Lifestyle change
The adherence problem
Lifestyle plays a key role in the development and treatment of many conditions. Whether we're talking about nonspecific pain, cancers, cardiovascular diseases, or any other chronic (or even acute) illness, a sizable chunk of the condition's etiology and severity is often directly attributable to modifiable lifestyle factors. Both from a scientific as well as a common-sense perspective, the way a person lives their life is an important factor in determining their health outcomes.
However, many clinicans feel that getting their patients to change their lifestyle is a monumental task. Forget about trying to avoid consequences far off in the future, even if the individual is experiencing symptoms right now, they just won't listen! They've got plenty of reasons to do something about their problem and we're telling them exactly how to fix it...
Why don't they do what we say?
Let's unpack the answer to that question.
Livsstil spiller en central rolle i udviklingen og behandlingen af mange sygdomme. Uanset om vi taler om uspecifikke smerter, kræft, hjerte-kar-sygdomme eller andre kroniske (eller endda akutte) sygdomme, kan en stor del af tilstandens ætiologi og sværhedsgrad ofte direkte tilskrives livsstilsfaktorer, der kan ændres. Både ud fra et videnskabeligt perspektiv og ud fra sund fornuft er den måde, en person lever sit liv på, en vigtig faktor for, hvordan det går med helbredet.
Men mange klinikere føler, at det er en monumental opgave at få deres patienter til at ændre deres livsstil. Glem alt om at forsøge at undgå konsekvenser langt ude i fremtiden, selv om personen oplever symptomer lige nu, vil de bare ikke lytte! De har masser af grunde til at gøre noget ved deres problem, og vi fortæller dem præcis, hvordan de skal løse det...
**Hvorfor gør de ikke, som vi siger?
Lad os pakke svaret på det spørgsmål ud.
What is lifestyle?
We'll need an operational definition of lifestyle in order to make sense of it:
"The summation of a person's consistent behavioral patterns deeply connected with their identity."
Identity can be loosely understood as the characteristics which define an individual and their sense of self (interests, opinions, beliefs, values, etc.).
When we talk about lifestyle change, what we're referring to is behavior change + identity change. You cannot sustain one without the other. Any theory that claims to tackle behavior change must also deal with identity. We'll examine a theory that addresses both as we start to untangle the following question:
What drives behavior?
The key word here, "drives," isn't the most apt term for our purposes. We're specifically interested in its synonym motivation, more widely used in professional settings. Understanding motivation, the why of behavior, is the key to understanding how to change behavior.
Hvad er livsstil?
Vi har brug for en operationel definition af livsstil for at kunne forstå det:
"Summen af en persons konsekvente adfærdsmønstre, der er dybt forbundet med deres identitet."
Identitet kan i grove træk forstås som de karakteristika, der definerer et individ og dets selvfølelse (interesser, meninger, overbevisninger, værdier osv.).
Når vi taler om livsstilsændringer, henviser vi til adfærdsændring + identitetsændring Man kan ikke opretholde den ene uden den anden. Enhver teori, der hævder at tackle adfærdsændring, skal også beskæftige sig med identitet. Vi vil undersøge en teori, der adresserer begge dele, når vi begynder at udrede følgende spørgsmål:
**Hvad driver adfærd?
Nøgleordet her, "driver", er ikke det mest passende begreb til vores formål. Vi er specifikt interesserede i synonymet motivation, som er mere udbredt i professionelle sammenhænge. At forstå motivation, adfærdens hvorfor, er nøglen til at forstå, hvordan man ændrer adfærd.
Motivation
How many times have you heard, "he has low motivation," "she needs more motivation," or even, "we need to motivate our patients more?"
Motivation is a concept often described as a linear quantity. You just need more of it if you want to be successful in adhering to a behavior, and it's our job as clinicians to "give" high amounts of motivation to our patients.
This interpretation of motivation is tightly coupled with the binary reward (the carrot) and punishment (the stick). In order to increase motivation, we increase the degree of punishment or reward. It's elegant in its simplicity. But this simplicity is an illusion.
Many people still hold the belief that motivation works like this; however, we'll come to see that it's an untenable position to hold. This reductionist approach often backfires and results in poor outcomes and patient and clinician dissatisfaction. We have to reframe our idea of what motivation is and where it comes from if we want to be successful in helping patients make positive lifestyle changes.
Motivation
Hvor mange gange har du ikke hørt: "Han har lav motivation", "Hun har brug for mere motivation", eller endda "Vi skal motivere vores patienter mere"?
