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The Arukah Project: collaborating with the Church to improve African American mental health

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The Arukah Project: collaborating with the Church to improve African American mental health

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Content Running Head: THE ARUKAH PROJECT
The Arukah Project: Collaborating with the Church to Improve
African American Mental Health
Tracie G. Meyers
Doctor of Social Work
University of Southern California
Suzanne Dworak-Peck School of Social Work
December 2019
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I. Executive Summary
Closing the Health Gap
The United States has one of the largest income-based health disparities in the world, making
closing this health gap a Grand Challenge of Social Work. The existing health gap leaves the
most vulnerable Americans at risk, but especially racial minorities. Galloway-Gilliam (2013)
found that despite the wealth of the United States, the health outcomes of those who identify as
racial minorities are often comparable to residents of the much poorer nations. Income
disparities play a significant role in determining the mortality of all Americans. Lower income
households are three times more likely to die “from anything” than households earning more
than $115,000 (NIMH, 2017).
The World Health Organization states that social determinants of health are primarily
responsible for health inequity in the United States. These determinants include social
environment, social policies, physical environment, and health services (World Health
Organization, 2014). For example, in the physical makeup of poorer communities, there often
exists a lack of outdoor public spaces such as parks which decreases the ability for residents to
have safe spaces to move and have physical activity. Grocery stores tend to be farther away from
residences and have less fresh produce creating food deserts and insecurity. Physical activity and
healthy eating are significant factors in one’s health. Those living in neighborhoods without
assessable, high quality supermarkets are 55% less likely than those with access to have a good
quality diet (Tulane University, 2018).
African Americans, in particular, suffer significant health disparities (Turner, 2018).
According to the United States Department of Health and Human Services Office of Minority
Health (n.d.), African Americans’ poverty level affects mental health status. African Americans
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living below the poverty level, as compared to those over twice the poverty level, are 3 times
more likely to report psychological distress. African Americans are at increased risk of
developing psychiatric disorders as they are disproportionately exposed to social determinants
that are considered to be significant contributors to the development of mental illness (Neighbors
et al., 2008 (Schnitther, Pescosolido, & Croghan, 2005).
The underutilization of Behavioral Health Services by African Americans is a significant
concern in the effort to close the health gap in America. Annually, 67% of African Americans
who need mental health services do not access them (Dalencour et al., 2016). This has
significant consequences upon the African American community and general society. African
Americans with mental illness are three times more likely to be incarcerated (Turner, 2018),
twice as likely to be hospitalized than those without, and can experience the loss of as many as
five years on an already shortened life span due to co-morbid medical conditions (Schnittker,
Pescosolido & Croghan, 2005). The cost of health disparities results in 93 billion dollars in
excess medical care costs and 42 billion in lost productivity each year in the United States
(Turner, 2018).
Attempts to address this problem have primarily involved integrating behavioral health
services into primary care and co-locating professional behavioral health services within
community spaces (Meyers, 218). The Federal Government has attempted to improve access to
health services for all Americans through the Affordable Care Act and offering the expansion of
Medicaid throughout the states however this has not had a significant affect upon closing the
health gap in America (Shearer, n.d). These attempts have not fully served to address the norms
that are identified as the root causes of the problem (Meyers, 2018).
Project Purpose and Methodology
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The Arukah Project is an innovation designed to build upon the trusted foundation of the
traditional Black Church to educate the African American community and provide church based
supportive services. The Arukah Project will train congregants in African American churches as
Lay Health Workers utilizing a curriculum based in problem solving theory. The Lay Health
Workers will provide a series of six support sessions to interested congregants and community
members who have been identified as experiencing mild to moderate depressive symptoms on
the Patient Health Questionnaire-9. The Lay Health Workers will receive regular supervision
from licensed mental health providers as they conduct support sessions as a means of support,
program oversight and ongoing training. The Arukah Project will decrease the depressive
symptoms of its participants, provide crucial information on mental health, mental illness and
resources and decrease stigma by normalizing conversations on mental health within the church.
The Arukah Project directly disrupts the identified norms that have held the problem of
African Americans underutilizing behavioral health services so firmly in place. These norms
include lack of information, stigma, distrust of the medical community and use of nontraditional
coping supports. The Arukah Project directly targets the issue of stigma that prevents Blacks
from seeking behavioral health treatment by encouraging conversations within the trusted
environment of the Black Church. The provision of services through parishioners serving in the
role of lay health workers increases access to effective services within a trusted environment.
Although the church has a longstanding history of providing support and resources within the
Black community, there are significant opportunities for innovation within this system. More
recently the church has been utilized to educate congregants on health issues that are particularly
significant in the Black community such as breast cancer, cardiovascular disease and stroke
(Collins, 2015). Health Ministries have been created that serve to provide education on chronic
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disease and remind congregants of the importance of regular health screenings and diagnosis.
The church has been more hesitant in addressing the mental health concerns of its parishioners
(Hankerson & Weissman, 2012).
The use of lay health workers to provide education and services to members of
disenfranchised communities is well researched in the literature. Lay health workers (LHW’s)
have been a part of health promotion and disease prevention efforts in the US for many decades.
Lay health workers typically provide health education, information, assistance with services, and
build individual and community capacity for health. Research has shown positive associations
between LHW interventions and improved community health (Shahbazi et al., 2018). The
process of using lay health workers to provide problem solving based support has been
researched extensively by Dr. Chibanda in Zimbabwe who has successfully used community
health workers to meet the mental health needs of community members who have very limited
access to mental health professionals.
Problem solving therapy is based in cognitive behavioral therapy and is designed to assist
participants in coping more effectively with life problems that cause stress which in turn
decreases psychological stress and symptoms (Meyers, 2018). Problem solving therapy has been
proven to be as effective as other psychosocial therapies and medication management in
reducing depressive symptoms in a wide variety of populations (Bell & D’Zurilla, 2009).
Aims for Project Implementation and Future Actions
The Arukah Project will be initially implemented in the Power for Living Church in Jersey
City, New Jersey. The initial facilitation aims to train three to four lay health workers including
church clergy and conduct support sessions for 15 – 20 participants. This facilitation will be used
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to collect program data to amend the training components and support sessions if indicated
before increasing the reach of the program to a larger number of people.
Future actions include applying for recognition as a 501(c)(3) to increase potential funding
streams, collaborating with the African Methodist Episcopal Church to broaden the program
reach and potentially seek funding support. The results of the initial program facilitation will be
shared through proposed presentations at relevant conferences which include the National
Association of Social Workers and the American Public Health Association.
The Arukah Project will eventually be offered for purchase as a package that will include
training of the proposed Program Director and all program materials including the lay health
worker training manual. The trained Program Directors will be qualified to facilitate the program
in their own communities and receive ongoing coaching and support by the writer. Data will
continue to be collected from these programs in order to strengthen the research on the
program’s efficacy.
Potential Implications
The Arukah Project serves to potentially broaden the existing delivery of services that
positively affect the mental health of African Americans by recognizing and taking into account
the cultural aspects, such as stigma and the use of alternate coping methods, that have
significantly affected the use of more traditional treatments. The innovation directly challenges
the popular notion of Western society that believes professionally trained providers are the
experts that are best suited to meet the health needs of community members in every
circumstance. The use of the lay health worker while well documented as effective is often not
utilized within the field of mental health to meet the needs of the disenfranchised. The project
can serve to expand upon the services of existing, more traditional mental health institutions
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through the development of church-based programs that utilize community health workers to
provide services to educate and support African Americans within the trusted and frequently
utilized environment.

