A Sociological Analysis of Depression in China [1st ed.] 9789811564703, 9789811564710

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I-Hsin Hsiao

A Sociological Analysis of Depression in China

A Sociological Analysis of Depression in China

I-Hsin Hsiao

A Sociological Analysis of Depression in China

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I-Hsin Hsiao East China University of Science and Technology Shanghai, China Translated by Junjun Xing East China University of Science and Technology Shanghai, China

Funded: The National Social Science Fund of China, China National Planning Office of Philosophy and Social Science ISBN 978-981-15-6470-3 ISBN 978-981-15-6471-0 https://doi.org/10.1007/978-981-15-6471-0

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Jointly published with East China University of Science and Technology Press Co., Ltd. The print edition is not for sale in China (Mainland). Customers from China (Mainland) please order the print book from: East China University of Science and Technology Press Co., Ltd. © East China University of Science and Technology Press Co., Ltd. 2020 This work is subject to copyright. All rights are reserved by the Publishers, whether the whole or part of the material is concerned, specifically the rights of translation, reprinting, reuse of illustrations, recitation, broadcasting, reproduction on microfilms or in any other physical way, and transmission or information storage and retrieval, electronic adaptation, computer software, or by similar or dissimilar methodology now known or hereafter developed. The use of general descriptive names, registered names, trademarks, service marks, etc. in this publication does not imply, even in the absence of a specific statement, that such names are exempt from the relevant protective laws and regulations and therefore free for general use. The publishers, the authors, and the editors are safe to assume that the advice and information in this book are believed to be true and accurate at the date of publication. Neither the publishers nor the authors or the editors give a warranty, express or implied, with respect to the material contained herein or for any errors or omissions that may have been made. The publishers remain neutral with regard to jurisdictional claims in published maps and institutional affiliations. This Springer imprint is published by the registered company Springer Nature Singapore Pte Ltd. The registered company address is: 152 Beach Road, #21-01/04 Gateway East, Singapore 189721, Singapore

CSWC

Think Tank Studies on Social Work and Social Policy. This book is part of the research results of the Project “A Comparative Study of Doctor-patient Relationship in Mental Health Care in Shanghai and Taiwan” supported by the 2015 National Social Science Fund of China.

Foreword

The book A Sociological Study of Depression in China is one of Dr. I-Hsin Hsiao’s important academic achievements, the fruit of his scientific research as a fellow at the Postdoctoral Research Station of Sociology at the School of Social and Public Administration of East China University of Science and Technology (ECUST). In 2013, after obtaining his Ph.D. in sociology from the University of Essex in the UK, Hsiao came to the Postdoctoral Research Station for a two-year research program. As his supervisor, I, as well as my colleagues at the School, was deeply impressed by his global vision, theoretical reasoning and his ability to pose and resolve research questions. It is for these special qualities that he was employed as a full-time lecturer at the School after he completed his postdoctoral research in 2015. Hsiao’s experience of studying and doing research in the UK certainly broadened his approach toward research. While some sociologists in mainland China focus more on the study of social issues from a local perspective, Hsiao is more concerned about how globalization exerts an impact on China. His research centers on how globalization evolves and diffuses through China and how it conflicts and integrates with local perspectives. The present book, a sociological analysis of depression, opens up a new field in China’s medical sociology. The author explores how the global discourse in Western medicine on depression integrates with China’s local features and perspectives, a process which involves adjustments, conflicts and compromises at different levels of the state, the society and even individuals. The academic characteristics and contributions of the book can be summed up as follows: First, it has opened up a new field in China’s medical sociology. Since the 1980s, some Chinese scholars have been conducting research in medical sociology, such as Prof. Qiang Li and his research team at the Department of Sociology of Tsinghua University. However, China’s medical sociology is still in its infancy, characterized by a fragmentation of topics, lack of systematic theoretical research and a limited number of monographs. In comparison, Hsiao’s book has expanded and enriched the theoretical research of medical sociology in China; its contribution to China's sociology is self-evident.

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Foreword

Second, it provides a new perspective on sociological research. In this book, depression in China is discussed within a global framework based on local perspectives. Dr. Hsiao proposes a sociological analytical framework to analyze depression in China based on a two-layered and two-faceted matrix—the “global/international level” and the “domestic/national level” and the “social structure” perspective and the “social construction” perspective. Many of the previous studies on depression focused more on the influence of social structure on individuals’ psychological health, neglecting the significance of social construction, i.e. how depression as a disease is created and constructed in the medical discourse and how people react to this discursive construction. The present book, integrating both the perspectives of social structure and social construction, conducts a systematic and unique analysis of depression in China. Finally, the book offers an integrated analysis of depression from five theoretical perspectives. Since the 1990s, the number of people with depression in China has risen year by year to become a social problem that the government and the public can no longer ignore. It is imperative to conduct more scientific research on depression. Along with research in the fields of medicine, psychology and social work, research from the perspective of sociology is of crucial significance. In the present book, Hsiao seeks to integrate relevant theories in sociology, anthropology, phenomenology and the interaction theory. Within this integrated framework, he examines and analyzes both the macroscopic construction of depression by the medical industry, the government, the medical academia and the media, and the microscopic construction of the subjective feelings of depressive patients and their interaction with doctors. The analysis also takes into account the patients’ unconscious feelings. As a result, the book offers unique and original discussions on depression in China. The three contributions and features outlined above are just my personal opinions. I believe that readers will garner other experiences and discoveries. I am also convinced that this book is worth reading for the scholars and practitioners in the fields of sociology, social work, medicine, public health and psychology and for staff in government administrations. Shanghai, China December 2015

Yongxiang Xu

Yongxiang Xu Second-level professor and doctoral supervisor in the Department of Social Work, School of Social and Public Administration, East China University of Science and Technology, Shanghai, China. Dean of the Institute of Social Work and Social Policy, Shanghai University Think Tank, Shanghai, China. Executive Committee Member and China Representative of the International Association of Schools of Social Work (IASSW). East China University of Science and Technology (ECUST), Shanghai, China.

Introduction

Depression has become increasingly common in modern times, creating a problem that the whole world faces. China is no exception. In such a context, the present book focuses on describing and explaining the causes of depression in China from a sociological perspective. This topic has not been dealt with sufficiently in the Chinese sociological academic community. The insufficiency is mainly reflected in the following three aspects: First, sociological studies in China are largely concerned with issues in medical sociology; the few which have dealt with medical issues are limited to the fields of public health or applied (clinical) sociology. Research in public health and applied sociology is practice-oriented and hence insufficiently attentive to theories of medical sociology. This has resulted in an unsystematic development of medical sociology in China and a lack of theoretical reflection on the application of medical sociological theories to medical problems. Second, studies on how depression occurs in China are mainly in the fields of medicine and psychology, while the sociological research related to depression is mostly in the field of applied sociology (or social work). The sociological research deals with how to solve the problem of depression or presents statistical investigations of depression (or mental illness) in different groups. In addition, the sociological explanations of how depression occurs focus more on the description of phenomena. Some of these studies are conducted under various theoretical frameworks, but there is a lack of interpretation based on an integrated framework of multiple theoretical perspectives or from a global perspective. Third, the sociological research in China seems to focus more on interpreting the causes of the depression from a local and regional perspective rather than a global perspective. The more fundamental aspect of depression, however, lies in problems of adaptation, resistance and acceptance, which are unavoidable when western mental health structures are introduced in China. This is also a global problem, which all non-western countries will face when confronting the western mental health system. Yet a global perspective has rarely been adopted in sociological studies in China.

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In view of the above inadequacies, this book attempts to provide a sociological interpretation of how depression occurs in China from a global perspective. To present a sociological framework with a global perspective of depression in China, the book first compares the different medical situations of depression internationally and poses the question why the lifetime prevalence of depression in China is lower than in other countries. In order to answer this question, the book draws on theories in medical sociology to put forward a sociological analytical framework based on a two-layered and two-faceted matrix—the “global/international level” and the “domestic/national level”, and the “social structure” perspective and the “social construction” perspective. The international perspective focuses on the process of neoliberal globalization, which since the 1970s has gradually come to characterize structurally the entire world. Its mode of operation affects not only the medical system and related systems but also the structure of society, which in turn affects the occurrence of depression and its social construction. For this reason, this book discusses in detail how neoliberal globalization simultaneously shapes the “social structure” and the “social construction” of depression. These two facets are explored along with the two levels “global/international” and “national/domestic”. The Chap. 1 highlights the importance of sociological research from a global perspective. More importantly, this chapter analyzes in detail the five research paradigms in medical sociology on how diseases arise: social structure theory, social constructionism, medical anthropology, phenomenology and interaction theory. Each of these five perspectives has its own advantages and disadvantages, but together they can provide us with a broader theoretical perspective to reflect on how depression arises. Based on these theoretical paradigms, the book is divided into two major parts, namely, the social structure of depression and the social construction of depression. The social structure analysis is inspired by social structure theory and the social construction analysis by social construction theory, medical anthropology, phenomenology and interaction theory. We discuss the social structure of depression from three aspects. The first (Chaps. 2 and 3) is the production side. We discuss how neoliberal globalization affects the changes of space and time on the production side, and then its influence on people’s emotional state. The drastic changes in space are reflected in factors of instability, such as frequent cross-border and trans-regional population flows, and by changes in previous stable family structures. The drastic time changes are reflected in the “competitiveness” of rapidity. These changes in social structure have intensified the factors that lead to depression. The second aspect (Chap. 4) is the consumption side, namely, how the specific connotation of the social and psychological environment is related to depression in the context of neoliberal globalization. The main social and psychological context is represented in the intensification of individualism, the formation of a narcissistic society, and people's emphasis on the fulfillment of their rights and desires. The production and consumption sides demonstrate that uncertainty and overwork on the production side and the increasing rights and desires jointly aggravate the generation of depression. The third aspect of social structure (Chap. 5) discusses the relationship between capitalism and depression from the perspective of Lacanian psychoanalysis. This

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aspect differs from the first two in that the previous three chapters focus on “visible” empirical data (both quantitative and qualitative) while Chap. 5 delves into the “invisible” unconscious field, which has often been neglected in sociological studies and explores how the capitalist discourse continuously creates split subjects with unconscious operating mechanism (in Lacan's term, the Real) and how the split subjects, in turn, consolidate the capitalist system. Depression is a representation of the split subjectivity and occurs with growing frequency. The three aspects explain from different angles how neoliberal globalization influences all aspects of life and drives the occurrence of depression. We discuss the social construction of depression in China from two aspects. Firstly, in Chap. 6, we discuss the social construction of depression on the medical supply side in terms of social constructionism. To be more specific, we explore how the complex of drug manufacturers, the government, academia and the media medicalizes depression. The main point of this chapter is that this top-down medicalization has completed the construction in some areas (e.g. classifying depression in the Chinese Classification of Mental Disorders, namely CCMD and accepting ICD disease labels), while other areas remain underdeveloped (e.g. insufficient psychiatric medical staff, high costs for psychological consultation, and lack of psychiatric training for general practitioners). In a word, the social construction of depression from the supply side is not as comprehensive as in the West. Secondly, in Chap. 7, we discuss the social construction of depression from the demand side, namely, the public's perception and experience of depression. We adopt the perspectives of medical anthropology, phenomenology and interaction theory to outline the medicalizing process of the western mental health system in China, namely, the complicated process of patients’ conflict and compromise with, and then partial adoption of the western treatment and conceptualization of depression. We find that patients tend to adopt somatized expressions, namely, to communicate their psychological distress in the form of somatic symptoms rather than consciously describing depression as a mental problem as in western medicine, and that stigmatization of depression is serious in China, which hinders patients from seeking treatment and conceptualizing depression. In addition, although patients take different actions and have different reactions to the treatment of depression, the key points are that neoliberal globalization renders more diversified treatment options to patients and that they do not passively accept western medical treatment for depression. Instead, they constantly endeavor to solve problems by taking active measures or to obtain another subjective experience of treatment. On the whole, the social constructions of depression from the supply side and the demand side have promoted the public’s recognition of depression as a mental disease. Such a recognition is closely related to the marketization of depression. However, it needs to be pointed out that the social construction from both sides is inadequate or invisible. Base on the above analysis, we come to the conclusion that the social construction of depression is more critical than its social structure in terms of how depression occurs in China. The social structure of depression has a social foundation, but its social construction is still insufficient or less visible. This is the

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reason why the lifetime prevalence of depression in China is relatively low. However, once there are sufficient conditions for the social construction, the proportion of depressive patients in China will probably increase.

Contents

1 How Depression Arises: A Sociological Questioning and a Methodological Reflection . . . . . . . . . . . . . . . . . . . . 1.1 Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1.2 Neoliberal Globalization and Depression . . . . . . . . . . . 1.3 Medical Sociological Studies on “How Disease Arises” 1.3.1 Social Environment Theory (Structure Theory) . 1.3.2 Social Constructionism . . . . . . . . . . . . . . . . . . . 1.3.3 Cultural Interpretation in Medical Anthropology 1.3.4 Phenomenology: Focus on Patients’ Life-World 1.3.5 Interaction Theory: Patient-Centered and Action-Oriented . . . . . . . . . . . . . . . . . . . . . 1.4 Methodology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1.5 Structure of the Book . . . . . . . . . . . . . . . . . . . . . . . . . References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Part I

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The Social Structure of Depression in China

2 Analysis of the Production Side: Depression in Drastic Space Changes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2.1 Intensified Uncertainty . . . . . . . . . . . . . . . . . . . . . . . . . . . 2.2 Immigrants’ Emotional Problems . . . . . . . . . . . . . . . . . . . . 2.3 Depression Arising from Family Crisis . . . . . . . . . . . . . . . 2.4 Blurred Work-Life Boundaries: Emotional Problems in Mobile Space . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2.5 Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

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3 Analysis of the Production Side: Depression in Drastic Time Changes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3.1 Competitiveness in Neoliberal Globalization . . . . . . . . 3.2 Case Study of Depression in the Competitive Discourse with Chinese Characteristics . . . . . . . . . . . . . . . . . . . . 3.3 The Happiness and Mental Status of Chinese . . . . . . . . 3.4 Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4 Analysis of the Consumption Side: Socio-Psychological Context of Depression . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4.1 The Socio-Psychological Context of Depression . . . . . . 4.1.1 Conflicts of Individualization . . . . . . . . . . . . . . 4.1.2 The Narcissistic Society . . . . . . . . . . . . . . . . . . 4.1.3 Democratization of Intimate Relations . . . . . . . . 4.1.4 Depression Derived from Cruel Competition in the Narcissistic Society . . . . . . . . . . . . . . . . 4.2 Case Studies of Depression Derived from New Psychological Needs . . . . . . . . . . . . . . . . . . . . . . . . . . 4.2.1 Depression Derived from Cosmetic Failure . . . . 4.2.2 Anxiety and Temptation from High Technology 4.2.3 The Narcissistic Personality and Frustrations of Only Children . . . . . . . . . . . . . . . . . . . . . . . 4.2.4 Emotional Needs Derived from Democratization of Intimate Relations . . . . . . . . . . . . . . . . . . . . 4.3 Social Structure of Depression: A Summary . . . . . . . . . References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

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5 Depression in Capitalist Discourse: A Lacanian Psychoanalytical Interpretation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5.1 Key Concepts in Lacanian Psychoanalysis . . . . . . . . . . . . . . . . 5.1.1 The Imaginary, the Symbolic, the Real and the Formation of the Subject . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5.1.2 Discourse of the Master and Discourse of the University . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5.2 Capitalist Discourse as Representation of the Discourse of the University . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5.2.1 The Production Side of Capitalist Discourse . . . . . . . . . 5.2.2 The Consumption Side of Capitalist Discourse . . . . . . . 5.3 Split Subject of Capitalist Discourse: “the Labor-Alienation Subject Without False Consciousness” and “the Cynic Subject” in the West . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5.4 Split Subject of Capitalist Discourse: “the Labor-Alienation Subject not Knowing False Consciousness” and “the Cynical Subject” in China . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

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5.5 Summary: Reflecting on Lurking yet Undiscovered Depression in China . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 132 References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 135 Part II

The Social Construction of Depression in China

6 Medicalization of Depression by the Production-GovernmentAcademia-Media Complex . . . . . . . . . . . . . . . . . . . . . . . . . . . 6.1 The Production-Government-Academia-Media Complex and Medicalization . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6.2 Development of Depression in China: Medicalization on the Medical Supply Side . . . . . . . . . . . . . . . . . . . . . . . 6.3 Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7 The Public’s Cognition and Conceptualization of Depression 7.1 Conflict and Compromise Between Chinese and Western Medical Cultures: A Medical Anthropological Perspective 7.2 Patients’ Subjective Feelings and Actions: An Analysis from Phenomenological and Interactive Perspectives . . . . . 7.3 Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

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8 Conclusion: A Sociological Analysis of Depression in China . . . . . . . 171

Chapter 1

How Depression Arises: A Sociological Questioning and a Methodological Reflection

1.1 Introduction The World Health Organization issued a warning to all countries in its 2000 “Global Burden of Diseases” report, stating that depression will rank second in terms of its global health priority in 2020, just after ischemic heart disease. According to the 2010 GBD study, depressive disorder now ranks second in terms of global disability burden and a major contributor to the burden of suicide and ischemic heart disease. The findings highlight the importance of including depressive disorders as a global health priority. What is depression? And what are the criteria for its diagnosis? Depression is a mood disorder, which includes major depressive disorder (MDD), bipolar affective disorder (manic disorder), hypomania, persistent depressive disorder (dysthymic disorder), cyclothymia (cyclothymic disorder), or other mood disorder caused by substance induced or occurred in response to a general medical condition (American Psychological Association 2000). According to the standard criteria for the classification for mental disorders in the Diagnostic and Statistical Manual of Mental Disorders, 4th Edition, Text Revision (DSM-IV-TR) published by the American

© East China University of Science and Technology Press Co., Ltd. 2020 I. Hsiao, A Sociological Analysis of Depression in China, https://doi.org/10.1007/978-981-15-6471-0_1

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Psychiatric Association (APA) in 2000, depressive disorders include major depressive disorders,1 dysthymic disorders,2 or other unspecified depressive disorders. In the ICD-10 (International Classification of Disease), which is published by WHO (1992) and provides a system of diagnostic criteria for classifying diseases, depression is categorized as mild, moderate and severe (also called “major”). Whatever the degree of depression, individuals often experience distress, loss of interest and pleasure, reduced vitality and hence increased fatigue and reduced activity. Noticeable fatigue appears commonly even after a little activity (WHO 1992; Kong and Kong 1998). Other common symptoms include: (1) reduced concentration and attention; (2) lower self-esteem and confidence; (3) feelings of guilt or worthlessness (even in the case of mild depression); (4) feelings of hopelessness or pessimism about the future; (5) thoughts or actions of self-harm or suicide, or suicide attempts; (6) sleep disorder; and (7) decreased appetite. More and more people suffer from these symptoms nowadays. According to the data from the China Association for Mental Health, the number of depression patients recorded in China in 2012 exceeded 30 million, and the actual number of patients is even larger and has been increasing (Xinhua Health 2012). However, the 2011 WHO World Mental Health (WMH) survey codirected by professor Ronald Kessler of Harvard Medical School and carried out in 18 countries with a combined interviewees of about 90,000, showed that the lifetime prevalence3 of depression in China was only 1 The MDD diagnosis is based on the symptom criteria listed in the DSM. According to the criteria,

a sufferer should have 5 or more of the 9 symptoms, and at least one of the first two criteria listed below: (1) depressed mood most of the day, nearly every day, as indicated by either subjective report (e.g., feeling sad, blue, “down in the dumps,” or empty) or observations made by others (e.g., appears tearful or about to cry) (In children and adolescents, this may present as an irritable or cranky, rather than sad, mood.); (2) markedly diminished interest or pleasure in all, or almost all, activities every day, such as no interest in hobbies, sports, or other things the person used to enjoy doing; (3) significant weight loss when not dieting or weight gain (e.g., a change of more than 5% of body weight in a month), or decrease or increase in appetite nearly every day; (4) insomnia (inability to get to sleep or difficulty staying asleep) or hypersomnia (sleeping too much) nearly every day; (5) more days than not, psychomotor agitation (constant restlessness, pacing, or picking at one’s cloths) or the opposite, psychomotor retardation (a slowing of one’s movements, talking very quietly with slowed speech), observable by others; (6) fatigue, tiredness, or loss of energy nearly every day. (7) Feelings of worthlessness or excessive or inappropriate guilt nearly every day (possibly to the extent of delusion, rather than mere remorse or guilt for illness); (8) diminished ability to think or concentrate, or indecisiveness, nearly every day (indicated by either subjective report or observations made by others); (9) recurrent thoughts of death (not just fear of dying), recurrent suicidal ideas without a specific plan, or a suicide attempt or a specific plan for committing suicide (American Psychiatric Association 2000). 2 Dysthymic disorder can be revealed by subjective statements or through observation by others. Depression appears almost every day for at least two years and the number of days when depression appears is more than that when it does not appear ( In children and adolescents, this may present as an irritable or cranky, rather than sad, mood.). Sufferers show at least two or more of the following symptoms (APA 2000): (1) poor appetite or overeating; (2) insomnia or hypersomnia; (3) low energy or fatigue; (4) low self-esteem; (5) poor concentration or difficulty in making decisions; (6) feelings of hopelessness (American Psychological Association 2000). 3 Lifetime prevalence refers to the proportion of a particular population that at some point in their life (up to the time of assessment) are found to be affected by a disease. The proportion is arrived

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6.5%, the lowest among all countries surveyed4 (Bromet et al. 2011). Therefore, we wonder why, in spite of the continuous increase of depression patients, the lifetime prevalence in China is so low by international comparison. To answer the question, this book first discusses the social mechanism of “how depression arises” and then attempts to establish an analytical framework from a sociological perspective to clarify the problem of depression in China. Current analyses on “how depression arises” are largely in the fields of medicine/biology and psychology. In medicine/biology, scholars mainly study how changes in nerve conduction substances and genetic genes induce depression (American Medical Association 1998). In terms of neurotransmitters, depression can occur when the

at by comparing the number of people found to have the disease with the total number of people studied. The “morbidity rate”, the proportion of people in a population who have a disease at a given time (usually in one year) to the total population, can also serve as an indicator. Both of them are prevalence rates. The incidence rate, in contrast to prevalence, is another indicator. It is a measure of new cases arising in a population over a given period (month, year, etc.). The difference between the two is that the numerator of the prevalence rate is the number of existing cases, old and new, of a certain disease in a certain population at a given time, while the numerator of the incidence rate is the number of new cases in a certain population over a given period of time. For prevalence, a patient who is not cured during the given period of time t is counted as a case, while for incidence, only a new occurrence of a disease in the specified population is counted as a “new case”. Among these indicators, the incidence figure is the smallest, the morbidity in the middle, and the lifetime prevalence the largest. In this book the analysis of depression is mainly based on the lifetime prevalence because it can track the proportion of sufferers in the past and capture the public awareness of depression, rather than being limited to the occurrence of depression over a given period. The lifetime prevalence is more comprehensive. 4 The study includes data from ten high-income countries (Belgium, France, Germany, Israel, Italy, Japan, the Netherlands, New Zealand, Spain, and the United States) and eight middle-income countries (Brazil, Colombia, India, China, Lebanon, Mexico, South Africa, and Ukraine), with a total sample size of 89,037 respondents. This study shows that the average lifetime prevalence rate of people in high-income countries is 14.6%, the highest being France (21%), followed by the United States (19.2%) while that of people in low-income and middle-income countries is 11.1%, China being the lowest, with only 6.5% (For details, please see Bromet et al. 2011). This study is based on the interview data from WHO Composite International Diagnostic Interview (CIDI). The interview is designed according to the definition of major depressive episodes in the fourth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM). However, in this transnational study, the research on China is mainly about depression in Shenzhen, and it may be questioned whether this survey is representative of the situation throughout China. There are other surveys which also indicate a low lifetime prevalence of depression in China. For instance, Lee et al. (2009) find that the lifetime prevalence in Beijing and Shanghai is only 3.6%; Ma et al. (2009) show a lifetime prevalence in Beijing of only 5.3%; Lu et al. (2008) note that in Kuming, the prevalence is only 1.96%. These are all large-scale surveys and adopt CIDI model to conduct interviews. They consistently show a low rate of depression in Chinese urban population, even lower than the 6.5% rate in Shenzhen. By international comparison, the depression rate in China appears low, as many studies have indicated.

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brain is deficient in serotonin,5 dopamine6 and norepinephrine,7 or has hormone disorders.8 When stressful life events follow one after another and the brain experiences a series of afflictions, quantitative change can result in a qualitative change and people can fall into depression (Yang 1999). In addition, hereditary genes can also lead to depression because genes affect a person’s personality (temperament), which largely comes from inheritance. Individuals who are positive, serious, responsible, hardworking, incorruptible, cautious and demanding both of themselves and others are diagnosed as having high neuroticism and are at greater overall risk for major depression, paranoia and psychosomatic disorder (Kindler et al. 2004). Ormel et al. (2001) find that neuroticism has a significant positive correlation with the onset of depression; but without high neuroticism, stressful life events have no significant correlation with the onset of depression. Neuroticism is a highly hereditary trait. These studies show that genetics is the only factor that causes depression, while other factors, such as divorce, illness or death of loved ones, only affect people who have genetic factors and make them more vulnerable to depression (Rosen and Amador 1996). In other words, stress can worsen depression, but it is only a contributing factor or an aggravating factor for depression, not the cause of depression; the hereditary personality trait is the cause (Hong 2008).

5 Serotonin,

also known as “5-hydroxytryptamine” or “5-HT”, can inhibit brain reticular formation (ascending branch) related to consciousness and sleep and so reduce the sensitivity of pain by inducing non-rapid eye movement sleep (non-REM sleep) and by raising the pain threshold. Therefore, depressed patients who lack serotonin often suffer from insomnia, wake up in the middle of the night or in the early morning. They are afraid of noise; because their central nerve system is alert, they wake up or are irritated by even little sounds and are prone to worry about trifles. They get irritated easily and complain frequently. Their bodies ache without any cause or disease. They nag, blame themselves, become remorseful and feel bored and lonely. Therefore, most patients who lack serotonin show an agitated depression that can easily be misdiagnosed as anxiety disorder, panic disorder, or phobic disorder. A majority of depression patients belong to this type and often show symptoms like tension headaches, soreness all over the body, gastrointestinal discomfort, dry mouth (high internal heat), vulnerability to colds, etc. (Albert and Benkelfat 2013; Wang 2012). 6 The decrease of dopamine can lead to the elderly’s slow speech, slow movement, long-time mourning, decrease in nervous coordination, stubbornness and mental rigidity, and depressive feelings, etc.. Lack of dopamine can lead to depression, while a high level can lead to mania or schizophrenia (Clausius et al. 2009; Gu and Li 2002). 7 The decrease in norepinephrine can lead to weakened alertness and reactivity, so that the sufferers may fail to respond quickly and appropriately to external changes. They become slow or hesitant in solving or making decision about urgent matters. They are reluctant to go out and do things, feel tired and frustrated and feel that their abilities fall short of their desires. They have poor appetite, yet sleep soundly (Gu and Li 2002). 8 Estrogen, a female hormone, is neuroprotective with respect to neuronal degeneration and susceptibility to toxins and can enhance women’s tolerance to stress, boosting their happiness and thus reducing the occurrence of depression. Therefore, menopausal women, if not supplemented with estrogen, are more likely to suffer depression and Alzheimer’s disease than men (Seeman 1997).

1.1 Introduction

5

In psychology,9 the mainstream view focuses on “personality—stress”, which reveals that some personality traits (e.g.: low stress resistance, heavy reliance on others, or strong desire to outdo others) can more easily lead to depression when individuals encounter severe contextual stress (Joiner 2001). Cognitive-behavioral therapy (CBT) is a main school of psychology that explains and treats depression. It points out that patients with depression tend to interpret events in a negative way, which leads to their mental illness. For example, Beck et al (1979) argue that depression patients have three cognitive characteristics that easily lead them to depression: cognitive triad, cognitive errors and negative self-schema (see Ke 2002); Murphy and Bates (1997) find that self-criticism shows high correlation with depression. The American Psychiatric Association (2000) states that the onset of major depressive disorder is often accompanied by the patients’ sense of guilt or worthlessness, which includes the unrealistic negative evaluation of their own value, or excessive rumination about their minor errors of the past. Therefore, it is quite common for them to blame themselves for falling into depression or being unable to fulfill their professional and interpersonal responsibilities. Hilt and Nolen-Hoeksema (2002) further points out that rumination refers to the tendency to focus on the symptoms of illness and respond to the symptoms in a repetitive, passive rather than active and problem-solving way; it is both a possible cause and result of the symptoms. Such characteristics can increase negative and hopeless thinking, result in a longer period of depressive symptoms and therefore, are more often diagnosed as major depressive disorder (Lyubomirsky and Tkach 2004; Hilt and Nolen-Hoeksema 2002). The above-mentioned studies lay emphasis on exploring and elucidating micro internal causes like nerve conduction substances, genetic genes or psychological factors. No much attention is attached to detailed analysis of social variables. These external variables are generally categorized as “stress”. The literature on depression in Chinese academic circles is predominantly in the fields of psychology and medicine, and the research focus is mainly on how to improve the patients’ health (Xing and Shi 2005; Sun 2005; Ma 2008; Ding 2009; Wang et al. 2009). Sociological research on depression is mainly under the frameworks of applied sociology (or social work), which includes analysis of how to improve the patients’ health condition (Gao 2013), the impacts of social support on depression (Wang 2010; Li 2014a, b), and statistical surveys on depressive (mentally ill) patients of different groups (Shangguan 1994), among which the most researched groups are the elderly, the adolescents and parturient women. The studies conduct surveys on depression or on methods to improve depression (Zhang 2010; Xun and Sun 2010; Cai 2014; Gao 2013; He et al. 2006; Yang et al. 2008). This type of study falls in the field of public health. In fact, such research orientation highlights the phenomenon that Chinese medical sociology is almost equivalent to applied clinical sociology 9 This

chapter mainly introduces the school of cognitive behavioral therapy, and psychoanalysis in psychology will be introduced in Part I. Psychoanalysis explains the relationship between patients’ internal mental state and the external environment. Though it is a psychological approach, it is close to sociological analysis. We will discuss in detail how the theories of psychoanalysis on depression can be applied to sociological analysis in Part I “Social structure”.

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or public health, while theoretical reflection on how to apply theories of medical sociology to real-life social cases is far from sufficient. There is very little literature on the sociological analysis of “how depression arises” (see Ning and He 2012; Chen 2011; Hu 2001). Hu’s article “A sociological reflection of depression” (2001) describes depression as a social phenomenon, but does not put forward a theoretical reflection of how depression arises socially. Chen’s article “How ‘neurasthenia’ becomes ‘depression’?: A sociological perspective” analyzes, in concise language, various aspects of how depression develops from neurasthenia, and is characterized by its analytical framework of social constructivism and medical anthropology. However, patients’ feelings and the complications involved in seeking medical treatment are not described and analyzed sufficiently. Ning and He, in their monograph People in Trouble: Depression, Emotion Management, and the Dark Side of Modernity (2012), put forward theoretical explanations of great sociological significance. The present research benefits greatly from their book. However, like the previous literature, the book does not present a detailed and systematic analysis of the relation between globalization and depression, which is what the present book aims to explore systematically. After implementing the reform and opening up policy, China has been integrating into the world economic system, and the social structure and medical system have undergone dramatic changes accordingly, but there is little research on the relationship between neoliberal globalization and depression in China. This relationship is what the book attempts to explore and interpret. The significance lies in the fact that China, after decades of reform and opening up, cannot shut itself off from the world to build a self-contained country; therefore, methodologically, research that focuses only on domestic conditions should be reoriented from the perspective of globalization. In addition, a more fundamental issue of the present research is the adaptation, resistance and acceptance of the western mental medical system in China. This is a global problem that countries with non-western medical system face, so the analysis of how depression arises socially has to take into consideration the globalized context of western medicine. For these reasons, this book attempts to construct a sociological analytical framework of “how depression arises” based on a two-layered and two-faceted matrix—the “global/international level” and the “domestic/national level”, and the “social structure” perspective and the “social construction” perspective. This framework attempts to analyze depression in China in the context of globalization (i.e. the dichotomy of “global/international level and national/domestic level”) because China cannot shut itself off from the world; so the analysis of depression in China should not be conducted only at the domestic level. Moreover, depression is a technical term from western medicine, so when China accepts western psychotherapy, comparative studies on depression in China and that in the globalized western medicine should be conducted. From this point, the book will advance to an integrated analytical framework of “social structure” and “social construction” (to be discussed in detail later). Before presenting the analytical framework, we will first discuss how we explain the relationship between economic globalization and depression, and then this chapter will sort through the relevant medico-sociological literature on “how

1.1 Introduction

7

disease (including depression, of course) arises” and discuss the merits and demerits of each of the five schools in medical sociology so as to provide a theoretical rationale for the analytical framework.

1.2 Neoliberal Globalization and Depression Before explaining why this research explores the connection between “neoliberal globalization” and “depression”, we need first to define neoliberal globalization. Neoliberal globalization in the present research is defined in terms of “form” rather than “content”. In other words, the whole world is confronted with the characteristics of the neoliberal “form”, but countries vary in how they deal with it. Take welfare models as an example. All countries have encountered the impact of the “form” of neoliberal globalization (transnational flow, flexible accumulation, shortterm employment, high unemployment rate, etc.), but they respond to the impact in three different ways, which can be categorized into three types of welfare capitalism, as outlined in Esping-Anderson (1990): liberal regimes (Britain and the United States), conservative regimes (Germany and France), and social democratic regimes (northern Europe). Neoliberal globalization is the common “form” for all countries, but countries differ in the way that they come to concrete “content” under this common “form”. No country has adopted the “content” practices of neoliberalism. We make clear the definition of neoliberal globalization for the purpose of outlining the global characteristics. If we merely take the “content” as the starting point and conclude that there is no “pure neoliberalism”, the analysis can only be carried out “locally” and cannot be verified from a global perspective. Please also note that we do not hold the view that there is “pure neoliberalism”. Instead, we hold the view that it is necessary to define neoliberal globalization in terms of the “form”; then different versions of “content” are allowed for different countries or regions to deal with neoliberalism. Therefore, in order to emphasize the “form” of neoliberalism, we use the term “neoliberal globalization” more often than “neoliberalism”. This book adopts the characterization of neoliberal globalization summarized by Harvey (1990, 2005) and Jessop (2002) as the foundation for defining the “form” of neoliberalism. The characteristics include post-Fordism flexible accumulation, competitiveness, public-private partnership, consumer society, etc. These characteristics show the close relation between the globalizing concept of market supremacy and the impact of neoliberal globalization on the development of depression.

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First, neoliberal globalization, emerging to reform the rigidities of Fordism10 typified by mass production and mechanized management, is a system to integrate capitalist accumulation through a geographical redivision of the world. It shifts to flexible accumulation, which is characterized by “just-in-time” production and outsourcing (Harvey 1990). It has completely restructured the labor market: employers often promote more flexible work time and labor contracts, thus reducing the employment of full-time employees in favor of part-time or flexible work time employees or temporarily dispatched workers; they also contract out part of the work. In this situation, employees are expected to be more flexible and geographically more mobile (ibid.). This is “post-Fordism”, a new system of economic production and consumption which leads to changes in the social structure and causes psychological problems for people (to be discussed in detail later). Second, neoliberal globalization places great emphasis on “competitiveness”. It drags all the states or countries into the system of international competition operated through free-trade norms, international organizations (WTO, IMF) and international laws and regulations. Competitiveness involves a wider range of participants, and competitiveness norms have spread to bodies and fields beyond the macro-economic level—management, local governments, mass media, academia and health care, among which the states or countries play a key role. The states are committed to promoting their innovative and technological capabilities and a transfer of technology in order to benefit as many manufacturers as possible. In fact, even in neoliberal economies, many growing sectors are very knowledge-intensive and capital-intensive and they call for extensive cooperation. This demand is intensified by the extension of space and the acceleration of competition. If the advanced capitalist economies desire to maintain their employment and growth, they face the pressure to upgrade technology and, in particular, their specialization in new core technologies. Due to the increasing pressure brought by newly industrialized countries that are reliant on a low-cost, low-skilled workforce and simple technology, the sustained growth and employment of developed countries become more dependent on high technology. However, as newly industrialized economies face challenges from industrialized countries with more advanced high technology, they are also under the pressure to upgrade their technologies. This reflects the increasing competitive pressure at the global level (Jessop 2002). At the same time, the countries have also begun to change the discourse on educating the public, placing more emphasis on “innovation”, “flexibility” and “entrepreneurship”. Moreover, employees’ original 10 Antonio Gramsci first used “Fordism” to describe a new American industrial life mode in his Prison Notebooks completed between 1929 and 1935. It refers to a rigid market-oriented production mode based on labor division and specialization with low-price products as a means of competition. Its characteristics can be summarized as the employment of mechanized, automated and standardized assembly lines and the corresponding organization and the increase in productivity resulting from the mass production of standardized products Through the division and redivision of labor, tasks are broken down into small ones, which are completed by low-skilled workers trained in a short time. Moreover, the wage increases gained through labor-capital negotiations and the pay/productivity linkage mechanism promote mass consumption and the further development of mass production (Gramsci 1992).

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focus on the right to life-long employment has been shifted to the right to skills retraining and life-long learning so as to ensure that they have the ability and flexibility for work. There are no longer “iron rice bowls” (occupations with guaranteed job security); people are required to become adventurous individuals (Jessop 2002). This means that neoliberalism emphasizes the individuals’ own responsibility to strengthen his “competitiveness”. In the medical field, the discourse has shifted to emphasizing the individuals’ autonomy of health management. Only by managing well one’s own body can one gain productivity and competitiveness—such a concept has become deeply rooted in people’s hearts. The “competitiveness” emphasized by neoliberalism permeates all ranks of society through state intervention. Discussions of competitiveness engender “pressure” at various levels from the country to the individual. Accordingly, the transition from a stable traditional society in the Fordism era or the planned economy era with a relatively stable production mode produces an obvious modification in people’s psychological state (to be discussed in detail in later chapters). Third, states promote technological strategies in the private sectors and the tertiary sectors to form public-private partnerships. These technological strategies focus on information and communication technology, manufacturing technology, nanotechnology, biotechnology, optoelectronic technology, genetic engineering, marine science and technology, new material science and biotech pharmacy (Jessop 2002). Therefore, when the states intend to steer the pharmaceutical industry, under the capital accumulation logic of neoliberalism, they will push more pharmaceutical manufacturers and services into the research and development race. In this way, knowledge-intensive medical research and development spurs more comprehensive researches on health, with an increasing number of quantitative statistical reports, medical articles, experiments and so on. This produces a continuously renewed medical discourse, new construction of disease, and new health concepts, which provide potential conditions for medicalization,11 and affect the construction and spread of depression in society. Finally, the consumer society comes after the change of production pattern in neoliberal age. As David Harvey points out, postmodern culture is an advanced stage of neoliberalism, and due to the innovation and progress of transportation and information technology, the feeling of space-time compression is stronger than before, which enables capital to flow quickly. The acceleration of production speed also requires rapid exchange and consumption. Therefore, in terms of consumption, the mass (vs. the elite) market has become very popular (Harvey 1990). Diversification of commodities under the logic of highly competitive commerce and timeliness is the norm of the neoliberal consumer market; thus the public’s desire for consumption is greatly intensified. The medical industry is also an industry spurring people’s endless desires. Because people often consume medical goods and services for the sake of health, pharmaceutical companies and medical service providers continuously 11 Medicalization regulates human behavior according to health and disease. If one does not conform to social norms, he or she is labeled as being “sick” and has to receive medical intervention (Conrad 2007).

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create demand (e.g. different types of depression drugs, such health food extracts for improving mood as St. John’s wort and semen ziziphi spinosae, and aromatherapy, music therapy, acupressure massage). The continuous interaction between the supply and demand is an important condition for capital accumulation to continue. These phenomena are all new forms of medical consumption in the consumer society. These phenomena—post-Fordism flexible accumulation, competitiveness, public-private partnership and the consumer society—are what I define as “neoliberal globalization”. They are associated with the gradual institutionalization of neoliberalism in international economic organizations (FTA, TRIPs, WTO) by US President Reagan and British Prime Minister Thatcher in the 1980s, which has drawn all countries into this economic production system. WTO members subject to its norms, in particular, have to make more adjustments for free trade. In this sense, neoliberal globalization demands political, economic and social adaptation at all levels, thus changing people’s life styles and affecting their mental health. Based on the above definition of neoliberal globalization, this book explores three main reasons for its association with depression. First, as mentioned earlier, neoliberal globalization has brought changes in social structures, the medical system and its discourse, but previous studies, whether at home or abroad, have not developed a framework for analyzing how neoliberal globalization is related to depression. This book believes that it is necessary to construct an analytical framework for depression studies on the foundation of existing theories in medical sociology. Second, apart from physiological factors, one cause of depression is the stress from family, work and environment. The variables are very complicated, and many aspects of people’s lives are influenced by neoliberalism. For example, globalization accelerates flows of transnational capital and personnel and widens the gap between rich and poor. Its performance-based competitive logic has resulted in higher unemployment rate and a greater sense of uncertainty. Its influence goes beyond the economic sphere to non-economic fields (including medical fields). Moreover, the theoretical construction of depression is closely related to the global operations of the pharmaceutical industry. The construction of depression in the pharmaceutical and medical industries also operates within the logic of capital accumulation: drugs are produced, diseases are named, production is regulated by the government, and business opportunities are created for drug companies to invent antidepressants; The government forms public-private partnerships with academia, the manufacturing industry, and the media to educate the public on the concept and characteristics of depression and its medical treatment. These issues are related to neoliberal globalization and how depression arises in China. That is to say, neoliberal globalization is pervasive in all domains and has indeed affected people’s mental health. The analysis in this book is not vulgar economic determinism, nor does it simply take neoliberal globalization as an independent variable and people’s mood as the dependent variable, seeing the two as having a simple correlation. Instead, it is argued that neoliberal globalization makes possible various conjugate changes which modify people’s surroundings—the social system, family structures, cultural forms, work styles, migration status, consumption patterns, individualized pursuits, or medical development. Such changes affect

1.2 Neoliberal Globalization and Depression

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people’s psychological status, people’s understanding and the continuous construction of depression, etc. In addition, they will continuously bring new changes and other possibilities, like the social mechanism to relieve depression spontaneously (e.g. the family reorganization in which the elderly share household chores). Therefore, the emergence of depression under neoliberalism is not a simple, banal process, but a complicated, pluralistic, conflictual and adaptive one (to be discussed in detail in later chapters). Third, China’s reform and opening up (after 1978) was implemented almost at the same time as the neoliberal globalization in Britain and the United States (early 1980s). At that time, China boarded the train of globalization to connect with the world. That was also the time when China experienced a profound transition from a planned economy to a market economy. The coincidence can easily allow the Chinese to believe that the marketization after reform and opening up is the only possible capitalist operation mode. In fact, if viewed in the global context, this operation mode is not the product of the Fordism of the era of welfare countries, but that the post-Fordism characterized by transnational capital flows and flexible accumulation, themselves the results of neoliberal efforts to promote transnational capital flows. The mode differs greatly from the economy system of pre-Fordism western welfare countries and China’s planned economy. China’s reform and opening-up did not follow the Fordism market economy and the market economy of western capitalist countries, but is directly involved in neoliberal capitalism. Although China does not adopt the neoliberal operation mode, it was inevitable that China is affected by this “form” of operation. The flexible accumulation, competitiveness, public-private partnership and consumer society mentioned above all emerged in China. Obviously, China cannot avoid the impact of neoliberalism, which is inevitably a global structural force that affects various aspects of people’s lives. China has, under the impact of neoliberalism, shifted from the planned economy to the market economy logic of highly flexible accumulation dominated. During this process, it has witnessed drastic changes from highly stability to instability which are bound to exert an impact on people’s mental health. Therefore, it is of great necessity to explore systematically the relationship between this operation mode and depression. After elaborating the reasons why depression is related to neoliberal globalization, we will examine and evaluate the relevant literature in medical sociology of “how disease arises” so as to provide a theoretical sociological foundation for the analysis of “how depression arises”.

1.3 Medical Sociological Studies on “How Disease Arises” Sociological studies on “how disease arises” can be categorized into five schools: social environment theory (or structure theory), social constructionism theory, medical anthropology, hermeneutic phenomenology, and interaction theory.

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1.3.1 Social Environment Theory (Structure Theory) This school explores how important sociological variables, such as family, sex, class, race, culture and other factors or a combination of these factors are related to the occurrence of depression. Take family studies as an example. Most depression patients come from families with broken social support systems or are victims of domestic violence. The more dysfunctional the family is, the more likely it is to cause depression to occur and relapse. For example, Diamond’s research (Diamond et al. 2002) clearly shows that family discord affects the onset and development of adolescent depression. These factors include (1) disengagement or weak attachment bond, (2) high levels of criticism and hostility, (3) parental psychopathology, and (4) ineffective parenting (ibid.). Keitner and Mille (1990) argue family functioning is related to the development, remission and relapse of depression. This is confirmed in the five-year follow-up study by Keitner et al. (1997). The researchers found that family atmosphere is a major factor affecting mental health. Addictive behaviors in the family, especially alcohol abuse by parents, will increase the likelihood of depression for children (Mayo Clinic 2004). Therefore, the interaction between family members is an important social structure for their emotional changes. If we see the family as a system, the interaction of one particular person with family members helps us to best understand that person. The symptoms of various problems can be regarded as a sign of family dysfunction. This view holds that personal problems may be a sign of family operations, not just individual maladaptation. If we cannot understand the interaction situation and scope among family members, we cannot correctly evaluate the individual’s mental state. In addition, gender factors are also often used to examine depression. In epidemiology, the morbidity rate between women and men is about 1.4–2.7: 1. This proportion is related to the multiple roles played by modern women. The increasing stress from family, workplace and interpersonal relationships, plus unique physiological factors like premenstrual syndrome and postpartum depression, are all likely to cause depression in women (Yang et al. 1998). A close connection also exists between migration and depression. Most immigrants have different cultural backgrounds and living habits. They bear more stress, stressful life events and troubles than indigenous inhabitants and thus suffer from higher rate of suicide and depression. There are studies which have focused on immigrants and explored the impact of such social environments/structures as state policies, social support networks, family structures, and cultural conflicts on their mental health (AI-Issa and Tousignant 1997; Portes and Rumbant 1996; Kitano 1969). A series of sociological variables are employed in these studies to explore whether immigrants are more likely to suffer from depression. Research of this kind endeavors to build a relation between social structural factors of immigrants and depression. Studies also show that people from low social class have a higher prevalence of depression. The support provided by social networks (e.g. emotional support

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13

and information backup) is also related to whether people will have emotional problems. When people lack social support and networks, they have more difficulties in adaptation, thus suffering from mental disorder (Yang 2002). Race can also be regarded as an important variable affecting mental health. Fernando (1991) explores the relationship between race and psychiatry. According to his study, psychiatrists often use “skin-color” as a method to diagnose a disease and a detailed description of mental illness is actually elicited in the process of diagnosis. Therefore, there is also a hidden cultural ideology in psychiatry, which classifies people into sub-groups to explain their differences, such as the pre-set impression of race or gender. Social structural studies focus on some important variables (e.g. family, gender, class, race, culture) in depression analysis. However, they haven’t explored how other factors like industry, government, academia, and the media interpret and conceptualize depression and make the conceptualization accessible to the public. For this reason, the social constructionism to be discussed in the next section can make up for the deficiency.

1.3.2 Social Constructionism Social constructivism in medical sociology analyzes the construction of diseases from the perspective of power. The most representative medical constructionist must be Foucault, whose research focuses on how knowledge is related to power and how it is constructed. He examined the history of madness in the west and finds that “segregation” and “incarceration” are the two main ways to treat patients with mental illness. Since ancient times, there has been only one general term for the so-called “mental illness”, namely “madness”. Mental diseases were labelled as “demonic possession” and “heresy” before the 17th century. From the end of the 15th century to the beginning of the 17th century, the way to treat people with mental illness in Europe was to pack them in a dumb ship and expel them to a distant place, yet they happened to be the freest prisoners on the sea. Influenced by humanitarian thoughts in the 1770s, people with psychological problems were regarded as “patients” suffering from mental diseases, and were no longer immoral or possessed by the devil. The perspective of explaining mental illness did not change until the birth of modern medicine. After that, brain diseases or the fact that diseases could alter the sufferers’ thoughts and behaviors gained more rational understanding. Thus Foucault (1965) holds that in order to identify the rational and moral forms recognized by society, political, moral and medical authorities initiated various discussions, made classifications, and established corresponding principles to define and differentiate madmen from irrational people. The contemporary discussion on madness is to suppress irrationality in the name of science and rationality. “Madness” is excluded from the category of rationality and is under the scrutiny of the public or the psychiatric professionals, which helps to further distinguish the subjectivity of self and the other and indirectly shows the understanding of mental illness (Foucault 1965/1992). Hence

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Foucault outlined some efforts to resist modern psychiatry in an attempt to make mad men argue and speak for themselves. His analysis of the history of madness is concerned with how people experience and treat madness at different times. People in different times have different experiences and perceptions, which means that they have different power control and power strategies. The perspective of power is what Foucault valued. However, in his analysis, a patient’s body is the passively observed as an anatomical medical body. He did not analyze the marginalized actions of the patients (Foucault 1973, 1987[1954]). The subsequent argument of “anti-psychiatry”, which questions the objectivity of psychiatry, also benefits from Foucault’s viewpoint on power. The representatives of this school are Szasz and Goffman. They are against the public power’s exclusive respect for psychiatry and its marginalization of other medical methods (Szasz 1974; Goffman 1961). For Szasz, the symptoms of disease are merely medical labels to authorize relevant institutions to get involved in the problem—the problem that people with deviant behavior violate social norms. Mental illness is therefore regarded as deviant behavior. What’s more, Szasz (1974) goes so far as to insist that mental illness by no means exists; it is merely a myth or belief system which inherits the spirit of religious myth and witchcraft. Mental illness offers a possibility for the patients to malinger in order to escape conflicts and unhappiness in interpersonal relationships, temporarily forget their social responsibilities and obligations, and secure peace of mind. Szasz believes that mental disease is different from physiological disease. Its symptoms are not identified by pathological methods but by a set of created standards. As long as there is mental illness, a set of standards will be created to measure it. What is observed is not a physical structure but a bodily function. Therefore, physiological diseases are “proven” while mental diseases are “declared”. Goffman also mentions that mental illness is not only a symptom caused by physiological or neurological disorders, but also a result that goes against the expected behaviors in public places, thus rationalizing the control of the “deviant”. “Mental illness” is a term constructed by the society to understand those people restless from mental suffering and their ways of life, so that the society can create a mental medical system to control them. It is a mythological social phenomenon, a product made by some members of the society who believe that certain methods must be adopted to explain, control and sanction deviant and dangerous behaviors. As a result of the mental patients’ deviant behavior, stigma and discrimination are imposed on them with negative economic consequence, which, in combination with media manipulation, enhance the negative perception of them. Mental illness is like a “stigma” the society imposes on the sufferers. When physicians impose a label of mental illness on patients, even if they are not ill, such a label will be a self-fulfilling prophecy for the patients, their families and friends. Because of such expectations, the patients finally accept the diagnosis and respond as expected (Goffman 1961). Researchers believe that mental illness is not only a product of biological diseases, but also a result of being labeled as such in social spheres. Therefore, they emphasize the constructivist view of mental illness as an imposed label and the mystification of such labels.

