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Increased Salivary Oxytocin and Empathy in Students of Clinical and Health

Psychology After a Mindfulness and Compassion-Based Intervention

Article  in  Mindfulness · April 2020

DOI: 10.1007/s12671-020-01316-7

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Mindfulness
https://doi.org/10.1007/s12671-020-01316-7

ORIGINAL PAPER

Increased Salivary Oxytocin and Empathy in Students of Clinical

and Health Psychology After a Mindfulness
and Compassion-Based Intervention
Miguel Bellosta-Batalla 1 & M. Carmen Blanco-Gandía 2 & Marta Rodríguez-Arias 1 & Ausiàs Cebolla 3,4 &
Josefa Pérez-Blasco 5 & Luis Moya-Albiol 1

# Springer Science+Business Media, LLC, part of Springer Nature 2020

Abstract
Objectives Mindfulness and compassion-based interventions (MCBI) have shown to be effective in increasing self-reported
empathy in healthcare professionals. However, no studies described a beneficial effect of MCBI on biological variables related to
empathy. In this study, we analyze the effects of an MCBI on the basal levels of salivary oxytocin (sOXT), empathic accuracy,
and self-reported empathy in students of clinical and health psychology (N = 90).
Methods In the experimental group (n = 37), an MCBI was applied. In the active control group (n = 27), students participated in
basic psychotherapeutic skills training. In the waiting list group (n = 26), students did not participate in any intervention. A
repeated-measures analysis of variance was performed, including pre- and post-intervention evaluations and the follow-up
evaluation.
Results Results indicate a significant interaction between the groups on the basal levels of sOXT (p = .045, ηp2 = .05) and
perspective taking (p = .040, ηp2 = .06), so that the experimental group showed increased sOXT at the end of the MCBI
(p = .009, d = .66) and in perspective taking on the follow-up evaluation (p = .001, d = .52).
Conclusions Introducing MCBI in the university education of clinical and health psychologists can help to improve their empathy
skills, which would ultimately have a beneficial influence on the health of the users of their services. Furthermore, sOXT could be
used as a valid biomarker in the study of the effects of MCBI on biological variables associated with empathy and affective bonds
in different settings.

Keywords Salivary oxytocin . Mindfulness . Empathy . Compassion . Clinical and health psychology

Empathy is the ability to infer the cognitive and emotional

state of others (cognitive empathy) and affectively synchro-
* Ausiàs Cebolla
nize with it (emotional empathy), inhibiting the appearance of
Ausias.Cebolla@uv.es
an affective fusion (Coutinho et al. 2014; Decety and Lamm
2009; Singer and Lamm 2009). Empathy has been associated
1
Department of Psychobiology, University of Valencia, with the success of psychological interventions (Norcross
Valencia, Spain
2011), by helping to establish a beneficial therapeutic bond
2
Department of Psychology and Sociology, University of Zaragoza, (Keijsers et al. 2000; Lambert and Barley 2001; Norcross and
Teruel, Spain
Wampold 2011). In this regard, patients’ evolution and symp-
3
Department of Personality, Evaluation and Psychological Treatment, tomatic relief have been related to perceived empathy from the
University of Valencia, Avda. Blasco Ibáñez, 21,
46010 Valencia, Spain psychotherapist caring for them (Elliott et al. 2011). The ef-
4 fective management of the emotions is essential in these situ-
Ciber Physiopathology of Obesity and Nutrition (CIBEROBN),
Institute of Health Carlos III, Madrid, Spain ations, because it facilitates a healthy bond and keeps the
5 psychotherapist from experiencing a response of empathic
Department of Evolutionary and Educational Psychology, University
of Valencia, Valencia, Spain distress due to coming into contact with others’ suffering
(Klimecki and Singer 2012).

