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Empathy is a basic psychological process that involves the development of synchrony in dyads. It is also a foundational ingredient in specific, evidence-based behavioral treatments like motivational interviewing (MI). Ratings of therapist empathy typically rely on a gestalt, "felt sense" of therapist understanding and the presence of specific verbal behaviors like reflective listening. These ratings do not provide a direct test of psychological processes like behavioral synchrony that are theorized to be an important component of empathy in psychotherapy. To explore a new objective indicator of empathy, we hypothesized that synchrony in language style (i.e., matching how statements are phrased) between client and therapists would predict gestalt ratings of empathy over and above the contribution of reflections. We analyzed 122 MI transcripts with high and low empathy ratings based on the Motivational Interviewing Treatment Integrity global rating scale. Linguistic inquiry and word count was used to estimate language style synchrony (LSS) of adjacent client and therapist talk turns. High-empathy sessions showed greater LSS across 11 language style categories compared with low-empathy sessions (p<.01), and overall, average LSS was notably higher in high-empathy versus low-empathy sessions (d=0.62). Regression analyses showed that LSS was predictive of empathy ratings over and above reflection counts; a 1 SD increase in LSS is associated with a 2.4 times increase in the odds of a high-empathy rating, controlling for therapist reflections (odds ratio=2.4; 95% CI: 1.36; 4.24, p<.01). These findings suggest empathy ratings are related to synchrony in language style, over and above synchrony of content as measured by therapist reflections. Novel indicators of therapist empathy may have implications for the study of MI process as well as the training of therapists. Copyright © 2014. Published by Elsevier Ltd.
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More than reflections: Empathy in motivational interviewing includes lan-
guage style synchrony between therapist and client
Sarah Peregrine Lord, Elisa Sheng, Zac E. Imel, John Baer, David C.
PII: S0005-7894(14)00137-3
DOI: doi: 10.1016/j.beth.2014.11.002
Reference: BETH 527
To appear in: Behavior Therapy
Received date: 20 May 2014
Accepted date: 4 November 2014
Please cite this article as: Lord, S.P., Sheng, E., Imel, Z.E., Baer, J. & Atkins, D.C., More
than reflections: Empathy in motivational interviewing includes language style synchrony
between therapist and client, Behavior Therapy (2014), doi: 10.1016/j.beth.2014.11.002
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More than reflections:
Empathy in motivational interviewing includes language style synchrony
between therapist and client
Sarah Peregrine Lord1, Elisa Sheng1 , Zac E. Imel2 , John Baer3, and David C. Atkins1
1 Department of Psychiatry and Behavioral Sciences, University of Washington, Seattle, WA,
2 Counseling Psychology Program, Department of Educational Psychology, University of Utah,
Salt Lake City, UT, USA
3 Department of Psychology, University of Washington, and VA Puget Sound Healthcare
SystemSeattle Division
Word count: 3,981
There are no declarations of interest.
Correspondence to:
David C. Atkins, PhD
Research Professor
Center for the Study of Health and Risk Behaviors
Department of Psychiatry and Behavioral Sciences
University of Washington
1100 NE 45th St, Ste 300; Box 354944
Seattle, WA 98195
Empathy is a basic psychological process that involves the development of synchrony in dyads.
It is also a foundational ingredient in specific, evidence-based behavioral treatments like
motivational interviewing (MI). Ratings of therapist empathy typically rely on a gestalt, felt
sense of therapist understanding and the presence of specific verbal behaviors like reflective
listening. These ratings do not provide a direct test of psychological processes like behavioral
synchrony that are theorized to be an important component of empathy in psychotherapy. To
explore a new objective indicator of empathy, we hypothesized that synchrony in language style
(i.e., matching how statements are phrased) between client and therapists would predict gestalt
ratings of empathy over and above the contribution of reflections. We analyzed 122 MI
transcripts with high and low empathy ratings based on the Motivational Interviewing Treatment
Integrity (MITI) global rating scale. Linguistic inquiry and word count was used to estimate
language style synchrony (LSS) of adjacent client and therapist talk turns. High empathy
sessions showed greater LSS across 11 language style categories compared to low empathy
sessions (p < .01), and overall, average LSS was notably higher in high empathy vs. low
empathy sessions (d = 0.62). Regression analyses showed that LSS was predictive of empathy
ratings over and above reflection counts; a 1 SD increase in LSS is associated with 2.4 times
increase in the odds of a high empathy rating, controlling for therapist reflections (odds ratio =
2.4, 95% CI: 1.36, 4.24, p < .01). These findings suggest empathy ratings are related to
synchrony in language style, over and above synchrony of content as measured by therapist
reflections. Novel indicators of therapist empathy may have implications for the study of MI
process as well as the training of therapists.
Keywords: empathy, motivational interviewing, synchrony, linguistic inquiry word
count, language style, motivational interviewing treatment integrity.
More than reflections: Empathy in motivational interviewing includes language style synchrony
between therapist and client
Empathy, the ability to understand and experience the feelings of another person, is a key
interpersonal process in psychotherapy broadly and significantly correlated with treatment
outcomes (r = .31; Elliot, Bohart, Watson & Greenberg, 2011; Flückiger, Del Re, Wampold,
Symonds, & Horvath, 2012; Valle, 1981) and specifically within Motivational Interviewing (MI;
Moyers & Miller, 2013; Miller & Rollnick, 2013). MI is a client-centered, empathic and
collaborative counseling style that attends to the language of change and is designed to
strengthen personal motivation for, and commitment to, a specific goal (Miller & Rollnick,
2013). MI was developed to help clients prepare for changing addictive behaviors like drug and
alcohol abuse (Miller & Rollnick, 1991, 2002) and has been shown to be effective to reduce
other harmful behaviors including tobacco, drugs, alcohol, gambling, treatment engagement, and
for promoting health behaviors such as exercise, diet, and safe sex (Lundahl, Kunz, Brownell,
Tollefson, & Burke, 2010).
