As I (Patti) approach the end of my five-year contract as Head of Counselling and Wellbeing at the China campus of a UK university, and with the likelihood that as borders reopen, Chinese students will again form a large proportion of international students studying at UK universities, it seemed a good time to reflect on what I have learned about counselling Chinese students, in case this can be helpful to colleagues working with Chinese students in UK university counselling services.
It is important to note from the outset that, by definition, I will be generalising, based largely on my experience, both as a clinician and a service manager. While Chinese students come from a more homogeneous society than students from many other countries, they are nevertheless as diverse as other students in temperament. This distillation of my learning, however, has been honed in discussion with a number of Chinese colleagues who hold a range of professional and academic roles within the university. In particular, some of the ideas in this article were formed in conversation with and were critiqued by a previous member of our counselling team and the second author of this article. That said, I am happy to acknowledge that any misunderstandings or over-interpretations are entirely my own. In fact, in writing this, I have purposely chosen to raise points with which I expect some colleagues either here or in the UK might disagree. This is based on a long-standing belief, which has been strengthened by my experience in China, that there is always learning to be gained from critical reflection on new ideas.
When I came to work at this university, I noted that the proportion of students using counselling relative to the total student population was quite small (less than 2%) and in particular that ‘domestic’ (anyone from Mainland China) students were significantly under-represented among service users. I was aware that this tendency of Chinese students not to access counselling or mental health support was a common phenomenon in the UK university counselling services.1,2 However, that, coupled with the discovery that many of the students with the most serious mental health issues or with the highest levels of suicidality were from the domestic population and had never accessed counselling, led to my first goal, that of increasing access to the counselling service for our domestic Chinese students. As 88% to 90% of the university’s students are from the domestic Chinese population, success was going to mean a significant increase in clients. Two-and-a-half years later, we reached the goal of Chinese students being proportionately represented among counselling clients, and currently overall demand for counselling by Chinese students is 120% higher than when I first took up post. However, in the process of getting to this point, I decided I must gain more understanding of what might prevent Chinese students from accessing counselling and which were the most significant issues they would need counselling to help them address. It is some of this understanding that I offer for your critical reflection below.
The impact of family structure and approach to parenting
The paradox of being a single child
Something for which China is well known is the ‘one-child policy’, which affects the generation who are currently attending university. Most of the students we see and most who currently attend UK universities will be single children, but it is not that being a single child is inherently problematic. It is this interaction with family values which I think creates many of the difficulties Chinese students experience at university. If you are a single child in China, you are likely to be the focus of attention of all your family, including both parents and both sets of grandparents. On the one hand, this attention can create feelings of entitlement and lack of awareness of and concern for the needs of others, and on the other hand, it results in tremendous pressure to meet the future hopes and expectations of your entire family. Traditionally, you may be considered responsible for your ancestors as well as living relatives, which can feel like a huge burden. In my mind, this creates a dichotomy between ‘having it all’ as a child and ‘owing it all’ as an adult, with the former leaving the individual ill-prepared for the latter.
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This situation can result in one of the issues that students most often bring to our counselling service – feelings of helplessness, hopelessness and sometimes meaninglessness, as they struggle to navigate a path which allows them to meet their responsibilities to their family without entirely foregoing the needs and desires they have to live their own lives in their own way.
Lack of resilience
Most Chinese children and young people whom I have met are, by Western standards, overprotected. They are commonly not allowed to take their own decisions and are frequently ‘helped’ by their parents to avoid the consequences of their own behaviours. For example, I have known many students whose parents asked their doctor friends or who have paid consultants to write medical notes claiming their children were sick in order to have a second chance at writing important exams, when actually the students tell me they just hadn’t studied enough. In addition, most students we see describe having no conversations about feelings or how to handle difficult situations with their parents. It seems difficulties are either ignored or managed by their families, leaving young people with no experience of having to think through or handle their own problems. When I first began counselling students here, our sessions reminded me of conversations I had with my daughter at about age 10–12 years, about how to understand the perspective of others and how to address difficulties with her friends. In fact, this building of resilience is one of the central features of our counselling work with domestic students. They are, of course, capable of developing these skills, but as with children elsewhere, need support and practice.
