

The Birth of Singapore's First Voluntary Welfare Organisation for Mental Health
REFLECTIONS
This article was written for SAMH’s 40th Anniversary publication in 2009
Dr Paul W Ngui
Past President SAMH: 1971-1973; 1975-1988
HISTORY OF THE SINGAPORE ASSOCIATION FOR MENTAL HEALTH
1969-1989: The First Twenty Years
In 1989, on the 20th anniversary of the Singapore Association for Mental Health (SAMH), I contributed a paper on its early beginnings to the SAMH Insight journal.
That article traced the personal journey of a young medical officer from Woodbridge Hospital following an invitation to the Hong Kong Mental Health Association Annual Dinner in 1958. The exposure to the association and the community mental health services left a deep and lasting impression. In later years, dream and vision coalesced to spawn a mental health association in Singapore.
The paper portrayed the early struggles of Woodbridge Hospital Rehabilitation Committee to establish the Singapore Association for Mental Health in 1969. It covered very briefly the work of SAMH from 1969 to 1985.
This article [circa 2009] is a sequel to the earlier paper [in 1989] and it chronicles the progress of SAMH in the eventful 1970s and 1980s, in meeting its key objectives of promoting mental health, the prevention of mental illness and the rehabilitation of the mentally ill.
But to truly appreciate the formidable challenges of managing mental illness in Singapore, it is important to cast an eye over the mental health scenario in the early 1950s.
Woodbridge Hospital, formerly known as the Mental Hospital, was built in 1928 for the care of the mentally ill. Just before the fall of Singapore to the Japanese in February 1942, mental patients were discharged to their homes and the milder cases numbering about 500 were transferred to St. John’s Island, the colony’s quarantine station. The transfer was in anticipation of converting the mental hospital into a General Hospital.
During the Japanese occupation, the Japanese used the hospital as a Japanese Civilian and Military Hospital. The Japanese surrendered in September 1945 and the Mental Hospital resumed its custodial function with just over 500 patients in April 1946.
In the early 1950s, the Mental Hospital, renamed Woodbridge Hospital, was the largest hospital here, its chronic wards filled with a backlog of long-stay patients abandoned by their families. The mental health sector was the “Cinderella” of the medical health services with low priority for development funds and subsidies.
Grossly understaffed with a mere handful of medical officers looking after as many as 2,000 patients, distantly located and isolated from the community, there was a huge dichotomy between hospital and community care. Overcrowded psychiatric outpatient services could not provide good continuity of care for the discharged mental patients.
An early discharge programme by Woodbridge Hospital in the late 1950s proved a dismal failure. Most families were ill-equipped to cope with a mentally ill relative. Discharging the recovered psychiatric patients to unreceptive families with highly expressive emotions led to a cycle of relapses and readmissions and contributed to the revolving door phenomenon of a mental hospital.
Public ignorance, fear and stigma of mental illness were obstacles that needed to be overcome.
Formation of SAMH
This was the mental health scene in 1967 when I was appointed Chairman of Woodbridge Hospital Rehabilitation Committee. I was faced with the daunting task of organising rehabilitation programmes for mental patients in the community.
I soon realised there were considerable limitations to what the Rehabilitation Committee, as part of a government institution, could achieve. A voluntary body such as a mental health association could do better.
The Woodbridge Hospital Rehabilitation Committee, together with Rotarians from the Rotary Club of Singapore West, mustered together a like-minded group of medical and mental health professionals, social workers and others committed to advance the lot of the mentally ill – stigmatised and marginalised by society.
A pro-tem committee was formed, the constitution drafted, and the inaugural meeting of SAMH was held at the Shell Theatrette on Saturday, 26 April 1969.
In the initial years, much of the early work of SAMH was executed by the Management Committee and a dedicated group of volunteers. It was a formidable task because of a lack of funding, personnel, and infrastructure and training facilities. There was also no paid staff.
SAMH identified mental health education as a priority and focused on community mental health education programmes to create public awareness of mental health and mental illness. Psycho-education was directed at the family and community with the important message that mental illness was treatable and mental patients could adjust to a normal life back in the community. Talks and seminars were also targeted at specific professionals.
Stigma and fears attached to mental illness needed to be erased before the community could readily accept the discharged mental patient at home and at the workplace, otherwise any effort at reintegration would fail.
1970s: A Decade of Consolidation and Growth
In the early years, financial constraints meant that the Management Committee had to be actively involved in fundraising such as organising fun fairs and walkathons in collaboration with the Rotary and Apex Clubs and others.
Out of necessity, many of SAMH’s activities were focused on mental health education programmes for the public and key professionals. They were generally self-financing.
