Using the Sex Offender Risk Appraisal Guide (SORAG)

Introduction

Following up on my article about how to use the Violence Risk Appraisal Guide (VRAG), this article reviews how to use a tool that is bundled with that tool, the Sex Offender Risk Appraisal Guide (SORAG). Like the VRAG, this is an actuarial tool that can be used to predict the risk of re-offending among sex offenders.

Before reading about the SORAG, it is helpful to review the VRAG post as many of the elements that are covered in that post are required before proceeding to the SORAG items. It is recommended that any completion of the SORAG be preceded by a completion of the VRAG as this will save you a significant amount of time.

Completing the SORAG

Like the VRAG, the first step is to complete the Childhood & Adolescent Taxon Scale (CATS) worksheet and the list of Conduct Disorder Symptoms.

Cormier-Lang Criminal History Scores

In order to answer item 5 on the SORAG, Criminal History Score for Non-Violent Offenses Prior to the Index Offense, it’s necessary to complete the Cormier-Lang Criminal History worksheet also provided on the SORAG. This worksheet is completed by filling out the number of non-violent offenses and applying the weight to them noted on the sheet.

Sex Offender Risk Appraisal Guide (SORAG) Items

The SORAG itself has 14 items that are similar to those found on the VRAG.

  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 (from Cormier-Lang system)
  6. Criminal history score for violent offenses (from Cormier-Lang system)
  7. Number of previous convictions for sexual offenses (pertains to convictions known from all available documentation to be sexual offenses prior to the index offense)
  8. History of sex offenses only against girls under 14 (including index offenses; if offender was less than 5 years older than victim, always score +4)
  9. 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)
  10. Age at index
  11. 11. Meets DSM criteria for any personality disorder (must be made by appropriately licensed or certified professional)
  12. Meets DSM criteria for schizophrenia (must be made by appropriately licensed or certified professional)
  13. Phallometric test results
  14. 14. a. Psychopathy Checklist score (if available, otherwise use item 12.b. CATS score)
    14. b. CATS score (from the CATS worksheet)
    14. WEIGHT (Use the highest circled weight from 12 a. or 12 b.)

You’ll note that many of these items are available from the VRAG. The tool indicates where there are overlaps in order to save you time filling out the worksheets and tools.

Determining Risk Level of Sex Offenders

After completing the tool, you must take the total score of the SORAG and compare it to the below levels.

  • A score of -17 to +2 indicates an individual is at Low risk for re-offending
  • A score of +3 to +19 indicates an individual is at Medium risk for re-offending
  • A score of +20 to +34 indicates an individual is at High risk for re-offending

An individual who is on the border between these two levels should have that indicated. For instance, someone who scores at +1 or +2 should be noted as “Low-Medium Risk” to highlight that they are at the edge of the established risk level.

Recidivism Rates using the SORAG

Rather than grouping an individual into low, medium or high risk categories, it is often more illuminating to examine the recidivism rates. These come from Violent Offenders as well.

Probability of Recidivism
SORAG score 7 years 10 years
< − 9 0.07 0.09
−9 to -4 0.15 0.12
-3 to +2 0.23 0.39
+3 to +8 0.39 0.59
+9 to +14 0.45 0.59
+15 to +19 0.58 0.76
+20 to +24 0.58 0.80
+25 to +30 0.75 0.89
> +31 1.00 1.00

References

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.

Cite this article as: MacDonald, D.K., (2017), "Using the Sex Offender Risk Appraisal Guide (SORAG)," retrieved on June 26, 2019 from http://dustinkmacdonald.com/using-sex-offender-risk-appraisal-guide-sorag/.
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Using the Violence Risk Appraisal Guide (VRAG)

Introduction

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%.

References

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 http://www.archivesofforensicpsychology.com/web/wp-content/uploads/2015/01/Brown-and-Singh1.pdf

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 June 26, 2019 from http://dustinkmacdonald.com/using-violence-risk-appraisal-guide-vrag/.
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Level of Care Utilization System (LOCUS)

Introduction

The Level of Care Utilization System or LOCUS tool has been designed by the American Association of Community Psychiatrists (2009) to allow staff who work on inpatient hospital environments with patients with psychiatric problems (such as emergency departments, psychiatric sections of general hospitals or in psychiatric hospitals) to determine the level of care that an individual should receive.

The LOCUS provides for six levels, ranging from the least intense (recovery maintenance, such as seeing a case manager once a month and having access to a 24-hour crisis line if needed) to the most intense (medically managed residential services such as being a hospital inpatient.)

