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Behaviour Research and Therapy 45 (2007) 901914 www.elsevier.com/locate/brat

Would Confucius benet from psychotherapy? The compatibility of cognitive behaviour therapy and Chinese values
Julie Hodgesa, Tian P.S. Oeia,b,
b

School of Psychology, The University of Queensland, Brisbane, Qld. 4072, Australia CBT Unit, Toowong Private Hospital, The University of Queensland, Brisbane, Qld. 4072, Australia Received 11 July 2005; received in revised form 10 August 2006; accepted 18 August 2006

Abstract The purpose of the present paper is to explore the conceptual compatibility between cognitive behaviour therapy (CBT) and the common values of Chinese Culture. In order to address such a question, the distinctive processes attributed to CBT (e.g., teaching of skills, emphasis on homework, cognitive processes, present/future focus), as summarized in the metaanalysis by Blagys and Hilsenroth [(2002). Distinctive activities of cognitive-behavioral therapy: A review of the comparative psychotherapy process literature. Clinical Psychology Review, 22, 671706], and the core values of Chinese Culture, determined through an integration of The Hofstede Project, [Hofstede, G.H. (1980). Cultures consequences: International differences in work related values. Beverly Hills: Sage]. The Chinese Value Survey [Chinese Culture Connection (1987). Chinese values and the search for culture-free dimensions of culture. Journal of Cross-Cultural Psychology, 18, 143164]. The Schwartz Value Survey [Schwartz, S.H. (1994). Cultural dimensions of values: Towards an understanding of national differences. In Kim, U., Trandis, H.C., Katiticibasi, C., Choi, S.C., & Yoon, G. (eds.), Individualism and collectivism: Theory, method and application (pp. 85119). Thousand Oaks, CA: Sage] were used. A strong degree of compatibility between the two was found and it is argued that rather than developing new indigenized therapies, with some structural changes to the processes of CBT, this therapy can be effective for Chinese clients. It is further proposed that Chinese clients may benet from challenging their irrational cognitions that are bound up in their strict adherence to social norms. Future recommendations for increasing the compatibility of CBT to Chinese culture are discussed. r 2006 Elsevier Ltd. All rights reserved.
Keywords: Cognitive behaviour therapy; Chinese; Culture; Values; CBT processes

Introduction In Western societies, psychological problems such as anxiety and depression have long been formally recognized and diagnosed as disorders, to the extent that, by 1952 the rst Diagnostic and Statistical Manual of Mental Disorders had been published. Psychotherapy for the treatment of such mental disorders has been systematically studied and applied in the West (Nathan & Gorman, 1998), however, in Eastern societies such as China, recognition and diagnosis of psychological disorders did not even begin to occur until after World
Corresponding author. School of Psychology, The University of Queensland, Brisbane, Qld. 4072, Australia.

E-mail address: oei@psy.uq.edu.au (T.P.S. Oei). 0005-7967/$ - see front matter r 2006 Elsevier Ltd. All rights reserved. doi:10.1016/j.brat.2006.08.015

