Transcript “Alcohol and Tobacco Interventions 101” for Primary Care

Tobacco Cessation
Interventions
Lunch and Learn Seminar
Series for Physicians,
Family Health Teams, and
other Health/Allied Health
Practitioners
Session 4:
Motivational
Interviewing Part 1
Faculty: Dr. Marilyn Herie, PhD, RSW
Housekeeping
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Please sign-in
Please ensure you have completed Learning Assessment 1
http://www.surveymonkey.com/s/fhtjuly2011la1
A link to Learning Assessment 2 will be sent by e-mail
Both Learning Assessments are required for the Letter of
Completion
If you haven’t already, please dial-in via audioconference
Conference #: 1-800-669-6180
Participant Code: 925619
The Adobe Connect webinar will remain ON until 1:00 pm
Please type in your questions and comments in the chat box at
any time!!
Dr. Marilyn Herie, PhD, RSW
[email protected]
416-535-8501 ext. 7434
Dr. Marilyn Herie has worked in a variety of clinical and leadership roles at
Ontario’s Centre for Addiction and Mental Health (CAMH) since 1992, and in 2007
became Director of the TEACH Project, a University of Toronto, Faculty of
Medicine Certificate Program in Cessation Counselling. She is also an Advanced
Practice Clinician at CAMH, Adjunct Professor at the Faculty of Social Work, U of
T, and Director-elect of the U of T School of Graduate Studies Collaborative
Program in Addiction Studies. Marilyn has taught graduate and undergraduate
university courses for the past eight years, and has facilitated professional training
workshops throughout Canada and internationally. She has co-authored books,
book chapters and articles in scholarly journals on brief treatment, motivational
interviewing, alcohol dependence, relapse prevention, dissemination research and
online learning, and is first author of the 2010 Oxford University Press book:
Substance Abuse in Canada. Her areas of interest include motivation and
behaviour change, group facilitation and presentation skills, and knowledge
transfer.
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Disclosures
Dr. Marilyn Herie
Honorarium from Pfizer, 2007
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The recipient of the funding is in
compliance with the CMA and the
CPA guidelines / recommendations
for interaction with the
pharmaceutical industry.
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Disclaimer
These materials (and any other materials provided in
connection with this presentation) as well as the
verbal presentation and any discussions, set
out only general principles and approaches to
assessment and treatment pertaining to tobacco
cessation interventions, but do not constitute
clinical or other advice as to any particular
situations and do not replace the need for
individualized clinical assessment and treatment
plans by health care professionals with knowledge
of the specific circumstances.
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Disclaimer: TEACH Curriculum Development
The TEACH Curriculum and slides were developed and compiled with funding
from the Government of Ontario, Ministry of Health Promotion. Content of
slides are primarily based on evidence based guidelines including:
US Guidelines Treating Tobacco Use and Dependence: clinical Practice
Guideline 2008 Update. US Department of Health and Human Services,
Public Health Service
Rethinking Stop-Smoking Medications: Treatment Myths and Medical
Realities OMA Position Paper, January 2008.
The development or delivery of the TEACH curriculum was not influenced or
funded in any part by tobacco industry. TEACH has not received funding
from the tobacco industry. The development of the TEACH curriculum has
not been influenced by pharmaceutical industry. TEACH project did receive a
$10 000 unrestricted grant from Pfizer, to develop video vignettes that are
used in our training. Information presented on pharmacotherapy refers to
generic products only, and recommendations are based on existing
research, including the US guidelines. An algorithm is provided to help
practitioners determine if and which pharmacotherapy is appropriate for a
smoker.
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Session 4: Learning Objectives
1.
2.
Identify strategies for asking about tobacco use in a
motivational way
Apply FRAMES (components of brief, motivational
interventions in Primary Care) with patients
a)
b)
c)
d)
e)
f)
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Feedback
Responsibility
Advice
Menu
Empathy
Self-efficacy
A pragmatic practitioner’s
definition
of Motivational Interviewing
(Why would I use it?)
Motivational interviewing is a personcentered counselling method for addressing
the common problem of ambivalence about
change.
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Spirit of Motivational
Interviewing:
Respect for Autonomy
 Collaborative partnership
 Evocation of person’s own wisdom
and motivation
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A-C-E
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Autonomy
V
Collaboration
R
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Authority
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Coercion
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Education
E
S
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Evocation
U
S
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Autonomy
In the end it is
your choice –
where would
you like to go
from here?
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Collaboration
I’m interested in
your ideas on
how you want to
tackle this
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Evocation
What do you
know about the
link between
smoking and
diabetes?
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5 As – Quick Review
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Ask about tobacco use
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Advise all people who smoke to quit
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“Quitting smoking is key to improving your health/staying healthy.”
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“What are your thoughts about your tobacco use?”
