Mental Health Care: Towards a New Vision
Lock up a normal and sane person (if you find one, please let me know! But anyway, let's just say a person who's within the range of what we call normal, so that we can go on with this article). Let's take a normal person, say, and lock him up somewhere. Better still if we leave him in isolation. However normal this person may be, at the end of a certain, undoubtedly short period of time, he will begin to show certain signs of "craziness." He may get depressed, lose his sense of time, talk to himself, have trouble sleeping, confuse day and night, and so on. Despite these symptoms, he won't be taken out of isolation; instead, he will be given medication to correct his behavior—medicine to make him sleep, to make him stop talking to himself, to make him less anxious... And there begins the vicious circle: The patient (and the psychiatrist) will get more and more caught up in this, until the doctor is increasingly convinced that the patient is crazy, and the patient (and it's true that one has to be patient to stand all this!) is also convinced of his own craziness.
But that's not all.... Let's now say we shut him up not in any old place, but in an insane asylum... a place where the patient is expected, where it is considered normal, to act crazy.…
Of course, to shut down the insane asylums isn't an easy thing to do, because "normal" people have a tremendous fear of the insane. And to avoid admitting that fear, we separate ourselves from them. That way we make their illness into something more terrible, because we add an ingredient: solitude. No one wants to speak with the insane. To justify this, we've invented the idea that the crazy person is dangerous. And I'm not saying that they aren't...
One of the essential steps towards shutting down the insane asylums is to face the demons that "normal" people carry around inside. To be reconciled with our own fears instead of projecting them on others (the insane). To accept the mentally ill within the family and the community. To humanize ourselves, to love ourselves.
Extracted from "Let's Shut Down the Insane Asylums"
by Michele Najlis, Nicaraguan writer and poet,
El Nuevo Diario, Managua, June 2l, l984.
The horrors of the pastAmong the many serious problems Nicaragua's revolutionary government inherited in l979 was the truly critical situation of psychiatric care. The only institution giving such care, the National Psychiatric Hospital in Managua located on kilometer 5 of the Southern Highway ("ready to be taken to kilometer 5" was a popular way of saying "you're crazy"), was a depressing place indeed. Besides having the forced atmosphere of any insane asylum, it was seriously overcrowded, poorly maintained and repressive—characteristics that reflected in great part the violence and corruption of the Somoza era.
The history of psychiatry in Nicaragua goes back to 1911, when a group of concerned citizens formed a committee to build an asylum. But it was not until 1933 that construction of the asylum actually began, on a plot of land donated by President Juan Bautista Sacasa. This was in Sandino's time. It was Somoza who finally inaugurated the asylum and he quickly converted it, as he did many institutions for social welfare, into his personal fiefdom, profiting off of its medicines and supplies.
The center's buildings were soon indiscriminately filled with people of all ages and with a wide range of physical and mental problems. The patients were half-dressed, dirty and hungry. There was no place to eat; food was pushed through a slot into the inmates' wards, where the law of the jungle prevailed. The inmates were bathed only once a week, all together, under a hose.
At first there were no doctors—except for the director—or other health care professionals working in the center. The staff lived on the premises, but had no special training. Some of the patients were raised to the rank of nurses and given the special task of preventing violent quarrels among the other patients.
Those who took part in such fights were punished by being shut in dark, empty cells or tied to their beds. All the staff, from the director to the cleaning woman, had the right to use electric shock, insulin shock or other violent treatments on the patients. It was not uncommon for such treatments to be used to teach patients a lesson, rather than cure them.
There was a horse-drawn cart that went through Managua picking up the "crazy people" found wandering on the city streets. In some cases, the asylum offered rewards for citizens who helped to locate and hospitalize the mentally ill.
With a change in management in the 1960s, the hospital entered a new phase. Some psychiatrists were hired, mostly trained in the United States. This brought about more humane treatment for the patients, to a certain extent. The use of drug treatment was also introduced. Two more buildings were added, bringing the total to six, three for men and three for women. The center became a training hospital for students in the university.
