PRACTICE AND POLICY LECTURE SERIES, FEBRUARY 2013 - CHRONIC DISEASE SELF-MANAGEMENT PROGRAM: IMPLICATIONS FOR POLICY AND PRACTICE

Dr. Kate Lorig: Thank you so very much. I am absolutely delighted to be here today. I come from Colorado Springs, where you all go in the summers. 

(laughter) 

Dr. Lorig (continues): Or at least you did when I was a kid. So I have known lots of people from Oklahoma, but I have never been here before. So this is a huge privilege for me. So what weÆre going to do is I'm going to go through a series of slides. 

If you want to and you see something you want to ask me, you can raise your hand even before I'm finished and we can, you know, so it doesn't get away. But we'll have definitely time for questions at the end. So let me explain a little bit about this first slide. 

No Audio: Chronic Disease Self-Management Program Implications for Policy and Practice.  Kate Lorig, DrPH.  Stanford Patient Education Center, 1000 Welch Road, Suite 204, Palo Alto, CA  94304.  650-723-7935.  self-management@stanford.edu,  http://patienteducation.stanford.edu.  Valerie Blue Bird Jernigan, DrPH, MPH. Assistant Professor, University of Oklahoma College of Public Health.

If you really want to find everything there ever was to know about our program, you can go to our website. It's pretty extensive. And if you don't remember all that, if you just put "patient education" into Google, it will come up pretty close to the top. 

And then, so who is Valerie? Well Valerie was a doctoral student of mine who is now a new assistant professor at the School of Public Health at the University of Oklahoma. She's in Tulsa. And she is terrific. She is a filmmaker. 

Her doctorate is in public health. And she is an A-number-one researcher. And so if you're kind of looking for someone in state who actually knows these programs fairly well - especially the online program - because she actually did her dissertation around our online program, Valerie is the go-to person. 

Okay so why should we even care about self-management? And people have been for a long time saying to me, "We need an elevator story." Now that is how do you explain self-management in an elevator to somebody? And this is my elevator story. That people live 99% of their time outside of the health care system. 

What they do in that time greatly determines their health, their quality of life and their use of a health care system. And therefore what self-management is, is giving people the skills and confidence to live this 99% of the time in life. When one has a chronic condition, one cannot "not manage." 

And a few years ago now I was invited to give two talks on self-management two nights in a row in the San Francisco Bay area. The first night was to a group of homeless people in San Francisco because the program is being used fairly extensively within the homeless community in San Francisco. 

And so I went to kind of a grotty church basement and met with the homeless. Now this gentleman was not part of that group because I didn't take any pictures that night, but he could have very well been. And my guess is thereÆs people not too different than him places here in your state as well. 

Anyway we had a little talk. We talked for a couple of hours. It was very, very pleasant. Very engaged folks. And I went home feeling pretty good about this. Well the next night I had been asked to speak to a lecture which was held in the home of the gentleman with the light colored tie. His name is Martin Pearl. 

Martin Pearl is one of our Nobel Laureates in physics. And Martin had these kind of monthly meetings in his home with Martin's friends and everybody or somebody spoke or they had an outside speaker at each of these monthly meetings. And quite frankly this meeting terrified me. 

Because although I've been to a couple of Martin's meetings and I kind of knew who his friends were, his friends terrified me as much as Martin did. Because these are really, really, really, really bright people. And anyway and I went to Martin's and we had a couple hours talk and it was all very pleasant. 

And it was much easier than I thought it was going to be. And on the way home that night I realized that what I had talked about with the homeless and with Martin's friends was exactly the same thing. That having a chronic condition is a human condition. And it's independent of living on the streets or winning a Nobel prize. The questions, the concerns, the comments were really the same both nights. And so I just kind of want to leave you with that message. 

