International Social Work 48(4): 409418

Sage Publications: London, Thousand Oaks, CA and New Delhi

*
i s w
DOI: 10.1177/0020872805053463

Western model, Eastern context

Cultural adaptations of family interventions for
patients with schizophrenia in China

* Winnie W. Kung

Since around 1970, mental health professionals in the West have

begun to pay attention to the role of families in the treatment and
rehabilitation process of patients with severe and persistent mental
illnesses. Various family intervention models have been developed
for patients with schizophrenia and tested, with very robust effects
in delaying patients relapses and improving patients functioning
and family well-being (Dixon and Lehman, 1995).
During the past 10 years or so in Mainland China, attention began
to be paid to caregivers of patients with schizophrenia. Some attempts
were made to adapt Western interventions to t the Chinese context,
with some encouraging results (Wang et al., 1993; Xiong et al., 1994;
Zhang et al., 1993, 1994). However, the high dropout rate of families
from treatment was noted. Moreover, the studies reported only broad
strokes of these interventions. Using an ecological and cultural lens,
this article aims to explore an indigenous approach in working with
these caregivers in China.

The unique Chinese context

As one examines Chinas specic sociocultural context in order to
develop an indigenous intervention approach for caregivers of

Winnie W. Kung is Associate Professor at Fordham University Graduate School

of Social Service, 113 West 60th St, New York, NY 10023-7484, USA.
[email: kung@fordham.edu]
410 International Social Work volume 48(4)

patients with schizophrenia, one must keep in mind the many diver-
sities in this vast land, including the great differences in cultural
beliefs and mental health service provisions between rural and
urban China, and the social norms and values that are undergoing
rapid changes (Phillips and Pearson, 1994a, 1994b).

The centrality of the family

Between 79 percent and 90 percent of patients with schizophrenia in
China live with their families (Phillips, 1993; Phillips et al., 2000), a
gure much higher than in the West (e.g. 23.7% in the US; see
Greenberg et al., 1994). This phenomenon reects both the cultural
preference of families to take care of their own and the ecological
constraint of limited community resources for the patients.
The 1981 Marriage Law in China mandated families to take care
of their disabled relatives. Moreover, most outpatient psychiatric
clinics require that at least one relative of patients be present
before they are attended to (Pearson and Jin, 1992). Some Chinese
cultural beliefs also act as push factors in shaping the centrality of
families in the care of their mentally ill members. Asian cultural
beliefs are said to discourage seeking external help since it would
suggest that the family is inadequate to take care of its own, which
thus brings shame (Sue, 1993). The serious stigma attached to
mental illness, seen as a result of the social and moral errors of
family members, also deters efforts to seek external help (Pearson,
1993; Phillips, 1993). Thus, individuals turn inward for family
support.
As a developing country, China has very limited mental health
and social services. In urban communities, beyond the acute phase
of the disorder, the provision of mental health service is limited to
drug treatment at outpatient psychiatric clinics (Phillips and Pearson,
1994a). This service is becoming unaffordable with the withdrawal
of medical insurance from work units, and fewer people entering
state jobs as China moves towards a market economy (Phillips,
1993). The condition is worse in rural areas where people may
have to travel more than one day for a follow-up visit to the nearest
psychiatric outpatient facility (Pearson, 1993). Psychosocial rehabi-
litation is almost non-existent, except for a handful of experimental
sites in a few large cities. Given the lack of social services, many
patients are left at home with their families.

