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Translating Daoist Concepts intoIntegrative Social Work Practice: AnEmpowerment Program for Persons withDepressive SymptomsCelia Hoi Yan Chan PhD MSW a , Timothy Hang Yee Chan MHES a &Cecilia Lai Wan Chan PhD aa Department of Social Work and Social Administration , Universityof Hong Kong , Pokfulam , Hong Kong , ChinaPublished online: 24 Feb 2014.

To cite this article: Celia Hoi Yan Chan PhD MSW , Timothy Hang Yee Chan MHES & Cecilia Lai WanChan PhD (2014) Translating Daoist Concepts into Integrative Social Work Practice: An EmpowermentProgram for Persons with Depressive Symptoms, Journal of Religion & Spirituality in Social Work:Social Thought, 33:1, 61-72, DOI: 10.1080/15426432.2014.873662

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Journal of Religion & Spirituality in Social Work:Social Thought, 33:61–72, 2014

Copyright © Taylor & Francis Group, LLCISSN: 1542-6432 print/1542-6440 onlineDOI: 10.1080/15426432.2014.873662

Translating Daoist Concepts into IntegrativeSocial Work Practice: An EmpowermentProgram for Persons with Depressive

Symptoms

CELIA HOI YAN CHAN, PhD, MSW, TIMOTHY HANG YEE CHAN,MHES, and CECILIA LAI WAN CHAN, PhD

Department of Social Work and Social Administration, University of Hong Kong,Pokfulam, Hong Kong, China

Chinese people display different usage patterns of mental healthservice, while mental health social workers report encounteringcultural difficulties in delivering traditional Western psychoso-cial interventions. Culture and behavior of Chinese people areheavily influenced by Daoist philosophy and practices. This arti-cle discusses the application of Daoist concepts in working withpeople with mental illness, and reports the development of apilot empowerment program for Chinese people with depressivesymptoms. In an uncontrolled study, participants (N = 61) afterthe program reported significantly lower levels of depression andanxiety. They also reported reduced affliction and increasedequanimity, two concepts pertinent in the Chinese conceptionof mental well-being. The findings suggest culturally sensitiveintegrative social work interventions can complement the existingmental health care system in Chinese communities.

KEYWORDS Daoism, integrative social work, depression,affliction, equanimity

Mood disorders in China are found to be less prevalent compared tothe West; repeated studies show a low prevalence rate of depression in

Received May 17, 2013; accepted October 12, 2013.Address correspondence to Celia Hoi Yan Chan, PhD, MSW, Assistant Professor,

Department of Social Work and Social Administration, University of Hong Kong, Pokfulam,Hong Kong, China. E-mail: chancelia@hku.hk

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metropolitan China, ranging from 1% to 2% within a 12-month period(R. Chen, Copeland, & Wei, 1999; R. Chen, Hu, Qin, Xu, & Copeland, 2004;S. Lee et al., 2009; Lu et al., 2008), compared to 4% to 10% in the Westerncountries (Kruijshaar et al., 2005). The lower figures found in China, althoughapparently a positive finding, belie the fact that psychiatric diagnosis in thecountry can be inconsistent. There are concerns that reporting is biased dueto stigmatization, diagnostic inconsistencies, and somatic presentation (Y.-C.Shen et al., 2006). In addition to reporting issues, mental healthcare profes-sionals often found cultural difference in service utilization in China or inChinese communities overseas. Chinese people tend to be less ready to seekmental health service as people in Western countries do (Chen & Kazanjian,2005), and they often present more severe symptoms when they first obtainservice compared to patients from other cultural backgrounds (Lin & Cheung,1999). These findings show that there is a pattern of underutilization ofmental health service among Chinese people.

There are several explanations for the apparent reluctance to seekmental health service among Chinese people. Discrimination against mentalillness is still prevalent in Chinese culture, and even help-seekers are beingstigmatized. Another reason is that Chinese people tend to report somaticsymptoms, and seek medical help as one would with a physical illness (Yen,Robins, & Lin, 2000). Although somatization may be a cultural tendency,it also reflects the reality that access to the mental health service in Chinaremains difficult (Parker, Cheah, & Roy, 2001).

