Reading: Ambivalence and decisional balance
Exploring the good and not-so-good things about substance use and about change.
Reading: Ambivalence and decisional balance
What you’ll learn
- Normalize ambivalence and describe the hill of ambivalence.
- Explore both sides with a decisional balance, without reinforcing sustain talk.
- Develop discrepancy, and use a recapitulation summary to invite a decision.
In contemplation, the client sees reasons to change and reasons not to, at the same time. Someone may enjoy drinking because it relaxes them, and feel guilty about the job they lost because of it and the money worries it caused their family. Feeling two ways is uncomfortable, and it’s normal.
- 1. Going upThe client starts to see reasons to change. Sustain talk and change talk compete, and the conflict grows.
- 2. The topAmbivalence peaks. This is often when clients feel most stuck, and most open to their own reasons.
- 3. Going downChange talk outweighs sustain talk. The client moves toward a decision and into preparation.
Normalize ambivalence
As clients get closer to a decision, the conflict often gets stronger, not weaker. Reassure them that mixed feelings, doubts and reservations are common, and that many people go back and forth even when they think they’ve decided.
Evoke change talk
Help the client up and over the hill by drawing out their desire, ability, reasons and need to change, and reflecting what you hear. The goal is for the client, not you, to make the case for change. Questions like these help:
- “How would you like things to be different?”
- “What don’t you like about how things are now?”
- “If you decided to make a change, how might you do it?”
- “What would make it worthwhile for you to cut back?”
- “How important is it to you to make this change?”
Decisional balance
A decisional balance explores the good and not-so-good things about using, and about changing. Asking first what the client gets from using shows you aren’t there to take something away, and often makes the costs easier to talk about.
Use it with care. Research links more sustain talk in a session with worse outcomes, so explore both sides without dwelling on the benefits of using. Think about the client’s stage first. A structured exercise that weighs both sides equally can increase ambivalence for someone in contemplation. Once a client has decided to change, exploring the pros and cons of changing can strengthen their commitment.
Develop discrepancy
Developing discrepancy means helping the client see the gap between how they’re living and what they value. Ask about their values, hopes and goals, then invite them to compare: “How does drinking fit with the kind of grandfather you want to be?” Let the client draw the conclusion. If you draw it for them, they’re likely to argue with it.
- Loss and grief
- What to keep in mindGiving up a way of life can feel like losing a close friend. Clients may need time to grieve. Pushing too fast can weaken their resolve.
- Reservations
- What to keep in mindSerious reservations, or missed appointments, can mean you’re ahead of the client. Keep exploring ambivalence and reassess where they are.
- Deciding too soon
- What to keep in mindClients may say what they think you want to hear. If they aren’t ready, slow down and return to contemplation.
- Keeping pace
- What to keep in mindSome clients have already decided. Exploring their concerns can evoke sustain talk unnecessarily. Move to a change plan.
- Free choice
- What to keep in mindFor some clients, using is tied to freedom or identity. Emphasize that the choice is theirs.
| Issue | What to keep in mind |
|---|---|
| Loss and grief | Giving up a way of life can feel like losing a close friend. Clients may need time to grieve. Pushing too fast can weaken their resolve. |
| Reservations | Serious reservations, or missed appointments, can mean you’re ahead of the client. Keep exploring ambivalence and reassess where they are. |
| Deciding too soon | Clients may say what they think you want to hear. If they aren’t ready, slow down and return to contemplation. |
| Keeping pace | Some clients have already decided. Exploring their concerns can evoke sustain talk unnecessarily. Move to a change plan. |
| Free choice | For some clients, using is tied to freedom or identity. Emphasize that the choice is theirs. |
The recapitulation summary
When you sense the client may be ready, pull everything together in one summary. Include as many of these as you can:
- How the client sees the problem.
- Their ambivalence, including what’s still attractive about using.
- Objective evidence of risks or problems.
- Your own assessment, especially where it lines up with the client’s concerns.
- Their change talk: desire, ability, reasons and need.
Then ask a key question that invites a decision: “So where does that leave you?” or “What’s next?”
Let me see if I have this right. Drinking helps you unwind, and it’s a big part of time with your friends. You’ve also missed some Mondays, your doctor is worried about your blood pressure, and you said you want to be around for your grandkids. Did I miss anything?
No, that’s about it. When you say it all together, it’s a lot.
So where does that leave you?
The summary acknowledges what the client likes about drinking, then gathers their concerns and reasons. The open question hands the decision back to them.
Write a double-sided reflection that ends on the change side.
ClientI know it’s not good for me, but it’s the only thing that helps me sleep.
Show a model answer
“Drinking is the one thing that helps you sleep right now, and you know it isn’t good for you.” Ending on the change side makes it the part the client is most likely to respond to.
Key takeaways
- Ambivalence is normal, and it often peaks just before a decision.
- Explore both sides, but reflect change talk more than sustain talk.
- A recapitulation summary and a key question invite the client to decide.
Adapted from SAMHSA, TIP 35: Enhancing Motivation for Change in Substance Use Disorder Treatment (2019), chapter 5. Public domain. Open TIP 35, chapter 5: ambivalence and decisional balance