Transcript The PRIME Theory of motivation and its application to

Addiction and behaviour change
Robert West
University College London
December 2012
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Aims
• To show how an overarching model of behaviour can
help to understand addictive behaviours and develop
effective intervention strategies for combating these
• To draw lessons from this to development of more
effective interventions for behaviour change more
generally
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Outline
1. A ‘synthetic model’ of behaviour (COM-B+PRIME) and
a framework for describing behaviour change
interventions (BCW)
2. An overview, using the BCW framework, of what has
worked and what has not in combating addictive
behaviours
3. What this tells us about developing interventions to
combat addictive behaviours and lessons for behaviour
change more generally
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The COM-B model of behaviour
For any behaviour to
occur the individual or
group must
• have the physical and psychological
capability
• have the physical and social opportunity
• be more motivated to do it at the relevant
time than anything else
Michie et al 2011 Implementation Sci
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PRIME Theory and the structure of human
motivation
West 2005 Theory of Addiction
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Reflective
Impulsive
Action
Affective
Reflective
Impulsive
Action
PRIME Theory and Dual Process Theories
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PRIME Theory: 1st law of motivation
• At every moment we act in pursuit of our strongest
motives (wants or needs) at that moment
– Want: anticipated pleasure or satisfaction
– Need: anticipated relief from, or avoidance of, mental
or physical discomfort
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PRIME Theory: 2nd law of motivation
• Evaluations (beliefs about what is good and bad) and
plans (self-conscious intentions to do or not do things)
are important in controlling our actions if they create
motives at the appropriate moments that are stronger
than competing motives coming from other sources
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PRIME Theory: 3rd law of motivation
• Self-control (acting in accordance with plans despite
opposing motivations) requires mental energy and
depletes reserves of that energy
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PRIME Theory: 4th law of motivation
• Our identities (thoughts, images and feelings and
feelings about ourselves) can be a powerful source of
motives
– Labels: the categories we think we belong to
– Attributes: the features we ascribe to ourselves
– Personal rules: imperatives about what we do and do
not do
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PRIME Theory: 5th law of motivation
• Motives influence actions by creating impulses and
inhibitions, which are also generated by habitual
(learned) and instinctive (unlearned) associations;
behaviour is controlled by the strongest momentary
impulses and inhibitions
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The rider and the donkey model of
behaviour
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Many other animals are possible!
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Behaviour Change Wheel
Michie S, M van Stratten, West R (2011) The
Behaviour Change Wheel: A new method for
characterising and designing behaviour change
interventions. Implementation Science, 6, 42.
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Addiction as a context-sensitive disorder of
motivation
Addiction involves repeated powerful motivation to
engage in a purposeful behaviour that has no survival
value, acquired as a result of engaging in that behaviour,
with significant potential for unintended harm.
West R. Models of Addiction.
EMCDDA Insight Report
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The rider and the horse model of addiction
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Behaviours with significant addictive
potential
Use
of
• nicotine
• alcohol
• opiates
• stimulants
• sedatives
• cannabis
gambling
internet?
