MENTAL HEALTH TRAINING FOR PHC STAFF IN SRI LANKA

CONTINUING PROFESSIONAL DEVELOPMENT

FACILITATORS’ GUIDE

Mental H
FACILITATOR’S GUIDE
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CONTENTS

1. Rationale for in service training course……………………………… …………

2. How to use the manual………………………………………………………….
3. Assessment and Evaluation Methods……………………………………………
4. Guidelines for preparing to run the course………………………………………
5. Preparing the venue, Welcome and Packs………………………………………
6. Starting the course and pre-test………………………………………………….
7. Unit 1 core concepts…………………………………………………………….
8. Unit 2 core skills………………………………………………………………..
9. Unit 3 common neurological disorders…………………………………………..
10. Unit 4 common mental disorders………………………………………………….
11. Unit 5 Policy, legislation, roles and responsibilities, mental health and HIV,
malaria, child health and reproductive health; HMIS community health workers,
traditional healers…………………………………………………………………
12. The way forward…………………………………………………………………..
13. Post test……………………………………………………………………………..

RATIONALE FOR INSERVICE TRAINING COURSE ON MENTAL HEALTH

Mental health is as crucial for all of us as physical health. Mental illness and neurological
disorder account for 10-15% of the global burden of diseases worldwide, and a quarter of
years of life lived with disability. At least 1 in 10 of the adult population has a mental
disorder at any one time, but many suffer in silence and only a few of those who need
treatment get it. A number of factors contribute to this situation including stigma at all
levels, inadequate knowledge of the conditions in patients, family, community and health
professionals, inadequate resources meet the needs of the clients. The situation is worse
in low-income countries like Sri Lanka.

In the primary care setting, every third or fourth patient seen has some form of mental
health disorder. Therefore primary care staff needs to be strategically prepared to serve
clients with mental health problems. Integrating mental health into Primary Health care is
essential if the population is to have equitable access to care.

It is therefore the aim of this training workshop to equip primary health workers with
knowledge, skills and attitudes for promoting mental health, preventing illness and for
caring for clients and families with mental health problems within their area of work. The
duration of the course is one week. Participants are expected to be health professionals
working in primary care, including clinical officers and nurses with no specialist training
in mental health, although they will have had some exposure during basic training, and
will also have accumulated much exposure to mental health problems during their daily
work.

HOW TO USE THE MANUAL

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The manual is a resource reference for facilitators and tutors conducting mental health
training workshops for primary care workers in Sri Lanka. The aim of this guide is to
assist facilitators to run the course smoothly with minimal difficulties. The manual gives
.
Overall rationale for course
How to use the manual
Guidelines for preparation of course
Guidelines for running the course

The manual is divided into five units, each on a different theme, with an indication
of how long each might take. Each unit
begins with a summary,
lists the topics to be covered and the teaching objectives,
indicates the facilitators’ role in the teaching and learning process.

• The manual is accompanied by

o Teaching slides
o Role plays
o Group Discussions
o The timetable for the week, indicating the time allocated to each topic

• The timetable is a crucial aid to managing the course within the time allowed,
finding the relevant role plays, and ensuring everyone gets to have lunch on time!

ASSESSMENT AND EVALUATION METHODS

There is a pre-training assessment to explore the basic knowledge that participants come
with to the course, and post training assessment on the last day to determine how
much participants have achieved from the course.
Continuous assessment is done throughout the course in terms of participation and
contribution from participants.
An overall evaluation is conducted at the end of the course. Participants and
facilitators will evaluate the effectiveness of the training workshop in terms of
strengths, weaknesses and suggestions for improvement.

GUIDELINES FOR PREPARING TO RUN THE COURSE Ensure all participants

invited and have confirmed-fill any gaps, as an empty space wastes precious training
resource
• Book venue, coffee, lunch, tea and supper
• Book accommodation
• Book audiovisual aids-computer, projector, video
• Check all hand out packs are complete-it is very frustrating for
participants if they can’t find something (see below)
• Name tags-? Sticky labels and pen
• Set up teaching slides

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• Check all arrangements in person

• Ensure the week before that the room will be open and ready by 7.30am
on day 1. Check where main keys, and back up keys, will be held.
• Ensure the week before that the refreshments will arrive on time so as not
to disrupt the timetable
• Review allocated budget guidelines, retain all invoices, and account for
all monies spent, per person and per course

