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Behavioral Medicine

Compared to psychosomatic medicine, behavioral medicine is a relative newcomer to science. Its birth was signaled by a 1977 conference at Yale where participants defined the field.

The discipline evolved after that. These changes were traced by Anne Herrington in a Foreword to The Handbook of Behavioral Medicine (2014):

When the discipline formed in the late 1970s, the founders wanted to distinguish it from the older field of psychosomatic medicine, with its emphasis on Freudian concepts and neurotic origins of physical symptoms. Behavior medicine "would not worry about unseen entities such as the unconscious or try to discover the alleged deep roots of maladaptive behaviors."

"Taking its cue from the laboratory" behavioral medicine emphasized proven behavior change techniques. Initially these included biofeedback, operant conditioning, and relaxation training.

In the 1980s the field started to emphasize chronic health conditions involving behavior "for which main­stream medicine often had few tools" such as hypertension, smoking cessation, pain relief, obesity, diabetes, eating disorders, and sleep disorders.

In the 1990s behavioral medicine began to rethink its "categorical resistance" to mental health issues. This was because psychiatry itself had changed, turning more toward biological and evidence-based approaches.

In the early 2000s, research started to show the importance of social factors. Practitioners realized they "needed to start asking questions about the behaviors of spouses and care­givers and not just patients."

The result was a hybrid. Behavioral medicine became a "no-nonsense, evidence-based field of research and practice—one that also has clearly grown a social conscience and cultivated a big heart." (Herrington, 2014)

A study that illustrates what Herrington is talking about focused on heart attack patients addicted to smoking. After surgery, they were asked to stop smok­ing. Could they do that without getting depressed or going back to smoking?

The researchers (Busch, Srour, Arrighi, Kahler, and Borrelli, 2015) focused on continuing valued life activities to improve mood during the difficult post-surgical phase. They found that restricted activities (such as smoking) had to be replaced with something enjoyable, to prevent depression and maintain smoking cessation.

How did research on smoking cessation post heart attack address emotional issues?

Psychotherapy helped, the researchers found, if it targeted "greater engagement in valued life activities." When such activ­ities were located and encouraged, peo­ple were much more likely to main­tain a good mood and not resume smoking.

The study included elements from each phase in the evolution of behavior medi­cine. It emphasized a behavioral out­come (smoking cessation). It addressed mental health (mood). The treatment involved social factors (valued life activities) and included psycho­therapy.

A behavioral approach to weight loss was presented in a 1972 book, Slim Chance in a Fat World (Stuart and Davis, 1972). It was subtitled, "Beha­vioral Control of Obesity."

The focus was entirely upon measuring and changing the behavior of eating. Special attention was paid to situational cues: triggers of eating.

The authors addressed the dieter's need for social and emotional support. They gave brief but forceful advice about benefits of exercise, the need to stay on the program, and the pros and cons of various food types.

Throughout there is also a strong, bottom-line emphasis on counting calories. Charts for doing this were included with the book. Simple, practical tips were offered to make life easier for a dieter. For example:

–Always keep on hand a variety of safe foods to use as snacks. ["Safe" foods have almost no calories.]

–Once you establish how many calories per day you should eat, keep track of how much you have eaten and how much more you can eat while staying within your diet at all times, every day

Of course, there was reinforce­ment:

–Build in some payoff for following every step in this program.

What was emphasized in a behavioral approach to obesity?

The program was simple, direct, and to-the-point, and it worked. It was tested on a variety of populations and proved success­ful. Because it focused on mea­suring and controlling calorie intake, there was no doubt about why it worked.

However, it required discipline. Also, there was not much money to be made promoting a program that could be fully explained in a tiny little book, 4x5 inches in size and only 90 pages long.

Perhaps that is why you do not hear much about the behavioral approach to obesity. There is much more money to be made by selling magic fat-burning pills, mail order meal programs, or other more expensive approaches.

Behavioral medicine started out being inspired by rigorous laboratory work on conditioning. It opened itself to other approaches as long as they were measurable, so evidence could be gathered. An example is gamification as a behavioral medicine approach.

Gamification is "the use of game design elements in non-game contexts." Video games are said to be addictive, so why not use those elements to promote health-promoting behaviors, making desirable behaviors as addictive as possible?

What is gamification, and why might it be relevant to behavioral medicine?

Cugelman (2013) pointed out that, to apply gamification, health practitioners needed (1) a list of game design ele­ments that make games addictive, and (2) ways to integrate those elements into health interventions. Existing research suggested seven game design elements that could contribute to the addictive qualities of video games:

  1. Goal setting: Committing to achieve a goal
  2. Capacity to overcome challenges: Growth, learning, and development
  3. Feedback on performance: Receiving constant feedback through the experience
  4. Reinforcement: Gaining rewards, avoiding punishments
  5. Comparing progress: Monitoring progress with self and others
  6. Social connectivity: Interacting with other people
  7. Fun and playfulness

Few previous studies focused on "fun and playfulness" as elements of therapy, but that seemed desirable for gamifi­cation. The first six variables were well established strategies for behavior change.

For example, self-monitoring is sometimes used as a therapy by itself. Social connectivity is presumed to be one of the reasons peer counseling works so well.

Gamification was invented as a concept around 2010, so evidence for its effec­tiveness was lacking when Cugelman wrote in 2013. Not all studies showed positive effects; some users com­plained that elements of attempted gamification like badges and scoring points were annoying.

Another "red flag" was that researchers often could not tell if reported outcomes were sustainable over the long term. Cugelman said the two ingredients that resulted in most behavior change were behavioral contracting (for goal-setting) and time management (for help in action planning), both time-honored strategies of behavior therapists.

What were potential drawbacks of gamification? How were elements of gamification already used in therapies?

A variable Cugelman described as "infrequently used in the health field, but popular among video game designers," was flow. Games must not be too easy (people become bored) or too difficult (they stop playing).

That idea might sound familiar if you read about the hedgehog theory in Chapter 9 (Motivation). Motivation is greatest in situations of optimal complexity, neither too high nor too low.

The jury is out on gamification, but if the goal is to introduce enjoyment and motivation to health-promoting behaviors, few people would be against it. Behavior medicine is open to such an approach because it involves behavior, the results can be measured, and who knows, it might work to improve compliance with therapies or health maintenance. This can only be determined by testing it.

What other two disciplines have become compatible with behavioral medicine?

Behavioral medicine has broadened by opening itself to other disciplines. If you examine the list of topics addressed in the discipline of psychosomatic medi­cine, it is not so different from the research in behavioral medicine.

Likewise, the field of Health Psychology has considerable overlaps with the other two. All three have become compatible with each other in the era of evidence-based practice (EBP).


Busch, A. M., Fani Srour, J., Arrighi, J. A., Kayler, C. W. & Borrelli, B. (2015). International Journal of Behavioral Medicine, 22, 563. doi:10.1007/s12529-014-9456-9

Cugelman, B. (2013) Gamification: What It Is and Why It Matters to Digital Health Behavior Change Developers. Journal of JMIR Serious Games, 1. Retrieved from: doi:10.2196/games.3139

Herrington, A. (2014) Foreward to the Handbook of Behavioral Medicine. In David I. Mostofsky (Ed.) The Handbook of Behavioral Medicine. Malden, MA: John Wiley.

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