Perceptions of minor mental health problems in China

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Perceptions of minor mental healthproblems in ChinaArnulf Kolstad a & Nini Gjesvik ba Department of Psychology , Norwegian University of Science andTechnology , Trondheim , 7491 , Norwayb Social Work and Health Science , Norwegian University ofScience and Technology , Trondheim , 7491 , NorwayPublished online: 12 Apr 2012.

To cite this article: Arnulf Kolstad & Nini Gjesvik (2013) Perceptions of minor mentalhealth problems in China, Mental Health, Religion & Culture, 16:4, 335-351, DOI:10.1080/13674676.2012.664816

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Perceptions of minor mental health problems in China

Arnulf Kolstada* and Nini Gjesvikb

aDepartment of Psychology, Norwegian University of Science and Technology, Trondheim, 7491Norway; bSocial Work and Health Science, Norwegian University of Science and Technology,

Trondheim, 7491 Norway

(Received 22 December 2011; final version received 5 February 2012)

The purpose of this study is to reach a better understanding of the perceptions ofminor mental problems (MMP) held by well-educated urban Chinese people incontemporary China, both within and outside of the context of traditionalChinese medicine (TCM). The methodological approach adopted in this study isqualitative and exploratory. The results are based on observations of andinterviews with six practitioners and students of TCM and eight laypeople fromthree urban sites. MMP are not labelled as disorders or illnesses, but as challengesin daily living and lack of harmonious relationships. ‘‘Life problems’’ rather thansickness, is the category that best summarises the perceptions of MMP amongChinese people. This points to a salutogenetic perspective, reflecting perceptionsof mental health and MMP as processes of adaption and interpretation ofmeaning, rather than medical conditions or sickness.

Keywords: mental health problems; China; life problems

Introduction

This study concerns the perceptions of minor mental problems (MMP) held by well-educated urban Chinese people in contemporary China, both within and outside of thecontext of traditional Chinese medicine (TCM). It focuses on how the traditional Chineseculture and the contemporary modernised and Western-oriented society both influence theperceptions of MMP.

During the reign of Mao and especially during the Cultural Revolution, the Chineseleadership did not accept psychology as a discipline in universities (Blowers, 1996), andmainland China was almost entirely closed to Western researchers until 1978. Since Chinawas ‘‘opened,’’ the Western tradition in the social sciences, psychology and psychiatry hashad an increasing influence. Lin (1985) highlights the conscious effort made bypsychiatrists in China in the 1980s to make Western psychiatry their point of reference.In psychiatry and psychology as well as in the social sciences, there were attempts to applyWestern concepts and methodological tools, and diagnoses were introduced and adopted.

Ots (1994) claims that there is no concept of ‘‘mental health’’ in TCM and that currentbeliefs about mental phenomena in contemporary China seem to be heavily influenced bythe Western concepts of mental disorders, illnesses and diagnoses. However, there are stilldifferences between Chinese perceptions of mental problems and the way they are

*Corresponding author. Email: [email protected]

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Mental Health, Religion & Culture, 2013Vol. 16, No. 4, 3 5–351, http://dx.doi.org/10.1080/13674676.2012.6648163

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described in the West. An exploratory survey of 999 Chinese students’ comprehension ofmental health labelled three factors as affective strength, adaptive strength and personalstrength (Wang & Miao, 2001). The students’ conceptualisation of mental health in termsof strength seems more consistent with a (Western) developmental paradigm of healththan with the medical dichotomous wellness-illness paradigm (Wang & Miao, 2001). Thisdifference also illustrates a more general dissimilarity in self-appraisal, thinking style andrelationships in East Asia compared to the West (Nisbett, 2005). It is expected that self-perception and one’s relations to others have an impact on how mental health problemsare categorised, perceived and handled.

Kleinman and Lin (1981) focused on how the Chinese culture influences normal andabnormal behaviour (both cognitive and affective) and how symptoms are perceived,interpreted and presented, together with their labels and societal responses. Most medicalethnographical studies in China have focused on either Chinese medicine (Farquhar, 1986;Hsu, 1999; Ots, 1994; Scheid, 2002), perceptions of mental health and illness in relation tothe Chinese culture (Bond, 1996, 2002; Kleinman, 1980, 1986; A. Kleinman & J.Kleinman, 1999; Kleinman & Lin, 1981; Phillips, 1996, 1998; Phillips, Liu, & Zhang, 1999;Phillips, Pearson, Li, Xu, & Yang, 2002; Tseng & Wu 1985; Yip, 2005, 2006) or illness andhealthcare in general (Liao, 2000). Tseng and Wu (1985) suggest a change of emphasis inChinese studies from major psychiatric disorders (psychosis) to minor psychiatricdisorders such as neuroses, psychosomatic disorders and adjustment reactions.Kleinman and Cohen (1997) call for perspectives that better explain the interplay betweenthe socioeconomic, cultural and biological aspects of mental illness in China. This study isan attempt to follow-up these inquiries.

Less serious problems are often labelled jiaolu zheng in Chinese. Jiaolu, according toMogel (2005), is a buzzword. It includes stress, anxiety and minor depression. Zheng istranslated as sign/symptom, an external manifestation of pathological syndromes (Cheng,2004). Depression has been translated into Chinese as yiyu. Yu literally means ‘‘notflowing, entangled or clogged’’ or ‘‘stagnation’’ in English (Ng et al., 2006). This constructis used for depression and correlates with symptoms like low mood or energy, butencompasses more somatic symptoms and less guilt (Ng et al., 2006). Yi reflects thestagnation of qi life-energy. Qi circulates in the body and mediates the functioning of theorgans and their relationships inside the body. Qi also mediates the relationships betweeninside (man) and outside (nature and the social world).