II. Conceptual Framework
Grand Challenge: Close the Health Gap
The American Academy of Social Work and Social Welfare has identified the need to close
the existing health gap as one of its Grand Challenge Initiatives due to its significant impact on
the lives of billions globally (Barth, Gilmore et al., 2014). A health gap exists when there is a
disparity between health care needs and health care services. The United States has one of the
largest income-based health disparities in the world. Health disparities are identified as
preventable differences in the burden of disease, injury, violence, or opportunities to achieve
optimal health that are experienced by disadvantaged populations (Centers for Disease Control,
2014). Millions of Americans have inadequate access to healthcare primarily due to existing
social determinants of health which are identified to be the conditions in which people are born,
grow, live, work and age (World Health Organization, n.d.). Social determinants of health are the
result of social policy and ideologies that shape the distribution of power and wealth that affect
one’s risk of disease and level of health vulnerability. It can also affect one’s access to
prevention and treatment. The existing health gap in the United States leaves the most vulnerable
Americans at risk. Galloway-Gilliam (2013) shared that despite the wealth of the United States,
the health outcomes of those who identify as racial minorities are often comparable to residents
of the much poorer nations.
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The underutilization of Behavioral Health Services by African Americans is a significant
concern within the effort to close the health gap in America (Lee, et al., 2014). 67% of African
Americans who need Mental Health services do not access them (Dalencour, et al., 2016). This is
a problem because research also shows African Americans with mental illness are three times
more likely to be incarcerated (Turner, 2018), twice as likely to be hospitalized, and can
experience the loss of as many as five years on an already shortened life span due to co-morbid
medical conditions (Schnittker, Pescosolido, & Croghan, 2005). The underutilization of
behavioral health care by African Americans in America is a complex problem that is deeply
rooted in the African Americans’ experiences of slavery, racism and continued discrimination.
Current Context
The concept of the underutilization of mental health services by African Americans is well
known and cited frequently throughout the literature. Attempts to address this problem have
primarily involved integrating behavioral health services into primary care and co-locating
professional behavioral health services within community spaces. The Federal Government has
attempted to improve access to health services for all Americans through the Affordable Care
Act and offering the expansion of Medicaid throughout the states however this has not had a
significant affect upon closing the health gap in America (Shearer, 2017).
Primary Care.
Although African Americans are more likely to receive treatment for behavioral health issues
in the primary care setting, primary health care has not been able to meet the challenge of
effectively closing the health care gap of the poorest Americans and particularly those belonging
to communities of color. Primary Care Physicians are found to be less likely to diagnose African
Americans as suffering from depression and significantly less likely to offer referral or resources
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for depression (Nicolaidis, et al., 2013). This discrepancy is thought to be influenced by a lack
of training in the manifestation of the symptomology of depression in African Americans (which
tends to be more somatic in nature than in other populations) as well as due to bias and racial
discrimination (Snowden, 2001).
Providing Behavioral Health Services through an Integrated Primary Health Care model is
one that is encouraged and endorsed by the Substance Abuse and Mental Health Services
Administration (SAMHSA) as it has been found to reduce the cost of behavioral health care and
be effective at reducing rates of depression (McFeature & Pierce, 2012) however it is a model
that can be difficult for health care agencies to reproduce due to issues of time, personnel
shortage and space limitations. The current primary care model is often developed based upon
the ability for health care agencies to bill for services provided. This places limitations on the
amount of time that is spent with each patient by the medical provider as well as whose services
will be paid for (Meyers, 2018). Primary care providers would need to receive training on the
identification of mental illness and recognition of symptoms as they are presented in African
Americans. Training is crucial in the prescription of psychotropic medications for illnesses such
as depression as this is a diagnosis that is experienced at greater chronicity for Blacks as well as
one that results in significant debilitating symptoms (Williams et al., 2007). It is imperative that
providers also receive training in the maintenance of patients on psychotropic medications for
more severe mental illness such as Bipolar Disorder and Schizophrenia as the co-morbidity rate
for chronic illness is significant in this population and will need to be understood in correlation
to treatment of these health disorders (Arzin, 2012).
Church Based Programming.
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The majority of health programming that has been offered in the traditional Black Church has
focused upon chronic health conditions and substance abuse disorders. There are very limited
studies on mental health services offered through the church (Hankerson & Weissman, 2012) and
those that have been conducted are often small in nature or attempt to support professional
mental health services by encouraging treatment adherence and healthy lifestyle choices.
Program Significance
The underutilization of mental health services by African Americans is a significant problem
that impacts not only members of the Black community but also the wider American community.
African Americans are 20% more likely to experience significant mental illness than other
populations due to the negative social determinant of health such as violence and poverty
(Neighbors et al., 2007). This leaves them at a higher level of vulnerability than other
populations for complications resulting from significant mental illness.
Individuals living with a serious mental illness are at higher risk of experiencing a wide
range of chronic physical conditions and are less likely to receive adequate treatment for co-
morbid conditions such as diabetes and heart disease, which can result in a significantly
shortened life span (DeHert et al., 2011). African Americans experience higher mortality rates
due to the increased experience of co-morbidity and untreated mental illness than do other
populations (Schnittker, Pescosolido, & Croghan, 2005). The Center for Disease Control
reported in 2014 that African Americans were thirty percent more likely to die from heart disease
than non-Hispanic Whites.
African Americans with mental illness are three times more likely to be incarcerated (Turner,
2018) and are less likely to receive comprehensive mental health treatment once they are
incarcerated. While people of color comprise 37% of the U.S. population, they represent 67% of
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the prison population. African Americans are more likely to be arrested, convicted, and
incarcerated than similarly situated white Americans (Ghandnoosh, 2015). Among young
African American males, one in three will spend some time incarcerated during his lifetime
(Ghandnoosh, 2015). Mass incarceration has long-term physiological effects that contribute to a
range of health issues, including mental health disorders, diabetes, asthma, hypertension, HIV,
and Hepatitis C (Dumont et al., 2012). These higher rates of incarceration have detrimental
generational effects upon the African American family and wider community. Studies report
numerous negative outcomes for children as a consequence of parental incarceration, ranging
from depression and anxiety to aggression and delinquency depending on circumstances such as
the child’s age and the length of a parent’s incarceration (Child Welfare Information Gateway,
2015).
Untreated mental illness has significant fiscal ramifications as well. The National Alliance on
Mental Health (n.d.) estimates that untreated mental illness costs the country up to $300 billion
every year due to losses in productivity. This includes time spent outside of the workplace due
call outs as a result of experiencing symptoms of mental illness and the high cost of
unemployment as well. It is estimated that the global economic cost of mental illness is expected
to be more than $16 trillion over the next 20 years (Penn State, 2018).
Conceptual Framework
The Arukah Project will train congregants in African American churches as Lay Health
Workers utilizing a curriculum based in problem solving theory. The Lay Health Workers will
provide a series of six support sessions to interested congregants and community members who
have been identified as experiencing mild to moderate depressive symptoms on the Patient
Health Questionnaire-9. The Lay Health Workers will receive regular supervision from licensed
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mental health providers as they conduct support sessions as a means of support, program
oversight and ongoing training.
The Use of Lay Health Workers.
Lay health workers have been defined generally as members of the community who work
primarily in community settings serve as connectors between health care consumers and
providers to promote health among groups that have traditionally lacked access to adequate care
(Witmer et al., 1995). Lay health workers offer a link between providers and underserved
minority community members as they often have an increased understanding of the needs of
their own community members and are able to better relate to them on an individual level. Lay
health workers (LHW’s) have been a part of health promotion and disease prevention efforts in
the US for many decades. Lay Health Workers typically provide health education, information,
assistance with services, and build individual and community capacity for health. Research has
shown positive associations between LHW interventions and improved community health
(Shahbazi et al., 2018).
The concept of using the lay health worker to address the mental health needs within the
community is based on the work of Dr. Chibanda in Zimbabwe who utilized trained
“grandmothers” to provide direct services utilizing problem solving therapy techniques to
community members who were primarily experiencing symptoms of depression and anxiety due
to HIV. The Grandmothers’ interventions successfully reduced self-reported psychiatric
symptoms and improved the participants’ quality of life as evidenced through multiple screening
tools (Chibanda et al., 2016). This project has been replicated around the world and has been
proven to reduce the reported symptomology of a significant majority of participants.
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Problem Solving Therapy as a Basis for Intervention.
Problem solving therapy is based in cognitive behavioral therapy and is designed to assist
participants in coping more effectively with life problems that cause stress which in turn
decreases psychological stress and symptoms (Meyers, 2018). Problem solving therapy has been
proven to be as effective as other psychosocial therapies and medication management in
reducing depressive symptoms in a wide variety of populations (Bell & D’Zurilla, 2009).
In utilizing the problem-solving model, the worker joins with the client in identifying
concerns that have disrupted the normal functioning of the client’s life. The problem is self-
identified by the client as are the potential methods at resolving the problem. This increases the
likelihood of follow through by the client as there is a sense of ownership of both the problem
and potential solutions. Clients are left with a sense of empowerment in the ability to identify
and address the problems that they presently face as well as those that occur in the future
(Turner, 2017).
Collaboration with the Black Church.
Houses of worship have a long and significant history within the African American
community of providing support, protection, comfort and information. Religious leaders are a
common coping mechanism used within the Black community as an alternative to seeking
professional behavioral health services (Snowden, 2001). The Black Church has served as a
source of support, education, sanctuary and self-efficacy for the African American community
since slavery. Slaves were allowed to meet for the purpose of Christian religious celebration and
were able to have some sense of self control over the services and the functioning of the church.
After the abolition of slavery, the church continued to serve as a meeting place for Black people
where they were able to fellowship and gain support from one another. The church allowed the
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sharing of resources and support for all members. The church leader was revered within the
community and considered a community leader. This was one of the very few places in
American society where African Americans held any position of power or esteem.
III. Problems of Practice and Innovation
Program Overview
The proposed innovation is entitled “The Arukah Project”. The word “arukah” is taken from
the Hebrew word meaning “restoration, restoring to wholeness” (biblehub.com, n.d.) The Arukah
Project will train congregants in African American churches as lay health workers utilizing a
curriculum based in problem solving theory. The lay health workers will provide a series of six
support sessions to interested congregants and community members who have been identified as
experiencing mild to moderate depressive symptoms on the Patient Health Questionnaire-9. The
lay health workers will receive regular supervision from licensed mental health providers as they
conduct support sessions as a means of support, program oversight and ongoing training.
Program Host Site.
The initial launch of The Arukah Project will be conducted within the Power for Living
Church in Jersey City, New Jersey. The church was identified through the relationship with a
member of the project Advisory Council who was aware of churches throughout Jersey City who
may be more accepting of inviting a mental health initiative within their respective houses of
worship. The Power for Living Church is a non-denominational Christian church that has a
congregation of approximately one hundred and is led by a female pastor. A non-denominational
Christian church is one that does not formally align with a structured denomination such as
African Methodist Episcopalian and is able to individually make decisions on things such as
programming without needing to abide by a set of formal rules and structure of a larger
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governing church body. These characteristics are ideal for the inaugural cycle of the innovation
in order to maintain control, modify the program as indicated and keep the project at a
manageable size.
A series of “talks” will be provided by this writer during regular Sunday services on various
topics concerning mental illness and the effects upon the African American community to begin
the conversation of mental illness within the sanctuary. This will serve to begin normalizing the
discussion of mental health within the trusted space of the church. The congregation will also be
educated on The Arukah Project and invited to apply to become lay health workers. The series
will culminate in a town hall style meeting on the state of mental health within the African
American community. The meeting will be co-sponsored by The Rapha Collective as well as the
church’s Health Ministry. Local stakeholders which include mental health professionals, clergy,
health professionals, neighborhood pharmacists, social service and human service agencies and
local residents will be directly targeted to attend.
Solicitation of Participants.
Attendees of the Town Hall meeting will be encouraged to complete the Patient Health
Questionnaire 9 (PHQ-9) if they desire to be assessed for depression and be considered for
program participation. Anyone testing positive on the initial evaluation tool will be invited to
complete a simple questionnaire that will serve to collect basic demographic data, history of
behavioral health diagnosis, treatment and symptoms of more severe mental illness such as
psychosis and mania. (See Appendix A). The completion of the questionnaire will be facilitated
by the writer as well as program interns. The program participants will be recruited utilizing the
characteristics identified on the PHQ-9 and the questionnaire. Eligible participants will have
scored mild to moderate depression on the PHQ-9, be over the age of eighteen, have no current
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psychosis, substance abuse, suicidal ideation or current participation in professional behavioral
health treatment. Anyone who is found to be suicidal will be immediately assessed for risk and
the appropriate level of clinical intervention will be facilitated. Continued solicitation for
program participants will be offered through the church as reminders in the church weekly
bulletin and identified posted space outlining project, mental health facts and information to
contact this writer for assessment and program consideration.
Congregants desiring to be trained as lay health workers will also be given the PHQ-9 and
receive a negative score (indicating no depression is present). They will also complete the
participant questionnaire to determine mental health history, level of education, substance use
and current mental health treatment involvement. Lay health workers will be free from suicidal
ideation, psychosis and current substance abuse. The initial group of lay health workers will
begin the six-week training module prior to the identification of initial program participants in
order to facilitate the start of support sessions within two weeks of identification. This will be
done so as not to lose the momentum developed by the program and patient interest. The initial
training cycle will be facilitated by this writer with the assistance of program interns.
Support Session Structure.
Support sessions will be scheduled based upon mutual need of participants and availability of
mental health interns. The sessions will be held within the church in a private office space.
Clinical supervisors will be available during and immediately following each session for support,
clinical emergency or questions. Clinical supervisors will consist on master’s level mental health
interns and licensed mental health professionals. Support sessions are outlined in The Arukah
Training Manual and follow the outlined problem-solving model. (See Appendix B). Problem-
solving therapy is an intervention intended to improve an individual's ability to cope with
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stressful life experiences or problems. The basis of the approach is the belief that the negative
symptoms a person is experiencing may be a result of them having ineffective coping or
problem-solving skills. Problem-solving therapy model is a technique that helps people take
action in their lives, helping them cope with difficulties, and teaching them to proactively solve
their problems. The supportive services that are provided are not intended to be viewed as
therapy or professional counseling. It is understood that lay health workers are not acting in the
role of a licensed professional, but rather as a trained lay health worker who will provide support
and assist in identifying resources that may be needed.
Problem solving should be done in several steps: learning how the participant handles
problems; identifying the problems being experienced; selecting one problem; defining the
problem and choosing a goal; brainstorming solutions; selecting a solution; creating a SMART
(Specific, Measurable, Achievable, Realistic and Timely) action plan; and evaluating (did it
work?). The participants will be given a copy of the Support Session Notes which include the
problem worked on, the identified goal, the SMART action plan and next session time. After
each session the lay health worker is able to debrief with the clinical supervisor to ensure no
immediate intervention is required, provide support for the lay health worker and to answer any
pertinent questions. citations
As each six week support session cycle ends, the participants will be given the Patient Health
Questionnaire 9 again and will complete a brief questionnaire to determine their level of
willingness to participate in professional mental health services in the future, the perceived
effectiveness of the program as well as any thoughts or suggestions they are willing to share.
Participants will be asked of their willingness to participate in a follow up interview within three
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months to assess their current depressive symptoms, perceived effectiveness in problem solving
and any participation in professional mental health treatments. (See Appendix C).
Contribution to the Closing of the Health Gap
The Arukah Project exists within the fourth strategy of closing the health gap, promoting full
access to health care, as identified by the American Academy of Social Work and Social Welfare
(2017). This strategy encourages the creation of community based, culturally grounded health
initiatives to meet the health needs of disenfranchised populations.
The Arukah Project will disrupt several of the norms that are holding the problem of African
Americans underutilizing mental health services firmly in place. By collaborating with the Black
Church, The Arukah Project will build upon the deeply entrenched tradition of African
Americans using the church as a center of knowledge and support and provide trusted persons
(fellow congregants and church leadership) with skills to assist one another in problem solving
and reducing their depressive symptoms. The Project will reduce stigma by facilitating
conversations on mental health and normalizing the experience of seeking assistance for mental
health symptoms. These guided conversations will also provide knowledge and resources on
mental health within the community which has also been acknowledged as being a significant
factor in African Americans not utilizing mental health services.
History, Landscape and the Contextual Environment
The African Americans underutilization of professional behavioral health services dates back
to the institution of slavery in America. Issues of racism and discrimination has had a lasting
effect on the Black population’s inclusion in formalized medical institutions. A review of the
literature shows that the reasoning behind this problem are complex. The primary causes found
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include issues of culture, stigma, access to treatment and financial limitations, use of alternate
coping mechanisms, lack of knowledge and issues of mistrust. citations
Culture.
African American beliefs concerning metal illness have been well documented. The idea that
depression is seen as a sign of weakness and must be handled without the use of professional
assistance or medication is pervasive (Conner et al., 2010) as is the belief that one can overcome
any problem if they work hard enough (Snowden, 2001). African Americans are more likely to
believe that someone with a mental illness is a physical danger to themselves and others (Anglin,
Link & Phelan, 2006). Due in part to a history of exclusion and disenfranchisement, Blacks have
a tendency to believe that behavioral health is not for African Americans and is a system
designed by and for Whites (Nicolaidis et al., 2010). The world views of Blacks and Whites are
vastly different due to the separate lives that they continue to lead (Pew Research Center, 2016).
Stigma.
For African Americans being a person of color and labeled mentally ill is a double stigma
(Newhill & Harris, 2007). African Americans are very concerned about being labeled as “crazy”
by others in the community or by treatment providers as result of seeking treatment for
behavioral health issues (Thompson et al., 2004). The sources of referral and entry to
professional behavioral health treatment often complicates the African American’s view of
engaging in care (Meyers, 2018). Blacks are often referred through systems such as child
welfare and judicial systems which increases patient fears of lack of confidentiality. These fears
prohibit people from discussing symptoms of mental illness that they may be experiencing. This
lack of communication affects the providers ability to properly diagnose patients which is
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compounded by the fact that African Americans often present differently when experiencing
conditions such as depression than other populations (Das et al., 2006). Due to issues of bias,
lack of education and awareness, primary care providers are less likely to diagnose and refer
African Americans with issues of depression and anxiety.
Access to Treatment and Financial Limitations.
A history of de facto segregation has produced entire neighborhoods that are devoid of
primary care facilities and medical specialists which has resulted in an unequal access to
healthcare. Hospital Emergency Departments frequently serve as patient’s main source of
medical treatment which results in a lack of continuity of care, no access to preventative care and
lack of treatment follow up (Snowden, 2001). This decreased access to resources has resulted in
as many as 59% of African Americans in urban areas utilizing hospital emergency rooms as their
primary means of healthcare (Pratt, 2017). This lessens the chances of patients develop trusting
relationships with medical provider and receiving comprehensive, long term care (Pratt, 2017).
Use of Alternate Coping Mechanisms.
The history of the African American in America has included enslavement, racism and
segregation which has greatly affected the inclusion of the population in the healthcare industry
as either patient or service provider. The history of Blacks in America utilizing treatment
resources other than doctors began during slavery when few were allowed to be treated by White
Physicians and few trusted their care to one if allowed (Murray, 2015). Slaves sought care from
knowledgeable elders within their own communities who utilized treatments such as herbs and
folks remedies (Bronson & Nuriddin, 2014).
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The use of community members for treatment and care continued after slavery ended due to
the continued policies of segregation, the high cost of treatment, as well as the discrimination
experienced by members of the Black community from formalized White institutions that
continued to perpetuate feelings of distrust and suspicion. Predominantly White institutions
were only sought out for assistance when the person was critically ill. This dependence upon
alternate coping has continued into the present day.
Clergy and houses of worship are often utilized as informal avenues of treatment as are
family and friends (Newhill & Harris, 2007). Lay people may not be aware when a person’s
symptoms trigger a need for a higher level of care and professional intervention. As these
coping systems are often also from the African American community, they are likely hindered by
the same lack of information as the affected person.
Lack of Knowledge.
Briggs, Briggs, Miller & Paulson (2011) found that African Americans have a lack of
knowledge and misunderstanding of what mental illness encompasses. It has been shown that
some of the hesitancy that African Americans exhibit in engaging in treatment with behavioral
health professionals is due to a lack of understanding of the treatment process and expectations
as well as a lack of knowledge of the signs and symptoms of mental illness (Thompson et al.,
2004). This affects a person’s ability to be able to recognize when professional intervention may
be indicated. Black patients have also shared they have fears of being “brainwashed” or
misdiagnosed (Thompson et al., 2004). There is also a fear of psychotropic medication as being
addictive (Newhill & Harris, 2007).
Mistrust.
THE ARUKAH PROJECT 21

