Chinese Patient – Western Therapist

This paper is to assess the problems of treating Chinese patients using western psychotherapy techniques and methods. In the first instance we need to look at the real problem in China of mental health breakdown and cultural boundaries to the treatment of clients presenting themselves for counselling.


The crisis in mental health in China is reaching epidemic proportions, in one report in the Shenzhen area one in five adults is reporting mental health problems. (China Daily 2007). In a survey in this city of 7,000 respondents who were 18 or above, 21{15aeb35eec840799df247626cfa6821cb9499241e90aba7a245c8546144fd8f4} said they had experienced a problem and 17{15aeb35eec840799df247626cfa6821cb9499241e90aba7a245c8546144fd8f4} that they were currently suffering from depression or stress related problems. In Guangzhou, extramarital affairs are running at the rate of 52{15aeb35eec840799df247626cfa6821cb9499241e90aba7a245c8546144fd8f4} causing many women to fear for their futures in a society where they submit to men’s dominance. (China Daily 2007). Of these only 10{15aeb35eec840799df247626cfa6821cb9499241e90aba7a245c8546144fd8f4} sort some sort of support from mental health professionals. Hospitals report that on average they only have about 10{15aeb35eec840799df247626cfa6821cb9499241e90aba7a245c8546144fd8f4} of the psychiatrists they actually need to cope and in Shenzhen they have 400 licensed counsellors most of which have little real experience or professional training. In the capital Beijing, 20{15aeb35eec840799df247626cfa6821cb9499241e90aba7a245c8546144fd8f4} of residents were considered to be sub-healthy in mental states! It is estimated that at any one time 130,000 serious psychiatric patients are wondering the city streets uncared for. The purpose of this paper is to look at the implications of therapeutic practice for the Western therapists in China and the training of new Chinese therapists to reach Western standards. Suicide amongst the young in China is the highest in the world, 52{15aeb35eec840799df247626cfa6821cb9499241e90aba7a245c8546144fd8f4} of all deaths occur in China as compared to the other 48{15aeb35eec840799df247626cfa6821cb9499241e90aba7a245c8546144fd8f4} in the rest of the world combined.

The Chinese Client – A Profile:

What makes up the thinking processes in the typical Chinese patient? For the therapist the first step is to understand some fundamental aspects of the national character. I have listed some of the more obvious ones and shall discuss them separately.

1. Face

2. Relationships

3. Drivers (Motivation)

4. Family (Fealty)

5. Custom & Tradition

6. One Child Policy (The legacy)

7. Clash of Cultures

8. Education (Expectations)

9. Work Ethic

10. Hidden Worlds

1. Face:

The first thing for the Western therapist has to understand is the client before them is not going to tell you the truth. This is not uncommon even amongst more free-thinking Western patients. However for the Chinese this goes deeper. Face means not being put in a position of shame. In the culture as a whole the taboo of mental illness is high. People will not admit to anyone that a family member has a problem of this kind or that they themselves are mentally unhealthy. The awareness of shame is very high and controls the daily aspects of business, government and personal behaviour. A man whose wife is cheating on him will simply complain of headaches to the doctor and wishes some medicine to help him. To admit that this is in fact stress would be to admit weakness of character – so in turn a physical complaint is easier to cope with. So how does this effect therapy? First even if you can get the person into a therapeutic relationship they will stay in denial to help not lose face in front of you. This then requires the therapist to begin sessions with an open honest approach to talking about shame and face directly to the patient. They will instantly understand your meaning and seek a non-judgemental attitude from the therapist in return. It still may take several sessions for the client to trust the therapist before a real exchange of information as to the true nature of their problems comes forth.

2. Relationship:

In China this word does not quite have the same meaning as the West. It means “favour”, a relationship is about what you do for each other. Often it is for advantage, a person “does a favour” for you. In return at some future point you will return that favour – often many times bigger than the original favour. This system of relationships works through government, business and daily life. It is not to be confused with corruption although this often takes place as a by-product of a low moral outlook on aspects of daily life. The student is failing, his paper is not good enough, the father makes a generous contribution to the University building program, the boys papers become better and marked higher. In the West this is corruption, in China just relationships being confirmed. In the future the student may become successful – he in turn one day is asked to contribute – he will feel under obligation to do so. It is these on-going obligations that cause much of the unhappiness in China. In England we have the old-boys-network, the inside practice of people from Oxford or Cambridge University giving jobs and promotion to those who like them went to the right places. It is no more than privilege and corruption; it is why 80{15aeb35eec840799df247626cfa6821cb9499241e90aba7a245c8546144fd8f4} of government jobs go to students from these two places. In China they do not have the prestigious University tradition but have this form of relationships born out of favour and return.

