A behavioural change is a change within someone's behaviour when compared to a previous behaviour and can be quite common after a cancer diagnosis and treatment. In this episode Charlotte shares what some of these common behaviours are and discusses the behavioural change model and role of obstacles.
We learn about the guilt and anxiety model, flexibility, the power of helpful language and other strategies that can help you adjust.
This podcast was recorded in February 2023.
We recommend that listeners exercise self-care when listening to this podcast, as some may find the content upsetting. BCNA’s Helpline provides a free confidential telephone and email service for people diagnosed with breast cancer, their family and friends. Our experienced team can help with your questions and concerns and direct you to relevant resources and services. Call 1800 500 258 or email firstname.lastname@example.org
Upfront About Breast Cancer is a production of Breast Cancer Network Australia. Our theme music is by the late Tara Simmons and this episode is proudly brought to you by Sussan.
Want to get in touch? Visit our website at bcna.org.au, email us at email@example.com, or call our Helpline on 1800 500 258
Voiceover [00:00:08] Looking for practical information to help you make decisions about your diagnosis with a DCIS, early or metastatic breast cancer. BCNA’s My Journey features articles, webcasts, videos and podcasts about breast cancer during treatment and beyond to help you, your friends and family as you progress through your journey. It also features a symptom tracker to help you manage the changing symptoms you may encounter during your own breast cancer experience. My Journey, download the app or sign up online at my journey.org.au. Welcome to Upfront about Breast cancer: What You Don’t Know Until You Do – Unlimited with Dr. Charlotte Tottman.
Kellie [00:00:56] Welcome back to elcome to Upfront about Breast cancer: What You Don’t Know Until You Do – Unlimited with Dr. Charlotte Tottman, a psychologist specialising in cancer distress. So behaviours can change after a breast cancer diagnosis can’t they?
Charlotte [00:01:11] Yes, they can sometimes in a helpful way and sometimes in a not so helpful way.
Kellie [00:01:18] Dr Charlotte today is going to share her thoughts on how motivation and complacency operate. It's really fascinating stuff. And just like our title, it's things you don't know until you do. A reminder that this episode is an unscripted conversation. The topics discussed are not intended to replace medical advice, nor represent the full spectrum of experience or clinical options. So please exercise self-care when listening as the content may be triggering or upsetting for some. You've titled this Hanging Out with the Bad Boys, Charlotte. What does that mean?
Charlotte [00:01:54] It reflects, I think, the very common experience for a lot of people, regardless of a cancer experience, of maybe engaging in behaviours that we kind of know might not be really good for us, but they are seductive and alluring nonetheless. But when we do hang out with those bad boys, too often, you know, it can end in tears, it can end badly.
Kellie [00:02:18] Bad boys being?
Charlotte [00:02:20] Things like typically alcohol, perhaps poor nutrition behaviours, perhaps poor exercise and activity behaviours. So doing things that maybe feel a bit indulgent and might feel quite nice in the moment, but might have as well as a short term kind of fix or high, I might have a more medium to long term downside.
Kellie [00:02:44] Meaning that you then in reflection beat up on yourself or it actually has physical consequence?
Charlotte [00:02:51] probably both. And I think the thing that happens in a cancer context is we do quite a bit of that review and reflection. And you know, we've talked about that in previous episodes where we're pretty good at then Self-flagellating and going, you know, shoulda woulda coulda. And that's where on diagnosis we see a peak in motivation to maybe make changes to some of that stuff. And that's the good side of perhaps behaviour change in a cancer context. The perhaps the not so helpful side is when we might engage in some of those indulgent behaviours as a way of coping with the stress and distress that comes with a cancer diagnosis, treatment and aftermath.
Kellie [00:03:28] For many, a cancer diagnosis is seen as a real wake up call and a chance to reframe and reduce the chance of it coming back.
Charlotte [00:03:37] Absolutely. And there is certainly a link, as we were discussing in a previous episode in this series, between the fear of recurrence and wanting to keep myself safe by maybe changing some behaviours and as we discussed in that episode, a flexible approach to that is really helpful so that it's not rigid and so that you can find a way to make some changes but cope with the fact that if life interrupts those changes, that it's not the end of the world and that your psychological system doesn't kind of crack. We often see that there is a real spike in fear, but also a real spike in motivation to make changes on diagnosis. And that's consistent with the theory around behaviour change in psychology, which is that we're most likely to engage in behaviour change when there's a significant enough positive consequence or a significant enough negative consequence. So if you've kind of had that gun pulled in your face and you feel like, you know, one of the ways you're going to make sure that gun being pulled in your face doesn't happen again is to make some positive behaviour change, particularly around lifestyle behaviours, risk factors known to be associated with breast cancer. Then that explains why your motivation goes through the roof. That's great. But the other thing that's common in behaviour change is the role of obstacles. And if an obstacle presents itself right when you're ready to make all these positive changes, it can derail the very good plan. And the thing that typically presents as an obstacle right after diagnosis is treatment. So you might be all ready to like get your gym shoes on and eat less processed food and, you know, worry positively about your sleep more. And then along comes treatment almost, you know, within days and you're managing really punishing side effects and a punishing treatment schedule. And as most people listening who've been through cancer treatment would appreciate, it's not just the side effects, it's the cumulative effect of those side effects. So it kind of gets tougher the further you get into treatment. So your actual ability to be able to engage in those behaviour changes consistently from the outset is usually impeded by treatment.
