This article is a report of the Psychiatrists Branch of the China Medical Association, and Bin Xie and Hong Ma are the authors of the report.
The Mental Health Law, which nearly 20,000 psychiatrists and 40,000 psychiatric nurses in China, and millions of patients with mental disorders and their relatives have been waiting for, has finally been made available for public consultation. As soon as it was revealed, its legislative purpose of “safeguarding the rights and interests of patients with mental disorders and promoting the development of mental health” was drowned out by the cries of “preventing citizens from ‘being mentally ill'”. The law was drowned out by the hue and cry of “preventing citizens from ‘being mentally ill'”. The fetus was not yet born, but was already locked by the strong and overwhelming “public opinion”. She came into the world with the important task of caring for one of the most distressed and vulnerable groups. Yang Zhong, Clinical Psychology Department, Changshu Mental Health Center
Unlike hundreds of laws with the same name around the world to date, China’s mental health law is destined to be introduced in a most peculiar way. Whether this peculiarity comes from misunderstanding, misinterpretation, incomprehension, or half-understanding, as a professional, we are obliged to explain to the public some questions that are of concern or full of doubts.
I. Mental disorders: medical reasons or moral character reasons?
The process of human understanding mental disorders is the most tortuous among all diseases. From “offending the gods” in ancient times, to “demonic possession” in the Middle Ages, from “offending God” in the Middle Ages, to “neural network malfunction” in the 17th century, and the 19th century. neural network failure” in the Middle Ages, and “moral degeneration” in the early nineteenth century, until the end of the nineteenth century, when it was largely recognized as a modern medical concept of disease.
But even in the twentieth century, mankind still had the darkest page for people with mental disorders: Nazi Germany had killed a large number of people with mental disorders considered “degenerate” in the name of “racial optimization”, and more than 200,000 patients were forced to undergo More than 200,000 patients were forcibly sterilized.
Society’s history of compassion, acceptance, and treatment of people with mental disorders is far shorter than its history of expulsion, imprisonment, and persecution. However, in the last 30 years, psychiatry has become the most rapidly developing discipline in the medical field, with functional imaging, neurobiochemistry, neuropsychology, molecular genetics, psychopharmacology, and other research tools shining brightly.
Therefore, what is scary is not to suffer from this kind of disease, but the fear, rejection and denial of it inside.
Second, the diagnosis of mental disorders: is it a health deficit or a stigma?
Many mental disorders are chronic, with a long and prolonged course and serious impairment of life and labor ability, and some patients even become disabled for life. A few patients also exhibit a tendency to engage in risky behaviors against themselves or others as a result of their symptoms.
The social burden caused by mental disorders is also very heavy. In 2002, according to the World Health Organization, mental diseases ranked first in China’s disease burden, accounting for about 16.07% of the total disease burden, and the loss of labor force for 10 mental diseases in China amounted to RMB 302.5 billion, accounting for 2.51% of China’s total GDP in that year. According to World Bank estimates, the burden of mental illness in China will rise to one-fourth of the total national disease burden by 2020.
Based on this, too much prejudice and discrimination has been attached to the diagnosis of mental disorders by society at large for thousands of years, and it has not been completely eliminated until today. Once the diagnosis of some patients is established, their rights to study, work, and even marriage and family life may be violated and deprived. In fact, today’s science has developed to the point that most mental disorders can be cured or at least live with the disease and create the same value in life as normal people, as long as they can be identified early and treated in time. For example, John Nash, winner of the 1994 Nobel Prize in Economics, was a severe schizophrenic. Nash, for example, was a person with severe schizophrenia.
So a diagnosis of some mental disorder, like a diagnosis of some somatic tumor, means only a life wound, a loss of health, not a personal or family stigma. Rather, it is the labeling of these diagnoses with a stigma that is a social stigma.
Third, involuntary medical treatment of mental disorders: is it kind relief or malicious punishment?
