Developing the skills to deliver an integrated

model for mental health in primary care

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INNOVATION IN MENTAL HEALTH

EDUCATION IN THE UK FOR GPS.

Facilitators

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Dr Ian Walton – ianwalton@btinternet.com

Lisa Hill – lisa.hill9@btinternet.com

Henk Parmentier – henk.parmentier@gmail.com

Introduction

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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.

The following workshop offers an

opportunity to

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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

Primhe believes and values

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The fundamental uniqueness of each

individual;

That everyone has the right and ability to

achieve wellbeing;

In enabling and supporting peoples’ maximum

potential;

That solutions are found at local level, created

by communities and driven by champions;

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Secondary Care

Primary Care

Who deals with what?

MSc in Primary Care Mental Health

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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.gNLP/spirituality/old age psychiatry

Masters Dissertation

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basrse

15 University Credits at level 3

50 credits for GP revalidation

Accredited Module in Primary

Care Mental Health

Includes practical skills useful in the 10 minute consultation

Taught by Local and National experts

Four afternoons set over one year - case study based

Anxiety , Depression, Psychosis, Dementia, Medically unexplained symptoms

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basrse

60 University Credits at level 3

100 credits for GP revalidation

Advanced Diploma in

Primary Care Mental

Health

Eight modules Taught by Local and National experts over 18 months

Module 1- 4 as per accredited module

Module 5 and 6 therapies

Module 7 and 8

Addiction , Alcohol, Eating Disorders, Personality Disorders

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basrse

180 University Credits at level 4

Masters Science in

Primary Care Mental

Health

8 Modules over 3-5 years

1.Study Skills and Design

2.Facts, Beliefs and Values

3.Enabling Service Development

4.Therapies, Interventions and Treatments

5. Service Redesign

6.Common Mental Disorders:

7.Ethics and Mental Health Legislation

8.Issues and Methods in Health Research

9.Masters Dissertation

Master class anxiety and

depression

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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.

Right Brain Functions Left Brain

Functions

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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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Between logic and emotions, which

will always win?

•People who are high on emotion are

not rational

•We need to calm our patient down

before we can reason with them.

•We do this by therapeutic rapport

•Men tend to want to give advice on how

to solve the problem, but for women

empathy is more important.

Psychological and Physical health

are linked

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The only way to separate the mind from the body is with an axe.

Physical illness causes stress

Stress may result in functional symptoms and organic alteration

The mind and body are one

“We knew all this but no-one had brought it together before”

We like people who are like us

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Hence mirror and match body

language

Keep your breathing slow so they

match you

EXERCISE 1

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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

EXERCISE 2

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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.

BATHE

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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.

Case Study

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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.

Childhood medical history

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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

Adult Medical History

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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.

Second appointment a week later

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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.

Affect

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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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engaging people

How to Ask About Suicidal Thoughts

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Possible questions to ask when inquiring about suicidal thoughts.

After each question respond with appropriate empathy and then move on to the next step.

1. How do you feel in yourself?

2. How does the future look to you?

3. How do the next few days look?

4. Have you reached rock bottom?

5. Can you face tomorrow?

6. Do you feel that there are only problems and no solutions?

7. Have things got so bad that you feel you may harm yourself in some way?

8. Have things got so bad that you have had thoughts of ending your life?

9. Do you feel that you just can‟t carry on „like this‟ or do you actually want to die?

10. How long have you had these thoughts?

11. Are they changing / getting worse?

12. How do you manage to resist these thoughts?

Refer for specialist opinion/start working on a crisis plan to resist the thoughts

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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.

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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.

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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.

Third appointment

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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?

Human needs

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Security-a safe territory-a space to growAttention (to give and receive)Having a sense of Autonomy and ControlEmotionally connected to others-intimacyBeing part of a wider communityThe need for privacy to reflect and consolidate experienceSelf esteem – via confidence and achievementThe need to be stretched which comes from a sense of meaning and purpose.

Personal Outcomes from the

Training

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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.

National outcomes

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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

Any

Questions

THANK YOU

GRACIAS

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