PsyCh Journal •• (2014): ••–••
DOI: 10.1002/pchj.75
Adapting cognitive behavioral therapy to meet the needs of Chinese
clients: Opportunities and challenges
Feng Guo and Terry Hanley
University of Manchester, Manchester, UK
Abstract: With the growing influence of China (Chinese people/culture) on the world’s politics, economy, and culture, the psychological
wellbeing of Chinese people is becoming increasingly important for both researchers and practitioners. Despite this, the cultural responsiveness of many conventional psychotherapeutic models has often been brought into question. In contrast, cognitive behavioral therapy
(CBT) is rapidly becoming one of the most popular approaches in the mental health service industry and has been successfully adapted into
many different cultural contexts. The current article is a theoretical discussion of the opportunities and challenges that CBT faces with
respect to how it might meet the cultural needs and preferences of Chinese clients. Suggestions for successful cultural adaptation are offered
based on existing research and practices. It is concluded that many features of CBT appear to match well with the Chinese cultural
perspective. However, despite this promising start further work is needed to focus specifically on its practical effectiveness for Chinese
clients.
Keywords: CBT; Chinese culture; counselor education; therapeutic adaptation
Correspondence: Mr. Feng Guo, Unit 1206, Student Castle, 1 Great Marlborough Street, M15NR, UK. Email: [email protected]
Received 3 June 2014. Accepted 9 October 2014.
Chinese people represent one of the largest population
groups in the world. Approximately one in every four people
today can be identified as ethnically Chinese (Lin, 2002).
Currently, the population of China is approaching 1.5 billion
persons (National Bureau of Statistics of China, 2012). It is
also the primary ethnic group of other Asian countries, such
as Singapore, Malaysia, and Indonesia. Further, there has
been an increasing flow of Chinese people immigrating to
other developed countries and regions every year. The
Chinese are becoming one of the largest immigrant groups in
countries such as the USA, Canada, and Australia. With this
growing Chinese influence on many of these countries, the
psychological wellbeing of this ethnic group should receive
not only local but also more international attention.
Although the need for psychological services targeting
specifically people with Chinese heritage has been identified
(Jenni, 1999; Miller, Yang, & Chen, 1997), there has been an
overwhelming hesitation by people from Asia, including the
Chinese, to access professional mental health support (Bui &
Takeuchi, 1992). Researchers have conducted numerous
empirical studies suggesting that Chinese people are less
likely to seek professional psychological help and that they
are more likely to dropout even if they do (Blignault, Ponzio,
Rong, & Eisenbruch, 2008; Ho, Au, Bedford, & Cooper,
2002; Shen, Alden, Söchting, & Tsang, 2006; Williams, Foo,
& Haarhoff, 2006).
There has been much speculation about why Chinese
people appear to be reticent to access psychological support.
Culturally, it could be argued that there is tremendous pressure for Chinese people to maintain a positive personal
image in order to protect the family or community reputation. Such a demand is further reinforced by the collectivistic
emphasis on placing the collective benefits over personal
needs. Thus, due to the potential shame associated with
psychological issues, Chinese people are more likely to keep
their mental health difficulties to themselves or within the
family circle, rather than to seek professional help (Williams
et al., 2006). Some scholars also suggest that Chinese people
are more likely to present psychological issues in somatic
forms and to seek help from medical doctors (D. Zhang,
© 2014 The Institute of Psychology, Chinese Academy of Sciences and Wiley Publishing Asia Pty Ltd
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CBT and Chinese Culture
1995). In addition, it is possible that Chinese clients would
experience greater hesitation in seeking psychological
support due to the culturally de-emphasized value of privacy
and confidentiality. As Chinese society is community orientated, it is acceptable and sometimes necessary for private
information to be shared to maintain the harmony of the
collective (Caldwell, Lu, & Harding, 2010; Meer &
VandeCree, 2002).
Furthermore, most of the currently operating psychological models were developed outside of the Chinese cultural
context (Hou & Zhang, 2007; Roland, 2006; Thomason &
Qiong, 2008). They were initially established based on
Western cultural references and individualistic values
(Benish, Quintana, & Wampold, 2011; Franklin, Carter, &
Grace, 1993; Liao, Rounds, & Klein, 2005; Shen et al.,
2006). As a result, Chinese clients are sometimes misdiagnosed or have difficulty establishing a positive working alliance with their therapists (Okazaki & Tanaka-Matsumi,
2010). Therefore, many researchers and practitioners have
argued that existing psychological approaches need to be
modified before applying them to culturally diverse populations such as Chinese people (Brown, 2009; Miller et al.,
1997; Wong, 2008).
