Distinguished Guests, Ladies and Gentlemen,

I am indeed honoured to have this opportunity to speak at this conference to share with you the subject of community mental health from the perspective of the Equal Opportunities Commission (EOC).

INTRODUCTION

The EOC was established by statute in 1996 to administer three anti-discrimination laws, namely Sex Discrimination Ordinance, Disability Discrimination Ordinance and Family Status Discrimination Ordinance. These ordinances prohibit discrimination on the grounds of gender, pregnancy, marital status, disability and family status. The EOC has a number of functions. We undertake investigation, conciliate complaints, provide legal assistance and litigation support in strategic cases where conciliation has failed, and promote equal opportunities through public education, research and training.

In the past eight years, we have witnessed significant changes in many spheres of life as regards equal opportunities in Hong Kong. This has been made possible as a result of our work in complaint handling, court actions and public education efforts. To a certain extent, we have been able to help the public reduce some deep-rooted stereotypes, and assist organisations to remove some outdated policies and practices. The public is generally becoming more and more receptive to the principle of equal opportunities.

Mental illness - a global health issue

One of the areas that the EOC is concerned about is the discrimination against the mentally ill, and how it affects their rehabilitation. According to the Rehabilitation Programme Plan of Hong Kong, the number of mental health service users is estimated to be around 96,000 in 2002. The World Health Organisation (WHO) has evidence to show that a large proportion of the global health burden is due to mental illnesses, and this proportion is projected to rise. Although not a major killer disease, mental illness represents a leading cause of disability worldwide. Surveys conducted in Hong Kong have shown that between 10-15% of the general adult population have some form of mental and behavioural disorders. Mental illness places a significant burden on, not only patients, but also carers, families and the community.

When talking about mental illness, people tend to regard it as a problem of others or something that is not related to them. However, in reality, mental and behavioural disorders are found in people of all regions, all countries and all societies. They are present in women and men at different stages in their lives. They are present among the rich and poor, and people living in urban and rural areas. The notion that mental illnesses are problems belonging to certain classes of the population is simply wrong.

From Institutional care to community based care

In Hong Kong, like in other parts of the world, there has been a shift in the care paradigm for managing persons with mental illnesses away from traditional institutional care to that based in the community. This is founded principally on the respect for human rights of individuals with mental illness and use of updated interventions and advanced techniques. The objectives of medical rehabilitation nowadays are to re-establish the self-identity, the social ties and the social skills of persons with mental illnesses, and to facilitate their re-integration into the community leaving only those who are acutely ill to be hospitalized. In recent years, new mental health services such as ambulatory care in the form of out-patient and day-patient services in psychiatric out-patient clinics and day hospitals; extended care in psychiatric hospitals; and community care such as the Community Psychiatric Nursing Service, Community Occupational Therapy Service, Community Psychogeriatric Service and Community Psychiatry Service have been expanded to cater for the varying needs of mental health service users.

On the social rehabilitation front, various residential services such as long stay care home, halfway house, supported hostel and supported housing are in place. Moreover, initiatives such as respite service, activity center for discharged mental patients, aftercare service for dischargees of halfway houses and parent/relative resource center are also provided to give support and help those in need to re-integrate into the community.

Discrimination against the mentally ill

Of the many vulnerable groups in Hong Kong, perhaps those with mental illness form the most misunderstood group. Attitudinal stereotyping and discrimination against the mentally ill still exist. They are generally perceived to be violent, suicidal, unpredictable and incapable of rational decisions. In Hong Kong, anecdotal accounts, media reporting, everyday observations, discrimination complaint figures and attitudinal surveys suggest that discrimination against mental illness is still widespread.

As mentioned earlier, the EOC was established in 1996 to implement the Disability Discrimination Ordinance (DDO). Under the DDO, it is unlawful for a person to discriminate another person with a disability, including persons with mental illness, on the grounds of that other person's disability. Disability harassment and vilification are also unlawful under the DDO. In the past eight years, the EOC has received over 2,500 complaints of disability discrimination. Among these complaints, over 400 (16%) were lodged by persons with mental illness. Of these 400 complaints, around 270 (68%) were employment-related cases. Moreover, over 120 of the 270 employment-related cases were complaints of dismissal. Statistics clearly indicates the single biggest problem faced by people with mental illness in Hong Kong is discrimination in the workplace. As you may note, the figures do not represent the actual situation as aggrieved persons are reluctant to lodge complaints for fear of revealing their identities and further stigmatization.

Another major type of discrimination against persons with mental illness is "disability harassment". Over 70 of the abovementioned 400 complaints were allegations of disability harassment. Disability harassment occurs if a person engages in an unwelcome conduct (e.g. by making abusive or offensive comments) on account of another person's disability, including mental illness.

Discrimination against family members of persons with mental illness

I would like to quote a landmark case to illustrate how the DDO works in addressing disability discrimination. In 2000, the EOC assisted three young men to take their claims of disability discrimination against the Fire Services Department and the Customs and Excise Department to the District Court. The departments admitted that the plaintiffs did not have schizophrenia themselves and that they were capable of discharging the duties of the jobs they applied for, except that they each had a parent who had or who was believed to have had a history of schizophrenia. Because schizophrenia is hereditary in nature, the departments assumed that the plaintiffs possessed an unacceptably high risk of developing schizophrenia sometime in the future, and withdrew the job offers to these three young men.

