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ScienceDirectCognitive and Behavioral Practice 20 (2013) 390–398

Collaborative Empiricism in Culturally Sensitive Cognitive Behavior Therapy

Chee Wing Wong, Chinese Association of Cognitive Behaviour Therapy

KeywoChine

1077-© 20Publi

Collaborative 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 chief“common factor” of all models of psychotherapy. It

has 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

7229/12/390–398$1.00/012 Association for Behavioral and Cognitive Therapiesshed by Elsevier Ltd. All rights reserved.

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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 CBT

in 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.

Collaborative EmpiricismCollaboration

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 “equal”share 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, and

prevents 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 and“why” 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 Wong

away 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 thousand flowers bloom” (Changet al., 2005). Unfortunately, eclecticism was practisedwithout due consideration of theoretical eclecticism versustechnical eclecticism as cautioned by Lazarus (1967).

Although behavioral and cognitive therapies were firstintroduced toChina in the late 1980s (Ji&Xu, 1989;Qian&Chen, 1998; Xu & Ji, 1996), the development of cognitivebehavior therapy in China was hampered by a lack oftranslated textbooks, learning materials, trainers, andsupervisors at the time. It was not until the last decadethat there was a steady increase of systematic trainingprograms to introduce cognitive behavior therapy to China(C. Wong, 2011; C. Wong & Ng, 2010, 2012). Chinesepatients favored behavioral approaches over psychoanalyticapproaches. The behavioral approach, perhaps moresynergistic with traditional Chinese culture and philosophy,appealed to the Chinese patient for its didactic, systematic,

393Collaborative Empiricism in Culturally Sensitive CBT

outcome-focused, and time-limited nature (Chang et al.,2005; Lin, 2002).

Following the introduction of cognitive behavior thera-py into China, and the application of cognitive-behavioralprocedures to Chinese patients worldwide, a number ofdiscussions ensued questioning the cultural fit of cognitivebehavior therapy to Chinese patients (Chen & Davenport,2005; Hodges & Oei, 2007; Lin, 2002). It has often beenargued that Western treatment modalities cannot betransposed en bloc cross-culturally, and some form of cul-tural adaptation will be needed. F. Wong, Chau, Kwok, andKwan (2007) attempted to indigenize cognitive therapy forthe use of Chinese patients inHongKong.This involved theadaptation of alternative colloquial terms that may makemore sense to Chinese patients, such as using the term“thought traps” in place of “automatic thoughts” (F. Wong,2010).

The mode of treatment protocols aside, the followingcornerstone questions still remain: How receptive areChinese patients to cognitive behavior therapy? Is therecollaboration between therapist and patient? Is it possibleto align a mutually agreed treatment goal? Are patientswilling to partake in behavioral experiments to see forthemselves whether real-life observation will occur aspredicted? In other words, are Chinese patients capableof being collaborative as well as empirical?

Collaborative Empiricism: Lost in Translation

Translation of English technical terms into Chinese ismore complex than one would imagine. There is nouniversally agreed upon thesaurus between the twolanguages, and translation often results in a conceptual,sometimes idiosyncratic, interpretation of a term'smeaning.The situation is further complicated by different terminol-ogies in psychology and psychiatry betweenMainlandChinaand Taiwan, both using Chinese as the root language. Evenwithin Mainland China, there are various translations of thesame technical term, resulting in frequent confusion andinconsistencies within the academic literature.

“Collaboration” is often translated as “cooperation” inthe Chinese language, which, although not entirelyincorrect, has lost some of the flavor of the original Englishword. As suggested by Freeman and McCloskey (2003),someone can be cooperative without agreeing on the basictheoretical premise. Indeed, one can be cooperative but doso in a disinterested or even perfunctory way. Recently, onetranslation of collaboration added a flavor of “assisting” ontop of “cooperation.” Another translation alludes to a“partner relationship.”None of these, however, is a perfecttranslation of “collaboration,” but at least there arecontinuous attempts toward improvement.

