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Comprehensive Clinical Psychology. Volume 10

Copyright © 2000 Elsevier Science Ltd. All rights reserved.

Editors-in-Chief: Alan S. Bellack and Michel Hersen

Table of Contents
Volume 10: Sociocultural and Individual Differences
Close
Preface
Contributors
Section I: Foundations,

10.01 Introduction to Diversity in Clinical Psychology, Pages 1-33, Harry C. Triandis

SummaryPlus | Chapter | PDF (437 K)

10.02 Cross-cultural Psychopathology, Pages 35-51, Fanny M. Cheung

SummaryPlus | Chapter | PDF (329 K)

10.03 Cultural Bias in Testing of Intelligence and Personality, Pages 53-92, Cecil R.
Reynolds
SummaryPlus | Chapter | PDF (469 K)

10.04 Cross-cultural Clinical Interventions, Pages 93-125, John E. Lewis

SummaryPlus | Chapter | PDF (444 K)

10.05 Competence Training in Clinical Psychology: Assessment, Clinical Intervention,

and Research, Pages 127-140, Felipe G. Castro
SummaryPlus | Chapter | PDF (255 K)

Section II: Special Topics, ,

10.06 Reconstructing Race, Rethinking Ethnicity, Pages 141-160, Maria P. P. Root

SummaryPlus | Chapter | PDF (327 K)

10.07 The Psychology of Gender and Health, Pages 161-172, Richard M. Eisler
SummaryPlus | Chapter | PDF (282 K)

10.08 A Cultural Perspective on Families Across the Life Cycle: Patterns, Assessment,
and Intervention Outline, Pages 173-205, Nadine J. Kaslow and Keith A. Wood Monica R.
Loundy
SummaryPlus | Chapter | PDF (440 K)

10.09 Sexual Orientation, Pages 207-232, Beverly Greene

SummaryPlus | Chapter | PDF (374 K)

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10.10 Diversity Matters: Religion and the Practice of Clinical Psychology, Pages 233-253,
Donald W. Preussler, Richard E. Butman and Stanton L. Jones
SummaryPlus | Chapter | PDF (339 K)

10.11 Mental Health in Rural Society, Pages 255-276, Michael Murray David S. Hargrove
Michael Blank
SummaryPlus | Chapter | PDF (345 K)

Section III: International, ,

10.12 Objective Personality Assessment: Computer-based Minnesota Multiphasic

Personality Inventory-2 Interpretation in International Clinical Settings, Pages 277-312,
James N. Butcher Ellen Berah Bjorn Ellertsen Patricia Miach Jeeyoung Lim Elahe Nezami
Paolo Pancheri Jan Derksen Moshe Almagor
SummaryPlus | Chapter | PDF (446 K)

10.13 Mental Health in the Arab World, Pages 313-324, Marwan Dwairy
SummaryPlus | Chapter | PDF (283 K)

Gailien Image
10.14 Perspectives from Lithuania, Pages 325-334, Danut Image
SummaryPlus | Chapter | PDF (231 K)

10.15 From a Monocultural Identity to Diversity Identity: A Psychological Model for

Diversity Management in South African Organizations, Pages 335-342, Kedibone Letlaka-
Rennert Wolfgang P. Rennert
SummaryPlus | Chapter | PDF (272 K)

10.16 Clinical Psychology in Asia: A Taiwanese Perspective, Pages 343-348, Sue-Huei

Chen Eugene K. Emory
SummaryPlus | Chapter | PDF (207 K)

10.17 Clinical Psychology in Aotearoa/New Zealand: Indigenous Perspectives, Pages 349-

355, Taima M. Moeke-Pickering, Mahalia K. Paewai, Amelia Turangi-Joseph and Averil M. L.
Herbert
SummaryPlus | Chapter | PDF (251 K)

10.18 Perspectives from Sub-Sahara Africa, Pages 357-364, Pius K. Essandoh

SummaryPlus | Chapter | PDF (218 K)

Preface Volume 10
Although psychology began as a science of individual differences, some would argue that it became a
science of means, medians, and modes based on a predominantly Eurocentric world view.

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Nevertheless, it is well accepted that research and practice in clinical psychology are dependent upon
an understanding of sociocultural and individual differences, and during the last several decades
multiculturalism has become a potent force in all psychology.

In the United States, multiculturalism has become institutionalized through mechanisms such as
accreditation criteria for professional psychology training programs and the development of
guidelines for psychological practice with culturally diverse populations. (American Psychological
Association, 1991, 1996). In fact, Bernal and Castro (1994) conclude from their review of United
States governmental and professional policy documents that "it is unethical for scientists who are
inadequately prepared to address theory, method, and interpretation of findings in scientific work on
minority populations to conduct research on them" (p. 797). Hall (1997) warns of "cultural
malpractice" by professional psychologists who are poorly trained in issues of diversity. Without
culturally competent services, clients may be misdiagnosed, mistreated, or prematurely terminate
treatment. Without culturally competent researchers, the development of new knowledge will be
limited at best. At worst we will be misled by inaccurate knowledge that has potential for significant
negative consequences. From an international perspective, psychology as a discipline will cease to be
relevant without continued attention to individual differences.

To detail each and every important sociocultural and individual difference in clinical psychology
would require a voluminous book series in and of itself. For example, McGoldrick, Giordano, and
Pearce (1996) published an excellent text on ethnicity and family therapy, yet in 700-plus pages
detailing 47 different family groups, they could only address one factor (ethnicity) as it was
embedded within one culture (the United States). Thus the approach taken for this volume of
Comprehensive Clinical Psychology has been to address broad issues of many aspects of diversity,
with descriptions of specific populations used for illustrative purposes only. The goal is to be
comprehensive about major issues in theory, research, and practice, without an attempt to be
exhaustive in scope. Scholars with expertise in issues of human diversity from throughout the world
have contributed chapters that are allocated to one of three sections: Section I, Foundations; Section
II, Special Topics; and Section III, International Perspectives.

Section I, Foundations (Chapters 1-5), addresses important foundations for our understanding of
sociocultural and individual differences.

Harry Triandis (Chapter 1, Introduction to Diversity in Clinical Psychology) focuses on the

importance of sociocultural issues for clinical psychology. The main purpose of this chapter is to
provide the conceptual underpinnings of culture and world views, as well as detail related to research
methodologies. Triandis defines basic terms in the area, and critiques a number of methodologies for
the study of world views while providing criteria for good cross-cultural research.

In Chapter 2 (Cross-cultural Psychopathology), Fannie Cheung describes how the Anglo-American

ethnocentric approach to psychopathology has dominated clinical psychology. She examines the role
of cultural factors in the etiology, presentation, and interpretation of psychopathology, and then
focuses on the growth of cross-cultural psychopathology. She advocates for a combined emic-etic
approach, asserting that utilization of such an approach will also facilitate bringing culture into the
mainstream of clinical psychology.

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Cecil Reynolds (Chapter 3, Cultural Bias in Testing of Intelligence and Personality) examines
cultural bias as a fundamental issue in psychological assessment. He details sources of bias and
discusses methodologic issues of related research, while highlighting the synergistic relationship
between test use and pure psychometrics.

John Lewis (Chapter 4, Cross-cultural Clinical Interventions) reviews research on proximal and distal
variables in cross-cultural counseling. He then examines the clinical intervention process, with a
focus on effective intercultural communication and the importance of proxemics, kinesics, and
paralinguistics.

Lewis also examines the long-standing debate regarding therapist-client match, and then details
methodologic issues in treatment outcome research that must be addressed for the field to progress.

Completing Section I is Chapter 5 by Felipe Castro (Cultural Competence Training in Clinical

Psychology: Assessment, Clinical Intervention, and Research). Castro highlights the importance of
training clinical psychologists for cultural competence. He presents a three-factor model that
operationalizes the development of cultural competence in assessment, intervention, and research
activities. Castro also addresses the implications for clinical training programs, and articulates the
need for a commitment to life-long learning if professional psychologists are to achieve cultural
competence.

Section II, Special Topics (Chapters 6-11), focuses on a selection of major features in sociocultural
and individual differences. Maria Root (Chapter 6, Reconstructing Race, Rethinking Ethnicity)
addresses the concepts of race and ethnicity, and their differentiation. She then describes processes of
identity development and summarizes current racial and ethnic identity models. Root proposes that
the field utilize an ecological identity model that considers not only race, but also gender, regional
history of race relations, generation, and class, which in her model includes inherited influences (e.g.,
language, values, sexual orientation, and phenotype) as well as traits (e.g., talents, coping skills).

Richard Eisler (Chapter 7, The Psychology of Gender and Health) provides a review of gender
differences in both somatic and mental health problems. He concludes that differences found are
related to an interaction of biological differences with psychosocial factors. To further elucidate these
relationships, Eisler examines the literature on gender role stress, and gender differences in coping
with stress, self-disclosure, help-seeking, and social support among other topics.

Nadine Kaslow and her colleagues (Chapter 8, A Cultural Perspective on Families Across the Life
Cycle: Patterns, Assessment, and Intervention Outline) articulate a cultural perspective of families,
noting implications for the conduct of culturally sensitive clinical interventions. The close attention to
family life cycle stages is an important contribution to our understanding of the culture-relatedness of
developmental issues.

In Chapter 9 (Sexual Orientation), Beverly Greene reviews research and practice related to sexual
orientation. In describing historical changes in diagnostic nomenclature, she reports the
depathologizing of gay and lesbian sexual orientations and describes the diversity within the
community itself.

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Although often ignored when addressing individual differences, religious diversity and its implication
for practice is addressed by Stanton Jones and his colleagues in Chapter 10 (Diversity Matters:
Religion and the Practice of Clinical Psychology). These authors address the heterogeneity of world
religions, describing important dimensions on which religions vary. They also articulate the
philosophical and empirical bases for consideration of religious diversity in clinical care, providing
numerous examples of how practice could benefit from such awareness.

Finally, as an example of dwelling-related sources of individual differences, Michael Murray and his
colleagues (Chapter 11, Mental Health in Rural Society) address the structure of rural society, with its
related health and mental health issues. These authors also describe the roles of psychologists in rural
communities, highlighting the special training required and ethical issues encountered.

Section III, International Perspectives (Chapters 12-18), presents a sampling of international

perspectives and is thus the most diverse of all sections in this volume. James Butcher has organized
Chapter 12 (Objective Personality Assessment: Computer-based Minnesota Multiphasic Personality
Inventory-2 Interpretation in International Clinical Settings) to describe the use of perhaps the most
widely employed and internationally adapted personality measure, the MMPI. The authors report an
empirical evaluation of computer-based reports on Australian, French, Norwegian, and American
patients, and describe clinical case examples from The Netherlands, Italy, Korea, Iran, and Israel.

Other chapters address mental health issues in various countries, including the impact of
sociopolitical forces on the development of psychology as a discipline itself. For example, Marwan
Dwairy (Chapter 13, Mental Health in the Arab World) describes the cultural background of Arabs
living in some 21 countries. He details important psychocultural features, and then discusses
implications for clinical assessment and treatment, presenting clear evidence of the inappropriateness
of Eurocentric models for many presenting problems.

Danute Gailiene (Chapter 14, Perspectives from Lithuania) describes the development of clinical
psychology in Lithuania as inextricably related to that country's sociopolitical history. Gailiene
highlights the impact of Soviet domination, perestroika, and the achievement of Lithuanian
independence upon psychology education and training and the development of professional practice.

In Chapter 15 (From a Monocultural Identity to Diversity Identity: A Psychological Model for

Diversity Management in South African Organizations), Kedibone Letlaka-Rennert and Wolfgang
Rennert describe sociopolitical changes in South Africa that have had significant impact on the
evolution of psychology. As their country moves from cultural exclusion and oppression to become a
"rainbow nation," psychologists' roles are shifting from support of apartheid to an active role in
diversity management and social transformation.

Eugene Emory and Sue-Huei Chen (Chapter 16, Clinical Psychology in Asia: A Taiwanese
Perspective) provide a Taiwanese perspective on mental health issues and psychology. They examine
the impact of collectivism on psychopathology and describe features of Asian culture related to the
types of clinical services needed and offered.

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In Chapter 17 (Clinical Psychology in Aotearoa/New Zealand: Indigenous Perspectives), Taima

Moeke-Pickering and her colleagues examine bicultural developments in psychology in response to
the needs of the Maori. This chapter provides an indigenous perspective of psychology as a discipline
with respect to theory, research, and service development.

Finally, in Chapter 18 (Perspectives from Sub-Sahara Africa), Pius Essandoh describes sociocultural
factors in psychological health in sub-Sahara Africa. He highlights the importance of beliefs related
to spirituality, kinship, and life-span development as well as the need for a mental health system that
is pluralistic rather than monocultural.

In its entirety, this volume provides a comprehensive, but not exhaustive, overview of sociocultural
and individual differences in clinical psychology. The reader is encouraged to focus on the
conceptual frameworks presented, the methodologic issues involved, and the training model
suggested in preparing for his or her own diversity competence for research, teaching, and practice in
clinical psychology. This volume is also culturally biased. For example, the value of diversity as a
core principle in psychology is promoted throughout the book, and authors consistently portray
cultural groups as equals, presenting a multicultural perspective as superior to racist, imperialistic, or
xenophobic viewpoints of human diversity. Indeed the editor did not seek authors representing these
latter perspectives. However, as Fowers and Richardson (1996) have so eloquently articulated, the
values of multiculturalism are themselves culturally based, rooted in Euro-American moral and
political traditions that have evolved to respect human dignity and rights. Ironically, the
universalization of multiculturalism represents the imposition of these values of tolerance and respect
on groups who might hold racist or ethnocentric views, or have different values regarding human life
and suffering. We must recognize that multiculturalism itself has moral roots in Euro-American
culture.

Acknowledgments

The greatest source of inspiration for participation in this project came from my graduate students in
clinical psychology at the University of Florida. It was their thirst for knowledge and craving for
experience with diversity that led me to develop a special course on the topic for our curriculum. The
systematic review of relevant literature for that course resulted in my recognition of the need for an
integrated text on the subject. Other major contributors to this effort have been Michel Hersen and
Angela Greenwell, who provided unfailing good judgment and help in pulling this volume together. I
would also like to acknowledge the ongoing support provided by my husband, Jean-Louis Monfraix.

Dedication

To Herbert and Glennie Belar.

References

American Psychological Association (1991). Guidelines for providers of psychological services to

ethnic, linguistic, and culturally diverse populations. Washington, DC: Author.
American Psychological Association (1996). Guidelines and principles for accreditation of programs

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in professional psychology. Washington, DC: Author.

Bernal, M. E., & Castro, F. G. (1994). Are clinical psychologists prepared for service and research
with ethnic minorities? American Psychologist, 49, 797-805.
Fowers, B. J., & Richardson, F. C. (1996). Why is multiculturalism good? American Psychologist,
51, 609-621.
Hall, C. C. (1997). Cultural malpractice: The growing obsolescence of psychology with the changing
US population. American Psychologist, 52, 642-651.
McGoldrick, M., Giordano, J., & Pearce, J. K. (Eds.) (1996). Ethnicity and family therapy (2nd ed.).
New York: Guilford Press.

Volume 10 Contributors
ALMAGOR, M. (University of Haifa, Israel)
*Objective Personality Assessment: Computer-based Minnesota Multiphasic Personality Inventory-2
Interpretation in International Clinical Settings

BERAH, E. (Monash Medical Centre, Clayton, Vic, Australia)

*Objective Personality Assessment: Computer-based Minnesota Multiphasic Personality Inventory-2
Interpretation in International Clinical Settings

BLANK, M. (University of Virginia, Charlottesville, VA, USA)

*Mental Health in Rural Society

BUTCHER, J. N. (University of Minnesota, Minneapolis, MN, USA)

*Objective Personality Assessment: Computer-based Minnesota Multiphasic Personality Inventory-2
Interpretation in International Clinical Settings

BUTMAN, R. E. (Wheaton College, IL, USA)

*Diversity Matters: Religion and the Practice of Clinical Psychology

CASTRO, F. G. (Arizona State University, Tempe, AZ, USA)

Cultural Competence Training in Clinical Psychology: Assessment, Clinical Intervention, and
Research

CHEN, S.-H. (National Taiwan University, Taipei, Taiwan)

*Clinical Psychology in Asia: A Taiwanese Perspective

CHEUNG, F. M. (The Chinese University of Hong Kong, Hong Kong)

Cross-cultural Psychopathology

DERKSEN, J. (University of Nijmegen, The Netherlands)

*Objective Personality Assessment: Computer-based Minnesota Multiphasic Personality Inventory-2

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Interpretation in International Clinical Settings

DWAIRY, M. (Nova Southeastern University, Oakland Park, FL, USA)

Mental Health in the Arab World

EISLER, R. M. (Virginia Polytechnic Institute and State University, Blacksburg, VA, USA)
The Psychology of Gender and Health

ELLERTSEN, B. (University of Bergen, Norway)

*Objective Personality Assessment: Computer-based Minnesota Multiphasic Personality Inventory-2
Interpretation in International Clinical Settings

EMORY, E. K. (Emory University, Atlanta, GA, USA)

*Clinical Psychology in Asia: A Taiwanese Perspective

ESSANDOH, P. K. (Jersey City State College, NJ, USA)

Perspectives from Sub-Sahara Africa

GAILIEN , D. (University of Vilnius, Lithuania)

Perspectives from Lithuania

GREENE, B. (St. John’s University, Jamaica, NY, USA)

Sexual Orientation

HARGROVE, D. S. (University of Mississippi, MS, USA)

*Mental Health in Rural Society

HERBERT, A. M. L. (University of Waikato, Hamilton, New Zealand)

*Clinical Psychology in Aotearoa/New Zealand: Indigenous Perspectives

JEEYOUNG, L. (Samsung Group, Jeongdun-Maul, Sungnam-City, South Korea)

*Objective Personality Assessment: Computer-based Minnesota Multiphasic Personality Inventory-2
Interpretation in International Clinical Settings

JONES, S. L. (Wheaton College, IL, USA)

*Diversity Matters: Religion and the Practice of Clinical Psychology

KASLOW, N. J. (Emory University School of Medicine, Atlanta, GA, USA)

*A Cultural Perspective on Families Across the Life Cycle: Patterns, Assessment, and Intervention
Outline

LETLAKA-RENNERT, K. (Johannesburg, South Africa)

*From a Monocultural Identity to Diversity Identity: A Psychological Model for Diversity
Management in South African Organizations

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LEWIS, J. E. (Nova Southeastern University, Fort Lauderdale, FL, USA)

Cross-cultural Clinical Interventions

LOUNDY, M. R. (Georgia State University, Atlanta, GA, USA)

*A Cultural Perspective on Families Across the Life Cycle: Patterns, Assessment, and Intervention
Outline

MIACH, P. (Monash Medical Centre, Clayton, Vic, Australia)

*Objective Personality Assessment: Computer-based Minnesota Multiphasic Personality Inventory-2
Interpretation in International Clinical Settings

MOEKE-PICKERING, T. M. (University of Waikato, Hamilton, New Zealand)

*Clinical Psychology in Aotearoa/New Zealand: Indigenous Perspectives

MURRAY, M. (Memorial University of Newfoundland, St. John’s, NF, Canada)

*Mental Health in Rural Society

NEZAMI, E. (USC/IPR, Los Angeles, CA, USA)

*Objective Personality Assessment: Computer-based Minnesota Multiphasic Personality Inventory-2
Interpretation in International Clinical Settings

PAEWAI, M. K. (University of Waikato, Hamilton, New Zealand)

*Clinical Psychology in Aotearoa/New Zealand: Indigenous Perspectives

PANCHERI, P. (5a Cattedra di Clinica Psichiatrica, Rome, Italy)

*Objective Personality Assessment: Computer-based Minnesota Multiphasic Personality Inventory-2
Interpretation in International Clinical Settings

PREUSSLER, D. W. (Wheaton College, IL, USA)

*Diversity Matters: Religion and the Practice of Clinical Psychology

RENNERT, W. P. (University of the Witwatersrand, Johannesburg, South Africa)

*From a Monocultural Identity to Diversity Identity: A Psychological Model for Diversity
Management in South African Organizations

REYNOLDS, C. R. (Texas A&M University, College Station, TX, USA)

Cultural Bias in Testing of Intelligence and Personality

ROOT, M. P. P. (University of Washington, Seattle, WA, USA)

Reconstructing Race, Rethinking Ethnicity

TRIANDIS, H. C. (University of Illinois, Urbana, IL, USA)

Introduction to Diversity in Clinical Psychology

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TURANGI-JOSEPH, A. (University of Waikato, Hamilton, New Zealand)

*Clinical Psychology in Aotearoa/New Zealand: Indigenous Perspectives

WOOD, K. A. (Emory University School of Medicine, Atlanta, GA, USA)

*A Cultural Perspective on Families Across the Life Cycle: Patterns, Assessment, and Intervention
Outline

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 Copyright © 1998 Elsevier Science Ltd. All rights reserved.

10.01
Introduction to Diversity in Clinical
Psychology
HARRY C. TRIANDIS
University of Illinois, Urbana, IL, USA

10.01.1 INTRODUCTION 2
10.01.2 DEFINITIONS 2
10.01.2.1 Culture 2
10.01.2.2 Cultural Syndromes 3
10.01.2.3 Identity 3
10.01.2.4 Acculturation 3
10.01.2.5 Ecology 4
10.01.2.6 Psychological Processes 4
10.01.2.7 Cultural Distance 4
10.01.2.8 Culture Shock 4
10.01.2.9 Ethnocentrism 4
10.01.2.10 Racism 4
10.01.2.11 Prejudice 5
10.01.2.12 Emic and Etic Aspects of Culture 5
10.01.2.13 An Integrative Example of These Definitions 5
10.01.3 WORLD VIEWS 6
10.01.3.1 Cultural Complexity 6
10.01.3.2 Tightness±Looseness 6
10.01.3.3 Collectivism 7
10.01.3.4 Individualism 7
10.01.3.5 Horizontality 7
10.01.3.6 Verticality 7
10.01.3.7 Active±Passive 7
10.01.3.8 Honor 8
10.01.3.9 Universalism±Particularism 8
10.01.3.10 Diffuseness±Specificity 8
10.01.3.11 Ascription±Achievement 8
10.01.3.12 Instrumental±Expressive 8
10.01.3.13 Value Orientations 8
10.01.3.14 Dionysian vs. Apollonian Cultures 9
10.01.4 METHODOLOGIES FOR THE STUDY OF WORLD VIEWS 9
10.01.4.1 Some General Strategies 11
10.01.4.2 Good Theory Can Eliminate Some Rival Hypotheses 12
10.01.4.3 Methods that Can Establish Measurement Equivalence Across Cultures 12
10.01.4.4 Emics and Etics in Cross-cultural Research 12
10.01.4.5 How to Use Emic Measurements of Etic Constructs 14
10.01.4.5.1 General recommendations 15
10.01.4.6 Examples of Multimethod Measurements 15
10.01.4.6.1 Ethnographic work 15
10.01.4.6.2 Establishing shared cognitions 16
10.01.4.6.3 Conclusions 17

1
2 Introduction to Diversity in Clinical Psychology

10.01.4.7 Translations 18
10.01.4.8 Ethics of Cross-cultural Studies 19
10.01.4.9 Ethnocentric and Androcentric Bias of Researchers 19
10.01.4.10 Summary of Criteria of Good Cross-cultural Research 20
10.01.5 ACCULTURATION 20
10.01.6 IDENTITIES OF AFRICAN- AND EUROPEAN-AMERICANS AS AN EXAMPLE OF THE
IDENTITIES OF CLINICIANS AND CLIENTS 21
10.01.7 METHODS FOR THE DEVELOPMENT OF AN UNDERSTANDING OF THE CULTURE
OF THE CLIENT 23
10.01.7.1 Methods of Culture Learning 24
10.01.7.1.1 Culture-general vs. culture-specific training 25
10.01.7.1.2 Self-insight 26
10.01.7.1.3 Experiential training 26
10.01.7.1.4 Exposure to many local cultures 26
10.01.7.1.5 Field trips 26
10.01.7.1.6 Culture assimilators or intercultural sensitizers 26
10.01.7.1.7 Behavior modification cross-cultural training 29
10.01.7.1.8 Some summary points about training 29
10.01.8 FUTURE DIRECTIONS 30
10.01.9 SUMMARY AND CONCLUSIONS 30
10.01.10 REFERENCES 30

10.01.1 INTRODUCTION provide reliable information concerning such

world views. The focus will be on helping
Clinical psychologists deal with many kinds clinicians discriminate reliable from unreliable
of diversity. While diversity due to culture may cross-cultural studies, so that they can begin
be the most imporant kind that affects their developing a body of knowledge about cultural
work, it is useful to remember that diversity in differences. Then, the chapter will examine the
social class, sexual orientation, gender defini- relationship of acculturation to varieties of
tions, disabilities, political perspectives, esthetic cultural identity (in both the majority and
preferences, religion, and the definition of what minority culture). Finally, it will describe
is ªtrueº may also affect their practice. methods and procedures that clinicians can
Diversity may be defined as the condition of use to develop more detailed understandings of
interacting with another person who is per- other cultures, and to improve the effectiveness
ceived to be ªdifferent.º It is a condition which is of their behavior when interacting with diverse
increasingly more frequent, since most societies clients.
are multicultural and a number of factors favor
interactions among the cultures. In the US the
clients of clinical psychologists are becoming 10.01.2 DEFINITIONS
more different from the white middle-class 10.01.2.1 Culture
which was the usual clientele of these profes-
sionals a few years ago. Culture is to society what memory is to
It is impossible to deal with all the aspects of individuals (Kluckhohn, 1954, p. 967). It
diversity in one chapter, so the focus will be on includes all the things which have ªworkedº
culture. However, some of the other kinds of in the history of an interacting group of humans,
diversity (e.g., in religion or social class) do and have become unstated assumptions, stan-
interact with cultural differences, and some of dard operating procedures, standards of per-
the experience which clinicians have acquired in ceiving, judging, deciding, and acting. Cultural
dealing with these other kinds of diversity may anthropologists (e.g., Kroeber & Kluckhohn,
prove useful in dealing with cultural diversity. 1952) have developed more than 100 definitions
This chapter will begin with definitions of of ªculture,º such as that culture is the human-
concepts such as culture, and the relevance of made part of the environment (Herskovits,
ethnocentrism, prejudice, and racism in making 1955). Such a definition is too broad, but it does
judgments about the behavior of other humans. have the advantage that we can ask: Is this
It will also examine the terminology for dealing particular element human-made? For instance,
with what is culture-common (etic) and culture- is this belief human-made? Then it is an aspect of
specific (emic). Section 10.01.3 will describe culture. The Herskovits' definition can become
some of the diversity of world views and values, more useful if we distinguish material culture
and will examine methodologies which can (tools, roads, houses) from subjective culture
 Definitions 3

(categorizations, beliefs, attitudes, self-defini- scale that measures an element of subjective

tions, role definitions, norms, values (Triandis, culture, then that element is an aspect of the
1972). cultural syndrome. Another method (see Tri-
Most contemporary anthropologists (e.g., andis, Bontempo, Leung, & Hui, 1990) is to
Shweder & Levine, 1984) agree that culture is form (say 50) triads of representatives of each
a system of shared meanings. Hence my favorite culture, and ask them to reach a group
definition: agreement on an element of subjective culture,
for example, ªDo you agree that widows should
Culture is a set of human-made objective and not eat chicken?º Agreement in less than 60
subjective elements that in the past have increased seconds, among say 90% of the triads, would
the probability of survival and resulted in satisfac- indicate that the belief is widely shared, and thus
tions for the participants in an ecological niche, it is an element of the culture syndrome. In sum,
and thus became shared among those who could
both the time to reach agreement and the
communicate with each other because they had a
common language and they lived in the same time percentage of triads which reach agreement can
period and place. (Triandis, 1994, p. 22) be used as criteria for determining the presence
of an element of a cultural syndrome. When the
Note that this definition, in addition to cultural elements, identified by such procedures,
focusing on what is shared, specifies that a which represent attitudes, beliefs, norms, role-
common language is important, and commu- definitions, self-definitions, and values are
nication can take place because people live in interrelated, we have defined empirically the
the same time period and geographic region. cultural syndrome.
Thus, in principle, people who live next door to
each other but speak different languages (say, in 10.01.2.3 Identity
Los Angeles, Hispanics and Thais), or during
different time periods (say, in Los Angeles in People make statements that include the
1950 and in 1996), or in different geographic words ªme,º ªmine,º ªmyself,º ªI,º and the
regions (say, in Texas and New York) may have like. All these statements taken together con-
different cultures. Physicians have their own stitute the self. An important aspect of the self
language in the hospital, and thus physicians- concerns statements about belonging to some
on-the-job may constitute a culture, by this group. For example ªI am a Koreanº specifies a
definition. According to this definition the Korean identity. ªI am a bridge-playerº is also
number of cultures is enormous. an identity. Brewer (1991) has argued that each
Humans regardless of culture have many individual experiences forces toward differen-
common attributes. All humans have language, tiation from groups as well as assimilation to
food habits, art, myths, religious practices, groups. These opposing forces are in equili-
family structures, economic systems, ªtruth,º brium at the point of ªoptimal distinctivenessº
government, war, kinship, shelter, training which is characteristic of each person. This
systems, hygiene, and incest taboos (Brown, point is determined by cultural norms, indivi-
1991). However, note that these categories are dual socialization, and recent experiences with
extremely broad. Take an easy one to think the group. For instance, in traditional cultures,
about: food habits. What people eat, when, which tend to be collectivist, the forces of
where, with whom, and to what effect are clearly assimilation are stronger than the forces of
diverse. If we are to pay attention to that level of differentiation, and thus the optimal distinc-
detail, it is obvious that the diversity of cultures tiveness point is closer to the group than in
is enormous. modern cultures.

10.01.2.2 Cultural Syndromes 10.01.2.4 Acculturation

Shared patterns of beliefs, attitudes, self- Some individuals, especially in multicultural
definitions, norms, roles, and values are some- cities, are exposed to numerous cultures
times organized around a common theme. simultaneously. They may use more than one
When they are and found among members of identity, for example, ªI am Mexicanº and ªI
a culture, they constitute a cultural syndrome. am American.º The more elements of one
The logic of shared elements of subjective culture are attached to an identity (e.g., Since I
culture allows us to identify such syndromes am Mexican I speak Spanish most of the time),
(Triandis, 1996). For example, we can examine the more influential is that identity in determin-
the response distributions obtained from sam- ing behavior. An individual may be more or less
ples in a particular culture, and if an arbitrary bicultural, include elements from both cultures
90% of the participants give a response on the in an identity, assimilated, include mostly
same side of the neutral point, on a nine-point elements of another culture in an identity,
4 Introduction to Diversity in Clinical Psychology

separated, that is, even though the individual language and the clinician an Indo-European
lives in an environment which includes many language), (ii) family structure (say, monoga-
cultures the identity is separate and distinct and mous vs. polygamous marriages can create
monocultural, or alienated, may reject all distance), (iii) religions (e.g., animist and
cultures. Christian religions), (iv) wealth and life style
(e.g., the difference between a wealthy jetsetter
10.01.2.5 Ecology and a member of a culture of hunters and
gatherers), (v) values (e.g., the difference
Ecology refers to where people live. It consists between conservative, very traditional values
of objects, resources, the geography of the and self-actualizing, hedonistic values).
environment, and the ways of making a living
and surviving in that environment. Ecology
provides schedules of reinforcement (Skinner, 10.01.2.8 Culture Shock
1981), which shape both the elements of Triandis and Gelfand (1994) presented a
subjective culture and the behavior of those model that links cultural distance and culture
who live in these ecologies. Thus, culture shock (Oberg, 1960). The larger the cultural
emerges from the ecology. distance the larger the culture shock. The model
posits that cultural distance leads to low
10.01.2.6 Psychological Processes perceived similarity. When people perceive each
Clinicians are, of course, focusing on psy- other as dissimilar and are also in contact, the
chological processes, such as personality, beha- relationship is tense, and punishing, resulting in
vior patterns, and the beliefs, attitudes, and distortions such as extreme stereotypes, inaccu-
values of their clients. It is obvious from the rate attributions (e.g., clinician and client
above definitions that culture influences many attribute different causes to the same behavior),
of these psychological processes. Poor clinical which lower the sense of control (ability to act so
analyses occur when the clinician and the client as to obtain positive outcomes from relation-
come from different cultures, because the very ships). A low sense of control results in culture
same behavior may have different meanings in shock. The model also includes other variables,
the two cultural systems and very frequently which need not concern us here.
these meanings influence important judgments,
such as diagnoses. 10.01.2.9 Ethnocentrism
Take one simple example: in collectivist
cultures, such as those found in the Far East, Most humans are ethnocentric (Brewer &
communications that are unclear and indirect Campbell, 1976; Campbell & Levine, 1968;
which save someone's face are expected and are Triandis, 1994). Ethnocentrism follows from the
very common. In individualistic cultures, such fact that most humans are only exposed to their
as in the West, people are expected to provide own culture. Only humans who live in multi-
ªstraight talkº and not ªbeat around the bush.º cultural environments, or have traveled exten-
Similarly, a lie is morally reprehensible in the sively, are moderately ethnocentric. The extent
West much more than in the East. Authenticity our culture influences our perceptions of the
(Trilling, 1972) is valued in the West, and that behavior of others is large and subtle. We are
includes ªtelling it as it isº and telling the truth. usually not aware of our ethnocentrism. Those
Thus, the same behavior can be interpreted who have been exposed to other cultures learn to
differently in the two kinds of cultures. Indirect appreciate aspects of these cultures which are
communications may be seen as ªtactful and not included in their own cultures, and thus
politeº and a lie can be seen as saving face in the become less ethnocentric. Clinicians must con-
East, while the same behaviors may be seen as trol their ethnocentrism by learning to appreci-
ªconfused and confusingº and reprehensible in ate other cultures. Yet that is especially difficult
the West. The interpretation is an aspect of an when the cultural distance between their culture
integrated conceptual system, and is often so and the client's culture is large. In that case it
compelling that it is difficult for either party to may be best to admit that they are not able to
easily use the other's way of thinking. help the client, and it is desirable to find
colleagues whose cultural distance is smaller
10.01.2.7 Cultural Distance and who might be able to help the client.

Cultural distance is an important concept in 10.01.2.10 Racism

understanding diversity, and the way it affects
human relationships. Cultural distance can Racism is a special case of ethnocentrism,
reflect differences in (i) language (e.g., language where the standards of one's own racial group
families, such as the client speaks a tonal are used to judge other racial groups.
 Definitions 5

10.01.2.11 Prejudice individualistic cultures that has been discussed

by East Asian social scientists (e.g., Ting-
Prejudice is judgment of the attributes and Toomey, 1988). The simpatia cultural script is
behavior of members of another culture on the an emic.
basis of negative preconceived ideas and In other words, when dealing with ingroup
inaccurate stereotypes. Such judgments are members or even acquaintances, Hispanics tend
usually associated with negative emotional to be more positive in their behaviors than non-
reactions toward members of the other culture, Hispanics. The practical significance of this
as well as with self-instructions to keep some pattern is that, relative to non-Hispanics,
social distance from the members of the other Hispanics will expect a clinician to be more
culture (rejection of positive and endorsement positive in situations that ordinarily will be
of negative behavioral intentions toward the ambiguous or call for somewhat negative
members of the other culture). People who are behaviors. For instance, criticism or other
very ethnocentric tend to be prejudiced. Even negative behaviors may be more upsetting to
people who score as nonprejudiced on attitude Hispanics than to non-Hispanics.
scales, when responding to ethnic stimuli For another example of an emic motif,
tachistoscopically, so that they do not have consider the amae pattern found in Japan
the opportunity to ªcontrolº their prejudice, (Doi, 1986). Japanese often presume that they
show themselves to use unfavorable stereotypes. may depend on others, the way a child depends
In short, the unprejudiced have learned to on a parent. Mutual dependence is an emic
control their prejudice and not show it to aspect of that culture.
researchers, but the negative stereotypes are The significance of the emic and etic distinc-
nevertheless present in their cognitive system tion is that it alerts us to which specific cultures
(Devine, 1989). may have idiosyncratic ways of cutting the pie of
experience. If we use only etics, we miss some of
10.01.2.12 Emic and Etic Aspects of Culture that information and do not identify many
cultural differences (Marin & Marin, 1991).
Phonetics deals with sounds which occur in There are ways to combine emics and etics
all languages. Phonemics deals with sounds (see Triandis, 1992), making our measurements
which occur in only one language. This led the culture-sensitive but also equivalent across
linguist Pike (1967) to coin the words etics and cultures. These techniques will be discussed in
emics to refer to the culture-general and culture- Section 10.01.4.5. Many techniques specific to
specific elements of culture. Etics reflect con- cultural studies have been identified (see
structs which apply to phenomena that occur in Triandis & Berry, 1980). Some of these use
all cultures. Emics are constructs which occur in methods (e.g., Szalay, 1970; Szalay & Deese,
only one culture. 1978) such as word association which are also
For example, in all cultures ingroup members used by some clinical psychologists.
(family, tribe, co-workers, co-religionists) are
treated better than outgroup members (enemies, 10.01.2.13 An Integrative Example of These
strangers, outsiders). That is an etic. However, Definitions
there are also emic patterns. For example, when
Hispanics and non-Hispanics were presented The ethnocentrism mentioned above is an
with several hundred situations and asked if etic. It is accentuated by two other phenomena,
they expected people in such a situation to use which are also probable etics: (i) we have a
positive (e.g., admire, respect, support) or tendency toward naive realism which limits our
negative (e.g., criticize, dominate, fight with) capacity to appreciate the extent to which our
behaviors, there was a response pattern which construals are subjective (Robinson, Keltner,
was called the ªsimpatia cultural scriptº (Tri- Ward, & Ross, 1995); and (ii) we have a
andis, Marin, Lisansky, & Betancourt, 1984) tendency toward false consensus, which is to
that emerged when the Hispanic responses were think that other humans agree with our
compared to the non-Hispanic responses to the positions more than is true, and disagree with
same situations. Specifically, Hispanics com- our position less than is true (Krueger &
pared to non-Hispanics expected more positive Clement, 1994).
behaviors and fewer negative behaviors in a In short, we tend to think that the way we see
wide range of situations. They expected people the world is both valid and universal. Our
to try to be simpatico, that is, to be nice and culture provides the ªlensesº for seeing the
pleasant, even in situations where non-Hispa- world in a particular way and that way of seeing
nics expected neutral or negative behaviors. is so obvious that it is not questioned.
This is similar, but not identical, to the greater Consider this example. In Orissa, India, most
importance of face in collectivist than in of the population believes that widows must not
6 Introduction to Diversity in Clinical Psychology

eat chicken (Shweder, Mahapatra, & Miller, preferences for social pathology are matters of
1990). When asked if this behavior should be taste, not scientific judgment!
universal they say: ªOf course. It is a great sin
for widows to eat chicken.º When told that
Americans do not believe this, they look down 10.01.3 WORLD VIEWS
upon Americans, and explain this ªmoral Many cultural syndromes have been identi-
deficiencyº by noting that America is a young fied thus far. The exact number of syndromes is
country which has not yet reached the level of not known, but a guess is that a score may be
moral maturity found in India. sufficient to describe the most important
Now, consider what happens when Illinois cultural differences. Here we present some of
participants are asked whether widows must not the most important syndromes.
eat chicken. They say that this belief is silly.
When asked if this rule should be universal, they
object vehemently. When told that people in 10.01.3.1 Cultural Complexity
Orissa, India, strongly believe that widows must
not eat chicken, they look down upon these Simple cultures such as hunters and gatherers
Indians, and point out that they are not have few roles, simple social structures, few
sufficiently developed to have ªcorrect views.º levels of social and political stratification,
Do you see the ethnocentrism in both simple religious beliefs, simple understandings
perspectives? The Indian view stems from the of the nature of the world, few domains of
basic assumption that people are interdepen- esthetic activity, and simple methods of eco-
dent. Married individuals are supposed to be nomic exchange (e.g., barter). Specific simple
linked to each other for ever. For a widow to eat cultures may be very complex in one domain,
chicken is a sin because they believe that eating such as people may have an extensive knowledge
chicken makes one sexually aroused, and such of the history of their ancestors, as is found
arousal will result in the widow having sexual among Australian aborigines, but in most
relations with someone, and thus breaking the domains they are simple. Many attributes of
eternal bond with her husband. Note that culture are associated with cultural simplicity.
cultures often have sets of beliefs which are For example, simple cultures are characterized
supportive of each other. by small communities (often bands of 50
Now consider the American view. The basic individuals), the use of barter, walking as the
assumption is consistent with American indivi- only means of transportation, and so on.
dualism (Triandis, 1995) which assumes that Complex cultures, such as information socie-
people are autonomous entities. Widows can do ties, have many roles, for example, a quarter of a
their own thing. If Indians have an idea that is million occupations in the Dictionary of Occu-
different from the American idea, it is because pational Titles, complex social structures, for
they are not sufficiently developed! example, General Motors, complex social and
Thus, both cultures conclude that their views political stratification (e.g., federal, state, and
are superior and the views of the other culture local governments), a multiplicity of religious
are inferior. Ethnocentrism leads to prejudice, beliefs, a complex understanding of the nature
and attempts to impose the subjective culture of of the world, for example, modern science,
one's own culture on other cultural groups. multiple types of esthetic activities, and numer-
This is not the place to debate the merits of ous methods of economic exchange, such as,
individualism and collectivism. Hofstede (1980) money, bonds, stock, certificates of deposit, etc.
linked these concepts with many ecological They include mostly urban social patterns.
variables. Triandis (1995) has suggested that Again, in one domain there might be consider-
individualism is associated with high levels of able simplicity, such as a family structure that
achievement, creativity, self-actualization, and consists of only a mother and her children, but
democracy, but also with high levels of crime, on the whole there is complexity in most
divorce, and child abuse. Collectivism is domains.
associated with high levels of social support, In complex cultures subjective cultures also
cooperation, interpersonal sensitivity, and tend to be more complex, for example, one finds
pleasantness in social relationships, but also large vocabularies (100 000+ terms in English)
with extreme conformity, low creativity, and and complex ways of classifying experience, as
ethnic cleansing. In short, both cultural well as complex beliefs.
patterns have both positive and negative
elements, and it is natural for most people 10.01.3.2 Tightness±Looseness
from all types of cultures to prefer their
cultures. As scientists we can examine the links Some cultures have (i) many rules, norms, and
of ecology, culture, and social pathology, but detailed specifications about how one is to act,
 World Views 7

and (ii) members who react quite strongly (e.g., roles imposed by their groups, and relate to
criticize or even kill those who deviate from the ingroup members by paying attention to the
norms) to minor deviations from the rules, needs of others rather than to their own needs.
norms, and ªproper behaviorº (Triandis, 1989, Many East Asian societies are collectivist, as are
1994). Such cultures are called ªtight.º Other many traditional societies in Africa and Latin
cultures are loose, that is, have few rules, norms, America. In the US, Hispanics and Asians tend
and do not specify how one is to behave in very to be collectivists.
many situations, and when a person deviates
from these few rules, norms, or conceptions
about proper behavior, people tolerate such 10.01.3.4 Individualism
deviations. Triandis (1994) speculated that this pattern is
Tight cultures provide criticism and severe maximal in complex, loose cultures, and is
sanctions (e.g., 50 lashes) for deviation; loose characterized (Triandis, 1995) by individualists
cultures criticize only major deviations and perceiving themselves as autonomous from
provide mild sanctions (e.g., a fine) for most their groups, giving priority to their personal
deviations. rather than to their ingroup's goals, behaving
Tightness and looseness are domain specific. according to their attitudes and feelings of
For example, a culture may be very tight about enjoyment, and dealing with members of their
the use of time, but be rather loose about the ingroups by paying attention to the ªprofitº and
way one chooses friends. For example, the US, ªlossº incurred from the relationship, as
in 1996, is very tight about writing bad checks specified by exchange theory (Thibaut & Kelley,
and rather loose about who one lives with. 1959). Many Western societies are individua-
However, across domains, tight cultures tend to listic, especially the US, Australia, and Britain.
be tight, and loose cultures tend to be loose.
Japan is an example of a tight culture, and
Thailand an example of a loose culture. The US 10.01.3.5 Horizontality
is fairly loose. For example, one extreme
Cultures that are egalitarian, such as the
incident that occurred in Japan in 1990 was
Eskimos, and tend to emphasize tit-for-tat, one
that a teacher killed a student who was two
person one vote and the like are horizontal. In
minutes late for class. Japanese opinion was
such cultures, people do not share or distribute
divided about this teacher, most arguing that he
resources according to need, contributions
was ªderangedº even though they understood
(equity), or status, but equally. There is little
his efforts to impose discipline. However, some
social stratification; most people carry out most
psychopathology is an extreme expression of a
of the tasks of the society.
cultural norm (Draguns, 1990)!
Rural Thailand is loose. An employee may
come to work, or not come to work, and no 10.01.3.6 Verticality
explanations are offered (Phillips, 1965). After
living in Thailand for several months, Phillips The cultural pattern of verticality emphasizes
(1965) had difficulty understanding ªthe mys- hierarchy. It is similar to Hofstede's (1980)
tifying American capacity to conform to the ªpower distance,º a cultural pattern in which
expectations of othersº (p. 204). people at the top of the power hierarchy seem to
be very distant from people at the bottom of the
hierarchy. Resources are divided according to
10.01.3.3 Collectivism status. There is much deference for those who
The collectivism syndrome has been studied have status. High levels of stratification are
more extensively than most of the other present.
syndromes (Kim, Triandis, Choi, Kagitcibasi,
& Yoon, 1994; Markus & Kitayama, 1991; 10.01.3.7 Active±Passive
Triandis, 1990, 1995). It has received a central
position in most reviews of cultural differences This syndrome was described by Diaz-
in social behavior (e.g., M. Bond & Smith, Guerrero (1979) when he compared US and
1996). Triandis (1994) has speculated that Mexican data. Those who are active, such as
maximum collectivism occurs in simple tight Americans, thrive on competition, action, and
cultures, such as theocracies. He also argued emphasize self-fulfillment. They try to change
(Triandis, 1995) that in collectivist cultures the world, rather than change themselves to fit
individuals define themselves as aspects of into the world. Those who are passive, are
groups (i.e., I am a member of . . . ), place the cooperative, emphasize the experience of being,
goals of their collectives ahead of their personal and tend to change themselves to fit into
goals, behave under the influence of norms and situations.
8 Introduction to Diversity in Clinical Psychology