Motivation er et begreb, der ofte beskrives som en lineær størrelse. Du har bare brug for mere af det, hvis du vil have succes med at fastholde en adfærd, og det er vores job som klinikere at "give" store mængder motivation til vores patienter.
Denne fortolkning af motivation er tæt forbundet med den binære *belønning (guleroden) og straf (stokken) * For at øge motivationen øger vi graden af straf eller belønning. Det er elegant i sin enkelhed. Men denne enkelhed er en illusion.
Mange mennesker tror stadig, at motivation fungerer på denne måde, men vi vil se, at det er en uholdbar holdning at have. Denne reduktionistiske tilgang giver ofte bagslag og resulterer i dårlige resultater og utilfredshed hos patienter og klinikere. Vi er nødt til at ændre vores opfattelse af, hvad motivation er, og hvor den kommer fra, hvis vi vil have succes med at hjælpe patienter med at foretage positive livsstilsændringer.
Theories of motivation
The past century there have been various competing theories that have emerged from the field of motivational psychology. Some of these theories build directly on previous work, while others provide complementary perspectives. Each of the theories attempts to analyze motivation from a different angle. Humans are complex animals, and the reasons which ground our behaviors even more so.
We can split these theories of motivation into two broad categories: content theories, concerning what makes up motivational states, and process theories, how those motivational states arise.
Examples of content theories
- Alderfer's ERG theory
- Herzberg's motivation-hygiene theory
- Maslow's hierarchy of needs
- McClelland's three needs theory
Examples of process theories
- Adams' equity theory
- Bandura's self-efficacy theory
- Skinner's reinforcement theory
- Vroom's expectancy theory
Teorier om motivation
I det seneste århundrede er der opstået forskellige konkurrerende teorier inden for motivationspsykologien. Nogle af disse teorier bygger direkte på tidligere arbejde, mens andre giver komplementære perspektiver. Hver af teorierne forsøger at analysere motivation fra en anden vinkel. Mennesker er komplekse dyr, og de grunde, der ligger til grund for vores adfærd, er endnu mere komplekse.
Vi kan opdele disse motivationsteorier i to brede kategorier: indholdsteorier, der handler om, hvad der udgør motiverende tilstande, og procesteorier, der handler om, hvordan disse motiverende tilstande opstår.
Eksempler på indholdsteorier
- Alderfers ERG-teori
- Herzbergs motivations-hygiejne-teori
- Maslows hierarki af behov
- McClellands teori om de tre behov
Eksempler på procesteorier
- Adams' teori om retfærdighed
- Banduras teori om self-efficacy
- Skinners teori om forstærkning
- Vrooms forventningsteori
Self-determination theory (SDT)
In this article we're going to focus on a macrotheory (a theory which encompasses several minitheories) of motivation, self-determination theory. Since psychologists Richard Ryan and Edward Deci formulated the first version of SDT in the 1980s, it has been the subject of intense development and research.
Today, SDT stands as one of the most, if not the most influential theory of motivation. It has a massive body of literature supporting its use across a broad spectrum of contexts, from coaching athletes to teaching in schools, trauma counseling, leadership in the military, and beyond. If you're interested in the literature, check out the official website, where all of the research on the theory to date is compiled and organized by topic.
Selvbestemmelsesteori (SDT)
I denne artikel vil vi fokusere på en makroteori (en teori, der omfatter flere miniteorier) om motivation, selvbestemmelsesteorien. Siden psykologerne Richard Ryan og Edward Deci formulerede den første version af SDT i 1980'erne, har den været genstand for intens udvikling og forskning.
I dag står SDT som en af de mest, hvis ikke den mest indflydelsesrige motivationsteori. Den har en massiv mængde litteratur, der understøtter dens brug i et bredt spektrum af sammenhænge, fra coaching af atleter til undervisning i skoler, traumerådgivning, lederskab i militæret og meget mere. Hvis du er interesseret i litteraturen, så tjek den officielle hjemmeside,, hvor al forskning om teorien til dato er samlet og organiseret efter emne.
Humanistic origins
SDT traces its roots back to humanistic psychology, a branch of psychology which concerns itself with the individual's journey toward greater autonomy and self-actualization. Humanistic psychology is deeply woven into the fabric of SDT, starting with the theory's principal axiom:
"...people are active organisms, with evolved tendencies toward growing, mastering ambient challenges, and integrating new experiences into a coherent sense of self. These natural developmental tendencies do not, however, operate automatically, but instead require ongoing social nutriments and supports." (selfdeterminationtheory.org)
According to SDT, we naturally take an interest in overcoming obstacles and integrating these experiences into our identity. We all tend toward personal growth, but whether or not this happens critically depends on our environment.
