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psychotherapy industry in China

China Paradigm transcript #91: What is so specific about China’s psychology industry?

Find here the China paradigm episode 91. Learn more about David Ammerschlaeger’s story in China, how he runs a WeChat blog about psychology and mental healthcare and China’s psychology industry in general.

Full transcript below:

Hello everyone. This is China Paradigm 91 where we, Daxue Consulting, interview season entrepreneurs in China.

Matthieu David: Hello everyone. I am Matthieu David, the founder of Daxue Consulting; a market research company based in China and its podcast, China Paradigm. Today I am with someone I have been wanting to have on the show for a long time. He is David Ammerschlaeger and he is working in China’s psychology industry that has a lot of interest to me and to Daxue Consulting. You are a psychologist and a psychotherapist now. I say “now” because you have a very different background and you have not always been counseling in China. You began to study taxes and business before arriving in China if my information is correct. This was 3 years ago as far as I understand. You got an interest in China’s psychology industry and started a business in the psychology industry. As an English-speaking therapist in China, you are currently managing a blog. It is a WeChat blog called PsiCare where you develop a new offer of counseling in China and that’s something that I would like to understand together with psychological consultation. Thanks for being with us David. Would you mind describing a bit more what you do with PsiCare and what is the size of your business now? How many patients do you have or how many partners do you have?  We want to understand what you do and the current size of your business?

David Ammerschlaeger: Thank you very much for this introduction, Matthieu. Yes, you are absolutely right. I have a very complicated and quite complete background. I have been working for 12 years as a tax lawyer, a business consultant and a Chief Financial Officer for L’Oréal research and development and indeed, 3 years and a half ago I moved from France to China. It was the opportunity for me to change completely my career again, as you correctly stated, it was a long process to work in China’s mental healthcare system. Actually,  I was developing myself and at the same time, I was developing my companies because I have several companies. I started doing this transition into coaching and training and first developed a company that was specialized in HR Consulting, so, I did not directly work as an English-speaking therapist in China. I partnered up with a German company for which I am a General Manager here in China. It is called E4P that stands for Excellence for Professionals and we are providing services in coaching, training, human resource consulting and my business partner who is a German lady who has a double Ph.D. in Neuro Science and Psychology. We are bringing China’s psychology industry into the Human Resource Consulting activity. While this process was going on I was finishing my coaching certifications and got more and more into the business. I started also studying psychology and I completed a Master’s Degree in psychology and from then on, I started to develop my knowledge and expertise in clinical psychology. Thus, I have been building a practice in clinical psychology that transpires through this blog whose name is PsiCare which stands for Psychological Services Information and Care and I am writing articles about psychology, psychotherapy, and wellbeing at large and discuss a subject like anxiety and depression in China. In order to develop this psychological activity, I partnered up with Chinese experienced psychotherapists and actually, one of them was interviewed a few months ago in one of your podcasts. She is Zhang Ying Fei who is a very experienced psychotherapist and she has been doing this for 20 years here in China and so this is actually one of my business partners on the counseling in China side.

Matthieu David: So, what’s the business model of your company? How do you monetize it? I strongly believe that people get a better understanding when they listen to us if guests talk about their business model. Who are your clients and who are your partners? You use the word ‘partner’ several times. So, who are the clients, who are the partners, do you have a mobilization process or it’s your own blog with your own communication to practice yourself? Would you mind telling us a bit more?

David Ammerschlaeger: So, for E4P, I would say the model is practically something quite classical in the consulting sector. So, I am the General Manager and the process is pretty standard with clients that we have. These clients are mainly from Germany because it is a German company so we are mainly working with German MNCs, but we are also working with international schools and we have several coaches that work for us and who can serve our clients. So, I am not going to focus too much on this site because I think you already had other consultants talking about this kind of consulting business model. I will focus more on the psychotherapy and psychological consulting business model. So, this is a little particular. In fact, the way you service clients is absolutely individual. You cannot have people working for you. Basically, the reason is that we are talking about China’s mental healthcare system. We have the same kind of model in France with the psychotherapists working in the medical industry. So, it is a small practice and clients will come to see us because they trust us personally and they trust our expertise as an English-speaking therapist in China. They trust our background and the relationship that you are able to build with them.

Matthieu David: So, this blog is actually your personal communication tool?

David Ammerschlaeger: Exactly. My blog is my personal communication tool. It is also a way to assert my credibility towards clients and clients who are reading my articles also see my personal style when looking for an English-speaking therapist in China. They see if they can relate to the way I am approaching the field and the issues. If they can trust me or build this relationship, then it eventually will transform into a therapeutic relationship.

Matthieu David: I see. When you talk about partners what are you referring to? When exercising your profession you have your own client and you are serving them personally so it is not a market place, it’s not a reference system. It is only yourself and your client. What about the partners? When you talk about partners you mentioned one we interviewed. What are they doing? What do they do? What do you do with them for counseling in China?

