Herzog (In this article, I discuss the illness and recovery of the depressed Moses Herzog, the protagonist of Saul Bellow’s novel Herzog . Using t Which approach to choose depends on the particular patient, their condition, and their personal preferences. One patient may have total confidence in pills, while another may be highly afraid of side effects or the danger of addiction and may prefer therapeutic conversations or expressive therapy. Furthermore, different approaches might very well be effectively combined, for example, when a patient is treated with medication and cognitive behavioral therapy. The merit of the work by narrative psychiatrists such as Bradley Lewis and SuEllen Hamkins is that they have shown, both in their books and in their psychiatric practice, the potential of a non-binary approach to psychiatry that combines different ways of looking at and treating patients suffering from psychiatric problems  views the depressed person primarily as a body with a disturbed biochemical balance that can be restored through the use of psychopharmaceuticals. In this view, depression is considered a brain disease that must be treated with pills. But many other approaches are possible, including psychoanalytic ones that accentuate the patient’s early life; cognitive behavioral techniques that concentrate on changing the patient’s attitude towards depression; approaches such as interpersonal therapy and family therapy that focus on the personal environment of the patient; therapies that stress the spiritual dimension, such as expressive therapy and mindfulness; approaches that stress the importance of role patterns and cultural context, such as feminist therapy; and several other ones. According to the view of what is called ms Lewis .Lebenswelt.Herzog ([1964] 2003). According to the criteria of the American Psychiatric Association’s , Herzog suffers from severe depression with manic characteristics.2Ways of approaching and treating psychiatric problems are closely related to perceptions of what a human being is. Depending on the view chosen, psychiatric problems may, for example, be seen as “broken” brains, the result of unconscious conflicts, cognitive distortions, family dysfunctions, or as a combination of these. There is no single correct view, and differing perceptions may complement one another. Surely, human beings are in part bodies with particular chemical balances. However, in addition to being a body with certain  properties, humans are also self-interpreting beings that are part of a iation’s  fifth edavant la lettre.3As mentioned above, a range of possible treatments would be open to Herzog today. Most likely, he would be treated with a mixture of antipsychotics and antidepressants, possibly in combination with temporary admission to a psychiatric hospital. Herzog is in such a bad way that such treatments might very well have been helpful; however, when the novel was written, such drugs hardly existed, and apart from a psychoanalytic approach, no good alternative treatments were available. Nevertheless, Herzog manages to control his depression: he gets a new grip on himself through writing letters about his experiences, thus examining and reinterpreting his life. As we will see below, in fact, Herzog becomes his own therapist, practicing a kind of humanistic psychotherapy The purpose of this article is threefold. Firstly, by investigating depression using philosophical ideas and a literary text, I aim to demonstrate how the humanities may contribute to our understanding of depression. Secondly, I intend to criticize a one-sided bio-psychiatric approach to depression, arguing that Bellow’s novel may help us reflect on a broader and more subject-oriented view of psychiatry, in which depression is approached in the context of biological as well as psychological, existential, and socio-cultural factors. Thirdly, the article aims to discuss the main tenet of narrative psychiatry, namely that no single approach is best in all cases. For a person like Moses Herzog, humanistic therapy might be a good choice, although alternative or additional treatments  could also be wise and helpful. However, other individuals with different personality traits, values, and personal convictions would probably benefit from different approaches.Feelings of Being , it became a public favorite and an unusual sales success; it was translated into many languages and millions of copies were sold. Herzog is a fictional account of depression, largely based on Bellow’s personal experiences.Saul Bellow was highly interested in timeless questions about the human condition and the interactions between humans and their environment. In 1976, he received the Nobel Prize for Literature for the way in which he exposed his ideas about humans and human culture in his novels: the committee praised both his “human understanding” and adherence to “the realm of values in which man becomes human” as well as his “subtle analysis of contemporary culture” Atlas , 461. HiHerzog’s opening line Madeleine sends him to Dr. Edvig, a psychiatrist who talks to Herzog four afternoons a week for some time. Edvig describes Herzog as “reactive-depressive” (60) and warns Madeleine that he is worried about Herzog’s condition (326). Edvig is an old-school psychoanalyst: he talks with his patients while they are lying on a sofa. In the novel, Edvig is portrayed as a charlatan who is more interested in the beautiful Madeleine than in his patient. He is of no use to Herzog, and, as we will see below, the latter will have to save himself. In what now follows, I will discuss what would happen if Herzog should visit a psychiatrist today: What diagnosis would he get, and what treatment would be started? Even though Moses Herzog is a fictional character from a novel written over half a century ago, a thought experiment like this may help to enhance our understanding of the experience and treatment of depression, as will be shown below.To determine whether a person is depressed, psychiatrists today usually use the DSM-5 criteria. Some of these are psychological; others are behavioral or functional. First, the patient must show at least five of the following nine symptoms on a nearly daily basis: (1) persistent feelings of somberness; (2) loss of interest in and enjoyment of things; (3) a marked change in weight; (4) difficulty in sleeping; (5) psychomotoric agitation, either excessive restlessness or inactivity; (6) fatigue or loss of energy; (7) feelings of guilt or worthlessness; (8) difficulty in concentrating; and (9) thoughts of death and/or suicide. A second criterion is that the symptoms exhibited cause suffering and impaired functioning . Furthermore, these symptoms must not be caused by other factors, such as a somatic disorder or medication use.How does the situation of Moses Herzog relate to this list? It appears that he meets the DSM-5 criteria for depression. Herzog shows symptoms 1, 4, 7, 8, and 9 to a clear or even high degree and symptoms 2 and 6 to a slightly less pronounced degree. Herzog’s basic mood is one of a deep gloom (symptom 1), verging on despair: “There is someone inside me,” he thinks; “I am in his grip.… He will ruin me” (14). He is afraid that he will “fall apart” (14) and would prefer to “creep into hiding, like an animal” (31). Herzog also suffers from insomnia (symptom 4) and takes sleeping pills “to preserve himself” . These are no longer effective, however, and he walks about drugged (88), sometimes more like a zombie than a human being: “His eyes were swollen and his head asleep, but his anxious heart beat faster than ever” (117). As a result of his insomnia, Herzog feels deadly tired (symptom 6): he is “careworn, busted” (298). Another consequence of his insomnia and fatigue is a loss of concentration and disorientation (symptom 8): he is “confused … feverish, damaged … and shaky” (38). In short, he is “a man deeply preoccupied” (9).Angst and Sein zum Tode—and especially for that of Heidegger’s successors, the existentialist philosophers like Sartre, for whom, according to Herzog, “the one true God is Death” (315): “Modern philosophers would like to recover the old-fashioned dread of death” (296). Eventually, as we will see below, Herzog will come to reject what he calls the “Wasteland outlook” (82) and overcome his fear; at the height of his depression, however, he suffers from “that infantile terror of death that had bent and buckled his life into these curious shapes” (289).Herzog suffers from severe feelings of guilt (symptom 7): towards his first wife Daisy, whom he has treated badly; towards his children, to whom he is barely of any use; towards his academic vocation, which he has let go to waste; towards his family and friends, whom he neglected; towards his girlfriend Ramona, who has been very good to him in his troubling condition, without getting anything in return; and towards himself, because he has been reluctant to confront his problems. A characteristic description in this respect is the following: “To his son and daughter he was a loving but bad father. To his own parents he had been an ungrateful child. To his country, an indifferent citizen. To his brothers and his sister, affectionate but remote. With his friends, an egotist. With love, lazy.