Kellie [00:05:45] I wonder if another example of that is when you first start that treatment and you're like you're saying your motivation is high on living a healthier lifestyle and cutting down on certain foods, but you've got all these offerings of home baked goods and people are dropping off the lasagnas and the casseroles that don't actually match that, that new frame of, I'm going to cut out these and I'm going to cut out that. But you're too tired and you're too ill to actually do something else about it.
Charlotte [00:06:14] Exactly. And human, we like easy. And so again, it's that obstacle idea that if I would like to eat more organic food, that means I've got to actually find an organic outlet and go there and buy it and prepare it from scratch versus yes, somebody dropped off the casserole on the lasagna. That's probably not unhealthy. But in our mind we might be thinking, you know, that's not what I'm going for, but I just do not have the wherewithal to be able to start something from scratch. And so, yes, there are all sorts of obstacles that get in the way of being able to engage with behaviour change from the get go. The one that probably I see is perhaps supported a bit more through treatment is exercise, because the messaging from oncologists and surgeons, which used to be, I think years and years ago a little more ad hoc around, if you'd like to do some exercise, that'd be fine. Now we know conclusively from the research that exercise during chemotherapy increases the efficacy of the chemotherapy itself. So the messaging now as best practice is that your oncologist or your surgeon would probably like you to exercise fairly regularly, might be 20 minutes a day through as much of treatment as you can. The messaging that they might give you around things like other risk factors or lifestyle behaviours is more like, Look, let's just get you through treatment and we'll worry about, you know, looking at your diet or looking at other parts of your life a bit more closely when we just get you through the treatment. So exercise is probably a bit of a standout, but even with that, I certainly do see people who start off in the first few weeks of treatment quite rigorously, you know, engaging and getting to the gym or getting out walking. And then we see that typically drop off as the side effects of treatment really cut in and make that so much harder.
Kellie [00:08:06] Even without those obstacles, do you actually see a tapering off the further you get away from that initial shock of diagnosis and fear?
Charlotte [00:08:17] Exactly. As just like I think I mentioned before in relation to what we all went through with COVID, once the threat starts to feel like it's not as new, it's not as big, we're feeling a bit safer because we might be in active treatment. We feel safer because we've got a plan. We feel safer because the news is not new. It's become weirdly familiar. And so with that decreasing threat can come a decrease in motivation and sometimes an increase in complacency. You know, it's like what we saw in COVID when, you know, people stopped doing the elbow bump and they started resuming, you know, hugs and kisses and not so much hand-washing and sanitising. It's normal human behaviour. And look, it's not a bad thing that the threat level comes off the boil and that our anxiety system starts to find its equilibrium. Like all of that is good. But I think again, it comes back to awareness and about going, okay, well if I'm not seeming to be quite so interested in all of that good behaviour change, I wonder, I wonder why. And I wonder whether that might need a bit of a refresh and it doesn't have to have fear as the motivator. It can just be that I'm re-engaging with, you know, my idea of life beyond cancer being a bit different.
Kellie [00:09:30] It could be a bit of a vicious cycle, though, couldn't it? Because once you get to complacency, the self beating up of, oh, I was going to do that, and I haven't So what does that say about me?
Charlotte [00:09:42] Yeah, absolutely. And that can lead to exactly more of that, you know, Bad Charlotte kind of thinking. And this is where we encourage people in behaviour change strategies and attempts to have a self-compassion approach, which is that when you do find that you aren't able to do the thing that you are promising yourself, you would, you don't self-flagellation and that you do view it as an interruption and you get back on the horse. The waiver there though, is that just like I say about so many things, you can have too much self-compassion. Self-compassion can slide into self-indulgence, sofinding the balance between kind of being accountable to yourself and being accountable to the commitments and plans that you've made to make behaviour change and also not being so hard on yourself if f you aren't able to achieve that all the time. Finding the balance between those two things is tricky, but you can.
Kellie [00:10:35] What do you mean by self-indulgence?
Charlotte [00:10:37] So self-indulgence is kind of where we go I'll just give myself a complete leave pass. You know, I wasn't I wasn't able to get to the gym or go for a walk or reduce my alcohol intake or cook a healthier meal with a few more vegetables. I wasn't able to do it as many times this week as I thought. And I'm just going to like, go, Oh, well, it doesn't matter.
Kellie [00:10:59] So you go from going, Oh, I missed out yesterday to, Oh, well, I didn't do it yesterday or the day before. Sod it, what's the point?
