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Social Work Education: The
International Journal
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Braving Human Suffering: Death
Education and its Relationship to
Empathy and Mindfulness
a

a

b

Joanne Cacciatore , Kara Thieleman , Michael Killian & Kyoko
Tavasolli

a

a

Joanne Cacciatore, Kara Thieleman & Kyoko Tavasolli, Arizona
State University, USA
b

Michael Killian, University of Texas at Arlington, USA
Published online: 06 Aug 2014.

To cite this article: Joanne Cacciatore, Kara Thieleman, Michael Killian & Kyoko Tavasolli (2014):
Braving Human Suffering: Death Education and its Relationship to Empathy and Mindfulness, Social
Work Education: The International Journal, DOI: 10.1080/02615479.2014.940890
To link to this article: http://dx.doi.org/10.1080/02615479.2014.940890

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Social Work Education, 2014
http://dx.doi.org/10.1080/02615479.2014.940890

Braving Human Suffering: Death
Education and its Relationship to
Empathy and Mindfulness

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Joanne Cacciatore, Kara Thieleman, Michael Killian &
Kyoko Tavasolli

Social workers are likely to encounter clients dealing with traumatic grief and death in
their practice. Though death education has gained in popularity and acceptance, few
social work students receive coursework in this area and many are unprepared to deal with
their clients’ and their own emotions regarding death and grief. Though death-related
content may evoke provider avoidance, mindfulness and empathy may help regulate
provider emotions and responses. This United States-based study evaluates the
effectiveness of experiential death education on mindfulness and empathy. Measures in
three separate cohorts were given at the beginning and end of the course. Results show
statistically significant increases on the Five Facet Mindfulness Questionnaire and the
Questionnaire of Cognitive and Affective Empathy, indicating that such a course may be
effective in increasing both mindfulness and empathy in social work students and those in
related fields.
Keywords: Pedagogies; Competency; Curriculum Development; Practice Learning;
Professional Conduct; Reflection; Health Care; Mental Health

To live fully is to live with an awareness of the rumble of terror that underlies
everything. (Becker, 1973)

Since Ernest Becker, Elisabeth Kubler-Ross, and others brought greater attention to
death studies in the latter part of the twentieth century, death education has
experienced growing acceptance worldwide. It may be an important component for
those in many fields, including physicians and nurses; spiritual leaders; first
Joanne Cacciatore, Kara Thieleman & Kyoko Tavasolli, Arizona State University, USA; Michael Killian, University of
Texas at Arlington, USA
*Correspondence to: Joanne Cacciatore, School of Social Work, Arizona State University, Phoenix, USA. Email:
joanne.cacciatore@asu.edu

q 2014 Taylor & Francis

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2

J. Cacciatore et al.

responders such as firefighters, paramedics, and investigators; funeral directors; social
workers; and mental health providers (Wass, 2004). However, the depth and breadth
of education varies greatly between and within fields, and many professionals who will
encounter death and grief report feeling unprepared (Bagatell, Meyer, Herron, Berger,
& Villar, 2002; Hunt & Rosenthal, 2000; Kirchberg, Neimeyer, & James, 1998; Sanders,
2004; Smith & Hough, 2011; Sullivan, Lakoma, & Block, 2003) or do not have
adequate support for their own work-related grief (Conte, 2011). When such
education is provided, the focus is often on death in late life, with little attention given
to traumatic deaths, such as those of infants and children (Bagatell et al., 2002).
The lack of adequate education is concerning. Social workers are especially likely to
encounter traumatic death and grief in hospital settings (emergency rooms, intensive
care units, obstetrics units, pediatric/neonatal intensive care units), substance abuse
agencies, schools, child welfare settings, and disaster and crisis services (Kramer,
Hovland-Scafe, & Pacourek, 2003). Preliminary data from the Centers for Disease
Control show that in 2011 there were a total of 2,513,171 deaths in the United States,
and accidents were the fifth leading cause of death (Hoyert & Xu, 2012). Of the total
deaths, 39,213 (or 1.6%) were among children and young adults aged between one and
24 years old, with accidents as the leading cause of death (38%), followed by homicide
(13%), and suicide (13%) in this age group (Minino, 2013).
In both undergraduate and graduate social work education, in-depth content on
death has traditionally been offered primarily in elective courses (Walsh-Burke & Csikai,
2005). Content in core courses is lacking. In a content analysis of 50 commonly used
social work textbooks (Kramer et al., 2003), researchers found that only 3.4% of material
was devoted to topics essential for practice in end-of-life care settings. In a study of
undergraduate social work students at seven schools in the United States, Sanders (2004)
found that students rated themselves as less than adequately prepared to deal with a
variety of end-of-life issues in practice. Fortunately, leading social work organizations
have recognized these gaps and have focused on improving end-of-life education in
social work courses and practice settings. For instance, in 2004, the National Association
of Social Workers in the United States issued their Standards for Palliative & End of Life
Care, designed to enhance ‘awareness of the skills, knowledge, values, methods, and
sensitivities needed to work effectively with clients, families, health care providers, and
the community when working in end of life situations’ (p. 8).
The need for such education is apparent when considering a variety of studies
showing that some students and clinicians report high levels of distress when faced
with death. In one study, fear of death in counseling students was strongly associated
with distress when encountering death and grief (Kirchberg et al., 1998). Those who
lack adequate preparation or have minimal exposure to death appear to have the most
difficulties helping clients with these issues, and may respond less empathically. Those
with personal experiences and death education may be less fearful (Haas-Thompson,
Alston, & Holbert, 2008; Kirchberg et al., 1998; Terry, Bivens, & Neimeyer, 1995) and
thus less avoidant of their clients’ pain and suffering.
One barrier to providing effective, compassionate care to grieving clients may be
clinicians’ own mortality anxiety and avoidance. Building on Becker’s (1973) work

