Psychiatry & Psychotherapy Podcast - Motivational Interviewing with William Miller

Episode Date: December 1, 2023

Motivational interviewing serves as a versatile enhancement to various professional practices, whether it's behavioral therapy, medication counseling, classroom teaching, or sports coaching. In the words of Dr. William Miller, "It's a way of being with people to help people make changes." This method emphasizes a collaborative and empathetic interaction style, focusing on empowering individuals to drive their own change, making it a valuable asset in any change or growth-oriented setting. By listening to this episode, you can earn 1.5 Psychiatry CME Credits. Link to blog. Link to YouTube video.

All right, welcome back to the podcast. I am joined today with Dr. William Miller. He is the founder of motivational interviewing along with Stephen Rolnik. He has been doing this for 40 years. He has countless articles that he's written on this, countless books. Probably most of interest is his fourth edition of motivational interviewing. This was actually a book that I read back in medical school, I think it was the first psychotherapy-esque book that I read as a third-year medical student, and it's what initially sparked some interest in psychiatry. And today we'll be talking about motivational interviewing. We'll be talking about change. We'll be talking about ambivalence. So welcome to the podcast. Thanks so much. I'm super excited to have you here. I feel like

I know you a lot more than you know me at this point. just because of your work, which is monumental to the field. And I wonder if we could talk about the why of why this episode and why talking about change is so important. And I was reading this article, it was a 2009 article called Adding Motivational Interviewing Pre-Treatment to Cognitive Behavioral Therapy for Generalized Anxiety Disorder, a preliminary randomized controlled trial by Wester at all. and was impressed that they found that in the most anxious group,

starting with a few sessions of motivational interview, and I think it was four 50-minute sessions, really improved CBT outcomes. And there was a bunch of studies that kind of had a similar thrust. And I'm wondering why you think motivational interviewing supercharged CBT in this study and others like it. Well, it makes sense, particularly with severe anxiety disorders, especially if you're going to be doing some exposure-based treatment, you're asking people to do something they really don't want to do, something that is quite difficult and even frightening for them. And so they better trust you.

You better have a good relationship with them to start. And I think that's one piece of it, just establish. a working alliance. I wrote another book with Terry Moyers in 2021, in which we went back through 70 years of psychotherapy research, looking for why is it that some therapists just get better outcomes than others do? Even using the same manual in a highly controlled setting, you still get differences. Even when you try to squash them as much as possible, you still get differences among therapists. And one of the better predictors of how a patient does is who treated them. So we finished that book and we come up with eight characteristics of therapists that over

these 70 years have been found to be related to better outcomes. And then I looked at the list after we finished the book and said, this looks awfully familiar. At least seven of the eight are things that have been characteristics or motivational interviewing from the very beginning. And so it just got me to thinking, is this what we've been studying for 40 years? What makes helpers more effective? So that piece, at least,

of establishing a good working alliance, then the other piece, of course, is mobilizing the person's own motivation for change and their own resources. And that's a feature of motivational interviewing as well. of evoking from people their own desire and ideas about change. So I think both of those things happening before you charge into an exposure-based treatment for anxiety disorders, it makes sense that that would help with outcomes.

Yeah, I was thinking about, so this is kind of like still in the vein of the why, why this episode, why thinking about change behavior, why this is relevant. And as providers, a lot of what we try to do is get patients motivated to engage in treatment, you know, whether it's compliance with medication, compliance with psychotherapy, compliance with exercise, compliance with things more related to the research of, you know, addiction, things that are heavily researched with motivation. I know it goes beyond that, but just I know that that's probably where the bulk of the research has been done. And so I was thinking about maybe we could role play an ambivalent patient.

And I'm like an ambivalent patient needing to seek care. Okay. And I'm making this up. This isn't me. But I could role play this and just see how it goes. What do you think? Well, it's good, but it tries. Yeah.

Okay. So the scenario is, let's say, that this person needs to do a sleep study and they need to to do exercise and they need to actually take their medication. And so they're coming in maybe for a second appointment and they haven't done any of that stuff. And so they're basically still depressed and anxious. These are things that you think they need to do and would help them and you would like them to do those things. And the presenting issue is depression? Is that right? Okay, so let's say

It's okay Yeah, yeah, yeah, I know I'm thinking about how you switch that on me Yeah, okay, so there are things that have Yeah, there are things like, let's say it's depression, let's say it's moderate to severe Yeah And yeah, so they're coming in for that

And they are not making movements towards that Right, okay, and you've prescribed these changes and so far it hasn't happened, right? Right, okay. And that includes medications, trying to get their sleep straightened out. Yeah, let's say you suspect that there's obstructive sleep apnea. Mm-hmm.

And so, you know, they're not sleeping well, they're not, and that could worsen depression. Certainly. And then they're not maybe, you know, they could exercise, but they're too depressed to exercise, or they're choosing not to exercise. Okay, yeah, but those are all sensible things to ask them to do. And on first try, it hasn't happened. And let's say, fourthly, they have not connected to the therapist that you recommended they connect with. Oh, I thought they were seeing you about this. So you're not a therapist?

Let's say you're taking more of the psychiatrist's perspective. And, you know, you're in a, like a lot of providers that I have, they're more in the prescriber. role, maybe they see the patient once a month, you know, and so they're needed to motivate the behavior change in, you know, a 15, 20-minute appointment, if possible, right? That's a high challenge, yeah. Okay, all right. All right, so I'll start up. Well, Dr. Miller, I just haven't gotten anything done this last month. I know you told me a lot of things to do, but I just didn't do it at all. Yeah, and sorry, I may have told you too much to do, I guess. I mean, that's part of feeling

depressed that you just don't quite feel like doing things. And so of the things that I have told you, or suggested to you, at least, might be helpful to you. We talked about sleeping better. We talked about medication. We talked about exercise. I think. think, which of those do you think would be the most feasible for you? Because I may have asked you to do too much all at once. Um, uh, so probably, probably the exercise. Yeah, I'm interested in your own hunch here of what, which are those would you be most able to do? And do you have a sense would be most helpful to you? Yeah, the medication, I'm just like, part of me is just not excited. to take a medication.

Not too sure with that. Yeah. And then the therapy, like, I just, ah, I don't know. Like, I don't know this person. I don't know if, like, they're going to be helpful. Yeah, it's kind of hard, a little bit scary to think about starting with somebody new. Uh-huh. Yeah.

Yeah. And then the sleep study, I don't know. It just, like, seems like a lot to schedule that. I don't know if it's even going to be helpful. Well, let's talk about a first step then, which, and I'm interested in your hunch that in a way the easiest first step might be to do some exercise. And there is a good literature on that helping with depression. So I think that's a good idea.