10.01.3.8 Honor do not like you) with cultures where people

respond with specificity.
Honor is a narrow syndrome, found in
environments in which property is mobile, 10.01.3.11 Ascription±Achievement
and thus individuals develop attitudes, values,
and behaviors that are designed to scare others, Parsons and Shils (1951) discussed cultures in
so as to ensure that their property is not taken which people judge others primarily on the basis
away from them. For example, cattle are more of ascribed attributes (e.g., sex, race, family
easily stolen than agricultural property, so that membership) with those which use achieved
people in cattle cultures are fierce, aggressive, attributes (e.g., has received this award).
hypersensitive to affronts, stress defense of one's
honor, and socialize their children to react to 10.01.3.12 Instrumental±Expressive
challenges more than occurs in agricultural
societies (Cohen & Nisbett, 1994; Nisbett & Parsons and Shils (1951) contrasted cultures
Cohen, 1996). Several kinds of studies support in which most interaction has instrumental
the view that the American South is high on this purposes (get task done) with cultures in which
cultural syndrome. Cohen, Nisbett, Bowdle, most interactions are expressive (friendship,
and Schwartz (1996) reported three experiments enjoyment).
where University of Michigan students from the
North or South of the US were insulted by a 10.01.3.13 Value Orientations
confederate. They reported that Southerners Kluckhohn and Strodtbeck (1961) identified
were more likely to think that their masculine several value orientations which may well be the
reputation was threatened, became more upset bases of additional cultural syndromes. Speci-
(as shown by the rise of cortisol levels), became fically, they identified societies where innate
more physiologically primed for aggression (as human nature is assumed to be (i) evil, neutral,
shown by testosterone levels), were more or good; (ii) mutable or immutable. When
cognitively primed for aggression, and more human nature is assumed to be evil, many rules
likely to engage in aggressive and dominant are introduced to control people and make them
behavior than students from the North. Cohen behave appropriately; when it is assumed to be
(1996) showed that this cultural syndrome was good there is a tendency towards minimal
reflected in social policies. An analysis of laws government; when it is assumed to be mutable
relating to guns, defense of self and home, institutions are created (e.g. educational sys-
corporal punishment, capital punishment, and tems) which can change them in the appropriate
attitudes toward foreign policy issues showed direction, but when they are assumed to be
greater approval of violence in the South than in immutable there is little support for such
the North. institutions.
While the Nisbett and Cohen research focuses (iii) Humans are assumed to be subjugated to
on the higher levels of honor found in the nature, in harmony with nature, or allowed to
American South than the North, extreme master nature. In cultures which emphasize
emphasis on honor can be found also in most mastery over nature, beliefs, attitudes, values,
of the Mediterranean societies, for example, and behaviors favor changes of the environ-
Corsica, the Serbs. Campbell's (1964) ethno- ment. Where harmony is emphasized, there is
graphy of a culture of Northern Greece (the more concern about not changing the environ-
Karakatzanoi) provides details of this syn- ment (e.g., the ªgreensº of the world). When
drome. subjugation is emphasized there are many
beliefs, attitudes, and behavior showing rever-
10.01.3.9 Universalism±Particularism ence for nature (e.g., in many Native American
Parsons and Shils (1951) contrasted cultures cultures).
where people categorize other people on the (iv) Varieties of time orientation, such as
basis of universal criteria, and cultures in which emphases on the past, present, or future. Time
people categorize other people by taking into orientation also differs because some societies
account their particular characteristics and the use linear time (e.g., the West) and others use
unique situation within which they are inter- circular time (e.g. the ancient Mayans). Mono-
acting with them. chronic use of time (i.e., people can carry out
only one conversation at a time) or polychronic
10.01.3.10 Diffuseness±Specificity use of time (i.e., people can carry out several
conversations at the same time) are also
Parsons and Shils (1951) contrasted cultures important cultural differences in the use of time.
in which people respond in a diffuse, holistic (v) The emphasis is on doing, being (the
manner (e.g., I do not like your report implies I experience), or becoming (growing, changing,
 Methodologies for the Study of World Views 9

improving). For example, in doing cultures, mon error is to take an instrument that has been
such as the US, a person's worth is measured by developed with middle-class mainstream under-
a record of accomplishments, income, previous graduates and use it with some ethnic group that
actions. In cultures which emphasize experi- is quite different from the standardization
ences, a person's worth depends on the sample, without any attempt to check the
experiences that the person has had. In cultures reliability and construct validity of the instru-
which emphasize becoming, the focus is in how ment in this new sample.
much and how fast the person is changing. Those wishing to do cross-cultural studies can
consult a more advanced text. The most
10.01.3.14 Dionysian vs. Apollonian Cultures complete one is the volume by Triandis and
Berry (1980). A shorter volume is by Lonner
Again this is a narrow syndrome focused on and Berry (1986). Special issues concerning the
the way people are expected to deal with equivalence of cross-cultural measurement, and
emotions. In Dionysian cultures they are taught the unstated assumptions that are made by
to express emotions. Loud speech is expected. people who collect cross-cultural data are
Beliefs that one should state a view by using discussed in Hui and Triandis (1985).
extreme language are common (e.g., as found Good cross-cultural research is like ordinary
among some Arabs), and attitudes such as the social research, only more difficult because of
positive evaluation of touching, kissing, close the complexity of the issues of translation,
positioning of the bodies, looking into the eye, equivalence of measurement, and the like.
and other behaviors are often associated with Those who want to do such research should
this pattern. become familiar with the writings of Campbell
The Apollonian pattern requires people to (1988), as well as the publications mentioned
control their emotions (e.g., East Asians), to above.
stand far from others, not touch, not look into A central issue in cross-cultural research is
the eye. Corresponding beliefs, attitudes, and whether we have a ªrealº cultural difference or
values support these behaviors. For example, it an ªapparentº difference due to an artifact or a
is impolite, and an indication of low social class, ªrival hypothesis.º For example, it may be that
to speak loudly. Related to the above pattern is: people in one culture respond to a particular
high contact vs. low contact cultures, which method of data collection differently from the
reflects high or low level of voice, eye contact, way people in another culture respond to it. In
frequency of gestures, touching, distance be- such a case we do not have a substantive finding
tween the bodies. Interrelationships of the but rather a finding that is best explained by the
syndromes. Since the concept of cultural way people react to the method of data
syndromes is relatively new, there has not been collection. Or, it may be that we have an
much research on their number or a clear apparent ªraceº effect, but careful examination
indication of how many syndromes there are or would reveal that it is a ªsocial classº effect.
how they are interrelated. To establish a ªrealº cultural difference we
In addition, there will be emic patterns, which need to eliminate all plausible ªrival hypoth-
will characterize each individual culture. To esesº (Malpass & Poortinga, 1986) that may
identify cultural syndromes it is necessary to do account for the observed difference.
research, based on the fact that syndromes Consider the following specific case. We
reflect shared psychological processes (see tested two samples and found a difference in
Triandis, 1996) to see exactly what cultural their level of anxiety. What are some of the
elements are to be included in each cultural plausible rival hypotheses?
syndrome. We need to develop reliable and (i) Anxiety may mean different things in the
valid methods for the measurement of cultural two cultures. The perceived antecedents of
syndromes, and then correlate these measure- anxiety may be different. For example, in one
ments to discover how the syndromes are culture it may be seen as caused by the prospect
related to each other. of lack of food and in the other by the possibility
of downsizing the corporations most people
10.01.4 METHODOLOGIES FOR THE work for.
STUDY OF WORLD VIEWS To eliminate this rival hypothesis one needs
to study the meaning of constructs, in the
The general perspective of this section is not relevant cultures, independently of their mea-
to teach the reader how to do cross-cultural surement. For example, one can ask samples of
research, but how to tell the difference between participants from the various cultures: What
a ªgoodº and a ªbadº study. I assume that makes you anxious? When you are anxious,
clinicians read the literature, but the literature what happens after that? Content analyses of
includes many ªbadº studies. The most com- the responses to such questions obtained in the
10 Introduction to Diversity in Clinical Psychology

relevant cultures can reveal both similarities and its own meaning in each culture, but it is unlikely
differences in the meaning of the construct. that an unsound hypothesis will be supported
Associations of events with anxiety, semantic with very different methods. It is especially
differential judgments involving the words important to replicate the study with both
ªFear,º ªAnxiety,º and their synonyms, can nonreactive (e.g., participant observations) and
result in an understanding of the these simila- more reliable (but usually reactive) methods,
rities and differences in the meaning of the such as tests or questionnaires.
concept. In sum, one must be skeptical about the
More generally, when we compare two equivalence of the meaning of concepts. For
cultures we are comparing entities that differ example, Diener (personal communication)
in a myriad of ways. The conclusion that the asked samples in different parts of the world
difference reflects a particular variable (e.g., whether they were ªhappy.º One respondent in
anxiety) requires that we ªcontrolº all the India said: ªI do not know; ask my husband.º
interactions of anxiety with other plausible In what follows I will identify some of the
variables. Furthermore, we need to sort out more obvious additional rival hypotheses which
which aspect of culture is the relevant one. For may produce an ªapparentº difference when a
example, in a comparison of African-Americans ªrealº difference is not present.
and White-Americans, we need to distinguish a (ii) The instructions may not be understood
difference due to race/color, per se, from the same way. This is especially likely if the
differences due to nutrition, social class, neigh- members of one culture have much less
borhood, historical influences, and so on. If all experience with a method or task than the
the observed differences are due to social class, it members of the other. Related to this variable is
is scientifically irresponsible to report them as the extent the two populations are familiar with
due to race. If both social class and race are the measurement method. For example, multi-
relevant, one must report that fact also. ple choice tests are widely used in the US and a
Since any two cultures differ in many ways, it measure which uses such a format can give US
becomes apparent that a two-culture compar- subjects an advantage over a population from a
ison will have almost no scientific value, since in country where such tests are not used.
science we want to find relationships among A special test which measures the ªunder-
well-defined, clear, reliably measured variables. standing of the instructionsº should be used
Suppose we want to check the relationship of routinely to eliminate this rival hypothesis.
nutrition to anxiety. Ideally (assuming we have Familiarity with the measurement format and
the funds), we should try to include a large content has to be equated. This can be done by
sample of cultures in our study that differ in using formats which are equally familiar (and
measurable ways on the nutrition variable. contents which have been pretested to be equally
Ideally, the cultures that we select should differ familiar) in the two cultures.
in many ways, except that they should be ranked (iii) The level of motivation to respond to the
on one clear variable, nutrition. Then the particular method of the two samples may be
countless other variables will not be system- different. Americans are likely to be motivated if
atically associated with nutrition, and we will be an experimenter tells them that their ªanxietyº
able to say something reliable about the will be measured to give an accurate response.
relationship of nutrition to anxiety (Leung, They may want to know ªtheir scoreº and how it
1989). compares to the scores of their peers. But in
Campbell (1988) makes a valid point: the other cultures, where ªanxietyº is perceived as a
comparison of any two cultures is essentially private matter not to be revealed to outsiders, or
useless (except for preliminary, hypotheses- where it is mandatory to lie to outsiders, or
generating work). This point requires us to where anxiety is conceived as something
study many cultures (a minimum of two ªhighº shameful, there may be strong motivation to
and two ªlowº on the variable of interest). The give an inaccurate answer.
more cultures we can include in our analyses, the Independent measurements of the levels of
better. Furthermore, we must select cultures motivation should be used to eliminate this rival
which are similar on the variable of interest but hypothesis.
very different on all other variables, because of (iv) The reactions to the experimenter may be
the phenomenon of cultural diffusion. It is well different. For example, in some cultures it is
known that cultural elements are copied in against the norms to cooperate with ªout-
adjacent cultures. If there is a lot of diffusion we siders.º In some cultures it is mandatory to ªlieº
do not have two independent cases, but actually to outsiders or trick them! In such cultures
only one case. villagers compete among themselves in telling
In addition, we must replicate the study with lies about their culture, and later discuss among
many different methods, since each method has themselves what lies they told and laugh at the
 Methodologies for the Study of World Views 11

researcher for having believed their lies. To (viii) The ethical acceptability of the method
overcome such difficulties it is necessary to use may not have been the same in the various
several researchers, some ªinsiders,º and some cultures. For example, in some cultures some
ªoutsidersº to obtain some estimate of the samples (e.g., women) are not supposed to have
importance of this factor. an opinion, let alone an opinion which is
(v) The meaning of the test situation is not different from their husband's. If one asks about
always the same. For example, in some studies that opinion, people can become embarrassed
(Bond & Yang, 1982; Bond & Cheung, 1984; or angry because the experimenter ªdaredº to
Yang & Bond, 1980) the language of the ask such a question. Pretests are needed in
instructions influenced the results. When in- which samples are asked after the pretest ªwhat
structions were given to Hong Kong subjects in did you think about this method?º It is useful to
Mandarin, Cantonese, or English, the results use a set of scales (such as good vs. bad, active
differed. Apparently, the language of the vs. passive, strong vs. weak) for the subjects to
instructions suggested to the subjects who was rate the test situation itself (was the test
interested in the results of the studyÐthe Beijing situation pleasant or unpleasant?) One of these
authorities, the Hong Kong authorities, or the scales could be moral vs. immoral. If the study
British colonial authorities. appears moral in one culture and immoral in the
(vi) Response sets differ across cultures (Hui other, it would be necessary to investigate the
& Triandis, 1989; Triandis, 1972). For example, matter further, before collecting much data.
in some cultures if one is ªsincereº one gives a It is clear from the above that there are many
strong answer (e.g., ªI strongly agree.º), but if ways in which a difference may appear. A
one is not sincere, one might use the middle of a difference is easy to obtain across cultures, but
Likert scale. In Japan it is arrogant to use an the question is: Is the difference a substantive
extreme response, and it is appropriate (modest, finding, or is the apparent difference due to
polite) to use the middle of the scale (ªperhaps I something which is indirectly associated with
agree with itº). In some cultures people only the measurement? We can never be sure that we
answer the questions which they are absolutely ªcontrolledº all rival hypotheses, so any con-
sure of; in others, they answer all the questions. clusions about cultural differences must remain
Marin, Gamba, and Marin (1992) found that tentative.
Hispanics in the US, relative to non-Hispanics, The discussion presented above does not
are more likely to use extreme responses (e.g., I mean that we must reject all forms of measure-
strongly agree) and to show acquiescence (agree ment. One can control statistically variables
with every question). The more acculturated which are correlated with the dependent vari-
(spent a lot of time in the US, are comfortable able of interest. For example, if there is a
when using English) the Hispanics are to the response set, one way to control it is to
US, the less they do that. In some cultures ªstandardizeº the data statistically. One method
people are expected to agree when asked is to standardize the data obtained from a single
questions; in others they are expected to participant (within participant standardiza-
disagree when asked questions by ªoutsiders.º tion), thus eliminating individual differences,
(vii) The samples, in the relevant cultures, but focusing of cultural differences. If one is
may not have been strictly equivalent. For interested in individual differences, the best
example, there might have been differences in strategy is to measure them within culture, not
social class, age, sex, religion, or some other across cultures.
demographic attributes which are the ªrealº
cause of the difference, yet the difference is
attributed to language/culture. One should 10.01.4.1 Some General Strategies
analyze the data separately for each demo-
graphic category. Furthermore, the two popu- When studying a phenomenon across cul-
lations under study may not be stable over time tures it is highly desirable to work with local
(e.g., sampling in 1960 and assuming that the social scientists who understand their culture.
results apply in 1999 may well be an error). Such scientists are likely to insist that culture-
When a population is heterogeneous, sampling specific aspects of the phenomenon be included
in one area and hoping that the results are valid in the study. Measurement can be made
in another area (e.g., sampling in New York and sensitive to the cultural context. Interpretation
assuming that the results apply to the whole of of the results can be much more sound when the
the US) may be misleading. For that reason, perspectives of many cultures are used during
ideally, one should obtain samples in different data interpretations.
parts of a country, and from different occupa- In addition, it is necessary to use more than
tional, sex, and age groups, and check the one method because each method has a different
consistency of the findings across these samples. meaning in each culture. If the results of several
12 Introduction to Diversity in Clinical Psychology

different methods converge, it is unlikely that looking for evidence that this extra work,
the same bias accounts for all the results. checking, and elimination of rival hypotheses
One must also do separate ªconstruct was actually undertaken by the researcher.
validationsº within each culture. In a construct
validation, one has a theory and tests the theory. 10.01.4.3 Methods that Can Establish
If the data hang together the way the theory Measurement Equivalence Across
predicts, then both the theory and the measure- Cultures
ments of the constructs must be valid.
Suppose you have a theory which predicts Several methods may be used to establish
that there are certain ªantecedentsº of anxiety in cross-cultural equivalence.
every environment and certain ªconsequences.º (i) Suppose one has measured several vari-
If you measure anxiety with different methods in ables in each culture and submits the correla-
each culture and you find that the correlations tions among these variables to a factor analysis.
between your measures of anxiety and the If the same factor structure appears in each
several antecedents and consequences specified culture (e.g., Tucker coefficients of 0.90 + for
by your theory are approximately the same in all each factor) that is one indication that the
cultures, then you have validated your measures variables have the same meaning in the relevant
in those cultures. If the patterns of correlations cultures.
are similar, and if certain statistical tests (ii) Item response theory (Hulin, Drasgow, &
(discussed by Irvine & Carroll, 1980) indicate Parsons, 1983) provides a statistical procedure
that the measures are equivalent, then you can which indicates if a particular item has the same
compare the results across the cultures. meaning in two or more cultures. The procedure
is based on the similarity in the way people
10.01.4.2 Good Theory Can Eliminate Some respond to that item and to all the other items.
Rival Hypotheses (iii) Psychophysical methods allow some
physical variable (e.g., distance between physi-
If one has a well-developed theory that makes cal objects) to be linked to a psychological
several predictions, and the theory is supported variable (how do you feel about social entities)
by the data, some of the rival hypotheses become (for an example, see Triandis, McCusker, &
less plausible (Malpass, 1977). Suppose my Hui, 1990).
theory predicts that in a collectivist culture
people will be low in anxiety when they are with 10.01.4.4 Emics and Etics in Cross-cultural
members of their ingroups and higher in anxiety Research
when they are far away from their ingroups. In
an individualistic culture my theory predicts no I introduced above the idea of etic (universal)
difference when the individual is tested when and emic (culture specific) cultural elements.
with or away from members of the ingroup. Here I will elaborate on the meaning of these
Suppose I collected data in rural China and constructs and explain how they might be used
rural America and I found what I predicted. In in the measurement of constructs.
that case many of the rival hypothesesÐ Emics, roughly speaking, are ideas, beha-
different definitions of the constructs, different viors, items, and concepts, which are culture-
levels of motivation, response setsÐbecome less specific. Etics, roughly speaking, are ideas,
plausible. behaviors, items, and concepts which are
This does not mean we should not worry culture-generalÐthat is, universal.
about rival hypotheses when we have good Emic concepts are especially useful in com-
theory. Clearly, if the theory and a rival municating within a culture, where one word
hypothesis make the same predictions, we can sometimes be used to convey a very complex
cannot use the theory to eliminate that rival idea. For example, a geographer who has
hypothesis. But in many cases the theory and the studied the inhabitants of the Tierra del Fuego
rival hypothesis will make different predictions in the Southern tip of South America, told me
and then if the data support the theory that is that they have a word, mamihlapinatapei, which
reassuring. means ªlooking at each other hoping that either
The main point to remember from this one will offer to do something that both desire
discussion is that cultural comparisons which but are unwilling to be the first to do.º
indicate a cultural difference require a lot of One can almost see the scenario when boy
work, checking, elimination of rival hypotheses, meets girl and they mamihlapinatapei! One
multimethod measurements, and the like, learns quite a bit about that culture by knowing
before the presence of cultural difference the definition of this word. Similarly, by
becomes plausible. As a sophisticated consumer learning particular words, we get to know more
of cross-cultural research, the reader should be about a culture.
 Methodologies for the Study of World Views 13

Emic concepts are essential for understanding someone showed me a convincing study, with
a culture. However, since they are unique to the hard criteria, which indicated that this view is
particular culture, they are not useful for cross- correct.
cultural comparisons. ªConstructionismº can result too easily in an
Let us consider an analogy, the comparison of image of reality which is found in only one
apples and oranges. Apples and oranges have person's mind. It might be good literature, but it
some common attributes, such as size, weight, is terrible science. The essence of science is a
price, and availability. They also have some conversation between scientists and nature. It
unique attributes, such as unique flavor and requires probing with multiple methods, to
aroma. Clearly, if we are going to understand replicate important findings, and establish
what an orange is, we need to know about convergence between observations and mea-
orange flavor. But we can not compare apples surements. If such convergence is broad, that is,
and oranges on orange flavor, except to say that includes humanistic ªfindingsº as well as
apples do not have it. On the other hand, if we findings obtained through scientific methods,
want to talk about price, we can compare apples we can be much more certain that we have
and oranges. If we want to compare price to size identified an important phenomenon than if we
or weight we can certainly do that, too. So, we have only one person's argument or a single set
can have a ªtheoryº of size±weight±price of findings obtained in one place, with only one
relationships and see if it holds as well for method. An important distinction between the
apples as it does for oranges, and we can even humanistic and the scientific method is the
extend it to other fruits. Emics are like apple or contrast between the subjective and the objec-
orangeflavor; etics are like size, weight, and tive. If the humanistic insight is to be taken
price. So, for certain purposes, such as seriously it has to converge at some point with
comparisons, we must use etic concepts; for other evidence; it cannot remain entirely
other purposes, such as getting a real ªtasteº of subjective.
the culture, we must use emic concepts. If we take a construct generated in our culture
More formally, emics are studied within the and use it in another culture, we may have a
system in one culture, and their structure is pseudoetic (false etic) construct. We must get
discovered within the system. Etics are studied empirical evidence that the construct operates
outside the system, in more than one culture, the same way in the other culture, that is, it is a
and their structure is theoretical. To develop true etic, before we use it to compare the
ªscientificº generalizations about relationships cultures. Remember the discussion about con-
among variables, we must use etics. However, if struct validity above? That is what needs to be
we are going to ªunderstandº a culture we must done to establish a true etic. Then we have to
use emics. make sure that this etic construct is measured in
Many anthropologists work with emics and ways that are culturally sensitive. That often
think that etics are silly. They would say: ªyou requires the use of local terms and ideas. In
do not know about apples by just knowing short, we must use both etic constructs and emic
about their price, weight, and size.º Psycholo- ways to measure them. That is why cross-
gists want to make generalizations about people, cultural psychologists advocate the use of both
so they do not want to get into the details of a emics and etics (Berry, Poortinga, Segall, &
single culture. Cross-cultural psychologists try Dasen, 1992; Triandis, 1972, 1992).
to both understand and compare cultures. They One advantage of such a strategy is that one
work with both emics and etics. can obtain more sensitive information about the
The important point is to find convergence relevant cultures, which implies that one can
between different methods of understanding obtain more cultural differences if one uses both
reality. I do not agree with the view expounded emics and etics in the design of cross-cultural
by some ªdeconstructionº humanists, or even studies. In one study (Triandis & Marin, 1983),
some who pretend to be scientists, who argue samples of Hispanics and non-Hispanics re-
that nature is constructed, not discoveredÐthat sponded to either a questionnaire based on ideas
truth is made, not found (e.g., Haraway, 1991). I generated in previous studies with American
think that this is an extreme position which is samples (pseudoetic) or a questionnaire which
not science, since it cannot be discomfirmed. On used ideas obtained from focus groups (in-
the other hand, I do grant that our subjective formal discussion groups which generated items
responses to reality are often constructed. I am a to be used in the questionnaire) of Hispanics
realist, so I do not believe that women are less and non-Hispanics. The latter questionnaire
good as Chief Executive Officers (CEOs), just included both emic items which were sponta-
because that is the male-dominated ªconstruc- neously generated only by the Hispanic focus
tionº and conventional wisdom of current groups and etic items which were generated by
CEOs. But I would agree with this view if both the Hispanic and non-Hispanic focus
14 Introduction to Diversity in Clinical Psychology

groups. Since the questionnaires in that study 10.01.4.5 How to Use Emic Measurements of
had 600 questions, one could get six cultural Etic Constructs
differences by chance (at the 0.01 level of
significance). The number obtained by the Any theoretical construct of some generality
pseudoetic questionnaire was 14 and the in psychology is likely to have both etic and emic
number obtained by the emic plus etic ques- aspects. For example, the concept of ªsocial
tionnaire was 50. In other words, one can miss a distanceº makes sense in every culture, and even
lot of subtle information about the way cultures among animals where territoriality is a well-
differ if one does not use emics. established phenomenon. You allow some
The importance of emics cannot be over- people to come close while you keep others
estimated. There are emic concepts that are away from you. The original concept, developed
extremely difficult to understand by people who by Bogardus (1925), was operationalized by
use an etic framework. asking people if they would like to ªmarry,º
Consider this example: What is a geisha? ªlive in the same neighborhood,º ªexclude from
Most Westerners are likely to freely associate the country,º etc. certain groups of people. It
ªprostituteº with that concept, and as a result was found that Americans, in the 1920s, showed
they will be quite wrong. A 500+ page little social distance toward Western Europeans,
ethnography about geishas (Dalby, 1983) shows especially those who came from the UK, and
that the closest association to ªgeishaº should much social distance toward ªNegroes,º
be ªjester.º Just like the jester in a king's court ªTurks,º and ªJews.º
had the function of diverting the king and his While the social distance concept is etic, the
guests, so a geisha has as her chief function way it is operationalized can vary with culture.
entertaining the clients of an establishment. In India, the idea of ªritual pollutionº results in
Most geishas spend their time reciting poetry, social distance, and while a person may not
singing, dancing, and serving their clients while mind living in the same neighborhood with a
they eat and drink. member of the lower castes, especially if that
Furthermore, there are many kinds of person is a servant, one can mind very much if
geishas, and only a minority are actual that person ªtouches my earthenware.º Thus, in
prostitutes (yujo). Most do other things, India, social distance is indexed differently.
including greeting people at the door or playing Touching earthenware is an Indian emic; social
musical instruments. The most highly sought distance is a theoretical concept, an etic.
geishas are older, more experienced, and thus Let me give you an example of how to use
able to act more appropriately. President Ford, emic items to measure etic constructs. In a study
the first US President to visit post-war Japan, I did a long time ago (Triandis & Triandis, 1962)
had dinner with several geishas as part of his I asked focus groups to generate items which
touring experience. The most beautiful were measure social distance in Athens, Greece, and
placed next to him; but the ones who did most of in Champaign, Illinois. I obtained at least 100
the entertaining were the older, more experi- ideas from each sample. I then subjected the
enced ones. Of course, without knowledge of items to Thurstone scaling, which eliminates
Japanese, President Ford may not have been items which are ambiguous in each culture, and
able to appreciate the entertainment. provides scale values for each item on an equal
The contrast between ªgeishaº and ªwife,º in interval scale. I found that some items were etic,
terms of the free associations of these words for example, ªI would accept this person as an
among Japanese males, is instructive. The intimate friendº had a scale value of 11.1 in the
former is seen as sexy, artistic, witty, and US, and ªI would accept this person as a best
economically self-sufficient; the latter as sober, friendº had a scale value of 13.5 in Greece. But
humdrum, serious, and economically depen- ªI would accept this person as a roommateº was
dent. The former is likely to be well read, know an American emic, with a scale value of 29.5. ªI
the latest poems and songs; the latter is likely to would accept this person as a member of my
talk about the problems of the children. pareaº was a Greek emic, with a scale value of
Now that you have a glimpse of the meaning 31.1. Parea means, roughly, regularly-meeting
of geisha, do you see that it is a culturally peer group. Thus, these two items mean more or
specific role, that corresponds to an emic less the same thing, but the American item does
Japanese term, and the Western view that she not make sense in Greece, and the Greek item
is a ªprostituteº is a pseudoetic, and becomes a does not make sense in the US. The method
true etic only when it uses the idea of ªjester?º allows for culture-sensitive measurement, since
The general point is that using our own emic Greeks rarely live in residential quarters in
terms to understand other cultures will generally college, and thus rarely have roommates, while
result in misunderstandings. We need to obtain Americans are used to that concept. On the
etic terms which correspond to the emics. other hand, Greeks do have regular-meeting
 Methodologies for the Study of World Views 15

peers and a term for that. ªI would accept this operationalized and measured differently in
person as my family's friendº had a scale value each culture, because behavior has different
of 40.9 in the US and 24.0 in Greece, indicating meanings in each culture (Triandis, Vassiliou, &
that while that item makes sense in both cultures Nassiakou, 1968). Those interested in a more
it implies much less social distance in Greece detailed discussion of this approach may find
than in the US. It apparently was more Triandis (1992) useful.
significant to be a friend of the family in Greece
(a collectivist culture at that time, where the
family was the most important social group) 10.01.4.5.1 General recommendations
than in the US. Similarly, ªI would rent a room
from this personº implied less social distance in In summary, for good cross-cultural work we
Greece (42.8) than in the US (57.5). On the other must start with the theoretical construct and
hand, ªI would exclude this person from my discuss it with local informants to see how it is
countryº had about the same meaning (95 in best operationalized. It is then useful to use
US, 82.6 in Greece). ªfocus groups,º that is, small groups that do
Thurstone scaling uses judges to obtain the some brainstorming, and come up with around
scale values of the items. The judges examine 100 ideas about how to measure the construct.
each item and place it on an 11-point scale, While these ideas will probably be different in
according to how much social distance is each culture, the chances are that some of them
implied when a person agrees with that item. will be generated in both cultures.
About 30 judges seem to be sufficient for each Next, we should take each of these 100 ideas
culture. The distributions of the 30 judgments and ªscale themº separately in each culture.
concerning each item are examined. When these This means local standardization of the items.
distributions are broad or bimodal, the item is The technique developed by Thurstone (1931)
rejected because it is ambiguous, or does not (see, Edwards, 1957, Chapter 5) seems most
measure the quality of interest. These judgments helpful, but other scaling strategies may also be
are then treated statistically to obtain the scale useful. With this method a small set of 15 or so
values for each item. In this case the top and scaled items can be identified in each culture
bottom of the scale were called 100 and zero for that have been locally standardized but link to
easy comprehension. the etic continuum under study.
When the actual people are studied, the items This method provides excellent locally stan-
of the social distance scale are presented to them dardized and equivalent equal-interval scales in
in a scrambled order. They are asked to pick the two cultures. Then the 15 items are
three statements which best represent how they scrambled and presented to the subjects under
would act toward a particular stimulus person, study in each culture with the instructions:
for example, a ª50-year-old unskilled Chinese ªPick three of the following 15 items which
laborer.º The respondent's social distance is the describe your most likely behaviors toward (the
average social distance value of the three items social category of interest).º
which were endorsed. One can generate stimuli
systematically, by varying, for instance, the age,
nationality, and occupation (or whatever one is 10.01.4.6 Examples of Multimethod
interested in studying) of the stimulus person Measurements
and then obtain the social distance each We have already emphasized the desirability
respondent feels toward that stimulus combina- of using multimethod measurements in cross-
tion. This allows the researcher to do analyses of cultural studies. The following list of methods
variance that show the relative importance of suggests the range of possibilities.
the attributes, such as age, nationality, and
occupation, as determinants of the social
distance judgments. Note that the data come
10.01.4.6.1 Ethnographic work
from the scale values of the statements that have
been generated and standardized in each culture This is based on observations, with some
separately. So, the fact that the statements have questioning of informants and occasionally an
different scale values in different cultures does experiment or survey (see Goodenough, 1980,
not produce a problem. They are emic values, for details). In such work an anthropologist
but the construct is etic, allowing cross-cultural spends one or two years among a group of
comparison. people as a participant observer. After learning
The same strategy can be used with most the local language, the scientist becomes a
concepts and any attitude. Concepts may have a member of the culture, and often assumes one of
universal meaning that most researchers under- the existing roles within the culture (e.g., the
stand the same way, yet they must be chief's son). After that, observations can be
16 Introduction to Diversity in Clinical Psychology

done informally or formally (see Longabaugh, Kong/Illinois study did that and convergent
1980, for details) using video tapes or films validity was obtained.
which are later coded by several coders to Another strategy which takes seriously the
establish inter-rater reliability. fact that culture consists of shared elements is to
examine the distributions of the responses of
people from each culture to any psychological
measure. If an arbitrary 90% of the respondents
10.01.4.6.2 Establishing shared cognitions
give the same answer, that is a cultural element.
This approach includes the measurement of a Clearly, the identification of cultural elements is
psychological construct with several methods in important in studying cultures, but is of little
each culture, and checking if the measurements interest when the focus is on individual
converge. However, it is important to be able to differences. The two strategies are quite differ-
distinguish a psychological from a demographic ent. When studying individual differences we
or cultural construct. Culture consists of shared should do it within culture.
elements. When we measure a psychological Interviews and surveys are often used (Pareek
construct we do not know if it is shared so it may & Rao, 1980). Some of these are informal and
or may not be part of culture. allow for questions to be asked as the interview
Triandis, Bontempo, Leung, and Hui (1990) proceeds, while others follow a rigid schedule.
have developed a method which allows a These interviews can be based on limited or
researcher to sort the personal, demographic, representative samples of the culture.
and cultural constructs. The basic idea is to have One might also use tests (Irvine & Carroll,
triads (three respondents) hear a question and 1980), attitude scales, personality scales, pro-
answer it while the time it takes for them to agree jective tests (Holtzman, 1980), and psychophy-
on the answer is measured. Cultural elements do sical tests.
not require debate. For example, if you ask three Experiments can be done in more than one
Americans whether ªfairnessº is important or culture, but they present special difficulties (see
unimportant in everyday life, they are likely to Brown & Secrest, 1980; Ciborowski, 1980). For
supply a ªYesº in less than two seconds, and example, it is extremely difficult to ensure that
over 90% of the triads which are tested will the same degree of manipulation of the
agree. But if you ask: Is ªfameº important or independent variables has been used in each
unimportant, they engage in a debate. Being culture.
famous is not a widely shared element of However, some interesting results can be
American culture; some want to be famous obtained when the same experimental proce-
and others do not. For those who want to be dure is used in each culture. Strodtbeck (1951)
famous this is a personal construct. provides an interesting example. He examined
Using these two criteria (length of time to whether culture is related to the probability that
respond, percent of the triads who agree), the the wife or the husband will ªwinº an argument.
researchers can pick those elements of the He tested 10 husband-wife pairs in each of three
culture which are widely shared. cultures: Navajos (where the custom was for the
This study was done in Hong Kong and husband to live with his wife's relatives, and
Illinois as a demonstration of what can be done hence one might expect husbands to have less
to measure cultural elements. The same could be power), Texans, and Mormons (where tradi-
done with demographic elements (men vs. tional male supremacy was used). The study
women, old vs. young, rich vs. poor) by began by asking each spouse a number of
assembling appropriate triads and measuring questions separately. The researcher noted on
how much time it takes for them to agree on how which questions the spouses disagreed. He then
to answer a question, and what percentages of put them together and tape-recorded their
the triads do agree. Also, this study was limited interactions while they discussed their answers
to ªvalues,º but it could be done with any to the questions and attempted to reconcile their
element of subjective culture. differences. If the couple finally agreed with the
Unfortunately, this method is participant- husband's original position, that indicated
intensive. To have 50 triads, which is not an husband dominance; if the couple finally agreed
especially large number for a somewhat hetero- with the wife's original position, it indicated
geneous culture, 150 people are needed in each wife dominance. The results were as follows:
culture.
It is possible to compare the data of this Number of decisions ªwonº by
method with the results obtained by questioning Husband Wife
one person at a time with other methods. If the Navajos 34 46
results are similar, one has evidence about the Texans 39 33
convergent validity of both methods. The Hong Mormons 42 29
 Methodologies for the Study of World Views 17

The hypothesis was supported. Culture predicts content analyses are operant techniques. In
who wins, with the Navajo more likely to agree most cases the researcher does nothing to
with the wife and the Mormons with the stimulate the production of the data. In some
husband. cases a minimal stimulus, such as ªPlease write
Finally, I will mention two methods which 20 statements which begin with the words `I
can obtain data from texts or other kinds of am,'º is provided.
published materials: By contrast, experiments, surveys, and inter-
(i) Content analyses (see Brislin, 1980) of views are ªrespondentº methods; the subject is
children's stories, newspaper stories, myths, responding to stimuli presented by the re-
formal and informal communications, speeches, searcher.
or movies produced in several cultures have Respondent methods are more obtrusive, and
been used to measure attitudes, motives, they are more likely to be distorted by reactivity.
opinions, values, and other attributes. For The respondents are more likely to distort their
example, one rates the materials on two answers, so they will appear to be socially
variables and sees if the ratings are correlated. desirable people to the researcher, their peers,
(ii) The human relations area files (Barry, the authorities in their culture, or from the point
1980) is a very useful data set. It consists of of view of their culture's ideal. In short,
photocopies of much of the world's ethno- respondent methods are more likely to result
graphic record classified alphabetically accord- in cultural differences due to the method.
ing to the content of each paragraph. Thus, for However, it is easier to ªcontrolº artifacts, when
instance, a researcher who is interested in using respondent methods because the study can
checking if the ªage of weaningº of a child is be replicated under a variety of conditions.
related to ªlevel of anxietyº in the culture's adult Operant methods are generally less reliable.
population would look in the files under Many observations or responses are obtained
ªweaningº and would find the ages of weaning and it is not clear which ones are the most
which were reported by ethnographers who had important. Operant methods also have a high
studied several cultures. Similarly, this research- ªdross rateº (irrelevant information is a high
er would find some categories which might proportion of the total information obtained).
index the extent adults in the culture are high or Furthermore, the observer may be biased and
low in anxiety. Then the researcher would either only see or hear what is consistent with a
plot the data, or use correlations or chi-squares hypothesis.
to check the relationship of age of weaning to Both kinds of methods should be used at
anxiety. different points in the research sequence. At the
Of course, ethnographies do not include every initial stages of the research, when one knows
type of information, so it may be that there is no little about the culture, lacks good hypotheses,
information relevant to anxiety in a particular and is dealing with respondents who are not
culture. The result is ªmissing data.º familiar with social science methodologies, it is
In these analyses the number of cultures is the best to use operant methods. Such methods are
number of observations on the basis of which especially good when investigating complex
the correlation is computed, or N cultures are relationships. These relationships can be kept in
classified as ªhighº or ªlowº on each of the mind while making additional observations.
variables to compute the chi-square test. In However, since these methods are not suffi-
other words, one can establish an association ciently reliable, and are difficult to check for
between two variables, based on holocultural reliability and validity, one should not reach
data (all cultures on which there is information; definitive conclusions by using only these
see, Naroll, Michik, & Naroll, 1980 for details). methods. Rather, it is best to refine existing
hypotheses, develop new ones, and keep an
open mind about the culture while using them.
At a later stage in the research process when
10.01.4.6.3 Conclusions
more is known about the culture, the hypotheses
It is ideal to test a hypothesis with as many of are more likely to be supported and then it
these methods as feasible. Some of these might be possible to design experiments,
methods are ªoperantº in the sense that the questionnaires, and interview schedules which
researcher provides a minimal stimulus and the are appropriate for the problem. It also helps if
subjects provide many responses (operate on the the participants are familiar with the research-
stimulus as they see fit when responding). For er's methods, since they may then be more likely
example, sentence completion or projective to give the same meaning as the researcher to the
techniques, ethnographies and the human testing situation.
relations area files, observations, unobtrusive In other words, no method is perfect; each
measures (see Bochner, 1980, for details), and method has both advantages and disadvan-
18 Introduction to Diversity in Clinical Psychology

tages. The sophisticated consumer of cross- are requested not to have children in the bar.º
cultural research will give more weight to At the office of an Italian physician: ªSpecialist
findings which have been supported by more in women and other diseases.º A Japanese hotel
than one method, particularly if the methods air conditioner: ªCools and Heats: If you want
were very different. just condition of warm in your room, please
Separate tests of hypotheses within cultures control yourself.º
and between cultures, and with more than one In short, one can make the case that
method, increase the confidence in any finding. translation should be avoided. But that is not
However, we must not assume that a test at always practical, so a word about translation is
the between cultures level will necessarily give necessary.
the same results as a test at the within cultures Translation of single words is unwise. It is
level. For example, consider the variable extremely difficult to establish exact equivalence
ªdegree of industrializationº and correlate it in meaning for single words. Only if the study
with the variable ªprobability that a worker will focuses on the meaning of single words and uses
vote for the communist party.º In India and the several methods to tap that meaning is transla-
US, there is a greater probability of a commu- tion of single words acceptable.
nist vote in a highly industrialized voting district The greater the context of a text, idea, or
than in a less industrial one. In other words, concept, the more likely it is that it can be
within countries there is a positive relationship translated properly. If one expresses an idea in
between the variables of interest. But when we more than one way, translation has a chance of
compare the two countries we see a negative reaching linguistic equivalence. Thus, it is
relationship between these two variables. In the helpful to introduce redundancy, synonyms,
US there is a higher level of industrialization and context.
and also a low probability that anyone will vote Brislin (1980) provides many useful sugges-
for the communist party; in India, there is less tions on how to maximize linguistic equivalence.
industrialization, but a relatively high prob- A good approximation to the ideal translation
ability that a worker will vote for the commu- uses the Werner and Campbell (1970) method of
nists. In short, there is a reversal of the sign of double translation with decentering. This
the relationship between the two variables when method is based on the realization that there
we study the phenomenon across vs. within are many ways to say the same thing, and careful
cultures. adjustments to the original language of the
This means that while we should do our research project may not produce any difficul-
analyses at both the between and within cultures ties for the research but may facilitate the
levels, we need not become discouraged when translation.
these results are inconsistent. Of course, con- For example, the researcher starts with an
sistency boosts our confidence that the relation- English text (E), and asks a bilingual to translate
ship is robust. There are examples (see Rohner, it into Japanese (J). Then, he/she asks another
1986; Schwartz, 1994) in which a hypothesis has bilingual to translate it back into English to
been tested at both levels and was supported obtain E'. A comparison of E and E' indicates
consistently. where problems may exist. If the discrepancies
of E and E' are significant, the researcher can
ªdecenterº the text by producing a new text (E@
10.01.4.7 Translations which is satisfactory for the purposes of the
research, but is closer to E' than to E). Such a
It is ideal to gather the data in each culture text is likely to translate into Japanese more
independently by using the same procedures but easily, since E' was an English version of a
without translation of specific items. This view Japanese text. The process of translation, back-
is supported by the realization that translation is translation, and decentering continues until two
at best approximate. English texts emerge that are more or less
There are some hilarious examples of poor identical.
translation that suggest how difficult it is to Back translation seems like a good way to
translate. For example, outside a Hong Kong obtain linguistic equivalence but it has pro-
tailor shop: ªLadies may have a fit upstairs.º In blems. First, many words in languages of the
a Greek tailor shop: ªOrder your suits here; same language family (e.g., Indo-European
because of a big rush we will execute customers languages cover a wide area from India to
in strict rotation.º An Italian laundry: ªLadies, Europe to the Americas) have the same roots
leave your clothes here and spend the afternoon but different meanings. For example, in the
having a good time.º In a Japanese hotel: ªYou Latin-based languages, the term sympatique or
are invited to take advantage of the chamber- simpatico means ªpleasant or agreeable per-
maid.º A Norwegian cocktail lounge: ªLadies son.º In English sympathetic means ªsomeone
 Methodologies for the Study of World Views 19

who feels like the other person does.º Clearly, ethical. Unfortunately, not all researchers carry
the meanings are not the same. Yet, bilinguals out their work ethically. Some study what is
are apt to translate it and back-translate it into easy to study, and as a result we know a lot more
the original language when in fact the transla- about the disadvantaged than the advantaged
tion is not correct. segments of most cultures. When two groups are
Second, skilled bilinguals are good at imagin- in conflict and a researcher offers to study the
ing what the original text might have looked conflict, the weak are more likely than the
like. So, suppose a Japanese text is being strong to accept the study. The powerful do not
translated, the interpreter may be able to guess submit to research very easily; that means our
what the original E or E' was and produce an E@ picture of the powerful members of a culture
which is just like it. The researcher would be may be distorted.
reassured, but the translation is imperfect. In Some researchers do not provide their
short, while back-translation is desirable, it does subjects ªinformed consent.º Ethical research
not guarantee linguistic equivalence. requires that the participants are able to avoid
One technique which is useful, continuing participation in studies they consider unethical
with our example of English and Japanese, is or disadvantageous to them. But in many
administration of both the English and Japa- nonliterate societies the concept of ªresearchº
nese version of a questionnaire to a sample of is nonexistent, and it is impossible for the
Japanese bilinguals. In such a case one can prospective participants to provide meaningful
compare the responses of the same person when informed consent.
answering in the two languages. This can With most operant methods the chances are
provide a check on the translation, since the that people will not be exposed to stress or risks.
same answer would indicate good translation. But with respondent methods some risks can be
However, even this technique is problematic significant. If risks beyond those of ordinary life
because bilinguals have a tendency to present are involved in a research method it is essential
themselves in a more socially desirable way to that the risks be explained to the individuals,
ªoutsidersº than to ªinsidersº (Marin, Triandis, and they should have the opportunity to decline
Betancourt, & Kashima, 1983). Thus, it is likely participation. This, of course, produces other
that a Japanese bilingual will present a more problems, such as distorted samples consisting
favorable set of answers when answering in mostly of volunteers. Nevertheless, if risk is
English than when answering in Japanese. involved the subjects must be informed.
In sum, to be safe do not translate. Basically, Since risk is perceived differently in each
you can carry out the same data gathering culture, it is important to bring research
operations in each culture, and the only text that collaborators into the decision-making process
needs to be translated is the instructions, which at the earliest points of a project. If a method
usually have a good deal of context. Then, which appears risk free in one culture is not risk
standardization is done separately in each free in another, the method may have to be
culture. Comparison of distributions, computa- changed. There are many ways to collect data,
tion of Tucker coefficients of the factor so it does not follow that because we changed
structures that emerge from the correlations the method we cannot test an important theory.
of the variables of the study, item response There are special problems of research
theory checks, etc. can be done to establish collaboration across cultures that are discussed
equivalence before any comparisons are made. in detail by Tapp, Kelman, Triandis, Wrights-
Finally, studies which report a large number man, and Coelho (1974). For example, research
of cultural similarities, and show the cultural collaborators may be harmed by collaborating
differences as being embedded in these simila- with someone from a culture that is politically
rities, are more dependable than studies which taboo in their country. It is generally believed
do not report similarities. If all the data from that researchers must leave something of value
one culture is different from all the data from in the culture they studied to avoid ªintellectual
another, it is very likely that the tasks were not colonialism.º What is of value will, of course,
communicated adequately from one culture to vary with culture but it can be information,
another, and the cultural differences are due to procedures, material goods, or payments.
some artifact.

