Atlas›Domain IX · Biomedical, neuro & digital›Guide 082
Guide IX-082

Behavioural medicine

Schwartz, Weiss1977
A 17 · L 75 · M 835 interventions in the Trinity explorer
Client cardCompare
[source: …] where a claim comes from[uncertain] not confirmed in a primary source[synthesis] the writer's reconstruction

1. Introduction

Version followed: the field as defined at the 1977 Yale Conference (Schwartz & Weiss, 1978); the Behaviour Change Technique Taxonomy v1, 93 techniques in 16 groupings (Michie et al., 2013); the COM-B model from the Behaviour Change Wheel (Michie, van Stralen & West, 2011); NICE guideline PH49 Behaviour change: individual approaches for intervention intensity, tailoring, maintenance and competences; the WHO report Adherence to long-term therapies (2003) for adherence; the Self-Management Resource Center Chronic Disease Self-Management Program (CDSMP) for group self-management; the AASM guideline on behavioural and psychological treatment of chronic insomnia (Edinger et al.) and NICE NG193 (chronic pain) as pointers.

Behavioural medicine is an interdisciplinary field, not a single therapy. Schwartz and Weiss defined it as the field concerned with developing behavioural-science knowledge and techniques relevant to physical health and illness and applying them to prevention, diagnosis, treatment and rehabilitation; psychiatric conditions and substance use fall within it when they act as routes to physical disorders [source: Schwartz & Weiss 1978, Springer abstract]. The Society of Behavioral Medicine (SBM) was founded in 1978 and the International Society of Behavioral Medicine (ISBM) in 1990, at an international congress in Sweden [source: Wikipedia, Behavioral medicine; secondary]. Its practising arm in psychology is clinical health psychology, which applies knowledge of how behavioural, emotional, cognitive, social and biological factors interact in health and disease [source: ABPP Clinical Health page].

Core idea of how change happens: health behaviours (taking agreed treatments, activity, sleep, substance use, self-care routines) are shaped by a person's capability, opportunity and motivation (COM-B). Change comes from diagnosing which of these is missing and deliberately applying named, replicable behaviour-change techniques, with the person as an active partner who agrees the goals, rather than a passive recipient of instructions [source: Michie et al. 2011 abstract; WHO 2003].

Scope for the psychotherapist. You work on the behaviour and its psychological drivers. You do not prescribe diets, exercise programmes, medicines or changes to medicines; the medical, nursing, dietetic or physiotherapy team sets the regimen, and your role is to help the person carry out what they have agreed with that team, voice ambivalence and side effects to the prescriber, and cope with illness. Nothing in this guide is a treatment for cancer or any other physical disease; it is psychological care alongside medical treatment [synthesis].

Credentials. In the US, board certification in clinical health psychology is awarded by the American Board of Clinical Health Psychology, a member board of ABPP, after verification of education, training and experience and an examination; the American Academy of Clinical Health Psychology offers applicants mentoring [source: ABPP Clinical Health page]. Specific degree, licensure and postdoctoral requirements are on ABPP's general requirements pages [uncertain: not verified]. In the UK, "health psychologist" is a title regulated by the HCPC [uncertain: not verified]. NICE PH49 sets out competences for anyone delivering individual behaviour-change interventions (see Section 3) [source: NICE PH49]. SBM, ISBM and APA Division 38 (Society for Health Psychology) are the main professional bodies; check each for current training routes [uncertain: not verified].

2. Framework

Behavioural medicine has no single fixed protocol. The sequence below combines the NICE PH49 recommendations on assessment, tailoring, intensity and follow-up with the WHO adherence framework; the phase names are a [synthesis].

Phase 0: referral, role and liaison. Goal: agree with the referring team what behaviour is the target, what the medical regimen is, and who does what. Format: a call or letter; consent to share information. Move on when the regimen and your role are clear in writing [synthesis].

Phase 1: assessment (1–2 sessions). Goals: assess the person's health in relation to the behaviour so that recommended actions are appropriate; assess the target behaviour with validated tools where available; assess physical and psychological capability, physical, economic and social context, and motivation; note needs linked to culture, faith, disability, sexual orientation, gender identity and other protected characteristics [source: NICE PH49 rec 8]. For adherence, assess all five WHO dimensions (social and economic, health system and team, therapy-related, condition-related, patient-related) [source: WHO 2003]. Move on when you have a COM-B formulation and the person has named a behaviour they are most ready to change [source: NICE PH49 rec 8].

Phase 2: matching intensity and planning (part of session 2). NICE defines four levels: very brief (about 30 seconds to a few minutes, mainly information or signposting, "ask, advise, assist"); brief (oral discussion, negotiation or encouragement, with or without written support, follow-up or referral); extended brief (similar content, usually over 30 minutes, one or more sessions); high-intensity (usually over 30 minutes, several sessions) [source: NICE PH49]. Match intensity to need; plan reviews before, during and after [source: NICE PH49 rec 8]. Discuss the likely effects of the change on the person's health and wellbeing and on those around them [source: NICE PH49 rec 8].

Phase 3: active change (typically 4–8 sessions for individual high-intensity work; [synthesis] except where a named protocol states otherwise). Goals and planning, feedback and monitoring, and social support are the core technique groups NICE asks for, plus others matched to need, each named and justified [source: NICE PH49 rec 7]. CBT for insomnia typically runs four to eight sessions [source: AASM guideline as reported by Sleep Review]. The CDSMP runs six weekly group sessions of about 2.5 hours, 8–15 participants, led by two trained peer leaders [source: SMRC workshop slides; Virginia Department of Health]. Move on when the behaviour is occurring reliably in the person's ordinary environment and they can review and adjust their own plans [synthesis].

Phase 4: maintenance and relapse prevention. NICE recommends supporting maintenance for at least one year after the intervention: regular feedback and monitoring so help is available if relapse begins, rehearsed if–then plans, changes to the immediate environment, adequate social support, and routines built from small manageable changes [source: NICE PH49 rec 10]. Format: spaced booster contacts (phone, text, app or in person) [source: NICE PH49 rec 7 on remote delivery].

