Tots Manual
Tots Manual
Tots Manual
mhGAP Training
of Trainers and
Supervisors (ToTS)
Training manual
ToTS
Introduction
to the Training
of Trainers and
Supervisors
training manual
mhGAP Training of Trainers and Supervisors (ToTS)
training manual
Introduction to the ToTS training manual
The mhGAP ToTS training manual has been designed to support implementation of the
World Health Organization’s (WHO) Mental Health Gap Action Programme (mhGAP) and to
ensure that future trainers feel skilled and confident in their ability to train and supervise
health-care providers to assess and manage priority mental, neurological and substance use
(MNS) disorders. In particular, an emphasis has been placed on interactive and contemporary
teaching and supervision skills.
The interactive teaching skills taught during the ToTS training are the same as those used in the
mhGAP Training of Health-care Providers (ToHP) training manual. Thus, the ToTS participants
can learn and practise using these teaching techniques whilst familiarizing themselves with
the mhGAP ToHP training materials. Time has been built into the ToTS training to ensure that
participants receive and can integrate feedback from their peers and the master trainer as
they learn and develop their skills as trainers.
The ToTS training also includes a module on supervision, where the participants will identify
the best method of supervision for their area, and start planning implementation.
mhGAP Training Manual for the mhGAP Intervention Guide for mental, neurological and substance use disorders in non-specialized health settings –
4 version 2.0 (for field testing)
Figure 1. Graphical representation of mhGAP training manuals, with the Training of Trainers and
Supervisors (ToTS) training manual and the Introduction to the ToTS training manual highlighted
Resources
available mhGAP Training of Trainers and Supervisors (ToTS)
to master training manual
trainer
Resources Resources
available available
to master to participants
trainer and mhGAP Training of Health-care Providers (ToHP)
ToHP trainer training manual
Introduction Modules
ToHP
to the ToHP ToHP training
participant’s
training ECP DEP PSY EPI forms
logbook
manual
CMH DEM SUB SUI OTH
Introduction 5
Who is this manual for
This manual is designed for use by master trainers to train future mhGAP-IG trainers and
supervisors. Master trainers are specialist (psychiatry or neurology) physicians or nurses
trained and experienced in using the mhGAP-IG, and/or existing supervisors within the non-
specialized health setting.
This manual should also be used with the mhGAP Intervention Guide (mhGAP-IG), and the
mhGAP-IG ToHP training manual, including the ToHP participant’s logbook.
While this manual has been developed based on extensive feedback and expert consultation,
we recognize that it will need to be adapted to each setting based on cultural context and
feasibility.
Material may need to be translated into the local language, and master trainers should be
aware that this may change the timing of the modules. A timed run-through of the modules
is recommended before the training.
When adapting the ToTS training to local context, care should be taken to avoid adding or
removing slides, eliminating activities or interactive components, or removing the opportunities
for participants to practise these skills. Instead, person stories, role plays, multiple choice
questions (MCQs) and video demonstrations which best suit the local context should be
chosen, or master trainers may wish to find or create their own.
There are several options available should the course need to be shortened. Importantly,
interactive activities should not be removed, but instead:
• Days can be extended with earlier starts and later finish times.
• If the group is very familiar with mhGAP-IG, the introduction on Day 1 can be delivered
quickly, and combined with the session on implementation. ECP can also be shorter and the
day can finish with an introduction to mhGAP ToHP training methodology.
• If the group is experienced in teaching, the training skills modules can be shortened and/
or combined.
• Homework can be set, particularly practising the training skills and preparing for the
participant facilitation exercise (ie. Day 2 and 3).
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• The participant facilitation exercise can be set for a shorter time, or the groups can be larger
(so there are fewer presentations).
When preparing for the ToTS training, the master trainer checklist (see table 1) can be used
to ensure nothing is missed from the planning.
ToTS participants
A group size of 15-16 is considered appropriate for ToTS training.
