In remote psychiatry, transporting oneself to the place of assessment is a complicated business. Without careful thought it can impinge on one’s ability to perform the clinical role. Safety precautions, four wheel driving, dirt roads and long distances were features that I had anticipated. But my experience has shown that a tolerance of unexpected adversity and acceptance of the factors beyond one’s control are essential. An entire itinerary for a trip of several days can be ruined very easily through mechanical failures, flash floods or ceremonial business closing the roads.
A two day trip with my supervisor from Sydney to several remote communities 300km from Alice Springs saw three flat lyres, a cleverly vandalised road sign causing a wrong turn and a 200km detour, becoming lost, our vehicle’s radio not working and needing two separate search parties – all on the first day! Not one patient was able to be seen for the whole trip as what little time we had available was spent trying to procure or repair spare tyres and to patch up frayed relations with inconvenienced clinic staff. Dry outback humour can be an adaptive coping mechanism in these circumstances, as we all took heart when we heard of the comment by the local policeman (a heavily tattooed Maori) when he was asked to search for the overdue Mental Health Team who were stuck somewhere on the road with a flat tyre: ‘What are they doing? They must be waiting for the tyre to want to change.’
Having been trained in the controlled environment of teaching hospitals, it took some adjustments to work where I did not have control over when and where I saw my patients.
Travelling would be done almost exclusively by four wheel drive, as opposed to flying, as it would allow (i) visits to several communities along the way (ii) making our own itinerary so that we could arrive at a community when no other visiting health professionals were present. Cowdy (33) in his work in remote Aboriginal communities of Northern Australia was first to point out that the Psychiatrist would achieve more if he timed his visits so that the District Medical Officer (DMO) was not present. Two doctors at one time puts a strain on the clinic nurse and Aboriginal Health Workers (AHW). My experience certainly reflected this especially with regard to accessing the time of the AHW’s whose help was vital in my work.
The roads are mainly unsealed and after rain treacherous washaways pose a hazard. Night time driving is to be discouraged because of large animals on the road such as cattle and camels. Exhaustion and fatigue are factors to be considered especially when a six hour drive may precede or follow a busy period of assessments. To enable me to function well clinically and to reduce the risks on the road, I had to become quite assertive in time management and resist the pressures to rush trips or to fit too much into a trip.
The following preparations were necessary for each trip:
- An itinerary would be submitted to the Remote Health’s travel coordinator and after hours to the St Johns Ambulance/RFDS in case of emergency.
- The community council required reasonable notice of the impending visit so that our trip did not coincide with ceremonial business or sorry business. Not only is it insulting for visitors to arrive at such times, but many in the community (including the patients we wish to see) may not be present.
- Clinic staff required notice of our visit to check that our trip would not clash with other visiting health professionals, for example the Remote Area Physician, DMO, or Women’s Health Nurse. This would also allow us to find out how many new referrals there were, how many of our regular patients were in the community and how they had been progressing. Importantly we would remind the clinic staff to inform the patients of our visit – this would not only maximise the chances of them being present on our arrival, but also allow the patient to be psychologically prepared to be interviewed. The interview process is enhanced without the intrusiveness of an unannounced visit.
- Accommodation had to be found. Most centres had deparunental accommodation but other options included camping out or offers to stay with clinic staff.
One of the unique aspects of remote psychiatry is that staying in a community means mixing with community staff after hours. This is often pleasant but sometimes draining as it can turn into a long night of listening to the staff ventilate their frustrations. The staff have very demanding jobs in isolated conditions and so it is not surprising that they will seek informal help from the visiting Mental Health Team, but this can quickly lead to the Team feeling overwhelmed. For this reason camping outside the community was often the preferable option for accommodation. The clinic staff’s mental health needs and what role I could offer formally or informally are discussed later.
- Provisions for the trip need to be procured prior to leaving Alice Springs as being self sufficient in food allows greater flexibility in the itinerary. Extra food items such as a cake to provide a morning or afternoon tea for clinic staff are helpful for psychiatric practice in remote communities. The staff provide vital corroborative history, knowledge of the patient’s family dynamics, background on recent events in the community and an important role in the management of the cases (often acting as case manager). McLaren (1995) emphasised the importance of informal time with clinic staff to enhance the working relationships: ‘Consequently, a lot of time must be spent in the apparently idle pursuit of having cups of tea with different people, talking with them about a whole range of issues.’
- Making room for transporting items or people to the community clinics (for example drugs, stationary or workers who might need transport).
- Checking the readiness of the vehicle including oil, tyre pressure, filling both the diesel tanks, having plenty of water and most importantly checking the VHF radio or satellite phone.
Regular planning meetings with the other remote mental health staff were needed to plan which trips to do and when. The frequency of visiting a particular community depended largely on the patient load there. The desired outcome of the meetings was to have a 12 month programme which could then be circulated to administration, the urban Mental Health Team in Alice Springs and to the remote communities (see Appendix 2 for a typical programme). This allowed (i) predictability for the community clinics to help their planning and to give patients advance notice of our trip, (ii) legitimising of the role of the Remote Mental Health Service, (iii) allowing people to know where to contact us while we were ‘out bush’.
The heavy rains of February threw our FebMarch programme into turmoil and it was quite noticeable how much more difficult it was to work in the remote areas when our visits were not at the scheduled times. It was necessary for me to average 1 000 km per week and three to four days out bush per week. This was a similar schedule for McLaren (1995) who stated: ‘The purpose behind this back breaking schedule was to see patients in their own settings with a minimum disturbance to their lives. It would be quite impractical to keep the psychiatrist in the Regional Hospital and bring the patients in to see him…’
Figure 5. At the remote clinics, good staff relations are essential. Areyonga clinic.
Figure 6. The picturesque community of Docker River (Kaltukatjara) nestled amongst the Peterman Ranges, near the border of WA