Gestalt Therapy: Yesterday and Today by Nina Bingham

This article is a theoretical analysis of Gestalt Therapy. It is an attempt to infuse 70 years of theory into a glimpse of the origin, philosophy, interventions, and limitations of the theory.  I will also comment briefly on why Gestalt Therapy appeals to me.

     In 1947 a psychoanalytically trained German psychiatrist working in South Africa wrote, “Ego, Hunger and Aggression.” It was Dr. Frederick (Fritz) Solomon Perls’ philosophical “maiden voyage,"  making a sharp departure from orthodox psychoanalysis to a never-before heard-of therapy in America called Gestalt. Dr. Perls dissatisfaction with Freud’s psychoanalytic system awakened after he studied the writings of pioneer German Gestalt founders Kohler, Wertheimer and Koffka. Said Perls, “While I was living entirely in the psychoanalytical atmosphere I could not appreciate that the great opposition to Freud’s theories might have some justification. We used to brush aside any doubt as “resistance.” But in his later years Freud himself became skeptical as to whether a psychoanalysis could ever be finished” (Perls, 1947, p.81). Perl’s first book disputed many classical psychoanalytic concepts such as the death instinct, while elaborating on others such as defense mechanisms. Perls' book introduced the concepts of the purpose of human aggression and the hunger instinct. However, it wasn’t until 1951 when Gestalt Therapy had its debut in America to an enthusiastic audience.

  

    In 1951 Perls, Hefferline and Goodman published, “Gestalt Therapy: Excitement and Growth in the Human Personality.” Hefferline was a Harvard psychology professor, and Goodman was a talented psychology writer and social critic. During the 1960’s and 1970’s Gestalt caught on like wildfire, as Dr. Perls taught groups which flocked to his Esalan Institute in Big Sir, California. American audiences were hungry for a less formal and more egalitarian approach than psychoanalysis offered, and Perls’ commanding, direct style and showmanship became a sensation. What about Gestalt Therapy was so revolutionary, new and appealing?

    
    As opposed to psychoanalysis where the therapist was out of the line of sight during therapy, Gestalt Therapists faced the client square-on. While psychoanalysis interpreted the symbolism of client’s dreams and defensive resistances, Gestalt asked the client to collaboratively investigate resistances, and be responsible for role-playing each dream character. Dr. Perls believed that to interpret for the patient was a therapeutic error; this philosophy was in sharp contrast to Freudian psychoanalysis, which interpreted everything for the client. What was the objective of Gestalt Therapy?

   
    Dr. Perls believed that maturation was the goal of psychotherapeutics, and his definition of maturation was: “The transcendence from environmental support to self-support” (Perls, 1969, p. 28). Perls would purposefully frustrate the patient because, “Without frustration there is no need, no reason to mobilize your resources, to discover that you might be able to do something on your own, and in order not to be frustrated, which is a pretty painful experience, the child learns to manipulate the environment” (Perls, 1969, p. 32). Perls staunchly believed, “Every time you refuse to answer a question, you help the other person to develop his own resources” (Perls, 1969, p. 36). Even when patients insisted they did not have the strength or answers (what Perls called “the impasse”), Perls would insist, “…these fantasizes prevent us from taking the reasonable risks which are part and parcel of growing and living” (Perls, 1969, p. 39). Gestalt directly challenges the client to take responsibility for his behavior, which is why Gestalt is considered an Existentialist therapy. Gestalt is also a Humanistic therapy, because it believes in the individual’s power to self-actualize. Perls emphasized that human nature has an inherent wisdom; that of organismic self-regulation. “With full awareness you become aware of this organismic self-regulation, you can let the organism take over without interfering…and I believe this is the great thing to be understood-awareness by and of itself-can be curative” (Perls, 1969, p. 17). Gestalt strives to increase the client’s self-awareness, believing that self-insight is the key ingredient to change and growth in the personality. What does Gestalt Therapy consider to be pathological?

