Keywords

History of the Chinese in Malaysia

Malaysia has a multi-ethnic naturalized population of about 28.4 million that is made up of three major ethnic groups, Malays (68.6%), people of Chinese descent (23.4%), and the Indian ethnic group (7.0%). The remaining 1.0% consists of the aboriginal people and people of mixed ethnicities (Department of Statistics Malaysia 2016). The population of Chinese in Malaysia is 6.65 million, only slightly less than the population of Hong Kong (7.4 million).

Historically, the Chinese have been settling in Malaya since the days of the Malacca Sultanate, when the Straits of Malacca was a major trading route in the fifteenth century AD. Many Chinese traders settled and integrated into the Malayan culture since then. The second large wave of Chinese entering Malaysia, consisting largely of planters, traders, and tin miners, was after Penang was founded in the late 1700s. Migration from mainland China became more established after the founding of Singapore in the early 1800s, with Chinese immigrants moving into manufacturing, banking, and timber trading (Tan et al. 2005). A total of about 17 million Chinese entered the Malay Peninsula by the nineteenth century, due to the poverty in coastal rural China and the employment opportunities in the British colony (Ching and McKenna 1990). Chinese in Malaysia call themselves “Hua Ren” (華人) – overseas born Chinese – rather than “Zhong Guo Ren” (中國人), the political nationality of Mainland Chinese.

Largely through trading and mining, the Chinese have been instrumental in the economic development of Malaysia, especially with regard to commerce and industry. A British administrator in Malaya was quoted as saying:

Under present conditions, the Chinese are the bone and sinew of the Malay states. They are the labourers, the miners, the principal shopkeepers, the capitalists, the holders of the revenue farms, the contributors to almost the whole of the revenue; we cannot do without them. (Tan et al. 2005)

Reinforced by the British policy to keep the different ethnic groups in separate sectors, the Chinese were seen as leading in business and trading (resulting in the “success minority myth”), while Malays dominated politics and government administration, and Indians provided blue-collared manpower (Fu 2007). As a result, the Chinese came to be perceived as a “threat” to Malays, to whom the British left political power after Malaya’s independence in 1957. The resulting racial tension led to the historical tragedy on 13 May 1969, where hundreds of Chinese were killed in a racial riot following an unsatisfactory election result for the Malay group (Ness 1972). During this time, many Chinese fled to join Singapore due to their fear of racial violence and victimization. In 1971, the New Economic Policy was introduced with the objectives of eradicating poverty in the Malay group and eliminating racial differences in economic function and geographical location. Despite preferential treatment under this policy of Malays in education and economy, the Chinese still flourished in business ventures (Fu 2007).

Influenced by the Confucian work ethic, the early Chinese settlers and their descendants have been regarded as hardworking and determined, leading to the stereotype of Chinese being the most entrepreneurial people. Today, many Chinese have ventured into and succeeded in various contemporary vocational areas. They also make up the bulk of the population in most urban areas of Malaysia today (Carstens 2005; Heng 2006). However, in recent years, despite an increasing wealth gap within the Chinese community, little attention has been paid to the marginalized Chinese from lower socioeconomic background (FMT Reporters 2017).

Unique Ecology and Diversities Within the Chinese Community

We have previously argued that the Chinese in Malaysia are different from other Chinese societies originating from more homogeneous countries and also different from other ethnic groups in Malaysia itself (Ting and Foo 2019). We would describe four major environmental factors as having decisive influence on Chinese in Malaysia – education, language, cultural practices, and political status.

Education System

Early Chinese settlers set up an independent Chinese education system, mow under the private schooling system in Malaysia. Chinese can choose to enter a private Chinese school or public school, which differ in language of instruction and in philosophy of teaching. Concepts and values related to Confucian teachings are preserved in the Chinese schools (Ingrid 1998; Lee 2007). This difference in education system has implications for cultural identity and even in political orientation (Tan 2000).

