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10 Signs You Need to Make a Behavioral Health Referral

Life is full of stressful situations. Frontline health workers, such as community health workers or promotores, are used to supporting clients as they juggle health issues along with stressors like child care and work. That’s on a good day.

Now think about how clients and patients deal with the outbreak of a crisis like the coronavirus disease 2019 (COVID-19) on top of day-to-day anxieties. This means more people are worried about paying the water bill, eviction, varying family obligations, changes to daily routines, and job instability.

[Download Now: Behavioral Health Resources]

Chronic stress can come from many sources such as poverty, long-term sickness, or domestic violence, in addition to a global pandemic. Stress has a serious effect on a person’s overall wellness. It can increase the risk of heart disease and strokes. It can increase depression, anxiety, and more serious mental illnesses—all associated with heart disease and a lower immune system. Stress can also lead people to unhealthy choices with food and substances.

“It’s now 455 days since my last sip of alcohol, and right now it feels harder than it has done, in over a year,” Yvette Mayer, a leadership coach, said on LinkedIn. “The idea of buffering with a bottle of red wine is appealing. I know I’m very unlikely to be alone in this ‘urge’.”

Supporting clients and patients in controlling stress is critical.

Managing Stress

10 Signs You Need to Make a Behavioral Health Referral

CHWs might feel helpless when they see clients have difficulty dealing with these anxieties, but they can still help. It’s always an important for CHWs to support clients’ behavioral health. They can do some things like be an active listener, give suggestions for telehealth, and coach healthy living. Here are two:

  1. Manage stress for health from the California Department of Public Health has some simple tips
  2. Free Online Sobriety Support During Covid-19 from the Sober Señorita is a great resource to share with clients with alcohol abuse issues

Supervisors of CHWs and program managers should look out for signs of stress and burnout among their staff. These resources are helpful with clients and also internally.

But there are some more serious signs that CHWs need to refer clients to a behavioral health provider who can give more support. Making a referral for a mental illness like depression or severe anxiety is an important step. Mental health disorders, like any chronic disease, can be managed or avoided with early intervention.

10 Signs Someone Needs a Behavioral Health Referral

  1. Suicidal thoughts
  2. Trouble concentrating
  3. Lack of interest
  4. Restlessness
  5. Constantly checking news outlets or social media
  6. Changed sleep patterns
  7. Fatigue
  8. Distant or withdrawn
  9. Mood swings
  10. Diet changes

These are 10 signs community health workers can look out for if you suspect someone in your community is struggling and needs help:

1. Suicidal thoughts

If someone talks about killing or harming themselves, make a referral right away. Call the 24-hour Suicide Prevention Lifeline at
1-800-273-8255 or text 838255. Not everyone who has suicidal thoughts shows them, but you can certainly notice subtle remarks that may point to trouble.

2. Trouble concentrating

When someone has difficulty concentrating on daily activities, are confused, forget things, has trouble getting anything done, this can be a sign of depression, anxiety, or substance use.

3. Lack of interest

Another warning sign is a lack of interest in things that used to cause joy, and even personal care. This can show up as the person not bathing or eating, stopping their hobbies, neglecting their job or responsibilities, and disengaging from their daily routine.

4. Restlessness

Someone might not be able to sit still. They might constantly shake their leg, shift between their feet when standing up, or fiddle with things in their hand.

5. Constantly checks news outlets or social media

Panic-scrolling is a sign of anxiety. This is the constant need to refresh social media channels, even knowing that nothing has changed since the last time they checked.

6. Changed sleep patterns

Someone might complain of sleeping more than usual or not sleeping at all. Significant changes in sleeping patterns can be a sign of a mental health issue—and can in some cases make it worse.

7. Fatigue

Feelings of fatigue might have nothing to do with sleep patterns. Even with normal sleeping, someone can feel constant fatigue. Even without realizing it, someone might feel this way because of irregular sleep, waking up in the middle of the night, or not being able to enter a deep state of sleep.

8. Distant or withdrawn

People who are clinically depressed often feel like withdrawing from social activities. Being isolated is not only a sign of mental illness but it can also be a cause of mental illness. This is especially challenging when so many people are required to self-isolate to stop spreading the virus.

9. Mood swings

Even though it’s fairly normal to go between moods in a week or even a day, someone who’s struggling with anxiety, depression, substance use, or other serious mental illnesses may experience wild changes in their mood quickly.

