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• 153 •
New Zealand Journal of Psychology Vol. 35, No. 3, November 2006
Cultural Considerations for CBT with Chinese People
Cultural Considerations in using Cognitive
Behaviour Therapy with Chinese People: A
Case Study of an Elderly Chinese Woman with
Generalised Anxiety Disorder
Mei Wah Williams, Koong Hean Foo & Beverly Haarhoff
Massey University
The under-utilisation of mental health services amongst Chinese people
is a well-known fact. This article describes a case study using a Western
therapy model, cognitive-behavioural therapy (CBT), with a Chinese client.
A CBT model, modifi ed for working with Chinese clients, is depicted with
reference to Chinese practices and behaviours, and this is then applied to
a case study with an elderly Chinese woman. CBT was shown to be useful
with this Chinese client. Challenges to the use of CBT with Chinese people
are discussed with implications for clinicians working in this area.
I
t is frequently noted that very few
Chinese people, here and overseas,
utilise mental health services and
even less will self-refer (Ho, Au,
Bedford, & Cooper, 2003; Netto, Gaag,
Thanki, Bondi, & Munro, 2001). If
help is sought, it is often when a crisis
occurs and, if treatment is initiated,
terminated prematurely. The factors
associated with low utilisation and high
dropout rates in mental health facilities
have long been recognised (e.g., Ho et
al., 2003; Williams & Cleland, 2006;
Williams, Graham, & Foo, 2004; Yip,
2005).
Traditional Asian beliefs liken
mental illness with insanity and, as
such, there is much stigmatisation
attached to having such problems and
seeing a mental health practitioner. It
is not surprising, therefore, that this not
only leads to denial of the existence of
a problem but also creates barriers to
help-seeking.
The low rate of attendance at
mental health facilities may lead to
erroneous assumptions that Chinese
people do not experience mental health
problems. A literature review by Ho and
associates (2003), in fact, revealed that
the prevalence rate for mental illness
of Asian people in New Zealand was
no different from that of European
New Zealanders. Recent migrants
experienced even higher levels of
mental health problems, presenting
with high levels of post-traumatic
stress symptoms, clinically diagnosable
depressive symptoms, and greater levels
of anxiety and emotional distress. Many
of these psychological symptoms could
be attributed to immigration and the
process of adjustment into a foreign
culture (Ho et al., 2003; Mak, Young,
Wong, & Zane, 2005).
Despite the growing literature on
cross-cultural counselling and the ethical
concerns surrounding competency and
training of psychotherapists working
with multicultural clients (Pedersen,
2003), little attention has been given to
the therapeutic framework that could be
used for counselling Chinese people (for
exceptions refer Harper & Stone, 2003;
Higginbotham & Tanak a-M atsumi,
1981; Hong & Domokos-Youngg Ham,
2001; Tanaka-Matsumi, Seiden, & Lam,
1996). Due to the stigma and shame
surrounding mental illness there is
often reluctance to seek help for mental
health problems. External explanations,
whether it originates from organic
or moral/spiritual sources, has far
greater acceptance than psychological
explanations, and thus psychological
distress is commonly manifested in
somatic symptoms for Asian people.
Consultations with medical practitioners
or traditional Chinese healers for somatic
complaints often legitimises help-
seeking for problems which may have
psychological origins. A therapeutic
framework that was compatible with
the expectations of Chinese people may
encourage utilisation of mental health
services and in improving treatment
outcomes.
It is frequently noted that Chinese
people favour treatment that is directive,
structured, and short-term (Young &
Davenport, 2005), as this conforms to
the expectations of professionals as
authoritative experts. It was found that
this style was more effective in treatment
outcome with Chinese people than with
a non-directive person-centred approach
(Chu, 1999). Cognitive-behavioural
therapy (CBT) is an evidence-based,
explicit, structured, and problem-
focused short-term psychotherapy. The
principles and practice of cognitive-
behavioural therapy (CBT) would
appear to be compatible with the
expectations favoured by Chinese people
as it promotes self-help and is psycho-
educational; teaching new coping
skills to manage distressing emotional
problems. Its conceptual framework is
also well-placed to take into account
the idiographic nature of the client’s
problems in relation to cultural factors
New Zealand Journal of Psychology Vol. 35, No. 3, November 2006
• 154 •
M. Williams, K. Foo, B. Haarhoff
and the impact of immigration, somatic
complaints, interpersonal relationships,
and other areas of importance that
impinge on the client’s psychological
well-being.
It would be expected that this match
in the expectations of treatment would
not only increase the appeal of CBT
for Chinese people but also of mental
health services. For example, Zane,
Sue, Chang, Huang, Huang, Lowe, et
al. (2005) found that even when the
therapist and client were not ethnically
matched, significant therapeutic
achievements were found if the therapist
and client shared similar perceptions of
the presenting problem, client’s coping
style, and expectations about treatment
goals. This therapist-client “cognitive
match” was significantly related to
positive attitudes towards the therapy
sessions, a reduction in avoidant coping
behaviours, and an improvement in
psychosocial functioning.
It is therefore proposed that CBT
could be used as a conceptual frame-
work in which to help the client develop
an understanding of his/her problem
and this then used for treating Chinese
people with mental health concerns. The
remaining paper will, fi rstly, present an
outline of the CBT model for working
with Chinese people, and secondly, a
case study in which to illustrate the
application of CBT with an elderly
Chinese woman with generalised
anxiety disorder.
