- According to the World Health Organization, the COVID-19 pandemic contributed to a 25 percent increase in the prevalence of anxiety and depression worldwide as of March 2022. Lockdowns, mass deaths, social isolation, disruptions to schooling and the transition to online work, uncertain economic futures, the politics of pandemic prevention policies, the intersection of inequality, and poor outcomes for the disease are all features of the pandemic that have affected individuals’ mental health.
- Many Chinese, especially young urbanites, are turning to psychological counseling. They do so as a way of making sense of their lives and as a form of healing.
- The use of psychological counseling has changed significantly over the past two decades, and it is now a significant social development in urban centers in China. The uptake in psychological counseling is a marked change from the way that individuals sought to understand themselves and resolve trauma in the past.
- The Communist Party is interested in using psychotherapy techniques in its personnel management systems and as a way of caring for and controlling specific groups. Institutions such as the police, the army, and schools are being encouraged to adopt psychotherapy practices.
Access to mental health care in China has expanded but still has a long way to go. Only 20 people per million in China have access to mental health services, compared to 1,000 in the United States. Eighty percent of general hospitals in China do not have a psychiatric department.
The COVID-19 pandemic has compounded these woes. Protecting the population against the virus, rather than living with it, has undoubtedly saved lives — China claims to have the lowest death rate from COVID-19 globally. But the ongoing grind of testing and lockdowns has had significant effects on people’s mental health. According to a recent editorial in the Lancet medical journal, “China’s lockdowns have had a huge human cost . . . with the shadow of mental-ill health adversely affecting China’s culture and economy for years to come.” One survey found that when Shanghai locked down in April 2022, nearly half the population was at risk of depression. That same month, searches in the city for “psychological counseling” on Baidu, China’s most-used search engine, rose 253 percent.
It was not inevitable that people in China would seek psychological counseling to cope with the current crisis. Rather, this trend is the result of two decades of significant development within the field of mental health care in China and the massive expansion of psychological counseling as a profession. It also represents a significant shift in the understanding of the importance of mental health, and that emotional well-being is something that can be worked on and improved.
According to a 2022 publication from China’s Mental Health Survey, 6.8 percent of the population suffers from depressive disorders, with clinical depression accounting for half that caseload. This means that 95 million people currently suffer from depression in China. The survey shows that around 280,000 people commit suicide each year — 40 percent of whom suffer from depression. The survey also notes extremely high levels of depression among adolescents: about 50 percent of people with depression are schoolchildren, and 30 percent of all depressed people in China are under age 18. As the previous paper in this series noted, schoolchildren face intense pressure to excel on their exams. As economic growth stalls, success on exams is no longer a guarantee of good prospects — precipitating an existential crisis among this generation.
Psychological Counseling in China: A Brief History
The spark in interest in psychological counseling in contemporary China represents a significant break from the Mao era, when psychology was deemed a bourgeois pseudoscience and people who suffered from depression were judged to lack revolutionary zeal. Even in the immediate aftermath of the Mao era, China was said to have a rate of depression 35 times lower than the United States, according to national epidemiological surveys.1 This statistic was inaccurate, but it showed that the government and medical establishment were either ill-equipped or unwilling to seek out a more realistic number. In 1993, the World Health Organization’s Global Burden of Disease report (part of the World Bank’s World Development Report) reframed the impact of disease to emphasize the relative burden of disease morbidity rather than simple mortality.
As a result, mental illness suddenly became the world’s most burdensome disease. In the wake of that report, China grudgingly began to consider a shake-up of its mental health care system. In 1999, it hosted the World Health Organization for a joint conference to raise awareness of the importance of mental health care within the country. The event marked a sea change in attitudes toward mental illness in China, prompting leaders to designate it as a serious public health concern and to commit to reforming the mental health care system.2
In 2001, the Chinese government launched a vocational qualification for psychological counseling, administered by the Ministry of Labor and Social Security (MoLSS).3 It was a sign of the times, roughly two decades after the launch of economic reforms, that the government had decided that psychological counseling constituted a profession, and as such, it should be administered as a labor issue rather than as a matter of public health. As medical anthropologist Huang Hsuan-Ying has noted, in the same year that psychological counseling became a recognized profession, so, too, did mushroom gardening and tea sampling.4 This was a holdover from the socialist era, as the government still sought to manage and control the proliferation of vocations created by the increasingly dynamic market. It would prove to be a losing battle.
The vocational qualification for psychological counseling was conceived as a way to increase public consciousness of mental health and to unburden the medical system and public security apparatus, which to that point had been the only institutional mechanisms available to address mental health problems, and only then when they became critical. The mass of “worried well” or people with suboptimal health status or “psychological subhealth” (心理亚健康) had few avenues for seeking help. The qualifying exam was held biannually and could be completed with a few months of practice and a week of practical training. However, many felt that the qualification was little more than window dressing. As one Douban commentator put it, the qualification created a “speedy assembly line” of reckless cowboys. From 2002, when the test was first administered, to 2017, when it was discontinued, it is estimated that a million people qualified.
