Neurosciences, Empathy, and Healthy Interpersonal Relationships: RecentFindings and Implications for Counseling Psychology

Joana Fernandes Coutinhoand Patrícia Oliveira Silva

University of Minho

Jean DecetyUniversity of Chicago

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

Keywords: empathy, neuroscience, interpersonal relationships, counseling psychology

In this article, we present and discuss recent findings on theneurobiological correlates of empathy and its implications for theresearch programs in counseling psychology and clinical practice.We start by framing the importance of empathy within the contextof the social brain hypothesis, pointing out its central role inthe psychotherapeutic process. In the next section, we present themajor results of studies that looked at the biomarkers of one of themost important psychological functions of the social brain: empa-thy. We start by reporting the correlates of empathy related to thecentral nervous system, with special attention to recent findingsrelated with the brain activity at rest. We then present someimportant findings about the peripheral biomarkers of empathy. Inthe last section of this article, we discuss the potential implicationsof the studies reported both for counseling practice and for a newresearch agenda in the field. We emphasize the implications ofempirical evidence pointing to the presence of a physiologicallinkage between elements of more empathic dyads. Our mainargument is that new research paradigms will in the future allowcounseling psychologists to integrate the knowledge produced bycognitive neuroscience with empathy promotion strategies and,more importantly, with their own internal and external empathicresponses.

The Social Brain and Its Importance forCounseling Psychology

Neuroscientists have been trying to improve our knowledge onthe neural basis of a wide range of human behaviors, from thesimplest sensory and motor behaviors to more complex ones suchas the social behavior. The “social brain hypothesis” states that ourbrains have expanded so much over the course of evolution be-cause of the challenges involved in living in complex social groups(Dunbar, 2012; Frith, 2007). In fact, social behavior is one of themost important for our ability to survive and adapt to the environ-ment. The metaphor of the human brain as social organ (Cozolino,2006) is supported by findings from neurodevelopment and attach-ment, suggesting that our brain develops in the context of ourrelationships and that brains regulate one another during moment-to-moment interactions (Lorberbaum et al., 2002). The establish-ment of human bonds and interactions is essential for humansurvival (e.g., Hrdy, 2009; Sroufe, 2000), which may explain whysocial stimuli are particularly powerful and salient for the humanbrain. However, social stimuli are complex stimuli involving theactivation of large brain networks and high-metabolic processes.Metabolic processes lead to processes of neurogenesis and synap-togenesis through the synthesis of new proteins; thus, in a way,interpersonal experience actually becomes neural structure (Cozo-lino, 2006).

Another important source of evidence for the social brain hy-pothesis comes from consistent data on the negative effects ofemotional neglect, social deprivation, and severe interpersonalinjury on the brain (e.g., Schechter, 2012). Curiously the centralimportance of connecting with other human beings for a healthydevelopment seems to mirror the organization of the brain in thatisolated neurons that do not establish connections with otherneurons initiate a process of apoptosis. It is thus not surprising that

Joana Fernandes Coutinho and Patrícia Oliveira Silva, Neuropsycho-physiology Laboratory, Cipsi School of Psychology, University of Minho;Jean Decety, Department of Psychology and Department of Psychiatry andBehavioral Neuroscience, University of Chicago.

Correspondence concerning this article should be addressed to JoanaFernandes Coutinho, School of Psychology, University of Minho, Campusde Gualtar 4710-057, Braga, Portugal. E-mail: joanafpc@gmail.com

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Journal of Counseling Psychology © 2014 American Psychological Association2014, Vol. 61, No. 4, 541–548 0022-0167/14/$12.00 http://dx.doi.org/10.1037/cou0000021

541

the great majority of psychopathological disorders are character-ized by any type of alteration in social behavior. Paradigmaticexamples of disorders characterized by social impairments arepsychopathy (e.g., Blair, 2005) and autism (e.g., Lim, Bielsky, &Young, 2005), which may be seen as manifestations of an antiso-cial brain in the case of psychopathy and an asocial brain in thecase of autism. Many other mental disorders are characterized bysevere problems on the functioning of the social brain. Socialphobia is marked by very high levels of anxiety in social interac-tions (Chambless & Gillis, 1993), schizophrenia is characterizedby severe social anhedonia and/or paranoid ideation in the contextof social interactions (Horan & Blanchard, 2003), depression isassociated with perceived social rejection and isolation (Cacioppoet al., 2006), and borderline personality defined, among otherfeatures, by the fear of abandonment and the difficulty in estab-lishing stable relationships (Benjamim, 1996).