No Audio: We Usually Think in Terms of a Single Program û People learn in different ways, 1) Some like to go to groups, 2) Some like the internet

Now when we think about self-management, when we think about having a chronic condition or when we think about a program, we really think about a single program. Here in Oklahoma you talk about living longer, living stronger. Yeah, I got the name right. 

(laughter) 

Dr. Lorig (continues): I've been working on that. I may not get it right every time. And I think in Oklahoma right now what you're doing is small groups. And small groups are terrific. And you all have done an incredible job in this state. You've done one of the best jobs of any state in the nation. However, if we really are going to get to all of our population, there are folks that will never go to small groups. 

There are folks that will never go on the internet. There are folks that donÆt read very well and will never do anything in just a written form. And so if we really want to reach our populations, what we have to start thinking about is the same program in many different ways. 

And right now, and I'm going to show you a little bit about the programs both in small group and online. I will tell you that our latest research project is that we will soon be doing a program which will be a mailed chronic disease self-management program. 

People are going to get a box in the mail with everything they need in it. For those of you in aging services: I am looking for 250 people who have never taken any of the Stanford programs that are willing to fill out a questionnaire. We'll send them the box - it's not a randomized study so everybody gets the box - and then fill out another questionnaire six months later. 

It's probably the easiest study in the world for a participant. If you are willing to help me find participants, email me. My email was on that first slide. And we would love to have a bunch of people doing this from Oklahoma. Because it doesn't matter where in the country they live. They do have to be able to read at about a seventh grade level. This is not a program for people with very, very low literacy. 

So that's where we are here. What is self-management? This particular... people always like definitions, this definition came from the institute of medicine. It's defined as "the task that individuals must undertake to live with one or more conditions." And these include having the confidence to deal with the medical management, the role management and the emotional management of chronic disease. 

And what that really means is they have to do the things their doctor tells them to do. They have to continue doing the things in life that are important to them; job, grandparents, going to school, whatever that is, doing photography, dirt-biking. 

I donÆt care what it is. And they have to live the emotional sequelae of having a chronic disease. One of the things that we know is that most people with chronic illness are either sub-clinically or clinically depressed. And if you don't deal with the depression, you're not dealing with anything. And I see a lot of heads nodding here. 

And so when we are building programs we always have to keep that in mind. So then the question comes how do you build this confidence? And at Stanford we have long used self-efficacy theory. Self-efficacy theory was first posited by Dr. Albert Bandura in the late 1970s. I've had the privilege of working with Dr. Bandura for a number of years. We work very well together. And we work very well together because I've never had much psychology. 

And so I can ask all the questions that every psychology major in the country in petrified to ask him. And he knows I don't know anything about psychology. And so he takes great pleasure in teaching me. So we get along really, really well. Because he knows I'm dumb and maybe someday I'll learn. And he also loves our programs because they're practical applications of his theory. 

So the way to build self-efficacy or confidence and also self-efficacy is, by definition it just says if someone believes they can do something they probably can. And if they don't believe they can do something they probably can't. And it doesn't matter if you're talking about health or kids in school. That's all self-efficacy theory is. 

Thankfully it is pretty easy to change somebodyÆs confidence. It is very easy to change someone's confidence. The first is skill mastery. It's very hard for somebody to say they can't do something if they've just done it. And that's the reason that in our program, every single solitary week, people make a commitment and action plan to do something. We don't care what that something is. 

What we're trying to do is build their confidence that they can do something. Because one of the things that goes with chronic disease is a helplessness. "Ugh, I now have emphysema. I canÆt do anything." Well, that's not quite true. So skills mastery is really important. 

The second thing that builds self-efficacy is modeling. Seeing people like yourself. And it's the reason we use peers to teach peers. It's the reason that here in Oklahoma you're using prisoners to teach prisoners, peers. Peers are really, really important. And because of the modeling. 

Now the other reason that modeling... the other place that we use modeling a lot is if you look at our materials. I just had I cannot tell you how many months of argument with a publisher to get the drawings correct. Because we wanted fat people and we wanted thin people and we wanted old people and we wanted young people and we wanted ethnic diversity. 

