Concept of Clinical Psychology

Definition of Clinical Psychology

Clinical psychology is an integration of the science, theory and clinical knowledge for the purpose of understanding, preventing, and relieving psychologically-based distress or dysfunction and to promote subjective and behavioral well-being and personal development (Society of Clinical Psychology; Plante, 2005). Central to its practice are psychological assessment and psychotherapy, although clinical psychologists also engage in research, teaching, consultation, forensic testimony, and program development and administration (Brain, 2002). In many countries, clinical psychology is regulated as a health care profession.

Characteristics of Clinical Psychology in Mainland China

Compared to the concept “Clinical Psychology” in North America, the “Clinical Psychology” in Mainland China is a relatively vague notion. It is always mixed up with other subject names , such as, Counseling Psychology, Medical Psychology, Psychosomatic Medicine, Healthy Psychology, Behavioral Medicine, etc. In psychology department of university, most of clinical or counseling related curriculums are set under Applied Psychology, a subordinate discipline of Psychology, with diverse course names. Most people who work in the area of clinical or counseling psychology have different training or education backgrounds. And many of them have not got a Master or Ph.D. degree. However, those professors or experts with Ph.D. are primarily devoted to teaching and research, but not clinical service.

Those people who provide psychological services are often called “psychological doctor ”. Because of the influence of traditional Chinese culture, people who are going to see a psychiatrist in psychiatric hospital or mental health center believe that they will be discriminately treated as “psychosis” or “insanity”. By contrast, it’s much better if they see a “psychological doctor” in a community based or college based clinics. Hence, the notions of psychiatry and psychology greatly differ from each other. The concept of psychiatric disorders is much discriminated by the society, while the concept of “Psychological disorders” is relatively much friendly accepted.

Given the limited space available, we are not to introduce the development of clinical psychology in Hong Kong, Taiwan or Macau.

History and Development

There existed rich ideas and practices related to clinical psychology before modern clinical psychology was introduced into China at the beginning of the twentieth century. In general, the development of clinical psychology can be divided into four phases as follows.

Before 1949 : Initial Spread of Modern Clinical Psychology

Before the establishment of Republic of China (1911), it was the preparatory period of Chinese local clinical psychology. A variety of Traditional Chinese Medicine (TCM) classics , such as Treatise on Febrile and Miscellaneous Diseases (伤寒杂病论) and Invaluable Prescriptions for Ready Reference (千金要方), recorded many psychosomatic diseases, interpreted the relationship of mind and body, and developed some corresponding treatments. In addition to TCM, witchcraft, divination and praying magic figures were also used to provide treatment in this period (Chen, 2012).

During the period from 1912 to 1949, modern western clinical psychology entered China and began to develop. The normal pavilion of Peking Imperial University, i.e., the predecessor of Beijing Normal University, first offered a psychology course in 1902, involving a variety of topics related to general psychology, experimental psychology, child psychology, etc. The first psychology lab was established in Peking University in 1917. In 1920, the first psychology department appeared at Nanjing Higher Normal School which changed to National Southeast University later. From 1923 to 1928, departments of psychology were founded in a few other Chinese universities including Beijing Normal University and Peking University. These psychology departments gave a number of clinical psychology courses, such as abnormal psychology, abnormal child psychology, principle of mental health, applied psychology, and so on (Gao, 2005). Moreover, mental health courses were also provided in some medical colleges in this period.

The Chinese Psychological Society (CPS) was founded in 1921 in Nanjing, and Chinese Association for Mental Health (CAMH) was founded in 1985 in Taian. Some hospitals, schools, child welfare organizations and medical research departments began to open mental health clinics, providing psychological assessment and counseling/therapy by professional psychological workers and social workers (Sun & Ji, 2010). The first mental health congress took place in 1948 in Nanjing (Gao, 2005).

From 1949 to 1976 : Stagnation of Clinical Psychology

In the period from 1949 to 1965, western psychology, particularly social psychology, psychological testing and mental health, was criticized and even denied (Gao, 2005). Psychological therapy work was done only to a limited extent. For example, the Institute of Psychology of the Chinese Academy of Sciences (CAS) and Beijing Medical College cooperatively developed a rapid comprehensive therapy, combining medical treatment, physical exercises, thematic lectures and group discussions, for individuals with neurasthenia, schizophrenia and some psychosomatic diseases like hypertension and canker (Qian & Wang, 2006).

During the Cultural Revolution period (1966–1976), psychology was declared pseudoscience, and psychology courses were stopped nationwide. It cancelled the Institute of Psychology of CAS as well as psychology teaching and research sections in department of psychology of universities, resulting in the complete stagnation of psychology.

From 1977 to 2000 : Restoration and Development of Clinical Psychology

The Institute of Psychology of the Chinese Academy of Sciences was restored in June 1977, and CPS resumed activities later in November 1977. In the following years, departments of psychology were reestablished in several universities including Peking University and Beijing Normal University. The Ministry of Health of the People’s Republic of China (CMH) proposed to offer medical psychology course at medical colleges, and to establish psychological counseling clinics in mental hospitals and comprehensive hospitals, providing psychological service. According to the regulations issued by the CMH, one of the rating criteria for comprehensive hospitals (first class hospitals) is whether a psychological counseling clinic is established or not. As a result, psychological counseling clinics are now available in thousands of first class hospitals nationwide.

Since 1984, psychological counseling centers have been set up one after another in universities, offering free counseling service for students (Huang, He, & He, 2008). In the following years, professional psychological counseling organizations were established in Chinese justice department (e.g., armed police, jails, and drug rehabilitation center), social service system (e.g., Disabled Federation, Women’s Federations, and communities), and enterprises as part of corporate training (Huang et al., 2008).

However, a great number of problems and challenges have emerged whether in psychological counseling clinics of medical institutions or psychological counseling centers of the higher education system, of which the primary is the majority of mental health service staff lacks systematic and standard professional training.

From 2001 to Today : Rapid Development of Clinical Psychology

Former Chinese Ministry of Labor (CML) released the temporary national qualifications for psychological counselors in 2001. The first qualification examination was carried out in 2002, and psychological counselors, as a new career, can conduct related psychological counseling only when they received the qualification certificate. In addition, the CMH incorporated psychological therapy into the qualification examination system for medical professionals. Individuals who passed the examination will receive the psychological therapist qualification certificate, which is the only qualification certificate approved by the CMH, in addition to psychiatrist, for conducting professional psychological therapy. These government measures promoted the popularity of psychological counseling and therapy service in public. However, problems still remained regarding psychological counselors/therapists’ professional training, continued education and management.

