Lessons and Challenges of Disaster Relief Work in Rural China

Abstract

Due to the disastrous Wenchuan earthquake that hit Sichuan, China, on May 12, 2008, approximately 70,000 people died, around 400,000 were injured, 18,467 were missing, and millions were left homeless due to the collapse of their homes. The substantial trauma and loss in the disaster area posed a challenge for disaster relief work focused on survivors’ psychological health. Many of the psychological interventions were based on Western or urban outpatient populations and were thus inappropriate for the uneducated, agriculturally based population of rural China, potentially limiting patient care and sensitivity during this postdisaster relief. This article discusses the therapeutic issues involved and finds that the collectivist nature of the rural Chinese culture and indigenized ways of working with the earthquake survivors are of paramount importance. It adds to the research literature by discussing the importance of relationships through the Chinese concept of Guanxi in the context of disaster relief work in rural China. Consistent with the concept of Guanxi, disaster relief volunteers must fully respect the world of the survivors while remaining flexible and creative in their work to build deeper connections and relationships.

Keywords

disaster mental health services therapeutic care cultural competence

Introduction

On May 12, 2008, an earthquake measuring 8.0 on the Richter scale struck Wenchuan, which is located in Sichuan Province, China. This was strongest recorded earthquake to ever hit China, and it frightened half of the nation’s population out of their houses and into the streets. According to the Ministry of Civil Affairs of China, 69,197 people were confirmed dead, more than 400,000 were injured, 18,467 were listed as missing, and approximately 6.5 million were left homeless. Additional earthquakes and aftershocks caused widespread devastation, and thousands of people experienced the death of family and friends, injury, loss of property and jobs, homelessness, and displacement (Xu & Song, 2011). In addition to enduring physical suffering, survivors were severely traumatized by the earthquake. Researchers estimated that 47.3% of individuals in the severely damaged areas and 10.4% of those in the moderately damaged areas suffered from posttraumatic stress disorder (PTSD; Kun, Tong, Liu, Pei, & Luo, 2013). Risk factors for PTSD include being elderly; being female; being unmarried, divorced, or widowed; losing a family member; having no household income; and having a damaged home (Kun et al., 2009; Kun et al., 2013; Xu & Song, 2011).

This large-scale devastation and the affected population resulted in an exigency for mental health services. Thus, help from all over the world poured into the mountainous region of western China with good intentions to provide the victims with mental health care. However, many of the mental health interventions proved to be ineffective because the therapeutic practices were based on Western or urban outpatient populations and, thus, failed to meet the needs of this uneducated, agriculturally based population located in rural China (Keats & Wang, 2013). Therefore, in this article, we discuss how the challenges of providing disaster relief mental health services across cultural, societal (urban vs. rural), and professionally divergent settings encouraged mental health providers to be more flexible, humble, culturally sensitive, and respectfully attuned to the needs of a vastly different population that traditionally does not seek mental health services. It can be concluded that these lessons and challenges are well aligned with a number of core tenets of humanistic psychology, which will be highlighted throughout the article.

The Challenges of Disaster Relief Work

Consider the following case. A couple in their 40s lost their 10-year-old son and 7-year-old daughter in the earthquake. They tried to bear another baby numerous times but did not succeed. Three years after the earthquake, the desperate woman, who was no longer able to bear the pain and sorrow of living without her children, committed suicide by jumping into a river. This case raises the following questions: How can the relief workers help the surviving widower? What treatment modality is most appropriate (e.g., psychoanalysis, cognitive behavior treatment, eye movement desensitization and reprocessing [EMDR], or some other modality)? A number of relief workers attempted to help the widower. However, he consistently replied, “How can you help me? You can do nothing. Can you bring my wife back? How about my two children? I do not need any help!”

One year after the earthquake, there was a 60-year-old man whose village was destroyed by the earthquake. Most of the people in the village were buried under the rubble, including this man’s brothers, relatives, friends, neighbors, wife, son, daughter-in-law, and grandson. Most of the people in his village did not survive. He regularly travelled to the collapsed mountains to cry alone, but the tears were not forthcoming. He felt as though he had no one in the world to live for.

