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The PRIME Theory of Motivation as a Possible Foundation for Addiction Treatment in the 21st Century
- By Robert West
- Published 07/1/2008
- Addiction Research
- Unrated
Robert West
Robert West, PhD is a Professor at University College London. His main research areas are nicotine and tobacco use, with other interests in addiction, traffic accidents and health-related behaviour. He is author of the book Theory Of Addiction - also see his website
Self-awareness is a prerequisite for self-control. According to the PRIME theory, self-control consists of the operation of evaluations and motives that stem from self-awareness. In order to exercise self-control to stop myself doing something, I must be aware of myself and my desires must include myself in that mental representation.
Non-self-conscious inhibition of a response (for example, because of a distracting or shock stimulus) would not count. Self-control is therefore based on a desire or evaluation concerning oneself (e.g., I want to be a nonsmoker).
This has some important and non-obvious implications.
For example, if thinking about myself is distressing, I will be less inclined to entertain self-awareness and hence less likely to exercise self-control.
Under the theory, self-control requires mental effort, which in turn requires reserves of mental energy. Like physical energy this becomes depleted through use.
Theme 5: The unstable mind. The fifth unifying theme is application of “chaos theory” to the motivational system. Human motivation is much more like a weather system than it is like domestic plumbing. Motivation is inherently unstable and kept more or less in check by constant balancing input. It is continually inclined to head off down a new path unless it is kept on course.
Chaos theory is a mathematical system for explaining, among other things, how systems can at one time appear to be deeply entrenched in a particular pattern of activity but suddenly switch to another. It explains how the tiniest of influences at a critical time can send the system down an ever-deepening rut. It deals with predicting over a period of time what is unpredictable at any given moment in time.
The single most useful concept for our purposes is Waddington’s visual model of the “epigenetic landscape” (originally developed to model embryological development; Waddington 1977). Waddington’s image suggests a way of modeling how environmental influences interact with the structure of the motivational system to generate behaviors (Figure 2).
Figure 2.2. An example of Waddington's epigenetic landscape. The state of a system at a given time is represented by the position of a ball in the landscape. The landscape itself unfolds and represents potential paths down which systems may develop while environmental forces move the ball laterally in that landscape. Small forces at critical moments can send the system down an ever-deepening valley. Once in that valley, large and/or sustained forces are needed to move it into a different one.
What PRIME Theory Means for addiction
Addiction metastizes into the whole motivational system. Because of the causal links between different elements in the motivational system, there will be many cases (probably the large majority) in which the distortion in priorities involves multiple levels. Strong habits are supported by and support powerful desires and these are justified by firmly held beliefs. In a “mature” addiction it will be rare that a single rogue element in the system is responsible for the addictive pattern of behavior, even though it may have been necessary for its initiation.
It is unhelpful to categorize addicts in terms of “stage of change.” Motivation to attempt to “give up” or “control” an addictive behavior pattern is fluid and highly situationally determined. Even small triggers can lead to sudden conversion-like transformations of the system, which then lead to lasting change. To label individuals in terms of their “stage of change” (Prochaska et al, 1992) is fundamentally to misrepresent the process of motivation to change addictive behaviors (West, 2005).
Clinical assessment of addicts can usefully be structured around the five themes of PRIME theory. The purpose of clinical assessment is to provide a basis for prognosis and treatment. The therapist needs to be aware of the prospects for the addict of cure, suppression, or management of the condition.
Based on the five themes outlined above, assessment should: 1) encompass all relevant levels of motivation to gain an understanding of how far the distortions in the motivational system has become manifest in impulses, desires, evaluations, and plans; 2) delineate the pattern of environmental triggers acting on the addict to determine the momentary environmental influences that pose a threat to change; 3) determine the results of neural plasticity in terms of acquired habits, drives, etc. to determine the importance of implicit and explicit expectancies, habits, and acquired drives in maintaining the behavior; 4) establish the involvement of identity to assess the barriers to exercise of self-control and how far embedded the addiction is in the addict’s/patient’s self-concept: and 5) evaluate the susceptibility of the addict to possible intervention strategies to determine what are the realistic prospects for shifting the state of the motivational system to a new pathway.
The treatment program needs to involve multiple components targeted at all the modifiable distortions in the motivational system. Because addiction will usually involve distortions across the whole system, the treatment program needs to address all elements that can be affected, for as long as is necessary either to achieve a cure or to suppress the addiction. In most cases, a cure is probably unrealistic because habits, acquired drives, expectancies, and sense of identity are too deeply established and because whatever personal and environmental characteristics made the individual susceptible to the development of addiction usually remain in place.
The focus needs to be on identifying the most appropriate targets for change, bearing in mind resources and ethical and practical limitations. Both medication and psychological techniques should be considered. Medications might be used to reduce acquired drive states, discomfort associated with abstinence, and emotional states that undermine self-control, as well as to mitigate generalized impulse control problems and to block selectively the reward provided by the activity.
