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

Micronesia

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12/01/2012 11:29:14

Small steps

And so, after three fascinating months, my time in Pohnpei has come to an end; the training programme has officially finished, and I have had to say my reluctant farewells. But this is hopefully the beginning of something, not the end. Over the last few weeks we have been trying to focus on service development and capacity building and putting together a concrete plan of how to disseminate the knowledge and skills gained to other people. Three of the trainees have shown good competency in the ability to train other people and so we have appointed them as the official people who will take on the task of developing a training programme for each of the four FSM SAMH programmes. One possibility is that they will come together periodically as a peer support group, supervising and advising each other in difficulties arising in training others or in the practicalities of using the Mental Health Gap Implementation Guide provided by the WHO, which has formed the basis of our training. What is needed as a matter of priority is the appointment of one or two dedicated medical professionals from each State hospital, to participate in mental health training and take on the role of mental health doctor for the SAMH programmes. It has been difficult to access the doctors here in Pohnpei and we have not had any along to the training, which I think is something that will need to be addressed in future training initiatives.

 

Micronesia blog by Dr Anna Stout

Supervision

I have been in email contact with a Dr Wally, a Palauan doctor who specialises in mental health and who has provided input to the FSM in the past, who has given me much valuable advice regarding the FSM. Two days before I was due to leave she arrived for a short spell in Pohnpei, so we have been able to meet in person and with the trainees, to discuss how best to take things forwards. One of the trainees who has been appointed as a trainer is a 26 year old lady who has only recently started work at the clinic as a counsellor. Delpihn has a degree in public health from Fiji but hasn’t been able to find a position in the public health department here, so has been appointed to the mental health team instead. I’m very glad – she has been a great participant, really enthusiastic and interested. But what I wasn’t aware of was how difficult it is going to be for her to provide training to certain members of the SAMH programme here.

Dr Wally raised this issue in our meeting - the traditional hierarchies which exist in the FSM, hierarchies based on clan but also on age and sex, mean that using certain terms and concepts, such as supervision and mentoring, don’t work; in fact, they disrupt the existing lines of communication and structure of the organisation. There are ways around it – Delpihn, for example, could train in another FSM state, and group training will not apparently pose such difficulties; it’s to do with the implications of the term “supervision”. I was aware that Delpihn might find it hard in a position of teacher, but not specifically in this contentious area of supervision, so I’m still finding out about huge cultural issues such as this, at the eleventh hour, and I’m sure, if I was able to stay longer, these kinds of obstacles would keep on surfacing.


Big issues

Raising awareness of the existence of SAMH and of mental illness in general is a big issue – in the twelve weeks I have been here there have been very few new referrals but there have been, very sadly, two completed suicides. There are many reasons why people do not come forward, including stigma, a lack of knowledge with regards mental illness and the possibility of help, and practical reasons, such as the fact people here who live a long way from the central town and who do not have vehicles or phones. As they cannot afford to pay for medical input or medications, they tend not to seek medical help unless it seems very necessary. People do not like to talk about their personal difficulties, particularly with people they do not know well. All of these complex factors need to be taken into account when addressing the problems of mental illness here in Micronesia. But hopefully, the trainees and I have managed to take some small steps towards doing so, in the three months we have spent together, and I really hope that I will be able to remain involved in mental health development in the FSM, in some way or another, in the future.

There are many things I would do differently, if I was starting over again – I think, for example, it would have been really useful to have been able to spend time in the other FSM states, working with the individual trainees from Yap and Kosrae and Chuuk. Each of the four FSM States are quite different in their cultures and geography and language, and it will be interesting to see how the mental health initiatives we have been discussing will need to be adapted to fit these different islands. They each seem to have their own unique characteristics – Chuuk is made up of many small islands, which are difficult to access; Yap is less Westernised, more traditional; Kosrae is very small and the church is hugely important there.

Gear-Up

Micronesia blog by Dr Anna Stout

While hanging out at the Peace Corps office one day I bumped into an American woman who is working in the schools in Pohnpei, setting up an initiative called Gear-Up, focusing on encouraging students to complete high school and improve their grades.

