Teaching part-time has been a very rewarding experience, but it has not without its challenges.
I love getting to that “Aha!” moment of realization in my students and I sometimes think that in order to really get people’s attention, one must really “invest” a whole lot, because although they can’t help it, these tired and stressed population DO NEED their beauty sleep.
So, I’m interested in trying out the #Flipped #Classroom approach tomorrow.
The challenges of referring patients with mental health issues in primary care to the Psychiatry service (For tonight’s #Healthxph Tweetchat)
A few days ago, a respected individual learned announced on his Facebook wall that he was going to throw in the towel, and was going to say goodbye to the world. By virtue of his status update, he was able to call to attention his readers, students and friends, who became alarmed at implicit declaration that he was going to end his life. They all became extremely worried, and exhausted all means to reach him before he could do something to harm himself. One of his friends called a psychiatrist for an opinion, and they were advised certain steps to take, and eventually, after everything, the situation was deescalated.
After the incident, his posts took on a more positive note, which made people believe that the worst was over. In a series of “likes” and positive posts, it seemed all was well. Yet, that unfortunate crisis left his friends frantic at the time, not knowing what to do, and hanging their head at the burden of the possibility…”What if he had really done it? I wouldn’t have been able to do anything!”
Well, this is not something uncommon. With social media being ingrained in our lives, it is commonplace to see people dealing with mental health issues online. For the aforementioned individual, all was well and good, because someone reached out to him. But what of the distressed relative, or non-health care practitioner who does not know how or where to go for help? Or, in practice, what of the physician who has a patient who walks in his clinic “hearing voices” when there is no one there, or who wants to kill himself/herself? Or what of the in-patient attending who encounters a challenging patient who one day, suddenly refuses to eat, sleep, talk, or worse, refuses treatment outright?
All these are legitimate reasons for referring to mental health professionals, psychiatrists in particular, for further management. However, it is never as easy as ushering your patient on to the nearest psychiatrist’s door. Or telling the patient to see one outright, the way you would refer to the, say, ophthalmologist, or the otolaryngology specialist, among others. There is a certain ‘flavor” with referring to a psychiatrist that is met with some initial hesitation, or in extreme cases, vehement disagreement outright. The stigma of mental illness is particularly strong in our present society and time.
In a study by Ballester and group,(2015), it was agreed upong that general practitioners indicated that they perceived the mental health problems among their clientele, but the diagnosis and treatment of these problems are still seen as a task for specialists. This is not a surprise, because of in a study of 531 general practitioners (Phongsavan), Mental health problems recognised by general practitioners at least once per week were psychosomatic (93%), emotional (89%), addiction (79%), social/economic (71%) and family (69%), two-thirds recognised sexual problems, sexual abuse and major psychiatric problems less frequently than once per week. Sixty-four per cent of general practitioners reported that patients felt uncomfortable about being referred to psychiatrists; 53% complained that that referral service waiting lists were too long; 51% deemed that they were insufficient local mental health services; and 25% indicated that communication difficulties between referring general practitioners and mental health specialists obstructed optimal care.
These are things we have had experiences with, at one point or another in our careers. How do we do this? What do we say? Which brings us to our topic for tonight’s tweetchat:
T1 In your experience, what are the usual reasons/factors that would make you decide to refer to a psychiatrist?
T2. What factors particularly hinder your referral to a psychiatrist?
T3. What are your recommendations to facilitate ease of referral by practitioners to psychiatry service?
For everyone, this tweetchat is a weekly event (Saturdays, 9PM) on Twitter, hosted by members of #Healthxph, with different participants, discussing relevant medical topics using the social media platform Twitter. To join in the discussion, type #Healthxph on search and stay with the latest posts.
On a cobweb afternoon
In a room full of emptiness
By a freeway I confess
I was lost in the pages
Of a book full of death
Reading how we’ll die alone
And if we’re good, we’ll lay to rest
Anywhere we want to go
In your house I long to be
Room by room patiently
I’ll wait for you there
Like a stone
I’ll wait for you there
On my deathbed I will pray
To the gods and the angels
Like a pagan to anyone
Who will take me to heaven
To a place I recall
I was there so long ago
The sky was bruised
The wine was bled
And there you led me on
In your house I long to be
Room by room patiently
I’ll wait for you there
Like a stone
I’ll wait for you there
The start of February had me going to Manila to participate in a lecture that focused on Psychodynamic Psychotherapy.
