Just over one month ago (although it seems much longer), my family had a bit of a shock. My son, nearly 18 years old, went to the doctor to check on a sore throat that wouldn’t go away…and left the hospital two days later with a diagnosis of Type 1 Diabetes. He had lost over 15 pounds (which he did not have to spare), and checked in at just over 100 pounds; yes, he had lost 13% of his body weight, mostly due to dehydration. Normal Blood Glucose (BG) levels are in the neighborhood of 70-100 mg/dl; my son maxed out the doctor’s BG monitor at 600. He was checked in for an overnight stay at the hospital, got lots of saline solution in an intravenous drip, learned how to test his own BG levels and inject himself with insulin. It was only the beginning of a routine he will have to follow for the rest of his life, barring technological advances.
Actually, technological advances are progressing at a fast and furious pace. The insulin he is injecting (two types, a slow, long-lasting one and a quick-working, briefer sort) were invented less than a decade ago, and are a tremendous improvement over what was available when my son was born. An insulin inhaler has recently been approved (although it would not replace all of his injections), and there are insulin pumps that can deliver insulin more-or-less constantly for a period of days. The plus side is, he would not have to inject himself nearly as often; the down side is that he would be wearing a device constantly. Of course, these days we all wear cell phones attached to our hips anyway…
I am not complaining, and to his credit, neither is my son. I can think of a thousand worse things to have happened—including the same diagnosis a century ago. Indeed, there is actually quite a lot to be grateful for in this diagnosis. It may actually increase my lifespan.
Let me explain. As I write this, I am sitting on a couch, arranged in a comfortable viewing distance from a television. It would be so simple, as it often is in our modern society, for me to spend a great deal of time on this couch, watching that television. It would certainly be simpler than heading outside for a walk…or even… a run. It is much easier, much more reinforcing (in the short run), to eat pie, than to go on a bike ride. Exercise is self-punishing. Eating is (often) self-reinforcing. I know I would probably live longer if I got in the habit of walking, biking, or otherwise exercising instead of sitting on the couch…but dammit, it is just not something that is easily shaped by the immediate contingencies.
But…my son’s diabetes changes the timeline. The things that are in my long-term best interest are in his short-term best interest. Put more scarily, the foods that could kill me sooner in the long run could kill him sooner in the short run. Exercise, self-monitoring of health, and a “Mediterranean diet”, are all things that would help me to live a longer, healthier life; they are also things that help my son simply live. Our whole family is cutting down on fats, watching carbs, losing weight, and increasing exercise. (In truth, we ate a healthier-than-average diet before this, but there is always room for improvement.)
Advances in medicine will, I hope, mean that my son’s diagnosis has absolutely no effect on his lifespan. Understanding diabetes will, though, probably mean an additional few years for me.
The science behind it…
It may seem strange to hear that Behaviorism, that stronghold of determinism, has a line of research on choice, and a more specific line of research on self-control. We define these terms a bit differently than others might, though… A choice is any situation in which more than one response is possible. Yeah, that’s pretty much all of them. Note, we do not look at “choice” as something that you do, but rather something in your environment that you respond to. What is important is the effect of various conditions in the environment that dictate your response—will you do A or B? What are the characteristics of A and B that determine your behavior?
In a self-control paradigm, the person (or rat, or pigeon, or whatever) is presented with a choice between two alternatives, a smaller, sooner reward (SSR) and a larger, later reward (LLR). Choosing the SSR is termed “impulsive”; choosing the LLR is “self-controlled”. This experiment can be run with pigeons, using access to grain (2 seconds access now, or 4 seconds access three seconds later), or on people, using money (ten dollars now, or twenty next week). In each case, many variations on the theme are easily set up; we can vary the size of each reward, the length of delay before the larger reward, the difference in size of the two rewards, the time between when the decision is made and when the reward will be available.
It turns out that this last one is a very important variable. While it might be tempting to choose ten dollars now instead of twenty next month if the ten-dollar bill is sitting right in front of you, it is much easier to choose the larger reward if the choice is between ten dollars in three months or twenty in four months. A little perspective makes all the difference. Interestingly, pigeons make the same choice: while they will choose the SSR if there is no delay between their choice and the presentation of the reward, if there is an 18 second delay between their choice and the sooner of the two rewards, they will choose the LLR (in both choices, the mechanism re-sets after 30 seconds, so choosing the SSR does not allow more runs through the process). Self-control is not so much a human characteristic as it is a function of the schedule of reinforcement…
What is more, if we give pigeons the ability to make a choice now (called a controlling choice) about which choice they will get to make later—that is, they can peck a button now to determine whether they will get the 18-second delay choice or the immediate choice—they learn to choose the delayed choice, and to maximize their reward. It is the pigeon equivalent of parking your car a mile from your office in the morning, when you have energy, so that after work when you are tired enough that a walk (which is in your long-term best interest) is not as appealing as just crawling into your car (very appealing in the short term), you have no choice—the car is a mile away. (One of my students—a retired engineer—did this last summer; he significantly increased his exercise, and lost 11 pounds over the course of the summer!)
Another key variable is the length of time between the sooner and later outcomes. The more distant the later outcome, the less influence it will have over our behavior. This should come as no surprise—we know that both reinforcement and punishment work better the more immediate they are. Reinforcement works via meliorization, not optimization—that is, it is driven by what is better in the short term, not what is ideal in the long run. (So is evolution, for that matter, which is why we suffer with bad backs and impacted wisdom teeth.) There is no guarantee that what is in one’s best long-term interest will be reflected in the short-term contingencies. A big part of “self-control” is making the controlling choices to make the long-term contingencies much more apparent in the controlled choices.
And of course, this is what is happening to our family, thanks to my son’s diabetes diagnosis. The long-term punishing consequences are no longer long-term. The same things that could take time off my life some decades into the future could put my son into the hospital (or worse) in very little time. The contingencies are not delayed, but are immediate. The controlling choice has been made for us. What remains is fairly simple. We pretty much have to take the path that leads to a longer, healthier life.
Like I said, we are not complaining.