And the first time I got all the drawings they were kind of... all the same, slightly tan, non-descript people. And quite frankly I've never seen anybody look like them.

(laughter)

Dr. Lorig (continues): And I said "No, no, no. We want folks that really represent the diversity of our nation." And strangely enough that sounds like it would be really easy to do. But we wanted to have somebody that was Muslim. And I didn't know enough about what was important to be covered and not covered and so I actually had to go out and find a few people that could tell me. 

And I learned all kinds of things. Like you have to wear socks. So we made very clear that the drawing of the Muslim is wearing socks. So it's not as I said it's not sometimes as easy as it seems. The third way of increasing self-efficacy is reinterpretation. Sometimes people think that their symptoms are caused by the disease, they can't do anything about the disease, therefore they can't do anything about the symptoms, so why bother trying? 

And one of the things that we do is every time we talk about a symptom we talk about it as having multiple causation and therefore multiple things that they can do about it. And they choose what they want to do. That's what we mean by reinterpretation. And then finally persuasion. Groups are very, very persuasive. 

If everybody around you is doing something, you will probably do it too. And so that's why I happen to really like group education. I like it on the internet. I like it in small groups. Our mail version of the program does not have group interaction. But there are a segment of our population that don't like groups of any kind. And so this serves them. Generally groups are good, sometimes not. 

No Audio: Stanford Self-Management Programs û Peer led (2 peer leaders), Community based, Standardized training for leaders, Highly structured teaching protocol, Standardized participant materials, No literacy requirements, Several topics per session, Self-tailored, and Evaluated in randomized trials.

Okay so what are the characteristics of the Stanford programs? How many of you know about the Stanford programs? Raise your hands. Okay. Some of you do, some of you don't. So we'll go through this. Each of the programs is two and a half hours a week for six weeks. They are led by peers. 

What is a peer? People that look and come from the same community as the people that are being taught. In Martin's community those peers would be Stanford Professors Americi. And we have some of those teaching. In the Choctaw nation they would be Choctaws. In prisons they would be prisoners. Peers can be anybody but they have to be like the community that they teach. 

The programs are community-based. That means instead of asking the community to come to you, you come to the community. And you go wherever people gather. And in every community people gather some place. Our job as health professionals, our job as community leaders, is to figure out wherever it is they gather. Seventh Day Adventist church on Sunday afternoons, senior centers on Saturday mornings, chapter houses. 

I don't care, but wherever it is that's where we try to have our courses. All our leaders have standardized training. It's four days. Our teaching protocol is highly structured. And this is something that some people find off-putting. "Our people are different, they will never do X." And that's sometimes true and sometimes not true. 

And so what we tell people to do is to try the program exactly like it's written, unless there's something really obviously different. Such as the fact that the nutrition stuff... Native Canadians that live way up north they told me, "We eat Caribou and berries. Forget all this nutrition stuff." 

(laughter)

Dr. Lorig (continues): But, for the most part you teach it the way it is. And then afterwards you ask the people how would you change it? If you do that, what's really interesting is only two things get changed. And we've seen this in communities all over the world. The two things that get changed are nutrition because people do eat differently and the second thing that gets changed is prayer. 

Even though there is no prayer really within the program, some communities it is not appropriate to do a program like this without prayer. And in some communities it would not be appropriate to pray. And so and if somebody had asked me when we started out if prayer would be an issue, I would have told them they were out of their minds. 

But those are the two things that we find when we ask the people. Now if I ask all of you what we could change, you would tell me a million things. I can tell you. You would just tell me a million things. We just had an organization that's doing the online program and they sent me a list of a 156 things they wanted to change.

