Therapist Empathy and Client Anxiety Reduction

in Motivational Interviewing: ‘‘She Carries With Me,

the Experience’’
m

Lynne E. Angus and Fern Kagan

York University

In this article, we examine the use of motivational interviewing (MI) to

treat generalized anxiety disorder (GAD) by means of case illustration
that focuses on four categories drawn from the client’s experience
of the key ingredients in MI therapy. The case illustration, drawn from
the York study on combining MI and cognitive behavior therapy in the
treatment of GAD (uses the client’s pre- and post-therapy narrative
interviews) to arrive at categories representative of the client’s
experience of MI therapy. The results of the qualitative analysis
highlight the key contributions to positive client outcomes and
readiness for change in brief MI therapy for GAD. & 2009 Wiley
Periodicals, Inc. J Clin Psychol: In Session 65: 1156–1167, 2009.

Keywords: motivational interviewing; psychotherapy; generalized

anxiety disorder; empathy

This article will focus on the contributions of therapist empathy for client anxiety
reduction in a short-term course of motivational interviewing (MI) for generalized
anxiety disorder (GAD). First, we present a brief description of MI and address the
fundamental contributions of therapist empathic attunement, referred to as the ‘‘MI
spirit’’ in MI therapy, to productive therapeutic outcomes. Next, we illustrate the
contributions of MI for the successful amelioration of GAD symptoms by means of
a case example drawn from the randomized clinical study on combining MI with
cognitive-behavioral therapy (CBT) in the treatment of GAD (Westra, Arkowitz, &
Dozois, 2007) conducted at York University. Finally, we discuss the implications for
clinical practice.
The contributions of a warm and secure bond with a caregiver for adaptive
psychological development have been noted by developmental researchers for
decades (Bowlby, 1969; Ainsworth, 1979). Psychotherapy researchers have also
identified the contributions of therapist empathy for the development of secure

Correspondence concerning this article should be addressed to: Lynne E. Angus, Clinical Psychology
Graduate Program, Rm. 108 C BSB, Psychology, York University, Toronto, Ontario, Canada M3J IP3;
e-mail: langus@yorku.ca

JOURNAL OF CLINICAL PSYCHOLOGY: IN SESSION, Vol. 65(11), 1156--1167 (2009) & 2009 Wiley Periodicals, Inc.
Published online in Wiley InterScience (www.interscience.wiley.com). DOI: 10.1002/jclp.20635
 Therapist Empathy and Client Anxiety Reduction in MI 1157

therapeutic bonds and productive outcomes in psychotherapy (Orlinsky, Grawe, &

Parks, 1994). As such, therapists’ capacity to empathically attune with clients on a
moment-to-moment basis in therapy sessions may be a key mechanism of change
across a range of approaches and clinical disorders.
Building on the growing research evidence that the quality of the therapeutic
relationship is foundational for effective psychotherapy, we will use the following
case illustration, based upon a qualitative analysis of the client’s experience of MI
therapy, to argue that a focus on therapist empathic attunement is a key requirement
for effective treatment in MI.

