Tearing down barriers

Institute of Mental Health chief executive Chua Hong Choon wants his patients to break down walls, in a manner of speaking, to engage more fully with life. He tells Susan Long how.

The Straits Times, 30 Aug 2013

IN THE main wing of the Institute of Mental Health (IMH) at Buangkok View is a little heritage garden. It has a display of rusting padlocks, metal grille doors and barred windows secured onto concrete slabs.

They are relics of the institute's past when it was set up in 1928 as an asylum to provide custodial care for the mentally ill.

They bear grim testament to a time when mental illness was thought to be incurable and the best recourse was to house the afflicted in a safe place where they would receive "humane" care.

Whenever IMH's Associate Professor Chua Hong Choon passes this little walk down memory lane, he visibly recoils. For the 48-year-old psychiatrist who joined IMH in 1993 - the year it changed its name from Woodbridge Hospital - and has spent his entire career there, it is all about breaking down walls.

On the 85th anniversary of IMH, he feels that it has come a long way from being known as the xiao keng (mad house in Hokkien) of yore. But it has a longer way to go to shed the stigma and exclusion associated with it.

Since he took on the chief executive job two years ago, he has got rid of the perspex panels at its outpatient clinic service counters, where patients once had to communicate with staff through a small hole. They are now completely open, to "reduce the institutionalised feel".

IMH will soon have a new dementia wing, laid out like an open-concept home with little nooks and colourful furniture, looking out at a garden of lantana and lilies. The gentlest of slopes leads down a circular path to a wooden pavilion.

Some might worry about elderly patients falling down on the slope. But the CEO prefers to mitigate dangers where possible, but press forth anyway, to let patients enjoy strolls and fresh air.

The specialist clinic reception, which sees 500 outpatients daily, used to be encased in concrete. Now it is clad in see-through glass, where life-size cut-outs of mental patients, who were persuaded to talk about their illness, are hung up.

Although the stigma is less now, rejection still awaits many of the 35,000 patients on its registry upon discharge.

After they arrive home, their family members sometimes get their MPs to write a letter, asking why the hospital discharged them so soon. "Imagine how you would feel if you got home from hospital after surgery and people say: 'Why did you come home so early? Who's going to look after you?' " he says.

Often, patients go home to "mini asylums". Even as he tears down walls within IMH, many more are built without. Many are put on Medifund and relegated to community homes or mollycoddled at home by their families, exempt from all responsibilities and expectations. "You can exclude someone with the best of intentions but it's still exclusion."

It is like a remaking of the old concept of mental illness, he says, where people with mental illness are seen as "very unfortunate, but since we don't blame them for it and there's nothing we can do, we will put them in a special place where no harm can come to them and exclude them from participating in work".

"So we don't employ them and don't give them opportunity to go to school. Or we treat them so special that they are completely excluded," he continues.

Wherever possible, he feels the mentally ill should be included.

They should be encouraged to integrate in the community and fulfil their maximum potential, even as they continue with medication and treatment.

His view is inspired by many of his patients over the last two decades. He darts to his desk to read out loud a cherished e-mail from a long-time patient who struggled with depression and mood swings throughout her teens. She repeated many years of secondary and tertiary education but never gave up. Finally, pushing 30, she won a statutory board scholarship to study abroad, earned a second upper honours degree and is now engaged to be married.

He laughs in amusement when he gets to the part where she admits her condition "didn't get better" under his care, but "so what", he says, she learnt to live life to its fullness in spite of her illness. She taught him that people are capable of much more than they believe.

Patients at centre

PROF Chua started life sickly and asthmatic but challenged himself to scuba dive and complete three marathons.

The elder son of a Malaysian general practitioner father and Singaporean teacher mother lived in Malacca till he was 13 and came here to study at St Andrew's Secondary School. He went on to Hwa Chong Junior College, then read medicine at the National University of Singapore and chose psychiatry as his speciality after he saw many patients getting well and staying well.

Shortly after he arrived at IMH as a 28-year-old medical officer, he discharged a patient who jumped to his death upon reaching home. He became convinced psychiatry was a "serious business", very much about "saving lives".

Twenty years on, he is focused on putting mental patients at the centre of their own care. He is hard at work trying to reduce IMH's re-admission rates, shorten hospitalisation stays and ensure new patients do not turn into long-stayers.

IMH has a bed capacity of 2,000, with about 1,700 patients warded at any time. Two-thirds are long-term residents who cannot be discharged because of the severity of their condition or loss of all social contact.

About a fifth of these long-stayers are above 70, largely "inherited" from the hospital's asylum era and who have known no other life outside. A handful are above 90 and will likely die within its walls.