The crucial role of social functioning in counseling psychologyis evident not only because, as mentioned before, several psycho-pathological disorders are characterized by social difficulties butalso because interpersonal problems per se constitute one of themajor and more frequent reasons that people seek psychotherapy(Horowitz, Rosenberg, & Bartholomew, 1993). In fact, the pro-motion of client’s social abilities, such as effective communicationskills, ability to regulate emotions in the context of intimaterelationship, and ability to deal with conflicts, is one of the mostimportant and challenging tasks required of the counselor. How-ever, empathy facilitates the development of the therapeutic alli-ance (Horvath & Bedi, 2002), which is known to be one of themost robust predictors of therapeutic success. Several decades ago,Carl Rogers (1957) pointed out that empathy is a necessary andenough of a condition for change in psychotherapy. More recently,the role of empathy as a crucial feature of an effective counselorhas been demonstrated in several studies (e.g., Lambert & Barley,2002; Wampold, 2001). In fact, empathy between the therapist andthe client may constitute in itself an explanation for the process ofchange in psychotherapy. Previous studies conducted by us dem-onstrated that when therapist’s empathic abilities are compro-mised, ruptures in the alliance emerge and tend to lead to thera-peutic dropout (Coutinho, Ribeiro, Fernandes, Sousa, & Safran, inpress; Coutinho, Ribeiro, & Safran, 2010). The more empathicallythe therapist is able to respond to the client’s needs, the more likelyit is the client’s experience of being understood and validated (e.g.,Bohart & Greenberg, 1997). In fact, it is through the empathicresponse that the therapist will attend to and satisfy the needsexpressed by the client during the session. Thus, it is the therapist’sempathic response perceived by the client that is critical for theprocess of change (Horvath & Luborsky, 1993). This was alsosuggested in another previous study conducted by us (Coutinho,Ribeiro, Hill, & Safran, 2011). In the present review article, weargue that two fields—counseling psychology and cognitive neu-roscience—have both been accumulating evidence for the impor-tance of empathy processes. Thus, both research areas can benefitfrom the establishment of a dialog between them. Specifically, intheir attempt to deal with the problems presented by their clients,counseling psychologists may inform their interventions withknowledge about the neurobiology of the social behavior comingfrom cognitive neuroscience.

The Neurobiological Correlates of Empathy:Central Biomarkers

In order to successfully deal with other human beings, we mustbe able to understand their emotional and cognitive states so thatwe can anticipate their actions and act accordingly. This allows usto navigate in an otherwise totally unpredictable social world. Hereis where the concept of empathy comes into play. Empathy con-stitutes one of the central constructs in counseling and clinicalpsychology and also one of the most controversial ones. The termhas been applied by psychologists, philosophers, and the generalpublic to a large spectrum of phenomena such as the concern withother people and consequent motivation to help them, the capacityto resonate with the other’s emotions, the ability to understand agiven situation from the perspective of another person in order toanticipate his or her actions, to name a few. Trying to defineempathy becomes an even more complex task when we notice thecommunalities with close constructs such as prosocial behaviorand altruism, emotional intelligence, social cognition, emotionregulation, theory of mind, and attachment.

