Are western community psychiatric models suitable for China? An examination of cultural and socio-economic foundations of western community psychiatry models using assertive community

Are western community psychiatric models suitable for China? Anexamination of cultural and socio-economic foundations of westerncommunity psychiatry models using assertive community treatment as anexample

Samuel F. Law*

St Michael’s Hospital, Toronto, Ontario, Canada Department of Psychiatry, University of Toronto,Ontario, Canada

(Received 29 September 2008; final version received 29 November 2008)

Western community psychiatry models, such as Assertive Community Treatment (ACT)and Case Management, are well-studied and considered to be effective and cost-effective; in particular, ACT is perceived as a gold standard for community treatment ofsevere and persistently mentally ill patients. With China’s recent rapid economic reformand attendant cultural and healthcare system changes, it is timely to examine thesuitability of these western developed models of community psychiatric for China. Inthis paper selected cultural and socio-economic foundations of community psychiatrywill be explored to ascertain their ‘fit’ in the Chinese setting. These are: availability ofpublic funding for psychiatric care; role of the family in patient care; availability offunctioning mental health laws and community and resource readiness. It is concludedthat there are wide ranging differences between China and the western jurisdictions thatcurrently operate extensive community psychiatry models. Wide adoption of thesemodels in China may not be feasible from financial, legislative and social perspectives atpresent, but selected local trials of culturally informed adaptation of these models,including ACT or its key elements, may be useful and beneficial. The developmentprocess may be very informative for China’s future services planning and provision andthe continued global evolution of community psychiatry as a field.

Keywords: China; community psychiatry; ACT model; cultural psychiatry

Introduction

Western developed community psychiatry models, such as Assertive Community Treat-

ment (ACT) and Case Management (CM) are well-researched and well-established

treatment and rehabilitative models serving the severe and persistently mentally ill

(SPMI) population (Marshall & Lockwood, 2003; Marshall, Gray, Lockwood, & Green,

1998; Mueser, Bond, Drake, & Resnick, 1998; Ziguras & Stuart , 2000). Assertive

Community Treatment, as a prime example, is one of the many forms of community

psychiatry services developed in the USA to help patients who returned to the community

as part of the de-institionalization movement occurring in the 1960�1980s (Killaspy, 2007;

Stein & Test, 1980; Stein, Test, & Marx, 1980). The main difference between ACT and CM

is that ACT has a set of ‘fidelity’ criteria that guides the selection of more severely ill

patients who have failed typical out-patient care, resulting in extensive hospitalization; and

*Email: [email protected]

International Journal of Culture and Mental Health

Vol. 1, No. 2, December 2008, 134�154

ISSN 1754-2863 print/ISSN 1754-2871 online

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DOI: 10.1080/17542860802511143

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ACT uses a team of multidisciplinary members sharing the case load, at low staff to patient

ratio (typically 1:10), with 24-hours-a-day, 7-days-a-week accessibility and is assertive in

serving patients who will typically refuse care (Allness & Knoedler, 1998; Bond, McGrew

& Fekete, 1995). In contrast, CM models are more varied in different settings, uses a case

manager (i.e. not a team) directly serving anywhere from 10�200 patients during regular

working hours (Gorey et al., 1998).Nevertheless, ACT and CM share the fact that the majority of both models’ patients

have chronic and severe mental illnesses such as schizophrenia, schizoaffective disorder,

major mood disorders or severe trauma and anxiety disorders etc. (Marshall & Lockwood,

2003; Marshall et al., 1998). Many of these patients also struggle with co-morbidities of

substance abuse and dependence, personality disorders, forensic problems, homelessness,

social isolation and severe poverty, making them an extremely vulnerable and difficult

population to serve with conventional out-patient-based mental health services (Allness &

Knoedler, 1998; Sledge, Astrachan, & Thompson, 1995). Research over the last 30 years in

North America and beyond has shown that ACT and CM models are effective. Results

include significantly reduced illness relapse rates, hospitalization rates, length of hospital

stays (e.g. typically around 50% for ACT) and lowered overall debilitating psychiatric

symptoms; quality of life outcomes, such as subjective sense of stability, patient satisfaction

and family satisfaction, are also improved (Bond et al., 1995; Burns et al., 2007; Lehman,

Dixon, Kernan, Deforge, & Postrado, 1997; Marshall & Lockwood, 2003; Marshall et al.,

1998; Ziguras & Stuart , 2000). Although expensive to run, particularly the ACT model,

given the strict operational design, studies in North America have shown that both ACT

and CM models are cost-effective as compared to long-term hospitalization (Gilbody &

Petticrew, 1999; Rosenheck et al., 1995; Weisbrod, Test, & Stein, 1980; Wolff et al., 1997).

These successes are attributed to factors such as optimization of the existing healthcare

resources, increased interpersonal and therapeutic contact, early recognition, intervention

and prevention of illness, enhancing community integration and rehabilitation, and active

public advocacy and promotion of de-stigmatization of mental illness (Gerber & Prince,

1999; Resnick, Rosenheck, & Lehman, 2004; Young, Sullivan, Burnam, & Brook, 1998). If

not already covered by a patient’s health insurance, ACT and CM services are always

provided free of charge, as part of the state’s medical-social and welfare services (Bustillo,

Lauriello, Horan, & Keith, 2001).

Over the years in North America, ACT and CM have become the standards of care

serving the SPMI population in the community (Dixon, 2000; Mueser et al., 1998). In the

USA in particular, the success of the ACT model has earned recommendations from expert

consensus panels (Frances, Docherty, & Kahn, 1996; Lehman, Lieberman, & Dixon,

2004), US Federal guidelines (Stroul, 1989), professional psychiatric organizations

(American Psychiatric Association, 1998) and national community organizations (i.e.

National Institute of Mental Health (Santos, Henggeler, Burns, Arana, & Meisler, 1995).