According to Tan (2007), the Chinese in Malaysia can be broadly categorized into two groups based on their exposure to different language medium in education. Members of the first group, constituting 85% of Chinese, build their cultural identity around three pillars: the Chinese-language schools, Chinese newspapers, and Chinese ethnic corporations. They are described as typically being independent business people, whose main concern is political stability for good economic returns. The second group, 15% of Chinese, consists of those who speak mainly English and are not educated in the Chinese schools. Members of this group are often disparagingly referred to by the first group as “bananas” (i.e., yellow skin [Chinese], white core [pro-Western culture]) (Tan 2007). Sometimes, these two “types” of Chinese co-exist within the same family due to generational differences in educational backgrounds. This difference in educational backgrounds is likely also to influence their beliefs and attitudes toward mental illness as well as help-seeking methods.

In a recent study, Ho et al. (2018) found that Chinese high schoolers, despite coming from the two educational systems (Independent Chinese Secondary School (ICSS) and National Secondary School (NSS)), all scored high on Chinese identity. Interestingly, students from NSS were found to have a more salient Chinese identity even though their proficiency in and use of Chinese language was lower than that of students in ICSS. In addition, the qualitative aspect of this study revealed that NSS students deemed the Chinese language as an important representation of their identity that keeps the togetherness of the Chinese group. For ICSS students, the Chinese language is more of a useful tool for global communication and continuation of education.

Language and Dialect Diversity

With regard to language and culture, although most Chinese are conversant in the Malay language – the national language – most retain their original traditions and mother tongue from their ancestral ties to China. Multilingual ability is more prevalent among Chinese in Malaysia than among Chinese elsewhere, such as Taiwan, Hong Kong, Indonesia, and Thailand. Tan (2005) estimated that there were approximately 5.4 million Chinese dialect speakers in 2000, 94.27% of Chinese in Malaysia at that time (Department of Statistics 2001). Heng (2006) categorized early Chinese settlers into five major dialect groups, Hokkien (37%), Hakka (22%), Cantonese (19%), Teochew (12%), and Hainanese (4%). Influenced by the Malay and English languages, some Chinese develop their own unique Chinese dialects, such as the Penang Hokkien which is unique and distinct to the northern peninsular region (Ong and Tan 2017).

Cultural and Religious Practice

Preservation of language and cultural practices enables the Chinese to preserve their identity as Chinese, unlike their counterparts in Indonesia and Thailand where national identity precedes ethnic identity. In fact, many still identify themselves as “Chinese,” even if they are acculturated Malaysians for more than a generation (Ang 2013). Confucianism plays a prominent role in learning core Chinese cultural values (Lee-Wong 2000; Yick and Gupta 2002). Most of the Chinese are Christians, Taoists, and Buddhists in Malaysia (Chong et al. 2013). The elements of these different religions influence perceptions of mental health despite modernization and westernization. For instance, Taoism, Confucianism, and Buddhism teach the virtue of restraining excessive behaviors and suppressing strong emotions (Yip 2005). For this group, healing methods for mental health problems are more likely to be tied to folklore beliefs and practices, such as shamanism or traditional Chinese herbal treatments (Zhong yao) (Chang et al. 2017; Edman and Koon 2000).

Sociopolitical Status

Given their economic strength and recognized leadership, Chinese do possess some political influence in the ruling parties as well as the opposition, although ethnic Malays hold the dominant political power in the country, and the political involvement of Chinese is decreasing (Freedman 2000).

In terms of inter-racial relationships, Chinese seem to prefer to remain within their own group, forming cliques at schools and at workplaces. Due to the ethnic-based political structure (“Malay supremacy”) in Malaysia, ethnocentric sentiments, which remain entrenched within each ethnic group, discourage meaningful inter-racial interaction. The existing affirmative policy for the Malay group relating to educational opportunity (such as “90:10” pre-university admission ratio) has cultivated a strong sentiment among Chinese who do not enjoy equal right of tertiary education and consequent disadvantage in public sector employment (Chiu 2000; Lee 2012). This sociopolitical atmosphere has resulted in increased migration to more developed countries (“brain drain”) by Chinese since the 1980s. Those who have remained face psychological insecurity as an ethnic minority. Rising racial tension can be seen in recent years due to some ethnic Malay groups’ rhetoric on “Ketuanan Melayu” (“Malay Supremacy” in English) and description of the ethnic Chinese as “Pendatang” (i.e., immigrants) and second-class citizens, which further harm positive inter-ethnic relations (Han 2015).

