Primhe Presentation Wonca Europe conference Malaga Spain October 2010 www.primhe.org.uk

1. INNOVATION IN MENTAL HEALTH EDUCATION IN THE UK FOR GPS. Developing the skills to deliver an integrated model for mental health in primary care www.primhe.org.uk 1

2. Facilitators www.primhe.org.uk 2 Dr Ian Walton – ianwalton@btinternet.com Lisa Hill – lisa.hill9@btinternet.com Henk Parmentier – henk.parmentier@gmail.com

3. Introduction Developing the skills to deliver an integrated model for mental health in primary care is an area lacking in investment within the UK. Government policies fail to focus on local and individual GP requirements for the complexity of mental health work. www.primhe.org.uk 3

4. The following workshop offers an opportunity to Experience specifically designed primary care focused education Gain an awareness of the emphasis on redesigning services to meet individual needs Develop skills which can be used in a 10 minute consultation www.primhe.org.uk 4

6. That everyone has the right and ability to achieve wellbeing;

7. In enabling and supporting peoples’ maximum potential;

9. MSc in Primary Care Mental Health www.primhe.org.uk 7 Facts, Beliefs and Values Leading and Enabling Service Development in Human Services. Issues and Methods in Health Research Therapies, Interventions and Treatments Service Redesign Common Mental Disorders: Recognition, Assessment and Management Ethics and Mental Health Legislation Option Module : e.g NLP/spirituality/old age psychiatry Masters Dissertation

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13. Master class anxiety and depression www.primhe.org.uk 11 How to deliver mental health skills in a primary care setting requires practical techniques as well as knowledge. This training is unique in that it is designed to meet the development needs of General Practitioners and staff working within primary care settings. It will be case study based and focus on the spectrum of depression and its links to anxiety, psychosis and suicide.

15. Right Brain Functions Left Brain Functions www.primhe.org.uk 13 Non Verbal Visual Spatial Emotional expression Imagination Fantasy Inventiveness Dreams Artistic ability Musical ability Involuntary memory Humour Verbal Speech Reading Writing Comprehension Logic Critical Ability Numeracy Intentional Memory Time

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18. We need to calm our patient down before we can reason with them.

19. We do this by therapeutic rapport

21. We like people who are like us www.primhe.org.uk 17 Hence mirror and match body language Keep your breathing slow so they match you

22. EXERCISE 1 www.primhe.org.uk 18 You are running late Your least favourite patient has come in AGAIN with his/her usual problem(s) Do your best to just get them out of the room as fast as possible by not listening, interrupting and being a “bad” clinician

23. EXERCISE 2 19 Now try again Give the patient the first couple of minutes of the consultation See how long your patient can talk for with a receptive listener.

24. BATHE www.primhe.org.uk 20 B: BACKGROUND What is going on in your life? The first two minutes belong to the patient. A: AFFECT How do you feel about that? Summarise the feelings – the underlying message is “I have been listening/ I am here for you” It helps the patient to hear their own feelings externalised reflected and summarised T: TROUBLE What troubles you most about that? What is the worst thing about this situation? = a focus Underlying messages 1.We can talk about anything here 2. Our time is short so we must focus H: HANDLING How are you handling that? The important thing is to manage this situation and not get stuck in overwhelming feelings. The underlying message is “You can handle this situation” E: EMPATHY That must be very difficult for you Normalise the situation for the patient - empathy means it sounds awful, and anyone would feel like this in this situation.

25. Case Study 21 33 year old Asian gentleman new to the practice, has an initial visit. He wants a continuation sick note as he has been off sick since his nephrectomy (surgical removal of a kidney) following a racially motivated stabbing 7 years ago. He says he is still angry and distressed and he is still a victim of racist abuse. You ask him to come back in one week so that you have time to check his notes and past history.

26. Childhood medical history www.primhe.org.uk 22 aged 1 fracture lower end of radius aged 4 lacerations to face aged 6 fracture femur aged 8 fracture radius aged 10 Seen in child psychiatry clinic for behavioural problems. He attended on own as both parents were at work. He wqs seen by an educational psychologist and a social worker, but as his parents didn’t attend he was discharged

27. Adult Medical History www.primhe.org.uk 23 Aged 21 alleged assault Aged 24 Assaulted, stabbed leading to small bowel anterior resection and nephrectomy Aged 25 Psychiatry referral Aged 26 Wants letter to help apply for disability Aged 26 Told he may have Post Traumatic Stress Disorder Aged 27 Cant sleep, worried --Diazepam Aged 28 Depression - Started on Paroxetine by psychiatrist Aged 29 Cannabis type drug dependence. Sent to plastic surgeon to deal with scarring Smokes 10/day drinks 2-4 units per week.

