Research Essay - The Great Burden of China

The Great Burden of China

中 国 巨 大 的 负 担

Architectural & technological strategies for urban psychiatric care.

Cameron Clarke Student Number: 170175 Urbanism and Societal Change

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Image 1.

(Cover Image).

Credit: Author

“It is not by confining one’s neighbour that one is convinced of one’s own sanity.”

Dostoyevsk y - A Writer ’s Diary 1877

Acknowledgements

I would like to express my sincere thanks to Dr Huan Wang of Beijing Capital Normal University, for her support and encouragement in undertaking this research paper.

In September 2018 I was able to visit two psychiatric hospitals in Beijing, inter view a mental health nurse and a professor of psychology from the Peking Institute of Mental Health all of which gave me a unique insight into the topic. Without Huan’s generous help, advice and translations this would have other wise been impossible, and I ver y gratefully acknowledge her assistance and friendship.

I would also like to thank my tutor, Christine Bjerke, for her enthusiastic and insightful engagement, feedback and support in the writing of this paper.

Finally, I would like to thank Henr y Humboldt for his careful proof reading and constructive criticism.

Introduction

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Abstract

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The Global Urban Crisis

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A Chinese Crisis

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Mental Health Burden with Chinese

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Characteristics

The Growing Economic and Societal Burden

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Spatializing Mental Illness: The importance

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of Neighbourhoods

Pushed to the Fringes

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Close to Home: Bringing care back to the

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Neighbourhood

Urban Technological Innovation

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Urban Architectural Innovation

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Conclusions

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Bibliography

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Appendix

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Image 2.

Urbanism on a inhuman scale - uninhabited residential towers, Shanghai .

Credit: Tim Franco

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Introduction

Abstract This paper investigates how the process of rapid urbanisation in China has impacted upon the country’s mental health, and aims to develop an understanding of the role that a network of contextual and community level architectural and urban interventions can play in the creation of a novel approach to psychiatric treatment.

Health Organisation datasets. It goes on to evaluate the Chinese social, economic and urban context inwhich this is taking place, through a series of interviews with local mental healthcare professionals, site visits to Beijing’s two leading psychiatric hospitals and a review of papers published by Chinese academics. The text then discusses possible future strategies which could be brought to bear in a reimagining of mental health treatment, and how a network of local, community centric treatment spaces combined with emerging communications and virtual reality technology could offer an effective strategy to address this pressing need.

China has urbanised at a rate unprecedented in human history (see figure 1), and so the effects of this transition from rural to city life on citizens psychology is profound.

While the mental health burden is a growing problem globally, in China it is compounded by drastic changes to lifestyle and a latent underfunding of mental healthcare provision.

It is hoped that this research will form a basis for the development of an architectural and/or systemic design response which can further highlight the potential of these strategies.

The paper begins by developing an understanding of China’s particular urban mental health crisis, set against the backdrop of global trends. This is achieved by a literature review, drawing predominantly from a range of medical journals, UN and World

90% 80% 1978 - Deng Xiaoping brings economic reform to China

% of Total Population

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Urban

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Figure 1.

Using World Bank data, this graph shows the rate of urbanisation across China following Deng Xiaoping’s economic reforms of 1978. China is now a predominantly urban country.

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Image 3.

Entrance to consultation room, Peking Institute of Mental Health.

Credit: Author

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The Global Urban Crisis In a 1994 editorial in Europe’s leading medical journal, The Lancet, the mental wellbeing of urban citizens was identified as being largely neglected by urban and medical policy. “To keep cities profitable into the 21st century,” the editorial asserted, “more attention will have to be paid to aspects of health other than the purely physical.” (The Lancet [ed.], 1994. p.1303)

a local, community scale. While there would always be a role for specialist inpatient care as could be provided at larger institutional teaching hospitals, “village clinics run by non-medical staff may be as appropriate to urban as to rural needs.” (ibid.)

Written a week before the 2nd sitting of the UN Commission on Sustainable Development, the Lancet’s editorial ended with a plea to politicians, urban planners and the medical profession to consider the psychiatric consequences of urban growth, and to look to develop a highly contextual and localised community-centric approach to this global crisis.

The potential for damage that could be done by ignoring the mental health of urban citizens would result in “violent behaviour, suicide, alcohol and drug abuse…” and that society should begin to seek solutions to this risk as a specific urban phenomenon, rather than to “regard it as an inevitable concomitant of urban life, as was done with cholera 20 0 years ago.” (ibid.)

By equating the danger of ignoring an urban mental wellbeing with the damage wrought onto societies by cholera (a disease which had killed millions of urban citizens across Europe during the 19th century), The Lancet was being emphatic about the scale of the impending psychiatric crisis that our cities face.

The editorial goes on to describe how despite being “woefully underfunded” there were opportunities for cities to reverse the scale of this mental health crisis by learning from the treatment and prevention strategies which had been pioneered by the World Health Organization in the 1950s, and which had been effective against many infectious and predominantly rural diseases.

The key to this strategy was that “rather than offering comprehensive healthcare at a few central sites, a better yield if health was seen to come from providing basic facilities close to where people live.” (The Lancet [ed.], 1994. p.1304) Better consequences would come from addressing mental illnesses at

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Image 4.

Psychiatric Hospital, Beijing 1989

Credit: Lu Nan, Magnum Photography

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A Chinese Crisis The Chinese economy has developed during the preceding three decades at a rate unprecedented in history. More people have been lifted out of absolute poverty than ever before (World Bank, 2018). The effects of this growth in prosperity have been profound, and it is most clearly manifest in the rapid development of urbanism across China.

and expectations required of urban residents, as greater pressure and competition grows in many aspects of life (Wang et al. 2018).

Today, almost 180 million Chinese citizens suffer from a mental health disorder, representing 17.5% of all adults (Xu & Wang et al, 2015 p. 137) almost 1 in 5 of the population. Of these 180 million people living with a mental illness, 160 Million have not had any psychological treatment or care (ibid, p. 138).

This urbanism has placed enormous pressure on infrastructures, cities, agricultural land and the environment.

The effects of this pressure has begun to make the country ask questions about the way in which it manages its growth and development. As a result, the Chinese Government has spent recent years developing large scale planning and industrial policy programmes, intending to better manage and direct the future direction of change.

This lack of treatment is a crisis inwaiting, and the economic and social consequences are yet to be fully comprehended.

The primary reasons shortcoming are twofold:

for

this

1.

The Chinese healthcare system, while having developed rapidly since 1978, has developed unevenly across the country, and across medical specialisms. Mental health-care has been left well behind the available treatment for other conditions. This discrepancy is best illustrated by Beijing University’s Institute of Mental Health’s estimate that the Chinese healthcare system has only 4,0 0 0 academically trained psychiatrists (Park et al, 2005. p. 43) - an order of magnitude smaller than that required to care for a country of 1.4 billion.

While the impact of this development to China’s urban physicality is now being widely discussed, relatively little debate has taken place about the effects to China’s urban psychology.

As a result of these three decades of rapid growth and urbanisation, mental health disorders have overtaken cancer and cardiovascular disease as the leading cause of health burden in China (Zhang & Zhao, 2015. p. 628), and it is a burden which has taken on unique urban characteristics. A growing body of research shows that the process of urbanisation has a directly detrimental relationship with mental wellbeing (Chen, J. et al, 2014). Urban residents are more likely to be exposed to environmental, physical stressors during daily life, such as air pollution, noise pollution and overcrowded living conditions.

Statistically, they are also more likely to directly experience traumatic personal events or circumstances, such as divorce or financial debt concerns (ibid). Finally, and most relevant to the rapidity of Chinese urbanisation, there is a constant adaptation to new living practices

2.

There is a latent social stigma in Chinese culture towards mental health. The divide between society and those with psychological problems has a historical precedent that runs back beyond the disassembly of China’s community based healthcare system under Mao (Zhang & Zhao, 2015. p.

628). This divide is notably expressed architecturally and urbanistically by the physical separation between sufferers and society. What limited mental healthcare resources China has, are predominantly concentrated in centralised urban institutions, following the European model, itself a descendant of the Victorian asylum

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Image 5.

Stills from 2015 film Shanghai Tulip: breaking China’s mental health taboo

Credit: Thomson Reuters Foundation

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- where security and safety to society at large take precedence over care, de-stigmatisation and understanding (Lui et al., 2011).

reflected directly in the built spaces for mental healthcare. As noted by the British Journal of Psychology in 2016, this is a global phenomenon, where the architecture of mental healthcare serves only to support the stigmatization of patients:

As a result it is often the case that those suffering from mental illnesses hide their symptoms and do not seek help from the institutionalised healthcare system. Most sufferers go without treatment altogether, although there is a small but growing number who, like the Shanghai based group Shanghai Tulip (see Image 5. for screenshots from the Thomson Reuters Foundation 2015 film ‘Shanghai Tulip: breaking China’s mental health taboo’), are utilising modern Chinese communications technologies such as WeChat (a cell phone messaging app) and Sina Weibo (a blogging platform) to group together and offer mutual support (Thompson Reuters Foundation, 2015).