I am aware as I write this, that the concept of ‘resilience’, as I know it, is a very Western construct and demands a considerable degree of flexibility. Conversations with my co-author reminded me that a quite different set of skills and a more rigid behaviour structure might be necessary for survival or success in life in China. These are likely to include academic competence, compliance with rules, maintenance of family/group harmony and a focus on the interests of the group over those of the individual.
However, lack of resilience, as it is understood in the West, may become particularly significant when students attend a university abroad, where they are bound to encounter challenges and where they are considered to be adults and expected to make their own decisions.
Inexperience in delaying gratification
Initially, I found myself somewhat irritated by student emails which requested (I sometimes felt, demanded) counselling at short notice. From new clients, it is relatively common to read, ‘I’d like to see you tomorrow at 10am’, as if the service has no other clients to consider. However, after observing parenting approaches on public transport, in shopping malls and on the street, which frequently involve parents and grandparents immediately giving the child whatever s/he demands, I understood how this might seem reasonable behaviour to the student. The fact that we as a service do not respond by offering exactly what the student expects, results in some students choosing not to use the service, and every year we receive suggestions from students that counselling should be available 24/7, on demand. For these students at least, our commitment to seeing all students for an assessment session within five working days, which I consider quite a good level of access, seems insufficient to meet their needs.
Once students engage in counselling and this matter is addressed directly, it is usually possible to work with students to develop ways of regulating their own emotions and also to learn that their needs cannot always be paramount. To me, these both seem important skills for adulthood in any culture.
Child or adult?
Another aspect of current Chinese society is that young people are considered to be, and are treated as, children, at least until they are married, and often beyond. From a Chinese perspective, the family invests considerably in their child, both practically and emotionally, and tends to view the child as an extension of the family, rather than a separate individual with different needs and wishes. This means that parents feel entitled or perhaps even obliged to intervene/protect/correct if their children are in difficulty. By extension, parents continue to assume they are entitled to know everything about their child, even when they are at university. Initially, one of the most difficult aspects of running a counselling service in a university in China was the expectation from parents that I would share information about their young person’s mental health and counselling sessions. This is no longer a problem as local colleagues now understand the boundaries of the counselling service and help me explain this to parents. However, this belief seems deeply embedded in Chinese society, and even now, I am often encouraged by some colleagues to change my view and the counselling service’s practice. Despite this, many students appreciate these boundaries, and service evaluations indicate that our high level of confidentiality is one of the reasons they choose to attend our service over other support services which are locally staffed.
Being ‘left behind’
The experience of a significant minority of Chinese children, termed ‘left-behind’ children, can have a long-lasting emotional impact. One of the acknowledged negative social consequences of China’s remarkable economic growth over recent decades is that many parents have gone to work in an, often, distant city, leaving their child with relatives, often grandparents. It is not uncommon for grandparents to have a number of grandchildren from their different children to look after at the same time. Some of the students I have worked with saw their parents only once or twice a year and did not live with their parents for most or all of their childhood. For some, living with their grandparents was a loving if physically tough or materially poor environment. However, for others, relatives were unable to look after them well and they experienced neglect and lack of protection, sometimes to the extent of physical and sexual abuse. As would be expected, these young people often lack trust and have difficult peer relationships when they come to university. When they reach a life stage where the desire for intimate relationships increases, many become aware of their difficulties in attachment and come to counselling for help.
Barriers to access
First interventions in our service
One of my first decisions was to employ a counsellor who was a fluent Chinese speaker, to see if this made a difference to the number of Chinese students accessing counselling. My local colleagues (pastoral care staff) were certain that having someone from a Mainland Chinese cultural background, not just a fluent Chinese speaker, was important. However, as counselling/counselling psychology is relatively undeveloped as a training and a profession in Mainland China, it proved impossible to find someone from Mainland China with native fluency in Chinese, who also met the standard of qualification required and had sufficient post-qualification experience, and who wanted to work in our city, which is not one of the main international cities. I decided to prioritise fluency in Chinese and an international standard of postgraduate counselling qualification.
