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Alessandra Colfi, Ph.D.(c)
Expressive Arts Therapy Doctorate Dissertation




" play it out is the most natural self-healing measure childhood affords"
Erik Erikson

Home Title Content Introduction Why a web-based Dissertation
Chapter 2:
Review of  Literature on Empathy
Ch. 3: Mirror Neuron - Empathy occurs in the Brain Ch 4 Story Telling
Cancer Patients Developmentally Disabled P.E.A.C.E. Bibliography

Chapter 3

Mirror Neurons - Empathy occurs in the Brain

through the Expressive Arts

Chapter 3

Mirror Neurons: Empathy Occurs in the Brain through the Expressive Arts

Whatever the intellectual quality of the education given our children, it is vital that it

include elements of love and compassion, for nothing guarantees that knowledge alone

will be truly useful to human beings. Among the major troublemakers society has known,

many were well-educated and had great knowledge, but they lacked a moral education in

qualities such as compassion, wisdom and clarity of vision.  ~ H.H. The Dalai Lama

The working assumption is that our psyche doesn’t distinguish between our personal experience of an event or emotion and witnessing someone else having the same experience, or seeing it in a movie or playing it out in an enactment, a ritual, etc.


The simulation “links imaginative stories to lived narratives”

(video: Feldman, 2006)


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I use visualization as a rehearsing tool in a wide range of instances, from when preparing for a session or a presentation, carefully reviewing in my mind the location and its logistics, what I’m going to do, what I need to set up, when, and especially what I’m going to say, do and how, down to mundane instances of planning a series of errands, attending an event, planning for a change of clothes, etc.  By doing so, I feel prepared to “perform”, and more confident and ready to overcome additional unforeseen aspects, changes and events. ‘Rehearsing’ each performance in their minds works well for athletes; increased blood flow to the muscles and measurable muscle contraction has been recorded during visualization resulting in improved athletic performance (Samuels and Samuels, 1975).


Facilitating creative processes with clients who have specific challenges in their lives, like cancer, anxiety, developmental disabilities, or have suffered physical and emotional trauma and abuse, allows me to observe empathy in action and assess clients needs. It also guides me in  creating treatment programs and interventions that enhance an individual’s awareness, their ability to empathize and their resilience.


The creative expression or output is a mirror of thought processes, visualization and emotional content and can be better understood and put to fruition with the help of neuroscience, through an observation of neurobiological mechanisms highlighting empathy during the therapeutic process. I am particularly interested in the empathic relationship that takes place among clients, between client(s) and therapist and between each client and his or her artistic expression – any visual art, movement/dance, music and sound, enactment/drama.  The manifestation of emotional, psychosocial and cognitive functions then relates to perceived and/or measurable improvement in the quality of life. What is really happening then?  As most artists know and often apply intuitively, even without direct awareness, in this discovery lays the foundation of the therapeutic process, now subject of neuroscience; investigating psychosocial and cognitive functions includes issues related to attunement and attachment theory, empathy, social cognition and morality.


This gives an empirical, experience-based ground to inquire and look at a theory in neuroscience about Mirror Neuron Circuitry, integrating action and perception. According to this theory we have neuron circuits in the pre-motor cortex that ‘fire’ when we either perform a given action or see someone else performing the same action or imagining it.


Neuroscientist Vilayanur Ramachandran, a neuroscientist best known for his work in the fields of behavioral neurology and psychophysics, Director of the Center for Brain and Cognition and is currently a Professor in the Department of Psychology and the Neurosciences Graduate Program at the University of California, San Diego, outlines the fascinating functions of mirror neurons. Only recently discovered, these neurons allow us to learn complex social behaviors, some of which formed the foundations of human civilization as we know it.

Although it is outside the field and scope of this dissertation, and well beyond my specific expertise, I will attempt to lay out an overview of the neuroscience supporting this assumption. In more general terms, the arts are valuable and meaningful expressions and catalysts for symbolic understanding and transformation.

