Setting up Addiction Treatment in Singapore
Muni Winslow Charts the Growth and Challenges of Developing Addiction Treatment in Culturally Diverse Singapore
I’m an addiction psychiatrist working in the multi-racial and cosmopolitan city-state of Singapore.
Born at about the time we gained independence from the British, I belong to a generation that is incredibly proud of our achievements in growing an independent nation, doing national service and reservist duties for 20 years, and watching huge social and economic changes take place in the 50 years of our independence. Unfortunately, our understanding and ability to help those with trauma and addiction issues have grown somewhat slower, though with time, I do trust that the pragmatic spirit that built Singapore will kick in and be able to find better solutions to helping those with addiction challenges.
I graduated as a medical doctor from the National University of Singapore in 1984, and in 1992 completed postgrad studies in psychiatry. At that time, we had a lack of psychiatrists helping those with alcohol and addiction issues, and so I was thrown head-first into looking after patients with alcohol and addictive issues. No training or advice offered. When I asked for guidance from the senior psychiatrist who was leaving and going into private practice, he hummed and hawed, and eventually said “don’t worry Muni, your patients will teach you what to do.” He was right – though a lot of the experiences were somewhat painful. If I didn’t learn that being cunning and manipulative was part of the “addiction”, I would have joined the chorus of doctors who want to have nothing to do with addictions. Fortunately, I was also able to see some really great examples of life changing sobriety, and this kept me going and enjoying helping those with addictions, while waiting for them to hit their “Ah-hah” moments. In 1995, the Singapore government, being pragmatic, decided we needed to learn more about addictions, so I was shipped off to Melbourne, Australia for over a year to study substance abuse, and how Australians treated people with addictions “as they seem to have lots of challenging people there”.
Melbourne, Australia 1995-96 was a real learning experience. In our Asian culture in Singapore, there was very little engagement of the individuals – and most treatment was psycho-education. The moral model also predominates, with many families seeing any addiction as incredibly negative, and a lack of control of self, with the outpouring of shame over oneself and by extension the family.
To illustrate, I once called an 80-year-old grandmother care-giver to come to see how we could help her grandson who was using drugs. She came into the ward, and proceeded to march up to her grandson, and start slapping him for bringing shame on the family. We had to intervene to protect him.
In the early 90’s, one of the best lessons I learn from the Aussies was that addictions were illnesses and not moral failings. I also learnt that we can help folk to overcome their illnesses via motivational interviewing, with a good understanding of the stage model of change. (Prochaska and Di-Clementi). I learnt a lot from the good natured way Australian doctors and therapists came alongside and helped their patients. A laconic wit used to muse out loud that addiction medicine was the best place to be because “if the client does well, it’s because you’re such a good doctor, and if they don’t get well, it’s because they didn’t listen to you, so you can’t lose!!”
On my return to Singapore, I was saddened to learn from my seniors that in the health service, I was supposed to only help those with alcohol or nicotine addictions – and that “the police and prisons are there to treat the drug users”.
Fortunately, I also learnt from the Australians that there are many ways to achieve one’s ends and you don’t have to take on the system head-on. In 2008 when I finally left public service, the head of my hospital lamented that even though she had given clear instructions for me not to treat drug addicted persons, for some strange reason, my wards seemed full of depressive or anxious or psychotic patients who just happened to have a co-morbid issue of drug dependence.
The turning point came in 2001 when I heard of a scheme at the Ministry of Health to provide grants and seed funding to explore better ways of treating illness groups. I had a supportive director at that time, who suggested I apply. I did, and was totally shocked when I got an affirmative answer to provide a community based addictions management service for five years, with funding for a full team of therapists, psychologists, nurses and doctors. The only constraint was that we had to use evidence-based treatments, provide accurate feedback on the programme yearly, and be under the over-sight of our hospital Financial Officer for funds management.
We also had to treat all addictions – both substance and behavioural – so I suddenly had patients asking for help with over-spending, shopping, sex and so on.
After the initial euphoria left – we got to work on the job of putting together a motley crew to take on the challenge thrown down. It was a really exciting time with lots of ups and downs. One of the key features we discovered was that providing detox and therapy alone didn’t help as much as when we had the recovering individuals participate in 12 step groups. We looked around and discovered that while AA was in town, it was unfortunately predominantly caucasian, with the locals not joining because they felt out of place, or for various other reasons. We met the community challenge by raising funds from the community, and building a 12 step drop-in and recovery centre. It was quite amazing to watch the way we could encourage 12 step groups grow. We started by asking groups of 5-7 recovering folk to commit themselves to meeting at least weekly and looked for at least two old timers or those with longer recovery time to help them learn the steps and traditions. No professional staff were involved in their meetings unless they also had a recovery background, and we asked friends in law enforcement to leave people in recovery to have a safe area to work out their recovery. The centre took off as recovering folk found that they had autonomy, and a proven programme (stepwork) as support. We hired a couple of therapists to provide more specialised groups in the community on emotional management, anger management and so on. The groups mushroomed, with groups starting with three growing to 30 within 6-9 months. I was also surprised at the growth of different 12 step groups as the core group discovered that they had more challenges – so suddenly we had AA, NA, Al-Anon, CODA, GA and even OA groups driven by felt needs of the recovering community.
I wish that I could say that we lived happily ever after, but not all things go like that. In 2004, the government decided that after almost 40 years of steadfastly opposing gambling, the cabinet agreed to allow Integrated Resorts – ie casinos which had a comprehensive benefit and appeal to the larger community and didn’t only run a casino. With its past stance against gambling, there was a strong need to show that they had the chance of increasing the numbers of gamblers under control, and so CAMP was ramped up, and became the National Addictions Management Service (NAMS) providing a 24 hour hotline for all addictions, detox beds, a custom built outpatient clinic and more. The increase in funding also came with many more layers of control, which some including me found difficult to cope with, so we moved on to new ventures.
Some of the things in the last 20 odd years I’ve learnt from working in recovery in Asia is to be real and authentic – I’ve discovered my patients have really well developed bullshit detectors, and use them on me and other therapists frequently; not opening up till they know that I really care about them (they don’t really care how much you know till they know that you care and are genuine and can be trusted with their secrets).
The next big thing was to instill hope – and not give up as the miracle of recovery could be just around the corner. Lastly, we need to be able to use evidence- based treatments, and engage the larger community and families hurt by addictions to witness and participate in the recovery journey.