Motivation, Medicine, and Mark Twain

2020 Annual Montana Diabetes Professional Conference10-23-2020

Geoffrey Williams MD, PhDMedical Director Collaborative Science and Innovation

Billings ClinicEmeritus Professor Medicine and CCH&P at U of R

Center for Mark Twain Studies, Elmira College

Disclosures and About Myself

I have no current conflicts of interest I have been funded on several NIH grants (NIDDK,

NCI, NIMH, NHLBI) and currently a PCORI contract on obesity

25 years as academic primary care internist and last 10 years, developing and delivering intensive motivation based interventions at CCH&P

WSU grad, PhD in health psychology Mark Twain Scholar

Overview of Self-Determination Theory and Twain

Self Determination Theory Overview Define Motivation as energy directed toward a goal Assumptions: needs for autonomy competence and relationship SDT Model for Health Behavior Change Meta-analyses Three ways to Motivate Change

Intrinsic Motivation - examples from Twains life and Tom Sawyer Locus of Causality - Huck Finn, Tom Sawyer, Internalization - examples from Huck Finn, Internalized Trust -Breast Cancer study

Clinician Behaviors that support motivation (need satisfaction).

MOTIVATION & HEALTH BEHAVIOR

Motivation is human energy (psychological energy) directed at a particular goal

Energy and goals need to be accounted for to understand motivation and how to facilitate maintenance of the desired behavior or change.

Motivation for growth and health is intrinsic

CVD Risk 45% of men and 50% of women will get

CVD in their lifetime (28% die from it).

This is our biggest single risk all of us face over a lifetime.

Tobacco use, and chol. account for 66% of first heart attacks, and 9 risk factors > 90%.

Yusuf et al., INTERHEART Lancet 2004;364:953-962

Impact of 5 Healthy Lifestyle Factors on Life Expectancy for 123,000 Health Professionals

Yanping Li et al., Circulation 2018: 137

• Never Smoking ‐stopping by 50 ‐ gain 6‐10 life yrs• BMI – 18.5 to 25 ‐ gain  2‐4 years• Moderate alcohol intake  ‐ gain 2 years• High Quality Diet ‐ gain 4 years• Physical Activity > 30 min per day ‐ gain 4‐8 yrs

• All Cause Mortality For 0 risk versus 5 risk factors  ‐ 0.26 (CI 0.22‐0.31)• Cancer Mortality ‐ 0.35 (CI 0.27‐0.45)• Cardiovascular Mortality ‐ 0.18 (CI 0.12‐0.26)• Adopting 5 at age 50   ‐ life expectancy >14 yrs longer for women

‐ life expectancy > 12 yrs longer for men

LDL Causes CVD- Evidence Base

-Over 200 studies

-2 million subjects

-20 million person years

-150,000 cardiovascular events

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How Can a Motivation Theory help?

30% of all prescriptions are never filled Only 40% of patients Persist with lifestyle change for > 1year stay on medications as intended Are able to stop smoking in best of treatments

Self-Determination Theory Motivation is human energy directed to a goal

Is tested in a free choice paradigm

Assumptions: humans are innately motivated toward well-being and personal growth Autonomy - Competence - Relatedness Internalization is the process of change

An organismic dialectic-individuals in the context of their social surround

Psychological Needs

Needs are defined as:

“psychological nutriments that are essential for ongoing psychological growth, integrity, and well-being”

Deci & Ryan, 2000. Psychological Inquiry, 11, 227-268.

Medical Professionalism – A Physician Charter & Biomedical Ethics

Primacy of patient welfare: a dedication to serving patients’ interests.

Patient autonomy: To empower patients to make informed decisions

Social justice: To eliminate discrimination

ABIM Foundation, 2002

US Preventive Services Task Force also adds patient autonomy in 2002 USPSTF added ‘Agree’ to 5A’s model Assess – patient history Advise – provide clear advice and rationale AGREE-is patient willing to adopt treatment Assist- skills build, problem solve, prescribe Arrange follow-up

Whitlock et al., Amer J. Prevent Med 2002

Motivation

Autonomous Motivation Behaviors are chosen and volitional Behaviors are performed for their inherent value

Controlled Motivation Behaviors are pressured or coerced Behaviors are performed for some separable outcome

Ryan & Deci, 2000; Deci & Ryan, 1991, 1995; Sheldon et al., 1997; Nix et al., 1999; Ryan et al., 1995

Multiple ways to facilitate volition—

• Intrinsic motivation (interest, enjoyment, optimal challenge)

• Internalized autonomous motivation(two types)

•Value the behavior for themselves

•Trust – the willingly adopt treatment on your recommendation

• Minimize controlling motivations

The Importance of Volitional Behavior

Internalization

an inherent, proactive process by which autonomous and competence motivations are increased naturally over time

Three Meta‐analyses SDT & HealthNg, J., Ntoumanis, N., Thøgersen‐Ntoumanis, C., Deci, E., Ryan, R. M., Duda, J. L., & Williams, G. C. (2012). Self‐determination theory applied to health contexts: A meta‐analysis. Perspectives on Psychological Science, 7(4), 325‐340. doi: 10.1177/1745691612447309. PubMed PMID: 26168470. 