Translation of the term “empiricism” into Chinese isevenmore challenging. A literal translation is “the doctrine

(principle) of evidence proof.” One Chinese translationalludes to “down-to-earth information.” It is obvious thatvarious translations would give rise to differing interpreta-tions and understanding of the term. Recently, someworkers translated “collaborative empiricism” into “coop-erative practice” (Li, personal communication, November,25, 2011), which may still be insufficient to reflect the coreessence of the term.

Collaboration in Chinese Patients

There exists a collectivism-versus-individualism distinc-tion between the Chinese and their Western counterparts,with the belief that the Chinese are less individualistic andhence less willing to express wishes andopinions thatdigressfrom social and authoritative values. It has also been positedthat traditional collectivist culture is still very much part ofthe Hong Kong scene (Cheung & Chan, 2002). A tendencytoward collectivism may also imply that in therapy, Chinesepatients may be more inhibited in volunteering individualopinions. Writers have also observed that Chinese patientsare passive and submissive, expecting their doctors to bedirective and authoritative (Hodges&Oei, 2007; Lin, 2002).However, it could also be argued that the cultural traditionsof class distinction and status/hierarchy are factors inChinese patients’ compliancy and cooperation in the cog-nitive behavior therapy process.

The practice of cognitive-behavioral therapy withChinese clients has been well-documented, and therapistsin general have not reported serious process impediments(Foo & Kazantzis, 2007; Lin, 2002; Ng, 2008; Qian & Chen,1998; F. Wong, 2010, 2011; F. Wong et al., 2007; Xu & Ji;1996). For example, Foo and Kazantzis reported thatChinese patients were highly compliant with homeworkassignments because, culturally, homework has beenconstrued as an essential learning process and a usefullearning tool. Successful application of cognitive behaviortherapy to patients with depression or anxiety in a groupsetting yielded encouraging results (F. Wong, 2007, 2008,2009). The only onus is that, in the above series of groupcognitive behavioral therapy sessions, Chinese participantsreported outpouring of negative emotions counterproduc-tive to the treatment process (F. Wong, 2011). This furtherreinforces the thesis that the Chinese are more reticent intherapy sessions than their Western counterparts (Cheung& Chan, 2002).

In working with Chinese patients, collaboration can bechallenging because of the hierarchical status perceptioninherent in the Chinese culture. The patient often expectsthe therapist to have all the answers and believes there is noneed to do any work in the guided discovery process. ManyChinese patients would ask the therapist about an opinionon the genesis of their problems. C. Wong and Ng (2012)considered that upbringing in traditional Chinesemedicine

394 Wong

might have prompted a strong belief of cause-and-effectrelationships. It is not uncommon for patients to inquireabout the underlying “cause(s)” of problems, believing thatevery problem must have a cause. They also believe thatonce the root of the cause is known, solution will follow.To a point, cognitive therapy can offer a form of causalexplanation—that emotional ailments are the results ofirrational and dysfunctional beliefs (C. Wong & Ng). Theproposition of core schema in determining thinking styles isalso welcomed and readily accepted. Ng (2008) found thatChinese patients are particularly receptive to sharing caseformulation, wherein “theory, research, his or her ownproblems as well as personal strengths were concocted in acrucible” (Kuyken, Padesky, & Dudley, 2008).

Empiricism in Chinese Patients

The traditional Chinese folklore is laced with myths andbelief systems. These include god-worshipping, burningofferings to ancestors, fortune-telling, alternative remedies,and other superstitious practices. One way of illustratingthis superstition versus empiricism dilemma is by way of acommon Chinese belief called feng shui. Feng shui is asuperstitious belief that arranging furniture and householditems in certain specified ways will alter the surroundingfield energy to ensure luck, wealth, and prosperity. Fortunetellers and feng shui experts have become very prosperousin a Chinese society. Firm believers of feng shui can get soentrenched in the theory that they would eschew anysuggestion that might prove to them otherwise. To them,the fact that their family is safe and happy is sufficientempirical evidence that feng shui is really working. Hence,it will be unlikely for them to get involved in anyexperimental attempts to test out if there is a truerelationship between wellness and furniture arrangement.At the backdrop of such unscientific and superstitiousethos, onewould anticipate thatWestern empiricismwill bedoomed to rejection by Chinese patients.

