Stages of Change and Stages of Change and Motivational Motivational

Intervention with Intervention with Clinical PopulationsClinical Populations

Heather LaChance, LMFT, Ph.D.Heather LaChance, LMFT, Ph.D.Assistant Professor of MedicineAssistant Professor of Medicine

National Jewish Medical and Research CenterNational Jewish Medical and Research CenterLicensed PsychologistLicensed Psychologist

Heather LaChance, LMFT, Ph.D.Heather LaChance, LMFT, Ph.D.Assistant Professor of MedicineAssistant Professor of Medicine

National Jewish Medical and Research CenterNational Jewish Medical and Research CenterLicensed PsychologistLicensed Psychologist

Dr. Heather LaChance is an Assistant Professor at Dr. Heather LaChance is an Assistant Professor at National Jewish Medical and Research Center. She National Jewish Medical and Research Center. She specializes in the treatment of smoking cessation, specializes in the treatment of smoking cessation, addictive disorders, and comorbid depression/anxiety. addictive disorders, and comorbid depression/anxiety. She is a licensed Psychologist and licensed Marriage She is a licensed Psychologist and licensed Marriage and Family Therapist in Colorado. She competed her and Family Therapist in Colorado. She competed her internship at Harvard Medical School in the internship at Harvard Medical School in the Addictions and Families Program. She also Addictions and Families Program. She also completed her postdoctoral fellowship at Brown completed her postdoctoral fellowship at Brown University specializing in the assessment and University specializing in the assessment and treatment of addictive disorders. She has a large treatment of addictive disorders. She has a large NIDA-funded grant investigating Behavioral Couples NIDA-funded grant investigating Behavioral Couples Therapy (BCT) for smoking cessation.Therapy (BCT) for smoking cessation.

Goals for Today’s Goals for Today’s TrainingTraining

Review Stages of Change ModelReview Stages of Change Model

Review Motivational InterventionReview Motivational Intervention

Answer several questions providedAnswer several questions provided

Case scenariosCase scenarios

Q&A (if time)!Q&A (if time)!

Stages of Change and Stages of Change and Motivational InterventionMotivational Intervention

What is the difference? What is the difference?

Stages of Change (SOC) = the model Stages of Change (SOC) = the model (the canvas)(the canvas)

Motivational Intervention (MI) = the Motivational Intervention (MI) = the methods or techniques you use to methods or techniques you use to enhance motivationenhance motivation(how you paint)(how you paint)

Stage of Change Stage of Change ModelModel

Stages of ChangeStages of Change

Prochaska and DiClemente theorized that Prochaska and DiClemente theorized that change is a change is a process THAT TAKES TIMEprocess THAT TAKES TIME and and that all people move through that all people move through stagesstages as they as they change.change.

Transtheoretical Model of Change (TTM) or Transtheoretical Model of Change (TTM) or

Stages of Change Model (1984-present).Stages of Change Model (1984-present).

http://www.uri.edu/research/cprc/transtheoretical.htmhttp://www.uri.edu/research/cprc/transtheoretical.htm

Stages of Change (SOC)Stages of Change (SOC) Stages of Change for addictions represent a Stages of Change for addictions represent a

very well-researched clinical model.very well-researched clinical model.

Effective interventions based on the SOC Effective interventions based on the SOC model have been successfully evaluated in model have been successfully evaluated in multiple clinical trials. (Velicer & Prochaska, multiple clinical trials. (Velicer & Prochaska, et al., 1998)et al., 1998)

For more on the research:For more on the research:

http://www.uri.edu/research/cprc/TTM/StagesOfChanhttp://www.uri.edu/research/cprc/TTM/StagesOfChange.htmge.htm

Motivational InterviewingMotivational Interviewing (2 (2ndnd Ed), Chapter Ed), Chapter 15, page 201.15, page 201.

see www.motivationalinterview.orgsee www.motivationalinterview.org

Stages of Stages of ChangeChange

Pre-ContemplationPre-Contemplation = Not yet = Not yet even thinking about behavior even thinking about behavior changechange

ContemplationContemplation = Ambivalent and = Ambivalent and thinking about changethinking about change

PreparationPreparation = Decision that change is = Decision that change is necessary and possiblenecessary and possible

ActionAction = Actively working toward = Actively working toward behavior changebehavior change

MaintenanceMaintenance = Sustaining new = Sustaining new behaviorbehavior

RelapseRelapse = PART of change cycle and = PART of change cycle and often several before maintenanceoften several before maintenance

