CMHT Programme Report 2018

CELEBRATING MILESTONES & ACHIEVEMENTS

MILESTONES & ACHIEVEMENTS Community Mental Health Team Programme Report 2018

CMHT PROGRAMME REPORT 2018

Contents Editor’s Message 1 Transforming Lives in the Community 2 Chief Nurse Shares her Perspective 4 The Journey Towards Recovery 6 We’ve Come So Far 12 Expanding Our Roles 13 National Mental Health Helpline and Mobile Crisis Team 14 Stats and Figures 16 What is Solution Focused Base Therapy (SFBT)? 18 Creating an Impact with Positive Ideas 22 The Power of Peer Engagement 26 Milestones and Achievements 28 Finding Strength 30

CELEBRATING MILESTONES & ACHIEVEMENTS

Editor’s Message

Throughout my 49 years in Nursing, I have worked at various hospitals but my longest term was served with the Institute of Mental Health (IMH). I am very thankful for the opportunities given to me during my service at IMH, including the training I received under the Health Manpower Development Plan (HMDP) scholarship.

It enabled me to pursue a course in Behavioural Psychotherapy at the Institute of Psychiatry in London.

I was also trained as an Emergency Behaviour Officer, which enabled me to facilitate disaster management. During the Silkair MI185 and Singapore Airlines SQ006 disasters in 1997 and 2000 respectively, I provided on-site support to the next-ofkin. My training also allowed me to act as a “stress buster” and train many others in Corporate Consultancy Service at IMH. I have also had opportunities to attend international conferences to present papers and submit relevant articles to nursing journals.

Outside of IMH, I was regularly invited to deliver lectures at Nanyang Polytechnic for its Advanced Diploma Nursing course.

I spoke on subjects such as Mental Health and Community and Gerontological Nursing. Where possible, I volunteered with the Singapore Association of Mental Health (SAMH) as a board member and participated in Psychiatric Outreach Programmes.

Mr Ong Seng Hong

The roles of community psychiatric nurses have evolved and transformed greatly. Instead of traditional duties such as monitoring defaulters, nurses now provide psychosocial rehabilitation that focus on patients’ recovery.

With the valuable opportunities, exposure, and other commitments I accumulated over the years, I was privileged to be an award winner for the 3M-ICN (International Council of Nursing) in 1981. I also received the Efficiency Medal (National Day) in the year 2000, the May Day Model Partnership Award in 2015, and the National Health Group (NHG) Teaching Award for Nursing Preceptors in 2016.

For the past seven years, I have also had the privilege to lead a Community Mental Health Team comprising committed nurses who have been providing quality care to patients living in the community. In the past five years, the roles of community psychiatric nurses have evolved and transformed greatly. Instead of traditional duties such as monitoring defaulters, nurses now provide psychosocial rehabilitation that focus on patients’ recovery.

Our nurses’ roles have also expanded to include networking and establishing connections with community partners. In the future, I foresee that our Community Psychiatric Nurses (CPN) will focus on rehabilitation, case management functions, and providing support to patients and their caregivers.

I am pleased to present this write-up, which will take you through the development and milestones of Community Psychiatry Nursing Service (CPNS) and Community Mental Health Team (CMHT) over the past 25 years. I am confident that the next generation of CMHT staff will not only provide quality person-centered care, but also expand their roles and responsibilities as collaborators with community partners and other restructured hospitals. This will help provide effective treatment, rehabilitation, and prevention of mental illnesses in the community.

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CMHT PROGRAMME REPORT 2018

Foreword

Transforming

Lives

in the

Community How IMH continues to evolve from hospitalbased to community psychiatric care.

The Community Mental Health Team (CMHT) programme was implemented 10 years ago in IMH as a new initiative under the National Mental Health Blueprint.

Its inception was led by Dr Lee Cheng at a pivotal point in the history of IMH. The programme marked a shift in IMH’s focus from hospital-based to communitybased psychiatric care. It was also the

first programme to test new models in interdisciplinary work that involved psychologists, medical social workers, and occupational therapists in addition to the main group of psychiatric nurses as part of a community outreach team. Besides direct clinical care and support, there was also a renewed focus on capability-building.

It was vital to increase awareness as well as improve the skills of various community partners in addressing mental health issues.

In subsequent years, CMHT went through further development and it continues to do so. The team upskills in order to become leading practitioners in psychosocial rehabilitation and help those with severe and chronic mental illnesses. Nevertheless, gaps remain in the services we provide. Thus, it is important for CMHT to continue being part of the local landscape of healthcare transformation. This way, it can effectively support patients as they live and work in our communities.

To date, IMH sees an estimated 40,000 unique patients annually.

With only 1,735 inpatient beds, 96% of IMH patients are managed as outpatients in the community. The majority of healthcare occurs

Left:

Dr Leong Jern-Yi Deputy Programme Director, CMHT Right:

Dr Wei Ker-Chiah Programme Director, CMHT

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CELEBRATING MILESTONES & ACHIEVEMENTS

at the less acute end of the scale within the community. This means that outcomes are controlled by individuals and families whose healthcare choices are strongly influenced by their values, culture, and communities.

Healthcare transformation lies in meeting the challenges of an ageing population that is living longer and expecting a better quality of life. We must move beyond a healthcare system centred around hospital- or clinicbased episodic care and develop longer term relationships with patients and caregivers. We must engage and empower them through community resources, so they become our partners towards achieving better health.

In 2017, IMH started on an empanelment approach to patient care. Patients are grouped into four regions (North, South, East, and West) according to residential addresses. They are also assigned to a fixed care team, so they can receive better continuity of care.

This approach enables patients to

It is important for CMHT to continue to be be part of the local landscape of healthcare transformation, to effectively support our patients as they work and live in our communities. see members of the same multidisciplinary team (MDT) throughout their care journey – from prevention, early detection, treatment and longterm care, to receiving support in the community.

Another key empanelment initiative is the assignment of a Single Point of Contact (SPOC) to each patient.

It allows patients and their caregivers to have faster and more consistent access to information.

The SPOC also helps connect patients and caregivers with relevant services within IMH and in the community. As the relationships between IMH and various community partners grow stronger, we hope to see our partners become more confident and capable of managing stable and low risk patients. This will allow

us to focus on providing tertiary care to more severely ill patients.

