Mental health training in Somaliland - Day 12

Sunday 29^th September

I join the team and head into the office to prepare some of the medical student teaching.  Whilst at the office, I have a meeting with two doctors from Somaliland, who have been undertaking Masters courses in Ethiopia. They are here for the next two weeks, carrying out data collection for some research they are doing as part of their programmes – looking into attitudes of healthcare workers towards mental illness. In 4 months time, they shall both return to Somaliland and will no doubt be an incredibly valuable asset to their country. They will be specialists in mental health and this is very much needed in Somaliland where there are currently no psychiatrists. We discuss the issue of supervision and their potential involvement in the supervision of the final year medical students and junior doctors, which is a very important subject at present here. We review some potential learning outcomes that may potentially form part of the 6^th year medical student portfolios in the future, should psychiatry be included as a discrete module on their final year curriculum. 

It is an absolute pleasure to meet two such enthusiastic and energetic doctors, who have a passion for mental health. They have also developed research experience which is very valuable, as there is currently little in the way of epidemiological or other data where mental health is concerned. These two are keen to commence some research when they return which would be great for Somaliland. This is exactly what is required here and we agree to keep in contact in the time they are here and beyond, to try and work together to help them in their tasks ahead.

The afternoon is spent teaching the final year medical students. Today we discuss and practice how one might break bad news in a medical/ psychiatry consultation and think about how one would approach this task in an examination scenario. 

Mental health training in Somaliland - Day 11

Saturday 28^th September

Today is spent developing resources for the upcoming medical student teaching. I review OSCE scenarios and MCQ examination questions which have been sent and reviewed by doctor colleagues both abroad and here in Somaliland. It is vital that the questions and exams are appropriate to the context, as many things differ. Khat consumption for example, is an important part of people’s daily lives here. Every afternoon, huge trucks of it can be seen being unloaded and distributed to all the small khat stalls dotted along the roads. Khat contains an amphetamine-like stimulant called cathonine which in the short term leads to euphoria, though it can also predispose to psychotic symptoms. It is an important issue when thinking about mental health/ illness in Somaliland as it is not uncommonly a co-factor to consider if a person presents with psychosis.

I spend the day also reviewing the feedback from the TOT Mental Health Skills Training course I led alongside another doctor here over the last week. The doctors who participated in the course were very happy with the outcomes and felt they had learned much from the course, which is the best outcome I could have hoped for. I also gained much from the whole process of designing, developing and organising this course in terms of leadership and team work skills. I also developed my own teaching skills and learnt much from the participant doctors on the course, with regard to teaching in Somaliland. 

Khat Stall

Mental health training in Somaliland - Day 10

Friday 27^th September

Today is the last day of the Teaching the Trainers Mental Health Skills Course. The students were due to have the last day tomorrow, though expressed that they wished to complete the course instead today, which is usually a holiday.  Participants lead the re-cap session first thing in the morning, something they have improved at greatly during the course of the week. They comment that they have developed an increased confidence when teaching their peers, something they found daunting at the start of the week. This renewed confidence is visible by the rest of us and will stand these doctors in good stead during their careers as hard-working doctors here in Somaliland, where the pressures on them are great, given the need for their services.

The doctors have all, in their groups, prepared a teaching session for the rest of us, using a learning resource as a focus for their teaching they are using the WHO document mhGAP-IG, which is an intervention guide, developed to aid non-specialists manage neurological, mental health and substance misuse disorders. Today, the doctors’ focus is on how they can teach effectively using this resource. In order to really test their teaching skills, we as an audience challenge them, with more difficult questions, distractions and interruptions to their teaching. This is a fun but also useful exercise, utilised to try and take them one step further. I am pleased to witness the doctors meeting the challenge and overcoming them, testament again to how much their confidence has increased during the week. We talk more about how one might broach teaching difficult topics in Somaliland, mental illness being one of these such topics, and in pairs they present challenges faced in teaching about mental illness and ways in which they might overcome such challenges through their choice of teaching techniques. Again, the participants demonstrate both imagination and creativity when presenting their ideas. I am truly impressed by the doctors who have attended this course. The hope is that they may go on and act as leaders for their juniors, that they may pass on this knowledge and supervise others who may then rise up into the same roles.

The doctors complete various post-course questionnaires at the end of the day, in order that we can review the course and improve it for next time. A number of doctors also take part in post-course filmed interviews, which can act as a record of their views and expectations both before the course began and afterwards. They comment that they are happy with the way the course has gone and most of all their own progress. We award certificates to those that have attended and agree to meet later in the week.

I am pleased with the outcome of the training and will use the very helpful feedback from the doctors in order to improve the next training. It is likely that this training will be continuing in Somaliland, in order to allow the doctors here to take this lead role in their chosen specialties. 

