Happiness in this World

Reflections of a Buddhist physician

The Problem With Prevention

How to motivate yourself to adopt healthier behaviors

Eating right, exercising, avoiding the sun or using sunscreen, moderating alcohol consumption, abstaining from tobacco use, getting mammograms, Pap smears, colonoscopies—almost every measure we're asked to take to safeguard our future health is difficult. It's a strange paradox that we have to work in some way, to expend energy, and experience discomfort of some kind in order to gain benefit in life. Wouldn't it be nice if the most pleasurable things also produced long-term benefit?

PSYCHOLOGICAL REINFORCEMENT

But it seems they rarely, if ever, do. Short-term pain appears to be an almost universal requirement for long-term gain. Which, though unfortunate, at least helps explain why people have so much trouble following through on plans to make themselves healthier in the long run. An ounce of prevention may be worth a pound of cure, but even that ounce seems beyond many of us.

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The reason for this likely has to do with the kind of reinforcement available to motivate preventive behaviors. Positive reinforcement is generally accepted to be superior to negative reinforcement in changing behavior as it leads to more lasting behavioral modification. In a positive reinforcement schedule, a reward is given after a desired behavior occurs (e.g., a dog gets praise after pooping outside). The most powerful positive reinforcement schedule is called the variable ratio schedule where rewards are given after a random number of responses (meaning a rat will get food after pressing a bar once, then five times, then seven times, then three times, then eight times, etc.). The weakest positive reinforcement schedule is called the fixed interval schedule where rewards are given only at certain time intervals after the desired response (e.g., a rat will get food after pressing a bar only if 10 seconds have passed since the last reward was given).

The problem with reinforcing preventive behaviors is that the reward not only comes too long after the desired behavior (years or even decades) but that it comes in the form of something that fails to happen (e.g., you don't have a heart attack or get colon cancer or breast cancer). This is called avoidance conditioning (when a behavior prevents an aversive stimulus from starting) and is one of the weakest forms of the already weak negative reinforcement schedule. It explains many failures, including our government's to invest enough money and resources in anti-terrorist activities until after the Twin Towers fell, despite literally decades of warnings from experts that a terrorist attack on U.S. soil was an eventual certainty.

Imagine then the psychological factors working against you when you're confronted with a delicious piece of pie that part of you wants to eat for the reward of immediately feeling good and that part of you doesn't for the reward of not gaining weight or not having your cholesterol rise and therefore increasing the likelihood of your not having a heart attack in twenty years. If all behavior arises from some motivation, it's not hard to see why carrying out behaviors that prevent future illness is so difficult.

HOW TO MOTIVATE YOURSELF

Certainly, some of us find even the weak reinforcement schedule of avoidance conditioning motivating. Perhaps we've already had a heart attack or have a close relative who developed or even died from, say, cervical cancer. But for many of us, the reward of preventing something bad from happening in the future is too remote to motivate desirable behaviors in the present, or to avoid non-desirable behaviors when non-desirable behaviors produce short-term pleasure (e.g., eating fattening foods) or enable us to escape short-term pain (e.g., not exercising). How then can we become better motivated?

  1. Educate yourself. People are far more motivated to act when they not only know why they should but own it themselves. Don't just trust your doctor. Find out for yourself the benefits of what's being recommended. Make them your concern, not just your doctor's concern for you. Learn about them firsthand, on the Internet or in the library (remember what that is—?). Leverage the fact that we're all more motivated by ideas that feel like our own than ideas that feel like someone else's.
  2. Tackle one painful change at a time. Don't quit smoking, start exercising, and radically change your diet all in one week. Pick one intervention at a time and stick with it until it becomes an ingrained habit. Then move on to the next.
  3. Find and focus on the positive benefits preventive behaviors provide you now. The decreased coughing that smoking cessation brings. The extra energy sleeping a full 8 hours a night releases. The peace of mind a negative colonoscopy provides. The benefits each of us finds motivating in this regard will naturally vary from person to person. Think creatively about what can motivate you to take better care of yourself. Find something concrete, something separate from the distant health benefit itself.
  4. Enlist a partner to encourage you and who you can encourage. Make it a contest between you to see who can make the most long-lasting changes in behaviors that lead to healthier lives. Or make it a competition. Or a series of shared goals. Or whatever works. Attach yourself to a person (or even better yet, to a group of people) who already think and behave the way you want to yourself. Their influence on you will prove to be greater than you expect. Even if this means distancing yourself from some old friends (perhaps who drink too much, or use drugs, or simply downplay the importance of healthy behaviors) and finding new ones—do it.
  5. Remember the glass is always half full. Don't allow yourself to become discouraged and give up (or fail to start) healthy preventive measures just because you fail at starting or continuing one (e.g., smoking cessation).

Despite the many barriers to adopting preventive care behaviors in our lives, many of us do manage to do it. If you're struggling to implement new healthy behaviors, a final suggestion would be to talk to people you know who've been more successful than you. Listen to them talk about how they do it, what works for them. You never know what you're going to hear that will work for you.

 

If you enjoyed this post, please feel free to explore Dr. Lickerman's home page, Happiness in this World.

 

Alex Lickerman, M.D., is a general internist and former Director of Primary Care at the University of Chicago and has been a practicing Buddhist since 1989.

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