SUMMARY REPORT 3$571(56+,36 - World Psychiatric Association

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SUMMARY REPORT 3$571(56+,36 - World Psychiatric Association

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

ASIA-PACIFIC COMMUNITY

MENTAL HEALTH DEVELOPMENT PROJECT

PARTNERSHIPS

2 Acknowledgements and Contributors

5 Foreword by Mario Maj

6 Preface by Norman Sartorius

SECTION 1 : OVERVIEW

9 Introduction

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

20 Australia

25 Cambodia

31 China

37 Hong Kong

42 India

48 Indonesia

52 Japan

57 Korea

61 Laos

64 Malaysia

69 Mongolia

74 Philippines

79 Singapore

85 Solomon Islands

89 Taiwan

94 Thailand

99 Vietnam

SECTION 3 : CONCLUSION

106 Concluding Remarks

107 Future Directions of the APCMHDP Network

1


PROJECT MANAGEMENT AND ACKNOWLEDGMENTS

EDITORIAL BOARD

Chee Ng

Julia Fraser

Margaret Goding

Sophal Chhit

L. Erdenebayar

Daniel S.S. Fung

Georgie Harman

Se-fong Hung

Irmansyah

Masato Itou

R.K. Srivastava

Young Moon Lee

Chih-Yuan Lin

Hong Ma

Apichai Mongkol

Phong Thai Than

William Same

Suarn Singh

Manivone Thikeo

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)

ACKNOWLEDGEMENTS

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

Janssen-Cilag

Royal Australian and New Zealand College of Psychiatrists

World Psychiatric Association

World Health Organization

ADVISORS

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

2

APCMHDP 2011 : ACKNOWLEDGMENTS


AUTHORS AND CONTRIBUTORS

AUSTRALIA

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.

CAMBODIA

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.

CHINA

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.

HONG KONG

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.

INDIA

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.

INDONESIA

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,

Hervita Diatri.

JAPAN

Editor: Masato Ito, Director, Kawasaki City Mental Health and

Welfare Center, Japan. Sub-Editors: Toshimasa Hagiwara, Yutaro

Setoya, Ryosuke Arakawa, Tadashi Takeshima.

KOREA

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.

MALAYSIA

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

Su Ming.

MONGOLIA

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 ,

G.Tsetsegdary.

PHILIPPINES

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.

SOLOMON ISLANDS

William Same, Director, Mental Health Services, Ministry of

Health, Solomon Islands.

SINGAPORE

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.

TAIWAN

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.

THAILAND

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.

VIETNAM

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.

LAOS

Editor: Manivone Thikeo, WHO Mental Health Consultant for

Laos, World Health Organization. Sub-Editor: Sing Menorath.

3

APCMHDP 2011 : AUTHORS AND CONTRIBUTORS


FOREWORD

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.

Mario Maj

President, World Psychiatric Association

5

APCMHDP 2011 : FOREWORD


PREFACE

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.

Norman Sartorius

President, International Association

for the Promotion of Mental Health Programmes, Geneva

6

APCMHDP 2011 : PREFACE


7

SECTION 1 : OVERVIEW


PARTICIPATING

COUNTRIES

ASIA-PACIFIC

COMMUNITY

MENTAL HEALTH

DEVELOPMENT

PROJECT

8


INTRODUCTION

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

Thailand.

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

community networks.


9

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

healthcare;

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.

11

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

12

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

region;

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

international community.

13

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

government.


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

SERVICE SYSTEM

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

similar goals.

16

SECTION 1: OVERVIEW


3. MUTUAL RESPECT BETWEEN PARTNERS

AND APPRECIATION OF DIFFERENCES IS

REQUIRED

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

adequately.

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

17

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

PARTNERSHIPS

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

become available.


18

SECTION 1: OVERVIEW


19

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.

20

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

and delivery.

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

significant issue.

FOCUS ON CHILDREN FOR LONG-TERM

BENEFITS

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.

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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

22

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

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

warranted.