(laughter)

Dr. Lorig (continues): And I think we got it down to about 12. Not sure exactly. So, highly structured standardized materials for the participants. And by standardized materials - we have a book that goes with the program. You know I don't care how people get that book. It can be lent to them for six weeks. You can give it to them. 

Doesn't really matter, but they do need the book during the program. And then you say, "Well, yeah, but how about if theyÆre not literate?" Well two things: 1) the book is available on CD so they can listen to it if they want, and 2) when we've actually worked with communities and low-literate communities, they've told us that as long as the book is written in simple language, even if they can't read it, people from their households can and they want to get the information into their households. 

So the book is written at about a seventh grade level. I am really good at writing at a seventh grade level. A little higher it becomes difficult. But if people are totally illiterate it's okay. The program can be done without any literacy requirements. Online can't, but small group can. 

Another piece of the program which is a little different than most programs is that we have several topics each session. And the reason we do this is because when you were at school you didn't spend a week learning mathematics and a week learning spelling and a week learning reading. 

What you did was you had those topics every single day and you added a little bit of information day after day after day. That's the way human beings learn.  Unfortunately in health education we tend to do a topic of the week. This week exercise, next week medications, next week nutrition. And why do we do that? Well we do it because it's very convenient for health professionals. 

But it doesn't happen to be the best way to learn. And so within our program if you look at you're going to look at "What is this mess?" Because you'll talk about five different things in two and half hours. But they all really do fit together and come together as the program goes on. 

Self-tailored. This is also something that's a little unique about our programs. Most programs... what we try to do is we try to learn something about the people that we're serving and then we try to respond based on what we learned. So we do readiness to change, or empowerment, or I mean there's lots of different ways of kind of deciding those things. 

But in all those cases it's us as health professionals making a decision about what people should learn based on something we know about them. Our programs are different. In our programs we give general information about a topic and interactive exercises about that topic and then we let the individual choose what they want to do. So they self-tailor the program to their needs. They're not doing what we want to do. 

Now sometimes that looks pretty funny. A lady online made an action plan that she was going to learn two new words of Athabascan three days this week. And I thought, "where did this come from?" And when the whole program was over I sent her an email and said, "Tell me about your action plan." 

"I'm an Alaskan native. I'm Athabascan. I'm a cancer survivor. I have chemo brain. My doc says I should do something about memory exercises. I've always wanted to learn more Athabascan so I decided I could combine two or three things together." She was right on track. Is there any way that I as a health professional would have ever known that? No. I thought she had a crazy action plan. 

And so what we actually find is about 90% of our people actually make action plans very pertinent to their own lives. Even though they don't seem sometimes that pertinent to us. In fact about 50% of them make action plans around exercise. And another 30% of them make action plans, 20-30% make them around something to do with eating. 

And the rest of them are all over the board. Alright, finally the hallmark of the Stanford programs is everything we do or almost everything we do has been tested in a randomized control trial. The bottom line reason that I get to stay at Stanford is because they think I'm a scientist and so that's why we do these things that look pretty much like drug trials. 

We get a bunch of people. Half of them get the program and half of them don't get the program. And six months or a year later the half that didn't get the program get the program. And over the years I've been really surprised with the thousands of people who have been willing to play our really silly game. I really have to thank them because without them we would have never been here. 

Alright, so we do it in six weeks online, six weeks small group. The groups are 10-16 people each. Yes if you're in really rural areas before you ask me, eight is okay. People with many different diseases show up at each class. And by the way, those diseases are both physical and mental health. 

So you can have people with schizophrenia and people with heart disease and people with lung disease all in the same class. And as we've said before they're taught by peers. So what do we teach? We have three core skills. And these core skills for the most part I don't think are seen in other programs. 

Problem solving - and this is how do you problem solve? Not that we're going to solve your problems. Action planning - making a commitment to do something each week. And now we're teaching formal decision making. When you have a big decision to make, here's a process that you go through and then you test the answer that you have against your gut and if your gut has a different answer, you go with your gut. 

