MI: Sustain talk and discord
Responding to Sustain talk
Sustain talk and discord are manifestations of the client's ambivalence. It helps to regard them as feedback pointing to a need to change intervention strategies-- especially by returning to reflective listening. .
Discord refers to client statements about the intervention process or relationship to the counsellor, particularly the direction in which the client perceives things are going (Miller and Rollnick, 2013).
"But you don't understand what I'm going through" or
"I am not ready to go there yet, if ever").
Discord is a normal human response to feeling pressured or challenged to do something about which a person is ambivalent. It often comes in the form of a "yes, but" statement.
"Yes, but I tried that before"
MI frames discord as an interpersonal process, which often occurs as a natural response to a counter-motivational statement or a directive or authoritarian stance on the part of the counsellor (MI-inconsistent responses).
Sustain talk represents the other side of a person's ambivalence about changing. It can be an expression of the client's desire for the way things are, feeling unable to change, having reasons for keeping things the same or needing to keep things the way they are.
Working with ambivalence
Earlier iterations of MI made heavy use of the concept of resistance. The more recent introduction of the terms "discord" and "sustain talk" has seen a shift in our understanding of these concepts as the logical complement to change talk. Both terms underline the continuing challenge of working with ambivalence in helping clients move toward healthy behaviour change.
Before and after we make decisions to change, we still experience ambivalence. Humans, especially when the stakes are high and the outcome is uncertain, tend to "ambivilate."
Three types of reflective listening can be particularly helpful ways to respond to discord and ride the wave of sustain talk. The following strategies can open the door to a more productive conversation—that is, dancing versus wrestling.
Simple reflection: empathically reflecting the client's statement. This sometimes includes a small shift in emphasis or selectively reflecting a particular element of what the person is saying.
Client: I couldn't change even if I wanted to. (sustain talk)
Counsellor: You don't see how it would be possible to change.
Amplified reflection: reflecting back what the client has said in an amplified or slightly exaggerated form (there should be no sarcasm in the counsellor's tone when using an amplified reflection).
Client: I have no intention of quitting smoking (sustain talk), and you can't make me! (discord)
Counsellor: Smoking is something that you never see yourself changing.
Double-sided reflection: acknowledging what the client has said and adding to it the other side of the client's ambivalence, using material the client has offered previously.
Client: I don't drink any more than most of my friends. What's wrong with a few beers now and then? (sustain talk)
Counsellor: So it's kind of confusing. On the one hand, you've told me you're concerned about how alcohol affects you, and on the other hand, it seems you're not drinking any more than your friends.
We can respond by shifting the conversation away from what seems to be a stumbling block to progress shifting focus). This means changing the subject when talking about an issue becomes counterproductive. An example of shifting focus might sound like "That doesn't seem like a problem to you right now. What are some of the things you're dealing with that you feel are a challenge?"
Emphasizing choice and control
Finally, simply emphasizing the client's choice and control (autonomy) can help minimize resistance and move the conversation away from sustain talk. This means explicitly stating something along the lines of "It really is your choice what you will do about _______."
Sustain talk, in particular, is to be expected in any conversation about change, especially when a person is feeling ambivalent. The counsellor's response can provide the forward momentum in the client's process of exploring and resolving his or her ambivalence and ultimately making a decision to change.
However, we should always be open to—and accepting of—the possibility that a client may very well decide not to change despite our best efforts. If we have respectfully and empathically stayed with our clients through to this decision, it is more likely that they will come back and re-engage with us if or when their circumstances or perceptions change.