Introduction
The concept of self-care in healthcare and medicine has become one of the most widespread and pervasive themes in contemporary debates and commentaries about health education, health maintenance, and health policy.2 However, while there is broad agreement as to its importance, there is no one generally accepted definition of self-care. Self-care has been variously defined as ‘care of the self without medical or other professional consultation’ (Random House Dictionary 2017), ‘the actions that individuals take for themselves, on behalf of and with oth-ers in order to develop, protect, maintain and improve their health [and] wellbe-ing’ (Self-Care Forum U.K.) and
The actions people take for themselves, their children and their families to stay fit and maintain good physical and mental health; meet social and psy-chological needs; prevent illness or accidents; care for minor ailments and long-term conditions; and maintain health and wellbeing after an acute illness [or injury].
(U.K. Department of Health 2005) According to Wikipedia, ‘Self-care includes all health decisions [which] people, [either] as individuals or as consumers, make for themselves and their families to ensure they are physically and mentally fit’ (Wikipedia: Self-Care). These and other definitions in common usage vary widely, notably with regard to the assumed scope of self-care (whether it is confined to physical and mental health, or extends more broadly to ‘well-being’ and psychosocial functioning); the extent to which self-help is seen either as a largely autonomous sphere of lay health choices or as an activity normally carried on in close collaboration with health professionals, and the extent to which self-care is seen as mainly a self-regarding activity or as a shared responsibility not only for the health of one individual but of his or her family, friends, neighbours, and co-workers (Easton 1993: 384–87;
Webbe et al. 2013: 101–6).
But while such definitions undoubtedly help us to understand the importance of lay conceptions of health and the centrality of lay decision-making in healthcare
choices, they scarcely do justice to the richness, complexity, and long histories of many of the ideas and practices included under the heading of ‘self-care’ both in Chinese and ‘Western’ medicine. In China, ‘self-care’ is closely associated, though not synonymous with, the concept and practice of yangsheng 養生, the traditional Chinese ‘art of nurturing life’ in all its various forms, whose origins may be traced back at least to the Han Dynasty, if not earlier (Lo 2001; Hinrichs and Barnes 2013: 11, 14, 69–70, 153–5, 166–7). Since the end of the Cultural Revolution and the partial relaxation of political controls over individual life-style and leisure choices which followed, yangsheng has undergone a consider-able revival in popularity, especially among older age groups in the cities, while in recent years there has also been a significant growth of hybrid commercialised forms of self-care which combine traditional Chinese health-related practices like taiji, qigong, and Buddhist meditation with new ideas and practices drawn from both modern Chinese and Western self-help movements and popular psychologies (Dear 2012; Farquhar and Zhang 2012; Farquhar 2013: 272–4).
In the discourse of western medicine and healthcare, the concept of self-care has a similarly long history and a variety of complex meanings. As Michel Foucault has emphasised, the idea and practice of self-care – or rather, of the
‘Cultivation of the Self’ – was already well established in Antiquity, and figures prominently in the works of philosophers and moralists such as Plato, Epictetus, Plutarch, Seneca, and Marcus Aurelius (Foucault 1990: 37–68), while for the Epi-cureans, philosophy itself was ‘a permanent exercise in the care of oneself’ (ibid.:
46). Subsequently, the classical tradition of self-care through self-cultivation went through many vicissitudes, partial revivals, and re-workings, but by the end of the twentieth century, for many people in the West, the ‘care of the self’ or ‘self-cultivation’ had become little more than a largely decontextualized, ad hoc com-bination of trendy health fads, including healthy dieting, jogging and exercise regimes, therapeutic dance routines, meditation, and self-help psychology.
In recent years, the classical Western discourse of self-cultivation, originally addressed to a gentlemanly and scholarly elite, has largely been replaced by a new, more impersonal and bureaucratic discourse concerning the strategic impor-tance attributed to self-care in the development of modern healthcare systems.
