Moving beyond ‘brain disease’ and ‘bad choice’ models of addiction

1. Moving beyond ‘brain disease’ and ‘bad choice’ models of addiction Robert West University College London September 2012

2. Aims • To propose a more comprehensive model of behaviour than hitherto that can provide a basis for development and application of improved intervention strategies to combat addiction West R. Models of Addiction. EMCDDA Insight Report

3. Outline • Defining addiction • An overview of models of addiction • A more comprehensive approach

4. The purpose of definitions • To include cases that should be included and exclude those that should not: i.e. to set the boundaries of a concept • To provide as concise a description of a concept as is necessary to help identify cases

5. Addiction as a brain disease

6. Addiction as compulsive behaviour

7. Addiction as choice

8. Addiction as a context-sensitive disorder of motivation

9. Seven things about addiction that need explaining • Most people who are exposed to the addictive substance/behaviour do not become addicted, but low impulse control and/or mood disturbance can increase vulnerability, as can adverse life circumstances • Even determined attempts to cease addictive behaviours have a low probability of success, but unaided recovery does occur • When ‘addicts’ attempt recovery, momentary risk of relapse is greatest in the first few days or weeks • Prevalence of a given addictive behaviour in populations is influenced by price and availability • Social norms substantially influence the chances of becoming addicted and recovery from addiction • Drugs that seek to reduce addictive urges can increase the chances of recovery but often do not • Behavioural interventions that seek to address addictive motivation and/or self-regulatory skills and capacity can increase the chances of recovery but often do not

10. Taxonomy of models of addiction

11. Automatic process theories

12. Reflective choice theories

13. Goal focused theories

14. Integrative theories

15. Process of change and biological theories

16. Population and group-level theories

17. A synthetic model (COM-B+PRIME) Aims to provide • a more comprehensive model of behaviour within which existing models can be understood and compared • a basis for improving existing models • a rational basis for the design of interventions to change behaviour

18. The COM-B model of behaviour Michie et al (2011) Implementation Science

19. The COM-B model of behaviour Physical and psychological capability: knowledge, skill, strength, stamina Michie et al (2011) Implementation Science

20. The COM-B model of behaviour Reflective and automatic motivation: plans, evaluations, desires and impulses Michie et al (2011) Implementation Science

21. The COM-B model of behaviour Physical and social opportunity: availability, prompts, reminders and cues Michie et al (2011) Implementation Science

22. PRIME Theory and the structure of human motivation

23. The rider and the donkey model of behaviour

24. PRIME Theory and Dual Process Theories Affective Reflective Impulsive Reflective Action Action Impulsive

25. PRIME Theory: 1st law of motivation • At every moment we act in pursuit of our strongest motives (wants or needs) at that moment • Want: anticipated pleasure or satisfaction • Need: anticipated relief from, or avoidance of, mental or physical discomfort

26. PRIME Theory: 2nd law of motivation • Evaluations (beliefs about what is good and bad) and plans (self-conscious intentions to do or not do things) can only control our actions if they create motives at the appropriate moments that are stronger than competing motives coming from other sources

27. PRIME Theory: 3rd law of motivation • Self-control (acting in accordance with plans despite opposing motives) requires mental energy and depletes reserves of that energy

28. PRIME Theory: 4th law of motivation • Our identities (thoughts, images and feelings and feelings about ourselves) can be a powerful source of motives • Labels: the categories we think we belong to • Attributes: the features we ascribe to ourselves • Personal rules: imperatives about what we do and do not do

29. PRIME Theory: 5th law of motivation • Motives influence actions by creating impulses and inhibitions, which are also generated by habitual (learned) and instinctive (unlearned) associations; behaviour is controlled by the strongest momentary impulses and inhibitions

30. The battle over time between resolve and urge/impulse When the urge is stronger than resolve and the behaviour is available, a lapse will occur Urge/impulse Time Strength of urge Resolve

31. Stage of change model versus the SNAP model ‘Personal rules’ govern behaviour, and transitions between these rules occur as a result of ‘tension and triggers’ People move through ‘stages’ on the way to achieving lasting change Create motivational tension and triggers to ‘snap’ people into action and then support to prevent them snapping back Move people to the next stage with ‘stage-matched’ interventions’

32. Sources of urges/impulses Triggers Reminders Urge/ impulse Positive beliefs Want or need Acquired drive’

33. Sources of resolve Reminders Resolve to abstain Want or need to abstain Personal abstinence rule Ability to inhibit impulses Beliefs and feelings about the behaviour and abstinence

34. Implications for measurement • Important to separate out: • prevalence of the behaviour precisely defined to match the nature of the problem • intensity of addiction through frequency and strength of the experience of motivation (means and SDs) • severity of addiction in terms of immediate harms • Develop composite measures involving multiple behaviours/substances • Measure motivation to change in terms of: • duty, desire and intention • Use COM-B+PRIME for a comprehensive assessment of the precise nature of the problem for individuals, groups or populations

35. Implications for intervention strategies • Broadens focus beyond just the individual or just the environment • Forces consideration of reflective, emotive and impulsive mechanisms • Provides a perspective that reveals the inappropriateness of debates about disease versus choice models • Provides a systematic system for designing intervention strategies for behaviour change

36. Behaviour Change Wheel Michie S, M van Stratten, West R(2011) The Behaviour Change Wheel: A new method for characterising and designing behaviour change interventions. Implementation Science, 6, 42.

37. The example of comprehensive tobacco control • Educate the population about the harms of smoking, the benefits of stopping and best ways to stop • Use hard hitting campaigns and health professional advice to persuade smokers to try to stop and use the most effective ways of doing this • Where appropriate incentivise quitting • Use tax and social norms to reduce the attractiveness of smoking • Reduce ubiquity of smoking triggers and reminders • Use modelling in social marketing strategies • Provide behavioural and pharmacological support for quitting

38. Conclusions • A broad perspective on addiction is needed to mount effective countermeasures • The synthetic model (COM-B+PRIME) is an attempt to integrate existing models into a single coherent framework • When linked with the Behaviour Change Wheel it provides a basis for designing an intervention strategy that can be effective • However practicability, affordability and acceptability are also key factors that need to be considered