As the basic efficacy and effectiveness of MI has been established, research has
increasingly focused on how MI works (Magill, Gaume, Apodaca, Walthers, Mastroleo, Borsai,
Longabaugh, 2014). The first principle of MI is to express empathy and understanding through
reflective listening (Miller & Rollnick, 1991, 2002, 2013). In MI, empathy is defined as 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 continual generation of
hypotheses as to the underlying meaning” (Miller & Rollnick, 1991, p. 20). High ratings of
therapist empathy are independently related to improved client outcomes such as reduced
drinking (Gaume, Gmel, Faouzi, & Daeppen, 2008), drug use (McCambridge, Day, Thomas, &
Strang, 2011), and other risk-behaviors (Pollak et al., 2011; Schwartz et al., 2007), as well as
increased treatment engagement (Boardman, Catley, Grobe, Little, & Ahluwalia, 2006) and
change talk preceding behavior change (Miller, Benefield, & Tonigan, 1993; Miller & Rose,
2009; Moyers & Miller, 2013).
Empathy in Motivational Interviewing
Given the emphasis on reflective listening in MI, fidelity measures include two types of
therapist reflections: simple reflections (when the therapist repeats more or less verbatim what
the client said) and complex reflections (when the therapist reflects deep understanding by going
beyond what is explicitly stated; Moyers, Martin, Manuel, Miller & Ernst, 2007, 2010). The
clinical theory underlying reflections has also been supported in the empirical literature.
Therapists who use more reflections than questions are more likely to be rated as exhibiting high
MI spirit and empathy (McCambridge et al., 2011). One study found that utilization of reflective
statements, more than all other MI skills, resulted in patients feeling high autonomy support, and
independent observers rated those clinicians as more empathic (Pollak et al., 2011).
Though reflections capture one aspect of therapist empathy, MI theorists agree that
empathy is more than reflective techniques focused on the content of the client’s words. To
capture the gestalt or felt-sense of empathy, MI fidelity measures like the Motivational
Treatment Integrity Scale (MITI; Moyers et al., 2007, 2010) include a global rating of empathy
encompassing the therapist’s behavior across the entire session. 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 (Moyers et al., 2007, 2010). Reflective listening is an
important part of this characteristic, but the global rating of empathy is intended to capture all
efforts that the clinician makes to understand the client’s perspective and convey that
understanding to the client.
Both MI theory and fidelity systems like the MITI are clear that empathy is a core
therapeutic process that is comprised in part of reflective listening but also more than reflections;
however, the specific linguistic aspects of empathy in MI over and above the contribution of
reflections are presently unclear. Are there additional linguistic indicators of empathy beyond
reflections or is global empathy more of a gestalt felt-sense that requires human judgment?
Empathy and Synchrony in General Psychotherapy
In basic psychological science, empathy is commonly conceptualized as a form of
behavioral synchrony (see the Perception-Action Model; Preston & De Waal, 2002). Behavioral
synchrony has been defined as “degree to which the behaviors in an interaction are nonrandom,
patterned, or synchronized in both timing and form” (Bernieri & Rosenthal, 1991, p. 403).
Theories like the Perception Action Model suggest that empathy is the process by which
perception of a state in a person activates a representation of that state in the perceiver. There is
consistent evidence that behavioral synchrony develops as two individuals interact over time. In
addition, synchrony is related to ratings of empathy and other measures of the quality of the
relationship between members of a dyad (Chartrand & Bargh, 1999; Chartrand & van Baaren,
2009; see also communication accommodation theory; Giles & Ogay, 2007).
There is also evidence for the development of synchrony between patients and therapists
in psychotherapy. Specific findings include synchrony in body movement (Ramseyer &
Tschacher, 2011), vocal prosody (e.g., pitch, intonation, accent, rhythm and loudness, use of
pauses; Couper-Kuhlen, 2012; Weiste & Peräkylä, 2013, 2014), as well as physiological
synchrony such as changes in skin-conductance (Marci et al., 2007; see also early studies on
heart-rate, Di Mascio, 1955; and emotional reactivity, Lacey, 1959). In general, these studies
have shown that greater synchrony is correlated with better ratings of therapist empathy and
other measures of the therapeutic relationship, and treatment outcome (see Reich et al., 2014 for
an exception). Specific to MI, the correlation of vocal tone synchrony between standardized
patients and therapists was twice as high in session with high empathy ratings (r = .80) as
compared to low (r = .36; Imel et al., 2014).
Measuring Empathy and Synchrony in Relation to the Words Said in Therapy
Examples of synchrony that involve vocal tone, skin conductance, and non-verbal
behavior, do not capture what clients and therapists actually say to each other (i.e., the words).
There is evidence that language defined as sets of words that affect how things are said (e.g.,
prepositions, pronouns) rather than what is said (e.g., nouns, adjectives) reflects relational
information that may be important for understanding empathy in the client-therapist dyad. For
example, the use of language style words such as pronouns has been found to be related to
measures of relationship satisfaction and distress in couples (Williams-Baucom, Atkins, Sevier,
Eldridge, & Christensen, 2010).
In studies of social interactions in laboratory and naturalistic settings, there is evidence
for language style synchrony occurring to a greater degree in closer relationships (Ireland &
Pennebaker, 2010; Niederhoffer & Pennebaker, 2002). In these studies, using the Linguistic
Inquiry Word Count (LIWC; Pennebaker, Booth, & Francis, 2007) software, Ireland and
Pennebaker (2010) identified nine language style categories (e.g., personal pronouns, articles,
negations, conjunctions) and developed a synchrony index that they called language style
matching. They found that persons who were more socially attuned, less neurotic, and who
identified as colleagues, friends or as part of the same social group, were more likely to
synchronize in language style. To date, there have been no clinical studies of language style
Current Study
In the present research, we examined if synchrony in language style predicts observer
ratings of empathy above and beyond what is captured by counts of therapist reflections.
Whereas reflections in MI should primarily capture therapist attempts to understand the content
of what is said or meant, synchrony in stylistic dimensions of language (i.e., how content is
expressed or phrased) may also provide important information about empathy. Accordingly, it
may be that synchrony in language style between client and therapist is an objective indicator of
empathy in MI, in addition to use of reflections. We hypothesized that high empathy sessions
would demonstrate greater language style synchrony with clients relative to low empathy
sessions. Moreover, to assess whether this may simply be a proxy for reflections, we
hypothesized that synchrony in language style would be predictive of empathy over and above
counts of simple and complex reflections.
Data Source
Data came from an 8-site MI training study, using therapists from National Institute of
Drug Abuse (NIDA) affiliated community substance abuse treatment facilities in the state of
Washington. Two methods of therapist training were compared. The therapist’s MI fidelity was
examined using both real and standardized patients (for details of original trial see (Baer et al.,
2009; Imel et al., 2014). Present analyses focused on sessions with standardized patients (SPs) to
control for patient variability (i.e., with real patients, therapist differences may reflect patient
case-load heterogeneity).
