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Schizophr Bull. 2010 July; 36(4): 836–845.
Published online 2009 February 4. doi:  10.1093/schbul/sbn180
PMCID: PMC2894603

“Excessive Thinking” as Explanatory Model for Schizophrenia: Impacts on Stigma and “Moral” Status in Mainland China

Abstract

Although psychiatric stigma in China is particularly pervasive and damaging, rates of high expressed emotion (“EE” or family members' emotional attitudes that predict relapse) are generally lower than rates found in Western countries. In light of this seemingly incongruous juxtaposition and because Chinese comprise approximately one-fifth of the world's mentally ill, we examine how one of the most widely held causal beliefs of schizophrenia—excessive thinking (xiang tai duo)—may powerfully shape how those exhibiting psychotic symptoms pass from “normal” status to stigmatized “other.” Using a framework by which stigma threatens an actor's capacity to participate in core everyday engagements, we examine how expressions of excessive thinking intersect with psychotic symptoms and how this idiom reduces stigma by preserving essential moral standing. Four focus groups with family members (n = 34 total) of schizophrenia outpatients, who had participated in psychoeducation, were conducted in Beijing. Open coding was conducted by 2 bilingual coders achieving high interrater agreement. Common expressions of excessive thinking—taking things too hard that is perceived as a causal factor and unwarranted suspicion that is used to benignly interpret paranoid symptoms encapsulated disruptive behaviors that closely overlapped with psychotic symptoms. Because excessive thinking is understood to occur universally, this idiom encourages socially accommodating behavior that signifies acceptance of these individuals as full-status community members. In contrast, due to beliefs implying moral contamination, those labeled mentally ill are threatened with both subtle and outright social exclusion. We discuss implications of this idiom for EE and the detection of schizophrenia “prodrome” in China.

Keywords: discrimination, psychosis, idiom, prodrome, expressed emotion, families, Chinese

Introduction

Stigma toward mental illness in Chinese societies is particularly pervasive and damaging1 resulting in harmful internalization of these negative conceptions and loss of self-esteem.2 Cultural concerns of preserving “face” lead to concealment of illness, poor treatment compliance,2 and intensified stigma when illness status is disclosed.3 Thus, societal stigma might partially explain the reported poor clinical and social outcomes of severe mental illness in China.4

Despite the strong societal stigma for the mentally ill in China compared with the West, rates of high expressed emotion (ie, “EE” or family members’ emotional attitudes that predict relapse) toward people with schizophrenia in China are generally lower than rates found in Western countries.57 Findings from other countries suggest that close-knit kinship bonds ameliorate the course of schizophrenia,810 but there is little evidence of this in China. Given that ethnic Chinese comprise approximately one-fifth of the world's mentally ill, it is important to reconcile this seemingly incongruous juxtaposition of greater familial inclusion and increased societal stigma. One approach is to clarify the cultural processes that enable people who exhibit psychotic symptoms in China to maintain “normal” status worthy of sympathetic inclusion and to avoid being labeled as the moral “other”—who merit stigma and discrimination.

Yang et al11 have recently proposed a conceptualization of stigma that highlights the moral standing of actors within a local context as integral to how stigma operates in China and other settings. Everyday social life revolves around the register of daily, practical engagements that defines “what matters most” for ordinary men and women or the “moral mode” of experience within that local world. To engage in these mundane, daily interactions is to certify one as a fully viable member of a local community. From this perspective, stigma can destroy an actor's capacity to take part in the core, everyday engagements that identify one as a moral or “full adult” person in a particular context and thus threatens the loss of what is most at stake. Both the stigmatizers and the stigmatized can be conceived as warding off stigma when they act to maintain their moral status and to preserve what is most vitally at stake in a local social world.

“Explanatory models” of schizophrenia powerfully affect community perceptions of whether people who suffer from this illness retain their fundamental “moral status” or humanity.12 Certain cultural groups favor interpretations of mental illness that differentially allow for continued integration of the ill individual into social groups. Mexican American relatives are more likely to use the more encompassing illness term nervios to interpret schizophrenia-like symptoms on a continuum of normal behavior, while white American relatives more readily adopt categorical terms indicating mental or psychiatric disorder.13 Acceptance of an official diagnostic label to interpret psychotic symptoms initiates conflicting processes: it not only enables treatment and care but also sets into motion the stigmatizing consequences of stereotyping, separation, discrimination, and power loss.14 In China, local understandings of schizophrenia are constructed via multiple frameworks of competing interpretive traditions, both traditional (eg, Buddhist, Confucian, traditional Chinese medicine) and biomedical. On one hand, the Mandarin Chinese construction of the character for schizophrenia (jing shen fen lie zheng or “mind-split-disease”), due to its association with stereotypes of insanity, implies a loss of full moral standing.15 On the other, inclusive indigenous idioms, while potentially delaying entry into biomedical treatment, symbolically convey continuity of a person's social and moral status, reducing stigma and allowing for continued participation in social life.

