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

(PART 2: CURRENT SITUATION)


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 (Part 2: Current Situation).
  International Journal of Psychosocial Rehabilitation.
10 (1) 35-42.



Abstract

Family caregiving for clients with mental illness is crucial in psychiatric treatment and rehabilitation. It is particular important in the People’s Republic of China where over 90% of clients with schizophrenia are taken care by their family members. In this paper, the writer attempts to describe current situation of family caregiving of clients with mental illness in the People’s Republic of China. Within social and cultural conditions in the People’s Republic of China, family is regarded as the most important caregiving for clients with mental illness. However, family caregivers in the People’s Republic of China are not properly supported by related professionals, interventions and services.


FAMILY CAREGIVING FOR CLIENTS WITH MENTAL ILLNESS: OPPORTUNITIES AND CHALLENGES
Family caregiving for clients with mental illness are influenced by various factors such as political, social, cultural contexts and related policies and services (Lefley, 1998; Lefley, 2001; Solomon & Draine, 1994; Johnson, 1994; Milstein, et.al. 1994). In the People’s Republic of China, all these factors played a crucial role in shaping the family caregiving of clients with mental illness. There are both challenges and opportunities in facing the current and future development of mental health services in the People’s Republic of China.

Social and Cultural Context of Family Caregiving
Under the influence of the traditional Chinese culture, family is regarded as the most important cohesive unit in the society. Based on related research findings in Taiwan, Hong Kong and the People’s Republic of China, Yang (1995) asserted that Chinese people are deeply influenced by `familism’ which means individual Chinese are accustomed to place family honor, family continuation, family prosperity and stability more than individual interests. On the one hand, individual family member should sacrifice themselves to preserve, maintain and enhance family honor, stability and prosperity. On the other hand, members of family can be or should be protected continuously by their families. Lau’s (1993) studies showed that Chinese families were unwilling to seek outside help in caring family members with disabilities as it may imply shameful disgrace to the whole family. Under that sort of Chinese social orientation, it is understandable that families in the People’s Republic of China are inclined to assume the responsibility in caring their family members with mental illness. They feel shameful to disclose family members’ mental illness to others. They may feel inadequate in asking external help including professional intervention.

Traditional and Superstitious Perception of Mental Illness
Within traditional Chinese superstition, mental illness is perceived as something mythical like demon possession or by some evil spirit. In Buddhist thinking, one’s suffering is the consequence of previous misdeeds. Thus, mental illness may be perceived as punishment of misdeeds done by clients themselves or their family members. Within this orientation, mental illness is shameful label for Chinese persons with mental illness and their family members. It implies that related family member may have done something immoral or mischievous in this life or the previous life (in Buddhism, one has three lives, the previous, the present and future. One is a man in this life but may become an animal in the next life because of his misdeeds) Being influenced by such superstitions, family members of clients with mental illness, especially those in rural areas where traditional superstition still prevails, family members may feel reluctant to disclose or even admit their relatives’ mental illness. Sometimes, even though the family members have good knowledge about mental illness, still their neighbors or friends may gossip around suspecting or believing that the occurrence of mental illness is a kind of punishment of misdeeds and immorality done by family members. Perhaps, the following self narration told by a Chinese farmer can briefly describe the influence of traditional superstition on family members of clients with mental illness:

`Oh heaven, what misdeeds I have done in my previous life that deserve that kind of punishment. I cast all my hope on my son. I spent all my money for his schooling but he was crazy just because the leaving of girl friend. He talked to himself frequently saying that he was the God of heaven that attracted beautiful girls. Everybody in the village knew that he was crazy. It was a terrible shame to our whole family. My neighbors gossiped around me thinking that my son’s madness was a consequence of my misdeeds done in my present and previous life. In fact, I have done nothing immoral in my life. I tried to be kind hearted to everybody. The only misdeed I had done so far was killing of my cow that had worked for me for fifteen years, but it was so sick and painful. My wife blamed me that my son’s craziness was due to my misbehaviors toward our god in our village temple. Last year I refused to go the temple and attended the annual ceremony for our god’s birthday. ‘

