In my previous piece on patient adherence, we explored Michael Pantalon’s six-question framework for helping patients persuade themselves to change. Today, I want to dive deeper into four specific questions from William Miller and Stephen Rollnick’s motivational interviewing work that can revolutionise how you approach behaviour change conversations.
If you’ve been experimenting with Pantalon’s approach—helping patients access their own motivation rather than trying to convince them—these four questions will feel like natural extensions of that philosophy. They’re designed to work alongside those techniques, giving you even more tools to transform resistance into genuine commitment.
The Psychology Behind the Questions
Before we dive into the practical applications, let’s understand why these particular questions are so powerful. They tap into three fundamental psychological principles:
Self-determination theory tells us that people are most motivated when they feel autonomous, competent, and connected to their values. These questions honour that autonomy by inviting patients to generate their own reasons for change.
Cognitive dissonance suggests that when people voice reasons for change but aren’t acting on them, it creates productive internal tension. Rather than resolving this by dismissing the importance of change, patients often resolve it by taking action.
Intrinsic versus extrinsic motivation research shows that internally driven reasons (wanting to play with grandchildren) are far more sustainable than externally imposed ones (avoiding complications your clinician warned about).
These four questions systematically activate each of these psychological mechanisms, creating the conditions where genuine behaviour change becomes more likely.
Question 1: “Why would you want to make this change?”
This question assumes there are reasons—you’re just helping the patient articulate them. Notice the presupposition: not “Do you want to make this change?” but “Why would you want to?”
Clinical scenario: Emma, a busy executive with Type 2 diabetes, has been inconsistent with blood glucose monitoring. Instead of explaining why monitoring is important, you ask: “Why would you want to get more consistent with checking your blood sugar?”
She might respond: “Well, I suppose it would help me know when I need to eat something before meetings. And my grandmother went blind from diabetes…”
What makes it powerful: You’re not telling Emma what her reasons should be. You’re inviting her to connect with reasons that already exist for her—maintaining energy for work, family history concerns. These personal motivations carry emotional weight that your clinical explanations simply can’t match.
Adherence challenge it solves: This question helps when patients seem intellectually aware they should change but haven’t connected emotionally with why it matters to them personally.
Question 2: “How might you go about it in order to succeed?”
This question shifts the conversation from whether to change to how to change. The presupposition is that success is possible—you’re just exploring pathways together.
Clinical scenario: James, recovering from rotator cuff surgery, has been struggling with his home exercise programme. Rather than prescribing solutions, you ask: “How might you go about fitting these exercises into your routine in order to succeed?”
James considers: “I think mornings work better for me. Maybe I could do them right after my coffee, before I check emails. And perhaps I should set out my resistance band the night before as a reminder.”
What makes it powerful: James is now problem-solving rather than making excuses. When patients generate their own solutions, they’re more likely to follow through because the plan feels like theirs, not something imposed on them.
Adherence challenge it solves: This addresses the common scenario where patients understand what to do but haven’t figured out how to integrate it into their actual lives.
Question 3: “What are the three best reasons for you to do it?”
The specificity of “three” is important—it’s concrete enough to feel manageable but requires deeper thinking than just one reason. The phrase “for you” emphasises personal relevance.
Clinical scenario: Maria, a teacher with chronic lower back pain, has been avoiding the strengthening exercises you’ve prescribed. You ask: “What are the three best reasons for you to stick with these core exercises?”
She reflects: “First, I want to be able to get through a school day without my back seizing up during afternoon classes. Second, I love gardening, and I can barely bend over to weed anymore. Third, I don’t want to end up like my mother, who’s been on pain medications for years.”
What makes it powerful: Maria has just articulated three personally meaningful reasons that connect to her work, hobbies, and family concerns. These aren’t benefits you’ve explained like improved strength, flexibility or posture—they’re her lived experiences and fears.
Adherence challenge it solves: This question helps when patients seem unmotivated or when you suspect they haven’t fully considered what’s at stake for them personally.
Question 4: “How important is it for you to make this change, and why?”
This two-part question first gauges intensity of motivation, then explores the underlying values. The “why” component is crucial—it reveals what the change represents to them.
Clinical scenario: Tom, a tradesman with sleep apnoea, has been reluctant to use his CPAP machine consistently. You ask: “How important is it for you to get comfortable with using your CPAP regularly, and why?”
Tom pauses: “It’s really important, actually. Maybe an 8 out of 10. I’ve been falling asleep on job sites, which is dangerous. And my wife says I stop breathing at night, which scares her. I want to be around for my kids.”
What makes it powerful: Tom has just rated the importance highly and connected it to safety, family relationships, and parental responsibility. When patients voice high importance but low confidence, you know where to focus your support.
Adherence challenge it solves: This helps distinguish between patients who don’t see the importance of change versus those who see the importance but lack confidence in their ability to succeed.
Putting Them Together: A Systematic Approach
These questions work beautifully as a sequence, building on each other:
- Start with “Why would you want to…” to access initial motivation
- Follow with “How might you go about it…” to shift into planning mode
- Deepen with “What are the three best reasons…” to strengthen commitment
- Close with “How important is it…” to gauge intensity and uncover values
You don’t need to use all four in every consultation. Sometimes question 1 alone reveals everything you need to know. Other times, you might focus entirely on question 2 with someone who’s already motivated but struggling with implementation.
Common Pitfalls to Avoid
Don’t rush the silence. After asking these questions, give patients time to think. The pause might feel uncomfortable, but it’s where the real work happens.
Resist the urge to fill in answers. If a patient struggles to respond, that’s valuable information. It might mean they haven’t connected with their own motivation yet, which is precisely what you need to know.
Don’t argue with their reasons. If someone says they want to exercise to “look good in a bikini,” that’s their reason. Your job isn’t to judge it but to work with it.
Watch for the word “should”. When patients use “should” language (“I should do this because…”), they’re often repeating external messages rather than expressing internal motivation. Gently redirect: “What would make this feel important to you personally?”
Building on Your Existing Skills
If you’ve been experimenting with Pantalon’s approach from my previous article, you’ll notice these questions complement that framework beautifully. Pantalon’s questions help patients discover their readiness for change; these four help them articulate the deeper reasons driving that readiness.
Remember Sarah with cystic fibrosis who found her motivation through wanting to perform well at netball? These questions would help her explore that connection even further:
“Why would you want to maintain your airway clearance routine?” (connects to netball performance)
“How might you go about it to succeed?” (practical planning around training schedule)
“What are the three best reasons for you?” (performance, lung health, independence)
“How important is this, and why?” (links to identity as an athlete and desire for normal teenage experiences)
The Deeper Shift
These questions represent a fundamental shift from the expert model of healthcare to a collaborative one. Instead of being the person with all the answers, you become the person with the right questions.
This doesn’t diminish your clinical expertise—it enhances it. Your knowledge of anatomy, pathology, and treatment options remains crucial. But now you’re using that expertise in service of what matters most to your patients, rather than expecting them to care about what matters most to you.
When patients convince themselves to change through answering these questions, something profound happens. They’re no longer following your treatment plan—they’re pursuing their own goals. The exercises aren’t homework you’ve assigned; they’re steps toward outcomes they’ve articulated as important.
This is the difference between compliance and engagement. Compliance is about doing what you’re told. Engagement is about pursuing what you want. And engagement, as we know, leads to far better long-term outcomes.
Your Next Conversation
The next time you encounter resistance, try replacing your instinct to explain or persuade with one of these four questions. Notice how the energy in the room shifts when patients start talking themselves into change rather than defending their current behaviour.
Remember: curiosity is the backbone of exceptional communication. These questions transform you from someone trying to convince into someone genuinely curious about what drives the person sitting across from you.
What if the resistance isn’t a barrier—but a signal that you haven’t yet discovered what truly matters to them?
Start with one question. Practice it until it feels natural. Then watch how differently patients respond when they’re exploring their own motivation rather than defending against yours.
Ready to move beyond goal-setting to motivation-building? If this approach resonates with you and you’re curious about more communication tools that actually work in real consultations, let’s explore how these insights can transform your practice.
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