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Journal of Counseling Psychology

2014, Vol. 61, No. 4, 541548

2014 American Psychological Association


0022-0167/14/$12.00 http://dx.doi.org/10.1037/cou0000021

Neurosciences, Empathy, and Healthy Interpersonal Relationships: Recent


Findings and Implications for Counseling Psychology
Joana Fernandes Coutinho
and Patrcia Oliveira Silva

Jean Decety
University of Chicago

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This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.

University of Minho

In this article, we define the construct of empathy and its relevance for counseling psychology. The
importance of deficits in empathic processes for most of the psychological disorders is presented within
the context of the social brain hypothesis (Frith, 2007). We provide a review of empirical research about
the neural correlates of empathy in terms of both the central and peripheral nervous system. We present
recent evidence on the cortical and subcortical regions involved in different dimensions of empathy
emotional contagion, cognitive and emotional empathy, and self-regulation. Regarding the autonomic
correlates of empathy, we present evidence about the correlates of sympathetic arousal associated with
empathic processes and review data supporting the idea of the physiological linkage or synchrony as
indicator of empathy in interpersonal relationships. The implications of these findings for counseling
psychology, particularly for the psychotherapist client relationship and for context of intimate relationships or couples therapy, are discussed.
Keywords: empathy, neuroscience, interpersonal relationships, counseling psychology

In this article, we present and discuss recent findings on the


neurobiological correlates of empathy and its implications for the
research programs in counseling psychology and clinical practice.
We start by framing the importance of empathy within the context
of the social brain hypothesis, pointing out its central role in
the psychotherapeutic process. In the next section, we present the
major results of studies that looked at the biomarkers of one of the
most important psychological functions of the social brain: empathy. We start by reporting the correlates of empathy related to the
central nervous system, with special attention to recent findings
related with the brain activity at rest. We then present some
important findings about the peripheral biomarkers of empathy. In
the last section of this article, we discuss the potential implications
of the studies reported both for counseling practice and for a new
research agenda in the field. We emphasize the implications of
empirical evidence pointing to the presence of a physiological
linkage between elements of more empathic dyads. Our main
argument is that new research paradigms will in the future allow
counseling psychologists to integrate the knowledge produced by
cognitive neuroscience with empathy promotion strategies and,
more importantly, with their own internal and external empathic
responses.

The Social Brain and Its Importance for


Counseling Psychology
Neuroscientists have been trying to improve our knowledge on
the neural basis of a wide range of human behaviors, from the
simplest sensory and motor behaviors to more complex ones such
as the social behavior. The social brain hypothesis states that our
brains have expanded so much over the course of evolution because of the challenges involved in living in complex social groups
(Dunbar, 2012; Frith, 2007). In fact, social behavior is one of the
most important for our ability to survive and adapt to the environment. The metaphor of the human brain as social organ (Cozolino,
2006) is supported by findings from neurodevelopment and attachment, suggesting that our brain develops in the context of our
relationships and that brains regulate one another during momentto-moment interactions (Lorberbaum et al., 2002). The establishment of human bonds and interactions is essential for human
survival (e.g., Hrdy, 2009; Sroufe, 2000), which may explain why
social stimuli are particularly powerful and salient for the human
brain. However, social stimuli are complex stimuli involving the
activation of large brain networks and high-metabolic processes.
Metabolic processes lead to processes of neurogenesis and synaptogenesis through the synthesis of new proteins; thus, in a way,
interpersonal experience actually becomes neural structure (Cozolino, 2006).
Another important source of evidence for the social brain hypothesis comes from consistent data on the negative effects of
emotional neglect, social deprivation, and severe interpersonal
injury on the brain (e.g., Schechter, 2012). Curiously the central
importance of connecting with other human beings for a healthy
development seems to mirror the organization of the brain in that
isolated neurons that do not establish connections with other
neurons initiate a process of apoptosis. It is thus not surprising that

