Beyond China’s drug century: Yunnan’s first therapeutic community and narratives of drug treatment and mental health care

Abstract

China is experiencing rapid cultural change and new forms of sociability that are accompanied by social problems and novel humanitarian interventions that have been formulated to address those problems. The pressure related to the rapid transformation of the countryside into mid-level cities has led to recreational drug-use as a means of escape. These illegal drugs have greased the wheels of what I call an affective biopolitics that has influenced Chinese citizens. Carlos Rojas argues that development in China results from the effects of discrete protocols, or practices that stem from tensions between capital and labor, governmentality and biopolitics, and nationalism and globalization. To tease out the particulars of Rojas’ protocols and practices, in this article, I first review two historical periods: 1) the rise and fall of opium consumption in the early 19th century, and 2) the 21st-century psychology boom. I use these two literature reviews to set the stage to discuss my ethnographic study of Sunlight, China’s first residential therapeutic community for drug users in Yunnan Province. Sunlight’s residents and founders provide a unique window into local everyday drug use at a particular time in China’s economic boom, from 2007 through 2015. We know much about China’s opium century but very little about the contemporary context, new consumers who partake in pleasure-consuming drugs, or the reformers who address these 21st-century public health issues.

Keywords

biopolitics China residential treatment substance use

“The water that carries the boat can also overturn it.”

(shui neng zai zhou, shui neng fu zhou水能载舟,水能覆舟)

Introduction

China is experiencing what many call the second industrial revolution: rapid cultural change, new forms of sociability that are accompanied by social problems and novel humanitarian interventions that have been formulated to address those problems. The pressure related to the rapid transformation of the countryside into mid-level cities is leading to recreational drug use as a well-worn means of escape. These pleasure-consuming drugs have greased the wheels of what I call an affective biopolitics that has influenced small groups of Chinese citizens (Hyde, 2017; O’Neill, 2013; Race, 2009). Carlos Rojas notes that “development [in China] does not result from historical imperatives or deliberate economic strategies,” but rather from the effects of discrete protocols, or practices that “stem from an overlapping mix of socialist and capitalist institutional strategies, political procedures, legal regulations, religious rituals, and everyday practices” (Rojas, 2016, pp. 6–7). In fact, in contemporary China, there are tensions between capital and labor, and nationalism and globalization.

To tease out the particulars of Rojas’ protocols and practices, in this article, I examine two histories that have deeply influenced drug consumption and mental health in China: the rise and fall of opium consumption in the early 19th century, and the more recent 21st-century psychology boom (Huang, 2014; Chen, 2015). Beginning with these two histories, I set the stage to discuss my ethnographic study of Sunlight, China’s first residential therapeutic community for drug users. Sunlight’s residents and founders provide a unique window into local everyday drug use at a particular time in China’s economic boom, from 2007 through 2015. As historian Frank Dikötter (2002) notes, we know much about China’s opium century but very little about the contemporary context and the consumers who engage in pleasure-consuming drugs, nor, I add, the reformers who addressed early 20th-century public health concerns.

Methods

As a medical anthropologist and former English as a Second Language teacher, I personally witnessed the opening up of China from 1985 to 2016. In 30 years, China moved from a peripheral Communist country to one of the most powerful on the globe. With its entry into global markets came the resurgence of former social practices that harken back to China’s 19th-century policy crusades over opium. After completing ethnographic fieldwork on the role of sex workers in the HIV/AIDS epidemic on Yunnan’s southern border with Myanmar and Laos, in 2006 I was invited by the Yunnan Institute of Drug Abuse to conduct a clinical ethnography of Sunlight residential therapeutic community, China’s first drug-related therapeutic community (Hyde, 2007). The joint collaboration between Sunlight therapeutic community (hereafter TC), originally a government supported non-government organization (a GONGO) supported by Sunlight-International, and the government-run Yunnan Institute of Drug Abuse (YIDA) have made the Sunlight TC project a pioneer in providing an alternative to the criminal justice system’s compulsory drug detoxification centers and an effort to bridge the treatment gap between the demand for prevention and available rehabilitation resources (Bartlett, Garriott, & Raikhel, 2014; Raikhel & Garriott 2013).

From 2007 to 2010, I studied Sunlight using a mix of methods common to anthropology. I lived 24/7 with staff and residents in their dorm rooms and staff quarters, working as a yoga teacher, grant writer, and occasional fill-in social worker running peer groups on gender and art therapy. I also conducted two different types of interviews: 1) impromptu interviews with 80 residents and staff over five years, and formal, taped interviews with 30 residents and staff. As for participant-observation, I spent a total of nine months over a stretch of three years living and working three days on and three days off (the common staffing pattern). I returned to the field over the next five summers to conduct short-term follow-up fieldwork. In my first two visits, I shared a room with Xiao Liu, the only female staff member, and when her position was eliminated two years later, I moved in with female residents in their bunk-bed dorms. As is the case in Therapeutic Communities around the globe, the peer-educator-staff were former users who had been “rehabilitated” at Sunlight (see Carr, 2010; Garcia, 2015). As an anthropologist, I took copious field notes and participated, on a daily basis, as a member of the 10 person staff team where I was affectionately known as “teacher” Hyde (海老師). I was allowed into all group sessions but not private meetings between therapists and residents, or family intake sessions due to confidentiality and “saving face,” what Westerners would call avoiding shame. My last visit to the Center was in 2015, when I interviewed the former director of the Yunnan Institute of Drug Abuse (YIDA), Dr. Li Jianhua, the psychiatrist who founded the original Sunlight, with its current director, Dr. Yang Maobin. Combing my field notes and interviews, I mined my research material for common themes and ideas about Chinese drug use and Sunlight’s methods.

