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| Integrating Religiosity into Motivational Interviewing and Nicotine Replacement
Therapy for a Patient with Schizophrenia and Nicotine Addiction: Lessons from a
Mental Health Service |
| Peter Thomas Sandy1 and Tennyson Mgutshini2* |
| 1Buckinghamshire New University, London, UK |
| 2Faculty of Human Sciences, University of South Africa (UNISA), South Africa |
| *Corresponding author: |
Tennyson Mgutshini
Faculty of Human Sciences
University of South Africa (UNISA)
Preller Street, Muckleneuk-Ridge, Pretoria
PO
Box 392, UNISA 0003, South Africa
Tel: 0027124293377
E-mail: mgutshini.ac.za |
|
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| Received June 07, 2012; Accepted July 09, 2012; Published July 12, 2012 |
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| Citation: Sandy PT, Mgutshini T (2012) Integrating Religiosity into Motivational
Interviewing and Nicotine Replacement Therapy for a Patient with Schizophrenia
and Nicotine Addiction: Lessons from a Mental Health Service. J Addict Res Ther
3:127. doi:10.4172/2155-6105.1000127 |
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| Copyright: © 2012 Sandy PT. This is an open-access article distributed under>
the terms of the Creative Commons Attribution License, which permits unrestricted
use, distribution, and reproduction in any medium, provided the original author and
source are credited. |
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| Abstract |
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| Background: Patients with schizophrenia have a higher incidence of smoking relative to the general population.
They are more likely to smoke high-tar cigarettes than patients of other mental health problems. Smokers with this
diagnostic category are therefore more likely to be addicted to nicotine, and are at an increased risk of developing
serious health complications. Despite this, they are generally unlikely to seek help to quit smoking, a function of
their inability to do so. Although this is the case, patients with schizophrenia are rarely involved in smoking cessation
activities. Hence, this case study of a smoking cessation programmes. |
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| Aim: The intention of this case study is to explore the effectiveness of an integrated smoking cessation programme
in enabling patients to stop smoking. This paper describes the application of this programme on patients with
schizophrenia and nicotine addiction. It also describes roles played by its components in smoking cessation. |
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| Methods: The integrated programme comprised of nicotine replacement therapy and motivational interviewing. It
is a 10-week programme that involved six patients. One patient was also offered an additionally 6-week tailor-made
integrated programme that comprised of nicotine replacement therapy and motivational interviewing that creates
space for discussion of religious beliefs. This is first to include religion, nicotine replacement therapy and motivational
interviewing in a smoking cessation treatment for patients with schizophrenia. |
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| Results: Five patients quitted smoking at the end of the 10-week programme, and one stopped smoking at the end
of the additional 6-week programme. In sum, the integrated programme was successful in enabling patients to stop
smoking. |
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| Conclusion: These findings indicate that stopping smoking is possible for individuals with schizophrenia,
especially if the treatment is tailor-made to incorporate patients’ wishes. Quitting should not be considered impossible
for individuals of this patient group. Religious beliefs do have a part to play in smoking cessation. The strength of
religious identification may enable people to abstain from substance use and misuse. |
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| Keywords |
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| Motivational interviewing; Nicotine replacement
therapy; Schizophrenia; Religion; Smoking cessation |
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| Introduction |
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| People with mental disorders are twice more likely to smoke than
individuals with no mental illness [1]. This chance of smoking is
even greater for people with severe mental health problems, such as
bipolar disorder and schizophrenia [2]. Approximately 85% of people
with schizophrenia smoke more cigarettes than smokers without this
diagnosis [3]. Individuals of this patient group are also 13 times more
likely to smoke high-tar cigarettes than patients of other diagnostic
categories like anxiety and depression [4]. Certainly, such smoking
characteristics lead to greater exposure to nicotine which, as reiterated
in a number of studies, contributes to reduced smoking cessation rates
in this population. |
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| The choice of medication offered also contributes to smoking