Some studies attribute the influence of traditional Chinese culture to the restraint ofemotions, stigma and to the high threshold for perceiving symptoms as mental problems inneed of treatment (Bond, 1996; Kleinman & Lin, 1981; Leung, 1998; Tseng & Wu, 1985;Yip, 2005, 2006). Kleinman’s (1986) first study of psychiatric patients in Hunan mentalhospital in 1980 showed that minor mental disorders were frequently described asneurasthenia (shenjing shuairuo). MMP seemed to be labelled and understood using thesomatic expression of ‘‘weak nerves.’’ Kleinman emphasises that depression as it isperceived in the West is not exactly the same as the Chinese perception of shenjingshuairuo, and this underlines the need for cultural interpretation (Kleinman, 1986).Chinese medicine rests on the principle of health as a balance, and in Chinese textbooks,this part of medicine is called ‘‘life-preservation’’ (Wang, 2003). The traditional perceptionof health or sickness may be different and more subjective than the medical or scientificperspective, which focuses on the objective pathogenic signs of disease.

Most studies on mental health and illness in China have used a quantitativemethodology and Western psychiatric concepts. There is a need for more qualitativestudies in a phenomenological and hermeneutic tradition to provide accounts of Chinese

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epistemology, concepts and traditional perceptions of mental health by releasing in-depthsubjective knowledge (Bond, 1996; A. Kleinman & J. Kleinman, 1999; A. Kleinman,J. Kleinman, & Lee, 1999). This study aims to understand complex, contextualised andsubjective knowledge and the interaction between cultural, collectivistic traditions andmodern, scientific, individualised knowledge.

Emic and etic perspectives of knowledge

Western-trained psychiatrists have tried to understand mental health in foreign culturesusing Western categories of mental illness (Helman, 2007) to illustrate an etic perspective.The conceptual schemes and categories which are regarded as meaningful, focus on logical,comprehensible, observer-independent knowledge which is valid in all cultures (Lett,2007). An emic knowledge perspective focuses on inherent cultural meaning and relates tophenomenological and hermeneutic traditions. The investigation of MMP among Chinesepeople in a Chinese context necessitates an emic focus on mind, language and meaning.This study is therefore based on the exploration of emic perspectives, although eticconstructs are used in the analysis to describe and translate meaning across differentcultural perspectives on knowledge.

This study focuses on the situation in the first decade of the twenty-first century, andemphasises the rapid pace of transitions in Chinese societies. New studies are needed tocapture the rapidly changing cultural knowledge which is important for the perception andconstruction of mental health. This article reveals primarily how the traditional Chineseculture influences the perception and management of mental health problems in a societywhich is becoming increasingly oriented towards the West.

Elaboration of concepts used in the article

MMP embrace a wide range of forms of mental distress that may or may not be associatedwith minor psychiatric disorders such as neuroses and psychosomatic and adjustmentreactions. This poses a challenge to interpretation in terms of the translation of meaningacross cultures. Diagnostic categories imply a Western meta-theory of psychiatric healthand ill-health (Ekeland, 2003, 2005), focusing to a large extent on the body (brain) andwhat is going on inside the individual. This conceptualisation is suited to an individualisticculture in which people are looked upon as more autonomous and independent than incollectivistic or interdependent cultures like China. Although the knowledge presented inthis study is interpreted through the lens of Western epistemology, since this knowledge ofmental health and ill-health is an important analytical tool, diagnostic labels were not usedin the fieldwork and interviews in order to approach a more authentic Chinese culturalperspective. The Chinese interdependency and strong family orientation cannot easily begrasped and understood immediately using more individualistic, autonomous Westernconcepts and categories.

The term MMP includes symptoms such as negative thoughts, fatigue, anxiety,restlessness, sleep problems, loss of appetite, some kinds of pains and headaches,menstrual problems and emotions like anger, worry and prolonged mourning. In order todistinguish mental problems from the problems associated with major psychiatricdisorders, the category minor has been added.

In addition to the traditional Chinese culture of Confucianism and Taoism, forcenturies, TCM has contributed to the way in which psychological functions and mental

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health are perceived. Chinese medicine is founded on classical Chinese Taoist andConfucian philosophical traditions, which focus on interdependence and dialectics. Thisincludes the relation, balance and unity of the opposing forces yin and yang, as well aschange (tao) as the way of the universe (Cheng, 2004; Zhang, 2004). Everything has atendency to return to the beginning and start again in order to achieve a higher state.Chinese philosophy does not stress the linear development of a subject based on time, butemphasises the return to its origins. Chinese Taoism stresses that the meaning of things isnot fixed and does not necessarily have a predestined answer. Answers and meanings areformed in ever-changing relationships and endless uncertain possibilities (Yue, 2007). Thedialectal relationship between the dynamic pair of opposing forces or qualities yin andyang is central to Chinese philosophy and ordinary Chinese people, even today. This ischaracteristic of Chinese thought. It means that everything changes; there is no linearity ordestiny. If something ‘‘goes down,’’ it is a sign that it will soon ‘‘go up’’; something bad orevil will turn into something good or advantageous.

