Abstract
The purpose of this qualitative study was to explore counselors’ efforts to implement a culturally responsive counseling practice in mainland China. Twenty-two counselors were interviewed about their perceptions of cultural discrepancies between Western-based counseling theories and approaches and the Chinese counseling context, as well as about the participants’ attempts to address these discrepancies in practice. Grounded theory was used as the method for data analysis, resulting in the identification of two main themes: Awareness of Cultural Discrepancies and Culture-Related Practice Strategies. For the latter theme, six subthemes were found: (a) relationship-oriented accommodation, (b) skill integration, (c) internal focus, (d) identifying commonalities, (e) employing accommodative approaches, and (f) theoretical integration. Implications for counselor education and practice in China, as well as further directions for research, are presented.
China’s rapid economic development and globalization brings opportunities, as well as challenges, especially in the mental health care field. The Chinese mental health service system faces challenges in meeting the burgeoning demands for professional service. An epidemiological survey of 79,581 adults aged 18 years and older in China found the adjusted 1-month prevalence of any mental disorder to be 17.5% (Phillips et al., 2009). In particular, depressive disorders have been recognized as a concern that extends to school-aged children (G. Zhang, Yang, Huang, & Sun, 2011). Lim, Lim, Michael, Cai, and Schock (2010) estimated that China has at least 100 million people suffering from various psychological problems, with a high suicide rate of 20–30 per 10,000 people. Unfortunately, there are not enough trained counselors living in China. Saxena, Thornicroft, Knapp, and Whiteford (2007) reported an average of 1.1–5.0 mental health professionals (psychiatrists, psychologists, nurses, and social workers) per 100,000 people in China, compared with 25.1–600.0 per 100,000 people in Japan and Korea.
Another challenge the Chinese mental health service system has faced is related to quality control, for some disadvantages exist in both the professional qualifications of practitioners and the potential mismatch between service approaches and the Chinese cultural context. Taking psychological counseling as an example, the Chinese government promulgated the Occupational Standards for Psychological Counselors in 2002 along with the Mental Health Counseling Training Program (Chinese Ministry of Labor and Social Security, 2002). Counselor certifications are classified according to three levels, with Level 3 being the lowest level. The minimal academic degree requirement for Level 3 counselors is a bachelor’s degree. Those who successfully complete the accredited courses and pass the required examinations, which are mainly knowledge based, can be qualified as Level 3 counselors. Level 3 counselors can attend Level 2 courses and take the next examination to gain higher certification credentials. The counseling certification requirements in China tend to emphasize more book learning and theoretical knowledge than practical application. Level 1 is still being developed and will be reserved primarily for those who have qualifying doctoral degrees in the fields of education, medicine, or counseling and have worked as therapists for at least 3 years. At this point, there is no examination for Level 1 practitioners in China.
Because of the predominance of Western-based counseling models in Chinese counselors’ practice, a potential discrepancy exists between these approaches and the Chinese cultural context. A survey in educational settings indicated that the most popular counseling models in middle schools or universities were behavioral therapy, client-centered therapy, rational–emotional therapy, and psychoanalysis (Luo, Liao, & Hao, 2009). Another nationwide survey had similar findings: Cognitive therapy, behavioral therapy, psychoanalysis, family therapy, and humanistic therapy were the top approaches of Chinese counselors (Qin et al., 2008).
Given the preponderant influence of Western-based counseling theories on Chinese counselors’ practice, the discrepancy between the Western cultural roots embedded in those theories and the Chinese counseling context potentially questions the validity and feasibility of these counseling theories’ application in China. As previous research has indicated, cultural differences exist in the ways people perceive, construct, and solve mental health problems (Yip, 2005). Chinese culture is rooted deeply in the philosophies of Confucianism, Buddhism, and Taoism, wherein self-cultivation and harmonious interpersonal relationships are highly valued (Hwang, 2009; Kwan, 2009). Without a tradition of professional counseling services, people in China are accustomed to seeking help for mental health problems within their ingroup circles, including family members, relatives, and close friends (Tseng, Lin, & Yeh, 1995). The standard one-on-one model of Western counseling is an unnatural way of communicating in Chinese culture (Cheung & Chan, 2002); hence, people in China are less familiar with counseling services and the client–counselor relationship (Yu, 2008). Kuo, Hsu, and Lai (2011) identified some beliefs rooted in Chinese cultural values that had significance in counseling practice. Those beliefs included reverence ascribed to authority, the centrality of collective familism, communication through indirectness, and deference as a means of saving face. The authors recommended that counselors in Taiwan be willing to “withstand a certain degree of ambiguity, while assuming a flexible and adaptable counseling stance” (p. 18).
Several researchers have highlighted the need to incorporate Chinese values into counseling when working with Chinese immigrants (e.g., Hwang, 2009; Kwan, 2009; Lin, 2004). Tseng et al. (1995) recommended integrating indigenous cultural characteristics and traditional healing practices, merging them with Western theories through technical adjustment, theoretical modification, or philosophical reorientation. Echoing their view, Duan and Wang (2000) suggested that “Western developed professional counseling practices should be culturally transformed to serve the target people and their culture” (p. 9).