As part of this, she is planning a summer camp with the theme of self esteem, and asked if the mental health team would be able to help out. So we arranged a meeting with the SAMH coordinator Aieleen, myself, this lady and her colleague – a school counsellor who works with kids who have problems with attendance and keeping up their school work. She hasn’t any mental health training herself and said she feels under skilled in recognising which children may have emotional difficulties, so we have arranged for the SAMH counsellors to spend some time with her looking at screening for emotional problems and early warning signs, and how to refer those identified to the SAMH clinic.

I remember when Aieleen and I first met, and were discussing the problem of suicide in young people, and the difficulties in discussing the issues given how taboo it is in the FSM, we had spoken about addressing contributing factors such as self esteem and identity issues in the adolescents here, so it’s really satisfying that this meeting has come about, and there are plans afoot.

Micronesia blog by Dr Anna Stout

Melting pot

So many exciting things just beginning; so much still to learn; but I have to leave, and am writing this from a hotel room in Guam, waiting for my “red eye” flight to Seoul. Guam is a very interesting place – I have a 23 hour stop over and have been exploring in the drizzle. It is, to my mind at least, a mad mix of the seedy side of Vegas, suburban American strip malls, and Bondi beach - a melting pot of stunning cliffs and golden beaches, huge five-carriage highways and sprawling shopping centres, run down high rise hotels, shooting ranges and strip joints on nearly every corner. I would happily spend another three months sussing out this place too!

I have had a great time – not easy at all, but always interesting, and a huge learning experience for me, about culture and mental health, about training in general, about myself and how my own culture has shaped me and my values and ideals, how I conceptualise mental health and illness, the assumptions I have held without realising it. For all these reasons, I’d recommend volunteering to everyone who is considering it. And Micronesia in general – not much visited by UK tourists but most certainly a hidden gem worth discovering!

Thanks for reading my blog.

08/12/2011 12:03:58

Ghost town

Storm season

Micronesia blog by Dr Anna StoutDecember has arrived, and the island has been assaulted by a tropical storm for the last few days – rain of biblical proportions in the streets of Kolonia, grey mist hiding the mountains, the coconut trees battered by gales from the Pacific.

I made it out snorkelling, before the storms, and saw an eight-foot shark lurking in the depths, and hundreds of fish – neon pinks and yellows, striped and spotted and tiger-print, and bright blue starfish on the coral

Micronesia blog by Dr Anna Stout

Local healer

I am now getting to know many of the regular clients of the mental health team. We have been spending time with a lady with a diagnosis of Schizophrenia, who, a month ago, asked to stop her antipsychotic injection and visit a local healer instead. She had never asked to do this before, and when we went to see her, she told us that she has started being visited by ghosts who talk to her and tell her to throw herself into the river. The mental health coordinator tells me about some of the local beliefs here – angry ancestral spirits are often held responsible for misfortune, including sickness, and the solution is to visit the gravesite of the ancestor involved, to tidy it up, or to “trap” the spirit inside it by making a hole in the tomb and filling it with herbs and plants recommended by a healer.

It’s hard to elicit a trigger for our lady’s recurrence of psychotic symptoms, but she isn’t sleeping at night and has lost a lot of weight recently, and reports suicidal thoughts – not long ago, her daughter found her taking a knife into her bedroom. I start her on Amitryptiline, the only antidepressant available here, but we also arrange to meet with the patient and her family, to talk through what they believe is wrong and further explain my diagnosis. The mental health team do not discourage patients from seeking help from local healers, although they try to encourage them to continue taking medication and engaging with mental health services at the same time.

As keen as I am to visit a local healer and see what they do, I don’t think it’s going to be easy: the mental health team say they don’t really have much to do with them, and I’m told local healers guard their secrets and methods very closely, particularly from outsiders like me. It’s really interesting to see how traditional beliefs in the supernatural exist alongside western concepts of illness.

