Read also A British Psychologist’s View of Psychotherapy in China by Stephen F. Myler, PhD

In this commentary, Hui Qi Tong explores questions and ideas raised in Dr. Myler’s article on a British Psychologists View of Psychotherapy in China. As a Chinese woman trained in medicine and psychiatry in China, having worked as a  psychotherapist and clinical researcher in the US and China, and now in a psychology internship in a doctoral program in California, she gives her unique perspective on psychotherapy in China, Taoism  and CBT, women in China, the role of shame, and her work with Chinese American clients.

From Shanghai to San Francisco

From China to the USA, and from the East Coast to the West Coast, I have worked with clients in both clinical and clinical research contexts. Thus, I was pleased to be asked by Psychotherapy.net to offer my commentary on topics raised by Dr. Myler on Psychotherapy in China as well as to offer some of my own thoughts based on my experience of having worked with clients in China and Chinese American clients in Massachusetts and California. It is my hope that my commentary and explorations will broaden the dialogue on the topic of psychotherapy in China.

Below, I offer an abbreviated history of my journeys in psychiatry and psychology to date, not just to introduce my training but, more importantly, to show the multiple ways that the worlds of east and west have come together in my work.

• Shanghai, China: I received my Master’s degree in Medicine (equivalent to an M.D. in the USA), specializing in Psychiatry from Shanghai Medical College, Fudan University, in 1994. I did my residency training in psychiatry at the Shanghai Mental Health Center and the Psychological Counseling Center, Zhong-shan Hospital, a teaching hospital of Fudan University.

• Boston, Massachusetts: I came to the United States to join a research lab at Children’s Hospital in Boston in 1995. After about six years doing genetics research on neuromuscular diseases, I went back to the psychiatry field and worked as a Clinical Research Associate in the Psychiatry Department, Tufts University School of Medicine.

• Shanghai, China: In 2001, I interviewed suicide attempters and their families as an ethnographic assistant for a multi-site study on Attitudes Toward and Cultural Meanings of Suicide in Contemporary Chinese Society, a project funded by the Chinese University of Hong Kong.

• Palo Alto and San Francisco, California: Since 2002, I have been a graduate student in the PhD program in Clinical Psychology at Pacific Graduate School of Psychology. I have served as a research collaborator and content expert for the Chinese Caregiver’s Assistance Program at Stanford University and I am currently a psychology intern with the San Francisco Veterans Administration Medical Center.

Now, I turn to my experiences in psychotherapy with clients in China and the United States, engaging the questions of Chinese culture, women, Taoism and CBT, my ideas about working with Chinese clients, and the status of mental health and training in China.

Seeing clients in China

While in China, where I was from, I saw clients at the Shanghai Mental Health Center in both the outpatient and inpatient units. Most of the patients are walk-in patients without scheduled appointments. I did not know who to expect to see before they came in the door. Patients were usually accompanied by their family members who sat with the patients during the visit to provide collateral information. As most patients had severe psychopathologies, besides observation of the patients, I relied heavily on the information on symptoms and medication provided by family members. While on the inpatient ward including a locked unit, I was assigned a few patients with diagnoses ranging from schizophrenia and schizoaffective disorder to bipolar disorders. My work was closely supervised by the attending psychiatrists on the ward.

Hui Qi with Colleagues in front of Fudan University, Shanghai

The experience with the Counseling Center at Zhong-shan Hospital was quite different. Zhong-shan Hospital is one of the top general hospitals and the clients seen there are mostly with neurotic disorders. However, clients with early stage schizophrenia were often seen there as well. Many families prefer to go to a general hospital rather than a mental health center which is less private and more stigmatized. The patients waited outside the room. The nurse gave them symptom measures such as SCL-90 and BDI for new clients before the psychiatrist saw them.

All of the therapists in the Counseling Center were psychiatrists. I first worked with my supervisor, Dr. Jun-mian Xu, observing him doing therapy. Most of the time, he prescribed medication as well, both Western and herbal medicine. He wrote the prescription on the patient’s record book (patients at the outpatient clinic kept their own medical record at that time) and I then copied them onto the prescription paper.

Most of Dr. Xu’s clients were scheduled in advance through the outpatient registration. He had to limit the number of patients he could see in one afternoon. I still remember we were always the last ones leaving the outpatient building on Saturday evenings around 7 pm. He saw 10-15 clients for an average of about 25 minutes each. Later on I started to see clients independently and discussed cases with senior colleagues, i.e., attending psychiatrists. However, there was no formal supervision when I worked there in the early 1990s. 

