Naturally when clients attend for counselling sessions, there should be some thought given to any vested interest we, the counsellor, have in the outcome. If, for example, the sign on the door has ‘Smoking cessation counsellor’ written upon it, we can, to some extent, assume the work is focussed on actually altering that behaviour and the same could be said for alcohol and other drugs, weight management and so on. These situations, of course, differ from a client who has come for help in resolving ambivalence around whether they stay in a relationship or not… and this is where the notion of counselling with equipoise (impartiality to the outcome) comes in. This article considers some of the ways in which our attending behaviours impact decision making and motivational factors within the client and the notion of how we can enact equipoise in our counselling.  

In short, the reason for enacting or attempting to achieve equipoise during psychotherapy is where there is genuine uncertainty over whether a course of action will be beneficial or harmful to the client; divorce or separation serve as clear examples but, of course, there are many other situations in which clients are often ambivalent. So, how might we influence, or potentially influence, clients in a biased or non-equipoised way? Let’s say we have a client who was is considering getting help with a decision over whether they separate from their husband or not, and they make a statement similar to the following: 

‘I feel like we have just grown apart; he is a good provider and works hard for the family, but we have not really been intimate in months. We have arguments often, but we try not to do this in front of the children and although I care about what happens to him, I don’t think I love him. I feel like years have been wasted missing out on a good relationship, I have never separated from the kids, and I am a good mum, and he is a good dad and so I am grateful we’ve been able to do this so long, together, without them experiencing losing one of us’. 

And then the counsellor chooses to make a double-sided reflection which includes both sides of the client’s ambivalence: 

  1. ‘It has been hard for you, missing out on romance and struggling to connect with each other, yet you also have successfully brought up your children together and you still care about him’. 
  1. ‘you have some concern for his future and see him as a good dad, but there is no intimacy, and you feel like you are not having your own needs fulfilled’. 

Review both of these double-sided, and arguably accurate, reflections and think about the feeling each engenders in you at the end. Humans tend to respond to the last thing that was said to them, i.e., rather than jumping back to the first part of a statement made to them. So, in all likelihood the client will respond to reflection 1, with a focus on successfully bringing up children and caring for their partner- they may also feel somewhat validated by the fact that the counsellor has also, in the first part of the reflection, acknowledged their struggle to stay in the relationship, i.e. the reflection may well not elicit any discord between client and counsellor because they feel understood, nevertheless they are also being directed, the end of the reflection rests on success child-rearing and caring about the husband, very often the client will respond to this, further elaborating on their success around the child-rearing and caring for their partner. However, in reflection 2, the focus will be on the client not having her needs met and the need for moving on…. In fact, both reflections would be valid, strategic attempts to direct the motivation/thinking of a client in a certain direction; and would serve within a bona fide motivational interviewing approach- but should be used with caution given the nature of the presenting issue.  

The problem then, is that the vested interest of the counsellor here could be exhibited, perhaps as an unconscious bias, a coder might ask: ‘why did you decide to reflect in that order? Do you have a preference/notion of what would seem to be best for this client’? Additionally, how do you present in an equipoise appropriate manner? One way would be to choose the decisional balance (Elwyn et al, 2009) as a tool for considering options. ‘That sounds like a really difficult position to be in, and I am wondering if I could suggest an idea to help us find out more?’ The decisional balance can be a simple two-way column exercise with reasons to keep the status quo in one column and reasons to change listed in the other. Otherwise, it could be 4 ways: the negative reasons for staying, the positive aspects of staying, the negative issues of leaving and the negative ideas for leaving. In whatever way it is delivered, in equipoise it is the counsellor’s job to maintain neutrality, to maintain, essentially, a mind-set that says: ‘I don’t know what the right decision is here, but I can be a sounding board for you to help work through this…’ 

One of the originators of Motivational Interviewing, William Miller, writing with Gary Rose (2015) discuss the notion of times needing to counsel in a way that stays out of the way of client’s decisions versus counselling in a way that clearly influences them: 

‘DB is an appropriate procedure when the clinician wishes to maintain neutrality and not favour the resolution of ambivalence in any particular direction. Evocation is appropriate when the clinician intends to help clients resolve ambivalence in the direction of change’. 