Gillison FB, Rouse P, Standage M, Sebire SJ, & Ryan RM. (2018): A meta‐analysis of techniques to promote motivation for health behaviour change from a self‐determination theory perspective, Health Psychology Review, DOI:10.1080/17437199.2018.1534071 

Nikos Ntoumanis, Johan Y.Y. Ng, Andrew Prestwich, Eleanor Quested, JennieE. Hancox, Cecilie Thøgersen‐Ntoumani, Edward L. Deci, Richard M. Ryan, Chris Lonsdale & Geoffrey C. Williams (2020): A meta‐analysis of self‐determination theory‐informed interventionstudies in the health domain: effects on motivation, health behavior, physical, and psychologicalhealth, Health Psychology Review, DOI: 10.1080/17437199.2020.1718529To link to this article: https://doi.org/10.1080/17437199.2020.1718529

SDT Model of Health Behavior Change

Personality Differences in

Autonomy

Intrinsic vs. Extrinsic Values

Autonomy

Competence

Relatedness

Mental HealthDepressionSomatization*AnxietyQuality of life*SuicidalitySuicide attempts

* RCT of Intervention to increase autonomy

Needs Support

Health Care Climate Important others

Physical HealthInsomniaNot Smoking*Physical activity*Weight Loss*Diabetes Control*Medication Use*Healthier Diet*Dental Health*Alcohol Intake*

Ryan et al., 2008; Ng et al., 2012

SDT Meta-Analysis

Figure 3. Path diagram of Williams et al.’s (2002, 2006) model using meta-analyzed correlations (n = 13,356). All paths are significant at p < .05; residual variances are omitted for presentation simplicity.

2 (3) = 76.25, p < .01, CFI = .98, RMSEA = .07, SRMR = .03.

PRISMA flowchart of study selection.Ntoumanis – Under Review

Need SupportK=22,21

Increase in autonomous  motivation 

K=23 Change in Health BehaviorK=49

Maintained Change in Health BehaviorK=28

Maintained Change in Physical HealthK=14

Change in Psychological 

HealthK=22 

g=.28, p<.03

Meta-Analysis of SDT RCT’s in HealthNtoumanis et al 2020 Health Psychology Review

SDT Health Interventions

g=.29, p<.01

Initial Change

Maintained Change

b=.39, p<.05

b=.67, p<.05

b=.35, p<.05

b=.39, p<.05

Combined Need SatK=23

g =.37, p<.01

Ntoumanis et al. Under ReviewResults/Discussion

• Analysis show SDT interventions (N=73) positively effect motivation:• a moderate effect in improvements in need support, competence, ANS, AM• Those effects were stronger at end of intervention then at follow‐up• These effects were consistent with findings in Gillson at 3 months

• SDT interventions positively effect:• Health Behavior Change, and Psychological Health at end of intervention• Health Behavior Change, and Physical Health at follow‐up• Change in Health behaviors were associated with changes in need support and autonomous motivation  

• An extensive set of potential moderators were explored including needs supportive techniques, behavior change techniques, settings, and intervention characteristics.  Coding was complicated. More research is needed.

Twain as Health Psychologist Injurious Habits

“I can quit any of 19 injurious habits at any time without discomfort or inconvenience … after a few hours the desire is discouraged and comes no more. Once I tried my scheme in a large medical way. I had been confined to my bed several days with lumbago. My case refused to improve. Finally, the doctor said: ’My remedies have no fair chance. Consider what they have to fight , besides the lumbago. You smoke extravagantly, don’t you? “Yes”

You take coffee immoderately? “Yes” …

You drink two hot Scotches every night?” “Yes”

Very well, there you can see what I have to contend with. You cant make any progress on the way the matter stand. You must make a reduction in these things. “I cant , doctor”

Why can’t you? “I lack the will power. I can cut them off completely but I can’t moderate them.”

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Injurious Habits – Continued -Following the Equator 1897

He said that would answer… I cut off all those things for two days and two nights… and at the end of the 48 hours the lumbago was discouraged and left me. I was a well man; so I gave thanks and took to these delicacies again.

