Behaviour Change Models For PWPs - FINAL - UCL
PWP Training ReviewBehaviour Change ModelsBehaviour change models and strategies for PWPsIntroductionCognitive and behavioural therapies are appropriately the models on which much ofPWP training and practice is based. Most low intensity psychological interventionsrecommended in NICE guidance for anxiety disorders and depression use a CBTmodel and approach. The self-help materials supporting these interventions explainproblems in terms of CBT models and set out CBT strategies for change. Thecompetencies required of PWPs to implement these interventions are accordingly asubset of the general CBT competency framework (Roth & Pilling 2007).Although CBT is the central model and approach, there are aspects of PWP work thatit does not cover. There are low intensity interventions carried out by PWPs which arenot CBT-based. These include medication management, exercise, signposting tocommunity resources and brief interventions for alcohol. As PWP roles are expandedinto areas beyond anxiety disorders and depression, the range of low intensityinterventions that are not based mainly on CBT is likely to further increase. In addition,the self-help aspect of low-intensity CBT-based interventions raises challenges foreffective delivery. Effective self-help puts more responsibility and demands on thepatient for carrying out the treatment than therapist delivered high-intensity CBT.Engaging and motivating people are accordingly central issues. While motivation iscertainly addressed in the CBT literature and in practice, the factors involved inenhancing motivation are not a central part of the CBT model per se.A higher order set of theories to CBT is behaviour change. Behaviour change theoriesand models set out the necessary and sufficient conditions for behaviour change andthe associated empirical literature describes the interventions and behaviour changetechniques that are effective. CBT draws on behaviour change theories and literature,but the scope and application of behaviour change is much wider. This paper describeskey aspects of the behaviour change literature that are relevant to PWP work andfocuses in particular on how one overarching model of behaviour change, the COM-Bmodel (Michie et al 2011, Michie et al 2014), might inform PWPs practice.Behaviour change models and techniquesA number of models of behaviour change have been used to understand healthbehaviour and to design interventions for changing health behaviour. These include theself-regulatory / ‘common sense’ model, the theory of reasoned action/theory ofplanned behaviour, the health belief model, social learning theory and thetranstheoretical stage model of readiness to change among many others (Michie et al2014). Behaviour change approaches based on these have addressed help seeking,motivation for treatment and adherence to treatment among other areas. All of thesemodels and associated behaviour change strategies could contribute to informing PWP"1
PWP Training ReviewBehaviour Change Modelspractice and some have already been used in this way. However each model explainsonly some aspects of health behaviour, there is overlap between models and,pragmatically, with the limited training and high caseloads of PWPs, it is not realistic forPWPs to learn and work with multiple models.A model of behaviour and behaviour change developed to address the problems oflack of integration is the COM-B model (Michie et al 2011, Michie et al 2014). This setsout that behaviour comes about from an interaction of ‘capability’ to perform thebehaviour and ‘opportunity’ and ‘motivation’ to carry out the behaviour. New behaviouror behaviour change requires a change in one or more of these. As COM-B is anoverarching framework of behaviour, it can supplement the CBT model in PWPpractice, both contributing to the implementation of CBT-based low intensityinterventions and suggesting approaches for low intensity interventions not covered bythe CBT model.Behaviour change techniques are the specific components of interventions to changebehaviour. Different behaviour change models may suggest that particular behaviourchange techniques will be effective, but many specific techniques are common to manydifferent models. Various classifications of behaviour change techniques have beenproposed (Michie et al 2013) and there are literatures on the effectiveness of behaviourchange techniques for a range of health behaviours and problems. Recommendationson effective behaviour change techniques have been issued by NICE in two sets ofNICE public health guidance (NICE 2007, 2014). The key recommendations in these ofrelevance to PWPs are summarised in Annex 1 of this paper.COM-B modelThe COM-B model sets out that to change behaviour one needs to change one ormore of ‘capability’ to perform the behaviour and/or ‘opportunity’ and ‘motivation’ tocarry out the behaviour. Translating this to PWP work, the key elements are: Behaviour: Behaviour change involves doing something new or differently. Insetting goals for treatment, patient and PWP set out the new behaviour desiredby the patient. Ideally this is explicit (SMART goals), but if not the