A smile

It all felt a bit odd. Definitely not the way we would do this stuff in Australia. But I went along without comment, which is not unusual.

I’ve been working with a GP and a Psychiatrist, both Balinese men practising in Ubud. The psychiatrist only comes here every couple of weeks or so. His schedule is a mystery to me, but I lose lots in translation so there may be a logic to it. His main practice is in Denpasar, twenty kilometres south. I have visited the day centre, Rumah Berdaya, that he started and runs through a ‘Yayasan’ or charitable status organisation. Most of the users are younger people with schizophrenia, and it’s a great place; full of pride in their achievements; getting severe mental illness out there into the heart of a busy city street.

The GP is an amazing guy, much admired by the ex-pat and local communities alike around Ubud. He seems to work endlessly, and while I’m sure he makes a good income from the ex-pats, his main driver is his Hindu religion. He just doesn’t seem to be able to turn his back on suffering, which is a recipe for burn-out that would deter most health professionals. A couple of years ago, he and I got talking about the almost complete lack of community services for people with severe mental illness in Bali.

Progress has been slow I think, but that may be my view of time, not necessarily shared by Balinese people. The hardest part has been finding people with mental illness in the local community. Attitudes are much like those in most countries where public health and welfare systems are still incomplete and/or inaccessible; where they just aren’t a reliable alternative to traditional medicine and doing your best to hide the problem in the family. ‘Coming out’ is a very big deal, so persuading families and individuals to seek western medicine takes great patience.

A couple of months ago I went with the psychiatrist and the GP practice manager to talk to two people whose families had asked for help. The first was in a beautiful family compound in one of the most prosperous streets in nearby Peliatan, which is world-famous for its dancing troupe. About fifteen people were grouped in a circle around the bale, the raised sitting area which is the outdoor focal point for many family activities. The psychiatrist and I sat apart on the bale, and two family members led a woman out of her room and motioned her to sit between us.

She is in her early forties, and is described by the family as being ‘possessed’ since she was about seventeen. She often talks loudly to herself, laughs for no apparent reason, and tries to leave the family compound, which they do not allow. She has ‘escaped’ several times, but was quickly found and returned.
She was visibly frightened of both of us, and sat in an almost foetal position, scratching at her upper body fiercely, sometimes giggling. In a family who were all well turned out, she was shabbily dressed, with lank hair, and extremely long fingernails.

So, there we were, perhaps twenty people in all, surrounding someone in obvious distress, all waiting to see what the psychiatrist would do. He began by asking what treatment the family had tried to find for her in the past twenty-five years. The answers, coming from many people, sometimes talking over each other, were all about faith healing, exorcisms and continual offerings at the temples. She had never met a doctor before. Like me, he doesn’t judge them harshly for this—they haven’t had much choice. Almost all GPs will not touch mental illness; just refuse to see it as their business. So, unless the family chooses to take her to the much-feared mental hospital in Bangli, the options have been non-existent. I make no judgement on Bangli—I haven’t been there–but it’s what these people believe that matters.

Because the discussion veered between Indonesian and Balinese, I only got the general gist. My Indonesian is passable but I know almost no Balinese. The psychiatrist’s brief summations in Indonesian, aimed at the family and me, helped me keep up to speed. Now the family, particularly the woman’s sister, were asking what could be done to help.

Rather than answer them, he turned to the woman, and made eye contact, by gently raising her chin. He said hello very quietly, re-setting the scene as a conversation between the two of them. The family members, ranging from babies to people who were most likely great-grand-parents, went quiet also, and most sat or squatted on the ground to watch.

He took her hand, and talked about her long brown fingernails, asking her if he could cut them for her. She seemed puzzled, started to pull her hand away, but he kept stroking it until she relaxed. Then he asked the family for some nail clippers. Excited chatter and a teenager dispatched produced them in seconds.
She flinched, looked worriedly into his eyes. He said (I think) ‘Let’s just do one and see how it looks.’ She nodded; looked intently at the clippers as if they were about to pounce on her. Mutters in the crowd intensified. Her sister said (I got this bit) ‘Just let the doctor do his work.’

One by one, with exquisite gentleness, the psychiatrist cut her nails, all the time talking quietly in Balinese. I saw her gaze shift from her fingers to his face, listening, apparently absorbed. He told me later he was explaining about the help she might get from an anti-psychotic medication. The first hand finished, he held it up for her approval. When she nodded and smiled, the whole family murmured support, and I sensed some excitement.

Without him asking, she put her other hand in his, smiling a little. Her body had relaxed now, her scratching stopped. Never hurrying, he cared for her nails one by one. The job done, he held up both her hands in his, and the family applauded. I wondered if this may have been for the first time in many years.

Throughout this process he had been asking for her consent to an injection, which was one that could be given once a month. When he now showed her the glass phial, she tensed up. Several family members jumped up, ready to restrain her. She began to panic immediately, but he held her hands and asked everyone just to sit where they were. He showed her the place, at the top of her buttocks, just below the belt-line of her skirt, where the injection would be, and she looked upset, but nodded for him to do it. I’ve often heard that Balinese people hate injections. If that’s true, she was brave, and his ability to gain her trust was outstanding.

It was over in seconds, and her frown turned to a smile, echoing many on the faces of the family. The toddlers I must say had looked horrified throughout, as soon as the needle appeared. I don’t know what they thought was going on, but theirs were the only frowns as we prepared to leave.

I felt I was in the presence of a special set of skills and insights. This young man, graduating only a couple of years ago, found ways to treat everyone involved with great respect, and to achieve an outcome with potential to change a woman’s life. She continues to have all the safety of the Balinese family and community system, which is now for the first time accepting that she has an illness for which there is treatment.

Post script
Yesterday I visited the same woman with a community nurse, for her third monthly injection. This time, only a handful of family members sat around as the procedure went ahead with no drama. But the big changes were in her appearance and demeanour. She was wearing newer and brighter clothes, her hair was clean and shiny, and she greeted us with a smile. The toddlers watched the injection closely, still frowning.

Because she only speaks in Balinese, I asked her sister how she was doing. ‘Happier, healthier, sleeping well now, not scratching’ was the gist of it. Does she still talk to herself? ‘A little Pak, but not like before.’ Then she asked who I was. I explained briefly, and she thanked me for coming. I shook hands with her and the woman we were visiting, who seemed unsure about the ritual. I don’t think she had shaken hands before.

This whole episode leaves me with mixed feelings; stuff to think about. Our western approaches rarely involve the whole family and a visiting retired mental health administrator sitting in on a consultation. While I don’t blame the family, it confronts me that they have effectively kept her a prisoner for her whole adult life. And I know that medication is only the first step to getting a life back, to becoming a full-functioning member of this community. She has so far to go on that journey, and there are no support services, government or private, to help.

It’s a start, a tiny shift in community acceptance of mental illness, and one person’s life given a little better chance to succeed. There are a few others in our project now getting similar help for the first time. I know there must be hundreds more out there in this district of half a million people. There has to be more I can do, but it’s not clear what that is. That woman’s smile is a much-needed energy booster.

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