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
January 2009
1
Outline
• Defining addiction and motivation
• Developing a theory of motivation
• Applying the theory to addiction
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Outline
• Defining addiction and motivation
• Developing a theory of motivation
• Applying the theory to addiction
3
Addiction
• Individuals repeatedly experience powerful motivation to
engage in particular maladaptive behaviours that often
undermine and overwhelm motivation to exercise
restraint
• Two elements:
– strength of motivation
– capacity for restraint
• Degree of addiction can be measured by indices of the
dominance of the motivation
– subjective reports or strength, persistence and/or frequency of
urges
– observations of priority given to the behaviour
4
Motivation
• Not just ‘reasons’
• Brain processes that energise and direct behaviour
• Relevant concepts:
–
–
–
–
–
–
–
impulse
drive
want
need
goal
choice
intention
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Where does motivation fit in?
Response control system
Skilled
Skill
Response generation system
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
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under the influence of other systems
Outline
• Defining addiction and motivation
• Developing a theory of motivation
• Applying the theory to addiction
7
A starting point for understanding behaviour
• We:
– act on impulse
• we do it without thinking about the consequences
– want or need something
• we seek a source of pleasure or satisfaction, or of relief
– think it is right or will serve a purpose
• we do what we consider best
– are following a plan
• we act on a prior intention
• And this motivation is stronger than any
competing motivation present at the time
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Example
• Faced with what appears to be a thief running towards
us on the street:
–
–
–
–
–
the impulse is to avoid physical contact (‘flinch’)
there may be anticipation of satisfaction from catching a criminal
there may be anticipation of harm from being attacked
there may be a belief that one should be a good citizen
there may be a prior generalised intention to fight crime where
possible
• Conflict between these different types of motivation will
determine what action is taken ‘in the moment’
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A possible structure for the motivational
system
• A motivational system with 5 levels, with higher levels
feeding into lower levels
– Responses
• starting, stopping or modifying actions
– Impulses vs inhibition
• Activation of CNS pathways underpinning actions, and competing
pathways inhibiting them (urges)
– Motives
• Mental representations of future world states with feelings of
anticipated pleasure or satisfaction (wants) or relief (needs)
– Evaluations
• Beliefs involving sense of what is useful/harmful (functional),
right/wrong (moral), pleasing/displeasing (aesthetic)
– Plans
• Mental representations of future actions associated with feeling of
varying degrees of commitment (intentions and rules)
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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
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‘Oughts’
• We use the term ‘ought’ or ‘should’ to refer to
actions that we do not want to do or feel a need
to do but which we evaluate positively
• According to PRIME Theory, ‘oughts’ will not
lead to behaviour unless they can interact with
identity (see later) to generate wants or needs
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Implications
• All goal directed behaviour is channelled through
motives (wants and needs) operating ‘in the moment’
• Motives are not the same as intentions or cognitions
• Evaluations and intentions will not influence behaviour
unless they generate motives at the relevant time
• Therefore measuring motives offers the best prediction
of goal directed behaviour and the best starting point for
understanding it
• Shift in focus from beliefs and intentions at the time of
measurement to predicting wants and needs in the future
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Dispositions and how they change
• Dispositions refer to characteristics of the system that govern its
operation
• Dispositions vary in stability and context sensitivity
• Dispositions change through:
– maturation
– learning
• habituation and sensitisation
• associative learning
• explicit memory
– analysis
– re-formulation
• The process of change is ‘chaotic’ (involving semi-stable states with
pseudo-random switching during periods of instability) and ‘dialectic’
(involving mutually interacting elements)
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Implications
• Behaviour change need not proceed in a linear fashion
through stages; change from one major disposition to
another can:
–
–
–
–
occur in a single complete transformation
happen without being intended
involve periods of instability of varying duration
occur in response to apparently insignificant triggers
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The role of identity
• Identity refers to our disposition to form mental
