Can't You Relate?Family Therapy in Taiwan

Hsiao Ming, currently in elementary school, was always a good and considerate little boy in his mother's eyes. But in the last year or so his behavior has had her deeply concerned. At home he's argumentative, frequently mistreats his younger brother, and rebels against being corrected. At school, he is often in conflict with his schoolmates, and his schoolwork has deteriorated. He and his father are like fire and ice, and the father has already declared that he has given up trying to teach the child anything. Thus the mother decided to accept the suggestion of Hsiao Ming's teacher and take him to see a psychological counselor.

First the counselor heard Mom relate the problem. Afterwards he spent an hour talking with Hsiao Ming alone. The therapist discovered that the most direct cause of the change in Hsiao Ming's behavior was the birth of his younger brother. Hsiao Ming began to feel that his mother was spending all her time looking after his brother, and ignoring him, and he began to show signs of regression. The therapist suggested that the mother spend more time with Hsiao Ming, and hug him as often as she can, so that he will know he is still loved.

The therapist also worked to resolve the anger, fear, and other emotions Hsiao Ming felt as a result of being neglected and misunderstood. After several sessions, Hsiao Ming's behavior definitely showed a turn for the better. However, the counselor did not believe that this was the end of the problem. He also spoke separately with Hsiao Ming's mother, and discovered that the root of the problem in the relationship between father and son went much deeper still, to the marital relations of the parents.

The father in this family spent a lot of time at work, with the mother taking care of the home. Over a long period of time, marital relations had gone out of balance. Worse, with the main male figure in the family so frequently absent, when Mom needed a man around, she often unwittingly prompted her son to play that role. For example, when she was pregnant with her second child, often it was Hsiao Ming who accompanied her to the hospital for check-ups.

In addition, these close relations between mother and son caused the father to feel frozen out, and he developed a subconscious jealousy toward Hsiao Ming. After this, the therapist held a meeting with both parents, and undertook marriage and family counseling. The main goals were to bring the husband and wife closer together, and to encourage the husband to devote more time to his family, in order to reduce the heavy burden Hsiao Ming felt as "substitute man around the house."

Teenage children's feelings are unstable, and they are under a lot of pressure at school. Family understanding and support is most important.

The scapegoat

Chao Shu-hua, a counselor in the family services unit of the Hsinchu Catholic Social Service Center, says: "The problems of the child are often simply a manifestation of larger family problems, like an iceberg whose tip is a visible but whose vast mass lies beneath the water. In fact the problem usually is with the family or the marital relationship." In her eight years of clinical work as a family therapist, in only a very small percentage of cases has the child's problem truly arisen from personal biological or psychological factors. "If you only explore deeper, in most cases you find that there's a problem with the parents or the family system."

She concludes, "Children are often the scapegoats. They are defined as 'the patient,' and thereby must accept the responsibility for reflecting larger family problems."

This idea comes from a main pillar of contemporary psychological therapy-family therapy theory.

Traditional therapy focused on the individual. Family therapy, on the other hand, does not consider the origin of psychological problems to be found completely in the individual. Rather, starting from the systems approach, it sees the family as a system, and if any member of that system has a problem, this may be connected to problems in system itself. Thus, the therapist looks not only at the problems that appear on the surface with the individual as a member of the family, but also at the relationships all the family members have with one another.

Treatment focuses on adjusting and improving the poor interaction that has been established in the family, in areas such as the division of labor, the power structure, and emotional relationships.

The Taipei City Psychiatric Center has established a special department of family therapy. Dr. Yang Lien-chien （second from right） has brought together social workers, psychologists, nurses, and other experts to form treatment teams. They constitute one of the "scarce" and "valuable" family therapy resources in Taiwan.

Family outing-to the psychologist?!

One question many people ask when they hear about family therapy is: If it addresses the family as a unit, is it necessary for everyone in the family to go to the therapist together? If someone is unwilling to cooperate, can family therapy make any progress?

Huang Yu (a pseudonym) has experienced this problem. From a young age, her son's reactions lagged behind those of his little friends, and his schoolwork was less than ideal. Her husband, a high-ranking civil servant, could not accept what was going on, and often called the child "stupid." This created a wall of ice between father and son, and the boy once even ran away from home.

