HELPING PEOPLE CHANGE BEHAVIOUR

DR MADHU NIMESH THAKKAR

BHMS

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IS CHANGING BEHAVIOUR THAT DIFFICULT THAT IT NEEDS HELP?

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HOW MANY OF US HAVE DECIDED TO EXERCISE AND REGULARLY DO

EXERCISE?

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WHAT IS OUR PRESENT STYLE OF COUNSELLING?

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Doctor as Counselor

• Daru sodum dya

• Tambacco band kara

• “Kashala ghetos”

• “Sodun ka det nahis”

• Nahi sodlis tar liver kharab hoil

• Tambaco ne cancer hoto, mahit ahe na?

• Nahi sodlis tar maron jashil

• Gharchyancha vichar kar

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DOCTORS ARE TRIANED TO BE BAD COUNSELORS

Directive

Prescriptive

Authoritative

Advice giving

Expert

Pill for every ill mentality

Don't like being questioned, esp Google patients!!!

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ASK ABOUT ADDICTION

• Ask each and every patient about drug abuse

• Sometimes you do not even have to ask—PPT on “Could it be Addiction?”

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ASSESS

• How Much, How Long?

• How Severe? Social, Excesssive, Abuse Or Dependence

• Cage, Audit, Dast, Fagestorm Scores- Download App

• Previous Quit Attempts And The Experience Of That Attempt

• Stage Of Change

• Ability To Change? Will-readiness-ability

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GIVE FEEDBACK

• The provision of personally relevant feedback (as opposed to general feedback)

• Give it in a very objective way- do not over exaggerate or undermine

• Do not use moralistic words

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GIVE FEEDBACK

• Providing feedback is particularly effective during oral examination.

• Keep a mirror handy, and show the patient evidence of the effects of tobacco.

• Even in the absence of demonstrable disease, measures to suggest that the patient is compromising on his/her health

are useful. Eg: Peak flow meter, carbon monooxide meter

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ADVICE

• Clients may be unaware that their current pattern of substance use

• Providing clear advice HELPS in cutting down or stopping substance use

• Advice should be CLEAR, STRONG AND PERSONALISED

• “The best way you can reduce GI is to cut down or stop using alcohol”

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DOES ADVICE HELP????????

• Advice Is Most Important But Just The First Step.

• Drug Addiction Is Physical, Psychological And Behavioural Addiction.

• We Need To Go Beyond Advice……….

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WE NEED TO UNDERSTAND…….

• Addiction and recovery cycle

• Stages of Change

• Motivational Interviewing technique

• Brief Intervention technique

• Application of all above in day to day cases

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UNDERSTADING ADDICTION CYCLE

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ADDICTIVE THINKING

• Denial - “I don’t have a problem”

• Projection: “I am not the problem, you are the one with the problem”

• Rationalization : “I have a problem because of my wife keeps on nagging all the time”.

*Addictive thinking by Abraham Twerski, MD.

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ADDICTIVE THINKING

• Low self esteem

• Distorted thinking

• Self deception

• Difficulty in dealing with conflict

• Emotional Hypersensitivity

• Manipulation

*Addictive thinking by Abraham Twerski, MD.

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ADDICTIVE THINKING

• Guilt and Shame

• Omnipotence

• Spiritual Emptiness

• Hard time admitting that they are wrong

• Feel constantly victimized by and are angry at everyone.

• “The Confining Wall”

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STAGES OF ADDICTION AND RECOVERY

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EARLY PHASE OF ADDICTION

• Relief using/drinking • Increase in tolerance • Preoccupation • Denial • Loss of control in amount • Continued use despite negative consequences • Sneaking, hiding

Ideal stage for intervening, but difficult to diagnose because both the patient and the

relatives are in denial 19

MIDDLE / CRUCIAL PHASE OF ADDICTION

• Family problems

• Social problems

• Financial problems

• Legal problems

• Emotional problems

• Occupational problems

Crucial stage to intervene, or it will be too late

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LATE/ CHRONIC PHASE OF ADDICTION

• Physical problems • Withdrawal symptoms • Drinking/using to feel normal • Obsession replaces pre-occuaption • Loss of support • Hopelessness and despair

Needs to undergo 12 step program,

admission in rehab, beyond scope of OPD management

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• Addiction to hard drugs like meow meow, meth, bath salts, LSD, synthetic cannabis,

etc do not pass through these stages.