DAY 0
Facilitators arrive on Sunday evening

DAY 1

WELCOME
As a facilitator you need to prepare yourself and resources well in advance:
Go to venue at 7am and ensure it is unlocked, well set and with proper ventilation
• Ensure room unlocked 30 minutes before start in mornings
• Ensure all technology working 30 minutes before start
• All photocopying to be double sided, and slide handouts 6 to a side

Set out the Packs for each participant

Curriculum Timetable for week
Pre-test,
WHO primary care guidelines
Sri Lanka Mental Health Legislation
Unit 2 Core skills
Post test
Blank note paper
Pen
Folder
Name tag

Set out the Teachers pack

Facilitators guide
Curriculum timetable
Handouts of slide units 1-5-you may need these if the electricity fails!

It is advisable to distribute the packs on arrival day so that participants can have a
look at night before coming to class.
Organization skills and team dynamics are very important at this stage.

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Formal Introduction
• Introduce yourself
• let participants briefly introduce themselves.
• Housekeeping-toilets, refreshment timetable, evening arrangements

Formal Opening
• If you decide to have a formal opening by the Principal or another, please
remember they are very busy people
o Give written brief to them well in advance
o DO NOT WAIT FOR THEM as they may often be held up by other
commitments.
o Proceed with curriculum timetable on time and simply break promptly for
ten minutes for formal opening when Principal arrives, so Principal is not
kept waiting.
o The Principal may also wish to observe for a while.

Explain Purpose of Training:

Increase mental health capacity in health centers and dispensaries by in-service
training.

At the start of days 2- 5

Revision of the previous day’s topics. 10 minutes
a. Ask participants how they found the previous day
b. Whether they have read the relevant parts of the WHOPHC guidelines
c. Any problems encountered
d. Any new learning experience

Setting the ground rules

Activity: Setting ground rules:

An interesting thing about adult learning is the purpose of learning. Learners come to learning situation
with a number of expectations and carry with them issues/roles and responsibilities, status etc. It is
important that ground rules are set together with participants so that they have sense of ownership. This
will minimize some domestic problems like going shopping and dogging classes.

Ask delegates what rules they are putting forward to facilitate smooth running of the course.
List them on the flip chart
Agree on the rules
Facilitator puts the rules on the wall to remain during the course as reminder to both delegates and
facilitators.

Identifying delegate expectations

Activity: Identifying delegates’ expectations, and setting strategies to meet these expectations.

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It is important to be aware of what expectations delegates come with to the workshop. Together the
facilitator and delegates work on the strategies that will ensure that expectations are met. This will act as
checks and balances throughout training workshop.

Objective: Explore from the delegates their expectations, issues/baggage they are bringing with them and
strategies to tackle them.
3-part activity
20 minutes

1. Give each delegate paper and ask them to answer the following questions (5 minutes max)
• What do I want from this course?
• One thing I hope will happen is………………………………
• One thing I hope won’t happen is……………………………
• I will know if the course has been successful if…………….

2. Pool ideas on to flip chart

3. The facilitator then puts the sheets on the wall where they remain for the duration of the course. And
referred to.
As they go up, the facilitator addresses each of the issues, for instance:
Positive: “Yes we will be covering this on day 3 so look out for it and be thinking about what questions you
have and what ideas you want to share (gets delegates involved and engaged).
Negatives, for instance: “I hope we don’t have to do role plays”
Facilitator question: What makes you dislike role-plays?
Typical discussion: Feel silly, will be laughed at”.
Well you need to know that we will be doing some role plays- as for some topics they are the best way of
helping you learn-as you can’t practice on real people!! I am sure other people are just as apprehensive and
will not laugh at you but support you.
Facilitator turns to group for confirmation.

Describe the Teaching and Learning Methods which will be used

The methodology adapted is participatory whereby a mixture of activities are used
including; lecture-discussion using slides, videos, role-plays, small group discussions
and large group discussion.
When choosing and adapting activities, facilitators need to bear in mind that the
order of units has been carefully thought through, so facilitators need to read the
whole document and teaching slides before hand, and follow the order set out and
the timetable.

Activity: Pre-training assessment:

Objective: To explore delegates’ knowledge on mental health

Facilitators administer a prepared pre-test to delegates-see appendix.