To address the issues of adapting Western-based counseling approaches to the Chinese context, Leung and Chen (2009) extended Enriquez’s conceptualization model for the indigenization of psychology in local contexts. Indigenization refers to the “adaptation of psychology originating in other cultures” (Church & Katigbak, 2010, p. 129). In Enriquez’s (1993) model, two routes of indigenization were conceptualized as indigenization from without and indigenization from within. The indigenization from without route refers to a process in which existing psychological theories, concepts, and methods are modified and adapted to fit a local cultural context. When it comes to counseling psychology, the route is similar to Tseng et al.’s (1995) suggestions regarding the cultural adaptation of Western therapeutic theories and methods. Enriquez conceptualized the indigenization from within route as the way in which internal theories and methods are developed on the basis of indigenous information. Leung and Chen extended Enriquez’s indigenization model into the area of counseling psychology and recommended that the indigenization of counseling psychology should take both routes.
Chinese counselors have made efforts at indigenization from without by integrating some indigenous healing components into their practice. These components have included Chinese music and calligraphy, Zen ideas, acupuncture, and self-soothing techniques such as Taiji and Qigong. These techniques have been generally viewed by counselors as adjunctive treatments to Western-based approaches (e.g., Chang, Tong, Shi, & Zeng, 2005; Hou & Zhang, 2007). There are also well-developed counseling models integrating Western approaches with Chinese practices, such as imagery dialogue therapy (IDT) and Chinese Taoist cognitive psychotherapy (CTCP). As reported by Zhu and Sun (1998), Zhu combined elements from psychoanalysis, Jung’s analytic psychology, and Shorr’s emotional imagery strategy to develop IDT. Although IDT is based on Western approaches, Zhu drew perspectives from Taoism and Buddhism to interpret clients’ imagery. Zhu abandoned the complicated process of dream analysis, which he thought to be unsuitable for Chinese clients, and alternatively used imagery skills that he thought were simple and would be easily accepted by Chinese clients (Zhu & Sun, 1998). Empirical studies have indicated that IDT was clinically effective in treating depression and drug abuse (Li & Liu, 2005; Ren & Zhu, 2007). According to Y. Zhang et al. (2002), they incorporated a 32-character Taoist formula into a cognitive therapy framework to develop CTCP. The formula provided clients balanced cognitive and behavioral principles. Empirical evidence demonstrated that CTCP yielded a slow but lasting effect for treating anxiety disorders and also had an effect on depression in late life (Yang, Zhao, & Mai, 2005). IDT and CTCP are widely considered to be indigenous counseling models by Chinese counselors, although they were developed by integrating Chinese cultural elements into Western approaches using the indigenization from without route.
However, the influence of indigenous models such as IDT and CTCP is weak compared with the imported Western approaches. Surveys of counselors’ theoretical orientations indicated that the application rates of IDT and CTCP were much lower than those of Western approaches (Luo et al., 2009; Qin et al., 2008). For the majority of Chinese counselors who utilize Western-based counseling models in their practice, their indigenization efforts usually present as fragmented interventions because of the lack of a coherent configuration between theory and practice. Furthermore, little is known about how counselors—the developers and implementers of those culturally adaptive strategies—perceive, construct, and synthesize theory and practice. To what extent are traditional healing approaches applied by Chinese counselors? How do they make decisions about what should be done to attune their practice to addressing discrepancies between Eastern and Western worldviews and cultures? These questions need to be answered to gain a deeper understanding of Chinese counselors’ practices.
To answer those questions, Hung and Chen (2003) conducted an initial exploration in Taiwan. They found that cultural shock and self-reflection functioned to bring counselors into conscious awareness of cultural discrepancies and motivated them to be more culturally sensitive in their approaches in practice. Kuo et al. (2011) explored an expert counselor’s indigenous crisis counseling and demonstrated how the participant based her interventions on her cultural perceptions, beliefs, and knowledge to ensure that the interventions were culturally responsive. Although Taiwan and mainland China have the same cultural roots in Confucianism, Buddhism, and Taoism, the mental health profession in Taiwan is much more advanced than in China. Counseling practice in Taiwan is similar to that in the Western world. Most of Taiwan’s counseling psychologists have been trained in the United States and Europe (Huang, 2005). Due to contextual differences, findings of these studies cannot be generalized to mainland China.
The Present Study
The present study was an exploratory investigation based on a review of the literature. The purpose of the present study was to answer the following research questions: (a) How do Chinese counselors perceive the cultural discrepancies between Western-based psychological counseling theories and approaches and the Chinese counseling context? (b) What are their attitudes toward, and what actions do they take to address, these cultural discrepancies? and (c) What are the characteristics of their counseling practice?
Method
We adopted a qualitative approach to explore the subjective experience of counselors, as well as the perceptions and constructions underlying their practice. Qualitative approaches are particularly valuable when exploring relatively new research areas. An individual, in-depth interview was conducted with each participant and later transcribed; interview transcripts were analyzed using a grounded theory approach (Glaser & Strauss, 1967).