In light of these changes, CMHT was recently remodelled, so it can be embedded into this empanelment system through the reworking of work processes and manpower complement. There is also renewed focus on building up community psychiatric nursing capabilities both within the service and for other nurses in the hospital. By doing so, we can integrate patient care with clinical teams in the four regions better, and improve the coordination of care across different settings. We hope that in the years ahead, CMHT will continue to reinvent itself to remain relevant and break new ground to best meet care needs in the community.

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CMHT PROGRAMME REPORT 2018

Foreword

Chief Nurse Shares her

Perspective

Looking after a patient’s needs goes beyond medication The Community Psychiatric Nursing Services (CPNS) at IMH has come a long way. Established in 1988, it provides support and follow-ups for patients in the community to prevent relapses and help them function optimally in the community.

Community Psychiatric Nurses (CPNs) help assess a patient’s mental state and functioning level, administer depot anti-psychotic medication when necessary, and look out for signs of side effects of the medication during home visits. CPNs also monitor a patient’s adherence to treatment, deliver continual psychoeducation, and provide psychological support to caregivers.

This enables patients and families to remain well in the community, which not only prevents illness relapse but also reduces readmissions.

In 1994, I was posted to the CPN department. I had the opportunity to be trained in England and obtained a specialisation in CPN. After a year of study, I shared many recommendations to enhance CPNS e.g. CPN’s structure, patient assessment and documentation, and psychosocial rehabilitation.

In the 90s, England implemented C-documentation. In 2009, IMH launched the Commcare@ IMH project to improve the management of patients’ information in CPN. Currently, CPNs have access to patients’ information through various IT systems at IMH. Patients’ clinical assessments are also captured directly in the IT system. The programme has been incorporated in a hospital-wide IT initiative on nursing documentation i.e. “E-Notes”.

My journey and experience as a CPN was interesting and meaningful. I remember a particular case where a patient with schizophrenia and post-partum depression was feeling distressed about her baby when I visited her.

Her husband was working two jobs to support the family.

Meeting and bonding in The Community Psychiatric Nursing Services (CPNS).

The baby was crying and hungry but there was no milk powder at home. I comforted the patient and rushed out to buy milk powder for the baby. It was a worrying situation.

I immediately referred the patient to family social services, and ensured

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CMHT caseworkers are well placed to influence individuals and families...as well as offer psychiatric rehabilitation skills to engage and empower patients to build healthier and happier routines. she had the capacity to take care of her baby. I was worried that the baby would be taken away from her. I visited her regularly, taught her how to manage her baby, and spoke to her husband to ensure food was provided. She eventually got better and learnt to take care of her baby and enjoy motherhood. It was satisfying to care for the patient and make a difference in her life.

In 2000, the hospital reviewed the CPNS care model in order to reflect a more focused and effective service. The referral system was revised for CPNs, so staff could source for and identify suitable cases for referrals. CPNs and Patient Educators carried out a joint pilot project on family psychoeducation. The objectives of this

pilot project were to encourage greater family involvement in patient management and provide case management training. CPNS has since moved on to provide a comprehensive range of treatment, rehabilitation, and support services through a multidisciplinary team approach. In 2010, it was renamed “Community Mental Health Team (CMHT)”. The National Mental Health Blueprint (MOH, 2010) funded Mobile Crisis Team (MCT) and the Assertive Community Treatment (ACT) programme. CMHT continues to provide psychosocial rehabilitation to patients with multiple readmissions, and keep them well in the community.

As IMH embarks on the empanelment journey, CMHT caseworkers are well placed to influence individuals and families through home visits. They provide practical guidance such as how to use a pill box to increase adherence to medication regimen as well as offer psychiatric rehabilitation skills to engage and empower patients to build healthier and happier routines.

Samantha Ong Chief Nurse

Caseworkers also link patients to community social services such as Family Service Centres and Social Services Offices, where patients’ financial needs can be looked after.

Meaningful routines such as Day Centres and Vocational Training and Placements are facilitated via partners such as Employment Support Services, Mindset Learning Hub, and Silver Ribbon. In addition to providing support for patients, CMHT caseworkers also connect caregivers to Caregiver Alliance for caregiver support and training programmes.

Our caseworkers play an important role in connecting patients and their caregivers with community partners.

As empanelment progresses further, we hope to look after patients’ needs better through increased support from community partners as well as regional care teams.

After all, personal recovery is about individuals being able to make meaningful and satisfying choices of environment in the domains of living, working, learning, and socialising – with minimal professional intervention.

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CMHT PROGRAMME REPORT 2018

1950s — 1970s 1950s

• Community Psychiatric Nursing in United Kingdom was established.

• Advancements in psychotics treatment enabled more patients to be discharged into the community.

1954

First outpatient nurses were appointed at Warlingham Park Hospital, Surrey.

1960

Implemented custodial care of psychiatric patients in Singapore. Patients were not discharged from hospital and only home leave was allowed.

1970s

• “Open door” policy introduced at old Woodbridge Hospital.

Acute wards were open on most days. Patients could move freely within hospital grounds.

• Depot injection “modecate” was marketed in Singapore in early 1970s for the treatment of schizophrenia; more patients were discharged.

• “Revolving door syndrome” occurred. Patients discharged home were readmitted. Having been institutionalised previously, patients lacked skills to integrate into the community when discharged. Caregivers were ill prepared to accept patients back home.

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1980s 1980

Mr Tan Kim Hock, nursing officer mooted the idea of implementing Community Psychiatric Nursing in Singapore.

This proposal was tabled to the Ministry of Health.

1982

Mr Tan Kim Hock attended community psychiatry training in Sheffield, UK. He returned in July 1983 upon graduation.

1984

Mdm Chew Kim Ai was awarded the Colombo plan scholarship to pursue the “Nursing Care of the Mentally Ill in the Community” course in the UK.

1985

1 Oct: Dr Tan Kuan Hoo became the first psychiatrist to attend the University of London under the MOH HMDP fellowship.

Dr Tan completed a course on “Social and Community Psychiatry”.

1987

13 Mar: At the opening ceremony of National Mental Health week, Mr Yeo Cheow Tong, Acting Minister for Health emphasised the importance of treating and rehabilitating patients, so they could return to the community.

