Can a knife and fork be used to eat fried rice? - The compatibility of Cognitive-Behaviour Therapy and Chinese culture

Tian P.S. Oei [BIO] & Julie Hodges (The University of Queensland, Brisbane, Australia)

Abstract

Hodges and Oei have explored the conceptual compatibility between the distinctive processes of Cognitive-Behaviour Therapy (CBT) - an evidence-based western method of psychotherapy - and the common values of Chinese Culture that is rooted in three systems Taoism, Confucianism and Buddhism pervading the Chinese way of living. Can CBT be successfully applied to the Chinese population - can a knife and fork be used to eat fried rice? In order to answer such a question, the distinctive processes attributed to CBT, as summarized by Blagys and Hilsenroth (2002), and the core values of Chinese Culture, determined through an integration of The Hofstede Project (1980), The Chinese Value Survey (1987) and The Schwartz Value Survey (1994), were used. A strong degree of compatibility between the two was found. Future recommendations for increasing the compatibility of CBT to Chinese culture are made. References: Blagys, M., & Hilsenroth, M. (2002). Distinctive features of Short-Term Cognitive-Behavioral Psychotherapy: An Empirical Review of the Comparative Psychotherapy Process Literature. Clinical Psychology Review, 22, 671-706. Hofstede, G. H. (1980). Culture's Consequences: International Differences in Work-related Values. Beverly Hills, CA: Sage. Chinese Culture Connection, (1987). Chinese values and the search for culture-free dimensions of culture. Journal of Cross-cultural Psychology, 18, 143-164. Schwartz, S. H. (1994). Beyond individualism-collectivism: New dimensions of values. In U. Kim, H. C. Triandis, C. Kagitcibasi, S. C. Choi, & G. Yoon (Eds.), Individualism and collectivism: Theory, method and application (pp.85-119). Newbury Park, CA: Sage. A cknowledgement: 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.

In western societies, psychological problems such as anxiety and depression have long been formally recognized and diagnosed as disorders (DSM- I, 1952). 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, formal recognition and diagnosis of psychological disorders did not occur until after World War II (Chang, Tong, Shi & Zeng, 2005; Kleinman & Kleinman, 1999). A proposed cause of this delay was the severe social stigma attached to mental problems that consequently resulted in the somatic expression of emotional distress in Chinese communities (Chang et al. 2005; Kleinman, 1982; Lee, 1999; Oei & Goh, 1998; Yan, 1999). Over the past several decades, however, there have been substantial changes in the Chinese communities. It is now accepted that the People’s 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, !999; Kleinman & Kleinman, 1999; Kleinman, Kleinman, & Lee, 1999). The liberalizing of the democratic process, global media saturation and commercialism has led to rising rates of disorders such as depression and anxiety, 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, Kleinman & Lee, 1999). 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 efficacious in the treatment of many psychological disorders (Chambless & Ollendick, 2000; Nathan & Gorman, 1998) in the Western world. Group CBT has been shown to be similarly efficacious (Mcdermut, Miller & Brown, 2001; Morrison 2002; Oei & Dingle, 2002, 2005). Despite minimal empirical evidence for its therapeutic efficacy in Asia (Lin, Y-N, 2002) support for both individual and group CBT has increased in popularity since the early 60’s (Chang et al. 2005; Mingyi, Smith, Chen, Xia, 2001-2002; Oei & Goh, 1998). This is particularly true for China, and given that China also has the largest population in the world and that Chinese culture is the most widely practiced in Asia, Chinese culture was chosen for the examination of the conceptual compatibility of CBT and Asian culture (Mingyi et al, 2001-2002). 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 and specifically for the Chinese culture (Chang et al., 2005; Lin, 2002; Oei & Goh, 1998). This paper, then, aims to examine, from a more conceptual perspective, whether the processes of CBT are compatible with Chinese culture.