    
    Freud labeled defense mechanisms as pathological, and Gestalt Therapy expounded on a few of Freud’s mechanisms, namely: neurosis, projection and transference. Dr. Perls introduced the emotional defense mechanisms of: avoidance, introjection and retroflexion, the polarities of aggression and self-expression, and how paranoia and projection are interwoven (Perls, 1947). Gestalt views psychopathology as a failure of the organism to be self-aware; that it may function, but with a scotoma, or blind spot (Perls, 1947, p. 236). How does the Gestalt Therapist enable the client to become more self-aware?

    
    An adept Gestaltist is able to reflect the client’s attitudes and beliefs like a mirror. The client can then look and sees himself more clearly. A Gestalt Therapist extensively discusses the client’s contact boundary, and the subject of polarities, asking the client to consider: are his boundaries rigid or loose? Is he isolated or confluent? Does the client polarize issues by catastrophizing, or its opposite: avoiding, denying or ignoring the problems? Gestaltists will regularly utilize experiments, or Gestalt techniques during therapy, the most renown of these being the “Empty Chair Technique,” where two polarized opinions of the clients are each role played by the client in succession. Gestaltists will also carefully monitor the client for indirect body language which are unconscious expressions of emotion. They may direct the client to exaggerate or repeat body language to give the symbolic gesture a “voice.” They will ask clients to describe dreams, and to play all the parts in the dream, giving the dream characters and items a “voice.” Dr. Perls believed every character and item in the dream is a “part” of the client, and every dream has an existential message or meaning. Gestalt Therapists may ask clients to repeat phrases for emphasis during therapy which are meaningful, and are not afraid to lead the client to a catharsis point. What are the limitations of the theory?

    
    Because Gestalt Therapy can be an intense and deeply cathartic experience, clients may experience abreactions in counseling. A strong reaction could cause some clients to withdraw prematurely from counseling. In order to mitigate this experience, I’ve learned it is important to allow time for the client to “debrief” after a particularly emotionally-charged session. Clients need an opportunity to share with the therapist what they experienced, how they intend to integrate what they learned into their lives, and to clarify unanswered questions. It is up to the counselor to provide a smooth transition from deconstruction to construction. Are there cultural limitations?

    
    From a cultural perspective, Gestalt Therapy may not be the therapy of choice for individuals from collectivist societies who are more private and reflective in nature. Gestalt encourages free outward expression of thoughts and feelings; the client is encouraged to share fears, anger and insecurities. Members of collectivist cultures which might not be accustomed to expressing anger or fear openly could be misjudged by a Gestalt therapist as withholding or resistive, unless the counselor is culturally sensitive. If the counselor understands the client’s cultural perspective, she can adapt the therapeutic approach to the client, rather than demanding the client adapt to the approach. What is on the horizon for Gestalt Therapy?

    
    Relational Gestalt Therapy is the most modern branch of Gestalt, and what I aim to practice. It has modified Dr. Perls’ abrasive style so that it is more “user-friendly” for people of all cultural backgrounds. Although Dr. Perls teachings did not focus as much on the client-counselor contact boundary as it might of, Perls admitted to its importance: “The We doesn’t exist, but consists of I and You, and is an ever-changing boundary where two people meet. And when we meet there, then I change and You change, through the process of encountering each other…” (Hycner, Jacobs, 1995, Introduction). Contemporary Relational Gestalt Therapy is dialogical and inter-relating, and what is hoped for is that it is more relational-focused than the technique-oriented Gestalt Therapy of the past. Co-founder of Gestalt Therapy, Dr. Laura Perls said about the development of Relational Gestalt, “With the gift of hindsight, Martin Buber’s philosophy of I-Thou seems the perfect antidote to the narcissistic flavor that infused Perls, Hoffman, and Goodman’s portrayal of the organism/environment field paradigm” (Hycner, Jacobs, 1995, Introduction). Based upon philosopher Martin Buber’s emphasis on the “I-Thou” relationship (Buber, M., 1958), a new generation of Gestalt Therapists are practicing warmly and sensitively, seeing dialogics as the ground upon which to find a cure rather than techniques.  Why do I feel Gestalt is a good fit for me?