Confucianism and family relationships in traditional Chinese culture

Confucianism may be regarded as primarily a secular social theory with the foremostpurpose of achieving a harmonious society (Bodde, 1953). Hsu (1971) argues thatpersonality is a Western concept rooted in individualism and focusing on anomicindividuals and their intra-psychic dynamics. In Confucian social theory, the individual isnever conceived as an isolated, separate entity. According to the Confucian definition,man is a social, interactive and interdependent being. Being human is conditional on eachman’s obedience to social norms in his daily interactions. Ren or human-heartedness canonly be cultivated in inter-human relationships in a social context. In the Confucianparadigm of man, man is socially situated, defined and shaped in a relational context. Hesees himself symbolically in the web of a relational network through which he defineshimself (King & Bond, 1985). Confucian social theory emphasises family relationships asthe core of a stable and harmonious society (Stockman, 2003). The five ethicalrelationships (wulun) refer to an order of priority and the superiority/inferiority of thefollowing roles and relationships: (1) ruler/minister; (2) father/son; (3) elder brother/younger brother; (4) husband/wife and (5) friend/friend. This implies that a balance ofduty and obedience will maintain harmonious relationships within the family and societyand thus avoid conflicts and tensions (Mackerras, 2006).

The heart and mind are not separate

Many Chinese terms for mental phenomena contain the radical xin, meaning heart. Thisterm is often translated as mind, emotions or mentality (Flaws & Lake, 2004). Themeaning of xin communicates that in the Chinese language, heart/emotions and mind/thought are not separate. In TCM the function of the heart is related to the integration ofthought and the regulation of emotions. This heart-mind function depends on the way inwhich we relate to others and how we speak and behave. It is not an internal or inbornquality, but is created through relationships and dialogue. The heart-mind balancedepends on communication with others and on knowing what is appropriate, how toexpress thoughts and how to behave. Unbalanced energy, such as an excess of yang orheat, leads to heat in the heart-mind. This excessive heat may result in phlegm, whichobstructs the flow of energy (qi) in the channels and disturbs the function of the heart-


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mind xin and spirit shen. This is expressed by the term jingshenbing, meaning spiritual/mental illness/disease and translated as ‘‘psychiatric disorder’’ or ‘‘illness’’ in Westerntextbooks (Flaws & Lake, 2004; Heyerdahl & Lystad, 2000).

Collectivism and individualism

Many studies on mental health among Chinese people have been carried out within across-cultural tradition. This perspective aims to explain and compare mental illnessesand health across cultures, and the concepts of ‘‘collectivism’’ and ‘‘individualism’’have often been used to separate cultures. The major difference between individualisticand collectivistic cultures lies in the relative importance of the ‘‘other.’’ Inindividualistic societies, the ties between individuals are loose and people perceivethemselves as independent and autonomous. This is different from the sense of self incollectivistic cultures, which is characterised as interdependent and communal(Triandis, 1989, 1995). Values connected to individual achievement and reflected inindividualism have also become important in China of late (Fong, 2004; Yan, 2003,2006). They are, however, still strongly connected to socially motivated goals like abetter future for one’s entire family and even for the ‘‘motherland,’’ China. There hasbeen a transition of values from the traditional Confucian values of filial piety,obedience, respect, benevolence and self-restraint to personal interest, money,prosperity and success. According to Chu (1985), the younger generation is recognisedto be more pragmatic, which he regards as evidence of their rejection oftraditionalism. Pragmatism may lead to utilitarianism and materialism, with a focuson individual opportunities and needs rather than concern for others. A Confuciansaying expresses the importance of a pragmatic attitude, which may be expressed asgoing with the changes, in the way of tao: ‘‘Do not dwell in the past. Do not stay inthe present. Change with the trends. Change with the time.’’ The history of Chinaover the last century has been filled with changes. This may have emphasised theimportance of a pragmatic attitude and ‘‘leaning to where the wind blows.’’ Theacceptance of the changing nature of the world influences how life events, includingMMP, are perceived. It may reduce the subjective sense of anomie in a transitionalsociety with changing norms and values.

Methods and materials

A fieldwork design with qualitative interview was chosen to investigate the content andmeaning of how MMP are perceived. Living in Chinese neighbourhoods and eating atlocal restaurants provided observational and contextual data for interpreting meaning ofdaily life in China. Watching television and reading Chinese newspapers and being awareof news about health issues were sources of knowledge and information. Making studyvisits to rural villages contributed to impressions of links between traditions andcontemporary daily life practices. Informal talks with people, telling about the study andinterest in MMP, also provided a basis for interpretation, meaning making and how theChinese perceive MMP.

Data were gathered in a four-month-field study in China. An interview guide wasdesigned before entering the field. The questions and their sequence tried to open a processfrom a more general level of disclosing meaning to a more accurate level focusing MMP.


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Questions concerning traditional Chinese culture and medicine were left until the end ofthe interview. The intention was to avoid the use of Western diagnostic etic concepts, andto access Chinese emic concepts.

Twelve of the interviews were recorded, while the two first interviews were taken noteson during the session. The interviews lasted 2–3 hours. Most of the interviews were done ina context where the person interviewed and we were alone. Other interviews were insettings that were agreed upon as convenient for the purpose.

