Transcript The PRIME Theory of motivation and its application to

Fact and theory in recovery from addiction
Robert West
University College London
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Outline
• Key facts about addiction and recovery
• Theory of addiction and recovery
• Application to behvioural support for smoking
cessation
What is addiction?
• Addiction can be defined as a chronic condition involving
powerful motivation to engage an activity to an extent
that is harmful. It undermines and overwhelms attempts
at restraint.
• Addiction typically develops when:
– the actions concerned are highly pleasurable and/or meet
important psychological needs
– there are weak inhibitory controls
– the underlying motivation relative to alternative behaviours
becomes amplified through repetition
– the environment provides frequent opportunities or prompts to
engage in the activity
How is addiction manifest?
• Continuing with an activity despite harmful
consequences and/or repeated attempts to stop
or reduce
• Subjective experiences of powerful motivation to
engage in the activity which take the form of
urges or a feeling of need
• Often, but not necessarily, there are adverse
mood and physical symptoms after a period of
abstinence
What are the presumed mechanisms?
• Stimulus-impulse associations developed
through operant and classical conditioning
• Acquired drives developed through physiological
adaptation
• Failure of inhibitory control mechanisms
• Psychological needs developed through social
and behavioural adaptation, and development of
maladaptive beliefs and emotional responses
What is recovery from addiction?
• Recovery occurs when an individual no longer
experiences powerful motivations to engage in
an addictive activity to an extent that is harmful
Key facts about recovery from addiction
• Some addicts recover without complete abstinence but
in pharmacological addictions this uncommon
• The chances of recovery may be improved in some
cases:
– with
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pharmacological treatment and/or behavioural support
social and spiritual support
a change in social or physical environment
a change in important aspects of identity
a positive, ‘approach’ coping style
– and if:
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the degree of addiction was lower
there were fewer other psychological or social problems
capacity for self-regulation was higher
there were stronger motives for attempting recovery
Theoretical approaches to addiction
• Learning theory
– addicts learn to associate the behaviour with reward and
abstinence with punishment
• Decision making theory
– addicts choose the addictive behaviour over abstinence
• Self-control theory
– addicts lack capacity for inhibitory control
• Identity theory
– addicts possess identities that make them vulnerable to
addiction
• Attentional bias theory
– stimuli related to addiction are more salient in perception and
memory
• Social learning theory
– addicts copy the behaviour of others around them
Developing and applying an integrated
theory
• Understanding behaviour as part of a system of
which motivation is another part
• Understanding motivation
• Developing a comprehensive model for
interventions to promote recovery
The Behaviour System: CMOB
Capability
Motivation
Opportunity
Psychological or physical ability to
enact the behaviour
Behaviour
Reflective and non-reflective
mechanisms that activate or inhibit
behaviour
Physical and social environment that
enables the behaviour
The Behaviour System: CMOB
Capability
Motivation
Opportunity
Capability, motivation and
opportunity must be present for a
behaviour to occur
Behaviour
The system is in dynamic
equilibrium and a change in
behaviour may require a
sustained change in one or more
of the other elements
PRIME Theory of motivation
• The theory attempts to provide an integrated
account of human motivation describing:
– The structure of the human motivational system
– How the motivational system changes and what gives
it stability
www.primetheory.com
The structure of human motivation
The structure of human motivation
Lighting up a cigarette
Taking a puff on a cigarette
Saying no to offer of a cigarette • Starting, stopping or
modifying actions
• Generated by the strongest of
competing impulses and
inhibitions at that moment
The structure of human motivation
• Impulses and inhibitions:
patterns of activation in CNS
pathways that organise and
impel or block specific actions
• Formed from strongest of
competing learned and
unlearned stimulus-impulse
associations
• Motives are important triggering
stimuli
• Impulses are experienced as
urges when blocked
• Vary in strength
Impulse to light up a cigarette
Inhibition of impulse to light up
The structure of human motivation
• Feelings of desire or attraction or
repulsion in relation to something
that is imagined
• Want: anticipated pleasure or
satisfaction
• Need: anticipated relief from mental
or physical discomfort
• Formed when stimulus generates
image to which past experience has
associated positive or negative
feelings
• Can vary in strength
Want to smoke
Need a cigarette
Want to stop smoking
The structure of human motivation
• Beliefs (internalised statements)
that something is good or bad
• Formed from acceptance of
communication or when stimulus
triggers recall of plans, memory of
beliefs, plans, wants and needs, or
inference
• Must generate motive (want or
need) to influence behaviour
• Can vary in strength of adherence,
ambivalence, extremity, valence
Smoking is harming my health
and costing me a lot of money
I ought to stop smoking
The structure of human motivation
One off: I will stop smoking
tomorrow
Personal rule: I will not smoke
• Self-conscious intentions to
behave in a particular way
(personal rule) or perform an action
(one-off plan) in the future
• Formed when positive evaluation of
action outweighs negative one
• Must be remembered and generate
positive evaluation to be enacted
• Can vary in: commitment, starting
conditions, specificity
