تجربه گرایی مشارکتی در رفتاردرمانی شناختی حساس فرهنگی

Collaborative empiricism, one of the main tenets of cognitive behavior therapy, could encounter conceptual and practical problems when applied 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, and superstition. These will be discussed in light of studies on the impact of Chinese culture on patient behavior. Evidence on the successful application of cognitive behavior therapy to Chinese patients will also be presented. There is a pressing need for culturally sensitive clinical procedures and skills adaptation. A case study is presented to illustrate how culturally mediated resistance in collaborative empiricism can be overcome by good clinical practice.

Therapeutic relationship is often held to be the chief “common factor” of all models of psychotherapy. It has been found that therapeutic alliance is positively related to change in various types of psychological interventions (Gaston et al., 1991 and Morgan et al., 1982). Such findings have been taken to suggest that therapeutic alliance is often a sufficient agent for change in effective psychotherapy. Orlinsky, Grawe, and Parks (1994) suggested that it is probably the decisive determinant of therapeutic effectiveness. To enhance therapeutic relationship, qualities of empathy, warmth, and genuineness in counseling and psychotherapy have long been accepted as the central attributes of an effective therapist (Heslop, 1992). However, A. Beck, Shaw, Rush, and Emery (1979) regarded the core conditions of empathy, warmth, and congruence as necessary, but not sufficient, for change in cognitive therapy. They also suggested that a collaborative relationship in which the therapist has considerable skill and expertise to be a further necessary factor. Such a view was further buttressed by Feeley, DeRubeis, and Gelfand (1999), who found that towards the latter half of therapy, the level of therapeutic alliance was predicted by the amount of prior symptom improvement, not vice versa, as implicated in earlier writings. A. Beck et al. (1979) emphasized that in cognitive therapy, the therapist and the patient should ideally form a team that unites and works together to solve the key problems. In this respect, A. Beck and Emery (with Greenberg; 1985) commented on the different but interlocking roles between the therapist and the patient: The cognitive therapist implies that there is a team approach to the solution of the patient's problem: that is, a therapeutic alliance where the patient supplies raw data (reports on thought and behavior …) while the therapist provides structure and expertise on how to solve the problems. The emphasis is on working on problems rather than on correcting deficits or changing personality. The therapist fosters the attitude “two heads are better than one” in approaching personal difficulties. (p. 175) J. Beck (1995, p. 8) also made the point that “cognitive therapy emphasizes collaboration and active participation,” and regarded it important that the therapist and the patient should work collaboratively in agenda setting, session reviews, homework assignments, and making frequent summaries. In the process, both the therapist and the patient will collect data and information pertaining to the way they construe and conceptualize the problems. This can only be done by examining the information experientially, objectively, and empirically. Thus, collaborative empiricism involves treating patients as informed consumers and providing them with information about their illness. J. Beck (2011) remarked that therapists do not generally know in advance to what degree a patient's automatic thought is valid or invalid. Using the process of collaborative empiricism, the therapist and the patient can work together to test the patient's thinking and to develop more helpful and accurate responses. A. T. Beck, in his foreword to the second edition of Cognitive Behavior Therapy: Basics and Beyond ( J. Beck, 2011, p. xi), observed that a number of participants in clinical trials could, at times, go through the process of cognitive therapy without any sense of the principle of collaborative empiricism. The current paper sets out to examine the definition of this important therapeutic ingredient in cognitive behavior therapy, and discuss how it operates in a culturally sensitive setting, specifically, working with Chinese patients.

The application of cognitive behavior therapy should be culturally sensitive in order to adapt to cultural differences. Using collaborative empiricism as a focal point for discussion, culturally specific caveats need to be considered in order to make therapy a success. The hurdles described in this paper may not necessarily be specific to the Chinese culture, per se. Other cultures, even those in the West or in other developed countries may pose similar problems. Therefore, what is needed is not a specific treatment algorithm for a specific culture, but a keen sensitivity on the part of the therapist towards a patient's worldview. Good clinicians should have innovative ideas and skills to help them negotiate roadblocks in therapy. Good clinical insight and skillful tactical flexibility are the cornerstones of therapeutic success. With increasing evidence of the applicability of cognitive behavior therapy to Chinese patients, it is perhaps no longer valid to treat the so-called “Chinese culture” as a static phenomenon around which psychotherapies should revolve. Chinese patients can be steered toward collaboration and empiricism via skillful clinical practice (Wong, 2011 and Wong and Ng, 2010). In the light of rapid globalization and shifting values, cultural factors such as traditional beliefs and philosophical convictions will likely be further watered down in the generations to come (Lin, 2002). Experience suggests that ongoing attempts in China towards theoretical integration in psychotherapy are futile. By the same token, the quest for an indigenous therapy is unnecessary, given the good fit between cognitive behavior therapy and Chinese values and worldviews (Hodges & Oei, 2007). Practical mandate for the cognitive-behavioral therapist is perhaps more on the use of good clinical innovation and the use of culturally appropriate metaphors and images. Sometimes, resistance stemming from culturally mediated convictions can be turned into advantages to enhance favorable clinical outcome via collaborative empiricism.