Especially for Smokers: A tobacco cessation counselor training program

1. Especially for Smokers:A tobacco cessation counselor training program Terry A. Rustin, MD University of Texas at Houston Health Science Center

2. Problem no. 1 • Insufficient number of treatment professionals are knowledgeable about nicotine dependence and skilled in its treatment

3. Problem no. 2 • A large number of treatment professionals are smokers; this has delayed the introduction of tobacco cessation into treatment programs

4. Professionals who smoke • Physicians: less than 3 percent • Registered nurses: about 25 percent • Licensed vocational (practical) nurses: about 35 percent • Addiction counselors: about 35 percent • Masters level social workers and psychotherapists: ?

5. Problem no. 1:More counselors needed • Strategy • Offer dedicated courses and workshops on tobacco cessation methods • Get invited to speak at conferences • Provide lectures and educational modules in the context of other courses and conferences • Provide inservices for staff at agencies

6. Problem no. 2:Lots of professionals smoke • Strategy • Educate • Inspire • Reward • Threaten • Plead

7. “We want you to run a smoking cessation group for our staff” • First effort: 1988 • Second effort: 1992 • Third effort: 1999 • Fourth effort: 2002

8. “We want you to run a smoking cessation group for our staff” • First effort: 1988 • Second effort: 1992 • Third effort: 1999 • Fourth effort: 2002

9. “We want you to run a smoking cessation group for our staff” • First effort: 1988 • Second effort: 1992 • Third effort: 1999 • Fourth effort: 2002

10. “We want you to run a smoking cessation group for our staff” • First effort: 1988 • Second effort: 1992 • Third effort: 1999 • Fourth effort: 2002

11. First effort: 1988 • Smoking cessation therapy group for staff at a private for-profit psychiatric hospital (smokers only) • Based on a traditional group therapy model • Minimal participation • No smoking cessation

12. First effort: 1988 • Group members were unwilling to share anything of importance • No one quit smoking • No one was satisfied

13. First effort: 1988 • Probable reasons for lack of success • Staff could not separate my two functions (treatment supervisor and group psychotherapist) • I learned things about the staff I didn’t really want to know

14. Second effort: 1997 • Smoking cessation educational group for staff at a private for-profit addiction treatment program (smokers only) • Based on a classroom educational model • Good participation • Good success in increasing knowledge and awareness • Minimal smoking cessation

15. Second effort: 1997 • We hoped that participants would quit smoking as they became more informed • One person (out of ten) quit a few months later • Everyone was satisfied with the program except the treatment program owner and me

16. Second effort: 1997 • Probable reasons for lack of success • Focus of the group allowed for bracketing the ego too completely • No clear expectation for smoking cessation • The program’s owner had the most to gain

17. Third effort: 1999 • Smoking cessation counselor training program for staff at a public not-for-profit mental health agency (both) • Based on a professional training model • Excellent participation (repeated by popular demand) • Good success in increasing knowledge and awareness • Good success in achieving smoking cessation

18. Third effort: 1999 • All participants were expected to provide client services at the completion of the program • A clear expectation for smoking cessation articulated at the outset • Six out of twelve smokers quit during the course of the two programs • Everyone was satisfied

19. Third effort: 1999 • Probable reasons for success • Focus of the group encouraged projection and cognitive dissonance (Festinger and Carlsmith, 1957) • Participants saw it as increasing their value as counselors/nurses/social workers

20. Third effort: 1999 • Other reasons for success • Participation was free • Continuing education credits provided • Certificate of completion provided

21. Fourth effort: 2002 • Smoking cessation counselor training program for staff at a public not-for-profit addiction treatment agency (both) • Based on a professional training model • Excellent participation (expanded to two sections by popular demand) • Good success in increasing knowledge and awareness • Good success in achieving smoking cessation

22. Fourth effort: 2002 • All participants were expected to provide client services at the completion of the program • A clear expectation for smoking cessation articulated at the outset • Half of the smokers quit during the course of the program • Everyone was satisfied

23. Fourth effort: 2002 • Success in achieving smoking cessation • Only 3 smokers out of 26 participants • One dropped out very early • One smoker quit and one did not

24. Fourth effort: 2002 • Probable reasons for success • Focus of the group encouraged projection and cognitive dissonance (Festinger and Carlsmith, 1957) • Professional expectations • Adminstration played no part in the program (it was grant-funded) • Participants saw it as increasing their value as counselors

25. Fourth effort: 2002 • Other reasons for success • Participation was free • Continuing education credits provided • Certificate of completion provided

26. This is to certify that ______________________________________ ______________________________________ has satisfactorily completed the workshop Tobacco Dependence Counseling, Session 5 on this 18th day of July, 2002 Instructor: Terry A. Rustin, M.D. TAADAC Provider 1312-96, valid through 2/28/2003 ______________________________ -1.5 hours- (Drug specific) Terry A. Rustin, MD, TEP Continuing Education Coordinator 2627 Caroline Houston, Texas 77004 (713) 970-7585 Rediscovery:The Psychodrama Institute of the Southwest Complaints about provider or workshop content may be directed to the Texas Certification Board of Addiction Professionals (TCBAP), 1005 Congress Avenue, Ste. 460, Austin, Texas 78701, Tel: (512) 708-0629, Fax: (512) 476-7297, email: TCBAP@tcbap.org

