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The author describes experiences gathered during several years of teaching psychodynamic psychotherapy with psychologists and psychiatrists within a 2- year-training programme in Shanghai, China. Questions and problems of the reception of psychoanalysis – shame, sexuality, harmony, abstinence - as well as possibilites and limitations of exporting psychoanalysis are discussed. Possible future development of Psychoanalysis in China is outlined.3 作者 描述 体验， 训练 中国上海 心理学家 精神科医生 精神分析动力治疗，问题与解答 关于 害羞 性欲 和谐 缺席， 中国精神分析发展的概况
Teaching Psychodynamic Psychotherapy in China, Transcultural approach, Cultural Relativity, Abstinence, Shame, Sexuality, Harmony.
Everyone is on the way to China.每一个人都在中国的路途中
A night scene in an overfilled third class train carriage with wooden seats and dim lighting, somewhere in China. This is how the novel of Dai Sijie starts, “Mr. Muo’s travelling couch“. Mr. Muo keeps records of his dreams - his own, during his travels through China, and those of his fellow countrymen. He has just completed his training in analysis in France and now, after returning to China, sets out to apply his acquired insights to cope in a country that seems to him, at least in part, grotesquely altered. He is convinced that nobody, not even the “official representatives of law and order“ can escape the truth of psychoanalysis. It is his intention to bring this truth back to his homeland where for a long period of time psychoanalysis was prohibited. His undertaking evolves into something of a ludicrous adventure. And the question arises: is China ready for psychoanalysis? Do we have anything to offer and do Chinese people need it?
Everyone is on the way to China. This also includes a group of German psychoanalysts who, like businessmen, politicians and professional athletes, take the plane to Peking or Shanghai to follow-up their contacts. In a time in which psychoanalysis in the West is not just fighting for recognition but for its very existence, the offers from Europe of courses of continued education meet with an enthusiastic reception. Twice a year, four times in all, some 200 Chinese psychiatrists and psychologists travel to Shanghai, sometimes over thousands of kilometres through the country. Their aim is to take part in a course that costs them half a month’s salary and at the end of which they receive a certificate on basic training in psychodynamic psychotherapy. The chances of acquiring a good position, such as head of a hospital with this qualification are great and so is the growth in demand for these courses. Many people who are interested have to be turned away because of the lack of capacities.
Freud and psychoanalysis; it was the translation of an American article. In the wake of this publication, the adoption of psychoanalysis in China was not restricted to short articles. In the 1920s and 1930s there were many translations from Freud, of secondary literature as well as simplified and explanatory texts. In 1949 upon the foundation of the People’s Republic of China, the interest in psychoanalysis disappeared. In a country in which correct political awareness is on a par with mental health, the “teaching of the dissection of the heart“ (a term formed by Zhang Shizhao) became obsolete.The western world has discovered China for itself - and for the export of psychoanalysis. And yet there were already contacts some hundred years ago: in 1912 a report came out about
It was only 40 years later that China rediscovered psychoanalysis for itself. In the late 1980s a few German psychoanalysts visited China and the upshot was that the German-Chinese cooperation took shape that was to bring over western methods of psychotherapy. There are training courses in Peking and Shanghai where, thanks to the initiative of Xiao Zeping, Head of the Mental Health Centre, a continuous further education programme has now been fully established. Alf Gerlach coordinated the group of German analysts. I myself have only been involved for a few years, although it seems to me to have been longer. There is a great deal that renders me thoughtful. The more I travel in this country, the more I feel convinced that it is impossible to do justice to its complexity and shimmering identity.
A country in transition - a split society. The dividing line between the glitter of the huge cities of the East where the Olympic Games took place and the bitter poverty in the West is deepening. The gap between rich and poor is greater than in many countries of Africa. Spectacular successes in economic growth and combating hunger merit our awe and admiration. I look for the familiar features and see people in the throes of shopping frenzies, the new businessmen who travel, wear designer fashion and enjoy the spectacle of Shanghai at night from the Italian restaurant in the Jin Mao Tower.