Humanistisk oprindelse
SDT sporer sine rødder tilbage til humanistisk psykologi, en gren af psykologien, der beskæftiger sig med individets rejse mod større autonomi og selvrealisering. Humanistisk psykologi er dybt vævet ind i SDT, startende med teoriens hovedaksiom:
"...mennesker er aktive organismer med udviklede tendenser til at vokse, mestre omgivelsernes udfordringer og integrere nye erfaringer i en sammenhængende selvfølelse. Disse naturlige udviklingstendenser fungerer dog ikke automatisk, men kræver i stedet løbende social næring og støtte." (selfdeterminationtheory.org)
Ifølge SDT har vi en naturlig interesse i at overvinde forhindringer og integrere disse erfaringer i vores identitet. Vi har alle en tendens til personlig vækst, men om det sker eller ej, afhænger i høj grad af vores miljø.
Basic psychological needs
The question then becomes, what are the specific criteria in the environment which either support or thwart personal growth (and as a consequence, self-realization)? SDT defines three basic psychological needs which must be satisfied: autonomy, competence, and relatedness.
"To the extent that the needs are ongoingly satisfied, people will develop and function effectively and experience wellness, but to the extent that they are thwarted, people will more likely evidence ill-being and non-optimal functioning." (selfdeterminationtheory.org)
Grundlæggende psykologiske behov
Spørgsmålet er så, hvad der er de specifikke kriterier i miljøet, som enten støtter eller modarbejder personlig vækst (og som en konsekvens heraf selvrealisering)? SDT definerer tre grundlæggende psykologiske behov, som skal tilfredsstilles: autonomi, kompetence og forbundethed.
"I det omfang behovene løbende bliver tilfredsstillet, vil folk udvikle sig og fungere effektivt og opleve velvære, men i det omfang de bliver modarbejdet, vil folk mere sandsynligt opleve mistrivsel og ikke-optimal funktion." (selfdeterminationtheory.org)
Autonomy
First up is autonomy, the desire to be the causal agents of our own actions. Irrespective of whether or not free will exists, SDT postulates that the subjective feeling of being in charge of your own choices and the feeling of psychological freedom this brings with it is necessary to be a healthy, functioning organism. Being self-motivated (also called autonomous regulation) leads to healthier outcomes compared to when we are told what to do (controlled regulation). We'll come back to and expand on the idea of "regulation" shortly.
Competence
When we choose to engage with a behavior, we seek a sense of control over the results of the behavior; we all want to experience mastery. Self-efficacy is a well-known determinant of long-term patient outcomes, and supporting a person's feeling of competence increases and sustains their confidence in their own abilities.
Relatedness
Humans are social animals, and we have a deeply rooted desire for belonging and connection with other people. Relatedness includes your sense of place in the world, the feeling that others care about you, and the knowledge that you benefit those around you.
Autonomi
Først er der autonomi, ønsket om at være årsag til vores egne handlinger. Uanset om der findes fri vilje eller ej, postulerer SDT, at den subjektive følelse af at være ansvarlig for sine egne valg og den følelse af psykologisk frihed, det medfører, er nødvendig for at være en sund, fungerende organisme. At være selvmotiveret (også kaldet autonom regulering) fører til sundere resultater sammenlignet med, når vi får at vide, hvad vi skal gøre (kontrolleret regulering). Vi vender tilbage til og uddyber begrebet "regulering" om lidt.
Kompetence
Når vi vælger at engagere os i en adfærd, søger vi en følelse af kontrol over resultaterne af adfærden; vi ønsker alle at opleve mestring. Self-efficacy er en velkendt determinant for langsigtede patientresultater, og at støtte en persons følelse af kompetence øger og opretholder deres tillid til deres egne evner.
Tilhørsforhold
Mennesker er sociale dyr, og vi har et dybt rodfæstet ønske om at høre til og være forbundet med andre mennesker. Tilknytning omfatter din følelse af plads i verden, følelsen af, at andre holder af dig, og viden om, at du er til gavn for dem omkring dig.