Charlotte [00:11:05] What's the point? And that's probably even beyond self-indulgence where we actually then get into what I call fairly black and white thinking and that's that rigid thinking I've mentioned in previous episodes. This is the flexible thinking that we're going for. So black and white thinking is very much like, Why bother? What was I thinking? You know, I'm not capable of this anyway. Flexible thinking is more like, okay, well, that wasn't a magnificent attempt, you know, room for improvement. I can give it another go and being able to, you know, get back on the horse and have another go . That's where we give ourselves the opportunity to kind of learn through experience. It's like what I say to myself in the mornings when I can't bear the idea of getting on the treadmill is that I had a guideline, not a rule I have because I don't like rules, but I have a guideline that I do about 15 minutes on the treadmill in the morning, and most mornings I wake up and think, I just can't think of anything I'd rather do less. And my response to that in my brain is to say, Just get on the treadmill, just get on it. Don't even think about like, how long you going to be on it, Just get on the treadmill. Just do something. Just start. And what do you know? I don't think there's been a time when I've done that where I haven't ended up doing the 15 minutes, because by the time I'm on it, I've sort of forgotten about the horror of it and I've got moving and, you know one thing leads to another, and it sort of takes care of itself. But it's so interesting when you adopt that flexible mindset rather than the rigid. The rigid would be, I can't bear the idea of it. And if I can't do the whole 15 minutes, then I won't bother at all. Whereas the flexible mindset is like, Well, if I do something, I'm in front. And that's what I say to my clients. We do one thing this week that you wouldn't have otherwise done in a positive behaviour change kind of way where you are in front, that's progress. You're getting there.
Kellie [00:12:53] It's as if you were going to cut down on your cheese intake, but we've just had one piece instead of the whole block.
Charlotte [00:12:59] Exactly. That's right. And what we know about behaviour change is that it is sustainable in incremental change over time. So small change over time. And there's tons of research about the fact that behaviour change doesn't stick for a while. And the hardest part is the beginning. So the first few days, the first two weeks are going to be the hardest and that's where you're going to have more self-doubt, more wobbles and probably more of the need for that self-compassion. The research used to be that years and years ago it used to be that a new behaviour took about six weeks for it to become kind of an established behaviour. The more recent research from studies of studies is that the average is about 77 days and that's 11 weeks. So that's like a school term, that's a long time, but it's helpful to know that because I think if you've got an expectation that, you know, if I do something for two weeks, then I'm there. It's like, well, probably not. It's probably going to take longer than that for it to become part of your everyday.
Kellie [00:13:57] And change or positive change is what motivates you to keep going.
Charlotte [00:14:01] That's right. Exactly. It's like an upward spiral. I mean, I talk about these spirals in my consulting work a lot, and the downward spiral is the less you do, the worse you feel, the less you do. But it works in reverse. The more you do, the better you feel, the more you do. So it is very much the case of like, you know, if I get on the treadmill and I do 15 minutes and it didn't really hurt too much and it wasn't too boring and it didn't upset my day too much. Then I go Oh, well, that's all right. So not only did nothing bad happen, but often I feel quite smug after 15 minutes on the treadmill. So then I have that nice feeling of, Oh, go me. I managed to do that. And so it's like I put a little notch on the wall. And human beings like streaks. We like to create a streak. So people who've done things like Duolingo or something on an app where you do things day after day after day and you start to create a streak. Human beings don't like to break the streak. So that becomes a motivator in itself.
Kellie [00:15:04] It's interesting, and I know positive body image is really important and acceptance. The reality, however, for many who have had breast cancer, a lot of women have hormone therapy, and that is notorious for weight gain, isn't it? So on top of a diagnosis and wanting to reduce recurrence and try to get back to feeling good about your body after you feel like it's possibly betrayed you, hormone therapy can really play with your emotions and your physical being.
Charlotte [00:15:39] Yeah, it's both a motivator and an obstacle for behaviour change. So on the one hand it's like my body doesn't look the same. I've got weight gain, I've probably got arthralgia, which is the feeling of like joint and muscle aches and pains. And I've got people like Charlotte telling me exercise will be a good idea. That'll help. And it feels like, Are you kidding me? You know, I'm when I stand up from a chair, I'm hunched over like a 90 year old woman. And it takes me a while to kind of for my joints to warm up. And the idea of exercise can feel very kind of counterintuitive and it can absolutely act as a barrier. What I know, because of my own experience with hormone therapy, was absolutely counterintuitively, it did work. It really helped. I don't know if it was just psychological. I don't think it was, I think it was physical as well. I think it did somehow do things physiologically that seem to mitigate the the chemical effect of the hormone therapy. But I for sure know that it helped me psychologically. It gave me a belief in myself that I wasn't broken and that I wasn't, even though I felt like I was an 85 year old woman, I could see that I wasn't because I was able to keep being mobile. I think I talked in maybe the exercise episode in series one about exercising in front of the mirror and being able to see that when I could see my muscles flex, that actually sent my brain a message that I am able and I can do and I am strong or regaining strength and capacity. So all of this stuff really does matter. But about like so many things psychologically, we need to do them to find out like we can sit and talk about this stuff like and I do in therapy. And a lot of people with behaviour change will come in so frustrated because it's like, I know I need to do this, I want to do this and I'm not doing this. And why is that Charlotte? And sometimes the best solution is that you give yourself the chance to just try it and the trying, it informs your experience and it allows you to then draw down on that experience and go, okay, well actually that did help. And even if I'm not quite sure exactly why it helped, I feel positive about I feel like it was helpful. So I'm going to do more of that.