“Psychiatric hospitals are often associated with a penitentiar y, an asylum, or a substitute of a panopticon… the low quality of buildings arise from popular attitudes both to people with mental illness and to mental healthcare.”

(Bil, 2016).

Such a view is particularly true of the mental health architecture of China. I was able to discover this anecdotally on a recent research visit to the Peking Institute of Mental Health, where I found an imposing high rise building, walled off from the street, which had only recently had the steel ‘prison’ bars removed from its windows (refer to photographs in appendix)

In my initial research, I have found a growing literature which advocates that the Chinese government tackles this deficiency in its healthcare system with a radical approach.

There is an opportunity to leapfrog the solely institutional response, in favour of a balanced holistic model which supplements inpatient care with a range of community and neighbourhood treatment services (Ibid p. 210; Park et al, 2005 p. 43; Xu et al, 2016. p.143; Wang et al, 2018 p. 112) . Evidence suggests that this not only makes for more effective patient treatment, it is also more economically efficient and simultaneously can tackle the social stigma which hampers understanding of and uptake of mental healthcare more generally. In addition, these findings are supported by a wider international body of research (WHO, 2003).

There is also a danger than in responding to the urgency required to meet the demands of mental healthcare in China, that the strategies imposed are imported directly from other contexts, bringing with them existing failings, or creating novel negative consequences when applied in the unique Chinese urban context.

Academic and clinical research supports the importance of a highly contextual approach to mental healthcare architecture, this is summarized aptly in a 2014 paper by researchers at McGill University entitled Towards a New Architecture of Global Mental Health:

This suggests there is an opportunity to reimagine the form that mental healthcare facilities take, and how they interact urbanistically with the neighbourhoods and communities of urban China.

“The concern is that in the urgency to address disparities in global health, inter ventions that are not locally relevant and culturally consonant will be exported with negative effects including inappropriate diagnoses and inter ventions, increased stigma, and poor health outcomes.”

(Kirmayer, 2014)

While this represents a highly political and social issue for Chinese society, it surfaces in a range of architectural scales across their cities. The lack of resources and social stigma is

Thus, it is critical that a new approach to the architecture of mental healthcare is understood through a contextual appreciation of the Chinese urban condition: socially, politically, and 15

Image 6.

Website of CogLeap a Shanghai based tech startup, pioneering use of VR in treatment and diagnosis of mental illness.

Credit: Cognative Leap Inc.

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tectonically.

applied in a exploratory approach to tackling China’s impending mental health care crisis.

In the last semester ’s research I developed an understanding of the the traditional Beijing Hutong neighbourhoods through the lens of ‘HomeMaking’, the process by which local communities were responsively adapting to meet the growing demands upon them by urban, economical and technological development. I discovered an incredible resilience and adaptability to this rapid change, and that its potentiality for success was based on its traditionally strong network of social connections and uptake of emerging digital communication platforms. This web of interconnection enabled incredible nimbleness of social and economic productivity.

My research will be directed around key thematics of the utilisation and support of urban community networks, the application and development of technological innovation ‘with Chinese Characteristics’ and the role of the architectural intervention to create new or synthesised programmes which respond to the unique contexts of mental healthcare in urban China.

I seek to propose that a strategy that combines the utilization of technology, community networks with responsive use of architectural intervention will offer the Chinese healthcare system a contextual and effective methodology of mental healthcare treatment.

I intend to use this project to investigate if the same neighbourhood resilience could be meaningfully

Urban Community Networks

Technological Innovation

Architectural Spatial Intervention

National Strategy & Policy Figure 2.

Within a national strategy framework, a radical urban form of psychiatric treatment is found by intersecting community networks, technological innovation and architectural intervention

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Image 7.

Ward corridor, Peking Institute of Mental Health.

Credit: Author

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Mental Health Burden with Chinese Characteristics

Before beginning to posit future radical scenarios for mental healthcare in China, it is important that I first outline an understanding of the historical context in which contemporary psychiatric care in China takes place. As mentioned in the introduction, China is notable in its incredible rate of change in the last six decades, economically, politically, socially and also in relation to the country’s provision of basic healthcare to its citizens. The result of these changes, which include some of the more controversial policy positions such as the ‘One Child policy’, is that China now has a slowing birth rate (now below the replacement rate of 2 children per woman), with fewer - but healthier - babies being born (Peng, 1998). This phenomenon, alongside a modernisation of basic healthcare facilities, has completely altered the makeup of illnesses

across the country. There has been a drastic reduction in the prevalence of infectious diseases, which were once commonplace in both rural and urban environments, and correspondingly there has been a transition towards a prevalence of more chronic diseases and illness. This transition has occurred at a rate much quicker than in many other countries (Cook & Drummer, 2004) and this is putting increasing strain on the healthcare system, as patients now require much longer treatment plans to manage their illnesses, particularly the case with cardiovascular diseases and cancers.

However, it is the rate of increase in chronic psychiatric illnesses that has been the most profound and this has been highlighted as a key issue facing the Chinese healthcare system.

While cancers and heart disease has had a similar impact on Chinese

1. Beijing 4. Tianjin 7. Zhengzhou 8. Wuhan 2. Shanghai 9. Suzhou 6. Hangzhou 10. Chengdu

5. Shenzhen 3. Guangzhou

Figure 3.

Map showing the 10 regions of China with the highest per capita demand for psychiatric services, with a concentration on rapidly growing urban centres.

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Image 8.

Consultaton waiting area, Peking Institute of Mental Health.

Credit: Author

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urban and rural communities (Zhu et al. 2011), psychiatric illnesses have had a pronounced development in prevalence in urban environments (see Figure 2 which outlines the 10 areas of China with the highest demand for psychiatrists). The much discussed rapid urbanisation of China has brought with it remarkable transformations to individuals lives, as rural to urban migration, a transition from agrarian and manufacturing to a knowledge economy creates competitive work environments and relentlessly-paced lifestyles. This causes much elevated levels of psychological stress, which has a particularly profound impact on those for whom the urban environment is an unfamiliar one, such a rural to urban migrant workers.

The stress caused by urban life in China is having a biological effect on citizens, as well as an environmental and emotional one. Research has shown that citizens who have had an urban upbringing have elevated cortisol levels, and show a change in the development of the adrenal gland - commonly known as being responsible for the ‘Flight or Fight’ mechanism (Faravelli, 2012).

More generally, a 2017 paper by the Brookings Institute described an unexpected phenomena across China which the authors termed ‘The

Paradox of Progress’ (Graham et al., 2017). The paper describes how “China has made remarkable progress in combating poverty, from one third of Chinese people suffering hunger to less than one tenth [in 50 years]” but that “...Life satisfaction in China has declined dramatically precisely at the time of its unprecedented economic growth and poverty reduction.” (ibid. p.

231)

As China shifted away from a centrally managed economy under Mao, through the economic liberalization of Deng Xiaoping in the late 1970s to free market principles, traditional social safety nets were dismantled across society. As countless millions migrated to urban centres for work, family and community bonds which had once provided an informal healthcare network were ripped apart.

Particularly psychologically hard hit by this change to a new economic paradigm were in fact those who found themselves situated in areas of the greatest economic progress. As the cities became more wealthy, they also became drastically unequal, and the inequalities found themselves concentrated to ever denser urban environments. Those left behind in the countryside saw relatively little change to their economic circumstances, and were correspondingly less aware of the rampant inequality which was

15 Million patients are currently treated in China for mental illnesses China has a total of 173 Million sufferers of mental illnesses Figure 4.

With each circle representing 1 million sufferers of mental illness in China, we see only a fraction of sufferers currently receive any treatment. Almost 160 Million go untreated, the same as the entire populations of France, UK and the Netherlands combined.

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Image 9.

Consultaton waiting area, Peking Institute of Mental Health.

Credit: Author

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enveloping the urban society. China was becoming a country of “happy peasants and frustrated achievers.” (ibid. p. 231) Several other studies have found further evidence for this condition, showing that the adverse changes to the countries mental wellbeing are in correlation to its rate of urbanisation.

the greatest burden that the country faces, far exceeding that of cancer and cardiovascular disease.

Unfortunately, for the estimated 173 million citizens suffering from a mental disorder in China (Phillips, et al, 2009), psychiatric healthcare has been chronically under invested in as part of the more widespread healthcare reforms of the last 50 years. Currently only 15 million of these sufferers receive any form of treatment - one of the lowest rates in the world (Graham et al., 2017. p. 234). Those that do access treatment are often subjected to underfunded facilities, overworked staff and a latent social stigma which can have even more deleterious effects to their lives and wellbeing.

“Chinese rural households reported higher subjective well-being than did their richer urban counterparts, and that migrant households in urban China have average happiness scores that are lower than their rural counterparts.”

(Knight and Gunatilaka, 2010) The evidence suggests that the process of urbanisation and economic development is not a happy one for many of China’s citizens. They find themselves caught in a country changing so fast that previous societal structures, that were once relied upon, are being torn apart before new ones can be built in their place.

Many in the Chinese healthcare profession are beginning to speak out about the chronic lack of funding and investment in their mental healthcare facilities, and are encouraging the Chinese Government to take more seriously the need to prioritise innovation in mental healthcare.