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War II (Chang, Tong, Shi, & Zeng, 2005; Kleinman & Kleinman, 1999a, b). It is suggested that this delay was due to the severe social stigma attached to mental problems, which were attributed to incorrect political thinking (Bond, 1993). Consequently, the somatic expression of emotional distress in Chinese communities was more acceptable and also elicited far greater social support (Chang et al., 2005; Kleinman, 1982; Lee, 1999; Oei & Goh, 1998; Yan, 1999). Indeed, it has been proposed that the Chinese have learned to listen with their bodies, and what has become known as somatization is not equivalent to a lack of psychological awareness, rather, the two may well co-exist (Bond, 1996; Chen & Davenport, 2005). Over the past several decades however, there have been substantial changes within Chinese communities. It is now accepted that the Peoples Republic of China has been transformed from a poor agricultural society to an emerging industrial power (Chang et al, 2005). This has led to the experimentation of Western ideas in many facets of society and consequently a greater acceptance of Western diagnoses and psychological treatment of mental disorders (Jenni, 1999; Kleinman & Kleinman, 1999a, b; Kleinman, Kleinman, & Lee, 1999). The liberalization of the democratic process, global media saturation and commercialism has led to rising rates of disorders such as depression, anxiety, and suicide, along with increased violence, trauma, and substance abuse, a weakening of community support networks, and greater competition in the workplace (Chang et al., 2005; Kleinman et al., 1999). Statistics from the Chinese Health Ministry indicate that currently 12.97% of children and teenagers under the age of 17 years have behavioural problems and 16% of college students suffer from anxiety, fear, neurasthenia or depression. Additionally, 250,000 people each year commit suicide, which is a rate of around 2030 per 10,000 compared with a world average of 14 per 10,000. As a consequence, the Chinese government has recently acknowledged the social burden caused by the increase in both diagnosis and incidence of mental disorders and has committed to improve psychological services to cater for the demand for such treatments (Chang et al., 2005; Oei & Goh, 1998). Individual cognitive behaviour therapy (CBT) has proved efcacious in the treatment of many psychological disorders in Western society (Chambless & Ollendick, 2001; Nathan & Gorman, 1998). Group CBT has been shown to be similarly efcacious (McDemut, Miller, & Brown, 2001; Morrison, 2002; Oei & Dingle, 2002, 2006). Despite limited available empirical evidence for its therapeutic efcacy in Asia, support for both individual and group CBT has increased in popularity since the early 1960s (Chang et al., 2005; Mingyi, Smith, Chen, & Guohua, 20012002; Oei & Goh, 1998; Oei, 1998; Abstracts of the rst Asian cognitive behaviour therapy conference, 2006). The core values of Chinese culture were chosen for the examination of the conceptual compatibility of CBT and Asian culture due to the fact that China accounts for 25% of the worlds population, is the largest Asian group in the United States, and that Chinese culture is the most widely practiced in Asia (Chen & Davenport, 2005; Mingy et al., 20012002). The wholesale transfer of Western CBT technology to the East, however, raises a number of questions regarding its validity and utility for non-Western cultures (Oei, 1998), specically for the Chinese culture (Chang et al., 2005; Lin, 2002; Oei & Goh, 1998). As such, the current paper aims to: (i) examine, from a more conceptual perspective, whether the processes of CBT are compatible with the core values of Chinese culture, (ii) document existing evidence supporting the proposed compatibility, and (iii) suggest modications to Western CBT processes that will allow smoother integration and greater acceptability of this therapy for Chinese clients. At rst inspection, the question of the compatibility of CBT and Chinese values seems to defy analysis. CBT is composed of a number of sub-theories. For example, Becks theory of depression (Beck, 1976), Elliss rational emotive behaviour therapy (Corey, 2001) and Clarks model for anxiety (1988) are all examples of the different theories and models that are collectively called CBT. Chinese culture is no less complex, and since 1976 the Chinese culture has undergone many multifaceted and rapid changes. Many traditional values and ways of life now co-exist with new, transitional values (Gao, 2001). Indeed, it has been advanced that all cultures are neither static nor homogenous, but reect intragroup diversity and change (Gao, 2001). Therefore, in order to examine the conceptual compatibility between CBT and Chinese culture it must rst be decided which values support, maintain, and are indeed representative of Chinese society (Bond, 1996). Given that CBT only gained prominence in China at the end of the Cultural Revolution, the available empirical research does not provide sufcient evidence on which to base the decision of compatibility (Lin, 2002). To use such evidence to draw conclusions about the relationship between CBT and Chinese culture only provides misleading, supercial and variable-specic explanations. Indeed, although the documented results are promising, drawing conclusions regarding the use of CBT for Chinese clients, based on the available