It was an extremely exciting feeling to be there to listen to my mentors do what they do best. They talked about their passion and zeal for Psychotherapy, as well as discussed the new trends and the principles and concepts behind it, with equal aplomb.
All of therapy is a relationship, and like any relationship, ground rules must be set and understood. One simply does not start psychotherapy, without a goal planned. What constitutes talk therapy is a whole lot of effort from both therapist and patient/client, and a good deal of time. And like any other relationship, both parties may come to a point where they have to say goodbye. To “terminate” properly, so that the lessons learned are understood. That feeling of abandonment, from when one is dropped hastily and without proper closure, does more harm actually despite the apparent progress in therapy.
This got me thinking about personal experiences with “improper termination” in a romantic relationship years back. The severance of that relationship was sudden, and the boundaries were never clear, and thus it took quite a while to adjust and process to. It was perhaps one of the most confusing experiences I’ve ever been through. The pain from which, has eventually become “useful” later in life. We sometimes learn our lessons in relating the hard way. Unpleasant, yes, but life-altering, definitely. #
Last month, I was very fortunate to have had a chance to participate in the #healthxph and Philippine Center for Health Research and Development’s collaborative 2nd Philippine Healthcare & Social Media Summit, health at the Philippine International Convention Center in Pasay City, in April 21, 2016.
I was tapped to speak on “The Psychology Behind Patient Narratives” , where I talked about how people grappled with telling their health and wellness journeys in the form that was most suited to their stage in their illness, and how it benefited/affected them and their families.
It was concise, and set the groundwork for the other lectures. The topics were interconnected, as what followed was a talk on “The Different Patients on Social Media” followed by “The Patient Manifesto”. What followed after was an intense brainstorming, and workshop activity that had the participants actively giving their own two cents worth to contribute to making social media a veritable tool in helping bring about better health care and research.
It was a momentous event, as it was the first summit with the #PatientsIncluded certification, meaning, the participants were not only just physicians and HCP’s talking to each other, there were also participants from different sectors in society. Most importantly, there were patients of different conditions, supported by organizations of the different conditions…and they all came together.
It was a heady feeling, to be in amidst the buzz of enthusiasm for connecting, and improving health care through a different kind of media, which could foster change where we really need it, in a form accessible to almost all.
I feel honored and humbled to be part of your activity. Thank you, Dr. Remo Aguilar, Dr. Narciso “Buboy” Tapia, Dr. Iris Thiele Isip-Tan, Dr. Gia Sison, and Dr. Helen Madamba! 🙂 You deserve a round of applause for your hard work, and innovative approach to promoting healthcare for all! 🙂
For some time, I thought it was ironic, how, I was a therapist, and yet, I didn’t have anyone who satisfactorily could do “talk therapy” on me. I mean, living out here in the province, I could not really find a supervisor type of person who would help me along with how I processed myself and things that were going on in my life. There has to be a considerable amount of effort (a.k.a. travelling) before I get to talk to my colleagues or peers (or supervisor).
It’s not that they don’t have time, but it’s mostly because they all have their own lives to take care of (and not enough training on how to do so).
I am at a loss. In recent times, I have had some distressing personal issues to deal with, however, I never really got to talk to anyone about it. Mainly, it was just a lot of rumination, some writing, and then the development of rationalization and anticipation maneuvers, which can’t have all been good.
My biggest annoyance is when you’re trying to be vulnerable… you’re in a situation where even telling the story is hard, but you also have to deal with the person you’re telling it to giving you a smart alecky retort…or a totally moronic and unfeeling statement, which leaves you feeling worse than you actually feel.
If you’ve ever been in an emotionally distressing situation, you would sometimes notice that talking about it really helps, but only if you felt safe enough to say what you wanted to say, and feel that you won’t be judged for it.