AMBIVALENTPREPARATION

ACTION

MAINTAIN

PermanentExit

Pre- Contemplation

RELAPSE

Prochaska-DiClemente Transtheoretical Stage Model

Simplified Stages of ChangeSimplified Stages of ChangeAMBIVALENCE:

-Thinking about Change

-May be trying small things

-“flip-flop” about smoking

-Not ready to quit -Ready to change

-Taking small steps

-Has many reasons (pros outweigh the cons)

PREPARATION:

ACTION:-Made a quit

-Completing behaviors

-Asking you questions & seeking out solutions

-Open to suggestions

SLIP or RELAPSE

Cycles Through the Cycles Through the StagesStages

Prochaska and DiClemente found people Prochaska and DiClemente found people cycle through stages of change 3-7 times cycle through stages of change 3-7 times before maintaining new coping skills.before maintaining new coping skills.

Slips or Relapse is considered Slips or Relapse is considered partpart of of treatment rather than failure.treatment rather than failure.

““Each slip brings a client closer to recovery.”Each slip brings a client closer to recovery.”

Evaluating triggers and heightening Evaluating triggers and heightening awareness after each slip or relapse can awareness after each slip or relapse can bring the client through the stages of change bring the client through the stages of change (rather than just giving up).(rather than just giving up).

Ambivalence is Ambivalence is NormativeNormative

In a study of active smokers it was shown that In a study of active smokers it was shown that the distribution of smokers fell in the first three the distribution of smokers fell in the first three Stages of Change. This has been replicated Stages of Change. This has been replicated across 3 large representative samples:across 3 large representative samples:

Approximately 40% of the smokers were in the Approximately 40% of the smokers were in the Pre-contemplation stage (not even thinking Pre-contemplation stage (not even thinking about it).about it).

40% were in the Contemplation stage.40% were in the Contemplation stage. 20% were in the Preparation stage. 20% were in the Preparation stage.

*About 70% of smokers are thinking about or *About 70% of smokers are thinking about or preparing to make a change preparing to make a change

(Velicer, et al., (Velicer, et al., 1995)1995)

Motivational Motivational Intervention (MI)Intervention (MI)

Basis for Motivational Basis for Motivational ApproachApproach

Miller tested the hypothesis that a Miller tested the hypothesis that a confrontational counseling style is self-fulfilling confrontational counseling style is self-fulfilling prophecy.prophecy.

Miller and Sovereign (1989, 1994) randomly Miller and Sovereign (1989, 1994) randomly assigned problem drinkers to either therapists assigned problem drinkers to either therapists using confrontational counseling or a more using confrontational counseling or a more client-focused approach. client-focused approach.

Drinkers who had confrontational therapists Drinkers who had confrontational therapists showed higher levels of resistance (arguing, showed higher levels of resistance (arguing, changing the subject, denial, interrupting, etc.) changing the subject, denial, interrupting, etc.) versus those given a more client-centered, versus those given a more client-centered, motivational approach. motivational approach. Therapist is coercive, or confrontational

Client defensiveness, resistance, or denial

MotivationMotivation Recent approaches view motivation Recent approaches view motivation

not as a trait, or something you have.not as a trait, or something you have.

Motivation is now seen as a Motivation is now seen as a dynamic dynamic statestate that can be influenced. that can be influenced.

Many clinical trials have found MI to Many clinical trials have found MI to be effective with a variety of disorders: be effective with a variety of disorders: high-risk and addictive behaviors such high-risk and addictive behaviors such as alcohol disorders, smoking, poly-as alcohol disorders, smoking, poly-substance abuse, HIV risk behaviors, substance abuse, HIV risk behaviors, bulimia, diet/weight and health issues bulimia, diet/weight and health issues (Burke et al., 2003).(Burke et al., 2003).

MI General PrinciplesMI General Principles

Express empathyExpress empathy Listen reflectivelyListen reflectively Develop awareness Develop awareness Ask meaningful questionsAsk meaningful questions Avoid argumentationAvoid argumentation Roll with resistanceRoll with resistance Provide selective feedbackProvide selective feedback Affirm self-efficacyAffirm self-efficacy

Confrontation as Goal- Confrontation as Goal- notnot Style Style

Goal of MI is to Goal of MI is to increaseincrease ambivalenceambivalence about about smoking not to force change process.smoking not to force change process.

Research shows clients become resistant Research shows clients become resistant when treatment providers use therapeutic when treatment providers use therapeutic strategies inappropriate for clients’ strategies inappropriate for clients’ current stage of change.current stage of change.

We change the MI strategies to fluctuate We change the MI strategies to fluctuate with readiness for change.with readiness for change.

The goal = have the The goal = have the clientclient argue for argue for change.change.

