Notes I.

Notes from “Mental Health and Psychiatry in Singapore: From Asylum to Community Care” by Kah Seng Loh, Ee Heok Kua, and Rathi Mahendran in Mental Health in Asia and the Pacific (Springer US, 2017)

“The shift from asylum-based institutionalisation to community psychiatry and the recognised importance of mental health are definite signs of progress. However, the continuing dominance of Western frameworks of psychiatry ignores both the rich experience of clinicians based in Singapore as well as the varied customary way in which Singaporeans have viewed and treated mental illness.”

Pre-war era – Occupational therapy common, but main focus was incarceration and separation from the general public. Therapy available to the very upper classes with emphasis on health. But most early mental patients were vagrants and destitutes removed from the street by colonial powers and detained in Convict Goals. Colonial emphasis on illness rather than well-being, and as symbolic of moral and material degradation. Asian perspectives generally leaned toward mental health as a spiritual problem, to be dealt with by witch doctors and traditional healers.*

1947 – 1950 – New physical methods of treatment introduced including electro-convulsive therapy (still used today) and insulin coma therapy.

1952 – 6 doctors, 1 matron, 8 nurses, 10 assistants to serve 1,700 patients a year.

1951 – The Mental Hospital is renamed Woodbridge Hospital after a bridge in the area named by the Chinese as ‘pang kio’ or wooden bridge. Politically-correct euphemisms however do nothing to reduce old stigmas.

1953 – First outpatient psychiatric clinic was established at the General Hospital for ‘less serious cases’, followed by four more clinics at other hospitals through the decade.

1954 – Push to recruit Chinese-speaking psychiatrists to replace expatriates and non-Chinese doctors as part of Malayanization of civil service.

1955-1958 – Social work department added to Woodbridge Hospital and introduction of social therapy – encouraging patients to take part in social and recreational activity such as group singing, dancing, discussion, film-watching.

1960 – Amendment to the mental health law allows doctors to admits patients into Woodbridge, as increasing numbers were going directly to government hospitals. In 1965, of the 2,797 patients admitted to Woodbridge, only 581 were voluntary cases.

1965 – Postcolonial health still racialized: “[The] Malay is more conservative and prefers to seek native treatment… Alcoholism is rarely encountered among the Chinese and Muslims… the Chinese usually drink with their meals or when entertaining their guests and here again food is served. Perhaps this social habit of drinking while eating presents them from becoming chronic alcoholics.” (1965 report from the Ministry of Health)

1968 – Child Psychiatric Clinic established in Woodbridge. Also an Association for Mental Health (an NGO) to promote mental health and provide daycare facilities for discharged patients.

1979 – Department of Psychological Medicine established at the National University of Singapore, based in Singapore General Hospital, and later moved in 1987 to National University Hospital. This was the first general hospital department of psychiatry.

1983 – Government decides psychiatrist training should be localised (previously would-be practitioners completed post-graduate work on scholarship at the Institute of Psychiatry, London), and NUS (with assistance from the UK) offered a Masters in Medicine (Psychiatry)

1993 – Woodbridge Hospital and Institute of Mental Health is built at Buangkok Green, with government stated aims towards therapy, training and research, rather than the custodial management of patients.*

2000 – Woodbridge becomes integrated into the cluster of hospitals called the National Healthcare Group. Elsewhere in Europe and Australia, efforts are made to close asylums.

2002 – Psychiatric departments in all the general hospitals and increasingly polyclinics, but public preference for care from the private sector due to long wait times, stigma, and a misplaced desire for privacy.

* Ee Heok Kua on ethnic perspectives towards mental health in Singapore from “Focus on Psychiatry in Singapore” in The British Journal of Psychiatry, June 2004.

“Family structures and cultural beliefs often determine illness behaviour and help-seeking tendencies. In a study of illness behaviour in 100 Chinese patients referred consecutively to the psychiatric clinic at the National University Hospital, it was found that 36 had also consulted a traditional healer (Kua et al, 1993). More women than men felt that their illness was due to spirit possession; but belief in possession was not related to educational status.

Classical Chinese medicine is based on the belief that there is a finely balanced and rhythmic relationship between bodily functions and the emotions. This belief is built on the concept of yin–yang, a bipolarity that is both opposite and complementary. The yin represents coldness and yang warmth. When this homoeostasis is disrupted by spirits, mental illness might result. In the family it is often the elders who seek help from the traditional healer to intercede for the patient to exorcise the spirits. If the traditional healer fails, the family might then consult a general practitioner who will refer the patient on to the psychiatrist if he has difficulty with his or her management.