Mental health training in Somaliland - Day 9

Thursday 26^th September

Again, a participant starts the day for us by re-capping on the previous days activities and exercises. I am pleased with the groups feedback and their delivery of this to their peers. There is an incredible respect shown between member of the group, which makes for a safe and enjoyable learning environment for them all, something that is integral when running a course of this kind. The participant led teaching session today concentrates on using OSCE/ role as a teaching technique. This has not always been used here, though is one that doctors and students enjoy and is also an incredibly helpful teaching method as it tests many different skills at the same time. The groups work well in a team and prove that they have thought about their teaching, organisational leadership and presentation skills. We visit the mental ward at the hospital for the third time this week. Each day a different doctor has led the teaching on the ward and each day they are met with new and different challenges of teaching in a clinical environment. This is useful, as they appreciate that it is not always as simple as it sounds in theory. The fact that they have practiced these skills all week has really led to them getting a feel for the challenges of each, something that is very difficult to appreciate just through learning about the theory. 

Mental health training in Somaliland - Day 8

Wednesday 25^th September

Now over half way through the teaching the teachers course. Today the groups teach the rest of us using group work/discussion as a teaching technique. They seem to really enjoy the practical aspects of the course and as such, I am tweaking the course as I go along, to match both their enjoyment and also the learning objectives we have set. Dr Mariam cannot attend today, as she is meeting with the Ministry to discuss her role as lead for STI’s in Somaliland. A few of the doctors we know have now started to work within the Ministry; Mariam, a previous mental health rep, who is helping me with the organization of this course is one of those. She previously worked in Hargeisa Group Hospital, though does so less now. Dr Abdirazak, also a previous mental health rep, now also works with the Ministry, as lead for mental health. I hear from him today, as he is also busy in meetings, though hopes to come by and witness some of the teaching at some point this week. 

Dr Abdirazak was, when I last visited in May 2013, working closely alongside the mental ward at Hargeisa Group Hospital and had much to arrange for our students to get clinical experience on the ward with patients. Today we visit the ward again. This time a course participant leads the teaching session, as an example of how one might teach in a clinical setting. The participants soon find out that putting into practice the theory is often much harder than it seems. We are met with a number of challenges, including it being lunchtime on the ward, to having enthusiastic patients wish to join in our discussion. Today we meet with Mariam and Mustafe, who are nurses on the ward and do much for the patients here. 

There have been significant changes on the ward over the last few years. Up until 2010, patients were still chained, now  they are not, which represents a huge leap forwards in how mental illness is viewed, even by those working in it. Mariam and Mustafe ask that I come back and conduct some training on the ward. I agree that I will explore whether I can come back next week and do some then. The course participants then work in groups to explore how they might lead or design a teaching course. Many questions and feedback are generated from this exercise and I am thrilled that now they are starting to get the hang of more analytical ways of thinking and expressing themselves through feedback. 

The afternoon is spent with the 6^th year medical students who are keen to practice their OSCE skills. We do a number of role plays, with them acting as both doctors and patients and also discuss their ongoing online supervision and tutorials on Medicine Africa, an online learning portal which adds and follows-up their training in country. They will all begin online courses with Medicine Africa. 

Mental health training in Somaliland - Day 7

Day 7 - Tuesday 24^th September

The Mental Health Skills Training Course continued for the second day at Hargeisa Group Hospital today. It is a joy to see the participants develop and become more confident, as they try out teaching techniques and move away from using only familiar techniques. Giving and receiving feedback and constructive criticism is something the doctors are not as comfortable with and so we spend some time practicing this. We visit the mental ward in the hospital grounds, in order that the participants can explore how they might lead a group of students if they were teaching in the clinical setting. The doctors appear calm and confident on the ward and I remember back to last year during their psychiatry course when many of them stated how scared they were to go onto a mental ward.  It illustrates their opinions and attitudes have changed. I see a patient who was there in May when I last taught on this ward. She is a young female with learning disabilities who now unfortunately lives on the ward as her family cannot look after her. She is happy to see us and spends much time watching the doctors carefully as they answer questions asked about teaching. 

Mental health training in Somaliland – Day 6

Day 6 - Monday 23^rd September

An early start to begin the Mental Health Skills Training course in Hargeisa. This is a ‘teaching the trainers’ course.  I shall be teaching mainly new doctors and junior doctors teaching skills that they may utilise in their own practice. This is the first time such a course has been run in mental health and it is an exciting opportunity. 15 participants attend, and I find I know many of the participants as they were medical students when I taught in 2012 in Somaliland. It is a real privilege to be here and to be able to facilitate their development further. They have all recently graduated as new doctors. 

Also on the course are more senior doctors who wish to improve their teaching skills. Many of the course participants comment that they have rarely taught using techniques other than lectures/ powerpoint, and they are keen to learn. They are also aware that their involvement in the course has changed, and rather than being passive recipients of information that is given, during this course they will all be practicing their teaching skills. Some are confident, others a little more nervous, though as the day progresses, I am impressed by their level of interaction. We spend today thinking about what makes a good teacher, what skills a teacher needs to use, what different roles a teacher may take on and how teaching is very much linked to professionalism, leadership, team work, supervision and audit. Most doctors were not familiar with audit, something which is very much needed here in Somaliland to improve the quality of services. 

