Using Motivational Interviewing to Address Client Resistance

This article explores the fundamentals of motivational interviewing, highlighting – through example case studies – useful MI techniques for addressing what other therapies – but not MI – call client “resistance” in therapy.

Related articles: From Resistance To Acceptance, Working with Lack of Insight: Denial, Motivational Interviewing: Update Your Understanding.

Related discussion: How do you foster engagement in clients?

Related resource: Motivational Interviewing: Quick Clinical Guide

Introduction

Motivational Interviewing (MI) has evolved over the past four decades into a broadly applied, evidence-based counselling style designed to help clients resolve ambivalence and move towards positive change. Miller and Rollnick (2023) describe MI as a collaborative, person-centred form of guiding that elicits and strengthens motivation for change. For mental health professionals, this approach can be indispensable when encountering clients who seem resistant, unmotivated, or even hostile towards treatment.

The spirit of MI emphasises partnership, acceptance, compassion, and empowerment (Miller & Rollnick, 2023). By positioning the client as the expert in their own life, the clinician creates a safe space where ambivalence can be explored rather than judged. This approach is particularly useful with resistant or ambivalent clients, as direct confrontation can often entrench clients further into defensiveness, whereas MI seeks to gently uncover discrepancies between a person’s current behaviour and their deeper goals or values.

This article outlines motivational interviewing’s key concepts, rationale, and techniques for addressing client “resistance” in therapeutic contexts, illustrating reflective listening, developing discrepancy, and softening sustain talk through example case studies.

Overview of motivational interviewing

The 4th edition of Motivational Interviewing: Helping People Change by Miller and Rollnick (2023) defines MI as:

“A collaborative, goal-oriented style of communication with particular attention to the language of change. It is designed to strengthen personal motivation for and commitment to a specific goal by eliciting and exploring the person’s own reasons for change within an atmosphere of acceptance and compassion.” (Miller & Rollnick, 2023, p. 30)

This definition underscores the client’s autonomy, situating MI as an approach that helps clients harness their own motivations and values rather than passively receiving prescriptive advice. Central to MI are four core processes:

1. Engaging – Establishing a trusting, empathetic relationship.
2. Focusing – Identifying and maintaining direction related to a particular behaviour or concern.
3. Evoking – Drawing out the client’s reasons for change, often through skilful attention to “change talk” and “sustain talk”.
4. Planning – Transitioning from intention to action by collaboratively developing a plan for change.

Underlying these processes is the spirit of MI, which comprises partnership (working alongside the client), acceptance (honouring a client’s worth, autonomy, and strengths), compassion (actively promoting the client’s welfare), and empowerment (not just accepting, but encouraging the person’s autonomy, with the understanding that the practitioner is not giving this to the client but helping them to appreciate and use what they already have) (Miller & Rollnick, 2023).

Rationale

Mental health professionals frequently encounter clients who are ambivalent or overtly resistant to change. Whether the issue is substance misuse, persistent anxiety, disordered eating, or treatment non-compliance, forcing insight or prescribing change often fails to produce lasting results (more on this in our article, Compliance vs Engagement: What’s the Difference?).

MI offers a non-confrontational alternative: it leverages empathy, reflective listening, and strategic questioning to empower clients to identify and articulate their own reasons for change (Apodaca & Longabaugh, 2009).

A growing body of research highlights MI’s effectiveness in improving therapeutic engagement, enhancing adherence to treatment, and increasing the likelihood of positive outcomes in mental health settings (Carroll, Ball, Nich et al, 2005; Hall, Sears, & Walton, 2020; Lundahl & Burke, 2009). Because MI attends closely to the language of change – i.e., the client’s own statements about why and how they might change – the approach fosters a sense of ownership and lowers defensiveness. This method aligns well with values of recovery-oriented practice, respect for client autonomy, and culturally sensitive care.