1990s 1988

1 Nov: A six-month pilot project of Community Psychiatric Nursing Services was launched. Ward-based nurses SN Theresa Lien and SSN Esther Heng were seconded to do full-time CPN work. Dr Tan Kuan Hoe managed a team comprising a psychologist, medical social worker, and two nursing officers – Mr Tan Kim Hock and Mdm Chew Kim Ai. 26 Nov: First evaluation meeting on CPNS took place. Of a total of 27 referrals, the team rejected two cases. CPNs made nine home visits.

1989

Mar: • Drafted questionnaire on the evaluation of CPNS. • Findings of a survey were favourable.

Jul: Decentralisation of CPNS to other outpatient clinics (Alexandra Psychiatric Outpatient Clinic).

Sept: To address influx of referrals from APOC, Toa Payoh Clinic was roped in to assist with cases.

1990

MOH approved the establishment of CPNS after a review of the report on the pilot project and survey.

1992

CPNS @NYP presented lectures for students in the Advanced Diploma in Psychiatric Nursing programme.

1994

Dr Eu Pu Wai attended a nine-month course on Community Psychiatry in Bristol, UK.

1995

• Ms Samantha Ong attended a one-year course on Community Health Nursing in Manchester, UK. • Mr Lim Cheong Chye began a five-month attachment in Western Australia.

• Staff from National Council of Social Services began their attachment with CMHT.

1997

CPNS became autonomous and was run solely by CPNs.

1999

• Order Entry Result Reporting/Maxcare was introduced to CPNS to capture services rendered to patients.

• Introduction of “SAP applied” for the registration of patients at Woodbridge Hospital.

CMHT PROGRAMME REPORT 2018

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2000s

2010s

2000

2003

• CPNs trained students in the Advanced Diploma in Community Health course.

• CPNS offered charging services.

• Woodbridge Hospital was restructured by MOH. Changes introduced for CPNS Woodbridge Hospital fell under National Health Group cluster.

2004

2001

2007

• Mr Ng Sin Liang began three-month attachment with St Vincent’s Mental Health Services in Melbourne.

Apr: CPNs were issued pagers.

Dec: • NHG introduced case management for CPNs in Woodbridge Hospital.

• Proposal submitted for a Mobile Crisis Team and Crisis Hotline Programme.

• Patients in long stay wards were transferred to step down facilities in the community.

• Proposal submitted for three island-wide Community Wellness Centres.

2002

Mr Ong Seng Hong and Ms Tay Sim Eng (behavioural nurse therapists) were posted to CMHT to conduct behaviour therapy for CPNs to help them manage patients with anxiety in the community.

CELEBRATING MILESTONES & ACHIEVEMENTS

1 Nov: • Launched Assertive Community Treatment.

MCT programme became a full-fledged service under Department of Community Psychiatry.

1 Apr: Launched Community Mental Health Team with a multidisciplinary approach under the blue print funding.

2008

Queenstown Community Wellness Centre shared its premises with Queenstown Polyclinic.

2009

• MCT helpline offered 24-hour services to better support patients in the community.

• Digital Psychiatry launched in CMHT with electronic documentation.

• Dr Joseph Leong attended his HMDP in Community Psychiatric Rehabilitation with distinguished Prof Robert Paul Liberman at the American Psychiatric Association (APA) Conference in San Francisco.

2011

2016

• Intermediate And Long Term Care Services (ILTC) was introduced to provide more subsidies to patients in the community.

Dr Joseph Leong led a team of CMHT staff including NC Mr Ong Seng Hong, SNC Khoo Xiaofen and SSN Rohaida Ishak to Taiwan for a conference. Dr Joseph also did site visits to 8 different psychiatric institutions around Taiwan island to exchange expertise over 10 days.

• Mental Helpline launched with the support of AIC and worked with Family Service Centres to manage individuals in the community suspected to be mentally unwell. CPNs provided mental state examination as part of early intervention.

2012

Pilot Supervision Programme was introduced to encourage patients to remain compliant with treatment through the provision of incentives. It was sustained for two years.

2014

Phase 1: Empanelment planning, care team divided into four regions.

IMH Quality Day 2016 Gold Award presented to CMHT project on ‘To Reduce Time Spent on Accompanying Patients to Various Follow-ups’.

Phase 2: Empanelment planning in designing care model and assessments for patients in four regions.

2017

Empanelment was rolled out.

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CMHT PROGRAMME REPORT 2018

We’ve Come So Far Stalwart Mr Lim Cheong Chye reveals how CPNS has evolved through the years.

Back in the 60s, Woodbridge Hospital (WH) trained its own Registered Mental Health Nurses (RMNs) and I was one of them. During my service with WH, I was very interested in monitoring patients’ progress in the community. In 1993, I was recommended by the Matron to join the Community Psychiatric Nurse Services (CPNS) and I have never looked back since.

I love this job because I can provide followups and continual care in the community.

This was missing for me in the inpatient ward, so this has been one of the motivating factors that fuelled my passion as a Community Psychiatric Nurse (CPN).

Mr Lim Cheong Chye

I was able to assist my patients to obtain financial help from social resources, which added significant meaning to the role of a CPN. I enjoyed talking to patients and their family, whether it was for supportive counselling or educating them on illness management and recovery strategies.

I was able to assist my patients when they needed to obtain financial help from social resources, which added significance and meaning to the role of a CPN. I enjoyed talking to patients and their family members, whether it was for supportive counselling or just to educate them about illness management and recovery strategies. This job gives me the greatest satisfaction when patients give feedback about how I have helped them to better understand mental illness and the available treatments. My job has helped patients and their families gain insight and understanding of different illnesses and associated treatments.

the therapeutic environment. After each outing, they could tell me whether they preferred indoor or outdoor activities, which allowed me to improve my communication with them. I strongly believe that such outings are a good form of rehabilitation.

I invested a lot of my time on the job in organising outings and spending time with my patients. This helped me to gain better understanding of their behaviour and personality and allowed me to plan the treatment according to their preference for

I think the future of CPNS is promising and challenging at the same time; I believe that with empanelment and the introduction of “teamlets”, CPNS will expand to cope with growing needs. If I could encourage CPNs by saying one thing, it would be to remind CPNs to fall back on basic principles — working diligently and providing the best care to patients.

