SUMMARY REPORT 2011
© 2011 Asia-Australia Mental Health (AAMH) www.aamh.edu.au
AAMH is a consortium of The University of Melbourne’s Department of Psychiatry and Asialink, and St. Vincent’s.
No reproduction of any part of this publication can take place without written permission from AAMH. While all reasonable endeavours
have been taken by AAMH to verify the information contained in this publication, AAMH does not warrant that the information contained in
this publication is complete and correct. The views expressed and information provided in the document by named authors are solely the
responsibility of those authors. The responsibility for the interpretation and use of the published material lies with the reader. AAMH and
the authors shall not be liable for any damages arising from its use.
Artworks by people who experienced mental illness have been included in this publication to remind us of the individuals affected by such
experiences. We are grateful to the artists whose work has been reproduced. Non-exclusive licence to publish images of their work have been
obtained from the artist or their family. The name of each artist and their illness is published only when they have given their consent.
Graphic Design: Ian Robertson. Printing: Bambra Press, Melbourne, Australia.
SUMMARY REPORT 2011
MENTAL HEALTH DEVELOPMENT PROJECT
2 Acknowledgements and Contributors
5 Foreword by Mario Maj
6 Preface by Norman Sartorius
SECTION 1 : OVERVIEW
11 Stage 2: Project Aims and Objectives and Outcomes
17 Principles for Building Partnerships in Community Mental Health Care
in the Asia-Pacific Region
SECTION 2 : COUNTRY REPORTS
37 Hong Kong
85 Solomon Islands
SECTION 3 : CONCLUSION
106 Concluding Remarks
107 Future Directions of the APCMHDP Network
PROJECT MANAGEMENT AND ACKNOWLEDGMENTS
Daniel S.S. Fung
Young Moon Lee
Phong Thai Than
Bernardino A. Vicente
MANAGEMENT AND EDITORIAL TEAM
Chair: Chee Ng, Director, International Psychiatry Unit, The University of Melbourne
and St. Vincent’s, WHO Collaborating Centre in Mental Health
Co-Chair: Julia Fraser, Associate Director, Asialink, The University of Melbourne
Coordinators: David Paroissien, Manager, Asia Australia Mental Health (Asialink)
Margaret Goding, Associate Director, Asia Australia Mental Health
Brigid Ryan, Manager, Asia Australia Mental Health (St Vincent’s)
AAMH would like to acknowledge the following for their considerable support
and assistance with the publication of the APCMHDP Stage 2 summary report:
Department of Health and Ageing, Australian Government
St. Vincent’s Health (Melbourne)
Department of Psychiatry and Asialink, The University of Melbourne
Royal Australian and New Zealand College of Psychiatrists
World Psychiatric Association
World Health Organization
Mario Maj, President, World Psychiatric Association
Norman Sartorius, President, International Association for the Promotion of
Mental Health Programmes
Shekhar Saxena, Director, Department of Mental Health and Substance Abuse,
World Health Organization
Bruce Singh, Assistant Vice-Chancellor, University of Melbourne
Helen Herrman, The University of Melbourne, WHO Collaborating Centre in
Mental Health, and World Psychiatric Association
APCMHDP 2011 : ACKNOWLEDGMENTS
AUTHORS AND CONTRIBUTORS
Editor: Georgie Harman, First Assistant Secretary, Mental Health
and Chronic Disease Division, Australian Government Department
of Health and Ageing, Australia. Sub-Editors: Colleen Krestensen,
Virginia Hart. Contributors: Australian Government Department of
Health and Ageing, and KidsMatter Primary Partners.
Editors: Sophal Chhit, Deputy Director, Hospital Service
Department, Ministry of Health, Kingdom of Cambodia;
Graham Shaw, Technical Officer HIV/AIDS, Drug Dependence
& Harm Reduction, World Health Organisation, Cambodia.
Sub-Editor: Phallyka Chou.
Editors: Hong Ma, Executive Director, National Centre for Mental
Health, China CDC; Xin Yu, Executive Director, Peking University
Institute of Mental Health, China. Sub-Editors: Jin Liu, Yue Li.
Editor: Se-Fong Hung, Hospital Chief Executive, Kwai Chung
Hospital, Hong Kong. Sub-Editors: Vivian Wai-Man Lim, Shu-
Keung Liem, Wing-King Lee, Dicky Wai-Sau Chung, Chi-Chiu Lee.
Editors: RK Srivastava, Director General of Health Services;
DC Jain, Deputy Director General of Health Services,
Ministry of Health & Family Welfare, Government of India.
Sub-Editors: Jagdish Kaur, Suman Kr. Sinha.
Editor: Irmansyah, Director of Mental Health, Directorate of
Mental Health, Ministry of Health, Indonesia. Sub-Editors: Albert
Maramis, Suryo Dharmono. Contributors: Fadhlina, Pandu
Setiawan, Eka Viora, Suyatmi Diran, Natalingrum Sukmarini,
Editor: Masato Ito, Director, Kawasaki City Mental Health and
Welfare Center, Japan. Sub-Editors: Toshimasa Hagiwara, Yutaro
Setoya, Ryosuke Arakawa, Tadashi Takeshima.
Editor: Young Moon Lee, Chairman, National Mental Health
Commission, Korea. Sub-Editors: DG Shin, TY Hwang, SM Hong,
MK Lee, MK Yoon, JH Lim, SH Baek, JW Lee, G Cheong.
Editor: Suarn Singh a/l Jasmit Singh, Technical Advisor for
Psychiatric Services, Ministry of Health, Malaysia. Sub-Editors:
Cheah Yee Chuang, Abdul Kadir Abu Bakar, Ang Kim Teng, Ong
Editor: L.Erdenebayar, Professor and General Director, National
Center of Mental Health, Ulaanbaatar, Mongolia. Sub-Editors:
D.Oyunsuren, N.Altanzul, N.Tuya, Nalin Sharma, O.Ganchuluun ,
Editors: Bernardino A. Vicente, Medical Center Chief II, National
Center for Mental Health, Philippines; Ruth A. Bordado, Medical
Specialist I, National Center for Mental Health.
William Same, Director, Mental Health Services, Ministry of
Health, Solomon Islands.
Editors: Daniel SS Fung, Vice Chairman Medical Board (Clinical),
Institute of Mental Health, and Program Director, REACH; Kim Eng
Wong, Chairman National Mental Health Professional Advisory
Committee, Ministry of Health, Singapore; Hong Choon Chua,
Chief Executive Officer, Institute of Mental Health.
Editors: Chih-Yuan Lin, Superintendent, Yuli Veteran’s
Hospital, Taiwan; Yu-Hsuan Chen Director, Euodia Community
Rehabilitation Center, Yuli Veteran’s Hospital, Taiwan.
Sub-Editors: Jian-Kang Chao; Po-Yu Chen; Lieh Yung Ping.
Editor: Apichai Mongkol, Director General, Department of Mental
Health, Ministry of Public Health, Thailand. Sub-Editors: Amporn
Benjaponpitak, Thawee Mekwilai, Chidchanok Opaswattan, Panit
Noonpakdee, Nopawan Oobkam, Kanjana Wanitrommanee.
Editors: Than Thai Phong, Vice-Chief, Community Mental Health
Care Service Unit and Foreign Affair Unit, National Psychiatric
Hospital No. 1; La Duc Cuong, Director, National Psychiatric
Hospital No. 1. Sub-Editors: Nguyen Kim Viet, Than Van Quang,
Chu Van Dieu, To Xuan Lan.
Editor: Manivone Thikeo, WHO Mental Health Consultant for
Laos, World Health Organization. Sub-Editor: Sing Menorath.
APCMHDP 2011 : AUTHORS AND CONTRIBUTORS
The World Psychiatric Association welcomed and encouraged from
the beginning the Asia Pacific Community Mental Health Development
Project, because of its aims not only to illustrate best practices in community
mental health care, but also to collect exemplary experiences and discuss
local needs in the Asia-Pacific region.
The steps, obstacles and mistakes to avoid in the implementation of community mental
health care are remarkably similar in the various regions of the world, as acknowledged by
the WPA Guidance Paper on this issue, published in World Psychiatry in 2010, translated into
many languages, and already adopted by several governments as their reference document
in updating their mental health system.
There is no doubt, however, that regional and national peculiarities do exist in the
organization of health services, the traditions in mental health care, and the attitudes of the
society towards mental disorders. These peculiarities have to be taken into account when
adapting international guidelines to local contexts.
The World Psychiatric Association welcomed and encouraged from the beginning the Asia
Pacific Community Mental Health Development Project, because of its aims not only to
illustrate best practices in community mental health care, but also to collect exemplary
experiences and discuss local needs in the Asia-Pacific region.
The WPA also welcomes now the second stage of the project, focusing on partnerships in
community mental health care, which is in line with the recent WPA Recommendations on
Partnerships for Better Mental Health Worldwide, in publication in World Psychiatry.
In fact, the success and sustainability of any mental health project crucially depends on the
involvement of key stakeholders in the community, including administrators, professionals,
users and carers, as well as the media and a variety of social services. This is an area in which
the impact of local resources, traditions and sensitivities is particularly significant, and the
utility of exemplary experiences and models based on those experiences particularly high.
This document represents a crucial step in this direction, and all mental health professionals
of the Asia-Pacific regions should be encouraged to read it and share the professional
competence, wisdom and enthusiasm it reflects.
President, World Psychiatric Association
APCMHDP 2011 : FOREWORD
There are two reasons why I am delighted to see that this book – bringing
together descriptions of practices and partnerships in community mental
health from many sites – has been published.
The first of these is that this volume makes it easier to build a good system of mental
health care. It has brought together examples of systems of health care that fulfilled their
tasks while being respectful of the culture in which they operate. Each of them has a feature
or features that are outstandingly good and can inspire others. Presented in one volume
they make it easier for those who want to build their own system of care to create it – as
one creates a mosaic composing it from many parts – by taking the best parts of many other
systems put together and amalgamate them in a manner that responds to local needs.
The second reason for welcoming this book is that its production has linked people working
in the field of community mental health in the countries of the region – and such a linkage
may be a good basis for the building of a network of mutually supportive centres and
countries united by their wish to improve the care for people with mental illness and their
families. The promotion of mental health and the treatment of mental illness have been
neglected in many of the countries of the region for a very long time. Reaching an appropriate
level of care for the mentally ill will require much effort and partnerships within and across
countries: the network for which this project has laid a foundation can thus help countries
of the region and those elsewhere to achieve this goal.
President, International Association
for the Promotion of Mental Health Programmes, Geneva
APCMHDP 2011 : PREFACE
SECTION 1 : OVERVIEW
Across the Asia-Pacific region a profound shift is occurring in the responses by
governments and societies towards mental illness. Joining a global movement
away from mental asylums and care in psychiatric institutions towards community
based mental health services, many countries in the Asia-Pacific are changing
their mental health policies and guidelines to reflect this change. The challenge is
to design culturally appropriate and effective mental health models, and to build
a sufficiently skilled workforce to run the community mental health services.
This is especially challenging as up until recently the
region has not attached a high priority to mental health
or allocated many resources to the sector. However rapid
economic growth, urbanization and the pressures of
modern life generally are making policy-makers think more
about the mental well-being of populations as well as
physical and economic indicators. Various adverse social
symptoms – from incidents of violent attack by mentallydisturbed
individuals to high suicide rates and social
withdrawal among the young in some countries – have
emphasized the risks of disregarding mental illness.
The Asia-Pacific Community Mental Health Development
(APCMHD) Project was initiated in 2005 to help countries
in the region introduce locally appropriate policy frameworks
for community mental health service reform. The
project was led by Asia Australia Mental Health (AAMH),
a consortium of St. Vincent’s Health and the University
of Melbourne’s Department of Psychiatry and Asialink.
The project was initiated in collaboration with the World
Health Organisation (WHO) Western Pacific Regional Office
and many key mental health bodies, and is consistent
with the WHO Global Action Program for
Mental Health (mhGAP).
The APCMHD project aims to illustrate and inspire
best practice in community mental health care in
the Asia-Pacific region through exchange of practical
experience and current evidence. The project works
through a high-level network of government mental health
officials, leading psychiatrists and research leaders from
17 countries/regions including Australia, Cambodia,
China, Hong Kong, India, Indonesia, Japan, Korea, Laos,
Malaysia, Mongolia, Philippines, Singapore, Solomon
Islands, Taiwan, Thailand, and Vietnam.
In 2008, AAMH published a report summarising the
work of the APCMHD project’s first stage. It documented
each participating country’s or region’s development of
community mental health services. Written by the region’s
mental health leaders, this unique document contains
country-specific examples of best practice community
mental health models and key guiding principles for
development of these services in the region. The Summary
Report was launched at the World Congress of Psychiatry
in Prague in September 2008 and acknowledged at the
World Psychiatry Association’s Assembly. The complete
document can be found at www.aamh.edu.au
The project has received international recognition,
published in a number of international journals and
newsletters, and is featured on the opening page of the
World Psychiatric Association website http://www.wpanet.
org/. The report was also translated and launched as the
first textbook for delivering community mental health in
At the APCMHD Project meeting in September 2008 it
was agreed that the project would continue to explore
and share innovations, progress and challenges in
developing community mental health services. The
network subsequently decided that Stage Two of
the project would focus on providing support for the
creation and maintenance of effective partnerships in
community mental health care delivery. Thus this stage
will help identify and strengthen partnerships between
mental health services and other health and non-health
agencies that will support community mental health care
through an integrated approach between hospital and
APCMHDP 2011 : OVERVIEW
Participants at the Asia-Pacific Community Mental Health Workshop, August 2009
10 APCMHDP 2011 : OVERVIEW
STAGE 2: PROJECT AIMS AND OBJECTIVES
The goal of Stage Two of the Asia-Pacific Mental Health
Development project is to develop and strengthen successful
mental health partnerships within and for communities
in our region.
THE APCMHD PROJECT AIMS
To collect and publish a wide range of exemplars that describe successful partnerships
in community mental health service delivery in the region;
To distil from the exemplars a list of key principles that partners can apply in building of
mental health services in the community;
To provide a set of practical evidence-based advice to guide the use of existing resources
in the community for mental health care;
To publicise and disseminate the project outcomes broadly across all sectors involved
in community mental health care in the region and globally.
DEVELOPMENT OF THE PROJECT
Stage 1 of the project contributed to the globally
recognized joint publication titled the APCMHDP
Summary Report which contains:
1 Mental health context and system for the Asia Pacific
countries involved in the project;
2 Each country’s approach to adapting appropriate
international policies to local situations;
3 Examples of best practice models of community-based
services or care which include:
specific local and culturally adapted community
services or community care model;
interaction with primary care and traditional
role of families, NGO’s and community agencies;
successes or inspirations, and difficulties or gaps;
strategies to overcome gaps;
4 Implications of lessons learnt from the findings for
countries in Asia Pacific; and
5 The APCMHD network vision for the long term goals
in community care.
APCMHDP 2011 : OVERVIEW
Stage 2 of the APCMHDP was launched in August 2009 in
Melbourne, where 48 high level delegates from 16 Asia-
Pacific countries met to discuss directions for this second
stage of the project. From this workshop it emerged
that supporting the development and maintenance of
effective partnerships in community mental health care
would be a priority. Summaries of the APCMHD meetings
including the Melbourne meeting can be accessed from
the Asia Australia Mental Health website (www.aamh.
edu.au) cited on the publications page.
At the Melbourne meeting the group identified actions
that would address the main challenges to building
robust community mental health services: high-profile
research reports on the value of community mental health
development; anti-stigma campaigns; advocating a whole
of government approach; involving patients and families
more directly; and preparing clear and striking publicity
campaigns. The consensus was that the network should
develop a set of common principles for partnerships
in community mental health, while also highlighting
the best-practice example of partnerships in particular
countries or regions.
Two supplementary meetings on Stage 2 of the
APCMHD Project were held in Taipei in November 2009
and November 2010 through collaboration with the
Taipei Medical University, Yuli Hospital and other key
institutes in Taiwan. Participants came from 11 countries,
including representatives from countries not previously
involved. The workshop sought to explore the existing
valuable partnerships in our regions and to broaden our
understanding of key principles required for building
collaborative research in community mental health.
India’s Ministry of Health and Family Welfare and the
National Institute of Health and Family Welfare partnered
AAMH in convening the final Stage 2 (APCMHD) Network
Meeting on 17–19 February 2011 in New Delhi India. The
Minister of Health and Family Welfare in the Government
of India, launched the meeting in the presence of all
his key health officials. Delegates included 29 mental
health leaders from 14 Asia-Pacific countries and over 100
participants from the Indian Ministry of Health, leading
mental health institutes and NGO’s across India.
The workshop explored ten principles of building
community mental health partnerships especially
the application for the Asia-Pacific region. The group
also discussed how the project could add value to the
APCMHDP 2011 : OVERVIEW
Facing page and above left: Discussions at the Asia-Pacific Community
Mental Health Workshop, August 2009. Above right: Shri Ghulam Nabi
Azad Hon’ble Minister of Health and Family Welfare Government of
India and H. E. Mr. Peter Varghese Australian High Commissioner to
India Commonwealth of Australia at the opening of the International
Conference and Workshop on Community Mental Health Development
in New Delhi 17–19 February 2011.
development of community mental health services in
the future and the priority areas for mutual cooperation
including partnerships with families and patients,
developing links with other regional and local networks,
disseminating and scaling up of innovative models.
ONGOING PROGRESS OF THE APCMHD PROJECT
The APCMHD Project continued to build and maintain a
regional resource to facilitate the sharing of experience
of best practices and real-life solutions in the continuous
evolution and development of different community mental
health care models.
There is a need to explore the implications of different
health systems and cultures in developing locally
innovative and sustainable partnerships for better
coordination of mental health services.
A critical success factor has been the APCMHD network
annual conference and regional meetings. These provide
a mechanism for:
engaging regional health bureaucrats, mental health
leaders and stakeholders;
showcasing best practice models from across the
building trust between nations for further co-operation
in mental health;
fostering dialogues aimed at developing creative
solutions to a global problem.
The network has been able to directly contribute to the
mhGAP which is WHO’s action plan to scale up services
for mental, neurological and substance use disorders
especially for countries with low and lower middle
incomes. The essence of mhGAP is building partnerships
for collective action and reinforcing the commitment
of governments, international organizations and other
stakeholders. The network recognises the principles of
mhGAP and agrees that successful scaling up is the joint
responsibility of governments, health professionals, civil
society, communities, and families, with support from the
APCMHDP 2011 : OVERVIEW
Top: Discussions at the Asia-Pacific Community Mental Health Workshop, August 2009. Above: Assembled participants from the workshop.
14 APCMHDP 2011 : OVERVIEW
“ The APCMHD project acts as a catalyst for the region to produce an integrated
network for knowledge transfer, to strengthen community mental health care in the
Asia-Pacific region. It offers the sharing of evidence, confidence, consumer and carer
experience, lessons in engaging with the media, joint training materials and events,
and anti-stigma initiatives. It is a type of stock exchange in which mental health plans,
implementation and operational policies are traded, to inspire all those supported by
the network, to show that ‘we are all in this together’!”
— Prof Graham Thornicroft Institute of Psychiatry King’s College London 2008
The APCMHD project captures the emerging dynamism
of the Asia Pacific region in the 21st century. The region’s
mental health sector are independently and collectively
developing creative, cutting edge and culturally
appropriate mental health solutions to the growing global
burden of mental illness.
Some representatives are able to identify local changes
that had been a result of involvement in this project over
the past few years. Participants in general value global
support and encouragement, including support for
influencing change in their own countries. Many felt that
they were able to learn from others as well as contribute
their knowledge and experience. Friendships developed
from this group were also highly valued.
The country/regional sections in this report on Stage
2 include many moving and intriguing examples of
innovation of community partnerships in bringing care
to the mentally ill, and in changing community attitudes
about mental illness. Such community mental health
initiatives are often campaigning at two levels of
history in psychiatric care – to bring patients and their
carers out of the asylums and mental institutions
resulting from 19th and early 20th century concepts,
and to overcome even older and more restrictive
patterns of confinement.
Isolation of the mentally ill and people at risk presents
itself in many different ways to challenge the mental
health communities belonging to the APCMHD network.
The mental health workers of Mongolia and the Solomon
Islands need to contact many small settlements
and households cut off from modern transport and
communications. Those in crowded and advanced
industrial nations like Korea are devising sophisticated
information methods such as insertion of mental health
themes in cultural events and new social media.
Network country members have given us frank
assessment of the successes and setbacks of their
initiatives, including the problems getting a range of
community agencies to work together, the struggle to
build up and retain expertise, and the ever-present
risk of funding being cut or withdrawn with a change of
15 APCMHDP 2011 : OVERVIEW
PRINCIPLES FOR BUILDING PARTNERSHIPS IN COMMUNITY
MENTAL HEALTH CARE IN THE ASIA-PACIFIC REGION
While interpretations of what constitutes community mental health care vary
enormously in the region, all countries /regions involved in the project are
grappling with the issue of a growing burden of mental illness, and faced with
a significantly under-resourced mental health professional workforce. All are
seeking effective, affordable and culturally appropriate ways of providing
mental health care that are compatible with the local help-seeking patterns
and acceptance of interventions.
Development is urgently needed to extend the reach
of mental health services beyond in-patient care at
psychiatric institutions, through creative and effective
partnerships that can augment the mental health
workforce. Such community partnerships may include
patient and carer groups, primary health carers,
volunteers, academia, local governments, community
groups, indigenous healers, religious organisations
and the corporate sector. Without such sustainable
partnerships in the community, given the enormous
burden of mental illness, mental health professionals can
only deliver limited services.
To supplement generic guidelines for partnershipbuilding
endorsed by international health bodies, the
APCMHD network countries have drawn up a set of 10
guiding principles in building partnerships for community
mental health care. These are derived from the regional
experience consistent with local cultures, communities
and health systems in the Asia-Pacific. Many of them are
also illustrated in the country/ regional exemplars of best
practice in the Asia-Pacific
1. IDENTIFY THE KEY STAKEHOLDERS IN
DEVELOPING THE COMMUNITY MENTAL HEALTH
It is critical to involve the right stakeholders, but in
general better to be inclusive rather than exclusive.
There is a matrix to consider across (i) multiple levels
(consumers/patients, family, neighbourhood, primary
care, hospital, government, etc), and (ii) multiple sectors
(social welfare, health, housing, employment, media,
community, NGO’s, etc). In particular, the participation
of people with mental illness as well as their families and
carers are critical to ensure that services are acceptable
and suitable to improve their health outcomes and
quality of life. Key stakeholders will vary across countries,
cultures and systems of health care. For example, some
countries may have strong consumer groups, and others
may have a well-structured government presence.
The identified priority groups may also depend on the
readiness of a stakeholder group, the level of resources
available and where the influence or power lies.
2. AS SUCCESSFUL PARTNERSHIPS NEED TO BE
MUTUALLY BENEFICIAL, COMMON PURPOSE AND
COMMITMENT AMONG PARTNERS IS ESSENTIAL
The best initial step is development of a shared vision
about improving mental health in the community and
promoting recovery for those with mental illness. The
vision should ideally be simple, inspiring, and shared by
all the stakeholders across different sectors.
Short-term goals may however differ, but in the longterm,
sustainable partnerships would usually have
SECTION 1: OVERVIEW
3. MUTUAL RESPECT BETWEEN PARTNERS
AND APPRECIATION OF DIFFERENCES IS
It is essential to take each other’s background into
account and involve partners in the planning from
the very beginning. Mutual understanding of different
cultures and values is important to further the working
relationships. This can be formal or informal where
flexibility and adaptability are an advantage. It may also
be helpful to learn from the differences between partners
which can enhance positive input, inspire confidence,
and build up empowerment. Appropriate and regular
acknowledgement of the value of working together is
likely to strengthen the partnerships.
4. GOOD COMMUNICATION IN SUCCESSFUL
PARTNERSHIPS CANNOT BE OVER-VALUED
Use multiple modes of communications consistently and
continuously. Communication must be done in a timely
and appropriate way, based around a common language
of understanding. Clear communication of the respective
defined roles is necessary. Confidentiality of information
sharing between sectors should also be assured.
Decisions that may impact on the partnerships require
early consultation and mutual negotiation. Frequent
face-to-face meetings and conferences are useful to
reduce misunderstanding and disagreement. It will
also ensure continuity of relationship especially where
changes (such as leadership) affecting the individual
partners have occurred.
5. PARTNERSHIPS TO IMPROVE PATIENT
OUTCOMES SHOULD IDEALLY INVOLVE PATIENTS
It is recognised that patient focus in the Asia-Pacific
region is greatly intertwined with focus on the family,
as the basic societal unit. Patients and families learning
to provide active and effective care rather than relying
on professionals have many advantages. Self-help and
user groups can provide practical and relevant help
for the individual with mental illness. Patients and
families may also provide useful advice and consultancy
for service design and delivery. Further, organised
advocacy through patient movements and family groups
may also have profound influence on mental health
legislation, policy, services and practice.
6. HIGH PRIORITY TOWARDS INVOLVING
THE FAMILY AND CAREGIVERS
Ensuring a family focus in partnerships is important, not
only because of traditional family ties but families are the
large majority of primary carers who can accept and care
for the mentally ill. They are a valued part of the informal
community care because of their knowledge of the person
with mental illness. For example, mental health education
about the early signs and symptoms illness, and the
importance of maintaining treatment can prevent relapse.
Efforts in promoting family resilience and coping abilities
must work with family beliefs and cultural perspectives.
Caregivers should be empowered to be involved in
decision making and be supported in terms of where and
how to get help early. Further, family networks can also
provide a range of services such as support groups, help
lines and respite care to deal with the patient’s needs
7. PARTNERSHIPS IN MENTAL HEALTH SHOULD
BE ORIENTED TO RECOVERY
The purpose of the partnerships extends beyond merely
treating symptoms of mental illness and needs to ensure
social inclusion. It involves the regaining of optimal
psycho-social functioning, and ultimately being part
of society. Recovery oriented services must consider
the views of persons with mentally illness and their
experiences of the mental health services provided.
Recovery-based services should involve consumers in
the process of getting help, getting back to their social
roles, and exercising their rights to live a normal life as
much as possible. Identifying optimistic but realistic
goals is required to improve patient’s quality of life as
best as they can achieve – not just in rehabilitation
but also in livelihood, relationships, education,
employment, and other meaningful activities.
8. PARTNERSHIPS WITHIN AND ACROSS HEALTH
AND NON-HEALTH SECTORS ARE CRUCIAL
Different partners can influence or deliver various
services separately but as a whole should provide comprehensive
support and coverage of service. Mental health
professionals and service providers cannot work alone
in meeting all the complex needs of the mentally ill. For
example acute mental health response in the community
will require the cooperation of emergency services
including police, ambulance, emergency departments
SECTION 1: OVERVIEW
and psychiatric crisis teams. Mental health promotion is
a multi-sectoral effort where village communes, religious
leaders, traditional healers, schools, health agencies
and local government can be all important players. The
sharing of knowledge, expertise and scarce resources are
clear advantages of a multi-sectoral approach. In contrast
sectors working in ‘silos’ are often inefficient, wasteful
and not easily accessible to the mentally ill.
9. COLLABORATION AND COORDINATION
BETWEEN PARTNERS ARE NECESSARY
INGREDIENTS FOR SUCCESS
Adequate coordination maximises the use of resources,
lessens duplication of effort, reduces conflicts and
competition, and brings partners together. Of course,
where mutually agreed one partner may take the lead to
act as focal point of collaboration. But all partners must
understand the whole process of planned work, and then
break it down into specific roles for each partner to share
the work. Regular work reviews and forums for discussion
will help ensure smooth and efficient cooperation.
10. CLEAR GOVERNANCE STRUCTURES AND
ACCOUNTABILITY ARE CENTRAL TO EFFECTIVE
Partners must be given the full picture including clear
roles for participating stake-holders, funding sources and
holders, and decision-making processes. This promotes
trust, transparency, and accountability for funding as well
as better coordination of activities. Terms of reference,
regulations and partnership agreements (eg. MoUs,
signed contract, etc) can provide clear guidelines for the
governance structure and minimize disputes. However,
some reasonable degree of flexibility may be essential
in certain circumstances which can enable partnerships
to be developed from bottom-up when local resources
SECTION 1: OVERVIEW
SECTION 2 : COUNTRY REPORTS AND
BEST PRACTICE EXAMPLES OF PARTNERSHIP
Top: Teacher, student and adult at a KidsMatter Primary school.
Above: Grandparent, student and parent in a school vegetable garden, a KidsMatter project.
APCMHDP 2011 : AUSTRALIA
AUSTRALIA : KIDSMATTER
The delivery of mental health care in Australia has come a long way
over recent decades and has involved significant national effort and action
to shift policy directions from institutional-based care to care delivered
in the community and in least-restrictive environments. Effort has also
focused on improving safety and quality of services, ensuring the rights
of people with mental illness, ensuring access to care particularly through
enhancing the role of primary care, and increasing the role of mental
health consumers and carers in policy and service development
The mental health and well-being of Australians is a central
focus of Australian Government activity. In Australia, 3.8
million people (17.2%) are estimated to be affected by
mental illness in any one year, and one in three (32%) will
experience a mental illness during their lives. This rises to
45% when alcohol and drug use disorders are included.
