This is my final project (May 8th, 2023) for college course Anthro 216GH: Case Studies in Global Health with Professor Felicity Aulino.
Word Count: 4397
In this essay, I explore the clinical and community mental health care in Chengdu, China. Using the biosocial theory of Local Moral Worlds, I argue that the nonalignment of the morals of mental health care providers and receivers is the root cause of the inaccessibility of mental health care in Chengdu. I propose three steps as a solution: 1) aligning the profiles of populations the providers are targeting and the actual receivers of care, 2) carefully examining the influence of care providers’ morals on the receivers, and 3) recognizing marginalized groups that are invisible in Chengdu and including them as mental health care receivers.
Kleinman (2010, p.1518) wrote on the biosocial theory of Local Moral Worlds. Local worlds are places and networks where people’s lived experiences happen. The values of each local world, including local cultures, law and policies, social norms, personal experiences and beliefs, history and hegemony, economic rules, and important interactions within and beyond communities, create local moral worlds that influence people’s health (cognitive, emotional, and physiological) in global health issues. Ethics are announced to justify certain values and promote certain outcomes. Yang et al. (2006, p.1524-1535) argued that stigma – the experience of being discredited – is a moral one, and it impacts people’s health through threatening the loss of values (and important things these values promote) or destroying these values in local worlds. Guo (2008) argued that in China, stigma transformed a normal person with HIV/AIDS or mental illnesses to nonpersons in the way they were perceived and treated.
What Are Clinical and Community Mental Health Care in Chengdu, China?
The Local Worlds of Chengdu people’s lived experiences of mental health care
Chengdu is the capital city of Sichuan province in southwestern China and the sixth largest city in China. The population is 16.33 million (2019). Clinical mental health care in Chengdu happens in places and networks of general and specialty hospitals, school and district (community) mental health service centers, online and in-person private clinical practices, and free crisis hotline 96008.
Although more civilian-run mental health care facilities appear, mental health care in general and specialty hospitals are mostly state-owned. The Fourth People’s Hospital of Chengdu, or Mental Health Center of Chengdu and The Clinical Hospital of Chengdu Brain Science Institute, founded in 1906, is one of the two largest mental health facilities in Chengdu. It offers care, training, research, prevention, rehabilitation, counseling, and psychotherapy. Its annual outpatient visits are 500,000 and the inpatient visits are 12,000. The Mental Health Center at West China Hospital, Sichuan University, is the largest psychiatric specialties of general hospitals and a co-establisher of psychiatry practice in China. It offers clinical care, training, and research. Its annual outpatient visits are 300,000 and the discharges are 6,000. Other mental health centers in Chengdu include Chengdu Mental Health Research Center for Youth at Chengdu Southwest at Children’s Hospital, Chengdu Jinxin Psychiatric Hospital, Mental Health Center of Chenghua District, and Chengdu Wenjiang District No.3 People’s Hospital.
Clinics take place on some campuses of universities, colleges, high schools, middle schools, elementary schools, nurseries, and kindergartens. Examples are the Mental Health Care Education Center at Chengdu University of Technology and Children Mental Health at Star River Nursery. A proportion of which schools offer mental health care is unknown. According to Chengdu Municipal Health Commission, each community within each district in Chengdu has its own health service center, where general care is offered without mental health care. This community refers to people living and acting in a certain area of several streets. People can find the address and line of these centers online. Examples of community (district) health service centers are Health Center, Jianshelu Community, Chenghua District and Chenghua Wannian Community Health Service Center. For mental health care on the community level, a list of mental health care facilities (enrolled in the yangguang mental health care program, 精神卫生阳光救助定点医疗机构) is offered with address and line. These are actually the hospitals mentioned above that offer mental health care. A free crisis hotline 96008 was set up to connect you to mental health services in several yangguang hospitals.
Psychotherapists and counselors are trained at different levels in Chengdu, China. The system of training is not standardized or rigorous, leading to chaotic experiences of seeking and doing therapies. Many psychotherapists and counselors offer online and/or in-person private practices. An example of online platform for mental health private practice is MyTherapist (简单心理). It offers assessments, therapies, tests, free hotline, physical service at Feeling Matters Wellness Center, and training. A psychotherapist can rent an apartment, set up the apartment as a counseling space, and offer therapies for people. Other private practice therapists can register and practice at private mental health centers like Chengdu Ruishi Mental Health Counseling Center (成都瑞时理心理咨询中心).