Joana Fernandes Coutinho and Patrcia Oliveira Silva, Neuropsychophysiology Laboratory, Cipsi School of Psychology, University of Minho;
Jean Decety, Department of Psychology and Department of Psychiatry and
Behavioral Neuroscience, University of Chicago.
Correspondence concerning this article should be addressed to Joana
Fernandes Coutinho, School of Psychology, University of Minho, Campus
de Gualtar 4710-057, Braga, Portugal. E-mail: joanafpc@gmail.com
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COUTINHO, SILVA, AND DECETY

the great majority of psychopathological disorders are characterized by any type of alteration in social behavior. Paradigmatic
examples of disorders characterized by social impairments are
psychopathy (e.g., Blair, 2005) and autism (e.g., Lim, Bielsky, &
Young, 2005), which may be seen as manifestations of an antisocial brain in the case of psychopathy and an asocial brain in the
case of autism. Many other mental disorders are characterized by
severe problems on the functioning of the social brain. Social
phobia is marked by very high levels of anxiety in social interactions (Chambless & Gillis, 1993), schizophrenia is characterized
by severe social anhedonia and/or paranoid ideation in the context
of social interactions (Horan & Blanchard, 2003), depression is
associated with perceived social rejection and isolation (Cacioppo
et al., 2006), and borderline personality defined, among other
features, by the fear of abandonment and the difficulty in establishing stable relationships (Benjamim, 1996).
The crucial role of social functioning in counseling psychology
is evident not only because, as mentioned before, several psychopathological disorders are characterized by social difficulties but
also because interpersonal problems per se constitute one of the
major and more frequent reasons that people seek psychotherapy
(Horowitz, Rosenberg, & Bartholomew, 1993). In fact, the promotion of clients social abilities, such as effective communication
skills, ability to regulate emotions in the context of intimate
relationship, and ability to deal with conflicts, is one of the most
important and challenging tasks required of the counselor. However, empathy facilitates the development of the therapeutic alliance (Horvath & Bedi, 2002), which is known to be one of the
most robust predictors of therapeutic success. Several decades ago,
Carl Rogers (1957) pointed out that empathy is a necessary and
enough of a condition for change in psychotherapy. More recently,
the role of empathy as a crucial feature of an effective counselor
has been demonstrated in several studies (e.g., Lambert & Barley,
2002; Wampold, 2001). In fact, empathy between the therapist and
the client may constitute in itself an explanation for the process of
change in psychotherapy. Previous studies conducted by us demonstrated that when therapists empathic abilities are compromised, ruptures in the alliance emerge and tend to lead to therapeutic dropout (Coutinho, Ribeiro, Fernandes, Sousa, & Safran, in
press; Coutinho, Ribeiro, & Safran, 2010). The more empathically
the therapist is able to respond to the clients needs, the more likely
it is the clients experience of being understood and validated (e.g.,
Bohart & Greenberg, 1997). In fact, it is through the empathic
response that the therapist will attend to and satisfy the needs
expressed by the client during the session. Thus, it is the therapists
empathic response perceived by the client that is critical for the
process of change (Horvath & Luborsky, 1993). This was also
suggested in another previous study conducted by us (Coutinho,
Ribeiro, Hill, & Safran, 2011). In the present review article, we
argue that two fields counseling psychology and cognitive neuroscience have both been accumulating evidence for the importance of empathy processes. Thus, both research areas can benefit
from the establishment of a dialog between them. Specifically, in
their attempt to deal with the problems presented by their clients,
counseling psychologists may inform their interventions with
knowledge about the neurobiology of the social behavior coming
from cognitive neuroscience.

The Neurobiological Correlates of Empathy:


Central Biomarkers
In order to successfully deal with other human beings, we must
be able to understand their emotional and cognitive states so that
we can anticipate their actions and act accordingly. This allows us
to navigate in an otherwise totally unpredictable social world. Here
is where the concept of empathy comes into play. Empathy constitutes one of the central constructs in counseling and clinical
psychology and also one of the most controversial ones. The term
has been applied by psychologists, philosophers, and the general
public to a large spectrum of phenomena such as the concern with
other people and consequent motivation to help them, the capacity
to resonate with the others emotions, the ability to understand a
given situation from the perspective of another person in order to
anticipate his or her actions, to name a few. Trying to define
empathy becomes an even more complex task when we notice the
communalities with close constructs such as prosocial behavior
and altruism, emotional intelligence, social cognition, emotion
regulation, theory of mind, and attachment.
Within the context of counseling psychology, empathy is typically defined as the ability to experience and understand the
feelings of the other person and is associated with a set of therapists behaviors such as unconditional acceptance of the clients
experience, active listening, and nonjudgmental communication
(Horvath & Bedi, 2002). For the purposes of this work, we adopted
one of the possible definitions of empathy: the one proposed by
Singer and colleagues in 2009. According to this definition, empathy corresponds to the process by which one infers the affective
state of another person and experience a similar state in ourselves,
while at the same time keeping a distinction between the self and
the other, in other words, being aware that the origin of that
experience is the other and not oneself (Singer, Critchley, &
Preuschoff, 2009).
One approach often used in the empathy literature (Decety &
Svetlova, 2012) to deal with the controversy around its definition
is to understand the empathic processes in a continuum, which
includes different components from the most basic affective processes (e.g., emotional contagious and the ability to share affective
states evoked by another individual) to the more complex and
cognitive dimensions (e.g., the ability to identify and understand
the mental states of others). Different neurobiological systems
seem to be involved in the various dimensions of empathy. Like
any other higher order psychological functions, empathy involves
the activity of several brain cortical and subcortical areas, as well
as the activity of the autonomic nervous system, hypothalamicpituitary-adrenal axis, and endocrine systems. In what follows, we
conduct a brief revision of the neuronal biomarkers of different
dimensions of empathy.
The bottom-up dimensions of empathy, such as the emotional
contagion by which we are able to vicariously experience the
feeling of disgust, pain, reward, and joy felt by others, has been
extensively studied (e.g., Bernhardt & Singer, 2012; Singer,
Critchley, & Preuschoff, 2009). The process of emotional sharing
not only facilitates the communication between members of the
same species but also promotes, under some circumstances, helping behaviors toward the other (Decety, Norman, Berntson, &
Cacioppo, 2012). Neuroimaging studies have shown that the same
neural networks that are activated during the first-person experi-

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NEUROSCIENCE AND EMPATHY

ence of pain (Rainville et al., 1997) are activated when we observe


others physical (e.g., Jackson, Meltzoff & Decety, 2005; Singer et
al., 2004) or psychological pain (e.g., MacDonald & Leary, 2005).
This constitutes a sensory-based route of empathy and involves the
activation of action-perception networks, by which the affective or
visceral state observed in others is simulated in ourselves, allowing
us to feel another persons suffering. The brain circuit involved
in our capacity to be affected by the emotional state of others
includes the anterior insula, dorsal anterior cingulate cortex, anterior midcingulate cortex, supplementary motor area, amygdala,
brainstem preoptic area of the thalamus, and periaqueductal gray
matter (e.g., Jackson et al., 2005; Lamm et al., 2011).
The reports of the existence of mirror neurons in the monkey
ventral premotor cortex (Gallese, Fadiga, Fogassi, & Rizzolatti,
1996) is in accordance with this perceptionaction model of empathy (Preston & de Waal, 2002). Mirror neurons constitute a
unique class of sensorimotor neurons that are activated both when
an animal performs a specific movement and when it observes
another individual performing the same action. It is important to
mention that evidence for the presence of the mirror neurons in
humans is still indirect (Turella, Pierno, Tubaldi, & Castiello,
2009), with some studies failing to reveal evidence for this system
in humans (Lingnau, Gesierich, & Caramazza, 2009). Moreover,
some authors argue that they are more likely to constitute motor
system facilitators acting via learned associations (Hickok, 2009)
and that motor resonance is not enough for our ability to fully
empathize with others (Jacob, 2008).
Abstract or representational dimensions of empathy are related
with other abilities to infer other persons internal mental states by
using our knowledge about the situation and the individual, without necessarily being exposed to concrete stimuli of pain or direct
observation of suffering, for example. This empathy dimension
consisting of our ability to attribute internal mental states, either
feeling, desires, intentions, or emotions, to others is close to the
concept of theory of mind, also termed mentalizing (e.g., Astington
& Hughes, 2011), and requires high-level brain functions such as
language and metacognition that seem to be unique to our species
(Stone & Gerrans, 2006). The neural networks involved in this
inference-based route of empathy are composed of the ventromedial prefrontal cortex (vMPFC), superior temporal sulcus,
temporo-parietal junction, temporal poles/amygdala, and posterior
cingulate cortex/precuneus (e.g., Frith & Frith, 2006). Prefrontal
regions such as the vMPFC, orbitofrontal cortex (OBF), and anterior cingulate cortex (ACC) also play an important role in our
ability to integrate cognition and emotion important for advanced
forms of empathy (Decety & Svetlova, 2012).
Finally, an important top-down empathic process has to do with
the ability to self-regulate our own emotional states (Astington &
Hughes, 2011), preventing the overflow of other peoples negative
affect over our own experience. This inhibitory and emotional
control depends on the development of executive functions and
metacognition made possible by the maturation of prefrontal regions (Decety & Jackson, 2004; Tamm, Menon, & Reiss, 2002)
and the intrinsic cortico-cortical connections of the OBF, medial
prefrontal cortex, and dorsolateral prefrontal cortex. An important
aspect of these regulatory mechanisms is the self other discrimination (e.g., Ruby & Decety, 2004).