Among African Americans in the Unites States there is a systemic history of distrust of
medical institutions that are a result of multiple factors including slavery, discrimination and well
documented instances of nonconsensual medical experimentation such as the Tuskegee Syphilis
Study (Gamble, 1993). A lack of trust in medical professionals has been found to negatively
affect health communication and acceptance of care by patients (Jacobs, Rolle, Ferrans,
Whitaker and Warnecke, 2006). Lack of trust also affects the likelihood that the patient will
follow through with provider recommendations.
Medicine as a means of social control has been studied by medical sociologists for decades
(Zola, 1972; Conrad, 2008). The power of controlling access to contraception, preventative
medicine and innovative treatments for disease highlights the divisions that exist in America.
The idea that there are some that do or do not deserve access to healthcare due to race,
citizenship status, sexuality or religion is an underlying theme that guides the discussion of
healthcare in America.
Access to behavioral healthcare treatment has effectively served to further disenfranchise
African Americans relegate many to a life of struggle with substance abuse and mental illness
which often results in incarceration, homelessness and poverty. African Americans have been
identified as a population that is undeserving of quality medical treatment as compared to
Caucasians since they were brought to America as slaves. A system of discrimination continues
to perpetuate this categorization and division.
Existing Opportunities for Innovation
Although the church has a longstanding history of providing support and resources within the
Black community, there are significant opportunities for innovation within this system. More
THE ARUKAH PROJECT 22

recently the church has been utilized to educate congregants on health issues that are particularly
significant in the Black community such as breast cancer, cardiovascular disease and stroke
(Collins, 2015). Health Ministries have been created that serve to provide education on chronic
disease and remind congregants of the importance of regular health screenings and diagnosis.
The church has been more hesitant in addressing the mental health concerns of its parishioners
(Hankerson & Weissman, 2012).
African American clergy are not currently prepared to counsel or advise concerning issues of
mental health. Anthony, Johnson, & Schafer (2015) conducted a study of African American
pastors to help demonstrate the preparedness of Black clergy to provide counseling services to
parishioners with issues of clinical depression. The study reiterates the fact that a significant
number of people who suffer from symptoms of depression and other mental illnesses do not
seek help from behavioral health or other medical professionals. The study also sheds light upon
the fact that the majority of clergy do not feel equipped to provide adequate counseling services
to people suffering from depression. The Arukah Project will be able to meet the needs of many
of the individuals who have mental illness and already seek support from the church by
educating church leadership and equipping congregants to provide direct services within the
church.
There has been an increase in public discourse concerning African American mental health
that can be seen throughout social media as well as with well known media personalities
revealing their personal stories and how mental illness has affected their lives. Web based sites
such as “Therapy for Black Girls” serve to assist African American women who are interested in
locating a Black therapist. “No More Martyrs” is another initiative that serves to educate the
THE ARUKAH PROJECT 23

Black population on mental health issues, create communities that serve to provide peer support
and improve the utilization of professional mental health services (Meyers, 2018).
Social Media.
Social media has been effectively utilized by agencies such as State Departments of Health to
disperse information on topics such as HIV, hepatitis and flu vaccines. Mental health advocacy
groups are utilizing podcasts, blogs and social sites to inform their audiences of current issues in
mental health as well as available resources in order to reduce stigma and improve general
knowledge on the topic of behavioral health. Many of these initiatives appear to be guided
toward individuals with post high school education who could freely access services once they
desire to do so. It is imperative that future efforts in public discourse be designed to involve all
those possibly affected by mental health concerns who may not have available access to
behavioral health services (Meyers, 2018).
Federal Government.
The Mental Health Parity and Addiction Act was intended to protect consumer access to
mental health and substance abuse services by legislating that mental health services are to be
covered at an equal rate to health services. It has been found that the Act had little to no effect
upon the utilization or access to mental health and substance abuse treatment for most
populations (Shearer, 2017). Goldberg and Lin (2017) did find that the Act had an effect upon
the referral behaviors of primary care physicians for patients who presented with issues of
depression however African Americans were still referred for treatment at significantly lower
levels than white and Hispanic patients.
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Nine states and Washington, D.C. and eighteen municipalities mandate private employers
provide workers with paid sick leave based upon the number of employers the organization has
and the number of hours the employee has worked. This legislation has had varying effects on
the amount of time away from work (Callison & Pesko, 2017) but has not been studied on the
effects of the legislation on mental health treatment access.

Alignment with Theory of Change
The Arukah Project directly aligns with the theory of change as previously discussed in
Section II as it trains lay health workers to provide direct problem-solving support-based services
to church congregants within the trusted venue of the African American Church. The problem-
solving model, which is based in cognitive behavioral theory teaches participants to identify
problems causing a disruption in their current level of functioning and identify potential means
of solving these problems. This method empowers the participant to be better able to solve
problems in the future. This has been proven to result in a decrease of problematic
symptomology of anxiety and depression (Chibanda et al., 2016).
The Arukah Project utilizes culturally sensitive strategies that have been found to be effective
within the African American community. As African American’s tend to use alternate systems of
coping rather than professional medical resources due to issues of mistrust of the medical
community, the Arukah Project capitalizes upon this reality and provides direct peer led services
in the trusted church setting by members of the trusted community who were already likely to be
utilized as a means of support but were previously less equipped to effectively provide it.
The Arukah Project has a high likelihood of success as it provides a service that research has
demonstrated is in significant need and is not being sufficiently met through other means. The
THE ARUKAH PROJECT 25

Arukah Project is culturally sensitive and relevant as it exists within the time-honored traditions
of the African American community and is mindful of the norms that have so strongly held this
problem anchored into place. The Arukah Project also is utilizing a program structure that has
been proven to be effective in countries with populations that also must take into account a lack
of resources, stigma, cultural traditions and a lack of information with people of color.

IV. Project Structure, Methodology, and Action Components
Prototype
The prototype presented, is the training manual for the lay health workers of the Arukah
Project. (See Appendix B). The training manual provides the guidance necessary to prepare and
support the lay health workers who will provide the problem-solving based support sessions to
identified participants.
Target Market

The Arukah Project is targeting African American men and women age 18 and older who are
affiliated with a predominantly Black church. The initial target are the congregants and
immediate community who are age 18 and older and surround the Power for Living Church in
Jersey City, New Jersey.
Market Need
In 2019 African Americans comprised 13.4% of the United States population (U.S. Census
Bureau, 2018) and 53% percent of them self-identified as being members of a religious
institution. This leaves 15,000,000 who could potentially benefit from The Arukah Project. One
in four Americans will experience symptoms of mental illness in any given year and African
Americans are 20% more likely than other populations to experience a serious mental illness due
to factors such as poverty, racism and trauma. Although they are more likely to experience
THE ARUKAH PROJECT 26

serious mental illness than other populations, African Americans are much less likely to access
professional mental health treatment services. Annually less than 33% of African Americans in
need of professional mental health services will utilize them.
New Jersey has a population of approximately 8.9 million people and is the most densely
populated state in the nation. Close to 3.1% of adults (SAMHSA, 2018) in New Jersey live with
serious mental health conditions such as major depression. Only 41.8% of adults with mental
illness in New Jersey receive any form of treatment from either the public system or private
providers (SAMHSA, 2018). The renaming 58.2% received no mental health treatment.
According to Mental Health America, New Jersey is ranked 6 out of the 50 states and
Washington D.C. for providing access to mental health services.
African Americans have a long history of utilizing other means of support such as the church
that can be traced to slavery. After the abolition of slavery, issues of discrimination and racism
have prevented African Americans from the full utilization of professional mental health
services. This tradition has continued to the present day. Church leadership however is often not
trained to recognize symptoms of mental health crisis or in techniques to effectively support
those experiencing symptoms of common illnesses such as depression. (Anthony et al., 2015).
This tradition of seeking help from the Black church indicates that African Americans would be
available for a mental health intervention available through the church.
Competition
There are no programs that currently provide free mental health support services through the
church provided by lay health workers. There are co-located programs that provided mental
health services that are supported by churches and programs such as Mental Health First Aid,
that can be brought into the church to educate interested members about basic mental health facts
THE ARUKAH PROJECT 27

and local resources. These programs are facilitated by mental health professionals and serve to
bring professional mental health services into the community taking advantage of the
endorsement of the trusted Black church as a trusted resource. While these programs educate the
community concerning significant mental health issues, they do not have a lasting presence as
they are single session programs and they do not directly provide mental health services to the
African American Community citations
Web based sites such as “Therapy for Black Girls” serve to assist African American women
who are interested in locating a Black therapist, however interested users will already be in the
market for a mental health professional (Bradford, 2018). Sites such as these are geared to the
33% that are already more likely to access mental health services. “No More Martyrs” is another
initiative that serves to educate the Black population on mental health issues, create communities
that serve to provide peer support and improve the utilization of professional mental health
services (No More Martyrs, 2018). This initiative appears to target a high functioning population
who are technological savvy and have the means to participate in “meetups” and functions
typically held in venues such as restaurants. This would tend to omit the population that have
limited internet access and limited financial resources.
Program Implementation Strategies
Planning and Preparation.
During the Planning and Preparation Phase of The Arukah Project, churches located in Jersey
City who may be candidates to host the initial launch of the program were scouted using
resources such local clergy members, members of religious leadership councils, local mental
health professionals and Jersey City residents. The initially identified church will no longer be
used as an inaugural site as the leadership began to make attempts to significantly change the
THE ARUKAH PROJECT 28

program structure which greatly affected the integrity of the program design. A member of the
church leadership recently began a doctoral counseling program and was attempting to utilize
this initiative to meet their own educational needs. This served to initially be a program obstacle
as a considerable amount of time and effort had been invested in identifying and collaborating
with the church leadership and health ministry working toward program implementation. The
process of identifying a new inaugural host was recently begun and has successfully resulted in
identifying a smaller church whose leadership has limited knowledge of mental illness but
recognizes the need within their own congregation and surrounding community.
A small Advisory Board was established to assist in the planning and implementation of the
project. The Advisory Board consists of a member of the clergy, mental health researcher, a
mental health professional and a lay community member. The Board serves to provide guidance
and insight from the different sectors of actors who are affected by the identified problem and
involve them in shaping the proposed solution. The Advisory Board was composed to represent
the significant stakeholders that are being affected by the poor access of mental health services
by African Americans. The Board was instrumental in the development of the training
curriculum as they ensure it would be clearly written in a language that was easy for the target
population to understand and relate with and use while providing the information and training
needed to conduct the support sessions. The Board also reviewed the use of the Patient Health
Questionnaire to determine its appropriateness for use in measuring the intervention. The
PHQ2/9 has been validated for use with African Americans and has been determined to be
reliable (Kroenke, Spitzer & Williams, 2001).
Program Design.
THE ARUKAH PROJECT 29

The Arukah Project is a line of business of the Rapha Collective. The Rapha Collective is a
Limited Liability Company that was organized in March of 2019 by the writer in preparation for
the project’s implementation. The Rapha Collective’s mission is to provide culturally competent,
mental health services utilizing community-based collaboratives as service partners to reduce
stigma, increase awareness and reach those who have not been able to easily access mental
health services. The Rapha Collective has established partnerships with New Jersey City
University to provide masters level mental health interns to support community based
programming and assist in providing mental health services to identified community members
who cannot be serviced through the lay health workers of The Arukah Project due to their level
of clinical need, scheduling, lack of health insurance coverage or other complications. The
Private Practice line of The Rapha Collective will serve as a source of financing to assist in the
implementation of The Arukah Project. This will assist in overcoming the financial barriers that
exist due to the Collective currently having a “for profit” status which limits the sources of
funding available for use. The Rapha Collective will apply to create a 501(c)(3) for The Arukah
Project after its inaugural run in order to utilize the data obtained to secure funding through state
and federal resources.
The Lay Health Worker Manual was created during this phase. The manual is to be used to
train and support the lay health workers as they prepare to provide support services within the
church. The manual will be edited utilizing feedback obtained from the initial workers who are
trained to take into account additional information or resources that they identify as needed for
future training. The manual may also be edited upon analysis of the data generated from the
initial program facilitation. Tools that will be used for program evaluation and participant
identification were also designed during this phase (See Appendices A & C).
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Revision.
During the Revision Phase of the program implementation, the data collected from the
participant’s interviews and Patient Health Questionnaires will be analyzed to determine changes
in participant functioning, identify potential changes that need to be made in program materials
or layout. The data analysis will be done in collaboration with the Advisory Board as will
program edits. The results will be shared with the leadership of the Power for Living Church as
well as with the lay health workers to gather additional suggestions for program editing. The
program will be continued within the church if leadership is supportive. A copyright will be
sought for the edited training manual at this time.
During this phase The Rapha Collective will complete an application to form The Arukah
Project as a 501(c)(3) to increase the funding available for program support and dissemination.
Additional collaborators will be identified to assist in program dissemination and support.
Collaboration will also be identified to assist in providing ongoing clinical support to trained lay
health workers in the inaugural church site as well as in the training of new lay health workers.
Organizations such as the National Association of Black Social Workers will be approached.
Financial Plan.
The Arukah Project will initially be funded through private investors and the financing
earned through the provision of paid mental health services provided through The Rapha
Collective’s private practice. The total forecasted funding required for a full year of start up costs
is $98, 583 (See Appendix D). The Rapha Collective will provide $45,000 toward the projected
need over the course of twelve months. $25,000 has been secured from an investor who wishes
to remain anonymous who has been closely impacted by mental health in their own lives as their
close family member committed suicide due to what they believe was a an unwillingness for the
THE ARUKAH PROJECT 31

family member to accept and access treatment due to the fear of seeming “weak” and “sick”. The
remaining $28,583 is being solicited from private investors who have expressed interest in issues
of mental health within the African American community including DJ Envy from the
syndicated radio show “The Breakfast Club” and Tyler Perry the television producer and
filmmaker. Crowd sourcing will also be utilized as a source of project funding.