Yet I also see the cyclists in pyjama look, in their wai di ren, the day labourer or migratory worker in the mega-cities who are transporting carloads of bricks on a board that is tied to the luggage rack. They see their wives and children, sometimes thousands of kilometres away, only a couple of times each year. These people now account for one third of the population of Shanghai. The Cultural Revolution weakened the old family structures and ties but now, even neighbourly contacts are severed due to people’s forced relocation away from the old city into new settlements. The old cultural values are laid bare to a rather brutal capitalism, but the governing party is communist. We are upset at the rigidity in which autocratic procedures are adhered to and by the violation of human rights that we read about in the press. During this period the news about the disastrous earthquake reached us and also about the tremendous sense of compassion and humanity among the Chinese. Many contradictions.
What is surprising to some: in this country psychoanalysis is not just tolerated. It has become an official issue. It merges into the parole of the “harmonious society“, the new magic word used by Chinese leaders. This concept recognises that a rapidly growing economy is not a panacea, but that it needs complementary measures to correct mistakes and avert destabilisation. In October 2006 the Communist Party of China published a resolution for the “furthering of the psychological (sic!) harmony of the population“ as an important political goal. On the one hand, this means a landslide, and on the other it comes as no surprise in view of 250,000 accomplished and 2 million attempted suicides each year. In other words, the door is open? Yes indeed. Yet the problems are rooted elsewhere. Towards the middle of the past century, Ernst Kris refused to treat Asian patients: “I am not familiar with the Ego of these people”. This was no less true for us, even if we did not travel to China to treat patients, but for furthering the education of Chinese psychotherapists. What were the difficulties we encountered? Let me now highlight some of what I experienced during my stays in Shanghai – to date I have been there four times – and comment on its significance for the project.
The strive for harmony 为和谐而奋斗
In Chinese cuisine, taste evolves from the merger of contradictions. A similar recipe is used if one wants to create an atmosphere of humanity and compassion and reciprocal commitment: the Ego is meant to absorb the You and vice-versa the Ego is to be embodied in the You. As Sun Longji describes in his book “Das ummauerte Ich“ [The immured Ego], the Chinese Ego is not familiar with clear borders and it is felt to be unseemly if emphasis is made of one’s own rights towards another person. That sort of behaviour is considered to be small-minded. The needs of the other are placed higher than those of oneself, a condition that can go as far as to almost domineer the western guest by satisfying the wishes that he is presumed to have, so that he could even feel robbed of his right to take a decision freely. With the call for harmony, an external conflict between one’s own needs and those of society is possibly averted. Intra-psychically, we see a conflict between impulses of autonomy and conformity, between the need for self-realisation and the enormous fear of social isolation.
During the last course session, I asked the participants to look back on how they had experienced the instruction in psychoanalysis and to say what they found was good and put forward a few suggestions as to what could be improved the next time. (You note I was diplomatic in wording this sentence). Without really expecting otherwise, I was greeted to many kind expressions of praise. Of course I was pleased to hear all this, but with the passing of time I felt uncomfortable, simply because there was no end to it. Again I asked for proposals for improvement and was met with dead silence. I tried to take a more confiding approach – after all, we had spent 8 days working 7 – 8 hours a day together: I could not imagine that nobody had experienced anything from which one could derive changes to the course or in the nature of our work. To be brief: I failed to elicit even one sentence from the course participants that could be seen as even partially critical.
I got the message; it was important for the participants to see me as an idealized object. The respect I was shown not just at the end of the course and about which any tutor in the western hemisphere can only dream, serves the purpose of harmony as the highest ethical value, and ultimately the furthering of one’s own self-worth. Were one to criticise me, the harmony would be destroyed. Even more, I would be ruined as object with which one could identify. According to the Confucian doctrine, identification with an idealised master, however, is a central mechanism, by which one magically acquires – or should one say by which one incorporates? – something new that one considers to be valuable. It is for this reason, therefore, that in China one is responsive to the wishes of the other. And this is most definitely the case with the German teacher, who has something of high ethical value to impart. This harmony with the wishes and conceptions of the other is different from the empathy, which does not override the differences to the other, even if there is a provisional identification.
At the final session last May, i.e. after 4 x 8 days when everyone had received their certificates and I had reiterated my obligatory question for criticism, I did actually receive a reaction: the case studies presented should embody more information; the opinions voiced by the course participants were not really beneficial; it would be better if I should speak more about my own views. (Well, at least the course had achieved something: a better ability to set critical distance).