“The deterioration of mental health in China seems to reflect individuals inability to adapt the drastic societal changes and rising aspiration towards the future” (Graham et al., 2017. p. 233)

The government, for its part, has begun to talk more openly about the scale of the challenge that it faces, that despite rapid growth and gains in prosperity, the national mental health burden has increased over the same period. In its opening chapter, the National Mental Health Work Plan

As a result of these changes in China’s health is the surprising fact that psychological illnesses are now

Psychiatrists per 100,000 people (2014)

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5 1.7 0 Japan

USA

Russia

Denmark

China

Vietnam

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Country Source: WHO

Figure 5.

Graph showing countries by number of qualified psychiatrists per 100,000 citizens Source: World Health Organisation, 2001

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Laos

Image 10.

Doctors in a training session at Weifang community health service center in Shanghai

Credit: Gilles SabriĂŠ for The New York Times

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of China (2015 - 2020) draws the connection between economic (and therefore urban) expansion and an increase in mental health problems: “Rapid economic and social development is associated with a significant increase in the pace of life and in the number of psychological stressors. Common mental disorders such as anxiety and depression and psychological behavioral problems are increasing year by year…

Mental health work in China still faces great challenges.”

(Wong & Phillips, 2016. p. 5)

One of the main barriers that China’s mental healthcare system presently faces is a scarcity in adequately trained psychiatrists and other care staff, with only 1.7 psychiatrists per 10 0,0 0 0 citizens, drastically lower than Denmark (9.5 per 10 0,0 0 0) and Russia (12 per 10 0,0 0 0) (World Health Organisation, 2001. - See fig. 5). The latent social stigma from traditional Chinese culture has made it hard for the medical system to recruit enough graduates to take up the study of psychiatry, over other medical specialisms. The lack of investment in infrastructure, innovative treatment methods and an emphasis on inpatient treatment has resulted in highly qualified medical staff leaving psychiatry, as they often feel they can be more effective elsewhere (Lui, J. et al, 2011) The Chinese government has also identified that a lack of public understanding of mental health concerns is an issue for developing effective diagnosis and treatment systems. The social stigma that this causes leads many patients to hide their symptoms and “only a few seek evidence based treatments.” (Wong & Phillips, 2016. p. 5) All of this evidence goes to illustrate how China faces uniquechallenges in addressing the scale of the problems caused by deterioration in the mental wellbeing of its citizens.

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Image 11.

Patients queue in the early morning to pay for treatment at Peking Institute of Mental Heath

Credit: Author

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Year

61 8 - 90 7 189 8

Policy / Milestone Mentally ill cared for by Bei Tian Fang, a charity organised by monks American missionary John Kerr founds first western style psychiatric hospital, in location of what is now Guangzhou Brain Hospital

19 4 9

Founding of Peoples Republic of China Psychiatric hospitals gradually built in every province.

Their role was to maintain social security and stability.

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First National Mental Health Meeting Community mental health work begins in Beijing, Shanghai,

and Jiangsu.

Facilities built to train professionals and to develop treatment plans for the prevention & treatment of psychosis, including relapse prevention.

19 6 6

Cultural Revolution

Begins

Government supported community mental health programmes cease altogether

19 6 7

Rehabilitation centres for patients with psychosis and care networks are organised by neighbourhood committees in Shanghai.

19 6 8

Treatment model for patients with schizophrenia and their families is developed in the suburbs of Beijing

19 8 0

Three tier (city, district and street level) network set-up for the prevention and treatment of Psychosis

19 8 2

Successful tests with treatment models, such as work-rehabilitation centres in urban communities Shanghai and Shenyang

199 0

Hospitals are encouraged, as part of the expansion of market economics takes hold, to make a profit.

992

Financially dependant mental health rehabilitation facilities are

1

closed or absorbed by larger hospitals

19 9 9

High level mental health conference hosted in Beijing by ten Chinese Government Ministries and the World Health Organisation

20 o 0

All levels of government declared intention to improve leadership for and support of mental healthcare and to facilitate the enactment of national mental health legislation.

2002

The first National Mental Health Plan (2002 - 2010) was signed by Ministries of Health, Public Security and Civil Affairs.

20 04

Chinese Central Government initiates nationwide 686 Programme named after the initial funding allocation of 6.86 Million Yuan

20 0 8 20 1 3

First Cognitive Behavioral Therapy research conference held in China China’s Mental Health Law comes into effect 27 years after its development being initiated

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Figure 6.

National Mental Health Work Plan (2015 - 2020)

Directory of key policy milestones in China’s Mental Healthcare development

Credit: Author

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Image 12.

Clinical staff morning meeting, Peking Institute of Mental Health.

Credit: Author

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The Growing Economic and Societal Burden Although only a fraction of those who suffer from mental illnesses in China are treated, its cost grows almost exponentially. The total expenditure of providing mental healthcare in China grew from $21 Billion in 20 05 to over $88 Billion seven years later in 2013 (Word Health Organisation, 2017).

This quadrupalling of costs to the healthcare system resulted in mental healthcare representing between 15 -20% of the total Chinese health budget in 2013, and over 1.1% of China’s gross domestic product that year. These figures however just represent the tip of the iceberg of potential costs. Currently 90% of sufferers do not seek , or are able to access, any professional treatment. If they did then the cost of mental health treatment alone would far surpass the entire Chinese healthcare budget

at almost half a trillion US Dollars per year (WHO, 2017. See Figure 7, below).

Clearly, this data shows that the current approach the the Chinese healthcare system is taking to mental healthcare is unsustainable in the medium to long term, if the country stands any chance of increasing the rates of treatment.

A number of independent research studies have pointed to China’s existing psychiatric system’s reliance of hospital inpatient care, and a lack of local community and tertiary care options for urban and rural populations, as a key cause of economic inefficiencies in the system (Xu and Wang et al, 2016; Liang et al, 2017).

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* Total Mental Health Spending if all patients suffering from mental health illnesses in China are treated.

Figure 7.

2010

2009

The above graph shows the rate of mental healthcare expenditure in China during the last decade. In white we see the amount of expendature that would be required if every mental healthcare sufferer was appropriatly treated. (WHO, 2017)

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$ Billions (USD)

400

Actual Mental Health Spending

% of total Chinese health budget

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Image 13.

Stills from 2018 New York Times Documentary ‘China’s Health Care Crisis’

Credit: New York Times (Wee, 2018)

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Mental Health Law and set out a series of goals to be achieved by 2020 to deliver on the overall agenda, which aims to create a comprehensive and holistic mental healthcare system:

However, in the last two decades the Chinese government has begun making moves towards reforming the provision of mental healthcare. A key milestone in this process was the initiation of the 20 04 ‘686 Programme’, so named after its founding funding allocation of 6.86 million yuan.

Also referred to as the “Central Government Support for the Local Management and Treatment of Serious Mental Illness Project, the goal of the legislation was to integrate hospital mental healthcare provision with community engagement, awareness and treatment. This policy was followed almost a decade later by the 2012 enacting of the National Mental Health Law, which for the first time legally recognised mental healthcare patient rights, and a commitment to improving mental health services across the nation. Despite these encouraging commitments, local state and government uptake and implementation of these policies has been slow and ineffective (Liang et al, 2017), as the priority of the general health policy has been to rapidly expand its basic, primary healthcare facilities and achieving nearly universal healthcare coverage.

The publication of the National Mental Health Work Plan of China (2015 - 2020) expanded upon the 2012 National

“[To] build a social milieu of understanding, acceptance, and caring for individuals with mental illnesses; raise community awareness of the importance of mental health; promote the psychological well-being of the public; and enhance the harmonious development of the society” (Wong & Phillips, 2016. p. 6) The Work Plan also seeks to spread the responsibility of mental healthcare into the private sector, away from solely being provided by state funded primary health services. As part of wider reforms being brought to healthcare more generally, the policy encourages private commercial and community organisations to develop services, products and treatmenta which can contribute to the overall mental health policy goals. There is a clear encouragement on the adoption of new technologies and in learning from new practices in the international community so that “successful experiences from international sources… should be rapidly applied in the practice of mental

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400 350 300 250 Start of the “686 programme” with a initial funding of 6.86 million RMB

150 100 50

Passing of the 2012 Mental Health Law

Universal coverage of health insurance in China

Local Government Funding

200

Managment of serious mental illness programme included in the “Basic Public Health Services” National Government Funding

Mental Healthcare Funding (Million RMB)

450

0 2005

Figure 8.

2006

2007

2008

2009

2010

2011

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Yearhealthcare funding, seen in relationship to key The above graph shows the level of mental policy publications by the Government of China. (WHO, 2017)

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Internet Enabled Social Networks Diagnostic & Treatment Apps

Community Support Groups

Urban Community Networks

Technological Innovation Intelligent patient monitoring, security & space utilisation

Educational Spaces

Community Treatment & Care Facilities

Architectural Spatial Intervention

VR Spaces created for Diagnostics & Treatment

Remote access to hospital consultations & specialists

Rehabilitation Facities

National Strategy & Policy

Figure 9.

