This study examined synchrony in voice pitch between clinicians and suicidal patients during crisis interventions to quantify the process of empathy. Analysis of audio recordings found that patient and clinician voice pitch were moderately synchronized. Synchrony correlated with higher ratings of therapeutic alliance during interventions but not risk assessments. Regulation of patient emotion by the clinician also correlated with stronger alliances, depending on the phase of treatment. The results suggest empathy and alliance are related to the mutual influence between patients and clinicians on an interpersonal, moment-to-moment level.

1. NATIONAL CENTER
FOR VETERANS STUDIES
Quantifying the process of empathy during crisis interventions:
synchrony in voice pitch among clinicians and patients
Craig J. Bryan, PsyD, ABPP
National Center for Veterans Studies &
The University of Utah

2. NATIONAL CENTER
FOR VETERANS STUDIES
NATIONAL CENTER
FOR VETERANS STUDIES
Co-Authors
Brian Baucom, PhD National Center for Veterans Studies & The University of Utah
Alex O. Crenshaw, BS National Center for Veterans Studies & The University of Utah

3. NATIONAL CENTER
FOR VETERANS STUDIES
NATIONAL CENTER
FOR VETERANS STUDIES
Disclosure
This work was in part supported by the Military Suicide Research Consortium (MSRC), an effort supported by the
Office of the Assistant Secretary of Defense for Health Affairs under Award #W81XWH-10-2-0181.
Opinions, interpretations, conclusions, and recommendations are those of the authors and are not necessarily
endorsed by the U.S. Government, the Department of Defense, the Department of the Army, or the MSRC.

4. NATIONAL CENTER
FOR VETERANS STUDIES
NATIONAL CENTER
FOR VETERANS STUDIES
• The ability to maintain a “collaborative, non-adversarial stance” with a patient in crisis is considered to be a
core competency for the clinical care and management of suicide risk (Suicide Prevention Resource Center, n.d.)
– Assumes an ability to establish and maintain a good working alliance with the patient (Rudd, Cukrowicz, & Bryan, 2008)
• Working alliance (a.k.a., therapeutic alliance or therapeutic relationship) refers to the extent of agreement
and/or harmony between the patient and clinician during psychotherapy
• Meta-analyses indicate positive correlations among various measures of the therapeutic relationship with
symptom reduction during psychotherapy (Elliott, Bohart, Watson, & Greenberg, 2011; Horvath, Del Re,
Flückiger, & Symonds, 2011)
– Correlation is largely accounted for by variability among clinicians more than patients (Baldwin, Wampold, & Imel, 2007; Del Re,
Fluckiger, Horvath, Symonds, & Wampold, 2012)
• Few studies have examined the correlation of working alliance with suicide-related outcomes
The ability to develop a strong working alliance with suicidal patients is viewed as an essential skill for clinicians and is consistent with meta-analyses indicating positive correlations among various
(Baldwin, Wampold, & Imel, 2007; Del Re, Fluckiger, Horvath, Symonds, & Wampold, 2012)

5. NATIONAL CENTER
FOR VETERANS STUDIES
NATIONAL CENTER
FOR VETERANS STUDIES
• Bedics et al. (2012): RCT of female patients with borderline personality disorder, DBT vs. expert therapists
– DBT: stronger therapeutic relationship  fewer instances of NSSI
– Control: no relation between therapeutic relationship and NSSI
• Bryan et al. (2012): primary care patients
– Therapeutic bond after first appointment not related to subsequent change in suicide ideation
• Conflicting results could be due to limitations in measuring working alliance, notably empathy

6. NATIONAL CENTER
FOR VETERANS STUDIES
NATIONAL CENTER
FOR VETERANS STUDIES
• Empathy: the ability for a person to experience an emotional or psychological state that is similar to another
person’s state as a result of observing and/or understanding the others’ situation (Preston & De Waal, 2002)
• Empathy entails perceptual and behavioral processes that are functionally intertwined (Decety & Jackson, 2004)
• Two dyadic processes may be involved in therapeutic relationship: synchrony and regulation
– Synchrony: degree of “match” or ability to mirror another person’s experience
– Regulation: decreased variability in affective expression

7. NATIONAL CENTER
FOR VETERANS STUDIES
NATIONAL CENTER
FOR VETERANS STUDIES
• Synchrony:
– Greater match in patient/clinician voice frequency during psychotherapy correlated with empathy ratings (Imel et al., 2014)
– Individuals who score high on empathy measures tend to mimic the actions of others (Chartrand & Bargh, 1999)
– Patient ratings of relationship quality associated with coordinated movements in patient/clinician (Ramseyer & Tschacher, 2011)
• Empathy:
– Trust and safety reflected by extent to which one person promotes affective regulation in the other (Geller & Porges, 2015)
• Although relationship dynamics and empathy are considered key to effective care of suicidal individuals, few
studies have investigated moment-to-moment dynamics within the context of therapeutic relationships among
clinicians and suicidal patients