Beyond the USA, the ACT model has also gained international recognition and

acceptance. Assertive Community Treatment programs have been developed in Canada,

parts of Europe (e.g. Germany, Italy, Sweden, Lithuania and England), Australia, New

Zealand (Burns, Fioritti, Holloway, Malm, & Rossler, 2001; Hambridge & Rosen, 1994;

Tyrer et al., 2007) and, most recently, the first Asian country, Japan (Horiuchi et al., 2006).

The outcome results of ACT and CM from Europe have been more conservative, but more

evaluation is underway, while stimulating informative international comparisons of

community psychiatry models (Burns, Catty, Watt, Wright, & Knapp, 2002; Burns, Creed,

Fahy, Thompson, & Tyrer, 1999; Burns et al., 2001).

International Journal of Culture and Mental Health 135

In Asia within the last three decades, China has rapidly transformed from an agrarian,

developing country, to a socialist market economy that has become the world’s third

largest (by World Bank’s Index of Purchasing Power Parity) (Kleinman, Kleinman, & Lee,

1999). The reform success has, on the one hand, provided unprecedented standard of living

improvements for the majority of Chinese citizens; on the other hand, it has also triggered

tremendous changes in medical and social welfare infrastructures that directly threaten the

chronically mentally ill. One of the pressing questions raised is how to secure and improve

care for the 4.3 million people with schizophrenia (Phillips, Yang, Li, & Li, 2004). From a

socio-political point of view, schizophrenia, recognized by the World Health Organization

(WHO) and the World Bank as one of the top-ten most burdensome illnesses in the world

(Murray & Lopez, 1996; Rossler, Salize, Van, & Riecher-Rossler, 2005; WHO, 2001), with

far reaching burdens on the patient, their family and the community and nation at large,

also demands attention from a developing economy like China.

However, there are daunting challenges faced by people with SPMI in China. To name

some of the most prevalent issues: (1) against the traditional role, families are increasingly

less likely to care for, and less able to afford treatment for, family-members who are ill (cost

of hospitalization and medications have more than tripled and out-paced the average

increase in income in the last two decades); (2) central governments have downloaded

financial and management responsibilities to local governments and individual hospitals,

resulting in more disorganized and unaffordable psychiatric services; (3) massive

urbanization and ‘industrialization’ lead to increased demand for services concentrated

in the cities, leading to neglect of the rural areas, where more than 70% of Chinese reside;

and (4) lack of skilled and willing psychiatric workers to fulfill the need and demand of the

growing field (psychiatry enjoys a very low status in the Chinese medical hierarchy) (Chang

& Kleinman, 2002; Eng, Xiang, & Liberman, 2005; Phillips, 1998; Yip, 2005; Zhu, He, &

Zhang, 2002; Zou, 2006).

Given the above concerns and the WHO’s authoritative recommendation for nations to

develop community mental health services in order to improve the quality of life,

rehabilitate, decrease stigmatization, improve prevention of illnesses and enhance com-

munity participation of the severely and chronically mentally ill patients (WHO, 2007), it is

timely to ask whether the ACT and CM models are suitable for China. The current

literature does not provide enough help for an organized approach to answer this question.

For example, International research on ACT has a history of focusing on comparison

studies on issues of ‘fidelity’ � how ‘authentic’ is the ACT teams’ programming as

compared to the original model. It is believed that the model needs to be reproduced as

faithfully as possible to ensure a successful outcome (Fiander, Burns, McHugo, & Drake,

2003; McGrew, Dieztzen, & Salyers, 1994). There is little analysis of cross-cultural

application issues and the foundational cultural and social economic factors that made the

success of the ACT model possible in the first place. Similar and more divergent issues also

plague international studies on the CM model.

With this backdrop in mind, this paper will examine the suitability of the western

community psychiatry models � using on the ACT model as a prime example � for China

by considering a number of key issues: the role of the state in providing psychiatric care

and other social welfare supports; the role of the family in the caring of the SPMI; and

availability of established and functioning laws regulating mental health. This comparative

exploration on the state of community psychiatry at large in China may add new

perspectives on how culture and political environment determine the establishment of

services, inform and shape the delivery of care; and by examining the ‘other’ one could also

136 S.F. Law

increase the understanding of the foundations of the western models, informing and

contributing to the continued growth of community psychiatry itself.

Methods

The author performed a standard MEDLINE (1966�2008) and PsychINFO (1974�2008)

search and reviewed the relevant literature on ACT, CM and China’s state of mental health

services, plus the key Cochrane Report on ACT (2003) and CM (1998). Based on the above

and the author’s personal work and research experience, key issues (i.e. social welfare andfunding, role of the family and the state, mental health legislations and community

readiness) are generated. Information related to the issues is synthesized and discussed to

put forward conclusions on the suitability of the western community psychiatry models �with a focus on ACT � for China. It is noted that the state of China’s mental health services

is complex and dynamically changing � it is impossible to give an overview without

resorting to some generalizations; this shortcoming is acknowledged and efforts to

minimize it are made.

Brief relevant background on China’s mental health services and the SPMI

With 1.3 billion in population and vast regional, economic, geographic, demographic and

cultural differences, China’s mental health services have understandably many unique

features and challenges (Blumenthal & Hsiao, 2005). Most strikingly, as the pace of socio-

economic reform accelerates and the level of central political control decreases, China is

experiencing increased rates of suicide, marital breakdown, family violence, rising

substance abuse and pathological gambling (Chang & Kleinman, 2002). For example,one study showed no reported new illicit drug use such as heroin or cocaine between the

years 1952�1986, but ‘illicit drug use has continued to escalate across the areas’ since 1986,

with one-year prevalence quickly reaching 1.17% (Hao et al., 2002); another study showed

a twenty-fold increase in alcohol-related problems during a ten-year period of the

economic reform (Hao, Young, Xiao, Li, & Zhang, 1994). Moreover, unprecedented

large-scale urbanization and its attendant psychological and mental stresses and the

exponential increase in the gap between the rich and poor in a nominally socialist society

have also been reported. Overall, the demand for mental healthcare is increasing (Phillips,Liu, & Zhang, 1999).

