Coping with Flashbacks and Dissociation


There are a variety of situations where a client or helpline caller may experience negative emotions and need to use coping strategies to help themselves cope. These can include flashbacks to abuse or trauma (such as in child sexual abuse or Post Traumatic Stress Disorder), dissociation, or simply intrusive thoughts or memories of a variety of painful experiences.

In these situations, there are a variety of techniques that can be taught to clients to help them stay grounded and cope. They are summarized below.

Physical Techniques for Coping with Flashbacks

Physical techniques focus on using your physical body or space to reduce your flashbacks or dissociation.

  • Plant your feet on the ground or grasp the arms of a chair
  • Repeat one’s name, age or location
  • Go to a safe space (e.g. home), a place where you feel calm and safe

Behavioural Techniques for Coping with Flashbacks

Behavioural techniques are actions that you can take when you feel stressed or overwhelmed. Ways of expressing yourself can give you a sense of control that will make it easier to cope.

  • Journal or writing
  • Verbalizing emotions
  • Calling a crisis line or mobile crisis team
  • Going to the hospital
  • Taking a walk

Cognitive Techniques for Coping with Flashbacks

Cognitive techniques are those things that involve your thoughts. These may be more challenging than the other techniques but with practice will become easier to use when you are feeling overwhelmed. Because these are hard to summarize they’ve been listed with more detail than the above techniques.

Identify Internal Cues

Internal cues are those things that prompt you to think that you are going to dissociate or experience flashbacks. Sometimes they come on randomly, but for other individuals there is a period of feeling flushed, having a racing heart, feeling anxious or restless, or other symptoms that precede the flashbacks or dissociation. When you recognize these occurring, using the other techniques on this list can help you cope.

Identify Associational Cues

Associational cues are those things that you associate with safety and security. These can be objects, sources of support like pets or other things that remind you that things will be okay. The association between the item and the positive thoughts it brings can help ground you.

Safe Space (Mind)

Going to a “safe space” mentally and remembering that what you are experiencing is temporary can be helpful. Guided imagery (described below) can help you find this safe space, which can also be a place in your own memory where you felt safe and protected.

Meditation and Guided Imagery

Meditation is a very common strategy for coping with flashbacks and dissociation. Meditation takes practice, but by using slow and steady breathing and trying to clear your thoughts when you are not in a state of dissociation or flashbacks, you will build this skill up to where you can implement it when you sense you are going to dissociate.

Guided imagery is similar, but rather than meditating or focusing on your own breathing, you focus on a guided story that will help keep you grounded.

Label Emotions

Labeling your emotions can be a very effective way of reducing immediate stress. This can be both to yourself (merely talking out loud), or to a support like a friend, a pet or a crisis line. Many people who experience trauma have difficulty labeling their emotions and this exercise (especially when practiced as part of comprehensive therapy) can help keep you grounded.

Cognitive Restructuring

Cognitive restructuring refers to techniques of identifying and challenging automatic or maladaptive thoughts. The simplest way to do this is with an ABC (Action, Behaviour, Cognition) worksheet. An ABC worksheet lists actions that made you feel bad, behaviours or results from that, and the cognitions that went along with that.

For instance,

  • Action: A girl didn’t smile at me when I smiled at her
  • Behaviour: I felt bad
  • Cognition: I’m not attractive

This is an example of a common ABC scenario. The goal is to identify other possible cognitions so that you can “rewrite the script.” An example of a different script:

  • Action: A girl didn’t smile at me when I smiled at her
  • Behaviour: I realized she probably didn’t see me
  • Cognition: Nobody has judged my attractiveness yet

This process is best accomplished with a therapist, but can be done in a self-help format. The book Mind Over Mood utilizes many of these techniques.

General Self Care for Coping with Flashbacks

  • HALT – Hungry, Angry, Lonely, Tired. These are the 4 states that make it harder to regulate your emotions and increase your impulsiveness.
  • Eating Healthy
  • Exercising
  • Medical Evaluation

5-4-3-2-1 Coping with Flashbacks

This technique is a very popular technique for coping that focuses on what you identify as real and also serves as a form of meditation.

