La agrupación de varias personas que realizan una misma actividad o actividades complementarias permiten a éstas obtener un conjunto de ventajas

As Miller and Rollnick observed, ambivalence about change is completely normal and is a part of the process of change. Patients can feel torn between what they consider to be two distasteful options. If we reflect on the term ambivalence, we may be reminded of the cliché “stuck between a rock and a hard place.” In fact, however, ambivalence is more emotionally intense than that implied by this cliché.

The cliché relates to the perceived need to make a decision when neither option is desirable. Ambivalence, however, is generated by frustration over confrontation with having to choose between one option that is gratifying and at the same time clearly unhealthy, possibly life threatening, and another one that is very difficult to initiate and yet would reduce or eradicate the threat to one’s well-being. The “bad” or unhealthy alternative is attractive because it is a behavior that has become ingrained in one’s lifestyle as the primary manner of experiencing pleasure or coping with stress. Sustaining an unhealthy behavior also allows the comfort of sameness rather than the anxiety of doing something new with the accompanying worry about the unknown or the possibility of failure. It also allows for continued control over one’s own life, rather than responding to or giving into the demands of others. The “better”

or healthier alternative is also made up of multiple facets, including better physi-cal health, progress toward achieving an ideal self-image, secure finances, enhanced relationships, and all around improved functioning. However, patients often have little actual experience with the positive aspects of changing their behavior and with success in making change, or it may have been a long time since they experienced a healthy lifestyle. Therefore, implementing a behavior change is difficult because the status quo is so attractive.

The behavioral result of this intense intrapsychic conflict is “sustain talk” (Fig. 6.1), arguments for the status quo; and “change talk,” arguments for the need to behave in a different way. The emotional intensity of ambivalence is manifested in the fact that these two types of “talk” will often occur in the same conversation (or even the same sentence). People can talk themselves out of change as easily as they can talk them-selves into it. Taking a person-centered empathic approach demands that we recog-nize both sides of the ambivalence. However, inherent in motivational interviewing (MI) is the expectation of facilitating movement toward the resolution of ambivalence, beyond the realms of thinking and talking about change and in the direction of acting to adopt healthier behaviors.

Motivational Interviewing68

To engage patients in this process:

1. Don’t overreact to sustain talk by looking for it or fishing for it. When patients tell you they don’t want to change, it is not important to ask or explore why this is so. In fact, it is likely that most patients have already talked about why they are attracted to the status quo. Find an element in patients’ statements that allows you to move the discussion toward change talk:

Patient: My wife tells me that I have to start paying attention to my cholesterol and triglycerides, but I really don’t know what I will eat. I mean, I grew up eating eggs, hamburgers, and pizza five or six times a week, doc. I don’t know anything else.

Besides, can’t I just take one of those “statin” drugs to lower them?

Trainee: You developed your eating habits in childhood and it is hard to even think about changing what you eat. While you were describing what you eat just now, you are sharing that you think you must give up all the foods you like.

Patient: Well, won’t I? Everything I see on TV or read online talks about how the American diet is loaded with all the bad stuff, you know, the stuff that clogs our arteries and raises our blood pressure.

Trainee: Actually, you’ll find that you can make excellent progress improving the health of your heart when you consider making small changes in your eating hab-its along with other parts of your lifestyle. For example, you probably know that getting regular physical activity helps and, yes, medications can help, too. The idea is to put together a routine that is made up of small changes in whatever areas you feel ready to make and that are really not that hard to live with. What specific changes in your activity level, diet, or medications could you imagine would work successfully for you?

2. Resist the righting reflex. Responding to patients’ dilemmas or distress with the righting reflex generally involves two elements. The first element is the desire to help.

It is almost an instinct to try to correct patients’ statements that their behaviors are not damaging. Here are examples of the righting reflex and what not to say:

Patient: Smoking relaxes me!

Trainee: But it’s terrible for your health!

Patient: I don’t think my drinking affects me that much.

S

FIGURE 6.1 Resistance and discord.

69Ambivalence and Discord Trainee: Of course it does. You’ve been arrested for drunk driving, and you said you’ve

gone to work hung over at least several days a week for the past month.

Patient: I feel fine. Why should I take my diabetes medications?

Trainee: Because you don’t want to end up blind and with an amputated leg.

These types of trainee responses are generally counterproductive because they gener-ate anxiety, frustration, or anger in patients. When patients are confronted with an unwanted reality in this manner, it causes discord in your relationship with them.

These types of responses are not collaborative, empathic, compassionate, or support-ive. In fact, they come across as condescending, pushy, and rude. Resistance in these interactions generally takes the form of “denial.” Counter to traditional counseling lore that highlights the use of stark confrontation to “break through denial,” the ironic truth is that such confrontation actually causes or increases denial. The result of this process is to put patients in the position of arguing for the status quo, which precludes any discussion of change. Conversely, the practice of MI assumes that the patient will be making the arguments for change, and the role of the trainee is to skillfully cultivate these arguments from patients.

The second element of the righting reflex is for medical trainees to suggest poten-tial answers to problems or to give advice about how to stop engaging in unhealthy behaviors. Without exploring patients’ perspectives and past experiences, we can-not even know what behaviors the patients are willing to change, and whether they want to try any suggestions we have to offer. Furthermore, it is quite possible that patients have already tried those suggestions without success. Rather than making suggestions, it is best to ask patients to tell you about the history of their behavior in response to the problem, as they define it. In so doing, you will come to understand the range of behaviors that have been attempted and, more important, the behav-iors that have the potential for being successful. This process involves emphasizing self-efficacy, which entails reviewing past successes each patient has experienced in addressing the problem, as well as behaviors each patient believes would help, even if they have not yet been tried.