Spirit level

Another patient is taken to jail – the only facility for acutely disturbed patients here who cannot be safely cared for at home – by her husband because she has started being aggressive at home, talking to herself and not sleeping at night. She also has a diagnosis of schizophrenia and tells me she is seeing ghosts at night which frighten her. Her husband says the house in which they live is cursed, and that local children have reported sightings of the ghost that haunts it. The ghost has come from Nan Madol, the ancient ruins on the island which are a very sacred place, and which many locals will not visit due to fear of offending the spirits there.

The husband tells us that he is happy for us to increase her medication and that he would like us to help her as much as we can, that he is aware she has a mental illness which he feels the medication is helpful for, but that he also believes in these ghosts and suspects she has been cursed. The other solution is prayer, and lots of it, but her relatives, he tells us, who lived in the house before them, also “went mad” and eventually moved out to escape the spirits.

Mangrove sickness

Micronesia blog by Dr Anna StoutThe mental health team coordinator is Aieleen, a lady from one of the outer islands called Pingelap, who studied nursing in Australia before returning to Pohnpei to work in mental health.

Aieleen is fantastic, and I’m regretful that she isn’t able to attend more of our training because she is too busy managing the clinic and looking after her four month old baby. I try to spend time with her as much as I can as I am learning so much from her about how mental health is conceptualised here in Pohnpei and the FSM, and also about the many difficulties and obstacles the mental health service faces.

Micronesia blog by Dr Anna Stout

Aieleen tells me about Mangrove Sickness, another local explanation for illness. Mangrove sickness seems to be a “catch all” term for all manner of ills, including aches and pains all over the body, chronic tiredness, despair, emotional turmoil, hearing voices, seeing things.. It’s caused by the Mangrove Demon, who possesses people who spend too much time in the mangroves or who go there after dark. Aieleen explains to me that although people here in Pohnpei are willing to accept Western remedies for illness, they will often say that if you want to get to the root cause of the problem, Mangrove Sickness is where it’s at.

Mangrove sickness is cured by Mangrove Medicine, but what Mangrove Medicine consists of is, again, a closely guarded secret of the traditional healers. I am fascinated by the mangrove swamps, and have spent many happy hours snapping photos of the dark, creepy, tangled roots which fringe the island. Pohnpei has no beaches, but the mangrove, in my opinion, is far more interesting. However, when I am struck down by food poisoning for the second time in a month, both times the day I am due to go out in the jeep to administer my “western medicine” and spread my western ideas, I do start to wonder if I have stirred up some ancient spectre and need some mangrove medicine of my own......

Stigma

The next week, we manage to get together with our first patient’s family – her mother and aunt, sister and daughter. We can’t seem to track down her husband. We ask about the ghosts and the local healer, but the family say they don’t want to see a local healer anymore and are happy for her to take our medication, even though they don’t seem to think it’ll do much good. It’s hard to get information from them about what they think is wrong. They have a private conversation with one of the Pohnpei trainees in the local language. Back in the jeep he tells me that they asked him not to translate for me, but he does, anyway – apparently, they believe the problem is she is too lazy and the best thing would be “to beat the evil out of her”. Oh boy!

Back at base, I switch my training session plan to a session on tackling stigma and psycho-education, and try to book another visit with the family as soon as we can. Time is going very swiftly, and we’re now moving on to “training the trainers” work, in order to try to capacity build.

Lock up

The trainees have some great ideas: the trainee from Chuuk is keen to teach her colleagues in maternal health about post-natal mental illness which they say is relatively unheard of here. It’s handy that everyone on island is related to everyone else – one of the Pohnpei trainees is the brother of the chief of police, so we should be able to organise a training session for the local force fairly easily. The police are depended on here for assistance when someone is very disturbed and needs a place of safety, and they seem to do a pretty good job with the limited resources and expertise they have. The policemen I have met seem empathic and concerned about the inappropriateness of jail for mentally ill clients.

In other parts of the FSM I am told it isn’t so good – in Chuuk, for example, the mentally ill are held in cells with criminals, who beat them and abuse them. There is very little legislation here for the mentally ill – if they are deemed unsafe to stay at home, jail is the only other option; the mental health team need to file a request with the court for a “commitment order” within 24 hours of incarceration, and the court then commit the patient to jail for a maximum of thirty days.