Indeed, if one traces the 5,000 years’ history of China,objective science, research, and the concept of empiricismare notmain tenants of the culture. The feudal system breda tradition of collectivism, bringing up children with astrong indoctrination of filial piety instead of encouraginginquisitiveness, skepticism and individualism. The educa-tion system rarely fosters the importance of a critical mind,as knowledge and wisdom are handed down fromgeneration to generation. It is no wonder, therefore, thatthe average Chinese worldview is often based on incidentalobservations, piecemeal evidence, hearsay information,culturally determined collective beliefs and superstition.The fact that psychotherapy inChina has, for decades, beenleaning towards uncritical acceptance of convenientimportations from the West without due considerationof empirical evidence may be a good testimony to thisobservation.

However, the Chinese are known for their practicalityand pragmatism. An axiom from Deng Xiaoping, lateleader of China, dictated, “I don't care if it is a white cat or ablack cat—the cat that catches mice is a good cat.” It is alsointeresting to note that in the Doctrine of the Mean, takenfrom the classic teachings of Confucius, wisdom ingrainedin the five processes of knowledge acquisition conformswith the basic tenets of empiricism:

1. To learn widely.2. To ask inquisitively.3. To think carefully.4. To argue wisely.5. To practice wholeheartedly.

In our clinical practice, we do encounter numerousexamples of superstitious beliefs, jumping to conclusions,and yearning for immediate and magical remedies. Thechallenge in creating a culturally sensitive cognitive therapysetting is to take heed of such distorted beliefs and expec-tations and to instigate an insidious realignment to fact andobjectivity through the process of collaborative empiricism.

Collaborative empiricism, in the context of this paper,thus calls for sensitivity to culture at the beginning oftherapy, as well as good clinical skills during the courseof treatment. Patients may need to be guided towardsreevaluation of their prevailing beliefs, and to learn toinitiate objective and rational dialectics with their corebeliefs. Ng (2008) observed that it might take more than8 to 10 sessions before a Chinese patient can becomeaccustomed to a collaborative stance. The process, none-theless, helps in building greater trust before such an“unconventional” working style could be safely accepted inthe therapeutic relationship.

Case ExampleChoice of Case Study

The following case study illustrates engagement andcollaboration. Some of the difficulties in this case probablystemmed from the patient's traditional beliefs that thetherapist is an all-knowing, omnipotent expert who will“cure” the patient. Cognitive therapy was also hampered bythe patient's limited participation in collaborative worksuch as agenda setting, guided discovery, and behavioralexperiments. There was also poor adherence to homeworkassignments. Another roadblock was the patient's firmconviction about her own theory of the mind, and washence reluctant to partake in behavioral experiments setout as homework assignments. As the therapy progressed,the patient agreed to try out in-vivo behavioral experimentson the condition that she was being accompanied by thetherapist. When experiential observations were contrary tothe patient's initial predictions, cognitive changes took

395Collaborative Empiricism in Culturally Sensitive CBT

place, which, in turn, expedited the progressive remissionof the core symptoms.

Background Information

Josie was a 38-year-old unemployed single female whocame from a wealthy family. She was referred to the clinic byher attending psychiatrist. Her intake information sheetindicated, “Hope to overcomemy fear towards other peopleand to reestablish normal interpersonal relationships.”

