The International Journal of Psychosocial Rehabilitation
Family Caregiving Of Clients With Mental Illness
In The People’s Republic of China

(PART I: HISTORICAL BACKGROUND)



Dr. Kam-shing Yip
Associate Professor
Department of Applied Social Sciences
Hong Kong Polytechnic University
Hung Hom, Kowloon, Hong Kong

Fax: (852) 27736558
E-mail: ssksyip@polyu.edu.hk



  Citation:
Yip K-S. (2005). Family Caregiving Of Clients With Mental Illness In The People’s
 Republic of China (Part1: Historical Background).
  International Journal of Psychosocial Rehabilitation.
10 (1),27-33.



Abstract

In this paper, the writer attempts to describe a brief historical review of family caregiving of clients with mental illness in the People’s Republic of China. Family responsibility in taking care of persons with mental illness was encouraged by traditional Chinese culture. However, political movement and ideologies in Marxism and Communism tended to replace family caregiving by political education and class brother concern. Later, the decline of the Cultural Revolution and modernization of economy brought back the importance of family caregiving in treatment and rehabilitation of persons with mental illness.


INTRODUCTION

Mental illness has long been a great problem in our society. The treatment and rehabilitation of clients with mental illness are regarded as a heavy burden for every government. In the People Republic ofsd China, it is estimated that there are 16 millions of adults with mental illness; 30 millions of adolescents and children with emotional and behavioral problems and numerous old people with dementia and mental problems (Ministry of Public Health, Ministry of Civil Affairs, Ministry of Public Security and Disabled Persons Federation, 2002). Apart from psychiatric treatment and rehabilitation services, the effort of the family caregivers can never be undermined. In the U.S.A, about 65% clients with mental illness who are discharged from mental hospitals returned to their own families (Goldman, 1982; Lefley, 1987). In Canada, around one to two thirds of persons with schizophrenia live with their family members (Seeman, 1988). However, in the People’s Republic of China, over 90% of persons with schizophrenia live with and are taken cared by their family members (Phillips, 1993; Pearson & Phillips, 1994). The burden of family caregiving in the People’s Republic of China is further intensified by its unique social, cultural and legal contexts. In this paper, the writer discusses the plight of family caregivers of clients with mental illness in the People’s Republic of China.

FAMILY CARE : THE ENDLESS BURDEN

Family care of clients with mental illness is an endless burden to family caregivers. Lefley (1996) identified three types of burdens faced by family caregivers. These burdens are also echoed by related studies.

1.      Objective burdens in coping with the mental illness (financial burden, time and effort in caregiving, disruption of daily routine and social life) . (Lefley, 1996; Lefley, 1992; Estroff, et.al. 1994; Saylor, 1994; Hatfield & Lefley, 1999).

2.      Subjective burdens in facing the mental illness (feelings of loss, shame, worry, anger and hopeless towards the client with mental illness) (Lefley, 2000 & 2001).

3.      Burdens in management of problem behavior of clients with mental illness (assault, mood swing, unpredictability, negative symptoms) (Lee, et.al. 2000; Bayer, 1996).

Regarding various types of family caregivers, parental caregivers seem to be most responsible ones. But they are also highly stressful, frustrated in taking care of their children with mental illness (Lefley, 1996; Lefley, 2000; Lee, et.al.,; Hatfield & Lefley, 1987 & 2000).  For spouse as caregivers, they suffer the transformation of their beloved ones with strong feelings of loss and grievance (Judge, 1994). Also, behavioral problems and functional difficulties of their spouses with mental illness are difficult to handle and explain to their children (Noh & Avison, 1988). Facing all these burdens, family members possess various types of coping strategies. There are various factors influencing the coping of family caregivers. These factors are availability of social support and network, opportunities and their willingness to join various types of family support services and programs (Solomon & Draine 1994 & Johnson, 1994). In fact, stress and coping of family caregivers are also influenced by mental health services and policy, as well as social and cultural contexts (Lefley, 2001; Lefley, 1998; Milstein, et.al., 1994; Manderscheid & Barrett, 1987; Manderscheid & Sonnenschein, 1992). In this paper, the writer tries to discuss various factors that influence the family caregiving of clients with mental illness in the People Republic of China. As related issues can be covered within the length of an article, this paper is divided into two parts, Part I and Part II. In Part I, the writer will give a historical overview of mental health services and family caregiving in China. In Part II, the writer will discuss the current situation of family caregiving in China.

