Community Behavioral Health Tobacco Recovery Wellness Initiative Behavioral

Community Behavioral Health Tobacco Recovery & Wellness Initiative Behavioral Interventions: Tobacco Awareness Tony Klein, MPA, NCACII Tony. Klein@rochesterregional. org

DISCUSSION § § Client Engagement Strategy Promoting Culture Change Advancing an Integrated Recovery. Oriented Tobacco Intervention Practical Counseling Methods

LEARNING OBJECTIVES Participants will: § § § Learn to adapt evidence-based tobacco counseling protocols to a recovery-oriented culture Identify 2 counseling methods to ensure that the intervention is appropriate to client stage readiness Describe 5 Tobacco Awareness topics designed to advance client stage readiness

“Tobacco use is a social and cultural problem with an individual addictive component. ” Bauer, 2006 Working Copy

Embrace Recovery! Be Physically and Emotionally Healthy…. Be Alcohol, Tobacco & Drug-Free

CULTURAL ADAPTATION Goal: To accommodate the cultural beliefs, values, attitudes, and behaviors of the target population Modify Evidence-Based Treatment § § Design Treatment components Approach to delivery Nature of therapeutic relationship Hawkins, Kreuter et al. , 2008 Take into account: Historical, Environmental & Social Forces

SURFACE &DEEP STRUCTURE § Surface Structure: match intervention materials and messages to observable social and behavioral characteristics. § Deep Structure: incorporate the core cultural values of the target group to increase saliency of the message and program impact. Changes in both facilitate participants’ experience of self-reference and identification with the message, which increases the likelihood that they will identify discrepancies between their actual and ideal behaviors. Resnicow et al. , 2000

RECOVERY SLOGANS • Easy does it • First things first • This, too, shall pass • One day at a time • Keep coming back • It works if you work it • Just for today • Pass it on • Let it begin with me • Practice an attitude of gratitude • You are not alone • Share your happiness • Share your pain • Respect the anonymity of others • We’ll love you, until you learn to love yourself • Courage to change • You can’t think you way into sober living; you have to live your way into sober thinking • It’s easy to talk the talk, but you have to walk the walk • Try it your 90 days, and if you don’t like it, we’ll gladly refund your misery • Today I have more solutions than problems • We give it away to keep it • Be part of the solution, not the problem

CULTURAL ADAPTATION PROCESS Change in Surface & Deep Structure Collection PHASE I: Data § Quantitative Data § Qualitative Data § Community Based Participatory Research Methods § Community Advisory Board § Develop Culturally Appropriate and Valid Measures § Ensure Health Literacy of Materials § Cultural Translation if Needed PHASE II: PHASE III: Treatment Modification § Treatment Content § Treatment Modality § Treatment Intensity § Treatment Delivery Pilot Test § § § § Acceptability Social validity Feasibility Satisfaction Comprehension Credibility Self-Reference Therapeutic Alliance § Preliminary Efficacy PHASE IV: Outcomes § Treatment Entry § Treatment Attendance § Therapeutic Alliance § Treatment Adherence § Treatment Response § Maintenance of Treatment Response Borrelli, B. (2010). Smoking Cessation: Next Steps for Special Populations Research and Innovative Treatments. Journal of Consulting and Clinical Psychology, 78(1), 1 -12.

REFRAME LANGUAGE Use language consistent to recovery culture, 12 -Step teachings and therapeutic community principles Public Health/Medical Terms Preferred Terminology § Smoking § Quit Date § Cessation § Tobacco Use, Hit, Fix § Recovery Start Date § Tobacco Treatment, Recovery The language we use is fundamental in creating environments conducive to a recovery process. – William White

SELF-DETERMINATION THEORY Deci & Ryan, 1985 Three Psychological Needs: § Autonomy – freedom to choose § Self-Efficacy – an inner sense of competence § Relatedness – a connectedness to others “… when self-determined, people experience a sense of freedom to do what is interesting, personally important, and vitalizing. ” www. psych. rochester. edu/SDT/theory. html