Ambivalence over decisions is, of course, a normal and common situation for any problems we have not already solved. The idea being that if we were not ambivalent, we would simply have already made a change. Even people who seek treatment for a specific issue are still often highly ambivalent, take a smoker wishing to quit for an example. Usually smoking still has an upside for those wishing or attempting to stop (something to do with your hands, a reducer of social awkwardness, a comforting friend that has always been there for examples). Often a helpful way of reducing such ambivalence is to focus on the positive aspects of a client’s change talk: ‘when you say you need to quit, what do you mean?’, for example, does the opposite of equipoise, as it evokes from the client their intrinsic motivation for stopping, it encourages them to focus on and even strengthens their movement towards change. So, imagine that approach with the potential divorcee: ‘when you say you have wasted years, what do you mean?’ will evoke the reasons and the need for change, the ideas around why things cannot stay as they are. 

Ambivalence is something that is likely to come along with the contemplation stage of the transtheoretical model (cycle of change) proposed by Prochaska and DiClemente (1984). Essentially, if the client was in pre-contemplation, they would likely not be ambivalent (i.e., they are not considering change at this point). Miller and Rose make a fascinating reference when they point out that the history of the decisional balance is not a recent invention but dates back, at least as far as 1772 and the polymath Benjamin Franklin: 

‘To get over this, my way is to divide half a sheet of paper by a line into two columns, writing over the one Pro, and over the other Con. Then during three or four days consideration I put down under the different heads short hints of the different motives that at different times occur to me for or against the measure When I have thus got them all together in one view, I endeavor to estimate their respective weights; and where I find two, one on each side that seem equal, I strike them both out: If I find a reason pro equal to some two reasons con, I strike out the three. If I judge some two reasons con equal to some three reasons pro, I strike out the five; and thus proceeding I find at length where the balance lies; and if after a day or two of further consideration nothing new that is of importance occurs on either side, I come to a determination accordingly’. 

Franklin, of course, was a notoriously efficient problem solver and the spirit in which his technique was used marries well with the notion of equipoise. The idea behind Rogerian counselling of course also fits well with the essence of equipoise as person centred counselling has an inherently neutral approach in the decision-making process. Rogers thought that if the proper conditions for client’s exploration of issues were provided/facilitated then the client would naturally move in the direction of healthy decision making and growth (Rogers, 1959).  

Miller and Rose present research finding which suggest that use of decisional balance may well promote not following a course of action rather than promoting it. The area is complex, however, with people who conduct a decisional balance after they have made a decision to change probably responding differently to those who are undecided. The authors think this is probably due to bias and the notion that individuals will overplay the pros for changing when that decision has already been made. Caution, therefore, is needed, in decisional balance and the way in which it is delivered, i.e., the order in which pros and cons are selected, the emphasis on one side more than the other are naturally key elements.  

Ultimately in our counselling work, we are seeking to identify whether we have vested interest, or not and act accordingly, perhaps it is overly naive to assume we have independence and neutrality in all presenting problems a client has. Smoking cessation, drug and alcohol issues and weight management all connect with roles designed to clearly alter (lower) these behaviours in clients. Marriage guidance, however, needs more neutrality, given the fact we cannot possibly know whether staying in a marriage or leaving it, is the best thing for our clients. The decisional balance when used well can be a useful tool for helping with equipoise.  

References 

Elwyn, G., Frosch, D., & Rollnick, S. (2009). Dual equipoise shared decision making: definitions for decision and behaviour support interventions. Implementation Science, 4(1), 1-8. 

Franklin, B. (1772). Moral or prudential algebra: letter to Joseph Priestly (September 19). The Writings of Benjamin Franklin (Vol. 3: London 1757–1775). 

Miller, W., & Rose, G. (2015). Motivational Interviewing and Decisional Balance: Contrasting Responses to Client Ambivalence. Behavioural and Cognitive Psychotherapy, 43(2), 129-141. doi:10.1017/S1352465813000878 

Prochaska, J. O. and DiClemente, C. C. (1984). The Transtheoretical Approach: crossing traditional boundaries of therapy. Homewood, IL: Dow/Jones Irwin. 

Rogers, C. R. (1959). A theory of therapy, personality, and interpersonal relationships as developed in the client-centered framework. In Koch, S. (Ed.), Psychology: the study of a science. Vol. 3. Formulations of the person and the social contexts (pp. 184–256). New York: McGraw-Hill.