Most recently, in response to increased community concern,
mental health has come to the attention of all Australian
governments in a forum known as the Council of Australian
Governments (COAG). COAG is the peak intergovernmental
forum in Australia, chaired by the Prime Minister and
including all first ministers from each state and territory, and
the President of the Australian Local Government Association.
COAG initiates, develops and monitors the implementation
of policy reforms of national significance and which require
cooperative action by Australian governments.
In the context of broader health care reforms, COAG has
agreed to consider future mental health reform options
in 2011 in order to improve and strengthen the system
to ensure people with mental illness across the lifespan,
their family and carers have access to appropriate care and
support options. In 2011, the Australian Government also
announced a $2.2 billion Delivering National Mental Health
Reform investment package (over 5 years) in response to this
FOCUS ON CHILDREN FOR LONG-TERM
Growing evidence indicates that an approach to mental
health that targets children and young people incorporating
promotion, prevention and early intervention activities can
have far-reaching benefits, by improving mental health
across the population as well as reducing the prevalence and
burden of mental health problems and mental disorders.
Based on the 2007 National Survey of Mental Health and
Wellbeing, the majority of Australians with mental illness
will experience onset in childhood and adolescence, with
64% having their first episode by 21 years. This approach
comprises a long-term investment in the social and
emotional wellbeing of Australian communities and has the
potential to achieve long-term cost savings.
Effective partnerships have proved critical to the successful
delivery of mental health services, particularly services
delivered in the community. A key example of effective
partnerships targeted at the mental health of children is the
Australia’s KidsMatter suite of initiatives which includes
KidsMatter Primary that uses schools as a key platform for
prevention and early intervention in the community.
KIDSMATTER: PRIMARY SCHOOL-BASED
MENTAL HEALTH PROGRAM
The KidsMatter suite of promotion, prevention and early
intervention initiatives aims to improve the mental health
and wellbeing of children, reduce mental health problems
amongst children and achieve greater support for children
experiencing mental health difficulties and their families.
APCMHDP 2011 : AUSTRALIA
Above, and facing page: Students’ Social and Emotional Learning activities and artwork in KidsMatter Primary schools
The KidsMatter initiatives include:
KidsMatter Primary – designed for implementation in
primary schools and targeting children throughout primary
school (generally aged between five and 12);
KidsMatter Early Childhood – designed for implementation
in early childhood services including preschool and long day
care, and targeting children aged birth to five years;
Aboriginal and Torres Strait Islander KidsMatter Early
Childhood – a targeted, culturally appropriate program for
Aboriginal and Torres Strait Islander early childhood services
to support the social and emotional wellbeing of the children
in their care currently under development; and
KidsMatter Transition to School: Parent Initiative – currently
being piloted in primary schools and targets parents of
children commencing their first year of formal schooling.
The KidsMatter suite of initiatives has been developed
and funded by the Australian Government in collaboration
with beyondblue: the national depression initiative, the
Australian Psychological Society, Principals Australia,
Early Childhood Australia and the Secretariat of National
Aboriginal and Islander Child Care.
BACKGROUND TO KIDSMATTER
In Australia the child and adolescent component of the
National Survey of Mental Health and Wellbeing undertaken
in 1998 found that one in seven children of primary school
age has a mental health problem, with anxiety, depression,
hyperactivity and aggression being among the more common
problems. Mental health problems in childhood can have
far reaching effects on the physical well-being, educational,
psychological and social development of individuals.
Evidence shows that when identified and treated early,
mental illnesses are less severe and of shorter duration,
and are less likely to recur. When early signs of difficulty
are not addressed, mental health problems can potentially
become more serious and possibly develop into mental
disorders. Early intervention is therefore critical to promote
recovery and reduce the incidence of mental illness. Parents,
carers, early childcare workers and school staff are key
figures in a child’s life and can make a significant difference
to their mental health. The school and early childcare
structure offers a systematic means to promote positive
development and identify children at highest risk or who
are already showing ‘early warning signs’, intervene early
and engage children and young people into effective mental
health treatment so that they are less likely to suffer from
severe and enduring difficulties. They are also uniquely
placed to provide information and support to parents and
families regarding their child’s mental health and wellbeing.
In light of the above, together with interest from both
the mental health and education sectors, the Australian
Government recognised that a mental health initiative
targeting children in primary schools was warranted.
At the same time, primary schools themselves showed
interest in accessing such an initiative, via participating in
the training for schools and teachers offered by the existing
APCMHDP 2011 : AUSTRALIA
Through KidsMatter Primary students are taught social and emotional skills,
such as making and keeping friends, and being able to cope with change.
At the same time teachers, parents and carers consider information on child
development and appropriate ways of responding to a child who is experiencing
mental health difficulties, and identification of local referral options if warranted.
MindMatters mental health initiative for secondary schools.
The Australian Government’s National Advisory Council on
Suicide Prevention supported the need for such an initiative
and a partnership was formed between agencies with
expertise in mental health and education.
KidsMatter Primary was the first initiative developed for
implementation in primary schools and targets children
throughout their primary school years (generally aged
between 5 and 12).
KidsMatter Primary provides a framework to help schools
implement evidence-based mental health promotion,
prevention and early intervention strategies. KidsMatter
Primary concentrates on four key components aimed at
improving student wellbeing and lessening the likelihood
of children developing mental health difficulties:
Component 1 – A positive school community
Component 2 – Social and emotional learning for students
Component 3 – Parenting support and education
Component 4 – Early intervention for students
experiencing mental health problems
KidsMatter Primary requires a planned and coordinated
approach throughout the school, involving all staff and
engaging parents, carers and the school community.
Schools establish an Action Team which includes the
principal, school staff and a parent to plan and oversee
the implementation of KidsMatter Primary. A range of
resources are also made available, including professional
development for staff, information packs on a range of child
development and mental health topics, an eNewsletter and
a website www.kidsmatter.edu.au
Through KidsMatter Primary students are taught social and
emotional skills, such as managing their emotions, making
and keeping friends, and being able to cope with change.
At the same time teachers, parents and carers consider
information on child development and appropriate ways
of responding to a child who is experiencing mental health
difficulties and identification of local referral options if
KidsMatter Primary was piloted from 2007 to 2008 in 101
schools in metropolitan, rural and remote locations in
government, Catholic and independent education systems
An evaluation of the KidsMatter Primary pilot, carried out
independently in 2009 by researchers at Flinders University
in South Australia and funded by beyondblue, found very
positive results in terms of educational and mental health
outcomes. These include:
improved student mental health and well-being such as
optimism and coping skills;
reduced mental health difficulties such as emotional
symptoms, hyperactivity, conduct and peer problems,
particularly for students experiencing higher difficulties
APCMHDP 2011 : AUSTRALIA
improvements in students’ school-work;
improved teacher capacity to identify students
experiencing mental health difficulties;
improved teacher knowledge on how to improve students’
social and emotional skills;
increased parent capacity to help children with social and
facilitated placement of mental health as an issue on the
schools’ agenda; and
a common language to address mental health and wellbeing
Following the successful pilot of the KidsMatter Primary
initiative, the Australian Government (and beyondblue)
has funded the development and piloting of a similar
initiative in early childhood, a complementary initiative in
the Aboriginal and Torres Strait Islander early childhood
sector, and an initiative for the important transition period
to primary school.
The KidsMatter initiatives are developed and implemented
in partnership with a number of organisations from different
sectors. This is a major strength of the initiatives as it brings
together the range of expertise required for success.
The partners are represented on the governance structures
established to oversee each of the initiatives and meet face
to face every month, as well as liaise regularly in between
meetings. The KidsMatter partners and the sectors they
The Australian Psychological Society, representing the
mental health sector;
beyondblue: the national depression initiative,
representing the mental health sector;
Early Childhood Australia, representing the early childhood
Principals Australia, representing the education sector;
The Secretariat of National Aboriginal and Islander Child
Care, representing the Aboriginal and Torres Strait Islander
early childhood sector.
Each partner has lead responsibility for different aspects
of the development and implementation of the initiatives.
Strategic planning is undertaken collaboratively.
An ongoing challenge for the partners has been developing
mental health resources and implementation approaches
that are easy to understand for the early childhood and
school environments. The partners have worked closely in
the development of the initiatives to meet this challenge.
With additional Government funding being provided for the
expansion of KidsMatter Primary to another 1700 schools
from 2011, new mechanisms will be developed so that
increasing numbers of children and communities across
Australia can implement and benefit from the program.
The following key ingredients for the effective
implementation of KidsMatter Primary will continue to guide
School leadership is committed to take a whole school
approach to implementing the KidsMatter framework in a
An Action Team is established, enabled and supported to
lead and drive implementation; and
Professional learning on the framework is provided to all
school staff and, where possible, community members.
Recently there has also been an increased focus on
developing new partnerships with education sectors
(government, Catholic and Independent) and mental health
sectors in each of Australia’s eight states and territories.
These new partnerships will focus on supporting schools
with the implementation of KidsMatter Primary and in
building linkages and referral pathways for children
experiencing mental health difficulties.
The KidsMatter initiatives will continue to work with
education, early childhood and mental health sectors in
each state and territory of Australia to support sustainable
implementation of the initiatives.
APCMHDP 2011 : AUSTRALIA
CAMBODIA : LINKING NATIONAL PRIORITIES
The people of Cambodia have experienced four decades of severe regional
and internal conflict, leaving a heavy burden of mental illness among many
other legacies. Domestic resources, in both human expertise and financial
capacity, that can be committed to the mental health sector have largely
been destroyed or dispersed elsewhere. Equally, since the emergence from
the turmoil of the Khmer Rouge regime in 1979, there has been little direct
investment into the sector by international development partners.
Consequently Cambodia still has a very big problem of mental illness
and a huge need for the development of mental health services.
GROWTH IN ILLICIT DRUG USE IN CAMBODIA
One symptom of continuing mental distress has been,
since the 1990s, the wide-spread use of illicit drugs, with
the pattern of drug use changing from oral to injecting drug
use (IDU). There have been only limited studies of illicit drug
use in Cambodia. But based on expert estimates (including
the National Authority for Combating Drugs Report on illicit
Drug Data and Routine Surveillance Systems in Cambodia
2007) there are about 23,000 Amphetamine-type Stimulant
(ATS) users, and between 1,000 to 10,000 heroin users. Most
heroin users (80%) are injecting the drugs.
From the NCAD reports, the overwhelming share (80%) of
known illicit drug users are young people, with the majority
of people who use drugs being in the 18–25 age bracket
(59.6%) and tragically nearly 17% even younger.
Farmers and labourers comprise more than a third of drug
users (37.8%), followed by street children (16.8%), students
(15.4%), and the unemployed (14.0%), respectively. Usage is
overwhelmingly male: female drug users accounted for only
6.5% of all drug users nationally in 2007.
Recently Cambodia was recognised internationally for its
great achievement in reducing the prevalence of HIV-tested
sero-positive results in 19 to 45 year olds from 3.6 % to 0.9%.
However the prevalence of HIV is likely to increase through
transmission from the sharing of contaminated injecting
equipment. Shared use of syringes and needles has long
been recognized as a pathway for HIV transmission among
inject ing drug users.
Until very recently, however, substance abuse including
use of illicit drugs has not been a priority for the Ministry of
Health or for Cambodia as a whole. Adequate services for
the detoxification and treatment of the drug dependent have
Recognizing the close linkage between the “triad” of HIV
transmission, drug abuse and mental illness, the Cambodian
government made drug abuse a priority in its Health
Support Strategic Plan 2008–2015, with strong support from
international partners. Tackling substance abuse is now a
main priority for the National Program for Mental Health.
TABLE 1: ILLICIT DRUG USE BY AGE, EMPLOYMENT STATUS AND GENDER
10–17 years old 16.9%
18–25 years old 59.6%
Over 25 years old 23.5%
Street children 16.8%
APCMHDP 2011 : CAMBODIA
Top: H.E Dr. Mam Bun Heng, the Minster of Health (middle), Mr. Phillipe Allen (right), the Minister-Counsellor, Regional AusAid, and Dr. Pieter van
Maaren (left), WHO-Representative in Cambodia, at the inaugural of the Center for Mental Health and Drug Dependence and the launch of Methadone
Maintenance Therapy (MMT) Program in Cambodia. Above: United Nation Secretary General Ban Ki Moon giving a speech during his visit to MMT.
APCMHDP 2011 : CAMBODIA
METHADONE MAINTENANCE THERAPY
This new initiative is part of the Harm Reduction Program in
Cambodia, established in response to growing awareness of
the need to reduce the harm caused by substance abuse, an
emerging priority for the national health sector since unless
effective evidence-based interventions are undertaken
urgently, HIV transmission rates are likely to rise again. The
establishment of the first Methadone Maintenance Therapy
(MMT) Program represents the most prominent achievement
of the Harm Reduction Program.
The Harm Reduction Program has been introduced as a
globally recognised method to prevent HIV transmission
in which Methadone Maintenance Therapy is one of the
main components. This is backed by the recent World
Health Organisation’s ‘Basic Principles for Treatment and
Psychosocial Support of Drug Dependent People Living
with HIV/AIDS’, as well as by its 2004 position paper with
other UN agencies, ‘Substitution maintenance therapy
in the management of opioid dependence and HIV/AIDS
The primary objectives of the Harm Reduction Program are:
to establish treatment services for vulnerable people
suffering from mental illnesses and substance use;
to integrate substance abuse treatment into the general
health care system;
to prevent HIV transmission through the application of a
Harm Reduction strategy;
to mobilise resources to support development of the
mental health sector;
to demonstrate the efficacy of community-based treatment
for drug dependence.
to develop a community-based approach to treatment
for drug users based on international good practice,
a demonstration project has been developed from
which lessons can be learned for replication in future
In collaboration with United Nations Office on Drugs and
Crime (UNODC), a pilot project for Community-Based
Treatment for Drug Users has been undertaken in five
provinces. The strong partnership with the Australian Agency
for International Development (AusAID) and the United
Nations team in Cambodia, especially with the World Health
Organisation (WHO), has assisted in these achievements.
Above: Ban Ki Moon giving a methadone dose to a client,
and Mr Ban’s note in the Golden Book.
The integration of the Substance Abuse Program into
Cambodia’s Mental Health Program is of benefit to patients
since both programs have similar interventions, human
resources, and challenges.
COMMITTED PARTNERS WITH CLEAR ROLES
At the policy and management level, partners have cooperated
to mobilise resources for the national program
for mental health, and to advocate to the government
and aid donors the need to use mental health resources
in prevention of HIV transmission and treatment for
drug dependence. The partners have worked to develop
legislation, guidelines and protocols to ensure good practice
among health care providers so that patients receive
effective treatment and quality care.
APCMHDP 2011 : CAMBODIA
Mental health problems and substance abuse are usually inter-related and
require a response that involves multi-sector collaboration. Tackling substance
abuse has become a main priority for the National Program for Mental Health.
Three groups of partners are involved in this effort:
1 National Government: the National Program for Mental
Health, the Ministry of Health and the Secretary-General of
the National Authority for Combating Drugs. The National
Government is responsible for planning, monitoring
and evaluating programs. It promotes partnerships and
strengthens coordination of partners and is involved in
developing laws for drug control and developing national
policy on drug abuse.
2 International organisations and donors: the World Health
Organisation (WHO), Joint United Nations Program on AIDS
(UNAIDS), UN Office on Drugs and Crime (UNODC), AusAID.
International organisations are responsible for funding
substance abuse programs, providing technical assistance
with practice guidelines and day-to-day implementation
and drawing on current research findings on opiatesubstitution
therapy. They also play a role in coordinating
partners to ensure effective implementation, and have
been strong advocates for the program with the National
3 Non-government and international organisation partners:
Korsang, Kalyan Mith, the Khmer HIV/AIDS NGO Alliance
(KHANA), Family Health International (FHI), Friends
International. These organisations play a key part in
implementation. They inform the injecting drug user
(IDU) community about the availability of methadone,
help users get access to MMT clinics for assessment
and regular dosage, and help manage their experience
of treatment. They follow up MMT clients to ensure they
continue with counselling in the community setting, and
provide technical support with case-management and
prevention of relapse.
These partnerships have developed from shared personal
commitment and interest among people with technical
expertise from the various organisations to assist this
vulnerable drug-using group through the mental health
program. From these beginnings, recommendations have
gone to the senior decision-makers in government to set
the official policies and allocate resources. Some partners
have come and gone, as funding commitments have not
been long-term in some cases, but the following challenges
continue to be demanding:
To retain approval and support from top decision-makers to
formalise and extend the work of the partnership
To build public understanding of mental health and
substance abuse issues in Cambodia
To overcome shortages of support, advocacy and workforce
in the mental health and substance abuse sectors
To solve coordination problems and institutional conflicts
which often arise in multi-sectoral collaborations
To secure funding commitments to establish and maintain
MEETING THE TARGETS
At the national level, a coordination mechanism has been
established with participation from all development partners
to ensure effective implementation. Mental health problems
and substance abuse are usually inter-related and require a
response that involves multi-sector collaboration.
Thanks to efforts from all partners, the Methadone
Maintenance Therapy program has been adopted by the
Ministry of Health, and with support from donors such as the
AusAID and UNODC it has become operational. Communitybased
drug treatment and holistic approaches have been
applied in demonstration sites in some provinces.
Three psychiatrists and two psychiatric nurses have been
selected and trained as National Master Trainers for
community-based treatment for drug users. Over 150 health
officials have been trained in dealing with the common
problems of drug users. Five referral hospitals now have
integrated treatment for drug dependence into their mental
So far some 1300 drug users have been referred for
counselling and treatment, and 100 heroin users have been
enrolled in the Methadone Maintenance Therapy Program.
This is the first time that treatment of substance abuse has
been merged into the National Program for Mental Health,
and its expertise applied to the substance abuse program.
As constraints on funding are a major problem in developing
countries like Cambodia, merging the treatment of mental
health problems and substance abuse has potential to attract
more funding support for the Mental Health Program.
APCMHDP 2011 : CAMBODIA
A single man, working as a police officer, had been
addicted to heroin since 2006. He was spending an
average of US$300 per month on heroin. He left his
work and sold family properties to pay for his heroin
supply, resulting in conflict with his parents, siblings
and other relatives. The livelihood and happiness of
his whole family was destroyed. His chaotic life made
him depressed, and he used more heroin to improve
his mood, consuming more money and increasing the
risk of overdosing. After treatment from the Methadone
Maintenance Therapy Service, he stopped heroin use,
and is no longer spending money on illicit drugs. His
mood is stable, enabling him to return to regular work,
and his health is good. His financial situation and
social connections have improved. Most importantly his
parents, siblings and other relatives are happy with him
and he can reintegrate back into the family. The whole
family has become harmonised.
Integration of substance abuse treatment into mental
health services is also helpful for the individuals concerned,
their families and the community. The physical and mental
condition of the patients is improved, as well as their
social functioning. This in turn leads to improvement in the
economic status of families and a more stable life.
LESSONS LEARNED FROM DEVELOPING
Timelines: It is important to be patient and not to raise
expectations that developments will happen quickly.
Funding: As Cambodia is a developing country, it depends
on external organisations and donors for funding. In order to
sustain project activities it is preferable to involve a diverse
range of donors so that if any one donor stops providing
support it will not mean the end of program development
Institutional Conflict: If there is no clear institutional home
and management structure, this can lead to institutional
conflict due to confusion about roles and responsibilities.
THE CHALLENGE OF SUSTAINABILITY
The main challenge now is to ensure sustainability,
dealing with the increased burden of care placed on
service providers, and at the same time maintaining the
commitment of all partners.
In the future, the Ministry of Health plans to promote
public and private partnerships including community
participation and community-based organisations in
mental health and substance misuse prevention, treatment
and care, to implement the Mental Health and Substance
Abuse Strategic Plan 2011–2015. Inclusion of substance
abuse into the health strategic plan and the mental health
strategic plan, and the integration of community-based
treatment of substance dependence into the general
health system, especially into mental health services,
would represent a major achievement.
As there has been little attention paid to mental health and
drug issues in Cambodia compared with other countries
in the region, advocacy is very important in mobilising
resources to support the program. The integration of
substance abuse treatment into the mental health program
will help build appreciation of the mental health program
and assist in gaining resources for a wider range of mental
As a poor country with little experience in mental health and
substance abuse issues, Cambodia has relied heavily on
assistance from development partners in these areas. Often
there are differences in perceptions and objectives between
Government and partner organisations. To get all partners
on the same wavelength, a strong coordination mechanism
needs to be in place.
To develop a successful program through partnerships,
such as the Cambodian Substance Abuse Program, good
leadership and political commitment are imperative. It is
very important that the UN team or the donor community
organisation takes a leadership approach to promote the
development of partnerships. Adequate time, flexibility
and the ability to take advantage of opportunities are also
important. Though it is important to start innovations at
the technical level, a lack of support at the policy level
means change will not occur. Partnerships should work at
both the policy and management level as well as at the
implementation level in order to be successful. Common
interest, mutual understanding and respect between
partners will sustain a successful partnership.
APCMHDP 2011 : CAMBODIA
Above: Wang Jun, Three Mountains, marker pen on paper, size 78 x 54cm. Born in 1958, primary school graduate Wang Jun was a farmer before suffering
from schizophrenia. While a resident in Nan Jing Zushantnag Mental Health Hospital his talent for painting was recognised by Mr. Guo Haiping of the
Nanjing Natural Art Centre, an NGO that assists mental illness patients. Since then his artworks have been acknowledged by many art organizations.
During his eight years in hospital, Wang Jun’s wife has never visited him, and his son has visited only once. Six months ago, Wang Jun’s wife decided to
divorce him. Since then he has told Mr Guo that he has no passion and willingness to draw anymore — the only wish he has now is to see his son.
He has said: “I am thinking of my son every single day”.
APCMHDP 2011 : CHINA
CHINA : MUTUAL RESPECT
The rapid development of China’s community mental health service over
the past ten years is inextricably linked to the strength of its international
partnerships, most particularly its partnership with Australia, through
Asia-Australia Mental Health, a consortium of St. Vincent’s Health and The
University of Melbourne’s Department of Psychiatry and Asialink.
From the start, the China-Australia collaboration in mental
health, like all successful partnerships, needed to create
a working philosophy that could accommodate inevitable
setbacks. The partnership model was based on a strong
bond of mutual respect.
The partnership has undergone a number of significant
transformations, from an initial period of negotiation,
exploration and uncertainty, through an intensive learning
and knowledge transfer stage, to what is now a solid and
true collaboration which has expanded to include new
national and international partners
THE LEGACY OF SARS
From the mid 1980s the Chinese government was focused
on growing China’s gross domestic product at a fast rate.
Public health, education, environment protection, and social
welfare did not register on anyone’s priority list. But in 2003,
the epidemic of Severe Acute Respiratory Syndrome or SARS
in China changed everything.
When the government released the facts about SARS, the
tempo of Beijing suddenly came to a halt. Shops were empty,
theatres closed. The only good thing SARS brought to China
was a lessening of road traffic congestion. It literally stopped
the economy in its tracks.
SARS taught China a huge lesson. GDP growth was not
sufficient as the only indicator for social development. A new
approach had to be adopted urgently. In October 2003 the
Ministry of Health announced its commitment to a three-year
intensive investment to rebuild China’s public health system.
Though China has an estimated 16 million people suffering
from severe mental illness, in 2003 mental health was not
yet included within its new public health framework. China
being a very centralized and government-directed country,
mental health development needed strong and continuous
support from government at all levels.
Initially, funding for mental health programs was difficult
to source as compared to other programs dealing with
communicable disease. There was no evidence base for
the success of interventions in China and no one answer or
specific method of disease control. Mental health seemed
far too complicated.
The task for the Peking University Institute of Mental Health
in China was thus enormous. In practice, how could China
deliver a culturally appropriate mental health service based
on World Health Organization principles for 16 million people
and their families
From October 2003 to March 2004 the situation looked
very unpromising for mental health advocates. A lengthy
application process had yielded no outcomes. It was
still uncertain that mental health would be included in
China’s public health system reconstruction. No psychosis
prevention and treatment solutions had been found for
public health programs, and all other chronic disease
programs had been excluded from the reconstruction
A POTENTIAL SOLUTION EMERGES
For a number of years previously, Chinese and Australian
mental health professionals had developed a deep respect
for each other’s work, with some people-to-people exchange
programs already under way.
A chance meeting in Melbourne of Chinese and Australian
mental health leaders and Asialink leaders in 2002 led to a
workshop on mental health and ageing being held in Beijing
the following year.
This workshop deepened the existing Beijing-Melbourne
relationships to a more institutional level, to include the
Peking University Institute of Mental Health and the newly
formed Asia-Australia Mental Health consortium. However,
as the cultural, political and economic contexts for mental
APCMHDP 2011 : CHINA
model could not be simply transplanted into China, as the
contexts were just too different. However the lessons learned
in Victoria’s story were extremely valuable: China did not
have to repeat the mistakes Victorians had made in building
a new mental health system 20 years previously.
Agreeing that this would be the starting point, the
China-Australia partnership in community mental health
commenced. Inspired by the potential of what they had
learned in Melbourne, the group sought advice from
professional consultants about adapting the model for
China at that stage of its economic and social development.
Spurred on by the positive finding that the Victorian model
could be adapted to suit China, the hard work of designing
the program and writing applications began.
Zhou Huiming, Music, 2006, oil on canvas, 100 x 80 cm. Born in 1954,
Zhou Huiming served in the Peoples Liberation Army and then worked as
a bench worker. He has suffered from schizophrenia since 2000. He has
painted for a long time. In 2010 his best friend Mr. Zhang Tianzhi took
some paintings to the Nanjing Natural Art Centre in the hope that they
could help Zhou Huiming with the further development of his art.
health were so very different in Australia and China, there
was no clear direction for future collaboration for this
promising new partnership.
China s small mental health leadership team knew that to
move forward it had to make mental health a priority for
China s national leadership.
In early March 2004, sponsored by WHO, a group of mental
health professionals visited the Britain and Germany’s
community mental health services to obtain inspiration and
guidance. Eventually, it was decided that the team should
visit Melbourne’s community metal health service.
After a week of site visits and four weeks of study of
system management study, discussions with key Victorian
government, academic and NGO experts and long nights
huddled around a whiteboard, a new model for mental
health sector reform in China began to take shape. Both
sides from the beginning were well aware that the Victorian
THE 686 PROGRAM — A PATIENT-CENTERED
In September 2004, after competing with over 50 proposals
and supported by a group of China’s leading sociologists,
economists and psychiatrists, the program for mental health
service reform became the only non-communicable disease
program included in China’s national public health program.
This event became a historical milestone for China s
welfare development. Mental health had become officially
integrated into public health.
Named the 686 Program after its initial funding of 6.86
million yuan, China’s mental health program is similar to
the Victorian model, which has at its core a patient-centred
approach which is community-based, seamless, functionoriented
China’s mental health program was managed by The
National Centre for Mental Health (co-located with the
Peking University Institute of Mental Health), overseen by a
national working group and an international advisory group
with experts drawn from Asia Australia Mental Health and its
By early 2005, 60 demonstration sites were established, with
one urban and one rural area in each of the 30 provinces of
China, covering a population of 43 million. The first three
years of the program proved that people could be effectively
treated in the community, given adequate resources.
The Australian Advisory Group provided technical support
that included training, development of a project evaluation
plan, monitoring in the field with China professionals, joint
research publications and speaking at annual national
APCMHDP 2011 : CHINA
From the start, the China-Australia collaboration in mental health, needed to
create a working philosophy that could accommodate the inevitable setbacks.
The partnership model was based on a strong bond of mutual respect. The project
partners work now as one team, not Chinese not Australian, but a team that
understands each other’s strengths and needs, and is focused on improving the
lives of the most neglected in all populations – people with mental illness.
A two-level training mode was adopted, first at the national
level utilizing a train-the-trainer approach, then with the
graduates becoming trainers themselves to build up teams
to run the programs at the provincial level. Contents of the
training courses included guidance on project management,
standardized treatment protocols, case management,
information management, family education, and the training
of police and Neighbourhood Committees.
From 2004 to 2010, 220 million yuan has been allocated
from the central budget to the 686 program. As of the
15h April 2011, the 686 program covers 680 districts and
counties in 161 cities/provinces and serves a population of
330 million. There are 277,000 registered psychosis patients.
200,000 high-risk patients regularly followed up, with free
medication distributed to 94,000 needy patients and free
hospitalization provided for 12,400 people.
The 686 program has also played a large role in ensuring the
security of China’s recent major events, including the Beijing
Olympic Games, Shanghai Expo, China’s 60th National Day,
Guangzhou Asian Games, and the Shaanxi Horticultural
Expo. All events, as part of their risk management strategies
have applied the 686 management model and have made
use of its working network of mental health professionals.
The Shenzhen National University Games and Nanjing Youth
Olympic Games have also included the 686 program model
in their preparations.
