Mental Health of Ethnic Minorities in Hong Kong Full Report

MENTAL HEALTH OF ETHNIC MINORITIES IN HONG KONG

Findings of Ethnic Minorities Well-being Centre

Between 1st January 2021 and 31 December 2022

March 2023

ACKNOWLEDGEMENTS

The Zubin Foundation would like to thank the following for their contribution to the Ethnic Minority Well-being Centre in 2021 and 2022:

 Strategic Partner and Sponsor: Lee Hysan Foundation

 Research Sponsor: Croucher Foundation

 Partner: Department of Psychiatry, The University of Hong Kong

 Advisors

o Dinesh BHUGRA, Emeritus Professor of Mental Health and Cultural Diversity at the Institute of Psychiatry, Psychology and Neuroscience, King’s College London

o Eric CHEN, Chair Professor, Department of Psychiatry, School of Clinical Medicine, The University of Hong Kong

o Michael WONG, Honorary Professor, Department of Psychiatry, School of Clinical Medicine, The University of Hong Kong

o Yi-Nam SUEN, Research Assistant Professor, Department of Psychiatry, School of Clinical Medicine, The University of Hong Kong

o Paul WONG, Associate Professor, Department of Social Work and Social Administration, The University of Hong Kong

 Supervisors

o Quratulain ZAIDI, Registered Clinical Psychologist in UK & Hong Kong, Mind n Life ( Hong Kong)

o Ginette P. C. CHEUNG, Clinical Psychologist, The University of Hong Kong

 Contributor to The Zubin Foundation’s Ethnic Minority Well-being Centre Treatment Manual

o Roger NG, Honorary Clinical Professor, Department of Psychiatry, Chinese University of Hong Kong

The Zubin Foundation would also like to thank Rosie Lanham for proofreading this report.

© 2023 The Zubin Mahtani Gidumal Foundation Limited. All rights reserved.

AUTHORS

Shilpa PATWARDHAN Lead Counsellor

The Zubin Foundation

Shilpa is a mental health counselor with 15+ years of experience in the field of mental health. Shilpa is a medical professional from India, where she has received her undergraduate (Batchelor in Medicine and Batchelor in Surgery- M.B.B.S) and postgraduate training (Doctor of Medicine in Psychiatry). In addition, she has completed Primary and Advanced Certificate Training in the Principles and Practice of Rational Emotive Behavior Therapy, from Albert Ellis Institute, New York and online courses in Acceptance Commitment Therapy (ACT) as well as in Dialectical Behavior Therapy Skills for adolescents and families. Shilpa practiced as a Consultant Psychiatrist and Sexologist in India for 7+ years. She has worked as an Assistant Professor in Psychiatry at a couple of Medical Colleges in India. In Hong Kong, Shilpa has been working as a Counsellor for 9+ years. She has worked with Refugees and the Non-Refoulement Claimant population presenting with various vulnerabilities. She is the founder of ‘Mind Direct’, offering online as well as in person counselling.

Winnie NG Project Director

The

Zubin Foundation

Winnie's main responsibilities at The Zubin Foundation are to oversee the operations of the Ethnic Minority Well-being Centre and to drive funding proposals and applications for new projects. Winnie started her journey of Corporate Social Responsibilities (CSR) in India in 2005, where she volunteered with the Unite Way of Mumbai on its fundraising efforts. She has since dedicated her career to CSR and has worked for both NGO and the private sector. Winnie previously worked at Hogan Lovells as Citizenship Manager, looking after the firm’s pro bono and other citizenship efforts in the Asia Pacific and Middle East regions. Prior to that, she worked at Cathay Pacific, running the airline’s major CSR programmes including aviation education programmes and inflight fundraising programmes. She also worked in Community Business, managing key projects including the Diversity & Inclusion in Asia Network; a network of leading companies in Asia that are devoted to progressing diversity and inclusion in the region. Winnie was born and raised in Hong Kong. She holds a bachelor's degree in social sciences from the University of Hong Kong. She lives with her husband and with two young children.