representations of ourselves and the feelings attached to
these
• It is a potentially important source of motives
• It is the ultimate source of self-regulation
• It is a major source of stability of behaviour
• Major elements are:
– Labels (e.g. non-smoker)
– Attributes (e.g. health-conscious)
– Rules (e.g. I do not smoke)
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Deliberate cessation of behaviour patterns
•
Self-consciously stopping doing something
typically means:
1. forming a rule (plan) not to do it, or
2. forming a rule (plan) that one will ‘try’ not to do it
•
Applying that rule in relevant situations which
generates a want or need not to do it which
adds to those that led to the rule
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Self-control
• Self-control refers to the self-conscious
application of a plan/rule in the face of
competing wants, need or impulses
• This process is effortful and require and use
mental energy to the extent that it involves
conflict with other wants and needs
• ‘Deep’ identity change involving changes to
labels, attributes and development of rules with
clear boundaries opposes formation of
conflicting wants and needs and reduces conflict
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Implications
• A strong, coherent, deeply entrenched identity that
places clear boundaries around a category of behaviour
and which anticipates potential challenges will provide
strong stability to that behaviour and yield a powerful
predictive measure
• Fostering such an identity around a new behaviour
pattern is a potentially important target for behaviour
change interventions
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Key points
1. Our behaviour is motivated at multiple levels from
impulses, motives and evaluations to plans
2. Higher level motivations must work through lower level
ones where they may come into conflict with other
motivations at that level
3. Plans in the form of ‘rules’ have a vital role to play in
organising our behaviour and protecting our longer
term interests in the face of immediate demands
4. Implementing them in the face of conflicting wants,
needs and urges can be effortful and use up mental
resources
5. But ‘deep’ identity change and rules with clear
boundaries reduce conflict and effort required
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Outline
• Defining addiction and motivation
• Developing a theory of motivation
• Applying the theory to addiction
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Understanding why people smoke ...
• They light up and puff on impulse
– much smoking is ‘habitual’, done without thinking
• They want or need to
– they expect to enjoy it; they experience a ‘hunger’ for a cigarette
after a period of not smoking
• They think it serves a purpose
– they expect it to help with stress, weight control and
concentration
• They form plans to smoke
– they plan to go for a cigarette during coffee breaks
• These motivations are stronger than any competing
motivations including a plan not to smoke
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How does this arise?
• Nicotine ‘hits’ from each puff of a cigarette binds to
nicotinic acetylcholine receptors in the brain causing:
– dopamine release in the nucleus accumbens which:
• generates an automatic impulse to smoke in the presence of
smoking cues
• provides pleasure and satisfaction associated with smoking
• makes other experiences associated with smoking more
pleasurable
• changes the functioning of the brain region concerned so that when
CNS nicotine levels are depleted there is need to smoke to restore
those levels (nicotine hunger)
– other chronic changes to brain chemistry resulting in
• adverse mood and physical symptoms such as anger, depression
and difficulty concentrating generate an additional need to smoke
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Nicotine reward
•
•
•
•
When nicotine is absorbed it attaches to nicotinic acetylcholine
receptors in the Ventral Tegmental Area (VTA) of the mid brain
This stimulates firing of neurons that project forward to the Nucleus
Accumbens (NAcc)
This causes dopamine release in the NAcc
This results in:
–
–
–
–
an impulse (urge) to smoke in situations that have been associated
with smoking
a mildly pleasant sensation
amplification of pleasures arising from other rewards present at the
time
a belief that smoking is enjoyable and adds pleasure to life
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Mesolimbic dopamine pathway
Nucleus accumbens
Ventral tegmental area
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Drug actions on the mesolimbic pathway
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Nicotine hunger
•
•
•
•
•
After repeated ingestion of nicotine, the motivational pathways are
altered to create a ‘drive’, somewhat similar to hunger, except that
it is for cigarettes
The drive increases in the minutes to hours since the last cigarette
and is influenced by triggers, reminders, stress and distractions
The drive is experienced as a ‘need’ to smoke
It usually reduces over weeks of not smoking but can re-emerge
unexpectedly
Relief from this need can be pleasurable and memory of the