Using the 5-part CBT model for
working with Chinese people
Padesky and Mooney (Padesky &
Mooney, 1990) developed the Five-Part
Cognitive Model that represents the
relationship between emotion, thought,
behaviour, and physical reactions, and
that these, in turn, have been infl uenced
by one’s environmental factors, such as
genetics, culture, history, and the actual
problem situation (see Figure 1). The bi-
directional arrows indicate the dynamic
interconnections between the various
parts of the system, indicating that
change in one area will create change in
the other areas as well. This 5-part model
provides a useful framework in which
to conceptualise the idiosyncratic nature
of a client’s presenting difficulties,
establish a therapeutic alliance, and to
guide treatment. In keeping with the
structure of Padesky and Mooney’s
model, each part of the model will be
discussed further below taking into
consideration the cultural characteristics
of Chinese people. Some parts of the
model will have greater prominence
for the Chinese client than others (refer
Figure 1).
Actual situation/problem
•
Problems usually regarded as social
and/or relational issues
•
Locus of control are seen as external
to self
History/family
•
Drowning child(ren) with love and over-protective
parents
•
Pressure by parents for child(ren) to achieve
•
The past may be seen as not signifi cant to therapy
•
Wider family members have role in therapy
•
Non-nuclear extended family living situation
Culture
•
Elements of Confucianism, Taoism,
and Buddhism still retained in spite of
modernization; e.g. fi lial piety, loss of
face
•
Infl uence of Chinese medicine and folk
psychotherapy
•
Collectivistic emphasis
•
Levels of adjustment/acculturation to
mainstream culture
•
Country of origin, rural/urban
upbringing
•
Self-effacement
•
For some individuals, English as
second language
COGNITION
Diffi culty expressing private
thoughts due to lack of psychological
sophistication or repression
eg “thinking too much won
’
t help”
EMOTION
Diffi culty expressing strong emotions
due to lack of psychological sophistication
or repression e.g. control of
affective
display since young.
Emphasis is not on “happiness” but on
being at peace and in harmony with
oneself and others.
BEHAVIOUR
Problem-focused
Solution-focused
BIOLOGY/PHYSIOLOGY
Often expressed in somatic terms like
aches and pains
Expectations of clientele
•
Lower tolerance for ambiguity
•
Greater respect for authority – desire
to please therapist, complete out-of-
session tasks
•
Preference for practical and immediate
solution for problems – “quick fi x”
•
Expect directive therapy process and
authoritative therapist
•
Expect value for money, brief therapy
(5-6 sessions)
•
Concern with good rapport
ENVIRONMENTAL
INFLUENCES
Figure 1
:
Cognitive behavioural therapy model for working with Chinese clients
• 155 •
New Zealand Journal of Psychology Vol. 35, No. 3, November 2006
Cultural Considerations for CBT with Chinese People
Environmental Infl uences
Expectations of the Chinese client
:
Chinese people regard professionals
as authority fi gures, knowledgeable,
and to be respected. Thus it would be
preferable to adopt an instructive and
didactic style early in the therapeutic
relationship, with less emphasis on
collaborative empiricism and guided
discovery in the initial stage of
therapy. Once rapport has been fi rmly
established then guided discovery and
collaborative empiricism can be used.
This will increase confidence and
trust in the therapist’s ability to help
and develop a therapeutic alliance. A
facilitative client-focused approach
to counselling does not conform to
the image of a traditional cultural
healer and taking this approach may
negatively impact on the engagement
of the Chinese client into a therapeutic
relat ionship. Chine se people also
believe in value for money so some
symptom relief needs to be achieved
early in treatment and therapy sessions
should be short-term; lasting no more
than five to six sessions. However,
the eagerness to get well and comply
with the therapist’s requests will make
the Chinese person an ideal client in
completing out-of-session tasks.
C u l t u r e :
T h e i nfluen c e s o f
Confucianism, Taoism, and Buddhism
remain strong despite Westernisation
and acculturation. They infl uence how
mental health is perceived and the cause
of the problem. They teach the virtues
of moderation and proper conduct, and
for the restraint of strong emotional
affect and excessive behaviours, the
avoidance of interpersonal conflict,
and the suppression of self-expression
(Yip, 2005). In fact, strong emotions
and interpersonal confl ict are seen as
the cause of distress and mental health
problems. Maintaining harmonious
social interactions are paramount and
it is through self-control and self-
discipline that tranquillity of the mind,
fulfilment, and peace are attained.
Traditional Chinese medicines are
frequently used as an adjunct to other
forms of therapy as physical and
mental illnesses are not considered
separate entities but are holistically
interconnected to mental health and
well-being.
Related to culture is the need to
understand the level of acculturation
of the Chinese client. Although the
majority of Chinese people have
been in New Zealand for less than
10 year s, ma ny are fr om se veral
generations of New Zealand-born
Chinese and therefore the issues they
face will be dissimilar to those of the
recent migrants. It has been shown
that cultural identity is related to
psychological health and help-seeking
behaviour (refer Kim, Atkinson, &
Umemoto, 2001).
History/Family:
The strength of the
Chinese family structure is in providing
an environment for mutual support
and interdependence (Cheung, 1986).
