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POSTGRADUATE TRAINING IN COMMUNITY PSYCHIATRY: FUTURE DIRECTION IN MALAYSIA

Correspondence
Dr Ruzanna ZamZam, Department of Psychiatry, Faculty of Medicine,
Jalan Yaakob Latiff, 56000 Cheras, Kuala Lumpur.
Email: ruzanna@mail.hukm.ukm.my Tel: 013 3934373 / 03-91703720
ORIGINAL PAPER
Postgraduate Training in Community Psychiatry: Future
Direction in Malaysia
Ruzanna Z, Marhani M
Department of Psychiatry, Faculty of Medicine, Universiti Kebangsaan Malaysia
Abstract: As the Malaysian mental healthcare system is progressing from institutions
towards more balanced care in the general hospital and community, future
psychiatrists need to have an adequate exposure to this relatively new service during
their training. This is because community treatment is different from working in
hospitals particularly in roles and approaches. Therefore, it is important to have a
continuous effort to tailor the current postgraduate training to the service needs.
This article will academically discuss the relevant issues related to postgraduate
community training in Malaysia. This includes the current approaches and
implementation process of the current training.
Key words: Malaysian mental healthcare system, postgraduate training, community
psychiatry
Malaysian Journal of Psychiatry September 2007, Vol. 16, No. 2
Introduction
As the Malaysian mental health care system is progressing
from institutions towards more balanced care in the general
hospital and community, future psychiatrists will face
more challenging roles in addition to their clinical
responsibilities. As professional training is not
uncommonly lag behind changes in the service delivery
(1,2). It is important to make a continuous effort to tailor
the current training to the service needed. It is important
to ensure the future psychiatrists are well exposed to this
relatively new service because community treatment is
different from working in hospitals particularly in roles
and approach.
Collaboration in training
The training of future psychiatrists in community psychiatry
can only be achieved by an effective curriculum (3). In
order to achieve this, it is important to develop the
collaboration between teaching institutions with other
stakeholders such as with Ministry of Health (4,5). In
recent years, a national conjoint committee has developed
this collaboration effectively. Overall program planning
and implementation is currently conducted in partnership
with the three universities and Ministry of Health. The
conjoint board of postgraduate training has agreed upon
the allocation of posting, duration and learning objectives.
Further collaboration and networking could
also be developed among the supervisors in the
Ministry of Health and the academic coordinators.
The collaboration would include the standardization
of the theory input, learning strategies, supervision,
sharing the resources and identification of training
centers. Even though it is often difficult for any
curriculum to be accepted and agreed by all as it is
subjected to disagreement, further modification
and edition would probably be one of the approaches
that can suit every stakeholder. Even though some
of the training resources have been developed, there
remains a pressing need in many institutions for the
establishment and implementation of teaching
programs. This could be due to the common
difficulties in translating the ideas into practice.
Principles of Training approach
In regards to clinical training of psychiatrists in
community mental health, few specific principles
have been suggested. Firstly, the training needs to
be conducted in the whole range of community-
based settings rather than hospital. Secondly, it
needs to cross-disciplinary involving teachers and
teaching sessions with other professions. Thirdly,
there needs to be an adequate time to reflect the
individual cases in detail with clinical teachers.
Finally, the training should allow a longitudinal
work rather than a cross-sectional perspective (6).
In the current Malaysian scenario, even though
community mental health units are structurally
developed as part of the hospital-based services, the
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RUZANNA Z
concepts of community mental health care delivery are
being followed.
The training also needs to be based on the demands
of the overall mental health system and the contextual
needs of the population (7). For example, the future task
of psychiatrist in the mainstream Malaysian mental
health system can become one of the important elements
that needs to be seriously considered in determining
what should be taught and how they should be taught.
This is the main reason to link the educational and
learning objectives to the actual required tasks of future
psychiatrist. In the Malaysian context, the future task
of psychiatrist would include clinical leadership skills,
designing mental health program for local population
and learn how to evaluate those program.