Shifting of Caring Responsibility from Government to Family
The central government of the People’s Republic of China presumes that family members should shoulder the caring responsibility of clients with mental illness. In the Marriage Law enacted 1980, Article 14, Article 15 ensured the obligation of a spouse to take care one another as well as their children in times of incapacity including mental illness (Pearson & Phillips, 1994). The obligation to care is further complicated by the withdrawal of the government in providing free care for clients with mental illness. Family members, especially parents and spouse are obliged to provide food, accommodation, and other facilities to support living of clients with mental illness. Furthermore, related legislation sanctions family members in making health care decision such as admission by mental hospital, accompanying clients in psychiatric outpatient clinics. In many cases, doctors can refuse to treat a client that is not accompanied by his or her family member (Phillips, 1993; Pearson & Phillips, 1994). The following story told by a Chinese psychiatrist can briefly show these situations.
`Very often, we can do nothing. It all depends on whether or not related parents and spouses are willing to take their children and spouses for treatment. Our legislation authorizes immediate family members including parents, spouses and children to make health care decisions rather than medical professionals. Once there was a client with mental illness with disposition of violence. He hurt his sister at home by a knife and was taken to our hospital by his neighbors. However, as his father refused the admission. They went home. We could do nothing, except waiting for next time the re-occurrence of another violent incident.’

Legally speaking, only those mental hospitals run by the Ministry of Public Security (forensic hospitals) can make involuntary admission and compulsory detention of clients with mental illness, disposition of violence and criminal records. For those mental hospitals that are run by the Ministry of Civil Affairs and Ministry of Public Health, family members are the final decision makers in determination of admission and discharge of clients with mental illness in mental hospitals. For those areas where forensic mental hospitals are absent, admission of clients with mental illness and disposition of violence is still determined by their family members.

Family Coping with Mental Illness
Facing the endless burden in taking care of the clients with mental illness, family caregivers in the People’s Republic of China have to cope by using their own resources and connection. In taking care of their children with mental illness, Chinese parents tried to ensure continuous care by having a marriage, finding suitable jobs and having grandchildren (Pearson, 1995; Phillips, 1993; Pearson & Phillips, 1994). Under the influence of traditional Chinese culture, an normal adult should be married, having a decent job and having one child (under the family planning law of the People’s Republic of China, every couple is only allowed to have one child). In fact parents with adult children with mental illness are kept between a dilemma. On the one hand, they feel shameful about their children’s mental illness. On the other hand, they may try to prove that their children are in fact as normal as other persons. The pursuit of arrangement of marriage, job and having grandchildren are highly symbolic in meaning in their coping of their children’s mental illness. First, it symbolically means that their children are normal adults as others. Secondly, it implies that their only child, especially the son can still succeed the family line in the next generation. Thirdly, it means that their children with mental illness can be taken care by their spouses.

Coping by Marriage Arrangement
Despite the disapproval of the Marriage Law which prohibited marriage with a person with schizophrenia and bipolar disorder, many parents still try their every mean to arrange marriage for their children with mental illness, in particular their sons. There are trade offs within these arrangements (Phillips, 1993; Pearson & Phillips, 1994). For example, a country girl living in highly deprived rural area may be willing to marry a rich man in a developed city so that her unit of residency can be transferred from deprived area into highly developed cities. In some cases, the parents concerned may disguise the mental illness of their sons or daughters in marriage. However, in real situation many of these marriages may end up with divorce or legal accusation. Related document and records show marriage of persons with schizophrenia bears ten times divorce rate in comparing with those average couples in the People’s Republic of China (Pearson, 1995).

Coping with an Arrangement of Job
Parents of clients with mental illness in the People Republic of China may try the very best to arrange a job for their children. As vocational rehabilitation in China is not well developed with only a few work station therapy units in well developed cities (Luo & Yu, 1994), clients with mental illness and their parents have to find their own resources. In rural areas, where labor intensive farming is needed, farmers like to keep   their sons with mental illness as a manual labor to help in farming work (Qiu and Lu, 1994). In urban areas, family members have to utilize their own social connection to secure a job for clients with mental illness. They may try to bring their children to the same factory they are working as simple manual labor. For those parents with authority and social status such as government official, heads of factories or managers in companies, they can easily make job arrangements for their children with disability including mental illness. For those parents who are poor, powerless and deprived, they have to keep their children with mental illness at home.

Pseudo-Coping with Avoidance, Denial and Tolerance
Drastic economy development in the People’s Republic of China does not bring along equality in wealth distribution. Instead it intensifies the difference between the poor and the rich. Within the 1.3 billion population, only a few are much more richer than before, most population still have to live a hand to mouth life, especially those in deprived rural areas. In family caregiving of clients with mental illness, only a few family caregivers can afford to pay charges for related medical treatment and rehabilitation for their family members with mental illness. Only few of them are able to use their own connection and resources to secure a job, and arrange a marriage for their children with mental illness. For most family caregivers in the People’s Republic of China, the coping mechanism they can use is avoidance, denial and tolerance. Avoidance implies the following:

1.    avoidance of admitting the mental illness of their family members;
2.    avoidance of contacting others, including neighbors, friends and relatives.
3.    avoidance of seeking for help from related professionals.