The intersections between digital platforms and physcial typologies creates novel possibilities for mental healthcare provision in urban locations

Credit: Author

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health work.” (ibid. p.12)

And finally, there is a unique requirement for an architectural and planning strategy on a local and national scale, with the creation of new collaborative care spaces in both physical settings and through an emerging treatment landscape of Virtual Reality.

Finally, there is a particular emphasis on strengthening community care, treatment and rehabilitation facilities which “involves the collaborative participation of specialised mental health facilities, community rehabilitation centres, social organisations, and families.” (ibid. p.7 ). One way that this policy is to be achieved is by the opening of a new type of architectural intervention: “public communitybased rehabilitation facilities.”

The policy aims to maximise integration with local communities, simultaneously enabling care to take place closer to patients existing social networks, while improving the wider public’s understanding of mental healthcare. The policy states that local governments:

The following three chapters I will outline the interactions between these themes, and how they can be synthesised in the unique contexts of urban China to offer the possibility of beneficially transforming national and neighbourhood mental healthcare.

“...should vigorously promote a comprehensive, community-based, open model of rehabilitation for individuals with mental illnesses that effectively links medical rehabilitation and social rehabilitation and that strengthens the technical support provided from specialised mental health institutions to community-based rehabilitation facilities” (ibid. p.8) Thus, it is possible to assess the strategies outlined in both the 2012 National Mental Health Law and the National Mental Health Work Plan of China (2015 - 2020) through the lense of the three interconnected thematics that was identified in the introduction: Firstly, the role of existing urban community and neighbourhood networks play in both increasing understanding, controlling stigma, opening access to diagnosis, treatment and rehabilitation.

Secondly, how rapid technological innovations are changing the methods of treatment for mental healthcare across the globe, and are enabling a move away from institutionalised care, to treatment in local neighbourhoods and in the home.

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Image 14.

Communist-era Beijing Danwei.

Credit: Tomaz Pipan, Architectural Association

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Spatializing Mental Illness: The importance of Neighbourhoods Despite China’s mental health burden existing at a national scale, the impact of its effects are to be most profoundly felt at a local, neighbourhood register.

For sufferers of mental health illnesses, traditionally the treatment and care (or lack thereof) would have taken place within the home, the street and the neighbourhood. The reliance on family and neighbour relationships has been of critical importance to healthcare more generally, and prior to the Cultural Revolution (1966 - 1976) healthcare was largely administered at a highly localised scale (Liu et al, 2011. p. 210).

There is a wide body of research in Western literature that shows a distinctive relationship between patient’s immediate neighbourhood context and the individual’s mental health (Chen & Chen, 2014 p. 102). While China’s urbanisation process is different in its scale and speed than most western contexts, many parallels can be drawn between these studies in European and North American cities, as many share similar neighbourhood conditions of health and income inequality to those found in cities such as Beijing and Shanghai (ibid).

While studies show that the impact of neighbourhood social relationships are more profound on mental wellbeing, the physical features of the local built environment have been consistently associated with conditions such as depression (Mair et al., 2008). The process of urbanisation in China has been described as an “Urbanisation of Place rather than an Urbanisation of People” (Chen & Chen, 2014. p. 108) and in doing so the deterioration of mental health in China is associated with “a dismantling of community safety nets [and] individuals’ inability to adapt to these drastic social changes.” (Graham, et al., 2017). Thus, the neighbourhood is a vital scale in which to understand the causes of mental health burden, and to offer possible solutions for prevention and care:

In cities such as Beijing and Shanghai a number of local community care and rehabilitation centres operated, organised by neighbourhood committees - the lowest level of governmental body - and were situated within the residential areas of the city (Zhang, 1990 & Shen, 1990.) Community care was also an integral component of rehabilitation programmes within major cities, which was particularly effective in minimising deterioration of chronic conditions (Park et al. 2005. p.

39) However, after the reforms to the healthcare system through the 1980s and ‘90s, there was an incentive for healthcare facilities to generate profit, and smaller neighbourhood clinics were enveloped by larger, city scale hospitals. Before 1990 there was at least one community psychiatric clinic per district in Shanghai - by 20 04 the number of these facilities had decreased by over 60% (Liu et al, 2011. p.211). In a city of Shanghai’s scale - with a population of over 24 million - there are now only 98 outpatient rehabilitation programmes (Park et al. 2005 p.39), and over 80% of mental healthcare funding is directed to a few large inpatient hospitals (ibid).

“Neighbourhoods are responsible for the conditions in which people are born, grow, live and age; neighbourhoodlevel characteristics may represent both and important driver of mental health problems and and opportunity for prevention.” (Chiavegatto, 2017 p.2) China has a long history of reliance upon close-knit communities to deliver much of the social and welfare

35

Residential buildings Walled perimeter

Figure 10.

Drawing of typical 1960s Beijing Danwei

Credit: Author

36

Central yard

Event Hall & collective dining building

Community health centre

Entrance from street

37

Image 15.

Guangzhou Danwei, surrounded by new residential development.

Credit: Institute of Urban Dreaming

38

provision at neighbourhood scales.

During the Maoist era citizens lives were organised around the socialist work unit, or danwei system, where residents were colleagues in local industry and delivered community services to each other within their danwei (Zhu, 2015. p.45. ). While this system encouraged residents to rely upon each other at a neighbourhood level, some have argued that concepts such as community social capital, neighbourhood attachment and community participation have now a reduced emphasis in contemporary Chinese urbanism (Hazelzet & Wissink, 2012. Forrest & Yip, 2007.)

During the tremendous spatial and social transformations that have occurred following Deng Xiaoping’s reforms the “traditional cohesive social fabric [has given way to] the individualistic pursuit of privacy and anonymity in modern neighbourhoods. (Zhu, 2015. p.46. ).

This social transition was mirrored in a change of governmental approach, as the state retreated from delivering services through the mechanics of neighbourhood level (communist party) organisations and shifted to top-down and centralised control and management, including for healthcare provision. The result is that Chinese urban citizens are living ever more isolated and independent lives, are unable to access the traditional safety nets that were once available from their local neighbourhood, and that this is a major contributor to the increasing urban mental health burden.

The combination of increasingly individualistic lifestyles and a mental healthcare care system which is centralised has lead researchers to conclude that: “Although urban residents have access to superior healthcare facilities and services, our results indicate that they may not be strong enough to offset the adverse health effects of urban environment and lifestyle.” (Chen & Chen, 2014. p. 108).

39

Figure 11.

GIS Map of Beijing showing locations of new psychiatric hospitals and population densities

GIS Data Source: Harvard University Centre for Geographic Analysis, ChinaMap

40

Pushed to the Fringes

There is a historical precedent for facilities for the mentally ill being pushed to the fringes of the city, and in doing so, of society. In his 1965 work Madness and Civilisation, Foucault draws parallels between the displacement of sufferers of leprosy from the city, and the contemporary spaces for confinement and treatment of mental illness. During the 14th and 15th centuries Leper houses were constructed on the edge of cities across Europe to cope with the millions of sufferers. Despite the disease being eradicated and these houses closing by the end of the 17th century, Foucault argued that the social structures of this urban experience remains in our collective urban consciousness: “Leprosy disappeared, the leper vanished from memor y; these structures remained...The formulas of exclusion would be repeated, strangely similar two or three hundred years later. Poor vagabonds, criminals and “deranged minds” would take the part played by the leper, and we shall see what salvation results from this exclusion, for them and for those who excluded them” (Foucault 1988, p.7) Figure 11 shows a GIS map of Beijing with new, high capacity psychiatric hospitals plotted (with blue circles) against the city’s residential population density. This map clearly shows the spatial strategy that has been employed in the planning of the urban mental healthcare system.

These new hospitals are concentrating facilities at the extremities of urban development, removing resources and patients from the denser residential neighbourhoods; and their interaction with their communities.

< 8,0 0 0 people / sq km 3,0 0 0 people / sq km Major Ring Road Psychiatric Hospital

41

Image 16.

Corridor in the Asylum, Vincent can Gogh (1889) - A painting made by van Gogh while at the asylum of Saint-Paul-de-Mausole on the outskirts of Marseille.

Credit: Metropolitan Museum of Modern Art

42

For Foucault we can understand this positioning of the mentally ill at the fringes of the city as highly symbolic.

While the asylums (literal, spatial prisons) may be of the past, locating the mentally ill on the limits of the city excludes them from the urban consciousness, “enclosing them” within the metaphorical walls of the city.

“If he cannot and must not have another a prison than the threshold itself, he is kept and the point of passage. He is put in the interior of the exterior, and inversely. A highly symbolic position, which will doubtless remain till our present day.” (ibid. p.11) Thus, it follows that the strategic decision to concentrate the treatment of mental illness on the edges of cities, while removing the bars from the windows, is erecting metaphorical barriers between the mentally ill and the rest of society in our collective consciousness: “...what was a formerly visible fortress of order has now become a castle of our conscience.” (ibid. p.11) By bringing Foucault’s discourse between space, the city and mental health to the discussion of healthcare planning in cities like Beijing and Shanghai, we can see that the impact of the architecture and strategic planning of psychiatric facilities extends far beyond only the patients and careers. It informs and reinforces society’s understanding of mental health and wellbeing. Thus, by challenging spatial presumptions, and developing a more nuanced and contextual strategic framework for care, we may contribute to a new societal conceptualization of mental wellbeing. Here, we find a wider argument for a new strategy which brings care facilities back into the city, into the community and to the neighbourhood.

