MINT Virtual Forum 2021 - What Makes Helpers Helpful?

Prof William Miller

January 18th, 2021 | 12:30 PM - 02:00 PM EST

Prof. Miller: I never know at one forum what I'll be talking about at the next. By the time it rolls around there is something new. I want to talk about where my own thinking has been going. From what we have learned in motivational interviewing, and it has brought into this topic. What is it that makes helpers helpful? It is a puzzle I have been thinking about for a long time. I want to share some pieces of that puzzle. We will see where it goes. 

The first is it has been clear for a very long time that accurate empathy, the skill of understanding what someone is saying and reflecting it back to them accurately is important. I will talk later about the effect size of .58. It has a medium effect size across all kinds of treatments and issues. Very large samples. It is what Carl Rogers was writing about in the 1950's. That quality of helpers, not just therapists but the helpers seems to be a really important piece of what helps people change. I want to go back to my early wake-up call about this. When I came to New Mexico I was teaching and doing behavior therapy for people with alcohol problems. I was also teaching Carl Rogers to my therapist and my students.

In the study I will be talking about, the citation is at the bottom of your screen, we had nine counselors. We trained them altogether and they were all being supervised. We are watching the practice. They were all working from a manual, so allegedly doing the same treatment for people with alcohol use disorders. Three of us independently rated these nine therapists for how empathic they were using the measures developed by Carl Rogers's own student -- Carl Rogers' own students in 1967. When we got the outcome, we found the outcomes were very different appending on who the therapist was even though they were all using the same manual, they were all trained together, all allegedly doing the same treatment. The success rates varied from 100% to 25%. As you can see from the graph it was related to how empathic the therapist was while practicing this behavioral therapy. The most empathic therapist, the one all of us rated at number one had 100% success rate. 100% of her clients changed in a positive direction. At the other end of the scale, another therapist using the same manual in the same error. Had a 25% success rate. The correlation was strong. In this study, we also had a group who are given self help materials at home. They had a 60% success rate. If you compare 60% for that group with all of the therapist average, the therapist average 61% success. It could lead you to say therapists are no different from self-help manuals. You would be wrong. Five of these therapist had success rates higher than people working on their own. One had exactly the same success rate. In the case of three therapist, it looked like the clients would have been better off going home. Averaging across therapist is misleading. You are missing something important.

It was with that study I went to Norway, into the meetings that would eventually lead to motivational interviewing, seeing how important empathy was to outcome. We were accounting for a large proportion of variance. At six months we could predict with the correlation of .82 how many drinks per week's client would be having based on how well their therapist listened to them. Even two years later we are still accounting for a quarter of the variance in how may drinks per week based on how empathic the behavioral therapist was. The second piece of the puzzle. I did not expect motivational interviewing would be a stand-alone intervention. I was thinking of it as a way of preparing people for treatment. In study after study we began finding that based on a motivational interview alone compared to no treatment, people were making significant changes. We were seeing big decreases in behavior. That did not occur on a waiting list. It is looking like motivational interviewing by itself is having an impact. Not something I had initially expected, but now confirmed in multiple analyses. The third piece of the puzzle. When you directly compare motivational interviewing is a stand-alone treatment with other therapies, other active treatments, typically there is not much difference. The average effect size is zero. You get similar impact for motivational interviewing as for more extensive treatments. These are graphs from project match, and the yellow line, which disappears, is cognitive behavioral therapy. The blue line is 12 step therapy and the purple line is motivation therapy. All three did very well with clients randomly assigned to treatments with no significant differences over 36 months of outcomes. That was unexpected, that motivational interviewing would be producing effects similar to those of more extensive treatments. That has been confirmed in multiple analyses as well, that when M.I. is compared with more extensive treatments, usually there is not much difference.

Something else that has been clear in my research is it matters what you do as a therapist. This is a study done by Lisa Glenn and Terri Moyers in which they changed counseling style every 12 minutes, fluctuate between motivational interviewing, or doing a functional analysis. The green bars are the amount of change talk. The red bars are the amount of sustained talk. In the first photo there is more change -- in the first period there is more change talk then sustained talk. Then 12 minutes later switches back to motivational interview, and now we have a two to one ratio of change toxicity in talk, which seems to be the place where the balance tips. Where you begin to expect behavior change. Then the balance switches back again. It makes a difference what the therapist is doing. Another thing is when different therapists deliver motivational interviewing, they have different outcomes. Although they are all supposedly doing the same thing, they're all delivering motivational interviewing, you get different outcomes depending on who is doing the motivational interviewing.

Over the decades we have heard members of MINT say I do not feel like they ever put motivation down, it is not that I turned that off. Even though I'm doing other kinds of treatments, I still feel I am being the same kind of person, practicing the same wave being with my clients. It is not like motivational interviewing is something I turn on and off. On a good day it is on all the time. Consistent with that, what the outcome literature is showing us that the most common use of motivational interviewing now is in combination with other kinds of treatment. There are fewer and fewer studies of motivational interviewing alone, and more studies of motivational interviewing combined with other treatments. Whether it is cognitive therapy, behavior therapy, or medication. It is putting them together. Meta-analyses tell us when you add motivational interviewing to another treatment, they both work at her -- they both work better it is a effect size of .6.