Even after the 2018 general election in Malaysia, with claims that Malaysia is being “reformed” by the more “liberal” leading party, the ex-Education Minister, Maszlee Malik, has attracted criticism following his comments (as cited in The Straits Times 2019) on the importance of retaining the race-based pre-university quota in Malaysia.

Due to a different political context and geographical distance, Chinese in East Malaysia form a distinctive culture and community that is different from the Chinese in West Malaysia (Chin 1981; Hing and Tan 2000). Sabah and Sarawak joined the independent Malaya in 1963 to form the Federation of Malaysia. Prior to independence, both were ruled by the British governors and the Malay Raja (king). East Malaysians usually do not possess as strong a sense of Malaysian nationality as do those from West Malaysia (“Civil movement” 2013; “GE 13: Movement” 2013; Rintod 2013).

Taking the current sociopolitical challenges faced by the Chinese into consideration, it is understandable that, in comparison to the other ethnic groups in Malaysia, the Chinese have been found to have the lowest level of happiness and subjective well-being (Minkov and Bond 2017). Continuing emigration and a low birth rate are resulting in a decline of the Chinese population in the country. The proportion of Chinese in Malaysia dropped by 4.5% to a total of 24.6% of the total population in 2010 (Department of Statistics 2011) to 23.4% in 2016 (Jabatan Perangkaan Malaysia 2016) and by a further 0.2% from 2017 to 2018. It is estimated that the proportion of Chinese will continue to drop to 20% by 2040 (Department of Statistics 2011).

Mental Health Protective Factors in the Chinese Community

The Chinese communities in Malaysia are characterized by a number of protective factors that support well-being, including the following:

  • Business vitality: The Chinese in Malaysia have a history of entrepreneurial success and leadership in economic development. They have high visibility in business, nationally and internationally. Although they do not hold much political power, their contribution to the Malaysian economy has been widely acknowledged (Gomez 1999).

  • Strong adaptability: The Chinese have a history of resilience through immigration and differentiation from China while building a new home and identity in a new land. Within a century, the Chinese became the second largest ethnic group in Malaya and continue to make an important contribution to the nation. In spite of the hardship experienced, particularly at the beginning of the twentieth century, the Chinese have adapted and flourished.

  • Strong family values: The strong family lineage and concept of filial piety have kept Chinese families intact. According to the 2010 Census of Population and Housing (Department of Statistics Malaysia 2011), the Chinese have the lowest divorce rate among all the ethnic groups. Filial piety, still highly emphasized, serves as a protective factor for the aging population as children are expected to take care of the elderly and family business (Simon et al. 2014; Iskandar et al. 2014). The tight networks based on blood-tie relationships have served as a buffer against social oppression and marginalization (Ng et al. 2011; Yeh et al. 2013). When there is mental illness in the Chinese family, all the family members feel obligated to take care of the ill family member, decreasing reliance on the social welfare system (Chang and Horrocks 2006).

  • Belief in good education: Malaysia is the only country outside China and Taiwan with a comprehensive and complete Chinese education system. It is also the only country in Southeast Asia that has perpetuated the Chinese education system established during the colonial era (Ang 2017). This illustrates the importance attached by the Chinese community to a good education, despite the lack of funding from the government. There are five private tertiary education institutes established by the Chinese community in which Mandarin is the medium of teaching (Wan et al. 2020). Chinese parents also often strive to send their children to foreign countries or private institutes for better opportunities in education.

  • Strong work ethic: The strong work ethic among the Chinese is a continuation of the “survival” mentality since centuries ago, and referred to by scholars as “Confucius dynamism” (Hofstede 2003). The older generation of Chinese continue to expect to pass on their business to their children (Iskandar et al. 2014).

