DBT's Motivational Approach

When we think about ambivalence and motivation, the first approach most of us think of is probably motivational interviewing. However, DBT also includes interventions designed to enhance motivation, and while there are some clear similarities to MI, there are also some differences.

In particular, DBT addresses motivation by targeting a related but distinct concept: commitment. In fact making a commitment or agreement to do something is a strong predictor of actual future behavior. Therefore, DBT sees eliciting and maintaining commitment as a key therapeutic task. Therapists elicit commitment from clients to participate in therapy, to target particular problems, and implement particular solutions. And it is often not enough to make a commitment once. With longer term choices (e.g., staying in therapy, making ongoing changes), commitments may need to be made and remade many times.

According to Linehan, "the therapist is often functioning like a good salfesperson. The product being sold is DBT, new behavior, a renewed effort to change, or sometimes life itself" (p. 286). As a result of this perspective, DBT borrows from social psychology's insights on compliance - the same insights used in sales. Most notably in this category is the "foot-in-the-door/door-in-the-face" technique. These terms refer to door-to-door sales or charity drives. The foot-in-the-door approach begins by making an initial easy request, followed by a more difficult request, based on findings that those who agree to one thing are more likely to agree to subsequent things. The door-in-the-face approach begins by asking for something much larger than what the asker really hopes to get, and then "settling for" something lesser (what the asker was hoping for to begin with). The idea is that people who say no to one thing feel more social obligation to say yes to the next request if it is reasonable.

While these techniques may seem "manipulative," they are based on a cultural reality, which is that most of us expect to do some negotiating in our social interactions. When we try to go directly for the commitment we are hoping for, the end result is often NOT an agreement from the client (it might be a flat-out refusal, agreement without follow-through, or negotiation to a lesser commitment). Linehan suggests that the "door" techniques can be used instead, to more effectively elicit agreement.

These techniques can be used separately, or combined. When combining them, either can be used first. In other words, a therapist might start with a very difficult request, followed by a fairly easy request, and finally progress to a moderately challenging request. Alternatively, the therapist might begin with an easy request, move to a very difficult request, and settle somewhere in the middle. An example of a combined approach would be first asking a client not to engage in a problem behavior at all in the coming week, then eliciting a commitment instead to not use the behavior on at least one day that week, and finally asking the client to use the behavior on no more than 4 of the 7 days.

A variation of the foot-in-the-door approach is to connect new commitments with prior commitments. This approach is particularly useful when the client seems to be losing commitment, or when current behavior is inconsistent with past commitments. Of course, in doing this, it's important to assess whether the client still feels committted to the prior agreement; clarifying, renegotiating, and renewing commitment may be needed.

Social psychology has also demonstrated that people are more likely to make commitments when they believe they have freedom of choice, and/or when they believe there are no other options consistent with their goals. These two conditions can also be combined, so that the therapist is simultaneously highlighting the client's freedom to choose, and the lack of viable alternatives. How is that possible? There may not be an alternative that would allow the client to reach the goals s/he has, but s/he is free to choose different goals if unwilling to do what is needed. However, the client's choice of goals has natural consequences, which the therapist also highlights.

Of course, DBT also uses other strategies to elicit commitment. Like MI, DBT therapists help clients evaluate the pros and cons of a particular commitment or change, particularly highlighting the advantages of the commitment, while developing counterarguments for any identified reservations about it. Also like MI, DBT therapists may "play the devil's advocate," arguing against the commitment in order to move the client to the opposite side of the ambivalence (the side in favor of change).

Have you ever used these, or similar, techniques to "sell" a client on change? Was it helpful/effective? Why or why not?

A Psychodynamic Slant on Motivation for Change

When we think about a client's motivation, probably the most common lenses we use are stages of change and motivational interviewing. We think about ambivalence, and how to shift the balance of pros and cons. We think about resistance, and the overall function of the behavior in the person's life. But we may not always think about identity.