For community mental health care in Chengdu, where community refers to non-clinical, non-state institutions, facilities, or networks outside private practices, limited information can be found online. Know Yourself (知我) is the largest community mental health care provider. It focuses on NeoMeditation (textual, visual, audio, and physical workshops of meditation), Daily Practice (self-help textual narrative), Text Counseling (the only clinical part, textual Q&A that combines Therap-e-mail and CBT), Psychological Assessments (professional and for entertainment), retreats, thematic peer support tea parties, corporate services, and media content about psychological topics like romantic relationships.
Local Moral Worlds of mental health care in Chengdu
As an example of local moral worlds in Chengdu clinical mental health care, Chengdu Mental Health Research Center for Youth at Chengdu Southwest at Children’s Hospital (成都市儿童青少年心理健康(家庭教育)研究中心) was founded in 2018 based on the aim of offering convenient one-stop shop mental health care hospital for youth and their families. Its core values are helping youth achieve physical and mental health, promoting youth mental health care, and guiding and helping Chengdu families form healthy family education values and have the right family education. It receives funding from Sichuan (province) Youth Concern Foundation (四川省关心下一代基金会) and is organized by Chengdu Family Education Promoting Association (成都市家庭教育促进会). It targets mental health issues of youth under 17 that take over 250,000 lives annually and emphasizes the inadequate family relationships and education environment behind these issues. It realizes the financial and psychological burden and illnesses of caretakers for youth with mental health issues. It recognizes itself as the most comprehensive and professional youth mental health care team in Chengdu.
As an example of local moral worlds in Chengdu community mental health care, Know Yourself (知我) has the mission of “helping people develop skills of happiness and lead a wellness lifestyle with an emphasis on mental wellness within the society.” It aims to promote a new value of health in China: a transition from traditional physiological health to both body and mental health. It hopes to make pursuing mental health a popular lifestyle like fitness. Its customer profile is people earning high salaries living in first-and-second-tier cities in China. Over 80% of their customers hold a degree above undergraduate.
Other values of the local world of Chengdu mental health care include categorizing mental health services by levels of the professionals and charging different fees for each level at The Fourth People’s Hospital of Chengdu. The hospital established this policy on May 4, 2023 to satisfy diverse needs of mental health and offer tailored mental health care for each visitor. To receive care, visitors are required to make appointments of 30-40 minutes with professionals categorized to four levels. Visitors pay 800 yuan for a 40-minute appointment with a level-one mental health professional, 600 yuan for a 40-minute appointment with a level-two, 400 yuan for a 30-minute appointment with a level-three, and 300 yuan for a 30-minute appointment with a level-four. The average monthly wage in Chengdu was 9696 yuan for the first 2023 season. The average monthly house rent is 2500 yuan.
Another value of the local world of Chengdu mental health care is the constant recruitment for the professional, free, and convenient Chengdu mental health hotline for over ten years as a response to the 2008 Sichuan earthquake of 8.0 Ms magnitude. The earthquake led to 69,227 deaths, 374,643 injured, and 17,923 missing. Earthquakes happen frequently in Sichuan province. Local news broadcasts earthquakes on time. First aid and emergency response and practices to earthquakes are integrated in Chengdu elementary school curriculum, and Chengdu people share a calm attitude towards earthquakes. This Chengdu mental health hotline provides mental health education, psychotherapies, and mental health crisis intervention for the general public, families where the only child is injured, disabled, dead and those have no babies or adoption after (as a response to the One-Child Policy), and middle-and-elementary students, parents, and teachers. Its values are caring for people’s mental health, guarding their peacefulness, and becoming the light in the dark. The Chengdu mental health hotline and the cultivated local mentality of being calm, positive, and prepared in the face of frequent earthquakes are in an interplay.
What’s the problem?
The key problem of mental health care in Chengdu, China, is that it is inaccessible. Specific issues demonstrating this inaccessibility include shortage of mental health facilities and professionals, difficulty in making appointments with professionals, unequal distribution of healthcare, limited forms of mental health care, no mental health care offered in the northern Sichuan area, high user fees of mental health care (not included in medical insurance), limited law strategies of caring for the mentally ill, marginalized, and poor groups, inconsistent quality of private practice, histories of abandoning mental health care that contribute to lingering rejection of care, criminalization of the mentally ill, economic instability and public health concerns, industrial development’s challenges to personal, relationship, and social functioning, stigma about mental illnesses, blaming people for having mental illnesses, and invalidating families, friends, visitors, or self’s experiences of mental illnesses.
