Help-seeking in Taiwan’s socio-cultural context

Medical anthropology emphasizes that help- and health-seeking behaviors exist within the broader context of illness behavior: the pattern of behaviors individuals tend to adopt throughout the course of an illness (Chrisman, 1977). The main categories of illness behaviors are (1) recognition and interpretation of illness, (2) communication of illness to others, (3) changing of social role, (4) seeking attention, help, or treatment, and (5) response to treatment. In summarizing research from medical anthropology, Zhang (2007) concluded, “Illness behavior and health-seeking strategies are

complicated processes that respond to a complex of personal, social, and material exigencies and involve negotiating among diversified perspectives and resources available to patients and their families” (p. 2). To account for the diverse range of health- and help-seeking services in different cultures, medical anthropologists discuss the concepts of medical systems and medical sub-systems. Medical systems are

coherent sets of illness-related beliefs, knowledge, and behaviors (Seijas, 1973), which consist of multiple overlapping medical sub-systems. Sub-systems are unique sets of illness-related etiological beliefs, explanatory models, definitions, classifications, diagnoses, treatments, assessments, prognoses, and prevention strategies (Chang, 1989,

p.119; Kleinman, 1980). Medical anthropologists have studied Taiwan’s diverse medical system extensively, and generally agree that Taiwan’s health-seeking

subsystems include Western medicine, Traditional Chinese Medicine (TCM), and folk healing (Ahern, 1975; Chang; Gould-Martin, 1975; Kleinman; Wu, 1978).

In creating a classification of help-seeking sub-systems for this research, we first considered the above classification of health-seeking sub-systems. Western medicine can be considered a help-seeking sub-system for two reasons: it includes the specialty of psychiatry, and is involved in treating and referral of patients who present to doctors with somaticized psychological distress. For example, 51% of first-visit attendees of a family medicine clinic in northern Taiwan had at least one Clinical Interview Schedule (CIS) psychiatric diagnosis (Liu, Chen, & Cheng, 2004). In addition, as will be

discussed later, TCM and folk healing are used in treating both physical and

psychological distress. Thus, we propose three main categories of help-seeking sources in Taiwan: (1) counseling, (2) Western medicine, and (3) indigenous healing which includes two main subcategories, TCM and folk healing. We include TCM and folk healing in the same category in order to draw a clear contast between counseling as a non-native healing system and indigenous healing as a set of healing systems developed over many generations in a specific cultural context.

Tseng (1999) provided a concise overview of the similarities and differences between counseling/psychotherapy and indigenous healing:

“…‘psychotherapy’ will be defined broadly as a special practice involving a designated healer (or therapist) and an identified client (or patient), with the particular purpose of solving a problem from which the client is suffering or promoting the health of the client’s mind. The practice may take various forms,

such as a religious healing ceremony, a special experience or professionally defined interaction between the healer and the client. The fundamental orientation may be supernatural, natural, biomedical, socio-philosophical or psychological. In folk therapy, healing practices, ceremonies or health-promoting exercises may be applied to resolve the problems, without being perceived as ‘psychological therapy.’ In contrast, in other practices, particularly professional psychotherapy, the therapist and the patient both recognize that the procedure is primarily for ‘treating or resolving a psychological problem’ and that they are engaged in an activity for that perceived purpose. Thus, there exists a broad spectrum of ‘psychotherapy,’ in terms of basic orientations, methods and goals to be achieved” (p. 132).

Thus, different types of help appear to have similar core characteristics. However, the differences are significant, especially in terms of the interaction between help systems and their socio-cultural contexts. This topic is further discussed later in this chapter.

2.1.1 The development of counseling in Taiwan

The field of counseling originated in the early 20th century vocational guidance movement in the United States, and then spread to Europe and other areas of the world, and is continueing to grow worldwide (Gerstein, Heppner, Stockton, Leong, &

Ægisdóttir, 2011; Stockton, Garbelman, Kaladow, & Terry, 2007). There is a distinct internationalization movement characterized by a global perspective, international cooperation, and attention to the indigenization of counseling in diverse cultures (Leung et al., 2009).

