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University of Nevada, Reno

Transformations in Treatment of Mental Illness in China

A thesis submitted in partial fulfillment of the requirements for the degree of Master of Arts in History

by Michael McClatchey

Dr. Hugh Shapiro/Thesis Advisor

December 2019

THE GRADUATE SCHOOL

We recommend that the thesis prepared under our supervision by

MICHAEL MCCLATCHEY

Entitled

Transformations in Treatment of Mental Illness in China

be accepted in partial fulfillment of the requirements for the degree of

MASTER OF ARTS

Hugh Shapiro, PhD., Advisor

Linda Curcio PhD., Committee Member

Edward Schoolman, PhD., Committee Member

Pu Xiaoyu, PhD., Graduate School Representative

David W. Zeh, Ph.D., Dean, Graduate School

December 2019

i

Abstract

In China, as in most societies around the world, once someone is diagnosed as mentally ill it becomes very difficult for that person to find a place in society, or even their own families. In

China, much of this lack of understanding and stigma of mental illness comes from a long history of societal norms in which those with a mental illness were to be looked after by the family and generally out of public view. This allowed the national governments of China to ignore providing care for the mentally ill as they could rely on the family to keep them out of trouble. With the beginning of the twentieth century, as China modernized and its population became more urban it would become clear that relying on the family was no longer enough. This embarked China on a long road to improving all aspects of care for the mentally ill. Beginning with local officials building hospitals in various cities early in the twentieth century leading to national conferences of psychiatrists designed to determine what areas needed improvement, and currently national laws and plans being enacted to continue furthering mental health care; many in China both at the national and local levels have worked hard to improve both the care and lives of the mentally ill.

Still, there are many areas that can be improved upon most important being the need to lessen the stigma still associated with mental illness amongst many Chinese. This paper focuses on the history of mental health care starting in the twentieth century to the present, the current national programs and laws currently in effect, as well as the current problems still facing mental health care like stigma still associated with mental illness today in China. ii Table of Contents

Introduction ………………………………………………………………………………. pg. 1

Mental Health Care in China pre- 2003 …………………………..…………………pg. 2

Caring for the Mentally Ill Family Member …………………………………………………...pg. 2

New National Government, Same Lack of Mental Health Care During the Republic of

China ………………………………………………………………………………………….pg. 4

The PRC Begins to Advance Mental Health Care on a National Scale (1949-

1967) …………………………………………………………………………………………..pg. 5

The Cultural Revolution and its Effects on Mental Health Care ………………………………pg. 7

Picking up the pieces after the Cultural Revolution (1977-2003) …………………………….pg. 9

A Renewed Push for National Mental Health Care Post- 2003 ………………pg. 12

The SARS Outbreak: A disaster leads to opportunity ………………………………………..pg. 12

Program 686: The First Effort to Centralize Mental Health Care Treatment and Research in

China ……………………………………………………………...... pg. 13

The 2013 National Mental Health Law and the Still Present Abuses of Patient Rights and Black

Prisons ………………………………………………………………pg. 17

The 2015-2020 National Mental Health Plan: Continuing the Progress Already

Made …………………………………………………………………………... pg. 22

Treating Mental Illness in Modern China: Combining Chinese and Western

Methods ……………………………………………………………………………………pg. 24

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Prescribing Medication: The Quick and “Easy” way to Treat the Symptoms of Mental Illness and

Rejoin Society ………………………………………………………………………………..pg. 24

Psychological Dredging Therapy ……………………………………………………………pg. 30

Imagery Communication Psychotherapy ……………………………………...... pg. 31

Private Institutions for Treating Mental Illness: Filling the Gaps Left by the

Government ………………………………………………………………………………pg. 32

Wenzhou Kangning Hospital …………………………………………………………………pg. 32

Online Resources for Those Suffering from Mental Illness …………………………………..pg. 34

Stigma Against Mental Illness: How it Affects the Individual Suffering from

Mental Illness, Their Families, and How it Prevents Proper

Care …………………………………………………………………………………………pg. 36

General Stigmas Associated with Mental Illness and the Results of Trying to Hide Mental

Illness ………………………………………………………………………………………...pg. 36

Stigma Associated with Depression …………………………………………………………..pg. 38

Stigma Associated with Schizophrenia ……………………………………………………….pg. 40

The Ever-Present Stigmas of Mental Illness Held by Health Care Providers ……………….pg. 41

Shanghai Tulip: An Example of How to Deal with Mental Illness and Help Combat Stigma Against

Mental Illness ………………………………………………………………………………..pg. 43

Conclusion ……………………………………………………………………………….. pg. 45

Bibliography ……………………………………………………………………………...pg. 47 1

Introduction

In China, as in most societies around the world, once someone is diagnosed as mentally ill it becomes very difficult for that person to find a place in society, or even their own families. In

China, much of this lack of understanding and stigma of mental illness comes from a long history of societal norms in which those with a mental illness were to be looked after by the family and generally out of public view. This also allowed the national governments of China to ignore providing care for the mentally ill as they could rely on the family to keep them out of trouble.

However, this would begin to change starting in the twentieth century and moving forward into the present as changes to society began to put caring for the mentally ill in the hands of the government instead of just their own families. The initial steps have been taken to ensure positive changes to the care for mental illness in China; with the national government including mental illness as part of the country’s health issues by passing national laws aimed at respecting mentally ill patient’s rights as well as passing National Plans specifically aimed at continuing to improve mental health care. While these are positive steps made at the national level in China there still remains stigma against mental illness among many in Chinese society due to historical prejudice related to mental illness. This still present stigma against mental illness shows why there is still a long way to go and the government must continue to ensure that care does not fall off, and it must take the next steps in providing better education on mental illness so as to lessen the stigma still attached with mental illness. So then how does one deal with a mental illness? This question is asked by many when faced with the reality of having to deal with the issue of mental illness.

Whether it be by the individual who has been diagnosed, the family of the individual, the doctors and nurses tasked with helping treat and take care of the patient, as well as the government itself who now must find a way to provide care for the mentally ill. Unfortunately, despite all of these 2 people who must ask these questions, along with many others about mental illness, there are still too many in society who do not ask. Who do not understand nor do they wish to try to understand all that happens when someone is mentally ill.

Mental Health Care in China pre- 2003

Caring for the Mentally Ill Family Members During the Qing Dynasty

Although care for the mentally ill has increasingly become more a part of the Chinese government’s national health care initiatives since the twenty-first century, it is important to understand the long road taken to where mental health care is now, and why it took until the twentieth century for the government to even acknowledge that providing health care to those with mental illness was its responsibility. In Chinese society leading up to the twentieth century much of societal norms were based off Confucian ethics about how societal roles were to be fulfilled, and within the family the Confucian ideal of filial piety dominated life and established these roles.

Filial piety instilled deep reverence for the family and held that the family was often the center of life. Chinese society was able to handle and tolerate the mentally ill through the concept of filial piety. This Confucian ideal “… taught that the preferred social location for the insane was a kinship clan obligation” (Szto 73, 2014) and it was within the family where the mentally ill would best be taken care of and be best suited to live in society. In fact, if a family sent a family member who was ill away or in any way did not take care of them it would have resulted in the entire family losing face in the community. This fear of losing face and through it bringing shame and embarrassment made Chinese families make it their personal responsibility to care for their mentally ill family members. This meant allowing them to roam free around the village and the community under the careful watch of a family member. The agrarian lifestyle that most lived in 3 leading up to the twentieth century allowed families to take care of their family members without much trouble and even allowed Chinese families “… to project the impression that everything was fine, even though this was not actually the case” (Szto 73, 2014). It was through this reliance on

Confucian ethics as well as the agrarian style of life that made it possible for the mentally ill to have a place in society; it was within the family under the close eye of their relatives and out of the way of everyone else, and certainly not within the purview of the government. As time progressed however urbanization would begin to change Chinese society, and family ties would no longer be able to remain as close knit as they had before. People were leaving the rural villages in order to find work in the larger cities. One can imagine it was difficult for families to look after mentally ill relatives even in the rural setting, it must have been near impossible to try and care for someone in an urban setting. It would not be until near the end of the nineteenth century that

Chinese families would even have the option of a psychiatric ward for their relatives. This first psychiatric ward, which was established in 1898, was not created by any Chinese government locally or nationally. Instead it would be established by American missionary John Kerr and through mostly his own dogged determination and his understanding of Chinese culture and customs was he able to finally open his refuge in Canton, modern day Guangzhou, after twenty- six years of attempting to establish one. This would mark the first time that caring for the mentally ill shifted outside of the family, as was traditional in Chinese society, and into a separate space designed specifically for them as had become the current form of care in Western societies. With the rapidly changing societal norms brought about by foreign influence and urbanization Kerr’s refuge “… offered Canton’s families an attractive alternative to China’s Confucian kinship based approach” (Szto 74, 2014) which was becoming increasingly difficult to live by. Kerr’s refuge would serve as the first psychiatric ward in China and would begin the slow process of more 4 psychiatric hospitals opening in other major cities and more studies being conducted on mental illness and psychiatry. It would also mark the slow transition of government taking more responsibility in providing care for its mentally ill people.