During my years of elementary, middle, and high schools in Chengdu, people in my network talked about how difficult it was to make appointments with doctors in large hospitals in Chengdu. During the COVID-19 pandemic, beds offered at hospitals were always full and healthcare professionals were lacking and exhausted. In smaller cities and towns, there were even fewer care facilities. Mental health care resources were allocated unequally among urban, suburban, and rural areas. Many patients had to travel to other districts for care. To address the unequal distribution of healthcare in Sichuan, in June 2022, Health Commission of Sichuan Province published a plan (《四川省“十四五”医学中心和区域医疗中心设置规划》) that cut the province into five areas and redistributed resources among each area. This initiative aims to construct an efficient and integrated healthcare system, reduce cross-district seek for care, promote level-based care, and ultimately provide people in Sichuan, the western China, and countries and regions of the The Belt and Road Initiative with quality, efficient, and accessible healthcare. However, the resources redistributed were general and specialty hospitals, excluding clinics, private practices, other networks and organizations, and community mental health care. This redistribution engaged healthcare in general, with mental health care offered at four out of five areas. The Northern Sichuan area did not offer mental health care, which means that people living in northern Sichuan still need to travel for mental health care. Also, the number of facilities or beds in hospitals remained the same.
Values that this initiative promotes in the local worlds of Sichuan health care are Xi Jinping Thought on Socialism with Chinese Characteristics for a New Era, the spirit of the 19th Central Committee of the Communist Party of China, the idea that people’s health is key, and establishing the advantages of the unique Chinese healthcare system. Chengdu local government promotes political thoughts, theories, and core values through media and policies, the party-directed organization structure of clinical mental health care centers, clinics, and hotlines, and meetings and training for mental health professionals.
More cases of mental health concerns and illnesses appeared in recent years when the pandemic and quarantine brought challenges to people’s lived experiences in their local worlds. The pandemic directly increased stress levels, separated intimate relationships, led to injuries, deaths, chronic illnesses, trauma, and disabilities, complicated the relationship between government and the people, grew unemployment and business bankruptcies, turned the macroeconomy and daily lives unstable, and doubled the consequences of inappropriate policy. Meanwhile, as the need for mental health care rose, the state leveraged resources to meet the need. It announced its work in investing in mental health care and declared a focus on offering mental health care, which closed some gap between the need and service in mental health care and alleviated stigma towards mental health illnesses.
Qin Lu, Deputy Secretary-General of Chengdu Municipal Committee of the Chinese People’s Political Consultative Conference and Professor of Psychology, argued that the district (community) mental health care in Chengdu lacks support from the healthcare system, falls short on mental health professionals, and has limited forms of services. District mental health care in Chengdu works to promote residents’ living conditions and happiness, and in turn, creating a safe, healthy, and civilized Chengdu city culture.
Chengdu medical insurance does not include mental health care. Visitors need to pay from their pockets. In 2012, the Mental Hygiene Law of People’s Republic of China (《中华人民共和国精神卫生法》) was passed on the 29th meeting of 11th National People’s Congress (NPC) Standing Committee as the first national law for mental hygiene. It states that people with severe mental disorders can access free public health services, and the poor among them can enjoy government-funded basic medical insurance, the priority of being cared for, and potentially subsistence allowance. Still, people’s social functioning is far from being guaranteed, and mental health care needs to be paid. Further, while the poor and mentally ill were addressed, other marginalized groups who are susceptible to mental illnesses were not discussed. So was comorbidity of mental illnesses or mental and other medical illnesses.
On mental health care in China, Zhang (2020, p.9-21) presented that in China today, estimating who has mental illnesses and what illnesses (epidemiological study) is difficult because mental disorders like depression and anxiety disorders were not introduced until the 1990s; people in need for mental health care could reduce their conditions to somatic and physiological and sought help from traditional Chinese medicine and Western medicine ([]); stigma makes coming out with having mental concerns and illnesses and looking for help challenging. Mental health facilities are too few for a large population in China, hospitals offer mostly drugs to people with psychosis, and the quality of psychotherapists and counselors is inconsistent. Zhang (2020, p.150-174) explained that introducing psychology to China renovated people’s values about the mind/mental (xin, 心); political governing was involved in therapeutic practice; therapies for individuals with anxiety are digesting the influences of rapid economic reform on people in China.