new behaviourdesired is at least implicit. COM-B analysis in PWP treatment applies to thesedesired behaviours/goals. In addition, during the course of treatment, a numberof tasks and specific homework targets are set (e.g. reading a section of abooklet, self-monitoring, a behavioural practice task, attending a further phonefollow-up session, etc) each of which is a new behaviour. The extent to whichthe patient carries out these behaviours necessary for successful self-helptreatment will also be a product of capability, opportunity and motivation andhence analysable by COM-B model. Capability: People may lack knowledge and/or skills to change behaviour.Coming to a new understanding of problems, of what maintains problems and ofself-help approaches to dealing with problems, can change behaviour; learningskills in self-help/self-management approaches can also lead to new behaviour.These are the essence of self-help approaches informed by CBT principles and,"2
PWP Training ReviewBehaviour Change Modelsin this respect, CBT based self help primarily targets capability. Capability mayalso be affected by impairments in reasoning or executive functioning, includingthrough concentration and memory difficulties in depression. Amelioration ofimpairments in cognitive capacity (for example through antidepressantmedication in severe depression) can make change possible. Opportunity: Social, interpersonal and physical environment factors in peoples’lives (all sorts of chronic adverse circumstances) maintain problems and makebehaviour change difficult. At a practical level, they can also make it difficult toattend appointments and carry out self-help homework tasks. Changes/improvements in adverse circumstances can lead to change in behaviour andamelioration of problems. Positive social environments and social support canencourage and support people in making changes Motivation: People may not consider it worth spending effort to change, theymay not believe change is possible or believe that it might be possible but notwith self-help. Self-help can require carrying out tasks (exposure, behaviouralactivation) in face of powerful avoidance motivational processes acting againstchange. Alcohol and drugs are powerful motivators that can interfere withattempts to change behaviourThe COM-B model can be used at assessment to identify goals (what is the best targetfor change) and what type of intervention is likely to be most effective (Michie et al2014) and during course of implementing an intervention. How a COM-B analysis canassist PWPs at each of these two phases is now outlinedAssessment: using COM-B to identify goals and interventionsThe COM-B model is especially useful in helping with identifying goals and deciding onan appropriate low intensity intervention. Which of capability, opportunity or motivationare most relevant for a target of behaviour change and which of these might presentmajor obstacles to change? For example, when people with anxiety disorders anddepression have major adverse social circumstances (opportunity) or significant drug oralcohol problems (motivation), a COM-B analysis would suggest that goals involvingdirect change in anxiety/depression related behaviours and cognitions even with themost effective CBT based self help approaches (which primarily target improvingcapability) are unlikely to be effective without addressing these other issues first. This isin accord with common clinical wisdom. The potential contribution of the COM-Bmodel is that it can support clinical decision making through providing a structure forsystematically considering the different factors and choosing interventions. It offers atheoretical underpinning for clinical wisdom.Table 1 below sets out the factors that PWPs might consider under each of capacity,opportunity and motivation. These factors should be considered alongside the problemstatement summary in considering and discussing with the patient goals and possibleinterventions."3
PWP Training ReviewBehaviour Change ModelsTable 1: COM-B factors to consider at assessment and intervention choiceCOM-BFactor to consider atassessmentImplication of factorCapacityKnowledge and understandingof nature of problemsPsychoeducation useful if lack ofknowledge and understandingKnowledge, understanding and CBT-based self-help useful if lack ofskills in self-help approachesknowledge, understanding or skillsthat might help with problemsImpairments in memory,concentration, reasoning and/or executive functioning whichmight limit capacity toundertake self-helpAlternatives to CBT-based self-helpmay be more appropriate (medication,exercise, step-up to CBT)Physical limitations that mightMay need to adapt interventions tolimit undertaking of some tasks physical limitationsOpportunityEnvironmental cues forproblem behaviours (e.g.drinking, anger)Interventions to focus on awarenessand management of cues (avoidanceor coping skills)Absence of environmental cues Interventions (e.g. behaviouralfor helpful behavioursactivation) to increase likelihood ofcontact with cuesMotivationPresence or absence of socialsupport for behaviour changeIf present, make use of the socialsupporter in intervention. If absent,signposting to support groups oragencies may be neededAdverse circumstancesmaintaining problem behaviourand likely to interfere withattempts to changeSignposting and facilitating access tocommunity resources or otherstrategies to address adversecircumstances may be needed asinitial interventionWhat problem is patient mostmotivated to deal withConsider addressing this firstExtent to which patientconsiders problem a concernand worth prioritising time toaddressIf low concern, explore pros and consof addressing problem as first step"4