The demand for cultivating culturally responsive psychological approaches is not limited to the Chinese population
alone. With rapid globalization, it has been an issue discussed in many communities all around the world. Multicultural research and practice are being presented at the center
stage of mainstream psychology (Hays, 2009; Hays &
Iwamasa, 2010). Some scholars have even recognized multiculturalism as the fourth wave of modern psychology
(Pedersen, Draguns, Lonner, & Trimble, 2002). One of the
major discussions within this field is around therapeutic
adaptation, which involves modifying key components of
therapeutic delivery to meet the needs and preferences of a
particular client group without compromising the fundamental principles of the practical or theoretical model (e.g.,
Benish et al., 2011; Nicolas, Aratz, Hirsch, & Schmiedgen,
2009). Many popular therapeutic models have become the
subjects of such processes, including cognitive behavioral
therapy (CBT).
CBT was developed during the 1960s by incorporating
cognitive principles with existing behavioral approaches
(e.g., Lin, 2002; Wilding, 2012; Wills, 2010). The fundamental assumption of CBT is that the ways in which people
think influence the ways they act and feel (Wills, 2010).
Through CBT, the therapist works with the client to identify,
evaluate, and potentially modify maladaptive cognitive and
behavioral patterns. Ultimately, it aims to facilitate the establishment of a more balanced system to regulate the client’s
thoughts, feelings, and actions. Practically, CBT is often
perceived to be solution focused and timely. It is designed to
efficiently identify the needs of the client and to develop
specific strategies to achieve them. CBT is also often
described as a directive approach. The therapist guides the
client to complete specific behavioral and cognitive tasks.
Furthermore, compared with other therapeutic models, CBT
places significantly more focus on psycho-education and
homework.
During the past decade, CBT has rapidly been solidifying
its position as the leading therapeutic model in the mental
health industry (Bernal, Jiménez-Chafey, & Domenech
Rodríguez, 2009; Wilding, 2012). Growing empirical evidence has demonstrated its efficacy and effectiveness in
treating a wide range of psychological issues, such as
anxiety, depression, and post-traumatic stress disorder
(Butler, Chapman, Forman, & Beck, 2006; Klien et al.,
2013). In addition, many of its characteristics allow CBT to
be effectively evaluated and implemented in a relatively
cost-effective fashion. Despite the criticism with respect to
its present status as the “golden boy” of psychotherapy, CBT
has a significant place in the development of international
psychology. It is because of its importance that this paper
aims to explore the opportunities and challenges for adapting
CBT to Chinese culture.
Cultural adaptation of CBT
As many of the current psychological approaches and theories are developed based on the majority culture, particularly
Euro-American social values (Henrich, Heine, &
Norenzayan, 2010), scholars have questioned the appropriateness of directly applying them to ethnic minority client
groups (Chentsova-Dutton & Tsai, 2010; Cheung, 2012;
Franklin et al., 1993). Additionally, despite acknowledging
the need for culturally responsive therapies, researchers have
revealed that very few of these tailored approaches are used
in the field (Bernal et al., 2009).
It has been suggested that in order to achieve higher
acceptability and effectiveness, many conventional
approaches to therapy need to be modified before implementing them with culturally diverse client populations
(Cheung, 2012; Kaiser, Katz, & Shaw, 1998; Ohnishi &
Ibrahim, 1999). Due to the particular popularity of CBT, it is
© 2014 The Institute of Psychology, Chinese Academy of Sciences and Wiley Publishing Asia Pty Ltd
PsyCh Journal
often adapted for clients from different cultural backgrounds
(Diaz-Martinez, Interian, & Waters, 2010; Jackson,
Schmutzer, Wenzel, & Tyler, 2006; Nicolas et al., 2009;
Shattell, Quinlan-Colwell, Villalba, Ivers, & Marina, 2010;
Shen et al., 2006). To date, researchers have suggested that
modified CBT can be effective within multicultural contexts
(Miranda et al., 2003). For instance, Diaz-Martinez et al.
describe a case study in which CBT strategies were incorporated with cultural values to understand and resolve psychological issues experienced by a Venezuelan woman. In
this particular case, Latino values of marianismo (selfless
sacrificing for the family), respecto (respect), familismo
(value of the family), and ser bien educado (describing
parents’ responsibility for the behavior of their children)
were taken into consideration when the therapist was making
sense of the automatic thoughts and core beliefs of the client.
