The Secret to Patient Compliance: An Application of The Four Tendencies Framework

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This report is a summary of a webinar presentation by Gretchen Rubin, author of The New York Times bestsellers, The Four Tendencies, Better Than Before, The Happiness Project, and Happier at Home.

Gaining an understanding of how other people think and operate can allow healthcare professionals to communicate more effectively, and, ultimately, enable patients to make good healthcare decisions. The Four Tendencies is a personality framework developed by The New York Times bestselling author Gretchen Rubin that divides people into four distinct types: Upholders, Questioners, Obligers, and Rebels. A person’s tendency shapes each aspect of her behavior, so understanding this framework can help people achieve their goals, meet deadlines, engage more effectively, and more.

This report covers the following:

  1. An overview of each of the Four Tendencies.
  2. An understanding of how these tendencies can affect behavior in a healthcare setting, particularly patient compliance.
  3. Practical tips for working with patients and colleagues that fall into different tendencies.

The Four Tendencies

One of the challenges healthcare professionals face every day is determining how to get people, including themselves, to comply with health guidance or recommendations. The Four Tendencies framework can make this task easier by revealing how each person responds to expectations. By asking this question, healthcare practitioners can gain exciting insights into how patients respond to expectations to in order to help them achieve their goals.

Everyone faces two types of expectations: outer expectations, such as a work deadline or a request from a friend; and inner expectations, such as the desire to keep a New Year’s resolution or start a meditation habit. How someone responds to the combination of outer and inner expectations determines his personality profile. When we know how others respond to expectations, we have a better understanding of how to help them be more effective.

Each of the Four Tendencies deal with expectations differently: 

  • An Upholder readily meets outer expectations but struggles to meet inner expectations. Upholders keep their New Year’s resolution without much difficulty. They want to know what people expect from them, but their expectations for themselves are just as important.
  • An Obliger meets outer expectations but struggles to meet inner expectations. This is someone who knows he would be happier if he exercised but can’t bring himself to do so regularly. He may have been an athlete in school and when he was on a team he never missed practice.
  • A Questioner investigates all expectations–both outer and inner. Questioners want to do what they think makes sense and resist anything they deem to be arbitrary or inefficient. They always want to do know why they should do something, so they make everything an inner expectation. If it meets their inner standard, they will follow through. If it fails their inner standard, they will resist.
  • A Rebel resists all expectations, outer and inner alike. They do what they want to do, in their own way, in their own time. Rebels don’t like to be told what to do and even dislike telling themselves what to do. For instance, a Rebel would not sign up for a spin class on a Saturday because he doesn’t know what he wants to do at 10:00 am on a Saturday.

Figure 1: The Four Tendencies: Source: GretchenRubin.com

The Four Tendencies and Patient Compliance

One of the challenges in healthcare is that patient behavior is the biggest factor in determining length and quality of life. Roughly 40 percent of how long and how well people live is determined by personal behaviors.  In comparison, traditional healthcare delivery has very little impact–around 10 percent. Because the Four Tendencies framework can indicate patient motivations and behaviors, it can be an effective tool to encourage healthy behaviors.

Figure 2: Behavior is the largest factor in determining length and quality of life. Source: McGinnis, Russo, et al. “The Case for More Active Policy Attention to Health Promotion.” Health Affairs, vol. 21, no. 2, 2002, pp. 78-93.  

As the healthcare industry shifts towards population health and value-based care strategies, practitioners are thinking more about preventative health than they ever have before. Once healthcare professionals have a basic understanding of the Four Tendencies, they can begin thinking about how it affects healthcare patient compliance and discover unique ways of communicating with patients.

Can we reduce healthcare costs as a result of more people adopting healthier lifestyles? Can we prevent a patient from ending up as a diabetic? This framework is extremely applicable as we think about population health strategies.

Patient Motivations and the Four Tendencies

Upholders are self-directed, so for the most part, they will faithfully follow advice to take medication, exercise, improve their diet, and be otherwise compliant.

  • They may experience “tightening” where the rules continually get tighter until they’re overwhelmed (so healthcare professionals should not exaggerate health expectations).
  • They embrace rules and schedules.
  • They can come across as rigid, cold, or judgmental because they don’t understand why other people are struggling.

Obligers require supervision, deadlines, and monitoring. Healthcare professionals should ensure that crucial systems of accountability are in place.

  • Obligers may fall into Obliger-Rebellion if overwhelmed, which can cause them to resist health-related advice, such as changing diet and exercise.
  • Obligers can often do for others what they can’t do for themselves.

Questioners put a high value on reason, research, information, and efficiency, and will meet health expectations only if convinced of the justification.

  • They will follow an “authority” only if they respect his or her expertise.
  • They often like to customize, so they may not follow instructions as prescribed.
  • They tend to enjoy monitoring their actions, which can be useful in healthcare.
  • They can drain and overwhelm others with their need for data and information.
  • They get caught in “analysis paralysis”–the desire for more and more information prevents them from making decisions.

Rebels like to do anything they want to, however, if someone asks or tells them to do something, they’re likely to resist. They can be inspired by the spirt of resistance or an appeal to their identity.

  • They don’t respond well to supervision, reminders, or directions.
  • They resist routines.
  • They often resist the demands of their own condition.
  • They can often be manipulated to act out of resistance.

Four Scenarios Applying the Four Tendencies Framework in Healthcare

This framework is an excellent tool for thinking through different ways to interact with patients based on their tendencies. Looking at some specific healthcare scenarios, different ways of communicating may be more effective in achieving better results for specific patients.