This article investigates a previously unexamined idiom that is widely used in conjunction with accounts of schizophrenia in China—the concept of “excessive thinking” (xiang tai duo). We seek to examine how this idiom overlaps with psychotic symptoms and to explore how it holds stigma at bay by preserving social relations and the moral standing of individuals. Phillips et al16 found that in Mainland China, over 25% of relatives of patients recently diagnosed with schizophrenia held thinking too much as responsible for their first hospital admission, making it one of the most commonly perceived causes of illness. Endorsing the idiom of excessive thinking may also beneficially impact on schizophrenia course. Yang et al17 found that patients whose relatives attributed illness behaviors to excessive thinking, and who perceived patients as having less control over illness behaviors, had fewer severe psychotic symptoms and rehospitalizations over 18 months when compared with patients whose relatives did not hold such attributions.

Documented as part of China's collective psychological makeup as early as the late 18th century in the classic epic Dream of the Red Chamber,18 excessive thinking remains in common use today. Although this Chinese idiom shares some behavioral features in common with North Americans’ conception of “nerves” (ie, being highly anxious and prone to worry over real or imagined troubles or being short-tempered, hard to get along with, and possibly aggressive13,19), it has no direct Western equivalent. Excessive thinking might initially be understood as someone who habitually “takes things to heart” (or “too hard”) or “who is unable to let go of negative thoughts or events.” To think excessively is also to violate the fundamental Chinese obligation to be restrained and moderate in one's actions by engaging in extreme behavior. In The Doctrine of the Mean, Confucius describes centering one's emotions and “cleaving to the central mean” as comprising “the great root of the world”20(p1) that in turn orders all human relationships.20 To think excessively is to defy this deeply embedded social ethic. This idiom consists of 2 commonly used, interrelated variants: (a) the action of “taking things too hard” (xiang bu kai) and (b) describing one who habitually thinks too much as “narrow-minded” (xiao xin yan). (Although the English phrase narrow-minded conveys particular meanings that are extraneous to the Chinese construct of excessive thinking [ie, having a prejudiced mind, being morally self-righteous], we have kept this phrase to describe those who chronically think excessively because it accurately captures the element of individuals not being receptive to new ideas and therefore having a “closed mind.” The minds of such individuals are narrow in the sense that they are unable to “release” or “open up” their thinking due to holding thoughts in.)

As cultural idioms, these linguistic devices may enable their users both to recognize socially aberrant behavior and to stop short of defining it as abnormal or psychopathological. Even when a diagnostic label is invoked, such idioms might still continue to modulate resulting stigma. Although excessive thinking is frequently utilized in association with schizophrenia, the mechanisms by which this idiom is viewed as an etiological factor and/or an alternative account of the bizarre behaviors of schizophrenia—and the ways in which it might diminish community and familial stigmatizing reactions to illness—are not well understood. Relatives are the primary caregivers for 90% of people with schizophrenia in China,21 so how they make use of such idioms is likely to affect help seeking, symptomatic recovery, and community response to the illness. We aim to examine how the use of the excessive thinking construct is utilized in association with schizophrenia and might act as a socially acceptable label that mitigates mental illness stigma. We utilize qualitative methods to extend established quantitative findings because the boundaries of what is under study have not been clearly established and local understandings of these phenomena remain in flux.22

Methods

Data Collection

We conducted 4 focus groups with 34 family members of outpatients diagnosed with schizophrenia at Anding Hospital in Beijing, China, from July to August 2002. Respondents were of Han ethnicity. Clinicians identified outpatients whose relatives had participated in a research-based family psychoeducational program and asked them for permission for researchers to speak with their relatives. Sampling relatives who had undergone psychoeducation is especially appropriate because it enables questioning regarding indigenous conceptualizations of mental illness (ie, beliefs held prior to psychoeducation) and change after exposure to biomedical knowledge (ie, current beliefs after psychoeducation). Researchers explained the study's purpose and methods to family members and obtained written informed consent that was approved by Columbia University's Institutional Review Board. We attempted to balance participants by gender and kin-relationship to ill member. Table 1 summarizes patient and family characteristics.