Ideally all ToTS participants will be familiar with, and have experience using, mhGAP-IG in
their clinical practice before attending a ToTS training. In many settings however, this may
not be the situation. If the ToTS participants are not familiar with mhGAP-IG, consider:
• Conducting a separate mhGAP Training of Health-care Providers (ToHP) training
• Ensuring that all participants read the mhGAP-IG before attending the ToTS training.
Before attending the ToTS, participants should also complete a training needs assessment
(see ToTS supporting material and training forms) of their own local context.
The following steps will help participants feel comfortable early on in the training:
1. Allow the participants some time to meet the master trainer and other participants before
the training starts, ideally over a casual meal.
2. Explain expectations early, including how long the training will take, that some evening
work will be required (particularly Day 3, or more if the training is condensed), and ongoing
expectations about the ToHP training and supervision.
3. Reassure the participants that the interactive teaching style may seem daunting, but will
be rewarding and invaluable for their skills and confidence-building.
4. Agree on common ground rules on how they will treat everyone in the group.
Training guidelines
1. Understand the local health-care system
Master trainers should familiarize themselves with local systems to adapt the course, help
with problem-solving, know local specialized services and which medications are available.
Introduction 7
4. Actively use mhGAP-IG
The mhGAP-IG and ToHP manual should be used repeatedly throughout the course to help
with familiarization.
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Conducting the Training of Trainers and Supervisors
(ToTS)
This section provides an overview of every module in the ToTS, including learning objectives,
duration, slide numbers, key content and activities. There is more detailed information on
each slide's notes on PowerPoint (see PowerPoint slide presentation: ToTS training).
Figure 2. Conducting the ToTS section within the ToTS training manual
Resources
available mhGAP Training of Trainers and Supervisors (ToTS)
to master training manual
trainer
Resources Resources
available available
to master to participants
trainer and mhGAP Training of Health-care Providers (ToHP)
ToHP trainer training manual
Introduction Modules
ToHP
to the ToHP ToHP training
participant’s
training ECP DEP PSY EPI forms
logbook
manual
CMH DEM SUB SUI OTH
Introduction 9
ToTS PowerPoint slide presentation
The set of slides and the trainer’s notes available online can be used by master trainers in
conjunction with the conducting the ToTS training section. The notes accompanying the
slides within Powerpoint provide discussion points to highlight key information and can be
adapted for use by the master trainer.
Removing or adding slides should be avoided, even where there are concerns about time
and length of the course. Instead, easier concepts can be covered in less time, if needed (see
How to use this guide: Preparation and adaptation).
Figure 3. Understanding the role of the PowerPoint slide presentation: within the ToTS training
manual
Resources
available mhGAP Training of Trainers and Supervisors (ToTS)
to master training manual
trainer
Resources Resources
available available
to master to participants
trainer and mhGAP Training of Health-care Providers (ToHP)
ToHP trainer training manual
Introduction Modules
ToHP
to the ToHP ToHP training
participant’s
training ECP DEP PSY EPI forms
logbook
manual
CMH DEM SUB SUI OTH
mhGAP Training Manual for the mhGAP Intervention Guide for mental, neurological and substance use disorders in non-specialized health settings –
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ToTS supporting material and training forms
Please note that all ToTS training forms are also used in the ToHP training.
Evaluation forms
Evaluation forms have also been designed to be used across both the ToTS and ToHP training.
They should be completed by both master trainers and participants for every module during
the ToTS training, and feedback should be reviewed immediately to adapt the course if needed.
