How can we improve behavioural support to help people overcome addictions?

1. 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 eachmoment • 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 www.primetheory.com

8. PRIME Theory: where desire fits into that structure www.primetheory.com

9. 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’

10. PRIME Theory: where decision theory fits Decision theory www.primetheory.com

11. PRIME Theory: where learning theory fits Learning theory www.primetheory.com

12. PRIME Theory: where self-control theory fits Self-control theory www.primetheory.com

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 Planning to change Attempting to change I have made a definite plan to change I am in the process of changing 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 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

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

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

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

31. 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 Smoking cessation: Supportive activities: communication 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: • 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