  1. In 5-4-3-2-1 coping, you begin by thinking about five things that you can see around you. Listing them off out loud can help you with this exercise. Study them and describe them to yourself. Performing deep breathing (a slow inhale over 5 seconds, holding for 5 seconds, and exhaling over 5 seconds) can help with this as well.
  2. Next, describe 4 things that you can feel, such as your heart beating, your feet on the floor or your back in your chair.
  3. Next, 3 things that you can hear, like a television in another room, traffic outside or birds singing.
  4. After that, 2 things that you can smell – or two smells that make you happy, like fresh baked cookies.
  5. Finally, end with one thing you can taste. Your saliva, gum, or food you ate recently? Some people also substitute “One thing you like about yourself” for this exercise as well.
Cite this article as: MacDonald, D.K., (2017), "Coping with Flashbacks and Dissociation," retrieved on October 22, 2018 from
Facebooktwittergoogle_plusredditmailby feather

Using the Violence Risk Appraisal Guide (VRAG)


The Violence Risk Appraisal Guide (VRAG; Quinsey, Harris, Rice, & Cormier, 2006) is a tool that can be used to estimate statistically the risk of recidivism. It is comprised of 12 items that are associated with a risk of re-offending and is completed with all available information. You can download the full VRAG in PDF format. The Sexual Offender Risk Appraisal Guide (SORAG) is reviewed in another article.

The VRAG is an actuarial risk assessment, involving a mathematical technique applied to determines what factors were present in offenders who later went on to commit violent crimes. (Brown & Singh, 2014) This approach eliminates the bias found in unstructured judgement.

The VRAG has been examined in over 40 studies, and has been found effective even with individuals who have a lower IQ. (Camilleri & Quinsey, 2011)

Completing the VRAG

The first step to completing the VRAG is to complete the Childhood & Adolescent Taxon Scale. Below, where a request for information relates to an “index offense” that is the one that led to the individual entering the Criminal Justice system

Childhood & Adolescent Taxon Scale (CATS) Worksheet

This scale includes 8 items that are scored from 0 to 1, based on the coding guidelines provided. These items are:

  1. Elementary School Maladjustment
  2. Teenage Alcohol Problem
  3. Childhood Aggression Rating
  4. More Than 3 DSM Conduct Disorder Symptoms
  5. Ever suspended or expelled from school
  6. Arrested under the age of 16
  7. Lived with both biological parents to age 16 (except for death of parents)

Conduct Disorder Symptoms

Next, the assessor will complete the list of Conduct Disorder symptoms, circling those that occurred before age 16 except for items 13 and 15 which are before aged 16:

  • 1. Often bullied, threatened or intimidated others
  • 2. Often initiated physical fights
  • 3. Used a weapon that could cause serious physical harm to others (e.g., a bat, brick, broken bottle, knife, gun)
  • 4. Was physically cruel to people
  • 5. Was physically cruel to animals
  • 6. Stolen while confronting a victim (e.g., mugging, purse snatching, extortion, robbery)
  • 7. Forced someone into sexual activity
  • 8. Deliberately engaged in fire setting with the intention of causing serious damage
  • 9. Deliberately destroyed others’ property (other than by fire setting)
  • 10. Broken into someone else’s house, car, or building
  • 11. Often lied to obtain goods or favors or to avoid obligations (i.e., “cons” others)
  • 12. Stolen items of nontrivial value without confronting a victim (like shoplifting, theft, or forgery)
  • 13. Before [age] 13, stayed out late at night, despite parental prohibitions
  • 14. Ran away from home overnight (or longer) at least twice while living in parental or parental surrogate home (or once without returning for a lengthy period)
  • 15. Before [age] 13, was often truant from school

Cormier-Lang Criminal History Scores for Non-Violent Offenses

This scoring form allows you to answer item number 5 below, the Criminal History Score for Non-Violent Offenses Prior to the Index Offense. This score is developed by counting the number of non-violent offenses and applying a weight to them. For instance, bank robbery is counted x7 while Indecent Exposure is counted x2. So an individual who has two instances of Indecent Exposure and 1 instance of Bank Robbery would have (2×2 = 4) + (1×7 = 7) = 4+7 = 11.

