It’s a family affair: Confucian familist philosophy’s potential to improve mental health care for ethnic Chinese in Aotearoa New Zealand

The idea of familism, which “emphasises strong interpersonal relationships within the extended family, together with interdependence, collaboration, and the placing of [family] group interests ahead of individual interests,”¹ is by no means new to Aotearoa New Zealand. It is well-known that many ethnic groups traditionally value familism, including Māori, as well as many Pacific, Asian, African, Latin American, and European cultures. Even in Anglo-American cultures, which are generally considered to be highly individualistic, families still have a large socio-cultural role. Despite this, the implementation of family-centred care in Aotearoa New Zealand can be challenging due to a largely individualistic orientation in healthcare ethics. In this viewpoint article, we examine the impact of individualism versus family-centred care on accessing mental health services in Aotearoa New Zealand, particularly focusing upon ethnic Chinese. We then propose a potential, culturally appropriate solution, based on Confucian philosophy, for integrating family-centred care while still respecting individual autonomy.

Ethnic Chinese are Aotearoa New Zealand’s third-largest ethnic group as of the 2018 census, numbering 247,770 nationwide.² The importance of familism in traditional and contemporary Chinese culture, similar to many other East and South-East Asian cultures, including Korean, Japanese and Vietnamese cultures, derives from the influence of Confucianism. Over 2,000 years old, the Da Xue (“The Great Learning”), one of the “Four Books” which make up the core Confucian canon, states that maintaining qi (“regulation”/“order”) within families is the culmination of personal development, as well as the foundation for broader societal benefits at local, regional, and national governance levels:

Their families being regulated, their states were rightly governed. Their states being rightly governed, the whole kingdom was made tranquil and happy.

Da Xue, The Text of Confucius, 5³

Familial harmony, and minimising intra-familial conflict, also holds significant value in the Confucian worldview:

Meng Yi asked what filial piety was. The Master said: “It is not being disobedient.”

Analects II, 5³

The Confucian ideal of familial harmony is built on a foundation of relational ethics. Familial harmony is not unilaterally imposed and enforced by an authority figure but relies on every member mutually fulfilling their distinct roles and responsibilities. For example, while children are expected to show obedience and xiao (“filial piety”) to their parents, parents also have a duty to show ci (“kindness” or “benevolence”) towards their children.

As a son, he rested in filial piety. As a father, he rested in kindness.

Da Xue, The Text of Confucius, 9³

Parallels may be drawn between the importance of family in Chinese culture and in Māori culture, which similarly emphasises the relational interdependence of individuals, particularly within hapū (extended family) units, and the importance of reciprocal rights and obligations in maintaining these relationships. In 2018, a survey of 1,400 Māori aged 15 and above⁴ found that Māori perceived multiple similarities between aspects of Māori and Asian cultures. The strongest cultural connections were identified in their respective views of whānau and elders within that family unit (kaumātua), kinship connections (whanaungatanga) and hospitality towards guests (manaakitanga).

The influence of Māori culture has led to the inclusion of some familist elements within Aotearoa New Zealand’s health system. The importance of family involvement, for example, has become well-recognised in health policy, with a need to further emphasise this repeatedly highlighted in successive health system reviews.^5,6 In the Government’s most recent health reforms, introduced in 2021, whānau involvement has continued to be emphasised. In Te Pae Tata, the Interim New Zealand Health Plan, “valuing the voices of consumers and whānau” is listed as a key priority, with the two nationwide health service providers (Te Whatu Ora – Health New Zealand and Te Aka Whai Ora – Māori Health Authority) instructed to “implement people and whānau-centred [service] design.”⁷

