VolunteeringR C P S Y C H

&InternationalPsychiatry.Newsletter of the Volunteering & International Psychiatry Special Interest Group #7                06/14

“It is crucial to understand that our personal & clinical values, which inform the way we work, can impose on values within communities where things work differently to our stereotyped norms.”

Dr Daniel Wolde-Giorgis & Dr Manshant Rani Kaur, page 8

Welcome to the seventh issue of the Volunteering and International Psychiatry Special Interest Group Newsletter

Volunteering & InternationalPsychiatry

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We welcome article submissions, and details for potential authors can be found below. Don’t forget to leave feedback on what you thought of this issue of the VIPSIG newsletter at www.surveymonkey.com/s/VIPSIGnewsletterfeedback !We hope you enjoy the newsletter! !Dr Susannah Whitwell Dr Daniel Wolde-Giorgis Dr Manshant Rani Kaur Dr Kiran Purandare Dr Lucy Potter VIPSIG Newsletter Editorial Team

If you have comments about any of the articles in this issue or would like to get more involved in VIPSIG please email us at susie.whitwell@gmail.com !!!The next VIPSIG meeting will be held on Friday 27 June 2014, Venue to be confirmed. !!!For more details check the VIPSIG webpage at www.rcpsych.ac.uk !

If you wish to make a donation to maintain the group and support volunteering in the UK and internationally, please see details below: !!!DONATIONS !All cheque payments should be made out to the ‘Royal College of Psychiatrists’. Please include details of the payment such as what the payment is for and name of the SIG.

DETAILS FOR POTENTIAL AUTHORS !We welcome contributions to the Volunteering and International psychiatry SIG on topics of interest to our membership including letters. We are particularly interested in articles from medical students and trainees regarding volunteering internationally and within the UK, from charities and NGOs who provide volunteering opportunities and advice to clinicians who want to undertake this kind of work. Articles should be a maximum of 1000 words excluding any references or appendices; they need to be submitted in MS word format, we encourage the use of photographs and figures submitted as separate .jpg files. Letters should not exceed 200 words. Please include your full name and titles, place of work and email contact details. Opinions expressed in the Newsletter are those of the authors and not of the College, unless otherwise stated. The editors reserve the right to edit contributions. !Articles to be submitted electronically to susie.whitwell@gmail.com

DR PETER HUGHES !Chairman, VIPSIG

!The  Chair’s  Message  

I  am  happy  to  write  my  first  column  in  the  VIPSIG  newsle8er.  It  gives  me  a  <me  to  reflect  on  the  work  of  the  special  Interest  group  and  the  future.  It  also  gives  me  an  opportunity  to  thank  all  those  who  work  so  hard  on  this  group,  who  a8end  all  the  mee<ngs  and  background  ac<vi<es.  I  won’t  name  as  you  know  who  you  are.    !Every  <me  we  meet  together  we  s<ll  have  that  ques<on  “what  are  we  doing,  what  do  

we  do  in  the  future,  what  are  we  about?  “.  This  is  an  inevitable  existen<al  ques<on  that  is  healthy  and  reflects  the  complex  world  of  volunteering  with  all  its  different  frustra<ons,  rewards  and  opportuni<es.  !We  have  had  two  conferences  and  

meet  three  to  four  <mes  a  year.  In  the  background  is  a  constant  flurry  of  ac<vity  around  developing  volunteering  opportuni<es.  What  has  been  a  constant  since  the  start  of  the  group  has  been  a  high  quality  Newsle8er  of  which  I  am  proud.      !We  had  our  Second  Conference  in  May  2014.  This  was  themed  on  disaster  and  spirituality.  This  comes  out  of  my  thoughts  about  the  lack  of  clarity  about  the  role  of  mental  health  in  disaster  seSngs.  The  Conference  moved  the  discussion  on  a  bit  and  it  was  felt  that  there  is  a  role  for  mental  health  in  

disaster  response  with  some  caveats.    !We  are  now  at  a  stage  when  we  can  no  longer  say  that  our  group  is  new.  We  need  to  move  to  a  new  phase  of  new  ideas,  and  consolida<on  of  previous  roles.  We  need  to  move  forward  in  energy  and  ideas.  We  have  s<ll  failed  to  make  any  major  impact  on  UK  volunteering.  What  we  depend  on  for  this  Special  Interest  Group  is  the  input  of  the  members.  I  call  out  to  all  readers  and  members  of  the  VIPSIG  to  move  forward  with  genera<ng  new  ideas  and  further  the  cause  of  volunteering.  I  need  to  touch  base  regularly    and  remember  what  a  joy  it  is  to  be  a  volunteer  in  mental  health  in  a  low  resource  seSng.  I  hope  that  all  of  you  can  have  this  life  changing  and  enhancing  experience.  You  will  come  back  a  be8er  clinician  than  before  and  even  a  be8er  person  I  would  dare  to  say.    !I  hope  you  enjoy  the  newsle8er  and  that  you  will  bring  new  energy  and  ideas  to  our  group.  I  remind  you  of  our  website  and  twi8er  #psychvolunteer  !