After having heard evidence from top world experts who cited research indicating that persons with family members suffering from schizophrenia carried only a slightly higher chance of developing the illness themselves, the court upheld the EOC's challenge. The judgment found that the department's policy of screening out first degree relatives of schizophrenics to be discriminatory. Damages awarded to the three young men ranged from HK$0.776M to HK$1.061M. From this case, one can see the real cost of discrimination, a heavy price to pay for the employer not to mention an image to mend; and for the young men, a loss of jobs as well as career aspirations. Last week, a similar claim made by a TV news reporter was widely covered by the media. I am glad to note that the government is willing to settle the claim out of court this time, without necessitating the claimant to go through the time-consuming and painstaking process of a trial.

EOC's study on mental health service users' perception and experience

The report of the study on Mental Health Service Users' Perception and Experience of Discrimination in Hong Kong jointly conducted by the EOC and Department of Psychiatry of the Chinese University of Hong Kong was released in April 2003. The study focused on the first-hand experience and perceptions of discrimination of 757 mental health service users in Hong Kong. The findings of the survey demonstrated that actual or anticipated discrimination was widespread among the group of mental health service users studied. Results showed that perceived discrimination adversely affected multiple domains of life, such as work, family, social relationships, professional treatment and health care. Case studies of subjects who experienced actual discrimination confirmed that work place marginalization, family rejection, social exclusion, and suboptimal treatment conditions were damaging to their self-esteem, functioning, treatment adherence, and well-being.

The study reveals that stigmatization attached to mental illness can be regarded as worse than having the illness itself. Typically there is a history of concealment and social exclusion, which prevents early detection and timely treatment. The study also found that frequency with which the side effects of psychotropic drug treatment impaired social functioning and precipitated discrimination was notably high. In order to avoid treatment-induced discrimination and to re-join the mainstream community, mental health service users often defaulted treatment at the cost of a relapse of the mental illness.

Although they perceived that the media perpetuated substantial negative stereotypes about mental illness, they were reluctant to speak up for fear of the traumatic consequences of exposure. Notwithstanding the painful impact of discrimination, mental health service users adopted predominantly passive modes of coping with actual or anticipated discrimination. These included concealment, putting up with unfair handling, avoidance, and/or isolation that did not effectively rectify the discriminating circumstances. Negative emotional reactions to discrimination, such as demoralization, attempted suicide, fear of intimacy, and guilt about concealment were common, especially among female mental health service users. Formal complaints against individuals or institutions that were perceived to discriminate were rare for fear of exposure and further unfair treatment.

Mental health service users suggested public education, responsible media reporting, legal measures, and improvement in psychiatric service as useful means of reducing the impact of discrimination.

Based on the findings of this study, the EOC has made the following major recommendations:-

1. the government and major social institutions to fund public awareness campaigns targeted at all levels using a multi-media approach;
2. unfair recruitment practices and other work related discrimination in both governmental and non-governmental sectors be urgently reviewed and rectified;
3. the media to take the lead in forming a multi-sectoral working group to examine the role of the media in reducing the formation of prejudicial attitudes and acts toward persons with mental illness;
4. a multi-disciplinary and cross-sectoral Mental Health Council to be set up by government to coordinate policy formulation, programme delivery, research and public education to safeguard patients' rights;
5. the need for more medications that cause fewer side effects and have better efficacy in enhancing patients' well-being to be reviewed;
6. more information on the clinical guidelines for drug prescription and the side effects of drug treatment to be given to patients and family members;
7. psychiatric treatment and rehabilitation to pay more attention to patients' overall well-being and quality of life in addition to clinical symptoms;
8. a client-focus approach to be adopted in service delivery, with flexible hours of service delivery, based in the community, primary care and general hospitals;
9. private general practitioners to be provided with adequate training to deal with common mental disorders to help relieve the burden on the public sector;
10. more programs be developed for educating and empowering family members in the knowledge and skills of caring for mental patients.

The study has also highlighted issues that require further deliberation, including human rights, medical ethics and legal rights. These issues are inter-related and fall into many domains that require a coordinated and holistic approach. To take the matter forward, input from various sectors is essential.

 

Conclusion

A person who is mentally ill has low self-esteem... excluded, frightened and discriminated by people around him or her. They require support, acceptance and understanding. They have rights to employment and dignity like anyone else.

Importance of community education

The education of the public is very important as many aspects of mental health care require the active collaboration of the community. Community understanding and acceptance is a pre-requisite in reducing stigma and enables people with mental illness to re-integrate into the community. The family remains an important source of support and care for persons with mental illness. They can only perform their roles effectively if they are not subject to rejection and discrimination by those around them in the school, workplace, and the community.

Provision of mental health services

People with mental illness are usually at a disadvantaged position in expressing their needs and having them met. They are easily marginalized by the social services, including health care services. Social and healthcare services policy makers and practitioners therefore have to be fully aware of this in formulating their policies and service delivery. Adequate and appropriate training for practitioners coupled with procedures and guidelines to be put in place will ensure the standard of service to meet the needs of the persons with mental illness.

Policies that empower people with mental illness and their families will help to expose and counteract inequities. At the same time, the move towards "mainstreaming" mental health services with those of general medicine may help to reduce stigmatization.

Role of media in community education

Lastly, I wish to mention the role of media. On one hand, the news media can create hurdles in our work to eliminate discrimination. On the other hand, it can be a catalyst to effect attitudinal and behavioral changes. The media can provide a forum and serve as a vehicle to facilitate the dialogue and play a significant role in educating the public. In recent months, I have witnessed closer dialogue between the media and the mental health professionals, and concerted efforts to provide information on mental health issues. There are positive signs towards better understanding and acceptance of the mentally ill.

In the long run, with concerted efforts of all parties concerned in policy formulation and public education, we hope to see more effective service delivery, and better involvement of service users. I am confident that we will be able to change attitudinal stereotyping, eliminate discrimination and provide effective treatment and rehabilitation services to create a more friendly environment for the well being of the persons with mental illness, their families and the community as a whole.

Thank you.

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