cessation failures. People with schizophrenia are often treated with
both typical and atypical anti-psychotic medication, with the former
often generating extrapyramidal side effects, such as akathesia and
tardive dyskinesia [5]. Smoking or nicotine consumption ameliorates
these side effects as well as some illness-related negative symptoms, like
amotivation and anhedonia [6]. It is therefore not surprising to note
a significantly high incidence and prevalence of smoking behaviour
among patients with this diagnosis [7]. Such an elevated rate of smoking
is a significant contributory factor to the high medical comorbidities in
schizophrenia [8,9]. Despite this, mental health services do not often offer smoking cessation services. However, infrequent general advice
to quit is noted in the literature to be provided by mental health nurses
who are often not trained to do so [10]. Acknowledging this, cigarette
smoking among people with schizophrenia is a serious health concern
which needs to be addressed by mental health services. |
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| Background |
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| Cigarette smoking is a worldwide problem that increases both the
morbidity and mortality of individuals. It is reported to accounts for 3
to 5 million deaths worldwide annually, an estimate that is predicted to
reach 10 million in the year 2030 [11]. Individuals with schizophrenia
are at a greater risk of death than those in the general population
[12]. Added to this, they are generally believed to die prematurely; approximately 25 years earlier relative to people in the general
population [13]. This risk of premature death is attributable to poorer
dietary intake and smoking-related illnesses, with the latter considered
as primary contributory factors [10]. |
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| Schizophrenia patients, particularly those who smoke regularly, are
at an increased risk of dying from stroke, cardiovascular and respiratory
disorders [14]. Despite this, individuals of this patient group are
generally unlikely to seek help to quit smoking, a function of their
inability to do so [15]. This appears to be the case, as many researchers
stress that many individuals living with schizophrenia do want to quit
smoking, but this desire is in the main impaired by loss of confidence
and ability caused by their illness [4]. Yet smoking cessation activities,
including counselling, are rarely provided to these patients. This is a
function of healthcare professionals’ assumption that members of this
patient category are unlikely to quit smoking. But taking into account
the high rates of cigarette smoking among people with schizophrenia
and the health implications associated with this behaviour, it is critical
to offer assistance with smoking cessation to this patient group. |
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| It is noteworthy to indicate that there is currently no specific protocol
available in the United Kingdom to guide smoking cessation activities
for people with severe mental health problems. This is based on the
view that the treatment approaches that are deemed to be effective in
other clinical populations are also valuable in enabling individuals with
severe mental health problems to stop or at least reduce their smoking
behaviour. These views are shared by healthcare providers in other parts
of the world. Taking Canada and Australia as examples, mental health
services are encouraged to implement smoking cessation programmes
similar to those that are effective in the general population [1,2,4].
However, taking into account that quit rates are significantly lower in
people with mental health problems than the general population, it is
critical to state that cessation interventions may require some degree of
adjustment, for example, in treatment duration, to effectively address
the needs of this patient group [16]. |
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| The standard treatments offered to smokers wanting to quit smoking
include nicotine replacement therapies (NRTs) and psychological
approaches [17]. NRTs are available in gum, inhaler, spray, lozenge
and nicotine patch. The psychological approaches, which include
motivational interviewing and cognitive behavioural therapy (CBT),
can be delivered using an individual or group format. The use of a single
treatment strategy, NRTs or psychological approaches, is identified in
some studies to reduce smoking rates in smokers with a diagnosis of
schizophrenia. Patches and inhalers are frequently used in in-patient
settings as the main forms of NRTs. The use of these forms of NRTs
reduced cigarette consumption among patients with schizophrenia
in both in-patient and community settings [2]. However, patients
with this diagnosis are often reported to experience some difficulties
maintaining long-term abstinence. Similar findings were observed in
studies which used single psychological approaches, such as CBT, to
facilitate smoking cessation in patients living with schizophrenia [18].