General notes to facilitator

• Follow the timetable as closely as possible
• At each break, make note of which slide has been reached to make it easy to
resume afterwards

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• If participants look sleepy , insert another role play immediately!!

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UNIT ONE: CORE CONCEPTS

Unit One introduces participants to the context and concepts of mental health and mental
illness.

Topics to be covered in this unit are:

1. Meaning and scope
2. Mental and physical health and illness
3. Mental and neurological health, gender and the millennium development goals

Objectives:
Upon completion of this unit learners shall be able to do the following:
Define mental health and mental illness
Understand the causes, symptoms and impact of mental illness to individual, family
and society.
Identify linkages between physical and mental health
Appreciate the contribution of mental health to Millennium Development Goals

Facilitators’ role:

Introduce the subject to participants by:

Write 3 questions on a flip chart and write
i. Mental Health?
ii. Factors influencing Mental Health?
iii. Consequences of positive mental health to individual, family,
community?
Ask participants to give answers to questions
Write answers on a flip chart
Discuss the answers
Duration 10 minutes

Write 3 questions on a flip chart:

iv. Mental illness?
v. Causes?
vi. Consequences at individual, family and community?
Ask participants to give answers to questions
Write the answers on flip chart
Discuss answers given.
Duration 10 minutes

Present the prepared slides with running comments.

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Conduct general discussion on the subject. Participants should be given

opportunity to share their experiences.
Duration 15 minutes

Summarize the topic.

NB: Participants will know quite a bit about mental health and mental illness. They
therefore need to be motivated to give out what they know and that can be shared.

Activity :

Review a.
Ask delegates in 2s to imagine they were to give a 3-minute talk to their local volunteers on mental health
and mental illness.
Give them 10 minutes to write a talk and then choose 2 groups to deliver (3 X 2=6minutes).
Lots of applause needed.
Will check learning and internalize it.

Review b
Ask delegates to return to their 3-minute presentations and add 2 minutes on symptoms of mental disorders
and psychosis.
Give them 10 minutes to review 1 and write 1a
Choose 1 group to deliver (6 minutes)

Review c
Ask delegates to return to their 5-minute presentations and add 1 minute on symptoms of mental and
physical health and MDGs.
Give them 10 minutes to review a, b and c.
Choose 1 group to deliver (6 minutes).

Summary:
Mental health is a positive sense of well-being, belief in own worth and dignity, and dignity of others, and
ability to function adequately. Mental illness thus is a condition whereby there is disturbance in thinking,
cognition, feeling and behaviour. It affects all aspects of human development including social and
economic burden, psychological and physical burden to individuals, families and society as a whole. We
can intervene in mental disorders by:
* Enhancing healthy functioning through promotion of health promoting activities such as good nutrition,
education, MCH services
* Stabilizing the disturbed functioning through early detection and appropriate treatment
* Restoring healthy functioning through rehabilitation activities

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UNIT TWO: CORE SKILLS ESSENTIAL FOR MENTAL HEALTH PRACTICE

Introduction
Mental health care is a problem solving process, and one needs essential skills to
facilitate the process. Communication is the most essential skill in human
interactions that is crucial for all parts of the process. We have divided the process
into the 5 components of assessment, diagnosis, planning, implementation and
evaluation skills.

assessment-the health worker has to collect, validate, organize and record information
using interview, observation and examination. Topics on identifying a person
with mental health problems, and mental state examination fall under this
component.

diagnosis-the health worker applies her or his thinking skills in interpreting information
in order to identify patient’s mental health status including strengths, problems,
causes of problems etc. topics covering diagnosis, differential diagnosis, and
case formulation fall under this component.

planning-the health worker plans what goals need to be met and how. the goals and
objectives should aim to meet patients’ needs and problems. priorities should be
specified and negotiate with the patient on treatment plan. a topic on “care
planning” fall under this component.

implementation-carrying out interventions is the core role of a primary care worker.

evaluation-the health worker has an obligation to assess the effectiveness of care

provided to the client. monitoring progress of the patient.