Selected Sessions. The data included digital audio and observer ratings of empathy from
122 selected MI sessions using SPs; this was 25% of the total SP sessions. Sessions were
purposefully selected for high (n = 77) and low (n = 45) empathy ratings (see details provided
below). The 122 sessions represented 122 therapists, 65% of the therapists in the original study.
Therapists were 81% female, and 83% Caucasian, 12% African American, 6% Native American,
4% Hispanic/Latino, 3% Asian, and 2% Pacific Islander. Mean age was 46.9 years (Standard
deviation (SD) = 10.7), and mean length of experience in clinical service provision was 9.4 years
(SD = 8.2).
Standardized Patients. Therapists conducted MI interviews with one of three SPs who
portrayed a recently referred client with a substance use problem and characteristics common for
agency clientele. SPs were trained to provide realistic clinical vignettes and to respond flexibly
to therapists during sessions. SP training was directed by study investigators and involved
considerable role-play practice in which SPs were provided feedback on authenticity of their
performances. Therapists were aware that SPs were confederates, but therapists were unaware of
study hypotheses (e.g., that there were two types of training being compared). The SPs were
similarly represented across the high and low empathy rating sessions (SPs 1-3 were in 29.9,
20.7, and 49.4% of high empathy sessions and 35.6, 15.6, and 48.9% of low empathy sessions,
respectively). Note that this variability in empathy by SP was a natural result of their interactions
with different therapists. SPs had no specific instructions relative to empathy (or other
dimensions of MI fidelity), and empathy ratings were not different across the three SPs
(F(2,119)=0.087, p=0.91).
Motivational Interviewing Treatment Integrity 3.0 (MITI 3.0; Moyers, Martin, Manuel,
Miller & Ernst, 2007). High and low empathy sessions were classified based on the gestalt
global empathy rating from the MITI. The MITI rating system is the most widely used measure
of therapist fidelity to MI (e.g., a recent meta-analysis of MI training studies found that 85.7% of
studies used the MITI or a more in-depth version of the scale; Schwalbe, Oh, & Zweben, 2014).
Raters were trained and supervised in the MITI and blind to assessment timing and practitioner
identifiers. The inter-rater reliability of empathy was acceptable (Intraclass correlation = 0.60)
according to widely-used standards (Cicchetti, 1994). The large group of community-based
therapists received a broad range of empathy scores, spanning the full range of the scale (1 to 7).
In the current set of 122 sessions, we defined high empathy sessions with an empathy score of at
least 4.5 and low empathy sessions with a score of at most 3.5.1 Scores for high empathy sessions
ranged 4.5 to 7 (mean (M) = 5.9, SD = 0.62) while scores for low empathy sessions ranged 1 to
3.5 (M = 2.2, SD = 0.54).2 Complex and simple reflections were measured as behavior counts,
which correspond roughly to the number of utterances (i.e., complete thought units) identified as
either complex or simple reflections. Sessions were 20 minutes in length and were coded in their
1 There were three independent raters that made up the coding team for the study. Almost half of the
included sessions were coded twice (n = 43, 48%) using the MITI. The remainder was coded once. For
sessions that were coded twice, we used the mean of the ratings to classify high or low empathy.
2 The present study purposefully sampled the ends of empathy rating scale. Sessions with empathy scores
of 1 or 7 were transcribed first, and then 2 and 6, and so on. Extreme groups sampling has tradeoffs
(Preacher, Rucker, MacCallum, & Nicewander, 2005). It was used in the present study for cost and
efficiency: Given the available budget, it was not possible to transcribe every session. However, the
present approach would not be able to detect nonlinear associations between language style synchrony
and empathy (should it exist), nor certain types of interactions.
LIWC (Pennebaker et al., 2007). LIWC software was used to quantify the semantic
content of MI transcripts. LIWC was initially developed to identify words along basic emotional
and cognitive dimensions common in social, health, and personality psychology (Pennebaker,
1993). For all words in a given text, the program reports proportions of words in 64 nonexclusive
categories organized under four main themes: linguistic processes, psychological processes,
personal concerns, and spoken categories. Current analyses applied LIWC to each MI session
(separately by speaker) as well as individual talk turns. Present analyses used 11 language style
categories studied previously (Ireland & Pennebaker, 2010; Ireland et al., 2011). 3
Language Style Synchrony. We adopted a language style synchrony (LSS) measure, the
cohesion statistic, developed by Danescu-Niculescu, Gamon, and Dumais (2011) to measure LSS
between therapist and client. For a given LIWC category and MI session, LSS was defined as the
occurrence of both therapist and patient use of the LIWC category in adjacent talk turn pairs,
averaged over all talk turns. Each pair of talk turns includes a single talk turn from a therapist
and a single talk turn from a patient. This measure takes values between zero and one, where
larger values indicate greater co-occurrence of an LIWC category across adjacent client and
therapist talk turns and hence reflects greater LSS. More generally, it is the proportion of total
talk-turns sharing a given indicator of language style. As a result, LSS is fundamentally a dyadic
index; it measures the similarity of particular types of word usage in a dialogue, but cannot
assign the matching to a particular source (in this case the therapist or client).
Ireland and Pennebaker (2010) proposed another measure of LSS, the language style
matching index, based on entire documents (e.g., letters); however in MI sessions, there are
3 Note that previous reports on language style matching used 9 LIWC categories, including the omnibus
category of personal pronouns; for present analyses, we used the three individual personal pronoun
categories, which yields 11 total categories.
many conversational turns within a single session, so treating sessions as documents ignores the
temporal sequence in conversation. Because Danescu-Niculescu-Mizil et al. (2011) developed
their measure for conversational data we chose to apply their methods in our analyses.
Statistical Analyses
Hypothesis 1. Sessions with a high empathy rating were hypothesized to have greater
language style synchrony in the 11 language style categories compared to sessions with a low
empathy rating. To examine this we performed a multivariate test of all 11 language style
categories by empathy status (high versus low) via a 2-sample Hotelling T2 test. To further
investigate which dimensions, or LIWC categories, of language style differed between the high
and low empathy sessions, the omnibus comparison was followed by individual comparisons of
LSS by empathy status using two-sample t-tests for each of the 11 categories.