… With his own soul, evasive” (7). Given all this, it is hardly surprising that a “perpetual thought of death” (38 [symptom 9]) takes place in Herzog’s mind. At the same time, he feels guilty about having such a thought, because it is “a sin” for him to turn away from life; he remembers the biblical advice “Drive your cart and your plow over the bones of the dead” (38). Herzog’s obsession with death takes the form of confused notes, such as “Death—die—live again—die again—live. No person, no death” (5). It also manifests itself as a fascination for the philosophy of Heidegger—and its contemptibly aching,” and he “would like to give this heart a shaking, or put it out of his breast” . His is “an injured heart, and raw gasoline poured on the nerves” (219); he lets “the entire world press upon him” (219). “You eat yourself alive,” a friend says to him (236). The situation is of a chronic nature, and suffering has become a “habit” (213). Herzog experiences his condition as hopeless: “I fall upon the thorns of life, I bleed. And then? I fall upon the thorns of life, I bleed. And what next?… I fall upon those same thorns” (225).Herzog thus shows many symptoms of depression. He also satisfies the second criterion mentioned above, as the exhibited symptoms actually cause serious suffering and impair his professional and/or social functioning. His academic career has come to a halt, and he is completely stuck with his book on the interactions between Christianity and Romanticism. His social life is also largely at a standstill. He suffers pain (252) and feels terrible: “his heart is But there is even more going on with Herzog. His depressive complaints are accompanied by behavior that exhibits manic characteristics. In order to determine to what extent this is indeed the case, we again consult the DSM-5, where the following criteria are mentioned to determine a manic episode: First, there must be an abnormally and persistently elevated, expansive, or irritable mood and an abnormally and persistently elevated level of activity or energy. In addition, three or more symptoms from the following list should be present: (1) a bloated sense of self-esteem or grandiosity; (2) a reduced need to sleep; (3) a high level of talkativeness or speech impediment; (4) a flight of thought or a feeling of having agitated thoughts; (5) increased distractibility due to irrelevant external stimuli; (6) increased activity  or psychomotoric agitation; and (7) engaging in dangerous activities . The other criteria for a manic episode include (as with depression) impaired  functioning and the condition that the problems are not caused by other factors such as a somatic disorder or medication use.Moses Herzog, indeed, clearly meets these criteria for a manic episode. There is abundant evidence of abnormal excitability and activity. In fact, he shows all seven of the symptoms mentioned above and symptoms 1, 3, 4, and 7 to a very high degree. Concerning his self-esteem (symptom 1), Herzog is described several times as a vain and narcissistic person . He is aware of this and feels guilty about it; indeed, he calls himself “lazy” in love, a “bad father,” an “ungrateful child,” and “an egotist” (7). When his psychiatrist Dr. Edvig mentions, in a conversation, characteristics such as pride, anger, competitiveness, the inability to endure criticism, hostile projections, and delusions, Herzog thinks to himself: “It’s all there—all!” (86).Herzog’s thoughts constantly take flight (symptom 4) and “are shooting out all over the place” (16); they “plunged and thundered with endless—infinite!—hungry, electrical power … with inexhaustible energy” (181). He broods over all sorts of things: over personal matters such as his ex-wives and children, his youth and his friends, but also over the historical study of ideas he is writing and over the state of contemporary American and Western culture. Herzog’s days are characterized by a “near-delirium and wide-ranging disordered thought” (303). He is tormented by “the extreme violence of thought and feeling” (237), which sometimes literally takes on a violent character. He regularly fantasizes about revenge: he “wanted to murder Madeleine. Yes, he was capable of killing her” (170), as “now his rage is so great and deep, so murderous, bloody, positively rapturous, that his arms and fingers ache to strangle them [Madeleine and Valentine]” (239). Herzog has the uncontrollable need to express his constantly grinding thoughts. This manifests itself partly as an urge to speak (symptom 3) but much more as an urge to write; as we shall see below, Herzog gives shape to his flight of thought in an endless series of notes and letters.But Herzog’s mania does not stop at thoughts and also manifests itself in his actions, which often take on dubious and sometimes even dangerous forms (symptom 7). There is talk of Herzog being committed to an institution because he sometimes behaves like “a mad dog” (40) and could become a danger to himself and others. He recognizes this himself: he says that he behaves “quixotic” (311); describes his mood as “eager, grieving, fantastic, dangerous, crazed and, to the point of death, ‘comical’” (102); and acknowledges that he is “in the grip of that eccentric, dangerous force that had been capturing him” (234). At an important point in the novel, Herzog thinks to himself: “Characteristically, he was determined to act without clearly knowing what to do, and even recognizing that he had no power over his impulses” (262). In most cases, his impulsivity is limited to relatively innocent things. For example, he buys clothes he does not need and cannot afford, and he travels to a friend’s summer home in Martha’s Vineyard (because “Seashores are good for madmen” [31]), only to return home immediately upon arrival because he cannot bring himself to be there and talk to his friends. But Herzog’s recklessness sometimes takes on more dangerous forms. While visiting his stepmother in Chicago, he secretly takes a bundle of old ruble bills and his deceased father’s pistol. He then drives to Madeleine and Valentine’s house in a state of great excitement: “The thread of life was stretched tight in him. It quivered crazily.… It did not seem illogical that he should claim the privilege of insanity, violence. It’s not everyone who gets the opportunity to kill with a clear conscience” (276–277). Once at Madeleine and Valentine’s house, Herzog calms down and, after a while, drives away. But the next day, his manic activity starts anew: “Blood had burst into his psyche, and for the time being he was either free or crazy” (288). He picks up his daughter for a day trip but does not pay attention in traffic and gets involved in a car accident. The girl remains unharmed, but he gets slightly injured and faints. He still has the rubles and the gun in his pocket, which causes all kinds of complications when the police arrive. Everything ends well, but the thread on which Herzog balances is thin: “Running to Chicago to protect his daughter, he almost killed her” (310).In summary, the DSM-5-based diagnosis of Moses Herzog is as follows: Herzog has severe depression with manic characteristics. In many patients with bipolar disorder, manic and depressive episodes can last for extended periods; however, in the case of Herzog, there is a so-called mixed mode, in which the manic and depressive episodes can alternate very quickly, sometimes even within a day. Based on this diagnosis and the list of symptoms mentioned above, a psychiatrist today would probably prescribe a combination of antidepressants, antipsychotics, and sleep medication. A few weeks in a psychiatric hospital would possibly also be advised until the medication begins to work properly and Herzog calms down so that his manic behavior no longer poses a danger to himself or others. As we have seen above, many alternative options  exist, and a narrative psychiatrist would carefully consider which treatment(s) to choose in consultation with the patient. However, most psychiatrists today would likely go for the medicinal approach, seeing other treatments as only serving a secondary and supportive role—if they were to be considered at all.From a (neuro)biological psychiatric perspective, symptoms like Herzog’s are first and foremost seen as manifestations of a physical (brain) disease. Psychiatric medication is prescribed to make the patient calmer (less confused