CPNS has evolved significantly over the years. Through continual training such as ISMR, MORS, SFBT, CPRP and MI, CPNs became better trained. Our job scope has expanded to psychosocial rehabilitation. It has gone beyond monitoring defaulters and reminding them about appointments.

CELEBRATING MILESTONES & ACHIEVEMENTS

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Expanding Our Roles Ms Leow Me Lye reflects on her rewarding journey in mental health nursing

I graduated from the School of Nursing and joined Woodbridge Hospital on 1 July 1982.

After working for three years, I developed a strong interest in Mental Health Nursing.

I went for post basic in Mental Health Nursing in 1985. In 1989, I was assigned to be in charge of the Day Hospital. The Day Hospital was a programme for patients who were discharged from the hospital. I gained a sense of satisfaction organising and conducting activities at the Day Hospital.

I shared the same office with my colleagues from CPNS (Community Psychiatric Nursing Service). They told me about their challenges in managing patients and supporting caregivers in the community.

I was amazed and found community nursing interesting. The role of a community nurse is different from the traditional nursing duties performed while patients are institutionalised. In 1999, I joined CPNS after the Day Hospital programme ended.

I received the Healthcare Humanity Award from Singapore President S R Nathan in 2010. This award was given in recognition of healthcare workers who go beyond the call of duty to provide care and comfort to the sick. My passion for volunteer work motivated me to be a first aider for public events. In 2003, during the SARS (Severe Acute Respiratory Syndrome) outbreak in Singapore, I volunteered to travel to nursing homes to administer depot injections for our patients.

In recognition of my contributions towards healthcare, I was awarded the HMDP (Health Manpower Development Plan) award. I was privileged to have the

Ms Leow Me Lye

We have moved from a medical paradigm to a bio-psycho-social model. CPNs are trained to provide psychosocial rehabilitation for patients in the community rather than just monitor patients’ adherence to treatment.

opportunity to complete my attachment at Johns Hopkins Hospital.

It was an eye opener for me and I acquired skills and knowledge in Community Mental Health Nursing and Community Psychogeriatric Nursing.

Over the years, the roles of CPNs (Community Psychiatric Nurses) have expanded. We have moved from a medical paradigm to a bio-psycho-social model. CPNs are trained to provide psychosocial rehabilitation for patients in the community rather than just monitor patients’ adherence to treatment. We also work more closely with community agencies to support clients and families in the community. In addition, we provide training to our community partners, so they can better understand and co-manage our patients in the community.

Moving forward, community nurses should be confident and knowledgeable about managing patients’ psychiatric and medical conditions in the community. Community nurses should also be trained in family nursing so they can manage complex family issues.

Community nurses should also be involved in research — to provide evidence-based best practices.

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CMHT PROGRAMME REPORT 2018

National Mental Health Helpline and Mobile Crisis Team

Mental Health Helpline (MHH) Maintain a 24/7 helpline 6389 2222 Support IMH patients and those with suspected mental illness facing crisis or pre-crisis situations • Qualified counsellors provide immediate assistance and advice • Counsellors help in these areas:

- During a crisis, counsellor may activate

home visits, conduct risk assessment of

situation, and assess current support system

and resources - Triage and de-escalate crisis situations - Provide clinical advice - Case management – offer referrals to

relevant follow-up healthcare services or

social agencies, focus on directing client to

IMH services • •

Roles The National Mental Health Blueprint (NMHB) was enacted in 2006 to promote mental health in the community through preventive care, early detection, timely treatment, and rehabilitation.

As part of this initiative, early detection systems for some mental illnesses were implemented in community and general hospitals.

Integrated Mental Health Care

Very often, schools, general practitioner clinics, and family service centres are the first to notice early warning signs of mental illness.

These institutions play a vital role in identifying people in the community in need of help. Our vision of psychiatric care is to move away from an acute illness-centred, institutionalisedbased healthcare delivery system towards a community-based model.

• • • • • •

Provide support to persons in need of mental health treatment Link IMH and partnering agencies Emergency contact point for persons in mental health crisis Reliable source for basic clinical advice, triaging cases Contact point for home visit assessment requests Improve community and public awareness of the scope of mental health and community resources so people know where to seek help

CELEBRATING MILESTONES & ACHIEVEMENTS

Aims Reduce impact of mental health emergencies through immediate response to crisis at community level • Prevent unnecessary hospitalisation and visits to the emergency department

•

Mobile Crisis Team (IMH) • Based on IMH’s Mobile Crisis Team • Home visits are scheduled Mondays to Fridays from 8.00am to 5.30pm only • Team of 4 experienced Community Psychiatric Nurses • Home visits consist of: - Assessment of basic mental state - Risk assessment and intervention onsite - Assessment of home environment and family dynamics - Clinical advice and psychoeducation onsite - Assessment of financial means-testing

documentation for the purpose of fee waiver

Primary Aim • Assess patient’s mental state at home

Secondary Aim •

Persuade patient to return to IMH voluntarily for assessment at E room. If patient is unwilling to follow the nurses, family members need to call a private ambulance to bring patient in the presence of the nurses

Home Visit Inclusion and Exclusion Criteria Raise request for MHH intervention through a home visit if any of the following criteria is present: • Patient/POI (person of interest) may have defaulted treatment and is presenting symptoms of a relapse related to a psychiatric or mental health-related problem • Patient/POI is non-compliant or not responding well to current medication and treatment • Patient/POI has significant history in past records that puts patient at risk of self-harm or danger to others (past admission records, previous forensic history, past suicidal ideations or attempts, previous history of violence, aggressiveness, and self-harm) • Patient’s/POI’s behavior or psychiatric symptoms potential risk of danger or harm to family members • Patient/POI displays poor self-care in the community and poses a risk to medical health

Intervention • MCT Homevisit Team will respond based on urgency of the required intervention, in accordance to NOK/patient’s preferred date of home visit date

Outcomes •

When admission is required: MCT Homevisit Team advises family on how to arrange for the patient/POI to be transported to IMH Emergency Department or other restructured hospitals with psychiatric wards. Modes of transportation include public transport, own transportation, police, or private ambulance (NOK consent and presence

is required) • When admission is not required, the MCT Homevisit Team will refer POI/NOK to other IMH services e.g. psychiatric outpatient clinics. The team may also advise patient to make an earlier appointment and follow-up with the psychiatrist.