Techniques

Here is a core set of MI techniques ensuring that clinicians remain grounded in the approach’s philosophy and method:

1. OARS Skills (Open-Ended Questions, Affirmations, Reflective Listening, Summaries)
   • Open-ended questions encourage clients to elaborate, rather than reply with a simple “yes” or “no.”
   • Affirmations highlight the client’s strengths, past successes, or positive traits.
   • Reflective listening conveys empathy and clarifies understanding.
   • Summaries synthesise key points and maintain direction in the conversation.
2. Recognising change talk. MI emphasises recognising and eliciting change talk – client statements indicating desire, ability, reason, or need for change. Clinicians also track sustain talk – statements favouring the status quo – responding non-judgmentally and using reflections to guide clients to explore their ambivalence (Miller & Rollnick, 2023).
3. Developing discrepancy. Clinicians help clients notice inconsistencies between their goals/values and their current behaviours. This is done gently, without confrontation, allowing the client to articulate the discrepancy themselves, thereby increasing motivation to resolve it (Magill et al., 2014).
4. Softening sustain talk. Confronting or arguing with “resistance” can reinforce it. MI’s approach is to “roll with” it, in a skill that used to be called “rolling with resistance” but now is talked about in MI as decreasing discord or “softening sustain talk” – recognising it as a sign of ambivalence (sustain talk) or a mismatch in pace or focus (discord). By validating the client’s concerns and exploring them, therapists minimise defensiveness and preserve the therapeutic alliance (Miller & Rollnick, 2023).
5. Supporting autonomy. Because change can seem daunting, especially when clients feel hopeless or overwhelmed, MI encourages therapists to highlight even small successes and affirm the client’s capacity for growth. This nurtures a sense of agency and optimism (Hall, Sears, & Walton, 2020).

Applications within mental health care

Although MI was first developed in the field of addictions, it is now widely employed in diverse mental health contexts (Apodaca & Longabaugh, 2009). It is effective as a stand-alone intervention or in combination with therapies like CBT, dialectical behaviour therapy (DBT), or family-based interventions. Research demonstrates MI’s value with adolescents, adults, and older adults dealing with anxiety, depression, trauma, and various behavioural health issues (Dean, Britt, Bell et al, 2016; Bischof, Bischof, & Rumpf, 2021; Apodaca & Longabaugh, 2009; Lundahl & Burke, 2009).

The guiding principle of autonomy makes MI well-suited for those who feel disempowered or wary of traditional hierarchical treatment relationships. For example, individuals who have experienced trauma may find the gentle, empathic style less triggering than more directive approaches. Likewise, adolescents, who often wrestle with authority and desire increased independence, can respond positively to the collaborative tone inherent to MI.

Understanding client “resistance” (= sustain talk or discord)

Traditionally, “resistance” is described as client behaviour (e.g., being defensive, reluctant, or passive-aggressive) that hinders therapeutic progress. Within the framework of MI, “resistance” is reframed. MI advocates that rather than viewing it as a client trait, clinicians should see it as either a natural manifestation of ambivalence (manifesting as sustain talk: the desire to maintain the status quo) or discord: a mismatch between client and clinician in the therapy’s pace or style (Miller & Rollnick, 2023).

Common presentations of discord/sustain talk

The following are examples of how client push-back (that is, sustain talk or discord with you) may present in your therapy room:

1. Verbal: “I don’t need therapy,” or “No one can help me.”
2. Behavioural: Frequent cancellations, arriving late, failing to complete tasks.
3. Emotional: Becoming defensive, angry, or shutting down when confronted with uncomfortable topics.
4. Intellectualising or minimising: Focusing on external problems (“It’s not me, it’s everyone else”) or glossing over personal concerns (“I’m fine – it’s not that serious”).

These behaviours often reflect deeper tensions or fears about change – whether it be fear of failure, losing control, or confronting painful feelings. By backing up to see where they have become mis-attuned to the client or engaging skills for softening the sustain talk, the clinician communicates respect for the client’s perspective, paving the way for more honest, productive conversations.

