Change is hard. Adherence is harder.

How do we motivate sustained behavior change when the external motivation disappears—like it's supposed to?

If you’ve ever tried to count calories, go on a diet, start a new exercise program, change your sleep patterns, spend less time sitting, or make any other type of positive health change, then you know how difficult it is to form new habits. New habits usually require a bit of willpower to get going, and we all know that that’s a scarce resource. (Or at least, a limited one.)

Change is hard. But the real challenge comes after you’ve got a new routine going—because now you’ve got to keep it going, even though your original motivations to change may no longer apply. Why keep dieting when you no longer need to lose weight? We’ve all had the idea at some point that we really should reward ourselves for that five-pound weight loss with a cupcake, right?

This phenomenon of the disappearing-external-motivation can turn long-term behavior change into a Herculean task. And when it comes to taking medication, such a major obstacle to adherence can become very dangerous.

Taking pills (or injections, or whatever) every day is a pain, sometimes literally. Most of us only do it when the consequences of not taking our medication more painful. But if the medication is doing its job, then the symptoms that motivated adherence in the first place will vanish. The patient will start feeling fine—maybe even fine enough that their biggest problem is now the medication’s side effects—and the motivation to stick to the burdensome routine will wane.

If you’re on long-term medication for something like diabetes, liver or kidney disease, or mental health disorders, then a slip in adherence—let alone quitting cold turkey, as many people unilaterally decide to do—can spell disaster. The challenge of sustained behavior change is real, and it is significant. And many doctors are still scratching their heads over what to do about it.

While I was in California for the O’Reilly Strata Conference last month, I organized a meetup of healthcare professionals and data geeks to talk about some issues of common interest. This question of adherence came up there, too, and one of the attendees threw out a half-joking suggestion that perhaps long-term medication should come with placebos at random intervals—the idea being that if symptoms occasionally returned, subtly and without warning, then patients would have intermittent “reminders” of why their medication was so vital.

Leaving aside the significant health and ethics concerns about such an approach, the attendee wondered, would that kind of negative reinforcement even work? Our guest speaker, Julia Hu, explained that negative reinforcements of that kind can work well for behavior change in the short to medium term, but are not all that effective over the long term. Adherence is harder than that.

You know who’s already very familiar with this challenge? Alcoholics and other addicts. The need to abstain is readily apparent when you’re at the bottom of a well of your own making. But after you’ve climbed out of that abyss and been sober for three, five, ten years, it can be very tempting to “have just one.” Successful education programs have taught us all that, for someone with an addiction, there’s no such thing as “just one,” and that avoiding that temptation requires long-term support.

I think the issue here may be one of comfort. It is discomfort that motivates us to take our medication (or make some other kind of health behavior change), and when that discomfort goes away, our motivation can go away too. We need to be reminded of that discomfort, relieved of the illusion that our current comfort is a given.

I believe in the power of technology to help us with many healthcare challenges. But on the subject of behavior change, the apps I see are all aimed at increasing our comfort: awarding us points, creating mechanisms to help us brag on social media, or even providing financial incentives. Call it “gamification” if you like: there are dozens upon dozens of apps aimed at the kinds of behavior change I mentioned at the top of this post, and most of them are downloaded, eagerly adopted, and then left by the wayside within two weeks.

We need to do better. We need to design better. We need to creatively dig into new ways  to rise to this challenge of sustained behavior patterns. Maybe it’s time to start experimenting with apps that make us less comfortable.

Change is hard. Adherence is harder. But the most worthwhile challenges always are.

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