The Psychosocial Rehabilitation“The community services programs andindividual living support in Taiwan”

台灣精神社區復健與支持服務發展現況滕西華Eva Teng
President, Taiwan Branch of WAPR
Vice president,

The statistics of the mental
health resources by 2018
心理健康服務現況統計
Data resources: The 2018 Health Statistic
Reports of the Ministry of Health and Welfare

＃我們與惡的距離Ｈow many people visit
psychiatrists in a year?
一年多少人看精神科？

The Services Resources by Service Types

Outpatient
門診

Emergency
急診

Mandatory
Compulsory
24hr
Community
Home
Psychiatrichospitalization
Treatment
Care
Admission
全日住院
強制社區治 居家治療
強制就醫機構療機構

Northern Taiwan

216

36

49

37

18

35

Central Taiwan

103

27

35

29

28

27

Southern Taiwan

168

27

37

29

28

37

Eastern Taiwan

15

10

10

9

6

8

Island Area

2

2

1

1

1

1

Summary

504

102

132

105

81

108

Northern
Taiwan250

emergency

200
150

IslandArea

Central
Taiwan100
50Outpatient
24hr hospitalization

0Compulsory Psychiatric
Admission

Eastern
TaiwanSouthern
Taiwan

The numbers of various professions

Mandatory Community
Treatment

Home Care

The Services Resources by Service Types (Continued)
Non-residential oriented Community
Rehabilitation Institutions社區復健
The number of
institutions
家數The number of theclients served byinstitutions人數

Residential oriented Community
Rehabilitation Institutions康復之家
The number of
institutions
家數The number of theclients served byinstitutions人數Northern Taiwan

23

1,055

98

3,361

Central Taiwan

21

977

24

1,755

Southern Taiwan

22

1,101

26

1,087

Eastern Taiwan

2

75

1

96

Island Areas

-

-

-

-

Summary

68

3,208

149

6,299

Note: The symbol of “-” indicated no available data

Northern
TaiwanEastern
Taiwan

100
90
80
70
60
50
40
30
20
10
0

Central
TaiwanThe average number ofclients that a nonresidential oriented
Community Rehabilitation
Institution needs to serve
The average number ofclients that a residential
oriented Community
Rehabilitation Institution
needs to serve

Southern
TaiwanThe Services Resources by Service Types Nursing Homes

Nursing Homes護理之家

The number of
institutions家數The number of the permitted
registered-beds核准床數

The number of the registeredbeds in actual utilization
開放床數

Northern Taiwan

17

1,379

1,252

Central Taiwan

10

1,108

735

Southern Taiwan

12

1,351

1,139

Eastern Taiwan

5

1,460

978

Island Areas

-

-

-

Summary

44

5,298

4,104

Note: The symbol of “-” indicated no available data

The Facilities of Psychiatry Treatment--beds
The beds of the 24hr hospitalization住院病床數The number of the permitted
registered-beds核准床數

The number of the registered-beds inactual utilization開放床數

Acute Beds急性Chronic Beds慢性Acute Beds急

Chronic Beds慢Northern Taiwan

3,405

5,059

2,979

4,506

Central Taiwan

2,218

4,572

1,882

4,295

Southern Taiwan

2,246

3,395

2,101

3,141

Eastern Taiwan

534

1,662

446

1,662

Island Areas

30

72

30

72

Summary

8,433(3.7/000)

14,7607,438(3.2)

13,676

Northern
Taiwan1

0.95
0.9

Island Area

0.85
0.8

Central
Taiwan0.75

Eastern
TaiwanAcute Beds
Utilization Rate
Chronic Beds
Utilization Rate

Southern
TaiwanHuman Resources of
Hospital and Clinical Agencies—Doctors醫師
Doctors
Full-time全職

Part-time兼職

Psychiatrist專科醫師

Non-Psychiatrist
非精神專科

Psychiatrist專科

Non-Psychiatrist
非專科Northern Taiwan

714

141

247

3

Central Taiwan

345

14

79

1

Southern Taiwan

432

69

124

4

Eastern Taiwan

74

15

10

-

Island Areas

3

-

2

-

Summary

1,568

239

462

8

Note: The symbol of “-” indicated no available data

Human Resources of
Hospital and Clinical Agencies—Nurse/Social Worker
Nursing Personnel護理人員