The interviews were conducted in English. Instead of using an interpreter that wouldhave made more complications to the dialogue, we looked for persons who could makethem self understandable in English not requiring extensive knowledge of English or fluentlanguage skill. Pinyin was used to go inside the Chinese vocabulary for some psychologicalproblems and how they are conceptualised in Chinese. We did not want to use only theWestern concepts since an idea with the study was to get the Chinese conceptualisationand perception.

Prototypical attitudes

When using an observational kind of method together with interview/dialogue, common insocial and cultural anthropology the aim is not to reveal the mean and the variance inattitudes, but the most typical (prototypical) attitudes and how they are related to culturalfeatures. The main aim is to find the coherence, or the consistency between attitudes andcultural traits, and to discuss simultaneously the interview/dialogue data and thecharacteristics of the specific cultural traits. This kind of qualitative studies do not dealwith traditional validity or reliability, as in quantitative studies, but focus on theargument, reason and contention about what is relevant, logical and consistent. Validity,in qualitative research also called trustworthiness, refers to whether the results may beregarded as answering the research question. According to Kvale (1996), ‘‘to validate is toquestion.’’

To evaluate the trustworthiness of the knowledge produced, a transparency of theprocess that has led to the result is important. It enables a critical look at the processes thatled to the result. By giving both an account and a critical reflexive look at how the researchprocess was conducted through all the different stages, the process, the choices, and thedilemmas are made transparent.

One author has been a student of TCM with practice in a Chinese hospital and being astudent at another university, the other author has lived in China since 2004 working withthe mental health services. The researchers have used their knowledge about the cultureand the topic in question to go into a dialogue with the interviewees and also to analyse theanswers, not only presenting them as some empirical ‘‘facts.’’ Quotations are used toillustrate the position and arguments given in the running text. The most typical orprototypical quotations, that means statements that best represent what the inter-viewees said are published. These quotations are used in the text to illustrate the moregeneral cultural values in the Chinese society relevant for how minor mental healthproblems and TCM are perceived. It is in this cultural context the statements are analysedand explained.

It is not focused on the differences between the 14 people interviewed since there aretoo few to make such differences meaningful and because the main aim has been to presentprototypical answers.


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Sampling

Purposive sampling used in the study is characterised by selecting information-rich casesfor study in depth (Patton, 1990). Certain criteria as being Chinese and living in China

were obvious to elicit a Chinese meaning within a Chinese contemporary context. Persons

within a TCM context were important to reflect TCM and traditional cultural knowledgeand practice within a contemporary cultural context. Persons outside a TCM context were

important to provide a lay perspective of contemporary culture.Different regions of China may represent different stereotypes with regard to the

importance of traditional culture and modernity. Three different sites were chosen for

fieldwork and interviews to get a mix of attitudes in case these stereotypes were of

importance. The selection of participants went on during the field stay and represented assuch ‘‘casual’’ or ‘‘opportunistic’’ (Patton, 1990, p. 178) sampling. The TCM doctors who

were interviewed worked in three different geographical contexts in China, a city in the

west, a city in the north and a city in the east. They had been working abroad for a periodof time, which influenced their knowledge of MMP. Two of the doctors were professors.

They were interviewed in their work context, the doctor from the East, in a busy clinical

hospital context, the doctor from the North, at the teachers’ office in a TCM university.The third was a newly educated TCM doctor who spent his summer holiday as a doctor of

apprentice in the TCM hospital in the West. We met at a teahouse for an informaltalk/interview, which was not recorded. Five of the participants outside a TCM context

were recruited through an advertisement in a university webpage, by requesting volunteers

for interviews about mental health. This had selected participants with interest inpsychological issues. It may have influenced knowledge presented in this study among lay

persons. Two of the students were interviewed together. Persons within and outside

TCM contexts were recruited from all the three sites, although in different proportions,two from Northern city, five from Western city and seven from Eastern city.

The sample consisted of mostly urban people with an academic background between

the ages of 22 and 37. Although many (five respondents) had grown up in rural areas in atraditional Chinese way, their education level was high and urban experiences had

influenced their attitudes and knowledge. If people within a rural context with less

education or older people had been included, the scientific and Western knowledge wouldhave been less influential and the traditional knowledge might have been stated more

clearly.Words like anxious, depressed, extremely tired, or timid, sleep problems, problems in

eating were used to check out perspectives of meanings in terms of symptoms of MMP.According to hermeneutical methods, the criteria for sufficient understanding are

developed when the understanding is validated by the participants and no more newmeanings seem to be developed by further interviews called saturation. When meaning was

considered to be sufficiently saturated, we stopped making interviews.In China, science has a very high position in what is regarded as knowledge, and the

fact that all the participants were educated people with a good knowledge of scienceseemed to make this the preferred perspective to be communicated. People within a

Confucian tradition emphasise highly the effect of what they say, whereas people in the

West emphasise communicating their personal meaning (Armstrong & Swartzman, 2001).Keeping face is important, not only to Chinese, as it is connected to self-respect. The

Chinese think of the aim and the consequences and are able to put their own (selfish) needsat abeyance to contribute to a common goal, which in the long run might also satisfy their

own needs (Blum, 2007). To be able to speak on equal terms is regarded as respectable and


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virtuous. This might have influenced what the participants thought was proper to say.Some of the participants outside TCM contexts excused themselves for not having thisknowledge.

