Psychiatry Comes to China: Will You?

Confucius say: If three of us travel together, I will find two teachers.

The American visitor to China will likely not be surprised by seeing McDonalds here and there, as the franchise has become global. It may be a bit more surprising to see all the Kentucky Fried Chickens, with Colonel Sanders looming and smiling overhead. Could one of the reasons be that if you would take off Colonel Sanders’ glasses, he looks a lot like Confucius and some beloved Chinese emperors? Maybe even Freud would have looked more like that if he ate a lot of Kentucky Fried Chicken and gained weight!

Now, after the inroads of this “Western” food for the stomach, has come some “Western” food for the mind in the form of 20th century psychiatry. Will it be as good a fit for China? Or, perhaps, for you?

If you’re getting thoroughly fed up with the obstacles to practicing high quality and reasonably reimbursed psychiatry in the USA nowadays, you might want to think about relocating to China. That, too, may seem surprising, given that psychiatry in China has traditionally been most known for its great wall of stigma, its very limited resources for care, and its suspected use of psychiatric hospitalization for political prisoners. Although world psychiatry has shown some concern about such abuse, response from the USA has been quite muted, especially compared to the prior uproar about psychiatric abuse in the former Soviet Union.

However, as a recent visit to China confirmed (organized superbly by Asia Transpacific Journeys), psychiatry is beginning to enter a developmental spurt like so many other services and businesses. The first verification is at airport newsstands in Shanghai and Xi’an. Right out in front, in the first row of magazines that catch your eye, is one called Psychologies. Most of the writing is in Chinese, but the cover picture is of Jennifer Aniston. That cultural discontinuity is not unusual, as you often see a Caucasian woman in advertisements where the Chinese seem to want to replicate the USA, especially in fashion.

I don’t read Chinese so I didn’t buy the magazine, but there were a few English words on the cover describing the feature articles. One was on “Couples”-- another was on “Parenting.” As it turns out, that proved to make perfect psychological sense to me. The one child policy, coupled with rapid economic growth, seems to have made each child (and especially still boys) precious. These children are often called “Princelings,” and you could see them in action in any mall we visited. If a boy loudly demanded a toy, this desire was often fulfilled. Young children had slits in the back of their pants instead of diapers--a different beginning to toilet training.

Given these observations, would you be surprised to find out that Freud is gaining a foothold in China? As psychoanalysis and related therapies are slipping in the USA, psychoanalysts from the US are beginning to train a cadre of interested clinicians in China. How else to help the anticipated increase in the prevalence of narcissistic personality traits and disorders as the next generation of children grows up and individuality becomes ever more valued in China? Self-psychologists, expert in Kohut, should be especially useful, as well as child psychiatrists if there is an opportunity to work on prevention.

The current official Chinese slogan, astonishing for its capitalism, is “Socialism with Chinese Characteristics.” Similarly, we may end up having a “Psychiatry with Chinese Characteristics.” And, here, I don’t mean giving out fortune cookies with sage advice from psychiatrists instead of Confucius.

Besides the noted variation in toilet training, there are other cultural variations that may be symbolic of psychosexual development that should be fascinating to psychoanalysts. Is the popular habit of clearing one’s throat by spitting out phlegm a kind of cultural oral compulsion? Is the Hospital for Anal and Intestinal Diseases a different reflection of the next stage? Maybe the public handling of toilet training is responsible for shame being more common than guilt. Of course, like other urban areas in the world, Shanghai and other large cities are notable for the ubiquitous phallic competition of ever taller buildings, but what about a predilection for the dish “cattle penis with garlic”? That makes eating snake seem mundane by comparison.

In some ways, visiting a big city in China is like viewing yourself, and viewing America, in a funhouse mirror of empathy: funny, flattering, and/or frightening. One obvious alteration is the language. If one doesn’t know or learn the local Chinese dialect, or the patient doesn’t know English, the “talking cure” will be a challenge. Then again, the talk in psychoanalysis is mainly by the patient, so that obstacle may not be insurmountable.

The same may be true on the other end of the treatment menu--ie, brief medication visits. Indeed, for over a decade, leaders in Chinese psychiatry have been consulting with experts from the US to develop algorithms and guidelines. The most recent is for PTSD. If the limited outpatient services expand, more psychopharmacologists will be needed.

The one child policy, coupled with movement of the young from the countryside to the cities for jobs, will inevitably take its toll on the elderly. A likely increase in grief and depression will call for geriatric psychiatrists.

