Monday 26 October 2015

Institute of Mental Health: Beyond the Cuckoo's Nest cliche

Forget stereotypes of prison-like institutions. Singapore's Institute of Mental Health is a safe haven and is embraced by the Hougang community.
By Chong Siow Ann, Published The Straits Times, 24 Oct 2015

Mental illness can be mystifying and, occasionally, frightening. And the housing of many mentally ill individuals within a confined locale has certainly exercised the imagination of the public.

At its worst, the public's perception of psychiatric asylums is how movies like One Flew Over The Cuckoo's Nest and the more recent Shutter Island have portrayed them - as dark, ominous and sinister places.

For all its 87 years of existence, Singapore's Institute of Mental Health (IMH) has also been, among other things, a "psychiatric asylum" for a sub-population of severely mentally ill patients. The original hospital built in 1928 was simply called "The Mental Hospital", and this was later renamed Woodbridge Hospital, which has loomed as an object of morbid fascination in the psyche of successive generations of locals.

And yet a good number of beds in this institute are occupied by patients who live out their natural lives there in a modern, safe and caring environment.

When I started my training in the then Woodbridge Hospital in 1989, it was a complex of barrack-like single-storey buildings with airy passageways and open grounds with abundant greenery. It was in this verdant and bucolic setting that I came into contact with the reality of mental illnesses from the numerous patients, many of whom had been living there for decades. Their histories were of lives devastated by mental illness interlaced with the exhausting struggles of their families.

The old Woodbridge Hospital was torn down shortly after the staff and patients moved in 1993 to the present IMH which has even more beds.

The present institute is, strictly speaking, no longer a public hospital, but a "restructured hospital" with greater autonomy and operational flexibility.


In spirit, of course, it is still a public hospital which serves all people with mental health issues, including those with little or no means. Of all the restructured hospitals in Singapore, the IMH has the largest proportion of patients who are on Medifund, a scheme that helps the poor pay their medical bills.

That to me is a fine thing: It indicates that it is indeed a "safety-net" institute and that it delivers care to the needy who would otherwise not be able to receive care.

In the intervening years, there have been significant advances in our understanding of mental illnesses and vast improvements in the way care is delivered. More and better services have also enabled more patients to live in their homes and be part of the community.

More well-designed, comprehensive, accessible and fully integrated community-based treatment is still needed for patients to reclaim their life and live meaningfully in the community. However, there continue to be, despite our best efforts, some patients who, because of the chronic nature and severity of their illness and the limitations of present treatments, need long-term highly structured and secure 24-hour care. These include individuals who are unable to look after themselves, and those who are potentially dangerous to others or themselves.

The IMH speaks proudly of the inroads made in the early detection of mental illnesses; it showcases innovations in mental healthcare and of its research, and highlights its success in restoring patients to their families.

But it is somewhat reticent when it comes to its role as an "asylum" - perhaps it is because that word, by now, has a derogatory and unsavoury connotation.


Asylums were born of a noble idea. They were built to provide moral and humane residential care to the mentally ill in an earlier era when there were no effective medications. (One edition of the Oxford English Dictionary defines an asylum as "a benevolent institution according shelter and support to some class of the afflicted, the unfortunate or destitute".)

This idea reached its apotheosis in 19th century America, where reformers built large stately buildings on sprawling grounds where mentally ill patients worked and lived out their lives within a cloistered community which accepted their mental illness.

But this idyllic state was not sustainable. The admission of more and more patients outstripped available funding and resources. By the 1950s, such asylums, already bursting at the seams, morphed into squalid and overcrowded "warehouses".

In 1961, American sociologist Erving Goffman published a scathing book which was based on research done when he went undercover as a worker in a psychiatric asylum in Washington, DC.

Dr Goffman described these places as "total institutions" with prison-like conditions where there was no connection between staff and inmates who were deprived of liberty, and subjected to cold, rigid and authoritarian rules without any empathy or regard for the individual.

The appalling situation of the mental health system, riddled with shocking and scandalous reports of abuse, led to outcries and reforms. President John F. Kennedy, in a 1963 speech, called for a "bold new approach" in which "reliance on the cold mercy of custodial isolation will be supplanted by the open warmth of community concern and capability".

But it didn't turn out that way - in fact, it went terribly awry.

A confluence of social, political and economic forces led to a wave of "deinstitutionalisation" that swept across the country - closing mental hospitals and jettisoning hundreds of thousands of mentally ill people into the community that was ill-prepared to receive them. (Somehow, that movement of deinstitutionalisation passed Singapore by).

In 1955, there were more than half a million patients staying in state psychiatric facilities but today there are just over 40,000 in the entire nation whose population has also doubled in that time - this represented a 95 per cent decline in the number of patients in such long-term care.

Most of the mentally ill - many of whom had lived in institutions for decades - ended up homeless on the streets, or kept revolving to general hospitals and the emergency departments where they received episodic and inappropriate care; others were jailed. The US penitentiary system ended up as the de facto largest mental health system: It is estimated that half of all prison inmates there have a mental illness or substance abuse disorder.


Dr Ezra Susser, a scientist in the School of Public Health at Columbia who worked with people with serious mental illness, said of their families: "You have to really be careful not to set up a situation where the family feels that they are being compelled morally to do more than they really can do."

With nuclear families replacing extended families and with Singapore's rapidly ageing population, there will be situations where elderly caregivers can no longer look after their severely ill relatives.

They need an assurance that there is a safe sanctuary where their charge can live with proper support and that they can turn to should that day come when they have reached the end of their tether.

The situating of the IMH - whether by intent or not - in the heart of residential Hougang is a good thing; rather than isolating and rejecting, the community seemed to embrace it and, in doing so, demystified it.

Its presence is also salutary: It reminds us that that our life has many human possibilities and becoming mentally ill could be one such possibility. We should, therefore, be grateful if we have been spared that, and be kind and considerate to those who had been struck down by it.

Eighty-seven years may not be a long time, but there is a sense of permanence about this institute. Generations of patients and staff will enter its doors and leave. The physical edifice will also change with time.

As a concept and symbol, however, the institute will endure. It represents an essence of a humane and civilised society: Caring for its mentally ill individuals in dire need, who are bereft of kin and support, and giving them humane treatment, protection and shelter.

The writer is vice-chairman of the medical board (research) at the Institute of Mental Health.

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