I think we need to have a good understanding of motivation if we are to achieve our health goals. Motivation is generally defined as the desire or willingness to do something, but it is one of those popular concepts that is hard to pin down. I did a simple web search for "motivation" and found there is no shortage of motivation language: "Yes you can!" "Make things happen!" "Believe in yourself!" This language is on posters and in books, and it dominates video presentations of all sorts. This language often comes with offers to make you, or your employees, richer, stronger, happier, faster, harder-working, and better-looking.
Psychologists have long studied motivation and agree that helping someone, or ourselves, to be motivated is a complex process. Clinical psychologists William Miller and Stephen Rollnick wrote the classic book about that process (Motivational Interviewing: Helping People Change) and their companion book (Motivational Interviewing in Health Care) offers strategies for healthcare providers to motivate change. While inspiration is important in kick-starting motivation, research shows that we also need step-by-step plans; changing what we do day-to-day and sustaining that change requires knowledge of ourselves and of what we really feel. Motivation is generally defined as the desire or willingness to do something, but as psychologists have found, the desire to do something is often paired in our minds with a true desire to not do it. Take exercise, for example. On the pro side of the equation we can list more energy, better health, getting in shape, being healthier, and maybe even looking better. But on the con side, we feel deep down that we really don't like the gym, or that exercise makes us sore or takes too much time. Further, even when desire and willingness are high, we tend not to change our behavior right away. We usually do so in stages. Psychologists are on that one too, with the "Stages of Change Model."
Let's start with an example. We begin by stating a concrete goal, a specific target behavior like "walking for a half-hour, four evenings a week after work or dinner." Being specific allows for clarity in examining what to do and how we feel about doing it. Being specific also helps us track whether we actually did the behavior or not (compared with "getting more exercise" which is hard to pin down). It is unlikely that we will change all at once, begin our new walking habit, and continue it without fail. Instead we are likely to go through the following stages.
Stage 1 is called Pre-contemplation. In this stage, I can easily list all the reasons not to walk (I'm tired after work; I prefer to watch the news; I don't have the right shoes.). If encouraged to do so I can probably come up with a reason to walk (I'll make my dog happy), but it's not easy. The goal behavior seems far off.
Stage 2 is Contemplation. I intend to start walking, maybe sometime this summer and I am becoming more aware of the potential positive effects of walking (e.g., getting stronger, having more energy) but I remain ambivalent because the arguments against walking are still strong (e.g., too many things to do in the evening, like laundry and cleaning up from supper). At this stage, though, I am open to being inspired by others who walk (e.g., several neighbors who walk their dogs in the evening). I might still think about the negatives and I put off the action, but I am moving slightly closer to taking the steps.
Stage 3 is Preparation and is just what it sounds like. I might get a new pair of walking shoes and find a later news show to watch while folding laundry after a walk. I have not started yet, but I'm getting close.
Stage 4 is Action. It took a while to get here (perhaps days; perhaps months), but my first evening of walking after dinner arrives. It is important at this stage to pay attention to the natural rewards of the action --to notice the coolness of the evening, or the friendliness of the neighbors, or how I feel better the next day. It is important to have a sense of pride in having taken action. If family members are supportive of the health behavior, it is important for them to say so and to acknowledge the success!
Stage 5 is Maintenance. We cannot emphasize enough the importance of reinforcement at this stage. Going for a walk four evenings a week does not have to win a person a new wardrobe or any large reward; in fact, small rewards are much better. For example, after a month of adhering to the plan, a movie night might be enjoyed.
Relapse-- a lapse in behavior and return to the previous state-- is bound to occur at some point. Bad weather or a cold can cause us to stop walking for a while and it is difficult to get started again. How we deal with relapse is crucial. We need to remember the strategies used in the past to get started walking. We should examine the impediments to walking (e.g., need a place indoors to walk in bad weather--like the mall). Perhaps it is time to switch to walking on a treadmill or riding a stationary bike at home (used fitness equipment can be inexpensive). We can benefit greatly from the support and encouragement of others at this stage. It is important for us to remember what has been accomplished and can be accomplished again with encouragement and support.
A very important concept in Motivational Interviewing is the "readiness to change." It's an overall feeling of (you guessed it) one's readiness to take action. Health professionals can ask their patients a simple question: On a scale from 0 to 10, where 0 means you are not at all ready to start (...walking, taking the medication regularly, meditating etc) and 10 means you are ready to start right now, where are you at this time?
"Oh, a 2 you say...okay, what would it take for you to be at 5 or 6?"
or "Great, you say 7. So can you elaborate on your choice of a 7?"
The individual who said 2 can be encouraged to express the reasons for their resistance; the person who chose 7 can begin to solidify the choice by expressing the reasons for their readiness.
There are four very important principles of Motivational Interviewing that can be used by clinicians working with patients, and by those of us developing and maintaining our own motivations for behavior change. The first principle is empathy, which involves understanding another person's perspective. Empathy can also involve integrating different parts of ourselves, our different perspectives. The reluctant, cautious, lazier parts of us need to be accepted and understood more patiently by the parts that are more impatient and critical. Understanding our situational constraints (time limitations, fears, aches and pains) can help us to find solutions. The second principle is rolling with resistance. Generally this means not punishing ourselves for not being perfect, not arguing or pushing, but rather being patient with our challenges and limitations. Even if we feel too lazy to walk some evening, we might start out and if it doesn't feel right, just return home. Many times we will feel fine once we get outside, and will enjoy our walk after all. The third principle is developing discrepancy: "Here is where I am; here is where I want to be (need to be). If I do this, I will get closer to my goal. Step by step. Not perfect but trying." The final principle is self efficacy: "I can do this, It's my choice and I can do it. I'm doing it. I've come so far. I can keep going." Maybe this is the point when the motivational cards and posters finally come in! (I have one on my desk that reminds me: "Most people don't know there are angels whose only job is to make sure you don't get too comfortable & fall asleep & miss your life." Amen to that.)
In his valuable book, The Power of Habit, Charles Duhig tells us that by understanding and enacting certain principles, we can recognize the cues in the environment that trigger our actions and the things that reinforce them. We can build or change any habit we put our minds to. Our challenge, I think, is to first analyze and understand our own process of "" putting our minds to" a behavior. We need to understand, develop, and sustain our motivation to put our minds to the multiple tasks of behavior change.
Some things are clear. The more we know about motivation, the more we can use it to help others, and even ourselves, to adopt health behaviors and maintain them for life. We need to be patient with ourselves as we specify our behavioral goals, think about their pros and cons, gather the necessary resources, take action, maintain that action over time, and restart the whole process if we relapse. Desire and willingness are essential to behavior change, of course, and so is a deep understanding of each of the steps, in our minds and in our actions, that we need to take in order to change our behavior. We need to plan out what we want to do, be clear and specific, do the necessary thinking and planning, be honest with ourselves, be kind to ourselves, and maybe also get a poster.... maybe one with an Olympic athlete on it.
**Health professionals: For more about Motivational Interviewing in Healthcare, I invite you to listen to Motivational Interviewing (MI): Strategies for Behavior Change. This presentation appears on QuantiaMD, a free web and mobile community for healthcare professionals. QuantiaMD is a division of Aptus Health. In this program, I examine strategies for building effective partnerships between clinicians and their patients and for applying the well-researched and supported techniques of Motivational Interviewing. I suggest ways to enhance effective communication with your patients toward the goals of greater patient engagement, adherence, and commitment to treatment.