However, the role of identity deserves consideration here, as psychodynamic theorists well know. Specifically, motivation to change seems to be closely tied to whether the behavior in question is ego syntonic or ego dystonic. Something that is ego syntonic is seen as an acceptable part of the ego (i.e., one's self-image, or identity), while something that is ego dystonic is seen as unacceptable to or in conflict with one's self-image.

These terms were developed by Freud, in reference to repressed material and ego defenses, but I learned them in the context of diagnosis. Specifically, I was taught that many of the personality disorders are ego-syntonic (which makes sense if they are based on personality structure), and some Axis I disorders can also be experienced as ego-syntonic, including dysthymia and anorexia nervosa. Various forms of addiction may initially be experienced as a choice, and therefore ego-syntonic, and not become ego-dystonic until well after physiological dependence has locked someone into continuing the behavior. In contrast, the majority of Axis I disorders are ego-dystonic; in other words, they are experienced as being at odds with one's identity, almost like a foreign incursion into the self. As a result, people are generally more motivated for treatment and change.

It makes sense, right? If something feels authentic to your self, you don't feel the need or desire to change it - you don't see it as a "problem," but a reality or state of being. However, if it feels like it's interfering with your true self, it's natural to want or need a solution to the problem. (Note, however, that wanting change to happen does not necessarily translate into feeling like one can or should do anything to bring about change - for example, people who are depressed universally want to feel betterm, but often feel unable to make the behavioral changes providers recommend).

Nevertheless, people enter treatment at all levels of motivation (sometimes because they want change, and other times as a result of external pressure to change) - that means that we are likely to encounter, from time to time, clients who experience the "presenting problem" as ego-syntonic. What can we do to raise these clients' awareness of the dissonance between the problem and their selves?

Two possible interventions spring to mind:
1) Externalizing conversations, a la Narrative Therapy - this therapeutic approach frames the problem as something separate from and external to the client, often by objectifying or personifying it. Then, by beginning to see it as something external, clients are helped to recognize the discrepancies between their own feelings, beliefs, goals, and values, and those the problem seems to be pursuing. For example, my clients with eating disorders can come to recognize that while they're trying to achieve perfection, their eating disorder is trying to kill them. These two goals are mutually exclusive; therefore the eating disorder begins to feel ego-dystonic.

2) Values-based action, a la ACT - while this approach does not intentionally externalize the problem, it does seek to elucidate clients' most deeply held values and goals, and encourages clients to identify and pursue goal-directed behavior that is in line with their values, irrespective of "inner experiences" (symptoms, feelings, thoughts, sensations, urges or memories). This in achieved, in part, through mindfulness and acceptance skills.

Are there other approaches you use or think might be effective with clients who experience their presenting problem as ego-syntonic?

Change Talk

One of the principles of Motivational Interviewing (MI) is that people are more likely to change if they hear themselves arguing in favor of change. However, most people considering change have some degree of ambivalence - arguments both in favor and against change. When someone around them voices only one side of the ambivalence, they are likely to voice the other. All too often, other people who are concerned about someone argue in favor of change, which causes them to voice the other (anti-change) side of the ambivalence. Hearing themselves argue against change then makes change less likely.

Since the goal of therapy is generally to facilitate change, it's important for therapists to avoid that trap, and instead find ways to get clients to voice the pro-change side of their ambivalence. MI includes the follow techniques designed to facilitate this process, which it refers to as "eliciting change talk."

1) Evocative Questions

Assume that the client is ambivalent, and therefore has some concerns suggesting change may be necessary. Ask open-ended questions designed to evoke these concerns. Specifically, ask about the disadvantages of the status quo ("What worries you about this problem? How has this problem gotten in your way?"), advantages of change ("How might things be better if you made a change? What would you like to be different about your situation?"), optimism about change ("What do you think would make it possible for you to change? What supports and abilities do you have that you could draw on? How have you made changes successfully in the past?") and intention to change ("What would you be willing to try? What do you think you might do next?"). Then, when the client offers change talk in response, reflect it back to them (so that they hear themselves saying it again), and reinforce it, while not reflecting or reinforcing aspects of their response that are not change talk.

