My patient is ambivalent about change. What can I do?
The field of health coaching is growing rapidly worldwide1,2,3,4, including here in Australia. One element of the many skills developed as part of a coaching approach is the use of motivational interviewing5. MI first emerged as a means of supporting people to manage significant and enduring addictions; however, its efficacy generally in supporting behavioural change is well documented. It is a collaborative and conversational engagement with the patient that does not give primacy to expert knowledge. Rather, this knowledge is offered “just in time” and only when absolutely necessary to support behavioural change
One of the very useful elements of motivational interviewing is the conceptualization of ambivalence. Coming from two Latin words, ambivalence literally represents the idea of “both options having strength” to the person. In practise, ambivalence is often seen as a problem to be overcome in the patient and this can lead very quickly to the health care provider engaging in an ultimately unhelpful tug of war – trying to pull the patient towards a particular behavioural change, while the patient resists equally strongly, to argue for the value they see in not changing.
But ambivalence need not be seen this way. It is a very normal and common human experience. Anyone who has ever scanned a restaurant menu and felt an urge for two different main courses, or experienced the pleasurable dilemma of being invited to two social events occurring simultaneously has had an experience of ambivalence. If you’ve sat in a roller coaster car at the top of a big drop and wondered “Do I really want to do this?”, that’s ambivalence. If ambivalence can be conceptualised in this way, it ceases to be a “problem to be solved” and can be looked upon as an energy or impetus within the patient to be worked with – much better to have a desire for multiple possible outcomes, than no desire for any.
How can clinicians work effectively with ambivalence, to support patient autonomy, and to create the conditions most favourable to health behaviour change in a patient?
Firstly, employ the fundamental tools of powerful communication and connection – deep listening, reflection of what is being said, and open inquiry to understand more. While there are many types of reflection in interpersonal communication, two approaches that particularly support working with ambivalence are the “empathy” and “double-sided” reflections6. An empathy reflection seeks to reflect the emotion embedded in a person’s words:
Patient: I really wanted to get to 30 minutes of continuous walking this week, but I just couldn’t.
Physician: You’re feeling disappointed that you didn’t reach the goal you set for yourself.
In the above example, a common and less helpful response is to respond by saying “Oh well – there’s next week”, or to immediately problem solve with “So what could you do next week to make it happen?”
A double-sided reflection seeks to capture all aspects of a person’s feelings about change (not only those related to the benefits of change):
Patient: I know that moving more could help, but I’m just so afraid of ending up in the sort of pain I was in last year.
Physician: You’re keen to experience the benefits of more movement, and wary of unintended setbacks too..
The common response in the above example is to tune in only to the “desire for change” element and reflect that alone: “I’m really pleased that you recognise the benefits of movement here – that’s really going to be the way forward in managing your pain I think.”
Learn the signs that indicate ambivalence. It frequently shows up in clinical consultations as a combination of “change talk” and “sustain talk”5 or as the patient beginning to redirect or correct your efforts to influence their choice. Change talk embodies the patient expressing desires, abilities, reasons or needs to make a change. Sustain talk, on the other hand, represents views expressed by the patient which seek to justify or legitimise not changing.
Change talk: “I really need to stop smoking – or at least cut back drastically. I tried to run for the train yesterday and I just couldn’t.”
Sustain talk: “I’m not sure about stopping smoking – it helps me relax and my dad smoked until he died at 85 – it didn’t hurt him.”
Change/Sustain talk: “I’m really noticing some things I can’t do anymore – I just run out of breath. But I’m worried about how I’ll relax if I stop smoking”
As a practise point, it’s important to avoid what Miller and Rollnick5 refer to as “the righting reflex” – the tendency of the practitioner to respond to sustain talk with change talk. This leads to a polarising interaction in which the practitioner more and more strongly occupies the “change talk” space and be patient strongly occupies the “sustain talk” space. If this continues, the patient will likely become irritated or agitated with the clinician and feel unheard and misunderstood.