In the development of effective curriculum, there
is a need for learning process to be based on broad
teaching and learning strategies. As the trainees are
adult, they need to be approached in specific ways in
their learning process. Some of their needs include
focusing on real life problems, being given meaningful
material and actively being involved in the learning
process (experiential learning) (8)
The Content (knowledge, skill and attitudes)
The updated core knowledge in community mental
health can be achieved by continuous revision of the
program. The global pattern of current core subjects of
many training modules in community mental health
include various essential topics (9-14) .
It can be summarized as the following.
Overview of mental health system in local setting
Crisis assessment, short-term intervention and
referrals to the acute psychiatric inpatient unit
Coordination of the care of patients including direct
treatment as well as liaison with other services
Provision of intensive home-based treatment for
patients with complex needs and high levels of
disability.
Alternative approaches in dealing with the needs
of patients with medium to long term residential
rehabilitation in a purpose-built cluster-housing
setting with 24-hour on-site nursing supervision
Provision of psychiatric service to the homeless
patients with mental disorders
Working with the multidisciplinary team during
the community mental health rotation.
Trainees are expected to gain experience and
specific clinical skills within different service
components. This integration promotes the continuity
of treatment for patients who may require periods of
treatment by different services during the course of
their illness. Thus both episodic and longitudinal care
form the overall continuity of treatment provided to the
patient in order to best meet their needs (9, 14-16).
There is a considerable need to also focus on the
development of attitudes in the training. Table 1 shows
the list of desirable and undesirable personality
characteristics for community mental health staff (17),
Undesirable characteristics Desirable characteristics
The rescue fantasy Strong sense of self: comfort with uncertainty
Consistent distortion of information Open minded: accepting and non-judgmental
Pessimistic outlook Patient and non-intrusive
Exploit client for own needs Practical, problem-solving orientation
Over controlling and needing to do for others Flexible
Suspicious and blaming others Emphatic
Optimistic and supportive
Gentle firmness
Humorous
Humble
Thinks contextually
Adapted from Mosher & Burti, 1994 (17)
Table 1: Desirable and undesirable personality characteristics for community mental health staff
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POSTGRADUATE TRAINING IN COMMUNITY PSYCHIATRY: FUTURE DIRECTION IN MALAYSIA
which could be used as a guideline in shaping the
attitudes of trainees. For example, psychiatrist need to
develop certain attitudes and modified certain traits of
their personalities in order to suit their tasks in
community setting. Although these characteristics are
applicable to all mental health staff, psychiatrist should
be the role model in demonstrating the attitudes in daily
routine clinical contact with clients. Therefore, some of
these characteristics can be useful and can be
recommended in the training module (6).
The trainers
One of the recommendations to improve a training
curriculum is to have an enthusiastic, experience and
knowledgeable role models who they themselves are
working clinically with serious mentally ill clients in the
community. This will enable role modeling and more
effective supervision to the trainees (3). It is essential
for the faculty members to be involved and participate
in the community-based services itself to encourage the
trainees to believe that it is an important part of their
future career (18). In order to achieve this, the academic
center needs to invest on the resource development,
collaborate with other training centers that provide
community services and develop more effective
community-based programs in the training centers (3).
Changing Work culture
While the changes in the work culture in community
setting is expected to be anxiety provoking; psychiatrist
need to know how to exercise informal power that can
indirectly giving a positive impact on policy and clinical
practice (19). There are few future concerns for the
psychiatric roles in community. Firstly, they might
view their roles in community setting as limited and
secondly the might develop a persistent view that
managing severely and mentally ill in the unsupported
and under-developed community services as frustrating
and unrewarding. Unfortunately in the Malaysian
context, it seems that they do not have the choice. If the
system is going to progress into developing more
community mental health facilities, trainees are expected
to be ready to work in such setting.
There is a debate regarding the leadership role of
psychiatrists in community mental health setting. While
sometimes it can be considered as inherently
ambiguous (20), some authors suggested clearer role.