27. This is to certify that • Sarah Goodman • has successfully complete a 16 hour course in Tobacco Dependence Counseling • at The Council on Alcohol and Drugs-Houston, • and is qualified as a • Tobacco Dependence Counselor • _________________________________ _________________________________ • Terry A. Rustin, M.D. • Program Director

28. Theoretical basis • Maintain boundaries and roles • Deal with personal issues through projection, not self-disclosure • Focus on training professionals in this additional content area with the expectation that they will soon provide direct services • Professional recognition (continuing education hours, certificate of completion)

29. Methodology • Start each session with a review • Lecture introduces new material, followed by a practice case (role-playing) • Introduce a new element each week, which can be used in that week’s case • Model each modality • Start simple, get more complex

30. Methodology • Use several catch phrases to maintain the group’s focus • If they could have quit smoking without help, they already would have • Of course these are difficult cases; anyone can treat the easy cases • Smoking is the best thing on God’s green Earth; if it didn’t kill people, there’d be no reason to quit.

31. Methodology • Twelve sessions, each 1.5 hours • One primary lesson in each session • Practice the skills each session • Keep it simple

32. What precipitates relapse? Withdrawal Craving Internal forces: moods, emotions, fears, worry; feelings of inadequacy External forces: cues in the environment Preventing relapse Treat withdrawal Prevent or manage craving Internal forces: prepare emotionally, resolve conflicts, understand moods better, receive medical treatment for depression, understand and recognize emotions; self-talk; spiritual well-being; acceptance; disputation of irrational ideas External forces: reduce or avoid cues; find alternative active responses; make a public commitment; obtain the support of others.

33. Confirm the diagnosis of tobacco dependence • Identify the stage of readiness to change • Provide an intervention designed to move the patient one stage further toward change

34. Confirm the diagnosis • Chief complaint • Quantity and frequency of smoking • History of initiation • Evidence of compulsive use • Evidence for withdrawal • History of quit attempts

35. Identify stage of readiness • “What are your thoughts and feelings about quitting smoking?” • Precontemplation: not ambivalent, not interested in quitting • Contemplation: ambivalent • Preparation: ambivalence has been resolved in favor of quitting

36. Intervention • Precontemplation • Direct, personal information (not instructions): “Your emphysema will improve after you quit smoking.” • Projection: “50 million people have quit smoking… why do you imagine all those other people have quit smoking?”

37. Intervention • Contemplation • Early: Reduce the fear of quitting by using the Example of One (“You know, I recently had a patient much like you…”) • Later: Increase the value of quitting by using Hope for the Future (“How will your life be better after you have quit smoking?”)

38. Intervention • Preparation • Provide a plan for success, based on elements that have previously been successful

39. Fears about quitting • Ask • “What are your thoughts and feelings about quitting smoking?” • Acknowledge the affect • “Those are reasonable concerns. “ • Clarify the issue • “Explain more about your concerns to me.” • Intervention: The example of one • “Let me tell you about another patient of mine…”

40. Focus on the future • Ask • “How will your life be better after you have quit smoking?” • Acknowledge the affect • “Wouldn’t that be great? “ • Clarify the issue • “Tell me more about that.” • Intervention: Obtain a commitment to change • “Shall we set a quit date?” “Not ready? Okay, how about we set a date to set a quit date?”

41. Transitional objects • What is a transitional object? • How to use one • What makes a good transitional object? • Demonstration

42. Name: Jordan Age: 34 Years smoking: 19 Brand: Benson & Hedges Currently smoking: 20 cigarettes /day You don’t want to quit smoking. Your parents both smoke and they are in their 60s; your grandparents all lived past 80, and all of them smoked. You are healthy. You work out at the gym and eat smart. You take vitamins every day. Cigarettes help you get through the day, because you are stressed out a lot. You work as a supervisor at the phone company, and you constantly have people asking things of you. Cigarettes are a way you cope with the stress. You don’t think you’d get through the day without them. You are married to a smoker.

43. Name: Mickey Age: 33 Years smoking: 10 Brand: Doral Currently smoking: 20 cigarettes /day You started smoking when you were 15 and quit when you were 20. You started again at 25 (when your lover left you) and quit 3 years later. You started smoking again 2 years ago (when your mother died) and you want to stop now. You previously used the gum and the patch, which helped. You play the piano and sing in a cocktail lounge and you are around smokers all the time.

44. Further extensions of the model • Academic class at the School of Nursing for nurse practitioner students • Repeat the counselor training program

45. Terry A. Rustin, M.D. University of Texas-Houston Health Science Center 1100 Holcombe Houston, Texas 77030 713-500-2061 Terry.A.Rustin@uth.tmc.edu www.QuitAndStayQuit.com