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Blech (2005) elaborates his social constructivist view from the perspective of the medical industry. He lays emphasis on the collusion between drug producers and the medical profession to pursue mutual interests: physicians tend to treat mental diseases with drugs, causing a deliberate ignorance of the side effects of drugs, their excessive usage and other problems. With the social phobia in 1998 as an example, Blesh points out that in order to market and sell Paxil, a therapeutic drug, the pharmaceutical manufacturers cooperated with American psychiatrists and a related professional group (Freedom From Fear), which eventually led to the overuse of Paxil drugs. Patients could only rely on drugs to relieve the symptoms but not to cure the disease. However, in reality, patients may encounter various physiological problems in the course of medication, such as sexual dysfunction, hallucinations, dizziness, nausea, drowsiness, while patients who take drugs for a long time may also experience psychological dependence or fear. In addition, the impact of drugs on patients may go beyond the physiological level and affect their life and adaptation more directly and violently. This kind of constructivist views attaches great importance to the perspective that the collusion among the media, the government, the pharmaceutical industry and physicians is the predominant cause for the wide-spread discussion of mental illness. It further points out that the use and marketing of drugs are promoted through professional physicians and the media, making drugs the main tool to treat mental symptoms. Generally speaking, the “anti-psychoanalysis” school believes that depression is a disease constructed by experts and that the huge economic benefits brought by the use of drugs are the reason for the development of psychiatry (Cooper 1967). In the late 20th century in particular, with the boom of globalization and science and technology, high-tech products gradually replaced the traditional diagnosis methods and treatment. Pharmaceutical companies grew into large multinational enterprises and the delicate and mutually beneficial relationship between the medical field and drug producers has become a new special phenomenon. Modern medicine is no longer merely medical treatment aimed at helping others, but also a symbiotic structure of interests driven by capitalism. The core concept of modern medicine makes medicine and chemical drugs as two sides of an organic whole—inseparable and sharing weal and woe with each other. The evidence in physiological research has brought about astonishing growth in medical technologies as well as the pharmaceutical industry. In modern times, normal physical aging, endocrine fluctuation, changes in physical appearance and mood can all be medicalized, which is actually closely related to the economic interests of the medical system. From the perspective of doctor-patient interaction, the view that doctors have power while patients are relatively passive is a common analytical perspective in medical sociology. This also shows that physicians’ authority is an important basis for the social construction of diseases while patients are at a relatively passive status. In the study of the doctor-patient interaction, although different scholars (Parsons 1978; Waitzkin 1991; Goffman 1961) have different positions on the social control of the medical profession, they all agree that the medical profession plays an important role in social control. Some scholars, such as Parsons (1951, 1978) and Szasz and Holleder (1956) believe that doctors, because of their medical expertise

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and authority, have developed an unequal interaction with patients. Doctors enjoy greater authority and power in the social construction of disease. However, their concern is that patients need professional treatment due to their physical discomfort, and they can help patients maintain a normal life, thus enjoying superiority over the patients. Doctors and patients build up interdependent relationship out of their mutual needs. Parsons, a prominent representative of functionalism, believes that doctors’ power and status, as well as their control over patients, are the inevitable results of their efforts to guide “deviant” individuals to a normal state, where they can function normally, emphasizing the functional value of their existence. Physicians’ authority has positive effects on the internalization of the patients’ values, because doctors try to put patients on the right track of conforming to the functional social norms. However, after the 1970s, researchers in medical sociology were more influenced by Foucault’s ideas on political power and the importance of advocating the rights of the disadvantaged. Functionalism, to them, covered up the problem of inequality and they preferred to focus on the fight for the rights of patients and on the restriction of doctors’ rights. Therefore, these researchers could hardly adopt a functional perspective. Doctors, to them, not only possess professional medical knowledge, but also leverage in diagnosis and interaction, which enables them to dominate the interaction and even suppress patients’ thoughts or viewpoints on their own diseases, leaving them in a disadvantageous position in the doctor-patient interaction (Freidson 1970; Kleinman 1980; Mishler 1984). The influence of this social constructivist view of “physician authority—patient passivity”, with the goal of representing and empowering patients, continues to this day. The social constructivism illustrated here focuses on discussing the power operation on the supply side of health care (i.e. physicians, medical system, etc.) (Freidson 1970; Zola 1972; Illich 1975). The criticism focuses on the structural power of medicalization and professional domination, overemphasizing the effect of social control achieved by the medical profession through the construction and definition of diseases, as well as the structural disadvantage of patients. This kind of viewpoint regards the patients’ identity construction and identification as being still regulated by the professionals in the medical field, so that the internal voices of the patients are ignored and the real situation cannot be effectively clarified. Although their intention is to speak for and empower patients, they seldom study specific medical cases and hardly observe changes of patients (Lin 2006a, b). The dispute over the side effects of drug treatment and the collusion between drug producers, the government and the medical system, seems to be one-sided and questionable in its applicability in explaining the complicated dynamic relationship between physicians and patients. In the actual interaction between patients and physicians, it is not solely a matter of interests in the medical structure. In the actual process of treatment, the patients often have quite complicated and multi-dimensional responses. Their speech, mood and even memory are constantly changing in the process of treatment. Therefore, we should not neglect the complicated identity of the patients and the actual social context Lin (2006b). As for physicians, prescribing medicines to patients is not solely for profit. We cannot completely and effectively clarify the controversy over drug

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treatment if we only approach it by looking at the medical market and the medical structure. Physicians and patients prefer drugs mainly because drugs can effectively ease and control diseases and symptoms. We should have a more subtle understanding of physicians’ preference for drug treatment and patients’ perception and needs of drug treatment, rather than merely focusing on the structure of medical interests. Since social constructionism focuses on the side of medical supply, the following three approaches which focus on the medical demand side (i.e. patients) can make up the deficiency of social constructivism to some extent. They can also be regarded as the process of social construction on the demand side of medical care.

1.3.3 Cultural Interpretation in Medical Anthropology Medical anthropologists need to understand the relationship between different cultural patterns and mental diseases to conduct cross-cultural and non-western research on mental diseases. They surprisingly find that many so-called strange behaviors in non-western societies are often regarded as mental diseases by physicians in the west, but the local authorities have their own interpretation and response systems to such behaviors. Kleinman (1985) finds after a cross-cultural comparison of affect and disorder in China and the United States, that there is a close relationship between culture and depression. In the west, symptoms which are easily diagnosed as depression are diagnosed as neurasthenia in China. When non-western patients complain about illness, they are more likely to express their mental distress as somatized distress (i.e. as a bodily ailment) than as psychological distress. Kleinman believes that the statements of mental illness, symptoms and emotions, and the judgment on the normality or abnormality are all closely related to culture (Kleinman 1985: 429). The study on patients and their treatment should be placed in the context of culture and researchers should understand the relationship between medicine, mental illness, and culture (Kleinman 1980: ix). On the whole, although there are standards for the diagnosis of depression, culture can also affect people’s feelings and description of depressive symptoms. In some cultures, depressive symptoms are often experienced as physical discomfort rather than sadness or sin. In Latin and Mediterranean cultures, people complain about “nervous problems” or headaches; people in Chinese and Asian cultures see themselves as weak, tired, “imbalanced” or even “having offended deities” in folk customs; in the culture of Middle East it is thought that there is a problem with the “heart” while Indian Hopis express the symptoms as “heartbreak”—they may all be describing depressive symptoms (American Psychiatric Association 2000). There are also differences in the emotional expressions in Chinese and western cultures. Most studies point out that Asian patients show the tendency of somatization, that is, they seldom describe their emotions, but they are more likely to express their mental distress as bodily ailments than as psychological distress (Li and Gao 2009; Kleinman 1985).

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In addition, compared with the western society, the Chinese society as a whole is still more dismissive of mental diseases and more afraid of the stigmatization brought by mental diseases (Li and Gao 2009). The cultural approach captures the mediating role of culture and the importance of cognition. These are variables that need to be considered in areas with non-western medicinal cultures. This also shows that when western medicine enters a certain culture, it will face a series of conflicts and have to adapt to the local culture. Based on this view, we can capture how patients hesitate in different medical cultures, for instance, how they waver between western medical treatment and traditional Chinese medicinal treatment. However, the cultural approach does not explore patient behaviors that are not culture-bound. The phenomenological approach and the interactional approach to be discussed in next two sections are concerned with non-culture bound patient behavior.

1.3.4 Phenomenology: Focus on Patients’ Life-World Modern medicine also depicts a medical taxonomy based on the concepts of similarity and dissimilarity. The same category of symptoms is referred to as a substantial disease, which means there is a universally acknowledged diagnostic attempt and therapeutic purpose. Standardized procedures and steps are emphasized in both the evaluation and intervention methods. In order to model the existence of “certain diseases”, psychiatry defines the “characteristics” of certain symptoms and the “quantity” of these symptoms. After that, a fixed diagnostic pattern will be formed for a certain person. At present, the most representative diagnostic guide for mental diseases in the medical field is the Diagnostic and Statistical Manual of Mental Disorders (DSM) by the American Psychiatric Association. In the fourth edition, the number of detailed diagnostic categories that are distinguished has drastically increased to nearly 400. People’s personality and emotional response such as sadness, depression, unhappiness and pessimism are heatedly discussed in the pathologization of mental illness, and popularized through the mass media as a new generation of “civilized disease”. Modern medicine adopts the “pathological” model for interpreting the human spirit, psychology and even the physiological problems of natural aging, attempting to apply standardized “medication” and “procedure” to treat them. The successful development of this positivistic approach has indeed brought about a new concept and understanding of disease, however, it is regrettable that in such an extensive scientific craze, the position of the “human being” has not received due attention. This kind of intentional or unintentional neglect is the new crisis in modern civilization. If we want to explore the causes of depression, we should also locate the position of “human being”, and phenomenology is a reflection on the topic. Phenomenology is an anti-positivism school of thought originated by Husserl. Its intention is to take philosophy back to the world of life. It is a method, practice and even a system of philosophy which emphasizes “back to things themselves” and lets

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things explain themselves with their own “phenomena”, so as to avoid all mistakes and prejudices that precede experience. For Husserl, it is impossible to leave the life-world and merely explore the truth of human beings in the scientific world. He points out that the crisis of science lies in its deviation from the real world of human life and the excessive interpretation of the situation of human beings in so-called objective, rational and mathematical ways. The scientific world mistakenly attempts to replace the life-world and narrow down the significance of human existence with a mathematical view of truth. The life-world is “pre-given” or “pre-scientific”, that is, it is already there before science explores the world, so the life-world should be the core foundation that all scientists or scientific activities must adhere to (Husserl 1992, translated by Zhang). Phenomenology opposes the biomedical concepts of biological body and disease orientation, namely against the human body as the object of scientific research, and against the transformation of the body into an organism in the anatomical sense and a tool for carrying out actions. It also opposes the view that a patient’s body is only a dysfunctional physical and biological object (Toombs 1993: 76–81). As a result, it focuses on the study of the patients’ subjective experience and explores their actions, thoughts and real feelings, as well as the changes and meaning of their bodies during periods of illness. Patients and physicians have two different interpretation systems, the basis of which is what happens respectively under their own conditions and contexts. Even if they are in the context and participate in the same activities, they will form different views: the patient’s view as an actor and the physician’s view as a professional. The distinction between “objective scientific knowledge” and “knowledge of the life-world” can also be drawn from the two voices mentioned in Mishler’s analysis of the physician-patient relationship. Mishler (1984: 103–4) compared the physicianpatient interaction to the dialogue between “voice of medicine” and “voice of life world”. He believes that in the medical situation, the interaction between physicians and patients is not only in conflict, but also dominated by physicians. The “voice of life world” is a view on people and things formed on the basis of life experiences and life events. This set of viewpoints comes from the accumulation of daily experience and vary according to different situational factors. In other words, it is a natural attitude with which the patient interacts with the physician and describes his symptoms accordingly. The “voice of medicine” is composed of medical professionals and is presented on the basis of technical guidance and scientific attitudes. Their rules and logic are “de-contextualized”. Under these rules, all events have a set of established criteria, which are standardized and do not relate to personal or social situations. For example, all the symptoms of patients can be explained or handled by an established pathology, pharmacology, etc. In the physician-patient interaction, patients tend to describe their illness with “the voice of life world” and emphasize some situational topics. For example, patients will talk about various situational factors affecting their illness when describing their symptoms. However, physicians will try to bring the interaction back to the topics related to medication and bring the interaction between the two sides back to “the voice of medicine”.

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Medical anthropology also conducts similar researches on the subjective feelings of patients from the phenomenological perspective. Arthur Kleinman, in order to distinguish the sickness defined by objective science and the patient’s subjective feelings of pains, proposes two distinctive concepts: disease and illness (Kleinman 1988). The former refers to the logic in the medical field, which involves the definition, identification and treatment of diseases. The process of treating diseases is regarded as an objective and neutral one, and the patient’s obligation and role is to cooperate with the physician’s instructions and treatment methods (ibid.). In contrast, illness is the patient’s subjective cognition and interpretation in the process of seeking medical treatment. Patients, affected by personal personality, fears brought about by illness, or unsuccessful interactions with doctors, often fail to conform to the logic and routines of traditional medical models. In addition, the illness truly exists in the patient’s conscious experience, is closely related to the patient’s experience and lingers in the patient’s life. More importantly, illness has a profound impact on patients’ cognition of the disease and its medical treatment. Kleinman (1988) points out that patients with chronic diseases often need long-term observation care and even treatments of various physiological pains, all of which make them increasingly depressed and discouraged during treatment. Gradually patients tend to develop a more passive and pessimistic cognition of the disease. From Kleinman’s study on patients and illness, we know that patients are not just sick individuals, but also participants of social life. As far as patients’ personal subjective experience is concerned, the information they receive is more than mere instructions to take medicine on time and on a regular basis, but also messages of how doctors evaluate patients or how they help patients to construct their identities. Under such circumstances, the questions patients are asked should not aim solely at solutions like “what should I do?”, but should also concern their identities, like “who am I?”. The problems that depression patients have to face are also more complicated than those from ordinary disease diagnosis and treatment. In the process of psychotherapy, patients must also try to understand the various factors leading to their illness, such as their personality, mood, family experience and so on. All these factors show that psychotherapy exists not only to construct “disease” or “control” patients, but also to create the patients’ understanding of their identity, memory or life experience (Yan 2010). On this account, the interpretations of patients and doctors, or the difference between patients’ actual feelings and the empirical medical treatment, are also reflected in the patients’ contact with western medical treatment. The phenomenological approach can help us to learn more about the conflicts that depression treatment faces in the process of globalization. However, there are also problems with this approach. It seems to presuppose that “patient’s viewpoint” and the “external society” are in binary opposition. It neglects that the patients’ “examined body” when they have intention in their actions. The body must continuously interact with the “objective body defined by the physician” to bring about the action—the two are inseparable (Lin 2006a, b). The Interaction Theory approach to be introduced next can make up for this shortcoming.

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Table 1.1 Models of doctor-patient relationship (Szasz and Hollender 1956: 585–592) Activity-passivity

Guidance–cooperation

Mutual participation

Physician’s role

Does something to patient

Tells patient what to do

Helps patient to help himself

Patient’s role

Recipient (unable to respond or inert)

Cooperator (obeys)

Participant in “partnership” (uses expert help)

Clinical application

Anesthesia, E.C.T., acute trauma, coma, delirium, etc.

Acute infectious processes, etc.

Most chronic illnesses, psychoanalysis, etc.

Prototype

Parent-infant

Parents-child (adolescent)

Adult-adult

1.3.5 Interaction Theory: Patient-Centered and Action-Oriented Interaction theory offers insightful views on the dynamic process of patients’ actions in the doctor-patient interaction. As early as the initial stage of medical sociology, Szasz and Hollender (1956) put forward three major models of doctor-patient relationships, as summarized in Table 1.1. Szasz and Hollender (1956) attempt to revise the “activity-passivity” viewpoint in Parsons’ functional theory. In their models patients have greater initiative and are no longer completely passive recipients at the mercy of doctors. They can choose their relationships with doctors and be active participants in the doctor-patient interaction. Doctors also need the patients’ active participation for their diagnosis. So patients can enjoy greater autonomy in the interaction. However, as mentioned earlier, Szasz and Hollender believe that the doctor-patient relationship is both complementary and unequal. The three models differ only in the degrees of doctors’ dominance; doctors are still the party with more power. In the “activity-passivity” model, doctors have almost all the decision-making power in medical situations, and patients can be said to have no power status. In the “guidance-cooperation” model, both parties are in a state of cooperation and patients can choose their cooperation status at their own will; but patients “cooperate” under doctors’ instructions, which is still a kind of unequal interaction with features of the “activity-passivity” model. In the “mutual participation” model, doctors and patients have a relatively equal relationship and share power. Patients have more active participation and greater initiative in the interaction, but the model is more demanding on the patients’ knowledge and education and therefore is only possible when the education and experience of patients and physicians are similar. In short, the doctor-patient relationship is often unequal and is developed between two parties with unequal power distribution (Szasz and Hollender 1956). Freidson (1970: 315–321) believes that Szasz and Hollender’s scheme is logically and empirically defective, for their models represent a continuum in the degree to which the patient assumes an active role in interaction in treatment

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without being extended to the logical point where the physician assumes a passive role. For example, as the interaction shifts from the “activity-passivity” model to the “guidance-cooperation” and to the “mutual participation” models, patients are assumed to take a more and more active role. In other words, they are more likely to express their requirements and opinions. However, logically it is not assumed that doctors may take a passive role. Moreover, doctors would still reject patients’ questions or requests which are unprofessional, unrelated or disrespectful in the doctors’ eyes, and in this sense, doctors still have their authority. Though Freidson criticizes harshly Szasz and Hollender’s scheme, his view does not seem to excel the traditional view that doctors have greater authority than patients. The above scholars approach patients from the doctor-patient interaction perspective, rather than focusing merely on the supply side of medical care. Their studies share similarities with the interaction theory. They try to analyze the patients’ initiative, but basically they are more interested in the more powerful operation of medical suppliers, as is emphasized in social constructionism. From these origins, medical sociology develops an action-oriented perspective on the study of patients, which gradually eradicates the unilateral view of social constructionism, which focuses on the supply side. This action-oriented view does not pursue an explanation of the “overall” social structure, nor does it take the phenomenological patient-centered approach to explore mental illness. It focuses on patients’ actions and thus reveals more patients’ expedients and even their resistance (Lin 2006a, b). For example, Conrad and Schneider (1985), on the basis of interaction theory, question the neutrality of biomedicine and its social influence. Apart from scrutinizing religious sins and legal deviations and the process of medically defining them as diseases in the name of science, they also point out the fight of public and non-medical professionals against medical dominance. For example, in the case of alcohol addiction and homosexuality, organized people and patients actively propose alternative “disease” structures to “remove the stigma” labeled by legal, moral and medical authorities. Goffman believes that people from the lower class gain their identification and recognition through strenuous negotiations with moral and institutional authorities. They employ various resources such as group territory, facilities, organized activities, membership and legitimate possessions to reshape themselves for their own development and adjustment (Goffman 1961: 173–320). Patients exist in various forms not only because they are embedded in social relations, physical space and the rules and practices in the social system but also because they have been competing for their own existence all the time. This shows that patients are closely connected with powerful agents and the medical system, and that patients can be more active than social constructionists describe (Lin 2006a, b). With the increasing emphasis on patients’ rights, patients may not be in a completely passive position in the process of doctors’ inquiry and observation. Much related research has been conducted on patients’ complicated identities and multi-dimensional subjective statements (Lin 2006a; Cheng 2002; Cai 2004). These studies mainly focus on patients’ multi-dimensional identities and sickness experience: patients are both the objects to be treated and practitioners of social pluralism and knowledge. In a study of patients’ articulation of their own needs, for example,

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scholar Leung Kai-Kuen from Taiwan, China and his collaborators (Leung et al. 1991) categorize the patients’ challenge to physician authority into two types: “information acquisition” and “question and criticism”. Patients are more likely to challenge doctors’ authority through “information acquisition” and such behavior is more likely to be found among patients with more education and from medicine-related occupations. Concerning patients’ attitude toward the doctor-patient relation, the “equal interaction” relation (79.1–97.0%) has the highest approval rate, followed by the “patients’ compliance to doctors” type (28.2–76.0%) and the “patient autonomy” (5.5–78.7%). The study shows that in the initial stage of doctor-patient interaction, patients expect or demand a position of equality and hope to obtain sufficient information. They challenge doctors’ authority in the process of acquiring information with the goal of striving for an equal and interactive relationship. It can also be seen that patients in Taiwan utilize available resources to question or resist western medicine treatment, which results in two distinct types of behaviour— “doctor shopping” and “use of multiple channels in medical care”. According to Zhang (1989), “doctor shopping” is more than a result of patients’ desires and initiative; it is also a product of the doctor-patient interaction. Unrelieved suffering and patients’ dissatisfaction are the main reasons for their constant switch of hospitals and physicians. Patients are not sure whether they have received correct or sufficient information, so they resort to seeing different doctors. This “doctor shopping” phenomenon observed by Chang results partly from the implementation of health insurance policy in Taiwan in 1995, when the public gained more access to medical resources. To be more specific, the root cause of the “doctor shopping” phenomenon lies in the shift to ensure patients’ interests after implementing the health insurance policy, under which the public could enjoy high-quality medical care with low health insurance premiums. Patients were free to change from one hospital to another and from western medical treatment to traditional Chinese treatment, all at relative low cost. Zhang (1998) maintains that Taiwan allows a ternary medical system with western medicine as the mainstay complemented by traditional Chinese medicine and folk therapy or alternative therapy. For the treatment of common diseases, patients seek western medical treatment in the initial stage and, if the symptoms do not improve soon, they go to traditional Chinese medicine. Wu (1981) finds that very few families in Taiwan utilize just one of the three medical methods; they usually combine different treatments at different times and in different situations. More than 60% of families opt for a combination of the three methods. Patients or their family members comply with a physician’s prescription while seeking traditional Chinese medicine to recuperate or folk therapy to ward off evil spirits. This highlights the fact that folk therapy is still deeply rooted in Taiwan. The sites of folk therapy, which are mainly found in folk martial arts museums and temples, provide alternatives to regular medical treatment. The above studies show that the people in Taiwan have access to multiple and diversified medical resources.

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The merit of the action-oriented research is that it focuses on the specific real-life actions of marginalized populations. Limited as its impact may be, its efforts cannot be ignored (Lin 2006a, b). This view can serve as reference for the study of patients’ actions and their interaction with western medicine. However, it is better for us to place the interpretation of patients’ behaviors and actions in the context of neoliberal globalization, because it affects patients’ voluntary actions in various ways. The strengths and shortcomings of the theories discussed above are summarized in Table 1.2. Inspired by those theories, the present research will analyze the economic and social origins of depression in China. Our view is that neoliberal globalization is the breeding ground for the social structure and the social construction of depression. The social structure captures mainly the way that economic systems affect people’s mental health, which should be expounded in both the global and local contexts. When analyzing social construction, attention should be paid both to the supply side (i.e. doctors, the medical system, etc.), which is emphasized by the social constructivism theory, and the demand side (i.e. patients). Therefore, to delineate the social construction, it is necessary to integrate three different approaches: the cultural interpretation in medical anthropology, the analysis of patients’ subjective experience from the phenomenological perspective, and the study of patients’ action in interaction theory. It is also necessary to observe and analyze how the medical demand side adapts, resists and achieves a balance in the social construction process of depression. Weighing the advantages and disadvantages of each approach, the book will integrate these methods to unravel the causes of depression in China. A sociological analytical framework of “how depression arises” built on these approaches will be introduced in the subsequent chapters. Detailed discussions will be presented in Chaps. 2–7. The above methods are the analytical perspectives of medical sociology on “how disease arises”. They are of course valuable theoretical resources in the study of “how depression arises”. However, depression is a mental problem which involves psychoanalytical analysis. Therefore, the present research will approach depression from a sociological perspective. Thus, our question becomes how to apply psychoanalysis to the humanistic study in sociology. Within the existing literature, the psychoanalysis applied to sociology or culture-related fields mainly concerns the interpretation of movies, novels or other literary forms, and Lacanian psychoanalytic theory is the most widely used. In China, the existing study of Lacan’s psychoanalysis mainly introduces Lacan’s theoretical ideas and seldom touches on its application to social issues (Wu 2010; Ma 2012; Liu 2006; Huang 2003a, b; Zhang 2005). No study has been conducted in China by applying Lacan’s psychoanalysis to the sociological interpretation of “how depression arises”. Therefore, this book will try to adopt this perspective to explain the social structure of depression in China. Detailed elaboration and application will be presented in Chap. 5.

Important sociological variables, such as family, gender, class, race and other external environmental factors, are related to depression

It focuses on the supply side of health care

1. Social environment theory (structure theory)

2. Social constructionism

• The medical suppliers take a dominant role in the construction of medical knowledge • The anti-psychiatry school questions the scientificity and objectivity of psychiatry, and opposes public authorities’ efforts to extend psychiatric treatment and marginalize other medical methods. Depression is just a disease constructed by experts. This school argues that the huge economic benefits brought about by the use of drugs are the reason for the development of psychiatry

Basic arguments

Approaches

Table 1.2 A comparison of 5 approaches to disease

It focuses on the structural power of medicalization and professional domination and the structural disadvantage of patients, with the aim to empower and speak for patients

It verifies the structural/environmental effect on depression

Contribution

(continued)

It neglects the patients’ struggle, inner reflections and actions taken in the construction process of depression

It neglects elements in the social construction

Defect

1.3 Medical Sociological Studies on “How Disease Arises” 25

All four approaches focus on Understanding of mental the demand side of medical illness varies greatly across care different cultures, because mental illness has its historical and cultural origins It describes and analyzes the subjective experience of the patient’s suffering process, which is different from the physiological “biology–anatomy” viewpoint It focuses on the patient’s actions and does not start from ontological assumptions. It gives more vivid description of patients’ responses to situations

Basic arguments

Approaches

3. Cultural interpretation in medical anthropology

4. Phenomenology: focus on patients’ life-world

5. Interaction theory: patient-centered and action-oriented

Table 1.2 (continued)

It captures the process by which patients achieve balance between the life world and the scientific world where they are treated

It explains the subjective experience of the body other than the objective pathological knowledge so as to understand the patient’s feelings

It lays emphasis on how culture as a variable plays a role in shaping the understanding of mental illness and its treatment in western medicine

Contribution

Action cannot be free of the influence of structure. The structure of neo-liberal globalization still has a role to play

The life-world and the world of science cannot be separated. The “experienced body” suffering from illness must interact continuously with the “objective body” defined by medical treatment before patients take actions

It neglects patients’ actions that are not directly affected by culture

Defect

26 1 How Depression Arises: A Sociological Questioning …

1.4 Methodology

27

1.4 Methodology To explore the questions raised, the author has compiled second-hand data related to depression from various sources: journals, monographs, research reports, news reports and literature in counseling psychology. This book will quote relevant secondhand literature under different headings. Some second-hand literature includes statistics on depression patients and the status of their treatment. These statistics can help us obtain a global picture of depression. However, quantitative studies cannot present personal experiences in detail and need to be supplemented by qualitative research. Therefore, when describing and analyzing patients’ subjective experience and actions or doctors’ viewpoints, we also include cases from the literature of counseling psychology and first-hand data collected by the author in 46 interviews (34 patients, 4 family members, 3 psychological consultants, 5 psychiatrists). Several representative interviewees were invited to make subjective statements about their experiences and feelings. The data will be presented under different themes in the book to support and elaborate its argument. However, the life experience of depressed patients is not an objective truth but rather a representation of personal subjective experience. Therefore, the qualitative research is certainly not representative of the situation of all Chinese people. Despite this inevitable limitation of qualitative research, the in-depth observation of some people’s life experiences does offer insight into the situation of a greater number of ordinary people. The interviewees construct and create their own life through language and narration, which are closely connected with the interpersonal, social and moral context in their life: meanings and stories emerge not only from independent individuals, but also from interactive negotiations in specific contexts. The pain caused by depression can help individuals understand the experience of their illness and make it meaningful (Crossley 2004). The depression patients in this book are all presented with pseudonyms or nicknames to protect their privacy. By conducting in-depth interviews and reviewing cases in psychological consultations, this book attempts to explore the relationship between macro social structures, social construction and micro health care behaviors and to offer a systematic sociological interpretation of the causes of depression.

1.5 Structure of the Book This book is organized into two parts: Part I “Social Structure” concerns the social structural causes of depression; Part II “Social Construction” is mainly about how depression is socially constructed. Part I has four chapters which are organized in three sections. The first section, constituted by Chaps. 2 and 3, focuses on analysis from the production side. The production side involves the concepts of time and space in sociology, so Chap. 2 “Analysis of the Production Side: Depression in Drastic Space Changes” deals with the impact of space changes on depression, while Chap. 3 “Analysis of the Production Side: Depression in Drastic Time Changes” is about the relation between time

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and depression. The second section focusing on the consumption side is presented in Chap. 4 “Analysis of the Consumption Side: Social-psychological Contexts of Depression”. Chapter 5, the third section, adopts Lacanian psychoanalysis to interpret the relationship between capitalism and depression. It is entitled “Depression in Capitalist Discourse: A Lacanian Psychoanalytical Interpretation”. Part II “Social Construction” is composed of two chapters. Chapter 6 “Medicalization of Depression by the Production-Government-Academia-Media Complex” deals with the social construction of the medical supply side, mainly the medical construction by the complex formed by drug producers and sellers, government, academia and the media. Chapter 7 “The Public’s Cognition and Conceptualization of Depression” outlines the social construction of medical needs. As to the analytical methods, for the social structural analysis in Chaps. 2–4, we cite findings and conclusions from research on the social environment to elaborate the content. However, we do not begin with variables in social environmental studies, but with the key factors in psychoanalytical studies on depression, and go on to elaborate how neoliberal globalization enhances the importance of these factors, using practical and theoretical analysis of both the production side (under the drastic changes in time and space) and the consumption side. In Chap. 5 we adopt a psychoanalytical perspective to analyze the relationship between capitalism and depression. The perspective, different from research based on “visible” empirical data (whether quantitative or qualitative), is valuable to understand the relationship between capitalist economic structure and depression. To this end, we use Lacanian psychoanalysis to interpret depression under the contemporary capitalist structure. In Part II “Social Construction”, we will analyze depression from the above-mentioned perspectives of social constructionism, medical anthropology, phenomenology and interaction theory. The perspective of social constructionism is of use to interpret medical commercial behavior and research on depression from the side of medical supply, while the perspectives of medical anthropology, phenomenology and interaction theory are applied to the analysis of patients’ thinking, subjective ideas and their immediate situation. Based on these multi-perspective analyses, we will sum up the sociological analysis of how depression arises in Table 8.1 in the concluding chapter. We will construct a sociological analytical framework based on a two-layered and two-faceted matrix— the “global/international” and the “domestic/national” levels, and the “social structure” and the “social construction” perspectives, in order to analyze the causes of depression in China and account for the comparatively low number of depressed patients in China.

References Albert, P. R., and C. Benkelfat. 2013. The neurobiology of depression–revisiting the serotonin hypothesis. II. Genetic, epigenetic and clinical studies. Philosophical Transactions of Royal Society. B: Biological Sciences 368(1615): 20120535. https://doi.org/10.1098/rstb.2012.0535 Al-Issa, I., and M. Tousignant. 1997. Ethincity, immigration and psycopathology. New York: Plenum Press.

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Part I

The Social Structure of Depression in China

The social structural analysis of depression cannot be performed without regard to the contributions made in psychology. Because of the mutual influence of human beings’ mental state and the society, it is logical to investigate the relation between psychological analysis and social analysis. There are two main psychological approaches to the study of depression—cognitive behavioral theory (CBT) and psychoanalysis. CBT focuses on an individual’s negative conception of himself. Theories of this approach include Beck’s cognitive theory of depression,1 Markus’ theory of negative cognitive self-schemas,2 Becker’s idea of self-depreciation,3 Seligman’s Learned Helplessness Theory,4 and Abramson’s Hopelessness Theory of Depression.5 All these theories emphasize that an individual’s habitually negative views of the self can trigger depression. The cognitive behavioral approach, which primarily 1 Beck

believed that depression arises from individuals’ faulty cognition, which triggers a negative self-schema when negative or upsetting events occur. This can further lead to the individuals’ cognitive distortions or illogical thought patterns, which in turn causes the cognitive triad of negative automatic thinking of the self, the world and the future (Beck et al. 1979). 2 Markus (1977) argued that once an individual forms fixed opinions on the self, he tends to maintain those opinions and is more likely to notice information that is consistent with these views. Therefore, once a self-schema is established, it cannot be easily changed. A positive self-schema can help the individual to form positive self-judgement, while a negative self-schema can lead to a cycle of negative thinking patterns. Depression patients are an example of this negative cycle. 3 Becker (1964) identified three mechanisms that he thought were responsible for depression: restricted behavior selection, rigid behavior modes and low self-evaluation. 4 According to Seligman’s Learned Helplessness Theory, depression mainly arises from the individual’s negative attributional style, namely, attributing negative events to some internal, stable and global factors. When an individual encounters a negative life event, depression occurs if the external conditions are also not positive at this time, such as lack of social support and lack of appropriate adaptation strategies (Seligman and Maier 1967). Those who attributed a negative event to internal, stable, and global causes were more likely to develop depression than those who attributed the same event to external, unstable and specific causes. 5 In the Hopelessness Theory of Depression, Abramson held that when highly desired outcomes are believed to be improbable and/or highly aversive outcomes are believed probable, and the individual has no expectation that anything he or she does will change the outcome, a sense of hopelessness results. However, the sense of hopelessness is an unnecessary but sufficient condition for depression,

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Part I: The Social Structure of Depression in China

analyzes depression at the individual level, is a mainstream approach in psychology that explains the causes of depression. The limitations of the “personality-stress” correlation view of this approach were presented and analyzed in Chap. 1 but not the psychoanalytic approach. Psychoanalytic analyses pay more attention to the relation and interaction between the individual’s inner states that give rise to depression and “external objects” (the Matrix, family, environment, etc.) Its viewpoint is closer to sociological analysis, so it can further our understanding of how depression arises. To this end, we will review the psychoanalytical studies of depression before we elucidate how the social structure in the new liberal globalization promotes the occurrence of depression. We can classify psychoanalytical views on depression into the following six types. First, depression is a form of self-attack. Depression originates from the sense of guilt and low self-esteem caused by the gap between the ideal self and the real self and is then internalized as self-attack. From the perspective of psychoanalysis, when individuals form strict and unrealistic judgments about personal emotions and thoughts, especially when they habitually turn anger into self-attack, they are susceptible to depression. When they encounter setbacks and disappointing situations, especially those beyond their control, they are prone to blame themselves, become angry and frustrated, and even enter a mental war that afflicts them. Freud pointed out that depressive patients often have a well-developed superego, which drives the ego to behave well. He said that when the superego is too strong and blames excessively the ego, self-attack will occur and then lead to depression (Freud 1917/2013, translated by Wen 2013). Bibring’s psychodynamic analysis shares similar views. Bibring (1953) believed that depression is the emotional expression of a state of ego-helplessness and ego-powerlessness of the individual’s inner conflict, which more than often diminishes the individual’s self-esteem. Depression arises from the psychic tension between high expectations and the impossibility of fulfilling these expectations. Lacan extended Freud’s idea of superego from the social and cultural perspective. He proposed the concepts of symbolic identification and the big Other to offer a social and cultural interpretation of Freud’s psychological superego. Symbolic identification is how an individual wants to be observed in the eyes of others (the society) and what kind of signifiers he or she should have. This is the identification of his or her social position, from which the individual observes the self and make it more adorable and more worthy of being loved. The symbolic big Other plays the role of superego. It represents the social symbolic order: mainstream values, ideology, trends of the time, cultural tradition, etc. The process of socialization leads to the establishment of superego. The individual, surrounded by the Other, is required to conform to the desire of the Other. He identifies with the Other under its gaze, seeing himself as the “object” of the Other and making himself objectified. The Other gazes at “I” or the ego and gives “I” some expectation, while “I” play the role expected by the Other in order to gratify it. For example, children fulfill parents’ expectations of “good children”, students teachers’ expectations of “good students”, wives while the negative event is an insufficient but necessary condition for the occurrence of depression (Abramson et al. 1989).

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husbands’ expectations of “virtuous women”, and citizens the expectations of “conformists”. The Other is a very abstract concept, but it can be embodied as anyone around us, especially those who are important to us: parents, brothers and sisters, teachers, friends, communities, etc. In other words, the Other is hiding in all our relationships (Žižek 1994). Integrating Lacan’s view with Freud’s, we can see that the more the Other demands from the individual, the greater the pressure will be on him or her and the more severe the superego will be. However, the individual may not be able to meet the expectations or demands even after strenuous efforts. In this situation, he or she turns to self-attack and falls into depression. Arieti (1977) held a similar view that depressive patients often live not for themselves but for “a dominant other or a dominant goal”. When they fail to live up to the expectations of others, many of them, instead of questioning their mistaken belief system, have doubts about their own values or qualities, believing that they are not good or worthy enough to win others’ care, love and protection. In addition, they, in their subconsciousness, believe that pain and self-sacrifice can be a last triumph card to obtain care and love from others. If pain and self-sacrifice do not work, depression becomes aggravated. As a result, they get depressed because of the loss of care and love from others, while they remain sorrowful and depressed to regain others’ care and love (Arieti 1977). Second, depression is related to narcissism. This view holds that the crux of depression lies in narcissism, and one of the conditions for depression is the narcissistic disorder in the individual’s early development. Depressive patients fail to successfully transform from narcissism to object love in their infancy. Therefore, they cannot help mourning when facing the loss of an object or the frustrating and disappointing object. That is to say, they cannot face the fact of losing an object, nor develop mature love for another object with the passage of time. In other words, a narcissistic individual is more likely to fall into depression when encountering setbacks, because he is too committed to his narcissistic image and acquires a sense of extreme meaninglessness because of the failure to maintain the illusion of narcissistic self-sufficiency (Lasch 1979). This view on depression was further developed by Lasch into the view of the narcissistic society which we will discuss in detail in Chap. 4. Third, depression occurs because the deprivation of the objects to lean on leads to the individual’s persistent uncertainty. One of the theories is Spitz’s Anaclitic Depression, which argues that the primary cause of depression is the loss of anaclitic objects (Spitz 1965). Bowlby (1988) held a similar view. He proposed the Attachment Theory to explain the emotional bond between infants and their caregivers. Safe attachments are important for infants to develop satisfactory interpersonal relationships in the future, while unsafe and unstable attachments reduce the adults’s ability to obtain appropriate emotional support, thus leading to a variety of mental disorders, including depression (Bowlby 1988). Fourth, depression can be caused by an individual’s mixed emotions of love and hate towards objects which he cannot vent on these objects. The psychoanalyst Melanie Klein argued that an infant splits their parents into either good or bad (binary splitting) and enters into the “Paranoid-schizoid Position”. When he becomes more cognitively mature, he realizes that the mother whom he fantasized destroying

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is the same mother he loves. But because he is unable to vent the emotions on the mother, he falls into the “Depressive Position”. In this way, he realizes that in reality the one who he loves and hates can be close relative and the self. If the object is the self, an individual develops the self-attack in Freud’s terminology and falls into depression. Klein (1952) also pointed out that every child experiences the loss of the mother’s breast that nurtured him It is a blissful feeling for an infant to be suckled and satisfied by the mother. Once the infant cries for suckling and feeding, if the mother doesn’t give him what he requires immediately, he becomes uncontrollably angry, because being rejected by the mother or feeling rejected by the mother is an early recurrent model of emotional loss (Klein 1952). This is also similar to the traumatic pain caused by the loss of anaclitic objects and the feeling of being rejected described by Spitz and Bowlby. Fifth, depression is triggered by the psychological shadow or fear developed in infancy. The Object Relations theory in psychoanalysis delves into the formation and division of self-object psychic structures (the relation between the self and others, or the internal images of objects) in infancy. It also explores how these internal structures are represented in later interpersonal interactions. Theorists of this school focus on the long-lasting influence of various infantile experiences on future relationships, namely, the shadow or remnant of early experiences. The internal object relations form an interactive relationship between the perception and feelings of the self and those towards others. Therefore, an individual interacts not only with a real other, but also with an internally imagined other. The inner other is a psychic representation, which can be a twisted version of a real person (St. Clair 1996). The Object Relations Theory is a main approach in contemporary psychoanalytical studies. Melanie Klein, one of the founders of the theory, believes that when an individual experiences a certain loss, he feels as if he has lost “all that he has”, so that he will negate in the future all objects related to the lost one. Klein maintains that the adult’s response to detachment from loved objects is related to the response to emotional loss in childhood. When an individual can recover from the loss or detachment, the lost objects can live on in his mind without any distortion. But if he cannot recover from the loss, depression occurs. It is widely accepted by scholars that family experience exerts influence on individual behavior patterns throughout life. From Alder’s concept of people’s “style of life” (or “lifestyle”, as we would call it today) in his individual psychology to the concept of “script” (or life-plan) in Transactional Analysis, all these theories maintain that family life affects how an individual copes with future life. An individual acquires from early family experiences a set of explicit and implicit expectations, values, attitudes, and beliefs which serve as points of reference for the evaluation of many subsequent interpersonal experiences (Canfield, Hovestadt & Fenell 1992). This view has been explained in various theories of family therapy. Therefore, in the social structural analysis of depression in China, we will analyzed not only the life stories of depressive patients, but also their family life events with loose or maladjusted structures. This will deepen our understanding of how an individual develops negative psychic structures in his lifetime. Sixth, depression is a psychological defense mechanism to escape from reality. Patients with mental disorders are sheltered in illness to some extent because it

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is a self-protection mechanism; they can benefit from sheltering in illness. Illness is also a kind of resistance and even retaliation against reality. It often presents symptoms when people cannot find a way out. Freud illustrated the mechanism with neurotic women. Those who are brutally treated and mercilessly exploited by their husbands almost always adopt the evasion of the neurosis, provided that their predisposition permits this. This usually occurs when the woman is too conservative or too virtuous to seek secret solace in the arms of another, or when she dares not separate from her husband in the face of all opposition, or when she has no prospect of maintaining herself or of finding a better husband. Her illness becomes a weapon in her struggle with him, one that she can use for self-protection and misuse for purposes of vengeance. “The neurotic escapes the conflict by taking refuge in illness”, (Freud 1917/2013, translated by Wen: 350). The neurotic certainly includes depressive patients. His insight into mental illness can also be applied to the analysis of the social conditions for the occurrence of depression in contemporary people. In other words, when people face both internal and external pressures and conflicts, maladjustment occurs, or the psychological state is out of balance mainly because of anxiety generated in the subconscious. When an individual experiences conflicts one after another but cannot solve them at the conscious level, various somatic symptoms result, such as psychosomatic symptoms and depression. Under such circumstances, the methods often adopted by the individual to avoid anxiety are various psychological defense mechanisms, the process of which can be regarded as one of adaptation. When an individual takes refuge in illness, he does not know the meaning of his behavior. As he places himself among the patients, he reduces his personal responsibilities and worries. By gaining other people’s sympathy, he has a better chance of successfully adapting to reality. In this sense, depressive patients often encounter a dilemma where they cannot find meaning and are unable or unwilling to resist reality; illness can offer him a space for survival. In a word, depression occurs because of the transition from the excessive demand of the superego into self-attack, excessively narcissistic responses to the frustrating object, the loss and trauma resulting from love-hate emotions towards loved ones, a continuous sense of uncertainty, a psychological scar or fear developed in infancy, or sheltering in illness to resist and retaliate against reality or protect oneself. Sometimes these factors are not independent of each other, but interwoven with each other. The above psychoanalytic theories explain the causes of depression. Part I of this book will focus on whether the social structure under neoliberal globalization strengthens these factors as causes of depression. It is found that neoliberal globalization actually makes the whole social structure intensify the role of these factors in shaping depression. We will support this argument from two perspectives. The first is the production side. As mentioned earlier, the development of capitalism today is no longer restricted to domestic capital flows but has expanded into transnational neoliberalism, namely, a global network in which capital can flow across borders and accumulate flexibly under the WTO framework. Capital mobility and frequent transnational trade make neoliberal globalization prevail in all countries, leading to a drastic change in the perception of time and space. In space, increased migration

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creates a sense of uncertainty, which in turn affects the stability of the family structure. We will discuss the relationship between depression and the changed space structure in Chap. 2. In time, the competitiveness logic that emphasizes speed influences all entities ranging from the country to the individual, which leads to people’s mental health problems. The relation between depression and time change will be discussed in detail in Chap. 3. The second perspective of depression under neoliberal globalization is the consumption side. We will discuss how depression is related to the specific connotation of the social psychological environment under neoliberal globalization. This will be the major concern of Chap. 4. In the second to fourth chapters, we will analyze the social structure that accords with the causes of depression identified in psychoanalytical studies. In these chapters, “visible” empirical data (both quantitative and qualitative) are collected to show how the causes of depression identified in the previous psychoanalytical studies are intensified by neoliberal globalization. However, psychoanalysis can go further to the analysis of “the unconscious” (the real order in Lacanian psychoanalysis) and penetrate into the deep underlying structure of social culture. Therefore, it is worth analyzing the social culture that nurtures depression, especially the structural relationship between capitalism and depression, from a psychoanalytical perspective. In addition, the social structure of depression is shaped not just by the drastic spatiotemporal changes on the production side, nor the psychological problems on the consumption side. Depression is a mental problem, so if we can further explore the relation between the “invisible” unconscious and the capitalist structure, we can deepen our understanding of the social structure of depression. For this reason, in Chap. 5 Lacanian psychoanalytical framework will be applied to the analysis of depression under the contemporary capitalist structure.

References Abramson, L.Y., G. I. Metalsky, and L. B. Alloy. 1989. Hopelessness depression: A theory-based subtype of depression [J]. Psychological Review 96(2):358–372. Arieti, S. 1977. Psychotherapy of severe depression [J]. The American Journal of Psychiatry (8):864–868. Becker, E. 1964. The revolution of psychiatry [M]. New York: Free Press. Beck, A.T., A.J. Rush, A.J., B.F. Shaw, and G. Emery. 1979. Cognitive therapy of depression. New York: Guilford. Bibring, M.D. 1953. The mechanism of depression [C]. InAffective Disorders, ed. P. Greenacre. New York: International University Press. Bowlby, J. 1988. Attachment, communication and the therapeutic process [J]. A secure base: Parentchild attachment and healthy human development137–157. Canfield, B.S., A.J. Hovestadt and D.L. Fenell. 1992. Family of-origin influences upon perceptions of current family functioning [J]. Family Therapy 19:55–60. Klein, M. 1952. Some theoretical conclusions regarding the emotional life of the infant [C]. In Envy and gratitude and other works 1946-1963. Hogarth Press and the Institute of Psycho-Analysis.

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Lasch, C. 1979. The culture of narcissism: American life in an age of diminishing expectations [M]. New York: W.W. Norton Co. Markus H. 1977. Self-schemata and processing information about the self. Journal of Personality and Social Psychology 35:63–78. Seligman, M.E.P. and S. F. Maier. 1967. Failure to escape traumatic shock [J]. Journal of Experimental Psychology 74:1–9. Spitz, R.A. 1965. The first year of life: A psychoanalytic study of normal and deviant development of object relations [M]. New York : International Universities Press. St. Clair, M. 1996. Object relations and self-psychology: an introduction (2nd ed.) [M]. Belmont, California: Brooks. Žižek, S. 1994. The Spectre of Ideology. In Mapping Ideology, ed. Slavoj Žižek. London & New York: Verso.

Chapter 2

Analysis of the Production Side: Depression in Drastic Space Changes

We have mentioned the flexible accumulation in post-Fordist economies brought about by neoliberal globalization and the mobility at work, which allows laborers to move across regions geographically at any time. The drastic space changes derived highlight the following problems.

2.1 Intensified Uncertainty The flexible accumulation under neoliberal globalization reduces the number of fulltime and long-term workers with career goals. It can lead to various types of insecurity, including including the uncertainty resulting from multiplication of short-term jobs, the uncertainty resulting from short-term work contracts, the possibility of unemployment, the fear of being dismissed, and the constant worry about securing a job for tomorrow (Jessop 2002). Researchers in Australia conducted a survey of the working and health status of 1188 subjects in their 40s. Nearly a quarter of the subjects said they had a very stressful job and little control over their work, and another quarter of them expressed a sense of insecurity about their jobs (Zhang 2003). The survey also showed that managers and professionals are three times more likely to suffer from depression or health problems than ordinary people due to fear of losing their jobs. These factors can also potentially lead to disharmonious family life and interpersonal relationships. It has become a norm for people to struggle in the tiresome external world. This situation makes them vulnerable to depression or abnormal behaviors because of the resulting increased stress. One instance can be addiction to alcohol as a result of frequent unemployment, maladaptation to social changes, and constant anxiety and setbacks (Cai 2007). Some studies have shown that family environment, economic situation and employment status are factors contributing to depression. Gutiérrez-Lobos et al. (2002) found that employment and marital status have great influence on depression, and unemployment increases the risks of depression across all marital status categories. In addition, if the individual is under excessive stress © East China University of Science and Technology Press Co., Ltd. 2020 I. Hsiao, A Sociological Analysis of Depression in China, https://doi.org/10.1007/978-981-15-6471-0_2

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or has inadequate ability to cope with the stress, the internal anxiety and frustration gradually accumulate and increase, causing his emotions and behavior to get out of control. The individual then tends to use violence both expressly and instrumentally as a means of coping with a build-up of stressor events (Gelles 1999). Family member, especially women and children, are easy victims of such violence and feel insecure all the time, thus affecting their mental health. Such intensified uncertainty is equivalent to Spitz’s view that depression arises from the loss of an anaclitic object and Bowlby’s view that depression arises from the loss of emotional attachment. When the social structure of flexible accumulation is established, the inevitable uncertainty derived from it threatens the stable structure in the old days, and depression results.

2.2 Immigrants’ Emotional Problems Because of flexible accumulation, migration has become a norm under globalization. It is also a process which generates a series of stress factors. Research in American medical sociology dealing with the causes of mental health centers around a series of social factors giving rise to mental problems, including social stressors, stress adaptations, changes in life events, and stress and social groups (Cockerham 1992: 71–80). Some scholars explore the mental health of immigrant populations and find that the social and psychological stress derived in the process of immigration can result in mental illness (AI-Issa and Tousignant 1997: 4). Shuval (1982) argued that three forms of change characterize the migration process: physical, social, and cultural. Physical change is the change in lifestyle, such as changes in climate and dietary habits, social change includes changes in social identity, economic status, social roles and social relations, and cultural change covers changes in social norms and values. Some scholars further pointed out that the more changes immigrants undergo, the more difficult it is for them to adapt to the new environment (Ascher 1985; Williams and Berry 1991), which can result in mental problems (Hurh and Kim 1990; Zheng and Berry 1991). Studies have shown that the mental health of immigrants is associated with at least four stressors: survival, a sense of loss, cultural differences, and expectations (Wong 1997). There are studies focusing on how depression is related to different factors. Survival involves the immigrants’ immediate needs, such as housing and work (Wong 1997). Financial difficulties and job loss (Nicassio et al. 1986; Thompson et al. 2002), language barriers (Vedder and Virta 2005), poor living conditions (Papadopoulos et al. 2004), and discrimination (Aroian et al. 1998; Yeh et al. 2003) are all related to poor mental health among different groups of migrants. Stress has a significant impact on mental health. Research by foreign researchers has shown that immigration’s economic and employment stress and interpersonal conflicts have a significant correlation with mental health (Nicassio et al. 1986; Thompson et al. 2002). Research in China on immigration centers on migrant workers. According to the survey conducted by Xinghua Guo and Fengwei Cai of migrant workers in Beijing and the Pearl River Delta region, more than 40% of the new generation of migrant workers have depressive symptoms of varying degrees,

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and 20.7% have moderate or more severe symptoms. Mobility is one of the factors in their mental problems. The “labor migration regime”1 generates the institutional pattern of out-migration of the new generation of migrant workers. It is the direct cause of the emotional problems of these migrant workers and has caused many problems in their adaptation to the changing life (Guo and Cai 2012). However, risk factors for depression can still be identified under the superstructure of mobility. Guo and Cai (ibid.) posited that urban identity is an important mediating variable which influences the mental health of migrant workers in their social interaction after settling in cities. Then, in terms of the forms of social interaction, group interaction can reduce the occurrence of depression, while the influence of individual interaction tends to be more complicated. Therefore, social support is another key variable that affects the mental health of migrant workers. In addition, migrant workers’ personal conditions, their labor rights and the factory system also exert an impact on their mental health. The widespread infringement of migrant workers’ labor rights has given rise to some of their mental health problems. In a word, social support, adaptation to new life and work, labor rights and interests, the factory system and other factors mentioned above are all problems arising after the formation of the mobility system. The mobility system is related to the rural-urban divide, which has been restructured after the reform and opening up. In this sense, mobility does have structural effects on the mental health of migrant workers. Chinese research on migrant workers centers more on their financial and employment difficulties. For example, their average wage and welfare benefits are lower than those of urban workers, while they work longer hours on the average; they are in a disadvantaged position in the labor market, lacking the power and ability to bargain with employers (Xie 2008; Li and Li 2007; Li 2004). These difficulties inevitably lead to mental problems. The social support network of their families, fellow villagers, colleagues and friends is certainly a contributor to their mental well-being, but the network itself can also become a stressor for them (Zhao 2008; Lin et al. 1985), because negative interference or mutual dissatisfaction may arise as a result of the workers’ emotional problems triggered in the adaptation process (adaptation to work, housing, education, medical care, etc.) or the emotional problems of someone in the support network. Scot and Scot (1982) revealed that migrant workers can experience an increase in marital and work conflicts as they adjust to a new and unfamiliar environment. Santos et al. (1998) suggested that migrants who have more marital and work conflicts have poorer mental health. What is also worth noting is that mobility does not inevitably lead to an increase in mental stress. If migrant workers are easily satisfied and do not have high expectations, they are less stressed. The situations of some migrant workers in China reflect this fact (He 2005; Li and Li 2007). The mental health status is not pre-determined, but manifested in 1 The

migrant labor regime was proposed by Cindy Fan when she analyzed China’s labor system and gender roles in labor migration. It is the product of a system that inherits socialist control instruments to strengthen the role of state in internal migration. It reinforces the differences caused by hukou (house registration) or residential status, places of origin, social class and gender to extract maximum values from rural labor. It fosters a deep divide between rural and urban Chinese by defining opportunities by hukou status.