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Empathy and the Resting Brain


As mentioned earlier, different brain systems seem to be involved in the affective, cognitive, and regulatory dimensions of
empathy: The ACC, the OBF, anterior insula, and amygdala are
implied in the more visceral emotional response and processing of
others emotional state (Decety & Svetlova, 2012); the precuneus,
medial prefrontal cortex, OBF, and temporal parietal junction are
critical for reflecting about our own internal mental states and
making inferences about the mental states of others (e.g., Northoff
et al., 2006; Ruby & Decety, 2004) and differentiating between
self and others (Vogeley & Fink, 2003).
More recently, the study of the patterns of brain activation at rest
has offered a complementary explanation for the brain correlates
of empathy (Mars et al., 2012). The resting state networks show a
high degree of functional connectivity when the brain is at rest
and the individual is not focused on any external demand. One of
the best known resting state networks is the default mode network
(DMN; Raichle et al., 2001), which comprises much of the abovementioned empathy-related areas: the posterior cingulate cortex
and adjacent precuneus; the medial prefrontal cortex; medial,
lateral, and inferior parietal cortex; and medial temporal cortex
(Buckner, Andrews-Hanna, & Schacter 2008; Raichle et al., 2001).
Likewise, there seems to be an intriguing overlap between empathy tasks and the psychological functions attributed to the
DMN: supporting internal mental activity (Mason et al., 2007),
integrating cognitive and emotional processing (Greicius, Krasnow, Reiss, & Menon, 2003), differentiating between self and
others (Vogeley & Fink, 2003), and action monitoring in self and
others (Amodio & Frith, 2006). In fact, this close relationship
between the activation pattern of the DMN and empathy was
already empirically demonstrated (e.g., Mars et al., 2012; Schilbach et al., 2008). This evidence lead authors like Schilbach et al.
(2008) to suggest that the DMN works as a physiological baseline of the human brain that is linked to our predisposition for
social cognition as the default mode of thought. This intriguing
idea proposed by Schilbach, Eickhoff, Rotarska-Jagiela, Fink, and
Vogeley (2008) is related with the social brain hypothesis, referred
to in the beginning of the present article. The interesting fact that
the DMN has also been reported in nonhuman primates (e.g.,
Vincent et al., 2007) may suggest that, as in humans, the DMN
mediates these animals social abilities. This is supported by data
showing that the DMN differs in individuals as a function of social
network size, specifically, monkeys housed with more other animals recruited more the DMN (Sallet et al., 2011).
However, evidence from the field of personality neuroscience
has shown that individual differences in DMN activity could be
related with differences in personality (e.g., Adelstein et al., 2011;
DeYoung et al., 2010), namely in prosocial personality traits,
which are normally positively related with empathy. A previous
study from our team (Sampaio, Soares, Coutinho, Sousa, & Gonalves, 2013) revealed that Extraversion (E) and Agreeableness
(A), two personality traits that reflect a prosocial orientation, were
positively correlated with the activity in the midline core of the
DMN. In addition, a voxel-based morphometry study developed
by us showed that E and A were related with the volume of DMN
areas (Coutinho, Sampaio, Ferreira, Soares, & Gonalves, 2013).
Specifically, E involved in the processing of social rewards correlated with the volume of prefrontal regions (middle frontal and

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COUTINHO, SILVA, AND DECETY

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orbitofrontal gyri), whereas A that was more involved in the ability


to respond to other peoples needs correlated with the parietal,
posterior cingulate, and occipital regions. We think that knowing
that the brain activity in a specific brain network such as the DMN
correlates with empathy may have important implications in the
future, namely, through the use of real-time functional magnetic
resonance imaging (fMRI) neurofeedback training (Hinds et al.,
2011). Preliminary evidence has shown that through this technique, individuals are able to learn how to regulate their own
pattern of brain activation.