In Taiwan, the seed of the counseling profession was the school guidance and career counseling movement that was founded in response to the challenges faced by students in an era of rapid industrialization and urbanization (Bigelow, 1989; Brammer, 1967). In the 1970s, secondary schools began to employ “guidance teachers,” whose responsibilities included leading in-class activities, psychological assessment, career guidance, and individual and group counseling (Chen, 2003). A rising suicide rate combined with the devastating 921 earthquake in 1999 provided the impetus for the legal establishment of the counseling psychology and clinical psychology professions (Chen; Wang, Kwan, & Huang, 2011). In November 2001, the Psychologist Act was passed, defining counseling and clinical psychologists as medical professionals under the supervision of the Taiwan Ministry of Health, and establishing graduate training and licensure requirements for practice (Lin & Hsu, 2008; Wang et al., 2011). Currently, counseling psychologists in Taiwan work as counselors, consultants, and supervisors in a wide range of locations, including universities, non-profit organizations, primary and secondary schools, and community counseling centers (Lin, Hsieh, & Sun, 2008; Wang et al.).

2.1.2 Indigenous healing in Taiwan

Indigenous healing refers to the body of knowledge and practices developed in a culture to treat illnesses. The practices of counseling and indigenous healing both aim to heal, but their healing theories and techniques are different (Burnhill et al., 2008; Tseng, 1999). Central to all psychotherapies, whether Western or indigenous, is a focus on the place of the individual within society and the suffering experiences encountered in this social context Yee (2005, p. 906). Lee, Oh, and Mountcastle (1992) identified three common characteristics of indigenous healing across cultures, including facilitation of

support via family and community networks, incorporation of local spiritual beliefs and practices, and shamanistic healing rituals. Most indigenous healing interventions possess the therapeutic factors that account for much of effectiveness of psychotherapy (Tseng, 1976; see also Kleinman, 1980, p. 244). Specific characteristics of indigenous Taiwanese healing systems that contribute to their popularity and efficacy include a focus on concrete improvements, shared healer/client explanatory models of illnesses, and healers’ attention to clients’ socio-economic contexts (Kleinman, 1980; Yee, 2005).

In Taiwan, the two systems of indigenous healing used in treating psychological distress are TCM and folk healing (Kleinman, 1980; Unschuld, 1985; Xu, 1982). There is considerable overlap between the two systems, and diversity within them (Kleinman, 1980; Lin, 1980). TCM developed through the integration of practitioners’ clinical experiences and a variety of classical Chinese philosophical ideas, including yin/yang, the five phases, the concept of qi (Kleinman, 1980; Unschuld, 1985; Zhang, 2007), Taoism, Confucianism, and Buddhism (Chung et al., 2012), and the medicine of

systematic correspondence (Unschuld, 1985). TCM is a holistic healing system in that it diagnoses and treats humans as a unified system embedded in social and natural

contexts (Chi et al., 1996). Emotional disorders are treated as a distinct category of illnesses termed qingzhi bing, which correspond to various behavioral, somatic, and psychological symptoms (Zhang, 2007). TCM has seven categories of emotions: joy, anger, anxiety, pensiveness, grief, fear, and fright. Each organ produces essential qi, from which the different emotions arise. Emotions are intimately connected to specific organs: the heart corresponds with joy, the liver with anger, the spleen with pensiveness, the lungs with anxiety, and the kidneys with fear. Emotions are seen as natural reactions to environmental stimuli. However, when the intensity or duration of emotions surpass the body’s ability to cope, yin and yang become unbalanced and the circulation of blood

and qi are blocked, resulting in disruption of the normal functioning of the

corresponding organ. The relationship between emotions and the organs can also go in the opposite direction when disruptions of the normal functioning of organs can cause dysregulation of emotions. Like other illnesses, emotional disorders are treated with herbs, acupuncture, and qi manipulation techniques (Xu, 1982; Yang, Phelan, & Link, 2008)

Past research provides a picture of the utilization of TCM in Taiwan. In 2001, 28.4% of Taiwanese used TCM services at least once, while in the six-year period from 1996 to 2001, 63% used TCM services at least once (Chen et al., 2007). Past research has identified demographic factors related to TCM utilization. Men and unmarried people are less likely to use TCM, while those with higher education levels or folk religion beliefs are more likely to use TCM (Chang et al., 2008; Chou, 2001; Shih, Liao, Su, Tsai, & Lin, 2012; Shih, Lin, Liao, & Su, 2009). The most commonly utilized TCM treatments were Chinese herbology (44.1%), therapeutic massage (24.8%), spooning (24.2%), massage (21.1%), medicinal herbs (18.6%), acupuncture (17.1%), and cupping (16.4%; Shao, Chang, Chou, Chen, & Hwang, 2011).