Skill #1 Reflective Skill #1 Reflective ListeningListening

1. Treatment provider forms a reasonable guess as to 1. Treatment provider forms a reasonable guess as to the the underlying or unspoken meaningunderlying or unspoken meaning. .

2. Rephrase what the person has just said, in a 2. Rephrase what the person has just said, in a statement, statement, not in a question. not in a question.

3. Reflect back to the person what you hear them 3. Reflect back to the person what you hear them saying.saying. “Sounds like you are feeling uncertain…” “Sounds like you are feeling uncertain…” “You are feeling pretty disappointed that you “You are feeling pretty disappointed that you slipped.”slipped.”

You know your reflection is right when the person says You know your reflection is right when the person says “Yes” “Exactly!” “Yeah” etc. or ASK you for more info. “Yes” “Exactly!” “Yeah” etc. or ASK you for more info.

Single-Sided Reflection Single-Sided Reflection (or (or simple reflections)simple reflections)

Single-sided reflections only reflect one side of Single-sided reflections only reflect one side of ambivalence.ambivalence.

These are called simple reflections. You are simply These are called simple reflections. You are simply reflecting what you hear the person saying:reflecting what you hear the person saying:

C- I know I really need to quit….C- I know I really need to quit….

T- You’ve been thinking of quitting…T- You’ve been thinking of quitting…

C- Yeah, I’ve thought about it for years but it’s just so C- Yeah, I’ve thought about it for years but it’s just so hard… I’ve quit so many times but I always relapse..hard… I’ve quit so many times but I always relapse..

T- You wish it would stick but it hasn’t yet..T- You wish it would stick but it hasn’t yet..

C- yeah… what can I do..?C- yeah… what can I do..?

T-Research shows that people who quit more often end T-Research shows that people who quit more often end up being more successful….up being more successful….

Confrontation-Denial Confrontation-Denial TrapTrap

If a health care provider takes one side of If a health care provider takes one side of the argument (to change) then the client the argument (to change) then the client who is not ready will take the other side who is not ready will take the other side of the argument of the argument (to stay the same or keep smoking).(to stay the same or keep smoking).

In this way, the conversation builds In this way, the conversation builds moremore denial and resistance.denial and resistance.

The goal is to reflect what The goal is to reflect what the clientthe client is is saying NOT to list the reasons a person saying NOT to list the reasons a person should change.should change.

Confrontation-Denial Confrontation-Denial TrapTrap

When a treatment provider becomes insistent on change, When a treatment provider becomes insistent on change, it can TRIGGER resistance. it can TRIGGER resistance.

C- I know I really need to quit….C- I know I really need to quit….

T- You’ve should really quit. It’s making your COPD worse.T- You’ve should really quit. It’s making your COPD worse.

C- I know. But at this point in the game, I don’t think C- I know. But at this point in the game, I don’t think quitting would help. Besides, I’ve quit so many times quitting would help. Besides, I’ve quit so many times before. I can’t do it.before. I can’t do it.

T- You can do it. It is the most important thing you can do T- You can do it. It is the most important thing you can do for your health.for your health.

C- I know, I know…. But I’ve tried to quit over 50 times! C- I know, I know…. But I’ve tried to quit over 50 times! You just don’t understand how hard it is… You just don’t understand how hard it is… Look, do we need to keep talking about this – I’m not Look, do we need to keep talking about this – I’m not going to quit.going to quit.

Double Sided ReflectionsDouble Sided Reflections Double sided reflections are used when a person feels 2 Double sided reflections are used when a person feels 2

ways about something. Reflect the bind the person feels by ways about something. Reflect the bind the person feels by the situation..the situation..

MOST PEOPLE FEEL CONFLICT ABOUT MOST PEOPLE FEEL CONFLICT ABOUT ANYANY CHANGE. CHANGE.

C- I want to quit smoking but last time I quit, I hated feeling C- I want to quit smoking but last time I quit, I hated feeling so edgy. so edgy. I was afraid I was going to get fired from my job because I I was afraid I was going to get fired from my job because I was so crabby.was so crabby.

T- So on the one hand, you don’t like how irritable you get T- So on the one hand, you don’t like how irritable you get but on the other hand, you really want to quit for good. but on the other hand, you really want to quit for good. Seems like it will be important to learn new ways to cope Seems like it will be important to learn new ways to cope with irritability without going back to smoking… (only with irritability without going back to smoking… (only reflecting, not jumping to solutions)reflecting, not jumping to solutions)

C- Yes… is there any way I can not get so edgy and irritable? C- Yes… is there any way I can not get so edgy and irritable? (asking for information, thinking about options)(asking for information, thinking about options)

Skill #2: Affirm and Skill #2: Affirm and Reward Change TalkReward Change Talk

When client begins to consider change – make When client begins to consider change – make positive affirming statements to reward the change positive affirming statements to reward the change talk.talk.