Now, one recent discovery that has been made by researchers in Italy, in Parma, by Giacomo Rizzolatti and his colleagues, is a group of neurons called mirror neurons, which are on the front of the brain in the frontal lobes. Now, it turns out there are neurons which are called ordinary motor command neurons in the front of the brain, which have been known for over 50 years. These neurons will fire when a person performs a specific action. For example, if I do that, and reach and grab an apple, a motor command neuron in the front of my brain will fire. If I reach out and pull an object, another neuron will fire, commanding me to pull that object. These are called motor command neurons that have been known for a long time’.

But what Rizzolatti found was a subset of these neurons, maybe about 20 percent of them, will also fire when I'm looking at somebody else performing the same action. So, here is a neuron that fires when I reach and grab something, but it also fires when I watch Joe reaching and grabbing something. And this is truly astonishing. Because it's as though this neuron is adopting the other person's point of view. It's almost as though it's performing a virtual reality simulation of the other person's action’ (Ramachandran, 2009).

Italian neuroscientist Vittorio Gallese (2005a) has been researching mirror neurons and their association with imitation, empathy and intersubjectivity. The psychotherapeutic implications of mirror neurons have an enormous clinical relevance for the creative arts therapies. The relationship between neuroscience and the arts has been increasingly receiving attention and rightly so, excitement with the possible applications and benefits for an ever-widening population.  Since the mid 1990s a group of Italian neuroscientists including Gallese documented discovering a type of pre-motor neurons that were becoming activated not only ‘in brain of the monkey performing the actions of grasping objects with its hand, but in a monkey or human witnessing those actions’ (1996). These neurons have been called ‘mirror neurons’; these neurons show the same behavior whether the person is engaged in the action or in the emotional event, whether he or she is only witnessing the same action or emotional event. Gallese (2005b) recognized that these mirroring behavioral properties are crucial in explaining social, kinesthetic and emotional processing as well as cognitive understanding. The neuronal ‘sparks’ or discharges are caused by a ‘direct simulation of observed events through the mirror mechanism’ (p.1), not by conscious reasoning.

A fundamental concept is that the mirroring behavior is activated in relation to a stimulus outside the self, which means, in relationship to another. It is believed that this type of pre-motor neurons could be located in those parts of the brain that respond to sensory-motor stimuli - visual, olfactory, tactile, auditory and gustative (Gallese, 2003, 2004, 2005a).


Empathy is defined as ‘emotional and/or intellectual identification with another, vicarious experiencing of the feeling or ideas of another’ (Guralnik, 1992). Empathy extends beyond the simple fact that one understands another’s emotional state; it embodies the experience of that state (Dolan, 2005; Gallese, 2003, 2005a & b). Similarly, Stern (1985, 2000), consider empathy ‘an embodied affective resonance that involves some level of cognitive processing. Cognition and emotion are integral to the evolvement of empathy’; the presumption is that neuronal connectivity between the prefrontal cortex and the limbic system serve as vital conduits.


Although, again, it is beyond the scope of this dissertation to lay out and give a detailed account of brain structure and functions as in neuroscience, here follows a vivid description by Diane Ackerman (2004) that paint a most fascinating picture of the human brain in a blend of poetry, playfulness and colloquial, ‘plain English’ science:

‘Imagine the brain, that shiny mound of being, that mouse-gray parliament of cells, calling all the shots, that dream factory, that petit tyrant inside a ball of bone, that huddle of neurons calling all the plays, that little everywhere, that fickle pleasure dome, that wrinkled wardrobe of selves stuffed into the skull like too many clothes into a gym bag. The neocortex has ridges, valleys and folds because the brain kept remodeling itself even though space was tight. We take for granted…the undeniable fact that each person carries around atop of the body a complete universe in which trillions…of sensations, thoughts and desires stream.  They mix privately, silently, while agitating many levels, some of which we’re not aware of…Our brain is a crowded chemistry lab, bustling with non-stop neuro conversations…an impersonal landscape where minute bolts of lightning prowl and strike…Sometimes it’s hard to imagine the art and beauty of the brain because it seems too abstract and hidden an empire, a dense jungle of neurons…thousands of wires…influenced by a caravan of hormones and enzymes’ (pp. 3, 4, 6).