Table 1.
Study Participants Demographics

Focus groups of 8–10 relatives each met for 70–90 minutes at a hospital meeting room. Facilitators (L.H.Y. and X.Z.) were bilingual and bicultural mental health professionals. Group members were asked to discuss how excessive thinking manifests both among their ill relatives and nonill local community members to enrich understanding of the various cognitive, emotional, and behavioral expressions of excessive thinking and how this idiom overlaps with psychosis. Respondents were also asked whether this idiom initiates either accepting or rejecting behaviors toward such individuals compared with the label of mental illness (for questionnaire, please see Supplementary Appendix). Because Yang et al17 found that 30% of relatives of patients with schizophrenia had spontaneously invoked excessive thinking as a causal explanation, we also presented 2 vignettes describing relatives using excessive thinking to explain behavioral symptoms of schizophrenia and invited participants to “think out loud” about the situations described. Discussions were audiotaped and transcribed by native speakers.

Analysis

Mandarin Chinese transcripts were then translated into English by a bilingual, bicultural translator. The 2 sets of transcripts were closely read by research team members (2 of whom were bilingual), and initial content analysis (“open coding”) was done following standard practice as described below.23 As we read the transcripts, we were primarily interested in (1) expressions of excessive thinking and how these intersected with psychotic symptoms, (2) use of excessive thinking as a cause and/or label for mental illness, and (3) how people behaved toward others who think excessively when compared with those labeled with schizophrenia. We thus paid particular attention to descriptions in the transcripts that referred directly to such phenomena and sought to classify variations on them in local practice. The research team met 12 times over the course of 12 months to compare readings of the text, identify emerging themes, and discuss coding and rough analytic notes. Eventually, a coding protocol of 10 codes (see Supplementary Appendix) was settled upon, of which 4 principal codes are reported here. Two team members then recoded the entire transcript sets (one Mandarin Chinese, the other English) with these 10 codes utilizing ATLAS-TI (qualitative analysis software used for text-based coding and retrieval that is especially useful for team-based research) and compared their results for consistency. Depending upon the focus group transcript, 97–195 text fragments were coded; agreement between the 2 coders ranged from 85%–90%.

Results

The results are organized into 3 parts. We first describe variants of excessive thinking expressed in everyday social life and how these are applied by relatives to common symptomatic manifestations of schizophrenia. Next, we show how excessive thinking plays several key purposes in relatives’ conceptualizations of mental illness, ie, is used to explain how mental illness originates and to deny the existence of mental illness (and its accompanying stigma). The third section examines how excessive thinking brings forth qualitatively different social responses when compared with behaviors elicited by the label of mental illness.

Expressive Variants of Excessive Thinking

Relatives used excessive thinking to describe a range of mental, nervous, emotional, and behavioral manifestations (or their interrelation), which frequently overlap with commonly occurring symptoms of schizophrenia. As reported in other cross-cultural studies, indigenous idioms that were used to describe psychotic illness typically incorporate clusters of deviant and socially disruptive behaviors.13 We identified 2 such conceptually distinct (if overlapping) expressive variants of excessive thinking. Detailed descriptions are first followed by accounts of community members (ie, persons identified as not psychiatrically ill) to more fully illustrate how each variant encompasses potentially disruptive behaviors that might occur in daily social life. These everyday accounts are followed by an example of how relatives applied these concepts to map onto behaviors manifested by family members who exhibit symptoms of schizophrenia.

“Taking Things Too Seriously” or “Too Much to Heart.”

When people who think excessively encounter a negative event, they typically have difficulty “thinking openly” or letting go of their ruminative cognitions. An illustrative phrase—zuan niu jiao jian (translated literally as “winding towards the tip of the bull's horns”)—represents how one's thoughts spiral into an ever more narrow cul-de-sac by perseverating over some minor matter. This expressive variant is further linked to an inability to adapt, a “poor capacity to endure” environmental stressors, and a tendency to react too seriously to even trivial events.

Taking things too much to heart has 2 common behavioral manifestations.

First is a general expressive restrictiveness or inability to communicate negative thoughts that may lead to anxiety, “mental pressure,” insomnia, and (in extreme forms) suicide. The second is excessive pestering of others uninvolved with these ruminations; the individual is so agitated by perseverative thoughts that he or she is compelled incessantly to “complain to” and “disturb” others about these concerns. In either manifestation, the person might feel so “under pressure” from thoughts that extreme behaviors result. This illustration incorporates both:

A co-worker made a mistake and created a lot of trouble for the company. For normal people, you might anticipate some kind of punishment, but then the ordeal is over. This narrow-minded person took it as if there was no way to resolve it or survive. He pestered everyone about this. If you talked about the situation for a bit, then it should be over. But this person, he hid to the side of a dam and killed himself (by jumping). We discovered his shoes by the dam. His shoestrings had a long string of knots [representing his rumination before jumping].

