The Strengths Model in Hong Kong The Strengths Model in Hong Kong Samson Tse, Eugenie Fung, Wann-Ka Iris Lo, Stephen Wong, Sau Kam Chan, Eppie Wan, Wing-See Emily Tsoi & Wing-Yan Winnie Yuen INTRODUCTION Mental health practice involves the continuous process of learning and refinement, especially when practitioners focus on the strengths and aspirations of individu- als who are coping with serious mental illnesses (Tse et al., 2016). Cross-cultural considerations include beliefs, language, the role of social support, and the distinc- tive characteristics of specific communities that require localization in designing and offering mental health services. In this chapter, we describe the experience of adopting the Strengths Model in Hong Kong, starting with an introduction to the mental health system in the city. We then illustrate the development and imple- mentation of the Strengths Model for the Chinese population in Hong Kong. We also briefly review research studies focusing on the Strengths Model in mental health practice in this cultural context (Tsoi et al., 2018; Tsoi, Tse, Canda, & Lo, 2019; Tse et al., 2019). The process of localization described in this chapter required the building of complex relationships among Strengths Model founders, scholars, organizations, caseworkers, and people facing mental health challenges. THE MENTAL HEALTH SYSTEM IN HONG KONG Mental health needs The territory-wide study on Common Mental Disorders (CMDs), the Hong Kong Mental Morbidity Survey (HKMMS) 2010-2013, indicated the clinical diagnosis of 223 Rooted in Strengths: Celebrating the Strengths Perspective in Social Work adults aged 16-75 years with a prevalence rate of one week was 13.3% for CMD (Lam et al., 2015) and 2.5% for psychotic disorders (Chang et al., 2015). The highest proportions of diagnoses include depression, generalized anxiety, and mixed anxiety and depressive disorders. The amount of public resources allocated to mental health services is insufficient in proportion to significantly increasing demands in recent years, particularly those associated with the social unrest since June 2019 in Hong Kong (Cheung, 2019; Hong Kong Government, 2013b). Hong Kong has a limit- ed number of psychiatrists; the latest Mental Health Atlas reported that Hong Kong has a ratio of 4.39 psychiatrists per 100,000 population, a low rate compared to that in other countries, such as Japan (10.1/100,000) and England (17.65/100,000). The city’s nursing workforce has a ratio of 29.15/100,000, whereas Japan has 102.55 and England has 82.23 (Chan, Lam, & Chen, 2015). Furthermore, Hong Kong has a sub- stantially high caseload rate for community psychiatric social workers of 5.9 social workers per 100,000 people in the population, compared to 17.93/100,000 in the United States (World Health Organization, 2011). According to a survey authorized by the Food and Health Bureau of the Hong Kong Government on access to psychi- atric care, the average period from symptom onset to initial psychiatric consultation is 42 weeks (Chan et al., 2012). Increased efforts are thus necessary to develop and retain mental health professionals. In addition, in a study conducted by Lam et al. (2015), it was found that less than 30% of those in HKMMS with CMDs had received professional help during the previous year, suggesting either a shortage of services or barriers to care. All of the above figures reflect the way in which a much larger population suffering from different mental health problems has not received profes- sional services. Psychiatric and Social Services The most recent census reported a total population of 7.4 million in Hong Kong (Census and Statistics Department, 2019). Approximately 92% of the population includes people of Chinese nationality and 8% are referred to as ethnic minorities (Census and Statistics Department, 2016). Since 1990, the Hospital Authority of Hong Kong (HA), which is a statutory body, has managed all of the city’s public hospitals, including the clinical administration of public mental health services (Cheung, Lam, & Hung, 2010). Regional psychiatric facilities have been expanded to support the growing need for inpatient care and outpatient services. In 2015/16, of the 228,700 Hong Kong citizens who received HA psychiatric services (Hong Kong Government, 2017a), over 60% of the services provided were to people suffering from different types of CMDs. Overall, the public mental health system in Hong Kong has taken shape with many similarities to community care in the West. A community psychiatric nursing service became available in 1982, followed by community psychiatric teams in 1994. As the services were extended throughout the community, new Integrated Mental Health Clinics came into service in each geographical