For non-Chinese people, the close
extended family unit may appear to
be overly enmeshed and controlling,
especially over its younger members.
For example, the Chinese parents may
seem to over-indulge their children,
almost to the point of “drowning them
with love”, be closely involved in
every aspect of the child’s life, and
make decisions for them, often without
consultation, into late adolescence.
Individual family members generally
have a strong sense of responsibility
and obligation to the family, with great
importance attached to academic and
occupational achievement. Pressure
on children to succeed may appear
excessive to non-Chinese people.
The traditional Chinese family
system is patriarchal with deference
given to those in higher authority.
Roles are strongly defi ned for each
member within the family structure,
and suppression of individual rights,
desires, wants, or needs to the greater
goals of the family are expected (Yip,
2005). The primacy of the family and
its infl uence on the individual family
member’s behaviour can be diffi cult for
non-Asians to comprehend (Curreen,
1997).
Situation/Problem:
Under the infl uence
of traditional Chinese culture, which
values reliance on the social collective
over individual autonomy, Chinese
clients are more prone to perceiving
the problem as being an external locus
of control than an internal locus of
control. Thus problems will generally
be presented as of social or relational
origin, rather than individually-oriented.
When confronted by oppressive and or
challenging social situation, the Chinese
client may exhibit passive-helpless and
egocentric behaviours, with solutions
expected from “authority” fi gures to
resolve the diffi culty (Yip, 2005).
Biology, Cognitions, Behaviour,
and Emotion
The emphasis on emotional restraint,
moderation and control of one’s
feelings and emotions will make
disclosure and sharing one’s inner
feelings uncomfortable for a Chinese
person. Disclosing private feelings
can feel strange and there is generally
a reluctance to discuss personal
details with someone perceived as
a “stranger”, even a professional.
Talking about somatic complaints or
issues of a more practical nature, such
as fi nancial or academic problems, is
usually easier than expressing mental
health symptoms.
These present potential problems
as identification of emotions are
central to CBT. To overcome these
barriers, instead of expecting the client
to verbalise and express feelings, it
may be more useful to focus on the
somatic symptoms and use problem-
solving strategies early in therapy.
As emotional and cognitive reactions
may not be spontaneously expressed,
direct enquiry into psychological
symptoms can be applied. Organic
symptoms relabelled or reframed
into psychological terminology may
become more acceptable as rapport
and trust develops. This is more likely
to engender rapport building and
enhance the Chinese client’s faith that
psychological therapy is benefi cial and
effective.
Research into the effectiveness
of the cognitive behavioural therapy
model with Chinese people is limited
(an exception see Chen & Davenport,
2005) and for this reason a single case
study design is presented to evaluate its
potential to work with Chinese people
with mental health concerns.
Case Study
“Mrs. Young” (a pseudonym)
1
was
referred by an Asian support group
in a public hospital. She was an
outpatient of the mental health facility
for older people at the hospital, and
had been diagnosed and treated for
New Zealand Journal of Psychology Vol. 35, No. 3, November 2006
• 156 •
M. Williams, K. Foo, B. Haarhoff
depression and generalised anxiety
symptoms for the past few months
by her psychiatrist. She was a 69 year
old Chinese woman
who had lived in
New Zealand for over 20 years and was
fl uent in both Cantonese and English:
English was used as the medium for
communication. Treatment had been
carried out in an interdisciplinary
team that included psychiatrists, social
worker, psychiatric nurses, and the
manager of the Asian support group and
was primarily psychopharmacological.
The referral for psychotherapy was
largely precipitated by the inexplicable
natur e of Mrs Youn g’s problems .
These seemed rather indeterminate,
with ongoing complaints of health
problems and cognitive difficulties
and little amelioration of the symptoms
despite the medication. Baffl ed by
the lack of progress, Mrs Young was
referred to one of the authors (FKH,
a Singaporean-Chinese) for CBT. No
psychotherapy had been carried out
prior to this referral.
History
Mrs Young’s problems with depression
and anxiety coincided with her husband
being hospitalized long-term and being
left on her own. She met her husband,
a New Zealander, whilst attending
an English language course in New
Zealand, and they have been married
for over 20 years. No children were
produced from this relationship. Mrs
Young reported the fi rst 10 years of
the marriage was happy and uneventful
but when her husband was diagnosed
with diabetes, she stated that had she
known of his illness she would not
have married him
2
. More recently, the
deterioration in her husband’s condition
required several operations so that he
eventually became incapacitated and
was placed into long term care as Mrs
Young was unable to look after him
at home.
In her family of origin, Mrs Young
was raised in a close-knit Chinese
family unit, being the youngest of three
children. She described being spoilt
and over-protected by her parents and
that most decisions were made for her.
Schooling and friendships were normal
and, upon leaving school, she trained
to be a nun. She left this vocation after
some years, coming to New Zealand
to attend an English course where
she met her future husband. After her
marriage, Mrs Young worked as a
language teacher.
Assessment
Clinical interview
:
The assessment
and initial therapy sessi ons were
conducted in Mrs Young’s home as
she complained of poor vision and felt
unsafe driving on her own to the clinical
sessions. It was later deduced that she
was capable of driving to her other
social activities without complications,
and that she was also having the
social worker and the psychiatric
nurse visit her at home every week.