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evidence (i.e., small samples from specic geographic locations or socioeconomic backgrounds and specic populations such as HIV patients, depressed elderly, or adolescents) can only be misleading. Given these circumstances, and in order to generate a parsimonious explanation, the relationship between CBT and Chinese culture is best examined at a conceptual level. Therefore, rather than examining the differences that exist between CBT theories, it is more important to look for the processes that unite CBT, and which also differentiate it from other therapies. Similarly, rather than looking for differences amongst the Chinese, the challenge is to identify a set of commonalities that can be used to dene Chinese culture. For the purposes of this paper, Chinese refers both to people living in Asian countries, that is, in The Peoples Republic of China, Taiwan, Hong Kong and Singapore and also those Chinese living in overseas countries. While it might seem that the process of acculturation would accentuate the diversity of values between expatriates and Chinese living in Asian countries, there is empirical evidence to the contrary (e.g., Chen & Davenport, 2005). A study conducted by Kim, Atkinson, and Yang (1999) revealed that in Asian Americans, behavioural acculturation occurs more rapidly than value acculturation such that three successive generations of Chinese living in the United States (US) displayed signicant differences on a behavioural measure, but none on a value measure. These authors note that while Asian Americans may adopt the behaviours of the US culture, which are needed to survive, they may maintain their Asian cultural values indenitely. It is justied, therefore, adopting a cautious approach and assuming that in order to provide culturally sensitive interventions it is better to assume that Chinese clients still hold many traditional values (Chen & Davenport, 2005; Kim et al., 1999). Our overarching aim is to identify if there exists compatibility between the processes of CBT (Ablon & Jones, 1998, 1999; Blagys & Hilsenroth, 2002; Burns & Spangler, 2000; Castonguay, Goldfried, Wiser, Raue, & Hayes, 1996; Goldfried, Castonguay, Hayes, Drozd, & Shapiro, 1997) and an identied set of Chinese values (Bond, 1993). By both identifying the distinctive features of CBT and isolating a set of values representative of Chinese societies, it will then be possible to determine where both congruence and incompatibilities exist. Assuming such compatibility, CBT can then be further rened to achieve the most effective treatment for Chinese clients. To this end, the processes of CBT and Chinese cultural commonalities will be examined in isolation and then a conceptual compatibility between the two will be explored. Distinctive processes of CBT The early conceptualization of CBT was based on irrational thinking. Later, CBT was broadened to include self-statements, negative thought processes, catastrophic thinking and meta-cognitions. Information processing was later used to dene this therapy (Brewin & Holmes, 2003; Casey, Oei, & Newcombe, 2004; Dalgleish, 2004). CBT is now so complex that there is no single easy way to accurately dene it. This complexity has led to difculties in demonstrating that CBT is distinctly different from other forms of psychotherapy. It has only been in recent years that empirical evidence has been produced that differentiates CBT from other psychotherapies (Ablon & Jones, 1998, 1999; Blagys & Hilsenroth, 2002; Burns & Spangler, 2000; Castonguay et al., 1996; Goldfried et al., 1997). Comparative psychotherapy process literature was examined in order to determine the aspects of CBT that differentiated it from other therapies, and also from the common processes of therapy. The meta-analysis by Blagys and Hilsenroth (2002) summarizes the distinguishing processes and values unique to CBT in order to specify its treatment-specic processes (Table 1). A wide variety of psychometrically sound instruments (reported in Table 2) were used to examine the comparative literature between CBT and Psychodynamic Therapy (Ablon & Jones, 1998, 1999; Blagys & Hilsenroth, 2002; Burns & Spangler, 2000; Castonguay et al., 1996; Goldfried et al., 1997). This meta-analysis found evidence to support six distinctive processes that characterized CBT. These processes (Table 4) have been ordered according to the amount of differentiating evidence: (1) The use of homework outside of therapy sessions: The purpose of homework within the CBT session is to practice skills learned in therapy and to generalize such skills to real-world situations. This out-of session work is believed to equip a client with the ability to cope with symptoms outside of sessions and is considered important for maintaining gains even after the treatment is concluded. (2) Direction of session activity: Cognitive Behavioural Therapists were found to exhibit control over the process of therapy by setting an agenda, utilizing pre-planned techniques at specic times during the session, deciding what would be discussed prior to the session and actively directing the client towards specic topics

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904 J. Hodges, T.P.S. Oei / Behaviour Research and Therapy 45 (2007) 901914 Table 1 Sample of studies representing the six distinctive processes of CBT (Blagys & Hilsenroth, 2002) Study Jones and Pulos (1993) Participants Twenty-ve women, 7 men with a diagnosis of MDD received CBT and pharmacotherapy alone and combination Panel of expert CB therapists (n 10) Findings PQSCBT rated higher (po0.001) than alternate therapy on discussion of specic activities or tasks to attempt outside of session (item 38) Discussion of specic activities or tasks for the patient to attempt outside of session (item 38) rated as highly characteristic of CB therapy PQS item 38signicantly more characteristic (po0.001) of CBT than alternate therapy Aspect of CBT Homework

Ablon and Jones (1998)

Homework

Ablon and Jones (1999)

Twenty-nine patients diagnosed with MDD National Institute of Mental Health Treatment of depression Collaborative Research Project (NIMH TDCRP) One hundred and eighty patients with MDD NIMHTDCRP

Homework

Hill et al. (1992)

Collaborative Study Psychotherapy Rating Scale(CSPRS: Hollon et al. 1998)CB therapists scored higher (po0.01) on items measuring the use of homework than alternate therapy System for Assessing Therapist Communication (SATC)behaviourists used direct guidance techniques signicantly more (po0.01) than alternate therapist Verbal response modes (VRMtherapists advised their clients using commands, permission, or prohibition signicantly more (po0.02) than alternate therapist PQSTherapist actively exerts control over the interaction (item 17) was signicantly more (po0.001) characteristic of CB than alternate therapy CB therapists talked more during patient narratives (po0.001) than in alternate therapy CSPRSCB therapists rated signicantly higher (po0.01) on behavioural skills than alternate therapists Shefeld Psychotherapy rating scale (Shapiro & Startup, 1990CB therapists rated signicantly higher (po0.001) on items measuring behavioural skills, operant approaches and rationale for behavioural approaches CB participants rated their therapists as signicantly higher (po0.01) on behavioural task dimension than alternate therapists

Homework

Brunink and Schroeder (1979)

Eighteen expert psychoanalytic, gestalt and behaviour therapists Eighteen CB therapists, 31 sessions

Direction of session activity

Wiser and Goldfried (1996)