In this view, self-care, which has been defined as ‘the [intentional] care of one-self without medical, professional or other assistance or oversight’ (Stedman’s Medical Dictionary 2002, entry ‘Self-Care’), is seen as accounting for most of the so-called ‘continuum’ or ‘sliding scale of health care’, up to around 80% of all healthcare in the U.K., according to one recent estimate by the U.K. Self-Care Forum (Self-Self-Care Forum U.K.; Self-Self-Care Continuum). British-based health educators and health economists believe that raising people’s awareness of the benefits of self-care in the forms of healthy diets, regular moderate exercise, healthy and temperate life-style choices (giving up smoking, reducing alcohol consumption, etc.), and self-reliance in the treatment and management of minor common ailments and symptoms like winter coughs and sneezes can not only enhance people’s health and well-being and prolong life but could also save the National Health Service up to £2 billion a year, according to the U.K. Self-Care
Forum (Self-Care Forum U.K.). Self-care is seen as a crucial form of primary care for patients with chronic conditions such as diabetes and heart disease, as well as some psychiatric conditions such as Obsessive-Compulsive Disorder, and self-care or self-management education, often seen as an essential first step towards ‘patient activation’ (Hibbard and Gilburt 2014),3 is seen as complement-ing more traditional forms of patient education in such a way as to help people living with chronic conditions to enjoy a better quality of life. In the U.K., one week in every mid-November is officially designated ‘NHS Self-Care Week’, an event which has taken place every year since 2009, at first under the auspices of the Department of Health and subsequently of the national Self-Care Forum formed in May 2011 as a joint venture by the NHS Alliance, the Royal College of Nursing, the Royal College of General Practitioners, Public Health England, and the U.K. consumer health industry. The most recent such N.H.S. Self-Care Week was held on 12–18 November 2018, with the slogan ‘Choosing Self-Care for Life’
(N.H.S. Self-Care Week 2018). In October 2016, the English Local Government Association, which since 2013 has taken on important responsibilities for public health and health education in England and Wales, published Helping People to Look After Themselves: A Guide on Self-Care, to help local authorities devise and implement local strategies to promote self-care (Local Government Association for England and Wales 2016). At the launch of the new guide, the L.G.A. stated that ‘Millions of visits to the doctor for coughs and colds are unnecessary’ and advised people instead to visit their local pharmacies or the NHS Web site, claim-ing that greater self-reliance on the part of the public could help save general medical practitioners up to an hour’s consulting time every day (Local Govern-ment Association Press Release 2016). Self-care, or ‘Improving and maintaining your mental well-being’, also features prominently on the Web site of Mind, the principal UK mental health charity backed by both psychiatrists and mental health service users (Mind 2018), and in much contemporary debate about how best to advise people living with mental health conditions to help themselves.
At the same time, self-care has taken on a variety of more specialised meanings in certain sub-sectors of the healthcare system. Thus self-care figures largely in modern nursing theory, where the ‘self-care deficit theory’ of the American nurs-ing educator Dorothea Orem (1914–2007) has been highly influential as a way of defining the sphere of nursing as occupying the space between self-care, on the one hand, and specialised professional medical or surgical intervention on the other. Viewed in this light, the restoration or attainment of the maximum level of self-care appropriate to the condition and to the patient is seen as the ultimate goal of nursing (Orem 2001; Hartweg 1991; Nursing Theory; Theoretical Foundations of Nursing 2011). In the work of Donald Kalsched and other Jungian psycho-therapists, self-care or, more precisely, ‘the psyche’s archetypal self-care system’
(Kalsched 1996: 4), is understood as a deep psychological defence mechanism developed to protect young and growing personalities from the effects of over-whelming physical, emotional or psychological trauma through intra-psychical processes of dissociation, blocking, and ‘splitting off’ (ibid.: Chs. 1–6). This is a highly specialised usage which hardly enjoys widespread currency outside the
rather select circles of Jungian analysis. But whether as a potential cure for the chronic deficits of healthcare systems in both developed and developing countries, as a means of successfully managing chronic physical or mental health conditions without the need for constant medical supervision, or as a key element of nursing theory and practice, raising the level of effective self-care through ‘patient activa-tion’ is a pervasive theme in modern healthcare discourse and a key strategic goal of contemporary healthcare policy-making.
