Motivational Interviewing in Nutrition and Fitness

by Dawn Clifford

A general rule of thumb is to reflect after almost every client statement.

  However, there are three especially important times to reflect what you hear.

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  reflect when you hear change talk

  This is the heart of MI. Clients often express reasons to make a behavior change, a need to change, plans for change, or even a previous occasion they were successful at changing. In reflecting change talk, clients hear their own positive feelings about change, ultimately fueling that desire.

  client: I know I could save a lot of money if I ate out less often, but that means I’d have to cook more. It’s not that I can’t cook. I’m

  actually a really good cook. I think I’m just being lazy.

  pRactitioneR: You recognize a few benefits of making your own

  meals at home more often and even believe you have the skills to

  do so. [reflects change talk]

  reflect when you hear the client express Ambivalence

  Clients may not be aware of their mixed feelings about the behavior change.

  By hearing both sides of the argument restated, they may start to understand why they haven’t already made the behavior change on their own. It’s also another opportunity to hear again reasons in favor of changing.

  client: I really want to train for this 10K my friend is doing. It would be so good for me. But I just don’t have the time.

  pRactitioneR: You’re not sure how to fit the training into your sched-

  ule and the thought of training for an event like this excites you.

  [double-sided reflection]

  reflect when you hear the client express sustain talk

  In reflecting the client’s hesitation, you can test the waters to assess motivation and increase the client’s awareness of current concerns regarding the behavior change. Reflecting sustain talk isn’t always the best tactic; too much emphasis on sustain talk can leave your client feeling stuck and hopeless. However, on occasion, reflecting sustain talk may be very powerful.

  client: I don’t think my diet is that bad.

  pRactitioneR: You’re not sure you need to make any changes to your

  diet. [amplified reflection]

  In reflecting change talk, clients

  While simply reflecting sus-

  hear their own positive feelings

  tain talk will make the client feel

  understood, reframing the sustain

  about change, ultimately fueling

  talk or using an amplified reflection

  that desire.

  can help nudge the client through

  Reflections 123

  ambivalence. What you emphasize in your reflections depends on your client and his or her readiness to change.

  client: I don’t think my diet is that bad.

  pRactitioneR: There are some aspects of your diet that are quite

  healthy. [reframe] Tell me about those.

  tyPes oF reFlectIons

  Reflections are often categorized into two groups: simple and complex.

  Simple reflections repeat or slightly rephrase elements of the client’s statement. Complex reflections add further or alternative meaning beyond what the client has just said.

  simple versus complex reflections

  Simple reflections are especially useful at the beginning of an appointment while building rapport. Notice the simple reflections in the following initial interaction:

  pRactitioneR: Mia, tell me about yourself.

  client: I work part-time as a teacher’s aide at my son’s school. I have three children; two are in high school and then my son is in the

  fourth grade. I’ve never seen a nutritionist before, so I don’t really

  know what to expect today.

  pRactitioneR: Today is your first appointment with a nutritionist

  and you’re wondering what to expect.

  client: Yeah, I’m not really sure how this works, but I saw your

  advertisement at the library and there was something that really

  resonated with me on your flier.

  pRactitioneR: It was a flier at the library that brought you in today.

  What about the flier spoke to you?

  client: I liked how you said that you could help people heal their

  relationship with food. I never thought of food as a relationship,

  but I guess just like anything else, it’s more complex than I had

  realized.

  pRactitioneR: You’d like to explore your relationship with food

  today because there’s something there that seems complicated.

  While simple reflections are helpful in the beginning of an appoint-

  ment, overuse can result in the client feeling parroted and sends conversations into circles. Complex reflections, especially those that emphasize

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  change talk, move the client forward, enhancing motivation for change.

  Often, in order to say what’s not yet been spoken, the practitioner must make a guess at the meaning behind the client’s statement.

  A complex reflection may emphasize feelings or the emotional dimen-

  sion of what the client has said. Consider the two different practitioner responses to the following client statement. The simple reflection repeats back what the client said, whereas the complex reflection moves the client forward into exploring the origins of her negative body image:

  • Client statement: “Growing up, my mom always complained about her weight. She was always dieting and making us eat her diet food.”

  • Simple reflection: “Growing up, you had to eat your mom’s diet food.”

  • Complex reflection: “Your mom put everyone on her diet, making you feel deprived at times and wondering if your body wasn’t OK

  either.”

  There are many ways to provide complex reflections. A certain type

  of reflection may fit the occasion depending on what you know about the client and the client’s readiness to change. Sometimes it might be helpful to understate the reflection, whereas at other times it might help to overstate or even amplify the reflection, gently guiding the client to consider other angles. Sometimes just the right metaphor can be used to drive home an

  emotion.

