BY DAPHNE FONG
In 2009, one-in-thirteen Chinese citizens experienced mental illness. That same year, the World Health Organization (WHO) reported that despite mental illness’ position as the number one financial burden on the Chinese healthcare system, only 5% of those afflicted have received professional help.
In China, there are 1.5 psychiatrists and 2.2 nurses for every 100,000 people. Worldwide, there are four psychiatrists and thirteen nurses for every 100,000 people. In short, the current situation is far from perfect.
Mental health has always played a prominent role in my life, whether through interactions with friends or my own personal struggles. I know what my friends think about it and I know what I think about it. But I can’t speak for the rest of my surrounding community.
As a half-Chinese international student living in Shanghai, the most populated city in the world, I wanted to understand the Chinese approach to mental illness beyond the statistics.
As a whole, the Chinese healthcare system is deeply stratified. A villager with a serious illness faces a dizzying hierarchy of institutions. This first includes a local clinic, then a county hospital, then a provincial hospital, and then a specialized national clinic in a major city, all necessary to receive care.
Due to China’s massive population, overcrowding plagues the healthcare system, allowing widespread corruption to become the norm. Physicians are underpaid and therefore reliant on supplemental income from bribes that come in little red packets, or “hongbao.”
Violence is also entrenched in the Chinese healthcare system. The Guardian reported that since 2002, “stabbings and mob-style attacks have risen 23% a year on average… A typical hospital suffers one such incident every two weeks.”
And while China provides almost universal health insurance coverage, less than 15% of the population receive insurance subsidies for psychiatric disorders.
In 2012, the country passed a mental health law to regulate mental health services and improve the transparency of patient treatment, but we still have a long road ahead. The estimated total disability adjusted life years (DALYs) of ten of the most prominent psychiatric disorders in China was over 253 million years, equivalent to a loss of 432 billion dollars.
To learn more about mental health, I spoke with Mr. Patrick Love, a former clinical child and family counselor currently working as a high school counselor in Shanghai. Instead of defining mental health as merely a state of well-being, he elaborated, stating that it is “the ability to worship… you are free to behave in the way that you are most meant to be behaving in.”
Mental illness, in his view, takes life out of one’s control. Just as a fever limits our ability to function, mental illnesses can prevent people from reaching their full potential. People cannot simply rely on medication to achieve recovery.
As Mr. Love told me, anxiety, for example, is “not just a chemical experience I’m having in my body, it’s really psychologically how I’m experiencing reality. I can take a pill to stop my anxiety, but… I’m only medically addressing it, I’m not relationally addressing it.” Oftentimes, both medicine and therapy are needed to alleviate the burdens of a mental illness. If we believe we, as humans, are inexplicably complex creatures, we must also accept that diseases of our minds are just as complicated.
Discussions of mental health are further challenged by the difficulty of defining “illness.” Mr. Love offered this insight: “I think that the idea of anxiety or depression is that it’s on a scale or a spectrum, so everyone has anxiety, everyone has depression, everyone has a lot of those conditions that we deal with.”
The idea that mental illness is on a continuum, he argued, can be reassuring for people who do not match every symptom for a disorder. This understanding can also encourage people to seek help sooner.
A 2010 study by Amelia Gulliver for the Centre for Mental Health Research at the Australian National University revealed that only “18 to 34% of young people with high levels of depression or anxiety symptoms seek professional help,” due to barriers such as difficulty identifying the symptoms of mental illnesses and a desire for self-reliance. People’s bodies and minds react in different ways, and one person’s illness may not be as severe as another’s, but once we realize that we are not able to reach our full capacity, we should seek help. As the organization Mental Health America puts it, “Why wait until you’re really suffering?”
This is where Western and Eastern perspectives deviate.
“In urban areas with young professionals, the idea of going to a counselor is so normal and so accepted. When I was living in Seattle, I would have friends that were going to their own personal counselor, and they were going to marriage counselors at the same time, and the people who weren’t doing those things were feeling disadvantaged,” explained Mr. Love. “To the other side of it would be where people are denying psychological conditions and there’s too much shame and repression around it.”
To hear more about “the other side,” as Mr. Love articulated, I turned to a woman who has lived all of her life between rural and urban China — Jiaxing, Guangdong, Hong Kong, and Shanghai — in both poverty and relative wealth: my mother.
When asked about differences in public perception of mental illness across China, my mother replied, “In mainland China, not really, but in Hong Kong, yes. Hong Kong is a very busy city, and everybody is very focused on their own problems… even between friends, there is less care, because… everybody is so busy that they don’t have enough time to care about other people.”
Without rest and reflection, the mounting stressors of a fast-paced environment can exacerbate mental illnesses. Certainly, Hong Kong is becoming increasingly separate from China. However, Hong Kong’s increasing Westernization does not bring about the same Western care.