Three key institutions were involved in Sunlight’s conception and development: the Yunnan Institute of Drug Abuse (YIDA), under the aegis of the Ministry of Health; Sunlight-USA, which trained Yunnanese medical staff and peer-educators in Sunlight-USA’s TC methods; and Sunlight-International, which helped foster the development of its Chinese protégée. The history of this residential center does not follow a teleological narrative, similar to Rojas’ comment about Chinese development stemming from the overlap of socialist (the communal) and capitalist (individual) institutional strategies and political procedures and, most important, everyday practices. Sunlight is not about the rise of the individual at the expense of the communal, but more about discrete protocols that change throughout the 20th century according to the political and medical mores of the time. Permit me to give you a sense of where Sunlight fits into China’s long drug century of consumption and rehabilitation.

In thinking of Rojas’ discrete protocols outside of a strict historical teleology, I’d like to move toward situating China’s drug century where opium and heroin production come together. I argue that one cannot understand contemporary heroin use without also understanding China’s long involved history with opium. In this endeavor, I add a second method in the form of two short literature reviews on the history of opium and Chinese mental health care. As Sunlight fits in tightly at the intersection of these two histories, opium and mental health, I include this key literature review as a background to my ethnographic study.

Background: From opium to Mao to Sunlight

Turkish and Arabian traders introduced opium to China in the sixth century (Li, Ha, Zhang, & Liu 2010). As Dikötter, Laamann, and Zhou (2004) and Zhou Yongming (1999) note, China’s struggle to modernize was entwined with British colonialism which only managed to exacerbate the opium problem. It was in the period between 1839 and 1860 that two opium wars were fought against the British, who forced China to accept imported Indian opium in exchange for silver bullion that was used to purchase silk, tea, and porcelain. As the Qing government (late 1800s) rightly despised this unequal arrangement, it is not clear that health was their major concern. In fact, Chiang-Kai Shek, during the Republican Era (1911–1949), felt that managing consumption, rather than eliminating it was a worthy solution, in much the same way countries now recognize that cultivating marijuana is a way to increase tax revenue (Baumler, 2002). Several historians argue that opium was a rather minor health problem until China’s own lenient policies came up against the 20th-century discourses of addiction and abstinence (Dikötter et al., 2004; Newman, 1995). According to historians Zhu Qingbao and Liu Ting (2012), by 1900 there were approximately 15 million opium users. In forecasting the present, this is exactly the current figure offered by contemporary epidemiologists.

Mao did not inherit a large epidemic, as the Qing government and Chiang Kai-Shek had eradicated much of China’s opium use. By the late 1940s the remaining opium users were primarily peasants and older men (Dikötter et al., 2004). When Mao Zedong took power in 1949 one of his goals, along with land reform, was to rid China of both opium cultivation, as it took land away from food production, and those who used it. Thus, the eradication of addiction and the success of the state were parallel Maoist projects where his three-year campaign succeeds in technically eradicating opium through the moral and political work of his Communist government (Zhou, 1999: 93). This campaign involved razing former opium fields and forcing former users into detoxification programs run by Communist Party neighborhood committees. By 1953 the Communist Party announced that China was drug free.

As China shifted from presenting itself as an addiction-free country to embracing 20th-century discourses on the war on drugs and addiction, Mao used his strategy of reform through labor. Maoism relied on labor to reform the “bad” classes, landlords, intellectuals, and business owners, who were considered too bourgeois for a new revolutionary country that needed to learn from peasants. In 1967, Mao issued a directive to “Fight Selfishness and Denounce Revisionism” (dousi, pixiu斗私批修), advocating for the intensification of self-criticism sessions (zi wo piping,自我批评) (Lu, 2004, p. 127; see also Guo, Song, & Zhou, 2009). These sessions were community and village spectacles intended to punitively shame political dissenters, where the “right” classes (workers, peasants, and soldiers) were allowed to scream, throw things, and belittle those from the “wrong,” or unhealthy classes. There was little of embracing what social anthropologist Robert Rapoport (1960) called two of the basic tenets of a Therapeutic Community: democracy and catharsis.¹ Unlike Western Christian confessionals, Chinese confessionals were designed for the confessor to atone for the crimes of the political class to which they belonged. In this regard it was not entirely personal or individualistic. According to linguist Lu Xing (2004, p. 128), for Mao it was possible to be educated or bourgeois and also reform oneself, as long as one was willing to expose one’s inner thoughts and engage in self-criticism in a public political forum to overcome shame and immorality. The form of these kinds of confessionals resurfaced in the therapeutic sessions at Sunlight. One resident Xiao Dong said, “[We] heard that the original American Sunlight actually read Mao and adopted his methods in the USA.”

By the early 2000s policy discussions shifted from re-education through labor (REL) to community-based detoxification and rehabilitation (Smith, Bartlett, & Wang 2012). Another critical step in this direction occurred on June 1, 2008, when a new People’s Republic of China Drug Law (zhongguo renmin gongheguo dupin fa中国人民共和国毒品法) went into effect. It ostensibly erased the labor camps, renamed the detoxification centers as “compulsory isolated rehabilitation centers,” (qiangzhi jiedusuo强制戒毒所) and added both pharmaceutical-based treatments like methadone maintenance therapy (MMT) and more community-based ones like needle and syringe exchange programs (NSEP) (Yu, Liang, Zhao, & Zhou, 2010). These achievements did not immediately result in a fundamental change in the way that the Chinese state approached and treated drug addiction. Sarah Larney and Kate Dolan argue that “despite the impressive expansion of needle and syringe programs and methadone maintenance treatment, compulsory detoxification and treatment in detention centers remain a widespread response” (2010, p. 165). With the bureaucratic reorganization of drug detoxification and rehabilitation came the problem of mediating between the conflicting goals of the Ministry of Health, the Ministry of Public Security, and the Chinese Federal Drug Agency. These institutions could not quite agree on where the problem of addiction lies: is it a security question or a social health problem or a public health prevention question, or a combination of all three? Furthermore, in an effort to provide MMT and NSEP, with a nudge toward community therapy, drug-related jail sentences remain the same, as drug use is still punishable by laws that condone compulsory confinement and unpaid forced labor (Smith et al., 2012, p. 329). None of this, however, stopped Sunlight from trying to forge a new vision and philosophy for mental health treatment and rehabilitation.