The stress young adults are encountering in the cities for success in increasing. Hypnotherapists are becoming especially popular and here, too, a whole lot of language skills may not be necessary. Office workers are starting to visit a hypnotherapist at lunch or after work. While the usual session might now cost $75-150 US dollars, a well-known expert can now charge upwards of $900 a session! And, just think. Right now you don’t need any special training or license to practice hypnotherapy in China.

As the divorce rate is rising, often instigated by the woman, more language proficiency will be needed for marital and family therapists. Those who are cognitive and behavioral therapists may be a particularly good cultural fit, as the Chinese are used to positive reframing slogans from Confucius to Mao. A new one I heard was “Happiness Will Create Harmony.” English is often bastardized in fascinating and simple ways. Take the admonishments at the World’s Expo in Shanghai: “No Noising” and “No Challenging.” Of course, these slogans can also be negatively reframed as state propaganda.

Besides using CBT, there probably is an untapped market for EMDR and other treatments for PTSD. Those who survived the trauma of the “Cultural Revolution” from 1966-1976, and who are still alive, must have some psychological scars. Traumatized dissidents who have been jailed and subject to “enhanced interrogation techniques” also may need such help.

For these and other outcasts from Chinese society, suicidologists can be important. The suicide rate is rising, especially among women in rural areas, where there are no longer any “barefoot doctors” to offer even psychosocial support. Overall, suicide is the leading cause of death in those 15-34 years old.

Cultural psychiatrists may be especially attracted to work in China. The country has a striking history of glory, scholarship, and invention, only to be disrupted by the Opium and, later, civil wars. Especially sensitive to humiliation, the country seems to be bursting with a new sense of nationalism and hubris. One wonders how much leftover anger remains toward prior enemies? They don’t see themselves as “Eastern” or even like the “Western” given name of China. The Chinese name for their country has traditionally been the “Middle Kingdom,” or the center of the world. Within China, the Han Chinese make up about 95% of the population, but there are more than 50 other ethnic minority groups, with their own folk values and healing traditions.

The Marxist history of modern China may be of particular interest to so-called radical psychiatrists. Similarly, the unique brand of communism that has evolved may intrigue political psychiatrists. The challenge is that there is not any single leader to (pseudo) analyze, as has been done with Hitler, Stalin, Mao, or Saddam Hussein. The ruling oligarchy may call for more expertise in small groups from group psychotherapists. Impressive is how quickly the ruling group gets things done, in contrast to the political gridlock and group conflicts between our two main political parties.

The question of whether China is playing “mind games” with the world and its citizens, a kind of combined “1984” and “Brave New world”, should interest not only politically-oriented psychiatrists, but also behavioral psychologists. Witness the positive reinforcements of “1984” pep talk and the sickle of “A Brave New World” of economic riches. For the youth, the Communist party is now even sponsoring rock festivals, where one can wear anti-government T-shirts and hear critical lyrics, although the words are in English that most attendees can’t understand. When positive reinforcement doesn’t work, the negative reinforcement of the hammer comes down, such as in Internet censoring.

If the long-delayed and revised law on mental hygiene ever gets passes, community psychiatrists will be needed. There are fragments of recovery to build on, including the Crazy Bakery (with a name that tries to paradoxically turn stigma on its head), which produces baked goods cooked and sold by the consumers of commissaries and schools.

As I finished my (psychological) journey in China, the city streets suggested two other specialists. Whereas opium is no longer problematic--that is, unless you believe like Freud that the rising religious freedom is a kind of opium for the masses-- the numerous bars and cigarette smokers indicate alcohol and tobacco addictive problems for addictionologists. A new challenge exists in some selected locations like Xiangtan. Starting at ten years old, 80% of residents chew the euphoric-inducing “bingling, called the betel nut in other parts of the world.

The apocalyptic air as far as one can see is a constant reminder of future tragedy. How appropriate, then, that the World’s Expo in Shanghai had urban sustainability as its theme. This calls for the vision of ecopsychiatrists.

The one psychiatry specialty that is unlikely to be on the plate anytime soon is forensic psychiatry. The Chinese government does not seem to want dueling psychiatrists in its courtrooms.

I must qualify all of these impressions, as they must be viewed as suspect as the subtitle of the popular travel journey book “Lost on Planet China: One Man’s Attempt to Understand the World’s Most Mystifying Nation” by J. Maarten. This is the one book I’d recommend to anyone going to China or to anyone trying to get a sense of what it would be like to do so. As in psychoanalysis, perception can be more important than reality. Our Chinese tour guide might say one thing, while our American tour guide would later say another. Fog or smog?

How psychiatry will influence China and the “inscrutable” Chinese will take time to tell. But if you do decide to visit, or stay, it may be best to come to China’s door with the attitude of a child on Halloween: trick or treat!?

[The opening photo is entitled "Staring at Confucius."]