1 Developing a comprehensive and useful theory of addiction to aid clinical practice Robert West University College London January 2007

2 Outline 1.Theories of motivation 2.Constructing a coherent synthetic model of motivation: PRIME Theory 3.Applying PRIME theory to addiction

3 1. Theories of motivation

4 Humans as rational decision- makers Expectancy value theories –We take decisions by comparing the attractiveness of expected outcomes Multi-attribute utility theory –We take decisions comparing the characteristics of the options under consideration The Theory of Planned Behaviour –We form intentions on the basis of our attitudes, perceptions of control and social norms and then act on those intentions Baron J (2000). Thinking and Deciding. Cambridge: Cambridge University Press ‘The drinker’

5 Humans as animals Operant learning –Habits result from experience of reward and punishment Classical conditioning –Neutral stimuli take on emotional tone by being associated with important stimuli Drive theory –Behaviours derive from biological imperatives Mook DG (1996). Motivation: the Organization of Action. New York: WW Norton

6 Humans as emotional decision makers Conflict theory –Our decisions are influenced by our needs and emotions Self-regulation theory –We attempt to exercise self- control in the face of impulses, desires and needs Identity theory –Self-labels and perceptions are important sources of motivation Baumeister RF et al (1994). Losing Control. San Diego: Academic Press ‘Smoke-scream’

7 Personality theory Trait theories –We vary in propensity to impulsiveness, anxiety etc. Psycho-analytic theories –Our experiences and behaviour stem from interactions and imbalances between different parts of our psyche, e.g. id, ego and superego Social cognitive theories –Our experiences and behaviours derive from the way we construct our world Pervin L (2004). Personality: Theory and Research. Chichester: Wiley

8 2. Constructing a synthetic theory

9 The starting point for a synthetic model Humans are more or less instinctive, habit- driven, emotional decision-makers with a propensity to make and break plans, powerfully influenced by our social world, with a sense of identity which can act as a source of self-control

10 Impulses Impulses can be generated by –Triggers interacting with innate dispositions (instincts) and learned dispositions (habits) –‘Motives’: feelings of desire (anticipated pleasure or satisfaction) and/or need (anticipated relief from unpleasantness or tension) They decay quickly unless ‘fed’ Responses Impulses versus inhibitory forces Triggers Motives

11 Motives Motives can be generated by: –Reminders interacting with the level internal tension at the time –‘Evaluations’: beliefs about what is good/bad, right/wrong, useful/detrimental etc. Responses Impulses versus inhibitory forces Triggers MotivesReminders Evaluations

12 Evaluations Evaluations are generated by: –Recall of observations –Analysis, inference –Accepting what others say –Motives –Plans Responses Impulses versus inhibitory forces Triggers MotivesReminders EvaluationsPlans

13 Plans Plans are ‘mental actions’ generated when: –Actions are considered to be required in the future –Actions are considered to be more likely to meet desires or needs if undertaken at a future time –Actions meeting desires or needs do have a sufficient priority to be enacted at the moment Responses Impulses versus inhibitory forces Triggers MotivesReminders EvaluationsPlans

14 The human motivational system External environment (stimuli, information) Responses Impulses (urges etc.) Motives (wants etc.) Evaluations (beliefs) Plans (intentions) Internal environment (percepts, drives, emotional states, arousal, ideas, frame of mind) Flow of influence through the system External stimulation Internal stimulation

15 The importance of the moment Everything we think, feel or do is a reaction to what happened or our state just prior to that acting on our dispositions We only think about things when we are prompted to do so The way that we think or feel about things depends to some degree on the current circumstances Not thinking about things is an important method of reducing dissonance Evaluations, wants, emotional states, impulses and plans are only present when triggered and have no influence when not present

16 Dispositions The way that we react is determined by our ‘dispositions’ These are more or less stable features of the functioning of our nervous system deriving mainly from the features of, and interconnections between, neurones At a psychological level, long term dispositions are thought of in terms of ‘personality’, ‘attitudes’, ‘mind sets’ etc. Short-term dispositions include things such as ‘mood’ and ‘frame of mind’

