People Have to Be Met Where They Are (At All Levels)
A Depressing Video
I recently watched a video about the use of new technology to change health behaviours in the elderly. It should have been inspiring and uplifting. Instead, it was depressing. The unhealthy elderly man in the video, let’s call him Jim, desperately needed to transform his lifestyle. If he didn’t eat more healthily and take more exercise his health would deteriorate; he might even die.
Ben C. Fletcher, D.Phil, Oxon, is a professor of psychology, a behaviour change expert, and the author of Flex: Do Something Different — How to use the other 9/10ths of your personality.
Editor: Nadeem Noor
As part of a behaviour change trial, Jim had been given various tools to help him. These included a hi-tech fork that measured the nutritional content of his food. There was a clever walking stick that measured how many steps Jim took. And even a sleep sensor to improve his sleep. The aim was for Jim to watch less TV, walk 2000 steps a day and cut down on fatty foods.
On the first day, Jim used the tools diligently. Within a couple of days, he rapidly started to lose momentum. The fork didn’t approve of his unhealthy breakfast. His walking stick registered that he wasn’t taking enough steps. The feedback messages from the sensors reminded him of his failures and Jim sank back on the sofa in a deep depression.
Wants And Needs Are Different
What Jim was told he needed was at massive odds with what Jim actually wanted. So Jim found a way around it. Not by changing his behaviour, but by cheating the sensors.
Whilst tucking into a fatty fried breakfast Jim dipped his fork into the healthy side salad. A young neighbour was happy to take Jim’s walking stick for a walk-in in return for a beer. And by throwing a cover over the sleep monitor he could carry on happily watching TV in bed late into the night.
Would Jim’s data have contributed to the research ‘evidence’ about the efficacy of health sensors? The results would suggest dramatic changes. The truth suggests otherwise. Not only was Jim carrying on with the old unhealthy ways he had also acquired a new cynicism about eHealth.
Jim did not want what the technology assumed he needed. Whilst the intentions behind the sensors are praiseworthy, the needs of people like Jim are simply not met.
Only Small Changes Are Needed – But They Are Still Too Big
A common theme in my previous blogs is that people can articulate what they want. Yet many do not want to do what is necessary to bring it about. This seems true even if only quite small changes are required. My second ever blog for Psychology Today – called Are You Living a Lie? – published in March 2012 seemed to strike a chord with some people and has received around four times as many views as other blogs I have written. Saying one thing but doing another seems to be a behaviour that many people recognise in themselves and a persistent conundrum.
The inability of people to make the changes they need, but don’t always want, has an impact on those around them too. It affects their partners, carers, friends and family. For every person who is trying to quit smoking or gambling or to curb their anger, there are many loved ones who would benefit from this change too (as I discuss in Love Not Smoking: Do Something Different).
Yet many of the changes needed may be quite minor. In an earlier blog, for example, I wrote about how a slight change in diet (eating one apple a day) could be as valuable to health as a lifetime spent on statins. Governments express serious concern about the unsustainable economic costs of some of our bad lifestyle habits. Our Western populations grow heavier and have more chronic health conditions such as diabetes. Medical care gets more costly and also adds years to the life of an ever-aging but unhealthy population.
So, what’s the problem? We may need to change. We may want to change. The changes needed are quite small. We know what we should do. Other people would prefer it if we changed and would help us. The benefits to us are clear. The benefits to others are obvious. The changes are sometimes necessary or essential.
And Yet We Often Fail. Many People Never Even Try
Why is this? It is because we are human. And animal. We have all sorts of drivers and habits that keep us doing what we do and prevent us from doing what we need.
The real challenge for psychologists and scientists is to understand how the negative circle can be broken. There has been a burgeoning increase in the number and range of behaviour change technologies available, drawing on all kinds of technological, medical, psychological and social approaches. Some help for some problems for some people but almost all promise more that they can do, or are based on models that give an illusion of benefit.
The Magical Need: Looking at Different Levels
The answer is to ensure that change interventions meet people where they are, not where we want them to be.
This will require a different perspective on change. It is not about stages of change, or techniques to boost willpower. It is about the different levels of the individual.
In my last book Flex: Do Something Different – I suggested there were at least 10 of these levels (including 2 biological ones, desires, habits, thinking, intention, saying, doing, remembering and reflecting).
Interventions that change only one of these levels are likely to be ineffective if other levels are also involved in the target behaviours. Even when there is good evidence that the problem is primarily at one level (perhaps, biological factors that can be tackled with drugs) changes are likely to be needed at other levels too. This holistic approach may sound difficult, but research evidence suggests (and probably your own experience does too) that simple solutions that address only a part of the person often do not work effectively. The ideal intervention would change all levels so that they are coherent or compatible with each other.
The solution is not just to give people what they say they won’t either, because ‘saying’ acts at only one of the 10 levels. This is why most information and education approaches have little change power. They principally work to increase intention or willpower and that is too weak for most people, most of the time. In Flex (link to the Living a Lie blog) I suggest that the 10 levels relate either to the real-time effort-expensive ‘Experiencing self’ or the off-line cognitive ‘Reflecting self’. Any change programme that fails to address at least both these elements is almost bound to fail. To be effective, change has to work on the automatic processes in real-time, as well as providing the person with positive feelings about what they are doing to reflect on. Without hitting both targets change results will be poor or short term. In Do Something Different we use small real-time Do’s (small new behaviours) to act as levers of reflective thoughts that happen as a result of the new experiences. A Do try to act on several levels, some consequentially and some in real-time.
Do Engagement and Do Change
There has been an explosion of wearable devices and sensor devices that can quantify our bodily functions, how we behave in real-time and can give us data relevant to our goals. Wearable activity monitors have been around for a while now, as have those that capture biological measures (such as heart rate or ‘stress’). It is now possible to measure such things as the nutritional values of food intake in near real-time.
So we could probably ‘know’ all we need to know about our caloric balance, for example, if we were wanting to be more active, eat more sensibly, or lose weight. But knowing is not enough.
As we saw with Jim’s example, the sensor information and change potential will be very short-lived. This is because this sort of data has little value or appeal to our experiencing self after the initial novelty value (it’s no fun!). The sensors cannot deal with our doubts and uncertainties about why we should behave in a different way. The sensor feedback does not provide any evidence that it is worth the effort. Sensors are fine for measuring things at the biological/physiological level. They are not so good at addressing wants. Or motives.
The challenge in effective behaviour change is to integrate the best interventions at all levels. This is being addressed in our EU Horizon 2020 Do CHANGE project in the area of cardiovascular health (the acronym stands for Do Cardiac Health Advanced New Generation Ecosystem). To be successful Do Something Different behaviour change technologies will be at the core of medical monitoring, sensor-based behaviour monitoring and healthcare professionals decisions.
This is not easy. It will require professionals and patients to engage. It will be important, therefore, to take cognizance of the magician’s trick. Engagement needs to appeal to the wants whilst, almost out of sight, the intervention also deals with the real needs.
These considerations are of critical importance wherever behaviour change is desired – at individual, organizational and governmental levels. The ‘trick’ may involve doing one thing under the guise of another. This may mean the person getting pleasure or having fun while adopting a healthier lifestyle. For ethical reasons this also needs to be done in an open and completely transparent way. The wonder of magic but even when people know how the trick works. After all, that is doing something different………