New National Government, Same Lack of Mental Health Care During the Republic of China

After the Qing dynasty ended and the new government of the Republic of China took over with an emphasis on modernizing, China’s mental health care was still an afterthought, especially at the national level. After Kerr was able to open his refuge in 1898 several other city governments would see the benefits of having a designed space for the mentally ill and began to open their own psychiatric wards. Between 1908 and 1926 psychiatric hospitals were established in Beijing,

Shenyang, Suzhou, and another in Guangzhou. However, these were all established by local city governments and not by the national government that had replaced the Qing in 1911. These measures taken at the local level were still little to nothing in terms of dealing with the amount of care needed as many of these hospitals were small, most only being able to hold twenty to forty patients at one time. On top of the lack of institutions to care for the mentally ill was the severe lack training and education of mental health within China. The first attempts at education on mental health and psychiatry was in 1910 by Dr. Andrew Wood in Guangdong and then later at Peking

Union Medical College. While the first attempt at training in psychiatric care would not take place until 1932 by Dr. R. Lyman at Peking, further demonstrating that during this period, as had been the case in the final years of the Qing, that “… mental health services in China were rare and confined to the influence of the western missionary” (Yip 107, 2005). There would be some grassroots attempts at accumulating and spreading knowledge about psychiatry and mental health with a few academic societies of psychiatry forming to discuss and examine psychiatric practices. 5

There were even publications such as Xi Feng (西风 ), or West Wind, that attempted to spread ideas about psychiatric care, but their effects were minimal. Without support from the national government of the time to provide funding, education, or training to psychiatry mental health care was still being left to more local levels of society. It would not be until after 1949 that the national government of China would begin to make efforts nationally in order to help those being affected by Mental illness.

The PRC Begins to Advance Mental Health Care on a National Scale (1949-1967)

When the Communist Party took over control of China it believed the entire system of the nation needed to be overhauled, and this would include the government’s involvement with caring for the mentally ill. After the PRC gained control in 1949 gradually they began to build a psychiatric hospital in every province. After only ten years, in 1959 China opened sixty-two new psychiatric hospitals with the number of beds for patients dramatically increasing. The PRC also saw the dangerously low number of trained specialists in psychiatry as well as nurses trained to deal with mentally ill patients and set out to begin training programs in several medical colleges in psychiatry. Soon psychiatry departments at “…medical colleges in Beijing, Shanghai, Changsha, and Chengdu… trained many specialists” (Xia, Zhang 24 1987) and China quickly began turning out more psychiatrists to deal with the needs of their mentally ill patients so that by 1959 the total number of psychiatrists in China had increased by sixteen times and nurses trained in psychiatry had increased by twenty times. As more hospitals were opened and more specialists trained, care began to improve within the hospitals as doctors learned how to better treat patients and run hospitals more efficiently. Within the hospitals patients had both individual and group sessions and were often encouraged “… to participate actively in their own treatment” (Xia, Zhang 25 1987) so as to give them a means of healing themselves as much as the treatments and doctors did. This 6 increase in hospitals and training naturally led to an increase in study and knowledge on the subject of psychiatry and mental health care at the national level in China. By 1953 the Chinese Medical

Association founded the Society of Neurology and Psychiatry, the first national government funded association dedicated to psychiatry, which began publishing the first journal dedicated to psychiatry The Chinese Journal of Neuropsychiatry . This would also lead to China holding its first national meeting on mental health in Nanjing in 1958 with the main topic being discussed being treatment and prevention. At the conference, aside from debating whether to move away from

Western theories on psychology and move more toward Soviet ideas, decisions made at the conference included: “The restraint of patients was finally abolished. Wards were completely opened. They also proposed the development of home-based treatment in rural areas by ‘bare foot indigenized doctors’” (Yip 108, 2005). Following this first ever national meeting on mental health, different provincial governments took it upon themselves to conduct surveys of the mentally ill within their provinces to ascertain just how many people were being affected by various mental illnesses. From there, provinces began to set up more local psychiatric wards as well as begin training more specialists locally to provide treatment, early detection, and relapse prevention.

Individual medical schools also began to do their own research with biological psychiatry beginning to be studied and clinical tests for various drugs also under way. More national conferences were held with the First National Symposium on Neurology in 1963 in Guangzhou, and in 1966 a National Seminar on Scientific Research on Mental Illness being held in Chengdu.

Chinese psychiatry was finally beginning to come into its own in terms of care, research, and training. Care was no longer dominated by Western missionaries, academic study had broken away from its reliance on Western theories and had even begun to pull away from Soviet ideas as well, and its research was becoming more in depth with each passing year. Unfortunately, this progress 7 would be slowed if not outright stopped, like most things in China would be, by the coming of the

Cultural Revolution.

The Cultural Revolution and its Effects on Mental Health Care

The Cultural Revolution, beginning in 1966 and lasting until 1976, would throw all of

Chinese society into chaos as “All normal educational, productive and social activities were replaced by zealous political worship of Mao’s ideas and fighting against enemies of Capitalism”

(Yip 108 2005) and mental health care would be no different. Psychiatrists now had to justify all of their actions, diagnosis, and treatments in terms of the extreme ideologies of the Cultural

Revolution, and eventually mental illness itself came to be defined by Mao; that mental illness was a result of the failure of the capitalist system, and an enemy to be fought and overcome through proper thinking in order to rejoin the peoples’ cause. Admissions to psychiatric hospitals became political as well, as people were submitted to hospitals on recommendations from their workplace leaders or other political bosses. Families could also admit a family member and hospital staff did have some say in admittance as well, but more often than not it was the Revolutionary Committees that would have the final say. Often times people would be coerced or otherwise forced to admit themselves through pressure placed upon them by their work leaders or even family members.

Once admitted the treatments too were based on political ideology beginning with the psychiatrists themselves who had to first correct any wrong attitudes they might have held in dealing with their patients. They were to treat their patients as class-brothers and sisters and make sure every act they took was to ensure their class-brethren could overcome the enemy that was mental illness and have them rejoin the glorious pursuit of building the new socialist Chinese society. Once the doctors and nurses had the correct attitudes needed to achieve this goal, they set up treatments for their patients that best allowed them to fight their mental illness. One way in which they accomplished 8 this was through “mutual collective help” in which patients were organized into fighting groups based on the similar model used by the People’s Liberation Army and encouraged to treat each other as comrades and look after one another. They were to take care of those sicker than they were and help new patients become adjusted to daily life within the hospital and in doing so would best equip themselves to fight mental illness. Another treatment practice was “self-reliance” in which patients were encouraged to personally investigate their symptoms and understand their own treatments. This was similar to psychiatrists’ practice earlier of trying to encourage patients to be active in their own treatments, but now they were told to reflect on their capitalistic thinking and understand Mao’s works and correct their attitudes about class struggles and the new Chinese society being formed by Mao. The third treatment technique was to form study groups on Mao’s works consisting of ten to fifteen people supervised by a member of the hospital staff and told to read a variety of Mao’s writings. Then they would analyze the works and criticize each other for any wrong ideas or thinking. This in theory would remove any individual and capitalist thoughts a patient might have and help them regain socialist thinking and allow them to rejoin society. As one could imagine this period did not see many advancements in clinical research or academic works in the field of psychiatry “… as little attention was paid to research design and experimental methodology, few reports of academic value were written” (Xia, Zhang 27 1987). On the more local level of society networks were set up to at least provide some assistance to those suffering from mental illness within the communities as proven Chinese drugs were given to those who needed them, and these networks were able to provide some form of care with “… hundreds of thousands being treated.” (Xia, Zhang 27 1987). The Cultural Revolution would derail many things in China and throw much of society into chaos, but with Mao’s death and the Gang of Four losing 9 their grip on power, things would slowly be built back up, and mental health care would again be no different.

Picking up the pieces after the Cultural Revolution (1977-2003)

As the Cultural Revolution ended and Deng Xiaoping came to power, life in the PRC slowly began to normalize, and deficiencies across China would begin to be addressed including psychiatry and care for the mentally ill. The tight grips that had kept Chinese society stagnate and in fear had slowly begun to fade and Chinese society began to open itself back up to new ideas within from its own people as well as to ideas found elsewhere in the world. In 1978 China held the second National Symposium on Neurology and Psychiatry in Nanjing to discuss mental health practices, how best to classify various mental illnesses, and how to best combine traditional

Chinese and Western medical practices. Another important topic discussed was that of academic theories and research regarding psychiatry which had been missing during the Cultural Revolution.

Soon new publications on psychiatry would be released such as the Journal of Nervous and Mental

Disease and Medicine Abroad as well as the revival of the Chinese Journal of Neuropsychiatry by the Chinese Society of Neurology and Psychiatry. Various medical universities began collecting information from psychiatrists and mental health care providers across China in order to create source books and reference tools for both current and future psychiatrists (Xia, Zhang 27 1987).

Once information was allowed to more freely flow amongst China’s psychiatrists and medical universities, research on psychiatry also began to improve as universities like Beijing Medical

College and Hunan Medical College resumed both researching mental health as well as providing classes and training to psychiatric students; and numerous hospitals began offering postgraduate education and training in psychiatry. Both the Shanghai Psychiatric hospital and Sichuan Medical

College resumed their own extensive research into the various fields of psychiatry, and institutes 10 devoted to mental health would be set up in Beijing in 1980 and Shanghai in 1981. With Deng’s opening up of China to the world in 1978 foreign ideas and practices regarding psychiatry were allowed to come into China, and exchanges of knowledge would be allowed to flourish. Various psychiatrists from the United States, Europe, and Japan all visited China in order to share their ideas and knowledge, and groups of Chinese psychiatrists were allowed to travel abroad to places like the United States in order to attend conferences on mental illness and psychiatry. After a decade of stagnation Chinese research into psychiatry and mental illness was picking up where it had left off before the start of the Cultural Revolution. This renewed interest in research, although important, is just half of the equation, and the now less politically charged government of the PRC would also need to address providing proper care to those being affected by mental illness.