THE EVOLUTION OF THE PARTNERSHIP
In seven years of implementation the China-Australia project
is continuously developing and extending. Over 100 Chinese
government health officials (including the Minister of Health,
the Director of China CDC and the Director of Mental Health
Li Hui, Delusion of vision, 2011,
brush and marker pen on paper,
80 x 60 cm. Born in 1962, Li Hui
worked in a bank before suffering
schizophrenia. Since then he has
been divorced twice, and is now
unemployed. In 2010, Li Hui read
an article about Nanjing Natural
Art Centre and contacted Mr. Guo
Haiping. He told Mr. Guo that
he painted for years at home by
himself, despite opposition from
his family. Mr. Guo helped create
an environment for Li Hui to paint.
Three months ago he re-married
and his new wife understands
and supports his desire to paint.
Currently he attends Nanjing Natural
Art Centre and they provide as much
help as they can. While Li Hui hopes
to have a studio for himself one day,
his new house is a ten square metre
room with insufficient space for a
APCMHDP 2011 : CHINA
Above: Zhang Yubao, Dreamer, 2010, oil on canvas, 60 x 50 cm. Born in 1975, junior high
school graduate Zhang Yubao suffers from schizophrenia and is a resident in Nanjing
Zushantang Mental Health Hospital. In 2006, Mr. Guo Haiping recognised his talent and
helped him to develop his art. As a result of media exposure, Zhang Yubao’s artworks such
as Roaring, Struggling, Half side man, Flag and The Dreamer have captured the attention
of people in the cultural arena. However, his parents are dead, his wife has disappeared,
and there is no guardian with whom he can live. Given that there are no facilities in
hospital that enable him to continue painting, his physical and mental situation are
deteriorating. Mr. Guo Haiping continues to regularly visit him, and informs us that Zhang
Yubao wishes to be discharged from the hospital in order to continue his painting.
Above: Yu Fei Yu, Ripples (series 10), 2007, oil pastel on paper,
78 x54 cm. Born in 1976, Yu Fei Yu worked as a miner before
suffering schizophrenia. In 2006 he attended Mr Guo Haiping’s
art project in Nanjing Zushangtang Mental Health Hospital. He
began drawing ‘fish’, then ‘curves’. He has said that a series
of curves is ‘ripples’, and the fish are beneath the ripples.
Repeating the ripples helps him to calm down. He doesn’t want
to disclose his real name, so Mr.Guo has named him Yu Fei Yu.
He is very pleased with this name, and is now back at home
where he always paints ‘ripples’.
Division) and mental health hospital directors have visited
Melbourne and studied community mental health programs.
The Australian and Chinese partners hold regular planning
sessions annually and participate in other activities in each
other’s country. The program has now extended to include a
third partner, the Chinese University of Hong Kong.
A key challenge for successful implementation of the 686
model is limited workforce capacity to deliver the program
at the local level. A large national core group is needed to
develop skills in appropriate community case management,
service delivery and training others. To meet this enormous
challenge, a training program was developed in 2007 by
the three-way partnership of the Peking University Institute
of Mental Health, Asia-Australia Mental Health, and the
Chinese University of Hong Kong.
The primary aim of the program is to train multi-skilled case
workers in community mental health service delivery. Building
on pre-existing links between Hong Kong and Melbourne
in community mental health training, the tripartite training
program is delivered in three locations: Melbourne, Hong
Kong and Beijing. The rationale for this approach is that while
intensive training can be conducted in Melbourne for a limited
number of people from China, a more efficient, less costly and
potentially more culturally appropriate and locally applicable
training program could be run in Hong Kong for a larger
number of multi-skilled case workers.
The tri-partite program is based on a curriculum that sees the
major training centres in Beijing, Hong Kong and Melbourne
developing and delivering complementary programs, with
specific training objectives appropriate to a variety of
participants and their future roles.
Encompassing best practice principles drawn from allied
health disciplines (nursing, social work, occupational
therapy, psychology) a basic set of knowledge and skills for
case management is outlined.
APCMHDP 2011 : CHINA
Site visits to a range of community mental health facilities
in Hong Kong (eg day hospitals, half-way houses, training
centres, and mental health support programs), and
supervision by community mental health team members
gave opportunities for clinical experience. Selected trainers
from Hong Kong and Melbourne visit and participate in the
training programs in China to familiarize themselves with the
Over 160 Chinese mental health professionals have now
participated in this ongoing and very practical training
program in Hong Kong.
KEY INSIGHTS DEVELOPED OVER THE LIFE
OF THE PARTNERSHIP
Mental illness is not a problem that affects any particular
strata of society, ethnic group or nationality. It’s a global
epidemic that is growing and can impact any one of us. From
its start, the China-Australia collaboration in mental health,
like all successful partnerships, needed to create a working
philosophy that could accommodate the inevitable setbacks
and ‘lost in translation’ moments. Our model was based on a
strong bond of mutual respect.
Technical excellence and valid experience were of course
essential foundations stones for the partnership s success.
But to be truly useful, all our staff needed to develop a deep
appreciation of the cultural, socio-economic and political
complexities of China and their impact on community mental
health reform. Cultural intelligence, really understanding
China, was the key factor for success in our ongoing
Initial misunderstandings based on unrealistic expectations
of each other’s capacity and motivations were at times
difficult to negotiate. However an underlying deep respect,
open minds and strong determination by both parties to
succeed all sustained the partnership during difficult times.
Ongoing optimism helped not only find the solution, but also
has deepened the friendship so that when real assistance is
required there is no question as to where this can be found.
For example, the partnership with Australia took on another
dimension when the 2008 Sichuan earthquake, affecting
an estimated 15 million people, threatened to overwhelm
China’s mental health leadership responsible for the
psychosocial response to the disaster.
Mental health professionals and volunteers working in
Sichuan were under-prepared and inadequately trained
to work in a coordinated and collaborative fashion. The
Chinese mental health leadership at the national centre
was in daily communication with AAMH about responses to
the urgent needs on the ground. With support from AusAID,
Asia Australia Mental Health was able to take a leading
role in providing the technical support to the National
Centre of Mental Health to assist in the co-ordination of the
psychosocial relief effort.
The fact that the Australian mental health system is
constantly undergoing reform provides China with many
current lessons, both positive and cautionary. When the time
is right for China in its own reform process, it can draw feely
from these examples. Feedback, creative ideas and practical
experience are shared honestly and openly with each other.
The project partners work now as one team, not Chinese
not Australian, but a team that understands each other’s
strengths and needs, and is focused on improving the lives
of the most neglected in all populations – people with
APCMHDP 2011 : CHINA
Leung, born 1966, crêpe
paper, 90 cm x 50 cm.
Leung spent 6 months
creating this artwork. “The
gracefulness of the rose
garden attracted the fairies
playing guitar and making
music. The difficult part is
to roll those pieces of crêpe
paper, in various colours,
and use them to make
patterns. The crepe paper
has to be small to make the
artwork fine and delicate.
The process is sometimes
boring, yet sometimes
thrilling. It gives me a sense
Leung completed the training
in the Day Hospital and now
works under the Supported
courtesy of the Occupational
36 APCMHDP 2011 : HONG KONG
HONG KONG : INTERVENTIONS FOR FREQUENT
RE-ADMITTERS PROGRAM (IFR)
The Interventions for Frequent Re-admitters Program (IFR) began in 2008
as a pilot community mental health program in Hong Kong, for people with
severe mental illness and heavy use of psychiatric services. The program
implemented an Intensive Case Management Model (ICM) in two out of
the seven clusters in Hong Kong public hospitals.
THE REVOLVING DOOR CHALLENGE
In the past, mental health services in Hong Kong were
largely based in hospitals with support from busy
specialist outpatient clinics. The model of care was mainly
institutional. Mental health professionals coped efficiently
with high patient volumes and rapid throughput.
Due to this heavy demand on services, however, it was
difficult for staff to develop personalized care and full
address the needs of patients. There was also a separation
of psychiatric and social welfare care, making it difficult
for mental health services in Hong Kong to deliver the best
recovery and rehabilitation outcomes for the patients.
Following the global trend of deinstitutionalization and
shifting emphasis to community psychiatric care, the
numbers of psychiatric beds in Hong Kong were reduced
from 4,730 in 2003–04 to 4,000 in 2008–09.
The reduction of psychiatric beds and the significant
development of community and rehabilitation services
implied that more people suffering from severe mental
illness could be better managed in the community. In
reality, as in many overseas experiences, the contraction
of institutional treatment was not matched adequately by
expansion of community support services. This raised the
readmission rate, creating the so-called “revolving door
In Hong Kong, public mental health services are provided
through seven geographically based clusters of the Hong
Kong Hospital Authority (HA): Hong Kong East (HKE), Hong
Kong West (HKW), Kowloon Central (KC), Kowloon West
(KW), Kowloon East (KE), New Territories East (NTE) and
New Territories West (NTW). An analysis of discharge and
admission records of HA clusters in 2006–07 showed
high numbers of patients with readmissions to psychiatric
hospitals after discharge (see table below).
Of 12,867 psychiatric admissions in all hospitals from
2006–07, 2,106 (16.4%) of them were readmissions, with
around 50% suffering from psychotic disorders.
Although there were medical and social resources available
to support patients, the lack of a key worker to guide and
monitor the patient through the appropriate services tended
to result in a fragmented and uncoordinated service delivery.
Previous studies showed that psychiatric readmission
had been closely associated with many psychosocial
factors. Further, the data seemed to indicate that a more
individualized service to this subgroup of patients with
complex needs might reduce re-hospitalization.
The reduction in long-term and rehabilitation bed capacity
was making it more urgently necessary to find alternative
models of care for the severely mentally ill.
TABLE 1: NUMBER OF PATIENTS WITH ≥2 ADMISSIONS IN 2006–07
HKE HKW KC KE KW NTE NTW
270 104 159 15 605 633 320
APCMHDP 2011 : HONG KONG
Aove: Left: The happy faces: doctor and case managers worked closely together, hand in hand, to provide the best care to the patients.
Right: Doctors and case managers on a rock climbing excursion.
CASE MANAGEMENT APPROACH PILOTED
In various regions of the world, case management in
the community was being implemented to deal with the
complexity of needs for those with severe mental illness and
at particular risk. Research studies looking at individualised
care by case managers showed promising results. Hong
Kong’s mental health service decided to follow this global
trend, to provide more specialised care delivered through a
case management approach that would be extended over a
number of years.
The Interventions for Frequent Re-admitters (IFR) began as
a pilot program to start constructing a case management
approach for Hong Kong
Using the intensive case management approach, the
program specifically aimed to enhance post-discharge
community support for a group of frequently re-admitted
patients with severe mental illness. The project was piloted
in the NTE and KW clusters, serving 3.2 million of Hong
Kong’s 7.1 million people.
A top priority for the Hong Kong mental health service was
the development of community teams. A mobile support
team comprising doctors, community psychiatric nurses
and occupational therapists was established. The team
members from different disciplines worked closely together
with patients and their carers to provide a shared and
personalized care, to support them in the community and to
INTERVENTIONS FOR FREQUENT
The IFR program aimed to address the individualized needs
of the clients and to reduce the readmission rate and bedday
occupancy by 20 percent. This was done through a
low-client-to-staff ratio (20:1), prompt interventions, flexible
hours in support and better coordination between staff
at the in-patient, out-patient, day-patient, accident and
emergency departments, and the community partners
Those with two or more admissions in one year or four or
more admissions in two years were screened for inclusion in
the program. The case-management service to be provided
had to be timely, collaborative, proactive, multi-disciplinary,
personalized, comprehensive, continuous, coordinated,
accessible and accountable. The clinical conditions and
adherence to medication routines by patients had to be
closely monitored, to spot relapses early and intervene.
As client needs are often complex and vary over time,
linkages with appropriate services and expertise is
essential. This means case managers need to build strong
relationships across the health sector and the community
to deliver services that meet the assessed needs of the
patients. In practice, this means nurses and occupational
therapists who are the designated case managers must
establish good partnerships outside their own normal field
of operation, with various medical, nursing, and allied health
professionals and community partners.
APCMHDP 2011 : HONG KONG
Having a well functioning multi-disciplinary team highlights the importance of
cross-professional partnerships in meeting the complex needs of patients with serious
mental illness, and reducing their risk of relapse and long term disabilities.
HOSPITAL BASED PARTNERSHIPS
The case managers worked closely with the team
psychiatrists to provide prompt medical interventions and
risk assessments in the early stage of relapse. Prompt
medical interventions are provided, such as early outpatient
review for mental state and risk assessment, day hospital
arrangements, medication regime advice, liaison with other
medical staff and community partners. Case managers
have regular access to the psychiatrist and medical backup
through weekly case review meetings and discussions.
When patients attend the emergency department, case
managers offer advice to medical staff about management
plans, and suggest alternatives to inpatient treatment
through identifying appropriate support in the community.
The case managers also worked closely with the in-patient
Below: Sze, born 1948, Chinese paper folding (Zhezhi). Sze was
stabilized after a manic relapse. “I enjoyed traditional Chinese
handcrafts”. She also used Chinese paper money and folded numerous
pieces of paper into boats, bringing good luck and fortune to her family
and friends. Artwork supplied by courtesy of the Occupational Therapy
Department, Shatin Hospital.
treatment team to facilitate early discharge. To deliver better
post-discharge support, they also liaise with staff in day
hospitals, including occupational therapists and medical
social workers. Furthermore, if patients are admitted to nonpsychiatric
wards, case managers work in collaboration with
the consultation liaison team about the management and
Case managers work closely with carers of patients to
provide support, counselling and education regarding the
effects of medication and signs of relapse. As many of the
patients live in halfway houses run by NGOs and in private
hostels, support and advice is provided to the hostel staff
about patients’ issues such as budgeting, behavioural
problems, daytime engagement, and management of
persistent symptoms. The case managers also discuss such
with NGOs and staff in the Housing Authority and the Social
Welfare Department (SWD) issues of patients’ finances,
housing, family and employment.
This changing role and the new service model have had
an impact on case managers. Previously, they delivered
psychiatric care to patients as sole operators, using only their
own professional expertise. Under this new program they
are called on to develop core case management skills that
include building and maintaining partnerships and teams.
Finding suitable staff with extensive community experience
and the ability to adapt to this new service model, beyond
their traditional boundaries, is essential. Training and
supervision is therefore important for case managers to
develop the required new skills and competencies.
The internal and external partners needed time to
understand this new role and working partnerships with
case managers. Equally, promoting understanding of the
goals and guiding principles of this program to community
partners was very important in the initial phase.
Another challenge was the provision of extended hours
of patient support up to 9pm on weekdays and during
weekends and public holidays. The program showed initial
promising results, thanks to committed staff that played
important roles, especially during the start-up phase.
APCMHDP 2011 : HONG KONG
With appropriate training, re-structuring of their working
roles and their own commitment, they were able to integrate
these new core competencies into their own specialized
expertise to provide better care to patients.
OUTCOMES OF IFR AND FUTURE PLANS
In the year when the program was implemented, 262 patients
were identified for inclusion, with the majority suffering
from schizophrenia (60%) and mood disorders (20%). Most
were in the 26–55 age group (80%) and male (54%). More
than 90% of patients were engaged in the program with an
average follow up of 524 days (up till May 2010).
Improvement of outcomes was noted when measures before
and after the program were compared. Patients were less
likely to be admitted, had shorter stays in mental hospitals
and were less likely to attend emergency departments for
psychiatric consultations. There was also mild improvement
in clinical symptoms and reduction in direct cost.
(a) The number of admissions, length of stay and emergency
department attendance were reduced by 82%, 82% and
61% respectively. Most cases (60%) had no admission since
recruitment. The Majority (89%) achieved service target (ie a
20 % reduction in readmission rate and bed day occupancy).
(b) Mild improvement in clinical symptoms was noted
measured by the Brief Psychiatric Rating Scale (BPRS),
measuring psychotic symptoms, general psychiatric
symptoms and mood symptoms. There was a reduction in
the BPRS score from 25.0 (at baseline) to 21.6 (at 12 months)
(c) Direct cost was calculated from the days in hospital and
Accident and Emergency Department attendance. A total of
HK$10.58 million was spent for this program. Compared with
“the days in hospital” and “AED attendance” before and
after the program, there was a cost reduction of HK$40.31
million, hence a saving of $29.73 million from the program.
(d) A majority of the program recruits remained unemployed
with no significant change. No obvious change in quality
of life was noted from baseline to twelve months. However
this may result other factors such as availability of housing,
and employment support. Improvement may not be obvious
without extra input from social resources
(e) Most patients (91.3%) remained in the program. Among
those who left the program, 20 cases refused follow up, had
prolonged in-patient care or were imprisoned, while three died
(one from suicide and two from other medical problems).
Identifying suitable cases can be challenging, so a thorough
needs assessment before recruitment helps to optimise the
service use. A small minority of patients failed to engage with
the service. Discharging patients who consistently failed to
benefit may free places for individuals who could achieve
Madam A was a 48-year-old divorced housewife,
living with her teenage daughter, who suffered from
schizoaffective disorder for twenty years. She coped
poorly with stress and had repeated admissions for drug
overdoses, up to five times a year. Her mood fluctuated,
she had poor social support and her relationship with
her parents was fraught. Initially, she had a pattern of
overdosing on psychiatric medications in the days after
outpatient follow-up. The case manager provided drug
supervision, assisted with the use of the drug box and
emphasized the harmfulness of excessive drug taking.
Strategies to cope better with stress were continually
explored. The case manager also engaged her parents to
help them understand her relationship difficulties with
others. She was encouraged to participate in various
daytime activities such as day hospital, day centre
and voluntary work organized by a non-government
organization (NGO). The case manager regularly worked
with the social worker of an NGO, to help reduce the
patient’s mood fluctuations and reduce her relationship
difficulties. To reduce harm, she was seen by a psychiatrist
every one or two weeks. The case manager also liaised
with the emergency department, to avoid it dispensing
psychotropic drugs in view of her persistent pattern of
drug overdose. Her daughter had significant carer’s stress
and needed constant support. Since the intervention, her
mood was better maintained, with fewer drug overdose
incidents, and she only had one brief admission to a
psychiatric unit. Better stress-coping and temper control
were observed. She utilized social services more readily,
could be engaged in voluntary work and attended the day
centre organized by NGO.
APCMHDP 2011 : HONG KONG
Above: The big family: The staff and the families arranged a joint healthcare talk and training program in the day camp.
In the next few years, comprehensive case management will
be extended to more patients suffering from severe mental
illness in different hospitals. A new community program,
Personalized Care Program (PCP) for patients with SMI, was
started in April 2010.
The program will continue to build partnerships with
community partners, including NGOs, government,
police, and others. Service co-location, extended hours of
service, better mobilization of community resources, and
individualized patient care plans will strengthen patients’
recovery and inclusion in the community.
Recruiting experienced nursing staff at the start of the
program may have contributed to the success of the
program. With these committed and experienced staff,
patients were better engaged and those with early signs of
relapse given care for promptly. Close liaison with medical
doctors of the IFR team provided strong medical backup
when required. Selecting appropriate cases with potential
benefit from the program was also important for its success.
Those with high risks were given priority to maximize
utilization of the service. Furthermore, the Government’s
support played an important role in enhancing case
management in the community. Development and expansion
of community mental health teams became one of the top
priorities in the Mental Health Service Plan 2010.
One of the key lessons from the Hong Kong experience is
that it is necessary to build strong partnerships within the
specialist health services and with bodies in the community
to minimise frequent readmissions to hospitals. Having
a well functioning multi-disciplinary team highlights the
importance of cross-professional partnerships in meeting
the complex needs of patients with SMI and reducing their
risk of relapse and long term disabilities.
The case management model however depends greatly
on the availability of the right human resources. There
was difficulty in recruiting experienced nursing staff at the
beginning, particularly as there is an overall shortage of
psychiatric nurses in Hong Kong. The lack of undergraduate
training greatly affected the development of new programs.
Further human resources are required, especially of
psychiatric nurses and allied health professionals.
Promotion opportunities may provide incentive to attract
experienced staff to work in the community.
Careful service and human resource planning beforehand,
such as a review of existing medical and social services is
helpful. Overseas training opportunities in case management
can help in the initial establishment. Ongoing training and
support for nursing staff and allied health professionals is
important for effective implementation of the program.
41 APCMHDP 2011 : HONG KONG
INDIA : REVISED DISTRICT MENTAL HEALTH PROGRAM
Before 1996 the situation in many districts of India was very bleak,
with virtually no formal mental health care services available. There was
no treatment for common mental disorders and mental health promotional
activities were unheard-of. Families would hide relatives with severe
mental illness for as long as possible. When the burden became too great
for families to bear, the mentally ill person would often be left in the care
of a religious order, or abandoned to fend for themselves.
PRE 1996: LACK OF ACCESS TO BASIC MENTAL HEALTH CARE
Mental disorders affect all sections and strata of the
community. Epidemiological studies suggest that 6–7 %
of the population of India suffer from mental disorders.
But mental health promotional activities must also consider
measures to enhance the wellbeing of the remainder of
Before 1996 the situation in many Indian districts was
very bleak, with virtually no formal mental health care
services available. There was no treatment for common
mental disorders and mental health promotional activities
were unheard-of. Families would hide relatives with severe
mental illness for as long as possible. When the burden
became too great for families to bear, the mentally ill
person would often be abandoned and left in the care of
a religious order.
Patients and their families had to travel long distances to
find what mental health care was available. These long
distances, combined with a lack of drugs and trained
personnel in the home district, caused many to relapse.
Those who had the resources to travel could still miss out
the benefit of early diagnosis and treatment, due to sociocultural
Myths and ignorance about mental illnesses were rampant,
resulting in a severe stigma being attached to patients.
The lack of availability of handy community mental health
services increased dependence on overcrowded mental
hospitals, deepening stigma and de-socialisation. For
persons with severe mental illness, this greatly lessened
the prospects of reintegration and rehabilitation in the
At the same time common mental disorders remained
untreated, adding to suffering of mentally ill people and their
families, and increasing the burden to the community.
With more knowledge and scientific awareness about new
models of community care and appreciation that mental
health was be an integral part of general health, community
treatment options for mental disorders came to be seriously
studied in India.
In 1996, following widespread consultations and discussions
with key stakeholders, a meeting of the Central Council of
Health, comprising the health ministers of all Indian States
and the central government, established the District Mental
Health Program or DMHP.
THE DISTRICT MENTAL HEALTH PROGRAM
The DMHP is a community based mental health service
delivery program implemented in 123 of the 652 districts
of India. The participating districts were selected on the
recommendation of the concerned state government as
being underserved in existing mental health services.
The program aims to develop partnerships between the
district mental health team, the primary health care teams,
community based organisations, non-governmental organisations,
users, family groups and various government
departments to deliver a comprehensive mental health
The district team is responsible for the networking
of all these stakeholders, training and sensitisation,
community awareness campaigns, service linkages and
support for promoting mental health and delivering
mental health services. With a focus on local needs,
APCMHDP 2011 : INDIA
Above: Awareness march at India Gate, Delhi on World Mental Health Day, 10 October 2010.
the partnership must be based upon mutual trust,
respect, accountability, effective communication, active
collaboration, sharing of resources, and the aspirations of
people with regard to mental health.
The overall goal of the DMHP is to provide early detection
and treatment of patients within the community. The
program aims to provide sustainable basic mental health
services to the community with the following outcomes:
Patients and their relatives no longer have to travel long
distances to hospitals or nursing homes in the cities.
Pressure is reduced on overburdened mental hospitals.
The stigma attached to mental illness is reduced through
public education to change attitudes.
Patients are discharged from mental hospitals, and treated
and rehabilitated within the community.
Once approval for establishment of a District Mental
Health Program in a particular district is given, funds are
transferred to the District Health Society and a timeline for
implementation is drawn up.
The district team is then recruited and placed at the district
hospital. Training of all primary care health staff is initiated
in phases, in collaboration with the zonal medical college or
mental health institute.
Psychotropic drugs are procured and made available at
primary health centres. Activities are started to raise public
awareness, and workshops held to sensitise teachers,
officers of the panchayati raj institutions, and local NGOs.
Linkages for primary, secondary, tertiary mental health care
and rehabilitation are established, along with monitoring
mechanisms. Services are supported initially by the Central
Government, with responsibility later on taken over by the
concerned state government.
PARTNERS AND THEIR ROLES
DMHP team: The specialised mental health team
which includes a psychiatrist, a psychologist, a social
worker, nurses and support staff. The team is based at
the district hospital. It provides referral support to the
primary health care providers who have been trained
APCMHDP 2011 : INDIA
The program aims to develop partnerships between the district mental
health team, the primary health care teams, community based organisations,
non-governmental organisations, users, family groups and various government
departments to deliver a comprehensive mental health care service.
to identify and treat common mental disorders using
a limited number of psychotropic drugs. Psychological
assessment, psycho-logical intervention, psycho-education,
psycho-social intervention, and mental health awareness
are also provided by this multidisciplinary team.
Primary Health Care Teams: These are teams of medical
officers and other health staff who are the first point
of contact for mental disorders in the community. After
receiving training in identification and the treatment of
common mental disorders, they provide a first level of
Below: Vishwa, Balance & ecstasy, 2005, oil on canvas, 24”
x 36”. Born in 1959, Vishwa has paranoid Schizophrenia.
Painting has helped him during the acute phase of his illness,
in his words: “...bringing a balance... towards awareness and
away from the complexity of the illness...”
mental health care with a limited list of available drugs,
under supervision and support of the district team.
Nodal Institution: The nearby Mental Health Institute or
Medical College is the tertiary care mental health service
provider for the area and is designated nodal institution
for the DMHP. It supervises the district team in training the
general health work force of the district and assuring the
smooth running of the program.
NGOs: NGOs working in the district help in running
awareness campaigns, screening camps, rehabilitating
persons with severe mental illness, providing shelter to
homeless persons with mental illness, and advocacy. They
can help the needy people to avail themselves of mental
health services, and distribute psychotropic drugs for
persons under their care.
Patients and Families of persons with mental illness:
Invariably they are keen to see services close to their homes
Community Council (Panchayati Raj): Local community
councils want mental health services to be available and
delivered in ways that ensure the ongoing stability and
mental wellbeing of the community.
OVERCOMING INITIAL CHALLENGES
In many districts, however, staff members with the right
skills were not readily available to build a specialised mental
health team, delaying the introduction of the program.
To overcome these shortages, guidelines were revised to
increase the remuneration of the team to encourage existing
health personnel to undertake additional training for mental
health care. This included short-course programs for:
medical officers, in psychiatry and programme
psychologists and psychiatric social workers, in clinical
psychology and psychiatric social work respectively
nurses, in psychiatric nursing
district-based psychiatrists, clinical psychologists,
psychiatric social workers and psychiatric nurses,
to expand and update their existing skills and
APCMHDP 2011 : INDIA
CASE STUDY: RAMESH — FROM DESPAIR TO HOPE
Ramesh is a well-respected teacher in a village school in
Orissa, one of the poorest and least developed states in
India. People know him as an intelligent man who is very
helpful. The only indication of his suffering from a major
mental disorder today is his monthly visit to the health
centre to get his prescription of antipsychotic drugs
which he takes religiously.
Three years back, Ramesh had developed acute onset
of abnormal behavior: suspicion, muttering to himself,
aggression, and aimless wandering. He stopped going
to school and would try to avoid contact with others.
Family and friends took him to many faith healers, but his
condition did not improve. He was suspended from his
job and his family suffered hardship. Relatives and fellow
villagers gave up on the family, and dismissed Ramesh as a
hopeless case. He remained confined to a room, with little
interaction with other people.
This changed two years back when the DMHP was launched
in his district. Regular camps were held for identification
of mental disorders in the community. Local health
staff were trained to identify and treat mental disorders
under the supervision of the district mental health team.
Psychotropic drugs became available. Information teams
went around the district holding mental health ‘camps’
to raise grassroots awareness about how to recognize
mental disorders and how they could be treated. When a
health camp was held in Ramesh’s village, local people
realized that Ramesh’s behaviour resembled some of
the symptoms of mental disorder they were being told
about. With great difficulty he was brought to the doctor
who luckily had been trained to identify and treat cases of
psychosis. He was put on antipsychotic medication. There
was significant improvement in his behavior and within a
few weeks his suspiciousness decreased.
Later during one of the supervisory visits, the district team
reviewed his case and diagnosed him as suffering from
schizophrenia. A management plan was drawn for his
recovery and rehabilitation. He continued on medication
from the primary health center and there was dramatic
improvement in his condition. The social worker of the
district team provided psycho-education to his family
and got a local NGO to help look after him during the day
and give skills training. Within six months Ramesh had
regained most of his lost abilities and started teaching
children coming to the NGO. The social worker liaised with
the district education officer. Nine months after the start of
his treatment Ramesh was back at his old job.
Ramesh’s complete turn-around had a great impact on
the attitudes of the local community. They now believe
that mental disorders are treatable. Ramesh continues
on medication and is a volunteer with the program. He
actively participates in the health camps organized under
the program and helps spread mental health literacy in the
The introduction of the DMHP has resulted in availability
of community based mental health services through new
linkages, and an increase in public awareness of mental
disorders in the districts involved.