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Social Work Education 3

and more contemporary research (Solomon, Greenberg, & Pyszczynski, 1991), terror
management theory suggests that awareness of death is at the root of anxiety. In the
past, many studies sought to determine whether death education, which confronts
individuals with reminders of their own mortality, has any measurable effect on
avoidant or anxious behaviors (e.g., Durlak, 1978– 1979; Knight & Elfenbein, 1993;
Rainey & Epting, 1977; Vargo & Batsel, 1984).
Bagatell et al. (2002) evaluated the impact of a six-week seminar in a small sample of
pediatric residents on their comfort when dealing with palliative care for dying children.
Pretest scores suggested substantial discomfort in a variety of areas and residents
reported little formal training on handling such situations. At posttest there were
statistically significant increases in physicians’ ability to discuss end-of-life care with
families, symptom management, issues around time of death, and personal responses to
caring for dying children. Seeking to measure factors relevant to clinical social work in
areas related to grief, Kramer (1998) assessed the perceptions of masters-level social
work students in the United States regarding their ability to handle their own losses, to
work successfully with grieving and dying clients, their skills and knowledge related to
grief, and their personal death acceptance. At baseline, both the intervention and
comparison groups felt unprepared to work with grief, despite the inevitability of
encountering grieving clients. After completing an elective death education course there
was a statistically significant increase in all four areas in the intervention group
compared to the subjects’ baseline scores and the scores of a comparison group.
Death education may be provided in different formats across disciplines. However,
experiential death education, providing an opportunity to address personal feelings
around death, seems to be a critical component of death education. Experiential death
education aims to explore students’ personal stories and experiences of loss, to provide
reflective activities and open discussions, and to utilize other teaching methods to
facilitate an engaging learning environment. This approach may produce better
outcomes than didactic death education (Durlak, 1978– 1979; Vargo & Batsel, 1984),
allowing participants to work through their own grief and death concerns and
enabling them to be more empathic when working with grieving individuals.
Death education may also shift the ways in which students experience their lives.
Wong (2009) found that a death education course with experiential components in
Hong Kong was associated with more positive attitudes toward life and death and that
a positive attitude was associated with less death avoidance. This finding is interesting
in light of terror management theory, which presupposes that when individuals
become aware of powerful, unconscious mortality repression mechanisms, the terror
of death abates, leading to a greater willingness to approach painful emotions (Becker,
1973; Grof & Halifax, 1978).
Terror Management Theory
Many studies have investigated how individuals manage confrontations with their own
mortality, often under the framework of terror management theory. This theory holds
that humans defend themselves against the awareness of their own mortality by

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J. Cacciatore et al.

creating an anxiety buffer of self-esteem and adherence to a shared cultural worldview
(Schimel, Wohl, & Williams, 2006). This worldview offers a path to immortality, either
literally, through a shared belief in an afterlife, or symbolically, through one’s children,
accomplishments, or contributions to society. When faced with reminders of their
own mortality (termed mortality salience), individuals attempt to increase self-esteem
by adhering to culturally valued norms and standards and a shared worldview while
reacting negatively to those who do not share their worldview (Schimel et al., 2006).
This has been interpreted as being protective against death anxiety, as individuals with
high levels of self-esteem demonstrate less defensive reactions to death-related content
(Greenberg et al., 1993; Harmon-Jones et al., 1997). However, this defensiveness may
also diminish a person’s ability to respond empathically to others.
Not all individuals react in the same manner to confrontations with mortality,
perhaps due to a variety of factors. Two factors that have been studied are mindfulness
and empathy. In a series of studies, individuals with high levels of mindfulness did not
exhibit the expected worldview defense response (Niemiec et al., 2010). Another study
found that individuals with higher levels of empathy reacted in a prosocial manner to
others, regardless of whether they shared their worldview, while individuals with lower
levels of empathy reacted prosocially only toward those who shared their worldview
(Schimel et al., 2006). Individuals with high levels of mindfulness and empathy may
react to a confrontation with their own mortality with less defensiveness and with a
greater willingness to approach and connect with others, rather than reacting
negatively toward those perceived to be different, facilitating effective helping
behaviors. A brief overview of both mindfulness and empathy is provided below.
Mindfulness and the Clinician
Mindfulness involves the focusing of attention on one’s immediate experience in an
open, accepting, and non-judgmental manner. This immediate experience includes
thoughts, emotions, and bodily sensations (Baer, Smith, Hopkins, Krietemeyer, &
Toney, 2006). This process entails turning toward, rather than away from, painful or
difficult experiences and promotes intentional responses instead of habitual reactions
(Baer et al., 2006).
Mindfulness is associated with a variety of positive outcomes for health and mental
health care providers, including empathy (Krasner et al., 2009; Shapiro, Schwartz,
& Bonner, 1998). In a study of mindfulness-based stress reduction (MBSR) conducted
with medical and premedical students, participants experienced decreased anxiety and
psychological distress (Shapiro et al., 1998). A later MBSR study replicated the finding
of less psychological distress in medical students (Rosenzweig, Reibel, Greeson,
Brainard, & Hojat, 2003). Physicians completing a mindfulness program showed
significant improvements in well-being, empathy, mood disturbance, burnout, and
emotional stability (Krasner et al., 2009). A similar study found that nurses reported
reductions in feelings of burnout (Cohen-Katz, Wiley, Capuano, Baker, & Shapiro,
2005) and an increase in relaxation and life satisfaction (Mackenzie, Poulin,
& Seidman-Carlson, 2006). An MBSR-based continuing education course was