district in 2012. These clinics are managed by family doctors and are sponsored by the HA’s primary care centers. The doctors receive supervision from experienced psychiatrists. To this day, the clinics 224 The Strengths Model in Hong Kong are running on a small, experimental scale. All of the above community care has contributed to a gradual reduction in the average length of inpatient stays from over 90 to around 60 days in the past decade. Furthermore, the HA implemented the case management care model (known as the personalized care program, or PCP) in 2010 (Hong Kong Government, 2017b). This model is aligned with similar support for home-based crisis interventions and other assertive treatments used in Western countries. This program allows an assigned case manager to follow up with a person who has a severe mental illness through a close alliance and individual care plans (Hong Kong Government, 2013a). To date, 315 case managers, mainly psychiatric nurses and occupational therapists with knowledge of mental health services, have taken care of more than 15,000 clients with severe mental illnesses, who are being treated in Hong Kong’s public sector. The government seeks to improve the ratio of case managers to clients from the current 1:50 to 1:40. While the HA mainly manages services for inpatients, the Social Welfare Depart- ment (SWD) is responsible for carrying out public policies and for developing and arranging social welfare services in Hong Kong. Most notably, the SWD offers an array of services for people affected by mental illnesses, with the aim of enhancing rehabilitation and community reintegration. Since 2010, the SWD has established 24 Integrated Community Centres for Mental Wellness (ICCMW), which are allocated across the region. These centers are recognized as the core providers of community mental health services in Hong Kong (Hong Kong Government, 2013a). In addition, the SWD also provides services for the younger population, children, families, the el- derly, and offenders (Hong Kong Government, 2013a). The Disability Discrimination Ordinance (Cap. 487), approved in 1996, is a legal framework for maintaining equal work, housing, and education opportunities, as well as reducing harassment and discrimination toward individuals with disabilities or severe mental illnesses (Hong Kong Government, 2013a). Along with the SWD, the Labour Department, the Employees Retraining Board, and the Vocational Training Council, as well as NGOs, all offer a range of employment support services, such as vocational training and workshops, for the public. Other community-based services include counseling and other resource centers that are largely staffed by health professionals and psychiatric medical social workers In addition to services directly offered by the government, in an effort to increase residential care, non-governmental organizations (NGOs) provide alternative com- munity-based residential services. These residential services are subvented by the SWD and include halfway houses, supported hostels, and long-stay care homes. These social rehabilitation service options support the re-integration into the com- munity of people with severe mental illnesses after they have been discharged from the hospital (Cheng, 2011). 225 Rooted in Strengths: Celebrating the Strengths Perspective in Social Work Prevention and Early Detection There have been a number of preventive programs in Hong Kong in recent years. The HA collaborated with the SWD to establish community-based programs for the prevention and early identification of mental health issues among various target groups. In 2001, The Early Assessment and Detection of Young Persons with Psycho- sis (EASY) program was created for individuals aged 15-25 years (extended to 15-64 years in 2011) presenting early symptoms of psychosis. The Elderly Suicide Preven- tion Programme (ESPP) was established in 2011, assisting adults aged 65 or above with depression or suicidal ideation. In addition, the Child and Adolescent Mental Health Community Support and Community Mental Health Intervention projects provide more focused support for children and adolescents. THE IMPLEMENTATION OF A RECOVERY-ORIENTED STRENGTHS MODEL IN HONG KONG Recovery-Oriented Services The concept of mental health recovery may still be foreign to people with mental illnesses and professionals in Hong Kong (Ng et al., 2008; Ng, Pearson, Chen, & Law, 2010; Davidson & Tse, 2014). However, some progress has been made in the past two decades. As the Mental Health Service Plan for Adults states, “the vision of the future is of a person-centered service based on effective treatment and the recovery of the individual” (Hospital Authority, 2011, p. 5). Even though such principles have been advocated only in