If the patient stabilises before then, the mental health team request release. If the patient is felt to need longer, the mental health team request longer detention. But families play a pivotal role in whether patients are allowed to go home – if the families insist they remain in jail, in jail they remain, because there is nowhere else for them to go other than home. Patients don’t have rights to lawyers or appeals or tribunals, and although the mental health team try hard to ensure nobody remains in jail for longer than necessary, they are dependent on families working with them and not obstructing release. There are no community facilities at all here, no hostels or supported living. It’s either with family, or on your own, and not many people at all can afford to live on their own or the severity of their illness means it wouldn’t be safe. The mentally ill are not entitled to benefits and there are no social services as exist back home in the UK.

Tomorrow is our Christmas party, storms permitting. We’re having it at the marine park, where the giant turtles live. More news to follow soon.

03/11/2011 10:44:08

Roast pig

Micronesia blog by Dr Anna Stout

Truly honoured

Micronesia blog by Dr Anna StoutMicronesia is an archipelago of several hundred islands in the Western Pacific, four of which make up the Federated States of Micronesia (FSM). Pohnpei, the largest of the four state islands, is 135 square miles of gleaming rainforest, mist-topped mountains and mysterious mangrove swamp, and where I have been now for three weeks as a volunteer.

The WHO Pacific Islands Mental Health Network was established in 2007, and currently has 19 countries as members, including the FSM. As part of this network, the FSM has established a Substance Abuse and Mental Health (SAMH) council at a national level and in each of the four states.

My placement in the FSM has been arranged by the World Health Organisation in collaboration with FSM’s SAMH project, led by the administrator for the programme, Mr Kerio Walliby. Kerio comes to meet me at the airport on the day of my arrival and almost immediately whisks me off to a World Mental Health Day party at a local restaurant in the bay, where they have roasted a pig in honour of my arrival. Kerio is proving invaluable as a source of much needed information, support and reassurance when I am having one my many blips - those times when I realise for the hundredth time that I know nothing of any relevance and have no idea what to do next. Nevertheless it always seems to work itself out again, one way or another, with Kerio’s calm, good humoured assistance.


"Does a bit of everything”

Each of the four states provides health care to the population via a private hospital, and a state hospital, with outreach health clinics, dispensaries and aid posts in the communities. The state hospital provides emergency and elective treatment, and is staffed by a number of general physicians. I meet Dr Elizabeth Keller, the Director for Health, in my first week here, and also the Secretary for Health at the government buildings in Palikir, the capital of Pohnpei.

There are seven trainees with me for the next three months – four from SAMH programme in Pohnpei and one from each of the other three states – Yap, Chuuk, and Kosrae. They have a range of job titles, including counsellors, outreach workers and community workers, but they say that everyone “does a bit of everything”. There are no psychiatrists on any of the islands, and the patients who need to see a doctor are seen by the general physicians in the State hospital on each island.

Mental Health care in the FSM is entirely community based - there are no inpatient facilities for mental health patients in any of the four states. Patients who are violent or unmanageable are held in the local prison. Pohnpei and Yap State have a “holding unit” – essentially a seclusion room – but these cannot be used unless families are able and willing to stay with their relative 24 hours a day and provide food for them. Given this is usually impossible, the jail is much more frequently used. Patients who are incarcerated in the jail are seen daily by the SAMH workers to be given medication, and once a week by one the doctors from the State Hospital. The decision that the patient is stable enough to go home is taken by the doctor in collaboration with the family, and there is no mental health legislation in any of the states. We plan to go to visit the jail and the clients there as soon as we can.

Micronesia blog - Dr Anna Stout

Tempermental jeep

Micronesia blog - Dr Anna StoutAll the clients of the SAMH programme are cared for in the community by their relatives. The church also plays a large role in supporting families and the mentally ill. Families don’t have the means to bring their relatives to the clinics in the towns and so the SAMH workers go to see them at home, or they might be taken to one of the local dispensaries, or community clinics. So several times a week, and whenever a call comes in for assistance, three trainees and myself pile into the temperamental jeep and bounce off into the jungle. These routine reviews are mostly to administer medication and check on how people are doing – patients are seen on average once a month.

