Asia-Pacific Community Mental Health Development Project - Summary Report 2011: Partnerships by Asialink

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© 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 5 6

Acknowledgements and Contributors Foreword by Mario Maj Preface by Norman Sartorius

SECTION 1 : OVERVIEW 9 11 17

Introduction Stage 2: Project Aims and Objectives and Outcomes Principles for Building Partnerships in Community Mental Health Care in the Asia-Pacific Region

SECTION 2 : COUNTRY REPORTS

Australia 25 Cambodia 31 China 37 Hong Kong 42 India 48 Indonesia

Japan 57 Korea 61 Laos 64 Malaysia 69 Mongolia 74 Philippines 52

79 85 89 94 99

SECTION 3 : CONCLUSION 106 Concluding Remarks 107 Future Directions of the APCMHDP Network

Singapore Solomon Islands Taiwan Thailand Vietnam

PROJECT MANAGEMENT AND ACKNOWLEDGMENTS EDITORIAL BOARD

MANAGEMENT AND EDITORIAL TEAM

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

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: t t t t t t t

ADVISORS t t

t t

APCMHDP 2011 : ACKNOWLEDGMENTS

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 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

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, ShuKeung 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. LAOS Editor: Manivone Thikeo, WHO Mental Health Consultant for Laos, World Health Organization. Sub-Editor: Sing Menorath.

APCMHDP 2011 : AUTHORS AND CONTRIBUTORS

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.

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

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

APCMHDP 2011 : PREFACE

SECTION 1 : OVERVIEW

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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.

APCMHDP 2011 : OVERVIEW

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. —

Participants at the Asia-Pacific Community Mental Health Workshop, August 2009

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 t To collect and publish a wide range of exemplars that describe successful partnerships in community mental health service delivery in the region; t To distil from the exemplars a list of key principles that partners can apply in building of mental health services in the community; t To provide a set of practical evidence-based advice to guide the use of existing resources in the community for mental health care; t 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 countryâ&#x20AC;&#x2122;s approach to adapting appropriate international policies to local situations; 3 Examples of best practice models of community-based services or care which include: t specific local and culturally adapted community services or community care model; t interaction with primary care and traditional healthcare; t role of families, NGOâ&#x20AC;&#x2122;s and community agencies; t successes or inspirations, and difficulties or gaps; t strategies to overcome gaps; 4 Implications of lessons learnt from the findings for countries in Asia Pacific; and 5 The APCMHD network vision for the long term goals in community care.

APCMHDP 2011 : OVERVIEW

Stage 2 of the APCMHDP was launched in August 2009 in Melbourne, where 48 high level delegates from 16 AsiaPacific 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.

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.

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.

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.

APCMHDP 2011 : OVERVIEW

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

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.

APCMHDP 2011 : OVERVIEW

A critical success factor has been the APCMHD network annual conference and regional meetings. These provide a mechanism for: t engaging regional health bureaucrats, mental health leaders and stakeholders; t showcasing best practice models from across the region; t building trust between nations for further co-operation in mental health; t 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.

Top: Discussions at the Asia-Pacific Community Mental Health Workshop, August 2009. Above: Assembled participants from the workshop.

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.

APCMHDP 2011 : OVERVIEW

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. —

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, NGOâ&#x20AC;&#x2122;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.

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.

SECTION 1: OVERVIEW

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

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. —

SECTION 1: OVERVIEW

SECTION 2 : COUNTRY REPORTS AND BEST PRACTICE EXAMPLES OF PARTNERSHIP

Top: Teacher, student and adult at a KidsMatter Primary school. Above: Grandparent, student and parent in a school vegetable garden, a KidsMatter project.

APCMHDP 2011 : AUST R A LI A

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 Australiaâ&#x20AC;&#x2122;s KidsMatter suite of initiatives which includes KidsMatter Primary that uses schools as a key platform for prevention and early intervention in the community.

KIDSMATTER: PRIMARY SCHOOL-BASED MENTAL HEALTH PROGRAM The KidsMatter suite of promotion, prevention and early intervention initiatives aims to improve the mental health and wellbeing of children, reduce mental health problems amongst children and achieve greater support for children experiencing mental health difficulties and their families.

