The Chinese equation in mental health policy and practice: Order plus control equal stability

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International Journal of Law and Psychiatry.Vol. 19, No. 314. pp. 437458,1996 Copyright 0 lYY6 Elsevier Science Ltd Printed in the USA. All rights reserved

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The Chinese Equation in Mental Health Policy and Practice:

Order Plus Control Equal Stability

Veronica Pearson*

The first decades of the Communist Party’s rule in China were characterized by the slogan “let politics take command.” All matters, be they social, economic, or personal, were to be judged against the standard of whether they were in accordance with the dictates of the Party’s leaders. Since 1978 and the start of what is known as the Reform Era, the driving seat has been taken over by economics, and some would say that the speed limits and safety belt regulations are being ignored, to the detriment of many of the less fortunate, including the sick and disabled. To the outside eye this looks remarkably like the earlier stages of capitalism, without the tempering effect of extensive welfare programs that have made such a form of economic organization palatable in other countries.

One of the consequences of loosening economic control has been a devolu- tion of power from the center to the provinces. Neither in terms of political nor economic power does the central government of China any longer wield effective control. By permitting some provinces to grow faster than others a two-tier system has developed. The coastal provinces, particularly those able to attract foreign investment, have become much more developed than the in- terior provinces, which lack the infrastructure and connections to the overseas Chinese communities and their investors that have so benefitted Guangdong, Fujian, and Zhejiang. Although only one-quarter of the nation’s population lives in these eastern coastal provinces, they contain over half the state-owned and collective industries (Leung & Nann, 1995). The richer provinces garner their own profits and do not feel inclined to donate them to Beijing in the form of taxes. Thus, Beijing is largely unable to redistribute wealth from the richer to the poorer areas of the country. The richer areas have their own purses, and the central government has little to put in the purses of the less developed ar-

*Professor, School of Social Work and Social Administration. University of Hong Kong, Pokfulam

Road, Hong Kong.

437

438 VERONICA PEARSON

eas. Hence, in neither case can the central government effectively use purse strings to tighten its grip over the provinces.

Yet the desire for control, and the order and stability control is believed to bring, is very strong. China’s experience this century has largely been one of chaos: the overthrowing of the Qing dynasty and the declaration of the Re- public; the descent into warlordism following that, compounded by the in- ternecine warfare between the Nationalists and the Communists; the Japanese invasion; the Great Leap Forward in 1958 leading to a disastrous famine; to be followed by the terror of the Cultural Revolution (1966-76). The importance placed on order can be seen in the Beijing government’s reaction to the stu- dent demonstrations in Tiananmen Square in 1989.

As we will see, the changing political and economic environment and the continuing concern for order and stability permeate through mental health policies and practice and inevitably have an impact on the lives of people with a mental illness. Of all conditions, mental illness is one that confounds a culture that values conformity, discretion, modesty, and rectitude. The potential for disorder and nonconformity that severe mental disorder represents-particularly the symptoms of mania and schizophrenia-is deeply disturbing within Chinese society. Stigma and rejection of the mentally ill are common experiences in most societies, but in China they seem to be felt with a particular intensity. This not only affects the experience of caring for family members (Pearson, 1993, 1995a; Phillips, 1993) but also the attitudes of staff, most of whom are very reluctant to work in the psychiatric field (Pearson, 1995a).

Severe mental illness is of major significance for health resources in China. For the first time in 1993, mental illness was featured in the China Health Year Book’s list of the major causes of death; mental illness was number 10. Schizo- phrenia is by far the most frequently diagnosed severe mental illness. Using prevalence figures from the 1982 epidemiological study of mental illness, the most complete so far, it is estimated that there are about 4.5 million people with schizophrenia in China (Phillips, 1993). The 1987 survey of disability sug- gests that approximately 1.69 million of these are significantly disabled by the illness (Tian, Pearson, Wang, & Phillips, 1994). What follows is an outline of historical and policy structures and the impact these have on the lives of such people and their families.

In the Beginning

Three issues have been singled out in this section as having continual and current influence on the provision of care. First is the importation of Western modes of treatment. Second is the policy emphasis on prevention rather than cure. Third is the banning of social sciences from the universities in the 1950s which has deprived Chinese psychiatry of a psychosocial understanding of mental disorder. Chinese doctors recognized mental disorders, and case histo- ries were meticulously recorded, but there was no tradition of institutional care for the mentally ill in old China.

Therefore, for good or ill, the introduction of asylums for patients with a mental illness and the various forms of treatment that accompanied them may be seen as alien forms grafted onto Chinese society rather than an indigenous

THE CHINESE EQUATION 439

product. The first such hospital in China was opened by a Presbyterian missionary named John Kerr in Guangzhou in 1898. It is very difficult to establish how many psychiatric beds and doctors there were by the time the Communist Party assumed power in 1949. Karl Bowman, who had completed a 3-month study of psychiatric facilities in China on behalf of the World Health Organi- zation in 1948, estimated that there were approximately 600 beds and 50 psychiatrists for a population of 450 million (Kao, 1979). Schaltenbrand (1931) said that he counted 1,200 psychiatric hospital beds, half of which were in Guangzhou. MO (1959) who became the medical superintendent of the psychiatric hospital in Guangzhou established in 1898, said that at one point it had housed 1,000 patients. However, the general picture in 1949 was that there were very few psychiatric facilities in China and that those that did exist were in cities where there had been significant foreign influence and missionary effort: Guangzhou, Chengdu, Beijing, Shenyang, Suzhou, Dalian, Shanghai, Si- ping, and Nanjing (Xia & Zhang, 1981) and Changsha and Harbin (Lin & Eisenberg, 1985). Bowman reported that conditions were very poor and that services that did exist reached an infinitesimal proportion of the Chinese population. Nonetheless, the model of hospital care and Western treatment for psychiatric patients had been established, and it was the one that China decided to follow (Pearson, 1991).