Contradictions and dilemmas faced by caregivers

China is considered a developing country in terms of technological
 Kung: Schizophrenia in China 411

development. It has been found that the prognosis of the course of

schizophrenia is better in developing countries than the more tech-
nologically advanced societies (World Health Organization, 1979).
This is because the more diluted and less emotionally charged inter-
actions in extended families typical of developing countries are less
conducive to relapses than interactions in nuclear families in devel-
oped countries (Leff, 1981). Also, patients in developing countries
can reintegrate into society more easily, with greater opportunities
for meaningful work and less unrealistic expectations, thereby facil-
itating rehabilitation (Leey, 1987). Although China is a developing
country, the majority of its patients do not enjoy these benets: the
family is changing to the nuclear type, and there is increased work
competition with the resurgence of the market economy in the
post-Mao era. Not only are Chinese mentally ill patients unable to
benet from the favorable social conditions of developing countries,
they are also deprived of comprehensive mental health services avail-
able in advanced countries. Thus, they get the worst of the two
worlds, leaving caregivers with formidable challenges.
These families also face some poignant value conicts as the
family-centered hierarchical Confucian paradigm in China inter-
faces with Western individualism (Phillips, 1993). Due to the debili-
tating impact of schizophrenia on young adults, their parents often
take over decision-making roles, even to the point of arranging
marriages, and are thus seen as lacking respect for patients auton-
omy. However, the parents may in fact be reacting pragmatically
to the changing norm towards individualism when extended families
are less valued. Parents may see a spouse for the patient as a means
to ensure care and protection because they anticipate the married
siblings reluctance to care for the patient when parents are gone.
The reality of poor community services also urges parents to seek
spousal care for patients. Unfortunately, due to the changing
social expectations of marriage, this fragile bond often cannot with-
stand the strain of the debilitating chronic illness, and divorce often
follows (Phillips, 1993). In any case, the changing social norms and
values in China sabotage the dependability of family support.
Another value dilemma these families face is whether to take care
of the ill member at high scal and emotional costs, or strive for an
increasingly valued economic success (Phillips, 1993). Nowadays in
China, economic buoyancy cannot be assumed, unlike during the
old communist regime. To care for patients, family members often
must make sacrices which may include structural or functional
modications in the household. For instance, parents will have to
412 International Social Work volume 48(4)

retire early or have the patients nuclear family or grandchild come

live with them. Since family members may subscribe differentially to
the importance of the whole family unit over their own individual
needs, conicts may arise.

Existing family interventions

Given the importance of and challenge faced by families in caring for
patients with schizophrenia in China, some service for these families
is much needed. A few studies on family interventions for such
patients in China were reported (Wang et al., 1993; Xiong et al.,
1994; Zhang et al., 1993, 1994). These treatments were adapted
from Western models with involvements from foreign experts,
with the following features. The treatment duration lasted between
12 and 18 months. All models consisted of psychoeducational
talks and multiple-family groups, and in some, individual family
counseling. Contents of the talks included the nature of the disorder,
medication management, early signs of relapse, behavioral manage-
ment of patients, and stress reduction for patients and families.
What is unique about these contents is the discussion on the nature
of talk therapy, social stigma, and patients marriage and family
plans. These topics need to be addressed with Chinese families,
since talk therapy is foreign to them, the implication of social
stigma strong and the desire for parents to see patients married
intense.
All the studies cited above indicated better results in experimental
compared with control groups: lowered patients rehospitalization
rates, lengthened duration between relapses, enhanced medication
compliance, and improved patient and family functioning. How-
ever, caregivers high tendency to drop out from treatment was a
big concern.

Suggestions for addressing clinical issues in family

interventions
Results of the initial clinical trials of family interventions indicated
that just making the service available is not enough to help these
families. Greater effort to engage them is needed to break down
formidable barriers to receiving external help. Given the brevity of
the literature in discussing clinical issues, ways to address them at
various stages of the illness will be discussed below, in addition to
engagement problems.
 Kung: Schizophrenia in China 413

The working alliance

Sociocentric Chinese culture prizes social connectedness over priv-
acy, but it is also an exclusive culture in that only families and
very close acquaintances are considered part of the inner circle of
trust, in which personal affairs will be conded. Chinese mental
health professionals, mainly psychiatrists and nurses (Phillips and
Pearson, 1994c), are considered strangers outside the circle with
whom contacts are kept minimal (Pearson, 1993). Moreover, due
to experiences during the Cultural Revolution, trust among people
was greatly damaged, making it even harder to establish rapport
with outsiders. Thus, effective means to reach out to these families
and keep them in treatment is crucial.
Bordins (1979) working alliance is useful in understanding the
clientclinician dynamic. He contends that treatment effectiveness
is a function of the bond between the client and the clinician, treat-
ment goals that are mutually agreed upon, and tasks and techniques
perceived by clients as relevant. The extent to which patients and
families see mental health professionals as allies in treatment affects
whether or not they stay in treatment.