Agree, support, and emphasize personal controlAgree, support, and emphasize personal control

““Great – sounds like you’re considering how to quit. Great – sounds like you’re considering how to quit. Just thinking about it is an important first step.”Just thinking about it is an important first step.”

““That’s ok if you are not ready to quit yet. It’s great That’s ok if you are not ready to quit yet. It’s great that you’ve tried to quit before. Research shows that you’ve tried to quit before. Research shows that the more people try to quit, the better their that the more people try to quit, the better their chances are to quit for good. You might try several chances are to quit for good. You might try several times before it sticks.”times before it sticks.”

Elicit Self-Motivation Elicit Self-Motivation StatementsStatements

The ultimate goal is to have The ultimate goal is to have clientsclients argue argue for change to resolve their ambivalence. for change to resolve their ambivalence.

SIGNS OF INCREASED MOTIVATION:SIGNS OF INCREASED MOTIVATION:

Recognition of behaviorRecognition of behavior:: ““I guess I need to think about that…”I guess I need to think about that…” ““I think I need to make a commitment to I think I need to make a commitment to

this…”this…” ““I didn’t realized NRT doubles my chance to I didn’t realized NRT doubles my chance to

quit…”quit…”

Asking for feedback or helpAsking for feedback or help:: ““Is there anything I can do?”Is there anything I can do?” ““How do people quit this kind of habit?”How do people quit this kind of habit?”

Roll With ResistanceRoll With Resistance You may not always get self-motivational You may not always get self-motivational

statements… statements… (if only we did…!)(if only we did…!)

How do you handle resistance???How do you handle resistance???

Agree With A TwistAgree With A Twist:: “ “I agree with what you are saying, no one can make I agree with what you are saying, no one can make

you quit except you. At this point, you are not you quit except you. At this point, you are not feeling ready to quit. I also think that when you are feeling ready to quit. I also think that when you are ready, you can be successful in quitting. Millions of ready, you can be successful in quitting. Millions of people have quit smoking.”people have quit smoking.”

Most clients, when agreed with, do not need to keep Most clients, when agreed with, do not need to keep arguing and defending their right to their opinion.arguing and defending their right to their opinion.

Asking Meaningful Asking Meaningful QuestionsQuestions

Use questions that generate self-Use questions that generate self-reflection combined with affirmations reflection combined with affirmations to propel talk about change forwardto propel talk about change forward

Research shows that Research shows that physicians/treatment providers physicians/treatment providers simply ASKING about smoking leads simply ASKING about smoking leads to a 30% increase into a 30% increase inpatients attempts to quit.patients attempts to quit.

Ask Open-Ended Ask Open-Ended QuestionsQuestions

Open questions are open-ended.. Evoke thought. Open questions are open-ended.. Evoke thought.

They start with WHAT, HOW, WHEN, WOULD They start with WHAT, HOW, WHEN, WOULD YOU, or TELL ME MORE…YOU, or TELL ME MORE…

Open questions encourage clients to think about Open questions encourage clients to think about what they are feeling and/or want: what they are feeling and/or want:

What do you like about it?What do you like about it?What are your concerns?What are your concerns?How might you change that?How might you change that?How are things different now?How are things different now?How would you want to work on this skill more?How would you want to work on this skill more?

Open questions generate exploration.Open questions generate exploration.

Open questions are VITAL to quality MI Open questions are VITAL to quality MI

Closed QuestionsClosed Questions Closed questions force a Closed questions force a yesyes or or nono answer. answer. Closed questions are usually about making Closed questions are usually about making

decisions or judgment.decisions or judgment.

Closed questions begin with: Closed questions begin with: ARE you…? DO You…? DON’T You….?, and ARE you…? DO You…? DON’T You….?, and

WHY are you..? WHY aren’t you..? WHY are you..? WHY aren’t you..?

Some closed questions are fine for information Some closed questions are fine for information gathering: gathering: Do you want NRT? Do you want NRT?

Most shut down the conversation, lead to Most shut down the conversation, lead to defensive answers, or are leading questions.defensive answers, or are leading questions. Aren’t you concerned about that? Aren’t you concerned about that? Do you see how it’s gotten worse over time?Do you see how it’s gotten worse over time?

Question Series #1 – Question Series #1 – Getting the Patient Getting the Patient

EngagedEngaged ““What do I do when a person is pre-What do I do when a person is pre-

contemplative and appears to shut contemplative and appears to shut down or become defensive when asked down or become defensive when asked about smoking cessation?”about smoking cessation?”

