Participants portrayed their experiences in the context of cultural perspectives in the subcategories of societal, gender and mental health aspects. The main themes within this category included the difficulty of sharing feelings, enmeshed family dynamics, the imperativeness of mian zi, gender inequality, that views of mental health had developed in a society where mental health issues are stigmatised and discriminated against and that mental health is a hidden subject (Figure 1). Kashima and Gelfand (2012)
suggested culture means a set of “meanings or information that is non-genetically
transmitted from one individual to another, which is more or less shared within a
population (or a group) and endures for some generations” (p. 3). I believe this concept
is reflected in category one.
The narratives of the participants in this category are consistent with the literature on Chinese culture, which was cited in Chapter 2. According to Tseng, Lin, and Yeh (1995), traditional Chinese culture promotes individual conformity, emotional restraint and the collective values of a society and family, which could explain the difficulty participants had sharing their feelings and the enmeshed family dynamics. In a survey conducted on Asian-American adults (Pew Research Centre, 2012.), it was found that 68% of Asian-Americans adults felt that their parents should have some influence on their career decisions and 66% felt that parents should have some influence on their
child’s choice of spouse, which was reflected in Stone’s (P2) narratives. Evelyn Lee
(2000) also stated that many Chinese young adults in America struggle with the dilemma of how to be differentiated and individuated within an extended family that is unusually enmeshed by the standards of their host nation. Although not specifically
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focused on Chinese immigrants in the UK, the above studies have shown that the interdependence of family members in Chinese culture is a common phenomenon. Gender is a critical determinant of mental health and mental illness (WHO, 2004), and the gender inequality experienced by the participants is possibly explained by the fact that men have more social status than women in traditional Chinese society (Pek & Leong, 2003; Marshall, 2008; Lai & Bond, 1997). From the sensitising concept of the dynamism of Chinese philosophies researched in Chapter 2, it was suggested that
Confucianism believes women should behave in a submissive way, and “three
obedience and four virtues” (San Cong Si De) were imposed on women. Labour
divisions are very much based on gender in a traditional Chinese household, with the men in the family making major decisions while the women are responsible for taking care of family members (Wong, 1972; Chan & Lee, 1995). The view of men being the
“master of the family” is reflected both in April (P4) and Max’s (P8) narratives.
The phenomena of face (mian zi) has also been illustrated in many previous Chinese studies within the dynamism of Chinese philosophies. In the view of Confucianism, an
individual’s achievement mainly depends on moral effort and a negative outcome is
solely due to moral failure (Lam et al., 2010). An individual’s mian zi can be seen as a perceived position in a social network; it can also be drawn from personal wealth, physical appearance, professional career background, educational level and family background (Ho, 1976). Mian zi is at the core of the Confucian doctrine that sees the
individual as a “person in relation” rather than a free standing agent (Hwang & Han,
2010; Chin, 2005). Fundamentally speaking, mian zi (in Chinese terms) encompasses social reputation and has enormous social importance in Chinese culture (Hwang & Han, 2010). Traditional Confucian values have a great impact on modern Chinese culture, including the medical and health care sectors (Guo, 1995). Therefore, the concept of mian zi hugely influences mental health beliefs and treatment seeking behaviours. The lack of knowledge about the concept of mental health is also supported by existing literature. Previous studies (Sproston et al., 2001; Chen & Kazanjian 2005) argue that the underutilisation of the mental health services within the Chinese community suggests that the amount of knowledge about mental health is very limited amongst Chinese immigrants. Studies have also found the stigma and discrimination surrounding mental illness is particularity pervasive and problematic within the Chinese community (Yang & Kleinman, 2008). Various studies (Ng, 1997; Phillips & Gao, 1999) have
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suggested that in Chinese culture people with mental illness are often perceived as dangerous and disruptive by society, which is reflected in the narratives. A study conducted by Tsang and colleagues, (Tsang, Tam, Chan, & Cheung, 2003) found almost
30% of 1,007 community respondents described people with mental illnesses as “quick- tempered” and agreed to comments that “people who had been mentally ill are
dangerous no matter what.” This perceived view of unpredictable behaviour being
linked to mental illness is also reflected in the participants’ narratives when they associate mental illness with the term “psycho”. The adverse effect of stigma on mental
health across all cultures is well documented (Markowitz, 1998; Perlick et al., 2001; Phillips, Pearson, Li, Xu & Yang, 2002). For mental health service users, mental health stigma can negatively impact their personal and professional relationships; subsequently mental health related stigma will significantly limit their views of self-worth, aspirations and capabilities (Thornicroft, 2006). Early studies suggested that simply
being known as a psychiatric patient has adverse effects on an individual’s reputation
(Goffman, 1963, 1968; Gove & Fain, 1973) which is reflected in many participants’ comments.