Now let’s take a look at a report by Luppino and Rizzolatti (2000), helping us to focus on the pre-frontal motor areas of the cerebral cortex; these areas are responsible for converting incoming sensory information into actions. Frontal cortex gets activated when we self-reflect. And here other complex behaviors are reported, including imitation and awareness of actions performed by others, which Luppino and Rizzolatti name ‘associative motor learning’. These are the workings of ‘mirror neurons’, which owe their name to the very fact that they are actively engaged in the process of simulation. (Bloom et al, 1985; Diamond et al, 1985; Luppino and Rizzolatti, 2000; Restak, 1984).

                        Brain picture


Of interest with regards to receiving information that activates mirror neurons is the occipital lobe, inserted between the parietal and temporal lobes. The occipital lobe is the primary visual center, directly linked to the eyes via the optic nerves. This area is dedicated to higher-level interpretation and/or analysis of visual information (Diamond et al., 1985; Luppino & Rizzolatti, 2000; Restak, 1984).


Gallese attributes a major role to the insula, a structure in the cerebral cortex, extending beneath the frontal, parietal and temporal lobes.  Mirror neurons within the insula are of specific interest to Gallese and his associates  (Gallese, 2003, 2005a; Rizzolatti, Fogassi & Gallese, 2001; Wicker et al., 2003). 


The insula is responsible for integrating autonomic information (Diamond et al., 1985). The association of mirror neurons with a personal value system, a social conscience, consciousness, awareness of the full range of feelings is of particular interest.


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This region networks with the limbic system, a C-shaped neural structure between the neo-cortical lobes and the brain stem; the limbic system participates in regulating the autonomic nervous and endocrine systems, as well as the flight-fight-freeze responses. The limbic system generates primary emotions like fear, anger, sadness, joy, disgust as well as aggression, and presides over homeostasis. In the system we note the amygdala, which associates with fear, pleasure and aggression (Bloom et al., 1985; Diamond et al., 1985; Nolte, 1981; Restak, 1984). The hippocampus has a key role in recording short term memory.


The brain stem functions like a ‘transfer station’ of electro-chemical discharges, which are selected and directed to activate muscles for action, thoughts and/or behavior. It also plays a crucial role in affecting and controlling basic functions like swallowing, respiration, heart rate, blood pressure, aspects of consciousness and arousal states (Bloom et al., 1985; Diamond et al., 1985; Nolte, 1981; Restak, 1984). Each electrical discharge fuels the release of a neuro-chemical substance – a neurotransmitter which in turn, triggers other cells carrying affiliated compounds. A specific group of neurotransmitters known as dopamine, norepinepherine and serotonin, are produced by amino acids and have been attributed a major role in affective states (Kolb & Wishaw, 1985; Restak, 1984, Thompson, 1975).


Although the depths and the complexity of the brain cannot be fully explored and expressed here, I’m confident in stating that isolating each part doesn’t do justice to the whole. Restak (1984) has given us a glimpse into the complex, interrelated and coordinated chain of events of nerve cells in both hemispheres which all have to act in concert even for simple actions like picking up a pencil to take place. It’s well accepted that the brain has highly specialized areas and yet acts as a highly sophisticated global system on a mission, which is the outward manifestation of meaningful actions and behaviors (Berrol, 1992).


How do we formulate a theory around mirror neurons and empathy, especially since research is constantly evolving?


