Motivational Interviewing Techniques for Ambivalent Clients

Practical questions, reflections and conversational strategies for helping clients explore mixed feelings about change – without persuasion, confrontation or premature problem-solving.

Related articles: The Four Processes of Motivational Interviewing, OARS in Motivational Interviewing, Change Talk vs Sustain Talk: A Practical MI Guide.

More resources: Explore Motivational Interviewing Training.

Before you start reading this article: MHA membership increases your choices and reduces your CPD costs. As a member, you only pay a fixed monthly or annual membership fee to access 650+ courses in our Catalogue. If you are not yet a member, learn more and join. Access for your team? Learn more about group memberships.

Introduction

Change is rarely a simple yes-or-no decision. A client may want relief from the consequences of a behaviour while also valuing what that behaviour provides, fearing the demands of change, or doubting their ability to succeed. Motivational interviewing (MI) treats this ambivalence as a normal part of change – not as defiance or a barrier to therapy (Miller & Rollnick, 2023).

MI is a collaborative, goal-oriented approach that helps clients explore their own reasons for and against change while preserving autonomy. Instead of persuading, confronting, or solving the problem prematurely, the practitioner listens for the client’s motivations, concerns, values, and capabilities and helps them examine these in a focused conversation (Miller, 2023; Miller & Rollnick, 2023).

This guide translates that approach into eight practical techniques for working with ambivalent clients, including double-sided reflections, questions that evoke change talk, importance and confidence rulers, values exploration, responses to sustain talk, and MI-consistent information sharing (Lubman et al., 2012; Substance Abuse and Mental Health Services Administration [SAMHSA], 2019).

Ambivalence is not the same as resistance

Labelling a client ‘resistant’ can locate the problem within the person and obscure what is happening in the therapeutic interaction. Contemporary MI instead distinguishes between ambivalence, sustain talk, and discord – signals that arise from different processes and call for different responses (Miller, 2023; Miller & Rollnick, 2023).

What the practitioner hears	Likely process	Appropriate response
‘I want things to improve, but I’m not ready to give this up.’	Ambivalence	Explore both sides without taking sides
‘Changing would make everything worse.’	Sustain talk	Reflect the concern and avoid rebuttal
‘You clearly don’t understand my situation.’	Discord	Repair the relationship and reconsider pace or focus
‘I want to change, but I know I’ll fail.’	Low confidence	Elicit strengths, prior successes, and available support
‘I don’t know why we’re discussing this.’	Unclear or imposed focus	Return to collaborative agenda-setting

Ambivalence involves competing motivations within the client. Sustain talk is language favouring continuation of the current behaviour, whereas discord signals strain in the working relationship. These may occur together, but they do not call for identical responses (Miller & Rollnick, 2023).

For a closer examination of this distinction, see Using Motivational Interviewing to Address Client Resistance.

Eight MI techniques for working with ambivalence

1. Establish autonomy before exploring change

MI is directional, but it is not coercive. The practitioner may have professional concerns and a legitimate change target in mind, but the client retains the right to decide what they will do (Miller & Rollnick, 2023).

Autonomy-supporting language reduces the pressure to defend the status quo:

• “It is ultimately your decision what, if anything, you do next.”
• “Would it be all right if we explored both sides of this?”
• “You have good reasons for feeling uncertain.”
• “I can offer information, but I don’t want to assume what is right for you.”

This is not passive neutrality. The practitioner can remain transparent about clinical concerns while avoiding an argument over who is correct.

2. Use complex and double-sided reflections

A simple reflection repeats or lightly paraphrases what the client has said. A complex reflection cautiously adds meaning, feeling, emphasis, or a possible underlying tension (Miller & Rollnick, 2023; SAMHSA, 2019).

• Client: “I know drinking is affecting my relationship, but it is the only way I can switch off.”
• Simple reflection: “Alcohol helps you switch off.”
• Complex reflection: “Right now, the relief alcohol gives you feels more immediate than the possible relationship consequences.”
• Double-sided reflection: “On one hand, drinking gives you relief at the end of the day; on the other, you are increasingly worried about what it is doing to your relationship.”

When using a double-sided reflection, placing the argument for change second can create a natural direction for the client to continue. Accuracy remains essential: overstating the change side may prompt the client to correct the practitioner by returning to sustain talk (Miller & Rollnick, 2023).

3. Ask questions that evoke change talk

Change talk is client language that favours movement towards change. The DARN-CAT framework distinguishes preparatory change talk – desire, ability, reasons and need – from mobilising change talk – commitment, activation and taking steps (Miller & Rollnick, 2023; SAMHSA, 2019).