10.01.4.9 Ethnocentric and Androcentric Bias of

10.01.4.8 Ethics of Cross-cultural Studies Researchers
The sophisticated consumer of cross-cultural Most cross-cultural researchers are Western
research will want to see that the research has men; we all have difficulties in escaping our
been carried out ethically. Good research is ethnocentric (my culture is the standard of
20 Introduction to Diversity in Clinical Psychology

comparison) and androcentric (my gender superpunctual in a culture where ªtime is

offers the only valid perspective on an issue) money.º
biases. We can try to control such biases, but the However, migrants who are rejected some-
choices of problems, theories, and methods are times react to the culture contact by emphasiz-
likely to reflect such biases. For example, we ing their own culture (ethnic affirmation). For
cannot be sure that we have controlled such example, they may become even more flexible
biases when we evaluate whether or not gender about their use of time, and advocate that one
inequalities are similar or different across should not own a watch, or bother to be on time,
cultures. Thus, when evaluating cross-cultural because that reduces one's freedom and makes a
research it is wise to ask whether such biases person like an automaton.
may have colored the reported findings, inter- A complication is that in some domains
pretations, and conclusions. A useful way to people show accommodation or overshooting,
overcome such biases is to collaborate with and in other domains they show ethnic
researchers from other cultures and the other affirmation. Triandis, Kashima, Shimada, and
sex. Villareal (1986) hypothesized that if newcomers
in the US are accepted they will show
accommodation or overshooting, but if they
10.01.4.10 Summary of Criteria of Good are rejected they will show ethnic affirmation. In
Cross-cultural Research addition, accommodation and overshooting are
more likely on visible traits, such as clothing,
(i) Does the study include many similarities
and ethnic affirmation is more likely on
across the cultures and are cultural differences
subjective traits, such as beliefs, stereotypes,
embedded in the similarities?
or values.
(ii) Did the study use multimethod proce-
A socio-political issue of great importance,
dures that converged (Fiske, 1986; Fiske &
when two cultures meet, is whether individuals
Shweder, 1986)?
should adopt or reject the other culture, and also
(iii) Did the study use tests both within
try to maintain or reject their own culture. Berry
(psychological level) and between (cultural
(1990) identified four outcomes of the accul-
level) cultures? Were the results consistent, or
turation process: he used the terminology
when inconsistent theoretically meaningful?
integration for the situation when the individual
(iv) Were rival hypotheses checked and
adopts the other culture while maintaining his/
eliminated?
her own culture; assimilation for the situation
(v) Did the study use etic constructs mea-
when the individual adopts the other culture and
sured emically, that is, with emic items gener-
rejects his/her own culture, separation for the
ated in each culture to tap the etic constructs.
situation where the individuals maintain their
Ideally, researchers should generate items from
own culture and reject the other culture, and
both men and women (Harding, 1987; Nielson,
marginalization for the situation where both
1990; Reinharz, 1992), as well as from all
cultures are rejected.
important groups that make the culture hetero-
Given that in the US, integration, as used in
geneous (e.g., social class, religion, language,
the press, means something different from
age, family structure). Were measurements
Berry's integration, it may be best to call that
standardized independently in each culture?
condition biculturalism. In any case, Berry,
(vi) Was the study conducted ethically?
Kim, Power, Young, and Bujaki (1989) found
(vii) Did the researchers make an effort to
that people who adopt the integration or
control ethnocentric and androcentric biases?
biculturalism solution to the acculturation
situation, and secondarily the assimilation
10.01.5 ACCULTURATION pattern, are better adjusted, both physically
and in terms of their mental health, than those
The discussion above assumed that cultures who use the other two acculturation patterns.
are isolated entities. However, in fact, they are in If we note that learning about another culture
constant interaction. Individuals are often is similar to learning another language, we can
influenced by many cultures. see the advantages of knowing about more than
When two cultures come in contact with each one culture. Segalowitz (1980) identified many
other, individuals have the tendency to adopt cognitive advantages associated with bilingual-
some of the attributes of members of the other ism, for example, cognitive flexibility, creativity.
culture (accommodation), and sometimes they Similarly, a multicultural person has more than
are so enthusiastic in adopting elements of the one way of interpreting reality. However, as
other culture that they overshoot. For example, Lambert (1992) has noted, bilingualism can be
individuals who come from a culture which uses both negative and positive. It is negative when in
time flexibly, for example, Mexico, may become the process of learning another language one
 Identities of African- and European-Americans 21

forgets one's own language; it is positive when cultural assumptions which underpin the parti-
one is actually comfortable in both languages. cular beliefs. Then one can create new alter-
Similarly, Triandis (1976a) has argued that natives which are based on, but are not limited
multiculturalism can be both negative (assim- to, the cultures involved. For example, in the
ilation) and positive (biculturalism). Adjust- clash of collectivist and individualist perspec-
ment is likely to be superior when positive tives, one might find a perspective which is
multiculturalism is present. compatible with both sets of assumptions. In
Social identity (Tajfel, 1982) is strongly linked our previous example about widows not eating
with the processes reflected in acculturation. An chicken, one could serve a food which is not
interesting example is provided by Rhee, Ule- perceived as having the attributes of increasing
man, Lee, and Roman (1995). They asked sexual desire (as seen in Orissa) and is
Korean and American participants to complete interesting and desirable (as seen in the US).
20 statements that started with ªI am . . . º They The next step is to check if the solution fits the
coded the responses into nine categories, one of assumptions of both cultures. One must discuss
which was ªpure traits.º Previous work (e.g., the solution with members of each culture to
Triandis et al., 1990) had found that in make sure that the solution is acceptable.
collectivist cultures the content of the responses
to the 20 statements is more social than in 10.01.6 IDENTITIES OF AFRICAN- AND
individualistic cultures. Clearly, pure traits is an EUROPEAN-AMERICANS AS AN
individualistic category. European-Americans EXAMPLE OF THE IDENTITIES
gave pure trait responses 29% of the time, OF CLINICIANS AND CLIENTS
Koreans did so only 12% of the time.
Asian-Americans were classified according to The US includes 125 ethnic groups with
whether when completing ªI am . . .º sentences nontrivial numbers (Thernstrom, 1980). Thus, a
they had identified their ethnicity ªnever,º clinical psychologist is likely to encounter
ªonce,º or ªtwice.º Those who never mentioned clients from many ethnic groups. Of course, a
their ethnicity gave 39% pure trait responsesÐa lot will depend on location. There are more
case of overshooting the European-American Albanians or Zairians in one city than another.
norm. They must have been the assimilated Also, fortunately, there are similarities among
Asian-Americans. Those who identified their cultures. Anthropologists identify ªcultural
ethnicity once (e.g., I am Asian or I am Korean- regionsº within which there is considerable
American) averaged 25%, almost the same as cultural similarity. Generally speaking, Africa
the European-Americans. Those who identified South of the Sahara is one region; the cultures
their ethnicity twice averaged 17%, which is around the Mediterranean, including most of
very similar to the 12% of the Koreans in Europe, have much in common; the cultures of
Korea. In short, those with a strong Asian- East Asia, South Asia, and the Pacific Islands
American identity responded like the Koreans. have similarities. Native Americans (of course,
The implications for clinical work of the they include tribes in South, Central, as well as
observation that biculturalism is best is that far North America) are among the most diverse
from pressuring clients to discard their culture, cultures. For example, according to the criter-
clinicians should urge them to maintain parts of ion of social structure, they belong to five
their culture as well as to acquire those aspects cultural regions (Burton, Moore, Whiting, &
of the mainstream's culture which will help their Romney, 1996). Clearly, clinicians cannot be
economic advancement. That may at times seem expected to know much about all 125 cultures,
difficult to achieve. However, there are oppor- or even about most of the cultural regions.
tunities for ªcultural synergyº (Adler, 1991). However, there are some ethnic groups which
Adler argues that when one culture solves a are sufficiently common to require such knowl-
problem one way and the other culture solves it edge. African-Americans are by far the most
in a different way, rather than become frozen in important, both because of their numbers and
the opposing ways to solve the problem, one the long history of cross-cultural contact
should seek creative solutions which are between them and the European cultures.
acceptable to both cultures. In short, rather Each pair of cultures has a unique history of
than the parochial ªour way is the only way,º or contact. For example, African- and European-
the ethnocentric ªour way is the best way,º there Americans have had a history of contact which
should be the synergistic, that is, the ªcreative is not the same as the history of Asian-
combinations of our way and their way may be Americans with African-Americans. It is im-
the best wayº (p. 107). portant to realize that the history of contact is
To achieve synergy one needs to understand an important factor in the kinds of identity
the point of view of each culture first. Second, which each group develops, and the kinds of
one needs to explore and understand the ªcontact modelsº which each group generates.
22 Introduction to Diversity in Clinical Psychology

Carter (1995) argues that people in the US aspect of the self. Individuals in this stage
develop a racial identity which affects their respect Whites and tolerate differences between
thoughts, feelings, and behaviors. Any valid Whites and Blacks. The emotions are self-
psychotherapeutic process in this country must confidence and security. At the most developed
include race. He believes that this identity is level of this stage there is individual activity to
important even in White±White interactions promote the welfare of Black people.
because so much of the content of social Carter (1995) describes five stages of White
behavior in the US reflects inter-racial experi- racial identity: stage 1, contact, includes persons
ences in school, work, dating, neighborhood, or who are unaware of others in racial terms, and
public policy. deny the importance of race. However, they
Carter (1995) also argues that each ethnic experience discomfort with unfamiliar people
group (Native Americans, Asian-Americans, and situations. They are characterized by low
Hispanics, African-Americans) goes through a anxiety, poor self-image, dependence, and are
series of stages in developing an ethnic identity immature interpersonally. Such people have
which is bound to enter into the clinician±client Euro-American values, but support organiza-
relationship. Ethnic identity reflects how the tions that promote equity.
individuals think about their own group as well In Stage 2, disintegration, people become
as how they view the relationship between their aware of social norms and pressures associated
group and the other ethnic groups. with cross-racial interactions, see negative
Ethnic identity, of course, also reflects the reactions by Whites to inter-racial associations,
kinds of acculturation patterns which are and attempt to find some balance between
operating, as discussed above. human decency and external pressures to be
Carter's (1995) discussion of Black racial negative toward Blacks. Typical emotions are
identity specifies four stages, each of which anger and guilt. They are still interpersonally
includes two levels. I will only describe the four immature, prefer a White counselor, are con-
stages. fused by Blacks, have Euro-American values,
Stage 1 is the pre-encounter stage during and may have negative views of racial issues in
which there is dependency on White society for the workplace.
self-definition and approval. Racial identity Stage 3 is reintegration. People at this stage
attitudes towards Blackness are negative and are fearful, angry and hostile toward Blacks.
White culture and society are seen as the ideal. They are anti-Black and pro-White, and see
There is an idealization of whites: much anxiety, Blacks stereotypically. Individuals idealize
low self-esteem, and a weak ego (in Loevinger's, Whiteness, devalue other races, and are anti-
1976, 1979, sense). Most Blacks in this stage Black. Their emotions include fear and anger.
have higher than average incomes and do not They feel high anxiety and hold racist views;
report that they experience discrimination in the they have Euro-American values and negative
workplace. The client in this stage prefers a views of the racial issues in the workplace.
white counselor. Stage 4 is called pseudo-independence. At this
Stage 2, the encounter stage, begins when the stage people understand that there are simila-
individual has a personal and challenging racial rities and differences between the races and
experience. It includes confusion, emotions accept the differences. However, these people
which are bitter, hurt, angry; there is high understand the differences only intellectually,
anxiety, low psychological well-being, high de- and remain emotionally distant from Blacks.
pression, and preference for a Black counselor. They may be interpersonally mature, may
Stage 3, the immersion stage, is characterized accept inter-racial dating, may be comfortable
by positive feelings toward Blacks and idealiza- in cross-racial settings, but nevertheless prefer
tion of Black culture, while having intense White company.
negative feelings toward Whites and White Stage 5, autonomy, is the most accepting and
culture. The emotions include rage and depres- flexible of the White racial identities. People at
sion. Individuals have low self-esteem and low this stage accept race as a positive part of the
self-actualization tendencies, are characterized self, are calm, secure, self-confident, mature
by emotional dependence, but people in this interpersonally, self-actualized, inner-directed,
stage have a strong ego in Loevinger's sense. support racial integration, have balanced views
This stage is most common among those of low of inter-racial relations, and positive racial
education, who are separatists with Afro-centric views of the workplace.
values and anti-White/system attitudes. Carter's theory is that if the therapist (Black
Stage 4 is internalization. Here individuals or White) and client (Black or White) are at
realize that both Blacks and Whites have both equivalent levels of racial identity development,
strengths and weaknesses. Black identity is there will be little improvement in the client's
experienced as positive, important, and a valued condition. Even worse, if the therapist is at a
 Methods for the Development of an Understanding of the Culture of the Client 23

lower stage than the client, there can be All 125 or so of the American ethnic groups
regression. Only when the therapist is at a (Thernstrom, 1980) are quite heterogeneous, so
higher stage than the client will there be progress that any statement made about them must be
in psychotherapy. Thus, he argues that racial used very carefully. For example, Hispanics are
identity is crucial in understanding the ther- quite different depending on whether they have
apeutic relationship. In fact, it is not race as such come from Cuba, Mexico, South America, or
but racial identity that is most important in Puerto Rico. Social class differences, the relative
understanding the course of psychotherapy. influence of African or Native American
Therapists who are not aware of the proper cultures, the genetic mixture of European-
way of understanding Black behavior may and Native-American populations, and factors
misinterpret as pathological behaviors which reflecting the history of the relationship between
are normal in the other culture, or clients might the ethnic group and the mainstream popula-
feel anxious for not being what the dominant tions of the US, have influenced the kind of
culture expects them to be. Thus, Carter (1995) culture that has emerged.
advocates that racial identity must be incorpo- A major difference between Asian- and
rated in clinical training and practice and he Hispanic-Americans, on the one hand, and
criticizes models of intercultural training which European-Americans, on the other, is that the
do not explicitly deal with racial identity. The former are more collectivist than the latter.
second part of his book reports empirical Many of the attributes of these two kinds of
studies which support some of these arguments. cultural patterns (see Triandis, 1995, for details)
This theory may have merit, but perhaps are reflected in the greater emphasis on polite-
Carter (1995) overemphasizes the importance ness, being a nice person, saving face (Ting-
of race, and also does not seem to take seriously Toomey, 1988), and the like which are associated
the importance of the situation. There is at least with collectivism and increasingly neglected
one study which suggests that identity may among extreme individualists. Asian-Americans
switch rather readily. Sussman and Rosenfeld are also said to be less assertive than European-
(1982) asked Venezuelan and Japanese bilin- Americans (e.g., Zane, Sue, Hu, & Kwon, 1991).
gual students to place their chairs anywhere in An excellent comparison of Chinese and Amer-
an empty room and chat for 10 minutes in icans can be found in Hsu (1981).
either their own language or in English. The Hispanics have been found to be rather
researchers measured the distance between the collectivist (Marin & Triandis, 1985), especially
chairs. They found that when these students familist (see Triandis, 1994, p. 247 for refer-
spoke in their own languages the Venezuelans ences), concerned with smooth interpersonal
placed their chairs close to each other and the relationships (Triandis et al., 1984), interperso-
Japanese placed them far from each other. But nal connections, and personalistic relationships
when these participants spoke in English there (dealing with each person differently). They are
were no cultural differences. This study would especially concerned with ªrespect,º ªdignity,º
suggest that the situation (speaking in own ªloyalty,º and ªcooperationº (Albert, 1996).
language or in English) determined the parti- African-Americans value expression in move-
cipants' identity and behavior. It would seem ment, sound, and the visual modalities more
that any theory about the way racial identity than European-Americans. Expression as per-
influences behavior should take the situation sonal style and movement, and the use of a ªcool
into account. poseº (Majors & Mancini-Billson, 1992), as well
as different patterns of communication in both
language (Landis, McGrew, Day, Savage, &
10.01.7 METHODS FOR THE Saral, 1976) and paralinguistically, require that
DEVELOPMENT OF AN for effective interaction with African-Ameri-
UNDERSTANDING OF THE cans, European-Americans must learn a good
CULTURE OF THE CLIENT deal about the African-American subcultures.
Some analysts have argued that African-
Analysis of the subjective culture of the Americans when compared to European-Amer-
clients (Triandis, 1972) requires examination of icans are more spiritual, higher in harmony with
the way clients categorize experience, the nature, more present oriented, use time more
meaning of key terms, associations, beliefs, flexibly, emphasize oral expressions, movement,
evaluations, expectations, norms, role defini- surprise, improvisation (see jazz), rejection of
tions, self-definitions, ideals, and values (see routine, have an identity that is defined by
Triandis, 1994, Chapter 4). This is often done expression, style, and spontaneous activity, are
most easily by reading ethnographies about the more gregarious, flexible, easygoing, affectively
client's culture, or empirical studies which have driven, and high in affect (Boykin, 1983;
measured these cultural elements. Jones,1986, 1988).
24 Introduction to Diversity in Clinical Psychology

The largest differences between European- guage. Can the time it takes to learn about the
and African-Americans have been found among other culture be justified?
those African-Americans who have never had a Also, most people are ethnocentric and feel
job (Triandis, 1976b). While those with jobs that others must learn about their culture rather
often have a very positive self-concept and a than they should learn about other cultures.
subjective culture that is not very different from After all, if clients are going to be successful in
the subjective culture of mainstream Americans, American culture they must learn how to
those who have never had a job often have negotiate situations within that culture, that
neutral self-concepts; they accept the conditions is, learn the culture of the clinician. So why
of the ghettos (e.g., high crime rates) as natural, should the clinician bother to learn their
have strong antiestablishment attitudes, and see culture?
little connection between what one does and Many clinicians also feel that they already
what one gets. They can be characterized as know enough. Thus, very little cross-cultural
having ªecosystem distrust,º that is, they do not learning is likely to take place.
trust people in their environment, and see events However, if one is to do a good job with a
in their environment as unpredictable. client from another culture it is important to
Some of these perceptions may reflect the learn as much as possible about that culture.
realities of life in segregated ghettos. For Changing a behavior which is central to the
example, if discrimination prevents people from other culture can do more harm than good. For
getting a job, not seeing a link between finishing example, clients from collectivist cultures often
school and a job may actually be a veridical appear to be too dependent on their families. A
judgment rather than an aspect of ecosystem clinician may be tempted to make them more
distrust. It may be the case that people in those autonomous. Yet that is likely to upset many
environments are untrustworthy. What is beliefs, feelings, and behavioral patterns if it is
striking, however, is that the great distrust is attempted too quickly and while the client is still
uncovered across the board, in the way they rate young. Changing a client without understand-
stimuli like mother, father, teachers, Black ing that behaviors which appear pathological
women, Black professionals, Black men, and are normal in the client's culture is extremely
so forth (Triandis, 1976b, p. 123). dangerous.
When clinicians interact with ethnics, such as Qureshi (1989) has written a whole book
those described above, they may well experience about misdiagnoses which are likely when the
ªculture shockº (Oberg, 1960). Culture shock is health provider and the client come from
a consequence of not having as much control different cultures. For example, if the clinician
(Langer, 1983) over the social environment as does not know that in Pakistan it is inappropri-
one is used to having. If the way clinicians ate to say ªI do not know,º or in India it is rare
usually approach their clients does not result in that one says ªthank you,º major misunder-
anticipated changes, the clinicians may feel that standings might occur. If the clinician does not
they have lost control of their clients. To regain know that in the Eastern Mediterranean there is
control clinicians need to put themselves into often a culture of honor (Campbell, 1964), and
the shoes of their clients (Brislin, 1993). That many people show an ªOthelo syndromeº which
means learning to make ªisomorphic attribu- consists of excessive concern about the chastity
tionsº (Triandis, 1975). That is, when they of spouse, jealousy, and delusions that the wife
explain the behavior of their clients, they must is unfaithful, he might interpret ªnormal
use approximately the same causal attributions behaviorº as abnormal. Differences in gestures,
as their clients use to explain their own behavior. such as using the gesture that in the US says
ªnoº to say ªyes,º as in Bulgaria and Southern
India, can cause serious problems for interac-
10.01.7.1 Methods of Culture Learning tion. Culture-linked diets can result in mis-
interpretations. Differences in what is normal
There are numerous ways clinicians can learn social structure (e.g., equality or inequality of
about another culture: they can spend time with roles), conceptions of beauty (e.g., fat is
members of the other culture; they can read beautiful in some cultures), taboos (what parts
about them; they can ask people who have of the body can a clinician not touch),
worked with members of the other culture to conceptions about what it means to be ªsickº
describe that culture. Each of these methods can and what one is supposed to do about it (e.g., go
be effective, but each has limitations. to a shaman or take a drink which contains
One of the major problems in culture learning mercury that is supposed to be a therapy for
is convincing the clinician that culture training is impotence), beliefs about the proper behavior
worthwhile. After all the clinician is busy, and after a birth, marriage, death, and bereavement
culture learning is like learning another lan- can also result in misunderstandings.
 Methods for the Development of an Understanding of the Culture of the Client 25

Psychopathology often is an exaggeration or (iv) Learn that it is most difficult to act

caricature of normal culture (Draguns, 1988). It correctly in an environment where the situation
may reflect culture-linked myths, religious looks just as it does in your own culture, but
beliefs, political views, esthetic standards, where the required behavior is very different.
economic conditions which are unknown to Most cross-cultural errors occur in such situa-
the clinician, and result in misunderstandings. It tions. You are in a situation called psychother-
often reflects the basic personality which is most apy and have tendencies to behave as that
frequent in the culture, social representations situation specifies, not taking into account the
found in that culture, the inability to deal with special attributes of the client that may require
specific environments, the values of the culture, some different behaviors.
specific forms of the self, methods of self- (v) Learn how to initiate conversations
control, and culture-linked lifestyles. Even which will teach you about the client's culture.
highly educated samples may use indigenous For instance, ask questions like these: What do
methods of dealing with illness. For example, you think has caused your problem? When did
Cook (1994) asked university level samples of it start? Who is likely to be involved in causing
Chinese, Indian, and Anglo-Canadians about your problem? Why do you think it started
their beliefs. Three kinds of methods of dealing when it did? What do you think your problem is
with 16 illnesses were provided: (i) biomedical doing to you? How does it do that? How severe
(e.g., consult a physician), (ii) psychosocial (e.g., is your difficulty? Will it have a short or a long
use a remedy recommended by the family), and course? What kinds of treatment do you think
(iii) indigenous (consult a religious leader). you should receive? What are the most impor-
There were highly significant differences among tant results which you hope to receive from this
the three cultural groups in the extent of treatment? What are the chief side effects which
endorsement of the indigenous and psychoso- your difficulty has caused you? What do you
cial beliefs, but their endorsement of the fear most about your condition?
biomedical methods was equivalent. For ex- From such questions the clinician can con-
ample, the Chinese indicated that in many cases struct the client's ªcultural model of the
they would not go beyond the family for help. problem.º Especially important is to obtain
Issues of ªfaceº are linked with going for help clear definitions of the meaning of terms,
outside the family in Chinese culture. There is associations between terms and other terms,
also much more somatization of psychological and the perceived antecedents and perceived
problems in that culture. consequences of the clients ªproblem.º For
There are many forms of cross-cultural instance, one can ask ªIn your culture, most
training. Here I will describe them briefly. people experience what conditions which result
Landis and Bhagat (1996) have provided a in the kind of problem you are having?º ªIn
Handbook which discusses them in detail. your culture, people who have the condition you
are having experience what kinds of conse-
quences?º
10.01.7.1.1 Culture-general vs. culture-specific
The cultural model that is identified may be
training
quite different from any model encountered in
There are many topics relevant to under- the clinician's culture. To place it in context, it
standing other cultures that are not specific to may be useful to inquire about religious beliefs,
any culture. These include: myths, norms, values, and the like which may
(i) Know that we are all ethnocentric. Try to have influenced the definition of the problem
catch yourself when you are ethnocentric. and the expected outcomes of the treatment.
(ii) Know that the attributions that clients (vi) Learn to see a positive aspect in every
will make about their own behavior are likely to one of the client's cultural traits.
be different from the attributions which you will (vii) Learn to suspend judgment, to live with
make about their behavior. Look for discre- ambiguity, to categorize broadly (e.g., while the
pancies in these attributions. client's response is different from the typical
(iii) Learn to sort what is personal from what response of most clients, it is not that different).
is ethnic. When clients react to you they are (viii) Learn how people react when they are
often seeing you as a ªrepresentativeº of your confronted by differences in attitudes and
own ethnic group. They may be hostile, not values: they are likely to (a) ignore the
because they do not like you, but because they difference; (b) bolster their position (I am
do not like your ethnic group, which may have obviously correct and you are stupid; they are
dominated their ethnic group. Also, people may likely to find additional arguments to strength-
be reacting to a cultural trait (e.g., they may not en their own position, or get social support from
like professionals who wear white coats) rather others who agree with them); (c) differentiateÐ
than to a personal trait. it is okay for people in the other culture to do it
26 Introduction to Diversity in Clinical Psychology

that way, and for us to do it our way; and (d) from South Pacific cultures. Many trainees
transcendÐboth are correct under some con- exposed to the rigors of that environment
ditions; our way is best under conditions X and decided to drop out, saving the Peace Corps
their way is best under conditions Y. Once you the expense of early repatriation and the
know these four ways of reacting to what is embarrassment of failure on the job.
different, try to suppress the first two and use This method, however, is expensive, and
the last one more frequently. depends on trial and error learning, which is
slow. Nevertheless, it produces results if the
training organization can spend the money and
10.01.7.1.2 Self-insight
the trainees have the time.
The emphasis in this kind of training is the
development of an understanding of how
10.01.7.1.4 Exposure to many local cultures
culture affects one's behavior. This technique
uses an actor to behave in the opposite way from It is assumed that the more experience
the way which is prescribed by the culture of the trainees have had in entering, learning about,
trainee. For example, in training Americans, and leaving cultures, the better equipped they
the actor behaves like a ªcontrast-Americanº will be to deal with new cultures. This type of
(Stewart, 1966). training was developed by the late psychiatrist
Topics include the American emphasis on Wedge. It encourages the trainees to join
material goals vs. stress on spiritual goals (e.g., different urban subcultures, such as the police,
as in India), the emphasis on achievement vs. the fire department, unions, top management of
ascribed status based on family prestige; corporations, school boards, religious groups,
Americans see competition as desirable, political groups, pickpockets, prostitutes, and
whereas in many cultures it is undesirable; so on. Each of these groups has a unique culture,
Westerners in general emphasize planning, and the skills required to join it should be
while traditional cultures emphasize fate; Wes- valuable. One has to learn how to scout, enter,
terners also place reliance on self, while in high explore, terminate, evaluate the new skills and
power cultures reliance on superiors is more transfer them to the next culture. The trainer
likely. Similarly, in low power distance cultures, helps the trainee get in and out of each
the emphasis is on equality, while status subculture, and discusses the experiences of
differences are most important in high power the trainees once a week in review sessions where
distance cultures. Other contrasts: the belief that each trainee's problems in getting in and out of
knowledge through observation is superior to each culture are examined.
knowledge received from authorities; the belief This method has a number of practical
that thoughts cannot influence events vs. the difficulties. It is difficult for a trainee to get
belief that they can do so. into some of these groups (e.g., in one case,
The actor interacts with the trainee and the when a trainee wanted to join some stevedores
session is videotaped. The trainer then spends they attacked him with a knife), and while there
time with the trainee going over the tape and is much to be said for the process skills which
explaining how the trainee's behavior is deter- one acquires, trainees do not learn much content
mined by culture. about the host culture.
This method is good because the trainee
learns about his/her own culture. However, the
10.01.7.1.5 Field trips
trainee does not learn anything specific about
another particular culture. The clinician may visit the culture of the client
for some weeks to become familiar with the
environment. This method teaches very little in
10.01.7.1.3 Experiential training
depth about the local culture.
Experiential training involves bringing the
trainees into contact with members of the
10.01.7.1.6 Culture assimilators or intercultural
host culture in situations where they can
sensitizers
make mistakes which will not hurt long-term
relationships. The introduction to this section mentioned
For example, in the early 1960s, the Peace the importance of learning to make isomorphic
Corps used an exact replica of a South Pacific attributions (Triandis, 1975). In order to train
village (no electricity, no movies, no running people to make isomorphic attributions this
water, etc.) in a valley on the Big Island of technique was developed and validated (e.g.,
Hawaii (Brislin, 1993). Trainees spent several Fiedler, Mitchell, & Triandis, 1971) and found
weeks learning the languages and customs of to work. It is the only cross-cultural training
such villages while interacting with trainers method that has been evaluated so far, with
 Methods for the Development of an Understanding of the Culture of the Client 27

random assignment of trainees to experimental which has identified differences in the subjective
and control groups and has been shown to be culture of the two relevant samples. Any item of
effective (Albert, 1983). This does not mean that cultural difference can be included. For exam-
the other methods do not work; it only means ple, if the trainer wants to teach what it means to
that rigorous studies have not yet been reported. be simpatico she would have one correct option
The culture assimilator is a programmed and several incorrect ones and let the trainee
learning approach to cultural training. It pick options and get feedback.
consists of a set of 100±200 critical incidents, In training persons from an individualistic
that is, scenarios where people from two culture such as the US to go to a collectivist
cultures interact. Each episode is followed by culture such as the Far East, one might include a
four or five explanations of why the member of variety of items such as:
the other culture has acted in a specific way. The (i) Differences in norms, such as do not bring
trainee selects one of the explanations and is a present of a certain color.
asked to turn to another page (or computer (ii) Differences in roles, such as the almost
screen) where feedback is provided concerning sacred parent±child role in some collectivist
the chosen explanation. cultures (so that if one's spouse disagrees with
Let us look at a simple example. Suppose you one's parents, it is obligatory to take the side of
are teaching a clinical psychologist to under- one's parents in such a dispute).
stand the behavior of a lower class Hispanic. If (iii) Differences in the way behaviors can
the psychologist understands the Hispanic's express intentions, so that ªnoº must be ex-
viewpoint, this is considered successful training. pressed most indirectly, and in a very subtle
Episode: A Hispanic lower class client looks way, for instance during a visit by serving two
down when spoken to. substances (e.g., tea and bananas) which are
Question: Why did the client look down? usually not served together.
Attributions: (iv) Differences in self-concepts, for exam-
(i) He was distracted. Turn to page 50. ple, collectivist selves are more likely to be
(ii) He was fearful. Turn to page 51. appendages of groups than to be autonomous.
(iii) He was respectful. Turn to page 52. (v) Differences in what behaviors are valued,
(iv) He was hostile. Turn to page 53. for example, that in collectivist cultures people
When trainees turn to pages 50, 51, or 53, use a modest introduction of their lecture, such
they find negative feedback, along lines such as as ªwhat I have to tell you is not very
these: ªNo, this is incorrect; try another ex- important;º or they may say ªI thank you for
planation.º When the trainees turn to page 52, spending your valuable time with me.º In
they get feedback such as: ªExcellent! That is individualist cultures they are more likely to
correct. When we presented this question to a present a self-assured front.
sample of 80 Hispanics and 95 non-Hispanics, (vi) Differences in the kinds of associations
85% of the Hispanics considered this answer to which people make, for instance, in collectivist
be the correct one, and only 36% of the non- cultures people are more likely to associate the
Hispanic thought that this was correct.º word ªprogressº with national rather than with
Note that the construction of assimilator personal progress.
training is culture-specific. It requires the use of (vii) Differences in the kinds of differentia-
samples of people from the two cultures who tions (sensitivity to hierarchies based on minor
study the episode and the attributions and select cues) which people typically make, for example,
the attribution they consider to be correct. in collectivist cultures there will be more
Thus, the training is validated as it is being differentiations on the vertical axes than on
constructed. the horizontal axes of social relationships.
In addition, the feedback gives the percen- (viii) Differences in the important determi-
tages of samples who agree or disagree with each nants of behaviorÐin collectivist cultures be-
answer. This avoids teaching stereotypes. havior is more likely to reflect norms than
Instead, one learns that judgments about why attitudes.
people acted in a given way are probabilistic, (ix) Differences in the kinds of reinforce-
and the probabilities differ across cultures. ments which people expect for particular beha-
Of course, in constructing assimilators it is viors in particular situationsÐin collectivist
necessary to have many more episodes than will cultures one is supposed to give a gift in many
be used in the final training, because some will situations in which in individualist cultures one
not discriminate the two samples of subjects, would pay.
and thus must be discarded. Triandis, Brislin, and Hui (1988) advised
Construction of the episodes is based on individualists to pay attention to group attri-
interviews with people who have wide experi- butes more than they do in their own culture, to
ence in the two relevant cultures, or on research learn more about the ingroups and outgroups of
28 Introduction to Diversity in Clinical Psychology

collectivists and to expect sharp differences in Stephan and Stephan (1984) used a culture
behavior when the collectivist interacts with assimilator to increase ªknowledge of Chicano
members of such groups, to expect more cultureº among Anglo students in New Mexico.
harmony within the ingroup, for example, no This study indicated that Anglo students'
criticism of high status people, than is typical of attitudes toward Chicanos in the Southwest of
their own culture. They also suggested that the US are related to three factors: (i) how much
trainees should cultivate long-term relation- they know about Chicano culture, (ii) how much
ships, be modest when presenting a lecture, contact they have with Chicanos, and (iii) their
stress equality and need when distributing parents' attitudes toward Chicanos. Contact
resources, and give more gifts than is customary with Chicanos was determined by the attitudes
in their own culture. of their friends toward Chicanos. Finally,
Construction of a typical assimilator begins contact increased knowledge of Chicano cul-
with 200 or so episodes extracted from discus- ture, and the assimilator training boosted that
sions with people who know both cultures, or by knowledge a bit more, so that those who were
analyzing relevant ethnographies to identify a trained had more positive attitudes than those
set of four or five attributions for each episode. who were not. The Stephans concluded their
Then the episodes and the attributions are study as follows:
presented to samples from the trainee's and the
host's culture, and differences in the response Simple intergroup contact, such as the contact that
patterns are examined. Those episodes which do typically occurs in desegregated schools, is not
not produce significant chi-squares are dis- likely to improve intergroup relations. However,
carded. Then the assimilator is printed in a book specially designed educational programs, designed
or placed in a computer. to reduce ignorance of the outgroup, do appear to
Administration can be done with each trainee improve intergroup relations. (p. 249)
working through the book or computer pro-
gram alone, or the trainer may select some of the Social distance often depends on the norms of
more interesting episodes and present them for our own group. If our own group urges us to get
discussion. Trainees may also role play the along with the other group, we are more likely
content of some of the episodes. to do so than if it opposes such friendliness. As
In principle, this method can be expanded for in the Stephans' study, when the friends favor
use with an interactive disk technology, so that contact, there is likely to be an improvement in
trainees see videotaped actors performing the relationships.
episode and participate by pushing buttons that For these reasons culture assimilator train-
indicate what responses they think are appro- ing is only one component of cross-cultural
priate. Feedback from the computer in the form training. It is not sufficient by itself. It needs to
of praise or criticism can make this task most be supplemented with other methods, such as
interesting. the self-insight method which is likely to
In evaluations of this kind of training, increase the motivation of the trainees to learn
trainees were assigned randomly to two groups: about the other culture, and experiential
they received or did not receive the training (e.g., training which can change emotions. Also,
Weldon, Carlston, Rissman, Slobobin, and the norms of social interaction between the two
Triandis, 1975). Such studies have shown that cultures need to be changed to modify social
trained people learn to make isomorphic distance.
attributions, they expand the range of explana- Another limitation of assimilator training is
tions they give for specific behaviors, they that it does not change behavior. It is one thing
become less ethnocentric, and develop more to know how one is supposed to behave, and
accurate expectations concerning appropriate quite another to behave correctly. To achieve
behavior. the latter goal one needs to have behavior
Assimilator training increases cognitive com- modification training.
plexity. Cognitive complexity makes it possible The development of assimilators is time-
to consider the subjective culture of the other consuming. It is obvious that any one clinician
cultural group as ªvalidº and thus lessens cannot afford to develop an assimilator for
prejudice (Gardiner, 1972). particular clients. However, a group of clin-
However, culture assimilator training does icians, such as the APA's Division 12, could
not strongly increase liking for the other group undertake the development of relevant assim-
or reduce social distance toward it. Liking ilators.
depends on the number of pleasant experiences In addition to assimilators which focus on a
one has shared with the other group. Just specific culture, there is a general assimilator
knowing how the other group thinks does not (Brislin, Cushner, Cherrie, & Yong, 1986). It
change emotions. deals with the fact that it is natural and to be
 Methods for the Development of an Understanding of the Culture of the Client 29

expected to: (i) feel anxious abroad, (ii) if they behave as they do at home. If they do not
experience disconfirmed expectancies, (iii) be behave as expected the locals will think of them
unable to feel that one belongs to the local as cold and undemonstrative ªGringos.º But
culture, (iv) experience ambiguity about what North Americans who behave this way without
one should do, and (v) be exposed to local proper training will feel that they are behaving
prejudices. It teaches that one must learn to inappropriately.
control one's own prejudices. Conversely, some behaviors have to be
The general assimilator also teaches trainees eliminated. For example, in some cultures
to expect differences in the way people view: (i) (e.g., Greece), to show the palm of your open
work, (ii) the relationship of work and social hand is an insult. It is called a ªmoutzaº and
interaction, (iii) time, (iv) space, (v) language, reflects utmost contempt. However, many
(vi) roles, (vii) groups, (viii) rituals, (ix) people are in the habit of greeting others by
hierarchies, and (x) values. waving an open hand. For these people to stop
It also helps the trainees to understand doing this requires some training. Most people
differences in: (i) categorization, (ii) differentia- wave without thinking. A trainer must catch
tion (e.g., some people know more about some them in the act, and tell them not to open their
subjects than you do), (iii) the importance of the hand. Self-correction after such acts can change
ingroup±outgroup distinction (e.g., between the habit, so that the person waves with the
collectivists and individualists), (iv) learning palm closed and turned toward themself.
styles (not everyone learns best the same way), Especially difficult is to change habits such as
and (v) attributions (how to make isomorphic nodding to say ªnoº and shaking the head to say
attributions). ªyesº (Bulgaria, Southern India). Here one
The general assimilator has been successfully needs a lot of practice to get over well-
evaluated (Cushner, 1989). Twenty-eight established habits.
trained adolescents from the Pacific Rim
visiting New Zealand were better adjusted than
10.01.7.1.8 Some summary points about training
22 control adolescents hosted by New Zealan-
ders. The trained adolescents completed a Cross-cultural training can be effective. Black
number of tasks measuring cross-cultural and Mendelhall (1990) reviewed 29 studies that
sensitivity better than the control subjects. measured effectiveness. They found that all the
A final point about assimilators: clinicians studies that measured how people felt about the
who have been warned that there will be training had positive results, all the studies
problems when interacting with members of a which measured effective interpersonal relation-
specific culture are more likely to be able to ships found improvements, all the studies which
deal with these problems than naive clinicians. measured changes in perception found them,
This phenomenon is parallel to findings with and all research which tried to reduce culture
hospital preoperative patients: those who were shock succeeded in doing so. Two-thirds of the
told that they will feel quite uncomfortable studies which measured performance obtained
after an operation dealt better with the post- improved performance.
operative pain than those who had been told In general these effects were found in field
nothing. In general, the more the training studies but not in laboratory studies. This may
creates realistic expectations about events, the be due to the limited time one can use in the
better. laboratory. A few hours of training are not
enough to produce major changes. Further-
more, field studies involve volunteers who are
10.01.7.1.7 Behavior modification cross-cultural
motivated to succeed. If we tried to train the
training
general public perhaps we would not have
Behavior modification techniques require positive results. No matter how good the
that people be rewarded for desirable behaviors training or the trainer, if the trainees do not
and be made to do an incompatible behavior wish to change, they will not. Nevertheless, the
whenever they have the urge or tendency to do studies with control groups and longitudinal
an undesirable behavior. For example, in Latin designs reviewed by Black and Mendelhall
America it is customary among friends to give (1990) show some impressive results which
an abrazo, a kind of embrace with the arms. should encourage more cross-cultural training.
Also, holding hands, touching, and other A meta-analysis which statistically combines
behaviors between good friends of the same the results from many studies has also found
sex are common. Yet North Americans have to that cross-cultural training is effective (Desh-
be trained to carry out such behaviors. If they pande & Viswesvaran, 1992).
behave as is expected by the Latinos they will be The scientific understanding of how culture
liked better when interacting with Latinos than affects social behavior and the use of this
30 Introduction to Diversity in Clinical Psychology

understanding to improve relationships across Bogardus, E. S. (1925). Measuring social distance. Journal
cultures has just begun, but it is a promising area of Applied Sociology, 9, 299±308.
Bond, M. H., & Cheung, M. (1984). Experimenter language
of activity. choice and ethnic affirmation by Chinese trilinguals in
Hong Kong. International Journal of Intercultural Rela-
tions, 8, 347±356.
10.01.8 FUTURE DIRECTIONS Bond, M., & Smith, P. B. (1996). Cross-cultural social and
organizational psychology. Annual Review of Psychol-
Future research should determine how many ogy, 47, 205±235.
cultural syndromes are needed for an adequate Bond, M., & Young, K. S (1982). Ethnic affirmation vs
understanding of cultural differences. Learning cross-cultural accommodation: The variable impact of
questionnaire language on Chinese bilinguals in Hong
about these cultural syndromes should allow Kong. Journal of Cross-Cultural Psychology, 13,
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 Copyright © 1998 Elsevier Science Ltd. All rights reserved.