They may also refer POI/NOK to other restructured hospitals with a psychiatric unit for assessment if patient/POI does not wish to seek treatment at IMH

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CMHT PROGRAMME REPORT 2018

Between FY08 and FY17, the Community Mental Health Team launched initiatives that were implemented and monitored using these indicators.

were engaged per FY.

From FY16, there has been a

Average hospitalisation episodes

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CELEBRATING MILESTONES & ACHIEVEMENTS

are provided to every FY.

were trained per FY

(stratified by PV/NH staff and other agencies’ staff).

scored at least

in the *CSQP survey. *CSQP: Customer Satisfaction Questionnaire - Patient

surveyed per FY were in the *CSQC survey. *CSQC: Customer Satisfaction Questionnaire - Customer

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CMHT PROGRAMME REPORT 2018

What is Solution Focused Base Therapy (SFBT)?

Empowering patients with an effective coping strategy that is client-centred.

SFBT, as the name implies, places emphasis on the positive aspects of our clients. It focuses on strategies or solutions devised by clients and refined during therapy sessions. SFBT is goaldirected and client-centred and places less emphasis on problem talk and more on recovery language.

Instead of focusing on the history of a client’s problem, SFBT tends to be presentand future-orientated. The past is only addressed to identify a client’s concerns and to show empathy towards the client. In SFBT, it is important to focus on exploring a client’s coping mechanism, successful experiences when he or she deals with the illness, and teasing out lessons and personal strengths learnt from setbacks or relapses.

SFBT consists of a series of speciallyconstructed questions asked by the practitioner. These questions can be classified as coping questions, miracle question, exception-seeking question, scaling question, and relational questions.

SFBT practitioners also use techniques such as normalising and affirmation.

When asking coping questions, therapists try to gain insights about a client’s coping strategies. It is vital that this coping strategy is made known to both client and therapist

because therapists will not be able to solve all the client’s problems. In SFBT, it is the client’s responsibility to address and resolve problems by using coping mechanisms that are most familiar and comfortable to him or her. However, when a client requests for assistance, the therapist can explore coping strategies with the client. Examples of coping questions: What works for you when you have to deal with stress? What have you been doing to stay well in the community?

When asking the miracle question, the client will be led to imagine and envision what his or her future would be like. The question may elicit a long answer and may seem abstract and surreal. However it is a question that is grounded in reality. Answering this question can give a client renewed hope and energy. It allows clients to think beyond their current problems and instead, envision how they can achieve a satisfying life. A miracle question could be phrased as follows: I am going to ask you an unusual question that requires some imagination on your part.

Here is the question: After this session, when you go home at the end of your day and it’s time to go to bed, imagine that everybody is sound asleep and the house is very quiet. In the middle of the night, a miracle occurs and the problem that you mentioned today is solved. However this miracle happened when you were sleeping, so you have no idea that there was a miracle and your problem has been solved. When you wake up from your sleep, what is the first small sign that would indicate that a miracle took place and your problem is gone! How would you discover this?

By answering this question, the client can take small steps to create a new reality after recovery. Such a question breaks the habitual problem-focused chain of thoughts typical of most clients and

CELEBRATING MILESTONES & ACHIEVEMENTS

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It is important to focus on exploring a client’s coping mechanism, successful experiences when he or she deals with the illness, and teasing out lessons and personal strengths learnt from setbacks or relapses. healthcare professionals. Ideally, after asking this question, there should be a visible change in the client’s demeanor e.g. smiling as clients attempt to describe solutions. After getting a reply on the miracle question, the next step is to identify instances when the clients achieves small “miracles” (exceptions). Clients are asked to recall and repeat these forgotten experiences.

When asking exception-seeking question, SFBT practitioners propose that no matter how serious a client’s problems are, there will still be exceptions. These exceptions can contain the solution of client’s problems. By asking exceptional questions, it is hoped that both client and practitioner are able to tease out the solutions to problems through the client’s answer. For example a client could be asked: When do you feel less stressed? What other ways of coping with stress haven’t you tried? When have you have felt better, even for a brief period in your life?

Scaling questions are a great asset to practitioners. They enable clients to do a self-assessment and evaluate their progress in manageable steps. These questions help a client quantify how close they are to reaching their life goals or how far they are from an undesired situation. Scales can be used to assess a client’s self-efficacy, selfesteem, motivational level, and hope. Here are some examples: On a scale of 1 to 10, with 10 representing very high hopes and 1 representing no hope, what’s your score? What do you need to do to maintain a score of 5? What needs to happen for you to move from a score of 5 to a score of 6? What can you do to proceed to the next level?

When asking relationship questions, clients will examine their issues in a more holistic manner and try to consider others’ perspectives.

This enables clients to gain insights on how their behaviour might

affects others. These questions provide clients with opportunities to broaden and refine solutions to their own issues. The questions can also be used in group therapy, which allows clients to tap the insights of other members. A client’s attempts to answer relationship questions also helps enhances a client’s awareness of the impact of their goals achievement on their significant others. Examples of such questions: How would your mother feel if you were to continue working despite your mental illness? What would your father say if he knew that you quit smoking?

Normalising is a technique used to address problem talk. It is based on the assumption that most clients who approach counsellors or case workers tend to feel overwhelmed by their own thoughts, problems, behaviours, and emotions. This technique involves a practitioner giving assurance to a client that his or her hardship and difficulties are understandable and problems that everybody faces. By reframing a client’s mindset and getting him or her to see that most people experience problems, it may help a client view problems as something that can be resolved and not pathological.

Reframing a client’s life problems as milestones or part of one’s life development

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is another way to normalise a client’s experience. For example the practitioner might say: It is not unusual to experience family conflict. We may feel angry, cry about it, or even experience periods of stress. We are humans after all.

Another statement that helps reframe a client’s experience is: Anybody with a situation like yours would also find it hard to cope.

This statement helps a client feel connected with those who experience difficult situations. It makes them feel that they are not alone in dealing with difficult situations.