Participants
The participants were 15 female and seven male counselors ranging in age from 28 to 48 (M= 40.59, SD= 5.75). All the participants obtained their education in China. All of them had professional certificates (12 had Level 2 counselor certification, and the rest had Level 3 counselor certification). Length of professional practice ranged from 2 to 18 years (M= 8.32, SD= 3.72). Seven participants who worked at universities were part-time counselors who also taught or had administrative duties. Ten participants had received more advanced training in psychodynamic therapy, family therapy, or cognitive-behavioral therapy. Advanced training included systematic training programs on a specific therapy for 2 to 3 years, 2 to 3 weeks per year. Short-term training programs usually range from several days to a week. All participants identified their theoretical orientations as eclectic. Participants were drawn from two municipal cities (Beijing and Chongqing) and five provinces (Henan, Shandong, Jiangsu, Guizhou, and Sichuan).
Researchers
The research team was composed of five individuals with diversity in gender, age, racial, and educational backgrounds. Bo Wu, a 38-year-old Chinese woman, was a family therapist and faculty member at a university. She had a master’s degree in family therapy and 13 years of counseling experience. She conducted all the interviews. Xiting Huang, a 70-year-old Chinese man, was the team’s organizer and auditor. This research was part of his program on the Chinese mental health service system. He had no counseling experience. Todd Jackson, a 46-year-old White man, was a Canadian clinical psychologist with practice and research experience. He was educated in Canada and had worked in China for several years. He joined the team during data analysis and assisted in writing the article. His theoretical orientation was cognitive behavioral. Dan Su, a 29-year-old Chinese woman, was a doctoral student. She had a Level 2 counseling certificate and 4 years of counseling experience. Her theoretical orientation was eclectic. Wu, Huang, and Su were colleagues. Susan L. Morrow, a White woman, was a U.S. counseling psychologist with practice and research experience. She joined the team and contributed to writing the manuscript. All members had experience conducting qualitative studies using a grounded theory method.
Researchers’ subjectivities and assumptions
Prior to developing the interview protocol, team members discussed their own subjectivities to bracket their previous experiences and assumptions (Yeh & Inman, 2007). The team recognized some bias. First, Wu, Huang, and Su had research experience in indigenous psychology. The knowledge gained in their previous research experience was seen as a bias that potentially could affect the interpretation of data in this study. Each author acknowledged bias in viewing indigenous counseling practice as important and inevitable, which might result in overinterpreting the participants’ practice experience. Second, these three authors had also conducted research on counselors’ practice in China. In addition, two researchers were in counseling practice. Those experiences might lead them to hold certain expectations of the participants’ responses based on their theoretical orientations (e.g., a family therapist might focus on in-law relationships, as the family system is particularly influential in Chinese culture). Third, the congruence in cultural heritage of both the researchers and the participants might limit the researchers’ sensitivity to certain culture-related issues in data analysis. To balance these research perspectives and the predilection toward indigenization, Jackson, a Canadian psychologist, brought a cultural outsider’s perspective. Other strategies the research team used to attend to potential biases included writing research memos, peer debriefing, research team member checking, and participant checking.
Recruitment and Data Collection
The study was approved by the ethics committee for human research at the researchers’ university. We used stratified purposeful sampling and theoretical sampling strategies to recruit participants. Initial stratified purposeful sampling was aimed at “sampling for specific instances of the criterion” (Minichiello, Sullivan, Greenwood, & Axford, 2003, p. 226). Six full-time counselors who majored in psychology or education were consequently recruited. They had been in the counseling field for at least six years and were diverse in gender, age, and residential locations. All six counselors were interviewed more than once to elaborate on emerging themes. Their transcripts were given to them before the follow-up interviews to act as a catalyst for discussion.
Certain themes emerged after the initial six interviews were transcribed and coded. Theoretical sampling was then employed to “maximize opportunities to discover variations among concepts and to densify categories in terms of their properties and dimensions” (Strauss & Corbin, 1998, p. 201). Theoretical sampling expanded to include part-time counselors and counselors in diverse work settings. Sampling continued until no additional open codes were generated. An acceptable interpretive framework was constructed after 22 participants were interviewed.
Prior to the interview, each participant was briefed on the study goals, and written informed consent was obtained. Two interviews were conducted in participants’ offices, and the rest were conducted via audiotaped phone calls. These initial 22 interviews averaged 60 min (ranging from 42 min to 74 min) in duration and were accompanied by demographic surveys. Six follow-up interviews averaged 17 min (ranging from 15 min to 33 min). Each participant was paid RMB 100 Yuan (about US$17).
In accordance with grounded theory method, an interview guide was developed by the research team and was continuously modified to accommodate emerging themes. For example, initial questions were mainly focused on the counselors’ awareness of approach–context cultural discrepancies and corresponding practice. As the data collection progressed, emergent themes implied that the attitudes counselors held toward indigenization might play a role, so the focus was extended to accommodate this new area. The interview protocol was as follows:
What counseling models or approaches do you frequently use in your professional practice? Why do you choose to use those counseling models or approaches?
The counseling models that you used and the whole system of counseling psychology have been imported from and are rooted in Western culture, whereas your professional practice is in a Chinese context. During the process of applying those models and approaches, have you experienced any cultural differences? How have you perceived the approach–context cultural difference? What is your attitude toward the application of Western approaches to Chinese culture?
Do you agree that Chinese counselors should modify or adjust Western-based theories, approaches, and models to make them adaptive to our culture? Why? Or why not?