The first lesson learnt from this establishment phase is
the need to have genuine engagement of all partners
and stakeholders to ensure synergy, and to increase the
acceptability and success of the program in the field.
The second is the need for a dedicated and effective
monitoring mechanism established right from the project’s
start. This helps identify potential problems or deficiencies
in the development phase so that necessary modifications
can be authorised and made swiftly. With a constant
focus on process and expected outcomes, the monitoring
mechanism provides timely inputs to enable mid-course
corrections, based upon experience in the field.
EXPANSION OF DMHP ACTIVITIES
In the initial stages, the project focussed on early diagnosis
and treatment, training of primary health care staff, and
information, education and communication activities with a
core clinical team. More recently, mental health promotional
activities such as life skills education and counselling
services in schools and colleges, work-place stress
management programs and suicide prevention services
have been added to the DMHP.
Apart from the core clinical team, the district centres have
a managerial team for implementing the various activities
of the DMHP. Funding first routed through the zonal mental
health institute or medical college is now routed through the
District Health Society in order to integrate the program into
general health services. Having a dedicated monitoring team
at the state level has strengthened supervision.
APCMHDP 2011 : INDIA
The important lesson from the District Mental Health Program is that
community mental health care delivery is possible and urgently required.
High levels of motivation, involvement, mutual respect, effective collaboration
and coordination across various stakeholders and sectors have been
important factors in the successes of the program.
Detailed guidelines for implementation and training materials
have been prepared. The program has been well integrated
into the broader community of the districts involved. New
stakeholders such as schools, colleges, and workplaces have
been added on the basis of needs identified from consultations
about ways to improve the program among patients, families,
mental health professionals and authorities, nodal officers of
the mental health program, public health experts, and NGOs.
The major achievement of the program have been the
development and availability of community mental health
services in what were previously the most underserved areas.
Training modules and mental health information materials
have been prepared, and training in mental health issues
provided in collaboration with community partners.
Above: Vishwa, Divine game of love, 2005, oil on canvas, 23” x 33”.
In the painter’s words: “... the universe is all interconnected...
reflected in love in the visible world, which is divine in quality ...”
MEETING NEW CHALLENGES
New challenges that have emerged are ways to expand the
DMHP to uniformly cover the whole country. The logistic
challenges in the expansion of the programme to all districts
are related to difficulty in recruiting the district mental health
teams due to shortage of qualified human resources in the
mental health field. The training needs for primary health care
staff are enormous due to the large numbers of primary health
care workers in India
A lack of awareness related to mental health and stigmas
attached to mental illness remain widely prevalent, and
still pose formidable barriers between the mentally ill and
community mental health services. Mental health is still a
comparatively neglected area, given the lowest priority in
social and development planning. There is still much to be
done to integrate mental health into the mainstream of the
general health system.
However, it is planned to expand the DMHP to all districts
in India and to develop regional training resource centres.
If qualified mental health personnel are not available in
a particular district, then the approach is to start with
short-term skill-based training for general health staff.
They will be linked to professionals in the private sector
APCMHDP 2011 : INDIA
for specialist referral services. Training the primary health
care team will be streamlined with standard training material
and detailed operational guidelines.
Integration of mental health training with the district training
program for primary health staff will avoid any potential
conflict with training for other programs.
Resources have been set up to develop evidence-based
training and health education material to help spread greater
public awareness and lessen the social stigma of mental
illness. Through life skills education in schools, counselling
services in colleges, and work place stress management,
the population will gradually become more literate in mental
health issues and individuals more resilient.
The integration of mental health into socio-economic and
health policies requires sensitisation, regular liaison and
the development of partnership with social welfare, health,
education, employment and other development agencies
based upon mutual trust, respect, good communication,
accountability and collaborative work plans focussed on
people with mental disorders and their families.
The program must be comprehensive, including primary,
secondary, tertiary and rehabilitative components. Difficulty in
recruiting mental health teams has been somewhat overcome
by short-term skill based training to general health staff.
The stigma of mental disorders is being effectively addressed
by extensive community awareness campaigns and
demonstrations of the effectiveness of treatment with severe
mental illness cases.
The program could be adopted in similar settings where
primary health care services are available. Its adoption
requires the development of training and public information
materials for specific local cultural contexts and governance
Finally there must be high level commitment to initiate and
provide ongoing funding and support.
The important lesson from the DMHP is that community
mental health care delivery is possible and urgently required.
High levels of motivation, involvement, mutual respect,
effective collaboration and coordination across various
stakeholders and sectors have been important factors in the
successes of the program.
To gain the necessary commitment, the program has to focus
on patients and caregivers. It has to consider all the demands
on involved people and agencies, and through consultation
employ their abilities and resources efficiently.
A lack of coordination between health and medical education
departments has caused conflicts in the program’s
introduction. Clear and detailed guidelines (including the
spelling out of roles and responsibilities), regular monitoring,
and communication are essential.
47 APCMHDP 2011 : INDIA
INDONESIA : COMMUNITY EMPOWERMENT IN TEBET
Tebet is an urban sub-district of South Jakarta with a population of almost
242,ooo people comprising more than 64,000 families, crammed into seven
localities or ‘villages’ on just 905 hectares of land – a population density of
nearly 27,000 people per square kilometer. Tebet has neither a mental hospital
nor any other specific mental health institution. Jakarta has two state mental
hospitals, the Soeharto Heerjan Hospital and the Duren Sawit Hospital,
but they are located over 12 kilometres away.
LARGE TREATMENT GAP
Tebet’s people must rely first on the services of Tebet
Primary Health Care (PHC), which runs a mental health clinic
staffed by a general practitioner trained in primary mental
health care and a nurse. In addition several psychiatrists run
private practices at their own consulting rooms or in private
The community experiences many psychosocial problems
caused by poverty, unemployment, low education, violence,
chronic illness and substance abuse. The 2007 National
Basic Health Research Report estimated that in Tebet about
3,600 people suffered from severe mental disorders with a
further 35,000 people experiencing other mental disorders
and or emotional problems.
But the numbers of visits and patients getting treatment in
the mental health clinic have been very low, with chronic
schizophrenia virtually the only diagnosis. Only some 300
people with severe mental disorders receive therapy at the
PHC and a similar number of patients visit other mental
health services, so the treatment gap in the district is very
high. Moreover, even those who did receive treatment were
not necessarily adhering to their medication regimes.
Poor understanding and knowledge about mental health
and severe stigma attached to mental illness continue to
exacerbate the mental health burden across Indonesia. Even
in the capital city of Indonesia, in the past five years, there
have been confirmed reports of three patients with psychotic
disorders who were put in pasung (physically confined or
restrained). Two were locked within their homes for many
years and one was restrained with a metal chain.
For a long period, only around 20 patients visited Tebet
Primary Health Care’s mental health clinic, all diagnosed
with chronic schizophrenia. A refresher course in mental
health care and follow up meetings with staff from the
Directorate of Mental Health of the Ministry of Health
provided the clinic’s staff with increased understanding of
the dimensions of the mental health problems in Tebet. They
realized there were still vast numbers of people with mental
health problems within their district who were not seeking
appropriate help at the clinic.
The clinic’s small staff became committed to reducing
the treatment gap in their sub-district. They believed that
for things to change, they also had to change community
attitudes and establish a more positive image for their work.
CHANGED PUBLIC PERCEPTIONS
In the first instance, the team convinced the directors of
the PHC to change the name of their Mental Health Clinic to
become the Family and Adolescent Consultation Clinic. The
change of name presented a less alarming, more welcoming
face to community members and signaled that the clinic
would be treating the full range of mental health problems,
not just chronic schizophrenia.
The mental health team also convinced the PHC to increase
the budget to cover adequate supplies of psychotropic
drugs and fund promotion activities to help address
poor community understanding and attitudes to mental
health. Based in the community, these awareness-raising
activities included home visits, community mental health
promotion activities and rehabilitation-related activities
that empowered patients and their families in their
APCMHDP 2011 : INDONESIA
Mrs. Tatiek Fauzi Bowo, wife of Mr. Fauzi Bowo, Governor of Daerah Khusus Ibukota Jakarta, meeting with a Tebet sub-district patient who was
previously isolated and neglected by her family.
After the name change to the Family and Adolescence
Consultation Clinic, the number of patients visiting the clinic
increased significantly with a variety of diagnoses, including
substance abuse. However the rapid increase in demand for
service far outweighed the small team’s limited resources
and capacity to deal with the complexity of the issues they
Their ambitious primary objectives to decrease the treatment
gap, increase patients adherence to treatment, increase
mental health knowledge in the community, decrease
stigma, and prevent pasung cases were beyond the capacity
of only two health workers. The team realized the challenge
of community mental health had to be made a priority for
the health sector. Partnerships had to be formed with key
stakeholders: the Jakarta metropolitan and district health
offices, professionals from mental hospitals and academic
institutions, families, volunteers, community leaders and
The first task for Tebet’s tiny mental health team was to build
its own mental health knowledge. Since 1998 the Provincial/
District Health Office has provided training programs in
mental health treatment for GPs and nurses. This training
is followed up by on-the-job experience supervised by
psychiatrists from the Soeharto Heerjan Mental Hospital and
by community mental health nurses. The mental hospital
psychiatrist’s supervision of GPs and advice on how and
when to provide a referral from the PHC, was very crucial in
increasing both staff confidence and professionalism.
The partnership with the large metropolitan hospital gave
the Tebet team the knowledge and confidence to provide
a high quality of mental health services that includes early
detection with an appropriate and efficient referral system.
Tebet PHC could now provide home visits, and deliver
mental health promotion activities to community volunteers,
community leaders, school teachers and students, and other
health workers within Tebet PHC.
APCMHDP 2011 : INDONESIA
The change of clinic name to Family and Adolescence Consultation Clinic,
combined with high quality training for staff, patients and their families and
community members brought about significant improvements for patients with
mental illness and their families in Tebet. Not only has the quality of service
improved, but community knowledge and awareness about mental health issues
had been greatly enhanced.
The determination and enthusiasm of the Tebet mental
health team was inspirational. The small team built trust
across the community resulting in partnerships with several
NGOs and national agencies such as BNN (the national
agency for narcotics control), Global Fund, the YPI (Yayasan
Pelatihan Ilmu, or Scientific Training Foundation) that
yielded direct assistance to the Tebet PHC. Support included
Voluntary Counselling and Testing training, provision of
medication, free laboratory tests, and even funding to
support occupational programs for patients. The Taskforce
for Mental Health System Development in Indonesia also
provided leadership training to assist capacity building and
To assist in managing patients with severe mental disorders
in the community, Tebet PHC built a partnership with
an Australian based NGO, MIND IT, and with a national
consumer group, Perhimpunan Jiwa Sehat (PJS or Healthy
Mind Association). MIND IT assisted with training of health
workforce, volunteers, and families while the PJS focused
on directly supporting patients and families within the
Tebet sub-district. NGO-initiated and run community based
activities include family social gatherings, peer support
and team building and activities focused on developing the
patients’ individual strengths and skills. These activities
contribute to the empowerment of patients and families.
More people with mental illness could be helped because
community members were trained to identify people in need
of treatment and knew where to refer them. For example,
one community volunteer (cadre) provided the GP with
information about a woman suffering from schizophrenia
who had been physically restrained for the previous 10
years. After treatment, the woman has recovered sufficiently
to become an active advocate for mental health and to give
her support to others in similar situations. As community
acceptance has grown, some patients have managed to
secure small jobs and become active contributors to their
community. Through family and patient education programs,
patients are better able to adhere to medication regimes.
The increased patient visits also included for the first time, a
significant proportion of patients with a range of diagnoses
other than chronic schizophrenia.
Below: Information and education training session for health officers
in the Tebet sub-district.
MORE PARTNERS REQUIRED FOR
The change of clinic name to Family and Adolescence
Consultation Clinic, combined with high quality training for
staff, patients and their families and community members
brought about significant improvements for patients with
mental illness and their families in Tebet. Not only has the
quality of service improved, but community knowledge and
awareness about mental health issues had been greatly
APCMHDP 2011 : INDONESIA
Right: Information and education session lead by medical
students and psychiatry residents to Primary Health Care general
clinic patients, Tebet sub-district.
Continuity, however, has been a particular problem for
the activities supported by the Perhimpunan Jiwa Sehat.
The partnership between the PHC and this NGO is based on
the goodwill of individual PJS members, their sincere desire
to help and their complete trust in the small PHC. Without a
formal contract between the NGO and the Tebet sub-district
PHC, however, this very worthy partnership has a temporary
and at times quite tenuous quality. Most PJS members are
volunteers who suffer from a mental illness themselves.
A lack of budget for their transport needs, their own health
status and their domestic situations can sometimes force
volunteers to reduce their participation and support for
Unfortunately the funding of most program partners depends
on local and time specific budgets. When budgets are limited
and priorities change for NGOs and the Provincial/District
Health Office, training programs can be drastically reduced or
halted altogether. A written contract is needed between the
parties to make expectations more explicit for both sides, and
goals clarified to assist in achieving progress.
One continuing shortfall is a failure to recognize and refer
mental illness cases at other GP clinics attached to the
Tebet PHC. Their GP’s and nurses need more intense mental
health training, especially in assisting in the identification
and treatment of mental illnesses other than schizophrenia.
The community also needs continuous training and
reinforcement to strengthen willingness to accommodate
people with mental illness adequately and appropriately
back in their own homes.
But there is new hope for continuity of the program, thanks
to a formal collaboration with key academic institutions. A
new strategy has been developed with medical students
from the Atma Jaya Medical Faculty and psychiatry residents
from the University of Indonesia. To help make the program
sustainable, the new partners will carry out a mental health
needs assessment for the district; support psycho-education
activities; run mental health services through secondary
consultation; make home visits for treatment evaluation;
undertake a specialist supervision program; teach case
identification and case management; and build a more
systematic referral mechanism. Apart from collaboration with
academic institutions and specialists from mental hospitals,
the primary health care clinic may also look to the private
sector for support of its mental health activities.
THE POWER OF INSPIRATION
Tebet’s model of a public health centre providing primary
mental health service and broader activities related to
community engagement and empowerment has been
adopted by at least five other PHCs in Jakarta. The success
of this important partnership has shown that commitment,
determination and enthusiasm are fundamental in improving
mental health services. The hard work of the small mental
team and their willingness to share with others was
inspirational in building trust and commitment by others
within their own community and beyond to achieve collective
goals. The basis of the Tebet PHC success lies in the variety,
quality and continuity of support from all partners involved.
Planning of mental health activities needs to be realistic,
simple and to consider already heavy workloads for staff
and volunteers at the community health care level. A formal
partnership agreement, adequate budget and provision
of resources, and ongoing training and support for health
workers and the community are critical for the continuity of
the PHC mental health program.
APCMHDP 2011 : INDONESIA
JAPAN : PUBLIC PRIVATE PARTNERSHIPS IN
COMMUNITY MENTAL HEALTH SERVICE IN KAWASAKI
With a population of 1.42 million, Kawasaki City is situated in Kanagawa
Prefecture Japan, between Tokyo and Yokohama. It consists of seven
administrative wards, each with a population of between 140,000 and
200,000. The number of persons suffering from some sort of mental illness
in Kawasaki is estimated to be 31,000. The most common disorder is
schizophrenia for inpatients and mood disorders for outpatients.
The southern area of Kawasaki City is industrially zoned,
the central area is mixed commercial and industrial, and
the northern area is a newly developed residential zone. In
contrast to other developed countries that were developing
community mental health services and decreasing their
hospital bed numbers, Japan, up until 1994 was steadily
increasing its psychiatric hospital beds. Counter to the
national trend, however, Kawasaki maintained a relatively
small number of psychiatric beds, because it too was
steadily developing a community mental health service
Each administrative ward has a public health centre that
acts as a base for the administration of community health
services including mental health. It provides counselling
services, outreach services, and group workshops for people
suffering mental health problems. It holds a case conference
The Kawasaki City Plan for Community-Based Rehabilitation,
developed in 2000, provided a policy basis to develop
welfare services for people with disabilities. Its aim and
direction contributed to the Kawasaki City Normalization
Plan in 2004 and the Kawasaki City Welfare Plan for People
with Disabilities in 2006.
Above: Oki, Stars, collagraph, 38 x 27 cm. This picture was made in
the art program of a day-care service provided by a mental hospital.
Oki seemed to be satisfied with this picture by portraying merely stars,
but he sometimes scatters a lot of eyes or dots on his works, regardless
of what those pictures depict. He says he does this because he thinks
it will make the pictures more enjoyable.
The Kawasaki City Mental Health and Welfare Centre,
established in 2002 in the southern part of the city is
responsible for planning Kawasaki’s mental health policies
and advises health centres. Further special services, such as
residential and vocational rehabilitation services for people
with mental illness, are provided by the Kawasaki Psychiatric
Rehabilitation Centre that was established in 1971 and
located in the central area of the city.
APCMHDP 2011 : JAPAN
Right: Michiko Kiyooka, untitled, oil pastels, watercolor, 38 x 26 cm.
Made at the day-care service provided by a mental hospital, this picture
depicts the artist’s great joy, and also her profound sadness. Michiko’s
pictures all make you feel as if her emotions are flooding out.
Both centres are however geographically distant from the
northern residential area of the city. People with mental
health problems living in the northern area of the city
waited for many years for the establishment of a special
organization close to their homes. They required a centre
that could collaborate with existing institutions such as
health centres, non profit organizations (NPOs) and private
The official announcement of the Reform Vision of Mental
Health and Welfare to reduce the number of psychiatric
beds by the Ministry of Health, Labour and Welfare (MHLW)
in 2004 led to a nationwide demand for community mental
As a result of three major policies (the Kawasaki City Plan
for Community-based Rehabilitation , The Kawasaki
City New Normalization Plan  and the Kawasaki City
Welfare Plan for people with Disabilities ), a new
community rehabilitation centre, The Northern Community
Rehabilitation Centre (NCRC) in the northern area was finally
established in 2008 to serve a total population of 370,000
across two administrative wards.
This new centre was designed to show the potential
for public and private sector partnerships in providing
community support for persons with disabilities.
CREATIVE SOLUTIONS TO THE CHALLENGE
OF LIMITED RESOURCES
Insufficient budget and human resources meant Kawasaki
City could not establish a new community support centre in
the northern part of the city by itself. To fill the gaps and also
because it wanted to establish a model for public/private
partnerships, the city released a general welfare plan
aimed at establishing a community support base, The
Northern Community Rehabilitation Centre (NCRC), in
collaboration with experienced private organizations.
The basic philosophy of the NCRC is to provide communitybased,
comprehensive, and high quality rehabilitation
services for people with physical, intellectual or mental
disability in the community.
The NCRC consists of three sub-centres: Yurigaoka Centre
for the Disabled (YURID), Yurigaoka Centre for Daytime
Activities (YURIDA), and Yurigaoka Centre for Activity Support
for People with Mental Illness (YURIASU).
At first, there was difficulty deciding how to share roles and responsibilities between
the public and private sectors, but this was resolved by considering the differences
of the respective operational areas within the community. The public sector became
responsible for the community mental health team, which operates as a branch of the
community support section of the Kawasaki City Mental Health and Welfare Centre, and
the private sector became responsible for community living support.
APCMHDP 2011 : JAPAN
To successfully establish the Northern Community Rehabilitation Centre in Kawasaki,
it was necessary to overcome two problems: the budget and human resources
constraints. Guided by mental health professionals, support was drawn from the
private sector and community with the public sector providing a stable environment.
YURID is a public sector organization and offers comprehensive
counselling and consultation services for people
with disabilities, their families and the organizations
supporting people with disabilities. It also acts as a
community support section of the Mental Health and Welfare
Centre and runs community mental health teams.
YURIDA is a private sector organization and offers daytime
training to people with disabilities.
YURIASU is run by a local NPO that was seeking a stable
environment to provide its services. It encourages the social
participation of people with mental illness who tend to be
isolated because of discrimination and prejudice. It also
gives support for hospital discharge, autonomous activities,
and daily living.
At first, there was difficulty deciding how to share roles and
responsibilities between the public and private sectors,
but this was resolved by considering the differences of the
respective operational areas within the community. The
public sector became responsible for the community mental
health team, which operates as a branch of the community
support section of the Kawasaki City Mental Health and
Welfare Centre, and the private sector became responsible
for community living support.
To successfully establish the NCRC, it was necessary to
overcome two problems: the budget and human resources
constraints. Guided by mental health professionals, support
was drawn from the private sector and community with the
public sector providing a stable environment.
The mental health profession put great efforts into advocacy
with local government officials so that the full significance of
the community treatment plan was understood. After many
long years of negotiation and discussion, they were finally
able to establish the NCRC.
However, a more comprehensive and systematic social
network including further health services provided by
psychiatric hospitals, clinics, health centres, and private
support centres is necessary. Since this is a new approach
for the city, it needs to be carefully monitored and evaluated
USEFUL LESSONS FOR COMMUNITY
MENTAL HEALTH IN JAPAN
At the time of completion of the Kawasaki City Plan
for Community-based Rehabilitation, the proposed
collaboration between the public and private sectors was
thought to be too challenging to proceed. However, it was
welcomed by private sector organizations struggling to find
a stable environment. The difficulties on both sides were
gradually resolved by a flexible partnership.
Below: Hana, Wind of the sea, watercolor, 35.5 x 24.5 cmm. This painting
is also produced in the art program of a day-care service provided by a
mental hospital. Hana likes to produce realistic depictions of still lifes,
landscapes and figure paintings. She is a reticent and quiet person,
though she sometimes has communication with others.
APCMHDP 2011 : JAPAN
CASE STUDY: AN EXAMPLE OF SUPPORT PROVIDED BY THE NOTHERN COMMUNITY REHABILITATION CENTRE
An individual who had been living by himself in the
community was admitted to a psychiatric hospital
because of a rapid deterioration in his mental health
condition. Before his discharge, staff at a health centre
arranged a meeting to discuss how to support him
back in the community. A community mental health
team of highly skilled staff was dispatched from NCRC
to attend the meeting. The community mental health
team assisted the health centre to determine an
appropriate support strategy and to arrange suitable
social resources for the patient. After his discharge, the
community mental health team continued to support
the health centre staff and the patient directly with
home visits. In addition, since the patient regularly
attended the community support centre of the NCRC, he
was able to engage in conversation with other patients
and staff members and thus maintain his daily routine.
Once the plan was established, the next issue was how to
share the roles between the sectors in the newly established
facility. This problem was solved as the plan developed,
defining the mission and the goal of each partner.
What then are the four most important components of
successful public private enterprises in mental health
First, it is important to determine the entire scope of
the project before it commences, to be able to gauge
accurately the amount and types of resources required.
Second, flexibility is the key in arranging resources in
Third, the plan must be based on and follow sound
administrative frameworks and processes that are
communicated to all key stakeholders.
Finally, financial resources need to be allocated if the
goal is to be really achieved. Budget allocation from
the national government will only come if the policy of
Kawasaki fits with national policy.
The evolution of mental health care in Japan can be
classified into three stages.
The first stage was to treat people with mental illness
adequately in psychiatric facilities and to provide them
with relief and stability.
The second was to provide them with high quality mental
health care in the community.
The final stage was to integrate the community mental
health services into society. The services provided are not
only for the people with mental illness and their families,
but they can also contribute to the whole community.
Community mental health in Japan is currently transitioning
from the second to the third stage. To promote the transition,
a strong partnership with society itself needs to be built.
Therefore, to achieve the third stage, the next goal for
Japan’s partnerships in mental health is to develop and
implement a community mental health promotion strategy.
The lessons learned from the successful Kawasaki model will
be very useful when developing the strategy.
55 APCMHDP 2011 : JAPAN
56 APCMHDP 2011 : KOREA
KOREA : BRIDGING MENTAL HEALTH AND CULTURAL SENSITIVITY
From the mid-20th century long-term institutionalization was the primary
policy and practice for people with mental illness in Korea. The 1980s saw some
university hospitals and departments of psychiatry in general hospitals initiating
therapeutic communities, and publishing evidence of the benefits from communitybased
care in the recovery of patients. In the 1990s, community mental health
ideas and practices began to appear in both private and public sectors.
FROM INSTITUTIONS TO COMMUNITY
In 1992–93, the first professional group for Korean mental
health reform was organized. It published recommendations
for a way forward. With input from a broad range of mental
health professionals, these recommendations were the basis
of the Mental Health Act passed in 1995. Since then the
legislation, revised five times, has provided the framework
and guidelines for a balanced development of community
care and hospitalization in Korea. (See the APCMHD
Summary Report, 2008.)
In 2010, under advice from the National Mental Health
Commission (NMHC), the Korean government published its
plan to set up a new mental health authority, the Korean
National Institute of Mental Health (NIMH), to develop,
evaluate and implement mental health policy nationally.
Despite the huge progress made in mental health reform
in Korea and the growth in community-based services,
deinstitutionalization on a large scale is not yet in sight.
Private mental hospitals and asylums are as yet unlikely to
discharge patients voluntarily into community services, to
shorten the average length of patients’ stay, or to decrease
the number of beds.
Ensuring the basic human rights of the mentally ill is
still an urgent problem to be addressed in Korea. Even
though recommendations by the Organisation for
Economic Co-operation and Development or World
Left: Exit No. 4. This poster illustrates the theme of the Gyeonggi
Theatre Festival in 2011. The unlucky number 4 is strongly connected
with death because the Korean pronunciation of ‘4’ sounds the same
as the pronunciation of the Chinese character for ‘death’. Korea has
the highest suicide rate among OECD countries. Through this play,
we ran a campaign of suicide prevention around the country.
Health Organisations are universal and appropriate,
each nation views them from within its cultural context.
The stigma of mental illness is very much influenced by
these cultural factors.
This suggested an approach from two directions. At a
government level, there must be a public statement
of intent to pursue community-based mental health
programs, presented with a time-table for reducing reliance
on institutional care and shifting financial resources to
community-based mental health projects.
In the sphere of public education, Korea must take up
the significant challenge of changing perceptions of
mental illness and reducing its stigma within Korean
society. Treatments within mental hospitals actually
perpetuate negative attitudes about mental illness and
reinforce common misunderstandings about the needs
of the mentally ill. Rather than throwing a veil of secrecy
and seclusion around themselves, mental hospitals and
institutions must reach out to the community and be
involved in public education around mental health issues.
Expanding the availability of community-based mental
health services, developing standardized criteria for
hospital admissions and providing flexible community
support programs will all be important in changing public
The new services and their linkages with the community can
be helped by strategic partnerships with local groups, even
those not directly involved in mental health. The following
account of the partnership between Gyeonggi’s annual
arts festival and the Korean mental health program, is an
example of one such strategic partnership.
APCMHDP 2011 : KOREA
A partnership between Gyeonggi’s annual arts festival and the Korean mental
health program was established with the objective of bringing mental health issues
into cultural sensitivities and developing greater understanding of mental illness
in the community.
ESTABLISHING A PARTNERSHIP
Gyeonggi Province is in the western central region of the
Korean Peninsula, surrounding the largest city and national
capital Seoul which is separately administered at a provincial
level. Its Gyeonggi Mental Health Commission (GMHC) is one
of 16 provincial commissions supervised by the National
Mental Health Commission. The GMHC is responsible for
developing the public mental health policy of Gyeonggi
province through data analysis and evaluation of mental
health activities in each of the cities and counties of the
From the 1990s, Gyeonggi has shifted considerable resources
into building a community mental health system. This has
included support for the Kangwha community mental health
project, subsidies to Suwon City and the community mental
health projects of Yeoncheon, and Yangpyeong. In 1996,
the GMHC started the first community mental health project
in Korea, providing basic services for people with severe
mental illness, care of child and adolescent mental health
and care for elderly people. In 1997, it assigned the planning,
evaluation and education programs for mental health
professionals to the private sector, most importantly the Ajou
University School of Medicine.
A partnership between Gyeonggi’s annual arts festival and
the Korean mental health program was also established with
the objective of bringing mental health issues into cultural
sensitivities and developing greater understanding of mental
illness in the community. In recent decades, psychiatrists
and other mental health professionals have given more
attention to the possibilities of culture as both a bridge to
increasing public understanding of mental illness and a
means of positively affecting the course of recovery.
The GMHC and the Provincial Mental Health Centre (GPMHC),
collaborating with centres in 31 cities and counties, initiated
this unique cultural activity related to mental health through
the province’s three major festivals, putting key messages
about people with severe mental illness.
One event is a performing arts festival involving both
professional and amateur theatrical groups. The theme of
the festival changes every year but is usually one that is
focussed on a current issue facing Korean society. So far five
plays have been produced in line with the festival themes.
At the 2011 festival, for example, suicide and its prevention
was selected as the main theme, under the title ‘Exit No.4’.
Previous themes have included ‘White Portrait by myself’
(2007); ‘I love, Mom’ (2008); ‘Germ box in my mind’ (2009);
and ‘Happy Mr. Sambok’ (2010).
