If you are clinically depressed, no matter which number you press, no one will answer.
Fortunately this is just a joke that has been going around recently. But psychological care really has become a hot topic in Taiwan of late. . .
What image do you have of psychiatrists?
Are they the type often described by the American movie director Woody Allen? A wooden-faced psychoanalyst listens to a patient reclining on a couch. The patient rattles off streams of associations until the session comes to an end and the analyst presents him with an enormous bill. Or is your image more like the ultra-intelligent, almost-demonic killer depicted in The Silence of the Lambs? Or maybe you've seen the recently popular Good Will Hunting and long for a mentor like the utterly trustworthy doctor who inspires Will to face the future.
Psychiatrists and those who work in clinical psychology are more than just characters in books and movies. In real life they play complex roles, and are complimented and criticized in equal measure. With the increasing occurrence of psychological disorders in modern society, the field has been growing. And those who work in this field are increasingly becoming the object of public debate.
An example of this new public debate occurred just a little over two months ago when Yu Pai-nung, who refers to herself as a psychological counselor, announced to the media that she planned to publish a book on convicted felon Chen Ching-hsing. The uproar stemmed from her intention to reveal both the results of psychological tests which she conducted on him and the contents of their counseling sessions. Both academic and practicing psychologists were shocked by her violation of the patient's privacy and basic rights. They felt she had breached their most important professional ethic-doctor-patient confidentiality.
But the most disturbing fact about the incident was that investigations into Yu Pai-ning's background revealed that not only did she not teach at any school, she also did not belong to any psychological counseling institution or group. Chung Shi-kai, a professor in the psychology department at National Chengchi University, says that under the current medical system, professionals of every stripe, including doctors of every specialty and nurses, all have legal requirements to meet and tests to pass. All have a certification system. What is infuriating to him is that there is no such certification system for psychological counselors, psychological testers or clinical psychologists. Because no legal standards or sanctions are stipulated, you can't go after Yu for practicing without a license.
The relevant bodies have begun giving serious consideration to the questions of licensing standards and supervisory organizations for clinical psychologists. The Department of Health, which oversees medical care in Taiwan, has also sped up its efforts to produce a "Law on Clinical Psychologists" to govern their practice. The Taiwanese public, however, still has many questions about the role and capabilities of psychologists. Originally all in the family
"Within the medical field, the position and capabilities of psychologists are, in fact, well defined. They are one part of the psychological treatment team," says Dr. Hwu Hai-Gwo, a professor in the psychiatry department at National Taiwan University Medical College. Hwu says that in a hospital, psychological treatment is handled by a team made up of a psychiatrist, nurses, a clinical psychologist, a social worker and an occupational therapist. Each of these persons has particular skills and a defined area of work.
He explains that when a patient first comes into the hospital, he is examined by a psychiatrist who treats his acute symptoms, such as insomnia, anxiety or depression. After his symptoms have been moderated, a clinical psychologist evaluates the patient's personality and his physical and mental condition. Based on this, the clinical psychologist then provides counseling. If the patient's abilities have deteriorated, an occupational therapist designs a rehabilitation program, which might include planning some recreational activities or interpersonal relations training. When the patient's condition has stabilized and he is ready to re-enter society, a social worker is brought in to help him readapt.
This method of treatment is an American transplant. In the US, clinical psychologists were working as assistants to psychiatrists even before the start of the Second World War, helping them with psychological testing of patients, as well as assisting them in understanding the patient's personality and mental state.Going out on their own
The American medical community gradually came to realize that psychological disorders are not always caused by entirely physical factors; cultural background, society and the patient's own mind all play a role. In addition, the two world wars left the US in need of a great many professionals to treat soldiers afflicted with psychological and emotional disorders. These factors, plus their own hard work, came together to help clinical psychologists carve out their own niche. They expanded the scope of their work to include training, treatment, rehabilitation and research and began to play a more important role in psychological treatment.
The development of the profession has translated into genuinely effective psychological treatment. Their methods help patients overcome nervous disorders and the symptoms of psychological illness, and help them better adapt themselves to life. It is difficult to take a step back and analyze our own problems coolly and objectively, whether they be large or small; we are too closely tied to them. But psychologists can provide us with this objective perspective. If we can work together with an experienced, well-trained psychologist, the results are often very good.
Clinical psychologists have moved far beyond their original positions as psychological testers working under the supervision of doctors. They are now healthcare professionals in their own right. With society's affirmation of their work, they have developed an independent profession. Every state in America now has its own certification system for clinical psychologists, allowing them to set up their own practices providing psychological care.