In 1970, SAMH organised and hosted a World Federation for Mental Health Workshop on “Mental Health Trends in a Developing Society”. Delegates from 14 countries attended.
In 1971, SAMH, together with the Singapore Teachers’ Union, organised a workshop on “The Teacher and Mental Health”. It emphasised the crucial role of teachers in primary prevention, especially in the early recognition and prevention of emotional problems amongst children under their wing. The workshop was also successful in bringing several different disciplines together, discussing the influence of the educational system on the mental health of students.
October 1975 marked an important milestone with the establishment of the SAMH Centre in Toa Payoh. The association finally had a headquarters to call its own and could consolidate its various programmes and services. It took two years to plan and it housed an administrative office, a library, a meeting room, a counselling room and a hall for social club functions.
The Oasis Club, a social club for recovered mental patients, was one of the earliest services organised by SAMH . It began humbly in December 1969 with meetings held at the St. Andrew’s Cathedral church hall and library. It arose from an acute need for a counselling and social programme for patients discharged from Woodbridge Hospital. The activities of the Oasis Club were moved to SAMH Centre, which eventually became a base for counselling services in 1981.
The Half Way House project came about after consultations with the Ministry of Health over the need for short-term residential care for psychiatric patients, many of whom suffered relapses and readmissions because of psychosocial factors, mainly a rejecting or hostile environment at home, at work or in the community.
There were rehabilitation programmes for male psychiatric patients at View Road Hospital but none for female patients. After two years of detailed planning, SAMH established the first Half Way House (HWH) for female patients in July 1977.
The Half Way House comprised two bungalows located in a residential area at Rochester Park close to Queenstown, a satellite town with small industries and factories. It could accommodate 20 residents.
All of those involved, including myself, were new to managing a Half Way House. It was an interesting hands-on, learning experience for the Half Way House Committee members and staff. We had a medical social worker, a nurse/supervisor and three assistant supervisors. The residents were responsible for grocery shopping, cooking, house-cleaning and gardening. Social, occupational and rehabilitation programmes were organised.
The assistant supervisors had a two week stint at Woodbridge Hospital to prepare them for their new vocation. Establishing the concept of a therapeutic community and an understanding of group dynamics to staff with no previous training in nursing or social work entailed intensive group meetings.
Regular fortnightly sessions with staff and separate group sessions with the residents were necessary to maintain the morale of staff working under trying conditions. Problem behaviour by residents was brought up and analysed, and group recommendations were made. Readmission to Woodbridge Hospital was an option for difficult, suicidal or aggressive behaviour. Only once was a night visit necessary to bring a very disturbed resident to Woodbridge Hospital.
Many patients have benefited from the Half Way House and, in later years, communicated their gratitude for the time they spent in the Half Way House. The Half Way House also established a sheltered workshop, in one of its annexes, for non-resident ex-mental patients.
It was a sad day when the Half Way House formally closed its doors in 1994. In a review, the Management Committee concluded that the programme was too costly to run and had outlived its usefulness. Singapore was in urgent need for other rehabilitation programmes which it still lacked, such as group homes, a kind of sheltered accommodation for stabilised mental patients who were in gainful employment.
In 1979, the National Health Campaign was launched to combat diseases due to harmful lifestyles, namely:
• Lung cancer
• Ischaemic heart disease (heart attacks)
• Mental illness
• Diabetes
The campaign also had graphic posters that read, “Mental Illness can be inherited” and “No child should be born to suffer”.
It was unfortunate that the core message of the campaign portrayed mental illness as a hereditary disease and consequently regarded as chronic and refractory. It created the undesired effect of increasing stigma attached to the mentally ill rather than reducing it. This, together with an earlier drive for voluntary sterilisation by ligation for mental patients at Woodbridge Hospital, provoked much controversy with adverse publicity and widespread negative public reactions.
It was a low point for mental health in Singapore.
In its wake was a flurry of public debate and professional views on the genesis of mental disorders and the relevance of the environment and stress as important causal factors. This was a positive outcome as it opened the eyes of the public to the existence of mental health problems in society.
1980s: A Period of Education
In October 1981, SAMH organised a seminar on “Mental Health – A Positive Approach”. It raised public consciousness on the priority of developing positive mental health for everyone.
In 1982, SAMH embarked on a wide-scale mental health education programme for the public. Its aim was:
• To inform and educate the public on positive mental health.
• To modify personal information, attitude and actions of the public to a direction favourable to mental health.
• To create a better understanding of mental illness and remove its associated stigma.
• To encourage patients to seek treatment early.
• To provide information on SAMH programmes and services and that of other mental health agencies in Singapore.
