Empathy is essential at all ages, in everyday life and every part of society. Affective empathy refers to the ability to feel other people’s emotional experiences indirectly, thus enabling to comprehend their intentions and anticipate their behaviors [1]. During childhood, experiencing empathic feelings for others is crucial to emotional development [2] and contributes to the development of social morality[3]. During adulthood, the ability to feel empathy allows effective interactions with people in social contexts. There is certain agreement that empathy includes two different components, cognitive and affective (or emotional) [4, 5], which are neurologically dissociable, underpinned by impairments in different areas of the brain [6, 7]. Cognitive empathy is being able to take the other’s perspective [8] or to understand the other’s emotions [9]. Affective or emotional empathy is the ability to respond with an appropriate emotional reaction to the other’s feelings or situation [4, 8]. There are important interindividual differences in emotional reactions arising from contact with other people in the general population [10]; and such variations in empathic abilities were shown to affect, in turn, one’s social life [11].
For instance, being able to feel empathy in a given situation, such as a person’s suffering, can be impaired in traumatic brain injury [12], in schizophrenia [13], in high risk states of developing criminal behavior [14], and nonexistent or inappropriate in psychopathy [15]. Affective empathic reactions have many positive effects on people’s social life and interactions. For example, affective empathy is closely connected to helping behavior and being human in caring (e.g., psychotherapeutic) relationships [16]. Possessing higher affective empathy is also associated with enhanced prosocial behavior [17], stronger intrinsic motivation for altruistic behavior [18], lower likelihood of engaging in traditional bullying [19] or substance using behavior [20], lower levels of aggression [21], and a better quality of sleep [22]. At the same time, the experience of empathy may lead to a confusion between self and other, and contribute, in turn, to psychological distress [23]. For all these reasons, a large range of psychotherapeutic approaches highlight the role of empathy as an important component of treatment [24]. Given that affective empathy was consistently shown to be elementary to social behavior, and because its impairment was linked to a range of psychopathology and behavioral problems, its exploration and measurement in adults’ populations represent a growing need for both clinicians and researchers. The following section expands on the different measurement tools currently available for the assessment of the (general and affective) empathy construct.
Measurement instruments of Empathy
Empathy can be reflected through many psychological constructs, and measured using self-administered tools [25]. A wide range of instruments have been developed and utilized to survey individuals’ ability to empathize with others either in general or in specific contexts, such as empathy among physicians [26], perceived relational empathy among patients in the consultation [27], teachers’ empathy for students [28], empathy for the vicarious experience of pain [29], empathy experienced as anger on behalf of a victimized person, and ethnocultural empathy [30] (for systematic review and meta-analysis, see [31]). General empathy instruments available for use in the general population include the 60-item Empathy Quotient [4], the 28-item Interpersonal Reactivity Index [8], the Questionnaire of Cognitive and Affective Empathy [32], the Questionary Measure of Emotional Empathy [33], the Toronto Empathy Questionnaire [34], the Empathy Assessment Index [35], and the Affective and Cognitive Measure of Empathy [36]. However, most of these measures showed limitations regarding factorial structure and convergent validity [31], which is likely due to controversies and a lack of theoretical consensus on the multidimensional conceptualization of the empathy construct [37]. In addition, some of the existing measures were designed to and used in specific subgroups, such as the Basic Empathy Scale intended for assessing empathy in adolescents with antisocial tendencies [9]. Furthermore, one of the most recurring criticisms of empathy measures is that the construct being assessed is often unclear. For example, it was claimed that the Empathy Quotient measures the ability to function socially rather than empathic tendencies of the individual [38]; the Interpersonal Reactivity Index contains a “Personal Distress” and a “Fantasy” dimensions that are distinct from the concept of empathy [4]; the Questionary Measure of Emotional Empathy appears to measure sympathetic reactions and emotional arousal by the environment in general rather than measuring empathy and other people’s distress in particular [39, 40]. As such, systematic reviews performed so far on measures of empathic ability both in specific populations [41, 42] and in the general population [31] concluded that no instrument could be considered and recommended as the gold standard assessment method for empathy based on desirable validity and reliability indices. To address these gaps, Lindeman et al. [38] developed a brief test of affective empathic ability arousal, the Pictorial Empathy Test (PET), and Konrath et al. [43] developed the Single Item Trait Empathy Scale (SITES). The PET stands out from the existing self-report measures that use text-based items because it proposes a novel approach to conceptualize the empathy construct from an ecological perspective using photographs as emotional stimuli [44], while the SITES stands out because it consists of a single item [31].