Lately, any number of "psychologists," "counselors," "marriage counselors" and "professional counselors" have been appearing in all varieties of media in Taiwan, from television to books, providing counseling and resolving problems. In fact, this is exactly what has professionals in the field most concerned.
"Most people don't really appreciate that psychological counseling and treatment are different things; they operate on different levels and have differing characters. The market is full of people who have tagged a 'professional counselor' onto their name and are trying to help people resolve their problems. This is confusing the public's understanding of professional counseling," says Chung Shi-kai.
Even more worrisome is that these so-called professionals often behave in an unprofessional manner, becoming improper models.
At the beginning of this year, a "lovers' quarrel" between a member of the media and a government official became public. At that time, the marriage counselor of one of the principals called a news conference on behalf of her client, trying to smooth over the quarrel. Although the counselor's loyalty was moving, it didn't seem that way to scholars of psychology. They instead bemoaned the fact that the counselor had gone beyond the bounds of counseling and had entered into the realm of public relations.
"In fact, this also reflects our society's needs," says Wang Hao-wei, a doctor in NTUH's psychology ward. Wang looks at this situation from the perspective of supply and demand. Something only appears on the market when the public has a demand for it. He cites publishing as an example. Based on his own observations, psychology books for the masses began to enter the publishing mainstream in 1981. And these are not just translations of books by foreign writers; local authors are also beginning to write on the subject.Pop psychology
For years, non-psychologists have been writing books which dissect and analyze topics such as the mind, the heart and marriage, relying on their own unique views, life experience and their concern for others to win the trust of their readers. One of the most famous of these has to be Madame Wei-wei, who has been writing a newspaper and magazine column for more than 20 years. In her Feelings and Life, she mentions that the Taiwanese never used to spend money to tell someone their problems. Even if they were evidencing very obvious signs of a mental problem, they would attempt to cover them up and would avoid seeing a doctor. Nonetheless, people wished they had someone to talk to. This situation inspired Madame Wei-wei to give them a mailing address for "someone to talk to." Now, however, "most readers ask me to give them the name of a real psychologist where they can seek more professional advice."
"Going to see a psychological counselor is not so prevalent among Chinese. This is because they already have so many people to whom they can speak," says Han Liang-lu, who has recently been an object of media attention for his explorations of astrology and fortune telling. Han says that the "right to privacy" is a completely Western idea. In Taiwan, even now some families don't allow family members to close the door to their own rooms. According to Han, "Following the same logic, there are a lot more opportunities for people to speak openly to one another here than in the West. Although this might have created a loose-lipped, gossipy culture, it also has the effect of decreasing the distance between people and reducing their anxieties."
But Taiwanese society is growing ever more industrial and those with the time to listen to a long story are growing fewer. Urbanization has also made interactions between people more complex. Some of the psychological problems of modern people are not like those of the past, which were comprehensible to the average person. For this reason, more people have been going to see psychological counselors over the last few years. The numbers of people waiting to see a doctor in the psychiatric wards of hospitals or at institutions which provide psychological care provide ample evidence of this.No certification system
Society's need is growing by the day, "But in Taiwan, the independence of clinical psychologists has yet to be formally acknowledged," says Hwu Hai-Gwo. He says that psychiatrists, nurses, social workers and occupational therapists are all regulated by law and have clear licensing systems. Only clinical psychology lacks these. "Perhaps it's because the field of psychology is so large in its scope that it is difficult to define. Moreover, anybody can talk about psychological problems. Family, friends, teachers, priests and ministers all can act as counselors. For this reason, no one has ever examined the problem with much rigor."
Currently, medical organizations in Taiwan all set their own standards for clinical psychologists, most of whom are graduates of the psychology departments of local colleges and universities.
Local educational authorities and certain individuals are also making a push which is gradually increasing the perceived importance of counseling work. Primary and secondary schools as well as colleges and some social services organizations are all establishing counseling centers. But there are major differences in the standards for and qualifications of those employed by these institutions.
