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Keywords:

  • Behaviour change;
  • integrative theory;
  • self-management

Theory is the best possible repository of good ideas, and canvassing underused theories for good ideas to alter addictive behaviours is a very worthwhile exercise. Webb and colleagues [1] provide us with a smorgasbord of strategies and cognitive constructs that might be useful. This is designed to complement a set of more used constructs described in West's book [2]. However, if we are to make the most of the feast, it is best to have a strategy to ensure that we do not overfill our plates (too many ideas), take too much of the one thing, or choose things that do not go together. Webb et al. try to provide an organizing frame using their Figure 1 based upon control theory, but this model is one that applies more to the ongoing regulation of reactive behaviour, while their review focuses upon cognitive elements that can be used to alter that functioning. I think an alternative, although complementary, framing is needed.

The essence of addictive behaviours is that they are driven by forces over which the person has limited volitional control—the dependent person knows that they should stop (or moderate) the behaviour, but are either unwilling or unable to do so. The key challenges where cognitive factors might make a difference can be organized around:

  • 1
    Motivational factors: help the person to make what they believe they should do something that they want to do and want to continue to do independent of contingencies; and
  • 2
    Self-regulatory capacity, which includes a range of different domains, to:
    • • 
      ensure that effective planning strategies are used;
    • • 
      weaken the capacity of environmental events and experiences to act as stimuli to engage in the addictive behaviour;
    • • 
      strengthen self-control mechanisms, including both capacity to resist impulses to act, and to invoke self-regulatory processes when needed; and
    • • 
      ensure an adequate repertoire of skills to replace any instrumental functions the drug use served (e.g. stress management, weight control).

Webb et al. provide ideas relevant to all these aspects, except perhaps learning new skills. However, they leave the reader with a great deal of work to do before they can use them.

The review identifies many aspects that relate to motivation, from threat appraisals and subjective norms to outcome expectancies. Someone needs to determine how all these constructs fit together and whether they affect behaviour directly or via intentions. Further, to what extent are constructs such as susceptibility and perceived threat the same, and if they differ, how?

In the area of self-regulation the challenges are similar. They identify three theories that argue for more specific intentions or plans: goal specificity (SMART), implementation intentions, and the TACT approach. How do these differ and, if so, which should we choose? Is there still a role for general overarching goals? Further, it is not clear how self-efficacy fits with the specific self-regulatory strategies; is it simply a summary of the person's confidence in their self-regulatory capacity, or something more?

The authors pick out the self-monitoring element from control theory to highlight the until recently neglected reality that the way in which we think about our experiences affects the way we respond [3], but do not mention other approaches to tackling this issue such as mindfulness techniques for altering the potency of external cues to act compared to internal ones (feelings, memories, etc.).

There is increasing evidence that for hard-to-maintain behaviour change, for example addictions such as smoking, the determinants of trying are different to the determinants of success [4,5]. How do the tools from these theories relate to the two aspects of behaviour change? The data from smoking cessation generally support the predictive value of wanting as a predictor of trying [4], but such motivational variables play much attenuated roles in maintenance. Recently we [6] found that expectancies (primarily around value of smoking, because positive expectancies for being quit did not predict) had their impact on maintenance of cessation attempts via experienced urges to smoke and self-efficacy, the capacity of the self-control mechanisms to resist. It may be that motivational factors are primary for trying, while self-regulatory processes are central to maintenance (although each can clearly also influence the other).

Webb et al. end by urging us to be more systematic in describing the components of interventions that we test. I think that will be easier to undertake if we focus upon the intervention components, rather than the theories from which they originate, and someone conducts a better job of sorting out the sets of equivalent (or near-equivalent) interventions and constructs described differently by the various theories. If the constructs really are different, it would help to define them in terms of how they differ from related ones, but if they are the same, then relabelling them as such.

If we are to get the most out of the feast, we either need a chef who plates up these ideas in ways that maximize their value or we need to put in the effort to organize the possibilities so that we can choose wisely. Taking everything on offer is likely to leave us with indigestion.

References

  1. Top of page
  2. Declaration of interests
  3. References