Psychotherapy in China: Western and Eastern Perspectives

Psychotherapy in China: Western and Eastern Perspectives

by Stephen F. Myler, PhD & Hui Qi Tong, MD

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From Leicester to Shanghai

I have been living and working as a psychologist in China for the past four years. During this time, I have been teaching psychology, counselling, and psychotherapy courses to Chinese university students. I am originally from Leicester, Britain, where I was trained as a psychologist.

In this paper, I give my perspective based on my own experiences teaching counselling, counselling patients, interviews, and conversations with friends and colleagues in China. I also learned a great deal from the numerous families that invited me to stay with them for a week at a time to observe family life, including those who are from wealthy homes, as well as peasants in the countryside who could ill afford to share their food with me but graciously did. My research with women has come from over 200 interviews with women in China who told me their stories of their lives and marriages. The majority of my clients for my private practice came from referrals from students, other professors, Chinese friends and by word of mouth. Some of my clients came from the Internet who read my profile and sent email requests for help.

Getting a feel for Chinese culture

When I first started seeing clients in China I had to rapidly adjust to a different way of thinking by the Chinese patient. Although the issues were similar to those presented in any typical Western setting, such as relationships, depression, anxiety, family disputes, and lack of self-esteem, the Chinese mindset is profoundly different from my own in regard to their cognition and their way of thinking.

For a Westerner, it takes time to understand the subtlety of the Chinese way of thinking out problems and solutions. It helps to get a feel for the society, the pressures, the traditional ideals, and the judgmental, conforming behaviour. And I am always open to learning something new. You have to take your Western training and try to match the social consciousness of those you are trying to assist. This is not an easy process and does take time. All of my friends here are Chinese and I spend a lot of my time listening to how they see things; it is the only way to understand. Most Chinese do embrace Western culture and see it as an important part of their future and improvements to society. Of course, many Western ideas are not suitable to this society, so we discuss these issues as well.

Cultural factors and psychotherapy in China

What is the culture of psychotherapy in China? What makes up the thinking and feeling processes in the typical Chinese client? Understanding these questions gives us a beginning of how to understand and make trusting alliances with the Chinese patient. Several factors play a large role in the Chinese culture and character that affect attitudes toward seeking help and dealing with emotional difficulties.

Other-centered culture: Many Chinese people see their own problems as coming last compared to the welfare of others. While this is adaptive and socially valuable for the culture at large, it also keeps people from seeking help for themselves and taking a constructive approach to emotional and life problems. The Chinese client often thinks they are troubling the counselor with trifles and are more concerned about the therapist’s welfare than their own well-being. Knowing and appreciating this feeling as normative can also help move the focus to the client in a respectful and therapeutic way.

Culture of therapy? In China, there is almost no culture of therapy that is comparable to the Western culture of therapy. Indeed, there is a great mistrust among Chinese people toward authorities in general, perhaps going back to the cultural revolution and the intimidations and damage done to openness and trust during this time. Most people do not discuss their emotional turmoil with anyone, as they will lose face. In China there is a high degree of anxiety about judgement, criticism and evaluation by the state and other people. This, as you can imagine, makes it very hard to separate social norms from inner feelings. And it adds an extra layer of caution and suspicion when the client comes to see the counsellor.

Face: A crucial thing for the Western therapist to understand is that the Chinese client before them is not going to tell the truth in a direct manner due to the issue of face. This is not uncommon even among more free-thinking Western patients. However, for the Chinese this goes deeper. Face means not being put in a position of shame. In the culture as a whole, the taboo of mental illness is high. People will not admit to anyone that a family member has a problem of this kind or that they themselves are mentally unhealthy. The awareness of shame is very high and controls the daily aspects of business, government, and personal behaviour. A man whose wife is cheating on him will simply complain of headaches to the doctor and request some medicine to help him. To admit that this is in fact stress would be to admit weakness of character—so in turn the physical complaint is easier to cope with and address.

How shame and face affect therapy: First, even if you can get the person into a therapeutic relationship, they will avoid opening up about their concerns to avoid losing face in front of you. This then requires the therapist to begin sessions with an open honest approach to talking about shame and face directly to the patient. The client will instantly understand your meaning and seek a non-judgemental attitude from the therapist in return. It still may take several sessions for the client to trust the therapist before a real exchange of information based on the true nature of their problems comes forth.

Relationships and favour: In China the word relationship carries with it the factor of favour—that is, a relationship is about what you do for each other. Often, it is to one’s advantage that a person does a favour for you. In return, at some future point, you will return that favour—often many times bigger than the original favour. This system of relationships works through government, business, and in daily life.