These values also became a central component of the treatment formulation with respect to coping strategies and cognitive restructuring. In the end, the therapist was able to use
a culturally responsive version of CBT to ultimately have a
positive impact on the client’s overall psychological wellbeing (Diaz-Martinez et al., 2010).
With respect to Chinese culture, CBT was among the first
therapeutic approaches to be introduced to modern China
and it is now widely used (Lin, 2002). Because of the early
political alliance between China and the former Soviet
Union, behaviorism was extremely influential during the
initial development of Chinese psychology (LaVoie, 1989).
Further, because the majority of early psychology programs
in China were established as part of teacher education (Hou
& Zhang, 2007), behavioral modification was a major component in the training of many Chinese psychologists.
Despite its popularity, theoretical literature and empirical
research regarding the use of CBT in the Chinese cultural
context are scarce. In one study, Shen et al. (2006) evaluated
a Chinese CBT program taking place in Vancouver, Canada.
The program was delivered by Cantonese-speaking cognitive
behavioral therapists. In addition, Chinese traditional values
and principles were further incorporated into their practices.
For instance, recognizing the cultural emphasis on social
hierarchy and professional expertise, they took a more active
and instructive stance in their sessions. They also anticipated
their Chinese clients’ reluctance to discuss personal and
emotional issues and they were more tentative in their exploration of such subjects. Furthermore, the therapists in this
program fully acknowledged the contradiction between
cultural values and what CBT traditionally described as
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adaptive. The results of their evaluation were promising,
with both the treatment efficacy and acceptability of this
form of CBT being found to be positive for the Chinese
clients involved (Shen et al., 2006).
Scholars have offered several possible reasons for the
apparent amenability of CBT as a multicultural therapy
(Hays, 2009; Jackson et al., 2006). First of all, CBT places
more focus on conscious processes. It relies more on action
rather than verbal expression. Thus, it reduces the effects of
linguistic and cultural barriers. Secondly, it uses the client’s
own strengths and support systems to facilitate changes and
coping strategies, factors that are presumably founded on the
client’s own cultural background. Thus, the therapists are
able to develop culturally responsive interventions. In addition, the underpinning principle of CBT recognizes the idiographic nature of the client’s problems (Williams et al.,
2006). It acknowledges that the issues that are experienced
by clients are deeply rooted in the family structure as well as
the social and environmental background, much of which is
culturally defined. In other words, it is cognizant of the role
that culture plays in psychological well-being (Padesky &
Greenberger, 1995). Finally, inherent within CBT theory is
the desire to create a cooperative relationship between the
therapist and the client (Shawe-Taylor & Rigby, 1999; Wills,
2010). Such a stance further allows the evaluation and modification of the treatment to achieve cultural appropriateness.
Opportunities for CBT
Within the limited research currently available, it appears
that CBT is a viable candidate to be adapted to meet the
cultural needs and preferences of Chinese clients (Du, Jiang,
& Vance, 2010). In one study (Wong & Poon, 2010),
researchers randomly assigned Chinese participants to either
a culturally attuned CBT group treatment or a control group
treatment. In the culturally attuned treatment, several modifications were made. First of all, all of the technical terminologies of CBT were translated into colloquial language to
counter the potential cultural differences in language expressions. For instance, “automatic thoughts” were rephrased as
“thoughts traps.” Secondly, all worksheets used in the treatment were translated into Chinese. Third, to meet the cultural
preference for authority, the therapists took more active positions in the initial stages of the treatment. Finally, with consideration to the collectivistic nature of Chinese culture, the
therapists encouraged the clients to identify their cognitive
pattern through exploring their family and interpersonal
© 2014 The Institute of Psychology, Chinese Academy of Sciences and Wiley Publishing Asia Pty Ltd
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CBT and Chinese Culture
relationships. After 10 3-hour treatment sessions, the
researchers compared the levels of improvement between the
two groups. The results suggested that the participants
undergoing the culturally attuned CBT group treatment
showed significantly greater improvement with respect to
general health and many aspects of psychological well-being
(Wong & Poon, 2010).