17 How dispositions come about Dispositions Genetic endowment Experience 1.Habituation/sensitisation - becoming less or more sensitive to repeated or ongoing stimuli 2.Associative learning - habit formation, classical conditioning 3.Explicit memory - images and thoughts recreated in response to cues Time

18 The development of dispositions Critical periods: points where the chreods fork Deep chreods: small forces will not lead to escape; the system will settle back once they are removed; but if the system is on a cusp a small force will tip it into a new path Environmental forces Waddington’s epigenetic landscape

19 The ‘unstable mind’ The fly-by-wire brain: the brain has evolved to be inherently unstable –this makes it highly adaptable and creative –but it needs constant balancing input to keep it from veering off in unwanted directions This is similar to modern fighter aircraft whose airframes are designed to be unstable and require constant input from computers to keep them on course

20 Simple examples Balancing inputs Major event Balancing inputs Trigger stimulus Balancing inputs Lack of balancing inputs Balancing inputs

21 Identity People differ in the propensity to think about themselves, the nature of the thoughts and feelings that they have, and how consistent and coherent these are Identity is a very important source of motives; it is the foundation of personal norms that shape and set boundaries on our behaviour Identity refers to a disposition to generate particular thoughts and feelings about ourselves

22 Self-control Self-control is a cornerstone of behaviour change. The moment-to-moment wants and needs arising from that must be strong enough to overcome impulses, wants and needs coming from other sources The exercise of self-control is effortful; it requires and uses up mental resources Self-control refers to wants and needs that arise from evaluations associated with our identity

23 3. Applying PRIME theory to addiction

24 Addiction and dependence Addictions are activities that are given an unhealthy priority because of a disordered motivational system Dependence refers to the nature of that disorder. It varies from individual to individual and behaviour to behaviour

25 Example: Motivation to smoke Smoking Impulse to smoke Desire to smoke Need to smoke Positive evaluations of smoking Anticipated enjoyment Anticipated benefit Nicotine ‘hunger’ Unpleasant mood and physical symptoms Smoker ‘identity’ Beliefs about benefits of smoking Cues/triggers Reminders Nicotine dependence involves generation of acquired drive, withdrawal symptoms, strong desires from anticipated enjoyment and direct simulation of impulses through habit learning

26 Example: Inhibition of smoking Not smoking Inhibition Desire not to smoke Need not to smoke Positive evaluations of not smoking Anticipated praise Anticipated self-respect Plan not to smoke Anticipated disgust, guilt or shame Fears about health Non-smoker ‘identity’ Beliefs about benefits of not smoking Cues/triggers Reminders Nicotine dependence also involves impairment of impulse control mechanisms undermining response inhibition

27 Basics of behaviour change What is behaviour change? –A change in the rate at which an individual engages in a particular type of activity (e.g. stopping smoking, cutting down on drinking, taking up exercise) What underlies the change? –A change in 1) propensity of the individual or 2) the social or physical environment What are the key principles? –The greater the perceived personal, social or financial costs of engaging in an activity or gains of not engaging in it, the more difficult it is, the fewer the opportunities to do it and the less often the idea of doing it is put into the mind of the individual, the less often it occurs; and the converse is also true.

28 Just changing dispositions Foster or reduce habit strength –Increase or reduce the strength of impulses to engage in the behaviour caused by stimuli associated with it Foster or reduce a need to engage in the activity –Increase or reduce drive states or adverse experiences from which the activity provides relief Foster or reduce a desire to engage in the activity –Increase or reduce the anticipated pleasure or satisfaction from the activity Foster or reduce motivation to engage in competing activities –Increase or reduce the need or desire to engage in activities that are incompatible with the target activity

29 Changing the environment Increase or decrease: –actual personal, social or financial costs and benefits of the activity –opportunities to engage in the activity –difficulty engaging in the activity –triggers and reminders that generate impulses, needs and desires underlying the activity –opportunities to engage in competing activities –difficulty engaging in competing activities

30 The role of self-control Most behaviour change requires self-control –because it stems from a conscious re-evaluation of the costs and benefits of making a change in the behaviour pattern Self-control stems from identity –it refers to the application of needs and desires that arise from evaluations of ourselves as we are or could be The decision to make a change in behaviour is a change in identity –it involves a new self-image as someone who behaves differently The new identity does not come about through calculation and analysis; it stems from a fundamental re- evaluation and re-orientation – often referred to as an ‘epiphany’ or ‘moment of clarity’