In your professional practice, have you encountered any cultural limits or difficulties in applying Western-based counseling theories, approaches, and models to Chinese clients (in aspects of beliefs, counselor–client relationship, and behavior)? Please give some examples.
What strategies or measures have you taken to adjust or modify Western-based counseling models and approaches in your practice to address those cultural limits and differences for the purpose of cultural adaptation? Why?
Data Analysis
The data were analyzed using NVivo 8. Given that data analysis and data collection are highly intertwined in grounded theory, data analysis began immediately after the first interview was completed and transcribed. Each interview was transcribed verbatim immediately following the interview. Twelve of the 22 interviews were transcribed by Wu, and the rest were transcribed by trained undergraduate students. All the transcripts were checked by Wu and Su to ensure accuracy in transcription (Lincoln & Guba, 1985).
Data analysis in qualitative research involves a cyclical descriptive process of categorization, coding, and recoding of data to achieve an internal order by identifying themes, categories, and subcategories. Accordingly, open, axial, and selective coding were used in data analysis (Strauss & Corbin, 1998). In the open-coding process, Wu and Su did a line-by-line analysis separately trying to uncover and identify different concepts presented in the interviews. Constituent units of meaning were identified and assigned to generate open codes. Constant comparison was used to incorporate data from each additional interview and to generate consistent open codes. Subsequently, Wu and Su used axial coding. By repeatedly examining and reexamining the open codes and making constant comparisons to identify similarities and differences in each transcript, subthemes were generated. Finally, selective coding was used to identify themes that converged to form working propositions. This process was repeated twice to make sure that no new themes or subthemes emerged (Strauss & Corbin, 1998).
Rigor of the Study
To ensure the validity of the analysis, several steps were taken, including writing research memos, peer debriefing, research team member checking, and participant checking. The use of the memo as a reflective tool is recommended in qualitative research (Birks, Chapman, & Francis, 2008). The researchers wrote research memos throughout the entire study. Prior to the interviews, we recorded researchers’ subjectivity and assumptions discussed in the team meetings in memos for further reference in the peer debriefing meetings (six meetings ranging from 2 to 3 hr). In the interview process, the interviewer wrote memos of participants’ nonverbal information and the interviewer’s analytic thinking (i.e., the assumptions and reasoning the interviewer had during the interview). The memos were discussed in the team meetings to monitor the potential influences of the interviewer’s subjectivity on the data collection process. During the coding process, coders wrote memos to note ideas, questions, or comments and emerging coding themes. The memos were used in the following peer debriefing meetings to make comparisons and were also used for the auditor (Huang, who had not been involved in the data analysis) to review in the audit trail.
Research team member checking was used throughout the transcription and coding stages (Strauss & Corbin, 1998). Transcripts were cross-checked by Wu and Su. In the coding stage, we took portions of each other’s open-coded data, recoded it blindly, and compared the newly coded data to the original. Coding discrepancies were solved through discussion until consensus was reached. Huang served as an auditor to review identified themes, codes, and memos and further establish the trustworthiness of our findings.
Participant checking was also incorporated into the data analysis procedures. Analytic themes and summaries of the data were provided to 22 participants to get feedback on the data analysis (triangulation; Morrow, 2005). Fourteen participants gave their feedback and comments, which were mainly about their own experiences recalled from analytic themes, and the feedback was used to clarify and elaborate on the emergent themes.
The quotes from participants were carefully translated verbatim from Chinese into English by Wu, and a doctoral candidate majoring in clinical psychology conducted a back translation from English to Mandarin. The differences between the original and the back-translated quotes were presented to a bilingual professor at the university to achieve consensus.
Results
A summary of the two main themes and the subthemes emerging from the coding process is presented in Table 1. Each theme is discussed in detail in the following paragraphs.
Culture-Related Practice Strategies by Awareness of Cultural Discrepancies
Awareness of Cultural Discrepancies
Participants’ awareness of the cultural discrepancy between Western-based counseling models and the Chinese context converged into two categories, unaware and aware. Unaware participants acknowledged that they had never thought about cultural discrepancies, and their responses included (a) beliefs about counselor learning, “I think counselors ourselves had actually internalized [the imported theories and approaches] in the training process”; (b)assumptions about trainer expertise, “I think they [the imported theories and approaches] were translated into Chinese and the expert trainers had culturally adapted them”; and (c) assumptions about client–counselor similarity, “I have never thought about it, for I actually share the same cultural heritage with my clients.”
Aware participants described a broad range of ways they perceived cultural differences, on a continuum from minimization of, to placing emphasis on, cultural discrepancies. Some counselors who minimized the influence of Western roots of counseling models (aware-minimize) identified discrepancies as insignificant, for they believed in natural commonalities among human beings. For others, approach–context cultural differences were recognized as significant but were handled in different ways. Some counselors addressed cultural discrepancies by making compromises (aware-compromise), namely by identifying commonalities between Western approaches and Chinese culture. Other participants acknowledged discrepancies and emphasized their ability to transcend potential conflicts (aware-transcend).