Yunnan’s multiethnic history and its designated 26 official minority groups also play a role in the story of illegal drug consumption. Minorities are often singled out for spreading the use and abuse of illicit drugs in Yunnan. The Nuosu ethnic group (also known as the Yi) is widely believed to contribute to the trafficking of heroin into and out of Northern Yunnan and Myanmar (Liu, 2010) because they live on both sides of the border. However, in the last 15 years, health policy has shifted to include all illegal drug users, minority or otherwise, opening up new conversations about mental health care and treatment options (Bartlett, 2013; Sullivan & Wu, 2007).

Late-socialist mental health care and the psychology boom

Gao et al. (2010, p. 75) note that during the Communist Revolution in the late 1940s, “mental illness and other forms of deviance were cast as problems of misdirected political thinking to be addressed through re-education, rather than mental health care.” In this sense, Mao’s influence still reverberates in Chinese society because drug addiction is still widely understood as a social moral failing rather than an individual illness. Anthropologist Zhou Yongming (1999: 93), among others, argues that while opiate addiction allegedly disappeared for almost three decades between the mid-1950s and the mid-1980s, illegal drug use re-emerged when China opened its doors to global commerce. When opiate use re-emerged in the 1980s, public security was given a broad mandate to detain drug users in re-education through labor camps (REL) and compulsory drug detoxification centers (CDDC).

If we fast forward to post-reform and opening in 1979, we find a very complicated system of mental health care shared by ministries with conflicting mandates including the Ministry of Health (MOH), the Ministry of Civil Affairs, and the Ministry of Public Security that all maintain bureaucratic networks at the city, county, and national levels for the prevention and treatment of psychoses (see Blowers & Wang, 2014; Wu & Wang, 2016). Beginning in the early 1990s, the national government urged hospitals to make a profit, and most small-scale facilities either closed down or became smaller psychiatric for-profit hospitals (Huang, 2014). The decade saw some psychiatrists begin to question the concept of the large hospital as well as for-profit care, which limited the number of people who could access care and left many rural residents without any care at all.

By April 2002, the three ministries (Health, Civil Affairs, and Security) and the China Disabled Persons’ Federation signed the first Mental Health Plan (MHP, 2002–2010). This MHP continued China’s emphasis on psychoses but expanded treatment coverage to include, for the first time, conditions such as suicide, depression, dementia, and post-disaster conditions. Treatment also became available to at-risk populations such as women, children, and adolescents (Huang, 2014, p. 189).

By August 2004 the Ministries of Education, Justice, and Finance were added as resources in an increasingly thick soup of government oversight. Overall, the command for providing mental health care was now shared by six different ministries. Through these efforts, China did not meet the demand for mental health care and upwards of 92% of citizens with a diagnosed disorder never found psychiatric care; they were left to fend for themselves and their families (Huang, 2014). This was partially due to the fact that funding for mental health care was not determined by catchment area, but was primarily hospital-based. Urban dwellers were privileged with access to the best tertiary care facilities, leaving rural areas with almost nothing (Huang, 2014). When I speak of large urban centers, they are dense and vast by global standards—there are 21 million people living in Beijing, 23 million in Shanghai, and 29 million in Chongqing.²

By 2006, mental health care was the only non-communicable disease program included in the national public health program. In recent years, whenever MOH tried to expand and extend mental health care, they faced the challenge of trying to train more multi-skilled caseworkers. Even as they borrowed the best practices from allied health professions including nursing, social work, occupational therapy, and counseling psychology, this was a tall order. There were small successes. By the end of 2009, the 686-program expanded hospital-based care in major urban centers to cover over 97 million people in 122 cities (Liu et al., 2011, p. 213). China still faces challenges in providing mental health care that reaches across income disparities from the rich coastal cities to poorer interior provinces. Physicians and communities are encouraged to spend money on community-based care while the mainstay is still the psychiatric hospital.

With the push to create more community-based centers, came the added challenge of fewer and fewer medical students choosing psychiatry as a sub-specialty. One solution was to rebrand these hospitals as public health institutions and to rely more heavily on allied health professionals (Liu et al., 2011, p. 214). Privately trained counselors, lay hotline peer educators, and private therapists have become part of a booming industry (see Chen, 2015; Huang, 2014; Zhang, 2016). Beginning in the early 2000s mental health services significantly increased as the “opening to the West” movement in China “promoted the revitalization of Chinese psychiatry and its re-engagement with Western scientific communities” through what has been called the “psycho-boom” (xinlire 心里热) (see Huang, 2014; Zhang, 2016).³ I place Sunlight firmly in this mental health movement to engage Western psychiatry by offering an alternative to the labor camps and drug prisons.

The establishment of an alternative model

According to Chinese epidemiologists and drug specialists, there has been a 30-fold increase in registered injection drug use (IDUs) from 70,000 in the mid-1990s to 2.098 million by 2012 (Xiao, Yang, Zhou, & Hao, 2015) and 2.5 million by the end 2016 (Pan 2018). If we include unregistered drug users, the estimates are closer to 15 million (Liu, Liang, Zhao, & Zhou., 2010). According to official Yunnan provincial police reports, in 2012 alone, provincial police seized 5.37 metric tons of heroin, 73% of the nationwide total that had been smuggled over the Myanmar border (Li & Wei, 2014). Reformers note that the rise in illegal drug use has contributed to China’s burden of disease, forming co-morbidities with hepatitis C, hepatitis B, tuberculosis, and HIV/AIDS and thus drug consumption became a public health issue (Zhou et al., 2012).

In the late 1980s, with an eye toward reducing these co-morbidities through behavioral therapy, some Chinese psychiatrists began to imagine and plan alternatives through the reigning institutions for managing drug use: the drug prison and the labor camp. A 2005 study by the National Surveillance Center on Drug Abuse reported that 62% of prison detainees relapse within three days of release, with a further 20% relapsing within 30 days. Another study in Anhui province found that there was no relationship between post-release drug use and time in compulsory treatment (National Surveillance Center on Drug Abuse, 2005, as cited in Larney & Dolan, 2010).