What can therapists do when faced with these traumatized individuals? What is the most important service relief workers can provide to them? Such deep trauma, suffering, hopelessness, poverty, and sense of being lost are commonplace among disaster survivors and represent ethical and therapeutic challenges for disaster relief work.

Incompatible Care

While many well-intentioned mental health professionals travel to disaster sites to offer their services, many of them fail to provide help for the following reasons. First, due to cultural and sociocultural differences, urban-based disaster mental health practitioners often fail to understand the practical challenges of working in rural settings (Barbopoulos & Clark, 2003; Werth, Hastings, & Riding-Malon, 2010). One expert from Beijing made the following statement to survivors: “You need to cherish this opportunity that I am providing to you for free. Many people pay a significant fee to come to my office for help . . . yet, you do not cherish this opportunity.” Not surprisingly, none of the survivors sought his assistance. In contrast, a different frontline relief worker commented,

I enter the community and become ‘friends’ with them. Sometimes the relationship is like a friendship, a family-like relationship or a therapeutic relationship. . . . I cannot find a simple relationship to describe our relationship . . . but it works, they trust me.

Therapy is deeply influenced by culture. Western culture and values, which gravitate toward individualism, fundamentally differ from Eastern traditional cultural values in rural China, which place greater emphasis on communal interdependence (Markus & Kitayama, 1991) and relationship-oriented ethics (Chiang, Lu, & Wear, 2005). Accordingly, the rural survivors were often confused and unable to understand the treatment/help they were offered. Care in rural China differs significantly from typical therapeutic care in Western outpatient therapeutic practices. Many of the rural disaster survivors had never encountered a mental health professional before the survivor camps were flooded with such professionals. Survivors and mental health professionals did not have a mutual understanding of therapy. One survivor stated,

They said they will come to offer some treatment for me. But, they did not give me medication. Instead, they ask me to talk and complete some very complicated homework. . . . I cannot understand it or do it well. This is so shameful. I do not want to do treatment anymore.

Second, humanistic psychology strongly considers the individual’s knowledge of his or her own needs and how to meet those needs (Joseph & Murphy, 2013). Thus, therapeutic care informed by humanistic principles is client centered (Quinn, 2013). However, many mental health volunteers failed to put this fundamental principle into practice. Rather, many practiced interventions that they were familiar with and believed were best rather than listening to the voices of the local survivors. In other words, they practiced technique rather than care and adhered to convention rather than responding to the local reality and needs of the individuals. Because of the practitioners’ lack of creativity and flexibility, these interventions were inappropriate, inhumane, and ineffective. For instance, some of the volunteers considered only the survivors’ symptoms and neglected their stories, traditions, communities, and culture. In fact, researchers found that many survivors were suspicious of outside intervention and felt they had to protect themselves from psychological intervention. Tragically, the following joke was often shared among the survivor community: “We need to be aware of fire prevention, epidemic prevention and the prevention of psychological intervention.” The quote is reflective of the unfortunate fact that many of the well-intentioned mental health volunteers exhibited cultural insensitivity and a lack of understanding and respect for the survivors’ needs (Ren, 2009).

Respect for Individual and Cultural Differences and the Uniqueness of Each Survivor

Respect is not only a principle of care but also the essence of client-centered care (Yip, 2005). Respect allows us to better understand what others express and to listen to their experience so that we can provide the necessary services (Hill & Peterson, 1997). Respecting individual and cultural differences and the uniqueness of each survivor is an ongoing learning process that involves self-awareness, cultural humility, and often an attitudinal shift whereby relief workers recognize that they have limited knowledge about the best services they can provide to each survivor (Sue, 1998; Wang & Kim, 2010). Respect requires that relief workers leave the office; visit the sites; get to know the survivors, the local leaders, the language, and the history; and gain an appreciation for the alternative forms of care embedded in the local tradition. Professionals can show respect by integrating such knowledge and each survivor’s personal preferences and cultural practices into clinical services. This is the process of indigenization, which demonstrates cultural competence such that the services provided can be equitable, accessible, acceptable, and appropriate.

