Mental Health Lessons in Mandarin

China pursues mental health reform in wake of school stabbings

Children mourn for their 8 schoolmates killed in Fujan province in 2010 / AP

China continues to pursue reform of its mental health system in an effort to encourage the sick to receive help after a string of violent attacks on school children by the mentally ill.

A law passed six months ago bans mental health examinations against a patient’s will, except in cases where the patient is deemed to be an immediate threat or has already caused violence. It also protects patient privacy and describes standards for mental health care in facilities.

China has long stigmatized the mentally ill and there were few protections in place for those who needed treatment, leading many with problems to avoid healing altogether.

The reforms come in the wake of a series of violent incidents at Chinese schools in which mentally ill offenders stabbed students.

A doctor in the Fujian province in 2010 slashed to death eight children at a primary school and was quickly executed. Also in that year, a man in northwest China with a cleaver killed seven children and two adults at a kindergarten. A 47-year-old man with a knife wounded 28 students at a Jiangsu Province kindergarten.

Xinhua News Agency reported in 2011 that a local farmer with suspected mental illness killed a young girl and three adults on their way to a nursery school with an axe. On the same day as the mass killings in Newtown, Conn. in December, a 36-year-old man in Henan Province stabbed an elderly neighbor and then slashed 22 children at a primary school.

A man in Shanghai province in March of this year stabbed to death his mother-in-law and sister before injuring six children and five adults at a Shanghai elementary school.

Prior to October 2012, China did not address mental health care at the national level. The country’s "mental health care system" involved taking down the names of all mentally ill patients, as submitted by psychiatrists, and either closely monitor them or simply commit patients to a facility for an indefinite period of time without judicial process or proof of illness.

The violent attacks on school children in China and America highlight the need for mental health reform in both countries, said Dr. Michael Phillips, executive director of the World Health Organization’s Collaborating Center for Research and Training in Suicide Prevention in Shanghai.

"The real debate across cultures is finding the right balance between care and control," said Phillips, also a professor of psychiatry at Emory University.

Although the new law helps address some concerns that China uses "mental illness" as an excuse to jail political dissidents, Huang Xuetao, president of the Equity and Justice Initiative, said it does not go far enough to prevent subsequent attacks.

"The mental health law still puts everyone’s liberty and safety at risks, especially since close relatives of the patient can make all medical decisions for him or her," said Huang, who is also a Shenzhen-based mental health lawyer.

While the U.S. mental health system has focused on protecting patients’ rights, China’s has focused on closely monitoring and containing patients, often against their will, said Huang.

"It has been nearly four years after the government decided to control every mental patient in 2009," said Huang. "During these four years, school children attacks have happened several times."

Phillips said the new law will take at least ten years to implement, and that it is a delicate balancing act between individual rights and community safety. He compared the Chinese law to American reforms.

The Community Mental Health Centers Act of 1963 in America allowed only patients who posed an imminent danger to be committed to a psychiatric hospital against their will. As a result, many mentally ill patients go without treatment or monitoring.

"America has, perhaps, swung the pendulum in favor of allowing very sick individuals to refuse any type of treatment," Phillips said.

A Substance Abuse and Mental Health Services Administration report found 40 percent of Americans with serious mental illnesses are not receiving treatment. China also has extremely low rates of care for mental health patients.

Phillips noted a study he performed found only eight percent of people in China with diagnosable mental illness received any treatment.

Prior to the mental health law’s passage, decisions for treatment were primarily up to the state or to psychiatrists, which Huang said left the door open for abuse.

"The involuntary commitment system was at very high risks of being abused to violate persons’ rights," she said.

Additionally, China’s developing judicial system cannot yet address patients who have been systematically abused, Huang said.

"Involuntary diagnosis, hospitalization and treatment of psychiatry, can be used as a tool to end a dispute, since persons tagged with mental illness do not have the right to appeal, to defend themselves, or even to be heard."

Dr. Craig Van Dyke, director of Global Mental Health Program at University of California, San Francisco supports the Chinese reforms.

"I think China needs to be given credit for beginning to recognized that they have a problem and I think that they are making a good conscious effort to address it," Van Dyke said.

For both China and the United States, Phillips said finding greater balance between care and control within the mental health system is the immediate priority.

"Finding the middle ground, given the ever-changing values in a community is the task that both China and the USA must now address head on rather than avoiding."