The second main type of indigenous healing currently practiced in Taiwan is folk healing. Kleinman (1980) identified two types of Taiwanese folk healing, secular and sacred folk healing. Since then, Taiwan’s National Health Insurance (NHI) has begun to cover TCM treatments, which have significant overlap with secular, but not sacred, folk healing. Unfortunately, we were not able to find any studies on the changes in Taiwanese folk healing caused by the implementation of NHI. Sacred folk healing is an extension of Taiwanese folk religion that is used in the treatment of physical and psychological distress (Chang, 1989; Lee, 1985; Liu & Yee, 2005; Unschuld, 1985).

Illnesses are viewed as resulting from supernatural causes, most commonly malevolent

spirits, and therefore have treatments which focus on the supernatural (Chang). Sacred folk healing practitioners in Taiwan include shamans (such as jitong), spirit media (such as ang-i), chien interpreters, and Taoist ritual masters, with the most common

interventions appearing to be exorcistic and spirit calling rituals (Chang; Kleinman, 1980; Lee; Lew-Ting, 2003; Yee, 1986). Among traditional Taiwanese folk healing practices, shamanism, divination, and fortune-telling are similar to Western counseling interventions in that they share a quasi-therapeutic relationship between practitioners and clients that is a key factor in their effectiveness (Tseng, Lee, & Lü, 2005). These three practices are discussed below.

In 1979, Kleinman and Sung reported that spirit media called jitong played a significant role in psychiatric care, crisis intervention, and general health care in Taiwan.

Jitong rituals begin when the healer enters a trance, during which he is believed to be possessed by a god and to have the ability to mediate between the world of humans and the spiritual world. Clients consult with supernatural beings through the jitong (Lin, 1980). To observers, the healing powers of jitong are ascribed to the healer’s

authoritativeness, making suggestions, and instillation of hope (Tseng et al., 2005). Yee (1986) studied the characteristics of 138 clients of a jitong in Taipei. The majority of clients were female (81%) and came at least two times per week (70%). Most clients were of lower socioeconomic status, and they came to ask for advice or to resolve problems involving family members, interpersonal disputes, or somatoform disorders.

In divination, the diviner or interpreter uses religious or supernatural methods to foretell the future. In Chinese cultures, temple-based chien interpretation is a common divination practice. Clients seek specific answers to important questions in their lives.

After offering incense to the main god of a temple, clients choose a chien stick from a large basket. The answers on the chien are written in an esoteric way, so interpreters

(often elderly) are available to interpret the answers into specific, concrete responses to clients’ questions. These answers usually include culturally-sanctioned coping strategies and culture values (Hsu, 1976).

Finally, fortune-telling is based on the assumption that humans are a microcosm of the universe. The ancient text The Classic of Changes (Yi Jing) can be used to determine one’s fate based on the exact date and time of birth and number of strokes in the Chinese characters of their name. Like divination, fortune-telling practitioner-client interactions involve transmission of cultural values and concrete advice (Tseng et al., 2005). Yee (2005) ascribed the healing properties of fortune telling to guidance and symbolic meaning.

