CHINA AND PSYCHOANALYSIS
American Psychoanalytic Association at
The Waldorf Astoria Hotel
January 17, 2008
The effects of cultural differences between Chinese and Americans on analyses and supervisions
Charles Fisher, M.D.
1. Carole Rosen, MA. MSW, LCSW
Overview of Some Cultural Differences and History with Some Comments on Clinical Implications
My comments reflect my experience with Chinese immigrants and my own life in China in the late 1970’s, and also being part of a Chinese family for 7 years.
The motivated patients who are in treatment or supervision with CAPA members are an unusual group in China. While the historical aversion to psychotherapy is changing, much psychotherapy in China is conducted in groups. For example, a group focused on road rage. To go outside the family with personal matters has been considered shameful. The Chinese “ego ideal” emphasizes interdependency and intergenerational bonding, in contrast to the Western ideal of separation/individuation. [Editorial note: The very term “ego ideal” contains the Western idea of ego.] Cultural change in China creates a problem for young people relating to traditional elders. Their internal conflicts between filial piety and desires for self-sufficiency and personal fulfillment, lead to guilt. Some individuals seek treatment with Western psychoanalysts in order to minimize their conflict about acting “more Western”. Cultural values de-emphasize open discussion and challenges to authority. Clearly this is relevant to clinical work.
Traditionally, males are valued. The written character for “good” depicts a woman with a male child. Children frequently share their parents’ bed. They are very free until school age. Education is often conducted in “Peking Duck” fashion; the children are stuffed with information. It is common for grandparents to care for young children while both parents work. Wives typically live with their husbands’ parents. Unlike American children, Chinese children are taken everywhere and exposed to many things (including parental sex).
The presentation of self in everyday life is different. Westerners appear boastful to Chinese people, who value self-effacement. Chinese people are taught to decline and say they’re not hungry when offered food. It can be difficult for an American to figure out what a Chinese person feels.
The Cultural Revolution had a profound impact on Chinese society. There was great violence, public humiliation, rigid morality where sex was seen as bourgeois, and sexual transgressions sometimes punished by death. Americans were seen as “foreign devils.” What residual effect does that have on the transference to a Western psychoanalyst? Even now, emotions can be seen as “correct” or “incorrect.” However, there is a significant generation gap between those who grew up during the Cultural Revolution and those who are younger. Many young people are remarkably uncritical of Western society.
Language differences are important. Some patients are afraid that we won’t understand them, and it is important for us to verbalize this issue. People who have had analysis in two languages have commented that transference is different in the different languages. It is difficult to say “tension” in Chinese. “He” and “she” are a single pronoun in Chinese. Mistakes in this usage do not typically reflect gender confusion.
Finally, as Salman Akhtar pointed out, it is important that the analyst not to be excessively interested in learning about the patient’s culture. This interest on the part of the analyst can detract from clinical work.
2. Dorothy Yang, MSW, LCSW
The Concept of Face and Loss of Face
The Chinese self is a we-self (unlike the Western I-self) collective and interdependent. People are expected to concern themselves with what is good for the family, the clan, and the large group. The interdependent self-concept influences how role and role relationships are conceived. More than two thousand years of Confucian social structure and ethics have emphasized hierarchy of authority and clearly defined roles as essential to the goal of harmony.
In the Confucian relational model, there are five basic relationships: parent-child, husband-wife, older sibling-younger sibling, teacher-student, and friend-friend. Obligations and responsibilities accrue to both members. The senior teaches and concerns himself with the junior’s welfare. The junior demonstrates respect and obedience. The concept of Face thus requires mutual respect in the we-self and the hierarchical placement of two people in a dyad. These cultural values have implications for psychoanalysis.
“Face” has numerous associated terms: the physical Face, ‘lien’; the social Face ‘mien tze’ (more accurately defined as honor and respect); many idioms for wanting Face. Various expressions: “desiring both the Face and the lining” means substance; “one’s Face is sweeping the floor” indicates great shame (far more serious than “losing Face”); someone who won’t “sell Face”, means they won’t show respect. These many terms illustrate the great concern Chinese have for honor and respect.
Usually analysts and patients see one another in a shared physical environment. Physical behaviors can convey respect. A particularly honoring gesture is to offer something (money, for example) using both hands. In SKYPE treatment, one sees only the Face. Chinese patients are concerned about the distinguishing between what is exhibited on the surface and what is real. One patient found it hard to be certain that a very early morning appointment he wanted was really acceptable to the analyst. The patient was aware that in a similar situation, he would provide every assurance that the time was no problem, even if that were not true. This surface Face experience reflects the possibility of “false Face”. Being in analysis on the couch, looking away, allows the patient to “drop the Face”.
