Helping People Change Addictive Behavior: Smoking Cessation as a Model

Andrée Aubrey, LCSW, CTTS and Mary Dailey, CTTSFSU College of Medicine

Area Health Education Center (AHEC)

Learning Objectives:

• Use core MI skills to build rapport, demonstrate respect, and support self-determination and self-efficacy for change

• Use reflective listening to skills to more fully understand client perspectives about “the problem” and potential strategies to address those problems

• Elicit and selectively respond to client motivational statements and “change talk”

What do we say next?

What would you say to this patient?

Typical Tobacco Cessation Counseling

Problems with Traditional Approach• Focuses on “fixing” the problem • Assumes knowledge and information are keys to

motivating behavior change • “Teaches” clients how to make the desired change • Deficit model: “I have what you need, and I am

going to give it to you.” – If you make people feel bad enough, they will change

• Often leads to a “Yes, but…” tug of war

Motivational Interviewing is an evidence-based intervention for tobacco users WHO

ARE NOT YET READY TO QUIT.

You can lead a horse to water but you cannot make

him drink!

However, you can increase his thirst.

MI Interventions “salt the oats.”

What is Motivational Interviewing?• A collaborative conversation style for strengthening a

person’s own motivation and commitment to change. (lay-person)

• A person-centered counseling style for addressing the common problem of ambivalence about change. (practitioner)

• A collaborative, goal-oriented style of communication w/ particular attention to the language of change. It is designed to strengthen personal motivation for and commitment to a specific goal by eliciting and exploring the person’s own reasons for change within an atmosphere of acceptance and compassion. (technical)

Underlying Theory of MI

• People are ambivalent about making changes

• When the clinician advocates for change, it will evoke resistance from the person

• Resistance predicts lack of change

• Getting the person to talk about making the change makes it more likely that he/she will do it

Core Skills – OARS • Give a brief structuring statement or ask

permission • MI skills:

– Open ended questions– Affirmations – Reflective listening– Summaries and

• Informing/ Advising

Using Open-ended Questions

Open Ended Questions: Eliciting Change Talk

• Sample open-ended questions

– “What worries you about your smoking?”

– “How would you like for things to be different?”

– “What are the main reasons you have for wanting to quit?”

– “What is there about your ________ that other people might see as a problem?”

– “What makes you think that if you decided to make a change, you could do it?”

Affirmations• Statement of appreciation and understanding

– Builds rapport and conveys respect for the person’s struggles, feelings, achievements, humanity

– Reinforces open exploration– Promotes self-efficacy for change

• Responding to change talk:

– “That is very insightful, and not something I would have noticed.”

– “You are feeling bad because you started smoking again. But what strikes me is that you were able to abstain completely for 4 days and now you are only smoking 3-4 cigs a day.”

Reflective Statements

Clinician

• Practice good listening

• Encourage more talking and exploring

• Avoid a premature focus on solutions

• Strengthen change talk

• Elicit more change talk

Person

• Listen to one’s own reasons

• Hear how the behavior fits into one’s life

• Ability to reflect on one’s experiences

• Freedom to explore the desire or reasons for change in a safe environment

It is not repetition, it is revelation!

Recognizing “Change Talk”Preparatory Change Talk:

• Desire to change: “I would really like to quit smoking.”

• Ability to change: “I think I could start cutting back.”

• Reasons for change: “I’d save some money if I quit.”

• Need to change: “I have to quit or my asthma is just going to get worse.”

DARN

Recognizing “Change Talk”

Mobilizing Change Talk: • Commitment to change: “I will call the quit-

line this week.” • Activation: “I’m ready to call the quit-line and

find out more about using NRT (Nicotine Replacement Therapy).”

• Taking steps: “I’ve stopped smoking in my car and cleaned out all the cigarette packs in the glove compartment.”

CAT

DARN CAT

Reflective Listening

• Use a down-turn in inflection• Make statements, vs. asking questions

– “You don’t think this is a problem?”– “You don’t think this is a problem”

• Focus on change talk

• ROLL with Sustain Talk

– RESISTANCE

Levels of Reflective Listening

• Repeating– simply repeating an element of what the client has said

• Rephrasing– substitutes synonyms or slight re-phrases, while keeping the same message

• Paraphrasing– clinician infers meaning and adds to/extends what has already been said

• Reflection of feeling– emphasizes the emotional dimension through feeling statements, metaphor, etc.

Small jump Big jump

Practice Simple and Complex Reflections

• Tobacco user: “I know I need to cut down, I wake up every morning coughing and hacking.”

– “You need to cut down.” – “You are concerned about the effects of

smoking on your lungs.” – “You have noticed some of the negative effects

of smoking.”

Practice Simple and Complex Reflections

• Tobacco: “I just cannot seem to quit. I’ve tried everything but I go back to smoking every time.”