   
    In the time I have practiced I have come to see one thing very clearly, and it is that the most dynamic force in therapy is not a set of techniques, or even a philosophy of practice. As Buber states: “In the beginning is relation” (Buber, 1958, p. 18). The dynamics of the therapist-client relationship, or "I-Thou" relationship is the primary defining element of success or failure. “The I-Thou experience is one of being fully present as one can to another with little self-centered purpose or goal in mind. It is an experience of appreciating the “otherness,” the uniqueness, and the wholeness of another, while at the same time this is reciprocated by the other person. It is a mutual experience” (Hycner, Jacobs, 1995, p. 8). However, I’ve also found that a set of time-tested techniques is helpful in the process of therapy, and having a clear philosophy of practice allows the therapist to structure the session cohesively. Relational Gestalt is a fascinating blend of dialogue and technique, and is well suited to my extroverted personality. I may not have the daring flair of Dr. Perls, but I do enjoy seeing what comes of a spontaneously created experiment, and the results of a technique like the “Empty Chair.” My personality is direct enough to confidently lead clients through an intervention, even if I may not know exactly what the outcome will be. Sometimes I’m unsure about where we will land…but I am working into being comfortable with the uncertainty which is Relational Gestalt Therapy. I’m no longer bound to a set of techniques, because I’m making it a priority to build a relationship with the client before me. I’m learning that the most powerful ingredient in the therapeutic relationship is what we create together, the therapeutic bond. The German world Gestalt is translated to mean, “An integrated whole.” With the emphasis being placed on relationship rather than techniques, I feel Relational Gestalt Therapy is becoming more of an integrated whole than ever before.

References:

Perls, Frederick, S. (1947). Ego, Hunger and Aggression: The Beginning of Gestalt Therapy. Vintage Books, A Division of Random House, New York.

Perls, Frederick, S., Hefferline, Ralph., Goodman, Paul. (1951). Gestalt Therapy: Excitement and Growth in the Human Personality. The Gestalt Journal Press, Inc.  

Perls, Frederick, S. (1969). Gestalt Therapy Verbatim. Real People Press, Lafayette, California.

The Counseling Dance by Nina Bingham

    Counseling is a little like couple's dancing: two people are endeavoring to link up and learn to step together. In this endeavor, every therapist walks a fine line with her client of knowing when to lead, and when to follow. I'm seeing it depends upon the client's personality. Some clients appreciate the unconditional positive regard and empathetic listening skills of a receptive counselor, while others crave a more assertive, solution-focused and goal-oriented approach. For a personality like mine which is direct and expressive, being completely non-directive or "Person-Centered" in approach (Rogers, 1942), doesn't come naturally. For me, learning to "follow" the client's lead is a learned skill. It takes a great deal of restraint on my part not to "dash off" in dialogue towards the "obvious" solution, and to allow the client to discover the answers in her way, in her own time; to allow an organic process of self-discovery to unfold for the client. An ancient Chinese proverb says, "Give a man a fish, and he eats for a day. Teach a man to fish, and he eats for a lifetime." As an expressive and extroverted personality, I'd be just as happy handing the "fish" to the client as teaching her how to fish for herself. However, as this Chinese proverb teaches, if the client discovers for herself how to fish, she will have learned a skill which will serve her well the rest of her life. And, some clients will benefit by the ego-strengthening which comes by leading the therapist. So as a therapist, how do you know when to lead, and when to follow?
 
    I admit that I still struggle to understand how much help is too much. Many clients come to counseling to find their own unique voice in the world. How can they exercise their will if they don't speak it in the safe confines of the counseling room? Therefore, some clients are not helped by directive counseling, and would benefit by a receptive counseling approach, such as Person-Centered Therapy. And yet it is the client low in self-esteem, ego strength and identity who appear to need the most direction. Many will present as "lost souls," having been blown off-course, and seemingly directionless. A therapist's first instinct will be to "rescue" the "drowning" person. Yet if Rogers was correct that all people have an "actualization tendency," which is the potentiality to be self-directed, the therapist should only act as the environment that the client "pings" off of, in order that she may make her way in the darkness. It was Gestalt Therapy's co-founder Laura Perls who wisely advised, "Give the client the least amount of support necessary for growth." According to Roger's theory, "The client centered-therapist does not intend to diagnose, create treatment plans, strategize, or employ treatment techniques" (Corey, 2009, p. 171). However, in times of crisis, the Person-Centered therapist makes suggestions, offers guidance, and even direction might be called for if clients are not able to function effectively (Corey, 2009, p. 179). If a client's mental illness has incapacitated their ability to navigate, that client will benefit from a directive approach from the healthcare provider. For them, the provider becomes their "port in the storm."

