2007 Hong Kong College of Psychiatrists

Hong Kong J Psychiatry 2007;17:109-14 Original Article

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Mr Peter WC Tam, M Soc Sci, Occupational Therapy Department, North District Hospital, Hong Kong, China.Dr Daniel FK Wong, PhD, Department of Social Work and Social Administration, The University of Hong Kong, Hong Kong, China.

Address for Correspondence: Mr Peter WC Tam, Occupational Therapy Department, North District Hospital, North District, New Territories, Hong Kong, China.Tel: (852) 2683 7862; Fax: (852) 2683 7863; E-mail: petertamwc@gmail.com

Submitted: 13 June 2007; Accepted: 29 August 2007

IntroductionApart from pharmacological interventions, recent study shows that cognitive therapy has a significant effect in improving depression.1 Cognitive therapy was founded by Beck in the 1970s and became popular because of empirical evidence in its favour and a clear conceptual framework. The concept of dysfunctional attitudes (DA) in depressed persons was first described by Beck,2,3 who suggested

that these may be core elements in the development and maintenance of depression. The structure of the cognitive theory was divided into the core belief, intermediate belief, and automatic thought. Intermediate belief consists of attitudes, rules, and assumptions. Dysfunctional attitudes are the manifested form of dysfunctional intermediate belief. Dysfunctional attitudes may place individuals at greater risk of depression. While interacting with stressful life events, the onset of somatic, affective, and motivational symptoms of depression may be triggered.4 This relationship between DA and depressed mood may be mediated by negative views of the future.5 The combination of DA and negative life events was related to higher levels of dysphoria.6 Dysfunctional attitude as a cognitive vulnerability is one main element related to depression.7 Dysfunctional attitudes are components of the cognitive process in the conceptual framework of depression. They are formed through what and how people perceive, evaluate, and interpret from their life events. Under different

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and the investigators clinical experience (Appendix). To test the questions and maximise the consistency between the researchers, 2 pilot case studies were undertaken and discussed between the researchers and the supervisor. During the interviews, information was sought concerning the participants DA and cultural beliefs. The interviews were audio-taped and transcribed for content analysis and identification of common themes. All subjects agreed to the audio-taped interviews. Participants were assured that the data would be treated confidentially. After completion of the interviews, there was no further contact between the researchers and the participants.

Data AnalysesThe interviews were transcribed. Coding and content analysis were performed on the data collected. Statements related to DA were extracted from the transcriptions and coded. Meanings and contexts were then identified from the coded statements. These meanings and contexts were analysed and corresponding themes were derived.

ResultsProfiles of the ParticipantsThe participants (15 women and 5 men) ages ranged from 22 to 57 (mean, 44) years. Thirteen were married, 5 were widowed, and 2 were single. Among these, 11 had received secondary education, 7 had only completed primary education, and 2 had acquired a tertiary qualification. Eleven (73%) female participants were housewives. Among the males, 2 had full-time employment and 3 were unemployed. Most participants were regarded as having moderate depression according to their BDI scores (mean, 25).

Dysfunctional Attitudes in Chinese Depressed PersonsTen DA domains (themes) were identified from the analysis of the transcriptions. They were: (1) vulnerability; (2) need for approval; (3) role performance within the family hierarchy; (4) familial harmony; (5) relational harmony; (6) imperatives; (7) fate; (8) face; (9) fairness; and (10) success-perfectionism. The most dominating themes were vulnerability and need for approval, which were both identified in 90% of the participants. Other dominating themes were those linked to family and social relationship (i.e. role performance within family hierarchy, familial harmony, and relational harmony), and affected about half of the subjects. The Table summarises the DA themes encountered. Themes previously identified in the literature from other societies were considered as general themes, and included: vulnerability, need for approval, imperatives, and perfectionism. The remaining DA themes were regarded as culture-specific, as they were only identified in this study on Chinese people.

Generalised ThemesVulnerability, the dominating DA, referred to the

cultures or belief systems, the contents of DA vary. Chinese people may have more DA concerning interpersonal issues, such as the need for approval and please others under the collectivistic backgrounds. One study reported that 4 maladaptive responses (physiological, cognitive, behavioural, and affective) are associated with emotional distress experienced by individuals in Hong Kong.8 The aim of this qualitative study was to explore the DA of depressed persons in Hong Kong, with an emphasis on exploring whether specific themes and interpersonal issues are particularly prominent in this population.