Dr. Li Jianhua,⁴ one of the key founders of Sunlight, explains that setting up YIDA, as a drug research center in the wing of a mental health hospital, was a novelty:

The Communist government repeatedly told us that we are already liberated; we succeeded in our anti-drug campaigns. In fact, illegal drugs do not even exist. As early as the 1980s, people started using drugs again, opium and heroin from Myanmar. Then slowly by 1987–1988 the situation was magnified and the Ministry of Health, with some international aid, suggested we set up two rehabilitation centers. One center was in Ruili on the Burmese western border with Yunnan and another in Pu’er (the famous tea capital) in Simao County. After doing field research, we discovered about 3% of the population were using drugs, while in Simao, the figure was less at 1.01%. The more we read, reviewed, and learnt from foreign experience from 1986–1990 the more we realized that it was [a] very complicated and very difficult [problem].

No one at that time thought there was a need for psychological rehabilitation. Many people thought that we should lock drug users up, or send them to an isolated place to fix the problem. In 1993 in Yunnan, we had an executive meeting in which the provincial government agreed to invest 24 million CNY (136 million USD) to set up a research center. My mentor and I, with 7 other people, left Yunnan Mental Health Hospital to set up what is now YIDA. It was officially established in September 1993 and afterwards the International Narcotics Control Board visited us and suggested that we should go abroad to see how other countries managed. (Field notes and interview July 20, 2015 Li Jianhua)

In 1999, YIDA helped found Sunlight TC to establish an integrated intervention project to reduce drug abuse-related harm among users—in particular injectables—and to increase HIV/AIDS prevention awareness (Hyde, 2011b). After many years of bureaucratic setbacks, the local TC was established with funding from the Ministry of Health and the International Narcotics Control Board. In the early 1990s, Dr. Li Jianhua and his protégées decided that YIDA should work with the branch of Sunlight-International that was based in the USA, even though there were existing TC models in Asia. Sunlight-International was a drug rehabilitation organization that has consultative status with the Economic and Social Council of the United Nations (ESCUN) working in 66 countries including Indonesia, Malaysia, Thailand, Kazakhstan, Tajikistan, and Hong Kong. The Council envisions a drug-free world and aims to achieve it by providing training, technical assistance, and support for developing competency in self-help social-learning drug treatment models. The ESCUN also aimed to foster a global network of addiction treatment specialists. In the late 1990s, Sunlight-USA mentored Sunlight-Yunnan by bringing three or four Chinese Sunlight employees to its rural center for three months of training in the American TC model (see Hyde, 2011b).

Sunlight’s vision and philosophy

In adopting what is called confrontational therapy, where former users are carefully monitored and criticized for drug use, Sunlight-International came out of the many movements in drug therapy in the 1960s in the US and the UK (see Hyde, 2011a, 2011b; White & Miller, 2007). Since the early 2000s Sunlight-Yunnan has had a precarious relationship with the Ministries of Public Security and Health because of profound disagreements among officials, public health practitioners, and HIV/AIDS and drug activists on how to best manage Yunnan’s recreational drug users. YIDA launched Sunlight TC as one possible project to rethink existing frameworks for addiction that linked it to crime and deviance, to move towards a more compassionate understanding of addiction. The TC model relies on the field of behavioral psychology that generally explains human behavior in terms of intra-psychic processes. Sunlight’s Chinese outpost adheres to this model, applying strategies that derive both from US behavioral psychology and confrontational therapy, which mirrors some of ideological tenets of the neoliberal logics of care, and Chinese moral management to support a healthy socialist nation (see Hyde, 2011b). However, these two frameworks co-exist in uncomfortable tension in China; confrontational therapy’s local historical allies include the tactics used during the Cultural Revolution to attack and reform one’s enemies. I will discuss these tactics in detail later.

As Sunlight was the first TC in China whose treatments were based on therapy rather than incarceration, it attracted an eclectic group of participants who were Han Chinese, along with a small minority of Bai, Hui, Uighur, and Tibetan participants. These drug users came from incredibly diverse social and economic backgrounds. They were truck drivers, former college students, surgeons, businessmen, sex workers, athletes, unemployed youth, fathers and mothers, diamond sellers, bus drivers, women from a village with the highest rates of heroin use in Yunnan, lay counselors who were former users, psychiatrists, and traditional Chinese medical doctors. As residents at Sunlight Yunnan, they all converged on the rural outskirts of a small, unsightly industrial city (Hyde, 2011b). The gender make-up of the center varied but on average was 70% male and 30% female, with the majority of the residents in their 20 s, 30 s, and 40 s, although the youngest member was 18 and the oldest in their late 50 s. Most had cycled through punitive drug prisons and rehabilitation centers before reaching Sunlight. At any given time, there were between 20 and 80 residents at Sunlight.

Trained community outreach peer educators, former TC residents, conducted intervention activities: maintaining a drop-in center, targeted needles exchanges, condom social marketing, psychological counseling, relapse prevention education and a loose organization of Narcotics Anonymous meetings. Still, the foundation of Sunlight was their TC outside Kunming. The TC’s methodology involved having residents participate in a daily series of group therapy sessions, more like encounter groups, that had names like the lost opportunities group (mijihuixiaozu迷机会小组), the fixed group (gudingxiaozu固定小组), the recount your emotions group (jizhuganqingxiaozu记住感情小组), and the conflicts group (pengzhuanghui碰撞会)。

Participants mentioned a variety of reasons for choosing Sunlight. Xiao Tao, a young man in his late 20 s, recounts:

It was my family that sent me here because I relapsed at Kunming’s government run compulsory rehab facility. I had never heard of such a place but after one month I think it is a good place to be. Compulsory rehab only deals with the physiological recovery from drugs, and it is impossible to change your mentality in there. It’s the culture here that’s good, we have so many activities that keep your mind off of drugs. I want to start my own Sunlight when I return to Xinjiang. (June 2008)

Xiao Dong, a young man of 40, said:

I started taking drugs because it was fashionable, because it meant you had financial means as only rich people did drugs; it was a trend in Shanghai. I tried chemical rehab innumerable times – insulin coma therapy and methadone as well but never had psychiatric therapy. In 2006 my cousin found Sunlight online that explained they focused on the psychological reasons for using drugs. The so-called psychologists here have gotten clean here so they share their experiences with me and that enables me to persist through physiological detox and then gradually accept psychotherapy. (June 2008)