For her son's sake, Huang Yu sought help from psychological counselors in religious groups and hospitals. But because her husband was unwilling to go along, several counselors said that there was nothing they could do. Her family simply muddled through day after day in this frozen state. "If my husband had been willing to go right from the start, who knows, maybe things would be a lot better today."

The idea that the whole family must go together "is a relatively early and narrow definition of family therapy," explains Chao Shu-hua. "Today the definition of family therapy is much broader, and means the exploration of individual problems from the viewpoint of the family system." So long as one is willing to discuss family problems, even if only one person seeks therapy, it can still be beneficial. This is because each individual is a member of the family system. If he or she changes, this could promote improvement in the whole system. In the past few years, this theory of approaching individual problems from the standpoint of the family system has become increasingly widely adopted in Taiwan. A number of books on the subject have been translated into Chinese and have sold quite well.

There are also a number of support groups based on the family. One example is the "family reconstruction" groups which are becoming increasingly widespread. These are formed from groups of a dozen or so to several dozen individuals. Under the guidance of the group leader, they seek out the key problems in individual cases, by having members of the group role-play to reconstruct a model of the family situation of the individual concerned. In this process, like a little play, individual problems can be replayed and explained.

Family system

Wang Ching-fen (a pseudonym), now 35 and working in the media, was helped by such a support group and the information it provided. "In the past I often felt confused about my relationship with my family. When I moved away from home to take a job, I missed home very much, and wanted to move back to live with my family. But, within a very short time after going home, I couldn't stand it anymore, and had to flee," she says.

Later, she participated in a family reconstruction therapy group, which used role-playing as a tool. In role-playing, the director brought her back to reconstruct her family situation when she was a child. She discovered that at that time, her parents were working constantly to satisfy the family's material needs, leaving her feeling neglected, alone, and unloved. "After I grew up, although I desperately craved affection, I was stopped by fear of being hurt and tied down, and by unresolved resentment from when I was child." After understanding her parents' situation, and after several painful episodes, she finally felt free of her resentment, and has been able to rebuild relations with her parents and family.

A family may "fall ill" because in the course of its life history it is exposed to shocks and stresses. Countless factors can affect the functioning of the family system: A child is born, matures, starts school, leaves home; relations sour between husband and wife; there is an accident. . . even political and social change matter. When a crisis is overwhelming-such as an affair, a death, financial crisis, illness-and the family cannot cope, that is when the family "falls ill."

Cheng Yu-ying, who has been a leader in founding and researching support groups, and who is currently an assistant professor in the department of social work at Fu Jen Catholic University, has-based on her vast experience-come up with several types of family problems common in Taiwan. For example, in families with a strong tradition of favoring men over women, the men may suffer from excessive expectations, while women are repressed or neglected. Moreover, given the Chinese tradition of "not airing one's dirty laundry in public," many problems such as domestic violence or sexual abuse remain dark family secrets. "Chinese families particularly stress mutual reliance and loyalty, and ask that members sacrifice for the sake of the family. As a result, many people find that their ability to stand on their own is damaged."

The root of the illness

Chen Chung-ming, director of the department of psychiatry at Provincial Taipei Hospital, states: "Unfortunately, often family members are unaware of or are unwilling to face problems. Long-term neglect or hiding of problems can lead to a serious crisis in the family." Based on his clinical experience, he has discovered that many of his patients require family therapy.

"Many psychological disorders are due to family problems. But patients who are unaware of this can spend vast amounts of time and money going to this department and that, but they can't get any explanation or help with their problem," says Chen. For example, many women suffer depression, psychological disorders, and anxiety, and although their physical condition is a factor in the illness, often the fuse is lit by family problems. For example, a woman might have been exposed to tremendous stress in taking care of the family on her own, or perhaps was subject to gender discrimination or gender inequality in power sharing and so on. In such cases, social workers and psychologists from the department will try to help the patient by using family therapy.

Yang Lien-chien, who was instrumental in setting up a special family therapy clinic at the Taipei City Psychiatric Center (TCPC), points out: In fact, the theory and practice of family therapy is a development that arises out of research into individual cases of psychiatric disorders.

