Table of Contents

Form and Function

Current Initiatives in Primary Care

Triple Aim

Patient Centered Medial Home Model

Primary Care Behavioral Health Model

Challenges to Evolving Primary Care

Lack of Preparation

Low Job Control

High Complexity Patients

Workforce Shortage

Recommended Strategies for Improving Behavioral Health Services in Primary Care


Review of Strategies


List of Abbreviations

The Team and Their Work

The Organization of Primary Care

Internal Primary Care Staff

Primary Care Clinician

PCP Training

Non-physician Primary Care Clinicians

Naturopathic Physicians

ND Training

Registered Nurses

RN Training

Licensed Practical Nurses, Nursing Assistants and Medical Assistants

Support Staff in Primary Care

Front Desk Staff Members

Ward Clerks

Appointment Line

Billing Specialists



Medical Directors

Nursing Director

Clinic Manager or Director

Other Leaders

Primary Care Behavioral Health Staff

Behavioral Health Clinician

Behavioral Health Clinician Assistant

Health Coach

Community Health Worker

A Note About Teamwork in Urban, Suburban, and Rural Clinics

Prosocial Teams

Acceptance and Commitment Therapy

A Word About Resilience

The Maslach Burnout Inventory

Compassion: An Antidote for Stress

Morning Huddle Compassion

End of Day Gratitude Circle

Recommended Strategies for Promoting Healthy PC Teams


Review of Strategies


List of Abbreviations

What Do Patients Want?

Measurement of Flourishing

Barriers to Flourishing

Psychological Flexibility and Inflexibility

Psychological Flexibility and Avoidance

A Clinical Definition of Psychological Flexibility

Basic Methods for Targeting Behavior Change in Primary Care

Recommended Strategies for Promoting A New View of Behavior Change in PC

Review of Strategies


List of Abbreviations

Starting a Conversation About Behavior Change

Standardized Assessments

Rating Scale Questions

The Contextual Interview Questions

Workability and Values Clarification

The Four-Square Tool

Contextual Assessment Checklist

Case Examples

Amy: Trauma and Health Risk Behavior

Bob: Life Stress and Difficulties with Self-Management of Chronic Disease

Mary: Grief and Demoralization

Pillars of Psychological Flexibility

Putting It All Together




A Note About Suicide and Risk Assessment

Recommended Strategies for Providing Assessments That Engage Patients in Behavior    Change


Review of Strategies


List of Abbreviations

A Syringe and Powerful Medicine

Primary Care Behavioral Health

Powerful Medicines

Focused Acceptance and Commitment Therapy

 Generating Information to Inform Interventions for Primary Care

Promoting Psychological Flexibility in Clinical Contacts

The Pillars Intervention Guide




Targeting Open and Aware

Targeting Values

 The “Relate the Problem to Values” Worksheet

Behavioral Experiments

Behavioral Variability



A Note About Time and Behavioral Experiments

Amy’s Behavioral Experiment

Bob’s Behavioral Experiment



Life Path

Working Smart in Primary Care

Use Assistants

Think Beyond Clinic Visits

Think Beyond the One-To-One

Strategies for Delivering Powerful Behavior Change Interventions


Review of Strategies


List of Abbreviations

Appendix A:

A.1.1 Contextual Behavioral Scientist Check-In

Appendix B:

B.3.1 The Flourishing Project Measure

B.3.2 The Acceptance and Action Questionnaire- II

B.3.5 The Approach-Avoidance Tool

Appendix C:

C.4.7 Rating Scale Questions

C.4.8 Contextual Assessment Checklist

C.4.9 Pillars Assessment Tool (PAT)

C.4.12 Contextual Interview Questions

C.4.13 Four-Square Tool

Appendix D:

Table D.5.1 The “Relate the Problem to Values” Worksheet

Table D.5.2 The “SMART Behavioral Experiment” Worksheet

Table D.5.3 Bull’s-Eye Plan Worksheet

Table D.5.4 The “Life Path Plan” Worksheet

Table D.5.7 FACT Pillar Intervention Guide (PIG)

Figure D.5.1 The Life Path Plan       

Figure D.5.3 Bull’s-Eye Plan

     I am writing this book to help people who want to help others be effective agents of change in the powerful setting of primary care. Primary care is the place where most people can access the services of a health care clinician, and this book aims to empower those clinicians to promote changes in behavior that help people to flourish (Fledderus, Bohlmeijer, Smit, & Westerhof, 2010). Whether you are a trained professional and re-locating to the primary care setting or a student preparing for a career in primary care, my hope is that this book will help you become an effective member of an inter-professional team member, capable of delivering interventions for patients of all ages for all behaviorally influenced problem when the patient asks for help.

     I have met and worked with physicians, nurse practitioners, physician assistants, team nurses and nursing assistants, pharmacists, physical therapists, social workers, psychologists, counselors, community health care workers, and health coaches all over the world. We have worked in rural, urban, and suburban settings in the United States and provided training and technical assistance in Sweden, Norway, Denmark, France, Spain, Italy, Great Britain, Germany, Ireland, Mexico, Argentina, Canada, Japan, Korea, Australia, Peru, and New Zealand. Everywhere, there are difficulties with healthcare and opportunities for improvement. The ability to effectively support behavior change among patients presenting with medical and psychological problems is central to realizing the Quadruple Aim outcomes of improved population health, patient experience, value, and primary care staff wellness (Bodenheimer & Sinsky, 2014).