The importance of empathy in the field of psychotherapy
points to the need to foster this ability in clinical and health
psychologists (Bohart and Greenberg 1997; Norcross 2011;
Norcross and Wampold 2011). Various intervention strategies
have been designed to increase empathy in the university ed-
ucation of healthcare professionals. These interventions em-
phasize external and observable aspects of this skill, using
writing exercises, activities related to the dramatic arts,
problem-based learning, and training in social and communi-
cation skills (Batt-Rawden et al. 2013; Teding van Berkhout
and Malouff 2016). However, most of these interventions do
not include management of internal states and emotions,
which is quite important in developing healthy and beneficial
empathy toward the patient (Coutinho et al. 2014).
In recent years, mindfulness and compassion-based inter-
ventions (MCBI) have been established as an important strat-
egy in the healthcare field, due to their extensive benefits for
health and well-being (Bellosta-Batalla et al. 2018; Galante
et al. 2014; Khoury et al. 2015). Likewise, some studies sug-
gest the advantages of including MCBI in the university edu-
cation of clinical and health psychologists, highlighting their
effects on empathy skills (Bellosta-Batalla et al. 2019a; Bruce
et al. 2010; Davis and Hayes 2011). In this regard, studies
have found an association between mindfulness and empathy
in psychotherapists, as well as between these variables and the
therapeutic alliance (Leonard et al. 2018) or patients’ symp-
tomatic evolution (Grepmair et al. 2007).
Mindfulness is a mental state in which the individual inten-
tionally pays attention to what happens within and around
him/her, with an attitude of curiosity, openness, acceptance,
and kindness (Bishop et al. 2004; Kabat-Zinn 1990; Siegel
2007). These attitudes involve a healthy approach to experi-
ence, and they function as an implicit form of self-compassion
(Brito et al. 2018). Compassion is understood as a feeling that
emerges in the presence of suffering – whether in ourselves or
in others – helping us to be open to its appearance and attempt
to relieve it (Elices et al. 2017; Gilbert 2005; Siegel and
Germer 2012). Meditation practice in which there is an in-
creasing mindfulness state may contribute to a stable trait
(Kiken et al. 2015), which is characterized by a greater regu-
lation of attention, an effective management of emotions, and
an increase in interoceptive sensitivity and self-awareness
(Cebolla et al. 2018; Hölzel et al. 2011). These effects facili-
tate an open and kindly approach to others, and when they are
sustained in the social area of the individual, they may exert a
positive influence on empathy skills (Bellosta-Batalla et al.
2019b). Moreover, compassion is closely related to empathy
because it involves a kind approach to the suffering of others
(Brito 2014; Siegel and Germer 2012; Vivino et al. 2009).
Current studies about the influence of MCBI on empathy
reveal that these interventions increase the empathic attitudes
of healthcare professionals in general, and clinical and health
psychologists in particular (Bibeau et al. 2016; Lamothe et al.
Mindfulness
2016). However, most studies have only used self-reports to
evaluate empathy, even though some authors point out the
limitations of this approach to the study of empathy, especially
in individuals with high empathy levels, such as healthcare
professionals (Boellinghaus et al. 2014; Murphy et al. 2018;
Vachon and Lynam 2016). In this regard, empathy is a com-
plex phenomenon in which different biological, social, psy-
chological, and behavioral factors interact (Gonzalez-Liencres
et al. 2013), so self-reported assessment is not always associ-
ated with the individual’s empathy skills (Eyal et al. 2018).
Thus, there is a need to broaden these investigations through a
wide assessment of empathy that includes these factors, ap-
plying measures of empathic accuracy, in order to analyze the
ability to infer others’ emotional states (Baron-Cohen et al.
2001), and focus on biological variables related to empathy
skills (Bachner-Melman and Ebstein 2014; Ebert and Brüne
2018; Shamay-Tsoory and Abu-Akel 2016).
Regarding the abovementioned, in recent years, interest has
grown in evaluating the levels of oxytocin and their involve-
ment in a series of skills related to empathy, such as emotional
recognition and social cognition (Gonzalez-Liencres et al.
2013; Patin et al. 2018). Oxytocin is a neuropeptide secreted
in the hypothalamus that acts as a hormone and neurotrans-
mitter and has a strong influence on stress buffering, sexual
behavior, and social bonds (Ebert and Brüne 2018; Feldman
2012; Patin et al. 2018). Although there are other neuropep-
tides involved in social behavior, such as vasopressin
(Bachner-Melman and Ebstein 2014), we chose oxytocin in
this study because it modulates its own liberation but also
vasopressin and opioid release (Kendrick 2000). Some studies
point out that the intranasal administration of oxytocin in-
creases attention to socially relevant information (Hubble
et al. 2017), empathic accuracy (Bartz et al. 2010; Feeser
et al. 2015; Schulze et al. 2011), and emotional empathy
(Hurlemann et al. 2010). Hence, measuring salivary oxytocin
(sOXT) can be a useful strategy for studying the effects of
MCBI on biological variables related to empathy skills and
affective bonds. Some authors indicate that sOXT is not a
reliable biomarker (Horvat-Gordon et al. 2005), even though
this evaluation procedure has been validated in human beings
(Carter et al. 2007) and analyzed satisfactorily in a large num-
ber of studies (Feldman et al. 2010; Lebowitz et al. 2016).
Salivary OXT has been measured to evaluate the effects of
different psychological interventions and exercises, which in-
fluence beneficially to the biological system of oxytocin
(Holt-Lunstad et al. 2008; Nilsson 2009; Vittner et al. 2018).
In the field of psychotherapy, sOXT has been used to study the
development of the therapeutic alliance, establishing an asso-
ciation between an increase in this biomarker in patients and
episodes of rupture of the alliance (Zilcha-Mano et al. 2018).
In addition, these authors observed a general increase in sOXT
in patients throughout the sessions. This indicates that oxyto-
cin is at the base of salient interpersonal interactions –
Mindfulness
regardless of their emotional valence – among which the es-
tablishment of empathy is included (Shamay-Tsoory and Abu-
Akel 2016).
Mindfulness and compassion practice fosters a greater un-
derstanding of others’ emotions and a healthy management of
our affective state, facilitating empathy (Hölzel et al. 2011;
Luberto et al. 2018). This emotional approach helps to im-
prove interactions and social bonds, and it is a process in
which the biological system of oxytocin may be involved
(Ebert and Brüne 2018; Gonzalez-Liencres et al. 2013; Patin
et al. 2018). Along these lines, it has been shown that oxytocin
increases benefits in emotional states of mindfulness and lov-
ing kindness meditation (Isgett et al. 2016; Van Cappellen
et al. 2016), although a beneficial influence of MCBI on basal
sOXT levels has not been yet described. In fact, a study that
analyzed the effects of a mindfulness-based intervention
(MBI) using this biomarker did not find significant results;
however, it was focused on improving sleep and included
some variations on the usual MCBI (Lipschitz et al. 2015).
Moreover, these authors observed an increase in the basal
levels of sOXT when applying a mind–body bridging inter-
vention that included some activities related to mindfulness.
Thus, MCBI would be expected to have a beneficial influence
on this biological marker.
Based on the above mentioned, the aim of this study was to
evaluate the efficacy of an MCBI in increasing basal sOXT
levels, empathic accuracy, and self-reported empathy in stu-
dents of clinical and health psychology. We compared the
effects of MCBI to an active control group, in which students
participated in basic psychotherapeutic skills training, and a
waiting list group of students who did not participate in any
intervention. We hypothesized an increase in these empathy
indicators in the students who participated in the MCBI, com-
pared to the other groups.
Method
Participants
The sample in this study was composed of 90 students in the
last courses of the Bachelor and Master’s degrees in Clinical
and Health Psychology at the University of Valencia
(Valencia, Spain). Regarding sex, 76.7% of the participants
were women, and 23.3% men. The participants’ ages ranged
from 20 to 55 years, with a mean of 23.71 ± 5.30 years.
Regarding their marital status, 82.2% were single, and
17.8% lived with a partner. In addition, 93.3% rated their
social network as good and 6.7% did not. The size of the
sample was determined with the G*Power program, estimat-
ing the need to include 81 participants. An expected effect size
of d = .40 (α = .05 and statistical power = .95) was taken,
based on the results of a meta-analysis focused on the effects
of MCBI on empathy (Luberto et al. 2018).
Procedure
The sample was recruited by announcing the study to different
groups of Bachelor and Master’s degree students in Clinical
and Health Psychology at the University of Valencia (N =
163). In addition, we included a group of students enrolled
in these degree programs who were going to perform basic
psychotherapeutic skills training as part of their study plan.
Different psychotherapy schools in Valencia (Spain) were
contacted which accept these types of students to do their
practical training. The study was advertised in three of the
schools whose training characteristics matched the MCBI in
the number of students and frequency and length of the ses-
sions (N = 62). In both cases, a researcher went to the Bachelor
and Master’s classrooms, and to the psychotherapy schools, to
explain the basic objectives of the study and to recruit the
sample. The exclusion criteria applied were experience with
meditation and/or previous participation in mindfulness or
compassion training, eliminating six students from the sam-
ple. Likewise, the other exclusion criterion applied was doing
less than 300 min of meditation during the MCBI because this
was the time spent on the meditation exercises in the training
sessions. Several information sessions were held with the in-
terested students (N = 136) to explain the general lines of re-
search and MCBI content. The students who decided to par-
ticipate (N = 95) signed an informed consent form that speci-
fied the study objective and guaranteed the anonymity and
confidentiality of the data. Moreover, they were told that sali-
va samples would be collected in the evaluation sessions. The
study was approved by the Ethics Committee of the
University of Valencia, and it was carried out in accordance
with the ethical standards for research in humans (World
Medical Association 2013).
The active control group was composed of students who
were going to begin the basic psychotherapeutic skills training
(n = 27). These students could not be randomly assigned be-
cause their choices of practical training were made before the
study began and were integrated in their university education.
The rest of the students were randomly assigned to the exper-
imental group (n = 42) and the waiting list group (n = 26).
Groups were homogenous with regard to gender, age, and
academic level, as well as the sociodemographic variables
evaluated. The experimental group (mindfulness and compas-
sion, MC) was divided into two groups of 21 students who
participated in an MCBI. Two clinical and health psycholo-
gists with extensive experience in the administration of mind-
fulness and compassion training applied the intervention joint-
ly in both groups. This intervention lasted for 2 months, with
one session per week that lasted approximately 2 h. These
sessions dealt with the essential aspects of mindfulness and

