Transcript for
Transferable skills and the role of GPs in child mental health assessment

Narrator [00:00:02] Welcome to the Emerging Minds’ podcast.

Sophie Guy [00:00:08] This episode is one of a four part series that sits alongside the Emerging Minds’ e-learning course ‘A GP Framework for Child Mental Health Assessment (5-12 years)’. The course looks at engagement skills, formulation, phases of a child mental health assessment, and the ongoing management of a child with mental health difficulties.

Sophie Guy [00:00:27] Today’s episode features GP and Emeritus Professor Geoff Mitchell. Geoff has extensive general practice experience in the Ipswich area of Queensland and a strong research interest in the role of general practitioners in complex conditions. He joins the podcast series today to discuss the experience that some GPs have of a feeling like an imposter working in the child mental health space, as well as what are key transferable skills that can be brought into this work.

Sophie Guy [00:00:57] Hi, Geoff. Welcome and thank you for joining me on the Emerging Minds’ podcast.

Geoff Mitchell [00:01:01] My pleasure to be here. Thanks for asking.

Sophie Guy [00:01:03] We’re here today to talk about the transferable skills that GPs have that they can bring to their work supporting children’s mental health. Before getting into that though, I wanted to touch on the idea of imposter syndrome and ask you why it is that GPs can have the sense of being an imposter when working in the child mental health space.

Geoff Mitchell [00:01:27] Child mental health is quite challenging. Generally, when people come, they come with their parents and there’s some very significant issue at home or at school that is causing distress. And they’ve tried the things that they normally try, talking to their friends, their neighbours, the teachers. They’ve done all of that. And so they’re coming to you to escalate the care that they need. And the health system, as it stands, is not well resourced for mental health and in particular, child mental health. So the time delay for getting to specialists is, can be quite substantial. But the person who’s talking to you is desperate now and can’t wait another 12 or 18 months or whatever the timeframe is in order to get the help that they need. They need it now and so basically you’re it. And because we don’t have a lot of training in mental health, then we have to do our best with the skills that we’ve got. And you can feel a bit of an imposter, kind of, quote, expert, unquote, hat on where in fact you’re hopefully relying on good common sense.

Sophie Guy [00:02:40] What is the role of a GP in a child mental health assessment?

Geoff Mitchell [00:02:44] Well, we’ve got to try and alleviate the problem that the patient has. And so that means we need to understand the environment that the patient lives in and the child at school as much as possible. We’re in a good position to do that if we had got a relationship with the family. We will have seen them over a period of time and get a good sense of the interpersonal dynamics that are at play, that the socio economic situation that the child is placed in. And over time, things get revealed that can be very, very relevant indeed. So we have good background. We also should know the facilities and resources that are available in our community and, therefore, should be able to direct the child and the parent to the resources that are going to be of greatest help.

Sophie Guy [00:03:37] And I wonder if you could talk a little bit more about the role and where it sits in amongst the health system more broadly. And could you maybe talk a little bit more about the role in the sense of where a family’s at when they come to see a GP about a children’s mental health problem?

Geoff Mitchell [00:03:55] Okay, so the GP is the gatekeeper of the health system. And there are a number of mechanisms that allow for referral to specialists. That includes some Medicare supported allied health and mental health professionals. They have to see a GP and get a mental health plan done by the GP in order to access Medicare support. Depending on the state that you’re in, you require a GP referral to go to a specialist clinic, to a public hospital. And again, it depends where you are as to which of those two systems are the predominant system. Where I work, public is very heavily used. Where I’m in a low socio economic area and we have a low private health insurance base. And so, you know, everything relies on the public system for many people. And because of the burden, they are very much in demand relative to the need. And so, so much falls back on us to try to assist people in desperate need. The other thing, of course, is that in a lower socio economic area, it is quite likely that you’ve got intergenerational maladaption. And so you can actually be a kind of role model for people just by showing them how you can relate to the children that you’re dealing with when you’re relating to them in the practice. So you kind of walk the journey with them. You’ve got to be ready for a long, slow haul. You might need to see them on a very regular basis to get a better sense of the effectiveness of some of the things you’re trying. You might try to change or influence one small aspect of a big problem at one time and try to get that right and then move on to the next aspect of the problem.

Sophie Guy [00:05:48] Mm hmm. Mm hmm. And so in that context that you’re describing of being in an area where there is more socioeconomic disadvantage and people are relying on the mental health system, and in amongst that, you know, this sense of feeling like a bit of an imposter working in this space. What do you actually do, when a family comes in and they seem very distressed and, you know, they’re hoping that you’re going to be able to, you know, solve that problem or help that child. What is going on for you in that consult when you first made a family?