10. Diet changes

Whether someone is overeating or restricting food intake, any drastic changes to their daily food habits are often a red flag. This is another symptom that could be a cause. A healthy diet, such as the Mediterranean diet or DASH diet, can help with mental health as well as a variety of other conditions—including virus immunity.

Success

Does your team need training in behavioral health? Read about our Healthy Living learning track.

10 skills CHWs can learn right now—without leaving the couch

Use at-home time to brush up on existing skills or pick up some new ones.

The now-global spread of coronavirus is affecting everyone. This disease has brought a host of medical, economic, and political problems. It’s brought all of us—CHWs, supervisors, program managers, clients, and patients alike–a ton of uncertainty and anxiety. This can have an enormous impact on everyone’s emotional and physical wellbeing.

Whenever you’re feeling unsure and anxious about the things you can’t control, it can be helpful to focus on the things you can control, such as your education. While you or your staff might be stuck at home or in a quiet facility, the Internet is still on. So rather than panic-scrolling through social media feeds about toilet paper, put that energy into picking up some new skills or improving the ones you already have.

[Related: The 27 New Skills You Can Now Learn on CHWTraining]

10 Skills CHWs Can Learn from Home

They say there is no such thing as useless knowledge. These 10 skills are definitely worth learning—and learning them can make time based at home time well spent. In the future, these skills form a great workforce development path and can make each CHW a better worker.

  1. Meditation and mindfulness techniques
  2. Depression, Anxiety and Stress
  3. COVID-19
  4. Smoking cessation
  5. Chronic illness
  6. Immunizations
  7. Motivational Interviewing interventions
  8. Healthy cooking
  9. Hand hygiene
  10. Language

1. Meditation and mindfulness techniques

Relaxation and mindfulness are skills that can help you in your personal and professional life—especially now when everything feels uncertain. Mindfulness practices can help people manage stress, deal with serious illness, and reduce anxiety and depression, according to the NIH. These are helpful skills to pass on to clients, employees, and the people around you.

“The most important thing to know when starting a meditation or mindfulness practice is that there is no right or wrong way to ‘do’ it,” says Laura Wells, a facilitator and coach who works with individuals, teams, and organizations to increase focus and build compassionate leadership.

“It is simply about learning to relax into the present moment — there’s nothing we have to, or can, ‘do’ to make the present moment happen. This is about allowing the space for a minute or two or five to not be in charge of what’s occurring. Simply breathing and bringing attention to what is already here in our experience.”

If you want to practice now, you can join Wells for a free 30-minute virtual meditation and connection session Tuesday, Mar 24, 2020, 12:10 PM Pacific Time. Click here to join and use meeting ID: 144 588 211.

2. Depression, Anxiety and Stress


Nearly everyone is feeling depression, anxiety, and stress right now, so it helps you and anyone you work with if you can pick up management skills. Start by recognizing the symptoms of depression from the National Institute of Mental Health.

Then what to do if you see them in yourself or in another. This guide will help you understand when it’s time to make a behavioral health referral.

Supervisors and program managers supporting a community health team with limited resources can easily feel overwhelmed. You have to think about self-care strategies to share, how to help them control stress, and spot signs of burnout and compassion fatigue.

Sign up for Supporting Mental Wellness in CHW Teams, a free on-demand session on improving your team’s mental wellness, identify signs that an employee is at risk for depression, anxiety, or secondary trauma, and show you how you can help your team improve their personal and professional lives.

3. COVID-19

If you’re looking to learn more about coronavirus, then the WHO is the place to start for any health professional. The OpenWHO Massive Online Open Courses for COVID-19 provide learning resources for health professionals, decision-makers, and the public. As the pandemic continues to evolve, new resources will be added, additional language versions will continue to be rolled out, and existing courses will be updated to best reflect the changing context. Some sample courses are “Operational Planning Guidelines to Support Country Preparedness and Response” and “Infection Prevention and Control.”

4. Smoking cessation and vaping


People with unhealthy lungs are particularly at risk for complications from coronavirus, and many other health issues. Learning about these risks can help you talk clearly to clients who smoke. There’s plenty of new information regarding severe lung disease associated with using vaping devices and e-cigarette products, so now is a time to learn about that, especially among youth.