Volunteering & InternationalPsychiatry

VIPSIG contents

!Great Partnership Psychiatrists Diaspora Conference…………..3-4 Dr Ahmed Hankir !MhGAP training in Kashmir……. ………………………………………5-6 Dr Sophie Thompson !MhGAP Orientation Teaching….. ………………………………………7-8 Dr Daniel Wolde-Giorgis and Dr Manshant Rani Kaur

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A Report on the 2013 Great Partnership Psychiatrists Diaspora Conference !

National Institute of Health Research Academic Clinical Fellow in Psychiatry, Manchester University

The Great Partnership Psychiatrists Diaspora Conference in Collaboration with the Royal College of Psychiatrists took place on the 7th of December 2013 at the new College headquarters. The venue of the event was sprawling with psychiatrists who travelled from cities across the UK. Indeed, the conference is the largest that the College has hosted since it relocated to the East End and was truly multi-national which was reflected by the heterogeneity of the delegates who attended it (the College corridors were echoing with a diverse variety of languages).

The conference was entitled, ‘Making a Difference’ and its aim was, ‘… to support overseas psychiatrists working in the UK and to help foster and support mental health initiatives and services in the developing world’.

Dr Mateen Durani, chair of the British Pakistani Psychiatry Association (BPPA) and conference organising committee, initiated the proceedings by galvanising the audience with an engaging and vivacious opening lecture. He paid tribute to Dr Makhdum who is acclaimed as the individual who made the proposition of founding A Great Partnership (AGP). AGP has expanded since its inception and today is a conglomerate of 9 associations: BPPA, Br i t i sh Indian Psychiatry Associat ion (BIPA) , Br i t i sh Arab Psychiatry Association (BAPA), Hellenic Psychiatry Association (HPA), SUD World P ro j e c t , S u d a n e s e P s yc h i a t r i s t s Association (SPA), Iraqi Mental Health Forum (IMHF), Sri Lankan Psychiatry Association (SLPA) and the RCPsych.

Dr Wendy Burn who is Dean of the RCPsych then extolled a thought-provoking talk on the major issues that the College faces today such as the differential pass rate of the CASC examination. She emphatically thanked the ethnically eclectic delegates for making the sacrifice of leaving their home countries and contributing to the betterment of British

Dr Ahmed Hankir E mail: ahmedzakaria@doctors.org.uk

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!The Great Partnership Psychiatrists Diaspora Conference 7th December 2013 !!

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society. Dr Burn stated that this population make up to 40 % of the mental healthcare workforce in the UK without whom the College would undoubtedly fail to thrive.

Dr Lawrence Mynors-Wallis, Registrar of the RCPsych, was next on the pulpit and stated that the College celebrates volunteering and international p s y c h i a t r y a n d h e acknowledged Dr Pe te r Hughes who founded one of the College’s most successful Specia l Interes t Groups VIPSIG.

The conference also provided a p l a t fo r m fo r the D ia spora Committee Organisations (DCO) to showcase some of their activities and achievements. A succinct description of the larger DCOs is provided below.

The BPPA was founded in 2001 and its aim is to develop social connections and provide peer support for their members. Fo l l o w i n g t h e d e v a s t a t i n g earthquake in Pakistan in 2005 BPPA developed the Earthquake Trauma Relief Initiative (ETRI). They also translated a UN manual on disasters into Urdu and adapted it for earthquake relief. In 2010 1/3 of Pakistan was submerged in water due to unprecedented deluges. In response to this, BPPA launched the Flood Trauma Relief Initiative (FTRI).

The British Indian Psychiatry Association (BIPA) is the largest professional body of psychiatrists in the UK after the RCPsych. It was founded in 1995 with the aim of advancing education, training and research in mental health for South Asian communities in the UK and India. BIPA’s vision is to provide equal access to black and Ethnic Minority (BME) patients in the UK, to help promote equal

opportunities for Diaspora doctors in the UK and to develop educational and research links with India to improve patient care. BIPA are currently engaged in a multitude of on-going projects such as curriculum reform in medical schools in Mumbai.

Next up after BIPA were BAPA. Dr Nadim Almoshmosh, president of BAPA, made reference to the crisis in Syria and revealed the shocking fact that there are only 100 psychiatrists serving a population of 20 million. He alluded to the UN’s figure of 2.2 million Syrian refugees displaced in neighbouring countries and the prevalence of mental health issues in this population such as PTSD and MDD. BAPA members have been on several visits to the Syrian refugee camps in Turkey, Jordan and Lebanon to provide workshops to their counterpart mental healthcare providers.