CMHT PROGRAMME REPORT 2018

Community Psychiatric Rehabilitation Programme (CPRP) by the Association for Psychiatric Rehabilitation Singapore (APRS) This three-day introductory programme explores the objectives of psychiatric rehabilitation, fundamentals of recovery, principles of psychiatric rehabilitation, and ethics in psychiatric rehabilitation. The objectives of psychiatric rehabilitation are to allow clients diagnosed with any mental health condition to restore age-appropriate functioning, achieve a better quality of life, have good mental health, feel happy, and be in control. Psychiatric rehabilitation requires clients to learn new skills, whereas community psychiatric rehabilitation focuses on learning skills that are beneficial to clients as they live, learn, work, and socialise in the community.

SFBT practitioners also habitually use compliments to affirm a client’s strengths, past achievements in overcoming life problems, and their efforts to achieve desired goals. Compliments give clients hope and helps affirm the things that are important to them. Compliments can be direct, for example: You seem determined to work things out with your wife.

The questions can also be indirect, for example: How did you manage not to get admitted to the hospital? That’s quite a feat!

The latter format is more desirable as it gives clients an opportunity to identify and reflect on their own strengths and resources. Indirect compliments invite clients to be more involved in bringing about change, leading to a more detailed account of events. It also increases a client’s self-awareness, boosts their self-esteem, and self-efficacy.

Practitioners play the role of the great celebrator. They cheer clients on while clients try to remain vertical in the community by tapping skills and resources as well as supporting learning acquired by undergoing community psychiatric rehabilitation. Recovery in the community is when clients need the least amount of direct practitioner intervention to be successful and satisfied in living, learning, working, and socialising.

Recovery is achieved through self-determination and options.

The road to recovery involves others and that may include nonprofessionals e.g. caregivers, significant others. Another definition of recovery is: a process where individuals improve their health, wellness, live a self-directed life, and achieve their full potential.

Recovery is a multi-dimensional process and there are ten fundamental recovery components. The components are: selfdirection, individualised and person-centered, empowerment, holistic, non-linear, strengths-based, peer supported, respect, responsibility, and hope.

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Throughout the programme, 12 principles of psychiatric rehabilitation (PSR) are introduced. They are: PSR Principle 1: Psychiatric rehabilitation practitioners convey hope and respect, and believe that all individuals have the capacity for learning and growth.

PSR Principle 2: Psychiatric rehabilitation practitioners recognise that culture is central to recovery, and strive to ensure that all services are culturally relevant to individuals receiving services.

PSR Principle 3: Psychiatric rehabilitation practitioners engage in the processes of informed and shared decision-making and facilitate partnerships with persons identified by the individual receiving services.

PSR Principle 4: Psychiatric rehabilitation practices building on strengths and capabilities.

PSR Principle 5: Psychiatric rehabilitation practices are person-centred. They are designed to address the unique needs of individuals, which are consistent with their values, hopes, and aspirations.

PSR Principle 6: Psychiatric rehabilitation practices support full integration of people in recovery into their communities where they can exercise their rights of citizenship, as well as accept responsibilities and explore opportunities that come with being a member of a community and larger society.

PSR Principle 7: Psychiatric rehabilitation practices the promotion of self-determination and empowerment. All individuals have the right to make their own decisions, including decisions about the types of services and support they receive.

PSR Principle 8: Psychiatric rehabilitation practices facilitate the development of personal support networks by utilising natural support within communities, peer support initiatives, and self- and mutual-help groups.

PSR Principle 9: Psychiatric rehabilitation practices strive to help individuals improve the quality of all aspects of their lives: social, occupational, educational, residential, intellectual, spiritual, and financial.

PSR Principle 10: Psychiatric rehabilitation practices promote health and wellness, encouraging individuals to develop and use personalised wellness plans.

PSR Principle 11: Psychiatric rehabilitation services emphasise evidence-based, promising, and emerging best practices that produce outcomes congruent with personal recovery. Programmes include structured programme evaluation and quality improvement mechanisms that actively involve persons receiving services.

PSR Principle 12: Psychiatric rehabilitation services must be readily accessible to all individuals whenever they need them. These services also should be well coordinated and integrated with other psychiatric, medical, and holistic treatments and practices.

Like other institutions, psychiatric rehabilitation practitioners work with ethical considerations. Five key ethical issues in psychiatric rehabilitation are highlighted during the programme. They are: competence, multicultural competence, self-determination, rights of people using services and conflicts of interest. Other fundamental healthcare related ethics include autonomy, non-maleficence (do no harm), beneficence (duty to assist others), justice, and fidelity (duty to deliver what is promised).

References Carey, V. (2018).

Introduction to psychiatric rehabilitation 2018: Presentation slides.

McLean, VA: Psychiatric Rehabilitation Association.

De Jong, P., & Berg, I.K. (2008). Interviewing for solutions (3rd ed.).

Pacific Grove, CA: Brooks/Coke.

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CMHT PROGRAMME REPORT 2018

Creating an Impact with Positive Ideas Projects initiated by QIP teams have gone a long way in helping us serve CMHT patients better.

2014 CMHT Intake form

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2015 CMHT Pill Box

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2016 CMHT Passbook

2017 Hoarding CPIP Poster

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2017 Recovery Wellness and Sustenance (RWS) Template

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CMHT PROGRAMME REPORT 2018

The Power of Peer Engagement Julius A. Chan is one of the first local Peer Specialist Practitioners (2012) certified by the Singapore Association for Mental Health (SAMH).

When he was 19 years old, Julius was diagnosed with chronic schizophrenia, anxiety, and depressive disorder. But Julius has since made a remarkable recovery.

Having experienced the difficulty of living with a mental health condition, he now gives back to the community by sharing the life skills he learnt over the years with others. Julius walks alongside those going through what he previously went through.

He gives them support and encouragement by sharing his amazing story of recovery.

Today, Julius is a Peer Support Specialist and a mental health advocate with the Institute of Mental Health (IMH). He is passionate about helping those with mental illness or mental health concerns to recover, rebuild their lives, return to work, continue learning, participate fully in the community, and live meaningful lives.

Julius conducts programmes and workshops to promote total wellness.

He believes that mental health advocacy should not only aim to help people within our community achieve resilience but build an inclusive resilient village beyond our shores as well.

