Be a Guide, Not a Drill Sergeant: Gently Promoting Healthy Behavior Change in Patients

Physical therapists are experts. Physical therapists also are dedicated health professionals who desire desperately to help their patients. This combination results in the inevitable expert/recipient role where professionals feel obligated to “fix” patient problems. Unfortunately, lasting behavior change must come from within the individual. It is extremely tempting to take charge of conversations related to health behavior change and instruct people in the right course of action. However, when pushing someone into behavior change, you may find that they push back.1

Have you ever wondered why your patient still smokes even though he has heart disease? Have you ever been baffled by a patient who frequently no-shows or cancels therapy appointments? And let’s not get started about the multitude of patients who do not adhere to their home exercise program. The list goes on…but what is the answer?

Enter motivational interviewing (MI), a method which was originated by psychologist William Miller as he struggled to counsel patients who were suffering from addiction. Through close observation and self-reflection, he came to the conclusion that traditional styles of counseling were not very effective. On the other hand, he noted that therapists who listened more and built empathy were more successful.2 This style of counseling is considered to be more “guiding” and lies midway between the two extremes of “directing” and “following.”

See if you can identify the different approaches using these three hypothetical interactions between a therapist and patient whose obesity is contributing to the patient’s musculoskeletal pain.

Scenario 1
Therapist: “I want you to try cutting out sweets this week and let’s see if you feel any better and maybe even lose a few pounds.”
Client: “Hmmm…. Well, if you say so. I’ll give it some thought.”

Scenario 2
Therapist: “You do whatever you think works best with regards to losing weight. I’m here if you need me.”
Client: “Okay, no problem. I’ll let you know how that goes.”

Scenario 3
Therapist: “You’ve mentioned you are concerned that your weight is negatively affecting your health. If you were going to make a change, what would that look like?”
Client: “Well, I’ve always wanted to get back to riding my bike. That may be a good place to start.”

If you guessed that scenario 1 was an example of the directing approach, then you are correct. Here the therapist instructs the patient to perform a certain behavior with the hope he is compliant. Let’s be honest here, who likes other people telling them how to live their life? Perhaps that approach will work for the short term, but long-term, committed behavior change will take real buy-in from the patient and the comment, “I’ll give it some thought” does not sound promising!

Scenario 2 takes a more passive, “following” approach to therapist/patient interactions. There are certainly times when this might be appropriate. Imagine someone who is in hospice care and the goal is to make them comfortable. THEY need to dictate how that works and the therapist should play a more supportive role. However, odds are that our patient with an unhealthy weight is not going to just spontaneously change by himself.

Enter Scenario 3, or the “guiding approach” to counseling patients for behavior change. This style of communication finds the happy medium between the two extremes. The client is in control and has autonomy for making decisions about his body, although he is not alone. The therapist is available to guide him through the conversation and the difficult process of behavior change.

Motivational interviewing (MI) is a little more complex than this, but the “spirit” of motivational interviewing essentially includes an acceptance that patients have autonomy over decisions affecting their health. We are there to help, not dictate. There should be a healthy dose of empathy and compassion, and perhaps most of all an acceptance of the patient for who they are, regardless of their decisions. The goal of MI is to help the patient resolve their ambivalent feelings related to behavior change. If they are riding the fence and can’t fully commit to change, can we gently guide them in a healthy direction by facilitating “change talk”?

Motivational interviewing also has formal processes such as: Engaging, Focusing, Evoking, and Planning. Engaging helps create a connection between therapist and patient. By focusing, the therapist steers the conversation to behavior change. Encouraging “change talk” and minimizing “sustain talk” is the role of evoking. Finally, planning is a great place to assist the patient with setting SMART goals.

Effective MI involves extensive active listening (reflection). The general idea is that if you reflect back what a patient says, she will elaborate further on the topic. Imagine how you currently communicate with patients during a typical visit. Are you doing most of the talking? Are you constantly imparting your great wisdom? You probably are, just like I did for many years. One thing is certain, when using MI to encourage behavior change, the patient should be doing most of the talking. This is very difficult for physical therapists to understand since it does not fit our usual and customary mode of operation.

Extensive research has been published on MI in relationship to health behavior change and some studies report moderate evidence for its effectiveness for a variety of uses.3 However, additional rigorous research is needed. My personal experience using MI suggests it is at the very least an effective method to gain rapport with patients, which helps to build trust and mutual respect.

Key Words: health promotion, prevention, motivational interviewing



  1. Berger J. How to persuade people to change their behavior. Harvard Business Review. April 20, 2020. Accessed April 3, 2024. https://hbr.org/2020/04/how-to-persuade-people-to-change-their-behavior
  2. Miller WR, Rollnick S. Motivational Interviewing: Helping People Change. 3rd ed. The Guilford Press; 2013.
  3. Frost H, Campbell P, Maxwell M, et al. Effectiveness of motivational interviewing on adult behavior change in health and social care settings: A systematic review of reviews. PLoS One. 2018;13(10):e0204890.


Additional Resources

Learn more about MI by visiting the MI Network of Trainers website at: https://motivationalinterviewing.org/understanding-motivational-interviewing

Join the AOPT Health Promotion and Wellness Engagement Community to learn more about the physical therapist’s role in prevention and network with like-minded professionals.


The author declares no competing interests.


Author Bio:

Howell Tapley, PT, MSPT, PhD is a Board Certified Orthopaedic Clinical Specialist with over 30 years of experience. He is currently Professor and Program Director for the DPT program at Indiana State University. Dr. Tapley has doctoral training in health education/health promotion and completed a certification program in motivational interviewing. Under his supervision, DPT students have provided extensive prevention and wellness programming to underserved communities. He is currently a board member for APTA Indiana and serves as Chair for AOPT’s new Health Promotion and Wellness Engagement Community.

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