International Journal of Psychosocial Rehabilitation
With Mental Illness
In The People’s Republic of China
I: HISTORICAL BACKGROUND)
Dr. Kam-shing Yip
Department of Applied Social Sciences
Hong Kong Polytechnic University
Hung Hom, Kowloon, Hong Kong
Fax: (852) 27736558
Yip K-S. (2005). Family
Caregiving Of Clients With Mental Illness In The People’s
Republic of China (Part1: Historical Background).
Rehabilitation. 10 (1),27-33.
In this paper, the writer attempts to
describe a brief historical review of family caregiving of clients with
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
ideologies in Marxism and Communism tended to replace family caregiving
political education and class brother concern. Later, the decline of
Cultural Revolution and modernization of economy brought back the
family caregiving in treatment and rehabilitation of persons with
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
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 &
3. Burdens in
management of problem behavior of clients with mental illness (assault,
mood swing, unpredictability, negative symptoms) (Lee, et.al. 2000;
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
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-
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.
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
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