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

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......


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.

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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.