Left: B.Y.K., Happiness, 2011, oil on masonite, 54 x 39 cm. The artist is a
woman who has never married and has suffered from manic-depressive
illness. She learned to paint from another artist during hospitalization.
Now living in the community she goes regularly to her local cultural centre
in order to paint. Within her pure spirituality, she has infinite dreams of
falling in love and mutual understanding. She won 1st prize in the Gyeonggi
Province art festival in 2011.
APCMHDP 2011 : KOREA
Above: In this scene from the play ‘Exit no 4’, characters who want to
commit suicide have joined a special group planning how to carry it out
effectively. They are now following rituals prepared by the ringleader.
We’ll leave you to guess the final scene. Do they choose to live or die
Come to Korea, see the play and find out.
The idea for this festival collaboration came from a GMHC
team leader committee meeting in 2006. Held monthly,
these meetings routinely provide local feedback regarding
community issues and the quality and appropriateness of
mental health service delivery in their areas.
The proposal was assessed by the GMHC for its feasibility,
effectiveness and financial impact. The strength of the
proposal lay in the willingness of a well-known theatre
academy to stage such a mental health-themed festival,
along with readiness of a major life insurance company to
This theatre festival has now spread throughout the entire
Gyeonggi Province, covering 31 of its cities and counties over
a three-month season that starts in Korean Mental Health
Week on April 4 each year – a date chosen to confront the
symbolic meaning of the number ‘Four’ which is considered
taboo (from its similar sound to the word or Chinese
character for death in many parts of East Asia). It has been
a huge challenge but in the outcome an enormous triumph
and an elegant solution to bridging mental health and
A WIDER CULTURAL APPROACH
The festival has now expanded its reach to include the visual
arts, with components including paintings of landscape,
human portraits and free themes.
People who have suffered from mental illness are invited
to submit their art throughout the year for entry. After
reviewing all submitted works in the annual competition,
board members from GMHC choose and display finalists’
art works in selected city galleries. A catalogue is produced
to accompany the exhibition, explaining the intentions and
inspirations of the artists and their works.
Photography is another art form explored for the festival,
with digital and film images highlighting issues of mental
health. In 2011, depression was the photographic festival
The festival has brought previously unrecognised artistic
ability to wider notice, with several talented painters
recognised as new artists each year. In 2010, one such artist
was invited to exhibit at a gallery in Japan, which has a long
history of discovering the artistic abilities of people with
mental illness and exhibiting their artworks.
In just four years, the visual arts component of the festival
has awakened deep emotions and compassion among
many mental health professionals. The engagement in art
has increased the awareness of patients about their inner
APCMHDP 2011 : KOREA
Above: J.M.K., Laughing, 2010, wtaercolour, 39 x 54 cm. The artist had
no formal instruction in painting, and taught himself to draw during
long-term hospitalization. Laughing is his response to the difficulties of
contact with the world around him. He won the 1st prize in 2010.
conflicts and given new ways to articulate them. It can be
argued strongly that the arts are an important therapeutic
component of recovery. Artistic energy and activity is linked
with mental health; some forms of mental illness can even
provide space for artistic independence and originality to
develop. Respecting the human rights of the individual,
which includes encouraging the pursuit of individual
creativity and freedom of expression, is therefore an
important ingredient for recovery.
The 31 mental health centres in Gyeonggi are now involved
in the festival, bringing them into contact with many figures
in the broader community from mayors and congressmen
to teachers, students, parents and the families of people
needing mental health care. Many art therapists now hold
art lessons at mental health centres, rehabilitation facilities
and hospitals to develop works for selection into the festival
The National Human Rights Commission in Korea, which
takes an active interest in supporting the rights of people
with mental illness and in 2009 published on the topic, also
strongly supports the festival.
Through this unique annual activity, all the community
mental health centres of Gyeonggi Province have joined in
delivering a common message, and inspire each other to
improve the acceptance and understanding of mental
LENDING OUR HEARTS
The prime challenge for mental health professionals in
public education is to remove the stigma attached to mental
illness. Because of ignorance and negative public attitudes,
the mentally ill find little understanding about their emotions
and behaviour, and the ways they can be helped.
The partnership with the arts world has achieved
considerable progress in reducing levels of prejudice. The
theatrical works and exhibitions in art galleries during the
annual festival demonstrate that:
People with mental illness should not be just defined by
their illness. They can also be accomplished artists and
Just because some-one has a mental illness, it does not
mean that he or she does not have to live without hope.
Community attitudes to mental illness can be changed by
using art as a bridge. Many festival audience members
commented that they had previously misunderstood
mental illness and misjudged people who were suffering
with mental illness. Those who were unfamiliar with
mental illness became aware how it made the afflicted
people suffer, and said they became aware of them as
people. They could now see that even with mental illness,
artistic sensitivity and ability can exist.
Our advice to those wishing to adopt such project is
that giving support and encouragement is most important:
“We have to approach first and lend our hearts. We have to
develop supportive environments where people with mental
illness can fully develop and exhibit their skills. We truly
hope that people with mental illness throughout the whole
world can live for their dreams without prejudice. We wish
that someday, that there will be no boundaries between
what is considered normal and what is considered mentally
ill, that our community exists connected by happiness
APCMHDP 2011 : KOREA
LAOS : A MULTI-SECTORAL MENTAL HEALTH TASKFORCE
Laos is a country with 6 million people, but only two psychiatrists. It has
no clinical psychologists, social workers or psychiatric nurses. The only
available acute mental healthcare in the country is a 15-bed psychiatric unit
in Mahoshot Hospital in the capital, Vientiane – but about 75% of the Laotian
people live elsewhere in rural areas where no mental health services of
any kind are available.
The World Health Organization has acknowledged that
“mental health issues are completely new” for Laos, and
a United Nations Country Assessment in 2006 noted
that “Mental Health is an area that has been particularly
Certainly, the lack of a mental health care system and
training, as well as limited resources and providers, severely
limited the mental health services that can be delivered to
people even in urban areas, let alone remote places.
In 2009, an international mental health mission consisting
of a team of psychiatrists and psychologists from Norway
and the United States visited Laos. During this visit, the team
collaborated with Lao colleagues to conduct a mental health
needs and services assessment. It found that the lives of
mentally ill children and adults in Laos are severely limited,
due to the country’s underdeveloped healthcare system
generally and it’s extremely poor mental health care service
The WHO appointed a mental health consultant for Laos
in 2010 to help build mental health care capacity. The
appointment led to a meeting of key stakeholders in Laos
at the WHO office in Vientiane in January 2011. Participants
included representatives from the Government, the Ministry
of Health (MOH), the University of Health Sciences, public
and military hospitals and institutions, the non-government
sector (BasicNeeds) and the WHO itself.
At this Vientiane meeting, all stakeholders present
recognised the importance of building mental health
capacity and the urgent need to reform mental health
services for Laos. Participants agreed to develop and
formalise a partnership of the key stakeholders represented
at the meeting. This new partnership would help raise
awareness and understanding of the current mental health
situation in Laos and improve access to mental health
resources and service delivery, especially for people in
remote areas. Most importantly, it would aim to create
and support local and international mental health training
opportunities for primary care providers and workers in
mental health services.
Each participant committed to work as part of the national
team to share knowledge, resources, and expertise which
would in turn lead to improved quality of mental health care
service, research, and training for the country. The mental
health partnership program in Laos was launched.
BUILDING THE SYSTEM
The primary objectives for establishing the partnership
To draw together all mental health stakeholders and
service providers in Laos in regular meetings;
To exchange knowledge, working experience, and share
To collaborate in building mental health capacity in Laos;
To provide support and consultation to mental health
providers to improving practice and service delivery to
people in need;
To develop mental health training, education, and services
for medical providers and public sector workers.
The Ministry of Health has oversight of the project, since
it has responsibility for mental health policy as for all
healthcare activities within the country and is the channel for
funding all healthcare services and training. The University of
Health Sciences is responsible for conducting mental health
training and research.
APCMHDP 2011 : LAOS
The partners meet monthly to share knowledge and resources, discuss progress
and find solutions to current challenges. A mental health taskforce has been formed
with representation from each stakeholder as a working committee to support the
partnership and develop plans and strategies for mental health capacity building.
The Mahoshot Hospital mental health unit and The Military
Hospital mental health unit provide inpatient and outpatient
mental health treatment for severely mentally ill people in
both the military and civilian populations. WHO provides
technical support, consultation and minor funding for mental
BasicNeeds is the first NGO in Laos and is currently providing
mental health outreach, education and treatment to needy
people in the nine districts of Vientiane and in Khammouns
province (in central Laos) where other mental health services
are not available.
Health Frontiers (HF) is an all-volunteer outreach initiative
of health professionals, focussed on outcomes in global
health and child development. HF has worked with Laotian
colleagues since 1991 to establish residency training
programs in paediatrics and internal medicine. Presently
HF is able to support mental health education for internal
medicine and paediatric residents only for one year.
The partners meet monthly to share knowledge and
resources, discuss progress and find solutions to current
challenges. A mental health taskforce has been formed
with representation from each stakeholder as a working
committee to support the partnership and develop plans and
strategies for mental health capacity building.
At the earliest stages of the partnership’s development,
interpersonal conflict, lack of open and clear communication
and absence of shared vision resulted in largely unproductive
and negative working relationships. Tensions
arose between the stakeholders, largely caused by major
differences in educational and professional backgrounds,
level of position and age. For example, placing senior staff
in high positions alongside junior staff on the committee
created problems due to hierarchical differences. Language
barriers also made it difficult for communication between
the international mental health team and stakeholders on
the ground in Laos.
The mental health partnership program in Laos is still
developing and has a long way to get to fulfilment of plans.
But most of the original stakeholders remain involved. A
major achievement has been the improved interpersonal
relationships, increased open communication and feedback
from each organization. Challenges in working relationships
remain. Maintaining trust, overcoming disagreements, and
complying with mutually acceptable work ethics requires an
ongoing effort to keep the partnership productive.
The National Science Research Centre for Psychology and
Mental Health was unable to remain in the partnership
due to difficulties with legal status, a lack of funding and
inadequate human resources to continue with the work.
However, some of their staff have remained as individual
volunteers serving the taskforce. The military hospital has
recently joined the partnership and become actively involved
in monthly meetings and sharing of resources.
The partnership has gained funds and scholarships to
enable two young medical doctors from the mental health
unit to attend short psychiatry training courses at Khon
Kean University in Thailand. The partnership also organized
and supported the participation of Laos at the 2nd Sub-
Mekong Countries Mental Health Forum in Da Nang, Vietnam,
to link up with mental health capacity building efforts in
Without additional funding and time allocation, work
undertaken by taskforce members must be in addition to
their already difficult workload. Attendance at monthly
meetings is not always possible for everyone. Less frequent
face-to-face meeting has led to less communication and
interaction between members. Poor funding, a lack of mental
health experts, inadequate access to new technologies, and
a shortage of experts for teaching and training students and
mental health workers are significant challenges.
To overcome these ongoing challenges, the taskforce
realises it must maintain commitment to its mission, vision
and objectives, as well as build concrete action plans to
achieve its goals.
APCMHDP 2011 : LAOS
incentives, poor mental health resources, and very limited
leadership support for mental health activities are obstacles
to moving partnership forward.
Despite these challenges, several lessons have been learnt.
Trust must be built between the partners. Any conflict needs
to be addressed early and resolved where possible. To
sustain a partnership, frequent communication that involves
sharing opinions, providing feedback and suggestions can
help reduce interpersonal conflict. Encouraging mutual
respect between working partners or organizations will
minimise tension and issues around hierarchy. More
particularly we have learned that:
5th community Mental Health Partnership monthly meeting at the WHO office in
Vientiane, Laos. Front row: left Dr. Manivone Thikeo, WHO mental health consultant
for Laos, Dr. Bouavanh Somsanith, BasicNeed Organization, Dr. Chantharavady
Choulamany, Director of BasicNeed Organization, Dr. Sengchanh Nanthavong, Chief of
Mental Health Department of Military Hospital, Mrs. Aphone Visathep, Head of Nursing
Department at Mahoshot Hospital. Back Row: left Dr. Asmus Hammerich, WHO health
program director, Vientiane, Lao PDR’s office, Dr. Sing Menorath, Vice President of the
University of Health Science, Vientiane Laos, Dr. Supachai Douangchak, WHO office
Health Technical Officer and Mental Health Collaborator, Dr. Vannareth Thammavongsa,
Director of Substance Abuse Rehabilitation and Mental Health, Ministry of Health.
Future plans include engaging social service organizations
and broadening the partnership with other government and
non-government sectors. Creating links with the international
mental health community and relevant organizations is also
planned. In addition to a rich source of new knowledge and
skills for domestic stakeholders, the international linkages
will strengthen domestic partnerships. Workshop retreats
for the various stakeholders, aimed at learning from each
other’s experiences and problem solving, would further
promote good working relationships, build leadership and
The Laotian mental health taskforce also hopes to work more
directly with country partners in the APCMHD network to
increase opportunities for exchanges and mental health and
leadership skills training.
LESSONS FOR THE FUTURE
Like many poor and developing countries where a mental
health system is not well established and service providers
are not familiar with developing cross-sectoral partnerships,
the first mental health partnership program in Laos has
faced several major challenges. No such mental health
partnership existed before in Laos. A lack of financial
Arranging time to socialize and having a regular meeting
place seemed to work best for our members.
Providing leadership and interpersonal skill training,
and working with those with partnership experience also
helped reduce conflict and improve leadership skills.
Involving partners from outside the mental health field
such as social service, welfare, law enforcement, justice,
school, and community can be both practical and positive.
Timing is critical. Before entering into a partnership, all
sides must be ready. They must be in a position to commit
sufficient resources, human and financial and time to
make useful contributions.
The development of a partnership should not be rushed. It
cannot be assumed that because people come together for
an initial meeting that they all share the same vision or are
committed to the same course of action. The partnership
should only be initiated after each organization can
demonstrate that they have the interest and willingness to
reach a shared set of goals.
Lack of clear rules, roles, mission, vision, goals and
strategies for the partnership will create confusion and
derail any plan of action.
Clear guidelines for each partner’s contribution will
In Laos, having a mental health leader or focal person in
the country is important for success in building mental
health partnership and capacity. This can be a mental
health consultant, an NGO or government sector worker
with initiative and dedication.
Financial support for regular meetings motivates member
to work effective together.
Frequent face-to-face meetings improve the partnership
and lessen misunderstandings.
APCMHDP 2011 : LAOS
MALAYSIA : SHARING THE BURDEN – A FOCUS ON CARERS
When the first Asia-Pacific Community Mental Health Development report
was written, Psychiatry Services Malaysia was focussed on strengthening and
integrating the various levels of mental health services within the national
Ministry of Health. As treatment services improved, the psychiatric profession
became aware that more adequate rehabilitation services were needed to
sustain the recovery and wellbeing of patients.
CARERS THE KEY TO SUCCESSFUL REHABILITATION
In response to a situation of limited resources, the Malaysian
Ministry of Health actively sought allies from outside
agencies, in both the public and private sectors. The result
was a partnership between various government and nongovernment
organisations to develiver rehabilitation services
systematically across the country.
A new Disability Act came into force at the beginning of
2010 providing for registration of the mentally disabled,
and giving recognition to the subjective and often changing
burden of the mentally ill.
Carers in Malaysia as everywhere experience both an
objective burden such as economic loss, impaired physical
health, disrupted relationships and reduced social networks,
and a subjective burden that is emotional in nature – grief,
guilt, shame, anger. The needs of carers change with the
progression of mental illness. At the onset of mental illness,
carers require information and basic coping skills. Carers
and the public in general need increased awareness to
enable early detection and prompt treatment.
This is evidenced by the 2003 to 2005 Schizophrenia
Registry statistics, which show the average duration of
untreated psychosis was 28.7 months (median 12 months)
prior to receiving treatment. This delay in seeking treatment
resulted in admission as institutional in-patients for more
than 40 % of all first contacts with the mental health
Several measures are now in place to lessen the time before
mental illness is noted and treated. Resident psychiatrists
are attached to all state hospitals. Most district hospitals are
without a resident psychiatrist but have visiting psychiatrists,
who provide consultation and training of medical officers
and allied health staff in the detection and management
of people with serious mental illness. Psychiatric units
give regular training for medical officers and health staff at
primary health care centres, in line with Ministry of Health
service goals of providing services close to home.
For patients who require hospitalization, the process is
facilitated under the legislation of Malaysia’s current Mental
Health Act (2001) and Mental Health Regulation (2010).
The Mental Health Act upholds the rights of the mentally ill.
Provision is available for voluntary hospitalization. People
subject to involuntary hospitalization (by carers or police
in civil cases) must be examined by a psychiatrist within
If the illness progresses, carers need assistance with to cope
with both the objective and subjective burden. Malaysia
began developing Family Support Groups in March 2003
as a grassroots movement encouraged by its national
coordinating body, the Family Health Division, Ministry of
Health, Malaysia and the nongovernmental Malaysia Mental
Health Association. They held a national workshop with
participation by 18 Family Support Groups from across the
country, psychiatrists, volunteers supporting the family
movement, and professional staff and administrators from
the Ministry of Health itself.
The Department of Social Welfare Malaysia (DSWM),
which comes under the Ministry of Women, Family and
Development, works in partnership with the Ministry
Of Health to support people with disability. A major
breakthrough occurred in March 2007 as the DSWM was
finalising the People with Disabilities’ Act, it was recognised
that mental illness had to be included. This was in line with
the UNESCAP Biwako Millennium Framework (2003–12)
which advocated an inclusive, barrier-free and rights-
APCMHDP 2011 : MALAYSIA
Above: Yong Ni San, Hope, 2011, colour pencils on paper 29.7 x 21 cm.
“This is a picture of a sailing boat to give people hope. The new moon
represents a new beginning. Fishes can live harmoniously with man
in the sea. They can watch the beauty of sunset together. The small
boats bring all the blessings and the stars twinkle with hope. When I
drew this picture, I was very sick and this picture gives me hope.”
based society for persons with disabilities in Asia and the
Pacific region in the 21st century. DSWM needed help to
re-categorize and outline the disability assessment process;
the Ministry of Health Malaysia responded by forming a team
with special expertise, including mental health.
FAMILY SUPPORT GROUPS ESTABLISHED
With the support of local psychiatric departments, which
provided the necessary professional assistance, carers
came together and started up the regional Family Support
Groups, with programs carried out by volunteers, families
and the patients themselves. The aim was to build creative
partnerships to promote knowledge about mental illness,
look at preventive interventions and give care to recovering
patients. Service providers and service users were equal
partners in the delivery of care.
The benefits of these Family Support Groups include greater
opportunities for disclosure, empathic connection, sharing
of goals, psychological adjustment and demystifying mental
illness. Their functions include:
Comparing experiences and decreasing negative emotions
Forming friendships and re-establishing networks
Establishing hope and focusing on positive roles
Information provision through guest speakers, books,
leaflets and videos
Helping increase knowledge about illness and services,
demystifying illness, enhancing coping and problemsolving
Education – psycho-education and family education
Adjunct to treatment and focusing on patients’ outcomes
Family education with a focus on improving family
After a period of time, some carers wish to help others by
sharing knowledge gained from personal experience and
become advocates for better services and care for their loved
ones. This evolution happens in Malaysia as it does in other
APCMHDP 2011 : MALAYSIA
Left: Yong Ni San, Medicines, 2000,
colour pencils on paper 29.7 x 21 cm.
“The picture represents the medicines
given to me by my doctors. Many colours.
All the beautiful things in life are wrapped
by the dull and black-coloured curls. Taking
medicines allow me to flag off all the bad
curls and give me hope, to grow healthily
like the flowers and the leaves.”
EXTENDING THE OUTREACH
Based in the community and composed mainly of carers,
Family Support Groups have mushroomed in almost all
the states of Malaysia since 2003. Initiative and technical
support from regional psychiatric units and psychiatric
hospitals, plus financial support from the Circle of Care
under the Malaysian Psychiatric Association, have been
major contributors to this growth. They now give support to
the carers of people with serious mental illness, acknowledging
that the daily burden of a carer is an endlessseeming,
Most Family Support Groups begin with the Family Education
Course which forms the nucleus of further training. The
course, adopted from the National Alliance for Mentally Ill
(NAMI) Psycho-education Course, has been translated into
the Malay and Chinese languages and presented in edited or
customized format to suit the local participants.
The early psycho-education courses were held in Government
clinics and organized by psychiatrists, with speakers
coming from regional psychiatric units or psychiatric
hospitals. Over time, organization of these courses has
gradually been taken over by carers themselves, who
share the role of speakers with regional psychiatric units or
Many of the regional Family Support Groups are registered
with the Registrar of Societies as Non-Governmental
Organizations. These regional Family Support Groups later
came together under the umbrella of a national family
support group, MINDA Malaysia.
MINDA Malaysia, an organization for Family Support
Groups, was officially established in August 2006, and
registered by the Registrar of Societies under the 1966
APCMHDP 2011 : MALAYSIA
For many years, the parents, spouses, siblings and friends of the mental ill
have worked tirelessly to bring mental illness out of the shadows. Family
Support Groups in Malaysia have brought them together as a united force to
improve the lives of people with serious mental illness, and help their carers.
MINDA Malaysia is the umbrella body for all family support
groups in Malaysia. It meets every three months to discuss
family support and education, as well as mental health
issues in general. The committee members of MINDA are
elected by the member groups and individual members,
with president, secretary and committee members (mainly
from carer families) drawn from all over Malaysia. It is mainly
self-funded, with occasional grants from the Malaysian
Psychiatric Association. Accountability is maintained through
annual general meetings and reporting of funding and
expenditure to all members.
Although the primary purpose of MINDA Malaysia is to serve
as an umbrella body for Family Support Groups, MINDA
Malaysia is an organization whose membership is open to
all individuals and registered mental health organizations
under the Registrar of Societies Act
(Affiliated Members), as well as to corporate members from
organizations (registered or non-registered) that provide
services or promote the cause of mental health
MINDA members were initially recruited from those who had
attended the Family Education Courses. Family and friends
and the public are encouraged to join in the programs. Talks,
forums and other events are open to all and are usually
advertised in the media and through flyers. Net-working with
other non-government organizations is also an important
avenue for mutual support and sharing of skills.
The Family Support Groups are most active in family
education programs, which are conducted in various
languages (English, Malay and Mandarin) to cater for the
needs of different population groups. The family education
courses help care-givers understand the biological nature
of mental illnesses, the importance of compliance with
medication, and the definition of recovery while enlisting
their advocacy for mental health issues.
The carers generally respond with urgency and commitment,
as the contact opens up their deep-seated and long-dormant
emotional and psychological needs. They learn more about
the impact of mental illness on families, the objective
and subjective burdens of caring, and the importance of
communication skills and self-care.
Follow-up activities to reinforce and expand the course are
crucial through talks and workshops, psycho-social activities
and social networking. The programs offered by Family
Support Groups embrace a wider community of individuals
and groups linked by mental health concerns and reach out
beyond the immediate circle of doctor/patient/family.
Besides the psycho-education programs, Family Support
Groups also organize public forums on mental health issues
and mental health disorders, workshops and leisure activities
such as drum circles and family wellness fairs. Activities that
are creative and relevant to mental health encourage greater
participation and support from those in need.
A few centres also provide psycho-social rehabilitation
activities for people with severe mental illness. The
Malaysian Mental Health Association in Selangor, which
runs a family support group, also runs a psycho-social
rehabilitation program modeled on Kim Mueser’s Illness
Management and Recovery programme in the United States.
Selangor started this program in December 2007, with 10–15
patients usually attending.
In 2010 on October 10 in conjunction with World Mental
health Day, MINDA Malaysia held an event called the MINDA
Big Walk in all states where the body is present.
DIFFICULTIES TO OVERCOME
The carers of the mentally ill are a very diverse group with
differing needs. They come from many different backgrounds
with varying resources, are facing different stages of illness
in their loved ones, and have varying levels of education and
awareness. Not all carers are active, sometimes because of
practical difficulties, sometimes because of the stigma of
associating with a mental health organization.
APCMHDP 2011 : MALAYSIA
Left: Yong Ni San, Grow strong, 2009, watercolour
and pencils on art paper, 21 x 29.7 cm. “This is a
colourful picture and it gives me hope. The trees are
rotting and the environment is not good. Yet, the
mushrooms survive and grow strong. I wish that all the
mushrooms will continue to grow together and make a
beautiful picture for this world.”
As non-governmental organisations with new officers and
committees sometimes elected every one or two years, the
family groups can suffer from lack of continuity in their plans
and programs. Malaysia still has few champions for mental
health care, perhaps due to the stigma attached to mental
illness and some shame associated with being involved
with mental health associations. The Family Support Groups
tend not to be able to attract prominent people (other than
psychiatrists) to lead their organisation and bring it to the
forefront of public attention.
Again, as non-governmental organisations with limited
resources, they are unable to pay salaries equal to those in
the commercial or government sectors. Consequently the
groups have difficulty attracting the right people to work with
them, or to stay for the long-term. Lack of funding also limits
the groups from opening adequate facilities to expand their
activities and services.
With Malaysia’s younger generation very savvy in information
technology, there is great potential to use the power of IT to
reach out to people in need, and to give information to the
general public. More funds are needed to allow associations
to recruit IT people expertise amid great competition from
much better-resourced sectors.
OUT OF THE SHADOWS
For many years, the parents, spouses, siblings and friends of
the mental ill have worked tirelessly to bring mental illness
out of the shadows. Family Support Groups in Malaysia have
brought them together as a united force to improve the lives
of people with serious mental illness, and help their carers.
Family Support Groups focus on support for persons with
serious mental illness and their families, act as advocates
for non-discriminatory and equitable policies, support
research into illness and treatment, and provide education
to eliminate the stigma surrounding serious mental illness.
The Family Support Group movement is entirely in line with
our Malaysia National Mental Health Policy, Ministry of
Health (1998), which emphasises accessibility, equity and
After many years of their work with carers and the public,
advocacy has emerged as a key role for the Family Support
Groups, alongside their basic functions of direct support,
public education and skills training. As relatively new
organisations, Family Support Groups face formidable
challenges, not least in creating awareness among carers
themselves. However carers can find it liberating and
empowering when they get an opportunity for their burdens
to be recognised and acknowledged, to speak and be heard.
This can only benefit the carers, other family members, local
communities and the national society.
APCMHDP 2011 : MALAYSIA
MONGOLIA : A PSYCHOSOCIAL RESPONSE TO DISASTER
A dzud is a Mongolian term to describe an extreme weather event that
makes livestock grazing impossible. In the 2010 winter, a lengthy and very
harsh dzud saw temperatures drop to minus 47 degrees celsius for more than
a month. Livestock and other animals died painfully at a rate of a quarter
of a million deaths every week.
THE DZUD: A NATURAL DISASTER
Some 81% of Mongolia and 57% (97,500) of households
were affected by the dzud disaster, with 8,711 households
losing all their livestock, and 32,756 households losing
more than half. By the end of April 2010, about 18.5 million
animals had been lost, with 133 soum (micro-districts)
adversely affected, of which 65 soum identified as critical by
the National Emergency Management Agency (NEMA).
Immediate consequences included lack of fresh water,
increased risk of communicable disease through inability
to dispose of dead animal carcasses, poor sanitation and
communities being completely cut off from essential services
such as hospitals.
According to government estimates, 180,000 families were
deeply affected. Of these some 20,000 lacked adequate
food and 9,700 families were left without fuel. Displaced by
loss of livelihood, there was also mass internal migration of
herders (over 1,400 households) to city areas.
Initial assessments conducted by the Ministry of Health
(MOH) on health-related problems in the affected provinces
highlighted increased morbidity among vulnerable groups
including pregnant women, children under 5 years of age
and the elderly. Maternal and infant mortality increased by
35% to 40%.
These setbacks were largely attributable to the lack or
difficulty of access to medical services, essential medicines,
food and warm clothes as a result of roads being blocked by
The psychological consequences of such a disaster matched
the more obvious physical and social effects. Three people
committed suicide with a further nine people reported to
have attempted suicide. There were also increased reports
of insomnia, depression and anxiety among populations in
Above: Extreme snow cover resulting from the dzud.
Along with the provision of emergency supplies like
food, shelter and clothing, the international community
provided some psychological help to victims. However,
although NEMA included a focus on health, there was
no consideration given to the inclusion of psychological
expertise in its teams.
It became evident that there was no considered strategy
in place to help the people of Mongolia to respond
appropriately to the psychological effects of natural
disasters such as the dzud.
To address this issue a partnership was formed between
the World Health Organisation, the United Nations
Population Fund, the Mongolian Ministry of Health, the
National Centre of Mental Health and Mongolia’s Public
Health Institute and the Department of Mental Health at the
Health Sciences University of Mongolia.
APCMHDP 2011 : MONGOLIA
The main objectives of the project to help the people of Mongolia respond
appropriately to the psychological effects of natural disasters were to improve
coordination of inter-sectoral teams at a local level, organize orientation and
training of aid workers in mental health and provide psychosocial support to
the affected population using a human rights framework.
