Mental Health Services: Under the Ecological Perspective
Stigma in People with Mental Illness
Self-stigma occurs ‘when members of a devalued group, being aware of prejudice, stereotypes, and discrimination targeted against them, endorse and internalize such feelings, beliefs, and behaviors toward themselves’ (Corrigan and Watson, 2002, cited in Mak and Cheung, 2010, p.268). Self-stigmatised individuals often have a lower self-esteem and self-efficacy (Corrigan and Watson, 2002). Mak and Cheung (2010) showed that self-stigma was associated with higher levels of depression and anxiety, and lower life satisfaction. It should be noticed that stigma does not necessarily lead to self-stigmatisation (Corrigan and Watson, 2002).
Corrigan (2004) suggested that self-stigma would discourage the full participation in mental health treatment. Greater perceived stigma was associated with treatment withdrawal in elderly with major depression, not in younger patients (Sirey, Bruce, Alexopoulos, Perlick, Raue, Friedman and Meyers, 2001 cited in Corrigan, 2004). Leaf, Bruce, & Tischler (1986, cited in Corrigan , 2004) revealed that people had a greater tendency to avoid using mental health services if they anticipated their family would get upset due to the utilization. Moreover, when a family member is diagnosed with mental illness, family stigma (blame, shame and contamination) would be imposed on the family, leading to their avoidance to social contact (Larson and Corrigan, 2008).
Based on the medical models, the power between psychiatrists and clients is unequal since clients are passive and disempowered—if not accepting the medical treatment, the clients would be assumed to choose being ill (Corrigan, 2004; McCubbin and Cohen, 1996). Interviews with mentally ill patients and their families, all of the interviewees being Hong Kong Chinese, reported that the current mental health system had neglected the patients’ needs to reintegrate in the community, but mainly relied on medication and hospitalization (Tsang, Tam, Chan and Chang, 2003). In fact, the interviewees felt stigmatised as long term dependents and suggested that social skills training, vocational training and placement services could promote social reintegration; however, those resources were limited. Furthermore, two patients’ mothers mentioned that they preferred taking care of their son at home since ‘the hospital had been a worse environment’, involuntary hospitalization being against their will (Tsang, Tam, Chan and Chang, 2003, p.126).
To reduce self-stigma, mindfulness strategies were integrated into Acceptance and Commitment Therapy (ACT) for individuals having substance use disorder, with positive outcomes (Luoma, Kohlenberg, Hayes, Bunting, Rye, 2008).
Contextual Barriers to Family-Centred Practices in Hong Kong (Wong, 2014)
Biomedical model (Macrosystem)
Family-Centred approach has gained more attention in Hong Kong since 2002. However, ‘psychiatrists occupy a superior position in the medical hierarchy ‘(Wong, 2014, p.217) and the biomedical models are still the dominant perspectives in the treatment of paradigm in mental health practices. This individual and illness paradigm greatly defines the role of psychiatric nurses, as providing support to psychiatric medical treatment and being subordinate to psychiatrists, and limits the development of family-centred practice in mental health services.
Psychiatric nursing training (Exosystem)
In fact, ‘psychiatric nurse education curriculum are mainly adopted from the west and individually focused’ (Simpson, Yeung, Kwan, & Wu,2006 cited in Wong, 2014, p.213). In Hong Kong, degree programs in mental health and psychiatric nursing in two universities does not include ‘topics related to work with families except some brief lectures by a guest speaker’ (Wong, 2014, p.213). Lack of family-related content in the undergraduate and graduate training is one of the great barriers to implement the family-centered approach (Bruce et al., 2002, cited in Wong, 2014; Hanson, 2005 cited in Wong, 2014). Interestingly, some nurses thought that adopting family-centred practices can enhance their profession (Wong, 2014).
Lack of time to work with families also greatly constrains the development of family-centred practices; therefore, administrative support to nurses would be crucial for the successful implementation (Wong, 2014).
Interaction between psychiatric nurses and patients’ families (Mesosystem and Microsystem)
The dominance of the biomedical approach, which is deficit-based, would affect the interaction between nurses (as a representative of mental health care) and the clients’ families. Wong (2014, p.217) revealed that ‘nurses tended to view the family negatively: the families were unmotivated, uncooperative, resistant and not forthcoming in seeking help’ and suggested that the passivity may imply ‘the families' strong feelings of helplessness and powerlessness in encounters with mental health professionals (Harden, 2005; Weimand, Sällström, Hall-Lord and Hedelin, 2013)’. ‘This perspective might result in families becoming labeled or stigmatized’ (Kaas, Lee and Peitzman, 2003, cited in Wong 2014, p.217). For the clients, ‘Chinese families expect helping professionals to act as experts to provide information, offer advice, and prescribe solutions (Ma, 2000; Yang & Pearson, 2002, cited in Wong 2014, p.217)’.