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Shalini MAHTANI Founder and CEO The Zubin Foundation

Shalini Mahtani is one of Hong Kong’s most authoritative and respected voices on social issues, particularly diversity and inclusion. In addition to founding The Zubin Foundationone of the city’s most accomplished think tanks on issues related to ethnic minority welfare and patient welfare - Shalini is the founder of Community Business, the first organisation in Asia that brings together companies and their management around women, LGBT and disabilities at work. In 2009, Shalini was honoured by the World Economic Forum as a Young Global Leader, and a year prior she was awarded an MBE from Her Majesty Queen Elizabeth II for her services in corporate social responsibility in Hong Kong. She was also recognised by the HKSAR Government for her contribution to issues related to ethnic minorities in Hong Kong. Shalini has authored research and opinion pieces on diversity and inclusion and is a frequent speaker on the topic. She is also a co-host on both BBC World Service and RTHK Radio 3. Shalini is from Hong Kong. She is a graduate of The London School of Economics. She is married and has three children.

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FOREWORD

by Shalini Mahtani, CEO, The Zubin Foundation

Mental Health is a major global health concern. Governments around the world, including Hong Kong, are paying heed to this growing problem of depression, anxiety and stress. Mental health impacts our mood, our ability to think clearly, get things done and contribute productively. It is a massive cost to the economy, the individuals who suffer and their families.

One in seven people in Hong Kong are said to suffer from mental health problems. The government, NGOs and private providers are all ramping up efforts to tackle this pandemic, but supply is working hard to play catch up with demand, with long waiting lists for sufferers.

For Hong Kong’s ethnic minorities, there is limited supply, and no one is talking about this invisible population For those who can afford to pay, the private sector is available. For those who belong to the low-income ethnic minority community, there is almost no help for talk therapy in native language. They add their names to the long waiting lists to see psychiatrists in the public sector, and often when they do, they feel unheard, and not understood. Many come away with medications but do not follow the medication treatment plan.

The Zubin Foundation is a Hong Kong charity that seeks to improve the lives of ethnic minorities in Hong Kong. In 2019 we started a pilot project to develop native language counselling for low-income ethnic minorities by qualified counsellors, thanks to a grant from the Caravel Foundation. We saw the demand for Hindi, Urdu, Nepali and English-speaking counsellors. Lee Hysan Foundation very kindly supported us with a grant to operate for two years and the Croucher Foundation supported an independent piece of research to gauge the effectiveness of this treatment from the Department of Psychiatry at The University of Hong Kong. Our service is called the Ethnic Minority Well-Being Centre.

In these pages you will see the unique challenges faced by the ethnic minority community. We have learned that by providing ethnic minority sufferers with qualified counsellors who understand their culture and speak their language, we can improve their mental health. The randomized control trial research conducted by HKU demonstrates this.

We are grateful to have the support of the Advisory Committee of Mental Health and their support for the three-year pilot of the Ethnic Minority Well Being Centre from 2023 to 2026.

Thank you to our Advisory Team, Eric Chen, Dinesh Bhugra, Michael Wong, Paul Wong and YiNam Suen. Thank you to our tremendous team of ethnic minority counsellors led by Winnie Ng and Shilpa Patwardhan Lastly, a massive thank you to Cecilia Ho at Lee Hysan Foundation.

In this evolving landscape of mental health, we need to work together as NGOs, government and private sector.

© 2023 The Zubin Mahtani Gidumal Foundation Limited. All rights reserved.

EXECUTIVE SUMMARY

The Zubin Foundation set up the Ethnic Minority Well-being Centre offering one-to-one counselling services to ethnically South Asian and Southeast Asian individuals from lowincome families in Hong Kong.

Between 2021 and 2022, Ethnic Minority Well-being Centre accepted 213 individuals to utilise its counselling service. 80% of clients scored severe or extremely severe using standardised psychometric assessments in their native language and 23% of clients were exhibiting signs of suicidal risks when they reach out for counselling help.

The most common issues triggering mental health concerns are a range of family conflicts. In intergenerational conflicts, contributing factors include differences in values between traditional parents and contemporary children, forced marriage, unfair treatment of girls and disturbed family environments. In marital conflicts, power imbalances, disagreements on family issues, extramarital relationships and lack of communication are impacting the relationships of our clients. Due to close family ties, extended families are actively involved in household and child matters and this can also be a contributing factor of mental health concerns. Aside from the aforementioned family conflicts, clients also referenced both past and present experiences of domestic violence and other forms of trauma. Managing a large family was also a source of stress for South Asian families, especially women in Pakistani communities.