Around that time, three or four of Dr. Xu’s graduate students, including myself, were learning Cognitive Behavioral Therapy and we all did our dissertations related to CBT, i.e., validating Beck’s Hopelessness Scale, studying the Cognitive style of Chinese who were depressed, etc.

During my work there, I did not feel that it was difficult connecting with patients though I worried that I was much younger than the majority of my clients. I found that discovering commonalities between myself and patients was often a big help to bridge the differences between us and build an alliance. For example, one of my male clients, much older than I was and a well-established engineer who just returned from Britain, insisted that we use English in our work. I gladly tried that as I’d been interested in language as well and it readily made him feel comfortable and open.

Being open to psychotherapy?

In my discussions on the question of psychotherapy with Chinese people, many have raised the question “Will Chinese clients share their deepest emotions/feelings?” “Will they open up to a stranger?” Speaking from my own experience, sure they do, but not in the same way that clients from the West might. In a similar way, I heard many times that group therapy won’t work for Chinese as Chinese people won’t share their deepest feelings or won’t “air their dirty laundry.” Now there is much group work done in China, especially since Irvin Yalom’s classic The Theory and Practice of Group Psychotherapy was introduced to the Chinese mental health community. 

I also attended groups in the Chinese Community in the Bay Area in Northern California with patients or/and family members. They did share in a group setting. They may be sharing in a way different from what we expected and different when compared to people who were raised in the West, but isn’t each individual unique in telling his/her stories and sharing his/her experiences with another person? To further explore these issues, I turn to the next common question: What is the role of shame in Chinese culture and how does it impact psychotherapy?

Shame and psychotherapy in Chinese culture

Chinese character for shame

The Chinese character of shame has two radicals: an ear on the left; and a stop on the right. Literally, anything you don’t want others to hear would be shameful. Shame can be distinguished from guilt: a total self-failure vis-à-vis a standard produces shame, while a specific self-failure results in guilt.¹ The universal view of shame states that shame is one of the quintessential human emotions and feelings of shame are the same cross-culturally which makes a lot of sense to me. Chinese culture values individuals who have a sense of shame, who know right from wrong and who have an awareness of falling short of a standard. In Western society it is not socially desirable to be shameless either, though what brings it about could be quite different. Culture plays a significant role in what precipitates shame, how shame is expressed and handled.  

Thus, what is normal in one culture could be viewed as shameful in another. For example, sending aging parents with dementia to nursing home for Chinese American caregivers is often viewed as something shameful as it violates the Confucian value of filial piety. Chinese families tend to rely heavily on family resources and do not seek external assistance until the internal resources are exhausted. Institutionalizing frail elders seems to be abandoning them. While guilt or shame may accompany family experiences in the West, nursing homes are home to many Western elders despite such feelings and the reaction seems quite different. Slurping noodles while enjoying the deliciousness of the noodle and the soup is culturally acceptable in China, however, it will bring embarrassment and shame if you do this even in a Japanese noodle house on Castro Street in San Francisco. Indeed, I was taught by my English tutor not to make noise while eating before I came to the United States. But something I would see as rude such as blowing one’s nose as loudly as one pleases in the office is common practice in the U.S.

Shame also was a theme that emerged in my discussions with colleagues on suicide in China. One colleague told me about his cousin’s tragic suicide in the 1980s in rural Hunan province after finding out that she was pregnant: “She was so ashamed.” Pre-marital pregnancy was often viewed as a moral debacle but an induced abortion required a marriage certificate or connection with medical staff at that time. Moreover, it could bring shame upon the whole family where the parents would be blamed as being incapable of raising their children properly. The young girl experienced her pregnancy as a failure to conform to the moral standard on her part and used death to get rid of the shameful feeling, at least from the perspective of her cousin.

While some amount of shame in a culture can help people get along, be considerate and avoid hurting others, there is also a downside. In the past decade, researchers in China began to study shame, mental health and personality among college students. Students who were high in shame tended to have a stronger sense of worthlessness and powerlessness and presented more self-denial and escapism in difficult situations.²

A collective, inter-dependent culture with standards that involves a prominent focus on consideration toward others is also more shame prone. Over time, I learned, as a parent, when my son did something unacceptable, to communicate, “I love you, but I don’t like what you just did” instead of communicating, “You are not a good boy,” so as not to elicit unhealthy shame so common in traditional parenting.

The Western humanistic value of self-actualization can be viewed as shameful in a culture like China that emphasizes conformity, causing clashes between satisfying individual needs and the needs of others. I personally know Chinese American college students who gave up their own career goals to conform to their parents’ demands in order to be dutiful children as valued by the Chinese culture. However, they became very depressed as a result.