It was decided the remaining therapy
sessions be arranged at the hospital
or clinic in order to preserve the
integrity of the therapeutic boundaries,
especially after one session at her home
when she asked the therapist to help
with chores around the home. Mrs
Young presented as frail, considerably
underweight, almost to the extent of
being emaciated, and dysphoric. She
was neatly dressed and spoke in a calm
soft voice. Although doubtful about
the benefi ts of psychotherapy, it was
agreed she would be seen initially for
six sessions. Despite her reservations
about being seen for psychotherapy,
Mrs Young was compliant and readily
volunteered a litany of problems that
troubled her, rapidly fl uctuating from
one problem to the other; to the extent
of being repetitious and unremitting.
The symptoms centred on low
energy, diminished concentration,
restlessness, sleep disturbance,
considerable weight loss, and inability
to make decisions. In addition, anxiety
symptoms were experienced, such
as trembling and palpitations, short
panic spells which occurred mainly
upon morning awakenings, and feeling
fearful when alone. She reported
continually worrying about her health
and her forgetfulness. When engaged
in social activities, these anxiety
symptoms diminished. She was
particularly reliant on her church and
friends for social interactions but had
noticed that people were avoiding her
and would not engage in conversation
for any length of time. When probed
on subjects she did not wish to talk
about, she rapidly changed the topic
of conversation, thus avoiding further
analysis of the issue. No evidence of
suicidal ideation or suicidal behaviour
was found.
Mrs Young identified her main
problems as her fi nancial diffi culties,
trouble taking the medication, sleeping
only about two hours each night, and
the inability to make decisions. She
expressed thoughts about “It’s my
fault for taking life so easy”, and
“I’m disappointed in myself (for not
managing)”. Since her husband’s
hospitalization, she had to rely on her
diminishing fi nancial resource. In order
to manage on her reduced fi nancial
state, she decreased her food intake to
save money.
Medication
Mrs Young was prescribed
Nortriptyline, Imovane, and Loazepam
for her anxiety, depression and sleeping
problems. They did not appear to
improve her symptoms and it was
later disclosed that she had not kept
to the medication regime. Mrs Young
had consulted the internet and after
fi nding out about the side-effects and
contraindications of these medications,
she considered they were harmful with
long term use and thereafter only took
the anxiolytic when she felt anxious
and the anti-depressant sporadically.
Traditional Chinese medicines were
taken at times in conjunction with the
psychopharmacology.
Psychometric measures
In addition to the clinical interview,
the following psychometric measures
were completed to evaluate therapy
progress:
Beck Depression Inventory:
(
BDI
(BDI (
:
Beck, Ward, Mendelson, Mock, &
Erbaugh, 1961), a self-rating scale
of attitudes and symptoms associated
with depression. Mrs Young’s score
was in the severe range for depressive
symptoms. Highest scores were given
for “I blame myself for everything bad
that happens”, “I can’t make decisions
at all anymore”, and problems with
weight loss, waking up several hours
earlier, and fears of making decisions
about everyday things.
State-Trait Anxiety Inventory
(
STAI
(STAI(
;
STAI; STAI
Spielberger, Gorsuch, & Lushene,
1970): A self-rating scale that measures
• 157 •
New Zealand Journal of Psychology Vol. 35, No. 3, November 2006
Cultural Considerations for CBT with Chinese People
state and trait anxiety. Mrs Young’s
score was in the range for an anxious
population group.
Automatic Thoughts Questionnaire
(
ATQ
(ATQ(
: Hollon & Kendall, 1980): A self-
rating measure of recent spontaneous
negative automatic thoughts or negative
self-statements, in which Mrs Young’s
score was in the depressed group
range.
Dysfunctional Attitude Scale
(
DAS
(DAS (
:
Weissman & Beck, 1978): This
self-report is used to measure core
assumptions underlying depressogenic
beliefs and attitudes. Mrs Young’s total
score was within the normal range
although she endorsed a number of
items that refl ected her need to receive
approval from others in order to feel
worthy and happy.
On the Suitability for Short-term
Cognitive Therapy scale (Safran &
Segal, 1990; 1993), the areas that
were identifi ed for Mrs Young as being
amenable to cognitive therapy were
her ability to access her automatic
thoughts, her willingness to carry out
out-of-session tasks, the development
of rapport with the therapist, evidence
of good interpersonal functioning
despite her current difficulties, low
level of chronicity in the problems,
and generally being open to discussing
her difficulties although there was
avoidance of specific anxiety-
provoking situations. Problematic
areas, however, were her lac k of
differentiation between her emotional
states, the expectation that the therapist
would provide the “magic solution”,
her lack of focus on task-specific
activities without prompting, and her
expression of scepticism about the
benefi ts of therapy.
Case Conceptualisation
Cultural Considerations
:
In order to
understand the idiographic nature of
Mrs Young’s current diffi culties, it is
important that her cultural background
are taken into consideration when
making a formulation of this client’s
problems, thus placing it within the
context of her culture, gender, and age.
Some Asian countries are exposed
to more Westernised influence than
others (eg Malaysia, Hong Kong,
and Singapore) but many Chinese
from these countries still retain their
traditional cultural beliefs and practices,
even if they have lived for many years
outside their country or have married
a non-Chinese. Mrs Young has lived
in New Zealand for over 20 years, but
despite this much of her presentation
is influenced by her early cultural
upbringing. Her age would predict she
would hold more traditional Chinese
cultural beliefs and values than a
younger person of Chinese descent
who would generally integrate into the
New Zealand culture more easily. Thus
many of the considerations for working
with a Chinese client are essential
when understanding the nature of Mrs
Young’s diffi culties.