Intrinsic and extrinsic motivation
SDT pioneered the idea that motivation can be described not only in terms of its quantity, but also its quality. Intrinsic motivation is the natural drive to seek out challenges. It derives from the enjoyment of and interest taken in the behavior itself. Intrinsic motivation is positively correlated with cognitive and social development, task performance, and well-being.
When the goal of a behavior is something other than the behavior itself, we're talking about extrinsic motivation. SDT expands on the concept of extrinsic motivation by delineating distinct subtypes, each defined by the degree of internalization of the behavior's regulation.
"Internalization of regulation" sounds complicated, but it's actually a relatively simple concept: does the thing which is making you act out the behavior (the regulation) come from outside yourself, from within, or somewhere in between (the degree of internalization)?
Intrinsisk og extrinsisk motivation
SDT var banebrydende for ideen om, at motivation ikke kun kan beskrives ud fra dens kvantitet, men også ud fra dens kvalitet. Indre motivation er den naturlige drivkraft til at opsøge udfordringer. Den stammer fra nydelsen af og interessen for selve adfærden. Indre motivation er positivt korreleret med kognitiv og social udvikling, opgaveudførelse og trivsel.
Når målet med en adfærd er noget andet end selve adfærden, taler vi om ekstrinsisk motivation. SDT udvider begrebet ekstrinsisk motivation ved at skelne mellem forskellige undertyper, der hver især defineres af graden af internalisering af adfærdens regulering.
"Internalisering af regulering" lyder kompliceret, men det er faktisk et relativt simpelt begreb: Kommer det, der får dig til at udføre adfærden (reguleringen), udefra, indefra eller et sted midt imellem (graden af internalisering)?
Types of extrinsic motivation
External regulation is the least autonomous, most "controlled" kind of motivation. Behaving in accordance with known or predicted external punishment or reward is a hallmark of externally regulated behavior. Motivations characterized by external regulation have a clearly defined, externally perceived locus of causality. The individual's sense of volition and control over their actions is absent.
Introjected regulation is characterized by internal rewards and punishments. Introjection is the voice in your head echoing external pressures, the internalization of others' thoughts and attitudes. Pride, social status, and other ego-related motivations are examples of introjected regulation. It is still characterized by an external locus of causality as this kind of regulation is not fully integrated with the self.
Identified regulation is the stage where self-determination gains a foothold. The individual starts to value the behavior because it contributes to a personally relevant goal; the locus of causality turns inward.
Integrated regulation is the most autonomous kind of extrinsic motivation. The behavior is not only deemed valuable in terms of other outcomes, it is also integrated with other aspects of the self. While integrated regulation is still "extrinsic" because the desired outcome is not the behavior itself, it can exhibit similar qualities and benefits to intrinsic motivation.
Typer af ydre motivation
Ekstern regulering er den mindst autonome, mest "kontrollerede" form for motivation. At opføre sig i overensstemmelse med kendt eller forudsagt ekstern straf eller belønning er et kendetegn ved eksternt reguleret adfærd. Motivationer, der er karakteriseret ved ekstern regulering, har et klart defineret, eksternt opfattet lokus for kausalitet Individets følelse af vilje og kontrol over sine handlinger er fraværende.
Introjiceret regulering er kendetegnet ved indre belønninger og straffe. Introjektion er stemmen i dit hoved, der gentager eksternt pres, internaliseringen af andres tanker og holdninger. Stolthed, social status og andre ego-relaterede motivationer er eksempler på introjiceret regulering. Den er stadig karakteriseret ved et eksternt kausalitetssted, da denne form for regulering ikke er fuldt integreret med selvet.
Identificeret regulering er det stadie, hvor selvbestemmelse får fodfæste. Individet begynder at værdsætte adfærden, fordi den bidrager til et personligt relevant mål; årsagssammenhængen vender indad.
Integreret regulering er den mest autonome form for ydre motivation. Adfærden anses ikke kun for værdifuld i forhold til andre resultater, den er også integreret med andre aspekter af selvet. Selvom integreret regulering stadig er "ekstrinsisk", fordi det ønskede resultat ikke er selve adfærden, kan den udvise lignende kvaliteter og fordele som intrinsisk motivation.
A spectrum of self-determination
Combining these concepts, we start to paint a picture of a continuum of motivation. One end represents extrinsic motivation in its most controlled form (external regulation), gradually becoming more and more self-determined until we arrive at integrated regulation and intrinsic motivation.