Violence Risk Appraisal Guide (VRAG) Items

Next are the 12 VRAG items. The tool provides detailed coding instructions for each of these:

  1. Lived with both biological parents to age 16 (except for death of parent):
  2. Elementary School Maladjustment:
  3. History of alcohol problems
  4. Marital status (at the time of or prior to index offense):
  5. Criminal history score for nonviolent offenses prior to the index offense
  6. Failure on prior conditional release (includes parole or probation violation or revocation, failure to comply, bail violation, and any new arrest while on conditional release):
  7. Age at index offense
  8. Victim Injury (for index offense; the most serious is scored):
  9. Any female victim (for index offense)
  10. Meets DSM criteria for any personality disorder (must be made by appropriately licensed or certified professional)
  11. Meets DSM criteria for schizophrenia (must be made by appropriately licensed or certified professional)
  12. a. Psychopathy Checklist score (if available, otherwise use item 12.b. CATS score)
  13. (Technically 12b) bCATS score (from the CATS worksheet)

Scoring the VRAG

Determining Risk

Risk categories are provided in the VRAG manual. They are approximated here although more detail is available in the complete manual. For each score, if an individual is close to the next score you should list them as a combination of the two. For instance an individual whose score is -10, -9 or -8 would be listed as Low-Medium rather than just Low.

  • -24 to -8 is Low Risk
  • -7 to +13 is Medium Risk
  • +14 to +32 is High Risk

Determining Rate of Recidivism

The risk of recidivism is presented below, from the same manual (pages 283-286):

Probability of Recidivism
VRAG score 7 years 10 years
< −22 0.00 0.08
−21 to −15 0.08 0.10
−14 to −8 0.12 0.24
−7 to −1 0.17 0.31
0 to +6 0.35 0.48
+7 to +13 0.44 0.58
+14 to +20 0.55 0.64
+21 to +27 0.76 0.82
> +28 1.00 1.00

This is to be interpreted as a percentage. For instance a score of -10 is in the -14 to -8 category; therefore an individual would have a 7 year recidivism rate of 12% and a 10 year recidivism rate of 24%.


American Psychological Association. (2006) Quinsey, V.L., Harris, G.T., Rice, M.E. & Cormier, C.A. (2006) 2nd Ed. Violent Offenders: Appraising and Managing Risk. Washington D.C: American Psychological Association.

Brown, J. & Singh, J.P. (2014) Forensic Risk Assessment: A Beginner’s Guide. Archives of Forensic Psychology. 1(1). 49-59. Retrieved on January 20, 2017 from

Camilleri, J.A. & Quinsey, V.L. (2011) Appraising the risk of sexual and violent recidivism among intellectually disabled offenders. Psychology, Crime & Law. 17(1) 59-74

Cite this article as: MacDonald, D.K., (2017), "Using the Violence Risk Appraisal Guide (VRAG)," retrieved on October 22, 2018 from
Facebooktwittergoogle_plusredditmailby feather

A Five Stage Model for Counselling Men

IntroductionSad man

This year I was honoured to be a panelist at the “Healing Journeys: Violence and Trauma Conference Focusing on Male Victims” by the Canadian Centre for Men and Families. I sat in on a panel discussing the needs of men, and had an opportunity to discuss the influence of men and suicide. It was a wonderful learning and networking opportunity.

We know that men have smaller social circles than women (McPherson, Smith-Lovin & Brashears, 2006) and they seek help less often (Courtenay, 2011; p. 13). Finding male therapists is also difficult (Carey, 2011), which can complicate things for men experiencing current or historical intimate partner or sexual violence.

Below is a model for counselling men from the second chapter of “Counselling Fathers from a Strength-Based Perspective” in Counselling Fathers (Oren, et. al., 2010; p.30.) Although this model was originally designed for working with fathers I believe it is equally applicable to working with men who are not fathers.

Five Stage Model for Counselling Men
Five Stage Model for Counselling Men

The five stages are:

  1. Rapport and Therapeutic Alliance
  2. Assessment
  3. Identification of strengths
  4. Interventions
  5. Resiliency and Termination

Each of these will be reviewed below.