Hypothesis 2. In addition, LSS was hypothesized to predict empathy over and above
measures of reflections. This hypothesis was tested via two, nested logistic regression models
with empathy category as the outcome. The first model included simple and complex reflection
counts from the MITI as two covariates, and the second model included standardized average
synchrony over the 11 language style categories as an additional covariate.3 We report model
estimates of the odds ratios (ORs) comparing high to low empathy groups, with robust 95%
confidence intervals.
Across all 122 MI sessions there were 362,289 words, and 95.4% of the words were
recognized and categorized by LIWC. The mean estimated LSS for the 11 categories of interest
3 Previously, language style similarity has been measured by averaging similarity scores over 9 language
style categories (Pennebaker, Booth, & Francis, 2007). We adopted a similar approach when considering
LSS jointly in a multivariate model of empathy.
among all sessions ranged .01 to .69 (i.e., 1% to 69% of talk turns exhibited synchrony across the
various categories). Average synchrony for each language style category by empathy group is
shown in Figure 1. Across categories the difference in estimated synchrony within the high and
low empathy therapists ranged -.01 to .11 (M = .04, SD = .04). Overall, average LSS was notably
higher in high empathy vs. low empathy sessions (d = 0.62).
[Insert Figure 1 about here]
Our first hypothesis focused on LSS in relationship to observer-rated empathy. An initial
multivariate test showed that the joint distribution of synchrony for all 11 language style
categories was significantly higher for sessions with high empathy ratings based on Hotelling T2
(F(10, 111) = 4.9, p < .01). Pairwise comparisons via 2-sample t-tests suggested that, on average,
sessions with a high empathy rating have higher language style synchrony compared to sessions
with a low empathy rating in second-person pronouns, impersonal pronouns, articles,
prepositions and quantifiers (p < .002). As seen in Figure 1, in the remaining categories (first
person pronounssingular and plural, auxiliary verbs, adverbs, conjunctions, and negations)
there was higher synchrony among high empathy sessions, but the mean differences were not
statistically significant. Table 1 summarizes the pairwise comparison results.
Our second hypothesis considered whether LSS is simply capturing therapist use of
simple and complex reflections, or a separate linguistic component of the gestalt rating of
empathy. Simple reflection counts ranged 0 to 19 (M = 7.5/4.6 for high/low empathy,
respectively) and complex reflection counts ranged 0 to 31 (M = 10.0/2.6 for high/low empathy,
respectively). Including average LSS significantly improved the fit of the model to the data,
relative to the model containing simple and complex reflection counts (χ2 (1) = 9.054, p = .002).
Interpreting the association of LSS with empathy, a 1 SD increase in LSS is associated with 2.4
times increase in the odds of a high empathy rating, controlling for therapist reflections (odds
ratio = 2.4, 95% CI: 1.36, 4.24, p < .01). Among otherwise similar sessions, an additional simple
reflection increases the odds of a high empathy rating by 25% (95% CI [0.98,1.60], p = .072),
and an additional complex reflection increases the odds by 89% (95% CI [1.41,1.53], p = .000).
Table 2 summarizes the nested logistic regression model results.
Finally, two sensitivity analyses were conducted. First, a sensitivity check was
conducted for potential differences in therapist speech rate, which could in turn influence the
total number of reflections in a given session. The total number of therapist words (from LIWC)
was included as a covariate in our final model; it was not a significant covariate of empathy (p >
.25), nor did it affect the association of LSS with empathy. Second, given that there were three
SPs, we examined whether there were mean differences in LSS by SP. There were no mean
differences between SPs in LSS (F[2, 119] = 1.8, p = .17), suggesting that the observed LSS
associations are functions of unique therapist and therapist by SP interactions, not SPs.
What exactly are we rating on the global gestalt of therapist empathy on rating systems
like the MITI? Prior research has shown that reflective listening is highly related to, and an
important component of, therapist empathy. Our study examined hypotheses about how language
style synchrony (i.e., how the client and therapist match the stylistic words they use to talk about
the topic at hand) was a component of measures of gestalt empathy. In the present analyses, high
empathy sessions had greater language style synchrony than sessions with low empathy ratings,
and language style synchrony was not just a proxy measure of reflections but was predictive of
empathy ratings over and above the presence of reflections. Both reflections and language style
appear to measure a different, but not necessarily competing, aspect of the MITI gestalt ratings
of empathy.
Following the literature from social psychology on mirroring (Chartrand & Bargh, 1999;
Chartrand & van Baaren, 2009), our study seems to indicate that when the therapist is objectively
perceived as empathic, there is more likely to be matching in the language style of therapists and
clients. Interpersonal synchrony has been found to be an integral important component of human
relations broadly (Strogatz, 2003) and recently has been objectively measured as related to
empathy and connectedness in clinical and non-clinical interactions (Ireland & Pennebaker,
2010; Imel et al., 2014; Weiste & Peräkylä, 2014).
Unlike psychotherapy empathy rating systems that have historically rated only the
therapist’s ability to express understanding (e.g., Moyers et al., 2010; Truax, 1972), our study
revealed that one objective indicator of empathy in MI may be obtained from the synchronization
of clients and therapists with each other. This understanding of empathy aligns with Rogers’s
(1959) original discussions of empathy that focused on mutual identification and congruence; in
fact, Rogers (1975) stated he was “appalled” by the reduction of empathic listening to
measurements of therapists activities (e.g., counts of micro-skills like reflections) and that he
preferred to discuss the qualities of positive regard and therapeutic congruence, which together
with empathy I hypothesized as promoting the therapeutic process” (p. 2). While measurements
of matching pronouns and articles may seem even more micro-focused or abstract from clinical
practice, language style synchrony may be tapping into a form of human inter-personal
congruence that is not conscious but that naturally occurs when people feel aligned and
understood in conversation.
The current study may also inform future directions aimed at developing objective ratings
of therapist fidelity in MI for real world settings. First, the sample was pulled from community-
based therapists working in outpatient substance abuse treatment facilities. All therapists were
trained in MI but had a representative variable range of MI abilities and skills (e.g., from high to
low empathy ratings). This is in contrast to many clinical trials with research-trained
interventionists that have only high empathy and fidelity to MI. Thus, the conclusions of this
study can be generalized to community-based therapist populations. Secondly, we have found an
objective indicator of empathy that is predictive over and above reflections, but unlike
reflections, measurements of language style synchrony can be conducted with computer software
rather than with human raters. When applied to MI, objective indicators of empathy can assist
increases in coding efficiency, which in turn can ease the use of coding for training and
supervision of MI.
