Imagine you live in a rural town with your 30-year-old son. He has spent the past seven years in and out of the hospital with schizophrenia, and each time he’s released, you find yourself back where you started, struggling to help him deal with an isolating condition that neither of you fully understands. Sometimes you even feel scared of him, but there’s no one you can turn to for help, and you’re ashamed to even acknowledge the problem.
For many Chinese, this is all too easy to picture. In the three years I spent reporting on mental health issues and how they affect communities across the country, I’ve seen firsthand how mental illness can stigmatize patients and exhaust their families. Yet because the mentally ill continue to be marginalized in China as an “abnormal” group, their voices and problems are typically ignored.
Instead, they’re often just medicated. But while this can be a vital part of treatment, it is by no means enough on its own. Even after medical interventions, many patients struggle to make friends, find work, or even leave their homes. Without an effective support network for patients and their families, any gains achieved through psychiatric treatment are all too easily lost.
That’s one reason China’s acute shortage of trained medical social workers is so unfortunate. While psychiatrists can diagnose illnesses and prescribe treatment, it is social workers who do the vital work of preparing patients to leave the hospital and reenter society. Social workers also stay in contact with patients after their release, helping them maintain a healthy mental balance, establish positive interpersonal relationships, and find jobs.
In 2015, the Chinese government issued a “five-year plan” specifically aimed at improving the country’s mental health care system. The plan urges local health care providers to hire social workers and provide community-based mental health care services.
Multiple studies have shown that these reforms can significantly reduce recurrence rates and help break the cycle of hospitalization. Yet implementation has been slow, and China’s few hospital-affiliated social workers are frequently diverted from their primary tasks by skeptical administrators. Even when they are given room to work, the system remains more focused on registering and “managing” patients — i.e., keeping them from causing problems — than on providing the services they really need to rejoin society.
The most common type of social worker in China is employed through an NGO, typically with funding from a local government agency or charitable foundation. But these positions are precarious and often poorly paid.
Other cities, including Shanghai, have started hiring social workers and assigning them directly to hospitals. Yet this has by no means been a cure-all. When I met with May, a social worker in Shanghai, I was expecting to hear about how she had spent the past two years organizing training sessions and supporting patients’ reintegration into society. Instead, she told me that she spends most of her time doing unrelated administrative tasks for the hospital where she works.
“I haven’t really done much of the work that I’d been trained to do,” May told me. Despite being the only social worker in a district with over 5,000 registered mental health patients at the time she was hired, May was immediately reassigned to the hospital’s publicity department.
The importance of social workers often goes unrecognized inside the hospital system, where many psychiatrists, physicians, and even some hospital directors continue to believe that patients can be cured simply by taking the right medication dosage.
“Sometimes the psychiatrists ask us, how can your work change their (patients’) condition?” Xu, a social worker at another hospital, told me.
In addition, because there are no clear national guidelines to define or measure social workers’ performance and responsibilities, it’s easy for hospitals to get away with assigning them other tasks that hospital heads consider more pressing, including filing paperwork and organizing events.
Meanwhile, outside the hospital system, the concept of social work remains poorly understood by patients, their families, and community leaders. Interestingly, this sometimes works in social workers’ favor, as many patients, unable to differentiate between social workers and doctors, give equal weight to their words.
More often, however, less recognition means less help. Once patients leave the hospital, they and their families are pretty much on their own. Community doctors provide little aid beyond monitoring their conditions, and mostly focus their attentions on patients who have been diagnosed with serious mental illnesses like schizophrenia or bipolar affective disorder.
“Some community rehabilitation center directors are even annoyed that our work might put extra burdens and risks on them,” Xu said, referring to the belief that social work activities meant to get people out into the community increase officials’ liability. “Their mindset is still about managing rather than serving patients, and they think that their biggest mission is to ensure that no one under their ‘management’ causes trouble.”
This management mindset is deeply ingrained. A large part of social workers’ jobs involves closely monitoring and reporting on registered patients’ conditions to their bosses in the municipal hospital system. Typically, they might check in with patients once a month, but in the lead-up to big events like national holidays, they are often required to do so daily — less for their patients’ own good and more to minimize the chances of an attention-grabbing incident occurring in their district.
But there are also glimmers of progress. Last July, I attended a class Xu led at a Shanghai community center, where I listened to the five participants talk about the friends they’d made playing sports or taking photos. They evaluated their conditions and discussed what they could do in the future to improve their health and prevent relapse. One woman told the group she now understood that she needed to control herself, but admitted she was still learning how.
“It’s important to let them know that they can achieve it (progress), and to acknowledge it when they have,” Xu said. Although Xu’s boss is relatively open-minded about social work, Xu, like many other social workers, is generally on his own when it comes to organizing these sorts of programs: He designed all the course content and led the group by himself.
But based on conversations with participants, Xu’s efforts have been rewarded. Several suggested they had learned to better manage their stress, and some said the class had helped them learn how to deal with their feelings of stigmatization.
This work is a small step forward in a long journey. Support networks and social workers can play a crucial role in improving the lives of the mentally ill, their families, and the communities in which they live. But first we must stop viewing mental health care as simply a matter of prescribing drugs and keeping the mentally ill out of trouble, and start considering how we can better serve those who need it most.
To protect the identities of the author’s interviewees, they have all been given pseudonyms.
Editor: Kilian O’Donnell.
(Header image: A social worker offers psychological counseling to local residents in Beijing, Oct. 20, 2012. Tuchong)