Psychoanalysis in China, Part One

By David E. Scharff, M.D.

In May of this year, my wife, Jill Savege Scharff, and I made our first trip to China. The invitation to her came after a Chinese graduate student wrote her with questions about one of her books, which he was reading. After she had answered him, he wrote a kind of “by the way” email asking if perhaps she would consider coming to Wuhan, where he was then working and teaching. She wrote that she would. An invitation came from Professor Shi, the head of the Wuhan Hospital for Psychotherapy, and she agreed that I could accompany her. The report that follows is a first encounter with a remarkable group of people in an eagerly blossoming land, not by any means without its struggles and contradictions.

May 13, 2007

It’s a long trip to Wuhan. More than 21 hours of flying, a 30 hour trip in all by the time we change planes in Los Angeles and again in Hong Kong. It is not so much with romance as with anxiety that I think we are on a trip into the unknown. We’re not going to the tourist part of China, and our hosts are unknown to us except for a handful of polite emails of invitation, first from a student who had read one of Jill’s books, then from his professor. When we sent a set of options as proposals for teaching plans, Professor Shi suggested we should do them all. Meeting a new group always involves a slow process of getting to know each other. While we bring theories through lectures with power point and examples of how we work, we are struggling to get to know the audience as a group and as individuals. We want to know their level of understanding, their interest, their ability to understand what we are trying to say in order that we can pitch our teaching to their needs. And even more, we want to meet them as people, to understand their lives, their professional interests and the kind of patients they see.

In Wuhan, we are met by a senior trainee doctor, Wu Xiaojan who tells us her English name is Rose. We soon learn that young educated people in China all pick an English name themselves. Dr. Wu introduces us momentarily to our host, Professor Dr. med. Qijia Shi, Director of Wuhan Mental Health Research Institute and of the Wuhan Hospital for Psychotherapy, and a board member of the Chinese Association of Psychoanalysis, who has studied psychoanalysis and family therapy extensively in Germany for more than four years as he made his own transition from neurological researcher and clinician to psychoanalyst and family therapist. Soon we also meet Professor Dr. med. Jun Tong, who has studied in Boston at Harvard and Tufts, and heads the inpatient program of the hospital, where they treat a great many patients with severe personality disorders, borderline personality, and PTSD in in-patient stays with intensive psychotherapy, and in follow up outpatient psychotherapy. This whole university clinic is devoted to analytic psychotherapy. The staff have profited not only from the training the chiefs have had abroad during the last ten years, but through guest teaching from people like us. During the last fifteen years, the German-Chinese Cultural Institute has offered training in China in a variety of forms of psychotherapy – family systems, cognitive-behavioral, and not least, psychoanalytic psychotherapy. So we are not going into a totally naïve culture, but at the same time, we do not expect they will have any grasp of our particular way of understanding development and personality organization or how we teach the conduct of therapy.

Dr. Wu meets us at our hotel the next morning, and walks us to the hospital. Soon the teaching begins. We have sent our teaching materials ahead for translation. Jill began, speaking one or two lines at a time, followed by Dr. Shi’s intensely modulated Chinese translation that sounds nothing like what she said. Sometimes he spoke much longer than we had, sometimes after a rather lengthy explanation, he spoke rather briefly. The students had our PowerPoint slides in front of them, with the Chinese characters as puzzling to us as we assumed our explanations might be to them. Jill began by explaining the overall import of object relations approach, of a way of working that begins with listening and responding to unconscious messages behind the conscious communications, of tracking affect, and of working through interpretation towards understanding in depth, looking to understand the interferences in the achievement of developmental levels rather than focusing merely on symptoms and their relief. The students are looking down, writing as Dr. Shi translates. Jill moves on to specific aspects of theory, briefly outlining contributions from Fairbairn on the introjection of experience with the child’s mother, and the internal organization of the child’s mind. She hands the microphone over to me to continue with contributions of Melanie Klein of the stages of mental development from paranoid/schizoid to depressive position, adding in what we consider the crucial idea by Thomas Ogden on an earlier phase of development, the “autistic/contiguous position” when the child first begins to negotiate the coherence of a rudimentary self through the process of negotiating close contact with the parents while still maintaining the autonomy of a self across a distance. It is a difficult idea to get across that once these three positions begin to organize mind, they are all three present in a kind of continuous cycle. It’s one of those foundation ideas that has an elegant simplicity to it, and yet is one of the most complex ideas we might discuss. What are the prerequisites for understanding that the foundation on which personality is built is a cybernetic, ever fluctuating system of organization, not just a series of linear inputs? We teach it at the beginning, but we still have no idea how much the students are taking in.