Kellie [00:17:50] So awareness is the first step to knowing what you're doing.
Charlotte [00:17:54] You can't change what you don't know you're doing.
Kellie [00:17:56] For an example, if you say, I know I don't exercise enough or I know I have too much dairy or I have too much alcohol, when people say that, is it possible that they're aware but they actually don't know. So if you were to keep a log, for example, that could possibly be a real eye opener. I know you spoke in the first series about keeping a log of your sleep and things like that because you knew you weren't getting enough, but it wasn't until after you reflected back on what you'd written down that you like. Wow.
Charlotte [00:18:29] Yep. Data logging is a really helpful thing because most of us can remember what we did in the last day or two. But if you said to me like, you know how much sugar or how many glasses of wine or how many pieces of cheese did you have last Monday, I mean, I wouldn't be able to tell you. So by data logging over a couple of weeks, we turn our perception of our behaviour into actual hard data, into evidence. The other thing that we know for sure is that in this space, in behaviour change and in substance sbuse territory, humans underreport. We routinely do underreport. But if you're data logging authentically, you're more likely to get a closer representation of what you are actually doing. It is usually the case that when I suggest to my clients that, okay, what I want you to do between now and the next session is to data log the particular behaviour that we're talking about changing. When they come back in, they're almost always quite surprised because they're almost always doing more of the unhelpful thing than I thought they were, or less of the helpful thing. And that's a really good starting point because. If you think you're having four glasses of wine a night. And then I say, Well, let's have that and go down to two, then that's very different. If you discover that you are having eight glasses of wine a night and Charlotte is trying to get you down to two, that's not going to work for a start. So starting from gathering actual hard data, evidence of your behaviour is a really good thing. And the other thing that's good about it is that awareness acts as a moderator. And that sounds weird, but as soon as you actually start to keep accurate track of what you're doing, that awareness seems to act as a limiting effect on what you're doing. So if, for example, it's how many Tim Tams you're eating and you think that you're having seven, and then you discover that you're eating a whole pack, you know, every two days. What you often find once you've data logged for a couple of weeks is when you go to eat the next Tim Tam you actually pause and you think, I wonder if I want to have this and you quite often don’t.
Kellie [00:20:30] I wonder if I want to write this down and have Charlotte look at it.
Charlotte [00:20:35] That’s quite possibly part of it. So there's accountability to Charlotte, but what it does is it introduces accountability, principally awareness, but then accountability to yourself. And I think that's one of the most fascinating things about psychology is how our brain kind of does some of that stuff almost independent of us even knowing. But I'll give you another example of behaviour change that I had recently, which I only just thought of now. I had a knee injury years ago and my left knee, the kneecap was shattered and it will it will never be a good knee again but I went and saw an exercise physiologist for the first time. I don't know what took me like six years to do. That would have been a very good idea to do it sooner because she's fantastic. Anyway, she said to me, What's your goal? And because she asked me what my goal was, I felt like I had to have a goal straight away. I didn't have a goal, but I went, Oh, I just want to walk on uneven ground more comfortably thinking to myself, That's not my goal, but I don't know what my goal is. Anyway, I went home and I was watching TV and I saw a middle aged woman squat down to pick up something off the ground and stand back up again in one kind of fluid movement. And I thought, That's my goal. That's what I want to do. I can't do that now. And so I went back to the exercise physiologist and I said, right, new goal I want to be able to do this move. And I described it. And she went, Right, okay. So she sent me some exercises, which was a lot around kind of like for anyone who's done plies like ballet it’s just that sort of squatting and quickly pushing up. Doesn't matter about the technical stuff. But the really interesting thing that happened to me was that for years when I've squatted down, I have squatted with my good leg and I have put my bad leg out to the side. I have not tried to do the fluid movement up. I have assumed I couldn't because it always hurt. And as soon as I set this goal, I stopped doing that without me realising and I started trying with my bad leg. I started trying to do the squat down stand up thing. Now I couldn't do it exactly the same as I can with my good leg, but I stopped doing the crab thing of putting my leg out to the side. I sort of noticed it after I'd done it a few times. And I was like, Oh my God, I only started doing that because I identified that I wanted to change the behaviour and I said it out loud to someone else. And that's sort of like it was like a little seedling in my brain. And my brain then started to go, Well, if you keep putting your leg out to the side when you squat down, that's not going to help. And I started to operate in a way that was helping me get to where I wanted to go. Just by the awareness and saying it out loud.
Kellie [00:23:20] It all sounds so simple.
Charlotte [00:23:21] Oh, doesn't it just. But I mean, that genuinely happened.
Kellie [00:23:26] Now you’re squatting like a boss.