For example, a university student is failing his course, so the father makes a generous contribution to the University building program, and the boy’s papers are then marked higher. In the West this is corruption, in China just a relationship being confirmed. In the future, the student may become successful; in turn one day he may be asked to contribute; he will feel under obligation to do so. It is this ongoing sense of obligation that causes a great deal of unhappiness in China. In England, we have the old-boys network: the inside practice of people from Oxford or Cambridge University giving jobs and promotions to those who, like them, went to the so-called right places. In China they have these forms of relationships born out of favour and return. Understanding this helps the therapist avoid being shocked and confused when favour is played out so directly.

Family (fealty) and the one-child policy: Family has always been strong in China and from an early age, family loyalty is seen as crucial to survival in the future, as one generation relies on the next for support in old age or infirmity. The one-child policy has dramatically affected the Chinese people’s experience and the lives of families. Under the one-child policy there comes an increased insecurity amongst the elderly and the young alike. Parents put enormous pressure on this one child from an early age to conform to educational expectations, moral responsibility, and the work ethic. In the past, maybe five or six children would have shared the burden, but today that is no longer true; single children feel the increasing need to make a success of life in order to care for their parents later. Cousins become brothers and sisters, which is an adaptive social support, but they cannot share the parental burden as each has their own.

The one-child rule is not rigid: one can have more than one child, but the state only recognises the first child as the recipient of state benefits and schooling freedom. Additional children become a financial burden to the parents. Girls are not appreciated in the family in the same way boys are. Although both genders tend to be over-indulged and spoiled in youth, the boys are definitely given more leeway and mothers’ dotage. In the past, boys were favoured over girls, and if a baby girl was suspected in the first pregnancy, it was often aborted or self-aborted under pressure by the family.

There are many issues that lead to the one-child policy that may seem quite unfamiliar to the Western point of view: over-population, not enough food, overcrowding in the city and lack of services in rural areas, shrinking agriculture and streamlining of production—all leading to massive unemployment and in some cases starvation and poverty. While the West may talk of the legitimate role and value of human rights—the right to choose to give birth or not—practical survival overrides this consideration in the minds of most Chinese people.
The impact of the one-child policy is yet to be known in terms of the psychology of these children, as well as the impact on society and families as a whole
The impact of the one-child policy is yet to be known in terms of the psychology of these children, as well as the impact on society and families as a whole, but it is something that is on the minds of psychologists, the people and the policy decisions of government leaders.

Clash of cultures: In modern Chinese cities it seems as if there is a KFC, McDonalds, or another mass-market fast food outlet on every city block. These fast food restaurants take away the traditional diet of high vegetable and low meat consumption. In return, the young are now enticed to a high-fat, high-sugar, and unhealthy but trendy diet of rubbish food. You can already see the problems of anorexia and obesity in children. The increase in cars and traffic in China is explosive and driving at high speeds is common with resultant high accident rates. The intensity and rate of change is so fast with the growth of the economy, population movement from the rural areas to cities, changes in family size and value systems, making it all quite stressful to keep up with and adjust to the changes.

Education: The educational system in China is very different from that in the West. It is based on memory learning and a strict examination system with little room for failure. Chinese schools manufacture the right qualities for the work place in conformity and strict adherence to authority figures. The system does not teach critical thinking, so wealthy Chinese often groom their one child to go to an overseas University to obtain a broader education, if they can afford it. The benefits of the Chinese educational system, including discipline and basic skills, are evident, but the pressures also impact the emotional well-being of the people.

Suicide: There are 25 suicides per every 100,000 people in China each year, compared with 15 per 100,000 globally. According to the Chinese Ministry of Health the leading cause of death amongst people ages 15 to 34 is suicide, which costs the country at least $3.5 billion a year and is second only to the US. A recent report by the Ministry on the nation's biggest killers listed suicide just after road mishaps.

Language issues: One Chinese woman inquired with me about how I could understand the Chinese psyche when I had no knowledge of the subtlety and non-verbal behaviour that accompanies the Chinese language and peculiarities of expression. I had to agree that this limits my understanding in some respects, which I attempt to fill in by asking more questions of the locals. Yet, as an outsider, I can report my experiences and observations, while people inside the culture give theirs; each view has its own intrinsic and unique value.

