Wednesday, 28.10.2020

Peter R. Martin: Historical Vocabulary of Addiction




        The noun motivation, according to the current electronic version of Oxford English Dictionary (OED), was formed within English by derivation modelled on a German lexical item, Motivierung (a noun meaning motivation or motive).  Thus, motivation is a combination of the verb motive and the suffix -ation (the particular form of the compound suffix which forms nouns of action from Latin participles).  The verb motive was formed within English, by conversion of the noun motive; the noun has multiple origins, as it is partly borrowed from French (motif), Latin (motivum) and Anglo-Norman (motif, motive).  The noun motive first appeared in the English language circa 1390 with a currently obsolete meaning (“An impression or apprehension that prompts a person to action; a counsel; a prompting or suggestion; specifically, a divine or angelic prompting.”) as in Chaucer (c. 1340s–1400), the English poet and author of the Middle Ages best known for The Canterbury Tales (1904): “This gentil kyng hath caught a gret motyf Of this witnesse.”  Clearly this original meaning is a prompt or demand to action from an objectifiable outside entity, whereas in the current usage, an intrapsychic call to act, is more due to interoceptive cues or an internalized perception of the environment.   The OED definition that seems most relevant to the field of addiction is: “A circumstance or external factor inducing a person to act in a certain way; a desire, emotion, reason, argument, etc., influencing or tending to influence a person's volition.  Also: a contemplated end the desire for which influences or tends to influence a person's actions.”  This meaning was used circa 1439 by John Lydgate (c. 1370–1449), the English monk and poet, known for his prodigious poetic output (Lydgate and Bergen 1923): “In this purpos, he... Ches for to deie… And to preferre… The comoun proffit: this was his motiff.”  A contemporary meaning of motive compatible with use in addiction is even more evident in a quotation of John Locke (1632–1704), the English philosopher and physician, widely regarded as one of the most influential of Enlightenment thinkers: “The motive to change, is always some uneasiness... This is the great motive that works on the Mind to put it upon Action…” 

        The definition in OED of motivation as used in addiction is: “The (conscious or unconscious) stimulus for action towards a desired goal, especially, as resulting from psychological or social factors; the factors giving purpose or direction to human or animal behaviour… the reason a person has for acting in a particular way, a motive.” An example of this meaning of motivation can be found in the first issue of the Princeton Review (1879): “Even psychological determinism is displaced by rigid mechanical necessity, and objective motivation is always real physical impulsation.”  The underlying hypothetical construct that the organism is propelled toward use of psychoactive agents or engagement in other self-destructive and out-of-control behaviors via a multi-factorial process termed motivation has continued to this day. As mechanistic explanations of relevant contributing factors to motivation are actively sought through current models of behavior merged with neuroscience, it has become evident that its modification is essential if such propulsive forces toward active addiction are to be diminished, diverted or stopped (Marlatt, Baer, Donovan and Kivlahan 1988; Heilig, Epstein, Nader and Shaham 2016; Lepack, Werner, Stewart et al. 2020).

        The concept of motivation has its origins in philosophical thought, namely the study of metaphysical questions such as the processes and causations underlying the relationship between mind and body.  By the 20th century, studies of motivation emerged as a founding principle of the relatively new discipline of psychology, in which the term came to encapsulate “all determinants of behavior” (Young 1936).  Since addiction is fundamentally expressed through behavior (Martin 2016), motivational psychology (Madsen 1973) and its underpinnings in neuroscience (Kalivas and Volkow 2005) have become the foundation upon which our understanding of the disorder has been built.  The scientific revolution launched by Charles Darwin (1809–1882), the English naturalist, biologist and geologist best known for contributions to the scientific discipline of evolution (1859), introduced a perspective that allowed the behavior of humans to be examined by comparison to those of other species from which they evolved. This has led to enrichment of the study of human motivation to include explanatory terms derived from studies of behavior in animals, such as drive, need, instinct, force, incentive, valence, salience, among many others.  Madsen (1973) described how modern motivational psychology emerged and evolved from Darwinian thinking.  Three seminal contributions to this new motivational perspective of human behavior originated from the works of the following innovators: William McDougall (1871–1938), a British-American psychologist whose “instinct” theories buttressed social psychology (1908); Edward Thorndike (1874 –1949), the American educational psychologist whose learning theories developed from studies in experimental psychology (1905); and Sigmund Freud (1856 –1939), the Austrian neurologist and founder of psychoanalysis whose studies led to an appreciation of personality theories and “drives” underpinning behaviors (2001).  

