Hong Kong J Psychiatry 2007;17:109-14

Introduction
Apart 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
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

2007 Hong Kong College of Psychiatrists

Original Article

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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PWC Tam, DFK Wong

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.

Methods
Research Design

This study was exploratory and qualitative in nature. A semistructured 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

Sampling

A 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 Collection

All 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 semistructured 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
110

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 Analyses

The 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.

Results
Profiles of the Participants

The 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

Persons

Ten 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 Themes

Vulnerability, the dominating DA, referred to the

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Dysfunctional Attitudes and Depression

Table. Dysfunctional attitude themes.

Theme
Vulnerability
Need for approval
Role performance within family hierarchy
Familial harmony
Relational harmony
Imperatives
Face
Fate
Fairness
Success-perfectionism

Number of dysfunctional attitudes

identified in the participants*
31
31
23
19
14
11
7
6
5
2

Number of participants
18 (90%)
18 (90%)
11 (55%)
10 (50%)
8 (40%)
6 (30%)
4 (20%)
4 (20%)
2 (10%)
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).

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.
Hong Kong J Psychiatry 2007, Vol 17, No.4

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 Themes

Role 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
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PWC Tam, DFK Wong

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 successperfectionism 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.
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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, hardworking, 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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Dysfunctional Attitudes and Depression

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 shameinducing, 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.

Acknowledgement
I 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?

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