A BRIEF OVERVIEW OF MENTAL HEALTH SERVICE AND FAMILY CAREGIVING IN THE PEOPLE’S REPUBLIC OF CHINA

Before the Establishment of the People’s Republic of China
Before the establishment of the People’s Republic of China, mental asylums were built by western missionary. The first one was built by an American missionary, John Kerr (Tucker, 1983; Spencer, 1981; Pearson, 1991). Gradually, small size asylums were found in Beijin,. Shenyang, and Suzhou. Only a few people with mental illness could be treated in these asylums, including five major hospitals and psychiatric wards (Bowman, 1948; Kao, 1979; Pearson, 1995; McCartney, 1926). Most clients with mental illness were in fact, either not being recognized or taken care by their own families. Within traditional Chinese medical perspective, mental illnesses were perceived as `insufficient spirit and air’ (weakening of mind due to poor condition of body) or `saliva blocks one’s mind’ (failure of one’s immune system confusing one’s mind and mentality). In terms of Buddhism, mental illnesses were consequences of one’s previous bad deeds done by oneself and his or her family members. Under such condition, persons with mental illness were only treated by Chinese herbalist doctors.  Most Chinese may seek the blessings from gods in local temples in curing the mental problems of their family members.

Initial Political Care from 1949 to 1963

After the establishment of the People’s Republic of China, the Communist Party embraced a political orientation in delivering related social and welfare services. Political ideologies such as Maoism and Socialism and political bureaucracy played a vital role in shaping mental health services. In 1958, the First National Conference of psychiatrists at Nanjing determined to abandon westernized individualistic treatment and replaced by collective political education (Lin, 1985); open door policy (Shen, 1985); rural home based treatment and indigenized Chinese treatment (Ho, 1974; Chin & Tuan, 1969; Pearson, 1995). Within this period, communist oriented `class brothers and sisters’ as well as `class enemies’ challenged the traditional Chinese family structures. Chinese people were taught to criticize their family members’ Capitalistic evil thinking so as to defeat class enemies. Under this circumstance, family care for clients with mental illness though still practiced by Chinese people, but was suppressed by related policy makers and professionals. Instead, medical professionals identified clients with mental illness as `class brother’ to fight against `mental illness’ which originated from `evil Capitalistic thinking’. In fact, class brother and bourgeois within Communism, was a challenge to traditional Chinese family orientation. In traditional Chinese culture, the family is so important to the Chinese that a special kind of strong familism has been formed, stressing the undeniable predominance of the family over its members in almost all domains of life (Yang, 1995:22).  Under the influence of traditional familism, individual Chinese have to subordinate their personal goals, interests, and welfare for the sake of their families (Yang, 1995) or sacrifice himself or herself for the sake of family honor, harmony, prolongation, and family reputation and wealth. However, under the influence of Communism, class brothers and the benefit to Community Party tended to challenge or even diminish the importance of familism. Family caregiving for persons with mental illness seemed to be replaced by caregiving rendered by political brothers and sisters.