Denial implies denying that their family members having mental illness. Within the influence of traditional Chinese culture, denial may appear by attribution the cause of mental illness to superstitious and mythical demon possession and follow by seeking the help from gods in local temples. Tolerance means endless tolerance of clients’ bizarre behaviors, fluctuation of emotions, withdrawal, inert and passivity. In some cases, parents in well developed cities may send their children with mental illness back to their mother village in rural areas and look after by close relatives there. In some families, one of the parent may bring the child to other city so to avoid the labeling effect on both the family and the client (Pearson, 1995). Perhaps, the following narration told by a family member in People Republic of China can briefly describe the plight of the family member in caring clients with mental illness.

`My son has suffered from schizophrenia for ten years. Within these ten years, life is a total torture. At first, we sent him to hospital for one month by borrowing a huge sum of money from my friend. When he was discharged from hospital, he looked better. But no sooner, he relapsed again, indeed, we could  not afford for further treatment. He simply turned worse by locking himself at home and refused to go outside. We could do nothing. You know, my wife and me have to work very hard to earn a hand to mouth in this highly competitive city. We could not look after him. Later, his grandfather brought him to my mother village and he was then looked after by his grandparents. Unfortunately, his grandfather died of heart attack one year later. My mother was sick and was too weak to after him. I brought him back home. His schizophrenic symptoms prevailed. I had tried every mean including praying to my God in local temple, seeking help from Chinese traditional medicine and tried to encourage him to work as manual labor in my factory. The manager in my factory was my classmate in high school. He was kind enough to care about my son. However, months later, he refused to work. He continuously isolated himself from the reality, absorbing in his delusion that he was a talented scientist that one day he could make a lot of money by new invention. Frankly speaking, apart from keeping him at home, I can do nothing. He is a shame to my family. I and my wife suffered a lot in taking care of him. To avoid being labeled by others, we avoid meeting with our friends, our relatives and our neighbors. My son is hopeless and my life is helpless. We have to endure the burden endlessly. Our worry is that when we die no one can take care of my son.

INADEQUATE FAMILY INTERVENTION AND SERVICES
Facing the insurmountable demand and burdens of family caregivers in the People’s Republic of China, there are only a few services and interventions provided by related parties. These services and interventions are: home based care, family counseling, guardianship network, psychoeducational programs and family support group.

Home Based Care
For those highly deprived rural areas where services accessibility is definitely a problem, home based care was tried out in some areas in the People Republic of China. Wang (et.al, 1994) described this in the following details:

`The home care treatment program is provided to patients with acute symptoms if their families are willing to manage them in the home and if their behavior does not pose a threat to self and others….The program which is primarily provided by the township level non-psychiatric physician, combines pharmacological treatment, counseling, family education, supervision and rehabilitation. Acute symptoms are managed with does of neuroleptic medication, but if the illness is too severe to manage in the home, the patient is sent to the country psychiatric hospital for treatment and then returns to the community after the symptoms have improved….The township-level physician and the village doctor instruct family members in the basic principles of rehabilitation and assess the patient’s functioning regularly.’ (Wang, Gong & Niu, 1994: 109)

In other words, basic outreaching services are provided by physicians with the help of a local village health worker which may be par-trained with experience in working with clients with mental illness. This sort of program is good in covering a wide range of rural areas. The one implemented by Wang, Gong and Niu (1994) in Yantai, Shandong was provided free of charge to clients with mental illness (Phillips & Pearson, 1994). However, in other places in the People’s Republic of China, outreaching services provided by physicians to rural areas are charged similarly as medical consultation provided by outpatient clinic which are unaffordable to those clients in deprived rural areas.

