Marriage and Family Therapy in the People's Republic of China ...

Journal of Family Psychotherapy, 23:173–183, 2012 Copyright © Taylor & Francis Group, LLC ISSN: 0897-5353 print/1540-4080 online DOI: 10.1080/08975353.2012.705626

Marriage and Family Therapy in the People’s Republic of China: Current Issues and Challenges JOHN K. MILLER Department of Family Therapy, Nova Southeastern University, Ft. Lauderdale, Florida, USA

XIAOYI FANG Institute of Developmental Psychology, Beijing Normal University, Beijing, China

China’s rapid social and economic developments over the last decade have prompted many changes across the population. The stigma associated with counseling and therapy is beginning to fade. With rich cultural traditions of multigenerational family connections, marriage and family therapy has emerged as a popular modality of mental health service. This article provides a review of the available literature regarding the development of mental health services in China, noting the recent transformations relevant to the practice of therapy. The implications for the future of clinical practice, education, and curriculum development are also discussed. KEYWORDS China, family therapy, mental health

BRIEF HISTORY OF MENTAL HEALTH SERVICES IN CHINA Indigenous forms of psychotherapy have existed in China for centuries; however, what is most commonly considered as psychotherapy today has developed out of the country’s political and academic influences from the West. From the founding of the People’s Republic of China in 1949 to the present, the development of psychotherapy may be divided into four stages. From 1949 to 1969 Chinese psychiatry was heavily influenced by

Address correspondence to John K. Miller, Department of Family Therapy, Nova Southeastern University, 3301 College Avenue, Ft. Lauderdale, FL 33314, USA. E-mail: jm2790@ nova.edu 173

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Russian neuropsychiatric models with political priorities focused on maintaining public order (Qian, Smith, Chen, & Xia, 2001). In the era of the Cultural Revolution (1966–1978) the government closed the nation’s psychology departments and research institutes. It dismissed psychology itself as a bourgeois pseudo-science promoting a false ideology of individual differences (Phillips, 1998; Qian et al., 2001). Mental illness and anything considered “deviant” were cast as problems of wrong political thinking to be addressed through reeducation rather than mental health care (Yip, 2005a). China’s attitude toward psychology changed dramatically after the end of the Cultural Revolution. Political and economic reforms initiated in the years between 1978 and 1986 facilitated the revitalization of Chinese psychiatry and its reengagement with Western scientific communities (Li, Duan, Ding, Yue, & Beitman, 1994). National professional meetings and international exchanges were initiated, clinical research resumed, and new periodicals and professional journals were founded. The fourth stage, from 1987 to the present, has witnessed tremendous growth of the mental health field in China. This growth has been fueled by the government’s recent acknowledgment of the social burden caused by mental health problems and a variety of state-sponsored initiatives to improve access to psychological services in the country’s hospitals, schools, and prisons (Li et al., 1994). Although the Chinese have been exposed to Western psychotherapies since the 1950s, the practice of counseling is a relatively new phenomenon. Additionally, marriage and family therapy is in its infancy in China but is beginning to gain some exposure and credibility (Meers, 2007). With China’s rapid transformation from a traditional agricultural society to a modern industrial society since the “open door policy” and economic reforms of the 1980s, dramatic changes are occurring in people’s daily lives (Chen, 1985; Perkins, 1994). These transitions are influencing the structure and attitudes of the Chinese family and have implications for the future of culturally appropriate Chinese family therapy. What unique issues are facing the Chinese family today? What are the implications of these issues for the practice of therapy? What are the current issues and challenges for the future development of a culturally congruent Chinese marriage and family therapy? The authors have reviewed the relevant available literature related to Chinese culture and therapy to shed light on these issues.

CULTURALLY RELEVANT FAMILY ISSUES IN CHINA Myth of a Single Chinese Culture Chinese civilization is one of the oldest societies on the planet. Often perceived in the West as being composed of one cultural group, the Chinese culture is actually a rich tapestry of ethnic and racial diversity. There are over 56 clearly identified different ethnic groups in China (China Travel

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Guide, 2008). China currently has five major language families and 129 different languages, excluding dialects or subdialects (Chinese Academy of Social Science, 2008). As we attempt to understand contemporary Chinese family issues, the diversity within the culture must be recognized and acknowledged. It is beyond the scope of this article to do justice to the description of the diversity that the culture of China represents. Therefore, we begin this investigation with a disclaimer regarding our limitation of scope and depth to the description that would be necessary to adequately describe the complexities involved. Yet, we hope our general overview will yield some light on the understanding of contemporary Chinese society and culture.