Josie was guarded in the initial interview and wasunwilling to disclose details of her family members. Theonly information that Josie revealed was that, at the age of12, her father left the family for a Thai woman, and she hasnot seen her father since that time. This happened afterover 15 years of strained marital relationship with Josie'smother. At this juncture, establishing a good therapeuticalliance involved not pressing Josie for more information,but to be sensitive that Chinese patients could feel shamefuland guilty in psychotherapy. Sensing her reluctance, thetherapist resumed the interview by focusing on presentingproblems with genuineness, concern, understanding, and aprofessed willingness to help.

When the conversation topic was changed, Josie becamemore spontaneous and animated. She described her chiefcomplaint as “feeling anxious towards middle-agedwomen.” She said that she could trace her problems backto her all-girl secondary school run by nuns. Her classmateswere snobbish and would not play with her. She then wentto Canada for university but did not manage to finish herstudies. She went back to Hong Kong and attempted anassociate degree course but again dropped out of college.Josie also remembered being teased and ridiculed by heraunt for her academic failures.

At the age of 27, she had her first episode of psychosiswith vivid auditory hallucinations. Her family doctorreferred her to a private psychiatrist whom she has beenseeing for the past 10 years. Her illness remitted withmedication, and she is currently well-maintained by regularpsychiatric follow-ups. She has not had any auditoryhallucination for over 5 years.

After the resolution of her psychotic episode, she startedto develop a fear of women, especially those in the agerange of 40 to 50. She stated that middle-aged women are“dirty and mean” because “they have lost the virility andtheir bodies are sagging.” She also believed that middle-aged women would use surreptitious tricks to extort moneyfrom her. They would always pick her out from the crowdbecause they know she is rich. They would approach herand would attempt to chat her up. They would then ask herfor money, which they would never return. Moreover, shethinks middle-aged women are all infected with diseasesand would pass the germs onto her. In the case of Josie, itis important to show adequate and appropriate under-

standing of her “internal reality” (Young & Beck, 1980),and to be mindful that her complaints could be part andparcel of her residual psychotic symptoms.

Josie reported that this fear had intensified in the pastyears, and she has virtually been living the life of a recluse.About 3 years ago, she asked her family to buy her anapartment so that she could live by herself. She was alsobeing provided with a chauffeured car. Every afternoon,she would go to the gym for 3 hours during which time adomestic worker would go into her flat to clean up and toprepare meals. She rarely went out and her social circle wasrestricted to a handful of close friends whom she could ringup or connect via Skype. Recently, she agreed with herpsychiatrist's suggestion that she should seek therapy fromaclinical psychologist for her fear of people and increasingsocial isolation.

Therapeutic Goals and Initial Treatment Attempts

Apart from being reticent about her family background,Josie was quite talkative, with no sign of any anxiety or socialinhibition. She explained that she has no problem withmen because they are not as unscrupulous as women. Thetherapist and Josie quickly agreed on a common treatmentgoal: to overcome her fearful attitude toward middle-agedwomen. When it was suggested that she should work closelywith the therapist to understandmore of her problems, shereplied, “I was told that you are the expert and you shouldknow all the answers.” When it was suggested that thetherapist might need her assistance in order to understandthe true extent of her problems, Josie retorted, “When I seedoctors with my mother, they always have answers andexplanations.” The therapist then suggested that he mighthave the answers, but heneededher help to check out if theanswers are 100% correct. To this, she replied, “You are theexpert, and it is for you to judge. Just tell me what is wrongwith me and how I can get rid of this fear.” It was apparent,at this point in therapy, that Josie was upholding a stronghierarchical patient-therapist role delineation, and expectedthat the therapist would be taking a directive and leadingrole in treatment.

The first session concluded by attempting to give Josiea homework assignment. She was asked to recordincidents in which middle-aged women (a) take noticeof her, (b) approach her, (c) chat her up, and, (d) ask herfor money. However, Josie came to the second sessionempty-handed and told the therapist that she had notdone her homework. The therapist decided to forgoinsistence on homework assignments lest the therapeuticrelationship weaken.