The possession-trance is a common culture-related phenomenon in Singapore and many countries in Asia. I have previously reported the characteristic features (Kua, 1986). People prone to this condition are often from less-advantaged backgrounds and have received poor education, they have previously witnessed a trance and the onset is usually before the age of 25 years. During the trance there is evidence of an alteration in the level of consciousness, and stereotyped behaviour of a deity which has possessed the person. The trance lasts for less than an hour, and is followed by physical exhaustion and amnesia for the period of the trance, with normal behaviour in the interval between trances. The young men in the study had these experiences soon after enlistment in the army, which was perceived as a stressful life event. Because possession-trance is not deemed an illness, a traditional healer is often consulted. This socially sanctioned behaviour is recognised as a sign of distress and evokes the appropriate family response of support and sympathy. The individual is treated with respect because he is perceived to be favoured by a deity. The healer shares the same belief system as the family, whose trust and hope are powerful factors in the treatment. During the therapy, the healer goes into a trance himself and the family participates in the rituals. This phenomenon can be explained as a defence mechanism to preserve self-dignity and self-worth. Treatment by the traditional healer lacks the stigma associated with referral to a psychiatric hospital.

The Malays and Indians have their own priests or healers who are consulted not only for spiritual matters, but also when someone is ill. Among the different ethnic groups, there are other culture-related conditions such as amok and koro which are less common now. One of the earliest reports on amok was written in 1893 by the British psychiatrist in Singapore, Dr W. G. Ellis. He concluded that amok was a homicidal–suicidal rage due to depression. The patient would often describe his mood state in the vernacular as sakit hati or sickness of the liver, the organ regarded as the seat of the emotions (Kua, 1991).

Because of their cultural beliefs, patients who seek psychiatric treatment will take medication from their doctor and also a herbal prescription from a traditional healer. Sometimes patients with schizophrenia who seek help from traditional healers are referred for psychiatric treatment after a delay of 2–3 years. With public education, we have noticed recently that the majority of patients with first-episode schizophrenia (80%) are referred to the National University Hospital within 6 months of the illness onset.”

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Hello Therapy!

I have been on more or less consistent psychiatric care for the last 7 years. But I have never really engaged in psychotherapy.

In Singapore (and I’m guessing elsewhere also), the function of meds and therapy tend to be separated for cost-effectiveness. The psychiatrist is the person who gives you the meds and may or may not talk to you. The therapist doesn’t give you meds, or answers. And because of our rapidly changing culture and ‘Asian values’, it can be hard to find a therapist you click with.

I had a free therapist at my very first consult at Raffles Hospital. It felt very much like a bargain deal, albeit at a fancier supermarket. Like Jasons. Raffles is one of the most expensive, private institutions we have and I felt terribly guilty that my parents were spending money on me to be preached at by a doctor who’s catchphrase was, “You gotta feel the burn.” My parents were under the impression that if I went to a private hospital, it would be harder for people to trace my medical history. I now know this isn’t so. My GP in my neighbourhood clinic is able to check on my history thanks to a collated national database and dispense short-gap psychiatric medication when needed.

I think this collation of personal material is… eventual. And on some level, I really don’t care for anyone in the ministries who would discriminate me for having my condition.

Anyway, my first therapist: She recommended I do things for myself. Like paint my nails. I wasn’t femme per say at that point. But I gave it a shot. 300 bottles of nail polish later, in my undergrad years, I sought the free treatment that came with being a student at National University of Singapore. The psychiatrist there was one of the ‘old guard’, that group of pioneer generation men that all seem to know each other. It took him awhile to admit he was uncomfortable seeing me because unbeknownst to me, he knew my father from those early pre-Independence days. It is this generation in Singapore that is perhaps the most suspicious of healthcare in general, mental health in particular. I don’t blame them. This was still the period of electro shocks and moralist correcting of personality.

(A writer named Loh Kah Seng has just released an academic paper titled “Mental Health and Psychiatry in Singapore: From Asylum to Community Care” which I have not read but very much wish to, to see if my observations are correct.)

The third time I got a therapist, I was warded in National University Hospital for exhaustion. We all got to talk to someone once a day. But I think it was really talking to each other that helped us to heal. Really what put me in NUH, aside from a suicide attempt, was that I could not find counselling for people who had contracted STDs from their partner (which I had at the time). The only groups available at the time came with the caveat that you had to be a married woman. The relationship I had been in was not casual, but I suppose that didn’t matter under the state’s aims, which were then IMHO about moralising sexuality (more on that some other time). Feeling that I wasn’t deserving of help was one of the many reasons I was suicidal.

At the current hospital I seek treatment at, I once had therapy with a middle-aged woman, T, who emphasised breathing exercises. I wanted to be polite, so I did not book a second appointment. I can’t take someone who recommends meditation and breathing to a depressive seriously.

My problem is meditating on my thoughts (or my non-thoughts) for such long periods, they paralyze me.

But my psychiatrist decided it was time for the talking cure after two years of just straight-up medicating and living from episode to episode. I said as much to the therapist he assigned me and who I met for the first time yesterday.

S is closer in age to me. She is pretty. Articulate. Knows how to validate me.

The problem with my condition is being very aware of this and constantly questioning intent.

We plotted my emotional cycles for the last ten years. She thanked me for my frankness. Including telling her I couldn’t take her predecessor seriously and to please not give me one of those stress ball brains.

I already have a collection.