During a trip to Beijing on behalf of the World Psychiatric Association, Dr. Stone witnessed up close how the psychiatry is practiced in today's China. What he found may surprise you--it certainly surprised him.
As previously reported (Psychiatric Times November 2004, p1), the World Psychiatric Association (WPA) and the Chinese Society of Psychiatry (CSP) agreed to an extraordinary meeting to discuss clinical, ethical-legal and diagnostic issues arising out of allegations of political misuse of psychiatry involving practitioners of Falun Gong and political dissidents. The meeting took place in Beijing in the last week of February and included presentations by leading Chinese psychiatrists and a delegation of seven WPA experts. My role in the delegation was to provide expertise in law and psychiatry. Working with student assistants, we had done extensive research on the Falun Gong, the reported allegations of abuse and background material asserting that Chinese psychiatrists had adopted Soviet-style tactics of political misuse of psychiatry. What follows is my personal account of the meetings in Beijing and how that experience changed my understanding of these matters. At the outset it is important to acknowledge that despite all of the research, I was ill-prepared for what I found in China.
During the week that the WPA delegation was quartered at the American hotel in Beijing, a free, English-language newspaper, the China News, was slipped under the door each day. One brief item in that newspaper put everything I had learned in a different perspective. The China News of Feb. 25, 2005, told a story about a 60-year-old father, a villager from Jilin Province, who had given his right arm so that his son could stay in college. The father's arm had been caught and mangled in a cotton-processing machine. He had been offered a choice: an expensive operation that would save his arm or a cheap amputation. He chose the amputation because his son needed the money for his college tuition. One might think the Chinese would want to conceal such cruel market economy choices in health care from English-speaking visitors; after all, China was once the land of barefoot doctors and the bastion of communist equality. But the father's choice to give his son "a brighter future" was presented as a heroic act of parental sacrifice in the real-world, free market economy of present-day China. And indeed what we found in China was that psychiatric facilities had been cast adrift by the state and expected to survive or fail in the market economy based on their entrepreneurial ability to generate revenues from their patients. China was far from Soviet-style psychiatry, and the changes had come about not by the enactment of mental health care laws, but as a result of the economic reforms that are transforming every sector of the Chinese landscape.
What this means is that in most cases, patients, their families, their villages or their employers must subsidize psychiatric hospitalization. Most of the rural population (like the sacrificing father) have no health insurance and, for those in the cities who do, there are significant copayments for psychiatric hospitalization. There is no communist equality in health care, and the primary directive in Chinese psychiatry is not about politics--it is about money, and psychiatry in China occupies the lowest rung in the medical hierarchy. With a population of 1.3 billion citizens, China has only 4,000 qualified psychiatrists and a total of 14,000 doctors working in its psychiatric hospitals. The stigma of mental illness remains an overwhelming fact of life in China and this sociocultural reality creates a barrier to care and makes the specialty of psychiatry less attractive to promising young doctors. Given the stigma and the lack of care available, it is not surprising that more than 90% of patients with schizophrenia get their primary care from their families and would be destitute without them. For most of the mentally ill in China, the family is the only support system. And for the psychiatric profession in China, the central concern is how do they make a reasonable income at the bottom of the medical ladder. Given the economic incentives and the greed unleashed by the free market, one of China's greatest problems is corruption, both among officials and the new entrepreneurs. There is every reason to believe that this corruption has infected the health industry, the medical profession and psychiatry. The "dangerous minds" in China are focused on the bottom line, not on ideology or politics.
If I had gone to China with the impression that psychiatrists, and particularly forensic psychiatrists, were power players in a monolithic Chinese communist bureaucracy, I came away with a quite different impression. Psychiatry in China is a struggling profession, with little market power and low income, low prestige, low sociocultural value and little public influence. The consistent response we got from the Chinese psychiatrists we met in Beijing was that their government had no need (and no use) for psychiatrists in dealing with political dissidents.