“There are many websites, webinars and listserves available for folks to learn the latest on commercial tobacco and vaping,” Says Norilyn de la Peña, Cessation and Outreach Project Manager at Public Health — Seattle & King County. It’s important to seek resources that are credible. People want information on what vaping products are how to have effective conversations about their use. She suggests learning about these tobacco cessation and vaping education topics for all providers:

  • What the products are and how they are used
  • Why it’s important to keep flavored tobacco and nicotine from youth (affects on brain and lung development, increase chance of addiction, increase likelihood of tobacco use, etc.)
  • Media literacy and tobacco and vape marketing intentionally target low-income communities
  • The importance of sharing valid information from appropriate online resources
  • How to talk to young people about vaping
  • Alternatives to nicotine and tobacco use; positive stress management and coping skills
  • What resources are available

She recommends the following general resources:

  • Truth Initiative
  • AAP (American Academy of Pediatrics)
  • SAMHSA (Substance Abuse and Mental Health Services Administration)
  • SCLC (Smoking Cessation Leadership Center)

Public Health — Seattle & King County’s website has Lung disease related to vaping and e-cigarette use. It has an excellent collection of materials, templates, and FAQs for providers, partners, and schools on understanding vaping and how it affects the lungs.

5. Chronic illness

CHWs are vital to successfully managing and avoiding chronic illnesses such as diabetes, heart disease, breast cancer, and cervical cancer. Since CHWs are health brokers who can connect providers with communities, take some time to learn more about the chronic diseases in your community and how CHWs can help.

If you’re a program manager or administrator new to CHWs, do some deep reading on building the policies and systems that support CHWs to see how they fit in with your organization. Start with the excellent document “Addressing Chronic Disease Through Community Health Workers: A Policy and Systems-Level Approach,” (PDF) from the CDC. Then take some time to watch Examining Community Health Worker Models in Managing Chronic Conditions.

If you’re a CHW, you can learn how chronic illness and mental health are closely linked. This video Ask an Expert – Depression and Chronic Illness Webinar (1:19) explores the relationship between depression and Nephrotic Syndrome, specifically, but the topic relates to people living with many chronic diseases.

CHWs can also save on CHWTraining’s chronic illness bundle. It helps you master working with clients with breast cancer (Breast Cancer Screening), cervical cancer (Cervical Cancer Screening and HPV), Diabetes and Prediabetes, and High Blood Pressure (Hypertension). Along the way, you’ll learn how to screen for disease, talk to clients, and connect to resources in your agency and community.

6. Immunizations


Parents and individuals are too reluctant to get vaccines, thanks in part to too much mistaken information. Patient education is an important way to let people know that vaccinations have an excellent safety record and are an important part of preventing serious diseases. A simple flu shot, covered by many health plans, is the best way for people to protect themselves and their children from getting the influenza.

The AAP is an excellent resource for educating parents and any individual on immunizations. It includes the recommended immunization schedule, information for parents, and communication tips for the conversations you’ll have with parents.

7. Motivational Interviewing interventions

Motivational interviewing (MI) is a technique you can use to help people discover their own reasons for positive change in a non-confrontational way. It was originally developed as a way to help people quit smoking, but MI techniques can be used for helping people make any kind of behavioral change.

Demonstration and practice are the best ways to learn and improve your MI skills, so spend some time reviewing some sample intervention videos, such as these:

8. Healthy cooking


Nutrition and health are closely related, from a healthy diet helping children grow up to avoid chronic diseases to managing—and maybe even reversing—conditions like diabetes. Learning healthy cooking is an excellent skill you can pass on to your clients, and your own family.

Try My Doctor – Kaiser Permanente, which has many how-to videos, ranging from short-and-sweet lessons like Add Flavor Without Salt (2:33) for hypertension, to Tips for Cooking Healthier (2:01), to in-depth webinars like Fresh Food Ideas (1:01:00) for parents.

9. Hygiene

Time to get serious about hand hygiene. Learn, demonstrate, repeat.

10. Language

Communication is a key skill for CHWs, and being able to speak and understand more than English helps. Learning a foreign language, such as Spanish for English-speakers or English for Spanish-speakers, is a great way to unlock better employment options and connect clients to resources.

Smart phone apps like Duolingo are great vocabulary builders, and you can do them whenever you have a few free minutes. Another fun one is Lirica, which matches language with pop music. It takes the music from such musicians as Enrique Iglesias and turns it into Spanish vocabulary and grammar lessons.

