Apport des thérapies comportementales et cognitives dans le sevrage tabagique

Abstract

Les thérapies comportementales et cognitives (TCC) sont validées dans le sevrage tabagique mais ne sont pas suffisamment utilisées en pratique courante. Quatre étapes sont importantes dans cette démarche TCC : l’évaluation, l’alliance thérapeutique, l’analyse fonctionnelle par la méthode des cercles vicieux ou l’utilisation d’une grille SECCA, dont vont découler les méthodes comportementales et/ou cognitives. Cinq techniques sont par ailleurs possibles pour augmenter la motivation, dont notamment la balance décisionnelle. Nous présentons dans ce cas clinique différentes séances d’une patiente qui a souhaité stopper son tabagisme par une approche en TCC. Nous présentons l’histoire de sa consommation de tabac, une analyse fonctionnelle de type SECCA, les évaluations réalisées au démarrage de la thérapie et leur évolution au cours de la thérapie, quelques séances spécifiques de thérapie avec le recours en particulier à la balance décisionnelle, une approche cognitive sur les « je dois » et « il faut », les colonnes de Beck avec distorsion cognitive, la reprise de croyance sur le tabac, les cercles vicieux et les cercles vertueux. L’approche a permis d’obtenir un sevrage en douceur. Nous discutons dans un dernier temps les intérêts des TCC et des produits pharmacologiques associées aux TCC dans le sevrage tabagique.

Behavioural and cognitive therapies (CBT) are validated in smoking cessation but are not sufficiently used in current clinical practice. Four steps are important in this CBT process: (1) psychometric assessment (before, during and after therapy); (2) therapeutic alliance (combining empathy, authenticity, warmth and professionalism); (3) 4R interview technique: reformulate (repeat what the patient has just said, as much as possible in his own words, sometimes by formulating an hypothesis), recapitulate (at the beginning of the session, at the end of the session and for the functional analysis), recontextualize (refocus the patient on the situation, on what he feels; the questions take a turn for the worst, which also facilitates the synchronic functional analysis, starting from a specific situation), reinforce (the patient's resources, re-emphazing the progress); (4) functional analysis using the Cungi vicious circle method (i.e. situation, emotions, automatic thoughts, behaviour, concrete and relational consequences) or the use of a SECCA grid. The behavioral methods used are relaxation, stimulus control, assertiveness and problem-solving techniques. The cognitive methods include four stages: highlighting automatic thoughts through the vicious circle method or through Beck's columns, finding alternative thoughts, highlighting and modifying cognitive distortions, and working on beliefs. Other techniques are also possible to increase motivation such as the decisional balance (advantages and disadvantages on continuing or stopping, advantages and disadvantages on continuing in the short-, medium- and long-term), vicious circles (the identification of vicious circles, leading insidiously towards disaster, makes it possible to face the reality of things), setting up constructive circles (with the beneficial consequences that it can have). We also use the “History of my life” scale, which goes from “sacrificing everything for the future” to “sacrificing everything for immediate pleasure”. Feeling good depends on a balance between what you enjoy right away, i.e. the daily pleasures, and what you do for the future. There is therefore a balance to be found between the efforts to be made and the pleasure of living. The patient chooses a point between his two limits, a motivational interview is conducted and we observe whether the point has moved at the end of the session. Making the history of a smoking life helps to no longer neglect the long-term consequences, to deter the “I must, I must, I must” (by thinking “I must not smoke”, the subject is already thinking about smoking, forcing himself not to smoke, thus increasing anxiety and discouragement, which leads to even more cigarettes to calm down. This activity reduces the sense of urgency and improves motivation). Finally, the Break-off letter (the patient writes about his life with cigarettes, what he loved, what it brought him, what bothers him now and why he wants to part with it, how he will go about it, how he sees life without it). In this clinical case, we present different sessions of a female patient who wanted to stop smoking using a CBT approach. We present her smoking history. During the first sessions, in addition to the therapeutic alliance, we perform a SECCA functional analysis, the evaluations carried out at the beginning of the therapy and their evolution. We use different techniques to increase motivation, including the decisional balance, the “I must, I must, I must” and the break-off letter. The four-step cognitive methods are detailed: highlighting automatic thoughts, searching for alternative thoughts, identifying logical errors such as minimization, working on beliefs. The evaluation showed that the desire to smoke has gradually decreased, that the desire to stop smoking has gradually increased. The approach allowed for a smooth withdrawal. Finally, we discuss the interests of CBT and pharmacological products associated with CBT in smoking cessation.