The power to make change - how does it work?
On reviewing a client recently, I was struck by the difficulty of changing a habit, even when they knew it meant they would be better off, in this case experiencing less pain. On reflection, a lot of long-term outcomes revolve around our ability to affect +ve changes in our clients' lives.
From my clinical perspective, the question was "Why would someone knowingly choose an action that causes them pain?" We could take smoking as a litmus test for this question. Smoking is strongly associated with every nasty health condition, the action is considered socially inappropriate, millions of $ are spent on education and each durry costs a small fortune. So you would think stopping would be a piece of cake. Smoking cessation has been extensively studied and on average it takes 6-30 attempts before a person successfully becomes a freshairian and kicks the habit for 12 months. So not that easy changing even a deadly habit!
This challenge of changing habits is one that I have come to experience consistently and thought I would share it through the filter of something I am passionate about. Since I completed my PhD examining the relationship between sleep posture and waking spinal pain, I now look forward to seeing clients who present with regular morning symptoms. Because I live in Esperance, a coastal holiday town, we have a lot of visitors who have seen a number of other therapists as they travel around Oz and have come to accept their current morning pain profile to be 'their lot'.
However, I have developed a program that changes their perception radically, literally overnight and gives them new hope. The interesting thing, is I have also observed that often after a honeymoon period of no pain and gasps of "Why didn't someone tell me this before", their old sleep routine resurfaces and their symptoms return. This brings us back to my original question, "Why knowingly would someone choose an option that causes them pain?" I emphasise here the 'knowingly' because before seeing me they didn't understand WHY they were experiencing morning pain/stiffness and poor quality sleep. After an education session, they knew why and they changed their behaviour, yet they later resumed their old sleep routine and yes, their pain also returned.
To better understand this, we need to look at the six stages of "habitology" - the study of habits :)
Education. This is when the client comes to us with a problem and we, through assessment and clinical reasoning deduce that their sleeping routine is contributing to their ongoing/repeated/flares of spinal pain. We explain the concepts of tissue loading, provide clinical examples, use education with oral, visual, and tactile cues and take them on a learning journey from current pain, to future pain-free status.
Contemplation. At this point in their journey, our client weighs the pros and cons of making a change. Remember we do not change until we are ready to change. Given they have come to us seeking assistance, they are likely ready to consider a change. Credit to Einstein for observing that to expect change without making a change equates to insanity. Armed with the new knowledge we have provided, linking their current sleep routine with pain, they have a concrete choice to make and a proposed outcome to experience. Will they do it?
In my experience the vast majority jump at the opportunity, because they have been experiencing ongoing symptoms for years, and they are tired of the Band-Aid solutions provided so far, it makes logical sense to them and we have empowered them to be responsible for their health.
Preparation. Here is when we line up their ducks, and they decide they are ready and willing to make the outlined change. This may require some props (e.g., a side sleeper pillow), but generally, I find clear education, physically showing them the ideal supportive sleep postures and a short 'fun' memory test, is all that is required to get them moving forward.
Action. Kind of speaks for itself. Here they put their new learning into practice and enjoy the benefits. This stage is interesting in that they often comment at the follow-up appointment how they initially experienced very restless nights, often thinking of me as they changed sleep posture (creepy). This worried me in the early phases of this program because poor sleep quality (i.e., fragmented sleep) is a poor outcome measure for health and well-being. However, after digging deeper, they stated they had way fewer morning symptoms. Yes! This is important because this was the reason they had first made their appointment.
Maintenance. Here it gets interesting. We are now talking about the long term, the goal, the flag at the end of the fairway. My experience here is a bit like the smoking cessation example. People fall back into habits of provocative sleep postures and I now make it part of my early education program to inform them of this. "It might sound weird, but I have a crystal ball and my crystal ball tells me in the next few days, you are going to experience an amazing reduction in your morning pain/stiffness. Pause. And it also tells me in the first few months of having great nights of sleep, blissful pain-free wakings, you are going to wake one morning and your old pain will have returned". Melodramatic sigh. This leads to the final stage...
Relapse. I can think of at least a couple of factors here to consider. One is based on our research. Even when people were educated, changed their sleep posture and woke with significantly fewer symptoms, they still spent a portion of the night in provocative sleep postures. So, they didn't have a perfectly 'pure' sleep posture routine. This makes sense. We don't have ideal posture throughout the day, but most of us manage just fine. I think it worth noting, that age, fitness, genetical factors (e.g. hypermobility) and support play a role at night just as they do during the day. A topic for another time.
Secondly, as noted above with smoking, it takes many times to knock out a habit. Setbacks happen (e.g., kids sleep in the bedroom, travelling and different beds, sickness, returning to old familiar habits) and clients must decide to reinstitute the sleeping postures they know work and reduce their pain or continue with the pain-provocative sleep habit.