Charlotte [00:23:29] Well, not quite, but I'm not squatting like a crab which is what I was doing. So I just think it Yes I mean, it does sound a little lovely, doesn't it. But that's the God's honest truth that happened to me. And I was like, quite delighted with myself to be able to move myself along in that direction. But I'm actually just a bit astonished that that's what that's what our brains can do if you give yourself the chance. And if you'd said to me that by saying out loud I wanted to be able to smoothly bob down, pick up something off the ground and stand up again, that that would within a week or two start my body behaving and I would have said, you've got to be joking. What an absolute load of crap. But it happened.
Voiceover [00:24:13] Your first call after being diagnosed with breast cancer can be difficult. BCNA’s Helpline can help ease your mind with a confidential phone and email service to people who understand what you're going through. BCNA’s Experience team will help with your questions and concerns and provide relevant resources and services. Make BCNA your first call on 1800 500 258 or email firstname.lastname@example.org.
Kellie [00:24:45] Talk us through the stages of change and how it happens.
Charlotte [00:24:50] Sure. So there's this model that we use in behaviour change in psychology, and anyone who's been to a psychologist around behaviour change may well have heard of this model. It's a circle in terms of an image and I'm going to just kind of describe what the circle looks like at the top of the circle where the 12 would be on a clock. There's the first stage which is called pre contemplation, and pre contemplation is the stage where the person who's going to engage in the behaviour change may not even be thinking about it themselves. Maybe somebody else is, is noticing that, you know, maybe their oncologist is saying, look Charlotte, I really think, you know, I'd like you to think about how much alcohol you're having or how much exercise you're doing or how much sleep you're having. And I think, you know, be good for you to pay some attention to that. So somebody else is perhaps thinking about it. You're not. The next stage at about 2:00 is contemplation, which is where the person themselves is now thinking about it and going, hmm, okay. I reckon that maybe it would be a good idea for me to like perhaps think about doing something about that. But all it is is thinking. And then at about 4:00 is determination. And that's where you've moved from thinking about it to deciding that, yes, actually I do want to do something about it, but maybe I haven't got much idea how to do it.
Kellie [00:25:59] So you've got motivation.
Charlotte [00:26:00] I’ve got motivation. I'm ready. But maybe I don't have any experience in changing behaviour or particularly changing this type of behaviour. And then at about 7:00 we've got action. So that's where you've moved from determination into action, which is I am doing it, I am changing my behaviour. And then at about 9:00 and this is really important, we've got relapse. When the behaviour change model was first developed by researchers, it didn't have relapse incorporated into it because the idea was that you change behaviour and then you're good to go and you get it right 100% of the time every time after that. Well, they discovered that all humans don't and humans relapse. In fact, I think every single human relapses in behaviour change. So they wanted a model that incorporated that because they didn't want people to feel like they'd failed if they weren't able to kind of like complete the change as per the model. So the model has relapse in that, which means if you relapse, it's like going, okay, well that was probably always going to happen. So I've got to get ready to then get back on the horse. And that's where we are, back into what we call maintenance, which is I continue on my behaviour change path.
Kellie [00:27:05] Do we actually go back to 12:00 with pre contemplation?
Charlotte [00:27:11] No. Not necessarily. We often jump back to determination, usually. Especially if they're frustrated and they've been kind of trying and not managing to execute it or execute it consistently. They'll come back and go like I keep going and doing it and then I fall off the horse and then I'm like, you know, I'm back to determination and I can't seem to get it going. But what this does generally improve with is repetition and repeated attempts. But also a lot of it is about identifying what the obstacles are and removing them. Because if you are living a life where the obstacles keep presenting themselves and you haven't worked out what the obstacle is, well, you're probably going to keep stumbling. So for example, in episode nine, when I talk about exercise, one of my obstacles in exercising was if I have to get changed, That sounds so pathetic, but...
Kellie [00:28:04] I remember, that's where you decided to do it in a nightie.
Charlotte [00:28:07] That's right. I exercised in my nightie. So my runners are in line of sight so I can open my eyes and I can see my runners. They've already got their socks because even going to get my socks is enough for me to go Yeah, too hard. So I get out of bed in my nightie, socks and shoes on straight down the stairs onto the treadmill, all within about 1 to 2 minutes. And if something gets in the way of that, then the chances that I will not engage in the behaviour change increased dramatically. So figuring out what your obstacles are is a really important part of increasing the chances that you will successfully engage in behaviour change.
Kellie [00:28:43] What if the obstacles are things like young children who need to be dressed? Or other commitments like work?
Charlotte [00:28:52] Yeah, absolutely. And We are really good at justifying, excusing and letting ourself off the hook and all the more so when it relates to the needs of loved ones, because it's a really easy get, you know, it's a really easy thing to go, Well, of course I've got to prioritise the children, of course I've got to get to work on time and I'm not going to say that those things don't matter because they absolutely do. But it is then about going, okay, well if they're the obstacles, then, And some of this requires some creativity and some of it also requires some discipline and not always letting those things be the priority, Sometimes it's about going, okay, well, I'll meet their needs and we will talk about this in boundary setting. I'll meet their needs, but maybe I'll make them fractionally later, or that I will do my thing But I'll have to get creative about when I do my thing. I mean, I've worked out as many people do that if I'm going to exercise, I need to plan to do it early in the day. Research has shown the later that you plan to do it in the day, the more likely it is not to happen.
