When there are lots of ways to do something, it’s a good bet that none of them work. Everyone uses a technique or tool if it really is superior. So with the internet, bookstore shelves and junk mail bins filled by peddlers selling motivation...hmmm. Since getting patients activated – actively engaged in maintaining their health – is a huge element of plans to improve population health, it’s worth examining how that might work.
It’s deceptively easy to think of motivation or activation as a state-of-being, reducing activation to a data point plotted on the graph of some mathematical equation modeling Life. But Life is not an equation, Life is more of a meander that could, perhaps, be modeled by an equation where someone traverses a Path from some Point of Inactivation to a different Point of Activation.
In counseling, knowing someone’s weight and state-of-activation are mostly useless without lots of knowledge about the Path of Life that led to those data points. Helping someone become activated is one of the most difficult clinical challenges, and is less about states-of-being than it is about shaping someone’s Path.
As noted in my last blog, advocating wellness visits, the most common response I hear from patients about lack of exercise is:
“Doc, I don’t have time for exercise”.
Nor do they have time, energy or money to invest in healthy eating, stress coping, or other element of healthy living! How does one “activate” such an individual, motivate them to restructure their priorities and adhere to a new set of behavior choices?
For the last decade or so, the ‘next big thing’ in lifestyle counseling has been motivational interviewing, but – truthfully – motivational interviewing typically achieves modest (10-20%) long-term benefits. In best cases it’s up to 40% benefit over usual care, but in some situations motivational interviewing has proven to be completely ineffective. Here are the facts from systematic reviews and meta-analyses:
Primary care: modest effects in multiple domains vs standard counseling
Health coaching: modest effects vs usual care
Obesity: 1.5 kg (3 lb) weight loss relative to controls
Tobacco: variable 2-45% benefit vs usual care interventions
Diabetes: no significant effect on A1c
Youth & alcohol: no significant effect
Youth & substance abuse: small effect
Substance abuse: ~20% short-term benefit but no long-term change (vs no intervention)
Substance abuse in mental illness: no difference over other interventions
Most important, the absolute benefits – the effect size – won’t have customers camping out overnight to be 1st in line. A 3 lb weight loss isn’t impressive to someone who hopes to lose something like 20 lbs (~7-10% of body weight needed to get clinical benefit). Particularly when they watch winners of The Biggest Loser achieve about 40% weight loss! No, I’m not advocating The Biggest Loser approach. In my opinion, this TV show has a bad influence on society, though the producers do know how to appeal to a person’s feelings, such as hope.
Motivational interviewing is helpful, but is no panacea. It is part of a long ascendance of counseling theories, including Prochaska & DiClemente stages-of-change theory, Albert Bandura’s self-efficacy theory, Carl Rogers client-centered or patient-centered theory (which most-directly spawned motivational inteviewing), Abraham Maslow’s self-actualization theory, BF Skinner’s theories on reinforcement, and so on past Carl Jung and Sigmund Freud. Recently, Judith Hibbard’s patient activation measure (PAM) has helped semi-quantitate an individual’s stage-of-change, and I myself like Carol Dweck’s work on how self-theories – one’s theory of oneself – can undermine motivation in most people. Collectively, these techniques provide useful skills that can help activate a patient, yet counselors who have mastered all these skills still struggle with many patients.
So, then,…exactly what is the plan to activate everyone, to move population health along a Path from a Point of Inactivation to a Point of Activation?
Politicians and health care adminstrators have probably oversold activation, though they also are upping the ante through higher health plan deductibles, bigger co-pays, with wellness and financial incentives to increase “accountability”. For highly-educated health care administrators who have lots of intrinsic abilities, financial resources, who cognitively and emotionally ‘get it’, healthy living seems obvious. But it’s not so obvious through the eyes of folks who live with health and socio-economic disparities, who are disportionately affected by diseases arising from poor health ecology.
The key problem is that most of what everyone responds to are feelings – emotions – and not logic or reason. The noun emotion, defined by the Oxford English Dictionary as “instinctive or intuitive feeling as distinguished from reasoning or knowledge”, derives from the Latin e- (out) and movere (to move), which is also the origins of the noun motive. Motivation and activation thus describe movement along a Path of Life, not a state-of-being, and the driving forces are primarily human feelings. Healthy living behaviors are mainly about emotions that are difficult to control, that are triggered by long-term exposure to a multitude of environmental stimuli.
Instead of addressing such feelings, health education heavily relies on teaching facts. Doctors, nurses, nutritionists, exercise physiologists, personal trainers and health coaches are primarily schooled in the molecular medical model of facts and formulas. Social workers and psychologists are more well-trained in dealing with emotions, but are typically dialed-out as being less valuable. Health behaviors are hard to quantitate for an electronic database, and are hard for molecular-oriented minds to analyze and understand. Our health system tries to force Paths of Life into being Points of Activation, trying to solve problems of emotions with logic and reasoning, to fix feelings with facts and formulas.
After a tough day, you want ice cream, but it’s 200 calories and is it worth the 2 miles it will take to walk it off? And how does all of that make you feel?
We must try to help people lead healthier lives. Our society cannot afford trying to solve diseases of lifestyle with expensive technologies and fancy drugs. Until we know a whole lot more about what drives personality, behavior and emotions, there will continue to be a lot of inactivated people who don’t motivate. Particularly if our society is not willing to invest in overcoming human behaviors driven by feelings and emotions. Patient’s lives are not some Field of Dreams fantasy. Just because we reform health care doesn’t mean people will activate, or that health professionals know how to motivate them. For people who do seek healthy living, we need to focus much more on their feelings than on their state-of-activation.
There remains much to learn. So when you next hear a health planner talk about activating people, ask them:
"Excuse me. What, exactly, is your plan"?
GEMoore, MD FACSM
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References
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Cleary M, Hunt G, Matheson S, Siegfried N, Walter G. Psychosocial interventions for people with both severe mental illness and substance misuse. Cochrane Database Syst Rev. 2008 Jan 23;(1):CD001088. doi: 10.1002/14651858.CD001088.pub2.
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http://en.wikipedia.org/wiki/The_Biggest_Loser_%28U.S._TV_series%29
http://weightmaven.org/2010/12/17/lies-damned-lies-statistics-the-bigges...
Yanovski JA., Yanovski SZ, Sovik KN, NguyenTT, O’Neil PM, Sebring NG. A Prospective Study of Holiday Weight Gain/ N Engl J Med 2000; 342:861-867March 23, 2000DOI: 10.1056/NEJM200003233421206
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