Motivational Interviewing in the Treatment of Anxiety

As defined by Miller and Rollnick (2002), MI is ‘‘a client-centered directive method
for enhancing intrinsic motivation to change by exploring and resolving
ambivalence.’’ Both MI and client-centered therapy share an emphasis on accessing
and understanding a client’s internal frame of reference regarding salient personal
concerns and working with discrepancies between problem behaviors and cherished
values. More specifically, Westra and Arkowitz (in press) argue that the therapist’s
capacity to embody the ‘‘MI spirit’’—defined as empathic attunement, collaboration,
evocation, and respect for the client’s autonomy—is essential for helping clients to
feel safe enough to disclose their most vulnerable and painful concerns and stories
for shared reflection and new understandings. Notably, both approaches emphasize
the importance of therapist empathic responsivity to emergent client concerns and
the communication of accurate understanding. However, in addition to empathic
attunement, MI also has a directive component that has specific goals of reducing
ambivalence and increasing a client’s own intrinsic motivation regarding change. MI
identifies four therapist principles of change: express empathy, develop discrepancy
between values and problem behaviors, roll with resistance, and support self-efficacy.
Therapist activities essential for fostering the MI spirit—ask open-ended questions,
listen reflectively, affirm, and summarize—are all classic methods of client-centered
therapy that are deemed essential for facilitating an empathic bond with clients. We
believe that it is the therapist’s capacity to embody the MI spirit and establish a
secure empathic bond with a client that is key to achieving positive treatment
outcomes in MI.
In terms of supporting client self-efficacy, which readies clients for change,
expressing the MI spirit helps promote clients’ active self-reflection during the
therapy hour and engenders a heightened sense of personal agency for the client.
Additionally, and perhaps most important, the capacity to engage in a productive
therapeutic relationship that enhances a sense of personal agency increases client
expectations for positive change as an outcome of the MI therapy experience, and it
amplifies motivation for engagement (Westra, 2004) in the tasks and goals of
therapy. The enhancement of client agency and client expectations regarding change
as a function of MI therapy may also increase client commitment in subsequent
therapeutic modalities.
Additionally, we believe that MI therapists have an important role to play in
helping clients identify unique outcome stories—positive change actions and
events—that emerge over the course of treatment and are, in essence, irrefutable
‘‘proof’’ of the client’s capacity to be an agent of change in their own lives. We shall
now focus on the importance of MI therapists’ embodiment of the MI spirit for the
Journal of Clinical Psychology DOI: 10.1002/jclp
1158 Journal of Clinical Psychology: In Session, November 2009

development of heightened client agency, self disclosure, reduced anxiety, and

increased motivation in a productive MI treatment for GAD.

MI and GAD
The MI focus, on addressing client ambivalence for change, speaks to a key
impediment encountered by therapists working with clients who present with
generalized anxiety disorder. Individuals with GAD hold conflicting beliefs about
worry, including both negative and positive perceptions of its value (Borkovec &
Roemer, 1995). Although GAD clients do see worry as a problem (e.g., it interferes
with concentration and memory), they also hold positive beliefs about it (e.g., worry
is motivating, ensures that one is prepared for negative events) and are, therefore,
ambivalent about reducing or relinquishing their excessive worry. Moreover, worry
itself has been found to have an important emotional avoidance and self-reinforcing
function, protecting the individual from experiencing distressing emotions and
reinforcing the maladaptive, anticipatory fear that emotional disclosure leads to
heightened emotional arousal.
The more evocative and descriptive the client can be regarding his or her
experiences of significant life events, the greater the opportunity the MI therapist has
to empathically resonate with and attune to the client’s feeling state (Angus &
Kagan, 2007). In particular, Borkovec and Roemer (1995) propose that obsessive
worrying—often experienced by GAD clients—suppresses the key psychological
change processes of imagery recall, affect and emotional processing that are linked
with the disclosure of emotionally salient, specific autobiographic memories (ABM).
Additionally, worry content in GAD often revolves around interpersonal fears and
relationships (Cassidy, 1995), and, thus, the focus on the therapeutic relationship
found in MI therapy offers the possibility of providing the client with a corrective
interpersonal experience, which may be of particular importance to clients suffering
from GAD. The articulation and processing of distressing emotions within the
context of a safe relational bond is a central therapeutic task when working with
chronically anxious clients and, as such, an important focus for MI therapists
working with GAD clients.

Case Illustration
Client Description and Presenting Problem
Previously described by Westra and Arkowitz (in press), Carol was a 50-year-old
divorced woman when she sought therapy for severe GAD at York University. The
MI therapist Carol saw was a seasoned clinical psychologist who completed an MI
training course. Carol described a chronic pattern of worrying, never being relaxed,
having ‘‘no peace or happiness,’’ and feeling constantly busy and rushed. She further
complained of chronic tiredness and exhaustion; however, she was puzzled because
‘‘there’s nothing major going on, yet my mind is busy all the time.’’ This is a classic
pattern in GAD where generalized, chronic feelings of anxiety seem unconnected to
daily life events and ritualized activities, such as household chores and checking for
and responding to new e-mail, serve as a distraction from relentless worry.
Carol reported worrying about everything, especially her relationships with other
people and the well-being of her family members. She stated that her worry caused
her distress and reported difficulties with insomnia, tension, and inability to
concentrate. In fact, Carol had to take a leave from her job due to the severe
Journal of Clinical Psychology DOI: 10.1002/jclp
 Therapist Empathy and Client Anxiety Reduction in MI 1159