  Metaphors

  A metaphor, simile, or analogy can help bring a concept to life. Comparing what the client says to an object or action helps emphasize the complex-ity of the client’s feelings. Often words can be rather limiting. By using a metaphor the practitioner paints a picture of how the client may feel. The imagery provides a new way to look at what was said, ultimately deepening the client’s understanding.

  client: I feel all over the place. One minute I’m counting calories, trying to be “good” with my eating, and the next minute I’m throw-

  ing in the towel and bingeing on a pan of brownies.

  pRactitioneR: Dieting can feel like a rollercoaster ride. Before you

  know it, you’re upside down.

  reframing

  A reframe is simply a reflection that highlights a different perspective within the client’s statement. It’s particularly useful to deemphasize sustain

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  talk. A practitioner may hear sustain talk and recast the statement into a neutral statement, change talk, or an affirmation. Here are some examples: client: I feel bad going to the gym after work because I hardly see my

  kids as it is.

  pRactitioneR: It’s important to you to be there for your kids.

  client: I’m just here because my doctor told me to come.

  pRactitioneR: You trust your doctor and you’re wondering how I

  might be able to help.

  client: I tried eating my dinner at the table without the TV on, like

  you had suggested, and I got more anxious and even lonely.

  pRactitioneR: While it didn�
��t turn out how you were hoping, you

  were mindful of your thoughts and feelings during this experi-

  ment.

  client: I notice that I don’t feel good after I eat a lot of junk food.

  pRactitioneR: You know your body well.

  Reframing the client’s seemingly negative statements into neutral or

  even positive reflections will likely affirm the client and direct her forward instead of allowing her to dwell on the negative aspects of behavior change.

  continuing the Paragraph

  Reflections that continue the paragraph take a guess at what is unstated but implied in the conversation. These reflections move the client forward, sometimes moving the conversation in a new direction. Continuing the

  paragraph is not the same as finishing someone’s sentence. Finishing someone’s sentence is discouraged in counseling, because it can interrupt the client’s train of thought. However, continuing the paragraph can help bring up new pieces of the puzzle in exploring ambivalence about a change.

  client: I’d like to go on walks with my sister. She’s a perfect workout buddy because she goes my pace. Her life is so hectic though.

  pRactitioneR: And you’re concerned she may not be reliable.

  In addition, continuing the paragraph reflections can take what the

  client says and accentuate any spoken or unspoken change talk.

  client: I’m tired of being tired. I drink way too many energy drinks.

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  pRactitioneR: And you want to make a change that naturally boosts

  your energy levels.

  There is often crossover between the different types of reflections. For example, continuing the paragraph can also reframe the client’s original statement, reflecting on what the client said from a new angle.

  client: I hate my thighs and bottom. I feel like people are always

  looking at those areas of my body.

  pRactitioneR: And there are other things about you you’d like them

  to notice.

  double-sided

  Double-sided reflections are used when the client is expressing ambivalence.

  When the client is sharing both advantages and disadvantages of making a behavior change, it can be productive to reflect back the expressed ambivalence so the client better understands his conflicted feelings. Double-sided reflections often start with “On one hand . . . ,” and finish with “On the other hand. . . . ” When providing a double-sided reflection, connect both sides with “and” instead of “but” in order to give both choices equal weight.

  client: I know I need to switch to diet sodas, but I just can’t stand the taste of fake sugar.

  pRactitioneR: On one hand you’re not so sure about the taste of arti-

  ficial sweeteners and on the other hand, you are concerned about

  how regular soda may affect your blood sugars.

  By reflecting the ambivalence you guide the client to consider the

  importance of both sides. However, at times the client will get stuck in his ambivalence, at which time it is best to use reflections that only emphasize the change talk.

  Reflecting both the change talk and sustain talk demonstrates empa-

  thy for the challenge of making a change. When using double-sided reflections, start by reflecting the sustain talk and end with the change talk. This strategy will increase the chance that the client responds with more change talk.