Rapport and Therapeutic Alliance

The first element of any therapy or counselling is establishing a strong therapeutic relationship. The SOLER elements of active listening (Egan, 2007) can be useful, although with a change noted below. There are also some things that can be used to establish rapport when counselling men or boys (Kiselica, 2003), including:

  • Displaying magazines relevant to men’s issues (sports, hunting/fishing, men’s health and fitness)
  • Flexible scheduling for appointments (shorter or longer to allow time for building rapport without getting tiring)
  • Using humour and self-disclosure
  • Sitting side-by-side rather than across from each other
  • Setting goals and working collaboratively
  • Using client-centered language

Kiselica also notes that traditional models of engaging with clients (especially young boys) may be ineffective, and that a more instrumental, active or group-based process may be useful.

Assessment for Counselling Men

A strength-based assessment (Graybeal, 2001) acknowledges the overlooked assets that men bring into the counselling relationship, rather than focusing on problems or challenges. This continues into the next stage (identification of strengths). In addition to identifying strengths, the concept of gender role conflict should be explored.

Gender role conflict (O’Neil, 2008) is defined as “a psychological state in which socialized gender roles have negative consequences for the person or others” and involves six elements (O’Neil, 1981) that have commonly be forced upon men:

  1. Restrictive emotionality – The inability of men to express their emotions (often because of society or familial prohibition)
  2. Health care problems – Men are less likely to seek help for their physical or mental health problems
  3. Obsession with achievement and success
  4. Restrictive sexual and affectionate behavior – Related to restrictive emotionality, men are sometimes prohibited from being affectionate with other men
  5. Socialized control, power, and competition issues – Men are socialized to pursue control, power and achievement at any cost, while men who choose a different path (for instance, by parenting) are considered weak or un-masculine
  6. Homophobia – Men who fear being called gay may be less likely to pursue heterosexual friends

By developing a deep understanding of the conflicts your client is experiencing you will be better able to identify strengths and plan appropriate interventions in the next stages.

Identification of Strengths

Identifying strengths is paramount to a positive therapeutic environment when counselling men, especially for men who have been rejected by therapists in the past. Some positive male qualities include (Oren, et. al., 2010; p.59):

  • Altruism
  • Courage
  • Generativity (Slater, 2003) – the concept of leaving your mark
  • Perseverance
  • Protection of others
  • Responsibility
  • Service

These and other values (self-sufficiency, achievement, efficiency, loyalty, and pride) can help build often-fragile male self esteem and provide a framework for intervening.

Interventions for Counselling Men

Now that you’ve performed a comprehensive assessment and you have an understanding of your client’s values, strengths, and what gender role conflict they may be experiencing you are ready to begin planning effective interventions while counselling.

Exploring times in the client’s past when they were able to cope with the problems they’re experiencing now and allowing them to narrate the stories in their life. (Smith, 2006)

Employment is often an area where men succeed, even as they are challenged in their personal life. Using work as a metaphor, men can apply the attitudes of being assertive, prioritizing, building relationships, and so on. Applying these lessons and potentially hidden skills to their personal life can help men improve their ability to deal with problems at home.

Mahalik (1999) used the concept of gender role strain – the idea that men are not living up to their gender or masculinity requirements – to help assessing and working through cognitive distortions. He suggested some strategies for changing cognitive distortions:

  1. Explore how men experience cognitive distortions as adaptive or positive instead of negative; for example, a man who values hard work in their career over everything else may experience positive career and financial benefits at the expense of their relationships with their family
  2. Examine the connection between gender role and these cognitive distortions
  3. Practice experiments to confirm or deny the accuracy of these distortions
  4. Provide more accurate beliefs to replace the distorted ones

Throughout the counselling process it’s important to recognize the impact that gender roles has on someone’s behaviour. Gently challenging these and other beliefs (like those around social support or emotional expression) and encouraging new ways of men expressing themselves are ways of working through the intervention stage. (Oren, et. al., 2010; p.145)

Resiliency and Termination

The final stage in counselling men is resiliency and termination. This starts with identification of male-positive resources or institutions such as programs to promote healthy marriages or healthy children (Oren, et. al., 2010; p.38) and finding other more informal supports in the client’s life such as friends, family, coworkers and professionals like doctors, coaches and clergy.

