Times’ medicine: temporal discounting and future-self continuity

How we perceive the implications of an illness and potential treatments in the present compared to the future can shape our attitudes towards treatments and thus influence adherence and outcomes.

We have a tendency to choose small short-term gains over long-term larger ones, which is described as temporal discounting. The value of an item today appears to be worth more than in the future.

This tendency to make choices which bias the present, often to our long-term detriment, is particularly prominent in smokers1 and can also be applied to medical adherence. Discounting in the value of future health risks, has been found to be correlated with adherence and treatment outcomes in both diabetes2,3 and multiple sclerosis.4,5

One potential reason why we favour the present could be linked to future-self continuity, how we perceive ourselves now, in comparison to ourselves in the future. This also links to illness perception. If the person does not feel ill, the benefit is not obvious, so it is difficult for patients to even discount.

In experiments, when participants are asked to assess how similar they perceived themselves to their future self, using the sets of circles (see below) and then undertake a temporal discounting task to see how likely they were to choose delayed monetary rewards (e.g. £15 today or £50 in three months), future-self similarity (assessed by the circle task) correlate with their likelihood of choosing delayed reward. The more similar people perceive themselves as more similar to their future self the more they save.7

When shown avatars of either in their current state or looking elderly as a retired version of themselves8 and asked questions such as: How much of your current income would you like to allocate for your retirement fund? Seeing the older avatar of themselves people increase the average percentage of their income they would choose to save.8

This has strong implications as it demonstrates that making a connection with our future self can help us make better, more forward-thinking plans, and patients make treatment choices more aligned with their long-term needs.

1. Bickel W, Odum A, Madden G. Impulsivity and cigarette smoking: Delay discounting in current, never, and ex-smokers. Psychopharmacology. 1999;146 (4): 447-454.

2. Lansing A, Stanger C, Crochiere R, et al. Delay Discounting and Parental Monitoring in Adolescents with Poorly Controlled Type 1 Diabetes. Journal of Behavioral Medicine. 2017

3. Lebeau G, Consoli M, Le Bouc R, et al. Delay Discounting of Gains and Losses, Glycemic Control and Therapeutic Adherence in Type 2 Diabetes. Behavioural Processes. 016;132: 42–48.

4. Bruce J, Bruce A, Catley D, et al. Being Kind to Your Future Self: Probability Discounting of Health Decision-Making. Annals of Behavioral Medicine: A Publication of the Society of Behavioral Medicine. 2016;50 (2): 297–309.

5. Jarmolowicz D, Reed D, Bruce A, et al. Using EP50 to Forecast Treatment Adherence in Individuals with Multiple Sclerosis. Behavioural Processes. 2016;132: 94–99.

6. Hershfield H, Wimmer G, Knutson B. Saving for the future self: Neural measures of future self-continuity predict temporal discounting. Soc Cogn Affect Neurosci. 2009;4 (1): 85-92.

7. Hershfield H, Garton M, Ballard K, et al. Don’t stop thinking about tomorrow: Individual differences in future self-continuity account for saving. Judgment and Decision Making. 2009;4(4): 280–286

8. Hershfield H, Goldstein D, Sharpe F, et al. Increasing Saving Behavior Through Age-Progressed Renderings of the Future Self. Journal of Marketing Research. 2011;48: S23–S37

Informed Consent – How much is too much?

Can too much information be harmful to your health? Informed consent is at the heart of many ongoing debates that seek to answer this question.

Informed consent refers to the permission granted in full knowledge of the possible consequences. Typically, it relates to that which is given by a patient to a doctor for treatment with knowledge of the possible risks and benefits. However, informed consent is a process that occurs both within healthcare and any research involving human studies.

There are many limitations and issues surrounding the process of informed consent that bring in to question its validity. One area that we at Spoonful of Sugar regularly consider within our work is the information that is given to patients around treatment side effects.

The informed consent process has the potential to increase patients experience of side effects purely by the mentioning of them as providing extensive information regarding adverse effects can generate nocebo responses; when the expectation of treatment side effects leads to those symptoms being realised. Extensive research has shown that including specific side effects within a consent form increases the incidence of the reporting of these symptoms. The variability in an individual’s risk perception in relation to side effects adds complexity to the issue.

Over the years researchers have investigated methods for minimising these nocebo responses whilst still maintaining patient autonomy, these are approaches SoS considers when designing patient support. One approach that has been suggested is contextualised consent which proposes a tailored approach to the information given, it considers adverse effects of a particular medication, the patient themselves and the illness concerned. Another method looks at how the information is presented, studies have shown that positive framing and personalising information helped patients to develop more functional treatment expectations and prevented expectation induced nocebo effects. These two techniques; framing and tailoring could go a long way to providing an effective informed consent procedure.

As of yet no consensus has been reached on the best way to approach the complex topic of informed consent and so continues the debate of ‘how much information really is too much?’


Lost in Translation – understanding cultural and linguistic differences for successful adherence programmes

We love the movie ‘Lost in Translation’ with Bill Murray, it really captures how things can go wrong and easily be misunderstood with differences in culture and language.

Running adherence programmes internationally requires a deep understanding of the role of culture and language. Cultural and language differences have a direct impact on how successful an adherence program will be. It is hard to be aware of every single aspect of each country’s culture from afar. That’s why we really do take this factor into account and have an international team in place to create effective programs efficiently.

It is good to remind ourselves that in life, communication is key to success. Being aware of cultural backgrounds is key to the adoption and use of programmes. Direct translation rarely effectively translates all intended meaning. This is also why we conduct research, because customer needs and demands, decision making, and social role views all varies by culture, and to understand the exact words and meaning ascribed to those words in the language and context the program will be

We have yet to find a better way than using people who are native speakers of the language, have been immersed in the culture and are trained in the underpinning psychological constructs.