We are in the business of helping people make positive health changes. Reluctance to make these changes will inevitably arise. Let’s pick apart what we often call resistance to understand it better.
Frustration means you are on the verge of a breakthrough.
Confusion can mean you are about to learn something.
Expect the breakthrough and expect to learn.
Out beyond the idea of right thinking
and wrong thinking is a field. …
I will meet you there. …
In the third edition of Motivational Interviewing: Helping People Change, Miller and Rollnick carefully distinguish between two very different things. What we encounter in our work and call resistance is either “sustain talk” or “discord.”
When a specific behavioral focus of change is being talked about, clients will voice both reasons to make the change and reasons to stay the same. Voicing this ambivalence is normal and all a part of the process of change. Sustain talk is what we hear from the client about reasons to not change. We may hear:
- “I really love to eat with the TV on.”
- “I eat healthy now.”
- “My blood sugar isn’t a problem.”
It is tempting to jump in with our arguments for change or to remind the client of reasons to change that she has mentioned. Our righting reflex (Tip #65) encourages us to react to this sustain talk by arguing. When we do, the client will naturally keep voicing sustain talk since we are arguing for the change side of the ambivalence.
Notice that in the sustain talk examples above the client is talking about herself and how she sees the situation and her health. When we hear resistance that is about us or our interactions in the session, this is discord.
Discord might sound like:
- “You don’t understand.”
- “I won’t do that.” (in response to one of your suggestions)
- “You can’t help me.”
Sometimes discord is more subtle than this. The client may interrupt us or appear distracted. We may sense the client getting defensive. For example, “It really isn’t all that bad.” Or “It’s not my fault.” People get defensive when they feel attacked. We may not intend to attack. If the client is responding with defensiveness, this signals that discord is occurring.
As we get better at picking up these subtle signals that discord is happening, we can quickly shift what we are doing. It is easy to unknowingly provoke discord. Our desire for this person to change can cause us to argue for change or to make unsolicited suggestions. This can quickly shift the client from sustain talk (a normal part of thinking about change) to discord. We then lose the opportunity to collaborate with the client toward change.
Responding to sustain talk:
Your best responses are similar for sustain talk and discord. Let’s look at sustain talk examples first.
Reflections form the basis of the most effective responses. These allow the client to feel understood. For example, in response to “I eat healthy now,” you could say, “How you eat now is keeping you healthy.” Because you did not jump into arguing, tempting as it might be, you may get some change talk such as, “Well, not completely healthy, I guess, because my cholesterol is still high.”
You could choose to amplify the sustain talk, such as, “Your eating habits are just fine and there is no room for improvement.” In this way you are acknowledging what the client has said and taking it up a notch. The client is likely to pick up the other side of the ambivalence, “Well, there are some days I overdo it a bit.”
Another approach is to reflect some of each side of the ambivalence: “You are fine with how you eat now and you also want to find a way to get your cholesterol down without medication.” This is called a double-sided reflection. Here you acknowledge the sustain talk first and then bring in something you know to be true for this person that points toward change. Be sure to use “and” instead of “but” (Tip #64)
Along with skillful reflections it can also be useful to:
Emphasize autonomy: “It’s your choice. It’s entirely up to you to decide whether to make some changes to your eating and see if it affects your cholesterol.”
Reframe: “Taking on any changes would be a challenge.” “You haven’t yet found a way to keep your healthy eating habits and also tweak them towards supporting your heart health.”
Agree with a twist: “You’re just fine with how you eat now. You’ve decided to stick with it even when the doctor says it’s time for medication.”
Some of these strategies are tricky. They can come across as sarcastic. This would quickly bring up discord. Practice these reflections and strategies in a sincere, neutral manner.
In all of these examples, your response to sustain talk acknowledges it without asking for more. Avoid the trap of chasing more of it with questions such as, “Can you tell me more?” Or, “What else do you like about how you eat now?” It takes lots of practice to adequately acknowledge sustain talk while encouraging change talk
Responding to discord:
Your approaches to discord can be similar to those for sustain talk. You can reflect discord simply or with amplification or double-sided. When you hear discord, you can also emphasize autonomy, reframe or agree with a twist.
There are a few additional ways to respond to discord. A straightforwardapology can turn around a conversation that is getting prickly. “I’m sorry, I misunderstood you.” “That hurt your feelings. I’m sorry.” “I’m sorry I’m getting ahead of you here.”
An affirmation, if sincere, can also heal a rift. When a client says, “I don’t need you to tell me how to do this. I can do it on my own.” You could affirm, “You’ve done your research and are good at figuring out how to make changes.”
Sometimes a shift of focus is necessary, especially when a client gets defensive. “What do you mean? I don’t have an eating disorder.” You could respond, “We’re not talking about labels here. We can focus on what you came in with, about how you get so confused choosing foods.”
Whether what we encounter is sustain talk or discord, we can affect the outcome by shifting what we do to move the conversation more toward change. There are plenty of ways to respond to sustain talk and to discord. The bottom line is that we accept the client and her autonomy, stay in a collaborative stance and avoid evoking more sustain talk.