Relational psychophysiology: Lessons from mother–infant physiology research on dyadically expanded states of consciousness

Abstract

The authors illustrate how their work on mother–infant “relational psychophysiology” might inform psychotherapy research. They examined psychophysiology in 18 mother–infant dyads (infants' age: 5 months) during normal interaction and a still-face perturbation. They measured respiratory sinus arrhythmia (RSA) as an index of emotion regulation and explored whether skin conductance (SC) concordance, previously linked to therapist empathy, occurs in mothers and infants. During the still-face episode, SC concordance correlated to infant negative engagement. Upon reengagement, when mothers often soothe their infants, concordance instead correlated to behavioral synchrony, an index of maternal sensitivity. Furthermore, maternal RSA became correlated to infant negative engagement. These findings suggest that a mother trying to calm her infant calms herself physiologically and her sensitivity on a behavioral level becomes coherent physiologically. Implications for psychotherapy research are discussed.     

Naturalizing empathy

Empathy is the ability to share emotions with others. It is acknowledged to be a powerful means of tacit communication, a key ingredient in any therapeutic relationship as well as in psychotherapy. Empathy is the cornerstone in the humanist perspective (Ego-psychology) in clinical psychology. This approach is often considered as poorly grounded on scientific and objective evidence. It is however acknowledged that empathetic therapists are more effective than less empathetic therapists. I shall argue that this paradox, i.e. it is the least scientific and the less validated psychotherapeutic approach that is the most efficient, can be eliminated if one considers the nature of empathy, its biological foundation, its evolutionary origin and its cognitive architecture. In this paper I will suggest that empathy is based on specific information processing modules which have been designed by natural selection to cope with social regularities in expressing and reading emotional states. This has provided adaptive benefits to individuals living in large groups bestowing them with mechanisms for cooperativity, altruism and more generally various aspects of prosocial behaviour. The capacity to express emotions, and to read and understand emotions of others also ensures implicit communication with others and may be at the root of intersubjectivity. This perspective on empathy is then articulated with two concurrent hypotheses regarding theory of mind (the simulation and the theory-theory) which aim to explain the human capacity to understand that the behaviors of other intelligent agents are caused by intentions, desires and beliefs. In this context, empathy can be considered as a simulation (or analogical) process that is necessary to understand but not sufficient to interpret other people. This last issue is relevant to clinical practice.     

Development of neural correlates of empathy from childhood to early adulthood: an fMRI study in boys and adult men

Although empathy is rooted early in life, the ability to understand and share the emotions of others continues to develop after childhood. Here, we aimed at exploring developmental changes in the neural mechanisms underlying empathy from childhood to early adulthood. Using functional magnetic resonance imaging, 47 healthy male subjects aged 8–27 years were investigated during an explicit empathy task. Emotional faces were presented and participants were either asked to infer the emotional state from the face (other-task) or to judge their own emotional response to the face (self-task). A perceptual decision on the width of faces was used as a control condition. Age-related activity increases were observed in the fusiform gyrus and inferior frontal gyrus, depending on whether subjects attributed emotions to self or other. During the self-task, activity in the right precuneus and right intraparietal sulcus decreased as a function of age. No age-related differences were observed in behavioral performance measures. Increased activity in the fusiform gyrus and in the frontal component of the human mirror neuron system with increasing age may be explained by greater experience and expertise accumulated during socio-emotional interactions. Greater recruitment of right parietal structures in younger as compared to older subjects might reflect developmental differences in the cognitive strategies to infer one’s own emotional response. This study is the first to show developmental changes in the neural mechanisms supporting empathy. Our findings may have important implications for the development of novel therapeutic interventions in clinical conditions characterized by empathy deficits, such as autism spectrum disorder.     

Empathy. We know what we mean, but what do we measure?

In recent years, quantitative researches on the empathic process in psychotherapy have resulted in definite recommendations for the technique of psychotherapy and the training of psychotherapists. What is not always observed, however, is that the methods employed for studying empathy have been based on brief segments of patient-therapist interaction in which judgments of empathy do not depend on hearing the patient's communications, and are in several ways discordant with what is meant by empathy according to clinical theory. Evidence suggests that it is the rater's impression of the "goodness of psychotherapy" rather than empathy that is being captured by these methods.     