The l972 earthquake that destroyed Managua damaged the asylum, although it did not claim any victims there. Part of the international aid sent for reconstruction was donated specifically for the psychiatric hospital, but as with other aid, the principal beneficiary turned out to be Somoza. During the dictatorship, a number of Nicaraguan psychiatrists were persecuted and forced into exile.
The general strike called by the FSLN in 1978, which was decisive in the overthrow of the dictatorship, was supported by the hospital's workers. For psychiatric care, as for most aspects of life in Nicaragua, the time had come for a change.
Psychiatry in revolutionary NicaraguaIn July l979, the psychiatric hospital had more than 300 patients warehoused in inadequate, overcrowded housing. Some 170 doctors and paramedics and some 150 other employees—in some cases sent there to work as a form of punishment—were on the hospital's staff. This high staff to patient ratio was more reflective of the way professionals enriched themselves off the public payroll than it was of a high level of care.
Before developing new therapeutic programs, the new government had to face more basic challenges: humanizing that concentration camp, cleaning it out, making doctor-patient relations more democratic and gradually discharging many patients.
The fact that the Nicaraguan government decided to pay attention to the question of psychiatric care, even in those first turbulent days after the triumph, was noted by more than one observer concerned with psychiatric issues. For complex historical and cultural reasons, psychiatry in many eras and in many countries has been relegated to a marginal role. Yet from the very first, the Sandinista government included the right to psychiatric care along with other health rights, revealing a new vision.
Mental health care was incorporated into the new National Health System, formed with the aim of decentralizing all health services in the country. This decentralization goal was a great challenge, involving many social sectors and institutions in the promotion of health care.
The government took steps to make conditions in the psychiatric hospital more humane, and to return patients to their communities whenever possible. By the end of l986, only 170 patients remained in the hospital, the majority of whom were considered chronically ill or had lost their family and community ties.
In l983 an interesting initiative took place, involving hospital inmates in the social life of the country. In a project coordinated by the Agrarian Reform Ministry, some 20 patients, accompanied by a group of psychiatric workers, participated in the annual coffee harvest. This experiment, which has been repeated in the years since, marks one step forward in the transformation of the "insane asylum."
As these initiatives progressed, the use of repressive and violent methods of treatment diminished. The supposed efficacy of electroshock therapy was questioned. The 4,644 electroshock treatments carried out as late as 1980 were reduced to 135 in 1984, and then disappeared entirely. In 1984, two of the four remaining hospital buildings were shut down.
The revolution also brought about another important change: the development of out-patient treatment for psychiatric patients. New mental health teams began to operate out of regular medical hospitals and health centers. Some of these teams became a permanent feature of the hospitals' health care staff. For the first time in Nicaragua, it was possible to treat clinical psychiatric cases without having to resort to hospitalization.
This is not to say, however, that the treatment given in the general hospitals is the best possible. In some cases, it is clearly inadequate. Like all aspects of the national health care system, psychiatric care is seriously affected by the war and by the limitations of an impoverished developing country. Neither the number of trained staff nor the supply of beds and medicine can meet the demand. Moreover, the Nicaraguan mental health care system has still not succeeded in completely changing the traditional rejection of the psychiatric patient, the "crazy person."
In the most isolated regions—which are now or until recently were war zones—even the most basic psychiatric care is lacking. In the more populated areas on the Pacific Coast, however, most hospitals now have a mental health team. In l98l, the first out-patient center dedicated exclusively to psychiatric care was opened in Managua.
In early 1984, the organization of psychiatric care took another step forward with the creation of mental health care centers known by their acronym, CAPS. The CAPS teams usually include a psychiatrist, a sociologist, a social worker, an occupational therapy specialist and one or two nurses. The aim of the CAPS is to offer comprehensive daily care to psychiatric patients on a long-term basis in order to avoid separating patients from their families and communities, and involving the whole community in the treatment of mental illness and the promotion of mental health.