Some mental disorders affect patients’ mental activities so severely that patients lose the ability to make proper cognitive and objective judgments about their pathological thinking, emotions, perceptions, and volitional behavior. Without timely and effective therapeutic interventions for this pathological condition, the disease may continue to worsen in some patients. The worsening of symptoms does not only manifest itself in the form of injury to oneself or damage to others. We have seen too many such patients who are unable to take care of their personal lives, who are poorly clothed, and whose will is faulty in areas where medical care is lacking or not available.
The involuntary medical care system was intended to be a way for society to exercise its “national paternal authority” over the sick and disabled, and to “limit the patient in order to help preserve his or her own (health) interests. But again, because the system’s predecessor was a means of forcible internment for social control in Europe and the United States in the sixteenth century and in Nazi Germany in the 1930s, Western society has always been concerned about it, and calls for its abandonment have never ceased. Since the 1960s, the United States has narrowed the criteria for involuntary medical treatment to “danger to self or others that has occurred or is about to occur,” and has set up a fully judicial process for implementation. Yet years later, surveys showed that less than 40 percent of the country’s severely mentally ill received stable treatment, and more than a quarter of the homeless were severely mentally ill, most of whom had never been able to receive any treatment. At the same time, the public perception of people with mental illness as “dangerous” increased from 4.2% in 1950 to 44% in 1996, precisely because of the “widespread adoption of risk criteria (for psychiatric hospitalization) in the United States. “.
In fact, patients who were involuntarily hospitalized and treated mostly agreed with the initial treatment measures after their condition had resolved or their symptoms had disappeared. A survey of patients involuntarily hospitalized for 15 consecutive months in Ireland found that 72% of patients felt that involuntary hospitalization was necessary for them at discharge, and 77.8% felt that treatment was beneficial; only 27.5% felt that such measures had a negative impact on their relationship with their families, and 26.6% felt that they had a negative impact on the doctor-patient relationship. The researchers also found that the better the improvement in symptoms, the more satisfied the patients felt with the involuntary measures in the first place.
Thus, the pros and cons of involuntary medical treatment do not lie in the system itself, or even to some extent in the evaluation of patients and their relatives, but care entirely about the attitude of society.
Mental health institutions: a place for saving lives or a place of detention and persecution?
The question that can reasonably be derived from this is whether psychiatric medical personnel are white angels or cold-blooded jailers.
The questioning of the character of psychiatric hospitals and the identity of psychiatric medical personnel has been profoundly described in the writings of Foucault, Szasz, and others, as well as in numerous Hollywood productions. The doubts also stem from the tortuous history of mental health services. After the birth of the first institutions for the mentally ill in the sixteenth century, such institutions were so effective in preventing criminal mischief by confining the mentally ill and jobless vagrants that they began to be built on a large scale in European countries from the seventeenth century onward. People with mental disorders were not considered as patients in these institutions, did not receive proper treatment and care, and were not even considered as human beings. It was not until the middle of the nineteenth century that the character of the mental hospital (or asylum) as a “hospital” was gradually established, and it was only after the 1950s that patients really enjoyed the results of modern medical technology in them. This is why the movement to “deinstitutionalize” or close mental hospitals, which has been prevalent in the West for many years, has had a wide social response.
The first psychiatric hospital in China was established in 1898 in Guangzhou by the missionary Kerr. It had a modern Western “hospital” identity from its birth. As a result, Chinese mental health institutions and their staff have never felt the heavy historical burden that their European and American counterparts have carried. Chinese society’s understanding of psychiatric treatment has long been based on a purely doctor-patient relationship.
Chinese psychiatrists were the backbone of the push for patient rights protection and mental health legislation: 26 years ago, Professor Liu Xiehe and other psychiatrists drew up the first draft of the Mental Health Law in mainland China in pencil; 16 years ago, Professor Zhang Mingyuan and other psychiatrists submitted the first proposal for local legislation on mental health in China. During the discussion of local legislation in Shanghai, a member of the National People’s Congress once said emotionally: This is the first time I have seen a draft regulation completely free of departmental interests so far in my deliberations on legislation.
Therefore, mental health institutions themselves are not shady, what is shady is the shady history.