2) The Importance Ruler

Ask the client to rate how important it would be for them to change, on a scale of 0 - 10 (where 0 = not at all important, and 10 = absolutely crucial). Then ask why they chose that number, rather than 0. (Note that asking the reverse question, why they chose that number rather than 10, elicits arguments against change, and is therefore counterproductive). You might also ask what it would take for them to move from the number they chose to a slightly higher number (e.g., from 3 to 6 or 7).

4) The Decisional Balance

Ask clients what the advantages of the problem are. Sometimes asking about the advantages will lead people automatically to the other side. If not, follow up by asking about its disadvantages. You might also ask about the disadvantages of change, followed by the advantages (note the reverse order - the idea is to end with change talk rather than arguments against change)

5) Elaborate

When a client identifies a reason for change, don't just rush on to find other reasons. Asking the client to elaborate, or provide supporting information for the reason they've identified, reinforces the motivation, and can also elicit more change talk. Ask for clarification, specific examples, descriptions. Make sure that the topic has been completely tapped before moving on.

6) Querying Extremes

If nothing comes of other techniques, try asking about extremes: the most extreme concern the client or others in their life have about the problem ("What concerns you most about this problem in the long run?"), the most extreme possible consequences ("What would be the worst thing that might happen if the problem continues?"), or the best possible outcome of change ("If you changed, what would be the best thing that might happen?").

7) Looking Back

Clients may be able to remember life before the problem began. Ask them to compare these memories with the present situation. This strategy can help develop the discrepancy between the problem, and how life can be without the problem. It may also increase optimism that life can actually improve.

8) Looking forward

Ask the client to describe how they imagine life would be if they were able to successfully change, and what it would be like if they did not make a change.

9) Exploring Goals and Values

Ask about what is most important in the client's life. Exploring what is really important helps develop the discrepancy between the problem and their real goals and values.

To learn more about these techniques, see Motivational Interviewing: Preparing People for Change. Have you tried any of them? How have they worked or not worked with your clients?

The Pink Cloud

In AA and NA, people talk about the "pink cloud" - that period of time in early recovery when everything feels and seems good. The physical withdrawal has passed, so people begin to feel healthier, and more clear headed. They're not having many cravings, and become confident in their recovery. The losses that may have motivated them to recover have started to turn around - they can see positive changes in their relationships, life circumstances, and perhaps even opportunities. Recovery seems like a cake walk, especially when compared with the throes of a serious addiction. People may conclude that they have beaten the addiction, and become overconfident in their recoveries.

Unfortunately, the pink cloud invariably bursts. Life stops improving at the same rate it had been, or may even seem to be getting worse. The reality of the recovery process, with all of its related difficulties and discomforts, comes crashing down on the person. He or she realizes that life is still hard, and that recovery is a long-term commitment. People feel discouraged, and sometimes even resentful. Cravings increase, and the risk of relapse is high.

Although the idea of the pink cloud comes from substance abuse recovery, which is a unique physiological process, I think that the phenomenon is also psychological, and applies to recovery from a wide range of problematic behaviors. It is therefore something worth thinking about, whatever type of change we're helping clients to make.

Specifically, I think the pink cloud relates back to costs and benefits - of both recovery, and the problem behavior (i.e., the good ol' decisional balance). People usually become committed to recovery when the costs of the behavior, and benefits of recovery, outweigh the benefits of the behavior and costs of recovery. When they first change the behavior, this balance shifts. They experience relief from the costs of the behavior, along with the benefits of recovery (improvement in how they feel, relationships with others, and functioning in various life domains). Recovery seems clearly better and easier than continuing with the problem behavior.

However, after some time in recovery, the balance shifts again. Life doesn't continue to improve at the same rate it did initially, and the difficulty of change becomes more evident. The costs of change, in what the person has to give up to achieve it, as well as the discomfort of the process, are at the forefront. At the same time, the costs of the problem behavior feel more remote, and the person may begin to miss whatever benefits they derived from the behavior, leading to more urges to return to it. The pink cloud is gone.

The good news is that, if people can persist in their change efforts, they ultimately move into a balanced and stable part of the process. They don't return to the illusion that recovery is easy, but they regain their confidence and commitment, recognizing that recovery really is better than the alternative. This shift is a natural result of the costs of change lessening, and the benefits of change increasing.