The second issue concerns the Communist government’s decision very early on to concentrate on prevention rather than cure-a policy continued even today (Pearson, 1995b). In 1949 China was known as the “sick man of Asia” and for good reason (Chiu, 1992). Civil war, the Japanese occupation and its after- math, grinding poverty, and general societal chaos meant that life expectancy was 32 years in 1950 (World Bank, 1984). The Chinese government’s strategy of controlling endemic and epidemic diseases through public health measures, mass educational campaigns, and so on was exceedingly effective. By 1985, China had a life expectancy of 71 years for women and 68 years for men (World Bank, 1989), much higher than expected for a country at its level of social and economic development. China has received many plaudits and much recognition for her achievements in the health care field.

However successful this strategy was it did not address the needs of people with recurrent or chronic illness who required hospitalization, including those with severe mental illness. A Western outsider might simply assume from what he or she knew of socialism that China would provide health care free to all her citizens. This has never been the case. The Chinese government was al- ways clear that it could not afford to do that. The best it could manage was to try to stop people becoming ill (Pearson, 1995a). Various insurance systems were supposed to cover people for in-patient care (Pearson, 1995b). Some, like those covering government employees, were generous. Others, like those for people in the countryside, were very basic, funded from the pooled resources of the communes. Thus, for many people, treatment was either un- available or unaffordable and families had to cope as best they could at home. As we will see, this actually worsened as time went by and China entered the reform era (1978 onwards).

The third point that needs to be made concerns the banning of social science subjects in the mid-1950s. Psychology began to be viewed with suspicion


as a means of accentuating individual differences. Intelligence testing and clinical psychology particularly were not encouraged (Chin & Chin, 1969). Point- ing out individual differences did not serve the revolutionary function of inte- grating people into society (Breger, 1984). Sociology and anthropology were also banned (Wong, 1979). Soviet psychiatry exerted a monopolistic influence on Chinese psychiatry. Following an influential conference held in China in 1953, Pavlovian theory was introduced as the dominant theory for understanding human behavior. A well-organized nationwide movement was launched by the Ministry of Public Health and the Chinese Medical Association to encourage, or even coerce, all psychiatric professionals to learn Pavlovian theory, which dominated Chinese psychiatry until the end of the Cultural Revolution (Lin, 1985).

Thus, no professional schools of social work, psychology, or occupational therapy exist in China (Pearson & Phillips, 1994b). Consequently, Chinese psychiatry has developed largely untempered by psychosocial understanding of human behavior. It can, of course, be argued that Chinese medicine is holistic and that all aspects of the person are taken into account when offering treatment. One might then expect this ancient tradition to be reflected in psychiatric practices. However, what has been absorbed is the Western biological model of medicine. The majority of psychiatric treatments are physical and the major treatment modality is Western psychopharmacology. Over and over again, when interviewing with Chinese psychiatrists, this biological orientation has been overwhelmingly apparent (Pearson, 199%). Indeed, patients’ and relatives’ explanatory models are considerably more holistic than those of doctors (Pearson, 1993). This biological mind-set is at least partly self-protec- tive. Psychiatrists suffered quite badly in the Cultural Revolution, as did psychiatric patients. The individualistic orientation of psychiatry came under suspicion.

Furthermore, an explanation of psychiatric illness that takes social factors into account is a de facto criticism of the social system. It is all very well to argue that capitalism drives people mad. But as it became apparent that mental illness was still occurring in Communist China, espousing notions of social causation became extremely dangerous. Biology is safer. And, in truth, is it so much different from mainstream psychiatric opinion in the West?

Policy Statements

Care of the mentally ill has not been high on the policymaking agenda in the People’s Republic. Consequently, there are primarily three documents that we need to discuss. The first was issued in 1958 by the Ministry of Public Health and is known as the National Illnesses Prevention Workplan 19.58- 1962-or the first (and as it turned out, the only one until recently) Five-Year Plan in this area (Kao, 1979). The plan was the culmination of the first national mental illnesses prevention meeting convened in Nanjing in the same year. The plan documents considerable progress in the 9 years since the Com- munists took over, with 11,000 psychiatric beds in 46 hospitals and 5,000 psychiatric personnel, 400 of whom are doctors. On the other hand, with an esti-


mated severe mental illness prevalence at that time of 2 per 1,000 population (which seems rather low) it was calculated that there were at least l,OOO,OOO psychiatrically ill patients. Thus, despite the improvements in numbers, resources were still grossly inadequate to cope with the demand.

In summary, a number of major difficulties were identified. Doctors over- emphasized Western forms of treatment and medication at the expense of tra- ditional Chinese medicine, and inpatient care over the less expensive outpatient treatment. Staff were criticized for being more conscious of their own convenience than the needs of patients. Indeed, some staff were said to have poor professional standards, while others positively disliked patients and treated them badly. People with a mental illness were not well-accepted by the general public or, sometimes, even their own families. Clear links to the potential for social disruption were made.

Mental illness brings not only pains and distresses to the patients, but also brings certain perils to industrial and agricultural production as well as to social security. . . . Many of the mentally ill persons, because of unavailability of timely and proper treatment and hospitalization, have affected productive reconstruction and disturbed social order (reproduced in Kao, 1979, Appendix 2, p. 123).

As far as treatment was concerned, the plan recommended that frontal lo- botomy and other clinical methods that “can injure the lives and health of the patients should not be used” and that binding or imprisoning patients should be resolutely opposed. Three types of treatment facility were recommended: a “medical base” (presumably hospitals and clinics), prevention units, and sana- toria for chronically ill patients. It was also recommended that those who could be treated at home should be, and others who were convalescing or in need of long-term care should be dispersed to the rural areas where there was a need for labor. However, this policy does not seem to have been carried out as such, and it is not difficult to imagine that compulsory internal deportation would have been unpopular with patients.

The plan also laid down the four types of therapy that were to be offered to patients: treatment by Western and Chinese medicine, proper labor therapy, systematic educational therapy, and therapy through organized sports and cultural activities. This still forms the basis of the current formal policy on treatment. All of this was to be pursued with “the Communist working style of imagination, outspokenness and daring.” Indeed, the document is generally apolitical, focusing rather on practical difficulties and their solutions. The only overtly political paragraph comes near the end, almost as an afterthought, and states:

Workers engaged in prevention of mental illness should strengthen their study of Marxism-Leninism as well as Comrade Mao Zedong’s writings by unfolding criticisms of the bourgeois idealist viewpoints in the theory of insanity and by hoisting the standard of proletarian dialectical theory of insanity and mental illnesses of the Chinese people (reproduced in Kao, 1979, Appendix 2, p. 126).