Guardianship Networks
Guardianship network was proposed by The Eight Five Year Plan for Disabled People, as indigenized service model for community integration of people with disability including clients with mental illness. However, only a few areas such as Shanghai, Guangzhou, Nanjing and Suzhou implement this type of services in psychiatric treatment and rehabilitation (Zhang, Yan and Philips, 1994). Each client with mental illness was cared by a group of three individuals, a family member, a local health worker, and a local community worker. This network was closely linked up with professionals in mental hospitals and psychiatric outpatient clinics. In Shanghai, these networks had already been established in 3630 of the lane committees (grass root political committees) throughout the city. In most cases, officials from lane committees appointed volunteers, usually retired teachers, professionals or workers to take care of the family and clients with mental illness. In 1989, there were in total of 52, 487 community members participating in these networks, supervising 51,232 clients. They played a total of 234,698 home visits. In fact, this service model is similar to case management and social support network in western countries. It can provide a comprehensive local network in community integration of clients with mental illness. However, it also implies a strong local control that governing the behaviors of both clients and family members in every day life. Within the political control of the Communist Party, it easily becomes a kind of political manipulation on political dissidents. Also, the organization of this local network requires a high input of para-medical staff or well educated volunteers with good mental health literacy. All that can hardly find in other less developed areas, especially in rural areas.

Psychoeducational Programs
Despite the influence of superstition and traditional perception of mental illness, family caregivers in the People Republic of China are, in fact, seeking for explanation of mental illness, especially those well educated ones. In a study conducted in mental hospitals in Hubei Province, the causes of mental illness regarded by family caregivers were personality problems (78.3%), social causes (75.6%), supernatural causes (40.5%) and somatic causes (18.9%) (Pearson, 1993). Thus, psychoeducational groups and programs in providing information such causes, treatment and rehabilitation of mental illness as well as daily care and management of clients with mental illness are important to family caregivers in the People’s of Republic of China (Phillips & Pearson, 1994). Preliminary psychoeducational programs had been tried out in some mental hospitals in developed cities like Shanghai, Guangzhou, Nanjing and Suzhou. These programs were proved to be effective by related studies (Zhang, et.al, 1994; Zhang, Yan & Phillips, 1994; Phillips & Pearson, 1994; Xiong, et.al, 1994; Wang, 1998; Zhang & Yang, 1993). However, all these programs are only implemented in a few mental hospitals in a few well developed cities. They have not been widely accepted by mental health practitioners in the People’s Republic of China.

Family Counseling and Therapy
Under the influence of western oriented family therapy and family counseling, some mental health practitioners in the People’s Republic of China are keen on conducting family counseling and therapy. Zang (et.al 1994) had conducted family counseling in Suzhou, Jiangsu. The content of family counseling is:
`Typical discussion topics at family counseling sessions were as follows: life events that occurred before and after the patient fell ill and methods for avoiding or resolving these stressful circumstances; family members’ attitudes about the patient’s illness; the importance of thinking of the patient’s symptoms as manifestation of illness, not the result of a `bad personality’ or `fate’; the necessity of not reprimanding the patient in a hostile manner; and value of not being over concerned that one excessively restricts the patient’s contact with the outside world’ (Zhang, et.al., 1994: 97)

From Zhang’s description, it seems that what they did was giving advice or conducting psychoeducation to individual family caregivers rather than doing family counseling or family therapy. They might not have sufficient training in family counseling and family therapy. Nevertheless, mental health practitioners in mental hospitals might still be fond of conducting family therapy and counseling. The reasons behind may be that family therapy and counseling are regarded as the basic requirement to upgrade the status of the mental hospitals. Also, among different types of services, family therapy and counseling can charge expensive consultation fees. In a less developed city in China, the average charge for clients in receiving family counseling is about 2 US dollar per hours and 4 US dollars per hour for family therapy (it more or less equal to the average daily salary of a factory worker). Many of these counselors and therapists are not properly trained. That means, though family therapy and counseling seems to be favorite of some mental health practitioners in the People’s Republic of China, its standard of professional practice is still questionable and its affordability to the general public is also highly doubtful.

Serving the Rich but Neglecting the Poor
The central government of the People’s Republic of China tends to withdraw funding in mental health services, related treatment and rehabilitation services, like hospitalization, outpatient medical consultation. Because of that, family counseling, family support group and family therapy have to run on a self sufficiency basis. Clients with mental illness and their family members have to pay for their own treatment and services.  As a consequence, these services may only be accessible and available to those rich enough to pay for their charges but not for those poor and deprived. For instance, the monthly fee for hospitalization is about 250 U.S. dollars in some less developed cities in China. It is more than five times of monthly take home of a factory worker. Similarly, for each consultation in an outpatient clinic, the client has to pay about 20 U.S dollars. Thus, instead of taking a client with mental illness for proper treatment, related family members may ignore treatment and rehabilitation as they can not afford to pay related fees.