The first partnership meeting on Disaster Health
Management was held at the Mongolian Ministry of Health
in January 2010. The key objective was to set up a Mental
Health and Psycho-Social Support team to provide a rapid
overview of emergency situations. This would include a crisis
impact analysis with initial estimates of needs, to provide
the best possible in-depth information on the mental health
condition of the affected population. The information would
be then used to improve service provision to people affected
by disasters, and strengthen the capacity of disaster workers
and other local community resources.
A GUIDING LIGHT
The main objectives of the project were to improve
coordination of inter-sectoral teams at a local level, organize
orientation and training of aid workers in mental health and
provide psychosocial support to the affected population
using a human rights framework.
The Mental Health and Psychological Support Team
project was supported financially and by in-kind expertise
and supplies from international, governmental and nongovernmental
organizations in the following ways:
Below: 18.5 million animals died during the dzud.
The WHO provided financial support for eight dzud
affected aimag (provinces), technical support /training
tools, assessment tools, and In collaboration with other
organizations, training at provincial and district levels.
The United Nations Population Fund (UNPF) provided financial
support for four dzud affected aimag, technical support /
focus group methodology, and the printing of six pamphlets
to help populations understand and deal with various aspects
of the disaster. (The titles were: Explaining the Disaster,
Understanding Depression Post disaster, Dealing with Alcohol
Problems, Anxiety, Stress Management, Insomnia)
The Mongolian Ministry of Health provided technical support
(project proposals and statistical information), information
about health conditions in dzud-affected areas in the
disaster network, and medical support.
The National Center of Mental Health provided a Project
team consisting of seven of its own psychiatrists and one
professional from the National Institute for Public Health
(NIPH). It also helped develop information and training
literature, gave training to disaster workers in 24 areas and
undertook field assessments. This was the coordinating
agency for the national mental health emergency response.
The Department of Mental Health, Health Sciences
University of Mongolia provided methodology for preparing
national and local trainers, guidelines and trainer’s
handbook for providing psycho-social support of disaster.
The National Institute for Public Health (NIPH) gave
technical support in assessing mental health problems
and psychosocial support needs, analyzed data, training
about disinfection of water and sanitation in dzud-affected
provinces. It organized orientation courses and training of
aid workers in mental health and psychosocial support.
There were many challenges that needed to be overcome
to ensure the success of the partnership. This included
a delay in project start time for six weeks due to lengthy
bureaucratic processes that withheld necessary financial
support, and a lack of information about the dzud condition
in affected areas.
APCMHDP 2011 : MONGOLIA
Psycho-social support and medical health care could not
be delivered to some people identified as “high need” due
to snow-blocked roads. Some organizations lacked the
resources to participate in the planning stages of the project,
leading to some difficulties downstream in assessing project
PARTNERS IN COMMUNITY MENTAL HEALTH
The project’s main focus was to prepare 12 teams of aid
workers, each team including psychiatrists, doctors, social
workers, midwives and volunteers, to provide community
based support and treatment for dzud-affected people. The
teams were to visit a minimum of two soum (micro-districts)
in twelve aimag (provinces). Clinical sessions were to be
held in each aimag and soum while data would be collected
and assessments made in collaboration with survivors.
The scope of the project encompasses the following:
Developing an assessment method using IASC, and WHO
guidelines to evaluate the psycho-social needs of those
affected by the dzud.
Training local team members in applying the assessment
Running the assessments in dzud-affected areas.
Preparing pamphlets for affected people on topics
such as stress management, depression, anxiety, alcohol
Organizing focus groups of herdsmen living close to
Developing and leading a two-day ‘train the trainer’
program that includes information and education about
mental health problems in disaster and the methodology
of psychological counseling, and various demonstration
TABLE 1: NUMBER OF PEOPLE COUNSELLED IN THE 12 PROVINCES
INDIVIDUAL GROUP PREVENTATIVE
COUNSELLING COUNSELLING EXAMINATION
Arkhangai 48 62 148
Bayankhongor 54 101 109
Bayan–Ulgii 30 55 147
Govi-Altai 53 43 118
Dundgovi 28 76 155
Umnugovi 23 74 106
Uvurkhangai 51 79 102
Zavkhan 13 65 117
Khuvsgul 13 96 260
Khovd 12 378 255
Uvs 17 120 106
Tuv 15 41 12
Total 357 1190 1635
TABLE 2: MAJOR NATURAL DISASTERS IN MONGOLIA 1980–2009
Extreme Temp (dzud) 2009 769,113 affected
Storm 2002 665,000
Storm 2000 571,000
Storm 2000 500,00
Drought 2000 450,000
Storm 2001 175,000
Storm 1993 100,000
Flood 2009 15,000
Wildfire 1996 5,061
Flood 2001 4,000
(Presentation of report Dr Nai Tuya 28/05/2010)
FIGURE 1: NUMBERS OF EMERGENCY AID WORKERS TRAINED IN THE 12 PROVINCES
PUBLIC HEALTH SPECIALIST BAG’S DOCTOR SOUM’S DOCTOR OTHER
exercises on stress management, breathing exercises,
role plays and hypothetical cases.
Following this training, a psychiatrist visited each of
12 affected provinces and conducted two-day training
programs on mental health for emergency aid workers
(doctors, nurses, soum governors, NGO’s and NEMA
officials). A total of 444 personnel received training.
Carrying out clinical examinations of dzud-affected people,
to assess their mental state, followed by individual or
group counseling if required.
The 12 local teams conducted psychosocial support for
193 herdsman families, individual counseling for 357
people, group counseling for 462 people, group meetings
for 1,190 people and conducted medical prophylactic
checkups for a further 1,635 people.
Above: S.M., b.1975, Peacock, straw (thatch), 32 x 20 cm. The artist once
suffered from schizophrenia and he continues to participate in
psychosocial rehabilitation activities.
SPIRIT OF RECOVERY
Children and adults living in dzud affected areas were
grateful to receive visits from the Community Mental Health
Partnership Project team because the local team members
were trained to meet survivors in the community and spend
time listening to their feelings and stories about the dzud.
Survivors greatly appreciated the psycho-social support
activities conducted through the project, including the
medical preventive checkups, psychiatrist’s meeting, and
group and individual sharing of experience.
A 48-year-old male, married with 5 children and residing
in Altanbulag soum of Tuv Aimag, presented with symptoms
of depression and suicidal thoughts which he had been
experiencing for the previous two months. There was also
a history of increased alcohol intake and withdrawal from
The dzud had caused the loss of his entire herd of 800
animals. He had feelings of shame and compared himself
with other herders who had still some remaining livestock.
He believed that they felt that he was not a good herder.
His wife was very stressed, having to cope with him as well
as the housework and caring for the children. They had
also taken a bank loan to meet university fee payments for
their two older children.
A family assessment was conducted. Once it was clear
that this person was experiencing serious symptoms, he
was interviewed privately to clarify the diagnosis, institute
a treatment plan and arrange for counseling. He was
commenced on antidepressant medication. Arrangement
was made for him to be reviewed within that week by
a midwife of the soum hospital who had attended the
training on disaster management.
A letter of referral with an outline of treatment plan was
made to the soum doctor, who was away at the time, for
follow up on his return. It was suggested the doctor refer
him to specialist psychiatrist service at the aimag hospital
for further treatment in case of complications. The visiting
psychiatrist also left a contact telephone number with the
midwife to call in the interim if required.This demonstrates
best practice when carrying out community assessments.
A management plan with clear levels of referral is important
in management of such cases in the community.
APCMHDP 2011 : MONGOLIA
Some dzud survivors in more remote areas had been cut off
from outside contact for an extremely long time, some for
around seven months.
The project demonstrated that effective partnerships need
planned coordination, especially when establishing intersectoral
partnerships that include government and nongovernment
organizations. Other key lessons learned were:
For ongoing project development, professionals need
training in research methodology. This allows them to
gauge and record accurately whether strategies are
working and targets are being met.
Bureaucracies need to have clear and easy pathways for
release of funds in emergency situations. Inefficiencies
and unnecessary red tape prevent funds not reaching
people in time and prolong suffering unnecessarily
Providing psychosocial support through home visits yields
better outcomes than when people have to travel long
distances to hospitals for visits often associated with fear
Psychiatrists need to be included at both national level
and at local disaster management committees to ensure
local people receive adequate training and victims are
dealt with appropriately
Dead livestock carcasses need to be disposed of
completely and in a timely manner to prevent the spread of
animal born diseases.
Training of bag (the smallest administrative unit in
Mongolia, roughly translated as commune) doctors, their
assistants and the health social worker in psycho-social
support in disasters is important as they are usually the
first point of contact with herdsmen and their families.
Psychiatrists who received training in disasters from NCMH
were able to conduct training at provincial levels. Group
discussions, role-plays, and case presentations were
effective teaching tools.
Group assessment is an effective intervention for a large
number of people who have undergone similar traumatic
experience. Adopting a holistic approach to assessment
is important in identifying the physical and psychological
complications of disaster and providing integrated
Home visits allowed the assessment team to identify
other stressful risk factors (such as disposal of carcasses)
and the hardships encountered in reaching soum or
bag centers for help. They also helped scattered herder
families become aware of what was happening with other
members of their far-flung society.
Above: A.O., b.1985, Wolf, hand-knitted beads. The artist suffers a mental
illness and has resided in a hospital since his adolescence.
Assessments highlighted the fact that both adults and
children suffered psychological symptoms as a result of
the disaster, and the already most disadvantaged people
and vulnerable groups were most at risk of mental health
problems in a disaster. Soum and bag doctors and local
governors are seen as the first source of psychosocial
Despite its many challenges, the project achieved
considerable success that will help ensure its sustainability.
A new psychosocial support management component
is to be included in dzud disaster management, with
trained psychiatrists now included in the National Disaster
A dzud assessment tool was developed according to the
Inter-Agency Standing Committee Guidelines on Mental
Health and Psychosocial support in Emergency Settings
(IASC 2007) and was very effective after this disaster.
Disaster management guidelines and a handbook have
also been developed to support training of disaster first-aid
workers both at national and local levels, and have been
extremely well received.
APCMHDP 2011 : MONGOLIA
PHILIPPINES : THE DISCHARGE AND FOLLOW-UP
Mental health care in the Philippines was located in a single government
institution for the entire country until the late 1980s when a quiet revolution
began unfolding. The National Center for Mental Health (NCMH) was set up in
1928 under the Department of Health (DOH) in Manila, and for the following
40 years remained the only psychiatric care facility in the country. Without
access to mental health care or medication a great number of people suffering
with mental health problems came to the centre for consultation, care and
confinement, leading to massive overcrowding.
Above: This colored drawing is by a 60-year-old female who was
diagnosed with schizophrenia in 1978. Painting and drawing for her is
a medium of self expression. She can relate how she feels and what
she thinks to other people in a colorful way. This drawing was inspired
by a Filipino mountain climber who reached the peak of Mount Everest
against all odds. This inspires her to conquer the challenges brought
about by her mental illness. She feels that she can overcome all the
hardships in achieving recovery with the help of other people, especially
the National Center for Mental Health. For her, being a person with a
disability is not a hindrance to her goal in life, which is to live her life to
OUT OF THE CONFINES
The National Centre for Mental Health hospital was
built originally with 3,000 beds, but by the 1960s it was
accommodating up to 8,000 patients at any one time,
many of whom came from Luzon, Visayas and Mindanao,
the three main geographical divisions of the country.
The average numbers of in-patients per day consistently
exceeded that of the actual bed capacity of the hospital,
as shown opposite in Figure I.
To ease this severe congestion, the government set up
“extension mental hospitals” in several regions of the
country from 1968, to decentralize mental health services.
Eventually they became independent specialized regional
hospitals providing mental health services. But even with
these regional hospitals in operation, the NCMH patient
population continued to rise.
After the First People Power Revolution in 1986, Secretary of
Health Dr. Alran Bengson initiated the Discharge and Followup
Consultation (DFC) program to resolve the problem of
massive congestion at the national hospital. Under the DFC
program, patients were screened for discharge and provided
with accessible follow-up consultations and treatment in
The DFC was a collaboration of several local government
health units, local hospitals, non-government organizations
and media groups. From an average of 6,000 patients (a
143% occupancy rate) on any day in 1986 at the start of the
program, hospital population was reduced to an average of a
little over 2000 in-patients (a 43% occupancy rate).
APCMHDP 2011 : PHILIPPINES
Authorized Bed Capacity
Average Number of In-Patients per day
Figure 1: Authorized Bed Capacity and Average Number of In-patients per day 1928–2010 (NATIONAL CENTRE FOR MENTAL HEALTH)
Some 3,000 mentally-ill in-patients were discharged back
|to their communities and families who were educated about
mental illness and suitable medication. Satellite centres
were established to provide accessible mental health
services to provide support for the patients, their families
and their communities. By the program’s full introduction in
1995, 52 satellite centres were established nationwide and
several general hospitals in the provinces opened psychiatric
THE ESTABLISHMENT PHASE
Although the DFC’s primary objective was to screen and
discharge patients to decongest the national hospital it
also had the more important aim of maintaining patients’
well-being and preventing readmission. The DFC extended
accessible mental health follow-up consultations and check
ups and psychotropic medications close to where the patient
The partners in the DFC made different but equally vital
contributions in their various roles:
The National Centre of Mental Health provided specialist
mental health consultation and psychotropic medication.
In particular the NCMH team screened patients for discharge
back to their communities, conducted consultations
for patient management in the community, provided
family and community mental health education and
trained local doctors in early detection techniques and
the management of psychiatric patients.
Local Government units (22 municipalities) provided
board and lodging for the NCMH-DFC Team, supplementary
manpower when required, arranged appointment and visit
schedules, transportation and meals, provided venues
for consultation & IEC activities, supplied medication and
provided protection when required.
Regional hospitals provided additional mental health
staff such as local doctors and nurses to jointly manage
the cases with the DFC Team and provided facilities for
consultation. It was expected that these hospitals would
also dispense psychotropic medication and provide beds
for acute psychiatric cases.
Non Government Organizations accompanied the DFC
Team on home visits, ran screening programs for early
detection, advised on new cases to be followed up by the
specialist teams and encouraged members of patients’
families and community members to attend forums and
educational courses on mental health.
The Media especially radio stations played an important
role in keeping the community informed of the visiting DFC
Team’s schedule, locations for mental health lectures and
other psycho-education activities.
The NCMH created the Discharge and Follow-Up Committee
under the Community Service branch of the hospital to
oversee and coordinate all the DFC activities. The Committee
initially asked the assistance of local health offices to
identify local partners for the project. These local partners
became a great help in organizing schedules and securing
venues for activities.
APCMHDP 2011 : PHILIPPINES
It is vitally important to develop the communities’ capacity to provide
mental health services, including support services, before embarking on a
program of deinstitutionalization. It is essential to prepare communities and
to make them fully aware of their responsibilities and the implications for
budget in caring for people in the community.
As the program progressed, local media joined in
disseminating information about the schedule and venue
of DFC activities. As the program gained participation and
approval in a particular district, nearby areas began to send
their patients to the venues and in many instances asked the
NCMH team to visits to their areas. Many patients who had
been previously restrained in their houses and locked up in
their rooms or cages were seen and treated.
Below: This drawing was done by a 42-year-old female diagnosed with
schizo-phrenia in 2005. She unable to progress beyond primary schooling
due to financial constraints. Her parents are both dead and she has lived
most of her life alone. This drawing was inspired by her desire to get
well. She has had no training in painting or drawing but appreciates the
combining of colors. In the drawing she wanted to convey her thoughts
about her illness and her hope of getting well. She emphasized the role of
faith in the process of recovery.
For a number of years, the program provided many patients
in different communities with timely and appropriate
mental health services including free medication. The
reintegration of thousands of patients into their communities
is considered as one of DFC’s major achievements. Other
accomplishments include identification and management
of new cases, early detection and prevention of further
deterioration and the physical confinement that resulted
in many cases.
However, its major success was the decongestion of the
NCMH, which resulted in the elimination of diseases
such as scabies and helped stop the spread of other
contagious diseases and epidemics. Overcrowding was
also a direct cause of human rights abuses. The NCMH
program resulted in much more humane patient treatment,
increased awareness of roles and rights of families and
communities and brokered cooperation between mental
health professionals and other agencies. Most importantly
it encouraged Regional Health offices with mental health
services to develop their own community outreach programs.
Over time, however, as prices of medicines and airfares
soared, and with no matching increase in the hospital
budget, it became increasingly difficult to sustain the
program. With no new budget for the DFC, the NCMH had
to attempt cost cutting measures, including minimizing
transport costs. NCMH Mental health teams were required
to extend their stays in the community and spend more
time in the field. This resulted in a shortage in the number
of on-duty psychiatrists at the NCMH and put increased
pressure on the hospital.
Partners were encouraged to share in the cost of medications.
As the program progressed, the expectations that local
health units or hospitals and or other partners would develop
their own capacity to provide mental health services to their
own constituents never materialized. Without specific local
legislation and funding, mental health was not high in the
priority list of any of the partners. Even the local media needed
sponsorship to continue. Communities became more and
more dependent on the Mental Health Teams of the NCMH,
including for supply of medicines.
APCMHDP 2011 : PHILIPPINES
CASE STUDY: THE DISCHARGE AND FOLL0W-UP PROGRAM
The Discharge and Follow-up Consulation affected the lives
of many people, particularly those living in isolated areas
where mental health care was previously inaccessible.
In Gingoog City, Misamis Occidental, the NCMH team was
requested to visit a farming family. Their traditional hut
was located in an isolated area on a mountain, a 7-km walk
from the foot of the mountain. Inside the hut they found
two adult females and two adult males in an emaciated
condition and completely unresponsive to any questions.
Tied with ropes, they ate, defecated, urinated and slept in
their own small area of the hut for several months.
When interviewed, the parents explained the need to
restrain them because they were uncontrollable and
roaming the mountains. They also related that the siblings
had previously joined a religious group, which forced them
to eat raw vegetables and engage in constant prayers day
and night for two months. This left them unable to sleep
and suspicious of other people. It also instilled great
fear in the community. Unwashed, they were observed
talking to themselves and when speaking with others were
incomprehensible. They became violent and assaulted their
They were examined by the NCMH team, and prescribed
free supplies of chlorpromazine and a Fluphenazine
injection once a month, under supervision of a social
worker and a nurse who gave the monthly injections and
made weekly patient progress reports After three months,
the patients no longer needed to be restrained and were
helping on the family farm. They were again given free
medications, haircuts and education about their illness
and became patients at the Out-Patient Service while
continuing to help their parents on the farm.
To alleviate the financial burden on NCMH, personnel in the
DOH regional mental hospitals were given more training
and then took over care and management of patients. Since
integration of mental health services into primary health care
did not materialize, psychiatric emergency training courses
for general practitioners were conducted.
Finally in 1999, the program was discontinued. Only satellite
centres capable of shouldering the cost of transport;
medicine, board and lodging were retained. This resulted in
patients being readmitted to the NCMH .
A major lesson learned from this program is that a
government hospital can take the lead in launching a
community mental health program provided it partners itself
with major stakeholders in the community. All partners must
be aware of the expectations from them at the beginning
to ensure sustainability. This must include a guarantee of
continued financial support to procure medication, including
mental health consultation in the out-patient services of the
regional hospitals, providing bed space for acute psychiatric
cases, and continuous training in mental health for primary
health care providers.
RENEWAL OF OUTREACH
The success of the DFC program was based on multiple
partnerships with local government units and hospitals,
NGOs, and media groups, with specific roles defined for
Major challenges were the financial constraints with the
costs of transportation and medications taken from the
operational expenses of the NCMH, an unexpected increase
in the number of new identified cases, cases from distant
areas still arriving at the national hospital, and lags in
integration of mental health services into the primary health
care system. Instead of developing their own capacity
to handle mental health cases, communities remained
dependent on the visiting NCMH DFC Team.
From this experience, it is clear how vitally important it is to
develop the communities’ capacity to provide mental health
services, including support services, before embarking on
such a huge program of deinstitutionalization. It is essential
to prepare communities and to make them fully aware of
their responsibilities and the implications for budget in
caring for people in the community.
There should be a well-planned program to formalize
community mental health activities, which includes clear
short term and long term objectives, provision of adequate
trained mental health personnel, a stable operations
APCMHDP 2011 : PHILIPPINES
ase or office, and most importantly a clear mandate from
the central Department of Health preferably backed up
by specific mental health legislation and yearly budget
Recently, under the new administration of President Benigno
Aquino Jr, the Department of Health is responding to growing
community mental health needs. Mental health is being
mainstreamed into the current Universal Health Care (UHC)
program, so that mental health care will be provided at the
highest possible quality to every Filipino. Regardless of
social and economic standing, every citizen should receive
the treatment that he or she needs; and mental health care
should be accessible at all levels and locations through
community mental health programs with dedicated mental
health care providers.
With this new drive, the National Centre for Mental Health
continues its effort to provide mental health services
to the communities by creating new partnership with
other agencies and services. The NCMH also continues
to strengthen the partnerships established during the
DFC program. Supported by the UHC objectives, the DFC
program will revive its services with the long-term objective
of developing self-sufficient and self-reliant partner
communities, which will provide mental health services for
their own constituents. At present, NCMH is collaborating
with the Department of Health, its regional offices and local
health units in providing training of primary health care
workers in psychiatric emergency management and at the
same time is providing in-service training to primary health
physicians in acute psychiatric care. With these, NCMH is
also providing out-patient consultations and domiciliary
services in several isolated islands of the country.
APCMHDP 2011 : PHILIPPINES
SINGAPORE : RESPONSE, EARLY ASSESSMENT AND
INTERVENTION IN COMMUNITY MENTAL HEALTH (REACH)
— A COMMUNITY PARTNERSHIP PROGRAM
Just over a decade ago, youth suicides in Singapore were among the
highest in the world: 0.8 and 0.7 per 100,000 for the under 15 age group in
2000–01. Media reaction resulted in three government ministries getting
together – the Ministry of Health, the Ministry of Education and the Ministry
of Community Development, Youth and Sports – to consider what needed
to be done. Spearheaded by the Institute of Mental Health (IMH) along with
the Health Promotion Board, a centralised mental health education effort
called “Mind Your Mind” was initiated.
YOUTH UNDER STRESS
Violent crimes against person and property by juveniles
increased from 437 in 2004 to 500 in 2007 (Singapore
Police Force 2009), resulting in more admissions to juvenile
detention facilities despite a shift to youth community-based
rehabilitation. A diversionary approach has been taken by
the police to avoid the juvenile justice system. A Guidance
program involving six months of supervision and counseling
has been shown to reduce re-offending rates. Rather than
focusing on prevention, these are downstream exercises,
not directly aimed at the causes of youth aggression and
A survey of 2400 children in the community showed that
almost 5% have externalising behaviours and more than
12% have internalising symptoms using the Child Behaviour
Checklist as the screening instrument. The risks of a lifetime
of academic failure, social dysfunction, poor peer relations,
substance abuse and school dropout are considerably
increased in these children. In Singapore, failure at school is
among the most common reasons for referral to child mental
health services and continues to rise. A Singapore study on
disease burden measured by the WHO concept of Disability
Adjusted Life Years showed that mental health disorders in
youth contributed to three out of the five top conditions for
children aged 0 to 14 years.
Children who have problems coping at school and home
due to their mental health problems are referred to the two
specialist outpatient clinics for children (Child Guidance
Clinics) under the Institute of Mental Health. In 2007,
there were close to 18,000 attendances at the Child
Guidance Clinics, including 3,000 new visits. This
represented a 14% increase in total clinic attendances
compared to attendances in 2003. One-third of the referrals
were from the community. It is evident that mental health
disorders affect a significant population that should be
targeted by population-based health interventions.
In 2005, the Singapore Government appointed a National
Committee for Mental Health with various sub-committees
focused on different age groups or special conditions.
This resulted in the development of a National Mental
Health Blueprint in 2007. The government recognized that
a concerted national program was needed to address the
multi-faceted needs of the population to maintain good
mental health, identify mental health disorders early and to
establish a comprehensive intervention program in primary,
secondary and tertiary healthcare settings.
The focus of the Blueprint for children and adolescents is
in the school system, as education is compulsory and
schools form an obvious basis for preventative as well as
early intervention efforts. To address the mental health
needs of children and adolescents in the community, a
new program was established under the leadership of the
Director of Medical Services of the Ministry of Health.
79 APCMHDP 2011 : SINGAPORE
Above: REACH team member and school counsellor conducting activities with, and explaining the instructions to primary school students.
The new community mental health team for children was
called Response, Early Assessment and Intervention in
Community Mental Health (REACH).
The REACH program involves a partnership between the
Ministry of Education and the Ministry of Health. It is
school-centred and has progressively involved Singapore’s
nearly 400 schools. (There are 355 mainstream schools
in Singapore and over 20 special schools. Primary school
education for the first 6 years is compulsory but secondary
school education is not).
The Ministry of Education has initiated a number of programs
to minimise school drop-out, which has been steadily
decreasing from 3.2% in 2003 to 1.6% in 2007. Every school
in Singapore has also been assigned a full-time school
counsellor. In addition, anti-bullying campaigns have been
undertaken with the assistance of a large non-governmental
organisation, the Singapore Children’s Society. A network
of family doctors (general practitioners) and four NGOs or
voluntary welfare organisations) also work with young people
and their families.
FORMATION OF COMMUNITY TEAMS
REACH was formed to work closely with community agencies
to create a primary mental healthcare network in Singapore.
The objectives of the REACH project were to:
Improve the mental health of children in the community,
with the school as the focus
Provide early intervention through the support and
training of school counsellors, social service agencies
and voluntary welfare organisations in managing at-risk
Develop a mental health network in the community to
support children at risk, involving voluntary welfare
organisations, general practitioners and community
pediatricians and schools.
The Ministry of Health took the lead in securing funding
for the Program but all stakeholders including the
schools (under the Ministry of Education), voluntary
welfare organisations (through the Ministry of Community
APCMHDP 2011 : SINGAPORE
Using the school counsellor as the nexus for transmitting expertise, school teachers
and staff are taught skills in identifying and managing problems early. At the same
time, local GPs and social service agencies are engaged in a similar fashion to form
a network of community support for students and their families.
Development, Youth and Sports with the National Council
of Social Services) and GPs had to contribute resources to
participate. The Key Performance Indicators (KPIs) involved
both process indicators, for example, number of staff
trained, as well as outcome indicators such as improvement
in mental health status.
The Department of Child and Adolescent Psychiatry of the
Institute of Mental Health and the Ministry of Education
piloted REACH as a prototype program in one school cluster
(consisting of 15 schools, including primary and secondary
schools) in August 2007. Its aims were to train and support
school counsellors in the early identification and support of
children with behavioural and emotional difficulties.
The first REACH team was formed to support 90 schools
in the North Zone. This team is located at the Institute of
Mental Health which is close to schools in the Northern
part of Singapore in order to provide easy access and quick
response. The second team of twelve members was formed
in 2009 to support schools in the South Zone. The team is
located in the Southern part of Singapore and is also near
the Institute of Mental Health’s Child Guidance Clinic at the
Health Promotion Board. This enables REACH staff to manage
referred REACH patients collaboratively with the clinical team
at the Child Guidance Clinic. The third REACH team opened
in the East zone of Singapore for easy access by its schools
in October 2010 and the final team, situated in the West
Zone, in March 2011.
The functions of the REACH teams include:
Clinical services such as early intervention in common
child psychiatric problems such as School refusal and
Attention-Deficit Hyperactivity Disorder (ADHD); primary
treatment of behavioural and emotional problems
and learning difficulties in collaboration with school
counsellors and government agencies; and sorting
patients for secondary and tertiary care.
Training of full-time school counsellors in identifying
mental health disorders (behavioural and emotional) and
symptoms, starting with ADHD and training of primary
physicians in managing primary psychiatric problems and
Integrating care by promoting linkages between schools,
social and community agencies, family physicians and
mental health service providers, including coordinating
inter-agency consultations and case conferences.
Mental health promotion programs in schools and social
Left: Anger Management group rules on school noticeboard. Right: Personalised speedometer drawn by a 9 year-old student who suffers from ADHD.
APCMHDP 2011 : SINGAPORE
The community teams form the framework for early
identification of emotional and behavioural difficulties.
Using the school counsellor as the nexus for transmitting
expertise, school teachers and staff are taught skills in
identifying and managing problems early. At the same
time, local GPs and social service agencies in the school’s
vicinity are engaged in a similar fashion to form a network of
community support for students and their families.
Over time, school parent support groups from schools
as well as national disease support groups such as
SPARK (Society for the Promotion of ADHD Research
and Knowledge) were enlisted to attend roped into the
mmeetings and conferences to help improve understanding
and disseminate the work of the community teams and
The REACH team has trained 386 school counsellors in a
myriad of child mental health topics, thus raising their ability
to detect, assess and manage affected students. The school
counsellors have given positive feedback about REACH
with 98% declaring satisfaction with the REACH support
services and more than 95% rating the training provided
as satisfactory and effective. With specialised training, the
counsellors were also able to detect children displaying
symptoms of mental disorders and refer them for more
Since 2007, 437 cases have been referred to REACH. Of all
the cases seen in 2009, more than 75% were appropriately
referred, as evident from the high concurrence with clinical
CASE STUDY: ‘KELVIN’
‘Kelvin’ (not his real name) was a 10-year-old boy, the
eldest of two siblings. Kelvin’s family was of low socioeconomic
status: his father, aged 50, was unemployed
and his mother, aged 46, was working as a cook. At
home, parents felt that Kelvin was obedient, had a good
relationship with them and got along well with his eightyear-old
brother. However, Kelvin was referred to the
REACH Community team by the counsellor for his frequent
angry outbursts and fights in school. These fights involved
the destruction of tables and chairs in his fits of rage.