Within the context of counseling psychology, empathy is typi-cally defined as the ability to experience and understand thefeelings of the other person and is associated with a set of thera-pist’s behaviors such as unconditional acceptance of the client’sexperience, active listening, and nonjudgmental communication(Horvath & Bedi, 2002). For the purposes of this work, we adoptedone of the possible definitions of empathy: the one proposed bySinger and colleagues in 2009. According to this definition, em-pathy corresponds to the process by which one infers the affectivestate of another person and experience a similar state in ourselves,while at the same time keeping a distinction between the self andthe other, in other words, being aware that the origin of thatexperience 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 definitionis to understand the empathic processes in a continuum, whichincludes different components from the most basic affective pro-cesses (e.g., emotional contagious and the ability to share affectivestates evoked by another individual) to the more complex andcognitive dimensions (e.g., the ability to identify and understandthe mental states of others). Different neurobiological systemsseem to be involved in the various dimensions of empathy. Likeany other higher order psychological functions, empathy involvesthe activity of several brain cortical and subcortical areas, as wellas the activity of the autonomic nervous system, hypothalamic-pituitary-adrenal axis, and endocrine systems. In what follows, weconduct a brief revision of the neuronal biomarkers of differentdimensions of empathy.

The bottom-up dimensions of empathy, such as the emotionalcontagion by which we are able to vicariously experience thefeeling of disgust, pain, reward, and joy felt by others, has beenextensively studied (e.g., Bernhardt & Singer, 2012; Singer,Critchley, & Preuschoff, 2009). The process of emotional sharingnot only facilitates the communication between members of thesame species but also promotes, under some circumstances, help-ing behaviors toward the other (Decety, Norman, Berntson, &Cacioppo, 2012). Neuroimaging studies have shown that the sameneural networks that are activated during the first-person experi-

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542 COUTINHO, SILVA, AND DECETY

ence of pain (Rainville et al., 1997) are activated when we observeother’s physical (e.g., Jackson, Meltzoff & Decety, 2005; Singer etal., 2004) or psychological pain (e.g., MacDonald & Leary, 2005).This constitutes a sensory-based route of empathy and involves theactivation of action-perception networks, by which the affective orvisceral state observed in others is simulated in ourselves, allowingus to “feel” another person’s suffering. The brain circuit involvedin our capacity to be affected by the emotional state of othersincludes the anterior insula, dorsal anterior cingulate cortex, ante-rior midcingulate cortex, supplementary motor area, amygdala,brainstem preoptic area of the thalamus, and periaqueductal graymatter (e.g., Jackson et al., 2005; Lamm et al., 2011).

The reports of the existence of mirror neurons in the monkeyventral premotor cortex (Gallese, Fadiga, Fogassi, & Rizzolatti,1996) is in accordance with this perception–action model of em-pathy (Preston & de Waal, 2002). Mirror neurons constitute aunique class of sensorimotor neurons that are activated both whenan animal performs a specific movement and when it observesanother individual performing the same action. It is important tomention that evidence for the presence of the mirror neurons inhumans is still indirect (Turella, Pierno, Tubaldi, & Castiello,2009), with some studies failing to reveal evidence for this systemin humans (Lingnau, Gesierich, & Caramazza, 2009). Moreover,some authors argue that they are more likely to constitute motorsystem facilitators acting via learned associations (Hickok, 2009)and that motor resonance is not enough for our ability to fullyempathize with others (Jacob, 2008).

Abstract or representational dimensions of empathy are relatedwith other abilities to infer other person’s internal mental states byusing our knowledge about the situation and the individual, with-out necessarily being exposed to concrete stimuli of pain or directobservation of suffering, for example. This empathy dimensionconsisting of our ability to attribute internal mental states, eitherfeeling, desires, intentions, or emotions, to others is close to theconcept of theory of mind, also termed mentalizing (e.g., Astington& Hughes, 2011), and requires high-level brain functions such aslanguage and metacognition that seem to be unique to our species(Stone & Gerrans, 2006). The neural networks involved in thisinference-based route of empathy are composed of the ventrome-dial prefrontal cortex (vMPFC), superior temporal sulcus,temporo-parietal junction, temporal poles/amygdala, and posteriorcingulate cortex/precuneus (e.g., Frith & Frith, 2006). Prefrontalregions such as the vMPFC, orbitofrontal cortex (OBF), and an-terior cingulate cortex (ACC) also play an important role in ourability to integrate cognition and emotion important for advancedforms of empathy (Decety & Svetlova, 2012).