Assessment of Impact
The success of The Arukah Project will be measured using the results obtained from the
Patient Health Questionnaire-9 and the structured interviews. (See Appendix E). Participants
will be given the PHQ-9 prior to receiving the intervention, after participating in three sessions
of the intervention and then again after the last session is completed. The scores will be
compared to identify changes. The scale results in a numerical score that can easily be compared
and are ranged from 0-27 with 0-4 designated as “none or minimal”, 5-9 being mild, 10-14 is
moderate, 15-19 is moderately severe and 20-27 is severe. It is anticipated that there will be a
decrease in score (reduction in severity of depressive symptoms) with program participation.
Participants will be offered an incentive to complete an additional PHQ-9 and participate in a
brief interview three months after the completion of their program to determine continued effects
of program participation. The structured interviews will be used to determine if there are other
factors potentially influencing the results of the PHQ-9 such as participation in professional
counseling, physical health crises, substance use/abuse or recent death or loss.
Ethical Concerns
Of primary concern is the potential for breaches in confidentiality by the lay health workers.
In order to combat this, lay health workers will receive training in the purpose and need for
THE ARUKAH PROJECT 32

confidentiality and the concept will be continually reinforced during ongoing supervision.
Participants will also be advised of the lay health workers need to session information to remain
confidential and will be provided the contact information of the Program Director if they are
concerned at any time that their confidentiality has been breached in any way. All concerns will
be investigated and treated with the utmost importance. If it has been found that the lay health
worker has breached confidentiality, they may receive consequences ranging up to dismissal
from the program.
The potential of lay health workers acting outside of their scope as lay community health
workers and attempting to counsel as a mental health professional is an additional ethical
concern. Lay health workers will consistently be reminded throughout training and in ongoing
supervision that they are not acting in the role of professional counselors. Training will include
vignettes and scenarios that will be used to assist the lay health workers in determining where
there support ends and the potential need for professional intervention may begin. Participants
will also be educated by the Program Director and staffing that lay health workers are not
intended to take the place of professional counseling services. If professional services are
needed, they are available to participants as crisis intervention or ongoing therapeutic services.
V. Conclusions, Actions, and Implications
Future Implications
The Arukah Project is intended to inform future research and innovations concerning the
improvement of access to mental health services of African Americans through direct
collaboration with houses of worship. There is a dearth of recent research in the area of
addressing the mental health disparities in the African American community and a significant
lack of research on programming involving church based mental health services. The innovation
THE ARUKAH PROJECT 33

directly challenges the popular notion of Western society that believes professionally trained
providers are the experts that are best suited to meet the health needs of community members in
every circumstance. The use of the lay health worker while well documented as effective is often
not utilized within the field of mental health to meet the needs of the disenfranchised (Chibanda
et al.,2011).. Citations
The Arukah Project serves to potentially broaden the existing delivery of services that
positively affect the mental health of African Americans by recognizing and taking into account
the cultural aspects, such as stigma and the use of alternate coping methods, that have
significantly affected the use of more traditional treatments. The project can serve to expand
upon the services of existing, more traditional mental health institutions through the development
of church-based programs that utilize community health workers to provide services to educate
and support African Americans within the trusted and frequently utilized environment. The
training manual for The Arukah Project can be immediately utilized by mental health
practitioners and organizations who desire to educate the community on problem solving
techniques and basic mental health facts or who desire to use the material to train existing
community health workers who need additional training in mental health and using problem
solving techniques with community members (Chibanda et al., 2011).
Limitations
Duplication of The Arukah Project can be significantly limited by issues of financing. The
services of the project are not reimbursable by insurance and by design are targeted toward a
population that may not be able to afford a self-pay service. Larger scale analysis should be
conducted to confirm the effectiveness of The Arukah Project to ensure its acceptance as an
evidence-based program that can be shown to improve mental health sequalae resulting in
THE ARUKAH PROJECT 34

improved functioning. As an evidence-based program, The Arukah Project would have access to
increased funding streams as training and education will be able to be marketed and sold.
Next Steps
Funding.
The inaugural facilitation of The Arukah Project is scheduled to begin in January of 2020.
The collected data will be analyzed, and programmatic changes will be implemented as
indicated. The project will continue in the Power for Living Church and an additional church will
be added in Jersey City. The 501(c)(3) paperwork will be completed by this time to allow for
increased solicitation for funding from sources such as Substance Abuse and Mental Health
Services Association and Robert Wood Johnson Culture of Health funding opportunities.
Collaboration.
Collaboration with the African Methodist Episcopal Church will be sought in this phase of
project dissemination. The Medical Director of the First District (which includes the state of
New Jersey), Reverend Doctor Burnett was instrumental in assisting in the initial phases of the
writer’s research into the identified problem and is a proponent of bringing mental health
services into the church. The results of the initial facilitation will be shared with her to assist in
the collaboration and potential funding of the project within the AME Churches of the First
District.
Dissemination of Information.
Proposals will be submitted for consideration sharing the results of The Arukah Project for
the 2020 and 2021 Annual Meetings of the National Association of Social Workers, the
American Public Health Association, the National Alliance on Mental Illness and the Society for
THE ARUKAH PROJECT 35

the Analysis of African American Public Health Issues. Articles will be submitted to the Journal
of Black Health and Social Work.
Project Dissemination.
The Arukah Project will become fully reproducible by 2021. The training manual will be
published and available for purchase through the purchase of the full Program Director Training
that will be provided by the writer to train future Program Directors to train lay health workers
and replicate the program in their own houses of worship or churches within their community.
Data from these programs will be submitted to the writer for continued analysis and program
revisions.
THE ARUKAH PROJECT 36

References

Anthony, J. S., Johnson, A. & Schafer, J. (2015). African American clergy and depression: What they
know; What they want to know. Journal of Cultural Diversity 22(4), 118–26.
Arzin, S. (2012). Research to improve health and longevity of people with severe mental illness.
National Institute of Mental Health. Retrieved from https://www.njmh.nih.gov.
Barth, R. P., Gilmore, G. C., Flynn, M.S., Frasier, M.W. & Brekke, J.J. (2014). The American
Academy of Social Work and Social Welfare: History and grand challenges. Research on Social
Work Practice 24(4), 495-500.
Bell, A. C., & Thomas J. D. (2009) “Problem-Solving Therapy for Depression: A Meta-Analysis.”
Clinical Psychology Review 29(4), 348–53. https://doi.org/10.1016/j.cpr.2009.02.003.
Callison, K., & Pesko, M. (2017). The effect of paid sick leave mandates on access to paid leave and
work absences. Upjohn Institute Working Papers. https://doi.org/10.17848/wp16-265.
Centers for Disease Control and Prevention – Division of Community Health. (2013). A
Practitioner’s Guide for Advancing Health Equity: Community Strategies for Preventing
Chronic Disease: US Department of Health and Human Services: Atlanta, GA.
Chibanda, D., Weiss, H. A., Verhey, R., et al. (2016). Effect of a Primary Care–based psychological
intervention on symptoms of common mental disorders in Zimbabwe: A randomized clinical
trial. JAMA 316(24), 2618–26. https://doi.org/10.1001/jama.2016.19102.
Child Welfare Information Gateway. (2015). Child welfare practice with families affected by
parental incarceration. Washington, DC: U.S. Department of Health and Human Services,
Children’s Bureau.
THE ARUKAH PROJECT 37

Dalencour, M., Wong, E.C., Tang, L. et al. (2016). The role of faith-based organizations in the
depression care of African Americans and Hispanics in Los Angeles. Psychiatric Services 68,
(4), 368–74. https://doi.org/10.1176/appi.ps.201500318.
DeHert, M., Correll, C.U., Bobes, J., Cetkovich-Bakmas, Asai, E, Detraux,J.E., et al. (2011). Physical
illness in patients with severe mental disorders. I. prevalence, impact of medications and
disparities in health care. World Psychiatry 10, (1), 52–77.
Dumont, D. M., Brockmann, B., Dickman, S., Alexander, N., & Rich, J. D. (2012). Public health and
the epidemic of incarceration. Annual Review of Public Health, 33(1), 325–339.
Galloway-Gilliam, L. (2013). Racial and ethnic approaches to community health. National Civic
Review 102(4), 46–48. https://doi.org/10.1002/ncr.21154.
Ghandnoosh, N. (2015). Racial inequity in the criminal justice system. Washington, D.C.: The
Sentencing Project.
Goldberg, D. M., & Lin, H. (2017). Effects of the Mental Health Parity and Addictions Equality Act
on depression treatment choice in primary care facilities. The International Journal of Psychiatry
in Medicine 52(1), 34–47. https://doi.org/10.1177/0091217417703289.
Lee, H., Porter, L., & Comfort, M. (2014). Consequences of family member incarceration: Impacts on
civic participation and perceptions of the legitimacy and fairness of government. The Annals of
the American Academy of Political and Social Science 651(1), 44–73.
https://doi.org/10.1177/0002716213502920.
McFeature, & Pierce, T.P. (2012). Primary care behavioral health consultation reduces depression
levels among mood disordered patients. Journal of Health Disparities Research and Practice,
5(2), 36-44.
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Meyers, T. (2018). Closing the health gap; Innovative strategies in primary care, Unpublished paper.
Submitted for SOWK704. Strategic Innovations for the Grand Challenges. Doctor of Social
Work Curriculum. Spring. University of Southern California.
NAMI: National Alliance on Mental Illness. (2019). Retrieved October 20, 2019, from
https://www.nami.org/
Neighbors H.W., Caldwell C., Williams D.R, et al. (2008). Race, ethnicity, and the use of services for
mental disorders results from the national survey of American life. Arch Gen Psychiatry.
64(4):485–494. https://doi:10.1001/archpsyc.64.4.485.
Nicolaidis, C., McKeever, C., & Meucci, S. (2013). A community-based wellness program to reduce
depression in African Americans: Results from a pilot intervention. Progress in Community
Health Partnerships: Research, Education, and Action 7(2), 145–52.
https://doi.org/10.1353/cpr.2013.0017.
Penn State. (2018). Poor mental health days may cost the economy billions of dollars. Science Daily.
Retrieved October 20, 2019 from www.sciencedaily.com/releases/2018/07/180730120359.htm
Pew Research Center. (2016, Jun 27). On views of race and inequality blacks and whites are worlds
apart. Retrieved October 20, 2019 from http://pewsocialtrends.org/2016/06/27/on-viewof-race-
and-inequality-blacks-andwhites-are-worlds-apart/
Pratt, E. (2017, November 4). Why do so many people still go to the emergency room? [Blog post].
Retrieved from http://healthline.com/health-news/medical-care-in-emergency-rooms/
Schnittker, J., Pescosolido, B.A., & Croghan, T.W. (2005). Are African Americans really less willing
to use health care? Social Problems I(2), 255–71. https://doi.org/10.1525/sp.2005.52.2.255.
THE ARUKAH PROJECT 39

Shahbazi, M., Kumar, M., Mawson, A., Lavigine, D. A., & Dove, C. (2018). Effectiveness of
community health workers in healthcare delivery: Evidence from the field. Journal of Health
Disparities Research and Practice 11(2).
Shearer, T. (2017). Mental health parity legislation (2008-2015): effects on mental health
outcomes (Graduation with Honors in the Economics). The University of Iowa.
Snowden, L. R. (2001). Barriers to effective mental health services for African Americans. Mental
Health Services Research 3(4), 181–87.
Strategies to Reduce Health Disparities 2014 - Minority Health - CDC. (2019). Retrieved October 20,
2019 from https://www.cdc.gov/minorityhealth/chdir/strategies2014/Strategies2014.html
Tulane University. (2018, May 10). Food deserts in America [Blog post]. Retrieved from
http://socialwork.tulane.edu/blog/food-deserts-in-america/
Turner, A. (2018). The business case for racial equity: A strategy for growth. Retrieved October 20,
2019 from https://altarum.org/publications/the-business-case-for-racial-equity-a-strategy-for-
growth.
Turner, F. J. (2017). Social work treatment: Interlocking theoretical approaches. Oxford University
Press.
U.S. Census Bureau. (2018). Population estimates July 1, 2018. Retrieved October 20, 2019 from
https://www.census.gov/quickfacts/fact/table/US/PST045218
U.S. Department of Health and Human Services, Substance Abuse and Mental Health Services
Administration, Center for Behavioral Health Statistics and Quality. (2018). National Survey on
Drug Use and Health 2016 (NSDUH-2016-DS0001). Retrieved
from https://datafiles.samhsa.gov/
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What are the social determinants of health?, (n.d.). World Health Organization. Retrieved October 20,
2019, from http://www.who.int/social_determinants/en/
Williams, D. R., Gonzalez, H. M., Neighbors, H., Nesse, R., & Abelson, J. (2007). Prevalence and
distribution of major depressive disorder in African Americans, Caribbean Blacks, and Non-
Hispanic Whites. African American 11.
Witmer, A., Seifer, S. D., Finocchio, J. L., & O’Neil, E.H. Community Health Workers: Integral
Members of the Health Care Work Force. American Journal of Public Health 85(8) 1055–58.