T h e c o n f e r e n c e w a s a l s o punctuated with lectures by eminent scholars in psychiatry.

Professor Mohan delivered an enlightening and consciousness raising talk on the Mental Health Act and the Mental Capacity Act entitled, ‘Marriage Made in Heaven or Hell?’ His lecture provided information on which act psychiatrists should use in certain scenarios. For example, ‘if there is no Deprivation of Liberty should mental health professionals use the 1983 MHA or the 2005 MCA?

Professor Tanvir Rana then espoused a talk on implementing the recovery model in developing countries. Dr Rana alluded to the eminent psychotherapist Vikar Frankl and his best-selling book, ‘Man’s Search for Meaning’ in which the author argues that man is future oriented. Professor Tanvir broached on the challenges of implementing the recovery model

in developing countries such as the lack of resources. He did, however, state that these countries are rich in social capital.

The President Elect of the World Psychiatry Association also graced the conference proceedings with h i s p re s e n c e a n d g ave a n enthral l ing talk on cultural competence. Professor Bhugra asserted that cultural competence is everyone’s business and reflects good c l in i ca l p rac t i ce. He described some of his own personal experiences adapting to the British culture when he first arrived from India. Professor Bhugra stated that culture is dynamic and that it affects all aspects of illness. He alluded to the ‘idioms of distress’ that service users use and also emphasised the point that they may not match diagnostic criteria. Professor Bhugra concluded that although culture is being homogenised by globalisation there are no universal models of psychotherapy or pharmacotherapy.

There were also parallel workshops which took place during the afternoon session. Professor Simon Wessely facilitated a workshop on the CASC exam and the dreaded revalidation process. Dr Saeed chaired a workshop on the GMC and minority ethnic psychiatrists. He spoke about the disciplinary issues that this population might encounter and the support that is available to them. Dr Peter Hughes also hosted a workshop on implement ing the MHA in developing countries.

All in all, the conference was a r e s o u n d i n g t r i u m p h t h a t celebrated the collaboration of the various associations that fall under the umbrel la o f the Great Diaspora. Keep an eye out for the 2015 which promises to be even bigger and better.

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The Mission

To go boldly into a challenging environment where modern health care is struggling and try to teach primary health care workers all about mental health care....in one week.

Could we really do this? The WHO mental health GAP manuals under our 6 pairs of arms and lots of ideas about how to translate this complex concise manual into real life changing care for people, we set off to Kashmir.

After a long flight to Delhi and a shorter one to Srinagar we were met with the smiling faces of our hosts and driven part way to our camp in Dobiwan. But along the way they politely suggested we travel further in an ambulance as the stone throwers would not attack an ambulance! Plenty of army and police vehicles supported the idea that we better quietly do what we were told! Accommodation on arrival was better than expected with rooms for each of us and shared bathing areas with buckets and ladels to washing . By the end of our stay we

had figured out how to make the water warm or simply wash during the hotter part of the day.

The first day was filled with introductions and welcomes as we geared up for the first module about depression. The participants enjoyed role plays thankfully and we managed to begin the manual. Phew..this looks like it may work...such a responsive and eager groups of 26 doctors, psychologists, social workers and students. Five groups totalling nearly 150 professionals. On the second day and we took it all further with how to diagnose and manage suicide attempts and people who present with lots of physical symptoms. Problem solving strategies and engaging social support skills were practiced. The following 3 days we managed to cover psychosis ,children and adolescents difficulties and family meetings as well as drug abuse. They told us alcohol problems didn’t happen there! Oh and we had to make sure Epilepsy and Stress were covered. Each evening we gathered around a simple but lovingly prepared meal table and talked with colleagues about how to

MhGAP Training in Kashmir !Dr Sophie Thompson

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make sure the training manifests into real life and continues. Skype supervision maybe . Another teaching module maybe.

The feedback from participants was wonderful, as were their lovely gifts. Proud to be Kashmiri ,we received plaques with silver Chinar leaves ,symbol of Kashmir.

When friends ask “How much did you get paid to work in Kashmir?” I say it cost me money but I was repaid in gratitude, hospitality and generosity of spirit many times over.

But will it change the way people with mental health difficulties in Kashmir are treated, and how could we know?