    How to assess whether the client would benefit from a receptive approach or a directive approach can be based on the client's reaction to the therapist's attempts at intervention. I think of a client I had who became defensive, suspicious,  and perturbed when I attempted even the slightest of experiments. She scoffed at my attempts to introduce even small interventions into the dialogue. When I brought this to her attention, she would again retreat into defensive postures. It was as if she was daring me to "get through to her." What I learned from this "resistive" client was quite important for my growth as a therapist. I learned that some clients have a high need to be "heard," and to direct the operation. She had a low tolerance for others  opinions, and a high opinion of her own. Gestalt Therapy's Dr. Fritz Perls would have referred to her as a "closed system." And yet, she had presented in therapy. Perls used to refuse to work with these sorts of "difficult" clients. However, perhaps the therapist should give the client what they are asking for...what they can assimilate, rather than what we wish they could assimilate! If a baby isn't ready for table food, we don't demand he eat it anyway. Instead, we spoon-feed the baby, until such a time when they develop a tolerance for adult food. With no insult intended, there will be clients who are not ready or able to assimilate the interventions the counselor would like to make. Should counselors be willing to work with this kind of emotionally immature client? Moving slowly, cautiously and tentatively will require great patience from the counselor, and he will need to abandon his "agenda." All his great skill, techniques and experiments will have to be put away, and what he has left to work with is simply himself, his personality, and his ability to empathize, to understand, and to confirm the client. He is stripped of his therapeutic "armor," and left standing in what sometimes feels like his undershorts! Then, he will be asked to follow rather than lead. He will have to find a way to "check" his ego, so that the client can shine. For an extrovert who doesn't enjoy dancing in the first place, taking my cues from the client (in my underwear) is uncomfortable business. And this is why I believe Dr. Perls wouldn't work with resistive clients; he wasn't accustomed to "following." But for some clients, this may be the best they can do to make contact.

    Contact is a strange thing. Too much of it and it causes repulsion. Too little, and longing for contact sets in. Most clients struggle with making contact with the therapist. I watch clients talk to the wall, the ceiling and their feet to avoid making contact with me, to avoid "being seen," as it were. They are avoiding my reactions and expressions. What they are "tuned into" is their inner world. The client who struggles to make eye contact in therapy is lost internally. They have disengaged with the environment, and lost touch. They have withdrawn. They do this to protect themselves. Hyper-verbal clients use words as a shield to keep others from seeing them; almost as if they keep talking you will be distracted and not notice them. Both methods of avoidance are ways of retreating from contact. When there are obvious signs of contact boundary problems, the person has often been the victim of abuse or neglect. They may have survived boundary violations but consequently, these violations served to breakdown healthy contact with others. In simplest terms, "getting too close to the fire" frightens these skiddish, ego-fragile individuals. The hope is that through a process of unconditional positive regard in therapy, the client learns it is safe again to trust the therapist with feelings.

