What ails psychiatry?

Awareness of the policy makers -need of the hour:

Consultant Psychiatrist Dr. Usha P. Gunawardhana, President elect of the Sri Lanka College of Psychiatry, speaks on the lack of awareness of the society especially on the part of policy makers. It has become an intractable issue for social development.

It also seriously affects the Human Development Index. Dr. Usha P. Gunawardhana is a Member of the Board of Study in Psychiatry, Examinations at University of Colombo & Sri Jayawardhanapura and a Visiting Lecturer at the Open University of Sri Lanka. She is also a Consultant Psychiatrist of the “Sahanaya”, the National Council for Mental Health.

Q: What ails Psychiatry? Isn’t this an astonishing observation? Do you wonder how this has happened?

I have my own explanation for this, which I wish to share with you to-day. What I believe is that individuals with a label of Psychiatry are seen as ‘crazy’ people by their community which means their opinion, their feelings, and their needs are of little consequence.

Therefore time, money and resources are deemed to be unnecessary for these people who are not worthy of our consideration. This of course is an opinion of the people in our society. And who would disagree with such an opinion? Such is the task before Psychiatrists, to attempt to make individuals in the profession, be it the administration or for that matter our own colleagues to pay a little more attention to the individuals who come to them, seeking their opinion, their advice, because their relatives do not want to take them to a Psychiatrist, themselves !

Don’t you think we have an enormous problem on our hands? May be this is why Psychiatrists are reluctant to make any attempts to rectify this situation. Now you might wonder why, I have at this moment in time, trying to do just that.

May be I have finally decided to make an attempt to do something to change this. Well this is my attempt!! What my observation of life is that, people make an attempt to understand something ‘New’ when it is introduced to them.

At least they will make an attempt, but something that is already there, really does not warrant any attempt. Psychiatry and psychiatric patients have been here as far back as we can remember, and we have an idea of how to deal with this.

So what the individual does is to carry on treating it the way it has been treated before. If you are a traditionalist isn’t that what you will do? On the other hand if you are not, still isn’t this what your colleagues are doing and there are modern enough for one to follow their example. So we arrive at square one!

Q: Is this treatment of Psychiatry and the psychiatrically ill person quite correct?

What I believe is that individuals need to look at this problem again, forget all they know, forget what they have been told and have no preconceptions about Psychiatry or the mentally ill person. More or less I am requesting you to see Psychiatry and the patient from our point of view.

Now what we observe is that the behaviour pattern of our patients is rather unusual and sometimes can be very embarrassing. Whatever it is, it is the behaviour that is in question. Ask yourself, why is someone behaving in this inappropriate manner? Is he/she seeking attention from you, or is he/she unable to express himself/herself properly or do you lack the knowledge or understanding of what he/she is trying to say to you.

What I believe is the latter. That is the key. UNDERSTANDING. That is what is needed here to solve this problem of the psychiatrically ill person. To be a little technical with regard to the subject-Psychiatry revolves around two main signs.

One is hallucinations and the other is delusions. They are both false. Hallucination is a false perception and it occurs in all five modalities e.g. visual, auditory, tactile, olfactory and gustatory. Therefore if anyone alleges that they can see, hear, feel, smell and taste things others are unable to agree with, these observations are then termed to a lie and false.

In that situation both the patient and the relative can begin an argument, each accusing the other of lying will you an example that might help you to understand, hallucinations.

The person who experiences hallucinations will report to his/her relative that the neighbours are plotting to harm them and when the relative asks the person how he has come by this information, the person will report that he ‘hears’ them talking about this.

So the relative will tell him to call them when he next hears the neighbours talking about them. And when the person next hears such an occurrence, he reports to his/her relatives, the relatives will of course deny that they have “heard” nothing, which will invariably culminate in the two parties having an argument and this will conclude with the patient accusing his relatives of taking the side of the neighbours to harm him!

So actually now the situation will deteriorate n the family dynamics. This will now aggravate the situation further than solving his problem. This is what hallucinations “will do” to the family relationship.

They will argue about something that “occurs” according to the perception, which is false. It does not occur, but one party truly experiences this. The same sort of thing can occur when the psychiatrically ill person can come up against false beliefs. Here too, more or less families will argue about something that the patient “thinks” he naturally believes to be true.

When the patient informs his relatives that he now understands why he was born and that he was born to be a leader and he has the experience and the ability to be one and hence forth every body needs to obey his commands, the family of course will object to this. So like in the other example there will ensure an argument and ill will.

Therefore disagreements will occur in the family and this will give way to any degree of unpleasantness. Actually they are both correct. Each of them is saying the truth. One experiences, hallucinations and the other does not.

How does one solve this! Now if we can make the person understand that what he/she is experiencing is a symptom of illness and the answer is medication and not being locked up or thought to be crazy, I believe, there will be a chance for us to put things right and be able to solve a very real problem that is in our community.

To recapitulate, then the problem and the solution will be to see a person who has specialised in Psychiatry. Thanks to the energies of the Health Ministry and the College of Psychiatrists such trained medical personnel are available for consultation not only at the centre but also in the peripheries.

