What to Do While Waiting for a Mental Health Referral. Learning Objectives. Don t Wait If the Patient is in Danger: Refer to Emergency Care

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1 What to Do While Waiting for a Mental Health Referral Francine Cournos, M.D. Professor of Clinical Psychiatry (in Epidemiology) Mailman School of Public Health, Columbia University fc15@columbia.edu August 13, 2015 Learning Objectives While waiting for a mental health referral, learn methods to help people cope with depression anxiety PTSD other mental illnesses Don t Wait If the Patient is in Danger: Refer to Emergency Care The danger can be medical as in the case of delirium (the sudden onset of acute confusion with a fluctuating level of alertness, disorientation, agitation and/or psychosis, etc.). If waiting for a medical evaluation, give fluids and sugar (glucose) to confused patients to help correct possible dehydration and low blood sugar. Refer for emergency care if you suspect the patient may be a danger to self or others and/or when the patient is very agitated. 1

2 Helping A Patient Cope Begins with Having a Conversation Many health care providers are ill at ease talking to people about mental illness. What are your own concerns? Some Barriers to Having Conversations with People with Mental Illness Lack of time to have such a conversation Discomfort with mental health problems Concerns that a patient may become violent Fear of not having the requisite skills Fear of not knowing what to say or do Feeling it s socially inappropriate to ask probing questions Some Reassurances about Having Conversations with People with Mental Illness Even brief conversations can be very helpful. Listening is more important than talking. You don t need to know the answers. You can instead help the person articulate his or her own strategies for coping. Health care providers ask probing questions about bodily complaints; it s okay to also do so with mental health complaints. 2

3 Your Single Most Important Therapeutic Tool: Listen to the Patient Listening without judgment is by itself therapeutic. As a person thinks out loud to an interested listener, s/he is often able to formulate new options for solving a problem or tolerating distress. Remember, mental health providers haven t learned to read minds; their power comes from knowing how to ask and listen and taking the time to do so (but even a few minutes of listening can do a lot of good). Listening Is the Most Basic and Powerful Way to Connect to Another Person A The. There. Helping Patients to Reduce Substance Use: Techniques in Motivational Interviewing (MI) Overlap with Active Listening Approaches Ask open-ended questions Express empathy Acknowledge strengths Support self-efficacy Avoid arguments Summarize discussions Use reflective listening to discover discrepancies: this technique is where MI adds something new to active listening 3

4 Using Reflective Listening to Discover Discrepancies: A Component of MI Clinician helps patient identify conflicts between patient s current behaviors and patient s goals/values Clinician reflects on discordance Patient realizes change is necessary and develops own solutions Chanut et al., Can J Psych, 2005 Psychological First Aid: An International WHOrecommended Approach to Helping People with Recent Trauma (Active Listening plus Practical Help) Psychological First Aid offers humane, supportive and practical assistance to people who recently suffered exposure to serious stressors and consists of: Non-intrusive, practical care and support Assessing needs and concerns Helping people to address basic needs Listening, but not pressuring people to talk Comforting people and helping them to feel calm Helping people connect to information, services and social supports Protecting people from further harm Psychological First Aid Is not something only professionals can do Is not professional counseling Is not psychological debriefing Asking for details of the distressing event Is not asking people to analyze what happened or put time and events in order It is listening to people s stories without pressuring them to tell you their feelings or reactions to an event and offering them sensible, practical, available help. 4

5 Examples: Mental health care by mental health specialists (psychiatric nurse, psychologist, psychiatrist etc) Basic mental health care by PHC doctors Basic emotional and practical support by community workers (Psychological First Aid) Specialised services Focused (person-toperson) non-specialised supports The place of Psychological First Aid in overall mental health and psychosocial responses Activating social networks Communal traditional supports Community Strengthening and family community supports and Supportive child-friendly family supports spaces Advocacy for basic services that are safe, socially appropriate and protect dignity Basic services and security Social considerations in basic services and security Prepare Psychological First Aid Action Principles Learn about the crisis event. Learn about available services and supports. Learn about safety and security concerns. Look Listen Link Observe for safety. Observe for people with obvious urgent basic needs. Observe for people with serious distress reactions. Make contact with people who may need support. Ask about people s needs and concerns. Listen to people and help them feel calm. Help people address basic needs and access services. Help people cope with problems. Give information. Connect people with loved ones and social support. Good Communication: Things to Say and Do Try to find a quiet place to talk and minimize outside distractions Stay near the person but keep an appropriate distance depending on their age, gender and culture Let them know you hear them, for example, nod your head and say hmmmm. Be patient and calm Provide factual information IF you have it. Be honest about what you know and what you don t know. I don t know but I will try to find out about that for you. TALK LESS, LISTEN MORE! Give information in a way the person can understand - keep it simple. Acknowledge how they are feeling, and any losses or important events they share with you, such as loss of home or death of a loved one. I m so sorry Respect privacy. Keep the person s story confidential, especially when they disclose very private events. Acknowledge the person s strengths and how they have helped themselves. 5

