Developments in Chinese psychiatry

During a recent visit to China, which included meet ings with psychiatrists in Beijing, Shanghai, Xian and Hohot, I noted that many of the political constraints of the Cultural Revolution on psychiatry had been removed. Clearly, Chinese society was still strongly influenced by Marxist doctrine, but there was greater academic and clinical freedom for the reinstated professionals who had previously been considered 'elitist'. Western textbooks and journals were avail

During a recent visit to China, which included meet ings with psychiatrists in Beijing, Shanghai, Xian and Hohot, I noted that many of the political constraints of the Cultural Revolution on psychiatry had been removed. Clearly, Chinese society was still strongly influenced by Marxist doctrine, but there was greater academic and clinical freedom for the reinstated professionals who had previously been considered 'elitist'. Western textbooks and journals were avail able, and the very fact that Chinese psychiatrists were able to communicate freely with me was in sharp contrast to the enforced isolation of the previous decade.
Through control of the media, the Communist party still regulates information coming into China and additionally promulgates respect for authority and current Party doctrine. Television, the radio and newspapers not only inform the public but also pro vide guidelines on what is acceptable thinking and behaviour. Despite some liberalisation, the state still controls self-expression, sexuality, relationships, dress and behaviour. This may be particularly diffi cult for young intellectuals who are better informed about the West through improved contact with visit ing Westerners. On the one hand they are proud of China's material achievements since 'Liberation', yet envious of Western influence and freedom.
The recent 'open door' policy to the West and cau tious reform suggests the possible development of a society less strictly influenced by central Party con trol. Recent political activity, however, gives us cause to re-examine China's approach to mental health.
Student unrest and demands for greater democracy, followed by a re-assertion of Communist Party auth ority, leave an uncertain future.1 Western liberal views have been blamed for the demonstrations, and it is unclear to what extent these views will be suppressed by an administration which is fearful of widespread social unrest. Whether this leads to a reassertion of Marxist dogma or continued reform will have profound effects upon the Mental Health Ser vice, which has always been influenced by political change.2 Since 'Liberation' in 1949, health has been a top priority not only for altruistic reasons, but also as a means of maintaining popular support, and as a pre requisite for a healthy workforce. The groundwork for a Community Mental Health Service was laid in the 1950s, following the Russian model. Service delivery was provided through primary care, backed up by scarce specialist facilities. During the Cultural Revolution, the community aspects were further developed, though specialist services were down graded and research and innovation discouraged unless they concurred with Party doctrine. Psy chology and much of psychiatry was devalued, with loss of status and sometimes harsh treatment of senior mental health professionals. I spoke to senior psychiatrists who bitterly recalled personal humilia tion, separation from their families, and demotion to manual labour. Service provision was principally through 'paramedics', and political indoctrination was widely used with patients through the encour agement of 'revolutionary optimism'. Over the last decade, since the demise of the 'gang of four', there has been a return of senior professionals, recom mencement of training programmes, and a more Westernised approach to treatment and research.3 The current mental health system is an integral part of primary health care, in association with the maintenance of 'correct' values and behaviour through the social order system and the educational system. In Chinese society, the needs of the individ ual are subordinate to the common good. Treatment for the psychiatrically disturbed is therefore aimed at the prevention of social disturbance, in addition to helping the individual patient. From an early age, children and families are encouraged to behave in socially acceptable ways.4-5 Family stability is enhanced by social pressure, with legal backing in the form of a marriage law which defines the obligations of parents to each other and their children.6 Simi larly, adults are legally bound to support their own parents. By these means the old Confucian values of allegiance to the State and filial piety have been transposed to the modern Communist State.
Socially unacceptable behaviour is monitored by 'neighbourhood watchdogs', who are retired workers. I was surprised to see teenagers meekly acquiesce when rebuked for some minor infringe ment, such as wheeling a bicycle on the pavement. In more serious cases the individual is reported to his family or neighbourhood committee. Action may be taken by these committees to provide help, censure or 'mediation' in family disputes. By the application of a highly organised system, Communist party doc trine, including that which relates to personal and professional thinking and behaviour, impinges upon the individual.
Health care in China is provided by two parallel systems; the governmental Health Care System under the supervision of the Ministry of Health, and the Industries and Business Enterprise Health Care System.2 Although these systems may operate inde pendently, they are both regulated in the same way by political ideology. In visits to various psychiatric facilities I observed the well-meaning but paternalis tic attitude of professionals towards their patients, who were generally compliant and respectful of authority. Clearly, under different political circum stances there is the potential for abuse of professional power and authority, though I saw no evidence of this during the time of my visit.
Future policy is to continue to develop the primary care system.7 Extensive grass roots organisation makes early screening and preventive programmes possible, with an emphasis on treatment within the community.8 There are also plans to continue the development of specialist psychiatric facilities and training centres which are available at county or municipality level. These provide support, training and points of referral for the rural commune hospitals and the urban district hospitals.
Over the last decade, there has been an increase in exchange of information with the West, with numer ous visits to China by Western professionals, and corresponding visits to Western countries by selected Chinese psychiatrists. Chinese mental health pro fessionals have always maintained that Chinese society requires its own approach to mental health, with suitable adaptation of Western methods. A more liberal climate has allowed the development of a biopsychosocial model to replace the former politi cal and biomÃ©dical models.9 This has enabled mental health professionals to employ psychological and sociological concepts for research and clinical prac tice. These developments have been welcomed by psychiatrists I met, yet it is clear that past experiences make them cautious about adopting Western ideas lest they may be considered politically unacceptable at a later date.
The Chinese are planning a comprehensive com munity mental health service through primary health care, the social order system, education and the media. Evolution of this service will depend upon political development and, in particular, upon whether Western influences are considered desirable or not. The Western notion of 'liberty' has always been problematical for the Chinese, with their emphasis on conformity for the good of society.