David Ammerschlaeger: So, we practically share the office. Then it’s also very important for psychotherapists to work, I would say as a team for expertise. So, let me explain. There are supervision groups and supervision here doesn’t mean the organizational way that we have in a company to supervise other people. This way is that we meet with other therapists and talk about cases on a confidential level, of course, because everything is absolutely confidential. We share our insights into different cases and into different issues and how we treat different clients in China’s mental healthcare system. This is very important to ensure a certain quality and also that we are not getting lost within our own methodology by helping clients. So, here this partnering is more like mutual help, mutual understanding, and mutual exchange of expertise on, for instance, anxiety and depression in China. Also if we have clients that we see and for whom we cannot service because maybe this is not something that we know how to do. Maybe, as I said a therapeutic relationship is extremely important and when we feel that this client is somebody who we might not necessarily be relating to or don’t really know how to work very well with, then, we can give this client to another therapist.

Matthieu David: I see. So, it is both because of business-wide sharing and so on. The methodology was a kind of peer review where you would actually exchange your findings or your thinking like a peer review with another English-speaking therapist in China. I have got it. I’d like to understand more about the context of running such a business in China. You have a background in psychology and psychotherapy in Europe. In Europe, you need a very specific set of certifications and a very specific accreditation to open an office. You don’t need all the documents as a coach since it is much less regulated even though I understand that with time, some people try to regulate it. In fact, there were coaches everywhere without any experience or certification. What about the situation in China? Is it still a grey area and you can operate without certification? Is it actually very regulated? Is it also part of the partnerships because you need to partner with someone who has a degree in China and can actually practice?

David Ammerschlaeger: So, in China, the situation is very grey when it comes to China’s mental healthcare system. As you said, coaching is one thing, psychological counseling in China and psychotherapy is another thing. Then, we also have psychiatry and a lot of people mix up those completely. I would say they are three areas which have little things in common. So, you are right that in China, the only really regulated profession is psychiatry because this is a medical profession and you need to have this medical certification that gives you access to hospitals in order to be able to prescribe drugs. The thing is,  a psychiatrist will mainly deal with clients very quickly. Indeed, the psychiatrist will have an appointment of ten minutes, especially in China where it is very, very quick in the hospitals. If you have been in a Chinese hospital you will see how fast it goes and the psychiatrist does not have time to really understand the patient for cases of anxiety and depression in China. I had a lot of cases where the psychiatrist has diagnosed anxiety disorder or depression and actually the fundamental issue was completely different and it was a misdiagnosis done by the psychiatrist because this person did not have enough time to understand the psychological state of the patient. So, that’s an issue of China’s mental healthcare system.

Now, on the psychotherapy and on the other side of the spectrum, there is coaching and coaching is a very different thing because coaching is addressed to people who are “okay”. Mentally they are okay and they just want to develop themselves to the next stage. So, this is typically what we would see in companies or maybe life coaches. Basically, these are people who are mentally okay and they feel okay. They just want to explore a bit more about their opportunities and possibilities and that’s where coaches can help. Now, psychologists regroup the psychological counselor and the psychotherapist. This is something that is very grey in China and basically, anybody can call themselves a psychotherapist and do counseling in China. As you correctly stated, in other countries like the United States or Europe, you need at least a Master’s Degree in Psychology. This is the reason why before starting this profession I wanted to graduate with my Master’s degree in psychology.

I apply the European standards and especially the United Kingdom’s standards because I am an accredited British therapist and a member of the British Psychological Society and an English-speaking therapist in China. Here in China’s psychology industry, this legal framework doesn’t exist and there is a big step to educate the general public as to what exactly is psychology about, how this mental health care sector is structured and what kinds of services exist. A lot of people directly visit a psychiatrist because they couldn’t sleep well or something like that. The reflex of the psychiatrist is to prescribe drugs and very quickly people can become drug addicts because the drugs that we have at the moment are not necessarily efficient for deeper issues. It is just like a very small help to make you physically better, but it doesn’t help you if you have a deeper issue with your relationships, your life and all the things that basically can cause mental distress and psychological disorders such as anxiety and depression in China.

Matthieu David: So far, are your patients coming from foreign countries or are they mainly Chinese?

David Ammerschlaeger: For me, it is 50/50. I don’t speak Mandarin well enough to provide psychotherapy in Mandarin so I am considered an English-speaking therapist in China. This is one of my personal projects in the next years. I definitely want to learn Mandarin well enough to do that, but I am far away from that. So, at the moment, I can service clients in French, German and English. So, I have a lot of foreigners as clients, but also a lot of Chinese people who are, I would say international and who speak very good English. A lot of Chinese people prefer to go and see a foreign psychologist for counseling in China because they know that this psychologist will apply standards from their own country. I am a member of the Shanghai Mental Health Association which is actually an association that requires Western standards for joining this association and be able to provide psychological services.

MATTHIEU DAVID: Interesting. Since you have local and foreign clients, I’d like to know the difference between foreigners and Chinese. You have initiated your Master’s as far as I understand just here or are you finished?

David Ammerschlaeger: I finished it, yes.