I think that's a great place where you could start. And I just gave you a kind of a menu of options, but too many. So let's start with this one. Okay. So first of all, what kind of exercise have you done in the past? and have you enjoyed? I used to run. I used to run a lot.

And, yeah, I guess I stopped when life got busy. Yeah. But a lot. You ran quite a bit, huh? Yeah, I used to do a little bit every day, every morning, or like most days of the more. And it just kind of fell by the weight side when you got busy. So that's something that you could do, clearly.

I mean, that's something you have done in the past. past. And I gather even enjoyed it because you were doing it on a regular basis. Yeah, mostly enjoy it. I don't know. Like, part of me, you know, just did it because I knew I would enjoy it afterwards, maybe. When it's over. Sure, sure, yeah. Well, and that's also one of the paradoxes with depression, that the things that you need to do, you don't feel like doing right at the moment, you know, and so it keeps you from it. And so that's what we're looking for. What could you start? Just one thing that might make some difference for you that just seems feasible. And so this is one running maybe. What other kinds of exercise you've enjoyed?

I used to go to the gym, you know, and yeah, it used to be helpful for me, I think. How was it helpful? I would, you know, like, I think I would feel better afterwards, or I'd feel more like I liked my body or I liked, you know, just feeling like I did something. So even then, you felt better, at least afterwards, and felt good about what you were doing in terms of taking care of yourself and building up your body. Yeah. So that sounds really promising, actually. Now, if you were to try out some exercise now, these are things you've done in the past, but they're gyms around. You can run anytime.

Where might you start? I don't know. I feel like I'm just so out of shape. I feel like it would be just really hard to start anywhere. Uh-huh. Just maybe just, yeah, maybe just like run jog or something like that. They'll kind of ease into it just to see how you are, what your, what your body can do as you begin to build back up to a better fitness like you used to have. Yeah.

So that one seems maybe like the most promising thing to just try a little bit of running. Yeah. I think that's probably the first of the four that I would be most open to try. Well, it'd be a great place to start then. Yeah. And how would you do that then? Knowing what you know about yourself, because you know more about yourself than anybody does, how would you make that happen? I probably, well, I used to just put my shoes and clothes, set kind of set it up the night before so it was just there and then i would just first thing in the

morning just before i even did anything really just get get my get my running clothes on yeah that makes sense it's right there it's ready to go when you wake up it's the first thing you're going to do you go right to it yeah yeah well that seemed to wear the try are you willing to do that yeah Uh-huh. Yeah. I think, and, you know, if that, if that isn't helping, we'll look at other things, too. But I just, I trust your hunches here, that that's something you can do and have done in the past. And it's pretty likely to, in the longer run, at least, kind of get you feeling somewhat better.

So, good place to start. I'm just, I'm just realizing that you're probably angry at me for not doing anything since our last visit. Not in the least, no. And it's perfectly natural. And as I said, this is part of depression also. You just kind of get weighed down. And so you don't feel like doing the things that you need to do to get better. So it isn't even surprising to me, let alone something that makes me angry. No. My concern is for you. And how can you do the things that will help you feel better? I just worry that next visit I won't have done anything again and you'll be just so upset at me or I'll be upset at myself.

There you go. You might be unhappy with yourself. Don't put that on me, you know, but this is something that, that, you know, sounds to you like, that's doable. I could do that. I think that would make a difference for me. It's possible. I might give it a try, that you're willing. willing to give it a try.

Okay. All right. So, okay, so things I appreciated that you did was that you took a very non-defensive approach with the four things, and you kind of, like, allowed him to pick one. Yeah. And allowed him to, you looked for change language. You emphasized it. And I think there was like some empathy for just how hard it was.

It's good. Honoring autonomy, just recognizing the person's right and ability to choose what they are going to do. Yeah. Just kind of automatic parts of motivational interview. Yeah. Sometimes you'll do like a number. And I'm curious why you chose not to do that. Sometimes you'll say something like on a scale from one to ten, how much do you want to change?

and then they'll say maybe like five and you'll and you'll say something like wow okay so it's it's five it's in the middle like tell me why it's five and not one so you kind of get them to talk about the positive aspect of the change that's one of one of many tools that we have for for inviting change talk i i don't use it routinely or you know all the time but we could have in this situation And I wouldn't have done it about change in general. I would probably say how important is it for you to start feeling better and getting out of this depression, for example. Okay, let's try that. Can you say anything else?

Yeah. Okay. So let me back up just a minute here and ask you a question also. Thinking about how you've been feeling, and you've told me some about that and how difficult this is. been for you. Just imagine a zero to ten scale. And what I'm asking is how important is it for you to start feeling better to get out of this hole that you're in? And zero is not at all important. And ten is this is the most important thing in my life right now. What number would you give yourself? Probably a four. About a four. So it's important. And why not zero? What is what's important

about starting to feel better? I think that I'm just tired of being. I'm tired of just feeling so lousy. Yeah, I mean, I can only imagine what you've told me how difficult it is. And so

it's at least that important to you to do something to get moving, to kind of get out of this. Yeah. And you can. It's possible for you. We've talked about a variety of things you could do, but that's right there in front of you.

This is something that I really want to do. I really want to get out of this rut and start something better. Okay. Yeah, so face shifting here. Yeah. So it's getting them to talk about the change, right? It's getting them to talk about the yearning or the desire to change. And so people have ambivalence, one way or the other.

Part of them wants to change. Part of them doesn't. Sure. But one thing that I've heard from you is that getting them to talk about the part of them that wants to change and then kind of repeating that back to them a couple times. Reflecting it back. So they hear it. Do you ever repeat back the part of them that doesn't want to change?

Sometimes. And I do it in a particular way. often with a double-sided reflection. So on one hand, this is really hard for you. This is difficult, and you don't feel like doing it. And on the other hand, you really want to get out of this hole. I mean, how are you feeling right now? You just don't want to stay there.

And so you'd like to do something to get out of there. Okay, so the double-sided reflection, as in like, there's part of you that doesn't want to quit. Yeah. smoking, but there's part of you that really wants to quit smoking. And so you're kind of like, that's the double side? Both things are true. Yeah. And you put the change talk second. Why would you do that? Because if you finish with a sustained talk, if you say, well, there's part of you that wants to quit smoking, and then there's a part of you that doesn't,

and you stop there, they're going to tell you more about why they don't want to. So there's a little art to the order in which you give things as well, of it with a double-sided reflection. But sure, and particularly at the beginning of a session, if you're not paying attention to and listening to their reluctance, you're losing relationship points, first of all. So listening to that well, letting them know you get it and understand it as like making deposits in the bank that you can draw on a little later, you know. but we certainly do listen to people's reluctance and sustained talk and discord and their

their unhappiness or discomfort with what's happening in this relationship right now. Okay. So, okay, so really I see motivational interviewing is so powerful to get someone to move from the pre-contemplation stage of I don't want to change to the contemplation stage where there's the ambivalence. and then moving them from there to like the preparation or action. Helping them move, yeah. I like, that's good.

