In May 2011 I had an opportunity to co-lead a training on Anxiety Disorders in Shanghai, China. While there I took the opportunity to interview two of the leading mental health specialists in China: Dr. Xu Yong, the Director of Education and Training at the Shanghai Mental Health Center and at the Medical School of Jiaotong University; and Dr. Jianping Wang a Professor at the school of psychology at Beijing Normal University, and the Vice Director of the Department of Clinical Psychology at Capital Medical University in China.
I recently co-led an intensive workshop training at Shanghai Mental Health Center. The focus of the training was how to use Cognitive Behavior Therapy for Anxiety Disorders. Dr. Yong, you organized this training. How do you see Cognitive Behavior Therapy (CBT) fitting into mental health care in China?
Dr. Yong: For a long time, treatment approaches for people with mental illness in China have predominantly used a hospital-based service model, and institutionalization and psychiatric and pharmacological treatment were mainly provided. The services delivered by clinical psychologists, social workers and occupational therapists were mostly unavailable. The over-reliance on the organic-medical approach to mental health care has yielded a narrow emphasis on symptom relief rather than recovery and improvement of life quality and social function. There is a huge gap between the supply and the demand of psychological intervention for mental disorders. I believe CBT, an evidence-based psychological intervention, can help us to bridge the gap.
Dr. Wang, you completed a three-year training in the United States learning Cognitive Behavior Therapy. What is your view of the role of Cognitive Behavior Therapy in mental health care in China? What are the differences you see in how Cognitive Behavior Therapy is practiced in the United States versus China?
Dr. Wang: Over the past 20 years, some people in China claimed to have been using CBT; however, their home-grown practices are a far cry from what CBT really is. In a sense, CBT only got started in China in the past 3 years (the first CBT conference in China was held in 2008). Since then, clinicians and students in universities started to become more interested in taking training courses and participating in workshops to learn real CBT.
The differences in practicing CBT between in US and in China are big in many ways. Generally speaking, CBT in the United States has gone through three stages or waves since the late 1950s, from classical Cognitive Therapy (CT) for depression by Aaron Beck, to a combined approach (Cognitive Therapy + Behavior Therapy) for anxiety disorders by D. Clark and D. Barlow, and now a more integrated approach incorporating eastern philosophy for personality disorders, like DBT by Marsha Linehan.
There has also been a lot of research done to test the outcome of treatment in the United States. In mainland China, we are just starting to learn the basics as the United States did in the 1960s through 1970s.
How would each of you describe mental health care in general in China?
Dr. Yong: Mental health has been recognized as a significant social and public health problem in China. A recent epidemiological survey in four provinces in China showed that the prevalence of at least one current mental disorder in adults was greater than 17% in 2001-2005, and mood disorders and anxiety disorders are the most prevalent types. The World Health Organization (WHO) has warned that the financial burden from mental disorders in China will constitute 1/4 of total burden from various diseases in 2020.
The remarkable social and economic changes in China during the last three decades have made the Chinese people realize the importance of mental health. Chinese people experienced many fast and significant societal changes, such as the dissolution of social security, internal migration, the one child policy, young adults caught between conformity and autonomy, the breakup of traditional family structure, and the individual search for happiness, and therefore experience much more psychological pressure than before. The demand for mental health service is on the rise, as evidenced by the increased utilization of both outpatient psychiatric and mental health counseling services and the tremendous popularity of hotlines and radio call-in programs. By 2009, the Shanghai Mental Health Center was providing psychological counseling to an average of 400 patients each day, a 300% increase from two decades before (data from Shanghai Mental Health Center). The most common reasons for seeking help were school-related problems, family/relationship difficulties, mental disorders, and insomnia. Financial worries and anxiety about adapting to the changing demands of the marketplace have also been identified as key concerns for many Chinese people.
Dr. Wang: In the past decade, there have been tremendous changes in many areas in mainland China. Mental health care is one of them. It is much better than before. Mental health is getting more attention by the public and government alike, especially in the aftermath of SARS in 2003 and the Wenchuan earthquake in 2008. There is also less stigma associated with seeking help for one's mental health compared to 20 years ago. Almost every university has a psychological counseling center to provide services free of charge, and almost every general hospital has a psychological counseling clinic. Some of them have inpatient units, although not all of them are up to appropriate standards. There is an enormous need for qualified therapists, as more and more clinicians in mental health centers learn psychotherapy and combine therapy with medication in their clinical work; and clinical psychologists are trying their best to develop clinical psychology training programs and register systems based on available resources to provide psychological help services. But there is still much room for improvement.
