China’s mental health care is improving, but stigma and politics still get in the way
By Alex Smith | June 11, 2020
A free counseling service in Shenyang, Liaoning Province, on February 12, 2020. Photo from cnsphoto via REUTERS.
Once deemed a symptom of “wrong” political thinking, mental illness has a fraught history in the People’s Republic. While the last two decades have seen rapid development in mental health care in China, there remain significant problems with stigma from an under-informed public, the government’s preoccupation with political stability, and under-resourcing. As a result, many are unable to access the services they desperately need, while others are forced into unnecessary treatment.
As China fought to control its coronavirus outbreak and placed much of the country under a strict lockdown, attention quickly turned to how authorities were responding to the virus’s ensuing mental health fallout. Stories detailed mental health hotline operators (New York Times, 1843 magazine) who worked through the night, listening as worried residents and distressed medical workers on the other end attempted to talk through their anxiety and panic.
And the focus on mental health appears to have outlasted the worst of the pandemic: More recent articles report that new psychiatric clinics for COVID-19 survivors have opened in Wuhan (in Chinese) and teams of grief counselors have been mobilized to provide support to those who have lost loved ones.
While COVID-19 may have refocused media attention on China’s mental health, Chinese authorities have been increasingly attuned to the country’s mental health problem since the late 1990s and have ushered in several waves of reform.
Such changes are commendable, yet China’s approach to mental health has a problematic past and an uncertain future. Doubts have been raised about not only the ability of authorities to deliver on their ambitious mental health targets, but also if the current approach makes as radical a departure from past practice as many would like to believe.
Missionaries, Mao, and the politicization of mental health
The Guangzhou Hui’ai Hospital. Photo via China Daily.
China’s first psychiatric hospital, the Guangzhou Hui’ai Hospital, was a little over 50 years old by the time the People’s Republic was established in 1949. Following the opening of the facility in Guangzhou in 1898 by American missionary John Kerr, China would amass a number of similar psychiatric hospitals across its provinces over the years. But the first three decades of Communist Party rule oversaw a marked shift in the nation’s approach to mental health.
Scholar Veronica Pearson documents how overarching concerns with economic output, public safety, and official state ideology saw treatments such as psychotherapy dismissed as bourgeois for their misplaced preoccupation with the individual. Authorities instead favored interventions in the vein of physical and labor therapy that not only benefited the socialist cause, but also sought to reintegrate individuals back into society. Ideologically informed treatment would become even more prevalent during the Cultural Revolution (1966–1976), where depression was often attributed to an individual possessing the “wrong” political ideas and personal priorities. Consequently, one’s self-absorbed neuroses could be eradicated by simply refocusing attention on the collective political mission through a close reading of Maoist works.
While mental illnesses were initially brushed aside as authorities strove to achieve a productive nation of workers, some officials would later begin to harness the label of mental illness for their own political ends. Scholars Arthur Kleinman and Guo Jinhua observe that the “label of mental illnesses was used as a weapon to delegitimize and attack political dissidents” (although it should be pointed out the history of politically abusive psychiatry is hardly unique to China).
While the 1980s saw a return toward more conventional approaches to mental health, the decade did not see a complete break with the past. In 1995, China enacted the notorious Maternal and Infant Health Care Law, originally termed the Eugenics Law, which mandated that couples undergo premarital medical examinations for hereditary mental and physical disorders with the aim of preventing “inferior births.” Although mandatory medical examinations have now been effectively abolished, mental illness continues to be weaponized as grounds to detain activists and vocal critics of the government, and as scholar Timothy Grose argues, it also informs the government’s current treatment of Uyghurs.
Overhauling the system
Despite the persistent politicization of mental illness for certain subsets of the population, central authorities have responded to the calls of mental health advocates and global efforts to improve mental health care, and have moved to overhaul the country’s general response to mental health. It is also possible that authorities recognized they could no longer afford to downplay the problem — according to the World Health Organization, approximately 54 million Chinese people suffer from depression, and an additional 41 million suffer from anxiety disorders.