PSYCHOTHERAPY FOR DEPRESSION IN CHINESE POPULATION

Traditional psychotherapies utilized by mental health professionals weredeveloped in Western countries with inherent social norms and culturalassumptions about human nature. For example, they usually adopt anindividualist and dualist approach, and emphasize on problem-solving, self-improvement, or direct confrontation with negative thoughts and distresssituations (Chentsova-Dutton & Tsai, 2009). Symptom reduction has becomethe major therapeutic goal in working with people with health and mentalhealth issues.

Mental health professionals who served Chinese populations reportedhow cultural differences affect client’s response to Western psychotherapies(Shen, Alden, Söchting, & Tsang, 2006; Sue & Sue, 1987). They noted theopen and predominant discussion of emotional issues, which often takesplace during therapy sessions, puts Chinese clients at unease because therequirement to talk does not square with their preponderance towards self-control, aversion to conflicts and emphasis on social harmony (Kim, Yang,Atkinson, Wolfe, & Hong, 2001; Sue & Sue, 1990).

Apart from therapeutic approach, the use of emotional concepts origi-nating from the West may also pose a problem when working with Chinese

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clients. The concept of depression, for example, was used to describe a widerange of emotions such as melancholy, lethargy, dysthymia, and hopeless-ness. In Chinese culture, the word yu (“not flowing, entangled or clogged”),which shares common characteristics with depression such as low mood,nonetheless represents a distinct psychological condition which attracts lit-tle discussion in the English-speaking world until recently (Ng, Chan, Ho,Wong, & Ho, 2006). Given the cultural barriers on how Chinese people usemental health service, it is essential to review how traditional Chinese cul-ture, which is heavily influenced by Daoism, can be translated to developcultural sensitive intervention for empowering Chinese people with mentalhealth issues.

INFLUENCE OF DAOIST BELIEFS ON MENTAL WELL-BEING

Although China’s history is marked by its factious periods, foreign influ-ences, and numerous ethnic groups, the Chinese populations in moderntimes, both in China and overseas, share a relatively consistent culture (Lim,Lim, Michael, Cai, & Schock, 2010; Yan, 2005). How the Chinese people con-ceptualize mental well-being, regulate emotions, and respond to stressfulsituations is heavily influenced by the Daoism, one of the main indige-nous religions and philosophy in China (Wong, 2011). Daoism describes aworldview through which Chinese people interpret the meaning of life andthe environment. Dao, literally means “the way,” refers to the harmoniousenergy that flows in the universe. The ideal state of well-being, according toDaoist beliefs, is that of dynamic equilibrium—that is, the ability to respondand adapt to the evolving circumstances appropriately. Achieving an optimalstate does not mean attaining enduring happiness or positive emotions; it isthe attainment of a level of resilience such that an individual can surf throughthe ups and downs in life.

More specifically, three tenets of Daoism are pertinent to the Chineseconception of well-being, namely as ziran, wuwei, and sanbao, whichdescribe respectively the desired state of well-being, the means to achieve it,and the venues through which it should be sought. One of the core values inDaoism, ziran (naturalness), refers to a state of being authentic and uncon-trived. Individuals with depression often have expectations towards self andothers, which cause suffering due to their unrealistic nature. Restoring to thestate of ziran requires the practice of wuwei (“nondoing” or “nonaction”),a seemingly paradoxical concept of achieving by not doing. It refers to thecultivation of the habit of exerting minimal efforts in daily life by followingthe natural course of action and by yielding to the flow of the immediatecircumstance. Individuals suffering from mood disorders often employ mal-adaptive coping strategies such as denial or overreacting in their attempts toregain control of the situation; according to Daoist teachings, the ability to“let go” would be an adaptive skill from which they can benefit.

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Another important Daoist concept is sanbao, namely three treasures,which stipulates that well-being depends on the full integration of jing (lifeessence), qi (life energy), and shen (mental well-being or spirit). It underlinesthe interconnectedness of different faculties of the human being actions, andserves as the fundamental framework for traditional Chinese health practicessuch as acupuncture, taiji, qigong, and Daoist meditation. This also explainswhy the Chinese culture tends to see physical, emotional, and spiritual well-being as different facets of the same holistic entity.