The Neurobiological Correlates of Empathy:


Peripheral Biomarkers
At the peripheral level, the empathy dimension of emotional
contagion has been associated with an increased level of autonomic arousal that tends to mirror the other persons internal state.
Both the cardiovascular response, specifically, the interbeat interval, represented by the temporal distance between successive R
waves in the electrocardiographic curve (Frazier et al., 2004), and
the electrodermic activity (EDA) (Boucsein, 2012) constitute indices of the increased autonomic arousal that occurs when we
experience any type of emotional resonance with others. EDA is an
indirect measure of the sympathetic activation in response to stress
(Boucsein, 2012). In empathy research, EDA measures have been
applied to indicate the degree of cognitive engagement and,
mostly, the intensity of the emotional responsiveness to empathyeliciting stimuli. The cardiac activity represents an elaborated
physiological system and is recognized as a physiological marker
of both affective and cognitive states, as well as of the interaction
between sympathetic and parasympathetic control. The physiological adjustment of arousal states between high and low level of
reactivity is a crucial ability for regulated emotional responding,
specifically, the discrimination between appetitive and defensive
responding (Appelhans & Luecken, 2006), having important implications for empathy research (Neumann & Westbury, 2011).
Studies exploring the psychophysiological correlates of arousal as
a function of empathic response level have revealed inconsistent
results. Oliveira-Silva and Gonalves (2011) analyzed the pattern
of psychophysiological responsiveness of college students in a task
involving empathic responses to emotional vignettes. They found
that higher levels of empathy were associated with heart rate
acceleration but not with differences in the EDA, which led to the
conclusion that cardiovascular activity appears to be the most
sensitive physiological marker for the detection of variations in the
level of empathic response. Thus, it is still not known which
measure of autonomic arousal is more associated with empathy
and its different dimensions. However, evidence seems to suggest
that too high (e.g., Nealy-Moore, Smith, Uchino, Hawkins, &
Olson-Cerny, 2007) or too low physiological arousalnormally
linked with lack of engagement in the relationship (e.g., Neumann
& Westbury, 2011)may compromise the empathic response.
Empirical findings also suggest that more than the level of autonomic arousal per se, the level of physiological synchrony between
the empathizer and the target may be more indicative of higher
empathy (e.g.Levenson & Ruef, 1992; Marci, Ham, Moran, & Orr,
2007).We elaborate on this in the last section of this article.

Factors That Modulate the Empathic Response


Empathic processes are far from being automatic processes;
several top-down factors dynamically modulate both the experience of empathy and the implementation of the empathic response.
These factors include the familiarity with the object of empathy
and the group membership and the characteristics of the empathizer, namely, his or her motivations, general beliefs and goals,
and self-regulation abilities (Decety & Moriguchi, 2007; Singer et
al., 2006). In fact, not only is empathy not an automatic response,
but it can also be specifically inhibited by the activation of antagonistic motivational systems. This may occur, for example, if the
relationship with the target is characterized by negative feelings
like those demonstrated in a study by Hein et al. (2010). The
authors found that when the object of empathy was a member of a
disliked outgroup (e.g., a fan from a rival football team), the
participants presented not only a reduced empathy-related activation but also an increased activation in reward-processing areas
such as the ventral striatum. In the same line, there is some
evidence that the relationship with the other person mediates the
neural mechanisms that are recruited when the observer is exposed
to the targets social pain (e.g., social exclusion). When individuals
are exposed to the social suffering of strangers, emotion sharing is
less likely and they tend to recruit mentalizing regions without
recruiting anterior cingulate and insula (Meyer et al., 2012). The
fact that empathy is a dynamic process in which we can exert some
control opens up possibilities for intervention in counseling psychology.