10.02
Cross-cultural Psychopathology
FANNY M. CHEUNG
The Chinese University of Hong Kong, Hong Kong

10.02.1 INTRODUCTION 35
10.02.2 ETHNOCENTRIC APPROACH OF CLINCIAL PSYCHOLOGY 36
10.02.3 CULTURE-BOUND SYNDROMES 37
10.02.4 KORO 38
10.02.5 ALTERNATIVE VIEWS ON CBS 38
10.02.6 TRANSFORMATION OF NEURASTHENIA 39
10.02.7 ILLNESS EXPERIENCE 41
10.02.8 SOMATIZATION AS A CATEGORY FALLACY 41
10.02.9 SOMATIZATION AS ILLNESS EXPERIENCE 42
10.02.10 CULTURE AND PSYCHOPATHOLOGY 44
10.02.10.1 Role of Culture in Psychopathology 44
10.02.10.1.1 Culture-produced stress 44
10.02.10.1.2 Culture-related problems 44
10.02.10.1.3 Culture-inherited vulnerability 45
10.02.10.1.4 Cultural contribution to choice of psychopathology 45
10.02.10.2 Cultural Explanations 45
10.02.11 CROSS-CULTURAL PSYCHOPATHOLOGY 45
10.02.11.1 Universalist vs. Relativist Approaches 45
10.02.11.2 Recent Research on Cross-cultural Psychopathology 47
10.02.11.3 Future Directions 48
10.02.12 SUMMARY 48
10.02.13 REFERENCES 48

10.02.1 INTRODUCTION peripheral curiosities about bizarre phenomena

in exotic cultures. Because of their peripheral
While psychopathology is embedded in the status, culture-bound syndromes were identi-
wider cultural context, theories of clinical fied without much systematic research into the
psychology have generally been ethnocentric cultural dynamics of these syndromes. While
in nature. Cross-cultural studies in psycho- they may have clinical meaning to the specific
pathology often started with the assumption of cultures, there is little relevance to the mainline
the universality of these theories and attempted theories. In this chapter, some of the culture-
to compare the similarities and differences bound syndromes are demystified. The roles
between cultural groups on aspects of these played by cultural factors in the presentation
theories. Earlier interests in culture-specific and interpretation of psychopathology are
aspects of psychopathology were related to examined. Recent research is incorporating

35
36 Cross-cultural Psychopathology

the universalist and relativist approaches of experiences, and healing practices of people in
cross-cultural psychology and bringing cultural other cultures are reduced to the status of
dimensions of psychopathology into the main- misinformed or superstitious obstacles in the
stream. diagnosis, treatment, and outcome of real
diseases which are based on an invariant reality
of biology.
10.02.2 ETHNOCENTRIC APPROACH OF These culture-bound assumptions result in an
CLINCIAL PSYCHOLOGY ethnocentric psychology based on ªculturally
specific ways of viewing individuals and their
Clinical psychology has always considered personality development,º ªdiagnostic cate-
itself to be a scientific field and has placed a gories of personality disorder that ignore the
strong emphasis on research (Routh, 1994). The fundamental influence of social context and
major content areas of research include psy- cultural norms on human behavior,º and ªa
chopathology, assessment, and intervention. psychiatric nosology that claims to be universal
Despite the empirical orientation of psychology, but does not take seriously the great cross-
a major deficiency in the prominent models of cultural diversity of somatic and psychological
psychopathology is the lack of cross-cultural symptomsº (Lewis-Fernandez & Kleinman,
awareness in both theory and research. The 1994, p. 67).
ethnocentric approach in Anglo-American clin- The lack of a cross-cultural perspective in
ical psychology may be reflected in the emphasis clinical psychology cannot be explained purely
on the individual or the intrapsychic self, be it on the grounds of the limited diversity of the
the biological paradigm, the psychoanalytic ethnic backgrounds of trained clinical psychol-
paradigm, the learning paradigm, the cognitive ogists. The ethnic backgrounds of clinical
paradigm, or the phenomenological paradigm. psychologists in the USA have diversified in
In none of these models is the wider cultural the past two decades and the population of
context considered to be an important factor in clinical psychologists in different parts of the
understanding the cause, course, and conse- world has vastly expanded. The little research
quences of psychopathology. found in cross-cultural clinical psychology has
Lewis-Fernandez and Kleinman (1994) focused mainly on applicability of Western or
pointed out three culture-bound assumptions Caucasian middle-class models of treatment or
which biased the professional concepts of assessment procedures.
mental health and illness in North America. In contrast, since the 1960s the field of
The first is the ªegocentricity of the selfº which psychiatry has developed a substantial, albeit
is seen as ªa self-contained, autonomous entity, peripheral, interest in cultural psychiatry, rais-
characterized by a unique configuration of ing sensitivity to cultural aspects of psycho-
internal attributes that determine behaviorº pathology and treatment. It has been pointed
(p. 67). The focus on the self, individual out that modern psychiatry was ªmoulded by
experience, and internal attributes of person- specifically Western philosophical and scientific
ality in understanding psychopathology misses traditionsº and should overcome the ªinertia of
the sociocentric ideology and interpersonal ethnocentricismº (Lin, 1982, p. 235). Large-
contexts which most of the rest of the world scale international collaborative research in
espouses. psychopathology and diagnosis is evident in
The second culture-bound assumption is the the activities of international psychiatric orga-
philosophical roots of mind±body dualism, nizations and publications of cultural psychia-
which leads to the division of psychopathology try. For example, a sociocultural lexicon for
into the organic disorders and psychological psychiatry (Mental Health Division, WHO, in
problems. This dualistic professional model press) will be published to accompany the tenth
would misinterpret the cultural expressions of revision of the International Classification of
patients in most parts of the world who Diseases (ICD-10; World Health Organization,
experience human suffering as simultaneous 1992). Global collaborative research projects
mind and body distress. The integrated soma- have been set up to compare the etiology,
topsychological idioms of expressions are often symptomatology and treatment of specific
viewed as a reflection of a lack of introspection psychiatric disorders such as schizophrenia
or psychological-mindedness. (World Health Organization, 1973, 1975,
The third culture-bound assumption that 1979, 1991).
biases professional concepts is the view that Within American psychiatry, there are at-
culture is ªan arbitrary superimposition on a tempts to make the role of cultural analysis
knowable biological realityº (p. 67). This more of a mainstream than a secondary activity.
assumption views culture as ªepiphenomenal.º Where the Diagnostic and statistical manual of
Cultural beliefs about disease categories, illness mental disorder (3rd ed.) (DSM-III American
 Culture-bound Syndromes 37

Psychiatric Association, 1980) has been criti- It has long been known that there are, in certain
cized for ignoring cultural diversity, efforts have cultural groups, peculiar aberrations of behavior
been made to represent cultural concerns in which are regarded by themselves as abnormal.
DSM-IV (American Psychiatric Association, Over the years a number of terms taken from
indigenous languages have crept into the psychia-
1994; Good, 1996). A Group on Culture and
tric literature to denote these conditions, but many
Diagnosis consisting of anthropologists and of them do not point to novel or distinct forms of
cross-cultural psychiatrists was formed to disorder unknown elsewhere. Some are simply
advise the DSM-IV Task Force on how to generic terms for ªmental disordersº without
make culture more central to DSM-IV. One of definite meaning, others refer only to healing
the specific aims of the Group was ªto devise a rituals, and still others to supernatural notions
mechanism that would facilitate the application of disease causation. . . . To avoid stagnation in
of a cultural perspective to the process of clinical this field, it is essential to apply the concepts of
interviewing and diagnostic formulation in clinical psychopathology to the analysis of these
psychiatryº (Lewis-Fernandez, 1996, p. 133). disorders, to integrate them into recognized clas-
sifications of disease if possible, or to broaden the
The Group on Culture and Diagnosis proposed
classification if necessary. (1974, p. 86)
an outline for cultural formulation to supple-
ment multiaxial diagnostic assessment in a
multicultural environment. As summarized by Initial interests in CBS have given rise to a
Lewis-Fernandez: host of ªfolkº taxonomies from different cul-
tures (Simons & Hughes, 1985). More common
the cultural formulation provides a systematic CBS include the following:
review of the individual's cultural background, (i) Latah. Originating from Malaysia and
the role of the cultural context in the expression Indonesia, Latah refers to the exaggerated
and evaluation of symptoms and dysfunction, and startle response followed by odd behaviors.
the effect that cultural differences may have on the The afflicted person typically responds to a
relationship between the individual and the clin-
frightening stimulus with an exaggerated startle
ician. (p. 137)
or jump, sometimes throwing or dropping a
held object, uttering some improper word, or
Eventually, however, only an edited and shor-
matching the words or movements of people
tened version of this outline was included as an
nearby (Simons, 1985, p. 43). The pattern is a
appendix instead of the central text of DSM-IV.
highly stereotypic, culturally labeled state
Nevertheless, compared with previous editions,
which, though contravening the social norm,
cultural concerns are represented in a much is differentiated from insanity.
more significant manner in the text of DSM-IV
(ii) Amok. Amok refers to the sudden mass
and are included in the introduction, in the
assault taxon indigenous to Malayo-Indone-
context of particular categories, as well as in a
sians, but may find parallel instances of indis-
glossary of cultural terms (Good, 1996).
criminate homicide in other parts of the world.
No such systematic approach to main-
It is defined as ªan acute outburst of unres-
stream cultural analysis is found in the field
trained violence associated with homicidal
of clinical psychology. Therefore, reference to
attack, preceded by a period of brooding, and
the knowledge base developed in cultural
ending with exhaustion and amnesiaº (Carr,
psychiatry is needed to review research in
1985, p. 199). It is believed to have originated
cross-cultural psychopathology and culture-
from the cultural training for warfare of the
bound syndromes.
early Javanese and Malays which was intended
to terrify the enemy into believing that they
10.02.3 CULTURE-BOUND SYNDROMES could expect no mercy and could save them-
selves only by flight.
The interest in culture-bound syndromes (iii) Pibloktoq. The term is also labeled as
(CBS) in cultural psychiatry in itself illustrates arctic hysteria, polar hysteria, or transitional
a process of transformation in the approach to madness, referring to a group of hysterical
cultural dimensions of psychopathology. Fas- symptoms among the Polar Eskimo of Green-
cination with CBS has its sources in the ªbizarre land brought on by the depressing or mono-
characteristics of the behavior displayedº tonous effects of the Arctic's winter climate.
(Hughes, 1985). Originating from the voyeur- The syndrome is composed of a series of
istic interest on folk illnesses in ªexoticº reactive patterns with different combinations
cultures, CBS are now included in the glossary of the features in different cases. Disturbance of
of cultural terms in DSM-IV. The study of consciousness during the seizure and amnesia
culture-bound syndromes has gained respect- for the attack are the central clinical features.
ability from the scholarly works of pioneers Some frequent behavioral symptoms are tearing
such as Yap who alleged that: off of clothing resulting in nudity, glossolalia,
38 Cross-cultural Psychopathology

fleeing, and running across or rolling in snow. retraction complaints. The syndrome was
Gussow (1985) suggested that Pibloktoq is a considered an emic or locally defined construct
reaction of ªthe basic Eskimo personalityº to unique to these cultures with culture-specific
ªsituations of unusually intense, but culturally etiologies.
typical stressº (p. 282). Cultural meanings have been offered to
(iv) Susto. Illness arising from spirit separat- explain individual and mass episodes of Koro.
ing from the body due to fright is widespread in For example, Bartholomew (1994) argued that
one form or another in Latin America. The folk Koro is ªa rational attempt at problem-solving
interpretation of Susto is based on the belief that that involves conformity dynamics, perceptual
a person comprises spiritual and organic ele- fallibility, and the local acceptance of koro-
ments. The spiritual element may be detachable associated folk realitiesº (p. 46). Gwee (1985)
from the host organism under unsettling ex- offers the interpretation that Koro is an ªacute
periences that disturb the equilibrium or when hysterical panic reaction, brought on by auto- or
the unsettled spiritual element is seized and hetero-suggestion and conditioning by the
controlled by the spirits of the natural environ- cultural backgroundº (p. 159). The indigenous
ment. The situation results in loss of appetite, ethnographic literature describes Koro attacks
weight, and strength; restlessness in sleep; as ªunpredictable, but [they] usually appear
listlessness when awake; and depression and after a shock which made the patient anxious or
introversion. ªFor recovery, the captured spirit frightened, after performing strenuous manual
must be retrieved from its captor, ransomed in labor or no labor at all, or as a result of
the folk treatment process, and `led back' to be immoderate nocturnal partyingº (Edwards,
reincorporated into the victim's bodyº (Rubel, 1985, p. 171). The etiology is attributed to
O'Nell, & Collado, 1985, p. 334). nonconformity with community norms in the
Most of the initial interest in CBS has cultural context of competitiveness. In Chinese
surrounded the description of these phenom- societies, these fears are associated with beliefs
ena. According to Prince and Tcheng-Laroche's about sexual activities. Suoyang appears as ªa
(1987) definition of CBS, the culturally distinct product of intra- and inter-personal violations
meaning of the illness for individuals and of medico-sexual regulationsº (Edwards, p. 183).
cultures affects the occurrence of signs and Originally believed to be indigenous to
symptoms of diseases in some cultures but not Southeast Asia, Koro has also been detected
in others. The difference in occurrence depends in Africa, South Asia, and North America since
on the psychosocial features of those cultures. the late 1970s (Chowdhury, 1996; Fishbain,
CBSs have also been called culture-reactive Barsky, & Goldberg, 1989; Holden, 1987).
syndromes, which suggests that the psycho- Attempts have been made to fit Koro into the
pathology is deemed to be rooted in social etic or externally defined psychiatric nosology,
environmental forces and/or situations. The including acute hysterical panic reaction, anxi-
signs and symptoms reflect an attempt by the ety states, depersonalization, conversion dis-
patients to adapt to major problems in their order, or atypical somatoform disorder (Simons
lives. & Hughes, 1985). Hughes (1985) justified the
In the following section, one of the more application of conventional diagnostic concepts
popular syndromes in the literature, Koro, will to culture-bound phenomena in that they
be discussed in greater detail to illustrate how provided ªthe basis for more informed judg-
the cultural context of CBS affects their ment regarding the ontological status and
manifestation. (eventually) etiology of the culture-bound
syndromesº (p. 21). He went on to point out
that a culturally informed use of the conven-
10.02.4 KORO tional diagnostic categories required knowing
the culture of the person being evaluated to
Koro arises from the belief about the retrac- make a valid assessment of the behaviors, as well
tion of the sexual organs (including penis, as being skeptical of the implicit values and
breast, nipples) into the body which leads to assumptions underlying these categories. He
eventual death. Koro was believed to originate warned that these categories should be tested
from the Malay word koro which means against the observed primary behavior patterns
ªshrink.º An alternative source is from the and not be taken for granted.
word kura which means a tortoise. The ªhead of
the tortoiseº is often used as an expression for
the penis by the Malays as well as the Chinese 10.02.5 ALTERNATIVE VIEWS ON CBS
(Edwards, 1985). A similar condition is also
found among Chinese under the name of In a reversed direction in the search for
Suoyang, another native terminology for genital culture-bound syndromes, some Western-based
 Transformation of Neurasthenia 39

syndromes such as anorexia nervosa, obesity, or nosology, has assumed the identity of a culture-
even adolescence have been postulated as related syndrome in Chinese societies. The
Western cases of CBS (Hill & Fortenberry, transplantation and transformation of neur-
1992; Prince, 1985; Ritenbaugh, 1982; Swartz, asthenia as a disease entity outside Western
1985). It was argued that anorexia nervosa fits societies provides an apt illustration of the
the criteria of CBS, namely, that ªthe syndrome pathoplasticity of culture-related syndromes.
cannot be understood apart from its specific
cultural or subcultural context,º that ªthe
etiology summarizes and symbolizes core mean- 10.02.6 TRANSFORMATION OF
ings and behavioral norms of that culture,º that NEURASTHENIA
ªdiagnosis relies on culture-specific technology
as well as ideology,º and that ªsuccessful Neurasthenia as a diagnostic category has a
treatment is accomplished only by participants vicissitudinary career in Western psychiatry.
in that cultureº (Swartz, p. 725). Notwithstand- Coined by the American neurologist George
ing the need for empirical evidence to demon- Beard (1869) to describe the exhaustion of the
strate that anorexia nervosa is indeed restricted nervous system, it was found to be common
to Western cultures, such an encapsulated among patients attending general practitioners
direction to search for CBS misses the con- in the early 1990s. It was, however, ignored as a
ceptual advances provided by CBS research in diagnostic category until being classified among
understanding the contextual nature of all the neuroses in DSM-II (American Psychiatric
forms of psychopathology. Association, 1968) as a condition characterized
Prince and Tcheng-Laroche 1987) justifiably by weakness, fatigue, lack of stamina, and
pointed out that Western diagnostic classifica- exhaustion, as distinguished from hysterical
tion systems, including both ICD and DSM, are neurosis, anxiety neurosis, and depressive
based on psychiatric conceptualization of neurosis. Literally, it connotes a condition of
Western medical science. Western medical ªweak nervesº in which the sufferer is ªthought
models are based on universal theories of to be easily overwhelmed by the ordinary
disease. CBS, on the other hand, do not fit stresses of life, with resultant symptoms of
well into these universal models. According to somatization, anxiety, and depressionº (Mental
Prince and Tcheng-Laroche, the inherent emic± Health Division, WHO, in press). It was
etic diversity and semantic specificities of the subsequently dropped from the later revisions
CBS hinder their incorporation into prototype of the DSM but is still retained in ICD-10
approaches. Instead, they suggested that the (World Health Organization, 1992). Because of
descriptive classification consisting of inven- the somatic focus of the symptoms, it is
tories of signs and symptoms based on the common for patients complaining of neurasthe-
meaning of illness both for individuals and for nia to be diagnosed by physicians for some
cultures rather than the etiological classification physical dysfunctions. The vagueness of the
would be more practical for clinical use. nosology, however, does not fit in with the
ªCulture-boundº syndromes are now gener- increasing emphasis on objectivity and func-
ally viewed as ªculture-relatedº syndromes tionality in the American classification system.
(Mental Health Division, WHO, in press). Despite its American origin, neurasthenia has
While these syndromes have been found with become a nondisease in America (Kleinman,
differing incidence or prevalence rates across 1982).
societies, they are considered to be more ªover- On the other hand, neurasthenia is now the
determinedº or ªrelatedº to certain cultures most widely utilized psychiatric diagnosis in
than they are ªboundº to those cultures. These China (Mental Health Division, WHO, in
culture-related syndromes serve to illustrate press), and is a popular folk nomenclature in
both the ªcore elementsº of a psychiatric Chinese societies and Japan (Lin, 1989).
disorder, as well as ªthose elements that can Literally translated as shenjing shuairuo (weak-
be modified by individual psychology, social ness of the nervous system), this Western term
context, and culture.º By examining how was believed to be ªimportedº into China via
cultural contexts affect the conceptualization Japan in the early 1990s (Lin). Popular books
and manifestation of these syndromes, we not on Chinese folk medicine published in the past
only expand our knowledge of aberrant phe- few decades have included neurasthenia as a
nomena unfamiliar to Western models of condition that could benefit from traditional
psychopathology, but also gain a better under- medical treatment, as if it were an indigenous
standing of the cultural contexts of the form of disorder. The term is also commonly
conventional models of psychopathology them- used among traditional doctors, physicians,
selves. For example, neurasthenia, once classi- psychiatrists, and lay persons to refer to a range
fied as a form of neurosis in Western psychiatric of neurotic, psychosomatic, and psychotic
40 Cross-cultural Psychopathology

disorders (Cheung, 1989; Lee & Wong, 1995). Even during the early days of the Great Leap
Etiology and treatment of neurasthenia are also Forward and the Cultural Revolution in the
elaborated using lay concepts of mental health People's Republic of China between the 1950s
and Chinese folk medicine. Cheung (1989) and 1960s, the problem of neurasthenia as a
suggested that the term's form of mental illness was readily accepted,
whereas other Western theories of psycho-
ambiguity as well as the overlap with other pathology were deemed mentalistic and there-
psychoneurotic disorders may be reasons leading fore inconsistent with the communist ideology.
to the rare use of this diagnosis in Western The concept of neurasthenia in the People's
psychiatry . . . [but] due to its popularity among Republic of China was originally based on the
the lay public that new life has been injected into Pavlovian theory of neurophysiology (Chin &
this imported medical term. Neurasthenia has been Chin, 1969) during the era of Sino-Soviet
incorporated into Chinese folk medicine, and a set cooperation when Soviet neuropsychology
of beliefs has grown up around the original had a strong influence on Chinese psychology.
definitions of the disease outlined by George Beard Neurasthenia is attributed to ªtension in the
in 1880. (pp. 235±236)
higher nervous system in excess of its capacity,
thus causing a weakening in the functioning
Cheung proposed two possible reasons to capacity of the brain tissues and a lack of
explain the popularity of neurasthenia as a balance or confusion in nervous activityº (p. 70).
diagnostic term among the Chinese. First, Serious disturbances occur in the activity of the
neurasthenia provides an acceptable paradigm nervous system relating to work, study, society,
of health and medicine. From its original and family. Its ªpolitically correctº etiology and
Western definitions, neurasthenia has been manifestation allowed the disease entity to
ªindigenizedº and incorporated into the para- survive the Cultural Revolution during which
digm of traditional Chinese folk medicine which other forms of Western diagnoses tended to be
is based on a holistic concept of health and denied (Cheung, 1989). Cadres and profes-
illness. Neurasthenia as a multidimensional sionals were spontaneous in their admission of
illness provides a conceptualization in terms the high prevalence of neurasthenia especially
of both psychological and somatic symptoms among their peers since they regarded neur-
and contexts. Among Chinese patients, somatic asthenia as the outcome of overwork and not as
symptoms form an important part of the a form of mental illness.
phenomenology of psychiatric illness. The ill- The manifestation of neurasthenia as an
ness experience of neurasthenia in the form of illness has also undergone changes within
what Kleinman (1982) described as a ªsocially Chinese societies. Earlier studies in China
and culturally shaped type of somatizationº and Hong Kong (Kleinman, 1982; Wong &
may be affected by the patientsº course of help- Chan, 1984) showed that the presenting
seeking. The somatic symptoms legitimize the complaints of neurasthenic patients were pre-
sick role whereby the patient can get sympathy dominantly somatic, especially weakness, fati-
and attention from medical professionals and gue, insufficiency of qi (vital energy), poor
yet not be rejected or stigmatized. appetite, backache, and weak limbs. A more
The second reason is the use of the term recent study with young university students
neurasthenia as a euphemism by psychiatrists (Lee & Wong, 1995) found a more psycholo-
and the lay public alike to destigmatize gical construal of neurasthenia. Moreover,
psychiatric disorders. As many as 30% of there is a disparity between lay and profes-
Chinese psychiatric patients describe themselves sional definitions of neurasthenia. According
as suffering from neurasthenia when presenting to Beard's (1869) or the ICD-10's (World
themselves to psychiatric clinics (Kleinman, Health Organization, 1992) definition, fatigue
1982; Wong & Chan, 1984). The distinction is considered a core symptom of neurasthenia
between neurasthenia and other forms of but is infrequently reported in Taiwan or Hong
psychiatric disorders may stem from its detach- Kong (Lee & Wong, 1995; Rin & Huang,
ment from the notion of insanity and the stigma 1989). The de-emphasis on fatigue distin-
of madness. Neurasthenia is attributed to guishes the Chinese experience from the
somatic depletion, overwork, irregular lifestyle, Western condition of chronic fatigue syndrome
and extended intellectual activities. It is an which may be considered as a contemporary
acceptable pretext for seeking help for a variety form of ªrevivedº neurasthenia in the West
of conditions including psychological symptoms (Abbey & Garfinkel, 1991). Such a disparity
such as overworry, irritability, and memory points to the importance of examining cross-
difficulties, which when presented on their own cultural differences not only in disease entities,
accord, may be considered inappropriate or but also in the conceptualization of the illness
insufficient cause for medical consultation. experience.
 Somatization as a Category Fallacy 41

10.02.7 ILLNESS EXPERIENCE 1988a; World Health Organization, 1973, 1979),

other diagnoses such as dysthymic disorder or
Medical sociologists and cultural psychia- anorexia nervosa are questioned as examples of
trists have distinguished between illness and ªcategory fallacyº which lack cross-cultural
disease (Mechanic, 1982). Kleinman (1988a) validity. When the culturally imposed categories
makes the distinction succinctly by referring to are found to differ from the illness experience
illness as ªthe patient's perception, experience, found within the culture, ethnocentric profes-
expression, and pattern of coping with symp- sionals tend to interpret the discrepancy as a
tomsº and to disease as ªthe way practitioners problem of the individual or the culture, instead
recast illness in terms of their theoretical models of questioning the relevance of the category
of pathologyº (p. 7). The illness experience is a itself.
culturally shaped phenomenon that is inter-
preted by the patients and their families
resulting in a particular course of action. These 10.02.8 SOMATIZATION AS A
interpretations are mediated by language, ill- CATEGORY FALLACY
ness beliefs, personal significance of suffering,
and learned illness behavior. The problem of category fallacy can be
The experiences of distress are multifaceted. illustrated by the way in which mental health
The distressed persons choose their form of professionals from Western cultures initially
expression according to their own sensitivity to interpreted the tendency among Chinese psy-
those facets that make sense to them or that chiatric patients to somatize their psychological
conform to their understanding. Folk under- distress. In the wake of early interest in cultural
standing of psychological distress seldom con- psychiatry, a number of studies on the patterns
forms to the professional classification of of symptom presentation among Chinese
disorders, especially in cultures where forma- psychiatric patients noted that these patients
lized mental health services are not popular or tend to somatize their problems and delay
are inaccessible. Thus, these expressions are psychiatric treatment (Kleinman, 1977; Lin,
necessarily selective, being bound by the 1982; Lin, Tardiff, Donetz, & Goresky, 1978;
personal and cultural repertoire of distress Marsella, Kinzie, & Gorson, 1973; Tseng,
idioms. The repertoire of coping and illness 1975). Somatization has been emphasized as
behavior is similarly acquired in the socio- the cultural feature of neurotic disorders,
cultural context. The illness experience encom- especially depression, among the Chinese.
passes not only the phenomenology of the Various aspects of the Chinese culture were
individual which focuses on the intrapsychic then put forth to explain the somatization
dimension, but also on the interaction of the tendency (Cheung, 1982, 1985, 1995; Cheung &
person with significant members and aspects of Lau, 1982).
the environment. These social and cultural One group of cultural explanations attributes
dimensions form an integral part of the the somatization tendency to denial, suppres-
dynamics involved in the process of illness. sion, or repression of emotions. The typical
A psychiatric diagnosis, on the other hand, is Chinese is described as being reserved in
a professional's interpretation of the person's expressing feelings and prone to avoiding open
experience which becomes formalized as signs of display of emotions, especially negative ones.
particular disease states in a static medical Another group of explanations argues that the
model. These diagnostic categories are often use of concrete physical terms in expressing
reified as real entities by the professionals who one's distress demonstrates that the Chinese
try to fit the reported experiences into one of the language lacks an adequate vocabulary to
categories. Through exposure, patients learn to express emotions explicitly. So physical meta-
report what the professionals expect of them. phors or terms related to body organs are used
However, when the diagnostic categories devel- to represent affective states. The third group of
oped in one culture are projected onto patients explanations is based on the assumption of
in another culture, their validity needs to be mind±body dualism as the standard of episte-
established. Mental health professionals who mology, so that the lack of distinction between
are mostly trained in Western medical models psychological and somatic systems among the
have often imposed these categories in non- Chinese was likened to the simple, undiffer-
Western cultures even when they lack folk entiated, and concrete level of thinking among
coherence. Some of these categories may be primitive cultures.
more valid or relevant than others, whereas These cultural assumptions have been chal-
there is strong evidence that psychiatric diag- lenged both on the grounds of cultural
noses such as organic brain disorders and specificity as well as interpretation. It has been
schizophrenia are valid worldwide (Kleinman, questioned whether somatization is indeed
42 Cross-cultural Psychopathology

specific to the Chinese as originally claimed. person is categorized as either sick or well. In the
Even so, the explanations for this culturally mechanistic world view, a specific cause is linked
related observation need further scrutiny. to a single effect. These approaches ignore the
Cheung (1982, 1985) criticized these cultural contextual nature of illness involving both the
attributions as post hoc explanations based on organism and the environment, in which there
cultural generalizations without empirical ver- may be interaction among multiple causes in the
ification. In an extensive review of the literature, organism and the environment.
Singer (1975) argued that in the first place, the The focus on somatization as a pathological
phenomenon of somatization is not exclusive to disorder misses the opportunity to understand
Chinese patients, but is also commonly found in a systemic way the various patterns of illness
among less educated and lower social-class behavior among Chinese patients, including
patients in Western countries. Kleinman (1986) their subjective experience, problem presenta-
later reckoned that somatization is also very tion, communication, and form of help-seeking.
common in the West although the fact may be
ignored or de-emphasized there. Cheng (1989)
compared survey results on the symptomatol- 10.02.9 SOMATIZATION AS ILLNESS
ogy of minor psychiatric morbidity in Taiwan EXPERIENCE
and in Britain and found the rates of somatic
symptoms for both countries to be comparable. While studies of Chinese patients in Chinese
There is also evidence to show that although societies have consistently found that somatic
somatic complaints are the dominant features in complaints are the dominant features in their
Chinese patients' symptom presentation, psy- descriptions of discomfort, it is also noted that
chological symptoms are by no means sup- psychological symptoms are readily reported by
pressed or repressed. Cheung, Lau, and both clinical and nonclinical samples, especially
Waldmann (1980±81) found that while de- if directly asked (Cheng, 1988, 1995; Cheung,
pressed patients reported mostly somatic com- 1982, 1987; Cheung et al., 1980±81, 1984). An
plaints to the medical doctor in general practice, attempt to understand the phenomenon of
they were very ready to admit to having a range somatization among the Chinese should take
of psychological and emotional symptoms when into account the phenomenology of discomfort
directly asked by the practitioner. Subsequent and suffering, the process of communication,
studies with psychiatric patients attending ways of coping and help-seeking, and the
psychiatric services for the first time also patient±doctor relationship.
revealed that psychological symptoms were In his recent works, Kleinman (1986, 1988b)
frequently reported along with somatic com- has provided an insightful perspective to under-
plaints (Cheung, Lau, & Wong, 1984). Studies stand somatization as human suffering con-
with the general population and with university textualized in the personal, interpersonal, and
students in Hong Kong also confirm that cultural meanings of illness. He proposed that a
psychological problems were commonly re- ªdialectical relationship exists between symp-
ported (Cheung, 1982; Cheung, Lee, & Chan, toms and societyº (p. 2). The examination of
1983). However, psychological problems may how social factors produce the connection
not be readily reported to the medical practi- between neurasthenia-depression and pain
tioner. Instead, the Chinese would turn to their which may be perceived as the cause of disease
friends and family members for help if they provides the illustration as to the way ªculture
perceive their problems to be psychological in shapes the strategic interpretation and nego-
nature. tiated experience of illnessº (p. 2). As an idiom
One of the problems of these early discussions of distress, somatization is an illustration of the
on the somatization tendency suffered from ethnography of the suffering experience. While
variations in the definitions of the term used. the narrative of human suffering is not confined
Somatization may be referred to as a psychiatric to bodily sensations, this mode of expression is
disorder, various patterns of illness behavior, highlighted in the medical context especially in
forms of help-seeking related to bodily symp- non-Western cultures.
toms, or a combination of these concepts. Based The meaning of bodily symptoms for the
on the formistic and mechanistic model of Chinese has been examined in terms of the
biomedicine (Schwartz, 1982), somatic presen- Chinese language and traditional Chinese
tation of distress is assumed to be due to an medical practice (Cheng, 1989; Ots, 1990; Tung,
underlying psychological problem masked by 1994). In traditional Chinese medicine, emo-
the somatic presentation of symptoms often tional problems are associated with different
equated with somatization. Somatization, thus, body organs. Dysharmonic emotions are patho-
is presumed to be pathological with maladaptive genic etiological factors which produce somatic
consequences. In the formistic world view, a dysfunctions, which, in turn, should be treated
 Somatization as Illness Experience 43

by harmonizing bodily functions (Ots, 1990). interpersonal interactions. Cheung and Lau
Tung also illustrated that the Chinese use body- (1982) showed that situational variations elicited
related verbal expressions in an all-embracing different expectations and behaviors from
fashion to express personal and social aspects of patients who behave according to what they
human concerns. Body-related words form believe is expected of them in the situation. When
expressions that are idioms of human condi- Chinese psychiatric patients perceived their
tions. These forms of expression are indigenous consultation to be medical in nature, such as
and often expressed in local dialects that escape attending a psychiatric clinic, they reported their
the attention of Western-trained psychiatrists physical as well as psychological symptoms. On
(Cheng, 1989). On the other hand, psychiatrists the other hand, when they perceived their
who try to fit the patientsº expressions into their consultation to be related to a judicial nature,
professional taxonomy would miss the rich such as being referred to the psychiatrist at the
information that accompanies the patients' correctional services by the judge, prisoners
expressions. would recount the events leading to their arrest
As illustrated earlier, the use of the term instead of presenting their symptoms.
neurasthenia provides culturally legitimized Studies based on experiences of psychiatric
somatic idioms to sidestep the Western frame- patients may be biased by the self-selection of
work of mental diseases which are highly people who have chosen to consult psychiatric
stigmatized. However, somatic idioms are more services, leading to the conclusion that Chinese
than just euphemistic substitutes for Western patients tend to somatize their psychological
diagnostic labels. They encompass schema to problems. To understand the illness experience
make sense of life problems and to direct of the Chinese people, their coping approaches
courses of action. Illness meanings are physio- and the course of help-seeking prior to the
logical as well as social. According to Kleinman psychological consultation need to be included.
(1986), ªthe lived experience of social reality Studies of the patterns of help-seeking among
mediated by the body . . . is the symbolic bridge, different ethnic groups have shown that non-
the socio-somatic reticulum that ties failure to Caucasian patients generally delay seeking
headaches, anger to dizziness, loss and demor- psychiatric treatment and approach other
alization to fatigueº (p. 146). indigenous resources instead, at least initially
Zheng, Xu, and Shen 1986) analyzed the styles (Cheung, 1987; Cheung et al., 1984; Lin et al.,
of verbal expression of emotional and physical 1978). In Hong Kong, psychiatric consultation
experiences of depressed patients and normal may be delayed by as long as 30 years after the
controls in China. Both emotional and physical initial onset of symptoms if they were perceived
expressions are used as narratives of human to be purely psychological in nature (Cheung,
suffering, depending on the nature of the 1987). The Chinese prefer to endure their
experience. For example, a purely psychological suffering, rely on themselves, or seek help from
verbal style with words such as ªunhappyº and their friends or family for psychological pro-
ªworriedº was used to describe abstract emo- blems. They would be more likely to seek
tional states such as indecisiveness, self-pity, medical attention for physical symptoms which
guilt, or helplessness. Purely somatic expressions would be perceived as illness needing medical
such as ªheart beatingº would be used for the attention (Cheung et al., 1983, 1984). The first
concrete emotional state of fear. The neutral medical consultation is predominantly with the
mode including both psychological and somatic general practitioner. Owing to the unfamiliarity
features (e.g., ªuncomfortable inside the heartº with mental health services, the patients gen-
or ªcannot use my brainº) was used to express erally do not make a distinction among medical
anxiety. For depression, both the somatic and and mental health specialties which are more
the neutral modes were frequently used. In the demarcations defined by the professionals.
expression of suicidal ideation, however, the The dominant role played by the general
person was often unable or unwilling to choose practitioner in directing psychiatric patients to
an expression, which the authors labeled as the mental health services has been highlighted by
deficient expressive style. The somatic style in Goldberg and Huxley (1980). They showed
expressing emotions among the Chinese patients that even in developed countries, only a small
in this study, however, was not related to minority of psychologically disturbed persons
symptom manifestation as reported on a reached psychiatric services. Many psychiatric
symptom checklist. illnesses passed unrecognized by general prac-
Cheung (1995) pointed out that ªsomatization titioners who prolonged medical attention on
as an idiom of distress is contextualized in a the physical complaints. Cheung (1991) likened
process of communicationº (p. 163). This the function of the general practitioner to that
process includes both the discourse between of ªa roundabout where routes may converge
Chinese patients and doctors as well as other and be redirected. When most travelers were
44 Cross-cultural Psychopathology

unfamiliar with the direct route to recovery, the across culturesº (p. 6). While acknowledging
roundabout was the hub they would return to the pervasive nature of multiculturalism in
before embarking on alternative treatment complex modern society, Pedersen's theory is
pathsº (p. 67). The patients' initial conceptua- focused only on counseling approaches.
lization of the causes and severity of their illness A few attempts have been made to apply
would direct their coping and help-seeking specific psychological theories to mental health
behavior. They would only seek medical atten- issues among ethnic subgroups in the USA. For
tion if the problem is perceived to be somatic example, S. Sue (1977) and Zane, Sue, Hu, and
and serious. Once they embark on the medical Kwon (1991) examined cultural differences in
course, the experience of medical consultation, learned helplessness and assertion among
in turn, would have shaped the patients' Asian-Americans using a social learning analy-
interpretation of their suffering. Patients who sis. Specific interest has been directed to the
finally arrived at the psychiatric clinic are likely identity development of ethnic minority groups
to have traveled through detours of medical and how minority identity development may
consultation which focus their attention on their affect mental health problems (Sue, 1989).
somatic complaints. They would be likely to These efforts result in better understanding of
present to the mental health professional, to the cultural diversities and cultural differences
them another medical doctor, that which they among specific ethnic groups. There is much less
deemed as expected and appropriate (Cheung, written on the general role of culture in
1987). psychopathology or abnormal psychology.
The reconceptualization of somatization in
terms of the individual's culturally embedded
10.02.10.1 Role of Culture in Psychopathology
illness experience and narratives of suffering
advances the theoretical understanding from Tseng and McDermott (1981) gave a more
that of a category fallacy to a useful framework comprehensive introduction to the role of
to interpret the phenomena. Psychopathology is culture in psychiatry. Culture affects psycho-
after all a scientific attempt to organize and pathology in many ways, including producing
explain the observed phenomena systematically. stress, creating specific problems, predisposing
Recognition of cross-cultural diversities poses vulnerability, and contributing to the choice of
new challenges to the traditional ethnocentric psychopathology (pp. 14±24).
ideologies that have encapsulated Western
theories of psychopathology and approaches
to clinical psychology. 10.02.10.1.1 Culture-produced stress
Stress may be created by culturally formed
anxiety or culturally demanding performance.
10.02.10 CULTURE AND Cultural attitudes and beliefs prescribe expecta-
PSYCHOPATHOLOGY tions and standards which if not met would
produce mental and emotional stresses. Many
The role of culture in counseling and societies have established taboos, rules, or rites
psychotherapy has received more attention from which, if contravened, would create anxieties.
psychologists than the role of culture in the area Individuals living in cultures that believe spells
of psychopathology (Leong, 1986; Pedersen, can cause death would become ill or even die if
1983, 1987, 1990, 1991; Pederson & Marsella, they think that they are under a spell. Similarly,
1982; Pedersen, Draguns, Lonner, & Trimble, cultural demands of individuals cause stress to
1981; Sue, D. W., 1977, 1978, 1989, 1990, 1991; those who are unable to meet those demands.
Sue, Arredondo, & McDavis, 1992; Sue & Kirk, For example, many cultures demand that a
1975; Sue & Sue, 1977, 1990; Sue & Zane, 1987; woman produce a male child. The woman
Vontress, 1974). Culture has gained the status of would be blamed and would feel guilty if she
a generic theory to explain counseling relation- continued to produce only girls. She would face
ships in general, and not just for understanding a loss of status or the threat of replacement by
exotic people. Pedersen (1991) proposed multi- another woman. These demands produce fear,
culturalism as a ªfourth forceº in counseling, anxiety, and shame.
complementary to psychodynamic, behavioral,
and humanistic explanations of human beha-
10.02.10.1.2 Culture-related problems
vior. The multicultural perspective ªcombines
the extremes of universalism and relativism by Specific problems may be created by a
explaining behavior both in terms of those culturally determined limitation in behavior
culturally learned perspectives that are unique to range, cultural changes, changing roles, and loss
a particular culture and in the search for of source of support, as well as sociocultural
common-ground universals that are shared discrimination. Within a cultural setting where
 Cross-cultural Psychopathology 45

rules are excessive, but the behavior range possession, soul loss, divine wrath, sorcery, or
allowed is very limited, individuals who are not violation of taboo.
prepared for these restrictions would encounter (ii) Natural explanations. Illness, misfortune,
problems. Similarly, rapid cultural changes may and unhappiness are related to the underlying
result in a confused value system to individuals principles of the universe which govern all
who are used to a stable and traditional culture. nature. Disharmony of the natural elements
Changing roles for women, for example, while within the human body, incompatibility with
improving women's social status and sense of natural principles in the environment, and
independence, may also render them more noxious factors in the environment upset the
vulnerable to loneliness and depression when natural principles and cause physical and men-
the protection and support women previously tal disturbance.
obtained from their families have diminished. (iii) Physical-medical explanations. The rea-
Sociocultural groups who face discrimination sons for illness are viewed as physical or
within a society suffer scorn, isolation, and physiological originating from the individual.
disadvantage, resulting in stress and deficits. The causes may be physical-physiognomy pro-
blems (such as facial features, body build),
10.02.10.1.3 Culture-inherited vulnerability physiological imbalance or insufficiency (such
as badly balanced diet, excessive sexual activ-
Vulnerability to stress may be predisposed by ity), or disease.
culturally prescribed child-rearing practices (iv) Sociopsychological explanations. Mental
which influence the child's personality. In some disorder is seen as a psychological reaction to
cultures, parents emphasize independence and the stress of internal or external maladjustment.
early decision making. This push toward Tseng and McDermott, however, did not
independence may put undue pressure on the make any distinction between the professional
young person who needs a longer period of or ªauthoritativeº explanations of abnormal
dependency. In other cultures, intimate depen- behaviors and the folk conceptualizations and
dency on mothers is extended for a much longer attributions of the experience of distress in these
time. This dependency is extended into adult categories. In non-Western cultures that have
relationships as well which may lead to later not adopted Western models of medicine and
problems in socialization with others. psychology, explanatory models are often based
on folk concepts. In cross-cultural comparisons
10.02.10.1.4 Cultural contribution to choice of of explanatory models, there may be biases
psychopathology when Western professional models of psychia-
tric classification are compared with local folk
Culture plays a part in how its vulnerabilities concepts of distress.
find expression by influencing model solutions
to problems that may themselves be patholo-
gical. The form of psychopathology found in a 10.02.11 CROSS-CULTURAL
culture tends to be linked with the stresses PSYCHOPATHOLOGY
within that culture. For example, excessive self-
10.02.11.1 Universalist vs. Relativist
depreciation, a result of compliance to strong
Approaches
external control, may become a cause for
depression. There is also a suggestion that Cross-cultural psychopathology is premised
low social cohesion in a community is related to on two competing orientations. The biological
the frequency of depression. approach assumes that the cultural invariance of
mental disorders, that is, the same disorders are
10.02.10.2 Cultural Explanations prevalent in all cultures (Fernando, 1988, p. 60).
In this approach, the ªuniversalistº would use
Once psychological disorders are detected, the psychiatric classification system developed
culture also plays a role in labeling these in the West as a basis of identifying disorders in
disorders based on its concepts of mental illness. other parts of the world. The social-anthro-
These labels describe the observed behavior, pological approach, on the other hand, empha-
attribute causes, provide explanations, and sizes the cultural relativity of psychopathology,
convey social acceptance or rejection of the with each culture having its own disorders.
afflicted. Explanations of the nature and cause Culture plays an important role in determining
of mentally disturbed behaviors are grouped the behavior, thinking, and emotions of the
into four categories by Tseng and McDermott individuals resulting in different forms of mental
(1981, pp. 29±33): disorders. The ªrelativistº looks at illness as a
(i) Supernatural explanations. The distur- part of the total cultural context deriving its
bance is explained as resulting from spirit meaning from the specific culture.
46 Cross-cultural Psychopathology

