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Paper

Barrier to treatment in Shenzhen, China: a qualitative study on the experiences of Chinese families facing eating disorders

abstract

Background. Eating disorders (ED) have become a rising mental health problem affecting children and adolescents in China since the Open Door Policy in 1980s. If not properly treated, the effects of the disorders on children and adolescents would be devastating. Early identification and early treatment are vital to ensure speedy recovery.
Drug treatment alone for ED is ineffective. Outcome studies conducted in England have shown that family therapy is superior to individual psychotherapy in treating emaciated children and adolescents aged 18 or below and with an illness history under 3 years (Russell, Szmukler, Dare & Eisler, 1987; Russell, Dare, Eisler & Le Grange, 1992). In Hong Kong, Ma and Lai (2006) assessed the applicability of family therapy in helping emaciated Chinese children and adolescents with encouraging and promising treatment outcome. Due to small sampling, the findings of this study cannot be generalized to other Chinese societies like Shenzhen.
In Shenzhen, treatment for the emaciated children and adolescents are bio-medical oriented. There is a dearth of family treatment for children and adolescents with ED. In view of this service gap, the first author has been offering family treatment to the afflicted children and adolescents three years ago in Shengang Family Treatment Center, the first family treatment centre in South China, excluding Hong Kong. Nevertheless, the engagement rate in Shenzhen is roughly 30%, in contrast to 86% engagement rate in Hong Kong; delayed treatment is common too.
Although contiguous, Hong Kong and Shenzhen differ significantly in their political, economic and social systems, the history of development and the degree of westernization. Shenzhen is located directly to the north of Hong Kong. Shenzhen has been rapidly transformed and urbanized since the 1980s from a rural town under a highly collective society with a planned economy into a vibrant city with an economy that is very much market-driven. Its population has increased from 314,100 in 1970 to nearly 6 million in 2005 (Shenzhen Statistic Bureau, 2002). The majority of Shenzhen's residents consist of young migrants from different parts of the Mainland China, predominantly from the rural provinces, looking for work and opportunities. However, there is a significant lag in the development of social institutions (e.g., development of social services). Cultural values and beliefs remain unchanged; for instance, the agricultural-patriarchal family patterns of interaction have tremendous influence on Shenzhen people's beliefs and behaviours.
While the study of eating disorders has attracted the interests of Chinese mental health professionals in the past two decades, little has been known on the treatment barriers for Shenzhen emaciated children and adolescents. Numerous studies have been published from 1980s onward, which can be roughly grouped into three types: (a) clinical summaries and clinical reports (Sung & Fang, 1990; Chen, 1990; Wang, 1999; Tai, 2001; Ding & Hun, 2001); (b) assessment of psychometric measures developed in the West for disordered eating, namely EDI (Zhang & Kong, 2004; Chen, Leung, Wang & Tang, 2005); and (c) a study of psychological factors predicting dieting (Xiao, Gail & Asian, 2001). Not a single study can be identified in Mainland China in general and in Shenzhen in particular, which aims to examine factors accounting for the low engagement rate and delayed treatment.
Learning the subjective experiences of the afflicted patients and the families in help-seeking will have direct implications for clinical practice and policy formulation, specifically in assisting them to overcome the treatment barriers and participate actively in treatment.

Purpose. Three burning questions have come to the authors' mind in the past years of clinical practice:

  • What are the essential factors affecting the motivation of these afflicted patients and families to seek family therapy?
  • Why do some of these patients and families drop out from the treatment?
  • How does a family therapist overcome these treatment barriers?


This paper reports the results of a qualitative study of ten Shenzhen families, whose members have sought family treatment or are going through family treatment for eating disorders in the centre, with the main purpose of addressing the above research questions. Multiple-cases study was employed as the research design. With the written consent of the participants, data were collected through the review of the video-tape of the family treatment sessions and individual interviews with the emaciated children and adolescents, using open-ended questions.

Key findings. There are four themes related to ambivalence in seeking help and the low engagement rate emerging from the participants' narratives: (a) The different expectations toward professional relationship between Shenzhen parents and the family therapist coming from Hong Kong, as well as the effects of the disparate expectations on developing rapport with Shenzhen children and adolescents with ED: Chinese parents in Shenzhen wanted to develop both primary and professional relationships with the family therapist before treatment but the family therapist only wished to establish a therapeutic relationship that is instrumental to helping. The emaciated children and adolescents had inevitably perceived the therapist as the alliance of their parents. Power struggles between the afflicted parents and children, usually evolving around eating versus non-eating, were common. The perception of the therapist as the parents' alliance had negatively affected the emaciated children and adolescent to participate in treatment. (b) Stigmatization of mental disorders in society and its linkage to drop-out in treatment: Shenzhen parents tended to conceptualize eating disorders as physical diseases rather than as mental disorders, due to the stigmatization effects of mental disorders in Chinese society. The onset of a mental disorder is a shame to the family, the parents and the afflicted children and adolescents. A patient narrated: "I don't like to come to the hospital because I don't wish to be laughed by my friends and my teacher. (c) The cost of treatment and the service barriers: Health care services in Shenzhen is operated on a self-financed mode; the treatment fee is RMB$300 (US$38) per session, which is quite high for low income families. The average monthly salary of employees in 2004 in Shenzhen was RMB$2,263 (US$290) (Shenzhen Government Online, 21/1/2008). Besides the high treatment fee, a few patients and families who were residing in the rural area of the province had to travel a long way to the centre. The travelling expenses and the long distance did affect the frequency of attendance of these families. (e) The afflicted patients, their families and helping professionals' insufficient knowledge of the disorders: The Shenzhen parents' bio-medical conception of the disorders had affected their help-seeking behaviours. Lacking the psychosocial perspectives, family therapy was never the parents' first choice of treatment. They usually shopped around different health care centres before coming to our centre. Helping professionals' knowledge of the disorder was as little as that of the parents, which accounted for the delayed referral and delayed treatment.
Findings of this study show that Hong Kong family therapists, whose professional knowledge is acquired mainly through Western training, have to be culturally sensitive and competent to resolve the engagement problem brought about by the intra-cultural practice that are present in family treatment.

Key references
Ma, J. L. C. & Lai, K. (2006). Perceived treatment effectiveness of family therapy for Chinese patients suffering from anorexia nervosa: a qualitative inquiry. Journal of Family Social Work, 10, 59-74.
Russell, G. F., Szmukler, G. I., Dare, C. & Eisler, I. (1987). An evaluation of family therapy in anorexia nervosa and bulimia nervosa. Archives of General Psychiatry, 44, 1047-1056.
Shenzhen Statistic Bureau (2002). Shenzhen Annual Statistic Report. Shenzhen, China: People's Republic of China.

Acknowledgement
This study was funded by the Research Grants Council of Hong Kong (CUHK 4294/03H) and the Shenzhen Research Grant (Project code: 200404182).

Contacts: Joyce L. C. Ma, R. S. W., Clinical Member & Approved Supervisor, AAMFT., Ph.D., and Professor, Department of Social Work, The Chinese University of Hong Kong, Shatin, New Territories, Hong Kong, China. E-mail: joycelai@cuhk.edu.h,. Phone (852)-2609-7513, (852)-2603-5018.

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