Direction of session activity

Ablon and Jones (1999)

Twenty-nine patients with diagnosis of MDD NIMHTDCRP Seventy-two patients NIMHTDCRP One hundred and eighty patients NIMHTDCRP Therapists and patients from the second Shefeld Psychotherapy Project

Direction of session activity

Crits-Cristoph et al. (1999) Hills et al. (1992)

Direction of session activity Teaching skills

Startup and Shapiro (1993)

Teaching skills

Silove et al. (1990)

Eighty-one participants (28% cognitive therapy; 17% behaviour therapy; 7% CB therapy)

Teaching skills

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J. Hodges, T.P.S. Oei / Behaviour Research and Therapy 45 (2007) 901914 Table 1 (continued ) Study Jones and Pulos (1993) Participants Thirty-two patients with MDD receiving CB therapy and pharmacotherapy alone and in combination Thirty patients diagnosed with MDD Findings PQS Therapist tries new ways of behaving with others (item 85)CB therapist rated signicantly higher (po0.001) than alternate therapists Coding system of Therapeutic Focus (CSTF; Goldfried et al., 1989)CB therapy was signicantly more likely (po0.001) to focus on future time frames CSTFCB was signicantly more likely (po0.003) to focus on a patients future than alternate therapy PQS Therapist explains rationale behind his/her technique or approach to treatment (item 57) was rated signicantly higher (po0.001) than alternate therapists CSTF (Goldfried et al. 1989)CB therapists signicantly more likely (po0.002) to provide the patient with therapeutically relevant information than alternate therapists PQS (Jones, 1985)Therapist explains rationale behind his/her technique or approach to treatment (item 57) was rated as highly characteristic of CBT Minnesota Therapy Rating Scale (MTRS)Therapists offered explicit rationale behind therapy was (item 44) SPRS (Shapiro & Startup, 1990)CB therapists scored signicantly higher (po0.001) on items reportedly measuring cognitive rationale, assessing cognitive processes, and evaluating and changing beliefs than alternate therapists CSPRS (Hollon et al., 1988)CB therapists scored signicantly higher (po0.01) on items reportedly measuring cognitive rationale, assessing cognitive processes, and evaluating and changing beliefs than alternate therapists MTRSRaters found that therapists examined or encouraged the client to examine the validity of the clients beliefs (item 5) Raters found that therapists worked to set up the experiment for the client to test something he/she believes by gathering data relevant to the belief, or behaving differently than he/she might typically (item 23) Aspect of CBT Emphasis on future experiences 905

Goldfried et al. (1997)

Emphasis on future time frames

Goldfried et al. (1998)

Twenty-two patients

Emphasis on future time frames Provision of information

Jones and Pulos (1993)

Thirty-two patients diagnosed with MDD received CBT and pharmacotherapy alone and in combination Thirty patients diagnosed with MDD receiving CBT

Goldfried et al. (1997)

Provision of information

Ablon and Jones (1998)

A panel of 10 CB therapists

Provision of information

DeRubeis, Hollon, Evans, & Bemis (1982) Startup and Shapiro (1993)

Six videotaped therapy sessions Therapists and patients from the second Shefeld psychotherapy project

Provision of information Cognitive focus of CBT

Hill et al. (1992)

One hundred and eighty patients from NIMH TDCRP

Cognitive focus of CBT

DeRubeis et al. (1982)

Six videotaped therapy sessions

Cognitive focus of therapy

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906 J. Hodges, T.P.S. Oei / Behaviour Research and Therapy 45 (2007) 901914 Table 2 Instruments used in the examination of comparative psychotherapy literature Instrument PQSPsychotherapy Process Q-set (100-item instrument) (Jones, 2000) CSPRSCollaborative Study Psychotherapy rating Scale (Elkin, Parloff, Halley, & Autry, 1985) VRMVerbal response modes. (Stiles, 1992) MTRS (Minnesota therapy rating scale) DeReubis et al. (1982) SATC (system for assessing therapist communication) (Brunink & Schroeder, 1979) SPRS (Shefeld psychotherapy rating scale) (Shapiro & Startup, 1990) TFAI (therapeutic focus on action and insight) (Samoilov, Goldfried, & Shapiro, 2000) Purpose Assessment of therapistpatient interactions Measure of the content of the in-session therapeutic process Investigation of verbal response modes during therapy Assessment of designation of specic tasks Assessment of the amount of control a therapist exerts over the process of therapy Measuring the focus on behavioral skills Assessment of therapy focuses on present and future action

