Cognitive Design

A recent paper on Self Determination Theory Applied to Health Contexts: A Meta-Analysis,  claims that health behaviors will change when people feel autonomous, capable and cared for.  More specifically, I am most likely to change when I:

1. Believe it is my conscious choice or under the control of my will
2. Have or can acquire the skills needed to make the change
3. Feel a sense of relatedness or understood and cared for.

These conditions create or correspond to intrinsic motivation for the change.

The paper emphasizes that health behavior change lasts when the program designed to bring it about meets the autonomy or volitional needs of participants.  That means understanding and respecting a person’s interests, values and choices in the change process.  It also means fostering their independence rather than dependence on an externally controlled change process.  This maximizes the chance that new routines will be deeply internalized and therefore last.

As cognitive designers know, meeting the volitional or autonomy requirement is hard because many will feel helpless or overwhelmed. Further,  many will have made choices or hold values that undermine the new health behaviors.   For example, I chose to smoke or be inactive. How can you respect that and help me stop smoking or starting moving more?  Resolving these conflicts takes time and considerable experimentation.

The best programs will be patient and offer a caring approach to learning from experience. They will transform initially external motivators into intrinsic motivations.

The key is to provide authentic emotional support and global change control while leaving more specific choices up to the individual. For example, the global goal may be to reduce calories using portion control but it is up to the individual to decide and experiment with ways to achieve that in their daily activities.

Health behaviors stick when I learn the new routines needed to support through volitional actions.

Or so argues Todd Park the chief technology officer (really the chief innovation officer) of Health and Human Services.    He makes his case in this video and suggests changing incentives (from volume based to value based) and the democratization of all types of health data are acting as “rocket fuel” for entrepreneurial activity in healthcare.  An interesting argument especially since many of the opportunities involve improving health behavior change, care coordination experience, decision making by patients and caregivers and other cognition-heavy challenges. This means:

Cognitive design and engineering sit right at the heart of  many entrepreneurial opportunities in healthcare.

In a recent study of how labels effect school children’s food choices researchers found:

“that by naming plain old carrots “X-ray vision carrots,” fully 66 percent of the carrots were eaten, far greater than the 32 percent eaten when labeled “Food of the Day” — and the 35 percent eaten when unnamed.”

Other behavior changing labels include power punch broccoli, tiny tasty tree tops and silly dilly green beans.  These are names the students created.

Vegetables can be transformed into cool new foods with the right labels.  New labels invoke a different set of mental models that bias our perception of the food in new ways. The effect appears robust  as it works on different age groups and ethnic backgrounds over an extended period of time.

For other evidence-based suggestions on how to nudge health food choices by children check out the Smarter Lunchroom Movement.

Self control is a prized resource.  Most of my clients and many students are interested in what it is and how to get more of it.  To design programs, products and services that improve self control we must first understand what it feels like. More specifically, what are the unique mental states, frame of mind or thoughts and feelings associated with a state of self control.  Until we have insight into that, it will be tough to apply cognitive design to the challenge.

 So what does self control think and feel like? We can study the question with introspection, self reports, ethnographic observation and protocol analysis.  And hope for an articulation (narrative description) that is accurate and specific enough to provide design insights.  We can also study the question with neuroscience and brain scans.  While lacking an articulation of the psychological contents, a neuroscientific  study can never the less lead to interesting interventions.

As an example of the neuroscience approach, I recently found a TEDx talk, A Brain Computer Interface for Exercising the Self Control Muscle, by Jordan Silberman a PhD/MD student at the University of Rochester.   We might not always know what self control thinks or feels like but we do know what it looks like in the brain (image to the right). Knowing that it is possible to develop an neurofeedback training scheme (see below) that correlates the brain state of self control to an external training signal (a bar that moves up and down on the computer screen.

This simple device lets the user learn to put themselves in the mental state of self control through rapid trial and error. By inducing the state you exercise your self control muscle. The video shows one experiment where people that used the training are able to maintain self control far better than the control group.

This is an exciting result with a lot of implications for cognitive designers once the technology matures a bit. In the meantime  you have to wonder, do people that go through this training have a better insight into the think-and-feel of self control? Can it be articulated and used to drive design innovations now?

Interested to hear from readers – how do you characterize the frame of mind (intellectual, affective, motivational, volitional) for self control?

Over 75% of the healthcare spending in the US goes to chronic conditions.  One reason for the high cost is that they are not managed well.  Recent studies show the ability to keep chronic disease in check is very difficult when patients have multiple conditions.

Keeping chronic conditions in check, and better avoiding them in the first place, requires a range of patient behaviors and choices. This point is dramatically illustrated in Living Not with One, But Six Chronic Conditions:

“It’s estimated that 80% of heart disease and stroke, 80% of type 2 diabetes, and 40% of cancers could be eliminated if Americans were able to do three things: stop smoking, eat a healthy diet, and get regular exercise. These same behaviors may also prevent exacerbations of existing chronic conditions.”

Fortunately, we don’t lack the science needed to manage these diseases well. What we do lack are programs that deliver the required evidence-based care in a cost effective and psychologically compelling way. We need programs that deliver a think-and-feel experience with enough power to shift smoking, eating and activity behaviors as well as support learning new condition specific self-care routines. Such programs must be based on understanding and meeting the cognitive needs of patients as they manage limited self-regulatory capacity and struggle to learn from experience which routines will fit-and-stick-with their personal circumstances.

In short we need a cognitive design initiative focused on managing multiple chronic conditions.

And the audience for such an effort is fairly well defined.  One report emphasizes how concentrated healthcare costs are.  The sickest 5% of citizens account for nearly 50% of all healthcare costs. More dramatically, just 1% (3-4 million people) account for 22% of the cost! Most suffer from multiple chronic conditions.

