Transcript Best Practices for Cessation Counseling

Best Practices for
Cessation Counseling
By VJ Sleight, MA, TTS
Goals
• Participants will be confident in providing effective
basic cessation counseling regardless of the time
restraints by understanding the biopsychosocial
motivations of clients who smoke.
• Goals for working with clients:
• Increase motivation and instill hope
• Boost self-efficacy
• Address ambivalence
• Encourage behavioral and social support
Agenda
Best Practices for Cessation:
Five A’s
• Ask, Advise, Assess, Assist, Arrange
Stages of Change Model
• Pre-contemplation, Contemplation, Preparation, Action,
Maintenance, Relapse.
Counseling Methods:
• Motivational Interviewing
• Cognitive-Behavioral Therapy
• Relapse Prevention
Best Practices: Five “A’s”
Assess
Yes/No:
Are you willing to quit right now?
Lickert Scales:
•
On a scale of 1-10, how motivated are you to quit using tobacco at this time?
(1= no motivation, 10 = highly motivated) 1 2 3 4 5 6 7 8 9 10
•
On a scale of 1 -10, how ready are you to set a quit date within the next 30 days?
(1= not at all ready 10 = I’ve already set my date) 1 2 3 4 5 6 7 8 9 10
•
On a scale of 1 – 10, how confident are you that you will not be using tobacco 6 months from
now?
(1= no confidence, 10 = very confident) 1 2 3 4 5 6 7 8 9 10
Open-ended Question:
“How do you feel about quitting?”
• “I don’t want to quit!?!”
• “I want to quit but….”
• “I’m ready, help me.”
(Pre-Contemplation)
(Contemplation)
(Preparation)
PreContemplation
No intention of changing
behavior
Contemplation
Relapse
Aware a problem exists,
not ready to commitment
to action
Fall back on old behavior
Stages of Change
Maintenance
Preparation
Sustained change, new
behavior replaces old
Intent on taking action
Action
Effective modification of
behavior
Assess and Assist
Intent to Quit
No Intent to Quit
Quit Smoking
Pre contemplation – Contemplation – Preparation – Action – Maintenance
Consciousness-Raising
Social Liberation
Emotional Arousal
Self-Reevaluation
Commitment
Reward
Countering
Environmental Control
Helping Relationships
Motivational Interviewing: A client centered
(Stage two)
method to enhance intrinsic motivation to change by exploring and
resolving ambivalence. (Stage 1)
Cognitive – Behavioral Therapy: Focus on
coping by thinking differently and acting different
Relapse Prevention: Help individuals
maintain healthy behavior by anticipating and coping
with relapse.
• Spend more money
• Health gets worse
• Bad role model
• Continue to stink
• Less energy
• More burn holes
• Can’t breath
• Spouse continues to nag
• Helps me concentrate
• Relieves my stress
• Controls my weight
• I enjoy smoking.
• It fills up time.
•
It relaxes me
•
All my friends smoke
Consequences of
Continuing to Smoke
Benefits of Continuing
to Smoke
Precontemplation
Contemplation
Benefits of Becoming
Smoke-free
• Save money
• Have better health
• Better role model
• Smell better
• More energy
• No more burn holes
• Breathe better
• Get along better with spouse
Consequences of
Quitting
Preparation
• Withdrawals
• I don’t know what to do when
stressed
• I might gain weight
• What will I do with my time?
• What to I say to my smoking
friends?
• Listen for disadvantages
of status quo
• Use Motivational
Interviewing to create
and/or address
ambivalence
• Reframe as a Benefit of
becoming smoke-free
• Reframe as a
•
consequence of
•
quitting
Consequences of
Continuing to Smoke
Precontemplation
Benefits of Continuing
to Smoke
Contemplation
Benefits of Becoming
Smoke-free
• Listen for advantages
of change
• Contrast smoking with
internal values
Consequences of
Quitting
Preparation
•
Listen for
optimism and
willingness to change.
• May use Cognitivebehavioral tools
Assist:
Building Motivation:
Personal and relevant
Assist:
Motivational Interviewing
• Communication style: Guide instead of
direct, or follow.
• Spirit of MI: Collaborative, evocative,
honors client’s autonomy
M. I. Strategies
• Express Empathy
• Develop Discrepancy
• Roll with Resistance
• Support Self-efficacy
M. I. Tools
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•
•
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OARS
Ask Open ended questions (door
openers)
Affirm (Acceptance facilitates change)
Listen Reflectively (Decreases
resistance)
Summarize (Client feels heard)
Listen for Change Talk
• Benefits of change (motivation)
• “I want to, I’d like to, I wish…”
• Disadvantages of status quo (motivation)
• “I ought, I should, I have to…..