Finally, modelling elements of good termination in general counselling can help the client terminate other relationships (such as with partners) in their personal life more effectively. These elements include (Hardy & Woodhouse, 2008):

  • Highlighting the positives of ending sessions
  • Providing an open discussion
  • Ensuring both client and therapist are prepared for the end of therapy


Carey, B. (2011, May 21) “Need therapy? A good man is hard to find” Retrieved on October 22, 2016 from

Courtenay, W.H. (2011) Dying To Be Men: Psychosocial, Environmental and Biobehavioral Directions in Promoting the Health of Men and Boys. Routledge: New York, NY.

Egan, G. (2007) The Skilled Helper: A Problem Management Approach to Helping. 8th ed. Thomson Brooks/Cole: Belmont, CA.

Graybeal, C. (2001). Strengths-Based Social Work Assessment: Transforming the Dominant Paradigm. Families In Society,82(3), 233-242.

Hardy, J. A. & Woodhouse, S. S. (2008, April). How We Say Goodbye: Research on Psychotherapy Termination.  [Web article]. Retrived from

Kiselica, M. S. (2003). Transforming psychotherapy in order to succeed with adolescent boys: Male-friendly practices. Journal of Clinical Psychology, 59(11), 1225–1236.

Mahalik, J. R. (1999). Incorporating a gender role strain perspective in assessing and treating men’s cognitive distortions.Professional Psychology: Research And Practice, 30(4), 333-340. doi:10.1037/0735-7028.30.4.333

McPherson, M., Smith-Lovin, L., Brashears, M.E. (2006) Social Isolation in America: Changes in Core Discussion Networks Over Two Decades. American Sociological Review. 71(3).

O’Neil, J. M. (1981). Patterns of gender role confl ict and strain: Sexism and fear of femininity in men’s lives. Personnel and Guidance Journal, 60 , 203–210.

O’Neil, J. M. (2008). Summarizing 25 years of research on men’s gender role confl ict using the gender role conflict scale: New research paradigms and clinical implications. The Counseling Psychologist, 36 (3), 358–445.

Slater, C.L. Journal of Adult Development (2003) 10: 53. doi:10.1023/A:1020790820868

Smith, E. J. (2006). The strength-based counseling model: A paradigm shift in psychology. Counseling Psychologist, 34(1), 13-79.

Oren, C.Z., Englar-Carson, M., Stevens, M.A. & Oren, D.C. (2010) Counselling Fathers. Routledge: New York, NY.

Cite this article as: MacDonald, D.K., (2016), "A Five Stage Model for Counselling Men," retrieved on October 22, 2018 from
Facebooktwittergoogle_plusredditmailby feather

Cognitive Behavioral Analysis System of Psychotherapy (CBASP)


CBASP is a form of psychotherapy first described in 1984 by James McCullough and expanded on in his full-length book Treatment for Chronic Depression: Cognitive Behavioral Analysis System of Psychotherapy (CBASP) published in 2000. Although its name sounds similar, it should not be confused with Cognitive Behavioural Therapy (CBT) or similar forms of therapy.

The goal of CBASP is to “teach the patient to focus on the consequences of behaviour, and to use problem solving to resolve interpersonal difficulties. (Driscoll, et. al., 2004, pg. 2)

A 2016 meta-review confirmed that CBASP is effective for the treatment of major depressive disorder, especially when combined with medication. (Negt, et. al., 2016), while a comparison of CBASP versus treatment-as-useful — other evidence-based therapies for depression — in Wiersma et. al. (2014) found that CBASP was at least as effective as the other treatments from 8 weeks up to 32 weeks but performed better by 52 weeks, suggesting it kept clients better, for longer.

Principles of CBASP

McCullough believes that depression is caused by “learned Pavlovian fears of interpersonal encounters, and maintained by a refractory pattern of Skinnerian interpersonal avoidance.” (McCullough, 2006) Essentially what this means is that clients develop a fear of relationships based on previous bad experiences that leads them to isolation and a disconnect from their environment.

CBASP involves the client completing paperwork called the Coping Survey Questionnaire (CSQ) in between each session. These CSQ forms are used to document stressful or challenging interactions with other people by exploring what happened, how the client reacted, and what the client wanted to happen. Then the CSQs are reviewed in therapy in a process known as Situational Analysis (SA).

According to Driscoll, et. al., (2004, pg. 4) analyzing one CSQ will likely take a full session in the beginning of treatment, but as a client masters the elements of the CSQ and the SA steps (described in more detail below) they will find themselves able to cover several CSQs in one session.