APCMHDP 2011 : AUST R A LI A

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,

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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

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.

t Component 1 – A positive school community t Component 2 – Social and emotional learning for students t Component 3 – Parenting support and education t Component 4 – Early intervention for students experiencing mental health problems

KIDSMATTER PRIMARY

KidsMatter Primary requires a planned and coordinated approach throughout the school, involving all staff and engaging parents, carers and the school community.

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:

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: t improved student mental health and well-being such as optimism and coping skills; t reduced mental health difficulties such as emotional symptoms, hyperactivity, conduct and peer problems, particularly for students experiencing higher difficulties at baseline;

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t improvements in students’ school-work; t improved teacher capacity to identify students experiencing mental health difficulties; t improved teacher knowledge on how to improve students’ social and emotional skills; t increased parent capacity to help children with social and emotional issues; t facilitated placement of mental health as an issue on the schools’ agenda; and t 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: t The Australian Psychological Society, representing the mental health sector; t beyondblue: the national depression initiative, representing the mental health sector; t Early Childhood Australia, representing the early childhood sector; t Principals Australia, representing the education sector; t 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.

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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: t School leadership is committed to take a whole school approach to implementing the KidsMatter framework in a planned way; t An Action Team is established, enabled and supported to lead and drive implementation; and t 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. —

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 injecting 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%

Farmers/labourers

37.8%

Male

93.5%

18–25 years old

59.6%

Street children

16.8%

Female

6.5%

Over 25 years old

23.5%

Students

15.4%

Unemployed

14.0%

Other

16.0%

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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.

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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: t to establish treatment services for vulnerable people suffering from mental illnesses and substance use; t to integrate substance abuse treatment into the general health care system; t to prevent HIV transmission through the application of a Harm Reduction strategy; t to mobilise resources to support development of the mental health sector; t to demonstrate the efficacy of community-based treatment for drug dependence. t 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.

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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.

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:

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t To retain approval and support from top decision-makers to formalise and extend the work of the partnership t To build public understanding of mental health and substance abuse issues in Cambodia t To overcome shortages of support, advocacy and workforce in the mental health and substance abuse sectors t To solve coordination problems and institutional conflicts which often arise in multi-sectoral collaborations t 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.

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.

health system, especially into mental health services, would represent a major achievement.

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 2011â&#x20AC;&#x201C;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

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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. â&#x20AC;&#x201D;

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”.

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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.

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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

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.

THE 686 PROGRAM — A PATIENT-CENTERED APPROACH

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

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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.

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.

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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.

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 34

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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’.

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.

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.

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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. —

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.

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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 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).

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.

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.

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.

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 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”.

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

NTE

NTW

270

104

159

605

633

320

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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 Kongâ&#x20AC;&#x2122;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 Kongâ&#x20AC;&#x2122;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.

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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.

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.

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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

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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.

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 patientsâ&#x20AC;&#x2122; 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 Governmentâ&#x20AC;&#x2122;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.

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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. â&#x20AC;&#x201D;

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 6â&#x20AC;&#x201C;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.

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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,

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 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.

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:

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.

t Patients and their relatives no longer have to travel long distances to hospitals or nursing homes in the cities. t Pressure is reduced on overburdened mental hospitals. t The stigma attached to mental illness is reduced through public education to change attitudes. t Patients are discharged from mental hospitals, and treated and rehabilitated within the community.

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.

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.

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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PARTNERS AND THEIR ROLES

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: t medical officers, in psychiatry and programme implementation t psychologists and psychiatric social workers, in clinical psychology and psychiatric social work respectively t nurses, in psychiatric nursing t district-based psychiatrists, clinical psychologists, psychiatric social workers and psychiatric nurses, to expand and update their existing skills and knowledge.

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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.

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.

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.

