There are so many different psychotherapeutic approaches, it’s becoming harder every day to track all the acronyms¹, let alone figure out how to start therapy.

We often hear more about CBT (cognitive-behavioral therapy), a straightforward-seeming approach in which unhelpful cognitions and their impact on feeling and behavior are examined and corrected over time (ABC: Affect-Behavior-Cognition).

Contrasted with CBT is traditional psychodynamic (or psychoanalytic) therapy, focusing on the impact of developmental factors on adult patterns of personality and relationship forming. Psychodynamic therapy highlights understanding the meaning of things, honoring ambiguity and taking time to work through complexities, and receiving less frequent direction from the therapist².

While CBT is typically presented as being more “evidence-based,” in reality both forms of therapy have similar statistical effect sizes. Psychodynamic therapy, however, has been found to have more enduring benefits after therapy stops, carrying forward on many levels including mental function, emotion, relationships, self-care, and behavior (Harari and Grant, 2022).

Empathy as a Core Common Therapeutic Factor

Regardless of therapy type, four common factors are thought to underlie psychotherapies: the treatment alliance, or therapeutic relationship; empathy, and related factors including compassion; expectations of and goals for treatment; and the effect of individual therapist style, or therapist “use of the self” (Wampold, 2015). Effective therapy is characterized by a change in self-acceptance, self-knowledge, relationship quality, and/or consideration toward other people (related to empathy and compassion).

For practicing therapists, empathy is a key factor allowing for perspective-taking in the form of both cognitive and emotional empathy, understanding intellectually and resonating effectively with the other’s inner state. Empathy serves as a foundation for both the therapeutic relationship as well as the capacity to reflect on one’s own inner states, and others’ (mentalization). In addition, patients in therapy take in the empathic relationship, ideally developing greater self-compassion and empathy for themselves and others. Empathy is, of course, important not only in therapy but in all relationships.

Inside the Therapist Brain

While most people who want to become therapists are likely high in empathy from the get-go, it’s important to understand how empathy develops with training and experience, and how this shows up in the brain.

Olalde-Mathieu and colleagues (2022) conducted research presented in the journal Neuroscience comparing brain activity between a group of 52 therapists and a comparison “control” group of 92 non-therapists. Measurements related to empathic capacity were correlated with resting-state brain connectivity to look for significant differences.

The therapists had been in practice an average of 15 years in “Person-Centered Therapy“–a form of dynamic therapy focusing on humanistic principles and close attunement. A subgroup of participants underwent resting-state fMRI (functional brain scanning) to look at baseline brain connectivity when not engaged in any particular task.

Participants completed two relevant psychological assessments, the Interpersonal Reactivity Index (IRI) and the Emotional Regulation Questionnaire (ERQ). The IRI measures four factors:

1. Fantasy, or the ability to imagine oneself in the place of another, such as while watching a movie.
2. Perspective Taking, or seeing things from the other person’s point of view, for instance during an argument.
3. Empathic Concern, or how moved one is by things that they witness.
4. Personal Distress; for example how embarrassed we become when we hear another person talk about their problems.

The ERQ looks at the extent to which a given person is likely to both reappraise situations (rather than taking them at face value) and buffer the expression of strong emotions in the face of challenges to self-control.

Psychotherapists had higher cognitive empathy in both Fantasy and Perspective Taking, but were similar to non-therapists on Emotional Empathy, Empathic Concern, and Personal Distress. Therapists were less likely to use emotional suppression for regulation and there were no differences between therapists and non-therapists in the use of reappraisal for coping. While there were no empathy-related differences between female and male therapists, women in the non-therapist group were higher on Empathic Concern and less likely to suppress emotion than men.

Functional connectivity in the brain at rest was different for therapists than for people who were not therapists. Therapists had greater connectivity between the left anterior insula (LAI) and dorsomedial prefrontal cortex (dmPFC), and less connectivity between the rostral anterior cingulate cortex (rACC) and orbitoprefrontal cortex (oPFC). Therapist Perspective Taking was correlated with lower LAI and dmPFC, and lower rACC and oPFC connectivity.

For both therapists and non-therapists, LAI-to-dmPFC connectivity correlated with Fantasy, and rACC-to-oPFC connectivity correlated with 1) Perspective Taking, with greater connectivity associated with lower scores; and 2) Expressive suppression, with greater connectivity associated with lower scores.

Relevance

Therapists scored higher on Fantasy and Perspective Taking, and were less likely to inhibit emotional responses. While for non-therapists, women were more empathic than men, for therapists no sex differences were found. This is what we might expect to find, especially in therapeutic approaches like Person-Centered Therapy which highlight attunement and focus on individual identity and authenticity. To that point, male therapists were less likely to suppress emotion than both female or male non-therapists.

The anterior insula mediates empathy, emotional awareness, compassionate and maternal attachment, as well as negative experiences including disgust and revulsion. The dmPFC is involved with self-reflective awareness, or mentalization, as well as executive function. It makes sense that they are connected more strongly in the presence of greater empathy, and that this is increased in a group (therapists) who cultivate their capacity for empathy, connection, and emotional awareness and expression.

The rACC is involved with conflict resolution and the oPFC with the rational processing of decisions, including impulse-control and inhibition. Inhibitory control, the ability to stop oneself when need be, is critical for self-regulation. Study authors suggest that underlying brain activity is associated with therapists’ capacity to reserve judgment, and to hold back from jumping to conclusions in the face of strong emotional reactions. By putting the brakes on knee-jerk appraisals based on implicit prejudices, therapists may be better able to slow down and see things from alternative points of view. At the same time, therapists must be able to access spontaneity and playfulness when appropriate, requiring a delicate balance.

Therapists are generally meant to be more self-aware, having “done the work” themselves; this capacity hopefully allows for greater openness and flexibility in relation to others through analysis of one’s own “countertransference” or reactions to patients within the therapeutic interaction which may be related to the therapist’s own background. (Patients’ reactions are called “transference,” transferring patterns from other relationships into therapy, where they can be observed and worked through.)

Norms within therapy, including greater empathy and a focus on the therapeutic alliance, mean that therapists practice these skills regularly. Given that practicing different behaviors associated with personality leads to changes in those personality traits, it is not surprising that therapists not only develop greater empathy and emotional expression, but also that these changes are reflected in resting-state brain activity.

In addition to its relevance for understanding how therapy changes the brain and how brain activity underlies core therapeutic factors, this research enhances our general understanding of the neuroscience of empathy, and suggests that these capacities can be cultivated more broadly.

Originally published in Psychology Today on April 13, 2022

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