““How do I get the PATIENT to talk How do I get the PATIENT to talk about smoking?”about smoking?”

““I sometimes lack the words to get the I sometimes lack the words to get the patient talking about it…”patient talking about it…”

Question #1 – Question #1 – EngagementEngagement

When a patient responds defensively or When a patient responds defensively or shuts down it is important to remember shuts down it is important to remember that this response is often SHAME, that this response is often SHAME, feelings of embarrassment, and/or fear. feelings of embarrassment, and/or fear.

They often worry you will look down on They often worry you will look down on them.them.

Responding empathetically is KEY.Responding empathetically is KEY.

People cannot open up to change if they People cannot open up to change if they feel judged or worried they will be judged.feel judged or worried they will be judged.

Question #1 - Question #1 - EngagementEngagement

Examples to open up the conversation :Examples to open up the conversation : ““I know this is tough to talk about, Sally, and I get I know this is tough to talk about, Sally, and I get

the sense that you might be worried that I’m the sense that you might be worried that I’m going to give you the big lecture…. (with a smile). going to give you the big lecture…. (with a smile). Instead I’d like to hear more about Instead I’d like to hear more about your thoughtsyour thoughts about smoking…” about smoking…”

““I work with a lot of smokers, Frank. I know it is I work with a lot of smokers, Frank. I know it is not easy to quit. In fact, nicotine is very addictive not easy to quit. In fact, nicotine is very addictive and has been found to be similar to cocaine or and has been found to be similar to cocaine or heroin in how addictive it is. Most smokers need heroin in how addictive it is. Most smokers need to quit several times before they can get the hang to quit several times before they can get the hang of it. I’d really like to learn more about your of it. I’d really like to learn more about your experiences and thoughts about…”experiences and thoughts about…”

Question #1 – Getting Question #1 – Getting EngagementEngagement

Asking meaningful OPEN questions OPEN Asking meaningful OPEN questions OPEN conversations. conversations.

Closed questions CLOSE the conversation down.Closed questions CLOSE the conversation down.

The The decisional balancedecisional balance, or pros and cons of , or pros and cons of smoking, can help smokers to begin to reflect on smoking, can help smokers to begin to reflect on their behavior.their behavior.

Often the “pros of smoking” give clues about a Often the “pros of smoking” give clues about a person’s needs or the role smoking is playing in person’s needs or the role smoking is playing in their lives.their lives.

Decisional BalanceDecisional Balance

Decisional Balance – assume the Decisional Balance – assume the client client hashas concerns or concerns or ambivalence: ambivalence: Use open questions to elicit and Use open questions to elicit and reflect self-motivation statements.reflect self-motivation statements.

Determine if the benefits to Determine if the benefits to continue are outweighing the cons.continue are outweighing the cons.

Try to heighten ambivalence about Try to heighten ambivalence about cons.cons.

Decisional BalanceDecisional Balance

T - Do you smoke? (closed question)T - Do you smoke? (closed question)

C- Yes. I know I should quit but I’ve tried many times C- Yes. I know I should quit but I’ve tried many times before and just can’t seem to do it….before and just can’t seem to do it….

OK. I know this isn’t easy to talk about but I’d like to OK. I know this isn’t easy to talk about but I’d like to learn more about your experiences and how you are learn more about your experiences and how you are feeling about it at this point. Could we talk a bit more feeling about it at this point. Could we talk a bit more about this?about this?

So, I’m curious to know what you enjoy about smoking?So, I’m curious to know what you enjoy about smoking?

What don’t you like about smoking?What don’t you like about smoking?

What concerns you the most about {health issue}?What concerns you the most about {health issue}?

Decisional BalanceDecisional Balance Responding to the “pros of smoking” (use reflections):Responding to the “pros of smoking” (use reflections):

““OK, so it sounds like you have a lot of stress in your OK, so it sounds like you have a lot of stress in your life right now. When you want to try to quit again, it life right now. When you want to try to quit again, it will be important to find will be important to find newnew ways to manage stress. ways to manage stress. Actually, there are lots of good techniques for stress Actually, there are lots of good techniques for stress management. It also sounds like smoking is a way for management. It also sounds like smoking is a way for you to take breaks and give yourself a reward. This is you to take breaks and give yourself a reward. This is very important….”very important….”

““So smoking has become more of a habit and you find So smoking has become more of a habit and you find very little enjoyable about it. That is good news! This very little enjoyable about it. That is good news! This means that it is not as rewarding or enjoyable as it means that it is not as rewarding or enjoyable as it once was for you. There are some new medications that once was for you. There are some new medications that can help you break the habit….Would you like to learn can help you break the habit….Would you like to learn more about them?”more about them?”