Culture-Related Practice Strategies
Responding to questions about their experiences of culture-related practice, participants described a wide range of practices regarding how and to what extent they addressed the approach–context cultural discrepancy. Coding results revealed that all participants, even those who were unaware of cultural discrepancies, actually practiced some forms of indigenization intentionally or unintentionally. Ten subthemes of indigenizing practice emerged across various aspects of counseling, such as client–counselor relationship, counseling structure, skills, case conceptualization, and so on. The 10 subthemes eventually converged into six subthemes, which are listed in Table 1: relationship-oriented accommodation, skill integration, internal focus, identifying commonalities, employing accommodative approaches, and theoretical integration. Compared with the unaware group, the aware group used supplementary strategies in addition to two shared subthemes (relationship-oriented accommodation and skill integration). Those extra strategies were influenced by the participants’ perceptions of the significance of cultural differences. These subthemes are described in greater detail in the following paragraphs.
Relationship-oriented accommodation
This subtheme characterized some adaptive ways in which participants interacted with clients in accordance with the relationship-oriented characteristics of Chinese culture. This subtheme included several subthemes. These were as follows: upholding an authority figure, being cautious about clients’ indirect communication, and accepting overlapping social circles with clients.
Upholding an authority figure
This subtheme emerged in the narratives of both aware and unaware participants. They acknowledged that, in the counseling process, especially at the beginning stage, they highlighted their authority by quoting “scientific data,” analyzing client’s projective works (e.g., drawing or handwriting), and giving concrete suggestions. A participant working in a university mental health center stated that it was inevitable to give concrete direction, for “education in its nature has a guidance function to give students specific and concrete suggestions.”
Being cautious about indirect communication
This subtheme characterized participants’ sensitivity to the implicit communications of clients’ unexpressed wishes, disagreements, or negative feelings toward participants or their service. One participant gave an example of her work with a teenage girl who seemed obedient and agreeable in the session. After the session, the participant stated, “I went to the public bathroom, and I heard behind the next door she was telling her mom that I was tedious.” Another participant mentioned that her clinic provided anonymous feedback forms after each session for the clients. However, few clients wrote negative comments even at times when the participants themselves recognized that “[the session] was not a good one.”
Accepting overlapping social circles with clients
Many participants had experiences of establishing professional relationships with clients who were introduced to them by mutual friends or by the clients’ relatives, leaders, or employers. One participant described this process: “It is quite common [to have overlapping interpersonal circles with clients]. They believe that you are reliable because of the shared social networks.” Another participant stated, “Sometimes I gave discounts to some clients who were introduced by my good friends, for I wanted to save ‘face’ (‘mianzi’) for my friends.”
Skill integration
Skill integration characterized participants’ integration of Chinese traditional healing skills and metaphors into their practice to make counseling more palatable for clients. This skill integration practice was evident in two ways. One was incorporation of traditional practices, such as traditional Chinese medicine approaches (e.g., massage, Qigong, and food cure) and traditional rituals. The other was utilization of Chinese idioms and sayings to explain counseling concepts. It is notable that all participants had more or less experience in skill integration. It seems that despite the lack of specialized training, traditional healing practice had its own place in counseling practice. A participant with a medical background had provided a depressed client “traditional Chinese medical massage on the acupuncture points of his ankles.” She remarked that she recommended some clients to eat certain vegetables with a bitter taste for “food cure,” and she explained that such vegetables “have effects of clearing heat, relieving restlessness, and eliminating dampness.”
Some participants used traditional rituals in their practice. One participant used a ritual of “letting go a paper boat.” In the ritual, people made paper boats and put them in rivers on a certain day to commemorate their deceased family members. This participant used the ritual in grief counseling with a group of college students who had lost their classmate. Another participant had provided effective counseling services to people of Qiang nationality who lost family members in a Sichuan earthquake in 2008, using Qiang’s traditional grief rituals. The application of Chinese idioms and sayings was common in participants’ narratives. A participant gave an example of using a famous Chinese verse, “It is better to pick a flower while it is blooming than to wait until it is fading,” to explain to clients the value of living in the moment. Another participant exemplified his adoption of the “yin and yang” (a concept of ancient Chinese wisdom to describe the two opposing principles in nature) to explain principles of dialectic behavioral therapy because “it is familiar to my clients” and “[using the concept] helps clients to understand what I want to convey in an easy way.”
Internal focus
This subtheme emerged from the narratives of the participants who believed cultural differences were insignificant. This subtheme characterized participants’ focus on the internal, such as emotions and thoughts, as opposed to the contextual level of clients’ experiences. Participants who used internal focus strategies emphasized the commonality in human life experience and identified cultural disparities as less salient at an individual level. One participant stated that, by studying a variety of counseling models, she found that “people are the same in the nature of personhood.” Some participants identified the cultural impact on clients as “not as much as we thought.” One participant noted that she had watched a number of counseling demonstration videos of foreign expert counselors and found that “foreign clients said the same things as Chinese clients did” and that “their [clients’] stories are the same.” In responding to questions about how they employed this strategy, one participant gave an example. He had a middle-aged female client whose main complaint was about marriage and in-law relationships. He acknowledged his professional limits in dealing with the clients’ intimate relationship issues directly but contended that relationship problems could be solved by working on an internal level with his client to enhance her inner strength.