concentration problems associated with her worry. She described herself as a

‘‘lifelong worrier’’ and had previously been treated with psychotherapy and
antidepressant medication with little improvement.
Carol described a history of feeling continually alone and rejected by others. As a
child, she felt distant from her parents because her father had a major accident that
left him disabled and her mother was largely preoccupied with her father’s care.
Carol left home at a young age to attend boarding school and learned English only
as a young woman, after she had immigrated to Canada from Poland. She described
a chronic pattern of excessive pleasing regarding others, accompanied by fears of
setting boundaries or saying ‘‘no’’ because this might engender disapproval and
abandonment, perpetuating her feelings of loneliness.

Case Formulation
Carol received 4 weekly individual sessions of MI with one therapist, which is the
focus of this case example, before participating in 14 individual therapy hours of
CBT with another therapist.
Carol’s video-recorded MI sessions were subjected to quantitative adherence
ratings using the motivational interviewing treatment integrity code (MITI; Moyers,
Martin, Manuel, Hendrickson, & Miller, 2005). The MITI uses multiple coders to
evaluate two core MI dimensions—therapist empathy and MI spirit—for the
dimension of therapist empathy. The therapist was rated 7/7 for all four sessions,
while MI Spirit, which includes assessment of preserving autonomy, collaboration,
and evocation, was rated 7/7 for sessions 1–3 and 6/7 for session 4.

Course of Treatment
Shortly after completing four sessions of MI, Carol participated in a semistructured,
post-MI therapy interview protocol that was adapted from the Narrative Assessment
Interview (Hardtke & Angus, 2004). In that taped recorded interview, Carol was
asked by an interviewer to reflect on her experience of MI, the therapist’s role in MI,
her own role in MI, change as a result of MI, helpful and unhelpful aspects of MI,
and expectancies for change. She was also asked to identity specific examples from
her therapy sessions, whenever possible. To provide Carol with a baseline point on
which to anchor her reflections, the interviewer recounted her pre-treatment
response—‘‘gain control of your mind and be more assertive’’—to the question,
‘‘If you could make a difference or change in you through therapy, what would
that be?’’
Both authors transcribed the post-MI therapy interview and then subjected them
to a qualitative theme analyses, which began with each author independently coding
the post-MI therapy interview and then meeting to compare and contrast the results
of each independent analysis to arrive at a consensus. Four core relational categories
emerged from the theme analyses: (a) I just opened myself up: disclosing painful
memories, feelings and concerns in therapy; (b) she carries with me, the experience:
therapist empathic attunement facilitates accessing, symbolizing, and disclosing
painful memories, concerns, emotions, hopes/fears; (c) I was just doing something
for myself: heightened sense of agency and purpose in life; and (d) achieving new
interpersonal outcomes. In this case analysis, we will address and illustrate the four
core relational categories by way of paradigmatic examples drawn from Carol’s post
therapy interview and her MI therapy sessions.
Journal of Clinical Psychology DOI: 10.1002/jclp
1160 Journal of Clinical Psychology: In Session, November 2009

