Other apps make use of punishment, a technique that Skinner did not approve of but that can be smartly incorporated into an otherwise Skinnerian program. GymPact, an iPhone app, asks users to commit to visiting a gym a certain number of times each week and agree to forfeit at least $5 each time they skip. The app confirms users’ presence at their gym via GPS and charges their credit card if they don’t show up as planned. The company then divvies up the skip fees among those who honor their weekly commitments—so you get reinforced for going, and punished for not going.
So far, the scientific literature is proving these programs effective. When the University of Vermont’s Harvey-Berino studied the effectiveness of online Skinnerian weight-loss support groups, for example, she found that the results in pounds lost were comparable to results achieved by in-person groups. She’s now conducting a larger study with $3.5 million in funding from the National Institutes of Health, which, along with the Centers for Disease Control and Prevention, has increasingly thrown its support behind behavioral approaches to obesity. (Michelle Obama’s “Let’s Move” campaign is essentially Skinnerian, seeking to change children’s environments in ways that encourage them to make small changes in what they eat and how much they exercise; the program is even sponsoring the development of diet-and-exercise apps.)
Abby King, a leading health-related behavior-change researcher at Stanford University, has studied smartphone apps that aim to get older, non-technology-savvy people to move more throughout the day. The study subjects, most of whom had never used a smartphone before, significantly increased their activity. “If it works on them, it will work on anyone,” says King. “Skinner was right-on, in terms of any sentient being from pigeons to humans responding to setting goals, tracking progress, and getting feedback. These tools can provide all that, and can reach into any population to do it.”
Looking forward, improvements in the technology powering these apps should sharpen their impact. “This line of research is beginning to blossom,” says the University of South Carolina’s Blair, who recently helped the school land $6 million in funding for a new center studying technology-driven weight loss and related behavioral changes. “Right now we can get 30 percent of people to change their behavior, which is huge, but we’ll learn to get 40 percent, and then maybe 50 percent.”
One turning point will come when smartphone apps can automatically tailor their recommendations and feedback to an individual user’s behavior, just as a real-life behavior analyst would. In a review study for the International Journal of Obesity, Hirohito Sone, a researcher at the University of Tsukuba, in Japan, concluded that while weight-loss programs that include online tools are already more effective than conventional programs, individualization of these tools will take them much further. Details that these programs may eventually take into account, he says, include “lifestyle and environmental factors like types of job, whom you live with, how busy you are, what ethnic group you belong to, and what kind of activity or type of food and drinks you like.”
That may sound like a tall order for a smartphone app, but software and hardware improve substantially almost month to month. Michael Cameron is investigating developing “smart algorithms” that would take care of much of what he now does in the process of helping people lose weight. “The software will pick up the behavior patterns,” he says. “You might still need someone to have an occasional conversation with the client about the patterns, but as soon as you start automating and guiding decision-making, the need for a person like me becomes much more manageable.”
Cameron helped my brother Dan notice, for example, that he tended to take the longest walks when he set out after dinner, with a family member, and recommended making that a daily routine. A smartphone, by using GPS to track when Dan walked and a family-and-friend-tracking app to note whom he was with, could easily have done the same. Eventually, Cameron says, phones will be able to track swallowing and stomach distension to provide even better analysis of eating habits, without requiring the user to so much as tap the screen.
Dozens of research centers and hundreds of millions of dollars in investment in mobile-health technology have made such capabilities imminent possibilities. “It’s all about finding ways to automate Skinnerian conditioned reinforcement,” says Stephen Intille, a researcher at Northeastern University’s new doctoral program in “personal health informatics.” “You put sensors in phones and throughout the home, you develop algorithms that can infer what people are doing, and then you provide tailored automatic feedback that reinforces the right behaviors.”
The mobile-health field—“mHealth” to those in the know—is a rapidly growing subset of the tech-heavy, preventive approach to health care that was a foundation of the Obama administration’s reform bill. Health-insurance companies and government officials alike are drawn to the ability of smartphone apps to reach tough-to-access patients, to effect long-term lifestyle changes, and to do it all at a very low cost. Weight loss is just one example. Today, an iPhone owner can also download Skinnerian apps to help her stick to her birth-control schedule, monitor her blood sugar, quit smoking, or get more sleep. Mobile health’s potential savings to the health-care system are enormous. A 2010 study by one research firm reckoned that the savings in the United States and Canada from mobile monitoring of patient health could climb to as much as $6 billion a year by 2014. If mobile apps could reduce obesity and its associated costs by just 5 percent, the savings would amount to about $15 billion a year in the U.S. alone. The effect on eldercare would be even larger; a Boston Consulting Group report from earlier this year projects a possible cost reduction of 25 percent, which by one study’s figures would amount to about $30 billion.
