Thursday, 26 March 2009

The Confusion: Counsellors and Councilors

Until recently when the word counsellor was used, it was commonly understood that we were referring to anyone who worked in the field of mental health, some were drug counsellors, school counsellors etc…but nowadays the word counsellor (written exactly the same in dhivehi) is commonly refered to mean atoll or island councilors or people who will be involved in the administration of atoll provinces.

Well....counsellors, councilors the use of these terms must be confusing to many but I hope it just remain at that …as long as there is no confusion in the different roles they each have to perform I do not think there should be an issue with it.

However, it may be worthwhile to start thinking whether it may be more appropriate to substitute the word counsellor for words like case workers; case managers; support workers, etc specially if the job performed by counsellors(those involved in work related to mental health) does not involve active counselling but is only dealing with case management or support work.

I thought of writing this article of fear that tomorrow some one in the public ignorant of the difference between councilors and counsellors may approach those elected for administrating the provinces for drug counselling, marital counselling etc..hmmm

Wednesday, 25 March 2009

The status of mentally ill patients in Maldives; Story of S

The status of mentally ill patients in the Maldives is pathetic. The way they are treated is miserable. Their rights are grossly neglected, their needs are little understood and the services to address the mental health needs of the nation is inadequate.

Let me share the story of S.
I went to a house in Male' , hoping to meet a friend. But , I was informed that the person I was looking for no longer lived in that house and was given directions to another address. Just when I was about to get back to the taxi, a middle aged lady came and touched my elbow saying ,
'Can you do something for me?'
I looked at her, I saw teary eyes which were almost pleading with me.
I went inside again. And she said,
'I know who you are, thats why I am requesting your help. Can you please meet my son? Just for this once?'
I asked her what was wrong with her son.
She said, ' I do not know. But I have not seen his face for the past 8 months.'
I said,' But how is that possible, if he is living in this house how is it possible that you have not seen his face?'
She began to cry as she explained to me ...
' He has his own room, with attached bathroom. About 8 months ago something happened to him , he came running , looking very scared one night, one of his fingers were bleeding too....he went and locked the room and said, he will never open the room and he has not allowed any one of us in after that. I will put his food near the door and when none of us are around he will quickly take the food in and after he finish eating, he will put the plate ouside. It will be nicely washed. If he needed anything he will make a shopping list and put it along with the plate'.

I found it hard to follow a story like this. It was difficult for me to comprehend that a person could live in such solitary confinement in his own house.
The mother requested me to try and see whether he would open the door for me, she said he knew me, he had mentioned my name before this happened to him. So she felt he may open the door for me. To give a try , all she wanted to know was how he looked like now, the status of his room.....
I asked her about his past. He had a criminal history, had been released from prison and had a history of substance abuse. No past history of mental illness.

This definitely was not a normal situation for me and I wanted an exit because I was personally not convinced that I could be of any help to them at all.
But I saw this mother, her pain and something in me ...just made me move, go up to that door and knock.

I called out his name, once , twice, several times. After about 15 minutes I saw somebody move two of the top louvres of his window. I said, I am so and so and that I wanted to meet him and I would be very fortunate if we could have a chat.
An hour or more passed. I stood there hoping he would open the door. I asked the family members to move away because I realised he was able to see us.

He opened the door slightly, and looked at my face. He recognised me immediately , but looked behind to see whether there was any one else with me. I told him I was alone.
Politely he asked me to come inside .
I went in.

It was a neat room. Not a speck of dust. The bed was made, the room was mopped, every thing was in perfect order. Near the bed there were sheets and sheets of paper. I saw that these pages were all write a nonsensical script.
He was neatly dressed , but he definitely needed a hair cut.
He asked me to sit down. Gave me his chair and sat on the floor and said he was sorry but he only had about an hour left...even if it was for me he was not in a position to give more time.

My antennaes went up immediately.
What did he mean? I asked,
'So you have an appointment in an hours time?'
He nodded and said,
He was in the middle of a UN meeting, the helicopter would come to pick him up soon'
I asked him 'where is the Helipad?"
He pointed at the ceiling and said,'Can't you see, its up there'
I nodded and said pointing at the sheets of paper.
'So you are a busy man, I can also see that you have been preparing some documents?"
' yeah , I am writing a document , on how to change things around here, but this person here keep troubling me, he is troubling me all the time ...see he is here now, he is telling me that you are an agent, sent by the gang who tried to kill me some time back , he says that you have come on their behalf so I should not have allowed you to come inside...he says he will whip me again tonight because I have disobeyed him'
In about 15 minutes time, he disengaged from me, he was talking to himself, banging his fist on the bed and was in an obvious arguement with the person he was hearing and seing through his auditory and visual hallucinations.