Respect Culture: Indigenized Mental Health Services

When providing disaster community mental health care, relief workers with a Western mental health training background may find themselves in a cultural background different from the situation they had trained in (Sue & Zane, 2009). The local cultural paradigm might be completely different from the paradigm based on Western ethics and clinical standards. In Western cultures, patients visit a clinic to request help. However, the scenario in the rural disaster areas of China is quite different because none of the survivors possess any knowledge of mental health. Therefore, relief workers must begin by participating in community life as fellow citizens, learning about the community, and cooperating with local residents. These actions will enhance the relief workers’ understanding of a local culture, and they will be better able to integrate the knowledge gained with the best course of action to benefit the people in the community (Israel, Schulz, Parker, & Becker, 1998).

One survivor stated, “I am not crazy. I do not need psychological help.” Another said, “Only the weak need therapy. Go help those people. I am ok . . .” Because of this lack of mental health knowledge, survivors have strong misconceptions that must be overcome, a process that takes time.

Accordingly, to provide mental health services to disaster survivors, professionals must make a long-term commitment (Chan, 2008). In the current case, a group of dedicated professionals, including psychiatrists, psychological counselors, social workers, local volunteers, medical doctors of various specialties, nurses, and others, committed to making weekly visits to the rural disaster settlement camps, which involved a round-trip commute of 6 hours of travel through mountainous terrains in various degrees of disrepair. Those who wished to commit to providing long-term services explored ways to provide culturally congruent effective psychological services. They made regular visits to seek clients who needed help rather than expecting survivors to seek a clinic independently. They traveled door-to-door to visit the survivors and spend time getting to know them prior to offering the survivors their services. Once an initial rapport was established, the professionals introduced themselves and explained their services while also educating the survivors about the types of help that were available. Thus, the volunteers took the initiative, and the patients visited the doctors. The doctors made house calls in a setting that was quite dissimilar from their traditional clinics. One counselor commented,

None of the survivors came to find help in the community. They did not consider symptoms of PTSD to be problematic. They did not consider themselves in need of psychological help because they had no concept of psychotherapy or mental health services.

At the same time, the professionals did not force their services on the survivors because it was critically important that they respected each survivor’s individual decision.

To provide community care outside of their professional institutes, professionals needed to become members of the affected community and approach their work in a way that suited to the local community. This is the slow work of indigenization. That is, it takes time to get to know the culture of the local community and understand the people’s needs from their perspective (Ho, Peng, Lai, & Chan, 2001).

Learn and Respect the Local Custom Regarding Gifts

Another aspect of indigenization is understanding the local customs and practices, including gift giving. There have been numerous debates about offering or accepting gifts in the field of medical services (Evans, 2014; Schaverien, 2011; Smolar, 2002). In many cultures, gift giving is a means by which long-term relationships with clients are built. Indeed, in general health care, long-term relationships between professionals and clients have been reported to become more personal relationships (Wiles & Higgins, 1996). In the rural communities of China, relationships are often maintained through gift giving (Kipnis, 1996). For example, during the early stages of the disaster relief work, one psychological professional stated,

In the beginning of our work, I knocked on the doors of survivors and asked them if they needed mental health help. I told them I was a psychiatrist, but none of them responded. Later, one survivor was not feeling well, so I brought gifts of sugar and milk to her, and she opened up to me. She let me come into her home, life, and inner world. Only then were we able to work well together. We then took the initiative to make sure we’d bring small gifts on our initial visits.

Thus, gift giving became a way to build and strengthen social bonds (Mauss, 1954). As gift giving is a central aspect of the clients’ regular communal life, it enhanced their social inclusion (Ootes, Pols, Tonkens, & Willems, 2013). One psychiatrist who worked in the disaster areas for 5 years stated,

Gifts have a special meaning in the Chinese culture. A gift is not just a gift, it is a symbol of a relationship. If you refuse the gifts that other people give you, it means you look down on them or you do not like them, especially in rural areas. People will feel rejected and may feel ashamed or lose face.

In the disaster areas, nearly all mental health professionals accepted gifts, such us meat, peanuts, fruit, and so on, from the survivors. These gifts were important cultural symbols of appreciation. Unfortunately, some therapists strictly refused gifts, which led survivors to discontinue treatments or avoid contact with the therapists altogether.

