Changing Behaviour, is an Educational Pamphlet Enough?

Behaviour; a simple term we are all familiar with that we understand as the ‘actions we take’. Often we act with thought and intention but not always, at other times we act intuitively or impulsively. The well respected psychologist Dr. Daniel Kahneman started questioning this concept of rationality about 50 years ago and discovered enough to win a Nobel prize. Many social programs and public policies are founded on this concept that if you just educate the public telling them what is needed, then the rational and correct behaviour will follow. If a doctor tells a patient to exercise they will go to the gym and if the pamphlet says eat 5 fruits or vegetables/day people will consume such. If everyone could just muster up a bit more self-motivation and discipline society and the planet would be better off.

But as Dr. Kahneman’s research has shown, behaviour is complex. If behaviour was merely a rational response; we would see people eating better, exercising daily, spending within their means and conserving our natural environment. What is actually observed is that individuals repeatedly make decisions that undermine their long-term well-being (Duckworth and Milkman). In other words, we often act in ways that don’t help us in the long term. To understand this trend and investigate how technology can help society make better decisions, a project called “Behaviour Change for Good” was initiated. These founders hope to determine the best behaviour-change practices in three realms: health, education and personal finance, helping people make better decisions.

So what does this have to with physiotherapy? Well it has a lot to do with health related behaviours and if we know anything from the bio-psychosocial model of pain, your general state of health is not separate from your current physical abilities. Health matters in the context of it all: back pain, knee pain, cancer treatment side effects, chronic fatigue etc. Making better and healthier choices isn’t a simple behavioural change, it’s more complex than just listening to the advice from a clinician. Maybe self-motivation alone just isn’t enough and strategy can be useful using some of the findings from the great thinkers mentioned above.

Daniel Kahneman’s idea of **behaviour is that it is an equilibrium, a balance between 2 forces: restraining and driving**

Behaviour is a dance between influences that push for the behaviour and forces that limit. We have started to learn that incentives, threats, negative self-talk and in other words, ‘pushing the driving forces’ well isn’t actually that effective. Instead, focusing on the restraining forces and how they could be lessened has shown to be more impactful. Make the behaviour an easier option by lessening the restraining forces, here are some examples of valuable questions one could ask is in hopes to make change easier:

1) Why hasn’t the behaviour been adopted?
2) How can we change the environment to better support the change?
3) How can we make it easier to adopt this behaviour?
4) How can we add more context or meaning to how this change may better for society at large? Can you think bigger than yourself?

So what might this look like in the context of health promotion and physiotherapy? Well instead of therapists just pointing fingers at patients who didn’t exercise or follow through with rehab maybe health professionals can create more space to ask the above questions. Perhaps instead of just handing out educational pamphlets or telling patients they need to exercise, clinicians can spend the time understanding the barriers that may be present in a patient’s life.

Put yourself in the shoes of a patient with cancer whose barriers to exercise are plentiful; would an exercise pamphlet be enough? Instead, what can we do as therapists, friends and family members to make it easier for our patients and loved ones to engage in healthy behaviours? What kind of spaces can we create to start to talk about these barriers? How can the environment change to make exercise easier?

These are the kind of questions I am asking myself daily when engaging with patients, as exercise as medicine is powerful only through behaviour change for good. Some patients can see a cancer physiotherapist weekly, whiles others cannot; so we need to work together to understand how to make change as easy as possible and create good habits. What can we offer in the environment to support healthier decision making? I like to believe that socialization, fun, positivity and accountability are all environmental supports that help make exercise easier. Reach out today if you need support to form better exercise habits, you’re not alone.

Another expert in the field Charles Duhhig in “The Power of Habit” speaks to habit loops. If we want to create long term change, it’s simply about all these short term habit loops adding up on the daily. Some key tips from his read:

Cues matter: set your environment and schedule up to trigger an action that can become a habit. Routines work.
Rewards matter: always finish with a feel good reward, the brain remembers the last part of experiences the most causing us to crave the habit loop again
Beliefs matter: you have to believe the habit is valuable, and understand that intrinsically
Small habits matter: small change can lead to behaviours that snow ball into many other areas of change
Willpower can be learned: be strategic, learn your energy cycles and optimze your day for the most important things

We’re all in this together, trying to form good habits. A cancer journey can create a lot of restraining forces and symptom burden, meaning simple habits are even harder. Clinical support of your chosen support level can help, but even so be kind to yourself as a start. When you feel ready, a rehab plan can be of great help in creating good habits to optimize recovery.

As always, thank you for your interest in science and rehab

Kindly,

The Cancer Physio