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 This changed two years back when the DMHP was launched children coming to the NGO. The social worker liaised with the district education officer. Nine months after the start of in his district. Regular camps were held for identification his treatment Ramesh was back at his old job. of mental disorders in the community. Local health staff were trained to identify and treat mental disorders Ramesh’s complete turn-around had a great impact on under the supervision of the district mental health team. the attitudes of the local community. They now believe Psychotropic drugs became available. Information teams that mental disorders are treatable. Ramesh continues went around the district holding mental health ‘camps’ on medication and is a volunteer with the program. He to raise grassroots awareness about how to recognize actively participates in the health camps organized under mental disorders and how they could be treated. When a the program and helps spread mental health literacy in the health camp was held in Ramesh’s village, local people 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.

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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.

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.

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

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 ...”

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

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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.

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 programâ&#x20AC;&#x2122;s introduction. Clear and detailed guidelines (including the spelling out of roles and responsibilities), regular monitoring, and communication are essential.

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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. â&#x20AC;&#x201D;

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.

APCMHDP 2011 : I N D O NE S I A

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.

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.

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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.

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 patientsâ&#x20AC;&#x2122; individual strengths and skills. These activities contribute to the empowerment of patients and families.

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.

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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.

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 GPâ&#x20AC;&#x2122;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.

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THE POWER OF INSPIRATION Tebetâ&#x20AC;&#x2122;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. â&#x20AC;&#x201D;

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.

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The Kawasaki City Mental Health and Welfare Centre, established in 2002 in the southern part of the city is responsible for planning Kawasakiâ&#x20AC;&#x2122;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.

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 artistâ&#x20AC;&#x2122;s great joy, and also her profound sadness. Michikoâ&#x20AC;&#x2122;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

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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.

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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.

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

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? t 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. t Second, flexibility is the key in arranging resources in appropriate locations. t Third, the plan must be based on and follow sound administrative frameworks and processes that are communicated to all key stakeholders. t 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. t The first stage was to treat people with mental illness adequately in psychiatric facilities and to provide them with relief and stability. t The second was to provide them with high quality mental health care in the community. t 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.

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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.

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 Japanâ&#x20AC;&#x2122;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. â&#x20AC;&#x201D;

A P C M H D P 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.

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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.

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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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.

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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

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:

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.

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t People with mental illness should not be just defined by their illness. They can also be accomplished artists and actors. t Just because some-one has a mental illness, it does not mean that he or she does not have to live without hope. t 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: â&#x20AC;&#x153;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.â&#x20AC;? â&#x20AC;&#x201D;

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

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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: t To draw together all mental health stakeholders and service providers in Laos in regular meetings; t To exchange knowledge, working experience, and share resources; t To collaborate in building mental health capacity in Laos; t To provide support and consultation to mental health providers to improving practice and service delivery to people in need; t 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.

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 partnershipâ&#x20AC;&#x2122;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.

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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 SubMekong 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.

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

A P C M H D P 2011 : LAOS

t Arranging time to socialize and having a regular meeting place seemed to work best for our members. t Providing leadership and interpersonal skill training, and working with those with partnership experience also helped reduce conflict and improve leadership skills. t 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. t 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. t 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. t Lack of clear rules, roles, mission, vision, goals and strategies for the partnership will create confusion and derail any plan of action. t Clear guidelines for each partner’s contribution will provide direction. t 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. t Financial support for regular meetings motivates member to work effective together. t Frequent face-to-face meetings improve the partnership and lessen misunderstandings. —

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

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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-

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.

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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: t t t t t t t

t t t t

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.

Left: Yong Ni San, Medicines, 2000, colour pencils on paper 29.7 x 21 cm. â&#x20AC;&#x153;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.â&#x20AC;?

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.

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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.

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.

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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 Mueserâ&#x20AC;&#x2122;s Illness Management and Recovery programme in the United States. Selangor started this program in December 2007, with 10â&#x20AC;&#x201C;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.

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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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.

Above: Extreme snow cover resulting from the dzud.

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%.

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.

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.

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.

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.

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 Mongoliaâ&#x20AC;&#x2122;s Public Health Institute and the Department of Mental Health at the Health Sciences University of Mongolia.

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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.

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.

A GUIDING LIGHT

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 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 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 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 trainerâ&#x20AC;&#x2122;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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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.