I am interested to hear from readers that have insights into deeply-felt and unmet psychological needs (cognitive, affective, motivational, volitional) of patients that are failing to manage multiple chronic conditions.

Imagine being able to design an experience that is so powerful it transforms  someone with a deep fear of spiders into someone that could touch a tarantula.  Now imagine this designed experience is only 3 hours long and creates lasting effects on the brain regions associated with fear that can be detected with a brain scan 6 months later!

That is exactly what researchers at Northwestern University achieved in a study of 12 adults with lifelong debilitating spider phobias.   Participants went through a single  3-hour session of exposure therapy as described below.

“During the therapy, participants were taught about tarantulas and learned their catastrophic thoughts about them were not true. “They thought the tarantula might be capable of jumping out of the cage and on to them,” Hauner said. “Some thought the tarantula was capable of planning something evil to purposefully hurt them. I would teach them the tarantula is fragile and more interested in trying to hide herself. “

They gradually learned to approach the tarantula in slow steps until they were able to touch the outside of the terrarium. Then they touched the tarantula with a paintbrush, a glove and eventually pet it with their bare hands or held it.

“They would see how soft it was and that its movements were very predictable and controllable,” Hauner said. “Most tarantulas aren’t aggressive, they just have a bad reputation.”

The cognitive and behavioral features of this experience design are clear. The question for innovators is will they work to produce rapid, deep and lasting behavior change in other contexts?

More generally, is exposure therapy a reusable design pattern for shifting mental models and producing lasting behavior change?

With a mountain of behavior-based health problems, ethical concerns and spending problems that answer is no!

There are lots of demands on our time but even more demands on our mental energy.  Watching, thinking, learning, deciding, stressing and controlling our own emotions, impulses and behavior all take a tremendous amount of mental energy.   As we start to run out of mental energy our cognitive performance and willpower begin to slip.  If our supply of mental energy runs too low our attempts to stick to our goals, resist impulses, manage biases when making decisions, learn deeply and other attempts at conscious self-regulation fail.

Mental energy is a limited resource.

Mental energy appears to be more than biological energy and brain sugar. There are subjective components including a sense of vigor and motivation.  This means our attempt to manage mental energy should include both psychological and biological interventions.  This point is illustrated well in a recent post of the science of willpower blog that look at temptations that actually boost our willpower. The temptations  include psychological tactics such as watching others pursue goals (e.g. reality TV) or a humorous or cute video as well as biological tactics including naps, snacks and caffeine.

From a cognitive design standpoint these are great tactics because they can be integrated easily into daily life, are science-based and avoid the paradox of using willpower to build willpower (we naturally want to do them).

Interestingly, the science behind some of these claims (those focused on glucose) have recently come into question.   For example, researchers at the University of Pennsylvania claim that the  Brain’s Willpower is not Fueled by Glucose.  This might signal a larger role for psychological tactics or even a powerful placebo effect.

Understanding the nature of mental energy and how to manage it through scripted interactions and experience is of central concern to cognitive design. How else can we create effective behavior change, learning and innovation programs? At the very least we want designs that avoid wasting mental energy and in fact seek designs that maximize mental energy on both a biological and psychological basis.

I am interested to hear from readers about what you do to keep your mental batteries charge on a daily basis. What advice do you have for creating, maintaining or otherwise managing mental energy?

Source of Image: Futurity

MISSING:  Enough physical activity during the school day to help avoid childhood obesity. REWARD offered to any party (school program or technology developer) that can find it by April 2, 2012.

There is a $100,000 reward for the school programs that do the best at engaging kids in quality physical activity and a $50,000 reward  for technology developers that can deliver innovative ways to motivate daily physical activity at school at beyond.

This a national innovation contest with a total of $0.5M in prize money.  Definitely a cognitive design challenge.

Image:  Physical Activity – the best medicine?

Emory university reports on a recent brain scanning study that reveals we are using different cognitive processes to make decisions involving sacred value versus those that involve cost-benefit logic. Sacred values run the deepest and involve as sense of self and culture as determined, for example,  by ethical principles, national identity or belief in God.

This is important for designer involved in creating behavior change. As the authors point out:

“Our findings indicate that it’s unreasonable to think that a policy based on costs-and-benefits analysis will influence people’s behavior when it comes to their sacred personal values, because they are processed in an entirely different brain system than incentives.”

Sacred values require special handling.

Sometimes progress and success messes things up.   For example,  demand for a start-ups product or service grows so fast they cannot meet it. Quality slips and promised delivery dates are missed.  Or a successful company becomes complacent and arrogant because they dominate the market and starts making mistakes.

According to an interesting post by Dr. McGonigal on her Science of Willpower Blog, this can happen during the behavior change process. As we make progress our executive function exerting the self control becomes satisfied and our impulse for the old behavior can kick in. Focusing on the progress we have made actually sets us up for a relapse.  Indeed, celebrating success, the way we traditionally do with a minor indulgence, may be the worse thing to do.

What to do? One way is to reframe what progress means so it maintains emphasis on the executive function of self-control:

“Progress can be motivating, and even inspire future self-control, but only if you view your actions as evidence that that you are committed to your goal. You need to look at what you have done and conclude that you must really care about your goal. So much so, that you want to do even more to reach to it. This perspective is easy to adopt; it’s just not our usual mindset. More typically, we look for the reason to stop.”

The goal is to reflect on the why or reason for your self-control, not just the accomplishment.  Using your accomplishment to stay focused on the psychology of commitment avoids success-related relapse.

Clearly a good insight into how  minds actually work and it is actionable enough for cognitive designers working on behavior change challenges.  The post in the Willpower Blog is sneak preview of one of the chapters in Dr. McGonigal’s  new book,  The Willpower Instinct.  I have it on pre-0rder and will do a review.