#WhatWENeed in Taiwan
1. De-colonization of the mental health sector
Taiwan was the first independent, Asian, democratic republic. However, it has had a complex history of colonialism, invasions and occupations by different nationalities (Dutch, Spanish, Chinese, Japanese, etc.). "Taiwan's culture and cultural legacy has been largely shaped by the processes of imperialism and colonization as the structural and psychological effects of successive colonial projects have been integral to developing Taiwan’s self-image and the evolution of both official and unofficial Taiwanese culture"(1). History goes that the British refused a proposal to occupy Taiwan. So, the country escaped having pre-human rights lunacy laws.
2. Full CRPD compliance and inclusion within disability frameworks
Taiwan government sought to voluntarily engage with the CRPD monitoring process. They appointed an Independent Review Committee comprising of CRPD Committee members and other independent experts to review CRPD compliance. Refer to the report here.
People with Disabilities Rights Protection Act was made in 2007, where people with psychosocial disabilities are indeed included. In Taiwan, 1,125,113 people are registered as having disabilities. Of these, 10% have been diagnosed as having mental disabilities. However, the estimation is from a medical psychiatric perspective, not from the perspective of disabilities. From 2014 there is a law to implement the CRPD - Act to Implement the Convention on the Rights of Persons with Disabilities（身心障礙者權利公約施行法), the goal of which is to comply with CRPD. In 2014, it is officially the domestic law in Taiwan.
A new Mental Health Act was introduced only in 1990. Writers on the history of mental health legislation in Taiwan are clear that this law was not made to protect the human rights of persons with psychosocial disabilities. As typically found in the region these days, it was not lawyers which made the law, but private psychiatrists: "The government commissioned a private mental institution to develop a draft of the Mental Health Act, with the purpose of protecting the public and reducing the dangers from psychiatric patients" (2). The MHAct leans heavily towards protectionism, guardianship and involuntary commitment.
The IRC recommended that "the State expedite the review of its terminology and approach in laws, policies and practices to enable the paradigm shift that recognizes persons with disabilities as full holders of all human rights and fundamental freedoms, and provide a timeline for completing such review".
3. Discard the medical model in favour of the social model of disability
Both these legislations lack focus on community resources, and put too much emphasis on Disability Cards, institutions and the medical model. The number of psychiatrist to persons is 1:17000, which is higher than other Asian countries. Persons who have a psychosocial disability find it hard to get a disability card from the government resources. The disability assessment system uses discriminatory medical language, such as "mildly disabled", "moderately disabled" and "severely disabled" in assessing persons with disabilities. In 2017, among those with chronic mental illness, 54.8% were moderately disabled, 28.5 % were mildly disabled, 15.9% were severely disabled, and 1.6% were extremely disabled. The most common cause of disability was chronic illness (71.1%). According to the “Report on the Living Conditions and Needs of Persons with Disabilities in 2016: Questionnaire Survey of Major Family Caregivers”, the incidence of "chronic mental disorders" was 37% from 18 to 30 years old, and the median age of occurrence of disorders was 28 years old. The proportion of "unmarried" people with "chronic mental disorders" was 47%, the proportion of "no children raising children" was 53.47%. The average number of years of family members caring for those with "mental illness" was 17.13 years, while the average number of years of care for intellectual disability was 23.49. These figures are quite high, and there is concern about how they were arrived at. The government has schemes for independent living, but excludes persons with mental disabilities.
4. Abolish Guardianship
There is no separate guardianship law. However, the Civil Code of Taiwan provides the order of commencement of guardianship and the order of commencement of assistance. An adult’s guardian shall be selected by a court ex officio. The said order would not be implemented until the adult loses his/her capability of communication. Under the circumstance, the definition of a ward’s "independence" cannot be met perfectly. The government has noted the gap. Therefore, in January 2015, the Ministry of Justice invited the social welfare groups, including Parents’ Association for Persons with Intellectual Disabilities, Taiwan, scholars and experts to discuss the “Voluntary Custody System”, which allows the person with disability to determine his/her guardian, so that the a person’s dignity and interest may be respected. Given this, Ministry of Justice will complete the draft of amendments to the laws for establishment of the voluntary custody system, and submit the same to Executive Yuan for examination as soon as possible. The Ministry of Justice will also proceed to record and research the motion about the capability of a person subject to the order of commencement of guardianship separately.
The guardianship refers to the circumstances in which the commencement of guardianship and assistance by the court. For the number of persons who have been commenced of guardianship and assistance by the courts (juvenile and family) from 2014 to 2016. As for the number of persons with intellectual and mental disorders that were not in guardianship, since it involves the national statistics of disability population, there is no reliable data available. The number of persons who have been commenced of guardianship and assistance by the courts from 2014 to 2016.
