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On Motivation and Time

When there are lots of ways to do something, probably none of them are any good. When something really is superior, everyone uses it; when nothing works all that well, there are umpteen ways to do something. So…why are there so many books about dieting?

Since many people are now in the throes of trying to sustain some New Year’s resolution, it’s a good time to look at the subject of motivation.

As an exercise doctor, the most common response I’ve heard from patients about physical inactivity is:

“Doc, I don’t have time for exercise”.

It’s the same for other aspects of lifestyle – diet, stress coping, tobacco use, etc. – each evoking a unique set of responses, challenges and barriers, but still the most common excuse is not having the time.

Ben Franklin is credited with the observation that time is money, so when a patient says to me that they can’t afford exercise (or fresh produce, or whatever), often what they’re saying is:

“Doc, I don’t have time”.

How does one “activate” such an individual, motivate them to restructure their priorities to make the time and then subsequently follow through with a high degree of adherence to short-, intermediate- and long-term behaviors?

In recent years, the “rage” has been motivational interviewing, but – truthfully – motivational interviewing by itself has limited efficacy and achieves long-term adherence of about 20%. So it’s much better than scolding and guilt! Motivational interviewing is slightly more effective in some settings, closing in on 50% in tobacco cessation (especially when combined with nicotine withdrawal medication), but is completely ineffective some situations. Here are summaries of recent analyses of motivational interviewing:

Primary Care - modest effects in multiple domains vs standard (fact oriented) counseling

Health Coaching - modest effects vs usual care

Youth & Alcohol - no significant effect

Youth & Substance Abuse - statistically significant but small effect

Substance Abuse - about 20% short-term benefit and no long-term benefit

Substance Abuse in Mental Illness - no advantage over other behavioral interventions

Obesity - 3 lb loss relative to controls (avg. holiday season weight gain is ~1 lb)

Tobacco - 2-45% benefit vs usual care interventions

Diabetes - no significant effect on A1c

Despite some of these being statistically significant differences, the absolute benefits – the effect size – won’t exactly have customers camping out overnight on your doorstep to be 1st in line. When lots of people need to lose more than 20 lbs (about 10% of body weight), 3 lbs doesn’t attract much interest.

Before motivational interviewing, Prochaska & DiClemente stages-of-change theory was the next big thing, before that it was Albert Bandura’s self-efficacy theory, and on to a long list – Abraham Maslow’s self-actualization theory, Carl Rogers client- (patient-) centered therapy, BF Skinner’s theories on behavior modification, and so on past Carl Jung and Sigmund Freud. Recently, Hibbard’s patient activation measure (PAM) has help semi-quantitate an individuals stage-of-change. I myself favor Carol Dweck’s work that suggests people are biased by prior learning experiences and form theories about themselves that can be self-constraining.

The truth is that, by themselves, none of these approaches are all that impressive. Collectively, they are very useful skills for a coach to master, because skilled coaches will call on all of these theories and more – particularly in an effort towards increasing positivity, thinking in a positive way – to help activate a patient.

So why do population health advocates, who rarely have a psychology background, seem so convinced that health care redesign will activate individuals and communities? From a highly-educated and self-efficacious health care administrator’s eyes, patient activation may seem self-evident. But sit one-on-one with a patient or lead a small group session and the challenge of activating patient motivation reveals itself.

Behavior change has less to do with logic and reason than about feelings. Note that the words “emote” and “motive” have the same root origins - to feel. Yes, most of what people respond to is not facts and logic, but feelings. There’s a problem lurking when health education models are based on teaching of facts, but the path to lasting behavior change is based on feelings.

For people who have lots of intrinsic resources that help them emotionally and cognitively “get” healthy living, and who have sufficient financial resources (which buys time), lifestyle choices may seem obvious and easy. But it’s not so easy in folks who have health (particularly mental health) and socio-economic disparities. Many chronic diseases are associated with adverse social and environmental risk factors.

To help someone with improving his or her health, a coach helps them understand their priorities and how they feel about changing them. It’s rarely a simple discussion – particularly for a patient who has low self-efficacy and self-image and very few resources. Many wellness programs favor financial incentives, but monetary benefits has limits. The real emotional work is almost always about something the patient values other than money.

If one seriously wants to help people change their lifestyle to improve health and well-being, one has to learn how to help someone find (and maintain) their motivation by guiding them to their feelings and priorities. And if we’re going to reverse the trend in cardiometabolic disease, that is precisely why physicians need health coaches in their practices!

by Geoff Moore, Chief Medical Officer


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