University College London 11 August 2011 How can we improve behavioural support to help people overcome addictions? Robert West University College London 11 August 2011

Topics What is addiction? What causes it? What is behavioural support? How effective is it? How can it be improved?

What is addiction? A repeated powerful motivation to engage in a purposeful behaviour, acquired as a result of engaging in that behaviour, that has significant potential for unintended harm Varies in: strength: extent of disorder of motivation severity: degree of harm sources: underlying mechanisms and causes West (2011) Models of Addiction. Lisbon: EMCCDA

What causes it? All behaviours arise out of: Capability: the physical or psychological ability to engage in the behaviour Motivation: a greater desire or impulse to engage in the behaviour than potentially competing behaviours Opportunity: a physical or social environment that prompts the behaviour or makes it possible Michie et al (2011) Implementation Science

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

Understanding motivation (PRIME Theory) We act in pursuit of what we most desire at each moment Desire (motive): feeling of want anticipated pleasure or satisfaction need anticipated relief from mental or physical discomfort triggered by imagined futures, interacting with past associations and drive states, arousal and emotions West (2006) Theory of Addiction. Oxford: Wiley-Blackwell

PRIME Theory: the structure of human motivation I intend to do X X is good/bad I want/need X Urge/counter-impulse to do X www.primetheory.com

PRIME Theory: where desire fits into that structure www.primetheory.com

Identity, plans and self-control mental representations of ourselves feelings (emotions, drives, desires) attached to these necessary for generation and enactment of plans includes: labels, characteristics, and personal rules Self-control process whereby plans influence behaviour in the face of desires arising from other sources requires and depletes ‘ego strength’

PRIME Theory: where decision theory fits www.primetheory.com

PRIME Theory: where learning theory fits www.primetheory.com

PRIME Theory: where self-control theory fits www.primetheory.com

The origins of addiction Powerful desires learned associations between cues and anticipated pleasure and satisfaction relief from pre-existing or acquired needs acquired drives Weak competing desires absence of, or weak competing plans/rules weak desires arising from punishment Impaired self-control failure of plans/rules to generate strong competing momentary desires

The process of ‘recovery’ Key driver is ‘identity change’ new label and set of personal rules Occurs when desire to change is greater than desire to continue with old behaviour pattern May or may not involve pre-planning New rules may be ‘suspended’ (lapse) or ‘rescinded’ (relapse) at any time depending on momentary desires Highly dynamic, involving ‘tensions’ and ‘triggers’ that lead to transitions between identity states

The SNAP model of behaviour change I am not trying to change Still doing it Attempting to change Planning to change I am in the process of changing I have made a definite plan to change Not doing it I have changed McEwen et al (2010) Practice Nursing

Moving between states Transitions occur as result of a combination of tension and triggers Tension Feeling desire to change (want or need) arising from dissatisfaction with current situation desire for new situation hope/assumption that change can be achieved Triggers Events that momentarily: raise the tension (including increasing urgency) reduce competing desires show a pathway by which the change can occur

What is behavioural support? Advice, discussion, encouragement and activities aimed at helping someone achieve lasting behaviour change Can be given face-to-face, by telephone, text-messaging, or internet in groups, couples, families or individually Based on presumption that the person has some degree of desire for change Michie et al (2010) Addictive Behaviors

Components of behavioural support (Behaviour Change Techniques)

Addressing motivation Foster new intrinsic motivations for change, e.g. new identity Establish a clear set of goals and a ‘route map’ Address pre-existing needs Create expectation of reward and punishment (usually social) Provide general encouragement Boost self-efficacy Maintain or increase salience of reasons for change

Enhancing self-regulation Promote avoidance of ‘tempting situations’ (cues to the addictive behaviour) Promote effective ways of escaping from tempting situations Promote substitute responses Promote ways of maintaining ‘ego strength’

Promoting adjuvant activities Promote effective use of activities that support the change For example: medication use exercise attendance at classes self-care mobilising social support

Supporting activities Promote continued engagement Establish and maintain rapport Collect relevant information Elicit and address concerns

Where does behavioural support fit in Intervention: The Behaviour Change Wheel The Behaviour Change Wheel: a new method for characterising and designing behaviour change interventions Susan Michie, Maartje M van Stralen, Robert West Implementation Science 2011, 6:42 (23 April 2011)

Is behavioural support effective? Smoking can improve odds of stopping by 50-100% Alcohol can significantly reduce consumption at least in the medium term Illicit drugs and gambling lack of clear evidence but strong presumption of benefit West (2011) Models of Addiction. Lisbon: EMCCDA

Identification of effective Behaviour Change Techniques Develop a reliable classification system using treatment manuals, transcripts or recordings Code interventions using the system Establish effectiveness of specific BCTs and combination through identifying those that are used in interventions shown to be effective in RCTs meta-regression predicting effect sizes in systematic reviews of RCTs regression involving clinical services known to vary in success rates fractionated factorial designs in experimental evaluations of innovations

The case of smoking cessation support Identified 53 BCTs in regular use subsets which are used in interventions found to be effective in RCTs predict success rates of Stop-Smoking Services (SSSs) Michie et al (2010) Annals of Behavioral Medicine

Smoking cessation: 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

Smoking cessation: Maximising self-regulatory capacity Facilitate barrier identification and problem solving Facilitate relapse prevention and coping Facilitate action planning/develop treatment plan Facilitate goal setting Prompt review of goals Prompt self-recording Advise on changing routine Advise on environmental restructuring Facilitate barrier identification and problem solving Facilitate relapse prevention and coping Facilitate action planning/develop treatment plan Facilitate goal setting Prompt review of goals Prompt self-recording Advise on changing routine Advise on environmental restructuring Set graded tasks Advise on conserving mental resources Advise on avoidance of social cues for smoking Facilitate restructuring of social life Advise on methods of weight control Teach relaxation techniques Set graded tasks Advise on conserving mental resources Advise on avoidance of social cues for smoking Facilitate restructuring of social life Advise on methods of weight control Teach relaxation techniques Blue: present in 2+ BSPs tested by RCTs; Red: linked to higher success rates in SSSs; Purple: Blue+Red

Smoking cessation: 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

Smoking cessation: 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

Smoking cessation: 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 To improve behavioural support we need to: This requires: adopt a comprehensive model of addiction and the process of recovery develop reliable systems for classifying specific behaviour change techniques (BCTs) used, linked to that model gather correlational and experimental evidence linking specific BCTs to improved outcomes This requires: comprehensive, accurate and comparable descriptions of interventions characteristics of clients/patients and context outcomes