The application of motivational theory to generating assisted quit attempts

1. The application of motivational theory to generating assisted quit attempts Robert West University College London September 2008

2. Aims of the talk • Briefly review main concepts of relevant motivational theories • Introduce a new integrative theory: PRIME Theory • Review practical ways in which this can be applied to promoting quit attempts that use evidence-based assistance

3. The nature and extent of the problem Smoking Toolkit Study: www.smokinginengland.info

4. Current theoretical approaches • Broad theoretical approaches • Learning theory • Decision theory • Personality theory • Integrative theory • Social cognitive theory

5. Learning theory • behaviour is controlled by • anticipated reward and punishment learned by association, often operating outside conscious awareness • interacting with • environmental cues and internal drive states Emphasis on: non-rational processes, the effect of experience, biological drives, habit learning

6. Decision theory • behaviour is controlled by • choices based on comparison of advantages and disadvantages • interacting with • opportunities and ways in which choices are presented (framing) Emphasis on: analysis and inference, conscious decision making, evaluation

7. Personality theory • Behaviour is controlled by • dispositions towards impulsiveness, reward sensitivity, punishment sensitivity, sensation seeking, anxiety, conscientiousness etc. that vary across individuals • interacting with • the immediate environment Emphasis on: individual differences in motivational dispositions that go beyond habit and preferences

8. Social Cognitive Theory • behaviour is controlled by • comparison of expected costs and benefits, shaped in part by goals, self-efficacy, and observing other people’s behaviour • interacting with • self-regulatory capabilities and environmental factors Emphasis on: goals, self-efficacy, social learning, self-regulation and the interaction with the environment

9. The need for an integrated theory ... that • brings together learning theory, decision theory, social cognitive and other approaches • accounts for individual differences in dispositions such as impulsiveness • uses concepts that are readily measurable • provides guidance on what motivational intervention techniques to apply in different situations

10. PRIME Theory • The structure of the motivational system • Dispositions and how they change • The role of identity and self-control • The unstable mind

11. 1: the structure of the motivational system • Behaviour is controlled by • the balance between potentially competing impulses and inhibitions active at the time • which are generated for intentional behaviours by • the strongest of potentially competing motives (‘wants’, ‘needs’ and ‘oughts’) present at the time • which are generated by • imagined futures and associated feelings of pleasure or satisfaction (for wants) and/or relief from or avoidance of discomfort (for needs) • evaluations which are beliefs about what is good or bad, right or wrong, useful or not useful (for oughts) • remembered plans which are more or less specific imagined actions and starting conditions together with a strength of commitment • which are generated by • stimuli in the internal and external environment • interacting with • more or less fluid or stable dispositions

12. The structure of motivation p Plans r Responses i Impulses m Motives e Evaluations

13. 2: dispositions and how they change • Dispositions refer to the propensity of the elements in the motivational system to respond in particular ways to stimuli and other elements • They change over varying timescales through: • habituation and sensitisation • associative learning • storing mental representations • analysis (calculation, deduction, generalisation) • maturation • homeostatic physiological mechanisms • pharmacological and physical ‘insults’ • The change process is variable often involves periods of unstable switching between semi-stable states

14. 3: identity and self-control • Identity refers to the disposition to form mental representations about ourselves and feelings associated with these • It is an important source of motives and evaluations • It includes (but is not limited to): • labels: categories in which we place ourselves • attributes: descriptions of ourselves • rules: plans that apply repeatedly • Self-control: • refers to the application of ‘oughts’ arising from identity • requires and depletes mental energy proportionate to the effort applied • greater effort is required to overcome stronger competing wants and needs

15. 4: the unstable mind • the brain has evolved to be inherently unstable, like a ‘fly-by-wire’ aircraft • this confers great adaptability but: • requires constant ‘balancing input’ to prevent the formation of maladaptive dispositions • has resulted in evolution of a ‘need for order’

16. Key points • Understanding behaviour • Focus on competing motives at the moment in question • Judge these in terms of ‘wants’, ‘needs’ and ‘oughts’ and how these are triggered in the immediate environment • Changing behaviour • Focus on establishing: • strong ‘wants’ as often as possible • clear-cut rules about actions that provide order and tie in closely with core aspects of identity • Move away from a focus on beliefs and gradual movement towards action

17. PRIME Theory applications • Coincide with some existing theories • use personal, moral and financial incentives • foster norms • maximise self-efficacy • focus on feelings • make rules specific • develop identity change

18. Novel implications 1 • GPs should promote assisted cessation without asking first whether smokers are ready to make a quit attempt • PRIME concepts: • dispositional instability • situational responsiveness • need for order • generating positive feelings about the target behaviour

19. Novel implications 2 • Use more communications bursts focusing on generating immediate physical action • PRIME concepts: • providing stability to unstable dispositions • summation of impulses that have brief existence

20. Novel implications 3 • When promoting the services, greater emphasis should be placed on creating a concrete attractive visual image of what it is like to speak to an advisor who will be ‘friendly’, ‘expert’, ‘professional’, and give ‘practical advice’ rather than talking about success rates • PRIME concepts • focus on generating an attractive mental representation rather than changing beliefs • using existing schemata to provide stability to those representations

21. Novel implications 4 • Communications should promote a ‘personal rule’ of ‘at least one quit a year’ and towards the end of the year ask ‘Have you tried this year?’ • PRIME concepts • the importance of rules as sources of motives • increasing sense of order • the importance of raising priority for immediate action

22. Conclusions • Theories of behaviour potentially have much to offer: • but are incomplete, overlapping and do not map well on to the physical world • PRIME Theory: • focuses on: • immediate wants, needs and oughts, and translating these into impulses • generating attractive mental representations, identity and rules as a means of doing this • provides • ideas for practical interventions • hypotheses for future research