20
Jul
13

reflections on a day at “El Batán”, a public psychiatric hospital in Puebla

Yesterday I had the pleasure of accompanying two of our MHIRT trainees to do some open-ended interviews with outpatients at Puebla’s psychiatric hospital. The hospital is a set of one-story, white concrete buildings on the outskirts of town. The bus from the centro takes about 30 minutes, and winds up a hill full of “residencias” – up-market, private-entry residential communities. El Batán is just 5 minutes more down the road, but a world away. It is sort of like stepping into a scene of “One Flew Over the Cuckoo’s Nest” (or Joao Biehl’s VITA, for my med anth friends), and it’s hard not to recoil at the unkept grounds, the inpatient dorms where seeing feces on walls or a patient in a psychotic episode chained to a bench is not uncommon.  The aluminum gates surrounding the hospital are open, and so on our way to the entry, we heard two inpatients pleading for money from people coming to the waiting room. The waiting room itself and the outpatient consultation rooms are in a new building, which is clean and orderly. Doctors on duty type up patient notes on old typewriters and patients and their accompanying family members sit quietly awaiting their turn for one of the brief visits in which they’ll check in with the attending psychiatrists or psychiatry residents and receive an updated “receta” or Rx for their anti-psychotic drugs. The patients we interviewed were two women in their 40s diagnosed with schizophrenia, both were on Risperal, around 2-3 mg/day. The interviews focused on the patients’ experience with psychotic illness, and I was especially interested in the explanatory models and illness narratives that emerged. Both women associated depression with the onset of their psychosis (which may be associated with the first phase of schizophrenia). The first woman, Ana, referred to her condition as “mal de la cabeza”, and didn’t seem to have any other term to describe her illness. Her mother and primary caregiver was worried that when she passed away, Ana would be left alone with no one to care for her, as her siblings had shown little interest in assuming this responsibility. The second interviewee, Katarin, was one of three sibilings with schizophrenia, and referred to her first major relapse as following the death of her father when she was around 19 years old. Katarin’s mother is aged and physically unable to care for her, but she is lucky that a sister has retired from a career with the social security administration in order to care for Katarin and her brother. Katarin has been able to hold a job as a janitor in a hospital and has raised one of her nephews since he was 6 months old – she is, in other words, higher functioning than Ana. Both women reiterated what I’d call the medical model of illness and treatment, repeating the idea that “If I take my pills, I’m fine”. They and their caregivers were grateful that they’d been able to enroll in Mexico’s public insurance program (“seguro popular”), so their treatment and medication were now covered. And indeed, looking through their charts, it seemed they’d received consistent, careful, professional care through the outpatient services at El Batán. During the interviews, I struggled to try to understand Ana and Katarin’s lived experience: what is it like to have auditory or visual hallucinations? to be viewed as mentally ill through the lens of social stigma? to be dependent on family caregivers and unable to live independently? to rely on anti-psychotic medication and suffer its side effects (muscular tension, dry mouth, flat affect, etc.)? The interviews also impressed upon me the value of family caregiving for patients with chronic psychosis – without their mother or sister, Ana or Katarin might have ended up as inpatients and living in the less-than-humane conditions of El Batán. Indeed, the hospital staff told us that often family members just “drop off” ill relatives leaving no identification or means of contact. Some of these inpatients have comorbid conditions like developmental delays or “retraso mental”, but the hospital staff has little option but to leave them as inpatients given the lack of other social services available. Still, on the bus ride back to the city center, I couldn’t help but think of more humane alternatives than institutionalization for the mentally ill – like community based care or residential treatment programs such as group homes, where residents are given roles and responsibilities in the life of the community (rather than just locked away). The importance of feeling “useful” was emphasized by both Ana and Katarin, who told us that one of the best parts of their lives is being about to help around the house and feel that “I’m good for something”. Indeed.

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