Family and culture play an important role in the mental health of ethnic minorities. Language barriers and cultural differences can deter ethnic minorities from opening up and seeking professional help. It is important for doctors, mental health professionals and frontline workers to be culturally sensitive and make a concerted effort to build trust with ethnic minority individuals. As clients may find it difficult to articulate their mental health issues, it is important to examine the underlying cause of the presenting symptoms. Interventions like Cognitive Behavioral Therapy (CBT) can be effective in addressing the mental health of clients. However, CBT can pose challenges for individuals with no formal education and practitioners may use simple diagrams or other means to help individuals apply these interventions. Some issues like forced marriage can be deep-rooted and multilayered, so cannot be resolved in a short period of time. In such cases, the focus of counselling has been on identifying what can and cannot be changed, and working on that which is within the control of our clients.

The long waiting period for public psychiatric services, combined with the prospective difficulty of navigating the eventual appointment when there are language barriers, can demotivate clients to seek professional support. We suggest increasing the accessibility of information about pro bono services or subsidised schemes for private psychiatric practitioners. Publishing information in languages of increased familiarity and competency for ethnic minority communities, such as English, would be a valued resource. At present, no such English language resource guide is available.

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Mental Health of Ethnic Minorities in Hong Kong

When seeking to refer clients with suicidal risk to the publicly funded Integrated Community Centre for Mental Wellness (ICCMW) or public hospitals, some clients rejected this intervention. They were extremely hesitant to open up to another professional. We suggest working together with other organisations to develop a service model for collaboration to cosupport ethnic minority clients.

We suggest providing training to grassroots ethnic minority mental health ambassadors in each district of Hong Kong to raise awareness of mental health amongst their local ethnic minority community and help identify and refer individuals with mental health needs to relevant professional services

INTRODUCTION

Need for Mental Health Support for Ethnic Minorities in Hong Kong

One in seven people in Hong Kong will experience a common mental disorder at any given time.1 Poverty, pervasive inequality between men and women, domestic and child abuse, forced and arranged marriage, cultural conflicts and discrimination, drugs and alcohol addiction complicate the severity of ethnic minorities’ mental health issues.

While the current public mental health system provides emergency support, psychiatric services and other integrated mental health support to the public (including the ethnic minority communities), some of the services - in particular psychiatric services - are in huge demand, and there is a long waiting time before individuals can access the service unless they are at risk. Ethnic minorities also face additional challenges because most of the practitioners of public health in Hong Kong are ethnically Chinese, so have not received adequate cultural sensitivity training, nor speak the native languages of the ethnic minority communities in Hong Kong. While use of translators can help address the language barriers, some ethnic minorities may be concerned to speak about their personal issues in front of the translators as they can be from the same community.

In general, the awareness of mental health in the ethnic minority communities is low. Many have accepted their sadness, anxiety and excessive stress as a normal part of their lives. There is stigma surrounding mental health in the community, and deeply held beliefs that associate mental health issues with being crazy, violent or weak. Ethnic minorities are also very concerned that their personal issues will become known to others in their community, resulting in shame and a loss of honour or ‘face’, which further hinders them from seeking support.

1 Lam LC, Wong CS, Wang MJ, et al. (2015). Prevalence, psychosocial correlates and service utilisation of depressive and anxiety disorders in Hong Kong: the Hong Kong Mental Morbidity Survey. Soc Psychiatry Psychiatr Epidemiol. Published online first: 2015 Feb 8. DOI: 10.1007/s00127-015-1014-5.

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Ethnic Minority Well-being Centre

The Zubin Foundation set up a pilot of the Ethnic Minority Well-being Centre (The Centre) in September 2019, offering one-to-one counselling services to South Asians from low-income families in Hong Kong. The service was provided by ethnically South Asian counsellors who understood the South Asian cultures and spoke English as well as Hindi, Urdu or Nepali; native languages of many South Asian individuals. The team of counsellors also delivered talks and workshops to raise awareness in the community. The Department of Psychiatry of The University of Hong Kong and a core group of leading global and Hong Kong mental health professionals became part of the Advisory Committee for The Centre

After receiving increasing interest in counselling from ethnic minorities, in January 2021 The Zubin Foundation formalised the counselling services and expanded it’s the scale of The Centre, offering services to the wider ethnic minority communities. The Centre targets those who meet all of the following criteria:

- Hong Kong residents

- 16 years old or above

- Self-defined as ethnically South Asian or Southeast Asian

- Comfortable to use English, Hindi, Urdu or Nepali language to communicate in counselling sessions

- From a low-income household

The Zubin Foundation developed a service treatment manual and service protocol to ensure consistency and quality of service. The counselling team also continued to conduct talks and workshops to raise awareness of various topics on mental health, such as stress management, anger management, understanding emotions and mindfulness. It has produced five episodes of short videos in English, Hindi, Urdu and Nepali that explain the premise of counselling in order to help remove stigma against mental health and encourage more ethnic minorities to reach out and seek help.

