Forming a refection is attempting to understand what the client is communicating to us. We listen to what the client is expressing and we provide a response in the form of a statement, and not a question. The reason we do this is because asking questions of the client often leaves them feeling defensive and a statement is more likely to continue the conversation. This allows the client to speak more than the clinician and gives the client the opportunity to hear themselves process their own thoughts, beliefs, values, etc. about changes they are considering. A question also requires a response from the client and may stop the flow of the conversation and processing by the client. Miller and Rollnick offer these sets of counselor responses. (You may have to speak them out loud to hear the difference):
鈥淵ou鈥檙e feeling uncomfortable?鈥�
鈥淵ou鈥檙e feeling uncomfortable鈥�
鈥淵ou don鈥檛 think this is a problem?鈥�
鈥淵ou don鈥檛 think this is a problem鈥�
鈥淵ou鈥檙e considering a divorce?鈥�
鈥淵ou鈥檙e considering a divorce鈥�
In these examples, can you hear the difference? And can you understand how someone may respond differently based on whether you ask a question or whether you simply offer a reflection. In English, the voice usually goes up at the end of a question, and with a reflection, down. When the voice goes down at the end of a reflection, they are typically experienced as reflections of understanding.
If we pressed people with questions to explain themselves and what they are trying to express, they often become distant and spend time thinking about what they have said is actually true, or whether they should feel the way they have just shared. Again, reflective listening is responding to the client in a way that is not a roadblock, but instead, continues the conversation from the client鈥檚 perspective as we try to understand more about the client and the meaning they are attempting to convey.
Below is an example from Miller and Rollnick of a counseling session with a man who had open heart surgery 3 months prior to this conversation. Notice that not only does the clinician reflect back what the client is sharing but is also very skillful in moving the conversation forward:
Clinician: How have you been feeling lately, since your surgery?
Client: It was quite an ordeal, I can tell you. I鈥檓 lucky to be here.
Clinician: You could easily have died.
Client: They said there was a 90% blockage, and at my age that kind of surgery is major, but I made it through.
Clinician: And you鈥檙e glad.
Client: Yes, I have plenty to live for.
Clinician: I know your family is important to you.
Client: I love seeing the grandkids-two boys and two girls, you know, right here in town. I like doing things with them.
Clinician: You really love them.
Client: I do. And I enjoy singing with the community chorus. They count on me; they鈥檙e short of tenors. I have a lot of friends there.
Clinician: You have a lot of reasons to stay healthy.
The clinician is using reflections and not any roadblocks in this brief passage. This allows the client to continue talking about their own experiences and exploring what is most important to them and how they will (eventually) plan to stay healthy. Also, the clinician is trusting that the client is the expert of their own experience and knows what is best for them and what will be the best way to maintain a healthy lifestyle.
If there is a time when a clinician offers a reflection that the client does not agree with, the client will usually just keep going and clarify anything that needs correcting. It is also possible to turn any question into a reflection. One way to do this offered my Miller and Rollnick is to first think about the question, 鈥淒o you mean that you鈥�?鈥� Then remove the question words at the beginning (鈥淒o you mean that鈥�) and have your voice go down at the end of the reflection. Consider this example of a client talking to a provider, 鈥淚鈥檓 getting really discouraged about controlling my diabetes.鈥� So it would look like this if the provider was offering a reflection to the client, 鈥淒o you mean that you鈥檝e been trying hard but your sugar levels are still high?鈥� And now make this a reflection instead of a question, 鈥淵ou鈥檝e been trying hard but your sugar levels are still high.鈥�
Reflections can take a lot of time and practice, and can be more challenging than asking questions. However, to keep the conversation going and to have the client focus on their own motivations, strengths, and wisdom, reflections can allow the client to explore and come up with their own reasons to change. Next month, we will continue with another MI technique called 鈥渙vershooting and undershooting鈥� with reflections. It is another way to listen and offer a reflection that encourages more exploration by the client. I hope you all have a great month and have opportunities to use and practice Motivational Interviewing!