If you think you recognise ambivalence, then don’t just do something – sit there. Resist the urge, if present, to convince the patient through force, facts or fear about the imperative of change. Instead, take time to listen and to understand the value that the patient sees in continuing along their current path. This can be done by using the decisional balance tool7, described below. In practise, the polarising interaction could look like this:
Physician : If you were to begin to gently increase the amount of exercise that you do, what do you think might be the benefits?
Patient:: Well… I’m not sure. Last time I tried that, the pain in my knees was unbearable.”
Physician:: A short term increase in pain is to be expected here, but it’s important that you understand that your condition won’t improve if you don’t start moving more.
Such an interaction can lead quickly and unhelpfully to the patient arguing more and more strongly about their pain experience, and the physician holding ground about the importance of movement.
The decisional balance tool provides a means for dispassionately exploring the patient’s perceived benefits and disadvantages of modifying their behaviour, and also continuing as they are; however, it is best approached in a particular order, beginning with the perceived advantages of not changing. This “meets the patient” at the strongest point of their ambivalence. It also demonstrates a desire to understand the reasons for this and avoids the perception on the part of the patient, that the physician may be pushing for change. From here, move to inquiring of the patient the disadvantages they perceive in modifying or changing their behaviour. Once this has been explored and reflected, inquiry about the disadvantages of not changing may be explored and finally conclude with a discussion about the perceived advantages of modifying behaviour. When undertaken in this way, the patient has walked logically through all areas of their perceptions and concerns and if appropriate, the discussion can continue, focused on what the patient might do to begin the process of change.
Lastly, remember the central role that autonomy plays in human behaviour. Autonomy is a primary psychological need of all sentient creatures8,9. If you want to see it in action, observe your dog next time you try and encourage him or her to move away from a scent that’s exciting and interesting. The drive to preserve autonomy may be particularly strong in those who have experienced some trauma. Nothing guarantees that any particular patient will engage in behavioural change; however, the honouring of autonomy maximises the likelihood that the patient will engage in a behaviour that has meaning and value to them and which they will be able to sustain in the long term.
- Singh, Harjit K, Gerard A Kennedy, and Ieva Stupans. 2020. “Competencies and training of health professionals engaged in health coaching: A systematic review.” Chronic illness:1742395319899466.
- Dejonghe, Lea Anna Lisa, Kevin Rudolf, Jennifer Becker, Gerrit Stassen, Ingo Froboese, and Andrea Schaller. 2020. “Health coaching for promoting physical activity in low back pain patients: a secondary analysis on the usage and acceptance.” BMC Sports Science, Medicine and Rehabilitation 12 (1):2.
- Sforzo, Gary A, Miranda P Kaye, Sebastian Harenberg, Kyle Costello, Laura Cobus-Kuo, Erica Rauff, Joel S Edman, Elizabeth Frates, and Margaret Moore. 2020. “Compendium of health and wellness coaching: 2019 addendum.” American journal of lifestyle medicine 14 (2):155-168.
- Sforzo, Gary A, Miranda P Kaye, Irina Todorova, Sebastian Harenberg, Kyle Costello, Laura Cobus-Kuo, Aubrey Faber, Elizabeth Frates, and Margaret Moore. 2018. “Compendium of the health and wellness coaching literature.” American journal of lifestyle medicine 12 (6):436-447.
- Miller, William R, and Stephen Rollnick. 2012. Motivational interviewing: Helping people change: Guilford press.
- Moore, Margaret, Bob Tschannen-Moran, and Erika Jackson. 2016. Coaching psychology manual. 2nd ed: Wolters Kluwer Health/Lippincott, Williams & Wilkins Philadelphia, PA.
- Miller, William R, and Gary S Rose. 2015. “Motivational interviewing and decisional balance: contrasting responses to client ambivalence.” Behavioural and cognitive psychotherapy 43 (2):129-141.
- Deci, EL, and RM Ryan. 1985. “Intrinsic motivation and self-determination in human behavior: Springer Science & Business Media.”
- Deci, Edward L, and Richard M Ryan. 2010. “Self‐determination.” The Corsini encyclopedia of psychology:1-2.
This article has been written for the Australasian Society of Lifestyle Medicine (ASLM) by the documented original author. The views and opinions expressed in this article are solely those of the original author and do not necessarily represent the views and opinions of the ASLM or its Board.