31 Successful self-control Successful self-control requires the needs and desires arising from the new identity to overpower the needs, desires and impulses that are driving the old behaviour pattern It requires and uses up mental energy Self-control is more successful when: –there is strong commitment to the new identity –the new identity has clearly defined boundaries –the physiological processes underlying response inhibition are functioning well –the new self-image is always triggered when required –the individual has plentiful reserves of mental energy

32 The dynamics of behaviour change The process does not involve cycling through stages of change as proposed in the Transtheoretical Model –It is much more fluid and responsive to the immediate situation –Individuals often do not go through stages involving planning to change before changing –It places emphasis in the wrong places when considering influences that promote change In conscious attempts at behaviour change two phases can be usefully distinguished: –Phase 1: Before an attempt at change –Phase 2: After the start of the attempt at change Factors that predict attempts at change are not necessarily the same as those that predict maintenance

33 Stopping smoking: Before the quit attempt 1. When the smoker is led to think about his or her smoking, he or she may feel a desire or need to stop that varies in strength and urgency arising from one or more of the following: Worry about health Dislike of financial cost of smoking Guilt or shame at smoking Disgust with smoking Hope for success at stopping Hope for improvement in health with stopping Hope for improved self-esteem with stopping Commitment to a remembered intention to make a quit attempt 2. These conflict with and are mitigated habit driven impulses and by a desire or need to smoke arising from one or more of the following: Anticipated enjoyment of a forthcoming cigarette Need for the forthcoming cigarette Concern about loss of self-esteem if the quit attempt fails Concern about unpleasant short-term effects of stopping Wanting or needing to hold on to the perceived benefits of smoking 3. Depending on the strength of the competing desires and needs, the conflict may result in: Putting the idea of stopping out of his or her mind Forming an intention to stop at some vaguely conceived future time point Forming a definite plan to stop at some future time point Deciding to stop immediately

34 Stopping smoking: After the quit point 1. On each occasion when the would-be ex- smoker is led to think about smoking, he or she experiences an urge to smoke arising from one or more of the following: A habit-driven impulse A need to smoke derived from ‘nicotine hunger’ A need to smoke derived from anticipated relief from negative mood A need to smoke derived from anticipated physical symptoms, e.g. mouth ulcers A desire to smoke derived from anticipated enjoyment or satisfaction A desire to smoke derived from anticipated benefits of smoking, e.g. weight loss 2. This competes with a desire or need for the smoker to stop himself or herself smoking which arises from one or more of: Commitment to the decision not to smoke Commitment to the identity of a non-smoker Worry about health Anticipated guilt or shame at having a cigarette Hope for improvement in health with stopping Anticipated disappointment at having wasted the effort expended thus far Anticipated effort required to acquire a cigarette 3. If the strength of the urge to smoke is greater than the inhibition arising from the desire or need not to smoke, and the opportunity to smoke is present, the would-be ex-smoker will: Smoke a cigarette but consider that the quit attempt is continuing Abandon the quit attempt but try to keep smoking within certain limits Abandon the quit attempt completely

35 Contrasts between TTM and PRIME TTMPRIME Assess stage of change before giving brief advice Actively promote change and offer help to all comers Focus on client’s beliefs about pros and cons Focus on client’s impulses and feelings of need and desire Encourage clients to delay the change point to allow preparation Encourage clients to change as soon as they want to Attempt to get the client to define goals Attempt to get acceptance of need for clear, fixed boundaries Focus on moving the client forward by stages Focus on generating ‘epiphanies’ and ‘mini-epiphanies’

36 Conclusions Motivation involves multiple levels: Plans, Responses, Impulses/inhibitions, Motives, and Evaluations The balance between impulses and inhibitions is the final common pathway through which all motivation operates Changing behaviour patterns requires changing dispositions to react in particular ways or changing the environment or both Identity is ultimate source of self-control which is usually required for behaviour change ‘Talking therapies’ for addictions involve finding out the specific motivations driving the behaviour and attempting to foster a change in dispositions to alter the balance of motivational forces to reduce the rate at which the behaviour occurs A major target is to generate a commitment to a fundamentally different identity