Editor’s note: Zhang Li is a professor of anthropology at the University of California, Davis, and the author of “Anxious China: Inner Revolution and Politics of Psychotherapy,” which explores how a new psychotherapeutic culture is taking root in China amid profound socioeconomic change. A Chinese version of the book was released this summer. Here, Zhang, who grew up in Kunming, capital of the southwestern Yunnan province, talks with The Paper about her personal journey, trends in mental health care, and the potential impact of artificial intelligence.

The Paper: In your book, you say that returning home to Kunming to conduct research into the city’s mental and psychological landscape was a “deeply emotional experience” that sometimes left you feeling vulnerable. How did your personal connection with Kunming shape this project?

Zhang: The idea for the book first came to me when I learned that my best friend from middle school had become a therapist. I was quite surprised. This was around 2000, when interest in psychology was just beginning to take off in China and few people knew anything about mental health counseling. When I talked to my friend about her work, I realized that it touched on all kinds of everyday issues but was relatively unexplored. Most of the anthropological field research I’d come across had been conducted outside China.

As I worked on the project, I discovered how deeply it was connected to my family. My mother died 13 years ago. Looking back, I realized she’d lived with post-traumatic stress disorder for much of her life. She lost her mother when she was 8 years old. Her father remarried, and her stepmother treated her and her siblings very badly.

Growing up, we became accustomed to her extreme emotional reactions, but we had no idea they were symptomatic of a psychological disorder. Back then, people simply described this behavior as having “a bad temper.” It was only after reading up on the subject that I came to understand that my mother had suffered from chronic anxiety and depression, but she lacked the language to express it.

Seeing a psychiatrist is more normalized now; back then, mental health was a taboo topic. When I began my fieldwork, my mother was 80. I repeatedly urged her to see a psychiatrist, and eventually she agreed. After a complicated and rather haphazard diagnostic process, she was prescribed a short course of Prozac, which helped improve her condition. In the final three years of her life, she was relatively at peace, and we could have calmer, more constructive conversations.

I chose Kunming for my fieldwork because it allowed me to leverage personal connections and familiarity with the local environment. In addition, scholars were already conducting similar research in major cities such as Beijing and Shanghai, so I wanted to look at a medium-sized city. Kunming was experiencing many of the same problems as larger cities amid China’s economic reforms and social transformation. Rapid, large-scale change inevitably causes disruption, and the psychological disruption individuals experience manifests in all kinds of ways.

Another factor, as I discuss in the book, is Kunming’s place in the history of psychotherapy in China. In 1988, the city hosted the country’s first Advanced Sino-German Psychotherapy Symposium. This earned Kunming a reputation as the “cradle of Chinese psychotherapy.”

The Paper: Why do you consider anxiety a key indicator for the pulse of contemporary Chinese society, and what distinguishes the anxiety here from that elsewhere in the world?

Zhang: Over the years, through interactions with people from diverse backgrounds, I’ve come to feel that Chinese people are an exceptionally anxious population, or as we say, neijuan, “involuted.” Some people are depressed or “low energy,” while others are energetic and highly strung, but anxiety is pervasive across social classes and age groups.

At the same time, anxiety is a global phenomenon. With our digital devices always at hand, constant exposure to news about climate change, geopolitical crises, and the threat of artificial intelligence further exacerbates our anxiety. Anthropologists in other countries, including India, Russia, Japan, and the United States, have found that people in all of these places experience anxiety. But while a general sense of anxiety may be shared across populations, specific trigger issues closely reflect local political, economic, and cultural pressures.

The Paper: The localization of psychotherapy is a central theme of the book. Based on your observations and personal experiences, what similarities and differences do you see between China and the United States?

Zhang: Psychotherapy began to take off in China in the late 1990s and early 2000s. In the West, psychotherapy has a much longer history and has undergone a lengthy process of professionalization. To become a licensed therapist in the U.S., you must complete an undergraduate degree and a master’s in counseling or psychology, and then accumulate a certain amount of clinical experience.

In China, the profession is relatively immature and poorly regulated. With low barriers to entry, practitioners vary widely in competence, and this makes it difficult to find a reliable, qualified therapist. A one-hour therapy session can cost 500 to 1,000 yuan ($75 to $150), making trial and error an expensive process.

In terms of specific techniques and theoretical schools, cognitive behavioral therapy (CBT) is the predominant approach in Europe and the U.S. In China, a wide range of therapeutic approaches are popular. In my book, I focus primarily on Satir-based systematic family therapy, CBT, and Jungian psychology-inspired sandplay therapy.

I have a great deal of respect for Jungian sandplay therapy because it resonates in many ways with traditional Chinese culture. However, many young urban Chinese tend to favor therapeutic methods they consider to be “scientific,” and have little interest in methods associated with traditional culture. The Satir model was influential in the U.S. in the ’70s and ’80s, but is no longer popular. However, its emphasis on family relationships resonates with Chinese cultural values and has helped make the Satir model hugely popular here.

Another difference is that Western practitioners emphasize language and narrative, with sessions generally taking the form of a conversation between therapist and patient. Chinese people are less comfortable with talk therapy approaches, and the popular models tend to use both nonverbal and verbal methods.

The Paper: In the book, you argue that Chinese therapists have not just absorbed and imitated Western therapeutic methods but rather selected and adapted approaches suited to the needs of the Chinese population. Where have these localization efforts worked, and what role has the market played?

Zhang: Whenever psychotherapy enters a new country, it always undergoes a process of localization. The efforts and experiments therapists undertook to adapt Western therapies to Chinese contexts were necessary, but also challenging. It’s difficult to say definitively how successful they’ve been.