Kellie [00:29:55] And for me, I know that when you've got something on your to do list, the further it gets along in your day, it's sort of like hanging over your head the whole time. It does actually really weigh heavy on you.
Charlotte [00:30:09] It doesn't feel like a positive. It doesn't feel like it's filling my cup. It starts to then start to feel like a stressor. And that's kind of not what we want. If you're wanting it to be a helpful behaviour change. So yes, identifying those sorts of things and understanding that yeah, if I plan to do my gym workout at 6 p.m. and all it feels like is I'm carrying a lead weight all day, well then that's not working for you and we need to revisit that and think about alright, well is there another time of the day? Is there another type of exercise that might be a better fit for you and make it more likely that you're going to do it? A lot of this is again very individual and what works for me isn't going to work for somebody else. So it is about figuring out and sometimes you can figure it out youself, sometimes you can figure it out working through it with a friend or with a therapist.
Kellie [00:30:55] So your trick, if you like, or path of least resistance, is putting your runners by your bed and you exercise in your nightie. What are some other cognitive tricks, if you like, that people could use for those that with wanting to make changes to their diet. And I know we talk about we've talked about reducing alcohol before but if you love a cheeseboard but need to tone it back, how smart are we at tricking ourselves?
Charlotte [00:31:28] One of the things that you can do when you're trying to change your behaviour to really examine the components of a behaviour we call this in psychology, we call it operationalising, which is where you break down a particular behaviour into little bite sized bits, if you like. So if you think about something like drinking a glass of alcohol or eating things off a cheese platter or off a dessert tray, you want to break it down and see if you can identify the component parts. So let's go with maybe eating cheese. Eating cheese means you are almost always using your hands and your mouth, sometimes maybe a knife or like a small like a utensil. But mostly it's bite sized pieces of food that go into your mouth in kind of like one whole piece, like with perhaps a crunch and a soft bit maybe if you’re having like a soft bit of cheese with a biscuit. And so thinking about, okay, well is there something and we this is approximating which we talked about in series one. Is there something that can approximate that experience. So what could I put out on, for example, a platter, on a board that maybe looks like a bunch of small things that I can pick up in my hand, maybe pair with something, something soft, with something crunchy, and then pop it in my mouth and get maybe a combination of my notes.
Kellie [00:32:46] And I'm rolling my eyes just a little bit and I'm thinking, are you going to try and tell me that the crunch and the something is going to make me think I'm having a nice big slab of French, you know, soft cheese on a biscuit?
Charlotte [00:33:03] No, I am not. But I am going to say that your brain's not that smart and that it might get enough of the feeling that you will be satisfied and that the deficit or the bit that you're not getting. So the piece of that that cheese high that you're not getting will be offset by the good feeling that you're getting of the behaviour change. So it might be that you have a combination of say and I know this might sound lame, but you might have a combination of say some dip and some cut vegetables. So it might be crunchy carrot with soft hummus. Now that's not ever going to be the same as French brie on a beautiful go cracker cracker. But it's also not nothing. So if you're going to say to me, okay, if I've got the option of French Brie on a cracker or nothing, or crunchy carrot and hummus, what's the compromise?
Kellie [00:33:57] It sounds like it's an exercise in trying to outsmart yourself.
Charlotte [00:34:02] Yeah, I mean, it sort of is. I mean, our brains are clever, but they're not always that clever. And I think, again, it comes back to being able to give things a try. And if you try this stuff and you discover, well, that was a complete waste of time And I long for the creamy cheese and the cracker. Well, then you can go, Right. Well Charlotte's full of rubbish and I'm not going to do that again. But trying is how you find out. Again, I use the same sort of strategy when I'm talking about things like chips and chocolate, you know, things that have got a little burst of flavour that go into your mouth in single pieces that you use your fingers for often come out of a packet. There are other things you can substitute for those things like. Dried fruit or individual raspberries and strawberries. Will they feel the same as a rocky road? No, they won't. And expecting that they will is going to only lead you to disappointment. But understanding that they are an approximation and that they're an effective compromise that gives you enough of what you want like enough of the good or enough of the helpful without the unhelpful bit. And again, it doesn't have to be all the time and it doesn't have to be forever, but it's going, okay, well, maybe I can do this for a while. And then instead of being like having the chocolate or the chip as a regular, it can be the exception. And if you can switch around the helpful behaviour to be the dominant one and the unhelpful behaviour to be the exception, then you're in front.
Kellie [00:35:31] Okay, so you often say that we take in information through our eyes. If I am looking at a grape, I'm pretending it's a nut. How does that work? It's a sensory thing is it? It is a grape. It's not a nut.