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Combating addiction involves combating
addictive behaviours (and their harms)
• Promoting attempts at control/cessation
• Prevention of relapse
• Prevention of initiation
• Prevention of escalation
Addictive use
Non-addictive use
Non-use
• Promotion of harm reduction
• Management of consequences
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Intervention functions
Function label
Description
Education
Increasing knowledge or understanding
Persuasion
Using communication to induce positive or negative
feelings or stimulate action
Incentivisation
Creating expectation of reward
Coercion
Creating expectation of punishment or cost
Training
Imparting skills
Restriction
Using rules to limit set boundaries around behaviours
Environmental
restructuring
Changing the physical or social opportunities
Modelling
Providing an example for people to imitate or aspire to
Enablement
Increasing capability or opportunity other than by other
intervention functions
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Primary sources
Alcohol and illicit drugs
Abraha et al (2012) Alcohol and Drug Misuse: A Cochrane Handbook:
Oxford Wiley-Blackwell
Smoking
ASH (2010) Inquiry into the Effectiveness and Cost-Effectiveness of
Tobacco Control: Submission to the All Party Parliamentary Group on
Smoking and Health. London: Action on Smoking and Health
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Education
Aims to improve
knowledge and
understand
about
• harms of the behaviour and benefits of
stopping or not starting
• best ways of avoiding uptake or stopping
Can be effective
when
• information is believed and provokes concern
(about the behaviour) or hope (about change)
or directs towards effective action
• opportunities and capability are supportive
Examples
• information about harms of smoking
• brief GP advice on smoking and alcohol
consumption
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Persuasion
Aims to
• provoke feelings of worry or concern about
the addictive behaviour
• undermine positive feelings about the
behaviour and provoke positive feelings about
change
Can be effective
when
• messages are attended to and engaged with
• opportunities and capability are supportive
Examples
• some mass media campaigns on smoking
• brief GP advice on smoking and alcohol
consumption
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Incentivisation
Aims to
• create anticipation of reward for avoiding,
decreasing or reducing the addictive
behaviour
Can be effective
when
• degree of incentive for those concerned is
large enough with minimal undermining of
other beneficial motivations
• opportunities for ‘gaming’ are closed off
• opportunities and capability are supportive
Examples
• financial incentives to promote cocaine
abstinence
• financial incentives for smoking cessation in
pregnancy
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Coercion
Aims to
Can be effective
when
Examples
• create anticipation of unpleasant
consequences for engaging in the addictive
behaviour
• the consequences are closely tied to the
behaviour
• the consequences are sufficiently unpleasant
• opportunities and capability are supportive
• raising the financial cost of smoking, alcohol
and illicit drugs
• automatic penalties for alcohol-related
offences
• contingency contracting for illicit drug use
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Training
Aims to
Can be effective
when
Examples
• develop cognitive, social and behavioural
skills to resist motivation to engage in the
addictive behaviour
• motivation to change is high
• there is sufficient motivation etc. to do the
training
• opportunities and capability are supportive
• school-based social skills training can prevent
illicit drug use in the short-term
• cognitive bias retraining may reduce alcohol
consumption
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Restriction
Aims to
• set rules that prohibit or restrict the addictive
behaviour
Can be effective
when
• they cannot easily be circumvented
• they are well internalised
• opportunities and capability are supportive
Examples
• cultural norms around alcohol consumption
• gender-related cultural norms around
smoking
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Environmental restructuring
Aims to
Can be effective
when
Examples
• reduce opportunities to engage in the
addictive behaviour
• cannot easily be circumvented
• able to be implemented
•
•
•
•
raising the legal age of sale
reducing density of alcohol outlets
restricting licensing hours
preventing tobacco marketing
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Modelling
Aims to
Can be effective
when
Examples
• motivate avoidance, cessation or restriction of
the addictive behaviour through identification
and imitation
• there is strong identification with the model
• opportunities and capability are supportive
• parental smoking cessation may reduce
smoking in adolescence
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Enablement
Aims to
• use diverse means to increase capability to
resist motivation to engage in the addictive
behaviour other than through education or
training
Can be effective
when
• opportunity and motivation are supportive
Examples
• behavioural support can improve chances of
success at stopping smoking
• agonist and partial agonist therapy can
improves chances of stopping smoking
• opiate agonists and partial agonists can
reduce heroin use
• acamprosate can promote continued
abstinence from alcohol
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Key points: what kinds of intervention?
• Behaviour change interventions that influence nonaddictive behaviours can be expected to work to a
significant degree with addictive behaviours
• Combating addiction requires in addition:
– special focus on the neurological and psychological
disorders that pre-dispose to, and result from, the
addictive behaviour
– recognition of the importance of harm reduction and
problem management
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Key points: how to develop and implement
improved interventions?
1. Recognise ‘addictive’ aspects of
non-addictive behaviours
– tame the horse, strengthen the
rider and landscape the path
2. Always start with a
comprehensive behavioural
analysis of ‘what would it take’?
– not what are the current
barriers and facilitators
3. Use theory to go from this to a
comprehensive intervention
strategy
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