The fact that the Chinese were asked by a Westerner may have affected their answerssomewhat. The interview created in this study may reflect a more Westernised perspectivethan if selection of participants had not been limited by language problems.

Analysis

Analysis of data started during the process of data-collection in what topics emerged asmost important. Kvale (1996) emphasises that knowledge produced is constructed as an‘‘interview’’ implying that social reality and our knowledge about it are constructed in themeeting of our meaning-making activity and the social context. The concepts in pinyinused by the participants to describe MMP were used in the forthcoming interviews toelaborate further meanings. When listening to their stories, we could ask more questions,and by not being too active in the interview situation we could more easily adjust into theirdescriptions of their perceived reality and question the conceptions. By taking thishermeneutic and phenomenological position, the interviews took a long time. Some themesfrom the interview-guide, which seemed to be less important than to get to a basiccomprehension of their perspectives, were tuned down.

The interviews were transcribed verbatim by one of the authors, staying close to theparticipants’ way of expressing meaning. Notes on fieldwork and impressions were writtenand sorted. During the process of analysis after the fieldwork, the interview texts werelistened to, read, and reread ‘‘vertically,’’ trying to find the meaning in each interview,making own remarks and recording thoughts. The meaning of each interview wascondensed, the most important words and texts, and themed statements according tomeaning. When reading the interviews particular attention was paid attention to whatseemed to be common themes (‘‘horizontal meaning’’), trying to find what sentence orword the participants had used that could illustrate these common themes. Summaryresponse statements were provided for each theme. The research questions guided theprocess of seeking meaning by using different perspectives related to contemporary andtraditional cultural perspectives on the text.

A descriptive level of analysis and labelling of sub-themes were decided to close theemic perspective. The texts used in the presentation of the results are not condensed toonly to elicit the theme but left in the context that the meaning appeared in. This is done toprovide more transparency in how interpretations were made. It makes for ambiguousmeaning as well as maintaining closeness to the context of the meaning and participants’voices and expressions.

Ethical reflections

The interviewees were informed about the aim and purpose of the study and aboutanonymity and the possibility of contact after the interview given an e-mail address andChinese mobile phone number. Every one interviewed gave an oral consent to theinterview. To protect the anonymity of the persons interviewed, no names were required.The participants were asked if the interview could be tape-recorded and all except oneaccepted.


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Results and discussion

‘‘Problems of life’’ and a daily life perspective rather than sickness was the category thatbest summarises perceptions of MMP in a health and ill-health perspective. This isrevealed in the help-seeking patterns in the clinical TCM context and in the problems offinding TCM doctors with knowledge of MMP. It is also reflected in the judgment ofmental problems in terms of degree of seriousness, which is shared inside and outside TCMcontexts. The differentiation and description of what they regard as serious and not seriousproblems became important to approach their perceptions of MMP. The problems weencountered with the use of the concept ‘‘mental’’ and their perspective of mental asserious problems made us aware of our cultural foreknowledge of Western health science.To approach their perspective of meaning, it became important to explore the labels theyused in Chinese and the meaning and attitudes exhibited in their perceptions of differentWestern and Chinese labels.

The professor of TCM from the North categorised mental problems into two groups:‘‘serious’’ and ‘‘non-serious’’ problems:

Mental problems are very serious if the patients can’t work, read or think. This is called kuangdian (TCM doctor).

The doctor’s labelling of serious problems as kuang dian reflects a culturalconceptualisation of major psychiatric disorders according to their seriousness in termsof functioning. Dian and kuang, which refers to withdrawal and mania, constitute a yin-yang pairing of conditions that can exist separately or alternate back and forth between thetwo (Flaws & Lake, 2004, p. 95). In the Chinese language, the general term for mentallydisordered behaviour is kuang, and the Chinese idea of madness is derived from rabid dogs(T’ien, 1985). The description dian-kuang would, in diagnostic terminology, refer topsychotic behaviour (T’ien, 1985).

During the three weeks of participant observation, MMP seemed to be a very rarereason for contacting a TCM doctor. These observations correspond with the impressionsat an earlier study-visit in 2004. In 2006 when looking specifically for MMP, it was stillhard to find MMP represented among the patients in clinical contexts and the clinicalpractice and knowledge of TCM doctors.

Doctors at West TCM hospital seem surprised when questioned about their experienceor knowledge of TCM and MMP. One doctor says; ‘‘These kinds of problems are treatedin special mental hospitals, not in TCM hospitals.’’ Their perspective on mental problemswas psychosis, bipolar disorder with mania, or grave depression, which they calledjingshenbing. Most of the doctors said, ‘‘I do not have the knowledge nor do I treat thiskind of problems.’’ It was very difficult to find a doctor willing to give an interview aboutMMP and few doctors perceive MMP as relevant. An English-speaking doctor at thehospital who had practiced abroad confirmed that it would be hard to find a doctor at thehospital with experience of MMP. She knew only one doctor. This non–English-speakingChinese doctor included mental aspects and mental problems in her clinical practice andperception of symptoms. She and her assistant student doctor seemed very familiar withthe term mental problems and MMP. This doctor considered muscular pain problems tobe integrated with those of mental and paid special attention to the latter when patientshad problems with menstruation and sleeping. She used the Five-element theory as well asspecific mental points and needling techniques to balance the mental aspects as anintegrated part of the treatment.

