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ScienceDirectCognitive and Behavioral Practice 20 (2013) 390398Collaborative Empiricism in Culturally Sensitive Cognitive Behavior Therapy
Chee Wing Wong, Chinese Association of Cognitive Behaviour TherapyKeywoChine
1077- 20PubliCollaborative empiricism, one of the main tenets of cognitive behavior therapy, could encounter conceptual and practical problems whenapplied to culturally sensitive settings. This paper sets out to discuss issues in applying collaborative empiricism to Chinese patients,taking into account a number of cultural determinants such as collectivism, hierarchical perception, passivity, reticence, andsuperstition. These will be discussed in light of studies on the impact of Chinese culture on patient behavior. Evidence on the successfulapplication of cognitive behavior therapy to Chinese patients will also be presented. There is a pressing need for culturally sensitiveclinical procedures and skills adaptation. A case study is presented to illustrate how culturally mediated resistance in collaborativeempiricism can be overcome by good clinical practice.T herapeutic relationship is often held to be the chiefcommon factor of all models of psychotherapy. Ithas been found that therapeutic alliance is positively relatedto change in various types of psychological interventions(Gaston, Marmar, Gallagher, & Thompson, 1991; Morgan,Luborsky, Crits-Chistoph, Curtis, & Solomon, 1982). Suchfindings have been taken to suggest that therapeuticalliance is often a sufficient agent for change in effectivepsychotherapy. Orlinsky, Grawe, and Parks (1994) sug-gested that it is probably the decisive determinant of thera-peutic effectiveness.
To enhance therapeutic relationship, qualities ofempathy, warmth, and genuineness in counseling andpsychotherapy have long been accepted as the centralattributes of an effective therapist (Heslop, 1992).However,A. Beck, Shaw, Rush, and Emery (1979) regarded the coreconditions of empathy, warmth, and congruence asnecessary, but not sufficient, for change in cognitivetherapy. They also suggested that a collaborative relation-ship in which the therapist has considerable skill andexpertise to be a further necessary factor. Such a view wasfurther buttressed by Feeley, DeRubeis, and Gelfand(1999), who found that towards the latter half of therapy,the level of therapeutic alliance was predicted by theamount of prior symptom improvement, not vice versa, asimplicated in earlier writings.rds: collaborative empiricism; cognitive behavior therapyse culture
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A. Beck et al. (1979) emphasized that in cognitivetherapy, the therapist and the patient should ideally form ateam that unites and works together to solve the keyproblems. In this respect, A. Beck and Emery (withGreenberg; 1985) commented on the different butinterlocking roles between the therapist and the patient:
The cognitive therapist implies that there is a team approach tothe solution of the patient's problem: that is, a therapeuticalliance where the patient supplies raw data (reports on thoughtand behavior ) while the therapist provides structure andexpertise on how to solve the problems. The emphasis is onworking on problems rather than on correcting deficits orchanging personality. The therapist fosters the attitude twoheads are better than one in approaching personal difficulties.(p. 175)
J. Beck (1995, p. 8) also made the point that cognitivetherapy emphasizes collaboration and active participation,and regarded it important that the therapist and the patientshould work collaboratively in agenda setting, sessionreviews, homework assignments, and making frequentsummaries. In the process, both the therapist and thepatient will collect data and information pertaining to theway they construe and conceptualize the problems. This canonly be done by examining the information experientially,objectively, and empirically.
Thus, collaborative empiricism involves treating patientsas informed consumers and providing them with informa-tion about their illness. J. Beck (2011) remarked thattherapists do not generally know in advance to what degreea patient's automatic thought is valid or invalid. Using theprocess of collaborative empiricism, the therapist and thepatient can work together to test the patient's thinking andto developmorehelpful and accurate responses. A.T. Beck,
391Collaborative Empiricism in Culturally Sensitive CBTin his foreword to the second edition of Cognitive BehaviorTherapy: Basics and Beyond (J. Beck, 2011, p. xi), observedthat a number of participants in clinical trials could, attimes, go through the process of cognitive therapy withoutany sense of the principle of collaborative empiricism. Thecurrent paper sets out to examine the definition of thisimportant therapeutic ingredient in cognitive behaviortherapy, and discuss how it operates in a culturally sensitivesetting, specifically, working with Chinese patients.