Implications for Psychotherapy and Intimate


Relationships: The Hypothesis
of Physiological Synchrony
In their book, Ivey, Ivey, and Zalaquett (2010) start by expressing the idea that counseling changes the brain of both the client and
the psychotherapist. In this section, we elaborate on how counseling may change the social brain by promoting healthier interpersonal interactions. We discuss possible ways in which knowledge
about the neuronal correlates of empathy can be applied to counseling psychology, namely, to the therapeutic relationship between
the counselor and the client and to the context of intimate relationships.
The empirical evidence that the degree of synchrony in the
autonomic responses is a physiological component of empathy
(Decety & Jackson, 2004), particularly of emotional contagion, has
important implications for counseling. The idea that when we are
being empathic our autonomic nervous system tends to mirror that
of another person has been around for several decades (Ax, 1964;
Kaplan & Blooms, 1960). Damasio (2003) proposed that we know
the emotions of others when we simulate the way they would feel
in ourselves, and this brain simulation rapidly changes our ongoing
body maps. This was supported by Adolphs, Damasio, Tranel,
Cooper, and Damasio (2000), when they found that the somatosensory cortex is involved in the recognition of emotion.
Likewise, in the context of intimate relationships, there is also
evidence for the association between physiological linkage and
empathy. Levenson and Ruef (1992) found that the accuracy of
rating negative emotion was greater for couples who presented
high levels of physiological linkage across time. In the same

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NEUROSCIENCE AND EMPATHY

direction, Thomsen and Gilbert (1998) found that, during conflictual interactions, couples in which partners patterns of heart rate
and skin conductance were synchronous with one another had
higher ratings of marital satisfaction. This is particularly relevant
for couples therapy, particularly in conflict situations in which the
need to empathize with negative feelings is more likely to alter the
pattern of physiological activation of each element of the dyad.
The context of intimate relationship is one of the main interpersonal contexts in which empathy appears to be critical for the
couples capacity to succeed or fail (Levenson & Gottman, 1985)
and for romantic relationship satisfaction (e.g., Duncan & Jowett,
2010).
The physiological linkage has also been observed in the psychotherapeutic relationship. In a classical study from DiMascio,
Boyd, and Greenblatt (1957), the authors concluded that the heart
rates of psychotherapists and their clients during interviews moved
in opposite directions when the client expressed antagonism toward the therapist. In the same year, Malmo, Boag and Smith
(1957) found that the amplitude of the electromyogram obtained
from the chin of the examiner and the client during a diagnostic
test both fell following praise and remained constant following
criticism. More recently, Marci, Ham, Moran, and Orr (2007)
found that the syncrony in the skin conductance level was associated with the clients perception of therapists empathic responses
and also with more positive socioemotional interactions for both
clients and therapists.
Taken together, these studies indicate that in order to respond in
an empathic manner to their clients, therapists should be open to
feel the emotional experience of their clients at the physiological
level, serving like a mirror of the clients distress. However, after
an initial period, in which the therapist matches the clients autonomic response, more empathic therapists are likely those better
able to biologically modulate their own and their clients autonomic level of sympathetic arousal. In other words, it may be the
case that biofeedback handles will allow more empathic clinicians
to modify their own autonomic arousal, which in turn will modulate the clients activation, leading to a synchronized and dynamic
autonomic dance between both elements, instead of a rigid
autonomic linkage in which both get stuck in high levels of
sympathetic activation.
The therapists ability to self-regulate his or her own affective
arousal is related with the personal costs, both physiological and
cognitive, of being empathic. These costs are particularly relevant
for professional helping relationships (Gleichgerrcht & Decety,
2011). Both functional imaging studies (Cheng et al., 2007) and
event-related potential studies (Decety et al., 2010) have shown
that physicians do not react to the pain of others in the same way
as nonphysicians. Specifically, they tend to activate more brain
areas involved in executive functioning and self-regulation. Moreover, as pointed out by Yamada and Decety (2009), the emotional
resonance with the other persons suffering and associated response of autonomic arousal may work against empathic concern
or prosocial behavior. This is so because to fully experience the
others suffering activates fear and concerns for our own safety,
which are usually associated with avoidance or self-protective
behavior (e.g., Muraven & Baumeister, 2000). Moreover, the
affective arousal experienced by the empathizer spends attentional
and cognitive resources that can no longer be directed to attend to
the others suffering (Eisenberg & Eggum, 2009).