Knowing that the pink cloud is a common part of the change process, which can - but doesn't have to - lead to relapse, what can we do to help our clients ride out the "storm?"

1) Educate them about the pink cloud and its aftermath, so that they know what to expect and can be prepared for the "crash."

2) Encourage them to persist in change efforts: highlight the benefits of change, and costs of the problem behavior, while assuring them that their current discomfort won't last forever.

3) When they first make a decision to change, consider asking them to write a letter to their future selves about what motivated them to make that decision. Then, have them read this letter when their motivation lessens, or they begin to glorify the "good old days" of the problem behavior.

4) Normalize slips as an expected part of recovery, and encourage clients to resume change efforts ASAP rather than letting a slip become a full relapse.

5) Keep track of the positive changes that have resulted from behavior change, and call attention to them when people begin to get discouraged.

6) ...what other strategies might you use?

Cold Feet

Last month, I wrote about the stages of change, and how they influence who comes to treatment - and who drops out. It seems to hinge on the degree of ambivalence. When the advantages of changing, and the disadvantages of not changing outweigh the disadvantages of changing and the advantages of not changing, people are motivated to enter/continue treatment. When the opposite is true, people are less likely to begin, and more likely to drop out of treatment.

I initially thought people in the action and maintenance stages were unlikely to drop out of treatment, and more likely to have planned terminations when they felt able to maintain changes on their own. However, I overlooked another possibility: ambivalence may resurface during the preparation, action, or even maintenance stages if there is a shift in the balance of advantages and disadvantages. This kind of shift seems not only possible, but very likely, and therefore important to consider as we help clients through the change process.

Why would the balance of advantages and disadvantages shift? Well, when people initially wrestle with ambivalence during the contemplation stage, and reach sufficient resolution in favor of change to move them into the preparation and action stages, the process and impact of change are hypothetical. People tend to imagine the ideal end result of the change process, but may not consider (1) the possibility that change may have other, less-ideal effects, or (2) what the process of change might be like before they reach the desired end state.

When the problem has been going on for any length of time, it can be very hard to imagine anything different. The experience of change is even harder to conceptualize without having been through it. As a result, clients often experience difficulties they didn't expect. After all, change is an uncomfortable, and sometimes messy business. The difficulty of the change process may cause clients to reevaluate the pros and cons of change...with some new additions to the cons column. And, since the desired outcomes tend to be more long-term than short-term, people may discount some of the pros because they're not experiencing those benefits right now. At the same time, making changes can paradoxically highlight the ways a problem may have felt helpful or necessary, further decreasing motivation for change. The result is an attack of "cold feet" that can sometimes lead clients to drop out of treatment.

It seems logical that, if people aren't experiencing the benefits they hoped for, but are experiencing more discomfort than expected, and are reminded of the ways a problem may have served them, they may decide they don't want to change after all. A key clinical intervention is to help clients ride out this shift in the balance of pros and cons in a way that keeps them motivated for change. We can do that by helping clients remember the negative aspects of the problem that prompted their desire for change, assuring them that the discomfort of the change process is time-limited, and helping clients recognize incremental progress toward their end goals. (However, we also have to be careful to avoid arguing too strongly in favor of change, lest the client respond by arguing against change all-the-more strongly - see this post on resistance. The trick is to get the client to state the argument for change). If we consistently monitor motivational issues that might arise, and intervene in this way, hopefully we can warm up any "cold feet" and maintain our clients' momentum toward their ultimate goals.

Medical Necessity, Revisited

Several months ago, I wrote about the intricacies of "medical necessity" - the criteria insurance companies use to determine whether to pay for treatment. Most basically, treatment is deemed "medically necessary" if:
1) there is a diagnosable (i.e., DSM or ICD classified) mental disorder, with evidence of specific symptoms supporting the diagnosis.
2) the mental disorder causes significant impairment in functioning, in areas such as social, occupational, educational, self-care, and judgment
3) the proposed treatment is consistent with accepted standards based on disorder and level of impairment

Ideally, it boils down to this: the client has a mental health problem that is getting in the way of functioning; treatment is offered that is appropriate for the client and problem; treatment follows a plan and results in improvement. The treatment continues to be deemed medically necessary as long as there is some improvement in response to treatment, but symptoms and impairments continue.

