Journal of Counseling Psychology 2014, Vol. 61, No. 4, 541-548

© 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 Patricia Oliveira Silva

Jean Decety University of Chicago

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 relation­ ships 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: empa­ thy. 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 be­ cause 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 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 our relationships and that brains regulate one another during momentto-moment interactions (Lorberbaum et al., 2002). The establish­ ment 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 (Cozo­ lino, 2006). Another important source of evidence for the social brain hy­ pothesis 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 Patricia Oliveira Silva, Neuropsycho­ physiology 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: [email protected] 541

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the great majority of psychopathological disorders are character­ ized 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 antiso­ cial 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 interac­ tions (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 estab­ lishing 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 pro­ motion of client’s 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. How­ ever, empathy facilitates the development of the therapeutic alli­ ance (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 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, in press; Coutinho, Ribeiro, & Safran, 2010). The more empathically the therapist is able to respond to the client’s needs, the more likely it is the client’s 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 therapist’s 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 neu­ roscience— have both been accumulating evidence for the impor­ tance 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 con­ stitutes 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 other’s 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 typi­ cally defined as the ability to experience and understand the feelings of the other person and is associated with a set of thera­ pist’s behaviors such as unconditional acceptance of the client’s 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, em­ pathy 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 pro­ cesses (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, help­ ing 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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ence of pain (Rainville et a l, 1997) are activated when we observe other’s 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 person’s 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, ante­ rior 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 perception-action model of em­ pathy (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, Piemo, 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 person’s internal mental states by using our knowledge about the situation and the individual, with­ out 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 ventrome­ dial 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 an­ terior 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 people’s 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 re­ gions (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 discrimi­ nation (e.g., Ruby & Decety, 2004).

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Empathy and the Resting Brain As mentioned earlier, different brain systems seem to be in­ volved 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 other’s 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 “em­ pathy 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 “base­ line” 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 ani­ mals 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, & Gonfalves, 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, & Gonsalves, 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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orbitofrontal gyri), whereas A that was more involved in the ability to respond to other people’s 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 ah, 2011). Preliminary evidence has shown that through this tech­ nique, 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 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 R waves in the electrocardiographic curve (Frazier et al., 2004), and the electrodermic activity (EDA) (Boucsein, 2012) constitute in­ dices 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 physiolog­ ical 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 im­ plications 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 Gonfalves (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-Cemy, 2007) or too low physiological arousal—normally 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 auto­ nomic 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 experi­ ence 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 empa­ thizer, 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 antag­ onistic 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 activa­ tion 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 target’s 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 psy­ chology.

Implications for Psychotherapy and Intimate Relationships: 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 and the 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 knowledge about the neuronal correlates of empathy can be applied to coun­ seling psychology, namely, to the therapeutic relationship between the counselor and the client and to the context of intimate rela­ tionships. 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 somato­ sensory 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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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 couple’s 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 interper­ sonal 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 psy­ chotherapeutic 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 to­ ward 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 associ­ ated with the client’s perception of therapist’s 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’ auto­ nomic response, more empathic therapists are likely those better able to biologically modulate their own and their clients’ auto­ nomic 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 modu­ late the client’s 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 therapist’s 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. More­ over, as pointed out by Yamada and Decety (2009), the emotional resonance with the other person’s suffering and associated re­ sponse of autonomic arousal may work against empathic concern or prosocial behavior. This is so because to fully experience the other’s 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 coun­ seling education tend to emphasize external and observable com­ munication 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 client’s 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 self­ regulation abilities instead of avoiding them or overidentifying with the emotional distress of their clients (e.g., Morgan & Mor­ gan, 2005). This evidence also offers important directions for counseling research, namely, for the study of effective therapeutic interven­ tions, by offering objective and ecologically valid methods for assessing therapist’s empathic abilities. We think that the physio­ logical 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 reduc­ tion. We propose that future research paradigms can extend this analysis to include neurobiological variables. Peripheral and cen­ tral 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 limita­ tions of self-report or observational methods. Previous studies conducted by us have shown that self-report measures have limi­ tations 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 em­ pathic 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 neuro­ science 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

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heart rate) underlying therapeutic collaboration, defined as the balance between therapist’s 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 heal­ ing 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 in­ volved 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 client’s 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 provid­ ing 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 psycho­ therapeutic 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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