Mental health training in Somaliland - Day 5

Day 5 - Sunday 22^nd September

This morning begins with a meeting with the Dean and the head of clinical work at Hargeisa University, to discuss the upcoming medical student teaching. This year we are due to teach a total of 68 5^th year medical students, which is a record number. We will have to adapt our plans to facilitate this number and the meeting discusses such plans.  Following this meeting I head back to the THET office where I take part in a filmed interview with Naj, a Somalilander, who currently lives in London, though is undertaking a placement with THET to document the work we are doing. She would like to film my current work as a volunteer and the interview is focused on my current hopes and expectations for my extended trip. 

Mental health training in Somaliland - Day 4

Day 4 - Saturday 21^st September

Further preparation for the teaching on Monday. I meet today with a previous mental health representative, Dr Adam, at the Mansoor hotel. Dr Adam was previously chosen for the position of mental health rep as he was keen to learn more about psychiatry and teaching.  Mental health reps are newly qualified doctors, who are chosen competitively each year for the position. They assist KTSP in the annual teaching of medical students, which gives them the opportunity to improve their teaching skills and gain leadership and team working skills.  They also participate in online supervision and act as mental health advocates in Somaliland amongst their peer group. Many previous reps are still heavily involved in psychiatry/mental health work, and some have made great progress with projects they have started and published articles about their work.  

Mental health training in Somaliland - Day 3

Day 3 – 20^th September 2013

The weekend in Somaliland is Friday and so I spend today preparing for my course on Monday, emailing friends, having Skype discussions with those in more distant places. I also receive supervision from Dr Susie Whitwell, Consultant Psychiatrist and Lead for KTSP. 

Mental health training in Somaliland - Day 2

Day 2 – 19^th September 2013

An early start in the THET office to meet with the team to discuss my schedule for the next 8 weeks. The time will fly by I have no doubt, as every day is planned out.  Dr Mariam, a member of the mental health group, also joins the meeting. She has been busy organizing participants for the Mental Health Training Skills course we shall run next week in Hargeisa. I work alongside Samatar to get the resources we will need ready, and we discuss how we might manage a potential of nearly 70 5^th year medical students to teach at the end of my trip. I communicate via telephone and email to Dr Jibriil in Borama, who is working hard to prepare those in Borama for the upcoming courses. 

Having conducted a final Skype interview yesterday for a potential applicant for the yearly position of mental health rep, we make the final decision today. Mental health reps are two newly qualified doctors, who are chosen annually via a competitive and standardized application process and who will take an active role in the teaching of psychiatry to medical students later in the year, as well as take a lead role in the advocacy of mental health in Somaliland. They are offered mentorship from seniors in the UK via the platform Medicine Africa and so gain added skills in team work, leadership, teaching and management, all of which are integral to any career they may later choose in Medicine/ Surgery. This extended trip of mine means that I will be available to work more closely with them prior to the annual medical student teaching, which this year will occur earlier than usual in October. 

I finish up my day by talking with Naj, a Somalilander who currently lives in London and is a documentary film maker. She is currently working alongside THET to develop a documentary detailing their work and my journey, with others who shall follow me. We map out potential opportunities during my trip for filming and we arrange to meet on Sunday for our first interview. 

Mental Health training in Somaliland - Day 1

Delivering Psychiatry Training in Somaliland

Dr Lauren Gavaghan is a Specialist Psychiatrist and Mental Health lead for the King's THET Somaliland Partnership (KTSP). She is spending eight weeks in Somaliland as a volunteer teaching Mental Health (MH) to medical students and delivering a Training of Trainer (TOT) course for MH focal people and Medical Faculties.

Everyday until the 8th November Dr. Gavaghan will be posting a new diary entry on the THET blog page to give readers a unique insight into delivering mental health training in Somaliland. 

Here's the first...

 Day 1 - 18th September 2013

Arriving from Nairobi on the ECHO humanitarian flight was a familiar journey this time. I have visited Somaliland twice before as a volunteer, working alongside THET, though only for 2 weeks at a time. This time my trip is for 2 months. I am excited, yet also a little nervous given the longer time period and the fact that this time I leave the UK alone- with co-workers arriving later on during my trip to work with me.

I am pleasantly surprised by the new runway at Hargeisa airport, which makes for a softer landing than in May when we landed in the bush.

As always, I am greeted at the airport by the driver from THET, who rapidly teaches me some Somali on the way to the THET office, which I rapidly forget!

I meet the team, most of whom I have met before and at once feel at home again. Samatar, the Logistics and Security Officer runs me through a further security briefing and the logistics of my extended trip. I also meet with Thomas the Programme Manager and Wario, the Country representative.  A number of emails and phone-calls later, and I have plans for the following day, to meet with members of the Core Mental Health Working group, a group made up of doctors who have an interest in mental health, many of whom have been mental health representatives in the past and continue to advocate for better mental health in Somaliland. 

Students in Somaliland receiving mental health training

To find out more about THET's work in Somaliland, visit our Somaliland Programme page.