Engineering Rehab Like A Resolution
A trip to the mall when I was in grade school was my first introduction to aerodynamics. Most youngsters learned about drag and wind flow the way I did, by sticking your hand out the window and holding it at just the right angle. Within seconds you find the sweet spot and your hand rides the wind like a wave. It was as effortless as it was elegant. Although I didn’t understand the variables at play and the meaning of efficiency I felt the end result. You can picture it: When I positioned my hand like a sail, the wind caught it – instant drag – and snap, my arm goes flying back. Now a few years later, maybe many years later, to the present day – I find myself working in the field of brain injury rehabilitation. There are many areas of this most complex of fields that need efficiency. With limited funds, even more so with the recent legislative changes, our clients need to get the biggest bang for the buck. Advances in technology allow us all to optimize all the paperwork that is associated with providing treatment. I have often read and repeated the phrase myself, ‘you can’t use a cookie cutter approach to the delivery of treatment.’ I’m not so sure anymore as there are some commonalities to all behaviours and behaviour change. We can use these common threads to improve rehab.
Brain injury rehabilitation is complicated; a field of care filled with many disciplines. When a person sustains a brain injury the course of rehab can take multiple routes, some of them concurrent. Barbara Wilson, a clinical neuropsychologist from Cambridge summarized the paths rehab can take to include: restoring lost functioning, using residual skills more efficiently, finding alternative means to the final goal and modifying the environment. The interventions and combinations between trying to restore functioning and compensating for the loss will change to suit the needs of the person going through rehab. Goals will change and life transitions will occur. Despite all the variations there is a constant companion – the effort required to move forward. To learn how to walk again, to talk again and to write again (to name but a few) are all cognitively demanding and emotionally draining. Hundreds if not thousands of hours may be required to restore function or learning how to use alternative means. Can we make the countless hours of therapy more efficient? Yes we can! Recent research about self-control, willpower and resolutions provides us unique opportunity to optimize rehab from within.
A quick look at the willpower literature gives us a fascinating framework to enhance rehab. Several weeks have passed since the annual ritual to change for the better on the first day of the year. Millions of people have such great intentions; goals are set and resolutions made. The statistics are dismal when you look at the success rates. A third will have broken their resolutions by the end of January, and a half will have lapsed by the end of July. A disconnect exists between those great intentions and the strategies used to attain them.
What’s most important to consider is that we have limited willpower. According to Roy F. Baumeister, Professor of Psychology and author of the New York Times bestseller Willpower: Rediscovering the Greatest Human Strength, willpower is like a muscle. When Baumeister conducted research he found that after people were asked to exert self-control for one task they would do worse on the second task. What happened in between the tasks? Some kind of resource decreased – and it’s called willpower. These results have been repeated in his lab and many others. The principle aspect of willpower that Baumeister emphasized is that we each have one stock of it. Regardless of the task, your willpower will be depleted if you need to exert self-control. You exercise self-control across a number of conditions; when you are trying to change a behavior, when you are learning something new and when cognitive load is increased.
Bridging the science to the practical and the lab to the field there are strategies we can use to optimize the rehabilitation process.
Baumeister’s findings show that literally making choices depletes willpower. The more decisions you make, the more cognitive load one takes on – the worse the decision-making becomes. We can limit the number of decisions we each make to save willpower for the important stuff. This is particularly important for people whose rehab is so intense that it literally requires a taxing of their willpower all day. In a Time magazine interview Baumeister commented on a novel application of limiting one’s decision-making to conserve willpower. President Obama only wears blue or grey suits which eliminates his need to decide what to wear. Baumeister applauded the President’s use of this strategy, “if you don’t have think about what to wear every day, you don’t have to deplete your self-control on that.” For some people going through rehab you can eliminate decision-making by changing how they dress, for others simplifying the breakfast routine will do the trick, while yet for another group entirely the solution that presents itself will have never occurred to anyone. As each person is unique, as will be their rehab – the creativity required in the application of these strategies must be as imaginative as the brain injury field is complex.
When people take on New Year’s resolutions they complicate the matter by trying to make multiple resolutions at once. Each time one resolution is afforded effort, in other words willpower, people take away their ability to work on the other goals. There is only so much willpower to go around. There are a couple of solutions. Working on the goals in sequence, starting with the easiest one proves to be more successful. Goals can be broken down into a hierarchy, with easier and smaller steps to start out with. Setting goals in this manner taxes willpower in an optimal way. A therapy technique called graded exposure when provided for a fear of driving, for example, is most often structured this way. Small incremental steps, with each successive goal (i.e. watching cars, then being a passenger driving slowly, then faster – all the way to actually driving) being small enough yet hard enough to be successful.
A wonderful thing happens when we move from starting a new behavior to when it becomes habit. As far back as 1887, William James wrote about the benefits of creating habits, “Any sequence of mental action which has been frequently repeated tends to perpetuate itself”. When new behaviors shift to established habits the cognitive load diminishes. We can spend our willpower on what’s most critical by transforming our activities of daily (at least some of them) to such a degree that they require as little cognitive load as possible. My favourite example of a habit is putting on a seatbelt. I sit in my truck and my hand automatically reaches for the seatbelt, without fail. Most importantly, it’s effortless – I don’t even think about. Our force of will always takes a back seat to good habits and we should take advantage of that.
Rehab is hard. It is hard work; a daily grind. With limited willpower and too often fewer resources to start with it, it behooves us to design the rehabilitation process to maximize the time, energy and willpower our clients have. Rehab can never be effortless but it can be elegant and efficient.
Originally published in Neuroconnect magazine
Baumeister, Roy F., and John Tierney. Willpower: Rediscovering the greatest human strength. Penguin. com, 2011.
James, W. (1890). Habit. H. Holt and Company.
Szalavitz, M. (2014). Willpower Expert Roy Baumeister on Staying in Control Retrieved from http://healthland.time.com/2013/01/14/qa-willpower-expert-roy-baumeister-on-staying-in-control/
Wilson, B. A. (2002). Towards a comprehensive model of cognitive rehabilitation. Neuropsychological Rehabilitation, 12(2), 97-110.