Training mental health professionals in China

This post was contributed by Viviane Green from Birkbeck’s Department of Psychosocial Studies. In 2014,  Viviane Green was appointed as the First High End Foreign Expert in the Field of Child and Adolescent Psychotherapy by the Chinese State Administration of Foreign Expert Affairs.

Chinese model familyMental illness is heavily stigmatized in China. Dr Zhang, a Chinese psychiatrist, has characterised his culture as ‘other-centred’, with families not wishing to burden a professional with their problems, underscored by shame and anxiety at losing face by talking about family troubles in public. Despite this, there has been a huge growth in the demand for counselling and psychotherapy. There is general acknowledgment by the Chinese child and adolescent psychiatric establishment that early intervention programmes are needed, especially for the millions of left behind children (those left with family in the countryside for long periods while parents work in the cities). In a population of 1.368 billion, there are 20 000 psychiatrists, which gives some indication of the scale of the need for training mental health professionals.

Since 2012 , in collaboration with my Chinese colleague Dr Wang Qian (Child Psychiatrist and Analyst), I have been involved in the Sino-British Psychoanalytic Psychotherapy Training Program for Children and Adolescents. This began as a one-off five-day training event and has rapidly developed into a three-year programme. It comprises two annual five-day sessions and weekly seminars over the internet with experienced UK-based child psychotherapists and psychoanalysts, in which students report on their weekly observations of a mother-infant relationship within a family setting. Three clinical groups have been established where students present anonymised clinical case studies. A specialist fortnightly seminar for developing Chinese clinical supervisors is about to be launched.

In the development of the programme many questions have had to be considered.

Is there a culture for psychotherapy in China?

The radical and rapid social change which China has experienced since the 1980s has undoubtedly created psychosocial stresses impacting on families. There has been large-scale internal migration. Social security has ended and there has been a breakdown of traditional family structures. Parents born during the one child policy (1979-2016) are now a ‘squeezed middle’, caught between ageing parents on the one hand and their child on the other. The one child policy, in the Chinese view, has created a generation of ‘little Emperors’ – children with more limited social adaptive capacities. There has been an increase in individuality, with young adults torn between conformity and autonomy. Increasing levels of anxiety among ‘anomic’ youth and overstretched parents struggling to make ends meet may have created the conditions ripe for a psychodynamic approach to flourish.

What are the challenges for the British teachers and the Chinese students?

Students are highly motivated with a traditional deep respect for teachers. They come with varying depth of understanding and experience. Sometimes a wide gap reveals itself between the ‘cognitive’ level and clinical understanding. A good deal of basic thought has to be given to how to ‘teach’ students to really listen and reflect without stepping in with ‘solutions’.

The challenge in teaching students who have long been involved in a highly competitive, structured, formal chalk/talk educational system that stresses achievement is how to foster peer group learning where peer group engagement is valued. It has meant explicitly avoiding stepping into the role of ‘expert’ and inviting participants to develop their thoughts or seek out the views of others in the group.

Is a psychodynamic approach founded on a Eurocentric model relevant to a Chinese context?

We are all aware that our model is Eurocentric and this is particularly apparent in the mother-infant observation seminars, where the observations are usually of a child growing up in a three generation household. Grandparents are omnipresent and often offer the childcare while both or one of the parents is at work. The particular dynamics between mother/father and paternal or maternal grandparents are part of the fabric for consideration. We are also aware how this affords a child an unusual degree of emotional investment.

A core question both at the level of theory as well as clinical practice is how we think about the self. Is the individuated self, where it is deemed a healthy norm to gain independence from the family of origin, one which needs recasting in the Chinese context, where instead of an ‘ego’ there is an embedded ‘wego’?

In moving between the ‘universal’ (i.e. we are all social beings with a mind and a developmental timetable which unfolds) and the ‘particular’ (the specific ways in which a culture may draw up the lines of internal conflict) we are in a process on-going learning from our students. It is in the relative safety of the smaller group clinical and mother-infant observation seminars that we get a more ‘intimate’ sense of what profoundly concerns the students and also what sparks lively debate, for example a sense that having been born a girl rather than boy can carry a sense of disappointment.

Looking to the future

The programme has clearly flourished since 2012 with the first cohort having graduated and a second cohort having completed their first year. The next steps needed to secure its future include the development of a framework for formal accreditation, identifying clinical competencies and embedding the programme in a university context, to give it greater sustainability.

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Guilt, pity and shame in humanitarian and human rights communications

This post was contributed by Dr Bruna Seu from Birkbeck’s Department of Psychosocial Studies

NGOs often use images designed to induce feelings of guilt in order to encourage donations

You have just sat down for lunch. You switch on the TV and you are confronted with the image of a malnourished child. Somebody is measuring their arm with a tape and the appeal asks you to donate £3. It’s simple: you have your lunch, they don’t. You feel guilty and you give.

This guilt-inducing formula raises much-needed revenue for NGOs and humanitarian organisations, so it is understandable why they return to it time and again. However, my research into the way the public responds to information about human rights violations and humanitarian crises suggests that using guilt as a fundraising tool is problematic.

The problem with guilt in humanitarian fundraising

The pain of guilt inspires in people a new capacity for reparation and the desire to right the wrong. While a monetary donation can momentarily alleviate the guilt inspired by humanitarian appeals, for many it does not constitute a sufficiently reparative action.

A more desirable aim than finding a way to momentarily alleviate guilt is to develop a feeling of connectedness with those suffering. Development of a meaningful understanding of the issues at play is hindered by narrow, racially-stereotyped portrayals of developing countries, which ignore the role of domestic actors in the global South and reinforce the perception that more charity is required rather than fundamental political and economic change.

A further problem is that the sheer volume of these guilt-inducing messages leads to a sense of hopelessness and helplessness that shuts down routes to improved understanding and connectedness, creating a vicious cycle where we feel guilty, donate to alleviate guilt, and then ignore the suffering other until we are bombarded by further guilt-inducing messages. This cycle leaves no room for alternative thinking that would increase awareness of development issues or behavioural engagement in the form of volunteering and campaigning.

Participants in my studies have shown awareness of guilt being part of their immediate reaction and that when ‘it wears off’, as they put it, they are left with nothing to hang onto. So we have a self-perpetuating cycle whereby people donate partly because they  feel pity, compassion, guilt and they want to help; partly because they don’t know what else to do; and partly, as a consequence of these two. Donating is a way of ‘switching off with a clear conscience’.

Shame vs guilt

My research is now beginning to consider the experience of shame as opposed to guilt, and whether this would lead to more meaningful engagement in the issues. There are many potential problems to invoking feelings of shame. However, while guilt is related to an action – something we did or didn’t do, shame is about the whole of ourselves. Yet, precisely because it is personal, rather than relating to a bad action, it rests on relationality – what needs repairing is the link with the other. Let’s say if guilt messages are of the kind ‘skip lunch – save a child’ and a child dies because you did not skip lunch, of course you give – you ‘did the right thing’. But what if messages prompted reactions such as: ‘I don’t want to be the kind of person who is informed of such horrors and doesn’t do anything.’?

Contrary to guilt, regulated by the world of norms and laws which is the territory of the superego – the self I ought to be, the referent in shame is the ego ideal – the self I wish I could be. It might seem a small difference, but one that shifts the terrain from the transactional to the relational. I am no longer saving the other, but on the contrary it is with the other that I can be saved. When the bond between self and other is intact we feel pride and harmony. Maybe such a relational mode could return dignity and power to the other and make us agents not of hand downs but of our own betterment as human beings.

This article is based on a talk that Dr Seu gave recently at the Dartington Centre for Social Research

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