We all know that habits are hard to break. As an educator, I spend a lot of time trying to prevent trainees from building bad habits at the start, since once they create those habits, it’s going to be very difficult to change. I’ve often felt that there is a sort of organic, uncontrolled quality to the creation of human habits. We go about our lives, maturing from childhood to adulthood to our professions, and seem to build our habits in much the same way we build other skills. I liken this undirected habit acquisition to how we acquire language skills as children. We listen to those around us, while building our language base, becoming more proficient over years of practice. And just as it is difficult to change an accent or an incorrect phrase with language, so is it difficult to adjust habits.

I recently read an interesting book about habits called The Power of Habit: Why We Do What We Do In Life and Business, by Charles Duhigg. This book provided some interesting perspectives on how we build and maintain habits and a method to change habits based on what we know from the psychological research. Let’s talk about what Duhigg teaches us about habits and how we might apply this information to our own experiences. He discusses examples of successful habit creation and its effects from many aspects of history and society and cites scientific research to support these concepts. The first half of the book reviews the details of what habits are, how to create habits, and how to change habits. The second half of the book is somewhat redundant, with various examples of others who have used the principles discussed previously, but it is highly readable. I strongly recommend reading this book for further detail.

Creating Habits

Creating a habit consists of a three-step loop. The first step is a cue, a trigger in our brains that causes us to go into an automatic mode. The second step is a routine (either physical or mental), the actual habit itself, and the third is a reward. The reward leads back to the cue, creating a self-reinforcing loop over a period of time and enough repetitions. An important aspect of this is that habits are automatic and essentially thoughtless.

Let’s take an example. Say I’m a podiatry student in my first year of school. I want to build a habit in which I spend four hours studying every day. I must first find a simple and obvious cue. How about eating dinner after class. I’ve arrived home after a day of lectures, and I make myself dinner. The next step would be to do the routine – studying my materials for four hours. Finally, I give myself a clearly defined reward. Let’s make it simple and give myself a chocolate bar. Over time I will learn to associate that reward with the act of studying. Sounds a bit like Pavlov’s dogs doesn’t it? I agree.

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Cue > Routine > Reward
Eat Dinner > Study 4 hours > Chocolate

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A key component here, according to Duhigg is we want to “cultivate a craving.” It is the craving that drives the loop to continue. For example, a smoker will see a box of cigarettes, which will stimulate the craving and push him to smoke a cigarette. For me, my big weakness is chocolate. Just the sight or smell of chocolate creates a craving in my mind that causes me to eat more, leading to the obvious reward of the pleasant taste. This self-reinforcing cycle creates the craving that drives the habit of eating too much candy. I’ll have you know that while writing this paragraph, I ate a chocolate bar – the craving is that strong!

Changing Bad Habits

This brings us to changing habits we don’t like (bad habits). To do this, Duhigg recommends the following method that he terms The Golden Rule of Habit Change.

“Keep the old cue, and deliver the old reward, but insert a new routine.”

This is a primary way in which Alcoholics Anonymous (AA) helps people to stop drinking. The cue for many alcoholics is life pressures, which previously led them to drink with the reward to feel better about their problems. As part of a comprehensive program, AA inserts conversation and counseling as the routine. For example, a support group with meetings and 24-hour access to a sponsor are pushed heavily. When an AA member has an emotional crisis that would otherwise push them to drink, they are given the freedom to attend a class or call their sponsor to talk out the issues. The reward, of course, is an improved emotional well-being but in a much healthier, more positive manner.

Let’s take a simplified example common for many of us in podiatric practice: helping a diabetic improve their blood sugar control. Mr Harris is a 50-year-old diabetic who lives alone. After having a conversation with patient, Dr Smith determines the cues for Mr Harris’ eating too much is being hungry but also being lonely. He eats when he becomes hungry, and the feeling of satiety is his reward. However, he feels bad about eating too much and understands the importance of improving his blood sugar control.

Together with Mr Harris, Dr Smith, also works with a certified nutritionist - making the following adjustments. They insert into his diet a larger number of smaller meals with a greater proportion of vegetables. This is meant to keep Mr Smith feeling full and not sensing the hunger as much. The nutritionist even suggests easy snacks that Mr Harris can have on the go when he starts to feel hungry. Additionally, Mr Harris is referred to a diabetic support group to help increase social support.

With these interventions, Dr Smith and his team have modified Mr Harris’ routine, allowing the creation of potentially healthy new habits. The key to creating new habits and changing bad ones is to believe that it is possible. It’s definitely not easy, and there’s no one perfect way for everyone, but having a framework of understanding and a little support from those around you will make it possible to be successful.