Listening is not hard to do, actually, it is merely a basic kindness we offer to people who need to tell their stories.
(And no, it is not always about YOU.)
(Also, I’ve filled notebooks full of musings and self-awareness…I need “processing” this time.)
Also, just a note…I posted something on facebook, and I was amused at how my experiment proved right. I wrote about the freedom of speech, but everyone thought I was talking about politics. Actually…I just wanted to say something about how I was not free to say things I wanted to say…personal problems mostly! It figures…everything, and I do mean everything, has the potential to be “colored” by things.
“I dream about you…I think about you all the time.
“I’m in love with you…That’s just the way it is.”
This was Tony Soprano’s little speech to his psychiatrist, Dr. Melfi. This was in Season 1 of “The Sopranos” where he had started going for psychotherapy after having panic attacks “out of the blue”. She, Dr. Jennifer Melfi, had started him on Prozac, and was his listening ear during his regularly-scheduled Tuesday appointments.
After his declaration, she had to let him down easy, and explain to him that the probable reason why he was “in love” with her was so was because she, like his Mother/Wife/Daughter, was an Italian woman, but the difference was that she had been understanding, compassionate and listened to all that he had to say. She accepted him unconditionally, which made the big difference there. (Although she is not what you would call “the ideal” therapist. She obviously had problems being objective sometimes, and was too empathetic sometimes.)
I’ve been watching The Sopranos episode by episode these past few days, upon the recommendation of a good friend. He had told me years before of the series, and I had never taken him up on the suggestion until now (I’ve had these files in my hard drive for years.).
So, why now? Well, after I started on one, I could not help but move on to the next…I was hooked. 🙂 I was told that it would really help me with my “psychotherapy skills”, but actually, I think he was just a big Mafia fan, and loved the character.
Ah, Tony Soprano…he was larger-than-life, an anti-hero with a ball-busting mother issue, who was doomed to be a gangster because it was the only way of life he knew. Despite his shortcomings, he had a big heart and was undeniably loyal to those he loved (and “honor and family, and loyalty”).
The “internal turmoil” and the conflicts that he could not freely talk about (until he had a psychiatrist to help him sort them out) and presented as physical and psychiatric symptoms, and they were very interesting to watch. Also the interactions between patient and therapist were very riveting…she wasn’t afraid to confront him, and he reacted accordingly, as the textbooks said.
Now, I have gotten many “I love you’s” in the course of my training in Psychiatry, and I was very careful about things going “violent” during confrontations, but I have never had any “fights” with patients and their families. I’ve never had any death threats…(not that I would want to). That is to be expected in practice, especially when you’re doing psychotherapy, but I haven’t seen it yet during the psychotherapy sessions that I’ve done so far.
An interesting bit I’ve read in the Jeffrey Kottler book, ” On Being A Therapist”,
“Conquering a therapist is the ultimate victory, proof that anyone can be corrupted. It is a way in which the client can regain control of the relationship and win power and approval. It satisfies the desire to flirt with the forbidden, and it gives the client a means to frustrate the therapist just as she has been frustrated by the therapeutic experience.”
The therapist’s efforts to confront the client regarding the seductive behavior often lead to frustration. If the feelings are discussed directly and the therapist gently yet firmly rejects the overtures,the client might feel humiliated and rejected.
If the transference feelings are interpreted, the client may fall back in denial. Yet, if the therapist attempts to back off and let things ride for a while, the seductive efforts may escalate.
There is no easy solution.
It’s pretty much like…dancing with a partner, but you’re doing it objectively. It’s not always asking ‘How do you feel?”, but actually, it’s a mix of different techniques and guided questions (something that can’t be talked about in one blog entry…because it is so vast a topic, and so interesting too).
P.S. The Psychiatry part is not the only interesting part…the quips about psychiatry, the scenes, and the dialogue between the quirky mafia men makes it so much fun.
(They’re optional, and because of that, I would definitely want one in my clinic.)