First, Mrs Young is from an older
generation to the therapist working
with her. Due to the deference given
to people from an older generation, it
is not expected that young people will
question or give advice to an older
person. This is refl ected in a Chinese
proverb “I have taken more salt than
you have taken rice”, which means
“I have more life experiences than
you and therefore you can’t teach me
anything”. A similar New Zealand
axiom would be “Don’t teach your
grandmother to suck eggs”. Receiving
therapy from someone younger and
eliciting personal information could be
regarded as great disrespect and “loss
of face” for an older Chinese person.
Threats to the therapeutic alliance may
be manifested by extreme politeness
and formality, telling you what s/he
thinks you wish to hear, and avoidance
of disclosing personal details. In this
particular situation, the therapist had
completed post-graduate training in
the application of CBT and therefore
perceived as an expert in this area,
which would help counteract the
negativity of working with a young
person. In addition, the therapist was of
similar ethnic match to the client (unlike
the members of the interdisciplinary
team) and this may have increased a
willingness to try a novel treatment
approach. Ethnic matching of client-
therapist variables is often seen as a
component in cross-cultural therapy
that enhances the therapeutic outcome
(Zane et al., 2005).
Second, as is typical in many
traditional Chinese families, Mrs
Young was raised in a close family
unit where she was overprotected
and cosseted by her family members
and it would be expected her family
would make important decisions for
her. Being a female with relatively
low social status, Mrs Young would
be seen as “marrying up” through her
marriage to someone from a Western
country, thus improving her social
status. This would be further enhanced
by moving to a country seen as superior
where there were greater opportunities
for a better life. There are pressures
therefore to make this new life succeed,
as failure would be seen as a “loss of
face” and bring shame to her family and
friends. In her marriage, Mrs Young’s
early modelling of dependency on her
parents would be transferred to her
husband as it is expected that a Chinese
wife would rely very much on her
husband for decision-making and that
he would provide for her.
Third, children, especially sons,
are important sources of support for
aging parents and are relied upon for
fi nancial and emotional support when
the parents are no longer able to take
care of themselves. As such, children
are greatly valued in Chinese families
and not having a child to take care
of one in one’s old age is an enigma
and socially stigmatizing. In studies
of elderly Chinese living on their
own, it was found that those who had
children to whom they could rely upon
for support had greater levels of life
satisfaction than those who had no
family support (Lam & Boey, 2005;
Lee, 2005). With her husband being
incapacitated, Mrs Young had no close
family member to whom she could
turn to for support and to take over the
carer role performed by her husband.
To some extent, Mrs Young’s request
to the therapist to do errands for her
was transferring her expectations onto
the therapist as she would a surrogate
“son”. It is most probable that had Mrs
Young had children she would have
relied on them instead and would not
have presented in the mental health
system. It is typical, however, that
Chinese clients will request help from
the therapist in areas that would be
regarded to be outside the therapeutic
relationship, such as inviting them to
family social activities, help for other
extended family members, intervening
with other agencies, and a range of
New Zealand Journal of Psychology Vol. 35, No. 3, November 2006
• 158 •
M. Williams, K. Foo, B. Haarhoff
different problems. Thus maintaining
the therapeutic boundary can be an
important issue in treating Chinese
clients.
Finally, Mrs Young was able to
legitimise seeking help from the mental
health service by focusing on the
physical aspects of her symptoms and
on more general vague health-related
complaints, such as tiredness and
memory/concentration problems. These
symptoms elicited help for problems
that she saw primarily as fi nancial rather
than her helplessness and inability of
cope and manage on her own. Her
frailty, passivity, and helplessness
elicited considerable amount of concern
and assistance from the mental health
team and her friends. However, her
expectation was that the mental health
team would resolve her problems rather
than actively participate in her own
recovery.
Problem formulation
:
Mrs Young
experienced problems with symptoms
of depression and anxiety, including
poor sleep and concentration, negative
thinking mainly concerning guilt
about not being able to cope, weight
loss, indecisiveness, and generalised
worries, which was precipitated by her
husband’s hospitalisation. Predisposing
factors included an over-dependency
on her husband and other authority
fi gures, an extremely sheltered marital
relationship, and not much experience
in taking responsibility for others
or independent decision-making.
Maintaining factors were her core beliefs
around vulnerability and helplessness
resulting in compensatory strategies,
such as frequent reassurance-seeking
and avoidance of situations requiring
independent decision making. Protective
factors included her sociability and this
being her fi rst presentation to the mental
health service. A diagnostic impression
gained was that Mrs Young wa s
suffering from features of depression
and generalised anxiety disorder against
the background of adjusting to her
changed circumstances caused by her
husband’s hospitalisation and being on
her own.
A diagrammatic cognitive-
behavioural formulation is given for
Mrs. Young in Figure 2 (Morrison,
2000). There are aspects of Mrs Young
presentation that are indicative of a
dependent personality, that includes
diffi culty in making every day decisions,
excessive reliance on others to obtain
nurturance and support, exaggerated
feelings of helplessness, and inability
to take care of herself. To diagnose her
with a personality disorder, however,
would be unjustifi ed as her presentation
is relatively common given her cultural
background, her age, and her situation.
