In the 1980s, Zhang Yalin and Yang Desen developed an indigenous form of cognitive therapy called Chinese Tao Cognitive Psychotherapy (CTCP) that integrated traditional CBT with Taoist philosophy. It was developed in response to increased rates of anxiety as China underwent seismic socio-political change following the end of Maoism. Life had become hugely unpredictable and Zhang and Yang recognized that Taoist principles including acceptance, flexibility, and alignment with the natural laws of the universe might help people to cope with their "new normal".

Almost 20 years ago, Zhang et al. (2002) found CTCP to be slower acting than benzodiazepines in the treatment of GAD in urban Chinese participants, yet improvement was greater in the long-term. However, until recently, this therapy had never been used outside China and its efficacy for bicultural Chinese participants was unknown.

Since Chinese Americans have a 10% lifetime prevalence for anxiety disorders yet are less likely to access mental health services than people from other cultural groups, research into the development of culturally-relevant, evidenced-based therapies is critical.

Chang et al. (2020) aimed to develop an English language instruction manual to help US practitioners in delivering an adapted version of the therapy, renamed Taoist Cognitive Therapy (TCT). The study explored whether TCT could provide a feasible, acceptable, and effective option for treating Chinese immigrants in the United States, especially those who had faced acculturative stress. 

Watch this video where Doris Chang, the first author of this paper, briefly explains the therapy and some of the Taoist principles on which it is based.

To learn more, visit Doris Chang’s website where you can find a presentation at the Asian American Psychological Association conference (2017) about this study.

The sample was made up of five Chinese Americans with GAD, two of whom also had Major Depressive Disorder (MDD). Despite living in the US for an average of 19 years, most spoke little English. None were familiar with Taoism before treatment.

Each received 14 -16 sessions of TCT delivered by two Chinese-American therapists, fluent in English and Mandarin.

Reduction in worry and anxiety was assessed before, during, and after treatment, and four months later. Questionnaires were used to measure symptomology, including the Chinese-Penn State Worry Questionnaire (Ch-PSWQ) and the Chinese Patient Health Questionnaire (PHQ-9). Depressive symptoms, cognitive inflexibility, and interpersonal functioning were also measured. In addition, the researchers measured the clients' perceived credibility of the treatment and expectations regarding outcomes. The Taoist Values Inventory was used to measure endorsement of Taoist principles.

All sessions, interviews, and assessments were conducted in Mandarin. 

After treatment, semi-structured interviews were conducted to explore and reflect on the patients' experiences of the treatment.

The therapy was more effective for those without comorbid MDD. Two of the three GAD-only participants experienced a statistically significant reduction in anxiety and worry after treatment and at the follow-up. The other’s husband was facing deportation leading to an unsurprising increase in symptoms, obscuring the impact of TCT for this participant. While depression, cognitive inflexibility, and emotional avoidance all decreased, daily functioning only showed clinically significant improvement for two of the five participants.

Qualitative data analysis revealed participants felt “validated and accepted by their therapists” and that they were “empowered to take an active role in their treatment and the strengthening of their coping capacity”. One of the practitioners suggested that although the participants had limited knowledge of Taoism, they engaged well with the principles because they were aware they were rooted in their cultural heritage. This said the other practitioner said that it was important not to assume that because the participants were Chinese they would necessarily interpret the principles accurately and that explicit teaching of the correct Taoist interpretations was crucial.

Overall the researchers concluded that TCP provides a person-centered, collaborative approach, and an efficacious way of treating GAD, which suggests that cognitive therapy can be adapted to meet differing cultural needs.

Generalisability is limited by the very small sample size, yet this was a preliminary study and the researchers note that the findings need to be replicated with a much larger sample in a random controlled trial with a control group, receiving traditional CBT, for example.

Participants received a payment of $85 for completing the questionnaires and received treatment for free. This means they may have felt indebted to the researchers by giving overly positive self-reports as a consequence, thus reducing internal validity.

Another problem with the study was that therapy sessions were only conducted once every 2 - 3 weeks due to participant availability. Typically, this sort of therapy would be delivered more regularly, meaning the benefits might have been greater has the sessions been closer together.

Internal validity was also decreased by the fact that some participants altered their medication during the trial meaning it was hard to distinguish whether symptoms reduction resulted from TCT or medication changes.

Without a control group, it is hard to determine the true significance of these preliminary findings; however, the researchers indicate that their results are in line with previous research conducted in China, suggesting the results are reliable.

The researchers note although TCT was beneficial for people with GAD, it may need to be adapted for people with comorbid depression. They explain that the Tao principle of wuwei or “actionless action” may have generated greater feelings of helplessness, due to a negative rather than positive interpretation of the role of inactivity, meaning depressive symptoms were reinforced rather than reduced.