Nonetheless, there is no universal policy. Professionals must be judicious in understanding the cultural meaning of gifts. Because gifts play a role in communicating intimacy between individuals, they forge close ties (Kipnis, 1996). Thus, it is best to discuss dilemmas regarding gifts with local leaders, community mental health service team members, and community survivors to increase one’s own understanding and develop boundaries regarding gifts. Accepting gifts is often a way to show basic respect for the survivors. However, it might also place an undue burden on people already experiencing economic hardship. In our practice, we placed a limit of gifts costing no more than 10 RMB ($1.50) to ensure that we did not place undue hardship on the survivors.

Respect Humanity

Many front-line workers say that both what they say and what they do reflect their respect for humanity. It exists in every word and deed (Byers & Gere, 2007). A front-line clinical worker said,

I could remember one of cases very clearly. After the earthquake, many psychologists and well-known clinical experts offered psychological intervention for a woman whose son and daughter lost their lives in the earthquake. Every time, psychologists would express that they understood her feelings and teach her how to deal with sorrows. She told the front-line worker that she didn’t refute these experts out of respect. “A stone that is held in the arms for 10 years can be warm, needless to say the person you live with morning and night. How can they understand my feelings?” said the client, and then she refused all therapy and left the staff outside the door.

This situation is common in after-calamity stories. Many therapists go to disaster areas to act as rescuers, providers, saviors, and as religious leaders. Respecting the population affected by the disaster means listening to their stories, discussing the pain they suffered, and helping meet their needs. The front-line worker should follow them quietly, respecting their choices and their way of handling their grief, perhaps by simply sitting together with the survivors to listen to their guidance and respect them. Survivors can also be accompanied on death anniversaries, and mental health providers should respect their unique way of coping with trauma in the local culture. Respect shows empathy both in word and action. We should show our respect and understanding with actions and be available when the clients are willing to talk. We should be mindful that the encounter between client and therapist is an interaction between two people and requires a basic respect for humanity.

They wanted to be treated as a whole person, a person with moral worth who belongs to the community and who has the freedom to determine and create his or her own cultural and religious traditions. Instead of being called survivors, patients, or victims, most of them wanted to be known simply as a person, and they desired humanity and dignity. Unfortunately, in some instances, they experienced exploitation rather than respect.

After the devastating earthquake, numerous individuals and organizations exploited the survivors in the name of aid. Many sought to advance their own causes rather than to serve the needs of the local people. In the early stages of recovery, numerous individuals and organizations arrived simply to provide token aid and take opportunistic photos promoting their aid. They appeared swiftly and left as quickly. One child in the affected area said, “Everyday there were so many people who came to ask for my story. They recorded my story and were quickly gone.” These are classic examples of disaster voyeurism or tourism (Van Hoving, Wallis, Docrat, & De Vries, 2010). Furthermore, many stories were obtained and broadcasted, and “interventions” were provided with little or no consent from the survivors. In some cases, consent was obtained based on prior hierarchical relationships. In the local rural tradition, it is impolite to refuse help; thus, survivors often gave their consent without any knowledge of what they were consenting to. In other cases, the survivors may have been informed, but due to their lack of education and prior experience, they may not have fully understood the nature of the consent.

Exploitation also occurred in the name of religious proselytization. Many religious individuals and organizations viewed the disaster as an opportunity to preach the Gospel and impose their religious beliefs on others in the midst of their misfortune. One older female survivor asked, “Can you tell where Mr. Wang is? I came to fetch food and financial support. Mr. Wang told me if I believed in God, I can come to get food and money every month for the next two years.” Another survivor said,

One counselor told me believing in God can make my life easier. However, if I did not believe in God, the end of the time will come in 2012, my spirit will be gone, and I will go to Hell.

Both the best and the worst of humanity are displayed in times of disaster. Although it may be difficult to believe, such instances of exploitation were, unfortunately, quite common.

Treatment Flexibility and the Need for Creativity

Consistent with humanistic values, disaster relief work across cultural and economic strata requires flexibility and creativity (Owen & Hilsenroth, 2014). Flexibility and creativity can increase the power of the person-centered services, which is significantly related to increases in client engagement, and subsequently predict treatment adherence, effectiveness, and outcome (Chu & Kendall, 2009; Kahn, 1999; Owen & Hilsenroth, 2014). Creativity is a relational process that contributes to moment-by-moment responsiveness and is a way to establish meaning and connection through the integration of different types of experiences (Rouse, Armstrong, & McLeod, 2015).

