Xu Kaiwen on "Hollow-Heart Disease"

Xu Kaiwen, “How Hard it is to Become a Mentally Healthy Student, Given ‘Hollow-Heart Disease’ and the Anxieties of Our Age?[1]
 
Introduction and Translation by Freya Ge and David Ownby
 
Introduction
 
Xu Kaiwen (b. 1973) is a professor of psychology at Peking University and is particularly interested in the mental health of China’s young people.  He coined the expression “hollow-heart disease”[2] to refer to the effects of China’s educational system on the psychological conditions of students.  In China’s test-driven educational system, students are evaluated solely on the basis of grades, which puts immense pressure on students to be the best (clearly mission impossible—by definition not everyone can be “the best”) and discourages them from developing interests in or valuing anything else, which might distract them from their greater purpose.   This is what "hollows out their hearts."

Parents and teachers are the enforcers in this system, parents because they want the best for their children (which of course reflects well on the parents as well), teachers because schools have also become part of the educational rat race, and are evaluated in terms of the number of students they send on to top-tier schools in China and elsewhere.  The pressures are the worst in the best schools.
 
This situation is not of course unique to China.  The heritage of Confucianism bears some of the blame, and the school systems elsewhere in those parts of East Asian historically influenced by Confucianism (Japan, South Korea, Taiwan, Hong Kong, Vietnam) are broadly similar.  Some parts of the American educational system display similar traits (see for example Daniel Markovits, The Meritocracy Trap), and parents of Parisian teenagers will hold forth on the perilous educational obstacle path their children are required to follow at the drop of a hat. 

But most of these highly competitive systems still leave room for diversity—sports, theater, music, debating, fine arts, dance…All of these are available in China (at least at the best schools), but students engage in them at their peril, because those determined to win will study all night, every night.  And most of the tests are multiple choice or fill in the blank, so that brilliance, insight, creativity, and originality make little difference.  You just have to know the answer, and the harder the kids work, the harder the tests become, because otherwise everyone gets 100%. 
 
It is not difficult to imagine how cruel such a system can be.  It is as if all of China’s best students are training for the Olympics.
 
When Freya Ge and I collaborate on a translation, I usually write most of the introduction and cite her observations as part of my text.  This time, I have revised Freya’s text slightly and given her the podium, because I find her text moving and powerful. 
 
“During my three years of high school, I have heard of too many cases of students who dropped out or even committed suicide because of mental illnesses such as depression and bipolar disorder. In my class-group 班[3] at a top international high school in Shanghai, three out of 24 students either dropped out or failed to advance because of psychological problems. The situation is similar for other class-groups of third-year students.  And these are just the students who have undergone psychological diagnosis. A lot of my friends are under a great deal of psychological pressure, but we don't even have the time or the opportunity to do therapy. China's social tradition of honoring grades and parents makes it hard for students to talk about their own mental illness, since it would be considered abnormal and unfilial.
 
During my college application process, I was stressed out by the need to manage grades, activities, essays, and interpersonal relationships all at the same time. For a long time, I woke up every day hoping to simply disappear, and many of my classmates expressed similar world-weariness and bitterness. Our school has an excellent admission record, and every day our school promotes the students who got into the top 20 universities and top 10 liberal arts colleges in the United States, as well as Oxford and Cambridge in the United Kingdom. This just adds more pressure.

Although international schools have attached great importance to the personal development of students, in China’s general educational environment, I feel that my original hopes and dreams fall by the wayside as I struggle to fulfill the tasks and goals the system sets for us, and any deviation from the system’s goals is met by the disapproval of teachers and counselors.
 
Of course, this might be the stress talking, because I did experience personal growth. I also got excellent offers, including from some of the world's leading law schools--Hong Kong University, New York University, University College London, etc. But now I find myself faced with new painful choices. I personally like Haverford College’s liberal arts program, and am accepted there, but my counselors and parents prefer law school in Hong Kong because of its high ranking and the financial future it promises, and overall costs are cheaper as well. Even though I have my own values, I still find it extremely hard to stick to my ideals.