This potential has made investment in this technology a no-brainer for health insurers and corporations. Blue Cross and Blue Shield of North Carolina, like many large insurers, offers its members Web-based weight-management and exercise-promoting tools, and is looking into providing mobile apps. “We’re very excited about the potential of these tools,” says Dr. Don Bradley, the company’s chief medical officer. “Up to 70 percent of health-care costs are related to lifestyle. If we can’t control those costs, we can’t keep our products affordable.”
And the outsized effect of simple Skinnerian tools has not been limited to health. Any number of apps allow users to kick other bad habits or cement good ones. Urge, a two-year-old “mobile behavior change company” based in Nashville, offers an app that prompts users to hold off on impulse purchases so they can hit budgeting goals, and reinforces their frugal decisions by tracking money saved for the purchase of a coveted item. Apps such as Habit Maker, Habit Breaker let users choose the behavior they’d like to target, whether it’s saying “thank you” more or going shopping less.
In Silicon Valley and the Bay Area, start-ups hawking these apps are becoming so common that you can’t avoid bumping into their founders. At Palo Alto’s storied University Coffee Cafe, I recently found myself sitting next to a young fellow named Yoav Lurie, who turned out to be running a Boulder-based company called Simple Energy, which uses Facebook as a social-reinforcement tool for conserving energy by tracking, sharing, and reinforcing certain behaviors. The product, like many of its competitors in the booming field of energy-related apps, is sponsored by large utility companies incentivized to reduce their reliance on conventional power sources.
Government agencies are in a similar position to benefit. I was speaking with a manager at the U.S. Department of Transportation about public transit when he mentioned that the agency is testing an app that provides local travelers with various transportation options for specific trips and that could gently reinforce decisions to use public transit by pointing out the extra calories commuters would burn by walking to the station and the carbon they’d avoid emitting by leaving their cars at home.
Of course, none of these tools would have much of a future if the public continued to harbor the kind of Big Brother paranoia that smeared Skinner’s reputation. Should we be wary of utilities that try to shift our energy use or health insurers that try to change our diets? Skinner would have celebrated these efforts, for their capacity to change society on a grand scale. But at what point does the interest of the individual diverge from the interest of corporations or the government—and will we even notice, if we’ve already surrendered all our choices to our iPhones?
The central irony of Skinner’s theory is that to control our behavior, we must accept a fundamental lack of control, acknowledging that our environment ultimately holds the reins. But an individual choosing to alter his environment to affect his behavior is one thing; a corporation or a government altering an individual’s environment to affect his behavior is another. The line between the two scenarios can blur. Nowadays most of us aren’t likely to wonder about the DOT’s motives when it urges us to take the light-rail instead of a cab. If it benefits the commuter, the government, and the environment, then what’s the problem? But the very definition of the Skinner box is that the inhabitant is not in control. In fact, he may not even know he’s in the box.
Julie Vargas, who lives with her husband in the house she grew up in, a few miles from Harvard, showed me her father’s study, which she has left untouched. It turned out to be the crowded basement sanctum of an inveterate tinkerer and gadget guy. Lacking WiFi and Bluetooth in his office, Skinner had jury-rigged strings and all sorts of wooden and cardboard doodads that enabled him to tweak his environment from his desk chair: by hiding the face of a clock he found himself watching, or by turning on a tape recorder that inspired him to organize his thoughts.
Though more advanced in execution, today’s electronic nudges and tweaks are identical in purpose: use what you can control to affect what you can’t. The simple elegance of this concept flips on its head Chomsky’s suggestion that behavior modification treats people as if they were no more intelligent than animals. What distinguishes our intellect from animals’ is not that we can go against our environment—most of us can’t, not in the long run—but rather that we can purposefully alter our environment to shape our behavior in ways we choose.