A Rising Tide Lifts All Boats A Chinese Paradigm By Herbert S. Sacks, M.D. APA President

This is the conclusion of a two-part series on Dr. Sacks’s recent trip to China.

In my last column I offered brief observations of my journey to China occasioned by an invitation to participate at the Regional Meeting of the World Psychiatric Association in Beijing. During the preceding two weeks, I visited five cities, giving talks and touring university medical centers. To prepare readers for my comments about Chinese psychiatry, I used the column to provide context - historic, cultural, and economic - with elaborations on human rights and psychiatry. I pointed out how these principles invoke the cultural sovereignty of China. But I recognized that guanxi, which means "personal relations and trust," when established with Chinese colleagues, elicits a deep feeling of familial loyalty and friendship. From the viewpoint of psychiatric theory and practice, I saw an opportunity to reduce these tensions derived from cultural sovereignty issues, on the playing field of science.

Venerable Savant

Eighty-two years old, Dr. Tao Kuo-tai appears to be 15 years younger, possessing a keen intellect, seemingly unaffected by the passing years. Dr. Tao is the father of child psychiatry in China. In this great nation of 1.2 billion people, there are fewer than 20 child psychiatrists. Psychiatry residents are deemed qualified by senior colleagues on completion of five years of training after medical school graduation, training that includes six months of adult psychiatry and six months of neurology. (In other conversations at university medical schools, I learned that after seven years of postgraduate medical education, residents in all specialties usually enter teaching programs as junior faculty.)

Importantly, there are no certification processes in China. In Hong Kong before July, certification was granted by organizations associated with the royal colleges in the United Kingdom. Since the turnover, those structures have been replaced by autonomous high-level certification bodies.

Dr. Tao in 1948 went to Langley Porter Clinic in San Francisco at the invitation of Dr. Stan Szurek, the distinguished chief of child psychiatry. Upon his return home, he became a staunch advocate for child training in Nanjing but met with resistance from adult psychiatrists who were ascendent in the system. The latter, trained in the Soviet Union, made Dr. Tao’s task a steep uphill climb.

Cultural Revolution

Professor Tao is a gentle man, underlyingly determined, with a ready smile in the face of adversity. For a decade beginning in 1966, the Cultural Revolution, led largely by cadres of young peasant activists, brought about the destruction of the country’s cultural treasures, the detention and execution of large numbers of professionals and educated people, and the "reeducation" of others by exiling them to work side by side in the fields with the peasants. They were subjected to forced confessionals, ideologic lectures, and privation. Dr. Tao, an educator/intellectual who had spent a year in the United States, was earmarked for "reeducation" for an indeterminate period of time. Hard farm work with peasants outside of Nanjing was seemingly endless "but I smiled at my attackers," he told me. After six years of punishment, he was released to his family and university, which was in disrepair, with books and equipment destroyed.

Like so many Chinese who endured this grievous period in recent Chinese history, he rebuilt his personal life and professional activities with growing optimism about the future of his country. In 1979, with the advent of normalization, Dr. Tao was an esteemed delegate sent to the APA annual meeting in Chicago. During that meeting, Professor Xia Zhen-yi, a prominent psychiatric leader who in 1981 became the first dean of the Shanghai Institute of Mental Health, told of his hope that "the friendship of Chinese and American psychiatrists will flow as easily as the currents of the Yangtze and the Mississippi rivers."

As Dr. Tao traveled more, he befriended American child psychiatry leaders: Jerry Wiener, Donald Cohen, and the late Joe Nosphitz in a guanxi experience.

Child Mental Health Research Center, Nanjing

Dr. Tao has been associated with the Nanjing Brain Hospital, founded in 1947. The institution, formerly known as the Psychiatric Hospital, underwent a name change three years ago to lessen stigma. In 1984 the Child Mental Health Research Center was established as part of the hospital through Dr. Tao’s efforts. The staff includes psychologists, who do psychometrics and some projective tests. There is no on-site training program, so psychologists often come to their hospital work out of undergraduate education. While there are no psychiatric social workers in the hospital, after the Soviet Union model, a notable exception is a remarkable woman, Mrs. Chu, a graduate in social work from Jingling Women’s College who upholds the standard of biopsychosocial approach to children’s problems.