Although individuals of this patient group are usually motivated to stop
smoking the absolute quit rates when single approaches are used, are
usually significantly lower compared with people without mental health
problems [19]. Acknowledging this, combining pharmacological and
psychological treatment approaches may optimise outcomes. |
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| A combined treatment approach of NRTs, CBT and bupropion on
patients with schizophrenia, indicated a significantly higher abstinence
rate at six month in the treatment group relative to the controls [20].
A comparable outcome is noted in a similar study conducted three
years later [21]. High quit rates were achieved in the treatment group compared with the control group, with indications of acute urges to
smoke noted in some members of the former [22]. The presence of
these urges indicates the possibility of relapse; meaning some patients
may resume their smoking behaviour. For these patients, this may not
only indicate a low readiness to quit smoking, but it may also suggest
the possibility of nicotine dependence. |
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| Nicotine dependence relates to compulsive use of tobacco product
and diminished ability to abstain [23]. In addition to compulsion to
smoke, people who are addicted to nicotine also frequently encounter
intense motivation to continue with their behaviour [24]. It is these two
factors, as repeatedly reiterated in the literature that overwhelm and
undermine people’s attempts at abstaining from smoking [25]. Clearly,
motivation to smoke is a central feature of nicotine dependence.
Accepting this, smokers` ratings of their urges or motivations to smoke
could serve as a useful measure of dependence severity. Knowing the
severity of nicotine dependence would enable healthcare workers to
offer appropriate cessation support to patients. |
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| The most commonly used tests of nicotine dependence are the
eight-item FagerstrÖm Tolerance Quesstionnaire (FTQ) [26], the sixitem
FagerstrÖm Test for Nicotine Dependence (FTND) [27], and
the Heaviness of Smoking Index (HSI), developed in 1989 using two
questions from the FTQ and FTND measures; time to first cigarette
after wake up and the number of cigarettes smoked per day [28]. These
questions have not only been noted to account for most of the cessation
predictive value of the FagerstrÖm questionnaires, they have also been
validated in a range of studies to provide similar results [29-31]. Simply,
the HSI is a reasonably reliable and valid test of nicotine dependence
[32]. Noting this, the HSI, a two-item easy to use instrument, was utilised
before implementing the integrated smoking cessation programme to
determine the severity of nicotine dependence of participants. It must
be stressed that low motivation to quit, noted among persons with
schizophrenia, is a major barrier to improved cessation outcomes [22].
Thus, it is advisable for cessation treatments to include a motivation
enhancement therapy. |
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| The author of this work implemented an integrated treatment
programme of motivational interviewing and NRTs on smokers with
schizophrenia in an in-patient setting who expressed intentions to quit.
This is a case study which intends to describe the role of the programme
components in smoking cessation. Although a generic approach was
adopted for all patients, more attention was paid on a specific patient
who was observed to have a long standing problem with cigarette
smoking (Details provided below). Permission to conduct the case
study was sought and gained from the Trust`s Research Ethics Service.
In addition to preserving anonymity, both verbal and written consent
were obtained from the patients for conducting the case study. |
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| Case Description |
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| A total of 6 patients took part in the integrated smoking programme.
All patients were men, had a diagnosis of schizophrenia and were
hospitalised on a male-only ward of a secure psychiatric hospital in
the United Kingdom. On average, five of the patients were 45 years
old and began smoking when they were 25 years old. This means they
had been smoking for approximately 20 years. For these patients, the
reported time to first cigarette was between 6 and 30 minutes, and
smoked an average of 24 cigarettes per day. These patients had a mean
HSI score of 4, which means they were heavily dependent on nicotine.