Phase 5: ending and handover. Summarise the plan in writing for the person and (with consent) the referring team; agree re-referral routes [synthesis].

3. Guiding principles

  • Biopsychosocial and interdisciplinary. The field was defined as integrating behavioural and biomedical knowledge [source: Schwartz & Weiss 1978; Wikipedia secondary]. Practical meaning: every formulation includes the medical facts, and every plan is compatible with the medical plan.
  • Adherence means agreement, not obedience. WHO defines adherence as the extent to which behaviour corresponds with agreed recommendations from a health care provider [source: WHO 2003]. Practical meaning: you work on goals the person has agreed with their team; if they do not agree, the task is a conversation with the prescriber, not persuasion by you.
  • Support, not blame. Health-system and provider factors are often neglected in favour of blaming the patient [source: WHO 2003]. Practical meaning: look for cost, access, regimen complexity and side effects before attributing non-adherence to motivation.
  • Adherence and behaviour are multifactorial and dynamic. No single strategy fits all; readiness should be assessed, advice given and follow-up done at every contact [source: WHO 2003]. Practical meaning: re-assess briefly each session.
  • Diagnose before you treat (COM-B). Behaviour depends on capability, opportunity and motivation [source: Michie et al. 2011]. Practical meaning: pick techniques that address the missing component (skills training for capability gaps, environmental change for opportunity gaps, motivational work for motivation gaps) [synthesis on the mapping].
  • Name every active ingredient. NICE asks practitioners to define and justify each technique; the BCTTv1 was built so interventions can be specified and reported consistently [source: NICE PH49 rec 7; Michie et al. 2013]. Practical meaning: record which BCTs (by number) you used each session.
  • Match intensity to need [source: NICE PH49 rec 8]. Practical meaning: do not run six sessions where a brief intervention and a follow-up call would do, nor the reverse.
  • Start with the behaviour the person is most ready to change [source: NICE PH49 rec 8]. Practical meaning: let the person choose among targets the team considers safe.
  • Use windows of openness. NICE names moments such as a new diagnosis or becoming a parent, and also asks services to recognise when an intervention may be inappropriate [source: NICE PH49 rec 8]. Practical meaning: offer change work at these moments, but not to someone in acute crisis or grief who needs other help first.
  • Build self-efficacy. The CDSMP is grounded in self-efficacy theory, built through skills mastery, modelling, reinterpreting symptoms and social persuasion [source: SMRC workshop slides]. Practical meaning: design small tasks the person is very likely to complete.
  • Plans the person is confident in. In CDSMP research, confidence in completing an action plan predicted completion, with a rating of 7 (on the programme's 0–10 scale) a useful cut point, and completing plans, not just making them, predicted later outcomes [source: SMRC workshop slides]. Practical meaning: if confidence is below 7, shrink the plan.
  • Empathic, reflective communication. NICE competences include reflective listening, empathy, rapport and motivating people to self-manage [source: NICE PH49 rec 12]. Practical meaning: technique delivery sits inside a collaborative relationship.
  • Equity. Tailor to culture, faith, disability and other characteristics and address health inequalities [source: NICE PH49 recs 8, 12]. Practical meaning: check that plans are affordable and accessible.
  • Plan for maintenance from the start [source: NICE PH49 rec 10].
  • Stay in scope. Do not set diet, calorie, weight, exercise or medication targets; refer to the clinician who owns the regimen, and pass on side effects and warning signs [synthesis]. BCT 11.1 Pharmacological support is in the taxonomy, but for a psychotherapist it means supporting a prescriber's plan, never advising on medicines [synthesis].
  • Psychological care alongside medical care. Never present a behavioural method as a treatment for a physical disease or an alternative to medical treatment [synthesis].

4. Intervention inventory

The inventory has four parts: A, assessment; B, the 93 BCTTv1 techniques (labels and numbering from the taxonomy; where the published taxonomy summary gave a definition it is paraphrased and sourced, otherwise the operational steps are [synthesis]); C, programme-level methods (brief interventions, adherence, self-management, insomnia and pain pointers, maintenance); D, collaboration in primary and specialist care. Example language is illustrative throughout. [source for labels: BCT Taxonomy v1 summary, HEE; Michie et al. 2013]

A1. Health-behaviour assessment interview

  • Purpose / when: first contact for any referral; defines the target behaviour precisely enough to measure.
  • Steps: (1) Ask the referrer and the person what the behaviour is, in observable terms (who, what, when, where, how often). (2) Establish the current baseline in numbers or a recent typical week. (3) Use a validated instrument for the behaviour where one exists, as NICE asks [source: NICE PH49 rec 8]; describe licensed instruments to the client without reproducing items. (4) Ask about the person's health in relation to the behaviour and confirm with the team any medical limits on what is safe [source: NICE PH49 rec 8]. (5) Map triggers, consequences, beliefs and emotions around the behaviour [synthesis]. (6) Ask about protected characteristics, culture, faith and practical circumstances that affect the plan [source: NICE PH49 rec 8].
  • Example language (illustrative): "Let's get really specific. On a typical day last week, when did you take the tablets the team prescribed, and when didn't you? What was going on at those times?"
  • Watch for: vague targets ("be healthier"); a behaviour the team has not actually recommended; medical limits you are unaware of. Working: you can state the behaviour and baseline in one sentence both you and the person agree on.