This was my thought when one of the consultants at the round-table discussion asked if we psychiatrists still had hour-long consults and couches in our clinics…
The senior psychiatrist said that it wasn’t necessary anymore, and that real consults did not take as long. I, being the junior, merely nodded, as the question was addressed to him, but being the idealistic young graduate that I was, I knew in my heart that I definitely wanted to have one. 🙂
Granted I do not know much yet about the nitty gritty of private practice yet, I do know that I wanted a place or a space where someone wanted to stay to talk about their troubles, and express themselves and correspondingly, in the same way, I wanted to have a conducive environment where I was comfortable enough in assessing someone’s case.
The image of the couch connoted hours and hours of free association as in the times of Freud, where one could spew forth thoughts and musings while a therapist would listen and take notes. More often than not, this is what people think of when they hear the word “Psychiatry” (or the other thing).
I suppose it’s a matter of choice…if I were to empathize with a troubled individual, and ask myself, “If I were a patient, what would I like?”
Well, for starters, I’d want to be able to talk in a calming atmosphere, somewhere without a lot of fuss and noise, or where I could just sit and talk and not be pressured to talk or behave as “psych patients” would do. I’d like to be able to talk freely, without worrying about whether what I would say to my psychiatrist would be tomorrow’s gossip fodder. Confidentiality was a big thing.
Also, comfort. 🙂
I do recall before, with my table and chairs set-up, talking to someone with a family problem. As he/she was talking more and more about the problem, I noticed that he/she had begun to lean back and then almost lost himself/herself in her narrative. I had to suppress a smile when I noticed that he/she had already started to put her feet up on the chair opposite his/hers. Or, if it was particularly nerve-wracking, or distressing, people would need to feel comfortable enough to hold onto something.
But that’s just me, though. I’ve never been a patient myself, but when I was a sophomore in training, I had a supervisor who had such a comfortable clinic. When we discussed our cases, he’d have me pick my seat on any of the couches, and he would take a different one somewhere else in the room, and we’d talk about the case that way. And, because I could see the books nearby, I felt free to ask him about the titles and to browse about Psychiatry textbooks, handbooks, novels, etc. It was more conducive to learning.
However, I also found learning better when I sat on the table perpendicular to my teacher, so I could see her face to face and talk about the case at close range.
I think I’m going to apply that in my clinic and future practice. There’s the option to use the couch, and there’s also the option to sit comfortably on the chair near the table. Either way, it can be an empowering thing for the patient to be able to decide how the problem will be tackled the problem. I think that having the person choose how he wants to start is one of the steps to achieving an impact with rapport and psychotherapy. Also, I want therapy session to be something they will look forward to because they know that the work they put in of coming to the clinic will help them recover.
I was provided with a nice black corner couch for starters, with throw pillows in black and while and silver accents. I’m getting a full couch soon, but for now, at least these two options (i.e. couch or table) will be available for the patient.
These were my picks for clinic couch when the next time I can get them, though. 🙂
(Photos aren’t mine…got them from random sites online, and Pinterest.)
When I see patients, I usually like to take my time, especially for first consults. (I enjoy the interview process, and talking to people.)
However, I think there is a need to “tailor” my interviewing to the time constraint factor.
Earlier, I volunteered a local psychiatric facility in my locality. It’s a government facility, so I expected that there would be many patients to see. However, I got more than I had bargained for. 🙂 I’m not complaining about the sheer volume of patients, though. I was more concerned about not being able to give enough time for each one, as much as I’d like to.
This morning’s exercise proved to be a good eye-opener… For one thing, it taught me the basics of budgeting my time, and second, it gave me a first hand experience of the way people in more rural areas viewed Psychiatry. (They kept coming and coming into the room.)
The stigma of mental illness is still very real in the province where I’m from. Even the mention of the place I was volunteering at was enough to connote that image of “locks, cages and hopeless cases”. (It was not so, of course, the staff was competent and they knew what to do, it was just that the way people thought about things for a very long time.)
It was a mix of patients and relatives, with an equally varied number of problems… They ranged from * problems with sleep, up to problems with the government’s not having enough stock in the place (but I think that that man was just having a bad day.)
I was thankful for the time to do some volunteer work, and also to spend some time with the students who were getting their firsthand experience of the interview with a mentally-ill patient. I wish there were more chances to teach.