The Dilemma of Change
MI pp 13-19
HC pp 33-35
◦ Review textbook
◦ Quiz
◦ Review handout
◦ Video
◦ Exercise
◦ Ambivalence: a reasonable place to visit, but you
would not want to live there
◦ Feeling 100% clear about something important is
probably more exceptional than normal
◦ This phenomenon of ambivalence is prominent in
psychological difficulties
 E.g. Individual suffering from agoraphobia vs. socially
isolated individual
◦ With certain problems, the part played by
ambivalence is even more central
◦ It is easy to misinterpret ambivalent conflict as
pathological—to conclude that there is something
wrong with the person’s motivation, judgment,
knowledge base, or mental state
◦ However, ambivalence is regarded to be a normal
aspect of human nature.
 Passing through ambivalence is a natural phase in the
process of change
 Getting stuck in ambivalence is a person’s problems persist
and intensify
◦ In order for change to occur, ambivalence must be
resolved.
 Brief interventions enable a person to make a decision
and move on toward change
 “Lack of motivation” can be thought of as unresolved
ambivalence
◦ Conflicts described as coming in 3 varieties:
1. Approach-approach conflict
2. Avoidance-avoidance conflict
3. Approach-avoidance conflict

Double approach-avoidance conflict
1. Approach-approach conflict
◦ Person must choose between
two similarly attractive
alternatives
◦
Important choice factors are all
positive
◦
E.g. Job offer
“Candy store problem”
2. Avoidance-avoidance conflict
◦
Person must choose between two (or more) possibilities,
each of which involves negative consequences
◦
Important choice factors are all negative
◦
“Caught between a rock and a hard place”
3. Approach-avoidance conflict
◦
Person is both attracted to and repelled by the same
object

“Yo-Yo Effect”
◦
This type of conflict has special potential for keeping
people “stuck”
◦
E.g. Fletcher Henderson song (“My sweet tooth says I
want to, but my wisdom tooth says no.”)
4. Double approach-avoidance conflict
 Person is torn between two alternatives, each of
which has both enticing positive and powerful
negative aspects
 E.g. Option A vs. Option B

Seesaw metaphor
◦ Two kinds of weights on each side
1. Perceived benefits
2. Perceived costs

Balance Sheet
◦ Used to specify what a person perceives to be a benefit
or cost associated with a behavior
◦ Comprises set of pros and cons for each option
◦ Oversimplification
 “Sometimes I stop myself, and other times I want to but I just
don’t care.”

Social and cultural values affect people’s perception of
their behavior, as well as their evaluation of its costs
and benefits.

A person’s motivational balance and ambivalence
cannot be understood outside the social context of
family, friends and community
◦ E.g. Stealing, using drugs, missing work, taking risks

Ambivalent people may not respond in a logical
manner
◦ Increasing negative consequences as a deterrent
 Does not always decrease attractiveness of behavior
 Painful consequences could strengthen and entrench a
behavior pattern
 E.g. The Fatal Shore

How does this type of response occur?
◦ Theory of psychological reactance
 Predicts an increase in the rate or attractiveness of a
“problem” behavior if a person believes his or her personal
freedom is being challenged.
◦ Change within social environment
 Losing social support that served to deter unhealthy
behavior could result in greater excess

Within the dynamics of ambivalence, paradoxical
responses are predictable aspects of human nature

People are not “unmotivated”; they are “poorly
motivated”
◦ People are always motivated towards something
◦ Conflict arises when two people are motivated toward
different goals
 E.g. Doctor and patient; counselor and client


Improper question: “Why isn’t this person motivated?”
Proper question: “For what is this person motivated?”
◦ What is highly valued by some will be of little importance
to others.

With specific regard to change, it is important to:


Discover and understand an individual’s motivations
Understand what a person expects to be the outcome of
different courses of action


Expectations can have a powerful effect on behavior.
E.g. Smokers and gamblers

Providing context for change:
◦ Focus on what the person does want, rather than
focusing on why the person does not want to make a
change
◦ Consider multiple ways to approach a desirable goal
 Motivation can vary, depending on the specific course of
action being considered

Core skills of MI
◦ Familiar skills that have a clear goal of health behavior
change
◦ A good guide will:
1. Ask where the person wants to go and get to know him or
her.
2. Inform the person about options and see what makes
sense to them.
3. Listen to and respect what the person wants to do and
offer help accordingly.

Conflicting motivations—to simultaneously want and
not want—are normal and common.
◦ “I need to lose some weight, but I hate exercising.”
◦ “I should quit smoking, but I can’t seem to do it.”
 A telltale sign of ambivalence is the but in the middle.
1.
2.
3.
Thinking of a reason to change.
Thinking of a reason not to change.
Stop thinking about it.

Patients will often go through a process of internal
deliberation, or a weighing of the pros and cons of a
behavior change.
◦ Pros (toward change)
◦ Cons (away from change)

When you take a directing style with an ambivalent
person, you are taking up one side of their own
ambivalence—the pro-change side.
◦ “Exercising and losing weight would decrease your risk of
a heart attack.”
◦ “I want you to stop smoking.”

Elicit “change talk” from your patients rather than
resistance.


When you hear change talk, you are doing it right.
When you find yourself arguing for change and the
patient defending status quo, you are off course.
◦ “Yes, I will.”
◦ “I wish I could.”
◦ “I’ll consider it.”
1. Ambivalence is a common human experience and a
stage in the normal process of change.
2. Getting stuck in ambivalence is common.
3. Once ambivalence has been resolved, little else may be
required for change to occur.
4. Attempts to force resolution in a particular direction
can lead to a paradoxical response.
5. It is important to elicit “change talk” from your patients
rather than resistance.