Project: Car Wash & Polish DR HJH RABAIAH MOHD SALLEH CONSULTANT FORENSIC PSYCHIATRIST HOSPITAL BAHAGIA ULU KINTA INTRODUCTION Hospital Bahagia Ulu Kinta, the largest of 4 psychiatric institutions in Malaysia came into operation way back in 1911. Then, it had a population of about 5000 inmates, some of whom had been brought in from places as far as Singapore and Sumatra, Indonesia. Slowly over time, with the advancement of better medicine and good psychiatric care provided, Hospital Bahagia Ulu Kinta (HBUK) was able to bring its total number of inmates to the present average of 1900-2200 Admissions to HBUK are either via civil or medico-legal admissions. The definition of medico-legal or forensic admissions is admissions via referrals through the courts, prisons and other relevant detention centers. Forensic psychiatric patients are those patients who have had some problems with the law. Usually their first contact with HBUK is as a result of running foul of the law and the judicial system. A large majority of the mentally disordered offenders gets referred by the courts for a psychiatric assessment as is provided for under the Malaysian Criminal Procedure Code (CPC). A psychiatric report is issued at the end of their stay, which is then used in courts. Most of them do not come back as forensic admissions anymore. However the law provides for readmissions to the Forensic Wards HBUK under Section 344 of the CPC, a section of the law which provides for detention because the patients (accused in the court of law) were not fit to stand trial and Section 348 of the CPC which provides for detention because the patients were found guilty as charged but acquitted because of insanity at the time of offence. Thus, most of the patients at the Forensic Wards of HBUK are those detained under the above-mentioned sections of the Malaysian CPC, 142 patients under section 348 CPC and 28 patients under section 344 CPC, out of which 15 are female forensic patients. The majority was diagnosed to be suffering from schizophrenia (90%) while the rest had diagnoses, which included bipolar mood disorder, organic mental disorder, mental sub normality and personality disorder with poor impulse control. FORENSIC REHABILITATION Forensic psychiatric patients are difficult to treat. They are involuntarily committed for treatment, and few would seek inpatient treatment of their own violation, despite or perhaps because of gross psychiatric and functional impairment. A psychosocial approach to treatment focuses on the reduction of psychiatric symptoms, primarily 25
through medication and the development of functional skills associated with relapse prevention and adaptation to less restrictive environments. The ultimate goals are recovery, reestablishment of normal roles in the community, development of a personal support network and increased quality of life. With the objective of preparing patients for an independent life in the community, a paradigm shift from totally custodial to active promotion of Psychosocial Rehabilitation with the support of a multidisciplinary team was actively pursued. Psychosocial Rehabilitation Therapy starts from the day a patient is received into the forensic wards. There are 5 wards especially designated for forensic male patients, comprising of ward 23 as a high security forensic ward, ward 22 and 24 as medium security forensic wards and ward 21 and 25 as open forensic wards. The Forensic Car Wash and Car Polish Projects are projects initiated especially for patients who have undergone rigorous assessment and work-up before they finally become residents in the open wards 21 and 25. Thorough and comprehensive patient assessment is an essential prerequisite to the appropriate provision of rehabilitation therapy services. Ward 21 is a 12-bedded ward while ward 25 is able to hold 25 patients. Most of the patients in these two wards are stable, quite motivated, may or may not have good family support but essentially they are all stable enough to be discharged back into the society. In preparation for their eventual discharge, being job-placed is one of the main focuses of the patients and staff attached to the wards. PROGRESS The Fountain Car Wash Project was initiated and officially declared open by YB Dato Hj. Ahmad Husni bin Hanadzlah, Member of Parliament for Tambun on 26 July 2003. With a grant of RM5000 from the Malaysian Psychiatric Association (MPA) and a further RM2000 from the Forensic Funds a simple extension was made next to ward 25. Technical assistance was given by several other Government and Private agencies to do the necessary drilling and pumping up of underground water to be used for the project. Electrical wiring and other necessary perihelia were sponsored by the Hospital Support Services. Seeing that the Car Wash Project was so viable and noting that the regular clientele had increased, the staff running the project agreed that the Project be extended further. Thus The Car Polish Project took off early this year (2007). Once again, the Malaysian Psychiatric Association (MPA) was approached and a grant of RM4960 was approved in October 2006. Part of the grant was used to extend the Project site further so as to accommodate more vehicles, which now include hospital ambulances, buses and lorries. A couple of nursing staff and patients were initially sent for training at a nearby petrol station. Since then, many more patients had undergone on the job training and the Project has gone into full swing. To date, the management of the Hospital Support Services had pledged their support to assist in sending all types of hospital vehicles for washing and polishing. The charges, worked out to be cheaper than those offered by outside agencies. 26
Being a big institution with approximately 1400 staff, getting customers is not too difficult. Even then, the public is also welcomed and with better publicity, more vehicles are coming in for the service. OBJECTIVES ACHIEVED What was initially thought to be a way of earning money for ward activities, turn out to be more than that. Being a structured activity, the patients are kept fully occupied. The Car Wash Project operates between 9 am to 5 pm everyday of the week except Mondays. 12 patients are divided into 2 shifts. At the end of the week, each patient receives an emolument of RM15 to be used as and when they like. At the same time, budgeting skills are put in place where the patients are encouraged to spend their hard-earned pay wisely and saved some for rainy days. With money stored away, their self-esteem increased. At the same time, because they work in groups and have to interact with the nursing staff and clients, there was subtle improvement in their communication and social skills. From there, some of them have graduated into better employment with higher pay as security guards, grass cutters, gardeners etc. It must be mentioned that all categories of staff are actively involved in the Project, from the Ward Attendants, to Medical Assistants, Occupational Therapist, Social Welfare Officers, Medical Officers and Psychiatrist-In-Charge. They each have their own roles in making sure that the principles and objectives of psychosocial rehabilitation are met and the ultimate aim of developing the patient s life skills, which will make their transition to life in the community easier. Charges wash and vacuum with polish Motorbike RM2.00 Car RM6.00 Van RM8.00 4-Wheel Drive RM12.00 Lorry (1 ton) RM15.00 Lorry (3ton and above) RM30.00 Bus RM50.00 CONCLUSIONS Despite the initial setbacks, in terms of lack of funding and number of interested staff, and the risks involved, the Forensic Car Wash and Polish Project, has seen remarkable changes among the patients, not only among those involved directly, but also patients from other forensic wards. The conflict between those who think that safety is paramount, that patients cannot be trusted to be responsible and that individual choice can be sacrificed for the greater good and those who argue that some patients need the opportunity to take responsibility and that individual choice is important both as a right and as a basis for therapy needed to be worked out before 27
the multidisciplinary staff were reassured enough to take up the challenge of dealing with the difficult and dangerous to handle patients. Both patients and staff recognized the Project as the carrot dangling at the end of a long pole, that the light at the end of the tunnel lies in being moved upwards from a closed, high security ward to an open ward and given the honour of being job-placed as a car-wash and polish assistant and later graduate to better paying jobs is the ultimate achievement. THE BEGINNING 28
CARe WASH PROJECT 29
CIRCLE OF CARE CARe POLISH PROJECT 30