Inconsistent findings exist for the utilization of folk healing in Taiwan. Yee (1986) found that the families of many Taiwanese university students who grew up in the 1960s and 1970s had experience with folk healing rituals such as spirit calling (41%), temple-based rituals (27%), making offerings to temple gods (60%), or visiting a jitong or Taoist ritual master (13%). In contrast, a nationally representative sample conducted in 2002 found that most respondents (86.1%) did not utilize sacred folk healing in the previous twelve months. Among those who did utilize, spirit calling (10.9%) was the most common, followed by jitong ceremonies (3.0%), fortune telling (2.8%), and Taoist rituals (2.6%; Lew-Ting, 2003). Although Kleinman (1980) reported anecdotal evidence that many well-educated Taiwanese were unwilling to use folk healing, no significant differences in the rate of sacred folk medicine utilization was found as a function of gender, age, or education level, but utilization was generally lower in larger cities (Lew-Ting). Wen (1998) found that the majority of individuals (84%) currently receiving psychiatric treatment reported previous utilization of folk healing, but in a different sample, Pan, Chen, Teng, Lu, and Shen (2005) reported that

only 35% had previously used folk healing. These inconsistent findings on folk healing utilization may reflect the diversity of Taiwan’s folk healing systems or changes in folk healing in recent years.

2.1.3 Help-seeking in Taiwan

Values are a key feature of culture and cultural differences (Bond, 1996).

Researchers such as Neville, Worthington, and Spanierman (2001) and Sue and Sue (2012) have presented compelling evidence that mainstream counseling contains culture-bound values. Counseling developed in the context of mainstream Euro-American cultures, and as a result, the assumptions and values of counseling largely reflect those of white, educated, middle- to upper-class Westerners (Das, 1995). These culture-bound values include an emphasis on the individual, an etic perspective that assumes mental health and illnesses are the same in all cultures, a dualistic view of mind and body, and the assumption that communication should be characterized by directness, assertiveness, emotional expressiveness, and self-disclosure (Corey, Corey, Corey, and Callanan, 2014; Lewis-Fernandez & Kleinman, 1994; Pedersen, 2003; Stiles, 1995).

Despite the accelerating growth of counseling in Taiwan in recent decades, it is still often seen as a Western cultural product, with research and practice still heavily biased towards Western cultural content (Lin, 2001a), having not fully adapted to the values of Taiwanese (Leung & Chen, 2009)

Past research (e.g., Hwang, 2009; Kwan, 2000; Saner-Yiu & Saner-Yiu, 1985) has identified Chinese values specifically relevant to psychological help-seeking, including filial piety, collectivism and hierarchy, social role expectations, emotional control, achievement orientation, reciprocity, high power distance, and high uncertainty avoidance. Traditional and modern Chinese cultures are strongly influenced by

Confucianism, Daoism, and Buddhism (Yan, 2005; Zhang, Lin, Nonaka, & Beom;

2005). Confucianism has a particularly strong influence on help-seeking in Chinese societies because it is a philosophy of individual self-cultivation and interpersonal relationships, including specific concepts such as (1) the emphasis on ren (benevolent love), li (etiquette), and he (harmony) in interpersonal relationships, (2) zhongyong (the doctrine of the mean) as the ideal way of resolving problems, (3) emphasis on proper behavior within societal and familiar roles, and (4) self-cultivation as the route to happiness and maturity (Yan, 2005). Chinese Culture Connection (1987) identified four factors in the Chinese Value Survey, termed Integration, Confucian work dynamism, Human-heartedness, and Moral discipline. Bond (1996) identified four culture-level values in Chinese people: individualism-hierarchy, orderly autonomy, discipline-assertion, and human-heartedness. Many of the values described above appear to conflict with the culture-bound values of counseling, and may have implications for how Taiwanese view counseling.

Lin (2001b, 2002) interviewed Taiwanese university students to understand their perspectives on seeking help from a counselor and help-seeking in general. Lin (2002) identified four fundamental helping-related beliefs. First, participants viewed help-seeking as a sign of weakness, preferring to solve problems on their own. Participants associated formal help-seeking with shame, weakness, and embarrassment. Second, participants would only seek formal help for serious conditions. Third, participants would prefer a helper familiar to them. Fourth, help from important others such as friends or family was the ideal source of help.

A number of core beliefs about counseling were also identified (Lin, 2001b).