Introduction 11
Figure 4. Understanding the role of the ToTS supporting material and training forms within the ToTS
training
Resources
available mhGAP Training of Trainers and Supervisors (ToTS)
to master training manual
trainer
Resources Resources
available available
to master to participants
trainer and mhGAP Training of Health-care Providers (ToHP)
ToHP trainer training manual
Introduction Modules
ToHP
to the ToHP ToHP training
participant’s
training ECP DEP PSY EPI forms
logbook
manual
CMH DEM SUB SUI OTH
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Master trainer checklist (to be used when preparing
for the ToTS training)
Table 1: A checklist tool to help the master trainer prepare for the ToTS training
Tasks completed
Review and familiarization of the following materials:
Introduction to the ToTS training manual
Conducting the ToTS
ToTS PowerPoint slides presentation
ToTS supporting material and training forms
Introduction to the ToHP training manual
ToHP Modules (includes ToHP step-by-step facilitator’s guide, ToHP PowerPoint slide presentation, ToHP supporting
material)
ToHP training forms
ToHP participant’s logbook
Preparation of the following:
Conduct training needs assessment (see ToTS supporting material and training forms)
Understand local context and existing specialized services
Adapt the ToTS training to suit local context and time restrictions
Logistics:
Send invitations
Book venue (seating, microphones, no noise, etc.)
Presentation materials (projector, computer, video, flip charts, pens, paper, etc.)
Printing of materials
Food and catering
Transportation +/- accommodation
Per diems
Pre- and post-test administration
Evaluation forms
Introduction 13
Conducting
the Training of
Trainers and
Supervisors
mhGAP Training of Trainers and Supervisors (ToTS)
training manual
Conducting the mhGAP Training of Trainers and
Supervisors (ToTS)
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Day 1
Learning objectives
• Understand the mhGAP programme and its progression.
• Understand mhGAP-IG and its integration into non-specialized health
settings.
• Understand implementation principles as they relate to mhGAP-IG.
• Promote mhGAP-IG use and training.
• Familiarize participants with mhGAP-IG and training manuals.
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Session 2 on the wall with the titles: community services/
organizations; in health services; and referral
(continued) services. Encourage participants to fill these pieces
of paper throughout the training as they think
of different services already available, in order
to start creating a directory of organizations and
ideas.
• Activity 3: Familiarization with mhGAP-IG Version 2.0:
Problem-based learning scenarios using the mhGAP-IG
(see ToTS supporting materials and training forms)
(40 minutes).
– Divide participants into groups.
– Explain that each group will receive a scenario
relating to a person presenting to the clinic with
a priority MNS condition.
– The groups will start by discussing the presentation
of the case, and as a group will decide how they
would assess and manage the person.
Homework
Assign participants different short
sections from the mhGAP Training of
Health-care Providers (ToHP) training
manual and ask them to prepare a
three-minute presentation to deliver
the next day.
End of Day 1
12345
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Session 2 PURPOSE: Introduce participants to the principles of
preparing for an mhGAP ToHP training; the need for
Preparing and brief training needs assessments (TNA), adaptation of
the training material to fit the local training context,
evaluating an mhGAP and steps needed to prepare for training. Introduce
ToHP training participants to the materials required to evaluate the
training.
Duration: OVERVIEW:
1 hour 30 minutes • Introduce participants to a TNA and give an example
of a brief TNA.
• Introduce participants to the need to adapt mhGAP
Slide numbers: training materials to fit their particular context and
39–53 discuss ways this could be done. As the participants
work with and use the mhGAP ToHP training manual
(throughout the ToTS training), support them to
begin this adaptation process.
• Introduce participants to the need to decide on the
length and delivery method of mhGAP ToHP training.
• Introduce participants to the need to prepare
themselves for delivering an mhGAP ToHP training.
• Activity 5: In pairs, brainstorm the attributes of an
effective trainer.
• Introduce participants to the different ways of
creating a comfortable learning environment.
• Introduce participants to the concept of course
evaluations and give them the mhGAP evaluation
tools with which to practise.
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Session 4 – The master trainer works with a co-facilitator (if
appropriate) or a volunteer.
(continued) – The master trainer plays the role of a health-care
provider.
– The co-facilitator or volunteer plays the role of
a person seeking help for feeling sad and crying
all the time.
– During the first role play, the master trainer gives
an example of how to use poor communication
skills (e.g. does not demonstrate active listening
and other clinical skills; excludes the patient from
the process and type of care they receive). The
co-facilitator or volunteer playing the person
seeking help should reflect non-verbal indicators
that they are unsatisfied with the direction in
which the session with the health-care provider
is going.