• Few doses can be enough to take the patient from “use” to 3rd stage of addiction

• They are so so addictive

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STAGES OF RECOVERY

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TRANSITION FACE OF RECOVERY

• Enters transition phase after reaching rock bottom or family/friends forces him into treatment

• Accepts that he/she have a problem

• Take supports to change the addictive behaviour

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STABILISATION PHASE OF RECOVERY (30 TO 90 DAYS)

• ACHIEVE ABSTINENCE

• RECOVER FROM WITHDRAWALS

• NO PREOCCUPATION/ OBSESSION

• HOPE AND MOTIVATION

• Rehab programs are minimum of 30 days and usually of 90 days –for stabilisation.

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Treatment/counselling in transition and stabilisation phase is acting

“externally”

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EARLY RECOVERY (6 MONTHS TO 1 YEAR)

• Physical healing (drinking problem)

• Psychological healing(thinking problem)

• AA steps: 1, 2 ,3

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MIDDLE RECOVERY (2 TO 3 YEARS)

• Emotional healing (Feeling Disease)

• Inter-personal healing( healing relationships)

• Actual housecleaning happens here

• AA steps: 4 to 9

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LATE RECOVERY (3 YEARS AND UP)

• Spiritual healing

• Self actualization

• Rediscover true self

• AA STEPS: 10 TO 12

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IT TAKES MANY YEARS TO TRULY RECOVER AND FIND TRUE SELF

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WHAT IS ADDICTION?

Addiction is a complex brain disease significant behavioural

characteristics

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Addiction is a disease of Brain

And we need to lay new networks for “de-addiction”

IT’S ABOUT BEHAVIOUR CHANGE

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“PILL FOR EVERY ILL” MENTALITY WILL NOT DO

IF WE HAVE TO CHANGE BEHAVIOUR , WE NEED TO UNDERSTAND HOW

CHANGE OCCURS NATURALLY?

Stages of Change Prochaska and DiClemente (1982)

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Stages of Change Prochaska and DiClemente (1982)

People often go through a series of “stages”

from the point they begin to realize that they have a problem and consider to do anything about it.

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CYCLICAL, NOT LINEAR

• Happy users

• Unaware a problem exists or underestimate

• Denial

PRECONTEMPLETION

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• Beginning to acknowledge there is a

problem

• Begin thinking of solutions

• But have not yet made a decision to change

• Ambivalent

• Want to be in this stage and change at the same time

• Procrastination as “indecision” is a painful feeling

• Perceived as “RESISTANT”

COMTEMPLATION 38

• Have made the decision to change • Ready to change in next 30 days • Trying to find out alternatives and solutions • Some anxiety about change may still persist • “ Let’s go”--motivated for change

PREPARATION STAGE

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• “Doing it” for few months( less than 6)

ACTION STAGE

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• Has been abstinent for few months

• Is not “preoccupied” about the object of addictions

• Has found new “re-inforcers”

Maintenance Stage

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Something happened and patient has slipped back to previous pattern of drug abuse

RELAPSE

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Pre- Contemplation

Contemplation

Preparation Action

How many patient’s are ready for treatment?

What if we wait for patient to go through this changes on his own ,

without any intervention?

Wait for he/she Reaching the Rock bottom

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“Reaching the rock bottom”

• When an addict realises that stopping drugs

is less painful than taking drugs, it is called “Reaching the rock bottom”

• Physical, mental, emotional and spiritual damage already might have occurred

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STAGES OF ADDICTION AND RECOVERY

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ROCK BOTTOM

SO CAN WE SPEED UP THE

CHANGE PROCESS?

• BY INFORMATION?

• BY EDUCATION??

• BY ADVICE???

MOTIVATION

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Change and motivation

• Motivation is a key to Change.

• Patients may not have to hit “rock bottom” to become

aware of the need to change.