Source: Ryan, R. M., & Deci, E. L. (2000)
There's one more "type" of motivation we have not yet talked about, shown in the diagram above: amotivation. It lies beyond external regulation; a person who is amotivated is totally indifferent and sees no point in pursuing the behavior in the first place. The behavior in question is entirely without regulation and the locus of causality is impersonal, neither external nor internal.
Amotivation aside (we'll return to it later), the motivations grounding our healthy behaviors will, over time, shift from being characterized by external "controlled" regulation to internal "autonomous" regulation given that our environment supports our basic psychological needs.
A number of positive side effects emerge as a result. Our task performance and activity engagement improves, we are more persistent in the face of obstacles and setbacks, and we become more confident and better functioning.
A spectrum of self-determination
Combining these concepts, we start to paint a picture of a continuum of motivation. One end represents extrinsic motivation in its most controlled form (external regulation), gradually becoming more and more self-determined until we arrive at integrated regulation and intrinsic motivation.
Kilde: Ryan, R. M., & Deci, E. L. (2000)
Der er endnu en "type" motivation, vi endnu ikke har talt om, vist i diagrammet ovenfor: *Den ligger uden for ekstern regulering; en person, der er amotiveret, er totalt ligeglad og ser slet ingen mening i at udøve adfærden. Den pågældende adfærd er helt uden regulering, og årsagssammenhængen er upersonlig, hverken ekstern eller intern.
Bortset fra amotivation (vi vender tilbage til det senere) vil de motivationer, der ligger til grund for vores sunde adfærd, med tiden skifte fra at være karakteriseret ved ekstern "kontrolleret" regulering til intern "autonom" regulering, givet at vores miljø understøtter vores grundlæggende psykologiske behov.
En række positive sideeffekter opstår som følge heraf. Vores opgaveudførelse og aktivitetsengagement forbedres, vi er mere vedholdende over for forhindringer og tilbageslag, og vi bliver mere selvsikre og bedre fungerende.
The marathon runner
A natural consequence of SDT is that there is rarely only one kind of motivation behind a behavior. We'll illustrate this with a thought experiment. Imagine that you just finished a marathon. What motivated you to train for and participate in the race?
At the end of the race, there are likely free food and drinks. Perhaps you'll be given a medal contingent on your performance. If those were the only reasons you had to train and run in the marathon, you probably wouldn't have followed through with it (external regulation).
The medal you were chasing could also represent an internal pressure to beat your personal record. Maybe your parents pressured you to perform well in sports when you were a kid. Those thoughts could well have stayed with you as an introjection. Or you saw the race as a way to elevate your status in your social circle by beating your friends' race times (introjected regulation).
The desire to run this marathon and get a medal could also be tied to your personal goal of running a sub-3 hour marathon. This was a stepping stone to achieving that (identified regulation).
You see yourself as an "fit person" and a "competitive athlete." Running marathons and beating the competition constitutes a part of this identity (integrated regulation).
Finally, you run and race for the sake of it. It just feels good to run long distances as fast as you can (intrinsic motivation).
Ask those around you at the finish line and each participant will point to different reasons to justify their decision to participate. Some people's decision to participate may have been dominated by external and introjected regulation, while others are so intrinsically motivated by running that they signed up just for fun.
Analyzing behaviors in terms of their constituent motivations and identifying the types of regulation which dominate the "motivation profile" can give an idea of where to focus your efforts if you want to encourage persistence, engagement, and well-being.
Maratonløberen
En naturlig konsekvens af SDT er, at der sjældent kun er én slags motivation bag en adfærd. Vi vil illustrere dette med et tankeeksperiment. Forestil dig, at du lige har gennemført et maratonløb. Hvad motiverede dig til at træne op til og deltage i løbet?
I slutningen af løbet er der sandsynligvis gratis mad og drikke. Måske får du en medalje afhængig af din præstation. Hvis det var de eneste grunde, du havde til at træne og deltage i maratonløbet, ville du sandsynligvis ikke have gennemført det (ekstern regulering).
Den medalje, du jagtede, kunne også repræsentere et indre pres for at slå din personlige rekord. Måske pressede dine forældre dig til at præstere godt i sport, da du var barn. De tanker kan meget vel være blevet hos dig som en introjektion. Eller du så løbet som en måde at hæve din status i din omgangskreds ved at slå dine venners tider (introjiceret regulering).
Ønsket om at løbe dette maraton og få en medalje kunne også være knyttet til dit personlige mål om at løbe et maraton under 3 timer. Dette var et springbræt til at nå det (identificeret regulering).