To measure the effectiveness of the service, The Department of Psychiatry of the University of Hong Kong (HKU) was commissioned to conduct a randomised-control trial study with eligible clients. A separate report on the study by HKU will be published in March 2023.

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Mental Health of Ethnic Minorities in Hong Kong

FINDINGS

Profile of Clients

Between 1 January 2021 and 31 December 2022, The Ethnic Minority Well-being Centre has accepted 213 people to receive counselling services. Below is the profile of the clients:

Gender:

85% of our clients were female.

Ethnicity:

Pakistani (43%), Indian (25%) and Nepali (15%) were the largest ethnicity groups that sought counselling, representing 83% of our total client population.

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Mental Health of Ethnic Minorities in Hong Kong

Age Group:

More than half of our clients (58%) were categorised as ‘youth’, aged 30 or under.

Severity and Risk Level

Severity Level:

80% of our client scored ‘Severe’ or ‘Extremely Severe’ on the standardised psychometric scale Depression Anxiety Stress Scale (DASS).

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Risk Level:

23% of clients exhibited a risk of suicide or self-harm. The majority of the 23% had repeated thoughts such as ‘it's better if something happens to me’ or ‘it’s better if I am not alive’ (demonstrating a passive wish to die), but were not actively suicidal. Most sought help from the Ethnic Minority Well-being Centre with the intention of mitigating their suicidal thoughts.

Some clients presented with self-harm behaviours, such as cutting their wrists, banging their head against a wall etc, as a way to distract themselves from their suffering and/or release their stress and anger.

Between January 2021 and Dec 2022, we made 31 referrals to the Integrated Community Centre on Mental Wellness (ICCMW) for case follow-up support by social workers and assistance in accessing psychiatric support in addition to The Zubin Foundation counselling service for clients who presented with risk of suicide or self-harm.

COMMON ISSUES

The most common presenting symptoms included:

 Anxiety

 Depression

 Stress

 Self-harm tendencies

 Low self-esteem

 Anger management

Exploring and addressing underlying issues is critical in mental health counselling. The following issues were observed

1. Family Conflicts

Family conflicts are one of the major contributors to the mental health of ethnic minority individuals. Family conflicts can be further categorised as follows:

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A) Parents-Child Conflicts

Parents and Children Value System

One of the biggest reasons for conflicts between parents and children is the difference in their values. Many parents were either the first generation in Hong Kong or brought up in their home country and therefore have more traditional values. However, the younger generation, many of whom were born and raised in Hong Kong, have been exposed to more contemporary western culture.

This difference has created conflicts like the way the children should dress, compliance to religious practices, values towards education and work, views on marriage, etc. The conflicts can result in frequent family arguments, or in some cases result in a total lack of communication and support from parents.

Forced Marriage

It is a common practice in Pakistani culture for young people to marry their cousins or someone within their extended family. These marriages are usually arranged by parents or elders in their family. Refusing a marriage is not acceptable in most cases as it would bring shame on the family. Therefore, reluctant women are sometimes coerced into marrying against their will. Although they technically accepted, in reality they did not have a choice.

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CASE STUDY

Asma - Forced Marriage

Asma (changed name), 22, is a Pakistani female, born and raised in Hong Kong who works as a teacher after completing her bachelor's degree. Her parents chose her husband-to-be, her cousin who lives in Pakistan. Asma wanted to marry someone else, also a Pakistani man, but from Hong Kong. She did not want to accept the marriage to her cousin but she also knew that she could not reject it, so did not know what to do. She gathered the courage to talk to her mother about her struggle. Her mother was furious with her, and eventually both parents stopped talking to her. She developed anxiety symptoms and started having panic attacks as a result of this conflict and finally approached The Zubin Foundation for counseling to deal with her anxiety.