Social worker社工Full-time全職

Part-time兼職

Full-time全職

Part-time兼職

Northern Taiwan

2,041

35

223

8

Central Taiwan

1,649

19

167

5

Southern Taiwan

1,588

11

146

6

Eastern Taiwan

524

4

38

2

Island Areas

18

1

2

-

Summary

5,820

70

576

21

Note: The symbol of “-” indicated no available data

Human Resources of
Hospital and Clinical Agencies—Psychologist/ OT
Clinical Psychologist心理師

Occupational Therapist職能治療師

Full-time全職

Part-time兼職

Full-time全職

Northern Taiwan

375

106

280

8

Central Taiwan

195

6

316

3

Southern Taiwan

198

7

188

9

Eastern Taiwan

37

2

61

-

Island Areas

3

0

5

-

Summary

808

121

850

20

Note: The symbol of “-” indicated no available data

Part-time兼職

Northern
Taiwan
2500
2000
1500
1000

IslandArea

Central
Taiwan500

Full-time
Psychiatrist
Full-time
Nursing
Personnel0Full-time Social
WorkerEastern
TaiwanSouthern
Taiwan

The numbers of various professions in hospital and the clinicalagencies護理之家和社區復健機構醫師數Doctors of
Nursing Homes and Community Rehabilitation Institutions
Doctor醫師
Full-time全職
Psychiatrist

Part-time兼職

Non-Psychiatrist

Psychiatrist

Non-Psychiatrist

Northern Taiwan

1

-

17

3

Central Taiwan

-

-

11

-

Southern Taiwan

-

-

14

-

Eastern Taiwan

-

-

8

2

Island Areas

-

-

-

-

Summary

1

-

50

5

Note: The symbol of “-” indicated no available data

護理和社工數Nurses and social workers of
Nursing Homes and Community Rehabilitation Institutions
Nursing Personnel護理人員

Social worker社工Full-timePart-time

Full-timePart-time

Northern Taiwan

142

104

71

117

Central Taiwan

108

16

39

27

Southern Taiwan

132

39

33

44

Eastern Taiwan

54

2

9

5

Island Areas

-

-

-

-

Summary

436

161

152

193

Note: The symbol of “-” indicated no available data

心理師和職能治療師Psychologists and OＴs of
Nursing Homes and Community Rehabilitation Institutions
Clinical Psychologist心理師

Occupational Therapist職能治療師

Full-timePart-time

Full-timePart-time

Northern Taiwan

4

45

26

101

Central Taiwan

7

15

48

34

Southern Taiwan

2

30

28

52

Eastern Taiwan

3

7

6

8

Island Areas

-

-

-

-

Summary

16

97

108

195

Note: The symbol of “-” indicated no available data2014-2018 compulsory treatment cases and expense
2014-2018強制住院與強制社區治療人數2

What we have known發現
1) The health service disparity by geographic factors isstill prominent (e.g., health resources, profession
human resources, resources utilization rate).
各項資源分佈仍有城鄉差距2) Compared to hospital and the relevant clinicalagencies, the part-time profession holders comprisea greater portion of the medical human resources innursing homes and community rehabilitation
institutions, regardless of geographic factors.
社區機構兼職的比例較高The Article 19 of CRPD
andresidential programs to support
disabilities living in community
社區居住支持服務People First“Human being” firstthenhuman “being sick”
是「人」生病，不是「病」人A. The origin of community living and its variations forthe needs in the modern society
Since the industrialization and its pervasivenessacross the western societies, the enlarging
wealthy gaps have resulted in the soaring
number of the poor.
In the first half of the 20th century, based on
intentions to improve aforementioned
shortcomings, institutions rapidly proliferated
and started to serve for not only the poor
but people with mental illness anddevelopment disabilities as well.
機構開始不僅收容貧戶，也收容精神障礙和發展障礙者deinstitutionalization is a key. 去機構化是關鍵