Xiao Li, a young man of 30, explains:

I was in and out of using drugs, and my mom took me on a tour around the country looking to see what kinds of methods or solutions were available. When I got to Chengdu, I saw that Chinese Central Television (CCTV) had a program on Sunlight and I thought this program could help me. I understood this as a sign… in your Western way you would say there was a supernatural plan for me, that god gave me a direction. Compulsory rehab was like compressing a spring, but here Sunlight allows you to find respect, responsibility, and honesty again. (June 2008)

Daily life at Sunlight

By 1999 Sunlight had a large office building in a poorer, less developed section of Kunming. With its combination of a Western model and Chinese staff, Sunlight aimed to advance a blend of both neoliberal logics of care with communal communist values and skills, which in several ways would help to transition drug users into Chinese market-socialist society. These included learning new ways to work in a peer group, new skills like cooking and electrical repair, and collaboratively working with a tightly-knit fictive kinship network in crowded dormitory rooms. The residents’ dorm rooms contained four double bunk beds, four small bedside tables, and four closets for hanging clothes and personal belongings and one large desk under the window. I spent many a day writing at that desk, engaging in intriguing conversations with my roommates about what I was writing, and fact-checking my notes on the spot.

Sunlight directs its residents to focus on three main goals: 1) self-mastery; 2) rebuilding the self; and 3) moving beyond individual suffering through peer group confrontational therapy. The first goal involves cultivating individual self-care mastery, specifically within the context of a tightly knit community. For example, every morning all residents must stand in front of their bunk beds and be subject to a bed inspection, as in the army (see Figure 1). If one’s bed was not made absolutely perfectly, one’s entire room was given a demerit on the inspection board in the form of a small paper black flag. Indeed, at Sunlight, psychological therapeutic notions of being well-cultured and being able to take care of oneself pepper discussions of treatment. The idea that the individual is significant is perpetuated as Sunlight’s methodologies are based on individualistic models of rehabilitation. The second goal is to rebuild the self in order to create a new persona, one that is socially dependent on the group but wholly accountable to only oneself. In one of the art therapy sessions I directed, I was surprised to note that individuals did not want to draw. Instead, they chose the best artist in each group of four and had them complete the exercise called drawing the road home. The third goal is to move beyond suffering by revealing one’s innermost fears and secrets to others, and to learn through group therapy and peers to express a full range of emotions including anger, sadness, and joy. There were opportunities to play: there were weekly soccer matches and my evening basketball games between residents and the local village teenagers. At the TC there was what I call a symbolic counter measuring semantic fairness, by which I mean that a drug user’s reluctance to voice their behavioral failures keeps them addicted, and verbalizing their emotions during group therapy allows them to heal (Hyde, 2017).

Figure 1.

Chart of a typical day.

Early morning group meetings at the TC provided a place to assign tasks for the day, recite the Sunlight motto, perform the news and weather, and offer direct criticisms. To perform was to engage in contact improvisation, to create an impromptu scene, or a stream of conscious criticism. When it was my turn, I performed the news as a Chinese rap song to absolute giggles of laughter. This was followed by a spontaneous round of criticism sessions. Here the octaves of peer-educator voices would rise into harsh screams as they began a series of criticism–self-criticism encounters where residents verbally reprimanded one another for “bad” behavior, not respecting their peers, not doing the dishes, smoking when not allowed, or, in my case, leaving my belongings outside my room. Staff and peers measure the quality of one’s behavior by the quality of one’s work from repairing the solar water heaters to cleaning the bathrooms and preparing three meals a day for the entire community including the farmers who tended the fruit orchard. At Sunlight there are four cardinal rules: no drugs, no stealing, no intimate contact with the opposite sex, and no physical violence toward yourself or others. Verbal critiques, however, are encouraged. These cardinal rules were strictly adhered to and punishment ensued if they were violated. Punishment involved facing a wall for hours and not participating in any activities, or being shouted at by the entire group until you broke down.

When I interviewed one of the international staff, he expressed concern about these punishments, insisting that they did not occur at this level of viciousness in other centers around the world. In contrast, the Chinese staff insisted the rules and punishments meted out in the US were much harsher than in China. For example, they observed the New York Center staff screaming at their TC residents as well. Xiao Dong said he heard that “Sunlight-New York’s founders actually drew from Mao’s Cultural Revolution methods, but the difference is that the Great Cultural Revolution meant to trample us to death, but here they mean to cure you” (June 2008).

These conflicting ideas stem from differing historical notions of what constitutes punishment. Throughout China’s long history with opium and now heroin, government attempts at eradicating both production and consumption relied on a variety of methods.

Discussion

The historical movements to eradicate opium and the rise of psychological treatments in China suggest that providing care for the mentally ill posed a challenge from the 19th century through to the present. Providing for a category of patients perceived as convicted criminals with loose morals actually conflicts with disease models of addiction, leaving few resources for long-term rehabilitation, let alone creative alternatives.

By taking into account the dual histories of opium and the recent psychology boom, we can see the complex tests facing Sunlight in their efforts to reform the way drug users are treated in contemporary Yunnan. Sunlight-Yunnan embraced global public health treatment modalities of harm reduction and residential care adopted by Sunlight-USA, but in the end, these modalities often failed to adequately address the needs of a generation of Chinese youth who have the story of China’s economic successes written, almost carved, on their bodies. Youth who came of age during late Communism, when economic reforms were underway, had to learn completely new systems of behaving, living, and functioning. Most residents at Sunlight are economic and environmental casualties if we consider the difficulty of functioning at the hyper-speed of rural and urban development without a means of escape. Recreational drug use comprised what one psychiatrist labeled a way of “deadening their feelings, to numb themselves.” It appears that the lighter policies of the Qing government and Chiang Kai-shek fell on deaf ears. According to director Dr. Yang Maobin, Chinese youth chose recreational drugs as a way to cope in ways very similar to those used by youth in the West. According to manager Dou, the reasons for using drugs “comes down to peer influence, curiosity, seeking excitement, and chasing the fashion of the time.”