3. Drivers (Motivation)

In the United States success is so important to material wealth that much of the cultures of movies for example are about the easy route to riches – i.e. theft. It is endemic in Western culture that the modern American Dream is beyond most people who in real life become just another cog in the wheel. In the West this had led to apathy and depression about life in general. In China materialism is alive and well at all levels of society. Parents are driven to push their one child (in most cases) to the pinnacle of educational success. Even in this means a loss of childhood, lack of imaginative growth and strict conformity to a cloning operation called – school. English speaking is seen as the crucial aspect of the edge required to succeed in the work place of the future in a capital global market. However the speed of change in China has left many bewildered and lost. Unable to compete or even understand the social change upon them. The young are driven by a need for materialism and money, anything less is a failure. The respect for the elderly and learning of higher ideals and philosophy are almost relics to modern thinking processes. In this atmosphere of fast paced change and a driven mind for success the seeds of Western apathy are being sown. As the young meet failure and frustration they will breakdown. The high expectations of parents and government are leading to a suicide epidemic.

4. Family (Fealty)

Family has always been strong in China and there is no room for Western style independence of thinking or spirit. From an early age family loyalty is seen as crucial to survival in the future. One generation relying on the next for support in old age or infirmity. However under the one-child policy this burden has become ten-fold in a lack of security amongst the elderly and the young alike. In the past maybe five or six children would have shared the burden on family but today that is no longer true all single children feel the need to make a success of life in order to care for the parents later. Parents put enormous pressure on this one child from an early age to conform to education, moral responsibility (but only in the family) and the work ethic. Cousins become brothers and sisters but cannot share the parental burden as each has the same. However some social support does come from this area. One last point is gender. Girls are not appreciated in the family in the same way boys are. Although both genders tend to be over-indulged and spoiled in youth, the boys are definitely given more lee-way and mothers dotage. Although this may be true of mothers world-wide in China it is almost frightening how mothers smother the boys with maternal love. In the future most of these boys when looking for a future wife – want to marry their mother – a girl needs to be completely controlled in order to fulfil the boy’s childlike behaviour. It is why most women in China have unhappy marriages. (See separate paper for this topic).

5. Custom & Tradition:

You often find the Chinese when in doubt or have no ready answer for why something is done or happens tell you it is the custom or traditional way. This is many cases is clear nonsense. A custom is merely a habit, often from a not to distant past, that has become a social norm simply because at one point in time it made sense. These so called customs often continue as if they were a proven fact of life and not a past expedient to some social desirable behaviour. In Cognitive Behavioural Therapy we are taught to challenge these assumptions by asking constantly for evidence for the beliefs that a person holds as sacrosanct. This form of challenge helps breakdown old thinking and replace with the new ideas or even ideology. So what about traditions, can we see a difference? Well a custom from tradition may have a historical reason again for happening, such as ancestor worship. Once a year the Chinese sweep the graves of the family dead, burn paper money for them and burn incense to ward off evil spirits around the graveside. While most modern Chinese may scoff at the practice as old suspicion them never-the-less continue to every year follow the tradition. It was also traditional to build houses to a certain way for the protection from evil and good karma. However this tradition has almost disappeared under the race for profit in the construction industry and many other commercial enterprises. In other words a tradition only lasts while it is useful. In order to understand the mind of the Chinese client remember what they do and what they believe and how they think may not match to what they say.