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the migrant workers’ actions taken in the adaptation process (He et al. 2010). On the whole, the emotional problems of migrant workers in China are similar to Spitz’s and Bowlby’s views that depression arises from the loss of certain support. The following four cases from our data collection manifest the effect of migration or immigration on depression. Case 1 Depression and trans-regional migration The 1990s witnessed a radical expansion of university and college enrollment in China. Universities set up many new departments and schools. The college enrollment rate also increased significantly. Students had more opportunities to receive university education than before. As a result, it has become the norm for students to move across regions. When they are old enough to go to college, they usually have to adapt to life in a new place. This inevitably leads to a series of adaptation problems, ranging widely from academic difficulties to emotional problems. Ni had depressive symptoms when she was a senior high school student. She wanted to be alone and didn’t want to do anything. She was under great learning pressure and mentally stressed. Her parents had high expectations of her. She suspended her study for a period of time. Before the National Entrance Examination or Gaokao (高考), she did not adjust well enough and so her performance was not as good as expected. Then, in the first semester of her sophomore year, her academic performance was not as good as in her freshmen year. She began to lose confidence, skip classes, complain about too much homework, play computer games, watch movies and listen to sad music. During this time, she fell in love with a boy five years older than her through the Internet. After that, she often lost her temper in the dormitory. She still did not go to bed at bedtime, causing troubles to her roommates. She was diagnosed with depression. Her depression worsened after her boyfriend broke up with her, causing her depressive symptoms to worsen (Li and Yao 2012).

In this case, Ni was forced to adjust not only to academic pressure but also to emotional problems derived from cross-regional mobility, which has become a norm and gradually made establishing interpersonal relationships more complicated. College students have to live in a relatively fixed environment for quite a long period of time. It is not easy to deal with the relationships with roommates, classmates, teachers, fellow villagers, people of the opposite sex and people in various college clubs and associations, etc. Maladjustment brings about a series of psychological conflicts and a large number of negative emotions like disappointment, frustration and pessimism. Such cases are not rare. Case 2 Depression and cross-border commuting Meishan and her husband are Chinese-Americans. The couple were international students in the United States in the late 1990s and ran a joint clinic there. In 2010, they returned to Shanghai to attend their nephew’s wedding. On the way, her husband suffered a sudden stroke. After being sent to a big hospital in Shanghai, he was diagnosed with transient ischemic attack (TIA), and medicine was immediately applied to dissolve the thrombus in his brain. However, less than five hours later, he suffered another stroke. His central nervous system was blocked and he was unable to breathe. He was in coma for several days in the intensive care unit (ICU). Fortunately, he survived the stroke, but awaiting him was a long period of recovery. The incident left Meishan without support all at once and she felt extremely helpless. However, she had to keep on running the joint clinic in the United States.

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Her husband was unable to take the plane and remained under the care of the relatives in Shanghai for recuperation. Meishan encountered a series of difficulties when she returned to the United States to run the clinic—real estate taxes, utility bills, and the monthly salary of the staff, a $1 million bank loan, etc. She often shivered and was unable to fall asleep for a few months. She had no appetite, often eating nothing for a whole day. Her husband in Shanghai was not well either. He was in crisis several times. Meishan eventually suffered from depression caused by a sudden loss of support and the spatial changes caused by cross-national commuting triggers depression.

This case illustrates how the panic and insecurity caused by a sudden loss of support and the spatial changes caused by cross-national commuting triggers the occurrence of depression. Case 3 Depression and acculturation Psychological counselor Zhenji Zhou (周振基) presented a case in his manuscript Jiao Lü: Yi Ge Xin Li Zi Xun Shi De Zhi Liao Shou Ji (Anxiety: A Psychologist’s Consultation Records and Notes). Dr. Di Wu had studied and worked in the United States for 15 years. He got married and had children there. Because his mother was critically ill in China with no one to take care of her, he planned to return to China and start a business so as to be closer to his mother. He hoped that his wife and children would return with him. But they firmly rejected his suggestion. In such a situation, Wu proposed a compromise plan: he would run his own business in China for a year and see how it worked out. If it turned out to be not as good as in the United States, he would go back to the United States; if he decided to stay in China, he would have to divorce. A year later, Wu successfully started a software company with friends in Beijing. He divorced and stayed in China to take care of his mother. Later, Wu met Xue Lu and started his second marriage. But after three months of marriage, his life was shattered. First of all, the sex life was not harmonious. Wu was energetic and had an American concept of sex. He expected a high frequency of sex and sought stimulation in sex life. But his wife Lu thought that sex was shameful and had no interest in it. Secondly, conflicts resulted from their personality differences. Wu was educated in both China and the United States. He insisted on independence and dared to take risks, while Lu, who had never left her parents’ protection since she was a child, developed a dependent character and didn’t dare to try new things. Moreover, Lu often blamed Wu for failing to do well in certain things or for not being courteous to her relatives and friends. Fierce conflicts between the couple resulted. Wu felt aggrieved and began to suffer from insomnia, headaches, distraction and depressed feelings.

Wu’s first divorce was the result of a conflict between filial piety and love, while the second unhappy marriage was due to the different attitudes towards sex in Eastern and Western cultures. Wu was frustrated by Lu’s unchanging attitude (Zhou 2008). The case demonstrates that depression arises when migrants living in different cultures encounter cultural conflicts. In contemporary society, where cross-national mobility is frequent, it is common for people to encounter various interpersonal conflicts derived from different cultural concepts. The probability of confronting cultural differences is higher than in the past, as is the probability of encountering conflict and anxiety.

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Case 4 Cross-border migration and recurrence of traumatic syndrome Professor Alf Gerlach pointed out that collective trauma affects not only those who have experienced it, but also their children and offsprings. In other words, it has transgenerational effects. Survivors’ “children then live in a double reality, in the past of the parents as in their own time” (Gerlach 2011: 198). Alf Gerlach presented a case of a Chinese patient who went to Germany in the late 1990s to write his doctoral thesis at a German university. After arriving in Germany he suffered severe feelings of loneliness and despair. This puzzled Gerlach—this 30-year-old young man was an appreciated member of his working unit, loved by his wife and son, and enjoyed good relationships with others; so why was he so desperate? Later, Gerlach discovered that the young man’s hidden memory of the past of his grandparents was activated at the time of his separation from his family when he went to Germany. During psychotherapy, the young man sobbed and articulated his narration intermittently in a voice which slowly became filled with the sounds of mourning. A subsequent interview showed that he had developed a typical defense and coping mechanism— he tried to overcome or counter-balance the humiliation and forced shame of his grandparents through hard labor and success to counter-balance their family’s past disgrace. This defense constellation may also be frequently observed as a reaction after narcissistic breakdowns. It leads to a form of isolation with a denial of affects, not of reality, and an overestimation of the values which have been damaged. It is as much a coping as a defense mechanism, because the aim is not the defense of libidinal or aggressive drives, but the mastering of social difficulties and changes. But overidentification with the family and high expectations of success often complicate the process of individuation and separation from the family (Fan et al. 2013). This case tells us that in cross-border mobility, a victim or a family member who witnessed the victim’s traumatic experience can succumb to loneliness in a foreign country. Their unpleasant memories and traumatic past can be activated if they have no relatives and friends abroad. This highlights that cross-border mobility under the neoliberal globalization forms a potential structure of universal loneliness. In other words, cross-border mobility aggregates the sense of loneliness and increases the recurrence possibility of traumatic syndromes.

2.3 Depression Arising from Family Crisis Apart from the problems caused by the above-mentioned cross-border or cross-region migration, the family is another increasingly important risk factor for depression in neoliberal globalization. Family members are affected by this economic structure, and members exert a mutual impact on each other. Family disturbances or crises are likely to lead to emotional storms in the family. The frequent mobility brought about by neoliberal globalization has resulted in the restructuring of the family. It is a globally common phenomenon that couples work separately in different places. In China’s urban areas, the ways of family gatherings are changing. For example, some young couples leave their kids at their parents’

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homes and only pick them up at weekends; or paternal and maternal grandparents take turns helping take care of the grandchildren in the young couples’ homes; or the wife lives with the children and her parents in one place, while the husband working in some other place comes home once every week at weekends. Even if young couples stay together in the same city, they need their parents’ help in taking care of the family, because they may work too far away from home to do everything themselves. All of these phenomena show that forms of family organization are changing (Shen 2013). In China’s rural areas, it is common to see “liushou” families (families with left-behind old grandparents and/or children). It is also common to see that left-behind children remain at home to be cared for and educated by the grandparents while the parents seek employment in cities. The above phenomena point to the fact that it is difficult for family members to stay together. It can be seen that rapid liberalization has gradually reorganized, restructured or even disintegrated the most basic support system in people’s lives—the family. Family restructuring and disintegration is a social phenomenon in which people lose support and develop a sense of uncertainty. This is similar to Spitz’s and Bowlby’s views that the loss of certain support can lead to depression. This situation affects both an individual and other family members because the family is a system, according to the family system theory. The family system integrates various parts related to the family into a systemic whole. The parts include family members, interaction patterns, family structure, family relationships, communication methods, attitudes, etc. The parts are continuously interconnected. A change in one component is inevitably associated with changes in the other components with which it is in relation. It also affects the operation and equilibrium of the family system. Therefore, when a disequilibrating family system brings about tension and stress, changes occur to the family, such as malfunctioning, changes in family structure, behavioral deviation of family members, etc. (Goldenberg and Goldenberg 1996). Following are some common situations. 1. The emotions of both husband and wife can be affected by marital quality, because marital quality is a risk factor affecting the mental well-being of married people. Previous studies have shown that dysfunctional marriages or love relationships can lead to depression (Monroe and Depue 1991; Hilt and Nolen-Hoeksema 2002). The severity of depression is related to factors such as whether the patient has a sense of support, mutual benefits or conflicts and negative responses in the interaction with the spouse. What’s more, marital discord is not only a significant risk factor for depression, but also affects treatment of depressive symptoms and the patient’s response to the treatment (Yang 2004). Research has proved that both males and females are more likely to suffer from depression when they are divorced, separated or widowed (Gutiérrez-Lobos et al. 2000; Miller and Reynolds III 2002; Stuart and Robertson 2003; Sadock and Sadock 2007). In contemporary society with high mobility, it is common that one spouse seeks employment in some other place. The long-term separation between husband and wife weakens their relationship. What’s worse, the one who seeks employment in some other place is exposed to multicultural impacts and his ideologies, attitudes

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towards tradition and ways of thinking become different from the spouse who stays at home to take care of children and the old. One of the consequences is higher divorce rates. Take China as an example: the divorce rate rose year by year from 1.28‰ in 2004 to 2.29‰ in 2012, showing a rising trend (People’s Daily online 2013). There are also reports showing that the incidence of depression caused by changes in marital status and family structure is more than 80%, with middle-aged and young people aged between 25 and 50 as the major population, accounting for 80% of the total number of outpatients (Gu 2010). In such an unstable family structure, children are brought up by grandparents or grow up in a single-parent family without the love of a father or mother (parents are divorced or are separated). They may develop a certain sense of insecurity in their personality and face increased risk of psychological problems in the future. Besides, children traumatized by the parents’ divorce may double their distrust toward marriage when they grow up, and the divorce rate of their generation will double compared with that of their parents. A survey of 100 juvenile delinquents found that 60% of them came from divorced families, and their parents’ quarrels and marital infidelity were the real culprits for their apathy and violent behavior. Parents’ divorce is a killer of children’s mental health (Qian 2014). Divorce increases the chances for children to develop a love-hate attitude towards their parents, just as psychoanalyst Klein pointed out: the mother he fantasized of destroying is the same mother he loves; but because he is unable to vent emotions on the mother, he falls into the “Depressive Position”. Additionally, the anxiety caused by such an environment can be easily triggered under future stress events, resulting in depression. 2. Depression can harm marital relationships. It often leads to marital discord (Yang 2004). Marital quality improves or falls as symptoms of depression increase or remit. There is bidirectional connection of depression with marital quality—poor marital quality increases the risk of depression, while depression also increases risk of poor martial quality (Joiner 2002). In terms of the impact of depression on marital relationship, research has shown that compared with partners whose spouses are not depressed, those with depressed spouses have lower satisfaction and more conflicts in their marriage (Schmaling and Becker 1991), or are less cooperative, more irritable and hostile and are prone to negative self-evaluation (Joiner 2002). When one partner suffers from depression, the probability of ending up in divorce is nine times as high as that of non-depressed couples (Rosen and Amador 1996). Some reports show that depressed patients are more dissatisfied about their marriages than non-depressed patients, which may be due to the patients’ negative attribution of their emotions, or the burden on the spouses, or the spouses’ anger and anxiety (Yang 2004). The interaction between depressive patients and their spouses demonstrates similar problems to the interaction between them and other people—when facing marital conflicts, most depressive patients take inappropriate coping measures, such as disputes, self-blame, selfdepreciation, and avoidance (Joiner 2002). In short, the interaction of depressed couples often results in negative communication or maladjustment, so they feel highly stressed and are even hostile to each other or unwilling to cooperate with

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each other. Such poor interaction is, on the one hand, the effect of depression, while on the other hand, also a cause for depression. If it lasts for a long time, it is obviously not conducive to the recovery of depression, nor to the maintenance and improvement of a marital relationship. 3. Depression also affects parent-child relationships. The Princeton Survey Research Association pointed out in 1996 that depressed parents are less likely than non-depressed parents to play with, hug, read to, or sing to their young children each day or to employ the same routine each day, and they are also more likely to get frustrated with their children on a daily basis (Comer 2001). What’s more, distressed forms of interpersonal relationships (e.g. sense of helplessness, social withdrawal, anger, neglect of feelings, and poor problem-solving skills like ineffective communication and creating conflicts) may also occur in the interaction between depressed parents and their children (Joiner 2002; Mufson et al. 2004). Depressed parents may even abuse their children physically and/or psychologically. They and their children are prone to developing a sense of incompetence and frustration in communication, leading to negative feelings toward each other. Studies have found that children of depressed parents have higher risk of depression (Joiner 2002; Mufson et al. 2004). In addition to biological or genetic factors, social and environmental conditions are also risk factors of depression for children of depressed parents or negative factors for their mental health. These social and environmental factors range from family stress identified by Goodman (2002) (e.g. parental disputes, parents’ negative behavior, parents’ negative ideas and criticism, and social deprivation) to a sense of tangled and negative emotions in the family and to a family atmosphere of anxiety (Comer 2001). There is also a unique form of depression called “swaddling depression” (infantile depression). Infants who are frequently separated from their mothers can demonstrate this type of depression when they are 6 months to one year old. They exhibit different degrees of various symptoms, including fear, sadness, crying, rejection of new environments, withdrawal, dullness, no appetite, insomnia and gloomy expressions. Swaddling depression may develop into “dysplasia” when infantile patients reach the age of four or five. They may have little affection and do not like to be close to others. At five or six, they may become irritable and cannot sleep well or eat well. They don’t make friends, have little self-confidence and frequently wet the bed. These are all depressive symptoms. Some of the children with swaddling depression may become timid, while others become more and more eccentric and like to destroy things. Because children do not think of the future or organize their memory like adults, they seldom think of the meaning of life. Their abstract emotions have not yet developed fully, so they may not have the same frustration and hopelessness as adult depressive patients; but their personalities will tend to become negative. In short, once a child develops negative emotions and modules in their growth, habitual negative attributional behavior may develop in the future, which may further affect his interaction with others.

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Intensified uncertainty, high mobility, and restructuring of the family—these drastic spatial changes in neoliberal globalization indeed exacerbate the loss of attachment or anaclitic support, in Bowlby’s and Spitz’s terms. In other words, when the objects and structures people can rely on have become fluid and floating, and the sense of loss, uncertainty, insecurity and loneliness brought about by drastic spatial and environmental changes has been intensified, depression may occur as a result. Under such circumstances, abnormal family relations emerge constantly, and children growing up in such families are more vulnerable to depression in their adulthood, which is in line with the argument of the object relations theory. The above research has shown the impact of the family on depression. In China, the family has a similar impact. Three cases will be presented to show how family crises trigger depression in China’s context. The first is a first-hand case while the other two are cases from two psychological counseling books. Case 1 Marriage crises and depression related to the high cost-of-living High-pressure life has become a norm for modern couples. The experience of Xiaokang,2 one of the author’s interviewees, is a microcosm of the modern highpressure life. Xiaokang suffered high pressure at work. He became a taxi driver after the company he used to work in went bankrupt. Later, he started a small business with his friends. Afterwards, he shuttled between different cities. He worked really hard, but didn’t secure much understanding from his wife. Xiaokang believed he was a responsible father, at least doing his best to provide financial support for his family. However, he always had conflicts with his wife in raising and educating their children and they often quarreled over this. In addition, because of his heavy work pressure, he was in a bad mood, getting drunk frequently and even taking his anger out on his children. His wife was extremely dissatisfied with this. Later, his business with friends went bad, and the quarrel between him and his wife got fiercer and more frequent. He was uncomfortable because they were often in opposition. Later, his wife proposed divorce, which troubled him severely. After that, he was diagnosed with depression by psychiatrists. Xiaokang said: “My life pressure now is really high. It’s not easy to be a good man. My busy work and the financial trouble of my company led to my constant tension and stress.” His simple statement epitomizes the life of modern people.

The pressure contemporary young couples bear can be epitomized by the description of the interviewee Xiaoqian. He said: “When I was a child, I lived in a flat allocated by my father’s workplace. Our family lived on the third floor while my father worked on the second. We got along very well with my father’s colleagues. My parents had stable jobs and payments. They hardly complained about anything and we were quite happy. I had a wonderful childhood. The only thing that was not so good was that everyone was poor, without today’s richness in material goods. Now I am married and have one child. The pressure is quite great even to raise just one child. You see, milk powder in China is not safe and I have to buy foreign products. Housing prices in cities are so high, everything is expensive. Working in cities, one needs to buy a car and an expensive license plate. With a car, it still takes three hours every day to commute between 2 Chinese people tend to add the character “little (小 xiao)” before surnames to address young people

and “lao” (老 old) for seniors. It is a way to show friendliness or intimacy between the addressee and the addresser. Xiao can also be used in first names. When it is used before surnames, it is translated as Little, and when it is part of the first name, it is translated as Xiao—Translator’s annotation.

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the company and my home. I have to pay for car maintenance. I also give a sum of money to my parents and parents-in-law to cover their daily expenses and their medical costs. With these expenses, I cannot save a single penny. Life is really not easy. Besides, there are so many troubles in life, such as encountering rude civil servants and impolite shop assistants, the problem of smog, and concerns for food and water safety. In fact, such hidden costs of living, in my estimation, can be really high. How can the pressure of such a life not be “as heavy as a mountain!3 ”

Xiaoqian’s self-articulation highlights that contemporary people are stressed and anxious in different ways from those in the past. In the era of planned economy, food, housing and work of many people were allocated and their education funded by the state. The main difficulty at that time was the lack of material resources. Later, the market economy was developed. People’s living conditions gradually improved, but they were under fierce competition for survival and encountered various intolerable disparities. Moreover, after the reform and opening-up and the impact of neoliberal globalization, real estate, health care and other sectors which used to be managed by the state were also privatized. Salary increases never catch up with the rise in house prices, goods prices and costs of social insurance. In addition, China’s fiscal system supports capital expansion in both its tax revenue and expenditure (Zhang and Gao 2014), which leads to a heavy emphasis on economic development. As a result, many problems have emerged in Chinese society after the reform and openingup, causing frustration and distress among many people. In his book Where the Chinese Anxiety Comes From, Yushi Mao (茅于轼) pointed out nine major factors that affect Chinese emotions—social injustice, soaring high housing prices, the gap between the rich and the poor, rampant privilege misuse, low incomes, employment difficulties, food safety, exam-oriented education and environmental pollution (Mao 2013). Sociologist Liping Sun (孙立平) also pointed out that China is at a stage of transformation with social “fracturation” and “disequilibrium”. Inadequate social and personal preparation for the transformation is manifested in people’s anxiety about the widening income disparity, the incompleteness of the legal system, and public security and social changes (Sun 2003, 2004). In particular, the absence of legal norms to regulate fraud, forces people to cope with it on their own due to the lack of a sound social protection mechanisms. This leaves too many “grey areas” for trickery and injustice. The traditional and stable planned economic structure disintegrated, but a reliable alternative system is not yet mature. Under such circumstances, the living cost is extremely high. It is really not easy for people to be in a good mood all the time, whether they go to work or school. They must face the smog, squeeze

3 Ya Li (压力 a word meaning stress) Shan (山 mountain) Da (大 large) is a popular expression to talk

playfully about the high pressure in modern life. Literally, the whole expression means “pressure is as heavy as a mountain”—Translator’s annotation.

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into crowded subways during rush hours, bear high housing prices and worry about food safety. This is the root cause for the occurrence of depression in China (News China 2007). Case 2 Depression and extramarital affairs Psychological counselor Zhenji Zhou presented two cases of depression resulting from extramarital affairs in his manuscript Yi Yu: Yi Ge Xin Li Zi Xun Shi De Zhi Liao Shou Ji (Depression: A Psychologist’s Consultation Records and Notes). Feiran Chen is a dutiful daughter and wife. She grew up in a family with loving parents who loved each other. No childhood shadow was left on her. She had excellent performance in study and work. However, her husband Mingjun Zhao plunged into extramarital affairs one week after he found pleasure from cheating online. The woman having an affair with Zhao was named Mei Ye. She found Chen and told her in detail about the affair with her husband. Chen collapsed after hearing about it. After that, Ye persistently wanted to be with Zhao, demanding that Zhao either compensate her with 10,000 yuan or divorce from Chen and marry her. However, Zhao felt guilty toward his wife and refused Ye when he realized the serious consequence. However, the more he refused, the more constantly Ye pestered him. (Zhou 2006: 1–32). Chen began to have a feeling of resentment. No matter how kind her husband was to her, she was not moved. She often could not fall asleep. Sometimes when she fell asleep, she would wake up crying. She suffered from depression. After having an interview with a psychologist, she began to think over her marital problems. Their marriage had undergone changes after the birth of their daughter. Her husband had complained that she was caring less about him and more about their daughter and that her husband’s needs had not been fully met. Her husband had seldom criticized her, but she had often criticized her husband and they had communicated less. In addition, Chen had been very busy, taking care of the daughter, doing the house chores, finishing her work, studying for an MBA degree, etc. She had often gone to bed very late and fallen asleep soon. Because their marital relationship was no longer harmonious, her husband Zhao eased his loneliness and emptiness for a while after he met Mei Yu online by chance. This example shows that if one partner neglects the communication with the spouse, the spouse may have extramarital affairs, which can lead to depression (Zhou 2006: 1–32). Another example is Lan Xiao and her husband. They were close to each other, as if they were glued together when they got married. But seven years later, Xiao found a long list of intimate and dubious messages from a woman in her husband’s cell phone, which confirmed that he was having an affair. Her husband left her and never contacted her again. Xiao was depressed (Zhou 2006: 33–66).

Psychologists identify the interaction between Lan Xiao and her husband as “parent-child” mode. Her husband took care of her like a father. At the beginning, it may not be a problem; such care may even be an affirmation of a man’s capability. But as time goes by, her husband may get bored. Their life becomes boring in the husband’s eyes. Psychologists believe that Lan Xiao has not yet grown up emotionally and her excessive reliance has exerted much pressure on her husband. Meanwhile, we also see that mobile-phone communication in the information era opens up the possibility of emotional exploration. Extramarital affairs may occur

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often when one partner is unable to achieve satisfaction or endures pressure, because the new communication tools open up new possibilities for interpersonal interaction (Zhou 2006: 33–66). The percentage of extramarital affairs during cross-border mobility is also on the rise. Lanshan Ji is one example. She had two marriages. She obtained her doctoral degree in religion before she began her second marriage. One year after she began her second marriage, she went to Boston in the United States for further education. She stayed there for one year. Because of the loneliness abroad, she fell in love with her Chinese classmate Little Zhang. Shortly before her study came to an end one year later, Ji felt extremely distressed. She knew that she could not marry Little Zhang, but she could not bear to leave him. After returning to China, she told Little Zhang about the pain of separation every day. Little Zhang thought the two had no hope of being together, so he decided to break up with Ji. Ji felt sorrowful, as if being thunderstruck, and decided to kill herself. Fortunately, she was rescued (Zhou 2006: 97–132).

This example illustrates the risks of extramarital affairs caused by cross-border mobility. Psychologically, the protagonist suffered tremendously because of the conflict between ethics and her personal pleasure. In the past, there was less mobility, ordinary people had fewer resources at hand and ethics played a greater role, so there was less probability of having extramarital affairs. However, in the contemporary era characterized by strong desires, high mobility, more loneliness, and greater resources (offered on mobile phones or the Internet), the probability of extramarital affairs has increased. Ji’s affair is partly due to her dependent personality, but the loneliness she suffered in an unfamiliar foreign culture contributes more to her affair. This may also be a risk factor for her future mental health. Case 3 Depression and the impact of depressed parent(s) Joiner (2002) and Mufson et al. (2004) found that if one or both parents have depressive symptoms, their offsprings face greater risk of depression. Little Ge’s mother has been suffering from geriatric depression in recent years, which has exerted great impact on him, the eldest son in the family. He found it was difficult to communicate with his depressed mother. He also found that he had depressive symptoms like negative emotions (frustration and anger) and reflections. In addition, his role changed to become the caregiver of his mum. He found it a great challenge. He needed to make new adjustments. He said: My mother’s depression has actually had great impact on me. I am like a depressed victim and my mood becomes automatically influenced by my mum’s. Every time she had a reaction I would immediately think about what’s going to happen next … and then I would be angry … The relationship between me and my mum has actually changed from the original mother-son relation to the patient-relative relationship, which is not a very good result. Xiaoxi has reflected on the causes of his depression since he was at high school. In his opinion, his father was addicted to alcohol and often lost his temper; he inferred that his father may have developed depression. In addition, both of his two half-brothers with the same father committed suicide. He couldn’t help worrying about the influence of genetic factors on himself. He also felt that the childhood experience in the former family with his genetic parents had hurt him. He had been precocious and unhappy since he was young. In

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2 Analysis of the Production Side: Depression … addition, the divorce of his parents made him suffer pain because of the disintegration of his family structure and his helplessness in the early days of his life. For him, the breakup of the family with his genetic parents was one of the major factors that drove him to depression. Marital discord often hurts the innocent children. When Xiaoyu was in grade five or six in primary school, his mom often quarreled with his father about money. His mother was enterprising and hardworking. She was very tired, but his father seldom helped her. Instead, he drank alcohol often. His mother attempted suicide several times. About the time when he was a third grader, his father was relocated to another place. He had an affair there and lived with that woman. During this period, his parents quarreled many times, and his father always took his anger out on him and beat him often. The parents divorced because of his father’s affair. After the divorce, they still hurt each other again and again. Xiaoyu was very aggrieved and drew others’ attention through his addiction to the Internet and attempts at suicide. His teacher kindly took him to see a psychiatrist, who diagnosed him with major depressive disorder (MDD).

All these examples illustrate that the emotions of one family member affect other members, an increasingly common phenomenon in today’s society.

2.4 Blurred Work-Life Boundaries: Emotional Problems in Mobile Space The flexible capital accumulation in neoliberalism, together with the wide application of Internet technology, has overcome the limitation of working in a fixed space and brought about a pattern that does not distinguish between work and private life. Employees work with no fixed working hours. For example, for work-from-homers doing online work and virtual receptionists, their customers or clients may become their friends. The overlap of work and private life is a product of neoliberal globalization. Due to the increase in the workload, job flexibility and labor dispatching have actually intensified the “bustle” and “impetuosity” in the workplace. Contemporary people often carry out activities in a virtual mobile space, dealing with business and private affairs in the multiple windows of smart phones, laptops and desktop computers. Social networking, marketing products, finding a life partner, posting advertisements and circulating information are always handled simultaneously. The work and life style make people use computers and mobile phones excessively, reducing their ability to relax and reduce tension and stress. As a result, people are prone to sleep disorders and poor work efficiency. In addition, high stress can occur at any time, making people exhausted in such “combat-like conditions”, and depression results. Little Guo was an outstanding student since childhood. He never let his parents worry about him. He once worked as a manager in a foreign company and was a “champion” automobile salesman. His responsible attitude won the trust of his superiors. He was always assigned to challenging jobs and sometimes assigned to

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deal with crises, especially to clean up the mess of his colleagues. Usually, Little Guo took either a high-speed train or a plane when he was on business in different places. His life was very tense and busy. In order to take good care of his family and work, he used various means of communication, such as cell phone, e-mail, QQ, etc. In this way he was able to keep in contact with his family or colleagues anytime and anywhere. For him, there was no boundary between work and family life. For a while, he was negotiating over a large project, but his son, who was in his puberty, made trouble quite frequently in school, which made him burned out like a candle with both ends on fire. Then emotional problems occurred. He was diagnosed with manic depression (also manic-depressive illness or bipolar disorder), which is more difficult to cure and more painful than unipolar depression. Typical symptoms of unipolar depression include loss of happiness, being sad and indifferent to everything. Unipolar depression can eventually lead to cognitive disorder, atrophy of action and various physical discomforts. Guo’s manic symptoms include euphoria at work, endless energy and having numerous ideas. He had even done absurd things such as speaking English on a spree and tipping 1000 yuan to strangers. But immediately after a manic state ended, depression hit. He was in increasingly low spirits, unwilling to get up and work, and suddenly lost the interests he used to have. It was like people who love eating losing their appetite, those who love shopping locking themselves in their homes, and those who love working suddenly not daring to go to work. This example shows that today’s work has lost its boundary with private life because of scientific and technological advancement. The work boundary is not as clear-cut as on the assembly line in traditional industries. But employers’ demands for high performance are increasing. If there are other things disturbing an individual, he may run into emotional problems.

2.5 Summary The above analysis illustrates that neoliberal globalization has resulted in frequent cross-border and trans-regional migration. Such high mobility has even disintegrated the previous stable family structure, which can change the personality of each family member. However, the Chinese have developed new adjustment mechanisms to maintain family ties. As mentioned earlier, when there is no sound social security mechanism that allows either spouse in a young couple to stay at home and bring up children, and when both go to work, the couple’s parents can help to take care of the children. In such circumstance, the couple’s parents may live with the couple and their children, or they may live in their own house and come to help during the day. This not only relieves the pressure of working couples, but also enables the elderly to enjoy the happiness of a family union. Chinese are not as individualistic as Westerners and tend to make greater efforts to maintain kinship relations,

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which can reduce the possibility of depression for a certain period of time. However, the unavoidable ethical conflicts in real life and difficult interpersonal tensions have encroached on the wiggle room between law and morality. Interpersonal networks are not merely a mechanism to relieve pressure, but also a source of pressure. How well they function depends on the situation an individual is in and the relations he establishes. We agree that depression is linked to personality and stressors. We highly appreciate the cognitive psychological explanations of the relations between them— personality is a key factor for depression because an optimistic individual can handle stress successfully, while an individual with excessive negativity may often fall into emotional disorder when facing stress events. Then what is the sociological interpretation of depression? The elements in the social structure identified previously have an impact on the formation of stressors and the development of an individual’s personality. In terms of personality development, the family plays the most crucial part. The reorganization of family structure can weaken the family’s emotional support for an individual, and the mood swings of one family member may also cause problems in the interaction with other family members. The family is an interactive interface and a carrier of structural reactions to social reality. It affects the development of children’s personality. This reflects the role of social structures in the formation of human character in neoliberal globalization. Stressors are related to the drastic spatial changes of social structure. That is to say, problems arising from adaptations to high mobility and to cross-border migration, problems in acculturation, stress reactions to transnational mobility, high living costs or marital infidelity caused by neoliberal globalization are all stressors that increase the risk of depression. Such social structures contribute to the occurrence of depression.

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Nicassio, P.M., G.S. Solomon, S.S. Guest, and J.E. McCullough. 1986. Emigration stress and language proficiency as correlates of depression in a sample of Southeast Asian refugees. International Journal of Social Psychiatry 32: 22–28. Papadopoulos, I., S. Lees, M. Lay, and A. Gebrehiwot. 2004. Ethiopian refugees in the UK: Migration, adaptation and settlement experiences and their relevance to health. Ethnicity & Health 9 (1): 55–73. Qian, Xi. 2014. Li Hun Lü Di Zeng Ti Xing Hun Yin Geng Yao “Qie Xing Qie Zhen Xi”. Ren Min Wang, 2014-06-19, http://opinion.people.com.cn/n/2014/0619/c100325172594.html (前溪. 离婚率递增提醒婚姻更要“且行且珍惜”. 人民网. [2014-06-19]. Rosen, L.E., and X.F. Amador. 1996. When someone you love is depressed: How to help your loved one without losing yourself . New York: Free Press. Sadock, B.J., and V.A. Sadock. 2007. Synopsis of psychiatry—Behavioral sciences/clinical psychiatry (10th ed.). New York: Wolters Kluwer. Santos, S.J., L.M. Bohon, and J.J. Sanchez-Sosa. 1998. Childhood family relationships, marital and work conflicts, and mental health distress in Mexican immigrants. Journal of Community Psychology 26 (5): 491–508. Schmaling, K., and J. Becker. 1991. Empirical studies of the interpersonal relations of adult depressives. In Psychosocial aspects of depression, ed. J. Becker and A. Kleinman, 169–185. New Jersey: Lawrence Erlbaum Associates. Scott, W.A., and R. Scott. 1982. Ethnicity, interpersonal relations and adaptation among families of European migrants to Australia. Australian Psychologists 17 (2): 165–180. Shen, Yifei. 2013. Ge Ti Jia Ting IFAMILY: Zhong Guo Cheng Shi Xian Dai Hua Jin Cheng Zhong De Ge Ti Jia Ting Yu Guo Jia. Shanghai: Shanghai San Lian Shu Dian (沈奕斐. 2013. 个体家 庭IFAMILY:中国城市现代化进程中的个体家庭与国家. 上 海: 上 海 三 联 书 店). Shuval, J.T. 1982. Migration and stress. In Handbook of stress: Theoretical and clinical aspects, ed. L. Goldberger and S. Breznitz. London: Free Press. Stuart, S., and M. Robertson. 2003. Interpersonal psychotherapy: A clinician’s guide. London: Edward Arnold (Oxford University Press). Sun, Liping. 2003. Duan Lie—90 Nian Dai Yi Lai De Zhong Guo She Hui. Beijing: She Hui Ke Xue Wen Xian Chu Ban She (孙立平. 2003. 断裂——90年代以来的中国社会. 北京:社会科 学文献出版社). Sun, Liping. 2004. Duan Lie She Hui De Yun Zuo Luo Ji. Beijing: She Hui Ke Xue Wen Xian Chu Ban She (孙立平. 2004. 断裂社会的运作逻辑.北京:社会科学文献出版社). Thompson, S., G. Hartel, L. Manderson, N. Woelz-Stirling, and M. Kelaher. 2002. The mental health status of Filipinas in Queensland. Australian and New Zealand Journal of Psychiatry 36 (5): 674–680. Vedder, P., and E. Virta. 2005. Language, ethnic identity, and adaptation of Turkish immigrant youth in the Netherlands and Sweden. International Journal of Intercultural Relations 29 (3): 317–337. Williams, C.L., and J.W. Berry. 1991. Primary prevention of acculturative stress among refugees: Application of psychological theory and practice. American Psychologist 46 (6): 632–641. Wong, F.K.D. 1997. A study of the psychosocial stressors, coping and mental health of mainland Chinese immigrants: Their first two years of experiences in Hong Kong. La Trobe University. Xie, Guihua. 2008. Nong Min Gong Yu Cheng Shi Lao Dong Li Shi Chang. She Hui Xue Yan Jiu (3): 84–109 (谢桂华. 2008. 农民工与城市劳动力市场. 社会学研究 (3): 84–109). Yang, Lianqian. 2004. You Yu Zheng Yu Hun Yin Zhi Liao. Zi Shang Yu Fu Dao (219): 34–38 (杨 连谦. 2004. 忧郁症与婚姻治疗.咨商与辅导 (219): 34–38). Zhang, Zhendong. 2003. Gong Zuo Bu Wen Ding Que Fa An Quan Gan Ying Xiang Jian Kang, Rong Yi Huan You Yu Zheng. Beijing Qing Nian Bao, 2003-11-30 (张振东. 2003. 工作不稳定 缺乏安全感影响健康 容易患忧郁症. 北京青年报, 2003-11-30). Zhang, Yueran, and Gao Bai. 2014. Zhi Du Fen Xi Yu Cai Zheng She Hui XUe: Ping Mo Ni Ka Pu La Sa De (Monica Prasad) De Zi You Shi Chang De Zheng Zhi (The politics of free markets). She Hui 34 (1): 229–241 (张跃然, 高柏. 2014. 制度分析与财政社会学:评莫妮卡·普拉萨德的 《自由市场的政治》 .社会 34 (1): 229–241).

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Zhao, Yandong. 2008. She Hui Wang Luo Yu Cheng Xiang Ju Min De Shen Xin Jian Kang. She Hui (5): 1–20 (赵延东. 2008. 社会网络与城乡居民的身心健康. 社会 (5): 1–20). Zheng, X., and J.W. Berry. 1991. Psychological adaptations of Chinese Sojourners in Canada. International Journal of Psychology 26 (4): 451–470. Zhou, Zhenji. 2006. Yi Yu: Yi Ge Xin Li Zi Xun Shi De Zhi Liao Shou Ji (Anxiety: A psychologist’s consultation records and notes). Zhengzhou: Zhengzhou Da Xue Chu Ban She (周振基. 2006. 抑郁:一个心理咨询师的治疗手记. 郑州:郑州大学出 版 社). Zhou, Zhenji. 2008. Jiao Lü: Yi Ge Xin Li Zi Xun Shi De Zhi Liao Shou Ji (Anxiety: A psychologist’s consultation records and notes). Zhengzhou: Zhengzhou Da Xue Chu Ban She (周振基. 2008. 焦虑:一个心理咨询师的治疗手记. 郑州: 郑州大学出版社).

Chapter 3

Analysis of the Production Side: Depression in Drastic Time Changes

After analyzing the spatial changes, we will come to the sociological analysis of temporal alterations. The drastic changes of time in neoliberal globalization are related to a logic of “competitiveness” which emphasizes fast speed.

3.1 Competitiveness in Neoliberal Globalization Karen Horney (Karen Danielson) raised a key question in her book The Neurotic Personality of Our Times: Why are there so many neurotic patients in our culture? She pointed out that the emphasis on competition in the commercial society we are in has catalyzed one human instinct, the instinct of hostility, which makes it difficult for people to let things go and thus relieve stress (Horney 1998, translated by Feng 1988). Her book was published in 1937, when the capitalist society was already promoting great competition. However, with the expansion of neoliberal globalization, time-based competition, namely, competition in terms of reaction time, has been intensified. In other words, time efficiency has more than ever become a priority. The intensification of time efficiency is embodied in the fact that individuals are required to be “competitive”. Competitiveness means being fast in production and having higher productivity than others. Moreover, now enterprises often reduce overstaffing to optimize the structure and maximize employee productivity. In the post-Fordism era, workers are required to be more flexible, to update their skills regularly, to take various forms of on-the-job training, and to accept and create new things (Jessop 2002). The post-Fordism era is more variable and flexible than the era in which Karen Horney lived. Therefore, contemporary people need to be able to adapt themselves to various situations, including knowledge management, proficiency in foreign languages, professional skills and so on, all of which are part of their “competitiveness”.

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The “competitiveness” emphasized by neoliberal globalization has expanded to the individual level from the international level. First of all, the logic of competitiveness increases the anxiety of parents and children. Children grow up in an environment of excessive competition, which increases their parents’ anxiety as well. Then, people who are accustomed to stability and cannot adapt to rapid changes are relatively prone to depression in an environment that emphasizes flexibility and mobility. In particular, children born in the Fordist era with stable and good welfare can no longer enjoy such welfare when they are grown up. They can only be nostalgic of the good old days. Now that they have to endure both the reduction of welfare and the cruelty of competitiveness, those who have difficulty in adapting are prone to depression. “Depression is closely related to one’s personality. The more serious, responsible and hardworking individuals are more likely to suffer from depression.” (Nomura 2008) such a personality is mostly appreciated and praised, but in the eyes of psychologists, people with such a personality are at high risk of depression. Ironically, the logic of “competitiveness” forces people to develop such a personality. In the context of highly competitive neoliberalism, which emphasizes economic performance, it is very difficult for individuals to maintain mental health. The logic emphasizing speed, efficiency and competitiveness is like the big Other who manipulates society and is internalized in the inner “superego”. The excessive sense of responsibility is the excessive development of the superego, which, according to Freud’s insight, can lead to the oppression of the self and a growing tendency of self-abuse and self-attack. This pressure to excessively pursue efficiency tends to become the oppression by the superego in neoliberal globalization. Changes in the economic structure have made most of the working population a salaried class. With different types of colleagues and bosses, interpersonal relationships have become a source of pressure for them. What’s more, they may face setbacks in the workplace, such as economic recession and layoffs. They are worried that they cannot match the model role that social norms have defined or the roles that the society expects them to fulfill. These multiple factors have made the current generation over-stressed and may finally lead them to depression. The logic of competitiveness has also shaped new types of personality. Christopher Lane found that the human personality traits of “shyness” and “bashfulness” gradually became an illness that needed to be defined and treated in the 1980s. In the Diagnostic and Statistical Manual of Mental Disorders (DSM), extreme bashfulness, introversion, eccentricity, reserve, unsociability and other temperament traits related to shyness have become the symptoms of “social anxiety disorder” (also called social phobia) and “avoidance personality disorder”. The connotation of “shyness” is now completely different from what it used to mean. People can only be “no longer shy” so as not to be diagnosed with social anxiety disorder. If an individual cannot express himself “openly” and “freely”, his shyness may even become the biggest obstacle in a competitive society (Lane 2007). For this reason, a disease is defined as a disease precisely because it represents a lack or deficiency under the supremacy of productivity. It must be defined as being abnormal in order to highlight the normality of the social ideology of productivity supremacy. It is an object that must be excluded under the hegemony of mainstream social culture.

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In addition, because competitiveness emphasizes time efficiency, procrastination is regarded as something pathological or immoral. In neoliberal globalization, procrastination has become a condemned act, a manifestation of lack of self-regulated performance (Tuckman and Sexton 1989). The idea that time is money has been deeply rooted in the hearts of the people since the rise of capitalism. With the flexible accumulation of neoliberal globalization, the demand for efficiency becomes even greater. Only with high speed can business opportunities be grasped. This logic of “demanding efficient use of time to achieve high productivity” is “reasonable” and “normal”, while procrastination is “unreasonable” and “abnormal”, because procrastination does not conform to the neoliberal concept of individuals as responsible players. Even when people are on vacation, it doesn’t mean they spend all their time doing nothing. Every minute must still be filled with activities other than work (such as planned leisure). The capitalist logic of limitless development makes the personal pursuit of success endless as well. People have to bear the pressure and anxiety of constant competition. This economic system is internalized through discipline in the modern ethics of time. In modern times, people often need to cope with the timebased anxiety with rational methods, such as psychotherapy and time management techniques, so as to facilitate reproduction. Martin (2007) believed that the transformation of economic and social structures causes a mental illness to be more serious than in the past.1 As market relations became more and more developed in the late neoliberal capitalist society, the economy dominated many sectors, and fierce and ruthless competition became more intense, which encouraged the “mania” that can increase productivity and effectiveness. In other words, the competitive economic system demands high morale for production—workaholic enthusiasm and increased labor intensity and efficiency, all of which need strong “manic” emotions. People cycle between manic highs and depressive lows, just as the market inevitably swings from cycles of boom to bust. Such “depression” is a “sense of not desiring to move because of a lack of life motivations” when the mood hits bottom. People tend to feel “depressed” after being “manic”. This kind of analysis may be a little too brief, limited to economic competition factors while ignoring other complex factors like personal experience and family influence; but it is enlightening and inspiring (Ning and He 2012: 112). Individuals who have exhausted themselves in their struggles and mobility may become “immobile (incapacitated) subjects” if they suffer from depressive symptoms. These people cannot adapt to productive and constructive functions (not desiring to consume, eat or go out). They avoid acting or fear to do things, and cannot meet the requirements of their social roles when they are seriously mentally ill. This is actually like the defense 1 Martin

(2007) explained the historical reasons for the shift from schizophrenia to bipolar disorder in American society. She attributed the occurrence of schizophrenia to the earth-shaking change of the traditional society to modern society and bipolar disorder to an era of complete market-oriented economy in which traditional reliance is completely lost and economic competition is fierce and ruthless. Schizophrenia is characterized by excessive detachment and no emotional fluctuation. It is mainly a speechless emotional abnormality which results from the fascinating and excessive stimulation in the 20th century, the anomie brought about by social changes, and anxiety and mental weakness caused by huge changes in personal adaptation to social changes.

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mechanism theory in psychoanalysis mentioned previously. Depression patients (or mental disorder patients) seek relief by hiding in diseases. Being unable or unwilling to move can be regarded as a protest against overwork and an excessively demanding environment. In neoliberalism, which requires high performance and emphasizes competitiveness with great productivity and enterprising spirit, the “immobility” and “incapacitation” of depression are, of course, regarded as serious deviations. Depression is defined in contrast to the neoliberal performance standard that emphasizes “mobility” and “capability”, which places depression more in the spotlight (Ning and He 2012: 111). After the reform and opening up, China followed the path of East Asian developing countries to catch up with and surpass other countries in national strength; as a large country with a large population, the market competition is extremely fierce. From the central government to governments at various local levels to individuals, competition is everywhere and speed is constantly stressed. The logic of competitiveness increases people’s stress and emotional problems increase accordingly.

3.2 Case Study of Depression in the Competitive Discourse with Chinese Characteristics Under the influence of neoliberal globalization, China has entered the competitive logic of the market economy. China used the imperial examination as a competitive mechanism in imperial times, so in those times the only way to get ahead was to study. The way was in general maintained until the reform and opening up. However, after the marketization with the reform and opening up, competition has extensively entered different sectors, including academia, business and entertainment (singing competitions, quiz and talent shows.) In these fields, all participants have to pass through cutthroat competition to stand out. Chinese-style competition was already fierce in the past; in neoliberal globalization, competition has permeated all walks of life and become more intense. The logic of competitiveness with Chinese characteristics includes not only the time efficiency highlighted in neoliberal globalization, but also its own traditional social norms: each individual should conform to the expected social roles of Confucian ethics. To be more specific, there is “a logic of happiness towards the road to success”—to live a good life, one must enter a good college, find a good job, buy a big house and car, find a good spouse, enjoy his/her retired life, and be a good father, mother, son, daughter, boss or employee. These ethical requirements together with the ethic of doing well one’s duty become a norm for people to make comparisons with others. Those who cannot go to good schools, find good jobs, buy cars and houses or shoulder their proper ethical roles are not defined by the society as living a beautiful life. The Chinese-style logic of competitiveness characterized by the ethic of doing well one’s part at every life stage and the capitalist time efficiency are like

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the big Other, demanding the subject to meet its needs all the time and exerting a kind of superego pressure on the subject. This is in line with Freud’s and Lacan’s views. In the following section, we will illustrate how Chinese people encounter and react to this big Other with case studies of individuals of different ages. Case 1 Depressed pupils under excessive competition Recently, the fierce competition has extended to primary schools. Logically, today’s children should have enjoyed a happy childhood, but in reality they have been severely deprived of their happy childhood. In this case, Xiao Zhuang, a fifth grader interviewed by the author, suffered from childhood depression. Following is the description of his emotional suffering. First was the pressure from the strenuous work of learning Chinese characters. When he was in first grade, Pinyin and Chinese characters were taught at the same time, which overwhelmed him because he hadn’t learnt these in his kindergarten years. He was also assigned much homework, always finishing it after 10 pm. In third grade, his Chinese teacher asked the whole class to join the class WeChat group, to take photos of their finished assignments and keep these photos, and then inform the teacher through WeChat. Competition was permeating not only the school, but also family life. Some children finished their homework soon after school, while others did not finish it until 10 o’clock in the evening, making their parents anxious and desperate to urge them to finish it quickly. Learning was originally a happy thing, but now the excessive and fast learning made Xiao Zhuang feel unable to breathe. Also because of excessive study, Xiao Zhuang became shortsighted when he was a third grader. Moreover, the average test scores from grade 3 to grade 5 are taken as the admission criteria for some “esteemed middle schools”. Parents, fearing that their children will not be able to attend renowned middle schools, try their best to urge their children to study hard. Xiao Zhuang was originally interested in learning, but later became extremely resistant due to the pressure of high competition. He was disobedient and rebelled against his teachers in school. After the teachers reported his behavior to his parents, they punished him more, making his resistance more serious. Finally, he was unwilling to study, being lazy and unmotivated all day. His mother also mentioned that he once said to her, “You know, life is boring. I really want to die.” He was then only eleven years old when he had the idea of suicide. At this point, his mother asked a psychological consultant to help the child out of depression.

