Stories From the Field:

TAIWAN

Stigmatization, Criminalization, and Mental Health Care in Taiwan

Justin Chen, MD, recently finished his residency at the MGH McLean Adult Psychiatry Residency Program and was granted a Center for Global Health Travel Award to spend one month as a visiting scholar at the National Taiwan University Hospital in Taipei, Taiwan.

During my residency training at MGH and McLean Hospital I developed a profound interest in the interplay between psychiatric illness and culture, and I have repeatedly found myself drawn to clinical rotation sites that allow me to provide care to Asian American populations throughout the greater Boston area. In 2012, with the support of the MGH Chester A. Pierce Division of Global Psychiatry, I pursued a month-long global elective at the Shanghai Mental Health Center, where I witnessed firsthand the deleterious effects of societal stigma on psychiatric outcomes.

The purpose of this year’s trip to National Taipei University Hospital (NTUH) in Taipei, Taiwan, was to work with a forensic psychiatrist named Dr. Kevin Chien-Chang Wu to propose suicide prevention strategies in East Asia from a sociocultural, historical, and legal perspective. In particular, we were interested in exploring how stigmatization and criminalization have developed in different societies as a means of suicide prevention. I first connected with Dr. Wu through Mass General’s outstanding network of global psychiatrists. Dr. Wu shares my interest in the overlap between culture and mental health, and has spent significant time as an exchange student himself, receiving both an LLM and PhD from Harvard. We spent many hours debating and fleshing out our arguments regarding our chosen topic, and chatting about the differences in mental health care services between Taiwan and the United States. Additionally, Dr. Wu arranged for me to take a trip to the Taichung Correctional Facility, specifically to witness the forensic psychiatry ward there and to learn about the care of the imprisoned psychiatric mentally ill.

Our study argues that discourses regarding the cause and appropriate treatment of suicide are divergent based on cultural tradition. In the West, suicide has evolved over the past 2000 years from sin to crime to illness, with a corresponding shift in oversight from religious to legal to medical authorities. Despite these shifts, it remains a stigmatized act. In contrast, suicide in China and other East Asian countries was never stigmatized in official documents, instead maintaining a socially acceptable role in certain circumstances to the present day. However, mental illness bears a much larger degree of stigma than suicide. Therefore, we argue that the suicide epidemic in East Asia has strong social determinants (not simply psychiatric, as is presumed in the West), and a Western public mental health approach to suicide prevention is likely inappropriate in East Asia.

In addition to collaborating on our manuscript, my trip represented a wonderful opportunity to put on my anthropologist’s hat and observe the practice of mental health care in a different culture. The time I spent in the NTUH psychiatric “acute ward” (equivalent to Blake 11 at Mass General) was invaluable in terms of gaining firsthand experience with cultural variations in the conception and treatment of mental illness. However, the strongest lesson I came away with was the universality of suffering caused by psychiatric disorders. In particular, I will never forget a tearful and emotionally charged exchange between a young man with schizoaffective disorder who had been involuntarily hospitalized following a suicide attempt, his mother, and the attending psychiatrist, whose gentle reassurance in the Taiwanese dialect eventually put both at ease. This powerful event highlighted to me the tremendous burden of suffering caused by psychiatric illnesses and the importance of culturally informed styles of doctoring.

Dr. Wu and I completed a lengthy (~7000 words) manuscript of our findings regarding suicide prevention. Given the scope of our argument, which has expanded from our original intent, we have had to adjust our plans for publication, and hope to find a journal with a broad scope that will be interested in our conclusions. Dr. Wu is a member of the Taiwanese national task force that will soon be drafting a so-called suicide prevention law for that country (following on the heels of Japan’s and South Korea’s laws in 2006 and 2011, respectively). It is likely that China will look to these precedents in eventually drafting its own suicide prevention law.

I am grateful to the MGH Center for Global Health for supporting this trip and work.