Lee Tien-tse, an assistant professor in Fu Jen Catholic University's mental rehabilitation department, expresses concern about this situation in his Professional Ethics for Psychological Care Workers. In it, he writes that enthusiasm, patience and compassion are not enough to be a counselor. A high degree of professional skill and a strict oversight system are also necessary to ensure that counseling doesn't lead to greater confusion.Media stars
The lack of a licensing system and professional oversight has left the public with no means to recognize genuine professionals. "In addition, the media demonstrates little selectivity and does little filtering on behalf of the public. This has allowed some publicity seekers to turn themselves into media stars by manipulating the media," says Wang Chueh, an assistant professor in National Taiwan University's department of public health. This has been a major reason why many people have been able to misuse titles to sell "professional knowledge" which is untested, worthless or for entertainment only.
The allure of fame is hard to resist, but professionals have a responsibility to rein in these non-professionals. "The media creates stars at its own whim, and is often an accomplice in damaging professional judgment and ethics," states Wang Chueh. Wang feels that one of the reasons the Yu Pai-ning case created such a sensation was that it involved Chen Ching-hsing, who had already been made a star by the media. Seduced by the prospect of fame and fortune, Yu made use of Chen. The likelihood of high book sales led to a publisher accepting the project without looking into the professional ethics of the matter.
For these reasons, the Mental Health Association in Taiwan will hold a series of seminars in October to discuss the connection between the media and the psychological health of society. The association hopes that the media will use recommendations that come out of these discussions to improve the quality of their reports.Let's play a game!
Popularizing professional theories and techniques to meet the demands of the market is not a bad thing in itself. But without legal oversight, counseling may too easily be vulgarized, stereotyped and misunderstood.
"A lot of people lump psychological counseling in with fortune telling," says Han Liang-lu. According to Han, those who go to see counselors are usually dealing with a particular kind of problem, such as a marriage crisis, nervous anxiety, problems with gender identity or sexual problems. These problems are rarely resolved in just one session. Instead, they require long-term evaluation, counseling and treatment.
People who go to a fortune teller for advice, on the other hand, might ask about anything. Love, marriage, health, work and money are all fair game. Seeing the fortune teller doesn't take so long, either. With just a one-hour visit, it's like you have seen your psychologist, marriage counselor, doctor, financial advisor and priest all rolled into one. With one visit, you get temporary relief. But you don't get a deep understanding of your problem.
The psychological testing which plays an important role in counseling is another widely misused aspect of psychological care.
Recently, local variety shows have been using sets of images to test popular actors and singers, and by means of these tests, allowing viewers to learn more about the likes and personalities of these pop stars. One particular self-proclaimed psychoanalyst is often invited to shuttle between these shows to administer the tests to performers. The analyst has the performer sign his or her name, or draw a simple picture which is then analyzed. The feature is very popular with audiences.
Having been tortured by major exams and minor quizzes since childhood, there are few Chinese who do not blanch at the word "test." Yet, somehow, everyone gets excited about psychological tests. Most of us have had the experience of being together with some friends chatting when someone begins to give another person one of these psychological tests. Everyone goes rushing over, curious to see and excitedly trying to make sure that they are next. And more of these testing games are appearing in newspapers and magazines where they attract readers.A medium for communication
The reason for the popularity of these tests is similar to that of astrology and blood-type analysis. "Modern people's interpersonal relations are complicated and confused. Understanding oneself and others has become something that people are very concerned about," says Wang Hao-wei. Wang admits that when he sees a column of this sort in the leisure section of the paper, he spends a minute or two testing himself. "They sometimes inadvertently touch on aspects of personality. This makes people feel that the games are somewhat accurate and pricks their interest. If the games stimulate interaction between people, then perhaps they can be thought of as a means of communicating with others in your leisure time."
Looking at this from a scientific perspective, such tests employ statistics and the principles and methods of analysis, so they are not completely inaccurate. "Psychological testing is a distinct field within the larger realm of psychology. Most of these tests have been carefully designed, intensively tested and statistically analyzed," says Ko Yung-ho, director of the department of psychology at National Taiwan University. Ko says that psychological tests are frequently used by clinical psychologists to help them understand their patients. They most frequently employ the principle of projection. When people have thoughts and feelings that are not easy or even impossible to express, such as unconscious experiences or desires, they often project them onto certain objects or scenes. Psychologists can use these projections to see a person's hidden personality and their internal life. These tests often incorporate images of journeys, forests, the home and mirrors because they are easy for people to associate with their lives, their selves and their desires.