In preliminary sessions, it is important to discuss how to address one another The following clinical example illustrates the cultural differences and all the earlier concepts that were introduced previously. During a first session, I laid out the options of the patient might address me, none of which included the title of “doctor”. While she herself was an MD, she was clear about her choice. She decided she wanted to give me face and show respect and so called me “Doctor.” She felt that to do otherwise would be impolite and uncomfortable for her. Chinese people use “doctor” more loosely than Westerners, calling acupuncturists and tui na massage therapist “Doctor” if they meet in an acupuncture clinic setting not in a beauty salon. Anyone who wears a white coat (e.g., a lab technician) might be addressed as “Doctor”. Chinese call all therapists and healers “Doctor.” This elevation of status is a form of giving Face or respect and, perhaps even more importantly, preserves one’s own Face. This placement in hierarchy is also a form of protection for the patient. Calling someone by an honoring title is a definition of role and relationship.
3. Ubaldo Leli, M.D.
Relationship with Authority and Historical and Cultural Conflict between
Rationality and Magical Thinking
There are several issues that require special technical consideration for psychoanalysts working with Chinese patients:
The analyst may be idealized as a parental figure entitled to automatic respect. This can be difficult to work
with analytically because it is so culturally syntonic.
It can be especially difficult for Chinese patients to express negative transferences of any kind.
While the Oedipus complex is ubiquitous, it can take unfamiliar forms in non-Western cultures.
Analysts may be expected to be infallible. Thus a deviation from textbook “perfect” technique may be seen as
a flaw. Similarly, rage towards the analyst may be taken to mean that analysis does not work or that
the particular analysis is failing.
Historically, the Emperor, and later the Party Chairman, were seen as magical authorities. Against this
background, psychoanalysis may be seen to work by essentially magical rather than rational means.
Because of this concept of magic, analysands may expect immediate results or else conclude that
psychoanalysis is useless.
The fundamental mechanism of psychoanalysis may be seen as a supernatural one in which individuals seek
to purge demons from their psyches. Highly educated patients are likely to be in some conflict
between a psychoanalytic paradigm and a centuries old culture.
On the topic of language, Dr. Leli pointed out that knowing a language is not just speaking it well. It requires having lived in the language for a substantial period of time.
4. Rebecca Mair, Ph.D.
Case Summary with Emphasis on Particular Aspects of Cultural Difference
Rebecca Mair presented a clinical vignette concerning the analysis of a female patient P. [Editorial note: Because the material presented was too undisguised to present on the website, it will be presented in very summary form, which will highlight a few of the themes developed in the presentation]:
A holiday interruption was dealt with in rather standard analytic fashion. The patient was concerned that the analyst would have difficulty in understanding her language, even in English. She was also concerned about a lack of similarity between patient and analyst. This issue was understood as reflecting, both a concern about cultural differences, and also as a typical psychoanalytic transference concern. This aspect of her treatment speaks to a universal language of longings, desire, loss, tragedy and hope and the cultural differences she was struggling to negotiate with me.
The emergence of these concerns allowed patient and analyst to explore multilayered transferential themes alongside the issue of all kinds of differences. The affective flow between analyst and patient, in some ways transcends ordinary communication. In this analysis, I have seen a deep affective flow (expressing feeling and emotion in a very direct way) The psychoanalytic frame takes shape and form with the ebb and flow of those differences that promote creating ways to communicate and understand one another. My thoughts are that alongside the transferential themes, conflicts, and repetitions there is an unconscious process that is creating a language to negotiate differences. Her narrative is being developed from within as she makes use of me to bear witness to her experience. Its not only the language and cultural differences; its a matter of what happens in the analytic space. There are multiple meanings of the cultural differences in the analytic space. The use of the Internet and web cam creates an almost eerie space, a remoteness that seems to paradoxically both intimate and close; a private intimate space where the deepest most intimate parts can emerge. The analytic process unfolds as two people negotiate a way to communicate, be connected at a deep level that speaks to the universal language of emotions. This discussion led to the patient’s associations about a disturbing movie about the Cultural Revolution, with scenes reflecting both sexual violence and sexual repression during that period
5. Gardner Jacobs, M.D. Notes on a Defense when English as a Second Language is Used
For reasons of confidentiality, since the number of Chinese in analysis is small and many of them know one another, the brief clinical material will contain beyond details from non-CAPA patient material. What might at first glance appear to be a cultural phenomenon, related to English as a second language, appears to be more universal. There is, not surprisingly, an intrapsychic component to English as a second, third, fourth, or fifth language. Individuals may be able to talk about and express feelings in English that they are inhibited in expressing in their native languages. The opposite may happen, translating Chinese into English,
Even early in analysis, or without analysis, as noted by Elise Snyder in her October Report on China #1, hate can be expressed more easily in a second or subsequent language than ordinarily happens with native English speaking analysands. A variety of other actions and feelings can also come forth with relative freedom using English as a second language, whereas they are often revealed with difficulty in the native tongue. Culture is one factor. Regressively “being good” in order to maintain the favor of a parental figure and fear of aggression and punishment are others.