Geoff Mitchell [00:06:21] Well, first thing you say to yourself is, don’t panic. You listen a lot. You try to get as thorough a picture as possible of the situation and the behaviours that are causing trouble, whether it’s in home situation or school or both or other situations. You try to identify stresses that might be leading to a problem, including recent changes in behaviour versus long term problems, which are more likely to be inherent in the dynamics of the family. Something new might have happened. You have to try and work out whether there’s a psychiatric illness there as well. You have to work out the urgency of the problem. Is this a mental health emergency like suicidal behaviour and suicidal ideation? And how severe is it. And do they have other medical problems? So hearing needs to be thought of. Vision. Diet. Are they actually eating appropriately? Were they going to school hungry? Once you work those things out, then you try to channel a parent and the child into the appropriate extra support that they may need. Sometimes it’s a reasonably straightforward and you can work on them with with basic things that maybe they haven’t thought of. Other times it’s quite clear that you need professional specialist help and you have to try then to organise that as expeditiously as possible.

Sophie Guy [00:07:53] And in situations where there are waitlists or there’s some time before that family can perhaps see a specialist in the public mental health system, how do you see your role or the GP role in supporting the family during that time?

Geoff Mitchell [00:08:10] It’s critical because it’s you or no one. And just regular review, regular contact with the family. Having them feel like there’s someone in their corner and that you’re going to kind of walk the journey with them is a very, very important role of our profession.

Sophie Guy [00:08:29] How do you convey that, that you’re, you know, you’re in their corner? If you’re with a family and in the moment, what is it you’re doing. You talked about regular so is it about being like, quite conscientious about booking in the regular appointments and making sure you continue to see them?

Geoff Mitchell [00:08:43] I know some clinics don’t operate on an appointment basis, but we do. I think it’s really important that that happens. And look, you show respect. Often people like this have very poor self-esteem because things are going wrong. You know, they’re parents, they should know what to do. You get judged even by looks around you. By other people saying that you’re not doing a good job. The teachers are on to you. You know, there’s pressure to do something on the parent and yet, if they haven’t solved it for themselves, that means they don’t have the ability to solve it for themselves. So they come to you for help. They come to you for reassurance. Reassurance that they’re not poor people, bad people, that they’re not stupid. There’s things like that, that you have to deal with on a regular basis. And just by showing respect by mirroring good interaction with the kids, showing them that it can be done. Very often, you can settle a child who’s having issues down quite simply with really simple techniques of communication. Having a bit of fun. All sorts of things you can do that allow you to create that rapport with the family and gives the mother, in particular, a sense that they are being listened to and they are respected.

Sophie Guy [00:10:03] Yeah, okay. The next question is perhaps going back again to this idea of imposter syndrome. I wanted to ask you, why do you think it is that GPs can lack confidence in this area?

Geoff Mitchell [00:10:14] Oh, we don’t have a lot of training in it. It takes time to develop good outcomes and often you’re looking at multi-factorial problems. And unless you manage all of the problems then it’s going to be difficult to see the overall problem through to a resolution. So if you’ve got fifteen minutes or ten minutes to try to do that, it’s impossible. And you kind of shake your head mentally and say, well, what do they expect me to do? Look at this. This is really difficult. And yet you’re it. So you kind of do feel like you’re thrust into a situation not of your own making and not where you want to be. But there it is. There you are. It’s a bit like being in, the hero in a movie that sort of stumbled into a disaster zone and it has to be the one that sort of saves the world. That sounds a bit egotistic. It’s, you know, in that little world, their little world, you know, you’re it. And it is a bit like that.

Sophie Guy [00:11:17] Yeah. Yeah. I mean, you’re are seeing people in crises, aren’t you?

Geoff Mitchell [00:11:20] Yeah, that’s right. Unless you’ve got a massive ego, then you’re really challenged by that. You’re really feeling like you’re inadequate, not up to the task.

Sophie Guy [00:11:31] Now I’ll switch to the topic of transferable skills and ask you, you know, what are some of the skills that GPs already have and already put into practice that they can use in this work with children and children’s mental health?

Geoff Mitchell [00:11:45] Well, a lot of what we do is relational. And so from two perspectives, I think that’s very important. The first is that having empathy and being able to speak to the level of the person coming to you is really important and being empathetic and not judgemental. Now they’re skills that are universal and are incredibly important. Communication skills and the ability to mirror them or model them with kids. Not everyone has that. But if you do have it, it’s a very useful thing to have and it can transform the situation from chaos. If you’ve got a mother who’s got one problem child and they bring the whole family because there’s no one else to look after the others. Then you’re looking at a very chaotic situation. And so managing that in order to get to the bottom of it.