Matthieu David: So it’s a British university. What differences do you assess between exercising this profession of psychological counselors in the West and China? To be more specific, we have a subconscious and I think your work is to deal with the conscious and subconscious aspects of the brain. I believe the way of seeing life should be very different in China’s psychology industry and in the West or references may be different. I don’t know if there is a complex here in China or if it is something to be used, but it has been used by Ford in Europe for instance. There are also many other myths that seem to take root in the culture. So, how can you apply the frameworks you have studied in Manchester to China and how do you have to adapt it? What are the differences?

David Ammerschlaeger: So, firstly I have to clarify one thing. There are many different approaches and therapies possible to treat anxiety and depression in China. So, what you have to understand is that there are about 200 kinds of therapeutic methods and not all of them are scientifically recognized. This is very important because a lot of psychotherapists, a lot of therapists in general and practitioners will call something ‘therapy’ which is not necessarily scientifically recognized by China’s mental healthcare system. So, when you are talking about the subconscious you are referring mainly to psychodynamic therapy which is like psychoanalysis and not all therapies work with the subconscious. You could have cognitive behavioral therapy which is mainly working with the cognition and the way we think and the way we behave. Behavior subsequently derives from our cognitive ways of approaching issues. So, here I would that it really depends on what kind of method we are using. Now, coming back to your question, yes, there are huge differences in dealing with western people and Chinese people. I could actually talk for hours about this. To start with, we have different ways of approaching life and family values and even expectations. Typically Chinese people will come to my practice and tell me, “David, heal me” and because I am a medical doctor, they think I will just push a button or something like that.

Matthieu David: Kind of really just believe in it, right?

David Ammerschlaeger: Exactly, some hocus-pocus and that will make them feel better. They don’t understand it and they don’t see that the healing process takes time. They sometimes don’t understand the therapeutic process and the relationship we will build, the way we will approach this together, the work that we will actually do together and that I won’t just do it by myself alone for them because it requires personal growth and it requires personal interception and understanding and so on. So, this is something that we work on together and this is something that they are absolutely not used to in China’s psychology industry. Also, I don’t want to jump to conclusions, but I would say the Chinese education system is not something that necessarily pushes people to think about themselves introspect and analyze themselves and have a certain philosophical understanding or critical understanding of life, of society, of whatever they are.

 So, this is a part of the process that I have, as an English-speaking therapist in China, to take into account and I am working with them from a different level and a different approach than with western people who are already very much used to analyzing themselves and thinking about themselves and sometimes even too much. A lot of western people will have very preconceived ideas about things. They think they know themselves and maybe there are also different limitations that western people might have because they might lack this blank page or this openness somehow. We have to build something together and they already have preconceived ideas.

Matthieu David: You have some experience and some underground experience which is exactly what we are looking for in the podcast, but what about the theory, the theory of psychological counseling in China or psychology in China and toward the west? Are there some books already serviced which help to actually identify different partners or approach differently the patients depending on whether they are from China or from the West?

David Ammerschlaeger: Well, one of the most used psychological therapies in China’s mental healthcare system is still psychoanalysis. The thing is that each therapy addresses a different type of issues. So, for example, psychoanalysis is extremely good to explore the subconscious and therefore also family issues, childhood issues and things that are suppressed within ourselves and that cause certain distress because we don’t know how to manage this subconscious and it immerged into our conscience through dysfunctional behaviors or dysfunctional feelings for instance. So, this is something that works very well in China’s psychology industry. I guess because a lot of people fear they had difficulties in their childhood or a certain number of frustrations between their expectations that really come from their subconscious. It can be expectations about life, society, about themselves that actually interfere with reality. So, psychodynamics and psychoanalysis therapies are the ones that are most popular for counseling in China, but you have the rise of other therapies that are much more common in the west, for example, something that is very much used in the west is cognitive-behavioral therapy. If you look, for example, in the United States, about 35% of the psychotherapists are cognitive-behavioral therapists. It is the dominant therapy in Anglo Saxon countries. In France for example, we are still very much psychoanalytic as well and Germany is a little bit more balanced. So, each area of the world or country has its own history in psychotherapy and preferred methods. The most important thing for me is that a psychotherapist knows all or as many therapies as possible in order to apply the most appropriate ones to his/her clients. Thus, he addresses a specific issue and this is something is lacking because a lot of therapists have already a very preconceived idea about the therapy they want to apply. They have also limited knowledge about therapy and they want to push a certain type of therapy to their clients with very different spectrums of disorders in terms of anxiety and depression in China. It is very important to specifically target an issue with a specific English-speaking therapist in China because the results are very different depending on the method used.

Matthieu David: So, what you are saying is basically that the difference between China and the west is just that the issues which are raised, the challenges that people face are different because of Chinese society or because of western society. The reason why I asked this question is that the name of this podcast is called China Paradigm. So, in the psychotherapy and psychology fields inside the China paradigm, is China or could China change its field? Could the fact that Chinese society has a different religious root, that there are no Christian roots, for instance, led to other types of research or other types of seeing psychology and also types of challenges and patterns? Is there a China paradigm? I feel you are saying no, but I would like to be sure.