It seemed an invaluable medical course, and I recommended it to a lady. She had run down and down and down, and had at last reached a point where medicines no longer had any helpful effect upon her. I said I knew I could put her on her feet in a week. It brightened her up… So I said she must stop swearing, and drinking and smoking and eating for 4 days and then she would be alright again… but she said she could not stop swearing, and smoking and drinking, because she had never done these things. So there it was. She had neglected her habits… She was a sinking vessel, with no freight to throw overboard… Why, even one or two little habits could have saved her, but she was just a moral pauper.

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About Mark Twain

Born Nov 10, 1835 Florida Missouri; • He was born 2 months premature and was not expected to survive• Raised in Missouri – 5th grade education and apprenticed as printer• He spent 2 years River Boat Pilot on Mississippi• Spent a few weeks in the Confederate Army – left for Nevada & Calif.

After Returning East in 1866 • Married Elizabeth Langdon from Elmira and summered at Quarry Farm • Published 1,700 novels, news articles, and a philosophical treatise• Became friends with US Grant and edited his war memoirs• Became known around the world; nearly drafted to run for President• Started smoking at age 8• And he smoked 30 cigars per day

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Twain wanted to tell us about human nature and motivation from his own experience.

"The last quarter of a century of my life has been pretty constantly and faithfully devoted to the study of the human race—that is to say, the study of myself, for, in my individual person, I am the entire human race compacted together.“ (Twain’s Own Autobiography – Michael Kisis, p. 225)

He often wrote from what he saw as his own flaws.

“I have studied the human race with diligence and strong interest in all these years in my own person; in myself I find in big and little proportion every quality and every defect that is findable in the mass of the race.” (AMT Vol 3, 130)

Psychological Needs: Supporting Optimal Motivation

Autonomy the need to feel choiceful and volitional in one’s behavior

Competence the need to feel optimally challenged and capable of

achieving outcomes

Relatedness the need to feel connected to and understood by important

others

Ryan & Deci, SDT Book 2017

Two Types of Motivation Intrinsic (or autonomous) motivation– refers

to those activities done because they are satisfying to us by themselves. Humans act spontaneously about things we experience as enjoyable, interesting or curious, that we value deeply, and to gain mastery of our world. Behaviorism cannot explain these behaviors.

Extrinsic or controlled motivation– refers to those actives that we do because we force ourselves to do through guilt or shame, or because of threat of reward or punishment

Ryan & Deci SDT Book 2017

Autonomy on a raft, or a boat.

From Huck Finn: "We said there warn’t no time like a raft,

after all. Other places do seem so cramped up and smothery,

but a raft you don’t. You feel mighty easy and comfortable

on a raft." (TAHF, 18)

Twain wrote to Joseph Twichell that rafting left his conscience

"in a state of coma, and lazy comfort, and solid happiness.

In fact there is nothing so lovely." (Mark Twain’s letters, ed

Albert Bigelow Paine, 1917 ).

Samuel Clemens to Joseph Twichell, in Mark Twain’s Letters, ed. Albert Bigelow Paine, 2 vols. (new York: Harper and Brothers, 1917,

2:588).

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Mark Twain clearly understood Intrinsic Motivation from writing his Autobiography

By 1905 MT had accumulated some 30-40 ‘false starts’ to his autobiography.

“Finally , in Florence in 1904, I hit upon the right way to do an Autobiography: start it at no particular time of your life; wander at your free will all over your life; talk only about the thing that interests you for the moment; drop it the moment its interest threatens to pale, and turn your talk upon the new and more interesting thing that has intruded itself into your mind meantime…

And so I have found the right plan. It makes my labor amusement—mere amusement, play, pastime, and wholly effortless…”

-Autobiography of MT, Vol 1, p. 220. 31

Twain also knew how our conscience controls us

"‘Is there any way of satisfying that malignant invention

which is called a conscience?"

‘But come, now, answer me that question Is there any way?’

‘Well, none that I propose to tell you, my son. Ass! I don’t

care what act you may turn your hand to, I can straightway

whisper a word in your ear and make you think you have

committed a dreadful meanness. It is my business-and my joy-

to make you repent of everything you do.’"Facts Concerning the Recent Carnival of Crime in Connecticut, 1876 p. 654.

Williams et al., Facts Concerning the Recent Carnival of Smoking in Connecticut Annals Int. Med. 1991) 32

Locus of Causality

Internal Locus of Causality is the perception of whether we are doing something fully of our own volition – for ourselves.

External LOC is when we feel we are doing it because we feel pressured or coerced by others or by pressure from ourselves.

This can change based on social surround, and by internalization.