Then as you know, we found spirit was important. When Steve and I were teaching motivational interviewing early, we were teaching techniques. Then we watched people practicing those techniques and we were not pleased with what we saw. It was clear we had left something out. What we had left out was the heart set and mindset behind the practice of motivational interviewing, which we now describe as including partnership, radical acceptance, compassion. The primary interest is the other person's well-being. We will shift the last of these from evocation to empowerment. We have been using a evocation to describe part of the spirit, to describe the processes of motivational interviewing, and also to describe a skill. It is too much use of the same word. I think a broader concept we will be using in the fourth edition, which we have started thinking about, will be empowerment. Part of this underlying spirit with which you practice. It matters how you are thinking. If you're thinking about using -- using motivational interviewing to trick people into doing what you hope they will do, that is very different practice from using the methods of motivational interviewing with this kind of spirit when the other person is in charge, when the other person is not a passenger in a plane you are flying. They are not even the copilot. They are the pilot and you are sitting next to them as a copilot. I went back to read a book I read long ago in graduate school , written in 1967. Written by two of Carl Rogers' students. They described how to measure these attributes Carl Rogers was talking about. When I read this book, I was surprised. I found they were not trying to promote a new school of psychotherapy. Not at all. They were talking about and interested in what is it that makes therapist more effective no matter what their school of psychotherapy. They are talking about not personality characteristics, they are talking about measurable skills you can observe and study and teach. These are things you can learn that seem to make therapists more effective regardless of their school of psychotherapy. Accurate empathy was one of those. There were three things Carl Rogers emphasized. The first was accurate empathy, which has held up over the decade.

The second is unconditional positive regard for the client, and the third is honesty. Being in touch and being aware of your own experience and being willing to share that when it is appropriate and when it is likely to be helpful to the client. These are always of measuring all three of those. All three of them were related to outcomes. They were interested in training better therapist, not teaching a particular school of psychotherapy, not teaching techniques so much as making better therapist. I saw the book in a different light than the first time I read it. As you're probably aware, in psychotherapy research one of the common findings is when you compare different bona fide treatments with each other, when you put them head-to-head, there usually is no clinically meaningful outcome difference between them. Sometimes he would get a statistically significant difference if it is a large sample, but the little differences are not ones that a clinician would regard to be meaningful. The bottom line finding in comparison of different kinds of psychotherapy is the outcomes look similar. Project match was a great example of that. We picked these three treatments because we thought they were as different as you could imagine. Different theoretical orientations, different procedures, a different way of thinking about what you are doing, and in the long run they all do just as well. A very common finding in psychotherapy research. So, it has come to be called the dodo bird verdict, drawing on Alice in Wonderland. Everyone has won and everyone must have prizes. But do you really leave there is no kind of treatment that is any better than any other? Do you really believe when you go into room with a client it does not matter what you do? You can do anything and they would get better? I do not believe that. It is a comparison of bona fide treatments. That is an important phrase.

A running debate, a hot debate in psychotherapy is what is it that matters in therapy? Is it specific treatment procedures, manual techniques you are using, or is it common factors that are present in all therapies? The problem for me and that is the word "or." The assumption it must be one or the other. It must be the techniques or something about the therapist. Do you really believe that all therapists are equally effective? That is not with the data is saying. Do you really believe it does not matter who provides the treatment? I think it does. That is what the data say. Do you think treatment success is attributable to factors that are common to all therapists? I do not think so. Here's a study that came out just a year after the one I mentioned. This is an alcoholism treatment program. He compared therapist who were low or medium or high in Rogerian skills. Client outcome is relapse rate, so up is not good in this case. The rates of going back to the same behavior are higher when working with a therapist who has poor client centered counseling skills than working in the green bar, with therapists who have a high level of interpersonal skills. The rates of relapse are two to four times higher in the red bar in the green bar. The combined study was another large trial we did combining medications and psychotherapy. We had 22 experienced therapist in this trial who treated at least 10 clients. We did not include them in this analysis unless we had outcomes for 10 of the clients. They were all delivering manual guidance combined behavioral intervention. We trained them altogether. They were all closely supervised. Every session was videotaped. The tapes went to Yale University where they were monitored. If therapist did not do a good job they could be withdrawn from the trial. What we looked at was the average percent days abstinent for each therapist client across 12 months of treatment and follow-up. That is what this graph is. Every one of these lines represents one therapist with at least 10 clients. The vertical bar is percent days abstinent. 100% is the highest it can go. You could see that over the course of 12 months there were enormous differences in the client outcomes , predictable from who the therapist was. Including therapists for whom virtually all of their clients were abstinent all of the time. And some therapist whose clients were drinking almost every day, and everything in between, so that even though we tried our best to control the content of the therapy, who the therapist was made an enormous difference in how the clients were doing.

We are still -- a consistent finding is that therapists do not get better with practice. After 30 years of practice psychotherapists are no more effective than they were when they started. Isn't that depressing? It is not true of surgeons. Surgeons do get better with practice. If you're going to have a surgical procedure, you look for one who has had a lot of them because you get better the more you do. That is not true across the board with psychotherapists. This suggests that maybe we have been looking in the wrong direction for evidence-based treatments. We have been looking for techniques that are more effective than other techniques. When bona fide treatment techniques are compared, there usually is no difference between them. There is almost always a difference based on who provided the treatment. Maybe we've been trying to solve this puzzle upside down with the pictures facing down. It is harder to solve a puzzle that way.