The American TC model worked in China because it reframed drug use as a personal, individual problem that required close work on the self in a group setting, as opposed to being a symptom of working conditions (Hyde, 2017). As previously discussed, there is ample evidence that widespread drug consumption is a consequence of rapid-scale development that resulted in easy access to refined heroin and other drugs like amphetamines. It is the result of both economic change and personal behavioral adjustment to those changes including the rise in an underground market in heroin and its accompanying individual recreational drug use. Several residents also noted that in the early 1990s, heroin was not that strong and did not cause much damage. But similar to the West, because heroin is now cut with new additives, it has wider health effects and is more damaging. While there are those who argue for the full-scale legalization of all drugs, the staff at Sunlight, like their parent organization, advocated abstinence based on the belief that one could not cope with life and drug use in the same space.

Sunlight directors embraced the American TC model and then expanded the model to be all things to all people, offering needle exchanges (NEP), short-term detoxification combined with methadone maintenance therapy (MMT), and a myriad of outreach activities including educational sessions with the local police. Without a steady stream of funding, the organization often felt a bit discombobulated as it focused on many activities at once. In 2011, Dr. Yang, the director of Sunlight, was imprisoned for adopting a herbal formula for treating heroin withdrawal. He was charged with marketing a fake medicine with a fake license, but in my interviews with staff, they conceded that the entire TC enterprise had become problematic. Dr. Yang’s imprisonment coincided with a large government-wide crackdown on corruption and many staff felt Dr. Yang got caught in the crossfire. The very same Dr. Yang, prior to his arrest, was to be promoted to the Vice Directorship of the Rehabilitation wing of YIDA. After his arrest he was stripped of his party membership and his job at YIDA. As a consequence, Sunlight lost its government funding and much guidance, although many loyal staff remain. By 2014, Sunlight became a local Chinese NGO without ties to YIDA or foreign-sponsored NGOs. However, it remains unclear if corruption occurred or whether the director was a scapegoat. Furthermore Dr. Li Jianhua pointed out that drug treatment could never be just one mental health organization’s problem.

Dr. Li said:

There is lots of research that shows that drug abuse is a chronic mental/psychological problem. If it is a chronic problem, then we should consider managing it as one, meaning that not only the TC has to do it, the community service center, and others should take part too. It is not just an issue of curing a disease, but also an establishment of and advocacy for a healthy way of life. Of course it also requires that the general public change their point of view. The most important thing is to manage it so that these people can function normally, to live in this society normally. But this is an ideal/utopian state.

From a policy point of view, for China, the focus is on supply reduction. We do not do well in demand reduction, or we do not do much work on it. Why? Propaganda and education are not targeted to specific groups, rather it’s too general. And it uses a threatening strategy, which does not work for the younger generation. The priority goes to reduce the supply, and demand reduction, prevention, treatment, and rehabilitation are placed second.

As drugs are not an individual case for a country, it is a global problem. We are a global village now we share this problem. Many new drugs will come out, and they will change their forms, and that is what we will face in the future.

As Dr. Li notes, the current drug wave is not new, given the long history of the opium and Mao’s 1950s eradication efforts. Nor it is an isolated homegrown industry—it was always global. While some globalization theorists define global health as a new phenomenon, China is the perfect case to show that in spite of the first couple of decades of the Communist Republic, China’s global influence reaches back to the 11th century (Hobson, 2004). While China’s reform and opening in the early 1980s definitely provided new pathways and methods for accessing and consuming heroin, opium is part of its drug century. Instead of having Indian opium forced on them under the Treaty of Nanjing in 1839, nowadays Southeast and Northwest Asian poppy growing countries play a big role in the illegal global production of heroin that moves through dense jungle in the Southwest and desolate desert in the Northwest.

Another test facing Sunlight is the abstinence and elimination policies in public security, evangelical Christian churches, some medical doctors, and the general public who view illegal drug users as morally deficient; not citizens who are ill or who have the right to consume drugs. As Dr. Li points out, the provincial government’s primary policy was to reduce the supply chain through drug raids, political treaties and its large security apparatus. Few resources are allocated for prevention, treatment, and rehabilitation; thus, Sunlight has a hard time staying afloat. Well-being is a mantra spread far and wide in Euro-America through the rise in integrative and functional medicine, and while China embraces Traditional Chinese Medicine (TCM), it has not integrated TCM into allopathic care. In many ways notions of care at Sunlight embraced ideas of collective well-being and fostering individual self-interest but still did not include any TCM treatments. Allopathic medicine for addiction does not leave much room for prevention in a project like Sunlight.

From the late Qing through the Republican era to the present, there have been drawn out battles over opium, struggles that created deep grooves in how the state responded to the revival of a plant that brought so much shame on China in the 19th century. Alongside this history of shame, as Rojas (2016) notes, there is a Maoist spirit of resistance: although he framed addiction as a moral failing, Mao also forged amazing programs like his Barefoot doctors in order to provide basic rural health care. Sunlight is also part of that legacy. Its visionaries and psychiatrists created another way to treat addiction as psychologically informed compassion and strict healers rather than just “locking them up” as Dr. Li said.

Drug rehabilitation is a solution searching for an explanation of a problem; one of my Public Health professors used to say: “we know the solution, but what exactly is the problem?” Anthropologist Michael Jackson (2011) calls this the “problems and solutions dilemma” in development, meaning narratives that define success using rapid assessment tools in turn lead to narrow results. Drug addiction is a very complicated, intensely heated health and social development issue that does not lend itself to quick-fix assessments or facile solutions.