Charlotte [00:35:55] Yeah. So I don't want to send the message that we're trying to fool ourselves. It's more about understanding that these are strategies that are using the good parts of the behaviour and eliminating the less helpful parts of the behaviour. So it's not about, yeah, we can ever persuade ourselves that a grape is a nut or vice versa. And that's not what I'm trying to do.
Kellie [00:36:21] Non-alcoholic drinks. And I know we keep coming back to alcohol, but it is the reality and it is worth talking about. And non-alcoholic offerings have come a very long way. So before, when we'd be encouraged to use the wine glass and put sparkling mineral water in it for the experience, now we have so many other options.
Charlotte [00:36:45] Yeah, absolutely. And I think that that's a really interesting development and it's probably pretty recent. Like I'd say even in the last maybe couple of years. I know myself that in family and social network kind of settings, I'm finding now it's not uncommon at all for, you know, in the eski along with the standard offerings of booze, there's now non-alcoholic or low alcoholic options. And the other thing that's really interesting is that the stigma or the ribbing that used to go with not having a drink seems to be reducing. Now, I'm sure there would be environments where that's not the case, but I've been like pleasantly surprised to find that there does seem to be an increasing acceptance about the merits of a bit less booze, and that's a big change in the Australian culture. And I think again, the more that we take a risk and try this and see what happens, the more that people can have the experience of like, well, maybe that is something that I can actually consider doing.
Kellie [00:37:46] And it can be without being such an obvious statement of, Hey, I'm not drinking, because to not be looking to be engaging in a social drink must add to isolation for people.
Charlotte [00:38:00] Exactly. And some people would even go so far, I think to not go to social events if they feel like, oh, I'm going to stand out, you know, not only do I feel like I'm standing out because maybe I've lost my hair or because I everyone knows that I've been through cancer treatment, but then I'm going to be there and I don't want to be the evangelist and I don't want to be cancer girl. But on the other hand, I also don't want to drink alcohol as much or possibly at all. Yes, being able to feel included because human beings like being included and accepted in a tribe, in a group. It feels safe, it feels comfortable. If you feel like you're standing out from the crowd, the spotlight's on you, or that your behaviour is, you know, like incompatible with your tribe that can make you feel really vulnerable and it can make you feel really isolated when you're already feeling isolated. I guess another example that I sometimes use in relation to approximating and that is around again, around drinking. I don't want to go too heavy on alcohol because I don't want to sound judgy at all, but this is sometimes helpful. With one client we worked out that she would often come home and go straight from sort of the car to the front door to the fridge and grab the bottle of wine and pour a glass and have it. And this was very much around the idea of needing to drink as a way of coping and needing a drink at the end of a hard day or needing a drink to get through what was going to be a tough evening. And I'll talk about that in a sec. She conceptualised the alcohol as something that soothed her in approximating this experience. We were trying to look for something else that might soothe her, that was also related to being in the kitchen and drinking out of a vessel, if you like. And I said to her, Is there ever a time in your life when you can remember being soothed by drinking a liquid? And she said, Well as it happens. When I was 12, I used to go to my grandma's house after school every day and we would have tea and grandma would make nice pot of tea and we'd play ladies and we'd have the tea. And it felt really soothing. It felt emotionally kind of like safe and comforting. And I said to her, okay, well, what's similar about the tea drinking and the, if you like, a glass of wine? And we identified that, you know, you had to be in the kitchen, you had to go to things like the cupboard and get out a vessel and you needed to prepare the liquid and then you needed to drink it. My client went out and bought a nice teacup and saucer that was similar to what she remembered having with her grandmother. And instead of coming home and going straight to the fridge for the wine, she comes home and makes herself tea and it helps. It soothes her. It gives her the sense that there is something kind of like nice at the end of the day. Now, I'm not going to be Pollyanna and say that it gives you the same physiological effect as a glass of wine does. But that's kind of the point. We're trying to eliminate that from her life, and she found that it was really helpful. So that's just another example. But on the topic of like what we need when we get to the point with any substance or behaviour and we feel like we're doing it because we need to. The risk is that we've then created a belief loop around I can only cope if I do that thing or I don't do that thing. That harks back to that rigid mindset where it can feel like the only way I can cope is to absolutely make sure that I have access to that substance or that behaviour, and that can then act as a perpetuater. And that's not a good thing. We can develop what we call a psychological dependence on that behaviour and being able to reduce that or limit that is really helpful and arguably quite important, particularly in a cancer space where we're wanting to maintain healthy lifestyle behaviours.
Kellie [00:41:35] So we've talked about the stages of change and complacency and motivation. When are we most successful in changing a behaviour?
