Every day we make thousands of choices. Some of these are habitual and strongly reinforced so we forget we’ve made them (like which side of the road to drive on), some of these require deliberate effort and we are aware of them. It’s the latter ones that have mental load and slow down our decision-making.
Naturally, humans want to conserve effort, so we’re prone to what psychologists call ‘System 1’ thinking – fast, skilled and relatively less sensitive to nuance (Tversky & Kahneman, 1973; Kahneham & Tversky, 2013). Kahneman and his longtime collaborator Tversky identified that people have systematic biases influencing their choices. In other words, people don’t always make rational choices because other things matter or we’re making habitual choices rather than considered ones.
Now why is this important? I make decisions about how much I do physically every day. If I go outside my ‘normal’ band of activity (do more than normal, do less than normal, do movements that I don’t normally do), then I’ll experience pain and fatigue.
The implications of this are that while mostly I don’t have to think too hard about what I choose to do, there is a constant mental load in the back of my mind weighing up the demands of an activity against two things: (1) my usual routine, (2) the value of the activity I’m deciding to do or not do, and (3) the impact of that activity on my body. I rely a lot on my System 1 thinking – I know my usual routine, my pain intensity, the other events coming up and I make quick decisions ‘yes’ or ‘no’ to activities.
Then I made the outrageous decision to try something new. In my case it was to head out to Adrenaline Forest, a zip-line, high-wire course in the tree tops at a local park. Out of my usual activities for sure. And I wasn’t sure how my body would react because I don’t usually wobble across nets or tightropes or hang off a flying fox!
Today I am feeling it, I have DOMS in my shoulders, belly and legs. It’s going to be there probably for at least a week, because DOMS doesn’t settle quickly with fibromyalgia.
Do I regret this choice? After all, rationally it makes no sense – I did a thing that pushed me out of my physical ‘usual self’ and I’m now paying the price for it. Today I’m having to draw on my System 2 thinking, using more mental effort, it’s slower, and means I will probably change some of my usual habits for a few days. Why would I do that?
My answer is – because it was worth it for the experience of being up high, for the time I spent with my partner (who did one more course than I managed), for the pride I have in knowing that I can do something even if I’m scared, and because I know my body isn’t harmed, it’s just cranky. These are values (not goals), they’re part of my intrinsic motivation for doing it.
How does this relate to what we do in pain management and rehabilitation?
- Clinicians can sometimes forget that people make decisions using System 1 – this is everyone’s default mode. Clinicians can think that if they provide ‘rational’ reasons to do a thing, this should be sufficient justification for a person to adhere to what the clinician suggests. But we all (including clinicians) do things out of habit, because it’s easy, because we know it well, and it doesn’t require too much mental effort, and it may weight values (or ‘why this thing is important’) over other factors. The implications of this tendency is that change of any kind is HARD because it will kick us into System 2 thinking. System 2 thinking takes longer to do, requires more mental effort, is more flexible and is used especially to self-monitor.
- When we’re helping people with persisting pain, as clinicians we can quickly jump into approaches that come easily. Things like the exercise prescriptions I see, the recommendation to ‘do mindfulness’ or ‘eat healthily’ or ‘pace yourself.’ Things that our evidence (from RCTs etc) might support on the basis of grouped statistics, but may not fit for this unique person in their lifestyle. Exercise, for example, is pretty easy to prescribe. You can quantify it, watch people doing it, measure their adherence (especially when they’re in clinic), and it’s socially sanctioned within healthcare systems (like ACC here in NZ), and by our professional colleagues. The problems lie with how effective it is for people who will leave our care, who may find their pain doesn’t reduce as hoped, and need to go on with their own lifestyles. If we don’t find approaches that people are willing to do in their own world, they’re likely to only do them while we’re watching. This is the reason intrinsic motivation matters (Eynon, et al., 2019; Morris et al., 2022). We need, as clinicians, to take the time to be creative and find out ways for each individual to do the thing. This is the essence of person-centred care, and fundamental for occupational therapists working in pain management.
- Both the intensity and intrinsic motivation matter in pain rehabilitation movement practice. If someone is going to get painful DOMS, or a flare-up, after doing a new movement practice, the risk is high that they’ll feel it’s just not worth it. This is positive punishment – an aversive experience that comes after an action and reduces the likelihood it’ll be done again. For most people with persistent pain, increased pain is common – and it can hang around a lot longer and be more intense than those without pain realise. It’s not like acute musculoskeletal pain where you do the movement and it hurts, but over days or weeks it settles down. For many people with persistent pain, increased pain intensity is maintained for weeks or months and radiates beyond the original area. Sometimes that pain increase continues forever. Avoiding these movements is not the answer (because you miss out on important life things when you do), but clinicians can forget just how debilitating the increased pain can be especially during the initial phases of doing new movements. This means clinicians need to be very careful about the starting point when suggesting a new movement practice. Listening to the person, using their current activity level as the baseline (however low that is), and only gently and gradually nudging up is absolutely vital especially for those with fibromyalgia. AND that movement practice needs to tap into intrinsic motivation – the practice needs to matter to the person. This can mean stepping right away from exercise programmes, and instead looking at activities the person values. If they value, as older people often do, social connection, recognition for their achievements, being out in nature, feeling safe – these things need to be features of the movement practice (Sandlund et al., 2018). For me, gardening, or walking my dog, or working on my silversmithing or dancing would be much more likely to be done than any set of exercises.
Life is always about choices. Humans may not always appreciate the long-term consequences of a choice especially if there’s a positive in the short-term. If we want people to live well in the presence of pain, we need to be aware of our clinical tendency for System 1 thinking, the effort needed to switch to System 2 thinking, and for us to collaborate with individuals to come up with creative ways to support behaviour change. Because, like it or not, pain rehabilitation and therapy/coaching is primarily about behaviour change.
Eynon, M., Foad, J., Downey, J., Bowmer, Y., & Mills, H. (2019). Assessing the psychosocial factors associated with adherence to exercise referral schemes: A systematic review. Scandinavian Journal of Medicine & Science in Sports, 29(5), 638-650. https://doi.org/10.1111/sms.13403
Tversky, A., & Kahneman, D. (1973). Availability: A heuristic for judging frequency and probability. Cognitive psychology, 5(2), 207-232.
Kahneman, D., & Tversky, A. (2013). Prospect theory: An analysis of decision under risk. In Handbook of the fundamentals of financial decision making: Part I (pp. 99-127).
Morris, L. S., Grehl, M. M., Rutter, S. B., Mehta, M., & Westwater, M. L. (2022). On what motivates us: a detailed review of intrinsic v. extrinsic motivation. Psychological Medicine, 52(10), 1801-1816. https://doi.org/10.1017/S0033291722001611
Sandlund, M., Pohl, P., Ahlgren, C., Skelton, D. A., Melander-Wikman, A., Bergvall-Kareborn, B., & Lundin-Olsson, L. (2018). Gender Perspective on Older People’s Exercise Preferences and Motivators in the Context of Falls Prevention: A Qualitative Study. Biomed Res Int, 2018, 6865156. https://doi.org/10.1155/2018/6865156