TABLE 1: NUMBER OF PEOPLE COUNSELLED IN THE 12 PROVINCES INDIVIDUAL COUNSELLING

GROUP COUNSELLING

PREVENTATIVE EXAMINATION

Arkhangai

148

Bayankhongor

101

109

Bayan–Ulgii

147

PARTNERS IN COMMUNITY MENTAL HEALTH

Govi-Altai

118

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.

Dundgovi

155

Umnugovi

106

Uvurkhangai

102

Zavkhan

117

Khuvsgul

260

Khovd

378

255

Uvs

120

106

Tuv

Total

357

1190

1635

The scope of the project encompasses the following: t Developing an assessment method using IASC, and WHO guidelines to evaluate the psycho-social needs of those affected by the dzud. t Training local team members in applying the assessment method. t Running the assessments in dzud-affected areas. t Preparing pamphlets for affected people on topics such as stress management, depression, anxiety, alcohol and disasters. t Organizing focus groups of herdsmen living close to the city. t 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 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

TUV

UVS

KHOVD

KHUVSGUL

ZAVKHAN

UVURKHANGAI

UMNUGOVI

DUNDGOVI

GOVI-ALTAI

BAYAN–ULGII

710

BAYANKHONGOR

ARKHANGAI

exercises on stress management, breathing exercises, role plays and hypothetical cases. t 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, NGOâ&#x20AC;&#x2122;s and NEMA officials). A total of 444 personnel received training. t Carrying out clinical examinations of dzud-affected people, to assess their mental state, followed by individual or group counseling if required. t 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.

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.

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.

Survivors greatly appreciated the psycho-social support activities conducted through the project, including the medical preventive checkups, psychiatristâ&#x20AC;&#x2122;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.

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.

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 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.

A family assessment was conducted. Once it was clear that this person was experiencing serious symptoms, he

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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: t 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. t 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 t 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 t 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 t Dead livestock carcasses need to be disposed of completely and in a timely manner to prevent the spread of animal born diseases. t 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. t 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. t 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. t 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.

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Above: A.O., b.1985, Wolf, hand-knitted beads. The artist suffers a mental illness and has resided in a hospital since his adolescence.

t 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. â&#x20AC;&#x201D;

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. 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 â&#x20AC;&#x153;extension mental hospitalsâ&#x20AC;? 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.

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.

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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).

Authorized Bed Capacity

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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: t 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.

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t 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. t 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. t 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. t 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.

It is vitally important to develop the communitiesâ&#x20AC;&#x2122; 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.

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 DFCâ&#x20AC;&#x2122;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.

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.

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

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.

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.

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 communitiesâ&#x20AC;&#x2122; 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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base 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. â&#x20AC;&#x201D;

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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,

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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.

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 Singaporeâ&#x20AC;&#x2122;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 Childrenâ&#x20AC;&#x2122;s Society. A network of family doctors (general practitioners) and four NGOs or voluntary welfare organisations) also work with young people and their families.

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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: t Improve the mental health of children in the community, with the school as the focus t Provide early intervention through the support and training of school counsellors, social service agencies and voluntary welfare organisations in managing at-risk children t 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

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 Healthâ&#x20AC;&#x2122;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: t 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. t 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. t 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. t 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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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

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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.

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 (Clinical Global Impression Scale)

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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.

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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

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. —

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REFERENCES t 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. t 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). t Ministry of Law 2010. “Singapore Statutes Online.” http://statutes. agc.gov.sg/non_version/cgi-bin/cgi_retrieve.pl?actno=REVED51&doctitle=COMPULSORY%20EDUCATION%20ACT <http://statutes. agc.gov.sg/non_version/cgi-bin/cgi_retrieve.pl?actno=REVED51&amp;doctitle=COMPULSORY%20EDUCATION%20ACT> (accessed September 11, 2010) t 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. t Singapore Department of Statistics. 2008. Yearbook of Statistics Singapore. Singapore: Ministry of Trade and Industry. t Singapore Police Force. 2010. “Crime Situation 2009.” http://www.spf. gov.sg/stats/stats2009_intro.htm (accessed April 18, 2010). t 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 t 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). t 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.

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

SENT HOME AND ‘FORGOTTEN’

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.

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.

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.