MethodsResearch DesignThis study was exploratory and qualitative in nature. A semi-structured interview schedule was developed. Information concerning DA in depressed participants was sought by open-ended questions. Data were analysed in a descriptive manner. A qualitative design was considered appropriate in studying DA, as this topic had not been comprehensively explored in Hong Kong.9

SamplingA convenient sample of 20 Chinese subjects was recruited. Eligible participants were patients diagnosed by psychiatrists as having depressive disorders, according to the Diagnostic and Statistical Manual of Mental Disorders (4th edition).10 Exclusion criteria were: unstable mental state such as suicidal risk and aggressive impulses, and severe cognitive, language, or hearing deficits. The subjects were selected from applicants wishing to attend a cognitive therapy group organised by the Department of Social Work and Social Administration at the University of Hong Kong. Interviews were carried out prior to any cognitive therapy session.

Data CollectionAll participants were first contacted over the phone for their consent to participate in the study. Each interview lasted for about 1 to 1.5 hours, and took place mostly at a local agency serving psychiatric patients. A few participants were interviewed near their residential areas or at their work places as requested. Socio-demographic data, Becks Depression Inventory (BDI) scores, and written consent were obtained before the start of the semi-structured interview. The researchers, who carried out the interviews, were an occupational therapist and a social worker. Both had received training from a supervisor who was a cognitive therapist. Semi-structured interviews were then conducted in Cantonese with the use of open-ended questions. The semi-structured format allowed the researchers to explore matters, beyond the first response to the interviewers questions. Issues arising from the answers to the questions could then be followed up in greater detail later in the interview. The questions were based on a review of literature on DA

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negative view or expectations of the participants regarding themselves, the environment, and the future. Examples of such negative views (dysfunctional core belief) were: I am inadequate, I am incompetent, and I am useless. The participants referred to the environment to their interactions with the family members, peers, and society. Whenever they carried this negative view, they tended to display a sense of helplessness, while interacting with the social environments. Eight participants had negative views of the future, expressed as a sense of hopelessness. They thought that they would enjoy no prosperity or that their depression had a poor prognosis. They also worried for the future of their significant others (such as parents and children). Examples of this theme were expressed as follows: I think I am incapable compared to my colleagues, I think he cannot help me, Nobody can help me. Need for approval was defined as the need in the maintenance of attachments and avoidance of social rejection or disapproval. It appeared to be another dominating DA, which was expressed by 18 (90%) of the participants and related to interpersonal issues such as family and social networks. Examples of this theme included: I do not need her appreciation, but I need her recognition and I do not want to talk too much so as to avoid rejection by others. Imperatives indicate ones need for self-control and self-coercive ideation. Six (30%) of the participants appeared to have this attitude. Their concerns included a need to control their emotions, a sense of righteousness and being trustworthy. The following examples illustrate this issue: I try my best to prevent myself getting agitated. I do not want to be unhappy, I should learn to neglect everything, so that nothing can bother me. I should learn to mesmerise myself, One should be independent. Seeking help means dependence. However, I always need others assistance such as to wake me up, and I feel useless and therefore regard myself as a failure. Success-perfectionism was defined as the seeking of perfect achievements and avoidance of weaknesses.

Perfectionism could be reflected by ones self-criticism, stringent self-evaluation of ones own performance, and unrealistic standards. One participant revealed DA related to this theme. One example was: Since I can never be perfect, I feel unhappy.

Culture-specific ThemesRole performance within the family hierarchy was a new theme observed in the participants of this study, and was similar to the theme need to please others stated in western articles. A proportion of the participants (55%) expressed a need to please their family members. They reacted in special ways to their family members by respecting, taking care of, or being forbearing, according to their role/rank in the familial hierarchy. Examples included: My parents will scold me for not being respectful to them...That is why I will do whatever they want, I am a traditional woman...I think a wife should conform to her husbands wishes. Ten (50%) and 8 (40%) participants showed concern with regard to maintaining familial harmony and relational harmony, respectively. They expected their family members or friends to behave in the same way in order to sustain harmony. They would also avoid conflicts by leaving alone situations in which conflicts might occur, forbearing on others, or withdrawing from social interactions that might lead to disharmony. For instance, they tended to avoid disagreement among family members; this entailed having appropriate social manner or skills, and being generous to others. Examples quoted are as follows: My father told us that he liked to have a harmonious family...I think we (siblings) should treat each other honestly and with love...I am disappointed that my sisters do not contribute much to our family, I expect to have no dispute or disagreement. I do not want to talk to them on this issue again, so as to maintain harmony, and When somebody ill-treats me, I have nothing to do except forbear...although I feel uncomfortable. Fate was a new DA theme identified. Four participants

