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:
Chen, Sylvia Xiaohua, Winnie W.S. Seeking Professional Help: Etiology Beliefs About
Mental Illness Across Cultures. Journal of Counseling Psychology, 0022-0167,
2008, Vol. 55, Issue 4. Print.
Jianlin, Ji. Suicide rates and mental health services in modern China. Crisis: The Journal of Crisis Intervention and Suicide Prevention, Vol 21 (3), 2000. pp. 118-121. Germany: Hogrefe & Huber Publishers, Inc. Print.
Jianlin, Ji. Hotline for Mental Health in Shanghai, China. Crisis: The Journal of Crisis Intervention and Suicide Prevention, Vol 16 (3), 1995. pp. 116-120. Germany: Hogrefe & Huber Publications. Print.
Yang, Lawrence H., Phelan, Jo C., Link, Bruce G. Stigma and beliefs of efficacy towards traditional Chinese medicine and Western Psychiatric treatment among Chinese Americans. Cultural Diversity and Ethnic Minority Psychology, Vol 14 (1), Jan. 2008 pp. 10-18. Education Publishing Foundation. Print.
Le Meyer, Oanh, Zane, Nolan, Cho, Young Il, Takeuchi, David T. Use of specialty mental health services by Asian Americans with psychiatric disorders. Journal of Consulting and Clinical Psychology, Vol 77 (5), Oct, 2009. pp. 1000-1005. Publisher: APA. Print.
Ryder, Andrew G., Yang, Jian, Zhu, Xiongzhao, Yao, Shuqiao, Yi, Jinyao, Heine, Steven J., Bagby, R. Michael. The cultural shaping of depression: Somatic symptoms in China, psychological symptoms in North America. Journal of Abnormal Psychology, Vol 117 (2), May 2008. pp. 300-313. Publisher: APA. Print.
Leung, Angela, K.Y., Cohen, Dov. Within-and between-culture variation: Individual differences and the cultural logics of honor, face and dignity cultures. Journal of Personality and Social Psychology, Vol 100 (3), Mar, 2011. pp. 507-526. Publisher: APA. Print.
Hsiao, Fei-Hsiu; Steven; Minas, Harry; Tan, Eng-Seong. Cultural attribution of mental health suffering in Chinese societies: The views of Chinese patients with mental illness and their caregivers. Journal of Clinical Nursing. Print.
Chan, Sally. Commentary on Hsiao F. H., Klimidiss, S., Minalt & Tan E.S. (2006). Cultural attribution of mental health suffering in Chinese societies: The views of Chinese patients with mental illness and their caregivers. Journal of Clinical Nursing, 15, 998-1006. United Kingdom. Wiley-Blackwell Publishing, Ltd. Print.
Kelly, Timothy A. Transforming China’s mental health system: Principles and recommendations. International Journal of Mental Health, Vol 36 (2), Sum, 2007. Special issue: Community health collaborations from Michigan to China. pp. 50-64. Print.
Domingo, G. (1982). Psychology and Psychiatry in the People’s Republic of China. An annotated bibliography. Summarizing 8 studies between 1973-1982. Print.
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.
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