Just as with their current level of research in psychiatry both government officials as well as health care providers in post-Mao China had to look at their deficiencies in providing care to their mentally ill citizens and begin immediately working on addressing them. This process began in 1986 when at the Second National Meeting on mental health services in Shanghai leaders in the field of Psychiatry within China gathered together, and after being introduced to western practices and experiences through international exchanges created an assessment of where China lagged behind in psychiatric care and what needed to be improved. Amongst the inadequacies listed were: shortfalls in treatment where 80% could not receive treatment and 95% could not be admitted to hospitals, many mental hospitals were poorly funded and in desperate need of repair, and there was inadequate training and social recognition of mental health workers (Yip 110, 2005). Another problem was that different types of mentally ill patients would be treated at different types of hospitals. Those rich enough and mentally stable enough would be admitted to hospitals run by the Ministry of Public Health, and if they were wealthy enough would be recommended to stay 11 longer than necessary so that the hospitals, who now had to generate their own revenue by charging their patients, could maintain themselves financially. Meanwhile patients who fell under the government’s category of poor and deprived based off the “three Nos: no home, no job, and no accommodation” (Yip 111, 2005) would be admitted to hospitals run by the Ministry of Civil

Affairs. Lastly patients who had a history of violence or criminal behavior would be taken and admitted to hospitals run by the Ministry of Public Security. With three different ministries running three most likely very different types of hospitals and providing different treatment programs it would be all but impossible to ensure equal treatment was being provided to the many patients admitted; let alone ensure the treatment they were receiving was adequate. These along with several other deficiencies opened many eyes to the dire situation care for the mentally ill was in within China, and both psychiatrists and government officials alike were intent on improving these conditions. Deng’s son, Deng Pu-fang, would take an active role in improving care provided to the mentally ill and made “psychiatric rehabilitation… an important part of services for persons with mental illness” (Yip 111, 2005) with various new rehabilitation techniques being implemented such as home-based care in rural areas and work station therapy. The national government would officially make mental health care a priority in 1999 when a high-level meeting involving ten separate ministries as well as the World Health Organization (WHO) would result in a declaration to create a national plan for dealing with mental health. This would lead to the government in April

2002 signing the first National Mental Health Plan (2002-2010) which among other things declared the government would establish an effective system of mental health care carried out by the government, improve knowledge and raise awareness of mental illness, and training new mental health care providers and improving psychiatric hospitals (Jin, Hong et al 2011). This National

Mental Health Law marked an incredible step in the national government’s commitment to 12 improving the level of care being provided to the mentally ill within China, and would also open the door for the next crucial step when the PRC government would green light and fund a new national program aimed at greatly increasing the amount and quality of care provided to mentally ill patients.

A Renewed Push for National Mental Health Care Post- 2003

The SARS Outbreak: A disaster leads to opportunity

Despite the positive steps toward improving care and awareness of mental illness within

China that started in the post-Mao era it would still take a national crisis before funding could be secured for a national program for mental illness. This crisis took form in the SARS outbreak in

2003. This outbreak, which would eventually lead to the WHO declaring a worldwide health threat, had its first case reported in Foshan, a city in the Guangdong province in late 2002. Due to the inefficiency of China’s national health care system, as well as perhaps inefficiencies in the Chinese government as a whole, SARS would spread in China ultimately leading to more than 5,300 people being infected and resulting in the death of 349 people nation wide (Huang 2004). The failing of the system to ensure the public’s safety and tragically leading to so many deaths and so many more infections may have had at least one positive result; that being the Chinese government’s realization that their public health care system as well as government’s officials’ responses to national medical needs would need a complete overhaul. It was out of this desire for improved care for the Chinese people that the PRC government would be approached with another new program aimed at improving treatment and providing care nationally to millions of Chinese citizens. 13

Program 686: The First Effort to Centralize Mental Health Care Treatment and

Research in China

This program was designed to provide care for mentally ill people throughout China and to better train specialists to treat those with a mental illness. A team of psychiatrists approached the national government with startling facts about the current level of treatment that China as a nation could provide to its citizens. As stated earlier the government was already well aware of its deficiencies in providing mental health care, but it become an even more glaring problem when given specific numbers like: having only 565 hospitals to provide any form of treatment for a nation of over a billion, less than 1 bed for every 10,000 people, and having just over 1 doctor providing any sort of treatment in hospitals for every 100,000 people (Ma 2015). The group pitching this new idea, also understood the government’s desire to reclaim social stability after the disastrous events from the SARS outbreak, made one last pitch to gain funding for their program, stating that if this initiative is funded “patients can get access to the care while the rate of violent issue will be reduced, and the society will thus achieve harmony” (Ma 2015). With the government’s already present desire to improve their health care system, and their public image being scared with the glaring statistics on mental health care deficiencies and this new program’s promise to reduce violence caused by those suffering from mental illness, the CCP decided to grant

6.86 million yuan to fund the project giving China’s first ever national mental health care project its name, Program 686 (686).

After receiving funding 686’s goal was to be able to provide better care for everyone in

China; especially those who live in more rural areas who often have a harder time reaching the treatment they need. In order to provide this care, 686 set out to take treatment out of the larger provincial hospitals and instead put them into smaller community-based hospitals, and by doing 14 so treatment could be centered around the rehabilitation of the patient. In order to do this 686 set out to build local community based hospitals and have them staffed by specialists trained in providing care for mental illnesses. In 2005 686 set up sixty demonstration sites in all thirty provinces in China, one being established in a rural setting and another in an urban one. Within these sites, a network was designed between the hospital dedicated to mental illness and the community hospital in which doctors from the community hospital are there to provide follow up care for patients. In the words of Ma Hong, one of the leaders in establishing 686, these community hospitals were meant to allow care for the mentally ill to “break out of the hospital walls” (Ma

2015), and allow those suffering from mental illness to not be locked away inside huge hospitals, but instead rejoin their families and become members of the community again. The success of this goal rests largely on the training of the multi-functional teams of specialists who have to be trained to staff these hospitals in order to provide the adequate level of follow up care to the patients.

These teams must be trained properly to be full-time providers of mental health care. The building of these community based hospitals and the training of these full-time specialists in mental health care marked 686’s biggest difference from the traditional models of care that had been provided in the decades before, and would lead to greater success in providing treatment as well as rehabilitation for those suffering from mental illness.

After its initial funding of 686 the CCP has since funded 220 million more yuan into mental health care in China, and this is due to the many successes 686 has seen in reinventing how mental health care should be provided. First and foremost, 686 has seen drastic improvements in the health care providers themselves and how they are able to provide care to their patients. In the traditional method of providing care primary health care doctors and nurses, who most often had the very minimal of training or even understanding of mental illness, would be instructed to be on the 15 lookout for signs of mental illness from the patients who they would see. This did not allow for many of those suffering a form of mental illness to be seen by a doctor at all, and most certainly did not allow them to get the proper treatment needed. With the training of these full-time and multifunctional teams to work in community based hospitals more adequate care can be provided initially, and allow for follow-up visits which allows rehabilitation to become the focus of treatment. Working in the community hospitals also allows these doctors to develop a higher level of competence in providing mental health care “and to provide community based care in reality rather than in name alone” (Good, Good 2012). Specialists trained under the 686 model of care show a better understanding of mental illness as well as treatment practices for mental illness (Ma et al. 2015). When discussing what their role in providing care for mentally ill patients those who are trained and operate out of the community based hospitals are more invested in their patients.

One health care provider working out of the 686 model of community-based hospital stated “As the administrator of severe mental illnesses, I play a role of bridge and tie between hospital and mental ill patients… In addition, I also should concern about the mental ill patients, talk to them and their family members with the life and job topics, in order to ease their tensions” (Ma et al.