While this was the case, they expressed a desire to quit smoking but
acknowledged limited confidence in their ability to do so. According
to these patients, the wish to quit smoking was in the man a function of their health concerns. The sixth patient was noted to be different in
a number of ways. It was these differences (such number of cigarettes
smoked) that triggered this case study. Hence, a detailed account of the
same is presented. |
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| Thomas (a pseudonym) is a 64-year old Caucasian male patient
detained under the Mental Health Act 1983. He was diagnosed with
schizophrenia at the age of 24 following referral to a local community
mental health resource centre by a relative who was concerned about
his behaviour. He was described at the time to be isolative with low
motivation to engage with people, limited interest in his surroundings
and occasional delusional expressions, which were in the main
associated with religion. |
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| Thomas had a long history of cigarette smoking. He commenced
smoking when he was 16 years old and claimed to use cigarette
smoking to cope with isolation. Thomas cigarette smoking increased
over the years. He was reported to smoke about 40 cigarettes per day,
and the time to first cigarette after waking in the morning was within
five minutes. Thomas was assigned a HSI score of 6, which was noted
to be higher than that of other patients (HSI=4). Thomas motivation
to quit was observed to fluctuate. This was usually influenced by how
he perceived his health. He had diagnoses of chronic bronchitis and
emphysema, and the latter was claimed to contribute to his frequent
experiences of breathlessness. Despite these health problems, Thomas
continued to smoke. However, Thomas has made three attempts to quit
smoking, but was unsuccessful because of reported limited skills to do
so. |
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| Components of the integrated programme |
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| Motivational interviewing (MI): MI is a directive patient-centred
counselling technique for eliciting behaviour change by helping
people to explore and resolve ambivalence or uncertainties about their
behaviour [22]. This approach is underpinned by the assumption that
people`s motivation to engage in a behaviour is fluid, as it can change
from one situation to another [22]. Consequently, counsellors using this
approach are required to adopt the view that people`s motivation can be
influenced to change in a specific direction. Hence, lack of motivation
to engage in behaviours, often described as resistance to change, and
should perhaps be perceived as something that can be changed. |
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| The use of aggressive or confrontational styles in MI can strengthen
resistance to change [22]. Noting this, MI involves the application of
carefully selected sets of techniques for addressing difficulties people
may experience about making behaviour changes. Examples of
these include assessing patients` readiness for change, ambivalence
about changing behaviours, eliciting change talk or self-motivational
statements, reflecting patients` self-motivating statements, summarising
and highlighting desire for change [33]. The implementation of these
techniques within a MI process is guided by four principles; expressing
empathy, developing discrepancy and rolling with resistance [22]. MI is
a brief psychotherapeutic intervention, applied in this case as a multisession
course of treatment. |
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| MI has enjoyed strong empirical evidence over the years in treating
addictive behaviours, particularly alcohol and substance abuse [22]. It
has demonstrated efficacy in treating medication adherence, safe sex
and exercise practices, and treatment engagement [34]. In relation
to nicotine addiction, a recent meta-analysis, using 31 control trials,
illustrates the efficacy of MI as a treatment option for this behaviour
[35]. These studies demonstrate that MI is an effective approach for
treating nicotine dependence among pregnant and non-pregnant
populations. Whilst MI has been extensively and successful applied in smoking cessation programmes for a wide range of clinical populations,
there is a dearth of literature of its use on smokers with schizophrenia.
To the author`s knowledge there is only one control trial on the use
of smoking cessation programme for people living with schizophrenia.
The study in question relates to the application of MI with personalised
feedback to enable patients with schizophrenia to seek treatment for
nicotine dependence [36]. MI emerged from this study as both an
effective and superior strategy over psychoeducation for motivating
patients to quit smoking [36]. MI is therefore used by this author as
part of a smoking cessation programme, as it is well suited to motivate,
engage and enable people to change health-risk behaviours [37].
