11th Johor Mental Health Conference: Deinstitutionalization

I just came back from Johor Mental Health Conference. This was my second attendance for the conference, and both as a delegate. I hope to attend it as a speaker the next time, Insyaallah.

I was interested about the keynote address given by Prof. Hermann from Melbourne on the first day. She talked about the Australian mental health policy and touched largely regarding the effect of deinstitutionalization for the homeless psychiatric patients. It was interesting to note that she sincerely acknowledged that Australia is still failing in deinstitutionalization of psychiatric patients although it is a developed country and has a very well-established and systematic health delivery systems.

I felt Malaysia is way way back than Australia in term of deinstituonalizing the mentally ill.

The first problem lies in the acceptance of our community towards the mentally ill. I am generalizing Malaysians when I’m speaking about this problem. Malaysians at large still think that mentally ill people should be living together with ‘those who have the same problems’ and separated from the ‘normal’ people. Malaysians also think that the government should take the fullest responsibility in caring for these mentally ill people. Things are made worst when psychiatrically impaired persons are admitted to the ward repeatedly, and the family will express their intention and utmost desire and request for the patient to be kept longer in a psychiatric institution thus the expressions of:

“kami tak tau nak buat apa lagi dengan dia ni, doktor hantar jer lah dia masuk Tg. Rambutan, bagi dia duduk lama-lama sikit kat situ, at least kat situ ada orang yang tengok dia makan ubat”

“lepas dia baik nanti, baru bagi dia keluar”

“kami ni semua kerja, mana ada masa nak tengok dia makan ubat dan bawa dia jumpa doktor”

“dia ni memang menyusahkan family la doktor, ada ker dia boleh pukul mak saya, saya balun la balik. Celaka punya anak”

These requests may have been accepted by the doctors 10 or 20 years ago, and patients will be happily transferred to the four psychiatric institutions available.

However, with the wave of deinstitutionalization that started in the 1960s in the west, and the introduction of a more comprehensive community care in Malaysia since 1990s, these requests were less entertained, and responsibility given to the family for the long term care of the mentally ill. The four psychiatric institutions were gradually minimizing their number of beds, and expansion of capability for psychiatric care in govermentment hospitals intensified.

Deinstitutionalization should be done concurrently with the empowerment of the family to care of the patients. Families should be prepared with basic knowledge of the illness (so that they understand the cause of it, the symptoms and indicators of relapses), the importance of medications and continuous follow-ups and the psychosocial rehabilitation programmes.

Then, the surrounding communities (neighbours, village folks etc) should be educated about mental health through small and short explainations, for example after solat jemaah or friday prayer, sermons at the church etc. The community in which the patients live must be told that a recovering/recovered mentally ill people is still part of their social fabric and should not be isolated.

Antipsychiatry movement and consumerism

http://www.ect.org/evolution-of-the-antipsychiatry-movement-into-mental-health-consumerism/

 

 The link was emailed to me by my friend last week.

My first impression was of shock that there are people outside there who still think that psychiatry is not a usefull branch of medical study. Later, after reading the first few paragraphs, only I start to realize that the antipsychiatry movement is due to the ‘conflict’ between the psychiatrist themselves. The question whether psychological-based or biological-based psychiatry is appropriate has been an open secret for decades, at least among the psychiatric community. It was quite shocking when the article mention about prominent names such as Foucalt, Laing and Szasz as the founders and thinkers of antipsychiatry movements at the initial stage. These are the names who still exist at least in the basic sciences text book of psychiatry that i’m reading for my exam. However, it was sad that the article did not mention any prominent names from the biological-based psychiatry who tried to counter their opinions.

The article described prominently about the ‘power’ biological psychiatry has over the states and goverment and has been trying to put bad lights on the psychological psychiatry. Many books and articles from the thinkers of psychological psychiatry was mentioned about the apparent overrule of biological psychiatry and their mistreatment of patients.

However, it was sad to note that the antipsychiatry movement has been taken over by so-called radical consumerism activity. The academic thinkers of psychological psychiatry has been shunned off to make way for former psychiatry patients to take over the leadership. I’m not sure what the article really mean by former patient. Maybe those who had already 100% cured from their psychiatric illness with nil relapse episode and not taking any kind of therapy anymore, or are they those who are only taking psychological-based therapy.

It’ll take another 10, 20, 30 or more years for patients and consumers in Malaysia to realize the antipsychiatry movement does exist and has been championing the rights to avoid involuntary admission, prescription of drugs and physical treatments. How are Malaysians gonna realized that when we are still believing that psychiatry is another disturbances in life due to the disturbing forces of the unknown, and when patients are more likely to be brought to see the traditional healers first before doctors.

Minta pertolongan mencari waris pesakit

  Pihak Jabatan Psikiatri & Kesihatan Mental Hospital Sultan Abdul Halim, Sg Petani, Kedah ingin meminta bantuan orang ramai yang mengenali pesakit di dalam gambar di atas untuk mencari waris beliau.