PWP Training ReviewBehaviour Change ModelsExtent of avoidance processes(depression and anxiety) thatwill interfere with changeDiscuss with patient at outset thatchange will require facing these, usegraded techniques to help reduceimpact, and use all approaches tomaintain motivation in face of theseAlcohol or drugsIf too strongly motivating (likely tosupport avoidance and disruptmotivation to address other targetbehaviours), then target directly firstTwo examples of how this might work in practice follow: Mrs Brown has panic disorder with agoraphobia. Other than seeing her GP andreading an article in a magazine, she has little knowledge about panic disorderand what can help (capability). She has a supportive partner (opportunity) and nomajor adverse circumstances in her life (opportunity). She is keen to obtain help(motivation) as she wants to be able to go on a Summer holiday with her family,which she has been unable to do for the past 3 years; but she is very frightenedabout the prospect (motivation). Her PWP decides, in discussion with her, that agoal of improving her panic management skills through guided self-help wouldbe appropriate as she lacks knowledge and skills in how to help herself(capability), there are circumstances that mean she is keen to change(motivation) and there are no major barriers from life circumstances (opportunity).Given the extent of her fear (motivation), the PWP discusses with her what wouldbe involved in her facing her agoraphobia with exposure in guided self help andbarriers that might interfere with her doing this (motivation) and suggests shediscusses with her partner helping her with the exposure tasks (opportunity).Figure 1 is the COM-B analysis for Mrs Brown. John is a young man who on assessment the PWP finds to be mildly depressedand to have moderate social anxiety. However, he does not see his social anxietyand avoidance as something that he needs help with or wants to change,insisting this is just how he has always been (motivation). The concern he hascome about is insomnia, which he would like to improve (motivation). The PWPalso learns he drinks four cans of lager a night (implications for motivation) whichhas contributed to him being in debt which he is not able to pay off as he is notworking (opportunity). He is also rather socially isolated (opportunity). The PWPagrees to help him with sleep management as changing his sleep pattern is whathe is keen to do (motivation) and discusses with him how drinking can bothcontribute to insomnia and interfere with attempts to change sleep patterns(motivation). They agree to work together on a brief intervention to reducedrinking (Kaner et al., 2007; Michie et al., 2012) and then for him to attend aninsomnia group run by the service, which would mean he could get support form"5
PWP Training ReviewBehaviour Change Modelsothers in the group in tackling his insomnia (opportunity). The PWP alsosignposts him for debt advice and employment support (opportunity).Intervention: using COM-B during interventionsThe COM-B model can help guide how best to carry out low intensity interventions. Itcan be especially helpful with low intensity interventions that are not CBT based, wherethere is often less clear guidance for PWPs. But it can also help with facilitation of selfhelp interventions based on CBT principles especially ensuring due attention to theimportance of motivation. Three examples of application of COM-B around medicationadherence, signposting and CBT based self-help follow.Figure 1: COM-B analysis of a possible treatment goal for Mrs BrownIssues with opportunityIssues with capacitySupportive partnerLack of knowledge around panicdisorderLack of knowledge and skills in selfmanagement approaches for panicincluding of exposureImplicationsImplicationsThese could be helped by CBTbased self-help approachedPartner could support change;involve partner in treatmentTarget behaviourTravelling abroad on holidayIssues with motivationPatient is very keen to go on holidaywith her familyIs very frightened about travellingImplicationsStrong fear will resist exposure tasks;go over likely barriers to exposurewith patient in advance"6