and/or less anxious) and to restore a disturbed biochemical balance (such as a serotonin deficiency). But at the time Bellow’s novel was published, such medication was hardly available. Herzog has conversations with a psychiatrist who works along psychoanalytic lines, but this man is hardly of any use to Herzog. Despite the lack of serious psychiatric or medicinal help, however, Herzog manages to overcome his misery in the course of the novel. How does he do that?Herzog refuses to wallow in self-pity and disillusionment and does not flee into booze or other stimulants; instead, he confronts himself. He fights back and does so in his own particular way: he writes letters, an endless series of letters, “to everyone under the sun” (3). He scribbles them down without ever sending them. Initially, many of his letters are rather confused. For example, he writes weird notes, such as “It has been reported that several teams of Russian Cosmonauts have been lost; disintegrated, we must assume. One was heard calling: ‘SOS—World SOS’” (14). Many letters are addressed to people in his own immediate environment and serve as an outlet for his emotions. For instance, he writes to his ex-wives, children, mother-in-law, psychiatrist, himself , and the dead . Other letters have a more intellectual content and are addressed to famous philosophers, including Montaigne, Rousseau, Kant, and Nietzsche . A third category of letters has a spiritual character and is addressed to religious thinkers—and even to God .Herzog’s writing, at first sight, appears to be the scribbling of a confused, or sometimes even insane, person but is essentially an ongoing self-analysis, a Socratic self-examination: “Late in spring Herzog had been overcome by the need to explain, to have it out, to justify, to put in perspective, to clarify, to make amends” (4). With the help of these letters, he tries to order his thoughts, control his emotions, and reinterpret himself into a comprehensible story. The letters, which gradually become more coherent and clearer, are his private form of therapy. While writing, Herzog searches for direction and tries to reinvent himself: “A loving brute—a subtle, spoiled, loving man. Who can make use of him? He craves use. Where is he needed? Show him the way to make his sacrifice to truth, to order, peace. Oh, that mysterious creature, that Herzog!” (335).At the beginning of his crisis, Herzog is a misanthropist, furious at all those who have betrayed him and hiding from the world in books and ideas—and constantly writing letters. But, although this helps him to understand himself better, reading books and writing letters, in itself, offers no solution. Above all, it is essential that Herzog shakes off his vanity and complacency and takes account of the social connections that have shaped his life; for, although not unsympathetic, he is an egocentric man, barely involved with his children, family, and friends, and difficult to get along with. He is demanding, suspicious, short-tempered, presumptuous, gloomy, a brooder, vain, and masochistic—not an easy man to live with. He realizes this and feels he must account for it: “He was in pain. He should be. Quite right” (252). Therefore, more important than the books and letters is remembering his youth, living in a poor family on the shabby Napoleon Street in Chicago, where his mother died of cancer when he was 16 years old and his father failed in one job after another. The memories of the bond he had with his parents, brothers, and childhood friends and of life in the city and community at that time are important building blocks in this process of self-investigation. “I am still a slave to Papa’s pain” (163), Herzog, for example, realizes.himself ” . He intends to become a more active father and also seems to find a renewed bond with nature. At the end of the novel, Herzog lies on the couch in his ruinous country house. He waits for Ramona and realizes his writing impulse is over: “At this time he had no messages for anyone. Nothing. Not a single word” (371). Herzog has conquered the turmoil in his head and is returning to the world.Thanks to this process of writing, remembering, and self-reflection, Herzog’s understanding of himself and of his shortcomings increases. Gradually, he starts to think a little milder about Madeleine and Valentine and begins to appreciate their good sides. More generally, he becomes less self-absorbed and more aware of his former self-pity and self-esteem: “Herzog smiled at this earlier avatar of his life, at Herzog the victim, Herzog the would-be lover, Herzog the man on whom the world depended for certain intellectual work, to change history, to influence the development of civilization” (115). Towards the end of the novel, he reconnects with the outside world, including his brother Will, his girlfriend Ramona, and some local residents. Realizing how much he loves his children, he now understands that “a man does not need happiness for I look at myself and see chest, thighs, feet—a head. This strange organization, I know it will die. And inside, something, something, happiness … That leaves no choice. Something produces intensity, a holy feeling, as oranges produce orange … this intensity, doesn’t it mean anything? Is it an idiot joy that makes this animal, the most peculiar animal of all, exclaim something? And he thinks this reaction a sign, a proof, of eternity? And he has it in his breast? But I have no arguments to make about it. (370)In his novels, Bellow stages humans as self-interpreting beings. Surely, we are partly determined by our biological properties and natural predisposition; at the same time, however, our lives are also shaped by the way we interpret ourselves and the world around us. This has to do with things like values, ideas, and intentions or, in short, with the perspective from which we view the world. In addition to being objects with physical  properties, humans are also subjects that cannot be grasped through the objectifying approach of the natural sciences. This conception of humans can be found everywhere in Bellow’s work. For example, Herzog is convinced that “a man is somehow more than his ‘characteristics’” and that “a Life is something more than such a cloud of particles, mere facticity” (289). At the low point of his crisis, he looks at his face in the mirror and thinks to himself, “My God! Who is this creature? It considers itself human. But what is it?… A desire. Where does it all come from?” (239). At the end of his spiritual journey, lying in a hammock in the garden of his country house, Herzog has found a new balance, but the mystery remains as big as it was:Bellow believed in the existence of an invisible dimension in human life and transferred that belief to the characters in his novels. “Something,” a “desire,” a certain “intensity,” a “holy feeling,” an “idiot joy”: it remains somewhat vague and mysterious and cannot be concretized or proven, but Herzog believes it exists. “And what about all the good I have in my heart—doesn’t it mean anything?”, he asks himself, to which he answers, “this good is no phony. I know it isn’t” (225). These intuitions and beliefs of Herzog are similar to those of his creator. In an interview, Bellow worried about the attempts to rid human life of its mystery: “Science with the aid of modern philosophy—what we call the positive outlook—has driven the ‘invisible’ into the dark night where enlightenment says it belongs” , Herzog says to a friend. He suffers, but he has the inner reserves to get through it, and he is convinced that it is his duty to do so: “He must live. Complete his assignment, whatever that was” (251). In an interview with Sanford Pinsker, Bellow said that Herzog’s task, which is to better understand himself and the world around him, is, in fact, that of us all. “I think in a world where people had better have an ‘earnest’ grip on reality in order to survive, it becomes a mental-moral project to understand your surroundings, yourself, and the society you live in”  environment. Nevertheless, Bellow maintained a humanist orientation. Herzog, for example, remains present as an individual—as a self that directs his existence—although his childhood experiences and family background have a major impact on him, and he does have ambiguities and contradictions. In fact, he realizes this very well, contemplating that “modern character is inconstant, divided, vacillating,” for it lacks the “stonelike certitude” of earlier ages (125). Although Herzog’s autonomy is thus problematized, a certain core of his personality remains; this core, as we will now see, can be understood narratively.Bellow’s portrayal of Moses Herzog illustrates the hermeneutic anthropology advocated by philosophers such as Paul Ricoeur, Charles Taylor, and Marya Schechtman. In their view, humans are, at least