The Committee of Clinical and Counseling Psychology was set up in CPS in 2001. In 2007, the executive committee meeting in Beijing approved two important documents: Chinese Psychological Society Registration Criteria for Professional Organizations and Individual Practitioners in Clinical and Counseling Psychology and Chinese Psychological Society code of Ethics for Clinical and Counseling Practice. The Clinical and Counseling Psychology Registration System (CCPRS) of CPS was founded to conduct quality control and self-discipline.

The Chinese Mental Health Act was launched in 2013. It first made a clear distinction between psychological counseling and psychotherapy service, regulating that (1) psychological counselors can only provide professional counseling service for the public outside of mental hospital system, but cannot conduct psychological therapy or mental disorder diagnosis and treatment; (2) mental disorder diagnosis should be made by certified psychiatrists ; and (3) psychological therapy should be conducted in medical institutions.

Professional Condition of Psychological Counseling and Therapy

Professional Training Systems

The Discipline Subordination of Clinical and Counseling Psychology

According to the rules of Chinese Ministry of Education (CME) and the Academic Degrees Committee of the State Council, Psychology is the first-level discipline and Applied Psychology is the second-level subject, while Clinical and Counseling Psychology is the subordination of Applied Psychology. Since 1998, China has set up Applied Psychology (4 years) as one of major of undergraduate, granting “Bachelor of Science”. So far, the number of colleges which set up Applied Psychology as a major is more than 200, and some universities opened courses named applied psychology.

The Training Provide in Normal or Comprehensive Universities

The department of psychology in universities resumed to recruit student in 1978. Since then clinical/counseling psychology related majors have been always welcomed by students. There are a lot of courses of applied psychology, but less practicum activities in department or school of psychology in university system. The school attaches great importance to scientific training, and the requirement of graduation for Master graduates is to publish paper on Chinese core peer review journals as first-author, and for Doctoral graduates is to publish paper on foreign core peer review journals as first-author. Only after publishing articles and finish their thesis, can students, whom no matter what programs they are, be qualified for the final oral defence. By contrast, there is no requirement of clinical related practice training by university, such as lacking of systematic, normative clinical/counseling training program and standards of practice and internship for students. As those clinical or counseling psychology professors working in university system have a whole lot different training background, most of them no clinical or counseling psychology system training, they offer no psychological service. Hence, what clinical training the students get from their schools depends on what their advisors or supervisors prefer to. In general, because of being short of practicum, internship and supervision, and other reasons, most graduates cannot be engaged in psychological counseling- or psychotherapy work.

Even so, some or a small number of clinical psychology professors themselves still insist on clinical work weekly, such as therapy sessions, supervisions and clinical intervention research and related practice, by overcoming all kinds of obstacles. Meantime, their students are required to get some clinical training and practice as much as they can. However, for various reasons, clinical or practical training for students is still limited.

It is worth mentioning that, in recent years, a few universities have started to pay attention to the clinical psychology program enacted by CCPRS which has already put up with a definite provision about courses, academic, practicum and internship requirements, hoping great progress and breakthrough could be made in the near future.

The Training Provide in Medical Schools

Unlike North America and other countries, in Mainland China, CME approved to set up applied psychology as a specialized subject for undergraduate student in nine medical colleges in 2001 which breaking through the situation that applied psychology major was only open for students in normal/comprehensive universities. By the end of July 2009, according to the official information from the website of CME, over 50 medical colleges have set up psychology or applied psychology major (not including psychiatry) (Shen & Tao, 2005; Wang & Du, 2010). Graduates majored in applied psychology from normal or comprehensive universities can not work in hospital system because of impossibility to acquire physician certificate, while those graduates from medical schools are qualified for acquiring it.

The Training Provide in Social Institutions

Since last early 90s, several influential training programs have been successively introduced into mainland China, such as “Sino-German Advanced Continuous Training Program for Psychotherapist” (also the first continuous training program introduced into Mainland China), the counseling training program conducted by Professor Mengping Lin (learn from Carl Rogers) from Chinese University of Hong Kong in Beijing Normal University. Most of the trainee from those programs later become the professional leaders in the field of psychological counseling, bringing great influence for the initial development of provision of psychological service in mainland China.

In recent a few years, more and more training programs of different schools gradually become systematical, such as “The China American Psychoanalytic Alliance (CAPA)”, “China-Norway Continuous Training Program for Psychoanalytical Therapists and Supervisors”, “Satire’s Family Therapy Continuous Training Program”, “Cognitive-Behavioral Therapy (CBT) Continuous Training Program” by Professor. Jianping Wang of Beijing Normal University, “China-German Advanced CBT Continuous Training Program”, etc. To a large extent, above training programs offset the deficiency of the clinical practice in universities, and improved the level of psychological service. Whereas, on account of the lack of resources of qualified supervision and solid theoretical foundation, the number of clinician with enough training to offer psychological service independently is very limited. Therefore, CCPRS has established several supervision working points in some provinces (so far about 10) where exist registered supervisors and psychological counselors or therapists.

However, besides the existence of those long-term programs, there still are many short-term trainings (a few days) in different skills or approaches in various forms. Some training teachers come from foreign countries, and some are from Hong Kong or Taiwan. On the whole, the professional level of training is still low (Yao, 2010).

The Training Program for Professional Master Students

The training program including applied psychology or mental health education for professional master degree began in 2011 for the undergraduate entrance, which is a 2-year full-time schooling education. Nevertheless, the admission standard and graduation criteria, comparing with the one for academic master degree are relatively low. The training program has no clear requirement for practicum or internship. Additionally, although some of students have acquired the Certificate for Psychological Counselor granted by the CML before or after their graduation, they are still not able to do the work like psychological counseling or therapy. Since 2013, some universities start to admit part-time professional master students, majoring in Psychological Counseling, Employee Assistance Program, Family education or Therapy and so on. And in 2016 fall semester, School of Psychology of Beijing Normal University is starting to conduct systemic professional clinical and counseling psychology training program, including practicum, internship and supervision hours for professional master students.

