said you came today because you would like help managing your dia-
betes and your doctor told you that diet and exercise can help. You
Summaries 137
have already made some changes to your eating habits on your own
and you’re feeling discouraged that while those changes improved your
blood sugars, they didn’t result in weight loss. I also picked up that losing weight is important to you and I’d like to find out more about that.
What is it that you feel losing weight will do for you?”
“It sounds like you have mixed feelings about change. On the one hand,
you’re excited to start working out more often and have even recently
purchased a gym membership. On the other hand, you have voiced a
few concerns about working out, mainly a fear of not reaching your
goal, your arthritis flaring up, and running out of steam in the eve-
nings, making it hard to get to the gym. We’ve talked about other
times in your life you’ve been active and you recalled having more
energy, sleeping better, and feeling less anxious. What did I miss?”
A more detailed example of piecing together a summary is provided
in Figure 9.1.
when to suMMArIze
Really, there’s no bad time for a summary. You can offer a bouquet of
reflections at any point along the way. Summaries are especially useful during the occasions listed in Figure 9.2.
to communicate Interest and understanding
Similar to reflections, summaries demonstrate your interest in understanding what the client is experiencing. And by piecing some key ideas together from the conversation, the client feels as though you are trying to make sense of how the smaller pieces fit together to form a bigger picture. For example:
“When you heard your father tell you to ‘go easy on the brownies,’
you felt like he was telling you that you needed to lose weight. And it sounds like that made you feel like his love for you was dependent on
your appearance or size. You see the connection between those child-
hood experiences and your current relationship with food and how
you see yourself. It’s as if your father’s voice followed you into adult-hood. Did I get it all? How does all that sit with you?”
to highlight Ambivalence
When you hear the client voice both sustain talk and change talk, it can help to summarize the ambivalence. In doing so, you help the client to
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Read the brief excerpt below. As you read, make a mental note of the pieces you hear from the client that you’d like to highlight in the form of a summary.
Client: Since starting the chemotherapy, I have the worst appetite. I try to eat because I know it’s important, but the second I smell the food coming from the kitchen, I feel sick.
PraCtitioner: The smell of food cooking makes it hard and yet you muscle through the nausea because you know it’s important to eat.
Client: When I don’t eat I get real y tired.
PraCtitioner: You want more energy during the day.
Client: Yeah, I don’t want to just sit around and be a chemo zombie.
PraCtitioner: You want to lead a full life. Finding ways to manage the nausea would help you do that.
Client: I know I can’t be at 100% right now and I’m going to have to rest more, but I don’t want this cancer to define me.
PraCtitioner: You’re noticing that there might have to be some give and take as you go through chemo. Tell me more about the food piece in this.
Client: I know food gives me energy, I just wish there was some way I could infuse that energy into my body so I didn’t have to actual y eat it.
PraCtitioner: Yes, it’s hard eating when you just don’t feel like it. I bet food has real y lost its al ure lately.
Client: It has. I used to be a big eater, loved eggs, bacon, cinnamon rol s in the morning.
Just ask my wife. She doesn’t know what to do with me.
PraCtitioner: I bet it’s been hard for her to see such a drastic change.
Client: Yeah, she’s always trying to get me to eat now and before she was always trying to get me to stop eating.
PraCtitioner: Yes, that’s quite a shift. She must real y care about you.
Client: Yes, she wants to keep me around.
Key pieces for summary:
• Chemo has resulted in food losing its appeal.
• Kitchen smel s trigger nausea.
• Sees food as a way to get energy.
• Doesn’t want cancer to take over his life.
• Wants to find ways to manage his nausea.
Practitioner Summary: “Overal , I’m hearing that food has lost its appeal. You’re here today because you want to find ways to manage the nausea so that you have more energy.
You don’t want this cancer diagnosis to define you and if we can figure out the eating piece, it could make all the difference. How does that sound?”
FIgure 9.1. Piecing together a summary.
become aware of the mixed feelings she has about change. It’s best to start with summarizing the sustain talk and end with summarizing the change
talk. Leaving the change talk for the end helps move the conversation forward and may evoke additional change talk. For example:
Summaries 139
Provide a summary to . . .
• Communicate interest and understanding.
• Transition from one phase of the appointment to another.
• Highlight client ambivalence.
• Reinforce change talk.
• Wrap up a session.
FIgure 9.2. When to summarize.
