Telling People What to Do Rarely Works.
At some point in your career, you have almost certainly had this interaction. You explain the plan in detail. It is evidence based, practical and thoughtfully tailored. The patient nods along as you speak, gives all the right verbal cues and perhaps even adds an enthusiastic “That makes sense.” You leave the session feeling quietly satisfied. And then they return the following week having done absolutely none of it. Not some of it, none. This is the moment many clinicians come face to face with the reality of behaviour change, where logic, expertise, and even the best intentions do not always translate into action.
As it turns out, simply telling people what to do, even when it is clearly beneficial, does not reliably lead to them doing it. In fact, the more directly we push solutions, the more likely we are to be met with hesitation, silence, or the familiar “yes, but…” response. Motivational interviewing offers a way out of this cycle, not by introducing complex techniques, but by gently shifting how we approach conversations. It moves us away from talking at patients and instead invites us to work with them in a way that fosters ownership and genuine engagement.
One of the biggest adjustments involves stepping out of what could be called the “expert trap”.
As allied health professionals, we are trained to assess problems and deliver solutions efficiently. This naturally positions us as the authority in the room, the one with the answers. While this role has its place, it can unintentionally create a disconnect when patients are expected to carry out these plans independently. A beautifully designed programme means very little if it does not fit into the realities of someone’s daily life. Motivational interviewing reframes this dynamic by encouraging collaboration, shifting the focus from prescribing the perfect plan to co creating a realistic one. It often sounds less directive and more exploratory, replacing statements like “You need to do this five times a week” with questions such as “What feels manageable for you this week?”
This shift becomes especially noticeable in moments where our instinct is to solve problems immediately. When a patient says, “I know I should exercise, but I just do not have time,” it is almost automatic to respond with time efficient strategies, simplified routines, or scheduling advice. Motivational interviewing, however, asks us to pause, to resist that reflex, even briefly and instead explore the barrier in more depth. Asking something like, “What does a typical day look like for you?” may feel slower and less decisive, but it often reveals the true challenge. By understanding the context, we are far more likely to develop a solution that actually works in practice, rather than one that sounds good in theory.
Ambivalence is another area where motivational interviewing proves particularly valuable. The classic “yes, but…” statements are not signs of resistance or lack of motivation, but rather an indication that the person is weighing competing priorities. They might want to improve their health while also feeling constrained by pain, time, fatigue or fear of worsening their condition. Instead of countering each concern, which can quickly turn into an exhausting back and forth, motivational interviewing encourages us to acknowledge both sides and guide the patient toward their own conclusions. When someone hears themselves say, “I suppose I could start small,” the source of motivation becomes internal rather than externally imposed, which significantly increases the likelihood of follow through.
This naturally leads to a reframing of what success looks like.
In clinical practice, it is easy to default to ideal expectations such as full adherence, consistent routines and measurable progress every week. In reality behaviour change tends to unfold much more gradually. A patient completing an exercise once during the week may not align with the original plan, but it represents a meaningful starting point. Highlighting and reinforcing these small gains shifts the focus from perceived failure to emerging capability. When patients recognise that even minimal effort is acknowledged and built upon, they are more likely to stay engaged rather than disengage entirely.
Underlying all of this is a skill that is often underestimated. It’s the skill of listening. Not listening with the intention of immediately responding, correcting or refining a plan, but listening with genuine curiosity and patience. When given the space, patients frequently articulate the real barriers themselves, whether it is fatigue after work, fear of reinjury, low confidence or previous unsuccessful attempts. These insights are far more valuable than assumptions and they provide a clearer path forward in terms of intervention and support.
Importantly, motivational interviewing does not mean abandoning your role as a clinician or withholding expertise altogether. Rather, it is about timing and delivery. Advice tends to be most effective when it is invited or when it follows a conversation that builds understanding and trust. In this way, the clinician’s expertise remains essential, but it is applied in a way that aligns with the patient’s readiness and context.
Ultimately, motivational interviewing doesn’t promise perfect adherence, flawless execution of home programmes or immediate transformation. What it offers instead is a gradual but meaningful shift, one where patients move from passive recipients of instruction to active participants in their own care. It reduces the number of conversations that end with polite agreement and no action and increases the likelihood of small, consistent steps forward. And in the context of long term behaviour change, those small steps are often far more impactful than any perfectly delivered explanation.
In the end, the goal is not simply to have patients agree with what we say in the clinic, it is to support them in doing something about it once they leave.