Changing Behaviour

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The vast majority of people change their behaviour with no external help. They just do it. ‘Change experts’ include psychologists who 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:

• Observable
• Replicable
• Irreducible
• A component of an intervention designed to change behaviour
• 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.”

bs-diagramdetailedThe top level of the ‘Behaviour Change Intervention Ontology’ (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.

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.

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.   In addition, our field evidence shows that the outcome is enhanced by having a personable delivery from a charismatic person who builds a positive therapeutic alliance.                  

bs-diagramdetailedWith so many missing elements, this an Incomplete Model of Behaviour Change

Where is the client person in the ‘Behaviour Change Intervention Ontology’, and what about their feelings and their own striving for new balance and equilibrium?  Where is the therapist and the therapeutic alliance?  The quality of the change agent, their clinical and interpersonal skills and the quality of the therapeutic alliance can be more important than the BCTs (Hilton & Johnston, 2017) .With so many missing elements, this is beginning to appear like a top-down model of behaviour change. One may be excused for wondering whether the people designing the ‘ontology’ have any real-world hands-on experience of delivering interventions.

Hagger and Hardcastle (2014) suggest that “Interpersonal style should be included in taxonomies of behavior change techniques”. The whole point is that the therapeutic alliance is something the therapist and the client need to strive for. The alliance creates a more equal power balance between therapist and the client. It is more important than another technique, another item on the list. It is more about the ‘chemistry’ of the client-therapist relationship than about a finely polished set of BCTs. The trouble is that the advocates of the BCT compendium/ontology appear unwilling to engage with the problem. Somewhat ironically, they are resistant to change. However, the problem will not just go away, but rears its head each and every time a therapist swings into action.

Behaviour change involves a collaboration between the client wanting to make the change, with their own desires and feelings, and the change agent/therapist. The therapeutic alliance between the two parties is crucial to the project’s ‘outcome’.  Therapist’s attributes such as being flexible, honest, respectful, trustworthy, confident, warm, interested, and open contribute to that alliance. From all of this it can readily be seen that the situation is far more complex than the proposed ‘Behaviour Change Intervention Ontology’. It is never as  simplistic as an ‘Intervention’,  ‘Mechanisms of Action’ and ‘Target Behaviour’.

To use an analogy, there is so much more to baking a cake than a set of ingredients. Of course one needs a set of ingredients (the BCTs) but one also needs a baker – the behaviour change agent (BCA). The BCA/therapist must be fully trained to prepare, mix and cook the ingredients, to be fully competent to deliver the BCTs in a stylish manner. The qualities of effective therapists have been studied for at least 50 years. The stock piling of a compendium of BCT ingredients without attending to the mixing and ‘baking’ of the ingredients by the BCA on the front line is a recipe for disaster.

smart chef character cooking behind kitchen table with various o

Including therapist attributes of flexibility, authenticity, respect, trustworthiness, confidence,  warmth, interest, and openness, along with the client’s goals, desires and striving provides a more accurate and comprehensive approach to behaviour change.

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Homeostasis Theory of Well-being

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Homeostasis is a singular unifying principle for all living beings. Homeostasis operates at all levels of nature in every living system: in molecules, cells, tissues, organs, organisms, societies, ecosystems and the planet as a whole (Lovelock, 2009). Tissue homeostasis regulates the birth (mitosis) and death of cells (apoptosis); many diseases are directly attributable to defective homeostasis leading to over production or under production of new cells relative to cell deletion (Fadeel & Orrenius, 2005).

Biochemical and physiological feedback loops regulate billions of cells and thousands of compounds and reactions in the human body to maintain body temperature, metabolism, blood pH, fluid levels, blood glucose and insulin concentrations inside the body (Matthews et al., 1985). A body in good physical health is in biochemical and physiological homeostasis. Severe disruptions of homeostasis cause illnesses or can be fatal.

The General Theory of Behaviour (GTB) extends the principle to behaviour, experience and psychological well-being.

ABCD tetrad
A basic structure for homeostasis of behaviour
[Illustration credit: Graham McPhee]

The General Theory proposes that all behaviour and experience follow the principle of homeostasis (Marks, 2015, 2016, 2018). The GTB distinguishes between Physiological or ‘Type I’ Homeostasis and Psychological or ‘Type II’ Homeostasis. Other types of homeostasis operate at higher levels of organisation including the social level (Type III Homeostasis) and the ecological level (Type IV Homeostasis).

A person in good health is in a state of homeostatic balance that operates across systems of biochemical/physiological, psychological, social and ecological homeostasis. Outward and inward stability in a living being is only possible with constant accommodation and adaptation. All living beings strive to maintain equilibrium and stability with the surrounding environment through millions of micro-adjustments and adaptations to the continuously changing circumstances. Adjustments and adaptations can be both conscious and unconscious. The majority of fine adjustments are occurring at an unconscious level, hidden from both external observers and the individual actor.

The Homeostasis Theory of Well-being utilises the fact that human beings are natural agents of change. Humans adapt, accommodate and ameliorate under continuously changing conditions, both external and internal, to maximise the stability of physical and mental well-being. The Homeostasis Theory of Well-being (HTW) is illustrated below.

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The Homeostasis Theory of Well-being (Marks, 2015)

Well-being is the outcome of a multiplex of continuously changing feedback loops in a system of psychological homeostasis with four main component processes: well-being; cognitive appraisal; emotion; and action. Homeostasis maintain both physical and psychological equilibrium with the ever-changing external and internal environments, courtesy of an infinitude of micro-feedback-systems that fall within four macrosystems.

Psychological homeostasis regulates through feedback loops that control thought, emotion and action. Continuously flexible micro-adjustments of activity within feedback loops maintain equilibrium from moment to moment. Psychological homeostasis occurs in response to the infinite variety of circumstances that can affect well-being, including both internal adjustments (e.g. emotional regulation) and external adjustments using deliberate behavioural regulation (e.g. communicating, working, eating and drinking). In synchrony and synergy with all of the body’s other homeostatic mechanisms, psychological homeostasis operates throughout life during both waking and sleep.

In prevention and treatment of clinical conditions, individuals can help themselves and be helped by external techno aids to monitor and maintain physiological variables using behavioural forms of homeostasis, e.g. in diabetes, metabolic syndrome, hypertension, thyroid problems, skin disorders such as urticaria, or obesity. Biochemical, physiological and psychological homeostasis are of similar complexity. Behavioural forms of homeostasis occur in actions designed to support neural systems of regulation. Social homeostasis in supportive actions by other humans, requested or volunteered, provides another way to support and protect an individual’s well-being.

Inputs to homeostasis include technological systems such as: (1) scales for measuring body weight; (2) thermometers to measure body temperature; (3) pulse measurements; (4) electro-mechanical homeostasis, developed by engineers to enhance human control systems such as heating (thermostat), driving (cruise control), navigation (automatic pilot), and space exploration (computer navigation systems); (5) life support systems (e.g. artificial respirators, drip feeding, kidney dialysis, intensive care units); (6) medical and surgical interventions; (7) pharmaceutics; (8) alternative and complementary therapies; (9) yoga and meditation.

People are social and emotional beings and these features need to be restored into theories of behaviour. The Homeostasis Theory of Well-being needs to be tested in randomised controlled trials and prospective studies to determine its scientific validity and applicability to health care.