Shame would be a very relevant issue to bear in mind when working with Chinese clients in psychotherapy. Characteristics like being incapable of holding down a job, establishing a family, or fulfilling the duty as a child, could be viewed as imperfect in regard to the standards of the Chinese culture and society in which one lives, and are common reason for the occurrence of shame. Family history of mental illnesses, of violence and trauma, especially childhood sexual trauma is very sensitive information that could be shame-laden.

Therapists first need to be comfortable asking such questions. They may need to provide a rationale for gathering such information and to normalize it as part of a routine procedure while remaining empathetic and supportive throughout. Sometimes, the client may take several steps or sessions to share the information they feel deeply shamed about. Once they do open up, they often experience a huge relief and it can be very healing as, perhaps for the first time, they are able to go through the darker and desperate roads with their therapists support and witness.

The Chinese woman, the Three Obediences and the Four Virtues

The traditional Chinese feminine ideal, as it is handed down from the earliest times, is summed up in the Three Obediences and the Four Virtues. The Three Obediences are: when unmarried, she lives for her father; when married, she lives for her husband; and when widowed, she lives for her children. The Four Virtues include: womanly character, womanly conversation, womanly appearance, and womanly work. As the Chinese community is going through rapid social and economic changes, these deeply ingrained ideals about women’s roles and responsibilities are changing quickly. Women are becoming more independent and most women in China work outside of the home: “Half of the sky belongs to women.” However, this can also become a double burden as women have to face the same pressure in work as men as well as being expected to be good housewives and homemakers.

The fact that China has one of the highest rates of female suicide in the world is deeply disturbing and warrants continued in-depth research. One may argue that Chinese women are not the most oppressed in the world. However, according to World Health Organization statistics, China is the only country in the world where more women commit suicide than men. (Of note, in the United States, more woman than men attempt suicide but overall, there are more completed males suicides.) Social, cultural, economic and healthcare system factors all contribute to the phenomena. Suicide can be understood as social resistance or protest against an oppressing patriarchal system, e.g., the last strategy used by disempowered women against maltreatment and brutality in an oppressive marriage.³

As the society keeps changing, the ambivalence about gender roles will still exist. Women will likely continue to be more dominant in the domestic domain while their roles in workplaces will be increasingly recognized. Traditions will continue to weigh heavy on women but with education, job opportunities, and improved women’s rights, they will have more inner and external resources to deal with difficult situations in their lives. With greater material security, both men and women will increasingly be able to seek a bond based on true feelings.

CBT and Taoism in China

In North America, I often hear the speculation that the directive approaches to psychotherapy match well with Chinese people’s respect for authority and their advice-seeking behavior. Indeed, this makes apparent sense. The structure of CBT also works well for a population that emphasizes learning and education. The practical, present and future centered focus of CBT also resonates well with Chinese people. Dr. Jun-Mian Xu, my supervisor and dissertation Chair at Fudan University in Shanghai, first introduced cognitive behavioral therapy to China after finishing a fellowship in Canada. He and his team have been working from this approach since late 1980s and have trained hundreds of clinicians in CBT. Now, over 20 published studies have examined the effectiveness of cognitive behavioral therapy for depression, anxiety, sexual dysfunction, and personality disorders, with promising results.

Chinese researchers are searching for cultural adaptations of CBT to fit better with the Chinese people. Asserting the influence of Taoism on Chinese cognitive and coping styles, Zhang, et al⁴ and his colleagues developed Chinese Taoist Cognitive Psychotherapy (CTCP). Clients are helped to achieve deep understanding of philosophical tenets such as “restricting selfish desires, learning to be content, and knowing when to let go,” “being in harmony with others and being humble, using softness to defeat hardness,” “maintain tranquility, act less, and follow the laws of nature.”⁵ Results of a randomized controlled study involving 143 patients with generalized anxiety disorder support the efficacy of CTCP.

Dr. Gallagher-Thompson’s group at Stanford University has finished one of the first randomized controlled outcome studies of a multi-component CBT-based manualized treatment for Chinese family caregivers for dementia patients in the Bay Area, Northern California.⁶ They found that this group of Chinese American caregivers were receptive to CBT and those that received treatment experienced less subjective burden and had substantially reduced depressive symptoms than the comparison group who received bi-weekly telephone support. Currently, pilot studies using this manual are being carried out in California and Hong Kong.