2015). Comparatively a practitioner from the traditional larger hospital centered form of mental health care stated “generally, I do what the township health center arranged. To telling the truth, I am rarely active to do the work, because I have many other things to do, such as managing the diabetes and hypertensions” (Ma et al. 2015) this practitioner although seemingly willing to provide care to someone who visits the hospital will not go into the community to provide care, and is not solely focused on mental health care. With the training of these full-time specialists 686 has also been able to create a larger database of mental health care records amongst mental health care providers and allow it to be shared throughout China. 16

Before 686 there was no central organization or body to collect the various data and treatment methods being performed across China. Before 686 it would be very difficult for a psychiatrist working in Guangzhou to learn about a new technique or rehabilitation method being used by a psychiatrist in Chengdu or Beijing. With 686, training the psychiatrists and then sending teams in to collect the data on the various differences being seen from province to province, if not community to community, a central database could be collected and then analyzed to see what problems are being seen nationally, and what programs are working and which are not. Centrally created programs are able to be implemented throughout the whole of China instead of in just a few hospitals, meanwhile new initiatives created at the more local level, when proven to be effective, can be instituted across the entire nation of China and better help thousands, if not millions more people. One such initiative occurred shortly after 686 was funded and initiated called the “Unlocking Project”, which came about after initial teams funded by 686 went into communities and found that some suffering from mental illness had been physically locked away by their families in order to prevent them from harming another family member or someone in the community. This locking up of mentally ill family members came about from the families having no ability to obtain care for their mentally ill family member and having no other options. These locking measures ranged from: being isolated in a separate room all day, to being put in a small hut close to the family house, to being locked in cages within the family home (Chang et al. 2015), and resulted in miserable lives for the family member suffering from mental illness as well as a huge burden on their families. After discovering this problem occurring in multiple places throughout China, 686 care providers set about a national program of “unlocking” these patients by providing funds to those poor families to immediately provide medication for the mentally ill, and enroll them in 686’s system to provide the adequate care that the patient, and their family, so 17 desperately needed. This program was widely successful in unlocking these patients, and although some would experience a “relocking” (Chang et al. 2015) most cases saw drastic improvements in the lives of the patient suffering from mental illness. Other programs developed from 686 or in connection with it have been “early psychosis programs, social skills training projects, family psychoeducation programs, or special post-hospitalization behavioral and psychosocial interventions (Good, Good 2012) all of which are improving the care being provided throughout

China.

The 2013 National Mental Health Law and the Still Present Abuses of Patient Rights and Black Prisons

As 686 has put an emphasis on proper care and treatment, as well as a renewed push for more psychiatric research, the Chinese government has also recently focused on improving the legal rights of its citizens suffering from mental illness with the enacting of a national mental health law in 2013. This new law, which the Chinese government began drafting in 1985 (Zhao, Dawson

2014), set out to clarify many issues in dealing with mental illness as well as how to deal with mentally ill patients that had, until its passing, been vague at best. Some of these issues included the actual definition of mental illness, and the definition of “dangerousness”. These were included to address the law’s main focus which was mentally ill patients’ rights, and deals with how and why a patient can be admitted to a hospital. The question of the rights of the mentally ill was put at the forefront of the government’s new mental health law due to the constant concerns raised by foreign activist groups, including the World Health Organization, as well as increased internal pressure from reports about abuses being practiced with admissions to psychiatric hospitals.

As stated earlier during the Cultural Revolution people could be admitted to psychiatric hospitals against their will at the request of family members, or much more likely, at the request 18 of their work leader or government official. This occurred without consent of the individual being admitted and often without contacting the family of the individual, and was often done for political reasons rather than medical. Needless to say, this led to violations of the patient’s rights, and only added to the turmoil and chaos felt by all who lived through that period in China. Unfortunately, even after the politically charged climate of the Cultural Revolution would end, rights of the mentally ill would not improve much as people were still being admitted involuntarily. Although improvement had been made, like family consent having to be given for hospitalization, anyone who displayed some sort of mental illness would still often be hospitalized without their personal consent. In 2002, a study conducted on the admission rates in psychiatric hospitals showed that out of 2,333 patients treated in 17 different hospital or health centers across China only 18% of those were admitted voluntarily (Zhou et al. 2015). A more recent study on hospital admissions for mentally ill patients was conducted between March 15 to April 14, 2013, just before the new mental health law would be enacted, but already on the books, to see if any improvement had been made in voluntary admissions. Of 797 patients recorded across 16 different medical institutions this time 28% were admitted voluntarily meaning that out of 797 patients 573 of them were admitted either involuntarily or only partly voluntary (Zhou et al. 2015) so improvement had been made, but not much. Many of these involuntary admissions were based off of a general lack of understanding of mental illness, and a fear of violence from the patient. Most often families of mentally ill patients who have their family member admitted against their will do so only after fear of harm befalling themselves or their family member, or fear of the mentally ill family member harming someone else. These involuntary admissions of those who did actually have a mental illness, although bad enough, was only half of the issue of abuses being reported by outsiders as well as those within China with regard to psychiatric admissions. 19

Even after the Cultural Revolution ended political dissidents, or those who go against the central government or local powerful officials can still find themselves being admitted to psychiatric institutions against their will for political purposes. It has been reported by countless human rights groups both inside and outside of China that one of the more effective ways the government has in dealing with political dissidents who try to speak out against them is to place these dissidents into black prisons, or black hospitals. These hospitals are called, rather ironically,

“Ankang” ( 安康 ), or Peace and Wellness hospitals and are run by the Public Security Bureau.

Once admitted the “patient” is forced to remain in the hospital for as long as the medical staff deems necessary. The admissions often last years and include treatments such as electro shock therapy and being strapped to beds for days at a time. Most often the dissidents who are hospitalized are human rights’ lawyers, or those trying to fight corruption within the government.

One such man Xing Shiku had been attempting to petition the central government about corruption he saw when the state-owned company he was working for was being privatized. He was arrested after traveling to Beijing and brought to an Ankang hospital where he was diagnosed with having a mental illness and had been locked there for six years when the story was reported in 2014. Many more have had the same happen to them in China where they are taken without cause and admitted to these black hospitals over night without family consent, and most often their families are never told what has happened to them or where they are. It has been reported that from 1998 to 2010 more than 40,000 have been committed to an Ankang hospital (Lubman, 2016). This process of being committed to a psychiatric hospital without demonstrating any form of mental illness has become so well known within China that it has its own term “Bei Jing Shen Bing” (被精神病 ) which can be translated to “the involuntary diagnosis and treatment of a mentally sound person as 20 a mentally disordered patient” (Zhou, Dawson 2014), or put another way being “mental illnessized”

(Shapiro 2017) being made into a person who has mental illness. This was an effective way to stop a protestor or petitioner from having an effect on the government, first obviously by removing them and keeping them within their Ankang facilities for years so as to “treat” them, but also being able to discredit the protestor by making it appear they had a mental illness and that is why they were protesting in the first place. They were not well, and so they acted out. These repeated abuses of rights in hospital admissions has led many in China to begin to call for more legal protection.

It is out of the concern for these involuntary admissions of those who do suffer from a mental illness, and those who don’t, that the 2013 mental health law would focus on. Although drafting of the law would begin in 1985 the process took twenty-seven years until the final version of the law would make it onto the books in national law. So, the later part of the drafting process, which took place in the 2000’s, had to deal with both foreign and domestic calls for legal protection of the rights of its citizens when being admitted to psychiatric care. The very concept of voluntarily being admitted to hospitals by psychiatric patients was argued amongst Chinese psychiatrists, as some argued how someone who is suffering from a mental illness but does not realize it or does not admit to it would voluntarily commit themselves to hospitalization. They argued that if a patient needed treatment and/or was a risk to public safety they should be allowed to intervene and have the person in question hospitalized. These arguments combined with years of not being adequately equipped to do anything about mental health care anyway prolonged the drafting process for as long as it did (Zhou, Dawson 2014). However, despite these arguments and long delays the law was finally submitted for review in 2011, entered the statute book in 2012, and would be enacted in 2013. The law, aimed at combating the human rights violations from involuntary admissions, focused on listing numerous rights protected under it, they included: right 21 to respect of human dignity, right to protection of one’s person and property, right to communicate and receive visitors, and several others aimed at addressing the issues involved with involuntary admissions (Zhou, Dawson 2014). The new law dictates that no person shall be forced to undergo a psychiatric test against their will, unless as prescribed by law which may still allow for a close family member or, if there is none, a local administration department can initiate one. The difference now is that the examination must be performed by a qualified psychiatrist and only a qualified psychiatrist can determine if a person has a mental illness. There is still the provision that if a history of self-harm or committing harm against others is demonstrated, a patient can be admitted and forced to remain under the care of a psychiatric hospital. However, if the patient or their family disagrees with the assessment they can request a reassessment be performed by two different and separate psychiatrists and a legal review must be carried out (Zhou, Dawson 2014).

Giving the patient and their family some means of challenging an assessment of mental illness if they believe one is warranted, and throughout the process patients are to be informed of their legal rights. The law also goes into detail about what the definition of mental illness is, and gives two; one for the broader purpose of legislation and the other for civil commitment. The broader definition being “a disturbance or abnormality in perception, emotion, cognition or other mental activity, brought on by any cause, that results in obvious mental suffering or impairment in social adjustment or other types of functioning” (Zhou, Dawson 2014). The law also defines the term

“dangerousness” which mainly relies on the basis of if a patient is deemed a harm to themselves, or poses a harm to the public. These were defined so as to better determine when a patient can be involuntarily admitted while acknowledging and upholding their basic rights. This new law while still not perfect in many ways (Zhou, Dawson 2014) signifies another step in the right direction for mental health care in China, this time from a legal standpoint. 22

The 2015-2020 National Mental Health Plan: Continuing the Progress Already

Made

Furthering this commitment to improving mental health care, the Chinese government on

June 4 th 2015 released the 2015-2020 National Mental Health Plan outlining where they feel mental health care stands in China and the goals which they hope to accomplish over the five years.

