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5 considerations for working with populations with mental illness

Rachel, a dietitian in the Hamilton/Toronto area with a passion for working in mental health, shares insights from her recent practicum experiences. 


RHHS1-(1).jpgRachel Hicks recently completed her Master of Public Health in Nutrition and Dietetics (formerly Community Nutrition) at the Dalla Lana School of Public Health at the University of Toronto. She is interested in many areas of nutrition on a local and global scale and has developed a passion for working with vulnerable populations in diverse communities. Connect with Rachel on LinkedIn.  

  

Nutrition and its association with mental health and mental illness is becoming more and more recognized. Compared to the general population, individuals with complex mental illness (CMI) are at a greater risk of developing disease comorbidities (abnormal triglycerides, hypertension, glucose dysregulation, and abdominal obesity) and subsequent chronic disease (cardiovascular disease, metabolic syndrome, and type 2 diabetes). This is significant, especially considering 1 in 5 Canadians experience some sort of mental health issue.

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I recently completed a three-month placement at Waypoint Centre for Mental Health Care, which is a medium and maximum security inpatient psychiatric facility. I was also involved with Waypoint’s outpatient facility and affiliated services such as the HERO Centre, which helps individuals manage their mental illness in the community.
 
Our role as dietitians working with those that have CMI is well defined. Yet, where are all of the dietitians working with CMI populations who are at significant risk of chronic disease? Many community mental health centres do not have dietitians and the inpatient facilities that do hire dietitians are generally understaffed.
 
I experienced this first-hand during my internship as I had placements at both the Centre for Addiction and Mental Health and Waypoint. Up until March 2016, there was only one dietitian covering all inpatient (> 300 beds) and outpatient services at Waypoint!  We are being under-utilized in this population. There is an important need for our expertise, particularly at the onset of illness, in order to help CMI clients with the nutritional issues they may encounter throughout their lives.
 
Upon realizing this, I began to ask myself these questions:
  • Are all dietitians trained in their undergraduate education and/or internship to work with this population? Should our education have mandatory training on working with this population?
  • Do dietitians feel competent working in mental health and mental illness settings?
  • What advocacy work needs to be done for our profession to be more involved with this population? 
  • What can I do to help as a new dietitian with some experience and interest in this area?
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As a dietitian with a strong interest in this area, I thought I could share some of my insights from my recent experience.
 
Here are five things to consider when working with clients with mental illness:
  1. Focus on small improvements.
This population often has complexities inherent to their mental illness that pose significant barriers to adequate nutrition (e.g. addictions, food security issues, lack of motivation/support/education, medication side effects, mental status, etc.). Working in small steps with these clients is usually the most successful. As always, dietitians need to be supportive and recognize what type of nutrition education is appropriate on a case-by-case basis.
  1. Learn to be adaptable.
Problem solving and thinking on your feet is key while counselling individuals with CMI. You need to be able to let go of your original plan if needed. You may be referred to see a client for one thing and end up providing education on a completely different topic or just end up offering your empathy and support to whatever struggles they may be encountering at the moment. 
  1. Recognize when a client may be receptive to nutrition intervention. 
The learning needs and styles of most individuals with CMI can be very different from the general adult population. For instance, you may need to reduce the grade level of resources, provide more hands-on opportunities (i.e. cooking classes), and continually repeat and/or reinforce important education points.
 
Become familiar with the complexities of the various illnesses and learn to recognize when individuals may be receptive to nutrition interventions. A very common symptom among this population is amotivation. Clients can find it extremely challenging to do what you may think is a small task. Be patient and meet a client where they are at.  
  1. Use some detective skills.
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Working with this population requires investigative skills and intuition. It can sometimes be difficult to clearly determine if the information clients are telling you is the truth. This can be the case for any population, but particularly with clients with mental illness as they may be struggling with delusions, OCD behaviours, or have personality disorders that can impact their response to something, such as a 24 hr recall or food record. Dietitians need to develop rapport with these clients, be aware of their social, medical, and psychiatric history and learn how to recognize when someone may not be telling the truth.
 
