Habits and Heuristics in Rehabilitation: Rethinking Behaviour’s Role
Rehabilitation following brain injury typically emphasizes observable actions: a patient’s use of a memory aid, adherence to an exercise regimen, or ability to structure their daily routine. When these actions are inconsistent, clinicians may respond by increasing reminders, applying reinforcement strategies, or enhancing motivational support. However, this approach, which prioritizes behaviour in isolation, may not entirely capture the underlying mechanisms determining whether an action persists, fades, or fails to emerge. Sustainable progress may benefit from a broader framework that clinicians should consider integrating with habits and heuristics alongside behaviour—because if we only chase behaviour, we’re always playing catch-up.
To provide clarity, three central terms should be defined. Behaviour refers to an individual’s observable actions, such as using a cane or completing a prescribed task. Habits are behaviours that become automatic through repetition, requiring little conscious effort—examples include locking the door before leaving or putting your seatbelt on. Heuristics is the process by which humans use mental shortcuts to make decisions. Humans, animals, organizations, and machines use heuristics to quickly form judgments, make decisions, and solve complex problems. These concepts—behaviour, habits, and heuristics—are interconnected, and exploring their roles in brain injury rehabilitation may offer insights into improving patient outcomes.
Heuristics: How Cognitive Shortcuts Shape Decisions
Clinical practice assumes that clinicians’ and patients’ decisions are based on deliberate reasoning. However, both frequently rely on heuristics, mental strategies that simplify decision-making under complexity or time constraints. While these shortcuts can be practical, they may lead to errors when applied in contexts where they do not fit, a consideration relevant to rehabilitation.
Dan Ariely’s experience as a burn unit patient provides a clear example. After sustaining burns across 70% of his body, Ariely underwent years of treatment, including daily bandage removal—a process marked by significant pain. The nursing staff had to decide between removing bandages quickly, causing a short but intense pain, or removing them gradually, resulting in a longer but less severe discomfort. They chose rapid removal, guided by the belief that a shorter duration would minimize suffering. This choice reflected an intuitive assumption that reducing time in pain was the priority, a view that appeared reasonable in their caregiving context.
As a behavioural researcher, Ariely later studied pain perception and found that patients experienced less overall distress with slower, less intense removal despite the longer duration. Though made with good intent, the nurses’ decision rested on a heuristic— “shorter duration is better”—that did not match the patient experience. This highlights how cognitive shortcuts can guide actions without supporting evidence. In rehabilitation, similar reliance on heuristics may occur. For instance, a person might resist vocational retraining after losing a professional role due to brain injury, perceiving it as a loss of identity rather than a path to adaptation—an inclination that reflects not defiance but a natural response to change.
Loss Aversion: Resistance as a Natural Response
Loss aversion, a well-documented heuristic, may significantly influence rehabilitation. Research in behavioural economics defines loss aversion as the tendency to prioritize avoiding losses over acquiring equivalent gains. This bias can affect how patients respond to change, perhaps appearing reluctant to adopt adaptive strategies, even when they could improve function.
Consider a person who experienced a stroke and offered a walker to enhance mobility and safety. They may decline, not because they question its benefit, but because it signifies a loss of independence or pre-injury identity. Similarly, a person with memory challenges might avoid a planner, though it could ease daily stress, as documenting tasks may feel like an admission of impairment. In another case, a person may resist using a planner for months. Then, they adopted a change, starting with a single daily task, within six weeks and noted reduced frustration, though the initial barrier was substantial. These reactions may sometimes be viewed as a lack of cooperation but reflect a natural response to perceived loss. Patients may eventually reach a place of acceptance, but the process takes time and varies for each person. The role of rehab isn’t just to prescribe exercises—it’s to help people navigate the mental barriers that make change feel overwhelming. Rehabilitation might address this by framing tools as gains—such as a walker enabling activity or a planner offering control—and introducing them gradually to lessen the sense of loss, supporting acceptance over time.
Habits: Temporary Measures Versus Lasting Routines
Not all behaviours in rehabilitation share the same purpose. Some target short-term recovery, while others must become permanent adaptations. This distinction, outlined in BJ Fogg’s Behaviour Grid, may guide effective intervention, though it is often overlooked. Fogg, a behaviour scientist, developed the Grid to categorize behaviours based on their intended duration and purpose, suggesting a way to separate temporary actions from those meant to endure. In the context of brain injury rehabilitation, this framework may help clinicians determine which behaviours should remain deliberate and short-lived and which should evolve into automatic habits to support long-term function.
For instance, rehabilitation after an anterior cruciate ligament (ACL) injury involves exercises like quadriceps strengthening for a limited period—typically six months—to restore function, not to form lifelong habits. In brain injury rehabilitation, however, routines like using a whiteboard for reminders or performing consistent mobility exercises may need to become automatic to sustain independence or prevent decline. Misjudging this can hinder progress. A person recovering from a concussion may be asked to track symptoms, exercise, and meditate daily; the combined tasks led to disengagement. Adjusting—stopping symptom tracking after eight weeks while embedding exercise—improved outcomes. Conversely, treating a memory strategy as temporary may leave patients unsupported later. Clinicians should evaluate each behaviour’s intended duration and provide tailored support, avoiding overwhelm or neglect of essential routines.
Rehabilitation as a Broader Approach to Change
Rehabilitation involves more than prescribing tasks or ensuring immediate adherence. It entails creating conditions where patients can manage recovery’s cognitive, emotional, and physical aspects, fostering enduring changes. This approach might include:
- Acknowledging heuristics and adapting strategies to complement them.
- Addressing a heuristic like loss aversion with gradual steps and gain-focused framing.
- Differentiating temporary behaviours from those needing to become habits, with appropriate guidance.
Focusing only on behaviour may not fully account for the factors driving patient actions. Struggles often arise not from lack of effort but from a framework that does not align with psychological and practical realities. Clinicians might explore a broader approach that integrates habits and heuristics to support environments where sustainable change can develop.
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