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Tobacco Dependence: Treatment Behavioral Solutions for Quitting
Tobacco Dependency continuing education psychologist CEUs

Section 17
Strategies for Implementing the Self-Efficacy Model in Smoking Cessation Counseling

CEU Question 17 | CEU Test | Table of Contents | Addictions
Psychologist CEs, Counselor CEUs, Social Worker CEUs, MFT CEUs

Implications For Counseling
As discussed, the advent of managed care has changed the practice of substance abuse counseling. If contemporary substance abuse counselors working in managed care settings are to survive, they must thoroughly attend to these changes, which requires abandoning traditional approaches that (a) treat all substance abusing clients homogeneously, (b) require a great deal of time to modify client behaviors, and (c) cannot be adapted to quantify counseling outcomes. Instead, contemporary substance abuse counselors need to adopt a model that emphasizes heterogenous and brief treatments that can be evaluated empirically. Substance abuse counseling based on a self-efficacy model attends to each of these important factors.

Levels of Care: Substance abuse occurs on a continuum, with occasional harmful use on one end and severe addiction at the other. However, this important conceptualization has not been acknowledged by many substance abuse counselors (Hser, 1995). Unfortunately, most individuals, regardless of problem severity, receive counseling based on a single model of treatment; they are encouraged to abstain entirely from psychoactive substances and to "work" the Twelve Steps of Alcoholics Anonymous (AA; Clifford, 1983; Collins, 1995). Although total abstinence, adherence to the principles of AA, and long-term residential stays are often suitable for individuals with a diagnosis of psychoactive substance dependence, they are ineffectual and inefficient strategies for those with minimal psychoactive substance involvement. In an effort to reduce this "waste of resources," managed care companies have pushed the counseling profession to provide interventions tailored to alcohol and drug problems differing in severity. Therefore, to ensure that the chosen treatment adequately matches a client's level of dysfunction, counselors have designated "levels of care" to categorize the problems associated with each interval along the continuum (Stevens-Smith & Smith, 1998).  Ostensibly, substance abuse professionals would benefit from a counseling model that can be adapted to function effectively at each level. Self-efficacy theory, and in particular the sources of efficacy, can be operationalized to address therapeutic issues at each point on the continuum. Those proposed by Marlatt (1995) are specifically classified according to substance abuse problem severity. For example, resistance efficacy most readily accommodates the needs of an alcohol and drug counselor predominately concerned with prevention. Alternatively, harm reduction efficacy is most appropriate for those who are not addicted to a drug but have a substance abuse diagnosis and need to reduce drug-using behaviors. Similarly, action and coping efficacy are appropriate approaches for helping an individual diagnosed as substance dependent to improve his or her ability to cope with cravings and high-risk situations. Finally, clients who repeatedly relapse are best helped by modifying self-perceptions related to recovery efficacy. Explaining and modeling specific methods for resuming abstinence improve client self-confidence in personal ability to reestablish sobriety after a lapse into drug use.

Brief Interventions
Although many have criticized restrictions inherent in managed care practice, research reveals that a large number of substance abusing clients respond quickly and effectively to individualized and focused brief interventions (Berg & Miller, 1992; Hester & Bien, 1995). Therefore, it is essential that those providing substance abuse services possess the necessary knowledge and skills to administer short-term counseling interventions effectively.

Several brief counseling approaches have been identified, including collaborative, solution-focused, cognitive behavioral, and strategic approaches (Hoyt, 1995). However, regardless of the underlying theory, certain characteristics are common to effective brief therapies (Welles & Phelps, 1990). Welles (1993) proposed several characteristics common to all:
Start working with the problem immediately.
Diagnose through action.
Provide the simplest, most immediate intervention.
Connect people with needed resources.

Self-efficacy based substance abuse counseling models fulfill each of these criteria. First, a self-efficacy approach allows a counselor to assess and address client problems promptly. Unlike traditional modalities that require the substance abuse counselor to spend excessive time explaining or defending the concepts of the disease model before modifying the problematic behavior, a self-efficacy approach allows counselors to assist clients to immediately change unwanted behaviors through a variety of methods including (but not limited to) identification and integration of previous mastery skills and development of new coping skills (e.g., craving resistance, refusal skills, and vicarious modeling).

Second, rather than relying on a solitary assessment to diagnose client problems, a self-efficacy strategy permits substance abuse counselors to evaluate client problems by monitoring daily behaviors. For example, at the end of a session, a counselor might ask a client with low coping efficacy to walk past a favorite liquor store in the company of supportive friends to help the client build confidence in his or her ability to resist cravings. If during the next session the client reports more positive expectations regarding the high-risk situation, the counselor can infer progress. On the other hand, if the client's efficacy beliefs fail to improve after mastery experiences, alternative means for improving the client's coping efficacy could be explored.

Third, brief interventions are simple and forthright. Obviously, traditional substance abuse counseling approaches that require a client to undertake the complicated task of developing a relationship with a deity to interrupt excessive alcohol or drug use are not simple. More important, making amends for past transgressions and developing a connection with a Supreme Being, although noble efforts, are not necessarily direct solutions to the problems of substance abuse. Alternatively, self-efficacy strategies are uncomplicated, avoid morality issues, and provide immediate solutions through rapid acquisition of pertinent skills. Marlatt (1995) noted the following:

By emphasizing the learning of new skills, the image of the addictive habit as an "immoral" activity is neutralized as an attitude of anticipated mastery begins to emerge in its place. The client begins to see the process of change not unlike other skill acquisition experiences he or she has experienced, such as learning to ride a bicycle, ice skate, or play a musical instrument. (p. 224)

Following a self-efficacy approach, counselors can immediately help clients manage substance abuse problems by providing skill training, drawing on past mastery experiences, and providing opportunities to model the behaviors of successfully rehabilitated clients.

