The Dilemma of Change MI pp 13-19 HC pp 33-35 Ambivalence The Dilemma of Change MI pp 13-19 HC pp 33-35

OUTLINE Review textbook Quiz Review handout Video Exercise

“I WANT TO, BUT I DON’T WANT TO” 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

“I WANT TO, BUT I DON’T WANT TO” 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

“I WANT TO, BUT I DON’T WANT TO” 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

“I WANT TO, BUT I DON’T WANT TO” 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

CONFLICT AND AMBIVALENCE Conflicts described as coming in 3 varieties: Approach-approach conflict Avoidance-avoidance conflict Approach-avoidance conflict Double approach-avoidance conflict

CONFLICT AND AMBIVALENCE 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”

CONFLICT AND AMBIVALENCE 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”

CONFLICT AND AMBIVALENCE 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.”)

CONFLICT AND AMBIVALENCE 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

DECISIONAL BALANCE Seesaw metaphor Two kinds of weights on each side Perceived benefits Perceived costs

DECISIONAL BALANCE 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 CONTEXT 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

PARADOXICAL RESPONSES 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

PARADOXICAL RESPONSES 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

PARADOXICAL RESPONSES 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

READINESS FOR WHAT? 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.

READINESS FOR WHAT? 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

READINESS FOR WHAT? 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

PRACTICING MOTIVATIONAL INTERVIEWING Core skills of MI Familiar skills that have a clear goal of health behavior change A good guide will: Ask where the person wants to go and get to know him or her. Inform the person about options and see what makes sense to them. Listen to and respect what the person wants to do and offer help accordingly.

PRACTICING MOTIVATIONAL INTERVIEWING 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. Thinking of a reason to change. Thinking of a reason not to change. Stop thinking about it.

PRACTICING MOTIVATIONAL INTERVIEWING 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)

PRACTICING MOTIVATIONAL INTERVIEWING 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.

LISTENING FOR CHANGE TALK 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.”

SUMMARY Ambivalence is a common human experience and a stage in the normal process of change. Getting stuck in ambivalence is common. Once ambivalence has been resolved, little else may be required for change to occur. Attempts to force resolution in a particular direction can lead to a paradoxical response. It is important to elicit “change talk” from your patients rather than resistance.

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