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For the patient willing to make a change attempt: Offer medication
and provide or refer for counselling or additional treatment
For the patient unwilling to change at this time: Provide
interventions designed to increase future change attempts (e.g.,
FRAMES)
Assess readiness to change
Assist all people who smoke in quit attempt
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“How many cigarettes per day do you smoke?”
Identify and document tobacco use status for every patient at every
visit
Arrange follow-up: continue support:
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For the patient willing to make a change attempt: Arrange for
follow-up contacts, beginning within the first week after the
quit/change date
For the patient unwilling to change at the time: Address tobacco
dependence and willingness to change at next clinic visit
How to ASK
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Explain that you will be asking a standard series of
health questions that are directed to all patients in
order to improve health
Avoid questions that suggest that you want a negative
response. Once the patient responds negatively, it is
difficult to explore the issue further
Example of Negatively-phrased
Question:
You don’t
smoke, do
you?
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Example of Positively-phrased
Question:
Please tell me a
bit about your
cigarette
smoking, now
and in the past
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When Asking…
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Be non-judgmental
Listen attentively to patient concerns
Refrain from negative comments or
reactions
Be sensitive to broader issues such as
poverty and abuse
Make positive statements about
progress at each visit
FRAMES
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Feedback: provide clients with personal and relevant
feedback regarding their individual status
Responsibility: emphasize personal responsibility for
change and the individual’s freedom of choice
Advice: include a clear recommendation on the need
for change, in a supportive rather than an authoritarian
manner
Menu: offer a menu of strategies for change, providing
options from which the client may choose
Empathy: be empathetic, reflective, warm and
supportive
Self-efficacy: reinforce clients expectation that she can
change
Before giving feedback:
First ask permission!
Can we take a
moment to talk
about your
smoking?
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Example of Less Relevant
Feedback:
Smoking is
going to make
your health
problems
much worse
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Example of More Relevant
Feedback
You mentioned
that your dog is
important to you
– what do you
know about how
tobacco smoke
affects pets?
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Example of Less Relevant
Feedback:
Smoking in
the home is a
risk for you
and your
partner
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Example of More Relevant
Feedback
I understand that
you and your
partner are hoping
to start a family. I’m
not sure if you
already know
about how men’s
tobacco use can
affect the fetus at
the earliest stages
of development?
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ADVISE about the risks
Use positive statements to provide an
accurate assessment of risks.
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Example of Negative Advice:
If you really
love your dog,
you will quit
smoking
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Example of Positive Advice
You really care
about Fido, and
you are worried
that your
smoking is
hurting him.
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Example of Negative Advice:
Your smoking
is a risk factor
for a
developing
fetus
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Example of Positive Advice
Stopping
smoking will
help give your
baby the very
best chance of
being healthy
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Menu of Strategies
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NRT
Prescription medications
Self-help (books, online support)
Cessation counselling
Telephone quit line support
Family and friends
Combination of tools and strategies
Empathy
Reflecting back what you hear the patient say
conveys empathy and understanding
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Reflective response
Yes I am
still
smoking,
and no, I
don’t want
a lecture
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You’ve been feeling
pressured by me and
probably others about
your smoking
Follow up with
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And what you do about your
smoking is your choice. How
could I be helpful to you in
way that wouldn’t feel so
pressuring?
Reflective response
My son is
just
relentless
about my
smoking
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He is concerned about
you, but it feels a bit
like nagging
Follow up with
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Can you tell me more
about some your son’s
concerns?
Self-efficacy
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Hope or optimism for change
Listen for patient change talk
DARN CAT
 Desire
 Commitment
 Ability
 Action
 Reasons
 Taking
 Need
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Steps
Questions?
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Applying the Skills Videos
The Angry Client
http://www.youtube.com/user/teachproject#p/u/5/79YTuZUFRIc
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Applying the Skills Videos
The Pre-contemplative Stage
http://www.youtube.com/user/teachproject#p/u/4/_YOULz-MPaU
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As you watch the videos, try to
make notes of examples of:
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Feedback
Responsibility (emphasizing autonomy)
Advice
Menu of options
Empathy (reflective listening)
Self-efficacy (change talk)
Discussion and Debrief
1.
2.
3.
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What strategies did the therapist use in these
videos?
How did the client respond?
What would you be willing to try out yourself,
and what would you do differently?
Resources
2002
2009
2007
2008
www.motivationalinterview.org
2011
Remember …
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A link to the Online Course Evaluation will be
sent by e-mail.
A link to Learning Assessment 2 will also be
sent by e-mail. This must be completed by July
27th in order to receive your Letter of
Completion
Next session: August 17, 2011:
Motivational Interviewing Part 2
**Application period is now open**
Thank
you!
Copyright
Copying or distribution of these materials is
permitted providing the following is noted on
all electronic or print versions:
© CAMH/TEACH
No modification of these materials can be
made without prior written permission of
CAMH/TEACH.
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