28. Second appointment a week later ww.primhe.org.uk 24 You look into the Background when you say “Hi, how’s life treating you?” He slams his top dentures on the desk, they have three front teeth in them. He says that he was called a Paki bastard and then was beaten up by a security guard who kicked his teeth out. He doesn’t see the point of living and wants diazepam. After you have let him talk for two minutes he has calmed down.

29. Affect www.primhe.org.uk 25 You ask him how he feels (Affect). He tells you that he feels angry and distraught. He is getting fairly frequent thoughts of hanging himself. He cannot see an end to the racism. Housing will not move him away from the situation as he is behind in his rent. Because he has no diagnosis of a mental illness his application for disability benefit has been turned down again. He doesn’t think he has the courage to kill himself and a local mosque is now supporting him, but he is scared things will get worse. He scores 13 (moderately depressed) on the HADs (Hospital and Anxiety Scale) You assess his level of risk. You also ascertain that he sees his mother and one of his brothers occasionally and suggest they might also give him some support

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32. How to Ask About Suicidal Thoughts www.primhe.org.uk 28 Possible questions to ask when inquiring about suicidal thoughts. After each question respond with appropriate empathy and then move on to the next step. How do you feel in yourself? How does the future look to you? How do the next few days look? Have you reached rock bottom? Can you face tomorrow? Do you feel that there are only problems and no solutions? Have things got so bad that you feel you may harm yourself in some way? Have things got so bad that you have had thoughts of ending your life? Do you feel that you just can’t carry on ‘like this’ or do you actually want to die? How long have you had these thoughts? Are they changing / getting worse? How do you manage to resist these thoughts? Refer for specialist opinion/start working on a crisis plan to resist the thoughts

33. www.primhe.org.uk 29 You ask him what troubles you most about his situation? Can’t sleep, get flash backs and his anger keeps getting him into trouble. No-body takes him seriously.

34. www.primhe.org.uk 30 How are you handling that? I’m smoking cannabis and listening to loud music which annoys my neighbours who call the police. Only the guys at the mosque are my friends.

35. www.primhe.org.uk 31 Empathy You empathise by saying how difficult it must be for him and explain that diazepam will only numb his feelings but will not help in the long term as the feelings will only resolve if he sorts out his underlying problems. Who would prescribe him diazepam at this point? Would you prescribe him anything else? You offer him support by referring him to the local psychiatric team, who know him well. He is not keen to see them as they have refused in the past to help saying he has a personality disorder which has meant he has not been able to get disability allowance.

36. Third appointment www.primhe.org.uk 32 He returns 10 days later saying he has found the true faith and the Koran is what is keeping me going doctor. He has noticed a lump in penis the last 2/52.He has had no sex since his girlfriend left him 3 years ago. He wants a circumcision for religious reasons as “I have found the true religion.” He is planning to go to college in Sept to study air conditioning On examination his penis is within normal limits, would you refer him for a circumcision?

37. Human needs www.primhe.org.uk 33 Security-a safe territory-a space to grow Attention (to give and receive) Having a sense of Autonomy and Control Emotionally connected to others-intimacy Being part of a wider community The need for privacy to reflect and consolidate experience Self esteem – via confidence and achievement The need to be stretched which comes from a sense of meaning and purpose.

38. Personal Outcomes from the Training www.primhe.org.uk 34 Helped them “grow”as practitioners and enable them to manage their most challenging patients. Developed local and national leaders in Service Redesign and developing integrated horizontal primary care models Improved communication skills which enable dialogue, conflict resolution and ensure negotiation with commissioners. Develop skills to be commissioners in there own right.

39. National outcomes www.primhe.org.uk 35 Developed a group of lead GP educators working alongside service users and carers to develop, lead and steer the course and its high quality content The new English Tsar (government advisor for psychiatry)and also the head of Royal College of Psychiatrists has met to discuss issues and proposals for mental health with all of the current cohorts Influencing and leading the implementation of the new UK government policy of putting mental health on the same status as physical health

40. Any QuestionsTHANK YOUGRACIAS www.primhe.org.uk 36