The Birth of Online Behavioral Interventions

Behavioral interventions encourage new and increase existing positive behaviors while reducing or ending unhelpful ones (Cutler, 2004).

They are used to manage and treat a variety of physical and mental health conditions in children and adults, including diabetes, obesity, asthma, and emotional difficulties (Brigden et al., 2019).

The continuing trend toward digital therapy opens up alternative possibilities for scaling and targeting specific online behavioral interventions (Tang & Kreindler, 2017).

This article explores the background of behavioral interventions before introducing guidance and techniques for designing and building digital tools on the latest online therapy platforms.

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What Are Behavioral Interventions?

Behavioral change programs follow several psychological models and theories and yet share a similar objective and approach. All make use of behavioral interventions to target physical and mental wellbeing, promoting “a better adaptation of the individual to a given situation and optimizing his or her personal resources in relation to autonomy, self-knowledge and self-help” (Ricou et al., 2019, p. 1).

Behavioral change programs use interventions to influence and direct the actions taken by individuals regarding their wellness. The development of such interventions follows a broadly similar series of steps (Cutler, 2004; Baddeley, 1990; Gross, 2020):

1. Specify the behavior that needs to change – typically defining small, measurable, and achievable goals.
2. State the goal – making it as precise and specific as possible.
3. Establish a baseline for how the person ‘normally’ behaves – detailed observation leads to hypotheses regarding what maintains the behavior.
4. Decide on a strategy – an example might include reinforcing non-yelling and ignoring yelling behavior.
5. Plan the treatment – this might include ensuring consistency with others in contact with the patient.
6. Begin the treatment – implement the intervention and treatment based on the strategy and plan.
7. Monitor the progress – for example, if the treatment is working, then yelling should reduce.
8. Change the program as required – revisit and revise the intervention based on the behavioral changes seen (or not) in response to the intervention.

The following sections explore the psychology behind behavioral interventions, their application in psychological and physiological wellbeing, and the potential for their use in online therapy.

The Psychology Behind Behavioral Interventions

Throughout evolutionary history, humans have been encouraged or forced to change their behavior in response to direct and indirect parental, kin, and group feedback (Buss, 2016).

Children are chastised when they reach for something hot, and teenagers are advised against embarking on rash, unwise behavior. The expectation is that the intervention will result in learning and a change in behavior in the future, usually in favor of the individual or group.

However, it wasn’t until the early 1900s that psychology began to attempt to formally explain behavior and how it could be changed through external forces (Gross, 2020).

Ivan Pavlov’s (1927) work with salivating dogs in 1904 led to the discovery of classical conditioning and the recognition that a stimulus could automatically and reliably trigger a predictable response.

Pavlov, a major influence in the field of behaviorism in psychology, showed that animals and humans could learn to respond to external stimuli (Gross, 2020).

A famous case in 1924, known as Little Peter, proved that it was possible to eliminate a phobia of animals through a behavioral intervention known as systematic desensitization (Jones, 1924). It is perhaps the earliest documented example of formal behavioral treatment within psychology (Gross, 2020).

Later, behavioral therapy, still rooted in the principles of behaviorism, built on the findings of classical conditioning, using experimentally established principles of learning to change unhelpful or disadvantageous (nonadaptive) behaviors (Wolpe, 1958).

Techniques known as behavior modification have since been developed to build appropriate behavior that didn’t exist previously or was present but too infrequent (Gross, 2020).

Cognitive-behavior therapy (CBT) is the most popular therapy in primary healthcare, most likely because of its low cost and effectiveness in both children and adults (Ricou et al., 2019). CBT is underpinned by the idea that when people evaluate their thinking more realistically and adaptively, they typically experience improvements in their emotional state and behavior (Beck, 2011).

CBT and other schools of behavior therapy, including Exposure Therapy, Dialectical Behavior Therapy, Rational Emotive Behavior Therapy, and social learning theory, typically share the following general characteristics of behavioral interventions (Farmer & Chapman, 2016):

• Empirical orientation:
  Use of empirically supported intervention strategies and ongoing assessments performed on the client’s targeted behavior.
• Therapist–client collaboration:
  The client and therapist work as a team to understand the client’s problem areas and formulate a plan for therapy.
• Active orientation:
  Clients are encouraged to do something about their problems and talk about them.
• Emphasis on environment–behavior relations:
  Actions are conceptualized in terms of the thoughts, emotions, and physical sensations the client experiences and the context in which they occur.
• Time-limited and present focus:
  Attention is on the current situation rather than the past, with appropriate time allocated for treatment.
• Problem and learning focus:
  Solutions to problem behaviors teach new or adaptive behaviors, impact aspects of the dysfunctional environment, and provide further information regarding behaviors of interest.
• Emphasis on change and acceptance processes:
  Interventions promote therapeutic change in a suitable context for encouraging self-validation and a nonjudgmental outlook regarding the client’s experience of thoughts, feelings, and bodily sensations.

