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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Multilingualism in psychotherapy

Professor Jean-Marc DewaeleThis post was contributed by Professor Jean-Marc Dewaele, who presented on this topic at a conference earlier this month to celebrate the 50th anniversary of the Department of Applied Linguistics and Communication. He originally contributed this blog post in 2013, when it won that year’s Equality and Diversity Research Award  from the British Association for Counselling and Psychotherapy for the paper Costa & Dewaele (2012).

Emotions play a crucial part in our daily lives. We share them, jokingly or seriously, in face-to-face interactions, in texts or emails, and this is a crucial social activity, which is crucial for our interpersonal relationships and our individual well-being.

It is much more difficult to communicate emotions in a foreign language (LX), because of gaps in the linguistic, pragmatic and sociocultural knowledge needed to express the full range of emotions.  LX users (and I’m one myself in English) can feel frustrated at not being able to project an accurate image of self. Interestingly, a majority of multilinguals report feeling different depending on the language they are using (Dewaele & Nakano, 2013). It typically takes a couple of months before LX users can be relatively confident that their communicative intentions in expressing emotions will be correctly decoded and that their capacity to infer the emotions expressed by their interlocutors is sound. The difficulty lies in the fact that as first language (L1) users we can express our own emotions precisely, and recognise other people’s emotions unerringly.  This sense of security is lost when having to communicate emotions in the LX (Dewaele, 2010).

I have explained in an earlier blog that emotion words can have a very different resonance in the different languages of a multilingual: swearwords typically don’t sound as offensive in an LX and expressions of love don’t sound as strong. A study on Turkish L1-English L2 bilinguals showed that emotional phrases presented in an L1 elicited higher skin conductance responses than the translation of these phrases in a L2 (Caldwell-Harris & Ayçiçeği-Dinn, 2009), in other words hearing Turkish taboo words made participants sweat more than the equivalent words in English.  It thus seems that the L1 is the language of the heart, while the LX often fulfills an intellectual function and is relatively emotion-free, creating a feeling of detachment or disembodied cognition (Pavlenko, 2013).  Research has shown that immigrants’ memories that were experienced in the L1 are generally richer in terms of emotional significance when recalled in the L1. When these L1 memories are recalled in an LX, some emotional intensity is lost.

This might not always be a bad thing, especially if the multilingual is talking about traumatic events like torture or rape.  It is crucial that psychotherapists are aware of this phenomenon.  Indeed, there are important psychotherapeutic implications of being multilingual both for the patient and for the therapist. Beverley Costa, director of the charity Mothertongue, was struck by a quote from a Greek-English-French participant in my 2010 book:

I think when I talk about emotional topics I tend to code-switch to English a lot. I remember when I was seeing a psychologist in Greece for a while I kept codeswitching from Greek to English. We never really talked about this…To my mind it may have been some distancing strategy. (p. 204).

Beverley contacted me to carry out a study on differences between monolingual and multilingual therapists.  The paper, which was published in 2012, showed that psychotherapists agreed that learning a language made them better attuned to other languages and to multilinguals. They also believed that through working across languages they had learned to think carefully about how they used language, to check understanding and to simplify their language. Although no therapist had tried out inviting other languages in to the therapy they were interested and saw the potential of trying this.  The judges from the British Association for Counselling and Psychotherapy who awarded us the Equality and Diversity Research Award (2013) particularly liked our recommendations for research, practice, training and supervision: “Firstly, it would be useful and interesting for further research to be conducted on language switching in therapy – how it is initiated and what it signifies. The second recommendation relates to practice. This research highlights the need for therapists to pay attention to the way in which the inherent self-disclosure is managed by the therapist who speaks multiple languages (…). It is also suggested that therapists consider if, when and how to initiate inviting languages they may not understand into the therapeutic space and the therapeutic implications of such an initiative. Finally, it is suggested that training of psychotherapists needs to include a component on the psychological and therapeutic functions of multi/bilingualism and underlying implications for therapy. Training and supervision for psychotherapists could also include practice for therapists to make formulations in different languages. With increasing numbers of multilingual people now accessing therapeutic services and becoming therapists, it seems timely for the curricula of psychotherapy courses and therapeutic practice for all therapists – mono and multilingual – to be revised in order to take into account the changing profile and language needs of users and providers” (Costa & Dewaele, 2012: 35).

The study and the award will be presented at the BACP Research Conference in Birmingham on 10-11 May 2013.

Other posts by Professor Dewaele:

References

Caldwell-Harris, C.L. & Ayçiçeği-Dinn, A. (2009) Emotion and lying in a non-native language. International Journal of Psychophysiology 71, 193-204.

Costa, B. & Dewaele, J.-M. (2012) Psychotherapy across languages: beliefs, attitudes and practices of monolingual and multilingual therapists with their multilingual patients. Language and Psychoanalysis 1, 18-40.

Dewaele, J.-M. (2010) Emotions in Multiple Languages. Basingstoke: Palgrave-Macmillan. doi:10.1057/9780230289505.

Dewaele, J.-M. & Nakano, S.  (2013) Multilinguals’ perceptions of feeling different when switching languages. Journal of Multilingual and Multicultural Development 34 (2), 107-120. DOI: 10.1080/01434632.2012.712133

Pavlenko, A. (2012) Affective processing in bilingual speakers: Disembodied cognition? International Journal of Psychology 47, 405-428.

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