partly, constituted by their (self-)interpretations. These interpretations have to do with our natural characteristics and embodiment, as we are biological beings, but also depend on our environment: the biographical, social, historical, and cultural factors that form the context of our lives. Self-interpretation and self-understanding do not take place in a void. “A human being alone is an impossibility,” says Taylor, “self-interpretations which define [an individual] are drawn from the interchange with the community” , 8. Ricowhat a human is  as it is with who a human is—namely, someone with a certain past, living in a certain social and cultural environment, and with certain values, motivations, goals, and intentions. A self is not an object in the world but a perspective on the world. Since a subject and its self-interpretation are not a visible part of the empirical reality, the notion of a self is meaningless from a scientific point of view. As Taylor writes, “What it is to possess a liver or a heart is something I can define quite independently of the space of questions in which I exist for myself, but not what it is to have a self or to be a person”  and ipse refers to identity as subjectivity. Idem refers to what we are; ipse refers to who we are. Considered as ipse, we do not remain identical in the sense of a physical or psychological immutability but in the sense of a developing personality. Idem belongs to “the category of events and facts”  interpretations resemble stories, which by their nature match the form of human life; they take place in time and are about the actions of characters with certain backgrounds and intentions. Ricoeur says that stories can express “the very structure of human acting and suffering” and points to “the inestimable value of narrative for putting our temporal experience into order” , 28, 31.Every life knows its tensions  and contradictions . Human identity is dynamic and characterized by changes and developments. “The issue of our condition can never be exhausted for us by what we are,” writes Taylor, “because we are always also changing and becoming” , 46–47. become human and transcend what we, of course, are as well: a biological being. Ricoeur, Taylor, and Schechtman speak of a narrative identity; that is, the self, as it comes about through interpretations and is expressed in a story. When we talk about a narrative identity, we refer to the self as ipse.Through my story, I can tell myself and others “who I am.” By approaching our life as a personal story, we can try to transcend the ambiguity and vicissitudes of our existence and see ourselves and our life as a unity; a unity that is not biological but thematic, moral, and existential. It is by putting together our own story that we truly The idea of narrative identity as a hermeneutic view of the self implies a belief in a certain degree of human freedom and, therefore, responsibility. “Narrativity serves as a propaedeutic to ethics,” says Ricoeur , 115 in cogito and imagination as well as on our embodiment and Lebenswelt. In articulating our interpretations and understanding of human identity, stories can play a crucial role in many ways: by justifying choices we made; making tensions and contradictions understandable; indicating which values are important to us; showing who we (think we) are and who we want to become—or, in short, by seeing our life in its coherence and meaning. “We must inescapably understand our lives in narrative form,” writes Taylor  and is largely left to his own devices . At times, he walks along the edge of the abyss—for example, when he arrives at the house of Madeleine and Valentine in a manic state armed with a gun or when he has a traffic accident with his little daughter in the car. Whereas modern psychiatry often places all emphasis on pills, there is no medication whatsoever in the case of Herzog, so his “treatment” is too one-sided as well.Through its humanistic orientation, Bellow’s novel warns us against a form of psychiatry that merely treats depression as a brain disease. Undoubtedly, there may be a biological basis for depression, and physical factors—such as hereditary predisposition—and the workings of neurotransmitters and hormones play their part. Fortunately, there are drugs that can improve our biochemical balance and offer relief. However, the depressive patient is not only an object consisting of biological properties but also a self-interpreting subject rooted in a Lebenswelt. Psychiatrists such as Jim van Os question the massive scale on which medication is prescribed, the effectiveness of medication and the lack of information about possible side effects, and, more generally, the one-sided bio-psychiatric approach that is the current paradigm. As mentioned above, philosophers such as Matthew Ratcliffe and Sanneke de Haan have proposed models for psychiatry that make room for the existential dimension of human life, a dimension that de Haan finds largely missing in the bio-psychosocial model . The humanism of Bellow and of philosophers such as the ones mentioned remains highly urgent in a time when neuroscientific research into what we are is considerably more influential than narrative reflections on who we are.I have argued that Bellow’s novel, as an account of the experiences of a person with severe depression, can help us to reflect on the shortcomings of current biomedical psychiatry and put us on the trail of more human-centered psychiatry. I sympathize with an existential humanist approach to depression that includes personal, socio-cultural, and biological factors, and the work of philosophers like Matthew Ratcliffe and Sanneke de Haan is of crucial importance in this respect. At the same time, it has to be acknowledged that human-centered approaches and enactivist models are still no more than particular narratives, albeit holistic ones that avoid reductionist focus on one factor. One problem with human-centered approaches might be that they work best with “strong” characters possessing a certain sense of autonomy and agency. But not everyone is like Moses Herzog, and for other types of patients, alternative views, narratives, and, therefore, ways of treatment will be better options. Herzog benefits from logotherapeutical letter writing, but for others, a biomedical approach or one of the many other available therapies like creative therapy, feminist therapy, or spiritual therapy might very well be a better choice. Narrative psychiatry reminds us that there are many plausible stories to tell and suggests that the decision of which story will be told should not be taken in a doctor-knows-best fashion; rather, it should be taken in a way that respects the values and the lived experience of the patients and honors the way in which they view themselves and their world.


The use of behavioural science and behaviour change within local authorities and public health has supported healthful change; as evidenced by its importance and contribution to reducing harm during the COVID-19 pandemic. It can provide valuable information to enable the creation of evidence-based intervention strategies, co-created with the people they are aimed at, in an effective and efficient manner.This study aimed to use the COM-B model to understand the Capability, Opportunity and Motivation of performing a constellation of eight COVID-19 disease prevention behaviours related to the slogans of ‘Hands, Face, Space, Fresh Air’; ‘Find, Isolate, Test, (FIT), and Vaccinate’ in those employed in workplaces identified as high risk for transmission of the SARS-CoV-2 (severe acute respiratory syndrome coronavirus 2) to support intervention development.This qualitative study recruited twenty-three participants , who were interviewed from three environments  across three local authorities. Semi-structured interviews were analysed using thematic analysis.Ten core themes were identified inductively; (1) knowledge and skills, (2) regulating the behaviour, (3) willingness to act, (4) necessity and concerns, (5) emotional impact, (6) conducive environment, (7) societal influence, (8) no longer united against COVID-19, (9) credible leadership, and (10) inconsistent adherence to COVID-19 prevention behaviours. Themes were then deductively mapped to the COM-B model of behaviour change and the theoretical domains framework and a logic model using the behaviour change wheel (BCW) was produced to inform intervention design.This study offers a novel approach to analysis that has included eight behaviours within a single thematic analysis and COM-B diagnosis. This will enable local authorities to direct limited resources to overarching priorities. Of key importance, was the need for supportive and credible leadership, alongside developing interventions collaboratively with the target audience. COVID-19 has had an emotional toll