Du ser dig selv som en "fit person" og en "konkurrenceatlet". At løbe maraton og slå konkurrenterne er en del af denne identitet (integreret regulering).
Endelig løber og konkurrerer du for din egen skyld. Det føles bare godt at løbe lange distancer så hurtigt, som du kan (indre motivation).
Spørg dem omkring dig ved målstregen, og hver deltager vil pege på forskellige grunde til at retfærdiggøre deres beslutning om at deltage. Nogle menneskers beslutning om at deltage kan have været domineret af ekstern og introjiceret regulering, mens andre er så indre motiverede af at løbe, at de tilmeldte sig bare for sjov.
Ved at analysere adfærd i forhold til de motivationer, den består af, og identificere de typer af regulering, der dominerer "motivationsprofilen", kan man få en idé om, hvor man skal fokusere sin indsats, hvis man ønsker at fremme vedholdenhed, engagement og trivsel.
Implications for clinical practice
Let's take a step back and revisit the question we asked ourselves at the beginning of the article:
Why don't they do what we say?
We're now in a position to see this question in a new light. The question itself is holding us back.
Controlling others and threatening them with the future consequences of their behavior results in the worst kind of motivation one can have. A clinical approach to lifestyle change informed by motivational psychology demands that we do not attempt to motivate our patients in this way. We should instead create an environment which is supportive of our patients' basic psychological needs, and the rest will follow.
Implikationer for klinisk praksis
Lad os tage et skridt tilbage og genbesøge det spørgsmål, vi stillede os selv i begyndelsen af artiklen:
**Hvorfor gør de ikke, hvad vi siger?
Vi er nu i stand til at se dette spørgsmål i et nyt lys. *Spørgsmålet i sig selv holder os tilbage.
At kontrollere andre og true dem med de fremtidige konsekvenser af deres adfærd resulterer i den værste form for motivation, man kan have. En klinisk tilgang til livsstilsændringer baseret på motivationspsykologi kræver, at vi ikke forsøger at motivere vores patienter på denne måde. Vi bør i stedet skabe et miljø, der støtter vores patienters grundlæggende psykologiske behov, og så kommer resten af sig selv.
Manipulate the clinical context
We can think of the environment surrounding the clinician-patient interaction as the clinical context. From the clinic's physical setup to our body language, everything we do and say has the potential to positively or negatively influence our patients' sense of autonomy, competence, and relatedness.
We can make a powerful impact on shaping healthy behavioral patterns and well-being through the context we create. Think about how you can support the basic psychological needs of yourself and those around you, irrespective of whether you're inside or outside of the clinic.
Manipuler den kliniske kontekst
Vi kan betragte miljøet omkring interaktionen mellem kliniker og patient som den kliniske kontekst. Fra klinikkens fysiske indretning til vores kropssprog har alt, hvad vi gør og siger, potentiale til at påvirke vores patienters følelse af autonomi, kompetence og samhørighed positivt eller negativt.
Vi kan gøre en stor indsats for at forme sunde adfærdsmønstre og trivsel gennem den kontekst, vi skaber. Tænk over, hvordan du kan støtte de grundlæggende psykologiske behov hos dig selv og dem omkring dig, uanset om du er i eller uden for klinikken.
Be a lifestyle coach
The lessons we have learned from SDT encourage us to rethink the entire foundation of our clinical practice. It demands a total change in mindset: to stop taking on a parental role when working with patients. You are now their lifestyle coach. You want to help your patients achieve their goals, but you do not get to decide their goals for them. Don't enforce a hierarchy.
Naturally, situations arise where it's not this obvious and clear-cut. If a patient surrendered all decision-making to you of their own volition, what should you do? You could respect their will and create their entire treatment plan for them, but would this be the best way of supporting their autonomy and competence?
Perhaps an even better solution would involve continuous education and encouraging the patient to experiment and take control of their own health. Not every patient will respond well to this right away (especially if they have been conditioned to be passive in their enviroment—see causality orientations theory, a minitheory within SDT), but it's a good long-term target.
Vær en livsstilscoach
Det, vi har lært af SDT, opfordrer os til at gentænke hele grundlaget for vores kliniske praksis. Det kræver en total ændring i tankegangen: at holde op med at påtage sig en forældrerolle, når man arbejder med patienter. Du vil gerne hjælpe dine patienter med at nå deres mål, men du skal ikke bestemme deres mål for dem. Lad være med at gennemtvinge et hierarki.