B. Why there are transitions induced bydeinstitutionalization in the modern society?
1. Based on human rights and resilience perspectives,
people with the mental illness and/or development
disabilities should have the same living rights asothers. Moreover, the whole society should notneglect their potentials to re-enter the surroundings
we are living now. 擁有在社區居住的權利
2. The advance and pervasiveness of psychotropic
drugs and therapies enable the treatment andrehabilitations accessible in not only institutions
but non-initialization sectors as well. 藥物的進步發展讓
治療和復健變得更容易執行
3. Shifting the financial burden from public sectors to
private sectors, regardless of central or local
government. 可降低政府財政負擔
Eisenberg, L., & Guttmacher, L. (2010). Were we all asleep at the switch? A personal reminiscence of
psychiatry from 1940 to 2010. Acta Psychiatrica Scandinavica. 122 (2): 89–102.

C. Within transitions from long-staypsychiatric hospitals to less isolated
community services for those diagnosed
with a mental disorder or developmental
disability, the following 2 ways are mostcommonly seen in the Western societies:
逐漸去機構化兩種最有效的方式

1. Directly reducing the population size ofmental institutions via releasing patientsand shortening their residential spell. 直接降低機構規模和縮短機構收容期
2. Reforming the services offered byinstitutions into what can assist patientsto adjust to a life outside of care. 要求機構
執行社區適應與社區支持服務
Stroman, D. (2003). The Disability Rights Movement: From
Deinstitutionalization to Self-determination. University Press of America.

From 1990 to 1995, Norway government had
transferred all people with mental illness anddevelopment disabilities from institutions to theirfamilies or relatives. In Denmark, similar trends
are also rapidly growing.
Since 1960s in the United States,
deinstitutionalization of institutions has
dramatically increased whereby the average
duration of residing within mental institutions
among those with mental illness anddevelopment disabilities was decreased by morethan 50%. Simultaneously, substantial efforts are
striving for enhancing the pervasiveness ofcommunity living.
Hanssen, J.-I., Sandvin, J. T. and Söder, M. (1996) 'The Nordic welfare states intransition', in J. Tøssebro, A. Gustavsson and G. Dyrendahl (eds)
Stroman, D. (2003). The Disability Rights Movement: From Deinstitutionalization to
Self-determination. University Press of America.

Positive changes brought bycommunity living
1. Longitudinal studies have confirmed community
living has functions to buffer the following
disadvantages encountered by people with mental
illness: cognitive impairment, depression, and low
frequency of social contacts.(Stuck, te al., (1999). Risk factors forfunctional status decline in community-living elderly people: a systematic literature review.
Social Science & Medicine, 48(4), 445-469.)

在社區的障礙者比較有能力面對負面情況，比如認知障礙、
憂鬱等，較有機會社交Positive changes brought bycommunity living
2.Notably, the empirical study has confirmed theextent of community living is significantly
associated with the intensity of buffering effects.
More specifically, higher level of community living
engagement leads to greater buffering effects on
the deterioration of one’s cognitive impairment.
(Lee et al., (2015). Changes in physical activity and cognitive decline in older adults
living in the community. Age, 37:20. )顯著的延緩認知缺損的惡化Positive changes brought bycommunity living
3. Community living is a significant
component of the delivery of effective
social interventions(Green, S. E., Lockhart, E., & Marhefka, S. L. (2015). Advantages anddisadvantages for receiving Internet-based HIV/AIDS interventions at home or atcommunity-based organizations. AIDS care, 1304-1408. )在社區更能夠有效的實施社會處遇介入

Positive changes brought bycommunity living
4. Community living has potent effects on
cultivations or reinforcement of one’s
ability to adjust to a life outside of care:
there are few options as community livingthat allows residents to explore theirpotentials of independent living under thesafety net and various professional cares.
(Stroman, D. (2003). The Disability Rights Movement: From
Deinstitutionalization to Self-determination. University Press of America.)