David Ammerschlaeger: Let’s say it this way. Psychology has developed in the past 150 years with western countries. So, you are very right to say there is a bit of a China paradigm because we are trying to apply psychotherapies that have been developed in the west for counseling in China. As you mentioned, it is a different cultural setting for people that have been raised in Western countries or in China and actually, we also have the same issue with Muslim countries. Muslim countries also have some differences in cultural understanding and approach to life and there has been a lot of research seeing how we can adapt or maybe develop specific therapies for Islamic countries. So, it is the same in China and if you look at the way China has been developing, there are remarkable social and economic changes in the country during the last three decades. It has made Chinese people realize that health care is very important. I also think that because, right now, the Chinese economy is slowing down, we will have more people in China facing psychological issues. Society has evolved so fast that people have been changing from, I would say, from poverty to relative wealth which can cause anxiety and depression in China. Especially in modern cities like Beijing, Shanghai, Quan Cho, Shen Gen, Hong Kong and so on, there is a huge social and cultural gap.

There is internal migration, important societal changes, people that are actually caught between conformity and autonomy because they want to conform to traditional and family models. However, the young generation also wants to break out from this traditional family structure and aim at the individual search for happiness. So, there are a lot of things that clash in Chinese society and creates a lot of distress thus impacting China’s mental healthcare system. I wouldn’t say it’s not necessarily completely new because you know, humans are the same whether they live in the United States, in Saudi Arabia or in China. I mean, we are all human beings and we all want more or less the same things in life. However, I would say the way that Chinese society and economy have evolved is so fast that there are a lot of things happening at the same time. According to a joined report by Jen Deng Sheng Lee and Beijing University on the domestic mental health industry, 60% of people who receive counseling are between 25 and 30 years old and 50% are single while over 70% are female.

Matthieu David: I feel that you are analyzing a lot. There are differences in the industry between the west and China. I use the word “industry” because I analyze through economical lenses and through the analysis of the economy. So, the analysis of the change in the economy. Does it mean that, actually, the cultural roots, the history is not impacting your industry? To give you a precise example, I know it is only one fill of your industry, but if you look at a void in the Oedipus complex do we find the Oedipus complex in China? Does it mean actually the same framework, the same topics, the same partners can be used in China or you feel that they are new and different or some which are absent?

David Ammerschlaeger: So, to answer your question, yes, we can absolutely apply the same patterns, the same frameworks in China’s psychology industry, the same theories to the Chinese context because these theories and this knowledge in psychology have been developed as a science. I mean psychology is researched through scientific methodologies and they apply to all human beings. So, we are talking about human basic features that are the same throughout the world. The thing that is different is how they are integrated within a specific social-economic environment and this is where people tend to change a little bit. Actually, if you look at it from a clinical psychological point of view it will only result in having certain disorders that will be more present in certain areas of the world than other areas. So, for example, when I look at what I am seeing here and my colleagues are seeing here as well, we have huge issues with anxiety and depression in China, but I would say anxiety is much more present here in China than in France where there are much more depressions. So, I would say it applies to different kinds of disorders. You mentioned the Oedipus complex. So, this, for example, will be extremely present here in China. You are totally right, in the Chinese family especially for the past 30 years due to the one-child policy. So, you have a lot of families that are structured around one child that will focus the whole hope and pressure for the whole family to achieve success, to achieve wealth, to care for the parents and even the grandparents. All these create a very strong relationship. That leads to an Oedipus complex nature between the child and the parents.

As an English-speaking therapist in China, I see a lot of dysfunctional families in my practice and the thing is even very strong nowadays because you have a single child getting married in their thirties. Often it was because of materialistic concerns. They wanted to find a spouse very quickly and they also have family pressure to find somebody else as quickly as possible. Then, having children as fast as possible. There was also huge pressure on materialistic status. Achieving a certain status within a company put a lot of pressure on these people who did not really have the experience of childhood, of a teenager-hood, a moment of relaxation or a moment also to question themselves, to work on themselves and to go through what we call a first existential crisis which a lot of people in the west are facing in their teenager-hood where they ask themselves deep questions like “Who am I? What do I want to do? What is the meaning of life and what kind of career or what kind of life do I want to lead?”. This is something that they have just taken over from society, from their parents and I have a lot of clients nowadays who are in their thirties and who face existential mid-life crisis questions. These things that basically we can observe either with teenagers in France or that we can sometimes see during the mid-life crisis in France typically for people in their mid-forties or maybe even in their fifties. So, here again, the pattern is the same. I mean we are all human beings. We function in very similar ways, but the way and the kind of disorders and the ages in which they occur will be different.

Matthieu David: Another question I had is how accessible English-speaking therapists in China are? By accessible I mean different things. I mean accessible to get the right information and right contacts, accessible to be able to assess the reliability of the therapist and thirdly accessible in terms of cost. Let’s begin with the third one maybe. How much does it cost in China to actually meet with a therapist?