The two orientations have led to different within a single culture provides a rich source of
research directions in cross-cultural psycho- information about the phenomena. However, as
pathology. The universalist or etic orientation pointed out earlier, attributions to cultural
has focused on cross-cultural comparisons in phenomena were often based on post hoc and
the rates of major psychiatric disorders, based generalized assumptions about the culture
on classification systems developed in the West. involved without elaboration on the functional
These studies have made use of population relationship between cultural processes and
surveys with results showing a range of rates of psychopathology.
major mental disorders in different countries The shortcoming of the universalist approach
(cf. Kleinman, 1988a, pp. 34±41, or Draguns, lies in its ethnocentricism which assumes that the
1985, 1986, 1989 for a review of the findings). Western culture is more developed and superior.
However, it has been noted that a narrower Cross-cultural differences are interpreted as a
range of rates is found when diagnostic criteria reflection of cultural underdevelopment, as in
are standardized and more homogenous sam- the early days of psychiatry when non-Western
ples of cases are used. International studies cultures were often referred to as ªprimitiveº
have been carried out to compare the pre- and ªsavagesº (Fernando, 1988, p. 60). It is
valence and symptomatology of common assumed that diagnostic categories developed in
psychiatric diseases such as schizophrenia a Western cultural setting are applicable uni-
(Sartorius et al., 1986; World Health Organiza- versally. Standardized research methods are
tion, 1973, 1979) or depression (Jablensky, developed to establish reliable diagnoses across
Sartorius, Gulbinat, & Ernberg, 1981; World cultures in Western terms. However, the cross-
Health Organization, 1983). These studies cultural validity of the disease as an illness or a
identified core syndromes of the disorders. phenomenon in those other cultures may not be
For example, across the nine research sites established (Fernando).
which represented both developed and devel- Similarly, the universalist approach to assess-
oping countries, the core syndrome of schizo- ment may lead to misleading clinical interpreta-
phrenia included ªrestricted affect, poor tions. For example, in the application of the
insight, thinking aloud, poor rapport, incoher- MMPI to the Chinese people, several clinical
ent speech, unrealistic information, and bizarre scales, including the Depression scale and the
and/or nihilistic delusionsº (Draguns, 1989, Schizophrenia scale, were found to be consis-
p. 242). The more modest project on depression tently elevated even among normal samples
involving four countries (World Health Orga- when the American norms were used (Cheung,
nization, 1983) also identified a small number 1995; Cheung, Song, & Zhang, 1996). Both in
of symptoms such as vegetative symptoms Hong Kong and the People's Republic of China,
which were present in most of the countries. On the mean T-scores for normal adults on these
the other hand, the experience of guilt is much two scales usually approach the clinical cut-off
less universal in the symptomatology of point used in the USA, although the mean
depression. scores for clinical samples are even higher. If
Similar to psychiatric epidemiological studies cultural universality is assumed, there would be
comparing specific disorders, cross-cultural a danger of overinterpreting clinical pathology
assessment studies have applied the major in the normal Chinese population.
assessment instruments developed in the West The relativist approach, on the other hand,
to other cultures and identified cross-cultural may not get beyond describing culture-bound
similarities and differences. For example, one syndromes and constructing intracultural ex-
personality test that has been translated and planations, thereby not contributing much to
tried out in the most number of countries is the cross-cultural psychopathology. By assuming
Minnesota Multiphasic Personality Inventory cultural specificity, no comparison can be made
(MMPI; Butcher & Clark, 1979; Butcher & between cultural units. Without a cross-cultural
Pancheri, 1976; Butcher & Spielberger; 1985, framework, the notion of culture, however,
Hathaway & McKinley, 1967). These studies becomes irrelevant. The determination of the
confirmed the clinical utility of the MMPI in cultural unit itself is also a subject of con-
other countries although cultural differences are troversy. Cultural groups are usually opera-
identified and cultural adaptations may have to tionally defined in terms of race, ethnicity,
be made (e.g., Cheung & Song, 1989; Cheung, geographic location, or religion, assuming
Song, & Butcher, 1991; Cheung, Song, & cultural similarity among members of the same
Zhang, 1996; Cheung, Zhao, & Wu, 1992). groups. Subcultural groups further complicate
The relativist or emic orientation has focused the assumption of cultural similarity.
on culture-specific phenomena, such as culture- An alternative approach to get out of the
bound syndromes discussed in an earlier impasse created by these two extreme positions is
section. Research based on in-depth studies to reconstruct cross-cultural psychopathology
 Cross-cultural Psychopathology 47

from the basic units of clinical psychology: cultures, guilt may be expressed in absolute and
observation of the phenomenological experience abstract terms involving self-accusation and
of individuals from their cultural contexts, condemnation. In collectivistic cultures, guilt
description of these expressions and manifesta- may be expressed in more concrete and inter-
tions on the basis of the individuals' perspec- personal modes.
tives, prescription of labels which are culturally To date, there are few studies on cross-
relevant or meaningful based on indigenous and cultural psychopathology using the other three
cross-cultural studies, selection of appropriate dimensions from Hofstede's study. Draguns
treatment alternatives, and prediction of out- (1989) further noted that psychopathology
come. While the world is becoming more varied across cultures even when there was no
multicultural, this contextualized analysis may substantial difference on Hofstede's four di-
become a ªuniversalº approach. mensions. He pointed to the need for more
multicultural studies involving both normal and
abnormal samples in order to formulate the
10.02.11.2 Recent Research on Cross-cultural functional relationship between cultural char-
Psychopathology acteristics and psychopathology.
The series of studies on somatization among
Recent research on cross-cultural differences the Chinese described in earlier sections also
in psychopathology has attempted to explain illustrates how cross-cultural differences in the
the similarities and differences in terms of the expression of symptomatology could be under-
cultural contexts. For example, while a pancul- stood in terms of the culturally relevant
tural nucleus of symptoms was found for cognitive schema and interpersonal contexts.
schizophrenia and depression, a variety of Through these cultural studies, important
cultural transformations was also identified. dimensions that have not been examined in
Draguns (1989) proposed a range of possible North American and Western European the-
relations between culture and the manifesta- ories could be incorporated to increase the
tions of the disorders. These include: cultural sensitivity of these theories. This
(i) magnification or exaggerationÐa cultu- cultural sensitivity is becoming more important
rally characteristic behavior being caricatured not only because ethnic and cultural pluralism is
and reduced to absurdity; becoming more prevalent in many societies.
(ii) violation of cultural normsÐdoing what What are thought to be indigenous categories
is not culturally permissible; can in fact be extended to explain the complexity
(iii) cultural differences in values affecting of human personality and psychopathology
the characteristic modes of expressing within and across cultures.
psychopathologyÐsymptom choice and expres- One example of this combined emic-etic
sion being conceptualized as social transactions. approach is the development of the Chinese
However, there are few studies that examine Personality Assessment Inventory (CPAI;
the functional relationship between cultural Cheung, Leung, Fan, et al., 1996) which
characteristics and cross-cultural differences integrated Western methods of personality
in psychopathology. Draguns (1989) attempted assessment with folk concepts of personality
to apply Hofstede's (1980) worldwide study of in the Chinese culture. In addition to etic
work-related values to manifestations of ab- personality constructs, emic constructs which
normal behavior across cultures. In Hofstede's were not covered in translated personality
original study, which involved employees from inventories were included in the CPAI. Scales
over 40 nationalities, four cultural dimensions were developed for personality characteristics
were found to be capable of accounting for most such as harmony, relationship orientation, face,
of the cultural differences. These four dimen- modernization, and thrift, which are salient
sions were individualism/collectivism, uncer- constructs for person descriptions among the
tainty avoidance, power distance, and Chinese. These scales were loaded on a factor
masculinity/femininity. Hofstede (1983) had labeled Chinese Tradition. The Chinese Tradi-
linked the dimension of individualism/collecti- tion factor was found to be a relevant predictor
vism to the distinction made earlier by Benedict of mental health measures especially for
(1946) between ªguiltº (individualist) and Chinese males. It enhanced life satisfaction
ªshameº (collectivist) cultures. However, the and prevented the acting out of antisocial
relationship between this value dimension and behavior particularly when the stress level was
psychopathology involves a more subtle pro- high (Cheung & Gan, 1996). The Chinese
cess. Rather than assuming that patients from Tradition factor was also found to be culturally
some Asian cultures do not experience guilt, distinct from the five-factor structure of
cultural differences may be found more in the personality which is currently accepted as a
way that guilt is expressed. In individualistic universal model of personality (Cheung, Leung,
48 Cross-cultural Psychopathology

Law, & Zhang, 1996). These emic constructs ing somatization as an illness experience and
may introduce new dimensions of the person- narratives of suffering, a more useful framework
ality structure to Western models of personality for studying the relationship between culture
and psychopathology. and psychopathology is also identified.
Culture affects psychopathology by produ-
cing stress, creating specific problems, predis-
10.02.11.3 Future Directions posing vulnerability, and selecting the form of
psychopathology. It also provides folk explana-
As Lewis-Fernandez and Kleinman (1994)
tions of the nature and cause of aberrant
concluded, ªwe might very well come across
behavior. Earlier research methods have
local indigenous categories, such as face and
adopted either the emic or the etic approach.
favor, that can be used to reformulate our
The emic approach focused on the relativistic
leading models of personality formation and
aspects of culture such as culture-bound
their relationship to psychopathologyº (p. 70).
syndromes. The etic approach, on the other
The study of cross-cultural psychopathology is
hand, assumes that Western-based constructs
expanding beyond the exotic frontier into the
are applicable in other cultures and attempts to
mainstream of psychology.
replicate these constructs in cross-cultural
Research in cross-cultural psychopathology,
studies. Recent studies attempt to incorporate
as in other fields of cross-cultural psychology, is
the emic±etic approaches. For example, the
incorporating the combined emic±etic ap-
development of an emic±etic instrument such as
proach. There is an increasing recognition that
the CPAI has introduced new dimensions of the
ªculture-boundº syndromes may not be unique
personality structure to Western models of
to a specific culture. Instead, culture-related
psychopathology. Other work such as that by
phenomena such as neurasthenia and somatiza-
Draguns (1989) are uses multicultural studies to
tion help to illustrate the dynamics of cultural
formulate functional relationships between
forces affecting illness behavior in different
cultural characteristics and psychopathology.
societies.
These new developments have pointed to the
Psychopathology is manifested in a cultural
importance of the interpersonal dimension in
context, and should be interpreted via a
psychopathology which has often been ne-
contextualized analysis. Cross-cultural psycho-
glected in Western models of psychopathology.
pathology research can help to identify con-
Future directions for study in cross-cultural
vergent and divergent dimensions in explaining
psychopathology need to bring culture from its
normal and abnormal behaviors across cultures,
marginal status into the mainstream of clinical
enhancing our awareness as researchers and
psychology.
practitioners of the cultural context of our
analyses. As our global community becomes
more multicultural, the dialectic process of 10.02.13 REFERENCES
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 Copyright © 1998 Elsevier Science Ltd. All rights reserved.

10.03
Cultural Bias in Testing of
Intelligence and Personality
CECIL R. REYNOLDS
Texas A&M University, College Station, TX, USA

10.03.1 INTRODUCTION 53
10.03.2 THE CONTROVERSY OVER BIAS IN PSYCHOLOGICAL TESTING: WHAT IT IS
AND WHAT IT IS NOT 54
10.03.3 THE NATURE OF PSYCHOLOGICAL TESTING ADDS TO THE CONTROVERSY 57
10.03.4 WHAT ARE POSSIBLE SOURCES OF BIAS? 59
10.03.5 MEAN SCORE DIFFERENCES AS TEST BIAS 60
10.03.5.1 Culture-free Tests, Culture Loading, and Culture Bias 61
10.03.5.2 The Question of Labeling Effects 62
10.03.6 THE PROBLEM OF DEFINITION 64
10.03.7 RESEARCH STRATEGIES AND RESULTS 65
10.03.7.1 Bias in Content Validity 65
10.03.7.2 Bias in Construct Validity 72
10.03.7.3 Bias in Predictive or Criterion-related Validity 77
10.03.8 CROSS-CULTURAL TESTING WHEN TRANSLATION IS REQUIRED 85
10.03.9 SUMMARY AND FUTURE DIRECTIONS 85
10.03.10 REFERENCES 86

10.03.1 INTRODUCTION have not been exposed to the cultural and

environmental circumstances and values of the
The issues of bias in psychological testing have so-called White middle class. Intertwined within
been a source of intense and recurring social the general issue of bias in tests has been the
controversy throughout the history of mental more specific question of whether intelligence
measurement. In England, the issue was raised tests should be used for educational purposes.
by Burt (1921) early in the twentieth century. Although scientific and societal discussion per-
The first investigations into cultural bias, how- taining to differences among groups on mea-
ever, can be traced to Binet, originating around sures of cognitive or intellectual functioning in
1910 in France (Binet & Simon, 1916) and to no way fully encompasses the broader topic of
Stern (1914) shortly therafter. In the USA, bias in mental measurement, there is little doubt
discussions pertaining to test bias are frequently that the so-called ªIQ controversyº has received
accompanied by emotionally laden polemics the lion's share of public scrutiny over the years.
decrying the use of mental tests with any It has been the subject of numerous publications
minority group member, since ethnic minorities in the more popular press (see Gould, 1981;

53
54 Cultural Bias in Testing of Intelligence and Personality

Herrnstein & Murray, 1994; or Jensen, 1980, meaning. Nevertheless, the discussion of bias in
chap. 1), and court actions and legislation have psychological testing as a scientific issue should
addressed the use of IQ tests within schools and concern only the statistical meaning, whether or
industry. not there is systematic error in the measurement
From Binet to Jensen, many professionals of a psychological attribute as a function of
have addressed the problem, with varying and membership in one or another cultural or racial
inconsistent outcomes. Unlike the pervasive and subgroup (Reynolds, 1982b). This definition,
polemical nature±nuture argument, the bias defined more technically as required later, will be
issue was until the 1970s largely restricted to followed throughout this chapter.
the professional literature, except for a few early
discussions in the popular press (e.g., Freeman,
1923; Lippmann, 1923a, 1923b). Of some 10.03.2 THE CONTROVERSY OVER BIAS
interest is the fact that one of the psychologists IN PSYCHOLOGICAL TESTING:
who initially raised the question was the then- WHAT IT IS AND WHAT IT IS NOT
young Cyril Burt (1921), who even in the 1920s
was concerned about the extent to which Systematic group differences on standardized
environmental and motivational factors affected intelligence and aptitude tests occur as a
performance on intelligence tests. Within the last function of socioeconomic level, race or ethnic
30 years, however, the questions of cultural test background, and other demographic variables
bias have burst forth as major contemporary throughout the various countries of the world.
problems far beyond the bounds of scholarly Black±White differences on IQ measures in the
academic debate in psychology. The debate over USA have received extensive investigation since
bias has raged in both the professional and the the 1930s. The preponderance of these studies
popular press for multiple decades (e.g., Fine, have been reviewed by Shuey (1966), Tyler
1975). Entangled in the larger issues of indivi- (1965), Jensen (1980), and Willerman (1979).
dual liberties, civil rights, and social justice, the Results have not changed fundamentally in the
bias issue has become a focal point for last century. Although the results occasionally
psychologists, sociologists, politicians, and the differ slightly, depending on the age groups
public. Increasingly, the issues have become under consideration, random samples of Blacks
political and legal ones, as reflected in numerous and Whites in the USA show a mean score
court cases and passage in the state of New York difference of about one standard deviation, with
and consideration elsewhere of what is popularly the mean score of the Whites consistently
known as ªtruth-in-testingº legislation. The exceeding that of the Black groups. The
magnitudeÐand the uncertaintyÐof the con- differences have persisted at relatively constant
troversy and its outcome is shown in two highly levels for quite some time and under a variety of
publicized US Federal district court cases. The methods of investigation. The exception to this
judiciary's answer to the question ªAre the tests is the reduction of the Black±White IQ
used for pupil assignment to classes for the difference on the Kaufman Assessment Battery
educably mentally retarded biased against for Children (K-ABC; Kaufman & Kaufman,
cultural and ethnic minorities?º initially was 1983) to about 0.5 standard deviations on the
ªYesº in California (Larry P. et al. v. Wilson intelligence portion of the scale, a controversial
Riles et al., 1979) and ªNoº in Illinois (PASE v. and poorly understood finding (see Kamphaus
Hannon et al., 1980), although the Larry P. & Reynolds, 1987, for a discussion). These
finding has now been overturned, giving a findings are consistent only for the US Black
consistent nature to court findings in the USA. population, however, and other, quite diverse
Unfortunately, we are all prisoners of our findings appear for African and other Black
language. The word bias has several meanings, populations (e.g., see Jensen, 1980).
not all of which are kept distinct. In relation to When a number of demographic variables are
the present issue, bias as ªpartiality towards a taken into account (most notably socioeconomic
point of view or prejudiceº and bias as ªa status), the size of the mean Black±White
statistical term referring to a constant error of a difference in the USA reduces to 0.5±0.7
measure in one specific direction as opposed to standard deviations (e.g. Jensen, 1980; Kauf-
random errorº frequently become coalesced. If man, 1973; Kaufman & Kaufman, 1973;
the latter meaning did not drag along the excess Reynolds & Gutkin, 1981), but remains robust
baggage of the former, the issue of bias in mental in its appearance. All studies of racial and ethnic
testing would be far less controversial and group differences on ability tests do not show
emotional than it is. However, as indicated in the higher levels of performance by Whites.
Oxford English Dictionary, bias as partiality or Although not nearly as thoroughly researched
prejudice can be traced at least to the sixteenth as Black±White groups, Oriental groups have
century and clearly antedates the statistical been shown to perform consistently as well as, or
 The Controversy Over Bias in Psychological Testing 55

better than, White groups (Pintner, 1931; Tyler, all of the observed group differences could be
1965; Willerman, 1979). Depending on the explained by any one of the three factors alone.
specific aspect of intelligence under investiga- Loehlin, Lindzey, and Spuhler (1975) con-
tion, other racial and ethnic groups show cluded that all three factors were probably
performance at or above the performance level involved in racial differences in intelligence as
of White groups. There has been argument over have a myriad of other researchers (e.g., Bou-
whether any racial differences in intelligence are chard & Segal, 1985; Flynn, 1991). In its
real or even researchable (e.g., Schoenfeld, present, more complex form, the cultural test
1974), but the reliability across studies is very bias hypothesis considers other factors than
high, and the existence of the differences is now culture-loaded items, as will be seen below. But
generally accepted. It should always be kept in the basics of Eell's summary of the cultural-test-
mind, however, that the overlap among the bias hypothesis still hold: group differences
distributions of intelligence test scores for the stem from characteristics of the test or from
different races is much greater than the degree of aspects of test administration. Because mental
differences among the various groups. There is tests are based largely on middle-class White
always more within-group variability than values and knowledge, they are more valid for
between-group variability in performance on those groups and are biased against other
psychological tests. The differences are never- groups to the extent that these groups deviate
theless real ones and are unquestionably com- from those values and knowledge bases.
plex (e.g., Reynolds & Jensen, 1983). This position has been reframed slightly over
The issue at hand is the explanation of those the years, principally by Mercer (e.g., 1979) and
group differences. It should be emphasized that reinforced by Helms (1994), who argue the
both the lower scores of some groups and the lower scores of ethnic minorities on aptitude
higher scores of others need to be explained, measures can be traced to the Anglocentrism
although not necessarily, of course, in the same (degree of adherence to White, middle-class
way. The problem was clearly stated by Eells in value systems of USA families) of aptitude
his classic study of cultural differences: measures. Mercer (1979) developed an entire
system of assessments designed to provide
Do the higher test scores of the children from high complex demographic corrections to IQs ob-
socioeconomic backgrounds reflect genuine super- tained by ethnic minorities that had the effect of
iority in inherited, or genetic, equipment? Or do equating these groups on mean scores. (This
the high scores result from a superior environment system, known as the SOMPA, had quite a bit of
which has brought about real superiority of the popularity for several years but is rarely used
child's ªintelligence'? Or do they reflect a bias in
today because of its conceptual and psycho-
the test materials and not any important differ-
ences in the children at all? (Eells, Davis, Havigh- metric inadequacies.) Lonner (1985) discusses
urst, Herrick, & Tyler, 1951, p. 4). similar issues under the rubric of cultural
isomorphism in testing and assessment. Helms
Eells et al. also concisely summarized the (1994) makes similar criticisms of ability tests,
cultural-test-bias hypothesis as it applied to rejects most psychometric research on these
differences in socioeconomic status (SES): issues, and posits (quite similar to Mercer's
position) it is the Eurocentric nature of aptitude
If (a) the children from different social-status levels tests that produces artifactual differences in
have different kinds of experiences and have mean levels of performance across ethnic lines,
experiences with different types of material, and focusing especially on the performance of Black
if (b) the intelligence tests contain a dispropor- Americans. In all of those conceptual models,
tionate amount of material drawn from the which are essentially contemporaneous even
cultural experiences with which pupils from the with arguments of Burt as early as 1921, ethnic
higher social-status levels are more familiar, one and other group differences in mean levels of
would expect (c) that children from the higher performance on aptitude measures are seen to
social-status levels are more familiar, one would result from flawed psychometric methodology
expect (d) that children from the higher social-
status levels would show higher IQs than those
and not from actual differences in aptitude (see
from the lower levels. This argument tends to also Harrington, 1975, 1976). As described
conclude that the observed differences in pupil IQs below, this hypothesis reduces to one of
are artifacts dependent upon the specific content of differential validity, the hypothesis of differ-
the test items and do not reflect accurately any ential validity for mental tests being that tests
important underlying ability in the pupils. (Eells measure intelligence more accurately, and make
et al., 1951 p. 4) valid predictions about the level of intellectual
functioning for individuals from the groups on
Eells was aware that his descriptions were which the tests are mainly based than for those
oversimplifications and that it was unlikely that from other groups. Artifactually low scores on
56 Cultural Bias in Testing of Intelligence and Personality

an aptitude test could lead to denial of environment best suited to them, and job
employment or in schools to pupil misassign- applicants may end up in occupations for which
ment to educational programs and unfair denial they are ill-suited or for which others are more
of admission to college, graduate school, or qualified. Further, research on the basis of any
other programs or occupations in which such group differences would be stifled, as would the
test scores are an important decision-making implementation of programs designed to re-
component. This is the issue over which most mediate any deficiencies. The most advanta-
legal cases have been fought in the USA. geous position for the true White racist and bigot
Further, there would be dramatic implications would be to favour the test bias hypothesis!
for whole areas of psychological research and Acceptance of that hypothesis inappropriately
practice if the cultural-test-bias hypothesis is would eventually result in inappropriate pupil
correct. The principal research of the twentieth assignment, less adaptive education for some
century in the psychology of human differences groups, and less implementation of long-range
would have to be dismissed as confounded and programs to raise intellectual performance.
largely artifactual because much of the work is Inappropriate confirmation of the test bias
based on standard psychometric theory and hypothesis would appear to maintain, not break
testing technology. The result would be major down, the poverty cycle (Birch & Gussow, 1970).
upheavals in the practice of applied psychology, The controversy is also not over the blatantly
as the foundations of clinical, school, counsel- inappropriate administration and use of mental
ing, and industrial psychology are strongly tied tests. The administration of a test developed and
to the basic academic field of individual published in English to an individual for whom
differences. The issue, then, is crucial not only English is a second language and whose English
to the science of psychology but to practice language skills are poor is inexcusable, regard-
(Lonner, 1985; Reynolds, 1980c). less of any bias in the tests themselves. It is just
On the other hand, if the cultural-test-bias as inexcusable to translate the test into the
hypothesis is incorrect, then group differences examinee's first or dominant language and
are not attributable to the tests and must be due assume the validity of the results. Translating a
to one of the other factors mentioned by Eells test from its original language is a wholly
et al. (1951) or to some combination of them. inadequate process and creates many problems
That group differences in test scores reflect real of reliability and validity. Instead, a test must be
group differences in ability should be admitted redeveloped, preferably following the steps
as a possibility, and one that calls for scientific outlined and discussed by Hambleton and
study. Kanjee (1995). It is of obvious importance that
The controversy over test bias should not be tests be administered by skilled and sensitive
confused with that over the etiology of any professionals who are aware of the factors that
obtained group differences in test scores (see may artifactually lower an individual's test
Reynolds & Kaiser, 1990, for a review) other scores. Considering the use of tests to assign
than to rule bias in or out as an explanation. pupils to special education classes or other
Unfortunately, it has often been inferred that programs, a question needs to be asked: What
measured differences themselves indicate genet- would one use instead? Teacher recommenda-
ic differences, and therefore the genetically tions are notoriously less reliable and less valid
based intellectual inferiority of some groups. than standardized test scores, which increases
Jensen has himself consistently argued since the probability of bias occurring. For college
1969 that mental tests measure, to a greater or admissions, this question was asked long ago
lesser extent, the intellectual factor g which has a and the use of grades and subjective letters of
large genetic component, and that group recommendation and interviews found to be
differences in mental test scores may then unreliable and biased. This research in the early
reflect group differences in g. Unless one reads 1900s led to the formation of the College
Jensen's statements carefully, it is easy to Entrance Examination Board and the Scholas-
overlook the many qualifications that he makes tic Achievement Test (SAT).
regarding these differences and conclusions. The controversy over the use of mental tests is
But, in fact, Jensen's or anyone else's position further complicated by the fact that resolution
on the genetic basis of actual group differences of the cultural test bias question in either
should be seen as irrelevant to the issue of test direction will not resolve the problem of the role
bias. However controversial, etiology is a of nonintellective factors that may influence the
separate issue. It would be tragic to accept the test scores of individuals from any ethnic group.
cultual test bias hypothesis as true if it is, in fact, Regardless of any group differences, it is
false. In that case, measured differences would individuals who are tested and whose scores
be seen as not real, and children, for example, may or may not be accurate. Similarly, it is
might be denied access to the educational individuals who are assigned to classes, chosen
 The Nature of Psychological Testing Adds to the Controversy 57

for universities, placed in jobs or vocations, and and of long duration. Indeed, there are still
who are accepted or rejected. As indicated by disputes about the nature and the number of
Wechsler (1975) and others, nonintellective processes such as emotion and motivation (e.g.,
factors, informational content, and emotional± Bolles, 1975; Mandler, 1975). One of the major
motivational conditions may be reflected in areas of disagreement has been over the
performance on mental tests. The extent to measurement of psychological processes. It
which these factors influence individual as should be expected that intelligence, as one of
opposed to group performance is difficult to the most complex of psychological processes,
determine. Perhaps with more sophisticated involves definitional and measurement disputes
multivariate designs, we will be better able to that prove difficult to resolve.
identify individuals with characteristics that are Assessment of intelligence and personality,
likely to have an adverse effect on their like that of many other psychological processes
performance on mental tests. Basically, outside in humans, is accomplished by standard psycho-
the major thrust of the issue of bias against metric procedures that are the focus of the bias
groups, potential bias against individuals is a issue. These procedures, described in detail in
serious problem itself, and merits research and general assessment texts (e.g., Anastasi, 1982;
analysis. Sternberg (1980), also concerned Linn, 1989), are only briefly summarized here in
about individual performance, observed a still relation to the issue of bias. Problems specific to
true matter: research on bias has concentrated validity are discussed in Section 10.03.7.
on status variables such as ethnicity rather than Similar procedures are used in the develop-
on functional variables such as cognitive styles ment of any standardized psychological test.
and motivations. First, a large number of items are developed that
for theoretical or practical reasons are thought
to measure the construct of interest. Through a
10.03.3 THE NATURE OF series of statistical steps, those items that best
PSYCHOLOGICAL TESTING measure the construct in a unitary manner are
ADDS TO THE CONTROVERSY selected for inclusion in the final test battery.
The test is then administered to a sample, which
The question of bias in mental testing arises should be chosen to represent all aspects of the
largely because of the nature of psychological population on whom the test will be used.
processes and the measurement of those Normative scales based on the scores of the
processes (Reynolds & Brown, 1984). Psycho- standardization sample then serve as the
logical processes, by definition internal and not reference for the interpretation of scores of
directly subject to observation or measurement, individuals tested thereafter. Thus, as has been
must be inferred from behavior. Theoretically, pointed out numerous times, an individual's
in the classic discussion by MacCorquodale and score is meaningful only relative to this
Meehl (1948), a psychological process has the normative base and is a relative, not an
status of an ªintervening variableº if it is used absolute, measure. Charges of bias frequently
only as a component of a system that has no arise from the position that the test is more
properties beyond those that operationally appropriate for the groups heavily represented
define it, but it has the status of a ªhypothetical in the standardization sample. Whether bias
constructº if it is thought actually to exist with does, in fact, result from this procedure is a
properties beyond the defining ones. A histor- specific question to be addressed empirically.
ical example of a hypothetical construct is gene, As has also been frequently pointed out, there
which had meaning beyond its use to describe are few charges of bias of any kind relating to
the cross-generational transmission of charac- physical measures that are on absolute scales,
teristics. Intelligence, from its treatment in the whether interval or ratio. Group differences in
professional literature, has the status of a height, as an extreme example, are not attrib-
hypothetical construct as does personality. uted by anyone we know of to any kind of
As even beginning psychology students cultural test bias or specific methods of
know, it is difficult to determine one-to-one measuring height. There is no question con-
relationships between observable events in the cerning the validity of measures of the height or
environment, the behavior of an organism, and weight of anyone in any culture. Nor is there any
hypothesized underlying mediational processes. question about one's ability to make cross-
Many classic controversies over theories of cultural comparisons of these absolute mea-
learning have revolved around constructs such sures (which variables, such as height, are
as expectancy, habit, and inhibition (e.g., clearly subject to genetic by environmental
Goldstein, Krantz, & Rains, 1965; Hilgard & interactions).
Bower, 1975; Kimble, 1961). Disputes among The whole issue of cultural bias arises because
different camps in learning have been polemical of the procedures involved in psychological
58 Cultural Bias in Testing of Intelligence and Personality

testing. Psychological tests measure traits that Wesman, 1975) was subsequently published in
are not directly observable, that are subject to the official journal of the APA, American
differences in definition, and that are measur- Psychologist.
able only on a relative scale. From this Subsequent to the ABP's policy statement,
perspective, the question of cultural bias in other groups adopted policy statements on
mental testing is a subsetÐobviously of major testing. These groups included the National
importanceÐof the problems of uncertainty Association for the Advancement of Colored
and of possible bias in psychological testing People (NAACP), the National Education
generally. Bias may exist not only in mental tests Association (NEA), the National Association
but in other types of psychological test, of Elementary School Principals (NAESP), the
including personality, vocational, and psycho- American Personnel and Guidance Association
pathological tests. Making the problem of bias (APGA), and others (Committee on Testing,
in mental testing even more complex is the fact 1974; Williams et al., 1980). The APGA called
that not all mental tests are of the same quality. for the Association for Measurement and Evalu-
Like Orwell's pigs, some may be more equal ation in Guidance (AMEG), a sister organiza-
than others. There is a tendency for critics and tion, to develop and disseminate a position paper
defenders alike to overgeneralize across tests, stating the limitations of group intelligence tests
lumping virtually all tests together under the particularly and generally of standardized psy-
heading ªmental testsº or ªintelligence tests.º chological, educational, and employment test-
As reflected in the Mental measurements year- ing for low socioeconomic and underprivileged
book (e.g., Buros, 1978), professional opinions and non-White individuals in educational,
of mental tests vary considerably, and some of business, and industrial environments.
the most used tests are not well respected by The APGA also resolved that, if no progress
psychometricians. Thus, unfortunately, the was made in clarifying and correcting the
question of bias must eventually be answered current testing of minorities, it would also call
on a virtually test-by-test basis. for a moratorium, but only on the use of group
In 1969, the Association of Black Psycholo- intelligence tests with these groups.
gists (ABP), a USA-based professional associa- The NAACP adopted a more detailed
tion, adopted the following official policy on resolution and joined in the call for a morator-
educational and psychological testing: ium on standardized testing of minority groups
at its annual meeting in 1974. The text of the
The Association of Black Psychologists fully NAACP resolution was:
supports those parents who have chosen to defend
their rights by refusing to allow their children and
themselves to be subjected to achievement, intelli- Whereas a disproportionately large number of
gence, aptitude and performance tests which have Black students are being misplaced in special
been and are being used to A. Label Black people education classes and denied admissions to higher
as uneducable. B. Place Black children in ªspecialº educational opportunities,
classes and schools. C. Perpetuate inferior educa- Whereas students who fail to show a high verbal
tion in Blacks. D. Assign Black children to or numerical ability, score low on the Scholastic
educational tracts. E. Deny Black students higher Achievement Test (SAT), the Law School Admis-
educational opportunities. F. Destroy positive sions Test (LSAT), the Graduate Record Exam-
growth and development of Black people. (quoted ination (GRE), etc., and are routinely excluded
in Reynolds, 1982a, p. 179) from college and graduate or professional educa-
tion,
Be it resolved that the NAACP demands a
Since 1968, the ABP has sought continuously
moratorium on standardized testing whenever
a moratorium on the use of all psychological and such tests have not been corrected for cultural
educational tests with the culturally different bias and directs its units to use all administrative
(Samuda, 1975, and Williams, Dotson, Dow, & and legal remedies to prevent the violation of
Williams, 1980, have provided a more detailed studentsº constitutional rights through the misuse
history of these efforts). The ABP, an organiza- of tests, and
tional leader in protesting test bias for all ethnic Be it further resolved that the NAACP calls
groups, carried its call for a moratorium to other upon the Association of Black Psychologists to
professional organizations in psychology and assert leadership in aiding the College Entrance
education. In direct response to the ABP call, the Examination Board to develop standardized tests
which have been corrected for cultural bias and
Board of Directors of the American Psycholo-
which fairly measure the amount of knowledge
gical Association (APA) requested its Board retained by students regardless of his or her
of Scientific Affairs to appoint a group to individual background.
study the use of psychological and educational Be it finally resolved that the NAACP directs its
tests with disadvantaged students. The commit- units to use all administrative remedies in the event
tee report (Cleary, Humphreys, Kendrick, & of violation of students' constitutional rights
 What are Possible Sources of Bias? 59

through the misuse of tests and directs National minorities have been raised by Black and other
Office staff to use its influence to bring the CEEB minority psychologists. Unfortunately, these
and ABP together to revise such tests. objections are frequently stated as facts on
rational rather than empirical grounds (e.g.,
Also in 1974, the Committee on Testing of the Council for Exceptional Children, 1978; Cham-
ABP issued a position paper on the testing of bers, Barron, & Sprecher, 1980; Dana, 1996;
Blacks that described their intent as well as their Helms, 1992; Hilliard, 1979). The most fre-
position: quently stated problems fall into one of the
following categories:
(1) To encourage, support and to bring action (i) Inappropriate content. Black and other
against all institutions, organizations and agencies minorities have not been exposed to the materi-
who continue to use present psychometric instru- al involved in the test questions or other
ments in the psychological assessment of Black stimulus materials. The tests are geared primar-
people; ily toward the majority class homes, vocabu-
(2) To continue efforts to bring about a cessa-
tion of the use of standard psychometric instru-
lary, and values. Different value systems among
ments on Black people until culturally specific tests cultures may lead to cognitively equivalent
are made available; answers scored as incorrect based on prejudicial
(3) To establish a national policy that in effect value judgments, not on differences in ability.
gives Black folk and other minorities the right to (ii) Inappropriate standardization samples.
demand that psychological assessment be admi- Ethnic minorities are underrepresented in stan-
nistered, interpreted, and supervised by competent dardization samples used in the collection of
psychological assessors of their own ethnic back- normative reference data. Population propor-
ground; tionate sampling with stratification by ethnicity
(4) To work toward and encourage efforts to is the herald for standardization samples for
remove from the records of all Black students and
Black employees that data obtained from perfor-
tests and is done to enhance the accuracy of
mance on past and currently used standard parameter estimation for scaling purposes. As
psychometric, achievement, employment, general such, although presented proportionately, eth-
aptitude and mental ability tests; nic minorities may appear in test standardiza-
(5) To establish a national policy that demands tion samples in small absolute numbers. This
the appropriate proportional representation of may bias item selection (e.g., Harrington, 1975,
competent Black psychologists on all committees 1976) and fails to have any impact of signifi-
and agencies responsible for the evaluation and cance on the tests themselves from these ethnic
selection of tests used in the assessment of Black groups. In earlier years, it was not unusual for
folk; standardization samples to be all White (e.g.,
(6) To establish a national policy that demands
that all persons engaged in the evaluation, selec-
the 1937 Binet and 1949 WISC).
tion and placement of Black folks undergo ex- (iii) Examiner and language bias. Since most
tensive training so they may better relate to the psychologists in the USA are White and speak
Black experience; only standard English, they may intimidate
(7) To demand that all Black students impro- Black and other ethnic minorities. They are
perly diagnosed and placed into special education also unable accurately to communicate with
classes be returned to regular class programs; minority childrenÐto the point of being in-
(8) To encourage and support all suits against sensitive to ethnic pronunciation of words on
any public or private agency for the exclusion, the test. Lower test scores for minorities, then,
improper classification and the denial of advance- may reflect only this intimidation and difficulty
ment opportunities to Black people based on
performance tests.
in the communication process or motivational
differences (Zigler & Butterfield, 1967), not
lower ability. In other countries, professionals
It should be noted that the statements by such as psychologists tend to be from the
these organizations have assumed that present dominant culture and similar issues appear.
tests are biased, and that what is needed is the (iv) Inequitable social consequences. As a
removal of that assumed bias. These assump- result of bias in educational and psychological
tions continue in the work of Helms (e.g., 1992), tests, minority group members, already at a
Mercer (1979), Padilla and Medina (1996), and disadvantage in the educational and vocational
others (e.g., Guilford Press, 1997). markets because of past discrimination and
thought unable to learn, are disproportionately
10.03.4 WHAT ARE POSSIBLE SOURCES relegated to dead-end educational tracks. La-
OF BIAS? beling effects also fall under this category.
(v) Measurement of different constructs. Re-
Many potentially legitimate objections to the lated to (i), this position asserts that the tests
use of educational and psychological tests with measure different attributes when used with
60 Cultural Bias in Testing of Intelligence and Personality

children from other than the majority culture of groups within the USA deserves comment and
a country, the culture on which the tests are raises an interesting set of legal and conceptual
largely based, and thus do not measure minority issues. The concept of separate but equal
intelligence or personality validly. programs, facilities, and the like was protested
(vi) Differential predictive validity. Although vehemently by minorities for many years and
tests may accurately predict a variety of out- ultimately rejected by the US Supreme Court. It
comes for members of a majority culture within a is of interest that some minority scholars would
population, they do not predict successfully any now seek ªseparate but equalº tests. This could
relevant behavior for cultural minority group lead to arguments that if the cognitive structures
members Further, there are objections to use of of various ethnic groups are so different as to
the standard criteria against which tests are require distinct tests of intelligence and person-
validated with minority cultural groups. For ality for accurate assessment, then schooling,
example, in the USA, scholastic or academic job training, mental health interventions, and
attainment levels in White middle-class schools the like might also need to be differentÐan
are themselves considered by a variety of Black argument long attacked and rejected by many
psychologists to be biased as criteria (e.g., see minority scholars and spokespersons.
discussion in Reynolds, 1982a, pp. 179±180).
(vii) Minority and majority aptitude and per-
sonality are qualitatively distinct. Championed 10.03.5 MEAN SCORE DIFFERENCES AS
by Helms (e.g., 1992), this position would lead TEST BIAS
to the conclusion that ethnic minorities and the
majority culture are so different as to require A popular lay view, and one promoted in the
different conceptualizations of ability and per- popular media, has been that differences in mean
sonality. Helms (1982), for example, argues the levels of scoring on cognitive, achievement, or
potential existence of a ªWhite gº factor that is personality tests among groups constitute bias in
separate from an ªAfrican gº factor (p. 1090) tests; however, such differences alone clearly are
that would necessitate separate tests for these not evidence of test bias. A number of writers in
groups. the professional literature have taken this
Contrary to the situation of the late 1960s position as well (e.g., Adebimpe, Gigandet, &
and 1970s, when the current controversies Harris, 1979; Alley & Foster, 1978; Chinn, 1979;
resurfaced after some decades of simmering, Guilford Press, 1997; Hillard, 1979; Jackson,
research now exists that examines the above 1975; Mercer, 1976; Padilla, 1988; Williams,
areas of potential bias in assessment. Except for 1974; Wright & Isenstein, 1977). Those who
the still unresolved issue of labeling effects, the support this definition of test bias correctly state
least amount of research is available on the there is no valid a priori scientific reason to
long-term social consequences of testing, believe that intellectual or other cognitive
although some limited data are available (e.g., performance levels should differ across race. It
Lambert, 1979). Both of these problems are is the inference that tests demonstrating such
aspects of testing in general and are not limited differences are inherently biased because there
to minorities. The problem of the social con- can in reality be no differences that is fallacious.
sequences of educational tracking is frequently Just as there is no a priori basis for deciding that
lumped with the issue of test bias. Those issues, differences exist, there is no a priori basis for
however, are separate. Educational tracking deciding that differences do not exist. From the
and special education should be treated as standpoint of the objective methods of science, a
problems of education, not assessment. These priori or premature acceptance of either hypoth-
are going to become more heavily contested esis (`differences existº vs. ªdifferences do not
areas for psychologists in the future, however, existº) is untenable. As stated by Thorndike
as the revision of the Joint Technical Standards (1971), ªThe presence (or absence) of differences
for Educational and Psychological Tests and in mean score between groups, or of differences
Manuals now underway is likely to add the in variability, tells us nothing directly about
issue of consequential validity to considerations fairnessº (p. 64). Some adherents to the ªmean
in test use, reflecting concerns by minority score differences as biasº viewpoint also require
groups within the USA over the consequences that the distribution of test scores in each
of test use with ethnic minorities. Educational population or subgroup be identical before one
tracking as a result of test performance is a can assume that the test is fair: ªRegardless of the
prominent problem for ethnic minorities in purpose of a test or its validity for that purpose, a
many countries applying such competitive test should result in distributions that are
schooling practices. statistically equivalent across the groups tested
The call by Helms (1992) and earlier by in order for it to be considered nondiscrimina-
Williams (1974) for separate tests for minority tory for those groupsº (Alley & Foster, 1978,
 Mean Score Differences as Test Bias 61

p. 2). Portraying a test as biased regardless of its achievement, or personality measures among
purpose or validy is psychometrically naive. selected groups are not evidence per se that the
Mean score differences and unequivalent dis- measures are biased.
tributions have been the most uniformly rejected
of all criteria examined by sophisticated psy-
chometricians involved in investigating the 10.03.5.1 Culture-free Tests, Culture Loading,
problems of bias in assessment. Ethnic group and Culture Bias
differences in mental test scores are among the
best-documented phenomena in psychology, A third area of bias investigation that has
and they have persisted over time at relatively been confusing in both the professional (e.g.,
constant levels (Reynolds & Gutkin, 1980a, Alley & Foster, 1978; Chinn, 1979) and the lay
1981). literature has been the interpretation of culture
Jensen (1980) has discussed the ªmean score loading and culture bias. A test can be culture
differences as biasº position in terms of the loaded without being culturally biased. Culture
egalitarian fallacy. The egalitarian fallacy loading refers to the degree of cultural speci-
contends that all human populations are in ficity present in the test or individual items of
fact identical on all mental traits or abilities. the test. Certainly, the greater the cultural
Any differences with regard to any aspect of the specificity of a test item, the greater the
distribution of mental test scores indicates that likelihood of the item being biased when it is
something is wrong with the test itself. Such an used with individuals from other cultures. The
assumption is totally scientifically unwarranted. test item ªWho was the first president of the
There are simply too many examples of specific United States?º is a culture-loaded item.
abilities and even sensory capacities that have However, the item is general enough to be
been shown to differ unmistakably across considered useful with school-aged children
human populations. The result of the egalitar- attending school since first grade in the USA.
ian assumption, then, is to remove the inves- The cultural specificity of the item is too great,
tigation of population differences in ability however, to allow the item to be used on an
from the realm of scientific inquiry. Logically aptitude measure of 10-year-old children from
followed, this fallacy leads to other untenable other countries. Virtually all tests in current use
conclusions as well. Torrance (1980), an are bound in some way by their cultural
adherent of the cultural bias hypothesis, pointed specificity. Culture loading must be viewed on
out that disadvantaged Black children in the a continuum from general (defining a culture in
USA occasionally earn higher scores on a broad, liberal sense) to specific (defining a
creativity testsÐand therefore, have more culture in narrow, highly distinctive terms).
creative abilityÐthan many White children A variety of attempts have been made to
because their environment has forced them to develop a ªculture-freeº (sometimes referred to
learn to ªmake doº with less and with simpler as ªculture-fairº) intelligence test (e.g., Cattell,
objects. The egalitarian assumption would hold 1979). However, the reliability and validity of
that this is not true, but rather that the content these tests are uniformly inadequate from a
of creativity tests is biased against White or high psychometric perspective (Anastasi, 1982; Ebel,
SES children. 1979). The difficulty in developing a culture-free
The attachment of minorities to the ªmean measure of intelligence lies in the test being
score differences as biasº definition is probably irrelevant to intellectual behavior within the
related to the nature±nurture controversy at culture under study. Intelligent behavior is
some level, and has been difficult for even defined within human society in large part on
databased, minority research scientists to the basis of behavior judged to be of value to the
abandon (e.g., Dana, 1993). Certainly data survival and improvement of the culture and the
reflecting racial differences on various aptitude individuals within the culture. A test that is
measures have been interpreted to indicate ªculture-blind,º then, cannot be expected to
support for a hypothesis of genetic differences in predict intelligent behavior within a variety of
intelligence and to imply that one race is cultural settings. Once a test has been developed
superior to another. However, as discussed within a culture (a culture-loaded test), its
previously, the so-called nature±nurture issue is generalizability to other cultures or subcultures
not an inextricable component of bias investi- within the dominant societal framework be-
gation. Assertions as to the relative impact of comes a matter for empirical investigation, and
genetic factors on group ability levels step into a tests should not be used cross-culturally without
new arena of scientific inquiry, with differing demonstrative evidence for the validity of
bodies of knowledge and methods of research. inferences to be drawn from such tests. The
Suffice it to say that in the arena of bias same holds true for personality tests and other
investigation, mean differences on aptitude, techniques designed to assess affective disorders.
62 Cultural Bias in Testing of Intelligence and Personality