Teachers, counselors, parents—the system—are thinking in terms of benefit-maximization for me and perhaps for the society, but I can’t make myself believe that this is something I want, but instead something that society is imposing on me. This leaves me with a sense of absurdity and meaningless, because I think I may not have the courage to insist on what I want even though my work and education throughout high school have taught me the importance of this. I may change my mind later, but I feel miserable right now. A lot of relatively 'clear-headed' students of my age hate themselves since all their work has not given them the power or strength to change the situation.
 
Many students are even more lost at sea than I am. A friend of mine in the Chinese public school system shared bad news with over and over. Two students in her class who had been pre-admitted[4] to Peking University committed suicide because of academic pressure, and I recently learned of a student who had been admitted to Peking University with full marks in three courses who also took his own life. Twenty-seven students in Shanghai committed suicide before the beginning of last semester. These numbers are striking. When I talk to my friends in Chinese high schools, I find that most high school students don't really think. All they learn is grades, not even knowledge, because knowledge is only used as a tool to get grades. This is what they were taught to do. So they are completely lost when it comes to thinking about their future. They don't know or even try to figure out what they really want, and instead just go for the best schools with the highest grades.

Even if they have a plan, it is very 'realistic' and even 'utilitarian,' which again comes from their parents and teachers: to become a civil servant, to get a white-collar job, etc. I have a friend who likes material science, but he does not dare to choose this major, because he’ s afraid that he will not find a good job in the future and thereby disappoint his parents. The fact that we are only evaluated in terms of grades limits the values that we can embrace and develop.  So when students encounter obstacles on their utilitarian path, they have no other strengths, which means that there is a great risk that these students will suffer great unhappiness and even mental illness, ultimately due to the lack of a more comprehensive assessment of what 'excellence' really means.
 
For all of the diversity of my generation, society is still trying to push everyone through the same mold.”
 
Translation
 
Prominent Mental Health Problems among Contemporary Youth 
 
Mental health problems are spreading to primary and secondary schools. I think that, in the wake of the pandemic, we are experiencing an age of great change, both in terms of international relations and institutions, such as the recent reform of education policies.
 
Mental health problems in primary and secondary schools suddenly exploded when school resumed after the epidemic last year.  The situation is very serious, with many extreme incidents.  The Ministry of Education and the National Health Commission are taking the situation very seriously, and have issued a series of policy documents to strengthen mental health work in primary and secondary schools.
 
The team of Zheng Yi, a professor at Beijing Anding Hospital, published an epidemiological survey of “Mental Disorders in Children and Adolescents in China,” which showed that 17.5% of adolescents suffered from a mental disorder over the course of the year.
 
Why are we seeing these problems? 
 
Up until 2005, the prevalence of anxiety disorders was 13% in China and 18.1% in the United States.  The prevalence of depressive disorders was 6% in China and 9.5% in the U.S.  If you look at lifetime prevalence, it is 50% in the United States.  Thus, we are living in an age of increasing material wealth, but the prevalence of mental illness is also increasing.
 
More than a year ago, I conducted an online survey concerning "sang culture"[5] on social networks and received responses from 2,371 college students. The survey revealed that the proportion of students feeling lost, confused, and depressed is very high.  Feelings of loneliness, powerlessness, frustration, and anxiety are all closely related to sang, and the proportion students reporting that they feel "very sang" or "relatively sang" exceeds 20%. This explains the popularity of terms related to sang culture, such as “lying flat 躺平” and “disengaging 佛系.”[6]  The sources of sang include academic and work pressure, peer competition, interpersonal relationships, etc., so stress is a very important factor. 
 
A survey of primary and secondary school students reveals a similar situation. A national mental health study conducted by the Institute of Psychology of the Chinese Academy of Sciences found that 26.4% of primary and secondary school students were depressed. This is similar to my own findings in public and international schools. 
 