Ryan & Deci – SDT 2017

Tom’s efforts to change Locus of Causality

Next, Tom appeals to Ben Rogers’ intrinsic motivation:

‘Like it? Well I don’t see why I oughtn’t to like it. Does a

boy get a chance to whitewash a fence every day?"

Tom then follows with a competence challenge to Ben

"… it’s got to be done very careful; I reckon there ain’t one

boy in a thousand, maybe two thousand, that can do it the

way that it’s got to be done.“ (TATS 2)

(Cont.)

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Ben begins to get interested.

Twain describes this change in locus of causality in Ben:

"Ben watching every move and getting more and more

interested, more and more absorbed. Presently he said ‘Say,

Tom, let me whitewash a little.’ (TATS 2)

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Twain as a Master of Motivation

Twain speaks to us directly as a master of human motivation in The Adventures of Tom Sawyer (Chap 2):

He had discovered a great law of human action, without knowing it --namely, that in order to make a man or a boy covet a thing, it is only necessary to make the thing difficult to attain. If he had been a great and wise philosopher, like the writer of this book, he would now have comprehended that Work consists of whatever a body is obliged to do and that Play consists of whatever a body is not obliged to do.

Change in Locus of Causality from Internal to External with Pay – Tom Sawyer

Twain then gives an example of adults who are motivated by the challenge of the task itself, and explains that pay would actually change their experience to that of a lower quality of motivation, such that this lower quality of motivation would not be enough to continue the behavior. He writes:

“There are wealthy gentlemen in England who drive four-horse passenger-coaches twenty or thirty miles on a daily line, in the summer, because the privilege costs them considerable money; but if they were offered wages for the service, that would turn it into work and then they would resign” (TATS Chap 2).

This loss of intrinsic motivation has been studied and confirmed in 129 studies in experiments by SDT researchers

Effects of Rewards and Punishments in 129 Experiments

Cohen’s d kAll people got expected

rewards-0.36 92

When people got less that max reward

-0.88 6

When some people got no reward

-0.95 1

Verbal Rewards 0.33 21

Deci Koestner & Ryan, 1999

The Undermining Effect: Deactivation of Bilateral Striatum as a Function of Rewards in Subsequent

Performance

Internalization –Twain called this ‘training’

An inherent, proactive process by which people take in society’s values and beliefs.

If our needs are supported by society, we more willingly (autonomously) and fully accept those values and we feel more competent to accomplish our goals.

Need Supportive Behaviors that Promote Internalization

Williams, G.C., et al. (2011). Contemporary Clinical Trials, 32(4), 535-543. PMCID 3162229.

Huck’s conscience tortures him led Huck to write letter about Jim. Chapter 31

… and if I was ever to see anybody from that town again I'd be ready to get down and lick his boots for shame. … The more I studied about this the more my conscience went to grinding me, and the more wicked and low-down and ornery I got to feeling. And at last, when it hit me all of a sudden that here was the plain hand of Providence slapping me in the face and letting me know my wickedness was being watched all the time from up there in heaven, … but something inside of me kept saying, "There was the Sunday-school, you could a gone to it; and if you'd a done it they'd a learnt you there that people that acts as I'd been acting … goes to everlasting fire." (TAHF Chapter 31)

(TAHF 31)42

Autonomy (raft) & Relatedness Satisfaction –results in Huck’s positive internalization

"And got to thinking over our trip down the river; and I see

Jim before me all the time: … and we a-floating along,

talking and singing and laughing. But somehow I couldn't

seem to strike no places to harden me against him, but only

the other kind. I'd see him standing my watch on top of

his'n, 'stead of calling me, so I could go on sleeping; and see

him how glad he was when I come back out of the fog;

(Cont.)

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Relatedness Satisfaction- Huck Finn

… and at last I struck the time I saved him by telling the

men we had small-pox aboard, and he was so grateful, and

said I was the best friend old Jim ever had in the world, and

the only one he's got now; and then I happened to look

around and see that paper.

(TAHF 31.)

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Internalization of autonomy supported by relatedness

It was a close place. I took it up, and held it in my hand. I

was a-trembling, because I'd got to decide, forever, betwixt

two things, and I knowed it. I studied a minute, sort of

holding my breath, and then says to myself:

"All right, then, I'll go to hell"—and tore it up. (TAHF 31)

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Baseline Autonomous Motivation

1-month Autonomy

Support

18-month Cessation

.14**

.05

.40** .34**

.33** .52**

Medication Taking

.19**

.32**

.68**

Note: Model Fit: adequately χ2(248) = 1193.14, p < .001, CFI = .92, IFI = .92, RMSEA = .066 ; Values represent standardized path estimates. + p = .10; * p < .05; ** p < .01.