Thinking again of Rojas, China’s development in the form of Sunlight TC did not result only from historical imperatives or economic and political strategies, but from the effects of discrete everyday practices that reflect an overlap of socialist and capitalist policies and Maoist resistance. For example, the central government was late to support methadone maintenance treatment (MMT) as they began their pilot program in 2004. However, there were many contravening discrete protocols that preceded the program in 2004 whereby Sunlight experimented with methadone before it was officially sanctioned. Everyday practices varied at the county level where not all drug prevention specialists envisioned overturning drug detoxification through incarceration. Many Yunnanese were astonished I would support psychological rehab over compulsory prison as they often viewed drug users as immoral. Moreover, the policy-shift from REL toward more robust community-based drug detoxification and rehabilitation centers (shequ jiedu kangfu suo 社区戒毒康复所) as interventions was not official policy until 2008 (Smith et al., 2012). Notably, prior to this legal policy shift, the provincial YIDA explored alternatives to reduce the impact of drug abuse and improve health. YIDA embraced best practices like harm reduction, giving users the time and space to slowly come off heroin through daily methadone maintenance therapy. In the larger community, they offered some needle exchanges at community centers along with abstinence training reframing addiction as an illness, not a crime. In this search for alternatives, YIDA, in conjunction with funding from the International Narcotics Board and Sunlight-International nurtured Sunlight-Yunnan.

Conclusion

There are winners and losers in China’s rapid scaling up of urbanization and globalization. There are those who have amassed huge amounts of wealth through business connections and property acquisitions, and then those who have lost ground in the post-socialist period. China is on par with South Africa as they have one of the highest Gini coefficients, a measure of inequality in the world today (The Economist, 2016). As with opium consumption in the early 20th century, contemporary heroin functions not just as a drug of escape, it also fuels social networks and business socializing, with individuals using drugs to secure connections and business acquisitions. As Xiao Dong said, “I started using drugs to grease the wheels of Shanghai business deals.” The diverse uses of heroin reflect and further perpetuate economic stratification induced by urbanization and globalization. The residents at Sunlight who bypassed government-run drug prisons were often those with status and wealth.

Similar to earlier projects to stave off opium consumption, the TC rehabilitation model was neither completely successful, nor a complete failure. Its pattern reminds me of a saying from the Talmud: “You are not expected to complete the task, but neither are you expected to put it down.” This idea of neither succeeding nor failing mirrors the TC’s rise and fall as it is a leitmotif that runs through China’s entire 20th century. Many residents and staff felt that the TC’s problems merely reflected China’s two competing models of treatment: the punitive model and the rehabilitation model, or the prison versus the community-based models of rehabilitation. I thus circle back to the epigraph that opens this article; the water that carries the boat can also overturn it. Drug rehabilitation in China is always on the verge of capsizing due to the immense pressures of finding a balance between the punitive and rehabilitative modalities of care; the national and local politics of treatment; and competing answers to the question of how to foster creative alternatives.

Footnotes

Acknowledgments

This article grew out of the May 2016 Advanced Study Institute in Cultural Psychiatry: Psychiatry for a Small Planet organized by the Division of Social and Transcultural Psychiatry at McGill Medical School. I sincerely thank Dr. Laurence Kirmayer for his invitation to participate in both the conference and the workshop, and for his patience in turning my presentation into a publishable article. I also graciously thank three groups of colleagues that were instrumental in helping me finish this piece: the participants of the ASI, and especially the commentary by Dr. Kirmayer and Dr. Jazwant Gudzer; the members of Prof. Danielle Groleau’s works-in-progress seminar in Transcultural Psychiatry, in particular her graduate students; and the participants of the June 2017 Residency at the Rockefeller Foundation Bellagio Center. At the end of the day, I thank the three anonymous reviewers from the journal for their hard editorial work in bringing my article to press. My final gratitude goes to my copy-editors, June Brady, to whom I dedicate this article as she unexpectedly passed away before seeing it in print, and to Jessica Mach.

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) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: Social Science and Humanities Research Council of Canada Grant # 410-2009-129160.

Ethical approval

McGill Research Ethics Board project # 390-0409.

Notes

Sandra Teresa Hyde, MPH Public Health, PhD Medical Anthropology, is an Associate Professor of Medical Anthropology and Social Studies of Medicine at McGill University in Montréal. She is writing a book, The Malleable Addict, on addiction treatment in China's first therapeutic community for drug users in Southwest China. She has published on the cultural politics of HIV/AIDS, sex workers, and ethnic minorities in Sipsongbanna, an autonomous region and a former suzerain state of Thailand, that draws on long-term fieldwork in China. She is concurrently working on an oral history project on what she calls living stories from one of the first major cohorts of female physicians at Cambridge University in England called Engendering Biomedicine.

References

Bartlett, N. (2013). Down from the mountains, out of time: Addiction reform and China’s heroin generation (PhD dissertation). Department of Anthropology, History and Social Medicine, University of California UCSF/UCB.

Bartlett

Garriott

Raikhel

(2014) “What’s in the treatment gap?”: Ethnographic perspectives on addiction and global mental health from China, Russia and the United States. Medical Anthropology: Cross-Cultural Studies in Health and Illness 33(6): 457–477.

Baumler

(2002) Modern China and opium: A reader, Ann Arbor: University of Michigan Press.

Blowers

Wang

S.XL.

(2014) “Gone with the west wind”: The emergence and disappearance of psychotherapeutic culture in China (1936–1968). In: Chiang

(ed.) Psychiatry and Chinese history, London, UK: Pickering and Chatto, pp. 143–160.

Carr

E. S.

(2010) Scripting addiction: The politics of therapeutic talk and American sobriety, Princeton, NJ: Princeton University Press.

Chen, W. (2015). Invoking personhood in contemporary China: Seeing through the lens of a Beijing family therapy center (PhD dissertation). Department of Anthropology, New York University, NY.

Dikötter

(2002) [Review of the books Opium, state and society: China’s narco-economy and the Guomindang, 1924–1937, by E. R. Slack. Opium regimes: China, Britain, and Japan, 1839–1952, edited by T. Brook and B. Wakayashi. Modern China and opium: A reader, edited by A. Baumler]. The China Quarterly 171: 741–744.

Dikötter

Laamann

Zhou

(2004) Narcotic culture: A history of drugs in China, Chicago, IL: University of Chicago Press.