The common definition of empathy is ’emotional and/or intellectual identification with another; vicarious experiencing of the feeling or ideas of another’ (Guralnik, 1992). Stern consider empathy an ‘embodied affective resonance that involves…cognitive processing’ (Stern 1985, 2000). We accept that mirror neurons are connected to psychological, social and cognitive experiences, development and behaviors, as well as empathy and morality (Gallese, 2005a, 2005b; Gallese & Goldman 1998; Goldman 2005; Schore, 1994; Stern, 1985, 2000). We can then assume that the neuronal connectivity between the prefrontal cortex and the limbic system is the vehicle for empathy to take place.


It’s clear that inter-subjectivity is a key aspect of empathy and how the mirror neurons become activated. Stern (1985, 2000) postulates that inter-subjectivity benefits from a ‘shared framework of meaning and means of communication such as gesture, posture or facial expression…The interpersonal behavior has moved…from overt actions and responses to the internal subjective states that lie behind the overt behaviors’ (p.125). This is also described as a form of ‘empathic projection’, a concept of immense significance to clinicians, including Expressive Arts Therapists.


This phenomenon can be traced back to early child development, when infant and primary caregiver (mother or mother-like presence) establish sustained mutual eye contact, thereby promoting neurobiological maturation by facilitating the mirroring and shaping patterns of behavior. Dopamine has been identified as the primary neurotransmitter in activating this neuronal interface (Schore, 1994; Stern, 1985, 2000). Schore observes that the mother’s facial expressions act as ‘a highly arousing unconditioned stimulus’ (p.83) and that ‘the mirroring self-object experience induces states of positive arousal and pleasure’ (p.86). Thus Schore defines the process of normal attachment as a behavioral patterning. Similarly, Stern (1985, 2000) attributes to ‘gesture, posture and facial expression’ a ‘shared framework of meaning’ (p.125), and the process by which an infant internalizes called attunement, which is responsible for nurturing the development of empathy. This process often takes place without conscious awareness.

Now there is another kind of mirror neuron, which is involved in something quite different. And that is, there are mirror neurons, just as there are mirror neurons for action, there are mirror neurons for touch. In other words, if somebody touches me, my hand, neuron in the somato-sensory cortex in the sensory region of the brain fires. But the same neuron, in some cases will fire when I simply watch another person being touched. So, it's empathizing the other person being touched’  (Ramachadran, 2009).

So, most of them will fire when I'm touched in different locations. Different neurons for different locations. But a subset of them will fire even when I watch somebody else being touched in the same location. So, here again you have neurons which are enrolled in empathy’ (Ramachadran, 2009) and here is the question: ‘why do I not get confused and literally feel that touch sensation merely by watching somebody being touched?  I empathize with that person but I don't literally feel the touch. Well, that's because you've got receptors in your skin, touch and pain receptors, going back into your brain and saying "Don't worry, you're not being touched. So, empathize, by all means, with the other person, but do not actually experience the touch otherwise you'll get confused and muddled."  Okay, so there is a feedback signal that vetoes the signal of the mirror neuron preventing you from consciously experiencing that touch. But if you remove the arm, you simply anesthetize my arm, so you put an injection into my arm, anesthetize the brachial plexus, so the arm is numb, and there is no sensations coming in, if I now watch you being touched, I literally feel it in my hand. In other words, you have dissolved the barrier between you and other human beings. So, I call them “Gandhi neurons”, or empathy neurons.

And this is not in some abstract metaphorical sense, all that's separating you from him, from the other person, is your skin. Remove the skin, you experience that person's touch in your mind. You've dissolved the barrier between you and other human beings. You are in fact, connected not just via Facebook, and Internet, you're actually quite literally connected by your neurons. And there is no real distinctiveness of your consciousness from somebody else's consciousness’ Ramachadran, 2009).

Empathy in child development

It’s worth mentioning that during the first years of a child’s life a normal aspect of brain development is the process of myelinization which facilitates the maturation of the limbic and cortical association areas; myelininization provides insulation, like a lining wrapping around the length of an axon, speeding electrical transmission of an activated neuron (Wittrok et al., 1977).


