MI Coaching Session 5 Reflective Listening DIFFERENT TYPES ...

MI Coaching Session 5 ? Reflective Listening

DIFFERENT TYPES OF REFLECTIONS AND REFLECTIVE LISTENING

? 2016 by Marc Steinberg

Listening carefully to the patient rather than thinking about what you will say next is a good way to learn how to think reflectively. Reflections are based on what you hear and may not be what the patient meant. Likewise, your patients listen to you and as they process what they heard they can misinterpret what was said. Reflections allow both parties to compare what they hear and provide feedback as to whether or not they have been adequately understood. You or you and the patient also need to identify a change target; otherwise you will have no way to distinguish change talk, the essential of reflective listening.

Reflective listening is the heart of MI and the change talk it evokes helps people make achievable plans to improve their self-care. Reflective listening is using one or more reflections in each statement you make. It is especially helpful in the MI processes of evoking, focusing and planning. It's common to get into a rhythm of 1 or 2 reflections followed by an open question at the end of some volleys (a single set of back and forth statements during the conversation).

Reflections can be simple statements, repeating what the patient just said, for example, "After you've been on a diet, you often regain the weight you've lost." Rephrasing is a type of simple reflection that changes the wording with synonyms, "When you get off a diet, your weight goes back to where it was before the diet.

When you add guesses, emotion metaphors or emphasis about what the person said you are making a complex reflection. For example, "You feel frustrated after you are on a diet because you regain weight you lost."

The following dialogue is an example of several types of reflections that are being used in reflective listening.

P (Patient): I can't lose weight. I've tried every diet there is. But when I get off the diet I regain the lost weight and sometimes even more than what I lost. I hate this back and forth." [sustain talk]

C (Clinician): "The weight you lose doesn't stay off." [simple reflection]

P: "Yeah. I've had such a hard time after my diets." [sustain talk]

C: "It bothers you that you can't lose weight, but it's something you really want to do. That's important to you." [double-sided reflection] A double-sided reflection is often used to

integrate both sides of a person's ambivalence. In this reflection the clinician adds guesses with an emotion about the person's sustain talk, "It bothers you that you can't lose weight." The second side of the reflection has the same framework, a guess followed by an emotion, "[weight loss] is what you really want to do [the guess]. That's important to you [emotion]."

Linguistically the word "but" cancels the meaning of a previous statement. This linguistic property of the word is seen in other settings too. For example, when your boss reviews your work habits and says, "You are always cheerful and on time (you're starting to feel good), but (uh-oh) you're not seeing enough patients." The word "but" in this example of reflective listening is important because it softens the patient's sustain talk about regaining weight. The clinician then adds another guess that is usually on target, "You really want to lose weight. That's important to you." You can also use "and" when making a double-sided reflection. But I chose in this example to emphasize change while softening the sustain talk that preceded it.

P: I'd love to lose 60 pounds. [change talk ? desire to lose weight]

C: You might feel better if you did that [complex reflection].

An understated reflection or question is more likely to evoke change talk. This complex reflection ("might feel better .") could facilitate the discussion about change. In many, but not all instances, we undershoot emotion.

P: I've never felt as good as I did last year when I lost 60 pounds. [change talk ? reason] I think the reason I can't keep the weight off is that I stop exercising after I lose weight. I just get out of the habit of it." [An affirmable insight]

C: You know a lot about this problem you're having. You've gained helpful experience from dieting. [The affirmation focuses on the insight that discontinuing exercise after successful weight loss contributed to regaining the weight. The affirmation is implicitly empathic. It provides a positive view; the patient's disappointments maintaining weight loss could be facilitated by that insight in a future attempt.]

P: I know it. It's no problem for me to lose weight [change talk], but keeping it off seems impossible to me. [sustain talk].

C: There's no way at all for you to keep weight off. So you probably won't ever try dieting again [this is stated in a respectful, amplified tone].

In settings where change seems distant, one option is to overshoot emotion by adopting the patient's position with a bit of amplification. This can evoke change talk. In MI this exaggerated complex reflection is often referred to as "coming alongside." In the future we will have sessions that focus on ways to work with people in an unhealthy status quo.

P: I never said that! I'm still young and I have ambition. That's why I've tried so hard in the past [strengthened change talk].

C: You're strong. You might even be interested in the easier part of this situation, losing weight [an understated guess].

P: Of course I'm interested in it [strengthened change talk]. But I need some help with the other part of this [asking for help].

C: Most people do need help after they lose weight because as you already know it's easy to regain weight [the clinician empathically normalizes weight loss recidivism in a person fearful of failure]. Would it be helpful if I provided some options [although the patient asked for help in the previous statement the clinician confirms her request before providing information in an EP-E style (elicit-provide-elicit)].

P: Sure.

C: We have a program here for weight loss that includes intensive follow-up. When people reach their target weight follow-up continues and physical activity is encouraged. You would work with a coach and a dietitian through the whole process. A second option would be joining a gym and establishing a schedule of regular attendance. Many gyms have trainers or coaches who could be helpful. Another choice would be some reading materials I could give you on dieting and avoiding weight gain after losing weight. And there is also an option of discussing this with a counselor who is capable and works with people who have eating problems. She helps them stay on track. What do you think of these options?

P: I've never done counseling for my eating problems. I would start out with the program here and if I had problems, I'd think more about seeing the counselor [activated change talk, taking steps toward change].

C: When you came in today you talked about how hard it was to keep weight off after dieting. You spoke in depth about your desire to lose weight too. This interest was strongly stated. I want to tell you that I'm impressed by your insight and commitment [affirmation]. I can help you get signed up here and I'm giving you a business card for the counselor. I'd be happy to you see again [summarizing reflection].

P: I'd like to see you. I will need your help with the unknowns, especially if I want an appointment with the counselor.

The clinician guided this brief encounter to the change goal of weight loss. By using MI she offered hope to someone profoundly dismayed by weight gain after multiple diets.

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