I speak about 200 common Mandarin words and can get by in most everyday situations, like in cafes asking for the check. Most of my clients are educated Chinese women and can speak good English. They start learning English from about age 12 and they think it is very important to their careers to speak it well. Occasionally, my Chinese assistants, some who are psych graduates, may sit in and translate, but this is quite rare. I have also found that being culturally aware and non-judgemental is more important than worrying about missing something. After all, it is for the client, not the therapist, to come to an understanding of self in order to cope with life’s problems.

Gender and society

There still exists a culture of male power, ownership, and control (of the money and wife). I have seen a mild change in Shanghai, because here many women out-earn men, creating a whole new social reality for both genders. Historically, women were not seen as integral to long-term family economics. This is traditional in the sense that boys were seen as continuing the farming and family work. Daughters would be married off to another village as quickly as possible, as this saves money in the long run. Even in modern China, parents still find it hard to imagine their daughters bringing in sufficient money to keep them in old age and so encourage good economic matches for marriage. A woman’s first boyfriend is often the husband-to-be, which leaves little room for comparisons and making informed choices.

China is a society dominated by men in all political, social, and business arenas. At one company I visited it was clearly the wife who ran the business and handled the money, but it was the husband who fronted the company to visitors and potential customers. Many male businessmen instinctively talk directly to the men as if the women are not even present.

Chinese women’s relationships and marriage: My exploration of Chinese women and marriage began by accident as much enquiry does: a few remarks here and there by Chinese women, the experience of suicides on campus, the attitude of the men in China and my own experience with living in Chinese homes. These chance remarks and conversations led me to a question: why are so many Chinese women unhappy in their marriages? In most of the homes I stayed in, I could feel the tension between the husbands and wives, almost a tangible atmosphere of resentment.

Most of my clients, who were women, came to me through recommendations via their friends. They seemed to know intuitively that I would not judge them; perhaps being an outsider helped. At first, my insight was rather poor, but as I understood the culture more, I was able to help many of these women face their lives with new hope, often through the technique of reframing: helping them to re-look at their lives and make some positive moves for change.

There are many factors and social pressures that impact women’s lives and marriages in China including the question of love vs. material security, the influence of the husband’s mother on the new wife, and the gender issues between men and women with regard to economic power and control.

Love vs. material security: Often women marry for material considerations and not for love. In my experience, women agree with the wishes of the parents wanting security for their daughters, but through years of socialization, they too believe this is in their best interest. Love is a luxury you cannot afford if you want to survive in a country with undeveloped social services and poor chances of surviving on one’s own.

In the United States about 50 percent of all marriages are now ending in divorce and these marriages were apparently based on love matches. The Chinese use this information to support the notion that love is just a temporary madness that soon dies. They have a point, but there may be other ways of understanding this issue. Most research shows that in order for a relationship to last, the couple needs to have common interests and shared goals in life. It is often when these areas diverge that divorce rears its head in the West. For the Chinese, marriage is about security, loyalty, and family, with love not being a valued factor, at least before marriage.

The wife and the mother-in-law: The new wife is traditionally seen as a new servant by the husband’s mother. Even today, women are often expected to join their husband’s family. Today, some young couples are talking about getting their own apartments and with it some privacy and freedom. Two things seem to get in the way of this: first, the spiralling costs of apartments in China reinforce the old ways, and second, the husbands often invite their mothers to live in the same house or provide her a room for whenever she wants to stay (often months at a time).

The traditional husband: The traditional husband sees the wife in ownership terms and believes her first loyalty is to his family and particularly his mother. Therefore, many wives feel marginalised in the marriage by the husband’s family. Chinese men rarely talk about these issues and they have great difficulty expressing themselves when they do. However, many women reported to me that they suspected their husbands of having girlfriends on the side. For the most part, men seem satisfied with this arrangement of wife and girlfriend, as the wife takes care of all his domestic needs and the girlfriend is his emotional outlet.

In most relationships and marriage difficulties, it takes two to make it and two to solve the problems. The man’s side of relationships and marriage is certainly worthy of more study and investigation. However, at the time of this writing, it is highly unlikely that a husband would come to a therapy meeting, let alone discuss his personal feelings. Perhaps this will change as the men and culture change, as well as new methods are developed to connect to Chinese men in ways that make sense to them. Women in China, however, given the opportunity to talk to a therapist, will open up and share their experiences.
The most important factor for them is a non-judgemental attitude from the therapist and confidentiality; these bedrock therapist traits and attitudes transfer just about anywhere in the world.
The most important factor for them is a non-judgemental attitude from the therapist and confidentiality; these bedrock therapist traits and attitudes transfer just about anywhere in the world.