The Chinese government has been very concerned with demonstrating their role of ensuring the welfare of the Chinese people in the past ten to fifteen years and showing its commitment to the mental health of their people is one more way in which they can show their care as, “mental health work has been an important activity for safeguarding and improving community welfare” (Xiong,

Phillips 2015). With this in mind it is no surprise that the five-year plan starts by pointing out all the accomplishments made in securing the welfare of the people at large with the numerous improvements made in the area of mental health care including highlighting the number of people now signed up and receiving follow-up visits through the 686 Program as well as the new-found respect for patients’ rights with the recently passed Mental Health Law. From there, the plan explains the key areas in which mental health care could be improved upon. These areas are the same that China has been dealing with in the realm of mental health care for some time. First and foremost is the still inadequate number of specialists trained to treat mental illness and lack of specialized mental health facilities. One way in which China is dealing with the lack of training in treatment of mental illnesses is by introducing psychiatry major programs for undergraduate medical students. These undergraduate programs would be “comparable to undergraduate psychiatry education programs in developed countries” (Hu et al. 2017), giving medical students six times more hours as well as clinical clerkships in dealing with mental health. Since the New

Mental Health Plan was put in place the number of Chinese medical schools that have 23 undergraduate psychiatric major programs has risen from four in 2014 to fifteen in 2016, and has seen the number of students enrolled in these programs go from under four hundred to over one thousand in that same time (Hu et al. 2017). Since 2015 residency training in hospitals has also increased in Chinese hospitals with one hundred thirty being approved to have residency programs in psychiatry. This saw eight hundred students complete residency programs in psychiatry in 2015.

The New Plan is also looking to continue training after doctors have graduated as well with the announcement of a five-year psychiatrist licensing program. The trainees for this program will be those who are already practicing in more rural or areas with less resources then larger cities and will involve them taking more than 150 hours of course work with ten months of clinical rotations.

The focus will be on “modules of psychiatry, clinical psychology, community mental health services, professional communication, and mental health rehabilitation” (Hu et al. 2017); this licensing program is meant to train over 8,500 doctors in mental health care by the end of the New

Plan in 2020. The distribution of the resources that are available is also a concern, with most still being focused in the more developed urban areas along the eastern coast of the country leaving much of the western and rural areas lacking in both facilities and properly trained personnel. This lack of resources has unfortunately kept some previously stated goals out of reach like establishing a community-based rehabilitation system, and plenty of those who suffer from mental illness still do not get the proper care they need either because they cannot get to proper facilities or there are not enough specialists to continue to provide the adequate level of care. Another area they hope to address is public awareness about mental health. Lack of knowledge about mental health causes the public to develop fears of those who have mental illness, because all people will see are the violent or disturbing outbursts that result from someone with a mental disorder not getting adequate care. These fears result in stigmatization of mental illness and leads to those who have a 24 mental disorder, as well as their families, to become ostracized and isolated from their communities. This leads to people trying to hide their illnesses which means they do not receive proper care until a disturbing outburst occurs that forces them to be taken to the hospital and treated.

As will be shown later, this creates and endless cycle of stigmatization and will ultimately be harmful to the harmonious society that the Mental Health Law and new mental health plan aims to help create. The introduction in the five-year plan highlights the important advancements in mental health care, but makes apparent “Mental health work in China still faces great challenges”

(Xiong, Phillips 2015).

Treating Mental Illness in Modern China: Combining Chinese and

Western Methods

Prescribing Medication: The Quick and “Easy” way to Treat the Symptoms of

Mental Illness and Rejoin Society

The passing of new laws to help improve both the quality of care and the treatment of mentally ill patients has shown China’s willingness to take action in dealing with the issue of mental health care amongst the Chinese people, but there is still the question of what is the best way to treat mental illness; especially in the ever-changing society of China. 686’s main focus was on ensuring that patients were able to get treatment at all, and has had success with regards to the training of more specialists and the opening of new centers dedicated to treating mental illness.

The question now is no longer about being able to get patients to the hospitals or doctors to the patients, but rather what happens to those who are admitted to the hospitals as far as treatment, and how can the person rejoin both their families and society. In the urban setting, “the community 25 approach to mental illness in China is primarily focused on control and only secondarily on treatment” (Yang 2018), since the focus for the government is on maintaining public safety and security rather than treating the underlying cause of a person’s mental illness. To this end China has followed Western practice of reliance on psychopharmacological treatment to deal with mental illness. With the new focus on mental health care beginning in the mid 2000’s, many Chinese patients were able to have access to western drugs such as antidepressants and antipsychotics. This was meant to help with “expediating ‘recovery’ in order to minimize the price tag for the state, as well as potential dangers including violence…popularly associated with mental illness” (Yang

2018). These new Western drugs were able to quickly subdue violent behavior in patients.

However, while drugs are able to rapidly treat symptoms of mental illness, they do not treat the underlying cause of the symptoms and are therefore not permanent solutions. In most cases the only way drugs have long lasting effectiveness is if patients take them for the rest of their lives which is a difficult and complicated issue for several reasons.

For many it is a question of money, many of the working class in China cannot afford to continue to pay for Western drugs to treat themselves or to see doctors at regular intervals to maintain the drugs’ effectiveness. This leads to a person being admitted to a hospital because of violence or some other disturbing outburst, being treated with drugs, and then sent out of the hospital as soon as the violent or disturbing symptoms have calmed down. However, if the person or their families are not able afford the medication needed to help keep the symptoms in check, they will eventually relapse and the symptoms will manifest themselves again most likely with another disturbing outburst.

Others are not willing to continue to take medication their whole lives as they are concerned about the long-term health effects the drugs may take. While conducting research at a mental health 26 center in Zhangqiu, Jie Yang for her book “Mental Health in China: Change, Tradition, and

Therapeutic Governance” interviewed psychiatrists who often prescribed drugs as methods of treating patients. One doctor, Dr. Wen, was able to convince his patients and their families that taking the drugs would not permanently damage their long-term health, but was often dismayed at the high relapse rate of his patients. Often describing a feeling of helplessness when seeing former patients acting crazy on the streets (Yang 2018). Many patients and their families that Yang talked too would often become frustrated by the slow recovery and reliance on drugs, and would go to larger hospitals in order to receive better treatment. Unfortunately, what they found was longer waiting times to see a specialist only to receive almost the exact same drug-based treatments. One patient Yang talked with found himself overall satisfied by the treatment at the center in Zhangqiu, but “saddened and frustrated… on the likelihood that he will have to take drugs for life to treat his bipolar disorder” (Yang 2018). This unease about having to rely on drugs for the rest of their lives is not unique to Chinese patients, but in fact is a common concern amongst patients in the West as well. One main cause for concern from having to constantly take medication in order to treat symptoms of mental illness is the side-effects caused by the very same drugs that are supposed to be helping them. At best side-effects from taking medication are the patient feeling subdued or a shell of themselves because the drugs, while keeping the symptoms of their illness in check, often cause them to feel as if they are not really themselves. Another person that Yang talked with who had been diagnosed with schizophrenia talked about having to balance the decision between treating the symptoms of her illness and the side effects of the drugs prescribed to treat her. The person in question, Lili, and her parents searched the entire city of Beijing to find treatments to control her episodes of delusion, insomnia, and non-stop talking. All of the prescribed drugs would only lead to relapses until eventually one doctor prescribed her the same types of medication, but 27 at a much higher dosage. This higher dosage finally worked, but at a cost. The side-effects of the drug including: weight gain, listlessness, and nausea became much stronger as well. Despite the side-effects Lili and her parents were satisfied with this treatment method as the symptoms were finally under control and she could begin to live a normal life on her own. This acceptance of the side effects is one made by both patient and doctor. Dr. Yuan, the psychiatrist who prescribed the higher dosage of medication, rationalized that the side-effects were a necessity in order to get Lili’s symptoms under control. Yang quoted Dr. Yuan: “the side-effects will eventually come under control, but the fear of possible side effects cannot become the reason to indulge the symptoms”

(Yang 2018), allowing the symptoms to persist is a much worse outcome for the patient then the side-effects according to Dr. Yuan. There are times that this does not always hold true. In one case that Yang was researching, a man who had witnessed an accident at the coal mining company he worked for developed acute stress disorder and then schizophrenia. His wife, named Sun, attempted to care for him herself for the next three decades, only sending him to the hospital when his symptoms became too destructive to himself or others. Eventually Sun had to send her husband to a hospital to receive treatment. However, when visiting him in the hospital Sun saw that her husband had changed. Instead of the vibrant man she knew her husband to be he was solemn and looked physically ill. Her husband cried and begged her to take him home saying “the big black pills he had to take every other day would kill him; the medication was so strong that it would make him sleep for two days” (Yang 2018). Upon seeing her husband in such conditions Sun immediately took her husband out of the hospital and continued caring for him herself. This is not to say that the psychiatrists do not care about the long-term well being of their patients. Dr. Wen’s feeling of helplessness at seeing the relapse of his patients is evidence of his desire to see his patients living normal and happy lives. Dr. Yuan too, wants to see his patients’ lives return to a 28 sense of normalcy and decreases the dosage of medication given to his patients once the symptoms begin to come under control. Rather it shows that the aim of both psychiatrist and patient is for the person suffering from mental illness to be able to once again become a normal functioning member of society as quickly as possible, and so drugs while not being able to cure the underlying symptoms of mental illness, are the quickest way to help people return to their families and society.

What then does a person suffering from mental illness do next? Clearly the medication is a (mostly) positive step in helping treat mental illness, but ultimately an incomplete treatment method. What can both patient and the psychiatric teams of doctors and nurses do next in order to continue to help ensure the goal of helping those suffering from mental illness can return to and be functioning members of society.

