Toothpaste stickers: simple and profound

Ashish Bhatia, GP; University medical tutor; founder of Really Well Being

Published in JHH17.2 – Mind-body self-care

It was a hot day. The fan blew a pile of prescriptions off my desk and as I knelt to pick them up something helped me pause. Slowly lifting them off the floor I read each person’s name, holding them in my hands and heart. I remembered that there was more to our lives than problems and prescriptions – and I was also able to see our beauty and potential. Now I sometimes call myself a GP, which playfully means gentle presence to me.This flows as a unifying quality through my roles as father, fighter, fool and friend, and most recently as founder of Really Well Being www.reallywellbeing.com

In GP consultations about lifestyle change patients set good intentions (eg to take a morning walk) but they rarely translate into sustained actions for changes. In this article a London GP describes four demotivating factors – fear, fatigue, forgetting and floundering – how habits begin and adapt, and the benefits of creating individualised toothpaste stickers during consultations. They appear to enable habits to change and the change to be maintained. Users report feeling empowered, less anxious about habit change, and more able to sustain those changes with less effort.

No act of kindness, no matter how small, is ever wasted.

Aesop, 620 BC

Would you like to try something new that can help bring out the best in you?

Toothpaste stickers (TPS) are stickers that go on your tube of toothpaste! They are as simple as they sound and yet the results are profound. These stickers are unusual because they are handwritten by you with an ‘I am … and I can …’ phrase.

Examples would be:

I am improving my sleep and I can turn off my phone one hour before bedtime.’ ‘I am a helping myself be a healthy eater and I can only drink water after 8pm.’ ‘I am a grateful being and I can give thanks for something after I brush my teeth.’

This simple practice uses tiny habit stacking (Fogg, 2020) to combine an already powerful habit (brushing your teeth twice a day), with a positive affirmation (an ‘I am’ phrase that reminds you of your core identity/values). Simultaneously the ‘I can’ phrase empowers positive actions by gently reminding you of something small you can do, which brings out the best in you. When they are combined these tiny changes often produce a keystone habit that can cascade (domino style) to improve other aspects of your life (Duhigg, 2012).

Because you automatically see the sticker at times of the day when you are especially receptive to priming and habit change (on waking and before bed), they can have a powerful influence on your sense of identity and behaviours (Diekelmann & Born, 2010).

Also, if other members of your household see them they may socially commit you to standing by what you value, even though it might involve some teasing.

I have been offering toothpaste stickers in my work as a GP for several years as a tool for empowering individuals to take positive actions to improve their lifestyle, with the intention to humbly facilitate people to align with their authentic self and core purpose and to live well. I have found that this can have a profound impact on peoples’ health and performance (Bodai et al, 2018).

Previous healthy lifestyle conversations in our consultations generated many good intentions (eg to take
a morning walk), but rarely translated into sustained actions and changes of behaviour. People often reported their flagging was due to ‘four Fs’ (fear, fatigue, forgetting and floundering). They would describe feeling a loss of confidence in the behaviour change especially when a life situation became more challenging. This would sometimes lead to a sense of failure, resignation and a reluctance to learn from the experience and to try again. This ‘learned helplessness’ and failure to nurture our sense of agency is a recognised factor in poor outcomes (Maier et al, 2016). So I began inviting people to write a toothpaste sticker during our consultations, at a time when they were in a highly motivated and activated state. Soon they were reporting that they felt empowered and less anxious about habit change, as well as being more able to sustain those changes with less effort. They have also reported a powerful sense of focus for kindness and honesty. If they did not follow the habit that day then the sticker still acting as a friendly reminder rather than a reprimand, offered a fresh start. The helpful recognition that the hero’s journey is challenging but also worthwhile transforms the four Fs from foes to friends. As the sticker is selfwritten in the consultation, so the person has a first mental rehearsal at that time and, with coaching, can recognise potential challenges and be helped to transform obstacles into opportunities to respond helpfully (Bungay & Michael, 2016). The only task required of them is to remember to put the sticker on the toothpaste, which is made easier by sticking it to the back of their hand during the consultation. Perhaps the little discomfort as the sticker is removed acts as a temporal primer for the start of their change adventure and will be a trigger for action. The minty fresh sensation of tooth brushing could feasibly set up an association with making a ‘fresh start’ to their habit-changing adventure every day.

There is good evidence that this process (according to self-affirmation theory) is effective in areas as wide-ranging as improved eating, smoking cessation, mental health, couples relationships, school grades, bullying and working performance (Cuddy, 2015).