Finally, an important top-down empathic process has to do withthe ability to self-regulate our own emotional states (Astington &Hughes, 2011), preventing the overflow of other people’s negativeaffect over our own experience. This inhibitory and emotionalcontrol depends on the development of executive functions andmetacognition made possible by the maturation of prefrontal re-gions (Decety & Jackson, 2004; Tamm, Menon, & Reiss, 2002)and the intrinsic cortico-cortical connections of the OBF, medialprefrontal cortex, and dorsolateral prefrontal cortex. An importantaspect of these regulatory mechanisms is the self–other discrimi-nation (e.g., Ruby & Decety, 2004).

Empathy and the Resting Brain

As mentioned earlier, different brain systems seem to be in-volved in the affective, cognitive, and regulatory dimensions ofempathy: The ACC, the OBF, anterior insula, and amygdala areimplied in the more visceral emotional response and processing ofother’s emotional state (Decety & Svetlova, 2012); the precuneus,medial prefrontal cortex, OBF, and temporal parietal junction arecritical for reflecting about our own internal mental states andmaking inferences about the mental states of others (e.g., Northoffet al., 2006; Ruby & Decety, 2004) and differentiating betweenself and others (Vogeley & Fink, 2003).

More recently, the study of the patterns of brain activation at resthas offered a complementary explanation for the brain correlatesof empathy (Mars et al., 2012). The resting state networks show ahigh degree of functional connectivity when the brain “is at rest”and the individual is not focused on any external demand. One ofthe best known resting state networks is the default mode network(DMN; Raichle et al., 2001), which comprises much of the above-mentioned empathy-related areas: the posterior cingulate cortexand 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 “em-pathy tasks” and the psychological functions attributed to theDMN: supporting internal mental activity (Mason et al., 2007),integrating cognitive and emotional processing (Greicius, Kras-now, Reiss, & Menon, 2003), differentiating between self andothers (Vogeley & Fink, 2003), and action monitoring in self andothers (Amodio & Frith, 2006). In fact, this close relationshipbetween the activation pattern of the DMN and empathy wasalready empirically demonstrated (e.g., Mars et al., 2012; Schil-bach et al., 2008). This evidence lead authors like Schilbach et al.(2008) to suggest that the DMN works as a physiological “base-line” of the human brain that is linked to our predisposition forsocial cognition as the default mode of thought. This intriguingidea proposed by Schilbach, Eickhoff, Rotarska-Jagiela, Fink, andVogeley (2008) is related with the social brain hypothesis, referredto in the beginning of the present article. The interesting fact thatthe DMN has also been reported in nonhuman primates (e.g.,Vincent et al., 2007) may suggest that, as in humans, the DMNmediates these animals’ social abilities. This is supported by datashowing that the DMN differs in individuals as a function of socialnetwork size, specifically, monkeys housed with more other ani-mals recruited more the DMN (Sallet et al., 2011).

However, evidence from the field of personality neurosciencehas shown that individual differences in DMN activity could berelated 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 previousstudy from our team (Sampaio, Soares, Coutinho, Sousa, & Gon-çalves, 2013) revealed that Extraversion (E) and Agreeableness(A), two personality traits that reflect a prosocial orientation, werepositively correlated with the activity in the midline core of theDMN. In addition, a voxel-based morphometry study developedby us showed that E and A were related with the volume of DMNareas (Coutinho, Sampaio, Ferreira, Soares, & Gonçalves, 2013).Specifically, E involved in the processing of social rewards cor-related with the volume of prefrontal regions (middle frontal and

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543NEUROSCIENCE AND EMPATHY

orbitofrontal gyri), whereas A that was more involved in the abilityto respond to other people’s needs correlated with the parietal,posterior cingulate, and occipital regions. We think that knowingthat the brain activity in a specific brain network such as the DMNcorrelates with empathy may have important implications in thefuture, namely, through the use of real-time functional magneticresonance imaging (fMRI) neurofeedback training (Hinds et al.,2011). Preliminary evidence has shown that through this tech-nique, individuals are able to learn how to regulate their ownpattern of brain activation.