Empathy

After defining empathy, discussing its measurement, and offering an example of empathy in practice, we present the results of an updated meta-analysis of the relation between empathy and psychotherapy outcome. Results indicated that empathy is a moderately strong predictor of therapy outcome: mean weighted r = .31 (p < .001; 95% confidence interval: .28-.34), for 59 independent samples and 3599 clients. Although the empathy-outcome relation held equally for different theoretical orientations, there was considerable nonrandom variability. Client and observer perceptions of therapist empathy predicted outcomes better than therapist perceptions of empathic accuracy measures, and the relation was strongest for less experienced therapists. We conclude with practice recommendations, including endorsing the different forms that empathy may take in therapy.     

Empathy: misconceptions and misuses in psychotherapy

The frequent misconceptions and misuses of empathy that occur during psychotherapy are related to confusion about the definition of empathy, misunderstanding of the difference between the process of empathy and the therapist's response of being empathic, countertransference exploitation of empathy to act out the therapist's needs, the therapist's unawareness of the "layering" phenomenon, and overlooking the patient's level of self-other differentiation. These misuses result in the patient's feeling misunderstood and damaged, with a subsequent weakening of the therapeutic alliance and, at times, a breakdown in self-other differentiation. Once identified, misuses should be addressed and explored in psychotherapy to offset disruptions in treatment.     

The meaning bearing other--a relational view of the child psychotherapeutic process

With child psychotherapy as the point of departure, meaning making in therapy may be described in light of the patient's relationship to the psychotherapist as "a meaning bearing other"-that is, someone who allows the possibility of meaningful thoughts and feelings, either through his or her actual communicative presence or as an unconsciously imagined communication partner. Within the theoretical framework of this article, being with a meaning bearing other is regarded as a prerequisite for development of both immediate, playful and reflective understanding of needs, wishes, and affect in self and other. The term meaning bearing other refers to three distinct but often synchronic modes of relatedness. These may be seen as developmental imperatives in both parenting and psychotherapy. The present article is a theoretical and clinical inquiry into the prerequisites for change in relationally oriented psychoanalytic psychotherapy. The article discusses what might be seen as basic forms of relatedness and interaction in light of Winnicott's developmental approach, relational and neo-Kleinian approaches within psychoanalysis, and also Heidegger and Gadamer's philosophy of meaning and interaction. The theoretical points of view are illuminated and illustrated through an excerpt from the first session from a twice-a-week psychotherapy with a 5-year old boy.     

MDMA enhances emotional empathy and prosocial behavior

3,4-Methylenedioxymethamphetamine (MDMA, ‘ecstasy’) releases serotonin and norepinephrine. MDMA is reported to produce empathogenic and prosocial feelings. It is unknown whether MDMA in fact alters empathic concern and prosocial behavior. We investigated the acute effects of MDMA using the Multifaceted Empathy Test (MET), dynamic Face Emotion Recognition Task (FERT) and Social Value Orientation (SVO) test. We also assessed effects of MDMA on plasma levels of hormones involved in social behavior using a placebo-controlled, double-blind, random-order, cross-over design in 32 healthy volunteers (16 women). MDMA enhanced explicit and implicit emotional empathy in the MET and increased prosocial behavior in the SVO test in men. MDMA did not alter cognitive empathy in the MET but impaired the identification of negative emotions, including fearful, angry and sad faces, in the FERT, particularly in women. MDMA increased plasma levels of cortisol and prolactin, which are markers of serotonergic and noradrenergic activity, and of oxytocin, which has been associated with prosocial behavior. In summary, MDMA sex-specifically altered the recognition of emotions, emotional empathy and prosociality. These effects likely enhance sociability when MDMA is used recreationally and may be useful when MDMA is administered in conjunction with psychotherapy in patients with social dysfunction or post-traumatic stress disorder.     