One-Child Policy In 1979 the Chinese government introduced the one-child policy as an attempt to reduce its growing population, which was believed to be a roadblock to China’s economic development (Hesketh & Zhu, 1997). The one-child policy has dramatically affected the Chinese people’s experiences and the lives of families (Hesketh, Lu, & Xing, 2005; Shek, 2005). The policy consists of a set of regulations that include restrictions on family size, late marriage and childbearing, and the spacing of children in cases in which second children are permitted (Hesketh et al., 2005). Contrary to popular perception, the one-child policy does not always mandate one child, especially in rural cities where approximately 70% of China’s people live. There are several exceptions to the one-child policy. First, where a family is located has a bearing on how many children they are allowed. The one-child policy is strictly enforced for urban residents and government employees. In rural areas, where approximately 70% of the people live, a second child is generally allowed after 5 years, but this provision sometimes applies only if the first child is a girl (Hesketh et al., 2005). In some locations if the first child is a girl or disabled the family is allowed to have another child, usually about 3 or 4 years afterward. In addition, a third child is allowed among some ethnic minorities and in remote, underpopulated areas (Hesketh et al., 2005). The one-child policy is underpinned by a system of rewards and penalties (largely meted out at the discretion of local officials) and includes economic incentives for compliance, substantial fines, confiscation of belongings, and dismissal from work for noncompliance (Hesketh & Zhu, 1997).

Son Preference Although the one-child policy has been estimated to have reduced population growth in the country of 1.3 billion by as much as 300 million people over its first 20 years, it has also brought on a host of unintended consequences. Probably the most well-known consequence of the one-child

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policy is China’s sex ratio. The sex ratio at birth ranges from 1.03 to 1.07 in industrialized countries (Davis, Gottlieb, & Stampnitzky, 1998). Before the implementation of the policy in 1979 the reported sex ratio in China was 1.06 nationwide. This grew to 1.11 in 1988 and 1.17 in 2001. Son preference is still the dominant mode, especially in rural China and among poor peasants (Graham, Larsen, & Xu, 1998). One exception to son preference is among higher educated women. In their study of gender selection in China, Chan et al. (2002) found that among women in Hong Kong, Beijing, and Shanghai, there was a tendency to prefer more girls than boys. More affluent and educated women are increasingly opting out of having any children (Liu, 2004). Wang (2002) found similar exceptions if parents had higher levels of education or held white collar occupations. These parents tended to be less likely to hold a son preference value and less likely to discriminate against their daughters. Son preference seems more relevant under conditions of resource constraints or with those families living in rural communities.

Little Emperor/Empress Family Dynamic One of the more visible unintended consequences of China’s one-child policy is the “Little Emperor/Empress” family dynamic, affecting both parents and their one child, especially in urban areas of China (Lau & Yeung, 1996; Wang et al., 2000). Chinese scholars have been studying this family dynamic and characterize it as a byproduct of so many children being raised as only children, receiving the full, and sometimes permissive, attention of both parents. These Chinese scholars maintain that with both parents lavishing attention and resources on their one child, the child increasingly gains a sense of self-importance and entitlement (Chen, Liu, & Li, 2000; Fang, 2008; Miller & Zhao, 2008). Mooney (2005) argued that parents of these children don’t want their child to be upset with them and potentially grow to resent them if they create or enforce rules, so they are more likely to give in to their child’s requests. These children grow up as the pride and joy of adoring parents and grandparents and are beginning to be known as the “spoiled generation” (Mooney, 2005). They are also more likely to be the center of their entire extended family. The one-child policy has shifted the focus from a parental to a child-centered culture.

Academic Achievement Pressure and Internet Addiction Although only children may experience increased indulgence from their parents and grandparents, there are also tremendous parental and societal pressures for academic achievement (Shek & Chan, 1999; Zhao, 2008). A growing culture of pressure and competition has sparked a mental health crisis for young Chinese (Chao, 1994; Hesketh, Ding, & Jenkins, 2002; Hess,


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Chang, & McDevitt, 1987; Tepper et al., 2008). The most common problem faced with only children in Chinese society is anxiety related to school performance, especially because there is often great parental pressure to do well (Tepper et al., 2008; Tsui & Rich, 2002). The expectation to excel academically may be too much of a pressure for some only children. Some Chinese researchers have linked the increased academic pressures with a rise in Internet addiction. Many Chinese youths addicted to the Internet have family and behavioral problems, which are then aggravated by their addiction (Yang, 2006). The Chinese government considers this obsession with the video game culture a national epidemic and has recently classified “Internet addiction” as a clinical disorder. Researchers have consistently found that exam stress, academic failures, and relationship problems are the most common reasons for suicide in China for those under 17 (Hesketh et al., 2002; Ryder et al., 2008; Tepper et al., 2008).

4-2-1 Family Dynamic China’s lower mortality rate, when combined with the one-child policy, has resulted in a dramatic aging of China’s overall population (Mian, 2007). Many Chinese families today face what is popularly known as the “4-2-1 phenomenon.” That is, four grandparents and two parents, both from singlechild families, must be supported by a single child. It is traditional in Chinese culture for several (three or more) of these generations to live under the same roof. By the year 2040 it is expected that 400 million Chinese (or 26% of the Chinese population) will be more than 60 years old (Hesketh et al., 2005). China’s demographic shift to an older society will have a profound impact on the Chinese family. The shrinking size of the Chinese family has created a dilemma in which seniors will have only one child to care for them in their old age. This family dynamic can result in increased pressure on the child, as the intergenerational hopes and expectations of the parents and grandparents are passed down through the generational lines. Some Chinese scholars have argued that these intergenerational pressures can present overwhelming expectations for the child, promoting stress-related illnesses and syndromes. Among the scholarly community this metaphor of the intergenerational and societal “pressure” is one of the main explanatory principles for mental health issues, especially among the younger generation (Fang, 2008; Hess et al., 1987; Miller, 2007a, 2007b).

Marriages and Divorces The marital structure has also experienced new challenges as a result of economic reform and the opening of the Chinese society to the West. Another

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unintended consequence of son preference is that it is increasingly difficult for young men to find women to marry (Davin, 2007; Hesketh et al., 2005). Although arranged marriages still exist, they have increasingly given way to free choice in marriage (Hong, 2006). This free choice is creating friction between the elders who are more in touch with tradition and the younger generation who value freedom of choice. There is an increase in unmarried professional women who choose the single life. Although they can gain higher education, status, and salary, they continue to receive pressure from their families of origin to marry (Liu, 2004). Divorce rates are rapidly increasing in China. According to the Chinese Ministry of Civil Affairs (2007) the divorce rate in China was 2.5% in 1979, 25% in 1999, 36.7% in 2002, and 39% in 2006. More prosperous urban cities have a higher divorce rate than poorer rural cities. The divorce rate in Beijing was almost 50% in 2006 (Ministry of Civil Affairs of the PRC, 2007). To a degree, China’s rising divorce rate is typical for a developing country that is rapidly modernizing and becoming more affluent. But the increase has risen dramatically since October 2003, when a new marriage law simplified the process for divorce by dissolving the requirement that couples needed approval to divorce from their employers (Palmer, 2007). Besides the simplified procedure, fast social transformation and changes in how marriage is viewed among men and women are also important factors for the soaring divorce rate. The increased divorce rate may reflect the changing attitude toward divorce, higher expectations of marriage, improvement in living environments, and economic growth. Personality clashes between couples have been cited as the main cause for marriage dissolutions in the urban cities (Xu, Xie, Liu, Xia, & Liu, 2007). Economic disputes arising from factors such as failing businesses and being laid off by companies has also triggered many divorces. Further, studies have also shown that the peak of marriage conflict has changed from 7 years after marriage to 3 years after marriage and that about 50% of urban couples had divorced within 7 years after marrying (Xu & Ye, 2002). The simplicity of the marriage and divorce process has led to new social phenomena among the young urbanites: “flash divorce” and “flash marriage.” A flash marriage is a term created in the last few years to describe a couple that marries quickly after meeting one another, sometimes after knowing one another for 7 months or less (Zhang, 2005). Couples are now engaged in shorter and shorter courtships due to the financial pressures of keeping up a long-term relationship before marriage. Soaring prices of real estate in bigger cities make speedy marriages more economical. There is concern that the impact of flash marriages may be that this population will not take seriously the responsibilities of marriage (Zhang, 2005). There is wide concern in China for the long-term stability of such relationships, although there is still a need to research this area further.


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DEMAND FOR MARRIAGE AND FAMILY THERAPY IN CHINA Historically, there has been no concept of “marriage and family therapy” in the Chinese language and no equivalent Chinese term for “therapist.” Things are now changing. Rising wealth and expectations of happiness are behind an unprecedented demand for mental health counseling services (Chang, Tong, Shi, & Zeng, 2005). Meanwhile, the stigma associated with professional treatment is beginning to fade, along with attitudes that encourage people to stoically endure problems or to solve them at home. A recent survey conducted in Shanghai found most families grapple with serious stress and anxiety yet only 2% acknowledged seeking professional treatment, whereas only 19% said they would ever consider professional help (Shanghai Women’s Federation, 2006). Although rare, family therapy services are available in China, especially in urban areas. Accessibility to these services is usually limited to the middle class and those connected with university settings (Miller & Zhao, 2008; Zhao, 2008). Most of China’s population (about 70% who live in rural peasant communities) are not likely to seek out professional help because they are too busy eking out a living, cannot afford it, are ashamed to seek help, or have no access to family therapy services. Although there is no formal practice of marriage and family therapy on a large-scale basis, there are pockets of recognition and isolated practitioners who are increasingly using a systems format for their work with patients and clients. The profession of therapy is still finding its way, with erratic standards and delivery modalities (Change et al., 2005; Miller & Zhao, 2008). A great deal of current Chinese family therapy involves giving advice and psychoeducational interventions (Miller & Zhao, 2008;Yip, 2005b; Zhao, 2008). On the academic track, though, Chinese psychologists are engaging more with Western scholars and looking for ways to adapt established theories and techniques to Chinese sensibilities. This raises both challenges and opportunities as Western-based family therapy is adapted to offer a culturally congruent service.

ADAPTATION OF WESTERN MODES OF FAMILY THERAPY TO THE CHINESE CONTEXT Western systems oriented family therapy provides a good fit for the treatment of some problems in the Chinese context, given the cultural emphasis on the family and intergenerational connectedness. Core systemic concepts such as “interconnectedness,” “intergenerational process,” “wholeness,” and “contextual views of problems” fit well with the culture and history of China. Yet, what is needed is an adaptation of the components of systemic family therapy that are culturally congruent in contemporary Chinese family processes. Although it is evident that China is beginning to open up to the

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practice of family therapy, many cultural barriers remain (Li, Xu, & Zhao, 2006). Chinese families have historically valued controlled expression of emotion, self-reliance within a family, the use of the family insiders rather than outsiders for help, and emphasis on hierarchy and education (Ma, 2000). With this dynamic in mind, it is logical that many Chinese families would expect the family therapist to play the role of an expert. They would be more likely to expect the therapists to adopt an authoritative attitude in relating to them by providing information, offering advice, and suggesting better ways of managing the problem (Wang, 1994; Wu & Tseng, 1985). These expectations are at odds with the culture of family therapy in the West, which emphasizes the role of the therapist as a facilitator who helps families to discuss their problem and identify the solution on their own. In light of these and other cultural differences, the challenge facing the practice of marriage and family therapy in China is to adapt established theories and techniques to fit Chinese sensibilities. There are only a few organized postgraduate marriage and family therapy programs in China. The Masters in Social Sciences in Marriage and Family Therapy program at the Hong Kong University Family Institute was officially established in 2003. The Hong Kong University Family Institute’s marriage and family therapy program was modeled after American Association for Marriage and Family Therapy’s standards of clinical training (http://hkufi.hku.hk/academic.html). Many more certification programs and workshops (ranging in length from one weekend to one month trainings) in marriage and family therapy are offered at various universities and continuing education programs within China (i.e., Beijing Normal University, Tongji University, Shanghai Xinqiao Education Consultation Center). Other issues that face the continued development of Chinese family therapy include the development of commonly recognized ethical standards and codes, licensure or other certification of clinical competence, the development of professional and academic associations, and standardized training and supervision curriculum.

FUTURE DIRECTIONS The demand for family therapy services has led to many Chinese graduate students and current counseling practitioners to seek training in marriage and family therapy. As practitioners in China have shown increasing interest in marriage and family theory and practice, the future looks bright for this field in China. However, there are still a number of major obstacles to improving and popularizing marriage and family therapy as a credible profession. The problems concerning therapist qualifications have drawn attention within the profession of psychology and counseling. There is a lack of a system for controlling the qualifications of the professionals who provide marriage and family therapy. In fact, psychologists were only first certified in 2003.


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Clinical supervisors and mentors are needed for university graduates and those wishing to learn marriage and family therapy. Although Chinese universities and training centers are offering courses in marriage and family theory and techniques, there is a need for experienced mentors and supervisors to oversee the work of beginning therapists. There is also a need for practical, supervised experience for students. Academic exchanges and cooperative trainings with Western universities continue to develop in China. As these collaborations continue, what role will the U.S. academic and professional associations play in this development? What are the ethical guidelines of exporting and adapting Western-based psychotherapy to the Chinese context? What impact will these developments have on international relations? These and other issues must be addressed as we continue to witness the development of Chinese marriage and family therapy.

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