Tell me why you corrected me there. Because it's not us doing it. The energy needs to come from them. The motivation comes from them. I don't get to make them motivated, you know. So I'm kind of listening to where the energy is in their own material. that wants to move forward to make a change. Yeah, beautiful.

I think the Rogarian sort of historically, I think you had kind of a Rojarian foundation, Carl Rogers. Is that true? I got trained in that first happily, yeah. And so when I came into cognitive behavior therapy, it was with that background of therapeutic relationships. and it just made a difference in how I do behavior therapy. And one of the first studies that I published was what a difference empathy makes

that has defined by Carl Rogers, the skill of listening and reflecting. What a difference that makes in how well behavior therapy works? It just struck me. It was a huge effect. So who's doing the behavior therapy and how are they doing it? The procedures of behavior therapy are fairly straightforward, and often there's not much discussion about the relationship within which you do that, but the relationship within which you do that carries probably more freight than the specific techniques they're using.

So they've always fit together for me. Yeah. Yeah, I think I'm big on the research of therapist effect as well. like what makes one therapist better than the other. It seems like I just recently did an episode on borderline personality disorder and the different therapies. There's like around six therapies that all seem to work about equivalently. That's a finding in the psychotherapy literature that when you compare two therapies,

even with very different theoretical approaches with each other, done by people who believe in them when they're trained in them, you tend to get similar outcomes. However, within each one, there are substantial differences and outcome based on who the therapist was. So, yeah, tell me a little bit more about how, like, is empathy a big piece of that, natural empathy, trained empathy? Not natural empathy, but the skill of accurate empathy, you know, you're not born with that. You learn it over time. I mean, there is a kind of empathy that is something that just happens developmentally.

You begin to be able to appreciate someone else's perspective. But with Rogers, we're talking about a particularly learnable, measurable skill that is related to client outcome. And of the eight that we came up with in that book on Effective Psychotherapists, it has the biggest effect. The most consistent effect of therapists' effectiveness is accurate empathy, the extent to which the person is the person. person is doing that while they're doing whatever else they're doing. So I've been started thinking about motivational anything as a way of doing what else you do, you know, whether it's behavior therapy or cognitive therapy or diabetes education or sports coaching or classroom teaching. I mean, it's a way of being with people as you're doing the technical things that help people to make

changes. Okay. So when I think of empathy and I say, you know, I consider like the Big Five personality types and there's some parts of the Big Five that are more associated with like affective empathy. Sure. Like agreeableness or sometimes openness. And but what you're talking about is that people can be trained in empathy, which I agree. I've seen a lot of studies on that. Yes. what specifically, I've also heard from you that it's not enough to go to a weekend motivational interviewing seminar. I learned that the hard way by measuring the outcomes of my training and finding there was very little evidence I had been there, you know?

Which I imagine was like, it's almost a piece of research that you want to squash, right? So I, well, it felt bad, you know. At the same time, it did what good research does, which has raised a better question. What does it actually take to help people learn this? And it's not warming a chair at a workshop. That's a good start, you know, but it clearly was not enough. Even though the ratings of the workshop on paper and pencil, outstanding, I learned so much, I'm using it every day in my practice, and then we listen to practice and it's not there.

So all I had done was increase false confidence. Okay, so that makes me think about another role play we could do. Now, for the record, like, I love supervision. Like, I think, like, I feel like this is supervision right here. Hopefully, this counts. Hopefully this counts as supervision. But I love, like, supervision. But I find that a lot of therapists, once they get into practice, they don't value pain for good supervision.

They don't value pain for good coaching, you know, around that. They get busy, you know, there's ambivalence there. They don't know who to reach out to. So I thought I could pretend to be one of those people. And it's been hard for me at times. So like I feel like I've, well, I don't know. That's a complicated question. that's a complicated statement. It has been hard at times to reach out for help when I needed help.

But as I've gotten more into my practice, it's easier. Well, and here's a, I mean, here's a maybe not widely appreciated fact, but one of the most widely, clearly replicated findings in psychotherapy research is that therapists don't get better with practice. So after 40 years of experience, you have about the same, if you're lucky, you have about the same outcomes as when you started. That's not true of surgeons. Surgeons get better with practice. There's a strong effect of how many times you've taken gallbladder out and so forth. But it's not true in psychotherapy. You don't automatically get better with practice, even though we think we do. So what does it take again? And that's where

the deliberate practice literature comes in. Now, for musicians, is they spend a lot of time practicing outside of their performances. Therapists don't necessarily. We just do our performances, which is treating clients, but not a lot of intentional time to strengthen those skills apart from, well, practice is what we call it, isn't it? But actually performing therapy. So there's a big literature on deliberate practice in many fields,

and it's also true in psychotherapy, that when you put in the time to get better at what you're doing outside of delivering services, that's how you get better at what you're doing. Those are the therapists whose outcomes are improving over time. Yeah, and I think it's so complicated because therapy is also a relationship. It's also empathy.

So it's like we need to be on our own process at the same time. Oh, it is complicated. Yes. It's not simply, like a musician or, you know, a taxi driver or, you know, like being really good at therapy is so holistic. It's so, it's such a part of who you are as a person as well. But it doesn't happen automatically. I know. I'm, I'm just pushing back a little bit to this idea that that you could train it in a

way that is repetitive and outside of the work of actually doing it. But I agree with you at the same time that there's something about having good supervision, having good ongoing therapy, and really self-care as well, right? Because like, it's like you have to have a balance and heal yourself. And a lot of what we, a lot of what we consume as things. As that, therapist is vicarious trauma as well. So it's like you have to grow to some degree. No, dealing with that is important as well. Therapy is complex. It's complex, yeah. But to your point, you have found that how to learn MI is actually you need more than just going to weekend seminar. You need ongoing coaching. How much coaching does one need from the studies that you found to learn the modalities?

of motivational interviewing? The good news is that in, well, the first thing we did after that embarrassing, humiliating study was a randomized trial of different training methods. So some people just came to the two-day workshop on motivational interviewing. Some were on a waiting list, so didn't get that. Some, in addition to their workshop, got systematic feedback about what they were doing, So their practice sessions were coded and they got that information back. Some got coaching calls and it was six half hour telephone coaching sessions after initial training.