Furthermore, there was no evidence of
psychopathology prior to her current
diffi culties.
Treatment
The goals of therapy were to obtain
symptom-relief from depression and
anxiety for Mrs Young and to familiarise
her to the fi ve-part model so as to help
her conceptualise the nature of her
problems. Initially Mrs Young agreed
to six to seven sessions of CBT, and as
therapy progressed she extended this to
thirteen sessions. As was typical with
Chinese clients, Mrs Young expected
therapy to be short-term and that
she would “get well” quickly. Early
treatment strategy was to orient Mrs
Young to cognitive behavioural therapy
using the Padesky and Mooney’s (1990)
5-part model. She quickly understood
the inter-relationship between affect,
cognitions, physiological arousals,
and behaviour. To monitor treatment
progress, the visual analogue scale
(VAS; see Figure 3) was introduced,
with “0” being “Not anxious at all”
to “100” being “Most anxious”. Self-
Early experiences
Overprotective and caring parents making most decisions for her
Sheltered marital relationship
Little need to get hands dirty (ie take responsibility for family, others)
Relatively comfortable and stress-free life
Core beliefs
I am helpless, I need someone to take care of me
I can’t cope on my own
I’m vulnerable if I don’t have someone to help me
Conditional assumptions/beliefs/rules
I must have someone who will support or help me at all times
Others must help me with my problems
Positive assumption: If I can get someone to help me, I’ll be fi ne
Negative assumption: If I don’t get help, I’ll be vulnerable and lost
Critical incidents
Loss of close supporter or helper
Being on her own
Faced with problems and having to make decisions
Compensatory strategies
Seek constant advice and reassurance from everyone around
Be helpless so that those around will resolve the problem
Avoiding situations that required decision-making
Negative automatic thoughts
I’m a failure for not being able to cope on my own
I can’t do anything right
People don’t have time for me anymore
Symptoms
Behavioural – demanding, undermine treatment, passivity, constantly seeking reassurance
and help, inability to make everyday decisions, somatic complaints
Affective – anxious, fearful, depressed
Cognitive – forgetful, diffi culty concentrating, continual worry on self and problems
Physiological – panic attacks, sleep problems, weight loss, tiredness
Figure 2
:
Cognitive-behavioural formulation for Mrs Young
• 159 •
New Zealand Journal of Psychology Vol. 35, No. 3, November 2006
Cultural Considerations for CBT with Chinese People
rating on anxiety levels were obtained at
each session. As the client seemed able
to articulate her thoughts clearly, the
thought record was presented in the fi fth
session in order to identify her negative
automatic thoughts and to challenge
her beliefs. The activity evoked strong
emotions in Mrs Young, to the extent
that she became agitated and avoidant in
using the thought record. It was decided
that intervention would focus primarily
on the behavioural-based components of
cognitive behavioural therapy.
Activity rescheduling
:
Activity
rescheduling is a commonly used
technique in cognitive therapy and
served several functions. Mrs Young
complained of boredom and having too
much time in which to worry, and thus
the schedule was used to identify the
times in the day when she became more
anxious or depressed and her level of
activity.
This showed Mrs Young to be
most anxious in the morning and when
she would most likely use the anxiolytic
medication. The period of time when she
was on her own or doing activities by
herself (such as gardening) were those
she rated as being the most anxious, but
when engaged in social activities her
anxiety levels reduced to zero.
By being aware of those periods
when anxiety was at its greatest,
Mrs Young was able to schedule in
pleasurable activities which she could
engage in on her own, such as listening
to music, knitting, watching television,
or phoning a friend. Relaxation training
was also given to manage the anxiety
symptoms. It was noted that by talking
about her anxiety periods it heightened
her attention and tendency to ruminate
on the problem and thus, later in therapy,
emphasis was placed on the pleasurable
activities in her schedule. A level of
rigidity in Mrs Young’s daily/weekly
schedule was also observed, in that she
would be infl exible to altering activities
to different days or time.
Interpersonal relationship skills
: M
rs
: Mrs : M
Young had some awareness that her
dependency on her friends and habitual
complaints about her problems were
starting to have a negative effect on
them, so that they started to avoid her,
not visit or phone her, and limiting their
time in her company. Her egocentric
focus on her problems clouded her
ability to consider the implications of
this, and as her friends were her main
source of support and socialising with
them improved her symptoms, it was
important that her interpersonal style
be addressed. It was not only with
her friends that she lacked this insight
but also the effects of the illness and
hospitalisation on her husband. Her
dependency on him and egocentric
focus on her concerns meant she found
visiting him a duty that was unenjoyable
and distressing.
To address these diffi culties, guided
discovery and role-plays were practised
in the session to help Mrs Young
gain an awareness of other people’s
perspective and their reactions to her.
For example, by taking the role of her
friends she gained an appreciation of the
adverse effect her incessant focus on her
problems had for them and to change the
conversation to one of mutual interest. A
behavioural experiment was designed in
which she was to talk to her friends about
other matters other than her problems.