Baseline Perceived

Competence

6-month Autonomous Motivation

6-month Perceived

Competence

Williams et al., Health Psychology 2006

Summary of Internalization

As Huck and Jim travel further south on the river- Huck’s introjects haunt him more and more pushing him to turn Jim in.

Each time he decides to do that-his positive experiences with Jim reminds him of their relationship and he doesn’t turn him in.

This pattern of internalization – moving from an introject to an autonomous regulation was difficult but occurred in the context of:• Autonomy – Hucks freedom of floating on the raft• Relatedness – his positive interactions with Jim

• This pattern is highly consistent with tenets of SDT. Mark Twain knew of this pattern and wrote about it in his stories to teach us.

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Basic Psychological Needs Underlying Volitional Motivation and Well Being

Volitional Motivation, Values,

Sustained energy

Well-Being

Autonomy

Competence

Relatedness

Clinical Implications Health Care Practitioners who learn to support

psychological needs: Elicit perspectives (listen) Acknowledge affect (reflect) Provide effective options for change-choice! Provide clear advice (rationale) for change Support initiative for change Minimize control and remain non-judgmental Skills build/problem solve with those willing Provide a positive relationship

May be more likely to motivate change, health, and improve quality of life for their patients.

Mark Twain

Always do the right thing.

This will gratify some people

And astonish the rest.

Thank you

Thank You!

CitationRichard Ryan & Edward Deci. Self-Determination

Theory. Basic Psychological Needs in Motivation, Development, and Wellness. 2017

EXCADI Intervention

12 months, two 60 min PA sessions per wk Choice of activities Mastery of PA by adapting to skill level Encouraging high intensity PA with rationale Training diary- for acknowledging, & feedback Focused on including everyone and learn names

Halvari et al., Scand J Med Sci in Sports, 2016

Audience Practice Counseling

Switch roles with partner Your patient tried the diet and lowered LDL

by 55 mg/dl (25% lower risk): 180 mg/dl Use principles of supporting internalization

to increase the value the patient has for further lowering of LDL with use of statins. 10 yr ASCVD risk = 10% Lifetime = 50%

Faith may be a third form of motivation according to SDT and to TwainRyan, Rigby, King JPSP 1993, 65(3), 586-96

Two types of religious internalization are conceptualized shown to vary in their relative autonomy. Introjection represents a partial internalization of beliefs and is characterized by self- and other-approval-based pressures. Identification represents adoption of beliefs as personal values and is characterized by greater volition.

Autonomy items: • I pray because I enjoy it• Turn to God because it is satisfying• Attend church because by going I learn new things

Controlled items• Turn to God because I would feel guilty if I didn’t• Pray because God will disapprove if I don’t• Attend church because one is supposed to. 55

Table S4. Behavioral Health Indicators and Outcomes‐Ntoumanis et al

End of treatment Follow up

k n k nHealth-related

behaviors

Physical activity 41 12,419 21 5,652

Dietary behaviors 5 706 1 383 Adherence to medication 1 1,006 2 279

Smoking abstinence 1 1,006 5 2,445 Other health related

behaviors 1 47 1 32

Alcohol consumption 1 1,176 1 202

Dental behaviors 0 0 2 279

Table S4. Physical Health Indicators and 0utcomes‐Ntoumanis et al

Physical health outcomes

End of Tx(k) (n)

Follow-up (k) (n)

Weight / body fat related outcomes 10 1,290 3 1,374

Physical fitness and functioning 4 467 1 218

Blood glucose / HbA1c 4 203 4 4,695

Blood lipids 3 318 4 5,054

Blood pressure 3 318 2 444 General physical health

and well-being 2 199 3 334

Dental health indicators 0 0 1 86

Table S4. Psychological Health Indicators and Outcomes‐Ntoumanis et al

End of Tx: Follow-upPsychological health

outcomes k n k nGeneral psychological

well- and ill-being 6 1,289 3 260

Quality of life 5 1,530 2 904

Vitality 4 430 2 382 Positive / Negative

affect 2 153 2 183

Depression / Anxiety 1 121 3 1,069

Self-esteem 1 552 1 559

Applying Self-Determination Theory to Understand Twain’s ‘Vision’ of Joan of Arc

Exploration of 4 ideas:

Twain became intrinsically motivated by her life story, as her faith based motivation was different than his.

