(This post is downloadable as a Word doc or a PDF file).

In a paper - "Commitment contracts as a way to health" - published a little earlier this year in the British Medical Journal, the authors (Halpern, Asch & Volpp from the University of Pennysylvania "Center for Health Incentives") wrote "Much illness stems from poor health behaviours.  But changing behaviours is difficult, particularly when immediate desires must be sacrificed to achieve future benefits (O'Donaghue & Rabin, 1999), as when people try to quit smoking, eat less, or exercise more.  To overcome these challenges, corporate ventures such as http://www.stickk.com/ and http://www.healthywage.com/ are banking, quite literally, on commitment contracts, offering the millions of people who struggle to lose weight or take their medicines more regularly the opportunity to deposit money that they will receive back only if they succeed.  Grounded in behavioural economic theory (Laibson, 1997), commitment contracts bring a risk of loss into the present, where the temptations also lie, and augment motivation to succeed. They potentially offer an efficient mechanism of behaviour change because people generally are more motivated to avoid losses than they are to achieve similarly sized gains (Kahneman & Tversky, 1979).  

Although new to health promotion, the idea of making voluntary commitments that restrict future options has a rich history.  Cortes scuttled his ships to enhance his soldiers' commitments to overthrowing the Aztec empire.  Odysseus lashed himself to his ship's mast so he could hear the song of the Sirens but not be tempted to throw himself overboard.  And for more than a century, people have saved money in Christmas club accounts that provide little or no interest and charge fees to prevent early withdrawals, despite the widespread availability of penalty-free savings accounts with higher interest rates. Indeed, recent evidence shows that some people use commitment contracts to help them save money (Ashraf et al, 2006), complete homework assignments on time (Ariely & Wertenbroch, 2002), and limit their consumption of what they see as vices (Wertenbroch, 1998).  Imposing restrictions on ourselves to overcome expected future temptations may seem irrational.  But succumbing to the temptations all around us to engage in unhealthy behaviours is at least as irrational.  Commitment contracts aim to redirect the irrationality that typically makes us fail to create situations where we are more likely to succeed."

There's a considerable amount of hope riding on these kinds of approaches.  The list of research projects at the "Center for Health Incentives" is certainly impressive - "A Randomized Trial of Behavioral Economic Interventions to Reduce CVD Risk", "Developing Interactive Technologies to Improve Research and Health Behavior", "Behavioral Economic Approaches to Dietary Control", "Randomized Trial of Healthy Eating Interventions", "Can Tying Tempting Experiences with Gym Visits Increase Exercise and Improve Health?", "Attitudes on Wellness Incentives: Carrots and Sticks", "New York State Medicaid Incentives for the Prevention of Chronic Disease Demonstration Project", "Improving Diabetes Glucose Control Through Peer Counseling and Incentives", "A Randomized Trial of Interventions to Improve Warfarin Adherence", "Deposit Contracts for Weight Loss", "Helping People to Exercise Regularly" and many more.  Research funders have to be critical about where they put their money.  There's clearly a large body of informed opinion betting that commitment contracts and other linked approaches can useful when we try to respond to the tidal wave of self-defeating and illness-inducing behaviours we're all vulnerable to. 

But what's available to us now?  Well one of the first in the field was http://www.stickk.com/.  Visiting their website immediately presents you with a drop down list "I commit to ... " with the options "Lose weight", "Exercise regularly", "Quit smoking", "Race!", "Maintain weight" and "Custom goal (everything else)".  StickK was founded by a couple of Yale University professors.  On the FAQ section of the website, they comment "Is there proof that commitment contracts work?  Years of rigorous academic research conducted by the founders of stickK have proven that using Commitment Contracts can more than triple your chances of success!  And it makes sense.  We all start off wanting to achieve our goal, but most of the time there's simply nothing out there to make us stickK to our word.  By entering into a Commitment Contract, backing out on that promise just got a whole lot harder.  If drinking a can of soda meant you'd have to fork over $10 to your friend, just about anyone would look for something else to drink.  Do I really need stickK to create a Commitment Contract?  It just wouldn't be the same without us.  And here's a little social psychology to prove it:  Let's say you want to clean out your attic, and you promise to pay a friend twenty bucks if you don't.  If you aren't successful, chances are your friend won't hold you to it.  But stickK has changed all of that.  We would love to be your friend, but we would love even more to see you achieve your goals.  That's why we ask for your credit card information upfront.  Don't worry, we won't charge you unless you are unsuccessful.  But watching your friends laugh as your money disappears isn't the only way a Commitment Contract can help you achieve your goal.  We provide you with email reminders, a commitment journal to track your progress, and an entire community of support to help you work towards your goals, which is of course better than slugging it out alone.  Invite your friends to encourage you during your contract as Supporters, find expert advice, and talk to other users just like you who are out to succeed, or have already reached the finish line!  Your Commitment Contract will also have an end date.  So procrastinators beware, the ticking clock just got a little bit louder." 

Well that's fairly gung-ho!  There's lots more research crying out to be done on these kinds of behavioural interventions, however the findings so far are encouraging.  A recent New York Times article commented "The more you precommit, the better you do, according to stickK's analysis of 125,000 contracts over the past three years.  The success rate for people who don't name a referee or set financial stakes is only 29 percent, but it rises to 59 percent when there's a referee and to 71.5 percent when there's money at stake.  And when a contract includes a referee and financial stakes, the success rate is nearly 80 percent."  The UK website "Weight wins" cites research suggesting their commitment approach is more successful than other more standard weight loss methods.  The somewhat similar US site "Healthywage" has the strap line "Win money for losing weight".  "GymPact" uses commitment contracts to help people exercise with their line "GymPact helps you commit to exercise and actually do it, using cash incentives!  Our members make 90% of their committed workouts."  Sites like "21habit" spread into more general territory with their encouragement to "Make or break a habit in 21 days".  And this overlaps with the many websites using social support to boost people's success in living more healthily.  And pretty much everyone is looking to use methods like GPS tracking, smart phones, concrete written goal setting with quantities & timing, and careful monitoring of progress - with the option of making all this publicly viewable.  Example websites include "Calorie count", "FitID", "Health month", "Strava", "Mindbloom" and, of course, the many smart phone apps.  The rising tide of obesity, diabetes, addiction and chronic disease highlights the problems of quick gratification being so easily available.  Great if other modern developments - using web-based technologies - can make some contribution to help us live healthier lives.

This post on commitment contracts focuses on one good way of increasing our ability to reach the goals that matter to us.  There are a series of other points about successful goal achievement that help to build a broader context and an even greater chance of success - see the post (and handout) "Building willpower: the eight pillars" and also "Commitment contracts: orientation, practicalities and use as therapeutic tools" .