At first inspection, the question of the compatibility of CBT and Chinese culture seems to defy analysis. Cognitive Behaviour Therapy is composed of a number of sub-theories. Beck’s theory of depression (Beck, 1976), Ellis’s Rational Emotive Behaviour Therapy (Corey, 2001) and Clark’s model for anxiety (1988) are all examples of the different theories and models that are collectively called CBT. Chinese culture is no less complex. Since 1976, the Chinese culture has undergone many complex 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 reflect intragroup diversity and change (Gao, 2001). Therefore in order to examine the conceptual compatibility between CBT and Chinese culture it must first 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 sufficient 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, superficial and variable-specific explanations. Given these circumstances, and in order to generate a parsimonious explanation, the relationship between CBT and Chinese culture must be examined at a conceptual level. 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 define Chinese culture. For the purposes of this paper, ‘Chinese’ refers to people living in Asian countries, that is, in The People’s Republic of China, Taiwan, Hong Kong and Singapore. Overseas Chinese not living in the countries specified are not included as the process of acculturation accentuates the diversity of values amongst such expatriates. Our overarching aim is to identify if there exists compatibility between the processes of CBT (Ablon & Jones, 1998, 1999; Blagdys & Hilsenroth, 2002; Burns & Spangler, 2000; Castonguay, Goldfried, Wiser, Raue & Hayes, 1996; Goldfried, Castonguay, Hayes, Drozd, & Shapiro, 1997) and an identified 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 refined 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 Cognitive-Behaviour Therapy

The early conceptualisation of CBT was based on irrational thinking. Later, CBT was based on self-statements, negative thought processes, catastrophic thinking and then on meta-cognitions. Information processing was later used to define this therapy (Brewin, & Holmes, 2003; Casey, Oei, & Newcombe, 2004; Dalgleish, 2004). CBT is now so complex that there is no one, easy way, to accurately define it. This complexity has led to difficulties 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 differentiating CBT from other psychotherapies ( Ablon & Jones, 1998, 1999; Blagdys & 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 & Hilsenroth (2002) summarises the distinguishing processes and values unique to CBT in order to specify its treatment-specific processes. A wide variety of psychometrically sound instruments (reported in Table 1) were used to examine the comparative literature between CBT and Psychodynamic Therapy ( Ablon & Jones, 1998, 1999; Blagdys & 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 3) 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

Table 1. Instruments Used in the Examination of Comparative Psychotherapy Literature

at specific times during the session, deciding what would be discussed prior to the session and actively directing the client towards specific topics or tasks. In addition these 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. Specific strategies based on behavioural skills and techniques were adopted to achieve this purpose. (4) The focus on client’s 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 client’s 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 patient’s illogical or irrational thoughts or beliefs. Moderate support was found for the cognitive focus of CBT based on testing, challenging and changing a client’s 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. Are these identified processes compatible with Chinese culture?

Chinese Culture

Just as dreams have been described as the key to unlocking the unconscious, so values are thought to be the key in explaining cultural differences (Bond, 1996). Schwartz (1994) described the basis of culture as the intentional and unintentional value socialization to which members of a society are exposed. Hofstede (1998, p.5) defines ‘culture’ or ‘mental software’ as broad, collective patterns of thinking, feeling and acting that have important consequences for the functioning of societies, of groups within societies, and of individual members of such groups. Over time, empirical studies of values have proved

useful in comparing groups and explaining those observed behaviours perceived to represent cultural differences (Bond, 1994). 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 judgment 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 (1996) are useful in explaining such values (Bond, 1996). 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, 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 profile 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 unifies and differentiates Chinese people.

The Hofstede Study (1980)

The Hofstede Study provided an analysis of work-related values of large numbers of employees (N >116,000) 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 thirty-two items tapping perceptions, personal goals, behaviour intentions and beliefs revealed four factors which accounted for fifty percent of the total variance ( Arrindell, Eisemann, Richter, Oei, Caballo, van der Ende, Sanavio, Bages, Feldman, Torres, Sica, Iwawaki, Hatzichristou & Cultural Clinical Psychology Group, 2003). These four factors were (1) Power Distance - the maintenance of social ranks and respect for authority and (2) Individualism - the condition in which the individual needs take precedence over group needs, and 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 (Arrindell, 2002). Individualism displays a strong negative correlation with power distance (-.67). (3) Uncertainty Avoidance - a preference for order and (4) Masculinity - Feminity - the social gender roles, particularly the patterns of male assertiveness and female nurturance (Arrindell et al., 2003).