Unfortunately, even this isn't always enough for insurance companies. I have been dismayed to have several conversations with insurance reviewers lately in which they were reluctant or unwilling to cover "medically necessary" treatment (i.e., diagnosis, impairment, clinically appropriate intervention, improvement in response to intervention, and continued impairment) - just because the client was ambivalent about recovery.

I've also written in the past about ambivalence...and so have people far wiser than I. An extensive body of literature has been developed around the centrality of ambivalence in all kinds of behavior change. Much of this literature hinges upon the Stages of Change model, which suggests that people go through five stages during the change process (though not necessarily in a linear fashion, and often several times before lasting change occurs):

1) Precontemplation - the person is not aware of, or at least not acknowledging, the existence of a problem or need for change 

2) Contemplation - the person is aware of the problem, but is torn between staying the same and changing (i.e., ambivalent) 

3) Preparation - the person has decided to make changes and is getting ready to act 

4) Action - the person is actually working on change 

5) Maintenance - the person is working on maintaining changes

Relapse - a return to an earlier stage (e.g., a resurgence of ambivalence) and/or reverting to pre-change behavior - can happen at any point, and the process of change resumes. The ultimate goal is to transcend the maintenance stage - to get to the point where the person no longer has to work on maintaining the change because it has become ingrained. Motivational Interviewing is largely designed to help people work through their ambivalence and progress through the stages of change.

The bottom line of all this is that ambivalence is absolutely normal and to be expected in the course of changing longstanding behaviors. Good treatment - treatment that adheres to acceptable standards in the mental health professions - works with this ambivalence and helps people to resolve it in a way that affirms life. I consider this early part of treatment absolutely necessary, because actual changes can't happen (or at least can't last) until ambivalence is addressed.

I find it deeply disturbing that insurance companies do not want to pay for treatment when the client is ambivalent. I find it even more disturbing when we consider that many behaviors that are a focus of treatment can cost people their lives - drugs, alcohol, eating disorders, self-injury.... If my client has a life-threatening problem and is on the fence about changing, I see treatment as beyond medically necessary - treatment is often the thing that tips the balance in favor of change, and therefore moves the client toward life-preserving change.

If an insurance company sends my client away until they're "ready" and 100% committed to change, what will the cost be? What will the literal cost be to the insurance company when that client keeps needing a higher level of care, and more importantly, what will the cost be to the client in lost relationships, opportunities, or even life itself?

I think it's time to redefine what we as a society consider medically necessary.

What's My Motivation?

Before launching into a new role, the stereotypical actor will ask the director: "What's my motivation" - meaning, what is driving this character? what is the character thinking and feeling in this scene?

Therapists ask a similar question when they meet a new client - what is this client's motivation? We need to know what's getting someone in the door in order to figure out how to "meet them where they are," and harness their existing motivation to help them move toward personally meaningful goals. 

Social psychologists talk about "intrinsic" and "extrinsic" motivation. Intrinsic motivation comes from within, fueled by personal desire, interest and appreciation of the task for its own sake. Extrinsic motivation comes from external outcomes - engaging in a task to obtain a rewarding outcome, or avoid a negative consequence. So, for example, some children choose to read or draw during free time because they enjoy these activities (intrinsic motivation). However, if they are rewarded for doing these activities (extrinsic motivation), the intrinsic desire to engage in the activity decreases.

The clinical parallel to intrinsic motivation might be the desire for growth or self-actualization. When this desire is strong, some theorists (e.g., Adler and Maslow) have contended that self-actualization will happen naturally once more basic needs are met and barriers are removed. We might infer that adding some sort of extrinsic motivation when a client is already intrinsically motivated might inadvertently reduce the drive toward self-actualization - something I, for one, would not want to do. 