Parameters

The LOCUS is based on a set of parameters that an individual is scored along. The level of care is determined based on the mix of parameters that each client has. These parameters are:

  1. Risk of Harm
  2. Functional Status
  3. Medical, Addictive and Psychiatric Co-morbidity
  4. Recovery Environment
  5. Treatment and Recovery History
  6. Engagement and Recovery Status

In most of these domains there are a number of states that are used to code the domain. For instance, “Risk of Harm” has five potential states from Minimal Risk of Harm to Extreme Risk of Harm. The exception is 4. Recovery Environment which has two subcomponents, Level of Stress and Level of Support.

The LOCUS manual provides detailed coding instructions to allow an individual to be assessed in a reliable, repeatable way.

Levels of Care

For each Level of Care, the manual provides for four categories, Care Environment, Clinical Services, Supportive Systems, and Crisis Stabilization and Prevention Services.

Care Environment describes where services are delivered and what facilities might need to be available. Clinical Services describes the type and number of clinical employees (nurses, etc.) and the types of therapies or treatments available. Supportive Services includes client access to things like case management, outreach and financial support, while Prevention Services include mobile crisis, crisis lines, and other access to services.

Scoring

Each of the levels includes specific individual scores required for a level, and also a composite score. The Composite Score overrides the individual scores to determine which level an individual is placed at if the Composite Score results in a more intense level of care.

Composite Scores

  • Level 1 – 10-13
  • Level 2 – 14-16
  • Level 3 – 17-19
  • Level 4 – 20-22
  • Level 5 – 23 – 27
  • Level 6 – 28+

Level 1 – Recovery Maintenance and Health Management

  • Risk of Harm: 2 or less
  • Functional Status: 2 or less
  • Co-morbidity: 2 or less
  • Level of Stress: Sum of Stress and Support less than 4
  • Level of Support: Sum of Stress and Support less than 4
  • Treatment & Recovery History: 2 or less
  • Engagement & Recovery Status: 2 or less

Level 2 – Low Intensity Community Based Services

  • Risk of Harm: 2 or less
  • Functional Status: 2 or less
  • Co-morbidity: 2 or less
  • Level of Stress: Sum of Stress and Support less than 5
  • Level of Support: Sum of Stress and Support less than 5
  • Treatment & Recovery History: 2 or less
  • Engagement & Recovery Status: 2 or less

Level 3 – High Intensity Community Based Services

  • Risk of Harm: 3 or less
  • Functional Status: 3 or less
  • Co-morbidity: 3 or less
  • Level of Stress: Sum of Stress and Support less than 5
  • Level of Support: Sum of Stress and Support less than 5
  • Treatment & Recovery History: 3 or less
  • Engagement & Recovery Status: 3 or less

Level 4 – Medically Monitored Non-Residential Services

  • Risk of Harm: 3 or less
  • Functional Status: 3 or less
  • Co-morbidity: 3 or less
  • Level of Stress: 3 or 4
  • Level of Support: 3 or less
  • Treatment & Recovery History: 3 or 4
  • Engagement & Recovery Status: 3 or 4

Level 5 – Medically Monitored Residential Services

  • Risk of Harm: If the score is 4 or higher – the client is automatically Level 5
  • Functional Status: If the score is 4 or higher – most clients are automatically Level 5
  • Co-morbidity: If the score is 4 or higher – most clients are automatically Level 5
  • Level of Stress: 4 or more in combination with a rating of 3 or higher on Risk of Harm, Functional Status or Co-morbidity
  • Level of Support: 4 or more in combination with a rating of 3 or higher on Risk of Harm, Functional Status or Co-morbidity
  • Treatment & Recovery History: 3 or more in combination with a rating of 3 or higher on Risk of Harm, Functional Status or Co-morbidity
  • Engagement & Recovery Status: 3 or more in combination with a rating of 3 or higher on Risk of Harm, Functional Status or Co-morbidity

Level 6 – Medically Managed Residential Services

  • Risk of Harm: If the score is 5 or higher – the client is automatically Level 6
  • Functional Status: If the score is 5 or higher – the client is automatically Level 6
  • Co-morbidity: If the score is 5 or higher the client is automatically Level 6
  • Level of Stress: 4 or more
  • Level of Support: 4 or more
  • Treatment & Recovery History: 4 or more
  • Engagement & Recovery Status: 4 or more

Given that there are a number of nuances in the exact scoring it’s recommended that an individual read or receive structured training in administration of the LOCUS. The LOCUS manual also provides a decision tree (not shown) to assist in making your determinations and a determination grid (shown below.)

Level of Care Determination Grid

LOCUS Level of Care Determination Grid

Research

Although the LOCUS is widely used, research is surprisingly limited.

The initial study validating the LOCUS was Sowers, George & Thomson (1999). Their study examined scores on the LOCUS and correlated them to expert decisions to see if the LOCUS matched that decision-making; their results indicated that it performed well in this function.