Naturligvis opstår der situationer, hvor det ikke er så indlysende og klart. Hvis en patient overlader al beslutningstagning til dig af egen fri vilje, hvad skal du så gøre? Du kunne respektere deres vilje og lave hele deres behandlingsplan for dem, men ville det være den bedste måde at støtte deres autonomi og kompetence på?
Måske ville en endnu bedre løsning involvere løbende uddannelse og opmuntre patienten til at eksperimentere og tage kontrol over sit eget helbred. Ikke alle patienter vil reagere godt på dette lige med det samme (især hvis de er blevet konditioneret til at være passive i deres omgivelser - se [causality orientations theory] (https://selfdeterminationtheory.org/wp-content/uploads/2022/02/2021_HaggerHamilton_GeneralCausality.pdf), en miniteori inden for SDT), men det er et godt langsigtet mål.
Amotivated or conflicted?
If a patient is truly amotivated when it comes to changing a specific lifestyle behavior, there is not much you can do. A person must be at least somewhat willing to change if they are to have any hope at all in succeeding. However, even though it might seem like many patients are amotivated, when you dig beneath the surface most people are not actually indifferent when it comes to making positive changes for their health.
Patients who presents as amotivated might just possess conflicting motivations. These could stem from negative past experiences and/or a suppressive environment. Maybe the person is unsure of their own values and life goals.
A complex internal motivational struggle can masquerade as indifference and amotivation. It's your job as a lifestyle coach to pull the "puzzle pieces" of your patients' motivations out of them, lay these pieces on the table, and then help your patients put together the jigsaw puzzle of their life.
It cannot be overstated how essential trust and empathy are during this process. Without a strong therapeutic alliance, there is very little chance your patients will open up and be honest with you about themselves. It takes good communication and sharp critical reasoning skills to navigate a person's internal landscape.
Amotiveret eller i konflikt?
Hvis en patient virkelig er amotiveret, når det handler om at ændre en bestemt livsstilsadfærd, er der ikke meget, du kan gøre. En person skal i det mindste være nogenlunde villig til at ændre sig, hvis de skal have noget håb om at lykkes. Men selvom det kan virke, som om mange patienter er umotiverede, når man graver under overfladen, er de fleste mennesker ikke faktisk ligeglade, når det handler om at foretage positive ændringer for deres helbred.
Patienter, der præsenterer sig som amotiverede, har måske bare modstridende motivationer. De kan stamme fra tidligere negative oplevelser og/eller et undertrykkende miljø. Måske er personen usikker på sine egne værdier og livsmål.
En kompleks indre motivationskamp kan give sig ud for at være ligegyldighed og amotivation. Det er dit job som livsstilscoach at trække "puslespilsbrikkerne" i dine patienters motivation ud af dem, lægge disse brikker på bordet og derefter hjælpe dine patienter med at samle puslespillet i deres liv.
Det kan ikke overdrives, hvor vigtig tillid og empati er under denne proces. Uden en stærk terapeutisk alliance er der meget lille chance for, at dine patienter vil åbne op og være ærlige over for dig om dem selv. Det kræver god kommunikation og skarpe kritiske ræsonnementer at navigere i en persons indre landskab.
Motivational interviewing (MI)
Motivational interviewing is a therapeutic technique which was developed specifically for counseling behavior change. MI has its roots in addiction counseling, but it has since been applied successfully in many other contexts, similar to SDT. Some people working on MI have even looked to SDT to explain why it works.
Although we won't fully explore how to do MI in this article, we've already laid a solid foundation for practicing the technique. Asking open-ended questions and reflecting questions back to the patient to help them reach conclusions by themselves (autonomy support), focusing on past successes to build self-efficacy (competence support), and listening in an active and empathetic way (relatedness support)—these are all cornerstones of MI.
Motiverende samtale (MI)
*Motiverende samtale er en terapeutisk teknik, der blev udviklet specifikt til rådgivning om adfærdsændring. MI har sine rødder i misbrugsrådgivning, men er siden blevet anvendt med succes i mange andre sammenhænge i lighed med SDT. Nogle mennesker, der arbejder med MI, har endda kigget på SDT for at forklare, hvorfor det virker.
Selvom vi ikke helt vil udforske, hvordan man laver MI i denne artikel, har vi allerede lagt et solidt fundament for at praktisere teknikken. At stille åbne spørgsmål og reflektere spørgsmålene tilbage til patienten for at hjælpe dem med selv at nå frem til konklusioner (autonomistøtte), at fokusere på tidligere succeser for at opbygge self-efficacy (kompetencestøtte) og at lytte på en aktiv og empatisk måde (relateringsstøtte) - det er alt sammen hjørnesten i MI.
