Dealing with mentally ill street-dwellers What are the solutions?

Sunday Stabroek speaks to two psychiatrists

There are a growing number of persons with obvious signs of mental illness on the streets and there have been many calls for the government to address this problem more especially in the light of some recent cases where persons were attacked by the mentally disturbed.

To start addressing the problem, according to two doctors who have been treating the mentally ill for years, there is need for education on the issue and a need for a caring population and government. These are the easier areas in which the problems can start to be addressed since the country does not have the facilities to effectively deal with those who are mentally sick.

“Mental illness has to be proclaimed as one of the concerns of a caring government. The government itself has to agree that or conclude that something needs to be done, so… they get to the point where they not only see…that there is a need, but…[can] separate biases and prejudices from the manifestation of the illness,” well-known psychiatrist Dr Frank Beckles told the Sunday Stabroek in a recent interview.

Dr Michaela McRae
Dr Michaela McRae

He said that the biases and prejudices of the country reveal themselves in the language of the average Guyanese, for example, when they use the term ‘mad,’ which suggests a bias not in favour of the mentally ill.

For Dr Michaela McRae, who practises out of the Woodlands Hospital, Guyanese need to become more caring. What is needed, she said, is education which is the most essential and also the easiest step, because it offers several opportunities, including the possibility of identifying situations before they get out of hand in the workplace, the family, among friends and in the neighbourhood. At this stage it would not have reached a point where it is uncontrollable and nobody wants to help any more.

“You can salvage this individual before the point of no return, so education is probably the number one step… also it would ensure a higher level of tolerance and understanding whereby instead of ridiculing and discriminating and aggravating the situation with our stupid comments, we can nurture, and nourish and support and help the individual…” she said, adding also that after a person has recuperated, with education they will be supported and not be made the object of unwelcome jokes thereby triggering a relapse.

The Sunday Stabroek attempted to have Health Minister Dr Ramsarran and government psychiatrist Dr Bhiro Harry respond to the issue, but an emailed list of questions as requested by both and sent to them more than two weeks ago have gone unanswered.

Minister of Human Services and Social Security Jennifer Webster in a brief comment to this newspaper pointed out that it is the Ministry of Health that has to address the problem, since persons of unsound minds cannot be accommodated at the Night Shelter which provides night accommodation for the homeless. She suggested that the persons be picked up off the streets and placed in the hospital, because they need medication and medical evaluation.

However, she quickly noted that current legislation does not support the arbitrary removal of persons off the streets and she suggested that her colleague minister Dr Ramsarran pilot the requisite legislation to facilitate this.

In reality Minister Webster’s suggestion is not practical according to Dr Beckles, because the available facilities cannot accommodate the sheer volume of persons. Coupled with this is the inability to effectively treat them and Dr McRae observed that it is not good to house persons with various mental illness together, as this in itself can pose problems.

Street dwellers in central Georgetown
Street dwellers in central Georgetown

‘Starts with the President’
According to Dr Beckles, who is a consultant psychiatrist and also deals with stress related disorders and organizational stress management, addressing the problem has to start with the President who must have a willingness to have something done about it. He suggested that the government call a series of meetings  dedicated to discussing the issue, and after the first meeting set up a working committee to obtain information because the information is not available.

“…there are many impressions but there is no solid information; the decision to intervene requires information, and information to be useful has to be gathered in a particular way, has to be collated and interpreted before more money is spent. So the government might be well aware of that,” Dr Beckles said.

He noted that there is not much that can be done for the persons on the streets in the immediate future since the capacity is not there to effectively treat them.

“Where are they going to sleep?  [Once] you have them there you are obligated to treat them, the government…like myself…don’t carry excess medication. I guess they would be tempted to start treating and run into problems and the same problem will still exist,” he said.

He went on to comment that he has no idea of what is done in the schools, but perhaps that will be the easier point at which to begin to address the issue. He said that some children come from households where there are mentally ill parents or other relatives, and they go back to these households uninformed and are taught whatever it is the parent thinks or feels or whatever the church tells them about mental illness, and so they remain uninvolved with the problem until something tragic occurs.

More trained doctors in the field are needed, said, since once treatment is started with the persons on the streets, the government will tell you, they will attract such a volume they can’t manage.

“The need is there, clearly; it is such a crucial need that nobody is willing to start. Or if they start they will quickly or eventually decide that this doesn’t make sense,” he said.

He pointed out that there are myriad reasons why persons end up on the streets, some may be unable to pay rent, others might have had their homes foreclosed and others might have lost their homes in fires. Another contributing factor is drug use and he is not sure if there is enough data to determine how significant it is.