There were some limitations to the current study. The study from which the data was
drawn was focused on methods of training therapists to do MI, and subsequently did not measure
patient outcomes. We could not assess the impact of language style synchrony on patient
outcomes. Another limitation is that the original measure of empathy had relatively low inter-
rater reliability (ICC = .60), which is not uncommon among MITI studies. This is somewhat
offset by the binning of empathy into high and low groups. The use of only SPs in this study
could also be seen as a limitation, though as noted earlier, our focus is on studying therapist
behavior, and SPs limit the variability in empathy ratings due to patients. In addition, the current
study focused solely on lexical (i.e., words) synchrony, whereas other research has shown
acoustic (Imel et al., 2014) and physiological (Marci et al., 2007) synchrony. Future research
could examine the combination of multiple indicators of synchrony. Finally, the current data
have a single session per therapist, but future research could explore how synchrony is clustered
within therapists using data with multiple patients per therapist.
This study adds to the growing literature focused on specifying the component parts of
empathy. Given its central role in clinical and counseling psychology, our study of empathy
must move beyond the felt-sense and gestalt measurement that has heretofore been common. We
hope that future research will build off the current findings to explore behavioral synchrony and
its relationship to empathy across multiple domains of interpersonal functioning.
Funding for the preparation of this manuscript was provided by a University of Utah Seed Grant
and was also supported by National Institute of Drug Abuse (NIDA) of the National Institutes of
Health under award number R34/DA034860 and the National Institute on Alcohol Abuse and
Alcoholism (NIAAA) under award number R01/AA018673. The original trial was supported by
a grant from NIDA (R01/DA016360). The content is solely the responsibility of the authors and
does not necessarily represent the official views of the National Institutes of Health.
Disclosure Statement
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Figure Legends
Figure 1 Average language style synchrony between low and high empathy sessions (N = 122)
across 11 language style categories. Synchrony is the sum of consecutive, pairs of talk turns
sharing the given LIWC category, divided by the total number of talk turns. It is the proportion
of total talk turns demonstrating synchrony.
Figure 1
auxiliary verb
impersonal pronoun
0.0 0.1 0.2 0.3 0.4 0.5 0.6 0.7 0.8
Mean Synchrony
Language Style Category
Table 1. Means and Differences in Means for LIWC Categories by Session Empathy (High vs.
95% CI
impersonal pronoun
auxiliary verb
Note. Mhigh and Mlow = means for high and low empathy, respectively. d = standardized mean
difference, and 95% bootstrapped confidence intervals.
Table 2: Logistic Regression Results Predicting Empathy with and without LSS
OR (95% CI)
Model 1
Model 2
simple reflections
1.15 (0.94, 1.42)
1.25 (0.98, 1.60)
complex reflections
1.82 (1.42, 2.35)
1.89 (1.41, 2.53)
(standardized) average LSS
2.40 (1.36, 4.24)
Note. Model 1 is the model of empathy (high vs. low) on simple and complex reflections; Model
2 additionally regresses on standardized mean LSS (LSS averaged over the 11 LS categories).
Therapist empathy ratings often rely on a gestalt felt-sense of understanding
Could a more objective indicator- synchrony in language style in therapy- predict ratings
of empathy?
We analyzed motivational interviewing transcripts with high and low MITI empathy
High empathy therapists showed significantly greater language style synchrony
Language style synchrony was predictive of empathy ratings above therapist reflection
... A semantically and content-based approach focusing on synchrony in language use was suggested by Lord et al. (2015). The authors used the software program LIWC (Pennebaker et al., 2007), which allocates word counts to a set of theoretically derived categories. ...
... The occurrences of both therapist and patient use of these categories in adjacent talk turn pairs were averaged over all talk turns. Language style synchrony (LSM) turned out to be positively associated with empathy displayed during the sessions (Lord et al., 2015). ...
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In individual psychotherapy verbal communication and movement synchronization are closely interrelated. The microanalysis of timing, rhythm and gestalt of movement has established dynamic movement coordination as a systemic property of the dyadic interaction. Movement synchronization supports and enhances the unfolding of linguistic meaning. In order to substantiate the importance of the concept of synchrony for adult psychotherapy we review evidence from developmental psychology and discuss approaches to measure synchrony with particular reference to the naturalistic setting of dyadic psychotherapy. As the concept of synchrony is still ambiguous, and the respective interactional phenomena are ephemeral and fluid, in the current paper we suggest a set of five criteria for the description of synchronization in general terms and eight additional criteria which specifically enable the description of phenomena of movement synchronization. The five general dimensions are: (1) context, (2) modality, (3) resources, (4) entrainment, and (5) time-lag. The eight categories for the description of movement synchrony are: (1) spatial direction, (2) amplitude, (3) sinuosity, (4) duration, (5) event structure, (6) phase, (7) frequency, and (8) content. To understand the process of participatory sense-making and the emergence of meaning in psychotherapy, synchrony research has to cope with the multimodality of the embodied interaction. This requires an integrated perspective of movement and language. A system for the classification of synchrony phenomena may contribute to the linking of variations and patterns of movement with language and linguistic utterances.
... settings, community-based implementation shortcomings include the availability of qualified personnel as well as ongoing staff training, supervision, and retention (Perry & Ellett, 2008). These facts raise the question of whether efficacy can be demonstrated for less expensive, more sustainable programmes that incorporate important aspects such as parental participation, individualised systematic instruction, skill generalisation planning, and treatment integrity (McIntyre et al., 2007;Lord et al., 2015). ...
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In Malaysia, Non-Governmental Organisations (NGOs) play important roles in establishing community-based early intervention programmes for children with autism spectrum disorder. However, there are limited understanding of how the intervention programmes may be used in community-based settings. This paper aims to explore the practices and challenges faced by the community-based intervention centres in Malaysia. A principal, 6 teachers, and a therapist from IDEAS Autism Centre were selected as participants in this study through purposive sampling. Five main themes were identified through thematic analysis: [1] Admission Requirement, [2] Teacher’s Role, [3] Current Intervention Program, [4] Objectives and [5] Challenges. The results reveal that their curricula were self-designed through adaptation. This study provides a base to improve the community-based early intervention programmes.
