Training for Promotoras/Community Health Workers

1. Behavior Change with Alcohol and Other Drug Use (AOD) and Mental Health (MH) Training for Promotoras/Community Health Workers Primary Authorship: Mary Sowder, MA, LCDC Contributions in writing and editing: Kimber Dowdy, BA Susan M. Gallego, LCSW

2. Purpose To educate Promotoras/Community Health Workers on behavior change concepts and specifically how they can be implemented with persons who have substance use or mental health issues.

3. Goals and Objectives • Experience and learn about motivation as a key component of behavior change • Learn Brief Intervention Strategies • Address own attitudes toward AOD and MH treatment • Describe basic information on AOD • Describe basic information on MH • Learn how to refer clients for AOD and or MH treatment

4. Behavior Change People change their behavior for different reasons. Some make changes on their own and others change with intervention from professionals, family friends, etc. And sometimes, people don’t ever change a behavior.

5. Personal Behavior Change Activity As the trainer goes over each of these, write down your answers to the following questions: • Think of a behavior you have changed in your life, either on your own or with help. What was that behavior? • How did you decide to change the behavior? • What stands out as being helpful to you when you were making the change? • What stands out as not being helpful to you when you were making the change?

6. Motivation “Motivation can be understood not as something that one has but rather as something one does. It involves recognizing a problem, searching for a way to change, and then beginning and sticking with that change strategy. There are, as it turns out, many ways to help people move toward recognition and action.” Miller, 1995

7. Assumptions about Motivation 1. Motivation is key to change 2. Motivation is multidimensional 3. Motivation is dynamic and fluctuating • Motivation is influenced by social interaction 5. Motivation can be modified

8. STAGES OF CHANGE 1. Pre-Contemplation 6. Permanent Exit Relapse 2. Contemplation 5. Maintenance Relapse 3. Preparation Relapse 4. Action Relapse Relapse Adapted from Prochaska & DiClemente (1982), “Transtheoretical therapy: Toward a more integrative model of change.” Psychotherapy: Theory, Research, and Practice, 19: 276-288.

9. Brief Intervention Brief Interventions are those practices that aim to investigate a potential problem and motivate an individual to begin to do something about his/her behavior.

10. FRAMES • Feedback is given to the individual about personal risk or impairment • Responsibility for change is placed on the individual • Advice to change is given by the promotora/community health worker • Menuof alternatives or options is offered to the client • Empathetic style is used by the promotora/community health worker • Self-efficacy or optimistic empowerment is engendered in the client

11. Examples of Brief Intervention Statements Pre-Contemplation • Tell me about your (behavior). What effect does it tend to have on you? • What difficulties have you had in relation to your (behavior)? • How has your (behavior) stopped you from doing what you want to do? • What kind of (behavior) are you? • What do your family/friends tell you about your (behavior)?

12. More Examples…. Contemplation • In what ways does your (behavior) concern you? Or others? • How much does this (behavior) concern you? • What do you like most about your (behavior)? What do you like least? • What do you think will happen if don’t change your (behavior)? • What concerns you about changing your (behavior)? • On a scale of 1-10 how important is the (behavior) to you?

13. More examples…. Preparation • What have you done in the past to change your (behavior)? How did that work out? • What do you think would help you change your (behavior)? Action • What are your plans to change your (behavior)? • What specific steps will you take to change your (behavior)?

14. Giving Advice How to begin: *State your concern *Give feedback based on the behavioral observations and consequences the patient reports *Give your advice *Emphasize the patient’s responsibility for change *Convey your confidence in patient’s ability to change *Involve the patient in making choices

15. Giving Advice • When a person is less ready for change: • * State the problem non-judgmentally • * Agree to disagree about the existence of a problem • * Elicit good and bad things about their behavior and of changing the • behavior • * Demonstrate discrepancies between what they value, and what • happens when they do the behavior • * Suggest a trial of changing behavior or cutting down • * Follow-up even if behavior hasn’t changed

16. Giving Advice • When a person is more ready to change: • * Assist with deciding goals • * Assist with information and resources • * Acknowledge discomfort (losses, withdrawal) • * Remind patient of strengths—e.g. period of change in behavior, the • fact they are seeking help

17. The Spectrum of AOD Use consumption consequences Lower risk Abstinence none none none

18. The CAGE Questions • Have you ever felt you should Cut down on your drinking/drug use/tobacco use? • Have people Annoyedyou by criticizing your drinking/drug use/tobacco use? • Have you ever felt bad or Guiltyabout your drinking/drug use/tobacco use? • Have you ever taken a drink/drug/smoke first thing in the morning (Eye-opener) to steady your nerves or get rid of a hangover/shakes/ headache?