In contrast, Family-Centred Approach is strength-based perspective, which ‘emphasises the collaboration with the family to find resources and strengths to solve the problems’ and ‘empower the marginalized groups in society’ (Wong, 2014, p.217).
The Role of Planning – Establishment of Integrated Community Centre for Mental Wellness in Hong Kong
The difficulties involved in promoting well-being in the Hong Kong community can be illustrated in the establishment of Integrated Community Centres for Mental Wellness (ICCMW). It was reported that a total of 24 ICCWMs were planned for the 18 districts in Hong Kong. 1These centres are planned to provide ‘one-stop, district-based and accessible community support and social rehabilitation services ranging from early prevention to risk management’ for individuals discharged from psychiatric care, ‘persons with suspected mental health problems, their families/carers and residents living in the serving district through a single-entry point’ .2
However, in February 2011, Ming Pao reported that only 6 out of the 24 ICCWMs would have permanent venues when the service commenced in October 20113 . One of the cases was an opposition led by a District Councillor in Wu King Estates in Tuen Mun when SWD assigned a former kindergarten that had been left vacant for two years to be an ICCMW. The problems are twofold:
Lack of public education and public engagement:
- As a result of a lack of thorough public education, there is misunderstanding, or even discrimination, of persons in recovery of mental illness.
- As argued by the District Councillor in Tuen Mun who led the opposition campaign, the Government chose the site without engaging local residents in the process.
Lack of planning for public services:
- As land use zoning for ICCWMs falls under the ‘Government, Infrastructure and Community’ (GIC) category, this broad umbrella is not particularly useful for NGOs to identify a suitable venue for providing ‘controversial’ services for the people with mental illness.
- Worse still, there is no long–term social welfare planning in Hong Kong, making the implementation of a new public service such as ICCWM a particularly difficult task, especially when there was an absence of carefully planned engagement of the local residents .4
- There is also a lack of mental health literacy in the community. Mental health and well-being are matters of relevance for every resident and every family in the community, not just for a subgroup of individuals with mental illness only. Mental health literacy needs to be raised in the community as a whole so that local residents are aware of its relevance to themselves and its importance for their overall health and well-being.
Community Arts and Mental Health Services
South Tyneside Arts Studio5
The South Tyneside Arts Studio (now re-branded as ‘Arts 4 Wellbeing’ 6) was located at South Shields, South Tyneside, U.K. It was a ‘community drop-in resource’ for people with mental health problems, as ‘priority members’, and people living in local community of South Shields, as ‘non-priority members’ (Everitt and Halmilton, 2003, p.21). It aimed to bridge the gap between people with ‘mental health needs’ and those without and endeavour to not perceived as ‘ghettoised mental health project’ (Everitt and Halmilton, 2003, p.21). Art sessions were run by paid artists and/ or local voluntary artists, who actively support members in creating artworks. Through partnership with libraries, banks and art galleries, artworks of members were exhibited in various venues.
An open space was available for daily art sessions on the middle floor, including ‘display of artwork produced by members, a library of art books, work in the process of completion, materials, notices a computer and coffee area’ (Everitt and Halmilton, 2003, p.22). On the upper floor, there were five small studios, rented by the artists who run the workshops, and a gallery for exhibitions. Those studios were accessible to members for meeting the artists. Moreover, an ‘open door policy’ between managers and staff and members were available for private conversations.
The senior managers in the health authority and local authority for South Tyneside were interviewed, for the reason why they allocate mental health budgets to the Studio (Everitt and Halmilton, 2003, p.62):
- ‘it’s not arts therapy’
- ‘it presents different choices for people’
- ‘it has a huge impact on people’s self-esteem’
- ‘it’s a move away from the medical approach’
- ‘it centres on people’s abilities and strengths’
- ‘it appears to make people blossom and glow inside themselves.’
- ‘normalisation is key to the South Tyneside Arts Studio’.