Hollow-Heart Disease: A Mental Disorder Caused by a Lack of Values 
 
Six years ago, I gave a talk on "The Age of Hollow-Heart Disease and the Economics of Anxiety." The anxiety economy teaches us that there is nothing in the world that sells better than anxiety and fear.  In this year's torrent of online education ads, one line really caught my eye: "Come to us, and we will train your child; don’t come to us, and we will train your child’s competition!" This is naked intimidation, and the wild capitalist pursuit of profit and monopoly is one reason pushing education toward involution 内卷 and the theater effect 剧场效应.[7]  
 
In this context, my observation is that students in primary and secondary school schools, as well as university, are all subject to hollow-heart disease, which I define as "a mental disorder caused by lack of values."  It’s main symptoms are the following:
 
Depression
 
Most people with hollow-heart disease have symptoms of depression, and are frequently diagnosed as such by psychiatrists. The current incidence of depression—26.4%—is extremely worrisome. Think about it. This means that in a hypothetical class of 40 people, more than 10 of them will be pathologically depressed.  In fact, the percentage was higher at what we call good schools, both international and public, and the effects of medication were not particularly good. Why is this? Because the children's problems aren't biological.
 
Loneliness 
 
In addition, teenagers today have a strong sense of loneliness and meaninglessness, feeling that life has no value and meaning. More than half of the people who come to my Daru Psychological Counseling Center are children and teenagers, especially middle school students. They sit on the couch and say that life has no value and meaning. They have no feelings about anything and nothing can make them happy.  Despite everything in the world that tastes good, that is fun, that is beautiful, that is happy—nothing moves them. They feel disconnected from the world, feel like they could take it or leave, feel like they themselves are completely dispensable.  For this reason, they find it easy to give up on themselves.  It's not so much that depression causes these feelings as these feelings cause depression.
 
Loss of sense of self 
 
Behind this loneliness lies the unresolved problem of self-identity and the lack of positive values to sustain them in life.  Who am I? What kind of person am I going to be? Where am I from? Where am I going? What is the value and meaning of human life?  Among adolescents, this kind of confusion is very common, because ego-development itself involves issues of self-identity, self-affirmation, which I don't think is pathological. But the problem is that it can last a long time with these children, perhaps even their whole lives, which can be very disturbing.
 
External approval 
 
As a result, when they lose their sense of self, children can only see their value through the affirmation of others, so they desperately pursue such affirmation. How does affirmation work? You become what others want you to be.  Who are these “others”?  Parents and teachers. The teachers want you to be a good student, so you become a good student, being nice to everyone and making everyone like you. But it is exhausting to live like this, because you are living on everyone else’s terms, you're not the person you want to be, and you're trying to please everyone.
 
The fear of being judged 
 
If you constantly seek external approval and are evaluated every day (by test scores and rankings), you will eventually fear being judged.  In the spring semester of 2016, I did group counseling with some students who I thought showed the symptoms of hollow-heart disease. These students, who were excellent in all respects, asked me not to praise or affirm them, saying "you may praise me this time, but you can do the opposite the next time, so we hate being judged."  Is it cool for kids to be evaluated and tested throughout their whole lives? It is not.  You know what’s harder than getting the best grade? Getting the best grade every time.  So every time a child gets a good grade, his fear grows, because it is too easy to slip down the rankings. Eventually learning becomes associated with anxiety and fear, leading to an aversion to learning.
 
Suicidal tendencies 
 
I once knew a student in an international school whose goal was to be admitted to an Ivy League school in the United States. He consistently ranked first in his class through his third year at the school. Then one day, his mother contacted me that he had killed himself, injecting himself with a poison that he had learned to make through his studies.  He had been studying until 4:30 in the morning every day and eventually collapsed, and finally didn't want to go on like this anymore.  Thus the kind of education we have now directly increases the pressure on students, and we are increasingly turning our backs on the basic nature of education, leading to serious psychological problems for our children.
 