What do you see as the main needs for mental health care in China?
Dr. Yong: The main need for mental health care in China is to provide mental health services to the rural population.
Dr. Wang: The main needs in my view are: (1) quality training programs for clinical psychology in professional institutions, (e.g., psychology departments in universities); (2) additional work by professional organizations, like CPA (China Psychological Association) to pool resources to provide and monitor quality training programs for students and young therapists; and (3) registration and licensure requirements for clinicians.
What are the differences in mental health care between urban centers such as Shanghai and Beijing compared to more rural areas of China?
Dr. Yong: Cities like Shanghai and Beijing have established infrastructures and greater material and human resources in contrast to rural areas. People in rural areas are still poor and many psychiatric patients are not able to afford the mental health care they need. There is also a shortage of basic in - and outpatient mental health services. The lack of follow-up and maintenance services contributes to the chronicity of illness.
Dr. Wang: When comparing farmers and urban residents in mainland China, there are enormous differences in many aspects of life. Health insurance, or lack of it, is one of them. For farmers, they simply lack health insurance coverage (in recent years however, a few rural areas have started to develop health insurance systems run by local governments). It is very hard for farmers to get proper or timely medical help, and mental health help is even harder to get. People in rural areas often have no sense of what psychological help is. In the past decade, psychological help needs increased at a very rapid pace in cities, especially in the larger urban centers. In fact, most professional providers of mental health services are in the larger cities, like Beijing and Shanghai.
What is the attitude of the average Chinese person toward mental illness and mental health care in China?
Dr. Yong: In Chinese society mental illness is still strongly associated with shame and stigma. And although people's attitudes toward some mental disorders, such as depression or anxiety disorders, have changed a lot because of the increased awareness and knowledge about these disorders, the stigma of schizophrenia is still very severe.
Dr. Wang: In China, people find it easier to accept "psychological problems" than "mental illnesses". People with mental illnesses would seek help by going to psychological help centers instead of going to mental health centers or hospitals. Unfortunately, many psychological help providers have no knowledge of psychopathology and have little or substandard training in clinical assessment and diagnosis. In general, the attitude of the average Chinese person toward mental illness is still negative. They are in denial or fear or shun individuals with mental illness. Additionally, the social status of a psychiatrist continues to be lower than other medical specialties. On the positive side, it has been getting better in the past 10 years and more and more students are choosing to become psychiatrists after graduation from medical school.
What would you like to see different in mental health care in China?
Dr. Yong: The Chinese government has already acknowledged the growing mental health problems and has been paying more attention to this field than it did before. Because of the lack of mental health professionals and the awareness of the significance of mental health and high demand of mental health service, more people were attracted to this field, and different kinds of counseling and psychotherapy training programs were provided. However, because counseling and psychotherapy in China are new, and in the past, there were no counseling or clinical psychology courses taught in the universities, the question of "how to train qualified counselors or clinical psychologists" has become a very critical issue. As China is still a developing country, it is unrealistic to expect to meet the mental health needs of a massive population with limited resources within a short time. Therefore, specific strategies will be needed to be developed with the Chinese mental health service.
Dr. Wang: In addition to some of the issues I have already addressed, I believe we also have to improve education for the general public to make people aware of their mental or psychological problems, to reduce the stigma they are subject to, and to get treatment in a timely manner.
What do you see as the biggest challenges for mental health care in China?
Dr. Yong: The biggest challenge for mental health care in China is the shortage of trained mental health professionals. There are only 16,383 psychiatrists among a population of 1.3 billion, and there are few qualified clinical psychologists and social workers in the mental health field.
Dr. Wang: The biggest challenge for mental health care in mainland China is a lack of systemic and high-quality training programs. Chinese people do not get quality treatment because there are not enough qualified professionals to provide services, especially in rural areas.
How do you see mental health treatment changing in the future for China?
Dr. Yong: In the last two decades, many psychotherapy approaches were introduced in China. In Shanghai Mental Health Center, we organized psychoanalytic psychotherapy, CBT, group psychotherapy and family psychotherapy. In the future, patients will have more choices to meet their needs.
Dr. Wang: I am an optimistic person. I would say mental health treatment in China is progressing very fast and becoming more and more professional. In the future, people will gradually have increased awareness and become more tolerant toward mental illness; the government will place more importance on people's mental health and appropriate more funds to this field, and service providers will be better trained. But there is still a long way to go.