Coping Survey Questionnaire (CSQ) for use in CBASP

Five Steps of Situational Analysis

The five steps of Situational Analysis mirror the items on the CSQ.

Step 1. Describe the situation

In the first step, the client is expected to describe in 3 to 4 paragraphs a specific situation that occurred without editorializing or providing extraneous detail. The goal is for the therapist to be able to understand all of the interactions that occurred in that single instance.

Step 2. State interpretation

In step 2, the client provides their interpretations about what occurred during that conversation. Many times clients will make interpretations that are broad, based on situations that are very specific. For instance, a client who receives poor customer service from a cashier may state, “He wasn’t nice to me because I’m ugly.” Asking the client to provide two or three thoughts that occurred during the interaction, or asking the client what the situation meant to them in the moment may help spur the production of interpretations.

The most effective interpretations are those that lead to the desired outcome (DO), what the client wished had happened in that situation had it occurred again.

Step 3. Identify reactions

In step 3, the client records all of their own behaviours and reactions. These include voice tone, body language, pace, and other reactions the client may have had like walking away from the situation. This allows the client to identify avenues for changing behaviours to more easily reach the desired outcome.

Step 4. Explain the desired outcome (DO)

In step 4, the client explains the Desired Outcome (DO). The therapist can ask, “What were you trying to get out of this situation?” or “How did you want things to go” in order to spur this part of the conversation. One DO should be produced for each CSQ that is completed. These DOs should be SMART (specific, measurable, attainable, realistic and timely.)

One important element related to DOs is that they have to involve the client themselves. A DO can’t involve change in another person because we don’t have control over that person. What the client does have control over is their own reactions and responses.

Step 5. Illustrate the actual outcome (AO)

The actual outcome (AO) is perhaps the easiest step, because this explores what the client actually got out of the experience. Usually this is a negative experience but it doesn’t have to be — a positive AO may be an opportunity for the client to identify what went right and how they can repeat this in the future.

After Situational Analysis

After the SA phase is complete, the client has explained the situation, what happened, how they reacted, what they wanted to happen, and how the situation ended. This is known as the elicitation phase. The next stage of the two-part process is the remediation phase.

In the remediation phase of CBASP, the interpretations and behaviours are looked at to figure out if they’re the most useful beliefs or effective responses to the situation. If they’re not (and many times they aren’t), more effective interpretations and behaviours are suggested in order to help the client better reach the DO.


Driscoll, K.A., Cukrowicz, K.C., Reardon, M.L. & Joiner, T.E. (2004) Simple Treatments for Complex Problems: A Flexible Cognitive Behavior Analysis System Approach to Psychotherapy. Mahwah, N.J.: Lawrence Elbaum Publishers

McCullough, J. P. (1984). Cognitive-behavioral analysis system of psychotherapy: An interactional treatment approach for dysthymic disorder. Psychiatry: Journal For The Study Of Interpersonal Processes, 47(3), 234-250.

McCullough, J. P. (2000). Treatment for chronic depression: Cognitive behavioral analysis system of psychotherapy. New York, NY: Guilford.

McCullough, J. P. (2006). Treating chronic depression with disciplined personal involvement: Cognitive behavioral analysis system of psychotherapy (CBASP). New York, NY: Springer.

Negt, P., Brakemeier, E., Michalak, J., Winter, L., Bleich, S., & Kahl, K. G. (2016). The treatment of chronic depression with cognitive behavioral analysis system of psychotherapy: a systematic review and meta-analysis of randomized-controlled clinical trials. Brain And Behavior, (8), doi:10.1002/brb3.486

Wiersma, J.E., Van Schaik, D.J., Hoogendorn, A.W., Dekker, J.J., Van, H.L., Schoevers, R.A., Blom, M.B., Maas, K., Smit, J.H., McCullough, J.P., Beekman, A.T. & Van Oppen, P. (2014) The effectiveness of the cognitive behavioral analysis system of psychotherapy for chronic depression: a randomized controlled trial. Psychotherapy and Psychosomatics. 83(5): 263-9. doi: 10.1159/000360795

Cite this article as: MacDonald, D.K., (2016), "Cognitive Behavioral Analysis System of Psychotherapy (CBASP)," retrieved on October 22, 2018 from

Facebooktwittergoogle_plusredditmailby feather

Quit Smoking Counselling


Counselling clients to quit smoking may be a part of your practice no matter what kind of therapy you do. While many clinicians may wish to refer clients to others for this work, learning the skills to handle smoking cessation may be a valuable addition to your work with clients in other areas and so is worth the time.