However, since the 1980s, Aotearoa New Zealand’s health system has been largely individualistic in policy and practice. This transition, from a formerly paternalist system, began with a series of health reforms emerging from the 1988 Cartwright Inquiry into the National Women’s Hospital ethical scandal.⁸ These were modelled on similar reforms in the UK and USA, which in turn were influenced by other ethical scandals, as well as the emergent consumer-rights movement and, more broadly, a Western political paradigm shift towards neoliberalism.⁹ In several respects, however, Aotearoa New Zealand’s reforms actually went further than in other parts of the world. For instance, the Code of Health and Disability Services Consumers’ Rights was introduced in 1992, which, similarly to the UK’s Patient’s Charter, established standards which service users should expect from their health providers. However, unlike in the UK, these standards were also codified into legislation under the Health and Disability Commissioner Act 1994 and were made legally enforceable by an independent Commissioner.^10,11

These changes altered the nature of the practitioner–patient relationship. Whereas under the previous paternalistic system users were seen as passive recipients of care, they were now described as “service users” in a marketplace: autonomous, self-sufficient individuals acting as active, independent participants in decisions regarding their therapy. A strong emphasis on patients’ autonomous decision-making and informed choice was thus enshrined as the foundation for medical ethics and medico-legal principles in Aotearoa New Zealand’s modern health system.

From this neoliberalist shift in health policy, however, emerged a potential tendency towards over-individualism. Family involvement remains inconsistent, with a 2018 inquiry into Aotearoa New Zealand’s mental health system finding family members still experienced “marginalisation and frustration … [and] frequent exclusion from communication … despite their day-to-day role in providing support.”^6,12

Thus, a tension exists between the acknowledgement of family-centred care as an aspirational concept at policy levels, and the individualism that dominates everyday practice. This has been shown to have negative effects on Māori healthcare experiences and outcomes^13–15. However, little is known about how this affects ethnic Chinese, who, as mentioned above, have similarly strong cultural links to familism.

In 2021 our research team conducted a series of interviews with providers of mental health services for ethnic Chinese in Aotearoa New Zealand: this was previously published in the New Zealand Medical Journal.¹⁶ This viewpoint article presents previously unpublished data from these healthcare providers, as well as seven ethnic Chinese former mental health service users and one patient caregiver, who were subsequently interviewed.

Ethical approval for the healthcare providers’ interviews was provided by the University of Otago  Human Research Ethics Committee in January 2021 (reference number D21/012), while ethical approval for the interviews with former mental health service users and the patient caregiver was provided by the same committee in May 2021 (reference number H21/052). Consultation with Te Komiti Rakahau ki Kāi Tahu (the Ngāi Tahu Research Consultation Committee) was also undertaken.

These interviews found that Aotearoa New Zealand’s individual-focused system is often a barrier for ethnic Chinese seeking mental health care. While protective of patient autonomy, this individualism can foster a negative perception of mental health therapy as divisive and ineffective. This could contribute to a general reluctance to access mental health services, which could in turn delay seeking help and leading to poorer outcomes.

As the following anonymised quotations from participants show, the continued dominance of individualism in practice occurs for a variety of reasons. Strong legislative protections of patient autonomy, for example, can make practitioners cautious regarding any actions which could be construed as threats to this, including encouraging family involvement in care:

Without patients’ consent, they are not supposed to tell the family about what’s happening ... sometimes, the clinician, maybe they follow the rule very strict.

Sam, nurse practitioner

As a result, there is a perceived reluctance for practitioners to proactively encourage family involvement:

They [the health care workers] would feel like you were interfering … always use privacy to block you … They did not want [family members] to care so much.

Colin, patient caregiver

Previous studies have shown that mental health stigma, particularly shame derived from perceptions of “insanity,” is still relatively common among ethnic Chinese.^17–19 Interviewees largely corroborated this, indicating that the traditionally family-centred nature of Chinese culture can intensify the impact of this shame:

If I am labelled as a psychiatric patient, I’m actually shaming my family. It’s not just me, this label does not just affect me, it affects my family.

Roman, nurse

Particularly among younger patients, this stigma was linked to a reluctance to involve their family in their mental health care, potentially depriving them of an important support network:

I wouldn’t be talking about a lot of things if my parents were in the room. Not even things like mental health, just things like sexuality, gender identity, sex in general.