David Ammerschlaeger: So, if you look at average costs in China, it is around 300-700RMB, per session knowing that a usual session lasts for about 1 hour. Now there is a huge discrepancy between the countryside and larger cities when it comes to counseling in China. In the countryside, you have few therapists and almost none that are qualified. They follow a bit the traditional way of doing. Wise men or people that have maybe some religious background, some spiritual background will help other people and so, I would say that having access to qualified therapists is very difficult. Information is also very existent because this is something that people don’t have in their mindset yet. For many people you are mad or you are okay. There is no in-between. So, most people will confuse real, strong mental issues, I am talking here about illnesses like schizophrenia, severe depression, for example, which can be really a societal issue and needs medical treatment. So, we are talking about psychiatry here which actually is only touching about 1% of the population and the other side which actually is much larger and it is not something that is very much considered by the general Chinese population is mental wellbeing or mental distress such as anxiety and depression in China.

If you look at the World Mental Health Association, they have studied China and found that if you about 20-25% of the Chinese population have clinically diagnosable disorders. So, this is not a surprise because this is typically the kind of number that we would find in the United States and in Europe. The big difference is that in the United States and in Europe about 30/40% of the people who have a clinically treatable disorder will go to see a therapist and in China, this is only 8%. So, only 8% of people who have a clinically diagnosable disorder will go to see a therapist and that is part of China’s mental healthcare system. For mental health, you need to know that there is also no immune system and so this means that if you catch a cold or if you have the flu basically your body will have an immune system and will heal itself.

 It is not the case for mental health because if you have anxiety and depression in China if you have bipolar disorder if you have an avoidant personality disorder or narcissistic personality disorder or whatever, it will not heal by itself. You can only heal by working on yourself and with counseling in China. Many people don’t do that by themselves so in this case, the therapist will be the only way for them to actually provide health care and to get better. This is something that is almost non-existent in the countryside. It is coming to big cities. So, the very interesting thing is if you look at the history of the past ten years, there were almost no degrees in psychology and university degrees in psychology and now it is coming. Previously, you had only private institutions training for what is called counselor 1, 2 and 3 levels and so these counselors 1, 2 and 3 have been actually canceled in 2017. So, it doesn’t exist anymore, but between 2009 and 2017 the numbers of students doing these counselor pieces of training went from 160 000 to 1 million people in China’s mental healthcare system. So, you have one million people who trained for psychology, but out of this 1 million, only 40 000 used this professionally as therapists which means that you don’t have a lot of university degree holders doing counseling in China. You mainly have people who have been trained by private institutions and I have seen what that is and it is very far from university standards in terms of training to treat anxiety and depression in China for instance. There are only 40 000 people in China who do this for a population of 1.4 billion people. So, the demand for China’s mental healthcare system is very far from being met and I know that the Ministry for Public Health in China has run some projections on the conservative projection for the needs and China would need at least 500 000 therapists and we are very, very far from having that, especially qualified therapists. Now, you have of course the therapist, but you also have, I would say related professions like special educators for children with special needs or social workers and in the United States you will have many different kinds of professions that will have something to do with mental health care and this is something that is very, very little developed. Many of the people in schools who do social work or who act as counselors don’t really have psychological background and don’t know much about China’s psychology industry. They have an educational background and this again very different.

Matthieu David:  To put it into perspective toward the pricing of similar models, a personal trainer in China is usually not less expensive than 400 RMB. A fitness personal trainer generally doesn’t have a related degree. So, 400 RMBis a minimum and then you have English teaching and project teachers and very often you get like 300 RMB or 400 RMB. It seems like the minimum is 300 RMB, per session. So, pricing at 500 RMB seems to be in the same range. It seems to make sense. I mean you said the average, right and not the minimum. So, it seems to make sense. What I feel in China, but correct me if I am wrong, is that with a personal trainer you see the result, you see that you get more muscular and you see that you lose weight and so on. For an English teacher, you see the result. You are able to speak better English, you are able to improve your accent and so on. Is my analysis correct if I say that the reason why maybe Chinese don’t consult as much as in the west is that there is no proof of immediate results? There are only tangible results after a few weeks or even months.

David Ammerschlaeger: Yes, you are right. It’s actually very comparable, somehow. Now, a psychotherapist of course as you mentioned is much more trained or should be actually much more trained because we are talking about medical services for China’s mental healthcare system. You should not mess up people more than they are already. I know a lot of life coaches and a lot of untrained therapists who actually do bad more than good when it comes to anxiety and depression in China. So, this is very important to consider. Yes, there is something similar in the process. Look, if you hire a sports coach or an English teacher you will not go from being an untrained obese person to a bodybuilder or athlete in one session. It will take probably at least 6 months to 1 year if you are really working hard. It will take years if you really want to see a change in your body and it is the same for English. If you are learning English from scratch, it will take years to actually achieve a certain level. I would say mental health care is even more efficient than that. It takes time to overcome anxiety issues and depression, but basically, we can have quite good effects very quickly from the first sessions. There always is a plateau. We will make a lot of progress during a period but then at some point won’t be a lot of really perceivable progress an then, again, suddenly a boom. It will again be very big progress. So, it is like a staircase. We are making progress, but it is also I would say, a process that depends on how deep the issue is and how deep we have to work on different levels because very often you have several issues.