When conducting a review on understanding this stigma within the Chinese community, I found the symbolic interaction approach was the most appropriate method to explain
mental health stigma. Symbolic interaction focuses on the concept that an individuals’
knowledge and understanding of the world occurs through social interactions (James,
1907); therefore, an individual’s ‘self’ is a product of social interaction, something that
is in constant development through every social interaction and other experiences (Mead, 1938). The symbolic interaction model of stigma places emphasis on the
interactions of individuals who are labelled ‘mentally ill’ and their social environment
(Roe, Joseph, & Middleton, 2010). This framework invests in understanding the meanings generated in such interactions, which validates perspectives from the mental health service users (Clifford et al., 1991). Early literature on the symbolic interaction
model of stigma saw Szasz (1960) argue that the label of ‘mentally ill’ is a socially
constructed phenomenon arising within the institutionalised settings of mental health services. This argument is still very relevant in understanding mental health stigma in the Chinese community. As noted in Chapter 2, mental health systems in China (Liu et al., 2011) are primarily hospital-based care systems. This institutionalised setting of mental health services in China could facilitate our understanding about the stigma surrounding mental health within the Chinese community.
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The somatisation of mental health issues could be related to Chinese cultural perspectives, as various research has suggested that different cultures can influence the expression of somatisation (Katz, 2014; Kleinman 1986). According to Katz (2014), individuals believe that they can seek treatment in a non-stigmatised and blameless way by expressing emotional distress through physical symptoms (Katz, 2014). Kleinman (1986) further explored the concept of somatisation as a “cultural idiom of distress” (p. 277), resulting from a negotiation between social and personal requirements. A study conducted by Kleinman (1986) in a Chinese psychiatric clinic observed the phenomena of neurasthenia (Shen Jing Shui Ruo), a term that encompasses a wide range of physical symptoms like insomnia, fatigue, dizziness, and headaches. The study found that 30%
of patients would seek help for the symptoms of “Shen Jing Shui Ruo” whilst only 1%
reported depressive symptoms (Kleinman, 1986). The study also found that although somatic complaints were central to the patients' reported distress in the Chinese psychiatric clinic, over 80% of the patients could be re-diagnosed as having some form of depression based on criteria in the Diagnostic and Statistical Manual of Mental Disorders during that time (American Psychiatric Association, 1980). Many later
studies supported Kleinman’s findings and have suggested that emotional distress is
often presented with somatic symptoms such as neurasthenia in Chinese culture (Kleinman, 1986; Farooq et al., 1995; Kirmayer, 2001; Mak & Zane, 2004). Insomnia is one of the most common physical symptoms (Yeung & Deguang, 2002), which is also
reflected in the participants’ narratives. Studies conducted outside of China also
provided evidence for the somatisation of mental health issues. Lin & Cheung (1999) found that Asian patients are more likely to report their somatic symptoms, such as dizziness, while not reporting their emotional symptoms until further questioned. The
participant’s narratives in this study support the idea that Chinese immigrants tend to
selectively express or present symptoms in culturally acceptable ways (Kleinman, 1977, 1988).
Another explanation about the somatisation of mental health issues could be the more holistic view of general health that is present in Chinese culture (Bond et al., 2010). This holistic view of body and mind is embedded in the history of China and still has a strong influence. The holistic approach shapes how Chinese culture views psychological distress and mental illness while explaining the somatisation of mental health.
121 Figure 4. 1. Category One