And then some got both, the feedback and the coaching. It's a long way of answering your question of what we found was that an average of five, which was the average completed, an average of five. an average of five out of six, half hour of telephone coaching sessions made a substantial difference in both acquisition, but also maintenance of skills. And more importantly than that, made a difference in client responses. So they were getting more change talk. And the only group that was successfully getting more change talk from their clients is the one that got both feedback and coaching.

Feedback is, what, to find feedback again? Feedback was getting in the mail, coding information about the quality of what you were doing, which was sort of a dumb idea in retrospect, you know, that we had the biggest dropout in that group because getting in the mail something that says, you know, well, you're doing okay, you know, it's not very encouraging and you don't want to stay with it, you know. So combined with coaching, it makes a lot more sense. But even the feedback itself did improve skills. But it was the combination of those.

And so that's where we began really emphasizing post-training training, some individual observed practice. I don't know how to help somebody unless I watch them. So there it is like sports. You know, you don't coach tennis over the telephone. You go down and you watch tennis. and play and you make suggestions, you know, or golf or musicians. I mean, in all those cases, to increase skill, you need to observe what the person's doing. Well, that's true here too.

So observe practice, giving feedback, which we do in a particular way, and coaching, which we do in a particular way, to help them develop skills. And in five, half-hour sessions was enough to make a significant difference after a two-day training. Okay. That's not a lot, if you think about it. It's not, no. It's not a lot. Okay.

It's enough. It's enough, yeah. So, okay, I think you were going to say something else about effective practice or discipline practice or, and were you going to say anything else about, like, what it looks like to actually practice? So what I've heard from you so far is recording video, looking at video with someone who's like got some level of expertise or some ability to give coaching. Is there anything else? We're actually practicing the skills.

What we did in the telephone coaching, we didn't just talk about motivation. I mean, we actually practiced a skill on the telephone. And so we're shaping clinical behavior there. And that's, you know, just this talking about, am I is not going to help you probably. but actually practicing the skill. Well, let's use empathic listening, which has the biggest effect. That's something that you can practice

almost anywhere anytime you're talking to people, you know? Absolutely. You can practice in real life. You can also, in a learning community or in other contexts, you can intentionally be practicing the skill of forming

reflective listening statements. which is learnable, but not something that you necessarily do naturally or automatically. We're much more likely to ask questions as therapists. We try to get people to the point of offering two reflections per question, and when you're starting, it's often 40 questions per reflection, you know. So it's a big change in what you're actually doing in practice. It makes a huge difference. So there's one.

And so this is like practicing the foul shots and basketball. Here's an observable skill. We know what it looks like when it's done well. You can practice it outside of doing counseling and psychotherapy and get better at it and bring that back into your session. So that's one clear example, I think, of a component skill of motivational interviewing. That's definable, observable. makes a difference in outcomes, and you can practice it and get better at it. Yeah, so it sounds like with a lot of the people you work with,

you really make a shift from them asking questions to them, giving empathic statements and reframing what the patient is saying. That's beautiful. Yeah, I love that. It's listening to and using the client's own wisdom. It's increasingly better than what I have to offer, you know. So you're really trying to pull out from the clients their own wisdom, not just give your own wisdom, is what I'm hearing.

Oh, I mean, I far prefer finding out about what the client knows and thinks and sees as possibilities than my coming up with stuff. I mean, that's where change is going to happen, you know. Yeah. How's my reflective listening on those last two things? It did well, yeah. Was that pretty good? Okay.

Okay, so I was thinking about, I want to jump into this change process. Sure. And I think it seems like a central idea in motivational interviewing is when people get stuck in this kind of ambivalence. Yeah. The contemplation stage. That's just human nature. Yeah. But I think maybe something I was going to say about this, a motivational interview we've learned,

is useful all through the stages of change. change and not just in the preparation process. We started out thinking, here's a way to get people from contemplation to action, and it does that, but you don't put it down at that point. I mean, this way of being with people you stay with and guess what? They start doing something, and then they get ambivalent about it and come back and haven't made the change they said they would make, and you still need it, you know, along the way. So one thing we've learned is that these skills are useful all the way through the stages of change and not just in the beginning.

It's not just a pre-treatment. It can be a pre-treatment, but it's not just a pre-treatment. That's good. Okay. That's helpful. Okay, so thinking about this ambivalence, because I know you love ambivalence. I think you wrote a book on ambivalence. Ambivalence is as a virtue.

Yeah. And I was thinking about this as something with... With someone with really high openness, I think they tend to have a higher ability to stay in an ambivalent place, right? Or a person who might be on the perceiver spectrum of the Myers-Brigg-Perceiver-judger. Yeah, much more comfortable with it. Yeah. It's like the judgeer just wants to make a decision move forward. The perceiver likes to leave their options open, right? Right. I'm a judgeer married to a perceiver. You're a judgeer?

Yeah, absolutely. Yeah. Okay. Yeah. So I've had to learn not to do that when working with clients. And you can learn it, you know. But yeah, no, I'm much too inclined to make a decision and get on, move on, even if it wasn't the best decision. That needs counterbalancing. And one way to get counterbalanced is to marry your opposite. We've been 50 years together. Wow. That's amazing. Congratulations. That's a lifetime. you were married before motivational interviewing was even bored oh yes yeah hadn't even thought of it okay so i'm curious though like with this like ambivalence how is it a virtue in your mind and do you find it's harder for some people to stay in this place of ambivalence than other people well you already said it is harder for some people than others i mean some are much more comfortable with the tension of ambivalence and being able to hold two things in mind at the same time that seem to be contradictory, and that's just fine. That's paradox. So that's true.

That's, you know, that's so. But it's absolutely normal for both kinds of people to be ambivalent. And we mistake it for lack of motivation. We mistake it for denial. mistake it for, you know, all kinds of things in the addiction field, which is where motivationally envy and grew up, being ambivalent was like not okay, you know. You're in denial and I'm going to tell you what you need to do, which is not a particularly smart way about going to help people, but that's what we were doing, confronting people at the time back in the 70s and 80s, and, you know. So it's helping people to resolve their ambition.

because part of them wants to change and part of them likes things the way they are, you know, nothing pathological about that at all. That's us, you know. So if you can imagine that there's a committee inside the person and you've got members who represent those different viewpoints, you know, you give more talk time to the members that are inclined to move toward change. you respect and listen to other committee members, but you don't hand them the microphone. And so it's differential attention to what we call change talk to the person's own arguments for change.

And literally you can predict whether change is going to happen from the ratio of the client's own change talk to their sustained talk. Change talk is the person's arguments for, doing something differently. Sustained talk is their arguments for not doing it. And the more the person's own arguments for change outnumber or counterbalance the arguments against change, the more likely changes to happen. So we can literally code sessions and predict the likelihood that the change is going to

happen from what the client has said over the course of the session. where they start is not the key. It's what happens over the course of the session. People come through the door in addiction treatment, come through the door angry and not wanting to be there and, you know, it's seeming very unmotivated.

