How can we improve behavioural
support to help people overcome
addictions?
Robert West
University College London
11 August 2011
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Topics
•
•
•
•
•
What is addiction?
What causes it?
What is behavioural support?
How effective is it?
How can it be improved?
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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
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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
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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
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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
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PRIME Theory: the structure of human motivation
I intend to do X
X is good/bad
I want/need X
Urge/counterimpulse to do X
www.primetheory.com
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PRIME Theory: where desire fits into that structure
www.primetheory.com
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Identity, plans and self-control
• Identity
–
–
–
–
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’
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PRIME Theory: where decision theory fits
Decision theory
www.primetheory.com
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PRIME Theory: where learning theory fits
Learning theory
www.primetheory.com
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PRIME Theory: where self-control theory fits
Self-control theory
www.primetheory.com
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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
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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
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The SNAP model of behaviour change
I am not trying to change
Still doing it
I am in the process
of changing
Planning to
change
Attempting
to change
I have made a definite
plan to change
Not doing it
I have changed
McEwen et al (2010) Practice Nursing
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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
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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
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Components of behavioural support
(Behaviour Change Techniques)
Behavioural Change Techniques ...
Address motivation
Enhance self-regulation
Promote adjunctive activities
Support the process
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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
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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’
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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
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Supporting activities
•
•
•
•
Promote continued engagement
Establish and maintain rapport
Collect relevant information
Elicit and address concerns
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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)
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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
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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
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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
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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
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Smoking cessation: Maximising selfregulatory capacity
• Facilitate barrier identification
• Set graded tasks
and problem solving
• Advise on conserving mental
• Facilitate relapse prevention
resources
and coping
• Advise on avoidance of social
• Facilitate action
cues for smoking
planning/develop treatment
• Facilitate restructuring of social
plan
life
• Facilitate goal setting
• Advise on methods of weight
• Prompt review of goals
control
• Prompt self-recording
• Teach relaxation techniques
• Advise on changing routine
• Advise on environmental
Blue: present in 2+ BSPs tested by
restructuring
RCTs; Red: linked to higher success
rates in SSSs; Purple: Blue+Red
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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
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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
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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
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Conclusions
• To improve behavioural support we need to:
– 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
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