Counseling initially focused on emotional regulation and management of her anxiety symptoms. Possible options to address to her marriage situation were also explored, including bringing in a trusted intermediary to engage with the parents on her behalf. The counsellor also worked with her on maintaining her mental well-being in the face of this family conflict.

Asma decided to get help from one of her uncles to talk to her parents on her behalf. She was not sure if her parents would agree but she decided to patiently wait for their decision, while she focused on maintaining her wellbeing and avoid taking any drastic steps, irrespective of her parents' decision.

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Love Marriage

Family conflicts can also be observed in cases of love marriage not being approved by the family. If a woman or man decides to go along with a love marriage, it is known that lifelong grudges may persist between the couple and the family . This is more frequently observed in the Indian and Nepali population.

The Girl Child

In most of the cases, daughters are less important than sons within the family structure. Their education is of lower priority and they must contribute to household chores irrespective of their study schedules or academic requirements.

In many ethnic minority households, girls are not supposed to express their opinions, emotions, or suffering. They are given less freedom than their brothers, need to follow more stringent rules, and mistakes are not tolerated. Girls raised in Hong Kong within an ethnic minority culture find it difficult to accept these cultural impositions, which can result in overt conflicts at home, or negative feelings against parents.

Domestic Violence

Disturbed or complicated family environments due to domestic violence are psychologically damaging. They can also contribute to further conflicts between parents and children. In some cases, the wife (mother) forgives her husband (father), but the children do not forgive their father and are angry at their mother for tolerating him despite history of being violent

B) Marital Conflicts

It is observed that marital conflicts are another common reason for mental health issues in our clients. These can be categorised as follows:

Patriarchal Families

Roots of marital discord can often be found in the power imbalances caused by the patriarchal family system, where the husband is seen as the breadwinner and decision maker, and the wife is responsible for taking care of the children and the household. The wife has no say in major decisions in the family, irrespective of her educational status.

Marital discord can be associated with domestic violence, where a husband may resort to physical violence against his wife if she does not comply with his wishes.

Husband- Wife Disagreements

Marital conflict can also result when the mother is blamed for the children’s behavior or perceived shortcomings, as well as when there is financial hardship within the unit and pressure to financially support extended family.

Other Intimate Relationships

Extramarital relationships can be a cause for marital discord, especially when the women continue to stay in a marriage despite knowing about the husband’s affair(s).

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Mental Health of Ethnic Minorities in Hong Kong

Parallel marriages or multiple marriages are also a cause of depression, anxiety and stress for women in Islamic cultures. Islam allows men to have up to four wives at one time, providing that they treat each wife fairly in terms of time, emotional attention, and financial resources. Furthermore, he must be able to provide financially for all his wives, as well as any children he has with them. These practices are also subject to the approval of the individual wife or wives.

In our client population, we observed that some women had mental health issues in relation to having to accept polygamy within their marriage. Women reported being stressed by increased responsibilities and parental duties. In some cases, husbands went to Pakistan to take another wife there, or abandoned his legal wife to take another wife locally and have children with her in Hong Kong. These situations create feelings of rejection, neglect, loneliness and increased stress for the family.

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Communication Failure

Marital discord can result from a lack of communication with the spouse. This is common in forced marriages, where separation or divorce are not considered as an option for the couple.

CASE STUDY:

Sarika – Domestic Violence and Marital Conflict

Sarika (changed name), 34, is a married Indian female, living in Hong Kong for 6 years with her husband and son. She is an arts graduate from India and worked as a salesperson before, but since she got married she has been a full-time homemaker. She does not have a cordial relationship with her husband and describes him as a dominating and short-tempered individual who does not take responsibility for their home except earning an income.

Sarika does not have a good relationship with her in-laws either, as her marriage was a love marriage that was not approved by her husband’s parents. The in-laws are also financially dependent on her husband, which often becomes a point of conflict between the couple.

Sarika is frequently beaten by her husband but has never officially reported the domestic violence. She has focused on her son and has suppressed her other emotions relating to her marital discord and domestic violence. Sarika is holding a dependent visa and her financial dependence on her husband is one of the reasons that she does not want to separate from her husband. Recently she discovered his extra marital affair and when she questioned him, he separated from her and took the son from her claiming that she could not take care of him anymore.

