Tensions in Mental Health Care in China: An Interview with Zhiying Ma

MIA’s Rebecca Troeger interviews medical anthropologist Zhiying Ma about mental health care in China today, including involuntary hospitalization, tensions between Western psychiatry and more holistic and socially-oriented local frameworks, and opportunities to rethink paradigms of care. This piece was first published by Mad in America on September 23rd, 2019 and can be accessed here.

Zhiying Ma is a cultural and medical anthropologist and disability studies scholar whose work explores the experiences and rights of those receiving mental health services in China. Her current book project, Intimate Institutions: Governance and Care Under the Mental Health Legal Reform in Contemporary China, investigates how the Chinese state has placed paternalistic responsibilities on families through their role in the care of those diagnosed with serious mental illnesses, in part through the practice of involuntary hospitalization.

Ma came to earn a Ph.D. in Anthropology after questioning psychology’s overemphasis on decontextualized human behavior while majoring in the subject as an undergraduate. She found that anthropology offered the more humanistic and socially oriented lens she was looking for, and this perspective informs her current work.

Ma collaborates with psychiatrists, social workers, human rights activists, lawmakers, families, and those with lived experience to not only conduct research but also to take part in China’s ongoing mental health policy discussions and push for community-based, socially inclusive care that is not simply “care as usual.”

Rebecca Troeger: Could you tell us about your current book project? What has stood out to you as you have been sitting down to write the book?

Zhiying Ma: My current project is about how families in China care for and manage people diagnosed with serious mental illnesses, and how psychiatric institutions and the country’s recent mental health legal reforms have shaped those family practices. It is based on over 30 months of fieldwork in psychiatric hospitals, community mental health teams, social work centers, and human rights agencies. I also spoke with lawmakers and leading psychiatrists about China’s mental health legal reform.

My main argument in the book is that the prevalence of involuntary hospitalization is reflective of what I call biopolitical paternalism in the country. That is, the state is using a discourse of paternalism, the practice of involuntary hospitalization and the demand for patient management to demonstrate its paternalistic care for its population.

At the same time, it also devolves paternalistic responsibility to patients’ families. The subject of paternalism is the patient, who is seen as a subject carrying pathology and risk, and who needs to be monitored and policed in order to maintain social order.

Troeger: Could you say more about the concept of biopolitical paternalism?

Ma: First, I should say that because of the long history of Confucianism and then socialism in China, there is an ideology that the family (and by extension, the state) has the responsibility and authority to take care of its subjects. In return for guaranteeing the lives and livelihoods of its subjects, they will identify with and totally depend on the family and the state. Many people in China endorse this ideology.

In response to human rights activists’ critiques of involuntary hospitalization, psychiatrists involved in drafting China’s mental health legislation appropriated this ideology of paternalism, claiming that by allowing for involuntary hospitalization, they’re actually engaging in what they call state paternalism, or guojiafuquan (国家父权), which literally means the state acting as a father. In this way, China is actually taking better care of its citizens than, say, the United States, where after deinstitutionalization people [diagnosed] with mental illness were just left to roam free and rot on the street.

With this paternalism ideology, the new subjects are no longer the filial son or working-class people as in the socialist version of paternalism. The new subject of paternalism is the biological object that carries pathology and risk to the public, and that should be managed by the state – this is the biopolitical part of biopolitical paternalism.

When psychiatrists appropriate this ideology on behalf of the state, they simultaneously devolve the actual responsibilities of enacting this paternalism to families. So, by using this term biopolitical paternalism, I want to highlight the ideological appropriation, subject formation, and devolving of responsibility components.

Troeger: How does this affect the role families play in individuals’ mental health care?

Ma: In my fieldwork, I have found that because of the strong emphasis on institutionalization and pharmaceutical management, there is actually a lot of conflict within families. Although paternalism as an ideology imagines the manager as the powerful father figure, actually, most of the responsibilities of care and management are carried out by women and the elderly, who do not have a lot of power or authority to coerce people with mental illnesses or lived experience.

This results in a great deal of struggle between the two sides and mutual injuries. There are many ethical ambiguities as well. For example, there is an ongoing argument about whether lifelong institutionalization, which some families with the means would choose for people diagnosed with serious mental illnesses, constitutes care or abandonment. This is a more extreme example of the ambiguities and controversies that occur; a whole spectrum of arguments happen within families on a daily basis because of the arrangements of biological paternalism in China.

