Psychological principles underpinning behavioural support

1
Psychological principles underpinning behavioural
support
Robert West

• University College London
• January 2009

2
Sources

• Cochrane reviews
• West R (2006) Theory of Addiction. Oxford
  Blackwells (see also www.primetheory.com)
• Shahab et al (2009) Report to Department of
  Health
• www.treatobacco.net

3
Why behavioural support is often needed

• After the start of the quit attempt smokers
• can experience powerful, frequent and/or
  persistent feelings of desire (want or need) to
  smoke (PRIME Theory)
• reductions in desire to remain abstinent
• reduced capacity to exercise self-control
• Medication can
• reduce the desire to smoke
• But
• there are limits to how much
• smokers often need behavioural support to
  optimise usage and benefits
• behavioural support may be needed to address
  sources of desire to smoke that medication does
  not
• behavioural support may be needed to maximise
  desire not to smoke and capacity for self control

4
Does behavioural support work?

• Systematic reviews show clear benefit from
• Individual face-to-face
• group face-to-face
• telephone-based
• internet-based
• delivered to
• smokers in general
• hospital inpatients
• pregnant smokers
• On average approx 1 in 20 smokers are helped at
  each quit attempt
• Benefit appears to accumulate with successive
  quit attempts
• But there is little evidence on what elements and
  combinations of elements of behavioural support
  are important

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Five key principles

• From PRIME Theory
• Maximise continued desire to maintain engagement
  with behavioural support
• Minimise strength and frequency of desire to
  smoke
• Maximise strength of desire not to smoke when
  needed
• Maximise capacity for self-control when needed
• Maximise effective use of supporting behaviours
  (e.g. medication usage)

6
Ideas for motivating engagement

• Create an image of the next appointment that
  meets wants and needs
• Be appropriately friendly and warm
• Establish credibility as someone who can help
• Make specific arrangements for next contact and
  set up feeling of positive expectation
• Use reminders where appropriate
• Create sense of identity for the person or
  team providing support (e.g. showing knowledge
  from previous session)
• Set up non-threatening opportunity for the client
  to report on experiences

7
Minimise desire to smoke

• Desire stems from
• smoking cues
• nicotine hunger
• unpleasant withdrawal symptoms
• beliefs about benefits of smoking
• Approaches to reducing desire
• avoiding and escaping cues
• distraction
• exercise
• medication
• re-appraisal of negative symptoms
• re-appraisal of beliefs about smoking
• promoting deep identity change

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Maximising desire not to smoke

• Desire stems from
• commitment to new identity as non-smoker
• concerns about harms of smoking
• positive feelings about not smoking
• extrinsic motives (e.g. pleasing the counsellor)
• Approaches to maximising desire
• fostering bond with client
• fostering appropriate new identity
• generating negative images of smoking
• focusing attention on positive feelings
  associated with not smoking

9
Maximising capacity for self-control

• Self-control stems from
• strong commitment to specific rules with clear
  boundaries
• sufficient mental energy
• establishing conditions that minimise temptation
• Approaches to maximising self-control
• establishing specific rules that create as strong
  a sense of external agency as possible
• support the rules with changes to other aspects
  of identity (self-labels and attributes)
• establish rules to minimise competing demands on
  mental energy (e.g. stress, other self-control
  needs)
• establish rules for minimising exposure to
  smoking cues or situations that generate the want
  or need to smoke
• develop skills for monitoring and responding to
  cues and desires

10
Maximising use of supporting behaviours

• Use of supporting behaviours (e.g. medication
  use, exercise) derives from
• high feeling of need for the behaviour
• low concerns over negative effects of the
  behaviour
• good understanding of how and when
• presence of prompts
• Approaches to maximising supporting behaviours
• provide a menu of potential activities with clear
  explanation of what is involved, what needs are
  addressed and how, and address any potential
  concerns
• establish clear rules for when, what and how and
  explain why
• check understanding of the above
• reappraisal of beliefs about supporting
  behaviours

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Behavioural support strategies in use
Brainstorming session by 80 tobacco control
practitioners from gt10 countries at workshop in
2007

• Agreeing a follow up
• Developing social support
• Discussing environmental change
• Developing a personalised plan
• Developing alternative behaviours
• Giving praise
• Structuring the day
• Preparing for potential difficulties

• Assessment
• Setting quit date
• Providing reassurance
• Addressing smokers concerns
• Developing rapport
• Giving CO feedback
• Discussing medication
• Focus on money saved
• Focus on health gains

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Techniques from authoritative sources 1

• Establish smoking history
• Assess past history of quit attempts
• Assess current readiness and ability to quit
• Identify clients reasons for wanting and not
  wanting to stop smoking/ keep stopped
• Provide information on positive or negative
  consequences of behaviour
• Explain expectations
• Provide advice/ information about medication
• Enquire about medication
• Offer incentive of free medication

• Provide information on withdrawal symptoms
• Enquire about withdrawal symptoms
• Provide normative information about others
  behaviour and experiences
• Explain the importance of abrupt cessation
• Goal setting
• Action planning
• Environmental restructuring
• Social restructuring
• Barrier identification and Problem solving

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Techniques from authoritative sources 2

• Relapse prevention and Coping planning
• Provide feedback on performance
• Prompt review of set goals
• Provide Reassurance (unspecified how)
• Boost Motivation/ Self Efficacy
• Elicit and answer questions
• Elicit client views
• Emphasise client choice
• Give client option of additional or later support
• Summarise information / confirm client decisions
• Set graded tasks
• Provide rewards contingent on successfully
  stopping smoking

• Provide rewards contingent on effort or progress
  towards stopping smoking
• Explain the purpose of CO monitoring
• Measure CO
• Build general rapport
• Use reflective listening
• Offer written information
• Prompt self recording
• Provide advice on conserving resources
• Tailor interaction to be appropriate to
  individual clients
• Prompt commitment from the client there and then
• Strengthen ex-smoker identity

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Review

• Behavioural support
• addresses needs that medication does not
• improves usage of medication
• is effective
• needs to focus on
• maximising continued engagement
• minimising desire to smoke
• maximising motivation not to smoke
• maximising capacity for self-control
• optimising use of supporting activities (e.g.
  medication)
• everything hinges on control of moment-to-moment
  desire (wants and needs) to prevent desire to
  smoke exceeding desire not to