社區服務模式在培養障礙者適應各種社區生存能力上是強而有效的，特別是在專業與安全的支持下，能進一步發揮潛在的自立生活能力

The early model
Large residential homes: Still featured
with institution-like models but
gradually sifting its services topromote independent-living
較大的團體居住家屋：但逐步轉而促進自立生活服
務1.Rotegard, L. L., Bruininks, R. H., & Krantz, G. C. (1984). Stateoperated residential facilities forpeople with mental retardation. Mental Retardation, 22, 69–74.
2. Kushlick, A. (1976). Wessex, England. In R. B. Kugel & A. Shearer (Eds.), Changing patterns inresidential services for the mentally retarded (2nd ed.). Washington, DC: President’s Committee
on Mental Retardation
Ericsson, K. (1996). Housing for the person with intellectual handicap. In J. Mansell & K. Ericsson(Eds.)

the current mainstream
Group homes: Featured with comprehensive
deinstitutionalization and high intensity of
supports offered by staffs, around 8 people live
together to implement their independent living
and learn how to enhance the relevant skills

社區團體家庭：8人以下
1.Felce, D., & Toogood, S. (1988). Close to home. Kidderminster: British Institute of Mental Handicap.
2. Horner, R. H., Close, D. W., Fredericks, H. D. B., O’Neill, R. E., Albin, R. W., Sprague, J. R., et al. (1996).
Supported living for people with profound disabilities and severe problem behaviors. In D. H. Lehr & F.
Brown (Eds.),
3.Ericsson, K. (1996). Housing for the person with intellectual handicap. In J. Mansell & K. Ericsson (Eds.)
1. Ericsson, K. (2002). From institutional to community participation: Ideas and realities concerning
support to persons with intellectual disability.

the emerging model that is rapidly
proliferating
Supported living: Featured with high similarity
to the daily residential places we are living.
More specifically, living with individuals theychoose, people in housing (own or rent it)
receive staff supports from agencies which haveno right dominating the accommodation

社區獨立居住支持服務
Ex:British Community care program via massive
policy reforms during the past decade, the British has
intensified its efforts to transform the existing
community services into the ideal one highly similar to
one’s own home
1.Kinsella, P. (1993). Supported living: A new paradigm. Manchester: National Development Team.
2. Stevens, A. (2004). Closer to home: A critique of British government policy towards accommodating
learning disabled people in their own homes. Critical Social Policy, 24, 233–254.

Article 19
Living independently and being included in thecommunity
States Parties to the present Convention
recognize the equal right of all persons withdisabilities to live in the community, with choices
equal to others, and shall take effective andappropriate measures to facilitate full enjoyment
by persons with disabilities of this right and theirfull inclusion and participation in the community,
including by ensuring that:(a) Persons with disabilities have the opportunity
to choose their place of residence and where andwith whom they live on an equal basis withothers and are not obliged to live in a particularliving arrangement;Article 19
Living independently and being included in thecommunity(b) Persons with disabilities have access toa range of in-home, residential and othercommunity support services, including
personal assistance necessary to support
living and inclusion in the community, andto prevent isolation or segregation fromthe community;(c) Community services and facilities forthe general population are available on an
equal basis to persons with disabilities andare responsive to their needs.

General comment No. 5 (2017) on living
independently and being included in thecommunity
Paragraph 1, Introduction, CRPD/GC/5
 Persons with disabilities have historically been denied
their personal and individual choice and control acrossall areas of their lives. Many have been presumed to beunable to live independently in their self-chosencommunities.
 Support is either unavailable or tied to particular living
arrangements, and community infrastructure is notuniversally designed.
 Resources are invested in institutions instead of indeveloping possibilities for persons with disabilities tolive independently in the community.
 This has led to abandonment, dependence on family,
institutionalization, isolation and segregation.

Core elements of article 19
Paragraph 38, CRPD/GC/5
In order to ensure that the realization of a standardized minimum support
level sufficient to allow the exercise of the right to live independently andbe included in the community is carried out by every State party. States
parties should ensure that the core elements of article 19 are always
respected, particularly in times of financial or economic crisis.

a) To ensure the right to legal capacity, in line with the Committee’s
general comment No. 1, to decide where, with whom and how tolive for all persons with disabilities, irrespective of impairment;b) To ensure non-discrimination in accessing housing, including theelements of both income and accessibility, and adopting
mandatory building regulations that permit new and renovatedhousing to become accessible;c) To develop a concrete action plan for independent living for
persons with disabilities within the community, including taking
steps towards facilitating formal supports for independent living
within the community so that informal support by, for example,
families is not the only option;