Although substantial progress has been made in the treatment of
smoking behaviour and nicotine dependence, treatments that combine
psychological and pharmacological approaches have shown the greatest
efficacy. |
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| Nicotine replacement therapy: This therapy uses nicotine as a
drug to minimise nicotine withdrawal symptoms in people making
attempts to quit smoking [38]. There are different forms of NRTs, and
the types used in the integrated programme were nicotine patches
or patches. This form of NRTs, sometimes referred to as transdermal
nicotine systems, provides a measured dose of nicotine through the
skin. Patches have different strengths or doses of nicotine. The general
trend is that individuals, particularly heavy smokers are commenced on
high doses of patches (e.g .22mg of nicotine) and subsequently weaned
of nicotine by gradually changing, over a course of treatment, to lower
dose patches (e.g. 5-14 mg nicotine) [10]. Although such approach
has been reported to be successful in reducing smoking rates, it has
been highlighted that individuals using nicotine patches occasionally
get addicted to them, and may experience serious side effects, such as
cardiovascular diseases [39]. As a result of this, the use of NRTs should
be carefully monitored to prevent the possibility of health problems.
Another problem that relates to nicotine patches is that using the same
over a prolonged period of time could result in another addiction. |
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| Religiosity: religious activities: Religion refers to an organised
system of beliefs, rituals and practices intended to mediate an
individual`s relationship to the community, and to the sacred [40].
Some of these practices, which include church attendance and personal
devotion, provide some social structures that may prevent humans
from engaging in self-destructive behaviours, such as drug and alcohol
abuse [41]. Religion is a form of social control and most traditional
practices discourage the use and abuse of substances that may
jeopardise people`s health [42]. For example, Muslim and Mormon
faiths totally proscribe the use of alcohol, an action referred to in the
literature as religious injunction [43]. This injunction has also been
extended to some Christians, such as the Seven-Day Adventists [44],
it is critical to note that most religions have conservative views about
alcohol and substance use; prohibit the use of the same [45]. This
protective function of religion is a well-know phenomenon in mental
health services. Besides offering protection from alcohol and substance
use and abuse, religion can help people recover from addictions and
mental disorders [43]. |
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| Starting with psychiatric conditions, patients receiving mental
health services often use religion to cope with their distress and other
life difficulties. It is repeatedly mentioned in the literature that people
with schizophrenia consider engagement in religious activities, such
as church attendance, the most beneficial alternative to health practice
[46]. Perhaps, this is a function of the view that religion is available to
anyone at anytime, irrespective of people`s experiences. It can therefore
be relied upon to offer resilience, coupled with a sense of meaning and
purpose even during adverse life circumstances [42]. In relation to depression and anxiety disorders, a large number of studies revealed
an inverse relationship between religious involvement and experiences
of symptoms [47]. Simply, this means that people with these disorders
may experience symptom improvement when actively engage in
religious activities. |
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| A similar relationship exists between religion and addictive
behaviour. It is claimed that the strength of religious identification and
the frequency of attendance to religious services predict lower substance
use [44]. Such a relationship is usually clearer in religious traditions with
stronger norms against substance use. Thus, incorporating patients`
religious themes into a cessation treatment may significantly increase its
efficacy. For these reasons, it is assumed that most users of substances,
including cigarette, would welcome the integration of religious beliefs
into their attempts to quit their health-risk behaviours. Yet, there
has been little attention given by researchers on the incorporation of
religion in the treatment of addiction. This study is among the few that
incorporated religion into a smoking cessation programme. It is the
first to include religion, NRTs and MI in a smoking cessation treatment
for patients with schizophrenia. |
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| Application of integrated programme |
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| The initial phase of this 10-week programme commenced with a
comprehensive assessment of all patients involved (n=6). This was
carried out by the patients` responsible clinician (psychiatrist) two
weeks before starting the cessation treatment. The intention was to
develop an understanding of their medical and psychiatric histories,
including smoking behaviour, dependency and motivation to quit. All
patients were observed to be severely addicted to cigarette, in other
words dependent on nicotine, a chemical (alkaloid) in cigarette that
causes dependency. Given the severity of nicotine dependence observed
among the patients, they were commenced on NRTs (patches), part of
the second phase of the programme. Patients were clearly instructed on
how to use the patches and used the same on a daily basis. A reducing
regime in the context of nicotine patch strength was adopted over the
course of the programme. Dosing began at 22 mg/day for six weeks and
was then switched to lower doses of 14 mg/day and 7 mg/day for two
weeks each. NRTs (nicotine patches) were provided in conjunction with
group motivational interviewing. |
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| Group motivational interviewing was offered to all patients on
a weekly basis for a period of 10 weeks. Each MI session lasted for
approximately 70 minutes. The sessions were facilitated by the author of
this report, a certified facilitator in smoking cessation programmes, also
a mental health practitioner experienced in group work. The sessions
focused on enhancing patients` motivation and commitment to
change, identifying triggers to smoke and developing coping strategies
to manage identified triggers. Patients` motivations were assessed by
exploring their perceptions of confidence and importance of change.
