What really motivates people

The recent tragic suicide of Dave Duerson, a great professional football player, who made a conscious decision to end his life in a way that enabled his brain to be donated to Boston University’s Center for Chronic Traumatic Encephalopathy, reminds us of a profound truth about our nation’s health care crisis: we have to address the root causes of unhealthy and destructive behaviors before we can change the behaviors.

The assumptions underlying many of our health care policies are that people are most motivated to do what is healthy for them and their families, and if we could only get them good information, and good and affordable care, they would do the right things. Unfortunately, the reality is much more complex.

As the Duerson case, as well as many other cases involving athletes, show, many athletes deliberately engage in unhealthy and dangerous activities because they value the experience, and, to some degree, the money that comes to them from playing a sport at an elite level. By the way, I do not think money is the prime motivator. Otherwise, why would scholastic and college athletes engage in the same destructive behaviors as their professional counterparts? Also, if we go back several decades in any professional sport, the financial rewards for professional athletes were not that great, but they still played violent sports.

What struck me in a TV interview with Duerson’s wife and son was the comment by his son that Duerson had died because he played a sport he loved and experienced one of the highest accomplishments an athlete can have: being part of a world championship team. If we were to turn the clock back to the beginning of Duerson’s career and tell him that playing professional football would so damage his brain that he might commit suicide by age 50, it is unclear whether he would have made a different decision.

Similarly, many athletes become heavy users of performance-enhancing substances, despite strong evidence that those substances eventually destroy their health, because they believe that the substances will give them a competitive advantage, or, at worst, allow them to stay even others also using performance-enhancing substances. The only thing that has changed in the last several decades has been the substance of choice, but the propensity for many athletes to seek out an extra edge has not.

In the rest of the population, we have found that every person has life goals and priorities, of which health is a contributor or an inhibitor. People cannot relate to “optimal health.” They can only relate to the benefits optimal health brings to them, or the problems that less-than-optimal health creates for them. Why does this matter?

If we are to use the many tools available to us to make people healthier and reduce our society’s runaway health care costs, we need to tap the more fundamental behavioral motivations that drive their health decisions:

• The 50-year-old who has just had triple-bypass surgery may be more receptive to giving up tobacco usage, because failing to do so may be fatal. However, the more fundamental motivation for that individual may be more concrete, like the desire to care for grandchildren or to pursue pleasurable activities.
• The 25-year-old single woman probably cannot be induced to give up smoking by making her afraid of lung cancer, especially since smoking usually makes people thinner than they would otherwise be, but if it reduces her chance of marrying the person of her dreams, she will find a way to curtail her tobacco usage.
• The teenager who drinks alcohol is more likely to be motivated by the desire to be accepted by peers than by whether alcohol consumption is healthy or unhealthy.

What does all this mean?

• To a significant degree, we have to supplement traditional health care system tools with personalized coaching that helps an individual figure out his or her deep life goals and that helps further those goals through healthy behaviors.
• The coaching may be face-to-face, telephonic, or even online, or some combination of all of these methodologies, but it must be tailored to how a coach might build trust with individuals to help them live healthier lives, while pursuing their life goals.
• The source of coaching will vary by person. Over the years, I have found that it can be peers, nurses, pharmacists, doctors, behavioral health counselors, psychologists, mentors, supervisors, parents, siblings, or revered relatives or members of the community. Most people have several sources of trust. The sooner those trying to help individuals be healthier can find those trusted sources and match individuals to them, the better.
• Sometimes, changed circumstances also change life goals. Earlier in life, individuals are motivated by wealth accumulation, the desire to start and build a family, or the desire to get secure employment and build a career. Later in life, financial security, retaining connectedness to loved ones and the desire to have accomplished something meaningful matter more. Matching health goals with life goals is an ongoing process, not a one-time effort.
• Everyone has life events that shock them into making changes in their behaviors, whether the event is a divorce, becoming a parent, losing a job, having an accident, or getting diagnosed with a life-threatening condition. Health counselors need to understand how those life events alter life goals and change the health coaching patterns.
• As individuals are either too young to have life goals and are very dependent on parents or other guardians, or too old to care for themselves, the health care system needs to recognize that there are individuals who will have far more influence on an individual’s state of health and wellbeing than the individual himself or herself might have.

As I have learned more about Dossia, the personal health record platform, that we offer through the Dossia Service Corporation, it has become clearer that, while we can be successful in empowering individuals to manage health and health care to a degree by providing information and insight, there need to be other motivators, such as financial incentives, recognition from winning games and contests, and the ability to engage in more life activities. We can offer Dossia as a standalone data repository, but its greater value derives from its integration with broader life goals to which optimal health contributes.