Nine years ago, similar problems about mental health care in China were raised and researched. Jinhua and Kleinman (2011, p.237-238) presented that in China, current epidemiological data could not inform the actual number of cases of mental illnesses due to reasons like various diagnosing criteria and difficulty in diagnosing psychosis. Available mental health care in Chinese hospitals did not meet the demand. Mental health care quality was lacking. Stigma blocked people from accessing care and added on to the suffering, making them socially dead. Mental illnesses were politicized as things to be abandoned during the Cultural Revolution. People of Chengdu who experienced the Cultural Revolution can find mental health care a threatening or bizarre idea, reject the existence of mental illnesses, project prejudice to people in their network, or miss the opportunity to understand themselves using psychological tools. Mental health care diminished then, and is now slowly growing. Baum (2018) traced the historical documents about mental health care in the early 20th century Beijing, China, and found the making and medicalization of madness.
Many people I met in Chengdu held their mental health issues and illnesses to themselves. Some reasons are families’ lack of understanding of mental health issues, not wanting families to worry about them, coming out would attract discrimination against them, explaining the whole situation of having mental illnesses is tiring and the listener might not understand, distrust of certified therapists, and more. When I went to a Chengdu certified therapist’s first private practice session in 2020, he blamed me for having depressive episodes as a privileged kid who did not acknowledge my privilege. He was invalidating my lived experiences of having Major Depressive Disorder and reducing my experiences to being vulnerable and spoiled. It took me a year to regain trust in therapists.
Other common issues of mental health care in Chengdu include reductive thinking of “you’re a negative person, why can’t you be positive?”, which rejects people’s experiences and relevant values like prioritizing their health. People with mental illnesses tend to be criminalized by misinterpretation of their presentation, when they have other marginalized identities, and more. When people go into jails without mental illnesses, they can come out with some, and depending on how much rehabilitation is offered, they face challenges of integrating into society.
What Are the Root causes?
Using the lens of Local Moral Worlds, I argue that the root cause of inaccessible mental health care in Chengdu, China is the nonalignment of the important values – morals or what’s at stake – between the provider and receiver of mental health care.
Many stakeholders are involved in mental health care in Chengdu. Here, I put mental health professionals, professors, care evaluators, managers, and researchers into the provider category; and people with mental health issues and illnesses looking for care into the receiver category. The nonalignment takes five forms: opposite, branching-out, parallel, missing, and crossing-over. When the morals align in the forms of complete overlap or ending on the same point (although starting from different points), mental health care becomes accessible. This relationship between morals of the mental health care provider and receiver can be understood as two lines with both starting and ending points.
In the morals of mental health care providers, there are claims of serving a certain population such as youth, elementary and middle school students, the severely mentally ill, the poor, families of youth, and the general public. Nonetheless, people who ultimately access the care might not fit these profiles. For mental health care receivers, factors like user fees, the distance from residency to care, trust of care providers, fear of being discriminated against or treated as madpeople by the providers, worries about providers disclosing their information are at stake. Since providers fail to address these factors important to the receivers, and both morals do not align, mental health care cannot be delivered. In this case, the nonalignment takes the shape of crossing-over as providers profile receivers and acknowledge certain challenges, however fail to support receivers.
Some mental health care providers serving the youth made clear that they promote certain familial relationships which they believe are right, and their care focuses on redirecting those relationships to the “right” direction. When the receivers disagree on the criteria for familial relationships (nonalignment – opposite), or the care fails to offer a step-by-step guide for those relationships (nonalignment – branching-out), the care is inaccessible because the morals of the providers and receivers do not align.
In the morals of mental health care providers in Chengdu, the LGBTQIA+ community never appeared on the receiver list, making the community invisible. The morals of people with mental health care needs in the community and those of providers do not align (missing).
What Can Be a Solution?
Interventions for the nonalignment of the important values – morals or what’s at stake – between the provider and receiver of mental health care in Chengdu, China should aim to bring alignment (complete overlap or ending on the same point) between the morals so that care is accessible.
The first step is aligning the profiles of populations the providers target and the actual receivers of care. This means that the providers list and analyze what’s at stake for the populations they aim to serve. Morals and relevant strategies here should include:
- affordable or free care. Work to include clinical mental health care, both drugs and psychotherapy, in medical insurance for the general public in Chengdu. Do not raise the price of health insurance or take other actions to increase the uninsurance rate. Lower the current price of mental health care. Increase the frequency of free clinic services or establish free clinics in the form of voluntary organizations. Leverage funding from the saved cost of the original clinical care model.
- increased transparency of care. People worry about the quality of care. Host group discussions on the quality of care. Hire filmmakers to document receivers’ feedback of care, their thoughts on current care and suggestions for improvement, their experiences of receiving care, and do screenings in different districts and communities to inspire more discussions on the quality of care. Run a hybrid platform with frequent calls for submitting evaluations of care and art works and writings about mental health care. Share the evaluations with the providers. Announce the current evaluation system for the providers within the system. Encourage more care providers to talk about their working experiences and values in communities.
