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Mental Health Stigma and Treatment in Han Chinese Societies
Author’s Note: You can watch this video below
This channel started off as a simple history channel but I quickly realized that I was also really interested in talking about social issues affecting today’s Chinese and the Chinese diaspora as well. What started off as a number of videos on birth rates and low wages is starting to expand into other issues like mental health wellness and Chinese styles of parenting (this video is in Early Access. See the Patreon). They don’t really get the same amount of views as something on semiconductors or big battles, but the comments are always fulfilling.
I hope that this video finds you well. The pandemic and its lockdown have affected many people’s mental states around the world. Take care of yourself out there.
If you want to see more Asianometry content, I recommend you check out the Patreon. I have been working on a deep backlog of content that is right now waiting for public release. The number fluctuates but for those who sign up for the Early Access tier, they get to see all of that right now in addition to every video as they are made. I feel you’d enjoy it and it would help out with the channel. Check it out and thanks.
Devotion is a 2019 video game by Taipei-based Red Candle Games. Most people know it for the brouhaha in its background art that got the game banned from the whole world.
Leaving that aside, the game's story, set in 1980s Taiwan, is quite good. You can watch this great video analysis (linked below)
It goes deep into the plot (spoiler alert). You should watch it first. Finishing the story, I was struck by the game's thoughtful and emotional reflection on mental health issues in Chinese and Chinese-influenced cultures.
It has led me to think about such challenges of mental illness for Han Chinese people adjusting to this new modern world. And thus, this video.
Thoughts on Culture, a Warning
I feel a little weird every time I have to write about something as slippery as culture. Everyone has had a different experience of a particular culture and how culture colors people's response to their issues.
I have friends - Taiwanese, Chinese, American and more - struggling with mental illness and all of their stories are unique. Whenever we make some generalization of a group of people, then you find a bunch of individuals for whom the generalization doesn't apply.
That's a good thing. Because we are deep, complex individuals and I think we should be more than just a single throwaway line. But our brains are descended from bacterium and aren't always quite equipped to fully comprehend the complexity of our world. So we need to boil things down and make generalizations like what we are about to do today.
I wanted to make all that clear before we embark on this story.
The Confucianism of Mental Illness: Disharmony and Dependence
Chinese cultures of the type found in Mainland China and Taiwan (and influence the cultures of other countries like Korea, Vietnam and Japan) can generally be described as having Confucian values.
Han Chinese society also see significant influence from Taoism and Buddhism - but we are going to set those aside for now. I don't want to get too far off track but do know that there’s other influences out there. And they do have their own perspectives on the mental health issue.
What is Confucianism? That is for another video, but I want to make clear that Confucianism isn't a religion like Catholicism or the like. Rather, it's a world-view. A philosophy of life. Outcomes of what Confucianism "thinks" of a certain situation or person's issues are variable and can be re-interpreted.
The core tenet of Confucianism is that each member of society has to follow the moral demands that their role requires in relation to others. When you disregard your obligations, then that causes disharmony. This is a big no-no, as Confucianism very highly values the maintenance of social harmony - in some cases higher than that of the individual.
Complying with those roles and actions help contribute to personal and social harmony. So for example, you have a job. Ideally, you go to your office as needed, do your job, and help your boss do their job. In return, your company - including your boss - is obligated to provide for you, do their job as well, and keep the company capable of providing a living for everyone.
This work relationship is modeled on the basic father-son relationship common in Confucian patriarchal societies. You can extrapolate the family model to extend throughout an entire company. The company is the family and its existence and survival takes precedence over the individual.
Mental Illness Stigmas
Chinese societies - Mainland China, Hong Kong, Taiwan, and Singapore, among others - show explicit evidence of a mental health stigma.
In one survey in Mainland China, 60% of 1,491 responders reported feeling a stigma from having a schizophrenic family member. Another survey in Hong Kong found that nearly half of 320 schizophrenic outpatients were first laid off from their jobs and had family members treated unfairly because of their illness.
Comparative studies of the ethnically Chinese people living in Asia and western societies find that native Chinese are more likely to believe that mentally ill people are "quick-tempered" and "dangerous no matter what". That they might "lose control" and can commit "outrageous acts in public".
These studies note Chinese people's strong emphasis on the idea of unpredictability. The fear of a mentally ill person suddenly doing something that no one else anticipates. Flying off the handle, so to speak.