The psychological counselor told the author that today’s children are in a state of high tension all day and are even forced to do things that are not suitable for their age to meet the expectations of their elders. Due to the elders’ great expectations and the cruel social reality, many children suffer from depression. Case 2 The agony of middle school students under the Gaokao pressure Xiaoqin, a high school student soon to take Gaokao, the National College Entrance Examination, was facing the pressure of excessive competition as well. Her performances in physics and mathematics had been unsatisfactory. In the year before the Entrance Examination, she had suffered from frequent diarrhea, dizziness and even anorexia. Her mother was very worried and took her to a psychological counselor for help. Her symptoms were relieved after taking part in some religious activities. According to her own description, she was a post-90 s single child (born in the 1990s) in a well-to-do family. As the only child, she received great care from her elders and grew up with their praise. She was used to setting excessively high expectations for herself. When her performance was not as good as expected or not affirmed positively by others, she would have doubts about herself. Praise from others

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3 Analysis of the Production Side: Depression in Drastic … strengthened Xiaoqin’s feeling of being special and drove her to work hard. However, the lack of others’ praise increased her anxiety and she would feel that she had failed. Xiaoqin excelled in school and was used to admiration and praise from others. As a result, she was more afraid of failure, because failure meant that she was no longer special. Failure would end her feeling of being special. Once she did not perform well in one or more subjects, many physical symptoms would appear under the great pressure, such as gastrointestinal dysfunction and anorexia. The emergence of the symptoms indicated that she had started her psychological defense mechanism. In addition, she was too preoccupied with herself and too concerned about her performance at school. She even blindly believed that others were observing her performance all the time, so she should not make mistakes. It was not until the psychologist guided her to focus on other things that she overcame her preoccupation with herself. A similar situation occurred to the 14-year-old boy little S, whose parents had stable jobs and high incomes. He lived with his parents before he went to junior high school, and they doted on him. After he went to junior high school, his father was often away and seldom came home. The stable family relationship was broken. Little S often lived alone with his mother and gradually became unwilling to communicate with his father. When he was alone, he always hid in a corner to read books or come up with foolish ideas. He became inattentive in class, and his academic performance declined sharply. However, his elder brother always had good grades. His parents often used his elder brother as a reference to criticize and blame him for failing to perform well at school. He gradually became less talkative. The school in which little S studied prioritized its college enrollment rate and did not allow students to behave in a way that could affect the teaching routines and goals. Most of the school time was devoted to study, and teachers paid close attention to students who had high scores in the exams and little attention to students like him. Instead of spending more time teaching him how to study and how to correct his study attitudes, his teachers exerted great pressure on him. What was more serious was that the teachers often criticized or incorrectly evaluated him in class, saying that he was stupid and unmotivated, only idling away his time. His classmates often made fun of him too. Some teachers even told his classmates with good academic performance not to be friends with him. The school environment made him feel less and less valued and aggravated his boredom with study, which developed into a boredom with everything around him. He was diagnosed with depression after seeing a doctor.

The above stories of young people’s growth reflect that when they are overly cared for or when they are in unhappy families, the stress events encountered in their study can trigger emotional problems. Case 3 Stress of college students from poor families The following case is presented by the psychological counselor Zhenji Zhou in his book Yi Yu: Yi Ge Xin Li Zi Xun Shi De Zhi Liao Shou Ji (Depression: A Psychologist’s Consultation Records and Notes). Jianhua Shao, a 23-year-old young man, grew up in the countryside. His father was a carpenter and his family was poor. He knew clearly that it was not easy for his parents to afford the expense for him to go to college, so he was unwilling to disappoint them. He achieved excellent results in junior high school, but when he entered a renowned senior high school, he was just average in his studies. In addition, he could not match his classmates’ accommodation and clothing. He had a sense of inferiority and was unwilling to associate with his classmates. When he was an undergraduate student, his grades were lower than average and he did not develop good interpersonal relationships. According to Zhou’s diagnose, Shao lacked positive encouragement. He was a rural boy who studied in the city, his academic achievements were not satisfactory and his material conditions were worse than others’—all these environmental factors strengthened his negative ideas and made him feel more inferior.

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Then the stress events of studying and living in a big city escalated the negative conflict and brought about drastic changes in his heart (Zhou 2006: 189–220).

This case shows that poor students are a special group in colleges and universities. They generally have heavy family burdens, which can lead to greater psychological pressure. They are often in a state of anxiety. Their sensitivity, melancholy and sense of inferiority lead to self-isolation and difficulties in developing good interpersonal relationships with others. In the face of difficulties, they are more inclined to develop self-defense mechanisms of suppressing, denying or projecting their feelings. Long-term and repeated use of these defense mechanisms may damage their normal psychological functions, accumulate negative emotions and lead to depression. Case 4 Pressure from academic discrimination Academic qualifications are what the Chinese value in job hunting. Lately, employers take as the employment standards not only the highest academic qualification, but also high school and undergraduate academic qualifications. Xiaoshi, a man who had only a secondary vocational degree, was discriminated against at work after graduation. His performance was better than that of his colleagues with a bachelor’s degree or above, but his salary was not as high. He was dissatisfied with his work, so he continued to study and finally obtained a master’s degree. When he got his master’s degree, he changed his job, but this degree did not make him gain better salary. In the job application form, he had to fill in both the highest degree and the first degree after middle school. When employers choose excellent talents from a group of graduates with high-level degrees, they no longer merely look at the highest degree; they also check whether the candidates graduated from a prestigious university or high school. As Xiaoshi graduated from a secondary vocational school, his pay was still lower than others’. He tried all means to win his boss’s approval and performed well in his work, but at the same time he was not satisfied with the boss’s discrimination against him. Once at a meeting, he argued with the boss and was fired. He was under the heavy pressure of a mortgage and living costs and could not accept the fact of unemployment in his heart; he said to himself that he had worked so hard but ended up like this. Later, he was diagnosed with major depressive disorder and was hospitalized in the Shanghai Mental Health Center for about one month. He had been unable to understand why society has such a serious discriminating attitude toward different academic qualifications and has set up so many barriers to stop those who are willing to work hard. He had been trying hard to prove that he was capable, but he did not receive due recognition. He lost his job, his life became hard and meaningless to him. As a result, he fell into depression.

In the case of Xiaoshi, depression arose not only from the economic burden of unemployment, but also from the inability to accept the discrimination against certain academic qualifications. His depression can be regarded as the mental exhaustion after excessive efforts. It is also an emotional protest against the unfair system. Case 5 High-level degree dilemma: “Oversea Returnees” (haigui, 海归) become “Returnees Waiting for Employment” (haidai, 海待) It is a problem that one’s academic qualifications are not acknowledged. It is a more serious one that those with high-level degrees from good universities cannot secure a job. One example is an oversea returnee who obtained a Master degree but faced unemployment after graduation.

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3 Analysis of the Production Side: Depression in Drastic … Little Shi, who obtained a Master degree in law in Britain in 2005, told us about his situation. He said that even for relatively wealthy families, the expensive tuition of Chinese students in Britain cost a considerable proportion of the family savings. Little Shi’s parents expected that his degree from a British university would enable him to earn more money and look after his parents. However, Little Shi’s return to Shanghai coincided with a “return rush”, which made his overseas academic qualifications less valued than before. He did find a job, but it was not as good as his parents expected of him. What is worse, the rising house prices in Shanghai made it impossible for Shi to buy a proper house on his own. He had to live in a small apartment his parents had bought earlier, while his parents bought a bigger house in the suburbs. Shi’s work made his parents feel very unhappy because their investment in Shi’s overseas education did not get proper returns. His parents’ attitude hurt him very much. In fact, his family and neighbors could not believe that a “returnee” with British academic qualifications could be unemployed. Their attitudes made him uncomfortable. During his long-term unemployment, he often couldn’t fall asleep and was stressed because of other people’s contemptuous attitudes. Such a situation lasted for about a year and a half, and he survived this depressive unemployment period with the help of a group of close friends and drugs. This reflects the current situation that returnees in China are facing in the neoliberal globalization— high unemployment, deep frustration and depreciation of self-value.

If we place Little Shi’s micro-story in the context of globalization, we can see the trajectory of neoliberal globalization. Since the 1990s, global higher education, on the one hand, has been influenced by the market logic of neoliberal globalization, and gradually a global academic capitalism characterized by internationalization, marketization and standardization has come into being. On the other hand, global higher education has expanded greatly in “quantity” (Dai 2001) and accordingly universities have increased their enrollment. Universities in Europe, the United States and other developed countries have successively launched masters and doctoral programs to attract foreign students. With increasingly enhanced economic strength, studying abroad has become a trend in China after the reform and opening up. Chinese people’s concept of education as an investment has also boosted the trend to study in European countries and the United States. Many parents save up and send their children abroad to obtain a degree. These factors have resulted in a wave of overseas study. However, as the number of returnees soars, many returnees are facing deeper anguish. They are facing a series of challenges, including employment crises, cross-cultural adaptation, conflict and adaptation after returning home. As the number of returnees surges in big cities, those with overseas academic qualifications or overseas experience no longer enjoy advantages in employment, and their salary level is not much different from those with a Chinese academic background. Many returnees who do not have irreplaceable high professional skills or special foreign work experience have become “returnees waiting for employment” due to their high salary expectations. The gap between the great efforts and investment in overseas study and the unemployment after graduation creates a potential basis for the onset of depression. Case 6 Young people’s pressure in the workplace In his book Yi Yu: Yi Ge Xin Li Zi Xun Shi De Zhi Liao Shou Ji (Depression: A Psychologist’s Consultation Records and Notes), Zhenji Zhou presented the case of Biying Huang. Huang was a child who grew up in others’ praise. She was very responsible and would not refuse others. She had a smooth life in her youth and formed a personality pattern of “being obedient and making no mistakes, then getting rewards”. Because of her personality, she won the

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trust of her colleagues after she was employed, but many of the colleagues often asked her to take on work beyond her ability. Because she was embarrassed to refuse their requests, the colleagues trusted her more and gave her more work to do. As a result of her responsible attitude, she became overworked and depressed (Zhou 2006: 221–250). Ironically, the work ethic of being responsible, which deserves praise, turns out to be a stressor in the globalized logic of competitiveness.

Case 7 Men’s pressure to get married Little P (male) and Xiaoying (female) came to Shanghai from other places. They had been in love for many years and finally were going to get married. But it was an annoying process to discuss the marriage arrangement with their parents. Xiaoying’s parents asked Little P and his family for 100,000 yuan as the bride price and demanded he buy an apartment for their wedding. Little P was only a young engineering technician and his parents were farmers, so they couldn’t afford this. The two sides were deadlocked for a long time. Xiaoying’s family, who took the apartment and a wedding banquet as conditions to test Little P’s love, insisted on the two requirements for the sake of her happiness. Little P finally compromised. Rural weddings emphasize ostentation, and it is customary to invite relatives and friends for a two-day banquet, which is typical for the sake of keeping face. Little P did not rely on his parents for help, so he had to borrow money from relatives and friends and banks to cover the expenses for the wedding, including the banquet, the bride and an apartment. After the wedding, he had to pay back his friends and relatives as well as the bank mortgage. Therefore, Little P worked seven days a week, doing his regular work in a company on weekdays and taking two part-time jobs on weekends. He enjoyed no quality of life at all. His wife ran a clothes store, but the sales were not good and the shop was losing money. Because of this, Little P was under more pressure and often regretted having married Xiaoying, whom he thought to be good at running the household, but who unexpectedly, brought him additional trouble. Therefore, Little P often quarreled with Xiaoying. Being upset, he suffered from insomnia and poor appetite. Later, he was diagnosed with depression.

Buying an apartment, paying a bride price and holding a wedding banquet when getting married are often the “tests” that Chinese men have to go through and are also a disguised form of competitiveness logic. The customary Chinese marriage often creates a lot of pressure for the newly wed husband to pay back the money borrowed. If other troubles occur, the pressure can often lead to emotional problems. Case 8 Depression from the images of “Good Man” and “Good Woman” The beautiful and happy life is becoming more and more elusive in a changeable environment, which is manifested not only in youth, but also in middle-age. The so-called “good days” (happiness) should not focus on a good life itself, but on the realization of one’s ideals. The dreamed good life (happiness) of depressed middleaged people seems to be perpetually delayed. There seems to be an inexplicable gap between their actual state of life and the rewards they deserve, leading to a midlife value crisis. Old Zhang, a middle-aged man the author interviewed, said, “It is difficult to be a real man in China today.” What he meant is that in today’s highly competitive society, men often work day and night, including weekends, to maintain their socalled competitiveness. They have been assessed according to various aspects— being a good husband, a good father and a filial son, etc. These images of what is

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called a “true and upright men” have become a signifier2 which is associated with the “beautiful and good life”. Aspirations for a better life may often be unfulfilled because of various stressors—the competitive discourse, the irregular economy, huge living costs, mortgage payments, education costs, and the inability to balance work and family life. They always ask why the good life is so elusive, but they still try their best to create a better image to meet the expectations of society. If they fail to achieve this, they feel inexplicable guilt. Not only middle-aged men but also middle-aged women can be depressed. In society, there is similar narrative of the “Good Woman” to that of the “Good Man”. To be a good woman is to be a good wife, a good mother and a good daughter. Ms. Wang, in her fifties, was retired. She was diagnosed with depression. Her symptoms included sleep disorder, poor appetite and vexation. She felt it was too hard to continue her life, and she often thought of killing herself. Her depression originated from the difficulty of playing multiple roles. After her father had just died, her mother lived on her own. However, due to various inconveniences in life, Ms. Wang shouldered the responsibility to take care of her mother. She intended to take her mother to live with her family, but her mother was very stubborn and unwilling to live with Ms. Wang’s family. Ms. Wang had to go to her mother’s house to look after her every day. A single ride on bus to her mother’s house took her as much as two hours. After a long argument with her husband, they came up with a compromise: she lived with her mother most of the time and went home twice a month to see her husband and children. However, her husband was discontent with her and wondered why she was the only one to take care of her mother when she had four sisters. Ms. Wang told him that her sisters were responsible for covering her mother’s expenses, and that her sisters all had to work and had no time to take care of her mother. But her husband did not understand and thought she was not a good wife, nor a good mother. Ms. Wang was very aggrieved because she was unable to play well the three roles simultaneously. She attempted suicide and was luckily saved. Her basic logic is clear to us, that is, she hoped she could perform well the social roles imposed by social norms in spite of the difficulties in her real life. Even if some situations were beyond her and anyone’s control, she still thought that she should be held accountable.

The above cases reflect some specific depressive situations of contemporary Chinese. Statistical data also show similar emotional problems of Chinese people. In December 2006, the Beijing University Student Development Report jointly launched by the Communist Youth League Beijing Committee and the Beijing Federation of University Societies showed that the depression rate of university students in Beijing reached 23.66% (Li 2006). In the same year, the US magazine Fortune made a survey of mid-level and senior-level managers in China. More than 70% of the respondents felt that they were under excessive pressure, and 20% had obvious “job burnout” (News China, 2007). In addition, according to the “2008 Report on the Current Work Situations of Professionals in China” based on an online questionnaire to one 2 Saussure’s

structural linguistics regards the sign as being composed of two parts: signifier and signified. The signifier is the sound-image, while the signified is the entity and concept the signifier refers to. The relationship between the signifier and the signified is arbitrary, but the signifier is fixed and mandatory with respect to the linguistic community that uses the signifier. The relationship between language signifier and signified is not natural and mutable. The sign combines both the meaning and the form. In terms of form, it is empty, while in terms of meaning, it is solid (Chinese version of Saussure’s Course in General Linguistics, translated by Gao 1999).

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million professionals, 61% of respondents felt relatively high pressure, nearly 2/3 had job burnout, and 70–80% of the police, medical and nursing staff and high-level managers felt that they were under great pressure (China Human Resources Development Website 2008). These figures show that young people and professionals in coastal areas where business is more developed and competition is more intense, as well as in metropolitan areas, are facing emotional problems. Competition and overwork seem to be part of the daily life of contemporary Chinese.

3.3 The Happiness and Mental Status of Chinese Besides the above personal stories, some large-scale surveys have also examined the happiness and mental status of Chinese people. First, let us look at the survey findings on the relationship between happiness and economic development. There are two major views on the relationship between happiness and economic growth. One is the happiness-income paradox, the other the happiness-income synchronization. The happiness-income paradox view claims that the improvement of material life and the subjective sense of life satisfaction (i.e. happiness) are not correlated or synchronized. Richard Easterlin formulated the “the happiness-income paradox” or “the Eastern paradox” in 1974. He suggested that in the short term, happiness varies directly with income both among and within nations, including developing countries, and the eastern European countries transitioning from socialism to market economy; but in the long run, there is limited possibility for economic growth to increase happiness. In other words, after happiness rises to a certain level with economic growth, it can show signs of stagnation or decline even though economic growth continues. In particular, Easterlin pointed out that in South Korea, Brazil and China people’s sense of happiness has decreased due to economic growth. His research team conducted an exclusive study on China’s subjective well-being in 2012 and found that China’s economic growth over the past 20 years had not resulted in a corresponding increase in people’s sense of life satisfaction (Easterlin et al. 2010). Other foreign surveys confirmed the happiness-income paradox. For instance, Appleton and Song (2008) found that from 1995 to 2002, the gap between the rich and the poor in China widened, and the life satisfaction of urban residents showed an obvious downward trend. Brockmann et al. (2009), based on the data from two Chinese surveys conducted as part of the World Values Survey (WVS) in 1990 and 2000, found that the average life satisfaction in China dropped by 0.9 point from 1990 to 2000, not increasing with China’s economic growth. Gallop has been conducting a long-term survey of the life satisfaction of Chinese people in recent years. The survey found that despite China’s skyrocketing economic growth, people’s life satisfaction shows a puzzling “flat line”. From 1999 to 2010, the average life satisfaction ratings of urban residents increased by 0.43 point, while those of the rural population decreased by 0.13 point. Although the number of people who were satisfied increased by 5% from 1999 to 2010, the increase was not salient among people with high incomes or low incomes (Grabtree and Wu 2011). Based on a sample of 15,000 individuals interviewed by the Gallup

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Organization, Kahneman and Krueger (2006) found that although ownership of color television sets, telephones and other material goods rose sharply, the percentage of people who said they were dissatisfied decreased by 15%. The United Nations World Happiness Report, jointly released with the Earth Institute of Columbia University in New York in May 2012, is perhaps the largest cross-national survey of people’s life satisfaction. The data in the report span from 2005 to 2011. The measures for the evaluation of happiness include GDP per capita, life expectancy, social trust, freedom of choice, degree of corruption and social tolerance. The three happiest countries are Denmark, Finland and Norway, all of which are Nordic countries. The unhappiest countries are concentrated in Africa and hit by poverty and war. The United States ranks 11th and China 112th. The survey also showed that in the underdeveloped countries, increasing GDP per capita is an effective way to improve people’s happiness; however, when GDP increases to a certain level, the correlation between GDP growth and happiness gets lower and lower due to marginal effects (Yu 2015). Some studies conducted by Chinese scholars have also shown evidence of the happiness-income paradox. For example, Zhu and Yang (2009), using the World Values Survey data, found that the number of Chinese who felt satisfied increased from 68% in 1999 to 78% in 2001, but the average ratings decreased from 2.95 to 2.87. Xing (2011), based on seven-year (2002–2008) data from Shandong Province, found that happiness does not increase with the rise of average GDP and income. Some scholars argue against the happiness-income paradox and for the view of happiness-income synchronization. For example, Veenhoven (1991) maintained that happiness is not relative, it is a natural and inborn emotion and depends on the gratification of basic needs. This is what he called the theory of absolute happiness (Veenhoven 1991). Using Gallup’s data from a global survey on human needs and satisfaction (Gallup 1976/77), Veenhoven (1991) found that the correlation between GNP per capita and average happiness reached 0.84 (p < 0.01). Veenhoven and Hagerty (2006), after analyzing life satisfaction in western European countries and developing countries such as India and Pakistan, pointed out that average happiness has increased considerably in the past 50 years in both the developing and developed countries. Stevenson and Wolfers (2008) analyzed data from nearly 100 countries and established a positive correlation between economic growth and happiness. Their findings were similar to that in Venhoven and Hagerty’s research (Stevenson and Wolfers 2008). Domestic studies with similar findings include Junqiang Liu, Moulin Xiong and Yang Su’s large-scale quantitative research (Liu et al. 2012). In their article “National Sense of Happiness in the Economic Growth Period: A Study Based on CGSS Data” published in Chinese Social Science, they employed data from the China General Social Survey (CGSS) from 2003 to 2010 to analyze the development of the sense of happiness in China. They obtained 44,166 samples and categorized them into five different time periods. The conclusion was that Chinese people’s sense of happiness has been on the rise in the past 10 years, and that groups of different political identity, household registration (hukou), age, income, marital status and ethnicity have all had a growing sense of happiness. Economic growth may be a driving force for the rising

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sense of happiness; however, once the economy shrinks, people’s sense of happiness drops with it, the authors concluded prudently. In order to ensure harmonious economic and social development, more and more detailed surveys and research should be conducted on people’s sense of happiness (Liu et al. 2012). Some studies confirm the happiness-income paradox, while some the happinessincome synchronization. The differences may result from different working definitions of happiness in the quantitative research or the different databases and time periods observed in these studies (Liu et al. 2012). Nevertheless, there seems to be more evidence for the happiness-income paradox, and those who argue for the happiness-income synchronization have also noticed the possibility of happiness changes under the “new normal” when the economy is no longer developing at a high speed. Now let us turn from the survey of happiness to the development of mental illness in China. Statistics have revealed that the incidence of mental diseases in China has shown an upward trend in line with economic development. The incidence of mental diseases in China was 2.7% in the 1950s and witnessed a significant increase in the 1980s. Based on epidemiological investigation results in some areas, some experts speculated that the incidence of severe mental disorders such as schizophrenia and depression is now 13.47%. The total number of patients with severe mental illness is about 16 million. Schizophrenia is the most common, reaching 6 million, which means one in every 60 households, and at least 100,000 new schizophrenic patients appear every year. The prevalence of obsessive-compulsive disorder, anxiety disorder and phobia in Beijing is 35.18% (Cheng 2015). The increase shows that many adaptation problems have emerged in the process of transitioning from the planned economy to the market economy. The Institute of Psychology of the Chinese Academy of Sciences (2004) conducted a large-scale quantitative research project “A Study of the Main Social Stressors and Mental Health of Different Occupational Groups during the Social Transition”. The research team conducted investigations and analyses of more than 10 different occupational groups. In August 2000, the research team went to Kailuan Group Co. Ltd. in Hebei Province and conducted 46 meetings with more than 10 occupational groups, including miners, community workers, laid-off workers, ordinary clerks, teachers, doctors, senior-level leaders and mid-level leaders. They also organized a large number of individual interviews with these participants. After these, they got back 1408 questionnaires, with a total of 8545 kinds of pressure. Based on statistical analysis of the questionnaires and the content analysis of the interviews and meetings, the research group summarized 89 stressors in 10 categories from the over 8000 kinds of pressures. The 10 categories, namely, social environment, work stress, personal achievements, income, interpersonal relationships, social support, family, housing, children and personal life, are of universal significance. Since 2001, the 89 stressors in 10 categories have been tested in different provinces and cities across the country. In four years’ time, the occupational groups surveyed have been extended to include company employees, medical and health care staff, educators, farmers and civil servants, with a total of 7999 participants.

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Some of the common pressures are considered as “characteristic pressures” in China’s social transition. For example, the social pressures are mainly brought about by the uncertainty of future social and economic development. In terms of work, the pressures from heavy workloads, labor intensity, work obligations and competition are more salient. In the social transition period, because of the reforms of the economic system and the labor system, employees suffered more and more competitive pressure. The social pressures are mainly caused by the uncertainty about future social and economic development. The research team conducted a survey on the employees of a state-owned enterprise and found that four of the social pressures ranked at the top of 89 stressors. They are worries about social morality, worries about social security, worries about social stability and the impact of unfair social distribution. The mental health status of the middle-aged working population is not brilliant either. A survey of the health status of 1000 middle-aged people in 2014 showed that they had a variety of health problems: overtime work, shortage of sleep, great pressure, no leisure and health care debts, frequent dreams, insomnia, difficulty falling asleep, frequent backaches and obvious memory decline. All these symptoms were common among the respondents. Half of them admitted that they were badtempered and anxious. These symptoms are a true portrayal of “job burnout” (Ma and An 2014). Job burnout is a state of mental exhaustion linked to long-term, unresolved, work-related stress. It is characterized by feelings of physical and mental exhaustions and feelings of energy depletion or exhaustion. It can occur in employees under great work pressure. Because of rapid social development and transformation, it has become “epidemic” among modern professionals. The quantitative findings above are in line with the findings we observed in the qualitative interviews we conducted.

3.4 Summary Scholars have not reached a consensus on the relation between happiness and economic growth, yet it is a fact that the number of people with mental disorders has increased after China’s reform and opening up. Both macro statistics and individual cases show that China’s economic transition, together with the external pressure of neoliberal globalization, has resulted in more uncertainty. Having reviewed the representative cases presented in the qualitative analysis in Sect. 3.2 and the statistics in the quantitative studies in Sect. 3.3, we further explore the question: What causes so many people of different ages to suffer from depression? To put it simply, the pervasive and increasingly fierce competition in modern society makes people suffer from academic and occupational burnouts, which is an important cause of the prevalence of depression. In developed countries, the transition from traditional society to a modern society was relatively gradual, while China has entered a high-speed modern society in a very short time. The previously stable planned economy with less mobility has been transformed into a highly competitive and fast-moving market economy. This change, together with the increasingly fierce competition in a large population, forces people to adapt to a more unstable life. In addition, traditional ethical concepts and social norms have also been incorporated

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into the competitiveness logic, thus forming a competitive discourse with Chinese characteristics. We can see that under the Chinese competitive discourse, people of different ages are facing the same problem—the superego or the big Other exerts excessive repression on individuals so that they fail to conform to the symbolic identification and thus succumb to self-attack and depression. In the narration of children and teenagers, education and employment are the central themes. In China, parents usually have high expectations of their children, hoping their children will have a bright future, so they usually invest a large amount of their savings in the children’s education. With the single-child policy since the 1980s, most parents had only one child and had higher expectations of and invested more in their child, which often caused their child to be highly stressed. In the context of prioritizing good academic performance and higher education, children are inculcated with the importance of excelling in examinations and other social competitions by their parents and teachers from an early age. Driven by this huge “superego”, every child has endlessly pursued the goals of attending esteemed schools and realizing their potential at all stages of education. They are happy if they realize their goals, but not long afterwards they start pursuing the next goal. They are on an endless journey to realize their goals. The idealized goal of young people is to complete all levels of education and to get a higher education degree, so as to obtain better employment opportunities in the highly competitive labor market. As a result, the whole society has constructed for them a path to a happy life: “only if you have good test scores can you enter a good school; only if you attend a good school (preferably abroad) can you find a good job; only if you find a good job can you make a lot of money; and only if you earn enough money can you have the capital to get married”. This path to happiness is internalized into the success model of the big Other, imposing itself on each individual. Competition not only exists during education, but persists as a specter in job hunting and work. Besides the increased competitiveness caused by neoliberal globalization, China is also a populous country and the influence of the traditional imperial examination system still remains—various tests are used as a means to change fate. These factors make competition in China even fiercer. Due to the cutthroat competition, various differentiation “barriers”, such as education degrees, age and gender, are set up by employers, which further aggravates the anxiety of many relatively disadvantaged people. In addition, young people often need to pay for rent, bank mortgages and rising prices and maintain good relationships in the face-saving economy with Chinese characteristics. As a result, they fall under heavy life pressure. Many young people are trapped in the quagmire of the ideal-reality disparity due to the increasing employment pressure and the “diploma devaluation”. The book Jingyu, Taidu Yu Sheng Huo Ya li—80 Hou Qing Nian De She Hui Xue Yan Jiu (Experience, Attitudes and Social Transition—A Sociological Study of the Post-80 Generation) (Li 2013) stated that the post-80 generation are fully confident in the future of the country, but have many complaints about the current society. They hope to change their fate with personal efforts, but they cannot escape from the bonds of greater social forces. The mainstream discourse in society advocates that anyone can “make it” as long as they work hard enough, while constantly exerting pressure on the already overworked and

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exhausted population (Li 2013). They have been told that they are now freer to choose their own road than ever before, but the road to success is actually full of restrictions. Those who fail to “make it” are dismissed as “Diaosi”(屌丝), a group of losers.3 In this populous country in the midst of neoliberal globalization, many people suffer unspeakable anguish and pressure. In the cases presented in this chapter, some young people feel themselves inferior and worthless, because they think that they cannot meet others’ expectations and are always disappointing them. “Overseas returnees” who used to be highly valued now become “returnees waiting for employment”, children and teenagers who are constantly frustrated by excessive competition have a sense of inferiority and worthlessness. They are completely unable to offer a sanctifying symbolic answer to the big Other who demands it. As a result, these people endure endlessly the living conditions rejected by the big Other. For them, this kind of rejection includes being rejected by others in real life. They may also have long felt they are rejected by society and considered as unfit for the world. Academic discrimination is another instance. The miserable narrative of young people presents a “value crisis”. In the fierce competition in education and the economy, children and young people feel that after strenuous effort, what they represent to the big Other for its evaluation is merely a pile of worthless rubbish. Therefore, what they face is foreseeable failure and profound disappointment (Ingersoll 2010). The image of the “Good Man” enables the traditional division of gender roles to strengthen the gender norms in patriarchal society. As the chief breadwinner for the family, men with great power may also fall into depression when their role expectations are not fulfilled. The image of the “Good Woman” obliges women to devote themselves to maintaining family relationships, namely relationships with husbands, children and in-laws. When they fail to do that, resulting in family conflicts, they are prone to depression. As for middle-aged people, both men and women with unbearable and endless pain feel compelled to configure the reasons why the promises of the good life continue to fall so tragically short. They have to reinforce their faith in the sanctity and legitimacy of the symbolic order (the images of the “good man” and “good woman”) while they are forced to silently accept various negative phenomena occurring in the social transition (Ingersoll 2010). In short, the traditional gender-based role model may have enhanced the gender-based cultural norm that men attach more importance to their work achievements, while women devote more to maintaining close family relationships. If a couple fail to conform to the norm, they may suffer depression. In addition, it is worth mentioning that although depression is more closely related to personal aspects like personality or life style, the cases with qualitative analysis in 3.2 are mostly about depression caused by stressors. The focus here is not on these people’s personality problems, but on why stressors increase and why they are sufficient to cause depression. Judging from these cases, the increase of stressors is related to the social structure of neoliberal globalization, such as the expansion of higher education, the rise of unemployment, the pressure of excessive competition, and the gap between rich and poor highlighted by migration flows. When there are more stressors now than in the stable planned economy period, depression is naturally more likely to occur. 3 See

Sect. 5.4 for more explanation.

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Looking back on Chaps. 2 and 3, we would like to stress that this book by no means propagates vulgar economic determinism. In our analysis, we take into consideration the fact that the multiple effects of neoliberalism are actually complex. In fact, many possibilities can arise in neoliberalism. The micro-mechanisms may vary with the individuals’ different social networks and be manifested multi-dimensionally. It is not that neoliberalism will definitely lead to mental problems for every individual. As mentioned in Chap. 2, the family restructuring with Chinese characteristics has been trying to ease the family crisis after the nuclear family structure breaks up, and immigrants’ interpersonal network contributes to their mental well-being; but these measures do not inevitably produce positive results. It depends on the individuals themselves. This book does not deny the contribution of structuralism, but it also highlights that different sociological variables (gender, rank, race, culture, etc.) can lead to different depressive conditions. What should be pointed out here is that these variables are inescapably affected by neoliberal globalization in that they are stricken by drastic spatial-temporal changes. In other words, the spatial-temporal changes caused by neoliberal globalization do not necessarily lead to depression, but their influence on sociological variables is an important reference for the detailed analysis of depression. With the fact that the global prevalence of depression is increasing, the macro-structure of neoliberal globalization still has explanatory power, as it is different from the previous social structure with fewer mental disorders. In short, neoliberal globalization has produced a series of structural changes from the family, education system to the workplace and the country. In this context, each individual experiences structural changes at various levels, which affect the mental health of both individuals and those around them.

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Jessop, B. 2002. The future of the capitalist state. London: Polity Press. Kahneman, D., and A.B. Krueger. 2006. Developments in the measurement of subjective well-being. Journal of Economic Perspectives 20 (1): 3–24. Lane, C. 2007. Shyness: How normal behavior became a sickness. New Haven: Yale University Press. Li Chunling. 2013. Jing Yu, Tai Du Yu She Hui Zhuang Xing: 80 Hou Qing Nian De She Hui Xie Yan Jiu (Experience, Attitudes and Social Transition— A Sociological Study of the Post-80 Generation) [M]. Beijing: She Hui Ke Xue Wen Xian Chu Ban She, 2013 (李春玲. 境遇、态 度 与 社 会 转 型 :80 后青年的社会学研究 [M ]. 北 京 :社 会 科 学 文 献 出 版 社). Li, Hong. 2006. Beijing Shi Tuan Shi Wei Xue Lian Tui Chu Shou Du Da Xue Sheng Fa Zhan Bao Gao. Xin Jing Bao, 2016-12-2 (李红. 2006. 北京市团市委学联推出 《首都大学生发展报告》 . 新京 报, 2006-12-2). Liu, Junqiang, Xiong, Moulin, and Su Yang. 2012. Jing Ji Zeng Zhang Shi Qi De Guo Min Xing Fu Gan—Ji Yu CGSS Shu Ju De Zhui Zong Yan Jiu Zhong Guo She Hui Ke Xue (12): 82–102 (刘军强,熊谋林,苏阳. 2012. 经济增长时期的国民幸福感——基于CGSS数据的追踪研究. 中国社会科学 (12): 82–102. Martin, E. 2007. Bioplar expeditions: Mania and depression in American culture. New Jersey: Princeton. Ma Kaihua, An Shasha. 2014. Nian Zhong Guo Gao Ji Jing Li Ren Ya Li Zhuang Kuang Diao Cha Bao Gao. Cai Fu Zhong Wen Wang, 2015-02-10, http://www.360doc.com/content/15/0210/09/ 535749_44762-3621.html (马凯华, 安莎莎. 2014.年中国高级经理人压力状况调查报告.财富 中文网 [2015-02-10)] http://www.360doc.com/content/15/0210/09/535749_44762-3621.html). Ning, Yingbin, and He Chunrui. 2012. Min Kun Chou Cheng: You Yu Zheng, Qing Xu Guan Li, Xian Dai Xing De Hei An Mian (People in trouble: Depression, emotion management and the dark side of modernity). Taipei: Tang Shan Chu Ban She (宁应斌, 何春蕤. 2012. 民困愁城:忧 郁症, 情绪管理, 现代性的黑暗面. 台北: 唐山出版社). Saussure, F.D. 1999. Pu Tong Yu Yan Xue Jiao Cheng (Course In General Linguistics) [M]. Gao Mingkai, Yi. Beijing: Shang Wu Yin Shu Guan, 1999 (索绪尔. 普通语言学教程 [M]. 高明凯, 译. 北京:商务印书馆). Stevenson, B., and J. Wolfers. 2008. Economic growth and subjective well-being: Reassessing the Easterlin Paradox. Brookings Paper on Economic Activity 39 (1): 1–102. Tuckman, B., and T. Sexton. 1989. Effects of relative feedback in overcoming procrastination on academic tasks. Paper presented at the meeting of the American Psychological Association, New Orleans, LA. Veenhoven, R. 1991. Is happiness relative? Social Indicators Research 24 (1): 1–34. Veenhoven, R., and M. Hagerty. 2006. Rising happiness in nations 1946–2004: A reply to Easterlin. Social Indicators Research 79 (3): 421–436. Xing, Zhanjun. 2011. Wo Guo Ju Min Shou Ru Yu Xing Fu Gan Guan Xi De Yan Jiu. She Hui Xue Yan Jiu (1): 196–219 (邢占军. 2011. 我国居民收入与幸福感关系的研究.社会学研究 (1): 196–219). Yecun, Zongyilang (Nomura, Soichiro; のむら そーいちろー). 2008. Gei Xian Ru You Yu De Ni/ Tu Jie You Yu Zheng Xiao Bai Ke Li Xiaowen, Yi. Taipei: Xin Zi Ran Zhu Yi (野村总一郎. 给 陷入忧郁的你/图解忧郁症小百科. 李晓雯, 译. 台北: 新自然主义). Yu, Cuiping. 2015. Xiao Kang Shi Qi Ti Shen Zhong Guo Ren Xing Fu Gan De Tu Jing Yan Jiu. Zhong Guo Shi You Da Xue Xue Bao (She Hui Ke Xue Ban) (2): 42–48 (于翠萍. 2015. 小康时 期提升中国人幸福感的途径研究. 中国石油大学学报 (社会科学版) (2): 42–48). Zhou, Zhenji. 2006. Yi Yu: Yi Ge Xin Li Zi Xun Shi De Zhi Liao Shou Ji (Anxiety: A psychologist’s consultation records and notes). Zhengzhou: Zhengzhou Da Xue Chu Ban She (周振基. 2006. 抑郁:一个心理咨询师的治疗手记. 郑州:郑州大学出 版 社). Zhu, Jianfang, and Xiaolan Yang. 2009. Zhong Guo Zhuan Xing Qi Shou Ru Yu Xing Fu De Shi Zheng Yan Jiu. Tong Ji Yan Jiu 26 (4): 7–12 (朱建芳, 杨晓兰. 2009. 中国转型期收入与幸福 的实证研究. 统计研 究 26 (4): 7–12).

Chapter 4

Analysis of the Consumption Side: Socio-Psychological Context of Depression

The occurrence of depression is correlated with social and psychological factors. In this chapter we will explore how the occurrence of depression is affected by the common modern psychological process of individualization, the narcissistic society, and the democratization of intimate relations, all of which are related to rapid capitalist development.

4.1 The Socio-Psychological Context of Depression 4.1.1 Conflicts of Individualization Individualization, self-affirmation and self-esteem are part of the mainstream cultural values which have gradually become accepted by the general public in contemporary capitalist societies (Horney 1998, translated by Feng). Therefore, it is imperative to take individualization into account when we analyze the causes of mental illness. Beck (1999) pointed out the dilemma confronting the current generation, namely, the conflicts of individualization, results in their trust in systems and experts, but in the end, these systems and experts cannot be trusted. That is to say, agents (individuals) are becoming increasingly free of structural constraints, but they are trapped in a dilemma of the loss of beliefs and norms, of being isolated, and the deprivation of the social support in traditional social networks, while they are facing many social risks. In this contradiction, liberated individuals become more dependent on systems, such as the labor system, the education system, the consumption system or social laws and regulations. Accordingly, interpersonal interaction shifts from “trust in people” to “trust in systems (or experts)”. As the social relations established by trust (in government, the financial system, the medicare system, experts, etc.) are characterized by social insecurity, high risks, uncontrollability and unpredictability, people living in late-modern society are always anxious. Giddens (1990) labelled © East China University of Science and Technology Press Co., Ltd. 2020 I. Hsiao, A Sociological Analysis of Depression in China, https://doi.org/10.1007/978-981-15-6471-0_4

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such anxiety “existential anxiety”, a psychological state highly affected by ontological security. According to Giddens, ontological security refers to “the confidence that most human beings have in the continuity of their self-identity and in the constancy of surrounding social and material environments of action (Giddens 1990: 92). In other words, ontological security comes from the continuous familiarity and identification with the surrounding social milieu and activities; thus life habits and routines are important sources of personal security. When individuals are subjected to rapid changes in globalization, high uncertainty, irresistible environmental and behavioral changes (e.g. immigration and divorce), they may suffer existential anxiety and even disorders in life. People have to constantly reflect on and inspect their own life history to ensure the continuity and sense of order in their own life, so as to maintain their own sense of security and avoid anxiety (Huang 2000: 91). This is related to the neoliberal emphasis on self-responsibility, freedom and competition with others in the market environment, which leads to a high reflexivity of the modern self. In Giddens’ words, “What to do? How to act? Who to be? These are focal questions for everyone living in circumstances of late modernity—and ones which, on some level or another, all of us answer, either discursively or through day-to-day social behaviour” (Giddens 1991: 70). Continuous reflection and self-observation shape “the trajectory of the self”, and the construction process of this trajectory is the implementation of “the reflexive project of the self”. In the implementation process, individuals are eager to achieve security and self-actualization within changeable life existences; they are not only desirous of confirming “who I am”, but also “who I am in the eyes of others”, which occupies an important place in the self-identification of contemporary people. In this context, contemporary life existences present a multiplicity of conflicts. Detraditionalization renders individuals open to opportunities without the constraints of tradition, but also undermines their sense of security by following traditions; individuals plan and worry about the future. They calculate specific risks in order to control them: they often become reflective and make plans (achieving self-identity, renewing career plans, etc.) based on information culled from the diversity of information provided by experts, government, and various systems that they are compelled to trust, which results in risk uncertainty as well (Giddens 1991). They are subjected to the uncertainty of self-identification and various forms of shame and anxiety, so they have to keep track of the direction for their future behavior through repeated reflexive questioning and the maintenance of the trajectory of the self, obtain a short sense of security from the consistency of life history, and then continue the cycle of questioning and confirmation. Therefore, although reflexivity can help individuals to build their self-identity, it also makes them sleepless at night and increasingly unable to control risks and predict the future. With the rise of consumerism in neoliberal globalization, individuals are trained to define “who I am/what I look like” among the numerous personalized commodity choices. This individualized reflexivity highlights individual responsibility, which means that in terms of career choice and planning, one cannot shirk the responsibility for failure, because one makes one’s own choices. Therefore, the social problems originally beyond the control of individuals become causes for emotional problems—when individuals fail in self-planning,

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social problems can directly become emotional ones, such as the feeling of guilt, anxiety, neurosis, etc. (Ning and He 2012). In addition, the intensification of individualization results in individuals’ increasing sense of loneliness and alienation, which are factors that affect mental health. It has been found that the social support received or provided is causally related to depression; those who receive or provide more emotional support experience less depression (Joy and Chuang 2000). In addition, supportive attachment for individuals in grief and loss can help prevent depression (Stuart and Robertson 2003). Karachi et al., in their study of social capital and community effects, also found that community residents with mutual interpersonal trust, mutual aid and a high sense of group membership are in better health (Yang 2002). Alpass and Neville (2003) investigated relationships between loneliness, health and depression in 217 older men (≥65 years). Their study showed that a diagnosis of illness or disability was unrelated to depression; however self-reported health was associated with depression, with those reporting poorer health experiencing greater depression, and that the most significant relationship to depression was that of loneliness, with lonelier men reporting higher scores on the Geriatric Depression Scale (GDS). All these studies show that lack of social support in the context of individualization can more easily cause depression crisis.

4.1.2 The Narcissistic Society The more individualization develops, the more individuals will move towards a selfcentered “narcissistic” state. The psychological state of narcissistic individuals in psychoanalysis has expanded into a social phenomenon, which western scholars label the “narcissistic society” (Ning and He 2012). It was mentioned at the beginning of this chapter that depression is related to narcissism. Therefore, the “narcissistic society” offers a perspective for analyzing the social structure of depression. In the psychological sense, narcissism means ignoring the difference between the self and the environment: “I” am the whole world and the whole world should obey me. A narcissistic image integrates with the mother, feeling that the self and the mother are one and that it is self-sufficient and almighty (Zheng and Huang 2005). However, in psychological clinical practice, narcissism is a personality disorder. The 1994 DSM-IV defined narcissism as “a pervasive pattern of grandiosity (in fantasy or behavior)” as indicated by the presence of five (or more) of the following symptoms: (1) a grandiose sense of self-importance; (2) a preoccupation with fantasies of unlimited success, power, brilliance, beauty, or ideal love; (3) a belief that one is special and unique and can only be understood by, or should associate with, other special or high-status people or institutions; (4) a need for excessive admiration; (5) a sense of entitlement, i.e., unreasonable expectations of especially favorable treatment or automatic compliance with personal expectations; (6) interpersonally exploitive behavior, i.e., taking advantage of others to achieve one’s own ends; (7) a

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lack of empathy, unwillingness to recognize or identify with the feelings and needs of others; (8) envy of others or a belief that others are envious of oneself; and (9) a demonstration of arrogant and haughty behaviors or attitudes. The key point is that narcissism is a type of psychologically self-centered attention-seeking behavior (ibid.). Observing the egotism and self-contained world outlined by narcissism, Lasch more radically proposed that contemporary society is a society characterized by “the Culture of Narcissism” (Lasch 1979). Media researchers Abercrombie and Longhurst also called contemporary society the “Narcissistic Society” (Abercrombie and Longhurst 1998: 88). The narcissism they discussed is not merely confined to its psychological sense, but has socio-cultural implications as well. To them, narcissism is not merely a type of individual behavior, but a consequence of changes in time and social environment. In other words, narcissism has become the psychological key for modern individuals. They put forward the following main reasons for the formation of the narcissistic society. First, the loss of the sense of continuous belonging. Individuals in the globalized contemporary society are fast losing the sense of historical continuity, the sense of belonging to a succession of generations originating in the past and stretching into the future. No one can do anything about the vast social environment or potential disasters, so “seeking security” has become a general mentality of the current generation. They dare not place too much trust in others, as they are afraid of hurting themselves. This deep sense of powerlessness has been transformed into a closed self-centralism, where individuals count only on themselves. Individuals shift the focus of their activities and attention to personal survival strategies and utilize the sense of security brought by physical and psychological self-control and improvement to avoid or forget their sense of powerlessness in the face of social risks (Lasch 1979). Second, the instigation of consumerism and the media. Due to innovations in transportation and the advancement of information technology, the feeling of timespace compression intensifies more than ever before and leads to rapid capital flows. Accelerating product turnover requires the acceleration of consumption. This has consequently ushered in the consumer society (Harvey 1990). It is a normal state that commercial products are diversified in the neoliberal consumer market due to the logic of competitiveness and time efficiency, and thus people’s desire to consume is greatly escalated. Commodities are replaced rapidly, and people are often dissatisfied with existing products because of the logic of high efficiency and the abundant choices of better products coming soon. Being fond of the new and tired of the old becomes a norm, and people are increasingly unable to be content and happy with the status quo. Contemporary society is replete with images created by the media and the conspiracy of capitalism and the commodity system, which not only turns society into a “society dominated by appearance (or images)”, but also alienates the relationship between individuals and commodities. Personal consumption is not necessarily what one needs, but what one wants because of the media instigation. Individuals have been persuaded by the media to “live for yourself” and believe that this goal

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can be reached through the consumption of certain material goods (Lasch 1979). The expansion of consumption is the result of excessive and diversified production, which is related to the flexible accumulation of capital under neoliberalism. Harvey (1990) pointed out that “flexible accumulation” is a new production system characterized by flexible labor division and quick and active responses to products, patterns of consumption, marketing skills and even fund-raising. It also opens up opportunities for small business formation in the era of neoliberalism because of the speculative production mode coincides with its emphasis on niche markets in the era of globalization and on the ever-changing cultural aesthetic. The commodification of aesthetics and arts as well as the diversification of commodities have resulted in excessive choices and have prompted people to pursue their own style. Third, the decline of patriarchal families. At present, most psychoanalysts follow Freud’s view that narcissism mainly originates from the experience at a young age and the early stage of self-consciousness. Lasch is one of their followers. He analyzed the transformation of family of origin under the social structure and maintained that family of origin plays a key role in children’s character formation. Contemporary people tend to develop a narcissistic personality due to the childhood experiences caused by family changes. In modern society, the decline of traditional patriarchal families causes individuals to depend on experts as a new way of life to replace dependence on patriarchal authority (Lasch 1979). Parents of the current generation no longer possess the authority of parents in traditional societies: discipline is handed over to the authority outside the family, the appropriation of family functions by the state and experts (such as juvenile courts) has become a substitute for the discipline of strict fathers; children grow up under professional guardianship taken over by medical and welfare institutions if the parents “orphan” their children by their inadequacy, neglect or cruelty; and laws prohibit domestic violence against children. Contemporary families advocate equality between husband and wife and children’s freedom. Families with equality among family members have changed the intimate relationship and upbringing of children. The results include love but little discipline in raising children, and children having no chance to experience the “crisis of Oedipus complex” (the absence of the fear of castration means the absence of punishment by strict fathers). This can lead to children’s narcissistic personality. However, it should be noted that Lasch did not mean that only the decline of paternal power can lead to narcissistic personality, nor the “kind father and strict mother” parenting mode (or parenting of both kindness and strictness) in the context of declining paternal power. The problem lies in the “loving father and loving mother” parenting mode in a family with equality. Here, “kindness and “strictness” cannot be narrowly interpreted as the ways or attitudes of teaching and raising children. Rather, they mean “having the real authority or not”. Lasch believed that what contemporary families lack is not parents’ power to discipline the children, but rather their authority to convince the children, that is, the lack of a strict father or strict mother, thus leading children to develop narcissistic personalities (Ning and He 2012). Fourth, the pervasive use of new media. Abercrombie and Longhurst (1998) analyzed the narcissistic audiences (diffused audiences) who display an imagined performance in front of others through the lens of the Spectacle/Performance

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paradigm. In modern society, the mass media are infused into everyday life. In particular, the Internet, via the use of computers and mobile phones, has become a key medium widely used by audiences. For some people, the time spent on the Internet daily is even longer than the time on other forms of mass media (for instance, “phubbers” can be easily spotted in buses, subways, airports or other places), which leads people to focus more on their own world. They may develop a narcissistic personality by taking the external world into their private life, namely, regarding the whole world as an audience of the self. In other words, everyone should know and see any trivia, moods and thoughts that “I” have from morning till night. This has become more common with the appearance of microblogs, where people often leave online messages, share their current mood and post photos anytime and anywhere. The media render every individual an audience and through the interaction between two or more audiences, it expands or creates a spectacle where all life events can be displayed publicly. Individuals attempt to find their own reflection in the mediapresented mirror images and so see themselves not only as an audience watching others’ performance, but also as performers watched by others. Media infusion, everyday life, performance and spectacle-narcissism constitute a circuit, allowing audiences to expect, identify and construct (ibid.). As a result, individuals may gradually develop a self-love life style. On the one hand, they develop their own preferences in various mirror reflections in the media. On the other hand, they detest being the same as others, so they keep trying to evolve their own style. Personal style or self-style is developed through performance and identification with the self-style achieved in the spectacle/narcissism circuit. However, social fashion can come and go in a trice, and personal style can also be constantly changing. The change of personal style may not necessarily mean blindly catching up with the fashion. It may be more likely to distinguish the useful parts from the changing and external information through self-reflexivity, and to repeatedly repair the ideal self. Such habitual operations strengthen individuals’ narcissism. Because of these changes, the self has become the focus of personal attention. We can sum up the attributes of narcissism as the “tendency to live in the present and to have no sense of the past or of the future; a dependence on others combined with a fear of such dependence; a worship of celebrity; an inner emptiness; intensely acquisitive and demanding immediate gratification” (Abercrombie and Longhurst 1998: 90). The relationship between narcissism and mental health has always been a focus of psychological research. The psychoanalytic view on the development of narcissism has led to the hypothesis of two forms of narcissism: overt and covert narcissism. Both share some key characteristics of narcissism—considering oneself omnipotent, entitlement, self-admiration and disregard for the needs of others (Zheng and Huang 2005). The difference lies in the fact that overt narcissists are inclined to have a direct expression of grandiosity and a preoccupation with receiving attention and admiration from others. They do not pay attention to or are not easily aware of the needs of others, but they still have great social charm and a high level of mental health. The grandiose self, by procuring self-satisfaction and admiration from others through hard work, enhances the emotional support for the self (Gabbard 2010, translated by

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Zhao). By contrast, covert narcissists have a sense of inferiority, and their grandiose self is established in the evaluation of ideal others. They are very sensitive to others’ evaluation and often feel unsatisfied. They openly display lack of self-confidence and initiative, an absence of zest for work and study, anxiety and insecurity. However, they are still marked by largely unconscious feelings of grandeur. Whereas overt narcissists have higher self-esteem and greater satisfaction with life, covert narcissists are usually anxious, ungratified, vulnerable to life’s traumas, and prone to depression. Combining this psychological point of view with the previous discussion of the narcissistic society, we can come to the view that covert narcissism can lead to depression because covert narcissists may be unable to bear failures due to their vulnerability to life’s traumas, hypersensitivity to criticism and excessively high expectations of the self.