What about therapist factors? Therapist factors have a substantial effect on outcome. In manual guided well-controlled treatments, and also in uncontrolled treatment as usual. Just in any community treatment program. Therapists are likely to have very different outcomes, even though they are all doing what is presumed to be simpler. In fact, when you think about it, evidence-based psychotherapy cannot be separated from the therapists who provide it. They are inseparable. They are one of a piece. Terri Moyers and I wrote an article called the forest and the trees about that phenomenon. The fact that these therapists characteristics are called common factors is misleading. Therapists differ widely in things like empathy and warmth and genuineness, things we know effect client cap, and we know therapists are different on those things. Like common sense, these may not be that common practice. They are certainly not universal. It is not the case that all therapists do this. The therapist who practice these things consistently have better outcomes than others. They also get called nonspecific. I think that is not a good term either. These skills can be specified. You can observe them. You can measure them reliably. You can learn them, you can get better at them. They do predict client outcomes. To call them nonspecific is misleading and suggests we have not done our homework, when a lot of the work is there to specify, observe, measure, learn, and teach these variables that do predict client outcomes.

That search for therapeutic factors has been there a long time and has a long history in clinical psychology. It is what Carl Rogers was searching for when he became the president of the American psychological Association in the 1940's. This is where clinical science began. Some of the first empirical work on outcomes of psychotherapy had to do with these kinds of factors, with Carl Rogers and his associates. Motivational interviewing certainly has its roots in this clinical science of Carl Rogers. Terry Moyers and I decided a couple of years ago we wanted to go back through and read 70 years of psychotherapy research and try to understand what is it about therapist that makes them more effective?

We came up with eight different characteristics that are skills. These are not personality attributes, these are skills therapists show that are measurable and learnable and predict client outcomes. Each one of them has an experiential side, and attitude side, a spirit side. It is what is going on inside you. Each one of them also has inexpressive side. Each one also has behavioral aspects to it. It seems like either one of these without the other is not complete. If you privately have strong empathy for your client, you really understand them, but you do not express it, that is not helpful for the client. We also found in our early work teaching motivational interviewing that just trying to do the techniques without the underlying experiential spirit of it is incomplete. It is interesting the two sides are still there.

The first chapters in our book is about accurate empathy. The ability to understand the client experience and convey that understanding back to the client. It is the most consistently supported clinical skill that predicts client outcomes across a broad range of schools of psychotherapy in different spheres of practice. Not limited to psychotherapists either. It is also true of teachers and physicians and sports coaches. The effect size, on average, cross 82 studies, was 6000 clients. .58, a light -- .58, a nice meaningful size. It is observable. You can measure it. It usually gets better with training. It is one of the things we teach. High empathy predicts better outcomes across a broad range of domains and low empathy is associated with significantly worse outcomes than no treatment at all. That is sobering.

The second, positive regard or warmth towards your client. It is prizing and respecting your clients, caring for them, and the ability to communicate that. If you just privately care for clients, it is not as helpful as if you communicate that to clients. Affirmation, which is one of the keys of motivational interviewing, is one of the clearest behavioral ways of doing that. Validating your client's strengths, what they are doing well, their values. Its average effect size is .36. Still meaningful across 64 studies. The specific behavior of affirmations is related to decreased client defensiveness, increased retention -- clients are more likely to stay with you if you are affirming them. Better treatment outcome. And whatever you affirm, you tend to get more of. The same is true with reflections. Whenever you reflect, you tend to get more of.

Number three of our eight, genuineness/congruence. It is being present and being open. Being a real human being with the people you are serving. Being honest. The absence of dishonesty is the most important. Your authentic. You cannot not come across as phony. You are a real person. It means you need to be aware of your own inner experience with clients. Emotionally engaged as the client story unfolds, and willing to reveal your own experiences, thoughts, emotions, and values if and only if they benefit the client. Those are the three Rogers talked about. That has held up over the years. Modest effect size, .46 across 21 studies. Three different clinical skills predicting client outcome. Acceptance. Another key piece in motivational interviewing. The ability to listen to people without judging them, without bringing in your own preconceptions, and to convey that nonjudgmental perspective to the client. In a weight is bringing a beginners mindfulness to every client. You cannot assume you know to begin with. You listen and follow the client and except what you are hearing without judgment. Behind that, the idea every person has inherent worth as a human being and deserves respect and does not need to earn it from you. The absence of disapproving, criticizing, disagreeing, and shaming is important. It does not take many of those to undo acceptance. 154 effects studied in outcome research, most of them were positive effects.

Here is a fourth focus. Clear therapeutic goals in a coherent plan for reaching them. When you're talking about whatever it is the client happens to be talking about that day, remember where you are going together. The goals need to be shared, not just your goals, but the clients goals as well. That is a big predictor of client outcomes. An interesting study we talk about in the book found that chat, the more chat there was the less client motivation and retention there was. And resolving ambivalence about goals is important. Having achievable goals improves outcome. In fact, if you think about evidence-based treatment, there is no way to know if a treatment is effective and less you know what it is supposed to affect. -- unless you know what it is supposed to affect. 

Number six, hope. Not just the clients hope. There is very clear evidence that therapist expectancies are self-fulfilling prophecies. If you expect your clients to have good outcomes, they are more likely to have good outcomes. If you are pessimistic, that is associated with negative outcomes. When you expect your client is not going to do well, they don't. That is not because we are amazing predictors of behavior, I think it is because our expectations are self-fulfilling prophecies. What we see as client possibilities is what they become. I think of our students, our children. Allegiance, we know that if you believe in the treatment you are providing, and that is an important component of effective therapy. We know in clients lack hope it is important to lend them some of yours. In the waiting list affect I have talked about several times, when you put people on a waiting list, they are less likely to change. When people are on a waiting list, they don't change it all. Why is that? Because they are doing what we told them to do. We told them to wait. We said you're not going to get better until I treat you, and then it will be OK to get better. And that is exactly what happens. The waiting list is also a self-fulfilling prophecy.

