It's a mind field

It was once taboo to talk about depression, mood disorders, and mental health issues in general in Chinese culture. However, in recent years, a growing number of people in Hong Kong have been seeking professional help from clinical psychologists.

Yet this city seems woefully unprepared. To start, there are simply not enough qualified professionals to cope with demand. Of the two institutions training psychologists, University of Hong Kong has just 20 vacancies every two years, while Chinese University offers 19 places annually. This means that only about 30 trained clinical psychologists graduate every year.

A broader picture can be gained by looking at Britain, where there is one clinical psychologist for every 5,000 citizens, according to the British Psychological Society. To be on a level pegging, Hong Kong would need 1,400 such professionals, but there are only 400 registered with the city's two professional groups, says Dr Sammy Cheng Kin-wing, a former chairman of the Hong Kong Psychological Society, Division of Clinical Psychology (HKPS-DCP).

"People who seek psychological services need to ask a medical doctor or a social worker for referral to a clinical psychologist who is in a hospital," Cheng says.

Some people may wait a year for their first hospital appointment, he adds, although there is a system to prioritise high-risk cases. "But even a low-risk case waiting for a year can become high risk."

To complicate matters, the profession is not regulated by the government. This concerns members of the HKPS-DCP and its twin organisation, the Hong Kong Clinical Psychologists Association (HKCPA), which have been lobbying the government for 30 years to regulate the profession to no avail. Problems can arise, they warn, when psychologists opt out of the groups' practise of self-regulation and set up their own private practices, specialising in areas such as child psychology and forensic psychology.

"Some countries, such as the US, emphasise diversity and welcome early specialisation, but in Hong Kong there is more comprehensive training because it is a small place, so psychologists should have overall training," Cheng says.

As a result, clinical psychologists, much like medical general practitioners, can treat all kinds of problems.

"We need to play the gatekeeper to protect the public. But we don't have the resources to tell people who is good and who is not. We have a website that has a list of psychologists, but we can only hope people can differentiate between who is qualified and who is not."

Aggravating the problem is the fact that private-sector psychologists can advertise online, and there are "psychologists" who only have a bachelor's degree. There are others who consider themselves qualified but don't have what the HKPS-DCP and HKCPA deem to be the proper qualifications. (Membership criteria for the HKPS-DCP and HKCPA are set up with the help of professionals from the Hospital Authority, Department of Health, Social Welfare Department and the two universities.)

Charles Pau Wai-ho, vice-chairman of the HKCPA is concerned about those calling themselves clinical psychologists who set up their own societies and may have less stringent requirements for membership.

"We don't know if their competency is guaranteed and this leaves clients vulnerable because they don't know how they can file a complaint against these so-called clinical psychologists," he says.

There's also a specific qualification that concerns some professionals - City University's Scope (School of Continuing and Professional Education), which offers a doctorate in clinical psychology jointly with Alliant International University based in San Diego. Their training mode is very different from the government-funded programmes.

Visiting professor Dr Christopher Tori has been teaching the programme since it started about nine years ago. Based in Phuket, and coming to Hong Kong every few months, Tori describes the programme's presentation as an "executive format".

"People who are employed can participate and complete the programme where the course load is full time, but instead of going to school all day, they can learn in the evenings and weekends," he says.

Supplementary time with the professor is available through emails and Skype. Tuition costs HK$500,000 and many of the students are nurses and social workers who want to enhance their skills.

For the practicum, in the first and second year the student must complete 10 to 12 hours a week, while this jumps to 20 to 40 hours a week for those in years three and four. Placements are chosen from about 50 organisations.

"All their work is supervised," Tori says. "They can't have someone there just doing things. That's dangerous."

Ah-Man (not her real name)disagrees. She claims to have had a bad experience with a supposed psychologist who turned out to be an unsupervised student of the Scope programme.

Ah-Man's then 15-year-old son had been diagnosed with ADHD and had been sent to live in a group home after a bout of domestic violence. A social worker told Ah-Man someone interested in her case would contact her, but the subsequent phone call raised red flags after the supposed clinical psychologist requested confidential information. "Usually such phone calls are to discuss where to meet, not give details," says Ah-Man.

Nevertheless, Ah-Man met the man, in his 30s, and she recalled family tensions, including telling him in confidence that she suspected her husband was having an affair. At the next meeting, which Ah-Man's husband also attended, the "psychologist" bluntly asked the husband if he was seeing another woman, to the shock of Ah-Man.

"My heart was beating so loud because I was terrified of what would happen to me afterwards," she says.

"The psychologist claimed he was using a new method to confront my husband to get him to speak the truth."

She later contacted the group home's social worker to complain and only then did she learn that the "psychologist" she had been seeing was actually just a student.

Ah-Man says that the times they saw this "psychologist", he was never supervised.

Carrie Cheng Ka-wai, a registered HKPS clinical psychologist, says a case like Ah-Man's would have been better handled if the trainee was supervised by a properly trained clinical psychologist.

"We would ask the clients first if they agreed to a trainee looking at their case. If they agreed, we would have a supervisor sit with the trainee to correct procedural mistakes," she says.

"It is our professional duty to ensure the client's information is kept confidential, even from another family member."

Tori, however, rebuts Ah-Man's claims. "We [are aware of the] complaint and we'll look carefully at it," he says. "Of course, I can make accusations … that happens."

He continues: "Every agency knows who the interns are and has people there to support them. Now what I think you're hearing is that some of our supervisors are not clinical psychologists. Some of our supervisors are social workers, some are psychiatrists, some are counselling psychologists and most are clinical psychologists. You might say it's not supervised, maybe not supervised by a clinical psychologist. So I think we have a battle going with another group."

Dr Eugenie Leung, chairwoman of the preparatory committee for the statutory registration of psychologists for the HKPS-DCP, doesn't believe statutory registration for psychologists is a top priority for the government.

"Originally, the government said there are only a few psychologists, so they are not a risk to life because they don't prescribe drugs. Recently, the government has been doing better at recognising the issue, but at the same time maybe we're not good as lobbyists," she concedes. "We've been trying to write to them, to talk to them."

Dr Ephraem Tsui Pui-wang, chairman of the HKCPA, says there are about 425 psychologists registered with the city's two professional groups, representing 90 per cent of the city's clinical psychologists. He estimates there may be as many as 50 who have not registered with either association.

"In the last five years, we've been seeing more people claiming to be clinical psychologists and their practices can be unethical or dangerous, but we as a professional association cannot do anything about it," Tsui says.

"As we search on the internet we see more people who claim they are psychologists but cannot find any information about their training. People don't know if their services are proper or not because the services are confidential. Even if they are misdiagnosed the client will not know. It's very worrying."

He adds the association found about a dozen questionably unqualified clinical psychologists last year, and double the number this year.

"Such clinical psychologists may be called to be an expert witness in court," says Tsui, who has testified in a number of cases.

"But they can say total rubbish even though they swear on the stand that they are qualified."