Identifying commonality
Some participants in the aware group addressed cultural discrepancies by identifying commonalities between Western approaches and Chinese culture. An example was given by a participant who mainly applied sandbox and family therapy. She indicated that sandbox therapy had an Eastern philosophic basis that was familiar to Chinese clients. The participant also viewed family therapy as sharing a common systemic perspective with Chinese culture. Several participants’ narratives indicated that they believed cognitive therapy was compatible with Chinese culture in taking cognitive distortions as the source of individuals’ emotional problems and focusing on cognitive processes to facilitate behavioral modifications. A participant stated that “cognitive distortions like polarized thinking and tunnel vision reflected ways of unbalanced thinking,” which he identified as a violation of the doctrine of the mean (zhongyong, the golden mean of the Confucian school that emphasizes the importance of balance and moderation). Another participant viewed solution-focused therapy as similar to Chinese pragmatism, stating, “[Solution-focused therapy] is agreeable to Chinese clients,” because it is “pragmatically focused on a solution directly.”
Employing accommodative approaches
Participants who recognized approach–context cultural discrepancies, and tried to transcend them, focused on employing accommodative approaches. Two subthemes emerged: employing indigenized counseling models and employing nonverbal, expressive art approaches. Indigenized counseling models such as IDT and CTCP were practiced by some participants, mostly as complementary approaches. A participant who applied IDT as his main counseling approach explained that he adopted IDT because it was “indigenous” and “highly accepted and less resisted” by his clients. Several participants regarded art therapies as “neutral,” “comprehensive,” and “less influenced by cultural factors.” One participant who incorporated drawing and music into her practice remarked that art therapies were flexible and more accommodating than other approaches such as psychoanalysis and behavioral therapy, although these approaches might bring complexity into the interpretation of clients’ artwork.
Theoretical integration
This subtheme emerged from the narratives of a participant who tried to transcend cultural discrepancies. It characterized a process where participants intentionally incorporated their understanding of Chinese cultural characteristics and Western counseling theories into a conceptual framework to guide their practice. The participant recognized his theoretical orientation as eclecticism with psychoanalysis, cognitive therapy, and family therapy as his main approaches. He developed a framework of case conceptualization in which he constructed clients’ problems primarily in their sociocultural context, and he drew concepts from his theoretical orientation as reference. His integration provided a systemic perspective of case conceptualization. He elaborated his framework in his paper and exemplified the significance of the sociocultural context in a case of a client who had a stuttering problem. The client was the first son of a family that moved from one city to another when he was an adolescent. He studied hard to live up to his parents’ expectations. When he started working, he found that a resourceful social network was crucial for his career, but he had none. He experienced enormous anxiety, and his slight stuttering deteriorated. In the participant’s conceptualization of the case, he emphasized the interactions among a series of sociocultural factors in understanding the client’s problem, such as the parents’ expectations for their elder son, traditional gender roles, and value conflicts. He depicted his framework as a temporal-spatial perspective in understanding clients’ problems.
Discussion
In this study, we set out to explore the cultural awareness of Chinese counselors and to identify theoretical themes that encompassed counselors’ efforts to address cultural discrepancies between dominant Western-based counseling theories and approaches and the Chinese cultural context. In responding to the research questions, six subthemes were identified. The findings indicated that the participants’ practices were influenced by their cultural awareness and their perceptions of approach–context cultural discrepancies.
Overall, the findings indicated that all participants, whether aware or unaware of the approach–context discrepancy, indigenized certain Western-based approaches to therapy in their practice, either intentionally or unintentionally. These findings suggest that cultural discrepancies between counseling models and a Chinese cultural context had a significant influence on participants’ counseling practice; therefore, they had to develop some active or passive strategies to adapt. Further comparison of the themes revealed that the unaware group’s practice converged on two subthemes including relationship-oriented accommodation and skill integration. It appeared that the lack of reflection on cultural disparities led to less intentional effort in addressing these discrepancies among unaware participants compared with their aware counterparts. Some participants attributed the absence of cultural consideration to being encapsulated in the same culture with clients. Their viewpoint that being a cultural group member might make them less likely to consider the cultural impact of their therapeutic approach has been supported by previous research by Hung and Chen (2003), who found that cultural shock and self-reflection helps to increase cultural awareness. Their findings and the unaware participants’ experiences in the present study highlights the importance of the cultivation of cultural introspection in counselors’ professional development.
Several indigenous strategies found in Kuo et al.’s (2011) research were also revealed in the participants’ narratives in this study, particularly upholding an authority figure and being cautious about clients’ indirect communication. Several participants strategically used projective analyses of clients’ drawings (e.g., a drawing task named “Tree-House-Person”), either for enhancing their clients’ perceptions of the participants’ insight and expertise or for “warming up” their clients. The attempt to uphold an authority role might reflect their trying to fulfill cultural expectations for counselors. In Wei and Heppner’s (2005) research on working alliances involving clients and counselors in Taiwan, they provided that the “counselor” title in Taiwan confered that the person was professionally knowledgeable and experienced, which was the same as in mainland China. Similarly, Kuo et al. (2011) identified implicit communication as a Chinese norm of “face-saving” in social communication and suggested that counselors discern and attune to clients’ unexpressed needs and wishes. The subtheme from the present study implied the significance of counselors’ adherence to the indirect communication pattern.