Kelvin was easily provoked by others over trivial incidents,
comments, or criticism and this disruptive behavior had
started one year earlier. He broke school rules by defying
dress and grooming requirements. He was frequently
late for school. It was reported that Kelvin had joined a
youth gang that primarily engaged in shoplifting. He was
often moody and claimed that he was worried about his
friend’s problems with teen gangs. The school provided
counselling and administered consequences such as
caning, public apology and suspension.
During counselling, Kelvin argued and blamed others
for his misconduct. Kelvin indicated that he could listen
to teachers he liked but he would deny responsibilities.
He confided with the counselor, “Society is unfair; I will
Kelvin often stayed out at night despite prohibitions by
his parents. Once when scolded by his father, Kelvin had
stomped out of the room and smashed a water cooler
because he felt he “lost face,” which is an important
cultural value in Singapore. Another time his teacher
asked that he keep his cell phone in his pocket. He did
not comply because he did not have a pocket. The teacher
called him a “stupid idiot,” so he broke a mirror. He
sometimes got into fights when others made insulting
comments about his family, and he felt obliged to protect
his family name. Academically, Kelvin was performing
poorly, but most teachers attributed this to his poor
With parental consent to access information, REACH
noted that Kelvin had been registered with a Child
Guidance Clinic, although he had not attended previous
appointments. Upon the doctor’s review at the Clinic, the
REACH team noted that Kelvin exhibited traits of conduct
and emotional disorders and would benefit from behavior
management at school. The team shared its formulation
of Kelvin with the school counsellor and conducted
a behavior analysis to assist the school counsellor
in developing a school management plan, involving
appropriate staff and students to help Kelvin. REACH also
arranged for a psycho-educational assessment in view of
his learning difficulties. Kelvin was diagnosed to have a
reading disorder and required remedial support through
the Dyslexia Association of Singapore. REACH assisted
the school counsellor to arrange individual therapy for the
student and offered family counselling should the need
arise. The school counsellor remained the case manager
for Kelvin and collaborated with the various parties
involved in the interventions.
APCMHDP 2011 : SINGAPORE
Above: Kucinta Cat Programme: Left: A student’s self-decorated toolbox lid. Right: Inside of the toolbox: “things I like to do, easy things, difficult things
and coping skills I learned.”
diagnoses. These results indicate that the detection and
referral system put in place by the community team has
worked extremely well. In addition, four out of five cases were
seen within a week, demonstrating a fast response time. Preand
post- assessments were conducted to determine how the
children responded to the interventions and treatments after
six months. The children showed good improvements in two
assessment ratings – the Clinical Global Impression Scale
(CGI) and the Strengths and Difficulties Questionnaire (SDQ).
With regard to the Strengths and Difficulties Questionnaire,
more than half the children showed improvement after the
REACH intervention. For the Clinical Global Impression Scale,
ratings of the severity of the problems were significantly lower
after six months – see Diagram 1.
Diagram 1. Severity of illness Pre and Post REACH involvement
(Clinical Global Impression Scale)
FINANCIAL YEAR 2007–08 2008–09 2009–10
Although the program has been generally well received by
counsellors, doctors and social workers in the community,
some partners were unhappy with the helpline service that
was provided. They commented that they were asked too
many questions about the student and family when they
called the helpline. They failed to understand the purpose
of the questions and were uncomfortable in speaking to the
family to get the information that was needed. Some also
gave feedback that too much paperwork was involved when
trying to refer their students. They did not see the need to
measure outcomes involving rating scales. These challenges
were overcome by developing a series of workshops on
understanding and using rating scales to help counselors in
their work. Results of the ratings were conveyed regularly at
school meetings allowing school management to recognize
the usefulness of outcome measurement.
Children who are at risk can be identified and detected in the
community setting. They include delinquent youth, school
dropouts, children from dysfunctional families and children
with parents who are mentally ill who are potentially at a
higher risk of developing some form of mental illness. The
REACH team focuses on providing community mental health
services to schools and building up the capabilities of school
counselors. The service was expanded to include other
partners in the community such as social welfare agencies
to help them manage some of these at-risk children in the
APCMHDP 2011 : SINGAPORE
community. This was done in collaboration with the National
Council of Social Service and the Ministry of Community
Development, Youth and Sports. The most critical element
of the community programme was the development of
successful partnerships across what were traditional silos
of care for children and their families. This allowed efficient
coordination, synergy of funding synergies with particular
partners actively contributing to different elements of the
programme with and clear governance withand a central
With the completion of the collaborative community model
of primary and secondary mental healthcare linking schools,
GPs and voluntary welfare organisations with REACH
community teams in all four school zones in the North,
South, East and West by 2012, Singapore will be one step
closer to developing a model of care that supports children
with moderate to severe mental health disorders.
The plan for the future is to re-engineer the role of hospital
services and the Child Guidance Clinics to become focal
points of a regional mental healthcare system for children
and adolescents. The four zones of Singapore will be
supported by the Institute of Mental Health and the local
children’s hospitals (Kandang Kerbau Women and Children’s
Hospital and the National University Hospital System),
giving a vertically integrated network for delivering services.
Singapore will then have a highly effective allocation of
scarce resources, establishing a comprehensive and holistic
child and adolescent mental health delivery system.
Lee, N. B. C., D. S. S. Fung, Y. Cai, and J. Teo. 2003. “A Five-Year Review
of Adolescent Mental Health Usage in Singapore.” Annals Academy of
Medicine, Singapore 32 (1): 7–11.
Ministry of Community Development, Youth, and Sports. 2009.
“Singapore’s Second and Third Periodic Report to the United Nations
Committee on the Rights of the Child.” http://app.mcys.gov.sg/web/
indv_uncrc.asp (accessed January 15, 2010).
Ministry of Law 2010. “Singapore Statutes Online.” http://statutes.
September 11, 2010)
Phua, H. P., A. V. L. Chua, S. Ma, D. Heng, and S. K. Chew. 2009.
“Singapore’s Burden of Disease and Injury 2004.” Singapore Medical
Journal 50 (5): 468–478.
Singapore Department of Statistics. 2008. Yearbook of Statistics
Singapore. Singapore: Ministry of Trade and Industry.
Singapore Police Force. 2010. “Crime Situation 2009.” http://www.spf.
gov.sg/stats/stats2009_intro.htm (accessed April 18, 2010).
Tan, S., Fung, D.S.S., Hung, S.F., and Rey, J. 2008. “Growing Wealth and
Growing Pains: Child and Adolescent Psychiatry in Hong Kong, Malaysia
and Singapore.” Australasian Psychiatry 2008: 1 – 6
World Health Organisation. 2006. “Suicide Rates (per 100,000), by
Gender, Singapore, 1960-2006.” http://www.who.int/mental_health/
media/sing.pdf (accessed April 14, 2010).
Woo, B.S.C., T.P. Ng, D.S.S. Fung, Y.H. Chan, Y.P. Lee, J.B.K. Koh, et al.
2007. “Emotional and Behavioral Problems in Singaporean Children
Based on Parent, Teacher and Child Reports.” Singapore Medical Journal
48 (12): 1100–1106.
84 APCMHDP 2011 : SINGAPORE
SOLOMON ISLANDS : COMMUNITY MENTAL HEALTH TEAM
The Solomon Islands is the third largest archipelago in the South Pacific
made up of nearly one thousand islands. Geographically extremely diverse,
the archipelago has both densely forested mountainous islands and low-lying
coral atolls that include tiny artificial coral islands along some coastlines.
Most of its 531,000 people reside in small, widely dispersed coastal
settlements, with 60% living in localities with fewer than 200 persons,
and only 17% in urban areas.
KINSHIP BONDS SUPPORT REHABILITATION
More than 75% of the Solomon Islands labour force is
engaged in subsistence farming and fishing. The linguistic
and cultural diversity in Solomon Islands is remarkable with
over 120 languages spoken across the country.
Mental Health services are provided at the National
Psychiatric Unit as well as in the acute wards of the National
Referral Hospital, in the capital Honiara, and in the five
regional hospitals. The National Psychiatric Unit is located at
Kilu’ufi Hospital, Malaita Province: transporting people there
for inpatient care is difficult for patients, family, staff and the
system in general. The Community Mental Health Team and
Rehabilitation Division work within the Integrated Mental
Health Services in Honiara, which is located on the island of
Melanesian culture, communal, clan and family ties run
strongly through the Wontok system, referring to people
from the same language group who are blood relatives and
part of an extended family network. The bonds of kinship in
the Wontok system involve important obligations extending
beyond the immediate family group to local and clan circles.
Recognising that the spirit of the wontok system could
provide an excellent basis for the care of mentally ill people
in the community, Integrated Mental Health Services in
Honiara formed a partnership with families and carers to
better promote the recovery of patients in the community,
Under the term Community Mental Health Team, the project
involved five people from two teams who managed the
program and addressed patients’ issues in a more holistic
manner in the community.
SENT HOME AND ‘FORGOTTEN’
Integrated Mental Health Services found that many of the
people admitted to the Acute Care Centre at the National
Referral Hospital were relapsing frequently. Patients were
‘forgotten’ after they were discharged from the Mental Health
Acute Care Unit. Much responsibility was given to family
members to care for them, but little assistance and follow-up
visits were provided to ensure ongoing treatment. Within a
year, the statistics were showing, many patients were being
readmitted several times with similar patterns of relapse,
even though many of the carers and family members did
want care and rehabilitation for the patients after discharge.
A brief survey was undertaken with patients and relatives
living in Honiara to get an accurate analysis of the situation.
Combined with clinical records, survey interviews and other
statistical information led the Ministry of Health’s Integrated
Mental Health Services to establish and organize a new
supportive network and began building up relationships and
interaction with local stakeholders, the families and carers
of the patients in the communities in Honiara. The partners
would contribute their time and labour wherever possible,
and collaborate with the Ministry of Health to provide a safe
environment, offering individual holistic care for people with
mental health needs.
More specifically the primary objectives of the network are:
To offer innovative services that promote recovery
To provide a friendly, supportive, therapeutic environment,
encouraging and building on the potential and strengths
of the individual
To create opportunities to restore and retain motivation
and social inclusion
APCMHDP 2011 : SOLOMON ISLANDS
Members of the Solomon Islands Community Mental Health Team, from the left: Registered Nurse Willie Cain, Registered Nurse Victor Atu, Director of
Integrated Mental Health Services William Same, Clinical Nurse Godfrey Thomas, and Community Mental Health Nurse John Wesley Ilopitu.
Inset upper left: Psychiatry Registrar Dr. Rex Maukera.
To ensure patients privacy, dignity, respect and upholding
of their rights.
To ensure that all therapeutic interventions are continually
updated and inclusive of research and evidence based
Three-day workshops were held to launch the partnership
with the community stakeholders and to begin forming the
network. The Community Mental Health Team followed up by
allocating team members for home visits to each client and
their families. The visits provided support, technical advice
and motivation for ongoing rehabilitation in the community.
The training workshop was aimed at building the capacity
of family members to help them develop the knowledge,
skills and confidence to support and rehabilitate their family
members suffering from mental illness. Sufficient trust
needed to be developed to allow the community mental
health team to work alongside families in the rehabilitation
of family members in their homes.
The initial workshops assessed the level of participation and
requirements in the home. Past assumptions from health
staff have been that families have sufficient resources to
care for people with a mental illness in the community.
This had previously led to misunderstandings between
health staff and the families and frustration about the lack
of support from both sides. Families and carers said that the
workshop was “an eye opener” for many.
Initial planning for the partnership included the expectation
that a patient rehabilitation centre would be built. Some
family members lose hope because patient rehabilitation
can be a life-long process: they can become ‘burnt-out’ along
the way. Therefore the Mental Health Department plans to
open a small but well-resourced rehabilitation centre within
the hospital setting where the patients can come during the
day to learn from the professional staff.
Activities will be planned according to the needs of the
community and include more home or village orientated
programs. In this centre, education and other collaborative
activities would be designed to involve all stakeholders,
including the patients themselves in innovative ways aimed
at preventing relapse and re-admittance.
Most importantly the centre’s activities would be aimed
at providing programs to restore patients’ lives as useful
people in their society.
86 APCMHDP 2011 : SOLOMON ISLANDS
Once a family member is discharged from acute treatment care in hospital,
the fully implemented program works to ensure that families and carers are
actively involved in after care and rehabilitation in the home.
The fully implemented program works to ensure that
families and carers are actively involved in the after care
and rehabilitation in the home, once their family member is
discharged from acute treatment care in hospital.
The program aims to assist with simple activities such as
dispensing medication and learning how to observe if there
are any adverse side effects of the drugs. The activities may
include taking care of their client’s daily living life skills such
as general hygiene, cooking and encouraging the clients to
get involved in the whole range of family activities such as
helping in the home and household business.
Officers from the Community Mental Health Team go out on
regular visits to encourage and motivate families in their
Many patients live in the villages, or retain strong
connections with their original communities which may be
in remote areas of Solomon Islands. Delivering services
locally can be problematic, especially within the lowresource
setting. Distances and road accessibility are major
challenges. There are times when families cannot be reached
because roads are in a very poor and unsafe situation.
Transport is difficult and often expensive, impacting greatly
on the sustainability of the ongoing projects. Communication
is also a very big problem because most patients and their
relatives do not have telephones at home; it is difficult to
contact stakeholders about any changes in the program.
Without good communication and technology, the patient
and family may not even be at home when the community
mental health team visits.
Finding the capital to establish the rehabilitation centre is
still a major challenge. In the short term, offices have been
partitioned to allow some of the activities to start. Mapping
of patient locations has started, although changes in their
residence can occur frequently and they become difficult to
follow up and can be lost.
Settlement on a reef island off Malaita, Solomon Islands.
APCMHDP 2011 : SOLOMON ISLANDS
the lack of specialist skills. With only very limited support
from the government and other stakeholders to provide
specialised training, the gap in quality care remains.
Coastal village, Nggela, Solomon Islands
The current approach is to visit the clients at their respective
environments with their family members. With only a
small team of trained community workers, the visits are
infrequent and average about once a month. These barriers
to regular contact can be discouraging for the team. Many
of the planned community contacts have not been fulfilled.
Expectations needed to be adjusted to suit resources and
the reality of the environment.
In response to these barriers and challenges, the Community
Mental Health Team has made some changes. The team has
been divided into two teams; one for acute treatment to
achieve clinical stability and the second for rehabilitation
purposes. The latter will be responsible for assessing the
patient’s home environment and then working with them on
developing suitable activities. Some activities have proven
unsuccessful in the home environment, so the Community
Mental Health team is continually assessing the program.
Finance is also required for purchasing of a vehicle to take
the officers to the patients’ homes. Basic provisions such as
clothing, food, and personal hygiene items can be barriers
for the clients from very poor family backgrounds. Many
basic supports must be provided before the clients and the
families can participate actively in the program.
There is limited support for workforce development in
community mental health. Qualified and skilled officers
are required to carry out the full range of activities needed
to support the ongoing and changing circumstances of the
patients and their families. Some staff may be qualified at
a basic level; but are unable to meet the real needs due to
A GOOD BEGINNING
The program has been in existence for just a year and half
when this report was compiled and had not been formally
evaluated. Future plans include extending the reach of
mental health rehabilitation support by merging the program
with other more general health programs such as the General
Rehabilitation Team. More engagement of community
leaders has also been identified as a way to improve
program success. Workshop training has been planned for
community chiefs, elders, pastors or priests to lessen stigma
in the community, and protect the human rights of people
with mental illness.
Establishing the partnership for the Community Mental
Health Team was well received by all stakeholders but
sustaining the activities requires much work and planning.
Constant enthusiasm, motivation and encouragement are
Although more than 80 percent of the families and careers
attended the scheduled workshops, attention needs to be
constantly focussed on ensuring that trust fostered during
the primary phase of the project is maintained.
Transport to patients’ homes remains the main challenge for
Although a rehabilitation centre in Honiara is starting to be
set up to provide training, promote interaction and increase
productive life, several expectations have not been met.
More work is required for the proper management of patients
in their own home settings.
It can been seen through this partnership that families in
Solomon Islands are actively accepting the responsibilities
of being carers for people with a mental illness in the
community. They are very interested in rehabilitation and
recovery from mental illness because the carers want their
close relatives with a mental illness to be useful members
of their family again. From the statistics, the major success
so far has been the reduction of patient relapses and
readmissions to the acute care unit. However, further
research would be needed to clarify all of the outcomes of
this community mental health team initiative.
APCMHDP 2011 : SOLOMON ISLANDS
TAIWAN : PARTNERSHIPS FOR COMMUNITY
REINTEGRATION AND EMPOWERMENT
Over the past 15 years, Taiwan has unfolded an extensive mental health
reform program. This has seen Yuli Veterans Hospital move from a custodialcare
asylum into a modern teaching hospital focusing on psychiatric treatment,
rehabilitation and research. A key emphasis of the reform is the reintegration
of institutionalised patients into the community.
YULI TRANSFORMS ITSELF
In 1958 a remote location, well-distanced from densely
populated urban areas in Taiwan, made Yuli, a small rural
town at the mid-point of East Rift Valley with only 30,000
inhabitants, an attractive site for the establishment of the
Yuli Veterans Hospital (YVH) for the mentally ill.
Since then, thousands of people with severe mental illness
were transferred to YVH from all over Taiwan for long-term
care. Yuli Veterans Hospital quickly became synonymous
with stigma, ostracism, rejection and hopelessness for the
mentally ill in Taiwan.
But over the past 15 years, Taiwan has unfolded an extensive
mental health reform program. This has seen YVH move from
a custodial-care asylum into a modern teaching hospital
focusing on psychiatric treatment, rehabilitation and
research. A key emphasis of the reform is the reintegration
of institutionalised patients into the community. To this
aim YVH launched vocational rehabilitation programs that
build collaborations with local business, to assist long term
unemployed patients secure jobs and thereby regain their
economic autonomy and social identity.
Employment offers opportunities for interaction between
patients and the local community. However, these
interactions can be quite limited, occurring only during
working hours, at a particular worksite, and sometimes only
between the employers and the patients. Although Yuli has
been the most supportive and friendliest community for the
mentally ill in Taiwan, many local people are still frightened
and anxious that patients may be a source of disruption and
be dangerous in their neighbourhood.
This runs counter to a growing body of evidence suggesting
direct contact is in fact the best way to eliminate fear and
stigma. In response, we actively searched for innovative
projects that enhance the scope and depth of interaction
between the patients and the community.
In 2005, a local church and its affiliate, the Christian
Holistic Renewal Association, completed the construction
of Euodia Clubhouse beside the traditional marketplace.
The Clubhouse was established to boost the momentum
of their ministry providing guidance for teenagers who
have difficulties with school and their families. The threestorey
building was designed with teenagers in mind. It’s
open, spacious, and contemporary in its architecture,
even including a rock-climbing practice wall. It was unlike
anything seen before in Yuli.
At the same time, the local church also continued its
hospital work, which had begun in 2000, ministering to the
long-stay mentally ill inpatients several times a week.
In February 2006 the superintendent of Yuli Veterans
Hospital and a colleague visited the pastors of the local
church. The meeting articulated a shared common vision
and mission to assist the disadvantaged to rebuild their lives
and reclaim their dignity. It was proposed that a joint venture
commence between Euodia Clubhouse and Yuli Veterans
Hospital to assist the severely mentally ill of YVH be further
integrated into the broader Yuli community.
REJOINING THE COMMUNITY
In May 2006, after three months preparation, the Euodia
Clubhouse Community Rehabilitation Centre began serving
50 patients with severe mental illness. At the Centre, they
were no longer tagged as “patients” but instead were called
APCMHDP 2011 : TAIWAN
Medical students from Taipei pay a visit to one of the Clubhouse centres as a part of 1-week medical humanity program in YVH.
This Clubhouse centre known as Pu-Shi Xue Yuan, similar to the Euodia Centre, commenced in 2010 and since then has accommodated
16 members of Euodia in its residential program.
To assist members’ integration through increased contact,
it was decided from the outset that Euodia Clubhouse should
remain as the main venue of the Association and all of its
programs. Both Association workers and the members would
use the same space and facilities at Euodia. The shared
use of space encourages relaxed natural opportunities for
contact and friendship, providing all users the time and
space to just “hang out” at the Centre
The first executives of this project were employees of YVH,
occupational therapists and vocational counsellors who for
many years been helping all of the first 50 members secure
and keep employment.
The Euodia Centre offered key YVH staff the chance to
design programs that included not only the principles of
vocational rehabilitation and supported employment, but
new opportunities that could enrich the recreational, art and
spiritual life of the members.
In a typical day, some of the members undertake work place
training at the Centre. This could include cleaning guest
rooms, offices, gardens and exercise ground and preparing
food and beverages for the Centre cafe. Some members have
transitional jobs in hostels, restaurants, and private homes
in the community.
At their leisure, all can participate in clubs of their own
particular interests at the Centre. These include dance club,
flute club, computer club and bicycle club. In addition there
are now three weekly Christian fellowship programs run by
the ministry and volunteers of the Association that address
members’ character and spiritual development.
APCMHDP 2011 : TAIWAN
The common objectives of the centre and the Association are to share love and
hope with the mentally ill, to help them live independently in the community, to get
rid of fear and stigma in the neighbourhood and to enhance community acceptance
and support for the mentally ill.
The Centre also provides training in the skills needed for
independent living in the community, for example culinary
and shopping skills, the use of transport, banking and
personal financial management, symptom management,
and productive leisure time management and building
knowledge of available civic services and social welfare
The common objectives of the centre and the Association
are to share love and hope with the mentally ill, to help them
live independently in the community, to get rid of fear and
stigma in the neighbourhood and to enhance community
acceptance and support for the mentally ill.
All 50 original ‘members’ lived in the campus of YVH, even
though many of them had been employed by the local
businesses for years in Yuli. This year there will be 12 to 16
members moving out of the hospital campus to live in a
group home in the nearby neighbourhood.
Moreover, we tried to reconnect the members and their
families by inviting their families to Yuli for festival activities,
sending thanksgiving cards and their latest photos to their
families. As a result, one of the members, whose family
at first rejected him has now begun to accept him, at first
allowing him to visit and stay for a few days. He has now
moved back permanently with his family since through this
program they have found he can take proper care of himself
and even make an independent living.
With the support of the hospital and the local church,
the partnership between the centre and the Association
has grown stronger with service capacity increasing to 80
members a day since 2007. As community familiarity grows,
local people are appreciating more the remarkable inner
strength of ‘members’ and their ability to give and receive
For example, many of the local community entertain
‘members’ in their own homes. Small groups of three to five
are invited for dinner at Christmas and Easter annually. This
began gradually, with nine families issuing invitations in
2006. In 2009, almost 60 patients enjoyed Christmas dinner
with 16 families. Many of the families have young children
who are now accustomed to having members in their
household. This warm familiarity has resulted in reduced fear
and stigma in the next generation, providing a stark contrast
to what is occurring in other communities in Taiwan.
Although there have been some setbacks over the past four
years, they were speedily resolved and resulted in thorough
reviews of the standard procedures for crisis intervention.
Community support has assisted members to remain
clinically stable. The rate of symptom relapse has decreased
considerably, with 23 members suffering symptom relapse in
2007, 17 in 2008 and 12 in 2009.
Furthermore, 50 members have been employed as full-time
workers by local businesses since 2006, with the help of
the centre. Although they are no longer in need of Centre
support, they still return regularly for fun and fellowship.
In the meantime, the nature of the relationship between the
members and the community has altered. Previously they
were based on work relationships around the exchange of
money and labour. There are now more positive interactions
outside the workplaces. Deeper friendships between
members and local community members have been evolving
FROM PATIENT TO PARTICIPANT
The major change for the project has been a paradigm shift
from vocational focus to holistic humanity development,
following the psychiatric rehabilitation model of YVH. At the
beginning, to help institutionalised patients get resettled
in the community we allocated all available resources of
YVH to vocational rehabilitation. We believed the only
and best way to help patients find their niche in the
community was through job placement. For the past two
decades, vocational rehabilitation was the major focus of
the psychiatric rehabilitation model for YVH. Called the Yuli
Model it achieved major successes in the scale and scope of
vocational rehabilitation programs, measured by increasing
number of patients in programs, salaries earned, and
diversity of jobs on offer in the community.
APCMHDP 2011 : TAIWAN
Left: Clubhouse Centre members
pictured going on a shopping
excursion by bicycle. After
shopping in the traditional
marketplace they would may
go for a picnic at a tourist
spot in the outskirts of Yuli
township. Activities like this
usually take place every other
week. Sometimes they may visit
historical and cultural heritage
sites. Through these kinds of
activities members become
more familiar with Yuli and more
aware of their citizen duties in
Therefore, as we started the Euodia Clubhouse project,
vocational rehabilitation was the central focus for
programming. All recreational, art and spiritual programs
were merely ancillary means to increase the opportunities of
interaction with the community.
However as time passed and programs were scaled
up, from time to time we found subtle changes in the
attitude, manners, behaviours, and even clinical stability
of the members. In general, the group was more clinically
and emotionally stable than when receiving vocational
Peer support became a feature, assisting each other in
many areas of life, including helping one another haggle
prices in the market, trading information of jobs, working
together to organize sightseeing tours or clubs of their own
interests. They also appreciated the support and friendship
from the Association and the loving fellowship of the local
church. Some took on volunteer jobs in the Association to
support young people. Every summer and winter break,
members helped primary school students complete
homework, read stories to them, organized activities and
accompanied children when their parents have to work.
Since 2008 we have changed our emphasis on vocational
rehabilitation to a more balanced and holistic approach.
We have learned the members need not only economic
autonomy but also the opportunity to learn and love.
We helped members enrich club activities and looked for
more community volunteer opportunities, such as free meal
delivery to the old people who live alone, fund-raising for
victims of natural disasters, and sharing their experiences in
community mental health seminars.
Given limited community and human resources, the biggest challenge we are
facing is how best to further enrich and diversify the programs to meet the individual
physical, mental, spiritual needs of the members. Now we have invited local senior
high school student groups, public interest groups and religious groups to join our
APCMHDP 2011 : TAIWAN
A graduate from the prestigious law school of Taiwan
National University and a schizophrenia sufferer for more
than 15 years provided counselling services for young
people who may have trouble with their own mental health.
By sharing her experiences of going through the ups and
downs of the illness and life, she felt self-fulfilled and now
holds a part-time counselling job in the Association. Another
member is an expert Chinese calligraphy painter. She
volunteered to teach Chinese painting in primary school and
helps raise funds by selling her artworks from time to time.
In many ways, the major achievement of this project, we
believe, is to change the members from recipients to givers,
from patients to helpers, far exceeding their own and even
our expectations when we started this project.
Staff retirements and movements as well as changes in the
board and executive director of the Association have not
affected achievements of the programs. The shared vision
and mission remain constant and the partnership becomes
even stronger because both the Centre and the Association
recognize the mutual benefits of helping the mentally ill
out of their miserable situations and at the same time,
strengthening the Christian mission of the local church and
even the whole community.
Given limited community and human resources, the biggest
challenge we are facing is how best to further enrich and
diversify the programs to meet the individual physical,
mental, spiritual needs of the members. Now we have
invited local senior high school student groups, public
interest groups and religious groups to join our rehabilitation
programs. For example: in August 2010 we began
a partnership between Yuli’s senior high school and our Pu
Shi Community Rehabilitation Centre.
It will reflect our stronger recovery and empowerment
strategy that 12 to 16 “members” will move out of hospital
accommodation to a group home in a nearby neighbourhood
to help them live independently in the Yuli community. We
are also training them to become the “seed” organizers
and helpers in the centre. As they become accustomed to
living in the community, we hypothesize, they will be able to
accurately assess what they and their fellow members really
need for independent living and thereby help us design
programs that are more finely tuned to their needs. We aim
to inspire and ignite their passion, hope and creativity to
break through the barriers ahead for them and others in their
THE CARED-FOR BECOME THE CARERS
First of all, a successful partnership is built on shared values,
vision and mission and recognition of mutual benefits
for all stakeholders, in this case to help disadvantaged
people reclaim their dignity as human beings. Secondly, all
stakeholders should be invited to design programs for the
mentally ill: the mental health professionals, community
members, and people with mental illness. All views need to
be taken into account. Thirdly, as many programs as possible
should be incorporated into the regular activities of the
already existing and active community organizations. This
not only creates opportunities for natural contact between
the mentally ill and the local community but also helps
build up social networks for the mentally ill. Finally, while
vocational rehabilitation is a very important starting point to
help the mentally ill resettle in the community, securing a job
is not the end. The goal of recovery is to reverse the patient
role to becoming a supporter for other people in need.