KidsMatter Primary was piloted from 2007 to 2008 in 101

schools in metropolitan, rural and remote locations in

government, Catholic and independent education systems

around Australia.

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

at baseline;

23

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

emotional issues;

facilitated placement of mental health as an issue on the

schools’ agenda; and

a common language to address mental health and wellbeing

issues.

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.

PARTNERSHIPS

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

represent are:

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

sector;

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.

FUTURE CONSIDERATIONS

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

this work:

School leadership is committed to take a whole school

approach to implementing the KidsMatter framework in a

planned way;

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.


24

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

been lacking.

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%

Farmers/labourers 37.8%

Street children 16.8%

Students 15.4%

Unemployed 14.0%

Other 16.0%

Male 93.5%

Female 6.5%

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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.

26

APCMHDP 2011 : CAMBODIA


METHADONE MAINTENANCE THERAPY

PROGRAM

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

prevention’.

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

development.

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.

27

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

Government.

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

the partnership

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

health services.

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.

28

APCMHDP 2011 : CAMBODIA


CASE STUDY

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

THIS PARTNERSHIP

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

health programs.

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.


29

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”.

30

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

process.

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

31

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

APPROACH

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

and multi-disciplinary.

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

associated faculty.

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

program meetings.

32

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

painting table.

33

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.

34

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

Chinese context.

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

partnership.

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

mental illness.


35

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

of accomplishment”.

Leung completed the training

in the Day Hospital and now

works under the Supported

Employment program.

Artwork reproduced

courtesy of the Occupational

Therapy Department,

Shatin Hospital.

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

phenomenon”.

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

37

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

promote recovery.

INTERVENTIONS FOR FREQUENT

RE-ADMITTERS

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.

38

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

discharge plans.

EXTERNAL PARTNERSHIPS

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.

39

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)

after recruitment.

(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

greater gains.

CASE STUDY

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.

40

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.

REFLECTIONS

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

the population.

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

factors.

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

community.

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

care service.

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,

42

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

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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

implementation

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

knowledge.

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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

community.

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.

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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

46

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

structures.

Finally there must be high level commitment to initiate and

provide ongoing funding and support.


KEY LEARNINGS

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

hospitals.

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

communities.

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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

were facing.

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

NGO’s.

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.

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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

networking.

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

SUSTAINABILITY

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.

50

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

others.

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.


51

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

system.

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

every month.

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.

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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

mental hospitals.

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

health services.

As a result of three major policies (the Kawasaki City Plan

for Community-based Rehabilitation [2000], The Kawasaki

City New Normalization Plan [2004] and the Kawasaki City

Welfare Plan for people with Disabilities [2006]), 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.

53

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

for improvement.

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.

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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

appropriate locations.

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

attitudes.

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.

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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

entire province.

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.

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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

provide sponsorship.

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

culture.

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

theme.

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

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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

program.

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

health issues.

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

actors.

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

and joy.”


60

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 BEGINNING

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

neglected”.

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

in particular.

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

program are:

To draw together all mental health stakeholders and

service providers in Laos in regular meetings;

To exchange knowledge, working experience, and share

resources;

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.

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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

health activities.

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.

SETTLING DOWN

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

neighbouring countries.

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.

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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

strengthen motivation.

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

provide direction.

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.


63

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

services.

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

24 hours.

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-

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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:

Emotional support

Comparing experiences and decreasing negative emotions

Forming friendships and re-establishing networks

Decreasing isolation

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

Advocacy

Education – psycho-education and family education

Adjunct to treatment and focusing on patients’ outcomes

Family education with a focus on improving family

outcomes

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

countries.

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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,

relentless cycle.

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

psychiatric hospitals.

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

Societies Act.

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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.

DEEPENING CONTACT

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.

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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

community participation.

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.


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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

heavy snow.

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

affected provinces.

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.

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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.

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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

outcomes.

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

method.

Running the assessments in dzud-affected areas.

Preparing pamphlets for affected people on topics

such as stress management, depression, anxiety, alcohol

and disasters.

Organizing focus groups of herdsmen living close to

the city.