From this basis, I was able to employ one Mainland Chinese counsellor who was a recent graduate from a master’s programme in Taiwan, and one counsellor from Taiwan with a master’s qualification and two years’ post-qualification experience. It was at this point that the demand for counselling from domestic students significantly increased. Currently, the service is staffed by three Mainland Chinese counsellors: the graduate from Taiwan, who now has over three years’ experience at University of Nottingham Ningbo, China (UNNC), and two recent graduates from master’s programmes in the US, plus a Malaysian, who is a fluent Chinese speaker of Chinese ethnicity with a doctorate in counselling psychology from the UK. Of course, as a campus of a UK university, all counsellors must also be able to counsel in English, so finding well-qualified counsellors meeting all of these requirements has been a challenge. However, working with this culturally mixed team has helped me come to some understandings about the importance of language and culture for Chinese students.
Language is particularly important in increasing initial access to the service. Although all teaching is in English at our university, the spoken language level of domestic students varies considerably, and despite International English Language Testing System (IELTS) requirements, this will also be true of students who come to study in the UK. Many domestic students fear they will be unable to make themselves understood when talking about personal matters in English, so many students request a Chinese-speaking counsellor. Certainly, some would not consider coming for counselling if they had to speak in English.
Because the educational culture in China involves reliance on test results for school and university entrance, speaking English is often experienced as a test of perfect grammar and correct vocabulary, not as a means of communicating. However, once a student accesses the service and meets the counsellor, whether English or Chinese speaking, language becomes less of an issue. Students discover that the counsellor will try to understand them and help them communicate. Personally, I have found that once we have met, many students want to continue seeing me in English despite the availability of fluent Chinese-speaking counsellors. And this has remained true, even in cases where we occasionally have to refer to the translation apps on our mobiles to assist with specific vocabulary.
That said, having Chinese-speaking counsellors is important on an ongoing basis for some domestic students. It is also particularly useful in cases where a student needs to return home and asks the counsellor to help them explain their situation to their parents.
Perhaps most importantly, having Chinese-speaking counsellors of Chinese ethnicity conveys a significant message in a UK university in China, as evidenced by the increase in the willingness of Chinese staff to recommend counselling to the students they support. My understanding of this is that it demonstrates the valuing of both Chinese and UK cultures by the counselling service, and this has resulted in Chinese students and staff feeling that the service is not just for ‘internationals’, but also for them.
It is more difficult to draw conclusions about the relevance of the nationality of the Chinese-speaking counsellor. As would be expected, there are circumstances in which having a counsellor from the domestic population helps students feel there is someone who will fully understand their cultural and political background, and this is helpful. However, there are other circumstances where students do not wish to speak with someone whom they believe will hold the same traditional values as their family. In addition, as the Chinese Government keeps a record on all citizens and therefore all students, some students express concern that their mental health/psychological issues would be added to this report, which follows them throughout their lives, and that a Mainland Chinese counsellor might not maintain the same level of confidentiality as a foreign counsellor. While I am reliably informed that mental health issues do not form part of this report, and I am certain that the Mainland Chinese counsellors on my team maintain the same high standards of confidentiality that I do, I recognise that these concerns can inhibit access. Therefore, I offer client choice by employing counsellors both from outside and within Mainland China.
