NOTE: these thoughts are based on my experiences - both recently and over the past couple of decades.

There have been improvements to the way mental health care has been provided in general practice.

However, it is my hope that we continue to move toward a more trauma informed model of care.

In the Practice/Clinic/Surgery

complex PTSD = Complex Care 

1.      My logic operates around perceived threat

Ø  Harder to create a safe environment

2.      What may not stress others out may REALLY stress me

Ø  e.g., wait room environment, examination instruments, masks, sudden changes in room layout  

o   need prior warning of changes, treatment modifications (e.g., ways examinations conducted)

3.      Easily overwhelmed

Ø  Write information down, break processes into steps

Ø  Simplify care

o   multiple instructions from multiple people overwhelming

o   the more complicated, the more people involved = threatening

4.      Relationship and continuity of care vital

Ø  cPTSD is chaos

o   need a trustworthy centre point

o   need consistency, predictability

o   General Practitioner (GP) is the safe person

 

Holistic Care: Don’t Cut My Head Off My Body

1.      Physical and psychological should be one package

Ø  Need the whole picture to effectively treat anything

Ø  Physical illness makes cPTSD worse and vice versa

o   impossible to talk about one without the other

Ø  Destabilising to divide brain and body

o   comforting to have physical and mental health treated by the same person

Ø  Ask about mental health at every consult

 

Identify Me

1.      Flag me as having cPTSD

Ø  In my file

Ø  In all referrals (prominently, not buried in a list of health conditions)

o   add specific needs (e.g., female specialist when possible), triggers

 

Advocate, Negotiate 

1.      PROACTIVELY advocate with specialists, allied health, hospitals

Ø  Flag needs, triggers, negotiate workarounds

o   e.g., loose wrist bands in hospital

 

2.      Brainstorm with me safe ways to conduct examinations, tests

Ø  Identify triggers, workarounds

o   e.g., Limit people in the room

 

Consider Accessibility to Mental Health Care

1.      Cost

Ø  Pension/low income limits care

Ø  Cheaper to attend GP

Ø  Increase Medicare rebate

Ø  Extend mental health care plan

 

2.      Transport

Ø  Hyperalert = stressful travel

Ø  Some places inaccessible to public transport

 

3.      Familiarity

Ø  Best if physical and psychological care in same location

o   GP surgery is familiar (so safe) environment

·        already know reception staff, lay out, exits

o   eliminates stress of traveling to multiple locations

o   have a psychologist who works out of the practice

·        safer as it’s someone the GP knows

 

4.      Telehealth

Ø  Pros:

o   physically accessible

o   safe location

o   cheap

Ø  Cons:

o   issues with video technology = stress

·        fear of it failing, complicated multi-step processes, loss of connection during consults

o   less likely to remember what was said during the consult

Ø  Simplify it

o   limit the number of steps in the process

o   if it doesn’t work first try, switch to phone

·        the longer you try to fix it as I wait, the more stressed I will get

Ø  Mixture of telehealth and face-to-face best

 

5.      Mental health programs difficult to access

Ø  Often ineligible for affordable mental health programs (e.g., age, not trauma focused, etc)

Ø  Many psychologists/psychiatrists do not treat severe trauma

Ø  Long wait lists

o   need more affordable trauma focused services

If Referring to Mental Health Services

 

Don’t Refer and Forget

1.      GP to be central

Ø  Familiar (safe) person

Ø  Consistency, predictability

Ø  Everything feels less chaotic

Ø  Need regular GP reviews

 

Recognise the Limitations of the Mental Health Care Plan

1.      10 sessions/year = less than one/month

Ø  Inadequate for cPTSD

o   requires long-term therapy

Ø  Can be counterproductive

o   stirs emotions/memories up and then no support until the following year

Ø  Requires GP monitoring

o   regular reviews – more often than once/year

o   may take multiple referrals to find ‘the right’ psychologist

·        GP is the only consistent person

Psychologist/Psychiatrist and GP ‘Shared Care’ 

1.      Benefits: 

Ø  Can increase number of support people; additional expertise

2.      Cons:

Ø  Mental health services poor at communicating with GP (esp. privately accessed counsellors)

Ø  Danger = Divided care

o   physical and psychological treated separately

·        no consideration to how physical impacts psychological and vice versa

·        psychological care may be sporadic

o   feel abandoned, a hot potato

o   erodes confidence in both professionals

Ø  Traumatic, destabilising when it doesn’t work

 

  

 A Few of My Disasters Over the Past 20 Years*

 

1)     Physical and psychological care divided

Ø  “I’ll leave your mental health for the psychologist to deal with and we’ll just deal with the physical stuff”

o   unable to discuss inter-relationship of cPTSD and health problems

o   unsure who to go to with symptoms – is it psychosomatic?  Who do I ask?

o   poor relationship with GP because she never asked about mental health

2)     My mental health history buried in the list of physical health conditions in my file

Ø  cPTSD assumed to be historical; no longer relevant

o   not flagged in referral to surgeon

·        GP suddenly left practice

§  traumatic hospitalisation

 

3)     GP discomfort

Ø  GP so uncomfortable with mental illness and child abuse that she refused to discuss

Ø  Annoyed whenever I asked for alterations to treatment

o    ‘staff are overworked’. ‘You should have already dealt with it in therapy’. 