She was autonomously motivated by faith which energized her to lead the French army, win her trials, and face her death

The French became autonomously motivated and with higher perception of competence, and by their faith in her and in God

How Twain’s view of Joan of Arc’s autonomy and of competence may be relevant to how patients may have a better quality of life as they face their illnesses and diseases

Williams. What Joan of Arc and Mark Twain Can Teach Us about Human Motivation and Wellbeing. American Literary Realism, In press

Audience Practice Supporting Intrinsic Mot. for Healthy Diet Pair up – quickly decide who will be Doc Patient is 55 y/o with LDL chol of 235 and

wont start meds until trial of healthy diet. They eat Southern diet – heavy in meats, eggs,

heavy sauces. You can recommend one of three diets: Whole food vegan, DASH, or Mediterranean

Try to “make the work fun” through interest, curiosity enjoyment or optimal challenge

Audience Participation

Practice this in clinic with the patients who want you to make the decision about meds after you ask: What do you want to do about taking a statin to lower your risk for stroke and heart attack? Levinson 2006 – 50% of patients want

prescriber to decide Martinez 2016 – 50% of breast cancer patients

want oncologist to make decision

Influence of Cardiovascular Risk CommunicationTools and Presentation Formats on Patient Perceptions and Preferences

Participants: 2706 subjects in clinics in 2015 where shown one of three hypothetical risk scenarios.

Objective: To determine how ASCVD risk time horizon, outcomes and format influence risk perceptions and treatment preferences.

Randomization: • 1- Lifetime risk for ASCVD • 2- 10 year risk for ASCVD event • 3- 10 year risk for CVD death

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JAMA Cardiology doi:10.1001/jamacardio.2018.3680Published online November 7, 2018.

Overview

“Go To Heaven For the Climate, Hell for the Company” Mark Twain

Twain as humorist - ‘healthy habits’

Twain as Psychologist – Three Motivations for Health• Intrinsic Motivation- Tom Sawyer (Work and Play)•Internalization of Autonomous Motivation with Independence – Huckleberry Finn

•Internalization of Autonomous Regulation with Dependence (or Faith)– Joan of Arc

INNOCENCE, loss ofNow when I had mastered the language of this water and had come to know every trifling feature that bordered the great river as familiarly as I knew the letters of the alphabet, I had made a valuable acquisition. But I had lost something, too. I had lost something which could never be restored to me while I lived. All the grace, the beauty, the poetry had gone out of the majestic river! I still keep in mind a certain wonderful sunset which I witnessed when steamboating was new to me. A broad expanse of the river was turned to blood; in the middle distance the red hue brightened into gold, through which a solitary log came floating, black and conspicuous; in one place a long, slanting mark lay sparkling upon the water; in another the surface was broken by boiling, tumbling rings, that were as many-tinted as an opal; where the ruddy flush was faintest, was a smooth spot that was covered with graceful circles and radiating lines, ever so delicately traced; the shore on our left was densely wooded, and the sombre shadow that fell from this forest was broken in one place by a long, ruffled trail that shone like silver; and high above the forest wall a clean-stemmed dead tree waved a single leafy bough that glowed like a flame in the unobstructed splendor that was flowing from the sun. There were graceful curves, reflected images, woody heights, soft distances; and over the whole scene, far and near, the dissolving lights drifted steadily, enriching it, every passing moment, with new marvels of coloring.

I stood like one bewitched. I drank it in, in a speechless rapture. The world was new to me, and I had never seen anything like this at home. But as I have said, a day came when I began to cease from noting the glories and the charms which the moon and the sun and the twilight wrought upon the river's face; another day came when I ceased altogether to note them. Then, if that sunset scene had been repeated, I should have looked upon it without rapture, and should have commented upon it, inwardly, after this fashion: This sun means that we are going to have wind to-morrow; that floating log means that the river is rising, small thanks to it; that slanting mark on the water refers to a bluff reef which is going to kill somebody's steamboat one of these nights, if it keeps on stretching out like that; those tumbling ``boils'' show a dissolving bar and a changing channel there; the lines and circles in the slick water over yonder are a warning that that troublesome place is shoaling up dangerously; that silver streak in the shadow of the forest is the ``break'' from a new snag, and he has located himself in the very best place he could have found to fish for steamboats; that tall dead tree, with a single living branch, is not going to last long, and then how is a body ever going to get through this blind place at night without the friendly old landmark?

No, the romance and the beauty were all gone from the river. All the value any feature of it had for me now was the amount of usefulness it could furnish toward compassing the safe piloting of a steamboat. Since those days, I have pitied doctors from my heart. What does the lovely flush in a beauty's cheek mean to a doctor but a ``break'' that ripples above some deadly disease? Are not all her visible charms sown thick with what are to him the signs and symbols of hidden decay? Does he ever see her beauty at all, or does n't he simply view her professionally, and comment upon her unwholesome condition all to himself? And doesn't he sometimes wonderwhether he has gained most or lost most by learning his trade?