43

Geel Belgium 44

Close to Home: Bringing care back to the neighbourhood Following his discourse on the conditions that form ‘madness’, in Madness and Civilisation Foucault moves on to investigate methods of treatment, with a particular emphasis on the process of spatial confinement in strategies to cure mental illness.

He discusses the small city of Geel in Flemish Belgium which is unusual in its adoption of a highly localised and community centred understanding and treatment of mental illness. In Geel, the separation between the mentally unwell and society was entirely disintegrated:

Geel, which has been described as “truly the first psychiatric therapeutic community in Europe” (van Bilsen, 2016. p. 208), has since the 13th century provided a unique haven for the mentally ill (Aring, 1974. p. 998). Originally a place of religious pilgrimage to the church of St Dymphna - the patron saint of the mentally ill - “possessed” (mentally ill) pilgrims would travel to the tomb of St Dymphna in hope of cure, and local villagers began to offer the pilgrims temporary accomodation in their homes (van Bilsen, 2016. p. 208). A number of these pilgrims stayed on in the town after their religious rituals, and so a family foster care system came into being, not on the initiative from the church or the medical profession, “but was an initiative from the the peasants.” (ibid.)

“What had once marked, here, the entire violent, pathetic separation of the world of madmen from the world of men, now conveyed the idyllic values of a rediscovered unity of unreason and nature...now it manifested that the madman was liberated, and that, on this liberty which put him on a level with the laws of nature, he was reconciled with the man of reason.”

(Foucault 1988, p.195)

Now, almost 60 0 years after accepting its first ‘patient’, Geel has built upon this long standing tradition of welcoming those with mental illness into its community, and has developed

Image 17.

Geel resident Maria Lenaerts & Jefkae Harbant,. She describes him as like a brother, although she has been his foster parent since her father died in 1982.

Credit: Judith Jockel

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Figure 12.

The World Health Organisation describes the development of mental healthcare globally as 3 phases.

While there are some countries which have taken the lead in innovative policy on treatment and care, most countries are still situated between phase 2 and 3.

46

Increased but not fully recognized role of the family

Public disinvestment in mental health services

Clinical psychologists, occupational therapists and social workers develop occupationally

Reduced role of the family

Public investment in institutions

Doctors and nurses the only professional staff members

Source: WHO

Primacy of containment over treatment

Decreasing number of hospital beds

Increasing number of hospital beds

Emergence of evidence-based psychiatry in pharmacological, social and psychological treatment Emergence of concern about balance between control of patients and patient independence

Less-disabled patients discharged from asylums

New emphasis on multidisciplinary teamwork

More community-based staff members

Increasing private investment in treatment and care, and focus in public sector on costâ&#x20AC;&#x201C;effectiveness and cost-containment.

Importance of families increasingly recognized in terms of care given, therapeutic potential, burden carried and lobbying potential

Decrease in hospital beds slows down

Asylums replaced by smaller facilities

Phase 3

Focus on pharmacological control and social rehabilitation

Growing influence of individual and group psychotherapy

Beginning of treatment evaluation and standardized diagnostic systems

Effective treatments emerge

Asylums neglected

Phase 2

Asylums built

Phase 1

Matrix of characteristics in the key periods of the historical development in psychiatric health care systems

into a city wide “professional and progressive institute for mental health treatment.” (ibid. p.209). Officially known as the Openbaar Psychiatrisch Zorgcentrum Geel integrates neighbourhood and community care with a specialised centre for medical treatment. Patients, referred to in Geel as ‘Boarders’, are assigned with a host family after a medical and character assessment designed to find the ideal match between host and boarder.

Boarders come to Geel with a wide range of psychological disorders, and while there are expectations put on them in terms of behavior, there are no demands on their activity or treatment; “Patients are allowed to function on their optimum level.” (ibid.) The system of community care that is found in Geel recognises the idiosyncrasies and complexities of each of the patient’s illnesses. The neighbourhood settings provide the security, safety and opportunities for the patient to do meaningful work and build connections in the community.

By being exposed to, and welcomed into, a ‘normal’ community creates what psychologist Albert Bandura calls “collective efficacy”, meaning that there is nothing more effective in influencing a patient’s behavior than seeing effective behaviors in use, in a natural setting (Bandura, 1997).

to provide diagnosis and treatment services that are “close to home, with short and long term residential facilities in the community…. mobile and reflect the priorities of patients.”

(WHO, 2003. p.7). The WHO sets out a series of key principles for a Balanced Community-based care model: autonomy, continuity, effectiveness, accessibility, comprehensiveness, equity, accountability, coordination and efficiency.

China’s mental healthcare system is yet to implement these principles.

Establishing the kind of treatment framework as is available in Geel would undoubtedly be impractical for a country of its size. However, there does exist an enormous potential in the utilisation of China’s flourishing technical capabilities to meet these goals. There is a growing industry and body of research which could efficiently connect patients to networks, communities and spaces of care.

The success of the Geel model has been widely recognised, and its has inspired other community centric treatment models across Europe and the United States, such as the Buurtzorg Nursing Model in the Netherlands (Sheldon, 2017) . In 20 01 Geel was recognised by the World Health Organisation in their report on mental health, which stated “One of the best examples of how communities can become carers of the mentally ill is to be found in the Belgian town of Geel.” (WHO, 2001). Many of the principles, on which Geel has been operating for centuries, have now become key recommendations by the WHO as it encourages nations to move their mental healthcare policies towards those based upon what it calls a ‘Balanced Care’ model (‘Phase 3’ in the matrix shown opposite).

The Balanced Care approach seeks

47

Image 18

Technological innovations such as Virtual Reality may cause a revolution in mental healthcare

Credit: Author

48

Urban Technological Innovation

It is projected by researchers from the University of Har vard that, by the year 2022, China will surpass the United States to become the world’s leader in technological research investment (Wu, 2015).

corporations in order to receive the maximum benefits from innovation the average in the EU is around 15% (ibid).

Globally, healthcare tech market is estimated to be valued at almost $30 0 billion by 2022, and technology which targets mental healthcare is growing at a particularly rapid rate (Bawkar, 2016) and is attracting a great deal of interest by new tech startups.

As China’s economy grows, it has increasingly sought to support this expansion through home grown technological innovation, and has invested many billions of dollars into fields of computer science and engineering (ibid). This programme of investment has had clearly palpable results, now in 2018, nine of the worlds largest tech firms are Chinese (Meeker, 2018).

In 20 09 US venture capital firms invested less than $50 million in mental health startups, just over five years later in 2015 this had grown to over half a billion dollars per year (Olsen, 2018) and the forecast for 2018 is almost $1 billion (Gaussen, 2018).

The Chinese population is also notably captivated by the promise of technology in their lives, with almost 40% of Chinese internet users declaring themselves ‘very willing’ to share their personal data with tech

In China too, there is a rapid expansion in interest by tech firms in providing solutions to the mental healthcare sector (Mei, 2017).

$900 Million

Venture Capital Invested per Year

$800 Million $700 Million $600 Million $500 Million $400 Million $300 Million $200 Million $100 Million

2009

2010

2011

2012

2013

2014

2015

2016

2017

2018

Source: Pitchbook

Figure 13.

Exponential growth of investment in mental health tech startups in the US

Source: Pitchbook

49

Image 19.

VR can enable domestic spaces to be tranformed to theraputic ones, and the role of the architect can extend into creating these virtual environments, reaching huge audiences

Credit: Author

50

These tech startups are broadly operating in one or a number of specialist applications for mental health diagnostics or treatment: 1. Computerised Cognitive Behavioral Therapy (CCBT) Utilizing patients familiarity with smartphone devices and applications to deliver programmes of self directed talking therapy in their home environment.

2. Telepsychiatry Enabling therapists to connect and communicate remotely with patients, to operate over large distances and provide cheaper therapeutic treatment that traditional face to face consultations.

3. Healthcare Provider Tools Creating tools and software which enables healthcare providers to communicate with each other, and maximise efficiency and to create flexible, contextual and responsive treatment programmes.

4. Patient Mobile Tools Building mobile tools which allow patients to track their treatments, or to communicate with other patients in their local or wider network, enabling and facilitating self run support groups 5. Hardware Using connected hardware such as VR headsets and motion trackers to deliver immersive virtual treatments, change perceived spatial conditions or utilise virtual environments to test and diagnose patients.

6. Applied Artificial Intelligence Connecting patient data with artificially intelligent machine learning to analyse patient conditions, treatment efficacy & to assist with diagnosis or prevention.

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Image 20.

Images from OxfordVR. A range of specific architectural environments have been created to treat sufferers of psychosis, PTSD and social anxiety.

Credit: OxfordVR.org

52

2393). As VR technology is able to move out from use in only specialist university laboratories, “VR has the potential to transform the assessment, understanding and treatment of mental health problems.” (ibid.)

A number of Chinese startups have identified the holes in the country’s mental healthcare infrastructure as being opportunities for technological innovation, able to rapidly meet the huge demand faster than government policy or changes to traditional healthcare infrastructure.

