Did you do your exercises?
Well, lucky for you, today we’re talking habits.
This topic is teeming with applications to our work & our practice as physical therapists. So by the end, you’ll have no excuse ...you noncompliant son of a…
I find habits so interesting because they’re something that we all engage in for a significant portion of our lives. Understanding the science of how habits work and having the tools to change my own habits has been extremely useful to me in my life. It’s also helped me in aspects of my practice that used to frustrate the hell out of me.
In this article, we’ll answer the fundamental questions about habits:
What are habits?
Why are they important?
How do they work?
How can we harness the power of the habit for our benefit and our patients’ benefit?
I learned a lot of this information from a book called Atomic Habits by James Clear. I’ve read a couple of books on habits and I think Clear’s is by far the best. It’s heavily informed by research and includes practical wisdom and personal anecdotes that make it an all-around great read.
So let’s get to it!
What are habits?
Habits are, by definition, a behavior that’s
Cued by a specific context
Often occurring without much awareness or conscious intent
Acquired through frequent repetition
This is important because a significant portion of our lives are habitual. We repeat ~40% of our behavior almost daily.
In this way, our habits shape our existence & our future. And if we change our habits, we change our lives.
It’s important to realize that habits don’t just relate to physical behaviors like tasks or activities. All the principles that we’ll discuss also apply to the mind.
Just as we have habits in our external world like our morning and nighttime routines, we also have habits of mind— patterns of thoughts and emotions that are highly influential in our lives. So keep that in the back of your mind as you read to see where other applications might lie for you or the people you work with.
Why are habits important?
1. At the core of what we do is lifestyle & behavior change.
We ask pretty much everyone we work with to change the structure of their life in some way. When we ask them to make time in their day to do exercises, walk, move, stretch, we’re asking them to form new habits or modify their existing habits.
This is not always easy to do. I mean, how many hundreds of times have you said or thought, “…Well if you’d just do your exercises you might be feeling better...”?
But the more we understand habits—how they work and how we can make forming new habits more likely to happen—the more we can work with people to help them change their behavior & their lifestyle.
2. The information problem.
The information problem is the notion that information alone is essentially useless. It’s only when it changes our behavior that it makes a difference.
If we want to elevate our practice, we must be equipped with the tools to change our own behavior.
When we learn something new, we need to be able to implement it into our practice for it to make a difference. And modifying our habits is a huge way that we can do that.
3. Work/life balance.
If you’re a Be A Better PT podcast listener, you’ll know that in my first podcast episode, I mentioned that I want to help you not only be a better clinician, but also achieve a better work/life balance and reduce your stress.
Understanding habits and being able to tap into that understanding to change our behavior is a game-changer when it comes to work/life balance. Being good at this allowed me to survive residency while simultaneously DIY renovating my wife’s and my first home (somehow).
How do habits work?
There are 4 steps that your brain runs through when engaging in every habit.
It’s called the habit loop and it’s made up of four phases:
Let’s go through these one at a time.
The cue is a contextual trigger that prompts your brain to initiate a behavior. It’s a piece of information that predicts a reward.
This is important because, from a habits standpoint, the brain is essentially a reward detector.
Our brains spend a lot of time scanning the environment in search of rewards. Primary rewards like food, water, sense pleasures. And secondary rewards like money, power, status.
Importantly, you don’t need to be aware of the cue for the habit to begin. This is especially important when it comes to breaking habits, where the process really has to start with awareness.
So the cue is the noticing of the reward
The craving is the motivating force behind every habit. Without craving (or desire), we have no reason to act.
Importantly, what we crave is not the habit or behavior itself, but the change in state it delivers— the way it makes us feel.
For people who smoke, for example, it’s not the cigarette itself, but the relief that it provides. The same thing can be said about alcohol, junk food, hugs, sex. What we crave is the change in state.
So the craving is the wanting of the reward.
The response is the actual behavior that’s performed.
And remember, the habit can be a task or other outward behavior, or it can be a thought or emotion.
So the response is the obtaining of the reward.
& The reward is the reward. Pretty straightforward.
There are 2 main reasons that we chase rewards, aside from survival reasons regarding our more basic needs:
They satisfy us by giving us temporary relief from craving
They teach us which actions are worth remembering for the future
If a behavior produces an effect that we like, we are more likely to repeat it
If a behavior produces an effect that we don’t like, we are less likely to repeat it
Cue, Craving, Response, Reward.