Number seven, this one comes right out of motivation. Eve OK. We know there are client factors that are also strong predictors of client motivation, engagement, hope, self-efficacy. The more of those your clients have, the better. And you can call those things forth. You can evoke them. You can strength them them. You are not just a victim of whatever the client has to offer . You can evoke the clients own resources. Rather than Inc. of yourself as a provider, you can eat -- think of yourself as a provider, you can evoke what is already there. Experience is talking about what is going on with you, not just talking about the past, not describing your life in abstract terms like an objective reporter might do, but talking about what you think, what you feel, what is going on inside you, and that is a measurable process. Experience is measurable. In experimental therapy, cognitive therapy. Experiencing talking about what is going on is something that predict a better outcome and is very related to what the therapist is doing. The idea here is that what sign -- clients say during treatment predicts outcome. What you ask, what you reflect, what you affirm, what you put in summaries, that is at the heart of teaching motivation for a long time. And solution focused therapy, conscious selective use of clinical skills in motivational interviewing is a key part of the process. You're constantly encouraging clients to talk about particular things, to talk in particular ways related to client outcome.

And then the last of the eight, giving information and advice. It may be the things clients most think of when they come to see a helper. It's directing at one end, telling people what to do, following at the other end, listening to and going wherever the client goes, and in between, guiding, which involve some directing, following, and listening. That kind of middle territory . Professional advice alone, like suggesting someone commit -- someone quit smoking has a small effect size. Advice alone seems to be helpful. But in motivational interviewing , we know a lot about how you give advice. It's not that the advice in general is effective, it's how you give advice. There is an art to it. If you are direct, the client is less likely to change then if you left them alone. But if you ask for permission, honor autonomy and ask choices -- and give choices, then you have a better chance of succeeding.

So these eight skills seem to mark therapists who have better outcomes, and not just better outcomes than other therapist. Each therapist also varies across clients. The more you are doing of these things with a client or in a session, the better the outcome. A lot of this sounds a lot like motivational empathy, doesn't it? Empathy, compassion, being accepting, having clear focus, expressing positive outcome expectancies and valuing the clients own resources.

I wonder if rather than these being eight separate skills, they kind of flow together in a way. Is there -- not a common source, but a confluence of these things ? There are some ancient concepts that sound a lot like a convergence of these things. In Judaism, it is often translated as lovingkindness, and it is translated that way because the translator could not find an English word that adequately captured the Hebrew. So they took two words, loving and kindness, intention and acting -- action, and put them together. In Buddhism, Meda, benevolence -- meta-benevolence. In Christianity, agape, selfless loving. In Islam, rahmah, compassion. Therapeutic concepts combine these things. Charles Rogers -- Carl Rogers toward the end of his life was writing about presence, by which he seemed to mean the confluence of these things, being truly present is to be warm, affirming, and accepting. Responsiveness. To what extent do you change your clinical skills depending on the client's present situation? We have emphasized that in motivational interviewing. The client is your guide. Real relationship is another term for that.

Carl Rogers last book, a way of being, said this is really what we are talking about, studying, and trying to understand, a way of being. And I wonder if maybe this is what we have been studying in motivational interviewing all along. We are not studying a different technique. We are not studying a school of psychotherapy. We are studying what it is that makes health care healthy. And if that is the case, we should be teaching this in clinical training. Clinical training so often these days focuses on specific techniques, even with therapist manuals trying to standardize treatment area that we know that you cannot standardize treatments. Therapist clinical skills account for more variable -- variance and client outcomes than specific treatment methods. So these should not be an afterthought or an asterisk in clinical training, I think they should lie at the heart of it. Because whatever therapeutic approach a person chooses, these things matter. Clinical training programs spend the first year evaluating and shaping these clinical skills. We were fortunate to have that as part of our clinical training. The first year, there were courses focused on how to talk to, listen to, and be with clients. They teach the fundamentals of therapeutic relationship before therapist start delivering therapy, before they start learning specifics, to learn how to be with clients. This needs to be taught and modeled so that supervisors and teachers themselves can also demonstrate and show it. And I think we ought to be screening people that we are training to be therapists for the skills because it is clear that low levels of these skills can actually harm clients. Here is what they wrote in 1967: Professions should take an active hand in weeding out or retraining therapist's, educators, counselors and so forth who are unable to provide high levels of effective ingredients and who therefore are likely to provide human encounters that change people for the worse.

They were passionate about this more than 50 years ago. Passionate about it. And yet I think 50 years later, we are not doing a much better job of screening out people who are likely to be harmful. So, in summary, what makes the room -- winner of a race? Is it the car or is it the driver? What makes a great meal? Is it the raw ingredients or is it the chef? What lights up a room? Is it the candle or the flame? What I am interested in is teaching safer drivers, better chefs, brighter flames. Thank you. Orla?

>> I am here. Can you hear me?

>> I can. What do we do now?

Orla: There are a couple of questions. You can stop the slide share. There are three questions in the Q&A. Do you want me to share them with you?

William: Please do.

Orla: Is this measure of accurate empathy still used or available?

William: It is. It is in the 1967 book. Our empathy measure is very much built on that one. I think the work Terry, Denise, and others have done has produced a better measure of global empathy than we had in 1967. But we are essentially doing the same thing, the observable skill of reflecting what the person is saying, getting closer to understanding. It's quite measurable, and there are countless studies that find it really affects client outcomes. Even going back to the original, you can use the current version of the mighty.

Orla: Thank. Another question from Ona. She said thank you for all that you do. She would love to hear more about research findings that affirm what you get more of.