Full Political Care During Cultural Revolution (1964- 1976)

During the Cultural Revolution (1964- 1976), the whole China was fully occupied by a zealous worship of political leader, Mao Zedong. His idea and ideologies were regarded as most responsible way to build up the `New Communist China’. Perception, treatment and rehabilitation of clients with mental illness were interpreted by Mao’s thinking and ideas. Revolutionary Committees in mental hospitals, neighborhood and in working places monopolized diagnosis, admission, discharge of clients with mental illness in mental hospitals as well as their integration within own communities. Political education of Mao’s ideas was regarded as the most effective way to cure mental illness (Yip, 1989; Kao, 1974; Kao, 1979; Leung, Miller and Leung, 1987; Pearson, 1995). Under this circumstance, family was no long regarded as the cohesive social unit for everybody in the society. Instead zealous political worship encouraged mutual criticism and battle among family members with different political orientations. Family care of clients with mental illness was totally ignored by related parties. In some cases, those family members with close connection with Capitalistic linkage might bring extreme mental stress or political torture to other family members. There were considered as the sources of `Capitalistic Evil’. A mechanism of `self criticism’ and `mutual criticism were used in political education group for persons with mental illness. In this group, members would critically debate, argue and criticize every one’s Capitalistic thinking so to eliminate `class evil’ in one’s mind and one’s family. Very often, one had to be highly critical about his or her Capitalistic family members. Such family members were labeled as `class enemies’ and Capitalistic thinking is regarded as the sources of mental illness. Some `Red Guards’ in those days even tortured their family members to death so to demonstrate their faithfulness to Maoism, Marxisim and Communism (Yip, 1989; Yip, 2004). Within this period, family caregiving, was in fact, totally replaced by `political caregiving’ for persons with mental illness.

Mental Health Services Reform (1976- 1987)

After Mao’s death and the fall of the Gang of Four, under the strong, leadership of Deng Xio Ping, China was gradually regained its momentum on economic development and modernization. Related welfare and social services examined their deficits and weaknesses. In 1987, the Council approved a formal document. `Opinions about Strengthening Mental Health Work’ (Pearson, 1995). In this document, the Chinese government admitted that measures had to be done to face the drastic increase in the prevalence of mental illness from 0.7% in 1970s to 1.54% in 1980s. Furthermore, because of serious inadequacy in related services, only 10% clients with schizophrenia could be treated in mental health services. Most of clients with schizophrenia could thus be cared by their own family members (The Second National Meeting on Mental Health Service: 1987) Within this orientation, the role of family care and family responsibility in taking care of clients with mental illness were resumed. However, because of the prolonged closed door policy in isolating influence of western countries, related professionals and policy makers did not propose any services or intervention to support family caregivers of clients with mental illness. Also, there

Commericalization of Mental Health Services (1988 to Present)

Drastic economic development in the People’s Republic of China brought along not only change in industrial production and urban life but also commercialization of welfare and medical services. China government began to withdraw funding from mental hospitals. In 1990s, staff in hospitals run by the Ministry of Public Health had to find 30% to 50% for their take home pay from the charging of admitted patients (Phillips, 1993; Pearson, 1995). In 2000, many hospitals have to run on a self- sufficient basis. For those deprived and poor clients with mental illness, they had to be admitted by mental hospitals run by the Ministry of Civil Affairs. On the one hand, under the influence of western scholars, professionals in China began to implement various types of family interventions including family counseling, home based care and family support group, (Zhang, Yan & Phillips, 1994; Zhang, Wang, Li & Phillips, 1994; Wang, Gong and Niu, 1994; Wang, 1998). On the other hand, all these new developed services only support these clients’ families who were enough to pay for their services.

SUMMARY
As a summary, this paper is a brief description about the historical development of mental health service and family caregiving for persons with mental illness in the People’s Republic of China. It seems that family caregiving in China was influenced by two forces. One was the political control and sanctioning on mental health services that reached its peak in times of Cultural Revolution. Another force was the traditional Chinese cultural perception of mental illness and family caregiving. Facing the drastic economic development and commercialization of social and medical service, there evolve another forces of scarcity of resources of in providing adequate mental health services and related support to both persons with mental illness and their family members. In the next article (Part II: Current Situation), the writer will discuss how these three forces shaped the challenges and opportunities of family caregivng for persons with mental illness in China.