The meaning of ‘counselling’ in the Chinese system
In our service, Chinese students often ask for ‘consulting’ appointments and they often begin their emails with ‘Dear Teacher’. This use of language is indicative of their expectations of counselling, ie to ask questions and get answers. Thus, there is an understanding of counselling as education about how to live your life better. But there is more to it than that. Chinese universities all have services provided by a department, usually known as ‘Student Affairs’, which provides a range of pastoral care services, including a kind of informal counselling called, at our university, ‘free talk’. These colleagues at our university are required to have a master’s level qualification in any subject; but in terms of counselling, they will have no qualification or, at most, a basic counselling skills certificate. More importantly, they are expected to act in loco parentis, and the current strap lines of this department at our university are: ‘You are not leaving home but arriving home’ and ‘It’s all about love and care’. One implication of this emphasis on being like the student’s family is that fudaoyuan (which can be translated as ‘advisor’ or ’instructor’, but also, ‘counsellor’) are seen as responsible for the physical, psychological, social and moral wellbeing of the young people they support. Their interventions are more often aimed at instruction than acceptance and empowerment.
In addition, a number of students who come to our service have had counselling before coming to university. They usually describe being taken by their parents to someone known to their parents, who might have some counselling training or more often is a teacher, doctor or psychiatrist who has worked with young people. These ‘counsellors’ almost always report to the parents about the content and outcome of sessions.
Therefore, Chinese students are likely to have very different expectations of counselling than UK-based students or counsellors. For some, these expectations will be a barrier to access in that they will fear counsellors will judge them for behaving outside accepted norms. For others, they might feel disappointed when they access counselling to find that advice and instruction are not provided.
The impact of stigmatisation in a highly normative society
The stigmatisation of disability, mental health, sexual orientation and sexual activity in the West is easily within my living memory, and the current situation in most of China, apart perhaps from international cities such as Beijing and Shanghai, reminds me very much of my early career 40 years ago in both Canada and the UK. However, in this case, the impact of stigmatisation is exacerbated by the normative nature of Chinese society. From our students I have heard many accounts of parents realising their child is ‘different’ and doing all they can to hide this. Clients have recounted parents destroying evidence of diagnoses of autism, diabetes and depression. Others tell me their parents have warned them never to disclose that they were sexually assaulted or pregnant, or that there is a physical or mental health condition in their family, as this will affect their chances of marriage. Most LGBTQ+ students we see in counselling do not disclose their sexual orientation to their parents and often plan to find a way of living abroad and never coming out to their families.
Many students have told me that initially they were reluctant to seek counselling for fear that their ‘difference’ would be seen as something wrong with them, as it had been in other contexts. They were aware that this was not the kind of ‘help’ they needed. In addition, there were concerns that this information would be shared with other university support services where attitudes are more conservative. Although the values and attitudes underpinning the counselling service are clearly published, it was word of mouth and referral by students who had used the service that, over time, effected significant increase in access by students from socially stigmatised groups.
Values – explicit and implicit
It seems important to note that many of the concerns which prevent Chinese students initially from accessing counselling are based on misperceptions of counselling. These misperceptions are to some extent rooted in the values espoused by Chinese culture, politics and practice, and it is to those that I will turn next.
The responsibility to educate others
There is a commonly expressed view that elders have not only the right but the responsibility to judge and correct younger family members. I am reminded of a conversation I have had on health promotion, an area for which I am also responsible. Initially, I was puzzled and concerned that locally generated health promotion material was, to my way of thinking at least, judgmental, rather than being purely informative as I had expected. However, it was explained to me that the purpose of health promotion in China is to guide students to behaviours which are considered morally ‘right’. As the campus of a UK university, we agreed to modify our material, to be less judgmental, but this made me think about what young people expect from professionals, including counsellors. Until they become familiar with counselling in the Western style, they are likely to expect judgment and moral instruction. My co-author explained that this need to know the right answer, and in fact the assumption that right answers for how to live life exist, is deeply rooted in Chinese culture. Therefore, it is not surprising that at times this is what students want and expect from counselling, and they can be frustrated at not receiving it. But, equally, fear of this kind of judgment will prevent others from seeking help.
I have appropriated this term from political discourse, where it describes positive ‘spin’, without intention to follow through with action, to also describe some experiences I have had in China, where discourse sounds powerful, but is universally recognised as not intended to lead to action.