  Consider the two double-sided reflections below and the order of sus-

  tain talk and change talk:

  client: I’ve thought about riding my bike to work, [change talk] but

  I’m afraid I’m going to be a sweaty mess when I get there. [sustain

  talk]

  Reflections 127

  pRactitioneR: You’d like to somehow work exercise into your com-

  mute [change talk] and you’re concerned that doing so would

  make you feel sweaty all day. [sustain talk]

  client: Yes, I’m afraid of how I would look and I’d just feel dirty the rest of the day. [sustain talk]

  client: I’ve thought about riding my bike to work, [change talk] but

  I’m afraid I’m going to be a sweaty mess when I get there. [sustain

  talk]

  pRactitioneR: Sweating is a concern, [sustain talk] and somehow

  working exercise into your commute remains appealing. [change

  talk]

  client: Yes, I’m jealous of the people I see ride past me on bikes when I’m stuck in traffic. [change talk]

  When the practitioner ended with change talk, the client spoke more

  change talk. When the practitioner ended with sustain talk, the client spoke more sustain talk. While this isn’t always the case, clients are more likely to respond to the end of the practitioner’s statement. Therefore, by reflecting the change talk last, you may propel your client forward toward change.

  undershooting

  An undershooting reflection might be used at times to encourage continued exploration. The undershooting reflection depreciates the intensity of the emotion expressed. Doing so may encourage the client to clarify what was meant which can deepen the client’s understanding of her feelings.

  client: I hate that my husband eats whatever he wants in front of me.

  He knows I’m trying to watch what I eat and it makes it so much

  harder for me to watch him eating things I can’t have.

  pRactitioneR: You’re not crazy about your husband’s eating habits.

  client: More than that, it makes me crazy and a little resentful.

  Undershooting reflections can bring out the client’s true emotion. They are especially useful when clients aren’t sure they should feel a certain way.

  Amplified

  An amplified reflection involves reflecting back what the person has said in an exaggerated form. This technique may encourage the client to back off a bit or consider another side of personal ambivalence. It’s important to provide amplified reflections in an empathetic manner, free of sarcasm.

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  client: I’m just so busy. I don’t know how other people do it. I go to

  work and when I come home I’m exhausted. When am I supposed

  to work out?

  pRactitioneR: There is just no space in your day for physical activity.

  client: Well, I don’t know. Maybe. I know a few guys get together

  right after work and go to the gym. If I was going to work out,

  it would have to be then because once I’m home I’m not leaving

  again.

  Understated and amplified reflections are used sparingly, as regularly

  overstating or understating client statements can result in clients not feeling heard or understood. It’s best to err on the side of undershooting, since it seems to help clients continue exploring their emotions. Figure 8.1 provides a summary of the different types of reflections along with additional examples.

  reFlectIng strAtegIcAlly

  A skilled practitioner knows when to use each type of reflection. In general, simple reflections are best when you’re first getting to know a client.

  Once you’ve built rapport, complex reflections are best for moving forward and unpacking deeper meaning. Novices will often say, “I feel like I’m just being annoying when I constantly repeat what the client is saying.” In general, echoing what the client is saying will get old after a while. If you feel like a broken record and you’re just going around in circles with the client, you’re relying too heavily on simple reflections.

  Simple reflections are typically neutral and stabilizing; although

  they help build rapport, they don’t often result in change talk within the appointment. One way to move the conversation toward change talk is to

  use complex reflections instead of simple, stabilizing reflections. Reframi
ng, double-sided, or continuing the paragraph are forward-moving com-

  plex reflections that help emphasize change talk. With any one of these, the practitioner is guessing at what is unsaid but implied. Consider the following stabilizing versus forward-moving reflections:

  • Client statement: “I know I’m supposed to eat vegetables, but I’m just not a big fan of them.”

  • Stabilizing reflection: “You don’t care much for vegetables.”

  • Forward-moving reflection: “You’re not crazy about vegetables and yet you know they have certain health benefits, so you’re wondering how you might be able to incorporate them in a pleasant

  way.”

  Reflections 129

  type of reflection

  Definition

  Example

  Simple

  Contains little or no

  “You walked for an hour

  additional content beyond

  yesterday.”

  what the client has said.

  Complex

  Adds more or different

  “The pressure of the gym

  meaning beyond what the

  membership adds a layer of

  client has just said; a guess guilt you don’t like and you

  as to what the client may

  prefer being outside in the

  have meant.

  open air.”

  Metaphor

  A word or phrase denoting

  “The appointment with

  one object or action used in your doctor lit a fire within

  place of another, suggesting and got you thinking about

  likeness or analogy between being active again.”

  them.

  Reframing

  Places the client’s

  “You like the idea of being

  statement in a new light,

  in nature and getting some

  giving new perspective.

  fresh air.”

  Continuing the paragraph

  The practitioner offers what “You’re more motivated to

  might be the next (as yet

  exercise when you can be

  unspoken) sentence in the

  outside.”

  client’s paragraph.

  Double-sided

  Includes both client sustain “On the one hand, you

  talk and change talk,

  don’t like working out at

  usual y with the conjunction the gym, and on the other

  “and.”

  hand, you’re feeling more