““What don’t you like about smoking?”What don’t you like about smoking?”

Question #2 -Repeatedly Question #2 -Repeatedly AskingAsking

““It is hard to feel like a ‘broken record’ and keep bringing It is hard to feel like a ‘broken record’ and keep bringing up smoking/quitting.”up smoking/quitting.”

Examples of ways to handle:Examples of ways to handle: ““John, it was nice to hear a bit about your smoking during John, it was nice to hear a bit about your smoking during

our last appointment. I’d like to hear a little more about it our last appointment. I’d like to hear a little more about it and find out if you’ve had additional thoughts since we and find out if you’ve had additional thoughts since we last met. What have you noticed over the week/s?” last met. What have you noticed over the week/s?”

““Sarah, it’s OK if you are not yet ready to quit. I know the Sarah, it’s OK if you are not yet ready to quit. I know the last time we talked you mentioned you worry about -----. last time we talked you mentioned you worry about -----. Tell me more about that…” Tell me more about that…”

Just to let you know, I will be checking in with you each Just to let you know, I will be checking in with you each time we meet to find out your thoughts about smoking. time we meet to find out your thoughts about smoking. This way, I can make sure that if you have new questions I This way, I can make sure that if you have new questions I can assist you, OK?”can assist you, OK?”

““Jim, just as I ask you if you have any new Jim, just as I ask you if you have any new questions/concerns about your health (or presenting questions/concerns about your health (or presenting issue), I also ask all my clients about their smoking. This issue), I also ask all my clients about their smoking. This helps me check-in to see there are any new questions for helps me check-in to see there are any new questions for me, OK?”me, OK?”

Question #3 – Intrinsic Question #3 – Intrinsic MotivationMotivation

““How do you source a person’s How do you source a person’s internal/intrinsic desire to change behavior internal/intrinsic desire to change behavior and resolve ambivalence?” and resolve ambivalence?”

The ONLY way to tap into internal The ONLY way to tap into internal motivation is to ask OPEN REFLECTIVE motivation is to ask OPEN REFLECTIVE QUESTIONS.QUESTIONS.

Telling people or even making a cogent Telling people or even making a cogent argument as to why someone should change argument as to why someone should change will NOT work but can actually back fire on will NOT work but can actually back fire on you.you.

Evocative QuestionsEvocative QuestionsDeveloping ConcernDeveloping Concern::

What are your biggest concerns about continuing to What are your biggest concerns about continuing to smoke? smoke?

How might your life be different if you quit?How might your life be different if you quit?

How might you feel if that happens?How might you feel if that happens?

What do you think will happen if you don’t quit?What do you think will happen if you don’t quit?

How has smoking stopped you from doing things you’d How has smoking stopped you from doing things you’d like to do?like to do?

What have you noticed about your health now compared What have you noticed about your health now compared to 10 years ago?to 10 years ago?

““What Else?”What Else?” Straightforward encouragement Straightforward encouragement

theme(s):theme(s):

What else have you noticed?What else have you noticed?What else worries you?What else worries you?What other ideas do you have about What other ideas do you have about this?this?What else would you change?What else would you change?What else could you do at this point?What else could you do at this point?Give me an example…Give me an example…

Evocative QuestionsEvocative QuestionsOptimism /Self-EfficacyOptimism /Self-Efficacy::

What encourages you (or how do you know) What encourages you (or how do you know) that you will make this happen?that you will make this happen?

If you did decide to change, what helps you If you did decide to change, what helps you know you’ll be successful?know you’ll be successful?

If you did decide to change, what are your If you did decide to change, what are your hopes for the future?hopes for the future?

Evocative QuestionsEvocative Questions

Intention to changeIntention to change::

If you were 100% successful in making these If you were 100% successful in making these changes, what would be different?changes, what would be different?

What would be the advantages of making this What would be the advantages of making this change?change?

I can see you are feeling stuck at the moment. I can see you are feeling stuck at the moment. What might be one possible solution to this What might be one possible solution to this issue? issue?

Providing FeedbackProviding Feedback In MI, a provider provides feedback selectively as part In MI, a provider provides feedback selectively as part

of the intervention and follows-up with reflections and of the intervention and follows-up with reflections and open questions.open questions.

““You are right to be concerned about your health… In You are right to be concerned about your health… In fact, research shows…”fact, research shows…”

““You look surprised. What do you make of this info?”You look surprised. What do you make of this info?”

Using feedback provides information and Using feedback provides information and education combined with self-reflection. education combined with self-reflection.