These experiences led me to think about what it means to Chinese students when we provide them with confidentiality contracts. If indeed it ‘happens all the time’ that formal rules are proclaimed by authority but then are not enforced or complied with in reality, and citizens live in a society in which behaviour is regularly monitored and reported, what can Chinese students make of our written assurances that we will not disclose personal information and that no one will see our records of their sessions? I have spoken with many students about this and found that many harbour suspicions that we do not mean what we say.
So now, in each assessment session, I and the counselling team go through exactly what confidentiality means in detail. For example, I list all of the people I will not speak to about their attendance at counselling or what they say in sessions, ie personal tutors, lecturers, parents, university support staff; and I explain that I will not do that even if someone senior to me, or their parents, put pressure on me to do so.
There is a Chinese saying which is similar to the English proverb, ‘Action speaks louder than words’ which I find an important guide for our practices in the counselling service. Only through students and staff experiencing our behaviour as consistent with our published rhetoric, will our service be trusted.
Competition is good – ‘winners’ and ‘losers’
This topic of conversation comes up quite often with colleagues as we try to understand and respond helpfully to the pressure many, perhaps most, students here experience. My view is that the pressure to be the best seems to impact negatively on the performance of many of our students. However, my local colleagues point out the obvious – in a country with a large population and limited resources, there will always be some who ‘win’ and some who ‘lose’. The Chinese education system publicly ranks students throughout their schooling, so no one is in any doubt about where they stand in relation to their peers. And I am told that if you are highly ranked in academic performance, this also increases your popularity with your peers and so you have more friends. In those circumstances, it is not surprising that parents and children alike want to be ‘winners’. But on the other side, not since my childhood in Canada 50 years ago, have I heard so much use of the term ‘loser’ as I do in present-day China. There can, of course, only be so many ‘winners’, and in this society, where dichotomous thinking prevails, if you are not a ‘winner’, you have little choice but to be ‘a loser’. As you can imagine, for many students, even having to consider counselling makes them a potential ‘loser’. This point may be particularly relevant to students who come to the UK to study, as they will largely be from the group of ‘winners’, and there are also implications of being ‘a winner’.
Saving face and avoiding shame
The implications of being ‘a winner’ often include never having experienced failure and therefore not knowing how to cope with even minor setbacks, and never having had to ‘admit’ when you are not coping well. It is common in China to behave as if nothing is wrong to save face, rather than to acknowledge there is a problem and seek help. So, there can be a cost in acknowledging that you need help, and that cost is being seen by yourself and perhaps others as inferior, no longer a ‘winner’. Chinese students who are ‘winners’ will be familiar with this and therefore are likely to try to avoid ‘admitting’ that they are not coping well. Admitting weakness can be both frightening and shaming. You only need to reflect on the dichotomous thinking I described earlier to understand why it is so frightening. In Chinese terms, if you are not ‘a winner’, you are ‘a loser’, and your life and the reputation of your family will be negatively affected. This may be particularly true of the students at a fee-paying university, such as ours, or indeed those who make it to a UK university, who often come from middle-class families who have worked hard to reach their current social position and are therefore focused on ‘upgrading’, or at least maintaining, that position.
The counselling service sees many students who are not achieving as well as expected academically, and it is common for their parents to express feeling ashamed of them. This shame is clearly demonstrated in the parents’ behaviour of actively concealing information from family and friends about the student having to resit exams, or suspend or retake years. I see many students who are two or even three years behind, and only their parents know. I am told that parents hide this information by saying their child is doing further study or changing majors. I also know students who are suspending or retaking years who do not tell their parents until their final year, when it is unavoidable. Such is the belief in the negative power of failure, that it cannot even be acknowledged.
Proxy-indicators of good treatment
There are two other broadly cultural issues which come to mind when I think of factors that might impact on Chinese students’ judgment of our UK-style counselling provision. My ideas are extrapolated from other conversations I have had with colleagues about accessing medical treatment.