·        traumatic hospitalisation

§  GP angry that I ‘caused problems’ at hospital

Ø  Distrustful relationship

o   felt like an important part of me was disregarded

 

4)     GP lack of understanding of trauma

Ø  Did not understand:

o   refusal to be referred to male psychiatrist

o   reluctance for certain examinations/treatment/hospitalisation 

Ø  No negotiation about how care could be made safer

o   ‘Why should there be concessions for you?’

Ø  GP annoyed whenever I freaked out

o   I felt like a nuisance, clammed up

 

5)     ‘Fired’ without warning by two GPs

Ø  After suicide attempt

o   told no GP at that surgery wanted me as a patient

·        distrustful relationship with subsequent GP

Ø  After self-harming

o   despite trauma history was referred to male GP

 

6)     GP agreed to treat me only if I concurrently saw a psychologist

Ø  No communication between the two

Ø  GP not involved except when mental health care plan due for renewal

o   mental health care plan inadequate (10 sessions not enough)

·        no support between plans

·        multiple referrals to different psychologists, locations difficult to access

o   No continuity of care - I felt like no one really cared about me

·        feeling forced into therapy eroded my relationship with GP

·        dropped out of mental health treatment

 

7)     Automatic assumption that ‘it is psycho-somatic’

Ø  a) psychiatrist told me not to ‘bother’ GP because ‘it is probably psychosomatic’

o   physical condition un-investigated, untreated

 

Ø  b) GP assumed physical symptoms (different illness) psycho-somatic because of cPTSD

o   difficulty convincing her to investigate

·        stressed because I thought no one believed me

 

Ø  c) psychiatrist unsure if symptoms psycho-somatic

o   assumed GP would deal with it

o   GP thought psychiatrist was dealing with it

·        I had to self-advocate until it was investigated

 

8)     Overworked GP, lack of services

Ø  No time to deal with mental health

o   long wait list for female psychiatrist

o   ineligible for mental health programs (age, not trauma appropriate, etc)

o   referred to male psychiatrist 200km away

·        unable to attend regularly; reluctant to talk to a male

·        GP too expensive to regularly attend

§  no support, monitoring

(i)     increased self-harm

 

9)     Non-communicative counsellors

Ø  Counsellors accessed without GP referral would not share information (even when I asked)

o   limited time in GP consults to explain cPTSD history, needs

·        GP never had full picture

 

10)  Medication issues

Ø  Psychiatrist did not realise the drug he was prescribing was contraindicated by health condition

o   GP unaware it was prescribed until I told her much later (psychiatrist non-communicative)

11) Telehealth failures

Ø  Complicated processes, technology issues

o   Unable to remember parts of the consults, stressed at even the thought of the appointment                            

 

Some Successes (all recent)

Ø  GP brainstorms workarounds

o   identifies my specific triggers, modifies treatment

·        e.g., arranged quiet place near exit during iron infusion; administered flu shot herself

§  increased psychological safety

o   organised webster pack with chemist

·        removed fear of accidental overdose

o   does mixture of face-to-face and telehealth, rather than just telehealth

 

Ø  GP proactively flagged cPTSD to specialists and hospital

o   in writing and by phone

·        advocated/liaised to create ‘safe’ environment

§  resulted in treatment modifications

o   only non-traumatic hospital experience I have ever had  

 

Ø  GP considers need for predictability, consistency, safety

o   e.g., pre-warned of changes in the surgery environment during COVID-19

o   re-arranged appointment to ensure wasn’t walking home in the dark 

 

Ø  Regular GP reviews incorporating BOTH physical and mental health

o   treated as inter-related

o   every part of me important, cared for

o   GP remains central point of contact with specialists/coordinates all care

·        consistent, safe person

§  reduced fear of treatment, less overwhelmed, more treatment compliant

·        don’t feel like I’m floundering, calm centring point in the chaos, totally supported

 

Ø  GP attitude to mental health

o   willingness to ‘hear me out’, make alterations

o   curiosity about why I may not want treatment, rather than frustration

o   cPTSD not treated as pathological

 

Ø  Good accessibility to services:  Surgery, chemist, pathology all in the same building

o   familiar location – psychologically safer

 

*Different GPs, psychiatrists, health conditions