compassion, as well as the application of mindfulness atti-
tudes to the different contents of experience (feelings,
thoughts, and emotions). In addition, they included two 20-
min meditation exercises (at the beginning and end of the
session), and a series of weekly meditation exercises were
proposed (Table 1). The students kept a written record of the
amount of time they meditated per week. Based on this, five
subjects from the MC group were eliminated from the study
for not doing enough minutes of meditation (n = 37). With
regard to adherence to the MCBI, 13.5% of the students
attended five sessions, 29.7% attended six sessions, 43.2%
attended seven sessions, and 13.5% attended the eight ses-
sions of the intervention. These students meditated for a mean
of 534.19 ± 208.85 min. During this period, the students in the
active control group (basic psychotherapy skills, BPS) per-
formed their practical training, attending one weekly session
that lasted approximately 3 h. In these sessions, they studied
psychotherapy theory from different approaches, and they per-
formed a variety of related activities, such as exercises simu-
lating clinical situations and observing psychotherapeutic and
supervision sessions. These practice sessions took place dur-
ing the 5-month period of the study. The control group
(waiting list, WL) did not participate in any intervention,
and the students stayed on the waiting list in order to later
participate in a brief mindfulness and compassion training
(Fig. 1).
An initial evaluation was performed before starting the in-
tervention in the MC group and the practical training in the
BPS group. The second evaluation took place at the end of the
intervention in the MC group, with a follow-up evaluation
3 months later. In the evaluation sessions, first, salivary sam-
ples were collected, and then the students performed an em-
pathic accuracy exercise and filled out an empathy self-report.
Table 1 Mindfulness and
compassion-based intervention Content
(MCBI)
Session 1 Introduction to mindfulness
Breathing
Session 2 Basic attitudes
Body scan
Session 3 Thoughts
Sounds
Session 4 Thoughts II
Mental scenario
Session 5 Emotions
Labelling emotions
Session 6 Emotions II
Emotions in the body
Session 7 Self-compassion
Loving kindness toward
oneself
Session 8 Compassion
Loving kindness toward others
Mindfulness
The participants were told not to eat or drink (except water),
smoke, or take any stimulants 60 min before the evaluation
sessions, in order to avoid their influence on the sOXT levels
and the possible contamination of the saliva samples. The
students in the BPS group and the WL group were invited to
participate in a brief mindfulness and compassion training
once the study had ended.
Measures
Basal Levels of Salivary Oxytocin
Saliva samples were collected from the participants using
Salivettes (Sarstedt, Rommersdolf, Germany). The saliva
samples were frozen at − 20 °C immediately after their collec-
tion, and they were conserved in this state until their analysis
in the laboratory. We have used the lyophilization process
instead of the chemical process outlined in the manufacturer’s
instructions, since lyophilize (freeze dry) samples effectively
achieve a similar outcome (Blagrove et al. 2012; Daughters
et al. 2015). Lyophilization has been found to increase the
validity of measuring oxytocin via EIA, although it has not
been demonstrated to give the same results as extraction
(Christensen et al. 2014; Leng and Ludwig 2016;
McCullough et al. 2013). Samples were centrifuged 5 min ×
1000 g, and then from each saliva sample, 1 ml of supernatant
was frozen at − 40 °C. The samples were lyophilized before
their analysis through freeze-drying (Modulyo® Freeze
Dryers, Thermo Electron Corporation). The samples were
freeze-dried for approximately 15 h and then dehydrated
(Daughters et al. 2015). These samples were reconstituted in
250 μl of assay buffer following the manufacturers’ instruc-
tions, resulting in a concentration four times greater than the
Weekly exercises
Full attention to eating
Full attention to walking
Full attention to sounds at different moments in the day
Full attention to thoughts
Full attention to emotions and their variability during the day
Full attention to emotion and its space in the body
Loving kindness toward oneself when getting up in the morning
Generalization of the practice
Mindfulness

Students of Bachelor and Master’s degrees

in Clinical and Health Psychology
(N = 225)

Students who were Students who could be interested in

in the psychotherapy schools participate in the MCBI
(n = 62) (n = 163)

Excluded (n = 1) Excluded (n = 5)
Experience in meditation Experience in meditation

Attended the information sessions Attended the information sessions

(n = 30) (n = 106)

Students who decided to participate Students who decided to participate

(n = 27) (n = 68)

No random assignment Random assignment

Basic psychotherapy skills Mindfulness and compassion Waiting list

(BPS, n = 27) (MC, n = 42) (WL, n = 26)

Eliminated from the study

Not enough minutes of meditation
(n = 5)

Mindfulness and compassion

(MC, n = 37)

Fig. 1 Assignment of the participants to the study groups

original. Therefore, they would fall within the kit’s sensitivity
range and be detectable in the standard curve. The sOXT
levels were measured using the commercial kit Oxytocin
EIA kit (Arbor Assays, Inc. Ann Arbor, MI, USA; ref.:
K048), following the procedure described in previous studies
due to its high sensitivity to saliva samples (Carter et al. 2007;
Lebowitz et al. 2016; MacLean et al. 2018). Neuropeptide
cross-reactivity was reported by Arbor Assays as < 0.001%,
and limit of detection was 11 pg/ml. The saliva samples were
read at 450 nm and all samples were run in duplicate. The
chemical validity of the EIA was assessed using tests of par-
allelism by assay of a serial dilution of pooled saliva samples.
Quantitative recovery was examined to determine whether the
sample preparation and lyophilization affected the results.
Salivary samples were spiked with varying amounts of stan-
dard of known concentration and then prepared for assay by
concentration in the lyophilizer. Recovery was determined by
comparing the assay results from the spiked samples to those
for assay buffer spiked with the same volumes of standard.
Precision of the assay was assessed by the variability in mul-
tiple measurements of unknowns (intra-assay CV). A dilution
series of pooled saliva resulted in a displacement curve paral-
lel to the standard curve (y = 1.10x − 6.61; r2 = 0.98). Tests of
quantitative recovery resulted in a high correlation between
expected and observed values (y = 0.68x − 14.46; r2 = 0.998)
and average recovery was 74%. Inter and intra-assay CV av-
eraged less than 10%.
Empathic Accuracy
Empathic accuracy was evaluated with the Reading the Mind
in the Eyes Test (Eyes test; Baron-Cohen et al. 2001). This

instrument is composed of 36 black-and-white photographs
showing the facial zone of the eyes of a series of actors. The
subject must infer the emotional state of the person observed,
choosing a response from different alternatives (Fig. 2). The
score on the Eyes test is calculated by adding up the number of
correct answers.
Self-Reported Empathy
Self-reported empathy was evaluated with the Spanish version
of the Interpersonal Reactivity Index (IRI; Davis 1980; Mestre
et al. 2004). The IRI is a self-report with 28 items, rated on a 5-
point Likert scale, from 1 (“Does not describe me well”) to 5
(“Describes me very well”). The IRI subscales are grouped
according to their cognitive or emotional nature. For the cog-
nitive aspect, perspective-taking (spontaneous attempts to
adopt the point of view of others in different situations) and
fantasy (tendency to identify with the feelings and actions of
characters from films and literature in fictional situations)
were evaluated. For the emotional aspect, empathic concern
(feelings of compassion and concern about the suffering of
others) and personal distress (feelings of anxiety and discom-
fort arising from observing others’ suffering) were evaluated,
with the latter known as empathic distress. These subscales
present good validity and variable reliability, with Cronbach’s
alpha values (α) between .56 and .70. In this study, we con-
ducted reliability analyses in R to calculate the McDonald’s
omega values (ω): perspective-taking (ω = .67, 95% CI [.54,
.76]), fantasy (ω = .79, 95% CI [.70, .84]), empathic concern
(ω = .65, 95% CI [.51, .77]), and personal distress (ω = .76,
95% CI [.65, .82]).
Data Analyses
First, after assumptions of normality and homoscedasticity of
the variables were checked (using the Kolmogórov-Smirnov
and Levene tests, respectively), an analysis of variance
(ANOVA) was carried out, to determine if there were signif-
icant differences between the groups before the intervention.
Likewise, a repeated-measures ANOVA was performed, in-
cluding the pre- and post-intervention evaluations and the
Embarrassed Fantasizing
Confused Panicked
Fig. 2 Image and choice alternatives on the Eyes test
Mindfulness
follow-up evaluation. We studied the main effect of “time”
(pre- versus post-intervention, and pre-intervention versus fol-
low-up) in the different groups (using the Bonferroni adjust-
ment), and the interaction effects (group x time). The
Greenhouse-Geisser correction of the degrees of freedom
was applied when necessary. The statistical analyses were
performed using the IBM SPSS (version 23).
Results
Influence of the MCBI on the Basal sOXT Levels
No significant differences were observed in the basal sOXT
levels (Fig. 3) between the groups before the intervention. In
the MC group, there was a main effect of “time” on the basal
levels of sOXT, F(2, 72) = 4.65, p = .013, ηp2 = .11, 95% CI
[.01, .25], with a significant increase between the pre- and
post-intervention values, p = .009, d = .66, 95% CI [.19,
1.13]. In the BPS group, F(2, 52) = 3.12, p = .053, ηp2 = .11,
95% CI [.00, .26], and the WL group, F(2, 50) = .01, p = .994,
ηp2 = .00, 95% CI [.00, .01], no significant differences were
observed. The effect of the “group × time” interaction was
significant, F(4, 174) = 2.49, p = .045, ηp2 = .05, 95% CI
[.00, .11].
Influence of the MCBI on Empathic Accuracy
In the case of empathic accuracy (Table 2), no significant
differences were observed between the groups before the in-
tervention. In the MC group, there was a main effect of “time”
on empathic accuracy, ɛ = .68, F(1.37, 49.19) = 3.72, p = .047,
ηp2 = .09, 95% CI [.00, .25], with a significant increase be-
tween the pre- and post-intervention values, p = .041, d = .40,
95% CI [− .06, .86]. In the BPS group, F(2, 52) = 2.64,
p = .081, ηp2 = .09, 95% CI [.00, .24], and the WL group,
F(2, 50) = .53, p = .595, ηp2 = .02, 95% CI [.00, .12], no sig-
nificant differences were observed. The effect of the “group ×
time” interaction was not significant, ɛ = .91, F(3.64,
158.13) = .68, p = .590, ηp2 = .02, 95% CI [.00, .05].
Influence of the MCBI on Self-Reported Empathy
In relation to self-reported empathy (Table 2), no significant
differences were observed between the groups on the different
subscales evaluated before the intervention. In the MC group,
there was a main effect of “time” on the perspective-taking
subscale, F(2, 72) = 7.20, p = .001, ηp2 = .17, 95% CI [.03,
.30], with a significant increase between the pre-intervention
values and the follow-up values, p = .001, d = .52, 95% CI
[.05, .98]. Likewise, there was a main effect of “time” on the
empathic concern subscale, F(2, 72) = 3.57, p = .033,
ηp2 = .09, 95% CI [.00, .21], with a significant increase
Mindfulness

