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Co-Occurring Schizophrenia and Substance Dependence/Abuse

Applying MI: Express Empathy

Substance Dependence
Substance Abuse
Assessment of Co-occurring Disorders
Motivational Interviewing
Applying MI: Express Empathy
Applying MI: Develop Discrepancy
Applying MI: Avoid Argument
Applying MI: Roll With Resistance
Applying MI: Support Self-Efficacy
Evidence Based for Motivational Interviewing
Future Research and Barriers to Service
Web sites of Interest

Express Empathy through reflective listening:

“Empathy is a specifiable and learnable skill for understanding another’s meaning through the use of reflective listening…It requires sharp attention to each new client statement, and the continual generation of hypotheses as to the underlying meaning”

                                              (Miller and Rollnick, 1991)


An empathetic style:


           Communicates respect for and acceptance of clients and their feelings

           Encourages a nonjudgmental, collaborative relationship

           Allows you to be a supportive and knowledgeable consultant

           Sincerely compliments rather than denigrates

           Listens rather than tells

           Gently persuades, with the understanding that the decision to change is the client’s

           Provides support throughout the recovery process


Empathetic motivational interviewing establishes a safe and open environment that is conducive to examining issues and eliciting personal reasons and methods for change.  Understanding each client’s unique perspective, feelings, and values is a fundamental component of motivational interviewing.  The therapist’s attitudes should be of acceptance, not necessarily approval or agreement, understanding and recognizing that ambivalence about change is to be expected.  MI is most successful when a trusting relationship is established between the therapist and the client.


Empathy “should not be confused with the meaning of empathy as identification with the client or the sharing of common past experiences.  In fact, a recent personal history of the same problem areas…may compromise a counselor’s ability to provide the critical conditions of change (Miller and Rollnick, 1991).  Reflective listening is the key component to expressing empathy.


Miller and Rollnick state that if the therapist is not listening reflectively but are instead imposing direction and judgment, they are creating barriers that impair the therapeutic relationship.  The client would most likely react by stopping, diverting, or changing direction. 


Twelve examples of such nonempathetic responses are identified:


1.         Ordering or directing.  Direction is given with a voice of authority.  The speaker may be in a position of power (e.g., parent, employer) or the words may simply be phrased and spoken in an authoritarian manner.


2.         Warning or threatening.  These messages are similar to ordering but they carry an overt or covert threat of impending negative consequences if the advice or direction is not followed.  The threat may be one the clinician will carry out or simply a prediction of a negative outcome if the client doesn’t comply –for example, “If you don’t listen to me, you’ll be sorry.”


3.         Giving advice, making suggestions, or providing solution prematurely or when unsolicited.  The message recommends a course of action based on the clinician’s knowledge and personal experience.  These recommendations often begin with phrases such as, “What I would do is…”


4.         Persuading with logic, arguing, or lecturing.  The underlying assumption of these messages is that the client has not reasoned through the problem adequately and needs to help to do so.


5.         Moralizing, preaching, or telling clients their duty.  These statements contain such words as “should” or “ought” to convey moral instructions.


6.         Judging, criticizing, disagreeing, or blaming.  These messages imply that something is wrong with the client or with what the client has said.  Even simple disagreement may be interpreted as critical.


7.         Agreeing, approving, or praising.  Surprisingly, praise or approval also can be an obstacle if the message sanctions or implies agreement with whatever the client has said.  Unsolicited approval can interrupt the communication process and can imply an uneven relationship between the speaker and the listener.  Reflective listening does not require agreement.


8.         Shaming, ridiculing, labeling, or name-calling.   These messages express overt disapproval and intent to correct a specific behavior or attitude.


9.         Interpreting or analyzing.  Clinicians are frequently and easily tempted to impose their own interpretations on a client’s statement and to find some hidden, analytical meaning.  Interpretive statements might imply that the clinician knows what the client’s real problem is.


10.       Reassuring, sympathizing, or consoling.  Clinicians often want to make the client feel better by offering consolation.  Such reassurance can interrupt the flow of communication and interfere with careful listening.


11.       Questioning or probing.  Clinicians often mistake questioning for good listening.  Although the clinician may ask questions to learn more about the client, the underlying message is that the clinician might find the right answer to all the client’s problems if enough questions are asked.  In fact, intensive questioning can interfere with the spontaneous flow of communication and divert it in directions of interest to the clinician rather than the client.


12.       Withdrawing, distracting, humoring, or changing that subject.  Although humor may represent an attempt to take the client’s mind off emotional subjects or threatening problems, it also can be a distraction that diverts communication and implies that the client’s statements are unimportant.


Ethnic and cultural differences must be considered when expressing empathy because they influence how both the clinician and the client interpret verbal and nonverbal communications.


           In individual motivational interviewing, the therapist uses empathetic, reflective listening to convey understanding and acceptance of the client (this appears to work to facilitate openness to change.

           In structured group sessions, therapists use an empathetic style in interacting with group members, while still maintaining control over the overall structure of the session.  During sessions all group members’ contributions were met with a reflective listening statement by the therapist and structured exercises are designed to incorporate group members’ own words and ideas.

(Miller, 2000)



Nicole & Colleen