Motivational Interviewing in Nutrition and Fitness

by Dawn Clifford

motivated to be active since

  meeting with your doctor.”

  Undershooting

  Diminishes or understates

  “Some days the gym

  the intensity of the content doesn’t do it for you.”

  or emotion expressed by a

  client

  Amplified

  Reflects back the client’s

  “You hate exercising

  content with greater

  indoors.”

  intensity than the client

  had expressed; one form of

  response to client sustain

  talk or discord.

  FIgure 8.1. Types of reflections. For each type of reflection there is a reflective listening response to the following client statement: “Gym memberships haven’t worked well for me in the past. I never end up going and then I always feel guilty about the money I wasted. I haven’t done much the last few months, but after my appointment with the doctor yesterday, I came home and went for an hour-long walk.”

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  • Client statement: “I don’t know how we’re supposed to eat better.

  My husband wastes all our money on his stupid cigarettes and online

  poker games. It doesn’t leave us much to work with each month. I

  don’t know what to do.”

  • Stabilizing reflection: “You feel stuck.”

  • Forward-moving reflection: “You want to provide your family

  with balanced meals and if you just knew what to do, you would

  do it.”

  • Client statement: “I probably sound like the worst mother. I know I’m not supposed to give my 2-year-old so much juice, but she runs

  around the house yelling, “Duce, duce, duce!” and it’s so cute. Plus,

  she throws a big fit when I just give her water.”

  • Stabilizing reflection: “It’s hard to say no to your toddler.”

  • Forward-moving reflection: “You feel torn. It’s hard to say no to your toddler and at the same time you want what’s best for her.”

  In each scenario above, you’ll notice that the stabilizing reflection is not necessarily “wrong” and may even be a better choice at times. The

  forward-moving reflections simply provide more momentum to affirm the

  client, take a guess at change talk, or encourage the client to consider other pieces of the puzzle.

  There’s really no such thing as a wrong reflection. Some reflections

  help the client move forward more than others, but you can never go wrong by providing a reflection. No matter what kind, as long as the tone is appropriate, you will always demonstrate empathy and a desire to understand the client. And if your reflection doesn’t

  quite represent what the client meant,

  There’s really no such thing as a

  he or she will correct you and still

  wrong reflection.

  appreciate your efforts toward listen-

  ing and understanding.

  If reflective listening is new to you, begin by being consistent with

  reflecting after most client statements. Once you become used to the consistency of reflections, then you may find it easier to attend to the types of reflections that can best help move the client forward. Don’t overthink reflections. It’s asking a lot for a practitioner to think of the best type of reflection and then how to say it all in a split second. Instead of focusing on the type of reflection you want to provide, think instead about the change talk and how to best express that piece back to the client. Different types of reflections will naturally flow with practice.

  The script below includes a variety of reflections. Notice the progres-

  sion from simple reflections to more complex reflections that include forward-moving language.

  Reflections 131

  pRactitioneR: Hi, James. Do you go by “James?”

  client: Yes, you can call me that, but most people call me Jimmy.

  pRactitioneR: Great, then if it’s OK with you, I’ll call you Jimmy too.

  client: That’s fine.

  pRactitioneR: Jimmy, your doctor sent you to me today because I’m

  a health coach and there were some behaviors she was concerned

  about. I have here that you are 15 years old and in high school. Is

  there anything else I should know about you?

  client: I don’t know. That’s probably all you need to know. My doc-

  tor told me she doesn’t want me drinking so much soda and play-

  ing so many video games.

  pRactitioneR: Right, video games and soda—that’s what she wrote

  here too. [simple reflection] What are your thoughts on being here

  today?

  client: I’m not crazy about it, but I know I’m not the healthiest.

  pRactitioneR: You see yourself as not all that healthy. [simple reflec-

  tion] Tell me more about that.

  client: I don’t eat that great and then there’s this “pudge.” I have

  this reputation at school as being the kid who eats anything and

  everything. I’ve even had friends challenge me to eating contests.

  pRactitioneR: Because of your larger size, kids have you pegged as

  someone with a certain eating style. [simple reflection] What’s

  that like?

  client: I mean it’s cool. I guess I get attention or whatever, but it’s also kind of stupid because any time I do an eating contest with

  someone I feel sick afterward.

  pRactitioneR: On one hand you like the attention from your friends,

  and on the other hand you’d like to be known for other cool things

  you can do because the eating thing is getting old. [double-sided

  and continuing the paragraph reflections]

  client: Yeah.

  pRactitioneR: What are the other cool things that you do?

  client: I don’t know. I guess I’m good at math. And video games. I

  can beat anyone in Combat Commando.

  pRactitioneR: All right, a gift for numbers. That’s cool! [affirmation]