Case studies exploring MI techniques applied to discord/sustain talk

Below are detailed case studies illustrating MI techniques applied to reduce and resolve ambivalence and/or discord between therapist and client. Each case provides context on the client, a demonstration of therapeutic dialogue, and a brief discussion of outcomes. One involves an adolescent, highlighting the particular nuances of working with younger clients.

Case study 1: Defensive adult with substance use

Martin, a 35-year-old male, was referred by his employer due to concerns about his frequent intoxication at work. He attends sessions begrudgingly and insists that others are exaggerating his alcohol use. His posture is defensive, with arms folded, and he often bristles at suggestions that he modify his behaviour.

Presenting discord/sustain talk

• Verbal: “They’re just making a big deal out of nothing.”
• Behavioural: Comes to sessions late, avoids eye contact.

Therapeutic dialogue (early in therapy)

• Therapist (T): “Martin, you’ve mentioned feeling cornered because your employer and partner think you drink too much. Could you tell me more about what worries you the most about being here?”
• Martin (M): “It’s not fair. People drink. I’m not an alcoholic.”
• T: “You feel like you’re being singled out unfairly, especially since drinking can be a social activity at work. It sounds frustrating to be told you need help when you don’t believe you do.”
• M: “…Yes, exactly.”

Here, the therapist uses reflective listening to validate Martin’s frustration without endorsing or dismissing his perspective. As the conversation progresses:

• T: “If we set aside what others think for a moment, what are your own thoughts about how alcohol fits into your life? Are there any things you’d like to see change, if at all?”
• M: (Pauses) “Maybe I don’t like how it makes me feel in the mornings. I’m tired… My partner and I argue when I drink too much.”

By evoking Martin’s own insights, the therapist hears emerging change talk about feeling tired and relationship strain. Over subsequent sessions, the therapist highlights this discrepancy – Martin’s desire for a better relationship and job stability versus his current drinking pattern – without pressuring him. As he begins to explore these discrepancies on his own terms, Martin becomes less defensive.

Outcomes

Within a few weeks, Martin decides to track his drinking and cut down to weekends. He reports fewer hangovers and improved communication with his partner. MI’s empathic, non-confrontational approach helped Martin reduce defensiveness and recognise his own reasons for change.

Case study 2: Adolescent with defiance

Aisha, a 16-year-old, was referred due to truancy and conflict with teachers. She frequently argues with her mother and insists school is pointless. Her posture and attitude in sessions – crossed arms, rolled eyes – suggest defiance and boredom.

Presenting discord/sustain talk

• Emotional: Eye-rolling, dismissive comments.
• Verbal: “School is a waste of my time.”

Adolescents often bristle under perceived authority and can respond well to a respectful, autonomy-supporting approach (Dean, Britt, Bell et al, 2016). MI’s spirit aligns with such needs.

Therapeutic dialogue

• Therapist (T): “Aisha, you’ve shared that school doesn’t feel meaningful right now. Could you tell me what it is about school that bothers you the most?”
• Aisha (A): (Shrugs) “I hate being told what to do every minute of the day. They treat me like a child.”
• T: “It sounds like you really value your freedom and respect. Being talked down to or forced to follow rules you don’t agree with feels stifling.”
• A: “Right. Nobody listens to what I want.”

By reflecting Aisha’s views, the therapist avoids a power struggle. The therapist then starts to explore possible future aspirations:

• T: “If you could create the perfect future for yourself, what would that look like, beyond what teachers or your mum say?”
• A: “…Maybe getting a decent job, not being stuck in a boring life.”
• T: “You want a decent job and more control over your future. How might school, frustrating as it is, factor into that?”

Aisha concedes that graduating might make it easier to find worthwhile work. This moment highlights the developing discrepancy between her desire for independence and her current pattern of truancy. Over subsequent sessions, the therapist continues using open-ended questions and affirmations of Aisha’s strengths (e.g., her creativity, intelligence) to build rapport.