Psychological techniques can be used to try to engender a radical change in identity—a kind of conversion experience leading to a fundamental change in the evaluations underpinning the addiction, and to try to engender new habits of thought, feeling and behavior. A third possibility is to reshape the addict's social and physical environment as far as possible to minimize the immediate triggers for the behavior, increase rewards for exercising control and disincentives for the addictive behavior, and provide distractions.
Many current approaches, such as nicotine replacement therapy and motivational interviewing, each address some of these targets; PRIME theory provides a principled basis for combining different treatment elements to achieve maximum effect and, where resources are limited, for choosing which target elements of the motivational system to focus on in which cases.
Making New Men and Women
In all this, we need to recognize that except in rare cases we are not carrying out the psychological equivalent of surgically removing a tumor from an otherwise healthy body. We are seeking to reshape the addict's motivational system—to change the addict as a person.
In some cases this may go to the root of his or her being. Perhaps we had better hope that our techniques for doing this never become too successful because in the wrong hands ...
References
Brown SA, Christiansen BA, et al. The Alcohol Expectancy Questionnaire: an instrument for the assessment of adolescent and adult alcohol expectancies. J Stud Alcohol. 1987;48(5):483-91.
Jellinek EM. The Disease Concept of Alcoholism. New Brunswick, NJ: Hillhouse Press, 1960.
Kearney MH, O'Sullivan J. Identity shifts as turning points in health behavior change. West J Nurs Res. 2003;25:134-152.
Lingford-Hughes AR, Welch S, et al. Evidence-based guidelines for the pharmacological management of substance misuse, addiction and comorbidity: recommendations from the British Association for Psychopharmacology. J Psvchopharmacol. 2004;18(3):293-335.
Lubman DI, Yucel M, et al. Addiction, a condition of compulsive behavior? Neuroimaging and neuropsychological evidence of inhibitory dysregulation. Addiction. 2004;99(12):1491-502.
O'Brien CP, Childress AR, et al. A learning model of addiction. Res Publ Assoc Res Nerv Ment Dis. 1992;70:157-177.
Prochaska JO, DiClemente CC, et al. In search of how people change. Applications to addictive behaviors. Am Psychol. 1992;47(9):1102-14.
Skog OJ. Addicts' choice. Addiction. 2000;95(9):1309-14.
Toneatto T, Millar G. Assessing and treating problem gambling: empirical status and promising trends. Can J Psychiatry. 2004;49(8):517-25.
Waddington C. Tools for Thought: How to Understand and Apply the Latest Scientific Techniques of Problem Solving. New York, NY: Basic Books, 1977.
West R. Time for a change: putting the Transtheoretical (Stages of Change) Model to rest. Addiction. 2005;
West R. Theory of Addiction. Oxford, England: Blackwells, 2006.
~~~
This is Chapter 2 from his book Theory Of Addiction
Related site: PRIME Theory of Motivation
Non-self-conscious inhibition of a response (for example, because of a distracting or shock stimulus) would not count. Self-control is therefore based on a desire or evaluation concerning oneself (e.g., I want to be a nonsmoker).
This has some important and non-obvious implications.
For example, if thinking about myself is distressing, I will be less inclined to entertain self-awareness and hence less likely to exercise self-control.
Under the theory, self-control requires mental effort, which in turn requires reserves of mental energy. Like physical energy this becomes depleted through use.
Theme 5: The unstable mind. The fifth unifying theme is application of “chaos theory” to the motivational system. Human motivation is much more like a weather system than it is like domestic plumbing. Motivation is inherently unstable and kept more or less in check by constant balancing input. It is continually inclined to head off down a new path unless it is kept on course.
Chaos theory is a mathematical system for explaining, among other things, how systems can at one time appear to be deeply entrenched in a particular pattern of activity but suddenly switch to another. It explains how the tiniest of influences at a critical time can send the system down an ever-deepening rut. It deals with predicting over a period of time what is unpredictable at any given moment in time.
The single most useful concept for our purposes is Waddington’s visual model of the “epigenetic landscape” (originally developed to model embryological development; Waddington 1977). Waddington’s image suggests a way of modeling how environmental influences interact with the structure of the motivational system to generate behaviors (Figure 2).
Figure 2.2. An example of Waddington's epigenetic landscape. The state of a system at a given time is represented by the position of a ball in the landscape. The landscape itself unfolds and represents potential paths down which systems may develop while environmental forces move the ball laterally in that landscape. Small forces at critical moments can send the system down an ever-deepening valley. Once in that valley, large and/or sustained forces are needed to move it into a different one.
What PRIME Theory Means for addiction
Addiction metastizes into the whole motivational system. Because of the causal links between different elements in the motivational system, there will be many cases (probably the large majority) in which the distortion in priorities involves multiple levels. Strong habits are supported by and support powerful desires and these are justified by firmly held beliefs. In a “mature” addiction it will be rare that a single rogue element in the system is responsible for the addictive pattern of behavior, even though it may have been necessary for its initiation.