The control of purposeful behaviour
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We act in pursuit of what we most desire (want
or need) at every moment
Wants and needs are distinguishable from
each other and from ‘oughts’ (beliefs about
what one should do) and intentions (what one
plans to do)
The motivational system encapsulates both
Capability and Motivation elements of the
CMOB system
– People have the experience of ‘not being able’ to
control an addictive behaviour
How elements of the system change
• Maturation
• Associative
learning
• Habituation
• Sensitisation
• Communication
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Imitation
Perception
Inference
Chemical ‘insult’
Physical ‘insult’
The dynamics of change
• The system is ‘chaotic’: fundamentally unstable
and kept in equilibrium by constant ‘balancing
input’
• This means that change can occur:
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suddenly for no apparent reason
suddenly as a result of a significant event
gradually following a small triggering event
gradually as a result of sustained changing input
gradually as a result of absence of input
• Stable new motivational dispositions require a
new stable configuration of the system
Promoting and sustaining change
1. Identify what components of the CMOB system
to target
2. Select one of more types of intervention
3. If necessary select one or more type of policy
to enact the interventions
4. Identify specific ‘behaviour change techniques’
(BCTs) to implement the interventions
The Behaviour Change Wheel
Behaviour type
Interventions
Modelling
Environmental/
social planning
Policies
A system for
choosing
interventions and
policies
Physical
Reflective
Non reflective
Social
Psychological
Physical
Focus on ‘behavioural support’ to aid
smoking cessation
• Immediate targets in CMOB :
– Psychological capability
– Reflective motivation
• Interventions
– Education
– Training
– Enablement/resources
• Policies:
– Service provision
– Guidelines
Behaviour Change Techniques in
behavioural support for smoking cessation
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Advice, discussion and materials aimed at helping
smokers to stop
Four components (MASS):
1. Addressing motivation
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Maximising motivation to remain abstinent and minimising
motivation to smoke
2. Promoting optimal use of adjunctive activities
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Helping smokers to make best use of medication or other quitting
aids
3. Maximising capacity for self-regulation
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Helping smokers avoid, minimise or resist urges to smoke
4. Activities that support the above
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Establishing rapport, undertaking assessment, engaging the
smoker, tailoring the support plan to the smoker’s needs
Addressing motivation
• Provide information on
consequences of smoking and
smoking cessation
• Boost motivation and self
efficacy
• Provide feedback on current
behaviour and progress
• Provide rewards contingent on
successfully stopping smoking
• Provide normative information
about others' behaviour and
experiences
• Prompt commitment from the
client there and then
• Provide rewards contingent on
effort or progress
• Strengthen ex-smoker identity
• Conduct motivational
interviewing
• Identify reasons for wanting
and not wanting to stop
smoking
• Explain the importance of
abrupt cessation
• Measure carbon monoxide
(CO)
Blue: present in 2+ BSPs tested by RCTs; Red: linked to higher
success rates in SSSs; Purple: Blue+Red
Maximising self-regulatory capacity
• Facilitate barrier identification
• Set graded tasks
and problem solving
• Advise on conserving mental
• Facilitate relapse prevention
resources
and coping
• Advise on avoidance of social
• Facilitate action
cues for smoking
planning/develop treatment
• Facilitate restructuring of social
plan
life
• Facilitate goal setting
• Advise on methods of weight
• Prompt review of goals
control
• Prompt self-recording
• Teach relaxation techniques
• Advise on changing routine
• Advise on environmental
Blue: present in 2+ BSPs tested by
restructuring
RCTs; Red: linked to higher success
rates in SSSs; Purple: Blue+Red
Promote use of adjunctive activities
• Advise on stop-smoking
medication
• Advise on/facilitate use of
social support
• Adopt appropriate local
procedures to enable clients to
obtain free medication
• Ask about experiences of stop
smoking medication that the
smoker is using
• Give options for additional and
later support
Blue: present in 2+ BSPs tested by RCTs; Red: linked to higher
success rates in SSSs; Purple: Blue+Red
Supportive activities: general and
assessment
• Tailor interactions
appropriately
• Emphasise choice
• Assess current and past
smoking behaviour
• Assess current readiness and
ability to quit
• Assess past history of quit
attempts
• Assess withdrawal symptoms
• Assess nicotine dependence
• Assess number of contacts
who smoke
• Assess attitudes to smoking
• Assess level of social support
• Explain how tobacco
dependence develops
• Assess physiological and
mental functioning
Blue: present in 2+ BSPs tested by RCTs
Supportive activities: communication
• Build general rapport
• Elicit and answer questions
• Explain the purpose of CO
monitoring
• Explain expectations regarding
treatment programme
• Offer/direct towards
appropriate written materials
• Provide information on
withdrawal symptoms
• Use reflective listening
• Elicit client views
• Summarise information /
confirm client decisions
• Provide reassurance
Blue: present in 2+ BSPs tested by RCTs;
Red: linked to higher success rates in SSSs
Conclusions
• Recovery from addiction is related to a wide
range of psychological and environmental
factors
• Explaining these requires an integrative theory:
– CMOB: The Behaviour System
– PRIME Theory of motivation
• This can provide a systematic basis for
designing interventions, policies and behaviour
change techniques to promote recovery
www.rjwest.co.uk