The vast majority of people change their behaviour with no external help. They just do it. ‘Experts’ including psychologists offer help when needed and often advocate behaviour change techniques in their interventions. A behaviour change technique (BCT) is any systematic procedure (or a category of procedures) included as an active component of an intervention designed to change behaviour. The defining characteristics of a BCT are that it is:
• A component of an intervention designed to change behavior
• A postulated active ingredient within the intervention (Michie et al., 2011)
The description, classification and investigation of BCTs has become a cottage industry. Places like UCL, Aberdeen and Cambridge Universities, together with IBM, have received several millions of pounds from the Medical Research Council and Wellcome Trust to construct an ‘ontology’ of behaviour change.
According to the project website, “Behavioural Scientists are developing an ‘ontology’: a defined set of entities and their relationships” which will be used to “organise information in a form that enables efficient accumulation of knowledge and enables links to other knowledge systems.”
The top level of the Behaviour Change Intervention Ontology (from the project website)
An ontology is a set of concepts and categories in a subject area that shows their properties and the relations between them. An ontology can only be helpful when nothing of importance to the system as a whole is left out.
A ‘BCT Taxonomy’ has been employed to code descriptions of intervention content into BCTs (Michie et al., 2011, 2013). The taxonomy aims to code protocols in order to transparently describe the techniques used to change behaviour so that protocols could be made clearer and studies could be replicated (Michie and Abraham, 2008; Michie et al, 2011). A taxonomy also can be used to identify which techniques are most effective so that intervention effectiveness could be raised and more people would change behaviour.
In one recent study, two reviewers independently coded BCTs and then discussed their presence/absence. Fidelity of treatment refers to confirmation that the manipulation of the independent variable occurred as planned. A 30-item Treatment Fidelity Checklist (Borrelli, 2011) was used to assess whether treatment fidelity strategies were in place with regard to study design, interventionist training, treatment delivery, treatment receipt and treatment enactment. Percentage scores for each area were awarded to reflect the proportion of items with evidence of at least one treatment fidelity strategy.
Twenty-seven BCTs were identified across five interventions with a mean (SD) number of BCTs coded per intervention of 10 (4.53), with a range of 4 to 15. (Michie et al., 2011) found that the most frequently occurring BCT was ‘problem solving’, which occurred in four of the five interventions. Three BCTs were coded in three out of five interventions: ‘information about social and environmental consequences’, ‘reduce negative emotions’ and ‘pros and cons’. All studies measured outcomes using self-reports.
The production of a structured list of BCTs provides a ‘compendium’ of behaviour change methods which helps to map the domain of behaviour change and inform practitioner decision-making. However it also risks becoming a prescriptive ‘cook-book’ of what therapeutic techniques must be applied to patients presenting with a specific behavioural problem.
Another problem with the compendium approach is that BCTs are not all optimally effective when combined in ‘pick-and-mix’ fashion. There needs to be coherence to the package that is provided by a theory that offers power and meaning and connects the components into a working set.
To use the analogy of a model train set, if you have a station, signals, railway lines, carriages crew and passengers but no engine, the train remains immobile. There is a need for a coherent theory that provides structure and meaning both for the change agent and the client.
I can illustrate this point by considering an intervention for smoking cessation, Stop Smoking Now (Marks, 2017). This therapy is an effective method for clearing the human body of nicotine. The desire to smoke and any satisfaction from smoking are abolished using different forms of CBT and mindfulness meditation. Stop Smoking Now includes 30 BCTs integrated within a coherent theory of change based on the concept of homeostasis. In Stop Smoking Now a structured sequence of BCTs is provided that takes into account the nesting of BCTs such that guided imagery works best in combination with relaxation and both of these work best following enhancement of self-efficacy, achieved using self-recording, positive affirmations and counter-conditioning.
With so many missing elements, is this a ‘Clockwork Orange’ Model of Behaviour Change?
Where is the person in this model, their feelings and their own striving for new balance and equilibrium? Of as much importance as the nature and number of individual BCTs (the intervention) is the quality of the change agent, their clinical and interpersonal skills and the quality of the therapeutic alliance (Hilton & Johnston, 2017). With so many missing elements, this is beginning to appear like a top-down, ‘Clockwork Orange’ model of behaviour change. Or, to return to the analogy of the model train set, the locomotive does not have an engine.
Behaviour change involves a collaboration between the client who is wishing to make the change, with their own personal purposes, desires and feelings, and the change agent. The therapeutic alliance between these two parties is crucial to the the project’s final ‘outcome’. The situation is far more complex than the prescribed ‘Behaviour Change Intervention Ontology’. It is never as simplistic as an ‘Intervention’, ‘Mechanisms of Action’ and ‘Target Behaviour’.
Including intentionality, purpose and desire, A General Theory of Behaviour offers an alternative ontology of change. It puts an engine inside the locomotive of change.