1. 1 Understanding addiction in contemporary society Robert West University College London

2. Outline 1.Defining addiction 2.What we know about development of addiction 3.What we know about recovery from addiction 4.Theoretical perspectives 5.A synthesis: CMOB and PRIME Theory 6.A comprehensive approach to behaviour change: the ‘Behaviour Change Wheel’ ‘Behaviour Change Techniques’

3. Defining 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

4. 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

5. Key facts about development of addiction Addiction is more frequent when: –the activity provides immediate pleasure meets an immediate need is prevalent changes the individual to amplify its reinforcing effect undermines potentially competing activities is readily accessible is not immediately punishing –the individual is more susceptible to the above factors –the environment accentuates the above factors

6. 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 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: 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

7. 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 Each of these addresses only part of the problem

8. Summary of key mechanisms Stimulus-impulse and stimulus-affect 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

9. 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

10. The Behaviour System: CMOB Opportunity Capability Motivation Behaviour Psychological or physical ability to enact the behaviour Reflective and automatic mechanisms that activate or inhibit behaviour Physical and social environment that enables the behaviour

11. The Behaviour System: CMOB Opportunity Capability Motivation Behaviour Capability, motivation and opportunity must be present for a behaviour to occur The system is in dynamic equilibrium and a change in behaviour may require a sustained change in one or more of the other elements

12. 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

13. The structure of human motivation

14. Starting, stopping or modifying actions Generated by the strongest of competing impulses and inhibitions at that moment Lighting up a cigarette Taking a puff on a cigarette Saying no to offer of a cigarette

15. 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

16. 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

17. 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

18. The structure of human motivation 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 One off: I will stop smoking tomorrow Personal rule: I will not smoke

19. The control of purposeful behaviour 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

20. Response Strongest of competing impulses and counter impulses Strongest of competing wants and needs Beliefs about positive and negative features Pre-formed plans Reflective Automatic Internal and external environment Reflective processes fail to get through to behaviour Failure of self-control

21. Some elementary processes of change Maturation Associative learning Habituation Sensitisation Chemical ‘insult’ Physical ‘insult’ Imitation Perception Assimilation Inference Analysis

22. The dynamics of change The system is ‘chaotic’: fundamentally unstable and kept in equilibrium by constant ‘balancing input’ This means that change can occur: –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

23. 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

24. The Behaviour Change Wheel Behaviour type Interventions Policies Regulation Environmental/ social planning Communication/ marketing Legislation Fiscal Persuasion Education Coercion Environmental restructuring Incentivisation Enablement/ resources Capability Opportunity Motivation Training Restriction Service provision Guidelines Modelling Physical Psychol- ogical Reflec- tive Automatic Physical Social A system for choosing interventions and policies

25. 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

26. Behaviour Change Techniques in behavioural support for smoking cessation Advice, discussion and materials aimed at helping smokers to stop Four components (MASS): 1.Addressing motivation Maximising motivation to remain abstinent and minimising motivation to smoke 2.Promoting optimal use of adjunctive activities Helping smokers to make best use of medication or other quitting aids 3.Maximising capacity for self-regulation Helping smokers avoid, minimise or resist urges to smoke 4.Activities that support the above Establishing rapport, undertaking assessment, engaging the smoker, tailoring the support plan to the smoker’s needs

27. 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

28. 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 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

29. 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

30. 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

31. 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

32. Conclusions To understand and combat addiction need a comprehensive approach: –model of behaviour in context (CMOB) –model of motivation (PRIME) –system for choosing types of intervention and policy (BCW) –system for choosing intervention components (BCTs)

33. www.rjwest.co.uk