Although there exists a universality to certain However, these studies have generally been of
psychopathological disorders (e.g., schizophre- a short-term nature, and have usually been
nia, bipolar disorder) in both taxonomy and conducted under quite artificial circumstances.
manifestation, the existence of certain disorders Typically, participants are asked to rate the
independent of a cultural context can be behavior or degree of pathology of a child seen
questioned readily (e.g., dependent personality on videotape. Categorical labels for the child are
disorder) and the symptoms or manifestations of systematically varied while the observed beha-
other disorders may well vary across cultures as viors remain constant. The demand character-
they do across age (e.g., depression, anxiety istics of such a design are substantial. Long-term
disorders). effects of labeling and diagnoses resulting in
Jensen (1980) admonishes that when one is special education placement or mental health
investigating the psychometric properties of treatment in real-life situations have been
culture-loaded tests across differing societies or examined less vigorously. For example, com-
cultures, one cannot assume that simple parisons of the effects of formal diagnostic labels
inspection of the content will determine which with the informal, often cursory, personal
tests or items are biased against those cultures or labeling process that occurs between teachers
societies not represented in the tests or item and children over the course of a school year, and
content. Tests or items that exhibit character- that is subsequently passed on to the next grade
istics of being culturally loaded cannot be via the teachers' lounge (Dworkin & Dworkin,
determined to be biased with any degree of 1979), need to be made. Although Reynolds
certainty unless objective statistical inspection is (1982b) called for this research in past decades,
completed. Jensen refers to the mistaken notion this important question has not been addressed.
that anyone can judge tests and/or items as The strict behaviorist position (Ross, 1974,
being ªculturally unfairº on superficial inspec- 1976) also contends that formal diagnostic
tion as the ªculture-bound fallacy.º The issue of procedures are unnecessary and potentially
item bias is revisited in some detail in Section harmful because of labeling effects. However,
10.03.7.1. whether or not the application of formal labels
has detrimental effects remains an open question
now, much as it did at the conclusion of a
10.03.5.2 The Question of Labeling Effects monumental effort to address these important
questions throughout the USA in the mid-1970s
The relative impact of placing a label on a (Hobbs, 1975).
person's behavior or developmental status has Even without the application of formal,
also been a hotly discussed issue within the field codified labels by psychologists or psychiatrists,
of psychometrics in general and bias investiga- the mental labeling, classification, and appraisal
tion in particular. The issue undoubtedly has of individuals by people with whom they come
been a by-product of the practice of using into contact are common, constant occurrences
intellectual measures for the determination of (Reynolds, 1979a). Auerbach (1971) found that
mental retardation. Although the question of adults often interpret early learning difficulties
labeling effects is a viable and important one, it of children as primarily emotional disturbances,
requires consideration in bias research only in unrelated to learning problems. According to
much the same way as does the ongoing debate Bower (1974), children who start the first grade
surrounding the nature±nurture question. As below the mean age of their classmates and are
the concept of consequential validity grows, this below average in the development of school
issue will likewise grow in importance. How- readiness skills or have behaviour problems are
ever, there are some important considerations more likely to be regarded as emotionally
regarding bias in referral for services, diagnosis, disturbed by school staff and are more likely
and labeling, which no interested student of the to be referred to residential placement than their
diagnostic process in psychology can afford to peers. The American Psychological Association
ignore. (1970) acknowledges that such constant apprai-
Rosenthal is the researcher most closely sal of individuals occurs at the informal level,
associated with the influence of labeling upon and in an official position statement takes the
teachers' and parents' perceptions of a child's stance that specialized, standardized psycholo-
ability and potential. Even though his early gical techniques have been developed to super-
studies had many methodological and statistical sede our informal, often casual approach to the
difficulties, labeling effects have been shown in appraisal of others. The specialized psycholo-
some subsequent experimental studies (e.g., gical techniques available to the trained exam-
Critchley, 1979; Foster & Ysseldyke, 1976; iner add validity and utility to the results of such
Jacobs, 1978), but not in others (e.g., MacMil- appraisals. The quantification of behaviour
lan, Jones, & Aloia, 1974; McCoy, 1976). permits systematic comparisons of individuals'
 Mean Score Differences as Test Bias 63

characteristics with those of a selected reference clearly indicate that they [psychologists] did
or norm group. It is not unreasonable to not make different recomendations on the basis
anticipate that the informal labeling of children of race.º Consistent with the results of Frame
so often indulged in by teachers and parents is (1979), psychologists were more likely to
substantially more harmful than accurate recommend special class placement for high
psychoeducational diagnostics intended to ac- SES status children than for low SES children
crue beneficial activity toward the child. Should when other varibles were held constant. Tea-
noncategorical funding for services to excep- chers showed no bias in regard to special
tional children become a reality (Gutkin & education placement recommendations on the
Tieger, 1979), or should the use of normative basis of race or SES. Upon investigating special
assessment ultimately be banned, the informal education placement recommendations as a
labeling process will continue and in all function of minority group status (Black, native
likelihood will exacerbate children's problems. American, or Oriental), Tomlinson, Acker,
From the standpoint of cultural test bias Canter, and Lindborg (1977) reported that
issues, the question of labeling persons or not psychologists recommended special education
labeling persons is moot. Cultural test bias is resource services more frequently for minority
concerned with the accuracy of such labels than for White children. Placement in a special
across some nominal grouping system (typi- education class, however, was recommended
cally, race, sex, and SES have been the variables more frequently for White than minority
of interest). It is a question of whether race, sex, children. A rather extensive study of placement
or any other demographic variable of interest in classes for the educable mentally retarded
influences the diagnostic process or the place- (EMR) in California also failed to find any
ment of an individual in special treatment racist intent in the placement of minority
programs, independent of the individual's children in special classes (Meyers, MacMillan,
cognitive, emotional, and behavioral status. & Yoshida, 1978). In fact, the tendency was not
Several well-designed studies have investigated to place Black children in special education
the influences of race and SES on diagnosis and classes, even though they might be failing in the
the placement recommendations of school regular classroom. An even earlier study by
psychologists (i.e., bias in test interpretation). Mercer (1971), one of the major critics of IQ
One of the studies investigated teacher bias as testing with minorities, reached the same
well. conclusion.
Frame (1979) investigated the accuracy of The general tendency not to label Black
school psychologists' diagnoses and consistency children also extends to community mental
of treatment plans within the USA, with regard health settings. Lewis, Balla, and Shanok (1979)
to bias effects associated specifically with race reported that when Black adolescents were seen
and SES. In Frame's study, 24 school psychol- in mental health settings, behaviors sympto-
ogists from a number of school districts matic of schizophrenia, paranoia, and a variety
diagnostically rated and provided treatment of psychoneurotic disorders were frequently
plans for hypothetical cases in which all dismissed as only ªcultural aberrationsº appro-
information except race, SES, and the achieve- priate to coping with the frustrations created by
ment level of the child's school was held the antagonistic White culture. Lewis et al.
constant. No differences in the accuracy of (1979) further noted that White adolescents
diagnosis (as defined by interrater reliability) exhibiting similar behaviours were given psy-
occurred as a function of race or SES. chiatric diagnoses and referred for therapy and/
Differences did occur with regard to treatment or residential placement. Lewis et al. contended
recommendations, however. With all other data that this failure to diagnose mental illness in the
held constant, lower SES Black children were Black population acts as bias in the denial of
less likely to be recommended for special appropriate services. A tendency for psychol-
education placement than their White counter- ogists to reward depressed performance on
parts or higher SES Black children. A more cognitive tasks by Blacks and low SES groups as
general trend was for higher SES children to be a ªcultural aberrationº has also been shown. An
recommended for special class placement more early empirical study by Nalven, Hofmann, and
often than children of lower SES. Bierbryer (1969) demonstrated that psycholo-
In a similar vein, Matuszek and Oakland gists generally rated the ªtrue intelligenceº of
(1979) asked whether SES and race influenced Black and lower SES children higher than that
teacher or psychologist placement recommen- of White and middle-class children with the
dations, independent of other characteristics same Wechsler Intelligence Scale for Children
such as adaptive behavior, IQ, and classroom (WISC) IQ. This tendency to ªoverrateº the
achievement levels. Matuszek and Oakland intellectual potential of Black and low SES
concluded that ªThe data from this study children probably accounts, at least in part, for
64 Cultural Bias in Testing of Intelligence and Personality

psychologists' reluctance to recommend special decision-making system and not on the test
education placement for these children; it could itself. The various selection models are dis-
also be viewed as a discriminatory denial of cussed at some length in Hunter and Schmidt
services, depending on whether the provision of (1974), Hunter, Schmidt, and Rauschenberger
services is considered beneficial or harmful to (1984), Jensen (1980), Peterson and Novick
the individual. Despite the outcome of these and (1976), and Ramsay (1979). The choice of a
other studies, it is common to read that decision-making system (especially a system for
psychologists overdiagnose psychopathology educational decision-making) must ultimately
in cultural groups outside the mainstream be a societal one; as such, it will depend to a
culture (e.g. Dana, 1993). large extent on the value system and goals of the
Bias by ethnicity in diagnosis of specific forms society. Thus, before a model for test use in
of affective disturbance has been the subject of selection (whether ultimately selection is for a
fewer examinations in the literature. However, treatment program, a job, a college, etc.) can be
there is little evidence to suggest that ethnicity or chosen, it must be decided whether the ultimate
SES independently influence clinical diagnoses goal of selection is equality of opportunity,
such as autistic disorders or attention-deficit equality of outcome, or representative equality
hyperactivity disorder (e.g., Cuccaro, Wright, (these concepts are discussed in more detail in
Rhownd, & Abramson, 1996). Nichols, 1978).
These studies clearly indicate that the demo- ªEquality of opportunityº is a competitive
graphic variables of race and SES do not, model wherein selection is based on ability. As
independent of other pupil characteristics, more eloquently stated by Lewontin (1970),
influence or bias psychologists' diagnostic or under equality of opportunity, ªtrue merit . . .
placement behavior in a manner that would will be the criterion of men's earthly rewardº
cause Blacks or lower SES children to be labeled (p. 92). ªEquality of outcomeº is a selection
inaccurately or placed inappropriately or in model based on ability deficits. Schooling
disproportionate numbers in special education provides a good model to illustrate these
programs. The empirical evidence, rather, concepts that are also applicable to mental
argues in the opposite direction: in the USA, health. Compensatory and remedial programs
Black and low SES children are less likely to be are typically constructed on the basis of the
diagnosed as having a form of psychopathology equality-of-outcome model. Children of low
than their White or higher SES peers with ability or children believed to be a high risk for
similar cognitive, behavioral, and emotional academic failure are selected for remedial,
characteristics. The data simply do not support compensatory, or other special educational
William's (1970) and others (e.g., Dana, 1993; programs. Adults vying for jobs may be placed
Guilford Press, 1997; Padilla, 1988) charges that in specialized job training programs. In a strictly
ethnic minorities are more likely to be overly predictive sense, tests are used in a similar
diagnosed with a variety of psychopathological manner under both of these models. However,
disorders. under equality of opportunity, selection is based
on the prediction of a high level of criterion
performance; under equality of outcome, selec-
10.03.6 THE PROBLEM OF DEFINITION tion is determined by the prediction of ªfailureº
or a preselected low level of criterion perfor-
The definition of test bias has produced mance. Interestingly, it is the failure of
considerable continuing debate among mea- compensatory and remedial education pro-
surement and assessment experts (Angoff, 1976; grams to bring the disadvantaged learner to
Bass, 1976; Bernal, 1975; Bond, 1981; Cleary ªaverageº levels of performance that resulted in
et al., 1975; Cole & Moss, 1989; Cronbach, the charges of test bias now in vogue.
1976; Dana, 1993; Darlington, 1978; Einhorn & The model of ªrepresentative equalityº also
Bass, 1970; Flaugher, 1978; Gordon, 1984; relies on selection, but selection that is propor-
Gross & Su, 1975; Helms, 1992; Humphreys, tionate to numerical representation of sub-
1973; Hunter & Schmidt, 1976, 1978; Jackson, groups in the population under consideration.
1980; Linn, 1976; McNemar, 1975; Moreland, Representative equality is typically thought to
1996; Novick & Petersen, 1976; Padilla, 1988; be independent of the level of ability within each
Petersen & Novick, 1976; Reschly, 1980; group; however, models can be constructed that
Reynolds, 1978; 1982b, 1995; Reynolds & select from each subgroup the desired propor-
Brown, 1984; Sawyer, Cole, & Cole, 1976; tion of individuals (i) according to relative
Schmidt & Hunter, 1974; Thorndike, 1971). ability level of the group, (ii) independent of
Although the resulting debate has generated a group ability, or (iii) according to some decision
number of selection models with which to rule between these two positions. Even under
examine bias, selection models focus on the the conditions of representative equality, it is
 Research Strategies and Results 65

imperative to employ a selection device (test) valid for one group but not another. Differential
that will rank order individuals within groups in validity refers to a condition where an inter-
a reliable and valid manner. The best way to pretation is valid for all groups concerned, but
ensure fair selection under any of these models is the degree of validity varies as a function of
to employ tests whose scores are equally reliable group membership. Although these terms have
and equally valid for all groups concerned. The been most often applied to predictive or
tests employed should also yield the most criterion-related validity (validity coefficients
reliable and most valid scores for all groups are then examined for significance and com-
under consideration. The question of test bias pared across groups), the concepts of single-
per se then becomes a question of test validity. group and differential validity are equally ap-
Test use (i.e., fairness) may be defined as biased plicable to content and construct validity.
or nonbiased only by the societal value system;
at present, this value system within the USA is
leaning strongly toward some variant of the 10.03.7 RESEARCH STRATEGIES AND
representative-equality selection model. In RESULTS
other sociopolitical structures, other models
The methodologies available for research into
may be more appropriate. As noted above, all
bias in mental tests have grown rapidly in
models are facilitated by the use of a nonbiased
number and sophistication since the 1970s.
test. That is, the use of a test with equivalent
Extensive reviews of the questions to be
cross-group validities makes for the most
addressed in such research and their corre-
parsimonious selection model, greatly simplify-
sponding methodologies are available in Berk
ing the creation and application of the selection
(1982), Camilli and Shepard (1994), Jensen
model that has been chosen.
(1980), Reynolds (1982b, 1995), and Reynolds
This leads to the essential definitional
and Brown (1984). The most popular methods
component of test bias. ªTest biasº refers in a
are reviewed below, along with a summary of
global sense to systematic error in the estima-
findings from each area of inquiry (these
tion of some ªtrueº value for a group of
summaries are based almost entirely on research
individuals. The key word here is ªsystematicº;
with ethnic subcultures within the USA). The
all measures contain error and in all cultural
sections are organized primarily by methodol-
settings, but this error is assumed to be random
ogy within each content area of research (i.e.,
unless shown to be otherwise. Bias investigation
research into content, construct, and predictive
is a statistical inquiry that does not concern
validity).
itself with culture loading, labeling effects, or
test use/test fairness. Concerning the last of
these, Jensen (1980) comments, 10.03.7.1 Bias in Content Validity

[U]nbiased tests can be used unfairly and biased Bias in the item content of intelligence tests is
tests can be used fairly. Therefore, the concepts of one of the favorite topics of those who decry the
bias and unfairness should be kept distinct . . . [A] use of standardized tests with minorities (e.g.,
number of different, and often mutually contra- Hilliard, 1979; Jackson, 1975; Williams, 1972;
dictory, criteria for fairness have been proposed, Wright & Isenstein, 1977). The earliest work in
and no amount of statistical or psychometric cultural test bias centered around content.
reasoning per se can possible settle any arguments Typically, critics review the items of a test
as to which is best. (pp. 375±376) and select specific items as being biased because:
(i) the items ask for information that ethnic
There are three types of validity as tradition- minority or disadvantaged persons have not
ally conceived: content, construct, and predic- had equal opportunity to learn; and/or (ii) the
tive (or criterion-related). Test bias may exist scoring of the items is improper, since the test
under any or all of these categories of validity. author has arbitrarily decided on the only
Though no category of validity is completely correct answer and ethnic minorities are
independent of any other category, each is inappropriately penalized for giving answers
discussed separately here for the purposes of that would be correct in their own culture but
clarity and convenience. (All true evidence of not that of the test maker; and/or (iii) the
validity is as likely as not to be construct validity, wording of the questions is unfamiliar, and an
and other, more detailed divisions including this ethnic minority person who may ªknowº the
one are for convenience of discussion.) Fre- correct answer may not be able to respond
quently encountered in bias research are the because he or she does not understand the
terms ªsingle-group validityº and ªdifferential question. Each of these and related criticisms,
validity.º Single-group validity refers to the when accurate, has the same basic empirical
phenomenon of a score interpretation being result: the item becomes relatively more difficult
66 Cultural Bias in Testing of Intelligence and Personality

for ethnic minority group members than for the does exist), one may contend that biased items
majority population, for example, an ethnic exist. Earlier in this area of research, it was
minority and a member of the majority culture hoped that the empirical analysis of tests at the
with the same standing on the construct in item level would result in the identification of a
question will respond differently to such biased category of items having similar biased, and that
items. This leads directly to a definition of such items could then be avoided in future test
content bias for aptitude tests that allows development (Flaugher, 1978). Very little
empirical assessment of the phenomenon. An similarity among items determined to be biased
item or subscale of a test is considered to be has been found. No one has been able to identify
biased in content when it is demonstrated to be those characteristics of an item that cause the
relatively more difficult for members of one item to be biased. It does seem that poorly
group than for members of another when the written, sloppy, and ambiguous items tend to be
general ability level of the groups being identified as biased with greater frequency than
compared is held constant and no reasonable those items typically encountered in a well-
theoretical rationale exists to explain group constructed standardized instrument. The vari-
differences on the item (or subscale) in question. able at issue then may be the item reliability.
With regard to achievement tests, the issue of Item reliabilities are typically not large, and
content bias is considerably more complex. poorly written or ambiguous test items can
Exposure to instruction, general ability level of easily have reliabilities approaching zero.
the group, and the accuracy and specificity of Decreases in reliability are known to increase
the sampling of the domain of items are all the probability of the occurrence of bias (Linn &
important variables in determining whether the Werts, 1971). Informal inventories and locally
content of an achievement test is biased (see derived tests are much more likely to be biased
Schmidt, 1983). Research into item (or content) than professionally written standardized tests
bias with achievement tests has typically, and that have been scrutinized for bias in the items
perhaps mistakenly, relied on methodology and whose item characteristics are known.
appropriate for determining item bias in Once items have been identified as biased
aptitude tests. Nevertheless, research examining under the procedures described above, attempts
both types of instruments for content bias has have been made to eliminate ªtest biasº by
yielded quite comparable results. Items on eliminating the offending items and rescoring
personality tests may be perceived differently the tests. As pointed out by Flaugher (1978) and
across cultures as well or appropriate responses Flaugher and Schrader (1978), however, little is
may vary dramatically and quite properly gained by this tactic. Mean differences in
deserve different interpretations cross-cultu- performance between groups are affected only
rally. If so, the items will behave differently slightly, and aptitude and achievement tests
across groups for individuals with the same become more difficult for everyone involved,
relative standing. This too is detectable through since the eliminated items typically have
analyses of item response data across groups. moderate to low difficulty. When race X item
One method of locating ªsuspiciousº test interactions have been found, the interaction
items requires that item difficulties be deter- typically accounts for a very small proportion of
mined separately for each group under con- variance. For example, in analyzing items on the
sideration. If any individual item or series of WISC-R, Jensen (1976), Sandoval (1979), and
items appears to be exceptionally difficult for Mille (1979) found the group X item interaction
the members of any group, relative to other to account for only 2±5% of the variance in
items in the test, the item is considered performance. Using a similar technique with the
potentially biased and removed from the test. Wonderlic Personnel Test, Jensen (1977) found
An early, widespread approach to identifying the race X item interaction to account for only
biased items involved analysis of variance about 5% of the test score variance. Thus,
(ANOVA) and several closely related proce- elimination of the offending items can be
dures wherein the group X item interaction term expected to have little, if any, significant effect.
is of interest (e.g., Angoff & Ford, 1973; Cardall These analyses have been of a post hoc nature
& Coffman, 1964; Cleary & Hilton, 1968; Plake (i.e., after the tests have been standardized),
& Hoover, 1979; Potthoff, 1966; Stanley, 1969). however, and use of empirical methods for
The definition of content bias set forth above determining item bias during the test develop-
actually requires that the differences between ment phase (as with tests like the K-ABC and
groups be the same for every item on the test. the TOMAL) is to be encouraged.
Thus, in the ANOVA procedure, the group X The ANOVA methodology is appealing
item interaction should not yield a significant conceptually but has some significant problems,
result. Whenever the differences in items are not even though it was the dominant methodological
uniform (a significant group X item interaction approach to the issue of item bias through the
 Research Strategies and Results 67

1980s. Camilli and Shepard (1987) have pro- Jensen (1976) investigated the distribution of
vided convincing examples, albeit using con- wrong responses for two multiple-choice in-
trived data, that ANOVA methods often miss telligence tests, the Peabody Picture Vocabulary
biased items, in both directions, and identify Test (PPVT) and Raven's Progressive Matrices
some items as biased which are not. An algebraic (the Raven). Each of these tests was individually
demonstration of the reasons for this is provided administered to 600 White and 400 Black
in Camilli and Shepard (1994) who conclude that children between the ages of six and 12. The
ANOVA should no longer be used. analysis of incorrect responses for the PPVT
Based upon their thorough and compelling indicated that the errors were distributed in a
analysis of methods for detecting biased items, nonrandom fashion over the distractors for a
Camilli and Shepard (1994) recommend meth- large number of items. However, no racial bias
ods derived from item response theory (IRT) to in response patterns occurred, since the dis-
detect what has come to be known as differential proportionate choice of distractors followed the
item functioning (DIF). IRT models are con- same pattern for Blacks and Whites. On the
ceptually similar to what other models such as Raven, Blacks make different types of errors
ANOVA attempt. IRT is concerned principally than Whites, but only on a small number of
with the probability of a particular response to a items. Jensen followed up these items and
test item as a function of the examinee's relative compared the Black response pattern to the
position on the latent trait assessed by the scale response pattern of White children at a variety
to which the item belongs. IRT models to detect of age levels. For every item showing differences
DIF are primarily superior to prior methods in Black±White response patterns, the Black
because they are less sample dependent and they response could be duplicated by the response
allow one to estimate multiple item statistics patterns of Whites approximately two years
more precisely than a technique such as younger than Blacks.
ANOVA. Using item characteristic curves, Veale and Foreman (1983) have advocated
DIF is more accurately and readily detected inspecting multiple-choice tests for bias in
when the probability of a particular response distractor or ªfoilº response distributions as a
changes as a function of some nominal variable means of refining tests before they are finalized
(e.g., ethnicity or gender) for individuals with for the marketplace. They note that there are
the same relative standing on the latent trait many instances whereby unbiased external
being assessed. criteria (such as achievement or ability) or
Early studies using other approaches for the culturally valid tests are not readily accessible
detection of DIF using a partial correlation for detecting bias in the measure under study.
procedure developed independently by Stricker Veale and Foreman add that inspection of
(1982) and Reynolds, Willson, and Chatman incorrect responses to distractor items can often
(1984) have found no systematic bias against lead to greater insight concerning cultural bias
American Blacks or against women on mea- in any given question than would inspection of
sures of English vocabulary. Willson, Nolan, percentage of correct responses across groups.
Reynolds, and Kamphaus (1989), using the Veale and Foreman (1983) provide the statis-
same partialling methodology, examined DIF tical analyses for their ªoverpull probability
of the mental processing scales of the Kaufman modelº along with the procedures for measur-
Assessment Battery for Children, concluding ing cultural variation and diagraming the source
ª . . . there appears to be little evidence of of bias within any given item.
systematic race or gender bias . . . º (p. 289). Investigation of item potential sources of bias
With multiple-choice tests, another level of during test development is certainly not re-
complexity is added to the examination of stricted to multiple-choice items and methods
content bias. With a multiple-choice question, such as those outlined by Veale and Foreman
three or four distractors are typically given in (1983). The possibilities are numerous (see
addition to the correct response. Distractors Camilli & Shepard, 1994; Jensen, 1980,
may be examined for their attractiveness (the chap. 9). For example, Scheuneman (1987)
relative frequency with which they are chosen) has used the results of linear methods on
across groups. When distractors are found to be Graduate Record Examination (GRE) item
disproportionately attractive for members of data to show interesting influences on Black±
any particular group, the item may be defined as White performance when specific item char-
biased. When items are constructed to have an acteristics (e.g., vocabulary content, one true or
equal distribution of responses to each dis- one false answer to be selected, diagrams to be
tractor for the total test population, then chi- used or not used, use of antonym items, etc.) are
square can be used to examine the distribution uniformly investigated. Although Scheuneman
of choices for each distractor for each group indicates that future research of this type should
(e.g., Burrill, 1975). reduce the number of variables to address (there
68 Cultural Bias in Testing of Intelligence and Personality

are 16 hypotheses therein), the results none- as biased, yet they collectively accounted for
theless suggest that bias methodology is a viable only 2±5% of the variance in performance
way in which to determine whether differential differences and showed no detectable pattern in
effects can ªbe demonstrated through the item content.
manipulation of relatively stable characteristics This method has proved popular with some
of test itemsº (p. 116). Scheuneman presented test publishers who desire to look at the items on
pairs of items, with the designated characteristic a test as a group, despite the fact this approach
of a question format under study present in one may be overly sensitive due to the instability of
item and absent or modified in the other. Paired estimates of P values (which would cause the
experimental items were administered in the correlation to be spuriously low). Using the
experimental section of the GRE General Test, most recent version of the Detroit Tests of
given in December 1982. Results indicated that Learning Aptitude (DTLA-3; Hammill, 1991),
certain ªitem elements'Ðcommon in general Hammill reported correlations of P decrements
form to a variety of questionsÐappeared to exceeding 0.90 for all subtests with most
have a differential impact on Black and White exceeding 0.95. Similar results have been
performance. For example, significant group reported for other aptitude measures. On the
version interactions were seen for one correct 14 subtests of the Test of Memory and Learning
true vs. one correct false response and for (TOMAL; Reynolds & Bigler, 1994), Reynolds
adding/modifying prefixes/suffixes to the sti- and Bigler report correlations across P decre-
mulus word in antonym items. The question is ments by gender and ethnicity that all exceed
thus raised as to whether the items showing 0.90 with most again above 0.95.
differential impact are measuring the content Another approach to this question is to use
domain (e.g., veral, quantitative, or analytial the partial correlation between a demographic
thinking) as opposed to an aspect of ªelementº or other nominal variable and item score, where
within the presentation to some degree. the correlation between total test score and the
Another approach to the identification of variable of interest has been removed from the
biased items has been pursued by Jensen (1976). relationship. If a significant partial correlation
According to Jensen, if a test contains items exists, say, between race and an item score after
that are disproportionately difficult for one the race±total test score relationship has been
group of examinees as compared to another, the partialed, then the item is performing differen-
correlation of P decrements between adjacent tially across race within ability level. Bias has
items will be low for the two groups. (ªP been demonstrated at this point under the
decrementº refers to the difference in the definition offered above. Use of the partial
difficulty index, P, from one item of a test to correlation (typically a partial point-biserial r) is
the next least or most item. Typically, ability a simple yet powerful item bias detection
test items are arranged in ascending order of approach, but its development is relatively
difficulty.) Jensen (1974, 1976) also contends recent and its use not yet common. The partial
that if a test contains biased items, the correlation approach also does not have the
correlation between the rank order of item problems of ANOVA methods. An example of
difficulties for one race with another will also its application may be found in Reynolds,
be low. Jensen (1974, 1976, 1977) calculated Willson, and Chatman (1984).
cross-racial correlations of item difficulties for A common practice has been a return to
large samples of Black and White children on including expert judgment by professionals and
five major intelligence tests: the PPVT, the members of minority groups in the item
Raven, the Revised Stanford±Binet Intelligence selection for new psychological and educational
Scale Form L-M, the WISC-R, and the tests. This approach was used in development of
Wonderlic Personnel Test. Cross-racial correla- the K-ABC, the revision of the Wechsler
tions of P decrements were reported for several Preschool and Primary Scale of Intelligence
of the scales. Jensen's results are summarized (WPPSI-R), the PPVT-R, PPVT-III, and a
in Table 1, along with the results of several number of other contemporary tests. The
other investigators also employing Jensen's practice typically asks for an ªarmchairº
methodology. inspection of individual items as a means of
As is readily apparent in Table 1, little locating and purging biased items in the
evidence to support any consistent content bias measure under development. Since, as pre-
within any of the scales investigated was found. viously noted, no detectable pattern or common
The consistently large magnitude of the cross- characteristic of content of individual items
racial correlations of P decrements is impressive statistically shown to be biased has been
and indicates a general lack of content bias in observed (given reasonable care in the item-
the instuments as a whole. As previously noted, writing stage), it seems reasonable to question
however, some individual items were identified the ªarmchairº approach to determining biased
 Research Strategies and Results 69

Table 1 Cross-racial analysis of content bias for five major intelligence scales.

Cross-racial correlation of rank order of item difficultiesa

Black±White White±Mexican±American
Scale correlationsb correlationsb

Peabody Picture Vocabulary Test (Jensen, 1974) 0.99 (0.79), 0.98 0.98 (0.78), 0.98 (0.66)
(0.65)
Raven's Progressive Matrices (Jensen, 1974) 0.99 (0.98), 0.99 0.99 (0.99), 0.99 (0.97)
(0.96)
Stanford-Binet Intelligence Scale (Jensen, 1976) 0.96
Wechsler Intelligence Scale for Children-Revised
(Jensen, 1976) 0.95
(Sandoval, 1979)c 0.98 (0.87) 0.99 (0.91)
(Mille, 1979) (1949 WISC) 0.96, 0.95
Wonderlic Personnel Test (Jensen, 1977) 0.94 (0.81)

a
Correlation of P decrements across race is included in parentheses if reported. b Where two sets of correlations are presented, data were
reported separately for males and females and are listed males first. The presence of a single correlation indicates that data were pooled across
gender. c Median values for the 10 WISC-R subtests excluding Digit Span and Coding.

items. The bulk of scientific data since the for Mexican-Americans as compared to Whites,
pioneering work of McGurk (1951) has not and the 15 items showing the most nearly
supported the position that anyone canÐupon identical difficulty indices for minority and
surface inspectionÐdetect the degree to which White children. The judges were asked to read
any given item will function differentially across each question and determine whether they
groups (Shepard, 1982). Several researchers thought the item was: (i) easier for minority
since McGurk's time have identified items as than for White children, (ii) easier for White
being disproportionately more difficult for than for minority children, or (iii) of equal
minority group members than for members of difficulty for White and minority children.
the majority culture and have subsequently Sandoval and Mille's (1980) results indicated
compared their results with a panel of expert that the judges were not able to differentiate
judges. The data have provided some interesting accurately between items that were more
results. difficult for minorities and items that were of
Although examples of the failure of judges to equal difficulty across groups. The effects of the
identify biased items now abound (Camilli & judges' ethnic background on the accuracy of
Shepard, 1994) and show that judges are right item bias judgments were also considered.
about an item about as often as they are wrong, Minority and nonminority judges did not differ
two studies demonstrate this failure most in their ability to identify accurately biased
clearly. After identifying the eight least racially items, nor did they differ with regard to the type
discriminating items on the Wonderlic Person- of incorrect identification they tended to make.
nel Test, Jensen (1976) asked panels of five Sandoval and Mille's (1980) two major conclu-
Black psychologists and five White psycholo- sions were that ª(1) judges are not able to detect
gists to sort out the eight most and eight least items which are more difficult for a minority
discriminating items when only these 16 items child than an Anglo child, and (2) the ethnic
were presented to them. The judges sorted the background of the judge makes no difference in
items at a level no better than chance. Sandoval accuracy of item selection for minority chil-
and Mille (1980) conducted a somewhat more drenº (p. 6). In each of these studies, the most
extensive analysis, using items from the WISC- extreme items were used, which should have
R. These two researchers had 38 Black, 22 given the judges an advantage.
Mexican-American, and 40 White university Anecdotal evidence is also available to refute
students from Spanish, history, and education the assumption that armchair analyses of test
classes identify items from the WISC-R that bias in item content are accurate. The most
would be more difficult for a minority child than widely cited example of a biased intelligence test
a White child and items that would be equally item is item 6 of the WISC-R Comprehension
difficult for each group. A total of 45 WISC-R subtest: ªWhat is the thing to do if a boy (girl)
items were presented to each judge; these items much smaller than yourself starts to fight with
included the 15 most difficult items for Blacks as you?º This item is generally considered to be
compared to Whites, the 15 most difficult items biased against US Black children in particular,
70 Cultural Bias in Testing of Intelligence and Personality

because of the scoring criteria. According to the psychometrically equivalent (or better) item can
item's critics, the most logical response for a be obtained as a replacement and the intent of
Black child is to ªfight back,º yet this is a 0- the item is kept intact (e.g., with a criterion-
point response. The correct (2-point) response is referenced measure, the new item must be
to walk away and avoid fighting with the designed to measure the same objective).
childÐa response that critics claim invites Researchers such as Tittle (1982) have
disaster in the Black culture, where children stressed that the possibility of and need for
are taught to fight back and would not ªknowº cooperation between those advocating statisti-
the ªcorrect White response.º Black responses cal validity and those advocating face validity in
to this item have been investigated empirically nonbiased test construction is greater than one
in several studies, with the same basic results: might think, given the above-cited research.
the item is relatively easier for Black children Judgmental analysis allows for the perception of
than for White children. When all items on the fairness in items, tests, and evaluations, and this
WISC-R are ranked separately according to perception should not be taken lightly. Tittle
difficulty level for Blacks and Whites, this item (1982) argues that ªjudgmental methods arise
is the 42nd least difficult item (where 1 from a different, nonstatistical ground. In
represents the easiest item) for Black children examining fairness or bias primarily on statis-
and the 47th least difficult for White children tical grounds, we may again be witnessing a
(Jensen, 1976). Mille (1979), in a large N study technical solution to a problem that is broader
of bias, reached a similar conclusion, stating than the technical issuesº (p. 34). Cronbach
that this item ªis relatively easier for Blacks than (1980) does not find the issue of fairness as
it is for Whitesº (p. 163). The results of these determined by subjective judgment to be outside
empirical studies with large samples of Black the realm of test validation. Cronbach states,
and White children in the USA are unequivocal: ªThe politicization of testing ought not [to] be
when matched for overall general intellectual surprising. Test data influence the fortunes of
skill, more Black than White children will get individuals and the support given to human
this item correctÐthe very item most often service programsº (p. 100). Tittle (1975, 1982)
singled out as a blatant example of the inherent argues that the general field of test development
bias of intelligence test against Blacks, but so requires greater consensus regarding specific,
selected using anecdotal impressions and ster- multidimensional steps taken in formulating
otypical views of Black cultural even by Black ªfairº measures, because ªfairnessº in testing
judges (see also Reynolds & Brown, 1984). will never be realistically viewed by the public
Even without empirical support for its from a unidimensional statistical standpoint.
accuracy, a number of prestigious writers Considerably less work has been conducted in
support the continued use of the ªface validityº all areas of bias relative to personality testing,
approach of using a panel of minority judges to where there would appear to be greater
identify ªbiasedº test items (Anastasi, 1986; opportunity for cultural, social, and ethnic
Kaufman, 1979; Sandoval & Mille, 1979). factors to act to produce bias. Research on item
Those who support the continued use of this bias of personality measures, though less
technique see it as a method of gaining greater extensive than with aptitude measures, has
rapport with the public. As pointed out by produced results similar to those with aptitude
Sandoval and Mille (1979), ªPublic opinion, measures (see especially Moran, 1990; Rey-
whether it is supported by empirical findings, or nolds, in press; Reynolds & Harding, 1983).
based on emotion, can serve as an obstacle to Research evaluating behavior rating scales is
the use of a measurement instrumentº (p. 7). also meager but at present supports the use of
The elimination of items that are offensive or parent ratings in the diagnosis of childhood
otherwise objectionable to any substantive psychopathology independent of the child's
segment of the population for whom the test ethnic background (e.g., see Mayfield &
is intended seems an appropriate action that Reynolds, in press). A common set of items
may aid in the public's acceptance of new and seems to measure consistently a variety of
better psychological asessment tools. However, personality and behavioral traits for Whites,
the subjective-judgment approach should not be Blacks, and various Hispanic and Latin popu-
allowed to supplant the use of more sophisti- lation residing in the USA (James, 1995;
cated analyses in the determination of biased Mayfield & Reynolds, in press; Reynolds &
items. The subjective approach should serve as a Kamphaus, 1992).
supplemental procedure, and items identified Thus far, this section has focused on the
through this method (provided that some inter- identification of biased items. Several studies
rater agreement can be obtainedÐan aspect of evaluating other hypotheses have provided data
the subjective method yet to be demonstrated) that are relevant to the issue of content bias of
as objectionable can be eliminated when a psychological tests, specifically the WISC-R
 Research Strategies and Results 71

(although now largely superseded in practice by subtests: Comprehension, Object Assembly,

WISC-III, little data regarding bias are avail- and Mazes. A trend was apparent for Blacks
able specifically on this new scale). to perform at a higher level on the Arithmetic
Jensen and Figueroa (1975) investigated subtest, while Whites tended to exceed Blacks
Black±White differences in mental test scores on the Picture Arrangement subtest. Although
as a function of differences in Level I (rote these results can be interpreted to indicate bias
learning and memory) and Level II (complex in several of the WISC-R subtests, the actual
cognitive processing) abilities. These research- differences were very small (typically of the
ers tested a large number of Blacks and Whites order of 0.10±0.15 standard deviation), and the
on the WISC-R Digit Span subtest and then amount of variance in performance associated
analyzed the data separately for digits forward with ethnic group membership was less than 5%
and digits backward. The content of the digits in each case. The results are also reasonably
forward and digits backward procedures is the consistent with Jensen's theory on mental test
same. Thus, if score differences are due only to score differences and their relationship to Level
bias in content of the item validity, score I and Level II abilities. The Digit Span and
differences across race should remain constant Coding subtests are clearly the best measures of
for the two tasks. On the other hand, since the Level I abilities on the WISC-R, while Com-
information-processing demands of the two prehension, Object Assembly, and Mazes are
tasks are quite different (Reynolds, 1997b), the more closely associated with Level II abilities.
relative level of performance on the two tasks Digit Span and Coding are also tasks adversely
should not be the same, as Blacks and Whites affected by increases in an examinee's anxiety
differ in their ability to process information level. The relatively higher level of performance
according to the demands of the two tasks. by the Black children on these tasks is also
Jensen and Figueroa (1975) found the latter to inconsistent with arguments that the testing
be the case. The Black±White score difference circumstance is more unfamiliar and more
on digits backward was more than twice the anxiety provoking to minority children relative
magnitude of the difference for digits forward. to their White counterparts.
Granted, this methodology can provide only From a large number of studies employing a
indirect evidence regarding the content validity wide range of methodologies, a relatively clear
of an instrument; however, its importance is in picture emerges: content bias in well-prepared
providing a different view of the issues and an standardized tests is irregular in its occurrence,
alternative research strategy. Since the Jensen and no common characteristics of items that are
and Figueroa results do not indicate any content found to be biased can be ascertained by expert
bias in the Digit Span subtest, they add to a judges (minority or nonminority). The variance
growing body of literature that strongly in group score differences on mental tests
suggests the lack of cultural bias in well- associated with ethnic group membership when
constructed, standardized tests, and their gen- content bias has been found is relatively small
eralization within a common language and with (typically ranging from 2% to 5%). Even this
some cultural diversity, at least for Black and small amount of bias has been seriously
for White US cultures. questioned, as Hunter (1975) describes such
Another study (Reynolds & Jensen, 1983) findings basically as methodological artifacts.
examined each of the 12 WISC-R subtests for Harrington (1975, 1976) argued that tradi-
cultural bias against Blacks using a variation of tional statistical methods would not detect DIF
the group X item ANOVA methodology and that tests are designed in a psychometrically
discussed earlier. Reynolds and Jensen matched flawed manner so as to always favor the
270 Black children with 270 White children numerically superior group in a population.
from the WISC-R standardization sample on Although Harrington's research and logic are
the basis of gender and WISC-R Full Scale IQ. impressive, his results have not held and the
Matching the two groups of children on the Harrington Effect is not seen in a variety of
bases of the Full Scale IQ essentially equated the works (e.g., Bayley, 1969; Beauchamp, Sam-
two groups for g. Therefore, examining Black± muels, & Griffore, 1974; Hickman & Reynolds,
White differences in performance on each 1986; James, 1995).
subtest of the WISC-R made it possible to Although the search for common ªbiasedº
determine which, if any, of the subtests were item characteristics will continue, and psychol-
disproportionately difficult for Blacks or ogists must pursue the public relations issues of
Whites. A summary of the Reynolds and Jensen face validity, ªarmchairº claims of cultural bias
(1983) results is presented in Table 2. Blacks in aptitude tests have found no empirical
exceeded Whites in performance on two support in a large number of actuarial studies
subtests: Digit Span and Coding. Whites contrasting the performance of a variety of
exceeded Blacks in performance on three racial groups on items and subscales of the most
72 Cultural Bias in Testing of Intelligence and Personality

Table 2 Means, standard deviations, and univariate Fs for comparison of performance on specific WISC-R
subtests by groups of Blacks and Whites matched for WISC-R full scale IQ.

Blacks Whites
± ±
WISC-R variable X SD X SD Da Fb p

Information 8.40 2.53 8.24 2.62 70.16 0.54 NS

Similarities 8.24 2.78 8.13 2.78 70.11 0.22 NS
Arithmetic 8.98 2.62 8.62 2.58 70.36 2.52 0.10
Vocabulary 8.21 2.61 8.27 2.58 +0.06 0.06 NS
Comprehension 8.14 2.40 8.58 2.47 +0.44 4.27 0.05
Digit Span 9.51 3.09 8.89 2.83 +0.62 6.03 0.01
Picture Completion 8.49 2.88 8.60 2.58 +0.11 0.18 NS
Picture Arrangement 8.45 2.92 8.79 2.89 +0.34 1.78 0.01
Block Design 8.06 2.54 8.33 2.76 +0.27 1.36 NS
Object Assembly 8.17 2.90 8.68 2.70 +0.51 4.41 0.05
Coding 9.14 2.81 8.65 2.80 70.49 4.30 0.05
Mazes 8.69 3.14 9.19 2.98 +0.50 3.60 0.05
Verbal IQ 89.63 12.13 89.61 12.07 70.02 0.04 NS
Performance IQ 89.29 12.22 90.16 11.67 +0.87 0.72 NS
Full Scale IQ 88.61 11.48 88.96 11.35 +0.35 0.13 NS

NS, not significant.

a ± ± b
White X ±Black X difference. Degrees of freedom = 1538.

widely employed intelligence and achievement 1982; Cronbach, 1970). Factor analysis as a
scales in the USA; neither differential for single- procedure identifies clusters of test items or
group validity has been demonstrated. How- clusters of subtests of psychological or educa-
ever, these results apply only to groups where a tional tests that correlate highly with one
common language exists among examinees. another, and less so or not at all with other
Personality and interest measures fare likewise subtests or items. It thus allows one to
but there is less good research available for such determine patterns of interrelationships of
tests. Test translations are a different issue and performance among groups of individuals.
required a different line of study altogether. For example, if several subtests of an intelli-
gence scale load highly on (are members of) the
same factor, then if a group of individuals score
10.03.7.2 Bias in Construct Validity high on one of these subtests, they would be
expected to score at a high level on other
There is no single method for the accurate subtests that load highly on that factor.
determination of the construct validity of Psychologists attempt to determine, through a
educational and psychological tests. Defining review of the test content and correlates of
bias in construct validity thus requires a general performance on the factor in question, what
statement that can be researched from a variety psychological trait underlies performance; or, in
of viewpoints with a broad range of methodol- a more hypothesis-testing approach, they will
ogies. The following rather parsimonious make predictions concerning the pattern of
definition is proffered: bias exists in regard to factor loadings. Dana (1993) notes that factor
construct validity when a test is shown to analysis across various cultural groups can be a
measure different hypothetical traits (psycho- useful means of examining the cross-cultural
logical constructs) for one group than for validity of tests of personality, behavior, or
another; that is differing interpretations of a cognitive skill. Dana argues that when ª . . . the
common performance are shown to be appro- factor dimensions resulting from different
priate as a function of ethnicity, gender, or factor analytic methods are stable, and there-
another variable of interest, one typically but fore present an invariant structure across
not necessarily nominal. cultures, then cross-cultural validity may be
As befits the concept of construct validity, inferredº (1993, p. 101). Reynolds (1982a,
many different methods have been employed to 1982b) has made similar albeit more detailed
examine existing tests for potential bias in arguments as have others in specific domains
construct validity. One of the most popular and such as intelligence. Hilliard (1979), one of the
necessary empirical approaches to investigating more vocal critics of IQ tests on the basis of
construct validity is factor analysis (Anastasi, cultural bias, has pointed out one of the
 Research Strategies and Results 73

potential areas of bias in comparisons of the coefficient of correlation between the factor
factor-analytic results of tests across races: loadings of the corresponding factors. The latter
technique, though used with some frequency, is
If the IQ test is a valid and reliable test of ªinnateº less satisfactory than the use of the coefficient of
ability or abilities, then the factors which emerge congruence, since in the comparison of factor
on a given test should be the same from one loadings certain of the assumptions underlying
population to another, since ªintelligenceº is the Pearson r may be violated. When one is
asserted to be a set of mental processes. Therefore, determining the degree of similarity of factors, a
while the configuration of scores of a particular value of 0.90 or greater is typically, though
group on the factor profile would be expected to arbitrarily, taken to indicate equivalent factors
differ, logic would dictate that the factors them- (factorial invariance). However, the most pop-
selves would remain the same. (p. 53)
ular methods of calculating factorial similarity
produce quite similar results (Reynolds &
Although researchers do not necessarily Harding, 1983), at least in large n studies.
agree that identical factor analytic results across In contrast to Hilliard's (1979) strong state-
groups speak to the innateness of the traits ment that studies of factorial similarity across
being measured, consistent factor-analytic re- race have not been reported in the technical
sults across populations do provide strong literature on IQ, a number of such studies have
evidence that whatever is being measured by appeared dealing with a number of different
the instrument is being measured in the same tests. The focus here is primarily on studies
manner and is, in fact, the same latent construct comparing factor-analytic results across ethnic
within each group. The information derived groups in the USA for aptitude tests, since these
from comparative factor analysis across popu- are the most controversial of tests.
lations is directly relevant to the use of educa- Because the WISC (Wechsler, 1949) and its
tional and psychological tests in diagnosis and successor, the WISC-R (Wechsler, 1974; now
other decision-making functions. Psychologists, superseded by the WISC-III, but as yet no such
in order to make consistent interpretations of bias research is available on the latter scale), have
test score data, must be certain that a test been the most widely employed individual
measures the same variable across populations. intelligence tests with school-age children in
Two basic approaches, each with a number of much of the world, it is appropriate that the
variations have been employed to compare cross-race structure of these two instruments has
factor-analytic results across populations. The received extensive investigation for both normal
first and more popular approach asks how and referral populations of children. Using a
similar the results are for each group; the second large, random sample, Reschly (1978) compared
and less popular approach asks whether the the factor structure of the WISC-R across four
results show a statistically significant difference racially identifiable groups: Whites, Blacks,
between groups. The most sophisticated ap- Mexican-Americans, and native American Pa-
proach to the latter question has been the pagos, all from the southwestern USA. Con-
foundational work of JoÈreskog (1969, 1971) in sistent with the findings of previous researchers
simultaneous factor analysis in several popula- with the 1949 WISC (Lindsey, 1967; Silverstein,
tions and now basically represented in the 1973), Reschly (1978) reported substantial
LISREL series of computer programs. How- congruency of factors across races when the
ever, little has been done with the latter two-factor solutions were compared (the two-
approach within the context of test bias factor solution typically reiterated Wechsler's a
research. Mille (1979) has demonstrated the priori grouping of the subtests on to a Verbal and
use of a simpler method (actually developed by a Performance, or nonverbal, scale). The 12
Jensen and presented in detail in Jensen, 1980) coefficients of congruence for comparisons of
for testing the significance of the difference the two-factor solution across all combinations
between factors for two populations. of racial groupings ranged only from 0.97 to
A number of techniques have been developed 0.99, denoting factorial equivalence of this
to measure the similarity of factors across solution across groups. Reschly also compared
groups. The two most common methods of three-factor solutions (three-factor solutions
determining factorial similarity or factorial typically include Verbal Comprehension, Per-
invariance involve the direct comparison of ceptual Organization, and Freedom from Dis-
factor loadings across groups. The two primary tractibility factors), finding congruence only
techniques for this comparison are (i) the between Whites and Mexican-Americans. These
calculation of a coefficient of congruence (Har- findings are also consistent with previous
man, 1976) between the loadings of correspond- research with the WISC (Mille, 1979; Semler
ing factors for two groups, and (ii) the simple & Iscoe, 1966), an intelligence scale originally
calculation of a Pearson product-moment developed and normed on an all-White sample.
74 Cultural Bias in Testing of Intelligence and Personality