But he wants to debunk the conventional thinking that mental patients are "different from other patients" and "can't possibly know what they want".

"If we see our patients who suffer from mental illness as different from other people who suffer from other illness, it's a wrong start. I always believe that you see what you want to see. At the root of it, they want nothing different from anybody else. They want to have security, healthy relationships, a meaningful existence."

On a one-on-one basis, he says most of his 2,200 staff connect with their patients as individuals. But when they organise themselves to deliver a service, he feels not enough room is made for patients to have a voice.

So he is changing that.

He has stepped up focus groups to get feedback from patients and their families. Beyond asking about the state of facilities, he makes it a point to ask what patients hope to see in their own recovery. "The focus is not about what can we do better but what we can do to help you do better," he says.

Next month, IMH is organising its first Singapore Mental Health Conference, together with the National Healthcare Group, that will see public and private sector psychiatrists, voluntary organisations and policymakers, as well as patients, giving talks.

In December, the IMH is also putting up a play written, performed and produced by volunteers, staff and patients, in celebration of mental health care. It also has a 15-strong patients' choir - a third of the singers are long-stayers - called the VSOP (Very Special Outstanding Performers), which regularly performs at civic events.

Inclusion advocate

BEYOND making hardware changes, he is also working on changing IMH's software and the way it works to deliver more customised care.

To prevent discharged patients from feeling lost between appointments, he has explored ways to keep in touch by getting a case manager to call them at home, a community nurse or volunteers to visit, or linking them up with community agencies to provide support to their families.

To make it easier for the mentally ill to seek help early, IMH is training neighbourhood GPs and polyclinic doctors to diagnose and treat common mental health problems. Over 50 GPs have since seen 1,300 of its more stable patients.

He is also working at turning on its head the "doc-patient" relationship of old, where the doctor was the "know-all, be-all, end-all of everything" and decided everything.

He is now setting up smaller, multi-disciplinary teams centred on each patient, led not necessarily by the doctor, but often the nurse, case manager or patient himself.

For example, he launched the Mood Disorder Clinic in 2011 for those suffering from depression, bipolar disorder and anxiety. Patients now receive more coordinated care from a team of psychiatrists, case managers, psychologists, medical social workers, pharmacists and occupational therapists, who meet weekly to discuss and review their cases.

The end goal he is trying to achieve, he describes, is when "patients are actively participating in their own care, in the way we organise our services and sitting on some of our committees".

He wants IMH to be a leading centre for mental health care, doing teaching and its own research, providing the latest treatments and trying the newest ways of delivering care.

Former schoolmate Adrian Wang, 47, a consultant psychiatrist at Gleneagles Medical Centre, believes he will get there. "I have always known him to be a determined person with a sense of mission. Once he sets a target for himself, he aligns everything around him to make it happen. He is neat and meticulous, to the point that we used to joke that he was almost OCD-like (obsessive-compulsive disorder), with his pens and pencils placed neatly in a colour-coordinated row.

"It is this attention to detail that makes him good at what he does. He thinks through the problem from all angles. He is able to see things from both an analytical and emotional perspective."

So it is with Prof Chua's unswerving conviction that "all are capable of change, even in the most difficult and unlikely circumstances", that he presses on, following his patients' lead.

IMH CEO Chua Hong Choon on:

Misconceptions about mental illness

"It is an illness like any other. We can work with patients. We can get them as well as anybody else. A lot of people still think that people with mental illness can never recover, that they are going to be dangerous. It's this that leads to their social exclusion. Even with the best of intentions, it's still exclusion. For example, don't employ them or treat them so special that they are completely excluded. But where they can, they should participate in life."

Doc doesn't always know best

"The time-honoured tradition of doctors is that we are the healers, we know best. So patients come to us at the base of a very steep gradient of knowledge, power, control. I know all, you know nothing. I am well, and you are ill, and therefore you seek everything from me.

That gradient is so much changed now and I'm a great advocate of that change. Much of the scientific information on health has been translated into a language that patients can understand. Of course, some of it on the Internet is wrong information. But there's enough of it for the health-care consumer to participate in his or her own care."

Ageing and the dementia epidemic

"Everybody is worried about ageing in Singapore. I'm the optimist. Recent studies suggest it may not be as bad as 5 to 6 per cent prevalence, as earlier thought. Those projections were mostly based on pre-war populations, people now in their 80s, and did not take into account a much better educated and informed population.

What prevents dementia are things like good nutrition, better physical activity, mental stimulation and higher education. But the issue is we are ageing with smaller families, so it's important to, first of all, empower individuals with mental health problems to look after themselves and then create systems in the community, whether it's relatives, community agencies or voluntary organisations, to surround them with assistance."