Psychiatry in China: Its Relevance for the US
Psychiatry in China? Up until about a decade ago, that could have been considered an oxymoron. Yet, just as China has modernized and embraced a Chinese form of capitalism, so psychiatry is becoming modernized in a Chinese form of psychiatry.
Table 1
You don’t understand how exciting it is right now. The atmosphere in China, it’s like what New York was in the 1960s for psychoanalysis. The enthusiasm is incredible.1
Elise Snyder, MD, American psychoanalyst
“Freud talks a lot about penis and vagina,” explained Ji, now 37. “As a teenager, I was naturally looking for books on sex so I picked it up. But I couldn’t understand anything. I’m pretty sure, looking back that the translator of the book himself didn’t understand.”1
Ji Xuesong, MD, psychiatrist in China
I, too, found the same excitement and quest for understanding when I visited China a few years ago. The fascination was so great that I temporarily thought of moving to practice in China upon my retirement. Yet, until 3 years ago, I knew little about psychiatry in China, nor was I particularly interested. Given my specialization in cultural psychiatry, I had strong interest in and knowledge about Chinese Americans and had developed a model curriculum for psychiatric residents.2 During that time, involvement in the Society for the Study of Culture and Psychiatry was an excellent source of knowledge and collegiality.
But psychiatry within China itself? Up until about a decade ago, that could have been considered an oxymoron. So little information was available that if the typical American psychiatrist thought about psychiatry in China at all, perhaps it was the paraprofessionals, the “barefoot doctors,” who came to mind.3 After all, as in the case of most totalitarian governments, psychiatry does not thrive in such governments-nor does truthful information. Take the former Soviet Union, where political prisoners were put in psychiatric hospitals, just as has been charged in China more recently; or Nazi Germany, where psychiatrists were often co-opted for the racial superiority goals of the government.4,5 Such governments tended to put the severely mentally ill and dissidents away, even into graves. The quest for individual insight, as in psychoanalysis, would not be desired. No wonder that in the countries where psychoanalysis was founded and developed, such as Germany and Austria, psychoanalysts like Freud had to flee, give up psychoanalysis, or be killed by the Nazis. Yet, just as China has modernized and embraced a Chinese form of capitalism, so psychiatry is becoming modernized in a Chinese form of psychiatry.
Cultural considerations
China, of course, is not monolithic culturally. There are scores of small minority groups. Because it is a country not easily understood by most Americans, care must be taken not to stereotype the people nor its psychiatric practice. The well-known psychoanalyst, Ernst Kris, in the middle of the last century, refused to treat Asian patients, saying something like: “I am not familiar with the Ego of those people.” That is an ethical stance for the time, but one that, hopefully, no longer stands.
Psychoanalysis was of interest in China until 1949. But then Mao gained control and banned it. The Chinese Cultural Revolution (1966 to 1976) disrupted family structure and devalued traditional Chinese medicine and the Confucian philosophy of life: China was left barren of medical and mental health care. Mao then established the so-called “barefoot doctors” to provide some minimal services in the countryside. (These barefoot doctors were somewhat akin to paraprofessionals used in community mental health care in the US. They were untrained citizens who had an interest in caring for others and were given basic training by professionals.) After the demise of the barefoot doctors and the beginning of more modern health care around 1980, psychiatric medications and psychiatric hospitals became more available. There was still a severe shortage of psychiatrists because a whole generation of doctors and therapists had been wiped out during the Cultural Revolution.
Since then, as China became a major economic power, the stress on society increased. Younger people moved from rural areas to the cities, disrupting family structure in a different way. The one-child family policy put extra emphasis on that child. Alcohol abuse increased as a coping mechanism. When violence and suicides rose as a consequence, the government began to make mental health a greater priority.6 The government understood that, at the very least, mental health care could keep people more productive.
The limits of pharmacotherapy as sole psychiatric treatment became apparent, and practitioners became more interested in psychotherapeutic techniques. Knowledge and skill gaps began to be filled by psycho-analysts from several countries, especially the United States and Germany, who provided training. Technologies such as Skype have also increased the ability to teach across countries.
The China American Psychoanalytic Alliance, led by Elise Snyder, has played a large role in this endeavor. However, cultural problems and challenges have also arisen. In a communist society the emphasis on the individual often causes ambivalence. In addition, because carefully worded interpretations are so important in psychoanalysis, language may be a problem. Psychoanalytic ideas have to be translated into equivalent Chinese concepts. For instance, Freud’s subconscious may be likened to the ghosts of Chinese superstition: both are invisible but nevertheless powerful forces.
Different therapies are emerging to supplement psychoanalytic therapy in China. One example is hypnotherapy-language is less important, the clinician is usually culturally congruent, and the technique can be learned quickly and readily applied. Patients can stop in after work for a quick session, and it can be quite lucrative for the hypnotherapist.7
Psychiatric developments
Chinese journals and conferences have started to proliferate. As of 2010, there were 14 psychiatric journals being published and the third Chinese Psychoanalytic Conference was held in September 2012.8
In 1994, the Chinese Society of Psychiatry was established. Responsible for the Chinese Classification of Mental Disorders, the society published the third version of the manual in 2001. It is similar to the ICD and DSM but adds some specifically Chinese categories. Neurasthenia is a central diagnosis and emphasizes somatic complaints. Others are koro (genital retraction syndrome), zou huo ru mo (a perception of uncontrolled qi), and mental disorders due to witchcraft. Ego-dystonic homosexuality is still retained.