• Intrinsic motivation is the basis for change, extrinsic

motivation provide suitable conditions for change.

• Motivation to change can be influenced by doctors, family,

friends, emotions and community support.

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DOCTOR AS MOTIVATOR

• Doctors still enjoy a privileged position in our “commercial” health sector.

• “After God, its Doctor’

• Good interpersonal skills is more important than professional training or experience

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DOCTOR AS MOTIVATOR

• Change is the responsibility of the patient,

our role is assist and encourage patients to recognize problem behaviour.

• We can help the patient feel competent to change, to begin treatment and prevent relapse

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BUT WE DOCTOR HAVE NO TIME

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NO SPECIAL TIME REQUIRED

Motivational interviewing*

Motivational interviewing is an EFFECTIVE way to talking to people

about change.

It is useful where you need a change in behavior- obesity, diabetes, HT,

exercise, etc

*Miller and Rollnick

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1200 PUBLICATIONS

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Role of Motivational interviewing

• MI helps resolve the AMBIVALENCE

• Elicits patients own motivation for change

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Motivational interviewing • Start “where the patient is” • Try to see things from the patient’s point of

view • Positive approaches are more effective than

confrontation or advisory approach

• “Be patient”

“Jism ki baat nahi, unke dil tak jaana hai. Lambi doori tay karne mein waqt to lagta hai”

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What exactly we do in motivational interviewing?

• Win the confidence of the patient

• Make him/her realise that he/she has a problem

• Help him find his/her own reason for change

• Help him/her develop ability to change

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Principles of Motivational interviewing

MI is founded on 4 basic principles:

Express empathy

Develop discrepancy

Roll with resistance

Support self-efficacy

These are basic counseling skills

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EXPRESSING EMPATHY

• Empathy comprises an accepting, non-

judgmental approach that tries to

understand the patient’s point of view.

• We express empathy by our “accepting” body

language and reflective listening skill

• Avoid confrontation and blaming or criticism

of the patient.

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EMPATHISE WITH THEIR REASONS FOR DRUG USE

• “Zop laagat nahi manhun thodi gheta roj”

• “Handling irritant clients at call centre is the reason for you using drugs to calm your nerves”

• “Ghanich kaam daaru ghetlya shiway hot nahi”

• “Bayko saarhki navin ghara sathi kit kit karte, manhoon drinks gheto”

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Develop discrepancy

Create and amplify in the patient’s mind a

discrepancy between their current behaviour

and their goals

What they want, and what will they get if they

continue the addictive behaviour

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Why ask patient?

We can tell patients why they should quit drugs

• “Cancer hoyil”

• “Liver kharab hoyil”

• “Tujhe aai wadil devsarhke- malkari ani tu daaru ghetos?”

• “Daaru ghena tujhya sarkhya shiklelya mansala ghena changala nahi”

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Patients will find their own reason to quit drugs

• “Mula mothi zali and shikale aahe. Tyaana me mishri khalela nahi aawadat”

• “My girlfriend hates me smoking”

• “I am applying for job in gulf and have to stop my smoking”

• “People say one cannot “perform” if you smoke, so I want to stop smoking

• “I am into marketing job and gutka stains my teeth. Its affecting my performance”

• “We are planning for child and want to stop smoking”

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DEVOLOPING DISCREPANCY HELPS…

“PATIENT express their own reasons for change”

The best idea come from the patient

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HINTS FOR NOT SO GOOD THINGS

Health – physical and mental;

Social – relationships with partner, family, friends,

work colleagues

Legal – accidents, driving while under the influence

of a substance

Financial – impact on personal budget

Occupational – difficulty with work, study, looking after home and family

Spiritual – feelings of self worth, guilt.

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HOW TO CREATE DISCREPANCY?

Asking open-ended questions to get patient start thinking and talking about their substance use

• “What are the good things about using drugs?”

• “What are the ‘less good things’ for you about using drugs?

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Patient may not be ready for change!!!!!!!!!!

• “Awadha samjhwun sudha tumhi sudharat nahi mahanje kay?”

