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Healthy Conversations Over Time! Read on for Further Details HEALTHY Conversations An Interactive Guide to Making Positive Change HEALTHY Conversations A guide for Community Health Workers about mental health and substance use to support clients making positive change Copyright 2014 Anansi Health Images from iStockphoto.com, with the exception of the gratitude jar on page 192, copyright Tiare Smith HOW TO USE THIS GUIDE This guide was written to help support direct care staff, including case managers, peer advocates, patient navigators, etc. to build healthy working relationships with their clients who struggle with mental health, substance use, or both. The goal is to facilitate honest, meaningful conversations that empower the client to understand their issues better and make small, positive steps to improve their health. The language we use here, Community Health Worker (CHW), is meant as an umbrella term for folks who work directly with clients in their homes, clinic, or community setting to improve health outcomes and quality of life. Please feel free to adapt the terms here to fit with your program (ie: change the word client to patient, consumer, or member, whatever your participants like to be called). We hope it will be a jumping off point for all kinds of healthy conversations over time! Read on for further details. Goals: • Build relationship and trust between Community Health Worker (CHW) and the client • Assess client’s issues, strengths, goals, dreams, perspective, and motivation about their mental health and/or substance use issues • Uncover barriers to optimal health, engagement in treatment, and self-care • Build client motivation for change towards greater health • Facilitate greater quality and quantity of client engagement in treatment and care, by helping client become more informed/empowered and less ashamed/stuck • Reduce the harm of current problem behaviors (ie: injection drug use, managing depression by drinking, etc) • Increase client capacity to reflect on where they are and take positive action • Increase CHW and client health literacy about mental health and substance use—more knowledge leads to more confidence • Help focus and guide visits between CHW and client How to Use This Guide | 1 Methods: Tailor to individual client: Give client an opportunity to have all conversations (even the ones that might not seem relevant) with a focus on priority topics. Flexible but intentional order: These conversations are set in this order so that they can build on each other. You can spend more time on topics your client is particularly interested in. You can also look through the Table of Contents together and pick the places to start. Help organize CHW and client: Our client’s lives are often chaotic and stressful, so staying on track is hard. This guide can keep you both oriented towards important conversations, making it easier for you to stay on the same page and move towards meaningful goals. Use in small chunks as part of a regular visit: Ideally, 15–20 minutes of a 60 minute visit will be spent working on formal curriculum, and the remaining time is client-led. Use MotivationaI Interviewing skills: How you present this material matters a great deal. We urge you to use MI: being nonjudgmental, listening actively, putting your client in the driver’s seat. We particularly like the OARS tool: Open Questions, Affirmations, Reflections, and Summaries all help to build a healthy collaborative relationship with your client. If you haven’t had MI training, please find some in your area. It’s been a key to success for many CHWs! For more details, please refer to the short MI chapter to introduce you to key principles as we apply them here or refresh your memory if you already know the basics. 3 tracks: There are three tracks for the curriculum: one for clients who only have mental health issues, one for clients with only substance use issues, and one for clients who struggle with both. For dually-diagnosed folks, you may need to proceed slowly because the client is dealing with multiple barriers and may be less motivated and more distracted/overwhelmed/afraid. Use your own words: The curriculum wording is a guide, but you will be most effective if you read through it first on your own to learn it, and then put it into your own words when you’re speaking with the client. If the client uses certain slang or phrases, it’s generally best to adopt their language if it feels natural to you. Always check in: While reviewing the educational material, check in with the client to see if any of it resonates with their own experience. Ask client: “What are your thoughts about that?” If you see any acknowledgement, nodding of the head, facial expressions, or comments that suggest your client identifies with something you have said, ask: “What do you think about that?” or “Does that make sense to you?” 2 | Healthy Conversations Using “Teachback”: At the end of each conversation, we urge you to use the teachback questions to find out what the client understands, what was meaningful to him/her, and to assess what topics/information you might need to spend more time on in the future. The goal is to tailor to a client’s individual needs, interests, and issues. This regular assessment will help keep you on track. Using Activities: Every chapter has interactive activities to help with assessment, support client learning, and make the process creative and fun. Ideally, you choose one activity per visit, according to the client’s interest. Some types of activities will be more comfortable for you than others (role plays vs. brainstorms vs. art projects), but try to offer the client a range of choices. You can do multiple activities briefly in one visit and give the client some related homework (such as list-making or drawing) to start from on the next visit. Tips for using curriculum with “special populations”: Clients with cognitive limitations: use repetition and imagery, break conversations into smaller pieces and review often, explain things as concretely as possible. Clients who are drunk/high during the session: Curriculum works best with clients who are clear, oriented, and sober. Some clients may always be under the influence when you see them. In that case, assess how impaired your client is. If she is so high she can’t have a meaningful conversation with you, save the material for another day. Brainstorm together on a more sober day about how to make some time together to review the curriculum (For example, maybe the client agrees to wait to drink until after your morning visit). Clients in mental health crisis (suicidal, delusional, hallucinating): Any time clients are in a crisis, curriculum can wait. Best to reach out to their other providers (PCP, psychiatrist, or therapist) for back-up and if need be, call the emergency mental health team in your area. Follow your agency policy around suicide assessment. Know the best way to reach your supervisor for guidance in the moment. Worse case scenario: call 911 and let an ambulance get your client to the ER to be evaluated. Clients who are not very motivated about their health: When in doubt, start with what your client cares about to build trust and communication. You can explain your role and the curriculum and let the client know you will devote part of every visit to health issues, and the rest of the time to whatever is most important to the client at that time. It’s a challenge that gets easier with practice: to both respect your client’s way of seeing things and to continue to bring health issues into the conversation without pushing your (or the care team’s) agenda of how the client “should” deal with them. How to Use This Guide | 3 Clients with strong stigma about their issues: Respect confidentiality, offer an invitation to discuss the material and respect when client says no, keep bringing up the topic and explaining why it’s important to talk about when the client feels ready. Troubleshooting: How can I use the curriculum if the client denies she has mental health or substance use issues when everyone else thinks she does? Go slowly. Build trust and get to know the client first. Understand her point of view and be mindful not to accuse her of having issues she’s not ready to own. Work with her on what matters to her in the moment and introduce curriculum slowly, using neutral language, and back off when you feel the client getting defensive or distant. You may want to say something neutral like, “Not all of this information may apply to your life, but you can share what you learn with people you know who might have these issues” or “These are topics I cover with all of my clients, to make sure I really understand what they’re dealing with and to make sure they have a foundation of knowledge to communicate well with their care team” or “Many people don’t even realize they are dealing with mental health issues and suffer alone for years. I want to make sure you have all the current information and options so you can decide for yourself how you want to take care of your health.” What if the CHW is personally triggered by what the client brings up? Or feels overwhelmed, like it’s outside their scope of practice? CHWs need to make good use of their Supervisor/Clinical Supervisor when these issues come up, particularly for people in recovery or who also have a mental health diagnosis. Getting support from fellow CHWs, particularly seasoned colleagues, can be very helpful. By getting support, you safeguard both your wellbeing and that of the client.
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