Learn more about Julius from “On the Red Dot – It takes a Village: Living with Schizophrenia” Search the web for more inspiring recovery stories: 1. Prof Patricia Deegan 2. Prof Elyn Saks 3. Dr Daniel Fisher 4. Mary Ellan Copeland 5. Eleanor Longden

Recovery Wellness & Sustenance Workshop (RWS) Julius started planning and developing the RWS workshop to empower patients with personal ownership in their recovery journey.

The workshop helps to broaden the social support they receive in the community and reduces patients’ admission rate and length of stay.

Workshop Objectives • • • •

Enter a brief recollection of personal past events and lived experiences to increase awareness Increase personal insight, acceptance, and understanding of mental health issues and conditions Coach persons with mental health issues and conditions to gain control of personal power and overcome loss Increase personal strategic experiential life skills of those on a journey towards recovery and sustained wellness who are reaching for their dreams with specific plans, with or without reduction of symptoms

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How is the RWS run?

In RWS chapters, the coach works collaboratively with participants to provide information, strategies, and experiential life skills that participants can use to improve their wellness. There is an emphasis on providing assistance and support to participants so as to improve their quality of life as well as promote inclusivity in the community. Participants learn to put the lessons learnt into practice in their daily lives.

Participants must have a level of awareness and stability to take part in the workshop. They need to believe in the possibility of recovery and understand the basic language of recovery. Participants must also complete reflection worksheets, participate in group sharing, and feel comfortable with group presentations.

Coaching RWS Lived Experiential Life Skills

1 The Recovery Journey and The Goal for Wellness Sustenance 2 Acquiring Experiential Life Skills Coaching 3 Moving From The Medical Model of Diagnosis & Acquiring Insights of Mental Health Issues 4 Acquiring Stress Awareness and Exploring Experiential Strategies 5 Adopting Natural Support Life Skills 6 Minimising Medication Dosages vs Maximising Effective Management 7 Care Plan as a Necessity vs Relapse with a Choice 8 Addressing Fears, Facing The Unknown – Engaging Solutions From Inner Wisdom 9 The Graduation Practice: Recovery & Wellness Sustenance (RWS) Workshop

BEFORE This photo was taken in July 2012 when Julius was recovering after being diagnosed with schizophrenia. Depressed, he had indulged in comfort eating that resulted in weight gain, borderline diabetes, high blood pressure, high cholesterol, and a fatty liver.

Feedback from participants

1 Promotes Peer Support Movement 2 Promotes mental wellness by improving peers’ quality of life 3 Improves partnership between health care professionals and peers 4 Promotes responsible stewardship in health care by empowering peers to take ownership of their health,

as shown in the comments by a peer.

5 Promote integration of social care and health care

Peers communicate via a whatsapp chat group named “Community Village”. Created by peer mentors, this communication channel allows peers to have a platform

to share resources, as seen in the chats below.

AFTER Determined to recover mentally and physically, Julius embarked on a weight loss regimen. Through a combination of healthy eating habits and exercise, he managed to shed 20kg in two years. Although he weighed 79kg previously, Julius became trimmer at 59kg and free from physical “ailments”. He is proof that anyone can achieve their goals with discipline and determination.

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Milestones & Achievements

Dr Joseph Leong Jernyi was awarded the Healthcare Humanity Award 2010 and the Distinguished Public Service Star Award 2013.

Welcome dinner held on 30 July 2010 at the Singapore Food Festival with HMDP overseas expert Prof Alex Kopelowicz (UCLA, Psychiatirc Rehabilitation), Dr Lee Cheng, and Dr Joseph Leong.

Best Poster Award 2012 at the World Association for Psychiatric Rehabilitation held in Milan, Italy was awarded to the Personal Effectiveness for Successful Living (Social Skills Training) Programme by CMHT.

Occupational Therapist Clare Ang conducting Social Skills Training in 2011 using the Personal Effectiveness for Successful Living format for behavioural rehearsal and scenario role play.

HMDP overseas expert Prof Alex Kopelowicz demonstrating motivational interviewing by role play.

Hosting overseas expert trainers Dr Kari Valtanen and Senior Nurse Practioner Mi Kurtti, who were attending the Open Dialogue in October 2014.

CMHT Motivational Interviewing Training for IMH staff in partnership with the Nursing Education Department (Dr Xie Hui Ting, Dr Joseph Leong, Nurse Clinician Sharon Tan).

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Open Dialogue Workshop held in October 2014 organised by the Singapore Association for Mental Health (SAMH).

CMHT doctors also act as advisors and social activists. Dr Hariram, President of Club2Care with Dr Joseph Leong, President of Association for Psychiatric Rehabilitation, Singapore at the Club HEAL event where Dr Leong serves as the Expert Advisor.

CMHT supporting the launch of the Peer Support Specialist Movement in IMH with CEO Chua Hong Choon and overseas expert Dr Lori Ashcroft from Recovery Innovations in 2015.

Dr Wei Ker Chieh awarded the Sayang Award 2012 and Healthcare Humanity Award 2013.

Dr Lee Cheng awarded the PS21 Star Award 2010 and NHGDistinguished Achievement Award 2014.

CMHT won the Excellent Service Team Award 2015 (when MCT is still part of CMHT).

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CMHT PROGRAMME REPORT 2018

Finding Strength When will the pain end?

The road to mental health wellness is not always smooth but with support from professionals, caregivers, and the patients’ efforts, there is always hope for a better future.

With the unwavering support and encouragement from the multi-disciplinary team of doctors and nurses together with family members, Patient I.T. braved through her personal struggles to eventually manage her insomnia and schizophrenia. This is her story.

“I started developing symptoms of schizophrenia when I was 18 years old. It started with insomnia when I was prescribed sleeping pills which improved my condition but resulted in me talking to the images in my mind. Little did I know these were the first symptoms of schizophrenia.

My condition worsened and soon I was totally controlled by my inner voices. Left with no choice, my father admitted me into IMH then known as Woodbridge Hospital.

Dr Leslie Lim was my attending physician at that time. Under his meticulous care, I was well for 4 years until I was pregnant. I had to stop my medications due to my pregnancy and after giving birth, symptoms of insomnia and schizophrenia arose again. As I was on confinement, I could not be admitted into the hospital and instead continued my treatment at Choa Chu Kang polyclinic.