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Appendix A

Participant Questionnaire

Name __________________________________ Date of Birth ___________________________
Address_______________________________________________________________________
Telephone _______________________________ Email ________________________________
Emergency Contact _____________________________________________________________

1. Why are you seeking support at this time? _________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________

2. Are you currently participating in any type of counseling? YES NO

3. Have you ever participated in any type of counseling? YES NO
If so when ____________________________________________________________________
For what reason? _______________________________________________________________
______________________________________________________________________________
Did you find it to be helpful? YES NO
Why or why not? _______________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________

4. Have you ever been hospitalized for a mental health reason? YES NO
If so when and for what reason? ___________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
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5. Do you currently have thoughts or plans to harm yourself? YES NO
IF YES STOP AND ASSESS FOR IMMEDIATE INTERVENTION

6. Have you had thoughts in the past of harming yourself? YES NO
If yes, when and explain _________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________

7. Have you ever tried to harm yourself? YES NO
If yes, when and explain _________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________

8. Do you ever hear or see things that no one else does? YES NO
If yes, explain _________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________

9. Have you ever abused substances or alcohol? YES NO
If yes, type and date of last use ____________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
IF YES ASSESS AND OFFER ASSISTANCE FOR TREATMENT REFERRAL

10. Current medications __________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
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11. Current medical conditions ____________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________

12. Date of last physical __________________________________________________________

13. How successful are you at problem solving?
1 (not at all) 2 (somewhat) 3 (neutral) 4 (successful) 5 (very successful)

14. How in control do you feel of your life?
1 (not at all) 2 (somewhat) 3 (neutral) 4 (in control) 5 (very in control)

15. How confident are you that you could handle problems that come up for you in your future?
1 (not at all) 2 (somewhat) 3 (neutral) 4 (confident) 5 (very confident)

16. How willing would you be to see a professional mental health counselor?
1 (not at all) 2 (somewhat) 3 (neutral) 4 (willing) 5 (very willing)
NOTES _______________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
THE ARUKAH PROJECT 44

Appendix B

The Arukah Project Lay Health Worker Training Manual

Lay Health Worker Training Manual

Tracie Meyers 2019 The Rapha Collective, LLC
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Special Acknowledgement is given to The Friendship Bench for serving as a resource in the
development of this training manual.

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Table of Contents
Introduction …………………………………………………………………………………….6
Problem History …………………………………………………………………………6
Project Background ……………………………………………………………………...6
A Note About Stigma ……………………………………………………………………8
Training Session Agenda ………………………………………………………………..8
Chapter 1 Overview of the Arukah Project …………………………………………………10
Overview of Intervention ………………………………………………………………10
Purpose of Program …………………………………………………………………….10
Structure of Support Sessions ………………………………………………………….12
Chapter 2 Common Mental Health Disorders ……………………………………………...,20
Depression ………………………………………………………………………………20
Anxiety Disorders ……………………………………………………………………....22
Generalized Anxiety Disorder ………………………………………………………….22
Panic Disorder ………………………………………………………………………….23.
Substance Abuse ……………………………………………………………………….24
Suicidal Thoughts (Ideation) ……………………………………………………….….27
Chapter 3 Problem Solving Theory Model ……………………………………………...….29
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Overview …………………………………………………………………………......29
Steps of Problem-Solving Model ……………………………………………………..30
How does participant deal with problems? …………………………………..30
How to Recognize Problems …………………………………………………31
How to select a problem, define the problem and choose a goal …………….34
How to brainstorm solutions …………………………………………………36
How to select a solution ……………………………………………………...38
How to make a SMART action plan …………………………………………40
How to evaluate solution (Did it work?) ……………………………………42
Chapter 4 Strengthening Support Skills …………………………………………………..48
Confidentiality ……………………………………………………………………….48
Qualities of a Skillful Lay Health Worker …………………………………………...49
Empathy ……………………………………………………………………...49
Ability to Listen ……………………………………………………………...50
Self-Awareness ………………………………………………………………50
Being non-judgmental ……………………………………………………….50
Recognizing Safety Concerns ………………………………………………..51
Remaining Calm ……………………………………………………………..52
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Handling Strong Emotional Reactions …………………………………………52

Chapter 5 Tools & Documentation …….…………………………………………………….55
Support Session Notes ………………………………………………………………….55
Patient Health Questionaire-9 ………………………………………………………….56
Suicidal Thought Questionnaire ………………………………………………………..58
Problem Checklist ………………………………………………………………………60
Problem Solving Worksheet ………………………………………………………...….61
Chapter 6 ……………………………………………………………………………………...64
Self-Care ………………………………………………………………………………..64
Review of Supervision & Structure …………………………………………………….65
Purpose of Supervision …………………………………………………………65
Using Supervision Effectively ………………………………………………….65
Resources ………………………………………………………………………………………68
References ……………………………………………………………………………………..71

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Introduction
Problem History
The United States has one of the largest income-based health disparities in the world. The
existing health gap leaves the most vulnerable Americans at risk. Galloway-Gilliam (2013)
shared that despite the wealth of the United States, the health outcomes of those who identify as
racial minorities are often comparable to residents of the much poorer nations. In 2016, people
of color made up 40 percent of the United States population and are disproportionately low
income and underinsured.
Research shows nearly 67% of African Americans who need Mental Health services do not
access them (Dalencour, et al., 2016). This is a problem because research also shows African
Americans with mental illness are three times more likely to be incarcerated (Turner, 2018),
twice as likely to be hospitalized, and can experience the loss of as many as five years on an
already shortened life span due to co-morbid medical conditions (Schnittker, Pescosolido, &
Croghan, 2005). The underutilization of Behavioral Health Services by African Americans is a
significant concern in the effort to close the health gap in America (Lee et al., 2014). The
underutilization of behavioral health care by African Americans in America is a complex
problem that is deeply rooted in the African Americans’ experiences of slavery, racism and
continued discrimination.
Background of The Arukah Project
The Arukah Project was created in 2019 by Tracie Meyers, MSW, LCSW for the purposes of her
Capstone Project to meet the qualifications for graduation from the University of Southern
California’s Doctor of Social Work Program. The Arukah Project was designed to address the
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underutilization of mental health services of African Americans by disrupting the norms holding
the problem in place which includes stigma, lack of information on mental health within the
African American community as well as the cultural preference to utilize alternate coping
mechanisms such as the traditional Black church (Bronson & Nuriddin, 2014).
The Black church has traditionally served as a significant source of support and information
within the community. The Arukah Project collaborates with predominantly Black churches to
provide congregations and church leadership with basic information concerning the most
common mental health disorders, symptoms and available treatment and resources. Interested
congregants will be offered participation in a six-week training program to become lay health
workers. The lay health workers will provide a series of support sessions to self-identified
congregants who are experiencing depressive symptoms. The Lay Health Workers will receive
close clinical supervision from licensed mental health professionals as they work with and
support participating congregants.
It is hypothesized that after participating in the lay health worker led, problem solving based
support sessions participants should experience a decrease in depressive symptoms, a decrease in
stigma and an increased willingness to access mental health services in the future if indicated.

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A Note About Stigma
Many people are hesitant to admit that they
may be experiencing symptoms of a mental
illness due to the stigma connected with
mental health in our society. Stigma can be
defined as discrimination against someone
or a group of people due to characteristics such as health status. People are
afraid they will be viewed as weak, defective or valueless. It is important that
we all are educated in mental health basics in order to increase our knowledge
and decrease issues of fear and misconceptions. We must take responsibility
for our words and refrain from using derogatory terms such as “crazy” when
describing someone who may have a mental illness and make it a point to
educate others.
Training Session Agenda
Day One
Introductions & Ice breaker
Overview of Project History & Purpose
Overview of Intervention
Structure of Support Sessions
Wrap Up & Review of Day Two Agenda

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Day Two Day Six
Review of Day One Review of Day Five
Question & Answer/ Reflections Question & Answer/ Reflections
Common Mental Health Disorders Self-Care
Wrap Up & Review of Day Three Agenda Supervision: Purpose, Structure & Use
Role Play & Practice
Day Three Wrap Up & Review
Review of Day Two Closing Celebration
Question & Answer/ Reflections
Problem Solving Method
Wrap Up & Review of Day Four Agenda

Day Four
Review of Day Three
Question & Answer/ Reflections
Skill Building & Review
Wrap Up & Review of Day Five Agenda

Day Five
Review of Day Four
Question & Answer & Reflection
Tools & Documentation
Role Play & Practice
Wrap Up & Review of Day Six Agenda

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Chapter One Overview
In this chapter we will review the purpose of the program and increase our understanding of the
role you will play. We will also review the structure of the program sessions.
Purpose of Program
Each year in The United States one in five people will experience a mental illness. African
Americans are twenty percent more likely than other populations to experience serious mental
illness in any given year however, they are fifty percent less likely than other populations to seek
and access professional mental health services. This underutilization of mental health services is
due to issues of stigma, lack of information on the topic of mental health, and a history of
discrimination that has led to a distrust of the medical profession. African Americans frequently
utilize alternate forms of support such as family, friends and the church.
The Arukah Project collaborates with churches to train church leadership and lay health workers
in structured problem-solving techniques to provide direct support to self-identified congregants
and community members who are experiencing mild to moderate depressive symptoms. This
project brings mental health information, resources and services directly into the church to meet
the unmet mental health needs of the community.
Overview of the Intervention
As a trained Lay Health Worker, you will be providing interested participants with a series of six
structured support sessions. The participants will come from your church congregation and the
surrounding community. The sessions will be held once per week or once every other week
within your church or church related setting. Each Lay Health Worker will be assigned a licensed
THE ARUKAH PROJECT 54

mental health professional that will be available for assistance during your structured sessions.
You will also receive weekly supervision meetings to review skills and answer any questions that
you may have.
The supportive services that you provide are not intended to be viewed as therapy or professional
counseling. It is understood that you are not acting in the role of a licensed professional, but
rather as a trained lay health worker who will provide support and assist in identifying resources
that may be needed.
Participants will be chosen after completing an assessment and interview process with a licensed
mental health professional to determine their appropriateness for program participation. Those
who are experiencing active substance abuse, experience symptoms of psychosis or are suicidal
will not be included in this program but will be provided resources that best meet their needs.
The support sessions you will be providing are based in problem solving therapy. Problem-
solving therapy is an intervention intended to improve an individual's ability to cope with
stressful life experiences or problems. The basis of the approach is the belief that the negative
symptoms a person is experiencing may be a result of them having ineffective coping or
problem-solving skills. Problem-solving therapy model is a technique that helps people take
action in their lives, helping them cope with difficulties, and teaching them to proactively solve
their problems.

This Photo by Unknown Author is licensed under CC BY-SA
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Support Session Structure
Session One
1. Ensure you have your notes and forms ready.
2. Greet Participant, introduce yourself.
3. Explain purpose of Arukah Project and your role. Remind participant this is a six week
program however if they feel they need support once program ends we will assist in
linking them with a professional counselor.
4. Complete PHQ-9. **If participant indicates thoughts of harming self, immediately
complete Suicidal Thought Questionnaire and follow all protocols listed.
If no suicidal thoughts are indicated continue:
5. Invite participant to speak. For example, you may ask “What brings you here today?” or
“How can we work together to help you?”
6. Listen empathically.
7. Complete Problem-Solving Worksheet.
8. Evaluate and provide feedback.
9. Give participant copy of PS Worksheet.
10. Make next appointment.
After participant leaves:
1. Complete session notes and attach copy of worksheet and PHQ-9.
2. Identify concerns or topics to review with supervisor.

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Session Two
1. Ensure you have reviewed notes from Session One.
2. Make sure you have a copy of completed Problem Solving sheet from Session One.
3. Greet participant and engage (let them know you are pleased to see them again).
4. Review Session One. How did the plan go?
If it went well (goal was achieved):
A. Praise/reinforce/affirm
B. Ask for another problem from list or a new problem participant would like to work on
Complete new Problem-Solving Worksheet.
If it didn’t go well (goal not achieved):
A. Explore reasons
B. Discuss obstacles
C. Complete new Problem-Solving Worksheet with adjusted SMART action plan
5. Evaluate and provide feedback
6. Give participant copies of paperwork
7. Make new appointment.
After participant leaves:
1. Complete session notes and attach copy of worksheet.
2. Identify concerns or topics to review with supervisor.

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Session Three
1. Ensure you have reviewed notes from Session Two.
2. Make sure you have a copy of completed Problem Solving sheet from Session Two.
3. Greet participant and engage (let them know you are pleased to see them again).
4. Complete PHQ-9. **If participant indicates thoughts of harming self, immediately
complete Suicidal Thought Questionnaire and follow all protocols listed.
If no suicidal thoughts are indicated continue:
5. Review Session Two. How did the plan go?
If it went well (goal was achieved):
A. Praise/reinforce/affirm
B. Ask for another problem from list or a new problem participant would like to work on
Complete new Problem-Solving Worksheet.
If it didn’t go well (goal not achieved):
A. Explore reasons
B. Discuss obstacles
C. Complete new Problem-Solving Worksheet with adjusted SMART action plan
6. Evaluate and provide feedback
7. Give participant copies of paperwork
8. Make new appointment.
After participant leaves:
1. Complete session notes and attach copy of worksheet and PHQ-9.
2. Identify concerns or topics to review with supervisor.
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Session Four
1. Ensure you have reviewed notes from Session Three.
2. Make sure you have a copy of completed Problem Solving sheet from Session Three.
3. Greet participant and engage (let them know you are pleased to see them again).
4. Review Session Three. How did the plan go?
If it went well (goal was achieved):
A. Praise/reinforce/affirm
B. Ask for another problem from list or a new problem participant would like to work on
Complete new Problem-Solving Worksheet.
If it didn’t go well (goal not achieved):
A. Explore reasons
B. Discuss obstacles
C. Complete new Problem-Solving Worksheet with adjusted SMART action plan
5. Evaluate and provide feedback
6. Ask participant if they are interested in beginning professional mental health treatment at
the end of this program. Discuss with them the process and that you will assist them in
locating a professional counselor.
7. Give participant copies of paperwork
8. Make new appointment.
After participant leaves:
1. Complete session notes and attach copy of worksheet.
2. Identify concerns or topics to review with supervisor.
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3. Notify supervisor whether or not participant needs assistance locating counselor or other
community-based services.
Session Five
1. Ensure you have reviewed notes from Session Four.
2. Make sure you have a copy of completed Problem Solving sheet from Session Four.
3. Greet participant and engage (let them know you are pleased to see them again).
4. Review Session Four. How did the plan go?
If it went well (goal was achieved):
A. Praise/reinforce/affirm
B. Ask for another problem from list or a new problem participant would like to work on
Complete new Problem-Solving Worksheet.
If it didn’t go well (goal not achieved):
A. Explore reasons
B. Discuss obstacles
C. Complete new Problem-Solving Worksheet with adjusted SMART action plan
D. Evaluate and provide feedback
7. Give participant copies of paperwork
8. Make new appointment and remind that next session is the final session.
After participant leaves:
1. Complete session notes and attach copy of worksheet.
2. Identify concerns or topics to review with supervisor.
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3. Notify supervisor whether or not participant needs assistance locating counselor or other
community-based services.
Session Six
1. Ensure you have reviewed notes from Session Five.
2. Make sure you have a copy of completed Problem Solving sheet from Session Five.
3. Greet participant and engage (let them know you are pleased to see them again).
4. Complete PHQ-9. **If participant indicates thoughts of harming self, immediately
complete Suicidal Thought Questionnaire and follow all protocols listed.
If no suicidal thoughts are indicated continue:
5. Review Session Two. How did the plan go?
If it went well (goal was achieved):
A. Praise/reinforce/affirm
B. Ask for another problem from list or a new problem participant would like to work on
Complete new Problem-Solving Worksheet.
If it didn’t go well (goal not achieved):
A. Explore reasons
B. Discuss obstacles
C. Complete new Problem-Solving Worksheet with adjusted SMART action plan
6. Evaluate and provide feedback
7. Give participant copies of paperwork
8. Praise participant for the progress and hard work during the program. Give participants
blank worksheets to use in the future when they are continuing to work on problems.
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After participant leaves:
1. Complete session notes and attach copy of worksheet and PHQ-9.
2. Identify concerns or topics to review with supervisor.

