Freedom of movement and my 'safe room metaphor' - part 2
In part one I explained the basics of the metaphor. If there’s a storm, it seems advisable to take shelter in the safe house. If there’s a threat to your body/system/organism, it probably is best to take protective measures. This seems like a healthy, adaptive response. Generally speaking, the protective actions mean that you give up some of your freedom. Let’s now look at some of the problems that can arise with these safety strategies.
Basically, problems can arise in three ways:
When do you go inside the safe room?
How long do stay in?
And how do you get out of it?
The last category is probably the most important clinically, but in today’s blog I’ll tackle the first two categories. These are important for when you treat patients from the acute phase of their problem.
Some people seem to take shelter too early, some too late. Some go into the safe room when only a little bit of bad weather is passing by. Some stay outside while the heavy storm is already at its climax. Some people look for safety for too long, some get out of the room while the storm is still raging.
But, most of the people, in my experience, seem to have more or less appropriate protective strategies: they go in the safe room at more or less the right time, and stay in for a more or less optimal amount of time. Although there are certainly differences between people, most people use adaptive responses. Only the extremes are maladaptive.
Let’s think about the reasons for variety, and maybe then understand why some people use extreme, maladaptive strategies.
Variation is normal in biology! Although we are all human animals, different people have different genetic make-ups. We’re not born with a blank slate, our personality differences are partly genetically determined. Some of our attitudes, beliefs, behavioural strategies are part of our human nature. Some people are born more protective, some less…
This brings us to the nurture side of the equasion: your past experiences (maybe especially your early years?), your education, your culture, your environment, … also determine your behaviour. If you’ve had a bad experience with a past storm, you’ll probably be more anxious when a storm is coming. Same thing if someone you know suffered damage from bad weather. And the opposite could also be true: if you’ve had many storms hitting your area, but your house was never damaged, you’ll probably react different.
Sometimes people react in a manner that seems maladaptive, but is understandable because of the context. Sometimes you’d prefer to take shelter, but a certain circumstance forces you to stay outside. Think of the following clinical examples: “I know I have to take it easy for a while, but my job/boss really does not allow it at this time.” “My body tells me to rest, but someone has to take care of the children.”
A current piece of information could also explain differences between people, some info primed them to take action. Think of a weather forecast, or an app that predicts local weather, … This information could be wrong, or not entirely right. Information is dangerous! Clinically there are many examples: “You need to rest, you don’t want to end in a wheelchair don’t you?” You’re not allowed to rest!” “You have the knee of an eighty year old.” “Your MRI-scan is really bad.” Be careful and nuanced with your information, and avoid nocebo effects.
If you know why a person has a maladaptive reaction to a threat, that’s a first step. But we have to consider a few more things.
The threat at hand does not have to be an actual threat, it can also be a perceived threat, or an expected threat. So people can take shelter, even in absence of a real, actual threat. This can be because the weather outside is changing, and a you are afraid of thunder and lighting. Or because you had a bad experience in a previous storm. It can be because the weather forecasts predicted a storm, and you take preventive measures. The forecast could also be wrong, and there’s no storm. Maybe there’s only a bit of heavy weather, that needed you to go inside, but not in the safe room. So the meaning of the threat is important. This meaning is highly personal and context dependant.
Also, for biological systems, it makes sense to have sensitive threat-detectors! You want to detect a threat before it is upon you. Randolph Nesse, one of the pioneers in evolutionary medicine, speaks about the smoke detector principle: you don’t want a smoke detector to miss a fire, so you allow the possibility for false alarms. Especially if the cost of missing a fire is much higher than the cost of a false alarm. The rustle in the undergrowth could be a lethal predator, or it could be just a squirrel, or the wind. Missing the former is a huge mistake, overreacting on the latter is a small mistake.
A very good paper on the smoke detector principle is Nesse’s The Smoke Detector Principle, Natural Selection and the Regulation of Defensive Responses. (there are some clinical implications in this paper, relevant to my story, but we’ll cover them in the next post)
This may be a good place to remember that protective action is not all-or-nothing. They can be subtle, they can be major (see figure from Hodges and Smeets in part 1). Sometimes the weather only pushes you on the front porch, or in the house, but not necessarily in the safe room in the basement. You could call it code green/orange/red, or threat level I/II/III/IV.
If you think people use maladaptive strategies, it’s good to know that these actions (whether consciously or unconsciously made) often are understandable, even logical. There’s no reason to blame people for this behaviour, but it is often enlightening to explain their protection. Enlightening, but most of the time not enough to change it. Our responses to threats are mediated by the older, deeper parts of the brain. Rational arguments are often not enough for change, something different is needed: experiences!
Now for the clinical implications of this part of the metaphor, concerning the reactions of people in the more acute phase:
Keep in mind that most of the symptoms can be defenses as well as defects.
There’s a lot of variety in responses, but most probably are adaptive, health promoting strategies.
Some responses may be maladaptive, but don’t judge the person, and understand that these maladaptive responses are often understandable.
In case of maladaptive responses, information (e.g. this metaphor) can be the first step towards change.
Don’t push people deeper in the safe room than necessary! Be careful and nuanced with your explanations and advice. Don’t scare them. Watch out for nocebo.
Don’t get people out of the safe room when the storm is still raging. Although early activation and movement are important, some rest and avoidance may be needed.
Some people need to be put in the safe room, for their own protection. Of course this does not mean we need to immobilise them. But some people tend to go on, no-pain-no-gain-style, and cause damage, or at least disturb the healing process.
Although most people show more or less adequate responses, many could benefit from a more subtle response, a more nuanced strategy, especially after the first few days of protection.
Let’s take a closer look at that last point. You find yourself in the safe room, because you thought it was the appropriate reaction to all the information at hand (past and current), but you’re wondering if your actions were really required. How would you know? You need feedback and information! How does this translate to the clinic? A person in protective mode needs feedback and information! What kind of information and feedback? Well, how does our movement system get its information? By moving! Moving in a safe, varied, explorative, meaningful way.
Actually, the whole last point could be considered part of ‘getting out of the safe room’.