Too much feedback, when person is not ready to Too much feedback, when person is not ready to hear it, can create defensiveness and hear it, can create defensiveness and resistance… resistance…

Use feedback correctly.Use feedback correctly.

Question Series #4: Question Series #4: Concerns/Fears about Concerns/Fears about

QuestionsQuestions ““It seems redundant or unnecessary to It seems redundant or unnecessary to

ask these smoking questions.”ask these smoking questions.”

““I hate to ask about smoking because I I hate to ask about smoking because I smoke. smoke. It makes me feel like a hypocrite.  I It makes me feel like a hypocrite.  I hate to ‘sic the doctor’ on them.”hate to ‘sic the doctor’ on them.”

““I anticipate this question will cause I anticipate this question will cause conflict.  What if the patient gets mad?  conflict.  What if the patient gets mad?  Or just stops coming here?”Or just stops coming here?”

Asking About SmokingAsking About Smoking Remember that Remember that simply askingsimply asking about smoking about smoking

has been shown to increase the frequency of has been shown to increase the frequency of quit attempts by 30%.quit attempts by 30%.

Every visit to a health care professional Every visit to a health care professional involves questions about medical/personal involves questions about medical/personal history, cholesterol, diet, exercise, etc . history, cholesterol, diet, exercise, etc . Smoking behaviors change over time so it is Smoking behaviors change over time so it is important to ask each time. important to ask each time.

If a health care professional is calm and caring If a health care professional is calm and caring in the way they ask in the way they ask anyany question, people will question, people will respond more openly and freely than you might respond more openly and freely than you might expect.expect.

Asking About SmokingAsking About Smoking Smokers or former smokers as health care Smokers or former smokers as health care

professionals… professionals… You are in the best position to be empathetic. You are in the best position to be empathetic.

You KNOW how hard it is to quit. You KNOW how hard it is to quit.

Your goal is to assess and assist others… even if Your goal is to assess and assist others… even if you smoke you are you smoke you are helpinghelping others. Try to focus others. Try to focus solely on the patient’s needs.solely on the patient’s needs.

If you continue to feel guilty, perhaps use this If you continue to feel guilty, perhaps use this as as motivation to consider making a quit attempt. motivation to consider making a quit attempt.

It is all in It is all in howhow you ask. you ask. Asking in a non-judgmental, open and caring Asking in a non-judgmental, open and caring

way maintains the relationship. Use reflections way maintains the relationship. Use reflections and empathy when people respond. and empathy when people respond.

Asking About SmokingAsking About Smoking Not wanting to ‘sic a doctor on a patient’ Not wanting to ‘sic a doctor on a patient’

brings up questions about the doctor’s andor brings up questions about the doctor’s andor clinic’s approach to smoking cessation.clinic’s approach to smoking cessation.

How might a Stage of Change approach be How might a Stage of Change approach be adopted by the clinic/doctor?adopted by the clinic/doctor?

How is the doctor or clinic motivating How is the doctor or clinic motivating patients?patients?

Remember that smokers need to decide and Remember that smokers need to decide and argue for change, not the health care argue for change, not the health care professional.professional.

If a Smoker Gets Mad…If a Smoker Gets Mad… Use MI skills! Help frame why you are asking Use MI skills! Help frame why you are asking

so it is normalized, not personal.so it is normalized, not personal.

““I’m sorry if asking about smoking upset you. I’m sorry if asking about smoking upset you. That is not what I intended. I ask all That is not what I intended. I ask all patients/clients about a lot of behaviors such as patients/clients about a lot of behaviors such as diet, exercise, their relationships, etc. I ask diet, exercise, their relationships, etc. I ask because if you have questions or want because if you have questions or want resources, I can assist you. If you are not ready resources, I can assist you. If you are not ready to quit, that is OK. We are here for you when to quit, that is OK. We are here for you when you are ready. Just know that we’ll ask you you are ready. Just know that we’ll ask you again when you are here next time. We ask again when you are here next time. We ask because we care about our patients.”because we care about our patients.”

Reflect and empathize with feelings.Reflect and empathize with feelings. Ask open questions.Ask open questions.