Many writers have suggested that several features of CBT,
including its underpinning theoretical principles and operational characteristics, match well with the cultural needs and
preferences of Chinese clients (Chen & Davenport, 2005;
Lin, 2002; Williams et al., 2006). Additionally, it is recognized that the congruence between therapeutic principles
and the client’s experiences and expectations is positively
correlated with the effectiveness and acceptability of the
treatment (Lin, 2002; Zane et al., 2005). Some of these features are outlined in the sections below.
Directive
Although CBT is commonly quite directive in its application, it is not intended to take full control away from the
client. For instance, many CBT training manuals stress the
importance of the client’s own motivation in the process of
change (Wills, 2010). Further, it is recommended that the
therapist and the client should establish a collaborative
working relationship. However, because CBT treatment
focuses on completing specific tasks, it often requires the
therapist to take a more instructive stance and to be more
active in the process. Under the Western individualistic
cultural framework, such a stance may be criticized for
undermining the autonomy and willingness to change of the
client.
In contrast, the perception can be quite different in the
Chinese cultural context. The Chinese social structure is
highly influenced by Confucianism (Wu et al., 2002). Confucian teaching often refers to human interaction in terms of
three relationships: between older brother and younger
brother, between father and son, and between the people and
the king. It places great emphasis on social hierarchy. It also
demands respect and obedience (Kolstad & Gjesvik, 2014).
Within the therapeutic relationship, Chinese clients often
expect the therapist to take the position of the authority, such
as an expert or a teacher. They are more ready to be given
instructions and directions.
Many writers have argued that, for Chinese clients, being
directive shows the therapist is professional and knowledgeable. It facilitates the development of trust and a therapeutic
relationship (Chen & Davenport, 2005; Lin, 2002; Williams
et al., 2006). In contrast, failure to establish such a position
may result in a rupture of the therapeutic relationship. This
preference for a directive counseling style has been well
documented among Asian clients such as the Chinese people
(Li & Kim, 2004). In their study, Li and Kim assigned Asian
participants to directive and nondirective counseling conditions. They concluded that participants under the directive
condition reported the therapists to be more empathic and
cross-culturally competent. They also experienced greater
therapeutic alliance and session depth.
Task focused
Another defining feature of CBT is that generally it is viewed
as more task focused. It aims to identify the specific cognitive and behavioral processes associated with the issue.
Whether it is a negative thought pattern or a maladaptive
coping strategy, the therapist works with the client to identify
and eventually resolve it (Joseph, 2011).
The stance that CBT takes is very pragmatic and structured. Numerous contributions to the literature have illustrated that such a stance is often preferred by Chinese
clients (Kim, Li, & Liang, 2002; Leong, 1986; Williams
et al., 2006). First, traditional Chinese culture emphasizes
the value of avoiding interpersonal conflict and controlling
emotional expression (Yip, 2005). Chinese clients are
often not as in touch with their own feelings and have difficulty discussing them in therapy. Compared with other
therapeutic models, CBT relies less on the clients’ own
ability to articulate their emotions and feelings verbally.
Rather, it places more focus on resolving more specific and
tangible issues. Hence, it allows Chinese clients to work on
their emotional issues without necessarily having to relearn
the abilities such as internal dialogue and emotional communication. Further, by focusing more on the tasks, it
facilitates the reduction of anxiety associated with emotional exploration, at least during the initial stages of
therapy.
Second, some writers have suggested that traditional
Chinese culture places significantly higher value on tangible
and practical matters than its Western counterparts (Kolstad
& Gjesvik, 2014). Compared with Western philosophers
who were interested in abstract matters such as metaphysics,
Chinese scholars offered more thoughts on practical issues
such as ways to live day-to-day life (He, 2002). Even within
modern Chinese society today, people in general seem to
adopt a more materialistic or utilitarian attitude toward their
© 2014 The Institute of Psychology, Chinese Academy of Sciences and Wiley Publishing Asia Pty Ltd
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lives. Thus, it is not surprising that the Chinese clients often
expect to experience tangible changes earlier on in their
therapy.
In addition, many of the therapeutic terms and vocabularies used in therapy to describe and interpret feelings and
emotions are often constructed based on the majority cultural reference. The original connotations are sometimes lost
when a therapeutic model is adapted into a different cultural
context (Ng, Chan, Ho, Wong, & Ho, 2008). By focusing
more on solutions rather than exploration, CBT is able to
reduce the miscommunications and difficulties resulting
from language difference.