People might have anxiety, depression, family issues, work issues, relational issues and so on. So, there are a lot of things that we have to work on at the same time, but, as an English-speaking therapist in China, I would say very quickly you see notable progress and wellbeing after 3 months to 6 months. It gets better and better and this is a life change. If for example, you are working out or you were doing sports and at some point, you stopped working out then basically your benefit is zero or you lose the benefit of whatever you invested in the past. With mental health care, the good thing is that you really have this for the whole life. Whatever you have done to yourself and whatever you have understood about yourself or the progress, the self-development, the self-growth is something that you carry on forever. It will help you also to have methods for yourself to work on yourself, to introspect, to analyze yourself and you are can learn how to deal with yourself and your emotions and with the world, with your relationships and everything around you. You are becoming psychologically much more functional. So, it is beyond health care. It is not just getting better, but it is also a learning process about learning about yourself, growing and personal development.

Matthieu David: How accessible is it, is the primary question, but also the psychological barrier and we may go back to the other two I mentioned which is how to find them and how to ask, but psychology barriers to say. I think in the US and maybe now it is the case in Europe, but people are prone to say, “I have my therapist. I work with a professional. I am taking care of myself. I am working on my way of how to interact with others. I am introspecting myself.” Is it something that people may talk about openly to say, “I have a therapist” or does it looks like a disease? I think that is the thing. You mentioned before psychology issues are much more seen as a disease.

David Ammerschlaeger: Yes, you are right. A lot of people are actually again, very black and white on this. Either you are mad or you are not and there is a whole range of grey in between these things. What do we call mad, right? I mean the notion of normality has been debated a lot in psychology, in sociology, and in philosophy. So, talking about clinical diseases like anxiety and depression in China,

 people, as I said before, will feel ashamed, feel worried to see a therapist because for them it is admitting that somehow they are mad. I get a lot of people asking in their first session, “David, tell me, am I mad? Am I crazy? Am I normal? What is happening to me? Please cure me. Please do something.”

They are feeling bad about themselves just going to see an English-speaking therapist in China. So, it is not like in the United States where you are almost proud to say, “Yeah, I told my shrink this and that and I saw my shrink yesterday.” No, here, people are almost always ashamed and this is a little bit sad because I would say, on the contrary, people who go to see a therapist are those who are courageous enough to face themselves. A lot of people escape from their issues and never want to face whatever issues they have and do not want to hear about China’s psychology industry. Typically those that think they are thriving on it like people who have a narcissistic personality disorder because they feel like they are behaving so good socially. Deep down, it is a very serious mental health issue that can break down your relationships with other people and isolate yourself or lead to anxiety and depression in China. So, in the end, people really feel ashamed about this and this is why people want to grow more to see coaches and I advertise myself also as a coach and I am a member of the International Coach Federation so that people can actually say, “I am seeing a coach” instead of seeing an English-speaking therapist in China. If that makes them feel okay. If that makes them feel better, then I am fine that they say to their friends that they are seeing a coach, but in the end what I will provide to them is clinical psychology and psychotherapy.

Matthieu David: One thing I would like to put in parallel as well is education. Chinese are investing a lot in the education of their children and it is a very long-term investment, very unpredictable. It is not something tangible you get like buying a phone or whatever. I feel there is a parallel in it that at one point working on your own psychology and seeing these therapists could be seen as something educational or as an investment. To go back to my initial question about the restriction and accessibility, how do the Chinese find therapists and how can they assess that it is a good service?

David Ammerschlaeger: So, you are absolutely right and this is also why I’m working a lot with international schools. I have worked with Wellington College, I am currently working with the Shanghai Experimental School and I am also exploring ways to work with the French schools and with the American schools. So yes, you are right. This is something that is up and coming more in these international schools which are very open to western culture and western ways of working. Something that has been working extremely well and was really a big changer at Wellington College was that they had mental health care classes. They had, for example, exercises on mindfulness, meditation or psychology that were provided to the children at the school. For example, nowadays, at Shanghai Experimental School, there is a section for psychological classes and teaching so that the kids can actually learn more about China’s psychology industry and more about themselves.

