The Cornerstone to Real, Personal Change

Most people don’t need more facts. They need motivation. As physical therapists, we often work with patients who know what they should be doing but aren’t quite there yet. That’s where motivational interviewing, or MI, comes in. It’s not about convincing people to change or flooding them with information. It’s about helping them discover their own reasons to take action.

Let’s start with something powerful. Around 99% of smokers already know smoking is bad for their health. They’ve heard it from doctors, seen it on warning labels, and maybe even experienced the effects themselves. And yet, many still smoke.

This tells us something important. Knowledge alone doesn’t create change. People often feel stuck in the middle, knowing they should do something different but feeling unmotivated or unsure. This is called ambivalence. MI helps people work through that by connecting change to what really matters to them: their personal values, goals, and priorities.

Common Patient Example:

Meet Dan, a patient with chronic low back pain. He’s been smoking for years, and you suspect it’s slowing down his healing. Instead of launching into a lecture about smoking, you ask Dan what matters most to him. He tells you he wants to play with his grandkids without feeling exhausted. That’s your opening. MI helps you guide Dan to see how quitting smoking isn’t just a health goal, it’s a step toward playing with his grandkids without being short of breath.

Four Key Principles of Motivational Interviewing

MI is based on the idea that people are more likely to change when they feel understood and supported, not judged or pressured. These are the core principles of MI, often referred to as the “spirit” of MI ^2,3 .

1. Express Empathy

Listening with empathy is at the heart of MI. Let’s say Dan says, “Smoking helps me relax when I’m stressed.” Instead of jumping in with advice, you reflect that back: “It sounds like smoking has been your go-to for managing stress, even though you’re also thinking about your health.” This kind of response makes people feel heard. It also avoids giving unneeded lectures about the dangers of smoking that Dan has probably now heard for years now. This enhances the therapeutic alliance and a good environment for potential change talk which we will discuss later.

2. Develop Discrepancy

Help patients recognize the gap between their current behaviors and what they really want for themselves. Dan might say, “I want to be active with my grandkids,” and you can ask, “How do you think smoking fits into that goal?” Here we are starting to try and connect how Dans behavior may be impacting his ability to participate in things he values deeply. Notice we are not outright saying this habit is negatively affecting what he values, we need him to do that himself.

3. Roll with Resistance

When we suggest a behavior change, it’s natural for patients to push back. This pushback is called resistance, and it’s a normal part of the change process. People may resist because they feel ambivalent, overwhelmed, or simply not ready.

Traditional approaches often trigger more resistance because they involve arguing, persuading, or confronting. In MI, we take a different route. Instead of pushing harder, we “roll with resistance.” This means acknowledging and accepting where the patient is, without trying to force them into compliance.

Let’s say Dan, your patient with back pain, says, “I don’t think quitting smoking will make that much of a difference for my pain.” A typical reaction might be to respond with more information or stats. But in MI, you’d reflect: “You’re not sure quitting will really help with your back pain.” This simple reflection lowers defenses and keeps the conversation going. It’s about respecting autonomy while still guiding gently.

You might follow up with a curious question: “What have you noticed about how your body feels when you’re smoking more or less than usual?” Now Dan is invited to explore his own experiences, rather than defend his stance.

Why Roll with Resistance?

When patients feel heard and not pressured, they’re more likely to lower their guard and start thinking about change. Rolling with resistance keeps the door open. Even if they’re not ready now, they may be ready later, and they’ll remember your respectful approach.

Key Tactics for Rolling with Resistance:

• Avoid arguing. Arguing only deepens resistance.

• Reflect resistance back. Show you’re listening and understanding, not judging.

• Use “double-sided reflections.” These acknowledge both sides of ambivalence. For example: “On one hand, smoking helps you manage stress. On the other hand, you’re wondering if it’s holding you back from healing.”

4. Support Self-Efficacy

People need to believe they can succeed. Highlight their strengths. Maybe Dan once cut back on soda or stuck with an exercise program for a few months. “You’ve made some tough changes before. That takes determination.”

Change Talk vs. Sustain Talk

One of the key goals of motivational interviewing is to get the patient talking about change in their own words. This is known as change talk, statements that reflect a desire, ability, reason, or need to make a change. Research shows that the more change talk a person expresses, the more likely they are to follow through with actual change² .