International aidThe solidarity movement has supported Nicaragua's efforts in the mental health field, as it has in so many other fields. From the revolution's first days, mental health care professionals sent by international organizations or coming on their own initiative have lent their services to Nicaragua.
These include a significant number of psychoanalysts—mostly Mexican and Latin American—who concentrate on group and family therapy. These professionals have visited the country since 1981, usually for short periods of time. They have been joined by a number of psychiatrists and other mental health care professionals, mostly Italians, other Europeans and Cubans, who have come for longer periods of time. Given the varied backgrounds of these international volunteers, it is hard to evaluate the influence they have exercised. But all of these international volunteers have had one common goal: to contribute to the birth of a new "Nicaraguan psychiatry," with its own identity, rooted in the cultural, social, and economic conditions of a country at war, in revolution and in a state of underdevelopment.
Nicaragua does not follow a single theoretical or organizational model of psychiatric care. As in the political and economic spheres, Nicaragua has not mechanically imported or implemented any one given model. Instead, the new psychiatry in Nicaragua can be defined as a "permanent experimental model," based upon the continual reevaluation of psychiatric practice against scientific theory and, most importantly, against results obtained in patient care.
In the search for its own vision, Nicaraguan psychiatry today is reexamining, on a methodological and empirical basis, the principles of mental health care, not to discount or deny them but rather to adapt them to Nicaragua's own scale of values.
The war and the economic crisisThe Reagan administration's low-intensity war against Nicaragua and the economic crisis intensified by the war affect every aspect of life in the country, including both the nature of the mental health problems found and the methods and resources available to treat them. Not only the contra war but also Nicaragua's whole history of colonization, exploitation, poverty and oppression, including the prolonged Somoza dictatorship, has conditioned the Nicaraguan people to the bitter realities of fear and hunger, of mourning and death.
According to a recent study, the "state of aggression" that the Nicaraguan population has endured for more than six years most strongly affects the population outside Managua. This "state of aggression" is a motivating factor in 18% of the psychiatric consultations in Nicaragua's rural zones, while it motivates only 9% of the consultations in Managua (according to the preliminary results from a l986 study on psychiatric care in Nicaragua involving 342 patients, by Dr. E. Kraudy, of the National Psychiatric Hospital of Nicaragua, and Drs. A. Liberati, B. Saraceno, and G. Tognoni, of the Mario Negri Institute, Milan, Italy).
Despite the high social costs they entail, national revolutions have always meant, the gradual regaining of a collective identity for the people who are their protagonists and the forging of their own historic project. This project revolves around new values, including political, economic and cultural self-determination, freedom of speech and the freedom to hope for the future. These social transformations translated into profound changes in consciousness on an individual level.
The war waged by the people of Nicaragua is a defensive war, not a war of aggression. Therefore, even though it is a constant factor affecting the national psyche, the psychological syndromes that affected, for example, US soldiers during the Vietnam war are practically nonexistent, as can be seen from the following quote from Dr. Manuel Madriz, Director of the Department of Psychiatry in the Dávila Bolaños Military Hospital in Managua. Strong parallels exist, instead, between the Nicaraguan soldier and the nationalist Vietnamese. "In Nicaragua we can state that there doesn't exist, within the armed forces, any kind of drug use. Every veteran returns home to a hero's welcome. He returns from a war we are winning. The defeat of the counterrevolution is believed to be coming soon, and the veteran is received with happiness, with love. Moreover, the revolutionary state grants him privileges. With the card that shows he has completed his military service, the veteran doesn't have to pay for public transport, he can go to movies for free and he is granted scholarships to study. He is the center of attention in his community... The Nicaraguan people in general have lived in a tense climate. This has been intensified by the scarcity of consumer goods, by the sons and daughters off doing their military service, by the presence of US aircraft carriers right off our coasts. An important component of low-intensity warfare is psychological warfare, a tactic with which the US government has a wide range of experience. One of the objectives of psychological warfare is to wear down the combative spirit, because a "destabilized" person loses his capacity to respond... But there hasn't been this type of psychological destabilization or collective hysteria. Life continues. The Nicaraguan people have learned to live with this situation. (From an interview published in El Nuevo Diario, March 18, 1987.)
