need for special services communication in psychiatry misdiagnosis with examples do deaf people hear...
TRANSCRIPT
• Need for Special Services• Communication in Psychiatry• Misdiagnosis with examples• Do Deaf People hear voices• Assessments – MDT• Inpatient Assessments and Treatment• Interpreting matters
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OUTLINE
A SIMPLE CURE – D.O.H.
• 35% - experienced difficulty communicating with Doctor
• 28% - difficult to contact their surgery to get an appointment
• 35% - left unclear about their condition
• 33% - unsure about instructions for medication – taken wrong amount of a medication
• 19% - missed more than five appointments in a year
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38.1% Deaf Population (S. Ridgeway)
12-17% Non-Deaf Population
GENERAL HEALTH QUESTIONNAIRE
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Communication is an influential determinant of inequality of access to, engagement with
and benefit from psychiatric services
COMMUNICATION
BHUI et al (August 2015)BJPsych
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• Persistent inequalities• Lack of engagement• Poorer access to effective services• Psychological interventions• Conflict between patients and staff
MINORITY ETHNIC GROUPS
BHUI et al (August 2015)BJPsych
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• Communications provide information • Deal with uncertainty/reassurance• Changes to the care to remedy dissatisfaction• Questions can also be helpful for patients who may
fear what is happening and that no one can help
IMPROVED OUTCOMES (1)
BHUI et al (August 2015)BJPsych
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• Communication is central to psychiatric assessment• Diagnosis, treatment adherence and recovery• Professionals struggle to empathise, assess the
patient’s emotions and understand symbolic and metaphorical idioms of distress
IMPROVED OUTCOMES (2)
BHUI et al (August 2015)BJPsych
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• Compromise clinical decisions/accurate diagnosis• Lead to disengagement/poor compliance• Cultural competence in communications• Explore patients’ narratives about their illness
IMPROVED OUTCOMES (3)
BHUI et al (August 2015)BJPsych
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• Diagnosis and Assessment• Discussion of treatment expectations• Understanding and empathy • Psychological interventions• Rely on conversation and challenging cognitive bias
THERAPEUTIC COMMUNICATION
BHUI et al (August 2015)BJPsych
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• Practical changes to the venue• Modifications of the content of written materials• Interventions in terms of language or metaphors• Use of Interpreters
ADAPTATION
BHUI et al (August 2015)BJPsych
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I.N.C.L.U.D.E.
• Intervention with• No• Communication• Leads to• Undermining the Rights of• Deaf People to• Equality
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IF YOU TALK TO A MAN IN A LANGUAGE HE UNDERSTANDS, THAT GOES TO HIS HEAD.
IF YOU TALK TO HIM IN HIS LANGUAGE, THAT GOES TO HIS HEART
Nelson Mandela
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DEAFNESS AND MENTAL HEALTH
Possible Misdiagnosis
• Deafness mistaken for Intellectual impairment• Mental Illness can be missed• Mental Illness diagnosed where none exists
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EEC STUDY – CHILDHOOD DEAFNESST MARTIN ET AL
• 3000 – Children
• 29% – Disability • 9.9% - Intellectual impairment
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MINIMAL SIGN LANGUAGE
Deaf people in mental health settings often have language dysfluency
• Some Deaf lack general knowledge/information
Exacerbated by:• Learning Disability• Communication breakdown• Impoverished emotional environment• Lack of access to appropriate education/poor incidental learning• Poor interpersonal and social relationships• Psychotic Processes
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Dysfluency Compared
DeafHearing
Incoherent MLS Compre- Proficient Fluent Eloquent hensible
Professor Robert Pollard – University of Rochester
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DO DEAF PEOPLE HEAR VOICES
• Residual Hearing• Phantasmal Voices• Tinnitus• Hallucinations of Communication• Analogous to Auditory Hallucinations• Hallucinations in Sign Language• Auditory Hallucinations
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Non Psychotic
Psychotic
AUDITORY PHENOMENA
• Tinnitus
• Phantasmal Voices
• Residual Hearing
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People born profoundly deaf
• Can understand the voices
• Voices are non-auditory – no sound, no pitch, no volume
• May see image of hands signing, lips moving or even vague figure
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J Atkinson
J Atkinson