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These lines of evidence suggests that training and supervision


programs of psychotherapists and counselors must include specific
learning components that help these professionals to learn how to
regulate their emotional arousal. Current training models in counseling education tend to emphasize external and observable communication of empathy rather than the internal mental processes
that lead to genuine empathic communication (Greason & Cashwell, 2009). Thus, students may learn to act as if they are being
empathic by correctly identifying and communicating about the
clients feelings in a concrete and specific way, without necessarily
developing experiences of genuine empathy. Mindfulness training
may be an important tool to help future counselors develop selfregulation abilities instead of avoiding them or overidentifying
with the emotional distress of their clients (e.g., Morgan & Morgan, 2005).
This evidence also offers important directions for counseling
research, namely, for the study of effective therapeutic interventions, by offering objective and ecologically valid methods for
assessing therapists empathic abilities. We think that the physiological linkage is an example of a research hypothesis that should
be further explored by new research paradigms in the field of
counseling psychology. It is interesting to note that the notion that
empathy is related to the development of synchrony between
interacting members in a dyad is not new in the field. Several
studies have already looked at synchrony at the behavioral level,
namely, in terms of nonverbal cues. As an example, a recent study
by Imel et al. (2014) revealed evidence for vocal synchrony in
clinical dyads as well as for the association of synchrony with
empathy ratings. In the same direction, Ramseyer and Tschacher
(2011) found that nonverbal synchrony is increased in sessions
rated by clients as having high relationship quality, and higher
nonverbal synchrony was associated with higher symptom reduction. We propose that future research paradigms can extend this
analysis to include neurobiological variables. Peripheral and central biomarkers of empathy can be innovative indicators that help
researchers to move from the more traditional research paradigms,
in which empathy has been typically measured either through the
introspective recall of the actors involved (clients and therapists)
or through the independent ratings of trained observers. Despite
the unquestionable value of these methods used for decades in
counseling research, we think they can be complemented by other
methods and measures coming from the neuroscience field. This
complementary paradigm may help overcome some of the limitations of self-report or observational methods. Previous studies
conducted by us have shown that self-report measures have limitations in terms of the detection of complex interactive processes
such as ruptures in therapeutic alliance (Coutinho, Ribeiro, Sousa,
& Safran, 2013), which are characterized by failures in the empathic processes. Thus, an alternative way of studying the efficacy
of therapy is to explore what characterizes the neurobiology of
dyads in sessions rated by observers with high and low empathy
scores, for example. In order to do this, peripheral measures can be
directly applied to the therapeutic context without compromising
the ecological validity of the study.
As examples of innovative studies that aim to integrate neuroscience methods with traditional research paradigms in counseling
psychology, we would like to mention two research projects that
are currently being conducted by members of our team. One
project explores the psychophysiological processes (EDA and

COUTINHO, SILVA, AND DECETY

546

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heart rate) underlying therapeutic collaboration, defined as the


balance between therapists supporting interventions that help the
client to feel safe and challenging interventions that stimulate
change (Ribeiro et al., 2013). The second example refers to a
current research project with couples that is being implemented by
the authors of the present article. This project measures the degree
of autonomic synchrony between both elements of the couple,
while they perform a structured empathy task. This is followed by
an assessment of the central biomarkers of empathy using an fMRI
paradigm that consists of vignettes extracted from the previous
videotaped interaction.

Concluding Remarks
Human interpersonal relationships can both create and cure
psychological disorders. Psychotherapeutic relationships are healing interactions that can trigger changes in the brain through a safe
and supportive relationship that is able to reshape neural networks
(Cozolino, 2006). Our knowledge about the neural networks involved in the different dimensions of empathy is still developing;
however, we think that the rapid increase of knowledge in socialcognitive neuroscience will provide the clinician with important
cues about the neuronal systems that are impaired and leading to
their clients social problems. In a not-too-distant future, this will
allow therapists to identify the type of psychological processes that
must be enhanced in order to modulate the activity of those
neuronal systems, promoting a process of positive neuroplasticity.
In other words, in the future, the psychotherapist will be more
close to assuming the role of a neuroscientist who investigates
what in the brain needs to change and how. The application of
neuroscience methods to counseling research will also offer an
alternative empirical validation of therapeutic efficacy by providing the scientific community with new indicators of effective
therapeutic skills. Innovative studies like the one by Barsaglini,
Sartori, Benetti, Pettersson-Yeo, and Mechelli (in press), which
demonstrated that brain networks found to be dysfunctional in
psychological disorders were normalized after effective psychotherapeutic intervention, have already pursued this line of research.
We are just beginning to understand how the architecture of the
brain can help us to understand individuals and their relationships.
We believe that the research on the neural correlates of empathy
will have important clinical implications for the development of
effective interventions of empathy promotion with couples and
other populations, namely, for psychopathological disorders
marked by the deficits in the empathic abilities such as autism and
personality disorders.

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Received December 1, 2013


Revision received March 17, 2014
Accepted March 17, 2014

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