Some Opinions About Strengthening Mental Health Work

The next official document appeared in 1987 and was entitled Some Opin- ions About Strengthening Mental Health Work, appearing under the official aegis of the Ministries of Public Health, Civil Affairs and Public Security. Thus, there is nearly 30 years between the two policy statements, and during that time China had passed through some of the most turbulent events of her history this century. including the Cultural Revolution. What really went on in psychiatric hospitals between 1960 and 1978 is largely unknown to outsiders. There are a variety of reports by Western observers, but these were mostly based on visits to Beijing and Shanghai (Taipale & Taipale, 1973; Adams, 1972; Ratnavale, 1973; Side1 & Sidel, 1973) neither of which could be considered typical of what was going on in more far-flung outposts, and both of which were heavily influenced by being close to the political heartland (Pear- son, 1995a). By 1987 the government had had nearly 10 years to set the country on a different path economically and was in a position to give attention to other issues. The report that was produced concerning mental health care was not optimistic.

Although the 1958 document was concerned about the issue of public order and the lack of facilities, it still contained a strong sense of optimism and concern for patients. The first paragraph of the 1987 document summarizes the achievements in mental health work ever since the First National Meeting in Nanjing, but after that the memorandum is exclusively concerned with current difficulties. These are discussed in detail in Pearson (1995a) and will only be summarized here. None of them are unfamiliar to Western practitioners.

The report emphasized the marked increase in the rate of mental illness (tenfold since 1958, if figures given are accepted as accurate) at the same time as a serious shortfall in all types of facilities. Psychiatric hospitals received only 50% of the funding the government gave to general hospitals at the same grade, and 80% of mentally ill people received no treatment at all. Only 5% of them could be admitted to a hospital. Once more, the threat to social order was emphasized, with many examples given of the serious damage that un- treated mentally ill people do, accompanied by a plea for more forensic beds. Generally, the psychiatric services are identified as the Cinderella of the health sector, with inadequate staff training, low pay, poor promotion prospects, and little respect or support from the general public. While the document is strong on identifying problems, its suggestions for remedies (better coordination, more public education, better training and more funds) are not accompanied by achievable strategies through which they could be implemented.

The Eighth Five-Year Work Program for the Psychiatrically Disabled (1991-1995)

This moribund state of affairs might have persisted had it not been for Deng Pufang and the “disability initiative” (Pearson 1995b). Deng Pufang is the older son of the Paramount Leader Deng Xiaoping and has been confined to a wheelchair since falling from a third-floor window during the Cultural Revolu-


tion. He has used his position and unparalleled connections to improve the lot of disabled people in China, of whom there are over 51 million (Tian et al., 1994). Largely through his influence, China undertook a national survey of disability, published in 1987, and in 1991 promulgated a law on the protection of the rights of people with a disability. His organization, the China Disabled Persons’ Federation, has become a powerful fighter for the disabled population. A number of senior psychiatrists with an interest in the rehabilitation of people with chronic mental illness persuaded Deng Pufang to include the mentally ill in his advocacy and empowerment efforts.

This led to the Eighth Five-Year Plan for the Psychiatrically Disabled, which was largely written by the members of the China Rehabilitation Research As- sociation for Mental Disabilities (a subdivision of the China Disabled Persons’ Federation founded by Deng Pufang). The plan specifies the development of pilot projects in 30 cities and 30 rural counties around the country (Phillips & Pearson, 1994; Pearson, 1995a). The sites were later extended by two in each category. The components of the plan are not particularly new or innovative. Rather, they extend aspects of care that have been found to be reasonably successful in China (Zhang, Yan, & Phillips, 1994b) and attempt to replicate them elsewhere. Mostly, the plan relies on collective industrial therapy in the community, “guardianship networks” (Pearson, 1992a, discussed in greater detail later), and exhortations for better and less restrictive treatment in hospitals. There is no mention of family-based interventions or the importance of the family in the treatment and rehabilitation of people with a mental illness, nor are other psychosocial interventions mentioned.

What is unusual about this plan and what makes it important is the amount of thought and planning that went into its implementation and the fact that it was nationally coordinated and backed by a powerful organization, the China Disabled Persons’ Federation. Each province is supposed to set up training centers for various levels of the personnel needed, and psychiatric units will be established in general hospitals, something the Chinese authorities have held out against doing for many years (Lin & Eisenberg, 1985). Registers of the mentally ill will be kept and there will be full- or part-time mental health workers at every administrative level in both rural and urban areas in the 64 chosen sites.

Although the Chinese government has allocated some money centrally to fund the organizations, technical support groups, and training programs needed at the national level, most of the funding is supposed to be found lo- cally. Local governments are directed to provide 0.05 Rmb (less than 1 cent) per person in their local area and to seek out other sources of community funding. However, it must be remembered that China does not have organizations like the Community Chest, Rotary, or Round Table that are familiar sources of nongovernment funding for deserving projects in Western countries. Thus, the requirement to look for alternative funding is a very difficult one for most local governments, short of forcing local industry or local people to make “voluntary” donations, which certainly happens.

What is distressing is that even with the amount of care and organization that has gone into implementing this plan, it is still most unlikely to succeed. Financial difficulties, the poor level of training, and the low motivation of gov-


ernment personnel constitute significant hurdles. What seems to be happening is that in those areas where there were already some facilities, some headway is being made. But in areas where there were few treatment or rehabilitation facilities for mentally ill people and where organizational structures were weak, not very much has happened. As Phillips and Pearson (1994, p. 135) point out:

a top-down plan heavily dependent on voluntarism and community compliance may have been effective in the authoritarian pre-reform era, but it is much less viable in the decentralized, competitive environment of post-reform China.

Policy Systems

As we have seen in the previous section, finances currently drive what can and cannot happen in the health sector, including mental health. To appreci- ate fully the changes that have occurred in the Reform Era the outsider has to be reminded that in the space of less than 15 years hospital administrative staff have gone from a system where virtually all costs were met by grants from local and national governments to a system where they must raise a very significant portion of the money themselves. In the 1980s the government decided to make cost recovery the foundation of its health care financing system (World Bank, 1992) and it reduced subsidies to hospitals, other than those covering basic salaries and the procurement and repairs of some expensive items.

