All of us who work in healthcare know that motivation is the key driver of behavioural change. In fact, regardless of the discipline in which you work, motivation is key. Sometimes our experience of supporting someone to connect with their motivation can be a little like chasing a rainbow – just as we think we’re reaching it, it’s moved!

Most health practitioners have an understanding of the differences between intrinsic and extrinsic motivation – it’s a simple but useful distinction. In what follows, I want to nuance that more for you and show how different types of motivation can be identified in our patients and clients.

Let’s start where our patients often do – external regulation. This leads to motivation that’s determined by a reward. Working extra hours for bonus pay is a common example. Often, the patients I see have been using external regulation with food to reward their perceived good behavior. They might go to the gym seven days in a row and then reward themselves with ice cream or a chocolate bar. The important thing to understand about external regulation is that it works! Until you remove the reward. Then the entire motivation for doing something has gone. If your patient is externally motivated, don’t discourage them immediately from this, but do explore with them other sources of motivation.

Introjected Regulation is that nagging inner voice – often guilt or shame – that drives a particular behavior. It’s another example of the broad category of extrinsic motivation but it’s the opposite end of the spectrum from rewards. People act to avoid a penalty or negative consequence rather than because they receive a reward. Patients can develop this type of motivation inadvertently from our efforts to warn them of the consequences of their behaviour. When we point out the health impacts from smoking, or being overweight, or doing no exercise, this can be introjected into “I need to stop smoking or else I’ll get cancer” or “If I don’t watch my diet this week, the doctor will be angry with me next week”. Again, this type of motivation can lead to some behavior change but as soon as the perceived negative seems far enough away or doesn’t have significance anymore, the motivation to behave differently goes away with it.

When we do something because we intellectually understand its benefit but don’t derive any reward from doing it (or avoid any negative outcome for not doing it), we’re being motivated by Identified Regulation. If you conscientiously eat more vegetables because you known it’s good for your health but don’t really enjoy (or dislike) it, then you’re being motivated in this way. Once again, it’s important to recognize that people can and do make behavioural changes as a result of this type of regulation, but if they lose sight of the benefit, or if the cost of the benefit begins to feel too high, they’ll tend to lose the impetus for behavioural change.

Integrated regulation is evident when we see people undertaking particular behaviours after careful reflection on the behavior and careful reflection on their own value and belief system. Enjoyment of the behavior and/or avoidance of a negative consequence don’t figure in this type of motivation. An example may be someone who chooses not to consume animal food products because doing this is inconsistent with their values and their belief system. Importantly, they’re not likely to experience guilt or shame (see Introjected Regulation above) if they don’t follow this behavior – but they do it because it “feels right for me”. It’s the most “intrinsic” of the external motivations but it still has an externalized dimension to it. Can it lead to behaviour change? Absolutely. In fact, both Identified and Integrated Regulation can be “kick-starters” of behavioural change. But what’s most likely to lead to long term sustained change?

Intrinsic Motivation involves undertaking something simply for the joy and satisfaction of doing it. It dovetails nicely with Mihaly Csikszentmihalyi’s theory of Flow from the field of positive psychology. Think about a time when you are fully engaged in something and doing it simply for the satisfaction it brings you in that moment and when you reflect on it. That’s Intrinsic Motivation at work. It appears when what we do aligns with a sense of meaning and purpose for us; when we do something because it’s so strongly aligned with what really matters to us in life. And it’s a robust predictor of sustained behaviour change.