Finally, connecting clients with appropriate sources of social support is essential for counseling success. Substance abusing individuals often need to substitute associations with drug abusing "friends" with associations with those who understand and support their decision to reduce recreational drug use. Therefore, it is crucial that helpful and effective relationships external to the counseling process be identified and cultivated. Welles (1993) aptly summarized this fundamental premise when he wrote

A good way of ending therapy is to make the therapist unnecessary. This can be most readily accomplished by encouraging the client, following a brief intervention, to make fuller use of the formal and informal support available within his or her natural environment. (p. 14)

Self-efficacy theory includes the concept of affiliation, or collective, efficacy that addresses this critical aspect of substance abuse counseling. Bandura (1997) defreed collective efficacy as "a group's shared belief in its conjoint capabilities to organize and execute the courses of action required to produce given levels of attainment" (p. 477). Research indicates that personal efficacy beliefs can be either strengthened or diminished depending on the individual's perception of the support group's competence (Bandura, 1997). Therefore, counselors can improve treatment success by helping clients to examine efficacy beliefs related to a variety of external support groups. The counselor should discourage a client's association with those groups the client concluded were ineffective and encourage association with those groups the client considered most adept and helpful. A self-efficacy approach allows the substance abuse counselor to help a client connect with groups or organizations most likely to enhance the client's efficacy beliefs and thereby increase the likelihood that goal behaviors are achieved and maintained.

Measuring Outcomes
The goals of traditional substance abuse counseling strategies, especially those based on theological constructs, are not easily stated in behavioral terms and consequently their outcomes are difficult to measure accurately. Collins (1995) summarized the complications associated with evaluation of conventional alcohol and drug counseling:

The changes [generated by managed care] are challenging the various assumptions upon which the disease model and the Minnesota Model of Treatment have been based. While these conceptualizations have undoubtedly helped large numbers of people to find recovery, they are presently under attack for their philosophical rather than empirical basis ... and because ... (they) lack credible outcome data. (p. 36)

For example, it is a methodological challenge for a counselor to measure exactly how well a client has "turned his or her will and life over to a higher power." Conversely, self-efficacy constructs provide a valuable approach for substance abuse counselors practicing in managed care settings because treatment goals can be stated in measurable behavioral terms.
Several instruments have been developed to measure self-efficacy related to a variety of drugs, including the Inventory of Drinking Situations (IDS; Annis, 1982), Alcohol Abstinence Scale (AAS; DiClemente, Carbonari, Montgomery, & Hughes, 1994), Smoking Self-Efficacy Questionnaire (SSEQ; Colletti, Supnik, & Payne, 1985), and Inventory of Drug-Taking Situations (IDTS; Sklar, Annis, & Turner, 1997). Each of these scales, and others like them, determines the level of an individual's perceived self-efficacy in relation to resistance, action, coping, abstinence, and recovery efficacy. Researchers propose that efficacy beliefs related to substance abuse can be measured using a client's self-ratings about perceived personal ability to resist an urge to use a drug in a particular situation. Annis and Davis (1989) listed samples of these types of self-rating items:
If I had an argument with a friend
If someone criticized me
If I would pass by a liquor store
If I ran into an old friend and she or he would suggest that we have a drink together
If there were fights at home
Monitoring the client's perceived efficacy related to high-risk situations by means of repeated measures or pre- and postassessments provides the counselor with an objective method for ascertaining a client's progress throughout the counseling process as well as for determining counseling outcomes.

Our review suggests that self-efficacy theory can be successfully operationalized to facilitate change in addictive behaviors. Moreover, a self-efficacy approach to substance abuse counseling offers several unique contributions. First, a variety of self-efficacy theories related to substance abuse have been identified, thus providing counselors with the means to address problems specific to those at various levels along the substance abuse continuum. Second, a self-efficacy approach provides substance abuse counselors with the means to administer brief interventions that immediately address client problems in an uncomplicated and forthright manner. Third, the evidentiary structure of self-efficacy theory promotes the development of valid, reliable, and objective techniques that counselors can use to assess and document counseling outcomes. Therefore, a self-efficacy approach to substance abuse counseling is a viable model on which substance abuse counselors can ground their professional practice and survive the rapidly changing health care system.
- Whittinghill, David; Whittinghill, Laura Rudenga; Loesch, Larry C.; The Benefits of a Self-Efficacy Approach to Substance Abuse Counseling in the Era of Managed Care; Journal of Addictions & Offender Counseling;  Apr2000; Vol. 20 Issue 2

Personal Reflection Exercise #10
The preceding section contained information about strategies for implementing self-efficacy theory in smoking cessation counseling.  Write three case study examples regarding how you might use the content of this section in your practice.

Online Continuing Education QUESTION 17
According to Whittinghill, what are three benefits of a self-efficacy model of treatment for tobacco addiction? Record the letter of the correct answer the CEU Test

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