‘‘I Just Opened Myself Up’’: Disclosing Painful Memories, Feelings, and Concerns
in Therapy
When asked by the post-therapy interviewer what the most helpful aspect of her MI
therapy was, Carol replied, ‘‘I just opened myself up. I was really, really—it
surprised me. It really surprised me that I was able to just say it, even in English y.’’
At therapy outset, Carol had been fearful that she would not speak fluently,
honestly, and openly to her therapist about her most painful concerns, a pattern that
plagued her in many of her interpersonal relationships. Importantly, this core
concern emerged in her first MI session wherein Carol revealed to the therapist that
she was deeply disturbed by the false front that she ‘‘showed the world.’’ The
experience of her own truth was very different from the impression she was giving to
others, and yet despite this awareness, she felt unable to make the shift to become
more authentic in her own life. The following excerpt is drawn from session 1:
Carol (C): I am always giving that image to people that I am happy and I am okay.
I am calm and I’m always, you know, good and helpful and kind and, I don’t know,
nice. But I know that there is something else going on, it’s not the truth, you know.
My image is different than y.
Therapist (T): Than what’s going on inside you? Right, so it’s almost like you are
the strong one, right? People come to you?
C: Yeah, people think I’m strong, you know, and always have some solution. And,
you know, I’m always happy because always I have a smile on my face. It’s like I am
the happiest person in my life.
T: Right, right.
C: But I know it’s not the truth.
T: Right, so inside y.
C: Inside, it’s opposite.
T: Right, so it’s kind of like this ‘‘you’’ inside here (indicates chest area) is saying
‘‘I can’t go on like this anymore?’’
C: Yeah, I didn’t want to have that image, you know, of what I am showing to the
world because it’s not the truth what is inside me. It’s like why I am playing this role?
For whom?
T: Right, right, for whom?
C: And for what?
T: And it’s kind of like, what is it, I’ve been playing that for other people?
The therapist’s empathic attunement and attitudes of non-judgmental inquiry in
response to Carol’s most poignant concerns helped support and sustain her
emotional disclosures to the therapist.
As Carol noted in her post-therapy interview, she was very ‘‘surprised’’ by the ease
with which she was able to disclose her most important and painful concerns to the
therapist: ‘‘I never experienced something like this, so I didn’t know what to expect.
I know for sure I was very scared of this. Anxious, you know, how I’m gonna, you
know, talk or if I can be open and honest with myself and with that person. And I
think I got that: the courage to be open and to say what I really feel or think.’’
Carol’s positive experience of feeling courageous when overcoming her fears of
accessing, experiencing, and disclosing painful feelings and beliefs constitutes an
important corrective relational experience in and of itself: ‘‘I felt so free and without
any fear or worries that I am not saying whatever I feel or I thought about it or some
experience that I went through my life and that I could share it for the first time in my
life with somebody.’’ The words that Carol uses to discuss this important new

Journal of Clinical Psychology DOI: 10.1002/jclp

 Therapist Empathy and Client Anxiety Reduction in MI 1161

development in her life are also significant: ‘‘I got that courage to be open.’’ Her
capacity to self-disclose to the therapist is a personal achievement that she has made
happen by courageously overcoming deep fears of being judged or disliked to be seen
and known by another, which constitutes a new interpersonal way of being.
The following excerpt was also taken from session 1:
T: Well, I really appreciate you being able to share these stories with me y and
the chance to see you! Because that seems to be very important. It takes a lot of
courage to come here and share these things.
C: [tearful, quiet] Thank you [softly].
T: What’s going on inside right now?
C: I would like to be helped. So I can be more myself or try to be more myself in
interactions with people, so that I can find myself in this world because I feel
completely lost.
T: I’m also hearing ‘‘it’s time.’’ It feels like it’s time.
The MI therapist demonstrated an early recognition of the importance for Carol
to openly disclose her personal feelings and concerns and validates the courage it
takes for her to risk doing so. Carol was also aware of the significant relational
impact that her MI therapist’s empathic attunements had on helping her to access
and explore emotional disclosures during MI sessions: ‘‘It was very important that
she (MI therapist) was with me, that she was with me. I found that she, she is really,
you know, um, with me in the situation that we were talking about.’’