A2. COM-B diagnosis

  • Purpose / when: after A1, to choose techniques that fit the barrier.
  • Steps: (1) Capability: physical (bodily skill and capacity) and psychological (capacity for the thought processes needed, such as comprehension and reasoning; in practice knowing how, memory, attention). (2) Opportunity: physical (what the environment affords: cost, access, time, equipment) and social (what the cultural milieu affords: family and workplace norms, shared language and concepts). (3) Motivation: reflective (evaluations and plans) and automatic (emotions and impulses arising from associative learning or innate dispositions, including habits) [source: Michie et al. 2011; NICE PH49 rec 8]. (4) Write one line per subcomponent; mark the main gap. (5) Choose intervention functions, the Behaviour Change Wheel's nine broad ways of changing behaviour: education (increasing knowledge or understanding), persuasion (using communication to stir feelings or prompt action), incentivisation (creating an expectation of reward), coercion (creating an expectation of punishment or cost), training (imparting skills), restriction (using rules to reduce the opportunity for the behaviour, or for competing behaviours), environmental restructuring (changing the physical or social context), modelling (giving an example to aspire to or imitate) and enablement (increasing means or reducing barriers beyond education, training and environmental restructuring) [source: Michie et al. 2011, Table 1]. The paper tabulates which functions can change each COM-B subcomponent (Table 2); for example, physical capability through training and enablement, psychological capability through education, training and enablement [source: Michie et al. 2011]. In one-to-one therapy, coercion and restriction normally sit outside the therapist's role and belong to service or policy levels [synthesis]. (6) Turn the chosen functions into technique groups: capability to instruction, demonstration and practice (BCTs 4.1, 6.1, 8.1); opportunity to environmental restructuring and social support (12.x, 3.x); motivation to consequences, pros and cons, identity and self-belief (5.x, 9.x, 13.x, 15.x) [synthesis].
  • Example language (illustrative): "It sounds like you know what to do and you want to do it, but the clinic hours clash with your shifts. That's an opportunity problem, not a willpower problem, so let's work on that first."
  • Watch for: treating every gap as low motivation. Working: the person recognises the formulation as fair and less blaming.

A3. Adherence assessment (WHO five dimensions)

  • Purpose / when: any referral about taking agreed treatments or attending care.
  • Steps: (1) Ask non-judgementally about how the regimen is actually followed (normalise missed doses). (2) Go through each dimension: social and economic (money, literacy, transport, support); health system and team (appointment length, continuity, cost coverage); therapy (complexity, side effects); condition (symptoms, demands of self-management); patient (beliefs, knowledge, readiness) [source: WHO 2003]. (3) Explore beliefs about the treatment, including how necessary it seems and what concerns the person has, a framework WHO recommends (Horne's necessity–concerns approach) [source: WHO 2003]. (4) Record side effects and concerns to pass to the prescriber with consent.
  • Example language (illustrative): "Most people miss doses sometimes. What gets in the way for you? And how do you feel about the medicine itself: how much do you think you need it, and does anything about it worry you?"
  • Watch for: any intention to stop or change a medicine: do not advise; encourage and help the person to talk to the prescriber promptly. Working: barriers are specific and at least one is outside the person (system, cost, regimen).

A4. Readiness and target selection

  • Purpose / when: when there are several possible targets.
  • Steps: (1) List the behaviours the team considers relevant. (2) Ask the person to rate readiness or importance for each. (3) Start with the one they are most ready to change [source: NICE PH49 rec 8]. (4) Check timing: windows of openness and reasons the intervention may be inappropriate now [source: NICE PH49 rec 8].
  • Example language (illustrative): "Of the things your GP mentioned, which one feels most doable to start on now?"
  • Watch for: choosing for the person. Working: the person picks a target and can say why.

B1. Goal setting (behaviour) and goal setting (outcome) — BCTs 1.1, 1.3

  • Purpose / when: start of active change. 1.1 agrees a goal defined as a specific action the person will take [source: HEE summary]; 1.3 agrees an outcome goal (e.g. a symptom or test result the team monitors) [synthesis on example].
  • Steps: (1) Turn the target into a concrete behaviour goal. (2) If an outcome goal is used, take its value from the medical team, not from you. (3) Agree a time frame and how it will be checked.
  • Example language (illustrative): "So the goal for this week is: walk to the bus stop and back after lunch on three days, as your physio suggested. Is that the goal in your words?"
  • Watch for: setting diet, weight, exercise or medicine targets yourself; outcome goals the person cannot control. Working: the person states the goal unprompted next session.

B2. Problem solving — BCT 1.2

  • Purpose / when: when barriers block a goal. Analyse factors influencing the behaviour and generate ways to overcome barriers or increase facilitators; simply listing barriers is not enough [source: HEE summary].
  • Steps: (1) Name the barrier precisely. (2) Brainstorm options without judging. (3) Weigh them; choose one. (4) Plan when to try it. (5) Review next time.
  • Example language (illustrative): "Forgetting the evening dose is the barrier. Let's list every way round it we can think of, silly ones included, then choose one to try."
  • Watch for: stopping at a list of difficulties. Working: a tried solution is reported back.

B3. Action planning and coping (if–then) planning — BCT 1.4

  • Purpose / when: after a goal is agreed. Detailed planning of when, where and how often [source: HEE summary]. NICE also asks for coping plans for relapse and rehearsed if–then plans [source: NICE PH49 recs 7, 10].
  • Steps: (1) Specify what, how much, when, where and how often. (2) Ask confidence on a 0–10 scale; if below 7, shrink the plan [source: SMRC workshop slides]. (3) Add one or two if–then plans for likely obstacles. (4) Rehearse them aloud. (5) Write the plan down.
  • Example language (illustrative): "How confident are you, from 0 to 10, that you'll do this plan this week? A 5? What would need to change to make it a 7 or more?" / "If the pharmacy is closed on Saturday, then I'll…?"
  • Watch for: plans that are wishes; over-ambitious first plans. Working: the plan is completed, which matters more than making it [source: SMRC workshop slides].

B4. Review behaviour goals, review outcome goals, discrepancy — BCTs 1.5, 1.7, 1.6

  • Purpose / when: every follow-up. Review progress with the person and adjust goals or strategy (1.5, 1.7) [source: HEE summary]; draw attention to the gap between current behaviour and the goal (1.6) [synthesis on steps].
  • Steps: (1) Ask what happened. (2) Compare with the plan without judgement. (3) Decide: keep, shrink, enlarge or change the goal. (4) Re-plan.
  • Example language (illustrative): "You managed two of three days. Shall we keep three, or make it two and build up?"
  • Watch for: shame at discrepancy. Working: adjustments are made collaboratively and quickly.