Thus, health care financing has become much more economic and commer- cial in orientation, a change reflected in the Report of the Ministry of Public Health on Some Policy Questions Concerning the Reform of Health Work passed by the State Council in 1985. It is not that this is unusual per se but that such a policy was previously unknown in China that has caused such confusion and distress among users but also among providers. Fees must now reflect the true cost of the provision of health services, and the government’s appropria- tion is to be minimized (Lee, 1993). Hospital fees, of course, vary throughout China depending on the wealth of the area. Fees may also vary within a city depending on the quality and fame of the hospital. On average, the cost of a month’s inpatient treatment in a psychiatric hospital would be about 800 Rmb (approximately US$96) and a course of treatment rarely lasts for less than 3 months. The resulting fee of 2,400 Rmb (US$289) is more than many urban dwellers earn in a year and more than twice the average per capita rural income. Fees have increased both absolutely and as a share of total health ex- penditures, from 14% to 36% between 1980 and 1988 (World Bank, 1992).

Previously, the majority of urban dwellers would have been substantially protected from the costs of hospitalization by health insurance provided through their workplace. Rural dwellers also had some insurance protection, although it was by no means as generous. However, the occupational and economic reforms of the 1980s have more or less destroyed the communally fi- nanced insurance systems in the rural areas and severely curtailed those in the urban areas (Pearson, 1995b). Thus, for the first time, many consumers are fac- ing the full costs of health care at the same time as hospitals are raising their fees as the easiest way available to them to raise money (Pang & Kao, 1992).


Hospital administrators and doctors are being encouraged to be entrepre- neurs in an effort to find alternative income sources for their hospitals. Some examples of entrepreneurship in psychiatric hospitals that are known to the author are renting out excess land to farmers, renting out fishponds, running a restaurant and/or hotel, and establishing factories on the grounds of hospitals manned by cheap, rural, female labor on a temporary basis to keep the manu- facturing costs down. But not every doctor or administrator is cut out to be a businessman, and some of these ventures only just break even, or worse, fail completely-leaving the hospital poorer than ever. Nor must it be forgotten that such efforts drain energy away from the main task of running a hospital.

As the World Bank points out (1992), there has been a redirection of effort away from basic prevention programs provided mainly by public benefits toward revenue-earning activities with limited (mainly private) benefits. As Sun (1993, p. 24) puts it, “in a nutshell they concoct all sorts of means to extract people’s wealth.” Fees are extraordinarily high, unnecessary treatments are prescribed (Pearson & Phillips, 1994a; Pearson, 1995a), and with a permitted profit margin of 15% on drugs, polypharmacy is frequent. Furthermore, the 1985 Report of the Ministry of Public Health of Some Policy Questions Con- cerning the Reform of Health Work permitted private practice and the opening of private hospitals. Since then, low-quality private psychiatric hospitals have sprung up where the most significant attribute of the staff is said to be “large muscles” (Pearson, 1995a).

The Psychiatric Troika

The lack of coordination between the different ministries providing various health services is seen as a source of duplication and inefficient management, as no single authority is responsible for planning and control (Sun, 1993; Yuen, 1994; Wong, 1995). Services for psychiatric patients are provided largely by three ministries; Public Health, Civil Affairs (i.e., welfare), and Pub- lic Security (police). Because of the lack of coordination the exact number of psychiatric beds in China is unknown. Official figures given in the Annual Di- gest of Statistics are misleading because they only count hospitals in the Public Health system (Pearson & Phillips, 1994a). More detailed information provided in a monograph by the Psychological Medicine Research Center of the West China University of Medical Sciences (1990) identified 473 psychiatric institutions under the Ministry of Public Health, 190 under the Ministry of Civil Affairs, 81 under the Ministry of Industry and Mining, 23 under the Min- istry of Public Security, 24 run by the People’s Liberation Army, and 12 under local collectives. Even this list may not be complete as I have come across at least one psychiatric hospital run by the railway ministry. The monograph does not state the exact number of beds, but Pearson and Phillips (1994a) esti- mate it at approximately 120,000 to 130,000, which comes to about 1.1 beds per 10,000 population.

The division of labor among the three chief ministries involved in running psychiatric hospitals used to be reasonably distinct. The Ministry of Public Health had the highest status and tended to take acute patients. The Ministry of Civil Affairs started running psychiatric hospitals in 1958. Traditionally, it


cared for those who were chronically ill and for the so-called “three have- nots”: no money, no family, no means of support. Given the aims set out in the 1958 policy document discussed earlier, it seems likely that the government gave it this responsibility in pursuance of its efforts to relieve Ministry of Pub- lic Health hospitals of the long-term patients who were blocking beds. The standards of the hospital, staff, and treatment in Ministry of Civil Affairs psychiatric hospitals were generally considered inferior to those in the Ministry of Public Health institutions.

However, in the Reform Era the goals of the civil affairs hospitals have gradually changed, so that they now accept a fee for servicing patients. This is entirely in response to the demand that they be more financially self-suffi- cient, rather than reflecting any good to the consumer (Pearson, 1995a). As of 1991, 59% of patients in Ministry of Civil Affairs Hospitals were fee-paying. The Ministry of Public Security provides approximately one hospital per province for the care of forensic patients, although these hospitals may also take patients who have not committed a crime (personal communication from the director of the Hubei Ministry of Public Security psychiatric hospital). While the Ministry of Public Security plays a relatively small part in direct service provision, it has power disproportionate to its contribution. As we have seen from the 1987 document, there is a great deal of government concern about the numbers of mentally ill people committing crimes. In addition, the ordi- nary job of community policing brings the police into contact with mentally ill people, particularly when they are acutely psychotic. The police have considerable power over the disposal of those whom they think are mentally ill, whether or not they have committed an offence (Pearson, 1992b, 1995a).