Sarika was devastated when her son was taken away and approached The Zubin Foundation for counselling and help seeking legal information. Initially the counselling was focused on learning emotional regulation, getting her back to into a routine and educating her on maintaining her safety in case of further domestic violence. Using CBT techniques, various available options were explored for maintaining her well-being amongst the ongoing storm in her life.

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C) Conflicts with Extended Families

Extended Family plays a big role in ethnic minority culture. They can be a great source of support for clients in terms of emotional support, guidance and practical household or childcare support (if they are in Hong Kong). Regardless of their geographical location, they often are involved in important family decisions or have opinions on the couples’ marriage, careers, and children’s education. This can create stress and tension between the couple. In some cases, the husband’s family members are financially dependent on him and this can be another cause of conflict due to the financial burden.

CASE STUDY: Sara – The Influence of Extended Family

37 year-old Pakistani Sara (changed name), is a mother of 4 children who moved to Hong Kong 11 years ago with her husband. She was a talkative person, a clothes designer and supported the family when her husband was sick due to an injury. She was never favored by her in-laws as they blamed her for her husband’s decision to move to Hong Kong. During one of their visits to Pakistan, they changed her husband’s opinion of her, that created a wedge between the couple. Around the same time, Sara lost her father. The loss of her father coupled with a strained marital relationship caused Sara to develop extreme anxiety symptoms and panic attacks. Her husband supported her in getting medical treatment, but the couple continued to have frequent disagreements due to issues related to the extended family. The counselling sessions focused on the management of her anxiety symptoms, exploring and working on her belief system, acceptance of her family situation and ways that she can maintain her well-being.

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2. History of Trauma

History of trauma was observed to be an important issue contributing to the development and persistence of mental health symptoms.

A) Physical Disciplining

Trauma can be a result of physical or emotional abuse at the hands of parents - often as part of a disciplining strategy which is widely culturally accepted - and is sometimes considered the only parenting technique to control children. It is intergenerational; parents who have been beaten as children, tend to beat their own children.

CASE STUDY

Nishi – Parent Abuse

Nishi (changed name), 24, is a Nepali female, born and raised in Hong Kong, who sought counselling for her anxiety symptoms. The underlying issues were conflicts with parents and work-related stress. Further exploration revealed that she was physically abused by her father, whom she described as ‘overinvolved’ and strict. She saw her mother as an absent parent, who did not protect her from her father’s abuse.

Nishi’s perfectionism was developed in an attempt to avoid being punished, and caused her to develop symptoms of anxiety. The counselling focused on emotional management, exploring and managing her beliefs and processing her childhood trauma.

B) Sexual Abuse

In our client population, we came across cases of sexual abuse at the hands of a family member, distant relative, peer or outsider. When the abuser was a family member or relative, if the parents were told about it they would often prefer to hide it. Therefore, the victim would not receive any help or support to deal with the trauma.

The majority of clients with a history of sexual abuse sought counselling for their presenting symptoms of anxiety, depression, low self-esteem, but not primarily for trauma healing. The history of trauma was mostly disclosed later in therapy sessions after establishing of trust and a therapeutic relationship with the counselor.

C) Domestic Violence/ Parental Marital Discord

Domestic violence serves as a source of marital conflict and trauma for the spouse, but seeking help is rare. One of our clients expressed ‘‘Beating the wife is a common thing in many families that I know; I never thought of seeking help for that’’.

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Domestic violence and/or marital discord between parents is also traumatic for children a; either as victims themselves or as witnesses and silent sufferers. At times, the parent looks to a child for support and the child becomes confused about whose side they are on.

Fahima (changed name), 55, is a Pakistani female, mother of 4 children who has been separated from her husband for 16 years. She sought help for depression and anxiety related to her own health and her children. After 5 counselling sessions, she opened up about her trauma in the form of domestic violence, which was the root cause of her anxiety symptoms.

She suffered from domestic violence for a few years before she finally got help from her brother to separate from her abusive husband. Even after separation, she suffered from the aftereffects of trauma and harbored guilt for not being able to protect her kids from domestic violence.

Dealing with traumatic memories during the counseling session gave her relief and eventually helped in improvement of anxiety and depression.

3. Stress of Managing Families

Large families are not uncommon in ethnic minority populations; a typical Pakistani family may have 4 - 5 children. The age range of the children can be significant; the oldest may be a teenager while the youngest is an infant. As the husband is considered the income earner hedoes not contribute to the daily household chores, so the wife is responsible for managing the household and looking after all the children.