– Stop the role play after five minutes.
– In the second role play the master trainer plays
a health-care provider employing skills learned
through mhGAP-IG to facilitate a successful
assessment, including participatory input from
the person, resulting in a satisfactory interaction
and outcome of the visit in the opinion of both
the person with the MNS condition and the
health-care provider.
– Stop this role play after five minutes.
– Ask the participants to reflect on:
› How the second role play differed from the
first?
› What it was like to experience the two
interactions as an observer?
› How it might be to experience those types of
interactions as a person seeking help?
› How this demonstration can be helpful to
you as a facilitator?
– If there is time, have the participants practise a
demonstration role play – either in front of the
whole group or in small groups.
End of Day 2
12345
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Session 1 has an assessment and management video, i.e.
depression, psychoses, disorder due to substance
(continued) use (drug use).
– Play the video and follow the step-by-step
instructions to model to the participants how
they should use that video to discuss the use
of the mhGAP-IG assessment and management
algorithms.
– Answer any queries that the participants may
have about using videos at the end of the
demonstration.
– Explain that participants will have a chance to
practise this skill when they deliver a part of the
mhGAP ToHP training the next day.
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Session 4 PURPOSE: Participants familiarize themselves with
the mhGAP ToHP training manual, have the chance to
Participant training practise all the training techniques they have learned
throughout the ToTS, and receive individualized
exercise feedback and support from the master trainer and
peers.
Duration:
INSTRUCTIONS:
1 hour 30 minutes • Divide participants into small groups and give them
a section of the mhGAP ToHP training manual.
Slide number: • Explain that they have the rest of the day to work
together and familiarize themselves with the mhGAP
130 ToHP training manual.
• Explain that tomorrow they will all take turns
delivering their mhGAP-IG training to the whole
group.
• Each group member must get a chance to demonstrate
at least one teaching skill.
• Ensure that the participants have access to all the
PowerPoint slides and additional materials that they
require.
• Assign a time slot for each group to present the
following day.
End of Day 3
12345
End of Day 4
12345
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Day 5
Learning objectives
• Understand the importance of supervision, highlighting the
role supervision plays in up-skilling participants and ensuring
sustainability of skills learnt.
• Understand the theory and techniques of good supervision.
• Understand implementation of supervision principles as they relate
to the mhGAP ToHP training.
• Able to utilize a variety of supervision models.
• Can organize and perform supervision.
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Session 2 PURPOSE: Enable participants to plan and prepare for
their local supervision.
Supervision: Practical
INSTRUCTIONS:
• Activity 15: Discuss the barriers to supervision and
Duration: how to troubleshoot them.
1 hour 30 minutes • Introduce the four different models of supervision,
stressing that there is a model to suit every situation.
Each model will be discussed in depth, with a case
Slide number: example.
149–179 • Introduce an approach to preparing for supervision
by asking “who, what, when, where and how”.
• Introduce tools which are available in the participant
logbook to help with supervision.
• Activity 16: Discussion in small groups then present
to larger group:
– Participants will break into pairs/small groups
according to their service location.
– As a group, they must answer the “who, what,
when, where, how” questions to start preparing
their own supervision.
– Each small group then presents back to the larger
group for discussion, feedback and problem-
solving.
Sessions 3 and 4 PURPOSE: Ensure that the master trainer can take (at
least) five minutes with each participant to give them
Individual feedback individual feedback on their progress during the course
and their next steps. Give participants the opportunity
and planning sessions to start planning when and how they will deliver their
for delivering training/ first mhGAP ToHP training of non-specialist health-
supervision care providers and plan the supervision component
at the same time.
Duration: OVERVIEW:
• Begin the afternoon sessions by setting the participants
3 hour 45 minutes the task of planning their own mhGAP-IG training.