I will also speak at Wellington College at the educational festival in April along with the founder of Wellington College and we will talk about these questions concerning China’s mental healthcare system. Something also interesting is that a few weeks ago I was invited to the American school for a speaking competition and so, I was working with ten children to make speeches. These ten kids, by themselves, chose to speak about mental distress. To explain how difficult their situation as children is, as students in this very high-pressured society and in this very performance-driven educational model are. It was very impressive because I didn’t ask them anything. I mean it was really something that they prepared before I even met them. It shows that there is a big concern amongst the children within themselves to address their issues and medical distress. Answering your question about how people can find a therapist, it is really difficult because China’s psychology industry is not clear. The information provided is not clear so you have people exercising and practicing psychotherapy in clinics and it is okay because there is usually a big selection in order to be able to practice in a clinic. The problem is that these practitioners will not necessarily take sufficient time for the people. They have a really low salary and I know a lot of therapists and colleagues that actually refuse to work in clinics because the pay is so low. You don’t have a lot of time with your clients. Usually, you have maximum 20-30 minutes to do counseling in China and if you really want to go to a deeper level of understanding, you cannot do much in 20 or 30 minutes. Sometimes II am even pushing some sessions up to an hour and a half because we really need to get comfortable to really go into a trustful relationship and the person needs to dig into themselves quite deeply to be able to understand themselves. So, I would say in clinics the training of these therapists is more or less adequate, but the time or setting is not perfect and in the end word of mouth is probably quite good. If you can have somebody that is referring to somebody then that is a good sign, but I would say in general, the big observation is that information is lacking very much in this field.

Matthieu David: I may rephrase my question. I understand the advice. I understand what people should do. What are people actually doing? The first thing you said is that it is defined by word of mouth, but I see a paradox here. People are ashamed of seeing a therapist and people are connected to Smartphones and computers and the Internet. It will take a lot of time for people to make a move. So I feel that word of mouth may be the smaller pie of the cake. There is somewhere else they look for information. Is it like the equivalent of Yahoo where they look for information themselves and auto-medication? The second thing is how to assess the therapist himself? You are advising them to look at degrees and to look at what they have learned about it, but is it really what people do?

David Ammerschlaeger: Yes, you’re right. So, as I said, most people actually don’t go and see an

English-speaking therapist in China. So, people usually go and see a therapist only when they really have no other solution. I have people coming to see me and they say, “David, I cannot get out of bed in the morning.” So, they wait too long before they see a therapist and when they see a therapist they are already at a very critical state of anxiety and depression in China. We could have avoided this critical stage if they had come earlier. Now, what do people do? There is a big boom in China with helplines. Personally, I am collaborating with a helpline which is called AnyHelper. They have a call line and people will call them and ask for help. I am getting quite a few clients in this way, but you have other centers in China’s psychology industry. For foreigners you have the community center in Shanghai, you have the Lifeline and for Chinese people, there is something called the Shanghai Mental Health Center. For example, I know that the Shanghai Mental Health Centre has tripled the volume of calls in the past few years. So, it is like a 300% growth of whatever calls they have been having concerning China’s mental healthcare system.

People go much more to this kind of anonymous website or call lines and I also know that certain service providers from abroad exist. I have a few clients who went to see, for example, American institutions and they work with video calls. So, you have some people asking American, European and other English-speaking therapists in China for help and they will be treated through video calls. Yes, it is very important that people look at the qualifications of the therapist when it comes to counseling in China. Also, people should look at which kind of professional body the therapist belongs to. For example, in France, therapists will be accredited by the Ministry of Public Health and in the UK therapists are accredited by the British Psychological Society and in the United States, it is more like on a state level and not necessarily on the national level. So it is important to see if your therapist belongs to a certain professional body because that ensures you a certain level of ethical behavior of a therapist.

This is another very important matter for therapists. Ethical behavior is mainly related to confidentiality, but also that the therapist knows when to let a client go. A lot of therapists will try to keep their clients coming back. As a therapist, you have to know that, when you have reached your limits and when you cannot help your client any further. Maybe he should see another therapist or maybe he should stop the treatment because he has achieved what he wanted. You have to let the client go. This is ethical behavior which is very important for me as an English-speaking therapist in China. Something else is about supervision. It is very important, as I mentioned before, that therapists are part of a supervision group that ensures peer quality. In these groups, we will review cases on a confidential level and everybody will help. I mean the therapists will help each other to approach the client’s issue. This is something that is absolutely standard in western countries but which is quite rare in China. This is probably due to the fact that there is a lack of therapists and especially experienced therapists which means that you have very few people who are experienced enough to act as supervisors.

Matthieu David: So, you said that it was partly what you see for yourself, but actually most people, as far as I understand, would first go to the hospital. If you look at the journey of the patient, then first Google or Baidu themselves and go to a hospital and then maybe talking to friends or going to those platforms directly to bump into someone who actually pretends to be a therapist.

David Ammerschlaeger:  Yes, talking about Googling and Baiduing you are right. Mainly people with Baidu will call the line for counseling in China. It is like that because most therapists here in China do not have a specific website or a specific WeChat account. I myself have one so I am a little bit more visible, but most therapists are not so much into this marketing exercise, I would say. So, people look a little bit for information, but again the information is lacking and very incomplete when it comes to China’s mental healthcare system.

Matthieu David: My last question is about a specific therapy which is group therapy and from a very external perspective people would say it doesn’t work in China because people will not dare to share in a group because they don’t want to lose the face and so on. What is the status now? Are there associations or groups of people or also professionals organizing group therapy?