Self-care in Zhang Yang’s Shower
All this may seem a far cry from the very concrete, small-scale, localized, and person-centred forms of self-care portrayed in the Chinese director Zhang Yang’s 1999 tragi-comic film Shower 洗澡 (Xi Zao), a ‘family drama’ of father-son rela-tionships set in an old-style privately owned Beijing communal bath-house.4 But despite the distinctive setting of Zhang Yang’s film and the great cultural dis-tance between the very traditional, unmedicalised forms of healthcare and aids to well-being portrayed in Shower and the modern Western medical discourse around self-care and patient activation, the stark contrast between Chinese tradi-tion and modernity within the film itself permits certain indirect but instructive comparisons to be made between Chinese and Western understandings of the role of self-care and mutual aid in the maintenance of health and well-being. Shower presents a vision of self-care among the mainly elderly and entirely male clientele of a somewhat dilapidated, unpretentious bath-house in an old hutong neighbour-hood of Beijing which is in sharp contrast to the hurried, mechanical, and totally impersonal hygienic services provided in the fast-paced, money- and technology-dominated world of contemporary China, as shown in the unforgettable opening scene at the totally mechanised urban ‘Shower Station’. In Old Liu’s bath-house, the all-male and mostly elderly clientele enjoy the benefits of a person-centred cul-ture of care based on the traditional creacul-ture comforts of the bath-house (massage, cupping, hairdressing, and pedicure, as well as bathing) and the values of personal service, face-to-face contact, mutual respect, and a broad measure of tolerance for the eccentricities and failings of others, all mediated through the physical and spir-itual healing powers of water and massage. The bath-house serves as a refuge from the modern world where those clients fortunate enough to be able to spend several hours a day bathing can sip tea or rice wine, obtain relief from their various aches and pains, read the newspapers, play Chinese chess, gamble on fighting crickets, seek advice and guidance – or at any rate sympathy – for their marital and domestic woes, imagine themselves as operatic tenors, exchange gossip and insults, and gen-erally pass the time in relaxing and mostly harmless pursuits. In the process, they learn to understand and appreciate each other’s qualities, limitations, and foibles and in doing so, reaffirm and strengthen their common humanity. For the devoted proprietor Mr Liu, his two sons Da Ming and Er Ming, and their regular clientele, the bath-house serves as a kind of school in the art of living well which does as much to enhance their psychological and spiritual well-being, and ultimately their common humanity, as it does their bodily health and physical comfort.
Self-care, Yangsheng and mutual aid in Shower
In another context, all these various creature comforts and forms of healthy recre-ation would probably be regarded as aspects of yangsheng, the traditional Chinese art and practice of ‘nurturing life’ (Farquhar and Zhang 2012: 14–18, 21–2, 26–8).
However, the relationship between the forms of physical therapy and pleasant pastimes depicted in Shower and the wider culture of yangsheng is not quite as straightforward as this might suggest. Indeed, if we take Judith Farquhar and Zhang Qicheng’s book Ten Thousand Things: Nurturing Life in Contemporary Beijing (2012) as a guide, we find that while this book is all about yangsheng, the authors do not speak of ‘Self-Care’ as such. There is no entry ‘Self-care’ in the Index, although there are numerous references to ‘Self-cultivation’ (zixiu 自 修) and ‘Self-health’ (ziwo baojian 自我保健). Nor are there any references to bath-houses, bathing or water in the Index, although there are a few references to massage, particularly self-massage, and qigong and many to taiji and other aspects of Chinese medicine and healthcare which do not feature in the film (ibid.:
345–7). Several pages of Farquhar and Zhang’s book are devoted to an apprecia-tion of Ning Ying’s 1993 film For Fun 找乐 (Zhao Le), which centres around the amateur outdoor performance of Chinese opera as a form of recreation, and there is also a brief discussion of Ning Ying’s later film Perpetual Motion 无穷动 (Wu qiong dong) (2005), but curiously there are no references to Zhang Yang’s Shower (ibid.: 90, 102–6). However, the film itself contains a number of scenes and visual clues which are clearly intended to place the physical comforts and amenities pro-vided by the bath-house within a wider context of activities which are recognis-ably ‘life-nurturing’. Thus we twice see a troupe of female fan-dancers rehearsing in the park very near to the bath-house entrance, along with a man in a shell-suit apparently practising qigong, while Old Liu and his younger son Er Ming’s even-ing jogs through the park and the quarter take them past the local outdoor theatre in which Miao Zhuang, a shy fat boy who is one of the bath-house’s