For Lili and her family, the answer was to include traditional methods of treatment with her medication. In order to combat the negative side-effects of the large dosage of medication she was taking Lili’s mother sought the advice of a practitioner of Traditional Chinese Medicine

(TCM). The doctor prescribed eating seven raw chestnuts in the morning and seven more at night in order to improve her qi, or life force, which the doctor said had been hurt by the medication she was taking (Yang 2018). In addition to the chestnuts the TCM doctor also recommended Lili join a hiking group not only for exercise, but in order to help facilitate more social interaction. This was appealing to Lili and especially her parents because, again, it focused on her rejoining society and interacting with others. This being her parents’ primary goal from treatment of her mental illness. Other people that Yang talked to while researching mental health centers described a desire to talk more about their illness rather than simply be given drugs to control their symptoms. Several patients at the Zhangqiu center expressed their disappointment that they did not have a chance to talk more about how they were feeling and the causes of their distress. Many welcomed talking to 29

Yang because it felt like she was taking an interest in them personally rather than just making sure they took their medication. Despite this desire of several patients to have more talk-therapy, and the seeming success of the addition of more holistic treatment in concert with the prescribed medication that worked for Lili it is unlikely that it will be widely utilized in major urban areas.

One reason for this is the demand it would take on a doctor’s time. In large urban areas it is difficult to dedicate large amounts of time to a single patient as there are likely dozens, if not more, waiting to also be treated. Dr. Wen, the director and chief psychiatrist at the center in Zhangqiu, sees thirty to fifty people daily. Most of the time he is unable to see them privately, and has to discuss symptoms and treatments in the presence of not only their family members but other patients waiting in the office. While Dr. Wen did attempt to talk to each patient or their family member for a period of time, there often was not much in the way of counseling. Instead the interaction would usually be a brief set of questions to form a diagnosis and then explaining what medication to take and how to take them, “Often within 10 minutes the patient receives a diagnosis and prescription…”

(Yang 2018). These brief consultations do not allow for much in the way of patient-doctor talking time or for the patient to adequately detail how they are feeling or what might have caused their illness in the first place. Cost is also a factor in the variety of care outside of just prescribing medication hospitals can provide. A hospital in Beijing that Yang did research at had much better financial backing then that of the center in Zhangqiu, and was able to better accommodate the patients as well as spend more time talking directly to the patients since they had more staff on hand. The nursing staff would organize morning exercise routines to keep the patients both active and increase their social interactions. The hospital in Beijing even had four consolers who spent time talking to the patients and would often help the psychiatrists in deriving an adequate prescription. Still, the talking time with patients was short and would still result in the prescription 30 of drugs (Yang 2018). Many of the people the Yang talked to who were patients in the facility felt that the counseling sessions did not provide enough time to fully describe how they felt and what was really causing them stress. One woman even going so far as to say she felt she was “being interrogated by both physicians” (Yang 2018). Chinese psychiatrists understand the limitation of prescribing medication to fully treat Chinese patients, and so have found ways to mix both Western medication and ideas with Chinese influence.

Psychological Dredging Therapy

Chinese psychiatrists have looked to develop new methods for treating mental illness in

China by combining Western practices with more traditional Chinese methods. One such method created by Chinese professor Lu Longguang is known as shudao liaofa or “psychological dredging therapy” and derives many of its methods from the traditional Chinese medical book the “Yellow

Emperor’s Canon of Internal Medicine” (Yang, 2018). Combining both traditional Chinese medical works as well as Western theories and treatments, Lu has been able to develop a new psychotherapy specifically for Chinese people living in Chinese society. Dredging is broken down into three steps “all of which comes from the precepts of the ‘Yellow Emperor’s Canon of Internal

Medicine’” (Yang 2018). The first step is communication in which the doctor and patient build a rapport in order for the patient to feel comfortable enough to talk about their lives freely. This allows the patient to self-analyze and understand the possible causes of mental illness or distress.

The next step is correction. Here doctors attempt to help patients combat negative attitudes until the patients can themselves control their own pathological intentions. The last step is guidance in which the doctor helps the patient in “constructing ‘normal’ psychological and behavioral conditions to strengthen healthy psychological dynamics” (Yang 2018). This form of therapy relies on language between the patient and doctor and relies on the doctor guiding the patient to becoming 31 self-aware of their own mental distress and its causes and then ultimately the patient self-correcting.

As Yang points out, while this therapy was created by Lu, a Chinese psychiatrist, and designed for

Chinese patients in Chinese society it is still a combination of both Western and Chinese methods.

Lu’s method “Like other Western psychotherapy, which focuses on the self, its core concepts include self-reflection and self-improvement” (Yang 2018), but it also takes from traditional

Chinese ideas derived from Confucianism and Daoism. The doctor showing compassion or love for their patient in order to help them during the treatment as well as instilling compassion in the patients themselves. This combined with the Confucian ideal of zhongyong , or the “Golden Mean” will allow the patient to obtain self-moderation and self-cultivation in order to achieve a healthy mind.

Imagery Communication Psychotherapy

Another form of psychotherapy developed in China is called Imagery Communication

Psychotherapy (ICP). Developed by professor Zhu Jianjun in the 1990’s. Zhu’s theory derives from the fact that Chinese language itself is pictographic and thus Chinese people tend to employ imagery and scenes to express their feelings or thoughts. According to Zhu, all psychological suffering comes from the “lack of sense of self-existence, misunderstanding one’s self, or inappropriate responses to stress” (Yang 2018). So, in order to combat mental illness through this scope Zhu’s method aims to help people look inside themselves and determine what the heart, or self, actually wants. Zhu’s method is broken down into five steps, the first being the introduction of imagination and relaxing of the patient whose eyes should be closed. Then they are asked to search for an image internally. In order to help with this the therapist may ask the patients to think of a particular image, usually a house which according to Zhu represents the body and mind. Then both the patient and doctor analyze the images the patient is seeing. Every aspect of the image can 32 represent a different psychological state or psychological stress “For example, if the house has a dark color, this often represents the client’s negative feelings or attitudes” (Yang 2018). The fourth step requires the therapist and patient to discuss and understand the patient’s feelings, attitudes, and transformations during the therapy. Finally, the therapist will summarize the session and give their patient a task to help continue their therapy. If say the patient imagined a dirty house then they are told to imagine cleaning the floors or windows of the house every day (Yang 2018).

Another way in which to use ICP is to change negative attitudes to positive ones through guided imagination. If a depressed patient describes themselves in a desert with little to no life, and themselves walking through with no purpose; a therapist can help by telling the patient all they need to do is continue walking forward and eventually they will find hope, and if they look around even in a desert, they can see life around them such as insects or plant life (Yang 2018). By replacing negative images with positive ones, a therapist can hopefully break the cycle of negativity and lack of support the patient feels. Both Zhu and Lu are professors at nationally funded universities and have benefitted greatly from the national government’s inclusion of mental health as a part of China’s overall medical issues. The development of new Chinese models for therapy shows the progress that has been made in both the study and treatment of mental illnesses. The question still remains in how to provide all of these new and developing treatments to everyone in

China who needs them.

Private Institutions for Treating Mental Illness: Filling the Gaps Left by the Government

Wenzhou Kangning Hospital 33

The government has been able to greatly improve both training and resources dedicated treating various mental illnesses in China, but still it is impossible for the government to be able to provide care for every individual in China. That is where private institutions can come in and help fill the gap in care. One such private institution, the Wenzhou Kangning Hospital, could lay the ground work for more in the future. The founder of this new, private hospital is Dr. Guan Weili who saw a desperate need for more institutions dedicated to mental health care. After graduating medical school in 1987 Guan was arbitrarily placed in the mental hospital to work. While there

Guan saw the desperate situation that Chinese health care was in with regards to mental health. In an interview with Forbes about his now large private institution Guan discussed the conditions he saw while at the public hospital in Wenzhou, “What I saw is that public hospitals did not have enough medical resources or enough hospital beds to meet demand, could not satisfy the need of the society. I saw it every day. I saw patients not getting proper care” (Chen 2016). Guan saw an opportunity to both help fill a desperate need for Chinese society, and allow himself to branch out from the public hospital he was working in. In 1996 Guan opened his own facility with twenty beds and slowly received funding from both the Wenzhou city government and later private equity outfits to expand. Guan has been able to expand to several different locations and provide incredible care because of the privately funded institutions. As noted in the Forbes article Guan’s affiliate hospital, Beijing Yining Hospital, has 38 beds that are staffed with 20 full time medical staff. Ratios much better than one can find in public hospitals. Guan’s facilities are able to maintain a large and well-trained staff because the pay at his private hospitals are much better than what the doctors and nurses receive at public hospitals. Thanks to the well-trained staff patients who come to Guan’s facilities are seen to improve much faster than at public hospitals with their average stay only being 47 days as compared to 60 days which is more common across Chinese mental health 34 institutions “With better medications and therapies come better results and shorter therapy sessions”

(Chen 2016). It is Guan’s hope that he can build his new business into a national chain across

China, which would help improve both the resources and quality of care for those who suffer mental illnesses. With the success of Kangning Hospital, both medically and financially, it could persuade others to start up and invest in privately funded mental health hospitals which could help fill the gap between the number of people who require treatment and the number of adequate facilities to provide such care.