That’s the habit loop.
These phases are all very dependent on one another: if a behavior is insufficient in any of the four stages, it will not become a habit.
This is exactly how we intervene, by manipulating the habit loop.
How can we harness the power of the habit?
Clear discusses what he calls The Four Laws of Behavior Change, which correspond to each of the four parts of the habit loop:
If we’re trying to form a new habit,
Law 1 recommends that we Make it Obvious (this is related to the cue phase of the habit loop)
Law 2 suggests we Make it Attractive (this relates to the craving phase of the habit loop)
Law 3 calls us to Make it Easy (as it relates to the response phase of the habit loop)
Law 4 is to Make it Satisfying (which relates to the reward phase of the habit loop)
If, on the other hand, we’re trying to break an existing habit, we simply flip the four laws.
Make it Obvious becomes Make It Invisible
Make it Attractive becomes Make It Unattractive
Make it Easy becomes Make It Difficult
Make it Satisfying becomes Make It Unsatisfying
Let’s go through these one at a time. I’ll tell you my favorite strategies using examples for each of the four laws.
Law I: Make It Obvious
When talking about building a new habit, the first strategy is to intentionally cue ourselves to engage in the behavior that we want to.
We want to make the desired behavior obvious so that we remember to do it.
My favorite strategies for doing this are:
Strategy 1: Scheduling
Time is a very common cue. We rely heavily on time in our lives to inform our behaviors. When we eat, when we sleep, when we work, when we rest, are all temporally influenced. Scheduling is a simple way to tap into this influence to create a new habit.
For example, if I’m trying to help Ms. Magnolia form a new habit of movement or exercise, I might ask her, "When in your day do you think this would fit?"
The process of thinking of a time in her day when she could see herself performing the movement or exercise makes it more likely that she’ll remember when that time comes. If she’s a calendar person, I might ask her to put it in her calendar as an extra obvious layer.
Let’s talk through another example, this one relating to my own habits.
Let’s say I want to boost my clinical reasoning skills by starting the practice of reflecting on my day. If I pick a specific time of day to do that, it’s much more likely to happen. Maybe it’s 6:00, right after I get off work, on my drive home.
Simply selecting this time is a step toward improved reasoning skills because I’m making my desired behavior—reflecting—more obvious.
Strategy 2: Habit Stacking
Habit stacking is the practice of adding something new to an already existing habit. Why start from scratch when we can piggyback a well-established habit?
Say Ms. Magnolia and I decide she will start stretching and walking. She says she can do this at 9:00 am. I might dig into her morning routine to find out what the flow of behaviors looks like in her morning. That way we can see where she can piggyback stretching and walking into her already existing routine.
Let’s say she normally:
Uses the bathroom
Goes downstairs to get a cup of coffee
We might decide together that she’ll instead:
Do some stretches in bed
Use the bathroom
Get her cup of coffee
Go for a walk
One of the best parts about scheduling and habit hacking is that they remove a lot of the decision-making of starting a new habit. The decision of “When should I?” can be exhausting and can be enough to make us avoid doing even simple things that we genuinely want to do and know are good for us.
Making these decisions in advance can make things flow much smoother.
Strategy 3: Visual Reminders
Using visual reminders is the simple act of creating a cue that stands out in the environment to serve as a reminder.
Since starting my nerd journey into habits, whenever people are super consistent with their exercises or other new habits that we discuss, I ask them how they did it.
One of the things that I’ve heard a fair bit from these consistent folks is that they’ll leave the equipment out as a reminder. And every time they see the piece of equipment they’ll do the exercise. Make it obvious.
Using our example from before, if I want to make it even more likely that I’ll reflect in my car at 6:00 on my drive home, I could put a sticky note in my car that says “REFLECT” to remind me to reflect.
…and maybe then I realize that I could practice self-compassion while I reflect so that I learn more and avoid a negative thought spiral. So maybe I add “...but be nice” to my sticky note.
These aren’t the only strategies for making it obvious, and you’ll end up coming up with some of your own. Just remember the concept: all these strategies are ways of making the desired behavior obvious so that we remember to do it.
