1. 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

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

3. 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

4. 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

5. 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

6. 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

7. 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

8. PRIME Theory: where desire fits into that structure

9. 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’

10. PRIME Theory: where decision theory fits

11. PRIME Theory: where learning theory fits

12. PRIME Theory: where self-control theory fits

13. 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

14. 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

15. 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

16. 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

17. 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

18. Components of behavioural support (Behaviour Change Techniques)

19. 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

20. 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’

21. 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

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

23. 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)

24. Is behavioural support effective?
Smoking
can improve odds of stopping by %
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

25. 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

26. 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

27. 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

28. 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

29. 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

30. 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

31. 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

32. 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