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Monday, Sep. 17, 2012
Goal Power
By Dr. Mehmet Oz

I am terrified of heights. Climbing to the top of a telephone pole three stories tall in the Arizona desert is not my idea of a good time. It didn”t help much that I would be wearing a helmet–a

three-story drop is a three-story drop, no matter what you”ve got on your head. It should have helped that I”d be wearing a safety cable, but that made no difference either. If you know anything about how the brain works, you know that what you understand in your reasoning lobes and what you feel in your emotional lobes are two very different things. And when it came to the idea of standing atop a swaying, creaking pole with the desert floor swimming below, my emotional lobes won in a landslide.

I had gone to Arizona with a crew from The Dr. Oz Show and a group of 50 women who had been offered a surprise trip and were taken directly from the studio in New York during the taping because they desperately wanted to make changes in their lives. Maybe one wanted to quit smoking; maybe another wanted to lose weight or exercise more or go back to school or get out of a lousy job. The point is they were stuck, rooted between the world of “I know I should do this” and the world of “I”m actually doing it”–a place where many of us can spend a lot of fruitless and frustrating time.

The three-story pole was a three-story metaphor. Take a step forward–or actually a step straight up–in Arizona and maybe we could all take other, even scarier steps elsewhere in our lives. I was paired with Pam, a 33-year-old IT worker from Long Island who had been obese as a child and hasn”t wanted to be singled out since for fear of embarrassment. So in the spirit of taking the counterintuitive step, she agreed to go first and be singled out for a very positive reason. I stood at the bottom of the pole, watching her go up and dreading the moment when she would reach the tiny platform at the top, which was big enough for only two, because that would mean I had to go. When I began the climb, it was just what I expected, by which I mean the whipping wind and the receding ground and my sweaty palms on the rungs were just awful. But there was a power in enduring that awfulness.

Pam shouted down encouragement, and as I neared the little platform, she reached out, took my hand and helped me take the final step. My real fear, it seemed, had not been of heights but of lack of control. Trusting Pam was the antidote. I flung an arm around her in a celebratory hug. The climb may have been terrible, but completing it

was sublime.

You Know You Should

There”s a strange, discordant pathology to the state of being stuck. Nobody who starts smoking plans to be hooked for life. Nobody who”s obese secretly wants to stay that way. When a doctor or family member pleads with us to make lifesaving changes, we mean it when we say, “I know, I know, I should. I will.” What”s left unsaid is the killer caveat: “Just not today.”

Over the years, I have had more conversations like this with patients than I can count, so many that the phrase “I know I should” has become a bright red flag–a sad predictor that I will probably one day crack open those patients” sternums in the operating room, trying to undo the damage that poor choices and unhealthy lifestyles have done to their hearts. Why these people spend their lives moving stubbornly toward major, potentially life-threatening surgery when they could avoid it with just a few wise moves is a riddle that has always dogged me.

But perhaps it shouldn”t. Getting people to make meaningful changes in their lives is much more complicated than explaining to them what to eat for dinner, how often to exercise and which kinds of tests they should get from their doctors. The psychology of health is every bit as complex as the biology, and to create seismic shifts in behavior, we have to probe the subconscious.

Psychologists divide behavior into the ego syntonic and the ego dystonic. Ego syntonic is when we embrace a mere fear as absolute truth and the unhealthy behavior that results as justified–as with an anorexic who truly believes she is overweight despite a doctor”s scale saying otherwise. Ego dystonic is when, for example, a person with obsessive-compulsive disorder knows that worrying about germs isn”t healthy but can”t stop anyway. When it comes to behavior, the ego-dystonic sort ought to be easier to fix: you already understand what has to be done. But if that were so, far fewer of my patients would have to make that long trip to the cardiac OR.

There are lots of ways to move the needle on the dystonic problem. A colleague and frequent collaborator of mine, psychologist John Norcross, is one of

the authors of a groundbreaking book, Changing for Good, which, as the title suggests, explains not only how to repair what”s not working in your life but also how to make those fixes stick. It does this with the help of what”s known as the transtheoretical model, which has been around since the late 1970s but is no less powerful now and even has special utility when two-thirds of Americans are overweight or obese and 600,000 of us are killed by cardiovascular disease per year.

The transtheoretical model divides the process of making changes into five key stages: precontemplation, contemplation, preparation, action and maintenance. Precontemplation is in many ways the most dangerous; you have no plans to make any changes and may not even be aware you have a problem. This is often the state of the early-stage alcoholic who clearly has a problem but has not yet lost a job or cracked up a car and can thus pretend everything”s fine. It”s less common in cases of obesity or smoking. There are too many reminders, from the warnings on cigarette packs to the pains in your chest to the numbers on the scale.

Much trickier are the contemplation stage, in which you begin to recognize the problem and weigh taking action, and the preparation stage, when you intend to act imminently. People who get stuck at “I know I should” generally get marooned on the shores of one of these states of mind.

So how to get unstuck? Here”s where psychology and a little spirituality can help. Throughout time, religion has been about not just worship but also life lessons, self-improvement and redemption, with earthly accountability to the community and congregation to help keep us in line. It”s hard to cheat a neighbor who sits next to you in church. It”s hard to skip an exercise class organized by your congregation. Alcoholics Anonymous was launched in the 1930s with a 12-step model based on the same idea. Here, too, getting the support and, if necessary, the scolding of a group leads to better results than what AA members call white-knuckle sobriety–when someone who puts the cork in the bottle relies on sheer tooth-gritting willpower to resist pulling it back out.