‘How prepared?’
Meanwhile, according to Dr McRae the real question is how prepared and interested the country is to do something about the problem, adding that another question is what facilities are available to address it.

Of particular concern to her is the fact that all persons who suffer from mental illness are housed in the psychiatric ward at the Georgetown Public Hospital Corporation (GPHC) but she said just as it is with other illnesses it is not a good idea to have all of them in one area.

“It is not always a good idea, it is not healthy to put everybody together…” she said pointing out that some of the conditions with treatment can be corrected, but when they are together like any gathering, friendships are struck up and relationships continue, and after their hospitalization habits are shared.

This means that additional risk factors are being visited on a population that already has difficulties functioning normally, adjusting and coping, and they do not need more calamities in their lives.

And while the idea of a national psychiatric hospital in Guyana is highly necessary, Dr McRae, who has been practising in the field for over thirty years, said right now it is a theoretical concept, since the country does not have the “resources, interest and consistency of effort to do what is necessary to really transform that institution for the purpose it is supposed serve in society.”

She said the institution in Berbice needs a lot more personnel, highly qualified doctors and nurses, physiotherapists, pharmacists and lab technicians.

“It would have to be an autonomous entity whereby it can survive on it is own. It would have social workers, vocational workers; people who are at different stages of care for these individuals could prepare and help them to reintegrate into society,” she said.

Instead persons are allowed to leave the institution when they like and end up right back on the streets and this, Dr McRae said, defeats the purpose.

Also another sore issue is the medication that is available which Dr McRae said is not the kind that is needed, as in many instances drugs which have been withdrawn from the market are still being used. She said while some old medication is still useful, there is a new generation that is very good and easier to use which ensures a higher level of compliance.

“When you have to use medication once a day as opposed to three or four times a day, and only one set of tablets as opposed to three or four, it is obvious why people would be more inclined to stick with that regimen than being cluttered with something which after a while makes them feel more sick…” Dr McRae noted, adding that it is harder to fight depression when you are reminded of how unwell you are by the sheer necessity of using handfuls of tablets every day.

‘Not accepted’
Dr McRae, who is Romanian born but has been living in Guyana for the past 30 years, said persons with mental illness are not accepted; they are pushed out and are not encouraged even by their own families. In Guyana, she continued, there is really no support system in place as while there are some support for alcoholics and drug abusers, there is nothing to deal with depression, anxiety and other illnesses. There is also no place where families can go and be educated and no hotlines where persons can call if their relatives suddenly freak out; sometimes they go to emergency and wait for hours.

“We are not organized to address this kind of situation, we don’t have what we need in place…” she noted.

There is need for counselling for families and if they are not prepared then it will remain a big problem as it is very difficult to deal with someone with mental problems.

“All these things need to be considered, all these are aspects of necessary intervention that could facilitate [change] because getting back to the origin of so many of them being on the road, you know why at some point the family can’t cope and they kick them out, so they end up sleeping on the road because nobody can put up with them any longer. This is another…category of homeless people with psychiatric illness who have been abandoned by their families [because they] could not cope any longer in the absence of any assistance or support.”

More doctors need to be trained in the psychiatric field which she said takes a great deal of time and energy. She pointed out that there are just four doctors who work in the field of psychiatry, all of whom are over 50, and there are no new doctors being trained in the field. While there are foreigners who would rotate for a year or two, Dr McRae said it is a disadvantage, as she has worked with them and their English is not good enough to ensure that they are helpful.

There is need for intense communication and if one cannot understand Creolese which is the only language in which some Guyanese are able to express themselves, then there would be a problem. There is also need to understand the context, circumstances and the spiritual and cultural background of the various races living in Guyana, and this will be difficult for a foreigner who is just visiting.

“Now if you don’t make the correct judgment, you cannot make the correct diagnosis nor can you venture to offer the correct solution which has to do with the treatment,” she said.

And one of the main factors of mental illness is drugs which have increasingly become more accessible in spite of the official noises, since many places in the city people access drugs openly.

“One of the reasons is because of the increase and the availability of drugs; obviously it is not just marijuana as it was long ago, marijuana now has been joined by a lot of far more potent and dangerous drugs…” Dr McRae said.

Also contributing to this are the many persons who are returned to Guyana who have been exposed to the harder drugs, and are on many occasions they are the ones who introduce it here since they come back with their habits. This aspect, she said, needs to be addressed, while questioning whether there is any system in place to trace such individuals on a regular basis to ascertain how some of them survive.

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