TOWARDS AN INTEGRATIVE APPROACH FOR EMPOWERMENT

In recent decades, there have been calls for the development of culturallysensitive intervention (Flaskerud, 1986; Sue & Zane, 2009). The introductionof mental healthcare in Chinese communities since the middle of the 20thcentury gave rise to efforts to develop interventions that take into consid-eration cultural characteristics of the population. Among those efforts, oneis the Integrative Body-Mind-Spirit (I-BMS) model developed by Chan andassociates (Chan, Ho, & Chow, 2002). The model is the result of both pastclinical experience working with Chinese individuals facing various adverselife events, and a more in-depth understanding of the Daoist culture that isdeeply ingrained in Chinese communities. It adopts a holistic approach thatreconciles traditional Western psychotherapy with the Daoist philosophy ofwell-being. Core beliefs of the I-BMS model include (a) the interconnected-ness of body, mind, and spirit; (b) the importance of spirituality as a domainof human existence; (c) the need to reach beyond symptom reduction toattain positive and transformative changes; and (d) the dual goal of healingand capacity building (Chan, Ng, Ho, & Chow, 2006). A detailed theoreticaldiscussion on the I-BMS model can be found in Lee, Ng, Leung, and Chan(2009).

Based on the I-BMS model, a pilot empowerment program was devel-oped for people with depressive symptoms in Hong Kong. It was atime-limited group intervention aimed at those who suffered from emotionaldisturbances but not under psychiatric care. As discussed, an ideal state ofwell-being is one that has reached a dynamic equilibrium within the person,between the person and others, and between the person and the environ-ment. The goal of the empowerment program was to promote self-healingpractices and build resilience in clients.

Intervention

The program spanned from February to August 2011. During the 7 months,four intervention groups have been conducted. Each group comprised

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TABLE 1 The Major Themes in the Empowerment Program

Session Theme Objectives

Working with QiOne The harmony of body,

mind and spirit• Introducing the concept of holistic health

• Regaining autonomy to heal oneselfTwo The way of dynamic

Balancing• Restoring equilibrium among physical, emotional, and

spiritual well being• Restoring balance among work, family, and life

Working with JingThree The choice of letting go • Accepting pain and suffering

• Letting go and accepting mishaps in life• Evaluating gains and losses in life

Four The state of “wuwei” • Fostering forgiveness to own self• Facilitating reconciliation with other people• Cultivating sense of tranquility and peace of mind

Working with ShenFive The beauty of simplicity • Appreciating own self and life

• Planning and committing to personal growthSix The law of nature • Instilling hope towards future

• Planning and taking action to help self and others

6 weekly 3-hr sessions. Group sizes ranged from 13 to 21. In each ses-sion, breathing exercise, therapeutic massage, simplified taiji movements,acupressure, meditation, and guided imagery were introduced, followed bydiscussions on suffering according to Daoist teachings (Table 1).

Participants

Participants were recruited at a community-based Chinese Medicine clinic.They were referred by licensed Chinese medicine practitioners at the clinic,or they could approach the practitioners for referral. The practitioners deter-mined whether they fit the criteria of yu diagnosis, which is similar to thewestern concept on depression and coined as stagnation (Ng et al., 2006).Upon referral, each of the participants received a 1-hr individual interviewbefore enrollment to determine their suitability for the empowerment pro-gram. A total of 61 participants completed the interview and attended theprogram (Table 2).

Measures

In order to measure efficacy of the program, the following measures wereused:

As part of the evaluation, a prepost comparison was conducted tosee whether participants had improvements on clinical outcomes. Threemeasurements were used: Hospital Anxiety and Depression Scale (HADS;

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TABLE 2 Characteristics of the Respondents

N %

SexMale 7 11.5Female 54 88.5

Age20–29 6 7.930–39 19 19.540–49 21 45.050–59 11 25.1≥60 1 2.5

Marital statusSingle 20 32.8Married 30 49.2Divorced/Separated 4 6.6Widowed 6 9.8

ReligionNil 29 47.5Chinese folk religion 5 8.2Buddhist 11 18.0Christian 14 23.0

EmploymentFull-time 34 55.7Part-time 4 6.6No employment 22 36.1

Psychiatric historyMood disorder 3 4.9General anxietydisorder

4 6.6

Both 13 21.3

Note. Percentage does not add up to 100 because of missing data.