Currently there do not appear to be child psychiatry residents in training. With 350 million children and adolescents under the age of 15, Professor Tao’s training efforts have turned to developing child care workers through a three-level system. More than 300 workers are trained each year who go into the communities advocating for child development programs, doing early case finding, and teaching young parents child-rearing principles.

One-Child Families and Kinship

Teaching young parents is especially important in a nation where there is a one-child-per-family policy designed to stem what 20 years ago seemed to be a runaway population. That policy still uses dissuasion and sometimes coercion to slow population growth. One consequence of the one-child policy has been to shrink markedly the size of extended families. In a nation that treasures kinship, young mothers don’t have readily available to them cousins and aunts to give them child-rearing guidance. But China is easing the family-planning restrictions in some urban areas, allowing many of the 50 million only children in their 20’s to have two children. In Shanghai the one-child policy has led to a population decline for three years running. A rapidly aging population is a new demographic problem with social consequences, so that 1 in 4 Chinese will be elderly in 2020; this is a heavy burden in a country with a low GDP/capita. Again, in Shanghai 17 percent of the population is over the age of 60, yielding a major welfare crisis. In many conversations I learned that professionals in their 50’s are concerned that the one-child policy may not allow them to be cared for adequately by their child as they grow older.

Returning to Professor Tao’s institution, there are departments of mental retardation, rehabilitation, and education. His inpatient service has 25 beds, and the average length of stay is 17 days. The main disorders diagnosed and treated by hospitalization include schizophrenia, severe learning disabilities, Tourette’s disorder, mental retardation, oppositional-defiant disorders, phobias, and hypochrondriasis. The outpatient clinic sees 40 to 50 children every day. During the past 20 years there has been an increasing number of children identified with ADHD, school-avoidance disorders, eating disorders, and suicidality associated with severe depression.

I met six child psychiatrists who were familiar with American literature and knowledgeable about the use of psychopharma-cologicals. There is no dynamic psychotherapy evident as we know it. Psycho-educational methods, vocational training, and other supportive measures are deployed. The use of psychopharma-cologicals is commonplace. In a supervised art-therapy group of school-aged children, the traditional childhood virtue of being guai, or docile, was evident. The children appeared to be comfortable, well nourished, and appropriately clothed. Many of them appeared to be dulled by illness and/or medications. One engaging youngster about 11 years old responded to my interest in his painting by jumping up and saying loudly, "Good morning, teacher!" He was hospitalized because he believed that his father would hurt him. When I questioned whether this was possibly so, had anyone visited his home, my concerns were reassuringly dismissed.

I addressed this faculty and more than 40 medical students and residents in adult psychiatry. The most enthusiastic response was to Helen Sacks’s lecture on recent developments in juvenile delinquency in the United States. My wife has directed a model psychiatric clinic in New Haven Superior Court for Juvenile Matters for 25 years. The clinic, state funded, is staffed largely by Yale clinicians. Her vivid case reports, descriptions of the court process, the clinician’s role in the proceedings, and the disposition of the children and adolescents in serious trouble resonated with many aspects of Nanjing’s problems with the young.

The staff expressed eagerness to begin a joint venture in delinquency research - a comparative study in Nanjing and New Haven. Ongoing research includes projects addressing high school students with emotional problems, a joint venture with the University of Hawaii in studying single-child personality development using Tom Achenbach’s scale, and family studies of autistic children.

The Chinese initiative for joint research demonstrates how the burgeoning economy has loosened constraints around professional international relationships. China’s planned economic growth is a rising tide that will lift the boats of not only democratic virtues but of bilateral collaboration.