Whilst presenting one case study, my interpreter who was simultaneously translating the Chinese text into English for me, became terribly embarrassed, started to stutter and blushed painfully. It emerged that the text was about masturbation, a word as much despised as the action itself. I was not prepared for this, nor had I reckoned with a situation in which the open addressing of the fact that a patient can – in the broadest possible sense – seduce us, would lead to an embarrassed giggling on the part of the participants (aged between 30 and 50). Seduction, I was informed, is a “bad” word. The striking, undeniable difference to our own culture in addressing sexuality also became clear to me when, at the end of the course, we held a little social gathering together and I was amazed at the almost child-like desexualised communication between the participants.
In this country, the suppression of one’s own wishes and most definitely of any sexual drive, is part of the standard mindset and any sexual information – or even worse, experience in this field – tends to be the exception rather than the rule before marriage. At the same time, confrontation with the sexualised western media has compelled people into a forced “post-maturation” in this respect. (Marriages tend to be bad, but permanent. Such was the opinion of a Chinese colleague. They are founded by the family or the working unit that has taken over the assignments of the family. Many people have other relationships, but because feelings are suppressed and as a result coldness evolves, these cannot be satisfactory in the long term).
The problem of shame and loss of face 羞耻与丢脸的问题
Shame is a universal affect. Its social significance and contents differ, depending on the respective culture. Social phobia is a rising phenomenon in China, a fact that could be indication of the significance of shame in this society. The Chinese culture appreciates individuals who can differentiate between right and wrong and who know exactly when they fall out of line. Shamelessness is also sanctioned in western cultures, but it looks different. In China it is normal to slurp when eating or to spit on the floor (this latter has now been prohibited, not least in Peking). Both manners of conduct call for a well-schooled ability on the part of the western visitor to conceal his revulsion. Vice-versa, it is hardly tolerable to the Chinese if we snort when blowing our nose. In fact I was painfully aware of this once when I used a handkerchief for the purpose.
On the one hand, a certain sense of shame helps one to cope with society. The downside becomes clear from Chinese studies from the year 2001: students with a high sense of shame feel inferior and socially helpless and tend to react in conflict situations uncontrolled or by withdrawal.
Self-realisation, so highly esteemed in western societies, along with the selfconfident behaviour and delineating conduct that is part of it, can be experienced as shameful in China, where conformity is so important. This is particularly obvious when Chinese youngsters come to the West. Conflicts between the fulfilments of their own needs and those of others are unavoidable, but even worse is the irritation felt if the other does things or voices views that are experienced as offensive.
Hui Chi, a young Chinese women who trained in analysis in the USA encountered her compatriots there who had given up their own ambitious career goals to satisfy their parents’ demands for obedient children, i.e. they behaved in conformity with the group in order to avoid being shamed. Depressive reactions en masse were the result.
I have also experienced the aversion of shame. I was amazed how openly and publicly the participants communicated with one another within the group and admitted their errors or the depth of their feelings that had been aroused whilst working together. They were harshly critical of one another and frequently the person criticised made absolutely no effort to defend himself. Possibly this happened in order to restore the threatened harmony again that – as I thought later on – is superior to feelings of shame and for the maintenance of which one is prepared to suffer shame. In the self-experience sessions – also part of the course – I witnessed both states: an almost perfunctory and obsequious cooperation that harboured an aversion as hard as bone and an overflow of shame, a sort of radical decisiveness to lay all one’s cards on the table, regardless of whether a feeling of trust and confidence had developed or not.
Abstinence and the Confucian culture of advising 禁欲主义和儒家文化的忠告
The Chinese therapist was perplexed. A 21-year old patient, a student at Shanghai University had just told him that he was conscious of homosexual impulses. Ultimately the therapist could no longer bear his own silence and broke it by standing up, going to the shelf and returning with 3 books on the subject of homosexuality, which he placed on the table. By the next session the patient was to familiarise himself with the books’ contents. 那个大惑不解中国的治疗师。他的21岁的病人，是上海同济大学的学生，告诉这位治疗师，他感觉到了同性恋的困惑。最后这位治疗师不能够忍受他自己的沉默、打断了他，站起来走到书架上取回了3本关于同性恋的书籍，并放在了桌上。下一节的治疗是病人自己去熟悉这些书的内容。
This situation was described by one of the participants in presenting a case study. I tabled the scene for discussion and was astonished that nobody seemed to find anything worth contemplating about it. I tried to broach the subject of abstinence, enduring uncertainty, leaving questions open, so that I could better appreciate the background. No group discussion was fired, a situation I had not encountered before. My explanations culminated in the argument that I believed would eliminate final uncertainty: advice and concrete responses to questions only impede the analytical process, keep the patient dependent, prevent him from developing an autonomous self. My comments drew looks from the participants that were completely lacking in understanding.这是一个被提交的研究案例中的描述。
I realised I had touched upon a feature of Chinese society that is by definition innate: the high value placed on giving advice, yet also of disposing of somebody who one can consult for advice. How was one to refuse to give advice, even if one was in a position to give it!