Although taking things too seriously more commonly results in less severe manifestations (such as sleeplessness or continued rumination over trivial events), several respondents classified such extreme suicidal reactions as being attributable to excessive thinking (in the absence of mental illness labels).

Relatives of persons subsequently diagnosed with schizophrenia most frequently used this variant of excessive thinking to describe the ruminative cognitions that typically accompanied their ill family member's delusions. This expression captured the inflexible and perseverative quality of the patient's internal processes:

When he first became ill, it appeared that he was “narrow-minded.” He always ruminated about certain things, and he always talked about whether he had offended someone or whether someone had offended him. He was always thinking about how this person was insulting that other person. He always talked about these kinds of situations.

This variant further encapsulates the tendency for the person with schizophrenia to persistently verbalize his or her delusional ideation to relatives and the patient's continued refusal to abandon his or her interpretation when relatives attempt to adjust their cognitions to conform to reality.

Unwarranted Suspicion

The second manifestation consists of an unjustified inference of threat from neutral environmental stimuli. A narrow-minded individual may perceive entirely unrelated interpersonal events as having personal significance. Selective attention and excessive focus lead to suspicious interpretations of innocuous events, such as taking offence at others’ innocent words or thinking that people talk behind one's back and mean one harm:

People who “think excessively” are especially suspicious. If he [the narrow-minded person] is walking in front and people are coughing behind him, he would believe that they were spitting at him. Or if people were chatting while having nothing to do with him, but they looked at him as he passed by, he would say “They must be talking about me …”

Relatives frequently used this variant to describe what might be classified as symptomatic manifestations of paranoid delusions and referential thinking commonly experienced by people with schizophrenia:

After he got ill, he became “narrow-minded.” If there were certain coworkers looking at him and laughing, he thought: “Was that because of what I did? Why are other people staring at me?”… He spoke about the time he went to work, and he thought he was late. Actually, he wasn't late. He told me: “Once I got there, the janitor was staring at me. Did he want me to do the janitorial work?” He had a lot of this kind of thinking.

Although the suspiciousness captured by this variant may closely resemble the paranoia common to schizophrenia, it is typically distinguished from psychotic referential thinking by referring to known others and not to complete strangers. This limits such paranoia to reality-based (ie, nonbizarre) forms. Further, the degree to which this suspicion is endorsed by those who merely think excessively will frequently not meet the level of delusional conviction required for formal diagnosis of a paranoid delusion. The suspicion will diminish once the individual successfully opens his or her thoughts, whether from his or her own efforts or in response to the actions of close social others.

Relationships Between Excessive Thinking and Mental Illness

Excessive thinking served several key functions in relatives’ understanding of mental illness. During the “prodromal” period prior to illness exacerbation (and in diagnostic hindsight), it was seen as a causal factor. Although relatives conceived of excessive thinking as occurring as a “matter of degree” among all individuals, when extreme, it was viewed as a precipitant to mental illness—but only after illness had in fact been recognized. In the period after illness exacerbation occurred and before formal diagnosis took place, excessive thinking was frequently utilized as a label and as a benign interpretation for symptoms such as paranoia and the delusional perseveration described above.

Excessive Thinking as Cause

While everyone is thought to be capable of manifesting traits of excessive thinking, usually in response to negative events, it does not typically result in severe impairment. The degree of excessive thinking depends on factors such as personality disposition (ie, inclination to “think openly”), age, gender, education, environmental influence, and severity of stressor. Thus, while anyone might express excessive thinking at any given time, some do so habitually.

When engaged in to an extreme degree, excessive thinking during the patient's prodromal period was viewed retrospectively (ie, after diagnosis) as contributing to mental illness. Respondents recognized that a qualitative difference could occur when initial excessive thinking mounted in severity and duration. If uninterrupted over time and deepening in seriousness, it can cross over to a state characterized as mental illness:

“Excessive thinking” and mental illness are connected …. More or less, we all “think excessively,” but “narrow-mindedness” and mental illness are not the same. Narrow-mindedness develops from taking things too hard. Once this becomes more serious, a person then becomes ill …. When “narrow-mindedness” worsens and a person reaches this level of anxiety and sickness, then it becomes mental illness.