Online Resources for Those Suffering from Mental Illness

In addition to privately funded hospitals that treat more serious mental illnesses, there are various resources being provided online that help with less severe psychological issues. One such site is Jiandanxinli which in Chinese translates to “Simple Psychology” launched in 2014 and was created by Li Zhen, a trained counselor and member of the China-US CAPA Psychoanalytic

Alliance, aims to give people quick and easy access to psychological help. On its website

Jiandanxinli provides access to articles that range from understanding mental illnesses to how to accept and deal with symptoms of mental illness on your own. It provides a test for people to conduct a self-test that “helps you understand your mental state” (Jiandanxinli), as well as allow people to type in questions regarding their own experiences of mental illness or disorder. What’s more, the site allows people to connect to trained psychiatrists and consultants wherever they are in China by allowing them to talk to psychiatrists online or over the phone to receive treatment and counseling sessions. This service helps people in China in two ways: first, it allows those who have demanding jobs to seek answers and counseling without having to take too much time away from their jobs, and second allows them to seek it privately without having to go to a hospital and thus helping them avoid unwanted knowledge about their mental state. Before deciding whether 35 to receive counseling or not, Jiandanxinli provides different information forms that range from explaining what counseling entails, the different types of counseling offered, and questions asked by others after they received counseling. Jiandanxinli even has an app that can be downloaded to phones. The quick and easy site allows people in China to be in contact with trained counselors across China and not have to go to a hospital to receive proper counseling. Many psychologists have moved to online counseling in recent years in China. Many use the popular Chinese app

WeChat to hold group sessions with white collar clients both online or at the companies their clients work at (Yang 2018). These advancements in the private field of care for mental illness has been growing exponentially since the inclusion of mental illness as a public health concern by the government. More and more individuals have seen the gap between those who suffer some form of mental disorder and the available resources to provide care for them as an opportunity to make their own profits. As long as they provide adequate care for those who have mental illness, these privately funded and run organizations should be welcomed by the Chinese government and help provide care for those who need it in China. Still, these private institutions can only do so much for Chinese society as a whole. For example, Guan’s Kangning Hospital and its affiliates are located in major urban areas only. Although his stated goal is to expand nationwide, Guan’s facilities are still going to be centered in major urban areas in China, because it would be difficult for his company/hospitals to be profitable otherwise. Even in the urban areas the cost of care is still something to be concerned about for the majority of Chinese. In the Beijing Yining Hospital, the cost of a room per day could be as much as 5,000 yuan a day. Quite expensive for the average worker in Chinese cities. As for online resources such as Jiandanxinli, it requires people to have stable internet access, something that is not a guarantee in the rural parts of China. As for the online counseling sessions on WeChat, again the focus is on more white-collar clients since that is where 36 money will be made for the psychologist’s services. Still these are all examples of improvement in resources available to those who suffer from different mental illnesses within China, and can continue to improve the available care. Still there is one issue within China that prevents mental illness being treated properly, and it goes beyond the building of hospitals or the training of new psychiatrists.

Stigma Against Mental Illness: How it Affects the Individual Suffering from Mental Illness, Their Families, and How it Prevents Proper Care General Stigmas Associated with Mental Illness and the Results of Trying to Hide

Mental Illness

The PRC government has made great progress in dealing with the issue of mental health care within China with improvements in treatment, research, and legal rights for the mentally ill.

Yet there is still one area that must be addressed in order to not only continue the excellent progress being made, but also to make even greater strides in terms of treatment both medically and socially for the mentally ill. That area being the lessening of the stigma attached to mental illness within

China. Several long-held stigmas against those who suffer from mental illness, as well as against their families include: the belief that mental illness comes from the result of the individual or their family’s immoral or unfilial behavior, that mental illness is an indicator of bad fate which can influence others who associate with the mentally ill person, the belief that mental illness is contagious, and that the mentally ill are violent and destructive (Phillips 1998). These stigmas have been cultivated by traditional cultural norms in China as well as a current lack of public knowledge about mental illness in modern day China. 37

Chinese society has been and still is centered around interpersonal relationships, and the ability to build social networks by acquiring and reciprocating favors. It is only after proving that one can perform these societal obligations does one earn the right to be considered a person and a member of society (Kleinman 2011). Those suffering from more serious forms of mental illness will have harder times fulfilling these societal obligations and thus, have a harder time being an accepted member of society. This often leads to misunderstandings and stigma setting into the minds of many and will force someone suffering from a mental illness into isolation from society.

When separated from society it becomes harder for people to notice the mentally ill as Chinese photographer Liu Yuyang explained “We can't see the mental illness patients in society. You won't have a friend or a classmate who is mentally ill so I think they are kind of invisible in our lives”

(Poon 2015). This makes it much easier to view them as not human as can be seen by Liu’s earlier view of people with mental illness “I actually thought before taking this photo essay that the mentally ill patients were like monsters” (Poon 2015), and this lack of knowledge and understanding only continues the horrible cycle of stigma and isolation. This fear of losing face and the stigma from having mental illness or having a family member who has a mental illness leads people to attempt to hide the illness.

Family members will hope that they can keep secret their children or sibling’s illness from the rest of society. Even when talking to specialists at hospitals trained to deal with mental illness

Chinese family members will often do their best to keep the illness secret. One psychiatrist working in Beijing had a woman come to see him to seek help for her daughter who had a mental illness.

The psychiatrist asked to see the daughter in person but the mother claimed that her daughter did not believe she was sick and so brought a photo to show the doctor instead. When the psychiatrist again insisted on seeing the daughter in person the mother said she could bring in as many pictures 38 as he needed going all the way back to when her daughter was a child. This anecdote shows “the lengths family members will go to in order to prevent publicly exhibiting the mental health issues of loved ones” (Yang 2018). This act of hiding a mental illness out of fear of being stigmatized and isolated from society is never effective; the truth eventually will come out and in some cases in disastrous ways. In 2016 a student at Sichuan Normal University was murdered, slashed over fifty times with a knife, by his roommate. The reason given was that his roommate was annoyed by his singing. It would be revealed that the person who killed his roommate for singing had a history of depression and had attempted suicide several times since high school. The mother never revealed this history of illness because she was afraid her son would be stigmatized and result in less opportunity both educational and professionally for her son. Instead of the son’s mental illness being dealt with and treated in some way, this situation led to a tragedy, and most likely another instance in which mental illness is associated with violence and disturbance. Thus, continuing the cycle of stigma and hiding of mental illness by those afflicted.

Stigma Associated with Depression

One of the most commonly known forms of psychological disorder in China, depression, still comes with its share of stigmas in Chinese society. Over ninety million people in China suffer from depression. Still, “the illness is generally viewed in Chinese society as a result of weak personality” (Yang, 2018), often times depression is associated with weak will and therefore those who have it lack the capacity to hold important jobs in business or as government officials. This stigma leads to many not seeking treatment with sometimes disastrous results; over two hundred thousand people commit suicide because of depression in China. The story of the university student who killed his roommate because of singing is an example of what can happen when depression is not appropriately treated, but also why it is not treated. The boy’s mother was so concerned that 39 the stigma would result in her son not being able to get a good education or find a good job that she chose to keep it a secret. Many who have depression desperately want to hide their condition to avoid the stigma that would befall them. So, they attempt to combat the illness on their own by continuing to act normally in their daily lives. It is their hope that by continuing to act normal eventually the illness will go away on its own (Yang 2018). Others may attempt to disguise their depression as some other medical issue. In one case and informant told Yang that she had gone to the hospital under the guise of experiencing menopause and described her symptoms under that medical condition. When the doctor found she was not in fact going through menopause, but instead suffered from severe depression, the woman pleaded with the doctor to only describe her symptoms in his report instead of putting depression as the cause. This way she would avoid the stigmatism of having a mental illness. If it was known her symptoms were the result of depression and not the more socially accepted menopause, the woman could have very well lost her job as she might be seen as being incapable of carrying out her job requirements. This fear only gets worse for those in high positions both within business and government officials. Government officials in

China who are diagnosed with depression will desperately try to keep their illness a secret, because their political careers would be all but dead if it was ever discovered by their peers that they suffered from a mental illness, even something as common and treatable as depression. The competitive nature of bureaucratic life in China mixed with the social view of depression and mental illness as a weakness of the individual and family, forces many officials who are diagnosed with depression to often see themselves as weak. Out of fear of letting their employer or peers see this weakness many will attempt that much harder to hide their ‘weakness’ and project that everything is normal in their lives. This leads to self-stigmatization which ultimately leads people to not seek help but instead try and solve the problem on their own (Yang 2018). Even with the 40 more common condition of depression, stigma still greatly effects the lives of those who are diagnosed. The stigma only becomes worse with less known, and even less understood mental disorders.

Stigma Associated with Schizophrenia

Schizophrenia is by far the most mysterious of mental illnesses and as such comes with perhaps the worst stigma from society. Although schizophrenia is difficult to understand and treat even by the best of professionals, the one aspect that society notices are the violent symptoms that come as a result of the illness. In China, the media often associates the disease with violence and therefore “criminalizes those who have developed the disorder” (Yang 2018) and this criminalization leads to those afflicted and their families to forever be stigmatized and sometimes isolated from their communities. Two of Jie Yang’s informants mentioned earlier who have schizophrenia described the stigma they or their family members had received because of their illness. When Lili was diagnosed with the illness her parents attempted to soundproof their apartment so that their neighbors would not hear her screaming and kicking at doors in the night.

