Psychotherapy in China: Western and Eastern Perspectives

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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.

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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.

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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, 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.

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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.

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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.

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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.

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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 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.

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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.

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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.
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Suggested readings

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

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