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Notes
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
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Chapter Two Common Mental Health Disorders
In this chapter we will learn about the most common mental health conditions that occur in the
United States. The information provided is not meant for you to use to diagnose or treat, but
rather as a resource so that you may become more informed concerning these conditions.
Depression (Major Depressive Disorder)
The term “depression” is frequently used to describe everyday feelings of sadness or
disappointment that comes and goes as a result of life stressors or disappointments. It is
important to remember that the passing “blues” or “feeling down” is not a true depressive
disorder. A major depressive disorder must last for at least two weeks and must affect a person’s
ability to work, carry out everyday activities and relationships.
Depression is a mood disorder that affects more than 16.1 million American adults, or about
6.7% of the U.S. population age 18 and older each year. While major depressive disorder can
develop at any age, the median age at onset is 32.5 years old. Depression is more prevalent in
women than in men.
Someone who is clinically depressed would experience two or more of the following symptoms
for at least two weeks (American Psychiatric Association, 2013):
• An unusually sad mood
• Loss of enjoyment or interest in activities that used to be enjoyable
• Lack of energy and tiredness
• Feeling worthless or feeling guilty though not really at fault
• Thinking about death or wishing to be dead
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• Difficulty concentrating or making decisions
• Moving more slowly or sometimes becoming agitated and unable to settle
• Having difficulty sleeping or sleeping too much
• Loss of interest in food or sometimes eating too much
Depression has no single cause and is often the result of biological and social factors which may
include:
• Loss of a job
• Death of a loved one
• Physical illness
• Being victimized
Depression can also result from certain medical conditions and as a side effect of some
medications.
Women who have recently delivered a baby may also experience a depression as a result of
hormonal changes and the stressors of caring for a newborn. While many women may
experience “baby blues” if the symptoms continue for more than two weeks, it is important for
the mother to be evaluated by a medical professional as the symptoms of postpartum
depression can have a significant impact upon the mother and infant as well.

Anxiety Disorders
There are several conditions that are categorized as Anxiety Disorders. We will learn about
Generalized Anxiety Disorder, Panic Disorder and Posttraumatic Stress Disorder.
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Generalized Anxiety Disorder
Generalized Anxiety Disorder (GAD) affects 6.8 million adults, or 3.1% of the U.S. population
each year. GAD is one of the most common mental illnesses in the United States. While it is
common to worry, this everyday worry is quite different from Generalized Anxiety Disorder as it
is difficult to control, last for over six months and affects many aspects of the person’s life. GAD
is characterized by the following symptoms (American Psychiatric Association, 2013):
• Excessive anxiety and worry that is difficult to control
As well as three or more of the following:
• Restlessness
• Being easily fatigued
• Difficulty concentrating / mind going blank
• Irritability
• Muscle tension
• Sleep disturbance
People with Generalized Anxiety Disorder often
anticipate the worse before it happens. They can have difficulty feeling optimistic and can find
themselves becoming overwhelmed by situations and experiences that have not yet occurred.

Panic Disorder
Panic Disorder is characterized by recurrent and unexpected panic attacks. Panic attacks are
intense bouts of anxiety that are frequently mistaken by the person who experiences it as a heart
THE ARUKAH PROJECT 66

attack. During a panic attack the person may hyperventilate and feel as if they cannot breathe or
catch their breath. Their heart may race, and they may feel lightheaded. Frequently the person is
fearful that they may die or lose control. A person with Panic Disorder continuously worries that
they will have another panic attack and begins to change their behavior and patterns as a result in
hopes of avoiding it.
Symptoms of a Panic Attack may Include (American Psychiatric Association, 2013):
• Palpitations, pounding heart, rapid heart rate
• Sweating
• Trembling and shaking
• Shortness of breath, sensations of choking
• Chest pain or discomfort
• Abdominal stress or nausea
• Dizziness, light-headedness, feeling faint or unsteady
• Feelings of unreality or being detached from oneself
• Fear of losing control or “going crazy”
• Fear of dying
• Numbness or tingling
• Chills or hot flashes
The characteristics of Panic Disorder include (American Psychiatric Association, 2013):
• Recurrent and unexpected panic attacks
At least one of the attacks has been followed by one month or more of the following:
• Persistent concern about having additional attacks
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• Worry about the implications of the attack or its consequences (i.e., losing control,
having a heart attack, “going crazy”)
• Significant change in behavior related to the attacks
Posttraumatic Stress Disorder
Posttraumatic Stress Disorder can occur in people who experience a traumatic event such as a
physical assault or a bad car accident. The traumatic event is life threatening or is perceived by
the person to be life threatening. The person responds to this with intense fear, helplessness or
horror.
The person reexperiences the event in one or more of the following ways:
A. Recollection of the event (images, thoughts, perceptions)
Dreams
Acting or feeling as if the traumatic event happened again
Intense fear and distress when being reminded of the traumatic event or parts of it
B. Avoidance of reminders (conversations, activities, places associated with the traumatic
event
Inability to recall memories of the traumatic event
Decreased interest in activities
Feeling of detachment and estrangement from others
Reduced ability to feel
Foreshortened sense of future
C. Physical hyperarousal
Sleep disturbances
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Irritability
Being startled easily
Hypervigilance
D. The person suffered from these symptoms for more than 1 month.
E. The person is significantly distressed and impaired in their functioning.

Substance Abuse
Approximately 8% of the population age 12 and older in the United States has a substance abuse
disorder each year. Substance abuse disorders often begin in adolescence or early adulthood.
Substance abuse disorders are twice as common in males than in females and often occur along
with depression and anxiety disorders (Kessler et al., 2006). It is common for people who are
experiencing symptoms of mental illness to abuse drugs or alcohol in an effort to self-medicate
and alleviate their symptoms.
Common substances include alcohol (which includes beer, wine and “hard liquor”), marijuana,
cocaine, crystal meth, angel dust (dust), PCP, embalming fluid (dip), opiates (such as heroin,
codeine, morphine, methadone), inhalants such as glue and over the counter medications such as
cough syrup or even mouth wash. Medication
prescribed to treat some mental illnesses can also
be abused such as Xanax and Adderall due to their
ability to change the person’s state of mind.

General Effects of Substances
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Intoxication
Each substance has usual symptoms (as experienced by most people) as well as unpredictable
symptoms (as experienced by some people). Marijuana may generally cause a feeling of
relaxation in most however it can cause feelings of paranoia and fear in other.
When symptoms are severe, it is difficult to distinguish them from mental illness
Withdrawal
• Some substances and alcohol can cause significant, even life-threatening reactions when
taken at large quantities for a significant period of time.
Physical effects
• Substance abuse may result in an increase of certain cancers, affect one’s brain
chemistry, and negatively impact organs of the body.
Emotional/ Psychological effects
• Substance abuse may result in ongoing paranoia, hallucinations or delusions, depression
and anxiety.
Substance use disorders include the following (American Psychiatric Association, 2013):
• Abuse of alcohol or other drugs which leads to work, school, home, health or legal
problems
• Dependence on alcohol or other drugs
The symptoms of substance dependence are:
• Tolerance for the substance (the person needs increased amounts over time or gets less
effect with repeated use).
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• Problems with withdrawal (the person experiences withdrawal symptoms or uses
substances to relieve withdrawal symptoms).
• Use of larger amounts over longer periods than intended.
• Problems in cutting down or controlling use.
• A lot of time spent getting the substance, using it, or recovering from its effects.
• The person gives up or reduces important social, occupational, or recreational activities
because of substance use.
• The person continues using the substance despite knowing that use has negative
consequences.
A Note Concerning Suicidal Thoughts (Ideation)
A person may experience suicidal thought (ideation) as a result of any of the
previously mentioned conditions. Suicidal thoughts may range from a person
“wishing they were no longer here” to someone having an immediate plan to jump from a bridge.
All expressions of suicidal ideation must be taken seriously and involve a licensed medical or
counseling professional. If at any time you are working with someone who expresses suicidal
ideation, calmly allow them to express their thoughts to you and let them know that this will
need to be shared with the Clinical Supervisor in order to ensure they are offered any additional
services or support immediately.

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Notes
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Chapter Three The Problem-Solving Therapy Model
In this Chapter we will:
Learn about the Problem-Solving Therapy Model
Learn how to use the model with participants
Practice using the model with one another
What is Problem Solving Therapy:
Problem-solving therapy is an intervention intended to improve an individual's ability to cope
with stressful life experiences or problems. The basis of the approach is the belief that the
negative symptoms a person is experiencing may be a result of them having ineffective coping or
problem-solving skills. Problem-solving therapy model is a technique that helps people take
action in their lives, helping them cope with difficulties, and teaching them to proactively solve
their problems.
The problem-solving therapy model is based in cognitive behavioral therapy. Cognitive
behavioral therapy is an intervention that aims to improve mental health. CBT focuses on
challenging and changing unhelpful thoughts and behaviors, improving emotional regulation,
and the development of personal coping strategies that target solving current problems.
Although you will not be providing therapy, you will be learning to use techniques based in these
models that have been proven to assist people in feeling more in control of their lives and reduce
symptoms of depression and anxiety.

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Problem Solving Steps
Problem solving should be done in several steps:
1. Learning how the participant handle problems
2. Identifying the problems being experienced
3. Selecting one problem. Defining the problem and choosing a goal
4. Brainstorming solutions
5. Selecting a solution
6. Creating a SMART action plan
7. Evaluating (did it work?)
Step 1. How Does the Participant Handle Problems?
We ask the participant how they normally handle problems that they face and what they think
about their ability to handle problems. Use this time as an opportunity to share with the
participant that there is a way to efficiently deal with problems that you are going to show them
and try over the next few weeks that has been proven to be very helpful in finding solutions and
helping to improve the person’s general sense of wellbeing and functioning.
HOW IT’S DONE
Ask the participant:
“How have you tried to solve problems in the past?”
“What do you do when you have problems?”
“How do you feel when you have problems?”
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Example:
Sarah has been intimate with a man she doesn’t know very well after going out on a date and
having too much to drink. She hasn’t been feeling well lately and is worried she may have
contracted some type of disease. She hasn’t spoken to the man about it and is not sure what to
do.
The Lay Health Worker asks Sarah: What do you do when you have problems?
Sarah: “I don’t know, I try to avoid thinking about it. I can’t solve problems.”
LHW: How do you feel when you have problems?
Sarah: “I feel Terrible and hopeless. I often can’t sleep and keep thinking.”
LHW: What problems have you managed to solve in the past?
Sarah: “Actually, once my aunt was angry with me, she thought I had taken money from her. I
spoke to my mother about it and my mom went with me to talk to my aunt and worked it all out.”
Step 2. Identify the Problems the Participant is Experiencing
Sometimes people are not able to handle problems because they lack the skill to break down a
problem into smaller parts. Instead of searching for solutions, they might avoid (withdrawal,
distraction, playing it down) or show impulsive reactions and behave in a way that is not helpful
(fighting, blaming oneself, quitting a job). Feelings such as anger or sadness and thoughts that
they are incapable, unlovable or worthless can contribute to these behaviors.
They may also have physical reactions such as feeling very tired, difficulty sleeping,
experiencing headaches, or frequent crying. Although these symptoms can stem from physical
ailments, they can also be symptoms of mental health conditions such as depression.
Your role is to engage with the participant to assist them in feeling comfortable in talking to you
concerning the problems they are experiencing.
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HOW IT’S DONE:
Encourage the participant to speak freely about what is going on in their life.
While you listen, summarize and identify those things that are problematic for the participant.
This is how you will create a problem list.
You can also use the problem chart to help categorize the problems.
Nature of Problem Check if it Applies to Pt.
Relationship
Marital
Work related
Bereavement/ Grief
School
Family
Interpersonal (loneliness, self-esteem)
Health related
Financial
Legal problem
Alcohol, drugs
Housing
Other

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Example:
Had unprotected sex
Drinks and does things she doesn’t normally do
Afraid to speak to man about it
Afraid to get tested, doesn’t want to know
Wants to avoid thinking about it
Afraid she has contracted an STD
Nature of Problem Check if it Applies to Pt
Relationship
Marital
Work related
Bereavement/ Grief
School
Family
Interpersonal (loneliness, self-esteem)
Health related X
Financial
Legal problem
Alcohol, drugs X
Housing
Other

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Step 3. How to Select and define a problem.
SELECT
The next step is to help the participant select one problem from the list created to focus on. The
problem should be one that is manageable and meaningful. It should also be practical. It is
important for the participant to feel that they have some control over the problem.
CREATE A GOAL
Once the participant has selected a problem, we discuss and formulate the goal and write it
down.
DEFINE
Use the following questions to explore more details. The a is to define the problem. Once the
problem has been well defined, write it on the worksheet.
HOW IT’S DONE
SELECT
Tell the participant “One problem needs to be chosen off the list to handle first. Let’s review the
list together and choose the problem that is most meaningful and manageable to you.”
CREATE A GOAL
Ask the participant “How will you know when the problem is solved? What will be different,
what will it look like?”