Fiona, patient

Some new migrants, additionally, had particular fears around the perceived negative ramifications of a mental health diagnosis, especially on their own, or their families’, residency and employment prospects:

They think that doctors are connected to Immigration [New Zealand] … if they diagnose me as depressed or schizophrenia, it’s like, you know, having the red mark … finding job and studying might be more difficult.

Cass, NGO social worker

Others found this individualism counterproductive. For example, a lack of involvement can leave family members feeling isolated from the care process, leading to misconceptions of mental health therapy as merely being a place to “talk badly about” other family members. This perceived threat to family harmony can lead to familial discouragement of help-seeking:

The family members may not necessarily want to drop them off to see the doctor if their main concern is a mental health issue. They feel that maybe the [patient] will talk badly about them…

George, general practitioner

Practitioners told us there is already a preconception among the ethnic Chinese community that mental health therapies, especially talk therapies, are ineffective, superficial, and not sufficiently focused on practical solutions:

I’ve heard it a couple of times from people, saying, ‘how is it going to help if I tell you my problems? … You can do nothing about it!’

Leon, acupuncturist and herbalist

An individual-focused mental health system risks validating that preconception, because individual acceptance of treatments, and maintaining adherence to them, can be difficult to sustain without family engagement:

A lot of Asian, I think, the patient might not be the decision-maker. You have to make sure that you engage with a family member who can make the decision to move forward. Otherwise, you just can’t get things [to] move.

Jenny, NGO manager

Relative to other ethnic groups, ethnic Chinese already under-utilise mental health services in Aotearoa New Zealand.^16,20 These negative perceptions of the mental health care system can exacerbate existing systemic barriers to access. There is currently a general reluctance to seek help, often until a late-stage “breaking point” at which activities of daily living have become adversely affected. This puts significant strain on secondary mental health services, leading to poorer outcomes:

[Ethnic Chinese seek help at the] last moment … So what they are dealing is very significant, serious cases. So mainstream always say, ‘Why Asian cases are always dramatic?’

Sandy, hospital mental health services manager

Our research is revealing that the importance of family to ethnic Chinese patients, in both its positive and negative aspects, is not sufficiently acknowledged and incorporated into Aotearoa New Zealand ’s mental health system. This can lead to poorer engagement and outcomes with mental health services. The cultural importance of family involvement, however, must also be balanced with the ethical and legal importance of protecting individual patient autonomy. Adopting a moderate Confucian familist approach to mental health care could provide an effective balance of these two competing interests.

The most important aspect of this moderate Confucian familist approach would support that, wherever possible, family members should be kept informed of, and participate in, individuals’ mental health care. Rather than seeing individuals in isolation, their place as one member of a wider family unit, with its own dynamics, hierarchies, and obligations, needs to be meaningfully acknowledged:

Humanity is [the distinguishing characteristic of] man, and the greatest application of it is in being affectionate towards relatives.

The Doctrine of the Mean, 20²¹

This moderate approach clearly requires individual consent for any family involvement to occur, in contrast to the strong Confucian familist model (as seen in some East Asian countries, notably China), which allows family members to override individual autonomy. From an ethical and practical perspective, strong familist systems are untenable, as they are predicated upon a well-functioning family whose members will always seek to act in the best interests of other family members.^22,23 As participants in our study have pointed out, this will not always be the case. Thus, individuals must still maintain the right to autonomously seek or refuse help and the right to reject the involvement of their family, even if their family does not agree.

Moderate Confucian familism supports that where a well-functioning, harmonious family does exist, its ability to positively contribute to individual health and wellbeing, and its importance, in turn, to broader society should be recognised and upheld:

When the family is so maintained with rectitude, the entire world will be settled and be at peace.

Yi Jing, Hexagram 37, Commentary on the Judgements²¹

“Rectitude” is translated from the Mandarin zheng, literally “rightness,” which describes “adherence to principle, decent behaviour and handling matters with fairness.”²⁴ It is a term which is intricately connected in Confucianism with the concept of governance (a different character, also transliterated as zheng), with leaders or authority figures expected to play a central role in maintaining this rectitude. Thus, the concept of reciprocity, and mutual, combined responsibility for the upholding of family harmony, is emphasised.