Involvement of the three ministries has been central to the development and implementation of policy concerning the mentally ill from the earliest days of the Communist regime. The notion of “three men leading groups” was first outlined in the 1958 document and became the foundation on which policy rested, The idea was that these groups (consisting of representatives from each of the three ministries or departments) should be set up at every administrative level (e.g., provincial, city, district in urban areas) to implement national policies at the local level and to ensure collaboration and cooperation among the three ministries. Since 1991 these groups have technically become “four men leading groups” as the China Disabled Persons’ Federation now has a role protected in legislation (Law on the Protection of the Disabled, 1991) to be part of the policy formation and implementation process. To a Western eye, this structure may seem a little strange, but it must be remembered that the formal horizontal linkage between different government ministries (or departments at the local level) is notoriously weak in China. “Leading groups,” although not having any executive power, are an attempt to impose coordination and rationality on mental health service provision. They may also contribute to the formation of informal personal networks (guanxi) through which most things in China get done.

In theory, in a country that is not well resourced and is vast and diverse, such an organizational framework looks achievable and effective. Indeed, in places where there has been an impetus toward improving the care of mentally ill people-for instance, in Shanghai (Zhang et al., 1994b)-it has worked


well. However, this is relatively rare. The more usual experience is that these groups exist in name only, or do the least that is possible. In some places, one feature of a service, usually the hospital, will dominate and may be well sup- ported by local officials, but other facets will be ignored-for example, “home beds” (a domiciliary visiting service), guardianship networks, and workshops/ work therapy stations, The government officials involved lack appropriate training, cannot be effectively motivated, and share the same prejudices that stigmatize mentally ill people in Chinese society generally. Even doctors and nurses are frightened of psychiatric patients (Pearson, 1995a; Bueber, 1993).

Policy Implementation and Consequences

Two sentences are instructive in starting this section, The 1987 document Opinions About Strengthening Mental Health Work carries the phrase “it has been approved by the State Council, please carry it out according to the local situation.” The 1991 Work Program for Disabled Persons During the Period of the Eighth Five-Year National Development Plan (Chapter 3, paragraph 6) says “local governments at all levels are requested to increase budgetary allo- cations to rehabilitative services.” Both these documents emanated from the highest levels, yet neither carried the force of compulsion. Such phrases are not the result of an exquisite Chinese sensitivity to etiquette but an admission that the central government simply does not have the financial clout to coerce the provinces into carrying out its orders.

The Community vs. the Hospital

As we have seen from the 1987 Opinions About Strengthening Mental Health Work, it is government policy to encourage community-based facilities on the grounds that it is cheaper and more suited to earlier treatment and rehabilitation. There is no doubt at all that there is a model of community care in China (Pearson, 1992a), and some outstanding examples of projects have been designed by Chinese people with Chinese conditions in mind (Zhang et al., 1994b; Wang, 1994; Luo & Yu, 1994; Wang, Gong, & Niu, 1994; Qiu & Lu, 1994). At the same time there seems to be a marked reluctance to adopt these models nationally. Even with the impetus that has gone into the Eighth Five- Year Plan pilot project sites, it is still proving very difficult to disseminate even a simplified form of the community-care model. This reluctance to use outpatient-based care was commented on in the 1958 policy document and, 34 years later, by the World Bank (1992).

A number of factors have to be taken into account to explain this phenomenon. First is the one we have already mentioned: that the system only works when for some reason there are people who feel enthusiastic about working with mentally ill people. The prime example of this is Wang (1994) in Shen- yang whose achievements are outstanding. Setting up facilities outside a hospital requires enthusiasm, commitment, entrepreneurship, and a talent for networking-generally talents in scarce supply.

Second, there is a conflict of interests between hospital and community- based services. The more successful community-based projects are, the more they


undermine the hospitals because patients have less need for inpatient care. Obvi- ously, this affects the hospital’s ability to make money through fee charging. This is complicated by the fact that some of the more successful rural projects (Wang et al., 1994) rely on county-level psychiatric hospitals and psychiatrists to provide training and supervision to the village-level doctors who are providing the medication and supervision to patients. This has usually been “a free service,” but as a model it has its roots in the voluntarism of the 1970s not in the commer- cial ethos of the 1990s and as such is not likely to be found very appealing in the current climate. It is, of course, possible to argue that community services should be charged at cost, rather than being subsidized by hospital fees, but this may lead to even fewer patients receiving necessary care and medication. It is very difficult to change a fee-charging structure that people have been used to for decades-hospital care is expensive; community care is cheap.

Another issue is that people are used to the idea that if someone is seriously mentally ill then the proper thing is for that person to receive hospital treatment. Because hospital care is so expensive, unless the patient has generous insurance, treatment is normally only sought when the condition becomes un- manageable at home. Then the patient disappears inside the hospital for 3 months, is generally detained under conditions of great security (wards are routinely locked), and finally released after the symptoms have abated. This is considered the normal pattern by patients and families. This is one of the areas where the absence of professions schooled in the social sciences has had a negative effect. Doctors and nurses, schooled in the tradition of hospital care, do not naturally look beyond the hospital walls, either as a treatment locality or to make themselves aware of the family, job, and other environmental pres- sures that may impinge on their patients’ lives.

Attempts to alter the hospital-oriented system in China may be viewed with suspicion. An example to illustrate this is taken from the city of Wuhan, the provincial capital of Hubei province. Wuhan has two systems of care for psychiatric patients, one run by the Department of Public Health and the other by the Department of Civil Affairs. A day hospital has been opened within the Civil Affairs system, the less dominant of the two systems. This is an innovative form of treatment in China, as day hospitals are extremely rare. But the day hospital has been caught in two cross currents. First is the families’ reluctance to send a patient there for treatment on the grounds that if the patient is well enough to be sent home they cannot see the point in spending more money on treatment. Second, in a climate where hospitals are competing for patients who can pay, the larger public health system refuses to refer its patients to the day hospital for fear of “losing” them to the system run by the De- partment of Civil Affairs. Of course, such illogicalities of distribution that damage the quality of patient care are familiar to us from Western systems, which are often driven by considerations of cost rather than concern for quality care. The surprise comes from finding the familiar in an unexpected place.