Professor Freeman has taken his academic research into VR and has founded a spinout tech startup, Oxford VR, which together with designers from the Royal College of Art has developed virtual environments to assist with the treatment of psychosis, social anxiety and post-traumatic stress disorder (OxfordVR, 2018).

One such company is Cognitive Leap a Shanghai / California based tech firm which is developing diagnostic and treatment programmes which harness the power of Virtual Reality to reach patients in the heart of communities across the country.

“With such large number of people needing help [in China] it’s impossible that they can all be treated by human [face to face] inter ventions. I think human inter ventions are ver y important, but in the meantime, to tr y and ser ve that many people technology has to play a ver y important role.”

Jack Chen, CEO of Cognitive Leap.

(CGTN, 2018)

There is an emerging new role for spatial designers, architects and product designers to offer there skills in the creation of these virtual treatment environments. By designing truly immersive experiences, it is possible to reach a enormously diverse group of patients, taylor their experience to their particular individual needs or social & spatial contexts. There is a particularly keen interest in these possibilities in China where for many citizens, the urban conditions they have found themselves in are largely out of their individual control. Many Chinese doctors have expressed an interest in using VR, and tend to welcome new technologies with “open arms, unlike their counterparts in America.” (Mei, 2017) This is seen as an opportunity for China to ‘leapfrog ’the US and Europe, as they have done with other digital technologies like mobile payments (ibid).

In October 2018, Cognitive Leap opened its first urban treatment centre in Shanghai, a completely new treatment typology. From here the company aims to deliver innovative treatment programmes in an environment which challenges the social stigma that is associated with traditional mental healthcare spaces (Cognitive Leap, 2018).

Jack Chen, the founder of Cognitive Leap sees the novelty of using Virtual Reality to treat psychiatric conditions has an advantage in encouraging sufferers to seek help; “the first impression [from patients] is not about mental health stigma, but about how much fun it is to use. We’ve seen this in both China and the US.” (Mei, 2017).

The efficacy of using VR in the treatment of a wide variety of mental health conditions, from anxiety to schizophrenia, is being validated by a growing body of international clinical research. Daniel Freeman, a clinical psychologist from The University of Oxford describes the potential of VR as a “technological revolution in mental healthcare.” (Freeman, 2017. p.

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Image 21.

The WeChat app Jiandan Xinli has created its own therapeutic ecosystem, combining CCBT, Telepsychiatry, Online and offline Tools for patients and training for therapists

Credit: Montage by Author

54

Another technological field that China has become a global leader in is digital social networks, platforms such as WeChat and Weibo have, despite focusing only on the Chinese market have become almost as powerful as their international western counterparts. With 1 billion active users WeChat provides a complete platform for every aspect of digital life within China (Statistica, 2018).

While Chinese society may have been moving away from traditionally spatialised social relationships, it has seen a rapid development in the technological infrastructure which has enabled an explosive growth in the use of digital social platforms such as WeChat. The potential for these platforms to be utilised to provide effective and novel routes to treatment has been long identified in academic research (Tse et al., 2013 p.

615 & Li et al., 2014 p. 102) , and within the last five years there have been a number of companies who have launched mental health applications on the WeChat platform.

Such is the interest in the use of digital platforms to provide access to

mental healthcare, some have called this recent period “China’s PsychoBoom” (Hsuan-Ying, 2017. p. 29). Most of these latforms are focused on the first 4 of the categories listed above (CCBT, Telepsychiatr y, Healthcare Provider Tools, and Patient Tools).

A leading platform to emerge during this ‘Boom’ is the mobile app Jiandan Xinli (translated literally: Easy Psychology), a Beijing based startup founded in 2014 by Chinese neuropsychologist Li Zhen.

Jiandan Xinli has created its own therapeutic ecosystem, which combines all 4 platform categories, along with AI data anaysis into one WeChat enabled application.

It connects therapists with patients, provides a resource of self help advice and also provides the infrastructure for the training and qualification of counselors. For a prospective patient, the app functions like a dating matchmaker, allowing one to search for therapists based on location, sex, price range, psychological condition, age group, identity and mode of treatment (online or

Image 22.

Patients can search for therapists in much the same way as in a dating application, and also access additional self help information and content.

Credit: Montage by Author

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Image 23.

The rise in use of social media platforms has been shown to exacerbate the mental health problems of the current generation of young adults in China.

Credit: Montage by Author

56

offline). From there, the patient can connect to a relevant therapist, pay via a subscription on WeChat and organise a treatment regime (ibid).

This has enabled therapists located in the centres of Shanghai and Beijing to offer treatment to patients remotely across the cities, drastically expanding the range of those able to receive treatment (ibid. p. 36).

of this analysis, given the fact that WeChat grants access to the Chinese government on all data transmitted by any application operating on the platform.

There are also wider concerns that therapy which only exists digitally is not a panacea for treatment as apps such as Jiandan Xinli would like to portray (Howe, 2016), lacking a physical therapeutic setting, meaningful contact with a therapist is limited and becomes an impersonal transaction of time and money (Hsuan-Ying, 2017 p.

37).

Jiandan Xinli has seen uptake across a broad range of Chinese urban society, but particularly amongst the generation who has grown up with the proliferation of smartphones; 82% of its users are between the ages of 18 - 35 (ibid.), the same age groups for whom mental illness causes the most years lived with disability in China (see figure 12, below).

In addition, there is a large body of international research which shows that encouraging social media use, in place of physical interaction, has a direct correlation with an increase in internet addiction, depression and social anxiety - especially when targeted as already susceptible and vulnerable groups (Pantic, 2014).

Most recently, the platform has expanded to offer its users ‘ peer support’, allowing support groups of patients to form digital connections, which often then lead to real world meetups, a phenomenon which previously would have been hampered by the fear of the associated social stigma (as shown the in the film of Shanghai Tulip).

Thus, there needs to be a new understanding of the role of the physical space of therapy and treatment within Chinese urbanism, so as to best combine the most effective digital platforms with the real world, spatial and human contact which is required for successful treatment.

The company has also offered its data to academic research, allowing researchers to mine it’s highly detailed data. However, questions have been asked regarding the data privacy

3 Million Years

2 Million Years

rs Ye a 80 +

35

rs Ye a 20 -2 4

Ye a 59

-3 40 9 Y -4 ea 5 rs Ye ar s

1 Million Years

rs

Years Lived with Disability

4 Million Years

Figure 14.

Age in 2010 Years Lived with Disability due to Psychiatric illness in China, by age group .

Source: Institute for Health Metrics and Evaluation, 2010

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Image 24.

Seven Key architectural spaces identified by the UK based Design in Mental Healthcare Network that research shows have a highly effective impact on patients health outcomes, when incorporated into architectural design of treatment spaces. Credit: Montage by Author.

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Urban Architectural Innovation

While there is currently little academic literature on the spaces of mental healthcare environments in the Chinese context, there is a broad body of research which has been produced in western literature which brings together the role of physical space with treatment. Perhaps the most comprehensive reviews of this literature is Connellan et al.’s 2013 study Stressed Spaces: Mental Health and Architecture (Connellan et al., 2013) . In this review of 165 articles at the intersection of mental health and architecture, they uncovered a series of key thematics which are most pertinent to the design of treatment facilities. They rank these major themes by their prevalence in the literature, and can offer a guide into how to evaluate and improve psychiatric spaces. In total they find 13 themes, however, each of these themes nevertheless overlap with each other, and I discuss the five most relevant groupings of thematics below:

conditions have a vital importance on supporting a healthy circadian rhythm in inpatients, which has a major impact on depression, anxiety, eating patterns and perception of pain.

The third most prevalent theme in the literature is that the design of facilities should be patient-centred, giving patients a sense of control over their environment, a degree of independence during care and a choice and variation of spaces across the facility. In particular there is an importance on green spaces, gardens and a connection with nature. Closely aligned with the second theme of lighting, incorporating nature into the environment of care supports a temporal orientation, the changes in weather, seasons, temperature and times of day can break up the experience and stress of undergoing treatment (Naderi & Shin, 2008).

Fourth is the ability of architecture to have a direct impact on mental health outcomes. In creating an environment with order, complexity and aesthetic beauty patients have an increase sense of personal confidence, self worth and feel more comfortable interacting with others. A strong aesthetic and spatial design of treatment spaces encourages patient’s positive sense of attachment to the building, as “A place of refuge and relative stability” (Curtis et al., 2009 p. 346). By creating the impression in patients that, through high standards of architectural design, they are valued , which in turn raises the expectation of recovery and a fixed location gives a sense of continuity throughout their treatment (ibid).

Firstly, security and privacy is of vital importance in the design of psychiatric care spaces, and their setting within the city and community. This includes vital consideration to architectural, urban & patient density, ensuring that overcrowding is minimised, and that different activities have clearly demarcated spaces to minimise confrontation between patients, staff and visitors. (ibid. p. 180).

Secondly, is the impact that well designed lighting can have on patients wellbeing and care. By combining careful and considered use of natural and artificial light, studies have shown that patients leave inpatient facilities an average of 2.6 days earlier than those where lighting conditions are poor (Beauchemin & Hays, 1996). Well designed lighting

Finally, much of the literature shows that there is a broad range of benefits to patient recovery when the architecture reduces the sense

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Image 25.

