A Client-Generated Strategy for Smoking Cessation for the Severely Mentally Ill William Collinge, Ph.D. & Tom McLaughlin, Ph.D.(c) Univ. New England/Spurwink.

A Client-Generated Strategy for Smoking

Cessation for the Severely Mentally Ill

William Collinge, Ph.D. & Tom McLaughlin, Ph.D.(c)

Univ. New England/Spurwink Center for Research

Portland, Maine

Sherry Sabo, Ph.D.

Counseling Services, Inc., Saco, Maine

I.PROGRAM

DESCRIPTION

“Exploring lay epidemiology...”

PurposeEmploy active clients (smokers)

attending a community mental health center as paid consultants in the conceptualization and development of a program of support for clients who smoke.

Program10 meetings12 CSI clients (4 men, 8 women)

participatedAll smokers and members of ACT teams

(Assertive Community Treatment)Average 5.3 sessions of attendance per

client

RecruitmentClients were informed by their therapistsClients contacted the project manager

directlyIncentives

Payment for their time and expertise - $10/session

Opportunity to provide authoritative leadership in development of programming relevant to them

Paid cab fare for those who needed it

Consultant agreementAll clients signed a “Consumer

Consultant Agreement” Purpose of the program Payment arrangement Meeting dates

First sessionReview of the Consumer Consultant Agreement Reiteration of the purpose of the program Not a treatment program No personal or private information was sought No confidentiality agreement needed

Clients are regarded as experts and that their views and experiences of being smokers and clients of a mental health center would be highly valued

Introductions Why the project was of interest to you Brief comments about smoking history

Participant characteristics

All were in either the contemplation stage or the preparation stage

Several expressed their intention to use the group to help them move toward quitting

Age at onset of smoking: ranged from 5 to 20Several began under age 9Most began in their teens. Smoking was the norm for adults in family

background.

Reasons for smokingChronic physical discomfortHistory of physical problems“I want to feel better” “It helps me with my nerves (panic and

anxiety disorder)” “Calms my nerves” “Helps me relax”

“Smoking is a stress reduction technique”“Helps me focus” “Helps me worry less, gets my mind off

other things”“Pleasurable taste”“Something to do: play with smoke rings,

manipulate with my fingers”

Reasons for smoking

“It’s been like an old friend for 27 years”“Cigarettes won’t let you down the way

people will.”

Experiences of the social dimensions of smoking

Vacuum of social support and connectedness for most of their lives.

Smoking as a social lubricant Social connectedness and support; e.g., standing

outside together to have a smoke affords a level of intimacy and rapport.

“It helps me get to know people better, it’s a bonding ritual.”

“When I’m with people who are not smoking, it’s easier for me not to smoke”

Social perceptionsScapegoated Stigmatized by societyNeed for more compassion, empathy, and

understanding by non-smokers

Experiences with medical support

Difficulty in accessing prescription-based aids.Many were given aids such as patches,

cartridges and gumLack of accompanying counseling or

psychological preparation or for how to use these methods successfully

Conclusion: these the aids “don’t work”.Personal sense of failure

II.CONSULTANT

RECOMMENDATIONS

“An approach that respects lay epidemiology...”

Program philosophy“Support group for people who smoke” rather

than a “smoking cessation program”Need social support in a more general sense,

and smoking reduction or cessation is unlikely to happen without a great deal of support.

When support is present, the intention and commitment to quitting can then grow stronger over time

The social support dimension is more important than the specific focus on smoking per se

Unconditional acceptance, interpersonal safetyNon-competitive, non-shaming, non-

confrontive, and non-pressuringConservative of praise as well, so as not to

engender shame or embarrassment when people “backslide”

Spontaneous reinforcement of one another

FormatAll of the participants had prior experience in

AA or other addiction treatment approaches similar to the AA model. There was a very strong consensus that something similar to the AA model (but not exactly) would be a good place to start for a smoking cessation program.

Confidentiality agreement

EligibilityParticipation in the program would be

open to people who are at any stage of the Stages of Change model in relation to smoking.

GoalsCutting down rather than quitting

completelyNo pressure or expectation to quitPeople can “fall down” and not feel

ashamed

Buddy systemA buddy system could be used as an

alternative to a sponsor system. Mutual support between meetingsDo not smoke together and do not smoke

while talking with each other on the phone

Educational componentGuest speakers and multimedia

presentationsStrong visual messages are helpful for

motivation to cut down or quitObjective information about the effects

of smoking. Group members choose guest speakers

Educational topicsHow smoking affects medication How much nicotine dependence is

psychological versus physical?How can you change the thought patterns?What are the different strategies available –

different things work for different peopleStress reduction techniques

Other supportMedical support should be availableConcerns about side effects should be

addressedOther modalities of support: massage,

bodywork, acupuncture, other complementary therapies, and counseling

Co-facilitatorsCo-facilitated by a paid peer and a

professional counselorAt least equal in responsibility for

leading Peer leadership importantKeep the discussions supportive

Do NOT try to motivate people to quit smoking.

(One participant had quit a smoking cessation group at CSI because she had been asked to report a count of how many cigarettes she’d had that day and felt ashamed.)

Facilitators must be unconditionally accepting and non-judgmental.

Agency roleOpen-ended and permanent commitment by the

agencyPeople will need to be able to come and go and come back

a few months laterPeople might come to 10-15 meetings, quit smoking, slip,

and come back.

Clinician should have this responsibility built in to his/her caseload, regardless of how many people show up. (Grant funding?)

Provide transportation to the meetings.

III.OUTCOMES

Participant outcomesSeveral participants came to the

consulting group looking for support to stop or reduce smoking.

Gail quit completely by the fifth session and had remained smoke-free at the tenth session:

“This is the group that helped me the most to quit smoking. It was the fact that we agreed that we didn’t have to quit, there was no pressure.”

Jane reported by the tenth session that she had cut down and never expected to:

“We just sat around and talked, there was no stress in the group. The group had no expectations of success. I’ve quit smoking in my bedroom and in common areas of the house. I only smoke in the bathroom now. I’ve gone from a pack a day down to six on a good day, twelve on a bad day. “My grand daughter (three year old who lives with her and accompanied her to the meetings) is the love of my life, I’m doing it for her, also because of this group.”

Consensus“Being able to just talk”, with no pressure

or expectations, enabled the consultants to explore their own intentions in a way which apparently enabled those intentions to strengthen.

Conclusions

A positive and supportive group process naturally brings out people’s tendency to move toward health, even in relation to smoking.

In the absence of any expectation to quit or reduce smoking, the intention and desire to do so seemed to grow.

Several had significant reductions and one was smoke-free for the last five weeks.

Participants spontaneously created the type of environment they were envisioning for a future program and reaped the benefits of it.

Conclusions (cont’d)Participants felt they know what they need, and

it is not a formal or highly structured or professionalized “smoking cessation program” per se.

The climate of unconditional positive regard, no expectations, and simple exploration of their experience had the paradoxical effect – even in participants who did not expect or believe they were capable of those feelings.

Future directions and challenges

Currently experimenting with implementationWINGS (Wellness Inspiration Networking

Groups for Smokers)Relationship with the new Collaborative Care

ProjectConsidering a two-level approach

WINGSStructured smoking cessation program adapted for

clients with persistent mental illness

Fini