People who think excessively cope poorly in social situations. They tend to misread the dynamics of trivial situations and are then unable to adjust and regulate their thinking and behaviors in response. Instead, they “hold thoughts in their mind” and fail to communicate to others, leading to imbalance and, if prolonged enough, mental illness. Once initiated, such continuous rumination can become self-perpetuating:

We (normal people) can adjust and manage our thoughts and behaviors. When “excessive thinking” cannot be adjusted and managed, eventually it will reach a degree of illness …. Narrow-minded people can easily get mental illness …. Getting mental illness depends on whether you can self-adjust and manage. Once you start ruminating about an insignificant problem, your thinking becomes split, and you lose the ability to adjust, you are finished. Then you get (mental) illness.

Idiomatic expressions such as “cannot walk out of the circle” emphasize the inflexible, perseverative, and “trapped” nature of the cognitions that can precipitate sickness. A “poor ability to endure” stressors and a tendency to “take trivial events quite seriously” further predispose illness. Initiated by taking things too hard when one encounters stressors, unrelieved rumination then progresses in severity. If uninterrupted by the individual or close social others, this can eventually lead to anxiety, depression, and “mental collapse.”

Excessive Thinking as Illness Idiom

Even after symptomatic behaviors (identified as such postdiagnosis) manifested, respondents commonly reported that ill family members’ paranoia and perseverative thinking were initially (ie, prediagnosis) interpreted as extreme forms of excessive thinking rather than mental illness. Similarly, rigidly held cognitions—such as being suspicious and “liking to eavesdrop,” fearing harm (social or otherwise) to themselves or family members, and ascribing harmful intent to innocuous interpersonal actions—were first attributed to excessive thinking. Relatives mentioned that having no knowledge of mental illness prior to psychoeducation played a role in their initial perceptions and only recognized their perceptions as erroneous after formal diagnosis was given. However, once ill family members’ strange behaviors reached a certain point of severity (eg, extremely illogical or bizarre) and/or pervasiveness (eg, suspiciousness at all times), relatives recognized these behaviors as crossing from what might be considered excessive thinking to a form of illness:

At the beginning, I didn't know that she is sick. So I thought she was “narrow-minded” …. Eventually, when the illness expressed itself, wherever I went, she followed [because she was suspicious of everyone else], as if how that bird is chirping conveyed a certain meaning. ”Oh my”, I thought, “Oh it's bad, it's definitely illness.”

Several relatives admitted that denial and fear of acknowledging mental illness motivated their use of excessive thinking to explain abnormal behavior, adding that they frequently underestimated the severity of such deviance in hopes that the condition would improve. Some also resorted to nonpsychiatric illness interpretations (eg, menopausal problems). Implied is that relatives attempted to forestall labeling the person with mental illness because it would result in categorizing him or her as no longer “one of us.” Such inclusive tendencies were not restricted to close family members; friends and other relatives may embrace interpretations of excessive thinking even when those closest to the ill person have given up such explanations for beliefs of psychiatric illness:

In the beginning, I didn't realize anything was wrong. My wife is “narrow-minded”; she eavesdrops and is afraid that others want to hurt her …. I thought that she might have this illness but I was not willing to admit it. [I preferred to think that] it's not mental illness, she's just not thinking openly …. If I said my wife has (mental) illness, many relatives and friends will say, “No, she doesn't have mental illness. When something happens, she's always stuck on it, she just can't think openly.” …. But [finally] I was able to recognize it [now that she has been diagnosed], it's definitely mental illness.

Such refusal to admit illness suggests preemptive efforts by relatives to avert the severe stigma (described below) that accompanies an official diagnosis of mental illness.

Social Response to People Who Think Excessively and to Those With Mental Illness

Respondents reported a variety of differing engagement strategies toward individuals who think excessively. Detached social responses (eg, avoidance) were commonly endorsed toward “distant” social others. However, excessive thinking behaviors just as often brought forth prosocial responses and elicited accommodating actions that strongly affirmed social ties. In contrast, those labeled with mental illness faced both subtle and overt forms of discrimination that blocked participation in daily life.

Distancing Responses Toward Excessive Thinking

When respondents interacted with persons who think excessively in casual social settings (eg, neighbors, coworkers), they reported a variety of negative emotions, ranging from “annoyance” and “dislike” to feeling especially “tired” or “unhappy.” Given the choice, respondents reported limiting contact by “not associating with” and maintaining a “respectful distance” from such community members to lessen opportunities for conflict. When avoidance failed, respondents sometimes reported becoming so annoyed that they quarreled.

“…. How can you fuss over such a tiny matter?” One person thinks the other is narrow-minded, so he will argue with and rebuke him.

Few instances of extreme negative reactions, such as “bearing grudges against” or “fighting (verbally)” were reported. More commonly, if compelled to interact with persons who think excessively, the chief response was one of pragmatic tolerance: one “…cannot classify people as narrow-minded and refuse to work with them.” But, the same respondent continues, “I would rather contact them less …. Normally outside of work, I wouldn't go out with them.” Grudging tolerance when inescapable was coupled with preferred avoidance when possible.

