Reflections are brief summary statements of what the patient says.

We use reflections in MI for two basic reasons. First, we want to ensure that we hear and understand the patient correctly. Second, we want to convey our understanding back to the patient. Using reflections helps us to facilitate accurate communication and build rapport with the patient. Here are a few examples:

Patient (mother): Billy has been running a 104 fever and I think he has an ear infection. I need you to do something!
Practitioner: So, you believe that Billy has an ear infection and needs antibiotics.

Patient: I have tried everything this week to fit exercise into my day, walking like we discussed, and I just couldn’t do it.
Practitioner: You’ve found it hard to make time to walk.

Patient: I ate a serving of fruit and one of vegetables this week, and I’m very pleased!
Practitioner: You are really proud of yourself for making the goals you set for yourself.

What is the Guiding Style in Motivational Interviewing?

MI is a patient-centered, directive approach to health education. MI is based upon the philosophy that behavior change springs more from motivation than education.

MI employs the guiding communication style to engage the patient or client, to increase his or her motivation toward health behavior change, and to negotiate a personalized action plan that fits with the patient’s readiness to change.

MI is a directive approach to health education that differs from traditional models in a three fundamental ways:

1. MI emphasizes the idea that rapport building is critical for effective health education, and we build rapport through empathy. By using skillful and reflective listening, we develop a keen but neutral interest in all sides of the patient’s behavior change dilemma.
2. The MI approach to health education is collaborative. Empowering the patient is essential, both to maintain rapport and to allow the patient to activate his or her own skills necessary for initiating and maintaining health behavior change.
3. MI uses non-traditional methods to deliver information. Whenever possible, the practitioner elicits the agenda from the patient rather than imposing it on the patient. This results in a consultation that is much more conversational than the typical health care encounter.

A typical MI consultation has an Ask - Tell - Ask rhythm:

Ask the patient’s permission to discuss his or her health. Elicit the patient’s current concerns. Ask to add a concern or two or your own if need be. Provide the information requested using simple, jargon-free terminology. Don’t mix opinion with fact. Try to use neutral language. When offering suggestions for change, keep them conditional and always offer options. Ask the patient for his or her reactions to your information, feedback, and advice. Ask the patient to voice action items to which he or she will commit. Affirm and support the patient’s decision-making.

This is the MI guiding style.

MI holds that ambivalence is normal whenever people are confronted with the possibility of changing their behavior. This is true even when (and perhaps especially when) the evidence in favor of change is very clear or even overwhelming.

In reality, there are almost always compelling reasons not to change, and it is only human nature to defend the existing behavior. If we as counselors argue for change, clients naturally will argue against it; and passionate arguments for change often undermine the clients’ investment in the change process.

Rather than fighting the ambivalence and labeling our clients as “noncompliant” or “in denial", appreciating, discussing, and honoring their ambivalence is key to fostering change in health behavior. It may sound counter-intuitive, but by understanding and empathizing with the client’s mixed feelings about change, we actually allow them to begin the process of changing.

We can assume that people do what they do in regards to their health for very good reasons, and that these choices bring something important to their lives. In the case of food, people choose the types and amounts of food they do because of tradition, habit, emotional comfort, and family preferences. The idea of changing dietary habits may be perceived as suffering a loss, or even simply not possible. At the same time, the patient may be convinced that such change is truly important.

Helping patients resolve this ambivalence is key, as is helping them talk about the compelling reasons for change. We know that people are more likely to change when they talk themselves into it. In MI we call this “change talk", and the spirit of MI helps bring it about.

The “Spirit” of Motivational Interviewing

The basic assumptions of MI differ from traditional or typical medical consultation, and this is what is meant by the term “spirit". Typical medical consultation begins by assuming that “the practitioner is the expert and the patient will be taught.”

MI is very different from the traditional medical approach because it assumes a “dual expertise” between patient and practitioner, meaning that both the client and the practitioner are experts in the consultative relationship. This relationship is collaborative in nature, and careful listening to what the patient says is essential. The clinician may be the expert in what the patient ought to do, but patients are the experts about what is important and possible in the context of their lives.

MI assumes that patients have all the answers they need, and our job is to help them evoke this information.

In contrast, the traditional health behavior consultative approach is “installation therapy", in which we assume that the patient has a deficit of information. Traditional consultation aims to transmit information properly and with enough enthusiasm so that the patient will have it and be able and willing to use it.

MI stresses that as health care providers, we must always remember that it is the patient’s life that is under discussion, and we must have no investment in the successful outcome of treatment. Our job is to guide, always respecting the patient’s decisions about whether or not to change.