Case examples

A few examples will help give a sense of the common themes that women have brought to counselling. One 27-year-old woman, Jiang (pseudonym), had been married for a few years and contacted me for a talk. She explained how, having married for the prospect of security, she now found herself mostly alone and with no common interests with her husband other than daily hassles such as rent and food. He ignored her emotional needs and Jiang felt isolated within his family.

I have heard these same stories so often now that it has become somewhat of a pattern. The issue is often one of security over emotional needs. For the woman, at first, emotional needs are not as important if she is secure from poverty, but as time goes by the loneliness of two people with no common feelings eventually leads to a major sense of loss and depression.

Another client, Li Ching (pseudonym), met her boyfriend at the university. They were together for four years, and in the final year they had sex for the first time in a backstreet hotel. Li Ching did not enjoy it. They married a year after leaving the university. Now married five years, Li Ching is extremely unhappy. Moreover, in a country with a history of a one-child policy from the government, Li Ching did not want any children; this is frowned upon by all in the husband’s family. She approached me to discuss her worries. Li Ching is now 28 years old and the first thing she told me was, “I do not love my husband and never have.” She had been unhappy for some time and often frequented night clubs with her girlfriends to dance out her frustrations. She had recently started to learn the Spanish language and at a club met a Spanish man. After a few months, she started to have an affair with this man and reported to me that she has discovered her sexuality and thinks she is in love.

Li Ching found a way to temporarily alleviate her pain via the affair, though of course such a method brings other difficulties and challenges such as divorce and potential shame from family. I am certainly not recommending an affair as a means of coping, only that in this case that is how this woman sought relief from her situation. Many Chinese wives do not see a way to improve their marriages or to find a way out—and rather than face the shame of divorce and the loss of face in the family, become severely depressed and feel that taking their life is the only viable option. Even in the countryside, some women take their lives with industrial fertilizer or pesticide, easy to obtain on farms.

The suicide rate amongst young women in China is high, as I have noted earlier, and it is often an option expressed by those who feel hopelessness. I have heard too many of the women report they had contemplated this end, and this has made me more determined to help where I can. Therapy is not a cure, but a system to help people cope in the world they inhabit. I am happy that, in my experience, most clients report improvement and the increased ability to control their own lives and decisions.

I have witnessed some happy marriages in China, but my research was not to look for happy marriages, which could be the topic of another paper. Instead, my research was to look at what was going on in the unhappy marriages that so many women were talking about.

One great thing about the Chinese clients I have seen, and in this case it is overwhelmingly women who come for counselling, is how loyal they become to people who have a therapeutic relationship with them. Even after treatment has ended many go on to write regular emails to let me know how they are getting on and many are on MSN, Yahoo, and Skype and often say hello and bring me up to date. The Internet has been an important tool for ongoing client support.

Psychotherapy training in China

When I first came to China four years ago, I worked in the research department of the Hubei University in Wuhan (central China). I am currently in Shanghai where I work as Clinical Director for a counselling training company and an EAP provider. At this company they train counsellors for the China licensing body. One of my assigned tasks here in China has been to train a new generation of young therapists with a Western perspective on client treatment. Another task is to supervise the trainers, who are often Chinese professors. The therapy organizations that do exist in China are not training on a wide scale. A beginning-level licensing system does exist and it is fairly easy to pass if you have enough money and time to train.

In China the students learn about the different forms of psychotherapy over an 18-week period, followed by 18 weeks of training in cognitive behavioural therapy and 18 weeks of transactional analysis. This educational background, coupled with experience counselling patients with supervision, gives them a beginning foundation from which to counsel clients.

The classes I teach are at different levels, ranging from undergraduates in their third year (they all do four-year degrees here) through Masters Degree students. Most of the Masters students concentrate on School Psychology and counselling for children with difficulties at school as well as how to handle exceptional children and mental retardation. Many of these Masters-level students go on to become teachers in middle or primary schools where they also act as the school’s counsellor and teacher advisor.

Many students will end up in fields other than psychology, having achieved better people skills and management potential. However, many also become counsellors at schools and colleges. Some who become full-time counsellors often keep in touch with me when they need help or advice. I have set up a peer supervision group for trainees to overcome the shortage of supervisors since many counselors often report to non-professionals. As for post-graduate internships, this is almost unheard of here.