Sophie Guy [00:12:42] What do you think are the important communication skills in working with children and in that particular environment where a family is perhaps under a lot of stress?

Geoff Mitchell [00:12:51] Look, I think the first thing is to acknowledge the child and make sure that they are included in the consultation. So, for example, if they interrupt and you try to get information or talk to the parent about something, then you can either say, just a minute. Let me just finish talking to mum, then I’ll talk to you. And make darn sure you do. Or you stop. Settle a child down. Then you get back so that the child’s got some sort of activity or something that they’re focussing on. It allows you then to speak to the parent uninterrupted. [Yeah.].

Geoff Mitchell [00:13:28] Paediatrics is a very skilled and special branch of medicine, but it’s still medicine. It is still a discipline where you have to take a history and do physical examinations and you use your clinical reasoning skills in order to come up with appropriate sort of working hypotheses. And so they’re transferable right across the board. I think life experience is very important. So if you have had kids yourself, you can kind of draw on what worked and what doesn’t when you’re dealing with the person in front of you. Now, paediatric or child psychiatry is an area where the unit of care is the child and the family. And it’s very important to not neglect the family and try to get a good sense of what’s going on there and be able to work with the adults in order to influence the child. And I think that might be underplayed by people.

Sophie Guy [00:14:24] Mm hmm. Are there any other transferable skills that come to mind for you?

Geoff Mitchell [00:14:29] You can learn counselling skills. If you’ve done mental health training, which most GPs who’ve been through the GP training program, have done at least basic training. They’re usually based on adult interactions. But you can transfer things like very basic cognitive behavioural therapy and you can shift from one area of medicine and apply them to some degree to others.

Sophie Guy [00:14:55] Mm hmm. Thank you. And the last question, what in your view can GPs do to start building their confidence with this work?

Geoff Mitchell [00:15:06] Commit to the patient and see them regularly. And avoid the temptation to say it’s too hard and refer on. Absolutely refer on but you know it’s going to take time so why don’t do, do some work while you’re doing it. There’s plenty of resources available. And if you’re in an area of low socioeconomic need, this is a very high prevalence problem. And so it is worth putting the effort in to get the resources, use them. Learn about new techniques that are available and so that you can be of more useful while the specialists come online.

Sophie Guy [00:15:45] Are there any particular resources that you know of? That can be helpful for GPs in the child mental health space?

Geoff Mitchell [00:15:52] In our area, we have a very active paediatric behavioural paediatrician and the PHNs uses him on a regular basis to provide resources and seminars and the like. In Queensland, Project Echo is a project where specialists have regular meetings with GPs who are caring for a particular problem, and they can present cases and get specialist input into the management of those cases. There are a lot of websites specifically for mental health. Probably more adult. Potentially some adolescent health would be more dealt with rather than kids. But they’re out there. And also, of course, specialist letters, letters back from psychologists and child mental health workers. So that you can see what’s done in other cases that you’ve been relating with and you can apply those kinds of skills to other similar cases.

Sophie Guy [00:16:53] So you’re saying you can sort of use them as a source of learning and growing your knowledge in the area? [Yep]. Okay. Is there anything else that you thought of around helping GPs to build their confidence?

Geoff Mitchell [00:17:07] Look, I think, I think you need to be prepared to fail in order to learn. That means you kind of have a boundary around your knowledge. And it’s not fixed. It’s expanding. And so when you get to a case that’s not quite in your comfort zone, you have the choice of referring that on straight away or attempting to deal with it and refer.  Work it up as much as you can. And by doing that and maybe pushing the boundaries of your knowledge and taking. I’ll say taking small risks in how you manage people, you’ll work out what works and what doesn’t. You also have to have a safety net. You always have to be sensible about this. But I think one of the problems that we have in medicine is that there’s a mindset that says if I’m not fully trained, I’m not competent, full stop. But that really is the imposter syndrome. You’re a lot smarter than you think and you’ve got a lot more skills than you think. You just have to commit to using them all as much as possible and to expand them by being logical and sensible in your approach to patients.

[00:18:19] Yeah. Thank you. I think that’s a really great point to end it on. So thank you very much for your time today, Geoff. I really appreciate it.

Geoff Mitchell [00:18:27] My pleasure.

Narrator [00:18:30] Visit our website at www.emergingminds.com.au you to access a range of resources to assist your practice. Brought to you by the National Workforce Centre for Child Mental Health led by Emerging Minds. The National Workforce Centre for Child Mental Health is funded by the Australian Government Department of Health under the National Support for Child and Youth Mental Health Program.