    It takes a large portion of academic skill and humanistic sensitivity to become an integrated, whole of a counselor. In fact, I can see I'll be working the rest of my life on it. I'm finding that what may feel like modest gains for me may feel like milestones for clients. When I see them progress, I know that in a sense, I have, too. I'm learning as much about this dance as they are. I'm learning how to establish contact in the counseling room, and so are they. This is a collaborative journey. Sometimes I'm not real sure where we're headed, and in those moments of blind faith in their ability to grow, and in my ability to catch them if they slip, I'm learning to relax my grip and let the client lead. Sure enough, they don't disappoint. They pick up the dialogue and we're off again exploring from a different angle. The longer I do this, the more I'm willing to set aside my my theoretical learning and to discover how to dance with the unique and sometimes puzzling individual before me. Clients don't "fit" perfectly into the "boxes" or diagnostic labels psychology has given them; these are real human beings before me, with real lives, and their challenges are about as diverse as they are. I'm learning to "toss aside" the way the books say it should be done in favor of whats happening; my hypothesizing and theorizing is lost in trade for exploring with the being before me. This "being with" is what Relational Gestalt Therapy refers to as the "between" which is created in the space of two people trying to relate to one another. And this is the magic of the therapeutic relationship! It is in the relational, dialogical interactions that the bond is formed. This bond is therapeutic, and is the goal of humanistic therapy. When I am attending to the person rather than to the problem, then I am in a position of effecting the healing work which is psychotherapuetics. This is what I've trained for! I am finding there is wisdom in waiting to be asked to dance.

References:
Rogers, C.R. (1942).  Counseling and psychotherapy. Boston: Houghton Mifflin.

Corey, G. (2009). Theory and Practice of Counseling and Psychotherapy. Eighth Edition. BROOKS/COLE CENGAGE LEARNING.

Saving Face: How Chinese Mental Health Care Is Evolving by Nina Bingham

Saving Face: How Chinese Mental Health Care Is Evolving

    This article will address how Chinese and Chinese Americans have been under served in mental healthcare. Stigma, shame and feelings of having to “save face” for both Chinese, and Chinese Americans regarding individual and familial mental illness originates in ancient Confucianism, and therefore, Chinese are less apt to seek mental health treatment. Traditionally, Chinese absolve themselves of mental illness symptoms by somatic symptoms which “explain” their illness. This paper will show how culturally sensitive systems can improve mental health delivery to this cultural group, reducing the stigma of mental illness, thereby  evolving from shame to “saving face” for mentally ill Chinese, and Chinese Americans.

    To say that Chinese, and Chinese Americans have been an under served population in mental healthcare, and delay seeking treatment, is an understatement. “The majority of Asian Americans (even though all met criteria for a psychiatric disorder) did not use specialty mental health services. However, the rate of mental health service use by U.S.-born Individuals were almost twice that of immigrant Asian Americans. This is consistent with Abe-Kim et. al (2007) who also found that U.S.-born individuals used mental health services at higher rates than immigrants” (Le Meyer, O., Zane, N., Cho, Y. I., Takeuchi, D.T., 2009). However, this does not mean Asians do not need mental health care services. “Lower utilization rates and delay in accessing Western health services contributes to Asian Americans exhibiting more serious mental disorders when treatment is ensued” (Flaskeruddltu, 1992; Yeh et al., 2002). What are some of the issues which keep Chinese and Chinese Americans from seeking mental health care? 

    Chinese present stress somatically as compared to Individualistic cultures. They view physiological complaints as due to the external environment; what might be termed, “externally oriented thinking” (Heine, S.J., Bagby, R.M., 2008). Why would the Chinese express psychopathology as somatization? The Chinese language itself is not conducive to emotional expression.  Leff, 1981, argued that, “Chinese somatization results from a lack of well-developed emotional vocabulary in the Chinese language-Chinese individuals, lacking necessary words, resort to somatic symptoms mainly. Mainly Chinese words which are terms for emotional expression are rooted in the body, so Chinese respondents use somatica when asked to express emotionally” (Tung, 1994). A survey of Chinese immigrants reported seeking counseling for somatic symptoms while Chinese Americans reported psychological symptoms” (Yen, Robins, and Lin, 2000). “Commonly reported somatic symptoms were: headaches (90%), insomnia (78%), dizziness (73%), pain (49%) and depressed mood only 9%” (Ryder, A.G., Yang, J., Zhu, X., Yoa, S., Yi, J., Heine, S.J., Bagby, R.M., 2002).      

