Accessibility Page Navigation
Style sheets must be enabled to view this page as it was intended.
The Royal College of Psychiatrists Improving the lives of people with mental illness

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


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.


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.

Subscribe to this post's comments using RSS


Add a Comment
Login - Members Area

If you don't have an account please Click here to Register

Make a Donation

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.