The subtheme of accepting overlapping social circles with clients emerged across the narratives of most participants. Tseng (1999) noted that clients of Chinese background prefer to classify people into in-group and out-group members and to share their personal feelings and concerns with only in-group members. Clients were more likely to regard counselors who had overlapping social networks as in-group members; therefore, in-group identity may enhance clients’ perceptions of counselors’ credibility and trustworthiness. However, this subtheme also aroused concerns among our participants regarding the potential risks associated with dual relationships. Professional ethics related to multiple relationships in China are focused on (a) counselors’ refraining from entering any multiple relationships and (b) measures that counselors should take in situations where multiple relationships are inevitable (Chinese Psychological Society, 2007), similar to the American Psychological Association (2010) codes. Deng and Qian (2011) explored cultural differences between Chinese counselors and their U.S. counterparts in their perceptions and attitudes toward dual relationships. They found that although Chinese counselors perceived dual relationships as inappropriate, they acknowledged that they would accept working with clients with whom they had overlapping social networks (e.g., a friend or an acquaintance). Other researchers investigated the differences in perceptions of professional ethics between counselors and clients and found that more than half of the clients perceived nonsexual dual relationships as ethical and acceptable (Gao, Qian, Cai, & Deng, 2008). Mok (2003) suggested that multiple relationships between counselors and clients might be valued in some Asian cultures. Chen (2003) contended that, under a multicultural counseling framework, the ethical code of restricting dual relationships should be rethought to make it more accommodative to the indigenous culture. Barnett, Lazarus, Vasquez, Moorehead-Slaughter, and Brad Johnson (2007) also recommended that multicultural counselors take cultural factors and individual differences into account to address boundaries and multiple relationship issues.
The skill integration subtheme was characterized by counselors’ incorporation of traditional healing practices into their intervention skills. Folk healing practices such as rituals, food cure, or some tranquilizing techniques not only provided clients culturally permitted channels for revealing feelings or desires and for emotional catharsis but also gave participants more options of healing skills that affirmed their central cultural values. The participants’ narratives of their employment of Chinese idioms and old sayings implied that skill integration might make the counseling process more palatable not only for clients but also for counselors, for skill integration reflected the ways in which counselors interpreted Western counseling models.
To explain their practice of working with clients at an internal level, participants grounded their stance in their beliefs of the universality of human nature, cognition, and life experience, echoing the observations of Chang et al. (2005). Because most participants who employed the internal focus strategy held client-centered therapy or psychoanalysis as their main counseling approach, their points might reflect their efforts in dealing with conflicts between the relational interdependence orientation in Chinese culture and the individualistic roots of Western counseling models. However, by working at an internal level, counselors might be at risk of losing sight of culture altogether by overemphasizing the generic aspects of the therapeutic interaction. Counselors need to keep clients’ cultural identity in mind and recognize that the Chinese social world produces unique manifestations of universal human experience. Pedersen (2009) indicated that counselors’ cultural reflection functions to enhance their self-awareness of their own cultural heritage and bias, and stimulates their reflection of clients’ cultural identity. In this way, counselors become empathic and develop insight into the unique individual and cultural experiences of clients. His perspectives implied that participants’ blocking out cultural factors might be an outcome of a lack of cultural reflection.
The subtheme identifying commonalities resonated to a certain degree with Wendt and Gone’s (2012) concept of cultural commensurability between a variety of psychological interventions and the treatment needs of culturally diverse populations. Leong and Kalibatseva (2011) proposed to reorient cultural adaptation of psychotherapies from cultural accommodation to cultural congruence by emphasizing the shared bases in psychotherapies and cultural values. The current findings provided support for their point. Participants’ narratives on specific models were in accordance with several previous studies, such as Cheung and Chan’s (2002) study on the application of the Satir model in Hong Kong, and Hsu and Wang’s (2011) study on solution-focused brief therapy in Asian Confucian society. The commonalities in philosophical orientations between counseling approaches and Chinese culture could make these approaches more accessible and relevant to the participants as well as their clients because of the similar ways of viewing human beings and their coping patterns. For instance, the adoption of solution-focused brief therapy by participants could be a reflection of coping patterns accepted in Chinese society that emphasize goal orientation and pragmatism (Chong & Liu, 2002).
The subtheme of employing accommodative approaches included subthemes of using indigenous and nonverbal, expressive art approaches. Although indigenous approaches are theoretically highly valued, they are applied with low frequency in comparison to dominant Western-based counseling models for several reasons. First, the development of counseling psychology in China relied heavily on imported Western counseling psychology, which resulted in the hegemony of Western models. In addition, imported counseling models are well developed and have well-defined systems of theory and skills, making them easily acceptable for counselors. Moreover, training programs for indigenous approaches are scarce, and the application of those approaches have been limited to certain areas and populations. Taking CTCP as an example, CTCP was developed in medical settings (Y. Zhang et al., 2002). The application, training, and empirical research on CTCP have been mainly restricted to the fields of medicine and psychiatry, which has limited its accessibility for a majority of counselors whose backgrounds are not relevant to those fields.