Inclusive Responses Toward Excessive Thinking

Just as evident were a number of positive responses to encourage persons who think excessively to open their thinking. These typically involved strategic interactive techniques such as “saying things a little indirectly” to prevent such persons from getting worried. Such measures, it was hoped, would prevent these persons from trapping negative thoughts in their minds.

Once someone exhibited signs of thinking excessively, respondents not infrequently resorted to “counseling” and “persuading” this person that his or her thoughts were fixed on insignificant matters. A relative trying to dissuade her narrow-minded sister from ruminating over a bank loan tells her: “Don't get anxious. We didn't borrow it from a private person where we have to pay it back all at once …. ‘Let your thinking open up’.” Such efforts could entail substantial social work, such as continuous “talking back and forth,” clarifying the situation and recommending a more proportionate response. Respondents also reported enlisting extensive social networks (eg, siblings, extended family) in this corrective, and socially inclusive, endeavor, thus further encouraging interpersonal connections.

Social Accommodation of Excessive Thinking

In some cases, this engagement went beyond mere counseling to active affirmation of a close social other's membership in a shared network. Because persons who think excessively often act inappropriately, their social partners may go to great lengths to maintain harmonious relations. Accommodation typically takes place among friends and relatives but may include more distant social others (eg, coworkers). Respondents report letting such individuals “have their way” and “enduring” behaviors associated with excessive thinking by “adjusting and managing” their own behaviors. Respondents recognized that their accommodating behaviors will not be reciprocated and that any favors will be “wasted.” Such social accommodation may go to extreme lengths:

At work, we each were getting a raise of one-and-a-half salary class [roughly 1% of total income]. This co-worker, perhaps it's because she had a bad relationship with the boss, but she received only a half salary class [raise]. At home, she got angry at her husband, saying how unsatisfied she was with her job. She complained to me several times; once I mentioned it, she started to sob and wail. I said, “If you can't think openly, I will go speak to the boss.” The boss said there is no chance [of changing his mind]. So I gave one salary class of my raise [roughly .70% of total income] to her [to preserve work group harmony] ….

Several respondents remarked that these sometimes elaborately accommodating behaviors served to preserve the face or “moral standing” of individuals who think excessively. The alternative is a kind of social death: not acknowledging obligations to individuals within a social network is to disconnect that individual from one's network of material and social opportunities (or guanxi).24

Social Exclusion of People With Mental Illness

In contrast to the social inclusion generally shown to narrow-minded people (eg, tolerated at work), respondents reported that people identified with mental illness suffered much harsher discrimination (eg, would not be hired at all). Respondents also described extreme social distance by community members toward people with mental illness:

…. Talking to a “narrow-minded” person is different than talking to a person with mental illness. With a “narrow-minded” person, everyone is a little less involved with him and does not have a deep association with him. That's fine. (However) People with mental illness, it's necessary to avoid him completely …. People hurriedly get far away. Once getting onto the bus, if I say that I have mental illness, people will immediately get far away from me.

Such fearful reactions were fueled by community notions of dangerousness and unpredictability on the part of people with mental illness (eg, that they “will hit and scold people” for no reason). However, key conceptions of moral wrongdoing or contamination also commonly marked perceptions of patients and their families that resulted in deeper social exclusion:

Don't go to that mentally ill person's home. Their home has a mentally ill patient. It's possible that their ancestors were lacking certain moral values. If it wasn't the parents, then it was their ancestors [who had committed a moral wrong to bring about the mental illness] ….

In addition to these overt forms of social distancing, social exclusion took place in often subtle ways. Because one's face or moral status is an embodiment of one's power to engage in interpersonal action in local worlds in China, “losing face” due to mental illness results in becoming powerless to engage in local social interactions. Rather than resulting in blatant discrimination, community recognition of schizophrenia frequently manifested in nonverbal behaviors and group gossip that directly attacked one's moral standing and consequently ability to negotiate effectively in the interpersonal sphere. Two respondents report:

…. Even if others were not saying disparaging things [to the ill family member], it was the way in which people stared at him strangely that was even more hurtful.

After being hospitalized four times, people were saying behind our backs, “Their kid is ‘mentally ill’ [shen jing bing; derogatory term implying being of ‘non-human status’ or a ‘lunatic’].” But people didn't say it directly to my face …. Before when they saw him, they would say, “Your kid is such a good kid.” Now whenever we went out, they wouldn't talk to him. They would stare at him in this strange way. Now how did our kid feel? That day, I asked him, “Why do you always stay home?” He said, “I don't have ‘face’ to go outside and interact with others…People would all stare at me in that way.” It provoked especially painful feelings in him.