The PET
The PET was designed as a visual measure of affective empathy skills. It consists of 7 sequential photographs of people in vulnerable states (i.e. physical and/or emotional distress) and that are susceptible to elicit empathic emotions. Respondents are asked “How emotionally moving do you find the photograph?”, with answers ranging on a 5-point Likert scale from 1 (not at all) to 5 (very much). Total PET scores can be obtained by calculating mean score of the responses, with higher scores reflecting greater affective empathy. The PET can be applied in different ways, as a web-based questionnaire, as a paper-and-pencil test, or as part of an interview [38]. As a photo-based instrument, the PET has the potential advantage over other empathy scales of having stronger ecological validity in assessing affective empathy, given that facial expressions of emotions generate an “emotional resonance mechanism” in their watcher, and are thereby central to empathic responses [45]. The PET can also be appropriate and convenient-to-use when applied in clinical samples who have difficulty to express their answers in questionnaires [38]. In addition, the PET is different from other measures, that are retrospective in nature, because it enables to immediately capture the respondents’ emotional reactions and empathic feelings. The PET was originally developed and validated in the Finnish language in three different samples of adults from the general population, where it demonstrated good internal reliability and seven-month test-retest reliability, adequate convergent validity, as well as a single-latent-factor structure [38]. Other cross-cultural adaptation studies have been carried out and reported equivalent psychometric characteristics to the original measure in different languages, countries and samples, including English [46], Turkish [47] and Spanish [48].
The SITES
In contrast with the PET which assesses an emotional, situationally determined “state”, the SITES assesses empathy as a “trait” that is relatively stable across situations and over time. The SITES was proposed as a shorter and more specific alternative to the Interpersonal Reactivity Index [8], which is composed of 28 items and theoretically designed to assess the same construct of trait empathy through different dimensions (i.e., Fantasy, Perspective-taking, Empathic concern, and Personal distress). Respondents are asked to rate the extent to which the following statement describes them “I am an empathetic person”; the answer is rated from 1 (“Not very true of me”) to 5 (“Very true of me”) [43]. In seven studies and a large sample of adults (N = 5,724), the SITES demonstrated good predictive validity, discriminant validity, convergent validity, and test-retest reliability [43]. Overall, the SITES was shown to be a valid and reliable way to assess empathy when an efficient, rapid, but still accurate, method for data collection is demanded.
Rationale
This study proposes to translate and validate the PET and the SITES into the Arabic language. This choice was made for several reasons. First, validation studies in different linguistic and cultural contexts are crucial, as they allow to generate and/or reinforce psychological theories that take into account the peculiarities of each cultural background [49]. Indeed, the vast majority of empathy measures, including the PET and the SITES, were developed and mostly used in Western societies of individualistic cultural orientation and it remains uncertain whether these scales also apply to individuals who grew up in the Arab collectivist cultural contexts. Additionally, there has been scant research on empathy in the Arab world, and no study has yet examined the psychometric properties of the PET and the SITES in the Arabic-speaking population to the best of our knowledge. Furthermore, the PET takes a few minutes and the SITES takes a few seconds to complete. As such, one potential benefit of these two scales over other empathy measures is that they are brief and could be easily completed by the respondent in a short amount of time and be easily interpreted by the evaluator, thus offering minimal respondent and administrative burden. The PET and SITES are therefore appropriate for use in Arab settings which often operate under severe human resources, time and monetary constraints. To add to the literature, this study aims to examine the psychometric properties of an Arabic translation of the PET and SITES in a sample of Arabic-speaking young adults from the general population of Tunisia. It is anticipated that the PET will show a unidimensional factor structure in both sexes, good internal consistency reliability. It is also anticipated that good validity will be evidenced through adequate associations with relevant constructs (i.e., psychological distress and self-esteem).