• Optimism of ability (confidence)
• “I can, I could, I might be able….”
• Intent to quit (willingness)
• “I’m going to, I will
Assess and Assist
Intent to Quit
No Intent to Quit
Quit Smoking
Pre contemplation – Contemplation – Preparation – Action – Maintenance
Motivational Interviewing: A client centered
(Stage two)
method to enhance intrinsic motivation to change by exploring and
resolving ambivalence. (Stage 1)
• Ask open ended questions
• Listen to the answer
• Summarize/reframe
Cognitive – Behavioral Therapy:
Repeat
coping by thinking differently and acting different
Focus on
Assist: Set a Quit Date
•Within 30 days.
•Plan around important social events (ie Superbowl).
•Decide which is better: a week-day or on the weekend.
•The night before: Flush and Crush all remaining cigarettes.
•Have a plan written down.
Assist:
Cognitive-Behavioral Therapy
Focus is on immediate problems in a structured
format, with the goal of coping by thinking and
acting differently.
Treatment elements:
• Support and encouragement
• Practical counseling in problem solving skills
and skills training
Assist:
Cognitive-Behavioral Therapy
Cognitive tools:
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•
•
•
•
•
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Think about positive health benefits or negative consequences of
smoking
Review commitment
Distraction/refocus thoughts
Positive self-talk
Relaxation through imagery
Mental rehearsal
Visualization
Behavioral tools:
•
•
•
•
Substitution (countering; Active diversion such exercise, and/or
relaxation techniques)
Reward
Environmental control
Helping relationships (supportive environment)
Assist: Common Elements
Recognize Danger Situations
Develop Coping Skills
Creating a Smoking Corner
• Make a smoking corner:
• Away from all household activities., outside someplace you don’t
normally smoke.
• In your smoking corner, don’t do anything else except smoke.
• The purpose is not to multi-task but to be conscious of what you are
doing.
• If you are driving when it is your “time” to smoke, pull over to a
safe area; get out of your car to smoke.
• Don’t smoke with other people. If your work place has a designated
smoking area, try to only go there at your time to smoke, do not talk to the
other smokers and leave as soon as the butt is put out.
Smoke by the Clock
• Smoke by the clock. Don’t smoke whenever you want to but let the
clock dictate when you smoke. Choose a time schedule so you smoke
often enough to not have strong withdrawals or cravings.
•
•
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Smoking a pack a day is one cigarette every hour;.
10 cigarettes a day is every two hours;.
Two packs a day is every half hour.
• Don’t try to cut down; the purpose is to learn new behaviors while
your brain is still calm by smoking and to break your old
associations.
• When it is your “time” to smoke, go to your smoking corner, stand
and smoke (unless you have a physical challenge).
• If you don’t feel the need to smoke when it is your time to smoke, you
don’t have to but you can’t have another cigarette until it is your next
time to smoke.
Creating a Personalized Action Plan
Supportive Environment
Assess and Assist
Intent to Quit
No Intent to Quit
Quit Smoking
Pre contemplation – Contemplation – Preparation – Action – Maintenance
Consciousness-Raising
Social Liberation
Emotional Arousal
Self-Reevaluation
Commitment
Reward
Countering
Environmental Control
Helping Relationships
Motivational Interviewing: A client centered
(Stage two)
method to enhance intrinsic motivation to change by exploring and
resolving ambivalence. (Stage 1)
Cognitive – Behavioral Therapy: Focus on
coping by thinking differently and acting different
Relapse Prevention: Help individuals
maintain healthy behavior by anticipating and coping
with relapse.
Relapse Prevention
• Short Term
• Manage withdrawal symptoms
• Ritual replacement (habits)
• Long Term
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•
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•
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Stress, negative emotions
Weight gain
Positive social events or situations
Alcohol
Being around other smokers
Seven FDA Approved Medications
• Nicotine Replacement
•
•
•
•
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Gum
Lozenge/mini-lozenge
Nasal Spray-Rx only
Inhaler-Rx only
Patch
• Non-Nicotine
• Zyban (bupropion)
• Chantix (varenicline)
Questions?
•
Suggested reading
• 2008 Treating Tobacco Use and Dependence, Clinical Practice
Guideline.
http://www.surgeongeneral.gov/tobacco/treating_tobacco_use08.pdf
• Miller, and Rollnick. (2002). Motivational Interviewing. The Guilford
Press: New York.
• Rollnick, Miller, & Butler. (2008). Motivational Interviewing in
Health Care. The Guilford Press: New York.
• Prochaska, Norcross, DiClemente, (1994). Changing for Good. Avon
Books: New York.
• Sleight. (2010). Tips to Win at Quitting. E-book .
• Sleight. (2013 est.). Selling Good Health. E-book.