Compassion in psychotherapy: The perspective of therapists nominated as compassionate

Abstract

Fourteen therapists nominated by peers as compassionate defined compassion in psychotherapy as connecting with the client's suffering and promoting change through action. They indicated that compassion was broader and deeper than empathy, helps clients feel understood, and relieves symptoms. Although indicating that compassion was innate, therapists felt it could be further awakened. Factors facilitating compassion in therapy were therapists feeling clients’ suffering, understanding client dynamics, identifying with and liking clients, client involvement, and a good therapy relationship. Hindering factors included clients being resistant, being aggressive, having serious pathology, or violating boundaries; therapists having interfering personal issues, feeling incompetent, or having negative reactions to or not liking clients; and a poor therapy relationship. A theory regarding compassion in psychotherapy is proposed.     

Biomarkers in the psychotherapeutic relationship: the role of physiology, neurobiology, and biological correlates of E.M.P.A.T.H.Y

Emerging biomarker research could powerfully influence the practice of psychotherapy, a standard treatment that is as strongly rooted in brain plasticity as are psychopharmacologic interventions. Psychotherapy is associated with measurable changes in central and peripheral neurophysiology. These markers could be harnessed to aid informed, personalized recommendations for specific psychosocial treatments, to guide a course of treatment, and to predict treatment outcomes, in lieu of relying on costly, trial-and-error approaches. Psychotherapy and empathy research also demonstrate that the patient-doctor relationship has important neurophysiological correlates that can be salient to treatment outcomes, as illustrated in a case example. These correlates include autonomic nervous system arousal manifested by heart rate, respiration rate, muscle tension, and galvanic skin resistance; electroencephalography; and brain-imaging markers. While additional biomarker research is unfolding, there are specific neurobiologically based clinical and subclinical observations, organized by using the E.M.P.A.T.H.Y. mnemonic, that may guide and enhance psychotherapy. Empathic attunement to patients is equally relevant for psychopharmacologic interventions and psychotherapy, and for all patient-doctor relationships.     

A critical look at the assumptions of cognitive therapy

The cognitive perspective has been a dominant force in psychology and psychotherapy since the 1970s. Cognitive therapists assume that changing cognition is the key to bringing about changes in emotional reactions and symptomatic behaviors. This article examines evidence that is not consistent with the assumptions of cognitive therapy. First, neurobiological evidence is not consistent with the assumption that cognitions are necessary for emotions. Limbic structures allow for the possibility that emotions can be experienced without cortical processing. Second, research indicates that experiences can be stored as isolated affective fragments that distort cognitive functions. The assumptions of contemporary psychoanalytic models of therapy are consistent with this evidence.     

Relating empathy and emotion regulation: Do deficits in empathy trigger emotion dysregulation?

Emotion regulation is a crucial skill in adulthood; its acquisition represents one of the key developmental tasks in early childhood. Difficulties with adaptive emotion regulation increase the risk of psychopathology in childhood and adulthood. This is, for instance, shown by a relation between emotion regulation and aggressive behavior in childhood age, indicating emotion dysregulation as an important risk factor of aggressive behavior and potential precursor of psychopathology. Based on (1) interrelations between emotion processes and social information processing (maladaptive emotion regulation and social information processing are associated with higher levels of aggression) and (2) recent neuroscientific findings showing that empathy deficits might not only result in difficulties labeling others' emotions but one's own emotions too, we suggest that empathy deficits might serve as potential trigger of emotion dysregulation. Different studies investigating the relation between empathy and emotion regulation are presented and discussed. Discussions are based on the assumed potential of empathy deficits triggering emotion dysregulation. Furthermore, developmental neuroscientific findings on empathy and emotion regulation are highlighted which provide further insights on how these processes might relate. Finally, possible directions for future research are presented.     

Recurrent attacks of fear and visual hallucinations in a child

The case of a 7-year-old boy suffering from recurrent nocturnal and occasional daytime attacks with intense fear and complex visual hallucinations is presented. His state was otherwise normal, as were routine electroencephalographic (EEG) and magnetic resonance imaging (MRI) investigations in the past. Several differential diagnoses such as panic disorder, pavor nocturnus, and nightmares were considered but could not be definitely established or excluded. Since the attacks appeared after the divorce of his parents, an adjustment disorder was suspected, and the patient received psychotherapy for more than 2 years without an effect on the attacks. Only when long-term video-EEG recorded two typical attacks with left temporal ictal seizure patterns was focal epilepsy diagnosed and successfully treated with antiepileptic medication. A suspected origin of seizures in the amygdala was supported by a high-resolution MRI showing a cortical dysplasia extending from the left anteromedial temporal lobe to the amygdala. The case exemplifies difficulties in the differential diagnosis of panic-like attacks and underlines the value of long-term video-EEG, which may be necessary to establish the correct diagnosis and to prevent ineffective therapeutical approaches.     