Fig. 3 Basal sOXT levels in the pg/mL

different groups pre- and post-
MCBI and in the follow-up
evaluation
200 *

150

Pre-MCBI
100 Post-MCBI
Follow-up

50

0
Mindfulness and Basic psychotherapy Waiting list (WL)
compassion (MC) skills (BPS)
*p < .05

between the pre-intervention values and the follow-up values,
p = .040, d = .42, 95% CI [− .04, .88]. Finally, there was a
main effect of “time” on the personal distress subscale, F(2,
72) = 4.81, p = .011, ηp2 = .12, 95% CI [.01, .25], with a sig-
nificant reduction from the pre-intervention values to the
follow-up values, p = .033, d = − .43, 95% CI [−.89, .03]. On
the fantasy subscale, no significant differences were observed,
F(2, 72) = 3.07, p = .053, ηp2 = .08, 95% CI [.00, .20].
In the BPS group, there was a main effect of “time” on the
fantasy subscale, F(2, 52) = 4.67, p = .014, ηp2 = .15, 95% CI
[.01, .31], with a significant increase from the pre-intervention
values to the values from the second evaluation, p = .046,
d = .39, 95% CI [− .15, .92], and from the pre-intervention
values to the follow-up values, p = .041, d = .41, 95% CI
[− .13, .95]. In addition, there was a main effect of “time” on
the personal distress subscale, F(2, 52) = 4.27, p = .019,
ηp2 = .14, 95% CI [.00, .30], with a significant reduction from
the pre-intervention values to the follow-up values, p = .026,
d = − .46, 95% CI [− 1.00, .08]. On the perspective-taking,
F(2, 52) = .14, p = .874, ηp2 = .01, 95% CI [.00, .07], and em-
pathic concern, F(2, 52) = .49, p = .616, ηp2 = .02, 95% CI
[.00, .11], subscales, no significant differences were observed.
In the WL group, no significant differences were observed
on any of the subscales: perspective-taking, F(2, 50) = .15,
p = .863, ηp2 = .01, 95% CI [.00, .08], fantasy, F(2, 50) = .93,
p = .403, ηp2 = .04, 95% CI [.00, .15], empathic concern, F(2,
50) = .13, p = .881, ηp2 = .01, 95% CI [.00, .07], and personal
distress, F(2, 50) = .27, p = .762, ηp2 = .01, 95% CI [.00, .09].
The effect of the “group × time” interaction was signif-
icant on the perspective-taking subscale, F(4, 174) = 2.57,
p = .040, ηp2 = .06, 95% CI [.00, .11], but not on the other
subscales: fantasy, F(4, 174) = 1.95, p = .105, ηp2 = .04,
95% CI [.00, .10], empathic concern, F(4, 174) = 1.02,
p = .397, η p 2 = .02, 95% CI [.00, .06], and personal

Table 2 Empathic accuracy (Eyes test) and self-reported empathy (IRI) in the different groups pre- and post-MCBI and in the follow-up evaluation

Mindfulness and compassion (MC) Basic psychotherapy skills (BPS) Waiting list (WL)

Pre-MCBI Post-MCBI Follow-up Pre-MCBI Post-MCBI Follow-up Pre-MCBI Post-MCBI Follow-up

M SD M SD M SD M SD M SD M SD M SD M SD M SD

Empathic accuracy
Eyes test 24.43 4.21 25.92 3.09 25.46 3.44 24.96 2.33 25.74 3.21 26.22 2.87 25.46 2.97 25.81 2.73 26.12 2.96
Self-reported empathy
Perspective-taking 27.73 3.84 28.51 3.69 29.62 3.39 27.74 3.38 27.67 3.27 27.41 4.10 28.54 3.50 28.77 3.96 28.50 3.37
Fantasy 25.84 5.09 26.95 4.66 27.30 4.35 25.81 4.35 27.63 4.92 27.70 4.79 27.69 4.99 26.88 4.85 27.73 5.10
Empathic concern 27.84 3.32 28.51 4.02 29.16 2.94 27.19 3.62 27.26 3.97 27.74 3.13 28.54 3.30 28.62 3.16 28.31 3.22
Personal distress 16.97 4.83 15.54 4.81 15.11 3.67 18.59 3.50 17.56 3.45 16.89 3.79 17.46 5.20 17.04 4.49 17.00 4.17