Core elements of article 19d) To develop, implement, monitor and sanction non-compliancewith legislation, plans and guidance on accessibility requirements
for basic mainstream services to achieve societal equality,
including participation by persons with disabilities within social
media, and secure adequate competence in information andcommunications technologies to ensure that such technologies
are developed, including on the basis of universal design, andprotected;e) To develop a concrete action plan and take steps towards
developing and implementing basic, personalized, non-shared
and rights-based disability-specific support services and otherforms of services;f) To ensure non-retrogression in achieving the content of article
19 unless any such measures have been duly justified and are inaccordance with international law;g) To collect consistent quantitative and qualitative data on people
with disabilities, including those still living in institutions;h) To use any available funding, including regional funding andfunding for development cooperation, to develop inclusive andaccessible independent living services.

Article 19 (a)Persons with disabilities have the opportunity tochoose their place of residence and where andwith whom they live on an equal basis with others
and are not obliged to live in a particular living
arrangement;
To choose and decide how, where and withwhom to live is the central idea of the right tolive independently and be included in thecommunity. Individual choice, therefore, is not
limited to the place of residence but includes all
aspects of a person’s living arrangements: thedaily schedule and routine as well as the wayof life and lifestyle of a person, covering theprivate and public spheres, every day and in thelong term. (Paragraph 24, CRPD/GC/5)

Article 19 (b)Persons with disabilities have access to a range of in-,residential and other community support services,
including personal assistance necessary to support living
and inclusion in the community, and to prevent isolationor segregation from the community;
Individualized support services must be considered a rightrather than a form of medical, social or charity care.
They(“support services”) are not restricted to services inside
the home, but must also be able to be extended to thespheres of employment, education and political and cultural
participation; empowering parenthood and the ability to reachfamily relatives and others; participation in political andcultural life; one’s leisure interests and activities; and travel
as well as recreation. (Paragraph 28-31, CRPD/GC/5)

….all support services must be designed to support
living within the community, preventing isolation andsegregation from others, and must in actuality besuitable for this purpose…. Therefore, any
institutional form of support services which
segregates and limits personal autonomy is not
permitted by article 19 (b).
It is also relevant to keep in mind that all support
services have to be designed and delivered in amode which supports the overall purpose of thenorm: full, individualized, self-chosen and effective
inclusion and participation, and living independently.

Article 19 (c)Community services and facilities for the general population areavailable on an equal basis to persons with disabilities and are
responsive to their needs.
Various deinstitutionalization programmes have shown that theclosure of institutions, regardless of their size and the relocation of
inhabitants in the community, in itself is not enough. Suchreforms must be accompanied by comprehensive service andcommunity development programmes, including awarenessprogrammes. Structural reforms designed to improve overall
accessibility within the community may reduce the demand fordisability-specific services.
Access to housing means having the option to live in thecommunity on an equal basis with others. Article 19 is not properly
implemented if housing is only provided in specifically designed
areas and arranged in a way that persons with disabilities have tolive in the same building, complex or neighbourhood. ……In addition,
housing must be affordable to persons with disabilities.
Individualized support services which do not allow for personal
choice and self-control are not providing for living independently
within the community.
(Paragraph 32-37, CRPD/GC/5)

Nowadays what we are doing in Taiwan
Provide independent living programs toindividuals and in institutions.在機構要求與對個人提供自立生活支持服務
Initiate independent living center andservices.建立自立生活中心
Minify the capacity of institutions as themain tasks gradually with building up
community-based programs. 逐步減床並增
加社區服務模式
Reimburse incentives for community
services and it is growing.增加對社區的給付

Nowadays what we are doing in Taiwan
Develop residential support
programs in community such likegroup home under 5 persons, rent
and lifehood stuffs subsidized,
individual assistants, etc.提供社區生活
補助，如租金、個人助理等
Implement Long-term care 2.0
services in community for disabilities.
長照2.0納入障礙者
Strength the manpower in and forcommunity.強化社區專業人力Thank you for your attention