Reflection can be a powerful strategy. By reflecting sustain talk, patients often respond with change talk, vocalizing the other side of their ambivalence.

Patient: I feel fine. Why should I take my diabetes medications?

Trainee: You feel that your diabetes can’t be that big of an issue if you don’t feel sick.

(Complex reflection) Or. . .

Trainee: Your health is exactly where you’d like it to be right now, so you see no reason to worry about your blood sugar. (Amplified reflection)

Amplified reflections offer a more exaggerated form of a reflective statement. While the technique is a straightforward reframing of what was said, such a reflection must be done with particular attention to nonverbal behavior. To avoid coming across as sarcastic or condescending, it is important to make a statement that implies your understanding that the patient is simply forming his or her opinion based on how he or she feels. Your response will come across as sarcasm if your statement is made with inflection in your voice, implying disbelief that the patient is being honest and that you assume he or she does not truly believe he or she is at risk simply because he or she

Motivational Interviewing70 feels fine at the moment. Tone is critical in making amplified reflections, and the tone should be understanding and flat rather than judgmental and questioning.

Trainee: You feel you are healthier than you would expect to feel if diabetes were a major problem. At the same time, it is very important to you to stay active and independent, and you would like to take whatever steps are necessary for that to happen. (Double-sided reflection)

Double-sided reflections reflect both sides of the patient’s ambivalence. Strategically, these reflections are more effective when you place the part of the ambivalence that supports change last, rather than first.

On a related note, it can sometimes be helpful to “come alongside” by agreeing with patients’ arguments for the status quo. Coming alongside can be used when patients argue very strongly for the status quo. Again, however, the effectiveness of the reflection relies on how it is framed. It is, of course, counterproductive to actu-ally agree with patients that they should continue unhealthy or risk-taking behavior.

Coming alongside is indicated when unhealthy behavior can be contrasted against another goal that the patient has indicated to be at least as important as continuing the status quo.

Patient: I really don’t see where it is anyone’s business how much weight I gain or how healthy I am. That’s my business. That’s what I tell my wife when she nags me about eating too much or drinking too much beer. And that’s what I am tell-ing you. As long as I am getttell-ing to work every day and keeptell-ing the roof over our heads and food on the table, I think I have the right to eat and drink whatever I want.

Trainee: I agree with you. You work hard because you value providing for the family and you take it very seriously. You work hard and you have the right to decide what you eat and drink.

Patient: Yeah, that’s the way I see it. I am a responsible guy. Taking care of the fam-ily is the most important thing. But after that I should be able to enjoy myself if I want to.

Trainee: No argument here. As long as you’re not doing anything that hurts your fam-ily, you should be able to do as you please.

Patient: Yeah, and I know a lot of people who think that way.

Trainee: I see here that you were in the hospital last year.

Patient: Yeah, I had to have my right knee replaced. The orthopedic guy says the other one isn’t as bad. I really only have pain in it in the morning. It’s stiff, you know, but once I get going, it loosens up. He’s another one who told me I need to lose weight—that’s what caused my right knee to give out. When I was in there, I told the guy I was waking up at night with chest pains and they checked my heart, turned out to be acid reflux. I am on medication for that now and haven’t had any problems with that. And they told me my blood pressure was high because I am overweight. That’s what started my wife on this health kick.

Trainee: How long were you laid up with all that?

Patient: It was almost 3 months before I could go back to work.

Trainee: That must have been hard on you and the family.

71Ambivalence and Discord Patient: Yeah, I got short-term disability but that doesn’t pay what I usually get and

I missed a lot of overtime. I have three kids. I tell you, it wasn’t easy. We almost had to go into our retirement savings, and there isn’t much there either.

Trainee: What would happen now if you had another episode like that? How would your family get along?

Patient: I got to admit, doc, I did think about it back then. For 6 weeks all I could do was lay around and so, yeah, I thought about it. I couldn’t wait to get back to work and once I did, I got back into the routine of making regular money and it didn’t seem like there was any need to worry about that anymore.

Trainee: You are really a responsible guy who wants the best for his family. You feel proud of yourself. I see a lot of patients who struggle with taking their responsibili-ties seriously. So, as you talk about it now, you would want to avoid having another time like that.

Patient: Yeah, who wouldn’t? I know it would be better if I could be healthier. But I just can’t do all those things they told me to do.

Trainee: They suggested you do too many things at once and this is so overwhelming to even think about it. What did they suggest?

Patient: They gave me this three-page list of all the things I should do. It seemed like they expected me to give up everything I like. And the guy there told me I should start swimming for exercise because it would help me lose weight and be easy on my knees.

I can swim, but, hell, I haven’t done that since I was a kid. It seemed like a lot. I tried to do some of the things they wanted me to do, but after a while it got too hard to keep up.

Trainee: What if we take another look at that list? I think you’ll find that you don’t have to do all those things all at once. There is a way we can come up with a few things that you can live with that can help you get healthier. I’ve done this before and it has worked for many of my patients. Would you want to try?

Patient: Sure, when you put it that way, it’s worth a shot.