At its heart was a mobile exhibition staged at various commercial firms, institutions and factories targeting staff at different levels. It consisted of talks, seminars and a film show, supported with information brochures and pamphlets. Similar events were also held at the National Library, the National University of Singapore and the Police Academy.
The response to the mobile exhibition was mixed, with better attendance in institutions of learning than in factories. It did reveal that misconceptions about mental health and mental illness were prevalent not only among factory workers but also among executives.
In October 1982, S.A.M.H. held a very successful seminar, “Bringing up Children Today”, targeting parents on the benefits of positive parenting.
SAMH Survey of the General Health of the Singapore Population
In November 1985, I chaired a General Health Survey Committee, comprising a team of experts, to organise a mental health survey of the general population.
The aim of the survey was:
• To determine the prevalence of minor psychiatric morbidity (MPM).
• To establish the relationship between minor psychiatric morbidity and the individual’s life cycle in work, marriage, family life, leisure and other variables.
• To determine whether the support of family, relatives and friends have an ameliorating effect.
We completed the background work and concept paper by June 1986.
Much planning and work were involved in the construction and modification of a 28- item General Health Questionnaire (GHQ 28) to be used as a measure of the well-being/ mental health of the people.
In September 1986, designated volunteer psychiatrists applied the modified GHQ-28 to 150 subjects comprising an equal sample of new psychiatric referrals and those from the normal population to test its validity. The validation was completed in late January 1987.
Between April and August 1987, a field survey was conducted on a representative sample of the adult population (a total of 1,153 respondents) between the age group of 21 and 55 years.
The significant findings were:
• The point prevalence rate of minor psychiatric morbidity was 17.95%.
Those individuals at higher risk were:
• Young adults 21-25 years old, most vulnerable with a significant high prevalence rate of 25.41%.
• The divorced, widowed and separated.
• Workers subject to environment such as
- Work pressure.
- Work with machines involving physical risks.
- Shift duty.
- Entertainment.
- Work of more than 60 hours per week.
- Overseas travel.
The number and severity of adverse life events (legal, health, employment, financial and interpersonal problems) were especially significant, particularly where the individual experienced three or more life events during the previous six months.
An important finding was the presence of family support or a personal confidante were significant ameliorating factors in protecting the individual against a breakdown.
Being one of the first mental health surveys of the general population done at that time, the prevalence rate of around 18% might have appeared alarming but the figure was consistent with other international findings.
However, findings from the survey provided the basis of systemic planning of services by SAMH for the mental well-being of Singapore. Despite the passage of time the contributory psychosocial factors to minor psychiatric morbidity still remain very relevant today.
1989 – 2009: The Next Twenty Years
The mental health scenario underwent a number of transformations for the better. The Institute of Mental Health was established to take on a broader function than those covered formerly by Woodbridge Hospital.
In 2004, a National Mental Health Survey conducted in Singapore found that 15.7% of adults suffered some form of mental health problem (it included anxiety, depression, phobias) that affected their effectiveness and well-being. This confirmed the SAMH survey finding that minor psychiatric morbidity was not an anomaly.
Of interest was that 12.5% of children (aged 6 to 12) had emotional/behavioural problems such as depression, anxiety and social withdrawal.
In 2007, the Ministry of Health announced more positive policies and programmes directed at the promotion of mental well-being in the general population, early detection of mental health problems, strengthening mental health manpower and mental health research.
The Government committed an additional $88 million over a period of five years (2007 – 2011) towards building Singapore into an emotionally resilient society with good access to effective mental health services. Another $17 million every year would thereafter be committed to promote mental well-being. With positive government support, the future augurs well for mental health in Singapore.
In Summary
I am happy and proud to have been part of the process in the early genesis, development and contribution to the objectives of SAMH.
The first 20 years of progress may be considered slow, but conditions in the field were tough. We managed to maintain an excellent standard of care and services with the bare minimum of professional staff and funding. For this, we have to thank many of the mental health professionals and voluntary workers who have been selfless in providing their time and expertise in the various SAMH programmes. Their unstinting efforts have provided the base from which SAMH has flourished rapidly in the subsequent 20 years.
Today, 40 years on, I am very pleased to see that SAMH has grown in stature with staff strength of over 60 and expanded services with several outreach programmes in the community.
I wish to congratulate the successive Management Committees for the grand transformation of SAMH into a vibrant organisation reaching out to the needs of a growing nation with multiple complex socio-cultural and mental health challenges ahead.
References:
1. S.A.M.H. Insight journal, 1989.
2. S.A.M.H. Survey of the General Population, report published by Singapore Association for Mental Health,
March 1989.
3. Press Release: “Strategic roadmap to build up a mentally resilient society”, 23 September 2007.