David Ammerschlaeger: Yes, you are right. I would say seeing what kind of issues Chinese people in my experience have most. Group therapy would be one of the forms that work best for anxiety and depression in China. I have a lot of people having social anxiety and social phobia, avoiding personality disorders and this kind of issue would be extremely well treated with group therapy. Now, you are right, because of social or cultural standards, many people want to keep their issues for themselves and don’t speak up very easily. Now, with my colleagues, we have found ways to actually try to make people more comfortable in a setting. For example, my business partner whom you have also already interviewed before and I have come up with something that is called the movie club. So, this movie club basically works like that: we are watching a movie with a small group of people – usually not more than ten people because that is the maximum which is good for group therapy. We are watching this movie and then we have like one and a half hours or a two-hour discussion. The discussion is not about the movie itself, but people’s emotions and issues that relate a little bit to this movie and that could be in relation to China’s psychology industry. Why we are doing this? It is because people will be more comfortable giving examples coming from the movie. So, for instance, if a person in the group has issues with their parents they might say: “I really relate to this character in this movie because the relationship he has with his father is very conflictual and I have a little bit the same with my father or I feel that my husband and my son has similar issues”. It will give them the courage to start talking about themselves in a group setting, but you are right, it is quite difficult for people to do group therapy with English-speaking therapist in China. So this is something a little bit experimental to be honest because we would not work in this way in western countries where people actually very often are eager to talk about themselves and happy to talk about themselves. They explain all the issues that they have and complain about life and their family and stuff like this. Here it is very, very different and we have a lot of people who come to see us and say: “No, everything is fine” and then you want to ask them, but “Why are you here?”. This is the moment where you feel they are struggling between telling and not telling and at some point, they will start to completely break down and cry and scream and say, “No.” Then we are talking and then we are getting somewhere, but they really have to be pushed to a breaking point in order to really start talking about themselves.

Matthieu David: What do you read to stay up to date about China; not necessarily books of course. It can be different media.

David Ammerschlaeger: So, on a media level I would say I keep up to date a little bit through WeChat accounts and articles that I read in China Daily where, at the moments, you find a lot of interesting things. On LinkedIn you find a lot of interesting things as well, but to be honest, the best way that I really feel a little bit of what is going on in the society is by talking to people. I am in a relatively privileged situation because of my clients. I have a lot of Chinese clients and also I have a lot of foreign clients. So, I get a lot of information from these people about their lives, about their relationships and it gives me, I would say, an intuitive or empirical understanding and feeling about what is going on in the society at least here in Shanghai where I am treating people. Did you ask me what kind of book I read and that was really impactful for me? Then, I would say, the Gift of Therapy by Irvin Yalom. He is a very famous psychotherapist and he is still living in the United States. He is one of the instigators of existential therapy and, in this book, he describes what therapy means actually to people, how he can provide that and huge benefits that it can have for people. It also describes the huge benefit it had on him as a therapist because he was growing thanks to his clients, thanks to the work he was doing. He was learning a lot about himself and he also said that everybody needs a therapist and even me, as a therapist or as a professional, I am seeing a

English-speaking therapist in China every week because I want to learn more about myself and understand more about the human being, the human mind and about myself which really shows that it is not just about mental health care or when you have any kind of disorder.

It is also about learning and it is also about discovery and self-exploration, it is about growing as a human being. So, this is something that impacted me a lot because it helped me also to understand how I should position myself with my clients and within myself and my profession.

Matthieu David: If you had extra time, what would you start as a business?

David Ammerschlaeger: I would definitely love to start an online training business or maybe a training business for psychology for people to learn more about themselves. An example is a sexual education. This is something that I feel is extremely lacking in China. Nobody tells young teenagers what sexuality is about and what relationships are about beyond sexuality. There is also the couple-relationship. What is love? It is about asking people what love represents to them. The diversity and actually the primitive; answers I am getting sometimes of the understanding of relationships, love relationships. What really is a life together and what building a family is? So, I would love to help people to understand a little bit more about how they can fair together, but it is one example is that there are many, many others and I feel we could achieve so much if people would just gain more knowledge about psychology, the human mind. I feel this is something lacking a lot in the education system and I am not just talking about China. I think in western countries it would also be a good thing to maybe have psychology as a class subject in high school or something like that.

Matthieu David: What unexpected failure have you witnessed in China? It can be business, it can be society, it can be a product.

David Ammerschlaeger: I would say a big failure in China is still not being able to really face their own issues. I have so many people always escaping from their personal issues either by blaming other people for something that actually they should be working on or maybe blaming themselves for things that are actually other people’s issues. So, people are very unclear about themselves about also setting boundaries. You have a lot of people not being able to set boundaries towards their family members, grandparents taking a lead in their grandchildren’s education. I wouldn’t say it is a failure, but I would say that it is still something that is quite immature in the way that it is dealt with and people are informed in general. So, this is something that we can definitely work on here.

Matthieu David: Thank you very much for the talk. I think there are a lot of opportunities in the sector you are in. There is still a lot to do in China and I am looking forward to seeing the evolution.

China paradigm is a China business podcast sponsored by Daxue Consulting where we interview successful entrepreneurs about their businesses in China. You can access all available episodes from the China paradigm Youtube page.

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