Most clinicians know the experience of offering a sensible suggestion and watching it slide right off. A client agrees that their drinking is damaging their marriage, or that avoidance is shrinking their life, then meets every proposed step forward with a reason it won't work.
In this video, motivational interviewing (MI) expert and researcher Dr. Theresa Moyers explains why this happens using a scenario most people will recognize from their own lives: the friend in an exciting relationship with someone who sounds plainly controlling and problematic.
If you tell your friend to leave, you'll hear “yes, but they're wonderful.” Tell them to stay and work things out, and you'll hear “yes, but they're driving me crazy.” The content of the advice doesn’t matter so much as the instinct to resist: whatever position you take, your friend takes up the other side. Dr. Moyers uses this ordinary social moment to illustrate a principle that sits at the center of motivational interviewing: when a person is ambivalent, they are at their least receptive to direction, however wise or well-meaning it may be.
Ambivalence is a normal condition of change
Therapists are especially familiar with this dynamic, as clients arrive to therapy in many varied states of readiness for change. Especially in environments where clients are mandated to attend treatment, or perhaps pressured by others to do so, ambivalence can be the defining feature of the therapy’s atmosphere.
Ambivalent clients can be easy to misunderstand. Historically, especially in the context of addiction treatment, a client who argued against change could quickly earn the label of treatment resistant, unmotivated, or even oppositional. Dr. William Miller, the founder of MI, took a different view. He reconsidered ambivalence as an ordinary stage on the way to change, acknowledging that most people pass through it before any significant decision. A client usually arrives in treatment already holding their own genuine reasons both to change and to stay the same. Both sides of the argument are alive in the client before the therapist becomes involved.
This is what makes advice so unreliable as an intervention. When someone external argues one side of a debate, the person tends to reflexively give voice to the other. This can easily be mistaken for defiance, or naiveté, but can usually be better understood as the result of ambivalence meeting pressure.
The righting reflex, and why it backfires
Dr. Miller and Dr. Stephen Rollnick (co-developers of MI and trainers in Psychwire’s Motivational Interviewing courses with Dr. Moyers) have a name for the impulse that compels us to interject in an attempt to correct the other person’s path: the righting reflex. The trouble is that for someone experiencing ambivalence, hearing another person represent a particular argument or offer specific advice can polarize their thinking in the other direction. While the urge to engage in this type of argument might come with good intentions, MI offers a unique perspective on how it can actually interfere with an attempt to support someone to change.
Clinicians are particularly vulnerable to the righting reflex, as most people enter the helping professions with a strong motivation to relieve the suffering of others and be helpful. From this place, the therapist voices the argument for change, then the client is compelled to voice the argument against it. Repeat this across a session and the client has now rehearsed, out loud and at length, every reason to stay exactly where they are.
What process research shows
Dr. Moyers speaks about this with particular authority, as the mechanics of MI have been the focus of her prolific research career. Her research group spent years coding therapy recordings to identify what actually moves clients, and the findings converge on client language. Statements favoring change, which MI calls change talk, predict better outcomes (Moyers et al., 2009), while high levels of statements defending the status quo, called sustain talk, predict worse ones (Magill et al., 2018). Therapist behaviors consistent with MI have also been associated with higher rates of change talk. This research has implications for the clinician’s evocation of their client’s “yes, but” response. Participating in this well-worn conversational dynamic can actually work against client change, even if the clinician’s suggestions are sound.
What ambivalent clients need instead
Motivational interviewing offers clinicians a suite of responses that support clients in a state of ambivalence. Rather than operating from the righting reflex, an MI clinician seeks to listen carefully to the client in their current state, with the eventual goal of evoking and attending to the client’s own ideas and motivation for change. By attending to and reflecting the client’s readiness in their own words, the clinician can disarm that “yes, but” impulse, and come alongside the client in a collaborative conversation, rather than end up in an argument against them.
This doesn’t mean that the therapist never offers advice or strategies for change. In MI, this is a matter of timing and permission. The same advice offered after ambivalence has shifted, or at the client's request, can be used to support meaningful change.
Learning to navigate ambivalence in clinical practice
Understanding ambivalence intellectually is fairly straightforward, but identifying it and responding to it differently in the pressure of a live session, with a client you care about who is describing something harmful, takes practice, knowledge, and feedback. Clinicians who want to build this capacity can learn directly from the researchers and trainers who shaped the method, within Psychwire’s Motivational Interviewing Foundational course. The course features client demonstrations and opportunities to interact with the trainers directly through an interactive forum. For a closer look at how the processes of MI work, The Four Processes of MI provides more detail about how a course of MI unfolds.