‘‘She Carries With Me, the Experience’’: Therapist Empathic Attunement Facilitates
Accessing, Symbolizing, and Disclosing Painful Memories, Concerns, Emotions, as
Well as Hopes and Fears for Herself
The second core category identified in our qualitative theme analysis picks up on the
key role played by therapist’s empathic attunement as a function of working within
the MI spirit. Carol viewed her MI therapist as having played both a central and a
supportive role in helping her to disclose her most important concerns achieving this
new outcome:

Whatever I brought from my past time, or some example she could, you
know, carry with me this y this experience and help me to understand or
just to say it, or just learn from it, what I could do, at that time, or what I
could change in the future y I felt that she was really listening to what I
am, you know, saying and what I try to say.

In essence, Carol provides an evocative description of the experience of being in

the presence of an empathic, caring other—her MI therapist. She is also aware of the
positive impact that her feeling of emotional safety had on her ability to tell her own
story:

I felt so comfortable with her. Because all my thoughts and feelings she
really moved, you know, forward with, so, I was able to continue. So, it
didn’t stop me for silence that I didn’t know what to say. Even maybe I
was not able to really express myself because of the language, but she was
just helping me to y to move forward with the thoughts, or just
questions, or just some idea, or giving the example. So, I thought that she
Journal of Clinical Psychology DOI: 10.1002/jclp
1162 Journal of Clinical Psychology: In Session, November 2009

was very helpful to y to move the time so I was not in silence and I
didn’t know what to say.

The role of the therapist’s empathy enhanced the client’s emotional awareness and
disclosure as evident in session 3. At the start of her MI session, the therapist began
by asking Carol how she was doing. When Carol responded a trifle hesitantly that
she was ‘‘okay,’’ the therapist immediately empathically attuned to her lowered
mood and inquires:
T: So you’re just okay?
C: Yeah, just okay. I have just those days when, you know, there is lots of tension
inside.
T: So, that’s one of these days?
C: Yeah, like the past months. Sometimes I feel just okay and other times it is just
like so much tension, I feel like, you know, I try to figure out why I have this tension
inside that I am aware of.
In the relational context of the MI therapist’s empathic attunement to her low
mood and her puzzlement about her tension, Carol began to explore her feelings
more deeply. As her therapist helped her differentiate between the days when she felt
tension and the days when she did not, Carol got in touch with a sense of feeling at
‘‘peace with the world,’’ which she experienced when not in the grip of chronic worry
and tension.
C: Yeah, it is like everything may be under my control. It is like I have done this
and this and everything is just y normal.
T: Right, so the sense of being in control, even a little bit, is part of the ‘‘at
peaceness.’’
Later in session 3, the following pivotal exploration of the emotional consequences
of worry in Carol’s life takes place:
C: People ask me: ‘‘Do you have hobbies?’’ No, I don’t.
T: And how would you, Carol, when you have this voice in your head that says
‘‘Do the garage, mow the lawn y.’’
C: Yes, this stuff that is occupying my mind all the time. ‘‘What would you like to
do?’’ they ask me. And I really don’t know.
T: Because I don’t even have a moment when I’m allowed to think about that. If
you were to do that, it would have to be, well, after the garage and y.
C: Yes, I would feel so guilty.
T: Guilty. Right. If we were to look at the up sides and the down sides of worry
and how it takes over, I would guess that one of the upsides of worry and guilt is
‘‘boy, you get a lot done.’’ That garage gets cleaned and the house gets straightened
up. Carol does a lot. Is that true?
C: [laughs] Yes.
T: Yes, it is true. And you’ve told me, too, that you’ve learned English, secured a
good education, job, and a home. You take very good care of your children. So, guilt
kind of drives a lot of this?
C: Even towards my husband I always feel guilty.
T: Towards your ex-husband. What’s this guilty feeling?
C: I just left him. So, whenever, it’s Thanksgiving or Christmas, I have to invite
him because I would feel so bad if I didn’t.
T: There’s that sense of ‘‘I’m responsible.’’
C: Yes. Or if he doesn’t call, then I think maybe something happened to him and I
have to find out if he’s okay. [laughing slightly and sounding disgusted with herself]
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 Therapist Empathy and Client Anxiety Reduction in MI 1163

