Following a Family Legacy: A Personal Journey

Liyi just finished his shift at the local outpatient psychiatric clinic. The frozen snow on the ground must have reminded him of his time in Vladivostok, Russia, where, after finishing his psychiatry residency in China, he spent the better part of a year as a fellow studying the intricacies of the diagnosis and treatment of psychosis. As he trudged through the mixture of sleet and ice, he arrived at the gates of his home in Jinan. It was a Soviet-style block apartment, typical of the Brutalist architecture that was a living manifestation of the state’s total control over society. Liyi noticed the smell of burnt diesel fuel, and a green paramilitary police vehicle pulled up next to him. Three men in olive green uniforms forced him into the car and drove off. Like countless others lost to the void of the Chinese Cultural Revolution, he was never seen again. Liyi’s story, however, would undulate, like ripples created by a small pebble, eventually washing onto the shores of the United States.

Psychiatric illness has always had an uneasy relationship with social acceptance, especially in East Asia. Early attempts to understand psychiatric illness elucidated it as a manifestation of supernatural phenomena. Hallucinations were seen as evidence of clairvoyance, depression was the result of hexes, and mania was the consequence of spiritual possession by “jinns,” the accumulation of bad karma due to prior misdeeds. In East Asia, reflected shame—shame that is brought on one’s family and community and known as “loss of face’”—is especially relevant. The diagnosis of mental illness can damage one’s reputation among one’s family and community to a life-altering degree. In traditionally collectivist communities with heavy emphasis on family structure, individual identity often derives from group membership (1). If stigma harms the affected individual’s in-group status, then that person’s identity is adversely affected. In terms of practical considerations, many individuals do not seek help because of the traditional customs of arranged or introduced marriages, where mental illness can be a red flag in one’s eligibility for marriage. In addition, it can severely damage one’s prospects of attaining desirable employment (2). In a culture where work represents the opportunity to demonstrate moral cultivation by repaying kinship obligations, the likelihood of employment instability is especially devastating (3).

The stigma of mental illness in China reached its zenith during the Cultural Revolution, from 1966 to 1976, when Western influence was seen as an insidious force that fomented counterrevolutionary ideas and corrupted the population. The educated elite, including many physicians, were seen as the vanguard of Western liberalism and were publicly shamed as being foreign agents or enemies of the people. Psychiatrists were no exception. In the province of Canton, there were 64 psychiatrists before the Cultural Revolution; 53 of them died by suicide during the Cultural Revolution. Those who remained were subsequently tortured or sent away to far-flung provinces for “re-education through labor” (4). Even though Zheng Liyi may not have known it, his fate was sealed the moment he swore the Hippocratic Oath.

The Cultural Revolution left an indelible mark on the field of mental health. A national survey of mental illness has not been performed in China since 1993; however, the number of practicing psychiatrists can be instructive. In 2018, there were an estimated 30,500 licensed psychiatrists in China, or 2.2 psychiatrists per 100,000 people (5). This is in stark contrast to the Western nations, such as France and the United States, where the numbers of psychiatrists per 100,000 people are 20.9 and 10.5, respectively (6).

Estimations of the true number of mentally ill patients in China vary widely. Per the Chinese National Health and Family Planning Commission in 2014, only 4.3 million people were registered as having a diagnosed mental illness. In a nation of 1.38 billion people, it strains credulity that only 0.31% of the population has a psychiatric disorder. Another source has estimated that 173 million people in China have a mental illness (7). In 2005, a survey sponsored by a nongovernmental organization found that in a random sample of 63,000 people, 16% had a mood disorder, which is on par with the prevalence of mood disorders in Western nations (8). The need for psychiatric care is as urgent in China as elsewhere, but the means to provide adequate care is lacking. In fact, many people seek help outside the formal, government-funded mental health system, via folk healers who use herbal or animal-product remedies, breathing exercises, and acupuncture (8, 9).

There are stirrings of hope for better mental health care in China. After the devastation wrought by the policies of the 1960s and 1970s, some cities have taken promising steps to address the need for psychiatric treatment. Grassroots-level change has been spearheaded by mental health professionals to provide inpatient services, case management, and home visits and to create neighborhood committees to offer social support (10). Community volunteers are trained in patient outreach to introduce themselves to community members who have a history of mental illness, defusing potential conflicts without use of violence. This system facilitates the treatment of acute illness and comprehensive monitoring of patient progress, as well as rehabilitation and prevention of long-term hospitalizations. One such program, known as the 686 Project, has registered 1.83 million patients, with follow-up rates of 88.7% (11). The only concrete measure available concerns violent events, with a 73.6% reduction among patients in the program.

A decade passed before Zheng Liyi’s family learned of his fate. He passed away in a gulag on the western frontiers of China, leaving behind a widow and a daughter 11 years of age. The experience left an indelible imprint on the psyche of this young girl, who later emigrated from China to the United States in search of the peace and stability that was so elusive during her formative years.