Mental health in China, explained by Shanghai-based clinical psychologist George Hu

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[Editor’s note: Below is a complete transcript of the Sinica Podcast episode on mental health care in China featuring George Hu, a Shanghai-based clinical psychologist who serves as president of the Shanghai International Mental Health Association and leads the United Family Mental Health Network.]

Kaiser Kuo: Welcome to the Sinica Podcast, a weekly discussion of current affairs in China produced in partnership with The China Project. Subscribe to The China Project’s daily Access newsletter to keep on top of all the latest news from China from hundreds of different news sources, or check out all the original writing on our site at TheChinaProject.com, including reported stories, editorials, and regular columns as well as a growing library of videos and, of course, podcasts. We cover everything from China’s fraught foreign relations to its ingenious entrepreneurs, from the ongoing repression of Uyghurs and other Muslim people in China’s Xinjiang region to China’s ambitious efforts to eliminate poverty. It’s a feast of business, political, and cultural news about a nation that is reshaping the world. We cover China with neither fear nor favor.

Kaiser: I’m Kaiser Kuo coming to you from beautiful Chapel Hill, North Carolina. Joining me from storied Goldkorn Holler in the rustic southwestern suburbs of Nashville, Tennessee, is the one and only Jeremy Goldkorn, editor-in-chief of The China Project and the man I always blame when ardent nationalists or Party apologists come after me for The China Project’s mainstream anti-China coverage. Yep, I am always happy to throw old Jeremy under the tankie, if you will. Jeremy, sorry, old buddy. Sincerely though, I’m sorry. I do that all the time, but greet the people, won’t you?

Jeremy Goldkorn: Yeah, hi. No, that’s fine. I’m tankie-proof. You can throw me under the tankie any time.

Kaiser: Well, it’s going to happen with increasing frequency as… Anyway, Jeremy, China, to state the obvious, is a country that has undergone a little bit of change in a short period of time.

Jeremy: A little bit.

Kaiser: Yeah, just a little bit. It’s a country with social structures that have been disrupted, upended, making a transition from very traditional modalities rooted in rural village life to the urban centered, atomized society that arguably typifies China today. Generation gaps in China, which has experienced so much change in just a couple generations, are really yawning chasms. Add to this the huge demographic changes brought on by the controversial family planning, one-child policy, throw in the hyper-competitiveness of school, work, dating. And for good measure, just recall the relative recency of society-wide trauma like the Cultural Revolution that’s still keenly felt in China, and I think any reasonable person would expect mental illness to be on the rise in China.

Jeremy: But, in China mental health is not discussed very much at all. Quite a contrast to America where people will tell you about their therapists two minutes after meeting you on the plane and the language of psychology, psychiatry and mental health is part of normal English here. Bipolar, ADHD, PTSD, depression, anxiety, and stress, these are normal words in American popular culture, but that certainly isn’t the case, or it wasn’t the case, in China.

I know, Kaiser, you and I have often debated whether this was because Chinese people were somehow more resilient. And I know I used to often tell Westerners who were complaining of depression or other psychological issues that they needed to be more like Chinese people and get a second job and go and sell lighters on the street at night and then they wouldn’t think so much about themselves. But on a more serious note, we’ve also talked about how mental illness may be just stigmatized in China or hidden from view.

Kaiser: Yeah. Yeah, yeah. It’s funny, that’s the side of the debate that I usually take and you’re the one who’s like, “Oh no, Chinese are really super resilient.” Anyway, I know coming from a Chinese family that it was definitely stigmatized, and at least when I was younger, it was treated as some kind of personal failing rather than as an actual disorder rooted in physiology and in brain chemistry. But my sense just in the years before I left China was that this was already changing quite a bit. Jeremy, did you sense that by the time you left?

Jeremy: I think it was changing certainly amongst the chattering classes, but I think one of the things I’m interested to talk about tonight is how much that has changed.

Kaiser: Yeah, yeah. Well, today we are very fortunate to have somebody who can tell us all about that. We’re joined by Dr. George Hu, who is a clinical psychologist and president of the Shanghai International Mental Health Association. George leads the United Family Mental Health Network in China and practices at United Family’s hospital in Pudong down there in Shanghai.

George is a Californian by birth, and like me, he’s one of those via-Taiwan ABC types. He’s been working in China since 2013, inspired to come to China after, I think it was a stint in Xi’an doing clinical training at a big Chinese hospital. Anyway, I cannot think of anyone better placed to talk about the state of mental health in China than George Hu. So George, a warm welcome to Sinica.

George Hu: Thank you. Thank you. Thank you so much for having me and it’s my privilege to be here, honestly.

Kaiser: Thanks, man.

Jeremy: Thanks, George. Let’s try to get an idea of the scale of mental illness in China. I imagine that must be pretty contested and that estimates range really widely, or is there some kind of consensus amongst mental health professionals in China about the size? What are the estimates of the number of people in China with mental health disorders and the percentage of those that are undiagnosed?

George: Wow. I mean that’s a huge question. That’s a huge question, I think, for any country but especially for a place like China with such a large population with many different subpopulations with very famous and well known sampling difficulties. There was a recent study that put the lifetime prevalence of mental illness at around 16, 17%.

Jeremy: Wow.

George: But many of these studies depend on self-report, which has notorious difficulties given the stigma that we talked about that exists here, and so it’s actually very, very difficult to put an exact finger on what the actual true prevalence of mental illness is. There’s also some definitional difficulties. We define mental illness, and this is probably something we could break down a little bit, but we define mental illness in largely a Western-defined context.

There’s specific criteria that are put forth that have been developed and normed in largely Western areas, and so we use that criteria when we do the sampling. But the question I think remains to be asked, do those criteria fit here? Are we catching people who are honestly having mental difficulties, or are we only catching people that meet a specific set of criteria?

Kaiser: What types of disorders, at least by the definitions that are in use right now among Chinese practitioners, among psychologists and psychiatrists in China, what types of disorders are prevalent? I mean, I would guess that they would be more or less the same ones that afflict countries or regions that have also undergone really rapid modernization, like South Korea maybe or Taiwan or maybe even the US in its early days. Can you draw some comparisons? What would you compare-

George: I can, yeah. Actually, according to the same study that I just referenced, with all of its sampling difficulties, anxiety disorders are the ones that are most common here in China, followed by mood disorders and then by substance use disorders. This does closely follow the patterns that we see in other similar societies, obviously with a different sense of scale. But like Korea, for example, we do see a similar pattern. However, in the States we actually see more mood disorders overtaking anxiety disorders.

However, the two are actually closely related. Mood disorders such as depression, anxiety disorders such as generalized anxiety disorder and its related cousins are actually, according to many clinicians, two sides of the same coin, two different manifestations of the same psychache, so to speak. So the two closely follow each other in many ways, but the substance use disorders are also a big difficulty here, as they are in many other parts of the world.

Kaiser: I can imagine.

Jeremy: Is that different from the United States? I mean, I thought here in the United States we were the king of the substance abusers.

George: Unfortunately not, maybe the king but not the only member of the royal family. Substance use disorders are definitely quite prevalent here. They’re the number three identified mental health issue here. Substance use issues are considered mental health issues by and large because they involve addiction and things like that. However, over here they’re typically governed by law enforcement. They’re typically treated by law enforcement hospitals and treatment centers and not typically by the healthcare system.

Kaiser: How’s that working out for them?

George: Not too bad. Obviously, there are severe consequences for selling drugs and things like that, and so that has actually helped here to quell substance use disorders. However, nicotine and alcohol continue to be big problems.

Kaiser: Exactly, exactly.

Jeremy: Can you talk a little bit about how mental health is actually diagnosed and classified? You did mention that perhaps there were cultural factors coded into our understanding of these disorders that perhaps don’t really reflect the Chinese cultural reality, but does China use something like that American DSM, the Diagnostic and Statistical Manual of Mental Disorders?

George: The US is actually the only jurisdiction that uses the DSM. The DSM is a distinctly North American tool. The rest of the world uses the ICD, which is the International Classification of Disorders, to codify not only mental health disorders but actually all disorders of the human body. That is what China uses, however, China uses a version of it called the Chinese Classification of Disorders, which is actually quite similar to the ICD. Yeah. That’s what is seen here. However, the DSM and the ICD, particularly in the later versions of the DSM, are actually converging. Many people believe that the two will converge more and more in later iterations.

Jeremy: How different is the Chinese version of the ICD from the international version? Is it correct that when homosexuality was still classified as a mental disorder in China, it was listed in one of those documents that the government uses?

George: It was. It was, as it was in the US. As it was in the US, homosexuality was an identified disorder by the DSM until the mid-70s.

Kaiser: Wow.

George: So this is not something unique to China. At the same time, just a few years after the DSM removed homosexuality from its list of disorders, China followed suit just a few years later. So yes, it was, but that’s not unique to China. I think the narrative here, and it’s something interesting that I think more researchers really should be paying attention to, and the narrative here is that China has, by and large, the Chinese healthcare system has adopted conceptions of mental health that have been promulgated by Western sources.

I think that that fits for many other aspects of health care, but mental health, actually as is a lot of other aspects of health care, but mental health in particular is multifactorial. There’s sociocultural, socioeconomic, historical, community factors that weigh into whether somebody is experiencing emotional or mental difficulty. The very way in which we describe it, the very way in which we conceive of or we take the spectrum of human functioning and we start to draw lines according to what is disordered or what is not disordered, and those lines change according to where you are, according to what generation you’re in, all sorts of things.

Researchers or developers of the ICD or the DSM have chosen to draw the lines in certain places according to what is seen in those populations, and China has, by and large, adopted them. But I think the question should be asked, what does it look like here? How do Chinese people experience difficulty? I’m choosing difficulty, the word difficulty, apart from mental health. Because even the word mental health, even the word psychology is laden with Western philosophies, Western concepts of the body versus the mind, Western concepts of the psyche, what that is, where is it located. What does it mean to experience psychological distress?

While we have commensurate Chinese terms for them, they are new. In the Chinese way of describing distress, in the Chinese way of describing pain or difficulty, it hasn’t been so focused on the mind. It hasn’t been so focused on what the Greeks called the psyche. The Chinese call it the xīnli 心里, but they don’t locate that in the mind. That’s called the center. It’s an undefined center. So there are questions I believe to be asked here about whether even the diagnostic categories that we have in the West are completely irrelevant here.

Now, that having been said, China’s been globalizing just like the rest of the world for generations, for a couple of generations, and so some of these questions may, by and large, become moot I think in a generation or two.

Kaiser: You talked about convergence in the way that mental health issues are diagnosed. It seems that they are importing, though, as you say, a lot of these concepts from Western psychiatry and from Western psychology and its intention, I suppose, with indigenous ideas about mental wellness or mental illness, but do psychiatrists in China, other mental health professionals in China, are they increasingly buying into the models for pathology as well? I mean do they, for instance, see depression largely as… They call it yìyùzhèng 抑郁症. Is it a matter of serotonin reuptake? Do they see it in the same kind of brain chemical terms?

George: The psychiatrists do and it’s not necessarily only because they’re trained to see it only in that way. I think that there is something in the Chinese healthcare system that almost pushes that, that necessitates that as the only type of treatment that we can offer currently in an accessible way, this sort of serotonin or other neurotransmitter deficit narrative of depression, if we take that as an example. And also anxiety, the same medications are used, by and large, to treat both. So there is that narrative that is pushed or at least utilized in the prescriptive world, and so the psychiatrists will prescribe SSRIs and other related medications really as a first-line treatment.

Kaiser: Benzodiazepines for anxiety.

George: Benzos for anxiety, et cetera. Yeah. Benzos are typically used in supplement to an SSRI, but one or both. But the access to psychological or what we call psychotherapy, counseling, psychological services, non-pharmacological psychological services are something that I think really needs to happen here. The access needs to be opened up. It is changing and it is becoming more accessible, but China’s a big place and it really does need to increase more and more.

Post-COVID I think that’s been changing. Post-COVID and the advent of all things online and all things video conference related I think has really helped psychotherapy and psychological services to become promulgated or evangelized, but that’s a pretty recent phenomenon.

Jeremy: So therapy of various kinds is still a minority phenomenon, I guess you’re saying, even if it is becoming more popular?

George: It is, and that has to do with several reasons, cost, the availability of really well-trained therapists and counselors, the availability of culturally competent therapists and counselors, and even psychotherapy in all of its various forms has been largely developed, again, on a Western population. The 50-minute hour, the eight to twelve session cognitive behavioral therapy modules, the dialectical behavior therapy modules, largely have been developed for a Western population.

Kaiser: Are the Freudians more common than, say, the Jungians or the-

George: It’s funny you say Freudians. Yeah. You know, Freud is really enjoying a resurgence here.

Kaiser: Yeah. Didn’t Evan Osnos write a really great piece in the New Yorker about-

George: Yes, he did.

Kaiser: Yeah, I remember. That was years ago, but it was really good.

George: But Freud, I have never been exposed to so much Freudian philosophy as I have here in China. My supervisor back in 2008, you referenced my training experience in Xi’an, at the public hospital, a large public hospital, was psychoanalytically trained and very Freudian, and so I received my first psychoanalytic supervision from him.

Kaiser: Fascinating. Did you think of him sort of as a father figure?

George: It’s funny, yes, I did in many ways. Yes. Yeah. It’s funny-

Kaiser: How did that make you feel?

George: Well, yeah. Really. It’s interesting because we enjoy a very close relationship even to this day, and that’s something that is quite culturally relevant here.

Jeremy: We’ve mentioned the extraordinary competitive pressure in China, and that starts even before you go to school with your parents saying, “You’ve got to get the first step in the race right. Otherwise, the rest of your life is ruined.” Get into the right preschool, the right $50 an hour jump rope lessons, the right primary schools, the college admissions test, university. And then once you’ve graduated, you’ve got to get a job and a car and a husband or a wife and so on, the terrible cycle of pressure. Is that a big-

George: You’re summing it up quite well there. You’re summing it up quite well. Yes.

Kaiser: The root of all mental health disorders in China.

Jeremy: Well, is it? Because that is the first thing that comes to mind when I think of mental health disorder, is that kind of life. Is that a big driver of mental health disorders, just the pressure to compete in Chinese society?

George: Yes, it is. Yes, it is. I say that as my personal belief, although obviously research identifies correlation and not causation, right?

So definitely, there’s a high correlation between what we call subjective feelings of distress and actual mental health, mental illness. We do see that high correlation and you’re right in that it starts very, very early. I remember being rejected from preschools for our second son because they laughed in my face when I called a mere four or five months before we wanted to matriculate.

I remember being laughed at on the phone by an admissions officer at a very well-known kindergarten here when she said, “You want it for this year?” She said, “This year?” She said, “People have their children signed up on our wait list from the moment they’re born.” I said, “Wow, okay. Yeah. I was hoping for this fall.” She said, “It’s not going to happen.” So yeah, the competition starts very early, although it’s very interesting to see how that might change.

As you know, recently, the government has essentially stamped out an entire industry, a very large industry. It’s amazing how, I think this is probably the only place in the world where an industry can disappear overnight like that. But yeah, it’s essentially disappeared and so it will be very interesting to see how that changes some of this.

Kaiser: George, do you think that’s actually in response to a perception of a mental health crisis in China? They have gone after these. They’ve recognized these phenomena like lying flat, you know tǎngpíng 躺平, and involution, nèijuǎn 内卷. This has been mentioned in speeches by Xi Jinping. Do you think that this is actually not just about having more babies but actually about addressing really underlying mental health issues in China?

George: Well, I believe so. I believe so. In the speeches, though, mental health has not been mentioned. In the speeches what’s being mentioned is sort of an equalizing, a leveling of the playing field. I understand that also from a socioeconomic perspective, of course, that not everyone had access to these very expensive after school programs and lessons and things like that. So I understand that, but I will say that there is, anecdotally speaking, and also speaking with other colleagues in our field, there is a very, very high correlation. I do suspect that mental health concerns were among the reasons as to why this was done. It is an unwinnable race, right, and a crazy-making race similar to a hamster-

Kaiser: Literally.

George: Literally. Literally speaking, and figuratively, of a hamster running on this wheel. You can never get enough. There’s always more to learn. There’s always more to prepare. Parents were talking about how school, actual real public school, was actually not where learning occurred anymore. Because most of the time when a lesson was presented at school, students had already seen it in their various and sundry after-school programs, or their tutors had already presented it. So in order to feel like you were keeping up with the Joneses, or in our case, keeping up with the Lis or the Changs, you had to sign up for more and more of these lessons.

But yeah, it’s something that begins way early. But if you think about it, I mean once you get to the place of the gāokǎo 高考, and that’s where everybody is aiming. Everyone is aiming for the gaokao or the college entrance exam, taken your last year of high school here. If you think about that, you are competing in one day against millions, millions and millions of other children taking the exact same test and you’re charged with differentiating yourself in some way to be one of those storied few that hit for the Beida-Tsinghua kind of level.

Kaiser: Right. What a nightmare.

George: Of which there’s only, yeah, one or two per province, perhaps, a handful. Chinese kids are born into this race and there’s a lot of anxiety pushing that race. I think there’s a lot of anxiety historically pushing that race.

Jeremy: Yeah. I must say, color me a little bit, let’s say, let’s wait and see if this new program of Xi Jinping’s actually makes Chinese parents reduce the pressure on their kids. Let me just put it that way.

George: Yeah. You know what I don’t hate is this new limit on video games.

Kaiser: Video games, yeah.

You’re a parent. Jeremy’s the same way.

George: I’m a parent. I do not hate that.

Jeremy: Yeah.

Kaiser: What else am I going to use to keep them out of my hair, though? Christ, I need those things.

George: You mean, what other electronic babysitter can we find?

Kaiser: Right, exactly.

George: Yeah, yeah.

Jeremy: Yeah, I know. It’s a very upper-middle class thing to look down on the iPad compared with our babysitters.

George: You’re right. Yeah, definitely true.

Jeremy: Parents, they like the video game ban. I think that we’re pretty confident on. What about general attitudes towards mental health? I mean, are they changing? Kaiser mentioned at the beginning of this talk, is there… I mean, there is more pop culture discussion of mental illness for sure, but is it really changing attitudes?

George: That’s a very interesting question. You brought up something in the introduction where this juxtaposition of the stigma that exists toward mental health here in China and this phenomenon in the West where everybody and their mothers talks about their therapist and what their therapist says, right? And I’m from California, so as much as the rest of the country experiences that, us in California, it is in vogue for sure to have a therapist or two that you have seen.

It’s interesting because I think in the States there has been a de-medicalization of mental health just as there has been sort of a semi-de-medicalization of other healthcare-related fields such as physical therapy or medical imaging sometimes or dentistry and things like that. In the States there’s been a de-medicalization of some of mental health, which I think has supported and reinforced the dropping of the stigma in the States. Now, I will say that there is still quite a mental health stigma even in the West and that is something that we should continue to address.

But here in China there is a very medical approach to mental health-related issues that I think in part drives the stigma between difficulties, emotional, mental wellness difficulties and disease. There’s a link here that’s driven by the healthcare system that promotes the stigma, that if you are experiencing a difficulty, that you’re sick. That if you are sick, then you must be debilitated. So there is that stigma I think that’s driven in part by the system.

Now, I will say that the medical system has done an amazing job. China is a society like no other, 1.4 billion people and the government is tasked with providing health care somehow at an acceptable level to all of these people. It’s a very difficult task and I think it’s a task that’s generally done surprisingly well for the most part, but for mental health I think the question needs to be asked, is this the best approach for this society?

Kaiser: George, earlier on in our conversation you were talking about culture as an important variable here as there’s a way that people interpret the very meaning of mental illness or mental wellness. I’m only really guessing here, but I imagine that the field of cross-cultural mental health must have some basic cleavages, like so many other disciplines do, with some people who would downplay the importance of culture and emphasize instead the basic biological or physiological nature of mental health and mental illness and others who would emphasize the cultural factors.

Am I way off base or is there a kind of division like that that exists in the mental health field in China?

George: Less and less. The intersection between culture and mental health is something that the conversation is definitely growing here. And this is a conversation that many very well-known psychologists and psychiatrists here in China are a part of, and a conversation that they’re pushing. I think that’s very, very necessary. It’s a conversation that the Chinese Psychological Society is pushing as well, and so I think it is something that, the intersection will be discussed more and more. That’s something that I think can really help to break down stigma, really help to understand that we all deal with frustrations and difficulties, and we all have baggage from our own backgrounds that needs to be discussed and processed.

Kaiser: For sure. No doubt about that in my mind. But aside from culture, there’s also history, right?

George: Yes.

Kaiser: You worked on PTSD extensively at the VA Hospital in San Francisco, the Veterans Administration Hospital. I think a lot of those were people who had come back from the wars in Afghanistan and Iraq. You have a lot of hands-on experience looking at trauma. In an earlier conversation that you and I had, you suggested that one’s worldview actually has a lot to do with how you process trauma.

You hinted, I think tantalizingly, this idea that individuals from a country like China that has in living memory experienced societal trauma on just such a scale, the Americans couldn’t even imagine, that they might handle stress or trauma differently from, say, North Americans. Societies that have experienced trauma might have actually built some resilience. I mean that was an intriguing idea to me. Can you talk more about that idea and how far are you willing to take that?

George: Yeah. Well, that’s a very interesting question. I think more research has to be done for sure on this, but the US is a country that has obviously for hundreds of years experienced relative peace. Apart from the Civil War, us as Americans have not fought a war on our land, on our soil, really ever since the Civil War. Now, I don’t want to discount the very real and difficult traumas that many in minority groups undergo in the US, so there are traumas to be experienced there.

Kaiser: Oh, yeah. Absolutely.

George: But by and large, America has experienced relative stability and relative peace. You and I growing up in the US have internalized that into our worldview, that the world is, or the society around us is, in general, relatively stable, or we have experienced very few completely discombobulating or destabilizing events, by and large. Over here, though, that has not been the case. China has undergone continuous shifts, continuous shifts in government, continuous shifts in its borders, continuous shifts for all of its existence, really. So there is an element of instability or an element of fear or anxiety that is sort of built-in to the Chinese experience, the Chinese worldview.

Kaiser: A baseline of mild trauma.

George: There’s a baseline there, and it’s expected. That’s something that colors everything. A lot of foreigners, a lot of Americans in particular, come here and they say, “Why is everyone crowding? Why is everyone pushing me out of the way? Why does it feel like everybody feels the communal rice bowl is only so big and everyone’s grabbing at it?” Right? Even that’s relevant-

Kaiser: Scarcity, man.

George: Yeah. I mean you see that on a sale of peanut oil at the grocery store. You see that on the subway, people trying to get in. You see that on a bus. You see that in people cutting in line. You see it. I think there is a scarcity mentality. Even though cognitively they know, okay, right now I’m in Shanghai in 2021, I don’t need to do that, but there’s something there that pushes it. I think there is this concept that if I don’t get mine, if somebody else gets theirs, that may mean less for me. That’s built in here because that has been felt in very recent history. Perhaps not this millennial generation, but just a generation before and our fathers and our parents’ generation, for sure.

Kaiser: For sure.

George: For sure. That affects the psyche in ways that I think really need to be studied.

Jeremy: Yeah. That is so interesting. It makes me recall how many times I’ve heard the word from my children’s teachers, inappropriate. “That’s inappropriate for kids to read a book like that.” I think of Chinese people my age who were watching these extremely bloody war movies at the age of seven. South Africa when I grew up was perhaps more similar to China in the sense of there were things we did not shield our eyes from, which were in the contemporary vocabulary very traumatizing, possibly.

Can we talk about the other side of the culture debate? I mean, it’s not all just about culture and how you grew up and the circumstances of your schooling. Isn’t there also hard science in mental health that is rooted in basic physiology and biology that is universal to all humans?

George: Absolutely. Like most other things, it’s this interplay. In the West, we call it the biopsychosocial model of mental illness.

Kaiser: Oh, I’ve never heard that before. Biopsychosocial. That’s good.

George: Biopsychosocial model, which means that there are factors that are biological, there are factors that are psychological, and there are factors that are social, that impact how a person feels subjectively their distress and whether or not a person becomes mentally ill or is now adaptive in their response to that distress. And I would argue that there are even more things than biopsychosocial.

There are other things as well, perhaps a spiritual element, perhaps other elements that also weigh in, but at least the biopsychosocial. That impacts everything and biology is part of it. There is a physiological response. There is a difference. There are things that serotonin, norepinephrine, other neurotransmitters can impact. There are other impacts from the endocrine system, things like that, that all need to be factored in to the conception of mental illness and also its treatment.

Going back to something Kaiser said a minute ago, one of the things that impacts trauma, or response to trauma in particular, is how well we can integrate what is happening, a traumatic event or events, into our worldview. This can go back to the psycho or the social model. For a person that feels like traumatic things should not happen, distressing events should not happen, they’re wrong, they’re not right, they shouldn’t happen, and that person hasn’t experienced a whole lot of traumatic events before, potentially that person could have a larger response, a more severe response, if you will, to that event or events.

Kaiser: So Chinese fatalism is actually really good insulation against…

George: Well, it could be thought of in that way, that this could be a protective factor that there is an existing worldview or a system that assists somebody to integrate what is happening to them. Be that system societal, religious or spiritual, or what have you, when there is a system that allows a person to integrate the trauma better, more successfully, then that does typically result in less symptoms, less of the classic PTSD or post-traumatic stress disorder symptoms.

Kaiser: Speaking of people who don’t integrate trauma particularly well, now I want to bring this up with sufficient sensitivity here, but I do feel compelled to ask you about this because I have friends, I’m thinking three off the top of my head who’ve told me things separately. They all run programs, this is of course before COVID, that bring college students from around the world to Beijing, in this case.

Some of them are based here in the States and others are… Well, one of them is based in Beijing, but they have told me separately that there is an alarming proportion of American students, and it’s only American students, who are on different prescription drugs, benzodiazepines and other anti-anxiety meds, serotonin reuptake inhibitors and other antidepressants and ADHD meds that include really powerful stimulants. They have also talked about the propensity of these American students to completely melt down, just requiring them to either go home and leave the program or to, I don’t know, check out somehow.

It’s just strange to me that not a single non-American student has either come into this program with a prescription or has had some kind of an incident like this. I mean, I know this isn’t just about China, but since China seems to have adopted more and more the American approach, I wonder if they are taking any caution from, I don’t know if it’s the over-diagnosis, the over-medication of psychiatric disorders, whether there’s reason to be hesitant about adopting the American model so enthusiastically?

George: I think that there is reason to be hesitant, for sure. I know exactly the phenomenon you’re talking about and I think it’s a good illustration of what Jeremy was just bringing up of this biopsychosocial model. I think it is because you have a bunch of 20-somethings, typically, what, late undergraduate, early graduate school aged, coming into Beijing. And when I was working in Beijing, we evacuated many of these students for the mental health challenges that they were having. They come and they are overwhelmed. They are overwhelmed in one aspect really because from the biological perspective, they are at a place, a place being an age, in which it is more likely that they can experience their first break. If there’s a family history, for example, of bipolar disorder or of manic episodes or of psychotic disorders, then typically that is the age at which the first break or the first experience and first episode will happen.

So you do have that biological predisposition that’s potentially there, but you will also have a big social change, right? These people are making a huge change, a huge transition coming to China, and living and studying and working or researching here, for a period of time. It’s a huge, huge transition that they need to overcome and they need to walk through.

Kaiser: But so are the kids that are coming from Europe or from Africa or from Latin America, or from Southeast Asia or South Asia, right?

George: Sure, yeah. But there is also, it’s interesting too and I suggest that the both of you and all of your listeners read it, there’s a book called Crazy Like Us written by Ethan Watters, and it talks about… The book is entitled Crazy Like Us, and I think it’s The Globalization of the American Psyche. It’s talking about how American concepts of mental illness have really been evangelized worldwide and have started to affect the ways that people become mentally ill.

He takes four examples. He takes the examples of eating disorders in Hong Kong, depression in Japan, PTSD in Sri Lanka, and I believe psychotic disorders in Senegal, and he uses these case examples to illustrate how American concepts of these disorders have started to affect the way that indigenous populations experience difficulties. When he talks about depression in Japan, he talks specifically about the serotonin or neurotransmitter deficit narrative of depression, that this is the reason why you’re depressed and this is what we should fix when we want to treat your depression, we should fix this deficit.

Kaiser: I’m buying this book right now. It’s sounds like something I am totally-

George: It’s a great book. It’s a great book. I believe, though, that at least here in China the conversation has evolved a little bit since that book was published in that we are talking more and more about other narratives and other correlates to mental health, besides the purely biological, and that treatment providers are definitely now asking the question, how are your social relationships impacting your mental health? How is your work? How is your family? How are you approaching the balance between these aspects of your life? How are you finding your own sense of purpose or fulfillment, and how that correlates to how you feel distressed or how distressed you feel.

These conversations are being pushed, but by and large, again, you have a healthcare system here that is heavily impacted and charged with providing care to over a billion people. So you do have the average six-minute mental health encounter here in the public system, six to seven minute. If you guàzhuānjiāhào 挂专家号, or if you buy the VIP service that a lot of public hospitals have, perhaps you’ll get a little bit more, up to 10 or 15 minutes, but it’s a system that is very, very impacted and it’s hard to find other ways of treatment that are accessible to the population.

At the same time, the public system allows people to treat their mental illness under the table. You can take a day off, go to the public hospital, see the psychiatrist, get your medications, and then take them in secret. You don’t need to let anybody know, whereas it’s harder to hide weekly or biweekly meetings with a psychotherapist…

… and to take that consistent time off work, for example.

Kaiser: That’s true.

Jeremy: I mean, I have to say when it comes to the amount of medications that American students are on, that is totally unsurprising. I think anybody who’s a foreigner who first comes to America is completely shocked by drug advertising here. I mean, you can’t get away from it. Even inside the doctor’s rooms, my family doctor’s at a big-ish hospital and inside the consulting rooms there’s a screen trying to sell me drugs, which I mean-

George: Well, I mean thankfully, I think that that’s reducing, by and large, in the US as people are paying attention to that. I think that’s reducing, and that’s actually reducing here as well. It wasn’t that long ago when many drug companies actually had offices and desks in hospitals where their representatives would park themselves.

Kaiser: Oh God.

George: Although now, that’s been reducing here as well. I think everyone’s paying attention to overprescription.

Kaiser: Yeah, I certainly hope so.

George: Starting with antibiotics and related medications obviously with antibiotic stewardship committees and actually the World Health Organization pushing attention to that but also trickling down to other types of medications. I think you’re right, I really do think that we need to change these narratives of mental health, not only to reduce the overmedication phenomenon, but also to respect the fact that mental health difficulties are multifactorial, like I said before. Study after study has really pushed the fact that in most cases the most successful treatment of mental health disorders comes by a mixture or a combination of psychiatric medication, if needed, and psychological interventions.

Jeremy: To shift topics a little bit, George, you just mentioned the World Health Organization. You have been in China throughout the pandemic and you have doubtless kept an eye out on how it was handled and is being handled in the United States and other countries. Do you think it says something about the values and political culture that the responses in China and the US to mask mandates and stay-at-home orders were so different, or is there something that you can say about psychology and mental health too?

George: Wow, that’s a big question and a great one, Jeremy. I have been observing this from the near and far, and it really is interesting. It really is interesting. Here in China, obviously, there’s been little to no resistance to mask mandates, stay-at-home orders, work-from-home orders. I remember giving an interview for the BBC in the height of the pandemic in early 2020, and the question was, “How did Chinese people manage the process of converting from work from office to work from home?”

I said, “Well, you know, literally you showed up at work one day and there’s a padlock on the door. So the question was, do you work from home or do you leave your job? So there wasn’t a process. For most companies it was like, you need to come into the office today by 5:00 to retrieve your laptop and work from home because tomorrow morning at 8:00 the door will be padlocked. And if you want to keep your job, you need to be able to do this. I’m not saying that was the best approach, but it was the approach that had to be implemented given the reality of what was happening.

And Mask mandates is another thing. I think that there is, and you guys have referenced this many times on your podcast, but there is a level of inherent trust of authority here that I think is different from back in the States. I think there’s a level of that and I think that there is a difference in the conception of Chinese people of the part versus the whole. I think there’s a difference here, that the two are much more intertwined, the part and the whole, than in the States. In classic yin and yang fashion, the two cannot be differentiated from-

Kaiser: Separated.

George: Yeah, differentiated from each other. Whereas in the States, the two definitely can. There is this I. There is this ego in the psychological sense. There is this I that is separate from the whole that develops independently that the whole needs to respond to. The whole must respond to me, must respond to the I. This is pushed and promulgated in a lot of different… The American desperado, the Lone Ranger, the elevation of this kind of life, I think it’s in a lot of American narratives in a way that’s not here, not in folktales and historical narratives here.

Kaiser: So they’re not reading Ayn Rand in China, thank God.

George: No. Then that trickles down to how a person responds to a mask mandate even in a place like a school, even among unvaccinated children, even among lots of unvaccinated children or things like that. Right? I think that affects how someone views a mask mandate as being extremely ego threatening, threatening to the self and threatening to my sense of integrity, the integrity of the ego, in a way that’s very different from here. Responding that way to the whole is not viewed as injurious to the ego here.

Kaiser: Yeah. So you as somebody who’s sensitive to both Western and then the Chinese side, I have to ask you something sort of selfish here, but I figure, how often do I get to talk to a bi-cultural Chinese-American psychologist, right? I have at times thought I could benefit from therapy, full confession. I’ve never actually experienced it except for a brief session in, I think it was 2002, that ended with a therapist telling me basically, “No, you’ve just had a rough breakup. You’re not depressed. You don’t need therapy. You just need to get a little more sleep, maybe exercise, and fall in love again.”

But the moments when I’ve most acutely felt the need were typically during these really dark periods in US-China relations where I felt like my whole life’s mission was just failing. Anyway, you know how that goes. I felt like the therapist I really needed would’ve had to be somebody who understands both the Chinese thing and the American thing. I mean, was I off base in thinking that? I’m just asking very selfishly here, is there a market for bi-cultural therapy, especially Chinese-American bi-cultural therapy?

George: Absolutely.

Kaiser: Yeah?

George: Absolutely. I first experienced that market back at home in California. I talk about this everywhere I go, which is that I work on both ends of the couch as it were. I am at the same time a treatment provider and also a consumer of psychological services, of psychotherapy, and I have been for much of my life. It’s not something that I keep secret. This field is a very difficult one and my job has a lot of pressure, but not just my job, life in general, adjusting to everything. I’m a father, I’m a husband.

I’m trying to move forward and make sense of this crazy thing called life in our world, and I need a sounding board. And when I look for one, I look for one that I believe can understand a part or some of my experiences, at least on the surface level of somebody looking like me, sounding like me, somebody who has had roughly the same experiences historically as myself and my family.

Kaiser: I’ve mostly been using Jeremy and that’s not working out so well.

George: Oh, yeah. That’s not working out?

Jeremy: Yeah, that’s a very bad idea.

George: But I say I experienced this first at home, the market especially for multicultural therapists, not just Chinese American but multicultural therapists. Because so much of this field is dominated by a white majority that I think we really, really need to change. So much of this field at home in the US is dominated by a white majority, I should say. So I first experienced this need in the market in California where I was doing much of my work, back in community mental health in California, I was doing a third of my work in Mandarin.

Kaiser: Oh, wow.

George: Yeah. Obviously, I worked in the Bay Area. There’s a high Mandarin-speaking population, high numbers of immigrants, and so people who felt like their heart language was Mandarin or their heart language was a Chinese dialect and Mandarin was the closest to it. So I worked a third of my patients in Mandarin and there was such a demand for bilingual and bi-cultural, multicultural therapists, particularly people back in California who could speak Mandarin or Spanish. Then the places that I worked, Farsi and Hindi as well.

Jeremy: On a related question, George, how particular is the Chinese family dynamic in Chinese people’s mental health? Because I’ve got to think a lot of what we think of, I mean certainly Freudianism seems to come from Jewish people’s obsession with their mothers. You know, some of the-

George: Jewish European, yeah.

Jeremy: … Jewish European family issues… But I mean the Chinese family is a really complicated and very difficult and very different beast.

Kaiser: It is, easily, it’s the source of most of my psychological anguish, that’s for sure.

Jeremy: Well, I didn’t want to say that, but…

George: I have already offered to pay for my kids’ therapy in the future. I’ve already put that out there, for sure. I’m not joking, I really have. But there’s been famous similarities drawn between the Chinese family and the Jewish family. But yeah, huge, to answer your question. And the Chinese family is very particular, it’s unique. You mentioned, Kaiser, in the opening, the one-child policy. Where in the world has there been a similar policy? The Chinese family historically has been very different from the one-child family that was a thing here for a couple generations.

Before, the Chinese society valued large extended families in communities. From the Chinese ways, from even Chinese architecture and home design you can see that, that what was traditionally valued here for thousands of years was something extremely different from the one child. And that necessitated, and this is where it intersects with socioeconomic realities, that coincided with a more nuclear-based structure. That was something that came down here within a generation or two. The Chinese family really shifted and now it’s shifting again.

The Chinese family is a very unique one that up until very, very recently you had one child raised by only children, and so that’s a phenomenon. Then you have multiple generations raising one child where you have-

Kaiser: Famous four-two-one.

George: Yeah. The focus of two generations, at least, on one individual. We were discussing pressure before, the pressure to perform that starts before preschool, and there is a pressure that starts very, very early that you are the one and only hope for your family. That you are the one and only hope for your family because your parents literally get one chance and you’re it. That’s a lot of pressure.

Kaiser: It sure is.

George: It’s a lot of pressure, combined with the societal pressure. Jeremy, you mentioned this in your opening too, the pressure to buy a house and get a car. Actually, the concept that you are unmarriageable, especially if you’re male, that nobody will marry you unless you have a car and a house. That’s very difficult to do. I live in Shanghai. I have a great job. I don’t have a car and a house. I just recently got a car.