B5. Behavioural contract and commitment — BCTs 1.8, 1.9

  • Purpose / when: to strengthen intention once a plan exists. Contract: a written, signed agreement on the behaviour [synthesis]; commitment: asking the person to affirm or restate their commitment [synthesis].
  • Steps: (1) Offer, do not impose. (2) Write the behaviour, period and review date. (3) Both keep a copy.
  • Example language (illustrative): "Some people find it helps to write the plan as a short agreement with themselves. Would that be useful, or does it feel like too much?"
  • Watch for: coercive use by family or services. Working: the person refers to the agreement when tempted to skip.

B6. Self-monitoring of behaviour and of outcomes — BCTs 2.3, 2.4

  • Purpose / when: from baseline onwards. Set up a method for the person to record their own behaviour (2.3) [source: HEE summary] and, where relevant, outcomes the team asks them to track (2.4) [synthesis].
  • Steps: (1) Choose the simplest method (paper, app, calendar tick). (2) Agree what to record and when (ideally soon after the behaviour). (3) Bring records to each session. (4) Review together.
  • Example language (illustrative): "Just a tick on the calendar each time you do it, and a word if something got in the way. Nothing more."
  • Watch for: monitoring that feeds anxiety or obsessive checking (e.g. body or symptom checking in health anxiety or eating disorders); stop or change the method if it does. Working: records arrive and reveal patterns.

B7. Feedback on behaviour and outcomes; monitoring by others — BCTs 2.2, 2.7, 2.1, 2.5

  • Purpose / when: to make progress visible. You monitor and give the person information or evaluation about their performance (2.2) [source: HEE summary]; feedback on outcomes (2.7); monitoring by others without feedback (2.1, 2.5) [synthesis on use].
  • Steps: (1) Give feedback that is specific and soon after the behaviour. (2) Lead with what went well (NICE uses this order for practitioner feedback; applying it to clients is [synthesis]). (3) Link to the plan.
  • Example language (illustrative): "Your diary shows you've attended every appointment this month. That's a real change from last spring."
  • Watch for: feedback that sounds like grading. Working: the person starts giving themselves the same feedback.

B8. Biofeedback — BCT 2.6

  • Purpose / when: feedback on a body process via a device. This is a specialised method with its own training and certification; see the biofeedback and neurofeedback guides in this domain for full implementation [synthesis].
  • Steps [synthesis]: (1) Ask whether the client wants to see a body process (for example muscle tension or breathing) more directly. (2) Explain in plain words what biofeedback is and that it needs trained practitioners and equipment. (3) If you are not trained, refer to a certified practitioner and share the behavioural goal with consent. (4) Keep the behaviour-change plan going alongside it.
  • Example language (illustrative): "There's a specific method where a sensor shows you what your body is doing; if you're interested, I can tell you who offers it."
  • Watch for: device claims that go beyond sources; attribute them.

B9. Social support (unspecified, practical, emotional) — BCTs 3.1–3.3

  • Purpose / when: whenever isolation or lack of help is a barrier. Advise on, arrange or provide general support (3.1), practical help (3.2) or caring, encouraging support (3.3) from others [source: HEE summary]. NICE lists friends, relatives, colleagues or "buddies" [source: NICE PH49 rec 7].
  • Steps: (1) Map who is available. (2) Decide the type of help needed. (3) Plan how to ask. (4) Rehearse the request (BCT 8.1). (5) Consider peer groups such as self-management workshops.
  • Example language (illustrative): "Who could give you a lift to the clinic? How would you ask them? Let's practise what you'd say."
  • Watch for: support that turns into nagging or control; confidentiality wishes. Working: a named person helped this week.

B10. Shaping knowledge: instruction, antecedents, re-attribution, behavioural experiments — BCTs 4.1–4.4

  • Purpose / when: capability gaps and unhelpful beliefs. 4.1: advise or agree how to perform the behaviour, including skills training [source: HEE summary]; the content of instructions about a medical regimen comes from the team, and you help the person learn and rehearse it. 4.2: identify situations and events that reliably precede the behaviour. 4.3: help the person find an alternative explanation for a symptom or for the behaviour. 4.4: test a belief by doing something and observing the result [synthesis on 4.2–4.4 steps].
  • Steps: (1) For 4.1, ask the person to explain back what the team told them (teach-back); fill gaps by checking with the team. (2) For 4.2, review self-monitoring for patterns of time, place, mood and company. (3) For 4.3, list possible explanations and the evidence for each. (4) For 4.4, write the prediction, design a safe test agreed with the team where health is involved, run it, compare result with prediction.
  • Example language (illustrative): "You expect that if you take the inhaler in front of colleagues they'll think less of you. Shall we test that this week and see what actually happens?"
  • Watch for: experiments that conflict with medical advice. Working: beliefs shift on the basis of the person's own data.

B11. Natural consequences — BCTs 5.1–5.6

  • Purpose / when: motivation gaps. 5.1: information about health consequences of the behaviour [source: HEE summary]; 5.2 salience of consequences (making them vivid); 5.3 social and environmental consequences; 5.4 prompting the person to monitor and record their feelings after doing the behaviour; 5.5 anticipated regret; 5.6 information about emotional consequences [synthesis on 5.2–5.6 steps].
  • Steps: (1) Ask what the person already knows first. (2) Offer information that comes from the team or a credible source (9.1), with permission. (3) Ask what they make of it. (4) For 5.4, add a feelings column to the self-monitoring record.
  • Example language (illustrative): "Would it be OK if I shared what your nurse explained about why the daily check matters? … What do you make of that?"
  • Watch for: fear messages that raise anxiety without a plan; anticipated regret in people prone to guilt or depression [synthesis]. Working: the person links consequences to their own reasons.

B12. Comparison of behaviour: demonstration, social comparison, others' approval — BCTs 6.1–6.3

  • Purpose / when: capability (modelling) and social norms. 6.1 show how to do the behaviour (live, video or picture); 6.2 draw attention to others' performance; 6.3 information about what others think of the behaviour [synthesis].
  • Steps: (1) Use demonstrations by the team or peer leaders (modelling is one of the self-efficacy sources the CDSMP uses [source: SMRC workshop slides]). (2) Use social comparison only when it encourages rather than shames.
  • Example language (illustrative): "In the group, Sam showed how he sets out his week's tablets on Sunday. Want to try his way?"
  • Watch for: unfavourable comparisons. Working: the person copies a modelled step.