Padesky (2004) suggested that collaboration can beunderstood as an equal working relationship. DeRubeis,Tang, and Beck (2001) also made the point that there is acollaborative relationship between the therapist and thepatient to assume an equal share of the responsibility insolving the patient's problems. Moreover, the patient isassumed to be the expert on his or her own experience andon the meanings he or she attaches to events. In otherwords, the cognitive therapist does not assume that he orshe knows the what, the how, and the why of thepatient's cognitions and feelings. Instead, both the therapistand the patient should work collaboratively to arrive at theanswers. Although cognitive therapy can be quite directive,proper respect for collaboration prevents any tendencytoward authoritarian practice. In light of these arguments,it is often assumed that collaboration entails an equalshare of commitments and responsibilities in the therapyprocess.
However, there are doubts as to whether the workingrelationship can be truly equal. Freeman and McCloskey(2003), for example, suggested that collaboration need notbe always 50:50. It may be 70:30, or even 90:10, in which casethe therapist will be providing most of the energy or workwithin the session. This is particularly evident in severelydepressed patients. In a depressed patient, for example, theenergy level may be low, and it may be necessary for thetherapist to do something upbeat in the first instance ratherthan working under the assumption of an equal respon-sibility. Thus, collaboration is something that has to bedeveloped, not assumed. It is also something that is dynamicrather than static. When the patient is at a low energy level,or is uncooperative or disengaged in therapy, the therapistwill have to work around the resistance by taking the lead.This can be done through suggestions, challenges, realign-ing treatment goals, Socratic questioning, or even throughmore didactic approaches such as psychoeducation, pro-posal of a problem formulation, or other behavioralmaneuvers (J. Beck, 2005; Leahy, 2001, 2003).
Young and Beck (1980) clearly defined collaboration intheir Cognitive Therapy Rating Scale Manual, stressing thatgood collaboration ensures compatible goals betweenpatient and therapist, minimizes patient resistance, andprevents misunderstandings (Young & Beck). J. Beck(2011) further enumerated a number of review questionsto ascertain the level of collaboration between therapist andpatient. For example, Have the patient and I truly beencollaborating? Are we functioning as a team? Are we bothworking hard? Do we both feel responsible for progress?(J. Beck, p. 350). Such questions are useful operationalguidelines in therapy to ensure appropriate compliance toeffective collaboration.Empiricism
While the concept of collaboration has been men-tioned on many occasions (A. Beck et al., 1979; J. Beck,1995, 2011; Young & Beck, 1980), empiricism is rarelydefined, and is therefore more complex to conceptualize.In everyday usage, empiricism refers to methods based onobservation or experiment, not on theory. To the cognitivebehavior therapist, empiricism is a process by whichpatients are skillfully guided to discover their automaticthoughts, assumptions, behaviors, triggers, and mainte-nance factors. It also furnishes the patient with alternativeexperiences based on personal observation, thus providingthemwith extra or competing data to facilitate reevaluationof their core schemas (i.e., their original theory of theworld).
However, personal experience, no matter how piece-meal or incidental, could, in the eyes of the person,constitute a piece of powerful empirical evidence. Atwiddle of the ear prior to winning a hand of blackjackcould be empirical evidence to the person that the behavioris a necessary precursor to a favorable outcome, although itcould be dismissed as a superstitious behavior (Skinner,1974). Going around the block to avoid a certain streetcorner where a person was robbed the week before couldbe, in the experience of the person, an empirically provenmaneuver to ensure safety in the future, although manycognitive behavior therapists would regard it as avoidanceor as a maladaptive safety behavior (Salkovskis, 1985).
Perhaps the key issue lies in the idiosyncratic under-standing of empiricism in the individual. Sadly, theappreciation of empiricism is never empirical. Commonfolklore, beliefs, and myths often stemmed from theuncritical acceptance of superficial, incidental, and insuffi-cient data. To the person, however, these are empirical datanevertheless. This issue is evenmore acute when an ethos ofsuperstition is implicit in a culture. Empiricism thereforeentails not what data to take, but which data to take andwhy such data should be taken. To be able to dispel oldbeliefs on the bases of new observation and experience, theperson needs the basic tenets of a scientific mind entailingthe basic concepts of objectivity and probability.