During the first year to 15 months the interaction between caregiver and baby most strongly impacts affect regulation (Schore, 1994; Stern, 1985, 2000). This is the time for building the foundation for social cognition and moral development; therefore empathy starts to form as well (Piaget & Inhelder, 1969; Schore, 1994; Stewart, 2001), becoming manifested and observable around 3 years of age.


By the time children enter kindergarten, they have become more and more aware both emotionally and socially; they have been learning acceptable and non acceptable behavior patterns and forming their moral cognition through play and reinforcements offered by the environment.


Studies of early right hemispheric prefrontal damage to the cortex and its limbic connections have revealed impairments in the development of empathy, manifested as moral behavior and social cognition (Stern, 1985, 2000; Schore (1994, 2005).

VS Ramachandran in his TED talk ‘on your mind’ tells us what brain damage can reveal about the connection between cerebral tissue and the mind, using three startling delusions as examples.


In the early 90’s research based on functional Magnetic Resonance Imaging (fMRI) (1)  of the brain analyzed clinical evidence that could reveal implications also for empathy development in cases of damages to the prefrontal cortex, the temporal lobes and the limbic/para-limbic systems.

Research protocols includes studies of normal and patient populations (The Medical College of Wisconsin, Department of Neurology, among others). Also there could be a relationship between borderline personality disorders and failed attachment and attunement, therefore precluding the individual from developing and experiencing empathy.

Grattan and Eslinger published a study in 1992 where they connect early prefrontal lobe damage in formative years and moral deviance. They concluded that early brain damage had a profound effect on their subjects’ psychosocial development.






(1) Functional MRI or functional Magnetic Resonance Imaging (fMRI) is a type of specialized MRI scan. It measures the hemodynamic response (change in blood flow) related to neural activity in the brain or spinal cord of humans or other animals. It is one of the most recently developed forms of neuro-imaging. Since the early 1990s, fMRI has come to dominate the brain mapping field due to its relatively low invasiveness, absence of radiation exposure, and relatively wide availability.

The relevance of the mirroring process in Expressive Arts Therapy is acknowledged, for instance in “Empathic Reflection”, a term exemplified by the practice of Dance & Movement Therapist pioneer Marian Chace, who was influenced by Carl G. Jung. She realized early on in her studies and in her teaching practice that the body and mind are interrelated; in fact she emphasized the expression of emotions over dance techniques in her classes, an approach enjoyed by her students who were reporting feelings of well being. She intuitively understood that in order to communicate and collaborate with deeply traumatized WW II veterans, she had to first establish an empathic relationship (Shelly, 1993). Marian Chace was able to establish inter-subjectivity by reflecting moods, movements and sounds of the patients; she was ‘picking up’ not only what they were doing, but the quality and intention of their behaviors (Sandel, 1993). Marian Chace used the process of empathic reflection to ‘gather information about the clients’ during a group session; ‘engage them in contact first with the therapist and then with one another and then develop a sense of mutuality which facilitates the communication and sharing of feelings’ (pp. 102-103). In other words, the therapist’s first task is to create an environment of safety and trust in order for the clients to feel “seen” and “accepted” and therefore be willing to open up to self-expression and to reconnect with others.  Dancing with movement designed to mirror each other and then to ‘build’ new movements off of each other’s input, like stepping stones, is one of the symbolic potentially transformative and therefore therapeutic forms that can be used (Boal, 2002).





In the following chapters, empirical evidence of empathy in action, testimonials and feedback on improved quality of life in clients will be offered as jumping off points for an inquiry on empathy as a vehicle for resilience. Guided visualization is one of the foundational tools in creating opportunities and scenarios for empathic reflections in clients; a chapter will be specifically dedicated to this aspect.




