Thedoctor’s perception ofmental problems as integratedwith somatic problems relies ona holistic knowledge of mental and somatic as not separable in TCM. In TCM, the Spirit is


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always considered to be embodied, and TCM physician resists, both intellectually andclinically, a separation of human life into components or dichotomies; mind and body,mental and physical, soul and body, moral and autonomic activities are linked (Kaptchuk,2000, p. 66). The concept of these relationships as not separable may explain the lack of ashared perspective of meaning when presenting the topics of interest. The term mentalidentifies a Western concept of mental problems as a distinct and separable entity fromphysical problems.

The three TCM doctors who were interviewed all knew MMP because they had beenpracticing TCM abroad. These experiences made it possible to communicate from a sharedperspective of MMP. One doctor in East City said that he often treats patients with MMP,but these patients are mostly foreigners. The three doctors said that MMP are verycommon among their patients abroad but not among their Chinese patients in China.

Less serious mental problems

MMP, which the doctor in the city in the North characterised as ‘‘less serious mentalproblems,’’ are separated into two stages:

The first step is liver yang rising or liver dysfunction. Jiaolu zheng is the Chinese expression. Jiaolucan cause a functional disorder of the liver or liver yang rising. The liver governs the patient’semotions and the liver energy qi regulates the balance. Liver qi stagnation leads to fire and symptomssuch as insomnia, becoming angry easily, being unable to concentrate and restless walking.

I would tell my patients that they have jiaolu, and advise them to do some exercises and changetheir lifestyle. These patients work all the time, stay at home on the computer and don’t gooutside. Sitting will lead to qi stagnation. I would advise them to go outside and do some deepbreathing exercises to make the qi change flow (TCM doctor).

The first of these two stages of less serious mental problems is liver dysfunction, whichmost Chinese people, the doctor stated, would regulate by themselves. She underlined theimportance of balancing mental and physical activity, referring to their interdependentrelationship of mutual promotion and control. These problems are associated with lifestyleand can therefore be explained in social terms. The doctor spoke of how an imbalance inthe yin or yang aspect of liver energy qi leads to symptoms associated with the regulativefunctions of the liver by using the terms ‘‘controls’’ or ‘‘governs.’’ If the liver’s regulativefunction is properly balanced, the doctor stated, one will be constantly good and kind, andthis is associated with feelings of satisfaction and relaxation. Stress may lead to problemswith liver qi, which may cause problems with the functioning of the liver. Liverdysfunction may cause the liver to lose its control or regulative function of anger and thebalance of muscular tension/relaxation and emotional problems relating to frustration andrestlessness and feelings of tension/stress. Also Heyerdahl and Lystad (2000) notes thatliver dysfunction may be associated with anxiety, minor depression and stress, as well aspremenstrual problems.

The necessity of balance is common knowledge for most Chinese people, according tothe doctor in the eastern city. He cited, like the doctor in the northern city, that lifestyle is acause of illness and that a change in lifestyle is the solution. A doctor cannot solve theseproblems with medicine. Most Chinese people do not perceive such problems as being anillness which needs treatment, according to the TCM doctors in this study but as problemsrequiring balancing strategies within the scope of daily life, which is also called ‘‘lifecultivation’’ (Wang, 2003). MMP as specific disorders seem to be given low priority amonglaypeople, doctors and society, as they are looked upon as part of life and perceived ascommon and not very serious experiences.


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The female doctor in the North city had practised in a Western country and had metmany patients with MMP who focused on their own psychological well-being. TheChinese, however, are not concerned about their own body and how they feel to the samedegree, and focus more on their money, job and family. She described the differencebetween ‘‘East’’ and ‘‘West’’ in this way:

I mostly meet patients with minor mental problems abroad. In China, people talk with relatives,family, on the Internet or MSN to solve mental problems. Chinese people always want to talk andexplain to other people why they feel like this. Foreigners think by themselves, and don’t talk topeople other than the doctor – they only trust the doctor (TCM doctor).

She emphasised the cultural difference between Chinese people who chooseunprofessional and lay contexts while foreigners choose professional contexts in whichto talk about emotions and share MMP. Chinese people talk and listen aboutpersonal matters more than people in the West. They visit each other in their villagesseveral times a day and share their joys, problems and worries with their family,neighbours and colleagues. They do not need a professional service in order to opentheir heart. This reflects how cultural traditions influence the perception andmanagement of problems, symptoms, coping and therapeutic measures (Ekeland,2003; Kleinman, 1988, 1995).

When asked about MMP, a student of TCM answered:

Minor mental problems are not considered as mental disorders. We do not recognise this kind ofproblem as serious unless it interferes with daily life or the family life, like not being able to see ortalk to other people. Xinli bing – disorders of the heart – have to do with relating to others.Chinese people call it Xinli zhang ai, not mental problems, which are far more serious (TCMstudent).

Thirteen of the participants did not regard MMP as serious problems, nor did theylabel MMP as mental problems unless they seriously affect functioning in terms of thepatient’s role and relationship to others. MMP, such as problems in relating to others, areperceived as common or normal difficulties. In the most usual sense, normal refers to thatwhich can be found in the majority, referring either to the average or standard of ameasurable characteristic (Canguilhem, 1989). Perceptions of MMP as non-seriousproblems reflect a judgment of MMP as normal and different from mental problems,which are regarded as serious problems.

