1 How do you get a horse to drink? University College London November 2011 Robert West

2 Ideas? Tell it that water is good for it Show it enticing pictures of drinking water Offer it money Warn it that if it doesn’t it will be punished Set up a water-drinking skills training programme Devise water-drinking regulations Put up signs pointing the way to the pond Show another horse doing it Give it a straw

3 Givens? Human behaviour arises from learned and innate reactions to external and internal stimuli occurring ‘in the moment’ Reflective analysis, choice and intention play an important role but are only part of the picture Much of our behaviour occurs –because anticipated pleasure or relief (even outside awareness) outweighs beliefs about what is good or bad –without evaluating more than one course of action –without any thought about the consequences at all There are severe limits to the capability to influence behaviour if one ignores emotion, habit, instinct and drive Current models of behaviour recognise this and attempt in different ways to provide an integrative account This presentation draws on the comprehensive review by Doug Mook in the book ‘Motivation: the Organisation of Action’ and Robert West in ‘Theory of Addiction’

4 Common terms for methods for inducing behaviour change Educate Train Help Expose to Inform Discuss Suggest Encourage Incentivise Ask Order Plead Coerce Force Offer Provide Prompt Constrain

5 COM-B system for analysing behaviour in context 1.Capability, motivation and opportunity all need to be present for a behaviour to occur 2.They all interact as part of a system 3.Motivation must be stronger for the target behaviour than competing behaviours 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.

6 Common terms for methods for inducing behaviour change Capability Educate Train Help Motivation Expose to Inform Discuss Suggest Encourage Incentivise Ask Order Plead Coerce Force Opportunity Offer Provide Prompt Constrain

7 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.

8 Understanding motivation Brain processes that energise and direct behaviour Not limited to choice and goal pursuit Needs to include –drive –habit –desire –instinct –self-regulation –etc.

9 Motivation: reflective and automatic Beliefs about what is good and bad, conscious intentions, decisions and plans Emotional responses, desires and habits resulting from associative learning and physiological states Automatic Reflective

10 PRIME Theory: the structure of human motivation

11 PRIME Theory: reflective and automatic processes

12 There are multiple change processes Automatic 1.Perception: acquiring information from the senses 2.Associative learning: operant and classical conditioning 3.Maturation: changes associated with growing older 4.Habituation: decrease in response with exposure 5.Sensitisation: increase in response with exposure 6.Imitation: direct copying 7.Identification: forming one’s own identity from perceptions of others 8.Consistency disposition: generation of motives, ideas from similar ones 9.Dissonance avoidance: negating or blocking uncomfortable beliefs 10.Objectification: generating evaluations from likes and dislikes 11.Chemical ‘insult’: pharmacological responses 12.Physical ‘insult’: brain lesions Reflective 1.Assimilation: acquiring information via communication 2.Inference: induction and deduction 3.Analysis: formal and informal calculation

13 Self-control, identity and behaviour change We are self-aware and form mental representations of ourselves to which are attached emotions (identity) These include labels and rules Deliberate behaviour change involves adopting a new personal rule To the extent that this is based on evaluations it requires effortful self-control

14 PRIME Theory: 8 core propositions (1-4) 1.At every moment we act in pursuit of what we most desire (want or need) at that moment. 2.Wants and needs involved imagined futures and feelings of anticipated pleasure/satisfaction (wants) or relief from mental or physical discomfort (needs) 3.Beliefs about what is good or bad can influence our actions if they generate desires that are strong enough to overwhelm those arising from other sources (e.g. drives and emotional responses) or impulses arising automatically out of habit or instinct. They will do this to the extent that they generate clear imagery that can trigger necessary emotional associations. 4.Identity (our mental representations of ourselves and the emotions attached to these) is an important source of desires and provides a degree of stability to our behaviour by virtue of the labels we apply (e.g. non- smoker) and the rules that govern our behaviour (e.g. not smoking).

15 PRIME Theory: 8 core propositions (5-8) 5.Identity change is the starting point for deliberate behaviour change (in terms of a new label and a new set of rules governing our behaviour) and can be regarded as an ‘act’ that occurs when the desire to make the change is momentarily greater than the desire not to. 6.Deliberate behaviour change is sustained when the desires arising from the new identity are stronger at each relevant moment than the desires arising from other sources to revert to the previous behaviour pattern, or are able to overwhelm habitual or instinctive impulses. 7.Self-control is the effortful generation of desire to adhere to a rule that is sufficiently powerful to overcome desires arising from other sources. 8.Personal rules that have clear boundaries and a strong connection with components of identity that involve strong emotional attachments will generate more powerful desires when required and better suppress countervailing desires and so have a stronger lasting impact on behaviour.

16 Motivation to stop predicting quit attempts N=2088, p<0.001 for linear trend see

17 Attempts to stop according to GP advice to stop smoking N=7611, p<0.001 for difference between offer of support/prescription and others see

18 What happened after smoke-free? see

19 Predictors of quit success VariableOdds ratio (adjusted)95% confidence interval Dependence (1-6)0.28** Time since most recent quit attempt weeks (reference) <1 week 1-4 weeks 4-8 weeks 8-12 weeks weeks ** 3.92** 1.39* Number of prior quit attempts in the past 12 months 0.64** Abrupt vs gradual cessation (reference)1.89** Method used Unaided (reference) NHS specialist support Medication Rx NRT OTC ** 1.73** see

20 Key elements of PRIME relevant to designing behaviour change interventions 1.Focus on what influences desire at key moments 2.Focus on imagery (not just visual) as an important source of desire 3.Promote formulation of personal rules with clear boundaries linked to core aspects of identity 4.More generally, try to make identity work in favour of rather than against behaviour change 5.Pay attention to potentially conflicting behaviours at key moments 6.Pay attention to sources of individual differences in the plans, evaluations, desires and impulses and efficiency of influence down the hierarchy 7.Bring as many powerful sources of desire to bear at key moments as possible, however diverse their source

21 Getting a horse to drink Make it thirsty (need) Give it beer? (want) Make sure that it has the capability do it and has the opportunity, then try to motivate it by getting it to need or want it more than it needs or wants to do whatever else might be on offer

22 PRIME Theory: the structure of human motivation