Our fears reveal our values. For a Confucian society that values predictability, social harmony and order, they fear the potential of mental illness to disrupt all that. The illness impairs a person's ability to fulfill their roles and duties. Thus, mental illness is seen as a problem of a person's weak character or spirit. A moral lapse or "defect".
Mental illness destabilizes the traditional Confucian relationships. The possibility that your child might be mentally ill - like what happens in Devotion - shatters the filial relationship expected in Confucian systems. The father expects an outwardly perfect daughter. The daughter failed to provide that. The shame and guilt from that failure falls on both the child and the parent.
Let's further dive into that.
Loss of Face and Secrecy
Like I said before, Chinese Confucian society values the harmony of the collective whole over the individual. It values the outward reputation of the family unit. Thus the consequences of errant behavior from one individual family member are shared by the family at large.
I mentioned shame and guilt earlier. Chinese traditions use those two feelings - shame and guilt - to enforce compliance to societal expectations and proper behavior. To weaken outsiders' confidence in our integrity and character, that is the meaning of "losing face" or 丟臉 "du lian". That’s the feeling imposed on you when you can’t live up to your duties and expectations.
Chinese individuals with mental illness problems often see this rejection and stigma coming. If not explicitly, then instinctively. In Hong Kong, 70% of respondents agree that if knowledge of their mental health were to get out at their workplace then they would be less likely to be promoted at work. Additionally, 60% of them are afraid that their significant other would break up with them.
The realization means that the first and primary coping behavior to mental illness is secrecy. They hide their issues from their peers, family members and coworkers.
It is a double-sided conspiracy with equal participation from both the members of the relevant social circles as well as the patient. 59.6% of patients from the prior Hong Kong study said that their family members also want them to hide their mental illness from the "outside world".
This internalization and concealment can lead to self-esteem-related issues and more further down the line - though this hasn't really been necessarily confirmed by western studies. It makes instinctive sense though.
When secrecy and concealment no longer work as the first line of treatment, then patients then tend to move to consultation with elders and after that, traditional healers and shamans. This is the line of treatment that the father eventually follows to great tragedy in Devotion.
On a side note, there are a lot of theories about why families would turn to traditional healers rather than Western therapies. Many of them have to do with Eastern ideologies around the merging of body and soul taken to an unusual extreme. There's a lot more to say here but we must move on. Perhaps in a future video.
Treatment and Mental Health Literacy
In America and the west, the lack and decline of treatment options for the mentally ill is a serious issue. I used to live in San Francisco and it is hard to ignore how the mentally ill are left to their own devices on the street. This is a hard problem - one that many believe starts with a lack of funding, training and empathy.
But over in Asia, options have been even more limited for sufferers. For many years, Asian governments focused on economic growth and expansion at the expense of providing social services such as mental health care. It was a stated governing philosophy. 1996 Hong Kong for example spent just 2% of its budget on psychiatric healthcare as compared to the US and the UK during similar time periods (6% and 10% in 2002).
Secrecy, guilt and shame all contribute to making it harder for mentally ill patients who recognize that they need help to get the help they need. While some of these funding trends are reversing somewhat, they far lag behind resources dedicated to mental health issues in Western societies.
In Taiwan specifically, mental health literacy remains poor - like as with many other Chinese societies in Greater China. And progress seems to be slow. Surveys of Taiwanese over time from 1990 to 2000 find an increase in people believing that people with mental illness should not be punished for their crimes. Those people are also more likely to support the idea of going to see a doctor for treatment. That's a good thing, and something I personally feel encouraged by.
On the other hand, there was an measured increase in people believing that "insanity is hereditary" and that it is caused by "offending the gods, devils or the souls of the dead". One in four Taiwanese up until now still believe that you can and should treat mental illness by going to a temple rather than a therapist. This attitude is a little more disconcerting and I am afraid can lead to further discrimination and shame for sufferers and their families.
These attitudes do seem to be influenced by the environment in which the person is living. A study of Taiwanese and Chinese immigrants to Australia found that being born in an Anglo-influenced society like Australia weakens this stigma. The strength of the stigma also seems to be affected by the person's age, opening the door to the idea that the younger generations are becoming more comfortable to Western concepts of mental illness. We shall see.
If you are interested in learning more about how modern Millennial Taiwanese in particular see and treat mental illness (and if you can also speak Chinese), I highly recommend this podcast interview of a Taiwanese psychiatrist, which dives into these issues. I feel that you can learn a lot from their empathetic and thoughtful conversation.
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