The Neurobiological Correlates of Empathy:Peripheral Biomarkers

At the peripheral level, the empathy dimension of emotionalcontagion has been associated with an increased level of auto-nomic arousal that tends to mirror the other person’s internal state.Both the cardiovascular response, specifically, the interbeat inter-val, represented by the temporal distance between successive Rwaves in the electrocardiographic curve (Frazier et al., 2004), andthe electrodermic activity (EDA) (Boucsein, 2012) constitute in-dices of the increased autonomic arousal that occurs when weexperience any type of emotional resonance with others. EDA is anindirect measure of the sympathetic activation in response to stress(Boucsein, 2012). In empathy research, EDA measures have beenapplied to indicate the degree of cognitive engagement and,mostly, the intensity of the emotional responsiveness to empathy-eliciting stimuli. The cardiac activity represents an elaboratedphysiological system and is recognized as a physiological markerof both affective and cognitive states, as well as of the interactionbetween sympathetic and parasympathetic control. The physiolog-ical adjustment of arousal states between high and low level ofreactivity is a crucial ability for regulated emotional responding,specifically, the discrimination between appetitive and defensiveresponding (Appelhans & Luecken, 2006), having important im-plications for empathy research (Neumann & Westbury, 2011).Studies exploring the psychophysiological correlates of arousal asa function of empathic response level have revealed inconsistentresults. Oliveira-Silva and Gonçalves (2011) analyzed the patternof psychophysiological responsiveness of college students in a taskinvolving empathic responses to emotional vignettes. They foundthat higher levels of empathy were associated with heart rateacceleration but not with differences in the EDA, which led to theconclusion that cardiovascular activity appears to be the mostsensitive physiological marker for the detection of variations in thelevel of empathic response. Thus, it is still not known whichmeasure of autonomic arousal is more associated with empathyand its different dimensions. However, evidence seems to suggestthat too high (e.g., Nealy-Moore, Smith, Uchino, Hawkins, &Olson-Cerny, 2007) or too low physiological arousal—normallylinked 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 auto-nomic arousal per se, the level of physiological synchrony betweenthe empathizer and the target may be more indicative of higherempathy (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 experi-ence of empathy and the implementation of the empathic response.These factors include the familiarity with the object of empathyand the group membership and the characteristics of the empa-thizer, namely, his or her motivations, general beliefs and goals,and self-regulation abilities (Decety & Moriguchi, 2007; Singer etal., 2006). In fact, not only is empathy not an automatic response,but it can also be specifically inhibited by the activation of antag-onistic motivational systems. This may occur, for example, if therelationship with the target is characterized by negative feelingslike those demonstrated in a study by Hein et al. (2010). Theauthors found that when the object of empathy was a member of adisliked outgroup (e.g., a fan from a rival football team), theparticipants presented not only a reduced empathy-related activa-tion but also an increased activation in reward-processing areassuch as the ventral striatum. In the same line, there is someevidence that the relationship with the other person mediates theneural mechanisms that are recruited when the observer is exposedto the target’s social pain (e.g., social exclusion). When individualsare exposed to the social suffering of strangers, emotion sharing isless likely and they tend to recruit mentalizing regions withoutrecruiting anterior cingulate and insula (Meyer et al., 2012). Thefact that empathy is a dynamic process in which we can exert somecontrol opens up possibilities for intervention in counseling psy-chology.

Implications for Psychotherapy and IntimateRelationships: The Hypothesis

of Physiological Synchrony

In their book, Ivey, Ivey, and Zalaquett (2010) start by express-ing the idea that counseling changes the brain of both the client andthe psychotherapist. In this section, we elaborate on how counsel-ing may change the social brain by promoting healthier interper-sonal interactions. We discuss possible ways in which knowledgeabout the neuronal correlates of empathy can be applied to coun-seling psychology, namely, to the therapeutic relationship betweenthe counselor and the client and to the context of intimate rela-tionships.

The empirical evidence that the degree of synchrony in theautonomic responses is a physiological component of empathy(Decety & Jackson, 2004), particularly of emotional contagion, hasimportant implications for counseling. The idea that when we arebeing empathic our autonomic nervous system tends to mirror thatof another person has been around for several decades (Ax, 1964;Kaplan & Blooms, 1960). Damasio (2003) proposed that we knowthe emotions of others when we simulate the way they would feelin ourselves, and this brain simulation rapidly changes our ongoingbody maps. This was supported by Adolphs, Damasio, Tranel,Cooper, and Damasio (2000), when they found that the somato-sensory cortex is involved in the recognition of emotion.

