Closing the Deal
MS3: Ms Smith is a 52-year-old woman who returns for a persistent cough. After looking at your previous visit notes, and talking with her—you have already discussed with her that the cough is caused by her smoking.
Dr M: That’s correct, she appears to have a typical smoker’s cough, and we have been working on getting her to make a quit-smoking attempt. How is she doing?
MS3: Well, I used the five A’s that we talked about, and Asked her about her smoking and Advised her to quit in the correct way—clear, strong, personalized—the way that you taught us in workshop and that we practiced. Um, the final A’s are Assess, Assist, and Arrange. I know that next we are supposed to Assess her willingness to make a quit attempt and, after that, Assist her in that attempt and then Arrange for follow up. I’m not really sure about the next step with her, though.
Dr M: Excellent job recalling the five A’s. So we’re in the Assessment phase. What is your assessment about her willingness? What stage of change is she in?
MS3: She says she doesn’t want to quit right now, so she’s in the Pre-contemplation stage?
Dr M: Be careful here; remember that the Pre-contemplation stage patient doesn’t think that smoking is a problem for them. Is that true for her?
MS3: Actually, she says she knows she needs to stop smoking but isn’t sure that she can do it. That would be more like Contemplation, right?
Dr M: That’s right. As you remember, the other stages of change are Preparation, identified by setting a date, Action, when patients actually begin the new behavior, and Maintenance/or Relapse.
MS3: So what do we do now?
Dr M: Actually, I was just about to ask you that question. She is in the stage of Contemplation, and we are helping her move to Preparation. We would know she had moved forward if she set a quit date. How do we help her move from Contemplation to Preparation?
MS3: Well, she brought in some homework that you asked her to do on your last visit. She has this list of pros and cons about her smoking. For the pros: she describes liking the taste of tobacco, smoking helps her relax, and she actually says that having a cigarette reduces her cough. For the cons, she said her family is nagging her to quit, cigarettes cost too much, and it makes her clothes smell bad.
Dr M: So how did you respond to that?
MS3: I remembered what you told us about de-bunking the pros and supporting the cons. I told her how the relaxing effect of smoking was really the result of treating the anxiety that goes along with nicotine withdrawal that starts in 2 hours after the last cigarette. She seemed interested to hear that.
Dr M: So it sounds like she is on the fence with regard to making a decision to stop. She knows she needs to quit but just doesn’t have the motivation yet. Let’s see if we can help with that. I want you to come in with me and observe the interview. Pay close attention to how I use the information we already have to help her come to a decision to quit by working with her emotions. We’ll talk about why I try to connect her emotions to her behavior after the visit.
[Dr M and MS3 knock on the door and enter the room.]
Dr M: Hi, Ms Smith. It sounds like you had a good conversation with our student here.
Ms Smith: Yes, I learned some new things about smoking, but I’m still not ready to quit.
Dr M: I hear you. It’s not easy to make that decision, is it?
Ms Smith: No, it’s the hardest thing for me.
Dr M: I understand. Would it be OK if we talked about some of the pros and cons on your homework?
Ms Smith: Yes.
Dr M: I see here that you mentioned that your family has been nagging you to quit. Can you tell me a little about that?
Ms Smith: Gosh, yes. They are relentless; both of my adult children never stop, and my husband, who quit smoking 2 years ago like it was no big deal, keeps on bringing up lung cancer.
Dr M: It sounds annoying. Tell me, do you know anyone who has had lung cancer?
Ms Smith: Well, my Dad died from it.
Dr M: Oh. Sorry to hear that. Was he a smoker?
Ms Smith: His whole life—didn’t even stop after he was diagnosed.
Dr M: How old was he when he died?
Ms Smith: 54.
Dr M: Only 2 years older than you are right now.
Ms Smith: Oh I never thought of that. Is my risk of lung cancer higher because he had it?
Dr M: Well, yes, but the smoking is the biggest risk. Tell me a little about his death—was he sick for a long time?
Ms Smith: He was diagnosed 2 years before he died—seemed a lot longer though.
Dr M: How so?
Ms Smith: Well, he lost so much weight, was in and out of the hospital, on oxygen, you know.
Dr M: I see, that must have been hard on you and your mother, to watch all of that.
Ms Smith: Oh it was terrible, especially in the end (tearful) he seemed to be in so much pain and could not catch his breath. My poor mother just did not know what to do.
Dr M: How old were you when this all happened?
Ms Smith: 22–23.
Dr M: How old are your children now?
Ms Smith: James is 24, and Mary is 21.
Dr M: (long silence) I wonder what it would be like for your children to have to go through what you did, with you being the one with lung cancer.
Ms Smith: (very tearful now) Oh my, that would be terrible
Dr M: You might be willing to do anything to avoid that, wouldn’t you?
Ms Smith: Yes, of course.
Dr M: Well, you know the one thing you can do that would most prevent that from happening, don’t you?
Ms Smith: Stop smoking.
Dr M: That’s right. Do you think you’re ready to give it a try?
Ms Smith: This is terrible, but I don’t think I am. I need to think about it some more.
Dr M: OK. Would you like to hear a suggestion about how you can think about it in a way that will help you to decide?
Ms Smith: Yes.
Dr M: Until you come back to see me, I would like you to try to think about that scene of your children standing around your hospital bed watching you dying from lung cancer each time you light a cigarette.
Ms Smith: Oh my. I don’t know if I can do that.
Dr M: Well, I don’t really expect you to do it every time, but I’d like you to try. Think of it as a dose of reality.
Ms Smith: I’ll try.
[Dr M completes the encounter. After Ms Smith leaves, Dr M and MS3 finish the discussion.]
Dr M to MS3: Well, what did you think of that?
MS3: Wow. That seemed over the top. I can’t believe you said those things in there.
Dr M: Yes, the last student I worked with felt the same as you. Emotions are a powerful tool in the decision to change behavior, especially when that behavior involves the reward center of the brain. Do you know why?
MS3: Because it all happens in the mesolimbic system of the brain?
Dr M: I have to be careful what I say around you, don’t I? You remember everything! Ms Smith knows intellectually that she needs to stop smoking, but she is overwhelmed by the craving for cigarettes. She needs a feeling as powerful as that craving for a motivator. So our job is to help her connect her behavior to authentic emotions that give weight to the pros and cons on her list. We are helping her make what she knows is the right decision, by putting emotional weight on some of the pros or cons that she is balancing.
MS3: So this approach might work for other addictions like alcohol or cocaine?
Dr M: Sure, to the extent that we are helping motivate the person to start the changing process. Also, this approach can apply to behavior changes related to obesity, exercise, and adherence to treatment regimens.
Robert Mallin, MD, Medical University of South Carolina, Author
Alec Chessman, MD, Medical University of South Carolina, Editor
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