Self-denial and self-hatred 
 
Donald Trump is an extreme example of a know-it-all. He brags about himself every day in front of the entire world, and American psychiatrists diagnosed him as narcissistic personality. Yet in a certain sense, it is more human to like oneself and affirm oneself.  So when I first came into contact with particular cases of self-loathing, I found it very strange, because to me the children were perfect, talented, and beautiful, but they hated themselves, even to the point of contemplating suicide.  So we see that real world success, in terms of good grades and popularity, does not bring self-affirmation. Why is this? After talking with them further, I realized that it was because they had felt all along that what they had been doing was worthless and meaningless. 
 
We might think:  you got the best grade, you won an Olympic gold medal, how could that be considered meaningless? But this is not how they think.  They think “90 is not enough, I need 95, maybe 100.” But to get those ten extra points, they might put in ten times as much time preparing for the test, all the time knowing that getting a better grade is meaningless, that it’s just a better grade.  And if you get into a so-called good school, you still have to study.  Everything is so cut and dried, so utilitarian. 
 
Given this mindset, teenagers now have a long history of depression, some beginning in elementary school. And not only does medication work poorly or not at all, traditional psychotherapy is also ineffective.
 
Understanding the misconceptions of contemporary adolescents 
 
Therefore, the more introspective children are, the more pain they feel, because a lot of it is neither biological nor psychological, but instead social and educational.  So can we medicalize education or social problems? When a child with hollow-heart disease goes to see a doctor and takes the prescribed medicine, will it cure him? It will only work for a few things, such as improving sleep and mood in the short term. 
 
It’s like smog.  Seeing a respiratory specialist while the smog is still there cannot solve the basic problem. If the fundamental problems in education and society are not resolved, any solution will only scratch the surface. So when the government cracked down on the over-the-top tutoring industry, I enthusiastically supported it as a moral policy to address the current mental health problems of teenagers. 
 
So why do teenagers have frequent psychological crises? One reason is that the process of modernization itself is constantly changing social norms. In merely 40 years, China has completed a modernization process it took Western countries more than a century to complete, so you can imagine the magnitude of the changes.
 
Diversity of values  

I have a friend who is a university professor and doctoral supervisor, but his third-grade child refused to go to school. The parents were very anxious and came to me. The professor said there was not way to understand today’s children, and the child replied, saying that professors like his father were stupid.  I told him I actually thought his son had a point. People like us were born in the 1970s, and when we went to school, values were very simple—we were born and raised under the red flag, with “five things to emphasize, four things to beautify and three things to love,”[8] and we tried to imitate Lei Feng.[9] My own idol was Premier Zhou Enlai (1898-1976), and the values and life meaning with which I identified had to do with studying to help China develop.
 
Generational differences between parents and children 
 
I met a high school student who was suicidal, and her parents were extremely anxious and brought her to see me. I asked them what happiness was. The parents, who were born in the 1960s, worked their way up to being college professors by being good test-takers 小镇做题家.[10]  For them, happiness is having enough to eat and clothes on their backs.  Their daughter had never wanted for food or clothing, so this made no sense to her.  For her, happiness means having her parents talk to her as an equal, respecting her enough to allow her to decide certain things about her own life.  Generation gaps aside, even people of the same generation can be different.  I might like a certain kind of game or a certain kind of book, and there are value differences in these kinds of subcultures.
 
Our evaluation system is extremely simplistic 
 
It is absurd that while our cultural environment is diverse, we evaluate our students uniquely through grades. I think the evaluation standard should emphasize teaching virtue and helping people achieve their potential as human beings.  From a psychological point of view, attitude comes first, then skills and knowledge. But in the current evaluation system, even skills are not necessary, only knowledge. You don't even have to be able to conduct experiments, as long as you do well on your exams.  Therefore, when grades become the only standard for evaluating children, then in order to compete for these grades, children will face ever more pressure, and their ability to fight back will grow increasingly feeble. The pressure of society as a whole will bear down on the children, which will inevitably cause problems.
 