The decision matrix
Making a decision matrix (also called a decisional balance) is an activity sometimes done in MI which can help an individual strengthen their commitment to a behavior change. First, draw a 2x2 table. The patient then identifies the benefits and drawbacks of either continuing with the status quo or making a change.
See an example decision matrix (PDF), also available on motivationalinterviewing.org.
As you work through this activity and the patient writes down their pros and cons for each option, they will get a clearer picture of what making a change would entail.
During this process you are a guide—support the patient's basic psychological needs and do not tell them what to do or what to think. Instead, ask questions. By having patients connect the dots themselves, you can get them moving on the path toward autonomous regulation of healthy behavior.
Beslutningsmatrixen
At lave en beslutningsmatrix (også kaldet en beslutningsbalance) er en aktivitet, der nogle gange udføres i MI, og som [kan hjælpe en person med at styrke sit engagement i en adfærdsændring].(https://pubmed.ncbi.nlm.nih.gov/24229732/) Først tegnes en 2x2 tabel. Patienten identificerer derefter fordelene og ulemperne ved enten at fortsætte med status quo eller foretage en ændring.
Se et eksempel decision matrix (PDF), også tilgængelig på motivationalinterviewing.org.
Efterhånden som du arbejder dig igennem denne aktivitet, og patienten skriver sine fordele og ulemper ned for hver mulighed, vil de få et klarere billede af, hvad det vil indebære at foretage en ændring.
Under denne proces er du en guide - støt patientens grundlæggende psykologiske behov og fortæl dem ikke, hvad de skal gøre eller tænke. Stil i stedet spørgsmål. Ved at få patienterne til selv at forbinde punkterne, kan du få dem til at bevæge sig på vejen mod autonom regulering af sund adfærd.
Summary
In this article, we explored a common clinical frustration:
"Why don't patients do what we say?"
To answer this question, we first gave a concrete definition to lifestyle, recognizing that the identities connected with lifestyle behaviors are just as important as the behaviors themselves.
Self-determination theory showed us that the reasons underpinning our behavior can be extremely complex. It gave us a framework to identify and categorize different kinds of motivation, as well as some guiding principles of how to move people toward healthier motivational states.
We discovered that the question we posed at the beginning was actually loaded with unhelpful assumptions. Instead of telling people what to do, we should focus on creating an environment which is supportive of individuals' basic psychological needs for autonomy, competence, and relatedness.
We briefly introduced motivational interviewing, a counseling technique designed to facilitate behavior change. Finally, we learned how to use a decision matrix to help patients strengthen their commitment.
Resumé
I denne artikel har vi udforsket en almindelig klinisk frustration:
"Hvorfor gør patienterne ikke, som vi siger?"
For at besvare dette spørgsmål gav vi først en konkret definition på livsstil og erkendte, at de identiteter, der er forbundet med livsstilsadfærd, er lige så vigtige som adfærden i sig selv.
Selvbestemmelsesteorien viste os, at årsagerne til vores adfærd kan være ekstremt komplekse. Den gav os en ramme til at identificere og kategorisere forskellige former for motivation, samt nogle vejledende principper for, hvordan man kan bevæge folk i retning af sundere motivationstilstande.
Vi opdagede, at det spørgsmål, vi stillede i begyndelsen, faktisk var fyldt med uhensigtsmæssige antagelser. I stedet for at fortælle folk, hvad de skal gøre, bør vi fokusere på at skabe et miljø, der understøtter den enkeltes grundlæggende psykologiske behov for autonomi, kompetence og samhørighed.
Vi introducerede kort den motiverende samtale, en rådgivningsteknik, der er designet til at fremme adfærdsændringer. Endelig lærte vi, hvordan man bruger en beslutningsmatrix til at hjælpe patienter med at styrke deres engagement.
Further reading
https://selfdeterminationtheory.org (official website)
Self-Determination Theory: A Macrotheory of Human Motivation, Development, and Health
Exercise, physical activity, and self-determination theory: a systematic review
Downloads
Motivation profile activity (.pdf)
Yderligere læsning
https://selfdeterminationtheory.org (officiel hjemmeside)
Selvbestemmelsesteori: En makroteori om menneskelig motivation, udvikling og sundhed
Motion, fysisk aktivitet og selvbestemmelsesteori: en systematisk gennemgang