“You seem conflicted. You want to avoid the headaches you get when
you stop drinking caffeinated beverages, while at the same time you
mentioned that you’d like to reduce your reliance on these drinks for
energy.”
to reinforce change talk
Perhaps the client has recently made several statements indicating an interest in change. You, as the practitioner, would like to summarize the change talk you hear. For example:
“While you still have concerns about the time it takes to buy fresh produce on a regular basis, you have a general interest in trying out the farmers’
market. You mentioned that you even looked into the dates, times, and
locations of farmers’ markets in our area. You’ve shared that this style of shopping may get you to eat more fruits and vegetables, which you
believe might help improve your health in a number of ways. What are
some other reasons you can think of to try out the farmer’s market?”
to transition to a new topic or Phase of the Appointment
You may want to switch gears at several points throughout the appoint-
ment. For example, you may be transitioning from the evoking part of the appointment to the planning part of the appointment, or from the engaging process to the focusing process. Perhaps you have a standard list of assessment questions you use at the beginning of each appointment. By
summarizing key pieces from the assessment, you can seamlessly transition the client to consider focusing on one behavior change to discuss further.
For example:
“Thank you for sharing more details about your current eating pat-
terns. I heard a number of themes we could revisit at some point, if
you’re interested. First, you shared a general out-of-control feeling
around sweet baked goods, especially in the evenings. You also voiced
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concerns about skipping breakfasts on busy weekdays, and I think I
heard an interest in limiting the number of trips you make to the coffee shop for drinks and p
astries. It sounds like we could head in a number of directions at this point. What do you already know about diet
changes typically made for lowering blood sugars?”
to wrap up a session
Just before the client heads out the door, it may be helpful to revisit some important components of the appointment. These summaries can help
remind the client of his or her personal goals and provide an overview of what just happened in the session. For example:
“As we wrap it up today, let’s take a second, if you don’t mind, to review the goals you chose. You plan to try out a new physical activity. You are particularly curious about boxing and said that you plan to research
some boxing classes in your area and share your findings at our next
appointment. Any final thoughts or concerns before you go?”
Once again, there’s never really a bad time to provide a summary; just like there’s never a bad time to use a full-length mirror instead of a hand-held mirror. In hearing a summary, the client gains perspective and sees the pieces fitting together, ultimately enhancing the counseling experience.
BrIngIng the oArs together
Each MI session has a steady rhythm of open-ended questions and reflec-
tions. Affirmations and summaries are the unique percussion instruments that are sprinkled throughout the appointment to enhance the overall musical number. Read the following script of a counseling session and notice the gentle rhythm that carries the client along.
pRactitioneR: How do you feel about the changes you attempted to
make last week? [open-ended question]
client: You’d be so proud of me! I actually put my fork down in the
middle of my meal the other night.
pRactitioneR: You’re excited that you were able to take time to check
in with your fullness level during a meal. [reflection]
client: Yeah, I mean, it was only one time, but I actually decided
soon after pausing that I was full for once and didn’t clean my
plate.
pRactitioneR: You feel like you were able to break a habit. [reflection]
Summaries 141
client: Yes!
pRactitioneR: By following through with your goal you’ve showed
yourself that you’re committed to making meaningful changes to
the way you eat. That is something to feel proud of. [affirmation]
What’s the next step for you? [open-ended question]
client: I really need to be more focused during lunch. I eat in front of my computer a lot.
pRactitioneR: You’d like to try eating mindfully during your lunch
hour at work. [reflection]
client: Yes. At least I would have a cleaner keyboard! You should see
the crumbs I shook out of it the other day. That can’t be good.
pRactitioneR: It sounds like you recognize the other potential ben-
efits to eating lunch away from your desk. [reflection]
client: Yeah—a cleaner computer and desk.
pRactitioneR: What might make it hard to be more mindful while
eating your lunch? [open-ended question]
client: I don’t know, I guess I just feel busy and stressed all the time, like I need to keep working to get it all done in time.
pRactitioneR: You’re more stressed out at work than in other eating
environments. [reflection] It sounds like you are quite committed
to your work. [affirmation]
client: Yes, I guess I am, but I’m also just really overworked.
pRactitioneR: What are other barriers to staying mindful during
lunches at work? [open-ended question]
client: Hmm, I can’t think of anything else. I think I’m just in the
habit of working while I eat at my desk. If I force myself to just
stay in the lunch room when I go pick up my lunch in the office
refrigerator, then I wouldn’t be as tempted to eat at my desk.
pRactitioneR: You came up with a solution on your own and that is
to eat in the lunchroom. [affirmation] What will your coworkers
think? [open-ended question]
client: Honestly, I don’t even think anyone will notice. And if they
do, I’ll just tell them what we’ve been working on in these appoint-
ments. Maybe it will make them want to try this mindful eating
stuff too.
