One of China's most knowledgeable forensic psychiatrists, Bin Xie, M.D., of Shanghai, has agreed to prepare a paper with me that will respond in detail to the accusations made by Western critics and taken up by human rights groups that are particularly concerned about political misuse of psychiatry. However, Xie assured me that in his eight years of forensic psychiatry consultations, he himself had never even been asked to evaluate a political dissident.
Given the attention psychiatrists in the West have paid to the broadside accusations about political misuse of psychiatry in China, it is astonishing how little interest there has been in the important and informative publications of Michael Phillips, M.D., a Canadian psychiatrist who has worked in China for the past 18 years. Phillips is a colleague of Arthur Kleinman, M.D., of the Harvard Medical School's department of social medicine. Kleinman is an anthropologist/ psychiatrist who is a specialist on China. Of greatest significance for our delegation was Phillips' excellent account of "The Transformation of China's Mental Health Services" in the January 1998 issue of the China Journal. It should be mandatory reading for those who sit in judgment on Chinese psychiatry. I have to confess that I read it only after I returned from China and with a sense of growing personal embarrassment. The transformation of Chinese psychiatry was documented in this article--available in English. Yes, the China Journal is not on my usual reading list and the focus of my own expertise was the law-psychiatry issues in China, but it now seems to me inexcusable not to have read it before going to Beijing.
Phillips describes and evaluates the effects of economic reforms on China's mental health care services, the prevalence of mental disorders, the diagnostic approach and cultural variations in nosology, the Qi Gong phenomenon of which Falun Gong is only one variant, the relevant laws and policies, the destruction of the social welfare net by the new market economy; and he does all this with lucidity, clarity and "numbers." In short, his work is an invaluable resource for anyone who wants to understand any aspect of psychiatry in China. Unlike the recent critics of Chinese psychiatry who seem to have no firsthand knowledge of the situation, Phillips has been working on the scene. He ran a 90-bed psychiatric ward in Hubei Province and is now doing superb research in Beijing Hui Long Guan Hospital. His resume is impressive and, based on our brief meeting in Beijing, I am of the opinion that he is an extraordinary human being. It should be emphasized that Sing Lee, M.D., and Kleinman did cite Phillips' article in their convincing response to Robin Munro, a human rights activist who has been the source of most of the accusations against Chinese psychiatrists. A review of Munro's most recent allegations suggests that his own focus is now on economic corruption rather than political ideology. I would hope that in the future, U.S. and British psychiatrists who have relied on secondhand sources to press the broadside allegations against Chinese psychiatry would add a careful consideration of Phillips' firsthand accounts to their deliberations.
All this being said, it seems clear that Chinese psychiatrists did, in fact, misdiagnose and mistreat practitioners of Falun Gong in the years after the government outlawed the spiritual movement in 1999. Fortunately, over the past two years, reports of psychiatric abuse of the Falun Gong have dramatically diminished. The Chinese Society of Psychiatrists has acknowledged mistakes in which unusual spiritual beliefs were characterized as delusions and the diagnosis of Qi Gong psychosis was accepted and applied uncritically. The CSP is now eager to work with the WPA and other groups to educate Chinese psychiatrists. They are prepared to reconsider the validity of the Qi Gong psychosis diagnosis and were willing to discuss cases in which Falun Gong practitioners were mistreated. However, the CSP consists of only 800 members, a small subset of the 14,000 total physicians who work in psychiatric facilities.
There are further difficulties posed in educating the hands-on professionals. First, many of the "physicians" working in psychiatry do not have the kind of basic psychiatric or medical training that is relatively standard in the West. Second, the training of these physicians is established hospital by hospital in a system of apprenticeships in psychiatry rather than according to national standards. Third, the economic mandate is to fill the beds in your hospital with paying patients, a mandate that has dominated U.S. psychiatry in the recent past. Fourth, the practice of Falun Gong is still legally a criminal matter in China and remains a sensitive issue limiting forthright and open discussion. Chinese psychiatrists were taken aback when I suggested that the basic system of beliefs of the Falun Gong be posted on their Web site as a resource for psychiatrists dealing with practitioners. The project of educating China's cadre of psychiatrists, most of them inadequately trained and working within severe economic constraints, will take a long-term effort by the WPA, the World Health Organization (WHO) and other interested organizations, but the CSP is eager to facilitate those efforts.
The lack of qualified psychiatrists, the divergent standards of training, the intense economic pressures, and the absence of central government control and command regulation all suggest a quite different situation than that which existed in the Soviet Union. If Falun Gong practitioners have been misdiagnosed and mistreated in psychiatric hospitals across China (and there is no doubt in my mind that they have been) it is not because orders came down from the Ministry of Health or Security in Beijing. Nor is there any evidence that an influential group of forensic psychiatrists carried out this psychiatric persecution of the Falun Gong in the secure Ankang hospitals. However, one cannot escape the conclusion that many of the 14,000 physicians who work in psychiatric hospitals were influenced by the fact that their government had declared the Falun Gong an "evil cult," declared its practices a crime, and launched a propaganda campaign against its followers.
As Phillips explains, China has a long history of criminalizing behavioral deviations that are considered illnesses in the West. One important contemporary example is that drug addicts are deemed criminals in China; they are consuming an illegal substance. Should we expect Chinese psychiatrists to ignore the laws of their own country in dealing with patients and adhere to standards set by Western authorities? This is not an easy question to answer, but in my personal view we cannot expect Chinese psychiatrists to ignore the criminal laws of their own country. When China passed laws criminalizing the practice of Falun Gong, those measures had an impact on psychiatrists and the families of Falun Gong practitioners. The new reality was that anyone who insisted on adhering to the "evil cult" could end up in prison or a labor camp. One can only assume that these considerations influenced the judgment of both families and psychiatrists.
Since the Chinese government's main approach to the Falun Gong was harsh punishment, can we now understand how the smaller subset of practitioners ended up in psychiatric hospitals? Unfortunately at the meetings in Beijing we were not supplied enough comprehensive or detailed evidence to answer that question; perhaps we will learn more in the future. However, certain facts are now quite clear. As the allegations posted on the Internet by Falun Gong support groups demonstrate, the use of psychiatric hospitals varied from province to province. This is consistent with what we learned about the relative autonomy of practice from hospital to hospital across China with no central regulation of standards and training. More importantly, we learned that the involuntary psychiatric hospitalization of patients in China takes place not only in the absence of any specific mental health statutes but also without any standard psychiatric criteria. If there are procedures to be followed by psychiatrists they are a matter of tradition rather than law, and now there is the pressing question of payment. The primary decision-maker is the family, and they will bear some financial responsibility. Sometimes the local neighborhood committee and the employer will also be involved as well as the police. Indeed, the only example of a functioning mental health statute in China applies to the city of Shanghai, and there the family has decision-making authority. As one might therefore expect in discussing disputed cases involving Falun Gong practitioners, Chinese psychiatrists invoked the family's decision as in some important sense absolving them of direct responsibility.