John G. Kerr Refuge for the Insane, Guangzhou Chinaâ&#x20AC;&#x2122;s first mental healthcare facility

Credit: Peking University Health Science Center

Image 26.

Guangzhou Brain Hospital

Credit: Oxford Journal of Neurosurgery, Volume 54

60

of institutionalisation, isolation and of being separated physically and emotionally from society, and the building’s context. The architecture should encourage social interactions (Day, Carreon, & Stump, 2000. p. 397) and, where possible, should have a domestic atmosphere and scale, and not be imposing in the urban fabric of the context (Dvoskin et al., 2012).

China, however, is yet to fully embrace this shift in treatment philosophy, and so much of its treatment infrastructure retains the architectural relics of the walled off asylum, either distanced from centres of population “on the city fringe” (ibid.), or behind a walled off compound, more directly resembling the architecture of internment than of care.

Alongside this academic research, there are now a number of organisations and professional networks which aim to bring together medical practitioners and academic researchers with architects and city planners. One of which organisations is the London based Design in Mental Health Network which works to bring together research and clinical expertise and into a format which can be easily engaged with by architects.

An example of their cross disciplinary approach is the 2017 publication Design With People In Mind (Reavey et al.

2017) which breads down key research and experience into six spatial conditions (shown in montage, Image 24): Therapeutic Space, Natural Space, Aesthetic Space, Nursing Space, Sonic Space and Sensor y Space (ibid) which more directly spatitalises the work done by Connellan and others.

In September 2018 I was able to witness this first-hand in Beijing on two research visits to two of the leading psychiatric hospitals in China - The Peking Institute of Mental Health and Beijing Anding Hospital. It is clear from both of these hospitals that the architecture is both stretched to capacity, and reflects a treatment methodology which is out of sync with best practice for care, and the aspirations of many of the staff members. While there I was able to interview a consultant psychologist and a psychiatric nurse (see appendix for transcript), and tour the facilities. Both expressed a desire to see increased funding of healthcare facilities, and that the next generation of psychiatric care spaces should reflect more the latest research, combine treatment with recovery, and be more engaged with the local communities.

The result of this body of research has lead to the architecture of mental health facilities in Europe and the United States moving towards a “deinstitutionalization” over the last two decades (Curtis, et al., 2009. p. 340) and away from the asylum model which had existed for a number of centuries (see figure 12, page 44). The process of treatment is increasingly seen as a more holistic and networked set of medical and psychological interventions, and so the architecture of the care environment is changing to reflect this, “away from the model of the ‘total’, ‘closed’ institution, towards increasingly ‘permeable’ regimes.”

(Curtis et al. 2009. p. 340).

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1

5 6 3

Principle Functions 1 Wards 2 Clinic 3 VIP Clinic 4 Research Labs 5 Education 6 Administration 7 Specialist Childrenâ&#x20AC;&#x2122;s Clinic 8 Recreation Courtyard Figure 15.

Peking Institute of Mental Health, Beijing - External compound

Credit: Author

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Internal Functions 1 2 3 4 5 6 7

Figure 16.

Main Waiting Room Research Offices Staff Education Spaces Ward Canteen 6 Bed Single Sex Ward Room 1 and 2 Bed Sing Sex Ward Room Patient Activity Space

Peking Institute of Mental Health, Beijing - Internal Spaces

Credit: Author

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7

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Image 27.

Maggieâ&#x20AC;&#x2122;s Centres in Glasgow, Inverness and Manchester, designed by OMA, Reiach and Hall & Foster and Partners.

Credit: Architects Journal, David Grandgeorge

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Outside of psychiatric care there is already a precedent for healthcare architecture being successfully reimagined, as treatment methodology and needs evolved. In the UK the cancer charity Maggie’s is developing a network of community ‘drop-in’ centres across the country, which offer support and advice to patients suffering from cancer. These centres are located detached from main hospitals, and aim to provide spaces which are less intimidating to patients, based on the founder ’s (Maggie Jencks, the late wife of architectural critic Charles Jencks) belief that “buildings have the capacity to uplift people” (Jenks, 1995). Each of the centres is specific to its location, and each has been designed by a world leading architect “Maggie’s Centres are places where people feel at home and cared for. At the same time, the lively imaginative atmosphere encourages people to dare to explore, and stimulates them to want to do so. The aim is clear. The object is to encourage people who feel frightened and anxious about coping with cancer to feel better by developing their sense of confidence and resourcefulness.”

(Blakenham, 2007. p. 27) There is much potential cross over between the spaces and functionality of these Maggie’s centres and those strategies which have been outlined above in creating effective new psychiatric facilities. The success and now global expansion of Maggie’s Centres (recently to Hong Kong and Toyko) should be studied with interest by those undertaking a reimagining of mental healthcare.

While it may not be feasible to hire a range of ‘star architects’ to create a future network of psychiatric care spaces on the scale needed in China; many of the principles that the Maggie’s Centres are built and organised with are certainly appropriate for further investigation.

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Image Placeholder

Image 28.

â&#x20AC;&#x153;Hospitals should be seen as nodes in the network, influencing and being influenced by other nodes and actorsâ&#x20AC;?. (Curtis, 2009. p. 341)

Image Credit: Montage by Author

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Conclusions

“China is facing health problems that occur in developing countries as well as developed countries. If these problems are not effectively addressed, people’s health may be seriously undermined and economic development and social stability will also be compromised,”

and the US, it will often be the tech innovators and creators who change modes of treatment before official policy catches up.

This is a process architects and urbanists must engage with, as their contribution in designing spaces for care will be as vital as ever, even though the physical realities will be mediated increasingly through wider systemic technological, digital and virtual infrastructures.

President Xi Jinping (China Daily, 2016) This paper has unfolded some of the specifics of China’s unique mental healthcare crisis, caught as it is between dealing with the challenges of a developing country while simultaneously managing the effects of its remarkable growth as the world’s second richest superpower.

As urban life in China becomes increasingly digitised; and social relations move between offline and online, social services (such as mental healthcare) should be “seen as networks rather than as bounded and closed spatial units.” (Curtis, 20 09. p.341). There is an exciting opportunity in China to develop a new network to deliver mental healthcare through a holistic range of novel mediums, from VR to social networks, while retaining much that is effective and necessary in traditional Chinese urban culture. In this network the spaces that architects and urbanists create “should be seen as nodes in the network, or field, influencing and being influenced by other nodes” where increasingly “one cannot make a clear distinction between what is occurring ‘outside’ or ‘inside’ a place.” (ibid).

My research has also uncovered some equally unique opportunities which place the county at a key moment of potential for transition in mental healthcare. In order to adequately deal with the scale of the crisis, China must look towards systemic change rather than piecemeal improvements.

But the country has shown, perhaps beyond all others in modern history, a remarkable capacity for large scale change over short periods of time. In the last 30 years, China has transformed a largely rural society into a rapidly urbanised one, now with six times as much urban area than in 1981 (Chen & Chen, 2014. p.102) – an urbanisation which has caused significant strains on its citizens, but also created enormous creative capacity for change, as a result of which the Chinese “tech revolution is now ubiquitous in urban life.” (Ash, 2018)

While the possibilities presented by this technology are certainly exciting, there is also reason to be cautious.

This is because mental health in China is still heavily, and when combined with the state’s use of technology to stretch its hand of control over citizens lives, there is a risk that the promise of future potential may swing towards a dystopian reality. The recent expansion of the Social Credit system, powered by huge data and artificial

Although slow to develop policy, the Chinese government has stated its commitments to prioritising finding new ways to treat mental health illness. But, as we find in Europe

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Image 29.

As China moves towards becoming the worlds most powerful nation, can they take the opportunity to lead the world in developing a new & progessive mental healthcare system?

Image Credit: Montage by Author

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Next Steps

intelligent infrastructure, will need to be monitored closely (Mozur, 2018).

There is as yet little research on the impacts of such policies on citizens’ mental wellbeing.

I plan to expand upon this research paper in the coming months, towards the development of spatial & strategic proposal which builds upon the understanding that I have been able to gain throughout the last four months.This research will be supplemented by a further research visit to Shanghai in January 2019.

The issue of mental health is particularly pertinent in contemporary societies, and the challenges it presents are shaped by cultural attitudes and social policies. These have significant bearing on urban planning, and successful interventions are likely to involve a combination of multi-disciplinary and technological approaches.

In addition, this research proposal was recently accepted by the Centre for Urban Design and Mental Health, an international think tank that seeks to answer the question: ‘How can we build better mental health into our cities?’.

The scale of China’s urbanisation has amplified a pressing need to explore innovative solutions in mental healthcare. Moreover, the lessons learned there will have impacts far beyond its borders and possibly hold the promise of a revolution in a global understanding of urban psychological wellbeing.

From January 2019 I will take a part time Research Associate position, and I hope to record my research progression in their peer reviewed Journal of Urban Design and Mental Health.

By further exploring the systemic and spatial possibilities that can be found at the interesection of technology, architecture and community networks, architects and designers have a key role to play in imagining and building for this revolution.