Perhaps there has been a change in the hearts, as well as the minds of our friends in Kashmir as one of them wrote in the Greater Kashmir newspaper:

“ We learnt a beautiful new term Human Placebo, where the doctor becomes an act of change, by just spending few more minutes with patients and not being mechanical. A galaxy of doctors from the Royal

College of Psychiatrists, whom I could not imagine meeting even in my dreams taught the basics of human care and love, to be extended to patients having psychiatric ailments. The role of the Department of Health, Psychiatric Hospitals, HELP foundation and Police Drug De-addiction Centre was so encouraging that we had to pinch ourselves know it was all real.”

I think we succeeded…all of us.. Thanks to all involved.

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Attending this training was a privilege.

Drs. Peter Hughes and Sophie were nothing short of inspirational and shared a sense of great fun and sense of humour despite the gravity of the situations that they were sharing with us. Working as they have across the Third World in disaster areas they have headed up the teaching with doctors and other non-specialist health workers in primary care.

The WHO launched MHGap to address the lack of care in low and middle income countries for people suffering from mental, neurological and substance misuse disorders.

The teaching was centred around working through the MHGap Manual. Going through the manual revealed the intense pressure of time available in doing this work in the field. What appeared incredibly simple was in fact quite complicated. Sophie summed this up in saying “ Imagine that you are working in a tent armed with the MHGap flow chart on the wall and the manual in your lap with no medicine and patients every 5 minutes. You also need to consider their religion, customs and spirituality and how to integrate that in your knowledge”

The following are some excerpts from the manual and teaching.

Golden questions - from the book by Vikram Patel

“ Where there is No Psychiatrist”

Do you have problems sleeping at night?

Have you been feeling as if you have lost interest in your usual activities?

Have you been feeling sad or unhappy recently?

Have you been feeling scared or frightened by anybody?

Have you been worried about drinking too much alcohol recently?

How much money and time have you been spending on alcohol or drugs recently?

Another great mnemonic from Sophie and Peter to help us remember the general principles of care was CATMAP:

Communicate with people seeking care and

MhGAP Orientation Teaching: 8th & 9th March 2014 !Led by Dr Peter Hughes and Dr Sophie Thompson !Written by Dr Daniel Wolde-Giorgis and Dr Manshant Rani Kaur

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and their carers

Assessment

Treatment and monitoring – including a plan for treatment continuation and follow up.

Mobilising and providing social support and how stigma can affect reliable social support but can come from religious sources too.

Attention to overall well-being, encourage , educate and understand the cultural and community context and pay attention to physical health.

Protection of human rights in order to prevent stigma, marginalisation and discrimination and promote social exclusion.

All this in a few minutes!

Sophie taught us a very easy way to express mobilising social support and psychosocial help otherwise known as “Distress tolerance” in DBT.

Look at your 5 fingers and write or remember the names of 5 people you can turn to.

!!!!!

Look at the 2 lines on your palm and think of 2 things you know that you can do to make yourself feel better.

Look at the 2 lines on your wrist and think of 2 sayings, quotes or verses (which could be religious, spiritual or inspirational) that could always help you.

The MHGap Master Chart was a very useful tool to decide which priority of clinical need and diagnosis needs to be assessed in a few minutes consultation. As part of learning this we carried out some role plays which were more difficult than we had assumed. It was like finding

a different language to express and communicate effectively and to learn how to pay special attention to particular groups of people and their culture. This could pertain to the elderly, women, children and those with HIV for example.

Teaching methods such as storytelling, quizzes, case studies, small group discussions, snowballing, didactic teaching, using drama were some of the forms of teaching used in Training the Trainers.

Problem solving techniques with patients were given significant importance too. Stress and acute stress management in the face of extreme stressors and over diagnosis of PTSD were all discussed.

The journey through the Manual and the learning via basic yet very complex clinical case studies combined with the interaction in the group during the two days led to a huge, excited and compassionate energy in the room. The two days were interspersed with many wise comments from the tutors, many touching and moving stories and a great sense of trying to reach out.

The complexity and the difficulty of imposing our way of working and our judgements and values on different communities in different countries became clearer. Peter’s tongue in cheek comment that middle aged male psychiatrists are hard to train in MHGap seemed to pinpoint some of these difficulties. Our need to change and adapt and have insight into ourselves and into our own pre-conceived thoughts, ideas and clinical and personal experiences must be an important part of working in MHGap.

It is crucial to understand that our personal and clinical values which inform the way we work can impose on values within communities and countries where things work differently to our stereotyped norms. It can also involve difficult negotiation with governmental policies which can add to the complexity.

It was very apparent to us that Peter and Sophie have developed a way of interacting with people in extreme situations in a non-judgemental, courageous, open and humble way whilst being able to empower the people they work with to have less fear and to work to regain some control over theirs and their loved ones lives.

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Disclaimer: The opinions expressed in this newsletter are those of individual authors

and do not necessarily represent the views of the Royal College of Psychiatrists.

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