Discussion

Our analysis illustrates how idioms associated with excessive thinking in Mainland China are used as everyday, socially inclusive tools to interpret wide-ranging (and frequently quite strange) behavioral displays that vividly contrast with responses to mental illness. What underlies this idiom's normalizing power is that excessive thinking is understood to occur to varying degrees among all individuals. In particular, the expressive variant of taking things too much to heart (leading to mental pressure and eventual collapse) provides an accepted “cultural logic” that enables community members to identify with narrow-minded individuals and commonly motivates integrative social responses that encourage such individuals to open up their thinking. A second variant, “unwarranted suspicion of others,” illustrates how excessive thinking frequently is linked to perceptions of schizophrenia (in particular, paranoid delusions). Because people who think excessively manifest what is perceived to be a universal condition, they often benefit from social accommodation that affirms membership in their social networks. The cultural elasticity of the excessive thinking construct serves to diminish the strangeness of potentially extreme symptomatic behaviors and mitigates social exclusion of those who might exhibit schizophrenia-like symptoms but have yet to receive a formal psychiatric diagnosis.

Community reactions to mental illness tend to be based on stereotypes that draw sharp boundaries between sanity and insanity. In China, in addition to beliefs of moral wrongdoing, people with schizophrenia are viewed as quite dangerous and unpredictable and are thus assigned an uncultivated or “outcast” moral status.24 Although persons who think excessively are regarded as annoying, avoided, or only reluctantly tolerated, the extensive social accommodation that some people undertake to preserve harmonious relations signifies that these individuals can still be accepted as moral (or full adult status) community members. Similar idioms identified in other groups—nerves among various cultural groups,13 “studiation madness” (“excessive mental emphasis on any subject, especially when acquired through reading”) in the Caribbean,25 and isamullatuq (“burdened down by thoughts”) among Inuit Indians26(p78)—serve as “culturally meaningful illness categories” that also act to preserve moral status.8(p301) This contrasts starkly with those officially labeled as mentally ill in China. Owing to beliefs implying moral contamination, such people are threatened with loss of moral standing (or face) and encounter both subtle and outright forms of exclusion from local social life. Thus, while mental illness stigma threatens an actor's capacity to participate in the mundane everyday activities that allow one to sustain moral or “full adult” status in a local context, so long as they are viable, idioms such as excessive thinking appear to preserve this essential moral standing.11

While not an explicit focus of our analyses, our findings might usefully contribute to literature concerning family emotional environment (ie, EE) in China. The excessive thinking construct, a normalizing semantic category imbued with “systems of emotional meaning,”8(p303) may serve to powerfully reinforce intimate family bonds by encouraging supportive inclusion of symptomatic family members. Because excessive thinking is frequently viewed as an enduring aspect of schizophrenia symptomatology even after diagnosis, “cultural scripts” that encourage counseling, tolerance, and “accommodation” might facilitate noncritical family environments and “low-EE” behaviors (eg, acting “calm, cool, and collected”7). This may also partially explain the generally lower rates of high EE found among relatives in Mainland China (28%–42%5,6) when compared with a review of studies conducted primarily in Western settings (median of 54% across 23 studies7) where family ties traditionally are less emphasized. Linguistically and conceptually, Chinese retain the flexibility with such elastic idioms to encapsulate socially disruptive behaviors, which allow communities to “hold onto” members as one of their own when what might otherwise be interpreted as illness symptomatology surfaces and frequently provides sufferers the benefit of culturally induced doubt. Our results suggest that severe mental illness discrimination may most readily take hold in China among the subset of individuals who abruptly display quite bizarre behavior or in whom long-standing schizophrenia symptomatology is apparent. In such cases, an official “mental illness” label becomes fixed and enduring.

Recommendations for Early Detection and Culturally Competent Intervention

Because excessive thinking is often used to describe prodromal states to schizophrenia, one future intriguing application of our research lies in the detection of high-risk clinical states for conversion to psychosis in China.27 For example, several key aspects of our phenomenological descriptions of excessive thinking bear discernible resemblance to the subtle, often only self-perceivable deficits that have been systematized by Huber as prodromal “basic symptoms” (eg, “inability to tolerate everyday stress,” “tendency for obsessional reflection”).28 These symptoms when operationalized have prospectively predicted conversion to later psychosis.29 Further, key excessive thinking behaviors might fit aspects of the “Attenuated Positive Symptom Syndrome” criteria assessed by the Structured Interview for Prodromal Syndromes.30 Consideration of this widely used idiom in the future cultural adaptation of prodromal scales might aid in accurate detection of such high-risk states in China.