pleasure makes smokers feeling that they ‘want’ to smoke: the
expect to enjoy it
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Nicotine withdrawal symptoms
•
•
After repeated nicotine exposure, abstinence results in
unpleasant withdrawal symptoms including depression
Adverse mood therefore comes to generate a need to
smoke and a belief that smoking can help with stress
and concentration
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The process of smoking cessation
• The process of smoking cessation involves a number of
events:
– the ‘quit attempt’
• initiation of a rule that smoking is not permitted
• arises at a moment when the desire to stop now is greater than the
desire to carry on
– lapse
• smoking a cigarette but keeping or suspending the no-smoking rule
• arises when the desire to smoke is greater than the desire not to
– relapse
• abandoning the no smoking rule
• arises when the desire to abandon the no-smoking rule is greater
than the desire to keep it
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‘Wants’ and ‘oughts’ to stop smoking
• Reports of ‘want’ to stop are
lower than seen when asked
on its own
• In multiple logistic regression,
only ‘want’ is associated with
quit attempts
Percent
– I want to stop smoking
– I ought to stop smoking
Endorsement of
motives for stopping
100
90
80
70
60
50
40
30
20
10
0
Want to stop
Ought to stop
Motives to stop and
past attempts
5
4.5
4
Odds ratio
• 3173 adult cigarette smokers
in the Smoking Toolkit Study
• Allowed to endorse either or
both of
3.5
3
2.5
2
1.5
1
Want to stop
Ought to stop
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Why smoking cessation is difficult
• The impulse to smoke
– Many smokers experience powerful cue-driven impulses in
situations in which they would normally smoke
• The want to smoke
– Many smokers enjoy and get satisfaction from smoking
• The need to smoke
– ‘Nicotine hunger’, adverse effects of abstinence
• Positive beliefs about smoking
– Stress relief, aid to concentration, weight control
• The routine of smoking
– Strong over-learned plans to smoke at certain times
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Wanting and needing to smoke
• Wanting to smoke
appears to deter attempts
to stop while needing to
smoke leads to relapse
once an attempt is made
Urges to smoke
90
85
Percent
80
75
70
65
60
55
50
Did not attempt
Percent
Data from 1479 smokers
in Smoking Toolkit
Study, followed up 6
months after ratings or
enjoyment and urges
were made to find out
whether: had attempted
to stop and if so had
relapsed
Enjoyment of smoking
Strong urges
Relapsed
No urges
100
95
90
85
80
75
70
65
60
55
50
Did not
attempt
Enjoy
Relapsed
Not enjoy
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Tackling the problem at all levels: reducing
motivation to smoke
• Reduce the impulse
– medication during smoking to break the smoking-reward link
– reduce exposure to smoking cues
• Reduce the want and need
– medication during smoking and abstinence to make smoking
less satisfying and reduce nicotine hunger and adverse
symptoms
– control exposure to events that provoke wanting and needing
• Change beliefs
– convince smokers that smoking does not confer benefits
• Change plans
– change routines that involve smoking
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Tackling the problem at all levels: increasing
motivation not to smoke
• Generate competing impulses
– set up competing habitual responses to smoking cues
• Increase the want and need not smoke
– use extrinsic rewards and punishments (e.g. social approval,
disapproval, vouchers)
– maintain salience of negative feelings about smoking (e.g,
disgust, anxiety)
– foster intrinsic rewards for not smoking (e.g. achievement)
• Change beliefs
– foster negative beliefs about smoking and positive non-smoker
identity
• Establish firm, coherent plans
– Establish clear ‘not a puff’ rule as part of new identity
– Establish clear if-then rules to minimise wants, needs and urges
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Implications: a reminder
• All goal directed behaviour is channelled through motives (wants
and needs) operating ‘in the moment’
• Motives are not the same as intentions or cognitions
• Evaluations and intentions will not influence behaviour unless they
generate motives at the relevant time
• Therefore measuring motives offers the best prediction of goal
directed behaviour and the best starting point for understanding it
• Shift in focus from beliefs and intentions at the time of measurement
to predicting wants and needs in the future
35
A simplification of PRIME Theory
• Most of our actions involve following what we most want
or need at that moment
• Wanting and needing involve forming an image of a
possible future and feelings associated with this
– Want: feeling of anticipated pleasure or satisfaction
– Need: feeling of anticipated relief
• We follow wants and needs when we can imagine how
to attain them or can do it without conscious thought to
generate impulses
• ‘Oughts’ (wants and needs based purely on plans) carry
little motivational impact
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What activities are addictive?