It is recommended that psychiatrists who work in the
community setting clearly need to have a broad-based,
humanistic, biopsychosocial perspective and to learn
the full range of skills required for modern psychosocial
rehabilitation (20-23). In addition, psychiatrists who
work in more developed community care services in
some countries are expected to balance between the
needs to be in control because they can be viewed by
non-medical mental health professionals as taking
over and imposing medical model(19, 24).
Therefore, they need to learn how to function in full
range of their professional expertise while
acknowledging the expertise of non-medical
colleagues (3).
Working with the most severely disabled people
can also be less attractive for trainees because they are
often viewed as low status, poor and disenfranchised
(3) and trainees might make a decision early to avoid
this group of patients in their future career (25), In one
survey about the attitudes of clinician in the treatment
of mentally ill found majority agreed that the chronic
mentally ill are not a preferred population to treat, half
prefer to avoid contact and refer them whenever possible,
professionally unrewarding, 68% agreed that most
clinicians do not receive adequate training in caring for
the mentally ill. It is also intellectually challenging to
understand chronic mental illness, 83% feeling burnout
is common,, 84% feeling frustrated because there are
not comprehensive resources (26)
A similar situation is likely to occur in Malaysia,
as many of the trainees will need to work in the public
mental health system , they do not have many options.
The majority of consumers who come to the public
mental health services are those who are severe mentally
ill. Therefore they are bound to their duty of care.
Therefore, there is a need for the curriculum to address
this issue so that there is no conflicting issue in between
roles and attitudes of psychiatrists and this possibly is
best done throughout the residential training (3). It is
also important to ensure the trainees have the chance to
develop positive values and attitudes towards working
with severely mentally ill people, who are often capable
of improvement and sometimes recovery (27,28) .
Conclusion
There is no doubt that developing an effective curriculum
in community mental health is an important step to
produce high quality of psychiatrists who able to meet
the future demands of the mental health care system in
Malaysia. At present, the curriculum has outline what
future Malaysian psychiatrists need to know and how
they are expected to behave when they work in
community setting. Even though the current community
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RUZANNA Z
mental health care system has not been fully developed,
this necessary change is timely. The changes in the
placement or training centers all over Malaysia to suit
the needs and objectives of the training is one of the
important strategy to achieve better training. The further
development of comprehensive community-based
treatment in the teaching hospitals itself would be also
an alternative in providing more effective training.
The future directions of the training need be open
to criticism and modifiable as the system change.
Therefore, future innovations and modifications should
be encouraged at any stage of the development and
should be responding effectively to the ongoing changes
of mental health system in Malaysia. The recognition
of the proposed curriculum needs to be planned
systematically to allow enough time for each stakeholders
offering their opinions.
The consultation with the major stakeholders,
including educational institution, course coordinator
centers, consumer organization, lecturers and trainees
is strategically essential in the implementation process.
Ideally, wider range of stakeholders should get involved
in the formulation of curriculum including consumers
and carers and this should be the direction for the future
training development in Malaysia.
References
1. Blackwell B, Schmidt GL. The Educational
Implications of Managed Mental Health Care.
Hospital and Community Psychiatry 1992;43(10):
962-64.
2. Rodriguez SC. Teaching Psychiatry: Under-
graduate and Postgraduate Education. In:
Querubin MLC, Rodriguez SC, Editors. Beyond
the Physical: The State of a Nations Mental
Health. The Philipines Report. Melbourne:
CIMH Melbourne; 2003.P.69-73.
3. Diamond RJ , Factor RM, Stein LI. Response
to Training Residents for Community
Psychiatric Practice. Community Mentah
Health J ournal 1993;29(3): 161-172
4. Ministry of Health. Mental Health Policy:
Ministry of Health, Malaysia; 1998.
5. National Mental Health Strategy Australia.
Learning Together:Education and Training
Partnership in Mental Health. Canberra:
Deakin Human Service Australia; 1999.
6. Thonicroft G, Tansela M. Key Resources:
Training and Morale of Staff. In: Thonicroft G,
Tansela M, Editors. The Mental Health Matrix.