Because of the time it takes Dr. Shi to translate each of our ideas, we make progress much more slowly than with an audience of native English speakers. I always wonder if that is not a good thing. These are difficult, basic concepts and the extra time may do as much to promote their absorption as anything. All of our slides are translated for them into Chinese, so we hope they have time to ponder them.

We’ve barely dented our theoretical overview, not yet introduced Winnicott or Bion whose ideas we need to put out, but we feel that the lecturing is in danger of going right over the heads of those from outside the Wuhan group, who, Drs. Shi and Tong tell us, have been introduced to these concepts. Those from outside may well be encountering them for the first time. And indeed, the last of our four days of teaching in Wuhan, the students who are not from Wuhan tell us heatedly that we have not been basic enough for them. It is disappointing to hear this late in the day when we are beyond our capacity to repair with this group of students.

So we decide to introduce a clinical experience to give a common element to the group’s experience. To ground the group, we show a video clinical interview. (It is important to note that this man, like any other video examples we use, has given full and knowing permission to use the video record of his interview for teaching. We are profoundly grateful to the volunteers who have contributed so generously to mental health education.) The young man Jill interviews in this video is a 26 year old student who has a past history of alcoholism, a difficult relationship to his mother, and a story of having almost blown up a dormitory inadvertently while drunk. It was this incident that caused him to give up drinking. The students have the translation of the interview into Chinese because we sent the transcript ahead, but now they can see the non-verbal aspects of the interview in the video. Jill interrupts every few minutes to describe her thinking as the interview had developed.

What I am trying to convey is how we have to feel our way in learning ourselves to teach this group of new students who come from such different worlds, getting a sense for what they already understand, what seems opaque to them, and what resonates with their ways of understanding. By using material that is familiar to us as a vehicle for teaching, we use the baseline of our previous teaching experience to see how this group expresses its capacity to take in, its way of puzzling at the material, the kinds of questions they ask to let us know where they are. We have at least two audiences in mind at the same time: The professors and experienced staff, who bring their own understanding and who need to feel that what we bring will suit their educational needs of their students, and the students and audience themselves, many of whom have little or no background.

Jill works with the reactions to the video, sharing her state of mind as she worked through the interview they watch. She discusses an episode the patient tells her in which he almost went to jail for banging two loaded propane tanks together while he was drunk in college. The story captures an unconscious image of destructive internal parents (the two tanks banging together represent the danger of bringing two parents together inside himself.), the hopes for more in his own life, and the way the confrontation with his destructiveness led to his recognition of a need for treatment for a legacy of shaky self esteem from a damaged and damaging self. We release the students at the end of the day, still unclear how much they can make sense of what we are trying to teach. We have come a long way to be so unclear about what we might have to offer.