distress, ɛ = .93, F(3.71, 161.43) = .73, p = .564, ηp2 = .02,
95% CI [.00, .05].
Discussion
The aim of this study was to analyze the effects of an MCBI
on the basal sOXT levels, empathic accuracy, and self-
reported empathy of clinical and health psychology students,
compared to an active control group that participated in basic
psychotherapeutic skills training and a waiting list group.
First, the results suggest that MCBI can be effective in increas-
ing the basal levels of sOXT because a significant increase in
sOXT was observed in the MC group at the end of the inter-
vention, compared to the other conditions. This increase was
not maintained in the follow-up evaluation, in which MC
group showed similar basal sOXT levels that BPS and WL
groups, suggesting that ongoing mindfulness and compassion
practice is necessary in order to sustain the beneficial effects of
the MCBI. It is important to point out that at the beginning of
the study, the sOXT levels in the BPS group were fairly high;
although they did not reach significant values, they declined
gradually in the following evaluations, approaching the base-
line levels of the MC and WL groups. These results can serve
as a reference for the general values of sOXT in this popula-
tion because these students were randomly selected.
Moreover, as expected, the sOXT levels in the WL group
did not vary in the different study evaluations, thus informing
us about the stability of this variable. It is possible that the high
baseline levels of sOXT in the BPS group are influenced by
some unidentified variable that would be associated with their
expectations or interest in receiving training in basic psycho-
therapy skills because there was no random assignment in this
group. Likewise, its decrease could be explained by habitua-
tion or adjustment of these expectations and interest through-
out training in the psychotherapy schools. However, currently
there is not enough research on sOXT in this area, which
makes it difficult to attribute this result to any specific aspect.
Analyzing the influence of the MCBI on the basal
sOXT levels, we observe that the effect size on this var-
iable was higher than described after a mind-body bridg-
ing intervention, in which some mindfulness exercises
were included (Lipschitz et al. 2015) and after a “warm
touch” support enhancement intervention (Holt-Lunstad
et al. 2008). Likewise, it was higher than described after
different exercises related to the biological system of oxy-
tocin, such as listening soothing music during bed rest
(Nilsson 2009) or a skin-to-skin contact exercise between
parents and infants (Vittner et al. 2018), so these results
are especially relevant. Mindfulness and compassion prac-
tice fosters an increase in self-awareness and enhances
sensitivity to our internal states and others’ emotions, pro-
ducing a beneficial influence on interactions and social
Mindfulness
bonds when attitudes related to them are applied in the
social area of the individual (Hölzel et al. 2011; Luberto
et al. 2018). These benefits are closely related to empathy
skills, and the biological mechanism of oxytocin may be
involved in them (Bachner-Melman and Ebstein 2014;
Gonzalez-Liencres et al. 2013; Shamay-Tsoory and Abu-
Akel 2016).
In addition to its influence on sOXT, the effect of the inter-
action on cognitive empathy was significant – and specifical-
ly, on the perspective-taking subscale – so that in the MC
group, there was a significant increase in the follow-up eval-
uation. These results are similar to those obtained in previous
studies using a self-reported evaluation of empathy (Lamothe
et al. 2016). On empathic accuracy and the other self-reported
empathy subscales, the effect of the interaction was not sig-
nificant. These results indicate that MCBI increased the ability
of students to take the perspective of others in the different
interpersonal situations where they are involved, although this
may not influence on other aspects of their cognitive and
emotional empathy skills (Eyal et al. 2018), including their
ability to infer affective states through facial expressions.
However, when analyzing the evolution of the groups sep-
arately, results are consistent with findings from previous re-
search, observing an increase in empathic accuracy at the end
of the MCBI and in self-reported empathy at the follow-up
evaluation in the MC group (Lamothe et al. 2016; Mascaro
et al. 2013). On the fantasy subscale, there are no significant
differences, although authors suggest interpreting it as an in-
dicator of absorption, rather than empathy (Murphy et al.
2018). Moreover, the lack of significant interaction effect on
empathic accuracy and the emotional subscales may be ex-
plained by the variations observed in the BPS group, in which
these skills were trained, as well as the low sensitivity to
change of the instrument used for its assessment
(Boellinghaus et al. 2014; Murphy et al. 2018). Along these
lines, mindfulness and compassion practice increases our at-
tention to the way we relate to ourselves and others (Elices
et al. 2017; Siegel 2007), which can mean that we are aware of
some already established interactions and bonds in which we
are not empathic, helping us to adopt a more open and kind
attitude toward our surroundings. However, this effect might
not be immediately reflected in self-report evaluations. In re-
lation to the above, it is observed that the increase in cognitive
and emotional empathy and the decrease in empathic distress
in the students who participated in the MCBI did not occur
until the follow-up evaluation; however, there was an increase
in the basal levels of sOXT and empathic accuracy in the post-
intervention evaluation. This result suggests that variations in
self-reported empathy require a longer time frame to occur,
because they need the application and consolidation of a series
of attitudes and states related to empathy held in the social area
of the individual to become a stable trait. In addition, it would
explain the results of some studies that found no effects of
Mindfulness
MCBI on self-reported empathy, but did not include a follow-
up evaluation (Boellinghaus et al. 2014).
In summary, MCBI can be a useful alternative way to im-
prove empathy skills in the university education of clinical
and health psychologists (Bruce et al. 2010; Davis and
Hayes 2011). These interventions are compatible with the dif-
ferent schools of psychotherapy because they help to develop
a series of skills underlying the practice of this profession,
regardless of the theoretical approach on which they are based
(Davis and Hayes 2011). Thus, MCBI has been shown to
increase cognitive and emotional empathy and have a benefi-
cial influence on the healthy management of this affective
bond (Bibeau et al. 2016; Lamothe et al. 2016), which is
especially important in the field of psychotherapy and facili-
tates the establishment of the therapeutic alliance (Coutinho
et al. 2014; Leonard et al. 2018; Norcross and Wampold
2011). The results of this study add to the current evidence
about the influence of MCBI on empathy skills by finding an
increase in the basal levels of sOXT, and applying an empathic
accuracy instrument, which has not been done in most previ-
ous studies (Lamothe et al. 2016). The study of these variables
is especially important because it helps to complement the
self-reported results obtained until now, increasing the evi-
dence about benefits of MCBI on empathy skills in clinical
and health psychology students. In addition, these interven-
tions may be useful in other students in the health and educa-
tional field, in which empathic skills are particularly relevant.
In this regard, sOXT could be used in the evaluation of the
benefits of MCBI on empathy skills and affective bonds in
different areas, acting as a biomarker of the effects of these
interventions on the biological variables associated with this
skill, as occurs with other biological markers related to stress
and health (Bellosta-Batalla et al. 2018; Black and Slavich
2016; Sanada et al. 2016).
Limitations and Future Research
This study has some limitations. First, the sample receiving
the intervention was mainly female, although this difference is
representative of students of clinical and health psychology. In
addition, the students who were going to receive training in
the psychotherapy schools were not randomly assigned.
Moreover, the intervention in the BPS group took place during
the 5 months of the study, whereas the MCBI was only applied
in the first 2 months, and no record of mindfulness and com-
passion practice was collected from the end of the intervention
until the follow-up evaluation, in order to avoid overloading
participants. Likewise, it is important to highlight that the aim
of the sessions in the BPS group was to train students in basic
psychotherapeutic skills, rather than establishing an individual
space for introspection. Thus, in future studies, it would be
interesting to analyze the effects of MCBI compared to some
type of experiential approach that fosters introspection – such
as the supervision of the psychotherapist or a personal analysis
– in addition to studying differences between MCBI and spe-
cific trainings designed to increase empathy skills (Batt-
Rawden et al. 2013). Along these lines, in recent years, some
authors have expressed the need for new studies in this re-
search field that would include an active control group to
analyze the effects of the MCBI on empathy skills (Kreplin
et al. 2018). We included this group, which allows us to com-
pare the effects of the MCBI to the effects of the practical
training currently offered by the university, instead of waiting
list or non-active control conditions, so this study increases the
evidence about the effects of MCBI on the biological variables
associated with empathy skills and affective bonds.
It is necessary to extend these results and analyze the
interaction of oxytocin with other biological aspects that
can influence it, such as vasopressin levels (Bachner-
Melman and Ebstein 2014), μ-opioids (Loseth et al.
2014), or dopaminergic system activity (Shamay-Tsoory
and Abu-Akel 2016). In this regard, the use of sOXT as a
biomarker inherently showed several limitations. First,
there is still some concern about the extent to which sOXT
is reflective of central oxytocin levels. To date, plasma oxy-
tocin is the most commonly used global biomarker of oxy-
tocin activity (Crockford et al. 2014), but we have to con-
sider that, like saliva, it is a peripheral measure and may
substantially differ from those of central oxytocin release
(Valstad et al. 2017). Several studies have reported that oxy-
tocin is released in a coordinated fashion within the brain
and from the posterior pituitary to the bloodstream
(Lebowitz et al. 2016; Neumann and Landgraf 2012),
reaching the salivary glands by active transport mechanisms
(Gröschl 2009; Proctor and Carpenter 2014). However, a
recent meta-analysis revealed a positive correlation be-
tween plasma and central oxytocin concentrations only un-
der specific contexts, like stressful situations or after intra-
nasal administration (Valstad et al. 2017). Secondly, recent
brushing or flossing may release blood into saliva, although
previous studies have shown that microinjuries in the oral
mucosa have little effect on the reliability of other saliva
assays (Kivlighan et al. 2004). Thirdly, oxytocin degrada-
tion small molecules are present in saliva (Szeto et al. 2011)
and may overestimate circulating levels. We did not perform
an extraction procedure with our saliva samples before run-
ning the EIA kit. Therefore, unextracted samples may lead
to increase signaling of oxytocin, as the antibodies used to
perform immunoassay can bind to other proteins and pep-
tides. It has been reported that oxytocin levels of
unextracted samples can be from 10- to 100-folds higher
than in extracted samples, which suggest that the assay is
detecting substances different from oxytocin (McCullough
et al. 2013; Saxbe and Mendez 2019). Although many re-
searchers perform extraction to remove these additional
molecules, some studies have reported inconsistent findings