Utilitarian education 
 
In the West, the origin of hollow-heart disease is closely related to economic development. In the 1960s and 1970s, European and American societies developed economically and enriched their material lives, but lost their souls. When your thinking revolves around materialism and consumerism, everything can be bought and sold, but people lose their spiritual beliefs. 
 
In China, another important factor leading to hollow-heart disease is our educational system, which is driven by capitalism and utilitarianism. Grades and the percentage of students who continue at higher levels have become the equivalent of GDP numbers for education, and are transformed into economic income. When a school or institution becomes famous, it can charge various fees and wind up becoming an industry. In this way, we ignore an education that cultivates people and teaches values, resulting in the increase of hollow-heart disease. 
 
The reason why we say that many children nowadays are becoming exquisite egoists[11] is because their parents and teachers are exquisite egoists. You can see this idea in some slogans, such as "increase your grade by one point and defeat one thousand rivals." People treat other students as the enemy.  Study has become a source of crisis, which is a ridiculous thing to value. 
 
An ounce of prevention is worth a pound of cure:  how we should view education
 
Finally, I'd like to talk a little bit about solutions.  First, I think human beings always need enough wisdom to understand the meaning of wealth.  I have a Swiss friend who has greatly influenced my views on education. She was studying in China, and we happened to both be doing our doctorates, and I asked her what she was studying. She said it was a kind of old Latin lost in the Middle Ages.  I asked her what she could do with such a rare topic in a relatively small country. After all, it doesn't sound very useful. 
 
She told me that there was only one job position related to her major in the whole of Switzerland, and her doctoral advisor had that job. But until he retires, she can work as his assistant, on contract.  I then asked why she would do something that makes no money.  Because you have to have enough to cover the basics, right?  She said she liked what she studies.  At some point I realized that Switzerland is rich, and its citizens rarely lack for money. And money also gives you more freedom of choice, which is the meaning of wealth. 
 
For example, I was born in the 1970s, and have now accumulated a little wealth, so how do I show my love to my daughter? Not by buying her a car or a house, but by allowing her to study what she likes. Even if her intended major is not a money maker, as long as she likes it, it's ok.  Therefore, the point of having money is to allow us to have more freedom of choice, so that we can study with an attitude not based in utilitarianism and instead choose on the basis of our own interests, values, and meaning. You don't go to college to get a high-paying job. You don't go to a prestigious university to get into one of the four big banks. 
 
Thus, people need spiritual pursuits, in addition to their needs at the biological and psychological levels. The more outstanding people are, the less they can be satisfied by material considerations or money. 
 
Second, we should return to our basic nature and our conscience. 
 
My doctoral thesis had to do with prisons, specifically with quarrelsome prisoners who were put in solitary confinement, where they had food to eat and clothes to wear, but where no one talked to them.  They might hold out for a week, but after two weeks they fell apart and cooperated with the authorities.  But there are many revolutionary fighters in history who could endure such mental torture, such as Jiang Zhuyun 江竹筠 (1920-1949), Fang Zhimin 方志敏 (1899-1935)[12], and Nelson Mandela. Why didn't they give up? I think the reason is very simple: they had ideals and beliefs, and they knew they were doing something meaningful.
 
Therefore, the supporting role of ideals, beliefs and values is very important and powerful.  What do Chinese people think about their basic nature and conscience?  Chinese people believe you are born with a conscience. For example, Confucius said that, "What the Great Learning teaches, is to illustrate illustrious virtue; to renovate the people; and to rest in the highest excellence." Mencius said, “Benevolence, righteousness, propriety, and knowledge are not infused into us from without. We are certainly furnished with them.”[13] Wang Yangming 王阳明 (1472-1529)[14] summed this up by saying that conscience means knowing without thinking, doing without studying. 
 
So my thought is that, when you have material needs, first take care of food and clothing.  When your material needs are satisfied, direct your soul upward and do something with value and meaning. Chinese culture stresses the unity of man and nature. Striving to help others, contribute to the community, the people, and the nation represents meaning is for us. 
 