So what we're really trying to do is get people to inform their gut. And believe it or not there's actually a whole bunch of scientific literature behind that. In fact there was an article I was really pleased was in the New York Times that says this is not a bad process. And then we talk about all these other things. 

How do you manage symptoms of chronic illness? How do you start an exercise program? Relaxation techniques, healthy eating, communication skills, medication management. Notice there is no anatomy and physiology. There is no discussion about specific diseases. Why not? Because, frankly, people can do exceedingly well without knowing any anatomy and physiology. How many of you know right this minute how many teeth you have in your mouth? Not very many of you. And how many of you brushed your teeth this morning? See, you self-manage and you don't even know the anatomy and physiology. 

(laughter)

No Audio: Small Group Chronic Disease Self-Management Program (Randomized Trial) Demographic Data - Age: 62 years, Male: 27%, Education: 14 years, Number of Diseases: 2.2.

Dr. Lorig (continues): Okay so let's look a little bit at the evidence for these programs. This was the very original randomized study. It took part, place in the early 1980s. We did it in the Palo Alto area. People have a lot of education. 

No Audio: Percent with Common Diseases û lung disease: 21%, heart disease: 24%, diabetes: 26%, arthritis: 42%.

Why these diseases? Because we were actually funded by California State tobacco money among other things. They said we had to do tobacco-related diseases so that's where you get heart, lung. Then the diabetes people just came along. They all had another disease so all of the people with diabetes either had heart disease or lung disease and then the state gave us arthritis because this was our first program after arthritis, and they decided we knew about arthritis, so it was okay to include arthritis. 

At six months we saw improvements in self-rated health. That is when you ask people how healthy they are; excellent, good, fair, poor - that improved. And who cares? Well the reason we care is because that happens to be the single solitary best measure we have of future health expenditures and future health. It's better than any other questions. 

It comes from the National Health Survey. They have less disability. They had better role function. They had less fatigue. Fatigue is the most common symptom of cross chronic illnesses.  And they were less distressed with their health state. 

At that time we didn't have a good depression scale, but this was a surrogate for depression. We also saw an improvement in costs. Now the interesting thing about the improvement in costs here is the treatment group did not change their cost much. 

They lowered their hospital days by about two tenths of a day, not much. It was the control group during that same time who increased their hospital days by five tenths of a day. I'm telling you this for those of you that are scientist here and are thinking about trials. 

That if you look at changes in cost in your own data you're not going to see much unless you have randomized controls. And quite frankly no you should not be doing another randomized control trial. But I'm also telling you not to be distressed if you don't see this. 

The estimated cost of the program is about $300 per person. I don't know. What is the cost? Do you know what your costs are in Oklahoma? Nobody knows. This is kind of a cost figure from across the nation. There are some places that go as high as $700 and some that are as low as $200. 

So then the issue was what can we do with Spanish speakers with diabetes? And when we started our diabetes program we started with Spanish speakers because there's a whole way you're supposed to do diabetes education. Any diabetes educators here? There's a whole way you're supposed to do diabetes education based on the American Association of Diabetes Educators. 

And I knew that there was, somehow or another we were not going to do it right. So I decided if we did it with Spanish speakers nobody would care. And I was right. Although, that's not true now. This is a very different demographic than you saw before. 

7.5 years of education, 72% of these folks were born in Mexico. All of them with type two diabetes. The program with diabetes is very similar to the program I just showed you. The exception is that we actually have a little bit more diabetes content. Hemoglobin A1C was reduced at both six and eighteen months. 

People had less depression, fewer symptoms of both hyper- and hypoglycemia. And we also saw some reduction in physician visits. But something really interesting happened in this study. After the end of the trial of the original program, we re-randomized people. 

So these are people that had been through the program and half of them got monthly automated phone calls. And these phone calls asked them how they were doing with their self-management. They got to choose little stories about Maria feeding her family or Jose having sexual problems or Elianza being depressed. And they could listen to as many of these as they wanted. 