Topics to be covered in this unit:

Communication Skills
Conducting interviews
Mental State Examination
Diagnosis
Differential Diagnosis, Investigations and Case Formulation
Care Planning
Psychosocial Support
Breaking Bad News
Community Based Rehabilitation
Medication Management
Managing Aggressive And Violent Patient Including Domestic Violence

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Objectives: Upon completion of this unit learners shall be able to do the following:
Create and maintain effective communication with clients and community
Identify a person with mental health problems
Utilize effective interviewing techniques in history taking
Understand the main points in Mental State Examination
Understand diagnostic criteria utilizing ICD-10 classification
Familiarize with case formulation (a comprehensive view of a client)
Understand care planning of the client to address the physical, psychological and
social aspects of care.
Understand the importance of psychosocial support to clients and family.
Utilize appropriate approach to breaking bad news.
Utilize principles of community based rehabilitation and community linkages in
mental health practice.
Manage commonly used medication for mental illness in your area of work
Familiarize with psychosocial and physical methods of managing violent patients
including domestic violence

Facilitator’s role:

1. Introduce the unit to participants

2. Present session on communication by starting with Activity on getting to know
each other
3. Present prepared slides for clarification
4. Introduce the subject on Identifying a client with mental health problem at
working setting by asking the following questions:
a. How will you identify a client with mental health problems?
b. What are the clues that may lead you to suspect mental illness?
5. Present the slides with running comments.
6. Present the case studies for group discussion and presentation.
7. Discuss on Mental State Examination
8. Present the slides with running discussion

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Case Scenarios

Scenario 1:
Joseph is a 45-year-old man married with 3 children. He also has one child with his
mistress of whom his wife is ignorant. Joseph has been a regular attendee at the clinic
with several complaints including frequent fevers, loss of weight and skin rashes. After
some investigations and management, the patient asks you if he could have HIV test with
condition that his wife should not be told. You discuss with Joseph who seem to be
understanding and have him tested. Results come to be HIV positive. This time Joseph
changes his mind that is not going to disclose to anybody.
How would handle this? Justify your approach.

Scenario 2:
Think of a patient that you have cared for, where they became emotional.
How did you handle the situation
How differently might you respond to an emotional outburst now?

COMMUNITY BASED REHABILITATION

MEDICATION MANAGEMENT
See role plays 5 and 6

MANAGING AGGRESSIVE AND VIOLENT PATIENT INCLUDING

DOMESTIC VIOLENCE

Case scenario 3: The violence cycle

Sita married Mr. Opatha when she was 18 years old. Soon afterwards Mr. Opatha began
to shout at her. At first she was concerned because he had been so loving before they
were married. The reasons for his anger were often small: One day it would be because
the dinner was not tasty: another day just because he had had too much to drink and was
unhappy at work. Sita spoke to her elder sister, who reassured her that a little anger was
normal in every marriage. But for Opatha anger seemed to get worse with time.
One day, Sita returned home later than usual from the market. Opatha was very angry. He
accused her of not being a good wife, and that he thought she was having an affair with
another man. Sita apologized and said she was not having an affair. But this only made
Opatha angrier. He slapped her on the face. Sita was shocked. It was the first time he had
slapped her. She ran to her room and cried. Opatha said sorry. But it happened again and
again. The beatings became more regular. After a severe beating, Opatha would cry and
say sorry. He would threaten to kill himself if she left. The accusation and threats made
her stop meeting her friends and she became isolated. She could no more enjoy sex with
him, which made him angry.

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One day when Opatha wanted sex, she refused. He became furious, again accusing her of
having affairs. Then he started beating her. Finally, he raped her. The next morning, Sita
tried to kill herself by drinking poison. It was only when she went to the hospital that the
health worker found out about the violence. In the meantime, 15 years had passed since
Sita had married Opatha.

Exercise
In your groups discuss the situation in the following areas:
* Identify the 3 components of violence cycle.
* How will you handle the situation?

