Chinese Taoist Cognitive Psychotherapy: A Culturally Appropriate Form of Therapy

Yimkwan Tsang

Cultural and Historical Context of Taoism in Mainland China

「道可道非常道 名可名非常名」(pinyin: dào-kĕ-dào-fēi-cháng-dào míng-kĕ-míng-fēi-cháng-míng; literal meaning: The tao that can be told is not the eternal Tao; The name that can be named is not the eternal Name) are the famous opening lines of the Tao Te Ching, the classic Zhou Dynasty text by Chinese philosopher Laozi (Laozi & Mitchell, 2006; 張子維, 2012). These lines not only introduce but also summarize the Taoist perspective of the universe and its system of values. It is important to understand the Chinese character Tao (道) because it is one of the most important terms in Taoism. Tao can be translated as the noun form of “path,” “principle,” or the verb form of “to speak” depending on one’s interpretation. The translation of the two opening lines of the Tao Te Ching varies by interpreter because of the lack of punctuation throughout the verses. However, people generally understand it as, “The ‘principle’ that can be ‘spoken’ is not the eternal ‘way’ and the ‘name’ that can be ‘named’ is not the eternal ‘name’” because it aligns with the other main concepts in Taoism (余秋雨, 2009). Essentially, the meaning of the phrase is that the world did not come into being with pre-existing principles for humans to follow to create meaning. Humans must understand and explain the world by making their own observations and interpreting their own experiences.
Because of this principle, Taoists also believe in the concepts of 「物極必反」(pinyin: wu-ji-bi-fan; literal meaning: things always reverse upon reaching an extreme) and 「無為」(pinyin: wu-wei; literal meaning: non action). According to Yip (2005), wu-wei is a combined concept of both “passive progressivity” and “harmony with nature,” that humans accept life’s natural order without intervening (p. 5). This concept is similar to the idea of 「順流」(pinyin: shun-liu; literal meaning: going along with the flow like water) in that humans must accept that their lives change and shift depending on their environment (Slingerland, 2003; Young, Zhang, Xiao, Zhou, & Zhu, 2002). As the I Ching, a classical Chinese text from circa 800 BCE (Hacker, 1993), suggests「陰陽」(pinyin: yin-yang; literal meaning: dark bright) is the force that provides persistent adjustment within balance between opposing forces. In other words, yin and yang keep the world functioning in its natural order because of the contrary but interdependent relationship between the two concepts.

The State of Mental Health Care in Mainland China

The Taoist system of values has been facilitating a solution to mental suffering since Ancient China (Cheng, Lo, & Chio, 2010). However, since Ancient Chinese philosophers never intended to study mind-body problems through empirical analysis, psychology in China has been viewed as a discipline that started in the West (Blowers, 2000). Compared to many other countries, China is far behind in terms of mental health development (Deutsch-Chinesische Akademie Fur Psychotherapie), partially because of the Great Proletariat Cultural Revolution set into motion by Mao Zedong in 1966 after his failed Great Leap Forward (Yang, 1998). The revolution has created the period of greatest political instability in the five millennia of Chinese history (Yang, 1998), bringing China to a “tempo unprecedented in history” in terms of development (Teng, 1971). The demand for clinical services increased dramatically after the multiple natural and man-made tragedies that happened within China in the past three decades (Xu & Wu, 2011). In fact, there are only about 16,000 psychiatrists (Liu et al., 2011) for its estimated 16 million people in need of mental health care in Mainland China (Kleinberg & Thomas, 2012).
Because modern empirical psychology was first developed in the West, the influence of Euro-American-based psychology has become the mainstream psychology across the world (Jing, 2000). Euro-American psychology has dominated other forms of psychology due to the massive exportation of its publications worldwide (Sexton & Hogan, 1992). The increasing number of adolescents educated outside of their own countries has also dramatically enhanced the transfer of Euro-American knowledge to regions beyond the borders of its origins (Blowers, 2010; Danziger, 2006). However, as Chinese sociologists Yang and Gao (1991) point out, Chinese culture (i.e. social structure and self) is almost the exact opposite of Western culture, and therefore, core values, standards of abnormality and treatments vary. In terms of therapy, for example, Chinese students perceive the counselor’s role more as one of an expert (61.8%) compared to a listener (31.4%), in contrast to American students’ view of counselors as listeners first (77%) and experts second (50.7%) (Mau & Jepsen, 1988). Hence, native Chinese mental health professionals are working to develop indigenous psychology in order to avoid the potential incompatibility of Euro-American psychological theories with the cultures to which these theories are exported (Jing, 2000). This paper will investigate Chinese Taoist Cognitive Psychotherapy as a culturally specific psychotherapy that may be more appropriate than Western forms of therapy within Chinese populations because of its basis in Taoist principles and Chinese language.