This was achieved by asking questions using a scale with graduations
from 0 to 10 for each of the dimensions. The patients were asked, for
example, the following questions on importance: on a scale of 0 to 10,
how important do you think it is for you to quit smoking? On this scale,
0 is not at all important and 10 is extremely important, where would you
say you are? Similar questions were asked about confidence: on a scale
of 0 to 10, how confident do you think that you can quit smoking? On
the same scale, 0 is not at all confident and 10 is extremely confident,
where would you say you are? This strategy enabled the patients to
verbalise and process their ambivalence further. |
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| Motivation for change was further explored by examining patients’
perceptions of the advantages and disadvantages of smoking. In this
context, they were initially asked to make a list of their likes and dislikes about smoking, as a preface to listing and talking about the likes and
dislikes of abstaining from smoking. This strategy enabled the patients
to clarify both sides of their ambivalence. This was generally followed
by the use of double reflections on the benefits and costs of smoking
with the view of strengthening change discussions. For example, it is
important for you to smoke in order to deal with the stresses of the
ward, but you also wish you could quit in the interest of your health.
This approach patients to focus discussions on their need for change,
stop smoking. Discussions relating to coping with stress were held. In
this context, patients were asked to make a list of factors on the ward
that cause them stress and how they cope with them. This strategy
generated discussions of situations, such as feelings of boredom,
patients perceived to be stressful and alternative ways of coping without
the use of cigarette. |
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| At the end of the 10-week programme, one patient, Thomas,
experienced some difficulties with quitting smoking. As a result, this
patient was provided an additional 6-week integrated programme that
included NRTs (patches) and individual MI. Thomas was on 7 mg/day
nicotine patch. |
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| Individual MI sessions were offered to Thomas, and each of the
sessions ran for about 60 minutes. In addition to the elements of the
group MI, the individual sessions focused on eliciting Thomas` own
self-motivational statements and affirming that change is always
possible but can sometimes be difficult to achieve. The sessions also
concentrated on enabling Thomas to consider the advantages and
disadvantages of continued smoking versus smoking cessation and
to formulate an individualised change plan that was realistic and
acceptable to him. Thomas requested for regular church attendance
and occasional religious discussions during MI sessions to be part of
the change plan. The issue of church attendance was addressed, as he
commenced attendance to a non-catholic church. Religious beliefs were
discussed during MI sessions only when raised by Thomas. For example,
he mentioned in three of sessions that his faith discourages cigarette
smoking, illicit substances and alcohol use. Thomas understanding of
this and impact on his smoking behaviour was explored when ever
raised. |
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| Results and Discussion |
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| This case study adopted an integrated approach that mainly utilised
NRTs and motivational interviewing, but also used religious discussions
on one patient who experienced some difficulties with quitting
smoking. Given that all the patients were heavy smokers, as revealed by
high HSI scores (≥4), their need for nicotine replacement was expected.
They were therefore commenced on high doses of nicotine patches,
which were gradually reduced as treatment progressed. People, who
are heavily dependent on nicotine, as noted in the patients of this case
study, may find it difficult to abstain from smoking [19]. Generally,
such difficulties are a function of high nicotine dependence, caused by
long duration of smoking and heavy daily cigarette consumption [4].