regarding the relationship between extracted and
unextracted samples for the measurement of peripheral oxy-
tocin levels (Robinson et al. 2014). In a recent study, oxy-
tocin was measured with and without extraction, and the
authors found that unextracted and extracted oxytocin were
positively correlated with depressive symptoms, but only
oxytocin levels measured without extraction were positive-
ly correlated with anxiety (Saxbe and Mendez 2019). In
addition, the kit we employed has only 0.14% cross-
reactivity with vasopressin and arginine. With our experi-
mental conditions, we obtained a 74% recovery rate, which
we considered acceptable, as previous studies have indicat-
ed (Nishizato et al. 2017).
Finally, future studies should analyze whether these results
can be replicated in clinical and health psychologists who are
currently practicing and, especially, whether the increase in
these empathy indicators acts as a mediator variable in the
symptomatology relief observed in patients of psychothera-
pists who participate in mindfulness training (Grepmair et al.
2007). The final goal of this emergent area of research is to
improve the university education of clinical and health psy-
chologists in order to guarantee effective attention to the users
of their services, thus producing a beneficial influence on the
health and well-being of the individuals in our society.
Acknowledgments Authors thank the kindness and collaboration in the
study to the “Centro Valenciano de Psicoterapia”, the “Centre Gestalt”,
and the “Clínica Psicoanalítica Baumgarten-Santamaría”. CIBEROBN is
an initiative of the ISCIII.
Author Contributions MBB: designed and executed the study, applied
the mindfulness and compassion-based intervention, performed the data
analyses, and wrote the article. MCBG: performed the sOXT analyses,
and collaborated with the writing and editing of the final manuscript.
MRA: collaborated with the sOXT analyses and the writing and editing
of the final manuscript. AC: participated in the design of the study,
assisted with the data analyses, and collaborated with the writing of the
article. JPB: participated in the design of the study, and applied the mind-
fulness and compassion-based intervention. LMA: participated in the
design of the study, and collaborated with the writing of the article. All
authors approved the final version of the article for submission.
Funding Information This study was supported by the Research Grants
2017 from the Banco Sabadell Foundation, and Grants for training pre-
doctoral research personnel from the Valencian Government (ACIF/2016/
383) and from the European Social Fund.
Compliance with Ethical Standards
Conflict of Interest The authors declare that they have no conflict of
interest.
Ethical Approval All procedures performed in studies involving human
participants were in accordance with the ethical standards of the
University of Valencia Ethics Committee (H1499537283854) and with
the 1964 Helsinki declaration and its later amendments or comparable
ethical standards.
Mindfulness
Informed Consent Informed consent was obtained from all individual
participants included in the study.
References
Bachner-Melman, R., & Ebstein, R. P. (2014). The role of oxytocin and
vasopressin in emotional and social behaviors. Handbook of
Clinical Neurology, 124, 53–68.
Baron-Cohen, S., Wheelwright, S., Hill, J., Raste, Y., & Plumb, I. (2001).
The "Reading the mind in the eyes" test revised version: A study
with normal adults, and adults with Asperger syndrome or high-
functioning autism. Journal of Child Psychology and Psychiatry,
42(2), 241–251.
Bartz, J. A., Zaki, J., Bolger, N., Hollander, E., Ludwig, N. N., Kolevzon,
A., & Ochsner, K. N. (2010). Oxytocin selectively improves em-
pathic accuracy. Psychological Science, 21(10), 1426–1428.
Batt-Rawden, S. A., Chisolm, M. S., Anton, B., & Flickinger, T. E.
(2013). Teaching empathy to medical students: An updated, system-
atic review. Academic Medicine, 88(8), 1171–1177.
Bellosta-Batalla, M., Ruiz-Robledillo, N., Sariñana-González, P.,
Capella-Solano, T., Vitoria-Estruch, S., Hidalgo-Moreno, G., et al.
(2018). Increased salivary IgA response as an indicator of immuno-
competence after a mindfulness and self-compassion-based inter-
vention. Mindfulness, 9(3), 905–913.
Bellosta-Batalla, M., Cebolla, A., Pérez-Blasco, J., & Moya-Albiol, L.
(2019a). La empatía en el ejercicio y formación de los psicólogos
clínicos y sanitaristas, y su relación con mindfulness y compasión.
Revista Argentina de Clínica Psicológica, 28(2), 210–220.
Bellosta-Batalla, M., Garrote-Caparrós, E., Pérez-Blasco, J., Moya-
Albiol, L., & Cebolla, A. (2019b). Mindfulness, empatía y
compasión: Evolución de la empatía a la compasión en el ámbito
sanitario. Revista de Investigación y Educación en Ciencias de la
Salud, 4(1), 47–57.
Bibeau, M., Dionne, F., & Leblanc, J. (2016). Can compassion meditation
contribute to the development of psychotherapists’ empathy? A re-
view. Mindfulness, 7(1), 255–263.
Bishop, S. R., Lau, M., Shapiro, S. L., Carlson, L., Anderson, N. D.,
Carmody, J., et al. (2004). Mindfulness: A proposed operational
definition. Clinical Psychology: Science and Practice, 11(3), 230–
241.
Black, D. S., & Slavich, G. M. (2016). Mindfulness meditation and the
immune system: A systematic review of randomized controlled tri-
als. Annals of the New York Academy of Sciences, 1373(1), 13–24.
Blagrove, M., Fouquet, N. C., Baird, A. L., Pace-Schott, E. F., Davies, A.
C., Neuschaffer, J. L., et al. (2012). Association of salivary-assessed
oxytocin and cortisol levels with time of night and sleep stage.
Journal of Neural Transmission, 119(10), 1223–1232.
Boellinghaus, I., Jones, F. W., & Hutton, J. (2014). The role of mindful-
ness and loving-kindness meditation in cultivating self-compassion
and other-focused concern in health care professionals. Mindfulness,
5(2), 129–138.
Bohart, A. C., & Greenberg, L. S. (1997). Empathy reconsidered: New
directions in psychotherapy. Washington, DC: American
Psychological Association.
Brito, G. (2014). Rethinking mindfulness in the therapeutic relationship.
Mindfulness, 5(4), 351–359.
Brito, G., Campos, D., & Cebolla, A. (2018). Implicit or explicit com-
passion? Effects of compassion cultivation training and comparison
with mindfulness-based stress reduction. Mindfulness, 9(5), 1494–
1508.
Bruce, N., Shapiro, S. L., Constantino, M. J., & Manber, R. (2010).
Psychotherapist mindfulness and the psychotherapy process.
Psychotherapy, 47(1), 83–97.
Mindfulness
Carter, C. S., Pournajafi-Nazarloo, H., Kramer, K. M., Ziegler, T. E.,
White-Traut, R., Bello, D., & Schwertz, D. (2007). Oxytocin:
Behavioral associations and potential as a salivary biomarker.
Annals of the New York Academy of Sciences, 1098(1), 312–322.
Cebolla, A., Galiana, L., Campos, D., Oliver, A., Soler, J., Demarzo, M.,
et al. (2018). How does mindfulness work? Exploring a theoretical
model using samples of meditators and non-meditators.
Mindfulness, 9(3), 860–870.