Zigmond & Snaith, 1983), Brief Symptom Inventory 18 (BSI-18; Derogatis& Fitzpatrick, 2004), and Holistic Well-being Scale (C. H. Y. Chan et al., inpress). The Holistic Well-being Scale is a self-report assessment instrumentdeveloped based on the affliction-equanimity model of holistic well-being.There are seven subscales: emotional vulnerability, bodily irritability, spiri-tual disorientation, nonattachment, mindful awareness, general vitality, andspiritual self-care.

In addition, participants completed self-constructed satisfaction ques-tionnaires by the end of each session, and by the end of the program.

RESULTS

Using 7/8 as a cutoff point for HADS anxiety and depression scores, a cross-tabulation is shown in Table 3 detailing the profile of the participants atbaseline. Over 80% of them had either depression or anxiety scores above

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TABLE 3 Scores of Hospital Anxiety-Depression Scale

HADS Depression <7 ≥8

HADS Anxiety<7 8 (13.1) 3 (4.9)≥8 16 (26.2) 32 (52.4)

TABLE 4 Summary of Session Evaluation

Session evaluation (N = 208) Mean (0–5) SD

How would you rate your participation in this session? 4.21 0.66How satisfied are you with the content of this session? 4.35 0.52Generally speaking, are you satisfied with this session? 4.30 0.56

TABLE 5 Summary of Program Evaluation

Overall evaluation (N = 39) Mean (0–5) SD

How much does the program help you deal with youremotions and stress?

4.02 0.97

Do you find the relaxation exercises taught in the programuseful?

3.87 1.09

How much support do you get from the program in face ofyour problems?

3.73 0.92

Did you have an enjoyable time in the program? 4.23 0.75How much does the program help you gain a positive

attitude towards life?4.02 0.82

How much does the program help you deal with youremotions and stress?

4.02 0.97

cut-off, while a majority of participants had both depression and anxietyscores above cut-off at baseline.

Attendance rate was on average 91.8%. The effectiveness of the programwas evaluated by two aspects: participant satisfaction and outcome.

Satisfaction

After each session an evaluation form was distributed to participants, whorated their participation, content satisfaction, and overall satisfaction. Of the208 responses received, satisfaction was uniformly high.

At the end of the last session, the participants were asked to ratetheir overall satisfaction with the program. The overall satisfaction and theperceived effectiveness were also highly rated (Tables 4 and 5).

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TABLE 6 Characteristics of the Respondents

Pre Post t

HADSAnxiety 10.20 (4.18) 7.82 (4.67) −4.361∗∗

Depression 9.42 (4.82) 7.70 (5.27) −2.751∗∗

BSISomatization 6.21 (4.13) 5.44 (4.49) −1.374Depression 8.84 (6.13) 6.57 (5.94) −3.327∗∗

Anxiety 9.48 (6.48) 6.18 (5.72) −3.992∗∗

HWS AfflictionEmotional vulnerability 36.87 (8.06) 33.76 (7.23) −3.625∗∗

Bodily irritability 20.86 (8.75) 15.49 (7.01) −3.991∗∗

Spiritual disorientation 43.53 (15.17) 37.11 (14.09) −3.079∗∗

HWS EquanimityNon-attachment 33.00 (8.32) 35.30 (8.36) 1.892Mindful awareness 26.27 (6.09) 29.13 (6.58) 2.944∗∗

General vitality 16.83 (7.33) 21.52 (9.38) 3.723∗∗

Spiritual self-care 21.95 (7.14) 25.61 (7.37) 3.500∗∗

Note. Valid N for analysis = 45.∗∗p < .05.

Outcome Measures

When comparing participants’ mental well-being in terms of HADS scores,both their anxiety and depression scores dropped significantly (t =−4.361 and −2.751, respectively; both ps < .01). Both scores were underthe cut-off point of 8 after the program. Similarly, in terms of BSI scores, par-ticipants reported significant improvements in both depression and anxiety(t = −3.327 and −3.992, respectively; both ps < .01), but not somatization(t = 1.374, ns). Participants reported lower scores in all three affliction-related subscales (t = −3.08 to −3.99, all ps < .01), while they had higherpostintervention scores in mindful awareness, general vitality, and spiritualself-care (t = 2.94 to 3.72, all ps < .01) (Table 6).