Urban Community Networks

Technological Innovation

Architectural Spatial Intervention

National Strategy & Policy

Figure 17.

February 2018 Edition of Journal of Urban Design and Mental Health

Credit: Centre for Urban Design and Mental Health, www.urbandesignmentalhealth.com

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Appendix

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Image 30.

Research visit to Peking Institute of Mental Health, September 2018

Credit: Author

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Image 31.

Research visit to Peking Institute of Mental Health, September 2018

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Image 32.

Research visit to Peking Institute of Mental Health, September 2018

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Image 33.

Research visit to Peking Institute of Mental Health, September 2018

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Image 34.

Research visit to Peking Institute of Mental Health, September 2018

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Image 35.

Research visit to Peking Institute of Mental Health, September 2018

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Image 36.

Research visit to Peking Institute of Mental Health, September 2018

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Research visit to Peking Institute of Mental Health, September 2018

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Image 38.

Research visit to Peking Institute of Mental Health, September 2018

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Image 39.

Research visit to Peking Institute of Mental Health, September 2018

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Image 40.

Research visit to Peking Institute of Mental Health, September 2018

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Image 41.

Research visit to Peking Institute of Mental Health, September 2018

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Image 42.

Research visit to Peking Institute of Mental Health, September 2018

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Research visit to Peking Institute of Mental Health, September 2018

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北 京 安 定 医 院 Beijing Anding Hospital 92

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Principle Functions 1 Wards 2 Clinic 3 VIP Clinic 4 Research Labs 5 Education 6 Administration Figure 17

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Interview with Mental Health Nurse from Beijing Anding Hospital Interview conducted on 27 September 2018, Beijing China

in your department?

Text in italics is inter viewee, Nurse ‘S’ who wishes to remain anonymous, but was happy for her inter view to be used in this research paper.

And how many members of staff in your department?

We have more than 60 patients

Around 20 or 25 How many doctors?

Cameron Clarke:

I think there are about less than 10

So, thank you so much for taking the time to meet with me and have a chat - I sent you my project introduction last week, and it’s been great to chat with you over wechat.

And do the patients stay in hospital?

I know you have a long night shift ahead of you, so I hope this won’t take too long. I’ll start with some easy questions!

How long have you worked in your job?

Nurse ‘S’: I’ve been working almost 10 years now!

What kind of illnesses do your patients suffer from?

Mainly depression and bipolar disorders Are these illnesses the most common that hospital treats?

Yes Does the hospital also treat conditions such as Alzheimer ’s and dementia?

Yes but in a different department And how many people do you treat

Yes patients with serious illnesses like depression stay in hospital I’m really interested to hear how in the past 10 years the hospital has changed, has the treatment in China changed?

I think it has definitely changed, when I started to work The patients were given more drugs than they are now But now the doctors are more careful when they are treating patients.

Ok, so is there more use of other treatment methods like talking therapy and counselling?

Yes, there are now different parts to the treatments that patients receive Do most of the patients come from Beijing?

No, most of the patients are not local, they come from all over china, other provinces and other cities because our hospital is the foremost one in china.

The treatment is ver y developed, and the facilities are the most developed in China.

And does the hospital conduct medical research?

Yes, they do work with universities in Beijing, but I am not involved in that - I only look after the patients

how strong the communities were in the Hutong just south of your hospital. Have you found that strong family relationships and ties to the community are important factors in helping patients get treatment?

I’m really interested that in the last 10 years China has changed a lot, in all aspects of society, it has grown and developed really quickly. And Beijing in particular has become a huge city. Now that most chinese people live in cities do you think that has changed the mental illnesses that people are being diagnosed with, and does it change how people think about mental health?

Unfortunately in China there isn’t much knowledge in the communities and so they cant do alot of these patients, often people in the community will only call the police when the patient is ver y sick, and then they are taken away to a hospital.

I think that recently depression has become much more common, and even some young people in Beijing now have started to associate being depressed with popularity, do you know? I have started to fake the symptoms, I think so - I have read some papers about this.

But my hospital [Beijing Anding Hospital] has this kind of group, for patients who have been in hospital, but have ended their inpatient treatment, our department will arrange a group to have this kind of people to do some social work, to arrange some kind of community activities, like exercise.

More serious illnesses such as schizophrenia, chinese people have some opinions about these people, they are scared of them, that they are doing something bad, and have been cursed.

This helps patients rejoin the community.

How do you think the communities feel about patients who are returning from hospital?

Is that a traditional way of thinking about mental health illnesses in China, that it’s the result of a curse it’s not treated as an illness?

I think people will have some fear.

People are surprised, they dont have much knowledge about mental health illnesses and so they are scared, and they say things about patients.

Yes, exactly.

And do you think that stops people who need treatment, getting treatment?

Do you think that more should be done to encourage more in the communities to open up and talk about mental health problems, because lots of research shows that they are much more common than most people think - even in Europe.

Some of them, if they get this kind of illness - the family is really really poor, because it can often be an inherited illness from their family. So the family doesn’t have enough money to travel to get treatment.

I think that in our major cities our living is under really huge stress, we have to work really hard and long hours to make money for our families.

Some people have to leave their families for work, and this puts even more pressure on them. Many people don’t have anyone to talk about their problems with, their feelings, so they are more likely to get depression.

Do you think that the Chinese government is investing enough money and effort in changing how mental healthcare is treated? Is it changing quickly enough?

I think that there is lots of change in the biggest cities, such as Beijing and Shanghai, but in the second tier cities and smaller towns and the countr yside, there is little change.

I read in some research papers that one of the groups that is most at risk from depression are actually they people who are successful and live in the biggest cities. People who have quite good jobs, but this brings

In my last project in Beijing, I was really interested to discover

97

anything, if they are treated well.

lots of pressure and they dont have time to see their families.

I’m interested in how life in the city is changing and affecting it is affecting mental health, and ways to treat it in the cities near to where people live, as when people are treated sooner, they get better quicker.

I read about a community organisation in Shanghai called Tulip, a meeting group for people who suffer from depression, to talk their illness, as some of them didnt have anyone else that they can talk to. Im particularly interested in that because the group was also on WeChat, its how they organised their meetings and they talked and connect to each other on the app.

I think that’s really interesting, because the same things happen in Europe, where it is very important that the whole of society is educated about mental illnesses. Everybody knows someone who has depression, but they might not talk about it, but it is very common. But everyone thinks that it is very rare, which stops people from going to getting help.

Yes, I agree I’m also interested in how you think that technology is changing how patients are being treated.

Are there similar groups here in Beijing?

I think it’s ver y important now that lots of patients use the internet to search for their symptoms and find information to help themselves , and can increase their own education about it

I dont think that we do have anything like that in Beijing, but it is a good idea.

Although it could be a bit of a risk if you joined a group like this, because you don’t know each other well, and people could take advantage of each other. The stigma means that sometimes when people leave treatment, or tell others that they are depressed it can have negative consequences.

And are there any self help apps that people use in China? In Europe there is an increase in apps which help people meditate, or take time to think about their mental wellbeing Yes, we have these kinds of apps in China, but they aren’t ver y popular or known about yet.

Yes, I heard an interview in a programme on CNN that often when people say that they suffer from a mental illness in job application forms, they never get called back for interviews.

Could you tell me a little bit about your training to become a psychiatric nurse? Is it a popular field to study?

Yes, that’s a really serious problem in China.

I think that at the beginning of our training, we don’t realise how serious these kinds of diseases are . Nurse training is all the same, we first don’t specialise in a particular kind of treatment.

Is there anything that could be done to change that?

I think it’s really important that we do more for education, so that more people understand more about these kinds of disease. Because for many people, with depression and bipolar, they can live a normal life and do

And what made you want to work in mental health?

I have no idea! I was just looking for a

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job, and then I found this one 10 years ago!

And are you glad that you have been working in psychiatric care?

Sometimes Iâ&#x20AC;&#x2122;m not really glad, because the patients feelings can begin to affect the staff. We get really anxious, especially when the patients are being aggressive.

Is there a system which makes sure that the staff have people to talk to about this pressure and these feelings of anxiety?

No, this is on you. You have to do this by yourself.

If you could imagine a big change, or one of two things that could change in ten years time, to improve mental health care in China, what would they be?

I think in the cities, and in our working lives we need some space to relax and to not be under so much pressure.

In our department we get paid per patient that we see, which means that we have to see lots of patients and donâ&#x20AC;&#x2122;t get to spend much time with each one. Patients are kept in hospital for the shortest time that we can, so that we can treat more patients and get more money for the hospital.

Does there need to be more investment hospitals and their staff?

We need to care for the patients more, but the government doesnâ&#x20AC;&#x2122;t provide enough money to properly do this for each patient, so the hospital has to earn money by treating as many patients as possible quickly.

So patients often pay for their treatment themselves?

Yes, some of them have the insurance.

But others have to pay themselves

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The Royal Danish Academy of Fine Arts, Schools of Architecture, Design and Conservation

Printed 9th December 2018 Approx word count 8200, 15 pages of A4 text (11pt Calibri, non inclusive of bibliography, footnotes, diagrams & appendix)