Importance of Language Within Culture

Understanding the Chinese cultural context is essential to interpreting Chinese Taoist Cognitive Psychotherapy. Cultural context is what makes one ethnic group different from another (Bond, 2010). Culture is comprised of many dynamics, including language for communication and tradition to express its characteristics (Bond, 2010). Culture and language are inseparable as they cannot exist and grow without each other (Brown 1994; Jiang, 2000). Although people may express the same idea differently, this does not necessarily mean that they have different ways of processing the same information (Boroditsky, 2010). Recently, cognitive scientists have begun to suggest that language can help construct human understanding of the essential but abstract ideas such as causality, space and time (Boroditsky, 2010). People build more complicated and abstract concepts, such as morality and beliefs (Boroditsky, 2010), upon the language that they are comfortable using and pass these concepts down through generations. Since language is a tool created by humanity (Piaget, 1962) to build and spread culture, it can be concluded that language is one of the most important factors that determine and define culture (Brown 1994; Jiang, 2000).
Because of the complex interplay of culture and language, it is critical to understand how cultural context informs meaning in language as well. The mistranslation of “mokusatsu” during World War II, for example, is one of the most infamous mistranslations in history, serving as a reminder of the serious consequences a mistranslation can lead to. “Mokusatsu” is a Japanese word that is composed of two kanji, 默(rōmaji: moku, literal meaning: silence) and 殺 (rōmaji: satsu, literal meaning: killing). It is an ambiguous term that means both “maintaining silence – no comment” and “treating it with contempt – not worthy to comment” (National Security Agency, 1968). The “ill-chosen translation” of the Japanese word “mokusatsu” served as a catalyst for the U.S. dropping two nuclear bombs in Japan (National Security Agency, 1968). Because an international news agency translated the word as “not worthy to comment,” the U.S. government assumed that the Japanese government was ignoring the terms of surrender, treating them with contempt (National Security Agency, 1968). The tragic linguistic error of “mokusatsu” reminds us that it is impossible to have exact translation counterparts in every other language. People sometimes use words that can only be understood accurately with appropriate contextual clues and cultural background despite seemingly paradoxical definitions (i.e. pretty and pretty ugly). People with diverse cultural backgrounds have their viewpoints influenced by their languages differently (National Security Agency, 1968).
The importance of understanding cultural context can also be shown in the comparison of the word for dog in Chinese and English. Most English-speaking people will associate the word “dog” with concepts like loyalty and “man’s best friend” (Jiang, 2000, p. 329). However, Chinese language has a rather negative connotation for the word 狗 (pinyin: gou; literal meaning: dog) (Jiang, 2000), especially in use of idioms such as 狼心狗肺 (pinyin: láng-xīn-gǒu-fèi; literal meaning: brutal and cold-blooded) and 豬朋狗友 (pinyin: zhū-péng-gǒu-yǒu; literal meaning: fair-weather friend). Although the word refers to the same animal, there is an apparent distinction between the ideas that each language expresses.
Studies suggest that the quality of many Western tests and assessments that are translated into other languages may be lacking (Cheung, Leong, & Ben-Porath, 2003). For example, cognitive assessment, with a heavy focus on verbal evaluation and understanding sentence structure, may have a questionable validity because of the linguistic difficulty of maintaining the meanings of all terms within the translation (Chan, Shum, & Cheung, 2003). As suggested in Jiang’s (2010) study, translated word may not always be the culturally appropriate word for the participant to stimulate an expected association. In this sense, it is fairly easy to explain the increasing demand of developing a form of psychotherapy for Chinese people that matches their language, beliefs, tradition and cultures.