Knowing when to probe and knowing what information to probe is key. Speaking with other professionals on a client’s health care team (i.e. social worker, psychiatrist) or a family member can be very helpful to gain more insight on their personality traits in connection with their illness.
  1. Recognize, appreciate, and learn from a client’s socio-cultural surroundings and past experiences.
Remaining client-centred (or what I prefer, person-centred), culturally sensitive, and using strategies from trauma-informed care and harm reduction is essential. It’s important to understand that all cultures do not view mental illness in the same way, some clients will believe in certain medicinal or food-related remedies and others will not. Acknowledge this and work through these differences with clients and their support systems. As many ethical issues can surface while working with this population, ethically sounds interventions are critical (as always).
 
There is a lot more to discover with regards to dietitians working with this population. This list could go on and on. People with mental illness should be able to easily access nutrition care and we should routinely be involved in their interdisciplinary health care teams – particularly for individuals on antipsychotic medications.
 
Most – if not all – dietitians will encounter someone with mental health issues during their career. In my opinion, more training should be required for dietitians in this area; whether that be embedded into a compulsory undergraduate course or e-learning module to complete during internship. We can truly make a positive impact in this area.
 
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Editor’s note: In 2012, Dieititians of Canada published an extensive 3-part report describing the relationship between mental health and nutrition, which also included information about the role of dietitians providing services in mental health care. This report, "Promoting Mental Health through Healthy Eating and Nutritional Care,was written by a team of dietitians specializing in mental health promotion and care. ​
 
More recently, in June 2016, Dietitians of Canada (Ontario) submitted letters to Health Quality Ontario with feedback on consultation drafts of Quality Standard for behavioural symptoms of dementia, schizophrenia, and major depression, including the recommendation that all individuals with mental health conditions should be screened for nutrition issues and be referred as needed for a more systematic assessment by a registered dietitian.

Do you have questions or comments for Rachel? Continue this important conversation by leaving them below.
  1. Excellent article Rachel!

    I just completed my internship and I was fortunate to have had the opportunity to complete a rotation in mental health. I was blown away because this was not an area that was covered in my undergraduate program, but there is such a large role for dietitians, as you mention. I relied heavily on the Dietitians of Canada 3-part report during this rotation.

    These are great points and definitely agree that this is an area that could use more focus.
  2. As the mental health dietitian for Parkwood Institute in London, I can relate to all of this article. Training in mental health and nutrition should be mandatory for all dietitians. I had to learn so much on the job. In any health care setting, you will see people with varying degrees of depressive or anxiety symptoms, and a few with bipolar or psychosis as well. Mental health is a key part of the whole person with huge impact on nutritional health.
  3. Hi Rachel,

    Sounds like you had an eye-opening experience! I certainly agree with you, it's so important to have RDs in various capacitiesa part of mental health care teams. I work in an outpatient mood disorders program and I also see a lot of potential for research.

    I think it's great you're advocating for the profession and for mental health care! Feel free to connect with me via email if you would like to discuss this any futher.

    Joy Guthrie
  4. Hi Susan,

    Great question.

    From my experience, I know presenting in a more informal, conversational way is key. Try to keep your session as short as possible and include breaks if you can. Also, incorporating different methods of communicating your material (e.g. resources/hand outs, cooking demos, videos, activities etc.). You need to engage your participants and allow them to participate in the conversation... in some cases I have started out sessions with the clients being able to dictate the direction of the session. I think another important part is to acknowledge their illness while you're speaking with them and the potential side effects they may be experiencing. This way you can work through some of the barriers they may be facing with respect to nutrition and their illness isn't 'put aside' so to speak. I believe you need to try to empower them in any way you can and allow them to come up with their own solutions, as this population is naturally wary of people telling them what to do. Also, trying to have a family member, friend or peer support worker attend the session with them might help. Overall, it comes down to reading your audience and understanding what might work best for them. Hope that helps! If anyone else has some ideas from their experience please feel free to comment.
  5. a question:
    Rachel, if you give any group lecture to outpatient mental health patients , is there any way you present it differently to get the patients engaged and participating in the discussions?
    Susan

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