But they did not all go on to practice. Only around 15 percent of people who qualified for the MoLSS accreditation went on to become full-time psychological counselors. The majority either provided counseling in their spare time or became psychology “hobbyists” (心理爱好者), primarily focused on using their training to better themselves and key relationships in their lives (for example, with family members or coworkers).
Beyond the vocational qualification, the field of psychological counseling was further boosted by a popular TV show, Psychological Sessions (心理访谈), which was launched by state broadcaster CCTV in 2005. The hit show gave viewers a peek into real therapy sessions, exposing the audience to the inner world of the participants and demonstrating how therapy could help people make sense of their lives. It also helped create a sense that trauma and mental strife could afflict anybody. The show’s producers were conscientious in drawing from a wide cross section of society, which meant that viewers could often find something of themselves in the episodes. This exposure to therapy as a viable option to manage inner turmoil was expanded in subsequent years via the internet. As apps like WeChat became key components of the digital infrastructure for navigating contemporary life, the burgeoning field of psychology and self-help found itself transplanted online.
An example episode from the latest series of the popular Chinese TV show Psychological Sessions, released in September 2022. The title of this episode is “最后一公里的爱——没有求助的帮扶,” or roughly: “The last mile of love — with nowhere to turn for help.”
In the 2010s, applications such as Know Yourself and Jiandan Xinli5 (简单心理) took off, attracting millions of dollars of venture capital funding and huge fan bases. Both apps were started by millennial women who launched their companies on the backs of successful careers as bloggers, writing about mental health for a popular audience. Qian Zhuang, of Know Yourself, was a master’s degree student at Columbia University who became impressed by its free counseling service. She started writing about the things she was learning, noticing that these services were not widely available in China at the time.
Li Zhen, of Jiandan Xinli, gained widespread attention for her blog posts about mental health and well-being. People began messaging her privately to ask whether she knew of any therapists they could trust. She recommended friends but soon grew overwhelmed by the volume of requests. She quickly realized that although China was accrediting counselors, there was still a dearth of trust in the industry among the general population. This is why she created an online booking service, offering a platform that would allow people to browse listings of therapists to find their best match. Soon this model was replicated across all the major online psychological service providers, significantly streamlining access for people seeking care in major cities.
These online services have been instrumental in increasing awareness of mental health and providing access to care. Considering that one of the main functions of such apps is to introduce people to the concept of mental health, they have done a good job of changing people’s attitudes toward psychological experience and well-being.
Online services have now taken on an outsized role in accrediting psychological counselors. In 2017, after years of debate over how to best manage the system, the government halted the MoLSS qualification. Was this a labor and social stability issue, or a matter of public health? How could an exam be administered that could create enough counselors to meet the demand but ensure better quality than the previous regime, which many had dismissed as chaotic and insufficiently rigorous? The government chose not to answer these questions. It shelved the qualification and did not replace it. As researcher Darius Longarino argued, this means that the “profession cannot meaningfully perform gatekeeping or housekeeping.”
These roles have now fallen to platforms like Know Yourself and Jiandan Xinli. The latter now runs an online university, charging tens of thousands of renminbi for a two-year course that trains fledgling counselors. If the government is serious about dealing with the psychological fallout from the COVID-19 pandemic, then coming up with a more systematic and resourced accreditation system for psychological counseling is a crucial first step.
As the pandemic dragged on in China, the term “political depression” (政治抑郁) started trending. This term was first popularized in the United States after Donald Trump’s election in 2016, typically associated with the despair that American liberals felt for the direction of their country. Though it is a sensitive term that seldom appears in official sources in China, it has become part of the vernacular for discussing the increasing sense of suffocation that people feel over draconian COVID-19 policies or the increasingly heavy hand of the state under Xi Jinping. While still a fairly niche term, it is worth noting for the way that it brings into focus the social dynamics of mental health.
Depression is both a clinical condition and a social reality. When Chinese netizens employ the phrase “political depression,” they acknowledge that their mental well-being is inevitably tied to the broader social environment in which they live. When people become increasingly uncertain about the direction of their country, this disquiet can become an embodied reality for individuals.
In China, counseling was also a response to the economic dynamism that came after Mao. As the team of anthropologists led by Arthur Kleinman, the famous medical anthropologist at Harvard University, argued in their book Deep China, the reform period has been a time of incredible social change for China, which has had huge impacts on the average person’s subjective experience. There has been a marked shift in personal subjectivity, from a highly circumscribed sense of personal agency during the Mao era, when the socialist planned economy controlled so many intimate aspects of average life, to modern China, where lives have dizzying potential.