In Canada, about 1 in 5 individuals smoke (Statistics Canada, 2014) and this level has been going down, as it has in most western countries, for many years. Tobacco smoking often begins in the teen years (U.S. Department of Health and Human Services, 2012) with the Surgeon General noting that “vast majority of Americans who begin daily smoking during adolescence are addicted to nicotine by young adulthood.”

Smoking often affects the poor, mentally ill and other marginalized groups. (Passey & Bonevski, 2014) The mortality rate of both male and female smokers is three times higher than non-smokers and the rate of heart attack in middle aged men is four times higher. (CDC, n.d.)

Most individuals who attempt to quit smoking will require multiple attempts to quit, with sources citing between 5 and 30 (Chaiton, et. al., 2016).

Benefits of Quitting Smoking

The following list of health benefits comes from the World Health Organization (n.d.), and may help convince a smoker who believes that there is no point in quitting, to attempt to do so:

Within 20 minutes of your last cigarette, your heart rate and blood pressure drop.

Within 12 hours, the carbon monoxide level in your blood drops to normal.

2-12 weeks, your circulation improves and your lung function increases.

1-9 months, coughing and shortness of breath decrease.

1 year, your risk of coronary heart disease is about half that of a smoker’s.

5 years, your stroke risk is reduced to that of a nonsmoker 5 to 15 years after quitting.

10 years, your risk of lung cancer falls to about half that of a smoker and your risk of cancer of the mouth, throat, esophagus, bladder, cervix, and pancreas decreases.

15 years, the risk of coronary heart disease is that of a nonsmoker’s.

The benefits are clear! But that doesn’t mean quitting smoking is easy.

Nicotine Withdrawal

When a client stops their regular smoking, they begin to experience withdrawal symptoms within about 2 hours (Medline, 2015) as the nicotine begins to leave their bloodstream. The Mood and Physical Symptoms Scale (West & Hajek, 2004) is a tool for measuring withdrawal symptoms. These symptoms can include depression, anxiety, irritability, restlessness, hunger, inability to concentrate, poor sleep and more.

Assessment of Smoking Behaviours

The Fagerstrom Test for Nicotine Dependence is a common measure of smoking-related behaviour. It asks six questions:

  1. How soon after waking do you smoke your first cigarette?
  2. Do you find it difficult to refrain from smoking in places where it is forbidden? E.g. Church, library
  3. Which cigarette would you hate to give up?
  4. How many cigarettes in a day do you smoke?
  5. Do you smoke more frequently in the morning?
  6. Do you smoke even if you are sick in bed most of the time?

See my article on assessments for substance use disorders for more information on the Fagerstrom Test.

Interventions to Quit Smoking

Nicotine Replacement Therapy (NRT)

Nicotine replacement therapy (NRT) includes products like patches, gum, inhalers and lozenges. Use of nicotine replacement therapy nearly doubled a client’s ability to quit smoking in a Cochrane review (Silagy, et. al., 2012) NRT is contraindicated  in the following groups (Department of Health, Western Australia, 2012):

  • Lactating women
  • Smokers under 12 years of age

As well, those:

  • Between 13 and 18
  • With severe heart problems

Should receive NRT under physician supervision. Additional recommendations (e.g. for people with diabetes, mental health issues or from specific cultural groups) are found in the Clinical Guidelines in the References. In general, clients should receive medical support from a GP who can properly monitor them when taking any medications, including NRT.

Motivational Interviewing

Motivational interviewing (MI) is a brief intervention that aims to highlight and amplify intrinsic motivation and intent to quit smoking that already exists in clients. (Rollnick & Allison, 2001) Some elements of motivational interviewing include (Sciacca, 2009):

  • Change and sustain talk, messages from the client that indicate either a willingness to change or a desire to keep things the way they are
  • Rolling with resistance, and recognizing a client’s desire not to change may be the result of the clinician’s approach, the client’s unreadiness or both
  • Ensuring empathy to build a strong relationship
  • Identifying discrepancies, for instance where a client’s values (“I want to be there for my children”) conflict with their behaviours (“My daughter had to wait in the rain so I could have a smoke”)

There is a large body of research (e.g. the metareview by Lundahl & Burke, 2009) supporting the effectiveness of motivational interviewing in helping clients to quit smoking or using other substances.