DEFINE
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Explain to participant how important it is to fully understand the problem. It is helpful for them
to speak about it and the better you both understand the problem the easier it will be to find a
solution.
You can use the following questions:
• What happened?
• Who was involved?
• When and where does it happen (or did it happen)?
• What happens right before and right after?
• Why does it happen? What triggers it?
• How often does it happen?
• When it happens how do you feel and what do you think of?
• How do you react?
• Do you have control over this?
Example:
SELECT
LHW and Sarah review her list of problems together and Sarah chose the issue revolving around
her fear of having contracted and STD as the problem she would like to work on. This is a
meaningful problem for her, and she feels it is manageable as she knows friends who have gotten
tested.
LHW helps Sarah to formulate the problem: “I am avoiding knowing if I have an STD”
FIND GOAL
The LHW asks “How would you like the situation to be when the problem is solved?” Sarah’s
goal is to not feel the fear she has been experiencing anymore and to not put herself at risk any
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longer. The LHW helps her to rephrase this to say, “to know my health status”. They note this on
the Session Note.
DEFINE
LHW asks “What happened?”
Sarah: I am scared I caught a disease
LHW: “Who is involved?”
Sarah: “Me and maybe my friend.”
LHW: “How do you feel when it happens?”
Sarah: “I feel scared and sick when I think about it”
LHW: “How do you react?”
Sarah notices she has been avoiding thinking about the problem and has been ignoring her
health. She stays awake at night worrying that she may contracted syphilis or even HIV.
Worrying hasn’t helped her.
LHW: “Do you have control over this problem?”
Sarah shares she has some control because she could actually go to the doctor and be examined
and tested.

Step 4. How to Brainstorm for Solutions
In the next step, we encourage the participant to come up with as many ideas for potential
solutions as possible. Remember to explain that during this step, the participant should not judge
any or their ideas, simply come up with any potential idea they can think of. The more ideas that
are generated, the better the chance that one of them will work. Write down all ideas generated.
HOW IT’S DONE:
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Tell the participant that they should come up with any ideas for solutions that they can think of.
“No idea is bad or wrong, at this point we are brainstorming freely. Later we can discuss whether
or not an idea may be feasible”.
You may need to encourage the participant to generate ideas. Try some of the following
questions:
Who could help?
Do you know someone with a similar problem? What did they do?
What would your mother/sister/best friend do?
Example
LHW asks Sarah to try to think of all possible solutions to her problem and writes them down as
she comes up with them. No solution is discussed until the brainstorming is over.
Could keep on avoiding
Could ask her pastor what to do
Could write a letter to her friend and ask him if he has a disease
Pray harder
Talk to her friend who is HIV+ and ask her what to do
Never see her friend again
Go to her doctor
Go to the health department for testing
Take a friend with her to go get tested
Step 5. How to Select a Solution
Now that the participant has brainstormed ideas for solutions it is time to choose one. You will
show the client how to sort through all the solutions.
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First Selection
At first review the solutions that are unrealistic, almost impossible or dangerous and discard
them.
Grouping
The remaining solutions are looked at in terms of similarity and should be grouped together.
Evaluating
The participant looks at two or three of the groups (if there are that many) and assess them
according to feasibility, impact on their wellbeing, impact on others, time, effort and cost.
HOW IT’S DONE:
First Selection
Ask the participant “Is there any solution on the list that just doesn’t seem impractical? If so,
let’s cross it out”
Grouping
Tell participant “Look over your solutions and see if there are any that are similar and can be
grouped together”

Evaluating
“Check the groups for the best feasible solution. How feasible is it? How would it impact your
wellbeing? What impact would it have on others? How long would it take? What would it cost
you? What benefit would you have from it?”
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Example
First Selection
The LHW ask Sarah if there is any solution on her list that appears impracticable
Could keep on avoiding
Could ask her pastor what to do
Could write a letter to her friend and ask him if he has a disease
Pray harder
Talk to her friend who is HIV+ and ask her what to do
Never see her friend again
Go to her doctor
Go to the health department for testing
Take a friend with her to go get tested
Grouping
The LHW asks Sarah if any of her solutions are similar and can be grouped together. Sarah has
found two groups of possible solutions. She decides to leave the other options out. Group A is
“going to get tested” Group B is “Getting spiritual assistance”

Evaluation
The LHW asks Sarah to judge both groups on their advantages and disadvantages. She also asks
the following questions for Sarah to evaluate the solutions in more detail.
How feasible is Group A?
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Sarah: “I could go to the doctor, I know where it is, I could take the bus”
“How would it impact your own wellbeing?”
Sarah: “I would be nervous but nothing really bad would happen if I went”
LHW: “What impact would it have on others?”
Sarah: “It really wouldn’t affect anyone else”
LHW: “How long would it take?”
Sarah: “Usually when I go to my doctor I am there about three hours because I have to wait”
LHW: “What would it cost you?”
Sarah: “Nothing, I have a bus card and Medicaid”
LHW: “How would you benefit from it?”
Sarah: “I would know if I caught anything and could begin treatment if I did”

Step 6. How do we make a SMART action plan?
This step involves determining how to carry out the chosen solution. You will encourage the
client to make a very concrete action plan of how they will go about solving their problem. You
will ask very specific questions and will also have to discuss what could get be a barrier to the
possible solution.
Once you create the plan write it down on the worksheet.
The action plan must be SMART:
• Specific
• Measurable
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• Achievable
• Realistic
• Timely
HOW IT’S DONE
The following questions help the client to come up with a very precise plan on how to realize the
action plan:
• How can you do it?
• When exactly can you do it? (what day, what time)
• Where exactly can you do it? How do you get there?
• Who can help you? Who can you do it with?
• What will you need to do it?
• What could get in the way of your plan and what can you do then?
Example
The LHW asks Sarah how exactly she could go about her solution. Together they discuss the
different aspects.
LHW: “How can you do it?”
Sarah: “I can make an appointment and take the bus to the doctor”
LHW: “When exactly can you do it?”
Sarah: “I can go Wednesday morning because I don’t have to work”
LHW: “Who can help you?”
Sarah: “I can ask my friend if she will go with me or at least talk to me on the phone while I
wait”
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Together they discuss possible obstacles like not being able to get an appointment for
Wednesday, Sarah tells her they always allow “walk ins” to see the doctor if needed. They write
the plan on the Session Note and the LHW shares with Sarah what a great job she did today.

After the action plan is completed, the participant goes home to perform it. Remind the
participant that together you will evaluate how it went at the next session.
Step 7. Did it work?
The plan is evaluated at the next session.
When you next see the participant, you ask how well they were able to carry out the action plan
and if it was successful. Encourage the participant to share details concerning the carrying out of
the plan.
If it went well and the participant was able to carry out the plan, praise the participant’s efforts.
The participant will now be able to choose another problem on the list and repeat the problem-
solving process.
If the participant shares they were unsuccessful in carrying out the plan, explore what made it
difficult.
Focus on the obstacles and barriers and treat them as problems and work with the participant to
find solutions for them. Empower the participant to continue and try again. Revise the SMART
action plan.
HOW IT’S DONE
Ask the participant “How did it go?” “What happened?”
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Example
LHW: “It is very good to see you again! How did you do on your action plan?”
Sarah: “I am so happy! I went to the doctor and all my tests came back negative.”
LHW: “That is wonderful news. Why don’t we look at another problem from your list that we
can go over, or would you like to talk about a new one?”
Exercise:
Break into pairs, one will play the LHW the other will be the Participant.
The Participant is very upset because she is very unhappy at work and wants to
leave. She feels underpaid and unappreciated. Although she wants a new job, she becomes
overwhelmed at the thought of starting the process, so she has done nothing.
Complete the steps and fill out the Problem-Solving Worksheet.
1. Learning how the participant handle problems
2. Identifying the problems being experienced
3. Selecting one problem. Defining the problem and choosing a goal
4. Brainstorming solutions
5. Selecting a solution
6. Creating a SMART action plan
7. Evaluating (did it work?)

Nature of Problem Check if it Applies to Pt.
Relationship
Marital
Work related
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Bereavement/ Grief
School
Family
Interpersonal (loneliness, self-esteem)
Health related
Financial
Legal problem
Alcohol, drugs
Housing
Other

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1. What problems are you facing?
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
2. Choose one problem you listed (meaningful, manageable, practical)
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
3. Identify a goal
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________

4. Explore all details of the problem
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______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
5. Brainstorm solutions
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
6. Select a solution
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
7. Develop SMART action plan
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
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Notes
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
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Chapter 4 Important Support Skills and Concepts
In this chapter we will review and practice skills that are important to successfully conduct
support sessions with participants.
Confidentiality
One of the most important aspects of your relationship with each participant is confidentiality.
This means that you do not share the information discussed within the sessions with others. This
includes your or the participant’s family members, church leadership, or friends. You may be
tempted to share what you are told without mentioning the person’s name however this should
still not be done. You will be sharing information with your clinical supervisor in order to
receive appropriate supervision and guidance.
It is important for participants to feel comfortable sharing information with you freely without
fear of you sharing the information with others. This is especially important as you be providing
support to others within your church and community.
Breaches in confidentiality will be investigated and may result in the dismissal of the Lay Health
Worker if the allegation is found to be valid.
Question: Have you ever had your confidence broken? How did it make you feel?
How do you think it would make a Participant feel?
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
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Empathy
Empathy is the ability to put oneself in someone else’s situation and relate to what they might
feel. It is important for the relationship between you and the particpant. The participant will feel
that they are being understood and heard. Be genuine, ask questions and do not pretend to
understand when you do not. Avoid advising the patient to stay strong, or not to cry. There is
nothing wrong with expressing emotion and the participant should not be made to feel apologetic
for doing so.
Question: What are ways you have shown empathy in the past? Has anyone
ever shown you empathy? How did they do it? What did it look like?
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
Ability to Listen (active listening)
The ability to listen actively is a good way of helping a person to feel heard. When a person feels
heard, they will also feel safer to speak about what is troubling them. There are many ways of
showing that we are listening. This is called active listening. Active listening involves showing
nonverbal signs of acknowledgement such as nodding, strong eye contact, facing the speaker and
leaning in toward the speaker. Verbal signs of active listening include saying this such as “yes”,
“I see”, etc.
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Part of active listening also involves summarizing what you have heard in your own words and
checking in with the speaker to ensure you are understanding what they are saying to you. If you
did not understand, ask the speaker to repeat themselves and again check for understanding.
Activity: Turn to your neighbor and take turns sharing with one another why you decided to
participate in this training. Demonstrate active listening when your partner is sharing.
Give each other feedback after you are done.
Self-Awareness
It is very important to be aware of yourself. In order to effectively assist participants in an
objective manner, you must be aware of your beliefs, values and attitudes.
Question: What are some values or beliefs that shape who you are?
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________

Being non-judgmental
We must accept each participant just as they are today and maintain a non-judgmental attitude
towards them. If you find yourself feeling very uncomfortable with a participant’s views and
feelings it is very important to discuss this with your supervisor to ensure it does not affect your
work together.
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Question: Think of something you have a strong opinion on. How would it
feel to have a Participant who strongly felt otherwise? How would you deal
with this?
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________

Recognizing Safety Concerns
It is important to always be aware of your surroundings. If a participant arrives for a session and
is noticeably intoxicated or under the influence of a substance, the session should not be held,
and the supervisor should be alerted. If at any time you feel uncomfortable with a participant, let
them know that you will be right back and go speak to your supervisor. Do not ignore these
feelings!
Question: What would you say to a Participant who you have been working
with who appeared to be intoxicated when they arrived at a session?
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
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Remaining Calm
There are things that a participant may share with you that you may find disturbing. It is
important that you remain calm and professional and remind yourself that you are there to assist
the participant. Remember to discuss the things that disturb you with your supervisor.
Question: Have you ever been in a situation where you needed to remain calm
when someone needed your help? How challenging was it for you?
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________

Handling Strong Emotional Reactions
A person who is experiencing depressive symptoms may become very emotional. They may
have never shared their feelings with anyone previously and may have some difficulty
controlling their emotional reaction. They might cry or express other emotions such as anger or
frustration. It is important to simply support the participant and make sure they feel calmer
before the session ends. If the participant is unable to calm down before the end of the session it
may be necessary to seek assistance from your supervisor.
When supporting a participant:
Empathize:
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Just be with the participant. The participant is expressing themselves in a safe environment and
we are supporting them.
Acknowledge:
Show understanding for the participant expressing their emotions. You can do this by nodding,
expressing sounds of approval, or paraphrasing (repeating what you have heard in your own
words). You can say things like “It sounds very difficult to deal with all of this”, “This must be
hard for you”.
Support/ Comfort:
You can give the client tissue if they cry or touch or hold their hand if they desire and you both
feel comfortable.
Normalize:
You can explain that it is normal to cry when someone feels overwhelmed. Crying helps to
release tension and shows others you may be in need of comfort.
Question: How do you feel when someone cries in front of you are becomes
loud and angry?
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
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Notes
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
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Chapter 5 Tools & Documentation
Support Session Notes
You will complete the Support Session Note as you conduct the session. At the end of the
session, give a copy to the participant and submit a copy to the supervisor.