All teaching involves this kind of ongoing assessment, but there is, of course, a much bigger cultural gap 10,000 miles from home and a world away. Yet in some ways the cultural gap seems less than we might have imagined. At the “ Red Passion Four Seasons” restaurant overlooking a small lake in the middle of Wuhan that night, the food was completely new to us – chicken cooked in a bag of bread, sliced spicy eel, the best fried tofu I ever tasted, melon strips unlike any at home and local beer. They marveled that we were comfortable with chop sticks, and we marveled that the excellent pianist played Western standards from the 40s and 50s, and that the dress was completely familiar jeans, shirts and blouses that would have looked completely ordinary on the Potomac River waterfront on a Sunday afternoon in Washington. The skyscraper bank buildings and new hotels that have gone up in Wuhan the last ten years look familiar too. Nothing of rural, strange China of that we might have imagined. This is a modern China, ever more cars, bikes, motor scooters everywhere. Except the pollution is pretty intense, and people wander across the street in the middle of traffic while cars, bikes and motor scooters weave miraculously as to miss them and each other. But while we are here, we come to understand that there are ever more cars, ever more smog, and a China heading for environmental confrontation with its own aggressive economic development.

The next morning, the traffic below the window at breakfast teems, flows, breaks up into eddies, a river of humanity on foot, scooter, motorbike, car and truck, and most of all bicycles, many with two riders, some with huge loads before or behind the rider. One has what seems to be an entire house full of goods loaded ingeniously on the back, chests and furniture all negotiating the river of pedestrians and vehicles mixing at this broad and unregulated intersection like eddying of currents when rivers meet the ocean. Passengers sitting side-saddle balance effortlessly over the rear wheel of bicycles, disembarking at a stoplight, hopping back on as the cycle picks up pace. A man pedals two children held in a tent contraption over the rear wheel. Perhaps he is bike-pooling the children to nursery school. A half hour later, he returns, the hutch now empty. A woman on a motor scooter with her small daughter riding in front of her, no helmets anywhere, seems to have been hit and a policeman emerges from nowhere to have a protracted discussion with her. She walks the scooter off to the sidewalk, the girl trailing alongside, and talks for a long time with other people. Finally, they disappear. The river of humanity is endlessly fascinating. We watch it every morning from our breakfast table, never tiring, like looking at a whirlpool or the never repeating pattern of flames from a campfire.

Yesterday afternoon Dr. Xiaojan Wu, who has never been outside China, presented a case to me. It was a nightmare of an experience. Dr. Wu’s English is good, although she seems at first retiring. We have become friendly since she met us at the airport. She presented in Chinese, while Dr. Jun Tong, head of the Outpatient Clinic, who has studied for two years in Boston at the New England Medical Center (where I did my own medical internship) and Cambridge Hospital where I also spent a small part of my training, translated. Dr. Tong excellent understanding of English, when given at lightning speed, was difficult for me to grasp, so I felt completely lost about the case. Not wishing to offend Dr. Tong, I struggled both to understand the case and to see how I could somehow more easily understand the case. Finally we realized that the thing to do was to have Dr. Wu tell me the case in English, and have Dr. Tong translate into Chinese for the audience. Only then could I relax into consulting to the case and using it to teach the principles that we had been lecturing about in the morning.

The case Dr. Wu presented was of a young man who had great difficulty speaking about himself. He told her a story of being able to go to University, where he helped a classmate study for an exam, only to find that the classmate did much better than he did himself. Not only that, but female classmates admired the other boy. He began to skip class as his resentment grew, his performance deteriorated, and in the end he had to leave university. In every way he painted a picture of himself as a victim, but he denied being angry and seemed to have no feeling about his situation. Dr. Wu found herself becoming more and more confused, telling him that of course he had to go to class and do his homework. This seemed to correspond to the image he had of his mother who told him what he should do in a way that made him feel criticized. In a recent session, he told her a story from a book about a composer who sent music he had written to a famous musician, only to later find the musician had made it famous, but as his own. The protagonist came home and destroyed his instruments. Telling his children never to play music, and he became alcoholic. One day he found that his youngest son had become a successful musician despite his bitter advice, and he died on the spot from agitation at this revelation. When Dr. Wu asked her patient how he felt in reaction to the story, he ignored her question and began to question her about her response, leaving her in renewed and continual frustration.