Theme Number of dysfunctional attitudes identified in the participants*

Number of participants

Vulnerability 31 18 (90%)Need for approval 31 18 (90%)Role performance within family hierarchy 23 11 (55%)Familial harmony 19 10 (50%)Relational harmony 14 8 (40%)Imperatives 11 6 (30%)Face 7 4 (20%)Fate 6 4 (20%)Fairness 5 2 (10%)Success-perfectionism 2 1 (5%)* Within any one theme (e.g. vulnerability), a subject can have one or more dysfunctional attitudes (such as inadequacy at work,

helplessness in social contexts).

Table. Dysfunctional attitude themes.

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commented on fate, and believed it was responsible for the adversity they and their family members had to bear. This penalty was believed to have been inflicted not only on themselves but also on their offspring. Examples included: The location of our ancestors graveyard is so bad (poor Feng shui) that it adversely affects us, Could I have done something wrong in my former life, for which reason I now have a child with mental retardation? Face was another DA theme. Four participants showed concern about themselves or their family loosing face. Face in Chinese could be explained as representing the confidence of society in the integrity of the egos moral character, the loss of which made it difficult for one to function properly within the community.11 This represents a kind of prestige, like a reputation achieved through getting on in life, through success and ostentation. Examples of this theme can be quoted as: I wished my husband could stop complaining as to give face to me, It was against my own will to have him stay here, I was scared that he would lose face and feel ashamed if he was asked to leave. Fairness was the last new DA theme identified from the interviews. Two subjects were concerned about fairness, which they linked to the demand for righteousness or justice. Examples included: They (siblings) do not appreciate my effort. They do not contribute to the family. I am the only one who contributesit is unfair to me, I really want to seek what is right for the sake of my children, but I cannot as there is no justice in this society and this world. I am in the minority; nobody in this society can help me.

Discussion Identified DA could be grouped into 2 categories the general and the culture-specific themes. Vulnerability, need for approval, imperatives, and success-perfectionism were common to both western societies and the Hong Kong Chinese population. In contrast to these themes already reported in the west,12-14 role performance within the family hierarchy, familial harmony, relational harmony, fate, face, and fairness were more culturally specific DA relevant to Chinese participants. Vulnerability was a prevalent DA theme among many participants, akin to the negative cognitive triad described by Beck2 as negative views of the self, the world (environment), and the future. Vulnerability was a reflection of depressed peoples pessimistic views of their lives. Depressed people are believed to be more likely to evaluate themselves, other people, their life events, and the future negatively.15-18 According to the cognitive triad, when individuals have negative views of themselves, they attribute their unpleasant experiences to psychological, moral, or physical defects in themselves. Many participants held the core belief that they are inadequate, incompetent, and useless. Inadequacy appeared to be the most apparent of their core beliefs. When an individual has negative views towards the future, he / she anticipates that current difficulties will continue indefinitely and expect to fail.

Participants, who express fears and worries about the future and display a sense of hopelessness about themselves, also express similar ideas about their family members. The need for approval could reflect ones sensitivity to others evaluations and a craving to be nurtured, admired, or accepted. Happiness depends on others and self-worth is derived from others approval. In this study, DA with this theme was found in the context of interpersonal issues, such as family and social networks. Sub-themes identified were the need for recognition, sensitivity to criticism, and emotional dependence on others. Imperatives was defined as the need for self-control, which is indicated by self-coercive ideation and control over ones own emotions. A few participants showed the need for self-control. Some needed to control their emotions; some set themselves goals, such as being righteous, trustworthy, hard-working, and independent. Success-perfectionism could also be reflected by self-criticism, stringent self-evaluation of ones own performance, in the light of unrealistically set standards. Perfectionism has been shown to be significantly predictive of depressive symptoms in Hong Kong Chinese adults.19 Success-perfectionism was one of the core DA themes also identified in the western literature. However, only one depressed participant in this study manifested this theme. Chinese people tend to describe themselves in terms of family roles. They have the propensity to use roles and their performance within them to evaluate themselves.20 This involves evaluating themselves as having failed, whenever they are unable to achieve their role. Their behaviours or responses are guided by the cardinal relations stated by Confucianism relations between emperor and minister, father and son, husband and wife, among brothers, and among friends. Power differentials and responsibilities are prescribed within these cardinal relations, where each person has a role or obligation to meeting others expectation. The obligation of respect and obedience to senior members of the family remains a traditional value, adhered to in Hong Kong. Concepts of filial piety and gender role difference are emphasised in Chinese culture under the influence of Confucianism.21-23 Having to forbear and lacking a channel for ventilation might increase the life stress of participants and contribute to the development of depression. Maintenance of a harmonious relationship in family was shown to be of great concern. Participants had expectations that their family members would behave in certain specific ways, so as to maintain harmony. If family members failed to behave in these expected ways, they would forbear their family members in order to avoid conflict, in the hope that eventually harmony could be maintained. The participant might be upset by the unmet expectations. Depression might be the result of the forbearance and self-sacrifice of benefit or original unresolved point of contention. A hope to maintain harmonious relationship may be extended to friends or other social contacts. However, the behavioural principles adopted in social structure in general may differ from those in the familial hierarchy. All participants believed