Preparatory change talk	Example question
Desire	How would you like things to be different?
Ability	If you decided to make this change, what might make it possible?
Reasons	What concerns you most about continuing as things are?
Need	How important does this change feel to you now?

Mobilising change talk	Example question
Commitment	What are you willing to do?
Activation	What do you feel ready to try?
Taking steps	What have you already done that moves you in this direction?

These questions should arise from genuine curiosity. Delivering a succession of ‘change questions’ without reflective listening can make the interaction feel like an interrogation.

When change talk appears, invite elaboration:

• Tell me more.
• What else?
• Why does that matter to you?
• Can you give me an example?
• How might your life be different?

Process research supports attending to the balance between change talk and sustain talk, although the relationship between particular language subtypes and outcomes is more complex than early MI accounts sometimes suggested (Magill et al., 2018, 2019).

4. Use importance and confidence rulers diagnostically

Scaling questions can help clarify whether the main barrier is low importance, low confidence or both (Lubman et al., 2012; SAMHSA, 2019).

Importance ruler

• Ask: “On a scale from zero to ten, how important is it for you to make this change?”

If the client answers four, avoid asking why they are not at eight; that question invites reasons against change. Instead ask: ‘Why a four and not a one or two?’ The client then articulates why the change has at least some importance. Follow with: ‘What might move it from a four to a five?’ (SAMHSA, 2019).

Confidence ruler

• Ask: “If you decided to make the change, how confident are you that you could do it?”

A client may rate importance at nine but confidence at three. Further persuasion about the importance of change is unlikely to help. The conversation should instead explore past successes, strengths, practical barriers, support and smaller achievable steps.

5. Develop discrepancy through values – not shame

Discrepancy is the perceived distance between the client’s current behaviour and something they deeply value. The practitioner’s role is to help the client notice and articulate this discrepancy, not to announce it accusingly (Miller & Rollnick, 2023).

• What kind of parent, partner, or professional do you want to be?
• Where does this behaviour fit with the life you want?
• What matters enough that change may be worth the difficulty?
• If nothing changes, what might your life look like a year from now?
• If this concern became less dominant, what would you have more room for?

A values discrepancy should generate clarity, not humiliation. If the conversation increases shame or defensiveness, the practitioner may be moving too quickly or implying moral judgment (Miller & Rollnick, 2023).

6. Respond to sustain talk without strengthening it

Sustain talk is not misconduct or proof that the client is incapable of change. It is language expressing one side of ambivalence (Magill et al., 2018, 2019; Miller & Rollnick, 2023).

• Simple reflection: Client: ‘Therapy homework never works for me.’ Practitioner: ‘You haven’t found it useful.’
• Complex reflection: ‘You are reluctant to invest effort in another strategy that may disappoint you.’
• Emphasising autonomy: ‘Whether you try it is entirely your decision.’
• Shifting focus: ‘Perhaps we are getting ahead of where you want this conversation to go.’
• Double-sided reflection: ‘The exercises have felt artificial, and you are still looking for something that could make day-to-day anxiety more manageable.’

Avoid repeatedly inviting elaboration of sustain talk unless understanding it is clinically necessary. Extended rehearsal of reasons not to change may strengthen the status quo argument (Magill et al., 2018, 2019).

7. Share information using elicit-provide-elicit

Clients sometimes need clinical information, recommendations, or feedback. MI does not require practitioners to withhold expertise; it changes how that expertise is offered (Lubman et al., 2012; SAMHSA, 2019).

• Elicit: ‘What have you already heard about how alcohol can affect sleep?’
• Provide – with permission: ‘Would it be useful if I briefly explained what we know?’ Give the information neutrally, in manageable amounts, without implying that agreement is required.
• Elicit again: ‘What do you make of that?’ or ‘How, if at all, does that fit with your experience?’

This sequence helps the practitioner remain informative without slipping into a lecture. It is particularly useful when discussing medication, health risks, treatment options, or assessment feedback (Hall et al., 2012; SAMHSA, 2019).

8. Wait for readiness before moving into planning

Planning too early can produce superficial agreement rather than genuine commitment (Miller & Rollnick, 2023).

Signs that the client may be ready include:

• Change talk is becoming stronger or more frequent.
• Sustain talk is softening.
• The client begins imagining how change could occur.
• Questions shift from ‘Why should I?’ to ‘How could I?’
• The client identifies possible first steps without prompting.

At this point, the practitioner might ask:

• What do you think you will do?
• What would be a manageable first step?
• Which option fits you best?
• What support would make that easier?
• How would you like to respond if the plan becomes difficult?

A plan should remain the client’s plan. Advice and options can be offered with permission, but commitment cannot be manufactured (Miller & Rollnick, 2023).

