Empathy in Motivational Interviewing: Moving Beyond Reflections

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December 7, 2015 by Nicholas Spence

reflectionEmpathy: “The ability to understand and experience the feelings of another person” is an essential clinical and life skill, which has been shown to be associated with behavioral treatment outcomes.

Far from surprising, empathy is a core principle of motivational interviewing, but there are gaps in the ways we measure this complex concept during an interview session.

This issue was given strict attention in “More Than Reflections: Empathy in Motivational Interviewing Includes Language Style Synchrony Between Therapist and Client,” by Lord et al. (2015) in Behavior Therapy.

Currently, one of the most popular fidelity measures, the Motivational Interviewing Integrity Scale (MITI), is used for assessing the quality of the skills of a motivational interviewer. The assessment includes a rating of empathy for the duration of a session.

As described in the article, “Global therapist empathy on the MITI incorporates an interest and attention to the client’s worldview, active and accurate understanding of the client’s perspective, and evidence of deep understanding of the client beyond what has been explicitly stated.”

Reflective listening has been the predominant focus of linguistic aspects of empathy measures, including the MITI. Reflections come in two main forms: simple reflections (therapist repeats client) and complex reflections (therapist reflects in a deep manner beyond client words).

Beyond reflections, which focus on the interviewer’s ability to understand the content of what the client is saying, this study assessed the utility of the concept called synchrony that is focused on the stylistic aspects of language between the interviewer and client. In other words, in this context, synchrony is concentrated on how content is expressed between the interviewer and client during a session using language style categories, such as personal pronouns, negations, conjunctions, and prepositions, as opposed to what is being said (e.g., nouns and adjectives).

Using data from a motivational interviewing training study from the National Institute of Drug Abuse affiliated substance abuse treatment facilities in Washington state, 122 MI sessions were rated for empathy (high/low) based on the gestalt global empathy rating of the MITI 3.0, in the form of digital audio and observer ratings. Reflections were measured using behavior counts that basically corresponded with the number of utterances identified as either complex or simple reflections.

The authors sought to assess whether synchrony in language style—matching how statements are phrased—between client and interviewer had any value as an indicator of empathy, beyond reflections. This was accomplished using a language style synchrony measure examining the similarity of word usage across 11 language style categories between the interviewer and client.

They found that motivational interviewing sessions high in empathy were consistent with higher language style synchrony with clients compared to low empathy sessions; and synchrony in language style was useful in predicting empathy beyond traditional measures centered on counts of simple and complex reflections.

Thus, as we aim to enhance fidelity measures that capture the central therapeutic processes of motivational interviewing, including empathy, this should lead to improved training, supervision and skills in the field.

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