On one of these visits we visit a family with two adult sons, both of whom have a diagnosis of schizophrenia. The father explains in Pohnpeian dialect that the eldest sometimes experiences distortions of his face, with tongue protruding and stiff jaw. When this happens, the parents stop his oral haloperidol for a few days, but then he begins to “act strange” again – angry and running off into the forest and onto the neighbours’ land, chopping at their trees – whereupon they start his tablets again.

We talk to the family about dystonia and the importance of maintaining medication to prevent relapses, and leave a prescription of anticholinergics to try. I am desperate to change his medication to an atypical......but we don’t have any. The only consistent supply is of Fluphenazine and oral Haloperidol, which runs dry from time to time.

Later on, in the jeep, Stencer and Kehn, the two Pohnpei community workers, tell me that there was another, eldest son, who was found murdered in the mangrove a year ago. They think he also had schizophrenia and was attacked and killed in response to his bizarre and aggressive behaviour, although no culprit was ever found.

The active caseload in Pohnpei is approximately 75 with another 100 ”inactive” – this is in a population of about 36,000. Inactive clients are those who are known to have mental health problems but who have refused to engage or take medication. The trainees tell me that frequently it is often the families who refuse, not the patient. Families play such a pivotal role here – no patients are seen without their families consent; it is families who bring their relatives to the hospital or clinic for help; families make decisions about treatment.

“I cannot be happy unless my family is happy”

I am touched by how welcome I have been made since I came. Pohnpeians are warm and generous, and I am trying to accept all of the many invitations that come my way. I am finding that this is a great way to learn as much as I can about the local way of life, and people’s ideas and beliefs about mental health, what works and what is still needed here. I've learnt that the reliance on family and community to support and help one another is the natural way here – that clan is more important than individuality. As someone says to me “I cannot be happy unless my family is happy”.
Micronesia blog by Dr Anna Stout

Suicide is an increasing problem here, with FSM having among the highest rates in the world. But it is also a taboo subject. Local people tell me that the majority of Micronesians believe that talking about suicide will “put the idea into the heads” of others – when I suggest reaching out to young people and educating them about suicide, the trainees tell me that parents would find this unacceptable.

I learn that local belief is that the spirit of a suicide victim will “infect” others and cause them to kill themselves too unless prompt action is taken – e.g. the tree that is used by someone to hang themselves is burnt to the ground. They tell me that “anger suicides” are rife – that young people who are refused some latest gadget by their parents, or who are jilted by a girlfriend or boyfriend, kill themselves as a way of punishing their families.

A man in town I talk to tells me that he thinks the problem is the decline of traditional values, respect for the elders, and that the young people here are “lost” amongst the conflict of local values with Western ideals. I wonder about depression and the role it plays, but the trainees tell me that depression as a concept is new and not widely held here, that people who are suffering from emotional distress or symptoms of depression are taken to the local healer and do not come to mental health. The SAMH clinic seems to only access patients when they become violent or chaotic. It is not a cultural norm here to talk about your feelings, especially not to an outsider like me.

Challenges

The trainees are enthusiastic, friendly and well equipped with a good sense of pragmatism and humour. They are keen to know more about how to explore psychopathology and how to tell one major disorder from another; and they are quick to come up with ideas as to how we can disseminate what we are doing to others once training is done. They tell me that the biggest challenges they face are to do with resources – human resources, transport to access patients, medications that run out and don’t get restocked.

There is so much for me to learn and to think about. I knew I would be challenged a lot out here, but I am utterly a novice, in so many ways. Three months is no time at all, and we’re already a month in!

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About this blog

Dr Anna Stout

 

 

 

 

 

 

 

 

Dr Anna Stout graduated from Edinburgh Medical School in 2000 and started psychiatric training in London. She was awarded a CCT in May 2010 and spent eight months in her first consultant post before leaving for Micronesia. She has always been interested in working overseas and has a Master's degree in Culture and Health from UCL.