Fact and theory in recovery from addiction

1. Fact and theory in recovery from addiction Robert West University College London

2. Outline • Key facts about addiction and recovery • Theory of addiction and recovery • Application to behvioural support for smoking cessation

3. What is 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. What are the presumed mechanisms? • Stimulus-impulse 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

6. What is recovery from addiction? • Recovery occurs when an individual no longer experiences powerful motivations to engage in an addictive activity to an extent that is harmful

7. 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

8. 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

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 Capability Psychological or physical ability to enact the behaviour Behaviour Motivation Reflective and non-reflective mechanisms that activate or inhibit behaviour Opportunity Physical and social environment that enables the behaviour

11. The Behaviour System: CMOB Capability, motivation and opportunity must be present for a behaviour to occur Capability Behaviour Motivation Opportunity 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. The structure of human motivation Lighting up a cigarette Taking a puff on a cigarette Saying no to offer of a cigarette • Starting, stopping or modifying actions • Generated by the strongest of competing impulses and inhibitions at that moment

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 Want to smoke Need a cigarette Want to stop smoking • 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

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. Maturation Associative learning Habituation Sensitisation Communication Imitation Perception Inference Chemical ‘insult’ Physical ‘insult’ How elements of the system change

21. 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

22. Promoting and sustaining change • Identify what components of the CMOB system to target • Select one of more types of intervention • If necessary select one or more type of policy to enact the interventions • Identify specific ‘behaviour change techniques’ (BCTs) to implement the interventions

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

24. 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

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

26. 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) Addressing motivation Blue: present in 2+ BSPs tested by RCTs; Red: linked to higher success rates in SSSs; Purple: Blue+Red

27. 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 Maximising self-regulatory capacity Blue: present in 2+ BSPs tested by RCTs; Red: linked to higher success rates in SSSs; Purple: Blue+Red

28. 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 Promote use of adjunctive activities Blue: present in 2+ BSPs tested by RCTs; Red: linked to higher success rates in SSSs; Purple: Blue+Red

29. 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 Supportive activities: general and assessment Blue: present in 2+ BSPs tested by RCTs

30. 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 Supportive activities: communication Blue: present in 2+ BSPs tested by RCTs; Red: linked to higher success rates in SSSs

31. Conclusions • Recovery from addiction is related to a wide range of psychological and environmental factors • Explaining these requires an integrative theory: • CMOB: The Behaviour System • PRIME Theory of motivation • This can provide a systematic basis for designing interventions, policies and behaviour change techniques to promote recovery

32. www.rjwest.co.uk