Theory Schools of Psychological Counseling

The western theories of psychological counseling or therapy, like dream interpretation and free association, were initially introduced into China at the beginning of the twentieth century, later followed by behavioral therapy in 1930s. Thus, psychoanalytical and behavioral therapy were the earliest approaches introduced into mainland China.

The real development of psychotherapy began in the late 1980s, with a few books on psychological counseling or therapy, primarily the works of Sigmund Freud, being translated into Chinese. In the 1990s, some psychodynamic therapists have already begun to independently offer psychological service. Until now, in mainland China, there are four psychotherapist certificated by International Psychoanalytical Association (IPA ) , and six psychoanalyst certificated by International Association for Analytical Psychology (IAAP) .

It is worth mentioning that Dr. Youbin Zhong, the native psychotherapist in mainland China, pioneered Cognitive Insight Therapy, also known as Chinese Analytical Psychology , which combines the principles of psychoanalysis with Chinese national conditions and traditions. Cognitive Insight Therapy is a short-term technique and is suitable for social anxiety and anxiety disorders (Qian & Zhong, 2012). Moreover, there is another technique worth mentioning, i.e., Imagery Conversing . It is a psycho-therapeutic technique developed by Dr. Jianjun Zhu in the beginning of 1990s. Based on psychodynamic theory, this technique creatively incorporates dream interpretation, hypnosis, humanistic psychology, and eastern culture into one application. It can be used for obsessive-compulsive disorder, school phobia, depression and other symptoms (Li & Zhang, 2011).

Behavioral Therapy was initially introduced into China in 1930s, not being widespreadly applied until the 1980s. It was not until the 1980s, Cognitive Therapy was introduced into Mainland China, and some works of Aaron T. Beck and Albert Ellis were translated as a main source of teaching materials. At that time, most people learned cognitive therapy by reading books themselves, and then used certain cognitive skills in the process of psychological counseling, and thus they classified themselves as cognitive therapist. Consequently, the data showed that the number of people who using cognitive techniques is the largest. And many of them consider it easy to learn and not necessary to attend a systematic training program to be a CBT therapist. Different from what is expected, many trainees finally found that it is far away from being a cognitive behavioral therapist after participating in my CBT training workshops (first author of this chapter). Therefore, the real Cognitive-Behavioral Therapy is not developed until recent years. So far, only three CBT therapist have acquired the certificate issued by the Academy of Cognitive Therapy (ACT) and one approved as an ACT’s Fellow (first author of this chapter) in Mainland China.

Although family education or therapy started relatively late in Mainland China, however, it has developed a little bit faster. The number of family counselors or therapists is only less than that of psychodynamics. In April 2007, the Ministry of Human Resources and Social Security of the People’s Republic of China permitted to grant Marital and Family Counselor as a new career. Later in June 2009, the first career certification exam for marital and family counselor was conducted. Wai-Yung Lee, the member and supervisor of American Association of Marital and Family Therapy, now is the chief director of the Hong Kong University Family Institute. She is the only Chinese disciple of Dr. Salvador Minuchin who is the founder of Constructed Family Therapy, contributing herself into the application and development of marital and family therapy both in Hong Kong and Mainland China. In mainland, Marital and Family Therapy Institution of Beijing Normal University run by Dr. Xiaoyi Fang is the earliest professional research and therapy institution.

Quite a lot of theoretical ideas and basic techniques of humanistic psychology have been the basis of other schools. Until now, related humanistic-existential psychological trainings , also some of the Chinese version of books written by Irvin Yalom, have already been introduced into mainland. Since 2014, the first successive 2-year professional certification course for “Humanistic and Existential Psychological Therapy ”, cooperating with International Institution of Existential and Humanistic Psychology, was introduced into China. The aim of this course was to assist domestic psychological counselors and therapists to better know the essence of existential-humanistic psychology and apply it to their clinical work.

In the year 2015, among the whole applicants in CCPRS , more than 70 persons applied for psychoanalyst or psychodynamics, ten applied for family therapist, only three applied for CBT, and one applied for narrative therapist. Obviously, psychoanalyst applicants leaded an overwhelming margin.

Mental Health Service Market

Service Providers

It was estimated that there were about 16 million persons with severe mental illness, about 39 million with depression, and about 130 million with various mental disorders in Mainland China (Qian, 2009). At present, the mental health service providers mainly consist of the following ten categories of professional or nonprofessional persons , which partially overlap.

Category 1: Psychiatrists . There are 1650 mental health professional organizations, 228 thousand psychiatric inpatient beds, and more than 20 thousand (author note: about 22 thousand) psychiatrists (Centers for Disease Control and Prevention (CDCP) of National Health and Family Planning Commission of the People’s Republic of China (NHFPC), 2015). In terms of location distribution, most resources are in eastern and urban areas; and there are no professional mental health organizations in a total of 37 cities (mainly in western areas), around one third territorial area and 41.9 thousand population covered (Guo et al., 2008). Most psychiatrists have a medical background and lack systematic and standard psychological therapy training. They primarily provide mental disorder diagnosis and medication treatment, and only a few can provide systematic and regular psychological therapy service.

Category 2: Psychological therapists. Since the first psychological therapist qualification examination in 2002, nearly 3000 persons have received the therapist qualification certificate, most of whom work in medical institutions to offer psychological therapy service (CDCP of NHFPC, 2015). Moreover, a variety of training programs have been introduced from Germany, the U.S., Norway and other countries, which improved a number of psychological therapy professionals’ technical skills and service quality.

Category 3: Psychological counselors . By the end of the first half of 2016, over 1.5 million persons participated in the national counselor qualification examination, and more than 900 thousand persons received the counselor qualification certificate (Level 2 and/or 3). Certified counselors are widely distributed in various industries, such as education, health, justice, labor/youth/women’s organizations, and the army (police) system. However, due to the low entry standard in early counselor qualification examinations and candidates’ various educational and professional backgrounds, even though the requirements for examination registration become stricter in recent years, the majority of certified counselors have had only a short-term course without practicum or internship training so that they can hardly provide professional counseling. A recent survey in Beijing, Shenzhen, Anhui province, Shandong province and other regions revealed that 1 year after receiving the certificate, about 8% counselors were still engaged in psychological counseling service, and no more than 3% were professionally engaged in counseling (CDCP of NHFPC, 2015).