6. One Child Policy:

I have already touched upon this in family so do not need here to repeat myself. However we must understand the implications of this decision by the political regime to see how it affects or did affect the people’s experience. First the rule is not rigid, you can have more children but the state only recognises the first for state benefits and schooling freedom. Any other children become a financial burden directly to the parents. Also in the past under the auspices of the government many forced abortions were carried out by untrained midwives and in filthy conditions with little or no after-care. Many women were sterilised at the same time as giving birth or after the abortion. Boy was favoured over girls and if a girl was suspected in the first pregnancy it was self-aborted under family pressure often. On a positive note did China have much choice? Over-populated, not enough food for self governing, too many unskilled workers who are not needed in an emerging capitalist society, shrinking agriculture and streamlining of production. All leading to a massive unemployment and in some cases starvation and poverty. While the West may talk of human rights – your right to choose to give birth – practical survival overrides this consideration in the minds of most Chinese people.

7. Clash of Cultures:

In modern China on every street is a KFC, McDonald or other mass market poor quality style outlets. They take away a traditional diet of high vegetable consumption with a low meat diet. In return the young are now enticed to a high fat, high sugar unhealthy but trendy diet of rubbish food. You can already see the problems of anorexia to obesity in the children. The future of mental health problems such as Obsessive Compulsive Disorder in the making around every corner. The increase in cars and traffic in China is explosive – the worlds leading consumer of modern vehicles. Pollution is every where and unregulated industries dumping and polluting on a regular basis. China cannot blame the West for this situation but look to its own failings in controlling there unhealthy changes.

8. Education:

The system of education in China is very different from the West. It is based on memory learning and strict examination system of no-failure. Cheating and plagiarism is rife and supported often by the teachers who are criticised for any failures. In this atmosphere reigns corruption and favour (relationships). You do not have to look far to see a missing childhood full of extra lessons and homework. The children of China are simply over-stressed and have a complete lack of creative imagination. They are not taught to think merely to follow. Karl Marx predicted that schools would manufacture the right qualities for the work place in conformity and strict adherence to authority figures. China does this best. Most students cannot think critically about anything, they have to have complete instructions in a task or cannot perform it. This is the sad legacy of the education system. No wonder most wealthy Chinese groom their one child to go to an overseas University if they can afford it.

9. Work Ethic:

It is an interesting aspect of Chinese society that everything is done slowly, walking, thinking, working, except one modern aspect driving where here they become insane with speed. The first thing most Westerners notice in the streets is how slow everyone walks. You spend you time trying desperately trying to get around them but find they also wander as the they walk and so fail to walk in a straight line. Not many years ago China was almost 90{15aeb35eec840799df247626cfa6821cb9499241e90aba7a245c8546144fd8f4} agricultural and farming methods were primitive. As they have moved into the industrial society the leisurely way of working the land has arrived with them. The 11.30 lunch time – which often includes a sleep – the return to work at 2pm. The start time of 7 and finish at 7, often waiting until the boss leaves before venturing to collect your coat and leave the office. However this does not mean they are working hard just because they are working long hours. In an investigation into work stress (see separate paper) it was found that many office workers spent many parts of the day surfing the internet and chatting on line. In fact despite the long hours they are less productive than the 9 until 5 worker in the West. Management is often by consensus or dictatorial. In other areas, “leaders” control every aspect of the work and much time is spent “talking” rather than doing. The relationship at work is what is seen as important; promotion comes through the system of favours not hard work or achievement. Just like in the West we may say, it is who you know not what you know. Another aspect of China is the quantity of people to do the work. Most companies employ far more staff than is actually required if everyone actually worked to their full capacity. You only have to go into a store to see staff often out-number the customers and more often than not actually get in your way of buying something.

10 Hidden Worlds:

In this last point I want to talk about the word “subtly” One Chinese girl reported to me that how could I possible understand the Chinese psyche when I had not the concept of the subtly of the non-verbal behaviour and listening in English will miss many of the Chinese languages peculiarities of expression. I had to agree. However I have never in three years of treating clients with therapy found this to be a serious problem in communication. It is much more important to be culturally aware and non-judgemental than worry if you miss something. After all it is for the client to come to an understanding of self in order to cope with life’s problems and not the therapist.

In Summery:

The article has tried to look at some of the aspects of the Chinese client in respect to their thought processes and the environment in which they perform social interaction. Much of the writing is based on three years of personal observation by a Western psychologist specialising in clinical and counselling work. I have to admit to much generalisation and as in the West degrees from the social norm will always exist and to be found in individuals. As a guide to new therapists in cultural awareness I hope I have achieved some degree of understanding and tolerance.

Professor Stephen F. Myler PhD (Psych)

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