That's fine. Nothing strange about that. But where does it go from there? That's a matter of therapist's skill. That's a matter of what you do, what you respond to, how you are with the person. And so beyond the Rogarian skills of respecting people and listening well to what they're saying and affirming what they're doing and so on, the oars that we talk about, open questions, affirmations, reflections, and summaries.

So those are right out of person-centered counseling. When you now get into the evoking part of motivational interviewing, now we're using those same skills differentially. we're asking questions, the answer to which is change talk. We're affirming change talk. We're reflecting change talk. When we summarize what the person has said, the summary includes the change talk that we heard. And as you're doing that,

the person's motivation is very much moving in the direction of change and is much more likely to happen. So it's a second mechanism in motivationally, being beyond the very good impact of empathic listening and the kinds of things that Carl Rogers was talking about. That's good. One of the things that when I first read your book years ago was your emphasis on we are not responsible for the change of a patient.

I think often as providers we feel pressure, we feel a weightiness. I'm thinking specifically, you know, if a patient commits suicide, you know, it's not just like a cardiologist might feel if a patient dies of heart failure. Let's say they're a heart failure specialist. They have patients die of heart failure every year. There's something different about mental health where we really take that weight upon ourselves. And I'm curious what you would say about this and your perspective. Well, it's an illusion that you can, that you can make people change. And so in a way, it's letting go of a control you never had in the first place, you know,

and knowing that the person who's going to make the choices is sitting across from you and is not you. And that's liberating. Now, that's not dismissive, you know. It's not, well, it's just up to you. Nothing like that. I'm very aware that what I do and say in this session makes a difference in what's going to happen. So I've got to pay attention to what I'm doing as well. So I know I can influence a person's direction here, but I can't make the choice.

I can't make people change. And once you know that in your heart of hearts, it frees you up and makes it easier to be helpful, actually, to easier to be empathic and listen without distress to what the person is telling you and to know that the power to change is not in you but in them you know and and that's what you're trying to do in a therapeutic relationship to to find and and liberate the part of them that wants to change and has ideas about how to do it and thinks it's important Okay, so I'm hearing you that we don't have the power to change, only the patient does,

but I'm also hearing you that we have the power to influence change. It's a paradox, yes. Okay, so, and I'm thinking about this one study, this is like my favorite MI study from when I was going through residency. I think it was like in Texas, there was patients who had hit an ER in the hospital. They would come in for some alcohol-related injury. and they randomize them to like one session of motivational interviewing or none. And then they followed them

and looked at all-cause mortality in the next period of time. Tell me about that study in particular. And it makes me think that we have power to change or to help people change. But tell me about the study. There's the difference.

That's what I was saying earlier. You have power to help people decide to change, to do it. But you don't get to make that choice for them. And if you feel the urgency of needing to make them change, people will push back against that. Actually, we don't like being manipulated. We don't like being told what to do. So once you let go of that and know that that's the change agent over there, now you can help them. Now you can help them move forward. There are a number of studies like that in the emergency rooms. I worked with an ER surgeon who came over and wanted to learn

motivational anything because she said, I keep patching up people for drinking related injuries. And to do nothing about the drinking is just wrong. I mean, they're going to be back, you know. So I should, in addition to taking care of them, which is, of course, what I do, I should be doing something to help them not come back. Well, that became a part of, you know, Espert and all kinds of other interventions that are around for when you have an opportunity like the ER, you know, an occasion with somebody, use that one occasion to do something that's likely to help them change. And it turns out it's possible. I mean, it doesn't always work, but it makes a difference even right down to all-cause mortality for

goodness sakes, you know. I mean, that's a rather important outcome. And so it's, you do with the time that you have what you can, basically, knowing that you can't do everything. I think it was substantial. I think it was like, do you remember what the reduction in all cause mortality was? I don't, no. I think, I think when I read it at the time, I was thinking, okay, you know, the microchanges that could happen that would reduce all-cause mortality are so small, like operating room stuff, you know, what procedure stuff, time to code, those kind of things, compared to the expert or the motivation of interviewing being sort of rolled out. And I was actually a part of, in residency, a hospital that had one of those programs. And so I would go with, I would go with Dr.

Teller. Shout out to Dr. Teller, addiction medicine doctor. And he would go into the room of every patient who had some alcohol in their blood when they had some sort of injury and I'd watch them do motivational interviewing and most of the time conversations went really really well and we're able to get them plugged into resources and such once in a while it was what dr. Teller would say too much truth that the patient wasn't ready for it you know oh okay that that And that has to be okay with you. It's not what you want, but you know that that's the case, too. That sometimes what you do won't be enough.

Yeah. Yeah, I think it's a weight that a lot of providers I talk to, Carrie. So I'm glad that you had some words for that. It looks like learning, motivational interviewing helps prevent burnout. We need better research on that. But there's an effect not just on your patients, but on providers of learning this skill, which is really interesting. It has something to do with lifting a burden.

It has something to do with enjoying the work more and feeling like you have real relationships with the people that you're serving. Even the 15-minute med consults, you know, are in the ER where you're not with people for a long time. But even in those contexts, it just seems to make a difference in, your own appreciation of your work and your own enjoyment of your work. And I'd like to understand that more if I were doing research now, which I'm not. That's what I would be looking at.

How does learning this change the provider? That's good. Okay, so I'm wondering if we could jump a little bit into the fourth edition of your book. So what are the changes in the book that you are most excited about? Let's start there. number one was we wanted to make it simpler. We were inspired by a quote from Oliver Wendell Holmes, Jr. That said, I wouldn't give a fig for the simplicity on this side of complexity,

but I would give my life for the simplicity on the far side of complexity. Once you've gone through 40 years of research and trying to dig into this and understand it, can you now make it simpler? Yeah. And it's possible to do that. So we could have made a bigger, more complicated, more pages, more references, fourth edition. And the fourth edition is still very well referenced, you know. But our goal was to focus on what's essential, what's fundamental to simplify all the complicated stuff we've learned over 40 years.

and the book came out 30% smaller than the third edition. So we were successful in that regard. I feel really, really good about that. We were also speaking to a much broader audience. So this has gone way beyond counseling and psychotherapy at this point. You know about the health care applications of it, but it's also found its way into dentistry, into classroom education, into leadership and management,

into just all kinds of fields that are about human relationships that have to do with change. And so we pulled out some of the psychotherapy jargon and tried to put it more in everyday language that is what a wider range of people will relate to, still including some insert boxes for therapists with the language that we all know and love. you know, but, but it's for a much broader audience than just psychotherapists. So simplification, broader audience, you know, de-jogonization as much as is feasible, still staying close to the data. So, you know, that was important. There was, of course, things we learned in the 10 years since previous edition.