Psychotherapy with Chinese American clients in California

Hui Qi with colleagues at APA Convention in San Francisco, 2007

When I began my studies in Clinical Psychology at the Pacific Graduate School in 2002 I was most interested in psychotherapy as well as the training systems in California.  In my second year, I did a practicum at a community counseling setting. Since 2005, I was first an extern and currently have been a psychology intern working with a military veteran population at the San Francisco VA Medical Center. In my clinical work, the greatest challenge has been the differences between me and most of my clients in terms of our language, ethnic, and cultural background. At the VA, we emphasize cultural competency as part of the growth of the therapist and the psychotherapy work. I often invite my clients to ask any questions and bring up concerns they have about me in terms of my education background, culture, language, etc. This often becomes the first step in building a rapport with my clients.

I also worked with a wide variety of Chinese American clients from the university students struggling with intergenerational conflicts, career choices and sexual identity to Chinese American veterans from WWII to newly returning veterans from Iraq. I first assumed that, since I am Chinese, it would be easier for me to connect with Chinese Americans. I found however, it depends on many factors such as the level of acculturation of the client and my self, the language, expectations about therapy, past experience of therapy, beliefs about mental health disorders, and personal fit.

For example, I was quite careful when I made my first phone call to a client referred to me as he was ambivalent about coming into therapy. It became clear early on that this young Chinese American refused to “be fixed” by a therapist as he experienced his parents as having tried to fix him all of his life. We set out with time-limited therapy with 8 sessions and started there, being sensitive to the core issues in his life.

Though each individual is unique, there are some common themes that emerged in my work with Chinese American clients. For example, most of them don’t talk about their depression or PTSD with family members. When asked, the two most common reasons given were: the stigma attached to mental disorder and the concerns about burdening their parents, “my parents won’t understand and I don’t want to make them worry.” While I seek to honor the traditional values of respecting one’s parents, I also emphasize the importance of family support and the exploration and removal of unhealthy ideas about shame and emotional problems.

I expect there is still much to learn and I will have many opportunities to work with Chinese American clients in the future. I would love to sum up some of the things I have learned from my work though it is difficult since there is certainly no one size fits all rule. With that in mind, here are a few ideas for working with Chinese and Chinese American clients in psychotherapy:

1. Acquire knowledge about the Chinese culture, tradition, values, history, and immigration through reading, surfing the web, consultation with co-workers; get to know and be part of the Chinese community if you can.

2. Get a sense of the client’s understanding and attitude toward mental disorders in traditional Chinese culture and medicine, stigma associated with mental disorders and emotional concerns, and their understanding of and expectation about psychotherapy.

3. Do not jump to the conclusion that “Chinese don’t trust” or “Chinese don’t talk about feelings.” Some do and some don’t and it often depends on the situation and setting. Maybe there are unique ways of showing trust but it may not be readily apparent or expressed verbally; behind that hesitance to open up, if that exists, may be past betrayals to explore, come to terms with and understand over time. Also, traditionally, silence and not talking about oneself can be seen as a show of respect for authority.

4. Show interest in the client’s acculturation process, e.g., struggles, triumphs, and questions.

5. Find commonalities between you and your client, i.e., interest in Tai Chi or a particular food or movies. This is particularly important with immigrant clients in order to forge a sense of connection and common interests which are assumed in people from the same culture.

6. Build rapport with the client at a pace the client is comfortable with, that is, be sensitive to their pace, be it slower or faster than yours.

7. Case specific formulation and treatment approaches are crucial regardless of the theoretical approach. Cultural patterns exist among ethnic groups, but the variation among people is still great and quite meaningful to that person.

8. Most importantly, be open and do not assume what a Chinese client will be like; instead focus on entering the room with compassion and genuine curiosity. Don’t be too embarrassed if you don’t know something since this not knowing can actually connect you to the client in a real way.

The more clients I see, the more I realize that people are often more similar than different. Certainly, many of the thoughts I listed above could be applied to my work with clients from other ethnic and cultural backgrounds.

The status of mental health training in China

Epidemiological studies reveal that about 190 million people (in a country of 1.3 billion people) meet the criteria for some type of mental disorder, however, only 10% of them receive treatment. In the past several years, there has been increased marketing of mental health practice and training. However, the result is limited and controversial. Since very few universities in China offer coursework in psychotherapy or counseling, the majority of the training is through continuing education programs such as those offered by the Department of Labor’s Mental Health Counseling Program, the German-Chinese Psychotherapy Training Program. These training programs attract trainees from all over China and can be conducted in a mental health center, a university setting, or a privately owned counseling company as long as the program is recognized by a licensing body.