Ackerman, Diane (2004) An Alchemy of Mind: The Marvel and Mystery of the Brain, New York.


Berrol, C.F., 1992: The neurophysiologic basis of the mind-body connection in dance/movement therapy. American Journal of Dance Therapy, 1491), 19-29.


Betensky, Mala: Self-Discovery through Self-Expression: Use of Art in Psychotherapy with Children and Adolescents, 1973


Bloom, R.E., Lazerson, A., and Hofstadter, L., 1985: Brain mind and behavior, New York, W.V. Mosby Company.


Boal, Augusto: Games for Actors and Non-Actors, 2002 Publisher: Routledge

Diamond, M.C., Schiebel, A.B. & Elson, L.M., 1985: The Human Brain Coloring Book (1st ed.) New York: Harper & Row Publisher.


Feldman, Jerry, From Molecule to Metaphor, 2006

Gallese, Vittorio, 2003: the roots of empathy: the shared manifold hypothesis and the neural basis of intersubjectivity – in Psychopathology, 36, 171-180.


Gallese, Vittorio 2005a: Intentional attunement: from mirror neurons to empathy. Paper presented at the Fourth International Conference on Neuroesthetics: Empathy in the brain and in art, UC Berkely.


Gallese, Vittorio 2005b: Intentional attunement: the mirror neuron system and its role in interpersonal relations (pp. 1-8).


Gallese, Vittorio et al., 1996: Action recognition in the pre-motor cortex. Brain, 119, 593-609


Grattan, Lynn M. & Eslinger, Paul J., 1992: Long term psychological consequences of childhood frontal lobe lesion in patient DT. Brain Cognition, 20(1), 185-195


Guralnik, David B. (Ed.): Webster’s new world dictionary of the American language, 1992.

Kolb, B., & Wishaw, I. Q., 1985: Fundamentals of human neuropsychology (2nd ed.) New York: W.H. Freeman & Company.


Luppino, G., & Rizzolatti, G., 2000. The organization of the frontal motor cortex, New Physiological Science, 15, 219-224


Nolte, H., 1981: The human brain: An introduction to its functional anatomy. St. Louis, MO: the C.V. Mosby Company.


Piaget, Jean & Inhelder, 1969: The Psychology of the child


Ramachandran, Vilayanur  Subramanian, 2007: TED:on your mind


Ramachandran, Vilayanur  Subramanian, 2009: TED India: The neurons that shaped civilization’

Ramachandran, Vilayanur  Subramanian & Blakslee, Sandra, 1998: Phantoms in the Brain: Probing the Mysteries of the Human Mind.

Ramachandran, Vilayanur  Subramanian, 2003: The Emerging Mind

Ramachandran, Vilayanur  Subramanian, 2005: A Brief Tour of Human Consciousness: From Impostor Poodles to Purple Numbers.

Ramachandran, Vilayanur  Subramanian, 2010: The Tell-Tale Brain: A Neuroscientist's Quest for What Makes Us Human.


Rizzolatti, Fogassi & Gallese, 2001: Neurophysiological mechanisms underlying understanding and imitation of action [Electronic Version], Nature Reviews/Neuroscience, 2, 661-670.


Restak, R., 1984: The brain. New York: Bantam Books

Samules, Mike, MD and Samuels, Nancy, 1975: Seeing with the Mind’s Eye

Sandel, Susan L., 1993: The process of empathic reflection in dance/movement therapy,

in Sandle, S.,  S., Chaiklin, and Lohn, A. (Eds.): Foundations of dance/movement

therapy: the life and work of Marian Chace (pp. 98-111).

Thompson, R.F., 1975: Introduction on psychological psychology. New York: Harper & Row Publishers.


Wittrock, M.C., Beaty, J., Brogen, J.E., Gazzaniga, M., Jerison, H. J., Krashen, S.D., et al. (1977): The human brain, Englewood Ciffs: Prentice-Hall, Inc.





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