It should be noticed that the difference between “art as a therapeutic activity” and “art therapy”, as a professional practice being long established in psychiatry and psychotherapy (Stickley and Duncan, 2007, p.27).
Art in Mind7
Like South Tyneside Arts Studio, Art in Mind, in Nottingham, was a project to promote social integration for people with mental health problems through community arts, with the approach of avoiding stigmatisation. Also, it aimed to strengthen social networks and enhance the sense of community. At the individual level, the project aimed to help participants feel empowered to deal with stigma and enhance their self-esteem.
Art in Mind was initiated since the ‘opportunities for creative expression’ of mental health services users were limited in local statutory services (Stickley and Duncan, 2007, p.28). A steering group, including local residents, local artists, service users, voluntary sector workers and health professionals, prepared the project proposal for two years without funding, finally nearly entirely funded by the UK government’s New Deal for Communities.
The activities, such as creative writing, photography, painting, were held ‘outside the primary care centres’ and located within ‘community environment not associated with health’(Stickley and Duncan, 2007, p.30). No referrals according to medical diagnosis were required for joining the project to avoid labeling. User-led groups were established for providing participants ‘the opportunities to achieve self-determined outcomes’ (Stickley and Duncan, 2007, p.30) .
Participants reported that ‘they had derived a sense of value and respect previously not experienced when engaging activities in health settings or day service provision’ (Stickley and Duncan, 2007, p.30). Enhancement in confidence and self-esteem, feeling of less stressed were also reported after joining the project.
 明報健康網: 24精神康復中心阻撓多僅6間落戶(13/02/2011) : http://mingpaohealth.com/cfm/news3.cfm?File=20110213/news/gok1.txt, accessed on 11 July 2014
 Source: Social Welfare Department, HKSAR. Integrated Community Centre for Mental Wellness (ICCMW), from http://www.swd.gov.hk/en/index/site_pubsvc/page_rehab/sub_listofserv/id_iccmw/, accessed on 3 August 2014.
 The materials on the Tuen Mun case are extracted from: 明報健康網: 24精神康復中心阻撓多僅6間落戶(13/02/2011) : http://mingpaohealth.com/cfm/news3.cfm?File=20110213/news/gok1.txt, accessed on 11 July 2014 and 張國柱: 社會福利用地規劃評析 (13/4/2011), from http://www.hkcss.org.hk/c/cont_detail.asp?type_id=7&content_id=517, accessed on 11 July 2014.
 張國柱: 社會福利用地規劃評析 (13/4/2011), from http://www.hkcss.org.hk/c/cont_detail.asp?type_id=7&content_id=517, accessed on 11 July 2014.
 The information of South Tyneside Arts Studio, extracted from Everitt, A., Halmilton, R. (2003). Arts, Health and Community: A study of Five Arts in Community Health Projects, download from https://www.dur.ac.uk/resources/cahhm/reports/Arts%20Health%20%26%20Community.pdf, accessed on 3 November, 2014
 Arts 4 Wellbeing, from http://www.arts4wellbeing.org.uk/about%20us.html, accessed on 3 November,2014
 Stickley, T. , Duncan, K. (2007). Art in Mind: implementation of a community arts initiative to promote mental health, Journal of Public Mental Health, 6(4), p.24-32
Stigma in People with Mental Illness
Corrigan, P.W. (2004). How Stigma Interferes with Mental Health Care. American Psychologist, 59(7), pp.614-625
Corrigan, P.W., Watson, A.C. (2002). The Paradox of Self‐Stigma and Mental Illness. Clinical Psychology: Science and Practice, 9(1), pp.35-53
Larson, J.E., Corrigan, P. (2008). The Stigma of Families with Mental Illness. Academic Psychiatry,32(2), pp.87-91
Leaf, P. J., Bruce, M. L., & Tischler, G. L. (1986). The differential effect of attitudes on the use of mental health services. Social Psychiatry, 21, p.187–192.
Luoma, J.B., Kohlenberg, B.S., Hayes, S.C. ; Bunting, K., Rye, A.K. (2008). Reducing self-stigma in substance abuse through acceptance and commitment therapy: Model, manual development, and pilot outcomes. Addiction Research & Theory, 16(2), pp.149-165
Mak, W.W.S., Cheung, R.Y. M. (2010). Self-Stigma Among Concealable Minorities in Hong Kong: Conceptualization and Unified Measurement. American Journal of Orthopsychiatry, 80(2), pp.267-281
McCubbin, M., Cohen, D. (1996). Extremely unbalanced: Interest divergence and power disparities between clients and psychiatry. International Journal of Law and Psychiatry, 19, 1–25.