Finally, since the Cultural Revolution the Chinese education system might be viewed as placing more attention on
developing logical scientific ability, rather than artistic
expression. It could therefore be argued that many Chinese
people in contemporary society are more used to conceptualizing issues in a rational and structured manner. The stepby-step approach of CBT therefore matches well with this
cognitive strength of Chinese clients (Shawe-Taylor &
Rigby, 1999).
Psycho-education and homework
Another important characteristic of CBT is its use of psychoeducation and homework. Cognitive behavioral therapists
often educate their clients with various relevant psychological principles. They also assign tasks for clients to complete
independently between sessions. In this sense, the therapeutic process of CBT can be perceived as very similar to a
training program. Such perception is highly valued and preferred by Chinese clients (Sue & Okazaki, 1990; Williams
et al., 2006). The benefits can be twofold. First, Chinese
culture can be seen to place a high value on education and
knowledge. Such a belief is well illustrated by a popular
Chinese proverb: “a book holds a house of gold; a book
holds a face as smooth as jade.” The Chinese people generally expect to achieve financial security and even romantic
relationships through education. Even today in Chinese
society, despite rapid Westernization, academic achievement
is still placed at the center of individual development. Hence,
a counseling model with many educational features is likely
to be perceived as more credible for Chinese clients
(Williams et al., 2006). Second, because mental health services are often stigmatized in Chinese society (Williams
et al., 2006), reframing the service as a training program may
reduce such anxiety, therefore increasing the accessibility of
the therapy.
5
Challenges
Despite much promise, directly importing CBT into Chinese
culture still faces many challenges (Lin, 2002; Shen et al.,
2006). The core principles and operational guidelines of
CBT are developed based on the Western individualistic
world view. It promotes the individual’s autonomy and
ability to change. It also emphasizes the individual’s need
for self-development. However, such a value may not be
relevant in the Chinese collectivistic culture, where the needs
of community are placed before the needs of the individual
and the individual’s locus of control is often externalized.
Thus, many practitioners have agreed that CBT still needs to
be modified in order to be culturally responsive for Chinese
clients (Lin, 2002; Shen et al., 2006; Williams et al., 2006;
Wong, 2008). In the following section, the authors will
explore some of the challenges that CBT faces with respect
to cultural adaptation.
Culturally defined core beliefs
One of the major goals of CBT is to identify maladaptive
core beliefs and potentially replace them with more balanced
alternative beliefs (Joseph, 2011; Padesky & Greenberger,
1995; Wilding, 2012; Wills, 2010). For instance, for
someone with an anxiety issue, the assumption is that the
anxious feeling is likely to be mediated by maladaptive
beliefs such as “I cannot do anything right. I am useless.”
Therefore, the CB therapist often helps the client to recognize that such a belief is unrealistic, irrational, or unhelpful
(Joseph, 2011). Subsequently, to resolve the anxiety issue,
the therapist works with the client to construct more adaptive
beliefs such as “I can do things right if I work for it. And
even if I do something wrong from time to time, it does not
mean that I am a useless person.” Under the Western cultural
reference, beliefs such as “Anger is bad,” “I must take care of
others before myself,” and “If I say no, I am a selfish person”
place unrealistic demands on the individual. As a consequence, they may generate anxiety or depression and therefore are perceived to be dysfunctional. However, for Chinese
clients they are fundamental collectivistic values. They are,
in a way, the core of their cultural identity. Some researchers
(Chen & Davenport, 2005; Shen et al., 2006) have suggested
that challenging these beliefs prematurely may result in identity crisis and further anxiety. Many clients may even perceive it as a betrayal of their cultural heritage or a corruption
by Western values (Shen et al., 2006). The potential of rupturing the therapeutic relationship is quite high in this case.
© 2014 The Institute of Psychology, Chinese Academy of Sciences and Wiley Publishing Asia Pty Ltd
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CBT and Chinese Culture
Instead, it is suggested that the therapist try to work with the
client to find more flexible versions of these culturally rooted
beliefs.
