“When I let go of what I am, I become all that I might be” (Lao Tzu)

In my last post I wrote about the idea that approaching the problem of preventable chronic disease starts with changing our mindset towards health and healthcare. I described health as a practice – not a destination and argued that along with treating disease, continuously improving our well-being and living an ever-expanding extraordinary life should be a core goal of healthcare.

The healthcare system needs a new mindset and updated business model, yes, but in order for this approach to succeed it is you and me that have to change. I think of this change as adopting a ‘health mindset’ and organizing our lives around strategies that lead to continuous well-being improvement. A health mindset is a growth mindset and in this post I’ll describe what that means, how I personally have experienced it, and then introduce some ideas for how digital health apps might leverage it.

Growth vs Fixed Mindsets

World-renowned Stanford University psychologist Carol S. Dweck, Ph.D. has been researching the psychology behind success and accomplishment for decades. In her engaging and best-selling book “Mindset: The New Psychology of Success”, Dweck defines the two opposing mindsets she discovered in her research, the ‘growth’ mindset and the ‘fixed’ mindset, and she explains why adopting a growth mindset is the preferred path to success in life.

In a fixed mindset people view their skills, abilities and traits as fixed, or at least relatively stable over time. In this mindset, the amount of effort it takes to accomplish something is interpreted as a gauge of innate talent. Increasing effort or failing to reach a goal are seen as negatives to be avoided because they highlight weaknesses. From Dr. Dweck: “In the fixed mindset, everything is about the outcome”. Often we think of our intelligence, athletic ability, personality and character as fixed traits that define our identity. This is the hand that we were delt by genetics and our childhood experiences. This is fixed mindset thinking.

In contrast, the growth mindset is an approach to life that is centered on learning, growing and improving. From Dweck: “people in the growth mindset don’t just seek challenge, they thrive on it, the bigger the challenge, the more they stretch. The growth mindset allows people to value what they’re doing regardless of the outcome”. So, a growth mindset is characterized by a focus on effort and purposeful strategies, not outcomes. Current status is not an indicator of success or failure, instead, success is defined by the effective execution of strategies to grow and failure is defined by not trying.

For example, at school, a student with a fixed mindset has a goal of getting good grades and a high GPA and poor grades or classes that take extra effort indicate subjects to avoid. Whereas a student with a growth mindset’s primary goal is to learn and learning takes effort. The easy subjects are OK, but the real fun comes from the challenging classes that require extra work to keep up.

When it comes to health a fixed mindset person considers themselves healthy if their numbers (such as blood pressure, BMI, HbA1c, etc) are in normal ranges. They don’t spend much time thinking about their health unless they get sick and then have to take the steps to return to that state of being healthy. If they end up putting on an extra 20 pounds, they may go on a crash diet to lose it before the class reunion this summer but likely won’t permanently adopt new habits to maintain their ideal body weight. But in the growth mindset, health is not about specific measurements as much as life strategies and daily habits. Blood pressure and BMI matter of course, they are important markers along the way, but the goal is to continue to evolve habits for exercise, nutrition and sleep not as means to an end, but as components of a well-lived life.

Sustaining a health practice over the long run definitely starts with a growth mindset.

My journey from fixed to growth…

For the past 5 years or so I have been on a path of personal change and growth, but until recently, I’ve been laboring from a fixed mindset with what I think of now as the before-and-after-photo approach. My journey began when I started studying the behavior psychology and neuroscience research behind habits to help inform my work in creating engaging digital health experiences for patients. Along the way I have been experimenting on myself by doing such things as creating a habit of daily exercise, replacing coffee with green tea, meditating every morning, converting to a gluten-free whole-food diet, waking up early, logging at least 100k steps per week on my Fitbit, quitting alcohol… I could go on and on (did I mention the cold showers? 😃).

But even though I have been working on all of these new habits and lifestyle strategies, I was still operating, until recently, from a fixed mindset. I was trying to create habits so that I could become the kind of person who does ‘x’ and therefore achieve certain goals associated with doing ‘x’. Going to the gym 4-days per week so that I could reach a specific weight, waking up early so I could become a ‘morning person’, heck, the new gluten-free diet actually cured my epilepsy! This is all very addictive before-and-after-photo stuff, but once the after photo is taken, then what? All of these new habits of mine need to be life-long strategies, but If I’m implementing them in order to get from here to there, then how do I keep going once I’ve gotten there?

It wasn’t until this last year when I was working through the challenge of quitting alcohol that I realized that I had to think differently about the problem. On January 1, 2017 on a lark, I decided to not drink alcohol for 30 days. Then in February I thought I’d extend it to the whole year. In this case I didn’t have an end goal; I wasn’t trying to become a person who never drank alcohol again, it was just a challenge for the year. The goal was the challenge. Along the way, I learned a technique psychologists call ‘surfing the urge’ to reframe the desire to have a drink from being a struggle that I needed to overcome to instead being an opportunity to grow. This surfing metaphor really worked for me. Catching a wave and riding it to the beach is pure joy, something to really look forward to. So I actually began to look forward to these waves – the moments that tested my resolve to not drink for the year. But as the year went by and I began to unwind alcohol from the events in my life, the urges subsided – there were fewer waves. I found myself looking for new challenges – a new beach with more waves. And that is when I realized that I was moving from a fixed to a growth mindset.