regular clients and who fancies himself as a budding operatic tenor, attempts to give a rendition of ‘O Sole Mio’. There are also a number of key scenes which clearly show that the three surviving members of the Liu family, father and sons, and at least some of their regular clients are fully aware of the deep psychological and symbolic resonance and even spiritual significance of water and of the bath-house as a kind of aquatic healing sanctuary. In addition to the dreamlike scenes harking back to the extraordinary sacrifices made by her peasant family to allow Er Ming’s mother to take the traditional bath prescribed for the eve of a young girl’s marriage in rural Shaanxi and to an epic Buddhist pilgrimage by an aged Tibetan grandmother and her granddaughter to bathe in a sacred, snowbound lake, there are a number of unmistakeable visual connections during the second half of the film to the idea of water as the source of all life, and as a gateway to the next world, to the maternal waters of the womb, and to immersion in water as a sign of both physical and spir-itual rebirth and renewal. This is apparent not only in the scenes just described, but also in several others in which Er Ming slides beneath the waters of the bath-house and holds his breath for a minute or more, at first in friendly competition
with his father, but then latterly as a means of escape and possibly even suicide when faced with the abrupt and tragic ending of his previously ordered and secure way of life following his father’s death and the authorities’ decision to demolish the bath-house. At several points in the film, we also see altruistic love or compas-sion wordlessly manifested through the medium of water, as when Old Liu opens up the valves of the bath-house to allow his estranged elder son Da Ming to enjoy a shower, or when Er Ming unexpectedly intervenes with a garden hose at a local open-air variety show in the park to enable Miao Zhuang to overcome his shyness and finally perform ‘O Sole Mio’ in public. In a key scene half-way through the film, Da Ming is woken by a violent storm in the middle of the night, and goes to the aid of his elderly father who has climbed out onto the leaky glass roof in the torrential rain to try to stop the rainwater pouring into the bath-house with tarpaulin sheets, while in another important episode, Mr Zhang, a regular client who habitually takes refuge in the bath-house from his wife’s constant nagging and scolding, eventually manages to overcome his impotence (or so we may infer) and be reconciled with his estranged wife in an after-hours tryst in the bath-house discreetly arranged by Mr Liu.
The story of Mr and Mrs Zhang is not without its comic side, but it also high-lights the extent to which the bath-house and its culture of care have become a focal point for mutual aid involving both the staff and the clientele. In much con-temporary discourse about the role of care in healthcare and medicine, self-care is implicitly contrasted with the hi-tech, capital- and labour-intensive forms of socialised medical and healthcare provision characteristic of most developed nations. But in Shower, self-care also goes hand-in-hand with relatively low-tech and spontaneous expressions of a communal lay tradition of mutual aid, which extends well beyond the sphere of physical health to include aspects of psycho-social and even spiritual well-being. Just as in Old Liu’s bath-house, the care and maintenance of physical health go along with the nurturing and enhancement of emotional and spiritual well-being, so do self-care and mutual aid appear as two sides of the same coin. This is one of the most important ‘messages’ of the film, one which takes the discourse of self-care to a level seldom attained in modern Western discussions of the role of self-care in individual health maintenance or health policy for the ‘community’.
Bodily and community care in ‘Shower’
In Shower, ‘self-care’ is not a psychological process or psycho-therapeutic prac-tice as such, nor is it a cure-all for the financial insolvency of healthcare systems, but rather, a system for maintaining bodily health and physical well-being through bathing, massage, cupping, tea-drinking, and other forms of relaxation, which indirectly serve to enhance the psychological and even spiritual well-being of the bath-house customers. The psychological benefits of the physical therapies offered by the bath-house are highlighted by wordlessly contrasting them with
In Shower, ‘self-care’ is not a psychological process or psycho-therapeutic prac-tice as such, nor is it a cure-all for the financial insolvency of healthcare systems, but rather, a system for maintaining bodily health and physical well-being through bathing, massage, cupping, tea-drinking, and other forms of relaxation, which indirectly serve to enhance the psychological and even spiritual well-being of the bath-house customers. The psychological benefits of the physical therapies offered by the bath-house are highlighted by wordlessly contrasting them with