Keep building skills

Just reading a PDF or a PowerPoint presentation isn’t enough to really learn. Practice your skills as soon as you can. Keep refreshing your skills once you’ve learned something. Bookmark this page so you can keep revisiting these resources and keep them fresh.

What Supervisors Can Do To Support Mental Wellness of CHW Teams

Anyone supervising a community health worker team knows how important it is to support clients with depression, anxiety or other behavioral health issues.

What they might not realize is that their own staff might be feeling the same as their clients.

We’re taking a closer look at the negative effects of feelings of depression, anxiety, burnout and compassion fatigue on CHW staff at the Unity Conference 2019, which I’m previewing on March 26 with co-presenter Jeanine Joy, Ph.D. We’ll offer some solutions and strategies managers and supervisors can share with their team.


Burnout and mental disorders in CHWs

Why CHWs Feel Overwhelmed

CHWs create strong bonds with clients and report that they feel fulfilled by their jobs. However, CHWs are often called on to respond to mental health crises, but they might not have the training to handle it. They could be overworked and become discouraged when a relationship they build with a client ends. When they take on too much, they run the risk of depression, anxiety, burnout and compassion fatigue. When their mental wellness is at risk, so is your program.

“CHWs are often lauded for their ability to develop trust with peers, yet this willingness and ability to create enduring emotional bonds could threaten programme delivery,” says a study published in BMC Health Services Research.

In fact, community-based health workers are more likely to have problems with depression and mental health issues than the other members of their health care team.

Supervisor Training Gaps

In the process of developing three new modules for CHWTraining’s catalog (Depression and Anxiety, Motivational Interviewing and Supervisor Training), we immediately noticed some troubling trends:

  • Supervisors lack general training for managing teams of CHWs.
  • Supervisors lack training for dealing with mental wellness issues among their staff.
  • Many programs have few resources for supporting either supervisors or their staff.

Clearly, there’s a training and support gap that needs to be addressed. We’ve added courses on this topic to our online community health worker certification program, and we’re taking a deeper dive in an upcoming presentation “Supporting Mental Wellness In CHW Teams” (March 26 at 10 a.m.).

Here are some quick highlights.

Burnout, Depression and Anxiety Warning Signs

If you work in a close team, you might be able to easily tell if someone is feeling undue stress. In our behavioral health course, we flag these as some of the items to look for if you suspect someone needs help:

  • Sleeping too much or not enough
  • Sudden weight loss or gain
  • Avoiding people and activities
  • Smoking or drinking more, or using drugs
  • Mood swings
  • Apathy and calling in sick to work

Support Strategies for Supervisors

Start Before Problems Begin

One of the best things you can do is look out for any warning signs. But it’s even more effective to help your team avoid these dangers in the first place. Not only will you prevent any problems, but problems are much harder to address when they’ve already happened. Be proactive about the mental health of your team.

Listen Up

If you’re not sure if one of your CHWs is starting to feel the pressure of their job, listen. Be the kind of manager who is willing to listen to work-related issues. This gives employees the sense that they can come to you when they need to share. If they don’t volunteer information, make a habit of asking.

Similarly, encourage teamwork and bonding among the team. If you’re not there to lend an ear, someone else who understands the unique nature of being a CHW can provide a sympathetic ear.

Burn off Stress

At the top of the list is burning off stress. Organize informal picnics or potlucks with your team, so you’re connecting with each other in a way that’s not all about work. Or suggest walking meetings to recharge, as they do at Berkeley County School District, Moncks Corner, S.C.

Some organizations provide a mindfulness space to encourage relaxation or meditation. See if you can assign a room as a place where your staff can stop feeling overwhelmed. If you don’t have space or have a workforce that isn’t in a room together, encourage them to sit at their desk quietly, noticing their body’s sensations as they sit.

Mental Health Days

Your program should also offer mental health days as part of a benefits package. However, you should also suggest your staff take advantage of them. This can help CHWs realize that you support their mental wellness and that they can feel comfortable asking for time when they need it. Same goes for vacation time.

So, would you like to learn more?

Join us as we discuss improving your team’s mental wellness, identify signs that an employee is at risk for depression, anxiety, or secondary trauma, and show you how you can help your team improve their personal and professional lives. Sign up for this free presentation now.