Imagine for a moment a patient named Sandra. Sandra has been slightly overweight most of her life, but as she gets into her 50s, those extra pounds are starting to take more of a toll. At her annual physical, her doctor does the usual blood work and finds that her A1C is still elevated. Sandra has prediabetes. Like millions of other Americans, lifestyle factors (like diet and exercise), as well as factors outside Sandra’s control (like age and genetics), have combined to put her at serious risk of developing diabetes — a disease that will increase her cost of care for the rest of her life and significantly impact her quality of life.
Sandra can’t make herself any younger or change her genetic makeup, so she’ll have to change her lifestyle in order to prevent diabetes. Her physician prescribes a new diet — lower calorie intake, reduced fat intake — and more physical activity. She also needs to lose weight to get to a healthy BMI. This intervention involves huge changes to Sandra’s behavior over a long period of time, and her physician stresses to her the importance of making these changes now. These lifestyle adjustments are achievable, but is Sandra really ready to undergo this change?
Of course, any doctor or counselor hopes his or her patient is coming in with a willingness to change, but changing behavior is extremely difficult and requires a deep commitment to the care protocol. The pressure of a spouse or a frightening diagnosis may not be enough to make patients change, as evidenced by the staggering numbers of patients who don’t adhere to physicians’ recommendations. What Sandra — and all patients whose care necessitates a lifestyle change — needs is internal motivation.
What is internal motivation?
Internal motivation is a willingness to do or achieve something that comes from “within” a person. This type of motivation can be far more powerful than external motivation, which is largely praise-based. Extrinsic motivation is derived from things like monetary gain, approval, or in some cases, the threat of punishment or pressure from others — what many of us know as “carrot or stick” motivation. This is not to say that external motivation isn’t effective, but when the catalyst for change comes from within, it can be much easier to achieve and sustain a behavior, such as taking medication at the same time every day, logging symptom patterns, or maintaining a specific diet.
Many of us have personally experienced the challenge of behavior change in the context of weight loss or other positive habits, like exercising regularly or getting up earlier. It’s easy to lose sight of long-term goals in favor of short-term comfort. But, research shows that internal motivation, over an extended period of time, is what’s going to get the results you want.
Identifying & creating internal motivation
So how can a doctor determine whether patients have the necessary internal motivation? One way to gauge motivation is by determining the patient’s view of self in comparison to their ideal self. This can be done through a motivational interview, which helps the patient gain awareness of their condition. This interview is non-confrontational and is a way to help the patient see the full scope of their situation and why it needs to change. It expresses the physician’s support and empathy for the patient, as well as helps the patient see that they have the ability to make changes for themselves. Through this process, the practitioner can determine whether the patient has the internal motivation they’ll need to succeed.
If the patient hasn’t already identified a strong intrinsic motivator — and many haven’t — it is possible to create this motivation. Again, it’s important for the patient to realize where their goal lies relative to their current state. In other words, they need to understand where they are now and where they want to be. Once they understand what they want to achieve, self-determination becomes the primary means for a coach to help a patient internalize their motivation. Self-determination consists of helping the patient find a meaningful impetus, recognize his emotions, and understand that the choice to change is his. This is how Noom’s trained coaches help our users create intrinsic motivation.
Still, many patients may not discover internal motivation so easily. So how can stakeholders like providers, patients, and caregivers overcome a lack of internal motivation?
Make the journey smaller. Encourage the patient to set specific, reachable goals that are small and concrete. For example: “Take medication at 4PM every day,” or “Limit chocolate intake to 2 squares a day.” Establishing something small the patient can do every day makes it easier and less intimidating to accomplish, and it will soon become a natural part of daily life. Once the patient sees that they can accomplish these smaller tasks, he or she will have more confidence to reach for bigger achievements.
What does it take to gauge motivation?
Naturally, it can be difficult to gauge motivation, and it requires that doctors spend more time having one-on-one conversations with patients. Just because Sandra says she will do something her doctor instructs does not mean she’ll actually do it. And if the physician assumes — as even the most well-meaning doctor might — that she understands why she needs to change and is motivated to do it, he or she may prescribe a care protocol that’s far too difficult for Sandra to adopt long-term. When she fails, her condition worsens, and her doctor, family, and even Sandra herself begin to feel that she simply doesn’t have the willpower to stick it out.
On the other hand, identifying that Sandra isn’t ready to change can be a crucial first step to arming her with the right plan — a plan that includes smaller, more manageable tasks she can likely achieve. Certainly, it’s tempting as a provider or caregiver to push for bigger, faster change, but this can be far more detrimental. This level of nuanced, individualized care is essential in complex lifestyle changes like those involved in reversing prediabetes, and that’s precisely what Noom is aiming to give its members.