China’s healthcare spending is about 5% of its Gross Domestic Product, about a third

of that of the USA (Chang & Kleinman, 2002; Kaufman & Stein, 2006; Yip & Hsiao,

2008). Eighty percent of the state’s healthcare spending goes to the cities, where medical

facilities are concentrated, while 70% of the nation’s population lives in rural areas

(Phillips, 1998) and coastal regions are typically more developed than inland regions. With

mental healthcare, the disparity is even more pronounced; services and expertise are

centered on a few national centers. For example, the capital Beijing and coastal regionalcentres like the city of Shanghai have better-developed infrastructure for community

mental health than the rest of the country (Zhu et al., 2002c). Shanghai, in particular, is a

national leader in psychiatric capacity � with more than 8500 psychiatric beds, 800

psychiatrists and a published ‘Shanghai Model’ for community psychiatry to serve its 20

million population, including models like psychiatric outreach, work rehabilitation centres

and community-based support (Chang, Yifeng, Kleinman, & Kleinman, 2002, Yan, 1998;

Zhang et al., 1997); while remote places like the territory of Tibet do not have any

psychiatric hospitals (Zhu et al., 2002b).


This disparity of services is particularly remarkable since the psychiatric system

currently relies on hospitals, rather than community delivery of services. Patients with

schizophrenia occupy over 90% of the psychiatric in-patient beds and very little community

care is available to provide an alternative for care (Phillips, 1998). Overall, the delivery of

mental health services is limited. In terms of professional training, psychiatry still occupies

a historical low status within the medical profession; medical students tend to avoid

entering psychiatry. A 1999 report found 13,000 physicians working in psychiatric

hospitals, with only 2000 of them fully qualified psychiatric specialists or consultants;

and most mental health workers had only high-school education, with very few allied

professional such as psychiatric social workers (Lee, 1999). A more recent update

calculated the Chinese national average at one psychiatric physician per 63,000 people

(Zhu et al., 2002c) � about one-sixth of the level when compared to the figures in the

developed countries currently with community psychiatry services, such as Canada (el-

Guebaly, Beausejour, Woodside, Smith, & Kapkin, 1991) and Australia (Burvill, 1992). In

terms of psychiatric service penetration, a recent survey done in the costal Jiangsu

province, China � a relatively well-resourced region � showed that 38.4% of mentally ill

patients in general, and 23.5% patients with affective disorders or schizophreniaspecifically, have not received any treatment (Chen & Zhou, 2005). The rate of care is

even lower in rural areas (Ran et al., 2003; Ran, Xiang, & Huang, 2001). Most researchers

attribute the low service rates to a lack of availability of services, among other reasons.

In terms of healthcare administration, the lack of any structure for centralized

coordination, with resultant uneven, uncoordinated and unresponsive service provision of

psychiatric care, is also criticized for the current limits in care (Blumenthal & Hsiao, 2005;

Kelly 2007; Yip & Hsiao, 2008). In essence, there are numerous, highly bureaucratic

government bodies, such as the Ministry of Public Health, the Ministry of Civil Affairs (the

main operators of public psychiatric hospitals,), the Ministry of Public Security (operators

of the forensic Ankang hospitals for patients with criminal infractions), the Ministries for

the military, veterans, minorities and the railroad workers etc., plus local organizations

such as major universities and some large state companies, have all developed separate

systems of psychiatric hospitals and services. These services are all uncoordinated, often

competing for insured patients, often in the same neighborhood and almost exclusively in

major cities (Pearson, 1992; Tian, Pearson, Wang, & Phillips, 1994; Yip, 2005).In addition to a lack of service coordination, deprioritization in the allocation of the

limited resources in China also contributes to the low level of psychiatric services to the

general public. One notable example is a widely-accepted generalization that China has a

historical and societal emphasis on social and political stability and harmony. Much effort

is spent on social control. As a result, the criminal justice sector and the forensic medical

and psychiatric systems are relatively well funded and the Ministry of Public Security (i.e.

the police) is officially given a significant role in the management of the mental health

services. In practice, many SPMI patients may not come into contact with any psychiatric

services until they break the law and are then incarcerated and treated in the forensic,

Ankang hospital system (Pearson, 1996; Phillips 1998).

With specific regard to those with serious and persistent mental illness, recently

updated research in China has found schizophrenia to be the second most prevalent mental

illness, after neurasthenia, with an adjusted point prevalence of 3.44 per 1000 (Cooper &

Sartorius, 1996; Phillips et al., 2004). This is a somewhat lower figure as compared to the

global average of 3.91 per 1000 (American Psychiatric Association, 1994; Murray & Lopez,1996; Sartorius, Guibinat, Harrison, Laska, & Siegel, 1996). However, schizophrenia has a

number of remarkable characteristics in China.

138 S.F. Law

Firstly, the prevalence of schizophrenia in women outnumbers men by 1.77 times � the

general trend in the rest of the world is the reverse, with men outnumbering women by 1.4

times (Aleman, Kahn, & Selton, 2003; Cooper & Sartorius, 1996). Secondly, there is a two-

thirds higher prevalence of schizophrenia in urban areas than rural areas � the large

difference suggests multiple possible factors at play, including selective migration of

schizophrenic patients to the cities, difference in rates of death (including suicide) and

different treatment outcomes amongst schizophrenic patients in rural and urban areas �with perhaps greater ‘remission’ rates in rural areas, as per the well-known finding that

schizophrenic patients fair better in developing countries than in developed countries

(Sartorius et al., 1996), among others. Thirdly, a tenth of all suicide in China is attributable

to schizophrenia, a rate notably higher than the average 6.4% figure found outside China