  Pesakit tersebut bernama Azmi Aziz yang telah dimasukkan ke wad psikiatri dalam bulan Januari tahun ini kerana dikatakan bertindak agressif. Walaubagaimanapun, pesakit didapati tidak mempunyai sebarang tanda-tanda psikotik semasa berada di dalam wad.

   Waris pesakit ini tidak langsung datang untuk mengambil pesakit ini setelah namanya dikeluarkan (discharged) dari daftar pesakit, malah memberitahu staf bertugas supaya meletakkan pesakit di mana sahaja yang difikirkan sesuai kerana mereka sekeluarga sedang berada di Kuala Lumpur kerana masalah kesihatan. Usaha untuk terus menghubungi nombor telefon yang diberikan sia-sia sahaja kerana bapa pesakit tidak mahu menjawabnya, dan satu lagi nombor telefon yang kononya dimiliki oleh abang pesakit sebenarnya tiada dalam perkhidmatan.

   Alamat pesakit yang terakhir adalah di Kulim, Kedah. Kami meminta sesiapa sahaja yang mengenali keluarga pesakit supaya dapat menghubungi pihak kami di 04-4457333 ext 3829/5001. Pihak kami tidak mampu lagi menyimpan pesakit dengan lebih lama kerana faktor tempat dan kemudahan, dan juga berasa kecewa kerana pesakit seolah-olah dibuang oleh keluarga beliau dan memberikan tanggungjawab kepada pihak hospital menjaga pesakit dengan sewenang-wenangnya

this is not what we hope for “kumpulan sokongan keluarga”

      I took yesterday’s session of our inaugural Kumpulan Sokongan Keluarga class. It was the 4th class and it was about problem solving regarding psychiatric patients and myths about psychiatric patients.

      The main problem was regarding the attendance of the participants. Yesterday, only 10 non-staffs who attended it, and from the 10, it was from 3 to 4 families only. The 3rd class, which was also given by me, saw attendance of less than 15. The only people who made up the numbers were those nursing students, and our own psychiatric staffs.

       This is not good to the programme, and certainly we will be having difficulty in achieving the target to encourage more public participation in the overall treatments of psychiatric disorders. The first, and to a lesser extent, second session showed quite a number of participants, until we need to put up additional chairs. Then the number started to drop. Some said it was because of the recently concluded election, and now because of the school holidays.

       It is so difficult to get co-operation from the public in this kind of no-reward-guaranteed event. The Malaysian public, regarding of any race, is very reluctant to come for informative talks, and events that will not give them direct benefits. Though unless, the participants are provided with free transport and also monetary rewards for attending these kind of event. Malaysians prefer their wellbeing taken care of once they leave the comfort of their home, and any matter that need sacrifices will likely be taken with only if it really affects their ‘comfortable’ life.

 

      As a goverment agency, we are trying to educate the public regarding better participation in term of social wellbeing of our patients. We try to give spaces for the caretakers to share their problems and successes in caring the mentally-ill, so that a person’s success could be taken as achance for the other person to try. We want the caregivers to know that we are not lying when we say that they are not alone in handling the mentally-ills, and there are those who have the same problems with them. Then, we want to use those who we had educate and train as mediums to access the local community to spread the right way of care for these unfortunate souls.

 

      I hope that the next classess will be filled-up again. There’s no point talking to the medical staffs alone, because our main aim is the public …… and it will be them who shall gain the utmost benefits of attending our little activity.

 

 

 

BERKIDMAT UNTUK NEGARA

I’m out

For a specific reason which is still unclear (but I won’t bother clearing it up), I was relieved from the job of Community Psychiatry Unit co-ordinator. The job was passed on to my senior colleague. Hell… I’m relieved! Huh! After this there will be no more ‘trips’ for home visits, and I can always concentrate on ward works.

No worry! I’m not disappointed! I’m actually glad. At least I already contributed to the initial setting and clearing up the initial mess and co-ordinating the first few home treatments and problematic cases. All the best!

when a mother rejects her daughter

This a true story:

   There is a young girl in her early 20s who started being our patient 2 years ago. Lets name her as SH. SH first presented to us with visual and auditory hallucinations. She was prescribed the usual medications for schizophrenia. However, we noted she seldom came to our follow-up and didn’t take her medications. She has several admissions to the ward with increased frequency since early this year. The most frequent reason for admission was her threat to commit suicide. Strangely nobody made police reports except on one admission. We started noticing that she became as normal as a human being can be after being admitted each time, however, she showed some depressive symptoms and anti-depression was thus prescribed upon discharge. At these times, we started to become suspicious of her psychosis. Another strange thing was that the family refused to take her back after discharge. So, we made an assumption that the girl might be having behavioural problem instead of true schizophrenia. A family therapy was dully done to educate the mother about her condition, but the session turned out to be a time for the mother to ventilate.