For example, I am a scientist, so I will use my scientific skills to solve the problems plaguing human beings and thus improve their living standards and increase their happiness. Thus in our age of anxiety, finding your conscience can strengthen your inner self and help you find your own happiness.
 
Notes

[1]徐凯文, “空心病与时代焦虑下，成为一个心理健康的学生有多难,” published on Sohu on September 7, 2021.

[2]Translator’s note:  There is a popular and very tasty kind of spinach in China known as —“hollow-heart vegetable” (kongxincai 空心菜).   I don’t know if Xu’s coinage is a play on words.

[3]Translator’s note:  Secondary schools and universities in China organize students into class-groups, the rough equivalent of “home room” in the American system, meaning that the students in these class-groups take some or perhaps all of their classes together.  The class-group is also an important social unit, as well as an instrument of administrative control over students and student life.

[4]Translator’s note:  Being pre-admitted means that the student does not have to take the university entrance exam, because their excellence at the high school level has already attracted the interest of the best universities.

[5]Translator’s note:  The basic meaning of sang 丧 is “mourning,” but it can also mean feeling dejected or frustrated.  It is widely used in China to refer to the malaise experienced by many contemporary youth as a result of the pressures of the highly competitive society in which they live, combined with considerable uncertainty in terms of life outcomes.  See here for a more extensive discussion.

[6]Translator’s note:  The term “lying flat” (tangping 躺平) requires little explanation; it means keeping your head down, getting out of the way.  The term I have translated as “disengaging” (foxi 佛系) is not so straightforward.  The term first appeared in Japan in 2014, and was used to refer to young men who had seen through and dropped out of much of life, a less extreme version of the hikiomori, who engage in extreme social withdrawal.  Later it was applied to youth in general.  The term literally means “Buddha-ish,” and in some contexts might be rendered into English as “Zen,” used as a slang word for “calm” (“He failed his French exam but was pretty Zen about it”).  This is not an exact equivalent, however, because it is more positive than foxi, which suggests weakness and passivity, papered over by a faux-Buddhist attitude that “nothing really exists so nothing really matters.”

[7]Translator’s note:  “Involution” refers diminishing returns on increasing inputs, in this context, young people studying and/or working harder and harder, but achieving less.  The idea of “theater effects” apparently goes back to Rousseau, who denounced the deleterious efforts of “performing” or “play-acting” in society.

[8]Translator’s note:  These are well-known slogans from the 1980s campaigns to build “spiritual civilization,” and refer precisely to “five things to emphasize (civility, politeness, hygiene, order and morality), four things to beautify (mind, language, behavior and environment), and three things to love (the motherland, socialism and the people).

[9]Translator’s note:  Lei Feng is perhaps China’s most famous model, a soldier who died in a freak accident, after which time his diary (as well as thousands of pictures of the heretofore unknown person) were found.  Lei is a model of selflessness and devotion to the common good, as defined by the Chinese Communist Party.

[10]Translator’s note:  The phrase xiaozhen zuotijia 小镇做题家, lit. “small town people who are good at taking tests,” is a derogatory term referring to people who manage to acquire the formal skills necessary to succeed in the educational system but who are generally incapable of doing anything in the real world. 

[11]Translator’s note:  This expression originated with Professor Qian Liqun's 钱理群 (b. 1939) criticism of the glibness of certain Chinese university students:  “Some of our universities, including Peking University, are currently training ‘exquisite egotists,’ who are sophisticated, worldly, thoughtful, good at playing a role, good at fitting in, and even better at using the system to pursue their own goals.  By exquisite egotists, I mean egotists who have been skillfully dressed up or even disguised.”

[12]Translator’s note:  Both of these are revolutionary martyrs, much celebrated in China. 

[13]Translator’s note:  Both translations are taken from www.ctext.org.

[14]Translator’s note:  Wang Yangming was an important figure in Ming Neoconfucianism, and argued that man was inherently good, and born with a conscience.