A brief MI conversation with an ambivalent client

Speaker	Dialogue and MI process
Client	I know avoiding social situations is making the anxiety worse, but the thought of exposure exercises makes me panic.
Practitioner	Avoidance is shrinking your life, and exposure itself feels threatening. [Double-sided reflection]
Client	Exactly. Part of me wants to do it, but I don’t think I can.
Practitioner	The desire is there; confidence is the part that is struggling. [Complex reflection]
Practitioner	If you did decide to try something small, how confident would you feel from zero to ten? [Confidence ruler]
Client	Maybe a four.
Practitioner	Why a four rather than a one? [Eliciting ability and existing resources]
Client	I did manage to attend my sister’s birthday. I stayed only an hour, but I went.
Practitioner	Even with significant anxiety, you found a way to be there for someone important to you. [Affirmation linked to evidence]
Practitioner	What did you do that made that possible? [Elaboration]

This exchange does not eliminate anxiety or prescribe the next step. It helps the client recognise motivation and capability already present in their own experience.

For a condition-specific example, read Treating Generalised Anxiety with Motivational Interviewing.

Common mistakes when exploring ambivalence

Taking the change side

When the practitioner argues for change, an ambivalent client commonly voices the opposing case. The more convincingly the practitioner argues, the more practice the client receives in defending the status quo (Miller & Rollnick, 2023).

Confusing questions with MI

Open questions are important, but MI is not a questionnaire. Reflections, affirmations, and summaries help create the relational conditions in which honest exploration can occur (Magill et al., 2018; Miller & Rollnick, 2023).

Overusing decisional balance

A balanced exploration can help when a client is genuinely undecided and the practitioner has no ethical reason to favour one outcome. Once a clear direction has been established, repeatedly rehearsing the benefits of the status quo may strengthen sustain talk (Miller & Rollnick, 2023).

Overshooting change talk

If a client says, ‘I might need to cut down,’ responding with ‘You’re ready to stop’ exaggerates their position. Reflect slightly behind the client’s level of commitment: ‘Part of you is beginning to question whether the current amount is sustainable.’

Treating MI as scripts

MI techniques depend on partnership, acceptance, compassion and empowerment. A technically correct question can still feel coercive if it is used to steer the client towards a predetermined answer (Miller & Rollnick, 2023).

Evidence, limitations and clinical judgment

MI has been evaluated across substance use, health behaviour, and mental health contexts. Reviews describe a substantial evidence base, but effects vary according to the population, behaviour, comparator, practitioner proficiency, and quality of implementation (Bischof et al., 2021; Miller, 2023).

Process research supports both the relational and technical dimensions of MI. It also cautions against reducing MI to the simplistic claim that ‘more change talk always causes better outcomes’. Sustain talk, the proportion of change language, and the context in which statements occur may all matter (Magill et al., 2018, 2019).

MI can complement CBT, exposure-based work, behavioural activation, and other interventions when ambivalence affects engagement. It is not a substitute for comprehensive assessment, diagnosis, risk management or specialised treatment. Where immediate safety, abuse, suicidality, or serious medical risk is present, practitioners must follow relevant legal, ethical, and organisational requirements (Bischof et al., 2021; Miller, 2023).

Develop your motivational interviewing skills

A useful learning sequence is to consolidate the MI spirit, OARS, and four processes before applying MI to more complex cases (Miller & Rollnick, 2023).

Motivational Interviewing: The Basics

• Format: Text
• Duration: 4 hours

A current foundation in MI spirit, OARS, four processes, ambivalence, change talk, sustain talk, and relational repair.

View course details >

Introduction to Motivational Interviewing: Resolving Ambivalence and Changing Behaviour

• Format: Video
• Duration: 1 hour

A concise demonstration of DARN-CAT, confidence rulers, and OARS for moving from ambivalence towards resolution.

View course details >

Using Motivational Interviewing with Alcohol Dependence and Depression

• Format: Video
• Duration: 1 hour

A case-based demonstration of open questions, affirmations, reflections, summaries, and eliciting change talk in a clinically complex presentation.

For a broader pathway across foundational and applied topics, explore the MHA course catalogue’s motivational interviewing course suite.

Related practitioner reading

• Motivational Interviewing: Update Your Understanding  –  review how the language and emphasis of MI have evolved.
• Using Motivational Interviewing to Address Client Resistance  –  distinguish sustain talk from discord and explore broader response strategies.
• Treating Generalised Anxiety with Motivational Interviewing  –  examine MI within a specific clinical application.
• Compliance vs Engagement: What’s the Difference? – consider why apparent behavioural compliance is not the same as meaningful therapeutic engagement.