Psychological counseling is booming at a time when self-help, success studies (成功学), astrology, and wellness are all massive growth industries in China. All are designed to help individuals develop and actualize their potential, a testament to the fact that many parts of China have reached a level of affluence that allows people to consider their postmaterialist needs. In the early 2000s, anthropologist John Osburg was in Chengdu conducting fieldwork on China’s new rich. He charted the murky dealings between businessmen and officials in bathhouses, karaoke clubs, and banquet halls as they sought to make it in the early decades of market reform. His most recent work, nearly two decades on, follows that same community of businessmen as they attend to a very different set of desires. Many of them have now converted to become Tibetan Buddhists. Obsburg’s work, therefore, is a handy signpost for what can happen to people once their material needs are fulfilled: They start to seek something that feels deeper.
This has reality led to a tension between what counselors think their profession is and what clients expect. I often hear from therapists that their clients come to them to help them make decisions in their lives: Should I get divorced? Should I send my kid to this particular school? This was not what the counselors believed therapy was supposed to be for. The therapists saw their role not as making decisions for their clients, but helping them sit with the decisions they had made themselves. “I’m not a life coach!” one therapist often lamented to me.
In her recent study of psychotherapy in China, anthropologist Li Zhang highlighted anxiety as the prevailing mood in modern China. When the therapists I interviewed described their clients’ misunderstandings concerning their roles, they were also subtly highlighting the level of stress their clients felt. In a society as competitive as China’s (see the last paper in this series), people feel a pervasive sense of anxiety. Chinese people face a society that is both unequal and has scant social safety nets. Such a reality means that the cost of a wrong move can be extremely high, and people feel constant pressure to maintain or better their social position.
Strategies to respond to this harsh dynamic include “involution” and “lying flat”; another is psychotherapy. Psychotherapy can help people steel themselves for further competition by building their emotional and psychological resilience. It can also provide a salve for people who are burned out and seek psychotherapy as a form of healing. It is no wonder that psychotherapy has become popular among affluent Chinese urbanites.
The anxieties that people face are made visible in the content that online psychological service providers publish. Many businesses publish articles and digital content as part of an effort to promote the idea of mental health in general as a way to justify their services. In Shanghai, I visited the offices of Know Yourself, which were styled like a large millennial digital start-up. There I met one author who had a sideline as a poet and had been hired by the company to write elegant articles about contemporary life — viewed through a psychological lens.
In an article on the 996 phenomenon, posted on Know Yourself, the thrust of the argument is how to balance relationships in a time of brutal competition and workplace stress. “My boyfriend was waiting for me at the entrance to my office building, but I chose work,” laments one of the interviewees. Another one, a tech analyst in his 30s, explains that the reason he feels able to work so hard is that he doesn’t have a partner, resulting in feelings of crippling loneliness. Here we see the anxieties of contemporary life play out for young people. To be attractive in the dating scene they need to have good jobs, but those jobs take up all the time they have available to be active participants in a relationship — it is a catch-22. This fraught set of circumstances is a serious psychological burden for young people, as no matter which choice they make, they feel a sense of failure over the neglected alternative. For the woman who chose to remain at her desk, she succeeded at work but failed as a partner. (The next article in this series will take a more in-depth look at how anxieties such as these are significantly altering intimate relationships.)
Psychotherapy as Control
While there is significant interest in psychotherapy among Chinese urbanites, there is also interest from the party state. As a number of anthropologists working on mental health in China have noted (see work by Jie Yang, Ma Zhiying, and Li Zhang), the Communist Party has actively sought to integrate psychotherapy into its governing apparatus. This takes many forms and is subject to regional differences.
Jie Yang’s case study Unknotting the Heart concerns a shuttered watch factory in Beijing. To prevent workers from protesting, the local party branch hired some of the newly unemployed and trained them in basic psychotherapy techniques as “talking companions” (陪聊). They were then instructed to keep tabs on their former colleagues, ensuring they did not cause trouble and organize as a collective. But they were also encouraged to intervene when they saw signs of people falling into alcoholism or depression and to remind people of their “potential” (潜力). Even though there was little hope that they would find new jobs — many of the laid-off were already in their 40s or 50s and thus too old to easily find more work — the “talking companions” were there to help them find hope in their situation.
Li Zhang’s study shows how psychotherapy can employed as a management tool for police officers, in the army, and throughout the party. Here there is significant overlap with the way that mindfulness and well-being have been rolled out as tools in Silicon Valley in the United States and in many other countries to create better work environments for employees. As many studies have shown, however, while these tools can make people feel better, they can also help people acclimate to exploitative conditions. Instead of advocating for change, they may change themselves to accord with the situation around them.