The first major turn was the introduction of the first National Mental Health Plan (2002–2010), which, among other ambitious goals, sought to establish an effective government-led mental health care system, improve services and workforce capacity, and boost the public’s understanding of mental health. The 2003 SARS epidemic then provided the opportunity to make changes to China’s health system. Central authorities launched the 686 Program, which aimed to integrate mental health care into China’s primary healthcare system, as well as hospital and community care services for people suffering from “serious” mental illnesses. Then in 2012, China passed the Mental Health Law, a move that has been described by scholars as a “landmark policy for protecting patient rights and improving mental health services.”
More recently, authorities have sought to implement the National Mental Health Working Plan (2015–2020). By 2020, the plan sought to deliver more coordinated mental health services, expand and strengthen the workforce, ensure that over 80% of patients with “severe” mental illnesses are supervised and over 80% of people with schizophrenia receive treatment, enhance the prevention and treatment of “common mental disorders and psycho-behavioral problems,” improve rehabilitation outcomes, and bolster public understanding. Similarly, the Healthy China Action Plan 2019–2030 aims to improve the treatment rate of depression by 80% by 2030 and continue to improve public understanding.
Care, not social stability and political transformation
Yet despite the central government’s stated ambitions, several experts have expressed doubts about the likelihood of these targets being met. One 2017 analysis of China’s mental health reform points out that while the Mental Health Law and Mental Health Working Plan require central and local governments to fund mental health services, both fail to provide specific funding allocations, significantly undermining the probability that either will be fully implemented. Moreover, demand for services continues to significantly outstrip supply and huge gaps remain in the abilities of urban and rural Chinese to access mental health services, both because services in rural areas are underdeveloped and because of the lack of affordable healthcare.
One of the most tragic ironies of China’s approach to mental health is that while many in need remain unable to access services, others who aren’t are forced into “treatment” in the hopes of stifling political dissent. While political dissidents continue to be detained on the grounds that their alleged mental illnesses pose a threat to social stability, authorities have also employed similar rhetoric in their justification of the mass internment of Uyghurs. As Georgetown University professor James Millward explains, policymakers frequently claim their actions are intended to “cure” Uyghurs of the Islamic extremist “thought virus” that has allegedly overtaken their minds. Similarly, the forced labor programs that Darren Byler notes aim to transform the very “quality” (素质 sùzhì) of Uyghurs into industrialized workers bear more than a striking resemblance to earlier notions of curing mental illness through labor.
Additionally, the ability of the general public to recognize mental illness and identify appropriate treatments remains low, and pervasive stigma surrounding mental illness not only further prevents people from seeking out treatment, but also disincentivizes people from pursuing work in the mental health sector, which faces a major shortage of trained staff — for every 100,000 people, China has just over two psychiatrists and around six registered psychiatric nurses, far below the averages of 13 psychiatrists and 23 registered psychiatric nurses per 100,000 residents in high-income countries.
Yet it is not just the feasibility of reaching official targets that has experts concerned. Scholars have also cautioned that reform efforts have been too focused on protecting public safety and security rather than on improving the well-being of individuals, with resources often being concentrated on services targeted at managing those with “violent” mental illnesses. As Guo Jinhua and Arthur Kleinman note in their study on stigma, mental illness, and HIV, “instead of focusing on patient needs and rights, Chinese governmental institutions focus on protecting society from patients, whose potential for violence is greatly exaggerated.” Scholars Di Liang, Vickie Mays, and Wei-Chin Hwang have echoed these findings, concluding in their analysis of China’s mental health services that the focus of China’s mental health system needs to be caring for patients rather than “merely keeping the society stable.”
Officials have recently acknowledged that COVID-19 has highlighted major shortcomings in China’s health system. While the new coronavirus, like its predecessor SARS, may provide an opportunity to rethink elements of China’s health system, until mental health is destigmatized to the point that it can no longer be used as a political weapon, and individual well-being takes priority over sensationalized notions of public safety and stability, such reforms are likely to only have limited efficacy.