Irvin Yalom (2002) suggested that we must create a new therapy for each client, a principle that is apropos with respect to disaster relief. As disaster relief settings vary, volunteers must learn to adapt to meet the unique situations of each setting. Despite advances in mental health care throughout China, most people who need care go untreated because of a lack of access to services, stigma, discrimination, economic problems, culture barriers, or a lack of awareness (Bartlett, Garriott, & Raikhel, 2014; J. Li, Li, Thornicroft, & Huang, 2014; X. Li, Stanton, Fang, & Lin, 2006; Phillips et al., 2009). Even when services are available, they are often not culturally appropriate. While this treatment gap is not peculiar to China, it was particularly evident in the case of the 2008 earthquake in Sichuan because all the survivors resided in rural China.

Flexible Location

Compared with traditional institutions, mental health services in rural settings are often decentralized, especially in the case of disaster relief. Often, the transportation infrastructure has been damaged or destroyed, hindering survivors’ access to services. Therefore, volunteers must coordinate with local rural hospitals to set up centers in the immediate disaster relief area. However, there is the additional complication of informing the people that the services are available. Similar to the disruption in transportation, the flow of information is often disrupted. Thus, it becomes necessary to travel door-to-door to inform individuals of the available services. Furthermore, mental health services are often not prioritized in the minds of survivors, which is easily understandable given that survivors are preoccupied with the tasks of rebuilding their homes and communities.

Even when centers are established in the immediate disaster area, survivors may feel uncomfortable seeking the services of a mental health professional due to stigma. Members of close-knit rural communities often monitor one another’s comings and goings, challenging privacy. Furthermore, because makeshift centers often lack privacy, sessions may need to be conducted elsewhere, even outdoors, because private sheltered areas are often nonexistent. Nevertheless, when time and resources permit, survivors should be invited to a private setting to continue treatment. Finally, given that typical disaster relief settings are often in flux, the center may often be relocated for various reasons, thereby adding to the challenges associated with providing stable and consistent care. Given the aforementioned challenges, disaster relief volunteers must be flexible and creative. Indeed, uniqueness is the hallmark of disaster relief care because mental health services rarely look identical across individuals or from one day to the next.

Flexible Times

A 45-year-old woman turned to therapists in the community for help because she had trouble sleeping in the 3 years after the earthquake. For the first 10 consultations, she just talked about her physically symptoms and insomnia as well as her daily life and troubles in her life. Then, she left after 20 minutes. These interactions are always client-centered, and the client decides what topics they want to talk about. Because the clients are busy with after-calamity reconstruction, consultants give them flexible time to talk according to their own conditions. One day, the client came to the office to talk about her physical condition and sleep as usual. After a silence, she also talked about the day that the earthquake happened. She said that she ran to the school after hearing about the collapse of the school. She sat on the ruins and heard her son crying “Help me, mom.” She could still remember her son’s voice. Then the voice disappeared. Three days later, a soldier dug out her son’s body. Talking and tearing up, she said she could not face the truth even 3 years after the tragedy. Flexible time in humanitarian psychological aid allows clients to talk about their issues in their own way and at their own pace.

It is safe to say that the traditional 50-minute hour is nonexistent in disaster relief mental health care, especially in rural settings. First, rural people who live in agricultural- and community-based settings operate according to event time rather than chronological time (Dietler & Herbich, 1993; Lucas, 2004). Thus, it is nearly impossible to keep fixed time appointments with rural survivors when beginning treatment. Rather, demonstrating flexibility with respect to time helps build a trusting relationship with rural clients. However, it is also important to educate clients about fixed time appointments. While stubbornly insisting on fixed time appointments based on Western psychotherapeutic practices often resulted in scaring and pushing the survivors away from treatment because they tend to view arbitrary limitations of time as unfriendly or unduly pedantry. Thus, time limitations may damage the relationship and decrease people’s willingness to obtain services. Second, it should not be assumed that survivors will return for consistent treatment because they simply have no conception of such a requirement. While rural residents may be accustomed to visiting the city for advanced medical care, they do not do so on a consistent basis. Indeed, many survivors are deeply appreciative of an individual who will listen to them and value their losses. Therefore, once they have opened up, it is not uncommon for them to spend half a day or more talking with relief workers about their sorrows and losses. Survivors often feel much better after these sessions and to do not wish to consume all of relief workers’ time. Thus, short-term intensive sessions are the norm, and there is rarely a need or desire for ongoing weekly sessions.