Christensen, J. C., Shiyanov, P. A., Estepp, J. R., & Schlager, J. J. (2014).
Lack of association between human plasma oxytocin and interper-
sonal trust in a Prisoner’s dilemma paradigm. PLoS One, 9(12),
e116172.
Coutinho, J. F., Silva, P. O., & Decety, J. (2014). Neurosciences, empathy,
and healthy interpersonal relationships: Recent findings and impli-
cations for counseling psychology. Journal of Counseling
Psychology, 61(4), 541–548.
Crockford, C., Deschner, T., Ziegler, T. E., & Wittig, R. M. (2014).
Endogenous peripheral oxytocin measures can give insight into
the dynamics of social relationships: A review. Frontiers in
Behavioral Neuroscience, 8, 68.
Daughters, K., Manstead, A. S., Hubble, K., Rees, A., Thapar, A., & van
Goozen, S. H. (2015). Salivary oxytocin concentrations in males
following intranasal administration of oxytocin: A double-blind,
cross-over study. PLoS One, 10(12), e0145104.
Davis, M. H. (1980). A multidimensional approach to individual differ-
ences in empathy. JSAS Catalog of Selected Documents in
Psychology, 10, 85.
Davis, D. M., & Hayes, J. A. (2011). What are the benefits of mindful-
ness? A practice review of psychotherapy-related research.
Psychotherapy, 48(2), 198–208.
Decety, J., & Lamm, C. (2009). Empathy versus personal distress. Recent
evidence from social neuroscience. In J. Decety & W. Ickes (Eds.),
The social neuroscience of empathy (pp. 199–213). Cambridge:
MIT Press.
Ebert, A., & Brüne, M. (2018). Oxytocin and social cognition. Current
Topics in Behavioral Neurosciences, 35, 375–388.
Elices, M., Carmona, C., Pascual, J. C., Feliu-Soler, A., Martin-Blanco,
A., & Soler, J. (2017). Compassion and self-compassion: Construct
and measurement. Mindfulness & Compassion, 2(1), 34–40.
Elliott, R., Bohart, A. C., Watson, J. C., & Greenberg, L. S. (2011).
Empathy. Psychotherapy, 48(1), 43–49.
Eyal, T., Steffel, M., & Epley, N. (2018). Perspective mistaking:
Accurately understanding the mind of another requires getting per-
spective, not taking perspective. Journal of Personality and Social
Psychology, 114(4), 547–571.
Feeser, M., Fan, Y., Weigand, A., Hahn, A., Gärtner, M., Böker, H., et al.
(2015). Oxytocin improves mentalizing – pronounced effects for
individuals with attenuated ability to empathize.
Psychoneuroendocrinology, 53, 223–232.
Feldman, R. (2012). Oxytocin and social affiliation in humans. Hormones
and Behavior, 61(3), 380–391.
Feldman, R., Gordon, I., & Zagoory-Sharon, O. (2010). The cross-
generation transmission of oxytocin in humans. Hormones and
Behavior, 58(4), 669–676.
Galante, J., Galante, I., Bekkers, M. -J., & Gallacher, J. (2014). Effect of
kindness-based meditation on health and well-being: A systematic
review and meta-analysis. Journal of Consulting and Clinical
Psychology, 82(6), 1101–1114.
Gilbert, P. (Ed.). (2005). Compassion: Conceptualisations, research and
use in psychotherapy. New York, NY: Routledge.
Gonzalez-Liencres, C., Shamay-Tsoory, S. G., & Brüne, M. (2013).
Towards a neuroscience of empathy: Ontogeny, phylogeny, brain
mechanisms, context and psychopathology. Neuroscience &
Biobehavioral Reviews, 37(8), 1537–1548.
Grepmair, L., Mitterlehner, F., Loew, T., Bachler, E., Rother, W., &
Nickel, M. (2007). Promoting mindfulness in psychotherapists in
training influences the treatment results of their patients: A random-
ized, double-blind, controlled study. Psychotherapy and
Psychosomatics, 76(7), 332–338.
Gröschl, M. (2009). The physiological role of hormones in saliva.
Bioessays, 31(8), 843–852.
Holt-Lunstad, J., Birmingham, W. A., & Light, K. C. (2008). Influence of
a "warm touch" support enhancement intervention among married
couples on ambulatory blood pressure, oxytocin, alpha amylase, and
cortisol. Psychosomatic Medicine, 70(9), 976–985.
Hölzel, B. K., Lazar, S. W., Gard, T., Schuman-Olivier, Z., Vago, D. R., &
Ott, U. (2011). How does mindfulness meditation work? Proposing
mechanisms of action from a conceptual and neural perspective.
Perspectives on Psychological Science, 6(6), 537–559.
Horvat-Gordon, M., Granger, D. A., Schwartz, E. B., Nelson, V. J., &
Kivlighan, K. T. (2005). Oxytocin is not a valid biomarker when
measured in saliva by immunoassay. Physiology & Behavior, 84(3),
445–448.
Hubble, K., Daughters, K., Manstead, A. S. R., Rees, A., Thapar, A., &
van Goozen, S. H. M. (2017). Oxytocin increases attention to the
eyes and selectively enhances self-reported affective empathy for
fear. Neuropsychologia, 106, 350–357.
Hurlemann, R., Patin, A., Onur, O. A., Cohen, M. X., Baumgartner, T.,
Metzler, S., et al. (2010). Oxytocin enhances amygdala-dependent,
socially reinforced learning and emotional empathy in humans.
Journal of Neuroscience, 30(14), 4999–5007.
Isgett, S. F., Algoe, S. B., Boulton, A. J., Way, B. M., & Fredrickson, B.
L. (2016). Common variant in OXTR predicts growth in positive
emotions from loving-kindness training.
Psychoneuroendocrinology, 73, 244–251.
Kabat-Zinn, J. (1990). Full catastrophe living: Using the wisdom of your
body and mind to face stress, pain, and illness. New York, NY: Dell
Publishing.
Keijsers, G. P. J., Schaap, C. P. D. R., & Hoogduin, C. A. L. (2000). The
impact of interpersonal patient and therapist behavior on outcome in
cognitive-behavior therapy. Behavior Modification, 24(2), 264–297.
Kendrick, K. M. (2000). Oxytocin, motherhood and bonding.
Experimental Physiology, 85, 111–124.
Khoury, B., Sharma, M., Rush, S. E., & Fournier, C. (2015).
Mindfulness-based stress reduction for healthy individuals: A me-
ta-analysis. Journal of Psychosomatic Research, 78(6), 519–528.
Kiken, L. G., Garland, E. L., Bluth, K., Palsson, O. S., & Gaylord, S. A.
(2015). From a state to a trait: Trajectories of state mindfulness in
meditation during intervention predict changes in trait mindfulness.
Personality and Individual Differences, 81, 41–46.
Kivlighan, K. T., Granger, D. A., Schwartz, E. B., Nelson, V., Curran, M.,
& Shirtcliff, E. A. (2004). Quantifying blood leakage into the oral
mucosa and its effects on the measurement of cortisol, dehydroepi-
androsterone, and testosterone in saliva. Hormones and Behavior,
46(1), 39–46.
Klimecki, O., & Singer, T. (2012). Empathic distress fatigue rather than
compassion fatigue? Integrating findings from empathy research in
psychology and social neuroscience. In B. Oakley, A. Knafo, G.
Madhavan, & D. S. Wilson (Eds.), Pathological altruism (pp.
368–383). New York, NY: Oxford University Press.
Kreplin, U., Farias, M., & Brazil, I. A. (2018). The limited prosocial
effects of meditation: A systematic review and meta-analysis.
Scientific Reports, 8, 2403.
Lambert, M. J., & Barley, D. E. (2001). Research summary on the ther-
apeutic relationship and psychotherapy outcome. Psychotherapy,
38(4), 357–361.
Lamothe, M., Rondeau, É., Malboeuf-Hurtubise, C., Duval, M., &
Sultan, S. (2016). Outcomes of MBSR or MBSR-based interven-
tions in health care providers: A systematic review with a focus on
empathy and emotional competencies. Complementary Therapies in
Medicine, 24, 19–28.