Category 4: Registered clinical and counseling psychologists . CCPRS of CPS was founded in 2007 to explore better professional management mode. By the end of 2014, a total of 13 professional mental health service agencies registered in the system; the number of registered clinical and counseling psychologists was 726 (CDCP of NHFPC, 2015); to include registered assistant psychologists and supervisors, the total number is still less than one thousand.

Category 5: School counselors . The CME launched documents in 1999 and 2001 to promote the training and certification of school counselors in primary and secondary schools as well as colleges and universities. The requirements for candidates are teachers and owning at least bachelor degree in education or psychology. There are about 60 thousand school counselors. They mainly help students to deal with developmental and some psychological problems.

Category 6: College instructors . First as political instructors in 1952, the role of college instructors has been largely extended, particularly since 2004, to help students in dealing with study and life problems, including emotional distress, interpersonal relationships, career planning, and so on. Due to the close relationship between college instructors and students, they are often quite aware of potential mental health problems among students, take first action like communication with students, contact students’ parents, help arrange counseling for students at university counseling center, and keep following up. Surveys showed that students preferred to ask help from college instructors with psychological problems, compared to psychological counselors (Chen, Wu, Zhao, & Ma, 2010). In recent years, more universities support and organize their college instructors to participate in continuous psychological therapy training programs in order to improve their professional capacity .

Category 7: TCM Practitioners and non-psychiatric doctors . A survey (Shi et al., 2000) in Shanghai Mental Health Center showed that only 50% (9/18) patients with bipolar disorder visited department of psychiatry first, and the ratio was 37% (51/138) for schizophrenia, 12% (11/91) for depression and 7% (5/74) for neurosis. Most patients received first TCM or other western medicine treatment, and about 10–28% patients received Qi Gong or Superstition treatment. One important reason why patients visited comprehensive hospitals first was the existence of accompanying physical symptoms, and other reasons included that patients or relatives lacked in mental health knowledge and viewed first-episode psychiatric symptoms as common thought, character and emotional problems, or that they were unwilling to visit psychiatric hospitals out of fear for social stigma (Shi et al., 2000).

It is noteworthy that the role of TCM in mental health service has drawn more attention in recent years. At present, applied psychology specialty has been set up in over ten colleges of TCM, and some colleges have even master and doctor degree programs in TCM psychology. Some TCM hospitals established department of psychological counseling and neuropsychological rehabilitation ward in Beijing and other cities.

Category 8: Religious persons . Due to some psychiatric symptoms associated with strong religious superstition characteristics, the Chinese people are likely to attribute the cause of schizophrenia to supernatural forces like ghost and thus turn to religion or superstition for treatment (Huang, Shang, Shieh, Lin, & Su, 2011). Previous studies showed that 21.0–70.7% patients with schizophrenia asked for certain form of religious or superstition help (see Deng et al., 2012). Folk religion has much more influence in rural areas where mental health resources are generally insufficient, and most studies used samples from urban areas, the (positive and negative) role of religion and superstition in rural and remote areas might be more significant.

Category 9: Social workers . The evaluation system of professional standards for social workers was set up in 2006. By the end of 2013, about 760 thousand persons participated in the qualification examination, and over 80 thousand persons received assistant social workers and social workers certificates. In addition, there is not mental health social worker training or specialty. So far, a few mental health agencies in Beijing, Shanghai and other cities have founded the hospital system of social work, established independent department of hospital social work, and equipped professionals to offer psychiatric social work service (Liu & Zhu, 2011).

Category 10: Family, friends and others . There were only pharmacies where TCM practitioners also gave disease diagnosis in ancient China. In general, patients received treatment at home and the practitioners visited them regularly. In nowadays, patients receive treatment at hospital, but family members must usually stay there to take care of them. The same is true in open psychiatric ward. Patients under the age of 40 were mainly took care of by parents, and those older than 40 were usually by spouse, adult children, or siblings (Bian & Xie, 2002). Thus, family members and friends provide very important assistance in mental health service.

Moreover, local government organizations in urban communities and subdistrict as well as in rural villages play an important role in mental health service. Actually, these organizations get involved in various problems of residents, if not everything, including couple conflicts, child and old people related problems, financial difficulty, organization of various public activities, and so on. Although these organizations often deal with mental health related problems, there are few mental health professionals employed in them. Thus, to better understand the situation of mental health service in Mainland China, it is necessary to include the contribution of these non-professional mental health resources, also including volunteers in local organizations (e.g., street aunts), police (e.g., when family violence occurs), and even leaders in work place.

Service Sites

As noted above, there is currently a great lack of psychological counseling and therapy professionals, and a great number of non-professionals are engaged in mental health service. These professionals and non-professionals mainly work in the following seven areas.

Site 1: Psychiatric hospitals . It is the major force in Chinese mental health service. Psychiatrists provide treatment, in the forms of diagnosis and medicine treatment, for patients with a variety of mental disorders. Since 2002, psychological therapists began to offer psychological therapy service, as supplementary to medicine treatment, for some patients (e.g., with depression, anxiety disorder) at these hospitals. The Chinese Mental Health Act (2013) requires that specialized medical institutions for mental disorder diagnosis and treatment should also be equipped with psychological therapy professionals. Shanghai Mental Health Center has now an independent building for psychological clinic, suggesting some recognition of the importance of therapy service .

Site 2: Psychological clinic at comprehensive hospitals . The CMH required that first class hospitals must establish psychological counseling clinics in 1987. Thus, the number of such psychological clinics is very large, but they receive actually little attention from hospitals. They also generally provide medicine treatment because of incapacity to offer professional psychological service.

Site 3: Education system . At present, the comparatively highest level of professional psychological service in Mainland China should be available in psychological counseling centers at university. Universities and colleges pay much attention to students’ mental health, particularly the prevention of suicide. Counseling centers were set up nationwide in all universities and colleges, and were equipped with full-time and part-time professionals. Nevertheless, only 30 thousand professionals are available to offer service for a total number of over 24 million college students (Kaiwen Xu, interviewed by Health News on July 25th, 2015). Most professionals are certified counselors, whose professional quality and skills are generally limited due to lack of systematic professional training. In recent years, psychological counseling centers have been also established in primary and secondary schools, or even kindergartens in Beijing, Shanghai, Guangzhou and other cities with rich mental health resources.