Conclusion

Working skilfully with ambivalence requires disciplined restraint: the aim is not to win an argument for change, but to create a respectful conversation in which the client can hear and evaluate their own motivations. When practitioners combine accurate reflection, selective evocation, autonomy support, and well-timed planning, ambivalence becomes useful clinical material rather than an obstacle. These techniques are most effective when delivered within the broader MI spirit and alongside sound assessment, appropriate treatment and ongoing attention to safety (Miller & Rollnick, 2023).

Key takeaways

• Ambivalence is a normal conflict between motivations; it is distinct from sustain talk and from discord in the therapeutic relationship.
• Start with partnership and autonomy. A clear clinical direction does not justify pressure, confrontation, or taking over the decision.
• Use accurate complex and double-sided reflections to hold both sides of the dilemma without exaggerating the case for change.
• Evoke the client’s own desire, ability, reasons, need, and commitment; use importance and confidence rulers to identify what the conversation needs next.
• Respond to sustain talk with reflection, autonomy support, or a shift in focus, and share information through elicit–provide–elicit.
• Move into planning when the client shows readiness, and keep any plan collaborative, realistic, and owned by the client.

Questions therapists often ask

Q. What is ambivalence in motivational interviewing?

A. Ambivalence is the simultaneous presence of motivations both for and against change. MI treats it as a normal part of change rather than evidence of pathology or unwillingness (Miller & Rollnick, 2023).

Q. Is ambivalence the same as sustain talk?

A. No. Ambivalence is the underlying conflict, while sustain talk is language expressing the side that favours maintaining the status quo. Change talk expresses the side that favours change (Magill et al., 2018; Miller & Rollnick, 2023).

Q. What is the best MI question for an ambivalent client?

A. There is no single best question. ‘What would you like to be different?’ can open the conversation, but its effectiveness depends on reflective listening, an agreed focus, and respect for autonomy (Miller & Rollnick, 2023).

Q. Should practitioners use a pros-and-cons exercise?

A. Sometimes. A decisional balance can clarify genuine uncertainty, but indiscriminately exploring the benefits of the status quo may strengthen sustain talk. Its use should match the clinical purpose and ethical context (Miller & Rollnick, 2023).

Q. How should I respond when a client says they do not want to change?

A. Acknowledge the position without argument and reinforce autonomy. You might say, ‘You have important reasons for not wanting this to change,’ before exploring whether the client wishes to discuss the issue further (Miller & Rollnick, 2023).

Q. When should MI move from evoking to planning?

A. Move towards planning when the client’s change talk strengthens, sustain talk softens and the client begins asking how change could occur. Premature planning can produce compliance without ownership (Miller & Rollnick, 2023).

Q. Can MI be combined with CBT?

A. Yes. MI is frequently used alongside CBT and other structured treatments, particularly when ambivalence affects treatment participation, exposure, homework, or behaviour change. The practitioner still needs appropriate competence in both approaches (Bischof et al., 2021; Miller, 2023).

References

• Bischof, G., Bischof, A., & Rumpf, H.-J. (2021). Motivational interviewing: An evidence-based approach for use in medical practice. Deutsches Ärzteblatt International, 118(7), 109–115. https://doi.org/10.3238/arztebl.m2021.0014
• Lubman, D. I. , Hall, K., Gibbie, T.  (2012). Motivational interviewing techniques: Facilitating behaviour change in the general practice setting. Australian Family Physician, 41(9), 660–667. https://www.racgp.org.au/afp/2012/september/motivational-interviewing-techniques
• Magill, M., Apodaca, T. R., Borsari, B., Gaume, J., Hoadley, A., Gordon, R. E. F., Tonigan, J. S., & Moyers, T. B. (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. https://doi.org/10.1037/ccp0000250
• Magill, M., Bernstein, M. H., Hoadley, A., Borsari, B., Apodaca, T. R., Gaume, J., & Tonigan, J. S. (2019). Do what you say and say what you are going to do: A preliminary meta-analysis of client change and sustain talk subtypes in motivational interviewing. Psychotherapy Research, 29(7), 860–869. https://doi.org/10.1080/10503307.2018.1490973
• Miller, W. R. (2023). The evolution of motivational interviewing. Behavioural and Cognitive Psychotherapy, 51(6), 616–632. https://doi.org/10.1017/S1352465822000431
• Miller, W. R., & Rollnick, S. (2023). Motivational interviewing: Helping people change and grow (4th ed.). Guilford Press. https://www.guilford.com/books/Motivational-Interviewing/Miller-Rollnick/9781462552795
• Substance Abuse and Mental Health Services Administration. (2019). Enhancing motivation for change in substance use disorder treatment (Treatment Improvement Protocol [TIP] Series No. 35; HHS Publication No. PEP19-02-01-003). https://library.samhsa.gov/sites/default/files/tip-35-pep19-02-01-003.pdf