... While this is currently a tentative consideration given the paucity of available studies, there is data to suggest that initial empathic responses during psychotherapy correlate positively to good psychotherapy outcomes [Malin et al 2015]. Current paradigms for measuring the therapeutic relationship are based on therapist and patient self-report, observer report, or analysis of vocal or language style synchrony [Lord et al 2015;Imel et al 2014]. By providing direct measures of brain activity associated with empathic interactions between a potential patient and therapist, NF-AP might be studied as a tool to augment the patient's and therapist's initial determination of whether they are a 'good match'. ...
Empathic communications between a patient and therapist are an essential component of psychotherapy. However, objective neural markers of the quality of the psychotherapeutic relationship have been elusive. Here we conceptualize how a neuroscience-informed approach involving real-time neurofeedback, facilitated via existing functional magnetic resonance imaging (fMRI) and electroencephalography (EEG) technologies, has the potential to provide objective information for quantifying therapeutic rapport. We propose several neurofeedback-assisted psychotherapy (NF-AP) approaches that could offer the potential for optimizing the experience of the individual patient and therapist across the spectrum of psychotherapeutic treatment. Finally, we consider how the possible strengths of these approaches are balanced by current limitations and discuss the prospects of NF-AP.
... In the clinical setting, LSM has been applied to therapy sessions and there is promising evidence that it may tap into implicit aspects of the therapeutic relationship such as empathy, alliance and goal consensus (Aafjes-van Doorn et al., 2020;Müller-Frommeyer et al., 2019), which are significant predictors of outcome (Flückiger et al., 2018;Tryon et al., 2018). For example, language style synchrony between therapist and patient is an indicator of empathy (Lord et al., 2015), a metric of interpersonal synergy and an implicit measure of the alliance (Aafjesvan Doorn et al., 2020). Moreover, preliminary evidence suggests that early LSM between the therapist-patient dyad is associated with a greater symptom reduction at end of treatment (Aafjes-van Doorn et al., 2020;Borelli et al., 2019). ...
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Objective: The aim of this study was to examine the processes involved in a guided self-help (GSH) pre-treatment intervention (RecoveryMANTRA) for patients with anorexia nervosa (AN), by measuring the levels of patient/mentor Language Style Matching (LSM). RecoveryMANTRA was supported by student mentors or peer mentors (recovered individuals) over six weekly chat-based sessions. We examined whether LSM during RecoveryMANTRA predicted patients'working alliance with the clinic therapist, motivation, eating disorder (ED) and general psychopathology. A further aim was to examine differences in LSM between student mentors and peer mentors. Method: 87 AN adults received RecoveryMANTRA plus treatment as usual. The LSM algorithm was used to calculate verbal attunement between patient and mentor. Participants were assessed at baseline and at the end of the intervention. Results: Both early (1st session) and late (6th session) LSM predicted higher working alliance with the clinic therapist. Moreover, late LSM predicted lower EDs symptoms at the end of the RecoveryMANTRA intervention. Patient/peer mentor dyads showed higher late verbal attunement than patient/student mentor dyads. Conclusions: These findings suggests that in the early phase of treatment relational aspects can impact on engagement with treatment. Verbal attunement in a GSH for AN is associated with working alliance and better clinical outcome.
... The relational construct of partnership, on the other hand, reflects practitioners' ability to engage clients in the conversation [13], whereas the construct of empathy in MI is characterised by practitioners' ability to perceive and communicate understanding of other people's feelings and their attached meaning [14]. High ratings of clinicians' empathy have been associated with positive behaviour change in several studies [15], and clinicians' reflective listening is one of the most important skills with regard to empathy in MI [13]. ...
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In this convergent mixed-methods study, the aim was to explore how objective and subjective quality ratings of school nurses’ motivational interviewing (MI) correlate whilst also considering the perceptions of delivering and participating in the same MI sessions. Quantitative and qualitative data were derived from seven intervention schools participating in the Healthy School Start Plus parenting support intervention. School nurses were trained in MI and conducted an MI session with parents of 6–7-year-old children to discuss children’s physical health and development. Quantitative data comprised objective ratings of school nurses’ MI competence using the Motivational Interviewing Treatment Integrity 4.2 [MITI-4] protocol, as well as parents’ and school nurses’ subjective ratings of the MI sessions. Qualitative data comprised semi-structured interviews with parents and school nurses about their perceptions of the MI sessions. First, quantitative data were analysed using Spearman’s rank correlation, and qualitative data were analysed using content analysis. Next, quantitative and qualitative findings were merged. Our findings suggest that school nurses’ MI performances were rated and perceived as valuable and family-centred by both school nurses and parents who had left the meeting feeling motivated and empowered to promote their children’s healthy behaviours. Nonetheless, school nurses were critical to their own MI technical performance, and they found that reflections were easier to deliver and to self-rate. Overall, MITI ratings were the lowest and parents’ ratings were the highest. Future studies should focus on relating clients’ subjective ratings of MI with clients’ behavioural outcomes.
... Past work on interpersonal coordination comprises a diverse body of work with investigations in general social interactions (Abney et al., 2015;Chanel et al., 2013;Louwerse et al., 2012), parent-child interactions (Abney et al., 2017;Crowell et al., 2017;Feldman, 2007;Nguyen et al., 2020), child-child interactions (Altmann, 2011), romantic partners (Butler & Barnard, 2019;Gottman, 2014;Randall et al., 2013;Timmons et al., 2015), families (Butner et al., 2018), strangers and friends (Bizzego et al., 2020;Galati et al., 2020), mental health-related interactions Ramseyer & Tschacher, 2011;Soma et al., 2019;Wiltshire, Philipsen, et al., 2020), teamwork (Dias et al., 2019;Likens et al., 2014;Palumbo et al., 2017;Reinero et al., 2020;Wiltshire et al., 2019), performance groups (Keller et al., 2014;Setzler & Goldstone, 2020), and even inter-species interactions (Wanser et al., 2021). In addition, there is evidence of synchronization phenomena in many modalities including non-verbal behaviors and movements (Ramseyer, 2019;Schoenherr et al., 2019), acoustic properties of speech (Fischer et al., 2017;Imel et al., 2014;Wieder & Wiltshire, 2020), alignment and matching in language (Duran et al., 2019;Fusaroli & Tylén, 2016;Lord et al., 2015;Niederhoffer & Pennebaker, 2002), physiological signals from the autonomic nervous system (Kleinbub, 2017;Konvalinka et al., 2011), patterns of neural activation (Dikker et al., 2017;Hoehl et al., 2020;Koban et al., 2019), and between multiple modalities (Amon et al., 2019;Gorman et al., 2016). ...