Site 4: TCM hospitals . Many people with psychological, psychosomatic, or even severe mental problems prefer to visit TCM hospitals and believe in the treatment effect of TCM. In ancient China, TCM has indeed played the role of psychological counseling or therapy to some extent. However, there exists some problems in the current development of TCM itself, and TCM practitioners vary greatly in their professional quality and skills. As a result, the potential effect of TCM on mental health problems is much reduced and thus very limited. Recently, a few TCM hospitals in Beijing, Guangzhou, Hangzhou and other cities have established department of psychological counseling, but its service quality is hard to be guaranteed.

Site 5: Enterprises . A number of large enterprises set up Employee Assistance Program (EAP) or similar section, and engage psychological counselors on site to offer counseling service for employees. However, many these counselors are often in lack of systematic professional training and sufficient professional skills.

Site 6: Private agencies and psychological hotlines . In recent years, private psychological counseling agencies are gradually increasing, varying in scale. Professionals are generally certified counselors with various education backgrounds. They primarily provide psychological counseling and hotline service for community population with psychological problems. There is little quality management and its service quality is hard to guarantee .

Site 7: Private foreign hospitals . For example, Chindex International engages certified professionals from the Europe, the U.S. and China to provide mental health services, using the American hospital standards including high price standards.

Service Delivery

Form 1: Traditional face-to-face individual session . At present, it is still the primary service form of psychological counseling and therapy.

Form 2: Online video counseling . Due to the lack of mental health resources and concentration in Beijing, Shanghai and other big cities, more and more psychological counselors and therapists provide mental health service via online video for distant visitors. In general, most counselors will not use online video to complete the whole counseling process, but rather use it as supplementary in emergencies when face-to-face session is not available. Moreover, online video is used more widely to conduct group supervision. Given the very limited supervision resources, this form of supervision plays a particularly important rol e. Sure, its effect is not as good as face-to-face supervision.

Form 3: Provision of psychological counselors via the Internet . It is a new trend, combining the Internet convenience into professional psychological counseling. Take the website “Jiandanxinli” for example, it is a platform which provides a list of selected psychological therapists with a detailed professional background introduction. The website users could make a face-to-face or online video counseling appointment with counselors via the platform.

Form 4: Hotlinecounselin . It is usually used as crisis intervention hotlines, and is also able to provide psychological counseling service. For example, the Maple Women’s Psychological Counseling Center Beijing offers both face-to-face and telephone counseling service for people in need. As regard to price, telephone counseling is 30–50% cheaper than face-to-face session.

Form 5: Information provision via the Internet . Recently, universities and colleges have all established their own mental health websites, and more and more medical institutions, enterprises and even individuals are setting up similar websites. The majority of these websites provide general mental health knowledge for the public, playing the role of mental health education. Many websites offer free online information service, primarily giving answers and advices to users’ questions in the form of text via BBS, Email and QQ (similar to MSN) (see Wang, Tang, Wang, & Maercker, 2012). It is actually a kind of consultation, rather than counseling. The users will be advised to visit professional mental health institutions for face-to-face sessions when needed. Some websites also provide individual counseling via telephone or QQ phone with very low price.

At present, there are still few Internet-Based Interventions (IBI) in Mainland China, i.e., providing systematic self-help or therapist-assistant psychological intervention via the Internet for specific mental problems. The authors of this chapter have recently introduced an IBI program for trauma recovery and achieved positive effects (e.g., Wang, Küffer, Wang, & Maercker, 2014; Wang, Wang, & Maercker, 2013).

Service Fee

Medical insurance system is complicated in mainland China. It covers certain kinds of medication fees (e.g., some medicines excluded and completely self-paid) and other medical costs in different percentages for different populations. Service fee is charged in various forms , mostly self-pay, and vary greatly across institutions. In general, private agencies charge highest fees; the education system offers free psychological service for their own students, but some professionals provide paid service for outside persons; the EAP service is paid by enterprises; and the psychological therapy price in hospital system is set very low so that no counseling or therapy professional is willing to do it. For example, while the price of individual face-to-face session is 120 Yuan per 50 min (about 18 U.S. dollars) in the Wuhan Hospital for Psychotherapy, local private psychological counseling or therapy agencies charge 500 Yuan per 60 min (about 77 U.S. dollars) (Jun Tong, interviewed by Health News on July 25th, 2015).

Compared to the price at Wuhan Hospital for Psychotherapy, the medical institutions in other regions charge even lower therapy fees. For example, the price is 30 Yuan per 50 min (about 5 U.S. dollars) in Beijing and 72 Yuan per 50 min (about 11 U.S. dollars) in Shenzhen (CDCP of NHFPC, 2015), but some private agencies in Beijing charge 3000 Yuan per 60 min (about 462 U.S. dollars) for psychological counseling/therapy. A psychiatrist and registered therapist and supervisor , in communication with the first author of this chapter, charged 200 Yuan (about 31 U.S. dollars) when he spent half a day doing 3–4 therapy sessions, but he could have charged more than 200 Yuan in a minute if he would prescribe medication.

Moreover, although Chinese medical insurance covers the medication fees for mental disorders, poor families can still hardly afford the systematic treatment due to the insurance’s limited coverage and low level of funding. Some severe mental health problems (e.g., suicide) and treatment methods (e.g., psychological therapy) are still excluded from the medical insurance coverage; recently published Essential Drug List also includes very few psychotropic drugs (CMH, 2009), which is completely impossible to meet the need of offering basic treatment for psychiatric patients (Xiao, 2009). Thus, family is still the primary provider of psychiatric patients’ life and treatment fees. Insufficient medical insurance remains an important obstacle for psychiatric patients to receive timely and systematic treatment.

Clinical Assessment and Research

Tests/Scales Revision and Development

Modern testing and assessments were introduced into Mainland China in the 1910s. In the following years, some important western scales, tests and questionnaires were revised, such as the first revision (1924) of Binet-Simon Scale by Zhiwei Lu. Chinese psychologists also developed some tests, such as a Moral Will Test by Shicheng Liao (1922) (Gao, 2005). With regards to clinical assessment, Rorschach Inkblots Test and Thematic Apperception Test (TAT ) were applied (Qian, 2011).