(Phillips et al., 2004). Fourthly, patients with schizophrenia in China typically have long

admission periods of 2�3 months, representing the vast majority � over 90% of the in-

patient psychiatry population and over 60�70% of outpatient psychiatric services in a

typical psychiatric hospital in China (Phillips, 1998, 2001). Lastly, some research indicates

that the prevalence of schizophrenia may be on the rise in China, possibly related to recent

massive social changes, among other reasons (Kleinman, 1996; Phillips et al., 2004). All

these characteristics highlight a diverse set of biological, social, environmental and cultural

determinants that affect the illness course and treatment outcome for those suffering from

schizophrenia.Lastly, there are a number encouraging recent developments related to the SPMI

population. In 1991, people with mental illness were officially included in the China

Federation for Disabled People, giving them official recognition and increasing their access

to services, and contributing to de-stigmatization of mental illness. This was also a

landmark event in terms of social changes brought on from a non-government, grass-root

level force (even though the Federation was founded by Deng Pu-Fang, the disabled son of

the late leader Deng Xiao-Ping) (Tian et al, 1994; Yip, 2005). Reform of the rehabilitation

service delivery system for the disabled population is reported, with effort to include the

mentally ill (Hampton, 2001). The emerging ‘third sector’ � non-governmental organiza-

tions (NGOs) that champion for the welfare of marginalized populations � may add to the

overall development of support networks for the SPMI (Leung, 1994).

In 1999, in collaboration with the WHO, the Chinese central government officially

reprioritized and designated mental health problems as one of the most important public

health concerns and mandated mental health service reform (Yin, 2000). More specifically:

suicide; schizophrenia; reform to recognize more patient rights; and increased funding for

evidence-based care are identified as goals and areas of importance in the reform. In a

subsequent meeting of the Third National Mental Health Symposium in 2001, the

concluding mission statements emphasized shifting mental healthcare focus from in-

patient care to community-based prevention, treatment and maintenance care; early

intervention and wider implementing mental health legislation were also prioritized (Yin,

2002). These new national trends will have significant impact on the discussion regarding

the suitability of western community psychiatry models for China.

Discussion of key issues

1. Public funding for chronic psychiatric care

Given the fundamental reality that the vast majority of people with SPMI are poor and

require intensive treatment and follow-up services, they rely on a social welfare system


where the state underwrites basic services for their care. So far, community psychiatry

models such as ACT have only been employed in developed countries with such a health

and social infrastructure, and one of the strong arguments for implementation of ACT is

how cost-effective it is as an alternative to state-paid in-patient care. No private, for-profit

company would offer such a model, given the large cost in starting and operating an ACT

team, the low likelihood of payment for such services from the clients and the long-term

financial and medical responsibility for the patients. For similar reasons, no for-profit

insurance company would adequately insure a patient who uses the services of an ACT

team, given the intensive needs and its high costs. Assertive Community Treatment is also

not typically funded by philanthropic and NGOs in the west, given the large, long-term

financial commitment. There is a widely shared value in th western societies that the state

should provide such care for marginalized populations (Clark, 1997). There is also research

that proves community-based services are cost-effective, if the underwriter of this cost is

not in conflict of interest to make a profit from hospitalization (Xiong et al., 1994).

The cost of CM is relatively lower and the range of services can be more flexible,

according to the budget and capacity. However, the basic requirement for a non-profit,state-sponsored financing is the same as ACT (Marshall & Lockwood, 1998).

Research unequivocally credits targeted, stable government funding and administrative

support (Isett et al., 2007; Lehman, 1998; Mowbray et al., 1997; Williams, Forester,

Mccarthy, & Hargreaves, 1994) or at least permission to alter the current configuration of

services provided by the state (Essock & Kontos, 1995) for the success of evidence-based

models such as ACT and CM. Within such a state-sponsored system, welfare and medical

services can achieve a reasonable level of service integration, continuity of service between

the hospital and the community, and work closely with supportive services in the

government and NGO sectors.

In China, during the Mao era (1949�1979), the Chinese communist party implemented

various national plans to provide free social and medical services to cover all citizens who

contribute to the state. Since there was virtually no private enterprise, the system was

egalitarian and basic medical care was accessible to all, urban and rural, when and where it

was available. With China’s transition into a market driven economy and economic

growth, the cost of healthcare has escalated exponentially. State policies have departedfrom a socialist ideology and resorted to privatization of healthcare services as a solution

since the late 1980s. One example is the state’s planned withdrawal from the Rural

Cooperative Medical Insurance system � the system that provided basic medical services to

the vast Chinese rural population (70% of the nation), leaving non-government, for-profit

structures to fill the vacuum and many economically impoverished populations in crises

(Chang et al., 2002). As of 1989, only 5% of the rural population still had this insurance, a

precipitous decrease from 84.5% only fourteen years earlier in 1975 (Gu et al., 1993). Also,

as of 1993, the state’s subsidies to the operating budgets of hospitals in general dropped

from nearly 100% to 9% (Lee, 1999; World Bank, 1997). Hospitals are forced to become

economically self-sufficient by increasing pharmaceutical prices and medical fees;

operating extensive commercial businesses on the premises (e.g. restaurants and health

clubs etc); and encouraging a culture of questionable practices of longer hospital stays,

prescribing higher cost medications and investigations etc.

Over the last three decades, with the state’s opting out of funding a basic healthcare

system and the removal of the social medical safety net, the cost of healthcare has beenshifted to patients, employers, healthcare facilities and the private sector directly. At the

patient level, one study showed that the average cost of an acute psychiatric admission has

increased from 33 to 78% of the annual per capita urban resident income and from 60 to

140 S.F. Law

167% of the annual per capital rural resident income (Phillips, Lu, & Wang, 1997; World

Bank, 1992). Recently, a conservative estimate showed that less than half of the people in

China have adequate medical insurance; most SPMI patients are unlikely to have any

insurance coverage (Yip, 2005). Furthermore, the variety of private sector, for-profit

insurance plans are selective and typically unobtainable by SPMI patients. A recent study

on poor patients who suffered mental illness in an area where services were available

showed that 70% of them did not seek help or obtain treatment because they were unable

to afford it (Gao, Tang, Tolhurst, & Rao, 2001). Despite the low number of bed counts in

China, an estimated 30% of the hospital in-patient beds are empty because families cannot

afford to pay for treatment (Hsiao, 1995). As a result, these long-stay institutional beds

across China are rapidly disappearing and families are forced to take the patients home.