(Including a 30-minute
Include a brief TNA – contacting health managers and
tea break in the middle)
programme planners to learn more about training
needs, and planning when and how to deliver the
training.
• Emphasize that as they plan the training they must
also plan how they will deliver supervision after the
training – as supervision is as important as training.
• Allow them to do this in groups and/or pairs. If they
work closely with another participant and are likely
to deliver training together, then it is essential that
they plan together.
• Ask them to think about how they could support
each other? Could they develop their own peer
supervision group to support each other?
End of Day 5
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ToTS
PowerPoint slide
presentation
mhGAP Training of Trainers and Supervisors (ToTS)
training manual
ToTS PowerPoint slide presentation
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34 version 2.0 (for field testing)
ToTS supporting
material and
training forms
mhGAP Training of Trainers and Supervisors (ToTS)
training manual
ToTS supporting material and training
forms
• Training needs assessment form
• Pre- and post- test
• mhGAP familiarization exercise
• Supervision role plays
• Evaluation forms
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Training needs assessment form
Please identify which of the following sources were used to complete this form:
WHO/UN sources of information Review of hospital admissions data
National sources of information Discussion with management
Other published literature Discussion with staff
Review of adverse events Discussion with patients
Audit reviews Other: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Target population
Which MNS conditions should be managed in non- specialized health settings? (as per national level protocols and
guidelines or discussions with stake holders):
Essential care and practice Dementia
Depression Disorders due to substance use
Psychoses Self-harm/suicide
Epilepsy Other significant mental health complaints
Child and adolescent mental and behavioural disorders
Local Resources
Which medications are available in this area?
Acamprosate Clonidine Methadone* Phenytoin*
Amitriptyline* Diazepam* Methylphenidate Risperidone*
Benzhexol Disulfram Midazolam* Sodium Valproate*
Biperiden* Fluoxetine* Morphine* Thiamine*
Buprenorphine Fluphenazine* Naloxone* . . . . . . . . . . . . . . . . . .
Carbamazepine* Haloperidol* Naltrexone
Chlorpromazine* Lithium* Oxazepam *
WHO Essential Medicines
Cholinesterase inhibitors Lofexidine Phenobarbitol* List 2017
What are local prescribing regulations?
Are mental health specialists available locally (i.e. psychiatrists, neurologists, mental health nurses)? Provide names and
contact details
Are other services available where people with MNS conditions can be referred? (i.e. gender-based violence support,
financial support, aged-care)
What facilities are available for training? Includes rooms, electricity, PowerPoint, Wi-Fi etc.
Health-care providers
What disciplines will attend the training? Specialist Doctors Nurses Allied Health Other
How many from each discipline are MNS
expected? providers
What do the trainees “do” in their work and how will they use this learning?
What knowledge, skills and experiences do the trainees already have in MNS conditions?
Expectations of training
What are the goals and expectations of the training according to the person(s) who requested it?
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Training needs assessment (continued)
Supervision
How much time and/or funding will be allocated to supervision after the course?
What other local solutions will help in the provision of the training and supervision?
Other considerations
Please note anything else relevant to planning the training and supervision
Conclusions
Dates for course: Venue:
Modules to be completed:
Essential care and practice Dementia
Depression Disorders due to substance use
Psychoses Self-harm/suicide
Epilepsy Other significant mental health complaints
Child and adolescent mental and behavioural disorders ToTS training
1. Which of the following is considered a core effective communication skill? Choose the
best answer:
A Speaking to the person only and not the carer
B Start by listening
C Using an open space for safety
D Limited eye contact
2. Which of the following is consistent with promoting respect and dignity for people
with an MNS condition? Choose the best answer:
A Making decisions on behalf of a person with an MNS condition, with their best
interests in mind
B Using correct medical terminology to explain things, even if complicated
C Ensuring consent to treatment is received from the carer and/or family
D Ensuring privacy in the clinical setting
3. Which of the following cluster of symptoms best fits with an episode of depression?
Choose only one answer:
A Marked behavioural change, agitated or aggressive behavior, fixed false beliefs
B Decline in memory, poor orientation, loss of emotional control
C Inattentive, over-active, aggressive behavior
D Low energy, sleep problems, and loss of interest in usual activities
5. Which of the following cluster of symptoms fits best with an acute manic episode?
Choose only one answer:
A Confusion, disorientation to time, place and person, marked functional decline
B Admits to consuming alcohol, has slurred speech and uninhibited behavior
C Has recently stopped taking regular benzodiazepines, and presents with
agitation, sweating and poor sleep
D Decreased need for sleep, increased activity and reckless behaviour
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7. Which of the following is part of a psychosocial intervention in psychoses? Choose the
best answer:
A Encourage participation in daily activities but recommend against work or
serious relationships as they may be too stressful
B Discuss with the carer and family whether long-term institutionalization may
be appropriate
C Provide psychoeducation, especially to avoid sleep deprivation, stress, and
drugs and alcohol
D Discuss with the carer different ways that they might be able to challenge the
delusions of the person
8. Which of the following statements concerning epilepsy is correct? Choose the best
answer:
A Epilepsy is a communicable disorder of the brain
B Epilepsy is a sign of spirit possession
C Epilepsy is always genetic in cause
D Epilepsy is one of the most common neurological disorders
9. Which of the following requires emergency medical treatment? Choose the best
answer:
A When someone starts to feel that a seizure is imminent
B If the seizure lasts for more than 1 minute
C If the seizure lasts for more than 5 minutes
D If the person is drowsy once the seizure is over
10. Which of the following is the best description of a child developmental disorder?
Choose only one answer:
A Child developmental disorders have a relapsing and remitting course
B Child developmental disorders are always associated with abuse and neglect
C Child developmental disorders category includes attention deficit hyperactivity
disorder and conduct disorder
D Child developmental disorders involve impaired or delayed functions related to
central nervous system maturation
11. Which of the following is good advice for any child and adolescent mental and
behavioural disorder? Choose the best answer:
A The carer can use threats or physical punishment if a child has problematic
behaviour
B The carer should remove the child from mainstream school as soon as possible
C The carer can use other aids such as television or computer games instead of
spending time with the child
D The carer should give loving attention to the child every day and look for
opportunities to spend time with them
13. Which of the following should be given as advice to an adolescent with a mental or
behavioural disorder? Choose the best answer:
A They should avoid community and other social activities as much as possible
B They should avoid the use of drugs, alcohol and nicotine
C They should avoid school if it makes them anxious
D They should avoid being physically active for more than 30 minutes each day
14. Which of the following is a common presentation of dementia? Choose the best
answer:
A Low mood and loss of enjoyment in usual activities
B Fixed false beliefs and hearing voices
C Excessive activity and inattention
D Decline or problems with memory and orientation
15. Which of the following is a common presentation of dementia? Choose the best
answer:
A Severe forgetfulness and difficulties in carrying out usual work, domestic or
social activities
B Drowsiness and weakness down one side of the body
C Fluctuating mental state characterized by disturbed attention that develops
over a short period of time
D Low mood in the context of major loss or bereavement
16. Which of the following is the best description of dementia? Choose only one answer:
A Dementia can have a large impact on the person, their carer, family and society
at large
B Dementia can be cured through pharmacological interventions
C Dementia does not interfere with activities of daily living, such as washing,
dressing, eating, personal hygiene and toilet activities
D Dementia is a normal part of aging
17. Which of the following statements best describes treatment options in dementia?
Choose only one answer:
A All people with dementia should have access to pharmacological interventions,
regardless of specialist availability
B Pharmacological interventions, if started early enough, can cure dementia
C With early recognition and support, the lives of people with dementia and
their carers can be significantly improved
D Psychosocial interventions for dementia should only be provided by a specialist,
due to their complexity
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18. Which of the following best describes symptoms of substance dependence? Choose
only one answer:
A Sedation, unresponsiveness, pinpoint pupils following use
B Current thoughts of suicide, bleeding from self-inflicted wound, extreme
lethargy
C Strong cravings, loss of control over substance use, withdrawal state upon
cessation of use
D Intravenous drug use once per month, but violent towards others when using
19. Which of the following illnesses should you screen for in people who inject opioids?
Choose the best answer:
A HIV and hepatitis
B Wernicke's encephalopathy
C Epilepsy
D Thyroid disease
20. Which of the following should you tell the carer of someone who has had an episode
of self-harm or a suicide attempt? Choose the best answer:
A Medication will be made available so that they can keep the person sedated
B Restrict the person's contact with family, friends and other concerned
individuals in case it is too overwhelming
C Remove access to any means of self-harm and try and provide extra supervision
for the person
D Forced vomiting is an emergency treatment option if they suspect any self-
harm or suicide
21. Which of the following is part of a psychosocial intervention where the person seeking
help witnessed the death of a loved one to violence? Choose the best answer:
A They should talk about the incident as much as possible, even if they do not
want to
B It is normal to grieve for any major loss, in many different ways, and in most
cases grief will diminish over time
C Avoid discussing any mourning process, such as culturally-appropriate
ceremonies/rituals, as it may upset them further
D Refer to a specialist within one week of the incident if they are still
experiencing symptoms
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45 Training supporting materials and training forms
1. = B 7. = C 13. = B 19. = A
2. = D 8. = D 14. = D 20. = C
3. = D 9. = C 15. = A 21. = B
4. = B 10. = D 16. = A 22. A = ii
B = iii
5. = D 11. = D 17. = C C = iv
6. = D 12. = A 18. = C
Pre- and Post-Test Answer Key
mhGAP familiarization exercise
Read the case example below and answer questions using mhGAP-IG.
Case example
A 30-year-old woman is brought to the clinic because of her restless behaviour.
The woman is not willing to sit down and is pushing her husband away from her.
She seems afraid and looks behind constantly. She is refusing to let anyone
examine her.
Blood type O+, antibody screen negative, VDRL (syphilis) negative, PPD (tuberculosis) negative,
HIV test negative, hepatitis B surface antigen negative, rubella immune, maternal serum triple
screen normal, glucose challenge test normal, haemoglobin electrophoresis 97% haemoglobin
A, no fever, not taking medication, no smell of alcohol.
Every time you ask her questions about her symptoms, she stops talking. When you insist on
learning more about her symptoms she becomes silent.
When you offer her medication to help her feel more relaxed and calm, she becomes more
agitated, saying that she is not crazy and will not take any medications.
You are able to speak to the woman’s husband in a private room away from the woman after
asking her if it is ok.
Her husband tells you that since the birth of their youngest child three months ago the woman
has been having “mood swings and anger problems”.
He says that she is neglecting her role as a mother and a wife. It is as if she has become a
different person since the birth of her baby.
He also says that she is convinced that the neighbours want to hurt her and her children and
as a result she does not want to leave the house.
The pregnancy was normal and there were no problems during delivery.
She has hardly left the house since the delivery but before that she was very sociable and
had a lot of friends.
mhGAP Training Manual for the mhGAP Intervention Guide for mental, neurological and substance use disorders in non-specialized health settings –
46 version 2.0 (for field testing)
Supervision role plays
Introduction
These role plays are designed to demonstrate different styles of supervision, particularly how
supervision can be done badly, and behaviours that future supervisors should avoid.
If there is time, each role play can be performed a second time, with the “supervisor” using
what they have learned to provide better supervision.
You have come hoping that the supervisor will help you
out. You want to know:
• Why is she hearing voices?
• What are the medication options and how should you
prescribe them?
• What should you do about the suicidal thoughts?
• How should you deal with the fact she does not want her
husband to know?
