The role of ambivalence in behavior change

Commentary to: Ambivalence: Prerequisite for success in motivational interviewing with adolescents? Motivational interviewing (MI) is a therapeutic method specifically designed for clients who are ambivalent about behavior change. Underlying mechanisms of action in MI sessions with mandated adolescents may differ from those in voluntary adult-seeking populations. Motivational interviewing (MI) is based upon the notion that ambivalence is a normal part of behavior change. In MI, a clinician seeks to develop a collaborative, supportive environment in which they can elicit a client's own reasons for change, known as 'change talk'. Therefore, MI is appropriate for clients who are ambivalent about changing a particular behavior: 'I know I should cut back on my drinking but it's so much fun to party with my friends on the weekends'. MI clinicians expect that an ambivalent client will offer both change talk as well as reasons to stay the same, known as 'sustain talk'. We train clinicians 1, 2 to reflect sustain talk as they build a collaborative relationship with the client, and during the course of the session to shift strategically to elicit and reinforce client change talk in an effort to 'tip the scales' toward behavior change. Feldstein and colleagues 3 provide an intriguing overview of the relationship between adolescent ambivalence and behavior change in the context of motivational interviewing sessions. They posit that the role of ambivalence in relation to behavior change may manifest itself and influence behavior differently in mandated-adolescent populations. Specifically, they suggest that ambivalence may be absent (and, if present, not necessary to facilitate subsequent behavior change). We agree that mandated adolescent substance users may have a limited investment in treatment due to a variety of external factors (e.g. nature of offense). This limited investment may manifest itself behaviorally as an absence of ambivalence: namely, little to no change talk and a great deal of sustain talk. That said, we propose that a discussion of the role of the external factors in relationship to the client's own personal values may elicit genuine ambivalence about the behavior of interest. Indeed, examinations of mandated college students' within-session language reveals both the presence of change talk 4-7 and sustain talk. In fact, both Borsari et al. 4 and Vader et al. 5 found that clinician MI-consistent behaviors predicted both change and sustain talk in a sample of mandated college students. Furthermore, change talk is evident from the very start of the session, contrary to what would be expected if ambivalence was absent. We suggest that MI, a directed conversation focused on the relationship between the client's current substance use and his or her values/goals, may quickly foster an atmosphere where the client can explore the pros and cons of behavior change, but we are reluctant to suggest that clinicians utilize the decisional balance as a strategic method of creating ambivalence, given recent evidence documenting a relationship between client sustain talk and poorer treatment outcomes 6, 8. Further, we note that a review of studies exploring whether a decisional balance was appropriate for use in MI indicated that for ambivalent clients in particular it was associated with increased sustain talk 9. Even if mandated adolescents explore and (and resolve) ambivalence in session, there is also the thorny question of whether this will influence subsequent behavior. MI is a treatment that was developed originally for problem-drinking adults, arguably a very different group in terms of ambivalence and internal motivation for change than adolescents who have been mandated to treatment because of status offenses. It cannot be assumed that a treatment stressing collaboration and autonomy support can be applied with equal efficacy to mandated adolescents, who may view themselves as coerced and may have a limited menu of options for changing behavior. Furthermore, a clinician-led discussion regarding a client's menu of treatment options may highlight the client's lack of personal choice and autonomy in the treatment process and have the unintended effect of facilitating sustain talk in this population. It is likely that MI, a therapeutic method that stresses the exploration and resolution of client ambivalence, may have limits to its efficacy with mandated adolescent clients. However, we feel that it is premature to suggest that MI does not work by resolving ambivalence. In an elegant meta-analysis, Magill et al. 10 found that the ratio of change and sustain talk in treatment sessions, when favoring change talk, was associated with positive behavioral outcomes. This approach, evaluating the behavioral manifestation of ambivalence, needs to be replicated with mandated adolescent population before ambivalence and its resolution can be discarded as a significant mechanism of behavior change in this population. None.