Some have made a significant impact. However, some localization efforts failed to preserve the essence of the original approaches, instead veering into something resembling ideological indoctrination — not a desirable outcome. But China’s psychotherapy field is still young, and there’s ample room for development.

The market has played a crucial role, because therapy is extremely expensive. In China and the West, therapy is mainly accessible to the middle and upper classes; it’s a luxury for the working class. With the exception of some mental health counseling services provided through psychiatric departments that can be covered by medical insurance, most therapy in China is paid for out of pocket. As a result, individuals’ ability to pay is an important factor shaping the development of the profession.

The Paper: You observe that by 2008, more than 100,000 people in China had obtained certification to work as counselors, yet less than 15% went on to work in the field, with many pursuing psychotherapy training as a form of self-care. Can psychotherapy training that excludes the patient-therapist relationship have a therapeutic effect?

Zhang: I found this phenomenon very interesting. When I spoke with individuals who had completed training programs, I discovered that many were facing difficulties in their lives, or problems in their marriages or relationships with their children. They wanted help, but when they sought a therapist, they found the cost prohibitively expensive. They figured they might as well spend that money on a counseling certification that could give them tools to help themselves and support their loved ones, as well as skills they could apply professionally. About 90% of interviewees had full-time jobs, including as teachers, police officers, and government employees. None of them intended to pursue careers in mental health care.

The therapeutic relationship is central to mental health care, and the effectiveness of therapy often depends on the rapport between client and counselor. However, these certification programs also involve close interactions among instructors and participants. Role-playing exercises add to this dynamic. The training environment functions as a safe therapeutic space, and the courses can have some therapeutic value for people dealing with relatively mild emotional difficulties.

When participants return home to their children or partners, they may not necessarily assume the role of a therapist, but the knowledge they’ve acquired may give them a new perspective on how to understand and interact with them.

The Paper: Why is it predominantly urban middle-class women participating in such programs?

Zhang: The people I interviewed were almost all middle class. A counseling certification program can cost thousands of yuan in tuition, and there may be additional expenses down the line. Lower-income urban residents already have their hands full making ends meet — they don’t have the time, energy, or financial resources to invest in these kinds of things. There are exceptions, of course. I encountered two migrant workers who pursued certifications after their children experienced serious mental health problems.

In the training courses I attended, the ratio was roughly nine women to every man. This discrepancy is partly related to gender stereotypes. In one course, I spoke with the sole male participant, a police officer, who told me his family was baffled by his decision to study counseling. They thought that when he encountered problems, he should just grin and bear it. But he found the training extremely helpful.

Generally, looking after the emotional well-being of family members is considered women’s responsibility, particularly when it comes to children’s emotional problems. This may be changing among younger generations, of course.

The Paper: Your book mentions the late-night talk show Xinli Fangtan, or “Psychological Time,” in the 2000s. Through counseling sessions, its guest experts sought to destigmatize family and work problems, framing them as social rather than medical problems. But today, mental health issues are increasingly medicalized, with hospital psychiatrists booked solid, and social media awash with clinical terms like “trauma” and ADHD. What’s behind this reversal?

Zhang: The medicalization of mental health problems and the individualization of structural problems are not phenomena unique to China; they are happening around the world. In the West, where psychology is much more developed, there has been considerable criticism of this trend. One of the main arguments is that psychology turns many social problems into individual problems, thereby eliminating the impetus to address the underlying structural issues.

But this is one side of a two-sided problem. On the other side, you have what my mother’s generation experienced: people talked only about social problems, never psychological ones. Many people were suffering, yet no medical resources or treatments were available to them. Now we’ve swung to the opposite extreme, where it seems every problem can be solved through therapy or medication. I don’t think this kind of binary thinking is helpful. Rather than treating every problem as either an individual medical issue or a social one, we need to understand how these factors interact and adopt corresponding approaches.

The Paper: You observe that corporate psychotherapy and mental health initiatives, framed as “psychological care,” are becoming new tools of management and control. What does this mean for employees?

Zhang: This is not limited to Chinese companies. In Western capitalist societies, it is very common for businesses to use mental health care as a tool of management and control.

For individuals in China, this approach has some appeal. In my interviews, many employees told me they liked it. Companies have outside experts or human resources staff lead sessions with employees. Rather than simply issuing instructions from above, they take a more egalitarian approach, offering advice on managing family and workplace relationships, or leading group activities such as meditation.

On the other hand, this form of management has attracted considerable criticism in the West. The mechanisms underlying it are often invisible: control over employees may operate at an unconscious level, potentially making it even more effective than overt coercion. However, based on my observations, this approach has some merits and should not be dismissed outright.

The Paper: Your fieldwork for the book ended in 2018. Have you continued to follow developments in this “inner revolution”?

Zhang: I’ve observed three major trends. First, public interest in psychology and mental health has increased. Second, many therapists report that their client numbers have declined in recent years and that fees have decreased. Many people are turning instead to online counseling services, which are cheaper and anonymous.

Third, the emergence of artificial intelligence has had a considerable impact. When people encounter problems, many turn first to free AI tools. Some even feel AI is more trustworthy than a therapist. Therapists have found that many clients who have consulted AI come into sessions with a clearer understanding of their problems. However, in more serious cases, timely medical intervention and medication may be necessary, which is where AI cannot replace a professional.

Reported by Zhu Fan.

A version of this article originally appeared in The Paper. It has been translated and edited for brevity and clarity, and is republished here with permission.

Translator: Carrie Davies; editors: Wang Juyi and Hao Qibao.

(Header image: Visuals from the book cover of “Anxious China: Inner Revolution and Politics of Psychotherapy” and VCG, reedited by Sixth Tone)