Homework compliance
As mentioned earlier, because of the cultural emphasis on
education Chinese clients may generally appreciate the educational elements and the use of homework in CBT (Shen
et al., 2006; Williams et al., 2006). However, in reality,
researchers have observed a lower rate of homework compliance among this group (Shen et al., 2006). They either
refused or failed to complete assigned homework. There
were several possible reasons offered to explain this paradox
(Shen et al., 2006). These reasons are outlined below in turn.
1. Culturally, Chinese clients hold experts and authority
figures in high regard (Wu et al., 2002). In a therapeutic
relationship, Chinese clients may prefer to see the therapist as the teacher. They trust the professional knowledge
and advice of the therapist. However, they may also perceive the expertise of the therapist to be sufficient for the
treatment. Therefore, they may find any self-help type of
task such as homework to be redundant.
2. Chinese culture places great value on achievement, particularly academic achievement. Individuals are often
under tremendous pressure to perform positively. In addition, as members of the collective community, it is very
important for Chinese people to seek approval from
others, particularly from those who are perceived to be
authority figures. Under such circumstances, any mandatory assignment may provoke unnecessary anxiety, especially for clients who are already feeling overly anxious.
With respect to CBT homework, Chinese clients may be
under the impression that their results are evaluated and
judged by their therapist. Thus, to avoid the potential
shame associated with failure or poor performance, they
may refuse to engage in doing homework all together.
3. Finally, some forms of the CBT homework, such as the
thoughts diary, require clients to identify and record their
feelings and thoughts. However, this may be a difficult
task as Chinese culture emphasizes achieving well-being
through self-discipline and emotional restraint (Williams
et al., 2006). Chinese clients may be uncomfortable or
unable to access and describe their internal processes.
Practitioners have found evidence that Chinese clients
generally favor behavioral tasks over cognitive tasks
(Shen et al., 2006; Williams et al., 2006).
This low compliance rate does not mean that homework is
not suitable for Chinese clients. In fact, many Chinese clients
express that they fully recognize the usefulness of homework
(Shen et al., 2006). However, it does suggest that therapists
need to reconsider the way in which they approach homework for it to be utilized most effectively.
Lost in translation
The issue of cross-cultural communication is experienced by
most therapeutic models, including CBT. As the primary
delivery system of most psychological treatments, language
plays a central role in the effectiveness of CBT interventions.
Although the solution and task-focused approach of CBT
result in it being less affected by cultural linguistic differences, much of the terminology that is used to describe
behaviors and cognitions is still based on the Anglo-Saxon
languages. Therefore, they are deeply rooted in the EuroAmerican cultural context. Thus, it is easy for a non-Chinese
or even a Chinese therapist trained under the conventional
CBT model to misinterpret the client. The issue of inappropriate assessment among culturally diverse clients, such as
Chinese people, is well documented and can lead to serious
consequences (Hays & Iwamasa, 2010; Shen et al., 2006).
Furthermore, it should also be noted that Chinese clients
may also misunderstand the psychological terms used by the
therapists.
In their recent article Ng et al. (2008) discussed an
example of such cultural misunderstanding in psychological
assessment and treatment. As one of the most common diagnostic terms, the meaning of “depression” is relatively welldefined in Western psychology. Furthermore, definitions are
quite consistent between the professional and colloquial
terms. When discussed in treatment, it is often easily understood and communicated. However, the matter becomes
more complicated when the client is culturally Chinese. The
term depression is officially translated into Mandarin
Chinese as youyu 忧郁. Recent research using word association and semantic differential analysis (Ng et al., 2008) has
identified that depression and youyu are two distinctive emotional concepts. Youyu is more closely related to the experience of stagnation, which is closer to the sense of being
stuck. It describes only one aspect of depression; therefore,
its complete diagnostic meaning is lost here.
Although the differences in translation can sometimes be
seen as subtle, they impact on the therapist’s ability to assess
the needs and issues of the client. Without a comprehensive
understanding of the matter in hand, it is difficult to construct
© 2014 The Institute of Psychology, Chinese Academy of Sciences and Wiley Publishing Asia Pty Ltd
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an appropriate formulation. In addition, language issues may
also influence the client’s ability to comprehend the intention and instruction of the therapist. Therefore, the treatment
might be less effective. Further, the communication barrier
may prevent the establishment of a positive therapeutic
alliance. Thus, the therapy may become artificial and
ineffective.