Implicit in the process of collaborative empiricism incognitive behavior therapy is the quest to steer a patient
392 Wongaway from subjective distorted beliefs based on insuffi-cient data to objective observations based on morerealistic facts. It is through this subjectivity-to-objectivitypathway that the cognitive behavior therapist could helpthe person to snap out of superstitious beliefs, or to stopengaging in futile safety behaviors. However, the conceptof empiricism as it stands does not implicate a distinctionbetween what is subjective versus what is objective.Moreover, there is little mention in the cognitive behaviortherapy literature as to how empiricism is operationallydefined, and how empiricism can be enhanced. Unlikecollaboration, there is little objective measure as to howsuccessful empiricism has been attained in therapy.
The following section will examine the application ofcognitive behavior therapy to a culturally sensitive popula-tion, the Chinese. The dimensions of collaboration andempiricism will be discussed in the light of the Chinesecultural context.
Cognitive Behavior Therapy for Chinese PatientsChinese Culture and Psychological Treatment
Sue and Sue (1990) posited that theories of counselingand psychotherapy represent a variety of worldviews thatmay clash with the worldview of the culturally differentclient in terms of values, biases, assumptions aboutbehavior, language, and constructs. This may be thecase when psychotherapy is applied to Chinese patients.The importance of cultural sensitivity in counseling andpsychotherapy has been reviewed in a number of studiespertaining to the Chinese (Cheung & Chan, 2002; Leong,1986; Lin, 2002).
Leong (1986), for example, reviewed the therapyprocess of American-Asians and suggested that Asians(Chinese people included) tend to have less tolerancetoward ambiguity and prefer structured therapy sessions withpractical and immediate solutions to their problems.Cheungand Chan (2002) furthermore suggested that Chinesepatients are not used to expressing their emotions openlyand in a free-flowing manner, and may require a morestructured and focused format in order for them to expresstheir feelings.
In line with the observation that Asian patients have lesstolerance for ambiguity, Lin (2002) found that cognitivebehavioral therapy is effective for Chinese people becausethe therapy can be carried out in a structured andsystematic format that emphasizes the step-by-step discov-ering and learning of new cognitive and behavioral skills. Itwas also found that Chinese patients perceive their groupleaders as effective when they take partial responsibility forthe process and play an active role in providing suggestionsand advice. It was further argued that Chinese patientsexpect the therapist to be active in the therapy process andbe able to provide concrete and practical advice that offersimmediate solutions to their emotional problems (Lin).In summary, these authors have alluded to some of thesalient cultural characteristics of the Chinese: collectivism,hierarchical class delineation, lower levels of verbal andemotional expressiveness, and a yearning for unambiguous,structured and clinician-led therapies that are short-termand solution-focused. All the above factors are seen to beimportant in maximizing the benefits of therapy.Importation of Western Psychotherapy Into China
In the early 1980s, Western psychotherapies found theirway into China. These included psychoanalysis, dynamicpsychotherapy, Jungian psychology, person-centered thera-py, and structural family therapy (Chang,Tong, Shi, &Zeng,2005; Qian, Smith, Chen, &Guo, 2002). However, there waslittle attempt to take into consideration culturally sensitiveissues in counseling and psychotherapy as espoused byLeong (1986) and Sue and Sue (1990). From then untilnow, there have beenmoves on three different fronts in thepractice of psychotherapy in China: theoretical integration,development of indigenous treatment approaches, andeclecticism.
The Chinese are staunch believers that the best option isto integrate different theoretical paradigms as a quest toreap the best ingredients out of quite diversified treatmentapproaches. One example is cognitive insight therapydeveloped by Youbin Zhong (Qian et al., 2002), whichremained largely a theoretical postulation than an empir-ically supported procedure. Another attempt was to weaveChinese Taoist philosophy into the premises of cognitivetherapy, resulting in a branch of indigenous treatmentapproach called Chinese Taoist Cognitive Psychotherapy(Zhang et al., 2002). Furthermore, there is a prevailingethos in China to adopt an eclectic approach in psycho-therapy. Clinicians simultaneously use quite diversifiedtherapeutic approaches on the same patient in the hopethat good will be done on all fronts. The phenomenon hasalso been described as a thous...