INSTRUCTIONS
Ask the supervisor for help. Do not stop the interview until
you feel you have the help you need.
mhGAP Training Manual for the mhGAP Intervention Guide for mental, neurological and substance use disorders in non-specialized health settings –
48 version 2.0 (for field testing)
Supervision SITUATION: SUPERVISOR (SPECIALIST)
You are the only neurologist in your city of 1 million people.
role play 1 You run outpatient clinics every week day, sometimes
seeing up to 50 people in each clinic. You also look after
the neurology ward of 20 beds, and sometimes have to
To experience and help with hospital administration. You often work at the
better understand weekend.
different styles of
You were asked to provide supervision for the mhGAP-
supervision IG Version 2.0 trainees. You did not particularly want to,
but there was no one else available. You feel comfortable
Duration: supervising regarding a patient with epilepsy or dementia,
but you feel pretty '’lost” when it comes to mental health
40 minutes or substance use.
INSTRUCTIONS
Provide supervision as instructed, without using your prior
mhGAP-IG knowledge except for epilepsy.
INSTRUCTIONS
You have come hoping that the supervisor will help
you out. You do not want any advice on psychosocial or
pharmacological interventions, you feel quite confident
in this.
mhGAP Training Manual for the mhGAP Intervention Guide for mental, neurological and substance use disorders in non-specialized health settings –
50 version 2.0 (for field testing)
Supervision SITUATION: SUPERVISOR (SPECIALIST)
You are a psychiatrist who has agreed to be a supervisor for
role play 2 mhGAP-IG. You are very senior in your hospital and thought
it would be good to volunteer your time to help with
supervision, as you believe you have a lot that people can
To experience and learn from you. You consider yourself very “no-nonsense”.
better understand You are efficient and direct, and do not like to waste time
different styles of with unimportant things.
supervision When someone asks for your help with mhGAP-IG you
go straight to the right page and talk them through it at
Duration: length. You do not like to be interrupted. You do not like
to trouble yourself with matters that you do not see directly
40 minutes related to the issue in front of you.
INSTRUCTIONS
Ask your supervisee what they want help with today. When
she says she has a patient with a disorder of substance use,
you turn to page 116. You stick to the algorithm and are not
willing to discuss anything else, which you believe would
be getting “off-track”. If the supervisee raises anything
else, you direct her back to the algorithm.
INSTRUCTIONS
You need to discuss a case for supervision. This is the most
interesting you case you have seen so far, so you decide to
discuss it. You are also quite proud of having diagnosed
and prescribed the medication without looking at the
mhGAP-IG and you would like the supervisor to recognize
how good you are.
mhGAP Training Manual for the mhGAP Intervention Guide for mental, neurological and substance use disorders in non-specialized health settings –
52 version 2.0 (for field testing)
Supervision SITUATION: SUPERVISOR (SPECIALIST)
You are a psychiatrist with an interest in psychotherapy.
role play 3 You are very happy to be a supervisor for mhGAP-IG. You
are well-liked as a supervisor, as you are very gentle and
calm, and do not criticize your supervisees like some of the
To experience and other supervisors do. You believe in allowing the supervisees
better understand a space to release tension in their time with you, and to
different styles of reflect on their practice. You believe in validating the work
a supervisee does. You never tell people outright that
supervision they have done the wrong thing, you try and get them to
reflect and see for themselves what they could have done
Duration: differently.
40 minutes You have met your new supervisee before. You noticed that
he seems a bit overconfident and does not take direction
well. You are hoping that by taking a very gentle approach
with him you can help him improve.
INSTRUCTIONS
The supervisee will present a case to you. Use your mhGAP-
IG psychoses module to help with supervision. Even if you
do not think the supervisee has done the right thing, you
do not say this outright – get them to reflect on what they
have done and try and identify this themselves.
Name of facilitator(s):
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
What did you learn from this module that you anticipate using again?
mhGAP Training Manual for the mhGAP Intervention Guide for mental, neurological and substance use disorders in non-specialized health settings –
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Trainer feedback form for each module
Date of training: Location of training:
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Name of facilitator(s):
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .