The Art of Listening to What Isn’t Said

When I suggest to a client they might benefit from getting up maybe three times a day and taking a short lap around the office, followed by a drink of water, I know exactly what’s going to happen. They’re going to nod enthusiastically, agree that this is a wise idea, then forget we ever had that conversation. They’ll return two weeks later, sheepishly admitting they forgot or got busy. They may even say, “I hate water.” Or, “My office isn’t big enough.” Are you laughing? Maybe smiling in recognition, or even sighing in frustration? Yep. That’s the dynamic, and it plays out every day in our treatment rooms.

We’re not physicians or health coaches, but we are health-care providers. Many of us have spent years perfecting how to make recommendations, just as clients have spent years perfecting their evasive maneuvers. Sadly, for those of us who prefer to look outside for the answer, the gap between clinical advice and real-world follow-through tends to boil down to our lack of curiosity and habit of using unskillful questions.

Along my winding path as a massage therapist, I have become a fan of two concepts I think have real potential to transform how we create treatment plans. The first is a care-communication framework developed by Dr. Saul Weiner and Alan Schwartz called “Contextualizing Care.”¹ The other is motivational interviewing,² which grew out of research by William R. Miller and Stephen Rollnick in the 1980s, initially to help patients with substance use disorders.

What They Don’t Tell You Tells You Everything

Our recommendations are worse than useless if they don’t take the person’s life and context into serious, actionable account. We all know “I’ll try” really means “That’s never going to happen.” So, let’s do something about it.

Weiner’s research on contextualized care invites clinicians to pay attention not just to what patients say and do, but also to what they don’t say and don’t do. For example, when your client mentions they “might try” to stretch before bed, what aren’t they telling you? Or, when they avoid eye contact while agreeing to book their follow-up appointment, how can you get curious?

When we shift our approach, it might challenge us, but it’s likely to result in better outcomes and clients who follow through.

Hedges and seemingly offhanded comments like this are what Weiner calls “contextual red flags.” They are invitations to listen for the gaps. Maybe they can’t afford weekly sessions. Maybe their job doesn’t allow time for daily stretches. Maybe they’d rather be slowly digested over a millennium in the Great Pit of Carkoon (you’re welcome, Star Wars dorks). Maybe they don’t like you and can’t wait to get out of your office. The only way to know is to ask.

Ask Different Questions, Get Better Answers

This is where motivational interviewing becomes your secret weapon. Instead of prescribing solutions and hoping they stick, you can help clients discover their path forward. It’s less “Do this thing. It will help,” and more “What would actually work for you?”

Here’s what this sounds like in practice:

• Instead of: “You need to stretch your hamstrings every morning.”
  Try: “What’s gotten in the way of stretching in the past?” or “Is there a time of day when you can imagine it feeling possible to make time to stretch?”
• Instead of: “Get up from your desk and move your head and neck three times a day.”
  Try: “If I suggested that you get up and stretch your neck during the day, does that feel like something you would do?” or “On a scale of 1 to 10, how confident are you that you could stand up and stretch your neck three times a day?”

You’re not lowering your standards. You’re gathering intelligence. When someone says they’re a 3 out of 10 on the confidence scale, you know your recommendation needs more collaborative input. When they mention their chaotic mornings, you need to amend that morning stretching routine you were about to pitch excitedly.

Use the Magic Question: “What Else?”

One of the most powerful tools in motivational interviewing is “What else?”

“My shoulder’s been really bothering me lately.”

“What else is going on?”

This question is a context bomb. Ask and wait. 

“Well, I’ve been sleeping on the couch because the apartment above me flooded, right over my bed,” or “I’ve been really stressed about my aging parents living alone.”

Suddenly, you’re not just treating a shoulder. You’re treating a person in a specific situation, and your recommendations will benefit from that context.

Make It Actionable (Without Making It Homework)

Following are three ways to put this into practice:

Listen for hedging language. “I’ll try,” “Maybe,” or “I really should” are red flags. Pause and ask what would make the thing more doable.

Use scaling questions. “On a scale of 1 to 10, how confident are you that you’ll do this?” Anything below a 7 means it’s probably worth modifying the plan (together).

Ask about barriers before they become excuses. “What might get in the way of you doing this?” This question gives clients permission to be honest about obstacles while you can still problem-solve together, and before their next session, when they’re apologizing for not doing something.

The Uncomfortable Truth

This approach is powerful but also uncomfortable. It requires us to let go of being the expert. It means accepting that our beautifully crafted treatment plan might need to become an action plan that’s less beautiful but actually doable.

When we shift our approach, it might challenge us, but it’s likely to result in better outcomes and clients who follow through, plus the satisfaction of knowing we’re providing health care that fits 
real lives.

So, the next time you’re about to make a recommendation to a client, pause. Ask what their day looks like. Listen to what they’re not saying. Then, create a plan together. Trust me. A recommendation they’ll follow once a day beats a recommendation they’ll ignore three times a day—every single time. 

Notes

1. Alan Schwartz and Saul Weiner, Contextualizing Care, accessed December 1, 2025.

2. Motivational Interviewing Network of Trainers, “Understanding Motivational Interviewing,” accessed December 1, 2025.