It has been my experience that most Chinese clients are generally not good candidates for Western-style cognitive behavioural therapy—it is too direct and challenging and makes them withdraw. Although CBT has been seen as quite useful for many Asians in the US because of these directive qualities, that has not been my experience. (See a different view of CBT in Chinese Taoist Cognitive Psychotherapy article and in Commentary below.) From my experience, it seems that traditional psychodynamic therapy is often not active nor supportive enough in its Western form for the Chinese client. (See Psychoanalysis in China, September Archive for another take.) I have found that transactional analysis (TA) works very well here.

Chinese people and clients readily understand Eric Berne’s model of the Parent, Adult, and the Child ego states. TA also talks about drivers, life positions, OK-ness, critical parents, and nurturing parents, which are all clearly understood. The one area of TA they all agree on is the position and dilemma of the adapted child—the child who seeks to do anything to survive by following the parents' lead.

Chinese psychotherapy students

Generally, my Chinese psychology students really enjoy learning about therapy and the techniques applied in a Western counselling format. Most had serious arguments with their parents about their choice of majoring in psychology. Parents would argue that there is no money or jobs in psychology, it is not secure, and would not help with getting a good marriage, as well as many other future catastrophes. For the students who managed to stand their ground, they had to endure enormous pressure. This means as a teacher you end up with strong-minded students, keen to prove their choice was the correct one and wanting and demanding the best teaching. For a teacher to have a room of 30 to 50 students who are attentive to your every word is heaven sent, and I am quite grateful.

At first,
many students find it hard to let go of their cultural prejudice and allow clients to be themselves versus a preconceived idea of the Chinese social norm.
many students find it hard to let go of their cultural prejudice and allow clients to be themselves versus a preconceived idea of the Chinese social norm. Many students report great difficultly in getting their clients to talk to them about feelings and they spend a greater part of sessions hearing about the goals and plans of the client, subjects clients present to avoid dealing with their emotional turmoil.

My students commonly reported that their clients do not trust them to keep confidentiality, which is as much based on distrust of authority as it is a view on therapy. The most common client reasons for hesitance to open up are, “I am okay, these feelings will not last,” “I will have to suffer,” and “It is the Chinese way.” Clients are part of a collective culture and mindset of shame-based attitudes, distrust of authority, and a persistent stigma about emotional troubles, thus making trust a difficult task to accomplish in therapy.

New counsellors in the West find it hard at first to relax a client enough for them to feel trusting and confident, but the clients usually expect and accept that therapy is a supportive tool despite their fears. In China the counsellors must work extra hard to gain the trust and confidence of the wary client. Unlike my students, I have had many years of experience as a therapist and know how to help most clients relax and open up fairly quickly. The counsellors I have trained directly have had rocky starts but they pick up these skills in time and soon find their own style of doing things, just as any Western trained therapist does.

In class exercises, when students practiced counselling each other, the female students found it particularly hard to get male clients to talk or share. The male students found it impossible to discuss personal problems with women. Thus, gender roles and issues must be considered and accounted for in working with Chinese clients as well.

Each student has to see psychotherapy clients over the training period at the undergraduate level. They produce a three-part report after each session to the supervising psychologist. At the end of ten sessions they must produce a three-page report summarizing their experience—a case biography, their assessment in technical terms of the clients presenting problems and their action, and exploration of their own feelings that came up while conducting the therapy and how it affected their thinking and outlook. This information enables the supervisor to interview the students and to understand the insights they gained.

The future of psychotherapy in China

It is my hope that mental health services can expand in China and different forms of psychotherapy and counselling will be accepted as normal for ordinary people to access with confidence. However, much progress in the view toward people who suffer from mental and emotional difficulties is needed so that help can be sought out without the fear of shame or losing face; it took a great amount of time for this to occur in the West, and there is still progress to be made there as well.

Certainly, new theories and techniques that are tailored to the Chinese people must be developed as Western and Chinese therapists alike gain more experience and insight. There are signs of greater acceptance of counselling and psychotherapy as witnessed by the training programs and the numbers of students interested in pursuing training, as well as the people who come to and benefit from counselling.

A personal note on my experiences in China

I have found the Chinese people to be friendlier and more willing to help others in a crisis than the people in most of the nations I have been to. I have been made more welcome in Chinese homes than ever in the West with its fortress mentality. The Chinese see each other’s efforts as having a direct effect on everyone and therefore are very considerate of others’ feelings and opinions. I have seen that they sometimes find a Westerner’s directness very unsettling, which I have learned to adjust to. In therapy, I have found that it is key to take into account the relationship as being of greatest importance to the client. I imagine that is true everywhere, and no less true here.