In Session 2, an attempt to set an agenda “to talk moreabout the dangers of middle-aged women” was met with acounterproposal that therapy time would be better utilizedin getting rid of her fears. This is a common request among

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Chinese patients as they tend to be more problem-focused,and, at the same time, seek quick, magical cures.Engagement through talking about her irrational thoughtsand beliefs proved to be a slow process.

Better rapport was established when questions werephrased along Josie's beliefs and convictions. For example,the therapist asked her to describe one example of amiddle-aged woman she saw in the gym. To this, Josiesuddenly becamemore engaged and animated, and starteda running account on the woman's hideous body and themean looks on her face. Along a similar line of approach,Josie slowly agreed to play a game of “How to identifydangerous women from benign women” using pictorialmagazines. With such a concrete exercise, the level ofcollaboration with Josie started to improve.

In the ensuing therapy sessions, attempts to ask her tocritically evaluate the realness of her perception ofmiddle-aged women and evidence supporting her asser-tions were met with blatant refusal. When it was suggestedthat Josie stand on the pavement for 5minutes and seewhathappens, she remarked, “You are not me, and you don'tknowhowdangerous thosewomen are.”Also, Josie said thatshe would not risk having women approaching her andextorting money from her. She was adamant in her beliefthat women are dangerous, citing firsthand experiencefrom her classmates and her aunt that women areunscrupulous and hurtful. For Josie, previous experiencehad become her own “empirical evidence” that her fearswere amply justified.

Treatment Sessions

It was then decided that therapy should move to a morebehavioral paradigm. In Session 5, the therapist decided totake advantage of Josie's preference for status andhierarchyby proposing that she experience the role of an all-knowingexpert by helping the therapist gain first hand informationon the dangers ofmiddle-agedwomen. Instead of staying inthe clinic, the therapist decided that themost “efficient useof time” (Young & Beck, 1980) was to have in-vivo exposuresessions with Josie. Somehow, Josie found this an amusingidea and agreed that she could help to educate thetherapist. After considerable nudging and coaxing, Josiefinally agreed to go with the therapist into the street toprove to the therapist thatmiddle-agedwomenare intrusiveand unscrupulous. Josie's initial apprehension was allayedby the therapist's gentle but confident reassurance that hewould fend off any unwelcomed woman trying to takeadvantage of her.

Session 6 was the first in-vivo session; it took place on abusy pedestrian foot-bridge adjacent to the clinic. Josie'sfirst task was to stand by the side of the foot-bridge toobserve approaching women and to give the therapistfeedback regarding the level of threat female passers-by

posed. Josie was also asked to make predictions as to howmany women would approach her and try to conversewith her. After 30 minutes, Josie made the following obser-vations: “I felt as if I was invisible”; “No one took noticeof me”; “No one bothered to look at me”; and “Wherehave those terrible women gone?” During a subsequentdebriefing session, Josie began to realize that reality was verydifferent from her predictions: that is, no one bothered toapproach her and to chat with her.

In Session 8, Josie was more confident in the behavioralexperiment, and agreed to try out something bolder. Thistime, she was encouraged to randomly approach a womanto ask for the time. Josie made the prediction that once sheapproached the woman, the woman would start chattingher up and asking her formoney. It took a while for Josie tomuster up enough courage to approach a passerby. ToJosie's surprise, the woman whom she approached simplygave her the right time and then walked off without anyfurther conversation. Again, Josie was surprised that noneof her predictions had come true.

In Session 9, Josie and the therapist stood at the entranceto the local underground where two women were solicitingdonations for a charity organization. Josie was encouraged towalk by the women.When she was being asked for donation,she was instructed to simply say “No, thanks!” and thenobserve what would happen. Josie predicted that the womenwould nag her into contributing a large donation. Josie cameback surprised that when she said “No, thanks!” the womensimply replied, “Thank you!” and nothing else happened.