Therapeutic alliance
Another major challenge that CBT faces with respect to
cultural adaptation is to establish a positive therapeutic alliance. Therapeutic alliance has been identified as one of the
primary common factors of any effective psychological
intervention (Horvath, Del Re, Fluckiger, & Symonds,
2011). For CBT, it is commonly surmised that a positive
therapeutic alliance must be established before any intervention can take place (Wills, 2010). The exploration of negative
automatic thoughts and core beliefs can be a frightening
process for clients and making changes to them can be even
more challenging. Therefore, it requires a tremendous
amount of trust between the client and the therapist. Without
a strong therapeutic alliance, it will be difficult for the intervention to have positive influence.
It could be argued that the importance of the therapeutic
alliance is even more significant with Chinese clients. Due to
the strong stigma associated with mental health issues,
Chinese clients are likely to perceive going to therapy as
negative or shameful (Williams et al., 2006). Therefore, they
may need even more emotional support and encouragement
to engage in therapy. Alternatively, Chinese society is highly
community orientated. As in many collective societies,
group cohesion is key to maintaining the appropriate social
structure. Further, on a micro level, group cohesion can be
reduced to interpersonal relationships. Unlike in many individualistic cultures, where the person’s own interest is
emphasized, in these collective societies the interpersonal
relation is the foundation of the community. In Chinese
culture, this relationship, also known as guanxi 关系, is an
essential concept for any social interaction. Thus, in the
therapeutic process, the establishment of guanxi often needs
to take place before any positive effect can occur. However,
as discussed previously, some issues regarding cultural differences, such as language and shared values, often prevent
the development of positive therapeutic alliances (Gelso &
Mohr, 2001). In one study, researchers compared the development of therapeutic alliances between Caucasian and
ethnic minority participants who were undergoing CBT
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treatment (Walling, Suvak, Howard, Taft, & Murphy, 2012).
The results showed that while Caucasian participants
reported significant increases in alliance scores, ethnic
minority clients were unchanged.
Therefore, in order for CBT to be effective with Chinese
clients, therapists have to pay particular attention to the development of the therapeutic relationship. Particularly, the therapist must become aware of the cultural differences in social
values, language, and communication styles. More points of
development for CBT, with respect to meeting the needs of
Chinese culture, will be discussed in the following sections.
Moving forward
As discussed above, CBT presents both opportunities and
challenges with respect to being adapted to the Chinese
cultural context. Encouragingly, most of its apparent challenges are related to the practical features rather than the
fundamental principles of the therapeutic model. Thus, it
would appear that CBT can be modified to meet the needs
and preferences of Chinese clients without compromising its
defining characteristics.
Several models for research and implementation have been
proposed to facilitate multicultural adaptation. Among them,
the Model for Effective Development and Translation of
Science into Practice (MEDTSP; National Advisory Mental
Health Council Workgroup on Child and Adolescent Mental
Health Intervention Development and Deployment, 2001)
and the Stage Model of Behavioral Changes (SMBT;
Rounsaville, Carroll, & Onken, 2001) are two of the most
popular (Nicolas et al., 2009). To fully acknowledge the complexity of intervention adaptation, the MEDTSP includes six
fundamental features: (a) underpinning research and theory,
(b) refining and adapting the intervention, (c) efficacy testing,
(d) transferring and translation, (e) identifying the effectiveness, and (f) incorporating social, economic, and cultural
elements. Similarly, the SMBT proposes three stages of adaptation: (a) identifying potential candidates, (b) efficacy study,
and (c) effectively transporting the treatment model. Both of
these models emphasize identification of the theoretical and
practical potential of the target therapeutic model, as well as
appropriate modification of the model.
Specifically for CBT, based on the identified challenges
noted above, several suggestions for modification are offered
to meet the cultural needs and preferences of Chinese clients
(Lin, 2002; Shen et al., 2006; Williams et al., 2006). These
are as follows.
© 2014 The Institute of Psychology, Chinese Academy of Sciences and Wiley Publishing Asia Pty Ltd
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CBT and Chinese Culture
1. Conventional CBT often focuses on using the client’s
personal/internal motivation to facilitate change.
However, because Chinese clients often perceive an external locus of control (Yip, 2005), these individuals may
believe that their ability to control a situation is partially
removed from them and placed in the larger community
or even predetermined destiny. In this case, the therapist
could consider using community resources and family
responsibilities to facilitate and support change.