(Unit:People)
2014 had 3609 commencement of guardianship cases and 260 commencement of assistance cases. 2015 had 3799 commencement of guardianship cases and 263 commencement of assistance. 2016 had 4081 commencement of guardianship cases and 266 commencement of assistance. There has been a steady rise in the guardianships for persons with psychosocial disabilities.
As can be seen, there is a big gap in legal compliance in guardianship and CRPD compliance. The IRC has recommended that "the State amend all relevant laws, policies, and procedures and that a system of supported decision-making be put into place that is compliant with the UN CRPD Committee’s General Comment No. 1, including the provision of adequate resourcing for such a new system".
5. Traditional healing
Taiwan has diverse cultures of Chinese, indigenous/aboriginal populations and cultural practices. Mahayana Buddhism has been practiced in Taiwan since centuries, however, the Chinese prohibited practices of Buddhism, which resurfaced only in 1978. Traditional Chinese medicine (such as: Acupuncture) is available widely in Taiwan but “healing psychological problems” is not often its main target. Chinese medicine is based on energy systems - chi and the yin and yang. Doctors working Chinese medicine consider adjusting the body’s energy as the primary goal. But it can help healing. Taichi, qigong, herbal medicine, yoga are also methods of healing. There are also temples that hold rituals for people having experience of a mental crisis. Traditional medicine is covered under the public health insurance scheme.
6. Community support systems
The IRC in 2017 have remarked repeatedly on the derogatory language commonly used in Taiwan, stigmatising persons with disabilities in general, and persons with psychosocial disabilities, who have internalized the identity as "mental patients". Families are the main form of support in long term care, and it is internalized by the persons with psychosocial disabilities as "burden of care". The government does not support them in any way. While policy is presently forced to think about "de-institutionalization", there is no provision for de-institutionalizing, by setting up community support systems. The mental health system is not adequately prepared for this, by integrating resources from other sectors notably labour, social services, general health care. The quality of care for community mainstreaming and inclusion needs to be enhanced, and the health care payment and evaluation provisions need to be revised to avoid the re-institutionalization. There is a proposal to create smaller institutions (50 beds or less), but this is still based on the penal model of involuntary commitment. Stigma is high, making "mental patients" resistant and afraid to seek medical treatment. As provided in the People with Disabilities Rights Protection Act, the valid term of a disability certificate is 5 years. The persons with disabilities in a community will take the government’s assessment at least once per 5 years, and the government will organize a professional team to confirm their needs and provide supportive care services for individuals and families. In addition, all levels of governments shall conduct need assessment on the living situation, health care, special education, employment and training, transportation and welfare and shall publish and announce the results of such research at least once per 5 years. In the performance evaluation indicators of social welfare, each local government shall make implementation plans and prepare and execute the budget in accordance with the assessment result.
The government has a budget of more than 20 million per year for persons with disability to live in the community, and only those who are identified as severely disabled can apply for the maximum number of hours - 60 hours per month - equivalent to only 2 hours a day.However, because the indicator for disability includes ADL and IADL, most people with mental disability are not eligible.
The core spirit of the CRPD is that the obstacles are not caused by the physical and mental defects of the physically and mentally disabled, but by the external environment, stereotypes, discriminatory attitudes, or interactions that will hinder the physical, mental, and physical participation of the disabled. There is still a long way to go for community-based care for "mental patients" in Taiwan. On the one hand, it is necessary to invest in the establishment of a sufficiently mobile community care team. On the one hand, it is necessary to create a friendly and acceptable community environment, with laws and resources in place, and cross-team cooperation such as health, social, labor and police so that mental patients can be more effective. The medical care and self-reliance can reduce the burden on family members and reduce the problem of social security. Mental patients are not terrible, terrible is the public misunderstanding and stigma. Only when everyone works together can the community-based care of mental patients succeed.
There are unmet needs of many community mental patients, including physical and mental symptoms, as well as the need for money, social welfare, and social relationships. In addition, it is very important to note that self-stigma has become an obstacle to the recovery of community mental patients. This is similar to the poll conducted by the Taiwan Psychiatric Association last year. 37% of "mental patients" are afraid to tell others that they have mental illness, and 41% of "mental patients" feel that others cannot accept that they are using psychiatry. In addition to the self-stigma of community "mental patients", the problem of social stigma of mental illness is also very serious. A 2017 survey found that 46% of people with "mental illness" were rejected or discriminated against during their duties and many believed that people with "mental illness" were at risk. Recovered people are still not accepted by the community or by the employers. The linkage needed between disability assessment and entitlements is not made so there is no social protection. There are a few clubhouses and very few peer support systems. Most resources are clinical/medical based. If one does not have professional licenses such as social worker or therapist, etc, she or he doesn’t have many resources (e.g. budget) to build up a community based support system, for example, peer support systems. Persons with psychosocial disabilities are finding it very hard to build up a self-run, independent support system.