Josie defaulted her next appointment anddid not returnfor follow-up. A call from the psychiatrist 2 weeks laterconfirmed that Josie was happy with the therapy, and shetold the psychiatrist that “middle-aged women are not asfrightening.”

Treatment Outcome

The case example illustrates resistance in engagementand collaboration from a Chinese patient with fear ofmiddle-aged women. The phobia could be part and parcelof her remitted psychosis. For 3 years, the patient managedto avoid the feared objects via a reclusive lifestyle madepossible by her wealthy family. Conventional protocols ofcognitive behavior therapy were met with such roadblocksas reluctance to disclose family information, refusal toengage in a collaborative therapeutic alliance, failure tocomplete homework assignments, insistence that thetherapist should be doing all the work, and harboring afirm conviction of her distorted beliefs based on pastexperience. The following culturally sensitive maneuverswere deployed: (a) avoid dwelling on topics sensitive to thepatient (i.e., family background); (b) encourage elabora-tion of her fears and transforming the dialogue into actiongames (i.e., picking out dangerous and benign women

397Collaborative Empiricism in Culturally Sensitive CBT

from magazines); (c) acknowledge the patient's tra-ditional hierarchical belief and turn it into an advantage(i.e., teaching the therapist about the dangers ofmiddle-aged women); (d) use behavioral strategies in lieuof verbal strategies (i.e., accompanying the patient duringin vivo exposure); and, (e) help the patient tomake senseofnew empirical experiences (i.e., encouraging cognitiveshifts in light of contradicting evidence collected viabehavioral experiments). Successful engagement andimproved collaboration resulted in opportunities to assim-ilate new information. In the end, satisfactory cognitive andbehavioral changes were achieved.

Conclusion

The application of cognitive behavior therapy should beculturally sensitive in order to adapt to cultural differences.Using collaborative empiricism as a focal point fordiscussion, culturally specific caveats need to be consideredin order tomake therapy a success. Thehurdles described inthis paper may not necessarily be specific to the Chineseculture, per se. Other cultures, even those in the West or inother developed countries may pose similar problems.Therefore, what is needed is not a specific treatmentalgorithm for a specific culture, but a keen sensitivity on thepart of the therapist towards a patient's worldview. Goodclinicians should have innovative ideas and skills to helpthem negotiate roadblocks in therapy. Good clinical insightand skillful tactical flexibility are the cornerstones oftherapeutic success.

With increasing evidence of the applicability of cognitivebehavior therapy to Chinese patients, it is perhaps nolonger valid to treat the so-called “Chinese culture” as astatic phenomenon around which psychotherapies shouldrevolve. Chinese patients can be steered toward collabora-tion and empiricism via skillful clinical practice (C. Wong,2011; C. Wong & Ng, 2010).

In the light of rapid globalization and shifting values,cultural factors such as traditional beliefs and philosophicalconvictions will likely be further watered down in thegenerations to come (Lin, 2002). Experience suggests thatongoing attempts in China towards theoretical integrationin psychotherapy are futile. By the same token, the quest foran indigenous therapy is unnecessary, given the good fitbetween cognitive behavior therapy andChinese values andworldviews (Hodges & Oei, 2007). Practical mandate forthe cognitive-behavioral therapist is perhaps more on theuse of good clinical innovation and the use of culturallyappropriate metaphors and images. Sometimes, resistancestemming from culturally mediated convictions can beturned into advantages to enhance favorable clinicaloutcome via collaborative empiricism.

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Address correspondence to Chee Wing Wong, Chinese Association ofCognitive Behaviour Therapy, Suite 1221, Bank of America Tower, 12Harcourt Road Central, Hong Kong; e-mail: wingwong@netvigator.com

Received: January 5, 2012Accepted: August 14, 2012Available online 17 October 2012