Here is the unavoidable clash that exists between outlooks that are culturally natural and the analytical mindset. The abstinent mindset of the analyst is hardly reconcilable with the Chinese culture of seeking advice and giving advice. One could assume that in terms of orientation, behavioural therapy would be better suited.
The relationship with the analyst or therapist is hardly any different in China to that with the teacher. This is a powerful person who nurtures the scholar and punishes him, but above all understands his need for being cared for. The teacher assumes the task of a fatherly object and frequently retains this position lifelong: “Once a teacher, forever your father”, as one participant pointed out when speaking of the private contact between analyst and patient: inconceivable that one fails to visit one’s therapist at Christmas or at least send a gift. (I too found small gifts left for me everyday, mostly something to eat or drink). I tried to impart the meaning of the shared search for the subjective truth of the patient and the important role of transference that has to be understood rather than acted out. The analysis of these feelings is central to the patient’s health and is only possible if satisfaction of the wishes addressed to the analyst is denied. It means a large step, difficult to accomplish, towards becoming a therapist, if all this can become evident. And for Chinese people it is perhaps particularly difficult to accomplish.
Chinese psychoanalysis: a fake copy? 中国人的精神分析：冒充的副本？
The Chinese course participants are all trained psychiatrists and psychologists, all of them highly motivated, and, with their willingness to absorb what is new and their assiduity, pure joy to any teacher. The Chinese ideal of harmony, however, renders our activity difficult, because of the lack of critical questions and feedback. The questions put during our sessions entitled “Questions and Answers” were partly a disappointment to me because they showed that some important theoretical contents had not actually reached the participants. As for example the central significance of the framework that I noticed when case studies were presented. Patients were presented by parents who then questioned the therapist every week about progress of treatment (to which questions the therapist replied), sessions were lengthened if required because the patient appeared to be so dissatisfied, or the therapist allowed himself to chat about his own private life. Above all, this related to aspects of analytical attitude that were found wanting, although in fact we had spoken about this at depth.
I changed my concept. One thing was clear: it is not enough to pass on knowledge as a cognitive insight, especially since elements of self-experience had to be reduced and could only be offered to a few participants (in the meantime the students now participate in self-experience in groups). So I suggested working on an example from a case study, in which a patient makes for difficulties for the therapist by persistently asking questions; I split the group up into smaller three-person groups in which one was to be the patient, another the therapist and the third was to observe. It was important to try a role-play in the security of the small group to ensure that the danger of a possible loss of face could be kept as low as possible. We then talked in the large group about what we had experienced, and it became clear that the refusal of the answer, the persistent analytical probing for the motives behind all the questions put, posed a tremendous problem. This time we got close to the problem of abstinence from the subjective angle: by experiencing the mental pressure and how to handle it. In the feedback at the end of the course, this was considered to be the most striking learning experience.
I do believe that this role-playing as form of emotional learning opened a new door towards furthering therapeutic competence. For the Chinese participants it constitutes a counterweight to the already mentioned tradition of holding a particular action in high esteem, taking hold of someone else’s achievement, appropriating it and using it. In our society, the plagiarist is ostracized; in China he is someone who acts wisely. The precise copying of a particular style is distinctive of the master.
I believe I could also identify this in the learning behaviour of my course participants, who showed great interest in taking over an example, said example being myself. During lessons too it is possible to bring over something of an analytical mindset, by listening, leaving questions open, stimulating the imagination and taking it all seriously. If the outer structure, the actual framework, is right, then a lot is possible. During the final assessment after the course had been completed, a young woman wept, saying she had felt loved in the group; it is moving and uplifting to have been able to contribute towards such developments.
What is to become of psychoanalysis in China? 精神分析在中国会变成什么样？
Of all the countries known for their fake copies, China tops the list. Is it possible to copy psychoanalysis in much the same way as a bag by Louis Vuitton features on markets that sell counterfeit products? Most definitely not. Nowadays we accept the universality of the psychoanalytical theory on the structure of the human mind, the impossibility of exerting influence on the subconscious and the general applicability of psychic mechanisms by which the Ego attempts to halt inner homeostasis.
