An Exploration of Empathy

I had the opportunity to attend a lecture by Dr. Miller in September of 2014 at Washington University in St. Louis that focused on the recent trends in opiate abuse. Speakers present at this lecture discussed the demographic shifts in opiate abuse, the underlying economic drivers that contributed to the issue, and the need for an increased focus on this crisis among medical professionals. Dr. Miller was the final presenter and he focused solely on one concept: Empathy. 

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Dr. Miller argued that empathy was the most important factor affecting recovery rates for clients with substance abuse issues. He argued that empathy is the foundation upon which effective therapeutic skills and systems such as MI, CBT, AA or the 12 step model can be built. He demonstrated convincingly with a variety of studies that empathy is the number one factor in an individual's recovery from a substance abuse issue. One of Miller's final statements during the presentation was something to the effect of: if you want to have effective clinicians and high rates of client recovery, all you need to do is hire for empathy (Miller, 2014). 

A meta analysis of therapeutic relationships endorsed by SAMHSA includes empathy and collaboration as key aspects of a helpful clinician-client relationship. This study found that the relationship between provider and client was at least as important as the type of therapy being provided. Further the study noted that efforts to use an evidence based practice without taking the realtionship into account are "incomplete and potentially misleading" (Norcross, 2010, pg. 1). Clearly, the relationship between the client and clinician is important, empathy is a prerequisite for any clincal modality in the behavioral health field.

Empathy: A Dictionary Definition
The Merriam- Webster dictionary defines empathy as "the feeling that you understand and share another person's experiences and emotions : the ability to share someone else's feelings" (2015). This definition focuses on the emotions and experiences of others, an empathetic person would be one who "shares" these things. The Merriam-Webster definition gives the reader a feeling of what empathy should be, but it lacks the depth or practicality needed for deeper understanding and application of the concept.

Rogers and Empathy
Carl Rogers provides us with a much deeper definition of empathy. Similar to the above definition, Rogers mentions sharing experience and feelings, "[empathy is] entering the private perceptual world of the other and becoming thoroughly at home in it." But Rogers also adds non-judgment as a further criteria for empathy, "moving about in it [the other's experience] delicately without making judgments, sensing meanings of which he/she is scarcely aware." Rogers then goes further to add that in order to be empathetic the listener must communicate their understanding back to the other "with fresh and unfrightened eyes." Rogers suggests a final part of empathy that includes "pointing to the possible meanings," and helping the person "to experience the meanings more fully, and to move forward in the experiencing" (Rogers, 1975).

The above definitions suggest by Rogers can be broken down into 4 key elements, which if applied could be used instructively when teaching the skills of empathy but also diagnostically when rating a clinician on a scale for empathy in their clincal appraoch. 

1) Ability to enter another's perceptual world.
2) Ability to refrain from judgement of other's perceptual world.
3) Ability to communicate to the other one's understanding.
4) Ability to help the other arrive at possible meanings. 

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Empathy in MI
Miller and Rollnick have put a lot of thought into empathy. As I noted earlier, Miller cites empathy as the most important quality in a clinician; he reports that a clinician's empathy is the aspect of treatment that is most predictive of client recovery. Since the development of motivational interviewing in the early 80's the definition of empathy used in MI has evolved to be more practical, tangible and measurable. One recent definition of empathy used in MI is below:

"The extent to which an interviewer communicates accurate understanding of the client’s perspectives and experience; most commonly manifested as reflection." (Miller & Rollnick, 2013)

This definition borrow's heavily from Rogers' concept of empathy. In this definition, not only does one need to have the ability to understand another's experience, but one must be skilled in communicating to others their understanding in a way that resonates with the speaker. In other words it is not good enough for the listener to listen and provide occasional "check-in" responses (simple reflections), empathy only works if the one speaking feels heard (often through complex reflections). Miller and Rollnick's definition provides one important way that a listener can help a speaker feel heard - reflection. One final aspect of the type of empathy used in MI is that a truly adept clinician should be able to not only understand what the client is experiencing, but the clinician should be able to have a good guess at deeper meanings and of what the client has yet to say (Miller & Rollnck, 2013).

This MI definition of empathy is very similar to the Rogerian view of empathy, but this definition provides us with some more specifics and perhaps a better target for accurate empathy. 

1) Ability to enter another's perceptual world (this requires the spirit of MI).
3) Ability to communicate to the other one's understanding.
3) Ability to allow client to feel heard.
4) Ability to help the other arrive at deeper meanings.

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Codifying Empathy
Using the above definition for empathy, Moyers, Manuel and Ernst have developed an empathy rating scale as part of the Motivational Interviewing Treatment Integrity Coding Manual (MITI) (2014). This rating scale would rate a clinician with no empathy as a 1, and a clinician with exceptional empathy as a 5. At the highest end of the empathy scale (a rating of 5), a clinician is able to convey an accurate understanding of deep meaning beyond what is being explicitly said by the client as evidenced by the employment of complex reflections (Moyers, et al. 2014). 

The concept of empathy is more than just understanding another's experience, feelings or perception. As used in MI, the term empathy refers to a quantifiable skill set that can be grown out of the spirit of MI. The operationalized concept of empathy given to us by Moyers et al. allows us to identify a clinician's ability to use empathy to help others. In a future article I will discuss how to apply the MI definition of empathy to the hiring process in order to meet Dr. Miller's recommendation that organizations who want to see more recovery should to hire for empathy. 

Works Cited


Empathy (n.d.). Merriam-Webster Online. In Merriam-Webster. Retrieved July 27, 2015, from http://www.merriam-webster.com/dictionary/empathy.

Miller, R.M. (2014). Lecture at Bringing Science to Addiction Services. Community Action Partnership in Addiction, St. Louis: Washington University. 

Miller, W.R., and Rollnick, S. (2013). Motivational Interviewing: Helping People Change. NY: Guilford.

Miller, R. M. & Rollnick, S. (2013). Glossary of Motivational Interviewing Terms. NY: Gilford Press. 

Moyers, T.B., Manuel, J.K., & Ernst, D. (2014). Motivational Interviewing Treatment Integrity Coding Manual 4.1. Unpublished manual.

Norcross, J. C. (Ed.). (2010). Evidence-Based Therapy Relationships. New York: Oxford University Press.
 
Rogers, C. R. (1975). Empathetic: an unappreciated way of being. The Counseling Psychologist 2, pp. 2-10.