In contrast, sustain talk reflects reasons to maintain the current behavior. It’s important not to argue with sustain talk, but rather to acknowledge it and gently guide the conversation back to values and goals.

What Does Change Talk Sound Like?

• Desire: “I want to feel better.”

• Ability: “I think I could start walking a few times a week.”

• Reason: “If I quit smoking, I’d probably have more energy.”

• Need: “I need to be more active to keep up with my kids.”

• Commitment: “I’m going to try cutting back this week.”

• Taking steps: “I’ve started looking at smoking cessation programs.”

These are patient-driven statements. The goal is for the patient to convince themselves to change, rather than being persuaded by the clinician.

How To Elicit Change Talk

Eliciting change talk means asking the right questions and using reflective listening to bring out what’s already inside the patient. Here are some strategies:

1. Ask Evocative Questions

These prompt the patient to explore their own motivations.

• “What concerns do you have about how this is affecting your health?”

• “How does this behavior fit with the kind of person you want to be?”

• “What would be the benefits of making a change?”

• “What worries you about continuing this way?”

2. Use Importance and Confidence Scales

Ask: “On a scale from 0 to 10, how important is it for you to make this change?”
Then follow up: “Why are you at a 5 and not a 2?” This question prompts the patient to argue for change. Similarly, explore confidence: “What would help you feel more confident in making this change?”

3. Reflect and Affirm Change Talk

When a patient offers even a small piece of change talk, reflect it back and affirm it to keep momentum.

• Patient: “I’m tired of feeling out of breath all the time.”

• Clinician: “You’re ready for that to change and want to feel more in control.”

Linking Change Talk to Discrepancy

This is where the money is for true change. Change talk is powerful because it builds discrepancy between where the patient is now and where they want to be. This discrepancy is the spark for motivation. People rarely change without it.

Let’s revisit Dan. He says, “I don’t want to be out of breath when I’m with my grandkids.” You can reflect, “You want to be present and active with them, and smoking feels like it’s getting in the way of that.” Now Dan is starting to see how his current behavior (smoking) is not aligning with his deeper values (being an active grandparent).

By focusing on change talk, we help patients connect the dots between what they care about and what they’re doing. When they begin to feel that internal tension—the gap between their values and their actions—they are more likely to choose change.

Best Tips to Implement in Practice

1. Start with What Matters

• Ask about values. “What’s most important to you in your health right now?” These answers are the foundation for everything that follows.

2. Reflect More, Lecture Less

• You’re not here to convince anyone. Your job is to listen, reflect, and help them find their own reasons to change.

3. Offer Choices, Not Orders

• Offer options. “Some people like to cut back slowly, others prefer to quit all at once. What feels right to you?” Giving patients control makes change more likely.

4. Timing Is Key

• Not everyone is ready. “Sounds like you’re thinking about it, but not ready to take action yet. I’m here whenever you want to talk more.” You’re planting seeds for change.

5. Celebrate Small Wins

• Set achievable goals. For Dan, it might mean reducing from a pack a day to half, or replacing one cigarette break with a walk. Each success builds momentum.

Parting Thoughts

Motivational Interviewing is about helping patients find their own motivation, not giving them yours. It’s about being curious, patient, and supportive. You’re not just treating symptoms, you’re guiding people toward the kind of life they want.

Whether it’s quitting smoking, staying consistent with home exercises, or making a healthy lifestyle change, MI equips you to meet people where they are and walk with them toward where they want to be.

References:

1. Centers for Disease Control and Prevention. Current Cigarette Smoking Among Adults in the United States. CDC. Published March 17, 2022. Accessed March 16, 2025. https://www.cdc.gov/tobacco/data_statistics/fact_sheets/adult_data/cig_smoking/index.htm

2. Miller WR, Rollnick S. Motivational Interviewing: Helping People Change. 3rd ed. New York, NY: Guilford Press; 2012.

3. Rosengren DB. Building Motivational Interviewing Skills: A Practitioner Workbook. 2nd ed. New York, NY: Guilford Press; 2018.

Disclaimer:

I am a current Doctor of Physical Therapy (DPT) student sharing information based on my formal education and independent studies. The content presented in this newsletter is intended for informational and educational purposes only and should not be considered professional medical advice. While I strive to provide accurate and up-to-date information, my knowledge is based on my current academic and clinical rotations and ongoing learning, not extensive clinical practice.