Money Matters

Another phenomenon is that present-day psychiatric hospitals in China are often half empty or less, a great change from even 4 years ago. They are


locked into a vicious circle of raising fees to meet costs and staff bonuses (which often constitute up to 50% of their take-home pay, which even with bonuses is not high), and seeing bed occupancy levels fall as a result, thus mak- ing them raise fees again. One psychiatric hospital with which I am familiar has recently opened a drug addiction treatment ward and is charging phenom- enally high fees (approximately 3,000 to 3,500 Rmb per month or about US$361 to $421) on the grounds that this, at least in their city, is a disorder of the middle classes, and if they can pay for expensive drugs, they can pay for expensive treatment. Their logic has not been wholly borne out by experience.

Much of this trauma is a consequence of the economic reforms. There is a crisis of unemployment in China (Leung, 1995) as the government tries to ra- tionalize employment practices that used to guarantee everyone a job for life. The state-owned enterprises are particularly top-heavy in this respect, consum- ing hugh quantities of state resources with a productivity growth rate (14%) that compares most unfavorably with collectively owned enterprises (29%) and foreign-owned enterprises (49%) (Statistical communique. . . , 1993).

It is estimated that in 1990 there were 70 million rural migrants living in Chinese cities, most of whom would form a pool of casual labor or be unem- ployed (Wong, 1994; Leung, 1995). It is estimated that 20% of those employed in state-owned enterprises are redundant (Leung, 1995). Among the unem- ployed, 82% are young people (Leung, 1995); 67% of people with a disability rely on family support and are not financially independent (Pearson, 1995b). To comprehend fully the significance of this one has to understand that employment was the path through which all manner of social welfare benefits were channeled: health insurance, housing, subsidized schooling, and retire- ment benefits. Without a job a person is cut off from many of the necessities of life, not just employment and a wage, and thus lacks the means to seek them elsewhere.

The consequences of all these changes on the lives of mentally ill people are serious. Schizophrenia typically develops in late adolescence or early adult- hood, about the time a person would be looking for employment. Frequently, jobs today are offered to young people on an initial contract basis for about 3 years. It is most unlikely that a person with schizophrenia would not manifest symptoms during that period of time. If they do, they will not be offered a per- manent job, unless one or both of their parents occupy a very powerful position or has excellent connections (guanxi) because no company wants to become responsible for the lifelong commitment to health costs that this will entail. This is very different from the position even 10 years ago, when most people with schizophrenia were allocated a job and managers did not object because they were not being judged by the profitability of their enterprise.

As time passes, and if the economic reforms stay in place, it will become increasingly rare for someone with schizophrenia to have health insurance. Some families will be able to bear the financial burden themselves but most will not. What will happen then is a matter of speculation. Three possibilities come to mind. More and more informal “hospitals,” where fees are low and care cursory, are likely to spring up as a means for families to shift the burden onto other shoulders. Families will continue to resort to what they have been doing for centuries, confining mentally disordered relatives at home with the


aid of ropes, shackles, and bars (Ng, 1990). Alternatively, as the Ministry of Civil Affairs turns more and more to competing with the Ministry of Public Health for paying patients, the streets of China’s cities will look increasingly like those of Western nations with the seriously deranged wandering around without care or hope. If this were to happen it is likely that the Chinese government would take action, as its overriding concern for social order would find such a visible source of disorder intolerable (Phillips & Pearson, 1994).

Families: The Hidden Treasure

Leff (1993) as someone familiar with both Western and Asian family structures, makes a plea for realizing how precious is the intact, extended and supportive Asian family in the care of people with a severe mental illness. In China, as in most other places (Perring, Twigg, & Atkin, 1990), families do most of the caring for sick family members. Yet families are noticeably absent in any initial discussion of policy developments-for instance, in the pilot project proposed as part of the Eighth Five-Year Plan for the Disabled (Pear- son & Phillips, 1994a) Also, their therapeutic potential and capacity to affect relapse are largely ignored (Pearson, 1993).

It is obvious that if, as the government claims, 80% of seriously mentally ill people are not receiving treatment, then it is the families who are left alone to look after them. Even when patients do receive treatment, doctors are unlikely to offer anything to families other than a routine lecture on the importance of the patient continuing to take medication, At least one doctor sug- gested to me that it was unwise to share too many “tips” with the family, as then they would no longer need to bring patients to the hospital-which, of course, reduces fee income.

Doctors, because of their biological understanding of human behavior, show little interest in family dynamics and how these might be related to symptomatology (Pearson, 1993, in press). In some cases, where they are deal- ing with peasant families, doctors seem convinced that peasants lack the education to understand much other than instructions to take medication. Fami- lies, on the other hand, show a desire to know more about the illness and how to handle that patient best at home (Pearson, 1993). Many of them glean the scraps of information they have pieced together from other families in outpatient waiting rooms and hospital wards to try to make sense of their own family member’s condition.

It is not surprising that under these conditions not very much has been published about family interventions in China. What material there is has found that the education of family members about the illness, combined with long- term support of the families’ caring efforts, to be effective in reducing relapse (Zhang, Wang, Li, & Phillips, 1994a; Xiong et al., 1994). Furthermore, Phillips, Xiong, and Xiong (1993) have shown that their family-based intervention significantly reduces the costs in comparison with standard care (hospitalization and outpatient follow-up). Meanwhile, families strive to be their own social worker as they employ whatever stratagems they can to ensure that their sick family member (usually, in the case of schizophrenia, an adult child) achieves


the goals of job, spouse, and child, all of which are needed in an attempt to guarantee support when the parents are gone (Phillips, 1993; Pearson, 1995a).

The Concern With Social Order

We have traced the development of policy initiatives that have directly and indirectly (as with the economic reforms) affected care of the mentally ill during the period since the Communist Party came to rule in China. We have examined some of the consequences of those policies, both intended and unin- tended, and pointed out how a concern about public order is a theme that can be commonly detected running through them. It is now time to draw some of these threads together and demonstrate how they interact in particular circumstances: consent to treatment and treatment under the least restrictive conditions, guardianship networks, the tradition of confinement, the law and mentally ill people, and regulations restricting marriage and childbirth, con- cluding with the good of the collective over the individual.

Treatment: Consent and Least Restrictive Conditions

Two of the documents that we have considered addressed the issue of conditions of treatment, in 1958 and in 1991. What is called the “open door method” of treatment (i.e., without locked wards) was strongly advocated. Thus, at one level, that of the policymakers, there is an awareness and accep- tance that treatment should be in the least restrictive conditions possible. However, this has almost totally failed to be translated into action at the ward level, even in the more advanced hospitals.

