Motivation, Medicine, and Mark Twain

2020 Annual Montana Diabetes Professional Conference 10-23-2020 Geoffrey Williams MD, PhD Medical Director Collaborative Science and Innovation Billings Clinic Emeritus 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

7

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 The Importance of Volitional Behavior 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 Internalization

. an inherent, proactive process by which autonomous and competence motivations are increased naturally over time Three Meta‐analyses SDT & Health Ng, 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

Needs Support Mental Health Depression Health Care Somatization* Climate Autonomy Anxiety Important others Quality of life* Suicidality Suicide attempts Competence Personality Physical Health Differences in Insomnia Autonomy Relatedness Not Smoking* Physical activity* Weight Loss* Diabetes Control* Intrinsic vs. Medication Use* Extrinsic Values Healthier Diet* * RCT of Intervention to increase autonomy 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 Initial Change b=.39, p<.05 Need Increase in Support autonomous b=.39, p<.05 K=22,21 Combined motivation Need Sat K=23 Change in K=23 Health Behavior K=49 g =.37, p<.01 Change in SDT Health g=.29, p<.01 Psychological Interventions Health b=.35, p<.05 K=22

g=.28, p<.03 b=.67, p<.05 Maintained Maintained Change in Maintained Change in Physical Health Change Health Behavior K=14 K=28

Meta-Analysis of SDT RCT’s in Health Ntoumanis et al 2020 Health Psychology Review Ntoumanis et al. Under Review Results/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.”

23 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.

24 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 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)

26 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 ).

29 Samuel Clemens to Joseph Twichell, in Mark Twain’s Letters, ed. Albert Bigelow Paine, 2 vols. (new York: Harper and Brothers, 1917, 2:588).

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)

34 (Cont.) 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)

35 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 dk All people got expected -0.36 92 rewards When people got less that -0.88 6 max reward When some people got no -0.95 1 reward 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.)

43 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.)

44 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)

45

Baseline .68** 6-month Autonomous Autonomous Motivation Motivation .19**

Medication .14** Taking 1-month Autonomy .52** Support .33** .32**

.05 18-month Cessation

.34** Baseline .40** 6-month Perceived Perceived Competence Competence

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.

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.

47 Basic Psychological Needs Underlying Volitional Motivation and Well Being

Autonomy

Volitional Motivation, Values, Competence Sustained energy Well-Being

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!

Citation Richard 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 Twain Ryan, 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

knkn Health-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 End of Tx Follow-up outcomes (k) (n) (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-up Psychological health outcomes knk n General 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

62 JAMA Cardiology doi:10.1001/jamacardio.2018.3680 Published 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 of Now 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 wonder whether 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) 68 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 (N=1,140) Est. SE p-value Est. SE p-value Race/ethnicity Self-reported health status White Excellent Black -0.17 0.06 0.004 Very good -0.12 0.07 0.093 Latina -0.39 0.07 <0.001 Good -0.16 0.07 0.025 Asian -0.12 0.08 0.149 Fair -0.27 0.09 0.002 Other/unknown/miss -0.80 0.17 <0.001 Poor -0.35 0.21 0.100 Age (continuous) 0.006 0.002 0.001 Site Education USC

Martinez, K. et al. (2015), Unpublished. University of Michigan. Locus of Causality – Building Intrinsic Motivation Chapter 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.)

76 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)

77 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."

78