He explains: "From both the psychiatric literature and clinical experience, doctors discovered that there's a peculiar phenomenon with people suffering psychological disorders. Once they're in hospital, the disorders can be controlled quite well, but when they return home, not long thereafter the symptoms re-emerge." Doctors thus became curious about the family backgrounds of their patients, and social workers were sent to investigate. The result has been the discovery of many dysfunctional families.

"Psychological illness is a scapegoat-it is simply an acute condition reflecting a family problem. If you cannot change the patient's family system, so that it becomes a support system, it will be very difficult to improve the patient's condition," he says. This is why he has devoted himself so much to family therapy: Not only has he founded the special family therapy clinic at the TCPC, he has also brought together other psychiatrists, social workers, and outside people from related fields to organize a group to study and treat the problem; together they help patients and record and collate case studies from Taiwan's own experiences with family therapy.

Over several years, they have discovered that the scope for the application of family therapy is enormous. For example, it can be applied to crises at every stage in a person's life, from education, to juvenile delinquency, to marriage problems, to the "empty nest syndrome." It applies to interpersonal relations such as those between husband and wife, parent and child, within the nuclear family, and even one's relationship with one's own self. And it applies to aberrant behavior such as stuttering, bed-wetting, alcoholism, drug addiction, bulimia, and psychosomatic illness.

First destroy, then rebuild

Chen Juo-chang, a professor at Tsing Hua University and one of the earliest to apply family therapy in Taiwan, devotes most of her attention to domestic violence and sexual abuse. She relates that when she was in the US studying about 15 years ago, she did an internship in a psychiatric hospital. There she met fathers guilty of incest. She discovered that the hospital staff had integrated family therapy theory into their techniques for handling the problem. First the daughter was isolated from the parent, then marriage counseling was conducted between husband and wife, and then there were therapy sessions between the daughter and, separately, the father and mother. "They started by destroying the family, and then moved on to rebuild the family," she says. "The ultimate objective was to get the abuser to recognize his own behavior, admit it, accept responsibility, and apologize to the victims."

After returning to Taiwan, Chen worked diligently to bring the theory and methods she learned into this country. Working with a social service agency, she handled individual cases of domestic violence. She has come away feeling somewhat powerless and disappointed. "We worked for more than 10 years for the enforcement of the domestic violence prevention law, but even today there are still stories every day in the paper of child abuse, spousal violence, and sexual abuse."

She says that what most deserves attention is that, while there is now legal protection for victims, relevant agencies such as those handling social work, medical treatment, and police and judicial functions, don't know how to proceed beyond separating the victim from the abuser. "We only know how to do the destructive work, but we do not know how to rebuild."

Getting to the root of the problem, Chen says, "There are not enough courses offered domestically on this, there are too few experts and practitioners, and there is little contact or cooperation between specialties." Moreover, she adds, the general public needs to be better informed. Chen, who founded a course at Tsing Hua University on "marriage and family" that is open to all students regardless of major, believes that exploration of the family system should not be limited to professionals, but should be a kind of parenting skill taught to everyone.

Expensive and scarce resources

Cheng Yu-ying says, "If you want to have the resources for family therapy integrated into social work and the medical system, the government will have to provide more and take the initiative." These resources, however, are still "expensive" and "scarce" in Taiwan. It can cost thousands of NT dollars for a single session in a support group. This is not something that most middle- and low-income families can afford.

It would be even more difficult to make training for practitioners widely accessible. In the past those interested in this field had to go abroad to learn. It was only in 1987 that the Shiuh-Li Liuh Memorial Foundation, a private group in Taiwan, established the Taiwan Satir Center. This center has invited specialists from abroad to give courses every year, and is currently the most important location in Taiwan for professionals to study family therapy. Yet, as one social worker says, "It costs well over NT$100,000 to complete the entire two-year course. You won't get any help from your agency either, you have to pay for it out of your own savings."

As for medical facilities, currently even general psychiatric treatment resources are scarce, much less resources devoted specifically to family therapy, which requires much more time and manpower. Only the TCPC and a few psychiatric clinics have family therapy departments.

Chinese people have always been proud of the emphasis placed on family. In fact, the many family problems currently being uncovered now reflect not a decline in this emphasis, but greater concern for the quality of family life. Thus there are many new laws related to the family which are allowing the legal system into the home, and exposing many dark corners and secrets of family life. The problem is, how can we go a step beyond to improve family values? Obviously this will require many more resources.