The IRC has strongly recommended "That the State amend all relevant laws and policies, including the Mental Health Act, so that involuntary detention on the basis of disability is prohibited, and that a system of procedural safeguards, including immediate access to legal assistance, be put into place, including ensuring the free and informed consent of the individual; and (b)That the State uphold the freedom to make one’s own choices as a principle in article 3 (a) of the CRPD and recommends an absolute ban on the deprivation of liberty on the basis of actual or perceived impairment".
7. Full CRPD Compliance
The current legislations do not meet the standards set by the CRPD. The IRC has commented on full participation of persons with disabilities and DPOs in developing laws and policies, and specific recommendations on all CRPD provisions. Towards assisting persons with disabilities in inclusion and adapting to communities, the government provides in Articles 26, Article 30, Article 32, Article 37, Article 47 of the Regulations of Personal Care Services for persons with disabilities, various community-based services - including life reconstruction, residence in communities, community-based day-care, community drop in facilities for operation at daytime, etc. With regard to the content of these services, besides providing daily living skill training, inter-personal relationships and social skill training, the government also plans to carry out campaigns to promote participation in life and adaption to communities simultaneously to assist persons with disabilities in actively participating in community activities, to enhance their interaction with families and communities and to enhance community engagement.
All local governments have been actively planning and establishing community-based day-care, residence-in-communities and family care service centers. As of the second quarter of 2017, there were 159 community facilities for operation at daytime, 114 community-based day-care service centers, 94 residence-in-communities service centers, and 129 family care service centers, which served 5,326 persons. Moreover, to assist persons with disabilities in living in the communities independently and choosing the living places that are suitable to them and participate in society equally under the preconditions that they can make their own decisions, choices and be self-reliant and that opportunities are equal for them, the government promotes supportive services for independent living of persons with disabilities and had served 14,402 persons by the second quarter of 2017.
In order to achieve the goal of “caring psychiatric patients in the community” and enhance the quality of psychiatric rehabilitation services, as well as to assist the psychiatric patients with better condition in returning to their community, in 2014, DPOs requested the department of public health in every municipality or county (city) to limit the total quantity of bed (50 beds or less) on the application of new establishment or service expansion proposed by mental institutions. As of the end of 2016, up to 84.24% of such institutions have adjusted their service scale to 50 beds or less successfully. This practice will be taken into consideration when amending the relevant regulations for such institutions in the future, to gradually reduce the patients’ number from staying at large rehabilitation centers or institutions. Rather, we aim to provide the persons with a wide range of community service choices to facilitate them adjusting and living within the community. However care is seen as within a medical model still and independent living is yet to become a reality for persons living with mental illness. CRPD compliance and social model is needed.
© Prepared for TCI Asia Pacific (2018) by TAMI and TGQRAA, Taiwan, for the Bali Plenary meeting, August, 2018.
About the organizations:
TAMI - The Alliance for the Mentally Ill of R.O.C., Taiwan(TAMI) is a non-government, nonprofit, grassroots, self-help organization of consumers, families, and friends of people with mental illnesses. Founded in 1997, TAMI currently has 29 group members from local organizations of 20 counties in Taiwan with more than 4,000 members who have made great efforts to provide services to people with psychosocial disabilities, working on the national and local levels in support and advocacy of mental health. TAMI has emphasized on support to persons with serious mental disorders and their families; advocacy for nondiscriminatory and equitable policies and treatments for brain disorders; also education to eliminate the pervasive stigma surrounding severe mental illness. TAMI works in co operation with professionals to change mentality; remove social and other barriers; addressing poverty, and enabling social support systems through employment; managing medicines, using psychotherapies, and social skilling; mainstreaming within communities; improving self determination of persons with psychosocial disabilities especially through providing transitional employment from asylums and social development; peer support trainings; personal life storying; building hope.
TGQRAA: We are building local peer support systems, amending 〈Mental Health Act〉, helping other organizations building peer support discourses.
1. Wikipedia, https://en.wikipedia.org/wiki/Culture_of_Taiwan, accessed on 26-10-2018
2. Wei-Tse Hsu, M.D., M.S.1 , Hui-Ching Wu, Ph.D.2 , Frank Huang-Chih Chou, M.D., M.S., Ph.D.1 A History of Mental Health Laws in Taiwan * Taiwanese Journal of Psychiatry (Taipei) Vol. 31 No. 3 2017 195-203.
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