Session Number _________
Date __________________
Participant ID
_______________________
Health Worker
________________________
Problem worked on:

Goal: SMART Action Plan:
Resources Needed:

Next Appointment: Health Worker Signature:
________________________

Clinical Supervisor:
________________________

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Patient Health Questionnaire-9
You will give the participant the Patient Health Questionnaire-9 to complete at the beginning of
Session 1, Session 3 and Session 6. The PHQ-9 can be completed by the participant
independently.
The Patient Health Questionnaire-9 is an instrument used for screening, diagnosing, monitoring
and measuring the severity of depression. It uses standardized criteria and leading depressive
symptoms. It is able to rate the frequency of the symptoms and the degree to which it has
affected the person’s life (Kroenke and Spitzer, 2002).
The PHQ-9 is not used by the Lay Health Worker to diagnose, screen or treat. It will be used by
the Program Director to assess the effectiveness of the program and the progress of participants.
However, after the participant has completed the form, you will need to review the final question
that asks, “if you have had thoughts that you would be better off dead or harming yourself in
some way”. If the person answers that they have had these thoughts in the past two weeks you
will need to complete the Suicidal Thought Questionnaire.

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Patient Health Questionaire-9
Session Number _____________________ Participant ID __________________________

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Suicidal Thought Questionnaire
Although we may not be comfortable discussing suicide with a participant, it is a myth that
asking someone if they are having suicidal thoughts will give them the idea of attempting
suicide. The Patient Health Questionnaire-9 asks “if you have had thoughts that you would be
better off dead or harming yourself in some way”. If the participant indicates that they have had
these thoughts, you must complete the following assessment and then immediately notify your
clinical supervisor so that it can be determined if the participant needs emergency medical
services.

If someone expresses that they have suicidal thoughts:
• Remain calm
• Encourage the participant to talk about how they are feeling.
• Complete the suicidal thought questionnaire
• Inform the participant that you must bring in the clinical supervisor to assist
in assessing whether additional services are needed.

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Suicidal Thought Questionnaire
Are you having thoughts today of taking your life and harming yourself?
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
Have you made any kind of plans of how you would do this?
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
Do you intend to kill yourself?
__________________________________________________________________________
__________________________________________________________________________
Have you ever attempted to take your life in the past?
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
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Problem Checklist
The Problem Checklist is used when brainstorming a participant’s current problems in order to
be able to better understand them and group them into categories. It should be kept with the
Problem-Solving Worksheet after the session is completed.
Nature of Problem Check if it Applies to Pt.
Relationship
Marital
Work related
Bereavement/ Grief
School
Family
Interpersonal (loneliness, self-esteem)
Health related
Financial
Legal problem
Alcohol, drugs
Housing
Other
Problem Solving Worksheet
The Problem-Solving Worksheet is used to note the participant’s answers as you go through the
problem-solving steps during a support session.
Session Number____________ Participant ID _________________ LHW_________________________________
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Problem Solving Worksheet
1. What problems are you facing?
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
2. Choose one problem you listed (meaningful, manageable, practical)
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
3. Identify a goal
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________

4. Explore all details of the problem
THE ARUKAH PROJECT 105

______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
5. Brainstorm solutions
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
6. Select a solution
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
7. Develop SMART action plan
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
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Notes
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________

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Chapter 6
Self-Care
As a Lay Health Worker, you may be exposed to many demands and stressors. It can be taxing
on the mind and body to listen to other’s problems and support them through their experiences. It
is important to practice self-care in order to remain physically, mentally and emotionally strong.
In addition to supporting the participants, you may share some of their same experiences as you
may live in the same communities as they do which means that you may be exposed to similar
stressors yourself.
Here are a few suggestions of what can be done to remain healthy and well:
• Check in with yourself and acknowledge signs of stress and fatigue
• Eat healthy
• Get enough rest
• Participate in physical activity
• Take medications as prescribed
• Surround yourself with friends and loved ones
• Avoid toxic relationships
• Ask for help when you need it
• Speak to your clinical supervisor when you need assistance
Question: What are some ways that you nurture yourself or recharge?
___________________________________________________________________________
_____________________________________________________________________________
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____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
Review of Supervision & Structure
Each week you will participate in an hour-long supervision with your clinical supervisor. Once
each month you will meet with other Lay Health Workers and your supervisor to receive group
supervision. You supervisor is also available to you for guidance and support as you conduct
your support session should the need arise.
Purpose of Supervision
The purpose of supervision is to ensure you have the support that you need to effectively conduct
support sessions with participants. Your supervisor will review with you what you have learned
during your training and continue to provide you with information to continuously improve your
skills as a Lay Health Counselor as you provide the services.
You will share with your supervisor updates on the participants you are seeing each week,
sharing any concerns or questions that you may have. Your supervisor will be available to
provide clinical support if a crisis arises during a session as well as to assist you in locating
resources that are needed to better serve the participants.
Using Supervision Effectively
It is important to prepare for supervision by having reviewed your session notes, having prepared
a list of any questions or concerns that may have arisen during the week. It is also important to
THE ARUKAH PROJECT 109

be prepared to discuss any training topics that you may want to review or learn more about. Your
supervision is your time to receive the support that you need in order to effectively provide
support sessions.
Question: Have you ever received formal supervision? What was your experience
like?
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________

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Notes
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
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Resources
Websites
Anxiety Panic Attack Resource Site
www.anxietypanic.com
Provides information pertaining to a variety of treatments and resources on anxiety. Provides
questionnaires, links to treatment resources and helpful publications.

Mental Health America
www.mentalhealthamerica.net
Information on mental health, getting help and taking action.

National Alliance on Mental Illness
www.nami.org
NAMI is a nonprofit, grassroots, self-help, support, and advocacy organization of individuals
with mental disorders and their families.

National Council for Behavioral Health
www.thenationalcouncil.org
Locate mental health and addictions treatment facilities in your community by using the “Find a
Provider” feature on the Council’s website.

National Council on Alcoholism and Drug Dependence, Inc.
www.ncadd.org
Information on local resources for getting help for a substance use concern, fact sheets, and
information on having conversations about substance abuse.

National Institute on Drug Abuse
www.nida.nih.og
Links to information for parents, teens, health professionals, teachers, and others about drugs of
all types.
THE ARUKAH PROJECT 112

Postpartum Support International
www.postpartum.net
Provides support, education and local providers.

Substance Abuse and Mental Health Services Administration
www.samhsa.gov
Find links to information about programs and resources on mental health and substance abuse.

Help Lines

National Suicide Prevention Lifeline
1-800-273-TALK
Hotline is available 24 hours a day. Calls are answered by trained counselors.

Support Groups

Al-Anon and Alateen
www.al-anon.org
www.alateen.org
Provides information and support for the family members and friends of people with alcohol
problems. Includes list of meetings in the United States.

Alcoholics Anonymous
www.aa.org
List Alcoholics Anonymous groups in your area.
American Self-Help Group Clearinghouse
www.mentalhelp.net/selfhelp/
THE ARUKAH PROJECT 113

Searchable database on national, international and online self-help groups.

Narcotics Anonymous
www.na.org
Lists Narcotics Anonymous groups in your area.

National Alliance on Mental Illness
www.nami.org
On homepage click “Find Support”

Recovery International
www.recovery-inc.com
On home page click “Find a Meeting” to find one in your area.
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References
American Psychiatric Association. (2013). Diagnostic and Statistical Manual of Mental
Disorders (5
th
ed.). Arlington, VA: American Psychiatric Publishing.
Bronson, J., Nuriddin, T. “‘I don’t believe in doctors much’: The social control of health care,
mistrust, and folk remedies in the African American slave narrative,” n.d., 27.
Dalencour, M., Wong, E.C., Tang, L. et al. (2016). The role of Faith-Based Organizations in the
depression care of African Americans and Hispanics in Los Angeles. Psychiatric Services 68,
(4), 368–74. https://doi.org/10.1176/appi.ps.201500318.
Galloway-Gilliam, L. (2013). Racial and ethnic approaches to community health. National Civic
Review, 102(4), 46–48. https://doi.org/10.1002/ncr.21154.
Kessler, R.C., Chiu, W.T., Jin, R., Ruscio, A.M., Shear, K., Walters, E.E. (2006). The
epidemiology of panic attacks, panic disorder, and agoraphobia in the National Comorbidity
Survey Replication. Archives of General Psychiatry, 63, 415-424.
Kroenke, K., & Spitzer, R. L. (2002). The PHQ-9: A new depression diagnostic and severity
measure. Psychiatric Annals, 39, 1–7.
Lee, H., Porter, L., & Comfort, M. (2014). Consequences of family member incarceration:
Impacts on civic participation and perceptions of the legitimacy and fairness of government. The
Annals of the American Academy of Political and Social Science 651, (1), 44–73.
https://doi.org/10.1177/0002716213502920.

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Schnittker, J., Pescosolido, B.A., and Croghan, T.W. (2005). Are African Americans really less
willing to use health care? Social Problems 52 (2), 255–71.
https://doi.org/10.1525/sp.2005.52.2.255.
Turner, A. (2018, April 18). The business case for racial equity: A strategy for growth. Retrieved
from https://altarum.org/publications/the-business-case-for-racial-equity-a-strategy-for-growth.

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Notes
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THE ARUKAH PROJECT 117

Notes
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THE ARUKAH PROJECT 118

Appendix C

Post Program Participant Questionnaire

1. Did you find the program to be helpful?
1 (not at all) 2 (somewhat) 3 (neutral) 4 (helpful) 5 (very helpful)
Explain _____________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________

2. Did you find the lay health worker to be knowledgeable?
1 (not at all) 2 (somewhat) 3 (neutral) 4 (knowledgeable) 5 (very knowledgeable)
What do you wish they knew more about? _________________________________________
___________________________________________________________________________
___________________________________________________________________________

3. How well do you think you handle problems?
1 (not well) 2 (somewhat well) 3 (neutral) 4 (well) 5 (very well)

4. How in control do you feel of your life?
1 (not at all) 2 (somewhat) 3 (neutral) 4 (in control) 5 (very in control)

5. Did the program improve your ability to be able to handle problems?
1 (not at all) 2 (somewhat) 3 (neutral) 4 (improved) 5 (very improved)

6. How confident are you that you could handle problems that come up in the future?
1 (not at all) 2 (somewhat) 3 (neutral) 4 (confident) 5 (very confident)

THE ARUKAH PROJECT 119

7. How willing would you be to see a professional mental health counselor if needed?
1 (not at all) 2 (somewhat) 3 (neutral) 4 (willing) 5 (very willing)

8. How likely would you be to recommend this program to a friend or loved one who needed
support?
1 (not at all) 2 (somewhat) 3 (neutral) 4 (likely) 5 (very likely)

9. What do you wish the program could have helped you with but didn’t?
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________

10. Would you be willing to complete a short follow-up interview by phone in three months?
YES NO

Any final thoughts or suggestions? _________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________

THE ARUKAH PROJECT 120

Appendix D

The Arukah Project Startup Costs

THE ARUKAH PROJECT 121

Appendix E

Patient Health Questionnaire-9

THE ARUKAH PROJECT 122

Appendix F

Lay Health Worker Pre-Questionnaire

Name __________________________________ Date of Birth ___________________________
Address_______________________________________________________________________
Telephone _______________________________ Email ________________________________
Emergency Contact _____________________________________________________________
1. Why do you want to be a lay health worker? ________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________

2. Are you currently participating in any type of counseling? YES NO

3. Have you ever participated in any type of counseling? YES NO
If so when ____________________________________________________________________
For what reason? _______________________________________________________________
______________________________________________________________________________
Did you find it to be helpful? YES NO
Why or why not? _______________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________

4. Have you ever been hospitalized for a mental health reason? YES NO
If so when and for what reason? ___________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
THE ARUKAH PROJECT 123

5. Do you currently have thoughts or plans to harm yourself? YES NO
IF YES STOP AND ASSESS FOR IMMEDIATE INTERVENTION

6. Have you had thoughts in the past of harming yourself? YES NO
If yes, when and explain _________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________

7. Have you ever tried to harm yourself? YES NO
If yes, when and explain _________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________

8. Do you ever hear or see things that no one else does? YES NO
If yes, explain _________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________

9. Have you ever abused substances or alcohol? YES NO
If yes, type and date of last use ____________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
IF YES ASSESS AND OFFER ASSISTANCE FOR TREATMENT REFERRAL

10. Current medications __________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
THE ARUKAH PROJECT 124

11. Current medical conditions ____________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________

12. Date of last physical __________________________________________________________

13. Can you commit to 6 training sessions? YES NO

14. Can you commit to weekly supervision while you provide support sessions? YES NO

15. What skills do you have that will be helpful as a lay health worker? ____________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________

16. What do you think will be most challenging for you as a lay health worker? _____________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________

17. Do you have any experience or education as a counselor of any kind? __________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
THE ARUKAH PROJECT 125

Appendix G

Lay Health Worker Post Training Questionnaire

1. I feel the six session were enough time for the material to be taught and understood.

1 (strongly disagree) 2 (disagree) 3 (neutral) 4 (agree) 5 (strongly agree)

2. I am confident I can successfully conduct a support session.

1 (not at all) 2 (somewhat) 3 (neutral) 4 (confident) 5 (very confident)

3. I think the skills I learned will be helpful in my own life.

1 (not at all) 2 (somewhat) 3 (neutral) 4 (helpful) 5 (very helpful)

4. I feel this program will be helpful in my church and community.

1 (not at all) 2 (somewhat) 3 (neutral) 4 (helpful) 5 (very helpful)

5. What do you feel you need to know more about before you begin conducting support
sessions? ___________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________

6. What do you wish the training had included but didn’t? ____________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________

7. What remaining questions or concerns do you have? _______________________________
____________________________________________________________________________
____________________________________________________________________________

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