They are activities that generate powerful impulses,
wants or needs and/or reduce competing wants or
needs
•
•
•
•
They may increase reliance on the addictive behaviour as a source of
reward or means of meeting particular needs
They may create unpleasant reactions when the activity is stopped
They may create a ‘habit’
They may create an ‘acquired drive’
West (2006) Theory of Addiction: Oxford: Blackwells
37
Who is susceptible to development of
addiction?
They have greater pre-existing wants and needs, greater
sensitivity to the motivating effects of the behaviour,
reduced competing wants or needs or reduced capacity for
self-control
•
•
•
•
•
•
•
They are more impulsive
They are less committed to conventional morality
They have a greater propensity to depression or anxiety
They are lower in self-esteem
They may be more sensitive to the rewarding effects of the activity/drug
They may be less sensitive to the aversive effects of the activity
They may be more sensitive to lasting effects of the drug on the brain
West (2006) Theory of Addiction: Oxford: Blackwells
38
What conditions promote addiction?
Social and physical conditions that provide opportunities
for the behaviour, establish wants or needs or reduce
competing wants or needs
•
•
•
•
•
•
A culture in which the activity is commonplace and regarded as normal
Peer groups in which the activity forms a part of social identity
An environment with greater opportunities to engage in the activity
An environment with reduced opportunities for other sources of reward
Adverse social, economic or environmental circumstances
Possibly an environment in which there is lower propensity for the activity to
lead to immediate adverse consequences
West (2006) Theory of Addiction: Oxford: Blackwells
39
What conditions promote suppression and
recovery?
Suppression is achieved by pharmacological,
environmental or psychological methods that reduce
wants, needs or impulses to engage in the behaviour or
increase competing wants or needs. Recovery is achieved
by methods that effect permanent changes to the
motivational system or environment that promote
suppression.
•
•
•
Full or partial agonist therapy can lead to suppression and sometimes
recovery
Life-changing events that introduce powerful new competing motivations
Epiphanies can lead to recovery
West (2006) Theory of Addiction: Oxford: Blackwells
40
Predicting smoking cessation
• Medium term prediction of attempts to stop smoking
– Thinking back over the past few weeks how much of the time have you
felt you wanted to stop smoking?
– How strong has that desire been?
• Prediction of early relapse
– How much of the time have you felt urges to smoke?
– How strong have those urges been?
• Prediction of late relapse in short-term successes
– Do you now think of yourself as a non-smoker for whom smoking is not
something you would even contemplate doing?
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Predicting successful interventions
• Generating quit attempts in unselected smokers
– focus on triggering action rather than changing beliefs
– promote use of effective aids to cessation to all smokers without
asking whether they are interested in stopping first
– time interventions to coincide with each other or other times of
heightened motivation to change
• Aiding quit attempts
– focus on developing and fostering a new identity
• abrupt not gradual change
• clear boundaries (not a puff)
• re-evaluate place of smoking in relation to other core identities
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Review
• Motivation involves multiple levels from impulses to
plans; higher levels must work through lower levels
• Wants and needs ‘in the moment’ are the key to goaldirected behaviour
• Plans/rules provide structure and stability but must
create wants and needs at the relevant time
• Self-control is fundamental to deliberate behaviour
change and stems from self-conscious plans interacting
with identity to generate wants and needs
• Self-control is effortful but less so when it involves ‘deep’
identity change and rules with clear boundaries
43