“It is because his body is thin and his arms are long…mmmm this is body psychiatry and he is schizophrenic”
I squirm in my chair, under the shade of the mango tree, as I listen to my trained psychiatric nurses diagnose a client after meeting with him for 5 minutes.
“When they are short and stout they are more likely to be anxious and stressed,” they pause as they perceive my face of horror, “Yes, Georgie, this is body psychiatry!”
I wonder if they learnt this from the same man who has rumoured to have been on the radio saying, “You need to understand, black men need to take double the psychiatric medication as white people or else it won't work”
This from a man who seems almost seems desperate to hold back the advance of mental health services in the country.
I'm told he has also been on the radio saying that everyone should ignore these new nurses and these Enabling Access to Mental Health people (my programme) as we are all crazy too.
After trying to disassociate myself from the conversation on “body psychiatry” I find the patient and sit down next to him – despite my nurses and his family telling me how violent and scary he is. He is calm and sits mumbling to himself, clearly troubled but coping to a degree.
“I am somebody – I studied and I am somebody”
I try to say that he will be again but the sentiment is lost in translation.
That is how I feel about my new job! Lost in translation. Over the next 6 month I must travel around the entire country setting up brand new community mental health services, spearheaded by these 21 psychiatric nurses. Two of the nurses I am currently travelling with are both male and old and cannot hide their distaste at being told what to do by a younger woman. Over the 3 days when we visit the hospitals and community health care clinics we are greeted by cries of “there is so much need for you people, tell God Tanki that you are here… Mental health is not a new thing here but it is neglected.”
Confidently I follow up that cry by asking how many people do they treat with mental health problems… and the answer has so far been “none”. It takes at least an hour of chatting before we come to an agreement that alcoholism and drug taking (which is rife in the rural communities) could be considered a mental health problem; and that similarly rape and resulting teenage pregnancies might impact on the individual's mental health and perhaps their subsequent bizarre behaviour was a consequence of the stress of what they have been through rather than witchcraft or demon possession. Where we seem to differ is domestic violence, the male perpetrators being described as the “victims” and the ultimate outcome always being to keep the couple united despite the intensity and frequency of violence that the woman suffer.
We bump along undulating red dust roads; rocks scraping the underneath of the car and long grasses brushing the sides; a 12 mile journey taking well over an hour and the sun sitting high above us burning through the open windows. We arrive at different Peripheral health units (PHU's) and meet with Community Health Workers (CHOs) and Midwives who we have trained in 2 weeks basic mental health and Mental health first aid (a new favourite concept from the WHO). The psychiatric nurses – the first psychiatric nurses trained in Sierra Leone – greet their subordinate CHOs with an air of arrogance and disinterest.
“So how many of these mental health cases are you seeing?” ask the nurses, for the last 5 PHUs the answer has been “none”, but finally, finally, in the most remote and distant PHU the CHO says “so many.”
I perk up and ask him to tell me more.
“I have this one lady who comes in every day complaining of chest pain. I have checked her blood pressure and she has had X-rays in the big cities, she is fine – so I asked her about her life and she said she was single mother who was struggling. She had watched her family be killed in the war and….”
At this point the CHO stopped, reading the professional pride – and maybe relief – in my face, and said “I am seeing her every week now and she is talking to me. Her chest pains have reduced”
A smile grows across my face as he continues “I have another lady who goes through periods of being fine, she is a teacher, but then every three months she starts misbehaving,”
“Go on,” I say.
“She throws stones at her husband and refuses to speak to him – I have treated him and he says she is crazy. He wants to take her to a traditional healer”
We sit and discuss what he could do to manage this case and I am enthused. These traces of good practice are going to be the sustenance I rely on to get through.
There has never been a mental health system here before.
Most cases are still being locked up in houses or chained to trees and taken to the bush to be cared for by traditional healers or are walking the streets of the bigger cities chronically unwell and almost past help.
Although most of my practice will be lost in translation I guess the idea is to create a new language.