Conditions in all Chinese psychiatric hospitals of which I am aware are pre- eminently security conscious. Not only are patients locked in the ward but frequently they are all, en masse, locked into the day room. One doctor described to me the regime on his ward as “semi-open” because the day room was open. If patients manage to escape, staff are punished (Pearson, 1995a). The environment, both for staff and patients, is punitive rather than supportive. Goff- man’s (1961) concept of “batch living” could have been designed with Chinese psychiatric hospitals in mind.

The hospital staff’s implicit understanding is that the patients are there against their will and that given the opportunity they would leave, which is probably true. The notion that a person may be mentally ill but willing to accept treatment for his or her condition, and therefore willing to stay voluntar- ily in a hospital, is very foreign to Chinese psychiatrists. When, during lectures and seminars, I have tried to explain that the majority of patients in Great Britain are not compulsorily detained, that many of those are kept on open wards, and that the rest are free to walk but mostly choose not to do so, my au- dience is frankly disbelieving.

Why are patients so unwilling? The conditions in Chinese psychiatric wards can be harsh and uncomfortable. Some of the treatments, like electric acu- puncture and ECT, which is routinely administered without anesthetic or muscle relaxant, are painful and the thought of receiving them creates a frightening environment. In addition, because hospital beds are so scarce and expensive it


may well be that by the time a patient is admitted the individual is more severely ill than would be the case in Western countries, where prevention, community support, and early intervention are comparatively more easily implemented and thus patients in the West are possibly more insightful about their condition at the time of admission.

For a patient, the experience of being admitted is essentially one of losing control. The decision is not the patient’s but the relatives. Once someone is defined as “crazy” neither his nor her family nor hospital staff consider that the patient has an opinion to which it is worth listening. Patients are routinely tricked into going to the hospital, in the guise of a family outing for a picnic, for example, or trussed up with rope and delivered onto the ward (Pearson, 1995a). Likewise, consent to treatment is not an issue for the patient. If consent is requested, it will be from family members, and then the concern often is whether the family is prepared to pay for something extra.

Patients without families are particularly vulnerable as there is then no brake on what treatment methods the doctors might choose to use, including those that would be considered to be “hazardous and irreversible” in Western juris- dictions. Psychiatrists in several well-known psychiatric centers (in Guang- zhou, Beijing, and Nanjing) have in recent years started experimenting with brain surgery again.

In sum, the psychiatric patient is considered as a source of disruption and chaos, someone who is an inherent threat to public order and who needs to be controlled by outside forces. The agents of control (hospital staff, in this case) are judged to be good at their jobs to the extent that they are effective at controlling and reducing social disorder.

Guardianship Networks and the Tradition of Confinement

Guardianship networks tend to be found only in areas with more advanced and comprehensive psychiatric services-for instance, Shanghai, Wuhan, and Guangzhou. Their occurrence is not uniform throughout China. There are variations in the way they are organized, but they essentially involve doctors, local officials, family members, and possibly volunteers in watching over the patient in the community. Their duty, as Xia, Yan, and Wang (1987, p. 83) de- scribe it is to “observe the patient’s mental health condition and report to rel- evant health personnel in case of disorderly conduct or breach of the peace.”

Both Qiu and Lu (1994) and Zhang and colleagues (1994b) are able to report that on the basis of well-designed research, these guardianship networks are successful in preventing relapse, in increasing social functioning, and in reducing socially disruptive behavior. Naturally, this brings benefits to the community, the families, and the patients. At the same time, the rhetoric is framed in ways that emphasize the need to control the patient, rather than the familiar Western rhetoric couched in terms of providing the most normal living conditions, increasing sense of self-worth and value, and improving quality of life. It may be that the goals are similar but the Chinese are more honest in stating them!

Although guardianship networks involve a number of systems, the work of supervision of the patient is usually the responsibility of the family member.


As they would routinely have to do this anyway, one might ask: What differ- ence do guardianship networks make? When they work properly, they provide family members with the support and back-up they so rarely receive. They know there is a responsible doctor, a government official, and so on with whom they have had previous contact and whose stated job it is to help. While this does not absolve family members of the daily tasks of caring, it does mean that they are relieved of some of the anxieties when a crisis begins to loom.

This may not seem very much to us, but compare it with the experience of people who are not linked into such a network. The Guangzhou authorities have counted 65 mentally ill people who are being physically restrained in their homes by their families, and this is in a city where services are relatively good. Families in such circumstances are usually reluctant to let the patient receive hospital treatment on the grounds of cost, and officials, while aware of the situation, cannot offer treatment unless family members are willing to pay. Families become resentful of the visits from officials, whom they perceive to be unsympathetic to their predicament and distress, and not able to offer any helpful advice. It is very likely that many of the 80% of mentally ill people in China who are not receiving treatment are dealt with in similar ways, but it is something that is rarely officially discussed or written about (although the 1987 document did acknowledge that it continued to be a problem).

Mental Illness and the Law

This issue has been discussed extensively elsewhere (Pearson, 1992b, 1995a) and the details will not be repeated here. There is no national law that specifi- cally deals with the mentally ill, although the need for one is commonly ac- knowledged. In general, legal provisions that deal with issues raised by the mentally ill are characterized by an authoritarian benevolence. Article 15 of the Chinese Criminal Law states:

A mental patient who causes harmful results in a situation of being unable to understand or control his actions does not bear criminal responsibility. However, his family members or guardians should be instructed to keep close watch over him and give him medical treatment. (Cohen, Gelatt, & Li, 1984, p. 14)

Perhaps the most significant law in this context is one from 1954, still in force, and titled Act of the People’s Republic of China for Reform Through Labor. This mandates a health examination for offenders who are committed to cus- tody. With the exception of those who have committed counterrevolutionary offenses, anyone who is found to have a mental illness need not stand trial. Rather, the Department of Public Security involved may decide to admit the person to a hospital, return the individual home under the supervision of a family member, or place the subject somewhere else considered to be appropriate. From the Chinese point of view, this is an act of benevolence, and infi- nitely preferable to a prison sentence.