Many families are unable or unwilling to do so (Pearson, 1995). There is no community-

based mental health service set up to provide continuity of care (Phillips, 1998).There is no doubt, with the disappearance of the social medical welfare system, services

for the SPMI population will be seriously affected. However, under the current market

economy as it applies to healthcare, development of services such as community psychiatry,

outreach services, preventative care to the poor and chronically ill is counterintuitive as it

will not be profitable. At the time of writing this paper, China’s media is reporting a

national-level debate on the future of healthcare reform, including ideas of a return to a

universal health insurance, or at least to insure the poor and needy for critical illnesses

(Anon, 2008). The results of this debate are eagerly awaited, as they will have major impact

on the conception of community psychiatry.

In conclusion. Development of preventative, rehabilitative and community-based mental

healthcare such as ACT and CM requires extensive social welfare infrastructure to allow

stable and sufficient funding, system coordination, standard setting and maintenance and

fostering of the variety of social support services required for the care of the SPMI

population. A for-profit health system is incompatible with proper care of the marginalized

population such as the SPMI. The state must be involved in providing the social safety net

for this population before such services are conceivable.

2. Role of family as caretaker of the SPMI

North American literature shows that typically about 80% of patients with schizophrenia

have families close by; more than 80% have regular contact with their families (Lehman et

al., 1998); and about 40�65% of patients live with one or more family members (Lehman &

Steinwachs, 1998; Soloman & Draine, 1995). Patients with more severe illness requiring

ACT and intensive CM services are considerably less likely to live with any family member

(Leman et al., 1997). Pathways to this relatively low family involvement are multifold,

likely largely related to the western culture of valuing independence, the downward social

spiraling effect of severe mental illnesses (‘burning the bridges with family’) and fast-paced

market economy resulting in the loss of protective ‘community’ for the mentally ill (Dixon

et al., 2001). Furthermore, stigma carried by mental illness can, among its many negative

effects, lead to societal blaming of the patient, resulting in family burden and estrangement

(Allness & Knoedler, 1998; Phelan, Bromet, & Link, 1998; Ritsher & Phelan, 2004).

Given this culturally rooted reality, the goal of rehabilitation and skill training for the

mentally ill is generally focused on independence promotion and self-actualization � in

keeping with the dominant western culture. Much of ACT and CM work is thought of as

providing a social support system akin to a ‘second family’. There is a parallel development


and availability of social welfare system that replaces the care-taking role of the family.

Needless to say, these services are resource intensive.

In China, in contrast, the primary care-taking responsibility for the chronically

mentally ill rests with the family. More than 90% of the chronically mentally ill live with

their families (Phillips, 1993). Families are also primarily responsible for the patients’

welfare and behaviour (e.g. in many regions, the family is charged the hospitalization fee if

a patient requires intervention from authorities and gets hospitalized, as the family is

perceived as having failed in monitoring the patient) (Phillips, 1998). Moreover, perhaps

the flipside of this responsibility, the families have the primary right to decide on all issues

related to treatment, hospitalization (including involuntary admissions), rehabilitation

goals and follow-up treatment for the patients. The patient is not very often involved in

treatment decision (Chien & Norman, 2003). A common explanation for these distinctive

social arrangements is the cultural tradition of Confucianism in which the family is the

fundamental unit of the society. A nation’s harmonious, stable and prosperous existence

depends on the success of each family in caring for and controlling its members. Therefore,

taking good care of the family member when he or she is ill is part of the traditional valuesystem and, in turn, an expected responsibility of the family. Understandably, this

tremendous resource can also be a source of intense burden.

Chinese families of the SPMI report a great deal of stress, social isolation,

stigmatization and emotional and financial burden (Li, Lambert, & Lambert, 2007).

Understanding the explanatory models of schizophrenia and help-seeking practices in

China may provide some insight on the nature of these stressors. Research shows that

stress-inducing, often superstition-based views of causes of schizophrenia are quite

common. These include beliefs of supernatural forces, such as ancestral spirit interven-

tions, retribution of ancestor’s evil deeds and ghostly possessions etc. (Chung & Wong,

2004; Li & Phillips, 1990; Lin, 1981; Yang, 1989). Many, particularly rural residents, would

only seek biomedical help after having exhausted the treatment from local shaman and/or

Buddhist or Taoist monks (Phillips, Li, Stroup, & Xin, 2000). Blaming the patients for

having bad fortune, luck or ‘fate’, not having worked hard enough to get better, having a

lack of discipline or being outright immoral and violent is prevalent. The high level of

negative views and stigmatization of mental illness in China have led to extensive

discrimination against the mentally ill in education settings, at work and in the communityat large (Chang et al., 2002; Phillips, Pearson, Li, Xu, & Yang, 2002). One report also

found mental health nurses held strong negative characterizations of the mentally ill

(Sevigny et al., 1999); another report found mental health nurses not long ago believed that

mental illnesses may be contagious (Phillips, 1998).

As a result of all the above, Chinese families typically try to manage their ill members at

home for as long as possible, in order to protect the family reputation and avoid the shame

and stigma brought on by having a mentally ill person in the family (Ip & Mackenzie, 1998;

Tsangn, Tam, & Chan, 2003). By the time medical treatment is sought, the illness and

negative impact of the illness are often quite advanced and the family quite exhausted.