8. NATIONAL CENTER
FOR VETERANS STUDIES
NATIONAL CENTER
FOR VETERANS STUDIES
Hypotheses
1. Emotional bond will be positively associated with synchrony in f0
2. Emotional bond will be positively associated with patient stability in f0
3. Differences in associations between emotional bond, synchrony in f0, and regulation of f0 during the suicide
risk assessment interview relative to during the intervention

9. NATIONAL CENTER
FOR VETERANS STUDIES
Method

10. NATIONAL CENTER
FOR VETERANS STUDIES
NATIONAL CENTER
FOR VETERANS STUDIES
Participants
• 54 active duty Soldiers
– Gender: 45 male, 9 female
– Years of service: M=4.89 (SD=3.91)
– Deployments: M=1.20 (SD=1.12)
– Race: 76% white, 9% black, 6% Native American, 2% other
– Ethnicity: 7% Hispanic
• Soldiers voluntarily presenting to emergency departments and mental health clinics for emergency behavioral
health evaluation referred to researchers for evaluation
• Inclusion criteria: active suicide ideation during the past week and/or lifetime suicide attempt
• Exclusion criteria: inability to provide informed consent

11. NATIONAL CENTER
FOR VETERANS STUDIES
NATIONAL CENTER
FOR VETERANS STUDIES
Procedures
1. Eligibility assessment
2. Informed consent
3. Turn on digital recorder (TASCAM DR-40 linear PCM)
4. Conduct structured interview focused on suicide attempt history
5. Turn off recorder
6. Patient completes self-report scales
7. Turn on recorder
8. Crisis intervention completed by clinician and patient
9. Turn of recorder
10. Patient completes self-report scales (including therapeutic alliance)

12. NATIONAL CENTER
FOR VETERANS STUDIES
NATIONAL CENTER
FOR VETERANS STUDIES
Measures
• Mean fundamental frequency (f0)
• Working Alliance Inventory Short Form (bond subscale)

13. NATIONAL CENTER
FOR VETERANS STUDIES
NATIONAL CENTER
FOR VETERANS STUDIES
Data Analysis

14. NATIONAL CENTER
FOR VETERANS STUDIES
Results

15. NATIONAL CENTER
FOR VETERANS STUDIES
NATIONAL CENTER
FOR VETERANS STUDIES
High emotional bond Low emotional bond

16. NATIONAL CENTER
FOR VETERANS STUDIES
NATIONAL CENTER
FOR VETERANS STUDIES
Suicide risk interview Intervention
LowemotionalbondHighemotionalbond
+ p<.10, *p<.05, **p<.01, ***p<.001

17. NATIONAL CENTER
FOR VETERANS STUDIES
Conclusions

18. NATIONAL CENTER
FOR VETERANS STUDIES
NATIONAL CENTER
FOR VETERANS STUDIES
• Patient and clinician mean f0 were positively correlated with each other (r=0.52) during both the risk
assessment and the intervention, suggesting patients and clinicians have a moderate degree of “match” in
vocally expressed emotional arousal
• Patient/clinician match was correlated with therapeutic alliance ratings during the intervention but not risk
assessment interview phase
– Information-gathering function of the risk assessment may lend itself to different relationship dynamics than the collaborative
intervention phase of a crisis encounter
• Affect regulation/dysregulation differed across interview and intervention
– During interview, dysregulating effect of clinician on patient associated with higher alliance ratings
– During intervention, regulating effect of clinician on patient associated with higher alliance ratings

19. NATIONAL CENTER
FOR VETERANS STUDIES
NATIONAL CENTER
FOR VETERANS STUDIES
• Overall (mean) levels of emotional arousal were less informative than the modeling of moment-to-moment
transactions between clinician and patient
• Emotional bonding during crisis encounters related to the patient’s overall level of emotional arousal during the
intervention phase (but not the interview) as well as the extent of synchrony that exists between clinicians and
patients during the intervention phase (but not the interview).
• Considering how patients and clinicians mutually influence each other reveals more nuanced details of the
interpersonal process
– Empathy and alliance are strongly related to the influence of the clinician on the patient
– Relationship is also related to the patient’s influence on the clinician

20. NATIONAL CENTER
FOR VETERANS STUDIES
Questions
Craig J. Bryan, PsyD, ABPP
craig.bryan@utah.edu