Charlotte [00:41:46] We're most successful when we when we're able to see the benefits of the change as soon as possible after starting. You know, I was talking before about how behaviour change successfully becomes part of your everyday experience when you've managed to do it fairly consistently for 77 days or thereabouts. The tricky thing with behaviour change is that for example, and this is where we have great difficulty persuading young men to stop smoking is because the bad side, the downside, the negative consequences considered to be so far away. You know, if I'm 17 and I'm enjoying cigarette smoking and someone saying you're going to get lung cancer, quite often people will think, oh, well, that's, you know, going to happen when I'm 60 or 70 and so far away that it's not enough of a motivator to be able to then engage in the behaviour change. If we start to change our behaviour and we start to see the benefits of it reasonably quickly, and that's what I was saying, the first couple of weeks are the hardest because that's when you're not likely to see the change, you're likely to feel the pain, but you're not likely to get the gain. And so that's where hanging in there and understanding that it is slow, incremental change over time and you won't see the benefit for at least a couple of weeks. But once you do, that will act as a motivator. The other part to that is that behaviour change that's done frequently with not too long between each episode, if you like, is going to give you that feeling of repetition which builds mastery and confidence, which we talked about in another episode. If you only do a behaviour change once a week, then it's not likely to have the same positive effect as doing something every day or every second day because your repetition is giving you the chance to feel the benefits sooner.
Kellie [00:43:27] And as you mentioned, relapse/interruption is going to happen.
Charlotte [00:43:32] It is going to happen. And I use the word interruption quite deliberately. I didn't used to I don't mind relapse, but I feel like relapse almost has more of a negative connotation. It sort of feels like a setback or going backwards. I like interruption because it sort of feels a bit more like you just in the same spot that you were, but you're just not able to move forward. Yeah, it's a pause. And so I think about, you know, with my treadmill, I mean, I make it sound like a treadmill every day. I do not treadmill every day. I'm here in in Melbourne doing the podcast. I'm not treadmilling. So there are interruptions to it and I view them as just that. They're just interruptions and often they are things outside my control or things that that simply cannot be changed and that's okay. And being able to frame them as an interruption again that's a bit of a cognitive trick. Means that I'm less likely to engage in negative feelings around that. I can be quite neutral about interruption that doesn't feel positive or negative, it just feels neutral.
Kellie [00:44:30] Great food for thought or not food.
Charlotte [00:44:34] Or grapes and nuts.
Kellie [00:44:37] Thank you for joining us on this episode of Upfront about Breast cancer: What You Don’t Know Until You Do – Unlimited with the very funny Dr. Charlotte Tottman. This podcast has been made possible with thanks to our sponsor, Sussan. If you found this episode helpful, please share it with someone you know. And of course, BCNA has many great resources to assist you when you need it. Go to bcna.org.au. In our next episode, we're going to talk cancer from a partner’s perspective. Lots to learn Charlotte, isn’t there?
Charlotte [00:45:11] So much to learn, Some of it a little disconcerting.
Kellie [00:45:15] Thanks for listening. I'm Kelly Curtain, and it's good to be upfront with you.
Voiceover [00:45:19] BCNA’s Online Network is a friendly space where people affected by breast cancer connect and share their experiences in a safe online community of support and understanding. Read posts, write your own, ask a question, start a discussion and support others. You're always connected, which means you're never alone. As our online network is available for you at every stage of your breast cancer journey, as well as your family partner and friends. For more information, visit bcna.org.au/onlinenetwork. Coming up in episode seven of upfront about breast cancer. What you don't know until you do. Unlimited with Dr. Charlotte Tottman. The view from the other side of the bed: The partners perspective.
Charlotte [00:46:05] As ever it comes back to communication. Sometimes when we're living with the cancer experience and we're thinking and feeling it all day, every day, we can slip into making the assumption that the people around us are similarly just as aware of, you know, things like the side effects or the lingering fatigue or the fact that my brain doesn't work the way that it used to, or that I'm scared about the future, and that if we don't put language around that again, we prevent the other people around us from understanding our position. You can ask your partner like, Hey, how are you going? But also how do you think I'm going? Like it's a three step thing. It's how are you? How am I, how are we? And that's quite cool. I was an absolute nightmare to live with, and he was aware that I was, as well as being fractured by hormone blocker treatment, I was also struggling with my own insecurities about body image and needing reassurance. He said to me, you know, he was also needing reassurance, just like I wanted to feel like I was still desired and desirable. He also wanted to feel like he was desired and desirable, and I wasn't giving him that, and he didn't want to put that on me. He didn't want to be rejected, but he also didn't want me to feel pressure.
Voiceover [00:47:21] This podcast is proudly brought to you by Sussan. Our theme music is by the late Tara Simmons. Breast Cancer Network Australia acknowledges the traditional owners of the land and we pay our respects to the elders past, present and emerging. This episode is produced on Wurundjeri Land of the Kulin Nation.
Let’s be upfront about death, dying and mortality.
Let’s be upfront about pain, side effects and palliative care.
Let’s be upfront about different perspectives during and beyond a breast cancer diagnosis.
Let’s be upfront about life after cancer treatment.
Let’s be upfront about the challenges for those living with metastatic breast cancer.
Let’s be upfront about causal beliefs and how they impact our feelings and behaviours.
*This article does not provide medical advice and is intended for informational purposes only.
Please consult a medical professional or healthcare provider if you're seeking medical advice, diagnoses, or treatment.