Since 1979, psychological testing has been rapidly developing, resulting in a number of revised or developed tests on intelligence, personality and capacity. Recently, with mental health drawing attention in Chinese society, the number of scales and questionnaires, for the use of assessing general mental health as well as various specific psychiatric symptoms and mental health problems, is gradually increasing. Until now, the most common scales used are still those translated from the West, such as Symptom Checklist 90 (SCL-90), Self-Rating Depression Scale (SAS) , Self-Rating Anxiety Scale (SAS), and Hamilton Rating Scale for Depression (HRSD) (Qian, 2011). The most authoritative Chinese testing book is Rating Scales for Mental Health (enlarged edition; 1999) published by the Chinese Mental Health Journal Publisher.

In general, although psychological testing is used to screen for mental disorders in Chinese medical institutions, these tests have actually played a lesser role. It is in research rather than in counseling and therapy practices that psychological tests play a major role.

To strengthen the management of psychological testing, the CAMH founded the Committee of Psychological Assessment in 1991. In January 2008, the Committee of Psychological Testing, founded in CPS, launched a psychological testing management document, authorizing the committee to register and evaluate psychological tests, to issue and manage psychological test qualification certificates, and to certificate the organizations that publish, sell tests and offer training.

Diagnosis Tools

Chinese mental health professionals generally use three diagnosis and classification systems for mental disorders: International Statistical Classification of Diseases and Related Health Problems (ICD), Chinese Classification and Diagnostic Criteria of Mental Disorders (CCMD) , and Diagnostic and Statistical Manual of Mental Disorders (DSM) . Among them, ICD-10 is the national standard for mental disorder diagnosis in Mainland China.

However, the usage of ICD-10 is less common than that of CCMD-3. Firstly, Chinese psychiatrists prefer to use CCMD-3 in clinical diagnosis of mental disorders. For example, a survey (Zou et al., 2008) revealed that among 192 Chinese psychiatrists, 63.5% used CCMD-3 as diagnosis standards, 28.7% used ICD-10, and 7.8% used DSM-IV. Second, reviewing the Chinese mental health literature, CCMD-3 is used more often than ICD-10. During the period from 2004 to August 2007, the usage ratio was 78.1% for CCMD-3, 8.6% for ICD-10, and 13.3% for DSM-IV in three top Chinese mental health journals (Chen, 2007). DSM-IV is the primary diagnosis standard in the English mental health literature by Chinese researchers. Third, since 1992, the majority of published Chinese textbooks and monographs in psychiatry more or less introduced ICD-10, and some compared the CCMD system with the DSM system in details; in chapters of specific mental disorders, however, most books used the CCMD system to illustrate the diagnosis of a particular mental disorder (Tang, 2009). Note that DSM-IV is the primary diagnosis standard in the English mental health literature by Chinese researchers.

It is noteworthy that since CCMD-2-R (1995), the CCMD system has started gradually adapting to the international classification of diseases, while retaining those mental disorder classifications with Chinese characteristics. The descriptive parts of CCMD-3 actually referred to the Clinical Descriptions and Diagnostic Guidelines of ICD-10, and the diagnosis parts of CCMD -3 referred to the Diagnostic Criteria for Research of ICD-10 and DSM -IV. As a result, the classification of diseases in CCMD-3 are greatly similar to those of ICD-10, and thus ICD-10 has a profound indirect impact on Chinese mental health professionals and practices. Given the increasing similarity between the CCMD system and the ICD and DSM systems, and more mental health professionals use the ICD system in recent years, some even question whether it is necessary to continue revising and using the CCMD system.

Research

Since the 1980s, the number of clinical psychology publications has been consistently increasing (Fu, Huang, Yin, Zhang, & Su, 2010). Besides the growth in quantity, the development over 30 years shows some significant trends.

Trend 1: On research methods , clinical trials are increasing and case reports are relatively decreasing. Take the top clinical psychology journal of Chinese Mental Health Journal for example, in the period from 1987 to 1997, it published about 130 articles related to psychological therapy, among which 34.6% were single case reports, 26.9% were reports of a group of similar cases, only 3.8% used the control group design to test therapeutic effect, and other 23.1% were theoretical studies (Zeng, 1997). From 2000 to 2009, the journal published 381 articles related to psychological therapy, among which 50.1% were empirical studies (66.0% of them using the comparison group design), 38.6% were theoretical studies, and 8.1% were case studies (Mao & Zhao, 2011).

Trend 2: On research themes , while the majority of mental health publications are on therapeutic effect, only a few on therapeutic process. For example, among the 191 empirical psychological therapy publications published in the Chinese Mental Health Journal from 2000 to 2009, 84.3% were examination of therapeutic effect, and only 2.1% were related to therapeutic process (Mao & Zhao, 2011). The Chinese Journal of Clinical Psychology, another important journal in Chinese clinical psychology field, published 204 articles on counseling and therapy from 1993 to 2007, of which 41.7% were related to therapeutic effect, and only 3.4% were related to therapeutic process (Hou, Gong, Yu, & Chang, 2008).

Although therapeutic effect studies are currently dominant in quantity, these studies are still at relatively low level. First, most empirical studies used pre- and post-intervention comparisons, but much less adopted the Randomized Controlled Trial (RCT) design (Qian, 2011). Second, most of empirical studies reported the statistical significance (SS) to examine therapeutic effect. Recently, some studies reported the effect size (ES). However, few studies reported the clinical significance (CS). Given that a high proportion of clinical patients have comorbid disorders and therapeutic process is hardly standardized as in research, further research should explore new ways in which clinical practices could more benefit from the findings in RCT studies (Wang, Wang, & Tang, 2011). Third, a majority of empirical studies used scales and questionnaires to test therapeutic effect, and less studies used other assessment methods, such as physiological indicators and behavior observation. A few professors’ research groups have been engaged in experimental clinical psychology all the time, and has cooperated with other research groups in brain science field to combine multiple indicators (e.g., emotional experience self-report, behavior change observation, brain function change) in experimental studies of clinical psychology (e.g., Wang, Lin, & Sun, 2002; Yan, Wang, Tang, Wang, & Xie, 2015).