UNIT THREE: MANAGING COMMON NEUROLOGICAL DISORDERS IN

PRIMARY CARE
Topics to be covered in this unit
Epilepsy
Dementia
Delirium
Parkinsonism
Headache
19.15. DELIRIUM
UNIT FOUR : MANAGING COMMON MENTAL HEALTH DISORDERS IN
PRIMARY CARE

Topics to be covered in this unit:

Depression and mixed anxiety-depression
Anxiety
Somatisation
Dissociation
Sleep problems
Post-traumatic disorders
Eating disorders
Adjustment disorders
Sexual disorders
Alcohol abuse
Drug abuse
Acute psychosis
Bipolar disorder
Schizophrenia
Learning disability
Childhood emotional disorders
Childhood conduct disorders
ADHD
ASD

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Objectives
Upon completion of this unit learners shall be able to do the following:
Understand the presenting complaints and diagnostic criteria for the common
mental health problems in their working area
Understand different management approach to clients with mental health problems
Understand specific education to be given to clients and families of mentally ill
clients.
Identify the needs and problems of children and adolescents with emotional and
mental health problems
Give appropriate advice to parents of children with emotional and mental health
problems
Care for clients with both physical and mental health problems.
Understand the relationship between different aspects of health conditions and
mental health.
Appreciate the contribution of mental health promotion, prevention of diseases,
treatment, reduction of disability and mortality.

Facilitator’s role

2. Make slide presentation for common mental health problems- psychotic

conditions.
3. Give time for discussion after every condition
4. Give a copy of case formulation for Mr. Hassan in groups of four for discussion.
a. Let participants identify patient’s diagnosis, differential diagnosis, cause,
investigations to be carried, treatment and prognosis.
5. Ask participants to make a case formulation of any case already covered for
presentation.
6. Facilitate discussion during presentations
7. Let participants role play management of patients with different mental disorders
e.g. Schizophrenia, Bipolar, Alcohol abuse
8. Discuss and summarize main points
9. Give participants evaluation forms to fill during their spare time.

Evaluation forms contain Strengths, Weaknesses and suggestions for improvement in

relation to course objectives, content, teaching methodology and presentation.

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UNIT 5
Topics to be covered in this unit:
Kenya health policy
Mental health policy
Roles and responsibilities at each level
1. PHC
2. District
3. Provincial
4. National
Mental health legislation
HIV/AIDS and mental health problems
Malaria and mental health
Reproductive health and mental Health
Childhood illnesses and mental Health
Health Management Information System
Community Mental Health Care
Traditional And Religious Health Practitioners
Mental Health Promotion
a. General Population
b. School Health Education
c. World Mental Health Day

Objectives:
Upon completion of this unit learners shall be able to do the following:
Understand the main points of health policy and mental health policy.
Understand the rights and expectations of people with mental health problems
Appreciate their key position in overall integrated system of delivery.
Understand roles and responsibilities at different levels of mental health delivery
Understand the relationship between mental health problems and legal system
Comprehend human rights issues, and their role in implementing legislation.

Activity: Imagine
Ask delegates in group of 6 to imagine they are a patient with mental health problems and what
human rights they would have the right to expect- 10 minutes feedback from each group.
Then facilitator links to policy.
Will make legislation more real.

Activity: Consequences of Legislation, Mental Health Policy

In groups of 2 :
Tell a story or draw

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1: a person with mental health problems and the world in which they live now (lack of care, with
their symptoms, with the causes and consequences, with risks and all the problems they face)
2: a person with mental health problems and the world in which they could live if policy,
legislation and delivery of services all came together; incorporating all you have learnt during the day 1 and
your understanding of new legislation.

Objectives:
Upon completion of this unit learners shall be able to do the following:
Understand principles of engaging with clients
Understand principles and approach to community mental health care
Appreciate the need to collaborate with traditional health practitioners in mental
health care
Understand mental health promotion
Initiate mental health promotion activities in your area of work.

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Case Scenario 5: Engagement with clients.

Rama is 25 years old and lives with his parents in a 3-bedroom house. He left school at the age of 18 after
completion of his ordinary level secondary education. His parents sent him to a private high school but he
could not perform. He has been using cannabis from the age of 14 without parent’s knowledge. At the age
of 19 Rama was arrested and charged with possession of cannabis.

While being held on remand his behaviour was agitated and he was also suicidal. He claimed to be
possessed by an evil spirit, which told him to adopt leadership position in the final war between good and
evil. He was instructed to cleanse the world of the opposite forces, but he was confused as to which side he
was on. He was assessed and diagnosed as Schizophrenia secondary to cannabis abuse.

