I’m working with a couple of people who are having a good deal of trouble maintaining a routine. Things like having a reasonably regular bedtime and wakeup time, eating regularly, having periods of energising activity, and periods of rest and relaxation. While some of our normal routines have been disrupted by the earthquake in Christchurch, and things like getting to a supermarket or petrol station or even to see a doctor can mean travelling further than normal, for these people, routines have not ever really been a strong point.
As someone who likes a bit of routine, I personally struggle to understand how people can miss out a meal or go to bed at wildly different times of the night (or early morning!). Although I have to say I’m not averse to the occasional lie-in! But there are some real problems with not having a bit of a framework from which we can temporarily deviate.
Why is having a routine helpful?
Well, some of our basic functions, like sleep and hunger, digestion and even alertness are initially based on cues from our environment. Although they can be influenced by many factors, these basic drives remain in place, and are there to keep our bodies in homeostasis.
Having a routine that acknowledges and integrates the requirements of our bodies helps to keep us functioning, at a physiological level. For this reason, most of us keep to a regular food intake over the course of a day, we rest or sleep at nearly the same time each night, and when we don’t follow this on the odd occasion, we usually make it up over the next day or so.
Having a regular bedtime and waketime provides a framework for establishing good sleep. Erratic bedtimes and waketimes make it difficult for the body to relax and fall asleep quickly, and to ensure consolidated sleep with the regular sleep architecture that gives us refreshing sleep. When bedtimes and waketimes are erratic, sleep can become disrupted and eventually, especially with daytime napping, sleep can be spread across almost the whole day. This makes it really difficult to get deep, refreshing sleep with appropriate REM sleep periods and delta sleep periods. Re-establishing good sleep typically means starting with a regular bedtime and wake time! For a nice explanation of sleep architecture, this post by Emily Deans of Evolutionary Psychiatry blog makes it all clear.
We use the idea of sleep patterns and mealtimes as an anchor for many things. Many medications need to be taken regularly, according to time rather than ‘as needed’ or ‘when I remember’. This can be because of the way the active ingredients of medications are released into the bloodstream, and how the body processes the drugs. It’s also one way of minimising the learning effect that can come from taking a medication when distressed, experiencing both a pharmacologic effect AND reduction of distress through taking action. Over time (and sometimes not very much time!), this can become a very strongly learned response, so much so that the relief experienced occurs well before any medication could be absorbed. And this can lead to increasing use of medication to reduce distress – and subsequent over-use, and in some cases, dependence on medications that can be harmful.
We also need to eat regularly to feed the brain. Brains use an enormous amount of energy, and without adequate food, brains simply don’t function all that well. It’s one of the reasons for having breakfast! Inadequate diet, or erratic eating patterns, sometimes because of pain and sometimes because of side effects of medications, and sometimes because eating hasn’t been all that important, contributes to difficulties concentrating and remembering, something that people with chronic pain can often complain about (here’s a 2001 paper by Peter Havel on the role of peripheral signals as they contribute to hunger and homeostasis).
In pain management, routines are almost assumed to be present. We’re used to establishing a baseline level of activity – whether it’s walking or doing the housework or going to work, when we’re starting a graded activity programme we ask the person to estimate how much they’re ‘usually doing’. So if the person’s not used to having a routine – oops! it’s pretty hard to set a baseline.
What’s the point of setting a baseline? Well it’s important for determining the starting point for increasing activity. It allows us to help the person maintain a consistent level of activity despite fluctuations in pain. We often find that people with chronic pain let pain determine how much and how often they do activities, and this interferes with their ability to plan ahead to go out socially, or to manage the grocery shopping, or go to work.
There’s quite a body of research on the development of habits and routines – and much more to learn! I’ve included a number of references for those interested in exploring this aspect of function in more detail. While the majority of these references are taken from a research meeting in 1999 and I truly hope more research has been carried out since then, they provide some background reading on concepts of habits and routines – and I’d especially draw your attention to the paper by Reich (2000), on the place of ‘routinization as a factor in coping for women with fibromyalgia’. This is essential research – pain often disrupts routines, and most pain management assumes that routines are present, or attempts to help people regain routines. Maybe we need to learn more and focus more on this in our treatments.
Clark, F. (2000). The concepts of habit and routine: a preliminary theoretical synthesis. Occup Ther J Res, 20(Sup 1), 123S-137S.
Davidson, L. (2007). Habits and other anchors of everyday life that people with psychiatric disabilities may not, take for granted. OTJR:Occup Particip Health, 27(Suppl 1), 60S-68S.
Poole, J. (2000). Habits in women with chronic disease: a pilot study. Occup Ther J Res, 20(Sup 1), 112S-118S.
Reich, J. (2000). Routinization as a factor in the coping and the mental health of women with fibromyalgia. Occup Ther J Res, 20(Sup 1), 41S-51S.
Reich, J., & Williams, J. (2003). Exploring the properties of habits and routines in daily life. OTJR: Occup Particip Health, 23(2), 48-56.
Rogers, J. (2000). Habits: Do we practice what we preach? Occup Ther J Res, 20(Sup 1), 119S-122S.
Tickle-Degnen, L., & Trombly, C. (2000). The concept of habit: a research synthesis. Occup Ther J Res, 20(Sup 1), 138S-143S.
Wiese, D. W. (2000). Habit: What’s the brain got to do with it? Occup Ther J Res, 20(Sup 1), 6S-20S.
Williams, J. (2000). Effects of activity limitation and routinization on mental health. Occup Ther J Res, 20(Sup 1), 100S-105S.
Williams, J. (2000). The concepts of habit and routine: a preliminary theoretical synthesis Occupational Therapy Journal of Research, 20 (1), 100-105
Good blog today – thanks for this!
Just to develop further on the point of establishing a baseline. In addition to the numerous physiological and psychological cues this can help with (as you’ve elaborated on already) the process of baseline setting and negotiation invariably encourages the patient to consider why routine is (or is not in this case) so important and how to prioritise accordingly.
As you’ve mentioned food may never have been seen as important, and so focussing on the benefits of regular food intake really needs to focus on the individuals priorities. Personally I’m all about sleep at the moment – so if anyone was to encourage behaviour change for me they just need to link it back to my sleep patterns and I’m all ears! eg Reduce caffeine intake, get off computer earlier etc.
I find the difficulties arise when the patient struggles to identify any such motivating factor or priority. Perhaps they are fairly comfortable in their current situation (despite the lethargy, poor nutrition etc) or lack the confidence to attempt an alternative approach. You’ve blogged plenty on the benefits of a Motivational Interviewing approach, and I imagine with such cases these skills would come to the fore.
Thanks again, always a stimulating read.
Thanks for the kind words Penelope! I think it is difficult to establish a desire for change without first determining that there is a discrepancy between what is happening NOW and what they would LIKE to be happening in the future. If, after exploring this, there is no discrepancy, then it’s unlikely that any change will occur except temporarily while the treatment team is there and able to ‘force’ compliance. And if we’re into self management, then we really need to find the discrepancy or our efforts as health providers will be in vain because the internal locus of control and drive for change won’t be present.