William: What you might think of as irrational thinking, thought patterns that tend to move clients in an unhealthy direction, you can get more of those. What you are expecting and looking for in a way gives you more of it. I was working with someone years ago who had been taught that what you need to do is unearth all of the horrible experiences of a person's past so they really experience them, so whenever a client would talk about a negative experience, it was affirmed, reflected, just more, more, more despair. It matters what you reflect. It is clear from Terry's work that the content being reflected is likely to be expanded on. After you get through an engagement process and into an evoking process, be very conscious of what you are reflecting because the client is more likely to focus on and elaborate on that. The same is true of affirmation. It also matters what Austin's you ask. The content the client speaks -- what questions you ask. The content the client speaks will affect what you reflect, affirm, and put in your summaries. And that is expressed in the work Carl Rogers was doing in the 1950's and 1960's.

Orla: There is another question from Catherine. She says can you talk about hope with end-of-life conversations?

William: What is hope there? Obviously, a person's understanding of the meaning of their life and of the afterlife is an important part of their perspective on dying. But the hope at that point is not to cure the illness, it is to come to peace with the process, peaceful acceptance of the process at the end of one's life is key there. But motivational style can be used at end-of-life care. Perfectly good place for it -- for an empathic, compassionate, warm, honest way of being.

Orla: Thank you very much. Sam says good summary, very thought-provoking. What do you think would be the best way of teaching these clinical skills ? Would deliberate practice be involved?

William: Yes, deliberate practice has a very good track record. You do this with active listening, for example. We have done a lot to teach about empathic listening. First, teach the person to think hypothetically. And then try first with questions. You mean this? And then reflected in a statement. There is a whole sequence of behaviors. And also teaching the mindset, heart set, and spirit behind it. Modeling is important and that as well. -- in that as well. In the book coming out in a couple of weeks, in February, we talk about a book by Ben Franklin. He has a list of virtues he is trying to practice in his own life, and he suggests working on them one at a time. Don't try to work on them all at once. Focus on one. How could you be more congruent? How could you be more empathic? How could you have clear focus? Just pick one. Don't try to do all ate at the same time. If you consciously, intentionally practice them one time, you get better at it. He suggests concentrating on one for a month, and the next month, concentrating on a different one, and there are 12, so over the course of a year, you have practiced all of them, and then you start over in January. I think there is some wisdom in that. Not necessarily 12 suggestions for what you could do differently, but what is one thing you could do here to better convey this? Consciously teaching these clinical skills, these interpersonal skills, it wasn't left out of my own clinical training, but that was an accident. The first year course, none of the behaviorists wanted to teach it , so they went over to the counseling program and hired an academic grandchild of Carl Rogers who spent the first year teaching us how to be with clients. I'm so glad I learned it that way. I think having an intentional span of time where you really focus on these and then as you get into supervision with particular forms of psychotherapy, remember that the way in which you deliver therapy matters almost more than the content of it.

Orla: I think the next question follows nicely on that. Stephen says great talk, thanks. How important do you think it is for helpers to have experience on learned from their own therapy? -- un-learned from their own therapy?

William: Well, if something very different has been modeled by a therapist or teacher or supervisor, I have certainly encountered groups who have been taught horrendous ways of being with clients. But ideally, you have less to unlearn. If you can from the beginning be teaching and showing these ways of being, that's a good start. But if you have been unfortunate to have a therapist take you in the wrong direction, there is some unlearning. And it's not just them. It's your teachers, your coaches, the people who have tried to love you and spent time trying to encourage you to grow who were not necessarily therapists. Who was the teacher who brought out the best in you? What was it about them? An parenting style I think also sets expectations. So the amount of unlearning depends on the person's own background.

Orla: Thanks. The topic of empowerment has come up. So David and Carl have both asked about it. David said you had a robust discussion about the term empowerment. People might like to hear more about your definition of it.

William: This gets to be a problem with spirit, because they do flow together, and they are integrated. I listening, by being empathic -- by listening, by being empathic, you are honoring the person's own spirit and strengths. Eva Kate and assumes a foundation of empowerment, which is that the person has strength -- h evocation assumes a foundation of empowerment, which is that the person has strengths. We are talking about seeing people as having strengths, as having wisdom of their own , having capabilities, and relying on them to make those changes. The person doing the changing is going to be the person sitting across from me, and the more we disempower them, by using the waiting list, for example, the less likely it is to happen. It's the mindset of seeing people is capable, having strengths that we can evoke and draw out, and trusting that. We have a little more work to do with this. We are trying to settle on a spirit term and how that sits with the other three is what we are working on.

Orla: Jesse, I see you have questions about empowerment as well. If you feel you want to ask another question, please add it to the list. What would be the best single question to ask a potential trainee or employee to assess their ability to be empathic?

William: Show me your best listening. We actually ask for the behavior. When we are interviewing potential therapists for the Center, part of the interview -- and we tell them this will be the case -- is for them to show us their best listening. We say you don't have to fix anything or make change happen. Just show us your ability to listen. Will have a staff -- we will have a staff member talk about some personal issue, nothing deep. The content almost doesn't matter. And within five minutes, we have a sense of the extent to which the person is capable of listening and reflecting back what is there. We would not ask for more than 5-10 minutes. It's like other kinds of job interviews. You ask for the behavior you want the person to give you. It doesn't mean if they are not superb at it now you can't hire them because these things can be taught also. I taught empathic listening for 30 years. There were very few people I felt like I wasn't successful in teaching empathic listening, but there were a few. So I think, are they in the ballpark? Are they able to listen? That's the behavior we want to see. If they cannot do it in a job interview, can they do it with clients? And if they can do a reasonable job in a job interview, we can help shape that up. And we did not stop observation then. Ideally, ongoing practice includes observation. There is another question which was interesting. Any thoughts on where they cut off for waiting out of people unable to do the skills should be, after how long of trying to learn it, etc.?

