1. Training for Promotoras/Community Health Workers
Behavior Change with Alcohol and Other Drug Use (AOD) and Mental Health (MH)
Training for Promotoras/Community Health Workers
Kimber—Fix the Gulf Coast logo (all white logo on blue strip) add slide numbers to all slides when finished and make sure they match trainer’s guide; and to Spanish version too. Make sure notes pages converted over and remove my notes.
Purchase and add graphics throughout presentations (and photos), get slide from Sue—Promotoras photos slide
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
3. Preparation
Relapse
4. Action
6. Permanent Exit
5. Maintenance
Relapse
Kimber—find new/current model and update accordingly…with Relapse and explanation (that it can occur within any stage) written in at the bottom.
Adapted from Prochaska & DiClemente (1982), “Transtheoretical therapy: Toward a more integrative model of change.” Psychotherapy: Theory, Research, and Practice, 19:

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
Menu of 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
Split this into two slides..Is advice the right word here? MI—ask before giving advice/feedback??

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 Lower risk Abstinence consumption consequences
Kimber-is there a more recent version of this pyramid? Put it on an all white background and cite its source.
Consider Mr. A’s alcohol consumption and where it fits on this spectrum of alcohol use. This is one way to think about the levels of use and unhealthy drinking that the physician was trying to identify. This depiction is adapted from a report from the Institute of Medicine. The amount of consumption is represented on the left side of the triangle, and consequences are on the right. Both increase as one moves up to the top of the triangle. In general, clinicians are accustomed to seeing and recognizing the more severe alcohol use disorders, which are Diagnostic and Statistical Manual of Mental Disorders (DSM) diagnoses, alcohol abuse and dependence. In these disorders, consumption is heavy and consequences severe.
Dependence is often referred to more colloquially as alcoholism.
Harmful drinking is a term from the International Classification of Diseases whose definition is similar to alcohol abuse from the DSM, meaning that there have been recurrent consequences of drinking without meeting criteria for dependence.
Problem drinking means a consequences or problem has occurred due to drinking.
Risky drinking refers to amounts that risk adverse consequences, but in the absence of consequences thus far.
Unhealthy alcohol use is a term that encompasses all the categories just described, and included within the red dashed border.
Lower risk drinking refers to more moderate amounts (less than risky amounts), also with no consequences (except perhaps some cardiovascular benefits for some).
In its 1990 report, the IOM recommended identifying drinkers in the red dashed border, particularly those who had not yet progressed to abuse or dependence, in the hopes of decreasing drinking and consequences when it was easier to do so and before significant morbidity or mortality occurred. Risky drinking is much more common than dependence:
almost one-third of drinkers in the US drink risky amounts and nearly one in four of these individuals have alcohol dependence.
About 1 in 12, or 17 million adults in the US suffer from alcohol abuse or dependence (more than have hypertension, asthma, or arthritis). Yet only about 10% receive treatment.
Finally, alcohol is a leading cause of preventable medical conditions, disability, and deaths, (approximately 85,000/year), second only to tobacco and physical inactivity.
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 Annoyed you by criticizing your drinking/drug use/tobacco use?
Have you ever felt bad or Guilty about 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. Mental Health Observation Checklist The following signs and symptoms may indicate mental health problems
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
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. 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. 6/13/06
Bibliography
Update this list accordingly

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