on those interviewed, however, promoting the value of disease prevention behaviours, over and above their costs, can facilitate behaviour. Developing knowledge and skills, through education, training, marketing and modelling can further facilitate behaviour. This supports guidance produced by the British Psychological Society COVID-19 behavioural science and disease prevention taskforce. Health psychology is a discipline in behavioural science that can help to guide the development of effective interventions to enhance population health and wellbeing . To do tAs of October 2022, in the United Kingdom there were 18,826,374 cases of people testing positive for COVID-19 on a first occasion, 1,312,947 re-infections and 183,579 deaths with COVID-19 on the death certificate , regulation/legislation  and service provision , to reduce the spread of the coronavirus that causes COVID-19. However, despite the use of these behavioural strategies, cases of COVID-19 continued to persist , with adBehavioural scientists have proposed principles for implementing COVID-19 specific behaviour change , citing Using this approach, behavioural diagnoses using COM-B have provided insight for COVID-19 intervention development  and specThree local authorities in the East of England identified schools, care homes and warehouse settings as areas of concern for increased risk of COVID-19 infection in the summer of 2021. This study aimed to investigate the core influences on COVID-19 disease prevention behaviours in these populations identified as at-risk. Brief descriptions of the identified behaviours of interest for the local authorities were: (1) hand hygiene, (2) wearing a face covering, (3) physical-distancing, 4) ventilation, 5) PCR testing when symptomatic or asked, (6) LFD testing when asymptomatic, (7) self-isolation when symptomatic or asked, and (8) vaccination uptake. The secondary aim was to produce a logic model using the Behaviour Change Wheel  32-item checklist .Recruitment: Participants were recruited between July–October 2021. They were eligible if they worked or were closely engaged within the three environments identified as experiencing high COVID-19 transmission (schools (S), care homes (CH), and warehouses (WH)) across three local authorities. A sign-up link , QR code and contact telephone number were circulated by community and workplace connections provided by local authorities, via posters located in community settings and sent around social media. The principal investigator (AMC) spoke on BBC Three Counties radio to promote the study and aid recruitment. In total, 260 people clicked the sign-up link. Of these, 131 did not provide any details, and 47 were not eligible due to employment setting or location . One person used the telephone number, but was not eligible to participate. All of the remaining 82 eligible candidates were contacted via email, text or phone call.Participants: Twenty-three participants  were included, selected at random until data saturation was reached. The sample was aged between 19 and 65 years old , 14 were residents of Bedford Borough (BB), 6 of Milton Keynes (MK) and 3 of Central Bedfordshire (CB) councils; 10 worked and/or had children in schools, 8 worked in care homes, 5 worked in warehouses, and 11 lived with under 18 s. Full participant details are in An interview schedule  designedn = 16), Zoom (n = 4) or Microsoft Teams (n = 3). The interviewer had no previous contact with participants and no one else was present during the interviews. An information sheet and consent form were sent prior to the interview, and consent was received prior to data collection.Interviews were held between 19th July to 27th October 2021 , timed to understand local behaviour following the named ‘Freedom day’ . At thisM = 45.57, SD = 6.54). Data saturation was reached at 20 interviews and although there was an unequal number of participants across the three local authorities, the team agreed to stop at 23 when no new themes were identified  ethics committee, [Ref: 2021ISPAR006] and followed the British Psychological Society’s Code of Ethics and Conduct . ParticiInterview transcripts were analysed (by PBR and AMC) inductively in NVivo, using Thematic Analysis , taking Thematic analysis inductively identified 10 themes; (1) knowledge and skills, (2) regulating the behaviour, (3) willingness to act, (4) necessity and concerns, (5) emotional impact, (6) conducive environment, (7) societal influences, (8) no longer united against COVID-19, (9) credible leadership, and (10) inconsistent adherence to COVID-19 prevention behaviours. These themes and their mapping to the TDF and COM-B are presented in TDF = knowledge, skills; COM = psychological capability, physical capability.A multitude of symptoms for COVID-19 were given by participants. While the recognised core symptoms  were often mentioned, there were many others identified, leading participants to conclude that the core symptom messaging was diluted.“The key symptoms are a persistent cough, a high temperature, loss of taste and smell. I know that there are others that aren't right now said by the government as key symptoms but still key to look out for.” “The key ones vary so obviously the temperature, continuous cough. Lack of taste and smell, that came in afterwards, but then it's a bit more varied, it's like a runny nose, sore throat, and that funny marks on your tongue and your feet? Shortness of breath. I think it's everything nowadays.” “Now they’re saying it’s fatigue, sore throat, headache, and there’s six things now. So my understanding is if I lose my taste and smell. Could that be the flu like I had last year, or is it COVID? I don’t know the difference really. So then they say, aches and pains in legs as well. If you’ve got the flu, you get that as well. So I just think it’s the same as the flu.” “I think the only one that is like the common one is a cough, because everything else can be COVID right now, everything else. So I would say that if I was coughing me or my husband started to cough, and like a lot, and was feeling this very extreme fatigue right away. And then the high fever again, you know, then I would be worried.” “I think the message has been lost because, you know, so many different organisations will tell you, Oh, that's another symptom… I've got lost in what's a symptom and what's not a symptom now and I think a lot of the time they're getting confused with the common cold symptom.” There was confusion surrounding the knowledge of ventilation in relation to ‘Hands, Face, Space, Fresh Air’. When initially asked to describe the core COVID-19 prevention behaviours, none of the 23 participants provided ventilation as a preventive measure. When asked about the ‘Fresh air’ part of the COVID-19 messaging, some conceptualised this as needing to exercise outside whilst others questioned the benefits of opening windows.“I think it [fresh air] actually relates to, I don't know, you can go and exercise outside?” “Yeah, our windows were sort of open and ventilated, how much of a difference that made? I'm not overly sure.” “I don’t think a lot of people are actually aware of the whole ventilation thing, and how it's now shown it’s more spread by airborne than on surfaces, everyone still just thinking about surfaces.” Concerns over the skills required to test young children were voiced and parents were frustrated at their inability to access appropriate guidance. Carers, however, with appropriate training and experience of testing, felt more skilled to test children. This was both in relation to the physical skills to perform the test and the interpersonal skills to put young children at ease to perform the test.“You will never see an NHS video doing a PCR test to a child of his age, the example is always with children that know what they’re [the child] doing.” “Cause obviously I'm fully trained on doing that [PCR tests]… So cause I was able to talk to the kids and just like, because obviously I do it to myself, I was able to sort of translate like, I’m not gonna stab you with this swab. Literally it’s just gonna be a tickle.” TDF = behavioural regulation, memory, attention and decision processes; COM = psychological capability.Participants spoke of the continuous conscious effort required to adhere to the COVID-19 preventive behaviours, with frequent incidents of forgetting and a lack of the ability to regulate behaviour. For many, the behaviours had not yet become habitual, and this often led to lapses in behavioural adherence. This was commonly voiced in relation to the requirement to perform regular LFD tests, or when individuals were moving quickly between areas in the workplace which had different face covering or hand hygiene requirements. Others, however, did suggest that it had become routine.