Mark Twain from his book - Life on the Mississippi 1884

Autonomy and Independence Autonomy has two types :

– Volition: willingness to act for oneself (even in relation to others’ intentions) Associated with motivation, positive affect, health People can want to stop smoking, and can accept

that others want them to stop, too. – Volitional Independence: to act willingly without input from others

For those patients who want to make all decisions for themselves – estimate 30% of population

Volitional Dependence: to act willingly based on recommendations from others – estimate 50% of pop

From Pudd’nhead Wilson’s Calendar

Habit is habit, and not to be flung out of the window by any man, but coaxed downstairs a step at a time, (PHW Chapter 6)

Tell the truth or trump – but get the trick. (PHW Chapter 1)

There is no character, however good and fine, but it can be destroyed by ridicule, however poor and witless. Observe the ass, for instance: his character is about perfect, he is the choicest spirit among all the humbler animals, yet see what ridicule has brought him to. Instead of feeling complimented when we are called an ass, we are left in doubt. (PHW Chapter 1)

Mark Twain and Smoking

"Now there are no arguments that can convince me that

moderate smoking is deleterious to me," he wrote to his wife

in 1870: "I have smoked habitually for 26 of my 34 years, &

I am the only healthy member our family has…. My health

is wholly faultless--& has ever been since I was 8 years old.

My physical structure—lungs, kidneys, heart, brain—is

without blemish. The life insurance doctor pronounced me

free from all disease & remarkably sound"(Lts-4, 21; K. Patrick Ober. Mark Twain and Medicine p 107)

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Mark Twain and Smoking

I have made it a rule to never smoke more than one cigar at

a time. I have no other restriction as regards to smoking…

As an example to others, and not that I care for moderation

myself, it has always been my rule never to smoke when

asleep, and never to refrain when awake… I have stopped

smoking now and then, for a few months at a time, but it

was not on principle, it was only to show off, it was to

pulverize those critics who said I was a slave to my habits

and couldn’t break my bonds. (Quoted in Camfield, 610) 69

Twain finally admits smoking caused his tobacco heart at age 74.

"However, the victory over me is not much of a victory after all, for it has taken 63 years to build this disease. I was immune that long anyway."

(John Cooley, ed., Mark Twain’s Aquarium: The Samuel Clemens-Angelfish Correspondence. 1905-1910, 262)70

References ABIM Foundation. (2009). Medical professionalism in the new millennium: A physician charter. Annals of

Internal Medicine, 136(3), 243-246. Beauchamp, T. L. & Childress, J. F. (2009). Principles of biomedical ethics. New York: Oxford University

Press. Deci, E. L., La Guardia, J. G., Moller, A. C., Scheiner, M. J., & Ryan, R. M. (2006). On the benefits of giving as

well as receiving autonomy support: Mutuality in close friendships. Personality and Social Psychology Bulletin, 32, 313-327.

Deci, E. L. & Ryan, R. M. (1995). Human autonomy: The basis for true self-esteem. In M. Kernis (Ed.), Efficacy, agency and self-esteem (pp. 31-49). New York: Plenum Publishing Co.

Deci, E. L. & Ryan, R. M. (2000). The “what” and “why” of goal pursuits: Human needs and the self-determination of behavior. Psychological Inquiry, 11, 227-268.

Fortier, M. S., Duda, J. L., Guerin, E., & Teixeira, P. J. (2012). Promoting physical activity: Development and testing of self-determination theory-based interventions. International Journal of Behavioral Nutrition and Physical Activity, 9, 1-14.

Moller, A. C., McFadden, H. G., Hedeker, D., & Spring, B. (2012). Financial motivation undermines maintenance in an intensive diet & activity intervention. Journal of Obesity, epub ahead of print.

Ng, J., Ntoumanis, N., Thøgersen-Ntoumanis, C., Deci, E. L., Ryan, R. M., Duda, J. L., & Williams, G. C. (2012). Self-Determination Theory applied to health contexts: A meta-analysis. Perspectives on Psychological Science, 7(4), 325-340.

“

References Nix, G. A., Ryan, R. M., Manly, J. B., & Deci, E. L. (1999). Revitalization through self-regulation: The effects

of autonomous and controlled motivation on happiness and vitality. Journal of Experimental Social Psychology, 35, 266-284.

Ryan, R. M. & Deci, E. L. (2000). Intrinsic and extrinsic motivations: Classic definitions and new directions. Contemporary Educational Psychology, 25, 54-67.

Ryan, R. M. & Deci, E. L. (2000). Self-determination theory and the facilitation of intrinsic motivation, social development, and well-being. American Psychology, 55(1), 68-78.