Rama has been non-adherent to medication. He considers his medication and any contact with the mental
health services as harmful and is only sporadically compliant with treatment. He considers that his family,
the mental health services, criminal justice and wider society are “setting me up each time by making me
take medication that harm, while society tries to stop me using the things that mellow and chill me out”. He
denies any need for mental health services.

Exercise

In your groups discuss on the following aspects:

* Identify the needs and problems of Rama and his family
* How would you go about ensuring that Jinasena and family are fully engaged with mental health
services?

HEALTH MANAGEMENT INFORMATION SYSTEM

A system of collecting, recording, keeping and reporting including dissemination of

health related information (mental Health) with a clear flow of communication from
service point to decision/policy level and vice versa.

COMMUNITY MENTAL HEALTH CARE

An approach of caring people within their social and geographical environment.

Services and support be provided in peoples’ homes, giving the person as much
independence as possible. The role of a community mental health worker is to;
• Establishing population-based needs for treatment and care
• Providing a service system linking with a wide range of resources of adequate
capacity, operating in accessible locations
• Delivering evidence-based treatment to people with mental illness
• Home visits should be conducted to assess mental status and general health,
patients’ compliance with medication, and to appraise the patient and her or his
family’s social economic position including interactions and how the client is
doing with the family environment.

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Summary:
Community mental health care is a comprehensive approach of caring clients, families
and community within their geographical and social environment.
It is an empowering strategy to both clients and professionals.

TRADITIONAL AND RELIGIOUS HEALTH PRACTITIONERS

Traditional and Religious Health Practitioners are the major health care resource in most
African societies. It is estimated almost 40% of clients will consult TH or RH at one time
in sickness or related problems. People often simultaneously consult both traditional
healers and western medicine. It is therefore important that efforts are made to enhance
collaboration and partnership with THs through dialogue, mutual trust, training and,
research development.

MENTAL HEALTH PROMOTION

Mental health promotion and disease prevention is the first level intervention in a health
continuum. It can be seen as a kind of immunization, working to increase the resilience of
individuals, families and communities, as well as to reduce conditions, which are known
to damage mental well-being in everyone whether or not they currently have a mental
health problem. Strengthening the mental health of individuals, families, organizations
like schools and communities not only reduces vulnerability to mental health problems
but also improves physical health, increases productivity, reduces risk taking behaviours,.
.
Mental health workers need to explore different avenues and opportunities for mental
health promotion within catchment area.
Mental Health education to school children, teachers and the community
Facilitating self-help groups
Supporting parents
Mobilizing communities for Mental Health day celebrations

SUMMARY/REVIEW, EVALUATION AND THE WAY FORWARD

Knowing where you come from helps to exactly strategize on where you want to go from
here. During the training we have learned quite a number of different things professional,
academic and social. All these are worth reflecting.

Topics to be covered:

Summary Of The Week

Post Course Evaluation
Future Working

Objectives:

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Upon completion of this unit learners and facilitators shall be able to do the following:
Conduct a post training assessment
Reflect main points covered during the course
Identify main strengths and weaknesses related to course aims, objectives, content,
teaching and learning methods including teaching and learning materials.
Give suggestions for improvement in relation to the course content and course
delivery.
Get into groups and plan the coming years activities
Appreciate future roles and responsibilities in ensuring continuity and sustainability
of training initiative.

Facilitator’s Role
1. Administer the post test assessment (15 minutes)
2. Give summary of what has been covered during the week using units as a guide.
a. Divide participants into 5 groups
b. Give one unit to each group for summary presentation
c. Discuss
d. Allow some questions
3. Evaluate the course with participants
a. Ask participants to give the overall evaluation of the course
i. What have they learnt from the course?
ii. What were the strengths of the course?
iii. What were the weaknesses or pitfalls of the course?
iv. How can we improve?
b. Summarize the points on flip chart and discuss
4. Discuss with participants on future roles and responsibilities

END OF COURSE

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REFERENCES

Andrews, G. & Jenkins, R. (Eds) (1999). Management of Mental Disorders (UK Edition).
Sydney: World Health Organisation Collaborating Centre for Mental Health and
Substance Abuse.

Paton, J. & Jenkins, R. (Eds) (2002). Mental Health Primary Care in Prison. London:
Royal Society of Medicine.

Jenkins, R. (Ed) (2004). WHO Guide to Mental and Neurological Health in Primary
Care. London: Royal Society of Medicine Press.

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