Participants viewed counseling as a helpful resource for a range of issues, including academic and career problems, problems with interpersonal relationships, psychological

symptoms, and physical symptoms such as sleep or eating abnormalities. Participants believed that counseling was most necessary for those with unresolved or severe problems in life, those without a strong support network, and those with specific personality characteristics such as pessimism or low self-esteem. Few participants expressed willingness to use counseling. If they had problems, they would seek help from friends, family, and others close to them first. Most participants viewed counseling as a last resort, but a few would never be willing to see a counselor due to discomfort, concern about confidentiality, or lack of perceived effectiveness.

Unfortunately, there is currently insufficient data on help-seeking behaviors in Taiwan to identify clear patterns of utilization of different help sources, or to understand which factors influence help-seeking behaviors. Anthropological work conducted by Kleinman (1980) and Chang (1989) provides valuable information about factors that influence help-seeking in Taiwan’s socio-cultural context, Kleinman delineated ten factors that affected health care seeking and help-seeking behaviors in Taiwan: type and severity of symptoms, course of illness, type of sick role, sickness labels and etiological beliefs, evaluations of treatments, demographics of patient (i.e., age, sex, role in family, occupation, education), background of the patient’s family (e.g., socio-economic status, modern vs. traditional value orientation), urban or rural residence, proximity to

treatment resources, and the patient’s social network and lay referral system. Similarly, Chang conducted anthropological fieldwork examining the socio-cultural, structural, and individual influences on the utilization of diverse medical sub-systems in a rural village in northern Taiwan. Socio-cultural factors were related to the village’s geography, economy, mass media, and the villagers’ religious beliefs and social activities. Structural influences included the availability and affordability of medical services. Individual factors included medical beliefs and individual characteristics.

Notably, females and those with higher SES used health services more. Lower SES and older age were associated with more frequent use of folk healing, and younger age was associated with more frequent use of Western medicine.

Two surveys of Taiwanese university students show that rates of counseling utilization appear to be low.Chang (2008) surveyed 995 first-year Taiwanese university students. Among the 316 students who reported experiencing distress in the previous month, a majority indicated seeking informal help from classmates or family members, while only 16 (5.1%) saw a doctor and 11 (3.5%) sought counseling in the previous month. In a sample of 666 Taiwanese university students, Wang (2010) found that 89 (13.4%) had previously seen a counselor, with significantly more females (58) than males (31) falling into this category.

2.1.4 Help-seeking attitudes

In the literature on help-seeking, there are many conceptual frameworks for understanding the factors which influence help-seeking. To date, however, none of these frameworks have gained broad acceptance (Gulliver et al., 2012). The theory of

reasoned action (TRA; Ajzen & Fishbein, 1980) is perhaps the most commonly used framework for understanding the relationship between counseling attitudes and actual utilization (Nam et al, 2013; Vogel, Wade, & Hackler, 2007), although recent finding have called its validity into question (Hammer & Vogel, 2013).

Because of the methodological difficulties involved with measuring prospective help-seeking, help-seeking research often uses various proxies for actual help-seeking, the most common of which is counseling attitudes (Nam et al., 2013). Counseling attitudes are consistently associated with previous counseling utilization (e.g., MacKenzie, Gekoski, & Knox, 2006; ten Have et al., 2010) with mostly medium or

higher effect sizes (Elhai, Schweinle, & Anderson, 2008). To date, several studies have examined variables related to counseling attitudes in Taiwan. Mirroring international findings (e.g., Nam et al., 2010), females have more positive counseling attitudes than males (Chang, 2007; Chen, 2006; Wang, 2010; Yeh, 2002). Among Taiwanese

adolescents and university students, higher levels of depressive symptoms are related to more negative counseling attitudes (Chang, 2007; Chen, 2006), interdependent and independent self-construals are positively correlated with counseling attitudes, and collective self-esteem is negatively correlated with counseling attitudes (Yeh). Wang found a number of psychological variables to be significantly correlated with counseling attitudes, including anticipated utility, anticipated risk, social stigma, stigma,

adolescents and university students, higher levels of depressive symptoms are related to more negative counseling attitudes (Chang, 2007; Chen, 2006), interdependent and independent self-construals are positively correlated with counseling attitudes, and collective self-esteem is negatively correlated with counseling attitudes (Yeh). Wang found a number of psychological variables to be significantly correlated with counseling attitudes, including anticipated utility, anticipated risk, social stigma, stigma,