B13. Associations: prompts and cues, reward cues, reducing cues, exposure, associative learning — BCTs 7.1–7.8

  • Purpose / when: automatic behaviour. 7.1 introduce or define an environmental or social cue at the time or place the behaviour should occur [source: HEE summary]; 7.2 cue signalling reward; 7.3 reduce or fade prompts; 7.4 remove access to reward; 7.5 remove aversive stimulus; 7.6 satiation; 7.7 exposure; 7.8 associative learning [synthesis on 7.2–7.8].
  • Steps: (1) Pick a cue tied to an existing routine (phone alarm, tablet box by the toothbrush). (2) Fade the prompt once the habit is established (7.3). (3) Exposure (7.7) for fear-driven avoidance of medical procedures or treatments: obtain informed consent, explain the rationale, build a graded hierarchy, check with the team for medical contraindications (e.g. needle phobia with fainting history may need applied tension and medical advice [uncertain: not verified]), stop if distress is unmanageable, and refer to a specialist exposure protocol where needed [synthesis].
  • Example language (illustrative): "Where in your morning could the reminder live so you can't miss it?"
  • Watch for: cue overload; exposure without consent or safety planning. Working: the behaviour happens without the reminder.

B14. Repetition and substitution — BCTs 8.1–8.7

  • Purpose / when: skills and habits. 8.1 behavioural practice or rehearsal; 8.2 behaviour substitution, swapping an unwanted behaviour for a wanted or neutral one [source: HEE summary]; 8.3 habit formation, repeating the behaviour in the same context so the context triggers it [source: HEE summary]; 8.4 habit reversal (an incompatible response to an unwanted habit); 8.5 overcorrection; 8.6 generalisation to new settings; 8.7 graded tasks, from easy to harder while staying achievable [source: HEE summary].
  • Steps: (1) Rehearse in session (role-play a conversation with the doctor, practise using a device the team has shown). (2) Anchor the behaviour to one fixed context for habit formation. (3) For substitution or habit reversal, pick a replacement that is easy and incompatible. (4) Grade tasks in small steps agreed with the team. (5) Plan generalisation to new places. Overcorrection (8.5) is a punitive-type technique; avoid in routine psychotherapy [synthesis].
  • Example language (illustrative): "Let's practise asking your consultant about the side effect right now. I'll be the consultant."
  • Watch for: steps too large. Working: the behaviour feels automatic in the anchored context.

B15. Comparison of outcomes: credible source, pros and cons, comparative imagining — BCTs 9.1–9.3

  • Purpose / when: ambivalence. 9.1 present communication from a credible source; 9.2 list and compare reasons for and against changing [source: HEE summary]; 9.3 imagine and compare future outcomes of changing versus not changing [source: HEE summary].
  • Steps: (1) Draw a four-box grid: benefits and costs of changing and of not changing [synthesis]. (2) Let the person fill it. (3) Ask which matter most. (4) For 9.3, guide brief imagery of a day a year from now on each path.
  • Example language (illustrative): "What do you get from things staying as they are? And what might it cost you?"
  • Watch for: arguing for change, which can harden the other side [synthesis]. Working: the person voices their own reasons for change.

B16. Reward and threat — BCTs 10.1–10.11

  • Purpose / when: motivation and maintenance. Material incentive and reward (10.1, 10.2), non-specific reward (10.3), social reward (10.4), social incentive (10.5), non-specific incentive (10.6), self-incentive (10.7), outcome incentive (10.8), self-reward (10.9), outcome reward (10.10), future punishment (10.11) [labels: HEE summary].
  • Steps: (1) In psychotherapy, mostly use self-reward and social reward: the person chooses a small pleasant reward for completing the plan. (2) Praise effort specifically. (3) Material incentives usually belong to service-level programmes. (4) Avoid future punishment [synthesis].
  • Example language (illustrative): "What small treat would feel like a fair reward for sticking to the plan all week?"
  • Watch for: rewards that conflict with the medical plan (e.g. food rewards in diabetes care) [synthesis]. Working: rewards are used and then become unnecessary.

B17. Regulation — BCTs 11.1–11.4

  • Purpose / when: 11.1 pharmacological support is prescribed by a prescriber; your part is to discuss it and support adherence to what they have agreed, never to recommend it [synthesis]. 11.2 reduce negative emotions, e.g. stress management, so the behaviour is easier [source: HEE summary]. 11.3 conserving mental resources (reduce demands on memory and willpower, e.g. pill organisers, simplified routines). 11.4 paradoxical instructions [synthesis on 11.3–11.4].
  • Steps: (1) Teach stress-management skills (relaxation, breathing, cognitive coping) as in your core training. (2) Simplify routines; ask the prescriber whether the regimen itself can be simplified, if complexity is a barrier (WHO lists regimen complexity as a therapy factor [source: WHO 2003]). (3) Use paradoxical instructions only with a clear formulation and consent [synthesis].
  • Example language (illustrative): "Juggling five times a day is a lot. Would you like to ask your doctor whether there's any way to make the schedule simpler?"
  • Watch for: sliding into advice about medicines. Working: fewer missed actions with less effort.

B18. Antecedents: environment and cues — BCTs 12.1–12.6

  • Purpose / when: opportunity gaps. 12.1 change the physical environment to make the wanted behaviour easier or the unwanted one harder [source: HEE summary]; 12.2 restructure the social environment; 12.3 avoid or reduce exposure to cues for the unwanted behaviour; 12.4 distraction; 12.5 add objects to the environment; 12.6 body changes (e.g. strength or breathing training, as delivered by the relevant profession) [synthesis on 12.2–12.6].
  • Steps: (1) Walk through the home or day in imagination. (2) Find one change that removes friction for the wanted behaviour. (3) Find one change that adds friction for the unwanted behaviour. (4) NICE asks for planned changes to the immediate physical environment to prevent relapse [source: NICE PH49 rec 10].
  • Example language (illustrative): "If the cigarettes weren't in the car, what would happen on the drive home?"
  • Watch for: changes others in the household have not agreed. Working: the environment does more of the work.