The g factor present in the WISC-R was shown validity for these three racial-ethnic . . . groupsº
to be congruent across race, as was also (1979, p.973).
demonstrated by Mille (1979) for the WISC. Gutkin and Reynolds (1981) determined the
Reschly (1978) concluded that the usual inter- factorial similarity of the WISC-R for groups of
pretation of the WISC-R Full Scale IQ as a Black and White children from the WISC-R
measure of overall intellectual ability appears to standardization sample. This study is particu-
be equally appropriate for Whites, Blacks, larly important to examine in determining the
Mexican-Americans, and Native American construct validity of the WISC-R across races,
Papagos. Jensen (1985) has presented compel- because of the sample employed in the inves-
ling data indicating that the Black-White tigation. The sample included 1868 White and
discrepancy seen in major tests of aptitude 305 Black children obtained in a stratified
reflects primarily the g factor. Reschly also random sampling procedure designed to mimic
concluded that the Verbal-Performance scale the 1970 US census data on the basis of age, sex,
distinction on the WISC-R is equally appro- race, SES, geographic region of residence, and
priate across race and that there is strong community size. Similarity of the WISC-R
evidence for the integrity of the WISC-R's factor structure across race was investigated by
construct validity as a measure of intelligence for comparing the Black and White groups for the
a variety of populations. two- and three-factor solutions on (i) the
Support for Reschly's (1978) conclusions is magnitude of unique variances, (ii) the pattern
available from a variety of other studies of the of subtest loadings on each factor, (iii) the
WISC and WISC-R. Applying a hierarchical portion of total variance accounted for by
factor-analytic method developed by Wherry common factor variance, and (iv) the percen-
and Wherry (1969), Vance and Wallbrown tage of common factor variance accounted for
(1978) factor analyzed the intercorrelation by each factor. Coefficients of congruence
matrix of the WISC-R subtests for 150 referred comparing the unique variances, the g factor,
Blacks from the Appalachian region of the the two-factor solutions, and the three-factor
USA. The two-factor hierarchical solution solutions across races all achieved a value of
determined for Vance and Wallbrown's (1978) 0.99. The portion of total variance accounted
Blacks was highly similar to hierarchical factor for by each factor was the same in both the two-
solutions determined for the standardization and three-factor racial groups. Gutkin and
samples of the Wechsler scales generally (Blaha, Reynolds (1981) concluded that for White and
Wallbrown, & Wherry, 1975; Wallbrown, Black children the WISC-R factor structure was
Blaha, & Wherry, 1973). Vance and Wall- essentially invariant, and that no evidence of
brown's (1978) results with the WISC-R are also single-group or differential construct validity
consistent with a previous hierarchical factor could be found. Subsequent studies comparing
analysis with the 1949 WISC for a group of the WISC-R factor structure for referral
disadvantaged Blacks and Whites (Vance, populations of White and Mexican-American
Huelsman, & Wherry, 1976). children have also strongly supported the
Several studies comparing the WISC-R factor construct validity of the WISC-R across races
structure across races for normal and referral (e.g., Dean, 1979b; Gutkin & Reynolds, 1980).
populations of children have also provided DeFries et al. (1974) administered 15 mental
increased support for the generality of Reschly's tests to large samples of Americans of Japanese
(1978) conclusions and the results of the other and Chinese ancestry. After examining the
investigators cited above. Oakland and Feigen- pattern of intercorrelations among the 15 tests
baum (1979) factor analyzed the 12 WISC-R for each of these two ethnic groups, DeFries
subtests' intercorrelations separately for strati- et al. concluded that the cognitive organization
fied (race, age, sex, SES) random samples of of the two groups was virtually identical. In
normal White, Black, and Mexican-American reviewing this study, Willerman (1979) con-
children from an urban school district of the cluded that ªThe similarity in factorial structure
northwestern USA. Pearson r's were calculated [between the two groups] suggests that the
between corresponding factors for each group. manner in which the tests are constructed by the
For the g factor, the Black±White correlation subjects is similar regardless of ethnicity and
between factor loadings was 0.95, the Mexican- that the tests are measuring the same mental
American White correlation was 0.97, and the abilities in the two groupsº (p. 468). At the adult
Black Mexican-American correlation was 0.96. level, Kaiser (1986) and Scholwinski (1985) have
Similar comparisons across all WISC-R vari- analyzed the Wechsler Adult Intelligence Scale-
ables produced correlations ranging only from Revised (WAIS-R; Wechsler, 1981) and re-
0.94 to 0.99. Oakland and Feigenbaum con- ported substantial similarity between factor
cluded that the results of their factor analyses structures for Black and White samples ob-
ªdo not reflect bias with respect to construct tained from the WAIS-R standardization data.
 Research Strategies and Results 75

At the preschool level, factor-analytic results (1979c) compared the general factor making up
also tend to show consistency of construct the MRT across races (Blacks and Whites) and
validity across races, though the results are less genders. Substantial congruence was noted:
clear-cut. In a comparison of separate factor coefficients of congruence across each pair of
analyses of the McCarthy Scales of Children's race±sex groupings ranged only from 0.92 to
Abilities (McCarthy, 1972) for groups of Black 0.99, with the lowest coefficient derived from
and White children, Kaufman and DiCuio the intraracial comparison for White females
(1975) concluded that the McCarthy Scales and White males. Eigenvalues, and subse-
showed a high degree of factorial similarity quently the proportion of variance accounted
between the two races. The conclusion was not for by the factor, were also highly similar for the
straightforward, however. Four factors were race±sex groupings. The lack of differential or
found for the Blacks and three for the Whites. single-group construct validity across sex has
Kaufman and DiCuio based their conclusion on also been demonstrated with aptitude tests for
factorial similarity on the finding that each school-age children (Reynolds & Gutkin,
ªWhiteº factor had a coefficient of congruence 1980c).
of 0.85±0.93 with one ªBlackº factor. One Black In a more comprehensive study employing
factor on the McCarthy Scales had no White seven major preschool tests (the McCarthy
counterpart with a coefficient of congruence Draw-a-Design and Draw-a-Child subtests,
beyond 0.74 (the Memory factor), and the Black the Lee-Clark Reading Readiness tests, The
and White Motor factors showed a coefficient Tests of Basic Experiences Language and
of congruence of only 0.85. Mathematics subtests, the Preschool Inventory-
When investigating the factor structure of the Revised Edition, and the MRT), Reynolds
WPPSI across race, Kaufman and Hollenbeck (1980a) reached a similar conclusion. A two-
(1974) found much ªcleanerº factors for Blacks factor solution was determined with this battery
and Whites than with the McCarthy Scales. The for each of the four race±sex groups as above.
two factors, essentially mirroring Wechsler's Coefficients of congruence ranged only from
Verbal and Performance scales, were virtually 0.95 to 0.99 for the two factors, and the average
identical between the races. Both factors also degree of intercorrelation was essentially the
appear closely related to the hierarchical factor same for all groups, as were eigenvalues and the
solution presented by Wallbrown at al. (1973) percentage of variance accounted for by the
for Blacks and Whites on the WPPSI. When factors. Reynolds (1980a) again concluded that
comparing factor analyses of the Goodenough± the abilities being measured were invariant
Harris Human Figure Drawing Test scoring across race and that there was no evidence of
item, Merz (1970) found highly similar factor differential or single-group construct validity of
structures for Blacks, Whites, Mexican-Amer- preschool tests across races or genders. The clear
icans, and native Americans. trend in studies of preschool tests' construct
Other investigators have found differences validity across race (and sex) is to uphold validity
across races in the factor structures of several across groups. Such findings add support to the
tests designed for preschool and primary-grade use of existing preschool screening measures
children. Goolsby and Frary (1970) factor- with Black and White children of both sexes in
analyzed the Metropolitan Readiness Test the very necessary process of early identification
(MRT) together for separate groups of Blacks (Reynolds, 1979a) of potential learning and
and Whites, finding differences in the factor behavior problems.
structure of this grouping of tests across races. Taken individually but especially as a whole,
When evaluating the experimental edition of the these various cross-group factor analytic studies
Illinois Test of Psycholinguistic Abilities, Le- contradict sharply Helms' (1992) assertion that
venthal and Stedman (1970) noted differences in Black and White groups within the USA have
the factor structure of this battery for Blacks significantly different latent cognitive struc-
and Whites. Two more studies have clarified tures. These results argue in favor of a common
somewhat the issue of differential construct human organization of abilities and neuropsy-
validity of preschool tests across race. chological processes among the many ethnic
The MRT (Hildreth, Griffith, & McGauvran, groups studied thus far. Although majority±
1969) is one of the most widely employed of all minority culturally related differences in level of
preschool screening measures in the USA, and performance differ in various ways across many
its 1969 version is composed of six subtests: ethnic groups, a common organization of latent
Word Meaning, Listening, Matching, Letter ability structures seems clearly evident at this
Naming, Numbers, and Copying. Reynolds time.
(1979b) had previously shown this to be As is appropriate for studies of construct
essentially a one-factor (general Readiness) validity, comparative factor analysis has not
instrument. In a subsequent study, Reynolds been the only method of determining whether
76 Cultural Bias in Testing of Intelligence and Personality

single-group or differential validity exists. WISC-R for Mexican-American children tested

Another method of investigation involves by White examiners. He reported internal-
comparing internal-consistency reliability esti- consistency reliability estimates consistent with,
mates across groups. Internal-consistency re- although slightly exceeding, values reported by
liability is determined by the degree to which the Wechsler (1974) for the predominantly White
items are all measuring a similar construct. To standardization sample. The Bender±Gestalt
be unbiased with regard to construct validity, Test has also been reported to have similar
internal-consistency estimates should be ap- internal-consistency estimates for Whites (0.84),
proximately equal across races. This character- Blacks (0.81), and Mexican-Americans (0.72),
istic of tests has been investigated with Blacks, and for males (0.81) and females (0.80) (Oak-
Whites, and Mexican-Americans for a number land & Feigenbaum, 1979).
of popular aptitude tests within the US Several other methods have also been used to
population. determine the construct validity of popular
With groups of Black and White adults, psychometric instruments across races. Since
Jensen (1977) calculated internal-consistency intelligence is considered a developmental
estimates (using the Kuder±Richardson 21 phenomenon, the correlation of raw scores
formula) for the Wonderlic Personnel Test (a with age has been viewed as one measure of
frequently used employment/aptitude test). constrict validity for intelligence tests. Jensen
Kuder±Richardson 21 values of 0.86 and 0.88 (1976) reported that the correlations between
were found, respectively, for Blacks and Whites. raw scores on the PPVT and age were 0.79 for
Using Hoyt's formula, Jensen (1974) deter- Whites, 0.73 for Blacks, and 0.67 for Mexican-
mined internal-consistency estimates of 0.96 on Americans. For Raven's Progressive Matrices
the PPVT for each of three groups of children: (colored), correlations for raw scores with age
Blacks, Whites, and Mexican-Americans. When were 0.72 for Whites, 0.66 for Blacks, and 0.70
children were categorized by gender within each for Mexican-Americans. Similar results are
racial grouping, the values ranged only from apparent for the K-ABC (Kamphaus & Rey-
0.95 to 0.97. On Raven's Progressive Matrices nolds, 1987) and the Test of Memory and
(colored), internal-consistency estimates were Learning (Reynolds & Bigler, 1994). Thus, in
also quite similar across race and sex, ranging regard to increase in scores with age, the tests
only from 0.86 to 0.91 for the six race±sex behave in a highly similar manner for Whites,
groupings. Thus, Jensen's (1974, 1977) research Blacks, and Mexican-Americans. Similar find-
with three popular aptitude tests shows no signs ings occur in male±female comparisons.
of differential or single-group validity with In the review work of Moran (1990) and in a
regard to homogeneity of test content or search for more recent work, it is apparent that
consistency of measurement across groups. only a few studies of the differential construct
Sandoval (1979) and Oakland and Feigen- validity of personality tests have been under-
baum (1979) have extensively investigated taken, despite large mean differences across
internal consistency of the various WISC-R ethnicity and gender on such popular measures
subtests (excluding Digit Span and Coding, for as the stalwart MMPI. Dana (1993) sharply
which internal-consistency analysis is inap- criticizes even the meager work to date on the
propriate) for Whites, Blacks, and Mexican- MMPI, stating that ª[C]omparative MMPI
Americans. Both of these studies included large research studies of Anglo-American and other
samples of children, with Sandoval's (1979) cultural groups have typically not only used
including over 1000. Sandoval found internal- inappropriate statistics but also failed to equate
consistency estimates to be within 0.04 of one groups adequately on socioeconomic criteria or
another for all subtests except Object Assembly. even to define ethnicityº (p. 98). The lack of
This subtest was most reliable for Blacks (0.95), extensive research using method designed to
while being about equally reliable for Whites detect test bias for such widely used scales as the
(0.79) and Mexican-Americans (0.75). Oakland MMPI is nothing short of appalling. A look at
and Feigenbaum (1979) reported internal-con- the newer MMPI-2 Manual suggests gender
sistency estimates that never differed by more differs in construct validity but provides no real
than 0.06 among the three groups, again with evidence either way. A few studies of factorial
the exception of Object Assembly. In this similarity of instruments such as the Revised
instance, Object Assembly was most reliable Children's Manifest Anxiety Scale show little
for Whites (0.76), with about equal reliabilities bias and high degrees of similarity by ethnicity
for Blacks (0.64) and Mexican-Americans and gender (Moran, 1990; Reynolds & Paget,
(0.67). Oakland and Feigenbaum also com- 1981).
pared reliabilities across sex, finding highly Constuct validity of a large number of
similar values for males and females. Dean popular psychometric assessment instruments
(1977) examined the internal consistency of the has been investigated across races and genders
 Research Strategies and Results 77

with a variety of populations of minority and selection model, the Cleary at al. (1975)
White children and with a divergent set of definition, slightly rephrased here, provides a
methodologies (see Reynolds, 1982b, for a clear and direct statement of test bias with
review of methodologies). All roads have led regard to predictive validity: a test is considered
to Rome: no consistent evidence of bias in biased with respect to predictive validity if the
construct validity has been found with any of inference drawn from the test score is not made
the many tests investigated. This leads to the with the smallest feasible random error or if
conclusion that psychological tests (especially there is constant error in an inference or
aptitude tests) function in essentially the same prediction as a function of membership in a
manner, that test materials are perceived and particular group. This definition is a restate-
reacted to in a similar manner, and that tests ment of previous definitions by Cardall and
measure the same construct with equivalent Coffman (1964), Cleary (1968), and Potthoff
accuracy for Blacks, Whites, Mexican-Amer- (1966), and has been widely accepted (though
icans, and other American minorities of both certainly not without criticism; e.g., Bernal,
sexes and at all levels of SES. Single-group 1975; Linn & Werts, 1971; Schmidt & Hunter,
validity and differential validity have not been 1974; Thorndike, 1971).
found and probably do not exist with regard to Oakland and Matuszek (1977) examined
well-constructed and well-standardized psycho- procedures for placement in special education
logical and educational tests of intellect, classes under a variety of models of bias in
personality, or behavior although data are prediction, and demonstrated that the smallest
not as thorough for the latter two categories number of children are misplaced when the
and much work is needed here. Cleary et al (1975) conditions of fairness are
met. (However, under ªquotaº system require-
ments, Oakland and Matuszek favor the
10.03.7.3 Bias in Predictive or Criterion-related Thorndike, 1971 conditions of selection.) The
Validity Cleary et al. definition is also apparently the
definition espoused in US government guide-
Evaluating bias in predictive validity of lines on testing and has been held in at least one
educational and psychological tests is less closely court decision (Cortez v. Rosen, 1975) to be the
related to the evaluation of group mental test only historically, legally, and logically required
score differences than to the evaluation of condition of test fairness (Ramsay, 1979),
individual test scores in a more absolute sense. although apparently the judge in the Larry P.
This is especially true for aptitude (as opposed to v. Riles (1979) decision (but overturned on
personality or diagnostic) tests, where the appeal) in the US Federal court system adopted
primary purpose of administration is the pre- the ªmean score differences as biasº approach.
diction of some specific future outcome or A variety of educational and psychological
behavior. Internal analyses of bias (such as in personnel long have adopted the Cleary et al.
content and construct validity) are less con- regression approach to bias, including: (i) noted
founded than analyses of bias in predictive psychological authorities on testing (Anastasi,
validity, however, because of the potential 1986; Cronbach, 1970; Humphreys, 1973); (ii)
problems of bias in the criterion measure. educational and psychological researchers
Predictive validity is strongly influenced by the (Brossard, Reynolds, & Gutkin, 1980; Kallin-
reliability of criterion measures, which fre- gal, 1971; Pfeifer & Sedlacek, 1971; Reynolds &
quently is poor. The degree of relationship Hartlage, 1978, 1979; Stanley & Porter, 1967;
between a predictor and a criterion is restricted Wilson, 1969); (iii) industrial/organizational
as a function of the square root of the product of psychologists (Barlett & O'Leary, 1969; Ein-
the reliabilities of the two variables. horn & Bass, 1970; Gael & Grant, 1972; Grant
Arriving at a consensual definition of bias in & Bray, 1970; Ramsay, 1979; Tenopyr, 1967);
predictive validity is also a difficult task, as and (iv) even critics of educational and
previously discussed. Yet, from the standpoint psychological testing (Goldman & Hartig,
of the practical applications of aptitude and 1976; Kirkpatrick, 1970; Kirkpatrick, Ewen,
intelligence tests, predictive validity is the most Barrett, & Katzell, 1968).
crucial form of validity in relation to test bias. The evaluation of bias in prediction under the
Much of the discussion in professional journals Cleary et al. (1975) definition (the regression
concerning bias in predictive validity has definition) is quite straightforward. With simple
centered around models of selection. These regression, predictions take the form of YÃi = aXi
issues have been discussed in Section 10.03.6. + b, where a is the regression coefficient and b is
Since this section is concerned with bias in a constant. When this equation is graphed
respect to the test itself and not the social or (forming a regression line), a represents the slope
political justification of any one particular of the regression line and b the Y intercept. Since
78 Cultural Bias in Testing of Intelligence and Personality

our definition of fairness in predictive validity to test simultaneously the equivalence of

requires errors in prediction to be independent of regression coefficients and intercepts across K
group membership, the regression line formed independent groups with a single F ratio (the
for any pair of variables must be the same for Potthoff equations may be found also in
each group for whom predictions are made. Reynolds, 1982b). If a significant F results,
Whenever the slope or the intercept differs the researcher may then test the slopes and
significantly across groups, there is bias in intercepts separately if information concerning
prediction if one attempts to use a common which value differs is desired. When homo-
equation for all groups. However, if the geneity of regression does not occur, there are
regression equations for two (or more) groups three basic conditions that can result: (i)
are equivalent, prediction is the same for all intercept constants differ, (ii) regression coeffi-
groups. This condition is referred to variously as cients (slopes) differ, or (iii) slopes and inter-
ªhomogeneity of regression across groups,º cepts differ. These conditions are depicted
ªsimultaneous regression,º or ªfairness in pre- pictorially in Figures 2, 3, and 4, respectively.
diction.º Homogeneity of regression across The regression coefficient is related to the
groups is illustrated in Figure 1. In this case, correlation coefficient between the two vari-
the single regression equation is appropriate ables and is one measure of the strength of the
with all groups, any errors in prediction being relationship between two variables. When
random with respect to group membership (i.e., intercepts differ and regression coefficients do
residuals uncorrelated with group membership). not, a situation such as that shown in Figure 2
When homogeneity of regression does not occur, results. Relative accuracy of prediction is the
for ªfairness in predictionº to occur, separate same for the two groups (a and b), the use of a
regression equations must be used for each regression equation derived by combining the
group. two groups results in bias that works against the
In actual clinical practice, regression equa- group with the higher mean criterion score.
tions are seldom generated for the prediction of Since the slope of the regression line is the same
future performance. Instead, some arbitrary or for all groups, the degree of error in prediction
perhaps statistically derived cutoff score is remains constant and does not fluctuate as a
determined, below which ªfailureº is predicted. function of an individual's score on the
For school performance, IQs two or more independent variable. That is, regardless of
standard deviations below the test mean are group member bs score on the predictor, the
used to infer a high probability of failure in the degree of underprediction in performance on
regular classroom if special assistance is not the criterion is the same. As illustrated in Figure
provided for the student in question. Essen- 2, the use of the common score of Yc for a score
tially, then, clinicians are establishing mental of X overestimates how well members of group a
prediction equations that are assumed to be will perform and underestimates the criterion
equivalent across ethnicity, gender, and so on. performance of members of group b.
Although these mental equations cannot be In Figure 3, nonparallel regression lines
tested readily across groups, the actual form of illustrate the case where intercepts are constant
criterion prediction can be compared across across groups but the slope of the line is different
groups in several ways. Errors in prediction for each group. Here, too, the performance of the
must be independent of group membership. If group with the higher mean criterion score is
regression equations are equal, this condition is typically underpredicted when a common re-
met. To test the hypothesis of simultaneous gression equation is applied. The amount of bias
regression, slopes and intercepts must both be in prediction that results from using the common
compared. An alternative method is the direct regression line is the distance of the score from
examination of residuals through ANOVA or a the mean. The most difficult, complex case of
similar design (Reynolds, 1980b). bias is represented in Figure 4 where the result of
In the evaluation of slope and intercept significant differences in slopes and intercepts is
values, two basic techniques most often have shown. Not only does the amount of bias vary
been employed in the research literature. but even the direction can reverse, depending on
Gulliksen and Wilks (1965) and Kerlinger the location of the individual's score in the
(1973) describe methods for separately testing distribution of the independent variable. Only in
regression coefficients and intercepts for sig- the case of Figure 4 do members of the group
nificant differences across groups. Using sepa- with the lower mean criterion score run the risk
rate, independent tests for these two values of having their performance on the criterion
considerably increases the probability of a variable underpredicted by the application of a
decision error and unnecessarily complicates common regression equation.
the decision-making process. Potthoff (1966) A considerable body of literature has
has described a useful technique that allows one developed regarding the differential predictive
 Research Strategies and Results 79

Yi
Criterion

Xi
Predictor
Figure 1 Equal slopes and intercepts result in homogeneity of regression that causes the regression lines for
group a, group b, and the combined group c to be identical.

validity of IQ tests and for tests for employ- by grade point average, GPA). In general, these
ment selection and college admissions. How- studies have found either no differences in the
ever, virtually nothing appears in this regard prediction of criterion performance for Blacks
with reference to personality tests (Dana, 1993; and Whites or a bias (underprediction of the
Moran, 1990) and this is a major weakness in criterion) against Whites (Cleary, 1968; Cleary
the literature. et al., 1975; Goldman & Hewitt, 1976; Kallin-
In a review of 866 Black±White test validity gal, 1971; Pfeifer & Sedlacek, 1971; Stanley,
comparisons from 39 studies of test bias in 1971; Stanley & Porter, 1967; Temp, 1971).
personnel selection, Hunter, Schmidt, and When bias against Whites has been found, the
Hunter (1979) concluded that there was no differences between actual and predicted criter-
evidence to substantiate hypotheses of differ- ion scores, although statistically significant,
ential or single-group validity with regard to the have been quite small.
prediction of job performance across races for Reschly and Sabers (1979) evaluated the
Blacks and Whites. A similar conclusion was validity of WISC-R IQs in the prediction of
reached by Jensen (1980), O'Conner, Wexley, Metropolitan Achievement Tests (MAT) per-
and Alexander (1975), and Reynolds (1982a, formance (Reading and Math subtests) for
1995) among others. A number of studies have Whites, Blacks, Mexican-Americans, and native
also focused on differential validity of the American Papagos. The choice of the MAT as a
Scholastic Aptitude Test (SAT) in the predic- criterion measure in studies of predictive bias is
tion of college performance (typically measured particularly appropriate, since item analysis
80 Cultural Bias in Testing of Intelligence and Personality

Regression line group b

Yb Com m on regression line c

Criterion

Yc Regression line group a

Ya

Xi
Predictor
Figure 2 Equal slopes with differing intercepts result in parallel regression lines and a constant bias in
prediction.

procedures were employed (as described earlier) and native American Papago children. A
to eliminate racial bias in item content during significant relationship occurred between the
the test construction phase. Anastasi (1986) has three WISC-R factors first delineated by Kauf-
described the MAT as an excellent model of an man (1975) and measures of achievement for the
achievement test designed to reduce or eliminate White and non-White groups, with the excep-
cultural bias. Reschly and Saber's (1979) tion of the Papagos. Significant correlations
comparison of regression systems indicated bias occurred between the WISC-R Freedom from
in the prediction of the various achievement Distractibility factor (Kaufman, 1975) and
scores. Again, however, the bias produced teacher ratings of attention for all four groups.
generally significant underprediction of White Reschly and Reschly concluded that ªThese
performance when a common regression equa- data also again confirm the relatively strong
tion was applied. Achievement test performance relationship of WISC-R scores to achievement
of the native American Papago group showed for most non-Anglo as well as Anglo groupsº
the greatest amount of overprediction of all (1979, p. 239). Reynolds and Hartlage (1979)
non-White groups. Using similar techniques, investigated the differential validity of Full
but including teacher ratings, Reschly and Scale IQs from the WISC-R and its 1949
Reschly (1979) also investigated the predictive predecessor, the WISC, in predicting reading
validity of WISC-R factor scores with the and arithmetic achievement for Black and
samples of White, Black, Mexican-American, White children who had been referred by their
 Research Strategies and Results 81

c
Yb
Criterion

a
Yc

Ya

Xi
Predictor
Figure 3 Equal intercepts and differing slopes result in nonparallel regression lines with the degree of bias
dependent on the distance of the individual's score (xi) from the origin.

teachers for psychological services in a rural overprediction of achievement for the Mexican-
Southern school district. Comparisons of American children. Reynolds, Gutkin, Dappen,
correlations and a Potthoff (1966) analysis to and Wright (1979) also failed to find differential
test for identity of regression lines revealed no validity in the prediction of achievement for
significant differences in the ability or function males and females with the WISC-R.
of the WISC and WISC-R to predict achieve- In a related study, Hartlage, Lucas, and
ment for these two groups. Reynolds and Godwin (1976) compared the predictive validity
Gutkin (1980b) replicated this study for the of what they considered to be a relatively
WISC-R with large groups of White and culture-free test (Raven's Progressive Matrices)
Mexican-American children from the South- with a more culture-loaded test (the 1949 WISC,
west. Reynolds and Gutkin contrasted regres- a test developed and standardized on all White
sion systems between WISC-R Verbal, sample) for a group of low-SES, disadvantaged
Performance, and Full Scale IQs and the rural children. Hartlage et al. (1976) found that
ªacademic basicsº of reading, spelling, and the WISC had consistently larger correlations
arithmetic. Only the regression equation be- with measures of reading, spelling, and arith-
tween the WISC-R Performance IQ and metic than Raven's Matrices. Although it did
arithmetic achievement differed for the two not make the comparison with other groups that
groups. The difference in the two equations was is necessary for the drawing of firm conclusions,
due to an intercept bias that resulted in the the study does support the validity of the WISC,
82 Cultural Bias in Testing of Intelligence and Personality

c
Yb

Yc a

Ya
Criterion

Ya

Yc

Yb

Xi Xi
Predictor
Figure 4 Differing slopes and intercepts result in the complex condition where the amount and the direction of
the bias are a function of the distance of an individual's score from the origin.

which has been the target of many of the claims and White children. Neither regression systems
of bias in the prediction of achievement for low- nor correlations differed at p 5 0.05 for the
SES, disadvantaged rural children. Henderson, prediction of the basic academic skills of
Butler, and Goffeney (1969) also reported that reading, spelling, and arithmetic achievement
the WISC and the Bender±Gestalt Test were for these two groups of referred children. An
equally effective in the prediction of reading and earlier study by Sewell (1979), a Black opponent
arithmetic achievement for White and non- of testing, did not compare regression systems,
White groups, though their study had a number but also found no significant differences in
of methodological difficulties, including hetero- validity coefficients for Stanford±Binet IQs
geneity of the non-White comparison group. predicting California Achievement Test
Reynolds, Willson, and Chatman (1985) eval- (CAT) scores for Black and White first-grade
uated the predictive validity of the K-ABC for children.
Blacks and Whites. Occasional evidence of bias A series of studies comparing the predictive
was found in each direction, but mostly in the validity of group IQ measures across races has
direction of overprediction of the academic been reviewed by Jensen (1980) and Sattler
attainment levels of Blacks. (1974). Typically, regression systems have not
Bossard et al. (1980) published a regression been compared in these studies: instead,
analysis of test bias on the 1972 Stanford±Binet researchers have compared only the validity
Intelligence Scale for separate groups of Black coefficients across racesÐa practice that tells
 Research Strategies and Results 83

only whether the test is potentially nonbiased. tigated the predictive validity of two preschool
The comparison of validity coefficients is readiness tests used in the US Office of
nevertheless relevant, since equivalence in Education (Cooperative First-Grade Reading
predictive validities is a first step in evaluating Study, 1964±1965 revision) and the Murphy±
differential validity. That is, if predictive Durell Reading Readiness Analysis (1964
validities differ, then regression systems must revision). Mitchell concluded that the two
differ; the reverse is not necessarily true, readiness tests performed their functions as
however, since the correlation between two well with Black as with White children and that
variables is a measure of the strength or the general level of predictive validity was
magnitude of a relationship and does not similar. This overstates the case somewhat,
dictate the form of a relationship. Although since only validity coefficients and not regres-
the number of studies evaluating group IQ tests sion systems were compared, but Mitchell's
across ethnicity is small, they have typically (1967) study does support the predictive validity
employed extremely large samples. The Lorge± of these readiness tests across race.
Thorndike verbal and nonverbal IQs have been Oakland (1978) assessed the differential
most often investigated. Jensen (1980) and predictive validity of four readiness tests (the
Sattler (1974) concluded that the few available MRT, the Tests of Basic Experiences battery,
studies suggest that standard IQ tests in current the Slosson Intelligence Test, and the Slosson
use have comparable validities for Black and Oral Reading Test) across races (Black, White,
White children at the elementary school level. and Mexican-American) for middle- and lower-
Guterman (1979) reported on an extensive SES children. The MAT, the CAT, and the
analysis of the predictive validity of the California Test of Mental Maturity (CTMM)
Ammons and Ammons Quick Test (QT; a served as criterion variables. Since the CTMM
measure of verbal IQ) for adolescents of is an IQ test, prediction of CTMM scores by the
different social classes. Social class was deter- various readiness tests is excluded from the
mined by a weighted combination of Duncan's following discussion. Although Oakland (1978)
SES index and the number of years of education did not use any test of statistical significance to
of each parent. Three basic measures: (i) the compare the correlations between the indepen-
Vocabulary subtest of the General Aptitude dent and dependent variable pairs across
Test Battery (GATB); (ii) the test of Reading ethnicity and SES, a clear pattern was found,
Comprehension from the Gates Reading Sur- showing higher levels of prediction for White as
vey; and (iii) the Arithmetic subtest of the opposed to non-White groups. Oakland also did
GATB were used. School grades in academic not compare regression systems, limiting his
subjects for 9th, 10th, and 12th grades were also study to the report of the various validity
used to examine for bias in prediction. Guter- coefficients for each race±SES grouping. Oak-
man reached similar conclusions with regard to land's (1978) results clearly indicate potential
all criterion measures across all social classes: bias in the prediction of early school achieve-
slopes and intercepts of regression lines did not ment by individual readiness or screening tests.
differ across social class for the prediction of The lower correlations for non-White groups,
any of the criterion measures by the IQ derived however, given their lower mean criterion
from the QT. Several other social knowledge scores, led to anticipation of bias favoring
criterion measures were also examined. Again, non-Whites in the prediction of early school
slopes were constant across social class, and, achievement.
with the exception of sexual knowledge, inter- To investigate this possibility, Reynolds
cepts were also constant. Guterman concluded (1978) conducted an extensive analysis of
that his data provided strong support for predictive bias for seven major preschool tests
equivalent validity of IQ measures across social (the Draw-a-Design and Draw-a-Child subtests
class. In reanalyzing the Guterman (1979) of the McCarthy Scales; the Mathematics and
study, Gordon and Rudert (1979) reached even Language subtests of the Tests of Basic
stronger conclusions. Certainly with school-age Experiences; the Preschool Inventory-Revised
children and adults, there is compelling evidence Edition; and the Lee±Clark Reading Readiness
that differential and single-group predictive Test) across race and gender for large groups of
validity hypotheses must be rejected. Blacks and Whites. For each preschool test,
As with constrict validity, at the preschool validity coefficients, slopes, and intercepts were
level the evidence is less clear and convincing but compared, with prediction of performance on
points toward a lack of bias against minorities. four subtests of the MAT (Word Knowledge,
Because of doubts expressed about the useful- Word Discrimination, Reading, and Arith-
ness of customary readiness tests with students metic) as the criterion measures. The general
of certain racial and ethnic backgrounds and advantage of the MAT as a criterion in external
with low-SES children, Mitchell (1967) inves- studies of bias has previously been pointed out.
84 Cultural Bias in Testing of Intelligence and Personality

In the Reynolds (1978) study, the MAT had the validity of the seven preschool measures
added advantage of being chosen by the described previously when these were combined
teachers in the district: data were gathered on into a larger battery, thus increasing the scope
a large number of early achievement tests, and and reliability of the assessment.
the teachers selected the MAT as the battery Since the definition of predictive bias noted
most closely measuring what was taught in their earlier requires that errors in prediction be
classrooms. Regression systems and validity independent of group membership, Reynolds
coefficients were compared for each (1980b) directly examined residuals (a ªresidual
independent±dependent variable pair for White termº is the remainder when the predicted score
females (WF) vs. White males (WM), Black for an individual is subtracted from the
females (BF) vs. Black males (BM), WF vs. BF, individual's obtained score) across race and
and WM vs. BM, resulting in 112 comparisons gender when the seven-test battery was used to
of validity coefficients and 112 comparisons of predict MAT scores in a multiple-regression
regression systems. Although the mean correla- formula. Subtests of the seven-test battery were
tions were slightly lower for Blacks, the 112 also examined. Results of a race X sex ANOVA
comparisons of pairs of correlations revealed of residuals for each of the MAT subtests when
only three significant differences, a less-than- the seven-test battery was employed revealed no
chance occurrence with this number of compar- significant differences in residuals across races
isons. Using the Potthoff (1966) technique for and genders, and no significant interactions
comparing regression lines produced quite occurred. When a subset of the larger battery
different results. Of the 112 comparisons of was submitted to the same analysis, racial bias
regression lines, 43 (38.4%) showed differences. in prediction did not occur; however, a
For comparisons with race as the major variable significant F resulted for gender effects in the
(and gender controlled), 31 (55.2%) of the 56 prediction of two of the four MAT subscores
comparisons showed significantly different (Word Discrimination and Word Knowledge).
regression lives. Clearly, racial bias was sig- Examination of the residuals for each group
nificantly more prevalent than gender bias (p 5 showed that the bias in prediction was again
0.01) in prediction. In comparing the various against the group with the higher mean criterion
pretests, bias occurred most often with the scores: there was a consistent underprediction
Preschool Inventory and the Lee±Clark, of performance for females. The magnitude of
whereas none of the comparisons involving the effect was small, however, being of the order
the MRT showed bias. Though race clearly of 0.13±0.16 standard deviations. Thus, at the
influenced homogeneity of regression across preschool level, the only convincing evidence of
groups, the bias in each case acted to over- bias in predictive validity is a gender effect, not a
predict performance of lower-scoring groups; race effect.
thus the bias acted against Whites and females Kamphaus and Reynolds (1987) reviewed the
and in favor of Blacks and males. A follow-up available literature on predictive bias with the
study (Reynolds, 1980b) has indicated one K-ABC and concluded that overprediction of
potential method for avoiding bias in the Black children's performance in school is more
prediction of early school achievement with common with the K-ABC, particularly the K-
readiness or screening measures. ABC Sequential Processing scale, than with
Brief screening measures, especially at the other tests. The effects are small, however, and
preschool level, typically do not have the high are mitigated in large part by using the K-ABC
level of reliability obtained by such instruments Mental Processing Composite. Some bias also
as the WISC-R or the Stanford±Binet. Linn and occurs against Blacks, but when the extensive
Werts (1971) have demonstrated convincingly nature of the bias research with the K-ABC is
that poor reliability can lead to bias in considered, results with the K-ABC are not
prediction. Early screening measures, as a rule, substantially different from the results with the
also assess a very limited area of functioning, WISC-R (with the exception of overprediction
rather than allowing the child to demonstrate its of Black academic performance by the K-ABC
skills in a variety of areas of cognitive Sequential Processing scale).
functioning. The one well-researched, reliable, Keith and Reynolds (1990) have suggested
broad-based readiness test, the MRT, has failed the use of path analysis as an alternative model
to show bias with regard to internal or external for assessing bias is predictive validity. In such a
criteria. Comprehensive and reliable individual path model, ability would be proposed to
preschool instruments such as the WPPSI and predict achievement, and group membership
the McCarthy Scales, while showing no internal would be assessed as a moderator variable. A
evidence of test bias, have not been researched diagrammatic representation of a biased and an
with regard to predictive bias across race. unbiased model is shown in Keith and Reynolds
Reynolds (1980b) examined the predictive (1990). Bias in prediction would exist in such a
 Summary and Future Directions 85

model when group membership affects mea- experiences with proposed solutions to cross-
sured ability independent of true ability, that is, cultural adaptation of psychological tests stem-
errors of measurement in testing of ability ming from some 30 nations from throughout the
would be correlated with group membership. world. The various contributors describe both
With regard to bias in predictive validity, the the strengths and limitations of adapting tests
empirical evidence suggests conclusions similar cross-culturally from one country to another,
to those regarding bias in content and construct providing perspectives from such diverse dis-
validity. There is no strong evidence to support cipline psychometrics, cognitive development,
contentions of differential single-group validity. psychology, and anthropology. More recent
Bias occurs infrequently and with no apparently guidelines and reviews of the issues involved in
observable pattern, except when instruments of cross-cultural adaptation of psychological and
poor reliability and high specificity of test educational tests can be found in Hambleton
content are examined. When bias occurs, it is (1994), Hambleton and Kanjee (1995), and Van
most often in the direction of favoring low-SES, de Vijver and Hambleton (1996).
disadvantaged ethnic minority children, or
other low-scoring groups.
10.03.9 SUMMARY AND FUTURE
DIRECTIONS
10.03.8 CROSS-CULTURAL TESTING
WHEN TRANSLATION IS There is little question that the issue of bias in
REQUIRED mental testing is an important one with strong
historical precedence in the social sciences and,
When a test is translated from one language ultimately, formidable social consequences.
to another, the research findings discussed thus Because the history of mental measurement
far do not hold. It is inappropriate simply to has been closely wed from the outset to societal
translate a test and apply it in a different needs and expectations, testing in all forms has
linguistic culture. A test must be redeveloped remained in the limelight, subjected to the
from scratch (although constructs may be crucible of social inspection, review, and (at
retained) basically before any such application times) condemnation in various cultures
would be appropriate. New items, new norma- throughout the world. However, the fact that
tive data, and new scaling would all be required. tests and measures of human aptitude and
This has been known since the early days of achievement continue to be employed in most
psychological assessment and testing. In the modern cultures indicates strongly that the
early 1900s, when the Binet±Simon tests were practice has value, despite the recurring storms
brought to the USA from France, approxi- of criticism over the years. The ongoing
mately 30 different versions of the test were controversy related to test bias and the ªfairº
developed in the USA by various researchers. use of measures will undoubtedly remain with
However, most of these were mere translations the social sciences for at least as long as we
or contained minor modifications to adapt to intertwine the nature±nuture question with
American culture. The Stanford±Binet Intelli- these issues and affirm differences between±
gence Scale, in its various incarnations, how- among groups in mean performance on stan-
ever, became the standard bearer for dardized tests. Numerous scholars in the field of
measurement of intelligence for nearly 60 years psychometrics have been attempting to separate
and was even more popular in France at one the nature±nurture issue and data on mean
time than the original French Binet±Simon score differences from the more orderly,
scales. The reason for the domination of the empirically-driven specialty of bias investiga-
Stanford±Binet series was Lewis Terman's tion, but the separation will undoubtedly not be
insight and tenacity in redeveloping the test in a clean one. A sharp distinction has developed
the USA. After determining that Binet's theory between the popular press and scientific
of intelligence applied, new items were written, literature with regard to the interpretation of
tried out, and a new scale devised for norming mental measurement research. The former all
that was conceptually consistent with the too often engenders beliefs that biased measures
Binet±Simon scales but in its practical applica- are put into use for socially pernicious purposes
tion was a new and different test. and psychology and education are often accused
The problems in translating verbal and of courting political, social, and professional
nonverbal concepts across linguistic cultures ideologies. The former appears to have created
are difficult but in any event the redevelopment confusion in public opinion concerning the
of tests in such circumstances seems required. possibility of ªfairº testing, to say the least. The
Cronbach and Drenth (1972) provide a book latterÐreported in this chapterÐhas been
length treatment of these problems and various demonstrating through a rather sizable body
86 Cultural Bias in Testing of Intelligence and Personality

of data that the hypothesis of cultural bias in A philosophical perspective is emerging in the
tests is not a particularly strong one at present, bias literature that is requiring test developers
at least in cultures with a common language and not only to demonstrate whether their measures
some degree (the extent or qualitative features demonstrate differential content, construct, and
of which are as yet indeterminant) of common predictive validity across groups prior to
experience. In any event, societal scrutiny and publication, but also to incorporate in some
ongoing sentiment about testing have without form content analyses by interested groups to
question served to force the psychometric ensure that offensive materials are omitted.
community to refine its definitions of bias Although there are no sound empirical data to
further, to inspect practices in the construction suggest that persons can determine bias upon
of nonbiased measures, and to develop statis- surface inspection, the synergistic relationship
tical procedures to detect bias when it is between test use and pure psychometrics must
occurring. We can argue whether the social be acknowledged and accommodated in an
sciences have from the outset overstepped their orderly fashion before tests gain greater
bounds in implementing testing for social acceptance within society. Ideally, a clear
purposes before adequate data and methods consensus on ªfairnessº (and steps taken to
were developed, but the resulting advancements reach this end) is needed between those persons
made in bias technology in response to ongoing with more subjective concerns and those
public inspection are undeniable. interested in gathering objective bias data
Data from the empirical end of bias investiga- during and after test construction. Accommo-
tion do suggest several guidelines to follow in dation along this line will ultimately ensure that
order to ensure equitable assessment. Points to all parties interested in any given test believe
consider include: (i) investigation of possible that the measure in question is nonbiased and
referral source bias, as there is evidence that that the steps taken to achieve ªfairnessº can be
persons are not always referred for mental health held up to public scrutiny without reservation.
or special eductional services on the basis of Given the significant and reliable methods
impartial, objective rationales; (ii) inspection of developed over the last several decades in bias
test developers' data for evidence that sound research, it is untenable at this point to abandon
statistical analyses for bias across groups to be statistical analyses in favor of ªarmchairº
evaluated with the measure have been com- determinations of bias. Test authors and
pleted; (iii) assessment with the most reliable publishers need to demonstrate factorial invar-
measures available; and (iv) assessment of iance across all groups for whom the test is
multiple abilities with multiple methods. In designed in order to make the instrument more
other words, psychologists need to view multiple readily interpretable. Comparisons of predictive
sources of accurately derived data prior to validity across races and genders during the test
making decisions concerning individuals. We development phase are also needed. With the
may hope that this is not too far afield from what exception of some recent achievement tests, this
has actually been occurring in the practice on has not been common practice, yet it is at this
psychological assessment, though one continues stage that tests can be altered through a variety
to hear isolated stories of grossly incompetent of item analysis procedures to eliminate any
diagnostic decisions being made (e.g., Mason, apparent racial and sexual bias. As scientists, we
1979). This does not mean that psychologists must also inform the media of our results,
should be blind to a person's environmental whatever they may be.
background. Information concerning the home, Bias research in the area of personality testing
community, and other environmental circum- must be expanded. Little has been done and this
stances must all be evaluated in the individua- represents a major weakness in the literature.
lized decision-making process. Exactly how this Only recently (e.g., Reynolds & Kamphaus,
may be done is addressed in all other chapters 1992) have publishers begun to give appropriate
and volumes of this work. Neither, however, can attention to this problem. Researchers in
the psychologist ignore the fact that ethnic personality and psychodiagnostics must move
minority group members who score at levels ahead in this area of concern. Similar problems
indicative of psychopathology are just as likely exist in the growing area of neuropsychological
to have problems and need intervention as are testing (e.g., Reynolds, 1997a).
majority-class individuals. Indeed, it is the
purpose of the assessment process to beat the
predictionÐto provide insight into hypotheses 10.03.10 REFERENCES
for environmental and biological interventions
Abebimpe, V. R., Gigandet, J., & Harris, E. (1979). MMPI
that will prevent the identified pathology from diagnosis of Black psychiatric patients. American Journal
continuity to exert a negative influence on the of Psychiatry, 136, 85±87.
person's life. Alley, G., & Foster, C. (1978). Nondiscriminatory testing
 References 87

of minority and exceptional children. Focus on Excep- presented at the annual meeting of the Southeastern
tional Children, 9, 1±14. Conference on Measurement in Education, New Or-
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 Copyright © 1998 Elsevier Science Ltd. All rights reserved.