As far as I am aware, there has been limited study of English as a second language. Review of PEP produced one article. Carole Rosen brought to my attention a book titled “The Power of Language in the Clinical Process” by Rosemarie Perez Foster. Working mostly with bilingual Spanish speaking patients, she reportedly described how different transferences arise in different languages.
A close acquaintance, for whom English is a third or fourth language of six, speaks and dreams in English unless she spends extended time with her parents. In that case she reacquires an accent and starts dreaming again in her native tongue. She finds she can do and say various things in English she is inhibited doing or saying in her native language.
We have an unusual opportunity- – -I would say- – -in addition to primary clinical goals, to make observations about English as a second language. Although many European analysts came to this country before, during, and after World War II, the literature, to my knowledge, on English as a second language with this native European population, is sparse, if it exists at all.
In summary, I have found less defense against certain affects and behavior than is usual, at least early in analysis, and otherwise, when English is used as a second or subsequent language. The verbal expression of hate is one example.
6. Reflections of a Chinese Patient
I was born in 1970s. Before I was four, the five members of my family lived in four different places so my mother had to care for me all alone while she worked which often involved leaving me alone for many hours during the day. Using English to describe and explain what and how it happened in China was difficult during the analysis. It made me feel some frustration towards the analysis. And I began to lose faith in my ability to express and communicate in English although I had been very confident about my English before this.
In the midst of a transition from psychotherapy in the chair to using the analytic couch, I missed a treatment session. I don’t know whether this was related to language problems or related to analysis. I was afraid I would fall asleep on the couch. I also feared too quick and deep regression on the couch. On the other side, I was eager to lie on the couch to be analyzed.
The charge for my analysis here is cheaper. I have doubts. Do I deserve this lower charge? How much can I get from analysis with it? This kind of thinking stays in my mind out of the therapeutic room.
7. Elise Snyder, M.D.
Voices From China: Summary of Responses to a Survey of Chinese Patients and Supervisees
about the Impact of Cultural Difference
In an informal email survey of patients and supervisees about the impact of cultural differences on their treatments and supervisions, they described typical attitudes and values of their parents’ generation: filial piety, hard work, respect for authority, group rather than individualistic identifications, male stoicism etc. They compared these to what they saw as typical American attitudes and values. It was important for many of them to see themselves as different from the cultural norms they described. One person said, “In recent years, Western value systems have impacted Chinese traditional values. People born in the 1980s accept Western values of individualism, critical thinking, and “living for oneself”. The older generation often views them as selfish, uncaring and anti-traditional.”
I think it is the belief in the existence and importance of these differences that plays a significant (defensive) role in treatment, rather than the differences themselves. When therapists, seeking to understand the “exotic East,” also subscribe to these beliefs, it plays a deleterious role. Some respondents mentioned that Chinese patients would find it hard to respond if they had complaints about their analyses. Here, the projection not the cultural difference needs analysis. Many, speaking about “traditional” values avoided talking about conflicts with their own parents about these issues.
Some Actual Cultural Differences: With me, people talked amazingly (by our standards) openly: anger at parents and bosses, sexual practices, extra marital affairs, money, etc. Was this because I was a foreigner and “didn’t count”? Some compulsion to confess? Or because I was an American with magical powers to fix everything? This idealization and gratitude are hazards, needing analysis. Analysts must be able to tolerate the ensuing feelings of disappointment. Our cultural histories are very different. Millions of rural people died of starvation during “the great leap forward.” Hundreds of thousands, were publicly humiliated, banished to the countryside or executed during the Cultural Revolution. Many of our patients are their children and wonder if we can understand those events. I think our patients need the same analytic work as the children of Holocaust survivors. Again, the focus on cultural difference has a defensive function.