4.1.3 Democratization of Intimate Relations The relationship between husbands and wives has also undergone transformation in neoliberal globalization. In Chap. 2, cases showed that there is an increasingly high divorce rate because husband and wife live in different places. In addition to that change, there have been changes in the ways of communication between husband and wife. As Giddens (1992) pointed out, the spousal relationship in contemporary society places more emphasis on communication and the feelings of the spouse than in traditional societies; the intimate relationship between couples is more democratized. However, the “democratization of intimate relations” does not guarantee the continuity of happy marriage—couples are likely to divorce at any time. The reason is that two individualistic individuals take the sustaining of individual rights, rather than commitment, as the principle for fostering intimate relations (Giddens 1991). In Giddens’ view, good communication based on mutual respect for each other’s rights and interests is the source of conjugal security in the modern era which lacks ontological security. Giddens (1992) believed that the basic rules, rational reflection and equal negotiation in the public domain have also infused into the private sphere in contemporary society, setting up an important principle for the subject to develop interpersonal relations and leading to a “democratization of intimate relations”. In this era, the main contents of intimate relationships are no longer confined to “romantic feelings or possessive desires such as love, possession, jealousy and loss, because these feelings or desires also imply unequal, bonded or symbiotic relationships. To maintain intimate ties, individuals have to negotiate about less romantic things such as freedom, negotiation, mobility, the demand for professionalism and economic equality. They have also to maintain a delicate balance between freedom and commitment” (He 2011). For this reason, Giddens put forward the concept of “Pure Relationship” to capture contemporary people’s view of love. It is an “internally referential” social relationship with modern interpersonal relationship. It is “based on the satisfaction

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and compensation that the relationship itself can provide, namely, it is the relationship that both parties are willing to accept after they evaluate their own experience in this relationship. This is very different from the traditional marriage relationship imbued with considerations of various interests, including status, wealth, family background and reputation, and also different from the modern love that is full of self-projection and mutual dependence” (He 2011). However, the “democratization of intimate relations” cannot guarantee everlasting affection, and the divorce rate remains high. The paradox brought by the individualization of love in contemporary society, as described by Beck and Beck-Gernsheim (1994), lies in the couple’s oscillation between the “quest for personal self-realization” and “conjugal happiness”. Many conflicts exist between the two individualized people when they maintain the balance between “self-rights/self-realization” and “rights and interests of both parties/realization of both parties” in the era of modernity which emphasizes self-rights and self-realization. This is common for contemporary couples. Although Beck and Giddens are not Marxists, what they have outlined illustrates the logic of capitalism. Illouz (2007) believed that the intimate relationship they expounded is actually dominated by the trend of emotional rationalization and ultimately subjugated to the logic of individualism and fair exchange, which is inseparable from the development of capitalism. The communication mode of modern intimate relations emphasizes “equality”. It is actually a manifestation of “consciousness of equal rights” and “fair exchange” in the private sphere. “Consciousness of equal rights” means individualism highlighting individual values and the freedom of choice based on negotiation and mutual understanding. “Fair exchange” is like rational calculation in the economy. Political consciousness (equal rights) and the economic consciousness (equality) differentiate modern intimate relations from traditional ones and endow them with features of modernity (Illouz 2007). The democratization of intimate relations reveals the rise of female consciousness. It means that women have more rights to demand from men. Therefore, communication plays an increasingly important role in marriage. Besides, modern couples have more psychological needs than before. If couples have poor communication and fail to achieve mutual satisfaction, marriage crises are more likely to occur (such as extramarital liaisons and divorce), and more serious emotional problems may result.

4.1.4 Depression Derived from Cruel Competition in the Narcissistic Society On the whole, China is also facing the trend of individualization. In a sense, neoliberal globalization does emancipate individuals from the shackles of tradition. Yan (2012) argued that since the reform and opening up, China has gradually relaxed its control over people’s daily private life. As a result, the values of the market economy and global consumerism have become a dominant force in shaping domestic life and social changes, making China encounter similar situations as the West. For example, the rise of consumerism in daily life has directly stimulated young people in rural

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areas to pursue luxurious bride wealth and dowries. However, the development of ultra-utilitarian individualism has caused many young people to neglect their obligation to respect the equal rights of others. Full freedom in private life, together with strict restrictions on public life, may eventually lead to the emergence of “uncivil individuals” (Yan 2012). Guo (2013) also argued that the status and individualization of vulnerable women are also on the rise. He investigated women’s status in the relatively backward rural village of E’nanya and found that some young women there had brought the “advanced concept” of modernity into full play in their life. They don’t think much of the local beliefs, customs and the traditional meaning of family life; instead they tend to become more and more individualistic and dare to pursue personal happiness—including sexual gratification in their marital happiness. They hardly agree with the view that the purpose of marriage is reproduction or that the meaning of life lies in the family. For them, their own happiness is of paramount importance (Guo 2013). In comparison with traditional bondage, this is indeed a kind of liberation. Women have shifted from their dependence on men for life meaning to the realization of self-defined life meaning. In addition, the incidence of suicide has decreased. These factors may bode a decline in depression. However, this is still an unfinished story. When they are liberated from tradition and move towards the self, they may encounter a loss of family stability or ontological security. Under such circumstances, each individual will be responsible for her own choice and must also bear the risks that this uncertain world may bring at any time. This may get them trapped in another type of possible anxiety. Although the context and development of individualization in China are different from the West, on the whole, individualization has become a global trend. Let us look again at the social structure of and public mentality in neoliberal globalization. In terms of the external social structure, on the one hand, neoliberal globalization has promoted the public’s awareness and acceptance of ideas like “competitiveness”, “entrepreneurship”, “flexibility” and “mobility”. On the other hand, the “flexible accumulation” of neoliberal globalization has diversified commodities and encouraged consumption, thus contributing to the formation of a consumer society. This, together with the wide application of new technologies (e.g. Internet and mobile phones), has created a powerful material force, intensifying greatly people’s desires and resulting in the universalization of a spectacle/performance mentality. All this has further strengthened individualization in contemporary society. As a result, contemporary society mirrors such an image: on the one hand, individuals are undergoing individualization, turning themselves into a reflective self (everyone is encouraged to come to self-realization); while on the other hand, they are facing great pressure from space-time compression (brought about by neoliberal globalization) and are forced to make substantial self-changes. In this way, the logic of neoliberal globalization works together with the potentiality of the narcissistic culture in shaping individuals’ mental health—once the personality formed by a narcissistic culture cannot bear career or other failures, the risk of developing depression may increase substantially. Narcissists put all their eggs in one basket, namely the full development of themselves: they make careful and delicate plans of self-development and

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manage themselves with great rationality and will. However, the process of selfdevelopment and self-reflexivity is accompanied inevitably by various moods and emotions, various external pressures and internal conflicts. That is to say, they are always in a state of love and hatred. To them, failure is an extreme denial of the self they loved in the past. As a result, when they lose the important object of self, life becomes meaningless, like losing their loved ones, and self-mourning arises, which is actually depression (Ning and He 2012). This situation is similar to the psychoanalytic explanations of depression mentioned earlier—the feeling of loss resulting from being excessively narcissistic but unable to reach one’s ideal, or the depressive feeling resulting from the inability to bear the loss of love objects (including ideals, loved ones and the self) that one is excessively counting on, or the realization that the love-hate object is actually the self that still must be faced. Therefore, under the combined changes of the individualized subject and external social milieus caused by neoliberal globalization, fierce psychological conflicts may result, which provide an explanation for the occurrence of depression.

4.2 Case Studies of Depression Derived from New Psychological Needs In the following section are case studies on the theoretical reflections mentioned above.

4.2.1 Depression Derived from Cosmetic Failure Reports from the South Korea’s daily newspaper JoongAng Ilbo or The Central Times (중앙일보) showed that 16,282 Chinese went to South Korea for cosmetic surgery in 2013, and 7 out of every 10 foreign “beauty seekers” or cosmetic surgery patients were Chinese. According to other media reports, at present, surgical accidents and disputes concerning Chinese having cosmetic surgeries in South Korea increase by 10–15% every year. Once a cosmetic surgery fails, in addition to the physical damage, there are psychological problems. Take Yili Chen for example. In 2010, she spent nearly 170,000 yuan for cosmetic surgery at Beautyline4u, a South Korean cosmetic surgery clinic. However, her face was disfigured after the first surgery—her nose was inflamed and deformed, her lips were asymmetrical, she looked ten years older and her facial features looked very abnormal. She negotiated with the clinic a refund of 30,000–50,000 yuan so that she could go to other clinics for repair. However, the clinic claimed that the beauty agency had taken a high commission and asked her to find Ms. Gao, the agent. Chen called Ms. Gao many times but failed to reach an agreement with her. Worse, Gao changed her phone number and could not be found. Over the past four years, Chen traveled to South Korea many times for repairs, spending a

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total of more than 600,000 yuan. She spent all her savings to go abroad and was in debt. Her boyfriend broke up with her. Her family did not understand her behavior of seeking cosmetic surgery and they often had disputes with her. Consequently, she suffered from depression and had to take sleeping pills every day to fall asleep. Because she could not overcome her psychological barriers and was afraid of seeing old acquaintances, she had to go abroad to “heal her wounds”. In the four years since her failed cosmetic surgery, she has been to the United States, Europe and Thailand and lived in these places for several months, just to go to some place where no one knows her (The Beijing News, 2015). This example highlights two aspects of neoliberal globalization. First, the consumer society has re-specialized the categories of medical treatment, and the re-specialized cosmetic surgery like this is a “lifestyle medicine”, which means that once some disturbing biomedical reasons or treatment methods are found, lifestyle wishes or disturbing health problems will usually be satisfied or resolved through medical treatment (Gilbert et al. 2000). In lifestyle medicine, the main motive for treatment is the urgency of lifestyle desires rather than the emergency of illness. This is also the case for some fat people who are not excessively overweight (such as baby fat). They may be healthy consumers rather than weak patients. These people are not troubled by health hazards in the strict medical sense, but they want to achieve certain lifestyle aspirations, such as removing the social stigma of being obese and making themselves more confident and more popular with others. The medical respecialization of cosmetic surgery has transformed the “doctor-patient relationship” into a “service provider-consumer” or “special expert-client” relationship under the logic of medical consumerism. Second, people’s attention to the body is a psychical imagination manifesting the fashion aesthetics and the drive of symbolic consumption. Particularly, when the discourses of “medicine” and “aesthetics” are combined, people tend to hate such ugly body images. This mentality constantly stirs up people’s desire for a “perfect” body. It is in line with Giddens’ argument that in the complex and fast-changing late-modern society with high uncertainty, individuals’ constant self-reflection and self-inspection of their own life history are essential to achieve self-identity, to sustain the continuity and orderliness in their own life, and to maintain their sense of security to avoid anxiety. Attention to the body is a concrete manifestation. Cosmetic surgery is just one of the many industries related to the body or beauty. It is worth noting that consumerism that pays too much attention to the body encourages people to have high expectations while also fostering high risks. This psychological need can cause the “beauty seekers” to fall into depression when there is medical negligence.

4.2.2 Anxiety and Temptation from High Technology Everyone has become used to the various convenient means of communication. When subways, buses, the Internet, or the telephone do not work smoothly or break down,

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anger and anxiety may result. People who live at a fast pace have difficulty getting used to a slow pace or living an inconvenient life. When contemporary people do not have access to the Internet for one day, they may get worried and anxious. Little Lin, one of the author’s interviewees said, “Life cannot go on without the Internet. Even when I go abroad, I need to have access to the Internet, otherwise I will feel unease! The boss uses WeChat to allocate work; while waiting for the subway, I can check any information or things that come to mind; I can find the location of a restaurant where I am going to meet my bosom friends; when I travel abroad, I need the Internet to share my photos. If the Internet breaks down or there is no Internet connection, I really have a sense of “emptiness” and “being deserted”. I can do nothing but stare blankly when I can’t blog even just for a few hours”. The anxiety of not having access to the Internet has become a social phenomenon after the popularization of the Internet. It affects people’s moods and emotions. Additionally, the increasing popularity of the Internet has made some people addicted to the Internet all day long, separated from group activities and life and losing their social support. Once they encounter setbacks, they may feel sad and helpless, unable to resolve their distress, and depression may result. Another interviewee, Little Lu, had been an excellent student since childhood. Because of his excellent performance, he was admitted to one of the top high schools in his city and was also appointed class monitor. However, just two months after entering high school, a boy whose parents had divorced became his good friend. He was instigated by this classmate to play online games together. He became addicted to online games and eventually skipped classes. In class, he would either sleep or think about how he could “complete the game missions”. He began to get cranky and eccentric and his academic performance declined dramatically. He wasn’t aware of his faults even after he was removed from his position as the monitor. He often replied defiantly to teachers and even had several fights with classmates. At the end of the second year of high school, under the persuasion of his mother, he began to realize his faults and decided to bid farewell to online games. When he returned to the class, many boy classmates deliberately isolated him, and the classmate who had enticed him to play games broke up with him. He began to reflect on his behavior in the past with regret, wishing he hadn’t done those things. He felt sorry for his teachers and parents and strong remorse and shame. As soon as he entered the classroom, he felt deep unease and wanted to escape from the classroom. After some time, he went to see a doctor and was diagnosed with depression. Lu’s case highlights the phenomenon that virtual reality is merely a space for escape if individuals fully project their repressed emotions into it. It cannot bring calmness of mind after catharsis nor ease of mind after the relief of distress. On the contrary, it will only make individuals more addicted to the projected pleasure and enhance their self-centeredness. Therefore, Internet addiction can cause individuals to neglect their interpersonal relationships, develop extreme egoism, and indulge in the virtual world, which promotes the development of narcissism, affects interpersonal interaction and leads to emotional problems.

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Another temptation of the virtual world is reflected in the case of extramarital liaisons, Case 2 in Sect. 2.3. In that case, one of the male characters met his mistress through online chatting and the other exchanged messages of love via the mobile phone. New technology provides an interactive platform for people living in loneliness and having a sense of emptiness. In addition, new technologies characterized by rapid information flow have produced a new type of anxiety: for some people, no “thumbs-up” (likes) or “comments” on the content they share on social networking SNS (Social Networking Service) apps, or no “response” from someone who has “browsed” the content can be an anxiety. Behind these interactions with online social networking platforms and communication software are various complex expectations, thoughts, motivations and implications. Young people are the most open to new technologies and new things, care about interpersonal interaction and need interpersonal support. As a result, such phenomena as no “thumbs-up” create space for infinite imagination and can result in more pressure and anxiety. In a “virtual-and-real” interpersonal relationship, if individuals place too much emphasis on the virtual part, or if they expect too many “thumbs-up” for shared online content, they may doubt the relationship with friends who care about him very much when the friends do not “thumb up”, even if they meet them every day. At a meeting with several friends, we talked about whether we would care about “thumbs-up” or “comment” to the contents we shared on online SNS (WeChat) apps. Xiaoshu said, “I will. There are always comments every time I post something. Once there is no comment, I lose confidence. I often wait for friends to ‘thumb up’ for my postings and sometimes I even can’t concentrate on my work while waiting.” Xiaoyuan said, “Almost every message I post has several or even dozens of comments, from those who have not chatted with me! I have posted something they agree with from the bottom of their hearts. It is a nice feeling! But one time there were few comments on the opinion I posted, and I really had a sense of emptiness. I couldn’t do anything enthusiastically that day.” It can be seen that once self-expression and self-management are constantly performed through social platforms, technological objects become related to emotions. With the popularity of Weblog and WeChat, people can easily see friends eating big meals, going to fun places, buying expensive items, dating beautiful women or handsome men, or taking part in fun activities. Those who are not mentally strong may feel inferior to others. However, most of what people post on such platforms are happy moments or events. Therefore, these platforms are more like a stage for deliberate performances than for observing others’ private lives. They are also a hidden “social disturbance” for many people. On the one hand, people admire (and are perhaps jealous of) the attention their friends get; on the other hand, they hope they can also get some “likes”. As a result, out of anxiety, people have become more and more active in WeChat and Weblog postings, contributing to the development of narcissistic society. It can be concluded that social networking websites and apps have changed people’s lives from being monitored to being regarded. Foucault condemned the panoptic schema of surveillance of power (the monitored people feel uneasy) in the

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past. But now, people are active, willing and desirous to be regarded (like exposing themselves to the gaze of others). The change from “hatred of being monitored” to “fondness of being regarded” is actually a transition from Foucault’s Bentham-Orwell panoptic society (the omnipresent surveillance of power) to Žižek’s “jouissance society”. Today, people feel anxious when they are not under the gaze of the big Other. For some people, attention is a guarantee of their existence, and the distinction between real life and performance is blurred. These trends reveal the subject’s urgent need to ensure his very existence by the fantasized gaze of the big Other (Žižek 2003). This persuasively proves that a new psychological need or expectation has been derived in the information society—the gaze of others becomes a kind of affirmation and a basis for self-identification. However, once the need or expectation of others’ gaze is not fulfilled, the subject may suffer a psychological blow and anxiety may occur.

4.2.3 The Narcissistic Personality and Frustrations of Only Children As mentioned in Sect. 4.1.2, Lasch argued that one of the key factors for the formation of the narcissistic society is the decline of contemporary parents’ family authority; their power of discipline has been transferred to authorities outside the family. Although Lasch’s observation was made in the context of the United States, which is different from that of China, his theory can still shed light on the current situation in China. The generation of parents with only children are no longer as authoritative and strict as previous generations. They tend to dote on their child. This can cause what psychoanalysis described as “experiencing no fear of castration”, namely, no punishment from a strict father (to be precise, from the family authority) and then lead to a narcissistic personality. Xiaomin, an only daughter, was a lively, cheerful and articulate girl before she studied at a technical secondary school. Her parents had started their own businesses, so she enjoyed an affluent life style. But her parents were busy with their work, so she was brought up by her maternal grandmother, who lived in the countryside. She didn’t return to live with her parents in the city until her grandmother died of illness when she was a middle school student. Her parents felt a little guilty for failing to take good care of her when she was very young. When she returned home, she was doted on, enjoying a “little princess” life. Her academic performance was not very good due to her parents’ negligence in guidance and discipline. She entered a technical secondary school after graduating from junior high school. In her first year in the technical secondary school, Xiaomin participated in the election campaigns for student leaders both at the school and department levels, but without success. Confronted with such a “heavy” blow, she, who was always competitive, fell into the mire of self-denial. What’s more, due to her competitive character, she was fond of arguing with her roommates and rarely gave in. As a result, all her roommates didn’t dare to “provoke” her. She encountered a crisis in her

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interpersonal relationships. She always suspected that others were talking about her and was hostile towards each roommate. Every time she saw others happily playing or studying together, she was replete with loneliness. She often had nightmares, suffered sleep problems and had poor appetite. She often lost her temper but didn’t know why. It was hard for her to control her negative emotions. Eventually she turned into a “different” type of classmate. She was aggrieved and tried to change herself, but she couldn’t hold on. She became distressed, lacked enthusiasm for life and rejected herself in almost all aspects of her life. She even lapsed into a state of self-isolation. Xiaomin fell in love in her third year at the middle school. She and her boyfriend were classmates. The good time lasted until their graduation from the middle school. They went on to different schools. They kept in touch and maintained their relationship until the second semester of her technical education. At noon one day, her cell phone beeped while she was taking a nap. She received a message from her boyfriend, which said, “Xiaomin, let’s break up!” She called her boyfriend, only getting a confirmation of the message. Lying in bed, she felt more and more wronged as she thought more. She could not accept the fact of breaking up. She felt hopeless and helpless as never before. She felt that she lost her dignity to live on and did not know the meaning of life. She thought of death. She wanted to end her life in the least painful way, so she thought of taking sleeping pills. She rushed to several drugstores and bought over 20 sleeping pills. Returning to the dormitory, she swallowed the sleeping pills all at once and went to bed. It was not until her roommates came back to talk to her and she made no reply that they found something was wrong with her. They immediately sent her to the hospital and she finally got out of danger after a gastric lavage and emergency care. After the incident, her parents realized the seriousness of her situation and took her to the hospital for an overall physical examination. The psychological doctor they visited diagnosed Xiaomin with depression and prescribed some medicine for her. He also suggested that Xiaomin not suppress her emotions, learn to let things go and establish a healthy state of mind by doing more aerobic exercises and physical exercises. After a period of recuperation, her condition improved significantly and she returned to her lively, cheerful and articulate former self. Xiaomin’s case is a typical example of depression caused by the way only children react to stress events. According to the survey results about the self-esteem of the public released in the 2010–2011 Report on Advances in Psychology, children with siblings generally have lower self-esteem than only children. Latest research shows that only children in China have a narcissistic tendency, and this high self-esteem narcissism deserves more social attention (Liu 2011). It is obvious that if only children grow up in a doting family, they may have a higher probability of suffering depression when facing stress events.

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4.2.4 Emotional Needs Derived from Democratization of Intimate Relations In Sect. 4.1.3, we listed Giddens’ idea of “democratization of intimate relations” as one aspect of the social and psychological context for the generation of depression. We also analyzed some cases of extramarital affairs and came to see that communication between husband and wife has become more and more valued in the contemporary era. Communication itself is a new psychological need. If couples do not know how to communicate on an equal basis, marriage crises may arise, which may lead to depression. Among the new psychological needs we analyzed above, single children in a narcissistic society and the democratization of intimate relations have a wider impact because both involve most families. In other words, if parents lose the family authority needed by their only child, only children are prone to a narcissistic personality. Narcissists go heart and soul into their self-development and thus are more likely to face failure in the highly competitive neoliberal globalization. Such a social structure has affected the development of children’s personality, leading them to narcissism and laying hidden dangers for depression. Then, a material and spiritual life that cannot satisfy the husband or wife, and lack of communication or inability to communicate can cause problems for couples in the current era, even though in the past such things could be tolerated or accepted. This is a process in which men’s and women’s demands for their rights are developing towards equality. It means that there is more equality in the psychological satisfaction of both, but it also means that dissatisfaction of either party may lead to divorce at any time, increasing the probability of mutual harm and giving rise to emotional problems.

4.3 Social Structure of Depression: A Summary The social structure of depression has been expounded in Chaps. 2–4. We analyzed the changes on both the production and consumption sides brought about by neoliberal globalization. These changes are closely related to the psychoanalytic interpretation of depression. Table 4.1 sums up the main ideas of the analysis in these three chapters. Since the reform and opening up, China has boarded the train of neoliberal globalization. Its social structure is no longer as stable as the urban-rural divided structure of the planned economy era. The dramatically changed social environment poses to individuals more challenges, both psychological and practical. Based on our previous analysis, we briefly summarize the social structural characteristics of depression in China after the reform and opening up. There are two aspects on the production side. We first analyzed the spatial changes. The human relationships and agrarian relationships in the past have given way to the closed space constituted by networks of dense highways, railways, aviation, the Internet, skyscrapers and virtual reality. These infrastructures have changed the speed

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Table 4.1 Social structural analysis of depression Social structure of depression Neo-liberal globalization

Production Side: Overwork from competition

Psychoanalytical theories

Situation in China

Depression in drastic space changes; 1. Intensified uncertainty 2. Immigrants’ emotional problems 3. Changes in family structures 4. Blurred boundaries between work and life

1. Loss of support leads to depression (Spitz, Bowlby) 2. Love-hate relationships with loved ones can trigger depression (Klein) 3. Depression can be triggered by psychological scars or fears developed in infancy (Object Relations Theory)

People encounter more problems: adaptation to regional and national mobility, adaptation to cross-border commuting, acculturation, family crises, blurred boundaries between work and life, etc. All of these show that people are prone to emotional problems due to the loss of anaclitic objects or attachments and ontological security in high spatial mobility

Depression in time efficiency

1. Excessive superego leads to “self-attack” (Freud) 2. Depression is a psychological defense mechanism to escape from reality (Freud)

The logic of competitiveness and “good life” shaped by social norms has become the big Other (superego), exerting discipline over and monitoring various age groups. However, some subjects, no matter how hard they try, fail to fulfill the expectation of the big Other. In some situations, they also suffer great pressure caused by high living costs and imperfect social systems in China. These factors make people feel inferior and frustrated, and depression may result (continued)

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Table 4.1 (continued) Social structure of depression Consumption Side (Stirring up desire, never satisfied)

Social and psychological context: 1. Conflicts of individualization 2. Narcissistic society 3.Democratization of intimate relationships 4. Cruel competition in narcissistic society

Psychoanalytical theories

Situation in China

Depression is associated with narcissism (Lasch)

Depressive symptoms derived from new psychological needs can be manifested in some individuals’ attention to their body images and the demand for scientific and technological gadgets and Internet use. The manifestations with wider impact are in the development of a narcissistic personality of only children and new emotional needs derived from the democratization of intimate relations. The strong desires and demands for equal rights give rise to higher expectations of life, which, under uncertain risks and the social atmosphere of intense competition, may lead to frustration and finally depression

of spatial flows. In the past 30 years, China, following the expansionistic logic of global capitalism, has witnessed rapid economic expansion. It has also undergone unprecedented changes in its traditional values, economic structure, social forms, culture and education, land development, community restructuring and life styles. As a result, interpersonal interaction has become less stable. When the mobility derived from the post-Fordist flexible accumulation leads to a sense of uncertainty and the loss of anaclitic objects, individuals’ emotional problems are manifested in their adaptation to mobility, tiredness from cross-border commuting, acculturation problems, and stress from unhappy memories of cross-border mobility experiences. Such a spatial structure with high mobility easily generates stress events that trigger

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depression. We also explored the impact of family structure on depression, mainly the impact of family crises like divorce, high living costs, extramarital liaisons, and depressed parents. All these stressors are part of the social structure during drastic spatial change. The family is the core of individuals’ life, so emotional problems of one member greatly affect other members. In this sense, family disharmony has become a breeding ground of depression. Then, we conducted a sociological analysis of temporal changes. The discourses of competitiveness and social norms have become the superego big Other— competition and social norms have become the superego exerting various pressures on all age groups and have plunged them into a value crisis in the symbolic order, thus triggering emotional problems. This means that factors such as the escalating competitiveness in neoliberal globalization, the state competition mechanism and the evolving competition rules have integrated into a big Other, which is more likely to form superego-like pressure when it is in operation. In this era, every individual has to try his best to adapt to the ever-changing new environment, which emphasizes speed and competitiveness. Such an external environment brings many novel stimuli and heavy pressures, resulting in individuals’ inner imbalance, agitation, tension, anxiety and sense of emptiness. On the whole, many classes of people are overworked. This is a structural problem resulting from China’s role as the world’s factory in neoliberal globalization. It is also part of the domino effect produced by the drastic spatial-temporal changes in China impacted by the post-Fordist production system of neoliberal globalization. It should be noted that many side effects of this development process have not yet been resolved. Problems such as high housing prices, pollution, insufficient social welfare and excessive concentration of urbanization also add to people’s burdens. The already overworked Chinese have to deal with these negative effects themselves, and thus their worries increase. On the consumption side, we found that increasing new psychological needs (including desires and equal rights) are important factors that affect depression. The major categories are narcissism and frustration derived from great desires, anxiety and temptation from high technology, and emotional needs from the democratization of intimate relationships. The changes on the production side can only delineate the suffering state of depressive patients under the logic of productivity and competitiveness, but not individuals’ changing moods and emotions brought about by the flexible accumulation of post-Fordism. When the needs individuals as consumers (on the consumption or demand side) are expanded, we need to combine the frustrating and exhausting social structure of production with the social structural analysis of the increasingly higher expectations of individuals. In this way, the gap between the ideal and reality can truly come to light, and the increasing incidence of individuals’ emotional problems can be fully accounted for. These new psychological needs are embedded in a social structure with relatively equal status among individuals. This social structure is characterized by its consumption-orientation, fast-changing technologies, and equitable reciprocal relations between men and women. Generally speaking, consumption shows a polarization trend. Rich classes can afford luxury goods and more indulgent enjoyment. Due to the large population base in China,

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despite the low proportion of the rich, the actual number is not small. As for the ordinary classes with fixed salaries, although they do not indulge in excessive consumption, they can afford various electronic gadgets since the prices of mobile phones, computers and the Internet have decreased considerably. New software, new apps and other technological products are constantly renovated and put on the market, complicating peoples’ ways of interaction. What’s more, the extensive networks of aviation, railways and highways have benefited all people with their convenience and affordable prices and offered them chances to participate in the race for productivity. A quick and impetuous lifestyle can stimulate the desire for more and speed up the cycle of replacing old things with new items. However, this new form of consumption (demand) oriented structure is the consumption jouissance acquired at the cost of more convenient cross-border capital accumulation. On the whole, individuals’ desires and rights in this era are more likely to become potential causes for emotional problems. Individuals today no longer resign themselves to adversity as people used to be, which, of course, maintains their basic rights. But when they have more “capital” and “mood” to fight adversities, when they are under overwork and irritating life pressures arises, they may encounter emotional problems.

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Chapter 5

Depression in Capitalist Discourse: A Lacanian Psychoanalytical Interpretation

In the previous three chapters, we have analyzed the social structure of depression in view of the changes in its production and consumption brought about by neoliberal globalization. This chapter will analyze the social structure of depression from the psychoanalytical perspective. More specifically, it will explore the relationship between capitalism and depression from the perspective of psychoanalysis. This perspective was not presented in the literature review in Chap. 1, mainly because the mainstream social structure analysis or medical sociology does not attach importance to this perspective, and there is very little literature. Therefore, this chapter will begin with a description and interpretation of psychoanalysis and its applications. The psychoanalytical approach proposed by Jacques Lacan and developed by Slavoj Žižek, a contemporary cultural critic of the Lacanian School, is adopted to analyze the questions explored in this chapter for the reason that their approach goes beyond medical treatment and psychotherapy to cover a wide range of political, social and cultural fields, delving deeply into the theoretical logic behind social phenomena. Most studies about social structure, whether quantitative or qualitative, take a strictly empirical approach, focusing “visible data or phenomena” (the Symbolic in Lacan’s triad), and do not explore the unconscious realm (the Real in Lacan’s triad). Such studies of the social structure of depression are grounded in the myth of “empiricism” or “seeing is believing”. Therefore, a psychoanalytical analysis of the social structure of depression can help to overcome the limitation of “empiricism” in previous studies by incorporating the “invisible” unconscious into the analysis of the capitalist discourse of depression. Moreover, as a mental problem, depression is inherently related to patients’ unconscious world. Psychoanalytical approaches extend the scope of social structure to the level of unconsciousness so that depression can be explained as a mental problem. Finally, articles and books on Lacanian psychoanalysis in China (Wu 2010; Ma 2012; Liu 2006; Huang 2003; Zhang 2005) are concerned more about introducing and interpreting the theory than about applying it to analyze social phenomena in China. Thus, adopting Lacanian psychoanalysis to analyze the social structure of depression in China represents a groundbreaking and promising approach. © East China University of Science and Technology Press Co., Ltd. 2020 I. Hsiao, A Sociological Analysis of Depression in China, https://doi.org/10.1007/978-981-15-6471-0_5

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We talked a little about Lacan’s big “Other” in the introduction of Part I, but this concept alone is obviously insufficient to analyze depression. Moreover, as Lacan’s thoughts integrate ideas from philosophy, psychoanalysis, structural linguistics, semiotics and even mathematics and topology, and his works are reputed for their obscurity, it is necessary for us to provide a rudimentary introduction to the key concepts of his psychoanalytical model.

5.1 Key Concepts in Lacanian Psychoanalysis 5.1.1 The Imaginary, the Symbolic, the Real and the Formation of the Subject Almost all the problems in contemporary society can be generalized into one: what is the subject? For Lacan, the structure of the subject is framed within the three Orders or Registers of the Imaginary (imaginaire), the Symbolic (symbolique) and the Real (réel), which are structurally interdependent as in the Borromean knot, in which the severing of any one of the three rings causes the other two to become separated (Evans 1996: 131, 132). The subject in Lacanian psychoanalysis is divided, non-identical, empty and nihilistic. This view of the subject radically challenged the classical subject concept inherited from traditional metaphysics and the Cartesian cogito in Enlightenment philosophy. Let us start with the Imaginary. The Imaginary originated from the mirror stage (stade du miroir, also translated in English as “the looking-glass phase”), which is one of the key concepts in Lacan’s theoretical system and the foundation for his other theories (Wang and Guo 1997: 129). The term “mirror stage” refers to a process in which a human infant aged 6 to 18 months recognizes his body or reflection in a mirror, thus identifying with the specular image (Du 1988: 129). By the early 1950s, Lacan’s concept of the mirror stage had evolved: he no longer considered the mirror stage as a moment in the life of the infant, but as representing a permanent structure of subjectivity. The focus of the mirror stage is that identification with one’s own specular image is a decisive turning point in the mental development of the child. An infant’s identification with his image or understanding of self is through the mirror reflection, which is not only the self but also the “other” (l’autre, the small other) for the infant. Lacan believes that the process of self-recognition by recognizing oneself as other is a kind of misrecognition (méconnaissance), which can also be observed in an infant’s getting along with others. For example, when facing a baby of similar age, the infant often fails to make a distinction between self and other—when raising his hand to hit a person, he thinks that the other person is hitting him, and when the other baby falls down, he cries. However, the original way of establishing subjectivity is to identify with the imaginary image in the mirror. To put it simply, the infant’s identification

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with his own image in the mirror or in the other creates what Lacan terms the “Ideal Ego”. Lacan reasons that in the mirror stage the Ideal Ego is constructed by the infant’s recognition of the mirror image as a perfect and well-structured whole or gestalt through a process of imagination. The Ideal Ego in the mirror stage is idealized, illusory and full of expectations because the baby lacks control over his bodily movements and the identification with the optical image as a gestalt object is a misrecognition. The baby still lacks coordination and demonstrates an imaginary mastery over the body. Since the mirror stage is the starting point of self-recognition, the baby’s sense of fragmentation of the body comes into being after the mirror stage, when he counteracts his primordial sense of the body with the realization of the wholeness of the mirror image. In this way, the mirror stage plays both anticipating and retrospective roles. However, the mirror stage shows that the Ideal Ego is the product of misunderstanding, so that the resulting anticipation or retrospection are both rooted in illusory or false recognition. That is to say, in the mirror stage, the mirror image and the identification with the image as an opposite object give the baby a sense of “I” (or subjectivity), the primordial form of which is the “Ideal Ego”. However, this act of self-recognition is fundamentally self-alienating, because the baby recognizes himself in the mirror image as an external other. It can be seen that the “I” does not exist before the baby can see the image in the mirror and get the sense of “that is me”. In other words, the “transformation” that occurs in the subject is one in which the subject recognizes the mirror image by self-alienation (Lacan 1977: 2–6). The mirror image recognition is “a drama whose internal thrust is precipitated from insufficiency to anticipation—and which manufactures for the subject … the succession of phantasies that extends from a fragmented body-image to a form of its totality.” (ibid.: 3). Such original narcissism is the subject’s earliest form of identification, and it undertakes an indispensable mission in the mental development of the subject. In addition, psychoanalysis emphasizes that a subject should not stay in this stage for a long time, but has to experience the Oedipal identification and enter the Symbolic (to be introduced later). The Imaginary originates from the mirror stage, but does not disappear with the end of the mirror stage. Instead, it develops into the relationship between the adult subject and others. The Imaginary consists of “fantasy” and “image”, which are projections of one’s subconscious. The baby’s infatuation with his image in the mirror stage is a typical imaginary relationship, which is centered on the minor “other” and the “id”. The subject can have pleasure in the imaginary space. The ego is an imagination constructed on misrecognition; it is an alienating identity of the subject who is firmly ensnared by imagination. For example, I create an imaginary image of some person and stare at it. I like it and take it as my idol. I gaze at it, imitate it and make myself be it. Through such gazed identification, I create a self. This idol is not necessarily an ideal and perfect image. Many a time, we sympathize with a failed, lame or weak image. For example, many criminals in Europe and America later became popular idols and were even engaged in promoting the sales of products; the Nazi Party and Hitler had many fans. It can only be said that an idol possesses some extreme characteristics, which cannot be judged as being good

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or bad. In addition, the idol can also be an imaginary image of myself established by exaggerating or extending my own characteristics. I identify with this anticipated self-image, which is the narcissistic structure. This imaginary identification focuses not on the characteristics of idols, but on the whole process of shaping the self. Let us move on to the Symbolic or the Symbolic Order. It is a linguistic or normative system, which includes symbolic phenomena such as logic/mathematics, language, social culture, law, customs, etc. It is also a set of concepts or structures like self, memory, words, symbols, etc., which underlie the daily reality. Lacan himself puts more emphasis on the order of language and social culture, because only with these two can one develop the Ego. The Symbolic functions not only logically and psychologically, but also socially and culturally. Because of its structure, it is called the Symbolic Order. For Lacan, the Symbolic is the transition phase from the imaginary subject to the real subject. At the age of 3–4, with the acquisition of language, children become aware of the distinction between self, other and the outer world, which indicates they reach the Symbolic Order (Wang and Guo 1997: 167). The subject will confront the Oedipus complex in the passage to the Symbolic Order. To put it simply, every (male) child has a subconscious desire to have an incestuous sexual relationship with his mother and to kill his father, who threatens to castrate him and suppress such a desire; as a result, the child accepts the father’s phallic authority. This is a process in which the subject creates a language-mediated symbolic order of social culture while his subconscious is suppressed (Liang 1993). Therefore, in the initial stage of the Oedipus complex, the child desires more than mere contact with the mother and her care, but also expects to be the only one that the mother cares for. Subconsciously, he hopes that, on the one hand, he can become the object of her desire—the imaginary “Phallus” that the mother lacks. On the other hand, however, he is in a “condition of lack” rather than being an independent subject, because he has not fully mastered language and fails to show his power in linguistic communication (Liang 1993: 138–139). The second stage of the Oedipus complex is characterized by the intervention of the father, either by depriving the child of his desired object or by depriving the mother of her phallic object. By showing that he has the phallus and neither exchanges nor gives it, the real father castrates the child in the sense of making it impossible for the child to persist in trying to be the phallus for the mother; it is no use competing with the real father, because he always wins. However, the child is finally able to put an end to the aforementioned deadly game with the mother. This also provides a possibility for the infant subject to identify with the father (Evans 1996: 150, 129). The castrated child undergoes the Oedipal process and knows that he can no longer depend on the imaginary stage of mother-child symbiosis. In other words, the child’s desire for the mother may cause his father, a powerful opponent, to castrate the child. As a result, the child will identify with the father, expecting to have other females than his mother as his desired objects when he grows up. At the social level, children (or people) identify with the “symbolic father” (representing law, ethics, morality, norms, culture, social order, etc.), a function of the Name of the Father (Nom-du-Père) rather than a biological parent. In this sense, children’s (or people’s) recognition of the “Name of the Father” is actually the recognition of a set of (symbolic) laws that predate them in civilized

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society. Once children identify with the symbolic father, acquire language, accept law and identify with social culture, they pass into the social and cultural order from the natural state. Accordingly, they leave/overcome the “Oedipus complex” and pass into the Symbolic, thus establishing their subjectivity (Liang 1993: 138–139). Thus, the Oedipus complex is an important stage in shaping the subject’s subjectivity; but the subject must undergo the castration by the symbolic father. Therefore, Lacan believes that the subject can be formed only through the Symbolic Order. Assimilation to the Symbolic Order is the main way that modern people construct their subjectivity. What emerges is no longer the imaginary other, but the symbolic big Other. It is a mechanism that represents the social symbolic order: mainstream values, ideologies, trends, cultural traditions, etc. The subject is assimilated in the gaze of the symbolic big Other (l’Autre): “I” regard “myself” as an “other” or an “object” and thus make myself objectified. The big Other gazes at me and delivers me an expectation, while “I” myself play the role it expects in order to satisfy the big Other. For example, children meet their parents’ expectations of “good children”, students teachers’ expectations of “good students”, wives husbands’ expectations of “tender and virtuous women”, and citizens the nation’s expectation of “obedient residents”. The symbolic big Other is very abstract, but it can be embodied in anyone around us, especially those who are important to us: parents, brothers and sisters, teachers, friends, communities, etc. In other words, the Other is hiding in all the people around us. The big Other cannot be assimilated through identification, but the symbolic layer mediates with self-identification through the big Other. The symbolic order also exists in the realm of the law that regulates desire; it is the domain of culture as opposed to the imaginary order of nature. The subject’s symbolic identification with the Other will eventually decompose the imaginary identification to a large extent and even fundamentally change the content of the imaginary identification (Žižek 1989: 110). The reason “I” can be seen is that the gaze of the Other guides, revises and determines how “I” am seen in the mirror image and how “I” can find the identity in the imaginary relation (Žižek 1989: 106). In contrast to the duality of Ego-other (mirror image) peculiar to the Imaginary Order, the Symbolic Order is characterized by triadic structures, because the intersubjective relationship is always “mediated” by a third party, the big Other (Evans 1996: 201–202). The last of Lacan’s three orders is the Real hidden in the unconscious, which is also the most elusive and mysterious, the most special and worthy part to be explored among Lacan’s concepts. Unlike the Symbolic, which is a set of differentiated, discrete elements called signifiers, the Real is vague and obscure; the real is, in itself, undifferentiated and ‘absolutely without fissure’ (Evans 1996: 159). It is incomprehensible and what Lacan called “the impossible”, because it is impossible to imagine, impossible to integrate in the symbolic order, and impossible to attain in any way. It is outside language and unassimilable to symbolization. It is this characteristic of impossibility and of resistance to symbolization which lends the real its essentially traumatic quality (ibid.: 159–160). In other words, there is an inseparable relation between the formation of self and the traumatic kernel created when the subject passes into the Symbolic Order. For Lacan, the traumatic kernel which cannot be integrated in the Symbolic Order is the Real. The Real is constantly

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fighting against the Symbolic Order, and in this struggle, the Real, which can never be integrated in the Symbolic Order, virtually controls the Symbolic and makes the Symbolic revolve around itself. This repeated process brings an indescribable pleasure, which is often associated with pain and suffering. This is called “painful pleasure” or jouissance. In addition, the Real also produces objects of desire and is the source of desire. Therefore, the Real Order is like Freud’s Id: it is the instinctual desire and the boundary line of the subconscious. The Real Order is more than a “pre-symbolic” or “excessive” state which resists symbolization. It is linked to reality, but it is a kind of traumatic intrusion. “Trauma” means the shock and incomprehensible consequences which result. For example, the Wenchuan earthquake or the great Sichuan earthquake which occurred on May 12, 2008, in southwestern China, is an objective reality; but its connotations for individuals and society go far beyond the objective descriptions (no one would say that it is “just a reality”), and no definite meaning can be attached to it. It is the intrusion of reality. The Real sometimes exists within the symbolic order, but cannot be integrated in it. It is like a big stone or a barrier. It is a lesion that cannot be stitched. It is an “impossibility” to which no meaning can be attached. It inherently exists in the kernel of the Symbolic Order; it is the core of the symbolic trauma and disrupts the Symbolic Order, which therefore constantly desires to exclude or suppress it (Evans 1996). The way in which the Symbolic Order excludes or suppresses the Real is not to turn a blind eye to it. Instead, it seeks to “empiricize” this impossible crack. Once an unsymbolized thing is visualized, it becomes a terrible fantasy. That is to say, a fantasy is the projection of the real when we are unwilling to bear it. Žižek (1989) cited the Jews as an example to illustrate these relationships. The Jew who is often encountered in the real world is just like us. He may be a generous good neighbor or a penny-pinching neighbor; he may be our good friend or merely an acquaintance, or a rival who quarrels with us. The Jews in reality will be treated by us with symbolic interpersonal rules in the same way as we treat other people. There is nothing special. However, once a Jew or a group of Jews exhibits some kind of strangeness or otherness which is incomprehensible, undifferentiated and unrecognizable, we are confronting the Real Order. The Jews as the other, as the “Real” intrude in our symbolic life. Because they lack consistency in content and are like the mysterious unattainable X, the signifier “Jew” seems to lose its content and become meaningless without reference to any signified, to become a void signifier. This makes us deeply uneasy and afflicted. If people make bad choices and endow the Jews with terrible images—they are incarnations of evil, they enjoy mysterious power, they are organizing conspiracy and corrupting our lives, they steal our enjoyment and they subvert our economy, etc.—this is a fantasy of the Jewish otherness or alterity. It means the projection of our own pain, anxiety and fear onto the Jews, attributing the fault to the Jews. At this time, because we attribute the unknowable and fear from the real order to the Jews, we derive the jouissance of anger. This jouissance may lead to bad acts: discrimination, exclusion, suppression, attacks and so on. Therefore, the subject often tends to externalize causes and avoid desire in the real order. By externalizing causes,

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the subject no longer focuses on the trauma that he encounters. Instead, the trauma is represented as a simple external cause-effect relation (Žižek 1989). The subject is formed by the interaction of the three orders. Lacan’s psychoanalytic approach challenges Descartes’ various Enlightenment concepts of subjectivity that centered on the cogito. The Cartesian subject focuses on the role of the Symbolic Order, analyzing the subject and the society with visible scientific (empirical) methods. Lacan replaced the self-sufficient cogito with the split unconscious subject of desire. The subject is the lack (manque) of being or the vacuum in the Real Order. This lack is desire and the subject is the subject of desire. Therefore, the subject is no longer treated as a given and static state, but as a changing process or dynamic movement. For Lacan, the Cartesian conscious and whole subject is nothing more than a metaphysical fictional illusion. The subject is essentially nothing but the unconscious desire. He builds his identity in the split process. In the Imaginary Order, the subject identifies with the small other (his own image or others who resemble him) and splits into the self (the fragmented body experience) and the ideal I or ego (the imaginary body image of totality) with the (small) other (the image of oneself or the one who resembles oneself). The ego is no longer a Cartesian cognitive subject of thinking and being. It is the product of an unconscious split process and a fantasy born from the unconscious. In Lacan’s view, identification, be it imaginary or symbolic, is characterized by alienation. The subject as “lack of being” must seek identification with others than himself (the small other in the imaginary identification and the big Other in the symbolic identification) to satisfy the lack. However, the exterior other can never be identical with the subject itself; there is always an unbridgeable gap between the other/Other and the subject. As a result, the subject, through identification with the other/Other, always exists as an incomplete ego lacking being. That is to say, the identity of the subject can never fully represent the true being of the subject, and it is never possible to fill the lack. What’s more, the Real Order that is not integrated in the Symbolic always haunts and disrupts the Symbolic Order, reflecting the lack in the Symbolic. This explains why Lacan does not agree with the Enlightenment subject which focuses merely on the effect of the visible Symbolic Order. We may briefly summarize Lacan’s view of the subject in this way: He believes that the subject is always split and that it is a “split I” (or “split subject”) ($), the formation process of which can be summarized as follows: “subject with a lack of being” (S) → the small other image (a) → the big Other speech (A) → “split I” ($). First, the subject with a lack of being (S) indicates there is an emptiness, which is the baby’s primordial state that has not been imagined and symbolized. Next, in the Imaginary Order, the image of the small other (α) will take up the position of the subject with a lack of being. The other includes the mirror reflection that the baby sees in the mirror stage and the images of others with similarities as the baby grows. Then, in the Symbolic Order, the big Other (A) will replace the small other. The big Other as a product of the discursive construction of other people is a signifier chain of speech, social norms, language, etc. It will intrude on the subject with a lack of being, which results in the split subject ($). In this process, both the small other and the big Other seize the position of the subject, namely, something that is not me has

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occupied my position in advance, making me unconsciously identify with this other as myself. I agree with him and recognize this object as myself. Therefore, I am not here, but the other “he” is; that other “he” is the split subject. The pre-existence of otherness is a violent intrusion (Lacan 1977).

5.1.2 Discourse of the Master and Discourse of the University Lacan’s theory of “four discourses” put forward in his later work is his great contribution to the field of cultural sociology. After understanding the basic concepts of Lacan’s psychoanalysis, we need to speak further about two of Lacan’s four discourses (Discourse of the Master, Discourse of the University) which are related to the issues to be analyzed in this chapter (the other two are Discourse of the Analyst and Discourse of the Hysteric). The operational modes of these two discourses are suitable for explaining the planned economy in China and the market economy after the reform and opening up. In order to understand these two discourses, we need to first interpret these concepts in Lacan’s mental analysis. These concepts include S1 (Master Signifier), S2 (knowledge), $ (split subject), and α (the surplus-jouissance or object petit α). In fact, the ideological space is constituted by the multitude of “floating signifiers” (also empty signifiers), which emerge in time, though without agreed upon meaning, and naturally form a signifier chain or a knowledge chain. However, the free drift of signifiers can be halted by a certain nodal point or quilting point (point de capiton) and S1 (Master Signifier) so that the entire ideological space and the signifier group have a holistic meaning. Therefore, a certain nodal point and S1 as a signifier without signified can fill the position of the Other, quilting the floating elements, stopping their slide and fixing their meaning. In this way, a certain ideology is created (Žižek 1989: 87–89, 100–103). In a nutshell, S1, which represents a subject for all other signifiers, is like a symbol with a general and guiding meaning. It occupies the most important position. Examples include “God”, “leader”, “hero”, “freedom” and “equality”. Lacan turns S1 into a signifier with special values and a function by which the “essence of master” can be supported (Seminar XVII “The Other Side of Psychoanalysis”). Žižek regards the effect of the nodal point as Louis Althusser’s ideological “interpellation”. The nodal point is one through which the subject is “sewn” to the signifier and at the same time one which interpellates the individual into the subject by addressing it with the call of a certain master-signifier (Žižek 1989: 101). “Knowledge” (S2) refers to an institutionalized structure, including various instrumentalized and systematic social or cultural mechanisms built within a framework of rational rules. It differs from the Master’s Signifier: in traditional society, the power of the master (such as the king and the judge) came from and was rooted in the above-mentioned symbolic quilting of the master signifier (S1); the master’s power was dependent on the fissure between S1 and S2. This was because S1, which occupies the position of the Other, has the power to transmit all the symbolic meaning. But

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in modern society, knowledge (S2) has gradually replaced the master in traditional society through the construction of various systems, causing the society to operate in a more “rational” and scientific context (Žižek 1991: 235–236). When talking about the Imaginary Order in the previous section, we introduced the small other or petit object α (objet petit α or α) as the object of desire which we seek in the other. However, the meaning of the small other has been continuously developed and extended in Lacan’s theories, referring not merely to the baby’s imaginary image in the mirror stage. From 1963 onwards, the small other or objet petit α comes increasingly to acquire connotations of the real, although it never loses its imaginary status; in 1973 Lacan can still say that it is imaginary. From this point on, α denotes the object which can never be attained, which is really the CAUSE of desire rather than the object towards which desire tends; this is why Lacan now calls it ‘the objectcause’ of desire. Objet petit α is any object which sets desire in motion, especially the partial objects which define the drives. The drives do not seek to attain the objet petit α, but rather circle round it. Objet petit α is both the object of anxiety and the final irreducible reserve of libido (Evans 1996: 128–129). In the seminars of 1962–3 and 1964, objet petit α is defined as the leftover, the remainder (reste), the remnant left behind by the introduction of the Symbolic in the Real; it is a surplus meaning, and a surplus enjoyment (plus-de-jouir). Objet petit α is the excess of jouissance which has no ‘use value’, but persists for the mere sake of enjoyment (ibid.: 129). Therefore, it is necessary for us to sort out the meanings of the small other or objet petit α. It means that the subject makes his lack or emptiness concrete and transforms it into a treasure or agalma (a Greek term meaning glory that Lacan extracts from Plato’s Symposium) projected onto other people, and then seeks it from other people. It is something “in you but more than you”, namely the object I want to attain from you. To be more specific, it is not you but the treasure or agalma inside you that I want. Therefore, the object is not an ideal image of totality; it is a part-object and can be ordinary, indecent and vulgar, but I will try to elevate it to a sublime position (sublime to me). However, such concretization does not mean that objet petit α can be presented as something fixed and substantial. It just wraps up the lack or emptiness; it is still in essence an empty thing. Hence its characteristic: it is forever unattainable. With the above properties, objet petit α is no longer the object of desire; it has also become the cause of desire. The subject circles around it, becomes the focus of its life and repeats the same process over and over again. This forms compulsory repetition: to pursue it desperately and to approach it, but to give it up rather than to obtain it, then to repeat the process. In short, objet petit α is the object in subject. It packs up and hides the emptiness in the subject; it is the embodiment of emptiness, driving the subject to circle around it, enhancing the subject’s psychological energy, and eventually becoming the subject’s source of jouissance. Objet petit α is the remnant part which is not integrated in and left by the Symbolic in the Real; it is the causeobject of desire which always appears in the form of emptiness to be filled (Evans 1996). The split subject $ (le sujet clivé) mentioned in the previous section is also called the divided subject or the barred subject symbolized by the bar which strikes through the S. It is also “the effaced signifier, the lack of signifier, the void, an empty space

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in the signifier’s network” (Žižek 1989: 101), and the subject “out of joint” (Žižek 1993: 12). The primary reason for the lack of signifiers is that signifiers are not linked to any specific content and the subject can never be completely represented by any signifier (Žižek 1996: 5). Lacan focuses on how the subject is formed in the other/Other and how the subject’s identity is always established in the external world. He points out that without the system of otherness, it is impossible to form the ego, and that the ego is constructed in the relationship with the other/Other. The non-central ego implies the logic of otherness. It can be said that “I have him in me, and he has me in him”, “I” is based on “he”, and the ego is the other/Other at the root. Lacan de-centralizes the subject in the sense of psychological ontology, pointing out that the ego is no longer a self-sufficient subject that rationally controls the world, but the split subject with lack that is deeply immersed in, constructed and subverted by culture. The traditional metaphysical philosophy of “I think therefor I am” holds that the existence of ego is only a deceptive illusion. Therefore, Lacan’s concept of the split subject is actually a revision of the Cartesian subject, which expands Freud’s discussion on the split of psychotic subject to the subject in general and reveals the non-identity of the subject (Yang 2013: 227) It is worth noting that, in a broad sense, everyone is a split subject; but Lacan’s split subject is one in the philosophical sense. In this book, we will add a sociological meaning to the term when we discuss it under the operation of the capitalist discourse. Capitalism can be explored from both the production and consumption sides: on the production side, we will adopt Karl Marx’ s theory of “labor alienation” to illustrate that the split subject in contemporary society means “the labor-alienation subject”; on the consumption side we will adopt Žižek’s ideas of “cynical subject” (more on this in the following section) to carry out the analysis. The reason why these two perspectives on the split subject are adopted is that they can explicate the specific effects of capitalist production and consumption on the subject and generalize features of the split subject in the process of neoliberal globalization. Of course, in this book, the split subject is used more narrowly to refer to the split subject in a pathological sense— patients with mental disorders, more specifically patients with depression. Therefore, in order to explain more clearly the effects of the capitalist discourse on the subject, we divide the split subject into two subcategories—“normal split subject” (i.e. ordinary people) and “abnormal split subjects” (i.e. patients with depression). The former group is able to withstand the effects of the capitalist discourse and does not show morbid symptoms. Subjects of this group have a normal psychology to adjust their life and mental state, but the social structure has led to their increasingly fragmented or split self. On the contrary, subjects of the latter group cannot withstand the effect of the capitalist discourse and become patients. The distinction between “normal” and “abnormal” shows whether the subjects can still have normal psychological functions after being exposed to and affected by the capitalist discourse; but whether normal or abnormal, all subjects function within the operational framework of the contemporary capitalist discourse. In addition to the four different symbols or elements in the discourse structure, Lacan distinguishes four different positions of the symbols. The discourse structure of the four discourses is shown in Fig. 5.1.