T: [picks up on client’s tone of voice] And there’s another part of you going,
‘‘What is that about?’’
C: Yes, because, you know, who is asking me? Why do I always have to worry
about the other person?
T: So, you give exceptional care to others. It sounds like you’re a wonderful
caregiver for other people and their needs. But on the other side, it’s robbing you y
What’s the down side?
C: Sometimes I just feel like I’m doing everything for others. Just to please them,
to make sure they are okay, that I don’t have any conflicts with anybody or that I
don’t insult anybody y.
T: So, this is a lot of work! [client laughs] No insults, no conflicts, making sure
they’re safe, they’re not lonely y.
C: I cannot even say y when a man calls me for a date, I can’t say ‘‘no.’’ So,
sometimes I just go even though I don’t want to.
T: So, somehow it’s easier to sacrifice me.
C: Yes. I feel like I am sacrificing a lot in my life.
T: Sacrificing me so no one is hurt or insulted or unsafe or y that’s all y.
C: It’s all about others! [sounding exasperated] How my kids are doing. Are they
okay? Constantly thinking about others. So, I don’t even have a moment for me.
T: And you’re saying, ‘‘Boy, there’s sure some costs to that for me, eh?’’ What are
some of the costs?
C: Depression.
T: What is that?
C: So sad y and lonely y and not able to do anything. I’m surrounded by people
but actually I feel so alone inside.
In the post MI interview, Carol identified feeling liked and prized by her MI
therapist who also made significant contributions to her increased feelings of security
and greater freedom to experience and disclose her most poignant concerns, as
illustrated in the following brief excerpt.

That she enjoys, you know, time, and I felt very friendly with her. Yeah.
Like, I was not in some tense or just terrified of what she is going to ask
me next or something. I didn’t have these y these thoughts. I felt so very
free to just express whatever we had some talks about.

‘‘I was Just Doing Something for Myself ’’: Heightened Sense of Agency and Purpose
in Life
When the post therapy interviewer asked Carol about how her participation in MI
sessions had impacted her, she stated ‘‘So, I’m just glad that I participate in this. It’s,
in some ways, it y gave me some strength, some values for myself that I had this
courage to think—to believe that this is gonna help me and the others that are
around me. Made me feel better about myself. That I am doing something for
myself.’’ Here, Carol identified the positive impact of telling her own lived story of
problematic life experiences to her MI therapist had on her views and experiences of
self ‘‘I had this courage, strength y made me feel better about myself, that I am
doing something for myself’’ that importantly, increased hopes for further positive
change in her MI sessions: ‘‘It made me feel that I really would like to enjoy my life.
I don’t know how to describe it to you, but I feel lighter y a little proud of myself.’’
Journal of Clinical Psychology DOI: 10.1002/jclp
1164 Journal of Clinical Psychology: In Session, November 2009