2. Even though Chinese clients are capable and willing to
discuss their thoughts and feelings in therapy (Chen &
Davenport, 2005), research has suggested that they are
often reluctant to do so out of fear of being judged or
feeling embarrassed (Shen et al., 2006; Williams et al.,
2006). Therapists are therefore advised to be cautious
when directly exploring such topics. Some practitioners
have even suggested taking advantage of the perceived
cultural preference for task-focused approaches by using
the initial stage of the therapy for primarily behavioral
work and psycho-education (Williams et al., 2006). Cognitive tasks might then be introduced subsequently when
the therapeutic alliance is well established.
3. As discussed earlier, Chinese clients might be less likely
to complete homework tasks due to their cultural heightened fear of failure (Shen et al., 2006). Thus, it may be
helpful to present homework as an experiment for better
understanding of the self rather than as a task to be
completed. It may also be useful to remind the clients that
the homework is a strategy to be more efficient with time.
It allows the therapy to progress faster with the clients
doing some of the work between sessions.
4. Finally, some of the core beliefs that Chinese clients hold
are culturally relevant. They are deeply rooted in their
collective identities as members of the community.
Directly challenging them without caution may result in
further anxiety. However, if these beliefs are identified to
be maladaptive they should not be left without discussion.
In such a situation, rather than altering them completely,
the therapist could consider encouraging the client to take
an open stance to questioning the absoluteness of these
beliefs.
Conclusion
Before this discussion is concluded, it is important to point
out that it is not the intention of this paper to imply that
Chinese clients all belong to a homogenous population and
propose a single therapeutic model to meet all their needs
and preferences. Indeed, as with any client group, those who
identify as Chinese comprise extremely diverse and complex
social groups. However, because of their similar historical
and cultural heritage, it can be argued that there is a consistent pattern that can represent the characteristics of the
majority of the members of these groups and inform the
work of psychologists. As a point of discussion, the current
article rests on this epistemological stance.
In addition, Chinese culture has over 5,000 years of
history. During its development it has been influenced by
many philosophical and religious traditions, such as Confucianism, Taoism, and Buddhism. In the present article, the
discussions were developed mainly around the Confucian
elements and their influences in the adaptation of CBT. This
does not by any means reject the therapeutic and psychological significance of other cultural elements. However, the
Confucian elements were included based on their relevance
to the particular subject of this article.
During the past decade the inadequacy of the Western
reductionistic approach has been recognized within the
therapeutic community with respect to explaining the full
range of human experiences. Thus, a trend for incorporating Eastern philosophies and practices with Western
therapeutic approaches, as for example the growth of
Mindfulness practices in therapy, is becoming increasingly
commonplace. Many models have been developed based on
such premises, such as Acceptance and Commitment
Therapy, and their cultural responsiveness has been evidenced through recent research (Woidneck, Pratt, Gundy,
Nelson, & Twohig, 2012). This indicates the potential for
more extensive and comprehensive therapeutic adaptations,
which include for instance an attempt by practitioners in
China to develop a practical model that combines Taoist
doctrines with the practices of CBT, and which has
shown positive clinical effectiveness in initial evaluations
(Y. Zhang et al., 2002). While further exploration of such
specific cultural adaptations is indeed worthwhile, it is not
the focus of the current contribution and must be left for
attention in a future study.
An additional topic worth exploration is the question of
the core irrational beliefs in Chinese culture that may cause
anxiety or depression, and how these differ from the core
irrational beliefs in Western culture. Interesting as this
matter may be, the purpose of the current paper is to discuss
the adaptation of CBT, rather than exploring such differences, so we leave that topic as well to further study.
© 2014 The Institute of Psychology, Chinese Academy of Sciences and Wiley Publishing Asia Pty Ltd
PsyCh Journal
9
In conclusion, this article explored the promises and the
challenges of CBT with respect to meeting the cultural needs
and preferences of Chinese clients. Many of its features,
such as being commonly directive and task-focused, match
well with commonly perceived Chinese cultural references.
At the same time, because the approach has been developed
based on Western individualistic cultural assumptions, some
practices of CBT need to be modified for cultural responsiveness. Although more culturally responsive CBT models
are being developed, as suggested by the MEDTSP (National
Advisory Mental Health Council Workgroup on Child and
Adolescent Mental Health Intervention Development and
Deployment, 2001) and the SMBT (Rounsaville et al.,
2001), these new interventions need to be continuously
assessed in practice for efficacy and effectiveness.
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