I think there were 18 scenarios in all because we used them over again. And then we asked them if they had any questions they wanted to ask us. They could leave us a message and we would call them back. People loved these phone calls. They liked them so much that they would call us and they would ask to speak with Alisha, who was the narrator on these calls. 

(laughter)

Dr. Lorig (continues): Alisha didn't exist, but they really loved these calls. They actually completed out of a possible 15 calls I think they completed on an average of 12. So they like these calls. And they didn't make one whip of difference. 

The people that got the calls and the people that didn't get the calls at 18 months were exactly the same. So much for my ability to do reinforcement. And I actually think that what goes on with the chronic disease program is if you learn the skill, you may not need to be reinforced. My guess is it's been a long time since anybody told you to brush your teeth. And yet we do it every day. 

And so if you actually learn the skill and you believe that it's beneficial for you, you probably don't have to need to have people hammering at you. I'm not completely convinced that reinforcement isn't important, but I'm not as convinced that reinforcement is as important as most people think it is. 

The literature on reinforcement, by the way, is very weak. There's a huge belief in it, but the actual literature on its effectiveness is not very strong. So let's look a little bit at the online programs. 20-25 people. No real time. They can log on as often as they want. And it's again six weeks, totally online. 

I'm not going to go into the details of it, but I can tell you that having run many thousands of people through these programs now they consistently improve quality of life. They improve symptoms. And they improve self-efficacy. And I'll just do this quickly. I'm not going to talk a lot about it. If you want me to I can, but...  

So we went online and people said, "Yeah, that's all fine to do internet stuff, but XXX." And you can fill that in. "Don't do that. It will never work in my community." And that's where Valerie came along. Valerie is Choctaw and Valerie said, ôI think it will work with Native Americans.ö And I said, ôI think you're crazy.ö Because I didn't think it would work. But I also had some other friends who were Native American and I talked to them and they said, "well you might as well try it. Why not?" 

So we did an online randomized trial with Native Americans. How did we get these people? We put notices on tribal websites. The homepage of the program was Native specific. The homepage is the first page that you look at. Nothing else in the entire program was tailored except the homepage. We then randomized these people and as I say no changes were made. 

We had 110 Native Americans, Alaskan Natives. They represented more than 70 tribes in this country. The mean age was 50. Men were 22%. And the years of education were 15. At six months these folks had less health distress, better role function, lower A1C and they were visiting physicians more. 

Which is probably a good thing because they were real under-utilizers to start out with. So what we learned is yes they can, will participate, and can benefit. We also did a study to look at how Native Americans, African Americans and others use the internet. And quite frankly these three groups use the internet very, very, very similarly. It was much more similar than it was diverse. 

And, yep, the Native Americans posted a little bit less. I think that's because most of them were doing their post from work. And they didn't work on weekends so we weren't getting Native American posts on weekends. But I'm not sure of that. So what do you need to scale this program? 

It's all fine and good to do it in Palo Alto or a few people here and a few people there. First I want to say the funding is necessary, but not enough. To really scale, and I was talking to some folks beforehand and they said that the reason that they thought Oklahoma had done so well was because of partnering. Partnering is really key to scaling. Fidelity. Keeping the program done as it should be. 

Getting community buy in. Knowing the competition. And having a business plan. I'm... because of time and I really want to have questions I'm going to just kind of go through some of this quickly. You can read it, you can have the slides, you can write to me. But this is what I mean by fidelity. 

No Audio: Fidelity and Scaling û infrastructure, number of people needed, types of personnel needed, training, program delivery, after program delivery.

What are the bumps in the road? Wrong program. Wrong partners. Wrong evidence. Wrong fit. This program is not for people with large cognitive deficits. It's a program that takes cognition. Wrong business plan. And then trying to do too much. 