Achieving New Interpersonal Outcomes

The therapist opened the fourth and final MI session by highlighting connections
between the positive actions that Carol has taken over the past week with new, more
positive feelings about herself and her life. Carol stated, ‘‘I didn’t waste my time this
week and I didn’t feel guilty—it wasn’t like I didn’t do anything for the holiday and
now the day is gone.’’ The therapist pointed to the difference between these feelings
from how Carol used to experience her life narrated by an internal voice that would
stop her from doing the things she wanted to do.
C: Yes, the voice that used to tell me to do other things, things that could wait,
they could wait.
T: Right, they could wait—like, ‘‘clean the garage’’—that could wait.
C: Right.
T: So, things like that. But that would seriously have you stopping to think, ‘‘Well,
maybe I shouldn’t go out. Maybe I should do this.’’
C: Yeah, so many times I just didn’t go because I said, ‘‘No, I have to finish this; I
have to still write a letter to somebody or something.’’ You know, more important
than, you know, doing something for myself.
T: Right, like go dancing or spend time with your daughter, spent enjoying
yourselves.
T: So, somehow, last week that voice didn’t stop you—you didn’t.
C: No, I think I was stronger. [laughs]
T: You were stronger.
In this passage, Carol exemplifies a heightened sense of agency; she identified
herself as being ‘stronger’ than the voice that used to stop her. Carol’s connection
to her true self was strengthened through therapy and she is clearer on what matters
to her; she stands up to the part of herself that used to keep her from reaching for the
happiness. By focusing on what Carol wants to redefine in her life (eliciting change
talk), the therapist is able to strengthen Carol’s desire to live her life differently and
honor her real priorities. The therapist commented on the significance of Carol’s new
priorities, noting that she was now able to keep obligations and the demands of
others at bay and make room for her own needs.
Carol then disclosed that she also felt a new sense of lightness and ease in
herself:
C: That I just, you know, took some action to control, a little bit, my life y I felt I
am just in some control.
T: Yes, I have some control. I have some choice and I acted on that.
C: Yeah. You know, when I started, you know, these sessions, I think I change a
lot, like, I’ve got that hope inside me that I am doing something really for myself that
I wanted y you know, in the past, I wanted to help myself.
T: Yes, you’ve wanted that for a very long time.
C: Yeah, so I have this hope that keeps me maybe like allowing me to just enjoy,
you know, my time, you know, with others and y.
T: Yes. This hope is very important y.
Here, Carol stated that she had begun to make important changes in her life as a
result of her engagement in the MI sessions, and she attributed her newfound sense
of hope to a new sense of personal agency and self-responsibility ‘‘doing something
really for [her] self’’ that she has been wanting to do for a long time. The therapist’s
empathic reflections highlighted Carol’s new experiences of positive change—unique
outcome stories—and bring salience to her expressed hopes for change. The

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 Therapist Empathy and Client Anxiety Reduction in MI 1165

therapist’s empathic attunement to Carol’s hopes for change scaffolds Carol’s

readiness to embark upon the process of change.
Enhancing relationships with others: New interpersonal story outcomes. When
disclosing the reasons why she decided to seek out therapy, Carol noted that a large
concern was the negative impact that her ‘‘personal dishonesty’’ had on her
relationships with others. Reflecting on her assessment of that concern post-MI
therapy, she stated that now she felt ‘‘hope or belief that I can be more honest what
myself and with the others.’’ She also identified how the new actions she had
undertaken have positively impacted her interpersonal relationships outside of
therapy: ‘‘My kids noticed for the past few days that I—I am, like, more relaxed and
I wanted to go out and do something or have some plans to enroll myself. So, I think
they noticed that and they don’t see me any more lying around and withdrawn or
isolated by myself.’’
In her final session, Carol and her MI therapist explored the new interpersonal and
emotional consequences of challenging her habitual ways of dealing with anxiety in
her life.
T: It’s interesting that these days where you let yourself go out and do things that
you liked with other people felt very productive, didn’t they?
C: Yes.
T: Can you tell me more about that? They didn’t feel wasted y they?
C: Yeah, you know, it’s, like, my life can be maybe different if I make that
difference for myself. That feeling, you know, I would like to keep [it] for a while y.
not go back to feeling always rushing, something in my head, you know?
T: Right, so that my life could actually be y more of this?
C: Yeah. That I’m just—alive y that I didn’t, you know, regret something that I
wanted to do and I didn’t because I couldn’t find time and I was just doing
something, you know, not so important y.
T: Right, so another important piece of this is that it allows me to live without regret.
C: Yes.
In this sequence, the MI therapist used empathic reflection and evocative
questioning to help Carol explore the positive emotional and interpersonal
consequences of undercutting worry by engaging in new interpersonal behaviors:
‘‘The role that I used to play with others is not so strong. And I think that all this
honesty I had with myself, it’s really influenced my relationships with others. I have
this hope or belief that I can be more honest with myself and with others. I feel
lighter and, like, I would like to enjoy my life.’’

