Traditional Chinese medicine in psychiatric practice in Singapore.

Around three-quarters of the Singaporean population are of Chinese ethnic origin, and so traditional Chinese medicine is the most widely practised non-Western system of healthcare on the island.

Traditional Chinese medicine was first recorded some 2500 years ago in the ancient textbook of medicine Classics of Internal Medicine (Huang-Di Neijing), a collection of dialogues between the Yellow Emperor and his court physician, Ch’i Po. Written during the era of the Warring States (476–221 BCE), it showed an awareness of emotional and psychological factors in the causality of physical illness. A mind–body nexus rather than dichotomy was emphasised.

In Chinese culture, theories of health and illness are embedded in customs and religious philosophies. Religious beliefs and spirituality are therefore important issues in psychiatric practice. Since ancient times, religious practice and healing have been closely associated, and healing has often been performed by priests. With advances in scientific knowledge, the healing role has now largely been taken over by doctors, but priests or traditional healers are still consulted first in many Chinese communities.

The basis of traditional Chinese medicine is the belief that there is a finely balanced relationship between bodily functions and emotions. This belief is built on the concept of ‘yin–yang’, a bipolarity that is opposite and complementary. The yin represents coldness and yang warmth. When this homoeostasis is disrupted, physical or mental illness can result. The prescription of herbal medicine or the administration of acupuncture attempts to restore the imbalance of the yin and yang. Besides physical treatment, it is the shared cultural beliefs of the healer and the patient and the relationship between these two that are pivotal in recovery.

Family and cultural beliefs often determine illness behaviour and the health-seeking tendency of the patient. In a study of the illness behaviour of 100 Chinese patients referred consecutively to the psychiatric clinic of the National University Hospital in Singapore, it was found that 36 had also consulted traditional healers.

Health-seeking behaviour

Family and cultural beliefs often determine illness behaviour and the health-seeking tendency of the patient. In a study of the illness behaviour of 100 Chinese patients referred consecutively to the psychiatric clinic of the National University Hospital in Singapore, it was found that 36 had also consulted traditional healers (Kua et al, 1993). Most of these patients were suffering from depression, anxiety or schizophrenia. It is common in the Chinese community to consult both the traditional healer and the psychiatrist.

The possession trance is a common culture-related phenomenon in Singapore and many other countries in Asia. The characteristic features have been reported by Kua (1986). Because possession trance is not deemed an illness in the community, a traditional healer is often consulted. This socially sanctioned behaviour is recognised as a sign of distress and evokes the appropriate family response – support and sympathy. Those with the condition are treated with respect because they are perceived to be favoured by a deity. Treatment by the traditional healer lacks the stigma associated with referral to a mental hospital. In a follow-up study of depression among elderly Chinese people, it was noticed that many did not seek treatment in a hospital or out-patient clinic but preferred traditional medicine (Kua, 1993).

To the depressed patient, symptoms of poor sleep, loss of concentration and listlessness are interpreted as due to a ‘weakness of mental energy’. It is difficult to explain or understand the patient’s neurotic problems in Western psychoanalytic terms like the ‘Oedipus complex’ or ‘ego strength’.

Physical treatment

In traditional Chinese medicine, herbs and acupuncture are the main methods of treatment for psychiatric conditions. Acupuncture has been used to relieve headache, insomnia, depression and chronic pain. A study by Luo et al (1997), from the Beijing Institute of Mental Health, showed that acupuncture was as effective as amitriptyline in the treatment of depression. Extracts of herbs like Astragalus membranaceus, Angelica sinensis and Wikostroemia chamedaphre have been claimed to be useful in the treatment of both depression and insomnia (Liu, 1981; Tien, 1985).

For many centuries, Chinese people have known about the effects on longevity of the consumption of Ginkgo biloba extract (from the leaves of the Ginkgo tree). However, there is a paucity of scientific data to support this assertion, although all round the world Ginkgo biloba extract is sold over the counter in pharmacies for the prevention of memory impairment in late life. De Smet (2002) reviewed the scientific evidence on the Ginkgo biloba extract as an antioxidant.

In traditional Chinese medicine there is also an emphasis on exercise as part of a healthy lifestyle to restore the yin–yang equilibrium. Tai-chi or kung-fu is encouraged as a form of exercise during the recuperation phase of physical or mental illness. It is interesting to note that many traditional healers and priests (e.g. the Shaolin monks) are themselves experts in kung-fu, which is taught in temples as an art of self-defence.

In Western psychotherapy, the focus is on the individual struggling with biological urges and social constraints. In Chinese culture, the emphasis is on the individual as a member of a family.

Psychotherapy

Particular types of what may broadly be termed psychotherapy reflect the cultural and religious milieu in which they are developed. In Western psychotherapy, the focus is on the individual struggling with biological urges and social constraints. In Chinese culture, the emphasis is on the individual as a member of a family. In Western psychotherapy, the patient plays an active role, whereas in the East, generally, the patient is more passive. In traditional Chinese medicine, psychotherapy is part of a holistic package of care, which includes herbs and acupuncture.

A powerful therapeutic factor is the rapport between the patient and the healer. The Confucian philosophy of the hierarchy in the state and family bestows high esteem on the healer. The aura of the healer is heightened if it is also known that he or she is an expert in tai-chi or kung-fu.

In the clinic, healers examine the patient largely through observation and feeling the pulse. There is minimal verbal communication and they explain to patients the state of their yin and yang. The healer explains the symptoms using the belief systems the patient is familiar with. To the depressed patient, symptoms of poor sleep, loss of concentration and listlessness are interpreted as due to a ‘weakness of mental energy’. It is difficult to explain or understand the patient’s neurotic problems in Western psychoanalytic terms like the ‘Oedipus complex’ or ‘ego strength’.

The Japanese Morita model of psychotherapy (named after Shoma Morita, 1874–1938) is influenced by Buddhism. During treatment, there is a phase of disengagement from the precipitating factor (e.g. leaving an intolerable relationship or situation), introspection (rethinking the issues and planning different strategies in problem solving), conflict resolution (with suggestions by the healer to overcome the impasse) and finally the phase of acceptance of reality and solutions. The paternal transference on the healer is likened to the master–student relationship, as in martial arts training. The healer’s suggestions help patients to accept themselves and to internalise the healer’s wisdom. A healthy diet with herbal supplements and regular exercise or martial arts training are integral to the recovery process.

Conclusion

In the provision of psychiatric care in the East, the role of the traditional healer is gradually being acknowledged. In Indonesia, psychiatrists work closely with traditional healers and organise training programmes to help them identify patients with psychosis, to ensure their early referral to the hospital for treatment with antipsychotic medications. This collaborative effort is especially vital in countries where there is a perennial shortage of trained psychiatrists and other mental health professionals.

In a study of depression in elderly Chinese people (Kua, 1993), many patients preferred traditional healers partly because of their accessibility (the clinics were usually near their homes) and because the fees were affordable. Consulting a healer also avoided the stigma of being labelled a ‘mental patient’.

With globalisation, the issue of ‘cultural intelligence’, as described by Earley and Mosakowski (2004) from the London Business School, is crucial as economic expansion crosses national boundaries and continents and so also very different cultures and customs. Modern psychiatry grew out of Western Europe and the United States. Most psychiatrists in the East are schooled in Western ideas of psychiatric practice. There is much to learn from the psychotherapeutic techniques of traditional healers in the management of psychiatric disorders. Fundamental in the therapeutic relationship is trust, and an understanding of the cultural belief system is a sine qua non.