1. Helping People Change Addictive Behavior: Smoking Cessation as a Model
Andrée Aubrey, LCSW, CTTS and Mary Dailey, CTTS
FSU College of Medicine
Area Health Education Center (AHEC)

2. 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”

3. What do we say next?

4. What would you say to this patient?
Die of Something
You’re feeling pretty hopeless about ever being able to quit
You’re really angry about this situation
You’ve resolved yourself to the idea you’ll never be able to quit – undershooting /overshooting
Something happened w/ your past quit attempts that have left you feeling frustrated
You really have nothing to lose

5. Typical Tobacco Cessation Counseling
The way in which we communicate with people SIGNIFICANTLY influences their motivation about change.

6. 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
Knowledge, coping skills, insight, dx, wisdom, reality, rationality
They are a person, not an info recepticle
Yes but is the cadence of ambivalence
Knowledge weakly correlated with behavior change
The traditional approach is: ID problem; evaluate risk of behavior; advise pt. to change
“I am going to teach you.”/ provider is expert and pt. should follow his advice.
If pt. does not change, the counseling/ interaction has been a failure.
The way in which you talk w/ pts. about their health can substantially influence their personal motivation for behavior change.

7. You can lead a horse to water but you cannot make him drink!
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!

8. However, you can increase his thirst.
MI Interventions “salt the oats.”

9. 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)
Spirit and style more than specific techniques – shaped by a guiding philosophy and understanding of what triggers change.
It involves the conscious and disciplined use of specific communication principles and strategies to evoke the person’s own motivations for change

10. 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

11. Core Skills – OARS
Give a brief structuring statement or ask permission
MI skills:
Open ended questions
Affirmations
Reflective listening
Summaries
and
Informing/ Advising
Emphasize SPIRIT AND STYLE OF COUNSELING.
EARLY METHODS: we don’t call them early methods because we use at the beginning and then abandon; it is important to use them right from the start
Informing/ Advising: Just don’t give the info. Ask how the person wants to obtain info.
These are pre-requisite skills for the proficient practice of MI
What charac MI is the particular way in which these skills are used strategically to help people move in the direction of change

12. Using Open-ended Questions
Help them talk more about the problem area. Don’t just note the info.
Not only should the ? Be open, it is imp the clinician is open, interested, and curious about the person to fully benefit from this question type.

13. 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?”
** What makes you think you do not need to change….what about the other side? What makes you think it is time for a change

14. 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.”
Appropriate level and frequency of affirmations will vary across social contexts
Affirmations are a way of thinking: Be on the look-out for client strengths
The point is to notice and appropriately affirm the person’s strengths and efforts

15. Reflective Statements
Person
Clinician
Reflective Statements
Practice good listening
Encourage more talking and exploring
Avoid a premature focus on solutions
Strengthen change talk
Elicit more change talk
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
A foundational skill!
It is not repetition, it is revelation!

16. Recognizing “Change Talk”
DARN
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.”
DESIRE – not essential, people can still do things even if they don’t really want to
ABILITY only signals change is possible
REASONS – may be god reasons but person may not want to change or may feel incapable of change
NEED does not imply desire or ability.
None of these indicate change is going to happen

17. Recognizing “Change Talk”
CAT
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.”
“will you tell the truth, the whole truth, and nothing but the truth? I want to, I could, I have good reasons to, I need to
Activation – movement toward action / almost there I’m ready, prepared to…, willing to…taking steps – already doing something in the direction of change

18. DARN CAT

19. 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
Listening is a complex clinical skill: What is said and not said, cultural filters, etc.
Offer more reflections than questions because questions can slow momentum that is building toward change.

20. Levels of Reflective Listening
Small jump Big jump
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.

21. 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.”
Hear the change talk within ambivalence and shine a light on it

22. 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.”

23. 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.”

24. 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.”

25. 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.” AA
Some important health behaviors are unpleasant (pricking your finger for glucose monitoring; exercising after surgery, side effects of meds, etc.)
People get stuck in ambivalence
I should exercise more BUT it is too hot
I should lose some weight BUT I hate exercising
I really should stop smoking BUT I am under so much stress right now.

26. 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.”
Your reflective statements need to be nonjudgmental, even if you do not agree with what the patient says. To help you do this sincerely and honestly, add phrases such as, "It sounds like you feel..." or "So, the way you see it is..."

27. 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.”
Just turn up the volume a bit of what the person is saying

28. Reflective Listening Skills
TALKER:
Discuss something you’ve been thinking about changing
LISTENER:
Respond with reflective listening STATEMENTS
Something you have been thinking about changing in your own life. A habit, attitude, or behavior. Something you have not changed yet. Something that would be GOOD for you to change or something you SHOULD change.
Remember, you don’t have to hit a home run, just put a little wood on it!

29. 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
SUMMARIES contain the pt’s own motivations for change
Imp and powerful for pt to hear accumulated motivations for change- maybe for 1st time
Your ability to summarize indicates you have listened and paid attn to what pt said – strengthens working relationship
Op to ask WHAT HAVE I MISSED/ WHAT ELSE
Summary allows you to draw conversation to a close

30. 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."

31. 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?”

32. END WITH AN AFFIRMATION
5 Key Questions
Why would you want to make this change?
If you do decide to make this change, how might you go about it in order to succeed?
What are your three best reasons to do it?
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?
So, what do you think you will do?
END WITH AN AFFIRMATION

33. Offering Advice Engage first Ask permission Use sparingly
Emphasize personal choice
Offer a menu of options

34. 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……”

35. 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.”

36. Possible Responses?
Zyban

37. Change Talk Jeopardy!
Write down 2 sentences you have heard that contain change talk
2 Groups – make your statement
2nd group responds w/ a question that could have elicited that change talk
EARS- explain or elaborate; affirm; reflect; summarize

39. Tobacco Free Florida

40. Questions?

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

42. 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