Nevertheless, the reality remains that basic and primary care ‘services’ for the SPMI in

China are deeply rooted in the family and, therefore, the community. There are also unique

intra-familial patterns of care taking, with females likely shouldering the lion’s share of the

caring (and burden), given the traditional Chinese female roles (Pearson, 1993). Thus,

working with the family in culturally specific ways to increase family and community ‘buy-in’ for treatment and rehabilitation is paramount. Understanding the families’ and

patients’ values, interests and needs, tailoring services to the unique needs of the patient

population, relieving families’ burden, working within cultural beliefs and hierarchical

142 S.F. Law

structures of families are essential in delivering care for the SPMI in China (Chien &

Norman, 2003). Preliminary research has shown Chinese families can benefit a great deal

from community psychiatry support and discharge planning support and are greatly

receptive to skill training and psychoeducation from professional sources (Pearson, 1993;

Yin, 2000; Zheng & David, 2005; Zou, 2006).

In conclusion. Basic ACT and CM assumptions of working towards a primary goal of

independent living, acting as a ‘second family’, may be at odds in the Chinese context.

How to utilize the ACT model in this environment rich with family resources, and the

family being much more prominently woven into the social fabric of the patients, needs to

be addressed. Development of services and support for the SPMI must include the family

and possibly be provided in conjunction with the family. Assertive Community Treatment

and CM models’ ability to address the intense resources required to serve the patients and

their families, having a multidisciplinary team to provide different expertise and being

available around the clock, would be strong advantages in the Chinese context, given the

Chinese families’ thirst for support. However, innovation on traditional ACT and CM

approaches is likely required.

3. Functioning laws regulating mental health

The need to strike a balance between individual versus collective rights as related to the

mentally ill is an issue heavily embedded in the culture and legal tradition of the individual

places. In the jurisdictions where community psychiatry is well developed, there are

invariably established and functioning laws regulating mental health. In the USA and

Canada, for examples, each State, Province or Territory has a statute that governs the

procedures, conditions and detailed timeframes under which a mentally ill person may be

detained, assessed or hospitalized involuntarily. The right of the patient for legal advice

and representation to refuse hospitalization or treatment and to challenge existing

treatment is largely guaranteed through the Mental Health Acts (American Psychiatric

Association, 1987; Gray & O’Reilly, 2001). Basic legal representation, Independent Review

Boards and regular reviews of involuntary status are free of charge to the patient. In

addition to the personal rights and rights to due process, other similar laws exist to

establish a framework for a fair review of the patient’s competence to self-care, to manage

finances and to consent to treatment. Rights to confidentiality and rights to refuse to take

part in experimental studies are also part of the larger context focusing on individual rights

and dignity (Appelbaum, 2001a; Brahams, 1986).

Given that community psychiatry � particularly ACT � contains an assertive outreach

component in its services provided, it is expected that it will often encounter people who

refuse and reject the services, as these services are not always consistent with the patients’

wishes. The balance between patients’ wishes and well-intentioned therapeutic goals is

always very delicate (Fennell, 1992). There is an on-going debate about whether the

assertive treatment approaches of ACT and CM care is ethical care � possibly too much a

form of social control (Chodoff, 1984; Stovall, 2001; Williamson, 2002). There have been

concerns that the patients’ perspectives and wishes are not considered enough when

community psychiatry teams impose their treatment plans and that patient’s subjective

experience are not considered enough in treatment decisions (Tam & Law, 2007; Watts &

Priebe, 2002). A well-established and functioning set of mental health laws act, at the

minimum, is a counterbalance for the fair and decent treatment of the mentally ill, as best


intentions can be malignantly employed without oversight by a regulatory system. This

regulatory system is again resource intensive and relies on the larger, societal legal

infrastructure, but is crucial for the healthy operation of community psychiatry models like

ACT and CM.

In China at present, there is no national legislation regulating mental healthcare.

Various provisions of a number of related statutes, such as the Criminal Law, the Civil Law,

the Law on the Protection of Disabled Persons and the Law on Maternal and Infant

Healthcare, among others, are loosely applied when the need is raised in the context of

mental healthcare (Phillips, 1998). One significant factor related to the lack of functioning

mental-health legislation development is a much stronger political tendency to value the

collective good over the individual right: the maxim of ‘The greatest happiness of the

greatest number’ is applied to the society at large, not just to those who are mentally ill

(Pearson, 1996). The government has traditionally also played a strong role in ensuring

that the mentally ill are controlled through its public security and psychiatric institution

system.Compared to the west, and from the perspective of global promotion of human rights,

the Chinese forensic mental health system has been criticized for suppressing individual

rights under the mandate of the state (Appelbaum, 2001b; Munro, 2002; Ramsay, 2002;

Shen &Gong, 2000; Tang, Li, & Zhao, 1996). Even the aforementioned community mental

health programs, such as the guardianship networks and the sheltered workshops (Luo &

Yu, 1994; Zhang, Yan, & Phillips, 1994), have been cautioned for their role as part of the

state’s control on the community, serving a purpose in neighborhood monitoring (Yip,

2005). In many parts of China, involuntary admissions to mental health facilities can occur

not just based on the family’s wish, but can be based on recommendations from the

patient’s employer, a community person of importance or government workplace leader;

coercive and forced hospitalizations or medication continue to be prevalent (Pearson,

1995; Wang, Livingston, Brink, & Murphy, 2006; Yip, 2005).

Some scholars believe that these concerns reflect the fact that psychiatry has always

had both a socio-political and biomedical context and a lack of standardized, open and

quality training of some psychiatrists in China today can lead to misuse of psychiatry;

more engagement, research, academic exchange of ideas and establishment of lawsregulating psychiatry can help to diminish these inappropriate practices (Lee & Kleinman,

2002). In this spirit, the Chinese Ministry of Health has commissioned a specialized group

to draft the Mental Health Law of the Peoples’ Republic of China since 1985, drawing

upon the WHO’s report on international mental health legislation and other international

legislative documents, including many human rights oriented pieces such as the

Declaration of Helsinki. However, China still has not enacted mental health legislation.