References
Bayer D.L., (1996) `Interaction in families with young adults with a psychiatric diagnosis’ in American Journal of Family Therapy, 24(1):21-30.

Bowman, K.M. (1948) `Psychiatry in China’ American Journal of Psychiatry, 105: 70-71.

Chin, R., & Tuan, C.H., (1969) Psychological Research in Communist China 1949-1966. Cambridge, MA: MIT Press

Estroff, S.E., Zimmer, C., Lachicotte, W.S., & Benoit, J., (1994) `The influence of social networks and social support on violence by persons with mental illness’ Hospital and Community Psychiatry, 45: 669-679.

Goldman, H.H., (1982) `Mental illness and family burden: a public health perspective’ Hospital and Community Psychiatry, 33: 357-560.

Hatfield, A.B., & Lefley, H.P., (1987) Families of the Mentally Ill: Coping and Adaptation, New York: Guildford.

Hatfield, A.B., & Lefley H.P. (2000) `Helping elderly caregivers plan for the future care of a relative with mental illness’ Psychiatric Rehabilitation Journal, 24(2):103-107.

Ho., D.Y. F., (1974) `Prevention and treatment of mental illness in the People’s Republic of China’ American Journal of Orthopsychiatry, 44:621-636.

Johnson, D.L., (1994) `Current issues in family research: Can the burden fo mental illness be relieved’ in H.P. Lefley & M. Wasow (Eds.) Helping Families Cope with Mental Illness (pp.309-328), Newark, New Jersey: Harwood Academic.

Judge, K., (1994) `Serving children, siblings and spouse: Understanding the needs of other family members’ in H.P. Lefley & M. Wasow (Eds.) Helping Families Cope with Mental Illness (pp.161-194), Newark, New Jersey: Harwood Academic.

Kao, J.J., (1974) `Psychiatry in the People’s Republic of China: A prospectus’ American Journal of Chinese Medicine, 2: 441-44.

Kao, J.J., (1979) Three Millenia of Chinese Psychiatry, New York: Institute for Advanced Research in Asian Science Y& Medicine Monograph Series.

Lau, C.C. (1993) `The Chinese family and gender role in transition’ J.Y. Chan & M. Brosseau (edited) Chinese Review, pp. 201-218; Hong Kong: Chinese University Press.

Lee T.T., Ziegel J.K., Sommi.R., Sugar C., Mahmoud R., & Lenert. L.A., (2000) `Comparison of preference for health outcomes in schizophrenia among stakeholder groups’ Journal of Psychiatric Research, 34: 201-210.

Lefley, H.P., (1987) `Impact of mental illness in families of mental health professionals’ Journal of Nervous and Mental Disease, 175: 613-619.

Lefley, H.P. (1992) `The stigmatized family’ in P.J., Fink & A. Tasman (Eds.) Stigma and Mental Illness (pp.127-138). Washington, D.C.: American Psychiatric Press.

Lefley, H.P. (1996) Family Caregving in Mental Illness, London: Sage.

Lefley, H.P. (1998) `Families, culture, and mental illness: Constructing new realities’. Psychiatry,  61(4): 335-355.

Lefley, H.P. (1999) `Helping parental caregivers and mental health consumers cope with parental aging and loss’ Psychiatric Services, 50(3): 369-375.

Lefley, H.P. (2000) `Cultural perspective on families, mental illness and the law’ International Journal of Law and Psychiatry, 23(3-4): 229-243.

Lefley, H.P. (2001) `Cultural psychiatry and medical anthropology: An introduction and reader’ American Journal of Psychiatry, 158(9): 1543-1544.

Lefley, H.P., Hatfield A.B., (1999) `Helping parental caregivers and mental health consumers cope with parental aging and loss’ Psychiatric Services, 50)3):369-375.

