Mental Health and Chinese Clients

By Dr. Sai W. Wong

Myths abound with regard to the idiosyncrasies of the Chinese culture. Before a practitioner embarks on mental health practice, it is important to clarify such myths. These myths and realities pertain to the concept of culture, the specific cultural stresses, coping style, symptoms of maladjustment, and the desirability and preference for certain forms of psychological help.

Culture

There are two major issues:

Chinese as a unique culture

This is a misnomer. There are many different subcultures among people of Chinese descent, often as many as there are nations in Europe. Moreover, even within each subculture, the ?cultural orientation? of an individual varies from other compatriots by the different degrees of interpretation of collective cultural values due to the varied degrees of acculturation. This is further complicated by various degrees of exposure to a second, third, or any number of other host cultures and thus the influence of secondary acculturation processes. Instead of applying global understanding from knowledge of the subculture, assessment of an individual's inner values that are deemed significant to their mental health should be made. This assessment applies more particularly to mental health workers from the same culture. Presumed understanding based on similar ethnic background is the worst enemy.

Emphasis on cultural differences

While much has been said about the need to heed cultural diversity, resulting in laudable ?respect? for the differences, not enough attention is paid to the more fundamental qualities which we all share is human beings ? the frailties, the sufferings resulting from vicissitudes of life, the universal need for regard, dignity, understanding, empathy, help and support. These qualities often transcend the cultural divide and assist in the process of establishing rapport and rendering help. Thus both differences and similarities need to be equally emphasised. Emphasising differences alone would be alienating, regardless of how well intentioned it might be.

Culture Specific Stresses

Whilst certain stresses are more common among Chinese subscribing to traditional ?Chinese? philosophies and values, the nature of theses stresses have similar qualities as those in occidental people, e.g. loss, frustrations and conflict. The ?Chinese? culture has often been regarded as highly moralistic, rigid, authoritarian and achievement-based. These predicaments have been blamed for causing much stress and mental ill health, especially among the young migrants. Whilst there is some truth in this, it is equally true that the culture also embraces values that are flexible and provides guidance, latitude and protection to those under distress in various situations. In other words, Chinese culture both hurts and heals by providing the latitude to help individuals to cope with stresses (e.g. Chinese culture provides both the moralistic views of Confucius, sitting side by side with the teaching of Taoism and Buddhism, emphasising the importance of tranquillity, release from life's dilemmas, and self-contentment). It is the lack of latitude and absence of flexibility in the carriers of these values (including the client and his/her significant others) that causes much suffering. The insight from such an understanding would allow one to shift attention from examining the culture outside, to those internalised values of individual culture carriers (e.g. the client's parents, spouse, peers and even therapists). In this context, the word biculturalism has a different meaning. It is the assessment of the internalised values between two or more interacting individuals (including the therapist) that is important.

Coping Strategies

The Chinese are said to be too compliant, and passive recipients of fate. This is far from the truth. Like their occidental counterparts, the Chinese repertoire of coping strategies also encompasses both active, passive and mixed methods. The only difference is that Chinese would prefer to use passive means as a first option. This is determined by the cultural emphasis on group cohesion. Thus, most coping strategies aim initially at compromising, inducing resilience and acceptance in individuals whilst at the same time preserving group harmony. () Respect should be given to such priority. Assertiveness, whilst acceptable at a latter stage of coping, would threaten one's relationship with others from the start and thus is not often desirable as a first strategy.

Symptom Presentations

It is often said that Chinese express emotional upsets somatically. But this does not mean to say that they are unaware of their feelings. Language utilisation and cultural inhibitions in expressing emotions often masquerade the presentation. As one looks behind the smoke screen, the feelings are there, within reach of the individual's conscious awareness.

Psychological Approaches To The Treatment

Counselling is not foreign to the Chinese ? only the process is different.

Chinese consult geomancers, fortune-tellers and even herbalists for personal problems. The therapeutic ingredients of such helping relationships are similar to counselling: the need for a trusting and therapeutic relationship, the provision of a framework to both explain the sufferings and as a basis for prescriptions for change. In this light, western individual psychosocial approaches could often be modified culturally to increase their acceptance. However, it is true among Chinese that relationship is more easily built with the Doctor than with other therapists because of the culturally exalted position of the doctor as a healer. In this regard being referred by and sharing a treatment role with an esteemed ?doctor? would often help to strengthen the initial rapport.

Form and structure of the therapy

Because of cultural emphasis on structure and practicality of every day events, therapies that are seen as structured, and providing advice to give some form of immediate relief from distress, are more acceptable than ?plain talk? alone.

Group and family therapies

It is believed that these are not well received by the Chinese. Solving problems within the family is nothing new. But these interventions are seen as efforts coming from within and negotiated by elders. The target is to maintain harmony. The introduction of an outside therapist, often initially seen as intrusive and threatening to family harmony (especially in steering the young ones away from the control of the parents), is much guarded against. However, a modification involving the endorsement from elders or a familiar intermediary would reinforce the rapport of the therapist with the family. A clear role of the therapist as a mediator aiming to preserve ?harmony?, however defined, would make family therapy much more acceptable.

Therapist Qualities

The success of a therapist relies much on his or her ability to be aware of ?biculturalism? (defined earlier), to be flexible and to have the skills necessary for establishing rapport, re-education, reinforcing positive culture specific strategies, and the ?redressing? of western therapies in culturally appropriate terms to enhance acceptance and maximise therapeutic effect.

For Further Reading:

Bond, Michael Harris (ed.). 1996. The Handbook of Chinese Psychology. Hong Kong: Oxford University Press.

March, Baldwin. 1998. Multi-Cultural Issues in Everyday Practice: Chinese Culture. Auckland: Auckland District Law Society.

Lee, Evelyn. 1996. Chinese Families In Monica McGoldrick, Joe Giordano, and John Pearce (eds.) Ethnicity and Family Therapy. 2nd Edition. New York: Guilford Press, 249-280.

Lin, Tsung-Yi (ed.). 1995. Chinese Societies and Mental Health. Hong Kong: Oxford University Press.

Tseng, Wen-Shing and John Streltzer (eds.) 1997. Culture and Psychopathology: A Guide to Clinical Assessment. New York: Brunner/Mazel.

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