The Challenge of Cross-Cultural Training in China

Angela Joyce introduced the panel and observed the great challenges inherent in adapting and transplanting descriptions of theory, method, and practice from Western culture to another setting.

Viviane Green introduced her paper “The Challenge of Cross-Cultural Teaching” by noting the huge socio-economic changes in China over the last 30 years.  As a country with an ethnically uniform (91% Han) population of 1.37 billion, there are only 20,000 psychiatrists.  She reports a sense of dislocation, anxiety and anomie.  These difficulties flourish in a population with large scale internal migration, the breakdown of the traditional family structures, an increase in individuality, and the prevalence of only children as a result of the one child policy from 1976-2016.

There are aspects of Chinese culture that may appear to be unsuitable for the development of psychotherapy.  For instance, people may not be use to talking of their problems in such a family-oriented culture, especially when shame is so prevalent, and boundaries between self and other seem less structured than in the West.  Moreover, the place in society of a professional offering certain defined services was not established in Chinese society, and not well understood. Nonetheless, there is a great need for psychological programs.  The Sino-British program grew from 60-80 students to 200, by the third cohort.

The Sino-British program is a 3-year training, centered on teaching how to work in the transference/countertransference, to develop competencies in working with children and adolescents.  It involves 2 annual 5-day training sessions, as well as the option of weekly mother-infant seminars over the internet with experienced child psychotherapists/analysts. There are also weekly clinical groups. The training is recognized by the IPA Chinese Committee and several significant Chinese mental health associations.  Training is conducted in English, with translators, which is challenging but workable.  The difficulty is trusting the accuracy of what the translator is conveying and how the students are replying.

Generally, a major driver of parents seeking help with their youngsters concerns educational difficulties.  Educational success is highly prized, with enormous pressure on the child.  Therapeutic outcomes tend to be judged by educational result.  

A second feature is a mercantile attitude toward the treatment.  Observed families want to be paid for their efforts.  The value of having a family observed and interacting with therapists had to be explained and experienced. Consent often had to be obtained from multiple generations within a family. Also, certain issues of access to the therapist were expected if money was involved. The notion of a professional offering defined services had to be conveyed. 

The teaching of psychotherapy is often done via online seminars, with participants in different cities and unknown to each other.  Green insists on seeing the full face of each participant, stressing confidentiality, and discouraging participation while traveling.  Establishing boundaries with the prevalent use of social media becomes important.  Another challenge is that many therapies are conducted online and the therapist never or rarely sees the client.  This may skew receptivity to unconscious material, and transference/countertransference.

A common problem in learning is the culturally determined deferential attitude of the Chinese students.  Deferential rule following had to be questioned, a “chalk and talk” expectation had to be countered, and curiosity had to be modeled.  It took time and effort to establish a process of the group thinking and talking together.  In group supervision the teacher would often feel pressure to give advice and guidance.  This was best understood as parallel process, allowing access to what the therapist feels.  It was helpful to demonstrate this to the students to teach and to avoid disappointment.  While many of the students have an intellectual understanding of transference and countertransference, a frequent difficulty arises in teaching how to metabolize countertransference feelings as an understanding reflecting the therapeutic communication.  This was more difficult and required careful attention.

A challenge is adapting the developmental model applicable in the West to fit Chinese culture.  The Western model posits a pathway toward separation and individuation from family of origin.  In the Chinese context, self-experience may need to encompass a “we go”, i.e. a self inextricably bound to the family.  Most families are 3 generational, and the family structure is often seen as an inverted triangle with the child at the bottom, with many adults watching over.  At best, this provides a rich environment with many attachment experiences; more often in our population the child grows up lonely in a pressurized environment. A challenge for the Chinese student involves who to identify with.  It appears it is often easier for the students to identify with the parents rather than the child.

Difficulties emerge when child abuse is an issue.  It is uncertain who can be called upon in China to investigate.  It often seems difficult for the student to maintain empathy for the child, rather than focusing on confronting the parents.  Another problem is the cultural perception of abuse.    What is culturally acceptable discipline?  How do we help students who may have been abused themselves recognize this abuse and the shame of acknowledging it, in order to recognize the abuse of their patients?

Green concluded with the observation that areas of Chinese culture are hard to perceive in their “difference.”  Often these differences are discovered as a surprise, as when in teaching Freud’s notion of the flow of psychic energy, a student easily related this to Chinese notions of “chi”, the idea of energy in Chinese medicine.  The teacher must operate accepting her blind spots, and recognize that just as students are encountering something new, so is she. 

Wang presented a paper on “The Process of Individualization and ‘We-Relation-Based Egocentrism’ in Transformation Period in China.”  She noted the incongruity of trying to apply psychoanalysis to a fundamentally family-centered unconscious “differential mode of association” (DMA) and the prevalence of Guanxi.

Guanxi is considered a specifically Chinese pattern of social networks, using personal relationships to get through life and work.  It combines a Chinese individualism with embedded relationships.  The DMA (differential mode of association), conceptualized as concentric circles with the innermost ego, then familial ties, familiar ties, and weak ties as the outermost band.  The boundaries between circles are ambiguous.

There is a growing individualization in China, understood as a detradionalization.”  This involves a shift, very incomplete, from traditional Confucian values of self restraint to more Western values of personal interest.  As a result, a growing proportion of the population is developing a bicultural self.  For instance, traditional collectivistic Chinese culture views psychological difficulties as challenges in daily life and relationships, while the Western model sees psychiatric illness.  Urban and educated Chinese will now see illness.  Detraditionalization involves the increasing separation of the individual from social ties and constraints such as blood ties, geographic ties, etc., so individuals become more isolated and atomized.  Individuals may become more detached from traditional social constraints. 

Another feature of individualization, Wang asserts, is that social structures compel people to become proactive and self-determining, developing a reflective self. Wang believes individualism leads Chinese youth to be lonely and self-centered, cynical and immune to spiritual inspirations, with little idealism.  In the public sphere Chinese youth tend to be rational pragmatists, skillfully moving toward goals and handling interpersonal relations, with a distaste for idealism.

Wang cites Fei Xiatong’s view that Individualism/collectivism may not define the West/East as much as the notion of distinct patterns of group formation, with DMA more characteristic of China.  The “ego” or “I” in “we-relation-based egocentrism is always related to family, clan, relatives, friends, etc.  The ego only exists within this social web.  This is what distinguishes the DMA “group mode of association” from Western “individualism.”  DMA may be regarded as an implicit organizing feature of Chinese thought, and is expressed as Guanxi.  “We-relation-based egocentrism” may represent a paradigm shift from egocentrism to individualization through transformative intimacy.

Wang concludes with a consideration of the idea of “reciprocal anthropology” developed by Alain Le Pichon.  When there is a cross-cultural “cross-subjectivity,” a new culture is created.  Reciprocal anthropology involves both cultures observing and being observed, all the while examining what lies below the surface patterns of each.  It is a true transcultural dialogue, and involves a suspension of judgment.  It is the start of true conversations between Chinese and Western scholars.  

There were a number of questions and comments from the floor.  One woman who teaches in China, Britain, and Sri Lanka said she was struck by the similarities in the psychological relatedness between children and parents in these countries.  Another comment from a woman from Singapore noted a lag between cultural change and economic change, and downplayed the growth of “individualism” in China.  She wondered whether Western concepts rooted in individualism really could be applied to China. Another person teaching in China remarked how all her stereotypes turn out wrong, and suggested Westerners teaching and treating Chinese should be prepared for surprise and open to learning new perspectives.

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