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the agent

the other

truth

effect

Fig. 5.1 Four different positions of the discourse structure

The first position (the agent) is the addresser and the dominant position which defines the discourse and start the signifying operation. The second is the other, the addressee or object of the addresser’s speech. This position is not necessarily occupied by a person; an institutionalized system or ideological apparatus can occupy it as well. The third position is the “effect”, which is the result or the effect of the discourse of the speech. The bars represent barriers, resistance, cracks and nonrelationships. The fourth position is truth, the agent’s hidden motivation. It is this truth that triggers the agent’s speech and determines the effect of the speech (Yang 2013: 227).

5.1.2.1

Discourse of the Master

One of the four discourses is the discourse of the Master (as shown in Fig. 5.2). In this discourse, the Master (S1) is the decisive force. He occupies the position of the agent. He is the center of the whole discourse. He is in perfect condition since his desires can be fully satisfied. Opposite to the Master under the bar is the Slave, occupying the position of truth in the discourse structure mentioned above. The Master can usurp the objects he desires, but the slaves cannot (Lan 2011: 79). The Slave does the work, but the goods he produces belong to the Master. In this sense, the slave is left with a permanent defect, which means that the slave subject is a permanently castrated one. Lacan uses a $ (S with a vertical bar) to symbolize the Slave. A key question arises here—if there is no slave, then there is no product for the Master to enjoy. Thus there is an intermediary between the Master and the product; the Slave is the intermediary. Therefore, the Slave ($) is the key factor for the product. Although the owner acquires and enjoys the product, it is the Slave’s labor that makes the product possible and makes it possible for the Master to generate knowledge (S2). The final effect is to generate surplus jouissance or enjoyment (α). The horizontal bar between

S1

Fig. 5.2 Discourse of the master

S2

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political authority (S1)

education (S2)

passion/abstinence subject ($)

ideology (α)

Fig. 5.3 Discourse of the master in China’s planned economy era

the agent and the truth indicates that the agent cannot fully express its own truth and that the speech does not have a transparent meaning at all. When the subject speaks, it splits into a conscious statement subject (the agent) and an unconscious speech subject (truth) (Lan 2011: 79–81) (see Fig. 5.2). The discourse in China’s planned economy era operated like the discourse of the Master (as is shown in Fig. 5.3). The discourse at that time was generated by the charisma of the leader, the absolute value and identifiability of the master signifier. The image of Chairman Mao Tse-tung (also spelt Mao Zedong) represents the master signifier in the media and in people’s daily life and there is inevitably secret support from the split subject for the master. The split subject is the people (Yang 2013: 229). During this period, the revolutionary narrative formed a powerful superego, which guided the people to transform their primordial desires into emotional representations in line with the dominant grand discourse of the nation. Individuals had to assimilate themselves into the nation’s abstract emotional context. On the one hand, “archives” became a record of the work unit’s evaluations of the individual. The evaluations included his achievements, his penalties, his work performance (whether he worked according to the requirements of the superiors), colleagues’ comments and opinions of him, and his political and moral development. Such an archive was the key to the individual’s promotion, the allocation of housing and the distribution of other benefits. Such management internalized the moral order, and as a result the big Other made individuals manage themselves autonomously. On the other hand, the enthusiasm for production was reflected in the process of shaping every individual into a revolutionary subject to realize the ideal of socialist public ownership. The mainstream narrative of the ideal was the national rejuvenation to surpass the United Kingdom and catch up with the United States; this kindled people’s enormous enthusiasm to conform with the country for the construction and transformation. Under the impact of the powerful national superego, the subject was in a split state. In other words, people took sacrifice, dedication and abstinence as virtues of production, while their desire for consumption was strictly suppressed. This realized the discourse of the Master. The master signifier (the state or Chairman Mao Tse-tung) was the agent of revolutionary enthusiasm (S1), which was considered to be a key force for the development of modernity in China. The state promoted the spread of anti-bourgeoisie ideas and the study of Quotations from Chairman Mao Tse-tung (S2) to achieve the surplus jouissance (α) of abolishing the bourgeoisie, traditional culture, etc. The master signifier could operate this way because he was supported by

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a group of split subjects who were both industrious and highly abstinent. The revolutionary revelries of these split subjects could be regarded as the representations of their surplus jouissance (α) under the suppression of superego. In this way, the ideology, as the effect of the discourse of the Master (Žižek calls it the sublime object of ideology), echoed with the split subject and formed Lacan’s fantasy formula: $a. The formula takes into account the subject’s desire when he faces the ideology as object petit α. It can be said that ideology turns into the subject’s fantasy ideology in an enchanting way, so the subject can only be in a split or divided state (Yang 2013: 232–233) (see Fig. 5.3).

5.1.2.2

Discourse of the University

The second of the four discourses is the discourse of the University (see Fig. 5.4). A significant difference is that the dominant position is occupied by knowledge (savoir) (S2), rather than the agent. In the discourse of the Master, the slave obeyed the master’s command and toiled at the master’s command. However, in the new way of life in capitalist society, such a direct relationship between the master and the servant has ceased to exist. This does not mean that people have gained complete freedom. Lacan mentioned that the transference from the classic master to the modern new master (we can call this “new master” capitalist) is nothing but a change in the status of knowledge. When S2 occupies the dominant position of the agent, it changes more than the structure of the discourse. Most importantly, S2 replaces the agent’s explicit authority with an implicit, hidden power. Žižek pointed out that in capitalist society, the superficial rule has gradually given way to scientific knowledge that is regarded as fact. It is precisely because scientific knowledge is an objective fact that people have lost their discursive power to scientific knowledge. In the meantime, however, those who have mastered scientific knowledge gain the real power to run the government. In other words, the Lacanian discourse of the University is closely related to the idea of technocratic government in modern discourse. In this technocratic discourse, modern science has made a disenchantment of our world, and itself has become a type of the discourse of the University which penetrates into every corner of society and successfully legitimizes the whole society (Lan 2011: 83, 85) (see Fig. 5.4). After China’s reform and opening up, the discourse of the University occupied the dominant position in the social and cultural fields. Here, the university refers to a social system which includes the knowledge system and the science system. Placed in the contemporary context, the discourse of the University is the capitalist discourse.

S2 (knowledge)

α (objet petit)

S1 (master signifier)

$ (split subject)

Fig. 5.4 Discourse of the university

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Why is it the capitalist discourse? Because what it desires is a surplus value. The commodity in the capitalist economy is an extracted value from the laborer. It is rationalized and legitimized. In the discourse of the University, knowledge gains the disguised veil of self-sufficiency and appears to be detached from power, but this does not change its essence as a power discourse. Ultimately, it serves power. However, it is different from the discourse of the Master, in which knowledge serves power directly and knowledge is fundamentally knowledge about power. In the context of contemporary China, S2 in the position of the agent can be expressed as a capital and commercial system because it manipulates, to a large extent, the overall operation of today’s discourse (Yang 2013: 233–234).

5.2 Capitalist Discourse as Representation of the Discourse of the University 5.2.1 The Production Side of Capitalist Discourse The discourse of the University can be analyzed from the two sides of production and consumption. On the production side, the discourse structure can be represented as Fig. 5.5. As far as the university itself is concerned, it is of course the student who occupies the position of objet petit α. The student is in the position of the exploited and the source of surplus value pursued by the university apparatus. The relationship between knowledge and the student is no longer a relationship between knowledge and slaves. Instead, it is assumed that the student is existence with lack. It (the student can only be referred to as “it”) does not have the slave’s knowledge of “it is so”. On the contrary, it is the object knowledge calls for or questions. For example, in college, we often hear a voice urging us: “Keep on working hard”, “Work harder”, and “Know more”, etc. Instructions like these are the master signifier, whose function is to duplicate or reproduce knowledge, or to spark the student’s vigor to strive for knowledge and be content to remain as objet petit α. The student as the objet petit α indicates that “it” is only the desired object of knowledge and power, and that “it” is only a surplus value that knowledge and power go after. It also indicates “it”, like the laborer in the market, is exploited, joining the assembly line at the cost of being exploited (Wu 2011: 828–829).

capital/commercial system (S2) political authority (S1)

the laborer (α) labor alienation subject ($)

Fig. 5.5 Production side of China’s capitalist discourse after the reform and opening up

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In the discourse of the University, the objet petit α is the surplus value of knowledge or the surplus jouissance. That is to say, the student himself is not the one who enjoys the jouissance, and his jouissance is the enjoyment of the other. Although he occupies the position of jouissance, in reality he is just a semblance (semblant) of surplus jouissance: there is no way to establish an effective connection between knowledge and objet petit α. As a result, the effect of the discourse of the University is the labor-alienation subject. The subject appears to have acquired knowledge, but the discursive order of “tireless learning” from knowledge as the agent only makes him feel that the more he knows, the more ignorant he is, and that the more jouissance he gains from his tireless learning, the less he enjoys. In other words, in the discourse of the University, more is less. This also means that the relationship between the labor-alienation subject and the master signifier occupying the position of truth is a relation of impossibility (Wu 2011: 829). The labor-alienation subject can be seen as a split subject in the sociological sense, which captures the characteristics of the split subject in capitalist production. The capital-labor relation of capitalism has the feature of the Discourse of the University. Labor is the objet petit α, the exploited and the foundation for the accumulation of surplus value. The laborer himself does not enjoy the jouissance or the surplus value. Here we see an operating mechanism similar to that in the discourse of the University: The discursive order of “working hard and getting rich” from the knowledge agent gives the worker the sense that the more jouissance he obtains from his desire to make money by tireless hard work, the less he feels that he is enjoying. The more effort he puts into hard work, the less leisure and enjoyment he has. This is the same principle as in the discourse of the University: more is less. Such effect is actually the alienation of labor. The objet petit α (the laborer) eventually becomes a split labor-alienation subject. The more effort he makes, the less he gets, and the even greater effort he needs to make (Wu 2011: 829).

5.2.2 The Consumption Side of Capitalist Discourse The analysis is conducted from the production side, but there is also the consumption side. If the discourse of the University is applied to the consumption side, we can come to its structure as presented in Fig. 5.6. The capitalist system aims to form a hedonistic society through consumption. This hedonistic society is the result of the underlying logic of incorporating surplus

capital/commercial system (S2)

commodity (α)

political authority (S1)

cynic subject ($)

Fig. 5.6 Consumption side of China’s capitalist discourse after the reform and opening up

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jouissance into the capitalist structure. That is to say, capitalism interpellates the subjects as consumers, as subjects of desires, and it needs to retain the jouissance because the drive of capitalist reproduction is not only capital accumulation but also the surplus jouissance at a more fundamental level (Žižek 2006: 61). Capitalism can create all kinds of possible desired objects because new objects are manipulated under the logic of continuous capital accumulation. It has been able to create a variety of consumption possibilities according to each individual’s personal needs and demands. It is a flexible system which can constantly create new possibilities. It adopts the surplus jouissance as its key foundation. It is different from the discourse of the Master, where there are always obstacles and suppression that symbolize order. It can even be said that without obstacles or suppression there is no sense of jouissance. In the discourse of the Master, the surplus jouissance was not openly expressed. That is to say, before the capitalist society, the surplus jouissance occupying the position of the objet petit α had always been hidden behind a glamorous appearance. But the surplus jouissance in the discourse of the University is to remove the suppression of the symbolic and to obtain enjoyment. It is not a despicable remnant, but an object that we can desire, an object of desire that has been made public. Through this operation, the famous objet petit α created by the capitalist system is the commodity. Žižek elaborates its characteristics with the example of Coca-Cola, a successful commercial case of capitalist production: “The more Coke you drink, the thirstier you are” or “The more you possess it, the greater the lack” (Žižek 2000: 23–24). This is obviously also the general and fundamental characteristic of commodities in the capitalist society. In a capitalist society, objet petit α not only can be made explicit, but also counted according to the laws of universal knowledge. In the knowledge construction of capital, everything, including the objet petit α in the unspeakable pre-modern discourse, becomes measurable. The objet petit α can be measured by the quantitative value system. The original destructive surplus jouissance gains a new quantitative form and thus becomes linked with the surplus value. Lacan believes that once a higher level has been passed, surplus jouissance is no longer surplus jouissance but is inscribed simply as a value so as to be inscribed in or deduced from the totality of whatever it is that is accumulated. In traditional labor theory, jouissance is basically regarded as a waste and loss. However, in order to ensure the operation of capitalism, its new development is to incorporate this useless waste into the structure, just as Marx regards surplus value as the driving force of capitalism. “Surplus value is nothing else but the waste or lost that counts, and the value of which is constantly being added to or included in the mass of capital” (Zupanˇciˇc 2006: 170). In this case, there is a link between the surplus jouissance and the creation of wealth (MacCannell 2006: 203). In other words, the void resulting from the lack of objects can be filled by the desired objects that can be constantly created in the capitalist world. The objects are constantly changing: video games, amusement parks, plastic surgery, brand-name cars, LV handbags, luxury homes, etc. Such a wide variety of choices and high frequency of substitution make it difficult for the subject to pacify his disturbed heart, thus becoming less and less gratified.

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On the consumption side of the capitalist discourse, the effect of S2 (knowledge) on objet petit α is the split subject, which often appears in the form of cynicism. This cynical subject, like the labor-alienation subject, has a sociological sense as well. Let us first discuss how cynicism appears as a split subject. Cynics do not believe in ideals, ridicule and doubt any indulgence in hedonic pleasure, but have no feelings of uneasiness and anxiety. Their reasoning is not naive. They actually understand certain problems clearly and are aware of the falsity or semblance of things. They know that there are ideological masks which cover up facts and that there are particular interests hidden behind an ideological universality. They do not take the institutional order seriously and maintain a mocking distance from reality. They are quite aware of the distance between the ideological mask and the social reality, but nonetheless still insist upon the mask for the sake of power and find reasons to rationalize their reliance on the mask. In other words, they still do things that they think are false, or take a negative, alienated, and indifferent attitude (Žižek 1989: 29). Cynics turn their dissatisfaction with the existing order into a kind of “indifference of not refusing”, “sensibility of not resisting” and “acceptance of not acknowledging”. As long as they are not harmed, they pay attention to their own benefit without thinking of others. They take a cynical attitude towards the world. Žižek also argued that the model of cynical wisdom is to conceive of probity and integrity as a supreme form of dishonesty, and morals as a supreme form of profligacy, the truth as the most effective form of a lie (Žižek 1989: 29; Wu 2006). This cynicism is therefore a kind of perverted “negation of the negation” of the official ideology (Žižek 1989: 29–30). Modern cynics share many similarities with skeptics. The difference is that cynics believe that right or wrong does not matter, while skeptics believe that there is no distinction between right and wrong. Žižek believes that cynics share similarities with two psychotic symptoms. One is paranoia, the other fetishism (or commodity fetishism). The cynical subject has a paranoiac form, according to Žižek’s analysis of cynicism in the Western context. Paranoia involves a mechanism that excludes an element from the symbolic order, as if that element never existed. The excluded object is the Name-of-the-Father, the fundamental signifier, which confers identity on the subject and the symbolic father (such as law, morality, ethics, norms, etc.). When the Name-of-the-Father is excluded, it leaves a hole in the Symbolic Order. However, once the excluded Name-of-theFather appears in the Real Order, the subject cannot integrate this foreclosed signifier and collides with it, resulting in psychosis in the form of hallucinations or delusions (Evans 1996: 134, 64–65). When the subject excludes the Name-of-the-Father and fails to recognize the existence or functions of the symbolic Other, he fantasizes the existence of an Other; but this big Other exists in the Real Order, not in the Symbolic Order. It is “Other of the Other”. The cynical subject does not believe that the symbolic big Other exists and functions in a way similar to the paranoid. He displays cynical distrust of any public ideology while indulging without restraint in paranoiac fantasies about conspiracies, threats and excessive forms of enjoyment of the Other. “The distrust of the big Other (the order of symbolic fictions), the subject’s refusal to take it seriously, relies on the belief that there is an ‘Other of the Other’, that a secret, invisible and all-powerful

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agent actually ‘pulls the strings’ and runs the show: behind the visible public Power there is another obscene, invisible power structure” (Žižek 1999: 362). In fact, the “Other of the Other” is what Lacan called objet petit α (Zupanˇciˇc 2000: 38). In other words, the cynic’s fantasy is “stained” by objet petit α; it is the big Other returned to the Real Order after the subject has excluded the Other in the Symbolic. The cynical subject indulges in the jouissance of the objet petit α. To put it simply, the cynical subject likes to see everything in terms of conspiracy; he believes that there is always some hidden conspiracy, so he is addicted to paranoid (Wu 2006). The cynical subject does not believe in the Other, but indulges in a painful jouissance from the imagined repression of the Other. The authority of the big Other is lost and replaced by the fantasy of the cynical subject, who will try to fill the hole of the big Other and let it appear in the real. The big Other with specific superego images is filled by the superego in the Real.1 The superego in the Real is what Freud described as a mixture of sadistic jouissance and masochistic pain, a painful jouissance of sadism and masochism. This painful jouissance is the scaffolding where the superego operates. Here, we must further explain the way in which superego works. It is often at work in the domain of the law and supports the operation of the symbolic law, because penalties can only be executed or guaranteed by an obscene agent-instrument who can trigger the guilty sense. This can be explained from two aspects. Firstly, the law can perform its function only if it presupposes that there will be a perpetrator and that the perpetrator is instigated to have a guilty sense. This operation provides a space for the obscene agent-instrument (Žižek 1991: 234). That is to say, the law will not work without the repression from the superego. Moreover, the repression from the super-ego will incite the inner evil. If the law does not stipulate that it is illegal to steal, then the subject does not know what it means to steal. The rule as the symbolic order stipulates how theft is operated in the subject’s mind, which in turn triggers his idea of committing theft. It seems that there is an evil force in the subject’s mind, which unexpectedly turns the original legal goodwill into a force inciting the dark side of the human mind (Žižek 1991). Žižek’s insight is similar to the description of “sin” in the Seventh Chapter of the Epistle to the Romans in the New Testament. Secondly, even if the subject is innocent, the superego can make him feel guilty of the unknown crime he has committed, or even guiltier because he does not know what crime he has committed. The order from the superego to experience jouissance is imposed on the subject in the form of an abstract and uncertain guilt and thus hinders the subject’s identification with ideological interpellations and legal orders. However, in order to escape this unbearable superego predicament, the subject must identify with the law or the Symbolic Order. In this sense, the dark superego both obstructs and sustains the symbolic law (Žižek 1996). It’s just like a person having been restrained by the parents’ mandatory orders from childhood, and unable to obtain enjoyment or 1 At first glance, the superego

seems to be the foundation of self-discipline, but it is not that simple. It grows and gradually imposes bans and restrictions on the ego, regardless of the changes in the real situations. It loses flexibility and rationality in making judgements, becomes obsessed with certain principles and demands ruthlessly the restraint of the ego. In the end, it becomes an unreasonable authoritarian fond of imposing punishment.

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jouissance. Under this situation, one way to obtain jouissance is not to get rid of the restraint (to become an indulgent bad child), but to procure it under the impetus from the superego (to be a model child with higher self-discipline). Therefore, super-ego sustains the structure of the symbolic law. However, in the Western context, when the symbolic authority of the father collapses, the darkness of the symbolic law (the real) reveals its sly face and controls unreasonably the subject with the superego, the unconditional order from the real. It is precisely because the superego functions like a pair of invisible hands that the subject thinks that there is always a dark and secret power controlling human life (Žižek 1999: 349). Therefore, in the Western context, the cynical subject is skeptical of everything and imagines that there is a conspiracy behind everything. The reason is that when the symbolic authority collapses, the object petit α in the real fills the hole in the symbolic in the form of a superego that resembles the symbolic authority. The objet petit α (Other of the Other) lets the subject indulge in the painful jouissance of constantly questioning the big Other. It is precisely because the cynical subject indulges in the jouissance of constant ridicule, distrust and conspiracy that he is still “normal” and does not turn into a psychotic paranoid. Cynicism has a structure similar to fetishism. When talking about cynics, Žižek proposed a formula to describe the symptoms of fetishism (or commodity fetishism), that is, “I know… but still I am doing…”, meaning the subject knows very well how things really are, but he still acts as if he did not know. Žižek’s concept of ideological fantasy is the same as that of cynicism—both explain the psychological reasoning and the subject’s psychical defense mechanism (Žižek 1989: 28–30). The reason lies in that the objet petit α (the surplus jouissance) has played a role of filling the hole in the Symbolic. Fetishism is not limited to an inanimate object of desire. Any psychological mechanism that fills the hole in the Symbolic with substitutes can be called fetishism. Fetishists exhibit three main characteristic traits. First, the fetishist is a paradox. For Freud, fetishism is related to some psychological lack, which the subject tries to fill with substitutes. There are two types of lack. The first is the lack of the object of desire: the subject desires an object, but the object is not available. The second is the lack of a complete self: the subject feels that he has some defects and the ego is incomplete. Freud believes that the fetishist is characterized by both his acknowledgement of the lack and the use of substitutes to fill the lack. Such paradoxical attitudes coexist. It is a kind of compromise under strong conflict. All types of psychical defense mechanisms show a paradoxical feature—the subject does not simply “disavow” the lack; he acknowledges it by negation. In other words, he is not unaware of what he is doing nor of his problems. In fact, he knows the reality well. Fetishism is also a kind of psychical defense mechanism, but its operation is a bit different. It is manifested as “disavowal by recognition”. The fetishist seeks a substitute to fill the lack, indicating that he recognizes the lack. But because he immediately fills the lack with substitute, he hides and disavows the lack, making the lack invisible. For example, when someone replaces his dead daughter with a doll, it seems that he knows that his daughter is dead, but in fact, he is denying the death of his daughter. The fetishist clings to such a paradoxical mentality (Jiang 2014: 71–72).

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Second, the fetishist is a resilient realist. Žižek mentioned that the psychological compromise in fetishism is not just found in pathological cases, but also in the general public. He believes that fetishism works because it has a protective function, which can save people from suffering. The compromising function of fetishism diverts our focus to a fetish and enables us to sustain the cruel truth. Žižek revised the common view that fetishists are dreamers lost in their private worlds and they are impractical. In fact, the opposite is true. Žižek believes that fetishists are thoroughly “realists” since they are able to accept the way things effectively are and use the fetish to counter the full impact of reality (Žižek 2001: 14). Compared with the pains caused by other pathological phenomena, fetishists enjoy more pleasure (Johnston 2009: 94). For example, when the subject “represses” a loss, the repressed trauma returns to disturb him and makes him suffer; in the case of a fetish, on the contrary, the subject disavows the loss with a fetish, which consoles and gratifies him psychologically. Therefore, fetishists “deliberately and knowingly enjoy their symptoms” (Johnston 2009: 94; Jiang 2014: 71, 72). Third, the fetishist is a fantasy weaver who sustains the mainstream ideology. Psychopathological fetishism is to be cured by the therapist, but the fetishism demonstrated in the general public aims at an adaptation to social reality. Žižek asserts that everyone requires some sort of “fetish” in order to adhere to the norms and rules of a consensus reality. That is to say, in the contemporary world, fetishism is not an aberrant, deviant phenomenon but a virtually innate structural feature of social reality, a necessary technique for subjects to cope with reigning ideologies (Johnston 2009: 94–95). The subject has unknowingly adopted this psychical defense mechanism to let himself succumb to certain concepts. This is not to argue that fetishism as a proper adaptation to reality, but to point out the composition of contemporary cultural neurosis: fetishes allow the subject to avoid subjectivity and lack of being. It’s not that we don’t know that we are in the context of cultural neurosis, but that we don’t want to know. Therefore, the fetishist is a fantasy weaver. The “fantasy” here is not a personal imagination, but a symbolic order: a norm or ideology that is taken for granted and not examined. Žižek cites as an example the heroine from Nevil Shute’s World War II melodramatic novel Requiem for a Wren. The heroine survives her lover’s death without any visible traumas, she goes on with her life and is even able to talk rationally about the lover’s death—because she still has the dog that was the lover’s favored pet. When, sometime after, the dog is accidentally run over by a truck, she collapses and her entire world disintegrates… (Žižek 2001: 14). Similarly, a woman takes her children to maintain her fetish fantasy, avoiding the lack of her own being. Once the child is no longer a possession she can control, the castle of her ego will immediately collapse. Similar examples include divorced women who have lost their spiritual edifice, empty-nest mothers who cannot bear their loneliness, and single mothers who are highly dependent on their children (Jiang 2014: 72). In short, self-protection by means of fetish fantasies not only maintains the mainstream ideology, but also avoids the lack of being and the subjectivity of the split subject ($). It is precisely because we are afraid that we constantly cling to people and things that we can possess and take the fetish as a protective veil to fill in the lack. However, this protective veil can be easily lifted, and one day we have to face what

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we are shunning. In this sense, the cynic, like the fetishist, is a paradox, a resilient realist and a fantasy weaver who maintains mainstream ideology. They try to ease the pressure from the symbolic order and hide the inner lack. They know the way things are but still act as if they didn’t know. Why is this? Žižek further analyzes this issue. Marx believed that the subject with a “false consciousness” could throw away his distorting spectacles of ideology once he saw things as they really were. However, Žižek believes that Marx’s concept of “false consciousness” has become more and more unsuitable for the contemporary world, because cynicism has become universal. He states that the formula of cynicism is no longer the classic Marxian “they don’t know it, but they are doing it” (Sie wissen das nicht, aber sie tun es); it is “they know very well what they are doing, yet they are doing it (Žižek 1994: 8). Cynicism renders impossible the classic critical-ideological procedure. The cynical subject is quite aware of the gap between the ideological mask and social reality, but he nonetheless still insists upon the mask. Cynical reasoning is no longer naive, but rather the paradox of an enlightened false consciousness: one knows the falsehood very well, one is well aware of a particular interest hidden behind an ideological universality and of the distance between the ideological mask and social reality, but still one finds excuses to retain the mask. Such cynical wisdom conceives the truth as the most effective form of a lie, morality as a supreme form of profligacy, and probity and integrity as a supreme form of dishonesty (Žižek 1989: 29). It is clear, therefore, that confronted with such cynical reasoning, the traditional critique of ideology no longer works. In Žižek’s view, cynics are fetishists in practice, not in theory: they know that in their social activity they pursue the fetishistic illusion, but they still do it (Žižek 1989: 28). Žižek believes that this logic of cynicism originates from the late bourgeois society with “‘pathological narcissism’, constituted of individuals who take part in the social game externally, without ‘internal identification’—they ‘wear social masks’, ‘play (their) roles’, ‘not taking them seriously’: the basic aim of the ‘social game’ is to deceive the other, to exploit his naivety and credulity;… the whole aim of the mask is ‘to make an impression on the other’” (Žižek 1991: 251). For Žižek, cynicism is by no means an occasional phenomenon; nor is it only embodied in certain social groups and events. On the contrary, cynicism is the product of the nature of the entire society or the era. In other words, a majority of contemporary social groups are more or less practicing cynicism because of the influence of certain features of this era. They believe that the illusionary symbolic order has no effect. They only believe in the jouissance from the fetish (money, power, social influence, nationalism, etc.). A cynical subject does not believe in any ideal, ridicules and doubts any devotion and indulges in jouissance, without becoming agitated and anxious. This is because he still believes in the truth of jouissance—because he has something to rely on (Wu 2006). Moreover, the logic of cynicism is not to make a minority of cynic individuals stop being self-critical, but to make the majority of individuals uncritical. As a result, social freedom, criticism and changes are unavoidably harmed, and the universality and severity of cynicism, a negative phenomenon, is eventually revealed. The universality

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of cynical subjects consolidates the operation of the capitalist discourse. However, cynicism in China demonstrates different features from that in the West. In summary, the Discourse of the University is actually the discourse of the capitalist. It entails both production and consumption, both of which lead to the split subject. On the production side, the effect is the labor-alienation subject, while on the consumption side, the effect is the cynical subject. To have a deeper understanding of the effect of the capitalist discourse, namely, the split subject, we will sort out the different features in the West and in China in the following sections.

5.3 Split Subject of Capitalist Discourse: “the Labor-Alienation Subject Without False Consciousness” and “the Cynic Subject” in the West In the capitalist discourse of neoliberal globalization, the labor-alienation subject on the production side and the cynical subject on the consumption side in Western societies are different from their counterparts in China. On the production side, Western societies have developed relatively sound systems for labor rights, workers’ movements, social welfare and commodity exchanges. Therefore, labor alienation has been the result of the reaction to the structural commonality of problems like wage stagnation, the prevalence of short-term workers, high unemployment, and pressure for industrial transformation and innovation in neoliberal globalization. Most individuals are no longer in the state of “false consciousness” Marx proposed. In this sense, the labor-alienation subject under the impact of the neoliberal globalization in the West is one without “false consciousness”, which emerges in the uncertainties like short-term jobs, frequent unemployment, and cross-border capital and labor flows. The key point is that although “false consciousness” has been exposed, the cynicism of “knowing what it is, but still doing it” has replaced the traditional “laboralienated subject not knowing false consciousness”. For example, individuals in Western societies are aware of the fact that their companies exploit overseas workers and destroy the environment in other countries, but they choose to remain silent because they benefit from the third world’s cheap yet high-quality goods. Their connivance with the capitalists of their own countries promotes the formation of the labor-alienation subject in the third world and reveals their cynical attitude. In addition, on the consumption side, it is a commonplace that Western commodification is accompanied by ridicule, complaint or cynical criticism. Ideas of emancipation and anti-oppression are pervasive in all aspects of life. These factors are actually shaping the personalities of contemporary Westerners and provide a potential basis for depression. The advancement of Western developed countries provokes in individuals the symptoms of the “post-Oedipus complex” so that depression becomes increasingly universal. The “post-Oedipus complex” means that the decline of the symbolic

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paternal or patriarchal authority damages the subject’s fundamental mode of subjectivity (the subject recognizes and accepts the authority of the enlightened rational big Other, being able to reason and reflect freely, to select his set of norms, and so on) (Wu 2006: 245). In contemporary Western society, what is affected is “not simply Tradition or some other reliable symbolic frame of reference, the functioning of the Symbolic Order is also potentially undermined” (Žižek 1999: 342). The contemporary risk society is characterized by “the subject’s non-reflected acceptance of the Symbolic Order” (ibid.). It is worth noting that the “post-Oedipal subjectivity” resulting from the decline of paternal authority generates more uneasiness and anxiety than pleasure in the fluid multiple identities and triggers demand for various new forms of strictly regulated domination and submission (Wu 2006: 245). Western “post-Oedipal subjectivity” demonstrates four characteristics. First, contemporary capitalism is constantly evolving and innovating in order to promote the development of new technologies and new products, to accelerate the replacement of obsolete goods, to increase profits, to accelerate capital turnover, etc. For instance, mobile phones, software, trendy products, fashionwear, advertising, etc. witness non-stop innovation. Therefore, contemporary capitalism develops a form of coercive innovation (Huang 2003: 37–38). The problems resulting from such coercive capitalist innovation confronting the subject who seeks innovations and changes are intensified in the context of the neoliberal globalization. However, it is difficult for the subject to disobey the injunction to “enjoy seeking innovations and changes”, which leads to frantic and meaningless changes in appearance, costumes and masks. In this sense, how to deal with the ego is the predicament for the post-Oedipal subject. Second, western societies have entered the era of value relativism. Everyone is endowed with the right to assert their own views and to respect the opinions of others, but there are no unanimous norms—if one tries to manipulate people with different points of view with unitary norms, he will be criticized as hegemonic. In the postmodern era, Western societies demonstrate a strong spiritual narcissism (represented by void of meaning, dissolution of values, absence of beliefs, multiplicity of choices, etc.), and a strong social “fashioning” (represented by lax control, commercialization, etc.). Post-modernity in western societies is embodied in the deconstruction of the subject, the fading of rationality, the void or emptiness of meaning, and the undermining of responsibility. Individuals take non-belief as their belief, refusing missions as their mission and meaninglessness as the substitute for meaning. Traditional social virtues and political ideals are increasingly ignored, and capitalist production becomes irresistible. Greatness is ridiculed, while vulgarity becomes popular; democracy is no longer a political concern, being applied merely to the free choices of fashion. Western societies, as (pro forma) “liberal” societies, govern with persuasive discourse and the consent of freedom. Individuals enjoy the freedom to criticize everything. In these societies, there is less hierarchy, less repression, less severe regulation. Individuals enjoy free and equal social relations and can become “the real self” to achieve the self-actualization. But once the subject is “the real self” with excessive self-centeredness, he will lose the symbolic framework where the symbolic order takes effect, thus leaving a void. In the post-modern era characterized by a plurality of values, lack of hegemony, and the commercialization

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of sarcasm, individuals no longer identify with the symbolic paternal authority that had a universal standard in the past; the subject, in order to fill the void, is trapped in an unstable state of constant change and constant personalization. The extreme individualization in this context leads to “the ultimate identity crisis: subjects experience themselves as radically unsure, with no ‘proper face’, changing from one imposed mask to another” (Žižek 1999: 373), since the subject is not constrained by the symbolic patriarchal authority. “What is behind the mask is ultimately nothing, a horrifying void they are frantically trying to fill in with their compulsive activity or by shifting between more and more idiosyncratic hobbies or ways of dressing” (ibid.). This has become an issue of subjectivity in post-Oedipal societies. Third, the dark side of the symbolic law (i.e. the Real) follows the decline of the symbolic paternal authority and reveals its ugly face, namely, the super-ego, the unconditional order or injunction from the Real. The superego is like an invisible hand and the suspension of the feature of symbolic identification gives rise to “the superego figure of the omnipotent Evil Genius who controls our lives” (Žižek 1999: 349). To this end, once the superego injunction to enjoy accomplishes its task successfully, what the subject gets is not satisfaction and pleasure, but painful jouissance, anxiety and feelings of guilt and haunting failure (Žižek 1999: 366–367). In the post-modern era characterized by plural values and lack of hegemony, individuals no longer identify with the symbolic paternal authority which had unitary norms in the past (e.g. unitary social values or authoritative government). Instead, they are subjugated by the post-Oedipal subjectivity of the superego injunction. What is brought about by the symbolic law, which transgresses the pleasure principle, is not freedom, but a ruder, constantly proliferating and ubiquitous superego injunction. Under the threat of the superego, the subject is forced to reshape his identity with jouissance and in a meaningless and irrational way (ibid.). In other words, the disintegration of the patriarchal symbolic authority, of the Name-of-the-Father, gives rises to a new figure of the Master, who is no longer the dominator in the symbolic order, but is transformed into an imaginary ideal. Then, with the collapse of the symbolic, the imaginary order disintegrates and overlaps with the real (Wu 2006: 245). The dark side of the real haunts the subject, who suffers with jouissance endless void and anxiety. Fourth, in the past social relation of “oppressing-oppressed”, Western societies were dominated by a culture of oppression or resistance. However, it is now difficult to find a clear “oppressing-oppressed” social relation. What is common is “postoppression” or “post-identification”. “Post-identification” means that the structure of identification (ego-ego Ideal) still remains, but what fills the void is no longer an authoritarian figure or value, but the obverse. It is widely believed that oppression no longer comes from a single source and that it should be interpreted in multifaceted power relationships (i.e. the sources of the oppression on “me” are more diversified and more blurred as well). However, this reveals a more fundamental problem: When I keep asking questions about oppression, I want to reserve a position of failed authority for myself (“I” am willing to create oppression). The post-Oedipal subject expects a failed Name-of the-Father so that he can continue to complain and see himself as a victim. Specifically, in this era of declining authority, what emerges in Western societies is a culture of complaint or a culture of victims. The post-Oedipal

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subject blames the Other for its failure and/or impotence, as if the Other is guilty of its inefficiency. The post-Oedipal era falls into a perverted worship of patriarchal authority. Individuals, like paranoids, insist on discovering a symbolic father who is full of lies, the Name-of-the-Father, who is incapable of accomplishing the mission of a symbolic agent. The obsession with the failure of patriarchal authority means that individuals constantly seek a Name-of-the-Father to be humiliated. This makes individuals attentive to certain information and tokens, which can display a muddleheaded, weak and impotent Name-of-the-Father. Moreover, individuals know well that even if such a Name-of-the-Father is under constant criticism, his potency as the symbolic agent cannot be activated. But individuals still do this with pleasure, trying to highlight how the Name-of-the-Father fails. In contemporary Western democratic societies, individuals are obsessed with finding bad and impotent leaders to shape a “symbolic father to be humiliated” via television, the Internet and other media. The logic behind this comes from considerations of commercial interests or audience ratings. It is because of this logic that individuals create such a failed Nameof-the-Father as the agent to be humiliated. In fact, an intention is hidden behind individuals’ rebellion or challenge to the paternal authority: to find a new paternal authority, a “real Name-of-the-Father” who can fulfill his role as the symbolic agent, or more possibly, to proceed toward this “new paternal authority”. Once individuals adopt such a psychological mechanism, the Name-of-the-Father is no longer the Ego Ideal but the “Ideal Ego”, the intrinsic imagined competitor, which leads to the reemergence of a ferocious superego to fill in the lack of symbolic prohibition. When symbolic prohibitive rules are increasingly replaced by imaginary ideals, it is obvious that individuals do not rid themselves of the Name-of-the-Father but rather compete with and imitate him in the opposite direction. The obsession with the failure of patriarchal authority is a variation of phallic centralism. Eventually, individuals are still pursuing and recognizing the paternal authority and the phallic power, thus forming a perverted worship of patriarchal authority. A post-identification mental state that magnifies and universalizes oppression will naturally lead the subject to be hostile to and dissatisfied with the world around him because the more the subject blames the Other, the more narcissistic his own structure is. This provides a potential social structure for depression. In other words, “sentimental groans and sighs” or “moaning without illness” are particularly prominent in post-identification—excessive narcissism resulting from the lack of paternal authority renders individuals insecure even in enjoyable environments, and they will proceed to find the object that oppresses him. This also accounts for the prevalence of sentimental groans and sighs in Western societies. From the above-mentioned characteristics of the Western post-Oedipal subject, we know that the split subject in the Western capitalist discourse is a more narcissistic personality, because he has constructed a relatively complete capitalist system and the western labor system has established settled norms. However, contemporary capitalism has a nature of coercive innovation on the production side. Such a nature is also due to the increasing demand for new changes and the fast rate of replacing commodities in a consumer society. These have created a frantic atmosphere. Political freedom and highly developed capitalism have promoted the popularity of mocking

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or critical TV programs and the development of mass media and commodities. Value relativism disintegrates the ultimate absolute authority of values and the decline of the symbolic paternal authority causes the superego to emerge from the Real Order to fill in the lack of the symbolic father; but the result is the subject’s endless emptiness. The subject tends to seek an oppressive object to replace the original symbolic father, which can lead to sentimental groans and sighs. In this way, the capitalist discourse provides a social structure for the occurrence of depression.

5.4 Split Subject of Capitalist Discourse: “the Labor-Alienation Subject not Knowing False Consciousness” and “the Cynical Subject” in China Due to the market mechanism after the reform and opening up, China has also experienced the effect of the capitalist discourse, namely the split subject, both on the production side and the consumption side. On the production side, it witnessed the emergence of the labor-alienation subject, while on the consumption side, it saw manifestations of the cynical subject. As far as production is concerned, before the reform and opening up, the dominant mechanism was public distribution rather than the market. At that time, people were generally poor and the gap between the rich and the poor was small. Workers did not have a strong sense of being exploited, or their sense of being exploited was not as strong as after the reform and opening up. They had a relatively weak sense of being deprived. However, after the reform and opening up, China boarded the train of neoliberal globalization and gradually stepped into its role as the world factory in the global system. The national strategy was to prioritize economic development rather than frame social policies. Accordingly, the central government has adopted a model that encourages governments at various levels to promote GDP growth in a competitive way. Under this economic structure, on the one hand, capital or management has derived excessive benefits. Particularly, foreign-funded enterprises with bright prospects have been granted more privileges and state-owned enterprises have also enjoyed certain privileges. The accumulation of capital in these enterprises has been achieved by extracting it from workers’ or labor’s interests. On the other hand, the country lacks a sound labor system and a sound social welfare system. Workers cannot effectively negotiate their demands with management, and the gap between the rich and the poor has widened. All these factors lead to the exploitation of the capitalist discourse on the objet petit α, the laborer. The capitalist discourse imposes on the laborer the injunction of “getting rich through hard work” and “striving to be better” from knowledge, the agent. The effect is especially obvious on the older generation of migrant workers: the more pleasure they procure from their desire to earn more by hard work, the less they enjoy; and the more hard-working they are, the less leisure and enjoyment they get. This also reveals the principle of “more is less” in the discourse of the University: the more workers strive, the less they get

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and the more they need to strive. There are laborers who do not recognize the nature of exploitation in the process of reform and opening up, and these laborers constitute the labor-alienation subject of false consciousness mentioned by Karl Marx. The exploitation by management is effective due to their unawareness. And this unawareness is one of the factors consolidating the operation of the Chinese socialist market economy. As a result, workers in China have become labor-alienation subjects with false consciousness, which is different from the enlightened labor-alienation subject without false consciousness in the West. The labor-alienation subject in China is the subject who does not recognize and is unaware of false consciousness. The government has seen the problems and tried to improve the labor system by amending the relevant laws, but it still relies on indirect taxes,2 which protect the interests of capital and the rich, and it lacks effective supervising mechanism for public finances. As a result, the exploitation and the income inequality indicated by the high Gini coefficient have not improved much. Public expenditure is mainly for infrastructure construction needed for economic growth and less for improving social welfare. In this sense, China’s fiscal system favors capital in terms of both tax revenue and expenditure (Zhang and Gao 2014). Because of this practice of favoring capital and less the protection of the individuals, China has, on the one hand, been able to achieve fast economic growth that other countries cannot match, but on the other hand, social inequality has become severe. Meanwhile, the changes in the income structure brought about by the fiscal system which protects capital have led to the formation of new interest groups, whose growth has made it very difficult to readjust the policy paradigm. The classes which have suffered (such as employees of state-owned enterprises, whose interests have been seriously damaged and farmers whose land has been expropriated without reasonable compensation) lack channels to express their interests in the political system. Such a lack causes the political tension generated under the fiscal system to lack legal channels for its effective release. This is actually the fundamental cause for the increasing number of mass incidents and individual violence in recent years (Zhang and Gao 2014). This shows that more and more labor-alienation subjects have been created by the 2 An indirect tax is a tax levied by the government on the purchase goods or services. Its feature is that

it can be transferred or shifted to a third party. When the government levies taxes on manufacturers or suppliers, they can raise the price of the products and thus shift the taxes to the consumers. An indirect tax can be applied to almost all goods and services and so has a large number of taxpayers and rich tax sources: regardless of the costs and the profits, as long as there is an exchange of goods or services, an indirect tax is levied. By contrast, a direct tax is levied upon personal income or property. Compared with the indirect taxes imposed on goods or services, a direct tax has the following advantages. First, the taxpayer cannot transfer the tax burden to someone else. Second, the government can apply a progressive tax rate, which varies according to the amount of personal income and property. The progressive rate gives flexibility for the levying of taxes and so can, to some extent, automatically adjust and compensate for income and property differences among individuals. Third, an income tax is levied according to the living conditions of the taxpayer and his or her family; various deduction systems and negative income tax systems have been established to ensure basic living needs. In this sense, a direct tax is in line with the equality principle and the ability-to-pay principle in the modern taxation system and thus performs a special regulatory function in the redistribution of social wealth and in the maintenance of social security (Ma 2007).