Likewise, in the context of intimate relationships, there is alsoevidence for the association between physiological linkage andempathy. Levenson and Ruef (1992) found that the accuracy ofrating negative emotion was greater for couples who presentedhigh levels of physiological linkage across time. In the same

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544 COUTINHO, SILVA, AND DECETY

direction, Thomsen and Gilbert (1998) found that, during conflic-tual interactions, couples in which partners’ patterns of heart rateand skin conductance were synchronous with one another hadhigher ratings of marital satisfaction. This is particularly relevantfor couple’s therapy, particularly in conflict situations in which theneed to empathize with negative feelings is more likely to alter thepattern of physiological activation of each element of the dyad.The context of intimate relationship is one of the main interper-sonal contexts in which empathy appears to be critical for thecouples’ 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 psy-chotherapeutic relationship. In a classical study from DiMascio,Boyd, and Greenblatt (1957), the authors concluded that the heartrates of psychotherapists and their clients during interviews movedin opposite directions when the client expressed antagonism to-ward the therapist. In the same year, Malmo, Boag and Smith(1957) found that the amplitude of the electromyogram obtainedfrom the chin of the examiner and the client during a diagnostictest both fell following praise and remained constant followingcriticism. More recently, Marci, Ham, Moran, and Orr (2007)found that the syncrony in the skin conductance level was associ-ated with the client’s perception of therapist’s empathic responsesand also with more positive socioemotional interactions for bothclients and therapists.

Taken together, these studies indicate that in order to respond inan empathic manner to their clients, therapists should be open to“feel” the emotional experience of their clients at the physiologicallevel, serving like a mirror of the clients’ distress. However, afteran initial period, in which the therapist matches the clients’ auto-nomic response, more empathic therapists are likely those betterable to biologically modulate their own and their clients’ auto-nomic level of sympathetic arousal. In other words, it may be thecase that biofeedback handles will allow more empathic cliniciansto modify their own autonomic arousal, which in turn will modu-late the client’s activation, leading to a synchronized and dynamic“autonomic dance” between both elements, instead of a rigidautonomic linkage in which both get stuck in high levels ofsympathetic activation.

The therapist’s ability to self-regulate his or her own affectivearousal is related with the personal costs, both physiological andcognitive, of being empathic. These costs are particularly relevantfor professional helping relationships (Gleichgerrcht & Decety,2011). Both functional imaging studies (Cheng et al., 2007) andevent-related potential studies (Decety et al., 2010) have shownthat physicians do not react to the pain of others in the same wayas nonphysicians. Specifically, they tend to activate more brainareas involved in executive functioning and self-regulation. More-over, as pointed out by Yamada and Decety (2009), the emotionalresonance with the other person’s suffering and associated re-sponse of autonomic arousal may work against empathic concernor prosocial behavior. This is so because to fully experience theother’s suffering activates fear and concerns for our own safety,which are usually associated with avoidance or self-protectivebehavior (e.g., Muraven & Baumeister, 2000). Moreover, theaffective arousal experienced by the empathizer spends attentionaland cognitive resources that can no longer be directed to attend tothe others’ suffering (Eisenberg & Eggum, 2009).

These lines of evidence suggests that training and supervisionprograms of psychotherapists and counselors must include specificlearning components that help these professionals to learn how toregulate their emotional arousal. Current training models in coun-seling education tend to emphasize external and observable com-munication of empathy rather than the internal mental processesthat lead to genuine empathic communication (Greason & Cash-well, 2009). Thus, students may learn to act as if they are beingempathic by correctly identifying and communicating about theclient’s feelings in a concrete and specific way, without necessarilydeveloping experiences of genuine empathy. Mindfulness trainingmay be an important tool to help future counselors develop self-regulation abilities instead of avoiding them or overidentifyingwith the emotional distress of their clients (e.g., Morgan & Mor-gan, 2005).