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that they should have appropriate social manners or skills, as well as be attentive and generous to others. Some also expected others to behave in the same ways. Some avoided conflicts by leaving or avoiding situations where conflict might occur. The belief that fate was the explanation of all the adversities they and their family members endured, was associated with the development of a sense of helplessness and hopelessness. Face is also significant and may overwhelm the importance of life. The loss of face may well be permanent in cases where misconduct is serious or directly contradict role-imperatives and / or tabooslead to suicide.24 As suicide is closely linked with depression, the loss of face may be a critical aspect of depression in Chinese people. In Chinese culture, loss of face is shame-inducing, not only for the individual, but also for the family. Fairness was described by the participants as righteousness or justice. Their seeking of fairness was linked with the demand for righteousness or justice in their lives. This was a qualitative study exploring DA domains in depressed subjects in Hong Kong, whose findings should be interpreted in the light of certain limitations. The first being its small sample size. The results only represent the experiences and beliefs of our participants, and call for further exploration and validation using a larger sample and quantitative research in depressed Hong Kong Chinese subjects. Another limitation related to the homogenous demographic characteristics of our participants, which only represented phenomena for a specific group. Fifteen participants were females, of whom eleven were housewives, which may also be relevant to findings pertaining to family issues. The sample was recruited from depressed subjects referred for cognitive behavioural therapy; such subjects may have more prominent DA than ordinary depressed local patients. This exploratory study provides preliminary findings on the profile of DA in depressed individuals with a Chinese culture. Cultural issues are believed to have great influence on the profile of DA. To enhance the effectiveness of treatment for the depressed persons, therapists have to be culturally sensitive to the intervention programmes. As Chinese depressed persons are especially concerned over family and interpersonal issues, these aspects should be emphasised during therapy. Further research with a larger sample size and focus on specific demographic groups is needed to revalidate these findings.

AcknowledgementI would like to express my gratitude to Mr Chun-kit Chan for his assistance in data collection.

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Appendix. The interview schedule.

Exploration of automatic thoughts Please tell me an incident that made you feel depressed. What had happened in that incident? How did you feel at that moment? Why did you feel so sad in that incident? What were the thoughts in your mind at that moment? Did you think of anything related to that incident which gave rise to your depressed mood? What were they? Who were present in that incident? Did the persons in that incident trouble you? Did they say something that sounded unpleasant to you? What were they?Exploration of the underlying dysfunctional attitudes Were there any underlying causes for your depressed mood? Why did these things / persons contribute to your depressed mood? What are your attitudes towards these things / persons? Why do you have these thoughts / negative views? Are there any underlying reasons to explain why you dislike those sayings of others? Are there any underlying assumptions / rules on what others should do or should not do? What do you expect others should be? Do you expect others to behave in some ways that you regard as correct or appropriate? Is it possible to get rid of these adversities or to have a better condition in the future?Exploration of social and cultural influences Do you usually think in this way? When did you start to have these dysfunctional thoughts / attitudes? How did these dysfunctional thoughts / attitudes develop? Did you learn them from someone else (e.g. parents) or at some places (e.g. school or social gatherings)? Is there any relationship between these dysfunctional thoughts / attitudes and your depression? Is there any (social or cultural) reason accounting for having these thoughts?Exploration of core beliefs (evaluation about oneself) How do you perceive yourself? What kind of person are you? What kind of person others think that you are? Why do you have these evaluations about yourself? Is there any relationship between your self-evaluations and depression? How do your self-evaluation link with the depression?