    Another factor in keeping Chinese from mental health care services has been social conditioning by ancestry to conceptualize mental illness as a “loss of face and shameful” (Zane & Yeh, 2002), and as a stigma. “A psychiatric stigma is a sense of spoiled identity, which motivates individuals to avoid psychological classification” (Goffman, 1963).  The word “face” in Chinese is “mientz,” and is a powerful social concept among Asians, meaning a concern over public image which represents both the individual, and her family’s social class. In Collectivist cultures like China, etiology of mental illness is considered social or due to personal weakness, while Western culture attributes mental illness to genetic predisposition, brain and nervous system and environment factors (Mallinokrodt, Shigeoka, & Suzuki, 2005).  “Desiring to “save face” can “inhibit emotional expression and help-seeking behaviors among Asians and Asian Americans” (Mak & Chen, 2006).  However, for Chinese Americans, the more acculturated they become, the more help-seeking they become (Atkinson & Gim, 1989; Tata & Leong, 1994;  Zhang & Dixon, 2003).      
 
    American health providers must understand Chinese society and their attitudes about what it means to be a Chinese person before they can provide culturally-sensitive care for Chinese mentally ill and their families. “Personal identity is judged on how one behaves according to one’s relation to the group” (Chan, S., 2008). Therefore, “Chinese people pay great attention to relationships with others, especially family members” (Hwang, 2000). In Chinese culture, family is perceived as the “great self” (Bedford & Hwang, 2003). “A Chinese individual feels obligated to do whatever it takes to maintain a well-functioning family. This is in contrast to Western Individualism which emphasizes an individual’s autonomy” (Sing et al., 1962, Tarwarther, 1966). For example, “Chinese children are brought up to pay great concern to their own families honor and reputation” (Ji et al., 2001). In China, to be a person is to, “…fit an individual’s external behavior to the interpersonal standards of the society and culture” (Chan, S., 2008). Therefore, “loss of face” (through mental illness) not only reflects on the individual patient, but also on the families and their ancestors (King & Bond, 1985). Additionally, “Traditional Chinese culture places value on self-restraint, suppressing and controlling emotions, and places little value or concern for them” (Tracey, Leong & Glidden, 1986).      
 
    Beneath these Chinese ideas of personhood is the religious philosophy of Confucius, upon which China has rested since 551–478 BC. Confucianism defines five types of relationships:
1. Sovereign and subordinate 2. Father and son 3. Husband and wife 4. Elder brother and younger
5. Friends. It also defines the guiding behaviors for these roles. “Individuals who act outside of the roles are seen as trouble-makers” (Hwang, 1978). Failure to fulfill your given Confucian role results in guilt and shame to that person. A Chinese person who is mentally ill may be prohibited from fulfilling their familial and societal role due to their symptoms, and to avoid this loss of role “Chinese families will go to great lengths to avoid the label of mental illness and it’s stigmatization effects” (Yang, Lawrence H., Phelan, Jo C., Link, Bruce G., 2008). Yet, however taboo mental illness has been in Chinese society, depression and suicidal ideation has exponentially been on the rise among young Chinese women and men over the age of 60 (Jianlin, J., 2000). The rise in mental illness among these two groups is understandable if you are aware of the Chinese socialization process for women and the elderly. “Chinese women, in particular, suppress emotion of suffering and anger. This suppression of emotions leaves them vulnerable to suicide” (Pearson et al., 2002). Regarding the rise in Chinese elder  mental illness rates, “We found that age differences in the effect of social exchanges apply only  to depressed affect, not to life satisfaction. One reason may be that life satisfaction is a relatively  stable construct that involves a global evaluation of life, whereas depressed affect is a mood state  that tends to be transient and to respond more quickly to social stimuli” (Lydia W. L. and  Liang,  J., 1991). Since 1991, economic reform has been in full swing, and with it, familial demographics have changed: “Similar to many developed nations, the Chinese population is
 aging rapidly (Kinsella & Velkoff, 2001). Family has been the primary institution for supporting  older people in Chinese society. Confucian teaching emphasizes that children should take care of  their parents (Leung, 1997). The lack of pensions and formal services in China also leaves many  older persons no choice but to depend on their families (Gu & Liang, 1994). While the economic  reform since 1978 has led to rapid economic growth, the Chinese government has not increased  public support in old age (Hsiao & Liu, 1996; Jackson & Howe, 2004). Meanwhile, Chinese  families are under stress to care for their older relatives as a result of increasing migration to  cities for jobs, an erosion of traditional status of older persons, and a disintegration of communal  systems in the countryside (Leung, 1997; Jackson & Howe, 2004). It is easy to surmise why, as  children leave the family to migrate to the cities, traditional honor for the aged is on the decline,  and generations of cohabitating families are no longer the norm, that Chinese elders are  experiencing depression in record numbers. “Verbal abuse was frequently associated with  depression amongst Chinese people” (Zhang et al., 1997), and, “…patient’s psychological  distress emerged when the patients did not receive family member’s support” (Phillips and  Pearson, 1997).
 
