Table 5 The six phases of each programme session

Phase 1

Education that is collaborative using motivational interviewing principles- obtaining permission from participants and ‘chunk-check-chunk’, that is give a little information at a time, check that this information is understood before giving another bit of information. This is followed by motivation building through engaging participants to describe their concerns and important life goals; and the barriers and facilitators to achieving them. Finally, there is agenda setting for the rest of the session.

Phase 2

Mapping of existing illness perceptions using CBT principles of assessment. Participants are stimulated to identify their illness beliefs and link the beliefs into CBT vicious cycle of beliefs/thoughts, mood, physical sensations, and behaviour.

Phase 3

Challenging maladaptive illness perceptions using CBT principles. Participants are encouraged to question their illness perceptions associated with maladaptive behaviour to explore if there is any utility (discovered by participants themselves) in having these perceptions.

Phase 4

Formulation of alternative illness perceptions and associated behaviours using CBT principles of guided discovery. Guided discovery involves participants being encouraged during group sessions to discover by themselves more positive ways of thinking and behaving in relation to their CLBP. Physiotherapist shows an understanding of participants’ point of view and encourages them to discover alternative ways of thinking about their concerns. Socratic dialogue is used to change maladaptive illness perceptions into alternative perceptions conducive to achieving life goals stated in phase 1.

Phase 5

Practising the alternative (desired) behaviour in a supervised session by completing the exercise and postural training sessions. After the cool down session, good posture in daily functional activities are practised. Participants are encouraged to explore alternative illness perceptions that may support performing exercises and adopting good posture in daily life. Subsequently, a plan for change is developed with the participants by exploring the incorporation of these activities into their daily lives. Motivational interviewing principles of ‘Elicit-provide-elicit’ are used. Physiotherapist facilitates the change talk by identifying and strengthening comments that show the desire to change, ability to change, reasons for change, need to change, commitment to change and taking steps towards behaviour change. Physiotherapist focuses at an individual level, on the most relevant area for each participant and stimulates the motivation to change by discussing outcome expectancies associated with exercises and good posture. For instance, participants can be told how exercising just before going to bed can improve pain and sleep, and how working from a table instead of the ground can reduce the number of pain episodes. There is exploration of participants’ risk awareness and self-efficacy. Goals to achieve the required behaviour change are set with the participants before the next session. Physiotherapist plans with the participants, the steps required for the exercises and good posture. Participants are encouraged to remember/record their activities. Social support is used to facilitate behaviour change by allowing each participant to identify a family member or significant other to support the exercises and good posture.

Phase 6

Testing of alternative illness perceptions and associated behaviours. Physiotherapist stimulates participants to test alternative illness perceptions and associated behaviours (exercises and good posture) by using CBT principles of behavioural experiments. Participants practise the behaviour (exercises and good posture) and appraise their efficacy in their lives. The desired behaviour is strengthened by participants confirming their utility in their daily life. This appears to correspond with the appraisal stage of the SRM. There is exploration of personal and social/environmental factors that may constitute barriers and facilitators to engaging in the exercises and good posture. Strategies to utilise the facilitators and reduce barriers to the desired change are explored with the participants. Culturally tailored goals are then set for personalised strategies to overcome the identified barriers. For instance, some participants who may not want to exercise on Sundays for spiritual reasons may be encouraged to exercise in the morning and later in the evening during the previous Saturday.