Mental Health Challenges Experienced by the Chinese Community

Despite the Chinese community’s many strengths and assets, clashes between tradition and modern values, the marginalized position in the Malaysian political arena, the stereotype of overachiever in education, and the “brain drain” of young well-educated Chinese have all caused strain in Chinese individuals and families (Sukumaran 2017). According to the 2015 Malaysia National Health and Morbidity Survey (NHMS), there has been an increase in mental health problems from 1996 to 2015 in both Chinese adults and children (Ahmad et al. 2015; Ministry of Health Malaysia 2015).

Children: Pressures for Achievement

In the past decade, the increase of mental health problems among the child and adolescent population in Malaysia has become a significant concern. Comparing data from the Malaysia National Health and Morbidity Surveys (NHMS) of 1996, 2006 and 2011, the prevalence of mental health problems among children and adolescents (between the ages of 5 to 15 years) increased by 49.2% from 1996 to 2011, with many struggling especially with emotional, conduct, hyperactivity, peer, and social problems (Ministry of Health Malaysia 2015). In the 2015 survey, the NHMS also identified Chinese children as having the second highest prevalence of mental health problems, next to the indigenous population (Ministry of Health Malaysia 2015). Another study confirmed that mental health problems among Chinese children increased by a staggering 366.7% from 1996 to 2006 (Ahmad et al. 2015). Specifically, many Chinese children struggle with psychological distress, anxiety, depression, and even suicidal thoughts (Alphonsus 2012). While depression among Chinese children could be associated with family factors, social factors, age and gender, ethnicity and culture, and physical factors (Zgambo et al. 2012), it is not clear which of these factors are most important in explaining the increase.

It is known that among many traditional Chinese societies, the pressure to excel and achieve begins at a young age and is closely tied to the Chinese family’s interests (Hau and Ho 2010). Failure to achieve and meet high standards reflects poorly on the individual child and has an impact on the Chinese family’s face, image, pride, and integrity. Such achievement-oriented upbringing and emphasis on family interests can be problematic for children, especially in the absence of adequate parental and social support, familial and household stability, and positive coping resources. The pressures and stress early in life may undermine mental health adaptability in young children which may have continuing consequences later in life (Wang 2015; Alphonsus 2012; Bernama 2016; Zgambo et al. 2012). Such academic stress may be continued until the college stage where Chinese have been found to have higher levels of stress and lower coping skills in comparison with other ethnic groups (Mazlan et al. 2012).

Adolescents: Pressures from Authoritarian Parents

The identity crisis of Chinese teenagers surfaces in their choices of friendships, dating relationships, and career paths, as parental authority is still highly emphasized (Chen and Liew 2015). While traditional Chinese parents expect their children to be “obedient and filial,” not many teenagers today can conform to such social norms and expectations. In a study with 14–16-year-old students from private schools in Malaysia, Chinese youth’s anxiety level is best predicted by more “anxious parenting styles” and less “parental emotional warmth” compared to other ethnic groups. (Mousavi et al. 2016). The insecure parenting styles for many Chinese families might subject their children to multiple psychological problems. In a survey of 2927 secondary school children, Chinese students were found to have the highest rate of depression among all ethnic groups (55%), which was associated with low academic performance and alcoholism (Latiff et al. 2016). Similar results were found in another study in Sarawak where Chinese adolescents had the highest rate of depression among all ethnic groups (Ghazali and Azhar 2015). Suicidal ideation and attempts are also found to be higher in Chinese adolescents in both West and East Malaysia – 13.7% and 10.7%, respectively – compared to adolescents from other ethnic groups (Ahmad and Cheong 2014).

Based on the Health Ministry’s 2017 National Health and Morbidity Survey (NHMS) statistics, 21% of Chinese adolescents have depression, and 36% of Chinese adolescents have anxiety; Chinese teenagers also rank second highest on prevalence of suicidal behaviors, next to Indian ethnic group (Ministry of Health 2017). It was also found that “Internet addiction” was highest among Chinese adolescents. Behavioral problems and teenage delinquency are rising as substance abuse becomes more prevalent in Malaysia (Singh et al. 2017). According to a survey conducted in Penang (Guan and Rahimi 2015), self-harm behaviors have also become prevalent among Chinese teenagers (56.8%), especially among female students (33.7%).