Suddenly he looked at me and said,
'When I was in the prison I had met you, thats why I opened the door for you, I told him that you will not harm but he is still not convinced'
I nodded and replied,
'Does this person talk to you constantly, can you see him too?'
' YES....YES..he says I must follow his instructions otherwise he will harm my family , may be even kill my mother, thats why I don't open the door for any one, specially my family members.........................'
I felt so sad .
Here was a person who was definitely mentally ill , probably suffering from an early onset of paranoid schizophrenia. He needed to be under the care of mental health professionals, he needed to be hospitalised immediately.....but who will take him ? Which law states that he be taken for mandatory treatment????
Do we have a system of care which can reach out to this individual with such florid psychotic symptoms? Do we have a mechanism within our health care , social care system which can come to assist in the treatment of this mentally ill adult? or ...who will help in alleviating the burden that is carried out by the family members of this distressed family?
I informed the family that he was seriously mentally ill, he needed to be hospitalised, I had to educate the family on the nature of the illness, give them enough to read on schizophrenia.
But the family was scared that if they approached the state for help a police entry to take him to the hospital or Guraidhu could result in possible violence and their son may land back in the they felt it was probably better for him to be left alone this way.
Mr. S refused to go for voluntary treatment and still live within the confines of his room.

Sunday, 22 March 2009

The status of mentally ill patients in Maldives; Story of I

As I read a report on the local newspaper about a 19 year old mentally ill girl being raped by her caretaker, something inside me snapped.

I have worked with people with mental illness in the Maldives from 2000 onwards. During my clinical practice , I came across several such incidences, many of which went unreported because this is how the parents wanted it to be.
However, if the violence was ongoing or if the chance of it being repeated was present, I had to take measures to report these incidents.

On several occasions these women are repeatedly abused by their own families and/or by others in the community.
These girls are often understood to be just bad 'badi' girls as people have little understanding of the nature of their illnesses.
Sometimes they may be below average in intelligence , with mental retardation or may have a learning disability. Or they may be going through a psychotic experience, which propels them to behave differently.
I remember once being called by a parent to advise this particular girl , let me call her lady I.

She was reportedly wandering on the streets of Male' for several weeks, sleeping at public places and parents had to run around searching for her frequently. However, after a while parents stopped even doing this because according to them, ' she knows to get back home , so she is just fine , nothing is wrong with her, she knows exactly what she is doing ....she is just out to tarnish our name...whore!"
I was asked to advise her to 'behave'. I visited her house because after the description of her behaviour, I thought this girl was probably going through a psychotic relapse and it was likely she was suffering from Schizophrenia. I felt the need to educate her parents and challenge their mindset and also facilitate her treatment.

I had to go to her house several times to catch her on the times she apparently returns home. Finally when I did meet her, I was positive about her diagnosis, she had delusions of persecution, and also had several command hallucinations , where one voice in particular was commanding her to remove her dress and expose herself.

I asked the parents whether she had been seen by the psychiatrist and after searching the house someone came up with a prescription slip from a psychiatric consultation which dated back to 2 years. She was not on any medication, she was not receiving any help to alleviate the distress she was going through due to her illness.

But one of the relatives said, she was being treated by this 'fanditha veriya' and even showed me some 'thaweeds' tied to her waist and neck.

I asked her where she had been and she said outside with some boys. She told me that this man was telling her to go and meet boys....etc etc. Her body was smeared with sperm. Later I came to know she was gang raped just before she met me.

I had to tell the parents that she needed immediate medical attention, she needed to be admitted in the hospital, and needed the attention of mental health professionals.
It took me a while to educate the family , explaining to them that tying taweeds was not the solution, calling me to advise her was not the solution. Their beautiful daughter was very ill, psychotic and needed to have appropriate antipsychotic medication as soon as possible. Not only was it their duty to treat her but they also had to protect her from a society which was largely insensitive and ignorant to the needs and issues of people with mental illness.

After all this is that country in South Asia which has no mental health policy, no mental health programme or mental health legislation.

She is lucky that atleast there is one outpatient facility at IGMH which can offer her treatment (and the entire country!!!) if she gets lucky may be she would be transfered to Guraidhu until her symptoms could be controlled.

Friday, 13 March 2009

It is time to address gang violence in Maldives in a comprehensive way

Maldives research is one organisation which had proposed to do research on gang violence in maldives following the initial occuring of this behaviour in Maldives, but ....why is it not being done?
Read about the proposed research on Maldives research website;

"Gang violence is a new phenomenon for the Maldives. The proliferation of gangs and its overt emergence in Maldives is increasingly highlighted by media and police reports. Gang culture and gang violence has have already caused deaths on the streets of Male, something which was previously unimaginable in the country......"to read the rest follow the link.

Unless we understand the core of it, we will make blunders in how we manage the situation and i strongly recommend the concerned authorities to follow up research such as these .
The current situation of day light murders is totally unacceptable and we all have to unite to fight this without any delay. That also means we have to develop comprehensive interventions to deal with victims, their families, other gang members...their families .
We must arrest those who are causing this violence, those who are operating from behind and go beyond putting them in jail ..we must unite as a society to fight this situation before it is too late!!