An interesting one is the affirmation, which is something we've always emphasized, you know, watching for and paying attention to what the person is doing well, rather than being the pathology detector, you know. And in particular, looking for strengths, looking for something, what is it about the person that is, you can appreciate and admire, really? well it turns out that that also increases change talk we didn't know that 10 years ago but it's a pretty strong relationship that that when you're taking the time to notice what's good about the person and what they're doing well they're more likely to change they're more likely to talk about change as well

so there were some of those findings that popped up that that influenced what we had to say in the fourth edition. The big picture was trying to get it down to the essentials that can be understood in a wide range of helping professions and what this is is about how to be a helper, basically. So just to reiterate that, and to probe into that some more, so you found that affirming patient strengths

really like paying attention, noticing, getting excited with them. I call this positive empathy. I think we can have empathy too much almost. Maybe there's never too much empathy. But we can have empathy for the negative, but not the positive. And so I love this because as a patient myself, you know, someone who's done therapy, there's something about someone getting excited when I'm excited or like, you know, it's powerful. And so I love how you found that that was related to change talk.

Well, as a psychologist, I was sort of trained to be a pathology detector, you know, to be figuring out what's wrong, you know. And there's, that's an important skill. I mean, if the person has PTSD or there's, you know, bipolar disorder going on, you want to recognize that and respond to it. But it's all the more important. actually to see what's going right and to affirm people for that and to be looking for their strengths to flip down your lenses that are always looking for what's strong and good about this person. And it turns out doing that also promotes change. Yeah. Yeah. So it's like getting excited when there's change that's occurring, getting excited for the small wins, getting excited, and getting excited

for things that they're excited about, like, whatever that is. But noticing and commenting on things about them as well, not just what they're doing. So in the fourth edition, we talk about simple and complex affirmation, the new concept that actually comes out of the effective psychotherapist book, but simple affirmation is just commenting positively on something the person did or said. I like the way you said that. Or thanks for getting here on time. or just something specific.

Complex affirmation is noticing the person's strengths and commenting on those. So something like that, you know, that took a lot of courage, what you did, you know. Now you're saying something not just about what they did, but about the person, you know. And I think we need more research on this, but I think complex affirmations are much,

more powerful and likely to influence change. I certainly feel that clinically, but it's a relatively new distinction. It came out of arguments in the, in my group about is praise bad? You know, can you, well, you can certainly overdo it, and Americans are inclined to overdo it and be cheerleaders and so on. And that can actually undermine motivations, an old literature on that. But there's nothing wrong with saying, well done, you know, here and there. But even better to find what it is about the person that you prize. And Rogers used that word, prising your clients and noticing what's strong and capable and good about them. And commenting on that even has, I think, a bigger impact.

Okay, so here's my positive affirmation for you, okay? All right. You founded motivational interviewing, and part of that process was you were in Norway, giving lectures, and you talk about how the Norwegians talked back. They asked you questions. They paused you. You woke it from me. Yes.

Yeah, I didn't go there with this idea. Yeah. So they noticed what you were intuitively comprehending. Which I hadn't noticed. And they saw it. And I actually, when I talked to Sue Johnson, she had this similar. thread. It was like it was intuitive to her and it took someone else looking in almost to see what she was doing. Yeah. She got it from her years watching her dad at a bar pub, which was, it's a European

pub. So families go there at night. You know, all sorts of people go there. But I think that that says something about your character as well because there's a humility in accepting feedback, not only accepting the feedback, but getting excited about the feedback and then using the feedback to catalyze the foundation of, you know, a heavy empathy-based change talk, which was counter to what people were doing at the time, right? I mean, I remember going in still, as a medical student, into the ward, watching the attending, be like, John, why weren't you at, you know, the addiction thing? You know, the addiction last morning. Yep.

Get up out of your bed. Get there. It's 9 o'clock. I want you to get ready. Like, there's no excuse for you, John. Get there. You know? We thought that was good for people.

No, it was, so it was very contrary to the sidegeist and the addiction field at the time, which relied on assuming people don't know and are in denial and you have to get in their face and make them see it and just a complete other end of the world. So, yeah, that's, I authentically think that that took some humility to receive the feedback, utilize the feedback to allow you to think, you know, I think a lot of, or it's our human propensity, I think, to not like feedback, to think like, but maybe it, Maybe it felt more relational or more helpful, actually, the feedback as they were giving it. Well, it's also good science.

You know, when you don't find what you expected in a study, I get interested and curious, you know. I don't get this. If I did the study, well, I don't get dismissed. Well, something wrong in the study. Why didn't we find what we expected? And most of my findings have not been what I expected and have been better than what I expected. And so going with what you're learning and not being defensive about it is just so much easier. And you learn so much more.

Yeah, Hippocrates, I think, you know, talked about actually noticing when your treatments don't work. And I think it's what separates. from like the shaman, which is like, you know, any bad treatment is not our fault. Any good treatment is our fault. That's good for us, those attributions. That's dandy for the therapist. Not so hot for your clients that if there's a good outcome, then the therapist did it. And if it's a bad outcome, then it's their fault.

Yeah. Yeah. So what would you say, like looking back, where some of the other things that were really helpful in the foundation of the, this. In the growth and development of motivational interviewing? Yeah. Steve and I started training trainers two years after the first edition came out,

thinking maybe the two of us won't be able to keep up with the demand for training. Boy, little did we know, you know. And after a few years of training trainers, some of the people who had been through our training said, could we like get back together and just kind of swap ideas with each other and, you know, see what other people are learning? I said, sure. So they had a little parallel meeting when we were doing another training for trainers. So it was going on out by the pool while Steve and I were inside working hard with training new

trainers. That became the motivational innovating network of trainers, which has been a rich source of new discoveries and morale and just to, you know, I go to those meetings. First of all, feeling like anybody there could be a friend, but also knowing I'm going to learn stuff every year about this topic that I've been involved with from the very beginning, but every year at that meeting. So to have people come together and just share ideas, there's a linguistic anthropologist named Somerson Carr who has been studying motivational living for 15 years.

She's devoted 15 years of her academic career to being interested in motivational interviewing because it's all about language. And she got fascinated with the way we use language and discovered things I would never have noticed, just like how we use pauses. and she thought we were doing it intentionally. I hadn't even thought about it, but it is a pretty consistent style, at least among English language speakers,

who do motivational inviating, to use pauses in what she said is quite an unusual way. She noticed that this is not something you find in a lot of other places. Well, anyway, one of the things that, she's also pretty philosophical, and said, One of the things that seems to be a core value in motivational interviewing is in expertise. I'm not an expert. I don't know.

