W.miller on+Second+Thought

On Second Thought:
Responding to Ambivalence in Helping Professions
William R. Miller, Ph.D.

University of New Mexico
Faculty Disclosure
• William R. Miller, PhD: Author Royalties—Guilford Press (Therapeutic Area:
Motivational Interviewing); Consultant—The Change Companies
Disclosure
• The faculty have been informed of their responsibility to disclose to the
audience if they will be discussing off-label or investigational use(s) of drugs,
products, and/or devices (any use not approved by the US Food and Drug
Administration).
• Applicable CME staff have no relationships to disclose relating to the subject

matter of this activity.
• This activity has been independently reviewed for balance.

Learning Objectives
• Describe at least three of the four "flavors" of ambivalence
(candy store, trap, yoyo, and pendulum)
• Explain how "horizontal" differs from "vertical" ambivalence in

which one pole is unconscious
• Differentiate directional vs. neutrality strategies in helping

clients resolve ambivalence
Ambivalence in Psychotherapy
• Clients often come seeking help with choice or change
• It is normal, not pathological,

to both want and not want
simultaneously
Janus, Roman god of beginnings,

doorways, and transitions
Ambivalence is human nature
and has a long history
Ambivalence in American Music
I’m so miserable without you, it’s almost like you’re here.
Billy Ray Cyrus
How can I miss you if you won’t go away?

Nick McCarthy
My sweet tooth says I want to,

but my wisdom tooth says no
Fletcher Henderson
9
Stages of Change
Prochaska & DiClemente
Ambivalence is a normal step toward change

10
80%
20%
“Come back when you’re ready to change”
is not good enough

Helping clients resolve (or live with) ambivalence
is part of a psychotherapist’s job
AMBIVALENCE
No one was ambivalent before 1910
• The word was coined by Bleuler in 1910

Latin ambi (two or both) +
German valenz (power)
• and popularized by Sigmund Freud

to describe conflicting motivations
Ambivalence is Like
New Mexican Cuisine
– Blends Mexican and Native American
traditions
– Capsaicin, the chemical agent in chilli
peppers, is a natural irritant for mammals
– The picante burning sensation varies
from mild to intense and is part of the
pleasure of eating this cuisine
– In New Mexico, pain is a flavor

Four Flavors of Ambivalence
1. The Candy Store

Approach-Approach
2. The Trap
Avoidance-Avoidance
3. The Yoyo
Approach-Avoidance
4. The Pendulum
Double Approach-Avoidance
“Vertical” Ambivalence
Horizontal Vertical
• Both poles are conscious • One conscious pole opposed by

an unconscious pole
Let’s just go in and see what happens.

The Language of Ambivalence
How we talk ourselves into and out of things
Change talk and sustain talk

in thinking, writing, or speaking aloud
21
Preparatory Change Talk: Get Ready
Four Examples
• DESIRE to change (want, like, wish . . )

• ABILITY to change (can, could . . )
• REASONS to change (if . . then)
• NEED to change (need, have to, got to . .)
22
Mobilizing Change Talk: Get Set
Three examples
• Commitment (intention, decision, promise)

• Activation (willing, ready, preparing)
• Taking steps
CATs
23
Sustain Talk
The Other Side of Ambivalence
• All of the same language can occur as sustain talk,

arguing for the status quo
• By listening, you can tell where the decisional

balance is at any moment
Desire
(want / wish / like)
CHANGE TALK SUSTAIN TALK
• I want to quit smoking • I want a cigarette

• I wish I could quit • I really enjoy smoking
• I’d like to be free of tobacco • I’d like to keep on smoking
Ability
(can / could / able)
• I’m able to quit • I tried and I can’t do it

• I think I can • I’m just not able
• I could quit smoking • It’s too hard for me
Reasons
(if . . . then)
• If I did quit, my kids would be happy • Smoking is the only way I have to relax
• Lung cancer is an ugly way to die • It’s how I cope with stress in my life
• I’d save a lot of money • I’d feel deprived
Need
(must / need / have to)
• I really need to quit • I don’t need to quit

• I have to cut down • I have to smoke
• I must get over my nicotine addiction • I must have this one pleasure
Commitment
(will / going to / promise)
• I’m going to quit • I won’t give it up

