Dr Nicola Holmes
Dr Nicola Holmes

I would like to share a few “scripts” and ideas from my last decade of working with complex mental health patients and youth. The therapeutic relationship is, itself, healing. Wise words from a mentor of mine -  “don’t just do something, sit there'' - remind me of the importance of silence and space within consultations with those in distress. 

Suppressing the urge to “fix” and “solve” is a hard instinct to overcome. Having always the curiosity of “what has happened to you” rather than “what is wrong with you” enables engagement. For patients with high ACE (adverse childhood experience) scores your medical consultation room is sometimes their first real-life experience of unconditional regard and respect as a fellow human being. Particularly with traumatised patients safety trumps everything else. You don’t get honesty without a feeling of safety. Without honesty your history is patchy, without a good history we lose our ability to craft a useful collaborative plan of “what needs to happen next”.

Your brain is like a 3D city. Roads like nerves intertwined and crossing each other. Messages are like cars travelling all day and night. Traffic lights in the brain are chemicals that allow the cars (messages) through junctions. If you biopsy someone’s brain with psychological distress (insert diagnosis here if you are diagnosis orientated) you will find a few differences. 

Firstly, there are not enough traffic lights, and like any city, e.g. Sydney, the “city” functions differently when there are less or no traffic lights. You can build up traffic lights by simple things such as exposure to sunlight, exercise, good sleep routines, healthy nutrition and of course medications such a SSRIs. 

The other difference is that often you get stuck going around on the same little goat tracks, e.g. “everyone thinks I’m fat and ugly”. To build new roads and put detours around unhelpful paths you are overusing, takes time and practice, like learning a new language, sport or musical instrument. This process is supported by psychologists and other mental health professionals to help coach these changes along. 

The goat tracks you may be stuck on are often formed in early childhood in response to your individual environment. Exposure to traumatic events as a child are like earthquakes in the CBD construction zone and the use of drugs and alcohol can also cause significant ongoing rexcept for lookingoad damage, potholes and erosion.

Thoughts come into your mind like sushi on the sushi train. You don’t often get to control what thoughts pop on the train. Sometimes there are weird random thoughts (especially in OCD) that are not fitting with who you are. You do however have control over whether you take the thought off the train and savour it, smell it, eat it and pay for it. 

Alternatively you can just leave it there to go past, (hmmm fried seaweed; not today). People with anxiety have a habit of taking negative thoughts off the train and totally expanding them out. If you just watch the thoughts go by then eventually they go out of date and are removed from the train. In OCD you need to learn to quickly, sort thoughts into “is that me or is that an OCD thought”. Remember thoughts are just thoughts, not the truth.

People who are anxious are very good at getting everyone who loves them, and even their doctor sometimes, to do things that help them avoid the horrible sensation of dread or panic or fear. This is natural because it feels awful. But avoidance feeds anxiety while decreasing your coping skills and eroding mastery. 

It starts small. For example mum advocates that you don’t need to do news at school in year 2 because it makes you feel yucky and vomit; next it’s avoiding sport days at school: next it’s moving to distance education and before you know it you are that teenager who hasn’t been out of the bedroom for three  years and uses a commode. The solution to anxiety is to lean into it gently and do more and more of what makes you anxious until it doesn’t. 

Panic attacks are totally related to blood carbon dioxide levels. They can be created by rapid breathing for 2-3 mins, and they can be undone by slow (at least 9 seconds – in for slow 3, hold for slow 3 and out for slow 3) breathing for 2 – 3 minutes. 

You can practice this grounding technique with patients. My favourite is the legs up the wall version. You lie on your back with your legs up the wall (they will never forget lying on the floor with the doctor!). Hands on belly. Slow breaths (9 seconds) in and out to make your hands rise up and down slowly. 

Distraction for anxious or suicidal thinking can be useful. I trace around the patient’s hand on a piece of A4 paper. At the top of the page write something like “Safety Plan”. Then ask for names of  three people they can talk to who would leave them feeling more positive after a conversation and list those at the top of the page. 

If they can’t think of any, prompt for lifeline or suicide call back service. (You can write down a script if they need it. For example “My doctor asked me to call you as part of my safety plan”.) Next ask them for two things they like the smell of (write in one finger), two things they like the taste of (next finger), two things they like the look of (next finger), two things they like to listen to (next finger). Be specific, music is not good enough. What song, what artist, etc. - encourage a special playlist for this activity. Lastly, two  things they like the sensation on the skin. Explain when stressed / anxious/ having suicidal thinking (which they will have noticed comes in waves and then settles) they should try to ring people from their list and have a 5-10 min conversation, then work way through the sensory mindfulness exercise doing as many as they can. (Close eyes; it heightens the other senses.)

If appropriate under the hand drawing you may list some emergency medications e.g. 5-10mg of diazepam or 5mg olanzepine wafers, etc. You can do staged supplies e.g. olanzapine wafers 5 mg x 28 dispense in lots of 2 with minimum interval one day from pharmacy X. This means the patient can always have access to a small amount of medication for emergency situations. 

Explain how distress comes in waves and this plan is to try and help them ride over the wave. If, when they get through all the activities they feel a little calmer, then the plan has worked. If, when they work through the plan, they are still escalating in distress then they should call the mental health access line 1800 011 511.  The Beyond Now app by Beyond Blue is excellent in safety planning around suicidal thinking  but I still often use the above techniques.

 A strategy I often use when either I or the patient is feeling stuck is to explain how people know what is important to you by what you do (not what you think or say). It is actions that demonstrate our values. 

There is a list on the internet at Carnegie Mellon University for a Values Exercise. You can write your own or use picture cards (I often use Louise Hays value cards). Whatever exercise you use, the idea is to get a small list of say, three of them. Then brainstorm a specific activity the patient can do between now and the next appointment to build up that muscle. If they choose compassion, perhaps they could buy some food for someone who is begging. If they choose appreciation perhaps they could make and send a card to someone important to them thanking them for their input.

When referring patients to other mental health professionals I ask them to complete two activities to take to the therapist (and I scan to them to the patient's notes). First is to do a genogram and write three descriptive words beside each person, e.g. Mum is creative, disorganized and kind etc. The other is a timeline - on one side of the line are the 10 best experiences they have had and the age they occurred, and on the other side sit the 10 worst things (if not too triggering to do) and the age they occurred. These exercises give an excellent contextual snapshot of a patient and will save a whole psychology session of information gathering.

Lastly, look after yourself. There is very little built into our systems or culture to support those who support the vulnerable and role modelling is the most powerful advice you can give.