Fear of Losing Face in China: Cultural Differences and Routine Outcome Monitoring



In the past two decades, psychotherapy has witnessed a significant development known as Routine Outcome Monitoring (ROM), which has garnered recognition in global clinical practice. Nevertheless, its acceptance varies significantly between Eastern and Western cultures. Research indicates that therapists in non-Western cultures tend to harbor more reservations about ROM compared to their Western counterparts. Remarkably, no study has rigorously explored the link between specific cultural factors and the adoption of ROM.

A recent study titled "Culture Matters: Chinese Mental Health Professionals' Fear of Losing Face in Routine Outcome Monitoring" addresses this gap by delving into the concept of "losing face" among Chinese mental health professionals. This research seeks to uncover how the fear of "losing face" impacts the utilization of ROM among therapists in China.

Zhuang She, Project Leader

Zhuang She (lead investigator and author of this blog)

What Does "Face" Mean in China?

Face represents an individual's social image and social value that they acquire through their performance in interpersonal contexts. Although the concept of face concern exists in both Eastern and Western cultures, it assumes greater significance in collectivist societies like China. In these cultures, maintaining face is essential for preserving group integrity and ensuring harmonious relationships among group members.

Face concern plays a significant role in the everyday interactions of Chinese people. It's only natural that this concept could also influence how therapists and clients communicate within the Chinese cultural context. In the Chinese context, face concern encompasses two dimensions: self-face concern and other-face concern. Self-face concern involves being mindful of one's own need to uphold face, while other-face concern pertains to considering the face-saving needs of others. For our study, we specifically examined self-face concern because it directly relates to how Chinese mental health professionals utilize ROM. This emphasis is justified by the fact that the utilization of ROM primarily signifies the therapist's “competence" rather than evaluating the client's adequacy, as further elaborated below.

How Does Self-Face Concern Relate to ROM Use?

Chinese therapists who are deeply concerned about their image may worry that using ROM could expose their limitations, potentially making them appear incompetent in their clients' eyes. This concern is understandable given China's hierarchical culture, which extends into the therapist-client relationship. Chinese therapists may prefer to maintain their professional reputation by demonstrating their ability to achieve positive results independently. Discussing negative feedback with clients could be viewed as a failure to meet their expectations, resulting in a loss of face within the Chinese context. Consequently, Chinese mental health professionals who are highly concerned about their image may hold a more negative attitude towards ROM and use it less frequently to avoid situations where they might lose face and jeopardize their social standing.

The Study: A Closer Look

A sample of Chinese mental health professionals (N = 371) completed questionnaires assessing their fear of losing face (measuring self-face concern), attitudes towards ROM, ROM usage, counseling self-efficacy, and perspective-taking. The study aimed to unravel how the fear of losing face influences therapists' attitudes towards and usage of ROM, as well as how counseling self-efficacy and perspective-taking shape the relationship between self-face concern and ROM usage. The key findings are summarized below:

  1. Fear of Losing Face: Therapists reporting a greater fear of losing face were more likely to harbor negative attitudes towards ROM. They perceived ROM as a potential threat to their reputation and were less inclined to use it.
  2. Role of Counseling Self-Efficacy: Interestingly, possessing a higher sense of counseling self-efficacy in handling challenging cases did not alleviate the fear of losing face. In fact, it intensified the relationship, making those with high self-efficacy even more concerned about using ROM.
  3. Role of Perspective-Taking: The study also found that a greater tendency to consider others' perspectives did not mitigate the fear of losing face. This suggests that even if therapists are empathetic and understanding, the cultural significance of losing face remains a substantial factor.

Why Does This Matter?

Understanding these cultural nuances is imperative for effectively implementing ROM in non-Western contexts. The fear of losing face is not solely an individual concern but a cultural one that can profoundly impact the effectiveness of mental health services.

Implications for Practice:

  1. Cultural Sensitivity in Training: Therapists in China and similar cultural contexts can benefit from training that directly addresses these cultural fears. Training can emphasize that client feedback merely reflects how well therapy aligns with client needs, rather than the therapist's inadequacy. Addressing ROM-related concerns is crucial in these cultures.
  1. Tailoring ROM Practice: Considering that Chinese therapists might prefer internal feedback to maintain face, targeted training emphasizing the value of external client feedback could be beneficial. Encouraging Chinese mental health professionals to gather external progress feedback from clients can supplement their existing knowledge.
  1. Client-Therapist Communication: Understanding therapists' fear of losing face can help establish more open communication between clients and therapists, ultimately enhancing the efficacy of therapy.


The fear of "losing face" constitutes a significant cultural barrier influencing the attitudes and practices of Chinese mental health professionals. Addressing this issue transcends cultural sensitivity; it is about enhancing the effectiveness of mental health care services. As the world becomes increasingly interconnected, understanding these cultural intricacies becomes more crucial than ever for the global mental health community. 


Zhuang She, Hui Xu, Gina Cormier, Martin Drapeau & Barry L. Duncan (2023): Culture matters: Chinese mental health professionals’ fear of losing face in routine outcome monitoring, Psychotherapy Research, DOI: 10.1080/10503307.2023.2240949

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Categorized in: Routine Outcome Monitoring (ROM), Chinese Cultural Practices, Mental Health Professionals, Fear of Losing Face, Therapeutic Communication

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