Stigma toward mental illness in Chinese societies is particularly pervasive and damaging1
resulting in harmful internalization of these negative conceptions and loss of self-esteem.2
Cultural concerns of preserving “face” lead to concealment of illness, poor treatment compliance,2
and intensified stigma when illness status is disclosed.3
Thus, societal stigma might partially explain the reported poor clinical and social outcomes of severe mental illness in China.4
Despite the strong societal stigma for the mentally ill in China compared with the West, rates of high expressed emotion (ie, “EE” or family members’ emotional attitudes that predict relapse) toward people with schizophrenia in China are generally lower than rates found in Western countries.5–7
Findings from other countries suggest that close-knit kinship bonds ameliorate the course of schizophrenia,8–10
but there is little evidence of this in China. Given that ethnic Chinese comprise approximately one-fifth of the world's mentally ill, it is important to reconcile this seemingly incongruous juxtaposition of greater familial inclusion and increased societal stigma. One approach is to clarify the cultural processes that enable people who exhibit psychotic symptoms in China to maintain “normal” status worthy of sympathetic inclusion and to avoid being labeled as the moral “other”—who merit stigma and discrimination.
Yang et al11
have recently proposed a conceptualization of stigma that highlights the moral standing of actors within a local context as integral to how stigma operates in China and other settings. Everyday social life revolves around the register of daily, practical engagements that defines “what matters most” for ordinary men and women or the “moral mode” of experience within that local world. To engage in these mundane, daily interactions is to certify one as a fully viable member of a local community. From this perspective, stigma can destroy an actor's capacity to take part in the core, everyday engagements that identify one as a moral or “full adult” person in a particular context and thus threatens the loss of what is most at stake
. Both the stigmatizers and the stigmatized can be conceived as warding off stigma when they act to maintain their moral status and to preserve what is most vitally at stake in a local social world.
“Explanatory models” of schizophrenia powerfully affect community perceptions of whether people who suffer from this illness retain their fundamental “moral status” or humanity.12
Certain cultural groups favor interpretations of mental illness that differentially allow for continued integration of the ill individual into social groups. Mexican American relatives are more likely to use the more encompassing illness term nervios
to interpret schizophrenia-like symptoms on a continuum of normal behavior, while white American relatives more readily adopt categorical terms indicating mental or psychiatric disorder.13
Acceptance of an official diagnostic label to interpret psychotic symptoms initiates conflicting processes: it not only enables treatment and care but also sets into motion the stigmatizing consequences of stereotyping, separation, discrimination, and power loss.14
In China, local understandings of schizophrenia are constructed via multiple frameworks of competing interpretive traditions, both traditional (eg, Buddhist, Confucian, traditional Chinese medicine) and biomedical. On one hand, the Mandarin Chinese construction of the character for schizophrenia (jing shen fen lie zheng
or “mind-split-disease”), due to its association with stereotypes of insanity, implies a loss of full moral standing.15
On the other, inclusive indigenous idioms, while potentially delaying entry into biomedical treatment, symbolically convey continuity of a person's social and moral status, reducing stigma and allowing for continued participation in social life.
This article investigates a previously unexamined idiom that is widely used in conjunction with accounts of schizophrenia in China—the concept of “excessive thinking” (xiang tai duo
). We seek to examine how this idiom overlaps with psychotic symptoms and to explore how it holds stigma at bay by preserving social relations and the moral standing of individuals. Phillips et al16
found that in Mainland China, over 25% of relatives of patients recently diagnosed with schizophrenia held thinking too much as responsible for their first hospital admission, making it one of the most commonly perceived causes of illness. Endorsing the idiom of excessive thinking may also beneficially impact on schizophrenia course. Yang et al17
found that patients whose relatives attributed illness behaviors to excessive thinking, and who perceived patients as having less control over illness behaviors, had fewer severe psychotic symptoms and rehospitalizations over 18 months when compared with patients whose relatives did not hold such attributions.
Documented as part of China's collective psychological makeup as early as the late 18th century in the classic epic Dream of the Red Chamber
excessive thinking remains in common use today. Although this Chinese idiom shares some behavioral features in common with North Americans’ conception of “nerves” (ie, being highly anxious and prone to worry over real or imagined troubles or being short-tempered, hard to get along with, and possibly aggressive13,19
), it has no direct Western equivalent. Excessive thinking might initially be understood as someone who habitually “takes things to heart” (or “too hard”) or “who is unable to let go of negative thoughts or events.” To think excessively is also to violate the fundamental Chinese obligation to be restrained and moderate in one's actions by engaging in extreme behavior. In The Doctrine of the Mean
, Confucius describes centering one's emotions and “cleaving to the central mean” as comprising “the great root of the world”20(p1)
that in turn orders all human relationships.20
To think excessively is to defy this deeply embedded social ethic. This idiom consists of 2 commonly used, interrelated variants: (a) the action of “taking things too hard” (xiang bu kai
) and (b) describing one who habitually thinks too much as “narrow-minded” (xiao xin yan
). (Although the English phrase narrow-minded conveys particular meanings that are extraneous to the Chinese construct of excessive thinking [ie, having a prejudiced mind, being morally self-righteous], we have kept this phrase to describe those who chronically think excessively because it accurately captures the element of individuals not being receptive to new ideas and therefore having a “closed mind.” The minds of such individuals are narrow in the sense that they are unable to “release” or “open up” their thinking due to holding thoughts in.)
As cultural idioms, these linguistic devices may enable their users both to recognize socially aberrant behavior and to stop short of defining it as abnormal or psychopathological. Even when a diagnostic label is invoked, such idioms might still continue to modulate resulting stigma. Although excessive thinking is frequently utilized in association with schizophrenia, the mechanisms by which this idiom is viewed as an etiological factor and/or an alternative account of the bizarre behaviors of schizophrenia—and the ways in which it might diminish community and familial stigmatizing reactions to illness—are not well understood. Relatives are the primary caregivers for 90% of people with schizophrenia in China,21
so how they make use of such idioms is likely to affect help seeking, symptomatic recovery, and community response to the illness. We aim to examine how the use of the excessive thinking construct is utilized in association with schizophrenia and might act as a socially acceptable label that mitigates mental illness stigma. We utilize qualitative methods to extend established quantitative findings because the boundaries of what is under study have not been clearly established and local understandings of these phenomena remain in flux.22