J Atkinson
J Atkinson
J Atkinson
J Atkinson
EPIDEMIOLOGY
• Same incidence of Schizophrenia as hearing people
• PD and Behaviour/Adjustment problems increased
• More likely to have Organic Syndromes
• Not less likely to suffer from depressive or neurotic disorders
• No more likely to suffer from paranoid psychoses
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Mental Illness
Pervasive Developmental Disorders
Problems Related to Deafness and Communication
Personality Disorder
Learning Disability
DIAGNOSIS
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0
10
20
30
40
50
60
5 10 15 20 25 30 35 40 45 50 55 60 65 70 75+
AGES OF 250 REFERRALS
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ASSESSMENT VARIOUS SETTINGS
• Outpatient Clinics• Domiciliary Visits• Other Hospitals• Court Reports• Prisons/Remand Centres• Probation Offices/Solicitors
• Residential Centres for Deaf People• Schools and Colleges for Deaf Children• Deaf Clubs
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ASSESSMENT OF DEAF PEOPLE
• Deafness and Development• Modes of Communication• Family Dynamics• Social / Relationship• Intellectual Ability• Educational Issues• Mental Disorder / Behaviour• Forensic Issues• Psychosexual Issues• Deprivation
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MDT ASSESSMENTS
• Mental State Assessment Psychiatrists/Psychologists• Risk Assessment Nursing Staff/Assistants• Social Care Assessment O.T./Art Therapist• Psychological/Neuropsychological SALT• Speech & Language Assessment Social Workers• O.T. Assessment Administrators• Community Assessment Interpreters• Family Assessments
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• Make questions specific not vague• Ask time questions carefully• Clarify name signs, placement and directional verbs • Ask what signs you don’t know mean• Check understanding• Use experienced interpreters and deaf relay interpreters
How to communicate with Deaf people who are mentally ill
• Limited emotional vocabulary• Limited world view and knowledge gaps• Don’t assume knowledge• Poor literacy• Misunderstandings• Nodding
Be aware of possible
• Awareness of:• Cultural, Linguistic, Psycho-Social Aspects of Deafness
• Understanding of:• Causes, Associated conditions, Deprivation, Development
• Facility in:• Sign Language• Communication Modes
KNOWLEDGE AND SKILLS (1)
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KNOWLEDGE AND SKILLS (2)
• Mental Health Issues• Mental Health Legislation• Forensic Issues• Risk Assessment and Management• Safeguarding
• Actuarial Risk Assessments• HCR-20• RSVP
• File review, psychometric tests • Structured clinical judgement• Factors likely to increase/decrease risk • Risk formulation / management plan
RISK ASSESSMENTS(HEARING)
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Hearing Population
• Actuarial risk assessments valid / reliable • Can be used Deaf population, with caution• Meaningfulness of certain items need to be considered
- Deaf developmental processes • Access to resources• Interpersonal Issues
DEAF RISK ASSESSMENTS
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• Items considered with caution in Deaf assessments • Employment• Early Maladjustment• Deprivation • Personality issues are less predictive of Risk in Deaf
population • Relevance of future Risk in relation to needs and resources
HISTORICAL RISK FACTORS: DEAF
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• Deaf Cognitions• Belief that offence occurred because of deafness• Don’t know/Don’t understand
• Attitudes Towards Hearing People• Negative and hostile attitudes towards hearing people • Paranoia misdiagnosed assessed by Mental Health professionals
• Hearing Environment/Services• Stressful / Poor communication / Isolation• Staff do not have the skills to assess changes of Risk
• Specialist Services requested to avoid mistakes
FACTORS UNIQUE TO DEAFNESS
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DEAF CENTRED THERAPIES
• Therapeutic Milieu• SALT• O.T.• Psychoeducational • Psychological Interventions
Sex Offender Treatment Substance Misuse Work Offence Related Work Anger Management
Group IndividualCBTA
DAPTED
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The environment is a therapy
• We think of tablets and counselling as therapies
• The environment is a powerful therapeutic tool
• Deaf people are particularly attuned to visual inputs
• This means the environment can be an especially powerful
therapeutic tool to help Deaf people achieve mental wellbeing
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H. Miller
The Therapeutic Milieu
• Therapeutic environment in which treatment is conducted• The therapeutic environment could be a source of improvement• The milieu or ‘life space’ provides a safe environment that is rich with social opportunities and feedback from caring staff• The milieu is mindful of the physical institutional, psychological and social environment• The environment is Deaf Aware