While behavioral interventions share similar features across the various theories, the types of interventions and how they are delivered vary considerably (Farmer & Chapman, 2016).

3 Examples of Behavioral Interventions

Behavioral interventions can be highly successful because of their targeted approach to unhelpful or problematic behavior. As with the following real-world examples, they can be tailored to specific groups and particular behaviors.

1. Infants

A 2016 study investigated the effects of behavioral interventions on infants’ sleep (Gradisar et al., 2016).

Results found that graduated extinction (the parent gradually increasing the time they stay away from the crying child at bedtime) and bedtime fading (paying particular attention to sleeping patterns and adjusting bedtime schedules accordingly) were successful interventions for improving sleep in young children, with no significant impact on stress or parent–child attachment.

2. Children

Behavioral intervention strategies have proven effective in school-related difficulties in children with attention deficit hyperactivity disorder (DuPaul, Weyandt, & Janusis, 2011).

The following interventions have proven helpful in promoting positive academic and behavioral outcomes in classroom settings (DuPaul et al., 2011):

• Modifying the environment in ways that positively affect their impairment.
• Keeping class rules simple and phrased positively, and sharing them periodically throughout the year.
• Changing the length and content of assignments.
• Giving students choices regarding which task they choose (all of which lead to similar outcomes).
• Use of tokens to reinforce positive behavior. These can later be exchanged for access to preferred activities.

3. Primary care

Primary care often treats patients with overlapping conditions of chronic pain, depression, and substance use disorder. The following behavioral interventions have all had success in treating individuals and groups (Barrett & Chang, 2016):

• Acceptance and Commitment Therapy
• Positive CBT
• Mindfulness
• Motivational interviewing

Crucially, such treatments have worked well in various settings and can be used in conjunction with conventional treatments at a relatively low cost.

The Birth of Online Behavioral Solutions

Online behavioral interventions are being used more frequently across multiple situations to promote changes in behavior (Ribbers & Waringa, 2015).

Digital technology and online therapy platforms are highly effective at targeting individual and group clients with regular communications, homework, tools, psychoeducation, and other interventions.

Social media campaigns on platforms such as Facebook, Twitter, Instagram, and YouTube are increasingly being adopted to scale up health-related campaigns (Pagoto et al., 2016).

The following studies uncover the power and potential for digital technology to target more people with specific interventions that can translate into beneficial educational and health behavior.

• Research has shown poor education to be an obstacle for social mobility. Behavioral interventions successfully increase student persistence and course completion (Kizilcec et al., 2020).

A 2020 study found that the following online behavioral interventions successfully improved the performance of students:

• • Plan-making interventions describe how and when to complete coursework.
  • Value-reference intervention helps students understand how the course reflected and reinforced their values.
  • Mental contrasting with implementation intention interventions prompt reflection on the benefits and barriers associated with striving for a goal.

Such interventions improve course completion and outcomes to varying degrees and benefit from being tailored to the needs of the students and context (Kizilcec et al., 2020).

• Online interventions prove valuable in encouraging people to exercise more, manage their weight better, and reduce alcohol consumption.

A meta-review of 29 papers, including 30 online behavioral interventions, found that social marketing health campaigns are highly successful because of their low cost and broad reach (Cugelman, Thelwall, & Dawes, 2011).

• While time spent online can be highly productive and a valuable source of learning and leisure, there are downsides. Many people, including teenagers, now spend many hours on social media, affecting other areas of their lives (Kovacs, Wu, & Bernstein, 2018).

However, digital behavioral interventions have proven valuable; they “variously inform, nudge, and encourage people to engage in behaviors more in line with their goals” (Kovacs et al., 2018, p.1).

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Planning a Behavioral Intervention With Digital Tools

Adequate time and resources are required to fully understand the problem and the behavior requiring change before creating an online behavioral intervention. Without appropriate analysis, the intervention will be less helpful or the outcome potentially unsuccessful (Michie, Atkins, & West, 2014).

Michie et al. (2014) offer the following eight steps for designing behavioral interventions:

1. Define the problem.
   Spend time understanding what the problem is that you are trying to solve in behavioral terms. Identify the context and the individual, group, or population involved.
2. Select the target behavior.
   Select the behavior that you are trying to change and how. Recognize that behaviors rarely exist in a vacuum, but are typically part of a system.

Consider what behaviors are most likely to bring about change and address the problem. It may be helpful to create a ranked list of relevant behaviors to identify the core ones.

3. Specify the target behavior.
   Define the behavior in as much detail as possible and how you wish it to be changed.

Ask yourself:

Who needs to perform the behavior?
What must they do differently?
When and where will they do it?
With whom and how often?

