especially for smokers: a tobacco cessation counselor training program terry a. rustin, md...

Especially for Smokers:Especially for Smokers:A tobacco cessation A tobacco cessation counselor training counselor training

programprogram

Terry A. Rustin, MDUniversity of Texas at Houston

Health Science Center

Problem no. 1Problem no. 1

• Insufficient number of treatment professionals are knowledgeable about nicotine dependence and skilled in its treatment

Problem no. 2Problem no. 2

• A large number of treatment professionals are smokers; this has delayed the introduction of tobacco cessation into treatment programs

Professionals who smokeProfessionals 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: ?

Problem no. 1:Problem no. 1:More counselors neededMore 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

Problem no. 2:Problem no. 2:Lots of professionals smokeLots of professionals smoke

• Strategy• Educate• Inspire• Reward • Threaten• Plead

““We want you to run a We want you to run a smoking cessation group for smoking cessation group for

our staff”our staff”• First effort: 1988• Second effort:

1992• Third effort: 1999• Fourth effort:

2002

First effort: 1988First 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


• Group members were unwilling to share anything of importance

• No one quit smoking• No one was satisfied


• 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

Second effort: 1997Second 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


• 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


• 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

Third effort: 1999Third 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


• 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


• 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


• Other reasons for success• Participation was free• Continuing education credits provided• Certificate of completion provided

Fourth effort: 2002Fourth 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

Fourth effort: 2002Fourth 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


• Success in achieving smoking cessation • Only 3 smokers out of 26 participants• One dropped out very early• One smoker quit and one did not


• 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


• Other reasons for success• Participation was free• Continuing education credits provided• Certificate of completion provided

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, TEPContinuing Education Coordinator2627 CarolineHouston, 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: [email protected]

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

Theoretical basisTheoretical 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)

MethodologyMethodology

• 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


• 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.


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

What precipitates relapse?WithdrawalCraving

Internal forces: moods, emotions, fears, worry; feelings of inadequacyExternal forces: cues in the environment

Preventing relapseTreat withdrawalPrevent 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 ideasExternal forces: reduce or avoid cues; find alternative active responses; make a public commitment; obtain the support of others.

1. Confirm the diagnosis of tobacco dependence

2. Identify the stage of readiness to change

3. Provide an intervention designed to move the patient one stage further toward change

Confirm the diagnosisConfirm the diagnosis

• Chief complaint• Quantity and frequency of smoking• History of initiation• Evidence of compulsive use• Evidence for withdrawal• History of quit attempts

Identify stage of readinessIdentify 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

InterventionIntervention

• 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?”


• 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?”)


• Preparation• Provide a plan for success, based on

elements that have previously been successful

Fears about quittingFears 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…”

Focus on the futureFocus 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?”

Transitional objectsTransitional objects

• What is a transitional object?• How to use one• What makes a good transitional

object?• Demonstration

Name: JordanAge: 34Years smoking: 19Brand: Benson & HedgesCurrently smoking: 20 cigarettes /dayYou 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.

Name: MickeyAge: 33Years smoking: 10Brand: DoralCurrently smoking: 20 cigarettes /dayYou 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.

Further extensions Further extensions of the modelof the model

• Academic class at the School of Nursing for nurse practitioner students

• Repeat the counselor training program

Terry A. Rustin, M.D. University of Texas-Houston Health

Science Center1100 HolcombeHouston, Texas 77030

713-500-2061

[email protected]

especially for smokers: a tobacco cessation counselor training program terry a. rustin, md...

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satisfiedfirst effort

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knowsecond effort

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