All was well till 2013 when I took up a full-time job. It started off well until I was promoted. I could not manage the increased stress and insomnia crept in again. I quit my job in October 2013.

The banks chased after for the repayment of my loans. I started stuffing myself with food to try to make myself feel better. Things were made worse when I found out my children were failing all their subjects in school. I was constantly in fear of not being able to fall asleep and resorted to drinking liquor to force myself to sleep. I did not bathe for days and ate instant noodles daily. I dared not even step out of my house.

One day, my mother visited me to find out how I was coping with my work since she had not heard from me for days. She was devastated to see me in this state and decided to bring me to IMH’s Emergency Services.

Under constant medication and care of the medical team, my condition stabilised and I was discharged.

I was referred to the Community Mental Health Team (CMHT). Ms Kuldip Kaur was my Nurse-InCharge. With her encouragement, I took up some courses and picked up useful skills. With her support, I was no longer addicted to alcohol.

Through these workshops, I also met Mr Julius Chan who was one of the trainers. He is an IMH peer specialist who shared his recovery experiences during the workshops.

I was inspired by him and was even more motivated to improve my condition.

I did not want to continue my treatment at IMH for fear of stigma

and was looking for a doctor from a private clinic. Dr Nigila whom I met at NUH kindly offered to take me in as her patient. She convinced me to continue with my treatment.

This arrangement continued for 4 months until I was stable enough to be employed.

I was devastated when one day, I found out that my husband had a mistress. In a bid to make myself feel better again, I spent endlessly. I went back to gambling and demanded money from my husband to repay my debts. I turned to liquor again and showed signs of abnormality.

Kuldip advised me to get admitted to IMH again. Dr Nigila and Kuldip visited me. I was touched. My treating doctor was Dr Vivek who took great care of me. Through the friends I made in the ward, I knew I was not alone as all of us were going through similar experiences.

Even till now while we are now working at different places, we still keep in touch. My brother also kindly helped to clear my debts and my husband ensured I took my medication regularly.

I am very thankful for my family throughout my recovery journey.

Even though the journey was not smooth-sailing, I made friends who were in the same boat and went through thick and thin with me.

Most importantly, under the care of Dr Nigila, Dr Vivek and Kuldip, I had the chance to live normally. A word of advice to all fighters battling this illness: Do not stop your medication unless instructed by your doctor.

Stay strong and persevere! You will get there one day.”

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Always By My Side “I was diagnosed with early psychosis. The side effects of my medication to treat psychosis were so unbearable that I skipped them most of the time.

This led to a vicious cycle of relapsing and readmission until my doctor sat me down and made me see how much this was hurting my loved ones. From then on, I started to take my medications regularly and stopped consuming slimming pills.

Three years passed. I realized most of my clothing could not fit me.

Believing it to be the side effect of my psychosis medication, I stopped them totally.

My condition worsened to a point that I had to be admitted into IMH. Dr Joseph Leong, my Psychiatrist, changed my life. I am

thankful that he introduced me to the Illness Self-Management and Recovery programme. Through this programme I met, Mr Julius Chan, the programme trainer who was one of IMH’s peer support specialists.

He was once a patient who suffered from mental illnesses. I was inspired by his recovery experiences which motivated me to overcome my illnesses. I was taught useful skills such as stress management and how to identify early symptoms of schizophrenia which helped me to better manage and be in control of my condition.

In addition, Dr Leong also referred me to Job Club to receive vocational training. I am happy to say that I am now employed and love my job. Dr Leong had also arranged for one of the Community Mental Health Team nurses, Ms Melissa Sng, to conduct

regular home visits to my house. I am grateful to Melissa as she was always there for me when I needed help most. Soon, activities like sports, daily exercise, volunteering activities and outings with friends gradually became a part of my life. Besides that, my family did not give up on me. My mother once said, “I want to see you well again, to be the same old bubbly girl you used to be”. With the support of the wonderful medical team and with having my family by my side, I am now better able to control my mind and emotions.

Editor’s Note: It was an arduous recovery journey for Michelle. Having battled psychosis and schizophrenia for 10 over years, she has met with many setbacks. Her determination, family support and compliance to the medical team have helped her go a long way.”

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Now I Know Nothing is Impossible It was just another typical day at the swimming pool — Water splashing, children laughing and shrieking at the top of their voices.

Patient A was there like any other mother reminding her children to be careful. Seeing her now, it would be hard to believe that she used to be diagnosed with severe depression. Through the Illness Self-Management and Recovery programme, coupled with her own resilience and determination, Patient A is now leading a happier and more fulfilling life.

Patient A lived with her husband, three children and mother-inlaw. On any typical day, she had to juggle affairs both at work and at home. Years ago, she was diagnosed with depression. She had been following up with her appointments and was taking her medication regularly. However, with her children misbehaving in school and feeling like her husband was neglecting her with his long hours at work, she started developing suicidal thoughts. This resulted in her sinking lower into depression and anxiousness which worsened the relationships she had with her family. Shortly, her son displayed anxiousness together with violent and aggressive behaviour and was referred to the Child Guidance Clinic in IMH. Things started to change for the better after Patient A attended her first counselling session. This allowed her to build a better relationship with her son instead of caning him each time he misbehaved. She also sought external help from private tutors

who were better able to teach and help her son to cope with school work. She found the space to empathise with her husband who had to work long hours to support the family. This greatly improved her relationship with her husband.

As the relationships with her family got better, Patient A’s condition showed signs of improvement.

Counsellors subsequently referred her to the Community Mental Health Team (CMHT) where she started on the Illness Self-Management and Recovery programme. She was taught to set goals for her recovery, gain further insights into depression, learning when relapse might be triggered and to better manage her stress levels. Hearing stories of patients that have overcome depression and anxiety successfully, Patient A was determined to overcome her mental illness as well. It has been 2 years since she was discharged and she has since been coping well with both her work and family life.

Recovery from depression is possible. It might take months or even years to manage it well.

However, with determination and support from CMHT and their families, we believe each patient will be able to see the light at the end of the tunnel.

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Buangkok Green Medical Park 10 Buangkok View, 539747 Tel: 6389 2000 www.imh.com.sg