So when I'm with patients, that's how I feel. I don't know who you are. I don't know how you work. You know more about you than anybody else does. But let's have a conversation and just kind of see what comes from that. Well, the same with the science. and the same with training, that you come in,

not assuming you're the expert who's got the answers, but you come in curious with some ideas that you're willing to share, you know. And that has so pervaded the network of trainers that it's just a wonderful meeting to go to. But I think she's onto something also. She calls it classic American pragmatism. So she's got all these grounding in philosophic traditions.

But she just published a book this year on her 15 years of work with motivational interviewing. And it's humbling and interesting and surprising and all kinds of things. Wow. Yeah. Yeah. Yeah. It says something about the network and the community. And it's kind of like it's probably really wonderful to have such a nice community that has such warmth.

and not competitive, you know. How many you find it here and there, but for the most part, it's, it's, hey, I got this idea. What do you think? Which is exactly how motivation being started. You know, I wrote down the ideas that we were coming up together with in Norway and just sent it to a few colleagues saying, what do you think about this? And one of them wanted to publish it. Ray Hudson, the editor of behavioral psychotherapy, and I said, Ray, I said, Ray, I, we just made it up.

I mean, like, the only numbers are the page numbers. I don't have any evidence here. And he said, let me publish it. I think it's a good paper. And it just took off from there. Wow. But it started with my just saying, you know, I don't know, but first an idea we had, but what do you think? And we're still pretty much there.

Beautiful. Yeah. What are some of the things that you are, like, what are some of the things that you are, like, what, what are some of the things that are the biggest surprises as you've kind of gone on, like ones that we haven't talked about already, maybe? Like any changes in the way that you've thought about things over the years and how they've... Well, I'm still surprised this works, you know? I mean, I sit with somebody and they have one conversation and they go off and change.

I think, dang. That's still refreshing to me that that's the case, that you can have a conversation in the middle of the night. in the emergency room for 15 minutes with somebody who's intoxicated at the time, you know, and have an impact not only on what they do, but on their survival, you know. That's humbling at least, I mean, and still surprising to me that. And I, you know, I think we don't understand maybe even most of what's going on in these interactions. We're getting better at it. at knowing what matters. But I'm sure there's all kinds of stuff happening

that we also don't notice or, you know, haven't really pinned down yet. So that's the case. I'm surprised how this spreads across cultures. I mean, there's there are quite a few studies now on motivational interviewing. I'm talking controlled trials even. Appearing in India, Africa, and Iran, and places that are really different from Western culture.

in which this grew up. But it's like there's something about this that people just seem to recognize. That's the verb I use. And people come to motivational interviewing in part because they read that it's something that works in a meta-analysis, but they kind of recognize it

and say, yeah, I kind of know this, you know? Or this is how I want to work with people. Yeah, there's something about it. So there's, to me, this sort of mystical spiritual aspect of this that I don't understand well, but I certainly experience, I certainly feel. And it's such a privilege to do this to sit with people and have a conversation with them about their own lives and their own change processes. And what a wonderful

way to spend your life. I mean, nothing would rather have done than having been a psychologist and being curious and trying to learn more about how it is that we work and how we can be helpful to each other. So, I mean, all of that is great. I mean, there have a little empirical surprises along the way. One that, another one that cropped up in the last 10 years is that the client's arguments against change are actually more powerful predictors of outcome than the client's arguments for change. So what we call sustained talk, if you have change talk and sustained talk compete with

each other for predicting outcomes, sustained talk wins, at least in the in the studies so far. That is, it's more powerful for people to be saying why they don't want to change than for them to say why they do want to change. Somehow it just makes status quo continue, you know. Well, that kind of makes sense to me. Also, we're talking about moving off of status quo, moving off of inertia, where we are. But if you counsel in a way that causes people to argue against change, if you counsel in a way that causes them to say, no, it's not a problem, I don't want to do that. It's not that serious, which is exactly the result of what addiction counseling was at the time. You've got a problem.

I'm going to tell you what you need to do about it. Here's what's wrong with you. That's taking responsibility for all the pro-change arguments. And the person's natural response to that is to give the other side of their ambivalence. The Senate is not that bad. I don't really want to do that. If you try to push harder and convince them, they dig in harder and talk themselves into staying the same and not changing. Motivational interviewing is about helping people talk themselves into changing.

with their own reasons, not with somebody else's reasons. It's surprising how well it works to me still, and just the power of this way of being with people. I know you're from other talks. I've heard you're a spiritual person. How has that influenced your sort of journey with this? Well, it certainly has grown out of my feelings. journey. I mean, that people don't have to share my faith journey to learn how to do this or

understand how it works or to do it. But within my faith journey, this is like the way we're called to be with people, to be accepting, to be encouraging, to be empathic and interested in them. So this way of being with people fit with my own upbringing, my own sense of who we're supposed to be while we have the little bit of time that we have here, you know. But I haven't never talked about this within the faith context that much. It's not, you don't have to share that faith journey or that faith perspective to understand. It just made it easy for it to grow in this soil that was me, I think. Have you ever used this, the change techniques, to change something in yourself?

Oh, yes. Oh, yes, sure. And there are even a couple of self-help books out now coming out of motivational interviewing, both of them by MI trainers, on how to use what we've learned in your own life, and to use it to harness your own motivation for change. So I think it's something that's helpful, even in your own life. It's maybe easier to do when you're talking to somebody

than to sit by yourself and do it. But it seemed to be possible to use what we've learned and follow some of the pathways that have emerged just to encourage yourself to change also. And there's not as much research on this as a self-help approach so far. But these seem to be just basic principles of human relationship and human nature. So it makes sense it would also apply in our own lives. And yes.

Coming back to that, I'm still thinking about that comment you made, that the, okay, so when someone's ambivalent and they voice the negative change talk, that's a stronger predictor for a lack of change. Yes. And if they verbalize the change talk. So I'm wondering, like, okay, let's say someone does voice strong reasons for not doing the change. how do you how do you

work with that before you said you could repeat that and then repeat the reason for change that they want to make right after well that's one thing what's another acknowledging

acknowledging their autonomy is one one fairly simple thing that we do but it really is up to you you get to decide about this I don't get to decide about this you know you're you're the one who

will be making the choice of whether you want to do this or not. And that's just the truth. Are there any other things you would say when someone starts talking about the non-change talk? Oh, yeah. Don't push back against it. And that's the tempting thing to do when you're a helper. You know, we go into helping professions because we want to help people. and somehow the starting point for that is to tell people what you think they should do and why they should do it. And that's actually not a helpful way of going about things because it invites the person to tell you the opposite.