B19. Identity — BCTs 13.1–13.5

  • Purpose / when: long-term maintenance. 13.1 identification of self as role model; 13.2 framing or reframing; 13.3 incompatible beliefs (drawing attention to discrepancy between behaviour and self-image); 13.4 valued self-identity; 13.5 identity associated with changed behaviour, such as seeing oneself as an ex-smoker [source: HEE summary for 13.5; synthesis for others].
  • Steps: (1) Ask about valued roles (parent, worker, friend). (2) Link the behaviour to those values. (3) Invite the person to try on the new identity in language.
  • Example language (illustrative): "You said being there for your grandchildren matters most. How does looking after your treatment fit with that?"
  • Watch for: identity work that adds shame when lapses happen. Working: the person describes themselves differently.

B20. Scheduled consequences — BCTs 14.1–14.10

  • Purpose / when: behaviour cost (14.1), punishment (14.2), remove reward (14.3), reward approximation (14.4, shaping), rewarding completion (14.5), situation-specific reward (14.6), reward incompatible behaviour (14.7), reward alternative behaviour (14.8), reduce reward frequency (14.9, thinning), remove punishment (14.10) [labels: HEE summary].
  • Steps: (1) In psychotherapy use the reward-based options: reward approximations (shaping), reward completion, reward alternatives, then thin rewards over time. (2) Do not use punishment or behaviour cost as therapist-delivered techniques; if a family uses them, explore the effects [synthesis].
  • Example language (illustrative): "Let's agree to celebrate getting halfway, not just the finish line."
  • Watch for: punitive regimes at home or in institutions. Working: progress continues as rewards fade.

B21. Self-belief — BCTs 15.1–15.4

  • Purpose / when: low self-efficacy. 15.1 verbal persuasion about capability: tell the person they can succeed and argue against self-doubt [source: HEE summary]; 15.2 mental rehearsal of successful performance; 15.3 focus on past success, recalling times they succeeded at the behaviour or parts of it [source: HEE summary]; 15.4 self-talk.
  • Steps: (1) Elicit past successes, even partial. (2) Rehearse the next step in imagination, including handling an obstacle. (3) Agree a short self-instruction for the difficult moment.
  • Example language (illustrative): "Tell me about a time you kept a routine going even when things were hard. What did you do then that we could use now?"
  • Watch for: empty reassurance. Working: confidence ratings rise after completed plans.

B22. Covert learning — BCTs 16.1–16.3

  • Purpose / when: 16.1 imaginary punishment, 16.2 imaginary reward, 16.3 vicarious consequences (observing consequences for others) [labels: HEE summary; steps synthesis].
  • Steps: (1) Prefer imaginary reward: the person imagines doing the behaviour and then a pleasant consequence. (2) Use vicarious consequences through peer stories with consent. (3) Avoid imaginary punishment, which is related to aversive methods [synthesis].
  • Example language (illustrative): "Picture yourself at the end of the week, plan done. What does that feel like?"
  • Watch for: imagery that triggers trauma or health anxiety. Working: the imagery is pleasant and motivating.

C1. Very brief and brief interventions

  • Purpose / when: opportunistic contacts, triage, or when a client raises a health behaviour in therapy for another problem. Very brief: about 30 seconds to a couple of minutes, mainly information or directing to help, using "ask, advise, assist"; brief: oral discussion, negotiation or encouragement, with or without written support, follow-up or referral [source: NICE PH49].
  • Steps: (1) Ask about the behaviour. (2) With permission, advise by pointing to what the person's own clinician recommends or to credible information. (3) Assist: offer a referral, a self-management course, or one action plan with follow-up.
  • Example language (illustrative): "You mentioned you've stopped going to the diabetes clinic. Would it help to talk for a few minutes about what's got in the way, or would you rather I gave you the number for the clinic team?"
  • Watch for: advice beyond your competence. Working: the person takes one step (call, booking, plan).

C2. Extended brief and high-intensity individual programmes

  • Purpose / when: when need is greater or brief work has not been enough. Extended brief: over 30 minutes, one or more sessions; high-intensity: over 30 minutes across several sessions [source: NICE PH49].
  • Steps: follow Section 2: A1–A4, then goals and planning (B1–B5), feedback and monitoring (B6–B7) and social support (B9) as the core, with other BCTs matched to the COM-B gaps; record techniques used; plan follow-up [source: NICE PH49 recs 7, 8, 10].
  • Example language (illustrative): "Over the next few sessions we'll set small goals, track them, and line up the support you need. Each time we'll check what worked and adjust."
  • Watch for: drift into unstructured talk. Working: session records show named BCTs and completed plans.

C3. Adherence intervention (talking about agreed treatment)

  • Purpose / when: non-adherence or ambivalence about an agreed treatment, medicine, monitoring or attendance.
  • Steps: (1) Assess using A3. (2) Address system and practical barriers first (costs, transport, appointments, regimen complexity) by helping the person raise them with the team [source: WHO 2003 dimensions; synthesis on steps]. (3) Explore necessity beliefs and concerns [source: WHO 2003, citing Horne]. (4) Match the intervention to readiness [source: WHO 2003]. (5) Use cues (7.1), habit formation (8.3), conserving mental resources (11.3), self-monitoring (2.3), problem solving (1.2) and social support (3.x). (6) With children, goal setting, cueing and rewards or tokens are named by WHO [source: WHO 2003]. (7) Follow up regularly, including by phone [source: WHO 2003]. (8) If the person wants to stop or change a medicine, help them prepare questions for the prescriber; do not advise.
  • Example language (illustrative): "It sounds like part of you thinks the tablets help and part of you is worried about the weight gain. Both make sense. Would you like to plan how to put that worry to your psychiatrist at your next appointment?"
  • Watch for: warning signs the labelling describes for the specific medicine (side effects, suicidality warnings in young people for some antidepressants [uncertain: not verified for the specific product]); pass them to the prescriber the same day if serious, and follow your service's urgent pathway. Working: the person reports discussing concerns with the prescriber; adherence to the agreed plan improves.