• “Tunhala tumchya gharchyanchi- mula balanchi kaljich nahi”

• “Nahi sodhlis tar maroon jashil”

• “Tula sodhaychich nasel tar majhya kade yeyo nakoos”

• Addiction is a chronic disease with remissions

and relapses

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Roll with resistance

• Avoid resistance or confrontation

• Shift perceptions

• Invite, but do not impose, new perspectives

• Value the patient as a resource for finding

solutions to problems

• Keep the doors open!!!!

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NOT READY TO QUIT- USE

• Relevance

• Risk

• Rewards

• Roadblocks

• Repetition

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Support self-efficacy The patient’s belief in the ability to change

is an important motivator

Optimistic empowerment

Restoring their self esteem

Thomas Edison

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Skills we need to develop for MI

• Ask open ended questions

• Affirmation

• Reflective listening

• Summarizing

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Open or closed?

• Are u having pain?

• How are you feeling?

• Don’t you feel like quitting drugs?

• What do you think about your drug habit?

• So are you ready to quit alcohol?

• What do you thing about setting a quit date?

• Does the wife gets mad at you?

• What is your wife’s reaction ?

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ASK OPEN ENDED QUESTIONS

What do you enjoy about your drug use?

What’s about the drug use that you don’t like ?

You seem to have some concerns about your substance use; tell me more about them

What concerns you about that?

How do you feel about ……..?

What would you like to do about that?”

What do you know about ….?

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OPEN Vs CLOSED

• OPEN ENDED QUESTIONS GETS US TO KNOW WHAT’S IN THE PATIENT’S MIND

• CLOSED ENDED QUESTIONS REFLECTS WHAT’S IN THE DOCTOR’S MIND

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Affirmation

Statements of acknowledgement about anything positive about the patient

To boost confidence

To build up self-efficacy

NO ONE TRUST THEM AND THEIR ABILITY

WE NEED TO …

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Affirmation

– “I think it is great that you want to do

something positive for yourself.”

– “That must have been very difficult for you.”

– “That is a good suggestion.”

– “I appreciate that you are willing to talk with me about your substance use.”

– You really care about your children

– It great to know that you had quit smoking almost for a week.

76 (Source: McGree, 2005)

REFLECTIVE LISTENING

• Understanding what the patient is thinking and feeling and then saying it back to the patient.

• Using reflective listening is like being a mirror for our patient

• Reflective listening shows the patient that the we understand what has been said and it can be used to clarify what the patient means.

• It conveys our empathy 77

REFLECIVE LISTENING

• “I do not want to upset my family.”

• Hmmm… I don’t know. Not sure…. I mean…

• Am I drinking so much?

“It is really important to you to keep your relationship with your family.”

“You are not comfortable talking about this.”

“You are surprised that your score shows you are at risk for problems.”

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REFLECIVE LISTENING

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Summarising

It is an important way of gathering together what has already been said.

Summarizing is used to highlight the patient’s ambivalence- it’s a long reflection

You can be selective to use your hidden agenda in summary to make a positive change in patient

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Summarising

“On the one hand, you enjoy drinking at parties and you are not using any more than your friends. On the other hand, your wife is not happy with your drinking habit and fights with you. Also it is now affecting your health that worries you”

81 (Source: McGree, 2005)

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Brief intervention

Brief intervention is low-intensity, short-duration counselling for those who screen positive

Uses motivational interviewing style

Incorporates readiness to change model

Includes feedback and advice

(Source: McGree, 2005)

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Rationale for brief intervention

• Studies show brief interventions (BIs) in primary care settings are beneficial for alcohol and other drug problems

• Brief advice (3 minutes) is just as good as 20 minutes of counselling, making it very cost effective*

• BIs extend services to individuals who need help, but may not seek it.