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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: t To offer innovative services that promote recovery t To provide a friendly, supportive, therapeutic environment, encouraging and building on the potential and strengths of the individual t To create opportunities to restore and retain motivation and social inclusion

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.

t To ensure patients privacy, dignity, respect and upholding of their rights. t 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. 86

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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.

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 clientâ&#x20AC;&#x2122;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 Settlement on a reef island off Malaita, Solomon Islands.

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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.

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.

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. 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

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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. —

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.

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.

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.

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.

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.

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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”.

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

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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.

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

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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.

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.

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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. —

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. 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 Buddhaâ&#x20AC;&#x2122;s teachings have been shown to have a powerful healing effect, shifting peopleâ&#x20AC;&#x2122;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.

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.

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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.

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: t To assist people with mental illness improve their capacity for self-care and quality of life thus enabling them to return to their communities; t 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.

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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. t The Community leaders (local government authority) provide financial and human resources. t Department of Mental Health and its health partners (general and district hospitals) deliver integrated mental and physical health servicesâ&#x20AC;&#x201D;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. t Health volunteers (villagers) back up the project by forming health volunteer teams to work directly with people in their villages.

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. t 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. t 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 Buddhaâ&#x20AC;&#x2122;s teachings, have been shown to have a powerful healing effect.

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t Consultations with all stakeholders to create a shared vision of how to improve mental health and well-being in their community. t 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. t Regular conferences with priests, local leaders, patientsâ&#x20AC;&#x2122; 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.

EXAMPLES OF PARTNERSHIPS WITH RELIGIOUS ORGANISATIONS AN EFFECTIVE APPROACH TO ASSIST PATIENTS TO ABSTAIN FROM ALCOHOL

BUDDHA’S TEACHINGS ENCOURAGE COMMUNITY ACCEPTANCE

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.

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.

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.

t Adequate budget and other material resources supplied by the local authority and government to support the project in a sustainable way. t 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

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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.

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: t 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

potential to assist people to deal humanely and effectively with both mental and physical illness. t 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. t 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. t 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 Thailandâ&#x20AC;&#x2122;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 Thailandâ&#x20AC;&#x2122;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. â&#x20AC;&#x201D;

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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.

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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.

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.

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The procedures and activities carried out in this project within the communes aimed to support: t Training in assessment, provision of basic mental health knowledge, document recording, and management of reports at the Primary Health Centres t Screening at the community level and collection of data from the family and community; t Special investigations by doctors and medical staff where appropriate t Treatment, management and follow-ups including the provision of medications, reviewed at a monthly interval t Rehabilitation for patients by volunteers, family and community in the context of daily activity t Education and mental health promotion for the wider community To assist in implementing the above listed activities the following process was followed: t Commune Community Mental Health (CMH) Program Managing Boards were established t 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

The key to the projectâ&#x20AC;&#x2122;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. t 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 t 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. t 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 patientâ&#x20AC;&#x2122;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. t 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 communesâ&#x20AC;&#x2122; radio channels. t 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

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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 3â&#x20AC;&#x201C;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 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 yearâ&#x20AC;&#x2122;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.

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). 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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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 103

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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.

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 projectâ&#x20AC;&#x2122;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.

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.

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.

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. â&#x20AC;&#x201D;

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SECTION 3 : CONCLUSION AND FUTURE DIRECTIONS

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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.

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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.

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. â&#x20AC;&#x201D;

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: t The exchange of study visits to best-practice exemplars in community mental health models between countries in the Asia-Pacific to share learning. t Regular conferences and meetings for the APCMHDP network of mental health leaders around community mental health development projects in the region. t Development of guidelines and publications in bestpractice community mental health care, treatment and service models. t 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.

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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: t Achieve a unified voice and advocacy for a whole-ofgovernment approach by bringing together all stakeholders â&#x20AC;&#x201C; consumers, professionals, GPs, psychiatrists, academics, primary and other health disciplines, local agencies, NGOs, media, and housing, government and corporate sectors. t Develop and strengthen capacity in leadership since effective leadership and management of community mental health services promote further development of services across the region.

t 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. t 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. t 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. 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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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’.” —