Therapeutic bond Given the peripheral role families assign to

mental health professionals, much initiative has to be taken by the
latter to establish the bond. In two of the reported studies in China,
50 percent of the contacts were made through home visits (Xiong
et al., 1994; Zhang et al., 1994). Clinicians active role conveys to
families that they really care. Also important in gaining trust from
these families are the professionals demonstrated competence and
expertise (Chu and Sue, 1984). Chinese expect an instructional and
directive role from mental health professionals as authorities (Klein-
man, 1980; Pearson, 1993). Thus, concrete advice is important.

Treatment goals As Xiong et al. (1994: 240) stated, the ultimate goal
of these families is to develop a sustainable family-based support
system for the dysfunctional individual. To this end, parents often
seek stable employment, a spouse and offspring for their ill child.
While clinicians attempt to match families goals, they also need to
caution them about their possible consequences. For example,
marriage and child-rearing may not help to secure present and
future care for the patient, but may cause more stress to the patient
instead. A viable mutually acceptable treatment goal is to ensure that
414 International Social Work volume 48(4)

realistic expectations are formed before commitment to marriage

or child-bearing. Clinicians can offer to meet potential spouses to
explain patients conditions, and seek ways to reduce stress and opti-
mize patients functioning in their new roles.
Phillips and Xiong (1995) found that parents in China are over-
involved with their mentally ill children, usually out of guilt and
anxiety. Thus, an important treatment goal is to help parents accu-
rately appraise the patients ability, thereby reducing frustrations or
overindulgence, which reinforces patients dependence.

Relevant tasks Since many Chinese families at treatment expect

concrete help, a problem-solving rather than an affective, reective
and insight-oriented approach would be appropriate (Berg and
Ajakai, 1993). As these families also expect to see observable
improvement, advice on maintaining drug compliance for sustained
symptom reduction is important.
Since families expect practical assistance from clinicians, attend-
ing psychoeducational talks about mental disorders and acquiring
practical management skills are very relevant tasks. In addition,
multiple-family groups with people who undergo similar caregiving
challenges could also provide mutual support. However, multi-
family groups including the patients and family members may
deter resolution, since confrontations within the family in front of
outsiders are unacceptable in the culture (Kung, 2001). A high drop-
out rate in family studies in China validated this concern (Wang et
al., 1993; Xiong et al., 1994; Zhang et al., 1993, 1994). One possible
solution is to conduct groups for patients and their families
separately but simultaneously. Since families usually care about
the well-being of the patient, they are more willing to show up if
the patient is also receiving help. Individual family sessions are
also necessary in which clinicians can help families to integrate the
knowledge gained in the talks in their daily interaction with patients,
and counsel them on family conicts and emotional issues.
Work carries a lot of weight in the Chinese context since it is
highly valued (Phillips and Pearson, 1994c). One important task of
the clinicians is to help as liaison between patients, families and
work units through negotiating insurance coverage, reintegrating
into the workplace and exploring vocational training. When the
tasks mental health professionals perform are seen as relevant, the
working alliance grows.
 Kung: Schizophrenia in China 415

The psychosocial typology of illness as a working framework

Rollands (1994) psychosocial typology of chronic illness, based on a
family systems perspective, lends a useful framework to address
important clinical issues at different stages of the illness.