Lebowitz, E. R., Leckman, J. F., Feldman, R., Zagoory-Sharon, O.,
McDonald, N., & Silverman, W. K. (2016). Salivary oxytocin in
clinically anxious youth: Associations with separation anxiety and
family accommodation. Psychoneuroendocrinology, 65, 35–43.
Leng, G., & Ludwig, M. (2016). Intranasal oxytocin: Myths and delu-
sions. Biological Psychiatry, 79(3), 243–250.
Leonard, H. D., Campbell, K., & Gonzalez, V. M. (2018). The relation-
ships among clinician self-report of empathy, mindfulness, and ther-
apeutic alliance. Mindfulness, 9(6), 1837–1844.
Lipschitz, D. L., Kuhn, R., Kinney, A. Y., Grewen, K., Donaldson, G. W.,
& Nakamura, Y. (2015). An exploratory study of the effects of mind-
body interventions targeting sleep on salivary oxytocin levels in
cancer survivors. Integrative Cancer Therapies, 14(4), 366–380.
Loseth, G. E., Ellingsen, D. -M., & Leknes, S. (2014). State-dependent μ-
opioid modulation of social motivation. Frontiers in Behavioral
Neuroscience, 8, 430.
Luberto, C. M., Shinday, N., Song, R., Philpotts, L. L., Park, E. R.,
Fricchione, G. L., & Yeh, G. Y. (2018). A systematic review and
meta-analysis of the effects of meditation on empathy, compassion,
and prosocial behaviors. Mindfulness, 9(3), 708–724.
MacLean, E. L., Gesquiere, L. R., Gee, N., Levy, K., Martin, W. L., &
Carter, C. S. (2018). Validation of salivary oxytocin and vasopressin
as biomarkers in domestic dogs. Journal of Neuroscience Methods,
293, 67–76.
Mascaro, J. S., Rilling, J. K., Tenzin Negi, L., & Raison, C. L. (2013).
Compassion meditation enhances empathic accuracy and related
neural activity. Social Cognitive and Affective Neuroscience, 8(1),
48–55.
McCullough, M. E., Churchland, P. S., & Mendez, A. J. (2013). Problems
with measuring peripheral oxytocin: Can the data on oxytocin and
human behavior be trusted? Neuroscience & Biobehavioral
Reviews, 37(8), 1485–1492.
Mestre, V., Frías, M. D., & Samper, P. (2004). La medida de la empatía:
Análisis del Interpersonal Reactivity Index. Psicothema, 16(2),
255–260.
Murphy, B. A., Costello, T. H., Watts, A. L., Cheong, Y. F., Berg, J. M., &
Lilienfeld, S. O. (2018). Strengths and weaknesses of two empathy
measures: A comparison of the measurement precision, construct
validity, and incremental validity of two multidimensional indices.
Assessment. https://doi.org/10.1177/1073191118777636.
Neumann, I. D., & Landgraf, R. (2012). Balance of brain oxytocin and
vasopressin: Implications for anxiety, depression, and social behav-
iors. Trends in Neuroscience, 35(11), 649–659.
Nilsson, U. (2009). Soothing music can increase oxytocin levels during
bed rest after open-heart surgery: A randomised control trial.
Journal of Clinical Nursing, 18(15), 2153–2161.
Nishizato, M., Fujisawa, T. X., Kosaka, H., & Tomoda, A. (2017).
Developmental changes in social attention and oxytocin levels in
infants and children. Scientific Reports, 7, 2540.
Norcross, J. C. (Ed.). (2011). Psychotherapy relationships that work (2nd
ed.). New York, NY: Oxford University Press.
Norcross, J. C., & Wampold, B. E. (2011). Evidence-based therapy rela-
tionships: Research conclusions and clinical practices.
Psychotherapy, 48(1), 98–102.
Patin, A., Scheele, D., & Hurlemann, R. (2018). Oxytocin and interper-
sonal relationships. Current Topics in Behavioral Neurosciences,
35, 389–420.
Proctor, G. B., & Carpenter, G. H. (2014). Salivary secretion: Mechanism
and neural regulation. Monographs in Oral Science, 24, 14–29.
Robinson, K. J., Hazon, N., Lonergan, M., & Pomeroy, P. P. (2014).
Validation of an enzyme-linked immunoassay (ELISA) for plasma
View publication stats
Mindfulness
oxytocin in a novel mammal species reveals potential errors induced
by sampling procedure. Journal of Neuroscience Methods, 226, 73–79.
Sanada, K., Montero-Marin, J., Alda-Díez, M., Salas-Valero, M., Pérez-
Yus, M. C., Morillo, H., et al. (2016). Effects of mindfulness-based
interventions on salivary cortisol in healthy adults: A meta-
analytical review. Frontiers in Physiology, 7, 471.
Saxbe, D., & Mendez, A. J. (2019). Maternal prenatal plasma oxytocin is
positively associated with prenatal psychological symptoms, but
method of immunoassay extraction may affect results. Biological
Psychology, 147, 107718.
Schulze, L., Lischke, A., Greif, J., Herpertz, S. C., Heinrichs, M., &
Domes, G. (2011). Oxytocin increases recognition of masked emo-
tional faces. Psychoneuroendocrinology, 36(9), 1378–1382.
Shamay-Tsoory, S. G., & Abu-Akel, A. (2016). The social salience hy-
pothesis of oxytocin. Biological Psychiatry, 79(3), 194–202.
Siegel, D. J. (2007). The mindful brain: Reflection and attunement in the
cultivation of well-being. New York, NY: W.W. Norton & Company.
Siegel, R. D., & Germer, C. K. (2012). Wisdom and compassion in psy-
chotherapy: Deepening mindfulness in clinical practice. New York,
NY: Guilford Press.
Singer, T., & Lamm, C. (2009). The social neuroscience of empathy.
Annals of the New York Academy of Science, 1156(1), 81–96.
Szeto, A., McCabe, P. M., Nation, D. A., Tabak, B. A., Rossetti, M. A.,
McCullough, M. E., et al. (2011). Evaluation of enzyme immuno-
assay and radioimmunoassay methods for the measurement of plas-
ma oxytocin. Psychosomatic Medicine, 73(5), 393–400.
Teding van Berkhout, E., & Malouff, J. M. (2016). The efficacy of em-
pathy training: A meta-analysis of randomized controlled trials.
Journal of Counseling Psychology, 63(1), 32–41.
Vachon, D. D., & Lynam, D. R. (2016). Fixing the problem with empa-
thy: Development and validation of the affective and cognitive mea-
sure of empathy. Assessment, 23(2), 135–149.
Valstad, M., Alvares, G. A., Egknud, M., Matziorinis, A. M., Andreassen,
O. A., Westlye, L. T., & Quintana, D. S. (2017). The correlation
between central and peripheral oxytocin concentrations: A system-
atic review and meta-analysis. Neuroscience & Biobehavioral
Reviews, 78, 117–124.
Van Cappellen, P., Way, B. M., Isgett, S. F., & Fredrickson, B. L. (2016).
Effects of oxytocin administration on spirituality and emotional re-
sponses to meditation. Social Cognitive and Affective Neuroscience,
11(10), 1579–1587.
Vittner, D., McGrath, J., Robinson, J., Lawhon, G., Cusson, R., Eisenfeld,
L., et al. (2018). Increase in oxytocin from skin-to-skin contact en-
hances development of parent-infant relationship. Biological
Research for Nursing, 20(1), 54–62.
Vivino, B. L., Thompson, B. J., Hill, C. E., & Ladany, N. (2009).
Compassion in psychotherapy: The perspective of therapists nomi-
nated as compassionate. Psychotherapy Research, 19(2), 157–171.
World Medical Association. (2013). WMA Declaration of Helsinki -
Ethical principles for medical research involving human subjects.
https://www.wma.net/policies-post/wma-declaration-of-helsinki-
ethical-principles-for-medical-research-involving-human-subjects/.
Accessed 9 September 2018.
Zilcha-Mano, S., Porat, Y., Dolev, T., & Shamay-Tsoory, S. (2018).
Oxytocin as a neurobiological marker of ruptures in the working
alliance. Psychotherapy and Psychosomatics, 87(2), 126–127.
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