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Social Work Education 5

associated with decreased burnout and improved mental well-being among
physicians, nurses, social workers, and psychologists (Goodman & Schorling, 2012).
MBSR conducted with masters-level therapists in training was associated with
decreases in anxiety, rumination, stress, and negative affect and increases in selfcompassion and positive affect (Shapiro, Brown, & Biegel, 2007). Mindfulness training
also improved self-compassion and quality of life for physicians, psychologists, nurses,
and social workers (Shapiro, Astin, Bishop, & Cordova, 2005).
Mindfulness practices on the part of providers may also benefit clients regardless of
the specific type of intervention being used. In a double-blind randomized controlled
trial, hospitalized patients of student therapists who participated in daily Zen
meditation practice showed better outcomes than patients of therapists who did not
meditate on a variety of measures, including greater symptom reduction and higher
evaluations of therapy (Grepmair et al., 2007). Mindfulness-based cognitive therapy,
modified to target stress, also yielded positive results among clinical psychology
trainees in the United Kingdom (Rimes & Wingrove, 2011). Mindfulness may also
diminish the risk of vicarious trauma, compassion fatigue, burnout, and emotion
contagion in helping professionals (Christopher & Maris, 2010; Thieleman &
Cacciatore, 2014; Ying, 2009). This may better enable the provider to be fully present
with the client’s suffering without being overwhelmed by it. Overall, mindfulness may
be one way to improve affect regulation, an important skill for those working with
distressed individuals.

Empathy and the Clinician
High levels of empathy may be important for individuals to be effective helpers
(Gerdes, Segal, Jackson, & Mullins, 2011). The use of empathic statements by
physicians discussing end-of-life decisions with families of patients in the intensive
care unit was correlated with greater family satisfaction with communication (Selph,
Shiang, Engelberg, Curtis, & White, 2008). Empathy may also improve social
cooperation in the face of adverse circumstances (Rumble, Van Lange, & Parks, 2010).
However, empathy seems to decline during the early academic years of some
professions such as medicine (Neumann et al., 2011).
Empathy may also benefit providers personally. In a study of medical students in the
United States, higher levels of empathy were positively correlated with well-being and
negatively correlated with provider burnout (Thomas et al., 2007). Fortunately, it may
be possible to increase empathy. For instance, medical students showed an increase in
empathy after an eight-session course about literature portraying doctors and patients
(Shapiro, Morrison, & Boker, 2004), and some studies aimed at increasing
mindfulness also report increases in overall empathy (Birnie, Speca, & Carlson,
2010; Krasner et al., 2009; Shapiro et al., 1998), pointing to a relationship between
these two traits. However, when instruments use subscales, not all subscales of
empathy are found to increase (e.g., Birnie et al., 2010; Krasner et al., 2009) and some
facets, specifically emotion contagion, in which an individual experiences the

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J. Cacciatore et al.

emotions of another, may place providers at risk of emotional exhaustion and burnout
(Miller, Stiff, & Ellis, 1988; Omdahl & O’Donnell, 1999).
Part of the difficulty in measuring empathy is that there is no universally accepted
definition of this concept and it has been measured in a variety of ways. However, the
general consensus suggests that empathy involves both cognitive and affective
components. Cognitive empathy involves a mental representation of another’s internal
state, while affective empathy involves the ability to recognize and vicariously experience
another’s emotions based on body language, facial expressions, and speech, and to identify
one’s own emotional state in response to another person. Both cognitive and affective
components are thought to be necessary processes in order for one person to respond to
another with full empathy (Reniers, Corcoran, Drake, Shryane, & Völlm, 2011).
Cognitive empathy may also serve a different purpose with regard to emotional
regulation; it can help an individual relate to others’ pain without being overwhelmed
or paralyzed by it, as could happen if relying solely on affective empathy, specifically
the emotion contagion component. High levels of cognitive empathy allow for
prosocial action and effective helping (Smith, 2006) without taking on another
person’s powerful emotional state. Indeed, affective empathy has been found to have
little to no effect on actual helping behavior (Marjanovic, Struthers, & Greenglass,
2012). Shkryl, Blatter, and Launikonis (2013) studied 7,584 physicians in Argentina
and found compassion satisfaction, which is protective against provider burnout and
secondary traumatic stress, to be more closely associated with cognitive rather than
affective empathy. At the same time, personal distress, an aspect of affective empathy,
was associated with burnout and secondary traumatic stress. Though both are
components of empathy, high levels of cognitive empathy may be protective for
providers working in highly distressing jobs where trauma and death are
commonplace, while high levels of some components of affective empathy could
potentially place the provider at risk for psychological distress.
The Present Study
Prior research suggests that experiential death education combined with mindfulness
and empathy may help prepare clinicians to provide effective care to individuals with
death-related concerns. Such a combination may decrease clinicians’ discomfort and
defensive reactions when faced with death-related situations, allowing clinicians to
approach clients in an open, non-defensive, and caring manner. The death education
course under evaluation uses a mindfulness-based framework and focuses primarily on
the deaths of infants, children, and adolescents, as well as death by homicide and suicide.
Methods
Research Design and Hypotheses
The purpose of this study is to explore the effect of a graduate traumatic death
education course on empathy and mindfulness in students from the beginning of the

