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Table 1 Behavioral insights identified through coding process

From: Using behavioral insights to design implementation strategies in public mental health settings: a qualitative study of clinical decision-making

Behavioral insights


How behavioral insight can determine TN implementation

Base Rate Fallacy/Mental Models

Base rate fallacy refers to when individuals ignore probabilities when making decisions and instead use the similarities between events to make predictions. Mental models are internal representations of the world.

Clinicians who experience the base rate fallacy may believe that aggregated data from efficacy trials, which are used to develop clinical practice guidelines, do not apply to their individual clients because of the perceived dissimilarity between their clients and trial participants. TF-CBT clinicians may have mental models of a “straight forward” or “typical” TF-CBT case, whereas other clients may align less with their image of the model of a typical TF-CBT case.

Choice Overload/Decision Fatigue

Choice overload occurs when decision-makers are faced with too many choices—the more choices, the more likely decision-makers will employ heuristics in lieu of reason. This relates to decision fatigue, or when people become fatigued the more decisions they make, which leads to poorer decisions.

Clinicians may feel that they don’t know how to choose among the many different intervention options (i.e., modality of the narrative, how to structure the narrative, etc.) they have at their disposal for a given client. They may feel psychologically taxed by the multiple decisions.

Default Bias

Default bias is the tendency for decision-makers to prefer the current state of affairs and an aversion to change.

Clinicians may prefer the current practices they implement in their clinical work. This occurs because the current treatments they are implementing are taken as a reference point, and any change from that baseline is perceived as less preferable.

Fear Avoidance/Ostrich Effect

Fear avoidance is the tendency to avoid thoughts or actions that cause people fear. The ostrich effect is related to fear avoidance; it describes people’s tendency to ignore or fail to seek, often negative, information.

Clinicians may avoid implementing the trauma narrative because it is difficult for them—they may not be as skilled in the trauma narrative as the practices they have been trained in, and therefore do not want to engage in something that makes them feel less competent or nervous. They may also fear the difficulty in hearing details they may learn during the trauma narrative.

Functional Fixedness

Functional fixedness is the tendency to conceptualize an object (broadly construed) only in terms of its most common use.

Clinicians may believe that the trauma narrative can only be done in the way that it has been taught to them. For example, if a clinician is only taught to implement the trauma narrative verbally, they may struggle to consider other methods/modalities by which to implement it.


Hopelessness and helplessness are the feelings that things will not get better and that there are no ways to improve the situation.

Clinicians may feel “stuck” when attempting to implement the trauma narrative because several other barriers or challenges have intervened their ability to implement it. Clinicians may feel that despite their attempts to implement the trauma narrative, due to factors outside of their control (e.g., the client’s psychosocial stressors, their inability to attend sessions) they are being insufficiently rewarded for their work, and therefore may be less inclined to attempt it with some clients.

Lack of Reinforcement

The lack of reinforcement is the absence of a reward that can strengthen a response or action.

Clinicians may feel they are not being rewarded for the uncompensated work they have to do to prepare for the trauma narrative session.

Risk/Loss Aversion

Loss aversion refers to the idea that losses are more painful than similar gains. This leads people to avoid risks when losses are involved.

Clinicians may perceive the risk of harm in conducting the trauma narrative as more salient than the benefits it may offer.

Social Norms

Social norms represent a psychological phenomenon in which people do something primarily because other people like them are doing it.

Clinicians may feel that if others at their agency are/are not using the trauma narrative, then they will be less/more likely to use it.

  1. Note. Behavioral insights are largely selected from the Behavioral Economics Guide 2018 [58] with several additions included by study coders with expertise in behavioral insights