Given such intensity and nontraditional care, it is important for professionals to work in teams when providing disaster mental health services (Jacobs, 1995). Disasters strike widely, resulting in substantial need in disaster areas. Because of the unpredictable nature of this work, more than one person should always be available in the event that one session lasts the whole day. Thus, to share the heavy workload, professionals must engage in teamwork. In fact, volunteers with basic training can ease the load by providing psychological comfort to survivors during extended sessions, as the seasoned clinicians are often quite busy and have limited time.

Flexible Types of Treatment

As previously discussed, some mental health volunteers arrived to the disaster relief areas with their own agendas. In some cases, their agenda was to demonstrate the efficacy of their own particular treatment approach, a plan that runs the danger of making everything a nail when one has only a hammer. While providing disaster relief, it can be observed that most survivors needed companionship rather than treatment or evidenced-based interventions. They most valued people who spent time with them and shared life with them in the midst of their recovering community rather than manualized treatment or deep interpretations. They most appreciated those who danced, laughed, cried, rebuilt, worked, ate, walked, and shared life with them. More than ever, it can be found that the Chinese phrase “Life Impacts Life” to be the truest maxim of all. One survivor claimed,

I have so many things that I need to handle. I need to rebuild my collapsed house, take care of my family. Yet, they ask me to come to their offices for treatment every week. What for? I have no time.

A sense of frustration and distrust is evident in this statement. In addition to being uninformed about traditional psychological services, the survivors exhibited a natural distrust of outside psychological interventions that was compounded by the recent trauma. Therefore, building trust was essential. In such challenging circumstances, it is even more important to adopt a flexible and creative approach to treatment. How can the needs of the local survivors be met instead of expecting them to respond to our treatment? In the words of one relief worker, “We have to be flexible to respond to the needs of our clients. Techniques are dead, but our treatment need not die.” Nearly all long-term disaster humanitarian psychologists had to assist their clients in locating basic resources, finding job opportunities, gaining access to education, or finding medical resources. These services were commonplace in the disaster relief communities.

Relationships (Guanxi) Rather Than Techniques or Treatments

Overall, relationships, rather than treatment or techniques, comforted the survivors and helped them to move on. The Chinese have a specific word for the important concept of relationships and bonding that underlies the structure of this collectivist society: Guanxi. Guanxi is a deep-rooted, important, informal, and subtle personal connection that binds people together through culturally implicated psychological contracts. The quality of Guanxi is based on mutual trust strengthened through a long-term relationship, mutual commitment, respect, giving face, loyalty, self-disclosure, dynamic reciprocity, obligation, and long-term principles based on equality (Chen & Chen, 2004). Guanxi is all encompassing in disaster relief work because it involves being a friend, family member, teacher, doctor, or whatever role the survivor needs at the time. Disaster mental health services were not welcomed by the local survivors, and many of the local relief workers were repeatedly rejected by local rural survivors. However, the workers remained persistent and provided services as needed, including reading newspapers, gathering information regarding new rebuilding policies, locating a doctor in the city, or participating in the dance circles as part of the local traditional holiday celebrations. They engaged in these behaviors in the name of Guanxi because these so-called trivial aspects of life nurture Guanxi.