pRactitioneR: Overall, you’re excited about this mindful eating
approach and removing distractions while you eat so you can be
more aware of your fullness. You were successful at dinner and
now you’d like to try eating this way at lunch. You mentioned a
concern that you won’t have enough time to take a short break to
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eat your lunch mindfully because you’re so busy at work. Not only
does taking a lunch break slow down your eating pace so you can
tune into how your body feels, but you also mentioned an added
bonus of a cleaner workspace and a crumb-free keyboard. You’ve
also figured out a plan, which is to eat your lunch in the break
room. [summary]
client: You know, it’s really not that hard to just take a few minutes
to eat. I may not be able to do it every day, but I could probably
try a few days a week, just to see how I like it.
pRactitioneR: It sounds like you’re interested in setting up another
little experiment. [reflection]
client: Yes. I liked how I didn’t feel so stuffed after dinner when I
just slowed down the pace and checked my fullness. If I did this at
lunch, I wonder if I’d feel less sluggish in the afternoon.
pRactitioneR: While the cost of 10–15 minutes to take a break and
eat your lunch may make you less productive at work, you’re won-
dering if you might have more energy in the afternoon because
you won’t feel as full or sluggish. [reflection]
client: Yes, so maybe it will be a wash, in terms of getting work done.
pRactitioneR: So, let’s see—a cleaner workspace, feeling more com-
fortable, and maybe even more energetic in the afternoon. [sum-
mary] Any other benefits of eating a more focused, mindful lunch?
[closed-ended question]
client: Yes. I might actually enjoy the meal!
pRactitioneR: Good point. [affirmation] It’s easy to forget that food
is supposed to be fun. Staying mindful might make eating more
enjoyable. [reflection] At this point, how motivated are you to eat
an undistracted lunch a few days a week on a scale from 0 to
10? Ten means very motivated, and 0 means not at all motivated.
[change ruler]
client: I’d say I’m at a 9.
pRactitioneR: That’s nice and high. Tell me more about why you’re a
9. [open-ended question]
client: Well, I’m realizing there are many benefits to slowing down at
lunch and that it may not even cost me any work time in the end,
especially if I’m feeling more energetic in the afternoon.
pRactitioneR: You see the benefits and yet, you aren’t quite at a 10.
[reflection]
client: I know there are certain days that it just won’t be possible,
given my schedule, the stressors at work, or even the social envi-
ronment.
Summaries 143
pRactitioneR: You’re realizing it will be impossible to be perfect with this behavior. [reflection]
client: Yes, but I can at least improve from what I’m currently doing,
which is stuffing my face at my computer.
pRactitioneR: Y
ou’re noticing that any movement forward is a step
in the right direction. [reflection] I’m wondering if it would be
helpful to set a more specific achievable goal for enjoying a more
mindful lunch. How many days a week would be reasonable for
you? [open-ended question]
client: I could easily do three weekdays, and at least one weekend
day as well.
pRactitioneR: That seems reasonable. [affirmation] OK, so we have
a specific goal to shoot for of three workdays and one weekend
day. This would be in addition to the more mindful dinners you’ve
been doing. [summary] At this point, how confident are you that
you that you can reach this specific goal on a scale from 0 to 10?
[change ruler]
client: I’m at a 9. I can’t say a 10 because I just need to try it first.
But, I’m feeling pretty confident now that I’ve given myself some
wiggle room.
pRactitioneR: You’re feeling pretty confident. [reflection] If you take a look at the next few weeks, what barriers, if any, might get in
the way? [open-ended question]
client: Well, I know I have a lunch meeting on Wednesday, so that
day is out. On the other days, I guess it’s just a matter of remem-
bering.
pRactitioneR: Can I share with you a technique other clients have
tried for remembering a certain behavior? [asking permission
question]
client: Sure.
pRactitioneR: Some of my clients have found that setting a cal-
endar reminder either on a phone or a computer can help. One
idea is that you could set this type of reminder to go off around
lunchtime and perhaps write a word that helps you remember the
plan such as “mindfulness.” [giving information] How does that
sound? [open-ended question]
client: Yes, that will work for me.
pRactitioneR: Great! Any other barriers that you can think of?
[closed-ended question]
client: Other barriers may come up, but I think I’m at least ready to
give it a try.
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pRactitioneR: Changing the way you’ve done something for so long
can be challenging. You’ve mentioned many reasons you’d like
to change the way you eat your meals. We’ve discussed different
Motivational Interviewing in Nutrition and Fitness Page 19