C4. Group self-management programme (CDSMP model)

  • Purpose / when: adults living with one or more long-term conditions, and carers; non-disease-specific, interactive, built on self-efficacy theory [source: SMRC workshop slides; Virginia Department of Health]. Derivatives exist for diabetes, HIV, chronic pain, cancer survivorship and caregivers [source: SMRC workshop slides].
  • Format: six weekly sessions of about 2.5 hours, 8–15 participants, two leaders who are Certified Peer Leaders trained through the Self-Management Resource Center [source: SMRC slides; Virginia Department of Health]. Self-management is defined (citing the Institute of Medicine 2004) as tasks people undertake to live with chronic conditions, including medical, role and emotional management [source: SMRC slides]. Topics include managing symptoms and medicines, communicating with family and doctors, difficult emotions, relaxation, healthy eating, exercise and weekly goal setting [source: Virginia Department of Health]. Leader training, licensing and fidelity rules are set by SMRC [uncertain: not verified].
  • Steps (as a psychologist delivering or supporting it): (1) Train and certify through SMRC before delivering it under its name. (2) Follow the manual's session order and wording requirements. (3) Each week, every participant makes an action plan and rates confidence; plans below 7 are revised [source: SMRC slides]. (4) Use pair-and-share activities [source: SMRC slides]. (5) The eating and exercise content is generic programme content; do not individualise diet or exercise prescriptions; refer to the person's clinicians [synthesis]. (6) Psychologists can also refer clients to local workshops and integrate the action plan into individual therapy [synthesis].
  • Example language (illustrative): "This week, what's one thing you'd like to do for yourself? … How sure are you, 0 to 10?"
  • Watch for: participants in acute distress who need individual care; peer advice about medicines. Working: weekly plans are completed and reported back.

C5. Insomnia pointer (CBT-I)

  • Purpose / when: chronic insomnia in adults. The AASM guideline strongly recommends CBT-I (cognitive strategies, education on sleep regulation and behavioural strategies such as stimulus control and sleep restriction), typically four to eight sessions; suggests multicomponent brief therapies and the single components stimulus control, sleep restriction and relaxation; and suggests against sleep hygiene as a single-component treatment [source: Sleep Review report of Edinger et al., AASM guideline].
  • Steps: (1) Ask the referring clinician to rule out or treat other sleep disorders (e.g. sleep apnoea) and medical causes [synthesis]. (2) Use a sleep diary (self-monitoring). (3) Deliver CBT-I from a recognised manual and training; this guide does not give time windows or prescriptions. (4) Check cautions for sleep restriction with the medical team, e.g. bipolar disorder, seizure disorders, or safety-critical driving or work [uncertain: not verified]. (5) Medication for sleep remains a prescriber decision.
  • Example language (illustrative): "The treatment with the strongest backing for long-term insomnia is a structured talking and behaviour programme. It usually takes a handful of sessions and a sleep diary."
  • Watch for: daytime sleepiness during restriction phases; hypomanic signs. Working: diary shows more consolidated sleep and less distress.

C6. Chronic pain pointer

  • Purpose / when: chronic primary pain in people aged 16 and over. NICE NG193 (2021) highlights ACT and CBT as beneficial, recommends exercise programmes and physical activity and allows acupuncture; it advises not starting some prescription drug regimens and supporting people already taking them to reduce or stop where possible [source: CSP news summary of NG193]. Prescribing decisions belong to the prescriber, exercise programmes to physiotherapy or other qualified staff.
  • Steps: (1) Do a person-centred assessment of what contributes to the pain, its effect on physical and psychosocial wellbeing and on quality of life [source: CSP summary of NG193]. (2) Offer ACT- or CBT-based pain management, or refer to a pain service. (3) Support shared decision-making and self-management. (4) If the person is asked by their doctor to reduce medication, support them psychologically through it; do not advise on the process.
  • Example language (illustrative): "We're not aiming to prove whether the pain is real—it is. We're working on what helps you live the life you want alongside it."
  • Watch for: new or changing symptoms (refer for medical review); low mood and suicidality. Working: valued activities and coping increase.

C7. Maintenance and relapse prevention

  • Purpose / when: from the last active sessions for at least a year [source: NICE PH49 rec 10].
  • Steps: (1) List likely high-risk situations. (2) Write and rehearse if–then plans. (3) Lock in environmental changes. (4) Confirm social support. (5) Schedule follow-up contacts with feedback and monitoring. (6) Agree what counts as a lapse versus relapse and when to get back in touch [source: NICE PH49 rec 10; step 6 synthesis].
  • Example language (illustrative): "A slip is information, not failure. If you notice two missed weeks in a row, what's your plan?"
  • Watch for: all-or-nothing thinking after a lapse. Working: the person restarts after a slip without needing a new referral.

C8. Practitioner fidelity and supervision

  • Purpose: quality. NICE asks that practitioners be assessed regularly, ideally from recorded sessions or with a reliable observation checklist, include service-user feedback, start feedback with good performance, and have refresher training [source: NICE PH49 rec 14].
  • Steps: record (with consent) and code sessions against the BCTs you planned; bring to supervision.
  • Example language (illustrative, to client): "With your agreement I'd like to record this session for my supervision; you can say no without it affecting your care."
  • Watch for: recording consent and data storage. Working: coded sessions match the plan.