19. Substance Abuse Observation Checklist The following signs and symptoms may indicate substance abuse problems: • Dilated (enlarged) or constricted (pinpoint) pupils • Unclear speech: slurred, incoherent, or too rapid • Unsteady gait; staggering, off balance • Scratching • Swollen hands or feet • Smell of alcohol or marijuana on breath • “Nodding out”: dozing or falling asleep • Agitation • Inability to focus • Needle track marks • Skin abscesses, cigarette burns, nicotine stains • Tremors (shaking and twitching of hands and eyelids) • Drug paraphernalia such as pipes, rolling paper, syringes, or roach clips

20. Depression* Sleeping less or more than normal Crying easily, sadness Difficulty concentrating Feeling hopeless, worthless or guilty Weight loss or gain Feeling restless or agitated Difficulty concentrating or making decisions Mental Health Observation ChecklistThe following signs andsymptoms may indicatemental health problems • Anxiety* • Faster heartbeat • Sweating • Dizziness • Feeling jittery • Trouble sleeping • Irritability • Tightening in the chest • Aches or pains in the stomach, head, and neck • Severe Mental Illness • Inflated self-esteem or grandiosity • Seeing, hearing or feeling things that other do not • Unable to complete everyday tasks such as getting dressed • Thoughts of harming or killing oneself • More talkative than usual or pressured speech • Physical restlessness or agitation • Easily distracted by unimportant stimuli *If persons have several of these symptoms and they last over a period of time, it may be an indication of a more serious mental or physical health problem. They should be referred for assessment as soon as possible.

21. Bibliography • Treatment Improvement Protocol (TIP), #34, “Brief Interventions and Brief Therapies for Substance Abuse”, Substance Abuse and Mental Health Services Administration, Center for Substance Abuse Treatment, 2003 • Treatment Improvement Protocol (TIP), #35, “Enhancing Motivation For Chang in Substance Abuse Treatment”, Substance Abuse and Mental Health Services Administration, Center for Substance Abuse Treatment, 2005 • Prochaska, J.O., Norcross, J.C. and Clemente, C.C., (1994) “Changing for Good”, New York, NY: William Morrow, Co. • Prochaska, J.O., Norcross, J.C. and Clemente, C.C., (9/92), American Psychologist, “In Search of How People Change-Applications to Addictive Behavior • Miller, W.R., Rollnick, S., (1991),“ Motivational Interviewing: Preparing People to Change Addictive Behavior, New (1991), “ Motivational Interviewing: Preparing People to Change Addictive Behavior, New York, NY: The Guildford Press • “Substance Abuse and Infectious Disease: Cross Training for Collaborative Systems of Prevention, Treatment, and Care.” Substance Abuse and Mental Health Services Administration; Centers for Disease Control and Prevention; Health Resources and Services Administration. • “Tales of Coming and Going and Mental Health: Manual for Health Promoteres/as”, ( 2004), California-Mexico Health Initiative, California Policy Research Center, University of California, Berkley, CA. • “Helping Patients Who Drink Too Much: A Web-based Curriculum for Primary Care Physicians”, Clinical Addiction Research and Education Unit, Section of General Internal Medicine, Boston University Schools of Medicine and Public Health, Supported by the National Institute on Alcohol Abuse and Alcoholism (NIAAA) R25 AA013822 • Patient/ Family Education Materials, Texas Department of State Health Services, Community Health, Community Health Programs and Initiatives, Texas Implementation of Medication Algorithms.www.dshs.state.tx.us/mhprograms/PtEd.shtm, 6/13/06

22. Resources slide?? List of resources found in participants manual Include list of Spanish links from Clearinghouse in resources