Her parents feared that if people found out about her situation then she would not be able to find a job and they themselves might lose theirs’. Even after finding Dr. Yuan and using his prescribed large dosage of medication Lili’s parents are still worried that her illness will keep her from finding a husband. Their fears are justifiable “…of five boyfriends, none would continue to see her after she told them the history of her schizophrenia and about the medication she takes” (Yang 2018), and their concern for their daughter’s marriage prospects only worsen as she gets older. In her early thirties Lili is already considered a leftover woman in China making her marriage prospects difficult enough, the added complication of her mental illness only adds to the stress of both herself and even more so her parents. The second of Yang’s informants, Sun explained the stigma that not 41 only her and her husband received after he developed schizophrenia, but that her son was subject to as well. Once it became known that her husband suffered from schizophrenia, she felt it was best for her and her family to move to a new village to start over. This resulted in her family moving four times and in each new village her husband’s condition would become known and have different forms of stigma placed upon the family. In one village after a neighbor had complained about her husband singing loudly, Sun explained that her husband was sick and could not control the level of his voice while singing. A few days later their landlord came and told them they would have to move because he had received complaints from neighbors as well as a warning from the village committee that her husband may be dangerous to the community because of his illness (Yang 2018). In yet another village she and her family moved to, Sun found her husband surrounded by a group of men who were all laughing at her husband who was naked performing handstands in the middle of a schizophrenic episode. Another form of stigma Sun noticed was during poverty relief programs in the villages they stayed in. While other small or poor families received assistance from the village committees hers was ignored because of the fear of violence from her husband’s illness. Sun’s son would not escape the stigma either. Like Lili, Sun’s son found it difficult to find a marriage partner because of her husband’s history of schizophrenia. It wasn’t until her own son was in his late thirties that he was able to find a wife. Still Sun worries about her husband’s illness negatively affecting her son’s marriage. Lili and Sun’s accounts of stigmatism due to their or their family member’s schizophrenia is a small example at the ways in which developing a mental illness not only forces people to try and find a way to quickly treat their condition, but also how it can affect their lives and place in society moving forward.

The Ever-Present Stigmas of Mental Illness Held by Health Care Providers 42

The situation is not helped by the fact that even those who are responsible for treating mentally ill patients can still demonstrate the same stigmas against mental illness that can be seen in the rest of society. A survey of mental health care providers in Guangzhou revealed a high level of stigma toward mental ill patients amongst the care providers. The study found that “The three elements of stigma are all present among community mental health staff in Guangzhou, problems of knowledge (ignorance), problems of attitudes (prejudice) and problems of behavior

(discrimination)” (Li et al. 2014). In another survey of mental health care providers in Liucheng and Liujiang, some stated that they were fearful of a patient relapsing and yelling at them or even physically harming them. One expressed their worry that dealing with mentally ill patients would have a negative effect on their life outside of the hospital as well “I am afraid of having problems with my dating, when they know that I regularly contact with mental disorders…. people usually have discrimination against those who serve the mental health patients.” (Ma, Huang et al. 2015).

These accounts from those providing care within hospitals shows how hard it is for those suffering from mental illness to escape the stigma place upon them by society. Even when being treated in hospitals it is there and this stigma has huge effects on both the person suffering from a mental illness as well as their families. Which leads to the endless cycle of stigma and self-stigma being associated with mental illness. As seen from the accounts shown suffering from mental illness can often lead to it being harder to find a job, find a spouse, or in any way find a stable and normal life because of the stigma associated with it. This fear of being stigmatized or mocked leads a mentally ill person to isolate themselves from society and might not seek the proper help they need out of fear of others learning about their illness. Their families might try and cover up the mental illness or try to deal with it themselves as long as possible before finally seeking help out of fear that the entire family will lose face and be looked down upon. This fear to receive treatment can lead to 43 symptoms becoming worse until a violent outburst or disturbance occurs, which after being reported on as a crime leads the public at large to view mental illness as dangerous and for those who have it to be avoided. That is why the next step in dealing with the issue of mental illness from the national level down to individual communities has to be better public education of mental illness.

Shanghai Tulip: An Example of How to Deal with Mental Illness and Help Combat

Stigma Against Mental Illness

An example of what people go through after being diagnosed with a mental illness, as well as the current situation of mental illness in China, can be seen in the short documentary “Shanghai

Tulip – Breaking China’s Mental Health Taboo” made by Chen Shanshan, which follows Chen

Wei, a man living in Shanghai who was diagnosed with bipolar disorder in 2003, who had set up his own self-help group for mentally ill people living in Shanghai. This group is the first of its kind in Shanghai. After feeling depressed to the point of being suicidal Chen went to the hospital where he was diagnosed with having bipolar disorder. After being diagnosed Chen found that his own mother had a hard time understanding his illness. She thought it was from “being narrow minded” and that if he went out more and became more open minded he could cure himself easily which only left Chen more distraught about his situation saying “I thought at the time she couldn’t understand me” (Chen 2015). At first his parents, who did not have much understanding of mental illness, were also worried about him and his position in society. With this diagnosis, they were concerned he could not find another wife after his divorce and they were worried about him finding a stable way to earn money. Chen went to a group therapy session put on by the hospital to try and help with his illness, but it only took place once a month on a weekday which did not fit with

Chen’s schedule. So, in order to both help himself as well as others who were suffering from 44 different forms of mental illness he started his own self-help group calling it Tulip. There he had people come in and discuss their situations, their lives, and generally help themselves and the others in the group to feel like they were connected to something. As the participants in Tulip explain in the documentary there wasn’t anywhere else they could go to discuss what they were going through as no one else really understands. One Tulip member explained that due to the still present stigma associated with having mental illness most don’t want it known that they suffer from a mental illness “You had better not discuss it. It will only bring you trouble” (Chen 2015), and he would go on to explain that those who work in the public sector often would not use national medical insurance to cover their medications.

With the creation of Tulip, the participants had a place to go to not only try and deal with their illness, but also have a safe place to interact with others as another member explained “We share similar characteristics, so we find it easy to communicate with one another… we don’t feel isolated” (Chen 2015). Chen began creating Pamphlets explaining Tulip and what its goals were in order to bring new members in to help deal with their illness, and also to help educate the public better about mental illness. Near the end of the short documentary Chen was in a park filming when an old woman asked what they were doing. Chen explained Tulip to her and a crowd began to form around, and many began asking questions that, as Chen Shanshan noted in a later article written a year after making the documentary “were so to the point that I could tell were not just asked out of curiosity.” (Chen 2016), these people asking questions most likely had a family member who had a mental illness or had one themselves. In that same article, Chen Shanshan explained that she returned to Shanghai to catch up with Tulip and to see how the group had been progressing. Unfortunately, she found that Chen Wei was no longer associated with the group as it had been months since even his closet friends within Tulip had spoken with him. According to 45 them he had not been taking his medications as often and seemed to be going through a period of sever depression. Tulip itself has run into financial issues and has not had many new members join recently. Still some in the group are still optimistic that even if Tulip does not survive they will, and they will be able to help others who suffer from mental illness just as Chen Wei had helped them.

Conclusion

Mental illness did not suddenly become a problem within China in the twenty-first century.

It has long been an issue that only recently has begun to be acknowledged by both the national government in China as well as its people. Treatment and care for the mentally ill had long been seen as the purview of the family of the person and not something that society was supposed to deal with. However, with the changes in society brought about by both the twentieth and twenty- first century that view was no longer viable for the government, the families, or society at large, and the difficult task of dealing with mental illness had to be addressed. The government’s commitment to furthering psychiatric research as well as funding national programs like Program

686 have greatly improved the care and treatment for the mentally ill. The enactment of the new national mental health law in 2013 was another positive step in improving the lives of the mentally ill, by stating and protecting their basic rights. The creation of private hospitals as well as online resources and grassroots self-help groups like Tulip are also positive signs that care and maybe even a better understanding of mental illness are continuing to take place. Still there is much that must be done to continue to improve the care for the mentally ill in China; 686 still has a long way to go before it accomplishes its goal of providing care to everyone who suffers from a mental illness, and must continue to be funded by the government and be given the time needed to continue 46 to train people in treating mental illness. The goals put in place to continue to train psychiatrists in

China and provide more resources in community hospitals by the 2015-2020 New Mental Health

Plan have been ambitious but difficult to accomplish and need to continue far beyond the year

2020 in order to provide care for China’s large population. While the question of how best to treat those, who are admitted to hospitals must continue to be explored and developed within China to best treat the ever-changing Chinese individual. The 2013 law still has many holes and issues that must be addressed before it can truly cover and ensure the rights of the mentally ill as well as citizens who protest the government are protected. While and most important step in bettering the lives of the mentally ill has to be lessening and ultimately trying to eliminate the long-standing stigmas against mental illness through public education and better understanding of mental illness.

These are all difficult tasks to undertake for all involved in trying to handle the issue of mental illness, but strides have already been made and perhaps as Chen Wei put it “… maybe in 30 years, the public will be well educated about mental illness. They will know how to deal with it just like they do with a cold”.

47

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