Ryan, R. M., Deci, E. L., & Grolnick. W. S. (1995). Autonomy, relatedness, and the self: Their relation to development and psychopathology. In D. Cichetti & D. J. Cohen (Eds.), Developmental psychology – Vol. 1: Theory and methods (pp.618-655). New York: Wiley.

Sebire, S. J., Standage, M., & Vansteenkiste, M. (2008). Development and validation of the goal content for exercise questionnaire. Journal of Sport and Exercise Psychology, 30, 353-377.

Sheldon, K. M., Ryan, R. M., Rawsthorne, L. J., & Ilardi, B. (1997). Trait self and true self: Cross-role variation in the big five personality trails and its relations with psychological authenticity and subjective well-being. Journal of Personality and Social Psychology, 73, 1380-1393.

Teixeira, P. J., Carraça, E. V., Markland, D. A., Silva, M. N., & Ryan, R. M. (2012). Exercise, physical activity, and self-determination theory: A systematic review [Electronic version]. Journal of Behavioral Nutrition and Physical Activity, 9, 78. doi: 10.1186/1479-5868-9-78.

Overview of Putting Self-Determination Theory Into Practice Self Determination Theory Overview

Define Motivation Applications of Engaging Pts with Motivation Assumptions: innate aspects of self, psychological needs Motivation and Medical Professionalism Incentives AND/OR Internalization to motivate change SDT Model for Health Behavior Change Meta-analyses

Randomized controlled trial - SDT Tobacco abstinence and Cholesterol management with lifestyle

Role Play –with feedback – Implications clinicians and policy.

Does Physician Communication Style Impact Patient Report of Decision Quality for Breast Cancer Treatment?

Objective: To examine the relationship between perceived provider communication style and patient decision satisfaction in breast cancer.

Methods: Using a population-based sample of women with localized breast cancer, we assessed patient perceptions of autonomy-supportive communication from their surgeons and medical oncologists, as well as patient-reported decision quality.

We used multivariable linear regression to examine the association between autonomy-supportive communication and subjective decision quality for surgery and chemotherapy decisions, controlling for sociodemographic and clinical factors, as well as patient reported communication preference (non-directive or directive).

Martinez, K. et al. (2015), Unpublished University of Michigan.

Does Physician Communication Style Impact Patient Report of Decision Quality for Breast Cancer Treatment?

TABLE 3: Multivariable linear regression of the association between autonomy-supportive communication and subjective decision quality for decisions with medical oncologist

Martinez, K. et al. (2015), Unpublished. University of Michigan.

(N=1,140) Est. SE p-value

Race/ethnicityWhiteBlackLatinaAsianOther/unknown/miss

-0.17-0.39-0.12-0.80

0.060.070.080.17

0.004<0.0010.149

<0.001Age (continuous) 0.006 0.002 0.001

Education<High schoolHigh school gradSome college or more

0.06-0.0001

0.060.05

0.3150.997

TreatmentLumpectomyUnilateral mastectomyBilateral mastectomyNo treatment

0.02-0.040.15

0.050.050.28

0.5810.6550.397

ComorbiditiesNoneOneTwo or more

0.0003-0.06

0.050.06

0.9940.358

Est. SE p-valueSelf-reported health statusExcellentVery goodGoodFairPoor

-0.12-0.16-0.27-0.35

0.070.070.090.21

0.0930.0250.0020.100

SiteUSCEmory -0.007 0.006 0.256

Communication style preferenceNon-Directive Directive -0.05 0.04 0.192

Adjusted mean (SE)

Autonomy-supportive communicationLow High

4.3(0.008)4.6(0.006)

0.18 0.04 <0.001

Locus of Causality – Building Intrinsic MotivationChapter II. Tom Sawyer is trying to exchange tasks, asking Jim

to whitewash while Tom gets water: "… ‘Gimme the bucket –

I won’t be gone only a minute. She won’t ever know.’

‘Oh, I dasn’t, Mars Tom. Ole missis she’d take an’ tar

de head off’n me. ‘Deed she would.’ "

Tom persists and offers to show Jim his sore toe in

reward for swapping jobs. (TATS-Chap 2)

(Cont.)

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Locus of Causality – Intrinsic Motivation

"Jim was only human—this attraction was too much for

him. He put down the pail, took the white alley, and bent

over the toe with absorbing interest while the bandage was

being unwound. In another moment he was flying down the

street with his pail and tingling rear, Tom was whitewashing

with vigor, and aunt Polly was retiring from the field with a

slipper in hand and triumph in her eye.’ (TATS, 2)

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Internalization – Huck Finn

“I liked the old ways best, but I was getting so I liked the

new ones, too, a little bit. The widow said I was coming

along slow but sure, and doing very satisfactory. She said

she warn't ashamed of me."

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