There are deeper (meta-cognitive) benefits too. With practise the person who uses toothpaste stickers also develops something that I call ‘A MAP’ to success.
Acceptance, Mastery, Agency and Purpose are a quartet of qualities found in people who ‘succeed’ beyond the limits their circumstances would predict. Such success can translate into significantly better health, wellbeing and performance outcomes (Meijer et al, ). These qualities also feel good, acting as they do as intrinsic motivators, which we know to be associated with improved performance, and contrasting with extrinsic motivators such as financial or physical rewards (Pink, 2009). Common phrases I hear in my practice are ‘I feel alive again’, ‘I believe in myself’ and ‘Now I know I can change that, what else can I achieve?’. From my perspective it feels hugely rewarding to engage with another being as they realise their beauty and potential. I feel too that these interactions have inspired improvements in my own health and wellbeing: something the evidence suggests can ripple out to improve the health of those under my care (Oberg, 2009).

Put simply, a habit is a (often unconscious) behaviour which gets repeated in response to a stimulus. While these automatic processes are indispensable for us to function efficiently they can, as we all know, be unhelpful too: what starts off as a comforting habit doesn’t really help.

So how do habits work? In my experience habits ‘START’ and recycle with five stages.

Setup – these are the internal and external factors that predispose the habit happening, eg cookies on the kitchen shelf and the memory that cookies can be comforting (a mentally rehearsed pathway from previous cycles of habit).

Trigger – these are factors that bring on the habit behaviour pathway. They often relate to situations – a certain time, or place, or persons, and preceding trigger events (eg standing in the kitchen, after a stressful day, when we are in a physiological dip and maybe see someone else eat a cookie on a TV advert). This sense of anticipation and release is initially mediated by the brain’s dopamine system (Wickens et al, 2007) that causes us to want, desire, seek out, and search. As dopamine oscillates in ultradian rhythms it increases our goaldirected behaviour and makes us curious about ideas and information (Pink, 2018; Mihaly, 1990).

Action – is what we do. It is often a default (automatic) behaviour that comforts in the short term but as with addictions, in the long term fails to help, or worse generates other problem, eg transform into a cookie monster, eat lots of cookies, perhaps without really tasting them.

 

 

 

 

 

 

Re-action – is what follows the action, like the pleasant sugar-serotonin-endorphin rush from eating the cookie but then the later guilt reaction. This can reinforce comfort-seeking behaviour and a disassociation from the underlying issues that led to the original discomfort.

Previous healthy lifestyle conversations in our consultations generated many good intentions, but rarely translated into sustained actions Click To Tweet Try again – if the habit cycle repeats in a stimulus response loop, the unwanted behaviour will be reinforced and amplified. This may happen even though we
consciously try to change it, because we keep unconsciously visualising and rehearsing the behaviour. For example, telling ourselves not to think about cookies
causes us necessarily to think about the cookies we don’t want to think about. This kind of ‘paradoxical intent’ and a means of graceful liberation through presence practices was described by Viktor Frankl in his psychological exploration of ‘man’s search for meaning’ (Frankl, 1984) and has been pondered through time from many physiological, phenomenological (Siegel & OverDrive, 2018) and spiritual (Tolle, 2004) perspectives.

The good news is that by understanding this cycle and what makes habits stick, you can gently redirect the flow of attention and action towards preferred behaviours and outcomes. Our ability to mentally adapt can enable old unwanted habits to fade, though it will not erase them. However, as we reinforce new helpful habits, neuroplasticity (‘neurons that fire together will wire together’) will eventually embed the different associations and actions into the hard-wiring of new nerve pathways. Toothpaste stickers (TPS) harness this using

7 features of sticky habits:

  1. Supportive. TPS offers kind inspiration twice a day when we brush our teeth, without relying on memory, motivation, external approval or reprimand. When
    seen in the morning they set us off on the right track and before bed they help us unwind and effortlessly reinforce new habits while we sleep (Diekelmann & Born, 2010). Some people use TPS in other settings too (eg ‘I am a healthy eater and I can count down from 10 to 1’ stuck on cookie jars) and also adapt brushing their teeth more frequently (eg after meals to affirm ‘I am hungry for life and I can close the kitchen after meals’).
  2. Simple. ‘The road to China starts with one step’. Being small, TPS invites compassionate attention to the achievable small steps that cascade into bigger changes. I have found it’s best to start where you are with an ‘I can’ goal so small that it is achievable even on a toughest day. Similarly many people find it helpful to use a bridging ‘I am’ phrase like ‘I am helping myself…get fit’ or ‘I am improving…my confidence’ as a gentle half-step toward the new identity.
  3. Satisfying. We respond well to timely feedback, particularly to rewards rather than punishments, and especially if they feel ‘doubly good’ (both pleasurable and meaningful (Fogg, 2020). By aligning a manageable action and meaningful statement TPS offer us a chance to be rewarded for simply trying our best whatever the outcome and to feel doubly good when we do well.
  4. Scored. We have a strong sense of social identity and accountability, even if it is only to ourselves that we feel accountable. Writing our goals down and checking in twice a day asks for honesty and commitment, enabling us to feel encouraged by our success and eventually to view negative feedback as an opportunity to improve. This monitoring process also primes us to look ahead to a future time when we imagine achieving our goal, so increasing the likelihood of it actually happening (Duhigg, 2012).
  5. Simulated. Practise makes perfect. At the time when the original TPS is written, and then every subsequent time it is encountered, the new behavioural habit (identity, attitudes, skills and knowledge) is mentally refined and reinforced. This process is optimised by our state of presence and poise, which is automatically empowered when we stand tall to brush our teeth (Cuddy, 2015). Therefore TPS helps one mentally prepare for a successful performance even in the face of adversity
  6. Spontaneity. No one wants to be trapped or defined, especially by a sticker. The advantages of stickers are that they are self-written and can be modified, but also that they do not last forever. Once the toothpaste is used up (typically after four weeks) the sticker goes too, so that the person doesn’t feel defined by their previous habits.
  7. Serenity. Many TPS users have reported a sense of relative serenity knowing that they are effectively focusing their efforts on something ‘good’. This, they
    tell me, allows them to enjoy the journey of change and make better (less reactive) judgements from their more relaxed state of mind (Kahneman, 2011).