RECOMMENDATION: FACING THE OPPORTUNITIES AND CHALLENGES
Facing all these challenges, the following suggestions may create opportunities to improve family caregiving of clients of mental illness.

1. Supporting Family to Support Clients with Mental Illness
It is important that the government can shoulder responsibility in supporting family caregivers in caring clients with mental illness. Instead of regarding all related services should be self sufficient by imposing fee charging on clients, government should finance related services so that family caregivers, especially those poor and deprived can receive proper support in caring clients with mental illness.

2. Relative Mutual Support Group and Locality Support Network
Instead of developing and rendering clinical services that are highly resource consuming and are unaffordable to most family caregivers in China, it is important that professionals can assist family caregivers to develop relative mutual help groups and locality family support network. Mutual help groups for family members encouraged family caregivers support each others in family caregiving of clients with mental illness. They can share feelings and experiences with one another. They can help one another in daily family caregiving such as reminding clients to take medication, dealing with client’s symptoms, facing public stigmatization and facing clients’ negative symptoms. Locality family support network ensures that clients can seek help from other relatives, neighbors and friends. All these natural informal support system are crucial in facing the scarcity of resources. All these social support and networks can also help clients with mental illness to integrated back to the community naturally.

3. Professional Training and Commitment
Many medical professionals in the People of Republic of China are still biochemical oriented. They tend to neglect the psychosocial aspects, in particular family influences. It is important that sufficient professional training can be given to related professionals so that they can appreciated the importance of family caregiving in the process of treatment, rehabilitation and community integration of clients with mental illness. Related workshops and courses on family caregiving should be jointly organized by schools of medicine, Ministry of Public Health and Ministry of Civil Affairs and departments of social work in universities. These courses can run in a self- sufficient basis and taught by related experts from western countries as well as Chinese scholars from Hong Kong and Taiwan.  

4. Culturally Sensitive Family Counseling
It is crucial that professionals in the People’s Republic of China can develop their own culturally sensitive family counseling and therapies rather than straightly borrow from those in the western countries. Family counseling and therapies done to clients with mental illness and their relatives should be modified, indigenized and shaped according to the unique political, cultural and social contexts in China.

CONCLUSION
As a conclusion, this paper is an attempt to describe the family caregiving for persons with mental illness in the People Republic of China. It seems that under the influence of traditional Chinese culture, family is regarded as the most important structure in caring vulnerable family members including those with mental illness. The shifting of the caring responsibility from the China government to the family further intensifies the endless burden of family caregivers of persons with mental illness. Furthermore, recently developed intervention and services for family caregivers seem to benefit only those rich ones but not the poor those as they can not pay the expansive charges on these services. As a result, many family caregivers are left unattended in an endless struggle with family members with mental illness. Facing all these challenges, recommendations are made in this paper to may create opportunities to improve family caregiving of clients of mental illness. All these suggestions should be further explored and supported by continuous research, pioneering projects and support form central government of China to make theme workable and applicable within, cultural, social and political contexts in China.
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References
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.

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.

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

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

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.

Pearson, V., (1993) `Families in China: An undervalued resource for mental health’ Journal of Family Therapy, 35: 163-185.

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.

Phillips M.R., & Pearson V.  (1994) `Editor introduction to rehabilitation intervention in urban communities’ British Journal of Psychiatry, 165, (Suppl. 24). 66-70.

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.

Wang, Q., Gong Y., Niu  K., (1994) `The Yantai model of community care for rural psychiatric patients’ British Journal of Psychiatry, 165: 107-113.

Wang, S.C., (1998) `Family management of schizophrenia in China’ Hong Kong Journal of Psychiatry, 8(1): 17-20.

Xiong, W., Phillips, M.R., Hu, X., (1994) `Family based intervention for schizophrenic patients in China: A randomized control trial’, British Journal of Psychiatry, 165: 239-247.

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.

Zhang M., Wang, M., Li, J., & Phillips M.R, (1994) `Randomized-control trail of family intervention for 78 1st episode of male schizophrenic patients: an 18 month study in Suzhou, Jiangsu’ British Journal of Psychiatry, 165(suppl.24): 19-27.  

Zhang, M., Yan, H., & Phillips, M.R, (1994) `Community-based psychiatric rehabilitation in Shanghai: facilities, services, outcome and cultural specific characteristics’ British Journal of Psychiatry, 165 (suppl.24): 70-80. 

Zhang. M. Y., & Yan H.Q., (1993) `Effectiveness of psychoeducation of relatives of schizophrenic patients’ International Journal of Mental Health, 22: 47-59.



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