All lay participants labelled MMP as xinli zhang ai. Xinli means ‘‘psychological’’ andzhang ai means ‘‘problems and obstacles’’ (Collins, 2004). Zhang ai expresses a perceptionof MMP as problems in the sense of obstacles. MMP are clearly distinguished from seriousmental problems relating to abnormal behaviour, thought patterns and hospitalisation.Serious problems, or jingshenbing, are associated with mental illness.Q: What is jingshenbing?

This is the most serious. People go to hospital, it is very serious. In daily use, jingshenbing meansa person is abnormal.

Q: Is xinli or heart problems like jingshenbing?

Oh no! jingshenbing is totally different. If you do not behave properly, you can’t do the rightthings, your mind is in a total mess, we say jingshenbing.

Q: Could you give an example?

[If patients] couldn’t behave properly, ran in the road, ignored the cars and people, and took offtheir clothes and were not ashamed. You see life differently and you have to come back to reality(Student).


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Most participants related jingshenbing to abnormality and the loss of normal functions.Many referred to serious deviance and to a lack of sense of shame and dignity, as reflectedin the common norms. The majority referred to abnormal cognitive functions andbehaviour. Some described serious mental problems as abnormal functioning or a diseaseof the brain or the nerves.

Labels and attitudes

The perception of MMP as common and non-serious problems, and not as mentalproblems at all, reflects the cultural norms and values embodied in cultural traditions aswell as in contemporary Chinese society. It communicates what has to be tolerated andaccepted as normal. The language and labels used to describe these phenomena show howthey are classified and conceptualised (Kleinman & Lin, 1981). A closer look at the labelsused when communicating about MMP opened up different perspectives on culturalmeaning and attitudes and underlines the differences between the traditional East Asianand modern Western cultures.

The label psychological problems refers primarily to ways of thinking. Many includeemotional problems, but the most common way of explaining psychological problems is interms of thinking and attitude. Ways of thinking and attitude seem to reflect each other,pointing to how problems are perceived and given meaning. It may be interpreted withinAntonovsky’s (2000) concept of sense of coherence in which xinli zhang ai psychologicalproblems reflect obstacles in terms of challenges and in terms of the ways in whichproblems are interpreted. The label mental is associated with nerves and pathologicaldysfunction in a disease perspective and treatment by Western Medicine and hospitalisa-tion. It reflects the serious problems in terms of mental diseases as major psychiatricdisorders.

TCM doctors who lectured for foreign TCM students used the term mental to addressthe mental aspect of symptoms and zang fu organ function as well as treatment strategies.Most laymen and TCM doctors who had been abroad were familiar with the term mental.It seems to signify their knowledge of the Western way of labelling and functions.It functions as a label to create a cross-culturally shared perspective. Mental used incommunication with foreigners seems to reflect a Western perspective of mental health andill-health, with a broad range of classifications from emotional distress and minor andmajor psychiatric disorders.

Many respondents used terms like normal, abnormal, popular, common and strangewhen describing MMP and mental illness. Most participants expressed a sceptical attitudetowards counsellors and psychology. Their explanations varied from ‘‘psychologists areexpensive,’’ ‘‘strange’’ and ‘‘not so good,’’ to ‘‘friends are better’’ and the ‘‘lack ofprofessional knowledge among counsellors.’’ Strange may reflect several perspectives.

Psychology, the xinli, is not so popular in China. I think most Chinese people think it is a kindof. . . how should I say. . . strange thing, and not a very good thing. So if they suffer from this kindof disease, they would not have the courage to tell others about suffering from this kind of diseaseor to seek a psychologist. But in the big cities, more people accept this kind of condition or disease(TCM student).

The commonly stated characteristics of psychology as strange and unpopular may alsocontribute to the perception of MMP as life problems rather than as sickness or mental ill-health. It may be regarded as stigmatisation to label problems as psychological. The termstrange may reflect, from a stigmatisation perspective, rarity (Feldman & Crandall, 2007),


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and therefore the labelling of something as abnormal in the sense of rare or strange

constitutes a threat. Some respondents in the most urban areas in the East said that

psychology was becoming more common, but that the majority of people would not like to

consult a psychologist if they had MMP. Yang et al. (2007) emphasise the moral aspect of

stigmatisation when dealing with what is at stake for the individual, and this may

explain why many do not want to label problems in terms that signal a need for

professional help. The underutilisation of psychological health services is not only a

phenomenon in China, but also among Asians in Western countries (Kim & Omizo, 2003;

Yip, 2005). By using a measure of adherence to Asian values as an index of enculturation,

Kim and Omizo’s study (2003) of Asian-Americans found an inverse relationship

between adherence to Asian cultural values and willingness to seek professional

psychological help.In high school there was also a counsellor for mental problems, but few students would go.

Q: Why?

It feels a bit strange, I think. I would talk to my friends or my mother. Friends are nearby, it iseasier to find a time, and they know you and your lifestyle, way of thinking, your workand hobbies. A counsellor does not know you so well; he would just look into theproblem (Student).

The opportunity to talk with friends who can see your problems as part of your life and

who know your situation was emphasised by many respondents as the preferred way of

dealing with MMP. This reflects that MMP are not regarded as a sickness, but rather as

life problems. This represents a salutogenetic perspective, focusing on a sense of

coherence and coping (Antonovsky, 2000). It represents a way of thinking, according to

which context and patterns are more important than regarding a problem as a separate

internal entity from a reductionist perspective (Nisbett, 2005). It also reflects

Western sociological and socio-psychological perspectives, focusing on relationships,

social networks and how meaning is socially created and context-dependent

(Gergen, 2005).Family and friends were also highlighted as important in overcoming obstacles and

problems in life in order to create new meaning. As these people know the individual in

question, they can easily see the problem as part of the context of his or her life and their

knowledge of the person, and they can focus on the individual’s resources. Talking with a

foreigner, a psychologist or a counsellor is something very different in China, and Chinese

people do not have much experience of doing so.