The Cultural Coherence of Chinese Taoist Cognitive Psychotherapy

Cognitive-Behavioral Therapy (CBT) is one the most thoroughly studied Euro-American therapies used by mental health professionals. The therapy has been used internationally because of its fundamental belief that “you are what you think you are,” which is derived from basic behavioral and cognitive principles (Dobson, 2012). It encourages members that are participating in the CBT session to develop and maintain a positive perspective regarding their experiences by increasing coping skills such as minimizing, reappraising and restructuring distressing thoughts (Hamblen, 2010) and changing maladaptive behavior (Klein, Bernard & Singer, 1992).
Previous literature suggests that Rational Emotive Behavioral Therapy (REBT), a derivation of CBT, is one of the most prominent theoretical approaches in Asian counties, including China (Hodges & Oei, 2007). Psychoanalytic and psychodynamic therapies are virtually non-existent (Cheng, 1993), whereas REBT, a comprehensive, active-directive and empirically-based psychotherapy, is fairly common. The framework of REBT matches the traditional Chinese values that seek a direct and solution-focused approach (Hodges & Oei, 2007) from a rational and authoritative expert (Chen & Devenport, 2005; Mau & Jepsen, 1988), rather than self-exploration (Cheng, 1993). In fact, Albert Ellis, the creator of this relatively new psychotherapy, advocated helping clients to change their irrational beliefs in order to alter their subsequent emotional consequences (Albert Ellis Institute). Although it is uncertain whether REBT is more effective in a particular population for a specific reason, literature emphasizes the increasing concern of the importance of language (Kung, 2004) by developing and modifying indigenous psychotherapies (Cheng, Cheung, & Chen, 1993; Zhang et al., 2002). As more and more educated Chinese mental health professionals grow aware of the differences in measurements of mental diagnosis (i.e. ICD-10, CCMD-3 and DSM-IV-TR) and social norms, there have been rising doubts as to whether Western-based treatments are suitable for Chinese people in the Chinese cultural context.
Taoist beliefs have been embedded in Chinese culture for centuries. Previous literature suggests that cultural factors are a critical element of individual mental health. (Tseng, Kitanishi, Maeshiro, & Zhu, 2012) Because Chinese medical anthropologists have discovered that perception of an illness’ etiology and symptoms varies between people with different cultural beliefs (Ji, Lee, & Guo, 2010), indigenous psychotherapy might be a more beneficial form of treatment in China. Two psychiatrists, Dersen Young and Yalin Zhang, studied Taoist attitudes of mental health principles and developed Chinese Taoist Cognitive Psychotherapy (CTCP) as a modification of REBT in 1992. Chinese Taoist Cognitive Psychotherapy (CTCP) is an instructive treatment based on eight Taoist principles. During the course of treatment, Chinese patients ask the therapist for explanations and guidelines as opposed to engaging in behaviors such as self-exploration (Zhang et al., 2002), which may be more suitable in independent cultures like that of the United States and Western Europe.
The eight core Taoist principles of CTCP are comprised of 32 Chinese characters from Tao Te Ching and used in clinical application: 1) 利而不害 (literal meaning: Benefit without harm to yourself and others); 2) 為而不爭 (literal meaning: Do your best without competition with others); 3) 少私寡慾 (literal meaning: Limit selfishness and moderate desire); 4) 知足知止 (literal meaning: Know when to stop and learn how to be satisfied); 5) 知和處下 (literal meaning: Know harmony and be humble); 6) 以柔制剛 (literal meaning: Hold softness to defeat hardness); 7) 返樸歸真 (literal meaning: Return to purity and innocence) and 8) 順其自然 (literal meaning: Follow the rule of nature) (Young et al., 2002). They applied these core principles to the ABC framework of REBT (i.e. identify the nature of the Adversity event, distinguish the irrational Beliefs from rational beliefs, and understand the Consequences of the irrational beliefs) to create its own ABCDE model: Assessment of Stress (i.e. Find actual stress factors), Belief System (i.e. Understand belief system), Conflict and coping system (i.e. Analyze conflict and coping styles), Doctrine direction (i.e. Imbue doctrine of Taoism), and Evaluate effect (Feng, Cao, Zhang, Wee, & Kua, 2011). The therapeutic model of CTCP, unlike REBT, incorporates Chinese Taoist philosophies into the treatment (Liu, & Leung, 2010). The main rationale behind the addition of Taoist philosophies is to regulate patients’ negative effect, correct maladaptive behavior, and treat psychological problems by utilizing Taoist values (Feng et al., 2011). CTCP emphasizes psychological, affective health and spiritual freedom along with Taoist concepts like detachment from excessive desires and compliance with the course of nature (Young, Tseng, & Zhou, 2005).
CTCP is a leading psychotherapy that has become widely acceptable and studied in China since 1995 (Mao, & Zhao, 2011). Literature suggests that, because of Taoism’s heavy emphasis on natural order without human interference, Taoist values are particularly helpful to patients with an anxiety disorder, depression (李梅枝, & 姜冬久, 2011), or to patients who have immediate family members with neurotic personality disorders (李梅枝 et al., 2008). Zhu, Yang, Xiao, and Liu (2005) also reported that CTCP has significantly reduced Type A personalities and anxious-depressive behaviors in patients with coronary heart disease. However, since CTCP strongly highlights the idea of detachment, it might not be an appropriate treatment for adolescents or young adults as it might lower motivation (李梅枝 et al., 2008). For that reason, older clients with internal emotional struggles may benefit the most from this psychotherapy.
Chinese people that are influenced by Chinese culture are prone to accept a more didactic form of psychotherapy because they tend to value hierarchical organization (Zhang et al., 2002) that prompts the respectfulness and compliance of authority dependence (Hsu, 1970). Therefore, they are more likely to benefit from following practitioners’ instructions and encouragements and from coping with mental health issues through Taoist values (曹鳴岐, 2004).