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In order to support the burgeoning field of research into intra- and interpersonal synchrony, we present an open-source software package: multiSyncPy. Multivariate synchrony goes beyond the bivariate case and can be useful for quantifying how groups, teams, and families coordinate their behaviors, or estimating the degree to which multiple modalities from an individual become synchronized. Our package includes state-of-the-art multivariate methods including symbolic entropy, multidimensional recurrence quantification analysis, coherence (with an additional sum-normalized modification), the cluster-phase ‘Rho’ metric, and a statistical test based on the Kuramoto order parameter. We also include functions for two surrogation techniques to compare the observed coordination dynamics with chance levels and a windowing function to examine time-varying coordination for most of the measures. Taken together, our collation and presentation of these methods make the study of interpersonal synchronization and coordination dynamics applicable to larger, more complex and often more ecologically valid study designs. In this work, we summarize the relevant theoretical background and present illustrative practical examples, lessons learned, as well as guidance for the usage of our package – using synthetic as well as empirical data. Furthermore, we provide a discussion of our work and software and outline interesting further directions and perspectives. multiSyncPy is freely available under the LGPL license at: , and also available at the Python package index.
... Also, these participants had normal baseline triglycerides and may have been more health-conscious than the general population with lower habitual alcohol intakes. It is conceivable that motivational strategies may be ineffective in the present written format, and face-to-face discussion is required with an empathetic caregiver [33]. Also, motivational interviewing in itself may not be superior to standard care for dyslipidemia [34]. ...
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Lifestyle management is the first line of treatment for moderately elevated blood lipids in healthy individuals. We investigated the effectiveness of providing food-based written advice for lowering low-density lipoprotein (LDL) cholesterol (intervention) or triglycerides (control) in a pragmatic randomized controlled trial with two parallel arms from 2018–2019 at a rural primary health care center. We sent feedback letters after 3 weeks and 6 months. Out of the 113 adult primary care patients randomized, 112 completed the study. There were no differences between the intervention and control groups for changes in LDL cholesterol after 3 weeks (mean ± standard deviation −0.21 ± 0.38 vs. −0.11 ± 0.34 mmol/L, p = 0.45) or 6 months (−0.05 ± 0.47 vs. 0.02 ± 0.41 mmol/L, p = 0.70) (primary outcome). Following the advice to consume plant sterols and turmeric was associated with a reduction in LDL cholesterol after 3 weeks. Following the advice to consume less carbohydrates was associated with reduced triglycerides. In the intervention arm, 14 individuals (25%) reduced their LDL cholesterol by ≥10% after three weeks. Their reduction was attenuated but maintained after six months (−7.1 ± 9.2% or −0.31 ± 0.38 mmol/L, p = 0.01 compared with baseline). They differed only in higher adherence to the advice regarding turmeric. In conclusion, this undemanding intervention had little effect on blood lipids for most individuals.
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Background Each year, millions of Americans receive evidence-based psychotherapies (EBPs) like cognitive behavioral therapy (CBT) for the treatment of mental and behavioral health problems. Yet, at present, there is no scalable method for evaluating the quality of psychotherapy services, leaving EBP quality and effectiveness largely unmeasured and unknown. Project AFFECT will develop and evaluate an AI-based software system to automatically estimate CBT fidelity from a recording of a CBT session. Project AFFECT is an NIMH-funded research partnership between the Penn Collaborative for CBT and Implementation Science and, Inc. (“Lyssn”) a start-up developing AI-based technologies that are objective, scalable, and cost efficient, to support training, supervision, and quality assurance of EBPs. Lyssn provides HIPAA-compliant, cloud-based software for secure recording, sharing, and reviewing of therapy sessions, which includes AI-generated metrics for CBT. The proposed tool will build from and be integrated into this core platform. Methods Phase I will work from an existing software prototype to develop a LyssnCBT user interface geared to the needs of community mental health (CMH) agencies. Core activities include a user-centered design focus group and interviews with community mental health therapists, supervisors, and administrators to inform the design and development of LyssnCBT. LyssnCBT will be evaluated for usability and implementation readiness in a final stage of Phase I. Phase II will conduct a stepped-wedge, hybrid implementation-effectiveness randomized trial (N = 1,875 clients) to evaluate the effectiveness of LyssnCBT to improve therapist CBT skills and client outcomes and reduce client drop-out. Analyses will also examine the hypothesized mechanism of action underlying LyssnCBT. Discussion Successful execution will provide automated, scalable CBT fidelity feedback for the first time ever, supporting high-quality training, supervision, and quality assurance, and providing a core technology foundation that could support the quality delivery of a range of EBPs in the future. Trial registration; NCT05340738; approved 4/21/2022.
Romantic partners in long-distance relationships tend to adapt their communication and their perceptions of the relationship to suit their relational goals. Guided by this premise, the aim of this study was to provide a more nuanced understanding of how communication and perceptions are adapted. For this purpose, self-reports and behavioral data pertaining to 61 heterosexual dating couples were gathered, who all kept a diary for a week, while communicating via a texting platform. By comparing the daily communication and perceptions of the relationship of couples in long-distance relationships to those of couples in geographically close relationships, the study offered solid evidence of behavioral adaption, as the former self-reported greater self-disclosure and greater self-responsiveness to their partners. These findings were supported by human coding and linguistic analysis results. Moreover, while relative to geographically close partners, long-distance partners demonstrated larger differences between partner perceptions and the partner’s self-report for both self-disclosure and responsiveness. The effect of long-distance status on perceived differences was mediated by relationship uncertainty and one’s own adaptive behaviors. The findings suggest that long-distance relationships are maintained through behavioral and perceptual adaptations, which are also meaningful for maintaining geographically close relationships.
