Transcript The PRIME Theory of motivation and its application to

Understanding, preventing and treating
addiction through the lens of PRIME Theory
Robert West
University College London
2009
1
Outline
•
•
•
Prevailing theories of addiction
Basics of PRIME Theory
PRIME Theory in practice
2
Outline
•
•
•
Prevailing theories of addiction
Basics of PRIME Theory
PRIME Theory in practice
3
Rational decision making
• Theory
– Addiction involves making a rational choice that
favours the benefits of the addictive behaviour over
the costs
• Evidence
– Many addicts perceive life as better with their
addictive behaviour
– Incentives and disincentives are quite effective in
modifying addictive behaviours
• Limitations
– Expected utilities are poor at predicting relapse
following decisions to cease the addictive behaviour
4
Irrational decision making
• Theory
– Addiction involves an irrational choice that inflates the
benefits and/or undervalues the costs
• Evidence
– Addicts exhibit cognitive and motivational biases that
promote the addiction ( e.g. attentional and memory
biases, short-termism)
• Limitations
– No evidence to date that such biases substantially
influence the course of addictive behaviours
5
Biological needs
• Theory
– Addiction involves development of physiological
needs which are met by the addictive behaviour
• Evidence
– Addicts report aversive withdrawal symptoms and
drive states which deter abstinence
– Medication that relieves these needs and drive states
improve chances of abstinence
• Limitations
– Relapse is frequent even in absence of withdrawal
symptoms or drive states
6
Psychological needs
• Theory
– Addictive behaviours meet psychological needs
• Evidence
– Individuals with psychological needs (e.g. depression,
anxiety) met by addictive behaviours are more likely
to become addicted and less likely to recover
• Limitations
– Many addicts show no evidence of psychological
needs prior to developing addiction
– Psychological health often improves following a
period of abstinence
7
Pleasure and reward
• Theory
– Addictive behaviours are particularly pleasurable or
rewarding
• Evidence
– Almost all addictions provide pleasure or satisfaction,
often to a high degree
• Limitations
– Many long-term addicts report little or no pleasure
from the addiction
– Degree of pleasure in at least some addictions is not
correlated with probability of relapse
8
Habit
• Theory
– Addiction involves the development of strong
automatic stimulus-response associations
• Evidence
– At least some addictive behaviour shows evidence of
automaticity
• Limitations
– Much addictive behaviour shows evidence of
involving conscious choice
9
Social and physical environment
• Theory
– Environmental factors are important in development
and recovery from addiction
• Evidence
– Clear effects of ‘contagion’, opportunity,
environmental triggers, and social facilitation on
development and recovery from addiction
• Limitations
– Genetic vulnerability has also been shown to be
important
– Does not address ‘internal’ factors
10
Prevailing theories: summary
• Each approach explains some observations but
fails to explain others
• In practice, interventions aimed at combating
addiction draw from an eclectic mix of theories
and un-articulated models
11
Outline
•
•
•
Prevailing theories of addiction
Basics of PRIME Theory
PRIME Theory in practice
12
PRIME Theory
• An attempt at a theory of motivation that puts
into a single model diverse features
–
–
–
–
plans and self-control
analytical decision making
emotional decision making and drives
habits and instinctive responses
• Uses as few concepts as possible
• Uses a language as close to everyday use as
possible
• Biologically plausible
13
Where does motivation fit in?
Response control system
Skilled
Skill
Response
Response
generation
generation
system
system
Motivation
Motivation
systemsystem
MentalCognitive
representation
Memory
Cognition
and inference
Information
Sensory acquisition
system
system
Information
Sensation
acquisition
Each system can operate in isolation but is usually strongly
14
under the influence of other systems
PRIME and addiction
• Addiction involves a chronic disposition
– to experience powerful motivation to engage in particular
volitional behaviours
– to fail to exert self-regulatory control over such volitional
behaviours
• It arises when the combination of
– individual vulnerability
– environmental promoters
– effects of an activity
• lead the individual
– to experience powerful wants or needs to engage in the activity
– and to fail to exert self-regulatory control to inhibit it
15
Key assumptions
• Structure of the motivational system
– Humans have evolved a motivational systems with
multiple levels (PRIME)
– Higher levels allow greater flexibility of response and
future-orientation but can only influence behaviour
through lower levels
• Function of the motivational system
– The system is fundamentally unstable requiring
constant ‘balancing input’ to prevent development of
maladaptive dispositions
– All behaviour is subject to the balance of motivational
forces acting ‘in the moment’
16
The structure of the motivational system
Five interacting subsystems providing varying levels of flexibility
and requiring varying levels of mental resources and time
p
Plans
r
Responses
i
Impulses
m
Motives
e
Evaluations
Higher level subsystems have to
act through lower level ones
where they compete with direct
influences on these
17
The structure of human motivation
18
PRIME
• Responses
– starting, stopping or modifying actions
– arise from the strongest of potentially competing
impulses and inhibitions
– measured by
• observation
• self-report
19
PRIME
• Impulses and inhibitions
– patterns of activation in CNS pathways that organise
and impel or block actions
– arise from strongest of potentially competing
• learned and unlearned stimulus-impulse/inhibition (SI)
associations (habit and instinct)
• motives
– measured by
• micro-actions
• self-reported ‘urges’
20
PRIME
• Motives
– wants (feelings of anticipated pleasure/satisfaction) or
needs (feelings of anticipated relief)
– arise from
• reminders interacting with past experiences of