I can now look back at all the other habits I’ve been working on from this new perspective, forget about the end goal, and instead focus on the strategy and the challenge. It works for all of them- exercising, getting up early, eating healthy. I’m definitely enjoying the results, but those are just side effects. I am able to find real joy in the process of continually evolving these habits.

And here we are in 2018! I didn’t start drinking again because I realized that the temptations to drink are still all around me, and still kind of tempting, and that makes it a good practice to use as a reminder to stay in the growth mindset.

Let me say that again a bit differently: I have decided to continue not drinking precisely because there are going to be regular and reliable temptations to drink that I can use as triggers to stop, take a breath, and become conscious of my growth mindset. Now, not drinking is amazing and I highly recommend it; it really simplifies and amplifies life, but for me there is no goal of never drinking alcohol again, the goal is to live a life of continuous improvement and stay squarely in a growth mindset.

Getting to Growth in Digital Health

My shift from a fixed to a growth mindset was a major aha moment for me – it has opened up a whole new way of approaching my days. And while I continue to explore strategies to further cultivate this mindset for myself, I am even more curious to discover how digital health apps might leverage the growth mindset to help people wake up and stop their incessant march towards preventable chronic disease.

How to help cultivate a growth mindset – I love this problem. The potential benefit is massive. What could be better than helping even one person change their approach to life so they end up healthier and happier. How about 10 thousand people? 10 million? The products or features that can contribute are potentially limitless. It will take great design, domain expertise, awareness of exactly who the customer is, prototyping, testing, and gobs of diverse qualitative and quantitative data to experiment with ideas and build solutions. How do you know what the users current mindset is? How do you know if it is changing? How do you know if they are staying in ‘growth’ mode over time? How does all of this coordinate with the companies mission and product vision? There is gold in these mountains, we just need to figure out how to find and mine it.

I personally arrived at this gold mine by reading and learning and experimenting, but even after reading Carol Dweck’s book on mindsets, it took more than a year before I really got it, and even then, it came indirectly. My goal to quit drinking for the year ended up waking me up to this new awareness. I was not even thinking about the concept of a growth mindset in relation to health, but ‘surfing the urge’ to have a glass of wine and then going back and re-reading Dweck’s book has led to my current and expanding experience.

This indirect approach of mine to mindset change is probably part of a successful strategy for helping others to get here too. Instead of going directly there, we have to come at it from the side. It’s like racing sailboats. The rules require each boat to go around a buoy that is placed directly upwind from the starting line. But a sailboat of course can’t go directly into the wind, it has to ‘tack’ back and forth at roughly 45-degree angles away from the buoy, seemingly going in the wrong direction and way out of the way to get there. Along the way the racers have to pay very close attention to the wind shifts and current and compare progress to other boats in the race that may be employing slightly different tactics. That’s what we need to do here too.

We’re surfing, we’re mining for gold, we’re sailing… Did I mention that I love this problem?!

Let’s take as an example a theoretical patient-facing app for a real company – Virta Health. Virta’s mission is to reverse type 2 diabetes by prescribing a low carb hight fat (LCHF) diet and coaching patients to successfully achieve a metabolic state called nutritional ketosis. When keto adapted, the body learns to derive energy from fat as it’s primary fuel source, instead of glucose. This metabolism adjustment, per Virta’s published trials and research, works to reverse the disease in a high percentage of patients. But this diet is a HUGE lifestyle change for most people and my understanding is that returning to previous carb eating habits will result in the diabetes returning. So this is a permanent lifestyle change, not a painful struggle to endure for the next 6 months like that crash diet to lose 20 pounds. That makes Virta a good use case to talk about the growth mindset.

I don’t work for or with Virta and have not seen any demos of the tools they do have, but when I think about the problem they are working on I can easily imagine the role of a patient-facing digital health app. The Virta patient app would need to provide features that support clinical instruction, medication management, biometric tracking, task management, scheduling, diet tracking and messaging to enable engagement with the clinical staff between visits. That’s a lot of stuff! But these are all features that directly support the logistics of helping a diabetic patient become a not diabetic patient – very before-and-after-photo stuff – and are therefore potentially very fixed mindset promoting. I.E. if not careful, a patient app with this set of features could actually be indirectly enforcing a fixed mindset and therefore working against the sustainable change found in a growth mindset.

Using Virta as an example, how can an app be a useful tool that helps patients get to desired measurable outcomes while at the same time helping to foster a growth mindset? Well, ideas of course are cheap and easy and the real work is in prototyping and experimenting to figure out what to spend time building and continuing to improve. With that said, here are 6 principles and ideas that might work: 1. Focus on strategies and habits, not outcomes. 2 Reward efforts, not just results. 3. Use team challenges that leverage social collaboration to keep patients engaged. 4. Leverage failure for learning and motivation. 5. Avoid referencing genetic and cultural factors. 6. Publish audio interviews that highlight the strategies of successful users. I’ll explain each of these in a bit more detail below.