(*Source: WHO Brief Intervention Study Group, 1996)

Components of brief intervention

“FRAMES”

• Feedback is given to the individual about personal

risk

• Responsibility for change is placed on the patient

• Advice to change is given

• Menu of treatment options is offered to patient

• Empathic style

• Self-efficacy or optimistic empowerment

PRECONTEMPLETION

• Offering factual information about the risks of substance use

• Providing clear , strong and personalized feedback about harm because of their drug use

• Eliciting the patient's perceptions of the problem

• Exploring the pros and cons of substance use • Express concern and keep the door open. • Roll with resistance

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CONTEMPLATION STAGE

• Eliciting and weighing pros and cons of substance use

• Evoking self-motivational statements for change from the patient.

• Summarize self-motivational statements.

• Emphasizing the patient's free choice, responsibility, and self-efficacy for change .

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Preparation Stage

• Offer a menu of options for treatment and expert advice

• Evaluate “ability” to change and empower

• Elicit from the patient what has worked in the past

• Negotiate a treatment plan

• Help the patient enlist social support.

• Have the patient publicly announce plans to change.

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MENU OF OPTIONS

• Keeping a diary of substance use (where, when, how much, who with, why)

• Helping patients to prepare substance use guidelines for themselves

• Identifying high risk situations and strategies to avoid them

• Identifying other activities instead of drug use – hobbies, sports, clubs, gymnasium, etc.

• Encouraging the patient to identify people who could provide support and help for the changes they want to make

• Providing information about other self help resources and written information

•

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MENU OF OPTIONS

• Inviting the patient to return for regular sessions to review their substance use and to

• work through the “substance users guide to cutting down or stopping” together

• Providing information about other groups or counsellors that specialise in drug and

• alcohol problems

• Putting aside the money they would normally spend on substances for something else

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STAR • S: SET A QUIT DATE

• T: TELL YOUR CLOSE PEOPLE

• A: AWARENESS ABOUT WITHDRAWALS AND COPING SKILLS TO PREVENT

• R: RE-INFORCERS, REPLASE PREVENTION, REARRANGE FOLLOW UP

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ACTION STAGE

• Acknowledge difficulties for the patient in early stages of change.

• Help the patient identify high-risk situations and develop appropriate coping and problem strategies to overcome these.

• AVOID-COPE-ESCAPE • Assist the patient in finding new re-inforcers of

positive change. • Help the patient find strong family and social

support. • Focusing on the benefits of change

•

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MAINTENANCE STAGE

• Help the patient identify and maintain drug-free sources of pleasure (i.e., new re-inforcers).

• Support lifestyle changes.

• Affirm the patient's resolve and self-efficacy.

• Help the patient practice and use new coping strategies to avoid a return to use.

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Relapse/Recurrence

• Relapse is not a failure

• If relapse occurs, identify what stage the individual cycled back to and move forward from there.

• Help the patient re-enter the change cycle.

• Assist the patient in finding alternative coping strategies.

• Maintain supportive contact.

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If only tool you have is hammer then every problem looks like a nail

CHARGE FOR YOUR COUNSELLING TIME

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Thank you

Dr Madhu Nimesh Thakkar

Muktaa Charitable Foundation www.mcf.org.in

Email: madhu.oswal@mcf.org.in MOB: 9890044477

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CASE 1

Yash, a software engineer, came with his wife who is in her 1st tri of pregnancy.

Yash complains of headache, increased cough with postnasal drip, sore throat. He feels very restless, irritable and found that he is not able to concentrate in his work.

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ASK and ASSESS

• Tumhala cigarrette, daru kinwa iter kuthly savay ahe ka kinwa hoti ka?

• If yes, how much, how long, how severe is the dependence?

• What stage of change the patient is in?

• Any past quit attempts and its experience?

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WHAT’S YOUR DIAGNOSIS?

• Fagerstrom score is 8, he used to smoke more 2 packs a day: Heavy user

• Now in Nicotine withdrawals

• Stage of Change: Action

• Intervention: Assist and Arrange

• Score more than 6: Need BI and Pharmacological help

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Action stage: Trying to quit

• Help them to set a quit date in the next two weeks- done.

• Let him declare to every one that he is quitting.

• Getting tobacco out of sight- THINGS AND PLACES AND PERSONS

• Educate them about withdrawal symptoms and simple ways of handling them.

• Advise them to plan on how to handle situations that set off urges to use in ways other than by using tobacco.