“Sometimes I forget [to take an LFD test], but I’d say 90% of the time I’m pretty good at it.” “That tends to be when I forget to do it [wear a face covering], is when some kids need you so you instinctively rush over to help them, and I’ll forget to put the mask on.” “Hand sanitizer, again it’s quite a new thing and I think it's, you know, we’re not used to going into a shop and sanitising the hands straight away. So yeah, for me it's not the first thing I think of to do.” “I think it’s [LFD test] one of the things that you get into the habit of doing, you know like, remember to take your tablets.” “Well now it’s [LFD test] become a bit routine like I'm not expecting it to not being negative so if it did come back positive it'd be a surprise.” TDF = intentions, social/professional role and identity, beliefs about capabilities, beliefs about consequences; COM = reflective motivation.Participants had the intention to adhere to the disease prevention behaviours. This included sustaining newly built routines, such as testing, or changes in behaviour when needed, such as self-isolating. Willingness was aided when participants felt capable and believed a task was easy to complete.“I'll still stick to the same routine [for social distancing] even if it’s [LFD test] negative.” “So tonight, before I go to the hen party, I will take one [LFD test].” “I’d just follow the guidance and so I think it’s [self-isolation] 10 days max from being pinged.” “I still carry on using masks in supermarkets and shopping centres.” The extent to which individuals felt protecting others was part of their social or professional role and identity influenced their willingness to perform the behaviours.“I think we have an obligation to be vaccinated because we’re looking after vulnerable people.” “I got them [LFD test] through work, it was a choice I didn’t have to do it but I decided to, to keep myself and everyone safe, it was the best course of action to take.” “We wanted the masks to be compulsory […] we didn’t want to risk one person getting it at the time when there wasn't the vaccination available, obviously like thinking about older members of staff, those with illnesses and things like that, the same to children…” TDF = social/professional role and identity, beliefs about consequences, optimism, intentions, goals, reinforcement; COM = reflective motivation; automatic motivation.The necessity for the different prevention behaviours varied. The importance of performing these behaviours to protect themselves and others was commonly voiced, however, there were concerns raised over some of the behaviours, such as vaccination.“But I feel, in order to protect ourselves and everyone else, it’s something that we need to do as a community.” “The social distancing that we had at the beginning, it’s just being carried on implemented and we still have the same approach like not getting too close to a person because we were thinking the risk was high to catch the virus.” “I don’t want to put my unborn child through that [vaccination].” People also expressed the view that behaviours were needed as routes to achieving specific goals, such as being able to travel, see family and allow society to get ‘back to normal’.“I’m gonna take the opportunity to be vaccinated from this virus, then hopefully the more people are vaccinated, the quicker we can get back to normal.” “Everything comes down to, because I want to travel, to see my mom, she cannot come here.” Those who had not caught COVID-19, and attributed this to their adherence to the disease prevention behaviours, saw value in performing the behaviours thereby reinforcing their beliefs in necessity and adherence.“I just think oh I've made it through another week and that’s a bonus (laughs), it’s more kind of thinking stick to it [prevention behaviours] cause obviously it's working.” “I'm an example of well if you follow the protocols, then the potential for you getting it [COVID-19] is a lot less likely.” This was most prevalent in workplaces where respondents spoke of the requirement of weekly testing. As participants were only taking LFD tests as a work requirement, as opposed to due to suspected COVID-19, they were expectant of a negative result. Therefore, when they received a negative result it reinforced the efficacy of their preventive behaviours and this did not change their future behaviour. Individuals stated that they would opt for a PCR test, even after a negative LFD test, if they had concerns over potential symptoms, highlighting their beliefs in the processes to prevent the transmission of the virus, to protect others.“It’s [negative LFD test result] just a confirmation that what I’ve been doing has been working.” “I did a LFT in the morning and that came back negative. So, I was like I still don't feel like completely safe so I booked into a drive thru proper swab test.” Participants drew on their experiential knowledge of the pandemic so far to assess the necessity of engaging in the disease prevention behaviours. When participants had not been personally ill themselves, they questioned the consequences of not performing the behaviours and were optimistic about not becoming seriously ill. This seemingly influenced their intentions to perform the behaviours  in the future.“I still haven’t had it [COVID-19]. And again if I did have it, it really obviously wasn’t that bad. So for me, having the vaccination. It kind of seems a bit redundant.” “I don’t want to go back to a face mask again. And to be honest with you I've survived long enough without it.” Costs for performing the behaviours were also voiced. The financial cost of testing positive and receiving reduced pay whilst isolating was raised as a concern. As was adverse reactions attributed to testing experienced by some of the participants, such as nose bleeds and tonsillitis. There were side effects to wearing face coverings experienced by some participants, such as impacting on breathing , impaired communication, initiated panic attacks and skin blemishes, whilst visors were associated with headaches.“They didn’t realise that employees wouldn't go there [testing tent] because they know, they will have the LFT and if it’s positive, they have to have a PCR and if it's positive, they have to isolate and they would be unpaid.” “They couldn’t afford to lose the wages. At that point they had just started contracts and they wouldn't have gotten company sick pay…” “I mean every time I touch my tonsils, I get tonsillitis…” “The mask, has taken a toll on my skin after a while…” TDF = emotions; COM = automatic motivation.There was an emotional toll from the pandemic that most frequently took the form of fear, sadness, frustration, anger, and relief. The disease prevention behaviours were a reminder to participants of the impact the pandemic has had on their lives.“The government has put way too much effort on this coronavirus thing and it has to stop, it has to stop because it takes too much mentally.” “That was very, very hard on our family, and it broke us, a little bit it broke us, not joking, it broke us a little bit, all this nonsense of, you know, testing or not testing, coming home or not coming home. You’re always stressed, like your adrenaline levels are always this high.” Many of the participants’ frustrations were exacerbated as they felt they were putting themselves and their families at risk by going to work. At times, as emotions became overwhelming, this impacted on adherence to the preventive behaviours.“To be honest with you walking in and seeing all the empty shelves [in supermarkets] it’s just soul destroying after a day at work. You know, and having to follow a one way system … I mean, to the point, this woman had a go at me because I'd walked the wrong way down an aisle and I went, 'how many hours have you worked today?!’” “I don't like doing that [testing] at all. My anxiety goes through the roof every time I have to do a test, because I know how long I suffer after the test.” Parents were left exasperated by testing their young children, describing the experience as ‘terrifying’ and a ‘nightmare’.“With a two-year old, pining them down, trying to shove it up their nose and it's, yeah, it's horrible.” “We spend like often half an hour, 40 minutes trying to grab him, two adults, we're not able to safely grab him, because the thing is like you cannot grab your child to a point because you know when you put that on the nose. If it does like this, it can hurt his nose. So, so yeah. After that morning when I nearly cried, because at that point it was a third one, I said this is ridiculous, because only people that have never tried to do this on a child at this age would make you do one.” TDF = environmental context and resources; COM = physical opportunity.Some work environments made the disease prevention behaviours more difficult. They did not allow for physical-distancing  or would necessitate major structural changes to increase handwashing .