She reported being positively reinforced
for this as she noticed they were more
friendly and warm, and spent a longer
time talking with her. To help Mrs
Young become aware of her automatic
response to talk about her problems,
Mrs Young’s attention would be drawn
to this whenever she did this during
therapy, and she would be refocused
to looking at her goals for therapy. All
members of the interdisciplinary team
were instructed to do the same, thereby
increasing the productiveness of the
therapy sessions.
Similar role reversal techniques
were applied to her relationship with
her husband. Mrs Young blamed him for
her predicament, although not overtly,
but felt guilty about not being able to
take care of him at home. By doing
the role-reversal, she gained a greater
appreciation of his perspective, being
able to accept some responsibility but
also accepting that she could not care
for him at home. This reduced her
negative reactions to his illness and her
guilt so that visiting him became a more
enjoyable experience.
Psycho-education
:
Several sources of
information were given to Mrs Young
to help her understand the nature of her
problems. These were information about
the development of generalised anxiety
disorders taken from Wells (1997) which
specifi cally focused on her excessive
and seemingly uncontrollable worrying,
and readings on depression from Mind
over Mood (Greenberger & Padeskey,
1995). Mrs Young also spontaneously
bought a self-help book on anxiety near
the termination of therapy.
Co nt rolled Worry Period
:
Ba se d
on Well’s (1997) recommendation
for treating “worries” a controlled
worry period was introduced. With
this technique clients are instructed to
schedule 15-30 minutes of their day
and devote this time solely to worrying,
rather than ruminate throughout the day.
This fi xed worry period was allocated
to when Mrs Young was instructed to
worry as much as she wanted. Should
worries occur at other times, she was
to put that aside until her controlled
worrying time. Mrs Young found the
exercise amusing but carried out the
homework assignment and found that
the amount of time she thought about
her problems decreased considerably
from throughout the day to only once
after dinner for a few minutes. As a
result, she noticed an increase in her
concentration, getting more work done
in the day, and learnt she could control
her worries. Furthermore, she could
see that worrying did not solve her
problems but only increased her panic
symptoms.
Relaxation techniques
:
Due to Mrs
Young’s anxiety and panic reactions,
diaphragmatic breathing exercise
was fi rstly taught to help control her
breathing and as a relaxation exercise.
It took several sessions before she could
slow down her breathing and helped
her become aware that her shallow and
rapid breathing were contributing to her
panicky state. On one occasion when
Mrs Young became highly agitated
and panicky after talking about her
husband’s illness and her problems,
refocusing technique was applied, in
addition to the diaphragmatic breathing
exercise. The refocusing technique made
Mrs Young attend to her immediate
environment using different sensory
organs, and grounded her and helped
her remain calm. Once she had control
of her breathing, progressive muscle
relaxation was taught to help with sleep
and relaxation.
Sleep problems
:
Stimulus control of
Mrs Young’s sleeping environment and
New Zealand Journal of Psychology Vol. 35, No. 3, November 2006
• 160 •
M. Williams, K. Foo, B. Haarhoff
sleep hygiene were discussed but she
was reluctant to change any of her sleep
habits. For example, she slept in a bed
that was kept at a high temperature so
that she would awake feeling overheated
and sweating. When this was discussed,
she refused to turn the heat down as
she did not wish to change the bed
temperature. Furthermore, despite
claims of sleeping only two hours a
night, Mrs Young did not appear tired
during the day, was able to participate
in her busy social schedule, function
well with day to day activities, and
there was no evidence that she napped
during the day. She was also reported
to sleep soundly during the night by
her boarder.
Problem solving techniques
:
In addition
to the fi nancial help Mrs Young was
receiving from other sources, problem-
solving strategies were used to help her
be solution-focused rather than problem-
focused. As a result of this Mrs Young
took on a boarder, with the intention that
this would provide company for her and
contribute to the cost of living. When
the boarder did not contribute to this,
assertive communication was practised
and rehearsed during the therapy session.
However, in the eventuality Mrs Young
decided not to carry this out.
Medication compliance
:
Interdis-
ciplinary discussion with Mrs Young was
held about her non-compliance
wit h m edi catio n, b ut she
remained opposed to making
changes to her ad hoc use of
traditional Chinese medicine
and psychopharmacology.
Outcome
The weekly VAS scores (see
Figure 3) showed considerable
fluctuations with significant
increases during the fi rst half
of the sessions but decreasing
sharply and eventually levelling
out to pre-treatment levels.
Psychometric measures
taken pre-treatment were re-
administered at the end of
therapy (see Figure 4). Although
the results were not remarkable,
they showed Mrs Young
moved from being severely
depressed to being moderately
depressed, with improvements
in problems related to sleep,
decision making; and a reduction in
state anxiety, especially in not feeling
as upset, worrying less about possible
misfortunes, and feeling more content.
Although retaining a number of negative
automatic thoughts, the severity of these
thoughts were below those associated for
depression. A number of dysfunctional
attitudes remained although there was
a reduction in her need for approval
from others.
Discussion and Conclusion
The results of this study showed that a
cognitive-behavioural (CBT) framework
can be effective in conceptualising the
client’s problem and in conducting
therapy with an elderly Chinese woman,
albeit in a limited way. Despite the
common perception that Chinese people
may not benefi t from Western forms
of psychotherapy, CBT was partially
successful in assisting the client to
40
40
40
80
90
60
20
50
60
30
40
45
0
10
20
30
40
50
60
70
80
90
100
1 2 3 4 5 6 7 8 9 10 11 12
Session
Anxiety levels
Figure 3
.