William: We have sort of cutoffs or criteria, but we made them up. So what is good enough for what purpose I think is the question. How much empathy do you need to be able to do counseling well? We have some data on that from the very first study that I showed you and some studies since then. It looks like there is a kind of good enough level. So it is not that everybody has to be superb at this. But they ought to be good enough. They ought to be able to listen well enough that they can stay with the person. I think the students I remember that I was just not successful in teaching them, it seemed to me, and I could be wrong, they had difficulty taking on any perspective other than their own current perspective. Even entertaining that there are other ways of seeing reality. Whereas with really skillful empathic listening, you are entering in with curiosity, trying to understand how that person sees reality and how it is different from your own and other people's and to try to literally see through their eyes without losing their own identity of course. But literally see the world through their eyes. It did not seem to be there and I don't know why but they could not seem to shake loose enough their own perspective on the world and see that there are other perspectives in the world.It was a small number . What is good enough focus, evoking, empathy, genuineness? It is the right kind of question. And for what purpose also? For being a sales representative over the telephone, you may need a different level of school fullness than being a psychotherapist. I don't know. If you have a particular task in mind to do well, what level of these skills is enough? It is a good question.

Orla: OK. Thank you, Bill. There is another question from Rosemary. She asks, if I wanted to teach the process of uncovering one's own biases or assumptions, which skill with this intersect with, congruence or genuineness?

William: Uncovering clients' bi ases.

Orla: It looks like she worded it, if I wanted to teach the process of uncovering one's own biases or assumptions about clients, so I think it is not for the practitioner's point of view.

William: I don't know anything better than reflective listening actually and following the person's own thought processes without judgment. As soon as you put judgment in, the process starts down. But to follow the persons thinking, therapeutic thinking or political thinking or whatever it is, you think about human beings. How does that work? With curiosity to follow it, you can get clearer getting inside the person's perspective. Whether the person you are doing this with will come to perceive that is biased or as reality, I don't know. But certainly if you are a supervisor, if you are in that kind of a relationship with a therapist in training, you can then begin to question the thought processes and the assumptions and the biases of the person as the therapist I mentioned for be clients to experience all the terrible experiences they have had. I don't think that is true. Let's try something different.

Orla: Thank you, Bill. I just want to check in with you, how you are doing, and if you are OK taking more questions.

William: I am fine. We are going until a quarter til l?

Orla: It is up to you. We can take more if you want to get want to see how you are doing.

William: I am energized thinking about this.

Orla: There is a question right up my street as well. Built, -- Bill, do you think waitlist outcomes would be more optimal if it was not called waitlist? Maybe positive associations with the preflight time.

William: The first study, because we had a self help group, we would have people on a waiting list. We would have another group of people that rather than saying we will see you in 10 weeks, we said, look, here is some material. Take this home. Read it. You can try it yourself. You can do it yourself this is empowerment. Follow the directions from it I will see you in eight weeks or 10 weeks and we will see how you are doing. The outcomes were dramatically different for people who were told "we will see you in eight weeks" verses, here, take this home, start practicing, and we will see you in eight weeks. By the time we saw them, they were doing just as well as the people we have been seeing for eight weeks. So anyway, you can -- so in a way, you can think about intake, which we mistakenly think of as a time that we need to collect a lot of facts. as the preparation proces, -- facts, as the preparation process. I call it a welcoming interview, which has a different feel from I have to get a ton of information here. So how you are thinking about the first visit, your mindset, very different. If you are thinking you have to collect all this information before helping the person versus Carl Rogers's perspective, you can start helping people right away. What you need to know, you will find out in time. But the surprise of the self-help groups was they did at least as well as people who began treating immediately. While I thought that people assigned to the self-help condition would be disappointed, very often they were pleasantly surprised. You mean I can do this on my own? Wow, that's great. And I will see you in eight weeks and we will check in. That is fantastic. Clients were not put off by it the most part. The instruction was get going. You don't have to wait for me. I wish we could see you right away, but you don't have to wait for me. You are some things you can do in the meantime to get started. -- here are some things you can do in the meantime to get started. The assessment assumption that we have to know a lot of things before we can be helpful just is not true. Really disliked psychological assessments and the assumption that had to proceed helping somebody.

Orla: Thank you. There is a question from Harry. Sorry if I missed it. I notice he typed twice. Harry is asking, any insight into biological correlates of therapist skills? For example, therapy and the report centers of the brain and therapists and their partners?

William: Know forget it is not my area of expertise. When people are practicing empathic listening, you see it in different parts of the brain when they are collecting information, they are asking questions and things like that. That is no surprise. Any kind of activity has particular activation areas. There is a lot to learn their. -- there. Also, I think it would be interesting as we get better at remote neuroimaging or social neuroimaging to see what is going on in the brain of the client also when a therapist is practicing empathy. What is happening? Surely different things are going on. Does that tell us more than the behavior does? That I don't know. I am not persuaded that all of the science research has taught us a lot about how to take better care so far. But I am open to the possibility that we can learn something from this additional source of information that could be helpful to us. But the behavior itself tells you a lot, what the therapist is doing, what the client is doing. That is what Rogers was looking at and one of them. -- in one of them.

Orla: Thank you. Vince, I have not ignored your question at all. Vince asked earlier, what is the actual empathy measure?