        Learning forms the mechanistic underpinnings of addiction and conditioning has emerged as a heuristically useful behavioral technique for understanding and experimentally modelling components of the disorder and its treatment (Martin 2019).  Elucidating the linkages between learning and motivation has become an essential element in comprehensive understanding of addiction as a pharmacopsychosocial disorder (Solomon 1980; Marlatt, Baer, Donovan and Kivlahan 1988; Venniro, Zhang, Caprioli et al. 2018).  Perhaps the most valuable consequence of incorporating motivation into our understanding of addiction is the identification of experiential elements of the disorder that may be modifiable and incorporated into treatment (Miller 1983; Prochaska and DiClemente 1983).  To motivation we attribute why individuals act as they do.  Therefore, only by better understanding the psychic forces that contribute to approach and avoidance behaviors of individuals within their environment (Martin, Weinberg and Bealer 2007), might we hope to modify the out-of-control and self-destructive behaviors that constitute addiction.  Stated otherwise and incorporating the motivating notion of craving (Martin 2020a): “The treatment forces and motivation together must be stronger than the craving if there is to be any chance of success (Bejerot 1972).”

        The treatment approaches that are currently most well-supported by experimental evidence have as their focus enhancement of the motivation to achieve recovery from addiction either through mutual support groups or individual psychotherapeutic approaches (Martin 2020b).  A heuristic behavioral model that has become widely promulgated throughout medicine and has demonstrated efficacy in treatment of addiction was proposed by Prochaska and DiClemente (1983).   In this model, they describe how therapeutic modification of addictive behaviors involves progression of the patient through five stages of change (in essence, stages of motivation to change): precontemplation, contemplation, preparation, action, and maintenance.  Through the course of treatment, individuals typically recycle through these stages several times before recovery of extended duration is accomplished.  To facilitate individuals through these stages of change, Miller (1983) implemented a psychotherapeutic approach he coined motivational interviewing, based upon principles of experimental social psychology, applying processes such as attribution, cognitive dissonance, and self-efficacy in which motivation is conceptualized not as a personality trait but as an interpersonal process.  

        Whether pharmacologic interventions can actually enhance progression through the stages of motivation to change in order to achieve recovery has not been formally investigated.  Suffice it to say, this is a somewhat different question from the significant research that is now available on reduction of alcohol/drug use with pharmacotherapy resulting in harm reduction (Martin 2020b).  However, the goal of significant restructuring of motivation and behavior to enhance progression to true recovery can be achieved by judicious parallel use of pharmacological and psychosocial strategies (Martin, Weinberg and Bealer 2007).  For example, treatment of opioid use disorder with the partial mu-opioid agonist buprenorphine allows the patient who suffers from severe opioid use disorder to awake each morning without the thought of having to look for the next “fix,” thus allowing enhanced self-efficacy and the motivation to face and modify life challenges which are the antecedents of true recovery.  Similarly, a patient suffering from bipolar disorder and accompanying poor judgement, resulting in addiction, may become more motivated to engage in behavioral changes needed for recovery if his/her psychopathology can be regulated by pharmacotherapy with lithium.  Although there are ample examples from behavioral pharmacology of altering motivational systems that contribute to drug self-administration (Bardo, Neisewander and Kelly 2013; Berridge and Robinson 2016; Bohus 1979; Lepack, Werner, Stewart et al. 2020; Volkow, Wise and Baler 2017), the major challenge in motivational research is how to augment psychological enhancements with pharmacotherapeutic approaches and vice versa.  It remains to be determined whether these two foundational constituents of behaviors that comprise addiction are, at this time, structurally compatible so as to be combined with the appropriate stoichiometry to reliably enhance therapeutic change in motivation and ultimately, the behavioral repertoire.



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September 10, 2020