PWP Training ReviewBehaviour Change ModelsSupporting medication management involves helping patients obtain optimal benefitfrom medication for depression and anxiety disorders in liaison with the patient’s GP.The COM-B model can be used to consider possible problems in adherence tomedication (Jackson et al 2014). Patients may lack knowledge and understanding(capability) that affects their adherence, for example that antidepressant medicationcommonly has to be taken for a few weeks before it has any benefit and must be takenregularly (rather than just when they feel bad). Family or friends may advise againsttaking medication (opportunity) or could be helpful in prompting taking medicationwhere a patient tends to forget (opportunity). In terms of motivation, a variety ofnegative beliefs about medication (it is addictive, it shows weakness and they shouldbe able to cope without, etc) or negative beliefs about the possibility of help/improving(“I am a mess and nothing can help”) will make it less likely that people will usemedication even when it might be beneficial (motivation). The PWP needs to explorewith the patient the reasons for nonadherence and tailor their intervention accordingly.Signposting to community resources is the intervention that most clearly addressesopportunity. For patients with chronic adverse circumstances maintaining depressionand anxiety disorders (debt, domestic violence, unsafe neighbourhoods, homelessnessor inadequate housing, etc), facilitating access to agencies to address these adversecircumstances is often initially the intervention of choice. Facilitating access tocommunity resources is also important for people with chronic histories of depression/anxiety, often isolated, whose lives are limited with few rewarding activities, social orinterpersonal relationships. Signposting to support groups of people with similarexperiences and backgrounds can be helpful in reducing isolation. In all these cases,an effective signposting intervention involves more than giving the patient the contactdetails of the community agency. Whether the patient will follow this up, make contactand attend the agency recommended will depend on their having adequate capacity,opportunity and motivation for this. The PWP needs to discuss these with the patient,identify potential barriers to attendance and ways to address these. These mightinclude one or more of information about the agency and how it could help, clarifyingpatients questions and concerns, helping the patient draw up an action plan forcontacting the agency, identifying who might support the patient in contacting andattending the agency, prompting the patient with a phone call to make contact,following up to see if the patient has attended and, if not, problem solving the barriers.Figure 2 sets out a COM-B analysis of implementing a signposting intervention to adebt advice agency.Low intensity interventions require patients to take responsibility for their own treatment,attending individual or group appointments, working through on-line programmes, andundertaking all sorts of homework tasks from reading, to self-monitoring behaviour, toputting into practice self-help strategies. Some of these tasks can be time consumingand some (e.g. exposure and behavioural activtation) will be resisted by the veryavoidant anxiety or depressive motivational processes that have brought the patient totreatment in the first place. Unless patients carry out these tasks, they are unlikely toobtain benefit. There is evidence that patients"7
PWP Training ReviewBehaviour Change ModelsFigure 2: COM-B analysis of a signposting interventionIssues with opportunityIssues with capacityMemory problems as a result ofdepressionIsolated; little social supportImplicationsImplicationsWrite down plan about contactingagency including when; follow-up withtelephone remindersUnlikely to attend without support andchild care; arrange for support andchild careSingle parent of 3 children not atschool or nurseryTarget behaviourAttending debt advice agencyIssues with motivationStrong doubts that anything can help withdebt problemImplicationsDiscuss doubts and reality test these indiscussion."8
PWP Training ReviewBehaviour Change Modelsare more likely to benefit the longer they stay in low intensity treatment (Delgadillo et al2014), although at some point additional sessions will have negligible additionalbenefit. Enhancing and sustaining motivation to carry out and persist with all thespecific elements of their low intensity treatment is accordingly critical to success.Approaches to supporting motivation from the behaviour change literature, which areespecially relevant for PWPs are: Prompting patients to make a commitment to undertake a task. When settinggoals and homework tasks to be achieved between appointments, prompt thepatient to make a commitment to doing the task (together with a pl
out that behaviour comes about from an interaction of ‘capability’ to perform the behaviour and ‘opportunity’ and ‘motivation’ to carry out the behaviour. New behaviour or behaviour change requires a change in one or more of these. As COM-B is an overarching framework of behaviour, it can supplement the CBT model in PWP
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2. Social-psychological theories of behaviour and change Tim Jackson (2005), in his review of evidence on consumer behaviour and behavioural change, lists a total of 22 different theories and models that explain people [s behaviour. Andrew Darnton (2008a) reviews over 60 social-psychological models and theories of behaviour.
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