Scenario 1: How to Get A Rebel Patient to Take His Diabetes Medication?

Healthcare professionals know that medicine works–there are clinical studies to prove it. Yet, people frequently struggle to comply with their physician’s instructions. This often comes down to communicating in a way that doesn’t resonate with a specific patient. In the case of Rebels, taking their diabetes medication is a doctor’s orders. They don’t like being told what to do, so this is unlikely to work. Instead, there are a number of other communication methods that are more effective for Rebels:

Appeal to Their Identity

Rebels have a strong identity. Appealing to their identity can make taking their medication seem like their choice and thus be more effective.  For example, a doctor could say to this patient, “You’re a strong, healthy person. You want to travel the world. You’ve got a million things you want to do. This is going to get in your way. Don’t you want to continue that lifestyle?” The doctor should remind them that taking their medication will help give them the life they want.

Information, Consequences, Choice

The sequence of information, consequences, choice can work well with Rebels, especially in terms of healthcare. First, healthcare professionals should give them the information: “You have diabetes.” Next, they should provide the consequences: “If you don’t treat your diabetes, you increase your risk of many serious health problems most of which are entirely preventable if you keep your blood glucose in a healthy range.” Lastly, the professional lets them choose. “Taking this medication will help keep you healthy.” Although it may seem severe to leave the decision to the patient, caregivers should remember that pushing or reminding Rebel patients to do something ignites the spirit of resistance.

Try a Challenge

A challenge can work well with some Rebels. They can be inspired by the spirt of resistance. For example, a care manager might say, “The doctor said he likes what he’s seen, but he’s not sure if you can stick with it for a year. I’ve seen you do amazing things when you put your mind to it, so I don’t know?” If it’s in the form of challenge, it just might work.

Scenario 2: How to Get an Obliger to Improve Her Eating Habits?

Knowing someone is an Obliger is a hugely important piece of information to have, because while the Rebel might resist accountability, for the Obliger accountability is essential.

Obligers are very different from Rebels in terms of what accountability looks like. Some of these patients might even be accountable to their future selves. For example, she might say to herself, “Well, Now Gretchen doesn’t feel like doing this, but think about Future Gretchen. A year from now, she’s going to be really upset if she hasn’t stuck with her diet.” Their duty to be a role model for someone else often motivates them follow through on something they think is important. A caregiver might prod, “Sticking with this will show your family that you’ve made health a priority.”

Outer accountability is very effective for most Obligers. There are many technology solutions, apps, or groups they can join to help provide the accountability they need to stick with a healthy habit. 

Scenario 3: How to Get a Questioner Employee to Participate in a Corporate Wellness Program?

Many corporate wellness programs are designed perfectly for an Obliger. These programs generally provide outer accountability with apps and team-based competitions, but they provide little motivation for Questioners.

Once Questioners have bought into something, they usually execute well. They don’t need accountability the same way that Obligers do. They need reasons and research behind what they’re being asked to do. The best way to get a Questioner to participate in a wellness program is establish credentials of the program and show why it is the most efficient up-to-date solution. They will resist anything that seems arbitrary. For example, many programs encourage the 10,000-steps/day goal, but the Questioner might say, “Why 10,000 steps?”

The Questioner employee needs links, pamphlets, data, etc. that support the reasons behind what they’re being asked to do. And, ideally, the program will be customized for their needs. Once they have the justification and they’ve bought in, they will follow through.

Scenario 4: How to Keep an Upholder On-Track When Expectations Change?

Upholders are very good at executing goals and probably the easiest tendency to keep on track. But, their rigidity may get in the way. Healthcare professionals should not exaggerate expectations as Upholders can easily become stressed or overwhelmed. In the case of a corporate wellness program, Upholders may resist systems they feel are unnecessary measures of accountability. Their ability to fulfill expectations on their own can be great, but can also be rigid. Changes in rules or expectations can demotivate or upset them because of their strict adherence to schedule. Despite these challenges, Upholders tend to be ideal patients in terms of patience compliance.

How to Determine Someone’s Tendency

Knowing that there are more effective ways of communicating with each of the Four Tendencies, how do you know what someone’s tendency is? A more in-depth description of each personality profile is available in The Four Tendencies book, the quiz, or the one-page flash guide. There are also clues to look out for that can reveal someone’s tendency, such as when someone says that something is “arbitrary.” That is a big sign of a Questioner. Any time someone uses words like “self-care.” or “make time for myself,” that person is usually an Obliger.

Rebels will often mention things like spontaneity or doing what they want. If a patient says, “I’ve been to see three doctors and I can’t do what they say. I have to live my own life the way I see fit,” that’s the sign of a Rebel. A sign of an Upholder is not usually specific words, but the way they’re thinking about something. If they seem very enthusiastic about executing something, that’s probably an Upholder.

In healthcare, the idea that there’s a magic one-size-fits-all solution is outdated and ineffective. Instead, healthcare is becoming more personalized and targeted, and the Four Tendencies provides a framework for personalization that can lead to better outcomes.

Additional Reading

Would you like to learn more about this topic? Here are some articles we suggest:

  1. Improve Patient Engagement with Five Public Health-Inspired Principles
  2. The Top Five Recommendations for Improving the Patient Experience
  3. Unleashing Patient’s Power in Improving Health and Care
  4. How Care Management Done Right Improves Patient Satisfaction and ROI
  5. Why a Patient-centric Approach Is Best: Stories from a Physician
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