Enhancing Motivation for Change in Substance Use Disorder Treatment. (2019). Substance Abuse and Mental Health Services Administration, 35, 38-40.
Ambivalence
A key concept in MI is ambivalence. It is normal for people to feels two ways about making an important change in their lives. Frequently, client ambivalence is a roadblock to change, not a lack of knowledge or skills about how to change (Forman & Moyers, 2019). Individuals with SUDs are often aware of the risks associated with their substance use but continue to use substances anyway. They may need to stop using substances, but they continue to use. The tension between these feelings is ambivalence.
Ambivalence about changing substance use behaviors is natural. As clients move from Precontemplation to Contemplation, their feelings of conflict about change increase. This tension may help move people toward change, but often the tension of ambivalence leads people to avoid thinking about the problem. They may tell themselves things aren’t so bad (Miller & Rollnick, 2013). View ambivalence not as denial or resistance, but as a normal experience in the change process. If you interpret ambivalence as denial or resistance, you are likely to evoke discord between you and clients, which is counterproductive.
Sustain Talk and Change
Recognizing sustain talk and change talk in clients will help you better explore and address their ambivalence. Sustain talk consists of client statements that support not changing a health-risk behavior, like substance misuse. Change talk consists of client statements that favour change (Miller & Rollnick, 2013). Sustain talk and change talk are expressions of both sides of ambivalence about change. Over time, MI has evolved in its understanding of what keeps clients stuck in ambivalence about change and what supports clients to move in the direction of changing substance use behaviors. Client stuck in ambivalence will engage in a lot of sustain talk, whereas clients who are more ready to change will engage in more change talk with stronger statements supporting change. Greater frequency of client sustain talk in sessions is linked to poorer substance use treatment outcomes (Lindqvist, Forsberg, Enebrink, Andersson, & Rosendahl, 2017; Magill et al., 2014; Rodriguez, Walters, Houck, Ortiz, & Taxman, 2017). Conversely, MI-consistent counselor behavior focused on eliciting and reflecting change talk, more client change talk compared with sustain talk, and stronger commitment change talk are linked to better substance use outcomes.
Table 1. Examples of change talk and sustain talk
| Type of Statement | Examples of Change Talk | Examples of Sustain Talk |
|---|---|---|
| Desire | “I want to cut down on my drinking.” | “I love how cocaine makes me feel.” |
| Ability | “I could cut back to 1 drink with dinner on weekends.” | “I can manage my life just fine without giving up the drug.” |
| Reasons | “I’ll miss less time at work if I cut down.” | “Getting high helps, me feel energized.” |
| Need | “I have to cut down. My doctor told me that the amount I am drinking puts my health at risk.” | “I need to get high to keep me going every day.” |
| Commitment | “I promise to cut back this weekend.” | “I am going to keep snorting cocaine.” |
| Activation | “I am ready to do something about the drinking.” | “I am not ready to give up the cocaine.” |
| Taking steps | “I only had one drink with dinner on Saturday.” | “I am still snorting cocaine every day.” |
To make the best use of clients’ change talk and sustain talk that arise in sessions, remember to:
- Recognize client expressions of change talk but don’t worry about differentiating various kinds of change talk during a counselling session.
- Use reflective listening to reinforce and help clients elaborate on change talk.
- Use DARN-CAT in conversations with clients.
- Recognize sustain talk and use MI strategies to lessen the impact of sustain talk on clients’ readiness to change
- Be aware that both sides of ambivalence (change talk and sustain talk) will be present in your conversations with clients.
A New Look at Resistance
Understanding the role of resistance and how to respond to it can help you maintain good counselor-client rapport. Resistance in SUD treatment has historically been considered a problem cantered in the client. As MI has developed over the years, its understanding of resistance has changed. Instead of emphasizing resistance as a pathological defense mechanism, MI views resistance as a normal part of ambivalence and a client’s reaction to the counsellor’s approach in the moment (Miller & Rollnick, 2013). A client may express resistance in sustain talk that favours the “no change” side of ambivalence. The way you respond to sustain talk can contribute to the client becoming firmly planted in the status quo or help the client move toward contemplating change. For example, the client’s show of ambivalence about change and your arguments for change can create discord in your therapeutic relationship.
Client sustains talk is often evoked by discord in the counselling relationship (Miller & Rollnick, 2013). Resistance is a two-way street. If discord arises in conversation, change direction or listen more carefully. This is an opportunity to respond in a new, perhaps surprising, way and to take advantage of the situation without being confrontational. This new way of looking at resistance is consistent with the principles of person-cantered counselling.
Extra Reading
If you would like to know and look at resistance in a different perspective with the principles of person-centred counselling you may take a look at Chapter 3 in Enhancing Motivation for Change in Substance Use Disorder Treatment