Multiple Relationships

Clinical and counseling psychologists should understand that the dual relationship (e.g., develop familial, social, financial, business, or intimate relationship with those who seek professional service) has the potential danger for exerting negative influence on their professional judgment and may cause harm to those who seek professional service. (Chinese Psychological Society, 2007)

As an alternative to the aforementioned warning, the counterargument from a more collective-oriented society is that multiple relationships are foundational to human connections and are deeply embedded in the Chinese culture. In fact, in the aftermath of a disaster, relationships are even more woven into the fabric of rural life, and their intricate ties become more evident. One woman lost her husband and daughter in the earthquake. More than five psychologists talked to her and offered her psychological treatment in the first several months after the disaster. She was unable to sleep at night and was very depressed. Moreover, she refused any type of help and was unwilling to talk to professionals, claiming that she did not believe the psychologists: “They listen to my stories, take some photos with me, then they are gone.” The psychologists hoped she would accept treatment, but she repeated, “I do not believe psychologists. They come and go randomly.” One psychologist, however, visited her in excess of 10 times. The woman eventually said, “If you really want to help me, let us become sisters because if you become my sister I will tell everything to you. I can only trust my sister.” The psychologist replied, “I am a psychologist. I cannot be your sister.” The client countered, “I will tell you nothing. You will leave me like my husband, daughter, and the psychologists who suddenly disappear.” The psychologist persevered but received the same response. Finally, the psychologist compromised and said, “I can be your therapist and your therapist-sister.”

Such examples challenge us to reflect on the concept of multiple relationships from a more balanced perspective of psychologists who sincerely wanted to help and had to adapt to the situation at hand. If the relationships outlined in the codes were strictly adhered to, they would have only served as barriers to providing humanitarian aid.

Connection With Survivors

Clinical and counseling psychologists should recognize their own potential influence on those who seek professional service. They should take steps to prevent conditions that may impair trust in the professional relationship or cause dependency on the professional relationship. (Chinese Psychological Society, 2007)

Just as a more balanced and nuanced view of multiple relationships is needed, the nature of the helping relationship must be understood differently in disaster relief work. First, as described above, a much more informal, and perhaps intimate, relationship with rural survivors is needed given that such relationships are part of the traditional rural agricultural society, in which interdependence is a necessity. After losing everything and everyone in the aftermath of an earthquake, an individual may need a meaningful, personal connection to help create new meaning in his or her life. While some survivors may require only concrete help to recover and regain their lives, others may need the comfort of new relationships and more intimacy to return to living their lives. This need may be interpreted as dependency in some circles, and overreliance is possible. However, when one’s entire social structure has been destroyed, a period of dependence may be necessary to regain interdependence, which is the natural progression endemic to rural China. Thus, it is appropriate for volunteers to visit the survivors regularly following the end of the initial stage of disaster relief, as their relationship has transitioned from a survivor–volunteer relationship to that of a friendship, which is the basis of Guanxi in the collectivist culture of China.

Conclusion

The survivors of the 2008 Sichuan earthquake were extremely vulnerable following the epic disaster. Many survivors lost their immediate family members, friends, homes, communities, and even culture. To provide human services and disaster relief to the survivors, workers had to forge their own set of ethical standards and codes of conduct by fostering respect, flexibility, and creativity. Although the treatment techniques employed for trauma and disaster relief have constantly evolved over the past decade and the research literature has confirmed the efficacy of different types of therapeutic techniques, the lessons learned from disaster mental health services working suggest that the nature of the therapist–client relationship is still foundational in disaster mental health services. This article adds to the research literature by discussing the importance of relationships through the Chinese concept of Guanxi in the context of disaster relief work in rural China. Indeed, consistent with the concept of Guanxi, disaster relief volunteers must fully respect the world of the survivors and be flexible and creative in their work to build deeper connections and relationships.

Footnotes

Acknowledgements

We take this opportunities to thank our friends Alvin Dueck, PhD, and Mark C. Yang, PsyD. They nurture our understanding of human suffering and culture psychology.

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

Author Biographies

Zhengjia Ren, MD, is a psychiatrist who works in China. In addition to teaching courses that focus on the dialogue between culture and humanistic disaster mental health services, he has been engaged in research on the role of culture in medicine and tries to promote humanistic mental health services in China.

Jason Dias, PsyD, teaches existential and humanistic psychology as Saybrook University and Pikes Peak Community College in Colorado Springs, Colorado.

Wei Zhang, MD, is a professor of psychiatry, associate dean of the West China Hospital at the University of SiChuan, and also head of the SiChuan Psychological Counseling Association. His research interest is in posttraumatic stress disorder, anxiety disorders, and humanistic services in medical health systems.

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