    Clearly, the clinical goal is to provide culturally-acceptable means by which Chinese  and Chinese-Americans can utilize more mental health services without experiencing a “loss of  face.” This goal can be accomplished by utilizing three interventions :

1. Public service media campaigns which psychoeducate the Chinese public should  advertise “respectable” methods of accessing mental health services for Asians, and  publicize that these services are being underutilized.
2. More culturally-sensitive health care professionals must be willing to  psycho educate their Asian patients (such as traditional community healers, and  primary healthcare providers) that there is no shame in seeking mental health  services, and encourage patients to do so if needed.
3. Lastly, Chinese and Chinese Americans need culturally sympathetic caregivers  who can recognize, accept, and display empathy for their patient’s cultural values and  beliefs.
“Therapy which aims to understand the impact of Chinese cultural values, interpersonal  conflicts, and on the sense of guilt and shame may need to be provided for Chinese patients and  their family members” (Carson, 2000).  Ways of “Saving Face” which “bridge the gap” in public  between East and West could include integrating mental health services with primary care, “so  individuals can access mental health care without explicitly seeking mental health services”  (Fang & Chen, 2004; Yeung et al., 2004). Another covert way of offering mental health services  to university students is to integrate mental health into the already established student health  services (Constantine, Chen & Ceesay, 1997).
 
    In Shanghi, China in 1994, in a period of 2 years, 8, 214 callers utilized an anonymous “Telephone Hotline to discuss and resolve problems” (Seeley, 1994). “Of these callers, 57%  called to seek help with marriage disputes, 51% called due to troubled love affairs, 3.5%  requested intervention for psychosis, 3.2% called to seek help with sleep disturbances, and 2.2%  called with suicidal ideation. Since that time, 26 Mental Health Hotlines in Shanghai have been  established. They are cost-effective, easy to contact, and anonymous, protecting the caller’s  privacy. In addition to the above, callers discussed the following psychological problems:  Emotional problems (anxiety and depression): 12.4%, Interpersonal Disputes-10.3%, Marital  Problems-9.1%, Health Problems-8.5%, Occupational Problems-8.3%, Family Disputes-5%, and  Sexual Problems-4.8%, Study Difficulties-4.3%, Psychosis-3.5%, Sleep Disturbances-3.2%,  Education and Child Care Concerns-3%, and Self-Harm- 2.1%” (Jianlin, J., 1995).  These  Hotlines are telling the whole story: Chinese and Chinese Americans are suffering in silence. In a  shocking example, “In the country of Tibet, no psychiatrist or special mental healthcare services  are available” (Jianlin, J., 1995). 
 