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CASE 2

• A 50 year old male comes for early morning headache for last 1 month.

• BP: 180/94 NOT ON ANY ANTI-HYPERTENSIVE DRUGS

• He is a business man

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ASK

• Using tobacco ( Gutkha) since 15 years

• 12 -13 pouches a day

• Tried to quit many times as teeth are stained and does not look nice when in business meetings.

• “Khup prayatne kele, pay sutat nahi”

• Now has given up the hope of quitting because of previous failed attempts

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Assess

• Fagerstrom score: 7

• Stage of change: Contemplation

• Failed in previous attempts as had a very strong craving and his friend circle all uses Gutkha

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Feedback

• “Your score shows you have a high nicotine dependence

• Your BP is high and even if we treat BP, it wont help unless the tobacco use stops

• Chances of cardiac complications increases when tobacco use is along with diabetes or HT.

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Responsibility: Tumcha nirnay….

• Now that you know the risks, what do you think you should be doing about your Gutkha habit?

• HE SAYS HE WANTS TO QUIT: Moved from Contemplation to Preparation stage

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Preparation Stage

• Offer a menu of options for treatment and provide expert advice

• Negotiate a treatment plan

• Help the patient enlist social support.

• Elicit from the patient what has worked in the past

• Have the patient publicly announce plans to change.

• Follow up when prepared to take action

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Case 3

• Mahesh, 23 years old, labor comes for URTI

• O/e: Leucoplakia

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Ask

• “Kya tumhe bidi, cigarrate, gutka daro ya aur kisi cheej ki aadat hai ya thi?”

• Kab se?

• Kitna?

• Kabhi chodne ka prayas kiya?

108

Ask

• Taking Gutkha since childhood when he was 8 year old

• Now he takes 8 to 10 sachets a day as its costly

• Never attempted to quit otherwise cannot do the hard hamali kaam

• But he had severe restlessness, anxiety when there was a sudden gutkha ban and availability was a problem

• Has to take Gutkha first thing in the morning

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Assess

• Fagestrom score: 7

• Stage of change: Precontemplation

• No quit attempt in past

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Feedback

• Your have a lesion in your mouth which could be precancerous- Show him mirror

• Its because of your years of Gutkha use

• If you stop Gutkha at this stage, the lesion may not progress.

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Responsibilty: Tumhe sochna hai

• He says he cannot do the hamali work without Gutkha

• And he has to feed a family of 6

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USE MOTIVATION ENHANCEMENT TECHNIQUE

• Express empathy by reflective listening

“ Tumhe bahut kathin kaam karna hota hai aur bina gutkha wo karna mushkil hai

• Develop discrepancy: “Aap ko che logo ka khayal rakhna padta hai aur koi kamana wala nahi. To aap ka swasth rehna jarori hai”

• Roll with resistance: Don’t argue if he is not yet ready to give up Gutkha at this stage.

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USE MOTIVATION ENHANCEMENT TECHNIQUE

• Self efficacy: “aap ko kam karne ke liye gutkha jarori kagta hai par aap ko swasth rehana bhi aap ke pariwar ke liye bahut zarori hai”Aap ko sochna hai aap ko kya karna hai

• Give him some reading material or ask him to see the posters in your waiting room.

• Assure him of help when he wants to quit

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NOT READY TO QUIT- USE

• Relevance

• Risk

• Rewards

• Roadblocks

• Repetition

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Case 4

• Rohan wants to go to Saudi Arabia and has come to you to get rid of his alcohol habit.

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ASK AND ASSESS

• How much you drink?- 4 -5 drinks( whisky) 2 to 3 times a week . Weekends 6 to 7 drinks

• Cage questionnaire: GUILT, wife is Annoyed • Audit: Score is 15 • Tried to quit in past during Shravan, but suffered from

severe craving. • Stage of Change: Preparation with motivation to stay

abstinent. • No H/o suggesting of cardiac disease • Clinically NAD except tremors. • LFT, RFT normal.

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ADVICE and assist

• Avoid high risk situations

– times,

– places,

– occasions,

– people,

– thoughts and emotions

Use problem solving approach.

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