Future Directions

Young and Zhang, two indigenous mental health professionals that are experts in the language and culture of their target population, developed CTCP partially in an attempt to address concerns that Western therapies were not suitable for the Chinese cultural context. The therapy’s directive approach of actively persuading patients to detach is an essential Taoist element that successfully tailors this psychotherapy to native Chinese people (Ji, 1994). Both practitioners and the target population benefit from this indigenous psychotherapy because most language or cultural barrier issues are minimized due to the mutual understanding of and familiarity with the language and culture. There are, however, some important issues to consider with regard to CTCP. A significant number of Chinese reports are limited to solely Chinese society because research reports generally have to be written in English for reception in the international community (Blowers, 2010; Cheung, Leong, & Ben-Porath, 2003). Future studies should take this into account in order to expand accessibility to the public. Additionally, it is uncertain whether CTCP is compatible with Chinese people that are heavily exposed to other cultures (Ward, & Lin, 2010). Chinese Americans, for example, might be experiencing a different cultural context with a complicated cultural identity and possible acculturation stress in addition to existing symptoms. Since there is a lack of literature explaining the low percentage of those seeking help from a mental health treatment provider (U.S. Department of Health and Human Services, 2001) or the high dropout rate of mental health treatment within the Chinese population in the United States (Wang & Kim, 2010), it is difficult to identify if differing cultural values or treatment incompatibility explain this underutilization. Studies have shown that in Chinese society, there is an intense stigma surrounding mental illness, and for those who require treatment, concern about shame or loss of face is common and demotivating (Kung, 2004). Previous research suggests that there is a comparably high utilization of CBT and psychodynamic psychotherapy within the Chinese population in the United States that identify as more “Americanized” (Kim, Atkinson, & Yang, 1999). However, it is uncertain whether the lower level of Chinese cultural stigma regarding mental illness or the higher level of familiarity of the English language and culture increases the likelihood of attending psychotherapy sessions for people that identify as more “Americanized”. It is therefore important to consider how strongly the patient identifies with his or her Chinese cultural heritage. Because of the development of Chinese psychology in both academic and clinical research, extra in-depth research on the effectiveness of CTCP in different populations must be done before further conclusions can be drawn.

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