“It has been hard, I mean, when we do personal care, we have to get within close proximity.” Adaptations made to the working environment, however, were raised as contributing factors to disease prevention behavioural adherence. Workplaces had provided individuals with the physical opportunity to perform the behaviours, by providing face coverings, tests, hand sanitiser, modifying seating arrangements and staggering shift patterns. Furthermore, some workplaces had scheduled testing time into the working day and others provided transport to vaccination centres.“They provide a lot of things, I mean, everybody can find hand sanitizer. I mean, they work a lot too, to keep the place as safe as possible, even in the canteen, they reduce the chairs at the table.” “We've all been allocated [time to test] on our timetables.” Behaviours were also supported by effective systems. Participants spoke highly of the processes for booking PCR testing, enabling them to easily access tests and receive timely results.“Very easy, very straightforward. Local one was a five-minute drive away. Very clear instructions on what to do when you arrive, what to expect. How long results will take, they were actually much faster at that point which was really good as well.” TDF = social influences; COM = social opportunity.The perception of judgement from others was a contributing factor to enacting a behaviour. Participants referenced adjusting their adherence to behaviours based on the actions of others, this was particularly prevalent for wearing a face covering.“You kind of think ‘Should I wear a mask?’, ‘Are a lot of people in masks?’ You know, just to save, I don't know, maybe people looking at you funny.” “You have to do what everyone else is doing, otherwise you look the odd one out don't you. Like wearing a mask at work, I hate wearing a mask at work, especially when it's hot and everything else. And, you know you're running around and you're out of breath, but you can't take your mask off, because everyone else at work is wearing their masks.” The social implications of disrupting the lives of others by spreading COVID-19 was also factored into people’s decisions to test themselves and their children and to maintain physical-distancing structures. Societal pressure was heightened in workplaces which chose to overtly monitor the behaviour of their employees.“I'm usually good [at testing] on Sunday because I sort of, I just feel I don't want to send them in [to school] and then find out that, actually, we've got it […] Some people send their children in with symptoms and their bubbles have to be closed. So it's more of a societal pressure there, from that perspective.” “I feel like I'm harassed by the social-distancing auditors because they are looking after you or chasing you, making sure that you don't step on the other side, even now.” Individuals reported feeling supported within their social environments to perform preventive behaviours. In particular, in workplaces where senior leadership teams worked closely with their staff, individuals felt empowered to speak up if they had any safety concerns.“We were told to and advised to and also very much given, SLT [senior leadership team] gave us the power as such, to at any point if we were uncomfortable, to voice that you're uncomfortable and that it's okay to say 'you're not wearing a mask, can we not', or 'you're too close, please back away', so that was quite nice and that message was constantly reminded to us, you know, please say if you're uncomfortable.” Equally workplaces which successfully delivered the message that they valued their staffs’ safety, had staff who perceived less barriers to enacting the behaviours.“Basically it's just you know, ‘Protect yourself. Protect your family, if you need any support. If you are going for PCR test, don't worry about work. We'll be here.’ They're very supportive.” TDF = social influences; COM = social opportunity.A societal disconnect was frequently discussed, conveying that the United Kingdom was no longer united against COVID-19. This manifested itself in two ways; mistrust of the media and frustration at others.Participants spoke of an awareness that ‘the news’ was not to be taken at face value and opted to either fact check, or to completely avoid mainstream media. Respondents had a sense that news outlets had their own agendas, leaving them without a clear trusted knowledge source.“I do think the news obviously can be a bit biased so I will listen to their news stories and what they're saying and tend to look more at links they've credited, where they've got their research from, and go to them.” Throughout the COVID-19 pandemic people’s personal experiences have varied widely, as have their capability, opportunity, and motivation to perform the disease prevention behaviours. However, participants expressed frustration that others did not behave in line with their expectations. The divide between people seemed to have grown over time, and left people feeling disunited and often frustrated with those in power.“I think people are now on two sides, people that believe that we should still be locked down and we should still be having all these restrictions and then the other people on my side of the fence who want to just crack on now.” “It does frustrate me because I've had, I've witnessed my [care home] residents, have witnessed people die from that, so there's all of this stuff. And yet you're [others] perfectly fine, not testing, spreading the disease.” “We are not on the same boat anymore because everyone is doing their own thing.” “I don't understand why they've [the government] just said, ‘Oh no, we don't need it, it becomes this, your choice,’ if you give people choices, they will, too many people will, choose the wrong option.” “And then other people are misinformed or don't quite understand, and then therefore, it just gets to the point where you think well why am I following the guidance when other people aren't doing it.” TDF = social influences; COM = social opportunity.Adherence to COVID-19 disease prevention behaviours was also influenced by access to credible leadership. Instances in which politicians had not adhered to the prevention behaviours were cited directly as reasons to question the purpose and benefit of behavioural adherence. The frequency with which political missteps have been made public was raised as causing a reduction in people’s willingness to do what they were advised.“It’s the same as the G7 summit, when they were all hugging at the barbecue. So we see politicians doing it, so when I have social time with my friends and family why can't I be doing the same sort of thing?” “I think by the time we had Mr. Cummings in the back garden of Number 10 And then Matt Hancock. I think a lot of people, they gave up and you kind of think that's it, it's [the country] leaderless.” Similarly, when senior leaders in the workplace were seen to be flouting the rules or not following disease prevention behaviours, it provided an instant rebuttal and devalued their request for others to adhere to any workplace guidance. This left employees to doubt the value of new guidance, thereby minimising behavioural buy-in.“I seen her [member of Senior Leadership Team] walking around without her face mask on so it's kind of like, you know, you can't tell us all to wear our face masks when you're going to walk around the warehouse not wearing a face mask.” “I think it [mask wearing at work] was more done to shut people up than it was anything else. You know, rather than have any sort of like good basis to help stop the spread.” COM-B = behaviour.The variation in people’s capability, opportunity, and motivation resulted in varying adherence to the COVID-19 prevention behaviours. This was evidenced through variability in performance (or not) of each behaviour addressed in this study.