Social Work Education 7

three-week course to the end. This study utilizes a pre-experimental single group
pretest –posttest design (Shadish, Cook, & Campbell, 2002). It was hypothesized that
there would be significant increases in overall empathy and mindfulness following the
completion of the death education course and that the increases in mindfulness and
empathy would be positively correlated.

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Participants
A total of 210 graduate students (includes 20 auditing students) were enrolled in the
traumatic death course offered through the School of Social Work at a large, urban
state university during three consecutive years in the United States. Of these students,
demographic data were available for 195, though because these data came from the
University administration it could not be linked to the students’ data. Of the students,
70.3% were in their second-year in the Masters in Social Work program, 22.4% were
from the Masters in Counseling program, and the remaining 7.3% were enrolled in
other programs such as the PhD in Clinical Psychology and Communication Studies.
Students were predominantly female (88.5%) with a mean age of 30.58 years
(SD ¼ 9.22). No other student data were collected. This course is an intensive five-day
graduate course encompassing 40 hours over a span of three weeks. Students who
chose to participate completed the questionnaire at the beginning of the course and
again at the end of the last day.
Procedures
At the beginning of the course students received a cover letter inviting their
participation in the study. The letter explained that participation was voluntary, that
the research was not part of the course though it was completed in class, and that
choosing not to participate or withdrawing would not affect their course grade. This
letter was used in lieu of a signed consent form. Students were also verbally assured
that non-participation would not affect their classroom status in any way. Participants
completed the questionnaires, which took about 15 minutes, at the beginning (pretest)
and upon completion (posttest) of the course in the classroom. Students chose a fourdigit personal identification number to use on both the pretest and posttest. Because
of its anonymity, this study was approved as exempt from IRB review by Arizona State
University’s Office of Research Integrity and Assurance prior to data collection. Of the
210 students in the course, 189 (90%) consented to take the questionnaire and
provided data for at least one of the two time points. Of those students, 173 (82.4%)
completed both pretest and posttest questionnaires.
Experiential Pedagogy
Experiential pedagogy is defined by Itin (1999) as a ‘holistic philosophy, where
carefully chosen experiences supported by reflection, critical analysis, and synthesis,
are structured to require the learner to take initiative, make decisions, and be

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J. Cacciatore et al.

accountable for the results’ and in which ‘learners are engaged intellectually,
emotionally, socially, politically, spiritually and physically in an uncertain
environment where the learner may experience success, failure, adventure, and risktaking’ (p. 93).
This death education course utilized many aspects of experiential learning, used
successfully to teach social work practice, theory, and values, particularly with complex
and unsolvable problems of human suffering (Flynn, 1997). The instructor allowed
and encouraged the sharing of personal stories of loss throughout the course when
appropriate, and engaged students in mindfulness exercises, reflective journaling, inclass discussions, lectures, documentary films, a bereavement panel discussion, music,
poetry, and literary quotes. Four primary components thought to foster a safe
environment for experientially-based education were included: empathic acknowledgment of thoughts and emotions; focused attention; noticing and accepting
experiences; and heightened sensory awareness (Napoli & Bonifas, 2011).
Throughout the activities, students moved ‘beyond mere “learning by doing”’
(Roberts, 2002, p. 281), into active engagement in feeling, acting, and learning (Flynn,
1997). This was accomplished through subtle mindfulness practices both in and out of
the classroom. Students kept self-reflection journals and engaged in activities
encouraging full bodily, social, and psychological awareness. Some of the exercises
were related to class material and some seemed unrelated (for example, an optional
exercise invited students to use their non-dominant hand in tasks for a day and notice
their responses). The course also encouraged internal awareness, processing, and
integration of personal losses when relevant. The culminating project was a creative
arts assignment wherein students were asked to use art, poetry, digital media,
sculpting, or another expressive form to capture their feelings and experiences of grief.
These strategies, while not explicitly mindfulness-based, foster self-awareness, a
necessary component for mindfulness.
Mindfulness is thought to represent one strategy of experiential learning for
increasing empathy among social work students, creating neural pathways related to
the cognitive processing of empathy (Gerdes et al., 2011). Combined with many of the
experiential aspects of the course, mindfulness may help cultivate empathy. For
instance, a documentary on the practice of home funerals exposed students to a
concept that was foreign to most of them and offered a chance to notice their own
biases and respond empathically to an uncomfortable, unfamiliar situation.
Experiential components of the course, such as reflections and creative arts projects,
can promote mental flexibility, perspective-taking, emotional regulation, and
awareness of self and others (Gerdes et al., 2011).
The instructor in this course has extensive research and practice experience in
traumatic death/grief. She is also a Zen practitioner with a long-standing meditation
practice. She utilizes an egalitarian and person-centered teaching style, with the
primary goal of creating a safe space wherein students can honestly explore the feelings
and emotions that may arise in the course. In prior research on death education,
Kramer (1998) noted that instructors, given the sensitive and intimate nature of the
subject matter, ‘must possess the interpersonal skills to respond authentically and

