Visit to Manila, Philippines 2000
In November and December 2000, WFSAD Past-president Margaret Leggatt and President Jim Crowe travelled to Manila, Philippines. It was their second trip in less than two years.
Observations from their first visit in May, 1999 are summarized in the following two quotes:
"While family support is deemed to be very necessary by the psychiatrists that we met, the idea of an independent family support organization had not been considered, nor had anyone any idea about what family organizations can achieve. There were certainly no initiatives from family members themselves."
"We presented ideas about training families in the idea of self-help, and in starting to see families and patients as equal partners so that they were trained in becoming less reliant on professionals as their confidence increased. This was described as a very revolutionary idea."
The doctors wanted very much to have ongoing contact with us to see how this could be made to happen.
Subsequent to this visit, Dr. Marissa De Guzman was invited to our Jerusalem conference to present a paper on her work in developing the Family Care Program in Calumpit, province of Bulacan.[You may obtain her presentation by requesting a copy of the proceedings of this conference from WFSAD].
During our second visit it was very rewarding for us to hear that several family groups had been formed. The following report outlines the conference Margaret Leggatt and Jim Crowe attended, as well as some of the family support they offered.
"Destigmatisation: Promoting Partnerships among Families and Caregivers Towards A Caring Community"
About 150 participants including clinicians, patients, family members and many representatives from the health and education sections of the Civil Service Commission, attended.
Keynote speakers were Dr. Zeb Taintor, the president of WAPR, who spoke on promoting partnerships with agencies involved in mental health service delivery, while Jim Crowe spoke more specifically on Strengthening Families through Empowerment. The conference was significant for the number of personal testimonies that were given by patients and family members.
Dr. Ladrido Lourdes Ignacio, President WAPR Philippines, spoke on Identifying priorities for developing countries in community and family works. Because of the low priority given to mental health, Dr. Ignacio felt that an important way forward was to piggyback, that is, to present a mental health perspective into health programs that were already in existence, or were about to be set-up.
These priorities are reported here under the headings that she used, as we feel we need to understand what mental health workers in the Philippines see as important:
- to increase the overall awareness of the health burden.
- to increase awareness of the availability of effective interventions medical as well as psychosocial.
- inclusion of mental health in the national health policy and budget.
- integration of mental health into the general health care delivery system, with an emphasis on shifting from hospital-based care to mental health care in the community. For example, there are already psychosocial programs attached to the disaster relief programs.
- focused activities directed at destigmatisation.
- focused activities directed at families and caregivers. (In the Philippines, caregiver is the word used for professional mental health workers).
Many excellent presentations followed from Filipino psychiatrists. Dr. Ornate challenged her peers about the way that they perpetuated stigma and discrimination.
Dr. Eliss Nazal Simon developed the following approach to mental health awareness. We have reported it here in some detail, because it seemed a very effective way of describing problems and what needs to be done. The first letter of each line, when combined, spell WE ARE O.K.:
Wake up. Families need to face the reality.
Educate. Psychiatrists fail to educate families.
Adjust. Correct wrong attitudes, lower expectations, do not give up your own life.
Review. Look at what resources you have not only financial but resources from among other families and friends.
Express. Find understanding through therapy.
Keep the faith - in God to help you to move beyond yourself.
This conference was notable for papers that talked about the relationship between spirituality and recovery. Mental health is an integrating concept - integrating the physical, psychological, social and the spiritual aspects of individuals.
Spirituality, especially for the Filipinos, was identified as a resource that needed to be acknowledged and utilized in recovery.
Dr. Ivan Escartin talked on The Family Care Program in Bulacan already mentioned in our first report. Bulacan is a rural community; stigma has been impenetrable up until now; the program is an example of central psychiatric services in Manila developing a psychiatric initiative in a rural area. He described the program under three headings:
- Awakening identification of a significant family member and asking for their commitment to a treatment program.