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government’s policies in favor of capital. However, workers’ awareness that they are exploited has led to more and more actions to protect rights and the increasing consciousness of resistance. Chinese workers have gradually changed from “laboralienation subjects not knowing false consciousness” to “labor-alienation subjects without false consciousness”. The social security system is not perfect, so neoliberal globalization and China’s strategy of prioritizing economic development inevitably leads to labor alienation on the production side. Even if individuals gradually develop into “labor-alienation subjects without false consciousness”, the lack of balancing social forces will make labor alienation a structural problem. On the consumption side, social control before the reform and opening-up was stricter and more effective. The socialist social order was proclaimed as the most reasonable and beautiful and the vast majority of people were forced but willing to believe that. At that time, the public was constantly stimulated by political movements and kept in a highly motivated state, forming the masses, more precisely, “the revolutionary masses”. In other words, the masses focused their attention on revolutionary enthusiasm, and the lack in their innermost heart was filled by ideological interpellation. Moreover, because the dominant mechanism for consumption during this period was distribution and there was no capitalist environment for people to consume at will, the cynical mentality was rarely seen. Basically, there were very few cynics. However, the commercialization after the reform and opening up has provided space for the formation of another type of split subject, namely, the cynical subject. People have been given a space to express their opinions because of the diversification of commodities. Political control is not as strict as in the past, but there is still a gap between traditional and real socialist ideologies. Besides, the system is not yet perfect and many problems still exist. People are dissatisfied but enjoy more freedom of choice under the commercialized structure. Because of this, space is created for people to express their complaints and mockery. But people cannot be too rebellious and are unable to change reality, thus creating the paradoxical subject who is righteous in public while being extremely cynical in private. “Saying one thing but doing the opposite” has become the basic feature of today’s cynical culture in China. It has become a self-protection and survival skill for contemporary Chinese as well as an unwritten code for fraudulent, hypocritical and corrupt behavior. In addition, cynics actually see through many things but inevitably display the following mentalities: being worldly-wise and playing safe, the less trouble the better, being practical, benefits come first, and telling people what they want to hear. Such “old-fox wisdom” is the same as Peter Sloterdijk’s comment that they know what they are doing with a downright shocking clarity, but they still do it (Sloterdijk 1987). The cynical subject is indeed a resilient realist. Therefore, it can be said that cynicism has become the typical mentality of contemporary Chinese and a common reaction to reality. The reasons, as mentioned above, are that people are dissatisfied with society and to some extent can see the hidden reality; that the state still functions as the symbolic patriarch authority, and that individuals can do nothing to make any change, they are unwilling to resist, only turning their dissatisfaction with reality into a non-refusing understanding, a non-resistant soberness, and an unrecognized acceptance. Therefore, “rejecting the

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sublime”, “waving farewell to ideals” and “living in the present moment” has become the common rhetoric and behavior of contemporary cynics. Cynicism is ubiquitous, especially in contemporary society with highly advanced information technology. Therefore, on the one hand, China has gradually become a narcissistic society after the reform and opening up because people have more choices in consumption and can temporarily relieve dissatisfaction with the pleasure of consuming commodities. On the other hand, cynicism resulting from the public’s repressed moral consciousness can be seen as the public’s helpless dissatisfaction and a protest against modern political utilitarian ethics. It also displays the public’s independent self-awareness (Xu 2015a). In an interview with People, a Chinese monthly magazine run by People’s Publishing House, Ben Xu, professor of English at St. Mary’s College of California, pointed out that “cynicism” is a very important concept in the analysis of contemporary China. It is important because a social and cultural concept is necessary for a comprehensive and integrated analysis of the social ills of contemporary China. In September 2014, the People’s Tribune Questionnaire Center published “A Report of Social Ills in Contemporary China”, which was reprinted by many online media. Nine of the 13 listed social ills can be said to be cynical symptoms. Therefore, it is quite appropriate to use the term to describe and analyze China’s social ills. The cynic symptoms mentioned in this report are as follows: i. ii.

amused to death (no goals or beliefs and drifting along in life); bystander mentality (seeing through the phenomenon, being indifferent, spectatorship, not bothering about other people’s business as it is useless to do so); iii. habitual suspicion (distrust of everyone, including the government and friends); iv. appreciation for the ugly (in an environment where there is no distinction between right and wrong, between beauty and ugliness, between good and evil, between truth and falsehood, why should we believe in beauty, virtue and truth?); v. ostrich mentality (the less trouble the better; the publicized reality is false, so it’s better to hide in an attic); vi. fear of thinking (many precedents show that the more I say, the more trouble I will get into, therefore I will say as you wish or demand—that is the golden means for survival); vii. ostentatious display of wealth (after seeing through the semblance of morals, ideals and aspirations, I realize that only money is real and that money is the only thing people value); viii. early aging (no future or pursuit; muddling along with no thought of tomorrow); ix. masochism or self-abuse (Professor Ben Xu believes that this statement is not accurate, because many people’s hatred of the system is an alternative rhetoric for their contempt and distrust of authority, rather than self-abuse. However, such equivocating rhetoric, which is neither honest nor true, is cynical in its own right) (Xu 2015b). These listed social ills generalize the characteristics of contemporary Chinese in the eyes of ordinary people as being cynical and acid-tongued, seeing through

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everything but not disclosing the truth, lying through their teeth, being shameless in pretending to be noble, complying in appearance but opposing in heart, drifting with the tide, believing that ignorance is bliss, holding that whoever suckles me is my mother, wearing masks and taking life as a play, stopping at nothing, playing a double game, etc. These characteristics can be regarded as the manifestations of cynicism (Xu 2015b). When these different manifestations are integrated sociologically into the term cynicism, it becomes a concept with deeper, more complicated and more complete connotations. In addition, these social ills are interconnected and can be converted into one another, so it is difficult to imagine that these ills can be cured separately when the overall institutional environment and social culture are not changed. Therefore, it is more feasible to ask: what is the illness of the whole institutional environment and social culture? If so many ills are present in the same society at the same historical stage, then what concept can sum up and integrate the ills to make them intrinsically linked? This concept should be a social and cultural one, which can generalize the phenomenal ills and penetrate into the universality and depth of the social problems. Cynicism is such a social and cultural concept. Although it may not be the only possible concept, so far it is the best one. Its function as the proper concept does not come from its definitions in a dictionary or an encyclopedia, but from the rich observations, analyses and elaborations of our predecessors and contemporaries who have contributed to the study of cynicism (ibid.). Cynicism in China after the reform and opening up has actually consolidated its capitalist development because characteristic behaviors like saving one’s own hide and securing one’s own survival, grumbling while being frustrated lead to the individual’s criticism and complaints about the society, but are not conducive to social changes. Cynical subjects taunt and criticize society and accumulate their dissatisfaction in private, but they indulge in illusions or fantasies and the surplus pleasure from their criticism and mockery, and so they are unable to reform the society. Cynicism is gradually universalized because individuals, who are under the pressure of overwork on the production side and whose desires for consumption are aroused, take on such psychological adjustments and defense mechanisms to deal with their dissatisfaction with the social reality. If they didn’t try to relieve their dissatisfaction with a teasing and sarcastic attitude, life would be sadder and more divided. The cynical attitude, as a realistic way to adapt to reality, can help individuals avoid being excessively anxious when confronting the gap between reality and the ideal. In fact, most individuals are well aware of the social ills, but because the symbolic paternal authority is still there, they adopt a teasing, mocking and cynical attitude to bridge the gap between reality and the ideal and enjoy and indulge themselves in taking such an attitude so as to ease their dissatisfaction. In the period of the planned economy, China was characterized by its statecontrolled “production-demand” system and the government played the role of the symbolic paternal authority. However, after the reform and opening up, the system has gradually evolved into the “consumption-desire” system, which is seemingly more liberated and multi-structural but still state-dominated. The authority of the state as the symbolic father remains the same, but the practice has been adjusted. Under this system, individuals’ desire to consume has been intensified, resulting in

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a large number of “material-manics” and “fetishists”. In such a context, many individuals do not think that they are “being blinded” (the object to be enlightened in traditional Enlightenment rationalism) but believe that they are completely “sober”. They don’t need enlightenment, they achieve self-enlightenment in attaining the jouissance. In other words, they can behave in this way because commercialization provides them with some kind of pleasure. The first example is people’s preference for parody or spoof programs. They clearly know that some TV entertainment parodies or spoofs are vulgar but they still like watching them. These programs or videos are the products of the “vulgarization” and “sensualization” of human desires. The folk “Doulezi culture” (逗乐子文化, the folk way to make people laugh and have fun) has accordingly lost its aesthetic value in acquiring high culture; such a transfer from the aesthetic subject to the jouisssance subject demonstrates a kind of “antiaesthetic pleasure” dominated by a hidden “fetishistic” desire. Another example are the online buzzwords or expressions, which reflect to a certain extent the public’s mentality, ways of thinking and value orientations. Some of the trendy expressions are “Da jiangyou” (打酱油, meaning have no concern for public issues, “this is none of my business” or “this is controlled by authorities and I cannot comment on it”), “Gods and horses3 are floating clouds” (神马都是浮云, meaning nothing is worth mentioning; there is a sense of complaint), the “Diaosi” (屌丝, happy losers, young people of low social status and mediocre life quality, who are dissatisfied with a boring life but accept the status quo, unrecognized by society and eager to maintain their self-esteem without knowing how, holding aspirations but no clear goals, lazy and lifeless and losers in the eyes of some people), “Tuhao (土豪, vulgar tycoons), let’s be friends”, etc. These expressions reflect the public’s lack of faith, their indifference, mockery, suspicion and fury towards society, and their helplessness in changing reality (Li 2014). However, these expressions also reveal an acceptance or connivance in society for ineffectual public criticism. Such an atmosphere has been created with the prevalence of commercialization and the Internet. It is evident that the capitalist discourse in China promotes the essential features of social cynicism: on the one hand, it highlights that the problem of anomie in this transformation period brings with it a crisis of trust; on the other hand, it also shows that the spread of consumerism results in a lack of faith (ibid.). In addition, a majority of individuals are well aware of the unfair distribution of wealth and the polarization between rich and poor and between urban and rural areas, and they have discovered the lies of the discourse system. However, they feel that silence and detachment are more real and important than the system itself. These phenomena are particularly related to the prevalence of various “post-” discourses in China after the 1990s. The collective ideology behind various “postisms” is actually a collective aspiration to “transcend” a traumatic history. The experience of trauma and repression is replaced by a new “fetishism” (narcissism, indulgence in sensual pleasure, temptations from commercialization, etc.), and the specter 3 Translator’s note: The Chinese characters for God and horse are pronounced as “Shen” and “Ma”.

Together they and “Shen me” (meaning everything) have a homophonic effect. The whole sentence literally means “everything is a floating cloud”.

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of history is “deconstructed” by the subject’s desires. This narrative with a wish to break from the past is in fact consistent with the nation’s historical narrative: the late 1970s and early 1980s were the beginning of “modern” China, and 1990s the “post-modern” China, because the economic transformation and the multiplication of material goods in this decade resulted in fetishism. These two decades contrast with the era under Chairman Mao Zedong’s rule. In the reform and opening up period with Chairman Deng Xiaoping as the core leader, the “modern” made its fabulous appearance—the previous historical experience was gradually hollowed out, replaced, suppressed, and “sublimated” in the catalysis of painful memory; everything started anew with the belief of “crossing the river by feeling the way over the stones”; people were encouraged to move forwardly bravely to create a highly productive socialist market economy with Chinese characteristics. This attitude of discarding the past actually derived from the deep traumatic memory of the collective consciousness. China was a relatively open society during this period and the hopes people cherished included the entrepreneurial opportunity to get rich and join the middle class, the liberalization of the market, the gradual elimination of social taboos on sex and politics, the possibility of mad consumption, and so on. These have constituted the underlying context for the period after the 1990s (Zhu 2001: 38–39). However, Chinese cynics and Western cynics are different mainly because of different social structures. In contrast to Western societies, China has not entered the stage of “post-Oedipal subjects” because the state and society maintain the authority as the symbolic father. The cynical subject in China does not replace the symbolic authority with an imaginary authority in the way the Western post-Oedipal subject does. In Western societies, the narcissistic post-Oedipal subject looks at the world with the conspiratorial idea of “Other of the Other”. The imaginary collapses into the darkness of the real, causing the subject to constantly change his mask, making frantic restlessness, complaint and mockery the norm. Besides, the over-liberal atmosphere resulting from relativist values in the West provides the basis for the subject to be capricious, which brings more restlessness and anxiety. In contrast, Chinese cynicism appears more as a psychological defense mechanism to survive under the symbolic paternal authority, which can be regarded as a mitigating behavior to avoid suffering mental disorders.

5.5 Summary: Reflecting on Lurking yet Undiscovered Depression in China Whereas the previous three chapters focused on the “visible” “social facts” (both quantitative and qualitative), this chapter analyzes the relation between the capitalist discourse and depression by delving into the “unconscious” (the Real). The unconscious is manifested as the split subject with infinite desires who, under the specter of the Real, constructs his identity around the objet petit. This view of the subject

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emphasizes not only the Symbolic, but also the Imaginary and the Real. Lacanian psychoanalysis integrates the three orders and enriches the study of subjectivity. This view of the split subject allows us to comprehend the labor-alienation subject on the production side and the cynical subject on the consumption side. The above analyses also show that the capitalist discourses in China and in the West have different effects. The Western “post-Oedipal subject” loses his symbolic paternal authority and seeks the oppressed object in a “moaning-without-illness” way. The anxious and torn post-Oedipal subject does not achieve true liberation. The narcissistic and “moaning-without-illness” mentalities are more obvious in the West than in China. In contrast, the symbolic paternal authority persists in China and, to some extent, suppresses the capricious “moaning-without-illness” mentality. In other words, the individual, aware of the repressive nature of the symbolic paternal authority, is forced to work hard to solve the problems he encounters every day by adjusting and adapting himself. Such an interpretation partly explains why the rate of depression in China is lower than that in the West. However, this interpretation is insufficient and incomplete because the following three phenomena suggest that depression in China may simply be hidden, undiscovered. In other words, depression in contemporary China may be much more widespread than official statistics suggest. A large number of people are actually or will be suffering from depression; but they are not identified or still on the verge of manifestation. Their accumulating dissatisfaction towards the symbolic paternal authority will eventually break out when it reaches a certain point. The following three phenomena, which are constantly evolving in China, should not be ignored when we analyze the social structure that produces depression. Firstly, workers’ awareness of their rights is improving and labor demands are rising. The first generation of migrant workers were hard-working and tolerated exploitation, but the second generation of migrant workers are more and more eager to work and live in dignity, to earn higher salaries, have more social benefits, enjoy the right to participate in important decisions and have equal rights to ensure their own interests. They are no longer willing to be deprived of their rights. Even the accumulation of wealth can no longer gratify their demands. Like other Chinese, they want to buy computers, smart phones, a decent car, and a comfortable house or flat. In addition, because of the lack of the mechanism for them to voice their interests, it is increasingly common for them to fight for the chance to express their needs and demands, so strikes have become an important element of labor negotiations. The relatively frequent strikes in recent years have shown that the workers are more aware of their rights, which has made dissatisfaction a more common phenomenon. If the authorities do not handle this dissatisfaction prudently or adjust labor policy appropriately, the consequence will fuel the outbreak of depression. Secondly, as time passes, it is undeniable that China is moving in similar directions to the West. For example, the narcissistic mentality is more obvious in the onechild generation or the children of wealthy parents (the 2G rich) than in the older generations. Today’s China seems to have a narcissism similar to that in Western societies. In addition, in a consumer society, the products are dazzlingly diversified, the replacement of obsolete commodities is surprisingly fast, people are more

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and more concerned about gratifying their desires and protecting their rights, and consumer awareness is becoming stronger, thanks particularly to the free exchange of information in the Internet Age. This results in the universalization of insatiable desires, which contributes to people’s anxiety. Thirdly, a more fundamental problem is that the Chinese people’s perception of depression and the construction of depression in the medical system are far less developed than in the West. Without sufficient social construction, people have no way of knowing whether they have depression. Moreover, depression is still a stigmatized disease. These two factors make depression a lurking and unexplored phenomenon. Therefore, it is more critical to further explore how depression is socially constructed. The first two of the above phenomena fall into the category of social structure. The changing social structure reveals that when China evolves from a society with the symbolic paternal authority to a pluralistic society like the West, when an atmosphere of enjoying rights and gratifying desires prevails, and when the society is more tolerant of people’s “capriciousness” and offers more ways for them to articulate their opinions and ideas freely, there will be more possibilities for the outbreak of depression, even if the Chinese do not become a complete “post-Oedipal subject”. As for the third phenomenon, it will be explored in detail in Part II “Social Construction” of depression. Finally, let us return to the main topic of this chapter, namely the psychoanalytical relationship between depression and the capitalist discourse. Lacan’s split subject is one in the philosophical sense. In this book, we add a sociological dimension to the term when we discuss it under the effect of the capitalist discourse. We endow Lacan’s philosophical “split subject” with a sociological and pathological sense: the “normal split subjects” (ordinary people) under the effect of the capitalist discourse appear socially as “labor-alienation subjects” on the production side and “cynical subjects” on the consumption side. However, if normal split subjects fail to develop a proper psychological adjustment mechanism to deal with social reality, they will become pathological split subjects (or the “abnormal split subjects” in this chapter), namely patients with mental disorders, which of course include patients with depression. It is worth noting that the capitalist discourse operates in a circular way. The split subjects in the sociological sense (including both the labor-alienation subjects and the cynical subjects) are constantly consolidating and promoting the development of capitalism, which in turn creates split subjects, including split subjects in the pathological sense (psychos). The reasons are as follows: First of all, under the capitalist discourse, the split subjects in the sociological sense will indirectly lead to split subjects in the pathological sense. On the production side, the labor-alienation subjects may develop depression because of overwork, unemployment, or the insecurity of temporary work. On the consumption side, the cynical subjects show that humans can develop psychological adjustment mechanisms to avoid morbidity. They demonstrate psychic structural features similar to mental disorders (paranoia and fetishism), but they do not have problems functioning in daily life. The universalization of capitalist commercialization leads to rich forms of objet petit α, so individuals can proceed to enjoy the pleasure from their criticism and mockery of social reality. The universalization of such cynicism is the

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key force to consolidate the development of capitalism in China. In addition, cynics may develop a pathological narcissism, and the universalization of sociological split subjects can lead to the proliferation of narcissism, which is an important trigger for the appearance of pathological split subjects (i.e. depressive patients). Secondly, the difference between a sociological split subject and a pathological subject lies in their different degrees of adjustment to social reality (the difference in adjustment can also be due to the ecological networks). The difference is closely related to the structure of the capitalist discourse. In the previous three chapters, cases have shown that when a sociological split subject cannot adapt to overwork or the demand of the big Other on the production side, or gratify desires for consumption and more rights on the consumption side, depression results. Cases have also shown the effect of the capitalist discourse on the occurrence of depression. Therefore, in the neoliberal globalization of capitalism, both sociological and pathological split subjects will show up continuously in both China and the West. Moreover, the sociological split subjects will also turn into pathological split subjects when they fail to develop a proper adjustment mechanism. In other words, depression will continue to spread under the effect of the capitalist discourse.

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Part II

The Social Construction of Depression in China

The first four chapters have analyzed the “social structure” of depression, which partly accounts for the occurrence of depression in China. But the social structural analysis has two limitations. First, it presents the factors that can trigger the occurrence of depression, but it is not enough to answer the question why depression, rather than other mental disorders, has become prevalent in contemporary China. Second, the transformation of social structure can explain the difference between the contemporary social structure and that of the previous era (and in this sense the social structure is a trigger of depression because countries show a tendency of increasing mental disorder due to marketization and frequent transnational capital flows); however, there are many complicated mechanisms and contingencies for the occurrence of depression, as individuals’ interactions with the social environment, other people and events also play a role. The social structure presents the potential conditions for the occurrence of depression, but it cannot explain the inevitability of depression. Therefore, the social structural analysis is not enough to explain depression in China. For this reason, the perspective of “social construction” is more important. The “social construction” of depression focuses on its rhetorical conceptualization, the knowledge and power relations behind the rhetoric, and patients’ participation in its construction (including how patients balance gains and losses in the construction process). We will discuss the construction of depression from two aspects. Chapter 6 will discuss its social construction from the side of medical supply. In the framework of social constructionism, we will discuss how the complex of producers (drug producers), the government, academia and the media medicalize depression, including the expansion of discursive disciplinary power, and how these complex and civil groups (social workers, psychological counsellors, etc.) jointly construct the discourse and medicalization of depression. Chapter 7 will discuss the social construction from the side of medical demand, namely, the public’s cognition and conceptualization of depression. Cultural interpretation in medical anthropology will be adopted to analyze the cultural influence on patients’ actions, methods of phenomenology will be applied to explore patients’

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subjective feelings, and the framework of interactive theory will be used to probe the complex process of conflict, compromise and partial adoption between the patient and the hegemonic Western medical system.

Chapter 6

Medicalization of Depression by the Production-GovernmentAcademia-Media Complex

The analysis of the “social structure” of depression reveals that the social upheaval in neoliberal globalization leads to the occurrence of depression. But in China, an interesting question arises—why were so few patients diagnosed with depression during the “Cultural Revolution”, whereas more depressive patients have been diagnosed after the globalization of neoliberalism? If people suffered intense trauma during the “Cultural Revolution”, manifested by even more intense reactions than after the reform and opening up, is neoliberal globalization still a convincing framework to explain the causes of depression? We believe that it is convincing, but the key lies not in the “social structure of depression” but in its “social construction”, the conditions which were lacking before the reform and opening up. This chapter will focus on the medicalized construction of depression by the Production-Government-Academia-Media Complex.

6.1 The Production-Government-Academia-Media Complex and Medicalization “Depression” as a label for illness is related to the naming of depression by academics (highly authoritative medical experts). The emergence of the term “depression” is also the result of sophisticated medical developments. “Neurasthenia” was a common term before the use of “depression”. It was put forward in 1868 by the American neurologist George Beard to denote exhaustion of the central nervous system, which he attributed to civilization. In the 1940s and 1950s, American psychiatrists debated whether neurasthenia was a medical diagnosis. This debate was mainly due to the rise of the psychogenic theory of disease, which took traditional neurosis as a psychogenic disease, a physical illness arising from emotional or mental stressors or from psychological or psychiatric disorders. Then “neurasthenia” gradually came to be a disease with many symptoms that are not organically linked (Zhong 1983). In the second edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-II) © East China University of Science and Technology Press Co., Ltd. 2020 I. Hsiao, A Sociological Analysis of Depression in China, https://doi.org/10.1007/978-981-15-6471-0_6

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published in 1968, “neurasthenia” was described as a pathological condition characterized mainly by chronic weakness, irritability and fatigue; but in the DSM-III it was deleted and replaced with more precise names such as “depression” and “anxiety disorder” (Chen 2011). The change reflected the shift from a neurological paradigm to a psychological paradigm. Currently there are two internationally accepted standards for the diagnosis of depression—The International Classification of Disease (ICD) developed by the World Health Organization, and The Diagnostic and Statistical Manual of Mental Disorders (DSM) developed by the American Psychiatric Association. They share similar views on the core symptoms of depression. As naming emerges from chaos, things are reordered, bringing new social order and cognition (Foucault 1973). Even if extreme social constructionists believe that depression is fictitious (a disease invented for the sale of drugs), the labeling effect of this nomenclature in a medicalized society or one that discriminates against mental illness can turn the labeled individuals into true depressive patients. In this sense, naming can turn “fiction” into “social reality”. The spread of the term “depression” is not merely the result of the public health system listing it in manuals of mental illness, but also of the promotion of the medical economy through neoliberal globalization, which means that all the actors— producers, government, academia and the media—are brought together by a common interest. In other words, once “depression” was accepted by the medical community as a term, what came after was the production and marketing of pharmaceutical companies, the social control by the government, the publicity by the media, and successive studies by academia. All these actors worked together to construct the medicalization of depression. The Production-Government-Academia-Media Complex in neoliberal globalization is also related to the development of medical commercialization and capitalist marketization, because the market (drug producers and sellers), the expert knowledge (in psychiatry), the government (state system) and the media in the complex are important actors in the construction of depression and share common interests. With the development of neoliberal globalization, countries are vigorously developing the knowledge economy, ushering in new core technologies as a force for economic expansion to enhance innovation capabilities and to form new publicprivate partnerships so that as many manufacturers as possible can benefit from new technologies brought about by research and development. The pharmaceutical industry is one of the key industries in the knowledge economy. Before the globalization of neoliberalism, pharmaceutical companies did not develop new drugs so rapidly. Since the globalization of neoliberalism, trade across regions has flourished and new drugs that can treat new diseases have huge market potential. Therefore, well-known multinational pharmaceutical companies are all actively engaged in the research and development of new drugs. Those companies, with the assistance of biotechnology, have generated a star industry. However, the pharmaceutical industry is a high-cost industry that must bear high risks of failure in clinical trials. Without sufficient funds, it is difficult to sustain the development of new drugs. Therefore, a complex or a composite network of the government, academia and producers was formed to drive the development of the pharmaceutical

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industry and enhance its competitiveness. Because of the international competition resulting from neoliberal globalization, governments in different countries often offer favorable policies to domestic pharmaceutical companies to support them directly or support the improvement of the institutional system and structure of the pharmaceutical industry. Measures include establishing and developing biotechnology industrial parks, subsidies, tax cuts, land lease concessions, assisting manufacturers to build factories, encouraging academics to join (research and development) or provide technical assistance, funding R&D, and coordinating academia with the pharmaceutical industry through public R&D projects and local-oriented joint R&D projects. Internationally, some developed countries have worked hard to construct free trade regulations that are conducive to their domestic pharmaceutical companies, such as the Agreement on Trade-Related Aspects of Intellectual Property Rights (TRIPS) administered by the WTO, which stipulates that all member nations, regardless of their original domestic circumstances or practices, must grant patents for new drugs which are enforceable for at least 20 years (Zhang and Huang 2006: 125– 131), so that their well-known pharmaceutical companies enjoy a monopoly in world markets. In addition, academia has also begun to set up drug research and development units. Pharmaceutical companies rely more on the findings of the academic community, while the academic community is increasingly concerned about technology transfer, fund-raising and obtaining patent rights, establishing research and industrial parks, and providing consulting services to companies. This accelerates the industrialization of higher education institutions and transforms university faculty into adventurous holders of knowledge capital. Employers and practitioners of the pharmaceutical industry are involved in the development of school curricula and managers are invited to join in the governance and agenda-setting of higher education. Talent flows between academia and non-academia are also encouraged. Then, the media disseminate the results of this cooperation (the introduction of disease names, drugs, etc.) via the producers-government-academia complex to the public to secure their own commercial interests. The formation of public-private partnerships and the formulation of free trade regulations have accelerated the efficiency of drug research and development, enhanced the role of R&D in improving the industry’s competitiveness, and changed the functions of government, academia and the media. This in turn has changed the development of the pharmaceutical industry in neoliberal globalization. The neoliberal economic development pattern integrates the producers, the government and the media into the circle of shared commercial interests, forming a symbiotic relationship, which in turn allows these actors to promote capital accumulation. The neoliberal logic that emphasizes competitiveness brings these actors together. The complex they form provides conditions for the social construction and medicalization of depression. In order to illustrate the symbiotic relationship among producers, the government, academia and the media, we take the United States as an example and analyze how the complex promotes the wide use of depression drugs there. First, pharmaceutical companies, in their marketing, emphasize drug treatment from a biochemical perspective and marginalize other forms of treatment. They argue that depression is caused by an imbalance of serotonin in the brain, so an effective

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drugs, SSRIs (Selective Serotonin Reuptake Inhibitors) like Fiuoxetine Hydrochloride (Prozac), should be used. Drug sellers sell such drugs to doctors in large quantities. In the 1990s, sales of such drugs in the country tripled, making depression drugs one of the top sellers, generating more than $20 billion in revenues for pharmaceutical companies (Moynihan and Cassels 2006). With such huge profits, the pharmaceutical companies strive to sell their own products and spread the biochemical perspective of depression and the chemical treatment methods in their marketing process. Second, there is a dubious relation of mutual interests between pharmaceutical companies and the government. For example, after the passage of the The Prescription Drug User Fee Act (PDUFA) in 1992, more than half of the FDA (Food and Drug Administration) expenditure for drug evaluation and approval activities came directly from the drug manufacturers (Moynihan and Cassels 2006). The government collects large fees for drug approval, and the sooner new drugs are approved, the faster they will make profits. The FDA requires pharmaceutical companies to pay for the application of new drugs, but the fees are nothing compared with the profits from the sales of the news drugs. The government implements neoliberal public-private partnerships in which companies and the government work together, but consumers are excluded. This reveals the government’s favor of pharmaceutical companies’ interests over consumers’ interests. This also shifts the government’s previous role as a drug censor to a conspiracy relationship with the pharmaceutical companies. In addition, most psychiatrists on the review teams of the FDA, the supreme institution in the United States for food and drug control, have some kind of shared interests with the pharmaceutical companies and may work for the benefit of the companies. For example, trial results may be fabricated, the time for the clinical trials of new drugs may be shortened and the launch of new drugs sped up because the supervisors are on the companies’ side. The long-term observation of side effects is neglected. Thirdly, the relationship between medical experts and pharmaceutical companies is even more complicated than between the government and pharmaceutical companies. Experts play an important role in the classification and definition of diseases. For example, DSM-IV published in 1994 listed 347 diseases over 886 pages. The number of diseases was more than three times that of DSM-I (published in 1952). DSM standards are strictly followed by the medical and pharmaceutical communities, and even the legal community. Every time the DSM is revised, new diseases are added and disease scope is enlarged. This enables pharmaceutical companies to gain many benefits. Experts who define and classify the diseases may cooperate with the pharmaceutical companies. Besides, in the FDA’s approval process of new drugs, classifications of drugs are established according to their applicability. This not only increases the number of diseases, but also commercializes disease (Fishman 20041 ). In addition, when pharmaceutical companies conduct drug marketing, their target clients are those who prescribe drugs (psychiatrists). Pharmaceutical companies may sponsor medical schools or their medical research and require the sponsored 1 The

author cited from the Chinese version published in Taipei translated by Cihui Chen & Yiyue Chen.—Translator’s note.

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school to offer psychotherapy courses. Psychiatrists may have taken such courses when they studied in medical schools. Psychiatrists can also obtain new information on psychotropic drugs through medical journals which include advertisements about the medical industry or are sponsored by pharmaceutical companies. The media may quote from these journals as well. Some research reports, even if they lack sufficient evidence, may be cited and spread by the media. For example, because psychotherapy cannot be assessed in an objective manner, results without objective quantitative statistics may be accepted; or statistical results in favor of the tested drug are retained and presented without consideration of the subjects who quit the trial, because the research plan is funded by pharmaceutical companies. Such partial information, via the publicity of the media, affects receivers’ cognition. Besides psychiatrists, pharmaceutical companies also sell drugs to doctors in other departments. Most of doctors’ compulsory on-the-job training activities are organized by medical education and training companies hired by pharmaceutical companies—“In this respect, the US spends 1 billion dollars per year, about half of which is from the pharmaceutical industry” (Moynihan and Cassels 2006). Pharmaceutical companies may hire prestigious psychiatrists to deliver speeches to the public or sponsor activities which help doctors learn how to use new drugs and how many people need the new drugs. This is the most effective way of marketing in the pharmaceutical community. Besides, to persuade hospitals to use their drugs, pharmaceutical companies may sponsor doctors’ research programs and lobby for them (in fact it is bribery). Such complex relationships enable some medical experts (psychiatrists or psychiatric scholars) to work in the government, the psychiatric academia and pharmaceutical companies. They may simultaneously be members of the Food and Drug Administration’s review teams of pharmaceutical consultants, research experts, and salespeople in the spotlight of the media. When experts have multiple identities at the same time, people will naturally and reasonably assume that the invention of diseases and the manufacturing and approval of drugs are all related to commercial interests. Finally, pharmaceutical companies market drugs to the general public through the media. They do not only sell drugs, but also introduce various concepts of disease to the public. They advertise their products and persuade the public to take drugs they actually do not need to treat diseases they actually do not have (Pogge 2008). An increasing number of advertisements lead the public to take common daily phenomena as diseases to be treated. Since 1998, pharmaceutical companies in the US have put pressure on the US Congress to allow psychiatric drugs to be advertised on television if side effects of the drugs are listed. Some psychiatrists appeared regularly on TV programs, telling the audience what were the current common psychological problems. Psychiatric drugs were also incorporated into movies and TV dramas, which is known as product placement or embedded marketing. Doctors had their articles published in popular medical magazines or wrote books on mental health in an easy-to-understand way to make medical information more accessible to the public. In addition, the media coverage of depression changed the public’s perceptions of it. In the past, people tried to find excuses for committing suicide, but now depression has become an acceptable explanation. Committing suicide because of

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depression is the same as dying of cancer. Depression provides a reasonable explanation for suicide. This suggests that suicide is a personal psychological problem that has little to do with others or the social environment. The media will judge a suicide by looking at whether the victim suffered from depression or whether his family had a history of depression (Ning and He 2012). The production-government-academia-media complex creates a symbiotic relationship among the actors under the influence of neoliberal globalization. Disciplinary power over people’s physical and mental health is not confined to the public health sector of the government. It is also exercised by the productiongovernment-academia-media complex. The cooperation between producers, government, academia and the media promotes the accumulation of various types of capital and leads to more refined classifications of mental illness. In the past, mental illness was relatively rare, and people who had mental illness were regarded simply as madmen with deviant behavior. However, as medical surveillance technologies (e.g. diagnostic and tracking technologies) become more sophisticated and medicalization is intensified, the scope of depressive patients is expanded to include people who were formerly perceived as healthy. Moreover, with the spread of the idea of “psychological disease prevention and treatment”, phenomena which are less severe than madness (e.g. insomnia, frustration, emotional management failure, autism, and somatization) have begun to attract attention. When the classification of mental illness becomes more refined, depression is defined as a mental illness. The production-governmentacademia-media complex helps to spread the idea of “anti-depression” and food or health campaigns against depression to gain interest. These developments have gradually disciplined the public’s perception of (anti-)depression. Finally, social workers, consultants, emotion managers, popular psychologists and spiritual formation groups are increasingly recognized as groups that help people manage their emotions. These groups also benefit from the classification of depression as a mental illness. They help to create an atmosphere in which the whole society gradually accepts the treatment of mental illness.

6.2 Development of Depression in China: Medicalization on the Medical Supply Side After sorting out the background, we return to the question raised at the beginning of this chapter: why were there so few patients diagnosed with depression during the “Cultural Revolution”, whereas more depressive patients have been diagnosed since the globalization of neoliberalism? During the “Cultural Revolution”, mental disorder was considered ideologically undesirable and suppressed. Its stigmatization was particularly prominent in that highly politicized period. Arthur Kleinman presented this view in his 1986 book Social Origins of Distress and Disease: Neurasthenia, Depression and Pain in Modern China.

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Kleinman surveyed the outpatients of the Department of Psychiatry of the Second Hospital Affiliated to Hunan Medical College on a certain day. 19% of the patients were diagnosed with neurasthenia, while only 1% with depressive disorder. However, 93 of the 100 cases diagnosed as neurasthenia could be alternatively diagnosed using criteria of the American Psychiatric Association’s Diagnostic and Statistical Manual (3rd edition) (DSM-III) as cases of depressive disorder. More interestingly, most of these patients experienced symptomatic improvement after they took antidepressant medicine. These findings led Kleinman to believe that the vast majority of neurasthenia cases diagnosed by Chinese doctors were “depression” in the eyes of American doctors (Kleinman 1986). But why were there so few diagnoses of depression during the “Cultural Revolution?” Kleinman presented an interesting political argument that it was because “depression” as well as other psychiatric labels was a stigma and equated with wrong political thinking. They were associated with demoralization, lack of enthusiasm, suspicion and betrayal of Communist ideals in that context of great political enthusiasm. At that time, patients and their families were unwilling to assume the label of depression. Neurasthenia was a safer and more acceptable idiom for conveying the state of frustration and demoralization. For some people, this was a discourse with a double meaning (on the surface it was a physiological discomfort, while hidden beneath was a political discourse) (Klienman 1986). Then why have there been more depression diagnoses since the reform and opening up? Sing Lee found that in the 1980s and the 1990s, neurasthenia, which emphasized psychical symptoms, was contested and reconstituted as the common Western disease of depression by academic psychiatrists in urban China. He argued that this dramatic change of diagnostic labelling was the product of a confluence of social factors. Since the “Cultural Revolution”, China has experienced great changes in social values (family, marriage, economy, etc.) and social structures. Many middleaged and elderly women committed suicide to resist the changes. The suicide rate in Chinese society is not low and as diagnostic techniques such as the DSM are applied as criteria for psychiatric diagnosis, suicide has been understood as highly related to depression. This has led to the rise of depression diagnoses. In other words, there has been a “medicalization of suicide” (Lee 1999: 368). Hidden behind is the transformation of what is collectively at stake in society into an individual pathology and strategy to cope with pressure (ibid.: 369). In addition, after the reform and opening up, the term “depression” was no longer a taboo. It gradually became a new cultural term in practice and was intentionally or unintentionally used widely in a non-psychiatric sense. For example, when someone says, “I suffer from depression”, it may not be that “I” am pathologically depressed. It may just refer to “a bad mood or being upset”. Such usage seems to be an idiom in people’s daily interactions. Therefore, “depression” has become a more widely used term after the reform and opening up. To answer the question of why there have been more depression diagnoses since the reform and opening up, we also need to probe the evolution of China’s classification of mental illness. First, the classification of mental illness in China before the reform and opening up was highly influenced by Soviet psychiatry in the 1950s and 1960s, when neurasthenia, hysteria and obsessive compulsive disorder were

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equally important types of neuroses. Therefore, neurasthenia was a common diagnosis. After the reform and opening up, Chinese psychiatrists began to abandon the Soviet-style classification and accept the Western viewpoint of depression diagnosis (Chen 2011). Therefore, the compilation of an analogous system for the domestic medical construction of depression has appealed to Chinese psychiatrists. The result has been the publication of several versions of the CCMD2 (Chinese Classification of Mental Disorders) by the Chinese Psychiatric Association. The CCMD has taken the ICD and DSM as references. The first (CCMD-1), second (CCMD-2), second revised (CCMD-2R), and third (CCMD-3) editions were issued in 1981, 1989, 1995 and 2001, respectively. The CCMD-2 pointed out that neurasthenia has aroused international disputes, and there was previously a tendency for over-diagnosis in China. Although Chinese psychiatrists used to be unfamiliar with the concept of somatoform disorder, pressure to unify the CCMD with globally accepted systems such as the ICD and DSM has resulted, for the first time in China, in the inclusion of the category of somatoform disorder in CCMD-3. Neurasthenia received a code of 43.5 in the CCMD-3, but it became insignificant compared with somatoform disorder and somatization disorder (Cai 2012). In other words, the CCMD, under the influence of the ICD and DSM, has increasingly reduced the use of “neurasthenia” and adopted other labels. Neurasthenia is rarely diagnosed (or diagnosable) by Chinese psychiatrists nowadays, at least in urban China, where professional awareness of international practices is greater and the CCMD-3 is followed more rigorously (Lee and Kleinman 2009). This also reveals the discrepancy in diagnostic practice between rural and urban areas. The institutionalized construction of mental illness analogous to the Western classification has given birth to a new diagnostic hierarchy, and the CCMD with Chinese characteristics has gradually become a “sincized” ICD, providing an institutionalized basis for the medical treatment and operation of depression. Chinese people began to know and understand depression only after the reform and opening up. In 1982, China conducted a large-scale national epidemiological survey of mental disorders covering 12 regions. The survey showed that the prevalence of affective disorders, namely depression, was only 0.076%, far below the global rate of 11% reported by the World Health Organization. Yezhi Hou, deputy director of the Beijing Mental Health Care Institute and the chief physician of Beijing Anding Hospital, explained that the rate was low because the diagnostic criteria for depression were too strict, and depression was even mistaken for schizophrenia (Sohu Health 2007). After the reform and opening up, thanks to the abundant information disseminated by the media, Chinese people got to know about depression. According to Peicheng Hu, a renowned professor at the Medical College of Peking University, the World Health Organization conducted a worldwide epidemiological survey of mental disorders in the late 1980s and early 1990s which included Beijing and Shanghai. The survey showed that the rate of inpatients with depression in Shanghai was as 2 The

Chinese Classification and Diagnostic Criteria of Mental Disorders in China (CCMD), compiled by the Chinese Psychiatric Association, has been developed in the third edition (CCMD3). While referencing to the ICD and DSM, it took full account of China’s social and cultural characteristics and traditions in the etiological and pathological classifications of symptoms so as to make the medical treatment of depression more operable.

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high as 24%. Hu said, “It is this finding and the increasing number of suicide cases in colleges and universities since the 1980s that made depression a major concern” (Sohu Health 2007). In addition, after the reform and opening up, China has worked hard to integrate into the international system, resulting in a proliferation of multinational companies. Multinational pharmaceutical companies, such as Eli Lilly and Pfizer, began to market their psychotropic drugs in China. These developments of neoliberal globalization have greatly affected the construction and development of mental health in China. People have more access to more medical information about depression as well as antidepressants. Although China has constructed the taxonomy of mental illness, its social construction is inadequate due to the lack of mental health care professionals. The number of people with depression in China is on the rise, as is the number of people voluntarily seeking medical treatment. For example, Dr. Xiuling Gu from the Beijing Chaoyang Hospital Affiliated to Capital Medical University said that, on the whole, Chinese people now know more about depression—“in the late 1980s, our hospital received 7–8 depressive patients a day, but now the number is about 100 a day” (Shan 2012). Yezhi Hou also said, “Before the 1980s, the outpatients in the Psychiatry Department were less than 10% of the total volume. But today, nearly half of the outpatients are depressive patients” (Sohu Health 2007). However, by 2011, there were only about 20,000 registered psychiatrists nationwide, or 1.46 psychiatrists per 100,000 people, only one quarter of the international standard. Therefore, mental health service capacity in China is extremely insufficient (Wang 2011). Yu Mao, deputy director of the Beijing Municipal Health Bureau, said that Beijing has the most psychiatric staff and beds for inpatients, but psychiatrists number fewer than 1,000 and nurses fewer than 2,000. Reasons include “psychiatrists have a limited student pool and take a long time to be trained, there is a bias against psychiatrists, the income is low compared with doctors in other departments and so psychiatrists are less enthusiastic about their work” (Wang 2011). Nevertheless, psychiatrists are highly professional and irreplaceable in the medical world. There are very few professional mental health care nurses mainly because of the possibility of being injured by severe psychotic patients (Chen 2011). Most people in China do not have easy access to qualified specialists; they go only to big cities such as Beijing and Shanghai if they need help from psychiatric experts. As a result, the proportion of people seeking psychiatric treatment is not high. Between 2001 and 2005, 88% of China’s patients with mental disorders did not receive professional treatment. According to a 2012 report, more than 30 million people with depression did not receive any psychiatric treatment (the rate was as high as 62.9%) (Xinhua Health of Xinhua News Net 2012). According to a survey conducted by the Shanghai Mental Health Center in 2009, among depression sufferers who had received professional help, fewer than half had received any treatment within the first six months (Kaiman 2013). Dr. Xiuling Gu also pointed out that many patients sought medical help in other departments because of their limited knowledge about depression. In clinical practice, doctors or physicians in community hospitals or general hospitals, rather than psychiatrists, are the first to have contact with depression patients. Because these

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doctors are not familiar with psychiatric symptoms or have not received sufficient training in psychiatric diagnosis, patients are misdiagnosed (Shan 2012). Moreover, in many places (especially rural areas), there are only physicians or general doctors who do not deal with mental problems; psychiatrists are only available in large hospitals (Phillips et al. 2009). Psychological counsellors and mental health support workers are still being trained to acquire the ability of identifying depressive symptoms (Xinhua Health of Xinhua News Net 2012). Finally, many Chinese find psychotherapy prohibitively expensive, so they turn to traditional Chinese medical remedies such as acupuncture and herbs; some refuse treatment entirely (Kaiman 2013). Because of these factors, on the surface the number of depression cases seems small.

6.3 Summary In summary, the medical construction of depression by the Production-GovernmentAcademia-Media Complex has been proceeding vigorously since the reform and opening up. This is the result of the neoliberal globalization characterized by transnational capital flows, industrial competition and diversified commodification. When the global public health system benefits from neoliberal globalization and the label “depression” is spread to all corners of the world, China certainly cannot be isolated from the globalization of the Western medical system. One consequence is that more and more patients are diagnosed as depressive patients, because China knows more and better about depression after the reform and opening up. The “Cultural Revolution” period lacked the social foundation for its construction. This proves that neoliberal globalization was key to fostering the social construction of depression in China after the reform and opening up. However, the social construction of a disease also depends on the operational system of medical service providers. The scarcity of mental health care professionals and the relatively high cost of Western medicine make the number of people with depression appear smaller than it actually is. It is for this reason that the medical construction by the Production-Government-Academia-Media Complex is critical to the sociological analysis of how depression arises.

References Cai, Youyue. 2012. Zhen De You Jing Shen Bing Ma?—Yi Ge Kua Wen Hua, Kua Ling Yue Jing Shen Yi Liao Yan Jiu Qu Jing De Ding Wei Yu Fan Xing. Ke Ji, Yi Liao Yu She Hui (15): 11–64 (蔡友月. 2012. 真的有精神病吗?一个跨文化、跨领域精神医疗研究取径的定位与反省. 科 技、医疗与会 (15): 11–64). Chen, Li. 2011. Wo Guo Mei 10 Wan Ren Jin You Jing Shen Ke Yi Shi 1.46 Ming. Fa Zhi Ri Bao, 2011-12-7 (陈丽. 2011. 我国每10万人仅有精神科医师1.46名. 法制日报, 2011-12-7).

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Fishman, J.R. 2004. Zhi Zao Yu Wang: Nv Xing Gong Neng Zhang Ai De Shang Pin Hua (Manufacturing Desire: The Commodification of Female Sexual Dysfunction). Chen Cihui, Chen Jiaye, Yi. Yang Beichang. Zi Ben Zhu Yi Yu Dang Dai Yi Liao. Taipei: Ju Liu (Fishman, J.R. 2004. 制 造欲望:女性功能障碍的商品化. 陈慈 慧,陈 奕 晔 译.//杨 倍 昌.资 本 主 义 与 当 代 医 疗. 台 北:巨 流). Foucault, M. 1973. The order of things. New York: Vintage Books. Kaiman, J. 2013. China starts to turn to drugs as awareness of depression spreads. The Guardian, Nov. 20. Kleinman, A. 1986. Social origins of distress and disease: Neurasthenia, depression and pain in modern China. New Haven: Yale University Press. Lee, S. 1999. Dignosis postponed: Shenjing Shuairuo and the transformation of psychiatry in post-Mao China. Culture, Medicine and Psychiatry 23: 349–380. Lee, S., and A. Kleinman. 2009. Are somatoform disorders changing with time? In Somatic presentations of mental disorders: Refining the research agenda for DSM-V, ed. J. Dimsdale et al. Arlington, VA: American Psychiatric Association. Moynihan, R., and A. Cassels. 2006. Yao Ni Sheng Bing—Yao Chang Zhi Zao Ji Bing De Zhen Xiang (Selling sickness: How the world’s biggest pharmaceutical companies are turning us all into patients). Zhang Aiqian, Yi. Taipei: Shi Chao, 2006 (Moynihan, R., and A. Cassels. 2006. 药你生病——药厂制造疾病的真相.张 艾 茜, 译.台 北: 世 潮). Sohu Health. 2007. Zhong Guo Xin Wen Zhou Kan: Yi Yu Zi Sha Lyu, Nong Cun Gao Yu Cheng Shi. 2007-04-16. . https://health.sohu.com/20070416/n249462349. shtml. ( , 2007-04-16, https://health.sohu.com/200 70416/n249462349.shtml. Ning, Yingbin, and Chunrui He. 2012. Min Kun Chou Cheng: You Yu Zheng, Qing Xu Guan Li, Xian Dai Xing De Hei An Mian (People in Trouble: Depression, Emotion Management and the Dark Side of Modernity). Taipei: Tang Shan Chu Ban She (宁应斌, 何春蕤. 2012. 民困愁城:忧 郁症, 情绪管理, 现代性的黑暗面. 台北: 唐山出版社). Phillips, M.R., J. Zhang, Q. Shi, Z. Song, Z. Ding, S. Pang, X. Li, Y. Zhang, and Z. Wang. 2009. Prevalence, treatment, and associated disability of mental disorders in four provinces in China during 2001–05: An epidemiological survey. Lancet 373: 2041–2053. Pogge,T. 2008. Yao Wu Qu De Guan Dao. Yang Huijun, Yi. Yang Beichang. Zi Ben Zhu Yi Yu Dang Dai Yi Liao. Taipei: Ju Liu Chu Ban She (Pogge, T. 2008. 药物取得管道. 杨惠君,译.// 杨 倍昌.资本主义与 当代医疗. 台 北: 巨 流 出 版 社). Shan, J. 2012. Survey reveals overwhelming susceptibility to depression, reluctance to seek help. China Daily, 07–16. Wang, Junping. 2011. Zhong Guo Jing Shen Ke Yi Shi Bu Zu 2 Wan Ren, Jin Wei Guo Ji Ciao Zaun De 1/4 [N]. Ren Min Ri Bao. http://discovery.163.com/11/1011/10/7G31H78F000125LI. html (王君平.中国精神科医师不足2万人 仅为国际标准的1/4[N].人民日报, http://discovery. 163.com/11/1011/10/7G31H78F000125LI.html. Xinhua Health. 2012. Zhong Guo You Bing Li Ji Lu Yi Yu Zheng Huang Zhe Chao Guo 30,000,000 http://health.sina.com.cn/news/2012-07-31/114742517.shtml. (新华健康. 中国有病 例记录抑郁症患者超过3000万. 2012-07-31. http://health.sina.com.cn/news/2012-07-31/114 742517.shtml). Zhang Tinghua, and Wenhong Huang. 2006. Shi Jie Mao Yi Zu Zhi Yu Gong Gong Wei Sheng Zhi Xiang Guan Xing. Quan Qiu Hua Yu Gong Gong Wei Sheng. Taipei: Ju Liu Tu Shu (张婷华, 黄 文鸿. 2006. 世界贸易组织与公共卫生之相关性//全球化与公共卫生. 台北:巨流图书). Zhong, Youbin. 1983. Shen Jing Shuai Ruo Jie Ti Le Ma?. Zhong Guo Shen Jing Jing Shen Ji Bing Za Zhi (2): 67 (钟友彬. 1983. 神经衰弱症解体了吗? 中国神经精神疾病杂志 (2): 67).

Chapter 7

The Public’s Cognition and Conceptualization of Depression

The previous chapter demonstrated that the construction of depression by the manufacturers, the government, academia and the media is a social construction from the supply side of health care. In this chapter we explain the social construction from the demand side. What we need to discuss further is that although the public gradually accepts the term “depression”, their cognition, understanding of and response to this concept in western medicine is a complex process involving strategic interaction, conflicts and compromises. To describe and interpret this complex process, it’s necessary to take into consideration the cultural issues proposed in medical anthropology, patients’ subjective thoughts and experiences analyzed from the perspective of phenomenology, and their actions studied in interaction theory. Even though patients are not as influential as the manufacturers, the government, academia and the media in the construction of depression, they can facilitate our understanding of their complex process of cognition and conceptualization of depression.

7.1 Conflict and Compromise Between Chinese and Western Medical Cultures: A Medical Anthropological Perspective Kleinman once pointed out from the medical anthropological perspective that in China patients rarely articulated their illness as “depression” or expressed their emotions. They rarely saw their symptoms as depression or went to see psychiatrists. More often, they complained to physicians about their somatic symptoms resulting from depression (Kleinman 1985). In Kleinman’s research, patients did not think or want to believe that their symptoms were mental disorders and were more willing to see their discomforts as physical illness. Kleinman came to the view that in Chinese tradition, emotional problems were not illnesses and only the “body”—as a visible, concrete and demonstrative object—was the locus of disease (ibid.). This © East China University of Science and Technology Press Co., Ltd. 2020 I. Hsiao, A Sociological Analysis of Depression in China, https://doi.org/10.1007/978-981-15-6471-0_7

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view makes it easier for us to understand that people suffered from the disease categorized as “depression” in Western medicine but described it or transformed it as other symptoms because there was no “depression” in traditional Chinese culture. An interesting cultural phenomenon is that many Chinese patients mainly complained about physical symptoms rather than their mental and psychological discomforts when they went to see psychiatrists. The somatic articulation of depression by Chinese patients is much higher than that of their Western cohort. This is particularly evident in patients’ clinical reports (Bazzoui 1970; Binitie 1975; Chang 1985; Crittenden et al. 1992; Mezzich and Raab 1980; Nikelly 1988; Yen et al. 2000). Patients who articulated their illness as somatic symptoms amounted to over 70% (Kleinman 1986; Chen 2007; Ji et al. 2005). The following are the possible reasons for the high rate of somatization in China. First, the mind and body are viewed as integrated with each other in Chinese culture, which is different from the dualistic and dichotomous body-mind relation in the West. Chinese expressions of emotional distress involve names of many body organs, such as those related to “Xin” (the heart)—Xin Huang (flustered), Xin Fan (upset), and Xin Tong (painful)—which are often used by depressive patients to describe their symptoms. It needs pointing out that “Xin” is not the “heart” in the Western medical sense. It means “disharmony of the heart” in the view of traditional Chinese medicine. The “body” in Chinese culture involves the invisible spirit, mind, and emotions. It is an integrated whole resulting from physical and mental interaction. Chinese take a monistic view of the body-mind relationship. For example, Lyu and Wang (2013) argued that Chinese people look at the body in the way of “Xiang thinking” which holds the view of universal connection—without sufficient evidence, it cannot be asserted that there is no correlation between two things or entities. The way to determine the correlation is not a strict Western-style scientific experiment (i.e. strictly obeying the cause-effect logic that X leads to Y), nor a probabilistic cause-effect view (i.e. X may cause Y to appear with a certain probability, if not all the time; the more data, the closer the cause-effect relation is to a fixed value, which can reveal a pattern or patterns). The correlation is determined based on the subject’s intrinsic experience and associations. In traditional Chinese medicine, diseases are defined as an imbalance or disharmony of the whole body. Body and mind are integrated with each other and the diagnosis of mental illness cannot exclude the body. As a result, mental illness is related to the disorder of the body organs of “five Zangs” (heart, liver, spleen, lung and kidney) and “six Fu” (small intestine, gallbladder, stomach, large intestine, bladder and San Jiao1 ). In this sense, Chinese medicine does not deny somatization. Instead, it takes somatization as inevitable. Precisely because of this traditional view, for Chinese patients, body and mind are seen as interacting and intertwining with each other, and maladjusted emotions or thoughts are directly related to physiological dysfunction, and vice versa. 1 San

Jiao is a traditional Chinese medicine term. It is also known as the triple energizer or triple burner. It has a name but it has no form. It is not an organ which can be removed from the body or observed on a lab table. It regulates fluid–not only in the spaces around the organs, but also in the fluid that surrounds the muscles, nerves and vessels in the peripheral limbs, interstitial fluid in the connective tissue.—Translator’s note.

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In traditional Chinese medicine, it is believed that mental or emotional problems are due to an imbalance or blockage of the internal organs and energy pathways (Jing and Luo, the meridians2 ). Therefore, depression can correspond to many symptoms in traditional Chinese medicine, such as liver or qi (chi or energy) stagnation, spleen and stomach deficiency, kidney deficiency or lung and heart meridian disorder, all of which of course depend on how doctors diagnose patients’ pulse conditions. If one “zang-fu” organ in disharmony or one blocked meridian is untreated or improperly treated, the symptoms of depression can spread to other organs and meridians. In this sense, the concept of “neurasthenia”, a disorder of the nervous system, coincides with the notion in traditional Chinese epistemology that the important “zang-fu” organs are in disharmony. Such a cognition leads some people to turn to acupuncture and Chinese herb therapies. However, in Western culture, the view of the body-mind relationship is different. Body and mind are viewed as dualistic, dichotomous entities. The DSM classification of depression as a mood disorder accompanied by somatic symptoms further reflects this division (Ying 2002). Second, the Chinese tend to minimize the articulation of positive self-concepts and positive effects. Emotions tend to be suppressed or expressed only implicitly. In the West, by contrast, individuals are encouraged to speak out both their positive and negative emotions. Such a difference originates from the different self-other relationship in Chinese and Western cultures. Hsu (1981) observed that in the West, a person is defined by his or her uniqueness and distinctions from others, while in the East, a person is defined by his or her relationships. As such, the Chinese conception of self is a social one. For example, a fundamental concern of Confucian education is to teach a child the proper social rules of conduct and submission of personal desires to those of others in order to avoid interpersonal conflict and social disapproval. In order to maintain social harmony, one should not make public his or her emotions. Even if one is in bad mood, he or she needs to suppress it. This can explain why the symptoms described by Chinese patients during the interview can be erroneous or inaccurate. Although there is a set of ways to conceptualize and treat depression in Chinese culture, the influence of Western psychiatry is becoming increasingly extensive in contemporary China. The term “depression” has been widely spread to patients’ family members and other contacts in their daily life, and the media acknowledge depression as a mental illness. Moreover, more and more people admit that depression needs to be treated by specialists, and more and more people accept the trend of seeking psychiatric treatment. Today, the public’s conceptualization of depression is obviously different from what was described in Kleinman’s canonic book Social Origins of Distress and Disease: Neurasthenia, Depression and Pain in Modern 2 The

meridian is a general term for meridians and collaterals. It serves as the pathway for the transportation of qi and blood throughout the body, thus connecting the viscera with extremities, the interior with the exterior as well as the upper with the lower. Meridians are the main trunks running longitudinally within the body, most of which run deeply inside and follow certain routes. Collaterals are the branches of meridians running reticularly over the body. They run deeply or superficially within the body; most run in the shallow region and some often give a visible appearance on the surface of the body.—Translator’s note.

