4 MIN READ

We are our own worst enemies

For a couple of decades now the topic of patient compliance with drug dosage regimes (and its more progressive variant: adherence) has had a magnetic draw in the field of drug delivery and medical device design.

Initially, it triggered a rush of claims from designers and developers; they claimed that their end users would be more adherent with their proposed new devices because their designs were appealing. Assertions of this type did the rounds for several years, despite it being well established that patient adherence is typically as low as 50%, even with life-sustaining drugs delivered in oral tablet form. If staying alive is not a sufficient enough motivation to adhere to an oral tablet dosage regime, the idea that good design of inhalers/injectors could provide a meaningful solution to the challenge of non-adherence should have been obviously absurd.

Now the buzz phrase is ‘behaviour change’; and it’s a good thing too.

What is it about some behaviours that make them challenging to influence?

Our community is, rightly, engaged with thinking about behavioural science and behavioural design. The drugs don’t work if they aren’t being taken and, therefore, human behaviour is at the root of one of the biggest failures of current medicinal therapy. Behaviour change is the therapy needed to unlock access to pharmaceutical efficacy.

But when we talk about behaviour, we are being fantastically and comically imprecise. Behaviour includes clicking a link, buying a product/service, managing a disease, giving up smoking, using an inhaler, adopting a new exercise regime, being a parent. At the excellent University College London’s Centre for Behaviour Change conference this week, a lot of papers focused on the benefits of greater precision and clarity around the specification of behaviours, and the benefits of a common taxonomy of behaviour change techniques (BCT’s). There is great promise here that some low hanging fruit can be identified and picked.

behaviour change UCL

But it is also interesting to have a good image of the ‘highest hanging fruit’. What is it about some behaviours that make them challenging to influence? Perhaps these behaviours might be colourfully labelled as ‘bad habits’: persistent patterns of behaviour with complex and deep roots involving a degree of internal, intrapsychic conflict.

To understand bad habits – such as our dangerously poor adherence with medication – we need, at the very least, an adequate basic model of human psychology. Just as economists acknowledged the weakness of their ‘rational man’ assumption in the behavioural economics revolution, we need to let go of ‘homo pharmaceuticus’ and recognise that each of us has the potential not to do what is in our best interests. We all have the potential to be our own worst enemy.

patient non-adherence
FDA

In his book ‘The Happiness Hypothesis’ the moral psychologist Jonathan Haidt draws on ancient philosophies and modern science to present a good candidate for a useful basic model of human psychology. He starts by highlighting the following as fundamental: “The mind is divided into parts that sometimes conflict. Like a rider on the back of an elephant, the conscious, reasoning part of the mind has only limited control of what the elephant does. Nowadays, we know the causes of these divisions, and a few ways to help the rider and the elephant work better as a team.”

As we approach the challenge of changing non-adherence behaviour, we’ll need a good map of ourselves. These maps aren’t new, they can be found in ancient philosophy, but modern science strengthens and sharpens them. Haidt’s book and his elephant and rider model is one good place to start.

If this sounds too challenging, it is worth reflecting that Haidt is a key figure in the positive psychology movement. His focus is on positive change, on possibilities and potential. Denial, on the other hand, is seldom a great basis for action.

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