It is unhelpful to categorize addicts in terms of “stage of change.” Motivation to attempt to “give up” or “control” an addictive behavior pattern is fluid and highly situationally determined. Even small triggers can lead to sudden conversion-like transformations of the system, which then lead to lasting change. To label individuals in terms of their “stage of change” (Prochaska et al, 1992) is fundamentally to misrepresent the process of motivation to change addictive behaviors (West, 2005).
Clinical assessment of addicts can usefully be structured around the five themes of PRIME theory. The purpose of clinical assessment is to provide a basis for prognosis and treatment. The therapist needs to be aware of the prospects for the addict of cure, suppression, or management of the condition.
Based on the five themes outlined above, assessment should: 1) encompass all relevant levels of motivation to gain an understanding of how far the distortions in the motivational system has become manifest in impulses, desires, evaluations, and plans; 2) delineate the pattern of environmental triggers acting on the addict to determine the momentary environmental influences that pose a threat to change; 3) determine the results of neural plasticity in terms of acquired habits, drives, etc. to determine the importance of implicit and explicit expectancies, habits, and acquired drives in maintaining the behavior; 4) establish the involvement of identity to assess the barriers to exercise of self-control and how far embedded the addiction is in the addict’s/patient’s self-concept: and 5) evaluate the susceptibility of the addict to possible intervention strategies to determine what are the realistic prospects for shifting the state of the motivational system to a new pathway.
The treatment program needs to involve multiple components targeted at all the modifiable distortions in the motivational system. Because addiction will usually involve distortions across the whole system, the treatment program needs to address all elements that can be affected, for as long as is necessary either to achieve a cure or to suppress the addiction. In most cases, a cure is probably unrealistic because habits, acquired drives, expectancies, and sense of identity are too deeply established and because whatever personal and environmental characteristics made the individual susceptible to the development of addiction usually remain in place.
The focus needs to be on identifying the most appropriate targets for change, bearing in mind resources and ethical and practical limitations. Both medication and psychological techniques should be considered. Medications might be used to reduce acquired drive states, discomfort associated with abstinence, and emotional states that undermine self-control, as well as to mitigate generalized impulse control problems and to block selectively the reward provided by the activity.
Psychological techniques can be used to try to engender a radical change in identity—a kind of conversion experience leading to a fundamental change in the evaluations underpinning the addiction, and to try to engender new habits of thought, feeling and behavior. A third possibility is to reshape the addict's social and physical environment as far as possible to minimize the immediate triggers for the behavior, increase rewards for exercising control and disincentives for the addictive behavior, and provide distractions.
Many current approaches, such as nicotine replacement therapy and motivational interviewing, each address some of these targets; PRIME theory provides a principled basis for combining different treatment elements to achieve maximum effect and, where resources are limited, for choosing which target elements of the motivational system to focus on in which cases.
Making New Men and Women
In all this, we need to recognize that except in rare cases we are not carrying out the psychological equivalent of surgically removing a tumor from an otherwise healthy body. We are seeking to reshape the addict's motivational system—to change the addict as a person.
In some cases this may go to the root of his or her being. Perhaps we had better hope that our techniques for doing this never become too successful because in the wrong hands ...
References
Brown SA, Christiansen BA, et al. The Alcohol Expectancy Questionnaire: an instrument for the assessment of adolescent and adult alcohol expectancies. J Stud Alcohol. 1987;48(5):483-91.
Jellinek EM. The Disease Concept of Alcoholism. New Brunswick, NJ: Hillhouse Press, 1960.
Kearney MH, O'Sullivan J. Identity shifts as turning points in health behavior change. West J Nurs Res. 2003;25:134-152.
Lingford-Hughes AR, Welch S, et al. Evidence-based guidelines for the pharmacological management of substance misuse, addiction and comorbidity: recommendations from the British Association for Psychopharmacology. J Psvchopharmacol. 2004;18(3):293-335.
Lubman DI, Yucel M, et al. Addiction, a condition of compulsive behavior? Neuroimaging and neuropsychological evidence of inhibitory dysregulation. Addiction. 2004;99(12):1491-502.
O'Brien CP, Childress AR, et al. A learning model of addiction. Res Publ Assoc Res Nerv Ment Dis. 1992;70:157-177.
Prochaska JO, DiClemente CC, et al. In search of how people change. Applications to addictive behaviors. Am Psychol. 1992;47(9):1102-14.
Skog OJ. Addicts' choice. Addiction. 2000;95(9):1309-14.
Toneatto T, Millar G. Assessing and treating problem gambling: empirical status and promising trends. Can J Psychiatry. 2004;49(8):517-25.
Waddington C. Tools for Thought: How to Understand and Apply the Latest Scientific Techniques of Problem Solving. New York, NY: Basic Books, 1977.
West R. Time for a change: putting the Transtheoretical (Stages of Change) Model to rest. Addiction. 2005;
West R. Theory of Addiction. Oxford, England: Blackwells, 2006.
~~~
This is Chapter 2 from his book Theory Of Addiction
Related site: PRIME Theory of Motivation