Pearson (1995a) gives several examples of circumstances where such action is taken. Often it involves people who are causing a public nuisance-stopping


the traffic, walking naked in the street, and destroying public property are frequently cited-or if the problems have involved family members the behavior tends to be excessively violent or dangerous-attacking father with an ax, setting fire to the house with people asleep inside, and similar acts.

Authoritarian benevolence does not emphasize retribution (the concept of “time for the crime” for psychiatric patients seems to be largely absent), but it is most concerned with damage control on the one hand, and doing what is thought to be best for the patient on the other. In other words, maintaining social order and controlling patients’ worst excesses, in their own interests and that of others. Decisions taken by the Department of Public Security are not subject to challenge or appeal, and they are informed more by what is considered the patient’s right to receive treatment when clearly needing it, rather than the Western notion of human rights, which eschews detention except in strictly delimited circumstances, hedged around by many judicial protections.

Restrictions on Marriage and Childbirth

Again, details concerning this issue are given at length in Pearson (1992b) and Pearson (1995d). The significant issue for our argument here is that attitudes toward severely mentally ill people being permitted to marry and have children are exemplars of the perceived need for control and order. From the 1930s the Communists had regulations in the areas of China they controlled that forbade marriage for certain groups of people on eugenicist grounds. The 1981 Marriage Law (Article 6b) forbids marriage for people who have an illness “which is regarded by medical science as rendering them unfit for marriage.” This has been widely interpreted within China to include schizophrenia and manic depressive disorder.

In 1986 the Ministry of Public Health and the Ministry of Civil Affairs issued a publication titled “Circular Concerning Pre-Marital Medical Check- Ups.” This rather innocuous-sounding document forbids people with a mental illness to have children, and says that marriage must be delayed until the illness is in a stable condition.

This saga was still being played out with the promulgation of the Maternal and Infant Health Care Law in 1994, which came into effect in the summer of 1995. The draft of this law caused much international concern because it advocated a frankly eugenicist policy of compulsory sterilization and abortion for mentally ill women. The revised version merely requires doctors to advise and persuade pregnant women with a history of mental illness to have an abortion. The Chinese concern is to reduce the numbers of their citizens who have a dis- abling disease (just as officials are determined to reduce the total population through the government’s one-child policy), not to create an Asian master race. However, their chosen methods have the disadvantages of being scientif- ically ineffective as well as transgressing some of the international psychiatric community’s most cherished values. In reality, this issue, as we have seen elsewhere in this article, demonstrates yet again the central government’s inability to impose its will, particularly in an area that offends so deeply against familial and humanitarian values. A large sample of acutely hospitalized patients showed that 50% of them were married and 41% had children (Phillips, 1993).


The Individual and the Collective

Underlying much of this discussion are profoundly different ideas (in comparison with the Western philosophical tradition) about the importance of the collective good over that of the individual. Ho (1974) makes the point that in- dividualism has very different connotations for the Chinese. In the West, it im- plies dignity, freedom, and responsibility. For Chinese people it is selfish and undisciplined action divorced from the group.

In so many areas, the Communist State requires citizens to sublimate their own desires within the ultimate goal of building “socialist spiritual civiliza- tion.” The feelings of the individual must be subordinated to the needs of the group of which he or she is a part: the family, the classroom, the production team, the entire nation. Thus, people are forced to restrict the size of their families for the greater good of the Chinese people. They are allocated to jobs according to the requirements of the Government Plan, rather than the dictates of personal interest or ability. They may be required to leave their homes, to be separated from spouse and child, to work in remote provinces- all for the good of the nation. Millions of people are being compulsorily evac- uated from the Yangtze basin area to be relocated in Xinjiang (one of China’s harsher and most remote provinces) as part of the Three Gorges Dam project. Seen in this context, the restrictions placed on mentally ill people for the greater good of the community are, in Chinese eyes, relatively minor, and they are entirely congruent with other aspects of community life.

Conclusions

Mental illness is a problem to be managed: by families who are expected to exert control over and direct the lives of their mentally ill relatives; and by officials who are required to develop services with increasingly small amounts of financial support from the government and often with little training. interest, or experience to guide them. The Chinese system has not been burdened by the large psychiatric institutions that have so bedeviled Western psychiatric care over the last 30 years. At the same time there is a sense among Chinese psychiatrists that hospital care is the “proper” treatment venue and a corre- sponding reluctance to develop non-hospital-based treatment modalities, although there are a number of successful Chinese models of community-based care. Hospitals are an effective way of controlling those who are believed to be in a condition where they are unable to control themselves. Even when community-based programs are implemented, the focus is very much on ensuring the patient does not pose a threat to public order, rather than issues about quality of life.

In addition, the Chinese system is designed in a way that is structurally anti- thetical to non-hospital-based care because of the pressure to be self-financing. Inpatient fees generate money while community treatment does not. Therefore, the pattern is to keep patients in hospital as long as they can afford to pay. There are perceived financial disadvantages to hospitals in the pattern of a short inpatient stay to treat acute symptoms, followed by community treatment and support, that has found favor in Western countries. As fewer


and fewer people can afford inpatient treatment and as government systems for supporting the chronically ill and vulnerable collapse under the expecta- tion of being financially self-supporting, the strong possibility exists that more and more psychiatric patients will end up living on the streets, thus challenging government ideas about order and control. The Chinese government, judged by the content of its policy documents, construes the need to maintain order and control as one of the main priorities of its mental health policy. It is difficult to see how this can be achieved without a greater input of resources on its part.

The experience of mental illness in China is played out against a backdrop of a turbulent and changing political and economic environment, a cultural context that values order and stability and construes mental illness as the an- tithesis of this. It is not hard to see that a culture that has routinely experi- enced the very opposite of order and stability might wish to expend considerable effort in ensuring a modicum of peace. Within this framework, the major focus is not on the rights or well-being of the individual, but on maintaining conditions in which the collective is as little disturbed as possible. “The greatest happiness of the greatest number” inevitably entails costs to the individual. In relation to China we need to remember that this maxim applies to all people, not just those who are mentally ill.

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Documents

The Chinese equation in mental health policy and practice: Order plus control equal stability