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

30

PUBLIC HEALTH SPECIALIST BAG’S DOCTOR SOUM’S DOCTOR OTHER

25

20

15

10

5

710

ARKHANGAI

BAYANKHONGOR

BAYAN–ULGII

GOVI-ALTAI

DUNDGOVI

UMNUGOVI

UVURKHANGAI

ZAVKHAN

KHUVSGUL

KHOVD

UVS

TUV


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.

CASE STUDY

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

daily activities.

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.

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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

and stigma

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

treatment.

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

support.

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

Management team.

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.


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APCMHDP 2011 : MONGOLIA


PHILIPPINES : THE DISCHARGE AND FOLLOW-UP

CONSULTATION PROGRAM

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

the fullest.

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

their community.

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).

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APCMHDP 2011 : PHILIPPINES


9,000

8,000

7,000

6,000

5,000

4,000

3,000

2,000

1,000

Authorized Bed Capacity

Average Number of In-Patients per day

1928

1931

1934

1937

1940

1943

1946

1949

1952

1955

1958

1961

1964

1967

1970

1973

1976

1979

1982

1985

1988

1991

1994

1997

2000

2003

2006

2009

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

out-patient services.

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

resided.

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.

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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.

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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

neighbours.

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

each partner.

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

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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

allocations.

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.


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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

violence.

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.

HELPING HANDS

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

children

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

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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

psychiatric crises.

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

service agencies.

Left: Anger Management group rules on school noticeboard. Right: Personalised speedometer drawn by a 9 year-old student who suffers from ADHD.

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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

partners.

OUTCOMES

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

specialised treatment.

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

manage it.”

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

behaviour.

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.

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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)

4.00

3.50

3.00

2.50

2.00

1.50

1.00

0.50

3.10

2.99

2.40 2.35

3.41

2.54

0.00

FINANCIAL YEAR 2007–08 2008–09 2009–10

CHALLENGES

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.

LESSONS LEARNED

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

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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

reporting system.

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.

REFERENCES

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.

agc.gov.sg/non_version/cgi-bin/cgi_retrieve.plactno=REVED-

51&doctitle=COMPULSORY%20EDUCATION%20ACT (accessed

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

Guadalcanal.

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

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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

practice.

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.

TENUOUS CONTACT

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

homes.

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.

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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

also required.

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

the officers.

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.


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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

“members”.

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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.

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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

resources.

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

genuine friendship.

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

gradually.

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.

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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

the neighborhood.

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

rehabilitation alone.

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

rehabilitation programs.

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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

recovery journeys.

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.


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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

HEALTH WORK

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.

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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.

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.

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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.

REACHING UNDERSTANDING

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

and contacts.

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

their community.

Forming an expert mental health team and systems to

provide support and strengthening. This would allow

priests, health volunteers, and community leaders to work

together cooperatively.

The success of the project is based on the following three

factors.

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

these needs.

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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

COMMUNITY ACCEPTANCE

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

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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

health issues.

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

work.

FUTURE DEVELOPMENTS

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.


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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 community.

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

commune levels.

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

health program.

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

their area.

To manage the complexity of the partnerships, the National

Psychiatric Hospital No.1 (NPH1) was designated the new

project’s implementing body.

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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

appropriate

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

community

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

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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




Hospital


DISTRICT CMH PROGRAM MANAGING BOARD




COMMUNE’S PEOPLE HEALTH CARE BOARD




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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

twelve months.

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

activities.

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

program activities.

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.

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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

public security.

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

monthly intervals.

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.

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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

be allocated.

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.


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APCMHDP 2011 : VIETNAM


105

SECTION 3 : CONCLUSION AND

FUTURE DIRECTIONS


CONCLUDING REMARKS

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

this publication.

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

health problems.

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.

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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

health problems.

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

community.


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

service models.

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

stages:

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

corporate sectors.

Develop and strengthen capacity in leadership since

effective leadership and management of community

mental health services promote further development

of services across the region.

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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

and society.

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

partnering’.”


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.

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APCMHDP 2011 : CONCLUSION

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