Despite the impact of the war, the Nicaraguan people continue to forge their own identity. The war and the economic crisis can slow down this process, but they can’t stop it. This era in Nicaraguan history is characterized by the dialectic between desperation and hope, between frustration and enthusiasm, between mourning for our losses and happiness over our triumphs. According to Dr. Madriz, "You can't separate psychology from politics, from the way human beings are shaped by a particular historical moment."
The war, of course, does limit the kind of care that can be given. If we were to simply survey the material and staff resources available for all health care services, medical as well as psychiatric, the situation would seem hopeless. But there’s a difference between a dependent and dominated developing country, and a country like Nicaragua, which is involved in forging its own identity. The high level of grassroots participation, the presence of international solidarity, the consciousness of participating in a historic process are in themselves powerful and effective resources, which compensate in part for the material resources that are lacking. It is precisely such resources that explain feats that would otherwise have been impossible, such as the massive vaccination campaigns, the literacy crusade, the neighborhood clean-up campaigns, the volunteer efforts to help those displaced by flooding or by the war. All these are invaluable to the development of preventive health care measures of a psychological as well as medical nature.
Psychiatric care: Between old and newThe development of collaborative projects is one of the many advances made in psychiatric and general health care since 1979. In l983 a group of psychiatric workers from the Health Ministry’s Mental Health Department made a visit to Italian psychiatric clinics, discovering some interesting methods—both organizational and clinical—that could be applied in Nicaragua.
Since 1978, psychiatric care in Italy has undergone a series of important changes. Italy was the first country in the world to pass a law prohibiting the construction of new asylums and phasing out existing ones. This radical departure from past practice—strongly attacked by the Italian Rght—has its roots in the experiences of the 1960s, when a group of psychiatrists under Franco Basaglia in the Gorizia Hospital launched the "Democratic Psychiatry" movement, which has had an impact worldwide.
The Nicaraguans' visit to Italy set in motion a project to train Nicaraguan doctors and mental health care professionals in Italy and to study the mental health situation in Nicaragua. This study, involving 13 of the 15 psychiatric centers in the country, has brought to the government's attention new perspectives and challenges for the Nicaraguan mental health professional today.
One of the most valuable fruits of the Italian-Nicaraguan collaboration in the psychiatric field is the Mental Health Manual, the first Nicaraguan handbook of its kind. The manual was edited by the Nicaraguan Ministry of Health (MINSA). Written by Italian psychiatrists Benedetto Saraceno and Fabricio Asioli and pharmacologist Gianni Tognoni (Mario Negri Institute, Milan), it was revised by Dr. Mario Flores Ortiz, psychiatrist and National Director of the Department of Mental Health, MINSA, and by MINSA psychiatrists Roberto Aguilar Briceño and Santiago Sequeira Molina.
The new strategy of psychiatric care in Nicaragua, as described in this manual, is a "psychosocial conception of the field, permitting a closer integration and coordination among the three basic levels of development in mental health care." Psychiatric services in themselves are only one part of this three-tiered system. The first tier, primary mental health care, takes care of simple diagnosis and treatment, and assesses the demand for services. The second, psychiatric care (consisting of the Psychiatric Hospital, Psychosocial Care Centers, Mental Health Care Teams and some general hospitals), is responsible for attending to the more serious cases. The third tier consists of community services, as part of the general program of social work, education and health care provided at a community level. (See Table I.)
The following are four basic challenges for the mental health care field in Nicaragua.
1. The role of mental health services in the nation's general health care system.
The revolutionary government's 1979 decision to incorporate mental health care within the overall health care system has, without a doubt, been justified. Its success is due to the fact that mental health is indeed part of the general health of an individual or group. This premise contradicts the perspective, shared by many industrialized as well as developing nations, that artificially separates physical and mental health.