Referral issues in psychotherapy and psychoanalysis

The authors consider the complex decisions involved in the initial consultation of a person looking for treatment when this person must be referred to a professional colleague. They explore the way decisions are made in the referral processes and the complex practical and transference-countertransference issues that arise at the outset and whenever second opinions are sought during an ongoing psychotherapy. They present four clinical examples in varying detail to emphasize how readily misunderstandings can develop when even experienced consultants are not sufficiently alert to the complex conscious and unconscious motives and messages being expressed in the exchanges. They make recommendations on how to conceptualize and respond to them.     

The therapeutic empathic communication (TEC) process

While the communication of empathy is thought to be a curative factor in psychotherapy, current conceptualizations usually focus on empathy as only an attitude or state of mind of the therapist. A five-stage model of therapeutic empathic communication is presented. The model is applied to analyzing the therapeutic impact of empathic communication in dynamic psychotherapy. Its usefulness is demonstrated in a case example.     

The influence of interpersonal factors on the speed of recovery from major depression

Abstract

Previous research has established that a subsample of depressed patients may experience an early positive response to psychotherapy. The preconditions of this phenomenon were studied in 62 depressed adults receiving 16 weekly sessions of supportive–expressive dynamic psychotherapy. One third of the sample experienced an early rapid response (ERR), defined as a reduction of at least 50% of their intake Beck Depression Inventory score by Week 6. Despite equivalent ratings of working alliance between ERR and non-ERR patients, the former were five times more likely to recover. Pretherapy characteristics of depressed patients less likely to rapidly respond included a lower interpersonal mastery, a more domineering interpersonal style, and greater social isolation and attachment fears concerning intimacy. As a whole, these findings suggest that ERR and non-ERR patients present with dissimilar interpersonal patterns, requiring different psychotherapeutic approaches.     

Empathy deficits in Asperger syndrome: a cognitive profile

Although lack of empathy has been considered a central characteristic of Asperger syndrome, quantitative and qualitative assessments of empathy in this syndrome are lacking. We present two cases of adolescents with Asperger syndrome who show extreme deficits on measures of both cognitive and affective empathy. Analysis of their performance on tasks assessing cognitive and affective processing did not reveal significant impairment in executive functions, nor in their ability to recognize emotions or the ability to create a mental representation of another person's knowledge. However, both patients were unable to integrate the emotional content with mental representations and deduce the other person's emotional state. These results suggest that impaired empathy in individuals with Asperger syndrome may be due to impaired integration of the cognitive and affective facets of the other person's mental state.     

Growth curves of clients’ emotional experience and their association with emotion regulation and symptoms

Objective: Emotional experience during psychotherapy is considered a core mechanism of change. Yet the sheer experience itself may not necessarily be beneficial; instead, the trajectories of emotional experience need to be explored as possible predictors of treatment outcomes. This study investigated whether clients’ pre-treatment levels of emotion regulation and symptoms predicted patterns of session-to-session change in emotional experience. We also explored which patterns better predict clients’ improvement in emotion regulation and symptoms from pre- to post treatment. Method: One-hundred and seven clients undergoing psychodynamic psychotherapy completed questionnaires on their symptoms and emotion regulation at pre- and post- treatment. They also reported their level of emotional experience at the end of each session. Results: Pre-treatment symptoms and difficulties in emotion regulation predicted greater instability in emotional experience. Higher mean levels of emotional experience during treatment were associated with an improvement in emotion regulation, and greater stability during treatment was associated with improvement in emotion regulation and symptoms. Conclusions: These findings lend weight to the idea that experiencing emotion in the therapeutic environment has significant implications for clients’ ability to manage their emotions outside the session. However, emotions experienced in an unstable manner within therapy are associated with poorer outcomes.

Clinical and methodological significance of this article: Therapists can benefit from observing the patterns and not only the level of their clients’ emotional experiences. The identification of clients’ difficulties early in treatment may help therapists guide clients through the delicate process of carefully attending to their emotions.