William: There is a global scale. And then there is specific behavior, the reflective listening aspect of it as well. Always had both, a global measure and a behavioral measure. And they are different. Some different things, but related. And it keeps getting improved. We are on 4.2 or 4.3 now so it has gone through multiple versions. Ways to improve the reliability of the measure. Whenever they get graders giving them different answers on a measure, the question is, what is wrong with the measure? And how can we tighten up and improve it? Is on the website. It is available for free. I think they have done very good work moving us forward to an understanding of not just the empathy component but multiple components.

Orla: OK. Thank you. If we take two last questions, and then I will save the others. Scott asks him are there any things you would suggest on agency or treatment provider needs to have a place to facilitate or support these behaviors and their clinicians?

William: Observational practice is the first thing. If you can't observe what your therapists are doing, you can't help them. I learned that early with therapists coming out of the room and trying to give me what happened verbatim. I quickly went with what they didn't see that I needed to help them. From then on, I would not do supervision without observation practice. That is often not present in agencies but it ought to be. Quality assurance. What phone called you you get anymore that does not say "this may be recorded for quality assurance purposes?" Listening to practice is so crucial. And then having a way to encourage deliberate practice to work on the clinical skills that are going to improve client outcomes. There has been research on deliberate outcomes improving entire agency outcomes over a span of years. So I would say observe practice is a key one and getting people accustomed to that. This is a part of how we do work. And this is how we get better. That is just a condition of employment here. We ought to be doing that. It is what they were talking about 53 years ago to improve quality of practice and to prevent harm, to prevent harmful practice. Unless you are observing practice, you don't know. I learned that when the hardware. We did an entire clinical trial and recorded the therapists doing treatment, but we did not listen to the tapes until the study was over. And then we began encoding. The therapists had not done anything even close to what they were supposed to be doing. We did not know it because we were not listening to practices happening live. That is a crucial piece.

Orla: Definitely something I benefited from. I agree. So our final question from Glenn. Hello, Glenn. Glenn asks, with most labeled as introductory, intermediate, advanced, with school fullness and pleasantly suggested in the classroom attendant, given what you are saying, how else might we be able to recognize it is the practitioner internal and external behavior that identifies levels of skill fullness? -- skillfulness?

William: Levels of training, although I have done that, intermediate training or advanced training, is troubling in a way because you are assuming a common entry-level that people entering intermediate all have a beginning level of skill. Unless you measured it, it is probably not true. If you have given advanced training, you are assuming everybody there already has intermediate skills. Unless you measure it, it is probably not true. Nor do the students know for that matter what their level of skill fullness is. That is why we do this in training for trainers. Unless you measure, you just don't know. The other thing is variability within whatever level. In a way, what you are trying to do is help each person trained up to criteria. Which raises the question of, what is good enough? Each person is working from their own baseline upward to more skillfulness. Every person is starting at a somewhat different place. Even people prescreened and coming into advanced training, what they need next is different. As I then observe and listen to their practice, I am always looking for what is the thing they need next? What is the piece? What is the clinical skill or technique or whatever that they need some deliberate practice with? Changing that is going to make a difference in client outcome. It is not that everybody enters any kind of training with a standard level of proficiency. Even if you measure it, there are going to be differences. It is a matter of helping each person as you do with athletes. Helping each person to improve on their own proficiency and their own skill fullness. With students -- same with teaching with students. I try to help students learn at their own pace in their own way to some level of proficiency. So just remembering that variability and not assuming that everybody enters with the same level of skill or will exit with the same level of skill. And not assuming that everybody needs the same thing. I guess those are my thoughts about beginning, intermediate, advanced.

Orla: OK. So it has come up to a quarter to 7:00 and there still are remaining questions. What would you prefer to do at this point?

William: Well, what was the allotted time for this session?

Orla: Well, we would go to 7:00, so we gave it the 90 minutes. But that was just time to talk or anything else you wanted to do.

William: That's good. I'm happy to take more questions. People can escape as soon as they wish. An advantage of this format is when you are tired of listening, you can just click leave and nobody knows. But for those who still have questions, I'm happy to continue for another 13 minutes.

Orla: That is very kind. There is a topic that has come up about fatigue and burnout, particularly in front-line workers and case managers at the minute in health care. And burnout and compassion fatigue. Any thoughts around that?

William: I do. I do. I do because of what people have told me about the impact of learning. If I am doing research now, which I cannot, I would be steady, what is the effect on providers of learning motivational inquiry or these clinical skills that I talked about in this talk? Because I very often hear stories from people that I was just on the verge of burning out. I started learning this and began getting really excited and have enjoyed work more than I had ever before. Those are stories, but it is frequent enough that I think there is something about this that decreases the likelihood of burning out. I suspect it is the mindset of curiosity. It is letting go of the burden that I have to make change happen. That is a terrible burden to carry for a probation officer or counselor or whatever. And kind of letting go of that knowing you actually cannot make it happen. But you can be with people in a way that facilitates it happening and then watching it happen. Getting outcome information because if you don't find out what is happening with the people you are seeing, you tend to only get bad news. You tend to only see people going backward or doing well. That is the real risk in addiction treatment. One thing I loved about doing the outcome research is we tried to find 100% of everybody who treated. When you do that, you find out how very well most people are doing. If you just wait for people to return to the clinic, most often they return when they are not doing well and you can get discouraged. So get some outcome information. Even what Scott Miller talks about, collecting session by session information. Because it can give you advanced warning of dissatisfaction and drop and burnout and so forth with clients. But there is something about a client-centered way of being with people I think that sustains you over time. It is not impersonal. It is not providing stuff to people that you get tired of being a provider. One of the great privileges of being a psychologist has been for me getting to know so many people at an intimate level over the course of a lifetime, which is not a privilege many people have that privilege of intimate caring and selfless love and compassion really nourishes and feeds you I think. I do think and would bet on it that there is something about learning these skills that is a protection against burnout. Makes you glad you entered the profession. At least my thought on that. I would like to know more about it. Hope research gets done on it. What is there suggested so far, but that is a good question. What is the effect of learning on the provider. Not just the clients, but the provider.