This evidence also offers important directions for counselingresearch, namely, for the study of effective therapeutic interven-tions, by offering objective and ecologically valid methods forassessing therapist’s empathic abilities. We think that the physio-logical linkage is an example of a research hypothesis that shouldbe further explored by new research paradigms in the field ofcounseling psychology. It is interesting to note that the notion thatempathy is related to the development of synchrony betweeninteracting members in a dyad is not new in the field. Severalstudies have already looked at synchrony at the behavioral level,namely, in terms of nonverbal cues. As an example, a recent studyby Imel et al. (2014) revealed evidence for vocal synchrony inclinical dyads as well as for the association of synchrony withempathy ratings. In the same direction, Ramseyer and Tschacher(2011) found that nonverbal synchrony is increased in sessionsrated by clients as having high relationship quality, and highernonverbal synchrony was associated with higher symptom reduc-tion. We propose that future research paradigms can extend thisanalysis to include neurobiological variables. Peripheral and cen-tral biomarkers of empathy can be innovative indicators that helpresearchers to move from the more traditional research paradigms,in which empathy has been typically measured either through theintrospective recall of the actors involved (clients and therapists)or through the independent ratings of trained observers. Despitethe unquestionable value of these methods used for decades incounseling research, we think they can be complemented by othermethods and measures coming from the neuroscience field. Thiscomplementary paradigm may help overcome some of the limita-tions of self-report or observational methods. Previous studiesconducted by us have shown that self-report measures have limi-tations in terms of the detection of complex interactive processessuch as ruptures in therapeutic alliance (Coutinho, Ribeiro, Sousa,& Safran, 2013), which are characterized by failures in the em-pathic processes. Thus, an alternative way of studying the efficacyof therapy is to explore what characterizes the neurobiology ofdyads in sessions rated by observers with high and low empathyscores, for example. In order to do this, peripheral measures can bedirectly applied to the therapeutic context without compromisingthe ecological validity of the study.

As examples of innovative studies that aim to integrate neuro-science methods with traditional research paradigms in counselingpsychology, we would like to mention two research projects thatare currently being conducted by members of our team. Oneproject explores the psychophysiological processes (EDA and

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heart rate) underlying therapeutic collaboration, defined as thebalance between therapist’s supporting interventions that help theclient to feel safe and challenging interventions that stimulatechange (Ribeiro et al., 2013). The second example refers to acurrent research project with couples that is being implemented bythe authors of the present article. This project measures the degreeof autonomic synchrony between both elements of the couple,while they perform a structured empathy task. This is followed byan assessment of the central biomarkers of empathy using an fMRIparadigm that consists of vignettes extracted from the previousvideotaped interaction.

Concluding Remarks

Human interpersonal relationships can both create and curepsychological disorders. Psychotherapeutic relationships are heal-ing interactions that can trigger changes in the brain through a safeand supportive relationship that is able to reshape neural networks(Cozolino, 2006). Our knowledge about the neural networks in-volved in the different dimensions of empathy is still developing;however, we think that the rapid increase of knowledge in social-cognitive neuroscience will provide the clinician with importantcues about the neuronal systems that are impaired and leading totheir client’s social problems. In a not-too-distant future, this willallow therapists to identify the type of psychological processes thatmust be enhanced in order to modulate the activity of thoseneuronal systems, promoting a process of positive neuroplasticity.In other words, in the future, the psychotherapist will be moreclose to assuming the role of a neuroscientist who investigateswhat in the brain needs to change and how. The application ofneuroscience methods to counseling research will also offer analternative empirical validation of therapeutic efficacy by provid-ing the scientific community with new indicators of effectivetherapeutic skills. Innovative studies like the one by Barsaglini,Sartori, Benetti, Pettersson-Yeo, and Mechelli (in press), whichdemonstrated that brain networks found to be dysfunctional inpsychological disorders were normalized after effective psycho-therapeutic intervention, have already pursued this line of research.We are just beginning to understand how the architecture of thebrain can help us to understand individuals and their relationships.We believe that the research on the neural correlates of empathywill have important clinical implications for the development ofeffective interventions of empathy promotion with couples andother populations, namely, for psychopathological disordersmarked by the deficits in the empathic abilities such as autism andpersonality disorders.

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Received December 1, 2013Revision received March 17, 2014

Accepted March 17, 2014 �

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