D1. Collaboration in primary and specialist care

  • Purpose / when: every case. WHO calls for a stronger multidisciplinary approach; NICE requires practitioners to know how to refer to specialist services [source: WHO 2003; NICE PH49 rec 12]. Telemonitoring and case management by several professionals are described as part of the field [source: Wikipedia, secondary].
  • Steps: (1) Obtain consent for information sharing at the start. (2) Agree with the GP or specialist team what you will and will not do, and the medical limits of the plan. (3) Send short, jargon-free updates: target behaviour, techniques used, progress, barriers that need team action (cost, regimen complexity, side effects). (4) Ask for medical review when you notice new or worsening physical symptoms, side effects, or warning signs [synthesis]. (5) In integrated primary care, adapt to short contacts using C1–C2 [synthesis]. (6) In specialist care (cardiac, diabetes, oncology, renal, pain), align with the condition's care pathway and the team's goals [synthesis].
  • Example language (illustrative, to a GP): "Mr X's main barrier to taking the agreed medicine is the cost of the prescription and worry about drowsiness at work. Could the drowsiness be reviewed at his next appointment? He has agreed to raise it."
  • Watch for: splitting (the client telling each professional something different); confidentiality limits; crisis and safeguarding pathways, which follow your service's procedures. Working: the team and the client describe the same plan.

5. Handling problems

The sources set principles (support not blame, tailoring, follow-up, maintenance) but give little case-level troubleshooting; responses below are [synthesis] unless tagged.

  • Stuck: plans repeatedly not done. Re-run the COM-B diagnosis; the gap may be opportunity, not motivation. Shrink the plan until confidence is at least 7 [source: SMRC slides]. Check for depression, cognitive difficulties or fatigue from illness, and ask the team about medical contributors.
  • Resistance or arguing back. Stop persuading. Return to pros and cons (9.2) in the person's words, reflect both sides, and ask permission before giving information. Remember adherence requires agreement [source: WHO 2003]; if the person does not agree with the regimen, help them take that to the prescriber.
  • Non-adherence to the medical regimen. Look first at system, cost, regimen and side-effect barriers [source: WHO 2003], then beliefs (necessity and concerns) [source: WHO 2003]. Never tell the person to start, stop or change a medicine; document and, with consent, inform the prescriber. If the person has already stopped a medicine, encourage prompt contact with the prescriber and note any discontinuation or relapse symptoms to pass on.
  • Non-adherence to homework (monitoring, plans). Simplify the monitoring, put the record where the behaviour happens, review it at the start of each session so it matters, and ask what made it hard.
  • Overwhelm (new diagnosis, multiple conditions, many targets). Pause change work; offer support for adjustment and emotion first. Then pick one behaviour (most ready, NICE rec 8) and make the plan tiny. Recognise when intervention is inappropriate now [source: NICE PH49 rec 8].
  • Shame, self-blame and stigma (weight, HIV, smoking, diabetes). Use non-judgemental, person-first language; name system barriers aloud [source: WHO 2003 "support, not blame" principle]. Avoid fear appeals and anticipated regret with people prone to guilt.
  • Ruptures (client feels lectured, policed or reported on). Acknowledge directly, clarify that your role is not to enforce the team's orders, revisit what is shared with the team and what is not, and repair before restarting plans.
  • Conflict between client goals and medical advice. Do not side with either; help the person clarify their own values and prepare for a shared decision-making conversation with the clinician.
  • Self-monitoring that worsens anxiety or obsessive checking, or eating-disorder risk. Stop or change the method; screen for health anxiety or disordered eating; avoid weight, calorie and body-checking targets; refer for specialist assessment where indicated.
  • New, worsening or unexplained physical symptoms. Do not interpret them psychologically by default; advise prompt medical review and inform the team with consent.
  • Suicidality or self-harm, including in the context of serious illness, pain or medicine side effects: follow your service's current risk-assessment and safety-planning procedures; where means include stockpiled medicines, lethal-means counselling covers secure storage and removal with the prescriber and pharmacist involved.
  • Exposure-based work for procedural fear (needles, scanners, dental work). Obtain consent, check medical contraindications with the team, grade the steps, and stop if distress or physical symptoms (e.g. fainting) become unsafe.
  • Family over-involvement or nagging. Shift social support from monitoring to practical and emotional help (3.2, 3.3); hold a joint session if the person agrees.
  • Lapse after the programme ends. Use the pre-agreed lapse plan; book a booster contact; review whether feedback and monitoring continued for a year as NICE recommends [source: NICE PH49 rec 10].
  • Health literacy, language or cultural barriers. Use interpreters, simple written plans, teach-back, and adapt to faith and cultural practices [source: NICE PH49 rec 8 on tailoring].
  • Scope creep (asked to design a diet, exercise or medicine schedule). Decline and refer to the dietitian, physiotherapist, exercise professional or prescriber; offer to help the person carry out what that professional recommends.
  • Claims that psychological work treats the disease. Correct them: behavioural medicine methods support living with and managing the condition alongside medical treatment, not instead of it.

Sources

Web sources:

Works cited:

  • Schwartz, G. E., & Weiss, S. M. (1978). Yale Conference on Behavioral Medicine: A proposed definition and statement of goals. Journal of Behavioral Medicine, 1, 3–12.
  • Michie, S., Richardson, M., Johnston, M., Abraham, C., Francis, J., Hardeman, W., Eccles, M. P., Cane, J., & Wood, C. E. (2013). The Behavior Change Technique Taxonomy (v1) of 93 hierarchically clustered techniques. Annals of Behavioral Medicine, 46(1), 81–95.
  • Michie, S., van Stralen, M. M., & West, R. (2011). The behaviour change wheel: a new method for characterising and designing behaviour change interventions. Implementation Science, 6, 42. (Table 1 lists the nine intervention functions and seven policy categories: communication/marketing, guidelines, fiscal, regulation, legislation, environmental/social planning and service provision.)
  • World Health Organization (2003). Adherence to long-term therapies: evidence for action.
  • Edinger, J. D., et al. AASM clinical practice guideline on behavioral and psychological treatments for chronic insomnia disorder in adults. Journal of Clinical Sleep Medicine, dated December 2020 (doi 10.5664/jcsm.8986); volume and pages [uncertain: not verified].
  • NICE (2021). NG193 Chronic pain (primary and secondary) in over 16s (via CSP summary; full guideline [uncertain: not verified]).
  • NICE. PH49 Behaviour change: individual approaches (publication date [uncertain: not verified]).
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