Outcomes

Aisha gradually shows up to more classes and explores interest-based electives. Though still sceptical of traditional schooling, she acknowledges that finishing her education could open doors for the autonomy she craves. MI allowed her to feel heard, reducing her defiance and increasing her intrinsic motivation to attend school.

Case study 3: Adult with depression and hopelessness

Sara, a 28-year-old struggling with chronic depression, presents with profound hopelessness. She often cancels sessions and expresses doubt that therapy or medication can help. She feels her life will always be unhappy and sees little reason to engage in treatment.

Presenting discord/sustain talk

• Verbal: “I’ve tried therapy before; nothing changes.”
• Behavioural: Misses appointments, avoids assignments.

Therapeutic dialogue

• Therapist (T): “Sara, it sounds like you’ve had a long, difficult journey with depression, and it’s hard to imagine anything could be different. That must feel exhausting.”
• Sara (S): “Yes, it’s pointless. I’m tired all the time.”
• T: “You’ve done a lot already – medication, different therapies – and haven’t felt the relief you want. Sometimes people in that position feel like giving up. Still, you came here today. What do you think keeps you coming, even if it’s not every session?”

Here, the therapist acknowledges Sara’s hopelessness without minimising it. Instead of lecturing on the benefits of therapy, the therapist gently elicits Sara’s change talk about any remaining reasons for showing up.

• S: “I guess I don’t want to disappoint my family. They keep asking me to try.”
• T: “So part of you cares about how your depression affects your family. That’s important. What else might matter to you personally, if anything, about feeling better – even a little?”

Sara mentions she would like to have more energy to do simple things, such as cooking or going for a walk. The therapist uses affirmations – e.g., “It takes courage to keep going when you’ve felt disappointed by past treatments” – and helps her set small, manageable goals that could yield noticeable improvements.

Outcomes

Over time, Sara reports slight improvements in mood when she takes short walks and practices daily self-care tasks. While her progress is slow, she remains engaged in therapy, and her sense of hopelessness begins to ease. MI provided a supportive environment where her scepticism was validated rather than confronted, leading her to re-engage with treatment on her own terms.

Case study 4: Older adult in denial about health concerns

John, 62, has Type 2 diabetes and hypertension. Referred for stress management and lifestyle modifications, he dismisses his doctor’s recommendations to change his diet or exercise. He believes that “at my age, I deserve to eat what I want,” and expresses frustration at medical “nagging.”

Presenting discord/sustain talk

• Verbal: “I’ve eaten this way my whole life; I’m not changing now.”
• Behavioural: Skips medical appointments, rarely checks blood sugar levels.

Therapeutic dialogue

• Therapist (T): “John, it’s understandable you’d feel this way after a lifetime of eating habits. Can you tell me about your goals now that you’re retired?”
• John (J): “I want to enjoy life – go travelling, fishing with my wife.”
• T: “Those sound like great plans. How do you see your health fitting into that? Do you have any concerns about how high blood sugar or blood pressure might impact these activities?”

As John shares worries about potential complications, the therapist helps him see the discrepancy between his health goals (staying active and enjoying retirement) and current behaviour. Rather than lecturing him, the therapist uses open-ended questions to let John discover for himself how lifestyle changes could support his aspirations.

• J: “…I don’t want anything to stop me from going on those trips.”
• T: “So, even though you’re not thrilled about being told what to do, there might be small steps you can take – on your own terms – that could keep your health strong enough for those travel plans. Any idea what the first step might be?”

John decides to cut back on sugary drinks and take short walks. The therapist offers affirmations for every positive step. Over time, John sees modest improvements, such as better energy and slightly improved blood sugar readings.

Outcomes

Though still resistant to certain dietary recommendations, John becomes more receptive and even attends a follow-up appointment with his doctor. The key to this positive shift was framing behaviour change in terms of his personal values and goals, rather than simply complying with medical advice.

