Ambivalence in psychotherapy

American Journal of Clinical Hypnosis, Oct 2006 by Gravitz, Melvin A

Engle, D.E. and Arkowitz, H. (2006). Ambivalence in psychotherapy. New York: Guilford Press. Reviewed by Hillel Zeitlin, MSW, The Maryland Institute for Ericksonian Hypnosis and Psychotherapy, Baltimore, Maryland

How does one write a straightforward review of a work on an elusive subject like ambivalence? Yet, that is precisely what the authors have done here. They have taken a subject at the heart of virtually all therapeutic dilemmas, and attempted to offer a unifying framework to understand and resolve ambivalence in a variety of psychotherapy approaches. The authors, both clinicians and professors at the University of Arizona, begin with the recognition that though resistance to change and non-compliance are central concepts in both psychotherapy and behavioral medicine, there is not a body of research or integrative theory that can usefully answer the question: "why don't people change." They propose that understanding and quantifying ambivalence, the simultaneous movement both towards and away from change, can illuminate the dynamics of resistance in psychotherapy.

The book begins with an overview chapter that profiles the prevailing research that has studied resistant ambivalence in psychotherapy, health care and self-directed change. Following that is an exploration of theories of resistance and ambivalence in major schools of psychotherapy, particularly psychoanalytic, cognitive-behavioral, and humanistic/existential.

The authors propose an integrative model of resistant ambivalence that highlights the internal and systemic discrepancies between a 'desired self and 'should', 'feared,' and 'reactive' selves. They conclude that therapists can best understand ambivalence as a state rather than a trait, and that treatment approaches based on empathy and support are more likely to facilitate change than more directive approaches. Another chapter profiles both selfreport and therapeutic observation approaches to measuring and assessing ambivalence. In exploring therapeutic approaches to working with resistant ambivalence, the authors highlight Gestalt two-chair work and Motivational Interviewing, and end with a chapter on integrating ambivalence work with other psychotherapies.

Missing from this book is any mention of hypnosis or hypnotically informed psychotherapies. This is unfortunate not just because the interests of American Journal of Clinical Hypnosis readers aren't included, but because hypnotic psychotherapies can add important elements to a fuller understanding of resistant ambivalence.

A hypnotherapeutic emphasis on the wisdom of the unconscious mind, for instance, can often provide a means for clients to understand change in new ways, and for ambivalent conflicts to give way to a sense of a powerful inner force. Furthermore, for many teachers of clinical hypnosis, what has traditionally been called client "resistance" in psychotherapy can equally be viewed as a lack of clinical skill. This view encourages therapists to take responsibility for the resistance, and to search for new and creative means to help people change.

Another category that is absent are ambivalences of people who might seek out hypnotherapy rather than more conventional psychotherapies. These might include ambivalences about the time, cost, or effectiveness of traditional therapies, or a magical belief in the efficacy of hypnosis. Furthermore, hypnosis is often associated in the public mind with special powers and vulnerabilities. How many times are we asked "you're not going to make me cluck like a chicken are you?" Exploring this kind of question could have led to a deeper discussion in the book about ambivalences clients may have about the influence and authority of therapists or other health providers.

Nonetheless, by illuminating the central role of ambivalence in the quandaries that bring people to psychotherapy or clinical hypnosis, this book provides an important service. The authors have taken a pervasive and difficult subject, and created important guidelines to help facilitate change.