Reflections can be extremely simple or very complex. At times, just repeating back to the client what they just shared can keep the conversation moving forward. The example below illustrates how the clinician repeats back to the client almost exactly what was said:
Client: I鈥檓 feeling very anxious today.
Clinician: You鈥檙e feeling anxious or Pretty anxious today
Marilyn Herie shared the metaphor of an iceberg, where a simple reflection is limited to what shows above the water, the content that has actually been expressed, whereas a complex reflection makes a guess about what lies beneath the surface. So if we used the original example again, a complex reflection may sound something more like this:
Client: I鈥檓 feeling very anxious today.
Clinician: You appear to be concerned about something or Since we last talked, something has happened
Simple reflections can be useful once in a while but can often keep the conversation going at a very slow pace. In order to move the conversation along, you may need to rely on reflections that add meaning and depth. A guess, perhaps, about what may come next. Below is an example from Miller and Rollnick of what this may sound like in a session with a client:
Client: I think I鈥檓 probably being too careful. My last test results were good. It just scares me when I feel pain like that.
Clinician: (making a guess) It reminds you of your heart attack.
In this example, the client doesn鈥檛 say the pain is related to a previous heart attack, but since you may have some information about the client鈥檚 past health experiences, you can make a guess about how the client is feeling. This adds more meaning and depth to the reflection and will likely move the conversation along.
Making these more complex reflections can advance the conversation much quicker. It can be challenging at first, but using these kinds of reflections becomes easier with practice. Also, it adds to the depth of conversation, and supports the understanding of what the client is attempting to express. Of course, you wouldn鈥檛 want to jump too far in thinking you know what the client means, but even if you do, the client will definitely let you know.
Reflections, in general, are particularly important after open-ended questions. A good rule of thumb is to offer about two or three reflections for every question asked. When this happens, it also avoids the quick question and answer game between the clinician and client that often leads to defensiveness by the client. It is a skill that can look easy when done well, but usually requires much practice and feedback, and a lot of trial and error. Next month, we will begin a series of blogs on some of the other core interviewing skills including open-ended questions, affirmations, and summaries. I hope you all have a great month and have opportunities to use and practice Motivational Interviewing!
For more information about Motivational Interviewing or related services, contact Eunice Akinyi Okumu, by phone (919) 843-2532, or by email, eunice_okumu@med.unc.edu.