      More and more countries are waking up to this idea and are initiating efforts to make delivery of behavior change services a routine part of primary care. Strategies recommended by the Primary Care Behavioral Health (PCBH) model (Reiter, Dobmeyer, & Hunter, 2017; Robinson & Reiter, 2016, 2007) offer guidance for these pilots and large-scale deployment following successful pilots. Dozens of studies on the PCBH model document its promise as an effective population health approach to delivery of behavioral health services and its association with positive clinical and system-level outcomes (Hunter et al., 2017). Strategies in this book are consistent with the PCBH approach, where many more people access behavioral health services than was possible in traditional soloed approaches to healthcare. PCBH services are also associated with the achievement of health equity, such that people who need healthcare the most can access it as easily as those with better health (

     The most significant barrier to PCBH deployment is the lack of a trained workforce, capable of delivering empirically supported behavior change interventions. This book is our attempt to promote rapid uptake of assessment and intervention strategies by all members of the interprofessional teams that are developing in primary care clinics around the world. This is a small book, with five chapters that can be read in any order by any member of the primary care team. The first chapter introduces readers to primary care—its mission and methods and its current challenges. The second chapter concerns the development and maintenance of strong teams. In the third chapter, we suggest a conceptualization for assisting patients of any age with on-going development of skills that promote flourishing and healthy aging. Chapters 4 introduces Contextual Interview Questions, a tool that helps clinicians complete a functional assessment of the problem that most concerns the patient. In Chapter 5, readers learn to intervene to promote more psychologically flexible behavior in patients and to develop engaging behavioral experiments with patients. Several metaphors commonly used by PC teams using Focused Acceptance and Commitment Therapy (FACT) are introduced, including the Bull’s-Eye and the Life Path. Both of these interventions can be used in individual and group visits with patients.

     The Appendices offer readers a Contextual Behavioral Scientist Checklist (Appendix A) to track their progress in developing skills in using the toolkit offered by this book. For convenience in duplicating and use of tools in skill practice exercises, the other appendices offer copies of the scales and tools introduced in Chapters 3-5 (Appendix B: Chapter 3 scales and tools; Appendix C: Chapter 4 tools; Appendix D: Chapter 5 tools). Readers will find these scales and tools on the book website as well (

     This book is for all healthcare professionals working to improve health in their communities, including Primary Care Clinicians (PCCs), nursing staff and nursing assistants, Pharmacists (Ph), Physical Therapists (PTs) and their assistants, Behavioral Health Clinicians (BHCs) and their assistants, Dieticians, Emergency Department and Hospital Staff, Specialty Service Providers, Health Coaches (HC’s) and Community Health Workers (CHW’s). This book is also written for clinic and healthcare system leaders. A fully informed leadership supports rapid, efficient change toward delivery of better primary behavioral healthcare services. To encourage the use of this book by leaders, we include a section for leaders at the end of each chapter (Tips for Leaders) as a part of the chapter summary. Knowledge gained from reading this book is a first step toward developing an evolved primary care service; mastery develops as a part of a flexible application of methods and strategies introduced in the book. To encourage our readers to attain mastery, we offer on-line coaching services to readers seeking assistance in applying and refining what they learned from reading this book (see

     Whether you are a healthcare leader or provider or a student preparing for a career in primary care, this book is for you. I hope that students of nursing, psychology, social work, counseling, marriage and family therapy, pharmacy, physical therapy, nutrition, exercise science, epidemiology, public health, and medicine will read this book early in their studies. This book is also for the faculty members that teach them. Increasingly, faculty members will team-teach inter-disciplinary courses to graduate and under-graduate students embarking on careers in healthcare. In this way, we develop a group of healthcare providers for the future, one that knows how to deliver high impact behavior change services as a part of an inter-professional team.

     I want to express our gratitude for the many people that assisted with and inspired this book. First, I want to thank Jeff Reiter for mulling over ideas for the book with me and for providing helpful feedback on several chapters. I wish his life circumstances had allowed him to co-write with me, as he is an excellent writer and a deep thinker. Second, I want to thank Justin Kerr for his proof-reading and editorial assistance; this book would not have been possible without his resolute assistance in the final days of writing.  Sharon Penulla, an editor at Springer, has shared a vision of better behavioral health services in primary care with me for almost 15 years. Thank you, Sharon. I also must name a few of my healthcare super-heroes, including Kirk Strosahl, Sue Hallwright, Jo Chiplin, Johnny O’Connell, Aaron O’Connell, Marcia Sasano, Julie Geiler, Ann Dobmeyer, Chris Hunter, Neftali Serano, Lt Col Matthew Nelson, Jodi Polaha, Jennifer Funderburk, Katie Kanzler, Kent and Megan Corso, Stacy Ogbeide, Nicola Silberleitner, Anneli Voncederwald, Margaret Lemp, Lisa Braverman, Emily Parker, Julie Oyemaja, Mary Peterson, Robyn Godye, Alysha Simonsen, Wayne Blackburn, David Bauman and Bridget Beachy. Finally, I am grateful for all the patients that have helped me learn about how to help people make small changes that improve the quality of their lives.


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