Troeger: What first made you interested in this topic?

Ma: As an undergraduate psychology major in China, I had an opportunity to do a class project in a psychiatric hospital and interview a patient there. That was my first time in a psychiatric hospital, and the patient I interviewed was a woman who had been hospitalized for 18 years. She told me about her desires for freedom and reconnection with her family, as well as her complicated emotions towards her family members.

Since this experience, the space of a psychiatric hospital has fascinated me. I became interested in how the institution, the discourse around it, and people’s practices with it shape our notions of what is normal, what is a desirable relationship, and what is just treatment for a vulnerable individual. As I have dug deeper into the topic, I have also been exposed to the ongoing mental health legal reform in China and Chinese society’s impassioned discussion about involuntary hospitalization and its possible abuse.

Troeger: Can you tell us more about that discussion that is happening right now in China around involuntary hospitalization and the mental health legal reform?

Ma: The discussion actually began around 2006, when a woman’s family claimed she was mentally ill and had her involuntarily hospitalized. The woman claimed that she had inherited a large sum of money from her deceased father, and her family wanted her to give the money to them or use it in a way they saw fit. There were heated discussions about whether the woman was actually ill or whether her family had had her hospitalized in order to take advantage of her financially.

A human rights activist and lawyer named Huang Xuetao became involved in freeing the woman and started a public discussion about families’ potential abuse of involuntary hospitalization. Because at the time in China local government officials and public entities also had the ability to admit a person involuntarily, the discussion eventually grew to address concerns about the potential political abuse of psychiatry and psychiatric institutions.

There is tension in mental health activism as well. There are some focused on concerns of diagnosis, arguing that involuntary hospitalization is based on false diagnoses, and want to get rid of the labels. Others are asking, what if a person really has a need for mental health services? What kind of services would actually help that person? That is what has happened over the last thirteen or fourteen years.

Due to this activism, China passed its first national mental health law in 2012, which went into effect in 2013. Although the law states that psychiatric hospitalization should, in principle, be voluntary, it also makes a number of exceptions regarding involuntary hospitalization, such as assuming that people with serious mental illnesses (i.e., schizophrenia, bipolar disorder) are under the guardianship of their family members.

There are still many loopholes people use in the wake of the law’s passage. Because of the lack of alternatives and available mental health services, many family members think they have to resort to involuntary hospitalization in order to access care. Furthermore, the state encourages this practice as a form of population management.

In China, involuntary hospitalization is sanctioned when a person is judged to pose an actual or potential danger to themselves or others, including to public sector agents. Because there is no precise definition of what constitutes an actual or potential danger, in practice, many people read this more broadly or manipulate this to have someone hospitalized against their will.

Troeger: It sounds like the interview you did as a psychology undergraduate with the woman who had been hospitalized for 18 years planted the seeds of your current work. How did you come to study mental health care and madness as an anthropologist? How does bringing an anthropological lens to these subjects differ from that of psychology?

Ma: As an undergraduate, I was unsatisfied with the “scientific” paradigm of psychology, especially the field’s quest for a universal and decontextual or a detached understanding of the human psyche.

For example, when I was in a psychiatric hospital interviewing that woman, my only task was to use the DSM, to listen to her symptoms, and to confirm her diagnosis of schizophrenia. During this process, I became dissatisfied with this paradigm and kind of became a black sheep. I chose to study cultural psychology in my graduate years, but I felt that even cultural psychology focused too much on individual behaviors and emotions.

I wanted a more historically, culturally, and socially situated understanding of individuals and communities. I gradually moved into medical anthropology, thanks to some of the great medical anthropologists at the University of Chicago who converted me. The advantage of anthropology and medical anthropology is that they offer a more situated and historical understanding of human behavior and a much more humanistic and interpretive approach. We care about the values of our interlocutors. We are also more transparent and conscious of our own values in conducting research.

