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The Royal College of Psychiatrists Improving the lives of people with mental illness

Myanmar - Teaching the mhGAP

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20/02/2015 13:08:42


Part One - Yangon

Welcome to the first of a two part blog from Myanmar (Burma) where a group of seven volunteers from the college VIPSIG in conjunction with the UK-based Charity "Mind to Mind" have been training primary care doctors (GPs) in how to use the mhGAP (mental health GAP). This is the WHO training programme to equip healthcare professionals in the fundamental skills in communication, assessment and treatment, mobilisation of social support, attention to overall wellbeing and protection of human rights (CATMAP! for anyone in the know!). This programme is the culmination of at least one year of organisation and training instigated by Dr Nwe Thein, a Consultant Old Age Psychiatrist in the UK, originally from Myanmar, member of the Burmese medical diaspora and founder of "Mind to Mind" Charity promoting mental health awareness in Myanmar, provision of free clinics and medication, and training of healthcare professionals.

The team

Myanmar Mediacal CentreAllow me to introduce "the team". You can see us in the picture attached from left to right: Dr Chris Vassilis (Consultant Old Age Psychiatrist), Dr Nwe Thein, Dr Sophie Thomson (Consultant Psychotherapist, mhGAP and volunteering "Veteran" and our "spiritual leader"!), Dr Brad Hillier (me...Forensic SpR in London), Dr John Tolliday (Associate Specialist, and former Royal Navy GP) and Dr Trizi Baldwin (Consultant Psychiatrist). I did say seven, and the picture shows six. You will meet our seventh team member in Part 2... Mandalay.

The inspiration for the Trip

I know that there had been a lot of behind the scenes thought and effort on Nwe and Sophie's part to arrange a suitable formal training for GPs in Myanmar. I discussed it with Nwe in November 2013 when I attended a mhGAP orientation weekend run by Sophie and Peter Hughes north of Manchester. Earlier that year I had returned from (an unusually highly facilitated) holiday in Myanmar where I had the chance to learn more about the history of the country, its peoples and its challenges. This is a country which will no doubt be familiar to all readers for the current developments in its political situation. That is all I am going to say about that.

Over the following year Nwe through her Mind to Mind Charity worked with the Royal College of Psychiatrists to organise this training. By Summer 2014 things were starting to look likely, and provisional dates had been proposed. mhGAPs had been brought from Geneva, Switzerland, via Springfield Hospital (thank you Peter!) and training dates in Yangon and Mandalay were set up by Nwe through her extensive connections within the medical communities there.

By November 2014 firm plans were in place, and further training days were held at the Royal College of Psychiatrists in Aldgate East (thank you to the College for excellent facilities and food), as well as at my home in South London (with certainly less impressive food!).

After final confirmations of dates, accommodations, venues, attendees etc etc etc the stage was set for all to arrive in Yangon and begin the training.

Training in Yangon

Training took place at the Yangon base of the Myanmar Medical Association. We were privileged to have an opening ceremony attended by the President, Professor Rai Mra, Dr Lin (WHO Representative in Yangon), the Professor of Psychiatry and Dr Myint Oo, Vice Chair of the GP Section. Our "trainees" were 60 GPs working as private practitioners (as all GPs in Myanmar work) in the community; hospital doctors are government employees.

Now for anyone who has not been to Myanmar before, the people are the most incredibly respectful individuals that I have ever come across. The respect for hierarchy, especially within the medical profession, is like nothing I have previously encountered. At the start of the training this, in combination with their being unfamiliar with the interactive group and role play format of the teaching, as well as their being softly spoken, and having to "double translate" from English to their own language, and back to English, were identified as potential challenges. However, with increasing familiarity with the trainers, and establishing a format of teaching with which the groups became quickly comfortable initial shyness was soon overcome. This can be seen from the progression of photos from the early part of the training as compared to the later part!