1: Focus on strategies and habits not outcomes.

In an app like this, there are very specific measurable goals such as blood ketone and glucose levels, BMI, blood pressure and daily carb consumption, and it is important to measure, track, and generate mindfulness of these metrics. But instead of orienting the app towards the daily tracking and progress of these numbers, the main focus of the app should be on the completion and tracking of the strategies and habits that lead to the numbers improving. Remember, the growth mindset is about embracing the strategies and effort to accomplish a goal, not focusing on the outcome. For example, a measurable goal might be eating 50 grams or less of carbs every day but a strategy to get there would be to bring lunch to work every day and making lunch for the next day before going to bed is a habit to support that strategy. As a strategy and it’s supporting habits become second nature and are no longer a daily challenge, encourage the user to move on and focus on new strategies and opportunities for continuous improvement.

2: Reward effort, not just results.

It is natural to want to put fireworks on the screen when a goal has been met to congratulate and encourage continued engagement, but instead of celebrating the goal, try to provide celebrating encouragement for the effort leading to the goal. Sticking your finger one or more times per day to measure glucose and ketone blood levels is uncomfortable. Committing to doing this and then sticking to the plan, 3 or 5, or maybe 10 days in a row, is challenging and this effort should be celebrated regardless of the outcome. The effort to measure regularly is far more important for long term success than any one outcome in the goal range.

3: Use team challenges that leverage social collaboration to keep patients engaged.

The key components of this idea are challenges and teams. I’ve written before about leveraging the power of social collaboration to keep people engaged and have often referred to my experimental StepToGive program where small teams of 10 or less work together to meet a team step count goal over a period of 4 to 10 weeks. Meeting the team goal at the end of the ‘quest’ results in a monetary contribution to a social cause the team cares about. This is an important technique in this growth mindset conversation because the outcome is a team goal, not an individual goal and winning results in a meaningful contribution to a cause much larger either the individual or the team. And the personally rewarding aspect of the challenge comes from participation more so than winning. This aligns perfectly with fixed mindset concepts of focusing on the challenge and the effort. Another relevant attribute of this step challenge is that step totals have nothing directly to do with staying in nutritional ketosis. Walking is of course always a good strategy for healthy living but it doesn’t directly contribute to the nutritional ketosis goal. It does help foster the growth mindset and it is a fun change of pace that may keep users engaged in the app, so in that way it is building a muscle that the patient can use to stay engaged in the ketogenic diet-specific strategies and habits.

4: Leverage failure for learning and motivation.

Examples of ‘failure to meet a goal’ in this scenario might be either eating well above the 50 grams of carbs allowed for the day or the team missing a weekly milestone step count goal on the way towards a 4-week total. These numbers could show up in the app in red with a sad face emoticon, or they could show up in blue and yellow with a lightbulb icon that leads to suggestions for implementing habits and tips and tricks to improve next time. And in the case of a missed weekly goal in the Step To Give challenge, this results in not earning bonus points for the week that are needed to meet the final goal. So the ‘failure’ for the week actually makes the game more challenging and fun because the additional steps now have to be made up by the team in the following weeks.

5: Avoid referencing genetic and cultural factors.

Stereotypes, family history, ethnic traditions and other persona categorizations are all powerful factors that affect our biology and behavior. But research has shown that priming or indirectly reminding someone of their identification with these types of groups unconsciously fosters fixed mindset thinking that can result in behavior and performance reflective of the expectation for the group. For example, diabetes has a genetic predisposition component, diabetes may be more prevalent in some ethnic, racial or socioeconomic groups, older people have a harder time changing their habits, certain ethnic food traditions increase the probability of obesity and diabetes, and on and on and on. Much of this may be based on valid science and there might be a logical case for introducing it in order to help patients understand and account for their risk factors, but if it is quietly reinforcing fixed mindset thinking, it isn’t helping the goal of getting to a growth mindset.

6: Publish audio interviews that highlight the strategies of successful users.

According to Kathy Sierra, if you could do only one thing to help your user succeed: “Provide repeated exposure to the performance, processes, and results of badass users”. A growth mindset is contagious, but catching it requires exposure. While advice from a clinical professional definitely helps, it can get stale before long, especially when the person giving the advice has not personally lived with and overcome the same challenge. Interviews with successful patients that highlight the strategies and failures on the path to eventual success is a very powerful mechanism to help ‘infect’ users with a growth mindset. The wild popularity of podcasts such as “The Tim Ferriss Show” that interview extraordinarily successful people in order to surface the habits and techniques that worked for them is evidence of the effectiveness of this technique. An overriding message of these podcasts is that success stems from the right strategies and consistent effort, not natural talent. This of course is at the heart of a growth mindset and the core principle of all 6 of these ideas.

And there you have it. Get out there, get your growth mindset on, and help your users do it too! And I am going to celebrate finishing this post with a nice glass of w… err… green tea!!