Law II: Make It Attractive
Make it attractive is the law that has to do with craving.
Essentially, if we want to help someone build a new habit, the more attractive they can make it, the more likely they are to do it.
My two favorite strategies for this are:
Strategy 1: Temptation Bundling
Temptation bundling involves pairing the task with something you like doing.
This is especially helpful for people who are exercise-averse. For these folks, I often find myself saying things like, “Foam roll while you’re watching TV” or, “Do this as you scroll on Insta”.
Temptation bundling can also be tacked onto scheduling and habit stacking to cover two laws at once. If Ms. Magnolia, from our previous example, takes her cup of coffee on her morning walk, that’s an example of temptation bundling!
Strategy 2: Cultural Influence
Cultural influence could be finding a workout buddy, a class, or even just someone at home to engage in the behavior along with you.
We're social creatures, so if we join a culture where the desired behavior is the norm, it can make it much easier to engage in that behavior.
This also fosters accountability, which is HUGE when it comes to behavior change!
Temptation bundling and cultural influence are both aimed at making the desired behavior more attractive so that we want to engage.
Law III: Make it easy
Make it easy is the law that has to do with the behavior itself.
It only makes sense that if we want to implement a new habit, it can’t be too difficult. Because the key to building a new habit is to start with repetition, not perfection.
This is one is probably my favorite and it’s so simple but it’s so often overlooked— by our patients and by us. There’s really one strategy here.
Strategy: The Gateway Habit
Make it so easy you can’t say no.
Want to help someone start a walking program? Start easy. Start with success.
Some say when you’re starting a new habit, it should take less than 2 minutes to do. I certainly don’t always follow that. BUT if someone tells me that they can walk 10 minutes currently and they’re not walking regularly, I’ll often have them start with 5 minutes. Make it so easy you can’t say no.
Another way we can follow this simple guideline is by not giving people too many exercises.
Giving people too many exercises is probably the best way to disincentivize people from doing them. Because you’re starting out difficult.
Starting with too many exercises is like starting the habit of running by going for a 5-mile run. You could do it. Some people do it that way. The general population does not respond to that method. (Not to mention, from a diagnostic standpoint, if we give people a bunch of exercises right in the beginning we’ll have no idea what’s helping & what’s not).
A great strategy is to simply ask the person how many exercises they want and give them that many. If you must give them more than that, make sure they’re agreeable and will actually do them. Over time, you can build up.
We can use this simple principle of making it easy for ourselves as well. If I want to start reflecting more as we discussed before, I could start by reflecting on just one patient on my drive home, or maybe two.
If I want to start reading more, I could start with 1-2 pages per day. That’s actually how I read Atomic Habits. It was a busy time, but I read 2-4 pages per night before bed and I got through the book in no time.
By making it so easy we can’t say no, we establish a gateway habit, that can be built upon over time.
Do not underestimate this law.
Law IV: Make it Satisfying
This final law has to do with the reward phase of the habit loop.
A key concept to understand is that when it comes to rewards, emotions (feelings) are everything.
Remember that the craving is the desire for the change in state; the way the habit makes us feel, which is the reward.
Positive feelings cultivate habits. Negative feelings destroy them.
This relates heavily to self-compassion. If I’m beating myself up for what I did “wrong” and not acknowledging what I did “right,” it will be very difficult for me to improve my practice or my life.
This is also a really key thing to listen for in those that you work with.
I’ve had a lot of people come in for a follow-up and they’ll say something like, “I haven’t been doing the exercises as much as I should...”
And I’ll say, “Well, how much did you do them?”
And they’ll say, “Only 3 times and we talked about me doing them 5 times.”
And I’ll say, “Good for you for doing it 3 times! 3 times is better than 0 times.”
This is of paramount importance because if the person is engaging in the behavior, but talking shit to themselves the whole time about how they’re not good enough or not doing enough, they’ll eventually stop doing it to avoid that discomfort— we all will.
So we need to be really careful about how we respond in these situations and be mindful of what we’re reinforcing. We sometimes fall into the habit of being tough or condemning people when they don’t do what they’re “supposed to do”. But from a habits standpoint, we’re making the target behavior undesirable by stripping away the reward.
Instead, rewarding the efforts that have been put forth is a much better option from a habits standpoint.