Troeger: Related to the topic of socially and historically situated work, several years ago, you researched experiences and explanations of schizophrenia in China. You found that patients and families use Chinese medicine and religious narratives to “recuperate” what you call “the social person,” which differs notably from Western psychiatry’s view of the individual as decontextualized. What might those of us who work within the mental health system in China, the US, and elsewhere in the world learn from this concept of recuperating the social person? What are your thoughts about how we might better support the recuperation and healing of “social people” who experience madness or severe emotional distress?

Ma: It is great that you bring up this concept of the social person. I actually do not think Chinese psychiatrists completely ignore this. For example, I observed psychiatrists in the field who listened to people’s distress, especially around relationship issues and tried to help address these issues by talking to family members about how to better care for the person by adjusting their own behavior.

Because of the dominant biomedical and psychopharmaceutical paradigm, this kind of attention to the social aspects of distress generally comes second, if not way down the line, for many psychiatrists. It is very ad hoc and depends on the particular practitioner. At the end of the day, pills are still the dominant mode to solve the problem.

By focusing on people’s use of Chinese medicine and folk religion in the treatment of madness and emotional distress, we see that people evoke language that focuses not just on the anatomical body, but encompasses human physiology, social relationships, and environmental processes in an understanding of and treatment of distress. I would argue that some of the language of Chinese medicine and folk religion has a much better capacity to allow for a relational reading of the human.

People also use Chinese medicine to repair some of the damage and adverse side effects of psychopharmaceuticals. In China right now, as is the case in many other places in the world, psychiatry is the dominant paradigm, and there is a lack of funding for research that might support the use of Chinese medicine in mental health care. There is also little discussion of the role folk religion might play in healing.

I think people in the helping professions (in China and elsewhere in the world) should think about ways for us to systematically include and investigate these alternative paradigms, care practices, and language used to understand, care for, and treat mental distress. This kind of integration and inclusion means we may need to change our own paradigms of understanding and use other indicators of good treatment outcomes. For example, the goal should not necessarily just be a reduction in some “positive symptom.”

Troeger: Can you say more about the language of Chinese medicine and folk religion and how it allows for a relational understanding of people?

Ma: There is a common conception that that Chinese medicine only focuses on the somatic or bodily side of things and that it doesn’t pay attention to people’s emotions. My work shows that this is not true. For example, patients and families who use Chinese medicine to talk about distress often use the phrase “thinking too much” to refer to chaotic or preoccupying thoughts that are misguided in some way.

Chinese medicine connects these kinds of mental and emotional processes with physiological processes. If you think too much, your bodily energy becomes congested. When people say “depression” in Chinese, they often use a term that means being sad and congested – in other words, one’s whole cognitive and physiological process has gotten stuck because of a preoccupation one has.

The way to solve this is for the whole family to help reorient the person’s attention, and to use readily available substances, including everyday food, to facilitate the flow of bodily energy. This is how relational, emotional, and physiological aspects are woven together in simple Chinese medicine terms.

Troeger: Can you also tell us more about how some people are using traditional Chinese medicine (TCM) to correct some of the harms of psychopharmacology?

Ma: Some psychiatrists in China prescribe Chinese medicine to address the damaging side effects of psychopharmaceuticals, such as weight gain and liver damage. There is a Chinese term, 热气 (reqi), which refers to disturbances from hot energy. In a TCM framework, liver damage would be understood to be a result of too much hot energy, and a cooling Chinese medicine could be used to reduce or balance this hot energy.

Troeger: You mentioned that you have observed Chinese psychiatrists tending to the “social person” by being focusing on relationship issues, but that because of the dominant psychiatric paradigm, this is not the first priority in psychiatric care. How are Chinese psychiatrists navigating this tension between different paradigms of care?

Ma: First, I think it is important to understand that in China, the resources available to those with “serious mental illnesses” such as schizophrenia and bipolar disorders are really just institutions and pharmaceutical care. There are almost no social workers in Chinese psychiatric hospitals, and counseling is not seen as appropriate for people with these diagnoses.

The upshot of this is that psychiatrists who are more reflexive feel the need to carry out the role of the social worker or counselor themselves. And because families are heavily involved in involuntary hospitalization and shoulder the payment for that, they are often present at the hospital to discuss the person’s care from admission to discharge. So even though the ultimate decision often lies with the family members, psychiatrists have a lot of weight to influence family members’ decisions.