Q: What is the position that psychiatry enjoyed in Sri Lanka’s health care budget and why has it been relegated to an area of low priority?

A: In Sri Lanka from time in memoriam Psychiatry has occupied a very low priority and today it is no different. Other branches of Medicine, like Cardiology, Nephrology, Paediatrics, etc., have always been high priority.

Mental Illness has always been given the proverbial Step-motherly treatment. The reasons are very many. In my opinion, it is that no one cares for this speciality because people have to understand the needs of the patient, there is a shortage of money and Mental Illness lacks the power to attract resources.

Q: I gathered that although nexus between abject poverty and psychiatric disorder has been established, authorities in the health sector have, apparently, not taken this fact into consideration. So this has resulted in concentration of psychiatric health facilities and services such as counselling in and around the major cities. What are the steps that you suggest to over come this issue?

A: It is true that there is a connection between poverty and Psychiatric illness; but why it is so cannot be simply explained. All people in poverty do not suffer from Psychiatric Illness.

The popularly abused term Depression does not meet this criteria. Because Depression is state of mood, and everyone who suffers from a sad mood or depression does not get treated with antidepressants and most of them do get over this condition spontaneously.

So depressive illness though it is found in people in poverty, it is only one cause of it. This is the reason that counsellors are employed to deal with this situation because it is believed that social factors contribute greatly to this population falling ‘ill’. So the employment of counsellors to solve this by means of social intervention is tried by the community, because been treated with antidepressants or being treated by a psychiatrist carries a great stigma.

Poverty as such occurs in equal proportions in both major cities, and in the villages. As such it is a fact that the counsellors are found in the major cities but when it comes to poverty, in the villages they have their families to fall back on ,which is lacking in the cities. I have mentioned before this ‘illness’ has many causes and having counsellors in the villages may be a solution; but I cannot go along and say categorically it is the solution.

Q: What are the measures that government and community can initiate to stamp out social stigma associated with psychiatric disorders? And how does this negative perception affect the recovery of persons suffering from psychiatric disorders?

A: Social stigma and Psychiatry go hand in hand, why this is so is that the psychiatrically ill person is deemed to have very many intolerable behaviour patterns.

This is the fundamental issue-and this is so is because the signs and symptoms of the illness is the main cause for this. When it comes to physical illness, for e.g. pneumonia, the symptoms are cough, fever, lethargy, etc.

This is well understood by the community and the person then warrants a medical opinion and the person will get such an opinion and he will benefit from that opinion and the outcome would be very satisfactory to the person, his family and community. But this is not so when it comes to schizophrenia and its symptoms.

The community fails to identify its symptoms and more often than not the opinion is sought from a wrong source. By the time the person comes to the right source, a lot of things have happened to the person, family and the community.

Therefore, the psychiatrist is now addressing very difficult and complicated problems. I believe, to address this problem is for the Health Department to organize educational programmes for the community so that they will be able to identify the illness and then be able to advise the concerned people where they could take the person for necessary treatment.

This sounds very easy to perform, but I do not think it is going to be an easy solution. This needs to be well thought of and organised properly to be effective. A psychiatrically ill person has to first realise he has a problem; the very realisation will bring unimaginable suffering to him.

It is very difficult when it affects you. This can traumatise you as well as the family. Therefore, the recovery from a mental illness can be difficult. What the person of the family needs is the understanding and support of the community.

Q: Schizophrenia and Bipolar Disorder is a condition that Sri Lankans are not familiar with. Can you describe how it affects the persons suffering from it and immediate relations or care-givers?

A: Schizophrenia and Bipolar disorder are debilitating to the person who suffers from it. It is a well known fact if a person suffers from an illness it will have an effect on his immediate family. One of the main areas that this illness affects is the functional capabilities of the individual.

How one speaks, interacts, behaves and last but not least is the capacity to work. When we assess a patient on these aspects, he fails to perform adequately. The problem that we have is to devise a programme to overcome this.

The easiest would be to resort to medication to treat the illness and later focus on the other aspects of the function. The caregiver, usually the parent or the siblings, bears the brunt of this problem. Sometimes they feel guilty about themselves; they feel that they have done something wrong. Sometimes they feel angry, sometimes they feel this should have happened to others and not themselves.

But in the end it is a feeling of a NO WIN situation, a sense of despair.

Q: What are the steps that can be taken to improve quality of life of those who are suffering from Schizophrenia?

A: To improve the quality of life of a person with schizophrenia is a start. The professionals involved should have energy, enthusiasm and empathy, because they have more or less undertaken to do the impossible.

Initially an assessment of the person’s ability, his motivation, his support network needs to be carried out. Following this, a programme needs to be formulated to address the needs as assessed.

The problems need to be addressed one at a time and there should be a monitoring mechanism and a time frame for this. Regular evaluation is a must in this situation. If a plan fails, there should not be recriminations but instead should be able to go back to the plan to re-examine how the next plan for the task should be changed.