Common phrases I hear in my practice are “I believe in myself” and “Now I know I can change that, what else can I achieve?

Any tool will have its limitations and harms. Yet having seen profound changes in people’s lives (including my own) from TPS, I am now rather boldly sharing it with the public (in free Really Well Being groups), as well as other clinicians and medical educators. Working with a team at Bristol medical school I am also exploring ways of empowering healthy lifestyle conversations with tools like TPS alongside other methods (eg motivational interviewing) as an alternative or adjunct to drug prescriptions If you would like to try it too, I’ve put some notes below and you can download a guide from www.reallywellbeing.com. Do let me know how it goes as I’d love to hear from you and please allow me a little time to reply.

To close I offer a question that arose as a humbling insight from my experience of TPS: if you could have anything you want, what would you really want to want? My first sticker was ‘I am lovingly recycling and I can make good use of surplus lab stickers’. My current sticker is ‘I am a gentle presence and I can see our beauty and potential now.

Now it’s your turn.

Follow the four steps below to make your toothpaste sticker.

  1. What goal would you really like to achieve? (eg healthier body, mind, home, work, relationships)
  2. Can you imagine the feeling of achievement when you try your best? (eg rising to the challenges and resolving the problems).
  3. Now write an I AM phrase in the box. Who would you be/becoming on this journey? (eg ‘I am being kind to myself…or I am helping myself improve…’).
  4. Now write an I CAN goal. What is the smallest thing that you can easily do to make this journey easier, including when you could do it? (see example below).

 

 

 

 

 

 

Tip: the SMARTEST goals are specific, meaningful, achievable, recordable, timely, enjoyable, simple, triggered. See www.reallywellbeing.com for other evidence-based healthy suggestions.

References

  • Bodai BI, Nakata TE, Wong WT, Clark D, Lawenda S et al (2018) Lifestyle medicine: a brief review of its dramatic impact on health and survival. Perm J, 22, 17–025.
  • Bungay S (2016) The coaching habit: say less, ask more and change the way you lead forever. Toronto, ON: Box of Crayons Press.
  • Csikszentmihalyi M (1990) Flow: The Psychology of Optimal Experience. New York, NY: Harper & Row.
  • Cuddy A (2015) Presence: bringing your boldest self to your biggest challenges (Large print edition). New York, NY: Little, Brown and Company.
  • Diekelmann S, Born J (2010) The memory function of sleep. Nat Rev Neurosci, 11(2) 114–126.
  • Duhigg C (2012) The power of habit: why we do what we do in life and business. New York, NY: Random House.
  • Fogg BJ (2020) Tiny habits: the small changes that change everything. Boston, MA: Houghton Mifflin Harcourt.
  • Frankl VE (1984) Man’s search for meaning: An introduction to logotherapy. New York, NY: Simon & Schuster.
  • Kahneman D (2011) Thinking, fast and slow. New York, NY: Farrar, Straus and Giroux.
  • Maier S, Seligman M (2016) Psychological Review, 123 (4) 349–367.
  • Meijer E, Vangelo E, Gebhardt W, van Laar C (2018) [Online] Identity processes in smokers who want to quit smoking: a longitudinal interpretative phenomenological analysis. Health: an interdisciplinary Journal for the Social Study of Health, Illness and Medicine.
  • Oberg E (2009) Physicians’ health practices strongly influence patient health practices, J R Coll Physicians Edinb, 39 290–1.
  • Pink DH (2018) When: the scientific secrets of perfect timing. Edinburgh: Cannongate.
  • Pink DH (2009). Drive: the surprising truth about what motivates us. New York, NY: Riverhead Books.
  • Siegel DJ (2018) Aware: the science and practice of presence: the groundbreaking meditation practice. New York, NY: Penguin Publishing Group.
  • Tolle E (2004) The power of NOW: a guide to spiritual enlightenment. Vancouver, BC: Namaste Publishing and Novato, CA: New World Library.
  • Wickens J, Horvitz J, Costa Rui M, Killcross S (2007) Dopaminergic mechanisms in actions and habits. Journal of Neuroscience, 27 (31).