A 2012 study in the journal Obesity explored the power of the collective, looking at the weight-loss rate among people in groups who succeeded at a 12-week diet. The participants were 12,000 people who took part in the 2009 Shape Up Rhode Island fitness campaign. They divided themselves into 987 five-to-11-person teams, stayed in regular communication over the Internet and competed with other teams to see who could lose the most at the end of 12 weeks.

In general, the researchers found there was a kind of virtuous loop among the most successful groups. The more pounds any individual member of a high-weight-loss group dropped, the likelier it was that other members would follow suit and shed more pounds too. At the end of the study, members of the most motivated and successful groups lost 5% of their body weight–a healthy and maintainable target that members of a lot of the other groups missed. Crunching the data, the researchers concluded that any person from the 5% group would have lost only 3.8% of body weight if moved to a less successful group. In other words, it wasn”t just the quality of the individual”s resolve; the quality of the group”s mattered too.

A 2008 study published in the New England Journal of Medicine took a similar approach, looking at the dynamics of smoking behavior in a large social network. Harvard”s Dr. Nicholas Christakis, the lead author of the paper (and a TIME Ideas contributor), is a pioneer in the young field of social networks and public health. He and others have found that a whole range of health issues, from depression to smoking to obesity, can be powerfully influenced by the other people in your social web, including–remarkably–some you”ve never met.

There”s no telepathy involved in that. Perhaps you decided to quit smoking because you saw a friend succeed at it. But she quit because her husband, whom you know slightly, had done so. And he quit because he was following the example of an office friend you don”t know at all. Twang one strand in the web and it can cause vibrations everywhere. The 2008 study explored more direct, first-person contact, but the results were still striking: people whose spouse quit smoking were 67% less likely to start or continue smoking; they were 36% less likely if a friend quit, 34% if a work colleague quit, and 25% if a sibling did.

Achieving a goal doesn”t always have to be a collective effort. Sometimes it can be simply a matter of breaking the job up into a lot of minigoals. Part of AA”s genius is its “one day at a time” dictum. You don”t have to quit drinking for the rest of your life; just do it today. Tomorrow you can make the same choice again. String together enough such days and you”ve put down the bottle for good.

In a 2007 study, a randomized clinical trial for postmenopausal women with Type 2 diabetes, investigators tested the effectiveness of the Mediterranean lifestyle–a regimen that includes regular exercise as well as a diet based on fruits, vegetables, olive oil, nuts, beans and lean meats, particularly fish and other seafood. The study found that the incremental approach works. Subjects who set short-term goals–increasing exercise sessions in five-minute increments, for instance–were doing better at the end of two years than a control group of people who simply adopted the program and, all too often, abandoned it later.

The Accountability Factor

Medication compliance is another critical area that can be improved by intervention and goal setting. From 50% to 75% of all hypertension patients currently prescribed drugs don”t have their pressure under control because they fail to take the meds dependably. A 2006 study conducted by the National Heart, Lung and Blood Institute and published in the journal Disease Management used the transtheoretical model to try to improve those numbers in a sample group of 1,227 patients. All the subjects were in the pre-action phase: not complying but planning to. And all were given the assistance of both an onscreen and a paper transtheoretical workbook that used questionnaires and other tools to explore why they were stuck and what it would take to get them to move. Significantly, participants were surveyed three times during the study, meaning there was follow-up and accountability in the mix. A year after the study was done, 73% of those who had received counseling were compliant with their drug regimens, compared with just under 58% for a control group. At 18 months it was 69% to 59%. That”s not 100%, but imagine slowing the No. 1 killer in the U.S. by simply getting resistant patients to take their statins and beta blockers.

I”m not pretending any of this is easy. Inaction is a powerful coping mechanism. Justification and rationalization are ways to handle feeling desperate, out of options, out of control. The National Institute of Mental Health published a revealing article in 2010 on the phenomenon known as emotional inertia–a sort of fixed state of depression, low self-esteem, anxiety or other condition that rarely seems to change even in the face of circumstances that warrant change. Using a series of role-playing games in which subjects were asked to work through a family problem, investigators found that when the need to act was most pressing, subjects dug into their habitual moods more than ever. The urgency paradoxically pushed them to cling more closely to the thing they knew, even if it was bad and unhealthy. I see this in some of my patients, who are so demoralized by their failure to lose weight or quit smoking that as soon as they leave my office, they seek comfort in a sundae or a cigarette.

In fairness, that is the nature of all of us. Human beings can be remarkably static creatures; it”s practically woven into our DNA. Why move from the familiarity of the campfire circle and step into the scary wilderness, even if wonderful, life-giving things might be there? Doctors, however, like to look at things another way. To us, life is never static. Everything is either growing or dying. When you delay your diet until tomorrow or wait to quit smoking until your next birthday, you are choosing, in a day-to-day way, to follow the route of the dying.

Taking action, of course, is the very hardest of the transtheoretical steps–the moment you stand up from the campfire, dust off your pants and begin walking toward the woods. Difficult as it is, though, it can be the start of an inexorable forward momentum. As Newton taught, a body in motion stays in motion. I often remind my patients of a favorite and familiar riddle: If you see 10 birds on a wire and five decide to fly, how many are left? The answer is 10. Deciding and doing are not the same.

I learned that fact anew at the base of that pole in Arizona. I traveled west that day having already decided to climb the blasted thing. But I hadn”t done anything at all until I actually put my foot on the lowest rung.