Kaiser: Neither do Jeremy or I, but we still managed to bag pretty cool Beijing chicks.

George: You still managed to get a spouse. Thankfully, I was married before I came here. Otherwise, I don’t think I could ever find one because all I have after all these years is finally a car.

Kaiser: Oh, right. Well, congratulations on that.

George: Yeah.

Kaiser: George, I can see I’d have a million more things to talk to you about, but I know if you were charging us for 50-minute appointments, we’d be… But thank you so much for taking the time. What a fascinating conversation. I’ll be calling you separately to book an appointment for therapy if that’s okay.

George: Absolutely. No problem.

Kaiser: Good. For now, though, let’s move on to recommendations. But first, let me remind everybody that the Sinica Podcast is powered by The China Project and if you like the work that we’re doing with Sinica or some of the other shows in the Sinica Network, by all means, just remember that the best thing that you can do to support us is to subscribe to The China Project access, our daily email newsletter, which is put together lovingly every day by Jeremy and his team. Lucas and Jiayun are just phenomenal colleagues, and you should check out the work that they do, the The China Project Access newsletter. That’s what keeps the lights on here at Sinica.

Kaiser: All right, man. Let’s go on to our recommendations. Jeremy, do you want to start us off? What you got?

Jeremy: Yes. I’ve just suddenly realized, well, I hope I haven’t done this one before, but a book called Entangled Life by Merlin Sheldrake. It’s about mushrooms and fungi, all kinds of fungi that are this amazing part of the global ecosystem in ways that you probably hadn’t thought about.

Kaiser: Yeah. That sounds like Richard Powers’ territory. I mean, he wrote about those fungal networks that connect trees to each other. Is that part of that book?

Jeremy: That’s a little bit, yeah.

Kaiser: Oh, that’s cool.

Jeremy: And all the other fun stuff that one can do with mushrooms too.

Kaiser: Oh, that.

Jeremy: It’s mostly about the networks.

Kaiser: Hey, George, how are you on micro-dosing? No, just… That’s fantastic.

George: You want to get me on record on that, huh?

Kaiser: Right. No, I’m not. I’m not.

Jeremy: He can’t prescribe from Shanghai, Kaiser.

Kaiser: Right. That’s true.

George: I can’t, and I don’t.

Kaiser: Yeah. This is not physician’s advice. Yeah, great. No, that book sounds great. What a fun guy you are. Great. What’s the name of the book again?

Jeremy: Entangled Life.

Kaiser: Entangled Life. I’ll check it out.

Jeremy: Because of the networks.

Kaiser: I’ve already bought one book while we’ve been going here, I’m getting Crazy Like Us: The Globalization of the American Psyche.

Jeremy: That sounds scary.

Kaiser: Yeah. Okay. George, what do you have for us recommendations wise?

George: Well, that was the one, Crazy Like Us by Ethan Watters. Yeah.

Kaiser: Okay.

George: That was the one. The Globalization of the American Psyche talks about, like I said, about how we have really evangelized a very particularly American way of being sick. Particularly interesting in this book is how it has started to affect the way indigenous populations experience this distress.

Kaiser: Oh, wow.

George: Yeah. I think it remains to be seen how this plays out over the next generation, whether this globalization really will continue and how that will affect the conversations in multicultural psychology and mental health.

Kaiser: Yeah, yeah. All right. I’m up. I’m going to recommend the new album from the awesome Inner Mongolian band Nine Treasures or Jiu Bao. The album is called Awakening from Dukkha, D-U-K-K-H-A. It’s just killer. These guys, they’re a metal band with horsehead fiddles and Mongolian throat singing. It’s just kickass. If you need a soundtrack as you and your band of hearty steppe riders fall upon a sedentary agrarian village with sword and torch, this is the album for you. And you know, we all need that from time to time. Before I…

George: Kaiser, when I grow up, I’m going to get your command of adjectives. That is my goal in life, is to have a similar command of adjectives. It’s beautiful.

Kaiser: Weird adjectives, yeah. Oh, thank you, George.

George: It’s beautiful.

Kaiser: All right. It comes from my distress.

George: Well, it’s a great way of coping.

Kaiser: Yeah. Yeah, yeah. George, thank you so much for taking the time, man. I am free, by the way, most weeks around this time, so we can book 50 minutes, right?

George: Absolutely. Absolutely. Not a problem. Thank you so much. It’s a great pleasure. I’ve been an avid follower of your podcast for a long time.

Kaiser: Thanks, man.

George: So it was one of the great-

Jeremy: I don’t know if you can help Kaiser with what ails him.

George: Whatever he has.

Kaiser: We’ll figure it out.

George: Well, I can probably commiserate with much of it. But I’ve been a follower of your podcast for a long time, and I got to tell you, it is a great privilege to be invited.

Kaiser: Well, it’s entirely our pleasure. And Jeremy, as always, a pleasure to have you back on the show. Let’s do this more often, man. We keep saying that, but I keep doing these obscure academic topics and Jeremy’s like, “No.” But we’ll do more like this. All right. The Sinica Podcast is powered by The China Project and is a proud partner of the Sinica Network. Our show is produced and edited by me, Kaiser Kuo. We would be delighted if you would drop us an email at sinica@thechinaproject.com or just as good, give us a rating and a review on Apple Podcasts as this really does help people to discover the show.

Meanwhile, follow us on Twitter or on Facebook at @SupChinaNews. You can follow Sinica specifically at @SinicaPodcast on Twitter, and make sure to check out all the shows in the Sinica Network. Thank you for listening and we will see you next week. Take care.