Photo: Val Ford

Fear and freedom
The people of Central America have been paying the price of war in emotional
as well as material currency. Lucy Marks and Val Ford contrast the attitudes of
Guatemala and Nicaragua to the mental health of their own people.

'It was seven years ago that the military attacked our village,' said the midwife in the Guatemalan province of Quiche. 'Many of our people were killed. And others were so deeply affected that they withdrew from the community, shutting themselves away in their homes. Seven years... but still every now and then one of them will suddenly run out into the street screaming.'

The people of Central America have had to live with fear for decades. We measure the region's troubles in terms of assassinations and war deaths but often forget the toll taken on the living by that everyday acquaintance with fear. No-one visiting Guatemala and talking to people from its majority Indian population could fail to see the psychological scars.

Equally no-one travelling on to Nicaragua could fail to notice the difference from Guatemala - people still have to live with civil war but for ten years have had a government that has actively promoted mental health. And in the aftermath of the February elections the worry is that Violeta Chamorro's new UNO government might stray off the positive mental-health track that has made the contrast between these two countries so striking.

In Guatemala, a beautiful country with a superficial air of tranquillity, the civil war has lasted for the past 30 years. In that time the military have killed 100,000 civilians and 40,000 people have been 'disappeared' by death squads.

We talked to health workers and campesinos all over the country. Many had witnessed extreme violence. In the early 1980s the military began destroying entire villages in an attempt to eradicate civilian support for Leftist guerillas. The long-term psychological effects of this kind of violence can be devastating. A nun told us, for example, of a man who had seen a massacre take place in his village. He kept a list of all those who had been killed, but could not talk about what had happened - he just cried incessantly.

A dread of torture and physical mutilation haunts the countryside - not least because so many people have witnessed the mutilated bodies of victims dumped in the street by the security forces. In a quiet moment our Guatemalan guide said that many people fear torture more than death.

Everybody is affected - but not everyone is overcome by feelings of despair and powerlessness. We spent an afternoon with plantation workers who continue to do health-promotion training even though they earn little and live in an area where such work can be rewarded by a place on a death list. And in the absence of government initiatives a non-governmental health organization has started training 'mental-health promoters to work with their own communities. Local people are familiar with the traditions and concerns of their community and are more likely to be trusted.

But this is clearly not enough. A psychological war is going on, one that controls the population by disrupting communities and instilling a climate of mistrust. The war must end. And until it does the people of Guatemala will need appropriate psychological support to help them resist.

This was the stage the Nicaraguan people had reached before the Sandinista revolution in 1979. Until then the only mental-health facility in the whole of Nicaragua was the psychiatric hospital in the capital, Managua. Well outside the city centre, it was ideal for removing the mentally ill' from the community and locking them away out of sight and out of mind. Two wards, built for 60 patients each, came to accommodate more than 550 people. President Somoza personally pocketed the international funding that was raised for a national mental-health programme in 1972.

One of the first decisions taken by the revolutionary government was to create multi-disciplinary mental-health teams operating in the community. Many people were already returning home and being supported in the community even before the new official policy of 'deinstitutionalization' was implemented in 1981. The hospital, now with fewer than 150 patients, is due to close altogether within five to seven years. Acute psychiatric cases are to be treated in general hospitals or new Crisis Intervention Centres.

In the mean time Dr Santiago Sequeira, the hospital's director, has been fighting his own revolution, battling against incredible odds to humanize the physical environment of the hospital and improve the quality of patient care.

Instead of the familiar mental-hospital pyramid (psychiatrists at the top, other staff below, patients at the bottom), relationships throughout the hospital are relaxed and friendly. Ward meetings are jolly occasions. Patients wander in and out of staff rooms at their leisure and no-one seems to mind. The next step is to safeguard these changes by formalizing patients' rights and encouraging patients to campaign for their own rights in self-advocacy movements.

Dr Sequeira and his team have inherited some 65 long-stay patients who have no family and no prospects of living in the community without financial and other support. Careful plans have been made for these people so that when the hospital eventually closes they will not find themselves on the streets.

One of these schemes is an agroindustrial project, ambitious by any standards and quite amazing in a poor country ground down by war and economic blockade. Four 'sheltered' homes, twelve family units and four staff houses are to be built on a site around a farm growing fruit and vegetables, with a factory to process the produce. The scheme aims to ensure the residents' economic survival and to maintain or create family units wherever possible. It has the support of the farmworkers' unions, not to mention soil technicians and mental-health professionals. More important still, patients are involved in the planning.