Leung Y., Miller W., & Leung M., (1978) `Chinese approach to mental health services, Canadian Psychiatric Association Journal, 23: 354-380

Lin, T.Y., (1985) `Mental diseases and psychology in Chinese culture: Characteristics, factors and major issues’ in Chinese Culture and Mental Health (Eds., W.S. Tseng, D.W. Wu) pp.369-394. Orlando: Academic Press.

Manderscheid, R.W., & Barrett, S.A., (Eds.) (1987) Mental Health, United States, 1987 (DHSS Publication No. ADM 87-1518), Washington, DC: US Government Printing Office.

Manderscheid, R.W. & Sonnenschein, M.A. (Eds.) (1992) Mental Health, United States, 1992 (DHSS Publication No. ADM 92-1942), Washington, DC: US Government Printing Office.

McCartney, J.L., (1920) `Neuropsychiatry in China: A preliminary observation’ Journal of Chinese Medicine, 42:616.

Milstein, G., Guarnaccia, P., & Midlarsky, E., (1994) Ethnic Differences in the Interpretation of Mental Illness: Perspectives of Caregivers, Brunswick, New Jersery: Rutgers University, Institute for Health, Health Care Policy and Aging Research.

Ministry of Public Health, Ministry of Civic Affairs, Ministry of Public Security and Disabled Persons’ Federation, (2002) The Future Plan of Chinese Mental Health Work (2001-2010). The People Republic of China: www.cma-mh.org/p/lawConsult.

Noh, S., & Avison, W.R., (1988) `Spouses of discharged patients; Factors associated with their experience of burden’ Journal of Marriage and the Family, 50:337-389.

Pearson, V., (1991) `The development of modern psychiatric services in China 1898-1949’ History of Psychiatry, 11:133-147

Pearson, V., (1995) Mental Health Care in China: State Polices, Professional Services and Family Responsibilities, London: Gaskell.

Pearson V., & Phillips, M.R., (1994) `Psychiatric social work and socialism –problems and potential in China’ Social Work, 39(3):280-287.

Phillips M. R., (1993) `Strategies used by Chinese families in coping with schizophrenia. In Chinese Families in the 1980s (Eds., D. Davis & S. Harrell), Berkeley and Los Angeles, CA: University of California Press.

Saylor, A.V., (1994) `Nannie: A sister’s story’ Innovation & Research, 3(2): 24-37.

Seeman, M.V., (1988) `The family and schizophrenia’ Human Medicine, 4(2):96-100

Soloman, P., & Draine, J., (1994) Examination of Adaptive Coping Among Individuals with a Serious Mentally Ill Relative, Unpublished paper, Hanerman University, Department of Psychiatry and Mental Health Science, Philadelphia, Pennsylvania.

Spencer, J., (1980) To Change China: Western Advisers in China 1620-1960 (2nd. Edition), New York: Penguin.

The Second National Meeting on Mental Health Service (1987) `Strengthening mental health service in the People’s Republic of China” China Mental Health Net, http://www.cma-mh.org

Tucker, S., (1983) The Canton Hospital and Medicine in 19th Century China (1835 -1990, Ann Arbor, MI: University Microfilm International.

Yang, K.S. (1995) `Chinese social orientation: an integrative analysis’in T.Y. Lin, W.S. Tseng, E.K. Yeh, (eds.) Chinese Societies and Mental Health, pp. 19-39., Hong Kong: Oxford University Press.

Yip, K.S., (1989) `Compare and contrast the psychiatric treatment model in the People Republic of China and South Australia: Its implications of the Hong Kong Mental Health Practice’ Social Work in the Australian Context: Proceedings of the 21st Biennial Conference of the Australian Association, pp-122-127. Townsville: James Cook University of North Queensland.

Yip, K.S. (2004) `Political dominance of mental health service in the People’s Republic of China’ Administration and Policy in Mental Health, 31 (6): 495-502, 2004




Copyright © 2005 Hampstead Psychological Associates, Ltd - A Subsidiary of Southern Development Group, SA.
All Rights Reserved.   A Private Non-Profit Agency for the good of all, published in the UK & Honduras