The 5 A’s of Quitting Smoking

The 5 A’s describe simple set of steps for a brief tobacco intervention, they come from MDQuit (2012).

  1. Ask – It’s important to ask the patient about their smoking. Do they smoke at all?
  2. Assess – If they do smoke, how much do they smoke. You may wish to use the Fagerstrom criteria for this (see above, Assessment for Substance Use Disorders)
  3. Assist – Help the client make an informed decision about their smoking behaviour if they wish to cut down.
  4. Advice – Provide information on the risks of continuing and the benefits of quitting.
  5. Arrange – Finally, arrange some form of followup if possible to check on their progress.

Quit Smoking Training

The Government of Western Australia has produced the Brief Tobacco Intervention Training Program designed to teach basic cessation skills to clinicians (nurses and doctors) in advising clients on how to quit smoking. It is available freely online and takes about 2 hours to complete.

The California Smokers Helpline provides a number of free courses and online webinars covering a variety of smoking cessation-related topics that may be eligible for Continuing Education (CE) credits.

In Canada, the Centre for Addiction and Mental Health provides the Training Enhancement in Applied Cessation Counselling and Health (TEACH) program, comprised of online and in-person workshops to teach clinicians skills in smoking cessation.


Centers for Disease Control and Prevention. (n.d.) “CDC – Fact Sheet – Tobacco-Related Mortality – Smoking & Tobacco Use”. Retrieved on August 11, 2016 from

Chaiton, M., Diemert, L., Cohen, J., Bondy, S., Selby, P., Philipneri, A., & Schwartz, R. (2016). Estimating the number of quit attempts it takes to quit smoking successfully in a longitudinal cohort of smokers. BMJ Open, 6(6), doi:10.1136/bmjopen-2016-011045

Department of Health, Western Australia. (2011) Clinical guidelines and procedures for the management of nicotine dependent inpatients. Perth: Smoke Free WA Health Working Party, Health Networks Branch, Department of Health, Western Australia; Retrieved on August 11, 2016 from

Lundahl, B., & Burke, B. L. (2009). The effectiveness and applicability of motivational interviewing: a practice-friendly review of four meta-analyses. Journal Of Clinical Psychology, 65(11), 1232-1245. doi:10.1002/jclp.20638

Medline. (2015). Martin, L.J. “Nicotine and tobacco” Retrieved on August 11, 2016 from

MDQuit. (2012) “Brief Interventions & 5 A’s |” Retrieved on August 11, 2016 from

Passey, M., & Bonevski, B. (2014). The importance of tobacco research focusing on marginalized groups. Addiction, 109(7), 1049-1051. doi:10.1111/add.12548

Rollnick S., & Allison J. (2001) Motivational interviewing. In: Heather, N., Peters, T.J, & Stockwell T. International handbook of alcohol dependence and problems. New York, NY: Wiley; pp. 593-603.

Sciacca, K. (2009) “MOTIVATIONAL INTERVIEWING –MI, GLOSSARY & FACT SHEET” Retrieved on August 11, 2016 from

Silagy, C., Lancaster, T., Stead, L., Mant, D. & Fowler, G. (2007) Nicotine replacement therapy for smoking cessation (Review). The Cochrane Library. (3)

Statistics Canada. (2014) “Smoking, 2014”, Retrieved on August 11, 2016 from

U.S. Department of Health and Human Services. (2012) Preventing Tobacco Use Among
Youth and Young Adults: A Report of the Surgeon General. Retrieved on August 11, 2016 from

West, R. & Hajek, P. (2004). Evaluation of the mood and physical symptoms scale (MPSS) to assess cigarette withdrawal Psychopharmacology, 177, 195-199.

Cite this article as: MacDonald, D.K., (2016), "Quit Smoking Counselling," retrieved on October 22, 2018 from
Facebooktwittergoogle_plusredditmailby feather