or tasks. In addition the authors found that CB therapists spoke twice as much and made more directive statements than psychodynamic therapists. (3) The teaching of skills to cope with symptoms: CB therapists were found to adopt a psychoeducational role in helping clients reduce, manage or control their symptoms. Specic strategies based on behavioural skills and techniques were adopted to achieve this purpose. (4) The focus on clients present and future experiences: It was found that evidence supported a greater focus on a time frame after the current session rather than past or childhood experiences. (5) The provision of information about a clients disorder: Moderate support was found to indicate that CB therapists provided clients with an explicit rationale for their treatment and detailed information in the form of books or handouts about their symptoms. (6) The focus on a patients illogical or irrational thoughts or beliefs: Moderate support was found for the cognitive focus of CBT based on testing, challenging and changing a clients beliefs. The meta-analysis conducted by Blagys and Hilsenroth (2002) found that these six processes differentiated CBT from Psychodynamic Therapy and from the general processes of therapy (Table 1). Are these identied processes compatible with Chinese culture? Chinese culture It has been suggested that values play a pivotal role in explaining cultural differences (Bond, 1996). For example, Schwartz (1994) described the basis of culture as the intentional and unintentional value socialization to which members of a society are exposed. Hofstede (1998) denes culture or mental software as broad, collective patterns of thinking, feeling, and acting that have important consequences for the functioning of societies, groups within societies, and individual members of groups such that one group is distinguished from another. To date, empirical studies of values have proved useful in comparing groups and explaining those observed behaviours perceived to represent cultural differences (Bond, 1994). However, what values underpin and maintain the social, economic and political systems of Chinese society? From a religious perspective, Confucianism, Buddhism and Taoism are the main ideologies underpinning Chinese culture. Each of these ideologies is characterized by many individual-level values and beliefs that are all valid representations of the Chinese culture. However, in order to make a judgement regarding the congruence between CBT and Chinese culture, it is necessary to decide not on individual-level values, but which country-level values best describe the Chinese (Bond, 1996). Studies such as The Hofstede Project (1980), The Chinese Culture Connection (1987) and The Schwartz Value Survey (1994) are useful in explaining such values (Bond, 1996), (Hofstede, 1980; Schwartz, 1994). Each of these studies has been able to conceptualize the psychology of countries by averaging, and then factor-analyzing value scores of a representative set of persons from that country (Bond,

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1996). The utilization of more sophisticated instruments and analyses, and the integration of the results from these studies have resulted in a more reliable and robust prole of culture-level values (Bond, 1996). By also combining a number of Chinese groups in a single study, it has been possible to determine what both unies and differentiates Chinese people. The Hofstede Study (1980) The Hofstede Study provided an analysis of work-related values of large numbers of employees (N4116,000) in multinational companies. Forty countries, including Taiwan, Hong Kong and Singapore were chosen for a country-level or ecological factor analysis (Bond, 1996). This analysis of the average response to 32 items tapping perceptions, personal goals, behaviour intentions and beliefs revealed four factors which accounted for 50 per cent of the total variance in self-assessed fears (Hofstede, 1980). These four factors were: (1) power distancethe maintenance of social ranks and respect for authority and an acceptance that power is unequally distributed; (2) individualismthe condition in which individual needs take precedence over group needs. There is a preference for loosely knit social relationships versus collectivism where there is a tendency to emphasize the interests and well-being of the group over those of each individual (Arindell, 2002). It should also be noted that Individualism displays a strong negative correlation with power distance (0.67); (3) uncertainty avoidancea preference for conformity and support for beliefs that promise certainty and institutions that protect order (Arindell, 2002) and; (4) masculinity femininitythe social gender roles, particularly the patterns of male assertiveness and female nurturance (Hofstede, 1980). The Chinese Value SurveyCVS (1987) The Chinese Value Survey was an attempt by a group of researchers, The Chinese Culture Connection, to establish an instrument that tapped fundamentally Chinese concerns. Accordingly, they reasoned that if results from an Eastern instrument correlated with ndings from a Western study, then the ndings would constitute a robust outcome. Four factors were identied: (1) integrationwhich includes such items as tolerance of others, non-competitiveness and trustworthiness, and reects a socially stabilizing emphasis (Chinese Culture Connection, 1987); (2) confucian work dynamismincluded thrift, persistence and ordered relationships reecting the Confucian work ethic. Interestingly respect for tradition, reciprocation and saving face loaded negatively on this factor; (3) human-heartednessrepresents kindness, patience and courtesy in dealings with others and; (4) moral disciplinerepresents the moral restraint and disciplined restraint required to follow the middle way. CVS integration and moral discipline correlated highly with Hofstedes factors of power distance and negative individualism (Chinese Culture Connection, 1987). The Schwartz Value Survey (1994) The Schwartz Value Survey, a sophisticated, theory-driven study provided the benchmark for other value instruments (Bond, 1996). This survey found that Chinese samples placed high importance on attributes such as, Hierarchy and Mastery (control), which emphasized hierarchical differences and highly regulated relationships. Four factors were identied by a higher-order analysis: (1) hierarchy-individualismfavouring a traditional, authoritarian inuence; (2) order and disciplineuncertainty avoidance, harmony, moral discipline; (3) confucian work ethicordered relationships, thrift, persistence, pragmatism and (4) achievement-oriented concernsmastery and diligent effort. Integration of the three culture-level studies yielded 12 common countries. Although any conclusions must be regarded as tentative, this integration demonstrates valuable value convergences. Bond (1996) found that whilst Chinese values were not generally similar, four culture-level values could be identied, (1) individualism-hierarchy, (2) orderly autonomy, (3) discipline-assertion, and (4) humanheartedness to be inuential in the day-to-day thoughts, beliefs and behaviours the Chinese people (Bond, 1996). Each of these ecological values is further expanded in Table 3. Having examined both CBT and Chinese values, the next step is to explore the extent of congruence between the distinctive activities of CBT and value convergences demonstrated in Chinese cultures. A study