Nonverbal, expressive art therapies, such as sandbox, drawing, and music, were recommended by the participants. They explained that these approaches are flexible and congruent with the covert, indirect, and deferential pattern of communication of Chinese clients. Moreover, they regarded nonverbal, expressive art approaches as less dependent on verbal expression and logical thought, which are deeply affected by culture. These findings echoed Iwakabe’s (2008) study of Japanese counselors’ cultural integration practice of Western counseling psychology. Iwakabe found that Japanese counselors’ technical adjustment was mainly the adoption of nonverbal cures. Most participants in the present study who applied nonverbal approaches took those approaches as complementary tools, except one counselor whose theoretical orientation was mainly sandbox therapy. It is notable that this counselor had received doctoral training in sandbox therapy. The participants’ narratives implied that more systematic training would be needed to fully apply those approaches.
One participant in the present study had some experience integrating Chinese sociocultural characteristics and imported Western counseling models at a theoretical level. Findings of Iwakabe’s (2008) study indicated that, in addition to technical adjustment, Japanese counselors had developed some innovative theoretical constructs that were more in agreement with Japanese culture and underlying worldviews. For example, they developed concepts that emphasized the importance of healthy dependence between mother and child. Although such concepts did not emerge in the present study, it seemed that counselors in China were making efforts toward theoretical integration.
Overall, it appeared that the culturally responsive practice strategies used by participants in this study fell within Enriquez’s “indigenization-from-without” model. Those strategies were developed by modifying and adjusting existing counseling theories, concepts, and methods. According to the suggestions of Church and Katigbak (2010), a well-developed approach to indigenizing counseling psychology should include both “indigenization from without” and “indigenization from within” routes. In the indigenization from within model, theories, concepts, and methods should be developed internally within a culture, using indigenous information as primary sources of knowledge. But such theories or methods were not applied by participants in the present study.
Study Limitations
A limitation related to the data collected in this study was sample diversity. Although the counselors interviewed were diverse in several aspects (e.g., gender, age, professional experience, professional affiliation, and economic status), a larger sample including counselors with nationalities other than Han might be more informative. In China, there are 56 nationalities, with the Han nationality accounting for about 92% of the whole population. The additional 55 nationalities are usually called minority nationalities because of their relatively smaller population size compared with Han people. Assumptions can be made that counselors from minority nationalities may experience greater cultural clash than the Han in their counseling practice and professional development, which may enhance the possibility that they may engage in cultural reflection and draw resources from their mental health traditions.
Implications for Counseling Psychology
The present study was designed to investigate the characteristics of counselors’ efforts to address cultural discrepancies in practice and to provide counselors in China and in other countries information for their consideration. Implications for counseling, training, and future research were gleaned from the present study.
Implications for counseling and training
First, the findings implied that, whatever the participants’ attitudes toward approach–context cultural disparities were, they had developed some strategies to adapt to the counseling context. Professional concerns about the efficacy and justification of those strategies were raised. Information gained from the present study might motivate counselors to reflect on their cultural awareness and bring critical consciousness into their practice. Second, the findings imply that counselors in China are in pressing need of guidance and supervision to enhance their cultural responsiveness and to guide culturally appropriate practice. To meet this need, counselor training systems in China must examine their overdependence on Western-based counseling psychology and amplify coverage of indigenous counseling models and traditional healing practices of various subcultural groups; this is especially true of accredited training programs. Structured teaching, guidance, and supervision systems need to be developed to keep abreast with the preexisting practice. Third, the findings from the present research echoed other research in implying the need to rethink the cultural rationality of the present ethical codes of dual relationships. Ethical codes need to be developed to guide counselors in situations where dual relationships are inevitable. For example, how do counselors fully inform the clients of potential disadvantages of dual relationships?
Future research directions
As there are few empirical studies of counselors’ indigenized practice, further research in several directions would broaden and deepen this research area. First of all, the findings implied that counselors’ constructions and awareness of cultural discrepancies are crucial to examine and to ensure counselors’ responsiveness and appropriateness in indigenous practice. Thus, future research on the developmental process of counselors’ cultural awareness that could be facilitated or impeded by some factors would be beneficial for developing training programs. It could be inferred that client variables (e.g., the heterogeneity of the clients’ background and their presenting issues), as well as counselor variables (e.g., theoretical orientation, training and practice experience), might have an influence on the process. These variables and their association with counselors’ cultural awareness could be explored in further investigations.
Moreover, this study examined only participants’ subjective perceptions. Further research could include an examination of clients’ perceptions and feedback on counselors’ practice, as well as counseling outcome assessments, to build on the findings from this study. Future questions to investigate this should include the examination of the effectiveness of those culturally adaptive practice strategies. Does effectiveness correspond to the number of strategies used by the counselor? Would clients be more satisfied with counselors who used more strategies? Does the use of those strategies promote stronger client–counselor alliances or more motivation for therapy?
Finally, given the enormous influence of Western counseling psychology in a variety of countries (especially in Asian countries where a tradition of seeking professional help was absent), similar native research on indigenous counseling practices of Asian as well as non-Asian counselors should be encouraged to draw a comprehensive picture of indigenous practice across cultures.
Footnotes
Declaration of Conflicting Interests
The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding
The authors received no financial support for the research, authorship, and/or publication of this article.