    Though it may seem like an impossible challenge to meet the mental health needs of the  Chinese, given the traditional view of “saving face,” transforming China’s Mental Health System  has been addressed by The “National Mental Health Project of China: 2002-2010.” With  depression and suicide rates rising every year, an estimated 16 million Chinese are already in  need of mental health services. 21% of the world’s population is Chinese, and 25% of the  world’s suicide rates are Chinese. The Chinese Ministry of Health, Civil Affairs, Public Security  and Disabled People’s Federation have agreed that China must “raise awareness of China’s  mental health needs and treat mental illness” (Jianlin, J., 1995).  The National Mental Health  Project of China 2002-2010 recognized this and called for Community-Based Services in place  of hospital care” (Kelly, T.A., 2002). The reality is that within the Chinese healthcare system  “There are no social workers and few clinical psychologists working. Most clinical work and  social or community service for mental patients are conducted by senior psychiatric nurses  trained in short courses” (Jianlin, J., 2000). Obviously, there is a higher need for trained  mental health clinicians who can work successfully with Chinese and Chinese American  mentally ill, and their families. “Some examples of the problems that two cultures can pose in  clinical care include the issue of maintaining confidentiality regarding the illness, and how to  interpret the high involvement that Chinese families have in the treatment process. What  Western Individualism would say is confidential communication, Chinese collectivism would  integrally involve the family in such communication” (Hsiao, F.H., Klimidis, S., Minas, H., and  Tan, E.S., 2006).
 
    As mental health care evolves, what can the American mental health model contribute to the  Chinese Collectivist tradition of keeping it “all in the family?” “America has relied on  institutionalization but is finally beginning to move towards community-based  services,” said Dr. T.A. Kelly, a speaker at the 2005 Pan Asian Pacific Conference on Mental  Health, in Shanghi. “By community-based we mean providing flexible services in the home and  community rather than forcing people into brief hospitalizations too often followed by discharge  to inadequate care. The ultimate goal is recovery (as opposed to dependence on mental health  care systems). This would allow people with serious mental illnesses to have a real job, a stable  home, and fulfilling relationships.” Understanding the cultural values and beliefs of the Chinese  as I do now, to isolate a Chinese person from his family in an institution with a formal label of  seriously mentally ill could be crushing to that person’s self-esteem , self-worth and identity, and  devastating to his family as well. However, caring for him at home without any clinical guidance  or supervision is neither safe nor the most effective for recovery. “China would do well not to  replicate the institutionalization of American psychiatric care, but rather develop effective and  innovative community-based mental health-care, as China has historically benefited from strong  family and community” (Kelly, T.A., 2007). Perhaps traveling psychiatric nurses could make  discrete home visits, checking on the patient’s condition, medications and the family’s coping  and caretaking skills? Perhaps small community mental health care clinics staffed by  psychiatrists or psychiatric nurses could join holistic community practitioners such as  acupuncturists and Chinese Naturopaths where the patient could be treated and then return  home? There is an ancient Chinese proverb that says, “If you are planning for a year, sow rice; if  you are planning for a decade, plant trees; if you are planning for a lifetime, educate people.” In both China and America, the time is right to educate a host of mental health care providers   who are dedicated to learning to become sensitive to the needs of the mentally ill within their  own culture. In America, health care workers are grappling with how to serve a culturally diverse  public, and in China, families are struggling with the issue of how to provide mental healthcare  for their loved one in a society where it is not acceptable to be mentally ill. As the international  mental health care community faces these cultural challenges, we do so together, so I hope our  willingness to learn and grow from one another increases over time.

References:
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Research which encompasses cultural problems and solutions (Belgun, D, 1978), Chinese Schizophrenia (Bloomingdale, L.M., 1980, Hsia, Y., Tsai, N., 1981), Chinese  Somatization (Cheung, F.H., 1982, Cheung,

F.M., Lau, B.W.K., Waldman. E., 1981), Alcoholism among the Chinese (Lin, T.X., Lin D.T.C., 1982), The stigma of mental illness (Mechanic, D., Kleinman, A. (1980),Traditional Chinese Medicine) Tseng, W., (1973), Psychiatric Problems and Traditional Chinese Management (Visher, J.S., Vischer, E.B., 1979), Problems with Chinese Adolescents, Yang, K. 1981). Print.

Li, L.W., Liang, J. (2007). Social Exchanges and Subjective Well-Being Among Older Chinese: Does Age Make a Difference? Psychology and Aging Copyright 2007 by the American Psychological Association, 2007, Vol. 22, No. 2, 386–391.  Print.