This is the case for the patients of this report, and it was reported that
the heavy and frequent cigarette smoking observed was attributable to
boredom and stresses associated with institutionalisation. |
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| Experiences of feelings of boredom and being controlled and loss
of control of some activities of daily living, such as when to retire to
bed, were acknowledged by patients to generate stress that led to anger
and frustration. In such a heightened emotional state, patients asserted,
customary ways of coping, which include social interaction, were
ineffective in restoring emotional calmness. These patients employed
cigarette smoking as an approach to regain emotional control. Despite this, it is consistently reiterated in the literature that group or individual
counselling can facilitate cessation and improve rates of abstinence
even in heavily nicotine dependent patients [18]. It is believed that
abstinence rates can be improved when patients are offered integrated
treatment approaches of psychological and pharmacological therapies
[20]. On the basis of this, the patients were also offered weekly group
MI sessions that facilitated discussions of smoking cessation, which in
turn offered support to group members. |
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| All the patients (n=6) completed a 10-week programme. Five
patients (85%) quitted smoking and remained completely abstinent
(verified using carbon monoxide technique) when followed-up at six
months after the programme. The motivation for these patients to quit
smoking was in the main intrinsic, as their commitment and desire
to engage in the programme was influenced by health concerns. In
addition to experiences of urges to smoke, particularly in the morning,
the patients expressed limited confidence and ability to stop smoking.
Clearly, they had low self-efficacy to quit. Hence, one of the key tasks
during the application of motivational interviewing was to enhance
patients` confidence, motivation and coping skills that would enable
them to engage in behaviour change. |
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| Motivation for change was enhanced by enabling patients to
explore the advantages and disadvantages of quitting smoking. In
addition to saving money, all patients reported that quitting would help
minimise the risk of developing health problems like cardiovascular
diseases. After the fifth group session, patients repeatedly stated that
they disliked tobacco odour. In addition to the health concerns, this
was a significant motivational factor noted among this patient group
to engage in attempts to quit smoking. Although this was the case, the
patients expressed a lack of confidence to do so. |
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| Feedback was used to address the issue of confidence. Provision
of personalised feedback using normative data, such as time to first
cigarette in the morning and amount of cigarettes smoked per day, was
significant in raising patients` confidence and motivation to quit. Other
MI strategies were used to strengthen patients` need to quit smoking.
Examples of these include eliciting patients` own self-motivating
statements, and eliciting and strengthening patients` confidence. With
regard to the latter, this was achieved by exploring with patients their
personal strengths and support for change. These refer to personal
characteristics, such as being optimistic, that may help patients achieve
behaviour change. So, questions, such as the examples that follows,
were asked to elicit the same. What is there about you that would help
you quit smoking? Are there others that could help you to make this
happen? |
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| One patient out of the six patients failed to quit smoking. This shows
that people with schizophrenia also have the ability to quit smoking.
Therefore, quitting should not be considered impossible for individuals
suffering from this disorder. However, it is critical to note that some
patients may find it difficult to stop smoking. |
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| The patient who failed to stop smoking reduced the number of
cigarettes smoked per day from 40 to 20 as observed at the end of the
programme. Given the fluctuated nature of the patient`s intention on
entrance into and during the programme, the reduction in smoking
rate noted was not surprising. This finding indicated the chronicity
of the patient`s smoking behaviour as well as the need to offer more
support and hope that change is possible. Patients with chronic
smoking behaviour can be enabled to quit by engaging them in
extended treatment regimes. Simply, the efficacy of interventions for some patients can be increased by extending their duration [22]. This
is apparently the case for individuals with long histories of smoking.
