Motivational Interviewing & Resistance

It seems apparent that what a person is doing either isn’t working or is self-destructive; you can see a better way, yet the person persists in the same behavior. In a way, it is captured in the words, “You would think . . . ”

“You would think that having a heart attack would be enough to persuade a man to quit smoking, change his diet, exercise more and take his medication.” (Miller & Rollnick, 1991, p. 3).

“You would think that hangovers, damaged relationships, an auto crash, and memory blackouts would be enough to convince a woman to stop drinking.” (Miller & Rollnick, 1991, p 3).

Change vs. Resistance: Two Sides of The Same Coin (Miller & Rollnick, 1991).

In a previous post, we discussed the nature of motivation: Here we consider it’s opposite: Resistance.

The Therapeutic Relationship: Consonance vs. Dissonance

“When things are going well in a motivational interview, there is a sense of moving together smoothly…the feeling is quite different when instead of moving together, the counselor and client seem to be struggling against one another” (Miller & Rollnick, 1991, p. 43).  In fact, conversations between therapist and
client occur along continuum, falling somewhere between understanding and misunderstanding.  Miller & Rollnick, (1991) utilize the terms consonance and dissonance to describe these extremes.  With consonance we have compatibility of perspectives between client and therapist: everybody is on the same page.  In contrast, dissonance involves an inconsistency and contradiction of perspectives: complete misunderstanding.

Miller & Rollnick, (1991) caution against defining dissonant conversations with clients as byproduct of resistance.  Resistance is a term that tends to implicitly apply blame to the therapist.  In reality, dissonant conversations with clients reflects more on the quality of the therapeutic relationship.  “Dissonance in a counseling relationship is not the product…of only one person’s behavior.” (Miller & Rollnick, 1991, p. 43). So what is the solution?  Miller and Rollnick, (1991) state it is the therapist’s job to recognize dissonance, interpret it accurately, and adjust accordingly in order to restore a feeling of consonance between therapist and client.

Client Behavior: Change Talk vs. Resistance

Miller & Rollnick, (1991) also assert that the insights on consonance and dissonance can apply to the understanding of client behavior.  “Resistance is a signal of dissonance in the client relationship…a meaningful signal” (Miller & Rollnick, 1991, p. 46).  The opposite of resistance is change talk, (discussed in a previous post).  Change talk reflects an increase in internal motivation and the resolution of ambivalence.  Resistance, in contrast reflects a high ambivalence, and low internal motivation.  Miller & Rollnick describe four categories of resistant behavior:

  1. ARGUING: The client contests the accuracy, expertise, or integrity of the counselor.”  (Miller & Rollnick, 1991, p. 48).
  2. INTERRUPTING: The client breaks in and interrupts the counselor in a defensive manner.”m(Miller & Rollnick, 1991, p. 48).
  3. NEGATING: The client speaks while the counselor is still talking, without waiting for an appropriate pause or silence.” (Miller & Rollnick, 1991, p. 48).
  4. IGNORING: The client shows evidence of not following the counselor.”  (Miller & Rollnick, 1991, p. 48).

How Should Counselor’s Respond???

“With patients in precontemplation, often the role is like that of a nurturing parent, who joins with a resistant and defensive youngster who is both drawn to and repelled by the prospects of becoming more independent. With clients in contemplation, the role is akin to a Socratic teacher, who encourages clients to achieve their own insights into their condition. With clients who are in the preparation stage, the stance is more like that of an experienced coach, who has been through many crucial matches and can provide a fine game plan or can review the participant’s own plan. With clients who are progressing into action and maintenance, the psychotherapist becomes more of a consultant, who is available to provide expert advice and support when action is not progressing smoothly” (Norcross & Krebs & Prochaska, 2011, p. 145)

Miller & Rollnick (1991) suggest that clients are “understood within the context of the counseling relationship” (p. 51).  Recognizing the fluctuation between dissonance and consonance in the therapeutic relationship is essential, so the therapist can adjust accordingly.  What follows are examples of what not to do:  

  1. “ARGUING FOR CHANGE: The counselor directly takes up the pro-change side of ambivalence on a particular issue and seeks to persuade the client to make change.” (Miller & Rollnick, 1991, p. 50).
  2. ASSUMING THE EXPERT ROLL:  The client structures the conversation in a way that communicates that the counselor ‘has the answers’.” (Miller & Rollnick, 1991, p. 50).
  3. “CRITICIZING, SHAMING, BLAMING, OR LABELING.”  (Miller & Rollnick, 1991, p. 50).
  4. “BEING IN A HURRY: Sometimes the perceived shortness of time causes the counselor to believe that clear, forceful tactics are called for in order to get through…if you act like you only have a few minutes, it can take all day to accomplish a change.”  (Miller & Rollnick, 1991, p. 50)

Misc Techniques…

References

Miller, W. R. and Rollnick, S. (1991) Motivational interviewing: Preparing people to change addictive behavior. New York: Guilford Press
Norcross, J. C., Krebs, P. M., & Prochaska, J. O. (2011). Stages of change. Journal of clinical psychology, 67(2), 143-154.

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