Yet the contents would appear to differ: many more suppressed affects, particularly the anger that has to be concealed under the blanket of reciprocal commitment, decency, adaptation, assiduity and striving for a career. These affects are present in a great many obsessive-compulsive disorders.
And the form too in which conflicts are revealed is another. The culturally anchored denial and desisting of mental disease means that such disease blossoms furtively, presenting itself in archaic manner. This was so in a case study about a patient who was hardly able to leave the home because he was compulsively occupied in covering the lower part of his body with his shirt, fearing that his father could amputate his penis. These are symptoms that would be inconceivable in our patients whose problems are reflected in greater symbolic subtlety; just as inconceivable nowadays as the arc de cercle. Oedipus appears in different clothing or quite simply naked. Possibly this might all result in consequences for the techniques of treatment, something we should think about. We are still in the early stages here. Do we really need other techniques for treatment or does it suffice if we are conscious during therapy of the differences in thought and feeling? I tend towards the second alternative.
In China there is a great need for a broadening of people’s own thinking and feeling, such as can be offered by psychoanalysis. Nevertheless, inner conflict can be triggered by a clash with traditional structures with which we need to be familiar if we want to pass on our knowledge. I have tried to illustrate a few areas in which conflict reigns.
I cannot offer any solutions. But without perception and recognition of the cultural differences, it will not work. This is also the approach of what is known as ethnography. What is called for is inter-cultural competence, meaning the mental attitude required to perceive differences and accept them as equitable. This also incorporates the ability to understand the medical explanatory model of the individual patient, instead of being led by the medical world’s conceptions “of the” Latino or “of the” Chinese.
In the self-experience part of the training I asked the young colleague, a 35- year-old psychologist from Shanghai about her biography. She said that up to the age of one, she had been fully breast-fed, a statement that I mentally ticked off. Returning to the subject of her early childhood in a subsequent session, she told me more. At the time of the Cultural Revolution, she was a baby and her mother worked in a nearby factory. Several times a day this woman cycled home, fed her baby, got back on her bike and returned to work. In the hours in between, the child was cared for by a group of seven different people. My assessment of the early childhood care (“adequate care, probably stable relationship with her mother in the oral phase and beyond”) was wrong and I could now view the young woman’s problems in a totally different light. I had been too quick in interpreting the statements from my own background of experience, instead of being more precise in putting my questions. Something that can be identically interpreted because it seems to reflect what one expects need in no way be the same.
Not only are those people interested in psychoanalysis, but also China as a whole is historically on the move. The aim is a greater rule of law, greater prosperity, more freedom of the individual. It is a course worth supporting - irrespective of the anger felt at the brutality of the police state. A gradual change is the aim, as Xiao Zeping said the day before yesterday. It is not boycott that can be the method of choice, but rather an ever-greater integration coupled with an acknowledgement of the differences. This insight I owe to the Chinese students, who forced me to take a far closer look at issues that are taken for granted.
Can psychoanalysis be exported to China? Yes, it can. Yet it cannot be expected to be taken over – like a counterfeit - 1:1. There has to be a differentiation between teaching about illness and teaching about treatment. Chinese society will probably take over the theory of neurosis because the psyche seems to work on ubiquitous principles. Yet it will reshape the therapeutic techniques derived from this theory so that they fit into the culture of the country.
Translated from German by Pauline Elsenheimer
Bulard, M. (2007) Der lange Marsch in den Kapitalismus. Edition Le Monde diplomatique No.1, 67-70
Jullien F (2007) Die Mitte als Ort der Möglichkeiten. Edition Le Monde diplomatique No.1, 99-103
Longji S (1983, 1990) Das ummauerte Ich. Leipzig: Kiepenheuer
Sijie D (2003 ) Le complexe de Di (Mr Muo’s Travelling Couch) Paris
Anne-Marie Schloesser, Psychologist, Psychoanalyst, training and supervising Analyst in the German Society for Psychoanalysis and the International Psychoanalytic Association. Private practice in Goettingen, Germany. Training and supervising psychoanalyst of the German-Chinese Training Course on Psychodynamic Psychotherapy, Shanghai. www.psychspace.com心理学空间网