The truth is, however, that most of my clients come in with some form of extrinsic motivation. Sometimes there is a reward on the horizon for positive change (more independence, the ability to progress toward personal and vocational goals, functioning more effectively in personally significant roles...). More often, the motivation is stopping or avoiding a negative consequence of not changing. Most simply, the client is often suffering and wants the suffering to stop (be that depression, anxiety, dope-sickness...whatever). There may also be the threat of losing things that are important to the client - a relationship, a job, custody, financial support, housing...for some problems, even fear of losing their lives. 

The answer to "what's this client's motivation" is rarely either/or - more often it's both/and: the desire to change coming in part from hope for a better life, and the expectation of positive results, and the wish for suffering to lessen, and the fear of what might happen in the problem continues or gets worse. By learning what the specific combination of factors is for each individual client, I can help them harness and build on their existing motivation to get and keep them engaged in the treatment process. 

How do you think about motivation? How do you work to build motivation?

Motivation or Manipulation?

As much as our profession values self-determination (i.e., everyone having the power and freedom to make their own choices in life), we're also put in the position of trying to prevent or minimize damage (to our clients or others) from destructive choices. It's an ethical dilemma.

We try to rationalize our way out of the dilemma by saying that we defer to clients' self-determination only in very specific circumstances: when it's life-or-death (suicide, homicide, or complete inability to care for self), or when a vulnerable population may be harmed (children, the elderly, persons with disabilities - including individuals whose psychosis is interfering with safety).

There seems to be no end of debate about the moral and legal nuances involved here, but that's not what I want to focus on. What I'm thinking about today is the way I intervene differently according to the risk involved.

Motivational Interviewing (MI) is considered best practice for substance abuse, as well as other "problem behaviors." Essentially, it assumes that people often enter treatment with some ambivalence - that part of them sees the behavior as a problem and wants to change it, while another part is comfortable with the behavior and doesn't want to change it. MI tries to strengthen the first part of the ambivalence, for example by "developing discrepancy" (i.e., highlighting the divergence between the behavior and the client's values and goals), and selectively reflecting "change talk" (i.e., highlighting things clients say from the first part of the ambivalence, while purposefully not reflecting back things that come from the second part of the ambivalence).

Part of the justification for this approach, from the perspective of self-determination, is that the clinician is following the client's lead by encouraging movement toward a change that the client has said s/he wants (at least partially), drawing on the client's self-identified motivators (e.g., goals and values). For this reason, I like MI as an approach...when there's time to do it without the problem becoming lethal.

On the other hand, I have a high-risk client who is teetering on the edge of suicidality. He isn't actively suicidal...at least, not today. As a result, he doesn't meet hospital level of care. However, he's holding onto the idea of suicide as a back-up plan, just in case things get worse, or don't get better. He's also severely depressed, and therefore not particularly verbal. He's not spontaneously coming up with any "change talk," and only occasionally reveals motivations in either direction. (I assume ambivalence because he is still alive, in spite of persistent SI).

I could wait and see - wait for change talk to come - but that feels too risky for me. I'm trying to develop some discrepancy - something that matters to him that's incongruent with suicide. The only thing, so far, is concern about his suicide damaging his children.

In trying to build some commitment to life, I admit I stooped to what felt like manipulation - elaborating on how his suicide might harm the kids (the only motivator he's identified), asking about what he'd be sad to miss (alas, even walking his daughter down the aisle at her wedding is not a good reason to live, in his mind), and even trying to cast doubt on his idealized image of going to heaven (shamelessly capitalizing on the Catholic belief that people can't go to heaven if they commit suicide, in spite of my personal belief to the contrary).

Yes, definitely seeming more like manipulation than motivation. Yet, that's what it took for me to feel like I'd done everything I could to keep him alive for another week. There are no guarantees, of course, but I'm cautiously optimistic because what he got out of all that was the (baffling, to him) sense that I care what happens to him, even after death. Maybe knowing that will be enough.

Resistance is Relational

"Resistance" is a common issue in psychotherapy - that moment when a client metaphorically digs in his or her heels, refusing either the direction of treatment, or change more generally. It can be confusing and exasperating for therapists. Haven't we all said at one point or another: "Why is this client even coming to therapy if s/he's not going to do anything?"