This can be challenging for women in Hong Kong as there is a lack of support from the extended families who often do not live in Hong Kong. The stress can be further heightened for those families with children who have special educational needs, medical, or behavioral issues.

4. Other Issues

A) Financial Stress

This was intensified during the pandemic. Many individuals in the ethnic minority population faced job losses and difficulties in finding new employment during the pandemic which created financial stress for their families.

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B) Pandemic-related Stresses

The main contributors were job insecurity, family separation resulting from travel restrictions, the stress of online learning (especially due to lack of space), and lack of community support. We also observed that the pandemic affected compliance towards the counseling treatment sessions (especially when the sessions had to be arranged online); mainly due to a lack of privacy and time as all the family members were forced to stay at home.

C) Others

Clients’ mental health issues were also affected by other common factors, like relationships with their partners, loss of friends/families, and disturbance of physical health.

OUR LEARNINGS – FOR PRACTITIONERS

1. Family and culture play an important role in the mental health of ethnic minorities

Many clients expressed a reluctance in seeking help before coming to the Ethnic Minority Well-being Centre. They felt their issues may not be understood by public health care professionals due to a perceived lack of knowledge and understanding of ethnic minority cultures in public health services.

The findings of the report shows that many of the issues faced by the ethnic minorities - such as differences between parents and children, forced marriages, etc. - are specific to ethnic minority communities. It is vital that mental health professionals working with ethnic minority populations are aware of this and upskill themselves to understand ethnical minority cultures and the nuances of their circumstances. Equally, mental health professional can be more aware of personal biases and stereotypes as part of cultural sensitivity training

2. Build a relationship with clients and gain trust

Establishing rapport with clients and gaining trust are important steps to provide adequate mental health support. Empathy and understanding are key components of effective counselling. Mental health professionals may not be knowledgeable about all aspects of a different culture, but exhibiting a readiness to understand (and allocating enough time for this during the sessions) is very helpful.

3. Understand underlying issues and not just the symptoms

To effectively treat clients’ mental health issues, understanding the underlying issues is equally important as addressing the presenting symptoms. We have clients who have visited professionals in the public health sector and have not able to articulate their feelings in words due to language barriers. They have been given medications that may address their physical symptoms such as headaches, insomnia etc. However, the underlying cause of these symptoms has not been addressed.

Exploration of the underlying issues can be achieved by asking clients to provide a detailed history including their family history, education, hobbies, marriage, religious beliefs, coping

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mechanisms, how they spend their day, etc. Understanding and addressing the underlying issues can help to address some of the presenting symptoms.

4. Some ways to encourage your client to share their story

It is not uncommon to face reluctance from an ethnic minority female client to share their stories. Some helpful tips include reassuring the client of confidentiality, educating the client on mental health symptoms and treatment modalities, sharing the benefits of seeking help, providing an overview of the counseling process, etc.

Professionals from non-ethnic minority backgrounds may also face resistance from the client due to concerns of cultural differences. In such situations, the professional can validate their concerns and assure their experience and efforts to understand various cultures.

5. Helpful and proven interventions

At the Ethnic Minority Well-being Centre, our treatment protocol is based primarily on Cognitive Behavioural Therapy (CBT). Some intervention strategies that we found to be useful are:

- Awareness and expression of emotions and emotional management

- Cognitive interventions including exploring unhelpful thought patterns, challenging them, and restructuring them in an effective way

- Promoting healthy routines and self-care practices

- Acceptance strategies

- Problem-solving strategies

- Exploring the support network (e.g. family, friends, etc.) and its maintenance

- Based on the client’s religious beliefs, religious practices can be incorporated amongst other healthy coping strategies

Outside referrals for psychiatric help should be sought in situations such as mental illness that indicate a need for psychiatric medications, risk of self-harm etc.

6. Monitor progress of at-risk clients

For clients with suicidal risk, we recommend them to receive psychiatric services and supply information on how to access the service. We provide counselling services in parallel, once clients have started medical treatment and their emotional state is more stable.

However, some clients may not comply with the psychiatric treatment fully or even stop taking their medications, which may result in client’s mental state becoming unstable again. We recommend practitioners develop a system to encourage and monitor client’s compliance with the psychiatric treatment and support clients to complete the treatment.