“Before they go to lunch, when they're coming in from break, we get them to just gel their hands.” “I mean none of them [colleagues] are washing their hands, none are using the sanitising stations.” “I wear a face mask at work.” “I don't wear one [face covering].” “We avoid touching each other, hugging or stuff like that.” “[Colleagues] are not keeping the distance, hugging each other, even during the last year. During the peak epidemic, it was really bad at my work.” “Our windows were sort of open and ventilated.” “They're only keeping the doors open when they're trying to load lorries.” “I have to do it [LFD test], I think it's a Wednesday evening or Thursday morning for work and I have to log it on the government website.” “The doctor said, ‘No no no, you should get a PCR test' and I said 'No, I'm not going to get a PCR test.” “Yeah, the minute I found out [identified as a contact of someone who tested positive], I contacted my school and went into isolation for 10 days after.” “I’ve got a four-year-old, who is joined to my hip, and he wanted to cuddle, he wanted to kiss, but [when isolating] as soon as he walked into my room, he had to have a mask on, he had to have a face shield and he had white gloves.” “Yeah, I’ve got it on my phone [track and trace app]. When I go to places like restaurants, I use the check in.” “We haven’t got the app [track and trace], I don’t want the app. We all deleted the app.” “I've been double jabbed.” “It's [the vaccine] not something I'm prepared to have myself.” Behaviour is central to COVID-19 disease prevention . This reA deductive COM-B behavioural diagnosis was performed, mapping themes to capability, opportunity, and motivation, along with their relevant theoretical domains from the TDF. All six of the COM-B constructs were identified in the themes, with psychological capability, reflective motivation and social opportunity the most commonly represented. All TDF domains were identified as relevant, namely: (1) knowledge, (2) skills , (3) social/professional role and identity, (4) belief about capabilities, (5) optimism, (6) belief about consequences, (7) reinforcement, (8) intentions, (9) goals, (10) memory, attention and decision processes, (11) environmental context and resources, (12) social influences, (13) emotions, and (14) behavioural regulation.There were clear gaps in psychological capability which contributed to behavioural non-adherence. Knowledge gaps were particularly prevalent regarding symptoms and ventilation, with confusion over the core and additional symptoms of COVID-19 and a lack of awareness of the importance of ventilation. Other research has shown that 40.4% United Kingdom participants were unable to identify the three primary COVID-19 symptoms . The BehWhere participants understood COVID-19 disease prevention behaviours, there were still instances of difficulties in behavioural regulation. This mirrors a COM-B analysis of hand hygiene in the early stages of the COVID-19 pandemic, which found psychological capability, social opportunity, and reflective motivation to influence this behaviour , 40. ComThere were also gaps in capability to perform behaviours. In particular, participants felt they did not possess the interpersonal and physical skills to test young children, both at home and at mobile PCR units. However, those trained to perform tests felt they had the skills to perform this behaviour, suggesting a roll out of wider training could address this issue. Skills can be enhanced through Behaviour Change Techniques  such as There was variation in opportunity to perform behaviours in both a physical and social context. The degree to which working environments had been, or were able to be, adapted had an impact on behavioural adherence. This aligns with previous COM-B analysis of physical-distancing and hand hygiene, which has shown physical opportunity can act as a barrier or enabler to these behaviours , 20. ResThe social environment was also found to influence behavioural adherence, with participants citing the influence of others as a factor for behaviours such as wearing a face covering. This aligns with studies that have shown wearing a face covering to be the behaviour most adhered to, with the suggestion this may be due to social pressures to conform , 43. UsiIn contrast, the current study also found evidence for a societal divide, resulting in a sense of no longer being united against COVID-19. This is in line with a longitudinal United Kingdom study which found the emergence of two partisan groups, merged across pre-existing societal divides such as income and/or education level, that were split by behavioural adherence . Trust, Ensuring trust in public health messaging and the messengers behind the message is important, with research highlighting the need for Transparency, cRedibility, Unified messaging, Social responsibility and norms, and Timely messaging [TRUST: ]. A focuConscious thought processes also contributed to behavioural adherence through a willingness to act and beliefs related to necessity of action and perceived concerns of consequences. These influenced people’s reflective motivation, via a pathway of costs and benefits, which can be further explained via the Necessity-Concerns Framework [NCF: ], which The NCF equally postulates that a reduction in behavioural adherence can occur due to concern over side effects . In the Behaviours may also be avoided due to unconscious drives, linked to emotion or habit, representing automatic motivation. This study highlights that COVID-19 and the related disease prevention behaviours have taken an emotional toll. People have felt isolated, which has been exacerbated during periods of lockdowns and self-isolation, and behaviours such as testing have caused feelings of anxiety. The Office for National Statistics  show an The investigation of a constellation of behaviours could be considered as a limitation of this study given that the BCW , 5 guideDespite efforts to engage, the study was limited by the low representation of people from ethnic minority backgrounds, who have a high residency in the areas sampled and are commonly under-reached. This is in spite of efforts made by the leads for the school, care home and warehouse workplaces to recruit a diverse population. Anecdotal feedback highlighted concern with participation in the study, and speaking out of turn about their workplace. This, in addition to the small sample size traditionally used in qualitative research, limits the generalisability of the results of this study. Future work would benefit from facilitating community champions and widening routes to access to ensure all representative voices are heard, reinforcing the assurances of anonymity.This study provides an novel COM-B and TDF analysis of a constellation of eight COVID-19 prevention behaviours in high risk-of-infection work settings in three local authorities. Through thematic mapping and production of a logic model, the study has provided direction for future intervention. Priority should be given to target individuals’ psychological and physical capability, physical and social opportunity, reflective and automatic motivation to maximise behavioural adherence. Organisations who are adapting their work environment to enable COVID-19 disease prevention behaviours should be commended. Leaders should ensure that they are a credible source and model appropriate and non-conflicting behaviours. Clear and transparent information and demonstration on how to perform behaviours should be made freely available and accessible, and strategies to prompt memory and behavioural regulation should be used. When changes to guidance are necessary, it should be made clear what the new guidance is, specifically related to behavioural actions and their efficacy and/or consequences. Messages should be unified and promote social responsibility and positive social influences.Findings from this study offer an extended approach to the understanding of a constellation of COVID-19 disease prevention behaviours, offering a combined COM-B diagnosis for related behaviours. Findings from this research support the Behavioural science and disease prevention: Psychological guidance produced by the BPS COVID-19 Behavioural Science and Disease Prevention Taskforce , which eThe data supporting the conclusions of this article will be made available by the authors, without undue reservation.The study was reviewed and approved by ISPAR Ethics - University of Bedfordshire. The participants provided their written informed consent to participate in this study.AMC, PB-R, FT, EC, JH, LBMTB-D, AM, GWS, TE, AK, DBO’C, EW, LJML, EM, VS, and MAA contributed to the conception of the study, commissioned by FT and EC representing three local authorities and informed by the work of the British Psychological Society COVID-19 Behavioural Science and Disease Prevention Taskforce for which AMC was Chair and JH, LBMTB-D, GWS, TE, AK, DBO’C, EW, LJML, EM, VS, and MAA were all members. AMC, PB-R, and FT developed the study design. FT and EC facilitated recruitment. PB-R conducted the interviews. PB-R and AMC analysed the data and wrote the first draft of the manuscript. All authors contributed to the article and approved the submitted version.This research was funded by Bedford Borough, Central Bedfordshire and Milton Keynes Councils, internally led by FT and EC, awarded to AMC at the ISPAR Centre for Health, Wellbeing and Behaviour Change, University of Bedfordshire. It was informed by the work of the British Psychological Society COVID-19 Behavioural Science and Disease Prevention Taskforce, which partially funded AMC time.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. 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