  And, that’s right—you’re good at video games. Between the two

  things your doctor mentioned, video games and sodas, which, if

  any, interest you today to talk about?

  client: Well, if I’m going to give up the eating contests, then I’m still

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  going to need to beat my friends at video games. So probably the

  soda.

  pRactitioneR: That makes sense; I’m sure the video gaming requires

  regular practice, so let’s leave that one alone for now. How do you

  feel about the soda?

  client: Well, obviously I like it. It helps me stay awake so I can play more video games.

  pRactitioneR: You like the taste and the caffeine buzz. [simple reflec-

  tion]

  client: Yeah.

  pRactitioneR: You really like soda, and yet you chose cutting that

  back as a change you’d be up for trying out. [double-sided reflec-

  tion] What are some reasons to make this change right now?

  client: I totally didn’t realize I drank that many until my mom

  pointed it out to the doctor. When I heard her say I went through

  a six-pack of Mountain Dew in a day, I was like, dude, that’s

  pretty bad.

  pRactitioneR: So it sounds like a lot to you. [simple reflection] What

  else? What are some other reasons to make this change?

  client: Well, there’s the “pudge.” I’m sure there are calories or what-

  ever in those drinks. I’m sure the extra around my middle can’t

  be good for me.

  pRactitioneR: You’re wondering about the association between

  weight and
health and you’re thinking that drinking fewer cans

  of soda might result in losing a few pounds. [continuing the para-

  graph reflection]

  client: Yeah, plus I gotta get a date to prom someday.

  pRactitioneR: You’re afraid some girls at school might judge a book

  by its cover. [metaphor reflection] What concerns you most about

  your current soda habit?

  client: I have an older cousin who’s in his 30s and he’s built like me.

  He actually got me started on Mountain Dew. He just got diabe-

  tes. I don’t really know what that is, but I know he has to prick

  himself all the time and I hate needles.

  pRactitioneR: Needles totally freak you out. [amplified reflection]

  client: Yeah, I don’t know how he does it.

  pRactitioneR: You’d like to cut back on soda because you don’t want

  diabetes and watching your cousin go through all of that has you

  worried. You’ve also shared that you don’t want to be someone

  who drinks a six-pack a day and even wonder if cutting back

  might change your appearance. [summary]

  client: Yeah, now my cousin has to eat all healthy and stuff. We’ll

  Reflections 133

  see how long he lasts on his rabbit food. My aunt said he’ll prob-

  ably stick with it for a few months and then go back to the soda

  and junk.

  pRactitioneR: It sounds like your family isn’t very optimistic that

  your cousin can sustain the change. [complex reflection] What do

  you think?

  client: I don’t know; it can’t be that hard.

  pRactitioneR: You’d like to see him stick it out because he’s someone

  you look up to. [continuing the paragraph reflection]

  client: Yeah, I guess.

  pRactitioneR: What do you think your cousin would say about you

  cutting back on soda?

  client: He’d tell me to do it.

  pRactitioneR: You have his support. [simple reflection] Who else

  might support you in this change?

  client: My mom. She’ll probably nag me to death.

  pRactitioneR: So she’ll be cheering you on, but possibly not in the

  way you’d like her to. [complex reflection]

  client: Yeah.

  pRactitioneR: How do you want her to help?

  client: She could probably stop buying so much of it at the store. But

  she drinks it too, and so does my older sister.

  pRactitioneR: So maybe she could help you by letting you make this

  change on your own and not nagging you, but also helping out

  by making it a little harder to get the sodas. You probably want

  other people in the house cutting back on soda too. [continuing

  the paragraph reflection]

  client: Yeah, they can do whatever they want, but it would make

  it easier if everyone was allowed a certain number of sodas each

  week and like we all had our own stash.

  pRactitioneR: You have an idea for how this could work. [affirma-

  tion] Tell me more about how you might make this change, if you

  were to make it.

  Reflections are a useful way of communicating with others, both

  in your work with patients, and in your personal relationships. Make a

  conscious effort to understand others and communicate that understand-

  ing through reflective listening. Relationships that had once been foggy under a blanket of misunderstanding can miraculously become as clear as a morning after a rainstorm. People feel connected to one another through understanding, compassion, and support, all of which are communicated

  through the strategic use of reflections.

  chAPter 9

  Summaries

  Listen carefully for the heart and essence of what the client

  has said, succinctly stringing together pearls that capture

  strength, resiliency, effort, aspirations, confidence, and

  motivations for change, adorning the client with a pearl

  necklace summary of change talk.