Gao

Jackson

Chen

Liu

Wang

Qian

Huang

(2010) There is a long way to go: A nationwide survey of professional training for mental health practitioners in China. Health Policy 95(1): 74–81.

10.

Garcia

(2015) Serenity: Violence, inequality, and recovery on the edge of Mexico City. Medical Anthropology Quarterly 29(4): 455–472.

11.

Guo

Song

Zhou

(2009) A to Z of the Chinese Cultural Revolution, New York, NY: Scarecrow Press.

12.

Hobson

(2004) The Eastern origins of Western civilization, Cambridge, UK: Cambridge University Press.

13.

Hyde

(2007) Eating spring rice: The cultural politics of AIDS in Southwest China, Berkeley, CA: University of California Press.

14.

Hyde

(2011a) “Screams, cries and whispers”: Traveling heroin therapeutics and humanitarian aid in post-socialist China. In: Redfield

Bornstein

(eds) Forces of compassion: Humanitarianism between ethics and politics, Santa Fe, NM: SAR Press, pp. 153–174.

15.

Hyde

(2011b) Migrations in humanistic therapy: Turning drug addicts into patients and patients into healthy citizens in Southwest China. Body & Society 17(2–3): 183–204.

16.

Hyde

(2017) Spending my own money, harming my own body: Addiction care in the Chinese therapeutic community. Medical Anthropology: Cross-Cultural Studies in Health and Illness 36(1): 61–76.

17.

Huang

H. Y.

(2014) The history of the psycho-boom in contemporary urban China. In: Chiang

(ed.) Psychiatry and Chinese history, London, UK: Pickering and Chatto, pp. 183–205.

18.

Jackson

(2011) Life within limits, Durham, NC: Duke University Press.

19.

Larney

Dolan

(2010) Compulsory detoxification is a major challenge to harm reduction in China. International Journal of Drug Policy 21(3): 165–166.

20.

J. H.

T. H.

Zhang

C. M.

Liu

H. J.

(2010) The Chinese government’s response to drug use and HIV/AIDS: A review of policies and programs. Harm Reduction Journal 7(4): 1–6.

21.

Y. Q.

Wei

(2014, December 11) 41 Party members expelled in Yunnan. China Daily.

22.

Liu

Y. L.

Xie

Y. F.

Tang

H. Y.

(2011) Mental health system in China: History, recent service reform and future challenges. World Psychiatry 10(3): 210–216.

23.

Liu

(2010) Passage to manhood: Youth migration, heroin and AIDS in Southwest China, Palo Alto, CA: Stanford University Press.

24.

Liu

Liang

Zhao

Zhou

(2010) Looking for a solution for drug addiction in China: Exploring the challenges and opportunities in the way of China’s new drug law. International Journal of Drug Policy 21: 149–154.

25.

(2004) Rhetoric of the Chinese Cultural Revolution, Columbia: University of South Carolina Press.

26.

Newman

(1995) Opium smoking in late imperial China: A reconsideration. Modern Asian Studies 29(4): 765–794.

27.

O’Neill

K. L.

(2013) Beyond broken: Affective spaces in the study of American religion. Journal of the American Academy of Religion 8(4): 1093–1116.

28.

Pan, S.M. (2018) The Truth About China's Unknown Millions of Drug Users, Sixth Tone – Fresh voices from today's China, January 23.

29.

Race

(2009) Pleasure consuming medicine: The queer politics of drugs, Durham, NC: Duke University Press.

30.

Raikhel

Garriott

(2013) Addiction trajectories, Durham, NC: Duke University Press.

31.

Rapoport, R.N. (1960) Community as Doctor, Springfield, IL: Charles C. Thomas Publishers.

32.

Rojas

(2016) Introduction. In: Rojas

Litzinger

R. A.

(eds) Ghost protocol: Development and displacement in Global China, Durham, NC: Duke University Press, pp. 1–14.

33.

Smith

Bartlett

Wang

(2012) A harm reduction paradox: Comparing China’s policies on needle and syringe exchange and Methadone maintenance. International Journal of Drug Policy 22(4): 327–332.

34.

Sullivan

S. G.

(2007) Rapid scale up of harm reduction in China. International Journal of Drug Policy 18: 118–128.

35.

The Economist (2016, May 14). Up on the farm. Retrieved from http://www.economist.com/news/finance-and-economics/21698674-rising-rural-incomes-are-making-china-more-equal-up-farm.

36.

White

Miller

(2007) The use of confrontation in addiction treatment: History, science and a time for change. Counselor 8(4): 12–20.

37.

Whiteley

(2004) The evolution of the therapeutic community. Psychiatric Quarterly 75(3): 233–247.

38.

H. Y. H.

Wang

W. H.

(2016) Making and mapping psy sciences in East and Southeast Asia. East Asian Science, Technology and Society 10(2): 109–120.

39.

Xiao

Yang

Zhou

Hao

(2015) Transition of China’s drug policy: Problems in practice. Addiction 110: 193–194.

40.

Liang

Zhao

Zhou

(2010) Looking for a solution for drug addiction in China: Exploring the challenges and opportunities in the way of China’s new Drug Control Law. International Journal of Drug Policy 21: 149–154.

41.

Zhang

(2016) The rise of therapeutic governing in China. Medical Anthropology: Cross-Cultural Studies in Health and Illness 35(2): 119–131.

42.

Zhou

Y. M.

(1999) Anti-drug crusades in twentieth-century China: Nationalism, history and state building, New York, NY: Rowan & Littlefield.

43.

Zhou

Y. H.

Yao

Z. H.

Liu

F. L.

Jiang

Zhu

J. W.

Zheng

Y. T.

(2012) High prevalence of HIV, HCV, HBV and co-infection and associated risk factors among injecting drug users in Yunnan Province, China. PLoS-One 7(8): e42937.

44.

Zhu, Q., & Liu, T. (2012). 鸦片战争后：瘾君子众生相 [Yapian Zhanzheng Hou: Yinjunzi Zhongsheng Xiang; Post Opium War: Lives of opium addicts]. Retrieved from http://doc.qkzz.net/article/e6eb0004-1d06-4ee4-b107-9fbca4af5013.htm.