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China. However, many Chinese people still believe in physical and mental interaction. When they fall ill, they naturally think of idioms or commonsense knowledge like “sickness originates from the heart (the mind)”, “anger damages one’s health” and “indignation harms the liver”. They reasonably come to suspect that emotional and mental problems result in somatic symptoms. Even if Western medical diagnoses do not confirm their ideas, they do not abandon this idea (Lyu and Wang 2013). In such a context, patients often hesitate or vacillate between Chinese medicine and Western medicine in the treatment of depression. Quite often patients do not know that they suffer from depression. After they have been treated unsuccessfully with traditional Chinese medicine for a long time, they may turn to psychiatric treatment. However, once advised to take Western medicine, they will doubt its effects and compare it to Chinese medicine. A common concern of patients is whether too much Western medicine will cause kidney deficiency, liver damage and brain injury. Patients “in theory or principle” conceptualize depression as a disease and accept the Western medical construction, but in practice they worry about the side effects of Western medicine and may turn to traditional Chinese medicine or take medicine as adjuvant therapy because of their inherent monistic view of the bodymind relationship. In addition, due to the stigma attached to depression, many Chinese are ashamed of suffering from depression. Studies have shown that patients are much concerned about the stigmatization. In the survey conducted by the World Psychiatric Association in 2012, nearly 13,000 people aged between 26 and 45 were interviewed. Among them, more than 45% chose not to receive medical care even if they suffered from depression. Among those who were willing to receive treatment, only 18% chose to see psychiatrists. People are ashamed to be diagnosed with depression and hope that doctors do not diagnose their illness as depression (Shan 2012). The reaction of Xiaogang, one of the subjects the author interviewed, is an example of this phenomenon. He was most afraid of people saying: “You are depressed? You are suffering a cultural disease, the rich man’s disease.” He dared not tell others that he was suffering from depression because he feared other people’s scorn and sarcasm. He tried hard to hide his symptoms from others. Another interviewee, Xiaoru, also said: “If I tell others, I will be considered mad, abnormal, and inferior.” These factors contribute to the low estimation of depression cases in China.

7.2 Patients’ Subjective Feelings and Actions: An Analysis from Phenomenological and Interactive Perspectives To interpret depression in the globalization process of psychiatry, we should focus not only on how medical treatment is constructed objectively, but also on patients’ experienced body from the phenomenological perspective and on their actions from the perspective of interaction theory.

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Although each patient has different depressive experiences, we can discover some common inner feelings through their statements and descriptions. Generally speaking, patients feel sad, unhappy, disheartened, painful, and uncomfortable. Some patients are particularly anxious and irritable, with reduced concentration and thinking ability or lack of decision–making capability. They are no longer interested in things or activities they were once interested in, lose vitality, often feel tired or even want to commit suicide. The following are the physiological descriptions of some interviewees. Every day I feel lazy and even feel that it’s a bother to commit suicide … I always feel feeble when doing things … I am too slow, too lazy to talk, easily fatigued, too weak, always at a loss, unable to focus and I often stare at things blankly … I can’t make a decision about whether to go out or not. All these make me very uncomfortable and very sad. (Little Zhu) I can’t eat anything and even suspect that I have lost my ability to taste … I feel deeply depressed and my breathing isn’t smooth. (Little Zhong) Most of the time, I feel depressed and powerless about everything, although nothing is particularly depressing to me any more … I lose interest in everything and become unable to focus. My heart is empty. I’m unable to focus, I feel tired, exhausted and have no fun at all… I have a deep sense of powerlessness and become devoid of desire. (Little Lin) It’s hard for me to sleep. For one long night after another I can’t fall asleep … I take sleeping pills every day, but I still can’t fall asleep … Sleeping has become my nightmare, I can’t sleep without taking pills, and I can’t sleep well even if I take pills. (Xiaojun) I wish I could sleep until the last day… It’s best to let everything end because life is more terrible than death… When I wake up, I always feel terrible, because I always feel insecure. (Xiaochun) I feel anxious and full of hatred, pain, sin and self-loathing … Sometimes, the panic feeling is slightly relieved, but this is then followed by a calm and strange sense of despair and unreasonable and unspeakable pain. (Little Chen)

In addition to suffering the physical troubles brought about by the disease, depressive patients also have to expend great effort to face the social stigma imposed on them (Sontag 2000). There is a general misunderstanding of depressive patients: they are regarded as people who split hairs, think and worry too much, make a fuss about an imaginary illness, evade their responsibilities and are weak, lazy and weak-willed (Dethlefsen and Dahlke 2002). Xiaoran, an interviewed patient, said: My dad always scolds me for sleeping day and night without doing anything worthwhile. He thinks that I’m a useless person … I’ve had enough of my life, and I have to listen to his nagging all day … He has no medical knowledge, but he blames and belittles me at will.

Depression is not limited to the symptoms recognized in DSM. From the experiences of these patients, we know that they suffer both physical and mental torture, pain and torment. Depression often destroys a patient’s reason, completely changes and destroys his ego, making him unable to do anything or go anywhere. His inner mind becomes a battlefield and he becomes his own enemy. It’s difficult for other people to understand such feelings. In addition, every patient has a perception that his “illness” and “discomfort” are different from the medical interpretation. In daily life, such cognition is revealed in

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the interaction with other people and reflected in his reactions to different situations. Their reactions are not unconscious. It is not because patients are mentally ill or lack the ability to judge and act realistically that they have such rections. Although their understanding and interpretation of “reality” may differ from those of the medical field and other people, depressive patients do not lose the ability to judge themselves, others and different situations. Such judgment and reactions are manifested in their daily interactions. Even if their interpretations of “reality” differ from those of others, it does not mean that they turn a blind eye to it. At present, the main methods to treat depression can be categorized into two types: drug treatment and non-drug treatment (such as psychological treatment). Generally speaking, doctors adjust or integrate their treatment strategies according to the different causes of depression. As “genetic depression” is closely related to biological heredity, doctors tend to adopt biological and pharmacological treatments, such as drug therapy and electroconvulsive therapy. Drug therapy is the most widely used biological treatment: depression is regarded as a brain disease which can be treated with oral drugs that mainly supplement serotonin, norepinephrine, dopamine and other substances to achieve anti-depression effect. It is similar to the treatment of diabetes caused by low insulin. The pharmaceutical industry and the Food and Drug Administration in the USA have contributed to the wide use of such treatment. Electroconvulsive therapy appeared earlier than drug therapy, but because of public misunderstanding and fear of it, it is used only when drug therapy is ineffective or when there is a high risk for patients to commit suicide. Other biological therapies, such as phototherapy, rapid cranial magnetic stimulation, and sleep deprivation therapy, have not been widely accepted and used only under special conditions (Hong 2008; Lu 2002). “Psychogenic depression” is a problem of adaptation, so it is more amenable to adopt psychological treatment. When interacting with patients, psychiatrists or counselors utilize various psychological counseling methods, including cognitive behavioral therapy,3 interpersonal relationship therapy,4 marriage therapy,5 family

3 The basic idea of this approach is that a person’s cognition determines how he feels. It is in essence

a psycho-educational model, because it emphasizes that treatment is a learning process during which a patient can, through consultation, acquire and practice new skills such as identifying and testing his negative beliefs, learn new ways of thinking like strategies for information processing, and learn to manage the situation more effectively so as to alleviate his pain and suffering (Hollon et al. 2002; Mufson et al. 2004; Purdon 2004). 4 Interpersonal psychotherapy (abbreviated as IPT) was proposed in the 1970s. Gerald Klerman, the principal developer, after reviewing the relevant research on how depression occurred, identified four interpersonal problem areas that may cause depression, namely, grief, interpersonal conflict, role transitions and interpersonal deficits. IPT argues that if one of these four problems can be dealt with, the patient’s depression can be alleviated (Klerman and Weissman 1993). 5 Marriage therapy approaches a couple’s symptoms and behaviors within the social context. It helps couples break the vicious circle of failing interaction from the perspective of systematic interaction, and readjusts their ways of getting along with each other (Ding and Chen 2006).

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therapy6 and group therapy.7 When necessary, psychiatrists also prescribe drugs for patients with psychogenic depression, because they are depressed due to the lack of 5-hydroxytryptamine, noradrenaline, dopamine and other substances in the brain (Lin 2002). Of these two categories of treatments, biological therapy is still the mainstream. However, patients’ subjective experiences and feelings are different from the objective knowledge constructed in western medicine. Patients react differently in their interaction with psychiatrists, and it is often a complicated question whether patients really understand doctors’ diagnosis and thus adapt to the situation after treatment or whether they have other ways and treatment strategies to understand the disease. The structural problems of the treatment system are important, but patients’ problems, often including their identity construction and adaptation to life after they leave treatment, are no less important. Based on interviews conducted by the author, patients’ reactions can be categorized into the following six types. 1. Transition from ignorance to understanding and accepting western psychiatric treatment A common pattern of patients’ seeking medical treatment is that they do not know enough about depression at first, and they go to see psychiatrists after unsuccessful treatment by doctors in departments other than psychiatry. For example, Mr. Wang, one of the interviewees, felt inexplicable pain and was always in bad mood five years ago. He went to see doctors in neurology and in cardiology, underwent brain CT scan and various other medical examinations and tried ECG therapy. However, the doctors just kept prescribing all kinds of physical examinations for him, without offering a convincing diagnosis or treatment. When western medicine failed, the only way for him at that time was traditional Chinese medicine. For 5 years he took many kinds of traditional Chinese medicine to treat spleen deficiency and kidney deficiency, but the effects were not satisfactory at all. After such frustrated medical experiences, one of his friends recommended him to try psychiatric therapy. He was diagnosed with depression and his condition was gradually improved in the process of treatment. Some people realize that they have mental problems, but are reluctant to consult psychiatrists because they worry about how others will look at them and how the diagnosis might influence their professional positions and chances for promotion. It is not until they can no longer bear the suffering that they bite the bullet and seek psychiatric treatment. This is the case with the interviewee Xiaojuan. For patients of this type, the process of seeking medical treatment illustrates the transition from ignorance to understanding and receiving western medicine treatment. 6 Family

therapy refers to the approach that a medical unit offers counseling to a patient and his family members simultaneously. Its basic assumption is that the root cause for an individual’s maladjustment may lie in the family; therefore, to improve the individual’s condition, the treatment should start with his family (Wu 2005). In other words, family therapy regards depression as a problem occurring within the family system (Mufson et al. 2004). 7 The main goals of group therapy are to perceive the similarity between one’s own needs and those of others, to find solutions to specific conflicts, to acquire more effective social skills and to increase the awareness of others’ needs and feelings (Mufson et al. 2004).

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2. Transition from resistance to acceptance of western psychiatric treatment Patients’ acknowledgement of depression is different at different stages: their attitudes can shift from early denial to later acknowledgement after being hospitalized. The following case is an example. Xiaohong, a 45-year-old woman who got married after graduating from a secondary technical school, is a housewife and her main responsibilities are cooking and sending her children to school; her social experience is evidently limited. When she was 41 years old, she sought medical treatment for inexplicable pain—without success. More than a year later, she was diagnosed in a large hospital with depression but was extremely resistant to acknowledging the diagnosis. According to her family members, she initially insisted that she was not suffering from depression. However, after five months or so, she started to use the term “depression” to describe her condition and seemed to have gradually acquired a sense of being mentally ill. More and more frequently she employed medical terms like electrotherapy, depression, course of medication and curative effect. After receiving treatment for a long time, she not only learned from the doctors the criteria to identify “depressive patients”, but also imitated the doctors’ modes of talking about and describing “patients”. She said of herself: “I am now mentally ill and should take medicine so that I can learn to live peacefully with depression… I have learned to monitor and control my physical and emotional states … Taking medicine has become part of my life.” After passively accepting the medication practices imposed on her by doctors, she actively developed her own medication habits. Although a mentally disordered person can always imitate doctors’ diagnosing and curing role and reproduce the role of “patients”, the key point in the process of diagnosing and defining “patient” is that the patient’s identity as a mentally ill person is constructed through his active participation and in a way the patient is able to approach and interpret. Doctors keep stressing that helping a patient develop the sense of being mental ill is a common method of treatment whose purpose is to help him understand and admit his illness to increase the possibility of recovery. As a result, a mental patient imitates the doctor’s discourse, accepts the role of “patient” voluntarily and ultimately accepts psychiatric treatment in hospitals. 3. Consulting a doctor after first learning about depression on one’s own In the process of seeking medical treatment, patients actually demonstrate high introspective ability to understand their symptoms and living situations. During the interviews, it can be found that some patients have high autonomy in choosing whether to seek medical treatment or not. In the process of seeking medical treatment, patients also surf the Internet to be informed of the doctors’ medical practices, their professional and public eveluations, etc. Based on the online information and discussions with friends, they decide whether to see a psychiatrist and which hospital and doctor they should choose. Patients show a considerable degree of autonomy both in their cognition of depression and their choice of doctors, rather than being ignorant of depression treatment. For example, Dajun said: At first it was painful, so I chose to see a doctor, hoping to improve my condition with the help of a doctor … because it was really painful … Of course, I think psychological

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counseling is also useful, but I need more direct treatment. I discussed this with my friends and they encouraged me to go to see psychiatrists. I believe that psychiatric treatment will help to some extent.

Xiaobo, another interviewee, described a similar process: I was very sad when I didn’t see a doctor. I suffered from insomnia. Later, I felt it became more and more serious and it seemed that there was no hope for getting better. So I surfed the Internet for depression scales, and then I became worried …I thought I could think through and solve these problems by myself, but I still tended to get myself into a blind alley and always could not fall asleep at night. In order to adjust my daily schedule, I went to see a doctor and asked him to prescribe some medicine to help me sleep … Before I went to see a psychiatrist, I spent some time on the Internet to see which doctor is widely recommended and how other patients evaluate him or her.

4. Medicalization on patients’ own initiative It is interesting to observe that although psychiatric departments are not common in Chinese hospitals and medical treatment rates are low, sales of anti-depressant drugs are on the rise year by year. According to a market data company’s research and a 2012 report, China’s antidepressant market is booming. Sales of anti-depressant drugs surged by 22.6% in 2012 to reach 326 million pounds—still a small part of total pharmacological turnover in China (Kaiman 2013). Even in small cities and towns where psychiatric departments are relatively rare, more and more people are taking antidepressants. According to an interview by the Guardian with drug sellers, one reason “may be that people in small cities have more accesses to information as a result of the popularity of the Internet”. Another reason may also be simply that “antidepressants are effective”. These people who actively seek medication by themselves may not have been included in the number of depressive patients (Kaiman 2013). Therefore, we can see that in order to cure depression, some patients do not reject western medicine and obtain drugs through various channels instead. This shows that some patients take the initiative to get medical care. 5. Cognitive hesitation/vacillation: strategically acknowledging or denying depression Another interesting phenomenon is demonstrated by the hospitalized depressive patients interviewed by the author: they do not have a consistent perception of their own illness and that of others; they see themselves as different from other patients in the same hospital or nursing home. They know their own physical experience and often say that the discomfort experienced by other patients in the nursing home is consistent with the symptoms of depression, while theirs is not. They come to such an understanding based on the severity of the disease. One patient, Little C, denied strongly that he was a depressive patient. He was sent to hospital by force by his family and was diagnosed with major depressive disorder. Patients of this type might have frequent interaction with other patients in the hospital. They do not deny depression by keeping physical distance from others; on the contrary, they often explain to other patients that there is no so-called “mental

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illness” or that mental patients have the same rights as ordinary people and encourage other patients to challenge unreasonable institutional systems. For example, when Little C saw other patients who were more serious, drooling and speaking with a mumble, he thought that such patients suffered “mental illness” because their symptoms were worse than his and that he was “normal” because he did not have these symptoms. In a private interview, he admitted that his situation was similar but still insisted that he was different from others. This demonstrates that his cognition of himself is achieved by the strategy of emphasizing his difference from others. However, in private, he also expressed to the author that he had emotional troubles, unhappy in his life, and realized that he had problems. It’s clear that the cognition of depression of patients like Little C is quite strategic, varying from person to person and from topic to topic. Patients have judgments about themselves, their environment and what they want to achieve. Their experiences cannot be fully covered as a collective existence, and can therefore illustrate the importance of describing and interpreting individual experiences in the patient-doctor interaction. 6. Hesitation/vacillation about western medical treatment: multiple therapy alternatives Most patients who accept that they are depressed do not question the label of depression. What they question is whether western medical treatment or psychiatric consultation really works. The most common question originates from their understanding of medication. In 2015, a questionnaire survey was conducted with depressive patients and psychiatrists in five big cities in China—Shanghai, Beijing, Guangzhou, Hangzhou and Nanjing, and got back 6000 valid questionnaires. The result of the survey was presented in the Report of Depressive Symptoms in Some Chinese Cities. It was found from the questionnaires of 1007 depressive patients that most of the patients had the three core symptoms of depression, but 93.5% of them said they refused to take drugs or took them intermittently because they were worried about the side effects. The survey also shows that about 28% of them would do exercise and change their diets to divert their attention away from the disease, about 28% would turn to relatives and friends or psychologists for help, 21% aimed for selfadjustment, and 21% hoped for improbement by reducing work pressure (Shanghai Evening News 2007). It is evident that these patients sought their own way toward improvement and that seeking professional help was far from the mainstream. The interview cases also revealed that some patients were not satisfied with psychiatrists’ hastiness in diagnosis and therefore doubted of the effectiveness of the psychiatric treatment. Xiaoquan shared her experience in psychiatric treatment: The conversation with the psychiatrist is relatively short, and the whole inquiry and diagnosis lasts only about 5–10 min …The doctor does not take the initiative, and I will not say anything unless he wants to know something. Therefore, I think I just get medicine from the psychiatrist, but I don’t expect him to cure me.

After listening to Xiaoquan’s view, the author asked Doctor A’s opinion. Doctor A said that he hoped to achieve an effective allocation for treatment resources while

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taking care of other patients waiting in the long line with possibly increasing impatience. As a result, “rapid diagnosis” with a “focus on key symptoms” has become the common strategy of many doctors. They have to find a compromise solution for considerations of resource allocation, their remuneration and patients’ impatience; otherwise the hospital may face the dilemma of imbalanced costs and benefit. In fact, due to limited time for diagnosis, it is very difficult for patients to describe fully and clearly their symptoms and related problems, especially when their condition is severe and they are unaware of the limits on medical resources. Consequently they fail to make good use of these limited resources to gain benefits. Under such circumstances, the short diagnosis time allocated to them affects doctors’ decisions on the cost-benefit balance and the interaction with patients and undermines the success of medical treatment. In the doctor-patient interaction, doctors have to, to some extent, rely on patients to depict the disease voluntarily. However, patients often fail to describe one or more of these aspects: personal history, family relationships, emotional disturbances resulted from depression, previous treatment, etc., because they are often in a passive position during the brief interaction. Moreover, patients’ fear, rejection, embarrassment, and inclination to guard their privacy may lead to uncertainty in the doctor-patient interaction. Such uncertainty can create difficulties for doctors’ diagnosis and treatment, as they understand patients and administer treatment based on the symptoms and they are unable to grasp the efficiency of drug treatment, patients’ real situation, and the degree of patients’ dependence on drugs, etc. Both doctors and patients expect immediate control of depression through drugs, but it is difficult for doctors to anticipate the real risks of taking certain drugs and the adaptation problems patients may encounter after taking drugs. Therefore, it is not surprising that patients question the efficacy of psychiatric treatment. In addition, depressive patients often have a negative attitude towards the use of psychiatric drugs (including antidepressants, sleeping pills, anxiolytic). Interviewees expressed such views: The drugs are prescribed by doctors, while I know nothing about these drugs …If I keep taking medicine, I will become dependent on it (Daqing). I’m afraid that I will return to former bad conditions if I don’t keep taking the drug, and I will be worse if I stop taking it halfway (Xiaoming). I think many people do not dare to stop taking drugs once they begin… I’m afraid that after stopping taking drugs, the disease may become worse (Little Zhong). I’m worried that I may never have a chance to reduce the dose of six pills per day and the dose may still increase. I’m worried about the side effects of taking so large a dose for a long time. It may turn me into a good-for-nothing (Xiaojun).

These patients with negative views towards drug taking maintain that psychiatrists have authority over the use of drugs (what to take and how much to take), but they don’t want to be addicted to drugs. Patients’ rejection of western medicine can also be attributed to their belief in traditional Chinese medicine. For example, Zheng mentioned that antidepressants can result in dryness-heat and make people weak. He insisted on this view because he gradually recovered from taking traditional Chinese medicine, while western

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medicine made him drowsy all day. His personal experience led to his favor for traditional Chinese medical therapy. He showed to the author the information he recorded about traditional Chinese medicine. Here is part of it. Understanding of the general rules of the toxic and side effects of antidepressants: Antipsychotic drugs and antidepressants mostly act on the spleen and stomach first, with dryness and heat, and hyperactivity of stomach fire as prominent symptoms. The side effects of these drugs on the spleen and stomach are not just hyperactivity of stomach fire (or yang8 fire), because the spleen and stomach are the pivot of the human body and qi (气 chi or vital energy) in the human body. While the spleen rules “ascending” functions, the stomach rules “descending” functions.9 In addition, the spleen governs transportation and absorption (运 化, yun hua), namely, the extraction of essence (精微, Jing wei) from food and water. The spleen also governs muscles. Dysfunction of spleen qi and stomach qi can lead to problems in transportation and absorption of essence, which can cause muscle dysfunction. What’s more, excessive stomach fire can damage the body fluid, consume qi, and turn fluid into phlegm, which can cause various bizarre symptoms. The side effects of antipsychotic drugs and antidepressants are first manifested on the spleen and stomach, causing dysfunction of the spleen and stomach in transporting and absorbing essence from food and water, or invigorating fire and consuming qi. In other words, the toxin from these drugs causes fire and heat which damage the healthy qi, resulting in the spleen’s dysfunction in transportation and absorption. As a result, stomach fire and heat coexist with spleen deficiency, abnormal appetite or excessively good appetite being common symptoms. When the spleen does not ascend the pure part and the stomach does not descend the impurities, the result is that essence from food and water cannot be transported to other zang-fu organs and the limbs. It is accumulated in the middle burner (中焦, zhong jiao) and spread throughout the body after it turns into phlegm.

Psychiatrists are more favorable to western medicine. Doctor B told the author that most depressive patients can not think logically, or make rational analysis and judgments of events. They even don’t listen to doctors’ opinions and suggestions, thus often heading into a blind alley. But how has doctor B persuaded patients to take medicine? He related to the author the experience with one patient who could not understand why he slept badly at night, had a poor appetite, was reluctant to take a bath, to get up and get himself dressed, and became unreasonable. Doctor B said to the patient: You have this disease because your brain is sick! Your disease needs professional treatment, just as patients with upper gastrointestinal bleeding or cancer need medical treatment. There is a very small structure in human brain called hippocampus. Hippocampus 8 According

to the zang-fu theory in Chinese traditional medicine, Zang and fu consist of the five zang and six fu organs. The five zang organs are the heart (including the pericardium), lung, spleen, liver, and kidney. The six fu organs are the gall bladder, stomach, large intestine, small intestine, urinary bladder and the sanjiao (three areas of the body cavity). Zang and fu are classified by the different features of their functions. The five zang organs mainly manufacture and store essence: qi, blood, and body fluid and are called Yin organs. The six fu organs mainly receive and digest food, absorb nutrient substances, transmit and excrete wastes, and are Yang organs. Being a yang organ, the stomach prefers a moist rather than dry environment. Excess of yang may sometimes cause “dryness fire” which leads to stomach disharmony as well.—Translator’s note. 9 The spleen ascends the pure part of digested food from the stomach for transformation into nutritional essence while the stomach pushes food downwards in order to remove its impurities.—Translator’s note.

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and its surrounding tissues are responsible for managing human emotions and vitality. It has two important neurotransmitters, serotonin and noradrenaline. The decrease of these two substances can cause depression and abnormal bodily functions. Taking medicine can increase the concentration of the two substances in the brain and cure depression. As long as the chemical elements in the brain are balanced, you will recover. The medicine is not poison, but tonic drug. It will improve your brain balance. Don’t exaggerate the side effects! Don’t stop taking the medicine at your own will because the side effects of stopping the medicine will be greater. As long as you are cooperative, the dose can be reduced gradually and finally it’s not necessary to take any!

Dr. B explained to many patients in this way because such an explanation was more convincing to patients. Yet, some patients stop or reduce the dose of their medicine at their own will, which is beyond his control. He does not agree with some viewpoints in traditional Chinese medicine which argue western medicine can cause physical weakness. He thinks that western medicine can improve the balance of chemical substances in the brain and is a scientific treatment. However, the dialectical treatment of traditional Chinese medicine is often too complicated and requires frequent change of medicine based on patients’ different physical conditions. It also takes a long time to treat a disease. Sometimes, a long-time treatment doesn’t achieve the desired therapeutic effect. Because traditional Chinese medicine and western medicine have different or even mutually exclusive views, some patients often oscillate between the two approaches. One patient described his feelings: In the bottom of my heart, I accept the treatment of traditional Chinese medicine, and western medicines are somewhat poisonous, inevitably causing physical weakness. I feel really uneasy and worried at the thought of taking them for a long time because that means it will make me weak all the time. I used to take Chinese medicines before and that didn’t relieve my depression. Now I feel better after taking western medicines, but they make me drowsy. If I don’t take the medicines, I feel depressed. Have I been addicted to them?

Patients often show hesitation/vacillation towards the use of drugs. They generally hold a positive attitude and thus trust and cooperate with doctors, but at the same time they worry about the side effects and reject the use of drugs; they also fret about the uncertainty in curing the diseases if they do not take drugs. Moreover, such negative perceptions of psychotropic drugs are common not merely among depressive patients, but also among their relatives and friends, which intensifies their worries about drug use. Great progress has been achieved in the research and development of psychotropic drugs, yet many people still try their best to avoid taking such drugs and turn to alternative therapies. Alternative therapies include taking herb medicine (St. John’s wort, gingko, walnut tea, etc.), taking supplements (vitamin B, magnesium, zinc, folic acid, omega-3 fatty acids and tyrosinase), relaxation techniques (deep breathing, massage, aroma therapy, music therapy and meditation, etc.), doing exercise (Exercise produces enkephalins, morphines that keep people pleasant if they are at a normal state) and homeopathy (diluted extracts from plants, animals or minerals or bach flower remedies are used to trigger the body’s inborn curing energy). Of course, they have some effects on patients with minor depression, but are not appropriate for patients with major depression. Due to the gradual opening up of the pharmaceutical

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market in China, alternative therapies are gradually recognized and commercialized, which provides people with more choices of medical services. Moreover, other spiritual healing therapies, such as religion and meditation, also provide people with more options for treating depression. In short, people have a number of choices besides the two dominant treatments offered by western medicine and traditional Chinese medicine. The interviews show that patients not only weaver between traditional Chinese medicine and western medicine, but also look for alternative therapies, and some of them are doubtful about the two mainstream medical treatments. One of such cases is a patient who did not get better after having taken traditional Chinese medicine and western medicine for about two years. Later she converted to Christianity. At the beginning, she took to reading scriptures and praying as auxiliary treatment but did not find it useful. Sometime later she had a cordial talk with her pastor, who advised her not to pray at home but to do something meaningful to show her value. He encouraged her to work as a volunteer in Wenchuan, an earthquake-stricken area in the southwestern province of Sichuan. During the one month she did voluntary work there, she was physically tired but gained spiritual satisfaction. She did not take any medicine to fall asleep and came out of her depression. After rejecting Chinese medicine and western medicine, she was cured through the value and joy she found in serving others in prayer and volunteer work. Her experience reflects her constant search for medical treatment through actions first turning to Chinese medicine and western medicine and then to religion for cure. Such experience enabled her to question the existing methods of Chinese medicine and western medicine and led her to begin a new search for the meaning of life. By taking actions, she redefined the meaning of her life in Christianity. She maintained that illness was not just a punishment for a series of mistakes in a previous life, but also a gift from God to return to God, the source of all life, who alone can cure and save people. This kind of subjective interpretation is different from the objective medical knowledge. The patient’s value lay in her life world. She rediscovered her value by serving others under the call of God. She also redefined how to regain health. In short, her definition of mental health was reestablished on the religious resources she relied on, rather than on the western or traditional Chinese medical treatment. Some of the patients who suffer depression for a long time loathe the low efficacy of drugs. However, if they don’t take antidepressant drugs, they suffer from serious insomnia; if they take drugs too much, they suffer serious side effects. Therefore, they turned to other ways of treatment. Xiaojun went to see eight psychiatrists in 15 years. Her depression was alleviated, but not cured. In 2013, she turned to a psychological counselor and began receiving psychological therapy every two weeks. She said that she had always been afraid to see masks, even afraid to see them on TV, in newspapers or magazines. Later, her psychological consultant advised her to recall these masks every day. About half a month later, she found that the masks in her mind resembled her mother’s face when she hit her and the expression in the eyes, in particular, closely resembled that of her mother when she abused her. Later, the counselor told her that what she feared was her mother’s face, not these masks. Her fear of her mother stemmed from her frustrated and terrible experience in sweeping the floor

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when she was a child—she was beaten every time her mother saw that there was a section left uncleaned. She has been working since she graduated from technical secondary school and she needed to support herself economically. Even though she was ill, she had to work. Medicine let her sleep better. But the depressive symptoms lingered on. Taking drugs for a long time led to her irregular menstruation. She had tried several times to stop relying on drugs, but as soon as she stopped, she could not sleep, which made her more upset and agitated. She experienced the low efficacy of drugs. Afterwards, on the recommendation from her psychological consultant, she joined a religious community and socialized with other people more frequently. Many friends in the community accompanied her, enabling her to have a stable life with bible reading, praying and frequent socializing. Gradually she was no longer reliant on drugs for sleep. With this experience, Xiaojun expressed her view of depression and gave a new interpretation to her identity. She said: Health means a balance of body, mind and spirit. My depression is caused by my endocrine disorder, mental trauma and spiritual sin. Depression was a turning point in my life. At first I felt it was a stain, but it gave me the opportunity to re-examine my life and rebuild the order of my life. Although depression can be improved by medical treatment and psychotherapy, for me, the healing power of religion is the most important force to pull me out of depression.

Among the patients interviewed by the author, three have never sought psychiatric treatment. They learned about self-rating of depression from the Internet or books and newspapers and identified themselves as mentally ill. However, they sought neither western medical treatment nor traditional Chinese medical treatment, because they were worried about the side effects of western medicine and the excessive pesticide residues in Chinese herbs. Therefore, they turned to alternative therapies like massage, sitting still for meditation, listening to soft and soothing music, doing sports and seeking psychological counseling, and finally they got cured. These three patients were actually influenced implicitly by traditional Chinese medical proposition that taking western medicine could hurt kidney and liver. But they did not believe in the safety of traditional Chinese medicine either. Alternative therapies offer them more options. These alternative therapies are commercialized and made known to patients through the dissemination of information about depression. The fact that some patients came out of depression after seeking these alternative therapies is also due in part to patients’ acceptance. These are the six different reactions to the western medical discourse and methods in treating depression. It is found that when mental and emotional problems become more common and ways of treatment get more diversified (e.g. religion, psychological counseling, alternative therapies, and antidepressants sold in pharmacies), patients do not passively accept western medical treatment for depression, nor are they obliged to choose between traditional Chinese medicine and western medicine. Instead, they constantly endeavor to solve problems by taking active actions, which is in line with patients’ subjectivity highlighted in the interaction theory, namely, making good use of all the available resources to get themselves cured. In addition, they reinterpret the body by observing and analyzing their own abnormal state; they question the concept of body in the objective knowledge system constructed in the

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medical field; and inspired by their religious belief or alternative therapies, they redefine the meaning of body and derive a key element of medical treatment. This process of reinterpretation and repositioning of self is built on patients’ subjective feelings and cannot be explained by objective medical knowledge. Everyone has his own special medical treatment experiences. Such subjective categories that lie outside the objective knowledge of western medicine can be seen as phenomenological manifestations in opposition to the objective construction. Here, we can see that the development of neoliberal globalization is in line with Foucault’s concept of power: power is dispersed and pervasive rather concentrated and unique; it is productive rather than repressive. Similarly, medicalization is no longer just a form of repression coerced by society, but also a force for individuals to actively construct a new identity. In this sense, neoliberal globalization has shifted from “the repression of power” to “the productivity of power”. On the one hand, neoliberal globalization has “individualized” responsibility for health and disease issues and shaped the concept of individualized and autonomic health management. The key notion is that health is a personal matter, not a national matter. Individuals should solve their own physical and mental problems and stay healthy by turning freely to medical services or other channels of their own choice. As self-management of personal health gains in importance, so do the possibilities for individuals to be medicalized voluntarily. On the other hand, the rise of the consumer society stimulates people’s desire to consume (including medical care) and offers them multiple medical choices. The development of the neoliberal global consumer society satisfies the various demands of patients, even those who are uncertain in the choice of medical methods. In this sense, medicalization is no longer merely constructed by the doctors or the manufacturers, the government, academia and the media (representing the repression of power), but also by people who are willing to seek various medical treatments to keep healthy (representing the productivity of power). This is a bottomup style of medicalization, in which people voluntarily and actively seek different channels of treatment (including religion) rather than simply resorting to western medicine.

7.3 Summary The two chapters (Chap. 6 and this chapter) approached the social construction of depression in China from two angles. Chapter 6 focused on the social construction of the medical supply side, mainly the medical construction by the productiongovernment-research-media complex, which includes the expansion of the discursive discipline and self-discipline of health management by manufacturers, the government, academia and the media, and the way the four fields and non-governmental organizations and groups (e.g. social workers, psychological counseling) jointly construct the discourse of depression and the phenomenon of medicalization. While this top-down medicalization has completed the construction of some areas (e.g. classifying depression in Chinese Classification of Mental Disorders, CCMD for

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short, and accepting ICD’s disease labels), other areas remain underdeveloped (e.g. shortage of psychiatric staff, expensive psychological consultation, general practitioners’ lack of psychiatric training,). In a word, the social construction of depression in China is not as comprehensive as that in the west. There is not enough medical staff capable of uncovering cases of depression; therefore, the incidence of depression appears to be underestimated. This chapter centered on the social construction of depression from the demand side of health care, namely patients’ cognitive conflict reflected in the process of denying, accepting and constructing depression. We analyzed patients’ subjective conceptualization of depression from the cultural perspective of medical anthropology, the phenomenological perspective and the perspective of interaction theory. The analyses show that patients’ cognition and conceptualization of depression does not follow a linear and direct path (namely, simply accepting western medical treatment); instead it is a complicated process which involves their interaction, conflict and compromise with, and partial acceptance of, western medical treatment and the corresponding discourse. From the cultural perspective of medical anthropology, Chinese patients, under the influence of traditional Chinese medicine, tend to adopt somatized expressions, namely to communicate their psychological distress in the form of somatic symptoms rather than via the discourse of depression in western medicine, and depression is still seriously stigmatized. In addition, in the treatment of depression, patients have different reactions: some changed from earlier ignorance to later understanding, some changed from denial to acceptance, some sought medical treatment after searching for data by themselves, some sought medical treatment actively, some strategically acknowledged or denied depression, and some sought alternative therapies. Some patients relieved depression through other non-western medical treatments, especially by resorting to religion. Some cases also show that patients’ suffering experience in fighting depression has indirectly changed their outlook on and attitude towards life. Perhaps, it is when a patient realizes the limitations and deficiencies of western medical treatment that the initiative in his body gives a new meaning to the sick body so as to transform his suffering body and then gain a new understanding of his own existence. This has phenomenological significance. Most field research reveals cowardice, fear and evasion as more common reactions. There may not be many patients who are truly capable of giving a “meaning” to diseases under the current social and cultural structure and medical system. Religious belief, alternative therapies and different knowledge systems cannot guarantee that patients can get rid of the pain of a long-term disease. The transformation of patients’ perception of meaning is achieved through long-term cumulative training based on their physical experience. It is a process of high subjectivity, which is difficult for outsiders to sympathize with. It is because of the subjectivity of personal perception and transformation that non-western medical treatment methods are effective for some patients. It is also discovered that patients might disagree with western medicine and their actions often depended on how they made use of different resources, which was explicated from the perspective of interaction theory.

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Judging from patients’ overall cognition of depression, the above six categories of patients’ reactions to western medicine can be regarded as the reactions of six types of people or the different cognition of depression of the same patient at different stages of his life. A common phenomenon is that even if some patients do resist the label of depression, they are quite few in number and are often forced to accept it in the end. However, even if the label of the disease is accepted, resistance to medical treatment still exists. Under such circumstances, the many types of treatment available in the context of neoliberal globalization offer multiple options. Religion, as one of the options, provides comfort for patients in an era of extreme uncertainty and individualism. Turning to religion for comfort and cure has been developing vigorously since the 1990s. Along with the construction of depression discourse in western medicine, these non-western medical therapies, approaching depression from different perspectives, have indirectly strengthened the public’s construction of depression discourse. It is found that the name of “depression” is gaining wide acceptance by the public because of the multiple treatment methods, though different patients have different feelings about the name or western medicine treatment and have different coping strategies at different stages.

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Chapter 8

Conclusion: A Sociological Analysis of Depression in China

After the explanations and analyses in the previous seven chapters, let us return to the question raised in Chap. 1: “In spite of the continuous increase of depression patients, why is the lifetime prevalence of depression in China so low by international comparison?” This book has tried to answer this question within the context of neoliberal globalization and proposed a sociological analytical framework with a two-layered and two-faceted matrix—the “global/international level” and the “domestic/national level”, and the “social structure” perspective and the “social construction” perspective based on a detailed comparative analysis of five research paradigms in medical sociology. The analytical framework is presented in Table 8.1. The social structural changes derived from neoliberal globalization have indeed led to an increase in the number of depressive patients in all countries. In fact, China already satisfies the conditions for the medicalization of depression. After its reform and opening up, China was immediately impacted by post-Fordist flexible accumulation and rapid capital flows. This has led to drastic spatial and temporal changes. The urbanization and marketization on the largest scale ever in history have brought high mobility, changes in family structure and fierce competition, all of which have affected people’s life and work style. But such great changes have not been accompanied by correspondingly sound social systems. The pressure people face is much greater than in the planned economic era. Changes in the external environment have also led to psychological changes. People have become more and more individualistic. Under the push of consumerism, individuals are increasingly emphasizing the fulfillment of their own rights and desires, and the traditional value of devotion to the family is gradually declining. The trends of individualization and narcissism in China are becoming increasingly explicit and demonstrate features different from the West. This means that on the one hand, individuals are liberated from the fetters of tradition, while on the other hand, they are deprived of ontological security, which implies that they have to be responsible for their own choices. In addition, as a result of the democratization of intimate relationships, couples have to negotiate about less romantic things such as freedom, mobility, the demand for professionalism and economic equality. Communication has become a key foundation for maintaining © East China University of Science and Technology Press Co., Ltd. 2020 I. Hsiao, A Sociological Analysis of Depression in China, https://doi.org/10.1007/978-981-15-6471-0_8

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Neo-liberal globalization

Social structure perspective

The drastic temporal changes in neoliberal globalization can lead to depression because of the emphasis on time efficiency

Production side (drastic spatial-temporal Intensified uncertainty, immigrants’ changes): emotional problems caused emotional problems, changes in family by new social structures and work styles structure and blurred boundaries between work and life are the major manifestations of the spatial changes resulting from neoliberal globalization. Due to these changes, individuals are prone to emotional problems and depression

Global/international level

Table 8.1 Sociological analysis of depression Domestic/national level Conditions for depression

• The logic of competitiveness and the “good life” shaped by existing social norms function as the big Other (superego), which disciplines and supervises individuals of all age groups • In addition to pressure from fierce competition, there are pressures derived from high living costs and unsound systems

(continued)

Sufficient

• The social structure differs greatly from Sufficient the planned economy era, and people are under greater pressure • Individuals have a sense of uncertainty and have to face more problems resulting from high mobility (cross-border adaptation, acculturation, etc.), which may cause depression • Family crisis, including divorce, high living costs, extramarital liaisons, influence of depressed family members, etc. can lead to depression • Blurred boundaries between work and life can trigger depression

Situation in China

172 8 Conclusion: A Sociological Analysis of Depression in China

Neo-liberal globalization

Psychoanalytical perspective: depression in the capitalist discourse

Consumption side: socio-psychological context

Global/international level

Table 8.1 (continued)

Capitalist discourse to create split subjects, who in turn further consolidate capitalism. As a result, depressive patients as the split subjects continue to emerge

The competitiveness and social structure of neoliberal globalization have led to increased social pressure. With the development of science and technology, neoliberal consumerism enhances individualization. Such changes have led to more subtle emotional conflicts than ever before, resulting in depression.

Domestic/national level Conditions for depression

The phenomenon of “post-oedipal subjectivity” characterized by “moaning without illness” (sentimental groan and sigh) is less prevalent in China than in the West

(continued)

It can explain why the proportion of depression in China is lower than in the West, but it is not a sufficient condition

• People’s attention to the body increases Sufficient their desires • The increasing demands for technological gadgets and the Internet access intensify people’s desires • Only children are prone to develop a narcissistic personality • Emotional demands resulting from democratization of intimate relationships have escalated • The risk of uncertainty and a highly competitive social atmosphere render individuals with high expectations more likely to be frustrated and depressed

Situation in China

8 Conclusion: A Sociological Analysis of Depression in China 173

Social construction

Construction by the production-government-research-media complex (the supply side)

Global/international level

Table 8.1 (continued)

The production-government-research-media complex develops the pharmaceutical industry. Pharmaceutical enterprises, the government, experts and the media have developed a complex relationship due to their mutual interests to promote the top-down medicalization of depression

Delayed and lurking

• The trends of individualization and the narcissistic society are more and more obvious • Labor rights are rising and improving • The narcissistic characteristics of only children are more obvious than that in the past • People have more desires, and their awareness of rights and consumption have been on the rise

Insufficient

• There is a shortage of psychiatric professionals • General practitioners do not know enough about psychiatry • Psychological counseling is expensive

(continued)

Under construction

• Officials, non-governmental organizations and social workers pay more attention to the prevention and treatment of depression • Consumption of depression drugs is on the rise

Depressive symptoms and labeling of Sufficient symptoms are officially regulated (in various versions of the CCMD modeled on globally accepted systems such as the ICD and DSM)

Conditions for depression

Domestic/national level Situation in China

174 8 Conclusion: A Sociological Analysis of Depression in China

The public’s cognition and conceptualization (the demand side)

Global/international level

Table 8.1 (continued)

Different cultures have different degrees of acceptance of Western medicalization of depression. In terms of the objective pathological descriptions and their subjective cognition of depression, patients often experience conflicts and then reach compromise to various degrees. However, neoliberal globalization has provided them with numerous meta-medical alternatives, which can promote the bottom-up medicalization of depression

Domestic/national level Conditions for depression

• In traditional Chinese medical culture, Lurking depression was more often articulated in a somatic way, which was not necessarily considered as depression • “Stigmatization” of depression has always been explicit, and the rate of patients seeking psychic treatment is low • People who obtain antidepressants with prescriptions are not counted as patients • Alternative therapies are commercialized, and patients often vacillate among traditional Chinese medicine, Western treatment and alternative therapies. Patients who only seek alternative therapies are not counted • Search for relief and treatment via religions

Situation in China

8 Conclusion: A Sociological Analysis of Depression in China 175

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good marital relations. However, a couple of two individualized subjects may experience frequent conflicts to maintain the balance between “self-rights/self-realization” and “rights and interests of both parties/realization of both parties” in the modern era which emphasizes self-rights and self-realization. When the new psychological needs derived from fulfilling personal rights and desires encounter the social structure with uncertainty and insecurity, the result is split subjects and frustration becomes a norm. In such a context, depression is just around the corner. However, from the perspective of Lacanian psychoanalysis, China has not yet entered the stage of the “post-Oedipal subject” as in Western societies. Therefore, Chinese individuals do not seek “the oppressor(s)” in the way their Western counterparts do. Nor do they “moan without illness”. Symbolic paternal authority is retained in China and to some extent suppresses the capricious “moaning-withoutillness” mentality. Due to the imperfect labor and social systems, the universality of overwork in the global labor division system, and the competitiveness with Chinese characteristics functioning as a big Other, individuals are forced to solve the problems they encounter everyday on their own and so have no chance to be capricious. Such interpretations can partly explain the lower rate of depression in China. However, they are still insufficient because of the development of individualization and narcissism, which are manifested as increasing awareness and improvement of labor rights, the more explicitly narcissistic personalities of only children, rising desires and demands for rights, and an increasing awareness of consumer rights. These factors make depression in China a looming phenomenon. The above social structural analysis of depression is not complete, outlining only a general picture, because depression is a product of both social mechanisms and individual responses. The social structural analysis has sorted out the social changes in neoliberal globalization that can trigger, but not inevitably lead to depression. These changes have also given rise to new self-protection mechanisms, like the new family form in which the grandparents help take care of their grandchildren, easing the burdens and pressures of younger couples. There are many complicated micromechanisms and contingencies behind the occurrence of depression, and individuals’ interaction with the social environment, other people and events also play a role. The social structure presents the potential conditions for the occurrence of depression, but it cannot explain the inevitability of depression. Therefore, the social structure is not a causal deterministic factor for depression. However, we cannot deny the explanatory power of neoliberal globalization for depression because it is an unavoidable fact that, in comparison with the more stable economic structure in the Fordist era or the planned economy era, new emotional problems do result from the uncertainties in neoliberal globalization. The “social construction” perspective on depression compensates the deficiencies of the social structural analysis. First, the Production-Government-AcademiaMedia Complex medicalizes depression, with different degrees of construction in different aspects. For instance, the top-down medicalization of diagnosis standards for depression have become quite developed, as manifested by the publication of several versions of the CCMD and the acceptance of depression categories found in the ICD, while other areas of the top-down medicalization are underdeveloped. These

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areas include a shortage of psychiatric professionals, general practitioners’ insufficient knowledge and understanding of psychiatry, and the high cost of psychological counseling. As a result, the social construction of depression in China is not as complete as that in the West. In other words, there are not enough psychiatric professionals to “reveal” depression, which leads to an underestimation of its prevalence. Second, the public cognition and conceptualization of depression is characterized by the following features: (1) due to cultural influences, people tend to understand depression in terms of somatized symptoms, rather than psychological pathologies; (2) depression is still seriously stigmatized; and (3) psychologically, patients may not accept Western medical techniques of treating depression and are constantly looking for alternatives. Because of these features, the public’s construction of depression is a complicated process which involves their interaction, conflict and compromise with, and partial acceptance of, Western medical treatment and the corresponding discourse. Ultimately, they are unable to counter the globalization trend of Western medicine, and depression is gaining wider recognition and acceptance. The social construction of depression in China has its unique characteristics, yet it is still necessary to interpret it in the context of globalization. The reason is that it is inevitable for China to adapt to the global psychiatric framework of depression when depression, as a mental disease constructed in Western medicine, is introduced into its own medical system. On the whole, depression has become a “globally recognized” illness. Agents who accept this “globally recognized” illness (international and domestic experts and the Production-Government-Academia-Media Complex) promote its construction and dissemination by manipulating various interests and power relationships (e.g. Chinese psychiatrists modeled the CCMD on the ICD or DSM to achieve a homogeneous medicalization of depression, and the hegemony of Western medicine exists in the medical systems of various countries). However, each nation embedded in this “global recognition” is simultaneously affected by multiple and usually very complicated mechanisms. The more a certain form of recognition is institutionalized, the more the “recognition” is “embedded” into such systems as laws, customs, organizations, etc. This can lead to the result that the “recognition” is assimilated and integrated in one area (e.g. CCMD), resisted in another (e.g. the stigmatization of depression), and contended in still another (e.g. neurasthenia remains a category in the CCMD). Therefore, the social construction of depression has come to different degrees of completion in China. In spite of the unevenness in the social construction of depression, the social construction on both the supply and demand sides consolidates the social operation of depression in many ways. After examining the social construction on the supply side, let us look at the demand side. There are two trends that deserve attention. First, sales of antidepressant drugs are on the rise. Depression sufferers are ashamed to seek psychiatric treatment, but their behavior of buying drugs privately reflects that they are constantly seeking treatment. The stigma of depression prevents some of them from openly admitting their condition. Second, the public is willing to accept the power on the production side, namely, the diversified alternative therapies to traditional Chinese medicine and Western medical treatment resulting from medical commercialization. These alternative therapies are not a denial of depression itself,

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but they are not included in the standard medical treatment of depression. Depression as an illness has not been rejected by the public. Instead, new methods for its treatment have been accepted. Therefore, when depression is medicalized in the context of globalization, therapies other than Western medical treatment also contribute to the social construction of depression. In other words, although people have not wholly accepted the psychiatric treatment of Western medicine, many other social networks, by proposing treatment methods different from psychiatric treatment, have facilitated the social construction of depression and consolidated the public’s cognition and conceptualization. These two trends reveal that neoliberal globalization directs power to production rather than repression. When patients recognize the disease and actively seek treatment, it shows that the social construction of depression is not limited to the top-down process on the supply side, but extends to an active bottom-up construction on the demand side. The latter is not formally included in the Western medical construction of depression; rather, it is patients’ voluntary behavior of seeking solutions on the drug market and in therapies other than Western medical treatment. In our view, this is an important part of the social construction of depression. Reviewing the analytic framework, we want to emphasize that the analysis of depression in China has to be placed within the context of globalization; therefore the double-layered “global/international” and “national/domestic” perspective is of great significance. Due to the inadequacy of a purely social structure analysis, the perspective of social construction is more critical to a systematic interpretation of depression. On the whole, in terms of the social structure of depression, China has an economic structure similar to the global economic structure. To be more accurate, Chinese people may endure higher pressure due to the high cost of living and incomplete social systems, which has already laid the foundation for depression. However, the social construction from both sides is inadequate or invisible. The conditions for generating depression on the supply side are still insufficient or incomplete, while on the demand side, many hidden cases are not counted. Once the “social construction” on both the supply and demand sides has sufficient conditions, a large number of depression patients are bound to emerge. It is thus clear why the proportion of depressive patients in China is lower than worldwide. Finally, it should be added that the proposed sociological analytical framework provides a comparative approach to the study of depression, comparing China’s unique features with the global situation of depression. This is the major contribution to sociological research in China. The framework may also be applied to analyzing the complex process of the adaptation of Western medical terms in other non-western countries. It can also be used to compare the depressive features in other countries with the “global/international” situation (replacing “China” in Table 8.1 with other countries). However, more comparative studies are needed to refine the framework and enhance its explanatory power. We certainly do not claim that we have listed all the factors for a comparative study of depression. We hope that, like the proverbial “cast a brick that attracts jade”, the present study can inspire others’ future research, which can refine the present framework and come to more valuable findings and interpretations. Our encouragement to all our research fellows!