In a democratic society founded on a constitution, such as the US, it should not be surprising that beginning in 1946, a series of mental health laws have been written. However, the fundamental problem with the US laws is that they generally depend on how each state decides to enact them. Consequently, public mental health care varies significantly among the different states. In states that forgo expansion and the related federal funding, mental health services can potentially deteriorate.
In China, the first-ever mental health law was established only recently, on May 1, 2013.9 This national statute supersedes any local regulations. The government apparently recognized the importance of psychological well-being for the country’s continued economic development. There are provisions for prevention, financing, management, and social welfare services. There is also legislative intent to fund nongovernmental organizations for services, research, and international collaborations.
The law mandates that, in most situations, psychiatric treatment is voluntary. Involuntary hospitalization is reserved for those who are deemed to be a risk to themselves or others, and who have severe mental illness. These patients do not have the right to refuse psychopharmacological treatment. Until this new law, families were responsible for-and could request hospitalization for-a family member. However, for this to continue to be feasible, funding for community-based services needs to be increased; for now, families are responsible for patients who live in the community and bear civil liability for the patient’s behavior.
The future of psychiatry in China
Confucius is being revived in China as a traditional source of wisdom. Religion is becoming more accepted, especially Buddhism and Taoism. Kentucky Fried Chicken rivals traditional dishes and, while fading in the US, Freudian psychoanalysis has become more popular in China. One might posit that the future of psychiatry in China will encompass Freudian theory, Western values, Confucian practical advice, and a quest for the harmony philosophy of Taoism.10
Is the rise of psychoanalysis in China a sign that we in the US have given up on psychoanalysis too early? Or will China mimic us, and psychoanalysis will first fascinate, then fade? Will China learn from our mistakes in inadequately funding community services for persons unable to afford private care? Will both countries be able to reduce their apparent over-reliance on psychopharmacology? Currently, there are more differences than similarities between psychiatry in China and the US (Table). But, as our economies continue to become more similar than different, our method of practicing psychiatry will become more similar as well.
With its focus on thinking rather than emotions, cognitive-behavioral therapy might become popular in China. Kohutian self-psychology should be helpful for a country of single children, especially wealthy males (“princelings”). For the elderly, often traumatized during the Cultural Revolution, eye movement desensitization and reprocessing is likely to be of interest.
Technically, it appears that China is at least 50 years behind the US in psychiatric treatments. However, in a theoretical and historical sense, it may be considerably ahead. The one basic, universal Chinese scientific theory over thousands of years is reflected in the importance given to Chinese medicine.11 Other aspects of Chinese science have traditionally been important for promoting human survival and welfare. In so-called “high medicine,” not only are the body and mind united, but so is an individual human and the rest of the world.
Relevance for American psychiatry
American psychiatry may also have much to learn from traditional Chinese science and medicine. The biopsychosocial model, although better in itself than a strictly biological orientation, is too fragmented. It would be better to have a general systems model. Health care in the US would do well to adopt, at least in part, China’s concept of traditional medicine. The 3000-year traditions of Chinese medicine combined with our 100 years (at best) of American medicine might make the ideal health care model. The Affordable Care Act (ACA) may be paving the way for this mind/body integration where psychiatry is part and parcel of the rest of medicine. Finally, in terms of systems of care, perhaps China has surpassed the US with its fledgling single payer system. Hopefully, the ACA is another step in that direction.
References:
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2. Moffic HS, Kendrick EA, Lomas JW, Reid K. Education in cultural psychiatry in the United States. Transcult Psychiatry. 1987;24:167-187.
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4. Chodoff P. Ethical conflicts in psychiatry: the Soviet Union vs the US. Hosp Commun Psychiatry. 1985;39:925-928.
5. Lifton RJ. The Nazi Doctors: Medical Killing and the Psychology of Genocide. New York: Basic Books; 1986.
6. Grohol J. Is mental health in China getting worse? 2011. http://psychcentral.com/blog/archives/2011/09/16/is-mental-health-in-china-getting-worse/. Accessed January 16, 2014.
7. Moffic HS. Psychiatry comes to China: will you? Psychiatric Times. http://www.psychiatrictimes.com/blogs/couch-crisis/psychiatry-comes-china-will-you. Accessed January 24, 2014.
8. Wu C, Wang L. Psychiatric journals in China. Am J Psychiatry. 2010;167:133.
9. Phillips M, Chen H, Diesfeld K, et al. China’s new mental health law: reframing involuntary treatment. Am J Psychiatry. 2013;170:588-591.
10. Zhang Y, Young D, Lee S, et al. Chinese Taoist cognitive psychotherapy in the treatment of generalized anxiety disorder in contemporary China. Transcult Psychiatry. 2002;39:115-129.
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