- Working together: Training community-based personnel in the management of psychiatric patients; teaching them how to handle focus group discussions, holding meetings between health center personnel and significant members of the family with a mentally ill relative. Verifying the technical capability of the treating doctor.
- Doing it on its own: Manila partners now stay in the background; regular meetings with families are convened where the health center personnel take the lead, but where the family members have now become very active. Attempts are being made to go beyond the resources of the health center to find money for medication, and for the development of livelihood projects.
A very important development for WFSAD was the description of the Philippines Schizophrenia Society. Dr. Bobby Capistrano started this family support group which now has 300 members and is doing very well. Dr. Capistrano described how he started this group very much as a psychiatrist, but found that as he got to know the families, he related to them more personally, going beyond the prescription of meds to hearing and responding to their distress. He believes that he now has to go the next step, which is for him to move away from being in charge of the group, but to assure the group that he will back it when needed. They now need a venue and minimal funds for operational costs.
The organizers of this conference hope to repeat it annually. [Note: It has been repeated in 2001]. It was an impressive beginning, involving as it did such a wide section of community representatives outside formal mental health services.
Leggatt and Crowe visited Nazal Halfway House which caters to 33 people and was founded in 1968 probably the only one of its kind in the area. They then made presentations at the Philippines General Hospital.
When organizing this visit, we had asked that at these presentations, we wanted family members and patients to be present not just medical staff. The audience was an impressive mixture of new psychiatric registrars, other staff members, family members and patients a first time occasion.
Jim Crowe presented techniques of early intervention, and Margaret Leggatt spoke on the process of working with families in groups (the McFarlane model).
They then visited the Veterans Memorial Hospital.
This hospital had also commenced a family support group. We were able to meet with them 28 family members attended of which 15 were new families. The original family members told the new families about the benefits they had received from belonging to a support group, stressing particularly that the information that they had received had allowed them to understand much better, to realize the importance of standing back and learning to be more patient. This hospital is for military personnel and is therefore rather privileged.
An interesting situation arose in this group when members asked if Australia and New Zealand could help them by purchasing medications, as most families could not afford to buy them once they left hospital. The interesting response from the psychiatrist in charge of the group was that Filipinos had to do things for themselves and not rely on others to help out. There are plans now to expand this group, and particularly to stay together because of the beneficial effects that the group can provide.
The emphasis in this meeting, was to support them by suggesting:
- Ideas for advocacy; e.g. how can they get the medications that they need in their country.
- That this illness responds to many other forms of treatment and care - psychological, social, emotional, vocational. These forms of treatment are often not provided by clinicians, and a family support group can work towards making sure that these treatments are given.
- One of the psychiatrists suggested that they should start to look at the development of street stalls, a prolific form of small business in the Philippines, which would be well suited for rehabilitation of psychiatric patients.
- Initial communication with the New Zealand Embassy - for some future funding through their Small Projects Fund as seeding money to develop the family support initiatives. Leggatt and Crowe would like to thank Moira Turley and Patricia Tan for their interest and support.
At the conclusion of our second visit to the Philippines, Jim Crowe and Margaret Leggatt want to make the following comments:
We have found what Prof. Deva (WHO) said on our first visit to Manila, that unless you show that you are seriously interested in them and are prepared to stay and really discover what is happening by staying for at least a few days, then Asian people will not feel that you are genuine, that you are really concerned and that you are prepared to understand their differences.
We feel more and more, that we have to visit the country and its people; it is not particularly appropriate that they come to visit us.
We just arrive! We have stated - repeatedly - that we come to learn first and foremost. What do they see as their needs? We asked questions and we listened.
We also repeated that we in the West have not yet got it quite right, that there is still a long way to go; especially as to the inclusion of families as partners in care.
Then together, we discuss possible ways that we might be able to work together, to share ideas and to learn from each other.
Above all, we are not coming in to their country to show them how to do it!!
This defeats all the principles of self help, is antithetical to the development of good relationships, is patronizing and arrogant.