  —SteVen m. BeRg-Smith

  Reflective listening goes beyond just the short reflections highlighting client statements. Reflections emphasizing ambivalence and change talk are linked together to create summaries giving the client a bird’s-eye view of his own thoughts and feelings about a behavior. When these summaries are sprinkled throughout the appointment, the client–practitioner rapport is enhanced, as the client continues to feel heard, supported, and understood.

  A reflection is like a small mirror that the practitioner holds up for the client to see experiences and feelings that are spoken. A hand-held mirror provides only a limited view. If a reflection is a hand-held mirror, then a full-length mirror would be a summary. The summary provides the client

  with a full view of key pieces that have been shared. The client has the opportunity to step back and see the entire view from a new vantage point.

  This chapter provides an overview of the benefits of summaries and

  strategies for providing meaningful summaries. Combined with open-

  ended question (O), affirmations (A), and reflections (R), summaries (S) are the final instrument in the OARS orchestra. Together, the OARS create a rhythm within a counseling session that is demonstrated through a full appointment script at the end of the chapter.

  BeneFIts oF suMMArIes

  Summaries provide another opportunity for the client to hear ambivalent thoughts or a genuine desire to change. Just like reflections, summaries 134

  Summaries 135

  provide evidence that the practitioner is listening. Through grouping several key rephrased statements together, the practitioner can help the client to organize or make sense of thoughts and feelings. A reflection is like a single small pearl offered to the client that represents a meaningful shared insight. A practitioner simply strings the pearls together every now and then and presents the complete strand back to the client.

  Summaries can be especially useful in transitioning the conversa-

  tion from one topic to another or to draw a client back from an off-topic tangent. Summaries are like roundabout traffic circles that help improve Summaries are like roundabout the flow of traffic and easily allow traffic circles that help improve for a direction change or continued the flow of traffic and easily forward movement. When a driver allow for a direction change or

  approaches a traffic circle, he or continued forward movement.

  she circles around and can continue

  straight in the same direction or head

  in a new direction. Similarly, summaries allow the conversation to circle around the topic and then either continue discussing the same topic or

  allow for a smooth transition in a new direction.

  tIPs For ProvIdIng MeAnIngFul suMMArIes

  When providing a summary, there’s no need to revisit every point the client makes. Only revisit the essential thoughts or feelings that will move the client forward toward contemplating

  or committing to behavior change.

  Choose summary components strate-

  When providing a summary,

  gically as if you are selecting flowers there’s no need to revisit every to create a beautiful bouquet for the point the client makes. Only client. If you were making a bouquet, revisit the essential thoughts or you wouldn’t include every flower in feelings that will move the client the field. You would consider the dif-forward toward desiring or

  ferent colors, styles, and condition committing to behavior change.

  of the petals. You would only select

  those that are beautiful and comple-

  mentary to each other.

  Similarly, you wouldn’t just throw them in a heap. You would organize

  the fl
owers strategically and in a way that emphasizes the beauty of each flower. In the same way, hand pick the client comments that are essential for the client to hear again, and present those “flowers” in an orderly, coordinated manner. However, like flower bouquets, they don’t have to be perfect to appear beautiful. Just like when you bring someone flowers, it’s the thought that counts.

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  Points revisited may include specific feelings, ambivalence about

  change, or even guesses regarding the client’s feelings based on verbal and nonverbal communication. Similar to reflections, the practitioner can guess at what the client may be thinking or feeling based on facial expressions or gestures.

  While summaries are generally longer than reflections, they are still

  brief. Refrain from long monologues and pick out only key points that will benefit the client to hear again. In other words, don’t allow your bouquet to become overcrowded with weeds.

  Summaries don’t require an opening line, but at times the following

  may be used:

  “Let’s see if I have it all. . . . ”

  “Let’s take a step back for a moment and look at all the pieces. . . . ”

  “In considering all that you’ve just told me, it sounds like. . . . ”

  “I’m noticing a few themes here. . . . ”

  It can also help to end a summary with a question such as:

  “How did I do?”

  “Did I get it all?”

  “Did I miss anything? What did I miss?”

  “What else?”

  Give the client time to process the summary and respond to the ques-

  tion. Both when reflecting and summarizing, consider the power of silence.

  Pausing after the client has spoken often prompts the client to talk more, giving important insight into his/her ambivalence. Silences can be uncomfortable and awkward, but necessary, especially for clients who require more time to process. In your responses you naturally set the pace of the discussion. Allow yourself permission to pause, consider, and talk at a speed that is comfortable for both you and the client. It can be easy to get swept away with a stressed-out client who darts here and there, changing topics and going off on tangents. By providing summaries and reflecting your client’s body language, you can keep the momentum flowing in the right direction.

  sAMPle suMMArIes

  Here are few examples of summaries provided during a counseling appointment:

  “Let’s take a step back for a moment and look at all the pieces. You