Ambivalence

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

2. OUTLINE • Review textbook • Quiz • Review handout • Video • Exercise

3. “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

4. “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

5. “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 ambivalenceis a natural phase in the process of change • Getting stuck in ambivalence is a person’s problems persist and intensify

6. “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

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

8. 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”

9. 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”

10. 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.”)

11. 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

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

13. 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.”

14. 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

15. 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

16. 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

17. 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

18. 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.

19. 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

20. 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

21. 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.

22. 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.

23. 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)

24. 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.

25. 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.”

26. 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.

27. QUIZ!