4. Identify what needs to change.
   Recognize what it will take to bring about the desired change. What must shift in the person or group and the environment in order to achieve the target behavior?

The more accurate the understanding of what needs to change, the more likely the change is to be in the right direction.

5. Identify intervention functions.
   Select the types of interventions that are likely to result in the desired change. For example, behavioral interventions could include:

• • Goal setting and making plans
  • Avoiding situations that are cues for the current behavior
  • Changing routines and the environment
  • Developing more healthy and appropriate beliefs
  • Developing new, positive habits

6. Identify policy categories.
   Behavioral interventions can come in all shapes and sizes. Social media campaigns and fiscal measures can impact entire populations. For example, taxes placed on cigarettes have been used to discourage smoking.
7. Identify behavior change techniques.
   Define the specific intervention content and how it can be implemented.

For example, consider how:

Better habits can be formed (for example, through rehearsal and repetition)
Goals can be set (agree and commit to the new behavior)
Behaviors can be monitored and scored

8. Identify the mode of delivery.
   Select the delivery mode. Will it be via video call with one person or a group? Will the behavioral intervention be delivered via email or within a platform such as Quenza? How can psychoeducation be shared and promoted?

When we define a problem in behavioral terms, we must be clear and specific regarding the individual or group involved and understand what behavior must be changed. For example, weight loss on its own is not a behavioral target. Increasing physical activity and eating more healthily by walking two miles a day and following a diet plan is a more specific intervention.

Determining how to motivate and sustain behaviors is equally important and may require ongoing monitoring (Michie et al., 2014).

10 Strategies & Approaches in Quenza

Therapists have a variety of behavioral interventions at their disposal to help their clients.

Powerful online platforms can create digital templates, and therapists can tailor them if necessary before sending them to patients and tracking their completion.

One online platform that provides interventions and allows therapists and coaches to custom-build their own behavioral interventions is Quenza. Quenza was built by the founders of PositivePsychology.com, with the help of the wider positive psychology community.

This powerful app provides an intuitive drag-and-drop activity builder, which offers an easy-to-use interface for creating behavioral interventions. Interventions can be customized from the existing library of tools, worksheets, questionnaires, and activities or created from scratch.

The intervention can then either be sent as a one-off, standalone exercise or included within a care pathway, with appropriate timings and additional psychoeducation.

Whether using a prebuilt or new pathway, activities can be scheduled to take place over several days, weeks, or months to create habits or alternative ways of looking at current behaviors and settings.

Consider using the following strategies and approaches for online behavioral interventions:

• Goal visualizing, setting, breaking down, and tracking
• Mindfulness and meditations to improve self-awareness, reduce anxiety, and handle stress
• Psychoeducation to provide the client with greater knowledge regarding their symptoms and potential treatments. This may include videos, motivational quotes, podcasts, and stories of others who have overcome similar challenges.
• Self-assessment and measures to monitor behavioral changes, thoughts, moods, and the success of treatments
• Desensitization homework, including tasks of increasing difficulty to desensitize the client from situations they fear; for example, slowly increasing engagement in social activities
• Stress interventions that help the client interrupt the chronic stress response and see stress in a more positive way while offering opportunities for growth
• Self-contracts that help the client commit to a desired behavioral change
• Focusing on strengths as a valuable approach to becoming more self-aware, increasing confidence, and managing difficult situations
• Increasing forgiveness and self-compassion as a way to achieve peace of mind and self-acceptance
• Learning to say no to the client’s own urges and unfair or incompatible requests from others

Behavioral interventions of each kind already exist with Quenza and can be tailored to suit the client’s needs. They can be placed within automated pathways to take the client through multiple stages of growth and include psychoeducation, assessment, and action to produce behavioral change.

A Take-Home Message

Online behavioral interventions have proven successful in promoting a wide range of prosocial, healthy, and positive behaviors, including physical activity, healthy eating, and educational achievement. While low cost, they can have a highly beneficial impact, targeting psychological mechanisms that underpin people’s behavior (Kizilcec et al., 2020).

Although digital tools within therapy have been around for some time, it is only in recent years that the usefulness and efficacy of online behavioral interventions have been fully recognized in multiple forms (Kovacs et al., 2018; Tang & Kreindler, 2017).

Social media presents a new and far-reaching method for intervening in the behavior of groups and populations, yet it may not be easy to track its impact on an individual level (Pagoto et al., 2016).

On the other hand, behavioral interventions created within custom-built online therapy platforms offer a dedicated and focused approach to scaling and targeting existing and new clients.

Why not try out Quenza with its dedicated platform built with the online therapist in mind? It offers easy-to-use functionality and a purpose-built toolset for helping clients address their needs. For just $1, you can try out Quenza, review some of the existing libraries of interventions, create some of your own, and combine them into effective and helpful care pathways.

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