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H. Miller
Hearing hospitals do not promote normalisation for Deaf people
• Visually very ‘noisy’• Confusing communication (writing) • No Deaf Awareness• Tired and stressed trying to concentrate• Feel isolated and frightened• Never know what is happening• No Sign Language Users
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Communication
• Subtitles on TVs• Use of pictures in signage• Visual materials displayed• All written materials are simple and avoid use of jargon• Pictures of staff are displayed• Visual timetables of activities
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H. Miller
Communication
• Deaf staff work on the ward
• All staff learn Deaf awareness and Sign Language
• The ward has a Signing Policy
• Staff and patients work closely with interpreters who
have expertise in mental health work
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H. Miller
ROLE OF INTERPRETERS
• Professional Sign Language Interpreters (NACDP)
• Training in Mental Health and Deafness
• Interpreter must be familiar with language dysfluency
• Regional Variations
• Do not use well meaning friends/relatives/staff
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KNOWLEDGE AND SKILLS INTERPRETING IN MENTAL HEALTH SETTINGS
• Recognised qualifications, Registration with National Body• National Register of Communication Professionals working with Deaf and Deaf Blind• Ability to modify language – Language Deprivation• People with Learning Disabilities, ASC• Dysfluency / Minimal Sign Language• Information as signed – not try to make sense (Psychoses – Thought Disorder)
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DO’S AND DON’TS
• Speak to and look at the Deaf person (not the Interpreter)
• Discuss with Interpreter prior to interview
• Clarify terminology and jargon
• Be aware that everything you say will be interpreted
• Assessment takes longer than with a hearing person
• Book 2 Interpreters/Breaks
DO
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• Use the third person e.g. “is he saying this?”, “Ask him”
• Ask Interpreter to comment on patient’s mental state
• Feel de-skilled if lack of coherent responses/simplify/clarify
• Feel embarrassed if asked to rephrase questions
• Accept ‘nodding’ as evidence of understanding
DO’S AND DON’TS
DO NOT
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CHALLENGES FOR INTERPRETERS
• BSL - articulate, emotive, descriptive, full of nuance
• Deaf people with mental health issues can have limited communication
• Proportion of Deaf population have ‘minimal language’/Dysfluency
• Idiosyncratic sign language/family home signs
• Finger spelling but words misspelt
• Not been given enough context to interpret
• Do they step out of role – to intervene
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OPEN INPATIENTBEDS IN UK
(16)LONDON
(12)BIRMINGHAM
(14)OLDHAM
(18)MANCHESTER
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RAMPTON HOSPITAL
HIGH SECURE
NOTTINGHAMSHIRE
DEAF SERVICES SINCE 2011
MANCHESTERLONDON
BIRMINGHAM
ALL SAINTS
ST ANDREWSNORTHAMPTON
MEDIUM
ALPHABURYLOW
ST MARYSWARRINGTON
MEDIUM
ALL SAINTSOLDHAM
LOW
FENCE
FENCE
12
24
4
6
OPEN
OPEN FORENSIC
REHAB
46
14
10 BEDS
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COMMUNITY
• Outpatient programmes
• CPN and Domiciliary Treatment
• Advocacy and Counselling
• Occupational Therapy and Home support
• Day Centres
• Residential Centres/Hostels
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Family
Social Worker
Local Doctor
Hospital Doctor
Hospital Ward
HEARING
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Family
Local Doctor
Hospital Doctor
Hospital Ward
Social Worker
DEAF
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Resp
onse
to T
reat
men
t
Team Effectiveness
Initial Provision
Pseudo Team
Potential Team
Real Team
Highly Effective
Team
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EDUCATIONAL ROLE
• Post Graduate Trainees• Psychiatrist/GPs• Audiologists• Speech & Language Therapist
• Social Workers• Counselling Certificate/Diploma• Mental Health and Deafness – Deaf Studies• Training Days – Open Days• Conferences
• BSMHD/ESMHD/WFD• Placements
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REFERRAL FROM A GP(1987)
“This deaf man has been very aggressive and challenging. He may be Schizophrenic,
mentally retarded or anything. Please do the necessary.”
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“As Ms Smith is profoundly Deaf, I would be grateful if you could possibly arrange for her to see a trained counsellor, who is able to do
sign language with knowledge of the deaf culture”
REFERRAL FROM A GP(2006)
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LUNCH
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