Adults: Family Differentiation Versus Lineage

Though the Chinese have been persistent in keeping their cultural heritage, increasingly, hybridized cultural identity could be clashing with traditional social norms. For example, several studies found that parental authority still plays a key factor for individuals of Chinese descent in determining their career goals (Chen and Liew 2015; Tang 2002; Iskandar et al. 2014). Issues with authority figures are frequently a challenge that adult Chinese have to work through in the therapy room. According to the first author’s clinical practice over the past 20 years, many Chinese adult clients complain about the interference of their parents in their daily life decisions. Finding their own voice in the traditional Chinese household would be a lifelong challenge due to the pressure to be the “perfect child.” Some traditional Chinese also value multigenerational living under the same roof (三代同堂) as a sign of prosperity for the family clan, although conflicts between in-laws and those who seek individuation from the family of origin may not be infrequent. Risk for postnatal depression and suicide among Chinese women may be exacerbated by an unsupportive family system, such as lack of support from the husband or conflicts with in-laws (Yusuff et al. 2014). Having to struggle with the patriarchal family system (e.g., in-law problems) increases Chinese married women’s vulnerability to mental illness, especially depression (Arifin 2015).

Chinese adults who uphold a stronger preference for familial “face” and shame concerns were more likely to report higher levels of psychological distress. The effort invested in managing interpersonal dynamics within the family can be psychologically taxing and distressing, especially in the event of failure to sustain interpersonal harmony among family members (Mak and Chen 2010). The need to be perfect in order to avoid negative consequences is also related to body image dissatisfaction and eating disorders among Chinese women aged 18–46 years (Choo and Chan 2012). In reviewing 39 studies related to suicide in Malaysia, Armitage et al. (2015) found that the Chinese have a high risk of suicide attempts, comparable to that of the Indian group which is also an ethnic minority in Malaysia.

Older Adults: Somatic Complaints and Empty Nest Syndrome

Based on the 2010 population census, one out of eight Chinese was aged 60 years and above, which was the highest compared to other ethnicities in Malaysia, because of lower fertility, emigration, and longer life expectancy among the Chinese (Chai and Hamid 2015; Tey 2016).

The Chinese community is known for its “international family” constellation, where younger Chinese who pursue higher education in developed countries remain in those countries for better living conditions and stable subsistence, while they would have limited opportunities for employment and promotion in Malaysia (Ward and Hewstone 1985). This kind of emigration is known as the “second wave diaspora among Chinese” (Ling 2008; Tan 2005). This pattern of migration, what Poston and Zhang (this volume) refer to as the Huayi (华裔) pattern, is the migration of people of Chinese descent living in one foreign country (in this case, Malaysia) to another foreign country (frequently the USA, Australia, New Zealand, Canada, or the UK). However, this creates a vacuum in the Chinese community in Malaysia, where the aging cohort lacks support from the younger cohort. Many older adults suffer from “empty nest” syndrome, with loneliness and depression, as their children and grandchildren are abroad, which goes against the cultural tenets of filial piety and family ethics (Simon et al. 2014). Care for the aged Chinese in Malaysia is a looming future challenge (Chai and Hamid 2015).

Many older generation Chinese continue to believe in traditional Chinese interpretations of mental health problems and in traditional Chinese medicines in their treatment. Depression is most frequently experienced somatically and in terms of interpersonal dysfunction (Chan 1990; Kleinman 1982; Watters 2011). Their losses and griefs might not be understood by mental health practitioners or taken seriously by their family members if negative emotions are being expressed rather indirectly with somatic symptoms (Mak and Chen 2010; Ting 2008).

Gaps in Mental Health Services

Chinese in Malaysia seek mental health services at quite low rates (Krishnaswamy et al. 2012), and there are substantial barriers to seeking help from mental health professionals.