Social Work Education 9

respectfully to students so that they may feel supported in exploring the difficult and
painful issues’ (p. 225) which often arise during these types of courses.
Measures

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This study utilized two questionnaires, which are described below.
Five facet mindfulness questionnaire
The Five Facet Mindfulness Questionnaire (FFMQ) is a 39-item self-report instrument
derived from other mindfulness instruments to measure five facets of mindfulness:
observing (noticing experiences such as emotions, sensations, thoughts, sounds);
describing (using words to label internal experiences); acting with awareness (acting
intentionally instead of automatically); non-judging of inner experience; and nonreactivity of inner experience (Baer et al., 2006). All items are rated on a five-point
Likert scale (1 ¼ never or very rarely true, 5 ¼ very often or always true) and some
items are reverse scored. Items include: ‘When I’m walking, I deliberately notice the
sensations of my body moving’ (observing); ‘I can easily put my beliefs, opinions, and
expectations into words’ (describing); ‘I am easily distracted’ (acting with awareness,
reverse scored); ‘I think some of my emotions are bad or inappropriate and I shouldn’t
feel them’ (non-judging, reverse scored); and ‘In difficult situations, I can pause
without immediately reacting’ (non-reactivity). Items for each subscale are summed
separately, with higher scores reflecting higher levels of that element. The possible
range of scores for each subscale is 8 –40, with the exception of non-reactivity, for
which the range is 7 –35 (Baer et al., 2008). Baer et al. (2008) found that the five-factor
structure demonstrated sufficient factor validity through confirmatory factor analysis.
Furthermore, groups with prior mindfulness training or experience were found to
report significantly higher scores on the measure (known-groups validity) while
higher scores were associated with measures of psychological well-being (construct
validity). The FFMQ demonstrates adequate to good internal consistency (Cronbach’s
a ranging from 0.75 to 0.91) with student samples (Baer et al., 2006).
Questionnaire of cognitive and affective empathy
The Questionnaire of Cognitive and Affective Empathy (QCAE) is a 31-item self-report
instrument that breaks empathy into cognitive and affective aspects (Reniers et al.,
2011). In addition, the QCAE has five subcomponents. Perspective taking (the ability to
see things from another’s point of view) and online simulation (the ability to imagine
what another person is feeling) fall under cognitive empathy (CE). Emotion contagion
(mirroring another’s feelings), proximal responsivity (affective response to another
person’s mood in a social context), and peripheral responsivity (affective response to
another person at a distance, such as in a film) fall under affective empathy (AE).
Each item is rated on a four-point Likert scale (1 ¼ strongly disagree, 4 ¼ strongly
agree) and some items are reverse scored. Items include: ‘I can easily work out what
another person might want to talk about’ (perspective taking: CE); ‘I try to look at

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J. Cacciatore et al.

everybody’s side of a disagreement before I make a decision’ (online simulation: CE);
‘I am happy when I am with a cheerful group and sad when the others are glum’
(emotion contagion: AE); ‘I often get emotionally involved with my friends’ problems’
(proximal responsivity: AE); and ‘I usually stay emotionally detached when watching a
film’ (peripheral responsivity: AE, reverse scored). The perspective taking and emotion
contagion subscales have a possible score range of 9 –36 and the three other subscales
have a possible range of 4 – 16. The perspective taking and online simulation subscales
are summed to comprise the cognitive empathy scale, with possible scores ranging
from 18 to 72. The emotion contagion, proximal responsivity, and peripheral
responsivity subscales are summed to comprise the affective empathy scale, with
possible scores ranging from 12 to 48. Higher scores suggest higher levels of empathy
on each scale. The authors report that the QCAE is strongly correlated with a similar
measure of cognitive and affective empathy and negatively correlated with measures of
‘empathetic anger, impulsivity, aggression, and psychopathy’ (Reniers et al., 2011,
p. 92), demonstrating convergent and construct validity of the QCAE. The two-factor
structure was additionally supported through principal component and confirmatory
factor analyses. The measure has demonstrated adequate to good internal consistency
(Cronbach’s a ranging from 0.65 to 0.85) with samples of university students and
employees.
Statistical Analysis
Paired-sample t-tests were conducted for testing the hypothesis that mindfulness and
empathy would increase using a significance level of 0.05 (two-tailed). Incomplete
pairs of questionnaires, such as when students completed only one of the tests, as well
as those with missing data points, more than one answer for an item, or an invalid
answer, were excluded from the analyses. This left 166 –173 pairs of the FFMQ and
160– 169 pairs of the QCAE that were included in the analyses (out of a possible total
of 189), depending on the missing items per subscale or total scale. The relationship
between increases in mindfulness and empathy was tested through Pearson’s r
correlation coefficients.
Results
Descriptive Analysis
Descriptive statistics and reliability analyses for the FFMQ and QCAE and their
subscales are shown in Table 1. Both the FFMQ and the QCAE showed very good
reliability at pretest and posttest (a range 0.84– 0.92). Each of the five subscales for the
FFQM also had acceptable to good reliability (a range 0.79 – 0.93). Both the
overarching scales of cognitive empathy and affective empathy had acceptable to good
reliability (a range 0.74 – 0.89). Three of the subscales had acceptable to good
reliability (a range 0.76 –0.87); however, two of the subscales, proximal responsivity
and peripheral responsivity, had only poor to moderate reliability (a range 0.52–