Trend 3: On therapeutic approaches , the integration of different western therapeutic theories and approaches is common, and new or revised Chinese therapeutic theories and techniques emerged. A review (Fu et al., 2010) on 475 therapy and counseling publications in 11 Chinese professional journals from January 2000 to October 2009 showed that 93.7% used western theories, 4.4% used theories originated from the West but revised (e.g., cognitive insight therapy, Zhong, 1988; Taoism cognitive therapy, Zhang & Yang, 1998), and 1.3% used new Chinese therapeutic theories (e.g., TCM psychological therapy, Xu, 1994). Among the studies with western theories, 37.2% used two different theories (mainly cognitive and behavioral theories) or three and more theories (mainly cognitive, family and Morita therapy), 9.3% used cognitive theory, 8.6% used behavioral theory, and 8.4% used rational emotion theory.

Note that many publications gave a very general description of their psychotherapeutic methods; although named as some therapy approach, it could hardly be worthy of the name; in many studies it was just positive attention, explanation and support. It is particularly true for cognitive therapy and behavioral therapy that are common in Chinese mental health publications. Most of so called “CBT therapists” name themselves as CBT therapists as they just simply practice some single cognitive or behavioral skills. But they actually what they did could not be regarded as a real cognitive therapy or cognitive behavior therapy.

Trend 4: On target population , more and more mental health publications provide psychological interventions for non-clinical populations. For example, among the therapy and counseling publications in the Chinese Mental Health Journal from 1987 to 1997, subjects were primarily psychotic patients and psychiatric disorders dealt with were obsessive compulsive disorder, phobia, anxiety, and so on (Zeng, 1997). During the period from 2000 to 2009, 61.5% provided interventions for clinical patients and 38.5% for non-clinical subjects (Mao & Zhao, 2011).

Professional Societies or Associations

CPS , initially established in 1921, is a non-profit and academic social organization, and becoming a member of the International Union of Psychological Science in 1980. It has 20 professional branches that cover a wide range of specialties, including Medical Psychology, Counseling Psychology. The purpose of CPS, in order to stimulate the development of psychology, is to unify national psychological workers, take academic activities, and enhance academic research.

CAMH aims at unifying national scientific workers from the institutes of mental hygiene, psychology, medical science, sociology, and education to conduct various forms of psychological education or service related activities. Since founded in 1985, there are almost 20 thousand members, and 28 local branches, subordinated by 16 professional committees, including children mental health, psychological counseling and therapy and psychological assessment. In 1997, the Committee of Psychological Counseling and Therapy of CAMH, as a group member, joined in the World Council for Psychotherapy.

Chinese Psychiatry Association (CPA) , a subordinate organization of Chinese Medical Association, is the most important and influential academic society in the field of psychiatry. Its predecessor was the Neuropsychiatry Society of Chinese Medical Association which was established in 1951. Later, it separated from Neurology Society in 1994, and then became an independent institute. By the end of 2015, it has had more than 20 thousand psychiatrist members.

NHFPC has 21 organizations, one of which is the unit of mental health. In July 2015, NHFPCPRC with other related institutions together launched the National Mental Health Working Plan (2015–2020), aiming to train professional mental health clinicians including social workers, conduct standardized mental health training programs for psychiatric residents, provide continuous training programs for clinical workers, increase the number of psychiatrists, and set or improve grassroots mental health systems.

Besides above professional psychological organizations, the Ministry of Education and local Department of Education from provinces or cities also offer support and help for people or institutes in form of providing psychological services in school setting. The Department of Education is a government agency governing primary schools, middle-high schools and universities. So far all universities in China have their own psychological counseling centers, which provide psychological services for all students without any payment.

Professional Rules and Regulations

Entrance Criteria

At present, the industry entrance criteria recognized by Chinese mental health professionals are a series of criteria set up by CCPRS of CPS, based on the document of Chinese Psychological Society Registration Criteria for Professional Organizations and Individual Practitioners in Clinical and Counseling Psychology, including: (a) registration criteria for master’s/doctoral degree training programs, (b) registration criteria for internship agency, (c) registration criteria for clinical and counseling psychologists, (d) registration criteria for supervisors, and (e) registration criteria for continuing education projects (see http://www.chinacpb.org, for more information). Note that these criteria are not established by the government and thus receive only voluntary application from individuals and institutions.

Regulations

The document of Chinese Psychological Society code of Ethics for Clinical and Counseling Practice, launched by CCPRS of CPS, offers professional ethics for the clinical and counseling psychologists registered in CPS as well as a basis for processing ethical complaints and inquiries initiated against the registered clinical and counseling psychologists. The professional ethical codes include seven areas in practice: (a) the professional relationship, (b) privacy and confidentiality, (c) professional responsibility, (d) assessment and evaluation, (e) teaching, training and supervision, (f) research and publication, and (g) resolving ethical issues (see http://www.chinacpb.org, for more information).

The Professional Ethics Committee dealt with the first name-identified ethical complaint against one registered psychologist (supervisor) in CPS in 2014, based on this Code of Ethics. It aroused a big repercussion in the public. By the end of 2015, the Professional Ethics Committee has received five to six cases of name-identified reports, suggesting an increasing impact of the Code of Ethics in counseling and clinical practices. Also, a number of rules are currently being tested and improved in actual practice.

Mental Health Act

The Chinese Mental Health Act was issued in 2013, which has gone through 27 years of planning. The Mental Health Act (2013) caused great repercussions in the society. On one hand, it plays a positive role in mental health work. For example, it recognizes the importance and necessity of psychological counseling, provides the law guarantee for certified counseling practices, and also offers some rules to regulate involuntary hospitalization, guardian rights and other problems (Liu, Tong, & Zhao, 2013). On the other hand, there is a lot of controversy over it among professionals, leaving many parts to be improved in future. For example, the Mental Health Act (2013) requires that psychological counselors cannot conduct psychological therapy or make diagnosis and treatment, but it is hard to accurately distinguish between counseling and therapy in practice; and it requires that psychological therapy should be conducted in medical institutions, so that it might be suspected “illegal medical practice” to offer mental health service for persons with mental disorders in the counseling centers of schools and communities.

At present, due to lack of professional title for psychological therapists in medical institutions, there has occurred brain drain in the industry. Thus, how to foster the healthy development of psychological therapy in the framework of the Mental Health Act (2013) has become an urgent problem to resolve.

Local Regulations

Over the period when the Chinese Mental Health Act (2013) was drafted and argued, some local regulations have been developed. For example, the first local law of Shanghai Mental Health Act was issued in Shanghai in 2001. From 2006 to 2011, local regulations on mental health were also developed in Ningbo, Beijing, Hangzhou, Wuxi, Wuhan, Shenzhen and other cities (Xie, 2013).