pleasure/satisfaction and pain/discomfort/drive states
• evaluations
– measured by ratings of ‘want’ and ‘need’
21
PRIME
• Evaluations
– beliefs about what is good or bad
– arise from
•
•
•
•
•
reminders
motives
inference
communication
plans
– measured by ratings of positive and negative value
22
PRIME
• Plans
– articulated intentions to carry out actions in the future
– arise from
• evaluations
• reminders interacting with stored plans
– measured by ratings of intentions
23
Identity, rules and self-control
• Humans form mental representations of ourselves
(identities) which are an important source of wants and
needs
• A major part of our identity involves ‘personal rules’
(types of plan)
• Changes in personal rules are the basis for deliberate
behaviour change
• Self-control involves domination of wants and needs
arising from personal rules
• Failure of self control arises when wants and needs
arising from personal rules (‘oughts’) are insufficient
24
The process of behaviour change
•
Starts with is a rule in which person
defines him/herself as
– attempting (‘I am trying to change’)
– engaging in the new behaviour (‘I have
changed’)
•
SNAP: 4 states based on the rules
smokers apply to themselves
People plan a change attempt when
Stay with
old beh
– the feeling of ‘want’ or ‘need’ to change
at a future date exceeds the desire to
continue
•
People make a change attempt when
– the want or need to change now
exceeds the want or need to carry on
•
People lapse when
New
behaviour
People relapse when
– the want or need to abandon the
change attempt exceeds the want or
need to continue with it
Planning
Attempting
– the want or need to revert at a given
moment exceeds the want or need to
stick to the rule
– the rule is still in force
•
Pre-quit
Post-quit
25
SNAP versus ‘Stages of Change’
SNAP
Stages of Change
Focus on momentary desire
to change
Readiness to change is a
state
Transition can occur
between any state and any
other
Importance of identity and
the nature of the personal
rule
Focus on stable intention to
change
Readiness to change is a
stage
Transitions must be
progressive
Importance of beliefs about
pros and cons of change
26
Resumé
• Volitional behaviour at every moment arises
from the strongest wants and needs at that
moment
• Beliefs about what is good or bad and prior
intentions will only influence our behaviour if
they generate sufficiently strong wants and
needs ‘in the moment’
• Identity is an important stable source of wants
and needs
• Self-control involves domination of wants and
needs derived from ‘personal rules’
27
Outline
•
•
•
Prevailing theories of addiction
Basics of PRIME Theory
PRIME Theory in practice
28
Behavioural support
•
•
Advice, proposed activities, discussion and
encouragement aimed at helping people to
achieve lasting change in behaviour patterns
Includes a number of ‘behaviour change
techniques’ (BCTs) aimed at
1. reducing the motivation to engage in undesired
behaviour and increasing the motivation to engage
in desired behaviour
2. increasing the capacity for self-regulation
3. increasing effective adoption of adjunctive activities
4. supporting the above
29
Classification of BCTs by function
BCTs
Focus on specific behaviour
Address motivation
Maximise self-regulation
Promote adjuvant activities
Supportive actions
30
Data from English Stop Smoking Services
• 43 services provided treatment manuals
• coded for number of times mentioned each of a number
of behaviour change techniques (BCTs): using taxonomy
developed by Susan Michie
• likelihood of a smoker achieving 4-week CO-verified
abstinence as recorded by the service was predicted by
exposure to each of the BCTs using logistic regression
• N=177,064 smokers
• BCT reliably associated with success if
– significant at p<0.01 separately in both males and females and
CO verified and self-report
31
BCTs associated with higher success
rates: motivation
•
•
•
•
Measure CO
Explain the purpose of CO monitoring
Strengthen ex-smoker identity
Provide rewards contingent on successfully
stopping smoking
• Boost motivation and self efficacy
• Provide rewards contingent on effort towards
stopping smoking
• Provide information on positive and negative
consequences of behaviour
32
BCTs associated with higher success
rates: self-regulation
•
•
•
•
•
Barrier identification problem solving
Change routine
Provide advice on conserving resources
Relapse prevention and coping planning
Goal setting
33
BCTs associated with higher success
rates: adjuvant activities
• Enquire about medication
• Provide advice and information about
medication
• Give client options of additional or later support
34
BCTs associated with higher success
rates: supportive actions
•
•
•
•
Elicit client views
Summarise information confirm client decisions
Enquire about withdrawal symptoms
Provide information on withdrawal symptoms
35
Some hints from PRIME Theory
1. Is there a general need for order?
– Help establish order and structure through the development of
personal rules with clear boundaries
2. What specific wants and needs are driving the
addiction?
– See how far wants or needs can be mitigated or met by
alternative means
3. How far is the addiction driven by failure of selfregulation?
– See how far self-regulatory capacity can be trained or the
environment can be managed to minimise the demand for it
4. How far is identity helping or hindering change?
– See how far it will be possible to develop new elements of
identity that are conducive to improved behaviour
36
Conclusions
• Prevailing theories account for some observations but
not others
• PRIME Theory attempts to account for all major
observations in a coherent model
• Focus is on momentary wants and needs and selfregulation involving personal rules that must generate
sufficiently strong momentary wants and needs to
overcome those driving the addiction
• Tackling the problem requires action on a broad front but
greater emphasis on
– addressing wants and needs directly, including identity change
– building self-regulatory capacity
• The BCT taxonomy approach offers the opportunity to
study this systematically
37
Reading
• West, R (2006) Theory of Addiction. Oxford:
Wiley-Blackwell
www.primetheory.com
38