Psychotherapy in China

The demand for psychotherapy in China is booming among its nearly 1.4 billion citizens. But psychologists are largely unable to help meet the demand for a simple reason: In 2013, a new law went into effect that, among other provisions, restricts the ability of psychologists in mainland China to offer psychotherapy. Unless they are working in hospitals with clients who have already been diagnosed by psychiatrists, psychologists must call themselves counselors and limit themselves to offering counseling and psychosocial support.
“Psychotherapy can’t be … practiced in settings other than hospitals,” says Buxin Han, PhD, president-elect of the Chinese Psychological Society (CPS).
The country’s Mental Health Law—available in an annotated English translation (Chen, Shanghai Archives of Psychiatry, Vol. 24, No. 6, 2012)—doesn’t define what services are considered psychotherapy or what training one needs to provide it. But the law does spell out penalties for situations in which “psychological counselors,” also undefined, provide psychotherapy or diagnose or treat individuals with mental disorders.
The law has its roots in earlier efforts to meet growing psychological needs, according to Han and other leaders of clinical psychology in China.
A complex history
Western-style psychology was introduced to China in the early years of the 20th century. With the creation of the People’s Republic in 1949, the field shifted its focus to industrial, educational and developmental psychology, with psychologists searching for ways to prevent worker burnout, among other priorities. Then it came to an abrupt halt in 1966, when the Cultural Revolution declared psychology a pseudoscience and outlawed its practice.
When the Cultural Revolution ended a decade later, psychological research and education began to develop rapidly. And clinical and counseling psychology became increasingly important in the wake of growing demands for psychological help, says Han, a professor at the Institute of Psychology of the Chinese Academy of Sciences in Beijing.
“Globalization, urbanization and economic development have all increased stress, either in life or work,” he says. Psychologists’ help after the massive Wenchuan earthquake of 2008, which left more than 87,000 people dead or missing, attracted even more attention to the field among both the public and the Chinese government. And psychologists themselves realized they could help with both individual and societal development, says Han.
To meet a growing demand for services, in 2002 the Ministry of Labor Forces began certifying psychological counselors, who typically received a few months of training from commercial agencies, then passed a certification exam—all without any clinical experience. But while the certification program helped promote psychology to the broader society, it also meant an increase in substandard professional practice, “often outright quackery and irrevocable damage to the psychologically vulnerable,” says Chee-wing Wong, an associate professor of clinical psychology at the Chinese University of Hong Kong. Around the same time, says Wong, the Ministry of Health introduced a certification program of its own focused on “psychotherapists”—streamed into basic and advanced levels—as a more stringent and nationally recognized qualification to provide psychological treatment.
In addition to provisions designed to improve access to mental health care and prevent human rights abuses related to involuntary commitment, the Mental Health Law that went into effect in 2013 is designed to protect the public from unqualified practitioners like the psychological counselors by restricting the diagnosis and treatment of depression and other mental disorders to psychiatrists or other clinicians working in medical facilities. The government stopped issuing new psychological counselor certificates in 2018, although the estimated 1.2 million people who already have certificates—the vast majority of whom do not practice—can still offer services. And while the Ministry of Health’s certification program is still ongoing, these practitioners are also limited to providing psychotherapy in hospital settings.
By restricting psychotherapy to medical institutions and thus primarily to psychiatrists, the Mental Health Law is making it difficult to address China’s psychological needs, says Han. “There are even fewer psychiatrists than clinical psychologists, but mental health needs keep increasing,” he says. According to a 2017 World Health Organization report, there are 23,000 psychiatrists in China, or just 1.7 per 100,000 people, compared with 12 per 100,000 people in the United States.
To comply with the Mental Health Law, even university-trained psychologists have had to change the name of what they do from “psychotherapy” to “counseling” or some variation. In some cases, they’ve had to shift the services they offer. At the nation’s first university counseling center, for example, there has been a change from calling services “therapy” to referring to them as “support,” says Wensheng Yang, PhD, who directs counseling and psychological services at Shanghai Jiao Tong University. Instead of providing services for those who have psychiatric diagnoses, such as depression or anxiety, the focus is on helping people who have relationship conflicts or worries about exams.
If Yang and his team encounter students with depression or other serious problems, they can’t provide therapy but must instead refer them to a hospital—even when that’s not the student’s preference. Many Chinese, Yang points out, fear psychiatric medication and refuse to take it. “Some students just want to talk,” he says. “It’s hard for us.”
Professionalizing the field
Now CPS is pressing for a new law that would make it possible for psychologists to offer psychotherapy outside of hospitals and independent of psychiatrists’ supervision, says Han. The first step in ensuring that clinical and counseling psychology have a strong future in mainland China is to distinguish better-trained practitioners from those with little preparation.
“We’re going to recruit professional candidates from those 1 million people,” says Han, noting the many training programs CPS has offered. “Of course, we’ll have much higher criteria.”
One of the programs is with a nonprofit research, training and social service organization called the Hubei Oriental Insight Mental Health Institute, which is helping to build the academic pipeline by offering more rigorous training, including to individuals holding the old psychological counselor certificates. “They’re trained according to academic standards even if they’re not at a university,” says Guangrong Jiang, PhD, Oriental Insight’s founder and a professor of psychology at Central China Normal University in Wuhan. The institute has also offered training for supervisors co-organized by APA’s Div. 29 (Society for the Advancement of Psychotherapy).
Universities are also building up their clinical and counseling programs. Responding to concerns about the dearth of graduate programs providing clinical training—since most programs focus primarily on research—teachers from departments of psychology in various Chinese universities came together in 2016 at a meeting hosted by the Chinese National Applied Psychology Graduate Education Steering Committee. The resulting consensus document, known as the Wuhan Declaration, calls for strengthening graduate education in clinical and counseling psychology, including internship and practicum experience. It recommends recognizing clinical and counseling psychology as a specialty area distinct from applied psychology. Other recommendations include defining training goals and strengthening the training of faculty (Psychotherapy Bulletin, Vol. 51, No. 4, 2016).
The emphasis is on master’s-level training, says Jiang, who participated in the meeting. As a result of the meeting, participants have created a training alliance of more than 60 colleges and universities that will help schools launch training programs, he says.
CPS has also created a system to help ensure that clinical and counseling psychologists meet standards of quality related to their educational preparation. Established in 2007, this formal registration system lays out criteria for practitioners at three levels: assistant psychologists, psychologists and supervisors. Members must re-register every three years. The registry also includes criteria for training institutions.
Ethics training is especially important, adds Mingyi Qian, PhD, vice chair of CPS’s division of clinical and counseling psychology and a professor in Peking University’s School of Psychological and Cognitive Sciences. Avoiding multiple relationships can be especially challenging for Chinese psychologists given the culture’s collectivist nature and emphasis on relationships, says Qian.
CPS is helping to ensure that ethical practice becomes the norm. In 2007, the society introduced the first-ever code of ethics for clinical and counseling practice, drawing on APA’s Ethics Code as well as those of other national psychological associations. The society revised the code in 2018 and now requires ongoing ethics training as part of its registration system, with 16 hours required for assistant psychologists, 16 hours for professionals and 24 hours for supervisors, with proof of ongoing training required for recertification.
For Jie Zhong, PhD, an associate professor in Peking University’s School of Psychological and Cognitive Sciences, these attempts at professionalization are welcome news. “The Chinese people want to get more mental health services and more professional mental health services,” he says. “We have to develop a new profession.”
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