Kimura, Yagi & Toshizumi (2013) reviewed the LOCUS by comparing scores on it to the Global Assessment Scale (GAS) scores, a similar tool and examining the change of scores from admission to discharge. They found it a sensitive and effective tool for clinical use in Japan.

Ontario Shores, a large mental hospital in Whitby, ON implements the LOCUS along with the RAI tools as well.

References

American Association of Community Psychiatrists. (2009) LOCUS Level of Care Utilization System for Psychiatric and Addictions Services, Adult Version 2010. Retrieved on January 18, 2017 from http://cchealth.org/mentalhealth/pdf/LOCUS.pdf

Kimura, T., Yagi, F., & Yoshizumi, A. (2013). Application of Level of Care Utilization System for Psychiatric and Addiction Services (LOCUS) to Psychiatric Practice in Japan: A Preliminary Assessment of Validity and Sensitivity to Change. Community Mental Health Journal, 49(4), 477-491. doi:10.1007/s10597-012-9562-6

Sowers, W., George, C., & Thomson, K. R. (1999). Level of care utilization system for psychiatric and addiction services (LOCUS): a preliminary assessment of reliability and validity. Community Mental Health Journal, (6), 545.

Cite this article as: MacDonald, D.K., (2017), "Level of Care Utilization System (LOCUS)," retrieved on June 26, 2019 from http://dustinkmacdonald.com/level-care-utilization-system-locus/.
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PREPaRE Model for School Crisis Intervention

Introduction

When we normally think of crisis intervention, we think of adults responding to events in their personal life. Of course, people young and old can require crisis intervention, and not just from events in their personal life. School violence, natural disasters and other elements can require crisis intervention.

Werner (2015) noted that the tow most important activities school counsellors can do to prepare for crisis events are to develop a comprehensive crisis plan and to practice it regularly. The goal of the PREPaRE Curriculum is to train mental health worker, school psychologists and other administrators, educators and clinicians to develop such a crisis plan, to build a crisis team to execute that plan and to understand the tasks of crisis intervention in the aftermath of a crisis.

School Crisis Intervention

Most school counsellors receive little or no crisis intervention training and therefore enter the field feeling unprepared to handle tasks that become assigned to them in the aftermath of a crisis. (Allen, et. al., 2002) Training like the PREPaRE Model and other programs can help bridge this gap.

Knox & Roberts (2005) performed a comprehensive literature review on school crisis intervention and specifically crisis intervention teams. They found that there was a need for well-thought out crisis intervention programs and plans before crises occur, and that there were similarities in the literature about how experts believed response to a crisis should be structured.

They recommended school crisis intervention be split into three phases:

Primary Interventions

Primary prevention activities are those that are provided to all students in order to promote safety and health. These could be “conflict resolution, gun safety and safe driving courses, alcohol and drug awareness programs, teenage parenting resources, and suicide prevention programs.” (Knox & Roberts, 2005; p.94)

Secondary Interventions

Secondary prevention activities focus on individuals in the aftermath of a crisis in order to limit its impact. This can include physical measures like moving students, debriefing and immediate crisis intervention in the aftermath, and notifying parents and the media.

Tertiary Interventions

Tertiary interventions include long-term counselling and psychotherapy that extends after the crisis period ends and the school environment returns to normal.

PREPaRE Framework

  • Prevent and Prepare for psychological trauma
  • Reaffirm physical health, perceptions of security and safety
  • Evaluate psychological trauma risk
  • Provide interventions and Respond to psychological needs
  • Examine the effectiveness of crisis prevention and intervention

The PREPare Model is structured around two workshops. The first (1-day) workshop is provided for all school staff to teach them how the crisis team and crisis intervention works, while the second (2-day) workshop is designed specifically for crisis team members.

PREPaRE Curriculum

The following information comes from Nickerson et. al. (2014):

Crisis Prevention and Preparedness (1-day workshop for all staff)

  • Identify four characteristics of a crisis event.
  • Identify the key concepts associated with the PREPaRE acronym.
  • Describe the four activities of the school crisis team.
  • Understand the importance of hierarchical crisis team structure and response.
  • Identify the five major functions of the Incident Command System (ICS).
  • Identify strategies for communicating with school boards creating or sustaining teams.
  • Identify three concepts related to crime prevention through environmental design.
  • Identify guiding principles in crisis plan development.
  • Identify essential components of crisis plans.
  • Identify key concepts from the workshop that their crisis team needs to learn or address to be adequately prepared for crisis situations

Crisis Intervention and Recovery (2-day workshop for crisis intervention staff)

  • Report improved attitudes toward, and readiness to provide, school crisis intervention.
  • Identify the variables that determine the traumatizing potential of a crisis event.
  • Identify the range of school crisis interventions indicated by the PREPaRE acronym.
  • Indicate how school crisis interventions fit into the larger school crisis response.
  • Specify the critical factors in evaluating psychological trauma risk after a crisis event.
  • Match psychological trauma risk to a range of appropriate school crisis interventions.