- Based on the evaluations above, set up a standardized system for evaluating all providers. Require providers who do not meet the standards to stop practice. Constantly meet and modify the system. Share the evaluations on websites and other media where people looking for mental health care can easily find relevant information and choose the care they trust. Send out surveys, conduct interviews, and use other research methods to collect data on whether that trust is met during and after the care sessions. Update the evaluations frequently. Study and analyze current law and policies of mental health care. Emphasize punishment when the providers and receivers violate the law.
- Reexamine the current training for mental health care providers. Standardize the training and offer more training spots. Aim to bring practitioners to the stage of performing their responsibilities fluently and understanding the group they serve.
- Continue to bring one-stop mental health clinics into all five areas in Sichuan. Establish more mental health care facilities, especially in the northern Sichuan area. Work to offer mental health care in the mental health center of every district. Encourage more students to study mental health. Save cars and fleet vans and hire drivers to transport people looking for care at a low price or for free. The drivers are employees of the care facility and are paid by the facility.
- Consider using the PACT model of community caregiving, Assertive Community Treatment (ACT) in community psychiatry (Brodwin 2012), recovery-oriented care (Myers 2015), People’s Free Medical Clinic of the Black Panther Party (Nelson 2011, p.75-114), peer support of the Wildflower Alliance (Lazović 2022), and other community mental health care models to align with the receivers’ morals of being accompanied, frequently checked-in, understanding more about mental health and themselves, participating in constructing the scientific knowledge of mental health and care, and advocating for themselves. Address the complexities of providers’ work in these models, where they struggle between following bureaucratic psychiatric practice handbooks and challenging these handbooks’ reductive approach on the mental health care receivers (as having abnormalities in their brain and biomedical systems). Discuss what recovery and care mean and what it takes to achieve them.
- Continue breaking the stigma of mental illness to respond to receivers’ fear of being discriminated against or treated as madpeople by the providers. Hold lectures, workshops, and discussions about stigma. Create interesting content about stigma and mental health and publish it in media such as Weixin and Toutiao.
- Call for proposals of online and physical mental health services of various forms so that receivers have more opportunities and approaches of accessing care. Some receivers can benefit from online care if their morals include traveling far to receive care. In 2022, Qin Lu proposed building online platforms for mental health to diversify the care format, gather and share information, chat live with multiple stakeholders, and hold bulletins and salons about mental health. On May 8, 2023, The Fourth People’s Hospital of Chengdu called for projects that utilizes digital evaluation and care through online platforms.
The second step is to carefully examine the influence of care providers’ morals on the receivers. In July 2021, the Mental Health Center at West China Hospital, Sichuan University published a thank-you letter to PICU (急危重症精神障碍病房) from a patient with severe Major Depressive Disorder. This content was published on large Chinese media platforms of Sohu and TouTiao. In the letter, the patient described the unstigmatized gentle inpatient (isolated due to high risks of suicide and violence) care that mental health professionals in PICU offered over twelve days. She wrote how the care at PICU was patient, detailed-oriented, and undiscriminating: “when we mentally brokedown, mental health care professionals here did not leave us alone in ‘detention’ rooms,” “people sending food did not rush or say ‘don’t be picky,’ nurses did not yell at them, ‘go to bed now,’ and doctors did not leave with ‘keep observing, take meds, you’re not allowed to meet your families,’” “you did not treat us like ‘psychopaths or mad people,’ instead, you treated us as people who are more sensitive, gentle, and kind.” She continued that because of the delicate and undiscriminating care, she felt empowered, calm, worriless, and brave. In this case, care providers’ attitudes, responses, behaviors, the relationships between the providers and the patient validate the patient’s experiences of mental illness and support the patient on recovery. Different results would happen if the providers were exerting authority, treating the patient as a nonhuman, or blaming the patient for their conditions.
The third step is to recognize marginalized groups that are invisible in Chengdu, China, and include them in mental health care receivers. This recognition will challenge the morals of care providers. The biosocial theories of structural violence and social suffering can be useful in analyzing these morals.
Mental health care in Chengdu, China, has many strengths and issues. The key problem is its inaccessibility, which is rooted in the nonalignment of the morals of mental health care providers and receivers. Using the biosocial theory of Local Moral Worlds, I propose three steps in a solution to this problem: aligning the profiles of populations the providers target and the actual receivers of care, carefully examining the influence of care providers’ morals on the receivers, and recognizing marginalized groups that are invisible in Chengdu and including them in mental health care receivers.
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