Stigma Toward Mental Health Issues

Though there is an increased awareness of mental health among the Chinese, mental illness and seeking help from mental health professionals are still highly stigmatized (Dollery and Yu 2011). As a developing country, the institutionalization of mental illness is still prevalent in the healthcare model of Malaysia (Chong et al. 2013), which perpetuates the negative stereotype of the mental health professions. In addition, the injunction to “never air your laundry outside the family” is still deep-rooted among the Chinese. Despite their degree of urbanization and mental health literacy, urban Chinese still prefer their family and religious networks over mental health professionals when seeking help for issues such as depressive symptoms (Loo and Furnham 2012). The stigma toward mental illness and the implication of personal and familial failure, weakness, and shame contribute to low rates of help-seeking and service utilization (Hwang 2006; Mak and Chen 2010). Chinese family caregivers in Malaysia still play the biggest role in the care and support of family members/relatives who suffer from severe and persistent mental illness. This also creates physical and mental burdens for these family members due to shame and embarrassment (Chang and Horrocks 2006; Chong et al. 2013).

Cost-Benefit Concerns

An additional barrier to help-seeking is the “pay structure” of mental health services. The existing healthcare insurance schemes in Malaysia do not provide coverage for mental illness. Certain mental health problems may require multiple therapy sessions that can be a financial burden to some. This situation discourages Malaysians from putting mental health as their priority (Hassan et al. 2018). Some Chinese are reluctant to pay a professional fee to seek help from “talk therapy.” They would rather opt for other forms of treatment, such as traditional herbal medicines for symptom relief, which is also consistent with their belief system (Chang et al. 2017; Chen 1981).

Lack of Multilingual and Culturally Sensitive Mental Health Services

For linguistic minorities, mental health interventions conducted in clients’ native language have been found to be more effective (Griner and Smith 2006) than interventions in the dominant language. In Malaysia, 56.6% (77 of 136) of known active clinical psychologists are of Chinese descent (personal communication with Malaysia Society of Clinical Psychologists). While the number of Chinese clinical psychologists has almost doubled in the past 15 years, Chinese counselors constitute only 12.7% (907 out of 7157) in the registry of the Malaysian Counseling Association (Ng 2005; Lembaga Kaunselor Malaysia 2016). With such a limited number of Chinese psychologists and counselors serving the whole Chinese community of 6.65 million (ratio, 1:7332), there is a major service gap in the system. Moreover, most psychological testings are conducted in English and normed on Western populations. Psychological assessment in Malaysia is still largely culturally and linguistically biased. The lack of Chinese translated and locally normed tools for intelligence and personality testing has been an impediment to the provision of culturally appropriate and fair services considering that 85% of Chinese in Malaysia identify one of the Chinese dialects as their mother tongues (Tan 2007).

As counseling and clinical psychology is still a young profession, and there are not many culturally competent senior Chinese counselors or therapists available, the younger generations of mental health professionals often lack supervision and role models, leaving them to stumble their way in gaining more clinical and educational experience (Ching and Ng 2010; Haque 2005). According to a survey, the mental health profession in Malaysia is dominated by individual-oriented therapists who practice individual therapy which might be inadequate to address complicated family-based conflict and pathology (Mohamed and Rahman 2011; Ng 2007; Ching and Ng 2010), which are common among the Chinese.

Uneven Distribution of Mental Health Services

Most mental health services are concentrated in big cities, such as Kuala Lumpur and Penang (Ng 2007). According to the latest statistics, there are 410 registered psychiatrists in Malaysia of whom 213 work in the government sector. Capital cities such as Kuala Lumpur have the highest density of psychiatrists, while the East Malaysian state Sabah has the lowest ratio of psychiatrists to population (0.54 per 100,000 population). In short, there is a severe shortage of psychiatrists in Malaysia based on the World Health Organization’s recommendation of 1:10,000. (Ng et al. 2018). In addition, there is a shortage of psychologists, counselors, psychotherapists, and social workers, particularly in remote areas and states.