Instead, to understand part of them, chances are part of them also wants to do this. Part of them wants to be better. Part of them is open and willing to it. But if you're championing that they should take this medicine, that they should get out an exercise, that they should be doing those things. And that's what you verbalize to them. The very predictable response is for the person to argue against it. You know, I don't know about that. I don't think I want to do that.

It's a product of you championing the change. and so instead you counsel in a way that helps the person to champion the change it helps them to make the arguments for change instead of our doing it it's it's tempting as a helper to just say i told them and i put it in the chart that i told them they need to do this and doctors sometimes say i my patients i tell them and i tell them and i tell them they still don't change well maybe the telling is part of the problem. Maybe that's what's going on, and that that way of

trying to help people, which is done with the best of intentions, actually isn't helpful, and actually moves people in the wrong direction. I'd say someone was listening to this and they were like, should I parent this way? At what point should I tell?

At what point should I use techniques like this? Is there a balance, do you think? Is there been any studies on parenting and kind of taking a more observant? Oh, yeah. One of Carl Rogers' own students named Thomas Gordon wrote a book in 1970 called Parent Effectiveness Training,

which is Carl Rogers for parents. Reading Rogers himself, he's not that accessible if you're like an everyday parent and so on. But Gordon knew how to put it in language that parents could relate to and understand. And so that a person-centered way of parenting has been around for a long time. Lots of research and styles of parenting, of course, with the extremes of being extremely permissive and extremely authoritarian. And, of course, the optimal parenting seems to be somewhere in the middle.

Present and authoritative, but not militaristic about it. but also not neglecting. They're wonderful. The colleague here was studying how children learn self-regulation. And one of the tasks that they had was to put children to a table with a whole lot of blocks of all different sizes and say, build the tallest tower you can. And what they watched was how the parent reacted with the children. There were parents who just sat back and read the newspaper and didn't pay much attention. you know, the permissive style of parenting.

There were parents who were trying to do it for the child, you know, get, no, no, don't do it that way, do it this way and show them. And the parents in the middle, interestingly, would often whisper. They would watch what the child's doing, and then they would, then they would sit back, sit up and say, but the big ones on the bottom, you know, and then sit back and let them do it again. that kind of present stepping in, giving a little guidance, stepping out, that was the parenting style that really taught kids self-regulation, how to control and direct themselves. And neither extreme of doing it for them or just ignoring them does that.

Well, there's direct, I think, relationship to therapy as well. and this is that kind of in the middle whispering some suggestions in a way of being with clients and then letting them do it beautiful yeah beautiful okay so as we kind of wrap up our time I'm wondering if you have any like last pearls or last thoughts that you'd want to put out there to mental health providers future mental health providers therapists psychiatrists this is learnable and you don't learn it by coming to a workshop or our continuing professional education model i think is seriously flawed that that the way you get new skills is you go and warm a chair for an hour or a day or two days and then you come back and you practice differently

chances are when you come back you do pretty much what you were doing before and and so we learned that the hard way from our training research that actually developing new practice behavior is something that takes some time and attention. And it doesn't happen just by sitting and listening and watching observations and videos or whatever. It takes that kind of guided practice, deliberate practice. So if you want to learn a new skill, don't just sit and listen to it. But set up your learning in a way that it's active and you get to actually practice the component skills. We set up learning communities, for example, where people practice together this component skills of motivational interviewing. And by the way, whenever we do practice,

we almost always use what we call real play, not role play. Rather than having somebody pretend they're a client, pretend there's somebody that they're not, and roleplay the client, we have people talk about themselves because all of us all the time have things we're ambivalent about and all of us all the time have things that we're thinking about changing and not sure if we're going to

and so you can have conversations about those things that are safe to have in the company, the people that you're with and learn much more. Even professional actors don't act like real people in interview situations like this. They enact a role and I learned that there are no clients as difficult as the ones that are role played by therapists.

Those clients don't exist even, you know, to be that impossible. And so when you're talking about yourself and someone is talking to you and practicing the skills of motivational interview, both people are learning. You're both actively engaged. And so that's the way we usually train rather than sending up role play, scenarios. We still do that some, but for the most part, it's having real conversations with real people that is the way you learn this. It's also okay, by the way, to be neutral, you know, to not be trying to nudge the person in one direction or another, but to simply be with them

while they make their decision. And there are all kinds of decisions in life that are like that, You know, should I get aggressive treatment for this cancer or go on the hospice? You know, I should not be nudging person one way or the other, you know. Should we have another child or should we have a first child, you know? Not my business to be nudging them one way or another there, but I can be helpful to them in trying to work through what's a complicated situation. and we actually know better how to be neutral from what we learned in motivational interview because we learned how to behave with people that helps to nudge them in the direction of change normally because that's what they asked us to do.

We also know how not to do that. We also know how to not even inadvertently without realizing it be nudging the person in one particular direction when what you should be doing is being neutral. And I don't remember that even coming up at my own class. clinical training of when you would take a stance of neutrality and when you would take a more directional stance of encouraging a person to move in a particular direction. And of course, ethics come into play there. Motivational living doesn't have the answer for when one of those is the right thing to do. But we have learned a lot about it anyhow. And it's also fine

to be neutral and you can be helpful to people, even when you're not trying to encourage them in one direction or another, when they're dealing with some of the difficult ambivalences of life. Yeah, beautiful. I think especially sometimes in marriage therapy, that can be kind of an interesting ethical predicament, right? Because you can hear one side of the scenario, which can make you want to push the people away, or you can hear the person wanting to stay in the marriage, despite maybe some abuse being present.

Any thoughts on? Or should we cut this out? Well, it's just came up at the last trainers' meeting in Copenhagen and I just came back from, we were talking about diatic ambivalence. So when couples are ambivalent, this is a little different from intrapersonal ambivalence, where inside you have both arguments.

Now you've got a couple, and they may both be ambivalent about it. They may be taking sides with one kind of arguing for and one arguing against and acting out the ambivalence in that way. They may truly have different positions also, that one wants to do this, have a child, and another one doesn't, you know. And so ambivalence gets even all the more interesting and complex when there are two people involved, than having the ambivalence, which may be partly within them and partly interpersonal. So it's, you know, just, again, just fascinating to me of the puzzles we get ourselves into

and how to help people unscramble. Wonderful. Well, thank you so much for coming on. I really appreciate it. I appreciate, I imagine my audience is going to appreciate this as well. And yeah, it's been wonderful to meet you in person. That's a benefit that I get, and I'm thankful for that. Thanks for being interested.