Since by now I felt in more direct contact with Dr. Wu, I turned to discuss how the patient had put the dynamics of his internal world into her, so that Dr. Wu came in the therapy to act like the critical mother at times, frustrated with her under-achieving son. At other times, she felt like the frustrated boy who could get no understanding. Meanwhile, in her confusion, she experienced the boy’s attacks on thinking and linking elements of experience to each other. I asked if she had been able to get supervision for her work with him? Supervision with Dr. Shi had indeed been helpful. She had a session with the patient last week in which, finally, he had become directly angry with her. She experienced this development with considerable relief. So now we could discuss how the months of psychological holding she had offered had come in due course to create a situation in which feeling, and especially anger, could form, and in which the young man could begin to trust her enough (in what I have termed the contextual transference) that he could bring the anger directly to her without overwhelming fear that she would abandon him just because he had dared to express it. A new phase of treatment looked as though it was finally going to be possible.

With considerable relief on all sides, Dr. Shi escorted us to his Volvo, and in caravan with Dr. Tong we left the hospital for a tour of the East Lake, one of the largest and most beautiful lakes in China. It was here that Mao Zedong would come to rest and write poetry, said Dr. Shi. He was a wonderful poet, and Dr. Shi wondered if I had ever read any of his poetry. We drove through the university district of Wuhan, divided from the commercial district of this burgeoning city, which suddenly is full of cars only in the last 10 years, to a vista of hills bordering the lake, small skiffs for pleasure rides – all framed by air clouded with smog. We strolled by the lake, then continued to restaurants across a causeway that were in the suburbs, serving country food, a completely different cuisine than last night’s. None of the food we ate here resembled any Chinese food we have ever had in the United States or Europe, and it was wonderful in its newness and variety, some mildly spicy, some not – cooked vegetables, duck, eel, cooked cucumber and cabbage, new and strange tastes, all in communal dishes to which we applied chopsticks. Forks were available for the asking, but we managed, sometimes with help from our friends, to serve ourselves without defaulting to Western implements. Every success, for instance in retrieving peanuts from the dish one by one, met with exclamations of admiration.

After dinner on the return to the city, Dr. Shi said that much has changed in the last ten years. Only now is it possible to learn psychoanalysis. While we were in China, and through reading books like Rob Gifford’s deeply informative book China Road, we came to understand that it is still rare to discuss politics in China, and not entirely safe. Fifteen years ago, it would not have been possible to have a discussion of the wisdom of the cultural revolution of the 1970s in which the young people were sent into the countryside because Mao recognized the danger of the young to his regime. There learning and idealism were stamped out ruthlessly, contributing to a second wave of devastation of intellectual growth. Our hosts did not take up these matters with us. But we did learn that the attack on beliefs and ideas had begun much earlier in China. Under the Qing Dynasty (pronounced ching) which began in Mongolia early in the 17th century, the conquering rulers had absorbed the Chinese culture steeped in Confucianism, Dao and Buddhism. With the Republican revolution of 1912 led by Sun Yat Sen, these ideas were attacked further, so that when Mao’s communist revolution attacked religion and Western ideas again at the defeat of Chiang Kai-shek’s Nationalist Party, most of the centuries of religious and intellectual tradition were already suppressed. The Cultural Revolution unleashed by Mao in the 1960s was another phase in this series of attacks, so that generations of Chinese lost connection to the rich heritage of civilization that predated so much of Western intellectual and cultural thought. But now, said Dr. Shi, there is an economic and cultural openness. It is unspoken but clear that political dissent is still unwise, but there is even official support for the gathering of ideas from the West towards the scientific and economic growth of China. Economic growth of the GDP is galloping at more than 10% annually – leading to increasing environmental pollution, but also to enormous expansion. Psychoanalysis is one of the areas of inquiry that have leapt onto Chinese radar. There is intense curiosity and a willingness to invest in finding out what the West has to teach that will improve mental health delivery in China. Wuhan is in the lead in this inquiry.

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