So these are what at least I see as the bumps in the road. If you go down Palm Drive to Stanford University this is what you'll see. So I thought I would bring a little bit of California to you. And I would love to answer questions. Don't make me dance. I don't dance well.

(laughter)

Dr. Lorig (continues): Not a single question. I thought... alright. 

Audience member 1: I taught a class at OU on social work and health and one of the... when we discussed this program she said that her association had tried it and it didn't work. So that slide you just shared about why I think it was like the American Heart Association or something like that, but they did not find it to be successful. I think what I heard was it's better taught by peers than maybe health educators. Maybe you could talk about that. 

Dr. Lorig: Absolutely, let me tell you another example of it didn't work because I don't know what happened here. But the Native American health center in San Jose, an urban Indian health center, asked us to give a program there years ago. We did not have any Native leaders. We took a couple of leaders that were very, very good at cross cultural communication. These folks were good. Sent them down there. The program fell apart after three weeks. 

A couple of years later they came back to us and said, ôCan we train some people from our community to do the program?ö And I said, ôSure.ö And they came to leader training and quite frankly they were not, in my standards, good leaders. They weren't awful. There was nothing really wrong with them. They just really weren't very good. 

And they taught and they taught and they taught and their groups kept coming back and the groups got involved in exercise. And this is a program that a lot of health professionals have a lot of trouble teaching because they want to teach people more. But they have to know about the "left ventricular yadda di yadda di ya." Or they really have to be warned that they can't start an exercise program without seeing a doctor. We don't do that. 

We start our exercise programs by saying to somebody, ôSo what can you do now without feeling worse when you finished than when you start?ö All of you in this room can answer that question. And it's different for everybody. Fine. Unless it's 20 miles or 10 miles. You know, as long as it's less than about 40 minutes of exercise. 

Do whatever that is and do it three times a week. And if you continue not to have any problems then you add to it by a few minutes at a time. You don't have to see a doctor to do that. We're not putting them on treadmills. Yeah?

Audience member 2: How did you get your community peers? Were they initially health care providers? How did you go about...

Dr. Lorig: The way I get a lot of my, when I say peers, because we're actually not doing the courses at Stanford anymore. We have a lot of agencies around us who are doing them, but we're not. The way we get our peers is I give a lot of talks and my staff used to give a lot of talks. 

So we go to senior centers, we go to churches and kind of even giving a talk like this and we would say, "By the way if any of you..." you know, we would go with clipboards. So anytime we give a talk we would start out first of the talk and we would say, "Okay, it's time for an announcement. I'm going to pass this around during this talk and if you think you would like to take this class, please put your name and address and phone number there." 

And by the way, if you do that you'll walk out of the room with two thirds of the names in the room. If you put it at the back door and say, "Sign up at the back door," you'll walk out with about 10%. So that's just a trick to use in the community. 

And then we would say, "And by the way the course is taught by people like you. If you think you might like to teach it, put a star by your name." And we would get probably 5-10% of the people that were in the room to put a star by their name. And then when we got ready to do our training we called them up, and talked to them very briefly on the telephone and if they didn't sound absolutely totally crazy, we would invite them to training. 

Because our training is such that you have to do two practice teaches and you live with these people for four days and you get to know them pretty well, pretty fast. And so where we really do the culling is in training. And that's how we got them. 

And then our leaders would tell us who they wanted really well. Who they thought could run the class. Online we do the same with facilitators. One of the Native Americans in that program, Winter Owl. I have no idea who Winter Owl is, but that was his screen name, was terrific in how he helped other people. 

So when we got around to doing facilitators we asked Winter Owl if he wanted to be an online facilitator. So that's how you get them.  Yeah, you kind of have to be in the community. I will tell you I am terrible at choosing them. I'm the one that chose, I'm the one that chose the alcoholic. I'm also the one that chose someone who had broken probation. So forget about asking me to choose people. I don't do it anymore. 

(laughter)