The Chinese Value Survey -CVS (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 findings from a ‘Western’ study, then the findings would constitute a robust outcome. Four factors Integration, Human-heartedness, Moral Discipline and Confucian Work Dynamism were identified. CVS integration and moral discipline correlated highly with Hofstede’s 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 bench mark 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 identified by a higher order analysis; (1) Hierarchy-individualism-favouring a traditional, authoritarian influence (2) Order and Discipline - uncertainty avoidance, harmony, moral discipline (3) Confucian Work Ethic - ordered relationships, thrift, persistence, pragmatism, and (4) Achievement Oriented Concerns - mastery and diligent effort. Integration of the three culture-level studies yielded twelve 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 identified, (1) individualism-hierarchy (2) orderly autonomy (3) discipline-assertion and (4) human-heartedness to be influential in the day-to-day thoughts, beliefs and behaviours the Chinese people (Bond, 1996). Each of these ecological values is further expanded in Table 2.

Table 2. Factor composition of integrated factor-level values (Bond, 1996)

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. Utilizing recent empirical studies as support (Table 3), 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 client-therapist relationship, there is a power differential. This high power distance grants therapists the right to tell people what to do. Indeed if advice is not forthcoming, the therapist is perceived as impersonal and afraid of accepting responsibility (Chang et al., 2005; Chong & Liu, 2002; Gao, 2001; Lau, 2000; Lin 2002), especially by Chinese clients. The Chinese client expects the therapist to give them directions (Chong & Liu. 2000; Gao, 2001; Lau, 2000). The CBT therapist can use this to advantage in therapy by actively defining the problem, setting goals and evaluating progress (Chong & Liu. 2000; Lau, 2000; Oei & Goh, 1998). As noted by Chong and Liu (2000), 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.

Table 3. Conceptual Relationship Between Aspects of CBT and Chinese Culture

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 (200I) 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, 2000; Lau, 2000; Lin, 2002; Luk, Kwan, Hui, Bacon-Shone, Tsang, Leung, & Tang, 1991). Chinese clients have the expectation that suggestions and advice will be given to direct their actions (Chong & Liu, 2000; Lau, 2000; Lin, 2002). They expect to learn practical and useful ways of managing their problems (Chong & Liu, 2000; Lau, 2000; Goa, 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 one’s problems will be brought about by diligent effort and persistence (Bond 1996; Chong & Liu. 2000; 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 on the past, but deal with 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, 2000; Gao, 2001; Lau, 2002; 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, Callaghan, Twinn, Lam, Chung, & Li, 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. 2000; Kleinman, 1982; Lau, 2002; 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, accessible, empirical evidence demonstrating the effectiveness of CBT with Chinese clients, the evidence that does exist (Lin, 2000; Molassiotis, Callaghan, Twinn, Lam, Chung, & Li, 2002) supports the use of CBT in a variety of situations including the socially sensitive research area of human immunodeficiency virus (HIV) (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; Goa, 2001; Lau, 2002). Indeed, in keeping with the shift in cultural values (Chang et al, 2005; Goa, 2001), it has been proposed that Chinese clients might benefit from challenging irrational cognitions and illogical thinking that relates 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. Findings by Molassiotis, Callaghan, Twinn, Lam, Chung, and Li, (2002), Wong, Sun, Tse, and Wong (2002) and Luk et al. (1991) suggest that the use of CBT in counseling Chinese is successful. However, these researchers recommend allowing more time for the identification of irrational thoughts and the use of closed (direct) rather than open questions to commence therapy. Wong et al (2002), also suggest starting the therapy with identifiable, somatic complaints and then making a connection between these physiological symptoms and beliefs held by the client.

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 modifications it seems that CBT can be an effective therapy for Chinese clients. As Lau (2002) 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). This author notes that 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 instead to create indigenous theories and therapies without showing that they do. Can fried rice be eaten successfully with a knife and fork? The evidence suggests that with small modifications, these utensils are more than equal to the task. The current challenge is for research to produce supporting evidence.

© Tian P.S. Oei & Julie Hodges (The University of Queensland, Brisbane, Australia)

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9.2. Buddhist Psychology: A Transcultural Bridge to Innovation and Reproduction

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