6 Good Communication: Things NOT to Say and Do Don t pressure someone to tell their story Don t interrupt or rush someone s story Don t give your opinions of the person s situation, just listen. Don t touch the person if you re not sure it is appropriate to do so. Don t judge what they have or haven t done, or how they are feeling. Don t say You shouldn't feel that way. or You should feel lucky you survived. Don t make up things you don t know. Don t use too technical terms. Don t tell them someone s else s story Don t talk about your own troubles Don t give false promises or false reassurances Don t feel you have to try to solve all the person s problems for them Don t take away the person s strength and sense of being able to care for themselves Learn More: See PFA Guide for Field Workers WHO publication Collaborative effort: World Health Organization War Trauma Foundation World Vision International Endorsed by 24 UN/NGO international agencies Available in several languages Key Long-term Messages for Trauma Recovery and Developing More Adaptive Coping Skills It is not happening now. The trauma is over. It is in the past. You are here in the present. You are not inherently dangerous/toxic. What is inside you (thoughts, feelings, dreams, impulses, etc.) cannot hurt you or others. You are good. Whatever you have experienced and whatever you have had to do to survive, you are a good, strong person who can contribute to your community. You can move past these traumas. You can heal and resume growth in the context of supportive and nurturing relationships. 6

7 Helping Patients Reduce Anxiety Discuss reducing the use of anxiety provoking substances such as caffeine (e.g. coffee, soda), nicotine (tobacco), and non-prescribed stimulant drugs. Encourage exercise. Rebreathing briefly into a paper bag to control a panic attack (by changing carbon dioxide level) is probably a placebo effect. Consider learning how to instruct patients in one or more simple relaxation techniques such as mindfulness or yoga breathing. Helping Patients to Improve Sleep Many psychiatric problems interfere with sleep Poor sleep in turn contributes to feeling unwell While often only partially effective, help patients implement good sleep hygiene techniques Sleep Hygiene: What to Do Take warm baths before bed Exercise for at least 30 min/day most days of the week Maintain a bedtime routine (e.g., going to bed and waking up at a set time) Make bedroom cool, dark, and quiet Place the clock out of sight If unable to fall asleep after 20 minutes, leave bed and do something relaxing (e.g., reading); return to bed later 7

8 Sleep Hygiene: What to Avoid Don t consume caffeine (coffee, tea, chocolate, soda), alcohol, or nicotine before bedtime Don t eat a large meal just before bedtime Don t nap during the day Don t exercise within 2 hours of bedtime Don t work, eat, read, or watch television in bed These strategies are based on expert opinion. For more information, refer to the Mental Health Guidelines Insomnia in HIV- Infected Patients at Helping Patients Manage Depression Self-management is very important to maintaining well being under all circumstances, and it is especially important for people with depressive symptoms or a depressive disorder. Even when a person with a history of depression has improved on an effective antidepressant regimen, ongoing self-management strategies remain important. 8

9 Management Strategies to Improve Mood Exercising Obtaining adequate sleep Pursuing meaningful goals and pleasurable activities Seeking social and spiritual support Reducing interpersonal conflict and negative thinking Avoiding preventable stressors Calming Down from Extreme Emotions: Invoking the Mammalian Diving Reflex Recommended by Marsha Linehan, the creator of dialectical behavior therapy (DBT) for the treatment of borderline personality disorder Shifts the highly aroused person from activation of the sympathetic nervous system (the fight or flight response) to activation of the parasympathetic nervous system, which allows for calmer and more deliberate activity. Calming Down from Extreme Emotions: Invoking the Mammalian Diving Reflex The mammalian diving reflex optimizes respiration to allow for staying under cold water for extended periods of time. (It s strongest in aquatic mammals.) In regard to humans, it allows them to survive longer without oxygen under cold water and serves as a survival strategy in the face of threatened drowning. Invoking the diving reflex provides immediate relief from feeling overwhelmed and allows for utilization of problem-solving skills. 9

10 How to Evoke the Diving Reflex Fill a bowl with icy cold water Bend/lean over Hold your breath Put face in icy cold water for 30 seconds, which will evoke the diving reflex Make sure the area underneath the eyes and above the cheekbones (the most sensitive part of the face) feels the icy water Caution: Invoking the dive reflex slows heart rate and is not recommended when this might create a medical risk (e.g. heart disease, anorexia nervosa, etc.) Use of Psychotropic Medication by Prescribers without Mental Health Training Use benzodiazepines judiciously. Use sleep medications to relieve insomnia on a short term basis while assessing and responding to the underlying cause(s) of the problem. Become comfortable prescribing two SSRI antidepressants: they can be used to reduce symptoms depression, anxiety and PTSD. 10