But are our Chinese patients significantly different from American patients in ways that impact their analyses? I think not. We need to analyze the defensive use of our patients talk about cultural differences. A Chinese man described the stoicism Chinese men are taught, their unwillingness or inability to express their feelings, his concerns that he “would not be a good enough analysand because he is unlike Westerners who have richer imaginations and show their feelings in concrete and specific ways.” He ended his email with this statement about his young son. “The baby’s name is Hang which means ‘sailing” in English. We both hope he can sail freely in his own sea of life and go anywhere he would like. And now the first important and joyful thing for me is to hold him in my arms every day after work.” (I have the person’s consent to mention his son’s name)
8. Anna Burton, M.D
Some Questions to Reflect Upon
Dr. Burton pointed out that the exotic nature of life in another culture can be quite distracting from psychoanalytic work. To talk about cultural difference in a broad sense may be misleading. There is a need to find more specific ways of talking about cultural issues that are close to clinical material. For example, she finds a heavy reliance on reaction formation as a defense in analyses of Chinese patients. It appears in the ambivalent relationships with parents, and in the transference. Perhaps the filial piety, which is so important in Chinese family life and literature, is maintained by reaction formation, and less successfully, by ambivalent swings in feelings, and in some cases, frank splitting.
She proposed several questions for further consideration:
What defenses are prominent in CAPA members’ Chinese patients in psychoanalysis? This is where we’ll understand the operation of culture in our work.
What kind of relationships do these patients have? Do attachment paradigms apply in SKYPE analyses?
SKYPE technology leads to anomalies: (1) so near and yet so far and (2) a face on the screen, versus seeing the whole person. The screen may operate as a kind of disconnect. How can we make both members of the dyad more real to each other?
[And perhaps there is a larger anomaly in working with people who are enthusiastic, but cannot yet apprehend the growth and development of psychoanalysis. Teaching its history would make it real.]
9. Xiaolu Hsi, Ph.D.
Deep Structure and Contextual Differences: Listening to Chinese Analysands and Supervisees
There is most likely a “deep structure’ of the human psyche (analogous to Chomsky’s “deep structure” in language) that enables psychoanalytic attempts to understand human beings across social, historical, cultural, ethnic contexts. Aside from the obvious hazards, speaking in a foreign language can provides a medium of safety (as well of defense) that helps the analysand articulate thoughts prohibited or difficult to articulate in his/her native tongue. In Chinese, affective expressions, especially for complicated emotions are abundant but exist mainly in written language, and are not readily available for oral colloquial speech. Chinese culture discourages “airing dirty laundry” and directs its children to “count your blessings”, “appreciate what you have”, especially how much “your parents have sacrificed for you”.
Western understanding of Chinese culture (and Chinese understanding too) has had an idyllic-looking “emphasis” on parents, family, children and community at large: the “collective self.” In addition to the cultural license given Chinese parents’ expectation of their children’s total submission, the last half century’s Chinese history has witnessed an extreme social and political demand for the individual to surrender his will and for “self-less” citizenship. “Losing face”, a.k.a. narcissistic injury, is not just the potential peril of disgrace in front of and being excluded from a group, but far more frighteningly, a threat to shatter fragile, poorly formed and barely guarded self with so flimsy a boundary that its only hope lies in a firm attachment to others. Chinese children are not raised with the aim of developing a self. If a Chinese self manages to take hold, it is likely in the shape of what the writer calls “self-less self”, one that has little way of knowing where it begins and the other stops. The candidness of the unsolicited confessions (marital infidelity, sexual practices) may result more from a lack of “common sense,” not having had the experiences that would produce common sense about one’s private self and inner thoughts, than from a feverish desire for analysis or a hopeful confession to the godly authority who is an American analyst. Its implications for treatment are obvious and the prevalence of boundary violations is not surprising.
If separation is not developmentally desirable, it should be obvious that abandonment is not a cultural standard. Historically, Involvement of grandparents has been viewed as a joy of old age, not as substitute parenthood. The ideal for the citizens to be single-mindedly devoted to “the revolutionary cause” and “the motherland”, at the exclusion of individual wishes and family life is a recent phenomenon. Many children grew up apart from their parents and spouses lived separately until retirement. Abandonment is nevertheless abandonment and sadly, is being recapitulated in the current generations because of economic strivings. The State’s demand for citizens’ devotion, like parents’ demand for filial piety eliminates the last thread of legitimacy of an individual will.
Dating from Confucius, the value of a life is determined by its social or familial worth: Confucian thought ranked order people by gender: man up, women down, later social hierarchy ranked scholar-peasant-craftsmen-businessman. Even moral character is equated or confused with gifts and accomplishments (e.g. people’s puzzlement at crimes committed by students from elite universities).
One of the most informative, respectful and eloquent comments about cross-cultural comments this writer has heard was what Dr. Anna Burton said, “take the mystique out of it.” We need to remember, “Every clinical encounter is a cross-cultural adventure”. Bon Voyage!