Most of my friends, when they speak to a stranger, do not know what to do or what to say. We allknow that communication is important, and we try to do it, but because of tradition and ourexperiences we have some mental problems communicating and talking with strangers. That’s acultural thing. For most of us, it is strange and hard (Student).

The term strange may reflect feelings of discomfort, strangeness and a lack of shared

knowledge of the world. Psychologists and counsellors are not ‘‘one of us’’; they are

‘‘outsiders’’ and do not share what the respondents think is the common or normal way of

thinking and feeling, which they find among their family and friends. Many Chinese

people do not trust ‘‘foreigners’’ or those outside of their family:

Q: Private counselling services are very expensive and unaffordable for most people.

It is not that they are expensive, because in China we don’t trust strangers (Student).

Q: So it is not only that it is expensive, but also because you don’t trust strangers?


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Both: Yes, yes.Female: The psychologist is a stranger for many people in China. Parents and friends are familiarpeople. A psychologist who does not know you cannot give the right answer concerning yourproblems in life. (two students)

In studies of Chinese culture, ‘‘outsiders’’ are described as those people to whomone has no obligations, as opposed to those in the ‘‘insider’’ position (Blum, 2007;Pye, 1992). If one has a relationship with an outsider, this is associated with being careful,suspicious and untrustworthy, as well as the possibility of losing face (Blum, 2007;Pye, 1992).

Communicating with strangers may therefore be associated with a sense of discomfortand uncertainty in terms of how to express oneself and communicate without losing face.Yan (2006) refers to an Internet survey by Sina.com, according to which 52% ofrespondents stated that they do not trust strangers. This points to a general scepticalattitude towards strangers as untrustworthy, which may influence whom one would trust,contact or talk to regarding personal problems like MMP. The respondents preferred tofocus on solutions rather than problems. They perceived psychologists as professionalswho focus on problems rather than practical solutions. This may also reflect thatthey prefer to be told what to do by parents and friends, rather than start an analyticalprocess focusing on how to think. The respondents seem to have a pragmaticpreference for a simple, fast and practical approach to problems which occur inlife so that they may get on with their lives, which is characteristic of Chinese culture(He, 2002).

The characterisation of psychology as strange may reflect that it is perceived as anunusual way of dealing with MMP, reflecting Western culture and science (Ekeland, 2003,2005) and a different way of thinking (Nisbett, 2005). Strange may also be interpreted asindicating resistance to the categorisation of MMP as sickness, as the term is reserved formajor psychiatric disorders. The lack of a perspective of MMP as sickness and theassociation of the term ‘‘mental’’ with serious mental disease means that the term, which isassociated with abnormality and insanity, is currently stigmatised in China. Alternativeways of labelling mental problems as psychological and connected to thoughts andattitudes indicate an attempt to move away from the stigmatising labels and attitudesassociated with serious mental illness and insanity.

Conclusions

Most Chinese people do not perceive MMP as serious problems, but as a common ornormal way of being for short periods, according to the participants. This differs from thecurrent Western perspective (Helman, 2007) which emphasises mental illness and aperspective of sickness or abnormal functioning. In the West, MMP are commonlyperceived as serious problems from a disease perspective, and as sickness in need ofprofessional treatment. Perceptions of MMP in China reflect a perspective based on dailyliving rather than sickness. This points to a wider range of what is regarded as commonand normal than is implied in the Western conceptualisation of minor psychiatricdisorders.

The understanding of MMP in China is influenced by both traditional culturalknowledge and Western categorisations and epistemology. The Western concept ofpsychological problems emphasises something inside the individual. Most Chinese peoplehave a social and not an individual or medical perspective on MMP. They emphasise


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family, relationships and lifestyle as the sources of the life problems that make peopleunhappy, sad or confused. The negative attitudes among Chinese people towardsprofessional treatment and care illustrate that these problems are comprehended from adaily life perspective as something normal which happens to everybody. There is resistanceto the categorisation of MMP in terms of sickness which requires professional treatment.This resistance to perceiving MMP from a Western perspective of sickness may beinterpreted as an unwillingness to medicalise life problems into sickness. The sense thatpsychology and professional help are strange strengthens the resistance to the individu-alistic perspective of such problems, in accordance with the traditional interdependent andcollectivistic Chinese culture. Since these problems are normal, widespread and a part oflife, they can be shared and talked about with family and friends and not in professionalcontexts emphasising a sickness perspective. This challenges what is seen as ‘‘normal,’’ asreflected in Western categorisations of minor psychiatric disorders (Canguilhem, 1989;Ekeland, 2003; Kleinman, 1988, 1995).

A mental diagnosis may have serious economic and social consequences, such as losingone’s job, one doctor stated. The judgment of seriousness reflects social as well aseconomic consequences. These consequences of a mental diagnosis are part of thejudgment that influences the way in which symptoms are perceived and labelled by doctorsand laypersons.

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Documents

Perceptions of minor mental health problems in China