The most recent major activity was development of the 15th draft of the Mental Health

Act in 2004 for submission to the State Council and the National Peoples Congress for

approval. The delay in approval of the draft is reported to be related to numerous

unresolved concerns, including the significant disparities in mental health services and

resources across China that make it very complex to establish a single national standard;

dispute over the unique role of the family over treatment decisions in the Chinese culture;

and the role of the government in mental health administration and service provision etc.

(Tan, 2005). Much debate is on how to incorporate Asian values that favour the role of the

collective and the family, while balancing the rights of the individual. On this note, the

current Japanese Mental Health Law, last revised in 1988, still places a high value andrespect for the authority attached to the family and permits involuntary hospitalization of

a patient based on consent by a close family member (Shinfuku, 1998).

144 S.F. Law

In the mean time, legislation at some municipal and provincial levels has been enacted.

The prime example is the ‘Shanghai Municipality Regulations on Mental Health,’ enacted

since 2002 (Tan, 2005). The Shanghai regulations were based not only on the national

draft, but also on similar law from Japan, Taiwan and England. Fundamental issues such

as involuntary admission and treatment, informed consent, policies on seclusion and

restraint, patients rights in receiving and refusing mental health services and patients’ right

of confidentiality, are incorporated in the Shanghai regulations and are close to the North

American standards and they will likely serve as a model for the national one in years to

come (Tan, 2005; Zhang, Ji, & Yan, 1997).

In conclusion. Quality community psychiatry care strongly requires a healthy functioning

set of mental health laws to counterbalance the inherent, well-intentioned, but ultimately

paternalistic nature of its work. Community psychiatry in the Chinese context must be

mindful of its historic emphasis in behavioural control of the mentally ill for the sake of

social order, over the rights of the individuals with mental illness. Development of mental

health regulations that takes into consideration of the cultural values is urgently needed

and its existence would be essential for further development of community psychiatry.

4. Community readiness and complementary resources

In the west, in addition to public funding of psychiatric care, operation and delivery of

community psychiatry models such as ACT and CM is not likely possible without the

parallel development and availability of other complementary services and resources

(Thornicroft & Tansella, 2004). Crucial infrastructure such as social welfare income

assistance, homeless shelters, legal aid, medication insurance etc. are parts of an essential

safety net for protection of the severely mentally ill (Chinman, Rosenheck, Lam, &

Davidson, 2000; Day, 2006; Gravel & Bond, 2005). More specialized resources such as

supported housing, peer and family supported programs and vocational rehabilitation

services all contribute to the stability and quality of life of the severely mentally ill and are

therefore critical to the functioning of community psychiatry (Becker & Drake, 1994;

Bond, 2004; Cheng, Lin., Kasprow, & Rosenheck, 2007; Cook, 2006; Davidson, Chinman,

Sells, & Rowe, 2006; Newman, 2001). Further innovations on community support such as

the Club House model for peer supported daily living (Herman, Onaga, Pernice-Duc, Oh,

& Ferguson, 2005; Nemens & Nicholson, 2006), court diversion and support of mentally ill

persons who commit minor crimes (Steadman & Naples, 2005), community wide training

and incorporations of the police in proper approaches and crises management of the

mental ill (Lamb, Weinberg, & Decuir, 2002) and mentally ill persons’ own initiatives for

recovery (Deegan, 1992; Segal, Silverman, & Temkin, 1995) are all part of a wider and

critical infrastructure contributing to the community readiness for rehabilitation for the

severely mentally ill.

At a larger level, research in quality of life and determinants of health for people with

severe mental illness have pointed out the importance of a well-coordinated and integrated

network of community services for the severely mentally ill, thus adding support for the

development of these complementary services in the community; equally important is

fostering a climate of non-stigmatization, tolerance and sensitivity in order to build self-

efficacy, self-esteem and dignity for mentally ill persons in the community (Gravel & Bond,

2005; Hansson, 2006; Lieberman & Kopelowicz, 2005). The development of these

complementary services reflects the societal attitude and commitment towards the

mentally ill and is undoubtedly culturally-, historically- and politically-based.


In China, one anticipates that it would be important to take time and resources to

develop similar but culturally appropriate infrastructure in order to improve the lives of the

SPMI and for community psychiatry models such as ACT and CM to flourish. One could

also argue that services like these do not necessarily translate to better outcome for the

mentally ill, as the well-known WHO studies found: despite the resources and services,

persons with schizophrenia in developed/industrialized countries have poorer outcome and

lower quality of life than those in developing nations. Perhaps these services are inferior

replacement of the factors that are at work at a community level in developing countries

(Sartorius et al., 1996). The factors that give rise to a better outcome in developing

countries such as China may be a higher level of community acceptance of mentally ill

persons, narrower social economic gap between the rich and the poor, and more available

family and community support network for the mentally ill (Hopper & Wanderling, 2000).

The provocative finding that a severely mentally ill person from a developing country is

able to enjoy a better outcome than his counterpart in the west has partly led the west to

respond by developing more community-based services, and community psychiatry

programs such as ACT and CM have been part of the key to fulfill this mission.It is with some irony that, as the west is promoting a return to the community, China is

undergoing some opposite changes. With China’s economic growth and political changes,

the advantages enjoyed through family and community support networks are disappearing

as massive population/work force have migrated to urban centers, leaving many families

and communities short; one-child-only family planning policy has resulted in a lower

number of family members for care taking; gaps between the rich and poor are rapidly

widening; and the increasingly market-driven economy has stripped the social-medical

safety net for the masses (Blumenthal & Hsiao, 2005; Kelly, 2007; Phillips, 1998). In short,

the WHO protective factors for the SPMI are disappearing, and there is no parallel

development of social services to replace the lost family/community support networks.