This isn’t to say that we can’t hold people accountable. We can still do that, but it’s important to acknowledge their efforts & affirm their virtues.
My favorite strategy for making it satisfying is habit tracking.
Strategy: Habit Tracking
The principle here is the mere act of tracking a behavior can spark the urge to change it. Self-measurement brings self-awareness.
Making something satisfying is tricky because you really want an intrinsic reward much more than an extrinsic reward. While giving oneself a tasty treat after exercising might be helpful initially, extrinsic rewards like this have been shown to not be so helpful for long-term behavior change.
What really helps foster long-term behavior change is intrinsic rewards. And an excellent intrinsic reward is progress.
The mere act of checking a box or putting a marble in a jar or doing something that shows progress is astoundingly motivating. And tracking a habit (or a process) vs. an outcome is extremely useful because we can’t often control the outcome, but we can control how often we show up.
The beauty of habit tracking is there are ways to do this that hit on all of the four laws (you heard that right, fellow nerds. All. Four. Laws.)
It’s super simple and I’m going to walk you through it right now.
Ms. Magnolia's had a lot of trouble in the past with sticking with exercise programs. We decide to start with all-hands-on-deck to give her as much habit-momentum as possible.
I open Microsoft Word or some other program with a calendar template. I pull up an editable calendar for the month or print one out.
See if you can spot the laws that we cover as we go
She tells me that she can walk 10 minutes (or better yet, we measure this in the clinic). We decide that she will walk 5 minutes
We decide that she will walk 5 minutes 4 days/week
We decide that those days will be Monday, Wednesday, Friday, Sunday
So on each of those days, I type into the calendar cells, “walking 5 minutes”
We decide that she will walk at 9:00 am after she wakes up, stretches in bed, uses the bathroom & gets her cup of coffee
So on each of the days, I type in her routine and where walking fits in that routine
I add “9:00 am” next to “walking”
Then I print it out (if I haven’t already) and I ask her, “So where can you put this in your house where it will remind you of your routine?”
She says that she will tape it to her cabinet, right above her coffee maker
Then I tell her, “So when you come back from your walk, put a big ol’ checkmark or "X" on that day and give yourself a pat on the back for getting one step closer to your goal! And try not to break the chain if you can help it. Most people find that if they don’t break the chain—if they don’t miss scheduled days—they really get on a roll and gain momentum.”
Let’s take stock of all that we covered with this simple little calendar strategy
Law I: Make it obvious
Putting the calendar somewhere she can see it is making it obvious
Setting specific days and times to walk is making it obvious
Working stretching and walking into her already existing routine is making it obvious
Law II: Make it attractive
Bringing her coffee on her walk is making it attractive
We could even take it a step further and see if she could find a buddy to walk with for some cultural influence
Law III: Make it easy
Starting with 5 minutes when she could really do 10 is making it easy (and of course, this will be progressed over time)
Law IV: Make it satisfying
Putting that simple checkmark on the calendar and giving herself a pat on the back is making it satisfying.
And seeing the check marks amass will be even more satisfying as time goes on
So this little calendar strategy covers just about everything that we’ve talked about!
One simple alternative to the calendar is to use a habit tracking app. Most of these apps do much of the same things as the calendar so for tech-savvy people, this could be a good option.
Most of them will allow you to set reminders, add notes, and they’ll give a pleasant little “ding” when you complete 3 days or more in a row, etc. I’ve used a habit tracking app called Way of Life for many things over the years. Currently, I use it for my daily intention-setting practice.
A habit is a behavior that’s:
Cued by a specific context
Often occurring without much awareness or conscious intent
Acquired through frequent repetition
*A habit can be a physical behavior as well as a thought or emotion
The habit loop includes 4 phases:
Cue: the noticing of the reward
Craving: the wanting of the reward
Response: the obtaining of the reward
**Knowing this, we can either grease the wheels of the loop to make it easier to start a new habit or we can create friction in the loop to break an existing habit.
These correspond to Clear’s four laws for starting a new habit:
Make It Obvious
Make It Attractive
Make It Easy
Make It Satisfying
**All of which can be flipped to help us break existing habits
So hopefully the next time your patient tells you they didn’t do their exercises, that will serve as a cue for you to get curious & work with them to implement your new habit knowledge.
Good luck out there.