DISCUSSION

Findings suggested the pilot empowerment program was well received bythe participants, as shown by the high attendance rate and high self-reportedsatisfaction rate. They also reported improvement in measures of depressionand anxiety. Perhaps more important than mood improvement, participantsreported higher awareness, more willing to take care of themselves spiritu-ally, while having less physical, emotional, and spiritual discomfort. Writtenfeedback solicited from the participants was positive too. Many of the par-ticipants reported the massage and acupressure techniques were useful in

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helping them improve their moods. Participants also recalled the spiritual dis-cussion on pain and suffering during the program, and said it was insightfulfor them.

Specifically, it was found that the scores of the three affliction-relatedsubscales (emotional vulnerability, bodily irritability, and spiritual disorien-tation) decreased significantly while those of the two equanimity subscales(mindful awareness and general vitality) increased significantly after pro-gram. According to Chan and associates (in press), affliction is a state similarto depression but qualitatively distinct, with additional intrapersonal inter-personal components of resentment, jealousy, and bitterness coming intoplay. It is also believed to manifest somatically in the form of irritability andnervousness, especially among Chinese people. People who are afflicted willdemonstrate an inability to let go of material and immaterial fixations resultsin a loss of direction and a reduced sense of meaning. On the other hand,equanimity is characterized by a sense of unflappability and resilience in faceof challenges. It is believed that people with inner resource can experiencea heightened level of bodily vitality, and a capacity of acute awareness.

With reference to the Daoist practice of wuwei, one of the strategieswas to help individuals understand and articulate the symptoms as a possiblemanifestation of overattachment or disconnection with any person(s) in thesocial environment or any disharmony with the physical environment, as wellas to revisit how the problem affects themselves. Instead of aiming as totalsymptom reduction, the participants were encourage to acknowledge andaccept the existence of negative emotions and physical discomforts, whilealso being aware of all potential experiences and emotions as resources formaking positive changes in life. According to the participants, they could staywith the bodily symptoms peacefully, even though they were not alleviatedwithin a short period of time.

The philosophy of “letting go,” promoted throughout the program, maybe conducive to the alleviation of affliction and enhancement of equanimity.By focusing attention and energy to positive life experiences, both regrets ofthe past and fears for the future become emotionally less valent. Participantswere facilitated to realize any nonfunctional belief, values, behavior, andexpectation that they have been holding on or attached to. Meditative exer-cises also enabled participants to make nonjudgmental observations and toaccept their current condition.

In order to revitalize the general life energy and spirit, participants werealso invited to reevaluate their life goals, broaden their perspectives, andfocus on personal fulfillment rather than overattach with the health and men-tal health outcome or their state of being depressed. In doing so, participantswere able to better re-examine the importance of life to them. As indicatedfrom the results, the participants could employ spiritual self-care after theprogram, which they could feel more empowered in helping themselves insurfing through the period of being depressed.

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Future research should address the limitations present in this currentstudy. First, this study used only single groups, making it difficult to dis-cern whether the presence of the group setting alone produced the positiveresults. In future studies, three arms should be included: control, interven-tion that uses empirically supported therapies, and the I-BMS intervention.Finally, future studies should include people with different levels of depres-sive disorders, so as to examine how the intervention can be integrative withmedical or psychiatric care practices.

CONCLUSION

The Daoist concept of well-being, deeply ingrained in Chinese culture, offersclues on how individuals can search for optimal functioning. By going withthe flow of nature and reorienting the goal of life towards minimizing suffer-ing, Daoism describes a state of being in human existence, through whichhuman distress can be resolved by restoring the balance between systemswithin individuals and outside the environment.

The empowerment program, inspired by the I-BMS model, has provideda platform for the individuals to experience new ways of perceiving, think-ing, acting, and responding while they are struggling through depressivesymptoms. The techniques introduced were effective ways of integrating thenew perception and action in their daily life. It is believed that individu-als can build up their own practice or self-help strategies in body, mind,and spirit domains, so as to develop the capacity to monitor their internalbalance among jing, qi, and shen. By learning more about Daoism and tradi-tional practices, social workers serving Chinese patients may appreciate therelevance of integrative social work in body-mind-spirit intervention.

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