Table 2.

Levels of reflection with relevant descriptors and illustrative examples.

Reflection levela and additional descriptors		Illustrative examples
Reflection level 0. Description: revisiting (description or statement about events without further elaboration or explanation; not reflective)
	Repeating or paraphrasing intervention content	“That exercise makes you less tired but also helps you sleep Better.” [SIDb 157, 47 years]
	Superficial imperative statements	“[G]et up and move.” [SID 95, 49 years]
	Surface-level comments	“I thought the extended mindfulness video was helpful.” [SID 100, 37 years]
	Platitudes	“Life is hard sometimes.” [SID 99, 68 years]
	Not responsive to the prompt	“Bad weather.” [SID 117, 64 years]
Reflection level 1. Reflective description: revisiting with explanation (description including justification or reasons for action or interpretation but in a reporting or descriptive way; no alternate explanations explored, limited analysis, and no change of perspective)
	Elaborating upon intervention content	“On our sickest days, there is more going right in our bodies than going wrong. I need to appreciate this. And celebrate this.” [SID 113, 50 years] “[T]hat the uncomfortable feel of exercise is actually good for me. I just need to embrace it.” [SID 140, 60 years]
	Imperative statements (including justification or reasons or descriptive strategy)	“I need to get moving, so I will feel better.” [SID 79, age not given]
	Personal insight	“[T]hat I’m good at putting things off.” [SID 134, 60 years] “I am totally the kid looking out the window—I try to make everything an adventure and to look at the positive mental attitude.” [SID 103, 45 years]
	Skill building or learning a technique	“I’ve learned how to focus away from the chatter in my brain.” [SID 99, 68 years] “[T]hat I can ‘pick up’ internal barriers which relieves some of the feeling of frustration and feeling like a failure.” [SID 98, 53 years] “I liked the shear stress explanation. I can picture that while I exercise.” [SID 100, 37 years]
Reflection level 2. Dialogic reflection: exploring relationships (a different level of thinking about intervention content; identifying or exploring relationships between relevant concepts; applying experience or knowledge, providing evidence of cycles of interpreting and questioning, and consideration of different explanations, hypotheses, and other points of view)
	Applying intervention content to one’s own life	“My old excuse of saying ‘I just don’t want to exercise,’ is not a good enough reason. I know the reasons are that it’s uncomfortable and inconvenient, but that’s really not true. Also, I know I can adapt and it won’t cause pain in my hip with bursitis.” [SID 145, 48 years]
	Commentary on the nature of the relationships between disparate concepts	“If I am going to change my fitness habits, I must see how they relate to my values.” [SID 124, 42 years]
	Taking a different perspective	“[T]hat I’m being invited, not required to experiment with activity and that I can choose how to do it. I liked the line about experimenting with what we’re being told the benefits are in our own bodies. That makes me feel more in control and interested.” [SID 137, 53 years]
	Applying new skills or knowledge and reflecting on this	“In the almost 14-minute extended mindfulness exercise, I found that it did relax me even though that wasn’t the objective. I kept my eyes closed during the entire exercise. At first, my other thoughts included anxiety over today’s election. One of the suggestions was to look at yourself from outside yourself. I find I’m usually able to do that anyway...as it enables me to be more compassionate and understanding of others’ pain because of what I’ve experienced. For me, the only distraction, as I kept my eyes closed, was hearing the/your voice telling me things. I had no problem with pushing away thoughts because the only thing I was seeing was inside my eyes as they were closed. Once opened, everything becomes a distraction.” [SID 133, 70 years]
Reflection level 3. Transformative reflection: fundamental change (revisiting an event or knowledge with intent to reorganize and do something differently; asking fundamental questions and challenging personal assumptions leading to a change in practice or understanding)
	Perspective significantly altered	“[T]hat I and many other people get very wrapped up in goals and disguise them as values. We find that we’re not measuring up and we get disappointed in ourselves and give up working at them. Looking at goals as finite and values as infinite and guiding principles that shape goals puts them in a different perspective. It gives me hope that I won’t judge myself too harshly if I don’t fulfill my goals, that I’ll realize that maybe that goal wasn’t right for me and didn’t fit in well with my values.” [SID 137, 53 years]
	A change in practice or understanding resulting from personal insight	“I am stronger than the spoiled, damaged, hurt child inside me. I don’t have to listen to her. Just put her plump pouty face in my backpack and carry on.” [SID 82, 64 years]
Reflection level 4. Critical reflection: wider implications (social and ethical issues are taken into consideration; generally considering the wider picture)
	A transformative reflection that weaves in broader social or ethical considerations	“My essential Self is still there...I am alive, the tiny kernel of me, the spark, though almost extinguished, has to be nurtured above all else now...or I am extinguished by the grotesque cancer industry conveyor belt.” [SID 110, 74 years]

^aFrom Fleck and Fitzpatrick [40].

^bSID: study identification number.