* t-test significant at p , 0.05.
** t-test significant at p,0.01.
*** t-test significant at p, 0.001.

131.33
26.10
28.97
26.71
27.92
21.58
96.19
61.78
32.73
29.08
34.29
10.81
11.71
11.77

Mean
15.56
4.62
5.34
4.72
5.76
3.76
10.06
7.39
4.44
3.99
5.47
2.63
2.16
2.08

SD

Pretest

0.91
0.79
0.90
0.89
0.91
0.81
0.86
0.89
0.87
0.82
0.80
0.79
0.64
0.55

Cronbach’s a
FFMQ
Observing
Describing
Acting with Awareness
Non-judging
Non-reacting
QCAE
Cognitive Empathy
Perspective Taking
Online Simulation
Affective Empathy
Emotion Contagion
Proximal Responsivity
Peripheral Responsivity

139.93
29.28
30.12
27.62
29.78
22.99
99.53
64.04
33.48
30.59
35.45
10.87
12.26
12.31

Mean
16.02
4.51
5.39
4.90
5.85
3.68
8.98
6.48
4.10
3.69
4.79
2.46
1.92
2.07

SD

FFMQ and QCAE Pretest and Posttest Descriptive Statistics and Reliability with Subscales

FFMQ
Observing
Describing
Acting with Awareness
Non-judging
Non-reacting
QCAE
Cognitive Empathy
Perspective Taking
Online Simulation
Affective Empathy
Emotion Contagion
Proximal Responsivity
Peripheral Responsivity

Table 1

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0.92
0.80
0.91
0.89
0.93
0.82
0.84
0.86
0.86
0.79
0.74
0.76
0.53
0.52

Cronbach’s a

Posttest

9.64***
11.89***
3.85***
3.30**
5.80***
6.40***
5.93***
5.95***
3.02**
6.79***
3.74***
0.39
3.99***
3.48**

Paired t-test values

Social Work Education 11

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J. Cacciatore et al.

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0.64). Both of these subscales are comprised of only four items. Due to the low
reliability, caution should be used in analyzing results from these subscales.

Changes in mindfulness and empathy
Paired samples t-tests were used to assess the hypothesis that there would be
statistically significant increases on mindfulness and empathy as well as all subscales
on both measures from pretest to posttest. Results showed a significant increase in
both mindfulness and empathy full-scale scores. When the FFMQ was divided into the
five subscales, there was a statistically significant increase in observing, describing,
acting with awareness, non-judging and non-reactivity. On the QCAE, there was a
statistically significant increase in both cognitive and affective empathy. Within the
cognitive empathy substrate, both perspective taking and online simulation showed
statistically significant improvement. Within the affective empathy substrate, there was
a statistically significant increase in proximal responsivity and peripheral responsivity.
There was no statistically significant change in emotion contagion.

Association between mindfulness and empathy
It was predicted that mindfulness and empathy would be positively correlated at both
pretest and posttest. This was tested with correlation analyses using the full-scale
scores for both measures as well as the cognitive and affective empathy subscales of the
QCAE (Table 2). FFMQ scores from the pretest and posttest were significantly
correlated (r ¼ 0.735, p , 0.001) as were the QCAE scores (r ¼ 0.726, p , 0.001). The
pretest scores of the QCAE and FFMQ were not significantly correlated (r ¼ 0.109,
p ¼ 0.153). However, these scores were significantly correlated at posttest (r ¼ 0.268,
p ¼ 0.001), albeit weakly so.
Prior research indicates a strong association between mindfulness and empathy, and
this association was tested through multiple regression modeling using the FFMQ and
QCAE scores. First, changes in mindfulness were calculated from the pretest and
posttest scores. On average, students reported an increase of 8.61 (SD ¼ 11.51) on the
Table 2

FFMQ and QCAE Pretest and Posttest Inter-correlations
1.

1.
2.
3.
4.
5.
6.
7.
8.