Bulletin of the Royal College of Psychiatrists
This is relevant to personal behaviour, family and community relationships and professional conduct. Possible disadvantages of too rapid liberalisation include social dÃ©stabilisation, with consequent breakdown of family and community support sys tems, as has occurred in some parts of Western society. Although the community service would tend to minimise such consequences, it is not certain that it would be adequate to provide for a society in the midst of rapid social change. Large scale social insta bility is clearly seen as undesirable, and possibly threatening to the State.
If the central Party reacts to recent disturbance by repressive counter-measures and controls, this will also affect the mental health system. In a monolithic political state such as China, it is not easy to tune finely the application of doctrine. Rejection of West ern liberal views of behaviour will inevitably restrict professionals, including mental health workers. The community mental health system may then be used to influence and control behaviour and thinking, as occurred previously during the Cultural Revolution. Similarly, professional development may be restric ted, with insistence on conformity to Party ideals and principles. In this way, the potentially beneficial com prehensive mental health system may be used to stifle thought and supress both patient and practitioner. Potential advantages of continued liberalisation include greater liberty for patients and greater professional freedom for mental health workers in relation to research and clinical practice. It is hoped that China will be able to sustain its measured liber alisation and allow the continuing development of a humane mental health system. As in many countries throughout the world, men tal health care in China is in a state of transition from that of a traditional mental hospital-based service towards a specialist service of community-based facilities, centred on the mental hospital or sizeable unit for psychiatry attached to a general hospital.' These patterns of change in mental health care have been apparent for more than a decade now and pro gress has been considerable and rapid throughout the land.2 The Cultural Revolution, 1966-1976, wreaked untold havoc in the country's medical and edu cational systems; and the neurosciences and psy chiatry in particular were severely curtailed and denigrated. Since 1976, however, there has been a significant resurgence of education, research and development in the neurosciences and in psychiatry.1-2 Both Parry-Jones and Crammer in recent accounts of visits to psychiatric services in the People's Repub lic of China, whilst mentioning organic states among the clinical problems present in the Chinese popu lation, make no mention specifically of the psychi atric problems of old age.1-2China, with its huge population in excess of one billion people, is already aware of the increasing demand made on health services from the elderly with mental illness, and particularly those with dementia.
The demographic changes taking place in the country are significant, while the socio-cultural changes in family structure are no less so. That the prevalence of dementia in the population will con tinue to increase and pose considerable problems for the psychiatric and medical services cannot be in doubt. Life expectancy has increased from 35 years in 1940-before the foundation of the People's Republic of China -to nearly 70 years today. In the capital city, Beijing, 15% of the population will be over 65 years of age by the year 2000. Whilst the country's Constitution states that adult sons and daughters are obliged to take care of their parents, it is a fact that already in 1987 more than 20% of per sons aged 60 years and over in Beijing lived alone and away from their children, while less than 3% of per sons aged 60 and over in rural areas lived alone and away from their children. In the rural areas the elderly are still virtually all cared for by their descendants and virtually none enter old peoples' homes.
Early in 1986 the Institute of Mental Health in Beijing undertook an epidemiological survey in an urban district of the metropolis to determine the prevalence of dementia in the elderly population. A rigorous protocol was followed, and a prevalence rate for moderate and severe dementia in the population aged 65 and over was 1.82%.' When