7. Deep-rooted issues take time to address

It is important to remember that many of the issues underlying mental health symptomssuch as anxiety and depression - arise from marital conflicts or forced marriage, so are deep rooted and cannot be resolved in a few sessions.

Ongoing issues may not be resolved for an extended period of time, or at all. The approach that we take in such cases (in addition to point 5 above) is exploring options available with

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the client and working on acceptance of what cannot be changed, identifying what can and can’t be changed, and focusing efforts on that which is within the client’s control.

8. Low-literacy clients

Clients with no formal education may have additional barriers and challenges when applying CBT models of therapy, especially when using worksheets or explaining concepts. We overcame these challenges by using pictures and diagrams instead of wordy explanations, simple language and examples from the client's everyday life, and further use of behavioural strategies.

OTHER OBSERVATIONS FROM ORGANISATIONAL OR SYSTEMIC PERSPECTIVES

Accessibility of the Directory for Psychiatric Resources

The demand is high for public psychiatric services and there is a long waiting time. This can demotivate clients to seek professional help. Making information on pro-bono services or subsidised schemes to access private psychiatric services in English and ethnic minority languages would be useful.

A Service Model for Organisations to Work Together

Many clients are hesitant to see a public health psychiatrist or register with an ICCMW . Part of the reluctance comes from the language barrier, client’s concerns regarding not being understood by someone from a different culture, or resistance to exposing their personal issues as repeating stories can be retraumatising.

In some cases, when the referral was made to an ICCMW, our clients reported it was hard for them to communicate with ICCMW social workers. On the other hand the ICCMW social workers also reported difficulties in contacting the clients and the service provision was delayed.

This has put us in a difficult position as counselling is not sufficient to help clients in those situations but the alternative support is either being refused or difficult to access One of the possible approach to address this is for The Zubin Foundations to work with ICCMWs/schools/hospitals to develop service model to co-support clients with risks.

Local Ethnic Minority District-based Mental Health Ambassadors

A team of ethnic minority mental health ambassadors in each district should be trained to help raise awareness of mental health amongst ethnic minorities, identify individuals with mental health needs and refer individuals to resources for necessary help.

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Mental Health of Ethnic Minorities in Hong Kong

ETHNIC MINORITY MENTAL HEALTH RESOURCES

Mental Health of Ethnic Minorities Online Resource Platform for Professionals:

The Zubin Foundation has created an online resource platform to help health professionals and other frontline workers to provide mental health interventions and support to ethnic minorities. The platform includes case studies and practical tips.

For more information, please visit: https://www.zubinfoundation.org/mental-health-resources/

© 2023 The Zubin Mahtani Gidumal Foundation Limited. All rights reserved.

THE ZUBIN FOUNDATION

The Zubin Foundation is a registered charity in Hong Kong (IR 91/12344), named after Zubin Mahtani Gidumal. We aim at improving the lives of Hong Kong’s ethnic minorities by reducing suffering and providing opportunities. We do this by outreach in the community and driving systemic change.

For more information, please visit: www.zubinfoundation.org .

CONTACT US

Website: www.zubinfoundation.org

Email: info@zubinfoundation.org

Phone No.: +852 2540 9588/ +852 2540 9488

DISCLAIMER: All information in this document is provided for general information only and is not in the nature of advice. It should not be relied upon for any purpose and The Zubin Mahtani Gidumal Foundation Limited (TZF) makes no warranty or representation and gives no assurance as to its accuracy, completeness or suitability for any purpose. Inclusion of information about a company, programme or individual in this publication does not indicate TZF’s endorsement. Where cited, you should refer to the primary sources for more information. TZF reserves the right to make alterations to any of its documents without notice. The information and ideas herein are the confidential, proprietary, sole, and exclusive property of The Zubin Mahtani Gidumal Foundation Limited. The Zubin Mahtani Gidumal Foundation Limited reserves the right to make alterations to any of its documents without notice.

COPYRIGHT: © 2023 The Zubin Mahtani Gidumal Foundation Limited. All rights reserved. Reproduction and dissemination of this document (in whole or in part) is not allowed without prior written permission of The Zubin Mahtani Gidumal Foundation Limited and due acknowledgment of authorship. If use of this document (in whole or in part) will generate income for the license, prior written permission to that effect must be obtained from The Zubin Mahtani Gidumal Foundation Limited. To obtain permission, write to info@zubinfoundation.org

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