    Things began to turn clearer this year. SH started running out from house, wandering around but most times sleeping and staying at the hospital’s visitors’ station. She alleged the security guards of molesting her (a baseless allegation similar to allegation that her brother raped her when she was 8-year-old) and threatening to jump from the building if she was not allowed to be admitted. She was admitted to the medical ward due to so-called seizure. No seizure was noted during her stay and subsequently diagnosed as pseudoseizure and discharged. The mother refused to pay the hospital bills and didn’t want to take her home. The ‘caring’ staffs of the ward collected money among them, paid her bills and let her go wherever she wanted (they need to vacant the bed to receive new admission). SH ended up at the same place, creating the same problems. I refused to admit her to my ward unless we agreed for some behaviour modification therapy. SH was really a pain in our ass during the stay! She was lazy and preferred to eat and sleep only.

We did sent her back home together with our CPU team. We talked to the bilaterally amputated father about her. He is clearly not the decision-maker of the family. We left her and promised to visit again after 2 days. She turned up at the hospital the next day, creating disturbances in the surgical ward, saying the mother fought with the father about her problems. But we decided to visit her house again after raya. This time we went there with a specialist and a senior medical officer and a social worker. We took her along although she blatantly refused at the beginning. That day we talked to the mother. Clearly, most of the problems stem from her. The mother was ready to accept her, but she was the one refuse to come back. She alleged her brother raped her. She once acted as if she was pregnant due to the raped. She spent money she collected for the school’s charity drive. A lot had been done to help her. The brothers chipped in energy and money, but none brought any benefit.Ok, I’ll be fair to SH here for a while:

She has a big family with 12 siblings; 7 males and 5 females. What I can say is that the males are not the usual males. They are quite ‘soft’. The way they communicate among each other is so childish. I found some of the behaviour awkward and inappropriate. Some of them might be having borderline or low intelligence. They live in a low-cost house in a densely populated low socioeconomic area. They managed to renovate the house (maybe due to the ability of one of the brother to run several wedding shops) and the house was surprisingly clean. For me, I think it’s quite difficult for teenagers or young adults to grow in that kind of situation. To add salt to the flavour, the mother is a type who would give free lectures.

    Now, back to the gist of the story:

We decided to make a police report. The mother agreed. She was also ashamed of her behaviour and didn’t mind the police intervention (the police had brought her back several times when she was found wandering, she once told them she only has a step-mother). Our aim was to scare her and showed that we really mean business about her behaviour and attitude. Quickly, SH agreed to get married (she has an admirer who is willing to marry her whenever she say yes) and to stay at home. NO WAY JOSE! We really wanted to teach her. We took her to the police station. While we were making the report, she got a round of lecture from a female inspector-in-charge and later, another bashing from the DSP of the unit. We completed the ‘preliminary’ report. If she ever make any more problems or disturbances in the hospital, another police report will be made and she’ll be seeing lights from behind bars.

We discharged her the next day to her house. I hope that will be the end. But we never can predict, as it’s too early to say whether the end has come.

So, enough of my notes today. Bye bye.

 

My first community psychiatry visit

Actually I wanted to put the title as “my first community psychiatry experience”, but since i has been involved with comminity psychiatry matters for already several months, I thought that title was not suitable.

  My first home visit was on Monday 10th October 2007, accompanied by 2 dedicated community psychiatry team (CPU) nurses and a sister initially. We started by bringing one dilinquent ’adult’ back to her home where we wanted to have a talk with the mother. Luck was not on our side as she was out to the wellfare department to collect the monthly aid. The house was a low cost house, but was well renovated. It was not like the low cost house which I used to go and visit when I was a child in my hometown. It was surprisingly kept clean except for some empty snack packets outside the front door.

  Reality really strucked me when we started visiting those who live in the rural areas of this large Malay heartland. I usually used the road at night to reach the seaside for the not so delicious seafood thus missing the real view of the villages. But, my visit that day opened my eyes to the harsh reality of life. These people were actually living in a really really small house that I think fit to be lived if we just achieved independence. The house was small to accomodate a large family, the surrounding area was dirty and smelly with animals and pets excrements, the inside areas were dark and damp (it rained that morning) although the cloudy, slightly wet and cold weather did lightened up my feelings, the furniture was not properly arranged, the toilet was not properly covered, and even the doors were not closed eventhough the occupants were either enjoying their late morning nap or out to work or town. Those conditions really surprised me! I’m confident that my sister-in-law will not take off her shoes and step into the house although she’s wearing her socks!

  These people don’t have a proper transport to come to our hospital for their follow-up, but we still insist them to come all the way. Their houses were located far away from the main road and far in between houses. Some of them are lucky enough to have motocycles, but imagine riding a motocycles with a yet-to-be-stabeld mentally ill patient! Yup, those houses I visited were the really poor people, and these people don’t have ASTRO satellites on their roofs, and no 16-inches TVs in their living room.

  I wonder how a mentally ill patient gonna take his/her medication properly with that kind of environment? They have to slug it out just to live, but with proper medical care, maybe they can’t even think of slugging it out.

    So, is home treatment the answer?