For example, in the context of seeking mental health care, maintaining zheng could mean familial authority figures such as parents or grandparents adhering to the principle of familial harmony by encouraging mental health help-seeking, showing decent behaviour by expressing concern over the mental wellbeing of family members, and exhibiting fairness by not getting involved in family members’ mental health care if it will be detrimental to their recovery. As a result, a system built on Confucian values, which promotes family involvement, can still be protective of individual autonomy and opposed to absolute paternalism.

In Aotearoa New Zealand, Whānau Ora provides a potential exemplar for a culturally grounded, family-centred approach to mental health care which could both be feasibly implemented in an individual-focused mental health system and deliver positive outcomes to individuals and families who may otherwise be disengaged from health services. In contrast to the standard individualistic approach, where each provider oversees a specific part of an individual’s health, Whānau Ora is instead designed around meeting families’ needs and aspirations, with practitioners coordinating different providers to meet that goal. Encouraging and strengthening family and cultural relationships is a key aspect of Whānau Ora, with practitioners ultimately aiming to encourage familial self-determination and improve longer-term outcomes.^25,26

Being a marked departure from Aotearoa New Zealand’s individualistic standard practice, Whānau Ora has undergone significant scrutiny since its launch in 2010, with stringent reporting requirements on the part of its commissioning agencies, as well as multiple reviews and evaluations.^26–28 These have returned positive findings, including improved patient and family outcomes, and increased health system engagement among a population with relatively low utilisation of, and trust in, government services. Similarly positive impacts on family engagement and outcomes have been observed across both Māori and Pacific populations using Whānau Ora services, with the flexibility of the Whānau Ora approach (being focused on positive outcomes for whānau, rather than the provision of specific services), the anchoring of such an approach in Māori and Pacific cultural values, and the closer connection that providers are seen to have with their local communities and whānau being highlighted as particular strengths that encourage user engagement among both Māori and Pacific populations.²⁶

There have been suggestions that, with the above-described parallels in cultural views of whānau, community and collectivism, adopting a more holistic (Kaupapa Māori) approach to mental health care could also be beneficial to Aotearoa New Zealand’s Asian populations.²⁹ Utilising a moderate interpretation of Confucian philosophy could enhance the acceptability of such an approach further, due to the significant influence that Confucian ideas have had on many East and South-East Asian cultures. These potential parallels could allow our moderate interpretation of Confucian philosophy to be integrated into the positive outcomes emerging from Whānau Ora, further supporting a framework that upholds both individual choice and family involvement.

While such integration presents some promise, there are also possible legal obstacles to this approach. Much of the impetus for the Government’s actions regarding Māori health, including Whānau Ora, come from its specific, bilateral legal obligations to Māori, especially the legal obligations of Te Tiriti o Waitangi codified into the legislation underpinning Aotearoa New Zealand’s public health system (currently the Pae Ora [Healthy Futures] Act 2022).³⁰ This means that specific interventions to promote Māori health equity are codified as legally binding core principles of Aotearoa New Zealand’s health sector, including engagement with Māori to improve Māori health outcomes, inclusion of Māori in decision-making processes, and adequate resourcing of Kaupapa Māori and whānau-centred services. Such specific legal obligations do not exist in the case of ethnic Chinese.

The Government’s legal obligations to Māori are understandably unique, based on their status as tangata whenua partners with the Crown. However, we believe that providing similar legal underpinnings for more specific, culturally sensitive involvement of families of other ethnic groups will be essential to equitably provide mental health services which are responsive to the needs of all patients and families, whether Chinese or other ethnicities. The persistent preoccupation and prioritisation of individualism embedded in the current system is causing active harms, in ways which were surely unintended when these reforms were first introduced. The moderate Confucian model we are proposing suggests a middle way, navigating between the extremes of paternalism and isolated individualism to maximise the benefits, and reduce the harms, from each. Understanding and systematically incorporating the role of the family in the ways moderate Confucian philosophy suggests may help reduce these harms, for all our benefit.

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