Before the Chinese Mental Health Act (2013) was launched, these local laws have played an important role in regulating mental health practices. They covered primarily the areas of mental disorder diagnosis, clinical and experimental research, prevention of discrimination, duties of the police, legal responsibility; and also involved some content related to mental health service, psychiatric patient rights, rights of family members and other nursing staff, legal capacity and guardianship, patients’ informed consent right in agent decided treatment, emergency conditions, constraints and limits, human rights protection, et c. (Di & Xiao, 2012).

Challenges and Outlook

Challenges

Since the twenty-first century, clinical psychology has entered a period of relatively rapid development, particularly in the past 10 years. However, there still exist many challenges.

Challenge 1: Insufficient professionals . As noted above, there are currently 22 thousand or so psychiatrists, about 1.6/100 thousand on average (10/100 thousand in Britain, 20/100 thousand in the U.S.). The psychiatrists primarily receive training in biomedical mode and have little psychological therapy training; the psychological therapists without a medical background are forbidden to directly receive patients in medical organizations; and there exists an inflexible boundary between non-medical organizations and medical organizations. As a result, the quantity of mental health professionals cannot meet the needs.

Based on the Chinese Mental Health Act (2013), psychiatrists and psychological therapists with a psychological background are able to conduct psychological therapy in medical organizations. However, persons without a medical background must be first employed by a medical organization and then they could have a chance to participate in the psychological therapist qualification examination. A first dilemma are currently no corresponding positions for such persons in either psychiatric hospitals or comprehensive hospitals so that they cannot be employed by medical organizations. A second dilemma is that the rules covering eligibility for the therapist qualification examination are not clear so that most provinces forbade persons with a psychological background to participate in the examination for some reason in 2015. A third dilemma is that even though persons with a psychological background enter hospitals to work, they can only get a technician position title, without promotion channel like deputy senior title and senior title. A fourth dilemma is that under the current legal framework those qualified therapists are forbidden to conduct therapy as long as they are not employed by medical organizations.

In addition, the situation is also hard for certified counselors. They vary greatly on education background, get the certificate with very low entrance standard, and receive management from different organizations. By the end of 2015, among 900 thousand certified counselors, 80–90% are part-timers and only a few really can offer counseling service.

Challenge 2: Low quality of professional service . A survey in Shanghai in 2003 showed that 18.6% of professionals in counseling organizations did not receive any training; and among those (81.4%) who received training, 48.8% received less than 3 months training and 35.8% received 3–6 months training. The insufficient professional qualities of psychological counselors and therapists lead to heavy occupational stress in themselves (Gan et al., 2007), as well as directly influence the service quality. A survey to one famous university counseling center (Hu & Jiang, 2008) showed that among randomly selected 29 cases, the average number of sessions were four. In fact, it is common that clients visited only one to two times. The cause does not lie in therapy approaches, but in the fact that counselors have generally not received enough training. Thus, it is essential for the development of clinical psychology to consider how to provide better professional training for professionals and how to provide better supervision for them so as to improve the service quality of professionals.

Challenge 3: Chaotic professional regulations . Due to lack of mental health resources, many non-professionals without systematic training enter the mental health service industry, such as the psychological counselors with the (low standards) certificate issued by the CML. Also, a number of persons are not in mental health positions, but they undertake partial mental health service, such as the TCM practitioners or doctors in medical organizations, the college instructors in the education system, and so on. As a result, it becomes very difficult to regulate the mental health service industry. There is much confusion about the entrance criteria for professionals, service quality, service fee, and the ethics for mental health service.

It is an important step towards quality control and regulation that CCPRS of CPS was founded in 2007. However, the influence of CCPRS remains currently to be further improved in the professional field. In addition, further studies are needed to explore how professionals with different education backgrounds could be registered at CCPRS in a different classification, through what channels the qualified among the certified counselors could enter CCPRS, and how CCPRS could play a leading role in the counseling and therapy field (CDCP of NHFPC, 2015).

Challenge 4: Policies. In recent years, mental health work has drawn much more attention from the government, such as the issue of Chinese Mental Health Act (2013) and the National Mental Health Work Plan (2015–2020). However, there still lacks the necessary policy support. For example, medical institutions currently lack rules and regulations to establish department of psychiatry, develop interdisciplinary service teams, and train a fast growing group of psychological therapists. The college graduates with a psychological background can hardly be employed by medical organizations; and according to the Chinese Mental Health Act (2013), those not employed by medical organizations can neither conduct therapy nor participate in the therapist qualification examination, leaving many persons specialized in applied psychology unused. In sum, there is an urgent need for policy change and improvement.

Challenge 5: Clinical assessment and research . Although universities and colleges offer many psychological testing courses, few are related to clinical assessment. The research in clinical psychology has recently much developed. However, it has still focused on the therapeutic effect of various (western) theories and approaches, and severely neglected the therapeutic process and the unique experiences related to Chinese culture in psychological counseling and therapy. Further studies are greatly needed to examine the accountability of western theories and the validity of western techniques in Chinese culture, promote the localization of these western theories and techniques, and develop new Chinese counseling and therapy theories.

Outlook

In conclusion, the clinical psychology receives a rich thought heritage from Chinese culture with its own unique development trajectory. Through a long process of development, clinical psychology is now in the phase of rapid growing. It brings hope to clinical professionals, although they are still facing much pressure now.

We believe that, with the support of government and the guidance of professional associations, it’s not far away from establishing and improving professional standards and regulatory systems, conducting standard clinical or counseling psychology training programs, formulating administration criteria for psychological graduates to work in medical system, and connecting the channels of psychological departments and medical institutes. Additionally, efforts are under way, such as adding more psychotherapy training into psychiatric residents’ regular training programs, encouraging psychiatrists to get more psychotherapy training through continuous education, in order to enhance psychiatrists’ ability of providing psychological services. We should allow qualified psychological professionals to do psychotherapy and run private clinics by re-interpreting current rules and making new related laws. We also should encourage psychiatrists and psychological profession also offer psychological services in general hospital, mental health center in community and other non-psychiatric institutions (Symposium Summary, 2015).

Finally, there is a need to make greater efforts to promote the registration criteria by Clinical Psychology Registration Committee of Chinese Psychological Society, including criteria for courses, internship set, supervision, training programs, and so on.