In Nicaragua, it is now recognized that it is impossible to ignore the effects of the family, work and cultural environment on either patients or those who treat them. A more holistic view of mental as well as physical health can prevent the narrow conception of mental illness as an exclusively clinical, medical problem. A broader conception would help change an excessively biological and technical view of human suffering, which divorces the patient from his personal and social history.
2. The role of psychiatry in the national health care system.
In many countries, there’s a certain tendency to consider any psychological problem, from the most serious to the most minor, as falling within the province of psychiatry. If this is taken to its logical extreme, no country would have sufficient psychiatric resources to respond to such a high demand.
In order to avoid this problem, Nicaragua has put into practice suggestions made by the World Health Organization to strengthen, in quality and quantity, the basic health infrastructure of any country. Psychiatry, like any other specialty, is considered part of the second tier of the national health care system. And herein lies the challenge: The first tier, the system of primary care—general practitioners, psychologists, and, in certain cases, the community itself—must learn to diagnose and treat many cases, identifying and referring the cases that really require psychiatric attention.
Nicaragua's capacity to screen such cases is limited. According to the study we referred to earlier, anxiety and depression are the principal symptoms detected in 50% of patients during the first consultation, whatever the patient's age. Some 11% were diagnosed as having an additional psychiatric symptom, including delirium and hallucinations. Only 3% showed symptoms of being psychotic. Mental retardation appeared in 8% of the cases.
Screening errors can result in real psychiatric cases failing to receive proper treatment. Hospitalization is still too often resorted to because the necessary resources are lacking in the workplace, family and community.
The National Psychiatric Hospital of Managua continues to handle the majority of cases, especially in the capital itself. While cases outside Managua can be referred to the regional general hospitals, the five mental health care services in Managua can refer cases only to the Psychiatric Hospital. So the country continues to depend on this institution, even though, having proven itself in the past to do patients almost more harm than good, it should be gradually phased out. Although hospitalization in some of the general hospitals outside Managua has had some good results, the continued existence of the old "insane asylum"—irrespective of the real reforms it has undergone—blocks the way towards a more decentralized and holistic conception of mental health care. Some 53% of mental health care services are still concentrated in Managua, where 33% of the population lives (see Table II).
A certain narrow institutional viewpoint still exists in some Nicaraguan medical circles, revealing the limits of a purely technical perspective, unattached to the social context, and thus unable to understand mental anguish and mental illness well enough to diagnose and treat it. Changing this perspective will be one of the principal challenges for Nicaraguan psychiatry in the near future.
3. The mental health care team.
In the majority of mental health care services, it is already customary for the staff to meet periodically to collectively discuss and evaluate ongoing work. This provides an alternative to the bureaucratic mentality that not only creates a rigid team structure, but also adversely affects staff-patient relations.
4. The mental health care team and the community.
According to the Mental Health Manual, a serious rehabilitation program is needed to help patients "reestablish their personal and community ties, claim their rights in the community and reclaim their social influence." A therapy based solely on drug treatment and psychiatric care is inadequate. Although hospitalized patients would still have to go through a process of de-institutionalization and socialization before they could take advantage of such a program, other patients could immediately benefit.
The aim of de-institutionalization is to "eliminate the practice and theory of institutionalization (the insane asylum) and its effects of violence, poverty, isolation, loss of dignity, injustice and the spread of 'institutional sickness,' whether it be of patients or caretakers." (See Table III.)
The strategy of mental health teams is to rebuild the patients' personal and social ties and to reestablish, as far as possible, their autonomy. The awareness that the social context is crucial to the development as well as the cure of mental illness is the rationale behind this move to base mental health services within the community.
From this perspective, the role of mental health care centers (CAPS) can be decisive in reorganizing mental health care. The CAPS program follows the basic principle that services should be provided in community centers or in the patient's own home, resorting only when absolutely necessary to brief hospitalization in a general hospital, drawing on all the resources of the mental health care team and the community.
On this road towards a more enlightened and comprehensive vision of mental health care, Nicaraguan psychiatry is taking its first steps.