A Manual to Improve Services. Cambridge:
Cambridge University Press; 1999 a.p.
142-154.
7. Faulkner LR, Eaton J S, Bloom J D, et al. The
CMHC as a Setting for Residency Education.
Community Mental Health J ournal 1982;18:
3-10.
8. Michael AH, Selby CJ , Richard B. Psychiatric
Residency Training, Managed Care, and
Contemporary Clinical Practice. Psychiatric
Services 2000;51(8):1001-1005.
9. Massachusets University.http://www.comm.
psych.pitt.edu/Training/Mass Mental Health
Curriculum.pdf. in; 2002.
10. Mount Sinai School of Medicine.http://www.
comm.psych.pitt.edu/Training/Sinai.pdf.
In; 2000.
11. Philadelphia University.http://www.comm.
psych.pitt/Edu/Training/Philadelphia2.pdf.
In; 2000.
12. The Royal Australian and New Zealand College
of Psychiatrists. Formal Education Course.
http://www.ranzcp.org/Members/Forms/
Linkdocs/Link25. In; 2004.
13. Centre of International Mental Health. Inter-
national Mental Health Leadership Program.
Curriculum and Course Handbook 2004.
In.Melbourne; 2004. P. 39.
14. Ng C. Community Psychiatry Training Program
In St. Vincents Mental Health Service. In.
Melbourne; 2004. P. 4.
15. Northeast Ohio University. http://www.
comm.psych.pitt.edu/Training/Northeast
Ohio University Curriculum.pdf. In; 2000.
16. Oregon School of Public Health. http://www.
69
POSTGRADUATE TRAINING IN COMMUNITY PSYCHIATRY: FUTURE DIRECTION IN MALAYSIA
comm.psych.pitt/Edu/Training/Oregon School
of Public Health Course.pdf. In; 2000.
17. Mosher LR, Burti L Community Mental
Health: Principles and Practice, W.W. New
York. Norton & Co. 1994.
18. Langsley DG, Barter J T. Psychiatric Roles in
the Community Mental Health Center. Hospital
and Community Psychiatry 1983;34:729-733.
19. Diamond RJ , Stein L, Braus KS. Adminis-
tration:Psychiatrist as Manager. In: Breakey
WR, Editor. Integrated Mental Health Services.
Oxford: Oxford University Press; 1996. P.
87-102.
20. Diamond RJ . Essentials and Non-essentials
Roles for Psychiatrists In Community Mental
Health Centers. Community Mental Health
J ournal 1991;42:187-189.
21. Factor RM, Stein LI, Diamond RJ . A Model
Community Psychiatry Curiculumfor Psychiatric
Residents. Community Mental Health Journal
1988;24(4):310-27.
22. Faulkner LR, Cutler DL, Khron DD, et al. A
Basic Residency Curiculum Concerning the
Chronically Mentally Ill. American J ournal Of
Psychiatry 1989;146:1323-1327.
23. Goldman CR, Brown DB, Thompson KS.
Community Psychiatry Training for General
Psychiatry Residents: Results Of A National
Survey. Community Mental Health J ournal
1993;29(1):67-76.
24. Beigel A. The Remedicalization of Community
Mental Health. Hospital and Community
Psychiatry 1984;35(11):1114-1117.
25. University Of Utah. Curriculum On Public
Mental Health.http://www.comm.psych.
pitt.edu/Training/Utahcurriculum.pdf. In; 2001.
26. Mirabi M, Weinman ML, Magnetti MS, et al.
Professional Attitudes Towards the Chronic
Mentally Ill. Hospital and Community Psychiatry
1985;36:404-405.
27. Nielson SD, Stein LI, Talbott J A, et al.
Encouraging Psychiatrists to Work With
Chronic Patients: Opportunities and Limitations
of Residency Education. Hospital and Community
Psychiatry 1981;32:767-775.
28. Lefley HP, Berheim K, Goldman CR. National
Forum On Training Clinicians to Work with
Seriously Mentally Ill Persons and Their
Families. Hospital and Community Psychiatry
1989;40:460-470.