Elements of a Crisis Team

A crisis team should be in place before a crisis occurs so that they can immediately get to work after a crisis occurs. Knox & Roberts (2005) recommend that the team be comprised of 4-8 multidisciplinary members (e.g. Principal, counsellor, nurse, etc.)

Responding to a Crisis

Brock (2006) indicates a variety of responses for each level of the framework that are available to the mental health professional facilitating a crisis intervention. These items assume that a crisis has already occurred.

Reaffirm physical health, perceptions of security and safety

  • Meet physical needs like shelter and water
  • Provide a sense of safety by removing individuals from the site of a crisis
  • Remove or restrict access to dangerous objects or crisis site (remove sharps, put up barriers, etc.)

Evaluate psychological trauma risk

  • Evaluate exposure to crisis and note reactions (physical, behavioural, cognitive)
  • Examine internal and external resources (within the school and local community agencies)
  • Refer clients to psychotherapy where possible

Provide interventions and Respond to psychological needs

  • Re-establish social support systems. This can involve
  • Provide psycho-education: Empower survivors and their caregivers
  • Provide immediate crisis intervention
  • Provide/Refer for longer term crisis intervention

Evaluation of the PREPaRE Curriculum

Brock et. al. (2011) performed the initial evaluation of the program and found that participants significantly improved on their skills related to crisis prevention, crisis intervention and displayed high general satisfaction with the workshops. When Nickerson et. al. (2014) evaluated the PREPaRE after making changes they found that these benefits continued to be demonstrated in follow-ups, proving the efficacy of the program.

Training in the PREPaRE Model

Brock (2006) publishes the content of the PREPaRE workshop online, where they can be accessed in order to help individuals build their crisis intervention skills. Additionally, workshops can be accessed through the National Association for School Psychologists (NASP).

References

Allen, M., Burt, K., Bryan, E., Carter, D., Orsi, R, & Durkan, L.(2002). School counselors’ preparation for and participation in crisis intervention. Professional School Counseling, 6, 96-102

Brock, S.E. (2006) “Crisis Intervention Training”, Workshop PDF. Accessed on November 19, 2016 from www.csus.edu/indiv/b/brocks/workshops/district/smfcsd.12.06.pdf

Brock, S. E., Nickerson, A. B., Reeves, M. A., Savage, T. A., & Woitaszewski, S. A. (2011). Development, Evaluation, and Future Directions of the PREPaRE School Crisis Prevention and Intervention Training Curriculum. Journal Of School Violence10(1), 34-52. doi:10.1080/15388220.2010.519268

Knox, K., & Roberts, A. (2005). Crisis intervention and crisis team models in schools. Children & Schools27(2), 93-100.

Nickerson, A. B., Serwacki, M. L., Brock, S. E., Savage, T. A., Woitaszewski, S. A., & Louvar Reeves, M. A. (2014). PROGRAM EVALUATION OF THE PREPaRE SCHOOL CRISIS PREVENTION AND INTERVENTION TRAINING CURRICULUM. Psychology In The Schools51(5), 466-479. doi:10.1002/pits.21757

Cite this article as: MacDonald, D.K., (2016), "PREPaRE Model for School Crisis Intervention," retrieved on June 26, 2019 from http://dustinkmacdonald.com/prepare-model-school-crisis-intervention/.
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Quit Smoking Counselling

Introduction

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.

References

Centers for Disease Control and Prevention. (n.d.) “CDC – Fact Sheet – Tobacco-Related Mortality – Smoking & Tobacco Use”. Retrieved on August 11, 2016 from https://www.cdc.gov/tobacco/data_statistics/fact_sheets/health_effects/tobacco_related_mortality/

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 http://www.health.wa.gov.au/smokefree/docs/Clinical_guidelines.pdf

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 https://medlineplus.gov/ency/article/000953.htm

MDQuit. (2012) “Brief Interventions & 5 A’s | MDQuit.org” Retrieved on August 11, 2016 from http://mdquit.org/cessation-programs/brief-interventions-5

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 http://www.motivationalinterview.net/miglossary.pdf

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 http://www.statcan.gc.ca/pub/82-625-x/2015001/article/14190-eng.htm

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 http://www.surgeongeneral.gov/library/reports/preventing-youth-tobacco-use/full-report.pdf

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 June 26, 2019 from http://dustinkmacdonald.com/quit-smoking-counselling/.
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