A holistic humanistic approach is required to reach this
goal. To begin this approach, we first need to tear down
the largest obstacle, our own ingrained beliefs and
misconceptions about severe mental illness. We need to
have faith that people with severe mental illness can recover,
be responsible again for their own lives and have the inner
strength and creativity that will allow them to remove the
inevitable obstacles that emerge on the pathway to recovery.
It is only when our own prejudice is removed that people
with severe mental illness can rebuild their dignity as human
beings and lead truly autonomous lives.
APCMHDP 2011 : TAIWAN
THAILAND : PARTICIPATION OF RELIGIOUS ORGANIZATIONS
IN MENTAL HEALTH CARE
In Thailand, temples are usually the first and only place where people who
suffer from physical and or mental ailments go to seek help. In this respect,
they can be the most important source of knowledge and information about
people with mental illness. A partnership between religious organizations
such as Buddhist temples and hospitals provides an opportunity for mental
health promotion as well as gradual recovery in the community, especially for
patients who have no caregivers or other social support system.
Temples remain a rich source of faith, hope and informal care
for villagers who are seeking relief from suffering for themselves
or their family members.
ENGAGING TEMPLES IN MENTAL
In many hospitals and psychiatric institutes throughout
Thailand, there are currently many long stay patients
who suffer from psychiatric illnesses and substance use
disorders. Community re-integration for these people is a
huge challenge. This is due to a diverse range of factors that
include: lack of community acceptance because of ongoing
stigma; long term hospitalization resulting in patients being
institutionalized and fearful of community living; and for
many chronic patients, the unfortunate abandonment by
their own families.
Nevertheless, the idea of re-integrating patients back to
their communities through rehabilitation is a vital step in
the journey towards recovery.
In Thailand, visiting Buddhist temples and more generally
following Buddha’s teachings have been shown to have a
powerful healing effect, shifting people’s thoughts away
from past and present troubles.
A partnership between religious organizations such as
Buddhist temples and hospitals can provide an opportunity
for mental health promotion as well as gradual recovery
in the community, especially for patients who have no
caregivers or other social support system.
Engaging Buddhist temples in the task of helping mentally
ill people return to the community has many advantages. In
particular, they can help individuals develop positive values
about themselves as well as facilitate greater community
acceptance of mentally ill people.
APCMHDP 2011 : THAILAND
Left: A monk conducts a presentation. The teaching and employment
of Buddhist values into mental health work has strengthened all stakeholders
and provided them with new self-reliance.
Even though there are many hospital facilities throughout
the country, the temples remain a rich source of faith,
hope and informal care for villagers who are seeking relief
from suffering for themselves or their family members. In
Thailand, temples are usually the first and only place where
people who suffer from physical and or mental ailments
would seek help. In this respect, they can be the most
important source of knowledge and information about
people with mental illness. Over many decades, monks have
continuously taken on important and complex roles of priest,
teacher and healer simultaneously.
There are a number of temples, which currently provide
psycho-spiritual programs. Some treat and take care
of psychiatric patients with alcohol and substance use
disorders through herbal medicines and teaching and
practising Buddhist values.
With no real bridge existing between mental hospitals and
religious organisations, however, there was no systematic
integration of the work of the religious organisations into
community rehabilitation resources and planning. To address
this issue and to fully realise the potential of involving
religious organisations in mental health promotion and
rehabilitation, The Department of Mental Health in Thailand
initiated a project connecting temple, community and hospital
in a formal program of community mental health care.
BUILDING ON EACH PARTNERS STRENGTHS
The project has two main objectives:
To assist people with mental illness improve their capacity
for self-care and quality of life thus enabling them to
return to their communities;
To build greater acceptance of people with mental illness
in their community.
To achieve these results the Department of Mental Health
established a formal partnership between Buddhist temple
personnel (monks and priests), health personnel (mainly
hospital staff), community leaders (local government
authorities) and health volunteers (local villagers).
While acknowledging the existing and ongoing good works
of the temples using Buddhist values and teachings to
support people with mental illness, evidence based mental
health knowledge was lacking.
To build an effective partnership to support the reintegration
of people with mental illness back into the community, the
monks and priests required the hospital staff to provide
them with evidence-based information about mental
illnesses and appropriate medical treatments. They needed
funding from the local authority and follow-up personnel
at the village level. The roles of the partners were therefore
designated as follows:
Priests and monks (temple) mainly responsible for mental
health prevention, promotion and rehabilitation using
approaches according to Buddhist teachings. They provide
life skills training for the patients to enable them to return to
The Community leaders (local government authority)
provide financial and human resources.
Department of Mental Health and its health partners
(general and district hospitals) deliver integrated mental
and physical health services—servicing patients, coaching
health personnel, prescribing medicines and referring
any complicated cases to experts. This provides religious
organizations, community members and villagers with
greater understanding of mental health problems and
the benefits of community mental health participation in
helping those with mental health problems.
Health volunteers (villagers) back up the project by
forming health volunteer teams to work directly with
people in their villages.
APCMHDP 2011 : THAILAND
With no real bridge existing between mental hospitals and religious organisations
there was no systematic integration of the work of the religious organisations
into community rehabilitation resources and planning. To address this issue, the
Department of Mental Health in Thailand initiated a project connecting temple,
community and hospital in a formal program of community mental health care.
The project required substantial investment in stakeholder
research and consultation before the project began. This
involved the following stages.
Identification of suitable religious organizations that
demonstrated a positive attitude toward patients with
psychiatric and substances use disorders, and who were
also willing to help them through using new knowledge
Researching the community in which the selected temple is
operating. Data on the socio-economic status of the region,
community understandings and the operating status of the
existing hospital and support system are required.
Below Left: Priests and monks are mainly responsible for mental health prevention,
promotion and rehabilitation using approaches reflecting Buddhist
teachings. Right: Visiting Buddhist temples, and more generally following
Buddha’s teachings, have been shown to have a powerful healing effect.
Consultations with all stakeholders to create a shared
vision of how to improve mental health and well-being in
Forming an expert mental health team and systems to
provide support and strengthening. This would allow
priests, health volunteers, and community leaders to work
The success of the project is based on the following three
Regular conferences with priests, local leaders, patients’
relations and local health personnel are scheduled to
discuss current priorities and key issues. The conferences
share ideas and reach consensus on cases and areas of
greatest needs, and decide on best solutions to meet
APCMHDP 2011 : THAILAND
EXAMPLES OF PARTNERSHIPS WITH RELIGIOUS ORGANISATIONS
AN EFFECTIVE APPROACH TO ASSIST PATIENTS
TO ABSTAIN FROM ALCOHOL
For patients suffering from alcoholism and with no social
support to help them stay sober, Jomthong hospital
cooperated with the local temple to establish a support
network. Under the supervision of health personnel and
community heads, Tham-thong temple is now a centre
for treating and rehabilitating alcoholic patients. A strong
management system has been established to cope with
alcoholic related issues; effective evaluation, group
therapy and life skills programs have been introduced.
HOME VISIT PROGRAM TO BACK UP
THE WORK OF THE PRIESTS
Srithanya psychiatric hospital collaborated with four
temples in Nontaburi province (Wat saun kaew, Wat
bang-ra-hong, Wat tha-it, Wat anake dit tha ram) that
have been working with patients with chronic psychosis
for many years. The partners began home visits every
three months for evaluation, support and occupational
training. This helps empower the patients to return to
society and resume normal life, thanks also to assistance
from community support teams and a new understanding
of mental illness among their neighbours and families.
The home visit scheme encourages and strengthens
community acceptance which in the long run potentially
benefits the community through the positive contributions
of the patients as they recover.
BUDDHA’S TEACHINGS ENCOURAGE
In order to better treat patients with chronic mental
illness, Nakornrajsrima psychiatric hospital has actively
integrated the Buddha’s teachings into community mental
health work. The approach is useful in encouraging the
community to accept patients back into the community,
and with kindness and understanding provide suitable
work opportunities to allow the patients to actively
contribute to the community.
COUNTERING THE PSYCHOLOGICAL EFFECTS
OF POLITICAL TURMOIL
Sathira Dhammasathan, a well-known Buddhist
Meditation Centre, started a project called “Crisis
intervention for the Community” to apply mental health
knowledge to the effects of the political crisis in Thailand.
The two opposing camps, the Red Shirts and Yellow Shirts
respectively, rocked the stability of Thailand in 2010. Mass
protests and rallies in April and May of that year left 90
people dead when demonstrators clashed with the army.
Many from both sides of the political divide suffered
discrimination, causing severe trauma. The Department
of Mental Health together with Sathira Dhammasathan,
established a “Basic Crisis Intervention” workshop. The
aim of the workshop was to assist volunteers to utilize
and teach Resilience and Buddhist concepts as tools of
community empowerment and healing.
Adequate budget and other material resources supplied by
the local authority and government to support the project
in a sustainable way.
Developing the mental health workforce through
appropriate training programs designed to transfer
knowledge on psychiatric assessment, drugs and
substances abuse issues, crisis management and
treatment for patients, counselling skills, family
communication and patient visit program.
THE POWER OF FAITH
Our partnership with the Buddhist clergy has had many
often-surprising benefits for improving mental health in
Thailand. The teaching and employment of Buddhist values
into mental health work has strengthened all stakeholders
and provided them with new self-reliance. People who
suffer from mental illness have been given a better
chance of community acceptance and as a result, better
prospects for recovery. Using a shared understanding of
Buddhist values as a way to deal with mental illness has
decreased psychiatric stigma and narrowed the gap between
stakeholders. This has resulted in a reduction of psychiatric
patient admissions and re-admissions into hospital, thus
decreasing the numbers of chronic patients presenting.
We have also simultaneously managed to increase both the
numbers of our mental health network and to extend the
reach of the network into the community.
What we have learnt from these partnerships are:
The Thai people’s deep and pervasive belief in the positive
power of Buddha’s teachings greatly affects the ways Thai
people live their lives. Buddhist principles have enormous
APCMHDP 2011 : THAILAND
potential to assist people to deal humanely and effectively
with both mental and physical illness.
The best starting points therefore to help people reintegrate
back into the community and to engender
community acceptance are the Buddhist priests. The
priests are strongly and sincerely motivated to help people
in need. At the same time community members place great
faith in the power of the priests to help them deal with
deep social and medical problems that include mental
Sharing responsibility for the care of people with mental
illness has had unintended positive consequences. The
stakeholders have formed a brotherhood around caring
for the mentally ill in the community. The community
participation activity in mental health has strengthened
the fabric of the broader community as well as supporting
the patients themselves.
The problem of mental illness is too large for one group
to handle alone and there will probably never be enough
formally trained community mental health professionals to
support the ever-increasing need. Sharing information and
resources between the temple, hospital and community
provide more sustainability in community mental health
Initial data and anecdotal evidence seem to suggest that
the model outlined above successfully reduces the need for
ongoing hospitalization and greater acceptance of mental
health in the community. However if the project is to be
scaled up a more formal evaluation must be conducted.
Key performance indicators and a timeline for expected
outcomes would need to be established with a report
recommending changes to improve actual effectiveness.
To ensure consistency of approach and to facilitate greater
understanding within the community, new simple mental
health protocols and practical training programs need to be
developed centrally for use across Thailand. This will assist
with more rapid up-scaling of the project.
According to the last census 94.6% of Thais are Buddhists.
However Thailand’s southernmost provinces have dominant
Muslim populations. There is also a Christian minority of
around 0.7% of the population, with a small number of
Sikhs and Hindus living mainly in Thailand’s cities. For a
more complete coverage of the population therefore and to
generate the participation of all major religious organizations
in promoting mental health, the program involving Buddhist
priests will need to be adapted for other major religious
faiths and their followers in Thailand.
APCMHDP 2011 : THAILAND
VIETNAM : PARTNERSHIPS FOR MENTAL HEALTH
CARE IN THE COMMUNES
In the early 1970s, Vietnam’s community mental health program was
extremely basic and provided very limited services. Stigma was extremely
high. Public knowledge and awareness of mental illness was characterised by
fear and superstition. Believing that a ghost haunted their mentally ill family
members or an evil spirit possessed them, people visited sorcerers to find
a cure. In 1976 the Vietnamese Government announced the 15/CP decree to
create an integrated mental health health network enabling a united
approach to mental health care.
DEVELOPMENT OF AN INTEGRATED PRIMARY HEALTH CARE SYSTEM
The 20th century was a time of great political and social
change for Vietnam. It was also a time of great change in
world psychiatry. Global mental health experts began to
emphasise deinstitutionalization and focus on community
mental health as the most effective way to treat patients.
People with mental illness needed to be integrated back
into their communities, receive respect and welcomed
back by their families.
The 15/CP decree of 1976 lead to the establishment of a
series of mental hospitals, mental health stations (centres)
and mental health departments in general hospitals
throughout the provinces, with some provinces having both
a hospital and mental health station.
However very many people with mental illness are from
underprivileged backgrounds, and are unable to afford
medications for long-term treatment from these facilities.
Untreated mental illness causes extra financial burden on
the family and society and in some cases a security risk in
The results of a national survey undertaken in 2000–01
estimated that the rate of mental disorders in the population
was 14.9%. In response, a national community mental health
care project (CMHCP) was established by the Vietnamese
government operating at the central, provincial, district and
The main objective of the CMHCP was to integrate mental
health care into primary health care offered at the Commune
Health Care Station.
For the new mental health project to be effective however,
partnerships needed to be built connecting all these levels.
For example all levels relied on the national government
and national psychiatric hospital to develop the national
work plan and provide financing. At the same time the
local governments needed to engage community supports
including district and commune governments, medical
staff in primary health care centres, health care workers
and volunteers to implement the community mental
Three Vietnamese government ministries worked together
to develop the initial project work plan and budgets.
Management boards were created at the national, province
and commune levels, responsible for management and
follow up of the mental health program. Psychiatric hospitals
worked with provincial health centres to adapt Ministry
of Health decisions to their local contexts. This included
cooperating with key community workers to develop work
plans, budgets and human resource management plans to
implement the community mental health program within
To manage the complexity of the partnerships, the National
Psychiatric Hospital No.1 (NPH1) was designated the new
project’s implementing body.
APCMHDP 2011 : VIETNAM
Implementation staff for mental health programs in community, Hai Phong Psychiatric Hospital, Hai Phong province.
Responsibilities included overall project management,
development of national budgets, work plans, medication
and equipment requisitioning and the writing of
implementation guidelines for provinces to implement the
program in their communities. Staff from the NPH1 visited
provincial mental health centres, hospitals and local health
care centres to provide support and training.
In addition the NHP1 was responsible for all training
programs and an annual comprehensive report for the
Ministry of Health using data from a national conference
convened annually to review all project activities.
The most important focus for the project was the Primary
Health Centres (PHC). In each of the 10,750 communes in
Vietnam, there is a PHC. The PHC is the most important first
line in health care in Vietnam. Each PHC has five to seven
staff including a chief doctor, assistant doctors, nurses
and pharmacists, giving a total of about 47,000 health staff
working in the PHCs. The PHC receives referrals primarily from
the family and health volunteers. There is usually one health
care volunteer within each commune who works with the
PHCs to implement technical services, such as examination,
medication allocation, early diseases detection, prevention of
communicable diseases and rehabilitation.
The procedures and activities carried out in this project
within the communes aimed to support:
Training in assessment, provision of basic mental health
knowledge, document recording, and management of
reports at the Primary Health Centres
Screening at the community level and collection of data
from the family and community;
Special investigations by doctors and medical staff where
Treatment, management and follow-ups including the
provision of medications, reviewed at a monthly interval
Rehabilitation for patients by volunteers, family and
community in the context of daily activity
Education and mental health promotion for the wider
To assist in implementing the above listed activities the
following process was followed:
Commune Community Mental Health (CMH) Program
Managing Boards were established
A conference between provincial mental health specialists,
district officers responsible for mental health and
commune CMH program managing board was held to
gain consensus about the action plan, clarify the human
APCMHDP 2011 : VIETNAM
The key to the project’s success was the education of health workers at all levels,
patients and family members and the broader community about mental health.
This included training on the nature of mental illnesses, ways to detect and manage
mental disorders, referral processes and treatment options, family education on
rehabilitation within the home, life skill training and monitoring.
resources available at the health care station and from
village medical co-partners and build a comprehensive
knowledge of local socio-economic factors to determine
the special needs of the local commune.
Training programs were written for supervisors and local
workers to provide basic mental health knowledge, patient
screening methods including interview techniques,
recording systems and management of patient information
A screening process was carried out with the lead
investigator and co-partner visiting the homes of all
families in the commune to gather detailed demographic
data and identifying signs of present and past mental
problems. Direct interviews were held with family members
and others who had knowledge of them. Family members
who required further investigation were referred on to
doctors specializing in mental health. These specialist
investigators visited the identified family member in their
homes for a more thorough examination and diagnosis.
If necessary medication would be supplied monthly and
treatment guidelines given with all records about the
course of the disease updated and held centrally at the
local health care station.
A rehabilitation program included medical co-partners
cooperating with family members to help them to maintain
Training about community mental health for medical
volunteers in communes in Phu Tho province.
the patient’s medication regime, and support them with
living skills and employment options. Every month, medical
co-partners report the condition of patients for whom they
are responsible to the head of the Health Care Station.
A communications strategy was implemented, supplying
leaflets, pamphlets, hoardings, posters and panels to
Health Care Station, medical co-partners and the families
of patients. Seminars for patients and families were
organised as well as broadcasts about mental health
through the communes’ radio channels.
Monitoring and evaluation was undertaken twice a year by
the Provincial Management Board and quarterly through
the District Management Board.
THE NATIONAL CMH PROGRAM STRUCTURE
NATIONAL CMH PROGRAM BOARD
CENTRAL CMH PROGRAM MANAGING BOARD
PROVINCIAL CMH PROGRAM MANAGING BOARD
DISTRICT CMH PROGRAM MANAGING BOARD
COMMUNE’S PEOPLE HEALTH CARE BOARD
APCMHDP 2011 : VIETNAM
CASE STUDY: PRIMARY HEALTH CARERS IN KONTUM PROVINCE
A primary health carer from the PHC in Kontum has
participated in training programs twice a year, for 3–5 days
each time, to learn about disease detection, treatment
options and rehabilitation techniques. His co-worker
from the village health care centre participates in a
one or two-day training program once per year. Training
consists of early detection techniques, use of mental
health information brochures, patient rehabilitation in
the home and family education regarding medication
compliance. This has allowed them to manage 21
patients with schizophrenia within a commune. All are
from ethnic minorities in deep areas of the commune.
Since commencing the program only two patients have
relapsed, five have recovered to live normal lives working
as farmers. There has been no incidence of serious
behaviour. All families are very happy and willingly
cooperate with the PHC treatment regimes (Interview from
staff in PHC center of Dakto district, Kontum province).
The National CMH program was well organised with partners
roles clearly defined, all operating to principles approved by
the MOH. An annual national conference is held each March
to review previous year’s activities and plan for the following
The main challenge for the National Community
Mental Health Program is the lack of appropriate
trained personnel. Staff members are overworked, lack
professional knowledge, technical skills and necessary
equipment and are poorly paid. Overloading meant that
there is less time and opportunity for workers to improve
their skills through exchanges and professional learning
programs. Limited connection with the private sector and
NGOs provided reduced opportunity for shared community
Despite these challenges, the Party, Government, and
Ministry of Health continued to provide ongoing support
for mental health. Strong support was also given by various
public organizations. Most remarkably and encouragingly,
although understaffed, the specialty cadre teams were
enthusiastic and highly responsible in carrying out the
Overall, the management of patients in the community and
mental health promotion, training and community education
have resulted in improved community awareness of mental
illness and greater public security. Access to medication and
improved psychiatric services in the local community, even
for poor patients, has decreased patient illness relapse and
lessened the burden for mental hospitals.
Left: Staff from National Psychiatric Hospital No1 help people in Ha Tinh province after flood disaster.
Right: Short training course about early detection, treatment and management of mental illness in the community
for doctors from communes in the southern province of Binh Duong.
APCMHDP 2011 : VIETNAM
Young staff recruited from hospital volunteers through the Youth Union, to examine and treat people in Primary Health Care Centers.
Good documentation, statistics and reports have ensured
regular and appropriate patient follow-up and improved
UP AND RUNNING
The project is now established in all 63 provinces across
Vietnam. The key activities remain constant and are aimed at
identifying and providing treatment for patients with severe
mental illness in the community; preventing relapses of
mental illness; and reducing the risk of harm to self or others
and chronic disability.
Training programs include patient screening techniques and
collection of data from the family and community, provision
of basic mental health knowledge, recording of patient
progress, and management of reports at PHCs. Patient
referrals to more qualified specialists are made by doctors
and medical staff where appropriate. Management and
follow-up include the provision of medications reviewed at
The knowledge, skills and experience of local staff involved
in the mental health program have risen steadily, as has
the importance of their role in the primary health care
system. While this has been of excellent value to the
local community, their increasing professionalism and
qualifications have accelerated their promotion to higher
positions in other locations or in non-mental health related
areas. This has meant that the project needs to continually
recruit and train new staff.
APCMHDP 2011 : VIETNAM
Participants, with head senior psychiatrists and professionals from provinces and universities,
from a workshop for strengthening the mental health care network in Vietnam.
EDUCATION A KEY TO SUCCESS
The key to the project’s success was the education of health
workers at all levels, patients and family members and the
broader community about mental health. This included
training on the nature of mental illnesses, ways to detect and
manage mental disorders, referral processes and treatment
options, family education on rehabilitation within the home,
life skill training and monitoring.
We learned that if you involve the community and educate
its members appropriately, then mental health care could be
successfully integrated into community primary health care.
Funding is always a problem and there is never enough.
As success occurs with the treatment of schizophrenia and
epilepsy at the community level, there is a tendency to add
more mental health disorders such as depression to the list
of illnesses being treated and managed by the small local
staff. This is counterproductive and further funding needs to
Overall the project is a success. Systematic monitoring
and documentation of treatment at all levels of the service
system, has been established. Training has also been
implemented across all levels and for all stakeholders.
The CMHC project has shown a reduction in admission rates,
relapses of illness and length of stay in hospitals.
APCMHDP 2011 : VIETNAM
SECTION 3 : CONCLUSION AND
In this report on Stage 2 of the Asia-Pacific Community Mental Health
Development Project, a wide range of best-practice initiatives in building community
partnerships have been described. They include linkages between different
government sectors, between government and non-government sectors, between
NGOs and public mental health services, and between community agencies and
families. Such multi-disciplinary, multi-level, multi-sector, and multi-linkage
approaches anchored in the local community are the hallmark of a sustainable
and comprehensive community mental health care system.
Mental health policy and practice in many countries
across the Asia-Pacific now share this approach, aspiring
to develop appropriate mental health services to meet
the complex needs of people experiencing mental illness
as well as the needs of their families and communities.
So we can observe a broad consensus in the region
about the guiding principles and the elements needed
to build effective partnerships for community mental
health care, as outlined in the introductory chapter of
In low and middle income countries, integrating mental
health services into primary health care is a highly
practical and viable way of closing the mental health
treatment gap in settings where there are resource
constraints. Such task-sharing with primary health care
as well as other health providers enables the largest
number of people to access services, at an affordable
cost, and in a way that minimizes stigma. However,
delivery of appropriate training, specialist service
support, strong governance and resources must be
sufficient to ensure this integrated primary mental
health service is sustainable.
Further, the integration of mental health, substance
abuse and other health sectors is essential for
coordinating clinical care as well as promoting the
efficient sharing of resources, technical expertise,
training and education, especially in under-resourced
regions. In addition Collaboration between the public
and private health sectors should begin with recognition
of the valuable role played by each and the mutual
benefit in providing community-based care for people
with mental illness.
Increasingly, focus is being directed to the approach
of recovery within their own communities in the care of
the mentally ill. As demonstrated in several countries,
the recovery-oriented approach must incorporate cultural
sensitivities and meanings in order to be relevant and
useful for patients and families. Such efforts can be
mediated significantly through effective partnerships
such as with arts communities, religious organizations,
traditional healers, and various community groups.
These are often the first contact point for seeking help
by mentally ill persons and their families, because they
are perceived to be more culturally acceptable, more
holistic and more accessible than the limited specialist
mental health services. Targeted partnerships and an
innovative approach can enhance the use of these local
cultural and religious circles in the community to provide
familiar, practical support for many of those with mental
The role of the family in the Asia-Pacific region is
critical in the care of people with mental illness. In
many countries, family members accompany patients
on admission to hospital, providing additional care
and support in poorly staffed units. In the community,
families carry the major burden of care for their family
members, and are often stigmatised themselves.
Although there is increasing emphasis on programs
to support carers there is a need to customize family
support, advocacy and education for each local culture.
Similarly the translation of educational and mental health
promotion materials into local community languages is
vital for increasing access to mental health services and
for promoting emotional well-being.
APCMHDP 2011 : CONCLUSION
Much can be learnt from these best-practice partnership
examples that place greater value on the contribution
and involvement of families and other informal care
providers in order to achieve better outcomes for patients
and their families. Sharing experience in improving
the mental health of children and adolescents through
training and engagement with primary care, schools and
community agencies would further strengthen regional
efforts to prevent and intervene early in youth mental
Further, for a region that is highly prone to natural
disasters, mental health input into disaster management
is critical especially at the local level of community to
cope with the psychosocial impact of devastation and
human loss. Effective disaster preparation and response
can be achieved only if an existing comprehensive
community mental health system has been established
that is grounded on multi-sectoral partnerships in the
FUTURE DIRECTIONS OF THE APCMHDP NETWORK
The wide range of experience and expertise within the APCMHDP network
through the combination of senior government officials, international organisations,
and young leaders gives a strong base for further development. They share a common
vision and goals, motivation to reach shared solutions, and commitment to the
APCMHD Project, reinforced by the recognition that progress is being made
in improving mental health services.
The Asia-Pacific Community Mental Health Development
Project set out to build the capacity of mental
health systems, and to implement policy and services
that contribute to the development and improvement of
community mental health care for people with mental
illness in the Asia-Pacific region. In this regard, the network
has achieved many of the planned activities since Stage 1
of the project. These have included:
The exchange of study visits to best-practice exemplars
in community mental health models between countries
in the Asia-Pacific to share learning.
Regular conferences and meetings for the APCMHDP
network of mental health leaders around community
mental health development projects in the region.
Development of guidelines and publications in bestpractice
community mental health care, treatment and
Establishing a website for the exchange of information
about community mental health care initiatives, and
documenting strengths and challenges that can be
shared across the region.
Apart from the learning derived from best-practice
models in building partnerships for community mental
health, one of the key goals of the project is to build a
supportive network of mental health leadership across
the Asia-Pacific countries whose activities contribute to
improving community mental health for the region. The
network members agreed that a shared vision of the key
action plan and the involvement of multi-sector groups
were critical to the success.
There was consensus that the following priorities would
be important for the network to follow up in the next
Achieve a unified voice and advocacy for a whole-ofgovernment
approach by bringing together all stakeholders
– consumers, professionals, GPs, psychiatrists,
academics, primary and other health disciplines, local
agencies, NGOs, media, and housing, government and
Develop and strengthen capacity in leadership since
effective leadership and management of community
mental health services promote further development
of services across the region.
APCMHDP 2011 : CONCLUSION
Provide, publish and disseminate evidence supported
by service evaluation and research showing that mental
health care provided in the community is cost-effective
and results in better outcomes for consumers, families
Improve mental health awareness across the community
though a coordinated public information, education
and communication strategy, and raise awareness of
the human rights of people with mental illness across
all sectors, within communities and within government
to increase the acceptance and involvement of
communities around mental health issues.
Build strong alliances with consumers, families and
care-givers to advocate better community mental health
services. This may include guidelines for promoting
consumer and family involvement in mental health care
and advocacy for improved services.
To quote Professor Graham Thornicroft of the Institute of
Psychiatry, King’s College London, WHO Collaborating
Centre: “[The APCMHD partnerships]…speak of the interconnectedness
of aspirations and initiatives to strengthen
community mental health care in the Asia-Pacific region. For
this to be truly effective then networks are needed at the
local, national, and international levels, to share learning,
to transfer confidence and hope, to allow common access to
pooled resources, in other words, to manifest the ‘power of
The APCMHDP network brings much strength to the
collaborative effort. The diversity within the Asia Pacific
region of cultures, views and development priorities
provides a wealth of experience and contexts. This,
together with a willingness to listen and understand
differences, and to remain open-minded is a key strength.
The partnerships between participating states and
countries, based on collegiality and mutual trust and
respect, the ability to work as a group and support and
encourage each other, is an essential element. The wide
range of experience and expertise within the APCMHDP
network through the combination of senior government
officials, international organisations, and young leaders
gives a strong base for further development. They share
common vision and goals, motivation to reach shared
solutions, and commitment to the APCMHD Project,
reinforced by the recognition that progress is being
made in improving mental health services.
APCMHDP 2011 : CONCLUSION