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908 J. Hodges, T.P.S. Oei / Behaviour Research and Therapy 45 (2007) 901914 Table 3 Factor composition of integrated factor-level values (Bond, 1996) Individualism-hierarchy Egalitarian commitment0.95 Individualism0.86 Integration0.85 Intellectual autonomy0.63 Power distance0.79 Conservatism0.80 Hierarchy0.97 Orderly autonomy Uncertainty avoidance0.89 Intellectual autonomy0.70 Harmony0.69 Moral discipline0.57 Affective autonomy0.48 Discipline-assertion Confucian work dynamism 0.74 Moral discipline0.68 Affective autonomy0.73 Mastery0.73 Achievement-orientation Masculinity0.93 Human-heartedness0.91 Mastery0.48

conducted by Luk et al. (1991) offers support for the compatibility of the distinctive processes of CBT and Chinese culture. In this study 91 Hong Kong Chinese (M 29 years) with a variety of psychological disorders: psychosis in remission (n 17); depression (n 8); neurosis (n 34); adjustment problem (n 200) and personality disorder (n 12) took part in 12, 2-h sessions. Participants were assessed pre-treatment, posttreatment and at a 3-month follow-up using the General Health Questionnaire, the Family Adaptability and Cohesiveness Evaluation Scales, Social Adjustment Scale, Personal Stress prole, clinical symptoms and target problem. Treatment consisted of directive, group sessions that focused on discovering links between depressive thoughts and interpretations, affect and behaviour and cognitive restructuring (cognitive processes), homework assignments, problem solving and communication training (teaching skills). Signicant improvements were found in psychiatric symptoms, improved capacity to cope with problems and more involvement in social activities. Utilizing recent empirical studies as support (Tables 3 and 4), a conceptual relationship between CBT and a set of integrated values representative of Chinese culture is proposed. The compatibility of distinctive aspects of CBT and Chinese culture Direction of session activity The importance placed on the power distance, the hierarchical nature of society and relationships suggests that social ranks in Chinese society are well maintained and authorities are highly respected (Chang et al., 2005; Chong & Liu, 2002; Lau, 2000). For example, in the clienttherapist relationship, there is a power differential, which grants therapists the right to tell people what to do. Indeed if advice is not forthcoming, the therapist is often perceived as impersonal and afraid of accepting responsibility, especially by Chinese clients (Chang et al., 2005; Chong & Liu, 2002; Gao, 2001; Lau, 2000; Lin, 2002). The CBT therapist can use this to their advantage in therapy by actively dening the problem, setting goals and evaluating progress (Chong & Liu, 2002; Lau, 2000; Oei & Goh, 1998). As noted by Chong and Liu (2002), Lau (2000), and Lin (2002), therapists are more often perceived as effective if they assume some responsibility for the process of the session as well as the outcome. A study by Li and Kim (2004) further supports these conclusions. These authors investigated the effect of counseling style and client adherence to Asian cultural values with 52 Asian American college students (M 18.94 years) from a large mid-Atlantic university. Li and Kim (2004) found that those clients in the directive counseling condition (n 23) rated the counselor as more empathic, crossculturally competent and reported stronger client-counselor working alliance and reported greater session depth than those in the non-directive condition (n 29). Teaching of skills Based on power distance and social hierarchy, there is a dependence on external authority and expectation by the client of direct, practical and immediate solutions to problems. Indeed, Gao (2001) suggests that following the Chinese Cultural Revolution, pragmatism has become a general life principle. Therefore, this practical perspective, achievement orientation, and a belief in the Confucian work ethic, result in an expectation that effort and learning are necessary to solve problems (Chong & Liu, 2002; Lau, 2000; Lin, 2002;

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J. Hodges, T.P.S. Oei / Behaviour Research and Therapy 45 (2007) 901914 Table 4 Conceptual relationship between aspects of CBT and Chinese culture Aspect of CBT Direction of session activity Aspect of culture Individualism-hierarchy Power distance Hierarchical nature of society Expect direction from experts Authorities directions should be obeyed Power distance grants therapists power of telling people what to do Collectivism requires that if help is requested then advice is given, otherwise counsellor perceived as impersonal and afraid of accepting responsibility Orderly autonomy Uncertainty avoidance Teaching of skills Individualism-assertion Dependence on external authority Expect practical, useful and efcient ways for dealing with problems Discipline-assertion Confucian work ethicchange through diligent learning Ordered relationships Discipline-assertion Confucian work dynamism (persistence, reciprocation, ordered relationships) Dictates an expectation that solutions are directive and practical in nature Desired change achieved through diligent learning Discipline-assertion Emphasis on practical solutions to problems Growing emphasis on fast solutions to problems and looking forward Individualism-hierarchy Orderly autonomy Power distance/hierarchy Bound up with the idea of giving information or advice Part of change through diligent learning and application to problem Orderly autonomy Uncertainty avoidance means there are problems with thinking about thinking, relates to acceptance of structure, rules and norms without critical scrutiny Implications for the structure of therapy; time to identify unhelpful cognitions is longer Education about the therapy process to reduce anxiety Reframe roles of therapist and client so that the therapist is the expert in therapy but the client is the expert in their life Lin (2002) Gao (2001) Bond (1996) Bond (1999) Luk et al. (1991) Chong and Liu (2002) Lau (2000) Sue and Sue (1999) Exum and Lau (1988) Miller and Yang (1997) Smith and Wang (1996) Suggested modications References 909

None anticipated

Wong et al. (2002) Gao (2001) Bond (1996, 1999) Luk et al. (1991) Chong and Liu (2002) Lau (2000) Miller and Yang (1997) Gao (2001) Bond (1996, 1999) CVS (1997) Chong and Liu (2002) Lau (2000) Lin (2002) Foo and Kazantzis (2006)

Emphasis on homework

None anticipated

Focus on present/future experiences

None anticipated

Gao (2001) Lin (2001) Chong and Liu (2002) Lau (2000) Lin (2002) Gao (2001) Foo and Kazantzis (2006)

Provide client information about treatment disorder

None anticipated

Cognitive processes Irrational thoughts and beliefs

Longer time allowed identifying unhelpful thoughts Reframe irrational thoughts as impractical, maladaptive or unhelpful Reframe role of parents in a more positive and less absolute

Lin (2001) Wong et al. (2002) Lee (1999) Kleinman (1982) Luk et al. (1991) Gao (2002) Bond (1996, 1999)

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910 Table 4 (continued ) Aspect of CBT Aspect of culture Suggested modications way to allow the clients to entertain the possibility that parents might be wrong References Parker, Gladstone, and Chee (2001) CVS (1997) Chong and Liu (2002) Lau (2000) Molassiotis et al. (2002) Chen and Davenport (2005) J. Hodges, T.P.S. Oei / Behaviour Research and Therapy 45 (2007) 901914

Individualism-hierarchy Previously unacceptable to express negative emotions; seen as a criticism of the state and loss of face; culturally acceptable to express emotional distress through somatic complaints e.g. neurasthenia. Chinese can identify feelings via closed rather than open questions. Work towards more open dialogue

Luk et al., 1991). Chinese clients have the expectation that suggestions and advice will be given to direct their actions (Chong & Liu, 2002; Lau, 2000; Lin, 2002). They expect to learn practical and useful ways of managing their problems (Chong & Liu, 2002; Lau, 2000; Gao, 2001). It is anticipated then, that this educational aspect of CBT will be well received. Emphasis on homework The Confucian work ethic, achievement orientation, order and discipline all point towards the acceptance of CBT homework as a necessary aspect of change. The Chinese client is likely to expect that solutions to ones problems will be brought about by diligent effort and persistence (Bond, 1996; Chong & Liu, 2002; Lau, 2000; Lin, 2002; Wu, 1996). The expectation of work outside the session should, then, be readily accepted. Focus on present and future experiences Chinese values emphasizing Confucian pragmatism and direct solutions to problems, do not dwell in the past, but deal in the present with an eye to the future. Following the Cultural Revolution, China and its people looked forward with a growing emphasis on fast solutions to problems (Chong & Liu, 2002; Gao, 2001; Lau, 2000; Lin, 2001). For Chinese clients, change and acceptable solutions to problems, are bound up with the idea of information giving or advice (power distance). This aspect of CBT also relates to an expectation that diligent effort is necessary to achieve positive gains. Having access to information is an integral part of this process (Bond, 1996; Gao, 2001). Cognitive processes Identifying and challenging irrational thoughts or thinking, on the surface, appear to be the aspect of CBT that is least compatible with Chinese values. The hierarchical nature of society, respect for authority, discipline and uncertainty avoidance mean that Chinese people generally accept rules, norms and imposed structures without scrutiny (Bond, 1996; Chang et al., 2005; Lin, 2000; Molassiotis et al., 2002). Order and discipline, manifested as a concern for others and conservatism have contributed to a general lack of acceptance of the expression of negative emotions. Expressed emotions are perceived to disrupt group harmony and status hierarchies to the extent that Chinese people are more likely to express emotional distress through somatic complaints (Bond, 1993; Chong & Liu, 2002; Kleinman, 1982; Lau, 2000; Lee, 1999). Does this then present a barrier to the compatibility of CBT and Chinese Culture? Gao (2001) suggests that by challenging (albeit slowly) unhelpful cognitions, therapy might act as an agent for cultural change. While there is at present, limited and accessible empirical evidence demonstrating the effectiveness of CBT with Chinese clients, the