In the past, resistance was understood to be a problem with the client - a function of the client's unconscious defenses, and/or "secondary gains." More recently, however, the field has started to understand resistance a bit differently. Motivational Interviewing is an approach largely based on such a reinterpretation of resistance. Its creators, Miller and Rollnick (2002) define resistance as something that occurs in the relationship between therapist and client when there is a mismatch between the therapist's approach and the client's readiness for change.

Motivational Interviewing assumes that change is difficult, and that ambivalence (feeling torn) is a normal part of the process. Resistance becomes an issue when the therapist doesn't adequately address this ambivalence, and instead jumps ahead to change. It often looks something like this:

• Client: "I'm not going to the party - I just feel like staying home." (expressing intention not to change)
• Therapist: "That's the depression talking. You'll start feeling better if you get out and socialize more." (assuming the expert role)
• Client: "I don't feel better when I'm trying to be social - I feel worse because it's more obvious what a loser I am!" (arguing the disadvantages of change)
• Therapist: "Maybe you'll find out that other people have similar worries - that you're not the only one" (arguing advantages of change)
• Client: "Whatever." (shutting down)

As this dialogue shows, therapists often respond to client statements against change by arguing more strongly in favor of change. Consequently, the client then feels compelled to argue the anti-change side of the ambivalence just as strongly - in the process, convincing him/herself not to change.

We can conclude from this phenomenon that directly confronting resistance only serves to strengthen the resistance. Instead, Motivational Interviewing suggests "rolling with resistance" - reframing or shifting it to create momentum toward change (think judo). In rolling with resistance, the therapist avoids arguing in favor of change or trying to impose new ideas on the client. Instead, the client is invited to consider new perspectives, but is given responsibility for generating answers or solutions to their problems (based on the assumption that he or she is knowledgeable about the problem and what may help).

Resistance, when it occurs, is a signal to the therapist that he or she needs to change tack and respond differently. It may be that the therapist's response doesn't match the client's stage of change (the right intervention at the wrong time), or that the therapist is responding in ways that tend to trigger resistance (the wrong intervention). Responses that invite resistance include: directly arguing in favor of change, taking on an "expert" or paternalistic role, acting rushed, and criticizing, shaming, blaming, or labeling the client.

So if those are the responses to avoid, what are effective responses to resistance? The general principle is to respond to resistance with nonresistance. Below are examples of responses to the client statement about ("I'm not going to the party - I just feel like staying home"):

• Direct reflection of the client's statement   "You feel more comfortable staying home"
• Amplified reflection of the client's statement (slightly exaggerate the client's stated thought/feeling, which can cause them to back off a bit, perhaps expressing the other side of the ambivalence - i.e., the pro-change side)     "You just feel like staying home. In fact, why leave the house at all?"
• Double-sided reflection (acknowledging the anti-change side of ambivalence the client has just expressed, and adding to it the pro-change side of ambivalence based on things the client has said at other times - i.e., not just your own opinion or agenda)    "You'd prefer to just stay home, but you also feel lonely at home sometimes, and have wanted to make friends."
• Shifting focus away from whatever seems to be the barrier    "You don't have to go to the party; maybe you'd rather just hang out with one or two people."
• Reframing (acknowledging the validity of the facts behind the client's statement, but offering an alternate interpretation)   "Depression makes the idea of going to a party feel daunting, but once you're there you know you'll feel better."
• Agreeing...with a twist (reflection, followed by reframing)   "You really feel like staying home - but sometimes you can push through that feeling."
• Emphasizing personal choice and control     "It's up to you whether to go to the party."
• Coming alongside (the therapist makes an anti-change statement, which may cause the client to argue the alternate - pro-change - side of the ambivalence)    "You're right. If you feel like staying home, you shouldn't go."

How do you "roll with resistance?" When do you find it hardest to do so?

For a fuller discussion, see Miller and Rollnick (2002) Motivational Interviewing, Second Edition: Preparing People for Change