• I promise I’ll quit • I am not quitting
• I will do it • I’m going to keep on smoking, and
nobody can stop me
Activation
(willing / ready / consider)
• I’m willing to quit • I’m not ready to quit

• I’m prepared to quit • I’m unwilling to quit
• I’ll think about quitting • I won’t consider it
Taking Steps
CHANGE SUSTAIN
• I threw out all my cigarettes • I plan to smoke the cigarettes I have

• I filled the prescription you gave me • I lost the prescription you gave me
• I told my family that I’m quitting • I bought four cartons today
Decisional Balance
Change Sustain
talk talk
The balance predicts stages of and readiness for change
Magill, M., Apodaca, T. R., Borsari, B., Gaume, J., Hoadley, A., Gordon, R. E. F., Tonigan, J. S., & Moyers, T. (2018). A meta-analysis of
motivational interviewing process: Technical, relational, and conditional process models of change. Journal of Consulting and Clinical
Psychology, 86(2), 140-157.
Prochaska, J. O., Velicer, W. F., Rossi, J. S., Goldstein, M. G., Marcus, B. H., Rakowski, W., Fiore, C., Harlow, L. L., Redding, C. A.,
Rosenbloom, D., & Rossi, S. R. (1994). Stages of change and decisional balance for 12 problem behaviors. Health Psychology, 13(1), 39-46.
A decisional balance intervention was developed to help people
resolve ambivalence without influencing the outcome
Option A Option B
Advantages Good things about Good things about

Option A Option B
Disadvantages Less-good things about Less-good things about

Option A Option B
Janis, I. L., & Mann, L. (1977). Decision making: A psychological analysis of

conflict, choice and commitment. Free Press.
33
There is no theoretical or empirical reason to believe that a
decisional balance (DB) intervention would promote change
• Doing DB with a person who is ambivalent about

change actually decreases commitment to change
• Doing DB after a person has decided to make a
change might increase commitment to change
• In other words, DB helps a person decide to change
only if they have already decided to do so
Miller, W. R., & Rose, G. S. (2015). Motivational interviewing and decisional

balance: Contrasting responses to client ambivalence. Behavioural and Cognitive
Psychotherapy, 43(2), 129-141.
Aware of it or not, you influence decisional balance
It matters what you choose to:
• Ask
• Affirm
• Reflect
• Summarize
Miller, W. R., & Moyers, T. B. (2021). Effective psychotherapists: Clinical skills that improve client outcomes.
Guilford Press.
35
What would you ask?
• Why haven’t you quit smoking?

• What would be difficult for you about quitting?
• Why would you want to quit?
36
What would you reflect?
• I really don’t want to stop smoking, but I know that I should.

I’ve tried before, and it’s really hard.
1. You really don’t want to quit

2. It’s pretty clear to you that you ought to quit.
3. You don’t think that you can quit
37
Can Counselors Influence Change Talk?
• In conversations with 47 people about drinking concerns

(i.e., ambivalent people)
• 9 counselors switched style every 12 minutes between:
– Seeking to evoke change talk (motivational interviewing)
• and
– Functional analysis of drinking behavior
• Coded for client change talk (CT) and sustain talk (ST)
38
Ratio of Change Talk to Sustain Talk
80 0.85 2.00 1.17

1.63
70
60
50
40
30
20
10
0
MI1 FA1 MI2 FA2
Glynn, L. H., & Moyers, T. B. (2010). Chasing change talk: The clinician's role in evoking client
language about change. Journal of Substance Abuse Treatment, 39(1), 65-70.
Neutrality or Direction?
To maintain neutrality To maintain move toward change
• Use decisional balance to keep Rowing with OARS

your balance • Ask Open questions the answer
• Give equal attention (asking, to which is change talk
affirming, reflecting, summarizing) • Affirm change talk
to pros and cons of each choice • Differentially Reflect change talk
• Privilege change talk in your
Summaries
Miller, W. R. & Rollnick, S. (2013). Motivational interviewing (3rd ed.). New York: Guilford Press
Denial as a Response to Ambivalence
Large segments of people have at times denied:

– that the earth is round
– that smoking causes cancer
– that 6 million Jews were murdered in the Holocaust
– that human activity contributes to global warming
– that the COVID-19 virus is real and dangerous
Ambivalence (doubt) is a first step toward unlearning

inaccurate information and beliefs.
Ambivalence as a Virtue
• “The test of a first-rate intelligence is the ability to hold two
opposed ideas in the mind at the same time, and still retain the
ability to function.” - F. Scott Fitzgerald
• It is an achievement to own one’s ambivalence rather than

projecting part of it onto others. (Segal, 2019)
• Ambivalent leaders spend more time and consider a variety of

perspectives before deciding
Segal, H. (2019). The achievement of ambivalence. Common Knowledge, 25(1-3), 51-62.

People who experience greater ambivalence
have been found to:
• Be better informed and make more accurate judgments

• Offer fair and balanced evaluations
• Read other peoples’ emotions more accurately
• Be more open to new information and alternatives
• Be more creative, see unusual associations / possibilities
• Experience more sexual arousal and desire
• Be less inclined to make impulsive decisions
Miller, W. R. (2021). On second thought: How ambivalence shapes your life. New York: Guilford Press.
Embracing Ambivalence
• Life would not be improved by eradicating ambivalence.
• Ambivalence does not need to be distressing. It is

possible to hold contradictory experiences without
needing to resolve them.
• Considering and choosing among alternative futures is a

remarkable ability and responsibility of humankind and is
a defining characteristic of democracies.

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On Second Thought:

Responding to Ambivalence in Helping Professions

William R. Miller, Ph.D.

• Applicable CME staff have no relationships to disclose relating to the subject

• This activity has been independently reviewed for balance.

• Explain how "horizontal" differs from "vertical" ambivalence in

• Differentiate directional vs. neutrality strategies in helping

• Clients often come seeking help with choice or change

• It is normal, not pathological,

Janus, Roman god of beginnings,

How can I miss you if you won’t go away?

My sweet tooth says I want to,

Ambivalence is a normal step toward change

is not good enough

• The word was coined by Bleuler in 1910

• and popularized by Sigmund Freud

– In New Mexico, pain is a flavor

1. The Candy Store

• Both poles are conscious • One conscious pole opposed by

Let’s just go in and see what happens.

How we talk ourselves into and out of things

Change talk and sustain talk

• DESIRE to change (want, like, wish . . )

• Commitment (intention, decision, promise)

• All of the same language can occur as sustain talk,

• By listening, you can tell where the decisional

CHANGE TALK SUSTAIN TALK

• I want to quit smoking • I want a cigarette

CHANGE TALK SUSTAIN TALK

• I’m able to quit • I tried and I can’t do it

CHANGE TALK SUSTAIN TALK

CHANGE TALK SUSTAIN TALK

• I really need to quit • I don’t need to quit

CHANGE TALK SUSTAIN TALK

• I’m going to quit • I won’t give it up

CHANGE TALK SUSTAIN TALK

• I’m willing to quit • I’m not ready to quit

• I threw out all my cigarettes • I plan to smoke the cigarettes I have

The balance predicts stages of and readiness for change

Advantages Good things about Good things about

Disadvantages Less-good things about Less-good things about

Janis, I. L., & Mann, L. (1977). Decision making: A psychological analysis of

• Doing DB with a person who is ambivalent about

Miller, W. R., & Rose, G. S. (2015). Motivational interviewing and decisional

What would you ask?

• Why haven’t you quit smoking?

What would you reflect?

• I really don’t want to stop smoking, but I know that I should.

1. You really don’t want to quit

Can Counselors Influence Change Talk?

• In conversations with 47 people about drinking concerns

80 0.85 2.00 1.17

• Use decisional balance to keep Rowing with OARS

Large segments of people have at times denied:

Ambivalence (doubt) is a first step toward unlearning

• It is an achievement to own one’s ambivalence rather than

• Ambivalent leaders spend more time and consider a variety of

Segal, H. (2019). The achievement of ambivalence. Common Knowledge, 25(1-3), 51-62.

• Be better informed and make more accurate judgments

• Ambivalence does not need to be distressing. It is