Outcome and Prognosis

Carol’s comments reflect both significant change with MI and increased readiness for
further change. Although specific techniques for anxiety management were not
discussed in the MI sessions, the evocative and empathic style of MI appeared to have
facilitated her spontaneous generation of solutions to her anxiety problems.
Interestingly, Carol reported that she had already implemented some ideas about
how to manage her anxiety, such as working on the tension in her body more
effectively and ‘‘seeing other ways in which I can cope.’’ Consistent with Miller and
Rollnick’s (2002) description of MI, the work with Carol emphasized both the non-
directive MI spirit and the directive components of MI, which are aimed at increasing
change talk. Although all four of Carol’s therapy sessions included both the directive
and non-directive elements characterized by MI, we have chosen to focus on the
Journal of Clinical Psychology DOI: 10.1002/jclp
1166 Journal of Clinical Psychology: In Session, November 2009

contributions of the MI spirit that helped to move Carol toward change. Although we
are focusing on the value of MI spirit, the characteristics that define MI include both
non-directive and directive elements. We emphasize this point because although we
used the non-directive and directive components of MI with Carol, this case report
emphasizes the value of MI spirit in contributing to therapist empathic attunement.
Clients with severe GAD, such as Carol, typically demonstrate significant
improvement after MI. Carol’s case was representative of this group of clients as
she showed significant symptomatic improvement and anxiety reductions subsequent
to completing four sessions of MI. Prior to starting her MI sessions, Carol scored 72
of a possible 80 on the Penn State Worry Questionnaire (Meyer, Miller, Metzger, &
Borkovec, 1990), indicating extremely high levels of self-reported worry. She also met
diagnostic criteria for major depressive episode, panic disorder, and social phobia.
Her scores on the Depression, Anxiety, and Stress Scale (DASS; Lovibond &
Lovibond, 1995) were in the ‘‘very severe’’ range, and she showed marked disability in
work, social, and family life on the Sheehan Disability Scale (Sheehan, 1983). After
treatment with MI therapy, her scores on the Penn State Worry Questionnaire
(PSWQ) dropped from 72 to 50; the clinical cutoff is 55. At her 6-month follow-up,
Carol’s PSWQ had dropped another 9 points to 41, where it remained at her 1-year
follow-up, at which time Carol met criteria only for social phobia.

Clinical Issues and Summary

Fostering a sense of mastery and the provision of a healing relationship are two key
components of all successful psychotherapies (Frank, 1961). Jerome Frank suggested
that many of the curative features of psychotherapy are targeted at ameliorating
demoralization, which he defined as a sense of failure or powerlessness to affect
oneself and one’s environment. With regard to MI and the case of Carol, we believe
that MI therapists’ ability to convey the MI spirit, which is best exemplified by
therapist empathic attunement, is fundamental to enabling GAD clients to begin to
consider change and regain a sense of mastery over worry in their lives.
The MI spirit is also foundational for the establishment of a warm bond that can
facilitate a corrective interpersonal experience for clients suffering from GAD. This
principle is well illustrated in the current case: The MI therapists’ attunement to
Carol’s fears of self-disclosure enabled her to ‘‘courageously’’ share her most painful
stories, emotions, and beliefs for the articulation of new views of self-corrective
experiences of being understood and accepted in an important relationship,
culminating in the mobilization of new hopes for change. Carol experienced being
a successful agent of change, in her own life, during her MI therapy sessions.
With regard to the practice of MI, it appears that eliciting client change talk,
within the context of a client-centered frame that privileges client agency, has great
power to mobilize hope and foster mastery in clients struggling with GAD. Therapist
empathy, as exemplified by conveying the MI spirit, sets the stage for an emotionally
corrective experience for clients. Being heard and understood by a caring other, who
follows and symbolizes the clients’ narrative, has enormous influence to combat
demoralization through the awakening of hope and the provision of a sense of
mastery built upon the self-efficacy gained by the successful communication of
feelings to an empathic therapist. In the words of Carol, ‘‘she [the therapist] carries
with me, the experience.’’ This collaborative, co-construction of the client’s
narrative, fueled by therapist empathy, mobilizes client agency, increases hope for
change, and enhances the emergence of new story outcomes.
Journal of Clinical Psychology DOI: 10.1002/jclp
 Therapist Empathy and Client Anxiety Reduction in MI 1167

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Journal of Clinical Psychology DOI: 10.1002/jclp