This can certainly be seen in the Chinese context. As Li Zhang notes, it is more effective to govern through care than through coercion. “The impact of this therapeutic turn goes even more deeply than the level of managerial styles because it inevitably entails the remaking of soldiers, police officers, and workers into new subjects through simultaneously being both governed and cared for.”
The tension between being governed and cared for plays out in the work of Ma Zhiying, who looks at the complicated tension in the character guan (管). As she notes, this character can mean both control and care. As she shows in the context of the 986 community mental health project, which is the largest project in the world, the aims are twofold. It is both an intention of the government to locate and identify the seriously mentally ill in the community so that they can be given proper treatment, and to surveil them to ensure that they do not disturb social stability. Here we see both control and care at work for those experiencing the watchful presence of the state (被管).
These tensions have played out in recent months as the Chinese government issued a guideline on “Exploring the work program of specialized services for depression prevention and treatment.” Acknowledging that depression is a serious issue in the country, the government increased screening for the condition. Groups such as secondary students, college and vocational students, pregnant women, the elderly, and other high-risk groups would all be screened. While on the surface, this sounds like a positive step to identify the scale of the issue and help people get appropriate care, a lot of concern arose online over a clause in the guideline stating that high schools and colleges should build mental health files for students, with a special emphasis on those with “abnormal” assessment results. This has created fear that people will be stigmatized for their conditions or singled out and prevented from engaging in certain activities.
It would be unfair to dismiss the Chinese Communist Party’s attempts to address the mental health burden in the country. Officials are sincere about wanting to alleviate the suffering of their population as much as possible, and they value the tools of psychotherapy in creating more effective and tolerable management systems. However, it is also true that the party has a tendency to overreach when it attempts to balance public security and offering people autonomy; the caring impulses of the party have also come with heavy-handed control.
In 2018–2019, I conducted 14 months of ethnographic fieldwork with psychological counselors in Chengdu, Sichuan Province. I observed that many people sought counseling to address issues directly tied to politics. No one I interviewed had ever lived in a China governed by anything other than the Communist Party (the oldest person I worked with was born in 1949), and so they had never experienced anything other than single-party rule. While this did not mean they had experienced a static or inert political system — China had changed immeasurably over each decade of their life — it meant that many had a foreclosed sense of the potential for political change within their country. Politics was something that existed above them (国家大事). They wanted help with what they understood as issues in their immediate family life (家庭小事).
It is not that they did not recognize the interconnectedness of these spheres of life. Instead, they were more interested in trying to effect change at a level they felt they had agency over, rather than draw themselves into potential conflict with a political system that was unlikely to hear them. This meant that the therapeutic space existed in part to vent issues that in a liberal or democratic regime might be more openly expressed in public.
One of the main contentions of my PhD thesis was that the dynamics of living in an authoritarian regime in which civil society is increasingly squeezed and the potential for social movements largely foreclosed means that people instead choose to attend to themselves. The people I worked with had chosen to work on improving themselves and the relationships closest to them.
Therapy should therefore be understood differently in authoritarian regimes. Scholarly work on this subject in the Russian context6 shows how the therapeutic space helps people fashion a self that is capable of existing among so much change. This was certainly true in post-Soviet Russia, as therapy became a place for people to understand themselves as neoliberal citizens emerging from the socialist state that had so defined their parents' generation.
Similarly, it is important to recognize the desire of people who turn to psychological counseling and other forms of psychotherapy to heal themselves and build better lives. But this trend can also reinforce the sense that their systemic political context is intractable. This ends up suiting the party’s priorities — which is no doubt why authorities see value in psychotherapy.
- Lee Sing, “Depression: Coming of Age in China,” in Deep China: The Moral Life of the Person, edited by Arthur Kleinman et al. (Berkeley: University of California Press, 2011), 77.
- Hsuan-Ying Huang, “The Emergence of the Psycho-Boom in Contemporary Urban China,” in Psychiatry and Chinese History, edited by Howard Chiang (London: Pickering and Chatto, 2014), 188.
- The Ministry of Labor and Social Security merged with the Ministry of Personnel in 2008 to become the Ministry of Human Resources and Social Security (中华人民共和国人力资源和社会保障部).
- Huang, “The Emergence of the Psycho-Boom in Contemporary Urban China,” 192.
- In Chinese, Jiandan Xinli literally means “easy psychology.” However, its official English name is “My Therapist.” This name refers to the platform but not the holding company that controls it, which is also called Jiandan Xinli. Considering the English name is not well-known in China, I choose to refer to it as Jiandan Xinli, following Hsuan-Ying Huang, “Therapy Made Easy,” China Perspectives, 2017/4, http://journals.openedition.org/chinaperspectives/7468 (accessed April 21, 2019).
- See, for example, Tomas A. Matza, Shock Therapy: Psychology, Precarity, and Well-Being in Postsocialist Russia (Durham, NC: Duke University Press, 2018).