But the state of a country's mental health lies not only in the fate of its hospital patients but also in the general condition of its people. The greatest improvement of all has of course been the removal of the old climate of repression and fear. And people now have much greater control of their own lives through their participation in neighbourhood committees in the barrios as well as in the mass organizations. But the Sandinista government also took the initiative by training brigadistas up and down the country in preventative techniques like simple listening skills, bereavement counselling, relaxation methods, even family and group therapy.

There is general agreement that in the elections which removed the Sandinistas from power earlier this year the Nicaraguan people voted against the long US-sponsored Contra war and their empty stomachs, not against the social reforms of the Revolution. But one of the first steps of the new UNO government may well be to wield its public-spending axe against health care.

They should look very closely at the Guatemalan experience before doing so. Nicaragua has shown that people can improve their psychological well-being and their quality of life, even in the face of extreme material poverty. Guatemala remains a terrible reminder of what Nicaraguans have fought so long and hard to replace.

Both the authors work in London; Lucy Marks is a clinical psychologist with Tower Hamlets Health Authority and Val Ford a community mental health worker.

Do what they say, say what they want Some women are said to be 'dangerous' if they act as many men do all the time. They are locked away indefinitely, without trial or treatment, in a cruel, forgotten corner of 'care'. Prue Stevenson talks to some of them. 'I'm not mad. I've just been bad. I've been angry. An angry woman. I've spent all my life from the age of eight in institutions. I've always been in trouble... All the reports to do with my mental state have said that I'm not crazy, and yet I was diagnosed as a psychopath and bunged in Broadmoor. In a medical book, the psychopath is cold-blooded, premeditated, uncaring, manipulative. I'm none of them. I care. I care very much about people. It was myself I didn't care about... I needed help. I needed something. Broadmoor was what they gave me. Toni, aged 25, spent three and a half years in Broadmoor. Like Rampton, Moss Side and Park Lane, Broadmoor is a maximum-security mental hospital housing the people said to be the most dangerous in the UK. To be sent to one of these 'special' hospitals you must be seen as a danger either to others or yourself. You must be diagnosed as suffering from mental illness, mental impairment or - the loosest and most controversial diagnosis of all - psychopathic disorder. A third of the women in the 'specials' are diagnosed as suffering from a psychopathic disorder, compared with less than a quarter of the men. This suggests that the predominantly male, white judiciary and psychiatrists who make the decisions use a different set of standards for women and men. Aggression, sleeping rough, unstable sexual relationships, heavy drinking, fighting, loud and lewd behaviour, the actions that you see men performing every day on our city streets, can all go against women when decisions are being taken about where they should be sent. While some patients in the special hospitals are dangerous, the majority are not. The specials look like prisons - high walls, barbed wire, electronic doors and large bunches of keys. Male nurses wear prison-officer uniforms. The special hospitals, however, still insist that they are not prisons but hospitals. Talking to women who have been there, or face the possibility of being sent there, you find that the fear of being put in the specials is far greater than the fear of imprisonment. 'You hear of the specials, but you think "that can't happen to me. I know I'm bad. But I'm not that bad." And then you realize that they mean it and you think "My God! If they send me to Rampton, what does that make me?"' Jo, now aged 26, spent six and a half years in Rampton. Life for women in special hospitals is harsh, mundane, stereotyped, sexist and racist - despite the best efforts of some of those who work there. Without ordinary social contact the women quickly become institutionalized. They complain that they receive little by way of treatment. Many won't talk to psychiatrists or psychologists, who are predominantly men. They are frequently put in seclusion because they have mutilated themselves - a cruel and inappropriate response to terrible acts of self-harm. 'As far as I was concerned they didn't do nothing to help me.' says one former patient. 'I hardly ever saw a doctor. It wasn't because of any treatment that I got out of Rampton. It was because I behaved. I did what they wanted. I used to put on that I'd accepted it, but I didn't really. You can't let it show, can you? I used to say what they wanted to hear. I used to make out that I'd changed. But I hadn't. It was all a false pretence. Do what they say, say what they want, just to get out. Prue Stevenson works for Women in Special Hospitals (WISH), which is run largely by ex-patients and can be contacted at 25 Horsell Road, London N5 1XL, UK.