Starting with the wrong school of psychology – why patient engagement shouldn’t begin with behaviourist theories – #medx

This week’s topic for discussion on the Patient Engagement Design MOOC began with a presentation by a patient that discussed that from a patient perspective, that level of engagement varies. I really liked how Dana Lewis (the patient) used Maslov’s hierarchy of needs as a way to present patient needs. When an issue is life threatening, the patient needs to be much more engaged – they are motivated to be much more engaged. I think this first presentation was a good started point at trying to develop an appreciative understanding of the patient experience. It helps to understand what the true ‘need’ is in the patient engagement problem.

Where I got lost was the presentation by Nir Eyal regarding the HOOK model (used in economics) and the entire focus on ‘habits’. I failed to see the link. When Nir Eyal confirmed that the HOOK model was based upon Skinner’s bevaviourist theory, I realized why I was having trouble. You see, behaviourist learning works great for temporary change (how many ‘habits’ have you developed only to stop them later?) – but not for life-long change. What wasn’t mentioned in the stimulus-response model was that when you remove the reward the behaviour stops. So, yes, the use of random (variable) rewards encourages the behaviour, what isn’t said is that when you stop the rewards the behavior also stops. This makes for a change that is not sustainable. Works well for short-term goals, but not for life-long goals.

In the field of education, when we consider deeper learning, and particularly when we are looking at learning that we want people to truly internalize, we look to the constructivist and social-constructivist theorists. This is a completely different view on how people learn (and therefore, how people change their behaviour). It is philosophically different.

In patient engagement, we use terms like ‘collaborate’ and ‘engage’ – and the assumption here is that we are looking for patients not just to ‘mimic a new behaviour’ but to truly believe in the change that is expected. So, if we want true engagement, we need to start from a theory that is based upon engagement. We should be talking about Vygotsky. We should be talking about how people learn through social negotiation with one another – and by actually engaging in conversation between patient and one’s care team, and through that engagement we can then co-develop (together) a treatment plan that works. Without the co-creation, we are going back to ‘dictating’ model that puts the physician as ‘expert’ and ignores the uniqueness of the individual patient. This is not engagement.

So now I challenge the course creators to find a better model or way of teaching this topic – one that is based upon the psychology theories of Vygostky and not Skinner!


6 Comments on Starting with the wrong school of psychology – why patient engagement shouldn’t begin with behaviourist theories – #medx

  1. Here’s a counter thought to chew on. How do you define “reward”? We often link reward to something tangible, e.g. money, gifts, etc. However, the “reward” of dieting is often better fitting clothes, better self image, feeling better, positive peer feedback, etc.. So I personally wouldn’t throw “reward” out with the proverbial engagement bathwater. Many studies of reward demonstrate how positive behaviors disappear when the tangible rewards stop. But an equal amount of studies demonstrate that the “reward” of small steps of progress towards a health goal can be a long-term behavior change.

    • Good point Joe. The payoff for my being angry with my doctors is I get to be sick AND angry so maybe that rates as a negative reward? As a result of my reflections in #medx it’s clear my previous behaviors were counter productive. The reward here is mostly in not carrying within me a category of people who can’t be trusted–which seems to be against my nature and might be a “sick-person” characteristic. Something I’d like to not have though I’m not sure I could accept this liberation were it offered to me by someone else. People whose sloppiness has almost killed me have told me I’m “lucky to be alive.” Should I take that as a reward?

      Have to think about this though. Is this adapting a weariness with mistrust to Eyal’s theory or does it describe something genuine? My difficulties with the medical system started in late 2007 and maybe I’m just tired? Or, like you say, I’m dismissing the reward idea too soon. One thing for sure, having grown up in Berkeley, I’m sworn to mistrust anything from Stanford:-)

      I’m not clear on this yet.

    • I don’t take issue with rewards – I don’t think they are a bad thing. However, the foundation that HOOK is built upon is behaviorist theory – which is where I take issue. You can have intrinsic and extrinsic rewards in non-behaviourist theories. To help people make real life-long change, they need to learn to see the intrinsic rewards of the desired behavior. For example, I exercise, not because I get a badge or a some other tool gives me feedback. I exercise because I recognize that it makes me feel better. I recognize the endorphin rush I get from cardio exercise. I have learned to crave it. I have learned to internalize that feeling I get from exercise. IMHO Helping people discover their internal motivators would be a more effective then some business model based upon a psychology theory that doesn’t align with long-term behavior change.

      • So Rebecca reward as positive feedback in a behaviorist frame is short lived? By building a working model that can integrate into our life goals the reward becomes a strategy or operational model over a need satisfied. Short term becomes long term. For instance: I can temper my nausea from chemo with a pill or I can change my diet and have the same result with fewer ups and downs. The act of doing something matters here too. The pill is someone else’s solution to a problem in my power to resolve with my own (self-constructed) solution. It’s much more sustainable and within my control to alter my diet and show I can learn from more than stimulus. I think Maha might agree that letting her daughter master her own behavior is empowering for both Mom and Child?

  2. Could be the Silicon Valley mindset on display here? Stimulus / Response /Next. Seriously, we want whole people and the strategies they might come up with to be part of their cure. Like feeling you have choices, a voice and your OWN needs.

    Alternately, the role of a sick person is a complexity that needs looking at. Have we created a simple identity for the sick that would respond to rewards? Do we want the SP to be compliant and conveniently quiet? Miserable, but graciously so?

    You’re right Rebecca, rewards are not a learning tool. “Sick” and “Well” are to ethereal to grasp as a place of being. I know what the words mean and feelings associated with both sick and well but they remain words rather than how I AM. Maybe we need a Zone of Proximal Wellness to reside in?

    And Maha, do you feel like rewards are too artificial to use on your Daughter? As if she was a problem to be resolved and not a reasoning complexity?

  3. Spot on, Rebecca!
    I personally see behaviorist theories as working only for animals (think Pavlov) and children, and I don’t even like using reward withmy child because it seems… Patronizing? I cannot believe they think of patient engagement from a behaviorist perspective! No wait, given how doctors usually treat patients, I can understand it, but I can’t understand how a course on patient engagement would go that route. But maybe they have something better down the road, and this was just an example of approaches that do NOT work, or that work for small illnesses for young kids or something…

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