Objective: Psychotherapy is the treatment of choice for anorexia nervosa (AN) but mechanisms of action are still largely unknown. Growing research suggests that synchrony between patient and therapist contributes to treatment success. Adding to this literature, this study examined the association between language style matching (LSM) among patient and therapist as an indicator of interpersonal (verbal) synchrony and treatment outcome in AN. Method: Audio recordings of mid-treatment therapy sessions (n = 25) in a multi-centre randomized controlled trial on the Maudsley Model of Anorexia Nervosa Treatment for Adults were transcribed and used to calculate LSM for each patient-therapist dyad. These scores were used to predict treatment outcome at 12-month follow-up. Results: LSM did not predict body mass index (primary outcome) at follow-up. However, higher LSM (M = 0.87, SD = 0.04) was associated with lower eating disorder psychopathology (accounting for 11% of the variance) and higher recovery rates (accounting for 28% of variance) at follow-up. Conclusions: These preliminary findings suggest that verbal synchrony between patients with AN and their therapists contributes to favourable treatment outcomes. High levels of LSM may reflect therapeutic empathy, cooperation, or mutual positive perception. Further research should explore the mechanisms of linguistic synchrony with larger samples to allow for stronger conclusions.
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Matching of nonverbal behaviors in conversation, known as synchrony, is sometimes shown to predict the rapport between conversational partners. The aim of this study was to examine whether synchrony in vocal pitch between psychotherapists and clients is similarly associated with rapport. Recordings of psychotherapy sessions were analyzed to extract the synchrony in pitch of therapist and client speech, and these synchrony measures were then related to measures of the therapy relationship and treatment outcome. Results indicated that pitch synchrony did occur in the sessions but higher levels of synchrony were related to poorer therapeutic relationships and greater distress. These findings suggest that the vocal pitch of therapists and their clients may be of importance in understanding the psychotherapy interaction.
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Objective: The technical hypothesis of motivational interviewing (MI) posits that therapist-implemented MI skills are related to client speech regarding behavior change and that client speech predicts client outcome. The current meta-analysis is the first aggregate test of this proposed causal model. Method: A systematic literature review, using stringent inclusion criteria, identified 16 reports describing 12 primary studies. We used review methods to calculate the inverse-variance-weighted pooled correlation coefficient for the therapist-to-client and the client-to-outcome paths across multiple targeted behaviors (i.e., alcohol or illicit drug use, other addictive behaviors). Results: Therapist MI-consistent skills were correlated with more client language in favor of behavior change (i.e., change talk; r = .26, p < .0001), but not less client language against behavior change (i.e., sustain talk; r = .10, p = .09). MI-inconsistent skills were associated with less change talk (r = -.17, p = .001) as well as more sustain talk (r = .07, p = .009). Among these studies, client change talk was not associated with follow-up outcome (r = .06, p = .41), but sustain talk was associated with worse outcome (r = -.24, p = .001). In addition, studies examining composite client language (e.g., an average of negative and positive statements) showed an overall positive relationship with client behavior change (r = .12, p = .006; k = 6). Conclusions: This meta-analysis provides an initial test and partial support for a key causal model of MI efficacy. Recommendations for MI practitioners, clinical supervisors, and process researchers are provided.
After defining empathy, discussing its measurement, and offering an example of empathy in practice, we present the results of an updated meta-analysis of the relation between empathy and psychotherapy outcome. Results indicated that empathy is a moderately strong predictor of therapy outcome: mean weighted r = .31 ( p < .001; 95% confidence interval: .28–.34), for 59 independent samples and 3599 clients. Although the empathy-outcome relation held equally for different theoretical orientations, there was considerable nonrandom variability. Client and observer perceptions of therapist empathy predicted outcomes better than therapist perceptions of empathic accuracy measures, and the relation was strongest for less experienced therapists. We conclude with practice recommendations, including endorsing the different forms that empathy may take in therapy.
This chapter investigates the linguistic resources deployed by recipients of conversational complaint stories to show affiliation (or not) with the teller, affiliation being understood as the display of support and endorsement for a conveyed affective stance, here typically anger and/or indignation. Among the verbal means for affiliative reception are claims of understanding, congruent negative assessments and by-proxy justifications, while factual follow-up questions, minimal responses and withholdings are shown to be non-affiliative. As a rule, affiliative verbal devices are accompanied by prosodic matching or upgrading, while non-affiliative ones have prosodic downgrading. The affiliative import of response cries is shown to depend even more heavily on prosodic matching or upgrading, although the transitoriness of prosody makes verbal reinforcement a desideratum. All in all, the data discussed here present a complex picture of what it takes to come across as affiliative in response to a conversational complaint story, but one not lacking in systematicity.
The chameleon effect refers to nonconscious mimicry of the postures, mannerisms, facial expressions, and other behaviors of one's interaction partners, such that one's behavior passively rind unintentionally changes to match that of others in one's current social environment. The authors suggest that the mechanism involved is the perception-behavior link, the recently documented finding (e.g., J. A. Bargh, M. Chen, & L. Burrows, 1996) that the mere perception of another' s behavior automatically increases the likelihood of engaging in that behavior oneself Experiment 1 showed that the motor behavior of participants unintentionally matched that of strangers with whom they worked on a task. Experiment 2 had confederates mimic the posture and movements of participants and showed that mimicry facilitates the smoothness of interactions and increases liking between interaction partners. Experiment 3 showed that dispositionally empathic individuals exhibit the chameleon effect to a greater extent than do other people.
Previous research indicates that motivational interviewing (MI) skills decline over time among participants in training workshops when post-workshop feedback and coaching are not provided. This study explored moderators of skill retention among trainees learning MI mainly for substance use disorder treatment in real-world treatment settings, including workshop enhancements and type and dose of post-workshop feedback and coaching. A meta-analysis of training studies was conducted with studies that reported MI skills using observational measures and that included trainees from real-world agency settings. Standardized change scores were calculated to indicate the magnitude of pre-post training change in MI skills; standardized change scores from post-training to 3 and 6-plus months follow-up were calculated to indicate the sustainability of training gains over time. Effect sizes were aggregated using random effects models. 21 articles that reported the effects of MI training on agency staff were included in this review. Across studies, training yielded gains in MI skills (d=.79). Studies that did not include feedback and/or coaching reported eroding skills over a 6-month follow-up (d=-.30) whereas post-workshop feedback/coaching sustained skills (d=.03). Effects of post-workshop feedback/coaching were moderated by frequency, duration, and length of training. Moreover, studies reporting low levels of attrition from training protocols showed small increases in skills over the six-month follow-up period (d=.12) whereas studies with high attrition showed skill erosion (d=-.29). On average, 3-4 feedback/coaching sessions over a six-month period sustain skills among trainees for motivational interviewing, mainly for substance use disorder treatment. However, high rates of attrition from feedback/coaching contributes to post-workshop skill erosion.