Goals Based on SOCGoals Based on SOCStage of ChangeStage of Change Ambivalent=Ambivalent=

Preparation=Preparation=

Action/ Quitting=Action/ Quitting=

Slips or Slips or Relapse=Relapse=

Therapist’s Tasks or Goals:Therapist’s Tasks or Goals:

Develop AwarenessDevelop Awareness= Simple or Double = Simple or Double Reflection, Reframes, Simple feedbackReflection, Reframes, Simple feedback

Amplify DiscrepancyAmplify Discrepancy= Double-sided = Double-sided reflections, Elaboration, Looking Forward,reflections, Elaboration, Looking Forward,Feedback and teaching, Set GoalsFeedback and teaching, Set Goals

Strengthen MotivationStrengthen Motivation= Looking Forward, = Looking Forward, Elaboration, Reflections, Behavior GoalsElaboration, Reflections, Behavior Goals

Reinforce Behavior/MotivationReinforce Behavior/Motivation= Reflect, = Reflect, Behavioral Goal SettingBehavioral Goal Setting

Reframe Slip as TreatmentReframe Slip as Treatment= Reflections, = Reflections, Shift Focus, Looking Forward, Goal Shift Focus, Looking Forward, Goal

Scenario #1Scenario #1

Patient is a 65 yr old smoker male with Patient is a 65 yr old smoker male with COPD, on oxygen and does not think COPD, on oxygen and does not think he can quit, when pushed/asked, he he can quit, when pushed/asked, he says he does not think it is worth it, says he does not think it is worth it, that he does not think he'll feel better that he does not think he'll feel better or that it will make a difference to his or that it will make a difference to his health.health.

Scenario #2Scenario #2

Young Latino mother in office with Young Latino mother in office with young child with ear infection. She young child with ear infection. She does not smoke but her husband does not smoke but her husband does and she does not want to talk does and she does not want to talk with him about it.with him about it.

Scenario #3Scenario #3

Patient is a 16 year old in for school/ Patient is a 16 year old in for school/ work exam and he smells like smoke, work exam and he smells like smoke, says he smokes but not much and says he smokes but not much and does not think it is a problem and does not think it is a problem and looks at the floor when you/ clinician looks at the floor when you/ clinician begins to talk about smoking.begins to talk about smoking.

References & SourcesReferences & Sources Abrams, D., Niaura, R., Brown, R., Emmons, K., Goldstein, M., & Monti, P. Abrams, D., Niaura, R., Brown, R., Emmons, K., Goldstein, M., & Monti, P.

(2003). (2003). The Tobacco Dependence Treatment HandbookThe Tobacco Dependence Treatment Handbook. New York: . New York: Guilford Press.Guilford Press.

Amrhein, P. Miller, W., Yahne, C., Palmer, M., & Fulcher (2003). Client Amrhein, P. Miller, W., Yahne, C., Palmer, M., & Fulcher (2003). Client Commitment Language During Motivational Interviewing Predicts Drug Use Commitment Language During Motivational Interviewing Predicts Drug Use Outcomes, Outcomes, Journal of Consulting and Clinical PsychologyJournal of Consulting and Clinical Psychology, 71(5),862-878., 71(5),862-878.

Burke BL, Arkowitz H, & Menchola M. (2003). The efficacy of motivational Burke BL, Arkowitz H, & Menchola M. (2003). The efficacy of motivational interviewing: a meta-analysis of controlled clinical trials. interviewing: a meta-analysis of controlled clinical trials. Journal of Journal of Consulting and Clinical Psychology.Consulting and Clinical Psychology.7171:843–61.:843–61.

Miller, W. R., & Rollnick, S. Motivational interviewing: Miller, W. R., & Rollnick, S. Motivational interviewing: Preparing people for change (2nd ed.) (2002). New York: Preparing people for change (2nd ed.) (2002). New York: Guilford Press.Guilford Press.

Prochaska JO, DiClemente CC. (1983) Stages and processes of self-change Prochaska JO, DiClemente CC. (1983) Stages and processes of self-change of smoking: toward an integrative model of change. of smoking: toward an integrative model of change. Journal of Consulting Journal of Consulting and Clinical Psychology, 51:390-5and Clinical Psychology, 51:390-5. .

Velasquez, M., Maurer, G., Crouch, C., DiClemente, C. (2001) Velasquez, M., Maurer, G., Crouch, C., DiClemente, C. (2001) Group Group Treatment for Substance Abuse: A Stages of Change Therapy Manual.Treatment for Substance Abuse: A Stages of Change Therapy Manual. New New York: Guildford Press.York: Guildford Press.

Velicer, W. F, Prochaska, J. O., Fava, J. L., Norman, G. J., & Redding, C. A. Velicer, W. F, Prochaska, J. O., Fava, J. L., Norman, G. J., & Redding, C. A. (1998) Smoking cessation and stress management: Applications of the (1998) Smoking cessation and stress management: Applications of the Transtheoretical Model of Transtheoretical Model of behavior change. behavior change. Homeostasis, 38,Homeostasis, 38, 216-233. 216-233.