find full-time employment. "My relationship with my relatives has
also improved," she says, "now that I don't go to their houses begging for money or food." Most important, "I realized at the Friendship Bench I have
someone who is willing to listen to my problems," she says. "I was so happy about that." (excerpt from Singh, 2017b)
B.A. Kohrt, et al. Clinical Psychology Review 82 (2020) 101920
In Ethiopia, unique approaches have been used to promote and
maintain empathy among community health volunteers engaged in HIV
care (Maes, 2016). That initiative incorporates dramatizations, com-
munity discussions, and extensive exercises in which the community
health workers are asked to imagine what the beneficiary might think,
feel, and want across physical, psychological, social, and spiritual do-
mains. In addition to burnout, stress, anxiety, and depression have been
recognized in mental health workers worldwide, and it will be chal-
lenging to teach a growing cohort of lay and professional helpers
strategies for resilience (Foster et al., 2019; Jovanovic et al., 2019;
O'Connor, Neff, & Pitman, 2018). Also, in Ethiopia, home-based skill
training for traditional birth attendants and education about life-
threatening maternal complications are helping to reduce maternal
mortality (Sibley & Amare, 2017); psychological rapport is vital to this
program, which can be a model for deployment of local people as
mental health caregivers. As mentioned above, persons delivering in-
terventions can also benefit from psychological techniques. For ex-
ample, Acceptance and Commitment Therapy has been adapted for
guided self-help to assist providers or trainers in learning to deliver
care, avoiding burnout, and even improving their skills at learning
different intervention methods (Hayes et al., 2004; Rudaz, Twohig,
Ong, & Levin, 2017).
6.5. Summary of added value of evolutionary perspective
Taken together, these points suggest that there are gaps in current
practice when considering an evolutionary perspective. First, reducing
in-group vs. out-group differences is vital in the mental health and
health workforce. This should receive greater attention through a more
representative workforce and through reducing the mechanisms of
stigma and discrimination. Next, healing approaches, recognizing the
advantages and disadvantages of group differences, should provide a
range of options, that potentially change over time. Care from out-
group members can feel advantageous when sufferers are concerned
about shame and confidentiality. Therefore, both out-group care
available and in-group services are important. In addition, it may help
to have out-group services (e.g., confidential hotlines, care from out-
group members, and chatbots) that have options for later connecting
with group members to promote social inclusion. This highlights that
social inclusion should be a key target of therapies. This is often ad-
dressed indirectly but could be a more explicit target and outcome.
Along with social inclusion, targets related to helping others would be
helpful. All of these could lead to reduction in depression and anxiety,
rather than foregrounding depression and anxiety symptoms, which
evolutionary medicine has critiqued (Nesse, 2019). For example, evo-
lutionary drivers can be more incorporated into treatments such as
interpersonal psychotherapy that focuses on social relationships. An-
other domain for exploration is to see how psychological care can better
integrate touch. This could be pairing talk therapy with occupational
therapy and massage services, or incorporation of practices from Chi-
nese or Tibetan medicine.
7. Conclusion
In the era of COVID-19, there are many questions arising about
psychological healing. How do we best do this when physical proximity
is not possible? As we have discussed, consoling behavior likely started
with proximity and touch. With the challenges to human physical clo-
seness, informal healing and consoling are now more difficult to access.
Healing is impeded by political processes which have accentuated in-
group and out-group differences. This damages the flow of empathy,
with some politicians, traditional media, and social media playing up
the suffering of others. Therefore, it is more important than ever to
consider how both the cultural distance of in-group and out-group
differences can be bridged, as well as virtually reaching across the
physical distances to find ways to deliver informal consoling and formal
psychological therapies. One important lesson from this pandemic has
been the power driving members of society to heal others. Hundreds of
thousands of healthcare staff and other frontline workers have put
themselves at risk even at the cost of their lives to help members of their
communities who are suffering.
To improve psychological services for the current moment and into
the future, we should consider a research agenda for an evolutionary
theory of psychological healing. First, identify barriers and facilitators
to empathy and compassion development. This could include compar-
isons based on training and supervision methods of the change in em-
pathy over time. Second, describe development of emotion regulation
among cadres trained to provide psychological support and the people
receiving their care. Emotion regulation could be studied using execu-
tive functioning neuropsychological tests, psychophysiology, and other
measures. Third, study the psychological and physiological effects in
cadres trained in psychological healing (e.g., study the psychological
wellbeing, physical health, social genomics, and social capital) among
formal and informal care providers. Fourth, assess differences in de-
livery formats, such as comparing the role of empathy and emotion
regulation in group vs. individual formats for therapies; explore the role
for touch in psychological healing; and identify how empathy, emo-
tional contagion, and compassion are involved in therapies delivered
through digital technology. Ultimately, by reflecting on social, clinical,
and public health practices through an evolutionary perspective, we
can consider the range of approaches to promote healing globally—an
extension of the mutual support in human groups during our evolution.
The authors are supported by the US National Institute of Mental
Health (K01MH104310 and R01MH120649, B.A. Kohrt;
U19MH113211, V. Patel).
Declaration of Competing Interest
The authors have no conflict of interest to declare.
We are grateful to the guest editors, Steven C. Hayes, Stefan G.
Hofmann, and David Sloan Wilson, for the opportunity to contribute to
this special issue and for their thoughtful and constructive feedback to
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