– “You’ve tried everything.”– “You keep trying to quit.” – “You’ve been quite tenacious about trying to quit.” – “You’ve been able to quit for short periods of time.”– “You’ve been trying really hard and it’s frustrating

that you’ve not been as successful as you had hoped.”

Practice Simple and Complex Reflections

• “No one at work knows I smoke. I’m a respiratory therapist and I should know better.” – “No one knows.” – “You’ve kept your smoking a secret.”– “You are embarrassed that you smoke. ” – “Smoking does not fit with your idea of being a

good RT or role model for your patients.” – “You’re frustrated with yourself for not quitting.”

Double-sided Reflections • May be used to highlight ambivalence

• “So, on one hand, you really enjoy smoking and it helps you deal with stress, while you also worry about the health effects of continuing to smoke and the impact it has on your children.”

Yes….but • People usually are ambivalent about change • Comfortable w/ status quo and disadvantages to

change • Arguments on either side of the ….but… cancel each

other out.

“You think it is going to be a great challenge to quit because you have relied on smoking to help you cope with stress for so long and you also want to figure this out because quitting has become more important to you.”

Practice Reflections

• Tobacco user: “All my friends smoke, and I feel like I wouldn’t belong anymore if I quit.”– “Smoking helps you fit in.”– “It is hard for you to imagine how you would fit in

with your friends if you gave up smoking.” – “There is a part of you that would like to quit and,

at the same time, you have some real concerns about how your friends will react.”

– “What is important to you is fitting in with your friends, even more so than the smoking.”

Practice Reflections

• I can’t imagine myself not smoking. It’s part of who I am, part of everything I do. – “Smoking is really important to you.”– “You just wouldn’t be you without smoking. It’s

so important that you may have to keep on smoking, no matter what the cost.”

– “Smoking defines you.”

Reflective Listening Skills

TALKER: • Discuss something you’ve been

thinking about changing

LISTENER: • Respond with reflective

listening STATEMENTS

Remember, you don’t have to hit a home run, just put a little wood on it!

Summaries:Pulling it all together

• Look back over all or part of the conversation and offer an abstract

• Focus on person’s own motivations for change• Opportunity to ask “What else?”

– Make sure that you aren’t missing anything

Help Get Patient Back On-track

• "So far you've listed three reasons to keep smoking; and three reasons to quit. And you found that quitting for your daughter's sake was the most important of all these reasons."

Summary Statements: transition to goal setting

• “So to summarize, you have cut down your smoking to about 15 cigarettes a day, but continue to struggle w/ your asthma. You are using your rescue inhaler almost every day. You think quitting smoking is very important for your health but you are not sure you can quit completely. And what about using NRT?”

5 Key Questions 1. Why would you want to make this change?

2. If you do decide to make this change, how might you go about it in order to succeed?

3. What are your three best reasons to do it?

4. On a scale of 0 to 10, where 0 is not important at all and 10 is very important, how important is it for you to make the change? *Why are you at___ and not 0?

5. So, what do you think you will do? END WITH AN AFFIRMATION

Offering Advice

• Engage first• Ask permission• Use sparingly• Emphasize personal choice• Offer a menu of options

Offering Information or Advice

Ask Permission• “If you’re interested, I have some ideas for you to consider. Would

you like to hear them?”

• “If you’d like, I can tell you about some things that other people have tried successfully. Would that be okay?”

Provide Info or Advice (Emphasize Choice)• “I can tell you about some options, but it’s really up to you.”• “You might or might not agree with my ideas…..”

• “Something you might try if you wish is…”

• “Based on my experience, I would encourage you to consider……”

Offering Information or Advice

Voice Confidence • “I am sure that when you decide the time is right, you will find a way to

quit.”

Elicit Response• “What do you think about those ideas?”• “I’m interested in hearing your thoughts about these ideas.”• “You look puzzled.”

Possible Responses?

Change Talk Jeopardy!

Tobacco Free Florida

Questions?

References

• Emmons, K., & Rollnick, S. (2001). Motivational interviewing in health care settings: opportunities and limitations. American Journal of Preventive Medicine , 68-74.

• Hohman, Melinda. (2012). Motivational Interviewing in Social Work Practice. New York

• Kilinger, C. (2004). Handbook of Motivational Counceling: Concepts, Approaches, and Assessment . United Kingdom .

• Rollnick, S., & Miller, S. (2013). Motivational Interviewing-Helping People Change. New York.

• Rollnick, S., Miller, W., & Butler, C. (2008). Motivational Interviewing in Health Care- Helping Patients Change Behavior. New York.

• http://rxforchange.ucsf.edu/curricula/ask_advise.php

Contact Information

• Andrée Aubrey, MSW, LCSW, Certified Tobacco Treatment Specialist (CTTS)

• Director, Area Health Education Center and faculty member of the Department of Behavioral Sciences and Social Medicine, FSU College of Medicine

• Andree.aubrey@med.fsu.edu• www.med.fsu.edu/AHEC/Tobacco• 850-645-6439