I would rather live in China than most of the hundred-plus countries I have visited over the years. The lifestyle is relaxed and informal—and I feel quite happy each day, since I am treated well by most everyone I meet. There is also a rich cultural history here and beautiful scenery, buildings, and art, which I enjoy often.

My appreciation: Thanks to the following participants in my explorations into Chinese life, culture, and relationships: ZheJiang Normal University, Institute of Psychology; Hubei University, School of Psychology; Shanghai Pinghe International School; the over 200 women in China who told me their stories, and the numerous families that invited me to stay for a week at a time in their homes in the city and the countryside.

Commentary by Hui Qi Tong


In this commentary, Hui Qi Tong explores questions and ideas raised in Dr. Myler’s account. 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.

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 to 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, e.g., 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 and/or 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

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 a 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.
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 therapist's 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 phenomenon. 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 heavily 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 the 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
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

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 in a community counseling setting. Since 2005, I was first an extern and currently have been a psychology intern working with the 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 linguistic, 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 myself, 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 eight 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.”
“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:
  • 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.
  • 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.
  • Show interest in the client’s acculturation process, e.g., struggles, triumphs, and questions.
  • 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.
  • 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.
  • 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.
  • 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 percent 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 and 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 any 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 in 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  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 was 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, training 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.

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.

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 ChinaJournal of Mental Health Counseling. Special issue: Counseling Around the World, Vol 27 (2) 104-116.


Suggested readings

Xue, Xinran (2002). The good women of China. Vintage Publishing.

DK Publishing (2007). China: People Place Culture History. DK Publishing.


Copyright © 2008 Psychotherapy.net. All rights reserved.
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Dr. Stephen Myler is from Leicester in England, an industrial town in the Midlands of the United Kingdom. He holds a B.Sc. (Honours) in Psychology from the UK's Open University, the largest in the UK; he also has an M.Sc. and Ph.D. in Psychology from Knightsbridge University in Denmark. In addition, Stephen holds many diplomas and awards in a variety of academic areas including journalism, finance, teaching, and advanced therapy for mental health. Stephen has many years teaching experience as a Professor of Psychology in colleges and universities in England and China to post 16 young adults, instructing in psychology, counselling, psychotherapy, sociology, English, marketing, and business. He has been fortunate to travel extensively from Australia to Africa to the United States, South America, Borneo, most of Europe and Russia. Stephen's favourite hobby is the study of primates and he likes to play badminton. He believes that students who enjoy classes with humour and enthusiasm from the teacher always come back eager to learn more.

Hui Qi Tong, MD, PhD is a graduate from Shanghai Medical College, Fudan University and a psychiatrist by training before she came to the United States in 1995. She was a research fellow at the Genetics Division, Children's Hospital Boston, Harvard Medical School, Clinical Research Associate in the Psychiatry department, Tufts University, School of Medicine and a research collaborator and content expert at the Older Adult and Family Center at Stanford University, Department of Psychiatry and Behavioral Sciences. Hui Qi graduated from Palo Alto University (formerly Pacific Graduate School of Psychology) with a PhD in Clinic Psychology in 2008. Currently, she is a staff psychologist with the Women's Clinic and PTSD Research Program at San Francisco VA Medical Center and program coordinator for UCSF Global Health Sciences/ Global Mental Health Program. Her main clinical and research interests are in trauma, women's mental health, suicidal behavior, attachment and psychopathology, cultural adaptation of psychotherapy and the integration of Eastern and Western approaches in psychotherapy and related topics. She has co-authored or co-edited about 30 papers and chapters and translated one psychotherapy book into Mandarin, Every Day Gets a Little Closer: A Twice-Told Therapy: by Irvin D. Yalom and Ginny Elkin. Currently, she is translating Sophie Freud's: Living in the Shadow of the Freud's Family.

Hui Qi is also the founding president of American-Chinese Academy for Psychotherapy (A-CAP), a non-for-profit organization established in the Silicon Valley with the mission of addressing mental-illness-related stigma and discrimination and promoting mental health among the Chinese communities both in USA and in China and promoting evidence-based psychotherapy in China through teaching and training. Contact Hui Qi Tong.

CE credits: 2

Learning Objectives:

  • Consider two different perspectives on psychotherapy in China today, one from a British psychologist in China and the other from a Chinese psychotherapist in the United States.
  • Increase awareness of how psychotherapists are trained and supervised in China.
  • Increase understanding of how western psychotherapies can be adapted to the cultural norms of Chinese and Chinese-American clients.