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evidence that does exist (e.g., Lin, 2000; Molassiotis et al., 2002) supports the use of CBT in a variety of situations including the socially sensitive research area of human immunodeciency virus (HIV) (Molassiotis et al., 2002). In this study, forty-six Hong Kong Chinese patients (M 39.1 years) symptomatic with human immunodeciency virus (HIV) were randomized into either group CBT (10 patients), a peer support counselling group (PSC; 10 patients) or a treatment as usual group (26 patients). The aim of the study was to improve mood and the quality of life and to decrease uncertainty in the patients illness. The intervention groups received 12-weekly sessions spanning 3 months. Mood assessment was carried out pre randomization, post-intervention and at three months follow-up. Quality of life and illness uncertainty were assessed pre-randomization and at 6 month follow-up. Results indicated that the CBT group showed statistically signicant improvement in mood, quality of life and illness uncertainty (Molassiotis et al., 2002). CBT and Chinese culture One of the expressed aims of cross-cultural therapy is to respect cultural traditions and differences. However, if such traditions exist as a legacy of not only Confucian tradition, but of a socialization process based on questionable political practice, should therapy transmit such traditions (Bond, 1996; Gao, 2001). CBT has the capacity to be an agent for positive cultural change by offering different perspectives and discourse styles (Chong & Liu, 2000; Gao, 2001; Lau, 2000). Indeed, in keeping with the shift in cultural values (Chang et al., 2005; Gao, 2001), it has been proposed that Chinese clients might benet from challenging irrational cognitions and illogical thinking that relate to the strict adherence to social norms (Lin, 2002). In order for this to occur some changes to the structure of CBT may be necessary (Table 4). Chen and Davenport, (2005) noted that the role of the teacher is well respected in Chinese culture and within the therapy Chinese clients expect direction and advice from the expert. While this is compatible with the direction of session activity in CBT, such expectations might also mean that Chinese clients are unwilling to disagree with the therapist. Chen and Davenport (2005) suggest that educating the Chinese client about the therapy process and reframing within-session roles so that the therapist is cast as the expert in therapy, but the Chinese client is the expert in his or her life can address this problem. The cognitive processes of CBT involving reasoning and thinking about thinking contradict somewhat the Chinese clients unquestioning acceptance of rules, norms and hierarchies (Chen & Davenport, 2005; Lin, 2002). Reframing irrational thoughts as unhelpful or impractical, and taking longer to identify such thoughts has been suggested as effective in addressing this general lack of critical scrutiny (Chang et al., 2005; Chen & Davenport, 2005; Gao, 2001; Lin, 2002). Finally, conceptualizing the role of the parent of the Chinese client as those who always have the best interests of the client at heart introduces the possibility that while this is the case, they may not always know what the client wants or needs (Chen & Davenport, 2005). Notwithstanding the suggested modications, ndings by Chang et al. (2005), Chen and Davenport (2005), Molassiotis et al.(2002), Wong, Sun, Tse, and Wong (2002) and Luk et al. (1991) suggest that the use of CBT in counseling Chinese people is successful. It does appear that CBT has much to offer Chinese clients. Indeed, given the similarities between Chinese values and those held by other Asian populations, there may be grounds for generalizing this compatibility to other Asian cultures. With appropriate modications it seems that CBT can be an effective therapy for Chinese clients. As Lau (2000) notes, the quest for an indigenous therapy is somewhat premature given the obvious compatibility between CBT and Chinese values, beliefs and current worldviews (Chang et al., 2005). There appears to be, among Asian therapists, a willingness to discard Western theories and therapies without empirical evidence demonstrating that they do not work, and subsequently create indigenous theories and therapies without showing that they do. Acknowledgements The preparation of this paper was partially supported by an ARC Discovery Grant. Professor Oei is also the Director of the CBT Unit, Toowong Private Hospital.

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