We further recommend that these explanatory models of illness be incorporated into psychoeducation for groups of Mainland Chinese descent (including recent immigrants to other contexts). In the absence of medical influences, relatives depend on their own cultural knowledge to conceptualize an ill family member's condition.8 Formally integrating this construct into the curriculum of psychoeducation programs may serve to ground the experience of psychotic symptoms in participants’ local vernacular. Accordingly, acknowledgement of this indigenous construct that is integrated with illness psychoeducation by psychiatrists during treatment planning with patients and family members may aid in adherence to pharmacological and psychosocial treatments.

More broadly, these results suggest an important means of improving psychosocial interventions with Chinese groups for whom a major obstacle to utilizing psychological services is the perception that many forms of psychotherapy induce analysis and reflection (ie, excessive thinking) of psychological problems. This belief, accompanied by the conception that “excessive worry” might disrupt the healthy circulation of qi (or vital energy), underlies underutilization of mental health services and refusals to participate in research.31 As several of our informants noted, outreach to such groups might be more successful if it effectively conveyed that psychological methods may help to “release trapped thoughts” in individuals chronically plagued by this difficulty. Better understanding of this commonly held indigenous notion may contribute to culturally adapted outreach and intervention programs to improve outcomes for schizophrenia in this population.

Limitations

While this qualitative design builds upon prior quantitative work and is especially suited to articulate complex cultural processes, study limitations include the relatively small and geographically restricted focus group sample. First, findings are most generalizable to relatives in Northern, urban China. Further, using a sample of relatives who have undergone psychoeducation may have led to a “halo” effect in responses, ie, reporting what they “know” to be correct rather than what they truly think. Although inclusion of subjects who had not participated in psychoeducation would enhance generalization, the presence of a continuing link between excessive thinking and mental illness in this group attests to the durability of the cultural connection and argues against a pervasive response bias due to psychoeducation (ie, “correct” responses ought to adhere to the biomedical model over all others). Nor should our results be taken to suggest that indigenous processes are sufficient to promote recovery from schizophrenia or that psychoeducational and pharmacological interventions are not useful approaches. Strong evidence exists for both to improve outcomes in China.32,33 Further, the explanatory power of this idiom may diminish in effectiveness because schizophrenia syndromes become chronic and may also negatively impact course via greater initial duration of untreated psychosis and medication noncompliance. Consistent with studies concerning treated and untreated course in China,9,33 we speculate that the most favorable conditions for recovery might be when diagnosis occurs and treatment is initiated by close family, but other community members persist in using inclusive idioms such as excessive thinking to explain illness behaviors.

Conclusion

Our analysis reveals how expressions of excessive thinking might powerfully shape both conceptualization and behavioral response toward people who exhibit schizophrenia-like symptoms in China. We illustrate how expressions of this idiom overlap with common manifestations of schizophrenia symptomatology and act as a cause and interpretation of such symptoms, and how their use may encourage supportive and accommodating social responses from others. Our results highlight how the indigenous notion of excessive thinking, in contrast to psychiatric illness labels, might act to preserve essential moral or full adult status in China. Future investigations might examine whether use of the excessive thinking idiom varies in response to the particular stage of illness and what the differential effects the application of this idiom might be at each phase. It would be of particular interest to identify to what degree manifestations of excessive thinking are present in and utilized to describe those who exhibit schizophrenia prodrome in China and what effects on help seeking, relatives’ response, and illness course might result. In addition, future mixed-method (ie, ethnographic and quantitative) research might also further elucidate causal pathways by which this idiom shapes EE and modulates stigma. In sum, greater awareness of indigenous conceptions about mental illness, such as those identified in this article, can not only aid our understanding of how the social context shapes course of schizophrenia in China but can also enhance communication and understanding of fundamental psychiatric concepts and their application to local settings in our increasingly global, multicultural society.

Funding

National Institutes of Mental Health (K01 MH73034-01 to L.H.Y., 5-T32-MH013043).

Supplementary Material

[Supplementary Material]

Acknowledgments

We wish to thank Dr Nolan Zane of the Asian American Center on Disparities Research and Dr Nadia Islam of the New York University School of Medicine Center for the Study of Asian American Health for their helpful comments. We also wish to acknowledge the efforts of the psychiatrists at Anding Hospital for aiding in data collection, Janel Sia and Kathleen Lam for helping with data entry, Hong Ngo for formatting, and Nancy Yang for translation of the data.

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