Conclusion

In mental health practice, addressing client ambivalence about change – and what is often consequent disord between therapist and client – is both a common and challenging aspect of providing effective care. The 4th edition of Motivational Interviewing: Helping People Change (Miller & Rollnick, 2023) offers a refined and comprehensive framework for understanding and working through such concerns in a collaborative, empathetic manner. By viewing client push-back as a sign of ambivalence (fear of changing) and/or discord with the therapist rather than stubbornness or pathology, clinicians can “soften the sustain talk” (the talk in favour of maintaining the status quo) and re-attune themselves to the client. By using such a framework, therapists respect clients’ perspectives and autonomy while gently guiding them to consider changes aligned with their own goals and values.

The case studies presented illustrate MI’s diverse applications: from an adolescent struggling with authority to adults wrestling with addiction, chronic health issues, or depressive hopelessness. Across these scenarios, a consistent theme emerges – when clients feel heard, validated, and free to explore their ambivalence without judgment, they are more likely to drop insistence on the status quo and embrace meaningful change.

Key takeaways

• Before addressing behaviour change, invest in building a trusting relationship. Discord and sustain talk often decrease when clients feel safe and understood.
• Confronting or challenging so-called “resistance” head-on can entrench it. MI teaches clinicians to accept and explore it instead, turning it into a pathway for deeper discussion.
• Inviting clients to articulate their hopes, goals, and values creates a natural platform for discovering discrepancies between what they want and what they currently do.
• Listening for and reinforcing statements that suggest a desire, ability, reason, or need for change promotes intrinsic motivation.
• Small wins and existing strengths boost autonomy. Affirming these helps clients see themselves as capable of further change.

References

• Apodaca, T. R., & Longabaugh, R. (2009). Mechanisms of change in motivational interviewing: a review and preliminary evaluation of the evidence. Addiction (Abingdon, England), 104(5), 705–715. https://doi.org/10.1111/j.1360-0443.2009.02527.x
• Bischof, G., Bischof, A., & Rumpf, H. J. (2021). Motivational Interviewing: An Evidence-Based Approach for Use in Medical Practice. Deutsches Arzteblatt international, 118(7), 109–115. https://doi.org/10.3238/arztebl.m2021.0014
• Carroll KM, Ball SA, Nich C, Martino S, Frankforter TL, Farentinos C, Kunkel LE, Mikulich-Gilbertson SK, Morgenstern J, Obert JL, Polcin D, Snead N, Woody GE; National Institute on Drug Abuse Clinical Trials Network. Motivational interviewing to improve treatment engagement and outcome in individuals seeking treatment for substance abuse: a multisite effectiveness study. Drug Alcohol Depend. 2006 Feb 28;81(3):301-12. doi: 10.1016/j.drugalcdep.2005.08.002. Epub 2005 Sep 28. PMID: 16169159; PMCID: PMC2386852.
• Dean S, Britt E, Bell E, Stanley J, Collings S. Motivational interviewing to enhance adolescent mental health treatment engagement: a randomized clinical trial. Psychol Med. 2016 Jul;46(9):1961-9. doi: 10.1017/S0033291716000568. PMID: 27045520.
• Hall, M. T., Sears, J., & Walton, M. T. (2020). Motivational Interviewing in Child Welfare Services: A Systematic Review. Child Maltreatment, 25(3), 263-276. https://doi.org/10.1177/1077559519893471
• Lundahl B, Burke BL. (2009). The effectiveness and applicability of motivational interviewing: a practice-friendly review of four meta-analyses. J Clin Psychol. 2009 Nov;65(11):1232-45. doi: 10.1002/jclp.20638. PMID: 19739205.
• Magill, M., Gaume, J., Apodaca, T., Walthers, J., Mastroleo, N., Borsari, B. & Longabaugh, R. (2014). J Consult Clin Psychol. 2014 December ; 82(6): 973–983. doi:10.1037/a0036833
  https://doi.org/10.1037/ccp0000315     
• Miller, W. R., & Rollnick, S. (2023). Motivational interviewing: Helping people change (4th ed.). Guilford Press.