As Thomas fitted well into this category, it was necessary to offer him
an extra 6-week integrated programme, which included elements of
religious discussions. |
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| Clearly, such an approach is an acknowledgement of the notion
of “harm reduction”, which stresses that a reduction in the amounts
of cigarettes smoked per day is an acceptable phase toward complete
cessation [48]. Thomas smoked less during the 10-week programme
and achieved cessation when committed and ready to do so. Thomas
stopped smoking towards the end of the programme and was abstinent
at six-month follow-up. This outcome suggests that smoking cessation
is possible for individuals with schizophrenia when treatment is tailormade
to incorporate their wishes. Thomas motivation to stop smoking
was significantly influenced by extrinsic factors, which were in the main
related to his religious beliefs and practices, such as church attendance.
The church which Thomas attended discouraged the use of substances,
including cigarette [46]. |
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| It is clear from the discussions thus far that religious involvement
is protective against substance abuse as well as promotes people`s
recovery from the same and mental disorders [43]. Noting this, it is
critical for healthcare professionals to be committed and prepared to
enable patients explore religious factors relevant to their substance
use. Although health professionals may not be experts in patients`
religious traditions, they occupy a unique position to generate religious
discussions. Not engaging with patients does not only indicate
disrespect for this important aspect of diversity, but it may also prevent
assessment and identification of religious needs. Thus, it is critical
for assessments during admissions and even during in-patient stay
to include discussions of patients’ religious beliefs. Doing so could
result in referral to appropriate religious leaders for in-depth in-faith
discussions. Hence, it is helpful for mental health professionals to
have knowledge of local religious leaders for referral and consultation
purposes, and to encourage the same to make regular visits to clinical
areas. It is also help for all mental health services to create special multifaith
environment for religious meetings. |
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| The author acknowledges that there are some limitations to this
case study, affecting its applicability to smokers with schizophrenia
across secure settings as a whole. It was carried in a single Trust and
utilised a small sample size of patients who expressed a desire to quit
smoking. These patients may be different from those in other Trusts in
the context of their demographic characteristics, smoking histories and
clinical presentations. The findings can therefore not be generalised to
smokers with schizophrenia across secure settings. However, they are
transferable across these settings, as they provide valuable insights and
context for understanding smoking cessation with this patient group. |
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| Conclusion |
| |
| Nicotine dependence is one of the most common co-morbidity
for individuals with schizophrenia. Because of the possibility of high
nicotine dependence, smoking cessation can be challenging for this
patient group. However, integrated smoking cessation programmes
can be effective for treating people with high nicotine addiction. The
effectiveness of such programmes can be enhanced by healthcare
professionals` willingness and commitment to engage with patients.
These professional attributes are essential as the duration of programmes
may extended to accommodate the chronicity of smoking behaviour,
severity of dependence of this patient population and institutional
barriers, such as boredom and feelings of loss of control, to cessation. Taking these issues into account, progress along the path of cessation
must be determined by patients` ability and readiness to change.
Patients should therefore not be coerced to stop smoking as taking this
stance may generate resistance from the same, which can be manifested
in a number of ways, such as unwillingness to change and reluctance
to engage. Although this was not indicated in this case study, religion
was discussed by one patient who stressed that it helped him to recover
from nicotine addiction. |
| |
| It has been noted that strong religious identification tends to predict
lower substance use. This assertion has implication for practice. Healthcare
professionals should identify at the outset during admission whether
patients embrace the norms of abstinence or have negative reactions
against them. In instances of the latter, the advice is not to confront but
to roll with resistance, as shifting focus in this case may be perceived as
disrespectful [22]. Acknowledging this, healthcare professionals may
encounter some difficulties to commence religious discussions with
patients. To overcome such difficulties, the recommendation is to use
open questions; they are a good place to start. An example could be what
do you believe in or have faith in? In sum, healthcare professionals need
to be aware of the religious beliefs of their patients, appreciate their value
as a resource for addressing problems of addiction. |
| |
| Acknowledgements |
| |
| The author gratefully acknowledges the patients who took part in the smoking
cessation programme. |
| |
|
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