2.

FFMQ Pre Total
–
FFMQ Post Total
0.735***
–
QCAE Pre Total
0.109
0.144
QCAE Pre Cognitive
0.314*** 0.345***
QCAE Pre Affective 20.235** 2 0.196*
QCAE Post Total
0.104
0.268**
QCAE Post Cognitive 0.270*** 0.420***
QCAE Post Affective 20.175* 2 0.064

3.

–
0.846***
0.682***
0.726***
0.599***
0.551***

* Correlation coefficient r significant at p , 0.05.
** Correlation coefficient r significant at p , 0.01.
*** Correlation coefficient r significant at p , 0.001.

4.

5.

6.

7.

8.

–
0.187*
–
0.666*** 0.429***
–
0.762*** 0.062
0.853***
–
0.212** 0.709*** 0.717*** 0.248** –

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Social Work Education 13

FFMQ, representing over a 0.553 standard deviation change in their scores from
pretest. In three multiple regression models, these FFMQ change scores were used to
predict the QCAE total posttest scores and the cognitive and affective empathy
subscale scores. Students’ pretest scores were entered into the model as a statistical
control for their baseline empathy scores prior to the experiential death course.
In the first model, FFMQ change scores significantly predicted QCAE posttest
scores [F(2, 153) ¼ 93.91, p ,0.001] after statistically controlling for the QCAE
pretest scores (Table 3). Change scores in mindfulness significantly predicted QCAE
total empathy posttest scores (b ¼ 0.122, t ¼ 2.87, p ¼ 0.005) after controlling for
their pretest scores, which were also significant in the model (b ¼ 0.636, t ¼ 13.06,
p ,0.001). Together, the QCAE total pretest scores and the change scores in FFMQ
explained 54.5% (adjusted r 2) of the posttest QCAE total scores.
Similarly, the FFMQ change scores significantly predicted the QCAE cognitive
empathy posttest scores [F(2, 156) ¼ 122.75, p ,0.001] after controlling for the
pretest QCAE cognitive empathy scores. The change scores (b ¼ 0.105, t ¼ 3.72,
p ,0.001) explained 60.6% of the variance (adjusted r 2) in the QCAE cognitive
empathy posttest scores after controlling for the QCAE cognitive empathy pretest
scores (b ¼ 0.657, t ¼ 14.83, p , 0.001). After controlling for pretest QCAE affective
empathy scores, changes in FFMQ scores did not significantly predict QCAE affective
empathy posttest scores (b ¼ 0.018, t ¼ .746, p ¼ 0.457).
Discussion
The purpose of the study was to test the effect of experiential death education on selfreported mindfulness and empathy in a sample of graduate students. Emphasizing
mindfulness and empathy within an experiential learning context is thought to be
associated with an increase in mindfulness and empathy surrounding death and grief.
Terror management theory suggests that mortality salience increases defensiveness
against death-related thoughts and decreases overall empathy for those considered to
Table 3

Changes in FFMQ Mindfulness Scores Predicting QCAE Empathy Scores
Outcome

F-score

1.

QCAE total
posttest scores

93.91*** 2, 153

0.545

2.

QCAE cognitive 122.75*** 2, 156
empathy posttest
scores

0.606

77.04*** 2, 155
QCAE affective
empathy posttest
scores

0.492

3.

** Statistic significant at p , 0.01.
*** Statistic significant at p , 0.001.

df

Adjusted r 2 Predictors in each model

Model

FFMQ change scores
QCAE total pretest
total scores
FFMQ change
scores
QCAE cognitive
empathy pretest scores
FFMQ change scores
QCAE affective
empathy pretest
scores

b

t-test

0.122 2.87**
0.636 13.06***
0.105 3.72***
0.657 14.83***
0.018 0.746
0.618 12.26***