Orla: I had a really interesting experience on the COVID board last week where the patients are frightened, scared, lonely, and isolated.

William: Yes.

Orla: And the doctors come onto the board and they are burnt out and tired and exhausted. And the interaction caused the patient more stress and anxiety.

William: Yes.

Orla: So doctors left and they were angry, the patient was angry him and I just stepped in and said, tell me how you are feeling, and I listen. Within a few minutes, he was calm and wanted his wife. We got his life on the phone. It was those moments to hear his voice. But I can see it from both sides of the point of view, that everyone is burnt out and scared really.

William: It is stressing out both people. When you behave in a stressed way, patients get distressed, and if you like you are not doing a good job and want to get out of there. It just feeds the whole thing is a cycle. Literally five-minute listening can make such a difference.

Orla: Yeah. It did. There is another question from Kelly. Kelly asks, can you speak to any cultural differences or considerations with empathic listening, emerging research, things to consider?

William: So are there cultures where people don't like to be listened to? I have not found one. There certainly are cultures where you are expected to listen respectfully. Native American cultures are a good example. Just charging in and giving advice is psychopathic behavior in Native American culture. You are expected to listen to the story respectfully. But I certainly don't have any evidence for culture or subcultural context in which empathic listening is harmful. It may not be all a person needs of course but it seems to hold up pretty well at least in psychotherapy research across all kinds of contexts and problem areas in schools of psychotherapy and so on. There are individual differences. When you begin to practice reflection with clients, we are certainly watching carefully for their response, and there are some clients that get uncomfortable in part because of how deep and fast it can go and you need to titrate a little bit to stay with them, but that is part of watching carefully what your -- how your client is receiving what you are doing. That is what responsiveness is. Adjusting what you are doing to how your client is responding to you is a key clinical skill as well. Other than that, there is nothing I can think of. If anything, there are cultures where empathic listening is the ticket, the entry card. And that is what you need to do. That is true of an awful lot of cultures.

Orla: OK. There is another question from Debra Collins asking, what are your thoughts about planning nonclinical staff who do not have a counseling background?

William: Of course for we never found a relationship and develop to learn MI. Isn't that interesting? When I say that's an audience, I even say PhD's to learn this. It is not how many years of education you had. It is being with people. There is something natural about it that children can do this also. And do make it a habit but there is something in us that is drawn to doing this. It is how people get into motivational interview. I think very few people are because of evidence-based. What people tell me is I heard about it, began learning about it, and it just felt like this is where I belong. This is how I want to be with people. It is that attraction of it that often draws people to this way of being. It is why it is so much fun to teach. Very few people are put off by it. You are tapping into something fundamental about humanity and wanted to belong together and be known and understood and accepted. Working with something much bigger than therapy here. Clinical training is not necessary to teach these skills and can be useful in all kinds of aspects of life besides being a therapist.

Orla: Thank you. And perhaps our final then is, what other changes are you considering for the fourth edition?

William: I don't know that we are far enough. We have a general goal of simplicity. We intend for it to be a shorter book, to de-jargonize as much as possible. There is a quote that Steve and I often used of simplicity beyond complexity. As you begin to understand at a complex level what is happening with motivational interviewing, you can then begin to teach it in a way that may be simpler. But you cannot start with simplicity. You can't start telling people just love your clients. It will be all right. There is a lot more to it than that. But as we begin to get a pretty good grasp on what is happening with MI, I think we can then begin to make it simpler, more accessible to people besides professionally treated people. And that is a goal for us. The overuse of Evo case -- evocation is something we are moving away from and the change in the spirit level is one piece of that. In a way, we are struggling with this one. In, focusing involves evoking as you are evoking the person's goals. Planning involves evoking. You are calling for the person's own ideas and willingness and so forth. Evoking is much more on the present after the engaging process. Maybe even during the engaging process. What does that mean? What is it about evoking? How can we make that simpler? We are just beginning those discussions. Steve is doing work on that second edition of MI in health care. I just finished a book on ambivalence actually. Kind of getting ready to have conversations. When Steve and I talk, things come out of it that neither of us would have come up with individually so I look forward to those conversations the next couple of years and see what the answer to that question is.

Orla: Thank you, Bill. It was a fantastic session. I don't know why my speaker is doing that. We want to say thank you so much for delivering this session for the open of the forum. It has been a pleasure listening to you. Because I have been so busy doing other stuff, I forgot to watch the recording back. I will let everyone know that this is recorded. It is available and we make it available via a link after the forum and. Thank you -- forum ends. Thank you so much for we cannot thank you enough for me and we have a break now until half past 7:00 before the next two sessions start, which is Stan talking about compassion and Katie and Denyse talking about -- it is going to escape my brain. But yeah. We will have a break now. If anyone is having any struggles at all, we will pick up your emails in this break before the next section starts. Any questions that have not been answered I have saved and I can send them on to Bill if you are happy for that. We have also saved the chat and I will make that available to people as well because there was such a lovely stream and you might want to see that as well to see the comments and replies that were coming. Yes, thank you so much. Thank you.

William: Thank you. Bye-bye.

Orla: Take care. Bye. Please stand by Please stand by Please stand by