Suggestions for Future Mental Health Services

In order to overcome the aforementioned barriers, we propose the following strategies to improve access to effective and culturally sensitive mental health services for Chinese in Malaysia.

Contextualizing Mental Health Theories and Paradigms

While reviewing and researching empirical studies related to Chinese in Malaysia, the authors found that ethnicity was seldom a major factor addressed in the literature. The Chinese group was often the “comparison group” to the Malay group, and the findings were generally interpreted through the lens of the dominant group, with Chinese culture invisible or not examined. Another common problem is that Chinese are often “lumped” with other ethnic groups as a “one Malaysian” sample, which obscures their distinct mental health needs. While many anthropologists and sociologists have studied the diversity of the Chinese, Malaysian psychologists have not developed a theoretical framework to understand and explain ethnic differences and uniqueness in our own country. Most of the psychological models employed by Malaysian psychologists are either a direct translation or importation from developed Western countries. Psychology practice occurs almost exclusively in the Euro-American tradition (Dueck et al. 2007). As Malaysia gained its independence from Britain only in 1957, it is understandable that Western health service models are widely adopted and recognized. The Chinese are often scrutinized for their “lack of mental health literacy” based on DSM and for not seeking professional treatment (Loo and Furnham 2012). There is still little awareness of the need to indigenize mental health services in Malaysia to reflect the local Chinese culture and needs.

Considering the current trend of racial segregation and the tight-knit Chinese community, mental health professionals could utilize community-based services to promote mental health awareness and services to this population. Instead of practicing from a private-practice model, community psychology could help in destigmatizing and demystifying psychotherapy, building a safety net of secondary preventive measures, and decreasing the prevalence of mental illness among the Chinese. For instance, as family is a big player in shouldering the burden of mental illness management, building a support system for family caregivers would be vital so that they could also share reliable mental health resources with each other. Another big helping hand in Malaysia is the vitality of its non-governmental and nonprofit organizations (NGOs), including religious communities. The government could collaborate with NGOs and religious communities to reach out to the rural and the high-risk Chinese populations and train more lay helpers within the community to reduce the stigma associated with seeking help from the outsiders. De-institutionalizing mental health care and promoting community-based care would reduce the stigma of mental illness and match the strong ties that are characteristic of Chinese society (Ting and Sundararajan 2018). There is also the advantage of mobilizing peer-mentoring groups, such as parenthood groups, adolescent mentoring programs, and support groups for family/caretakers of the severely mentally ill, among the Chinese community. In rural areas where mental health resources are scarce, the training of lay counselors and peer counselors who come from diverse backgrounds would be a high priority. It is anticipated that local counselors would be able to reach out to the Chinese family units in a more culturally appropriate manner than is possible for external consultants. Ultimately, developing a Chinese psychology theory in Malaysia would help to counteract the misinterpretation of Chinese behavior by Western approaches (Ting and Thong 2019).

Enhancing Multicultural Competency and Literacy in Mental Health Professional Training Program

While it is not possible to train sufficient multilingual staff, it is realistic to train multiculturally competent therapists in post-graduate programs. It is highly recommended that higher education institutions mandate multicultural therapy as core coursework in counseling training programs. For therapists who are providing services to the Chinese community, it would be imperative to have a clear understanding of Chinese culture and subcultures through reading and cultural immersion experiences. For example, many Chinese still view mental health in a strong-ties perspective and express their symptoms in interpersonal terms (Palmer 2015), which might not be understood by a therapist with poor cultural literacy. With multicultural competency, a good therapist will first examine his/her own biases and values toward different groups of Chinese. Multicultural competency training would include close supervision of intern counselors working with the Chinese and help trainees work through their own cultural stereotypes and counter-transference challenges with various clients.