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14

J. Cacciatore et al.

be outside an individual’s cultural group (Schimel et al., 2006). However, mindfulness
and empathy may mitigate this defensive reaction and may thus provide a space for
compassionate responses to others even when reminded of one’s own inevitable death
(Niemiec et al., 2010; Schimel et al., 2006).
Students enrolled in this particular death education course demonstrated increased
levels of overall mindfulness and empathy from pretest to posttest. Within the FFMQ,
measuring mindfulness, significant increases were seen in all five of the subscales:
observing, describing, acting with awareness, non-judging, and non-reactivity.
It should be noted that a prior study (Baer et al., 2008) found differences regarding the
observing subscale between individuals who meditated and those who did not, with
increases in observing correlated with psychological well-being in meditators but
slightly correlated with maladaptive traits in non-meditators. The authors speculated
that meditators may notice a wider range of experiences, while non-meditators might
focus selectively on negative experiences, similar to how depressed individuals may
ruminate. Because the current study did not inquire as to whether students meditate, it
cannot be concluded that the increase in this subscale reflects a positive change.
Within the QCAE, measuring empathy, both the cognitive and affective empathy
substrates showed significant increases; however, the emotional contagion subscale of
affective empathy did not significantly increase. Both subscales comprising the cognitive
empathy substrate showed significant increases, while only the proximal responsivity
and peripheral responsivity subscales of the affective empathy substrate increased
significantly. The increase in both cognitive empathy subscales is noteworthy, as
cognitive empathy has been associated with compassion satisfaction and other favorable
outcomes (Shkryl et al., 2013; Smith, 2006). The lack of significant increase in the
emotion contagion subscale of the affective empathy substrate is intriguing. High levels
of emotion contagion may place providers at risk for burnout and emotional
exhaustion. Thus, it may be beneficial to increase other aspects of empathy while keeping
emotion contagion low, since this is the facet of affective empathy most closely linked to
adverse outcomes (Miller et al., 1988; Omdahl & O’Donnell, 1999).
The previously noted positive relationship between mindfulness and empathy was
observed in this study. In the regression analyses, changes in mindfulness predicted
cognitive, but not affective, empathy in the current sample after controlling for their
pretest levels. Shkryl et al. (2013) found that cognitive empathy sustained through
empathic concern, perspective taking, and altruism seemed to increase compassion
satisfaction amongst physicians when controlling for time in the field and gender.
Conversely, they found that affective empathy through high emotional contagion,
personal distress, and alexithymia, when not combined with aspects of mindfulness
such as self-awareness, emotion regulation, and self-compassion, correlated to
burnout and secondary traumatic stress.
Both mindfulness and empathy resonate deeply with the goals of social work as
outlined by its code of ethics (National Association of Social Workers, 1999), including
enhancing well-being, building a trusting relationship, and honoring the selfdetermination of clients. Mindfulness cultivates attention, affect regulation, and
attunement, considered foundational to the therapeutic relationship (Turner, 2009).

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Social Work Education 15

Social work students and those in related areas will be faced with a variety of emotionally
intense situations and are in need of tools to help them engage positively and effectively in
such situations. Mindfulness practice may be one tool for improving both provider wellbeing and client outcomes (Grepmair et al., 2007; Shapiro et al., 2007).
The increase in mindfulness observed in the current study may have helped students
cope more effectively with their own emotions, making them better able to be fully
present with class material. Research suggests that mindfulness in the context of
bereavement may lead to diminished focus on one’s own existential concerns and thus
to more empathic responses toward clients (Niemiec et al., 2010). The significant
increases in cognitive and affective empathy overall may also benefit students when
they encounter clients experiencing traumatic death in practice by allowing for greater
attunement and sensitivity. Simultaneously, the stabilization of emotion contagion
may be protective against vicarious trauma and burnout (Miller et al., 1988; Omdahl
& O’Donnell, 1999). Ideally, this would improve providers’ ability to meet the needs of
grieving and traumatized clients while maintaining their own sense of balance.
Limitations
This study used a pretest– posttest, single group design. Without a control or
comparison group, it cannot be concluded definitively that the experiential death
education course caused the increases in mindfulness and empathy. More rigorous and
longitudinal designs are needed to evaluate the benefits of this form of traumatic death
education. An additional limitation is the lack of student demographic data and other
personal variables, which could potentially account for some of the findings. The study
is limited by the overwhelmingly female sample in a university setting. Demographic
data could not be included in analyses because it was provided by the university
administration and could not be linked to student self-report data. Gathering
additional information in future studies could address this shortcoming.
Prior research suggests that exposure to death-related material decreases empathy in
those with low levels of mindfulness (Schimel et al., 2006). Given that changes in
mindfulness predicted posttest empathy, it is possible that mindfulness combined with
traumatic death education, rather than the course content solely, may have been
responsible for increased empathy. This is congruent with prior findings linking deathrelated material to decreased empathy in those with low levels of mindfulness (Schimel
et al., 2006) and with outcomes demonstrating that an increase in mindfulness also
increases empathy (Shapiro et al., 1998). Further research is needed to address this
issue as well as to determine which parts of the course may have produced the results
noted in this study. Additional research could explore whether mindfulness and
empathy were maintained in students after graduation.
Conclusion
Traumatic death may be a difficult subject for students, researchers, and clinicians.
However, an experiential traumatic death course using a mindfulness-based

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16

J. Cacciatore et al.

framework may help prepare individuals to be effective helpers in such situations by
providing a chance to work through their own death-related concerns and by
increasing empathy and mindfulness. These traits may be especially important when
faced with traumatic deaths, such as the death of a child (Cacciatore & Flint, 2012).
Among providers in emotionally stressful positions, those who practice mindfulness
may experience fewer symptoms of burnout and secondary traumatic stress and score
higher on empathy measures (Krasner et al., 2009; Shapiro et al., 1998; Thieleman &
Cacciatore, 2014).
Teaching mindfulness in the context of traumatic death may allow clinicians to
respond with a more empathic presence to clients in these situations. Mindful
clinicians will likely be more attuned to bereaved clients and be more effective in the
provision of psychosocial caregiving that has a positive impact (Cacciatore & Flint,
2012). An experiential death education model that emphasizes mindfulness may
ultimately improve clinicians’ ability to remain present with clients experiencing grief
instead of reacting defensively or attempting to distance themselves from such clients.
Though the results from this study are promising, additional research is needed to
further evaluate this model and its potential to improve clinician well-being and client
outcomes.
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