Onset of the illness Schizophrenia usually has a very acute onset

with the psychotic outbreak. Thus, the initial phase of the illness is
a crisis situation during which families need to quickly mobilize
practical and emotional crisis management skills. Clinicians can
help families mobilize resources, restructure their daily routines to
regain a sense of control, maintain exible roles within the family
and seek external help. At this point, coaching families to manage
patients medication and behaviors at home is of prime importance.
In addition to problem-focused coping, clinicians also need to
help families cope with their emotions. After the patients psychotic
outbreak, families would have to tolerate highly charged emotional
situations. They may also be searching for a meaning or cause of the
illness. It is important to help them formulate an empowering illness
narrative which is also realistic. The seminal stress and vulnerability
model postulated by Zubin and Spring (1977) is found helpful as it
sees physiological and psychological vulnerability as predisposing
factors leading to the illness, but also empowers the family to modu-
late stress factors in patients lives so as to reduce the chances of
relapse (Kung, 2001). Families must also grieve for the loss of the
person they once knew and grapple with the reality that the illness
is there to stay. This grief work has to be dealt with after the initial
crisis subsides.

Course of the illness and incapacitation The course of schizophrenia

often takes a relapse and remission cycle. Although patients usually
cannot be expected to function as well as before the illness, their level
of incapacitation is much less during remission than during relapse.
Families should shift gears to adapt to the varying demands at
different phases. Families pulling together resources during the
crisis are very adaptive, but they should be helped to avoid being
permanently frozen in a previously adaptive structure that has out-
lived its function. For example, intense attention and monitoring of
patients is necessary when they are actively psychotic, but would
become overprotection during remission. Families must be educated
about signs of relapse and be prepared to shift to a different mode of
operation.
416 International Social Work volume 48(4)

Family life cycle stages It is important to view the unfolding

chronic illness from the family life cycle perspective. This perspective
highlights the different developmental phases of the family in terms
of life structure building or maintaining and life structure changing
or transitional periods (Rolland, 1994). These phases may demand a
centripetal or centrifugal mode of relating among family members
(Combrinck-Graham, 1985). During the child-rearing stage, a
centripetal force pulls families together for support, but as children
grow up and become independent, families experience a centrifugal
force pulling outward. The acute or relapse stage of the illness is not
unlike the child-rearing stage pulling in family members and their
resources. It is important to note how the illness cycle interacts
with the family life cycle, so that the developmental needs of
family members will not be overlooked. For example, the relapse
phase may coincide with a siblings need to plan for his or her
career or marriage. It is important that families recognize such
developmental needs of their members and maintain exibility so
that these needs can be met without guilt or blame for being disloyal.
This attempt to balance family members needs will maximize the
long-term adaptation of patients and their relatives.

Contextual limitations of family interventions

Although one strives to improve family intervention models for
caregivers, their effects are limited by two main factors: the poverty
of mental health services and the lack of trained professionals. The
inadequacy of mental health services greatly curtails the effective-
ness of family interventions which are important only as a sup-
portive service to the caregivers. A comprehensive and systematic
psychiatric outpatient follow-up service is of paramount impor-
tance, together with rehabilitation services to patients such as shel-
tered workshops or day activity centers. Without these services,
the effect of family intervention is limited. The lack of mental
health personnel is another problem that springs from the stigmati-
zation of mental illness. Psychiatric service is not a popular specialty
among physicians and nurses, and psychiatric social workers are
non-existent in China (Pearson and Phillips, 1994). However, with
social work being an emerging profession in China, with over 100
social work programs offered by universities and institutions run
by the Ministry of Civil Affairs or the Federation of Women, the
picture is optimistic. The real challenge will be whether these current
and future social workers are ready to go beyond passively xing
 Kung: Schizophrenia in China 417

problems with meagerly allocated resources, or will venture into the

role of active advocates. They will have to bring the authorities
attention to the neglected needs of this clientele, and mobilize
resources to develop a more comprehensive mental health system
in China before the lives of patients with schizophrenia and their
families can really be beneted.

Acknowledgements
Part of this article was presented at the Conference on the Develop-
ment of Social Work in China in Beijing, June 2000. The author
would like to express her appreciation to Dr Kyu-Taik Sung for
his input to an earlier version of this manuscript.

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