Concrete plan 

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.

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 

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.

Storm season 

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

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.

Truly honoured

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.

Tempermental jeep

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”

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!