"However, the form and content of real psychological tests is totally different from those out on the street, which typically only employ one topic or image together with a few simple answer choices," says Ko. The tests used by clinical psychologists, on the other hand, have been carefully and professionally researched. Their validity has been tested again and again. They are only used after their effectiveness and reliability has been proven. And when they are used, they require an experienced professional to interpret. This process is "psychological measurement," one of the primary tasks of a clinical psychologist.Peer pressure
If the public misunderstands something, professionals have a responsibility to set the record straight. But, "Most psychologists in Taiwan are focused on their own research or clinical practice. They just tend to express an attitude of disbelief towards the media, or ignore it completely," says Chung Shi-kai. He adds that in addition to correcting the media, professionals should also be carrying out "quality control" on their own field to increase the confidence of the public in psychological care and improve its collective psychological health.
The work of psychological professionals is "people" work, the major portion of which involves them with issues including respect for human feelings, life's struggles, adaptation to life and even questions of life and death. Sometimes, the misgivings they inspire and the demands made of them exceed those placed upon other medical care givers. Both in Taiwan and in the advanced countries of the West, this results in frequent discussions and disputes about the field and those who work in it. Of these, those that occur most frequently concern psychologists who have exceeded the bounds of the counseling relationship by having a relationship with a patient that goes beyond friendship or by using the patient to satisfy the doctor's own needs.
With Taiwan still not having passed a law regulating clinical psychologists and lacking a formal national certification, for the moment the island must rely on organizations trusted by the public to fill the gap.
Lee Tien-tse says that in countries where the field of psychological counseling is more developed and mature, scholars and practicing professionals typically organize themselves into professional associations. Each of these has its own clearly stated list of professional ethics. "On the one hand, these provide guidelines for professionals. On the other, they also serve to protect patients who are seeking counseling. They allow the profession to maximize its effectiveness and provide the best service to care-seekers."
Local organizations, such as the China Association of Counselors, have also set their own ethical guidelines which cover the counselor's responsibilities, the basic rights of the patient, the counseling relationship, doctor-patient confidentiality and the scope of counseling services. "But, in fact, the level of importance attached to these guidelines is determined by the counseling organizations and individual counselors. And it was not demanded of most counselors that they spend much time on professional ethics while they were undergoing training," says Lee.A license doesn't guarantee understanding
Sophie Liu, executive counselor at the Shuih-Li Liuh Memorial Foundation, which provides individual counseling and development classes, says that when a professional group is evaluating a counselor or a psychologist, important areas of consideration include not only the candidate's background and skills, but also his character and beliefs. These latter two are factors which do not appear on any license. "Those who seek the help of a counselor often have nowhere else to turn and are in an extremely fragile state. The counselor must respect the patient's basic rights as a person and his values system. He must also be aware that the focus of his work is to provide a service to the patient."
Lee Tien-tse believes that professionals must follow ethical guidelines. However, he acknowledges that the guidelines are not sufficient to every circumstance. "All the ethical problems which come up occur in the very large gray area that exists between right and wrong, between black and white." He says that the counselor's character, life experience, values, religious beliefs and compassion for people all affect the counselor-patient relationship. And it is these factors which determine the effectiveness of treatment.
The counselor's particular character and values often influence the method of treatment. For example, abortion, rape, divorce, and suicidal or murderous tendencies can lead to unfortunate values-based conflicts between the counselor and the patient.
There are many schools of thought about psychological care, each with its own theories and methods. And the theoretical basis from which a psychologist operates is an important factor in the effectiveness of the treatment a patient receives. For example, in The Family Crucible, an American book on family therapy much admired by the psychological community in Taiwan, the writer mentions a case in which an adolescent patient was originally diagnosed as being schizophrenic. However, another group of psychologists reevaluated her case from the perspective of family therapy and found that she was a scapegoat for a problem marriage. In treating a problem, you must get to the root cause.Becoming a person
"From another perspective, the public are consumers with respect to psychological care. They should know how to protect their own rights," says Sophie Liu. Liu says that this is explicitly stated in the counseling guidelines and professional ethics of many groups. For example, in addition to being able to request that the counselor strictly observe doctor-patient confidentiality, a patient can also ask that the counselor present his credentials before formally beginning treatment. If there is something that makes the patient uncomfortable during treatment, he can say so directly. A patient also has the right to change his counselor. "Consumers certainly have the right to choose and the right to protection."
In helping people, the most important thing is to earn their trust. The reason the psychologist in the movie Good Will Hunting is able to do so is that in addition to his professional abilities, he dares to take up the challenges his patient offers him, adjusts to the patient's needs and respects the patient fully. He supports his patient in his development of an autonomous personality. It is only when this kind of excellent relationship exists that we can say, "Those seeking psychological treatment are healthier than those who are unwilling to do so."
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