The term guanxi, usually translated as ‘connections’, ‘pulling strings’ or just ‘relationship’, is a common phenomenon in modern China. Local colleagues tell me that you can only access good-quality medical treatment in a timely manner if you can use your family connections. It is still possible to see a doctor if you have no strings to pull, but the skilled and well-qualified doctors are always fully booked via the public medical booking system. To book a good doctor via this system requires completing the online booking very quickly and at just the right moment, or getting to the hospital ‘very, very early’ to queue and register. Sometimes, registration via this process requires several attempts, and you will still have a long wait and a very short consultation. I was recently told of a paediatrician in a local public hospital who has 300 children to see every day. That allows three minutes per child. However, if you have guanxi, you don’t need to make all of this effort, as you are given priority and more access to the better doctors.
One practical implication of this is that despite clear instructions to access the counselling service via our service email, some students email me personally in the hope of getting preferential treatment. My standard response to this is to kindly explain that our published assessment and allocation process is the best way to get the help they need, and to refer them back to that system. However, it is not uncommon for students to continue to explain why I am the only counsellor they wish to see.
In addition to connections, you need money to access good medical treatment, at least in the city in which I live and work. Naively, when I came to China, I assumed that under communism or socialism, all forms of medical treatment and education would be free at the point of access. However, this is not always the case, and the quality of treatment you receive, at times, directly correlates with the amount of money you can pay.
This knowledge and experience made me wonder how Chinese students might understand a counselling service where special relationships are not allowed and where treatment is free. One action I took in response to this thinking was to increase my profile as Head of Service and thus my connections within the university, by running training sessions for staff, presenting papers to the University Management Board, managing high-visibility wellbeing events for the whole university and, just before COVID, agreeing to move those events out into the wider Ningbo community. However, none of this is as useful as students who have used our service speaking about it to friends and writing about it on social media. Many of our current domestic clients are referred by others who have used our service and found it helpful. I continue to receive referrals of current students from my previous clients, who are now studying abroad, and I am told clients continue to write about their counselling experiences on social media. (I have to say in this context that I am glad I cannot read Chinese, as I think knowing the detail of what is being written about how I conduct my sessions could be rather inhibiting!). Word of mouth will of course be a significant referral source to some extent in all counselling contexts, but in a society where actions speak louder than words, and social connections are considered causally related to quality of provision, it is of particular importance.
In this article, I set out to write 2,500 words, and found that, without any difficulty at all, I had written 5,000! And as I wrote, I became aware that I am only touching the surface of what is different about the life, values and experience of Chinese students from those of most students in Western countries. I hope it will be possible at some point to explore, in more depth, aspects of process and relationship that are particularly relevant to counselling this student group and the therapeutic approaches that are likely to be more accepted and more effective. However, for now, I’d like to conclude with a reflection on my overall experience in this role.
Heading a university counselling service in China has been one of the most challenging, interesting and enjoyable experiences of my 44-year career, which includes being a nurse, midwife, therapist, supervisor, service manager, occupational psychologist, academic and university manager.
Perhaps consistent with Western stereotypes, I have found Chinese students to be polite, willing to work hard, appreciative of direct guidance or instruction, and respectful of authority and older counsellors like myself. However, in addition, I have found them to be emotionally open, relational, truly wanting to engage in counselling and very able and willing to change and develop. It is this latter point that I would like to emphasise. Contrary to popular opinion, in my experience, Chinese students do want counselling and they are able to benefit from it at least as much as students from more Western societies. Although a common language can certainly facilitate uptake of service, most important is counselling staff who are willing to understand and acknowledge the importance of often quite different and deeply held cultural and political values and perspectives and a counselling service which supports this approach.
1. The University of Nottingham. Investigation into the mental health support need of international students with particular reference to Chinese and Malaysian students. Nottingham: University of Nottingham; 2011.
2. Bentley A. ‘It’s like a counselling service is our last choice, it’s our worst choice; sorry!’. University & College Counselling 2018; 6(3): 24–28.