People with severe mental illnesses are usually hidden away, which is perhaps related to traditional Asian notions of losing face or familial shame. While my mother acknowledged that humiliation could be a possible reason for repression, she also pointed out that a typical Chinese family would want to shield their afflicted family members because they don’t want “other people to look down on them… They want to protect you.”
When I asked why she thought the Chinese and Americans perceived mental illnesses differently, she said, “Before, China was incredibly poor. Just surviving was enough… Having enough to eat would make them very happy already.” Having been parented by two impoverished teachers under the rule of Mao Ze Dong, my mother has incredible insight into the mentality of poverty.
She believes that it is only after people have enough material things that they begin “…looking at other things. Once they feel empty and unsatisfied, they become depressed.”
Interestingly, upward trends in wealth may be correlated with the increasing number of mental health problems in China. Between 2003 to 2008 alone, the incidence of mental illnesses, especially stress-related disorders, increased by over 50%.
Her understanding of China’s approach to mental illness recalls Abraham Maslow’s hierarchy of needs. Once fundamental, physiological needs are satisfied, people can begin to seek higher things, such as love and esteem. If those higher needs are not met, though they are not necessary for survival, they can cause extreme unhappiness. With more time to foster desires beyond survival needs, it is no wonder that the West has come further in the realm of mental health, compared to China.
Dr. Alice Fok-Trela, a psychologist at the Parkway Health Medical Center, has worked in Los Angeles, Vancouver, and now, Shanghai. She suggested that stigmas may persist because “in general, people are wary of people who are not like themselves… people don’t like the idea of not being able to control themselves or their own minds… If someone was like, ‘oh, I got a cold,’ people will be like, ‘that’s no big deal. I don’t mind getting a cold.’ But you never hear someone saying, ‘I don’t mind getting schizophrenia’ or ‘I don’t mind getting depression.'”
According to Dr. Fok-Trela, people want to feel in control and in charge of themselves. The fact that an illness of the mind can prevent that from happening is often a new and difficult idea to accept.
Although treatment for mental illnesses is virtually nonexistent in rural China, as only 2.35% of the country’s health budget is allocated towards mental health, urban dwellers can find help, albeit limited, in centers such as the Shanghai Mental Health Center. As well as being a research facility affiliated with universities such as Shanghai Jiao Tong University, the Center offers patients psychotherapy and medication.
Dr. Fok-Trela describes the Shanghai Mental Health Center as “a throwback to the 1940s… the way they deal with mental illness is the way we dealt with it in Canada and the US in the 1940s.” Instead of using chemical restraints, the Chinese “medicate [patients] and physically chain or strap them down if they’re violent or dangerous to themselves.”
One of the most shocking revelations was about the prevalence of electroconvulsive therapy (ECT). In Canada, to receive an ECT session, “you have to apply to an external government source, and three doctors have to review your whole medical file before determining whether or not to grant permission to do ECT sessions,” says Dr. Fok-Trela. “In China, everybody gets ECT. Standard treatment when you arrive at the Shanghai Mental Health Center, for whatever reason, no matter what your diagnosis is, ten sessions of ECT.”
That people who do not suffer from severe depression or catatonia receive this sort of undifferentiated treatment is worrisome. Though Dr. Fok-Trela has not worked at the Shanghai Mental Health Center, she has a friend who works there as a therapist, and often supervises his cases. Despite the fact that they have seen multiple misdiagnoses from psychiatrists, they cannot challenge the decisions because “therapists are nobody in China.”
Not only are dangerous bolts of electric currents shooting through people’s brains, but patients are also misunderstanding their illnesses, which makes it even harder to get better.
Dr. Chelina Wang, who has worked as a teacher and a nurse in China and the United States, currently serves in Health Promotion at the Shanghai branch of New York University. She is involved in both the physical and mental well-being of students by teaching students how to properly take care of themselves. Dr. Wang believes mental health may be “even more important than physical health, because a surgeon can open your body up to remove your cancer, but they cannot open your brain to remove your depression.”
In short, there is no quick fix.
Treatment requires effort from both the patient and the doctor, and the fight against mental illness can potentially be life-long. Patients must find the inner strength to continue treatment every single day.
Dr. Wang believes that the key to overcoming stigmas in China is “to improve society’s health literacy about mental health… the discrimination is based on [the fact that the Chinese] don’t have enough education about this subject. We actually improved a lot, but it takes time. It takes time to improve everybody’s awareness about the situation.”
It does take time to develop, especially because China is still a developing country. However, China is increasingly turning its focus towards the well-being of each citizen. Although Chinese citizens are often not ready to talk openly about mental health, awareness is growing.
Before, everyone with a mental illness was just labeled crazy, or “feng,” but as my mother noted, “there is a term for depression now. ‘You yu zheng.’ People are starting to understand.”
Daphne Fong is the deputy editor of Beautiful Minds Magazine. Art by Daphne Fong.