Chinese forensic psychiatrists have nonetheless been portrayed as playing a critical and malevolent role in their government's persecution of political dissidents. The most damning allegations describe them as engaged in systematic political abuse of dissidents from the time of Mao's regime. This claim was impossible to credit even before this trip to China. Psychiatry has always been a marginalized profession in China, and during the Maoist era psychiatrists were much more likely to be the victims of the Cultural Revolution than its enforcers. Most psychiatric facilities were closed down during the Cultural Revolution, and those that remained open were required to use political reeducation as a primary basis of treatment. Certainly during the years of the Cultural Revolution, all of the secure facilities were taken over and run by political operatives who had little use for psychiatry or psychiatrists. Forensic psychiatry, we were told by Chinese practitioners, did not exist in any meaningful sense until the 1980s.
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.
Obviously by any professional standard this is unacceptable on ethical and clinical grounds. The family cannot insulate psychiatrists from their own independent medical decisions about the need for hospitalization, medication and other treatments. Nonetheless, perhaps the best way to continue the dialogue with Chinese psychiatrists might build on this issue of the role of the family in involuntary mental health care treatment. In the Western world, mental health statutes and policies have come to assume that the family has a disqualifying conflict of interests that threaten the "identified" patient's autonomy. On the other hand, our laws and policies were formulated in contexts where it was assumed that less restrictive alternatives were available, that there were government programs to provide a safety net of care, and these policies were advanced in sociocultural contexts where the traditional patriarchal family was itself being challenged. In a society like China, where for hundreds of millions of people there is no less restrictive alternative and the only safety net is the family, it may be necessary to reconsider the assumptions that have guided the legal reforms of mental heath law in the West. If, in China, families are by custom/tradition allowed to have an important role in these decisions, then future dialogue with our colleagues might focus on the standards psychiatrists should adopt and regularize for evaluating family decisions and exploring conflicts of interest. Furthermore, Chinese psychiatrists need to formalize their own independent medical criteria for involuntary hospitalization and treatment. The development of some such uniform clinical and medical criteria might be another basis for constructive dialogue with our Chinese colleagues. The importance of developing such medical and psychiatric criteria in China is particularly compelling, since in many provinces there is no legal infrastructure of courts and lawyers on which psychiatrists, psychiatric patients and their families can rely.
Some human rights advocates distrust all psychiatrists and all psychiatric treatments and therefore urge that strict legal safeguards be in place everywhere. The WHO recently proposed a model Mental Health Statute for all nations of the world that implements this agenda and ignores the important role of the family in traditional societies. And the WPA's own Declaration of Madrid on psychiatric ethics leaves little room for the family to participate in decisions about a patient's treatment. There are many psychiatrists, human rights advocates and lawyers who have an almost missionary zeal to impose a Western-style mental health statute on all the provinces of China. Putting aside the monumental allocation of resources necessary to create the essential infrastructure of lawyers, judges and courts where none now exist, it is by no means clear that the individualistic, legalistic values favored in the West should be imposed on one of the largest populations in the world, undercutting the traditional values that have sustained the people of China for centuries.
A dialogue that respects China's traditional values and that helps Chinese psychiatrists to develop and regularize their own clinical standards for diagnosis and involuntary treatment seems to me a first step in the path of progress. It now seems realistic to suggest that in the future, ethical issues resulting from economic, not ideological issues will become central. Such a dialogue may prove instructive to those of us in the West who can--with an open mind--examine our own economic situation and reconsider the traditional role of the family in formulating our own mental health laws and policies. But the most important message I bring back from China for my psychiatric colleagues is that we should resist the impulse to make the struggling profession of Chinese psychiatry a target of opportunity for human rights advocates whose real political grievances are with the Chinese government. Psychiatrists in China need and want our help; their failings and virtues seem to be no different than our own.
Dr. Stone is the Touroff-Glueck Professor of Law and Psychiatry at Harvard Law School.