MENTAL HEALTH China's sane solution

Chinese puzzle
There is very little mental illness in China. This is not propaganda
from the Communist Central Committee, but the conclusion of independent
research by two American social scientists. Anuradha Vittachi looks at their findings.

A family doctor in the West is likely to wish, despairingly, that she had trained as a counsellor rather than a medical practitioner, since at least half her patients come to her for mental and emotional support. But a Chinese doctor may see no more than one or two patients a day suffering from mental distress.

It hasn’t always been so. In the first half of this century China was known as ‘the sick man of Asia’, with both physical and mental diseases rampant. Tertiary syphilis was a major cause of mental illness. Opium addiction was another. Then there was the traumatising effect of the Sino-Japanese War in the late 1 930s, plus the usual ragbag of unhappiness and confusion that psychiatrists give labels like ‘depression’ or ‘schizophrenia’.

But now, amazingly, China appears to have no cases of tertiary syphilis; not ‘fewer cases’ but none. And it is claimed that China is the first nation in the world to become free of drug addiction. So VDrelated and drug-related mental illnesses are no longer an issue. And the same means to be true of other mental illnesses, which afflict far fewer people than in the West - about six in a thousand people (compared to about 150 in a thousand) of whom only two to four are schizophrenics, about one-fifth of the incidence of schizophrenia in the West.

These claims are made in a new American study, The Minds of the Chinese People* , by psychiatrist Paul Lowinger and psychologist Martha Livingston. Their findings suggest that maintaining a strong relationship between the individual and his or her social environment seems to be the key to mental health in the new China.

In the West privacy is guarded as a treasure but loneliness is epidemic. The individual hangs on to his sanity in private desperation, whatever the pressures. Behind doors depression cracks hearts and blurs minds - discreetly. But in China it’s difficult to be private in a tiny apartment sleeping four to a room. But it is also difficult to be lonely.

Every apartment block has its ‘courtyard committee’ and every street has a neighbourhood committee. They aren’t there just to check that the cisterns are working and to prevent graffiti on the stairs. They involve themselves in pastoral care. If children get anxious because their parents keep quarrelling, they may tum to the committee for help. Friends from the committee will then come along to intervene (perhaps we would call it ‘interfere’) by talking first to each parent alone; then both together; and then perhaps to the whole family, children and grandparents included, if that seems necessary.

In the West, this system is known as Family Therapy. It’s expensive and trendy - daunting on both counts. But in China it’s free and ordinary.

Neighbourhood committees support families in practical ways, too; ways that have widespread consequences for mental health. If a mother with a pre-school-age child wants to go out to work, she can easily find a grandmother in her block eager to work as a child minder. One woman’s need is met by another’s and both women can be productively occupied.

Mental diseases associated with old age - involutional melancholia (depression in layman’s terms), for example, or senile psychosis - are almost non-existent in China, according to the Lowinger-Livingston study. Where the old are active and feel themselves to be useful members of the community, they stay as mentally stable as anyone else.

These intimate and resilient networks can prevent or resolve problems that the large, impersonal welfare structures of the West are simply too clumsy to handle. Take, for example, the case of the old man who was knocked over by a student on a bicycle. The hospital bills were taken care of by the State, but a problem remained. The old man was left too frail to cope with his household chores. So the neighbourhood committee decided the boy should help with the chores till the old man was well: a constructive, cooperative decision that took care, not only of the practical needs of the old man, but defused the resentment he might otherwise have suffered.

This attitude of constructive reconciliation seems to be a key component of the Chinese approach. In the West the tendency is the opposite: less-then-well members of society are pushed out of sight and out of mind. And even though ‘community care’ is now fashionable, it usually just means that inadequate clinical care is exchanged for seedy hostel care.

In China, on the other hand, social policy supports the re-integration of the mentally ill from several sides. If you have to go into hospital, your job will be held open for you: not for a few weeks but for months - and on full pay. If your illness goes on for years, you will still get around 70 per cent of your salary. And when you feel well enough to return to work, your doctor may talk to your colleagues to check that the job you resume won’t be too taxing. Most important of all, s/he will emphasise your need for a warm welcome, and the assurance that being mentally ill is not something to be ashamed of. On the contrary: being well enough to help rebuild China once more is something to celebrate.

As with physical health care, the emphasis in China is on prevention as well as cure. Each local region operates a mass mental illness prevention and treatment programme. In Shanghai, for example, some cotton-weaving factories have established a mental health care unit, including a sheltered work shop for patients and services for their families. This kind of support greatly reduces the recurrence rate of mental illness. One exmental patient from China described the new attitude like this: ‘In the old society I would have disappeared: in the new society I can recover.’

Inside the hospital, too, the emphasis is firmly on getting back into the real world. A list of rules pinned up on a hospital wall begins: ‘1. Read the newspaper every day, and study Marx, Lenin and Mao thought.’

Lobotomies have been banned in China since the Great Leap Forward. The use of electroconvulsive treatment was banned too, but has since been renewed in rare cases. And drugs like chlorpromazine are used in much smaller dosages than in the West, because they are used in conjunction with acupuncture, which has a powerful impact of its own. The purpose of drug therapy, too, is different: it is not used to drown the patient’s mind into a soggy stupor, but to dampen excitability down sufficiently for the doctors to discuss with the patient the nature of his or her illness and the means by which he can climb back to health.

And theory is placed squarely within a political perspective. Says psychiatrist Wu Chen-I, ‘If you don’t believe you will be able to make changes, it’s not easy to overcome the difficulties you must face. Patients need to be armed with revolutionary optimism.' Patients are encouraged to regain confidence and control so that they can once more contribute to rebuilding China - the larger purpose which gives meaning to individual lives.

In the West, psychiatrists feel obliged to maintain the fiction that the treatment they offer is devoid of political ideology. Mental illness resides within the patient - somehow his or her ‘wires have got crossed’; and the psychiatrist, with kindly but professional detachment, has to do something to uncross those wires.

In China, a psyciatrist’s politics aren’t a matter for concealment: they are a source of inspiration. Mao’s writings - On Contradictions and Where do correct ideas come from? - are looked upon as essential psychiatric tools. For Mao, an individual’s mental problems don’t exist in isolation: they reflect conflicts between that individual and his or her environment. The patient’s circumstances are not an ‘extra’ factor contributing to his or her breakdown, but are an intrinsic part of the illness.

The dramatic eradication of VD-related and opium-related mental illness could not have taken place without the political beliefs underlying the revolution. Before Liberation, the usual punitive methods were employed: drug addicts were even executed as a deterrent. But addiction remained rife. After Liberation, major pushers were executed, but minor pushers and addicts were ‘re-integrated’ into Chinese society. And, like exalcoholics in the West, they became spokesmen warning against the bad old ways of the bad old days.

That’s the point. The blame wasn’t placed on the people for their anti-social behaviour, but on the anti-social political structure that had brought such behaviour about. To have syphilis was presented as not a matter for personal shame: it was a relic of the old society. Shame only lay in clinging to the past. Self-respect lay in coming forward to be cured and helping to build a new, clean and healthy China.

*The Minds of the Chinese People: Mental Health in New China
by Martha Livingston and Paul Lowinger, MD. Prentice-Hall Inc,
Englewood Cliffs, New Jersey 07632 $16.95 (hardback).