As many Chinese still practice folk religions (e.g., Taoist) and ancestor worship, Chinese mental health practitioners have already started integrating their religious faith into their research and practice, such as mindfulness and meditation for Buddhist therapists and prayers and scriptures for Christian therapists (Ting and Ng 2012). Therapists are encouraged to talk to different religious leaders in the Chinese community for wider exposure. Academicians could also study the effects of such integrated therapeutic approaches for empirical evidence. Instead of adopting a dualistic viewpoint of mind-body interaction, learning to view mental health from a traditional Chinese medical perspective might also be helpful to build holistic care for the more traditional Chinese individuals.

Cultivating the Next Generation of Chinese Service Providers

It is highly encouraged for the next Chinese generation to pursue a career in the mental health professions due to the great need among its own community. In the past, careers in the mental health field have been also associated with the stigma of mental illness. However, there is a turn in the last decade, where greater visibility of psychology and mental health practices among the Chinese can be seen. The establishment of Chinese counseling centers and associations and the blossoming of counseling seminars and various continuing education courses have led to a wider acceptance and understanding of counseling and mental health within the Chinese society. More Chinese are expressing interest in psychology and counseling courses. These demands further stimulate the expansion of psychology departments in some private institutions in Malaysia (EduAdvisor 2017).

Many textbooks and literature in counseling/psychology have been translated into Mandarin in Taiwan, Hong Kong, and China, and Chinese Malaysian counselors could benefit from such overseas resources by accessing firsthand knowledge from their counterparts in other countries. There is also more interchange with Taiwan counselors to develop skills through intensive training and workshops. Some Chinese counselors/therapists have started to publish their own works (such as Bridge Communication Press), as well as to contribute to newspaper/journal columns (such as Sin Chew Daily and Guang Ming Daily). Online media exposure and radio interviews could also help to destigmatize the mental health field, as well as promote social status of counselors (Hanafiah and Bortel 2015).

In addition, a substantial number of Chinese counselors/therapists speak at least one Chinese language/dialect (Ng 2007). Most, if not all, Chinese therapists are also able to speak and write in English and Malay (Ng 2007). Chinese therapists are therefore often able to reach out to a non-Chinese clientele without the need for translators, as well as serving the Chinese community. Unlike other ethnic groups who are usually monolingual or dual lingual, multilingual Chinese therapists have wider access and flexibility in providing much needed services to the general Malaysian population.

Building a Chinese-Friendly Society Through Advocacy and Public Policy

The public slogan of “Satu Malaysia” (One Malaysia) promoted by the previous Malaysian government with the intention to unite the ethnic groups into one nationality has not been encouraging toward ethnic studies. Emphasizing national identity over ethnic identity is a strategy that encourages assimilation and reduces tension between multiple ethnic groups. Yet, if efforts are not balanced by celebrating diversity under the umbrella of nationality, cultural heritage would disappear, and the identity of any ethnic group would be compromised. We advocate for a moderate public policy to embrace the diversity within the Malaysian population, as well as a mental health field that fosters peaceful dialogue between Chinese and other ethnic groups. All Malaysian citizens, including the Chinese, should have equal access to mental health services in the public arena. The government sectors should also ensure ethnic diversity among employed mental health practitioners (e.g., psychiatrists, counselors, psychologists) to serve the diverse Malaysian population. Many trained Chinese clinical psychologists or counselors were actually “drained” to foreign countries, such as Australia and Singapore, as they found current employment in Malaysian government sectors not achievable. Though there is no overt racial oppression and violence toward the Chinese at the moment, the existing racial quota in the government education and employment systems could restrict development of Chinese mental health practitioners. It is timely for all mental health professionals, regardless of ethnic backgrounds, to come together to share resources in the community and promote inter-racial harmony.

Conclusion

This chapter is an attempt to introduce the complicated mental health issues faced by a heterogeneous group like the Chinese in Malaysia. It is our hope to stimulate further dialogue about this unique population rather than perpetuating any existing ethnic stereotype. The sociopolitical struggle is quite obvious as Malaysia is a relatively new country struggling to find its multiracial-multicultural identity after more than 60 years of independence from Britain. It is therefore imperative to cultivate a mental health system that is open to serving the Chinese population, as well as being sensitive to its historical and cultural background.