The majority of the licenses offered so far are from the Department of Labor and Social Insurance. Five-hundred hours of training will qualify a trainee at a bachelor’s level from whichever undergraduate field to attend the licensing exam. However, the quality of training and the license are often of great concern and are not necessarily honored by the professional mental health organizations. Currently, once licensed, the counselors are generally not allowed to work in a medical setting. Private practice is also very hard to build as competition is fierce. Medical doctors, especially psychiatrists who have both a medical license from the Chinese Medical Association and the License for Counselor from the Department of Labor are at a much greater advantage. During the Chinese-German Conference held in Shanghai, May, 2007, mental health professionals discussed the current status and strategies for psychological counseling and psychotherapy in China, including more systematic training, establishing licensure examination within the professional organizations and promoting communication among different disciplines.⁷

No doubt that there will be many ramifications in the process of professionalism in clinical and counseling psychology in China. For instance, some people raised concerns about the possibility that those licensed through the Department of Labor and Social Insurance would be at a disadvantage and lose their jobs. However, I am optimistic as I believe those who became the first licensed counselors are those who are most sensitive to what is going on in the mental health field and the job market. They also had the courage to take some risks when the outlook is less than clear. They are well positioned to adapt to an ever-changing market and ever-changing system. Indeed, many licensed counselors are seeking further education beyond 500 hours like my colleague, Ms. Wang who recently stated: “It is not enough to work with clients with this training. I am seeking opportunities to further my education and training in counseling.”

The future of psychotherapy in China

Currently, trainings models from various approaches, such as psychodynamic therapy, cognitive behavioral therapy, family systems, transactional analysis, and existential all find their way to the mental health training system in China.⁸ However, it is too early to draw any conclusions regarding what approach works for Chinese at this point before more well-designed research is done. The result may well be the same as in the West: all works but how much, with whom, and when, become the more important questions.

It’s the psychotherapist’s responsibility in China, the US and around the world, to figure out what cultural adaptations to psychotherapy are needed to serve different populations. Even people within the same culture differ hugely (as we know that intra-group difference can be greater than inter-group difference). Case-specific formulation is increasingly emphasized in the West; so too should it be emphasized in the East.

My friend and colleague, Dr. Qi-feng Zeng, the founding president of the Chinese German Psychological Hospital in Wuhan, comforts me with these words: “It is worrisome that it is chaotic in the mental health training system, but we Chinese believe, out of great chaos, emerges great order!”

With the help and expertise of our Western colleagues in the mental health system in China, and the dedication of a new energetic group of Chinese psychotherapists, I believe a system of psychotherapy will emerge that will better serve Chinese people and contribute to a better understanding of human behavior.

Read A British Psychologist's View of Psychotherapy in China by Stephen F. Myler, PhD

Notes.

1 Lewis, M. (1995). Shame: The Exposed Self, New York: The Free Press.

2 Qian, M., Liu, X., & Zhu, R. (March, 2001). Phenomenological research of shame among college students. Chinese Mental Health Journal, Vol 15 (2), 73-75.

3 Lee, S., & Kleinman, A. (2003). Suicide as resistance in Chinese society. In E. Perry & M. Selden (Eds.), Chinese society: Change, conflict, and resistance (2nd ed., pp. 289-311). London: Routledge Curzon.

4 Zhang,Y.,Young, D., Lee, S., Li, L., Zhang, H., Xiao, Z., et al. (2002). Chinese Taoist cognitive psychotherapy in the treatment of generalized anxiety disorder in contemporary China. Transcultural Psychiatry, 39, 115–129.

5 Zhang,Y.,Young, et al.

6 Gallagher-Thompson, D., Gray, HL., Tang, PC., Pu, CY., Leung, LY., Wang, P-Ch., Tse,C., Hsu, S., Kwo, E., Tong, HQ., Long, J., & Thompson, L. (2007). Impact of in-home behavioral management versus telephone support to reduce depressive symptoms and perceived stress in Chinese caregivers: results of a pilot study. American Journal of Geriatric Psychiatry, Vol. 15(5), p 425-434.

7 Xiao, Z. P. (2007). The current situations and strategies for psychological counseling and psychotherapy in China. Presented at the Chinese-German Congress on Psychotherapy, May, 2007.

8 Chang, D.F., Tong, H.Q., Shi, Q.J., & Zeng, Q.F. (2005). Letting a hundred flowers bloom: Counseling and psychotherapy in the People’s Republic of China. Journal of Mental Health Counseling. Special issue: Counseling Around the World, Vol 27 (2) 104-116.

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