STAGES OF READINESS TO CHANGE Prochaska & Di. Clemente Transtheoretical Model, 1983

STAGES OF READINESS TO CHANGE Precontemplation: The individual does not expect to make any change in behavior within the next 6 months. At this stage, the individual is resistant to hearing or learning about health behavior change. Contemplation: The individual plans to make a behavior change within the next 6 months. This stage is characterized by ambivalence about smoking. Preparation: The individual anticipates making a behavior change within the next month. Individuals in this phase have made plans for taking action and intend to make a change. Action: The individual has made a significant change; this means that the individual has quit completely. Maintenance: The individual attempts to prevent relapse. Prochaska & Di. Clemente Transtheoretical Model, 1983

READINESS TO CHANGE BEHAVIOR IMPORTANCE (Knowledge) READINESS CONFIDENCE (Skills)

TOBACCO INTERVENTIONS Two Levels of Behavioral Counseling to Match Intervention to Client Stage-Readiness: Tobacco Awareness Cognitive) § Engagement § Develop Interest § Highlight Importance § Advance Stage-Readiness Tobacco Recovery Behavioral § Learn Coping Skills § Elevate Confidence § Embrace Lifestyle Change § Always with Pharmacotherapy

TOBACCO AWARENESS 40% FACILITATION When to Use MI 40% 20% When to Use CBT (Tobacco Recovery Counseling) Norcross, J. C. Psychotherapy Relationships That Work, Seymour Fisher Memorial Workshop, State University of New York Upstate Medical Center, October 2005

TOBACCO AWARENESS Matching Counselor Role to Stage Readiness FACILITATION Stage Readiness Pre-contemplation Role Nurturing Parent Objective recognize problem behavior Contemplation Socratic Teacher Preparation/Action Experienced Coach develop willingness to change acquire skills Maintenance Trusted Consultant prevent relapse Norcross, J. C. Psychotherapy Relationships That Work, Seymour Fisher Memorial Workshop, State University of New York Upstate Medical Center, October 2005

TOBACCO AWARENESS FACILITATION Goals § Promote insight into tobacco use behavior § Identify correlation to AOD § Express a recovery-oriented message § Promote ambivalence § Elicit change talk Methods § Motivational Interviewing § Narrative Therapy § Psychoeducation (foster teachable moments)

TOBACCO AWARENESS The more change F talk that clients demonstrate, the more ACILITATION likely it is that they will move towards making a change Change Status Quo

MOTIVATIONAL INTERVIEWING § “Motivational Interviewing was developed from the rather simple notion that the way clients are spoken to about changing addictive behavior affects their willingness to talk freely about why and how they might change. ” Stephen Rollnick, Addiction 2001; 96: 1769 -70 § Motivational that works on facilitating and engaging intrinsic motivation within the client in order to change behavior. § MI is a goal-oriented, client-centered counseling style for eliciting behavior change by helping clients to explore and resolve ambivalence. www. motivationalinterviewing. org

MOTIVATIONAL INTERVIEWING 5 Principles of MI • Express empathy • Develop discrepancy • Avoid argumentation • Roll with resistance • Support self-efficacy MI Skill Basic • Reflective Listening & Thinking • Asking Clarifying Questions • Resolving Ambivalence • Enhancing Self-Motivational Statements MI in Practice • Talk less than your client • Most common response should be a reflection • Ask mostly open-ended questions • Most Important – Avoid getting ahead of your client’s stage readiness MI Method – OARS Open-ended Questions Affirm Strengths Reflective Listening Summarize Building Motivation • Ask permission • Listen Reflectively • Affirm and Support • Raise Concern • Elicit Self-Motivational Statements • Summarize www. motivationalinterviewing. org

WHAT DOES A GREAT FACILITATOR DO? § § § § § avoids taking sides (neutral position) demonstrates confidence and honesty (authenticity) is aware of the group mood and behavior of individuals demonstrates active and reflective listening asks questions that encourages client self-disclosure promotes peer to peer dialogue has a sense of humor can tolerate conflict within the group can summarize the discussion simply

