One element of the many skills developed as part of a coaching approach is the use of motivational interviewing (Miller and Rollnick 2012). 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 client 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 features 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 practice, ambivalence is often seen as a problem to be overcome in the client and this can lead very quickly to the health care provider engaging in an ultimately unhelpful tug of war - trying to “pull” the client towards a particular behavioural change, while the client “pulls” equally strongly, to argue for the value they see in not changing.
But ambivalence ought not be seen in this problematic way. Rather, it can be viewed as an opportunity to celebrate purpose and drive. Why? The person experiencing ambivalence is feeling driven towards two (or more) quite different outcomes. 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 client to be worked with – much better to have a desire for multiple possible outcomes, than no desire for any.
We all experience ambivalence, and we experience it frequently throughout life. If you’ve ever scanned a cafe menu and felt an urge for two different breakfast options, or experienced the pleasurable dilemma of being invited to two social events occurring simultaneously, or felt thrilled and terrified at the same time as your roller coaster car crests the top of the rise, you’ve had an experience of ambivalence.
How can coaches work effectively with ambivalence, to support client autonomy, and to create the conditions most favourable to health behaviour change in a client?
Firstly, employ the fundamental tools of engaging communication and connection – deep listening, reflection of what is being said and not 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” reflections (Moore, Tschannen-Moran, and Jackson 2016). An empathy reflection seeks to reflect the full experience of the person, not only their words:
Client: I really wanted to get to 30 minutes of continuous walking this week, but I just couldn’t.
Coach: You’re feeling disappointed that you didn’t reach the goal you set for yourself.
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):
Client: 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.
Coach: You’re keen to experience the benefits of more movement, and wary of unintended setbacks too.
Learn the signs that indicate ambivalence. It frequently shows up in consultations as a combination of “change talk” and “sustain talk” (Miller and Rollnick 2012) or as the client beginning to redirect or correct your efforts to influence their choice. Change talk embodies the client expressing desires, abilities, reasons or needs to make a change. Sustain talk, on the other hand, represents views expressed by the client which seek to justify or legitimise not changing. As a practise point, it's important to avoid what Miller and Rollnick 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 the client strongly occupies the “sustain talk” space. If this continues, the client will likely become irritated or agitated with the coach and feel unheard and misunderstood. In practice, the polarising interaction could look like this:
Coach: If you were to begin to gently increase the amount of exercise that you do, what do you think might be the benefits?
Client: Well… I'm not sure. Last time I tried that, the pain in my knees was unbearable.
Coach: 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.
Client: But I just couldn’t stand any more pain than I have already…
If you think you recognise ambivalence, then don’t just do something – sit there. Resist the urge, if present, to convince the client through force, facts or fear about the imperative of change. Instead, take time to listen and to understand the value that the client sees in continuing along their current path. This can be done by using the decisional balance tool (Miller and Rose 2015).
The decisional balance tool provides a means for dispassionately exploring the client’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 client” 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 client, that the Coach may be pushing for change. From here, move to inquiring of the client 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 client has walked systematically through all areas of their perceptions and concerns and if appropriate, the discussion can continue, focused on what the client might do to begin the process of change. A decisional balance process may look like this:
Coach: What are the benefits you see for yourself in not making any changes to your exercise and activity habits?
Client: Well for one thing I won’t get the pain – it’s a killer when that happens. I really can’t stand it.
Coach: Mm-hmm– what about the disadvantages you see in increasing the amount of exercise that you do?
Client: Apart from the pain, I guess I'd have to re-organise some things in my day to make time for it. And I'm really not sure if I'd be doing the right thing – it's a long time since I exercised. And I don’t know what’s going to be helpful and what may not be.
Coach: OK…you’re uncertain about the steps to take and whether they’re the right ones…tell me about the risks you see in not making any changes?
Client: All the things you and I have spoken about already – my mobility will continue to decline; the pain I get probably won't ever really go away completely. And in a few years’ time I may find that I’m even less able to do things I want to do. And as I say that now, I worry about that because I really want to travel after I retire.
Coach: Right – you need mobility for your vision for the future – so what are the benefits to you of making a change to your patterns of exercise?
Client: I do know that exercise will help – and I do really want to be able to move around more freely and without pain. My wife and I have been talking for years about walking the Camino de Santiago when we retire…
Lastly, remember the central role that autonomy plays in human behaviour. Autonomy is a primary psychological need of all sentient creatures (Deci and Ryan 1985; Deci and Ryan 2010). 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 also be particularly strong in those who have experienced some trauma. Nothing guarantees that any particular client will engage in behavioural change; however, the honouring of autonomy maximises the likelihood that the client will engage in a behaviour that has meaning and value to them and which they will be able to sustain in the long term.
So we should not be afraid of ambivalence – instead, quietly celebrate the energy and interest your client has in exploring and experiencing so many dimensions of life. By always honouring autonomy, and systematically reviewing all dimensions of a possible change, we can help build a solid foundation on which lasting change – driven by deeply held values – can be cultivated.
Resources:
Deci, Edward L, and Richard M Ryan. 2010. "Self‐determination." The Corsini encyclopedia of psychology:1-2.
Deci, EL, and RM Ryan. 1985. "Intrinsic motivation and self-determination in human behavior: Springer Science & Business Media."
Miller, William R, and Stephen Rollnick. 2012. Motivational interviewing: Helping people change: Guilford press.