We trainers did not slavishly follow the mhGAP guide; we had extensive discussions prior to reaching Myanmar concerning particular areas of focus that may be of greatest benefit in the (always) limited time available. In addition, given that the mhGAP is an excellent but evolving document which has not (yet) been translated into Burmese, it was considered appropriate to provide a combination of familiarisation with the manual with some short talks, videos and lots of role play, practising the assessment/treatment/interventions. We also decided during preparation in the UK to incorporate some easy to access psychosocial and practical approaches which may be of immediate use within the context of busy GP clinics where pressures for time are high, and where patients may be under financial difficulties. Therefore, we introduced the GPs to basic psychosocial interventions using the UNICEF hand (five friends you could turn to for your fingers, two things you could do on your creases, and two sayings you could use to make yourself feel better on the wrist creases).

As a primarily Buddhist country, meditation and mindfulness are well established culturally integrated practises. It was possible to readily translate and demonstrate how these could be used as relaxation techniques for distressed, anxious or depressed patients, and this was the source of some extremely interesting discussion about their use in Western countries. An introduction to "Motivational Interviewing" was described as an approach for communication in both situations relevant to substance an alcohol misuse as well as towards general communication in the GP clinic, and simple problem-solving skills were taught. We even had opportunity to teach and practise through role play simple family interventions and psychological first aid. All of these were within the context of the core mhGAP target areas within the manual.

The level of laughter and fun increased throughout the week and we as trainers were touched by the level of engagement, gratitude and courtesy with which we are welcomed by the attendees and hosts. A particular mention should go to Dr Myint Oo who provided the organisational contact in the MMA, and his wife who provided superb catering every day. Dr Myint Oo appears to be working tirelessly with his connections from all around the world to develop a robust CPD programme within the MMA, and this has attracted support and attention from other medical Royal Colleges such as the Royal Colleges of Pathologists, Physicians and GPs amongst others from the USA, Australia and elsewhere. It is even possible for some aspects of the MRCP examination to be taken by Burmese Medics again owing to the strong connections within the MMA and the RCP, with a number of the Professors having trained in the UK. No doubt this will be an area of consideration for the Royal College of Psychiatrists to reflect on in light of our medical colleagues' experiences.

Pictures really speak a thousand words, and short of describing blow by blow the training in any more detail than above, I would invite readers to glance through the photo record of the training attached to this blog. And to reflect that Myanmar has quite possibly one of the slowest internet connections in the entire World. Seriously, I believe I have had better connection on Pacific Islands and Sub-Saharan Africa. Be grateful for the upload time!

Other highlights

There are some further highlights that I would like to mention here: The kindness of our hotel host, (Dr) Ko Khaw, who invited us to a rooftop FEAST at his family's Hotel Novel, with an exquisite selection of Burmese food in a fantastic setting. Also his excellent standard of service in his hotel. (After this a few of us went to a local Peace Festival which we  had noticed the previous evening - this interesting experience resulted in us being invited backstage to the dressing room of a famous Burmese Dance Troupe as honoured guests, which I believe included being filmed for the television! This was a lovely example of how being taken as white people by a local resulted in something that if we were not together would never have happened through being unable to speak the language and/or feeling unsafe or unsure of what was going on).

As I write this during the days between training events, the group has taken the opportunity to visit some of the most famous and spiritual sites in Myanmar, including the temples of Bagan and the Inle Lake region. I remain in Yangon where I have had the chance to visit the sacred buddhist pagodas at Shwe Dagon and the Golden Rock, sample Myanmar cuisine, and even have a visit to the Yangon psychiatric hospital including a guided tour of the forensic unit. The conditions, and levels of security are VERY different, and I find myself wondering even more what it is possible for US to learn in our approach to mental health problems and care as opposed to our considering it natural that we adopt the role of the teacher/experts.

I have also been fortunate to meet ex-pat friends of friends which has in turn led to my meeting local people. I have been repeatedly humbled by the kindness, warmth and hospitality of the Myanmar people at every step, and already this country and its people hold a special place for me, a connection that I hope can become a part of my future career.


Check back soon for part 2 - Mandalay!



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Bradley Hillier







Dr Bradley Hillier is a Specialist Registrar in Forensic Psychiatry in South London. Working with Mind to Mind Myanmar (M2MM) and the RCPsych this year is his first overseas volunteering project.

Brad has an interest in international psychiatry, especially forensic issues, and psychotherapy. This volunteering project is hopefully the first of many in the future!