SUGGESTED FACILITATOR TOPICS § The traditional use of tobacco use in the recovering community, i. e. coffee and cigarettes at 12 -Step Meetings § Share information on how cigarettes have been “re-engineered” to make them more addicting § Highlight and thoroughly explore the role that tobacco plays within alcohol and drug use rituals § Acknowledge how tobacco use may increase the potential for alcohol/drug relapse § Conduct a group decisional balance exercise § Elicit client experiences on emotional detachment

TOBACCO AWARENESS FACILITATION FUNDAMENTAL CLINICAL OBJECTIVES § Create a safe therapeutic “environment” to set the tone and direction of the discussion § Approach the topic from the clients’ perspective, experiences, existing knowledge of chemical dependency and drug recovery § Foster teachable moments § Establish a group consensus § Clearly summarize key points of the discussion

TOBACCO AWARENESS To create a safe therapeutic “environment” to set the ACILITATION tone. Fand direction of the discussion § A client-centered approach to support autonomous motivation § Set the Stage - provide a brief overview of the topic of discussion § Emphasize to the group that their verbal contribution is valuable § Ask the group for their permission to explore the topic

TOBACCO AWARENESS Sample Dialogue – Setting The Stage FACILITATION “Good morning everyone. Today, I’d like to explore some aspects of addiction and recovery that may be new to some of us. What you do with this information is totally up to you; nonetheless, it will be interesting to see if any of us can relate to the topic from personal experiences. So with your help, I’d like explore how tobacco use may be a part of the use ritual of other substances. Does anyone in this room hit on a cigarette or a cigar while drinking or getting high? Is tobacco a part of your drug use ritual? [Ask for a show of raised hands and wait for a response. ] I believe that you’ll find this discussion helpful and I’d like to share some current research on the topic. Is it OK to talk about this? ”

TOBACCO AWARENESS To increase tobacco awareness by approaching the topic from the ACILITATION clients’ perspective, F experiences, existing knowledge of chemical dependency and drug recovery “So let’s start by seeing if there is a connection for some of us to alcohol. When you’re drinking, is a cigarette a part of the picture? Would anyone like to share your experiences? ” As clients disclose their personal experiences, use reflective listening responses and summarizing as much as possible. The objective is to sustain and enrich the dialogue keeping the center of attention on the clients, not turn the session into a question and answer process. After thoroughly exploring the associations of tobacco to alcohol, give equal time to marijuana, heroin, cocaine, etc.

TOBACCO AWARENESS As clients verbally contribute to the session, explore the following: FACILITATION • Was it sometimes or always a part of your use ritual? • Would you hit on the cigarette before, during, or after hitting on the blunt? • So it sounds like a cigarette was a major player in your drug use ritual. Can you explain why it was so important? What did it do for you that made it so important? • The cigar would affect your high. Can you say more…what do you mean? • What would you do if you had a bag of dope, but didn’t have a cigarette? Typically, you will experience a session with most clients acknowledging that tobacco use is central to their drug use ritual and indicative of addict thinking, feeling and behavior. As those conclusions are shared, it’s helpful to amplify and inject humor into your reflective responses, keep the dialogue flowing, maintain the emotional energy, and repeatedly summarize client disclosure to reinforce the key points being shared.

REFLECTIVE LISTENING Simple, Amplified and Double-Sided Reflection “I always need to smoke a cigarette when I’m getting high. I go through a whole pack when drinking or drugging and totally panic when I’m down to my last cigarette or run out. ” Content Reflection “There is a strong association between your drug of choice and tobacco use. ” Feeling Reflection “You get anxious when you run out of cigarettes. ” Meaning Reflection (12 -Step Reference, Amplified) “So it sounds like you’re powerless over tobacco. ”

FINAL THOUGHTS JUMP ON IN, THE WATER IS FINE! § The more often you facilitate a tobacco awareness session: • the more narratives you will hear and can reference in future sessions • the better you become in being able to reframe language for greatest impact • the more will learn about the topic from a “street perspective” • the more depth to client disclosure will be presented § Don’t be afraid to say “I don’t know, I’ll look into it!” § Have fun!