Dr. Bonnie J. Spring is a professor in preventive medicine, psychiatry and behavioral sciences at Northwestern University’s Feinberg School of Medicine. Originally focused on mental health problems, Dr. Spring realized that psychotherapy, while effective, was not “an efficient or scalable way to produce behavior change.”
“There’s so much of the population that needs help,” she said. “And treating one person at a time in that way is just not going to have much of a population impact.”
Now, as a clinical health psychologist, Dr. Spring aims to find effective and efficient ways to reduce behavioral risk factors like obesity, poor quality diet, physical inactivity and tobacco use. Much of her research has focused on how technology can help physicians, nutritionists and psychologists monitor and modify such behaviors. NPR, the Boston Globe and the Chicago Tribune have all cited her work in recent articles. Science in Society spoke with Dr. Spring to learn more.
What is the focus of your research?
One of the important values of my field is to help people understand that it is complicated. Often people (physicians) say, “Well, I told my patient to quit smoking or lose weight.” And they’re astonished that they didn’t do it. These are actually very complex habits, and there’s a science to understanding the mechanism that underlies them.
Tell me about the studies you've recently published.
One of them is looking at a very fundamental question that we don’t know the answer to: the fact that most people don’t have one health risk behavior – they have multiple.
They don’t eat enough fruits and vegetables. They have a diet too high in saturated fat. They don’t get enough physical activity, and they watch too much TV.
And those two things (the physical activity and the sedentary time) are actually not even interrelated. You might think they were, but they’re not. And they have separate adverse effects on health.
Now if you add to the mix that they’ve got depression or smoke as well. What you see is the kind of problem that presents to most primary care docs. Where to begin? You’ve got multiple things going on.
So the first study was really about trying to figure out, OK, what’s the best way to begin? If you had to pick two behaviors to start with, which are the best two? Is it better to try to increase healthy behaviors hoping that they’ll crowd out unhealthy ones? Or is it better to have people try to cut out the unhealthy ones, hoping that it will make room for the healthy ones to fit in?
How can technology be used in behavioral psychology?
We’re concerned about trying to take my expertise as a clinical psychologist that would normally present in a 50-minute hour, and figure out a way to present it more efficiently, less expensively, in a way that’s accessible to more people.
And so, we use technology to do that. And we started doing work almost a decade ago, maybe even more, with palm pilots. And now, we use mobile phones and other sensor technology. And the gist is, we are helping people to have tools that they can take with them, and have help and support in the moment when they need it.
Because, whether you’re seeing a therapist for a 50-minute hour once a week, or you’re seeing your primary care doctor every six months, those people aren’t going to be with you when you have to make your decisions about what to eat. You need help in the moment.
So, the beauty of these mobile tools is they are with you in the moment.
So, when you enter the food, this app converts it into calories and shows it to you on an appealing color-coded fan that’s green when you’re doing fine (you’ve got lots of calories left for the rest of the day), yellow when you’re a little close, and red when you’re over the top.
Why do you think that using an app is more effective than writing everything down in a journal?
This is very interesting, and we have a study going on right now testing that. I think there are a couple of answers.
One of them is when you’re writing something down on a piece of paper, it’s not an awful lot of fun, and it doesn’t give you any feedback immediately. When you’re entering something into an app, it gives you feedback. You enter something and it changes. It changes the color of this fan, or it changes how filled up your physical activity thermometer is. It’s giving you decision support and feedback in real time when you need it.
In contrast, if you’re filling something out on paper, you have to take the paper log in to your nutritionist and they have to enter it into a computer. It will be two weeks, at least, before you get feedback on that, by which time your behavior was so long ago you don’t get the stimulus-response connection. The learning isn’t really effective.
Is human interaction still important, and how so?
Another thing we have learned through all of these trials is that one of the most effective ways to get people to change their behavior is through a principle we call supportive accountability.
There are two things, basically, that we know help people to change their health behaviors. One of them is what we call self-monitoring (tracking it by writing it down either on paper or in an app). The second is, having support from somebody. And that support can be either from a therapist or a coach, or even a peer. So those are the things with a long track record – we know those things work.
You may not see an interventionist until the end of the week. But, that person is tracking whether you’re entering or uploading, or you’ve just sort of stopped your self-monitoring. Or maybe you’re having technical problems with the equipment.
So, our coaches monitor how people are doing, and if they’re obviously having trouble, they reach out to them. This lets somebody know that somebody is paying attention and caring. And so the coach doesn’t actually have to do an awful lot, except what we sometimes call hovering.
In the future, do you think physicians will be able to monitor all their patients electronically?
Absolutely. And I think it’s also very consistent with this move we have towards team-based care.
Doctors have far more than they can do in the limited time that’s available to see patients. And what’s happened in this country is they deal with the illness problems first. That’s what they can do and nobody else can do. But there are other members on the team, be they people in the office (a physician assistant, a nurse, a nutritionist, a psychologist) or even outside of the office who can take on this monitoring function.
So, we have the ability to use some of these electronic tools to bring in team members who are either located in the physician’s office, or remotely located and can still function as a part of the team.