For example, a family might be concerned about a patient’s wish to get married after they are discharged. A psychiatrist might make recommendations about what to do and how to lead a life that is socially and emotionally more fulfilling than just taking meds and not doing anything else to heal after discharge. There is room for a psychiatrist to do this, but it is pretty ad hoc. No one asks them to do this or trains them to do this, and many psychiatrists do not have time to practice in this way.

I think that to promote psychiatrists’ potential to help people socially, emotionally, and holistically, we need to fundamentally redesign the job flow for psychiatrists, and build a more holistic team of care for people with serious mental illnesses.

Troeger: The contemporary field of mental health is still emerging and evolving in China, and infrastructure, policies, and laws are changing in real-time. In what directions are you hoping to see the field move?

Ma: Social workers are emerging in large numbers in China, and some of them are tasked to serve people [diagnosed] with mental illnesses in the community. Some of them are employed in community agencies, and a handful are currently employed in hospitals. I think it is very important to think about what social workers’ roles are and should be in mental health care, whether they are just smoothing the way for the engine of biomedicine, or whether there is actually space for them to propose an alternative reading of the person and propose alternative treatments to psycho-pharmaceuticals.

I hope there will be room for them to participate in policy dialogue and rethink the current paradigm of care, which puts all the responsibility on family members. Will there be room for them to say, hey, independent living as possible? Not every person has to live with his or her family members, and we need to have resources to do that. We need to closely watch the development of mental health social work in China and watch the everyday practices of social workers.

Troeger: What precipitated the emergence of social work in China at this moment?

Ma: Social work has been growing very rapidly in China for more than a decade now. The Chinese state is moving towards trying to envision a mode of shared governance instead of just top-down governance.

During the socialist era, social management was achieved through socialist entities such as work units, which would not only employ people but also provide everyday services and resources to workers. The state is trying to think about ways to fill gaps left by the collapse of work units, and social work has been one of the things that have filled these lacunae.

Troeger: Do you see evidence that social workers have been able to engage in policy dialogue there?

Ma: I would say a very tentative yes. Some leading psychiatrists do not think that biomedicine is going to solve everything, and who believe we need a more holistic understanding of the person. In cities like Guangzhou and Shenzhen in the south, social workers have been very active in helping us rethink mental health services.

Overall, psychiatrists are still very dominant in the game, and I think other helping professionals like social workers and counselors need more opportunities to engage.

Troeger: That also makes me wonder whether the voices of people with lived experience are being included in these discussions.

Ma: That is actually the direction of my next project. I am currently working with people with lived experience and progressive social workers, psychiatrists, and policymakers in South China to think about and try to launch a program that would include people with lived experience in service provision, service design, and policy dialogues. We hope to do this systematically so that the system can recognize these people’s voices and expertise. That is what I hope to focus on in the next few years.

Troeger: Is there anything else you wanted to add before we wrap up today?

Ma: I would like to add that looking at the practice of involuntary hospitalization and the dominance of biomedical services in China offers a way for us to understand health disparities in China in a way that does not just valorize biomedicine.

In China, we are seeing two things happening at the same time. In cities or in places where psychiatric hospitals are available, families often resort to involuntary hospitalization to solve any perceived chaos in the family and the household. The state is encouraging that, much to the dismay of those with lived experience.

On the other hand, in rural areas of China, and in places where there are no psychiatric hospitals, there is almost no service at all for people in need. Some leading psychiatrists use the latter half of the phenomenon to say that we need more institutionalization in China to address healthcare shortages.

My response to this is: I do see the disparity in existing resources, but I think that by looking at the damage and complications of involuntary hospitalization and the sole focus on biomedicine, we should look at areas that still lack services and ask, what kind of services do we want to develop? Do we just want to develop care as usual, care as it exists in these urban areas? Or, do we want to develop more community-based, inclusive care that could integrate alternative understandings of the human? We should approach the process of developing services in these areas as an opportunity to rethink the whole service paradigm.

MIA Research News Team: Rebecca Troeger is a doctoral student in the Counseling Psychology program at the University of Massachusetts Boston and has a Master’s degree in Psychology. Her work explores how Western psychology can move towards valuing other cultures’ knowledge more deeply. She is also interested in the impact of social support and community life on mental health and anti-racism interventions.

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