A better way to manage human motivation

Behavior science has been part of in-person care in a pretty robust way for many years. There are studies from 20+ years ago that illustrated key principles around motivation, emotion regulation, and behavior change. But it’s only in the last 10 years or so we’ve really seen an explosion in the translation of those into digital health. There are also companies that design new digital apps and interventions that don’t focus on behavior science, but I think that’s why in many cases they don’t work.

To make health behavior changes that last, you have to be thinking about motivation over the long term and the components of behavior change that sustain it. It’s not simply a “nudge” or the incentives you might apply when you want to achieve a discrete ending or short-term outcome. It’s different in health behavior—it’s an ongoing activity, a process that you have to continue to maintain and attend to. When health interventions don’t account for that, they tend to focus on quick wins. That’s why you see fad diets where people can often make big changes quickly, but they’re not sustainable because the changes haven’t really been integrated into their lives. They might be able to go without carbs for a few months, but once they start integrating them back in, it doesn’t work. If you think about why these ideas don’t necessarily translate in a clinical setting when you deliver in-person care, it’s often because clinical care happens only in short meetings. The actual change that needs to happen occurs in between the time you meet your caregiver and the next time you see them again—in those moments you’re making a decision around eating that cookie or when you’re having an emotionally tough day.

You need different approaches. First is a bottoms-up, individualized approach, where you iterate and create an intervention based on a person’s inputs. You want to have it make sense to the person and be easy and well-organized. You design it so that patients feel seen through the inputs they provide, and then you can tailor and personalize and iterate on an experience just for them.

But making health behavior changes is hard, and many people aren’t sure how to approach behavior change. They haven’t yet figured out a formula for what will be sustainable. So you have to combine it with guidance based on science—provide a structure for people that explains how behavior change actually happens. If you give people a roadmap and choices about how to engage, they can orient around how to go about making the change. You have to give them the building blocks of being able to make sustainable changes.

Engagement is an important thing to measure, not just how many times you click into an app, but how much effort you are putting into trying out actual behavior changes. That said, you can also measure health benefits from seeing how people are making small, incremental changes towards different behaviors. One person might not lose a ton of weight, but if they’re walking more and they’re eating healthier, that’s going to have a benefit to long-term health.

Many programs pay attention to the markers that are important in terms of business and lowering costs, but often don’t pay enough attention to what’s most important to patients in terms of their own goals.

Most people who join a weight-loss program will say they want to lose weight because it’s a common goal. But when you dig into that more, you find there are other goals that they really want. They want to feel better in their clothes or feel better about how they look. They want to reduce their risk for disease, be able to be more mobile, or have less pain or have more energy.

Often, those things are tangible markers that help them to stay engaged. When we pay attention to these issues that make sense to them, it can help them to see progress—even if the number on the scale isn’t moving.

Concepts like “tiny habits” and nudges are ideas that feel compelling and receive a lot of attention, but they generally don’t have a long-term impact on health. Many of those applications are based on the idea that if I just push you or pressure you to make a change in small ways and I get you to practice that, it will translate into long-term behavior change.

Problem is, we know a lot from science about motivation. When people feel pressured to change—by your spouse or your doctor or even by fear—the changes are short-lived, and only last to the extent that that pressure is still present. In fact, some people react to the pressure by disengaging from the behavior completely. Think of the angry teenager who is done being nudged or pushed to do something. They either dig in and absolutely don’t do it, or they do the opposite.

We all have the angry teenager inside of us. You have to be able to tie motivation to other things that are meaningful to the person, like, bigger-picture life goals such as being able to more easily play with their kids or keep up with activities with their friends, or else it’s not sustainable.

I try not to use the words success or failure, or even to focus on simply reaching an outcome. Many people have gotten stuck in the idea that you either reach an outcome or you don’’t. If you meet your long-term goal for your weight loss, that’s success, and anything short of that is failure.

The problem is, if a patient doesn’t reach a goal, they don’t see it as just failing at a particular task. They will think, “I’m the failure. I’m no good. I’m not ever going to lose weight, I’m never going to be healthy.” When I work with patients, and even with the coaches, we talk about helping people to recognize the strengths that they have in those moments, and focus on building that muscle to be resilient in those moments and learn from their experiences. Those learning moments are what creates change.