Session-by-session self-rated anxiety levels
Note: BDI = Beck Depression Inventory, STAI-S = State-Trait Anxiety Inventory (State
version), ATQ = Automatic Thought Questionnaire, DAS = Dysfunctional Attitude Scale
Figure 4
.
Psychometric measures pre- and post-treatment for Mrs Young
26
22
52
48
92
73
112
126
0
20
40
60
80
100
120
140
Scores
BDI STAI-S ATQ DAS
Measures
Initial
Final
• 161 •
New Zealand Journal of Psychology Vol. 35, No. 3, November 2006
Cultural Considerations for CBT with Chinese People
understand the nature of her problem and
guiding treatment to ameliorate some of
her anxiety and depressive symptoms.
She gained a sense of self-effi cacy in
being able to control her “worries”, take
another’s perspective which helped to
improve her interpersonal relationships,
and successfully applied problem-
solving strategies. Moreover, the
client remained in therapy for a longer
period than expected despite her initial
reluctance to be exposed to a novel
treatment approach. In a study by Lin
(1994) the median duration of therapy
for Chinese mental health patients was
eight sessions even when the therapist
was matched on ethnicity and language.
In this case, the client attended 13
therapy sessions and the reason for
terminating treatment was that the
therapist was leaving the service. The
interventions used in treatment were
mostly behavioural, however, as the
cognitively-based techniques were not
appropriate for this client. Although
behavioural interventions are commonly
the treatment of choice when working
with the elderly, the limitations of not
using cognitive or schema-focused
therapy is refl ected in the outcome data
that showed the client’s dysfunctional
negative beliefs remained largely
unaffected after treatment.
A number of difficulties were
encountered in working with this client.
The client’s exceeding dependency and
neediness and her lack of appropriate
boundaries made therapy challenging.
Dependent patterns of behaviours are
commonly observed in older women
raised in traditional Chinese culture,
which from a Western perspective
may b e s een a s d y sfu ncti ona l .
However, achieving self-individuation
and autonomy is not a conventional
repertoire in Chinese culture, where
one’s sense of self-worth, self-identify,
and happiness is connected to, and
infl uenced by one’s relationship with
others (Yip, 2005). As commented
by Yip (p. 397) “traditional Chinese
concepts of mental health facilitate a
form of passive egocentric preservation
which is a form of self-alienation from
intense social demands and social
inequality”. This passive egocentricity
was manifested by this client, which was
characterized by her demandingness
on her friends and therapists, concern
mainly about herself and her problems,
her helplessness to make decisions
about day to day functioning, avoidant
patterns, and an expectation that the
mental health system and others would
resolve her problems.
According to Stein and Young (1992)
people with dependency personality traits
have impaired autonomy in that they
cannot perceive themselves as able to
survive and function independently and
to cope with every day responsibilities
without considerable help from others.
They exaggerate fears about illnesses or
disasters that may befall as they do not
believe they are capable of protecting
and taking care of themselves. To label
this client with dependent personality
disorder, however, would be an injustice
as it does not take into account that her
behaviour is not atypical within the
context of her cultural background and
experiences.
Notwithstanding the above, the
client’s motivation for treatment could
be questioned as she showed evidence of
being resistant to making changes. For
this client, being symptom-free may not
be a realistic goal as it would mean a loss
of support and attention from her friends
and the mental health system to which
she had become dependent upon, in the
absence of a family caregiver. Secondary
gains and her need to hold on to the
symptoms would need to be addressed
with her. This could be achieved by
increasing her sense of self-efficacy
to manage on her own, accepting her
situation about being on her own, and
improveing her communication and
interpersonal skills.
In summary, the 5-part model of
CBT was partially successful, in helping
the client gain insight into the nature of
her problems and to have control over
aspects of her life, even if she was not
fully prepared to do this. It was crucial
also that the therapeutic processes
were appropriate for the client, that
the treatment progress was closely
monitored, that fi rm boundaries were
maintained, that the focus remained
on the client’s therapeutic goals, that
a collaborative relationship were
developed, and that the therapy was
short-term and structured, as thes e
factors contributed to the usefulness
of the CBT framework. It may be that
the client would benefi t from booster
sessions at a later stage to assess
the extent to which the gains from
therapy have been maintained and are
generalised. Thus, CBT has shown to be
useful in treating Chinese people as long
as cultural considerations are taken into
account when formulating the problem
and in carrying out treatment.
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Notes
1. All names and some personal
details have been changed to protect
confi dentiality
2. This comment was rightfully
noted by one reviewer as refl ecting
negatively on the client. Whilst not
wishing to judge the client’s comment,
it is provided as typical of Chinese
candidness and possibly pragmatism.
Author Notes
Mei Wah Williams
Lecturer and Clinical
Psychologist, School of
Psychology, Massey University
Koong Hean Foo
PhD candidate and PG Dip
Cognitive-Behaviour Therapy,
School of Psychology, Massey
University
Beverly Haarhoff
Senior Lecturer and Clinical
Psychologist, School of
Psychology, Massey University
Address for correspondence
:
Mei Wah Williams
School of Psychology
Massey University
Albany Campus
Private Bag 102 904
North Shore MSC
Auckland
New Zealand
email:
M.W.Williams@massey.ac.nz