Given these changes, community psychiatry development in China will likely be

challenging at multiple levels, one of which will be the fundamental question of whether

the community is ready as a place of rehabilitation � is there community support for this

philosophy and therefore support for the existence of models of community psychiatry

such as ACT and CM?Studies on community mental health in China show that patients and families, when

given a choice and proper support, prefer community-based care as it is less costly, less

disruptive and more facilitative to improved quality of social life (Chang et al., 2002;

Chang & Kleinman, 2002; Tian et al., 1994). Historically, there has been some effort at the

national level in China to integrate community psychiatry into primary healthcare (Jiang,

1988) and to develop community mental health services and protected vocational

rehabilitation models, using community volunteers, neighbourhood organization officials

and family participation (Xia, Yan, & Wang, 1988). However, the overall development of

community services and meaningful integration of the SPMI patients into the community

has been limited, likely due to a low level of effort, low resources, low community ‘buy in’

and lack of infrastructure to support such services (Pearson, 1992; Phillips & Pearson,

1994).

More recent uniquely Chinese development shows that the notion of psychiatric

rehabilitation is becoming more known in China and the development of psychiatric

nursing as a profession is taking place in part of China (Zou, 2006). Increased activity bygrass-root organizations and lobby groups such as the Rehabilitation Association for the

Mentally Disabled will likely exert increasing influence and play an advocacy role to

increase quality of community-based care for their constituency (Hampton, 2001).

146 S.F. Law

Cultural attitudes towards SPMI patients may slowly change, with increased openness in

the society, awareness of notions of humanitarianism and increased value placed on mental

health (Lee & Kleinman, 1997). There are a number of pioneering projects promoting

community psychiatric service that are proven locally successful in the Chinese context and

can inform community service development at large. The aforementioned Shanghai Model,

with community follow-up programs for the SPMI by hospital-based physicians and

nurses, guardianship networks by retired neighbourhood volunteers and work station

therapy, factory sponsored rehabilitative positions, day hospitals and family supportgroups, is a prime example (Chang et al., 2002; Zhang et al., 1994). Other innovations

include home-based beds supported by community mental health workers (Wang, 1994);

family psycho-education and community re-entry programs that reduce recidivism and

increase patients’ quality of life, social functioning, insight and employment rate (Wong et

al., 2008); and enterprise-based sheltered workshops (Luo & Yu, 1994). Hong Kong, the

most modernized part of China, has a community-based, multidisciplinary case manage-

ment team model for the chronically mentally ill that may serve as potential model of

community development (Ungvari & Chiu, 2004).

In conclusion. The existence of a wider social infrastructure of complementary services andprograms to protect and support the severely mentally ill is considered critical for the

success of community psychiatry programming. With the understanding that each locale

will have locally meaningful developments of support according to the resources and

needs, China is currently found to be inadequate in community resources, while losing

some of its traditionally supportive factors for the mentally ill. The current changes in

economic and political landscape in China need to preserve, promote and enhance the

readiness of the community as the place of rehabilitation if models such as ACT and CM

will be considered.

Conclusion

The severely and persistently mentally ill in China are currently mostly treated and housed

in in-patient facilities or cared for by their families unassisted, imposing enormous social

and economic burdens. There is an urgent need for development of community based

mental health services in China. The climate and demand for considering successful

western models such as ACT and CM is propitious: increased costs of in-patient care,decreased availability of in-patient care, increased reluctance and readiness of family to be

solely responsible for the caring of the mentally ill, the unwillingness of most chronic

patients to attend out-patient clinics or follow-up and the rising interest in community-

based treatment approaches that will enhance the quality of life and dignity of the mentally

ill.

Discussions on the selected, essential, culturally-salient community psychiatry founda-

tions have not only provided a chance to reflect on the basic assumptions of community

psychiatry models in the west, but help to arrive at the view that wide adoption ofcommunity psychiatry models such as ACT and CM in China may not be feasible from a

financial, cultural and political perspective at present. However, examination of the

community psychiatry foundations, as represented by ACT, in the Chinese context may

serve as a cultural and clinical reference point for future development of sound strategies

and effective services for the SPMI. Community mental health programs need to consider

the limited resources and training available in China at present, the stigma faced by the

patients and family, strong family involvement and commitment, the social expectations of


social responsibility from families and patients alike. Community psychiatry program

development in China needs to be socio-culturally and ethically congruent with the

community it serves, as well as to advocate for social justice and promote patient welfare.

Large-scale implementation of the ACT and CM models in China is not realistic, given

the large disparity in resources and infrastructures existing today. However, local trials of

culturally informed adaptation of the ACT and CM models or its main elements (e.g.

community outreach, multidisciplinary team work, high availability, advocacy etc.) in parts

of China (e.g. Shanghai) would be very feasible and informative for future servicesplanning and provision in China as a whole. Given the ‘twin goals’ of social supervision

and rehabilitation favoured in Chinese society, possible initial trial of a service as a part of

the well-funded and more organized forensic system would be a likely starting point if the

philosophy of psychosocial rehabilitation is implemented. Support of University academic

departments that are interested in studies of service delivery models and input from experts

on ACT and CM from the west would enhance the potential for success. Working within a

catchment area with high rates of insured SPMI patients may also help to demonstrate the

financial advantages of the ACT and CM models in China. The development of ACT andCM models in China would provide important insight into the factors associated with the

successful caring of the patients with SPMI and shed light on the development of the ACT

and CM models world-wide.

Notes on contributor

Samuel F. Law, MD, FRCPC, is an Assistant Professor at the Department of Psychiatry at

the University of Toronto, and is the Chief Liaison person for China related collaborations

in research and scientific exchange on behalf of the Department of Psychiatry at Universityof Toronto. He is a staff psychiatrist at Toronto’s St. Micheal’s Hospital and Associate

Staff at Mount Sinai Hospital. His clinical work centers on psychiatric services in the

community, focusing on the inner city populations with severe and persistent mental

illnesses. He also works extensively with Asian immigrant and ethnic minority populations.

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Are western community psychiatric models suitable for China? An examination of cultural and socio-economic foundations of western community psychiatry models using assertive community

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