V. Families of people with mental disorders: are they honorable or reprehensible people?
The history of social services on a large scale in the West has flourished since the Industrial Revolution. Since then, the responsibility of caring for the mentally ill has gradually shifted from the family to society. Since the 1960s, most European and American countries have shifted the focus of mental health services to a “community-based” approach. Even when patients are on the streets, their care is the responsibility of society rather than the obligation of the family. In the United States, for example, the number of mental health professional social workers exceeded 110,000 in 2004. In China, there are currently less than 100 social workers specializing in mental health.
For thousands of years, relatives of Chinese patients with mental disorders have taken on the heavy burden of caring for them without complaint. Surveys show that patients under the age of 40 are mainly cared for by their parents, while those over 40 are mainly cared for by their spouses, adult children or siblings; 40.3% – 59.5% of patients are escorted to hospitals by their families or guardians. The burden of care is not only financial and physical, but also psychological. A survey of spouses of mentally ill patients showed that they were far below their peers in many aspects of quality of life. Factors that have a greater impact on their quality of life (in their words) are mainly: fear of poor treatment, fear of relapse, fear of endangering society, fear of passing on to their children, and fear of being looked down upon.
Therefore, it is to the credit of the relatives of people with severe mental illness that Chinese society does not have a large number of mentally ill people living on the streets or people who cause accidents one after another. Any accusations against their so-called “motives” are pale in comparison.
VI. Besides the fear of “being mentally ill”, what else is there to see in the law?
People who have never been in a mental hospital can imagine the horror and terror of a mental hospital, but they will never have the opportunity to experience the poverty and social discrimination that patients and their families experience because of this type of illness that science is not yet able to completely solve.
As of April 2011, the free treatment program for serious mental illnesses supported by the central government since 2004 has covered 680 districts and counties nationwide, with 277,000 cases of serious mental illnesses voluntarily enrolled in treatment, of which 94,000 cases of poor patients who have committed crimes and have received free drug treatment, and 12,400 patients have received free hospitalization. The national financial investment of 220 million yuan has brought ten million families back to heavenly bliss. Among these patients, 125,000 belong to the poor population, with a poverty rate of 59.9%. According to our current poverty line (1196 yuan/person/year), the average poverty rate of our population is 3%, and the poverty rate of the mentally ill is 20 times higher than the poverty rate of the general population!
After the Wenchuan earthquake, the United Nations Development Program (UNDP) conducted a study on the vulnerable groups that are most difficult to recover and rebuild after the disaster, which showed that in the national poor villages, provincial poor villages and ordinary villages, those who are least able to recover and rebuild after the disaster are families with patients, and 55% of these families have patients with mental illness! They are excluded from social life because of poverty, and the most humane wedding and funeral in rural China do not include these families, and they are the ones most in need of legal protection of their right to treatment.
Therefore, the biggest point of the mental health law should be the protection of vulnerable groups. If this law is “mental illness”, our compatriots who are poor because of illness will be in tears, because they sincerely hope to get treatment through legal protection, so that they can stand on their own feet and no longer receive assistance from the state.
The debate over the Mental Health Act will inevitably continue. But in any case, instead of focusing on how to “prevent normal people from being mentally ill,” we call for a law with a broad mind and vision in China. She should do her best to defend the right of citizens to mental health – because without mental health, we cannot talk about health; she should effectively guarantee the right of every person with mental disorders to have access to quality and efficient mental health services – to stop facing inner fears and discrimination around them; she should protect the right of every person with mental disorders to have access to mental health services. She should protect the development of mental health care in China as a “building” for the maintenance of mental health – because under a dilapidated building, there is no freedom and health rights for individuals. She should promote social security and social services for people with mental disorders, so that the relatives of patients will not shed blood and tears – otherwise, as China’s family structure changes and an aging society approaches, how will the future of patients rest as their loved ones grow old? ▪
(Xie Bin is deputy director of the Mental Health Center of the Chinese Center for Disease Control and Prevention and chief physician of the Mental Health Center affiliated with Shanghai Jiaotong University School of Medicine; Ma Hong is executive deputy director of the Mental Health Center of the Chinese Center for Disease Control and Prevention and chief physician of the psychiatric department of the Sixth Hospital of Peking University)