Sirey, J.A., Bruce, M.L., Alexopoulos, G.S., Perlick, D.A., Friedman,S.J., & Meyers, B.S. (2001). Stigma as a barrier to recovery: Perceived stigma and patient-rated severity of illness as predictors of antidepressant drug adherence. Psychiatric Services, 52, 1615–1620.
Tsang, H.W.H., Tam, P.K.C., Chan, F., Chang, W.M. (2003). Sources of burdens on families of individuals with mental illness. International Journal of Rehabilitation Research, 26 (2), pp. 123-130
Contextual Barriers to Family-Centred Practices in Hong Kong
Bruce, B., Letourneau, N., Ritchie, J., Larocque, S., Dennis, C., Elliott, M. R. (2002). A multisite study of health professionals’ perceptions and practices of family centered care. Journal of Family Nursing, 8(4), pp.408–429, http://dx.doi.org/10.1177/107484002237515.
Hanson, S. M. H. (2005). Family nursing: Challenges and opportunities: Whither thou goeth family nursing? Journal of Family Nursing, 11(4), pp336–339, http://dx.doi. org/10.1177/1074840705280821.
Harden, J. (2005). “Uncharted waters”: The experience of parents of young people with mental health problems. Qualitative Health Research, 15(2), pp. 207–223, http://dx.doi.org/10.1177/1049732304269677.
Kaas, M. J., Lee, S., Peitzman, C. (2003). Barriers to collaboration between mental health
professionals and families in the care of persons with serious mental illness. Issues in Mental Health Nursing, 24(8), pp. 741–756, http://dx.doi.org/10.1080/01612840390228022.
Ma, J. L.C. (2000). Treatment expectations and treatment experience of Chinese families towards family therapy: Appraisal of a common belief. Journal of Family Therapy, 22, pp.296–307, http://dx.doi.org/10.1111/1467-6427.00153.
Simpson, P., Yeung, F. K. K., Kwan, A. T. Y., Wu, K. W. (2006). Family systems nursing: A guide to mental health care in Hong Kong. Journal of Family Nursing, 12(3), pp. 276–291, http://dx.doi.org/10.1177/1074840706291436.
Weimand, B. M., Sällström, C., Hall-Lord, M., Hedelin, B. (2013). Nurses’ dilemmas concerning support of relatives in mental health care. Nursing Ethics, 20(3),
Wong, O.L. (2014). Contextual Barriers to the Successful Implementation of Family-Centered Practice in Mental Health Care: A Hong Kong Study. Archives of Psychiatric Nursing, 28, pp. 212-219
Yang, L. H., & Pearson, V. (2002). Understanding families in their own context: Schizophrenia and structural family therapy in Beijing. Journal of Family Therapy, 24, pp.233–257, http://dx.doi.org/10.1111/1467-6427.00214.
The Role of Planning – Establishment of Integrated Community Centre for Mental Wellness in Hong Kong
Social Welfare Department, HKSAR. Integrated Community Centre for Mental Wellness (ICCMW), from http://www.swd.gov.hk/en/index/site_pubsvc/page_rehab/sub_listofserv/id_iccmw/, accessed on 3 August 2014.
明報健康網: 24精神康復中心阻撓多僅6間落戶(13/02/2011) : http://mingpaohealth.com/cfm/news3.cfm?File=20110213/news/gok1.txt, accessed on 11 July 2014
張國柱: 社會福利用地規劃評析 (13/4/2011), from http://www.hkcss.org.hk/c/cont_detail.asp?type_id=7&content_id=517, accessed on 11 July 2014.
Community Arts and Mental Health Services
Everitt, A., Halmilton, R. (2003). Arts, Health and Community: A study of Five Arts in Community Health Projects, download from https://www.dur.ac.uk/resources/cahhm/reports/Arts%20Health%20%26%20Community.pdf, accessed on 3 November, 2014
Stickley, T. , Duncan, K. (2007). Art in Mind: implementation of a community arts initiative to promote mental health, Journal of Public Mental Health, 6(4), pp.24-32
Other Related Resources:
The Guardian (2006), South Tyneside Arts Studio - South Shields
Durham University- The Centre for Arts and Humanities in Health and Medicine