10.04
Cross-cultural Clinical
Interventions
JOHN E. LEWIS
Nova Southeastern University, Fort Lauderdale, FL, USA

10.04.1 INTRODUCTION 94
10.04.2 PROXIMAL VS. DISTAL VARIABLES 95
10.04.2.1 Proximal Variables 95
10.04.2.2 Distal Variables 96
10.04.3 CLINICAL INTERVENTION PROCESSES 97
10.04.3.1 Cross-cultural Competence and Sensitivity 97
10.04.3.2 Intercultural Communication Style 98
10.04.3.3 Cross-cultural Verbal Communication 100
10.04.3.4 Nonverbal Communication 100
10.04.3.4.1 Proxemics 100
10.04.3.4.2 Kinesics 101
10.04.3.4.3 Paralinguistics 103
10.04.3.5 Use of Translators 103
10.04.4 THERAPIST±CLIENT MATCH 104
10.04.5 TREATMENT OUTCOME 107
10.04.5.1 Definition 107
10.04.5.2 Cross-cultural Outcome Research 107
10.04.6 METHODOLOGICAL CONSIDERATIONS 109
10.04.6.1 Reliability and Validity in Cross-cultural Research 109
10.04.6.2 Recommendations 110
10.04.7 FUTURE DIRECTIONS 111
10.04.7.1 Terminology 111
10.04.7.2 Ethical and Professional Issues 112
10.04.7.3 Future Research 112
10.04.7.3.1 Research agenda 113
10.04.7.3.2 Assessment techniques 114
10.04.7.3.3 Theory of multicultural counseling and therapy 114
10.04.7.3.4 Specific research topics 114
10.04.7.4 Global Psychology 115
10.04.8 SUMMARY 116
10.04.9 REFERENCES 116

93
94 Cross-cultural Clinical Interventions

10.04.1 INTRODUCTION lack of power in the dominant culture; finally,

culture has taken on broader implications in the
While attempts have been made to trace the literature of the 1990s to include demographic
evolution of multicultural counseling from variables (e.g., age, gender, and region), status
ancient civilizations to the present day (Thomp- variables, affiliation variables, and the tradi-
son, 1989), current thinking supports the notion tional variables of race and ethnicity. This view
that multicultural counseling is only several of culture focuses on its nonstatic nature, as
decades old. This is evidenced by the increased culture also denotes patterns of behavior, family
intercultural focus in publications from 1960 to life, and beliefs (Fernando, 1995). Poortinga
1995 (Jackson, 1995). (1992) has argued that culture constitutes a set
Early in the 1990s multicultural counseling of shared constraints that limit individual
and therapy (MCT) was hailed as the fourth members of groups in terms of their behavioral
force in psychology (Pedersen, 1990, 1991b, responses.
1994; Pedersen & Ivey, 1993). As a result, the Goodchilds (1991) described race and ethni-
movement has been to formulate a framework city as dimensions not categories. Phinney
for MCT in an attempt to describe and explain (1996) argued that one needs to explore three
the impact of cultural diversity on psycho- dimensions that differ between and within
therapeutic interventions. This movement ethnic groups: ªFirst, cultural norms and
spawned a definitive explication of MCT theory attitudes that may be influential in psychologi-
in a conceptual treatise (Sue, Ivey, & Pedersen, cal processes. . . . Second, the strength, salience,
1996). The work provides a metatheory for and meaning of individuals' ethnic identities. . . .
cross-cultural interventions that espouses six Third, individuals' experiences as a member of a
basic propositions, encompassing 47 corollary minority group with lower status and powerº
suppositions. (p. 925). Readers are diverted to more complete
The propositions and corollaries were origin- explanations of the terminology concerning
ally proposed by Sue (1995), but were refined by culture, race, and ethnicity (Gaw, 1993; Jack-
Sue et al. (1996) to help psychologists move son, 1995; Marsella & Pedersen, 1981; Marsella
from a culture-bound theory of intervention to & White, 1982; Pedersen, 1991b; Phinney,
a theory that could encompass a variety of 1996).
existing world views. The propositions and This new emphasis has spawned concern
corollaries acknowledge that (i) both therapist about the terminology and definitions used
and client identities are formed and embedded by researchers and practitioners alike. In
within a complex set of experiences that have a particular, current terms such as ªmulticultural
fluid dimension and a contextual salience, (ii) counseling,º ªculture-centered counseling,º
the development of one's cultural identity cross-cultural intervention,º ªcross-cultural
encompasses attitudes to one's own culture communication,º ªminority counseling,º and
and other cultures; (iii) psychotherapeutic out- ªpluralismº have tended to obfuscate an already
comes are more successful when goals and complex area of interest.
therapy modalities are consistent with a client's Pedersen (1991b) has suggested that psychol-
values, goals, and cultural experiences; and (iv) ogists use a broad definition of culture that
individual counseling may need to be balanced includes demographic variables such as eco-
with models that incorporate family and societal nomics and education as well as informal and
units. formal affiliation variables to supplement the
This new framework spawned critical debate traditional cultural variables of ethnicity, race,
(Casas & Mann, 1996; Corey, 1996) centered on nationality, religion, and linguistic group. This
the lack of adequate definitions within the field wide view of culture seeks to balance culture-
of MCT. The terms ªrace,º ªethnicity,º ªmin- specific with universal perspectives that underlie
ority,º and ªcultureº have not been clarified a client's behavior, cognition, and affect.
and, thus, are constantly confused by profes- Pedersen (1991a) has also called for the term
sionals (Atkinson, Morten, & Sue, 1993). In ªmulticultural counseling and therapyº to be
1994, Pedersen defined these terms. He stated used since it ªimplies a wide range of multiple
that race is a classification based on genetic or groups without grading, comparing, or ranking
biological differences and includes a shared them as better or worse than one another and
genetic history and/or physical characteristics without denying the very distinct and comple-
such as skin color; ethnicity refers to a common mentary perspective that each group brings with
sociocultural history that can include political itº (p. 4).
history, similar genealogy, and religion; minor- Keeping in the forefront the concepts and
ity is used to identify a group that has been definitions integral to MCT, this chapter will
treated unfairly or has suffered from collective focus on issues pertaining to cross-cultural
discriminating practices due to the minorities' interventions. First, proximal and distal factors
 Proximal vs. Distal Variables 95

will be described. Second, interviewing and The study of values within a cross-cultural
clinical interventions will be examined, by framework is best exemplified in the work of
summarizing the research on effective inter- Kluckhohn and Strodtbeck (1961). This model
cultural communication, and verbal/nonverbal recognized that cultures differ in their percep-
language factors in counseling and psychother- tion of time, attitudes towards activity, their
apy. Third, the issue of client and therapist lineal versus collateral relationships, and their
match will be explored. This discussion will notion of the nature of people. These value
evaluate the notion that therapists and clients orientations have been modified and expanded
from similar backgrounds have more accurate by Ibrahim, (1985) and Kohls (1979) to provide
communication and greater potential for suc- social/cultural interpretations and examples.
cessful therapeutic outcomes. Fourth, the Carter (1991) reviewed the research on the
treatment outcome literature will be examined Kluckhohn±Strodtbeck model and concluded
with a view to evaluating the efficacy of that a counselor needed to understand a
particular intervention strategies with culturally culture's value structure if he or she hoped to
different clients. Fifth, present and future understand both the unique and universal
methodological issues that relate to the clinical attributes of that culture.
interventions with a culturally diverse clientele Schwartz (1992, 1994) has examined the
will be examined. Finally, future issues in this universal content and structure of values. He
area will be discussed. identified, through the results of a self-report
values instrument, 10 universal value domains
at the individual level and seven at the global
10.04.2 PROXIMAL VS. DISTAL cultural level. Scores were obtained for 38
VARIABLES different cultural groups (Schwartz, 1994).
These culture-level scores have been compared
Two prerequisites of culturally responsive
to the results obtained in Hofstede's studies.
behavior are attitudes and beliefs (Ridley,
Hofstede (1980, 1991) described a pattern of
Mendoza, Kanitz, Angermeier, & Zenk,
universal and culture-specific variables in 55
1994). These two constructs can be discussed
countries. He identified measures that related to
by using Poortinga's (1992) notion that beha-
thinking, feeling, and behaving and claimed that
vioral responses are dependent upon internal
these patterns, or mental programs, were
and external constraints which are governed by
constructed differently by different cultures at
a person's sociocultural history. These con-
different times. In addition, he described four
straints have been delineated into two variables:
dimensions that varied among the countries:
internal±proximal and external±distal. Proxi-
small/large power distance, collectivism vs.
mal variables, also called proximal levels,
individualism, femininity vs. masculinity, and
include aspects of the immediate setting and
weak/strong uncertainty avoidances. More
behavior of the client, and the ªrelated flux of
recently, researchers (Kim, Triandis, Kagitci-
affect and cognition during a particular inter-
basi, Choi, & Yoon, 1994; Smith, Peterson,
actionº (Fletcher & Fitness, 1990, p. 464). Distal
Akande, Callan, & Cho, 1995) have examined
variables, or levels, are generally ªstable
specific value orientations in different countries
dispositional variables that predate the im-
and have illustrated clear patterns of cultural
mediate proximal contextº (Fletcher & Fitness,
difference with respect to external±internal
1990, p. 464). Distal variables include person-
control and collectivism, respectively.
ality characteristics, levels of effect, and client
Whereas values exemplify what a culture or
expectations. They also include ethnicity and
individual holds as important, beliefs encom-
race (Sue, Zane, & Young, 1994).
pass an individual's or culture's sense of how the
world is construed. The most often studied
10.04.2.1 Proximal Variables variable in this area is locus of control. This
concept was formulated by Rotter (1966) and
The effect of proximal variables on relation- incorporated the notion that people have
ships and communication processes has differential beliefs about how outcomes are
emerged in studies originating in the field of obtained in relation to personal power. Rotter
social cognition (Bradbury & Fincham, 1988; described two dimensions, internal control and
Fletcher & Fitness, 1990; Kelly et al., 1983). The external control. Internal control referred to the
social cognition notion of proximal level can be idea that people can control their own out-
expanded into cross-cultural interactions. The comes. External control referred to the notion
therapist must identify the thoughts and feelings that outcomes are more determined by chance
experienced by the client immediately preceding environmental circumstances rather than per-
a therapy session, especially values and beliefs sonal power. Through the socialization process,
(Bond & Smith, 1996). people learn one of these two views. These
96 Cross-cultural Clinical Interventions

locus-of-control beliefs of clients are related to chotherapy. Rather, they believe that ªit may be
how a client experiences ªcontrol harmony, and wiser to focus on the proximal process of
submission with respect to the environmentº therapist credibilityº (p. 39). This credibility
(Bond & Smith, 1996, p. 211). involves a therapist's ability to conceptualize the
Locus of responsibility is closely related to client's problem, sensitivity to culturally appro-
locus of control. This belief, which has emerged priate means of problem resolution, and client±
largely from attribution theories in social therapist goal compatibility. In other words,
cognition (Fiske & Taylor, 1991), is concerned high achieved and ascribed credibility is likely to
with how much blame is placed on individuals produce an effective therapeutic process,
or systems. Sue and Sue (1990) have described whereas low ascribed and achieved credibility
these emphases as important for a client's life will result in early termination of therapy.
orientation development. They believe that a Akutsu, Lin, and Zane (1990) stated that the
person-oriented, person-blame individual tends proximal±distal model predicts that counselor
to focus on individual responsibility attributes. credibility is related to continued involvement
He or she tends to focus on a person's in treatment, whereas the distal variables, cul-
motivations, values, feelings, and goals and tural knowledge, and techniques are mediated
tends to attribute successful or unsuccessful through the credibility that exists in the thera-
outcomes to a person's strengths and weak- peutic relationship. They tested the proximal±
nesses. These individuals see a strong relation- distal model with Chinese students and con-
ship between individual effort and success. This cluded that counselor credibility was related to
stance allows some members of the dominant the client's intention to utilize therapy and that
culture to view minorities as totally responsible relationship variables and therapist style were
for their behavior and ignore contextually mediated through the subject's evaluation of the
relevant information that may contribute to counselor's credibility. Proximal factors, there-
or cause a person's behavior. Some clients, on fore, were seen as essential for continued
the other hand, tend to be situation-blaming. intentions for therapy by culturally diverse
They tend to attribute successful and unsuccess- clients.
ful outcomes to variables outside of themselves, Berry (1990) has studied distal factors with
in the sociocultural environment. Sue and Sue respect to ethnic group relationships. He
believe that therapists need to view the identified a map of relationships that included
individual±system blame continuum in an effort three sociocultural factors: collective stereo-
to understand their clients and to see the types, history±economics±politics, and collec-
culturally relevant factors that may impact on tive behaviors. These categories influenced
a person's situation. various psychological variables, including per-
Other beliefs that are not universal, but ception, attribution, attitudes, and behavior.
culturally specific, have been suggested. They Fiske (1992) has described sociocultural factors
include the notion of justice (Furnham, 1993), by proposing a four-component model, stating
global cooperation (Der-Kerabetian, 1992), and that social relationships in cultures include
beliefs and attitudes about the work ethic communal sharing, authority, ranking, equality
(Furnham, Bond, Heaven, Hilton, & Lobel, matching, and market pricing. Berry (1990) and
1993). Further research is needed to clarify and Triandis (1994) have called for more studies that
verify these variables. are sensitive to external, distal ethnic variables.
The preceding discussion has encompassed
the notion that universal and culture-specific
10.04.2.2 Distal Variables thoughts, feelings, and behaviors affect client±
therapist interaction. It was Frank (1961) that
There has been a notable lack of empirical stated a ªpsychotherapist in any culture works
studies that have focused on external±distal to assist in the definition of subtle gradations of
factors. Bond and Smith (1996) have concluded implicit rules governing behavior which derive
that ªalmost all current models of cultural from a vast array of norms, value systems, and
difference are thus proximal rather than distalº ideologies present in the shared assumptive
(p. 211). Sue and Zane (1987) discussed the worlds of the patient and therapistº (p. 28).
proximal±distal issue by evaluating whether Therapists with culturally diverse clients are
cultural knowledge or culture-specific techni- required to decode implicit rules that are
ques were linked to psychotherapeutic success. culturally determined and to make them more
They formulated a proximal±distal model that situationally appropriate in therapy. It necessi-
suggested cultural knowledge and technique- tates a therapist's close attention to what
oriented methods in therapy are of a distal individual and sociocultural variables are
nature and, therefore, may not contribute salient at any given moment during the cross-
significantly to effective counseling and psy- cultural interaction. Failure to do so will result
 Clinical Intervention Processes 97

in cultural encapsulation, ineffective client± counselor understanding of client's world view,

therapist relationships, and possible ineffective and the development of culturally appropriate
treatment outcomes. intervention strategies and techniques. Of
The issues involved with distal and proximal particular relevance were the recommendations
variables are at the core of interviewing skills for interventions, which included the need for
and clinical interventions. The act of interview- more accurate verbal communication, increased
ing and therapy involves the formation of a understanding of nonverbal communication,
close relationship between client and therapist. greater proficiency in dealing with clients'
This relationship, inevitably, exposes the prox- diverse behavioral and affective response styles,
imal and distal factors present in the lives and increased understanding of the role of
of both participants. Sensitivity to proximal societal and familial issues in therapy.
and distal factors, as well as culture-specific In 1993, the American Psychological Asso-
and universal expressions of behavior from a ciation (APA) established guidelines for the
client, are fundamental concerns in clinical provision of services to ethnic, linguistic, and
interventions. culturally diverse populations. These guidelines
stated: ªPsychologists need a sociocultural
framework to consider diversity of values,
interactional styles, and cultural expectations
10.04.3 CLINICAL INTERVENTION in a systematic fashionº (p. 45). In response to
PROCESSES this need for frameworks for effective
cross-cultural interactions, psychologists have
The area of clinical intervention process examined cultural differences and universal
encompasses topics as diverse as cross-cultural expressions of client behavior (Sue & Sue, 1990).
sensitivity and competence, intercultural com- Culture tends to have a limiting or restructur-
munication style, cross-cultural verbal commu- ing effect on universal expression. These
nication, nonverbal communication, and the cultural differences create stress on the ther-
role of translators during therapy. apeutic relationship. Problems can occur when
the therapist becomes too enamored of his or
her own cultural values. Wrenn (1962, 1985)
10.04.3.1 Cross-cultural Competence and created the term ªcultural encapsulationº to
Sensitivity describe the notion that some therapists: (i)
substitute stereotypes for the real world, (ii)
Cross-cultural counseling has been defined as ignore cultural variations across cultures, and
ªany counseling relationship in which two or (iii) adhere to a technique-oriented, static
more participants differ in cultural background, notion of the therapeutic process. The result
values, and lifestyleº (Sue et al., 1982, p. 47). of cultural encapsulation is that the therapist's
This definition has led many counselors and role becomes rigidly defined with an ensuing
therapists to the conclusion that all counseling universal notion of health, normality, and
could be considered to have a multicultural pathology.
dimension (Pedersen, 1994; Speight, Myers, This notion of cultural encapsulation led Sue
Cox, & Highlen, 1991; Sue, Ivey, & Pedersen, and Sue (1990) to outline the characteristics of
1996). In fact, it is argued that within-group the culturally skilled counselor and therapist.
differences have at least equal impact as These characteristics involve the development
between-group differences on the clarification of attitudes and beliefs that have understanding
of cultural issues (Speight et al., 1991). of the self and the client's world view at their
These definitions and statements have de- core. The culturally skilled counselor
manded the attention of organizations and (pp. 167±169):
policy makers concerned with the provision of (i) has moved from being culturally unaware
psychological services. In 1992, the Association to being aware and sensitive to his or her own
for Multicultural Counseling and Development cultural heritage and to valuing and respecting
(AMCD), a branch of the American Counseling differences;
Association (ACA), published a document that (ii) is aware of his or her own values and
outlined multicultural counseling competencies biases and how they might affect minority
and standards for inclusion in psychological clients;
service provider programs. This document (iii) is comfortable with differences that exist
espoused a three-by-three matrix for organizing between themselves and their clients in terms of
and developing cross-cultural competencies. race and beliefs;
This matrix identified three areas of concern: (iv) is sensitive to circumstances (personal
(i) beliefs and attitudes, (ii) knowledge, and (iii) biases, stage of ethnic identity, sociopolitical
skills in relation to counselor self-awareness, influences, etc.) that may dictate referral of a
98 Cross-cultural Clinical Interventions

minority client to a member of his or her own to adopt a ªnaiveº posture in processing
race or culture or to another counselor in information (p. 129). Third, cultural sensitivity
general; is a prerequisite for interventions that are
(v) is aware of his or her own racial attitudes, culturally responsive.
beliefs, and feelings; Fourth, cultural differences that exist be-
(vi) must possess specific knowledge and tween client and therapist may interfere with a
information about the particular group he or therapist's information processing. Fifth, cul-
she is working with; tural sensitivity is grounded in the information
(vii) must have a good understanding of the processing theory of perceptual schemata;
sociopolitical systems' operation with respect to mental schemata develop likely as a natural
its treatment of minorities; process during client and therapist interactions.
(viii) has clear and explicit knowledge of The authors have called for empirical studies
the generic characteristics of counseling and that can verify or expand this model.
therapy; Culturally sensitive counselors, therefore, are
(ix) is aware of the institutional barriers that seen as implicitly facilitating therapy that has
prevent minorities from using mental health more effective outcomes for diverse clients,
services. while culturally insensitive counselors are seen
These attributes of the skilled multicultural as ineffective change agents. Culturally insensi-
therapist have been discussed more elaborately tive counselors have been viewed as a main
in the cross-cultural competencies and stan- contributor to problems of ethnocentrism, lack
dards outlined by Sue, Arredondo, and McDa- of empathy, misdiagnosis, and treatment selec-
vis (1992). Attempts to measure these tion errors (Gim, Atkinson, & Kim, 1991). In
competencies have been made with two rating addition, the underutilization of mental health
scales: the Cross-cultural Competence Inven- services and early termination by minorities
tory (Hernandez & LaFromboise, 1985) and the have been attributed to the lack of sensitive
Cross-cultural Competence Inventory±Revised therapy services (Romeo, 1985; Sue & Sue,
(LaFromboise, Coleman, & Hernandez, 1991) 1990).
and three self-report measures: the Multicultur- Pedersen and Lefley (1986), Sue and Sue
al Awareness±Knowledge±Skills Survey (D'An- (1990), and Sue et al. (1992) state that, for
drea, Daniels, & Heck, 1991), the Multicultural effective counseling to occur, the counselor and
Counseling Awareness Scale (Ponterotto, San- the client must also be able to appropriately
chez, & Magids, 1991), and the Multicultural and accurately send and receive both verbal
Counseling Inventory (Sodowski, Taffe, Gut- and nonverbal messages. The next section of
kin, & Wise, 1994). this chapter looks at the various factors that
Cultural sensitivity has been defined in lead to effective interviewing and counseling. In
various ways: cross-cultural competence, cross- order to understand effective interviewing and
cultural expertise, cross-cultural effectiveness, counseling strategies, however, one must first
culture responsiveness, cultural awareness, and examine the elements of effective intercultural
cultural skill. This has led to confusion in the communication and the barriers present in non-
vast literature surrounding cultural sensitivity effective communication. This necessitates a
(Ridley, 1984; Ridley et al., 1994) as authors discussion of how communication styles differ
have tended to use the terms interchangeably. between client and therapist.
Speigal and Papajohn (1986) have accordingly
questioned how one can operationalize the 10.04.3.2 Intercultural Communication Style
terminology in order to construct treatment
models. Communication style refers to those aspects
Ridley et al. (1994) have called for cultural that go beyond the literal content presented in
sensitivity that is linked to culturally responsive verbal interactions. It includes the cadence of
interventions. They formulated a model that speech, inflection, tone, syntactical structure,
proposed that cultural sensitivity can be viewed fluidity, and depth. Communication styles are
as being measured on a continuum which has strongly correlated with race, ethnicity, and
underlying prerequisite behaviors, culturally culture (Sue & Sue, 1990). For example, Yum
responsive behavior, and the effects of this (1991) has suggested that Confucianism has
culturally responsive behavior. The assump- strongly impacted on communication styles
tions that underlie this model are fivefold. First, with Asians; the main function of communica-
the authors believe that cultural sensitivity tion is to initiate, foster, and maintain social
depends on the personal meaning that a client relationships. Communication, therefore, en-
has about events that depend on the broad courages these relationships and sets the frame-
spectrum of cultural attitudes available to the work for an infinite interpretation (Cheng,
client (Pedersen, 1994). Second, therapists need 1987).
 Clinical Intervention Processes 99

In a multicultural setting the therapist usually cultures are based on this notion of individu-
conducts therapy without the familiar cultural alism. Many cultures are socialized in a system
guidelines that are normally present in counsel- of communality and codependence. The values
ing sessions with mainstream clients (Pedersen, in non-Western cultures differ markedly in that
1994). Garza, (1981) focused on issues that some might view individualism as an impedi-
emerge during initial diagnostic interviews with ment to true mental health. Thus, counselors
minorities. He discussed the notion that who do not deal with individualism versus
therapists, when confronted with a culturally group orientation will potentially create pro-
different client, depart from their usual ways of blems in the interview. An extensive review of
interviewing. These departures include the use cooperation and individualism in various
of cultural stereotypes as a distancing device. cultures has provided support for this viewpoint
The therapist also tends to use generalizations (McGoldrick, Pearce, & Giordano, 1982).
which produce dehumanizing consequences. Second, many therapists create an atmo-
Furthermore, therapists are guilty of simplify- sphere within an interview that promotes
ing the task of diagnosis by overinterpreting, verbal, emotional, and behavioral expressive-
Garza stated: ness. It is felt that such openness will allow a
more accurate exploration of the problem and
Overdiagnosing issues around cultural difference, concomitant issues. Also, that it will provide a
precise and accurate as it may be, can at times serve more focused emphasis on intrapsychic issues.
the purpose not so much of enhancing the This belief is especially important since it can
diagnostic process through the lens of a bicultural lead to misperceptions and labeling of the
perspective, but of avoiding the task of really client's reactions during the interview. Clients
getting into the complexities of another's indivi- are in danger of being labeled as apathetic,
dual life. (p. 15) repressed, or resistant if they do not exhibit
expressiveness and openness. An open, expres-
Sue and Sue (1990) have delineated generic sive communication style is not predominant in
characteristics in Western counseling and psy- Hispanic, Asian, or Aboriginal cultures (Sue &
chotherapy. These characteristics incorporate Sue, 1990). Studies have shown, for instance,
culture, class, and language issues. Specifically, that Chinese and Japanese cultures value
these generic characteristic include standard restraint of feeling and circumspectual ap-
English, verbal communication, individual-cen- proaches when communicating (Samovar &
tered therapy, verbal/behavioral/emotional ex- Porter, 1991). Additionally, openness and
pressiveness, openness, cause and effect expressiveness are antithetical to Native Amer-
attributions, and clear mental±physical dimen- ican communication styles (Dignes, Trimble,
sions. In addition, counseling models and Manson, & Pasquale, 1981; Thomason, 1991).
techniques have traditional middle-class use Many interviews and psychotherapeutic in-
of language, verbal communication, rigid time terventions encourage and foster self-disclosure
frames, long-range goals, and ambiguity. Sue from the client. The problem with this approach
and Sue (1990) describe these variables as being is that self-disclosure has been determined to be
largely used in Western models of counseling a negative value trait among many cultures ( Sue
and therapy. Non-Western cultures, on the & Sue, 1990). Self-disclosure is a Western
other hand, have different modes of expressing psychotherapeutic value. It has been called
affect, using silence, different language usage, the sine qua non of most approaches to therapy
differing time perspectives, nonstandard Eng- (Poston, Craine, & Atkinson, 1991). Therapists
lish, and a focus on individualism versus may misinterpret a client's nondisclosure, as
collectivism. different cultures teach and validate different
Sue (1977, 1981) has outlined in detail the levels of self-disclosure (Pedersen, 1994).
barriers to effective cross-cultural counseling Another culture-bound barrier involves the
that have evolved as a natural consequence of notion of ªinsightº in psychotherapy. Client
utilizing generic modes of counseling with insight is generally assumed to have positive or
culturally diverse clients. Culture-bound values beneficial consequences, but clients from dif-
encompass several areas of concern. First, most ferent cultures may place lower value on insight
forms of therapy are individually focused, (Sue & Sue, 1990). This dichotomy can impede
emphasizing the importance of the client± accurate communication. In addition, Sue and
counselor relationship. Some Western cultures, Sue described counseling and therapy within a
such as are found in the USA, have been Western context as linear and analytic with an
identified as cultures that are based on emphasis on cause-and-effect explanations of
individualism and competition between mem- healthy psychological functioning and psycho-
bers. Individualism and competitiveness are logical maladjustment. This reliance on scien-
seen as virtues within the culture. Not all tific method and rationalism has contributed to
100 Cross-cultural Clinical Interventions

client±counselor barriers in therapy, since systems present in Asia which differentiate the
different attributions about the etiology of use of words based on formality or informality
psychological problems may exist between of context (Ogino, Misono, & Fukushima,
client and therapist. 1985). Dillard (1983) and McWhirter and Ryan
Finally, the culture-bound barrier of ambi- (1991) have described the enormous number of
guity is concerned with the level of structure that dialects and language systems in North Amer-
is present in an interview or counseling session. ican native clients. Cross (1995), Dillard (1983),
Sue and Sue (1990) state that lack of definitive Pennington (1979), and Sue and Sue (1990) have
structure may be confusing to clients from described the language characteristics of
Hispanic backgrounds and may impede the African-Americans and their impact on therapy.
communication process. They go on to state Language plays a critical role in psychother-
that the patterns of communication among apy, especially when the therapist and client do
culturally diverse clients are dependent upon not share a common language. Westermeyer
one's cultural upbringing. (1993) has stated that most cultures have a
The focus on differing communication styles lingua franca or single major language. Comas-
has led to an ever-increasing list of models, Diaz and Griffith (1988) have described the
prescriptives, and resources for effective inter- differential impact of a client using nonstandard
viewing and counseling with specific popula- English. They claimed that clients are diagnosed
tions (ACA, 1990; APA, 1994; Eisenbruch, and assessed primarily on the basis of their
1990; Fiksdal, 1990; Gonzalez-Lee & Simon, ability to use standard English. They stressed
1990; Hollingsworth, 1987; Pedersen & Ivey, the importance of accurate and meaningful
1993; Song & Parker, 1995; University of client±therapist communication.
Wisconsin, 1991). In particular, these differ-
ences in communication styles have led to a
detailed examination of language issues that 10.04.3.4 Nonverbal Communication
encompass verbal and nonverbal aspects of
communication. Effective intercultural counselors need to be
aware of the total process of communication.
They must be sensitive to the fact that
communication is both verbal and nonverbal
10.04.3.3 Cross-cultural Verbal Communication (Wolfgang, 1985). The study of nonverbal
Language issues constitute one of the most behavior has been divided into three areas:
important differences and one of the greatest proxemics, kinesics, and paralinguistics. Over-
barriers to effective communication between views of the early work done in nonverbal
cultures (Argyle, 1991). Labov and Fanshel communication can be found in Harper, Wiens,
(1977) state that the most important data & Matarazzo (1978), Henley (1977), and
during the counseling session are the words LaFrance and Mayo (1978), and a comprehen-
spoken by the client and counselor and, thus, sive bibliography of the nonverbal literature
whatever is construed from these words. from 1859 to 1983 has been compiled by
Further, Ivey (1981) has stated that any Wolfgang and Bhardwaj (1984).
person-to-person encounter must consider the
language of helping. This is especially crucial in
10.04.3.4.1 Proxemics
multicultural counseling since different cultures
use different words, syntax, and constructs to Hall (1959) initiated the study of proxemics.
convey meaning. He demonstrated the impact of ethnicity and
Ivey called for an examination of language culture on various nonverbal behaviors such as
patterns as central to effective cross-cultural eye contact, gestures, and personal space. The
interviewing and therapy. Language in therapy term ªpersonal spaceº was introduced by
can be idiosyncratic and misunderstood by Sommer (1959) to denote the area that separates
therapists who are not familiar with a particular ourself from others. The size of this area varies
culture (Draguns, 1981). Meaning is lost in with situations and contexts. Hall (1969)
therapy when the counselor is not attuned to the delineated four zones of interpersonal distance
subtleties of specific cultural uses of affect, that characterize Western culture: intimate (up
diagnosis, and treatment (Vontress, 1981; to 18 inches), personal (18±48 inches), social (48
Yamamoto, Silva, Justice, Chang, & Leong, inches to 12 feet), and public (greater than 12
1993). feet). Extensive research into proxemics has
Yum (1991) has indicated that east Asian revealed that conversational distances vary
communication patterns differ from those in cross-culturally and that these differences have
North America. East Asian languages are very an impact on formal and informal counseling
complex and there are honorific linguistic interactions (Wolfgang, 1985).
 Clinical Intervention Processes 101

Ramsay (1979) examined the studies that avoidance of eye contact: shy, unassertive,
evolved from the proxemic inventory described sneaky, or depressedº (p. 55). Studies have
by Hall (1959). These studies examined Arabs, illustrated that higher levels of gaze and eye
Latin Americans, southern Europeans, north- contact invite more positive reciprocal non-
ern Europeans, Indians, Pakistanis, east Asians, verbal behavior (Smith, 1984). Studies on gaze
and Puerto Ricans. This body of literature behavior in Europe have been analyzed and
served to illustrate that different cultures have summarized by Ellgring (1984); these studies
different culturally determined ideas of appro- showed cross-national differences among
priate social distance. Hanna (1984) studied the subjects.
interactional distances between blacks and Ramsey (1984) discovered differences be-
whites in the USA and discovered substantial tween Eastern and Western cultures in eye
variation in conversational distance. Jensen gazing behavior largely through an analysis of
(1985) discovered smaller acceptable conversa- studies conducted in Japan. Graham (1985)
tional distances for Latin-Americans, Africans, discovered differences in gazing behavior
African-Americans, Indonesians, Arabs, and among Brazilian, Japanese, and American
South Americans than Anglos. negotiators. Researchers have investigated the
Some studies have extended the investigation role of gaze-directed behavior and reciprocal
to include cultural attitudes toward crowding interactions (Argyle & Cook, 1976; Argyle &
and its resultant effect on intimacy (Altman, Dean, 1965; Exline, Gray, & Schuette, 1985).
1975; Altman & Chemers, 1980; Pandey, 1978, Johnson (1972) discovered differences between
1990, 1996; Worchel & Teddlie, 1976). These black and white clients with respect to eye
studies illustrate that attitudes towards crowd- movements and discovered eye-rolling behavior
ing differ around the world with respect to in black American speakers. These eye move-
individual comfort level, as every culture has ments were used to convey disapproval, im-
different tolerance levels for personal space. pudence, and hostility.
Further research is needed to clarify the Ivey (1994) identified the dimensions of
relationship of these findings to the dynamics attending. The first dimension concerned the
of interviewing. use of the eyes. He stated that eye contact is
desirable in some cultures, while in others it has
negative connotations. He claimed that eye
10.04.3.4.2 Kinesics
behavior had the universal characteristic of
The study of kinesics was originally described being used to convey meaning. Ivey concluded
by Birdwhistell (1970) and focused on body that eye contact should be modeled by the
movements. Kinesics include facial expressions, counselor as early in the relationship as
gestures, eye behavior, and posture. Kinesics possible. Pedersen and Ivey (1993) offer
are influenced strongly by the norms of one's practical suggestions on improving one's eye
culture (Smith, 1984). Rosenthal, Hall, Archer, contact and other attending skills for use in
Dimatteo, and Rogers (1979) discovered that cross-cultural counseling and therapy.
subjects from outside of the USA, in countries Gestures refer to the types of hand move-
that were culturally and/or linguistically similar ments that people make. Although there has
(e.g., Canada, New Zealand, and the UK), been a great deal of disagreement as to what
scored higher than other nations on tests constitutes a gesture (Krauss, Chen, & Chawla,
measuring the nonverbal accuracy of meaning. 1996), a typology of gestures has been proposed
In other words, the subjects were able to by Kendon (1983). This classification system
interpret the body movements and gestures describes symbolic, conversational, and adap-
accurately. American subjects received the tational gestures. The differentiation of gestures
highest accuracy scores, indicating that cultu- grew largely out of early anthropological
rally specific cues are present in a person's body studies with Darwin and included the work of
language. Key (1975) described nonverbal acts Kleinberg and LaBarre (Efron, 1972; Ramsey,
within an overall structure that related kinesic 1979). Morris, Collette, Marsh, and O'Shaugh-
qualities to communication channel, time, nessy (1979) studied the meaning given to
distance relationship, cultural affiliation, en- various hand movements in British, Greek,
vironmental considerations, and individual Spanish, Turkish, and Italian subjects. They
differences. She believed the preceding determi- studied 20 forms of gestures and discovered that
nants of nonverbal language should be con- only two had universal use, and five had
sidered as interactional in nature. widespread use. The occurrences of the remain-
Sue and Sue (1990) state that eye contact is ing gestures were found to be culturally specific.
ªperhaps the non-verbal behavior most likely They concluded that people from various
to be addressed by mental health providers . . . regions in Europe use substantively different
counselors attribute negative traits to the gestures when communicating.
102 Cross-cultural Clinical Interventions

The most often studied area in cross-cultural of expression are both universal and culture-
interaction is conversational gestures, which are specificº (p. 391). In particular he studied
hand movements that accompany speech and facially active vs. facially inactive subjects.
seem to be related to the meaning of that speech. The first issue of concern was specificity. This
LaBarre (1985) documented the different ges- refers to any differences that exist in the
tures of politeness in south Asian, African, manifestation of emotions. Are clients facially
European, Pacific islander, east Asian, and active with some emotions, yet facially inactive
American cultures. He also identified cross- with others? Ekman (1993) concluded that
cultural differences in gestures of contempt, individual differences are present with respect
beckoning behavior, kissing, and sticking out of to specificity and that future research on these
one's tongue. These culturally determined differences may shed light on the issue of
nonverbals have been analyzed extensively by universality. Yamamoto and Kubota (1983)
Krauss, Chen, and Chawla (1996). They have described the differences in facial expressions
indicated that gestures contribute to compre- between Asian and European clients. In
hension and communicative intent in conversa- particular, restraint of facial expressions was
tions and interviews. Touching another person valued in Asian culture.
has been studied from a cross-cultural perspec- The second issue is threshold. Do individuals
tive. It has been claimed that touching holds have a lower threshold for emotional experience
special significance in Anglo cultures because of than facial expression? Are clients able to
its infrequency of occurrence (Henley & La- experience psychological distress without show-
France, 1984). Touching behavior studies, even ing physical signs? Izard and Izard (1980)
though generally focused on gender issues, have theorized there was a cultural universality of
been reviewed by Knapp (1984). emotion that was strongest in the area of
Eakins and Eakins (1985) have gone beyond primary emotions such as fear, sadness, and
looking at hand movements to an examination happiness. He argued the further one was
of head movements. Jensen (1985) has illu- removed from these basic primary emotions,
strated that cultural differences exist in the the more cultural specificity occurred in the
meaning attached to head movements. A most expression of emotion. Ekman (1993) has
detailed focus on head movements can be found suggested further research is needed in this area.
in Erickson and Schultz (1982). The authors Choosing one postural stance from the many
used a microethnographic approach to study options that are available appears to be
social interactions. Head-nodding behavior was culturally determined (Hewes, 1955; Ramsey,
analyzed within a cultural context. It was 1979). Mehrabian (1972) described posture as
discovered that head nodding was part of a having two dimensions. These dimensions,
conversational rhythm that contained culturally immediacy and relaxation, were found to be
specific patterns. They described the impact of related to how one communicates one's atti-
cultural organization or shared standards and tudes. Leaning forward increases immediacy of
communication traditions on nonverbal social contact and communicates acceptance and
interactions. They stated that ªboth the ends liking. Leaning backwards tends to indicate
and means of communication are culturally relaxation and sometimes disinterest. These
defined as appropriate, effective, and intellig- dimensions have been studied by Bond and
ible. When persons meet who have learned Shirashi (1974) with Japanese subjects. They
different communicative traditions regarding discovered preferences for counselors to lean
intelligibility, effectiveness, and appropriate- forward, since flexibility and politeness were
ness, troubles can result in the social organiza- attributed to this postural movement. Scheflen
tion of their interactionº (p. 100). (1964) linked the notion of posture congruence
Pearson (1985) believed counseling interpre- to successful psychotherapy. He claimed that if
tations can be based on the facial expressions of a therapist wished to communicate congruent
a client. Early studies of facial expression feelings, he or she needed to have a relaxed
focused on the universality of expressions and posture that was reflective of his or her state of
the culturally specific interpretations of facial mind.
movement (Ekman & Friesen, 1975; Izard, From the field of neurolinguistic program-
1971). Ekman (1993) claimed that such psycho- ming there have begun to emerge studies on
logical luminaries as Allport, Brunswik, Hull, posture that are cross-cultural in scope. Sandhu
Maslow, and Titchner all studied facial expres- (1984) found that therapists' mirroring of
sions early in their careers, each focusing on the Choctaw adolescents in the USA increased
dilemma of whether or not facial expressions are adolescents' perceptions of empathy present in
universal or culture-specific. Ekman concluded the therapists. Sandhu, Reeves, and Portes
after considering the history of kinesics, ªI (1993) further studied the effects of mirroring
found more than one answer. Different aspects on empathy with Native Americans. They
 Clinical Intervention Processes 103

concluded that postural mirroring may signifi- Thomas (1995) has stated that, in Great
cantly aid in the building of rapport with Britain, English is the predominant language
culturally different clients. used in intercultural counseling. He believes
that therapists experience difficulty in attending
to the message delivered by the client because of
differential usages of the English language.
10.04.3.4.3 Paralinguistics
These paralinguistic patterns also include the
Paralinguistics is the study of vocal cues that notion of monochronic and polychronic time
clients use to communicate meaning. Poyatos systems (Hall, 1976). Hall stated that mon-
(1984) defined paralanguage as ªthe ever chronic time patterns are prevalent in the USA,
present co-occurrent voice modifications or where punctuality is valued, and the pace of the
alternating independent sounds of perfectly conversation differs from the polychronic time
lexical valueº (p. 433). These aspects of orientation found in Mexico and other Latin
language include the higher volume used in American countries. Kim (1988) stated that
conversation with Latins and Arabs, high- these vocal patterns help to establish the
pitched or breathy intonations of some clients, emotional and attitudinal foundations of social
tongue clicking as seen in South Africa, and interaction and clarify the relationship between
sighing. It includes the use of silence, hesitations client and therapist.
or pauses, rate of speech, inflections, and
expressiveness (Sue & Sue, 1990).
Lass, Mertz, and Kimmel (1978), Mehrabian 10.04.3.5 Use of Translators
and Ferris (1976), and Poyatos (1976, 1984)
concluded that paralanguage is culture specific. Translation has been described as ªthe
Wolfgang (1985) has described the use of exchange of the demonstrative meaning of a
extraverbal elements associated with speech, word, phrase, or sentence in one language for
from a cross-culture perspective. He has the same meaning in another languageº (Wes-
described these elements as operating at the termeyer, 1993, p. 129). Some therapists call for
unconscious level in clients. Weitz (1972) out- literal translations when working with linguis-
lined the effects of paralanguage in black tically different clients; however, many thera-
American and white American communica- pists move beyond literalism to the
tions. Crystal (1975) has looked at the various interpretation of a client's words through the
cultural uses of paralanguage. Apple, Streeter, discovery of connotative meanings. The latter is
and Krauss (1979) indicated that pitch and attempted in order to achieve accuracy of
speech rate can significantly affect a person's meaning. De Figueiredo (1976) and de Figueir-
attributions. Erickson and Shultz (1982) pro- edo and Lemkau (1980) stressed the need for
vided a detailed exploration of interactional accurate translation when interviewing in
rhythmic styles in social interactions. They Portuguese and Knokani in Goa, India. Kline,
explored cultural differences with regard to Acosta, Austin, and Johnson (1980) interviewed
pauses, hesitation, and silences. The authors Spanish-speaking patients with the aid of an
concluded ªbehavioral regularity, especially interpreter. They discovered increased patient
rhythmic regularity, may be prima facie evi- satisfaction and greater client understanding.
dence of shared interpretative frameworks Therapy with the use of translators has been
among those engaged in interactionº (p. 143). shown to be time-consuming, inaccurate, and
Nonmembers of the culture may display difficult (Carillo, 1982). Marcos (1976) has
interactional arrhythmia and fail to engage a studied bilingual therapists and patients and
client in a smooth conversation or verbal discovered that language switching can be used
interaction. Erickson and Shultz (1982) have by the patient to distance themselves from
claimed that when counseling occurs with emotional issues in therapy. This process,
ethnically and racially diverse clients, interac- labeled ªcode switchingº (Pitta, Marcos, &
tional arrhythmia occurs which causes discom- Alpert, 1978), has been shown to occur in
fort in the one-on-one interview. These Hispanic clients (Price & Cuellar, 1981; Rivas-
interactional differences may cause counselors Vazquez, 1989). Russell (1988) determined that
who are unaccustomed to the interactional code switching during an interview or therapy
rhythm to be ªout of sync in communicatingº session is a clear signal from the client that
(Kim, 1988, p. 91) with different language clinicians should ignore; it will have impact on
proficient clients. In addition, Kim (1988) the credibility of the therapist. In cultures where
indicated that stuttering, accents, and other bilingualism is present, code switching can
paralinguistic patterns which differ from the occur. The result is that communication
language used in therapy could also stifle the accuracy is minimized (Berkanovic, 1980; Kline
communication process. et al., 1980). Moreover, when bilingual clients
104 Cross-cultural Clinical Interventions

switch to their mother tongue, an increase in creation of a course ªAmerican for Foreign
emotional response has been observed (Marcos, Medical Graduate Psychiatric Residentsº de-
Urcuyo, Kesselman, & Alpert, 1973). Santiago- signed to equip therapists with slang, colloquial
Rivera (1995) has concluded that therapists language, and subtleties of humor. Follow-up
need to assess a client's language dominance and indicated that greater communication skills
preference prior to assessing their psychological were present in the trained experimental group
and physical health. than in those in a nontrained control group.
Difficulties in translating mental health The use of bilingual or bicultural counseling
concepts into different languages occur when has received attention in the literature. Ruiz and
attempting to apply Western methods of Casas (1981) indicated that bicultural counsel-
therapy in other parts of the world. Wester- ing can be considered as a blending of majority
meyer (1993) illustrated these issues with Thai- and minority approaches to communication.
Lao language translators. Nichter (1981) dis- There is evidence that bicultural/bilingual
covered similar issues when working in south therapists have increased flexibility, greater
India where undesirable connotations occurred tolerance for ambiguity, and serve well as
with translated terminology. Edgerton and cultural mediators (Szapocznik, Rio, Perez-
Karno (1971) discovered differences between Vidal, Kurtines, & Sanisteban, 1986).
Mexican-American English speakers and Song and Parker (1995) focused on bicultural
Mexican-American Spanish speakers with re- Chinese-English and Korean-American young
spect to describing symptomatology. Jackson adults. They discovered their interviews were
and Moto (1996) translated various forms of filled with shifting multiple positions as well as
psychopathology and therapy terms from identifications rather than a single unitary focus
English into Chichewa, one of the main on identification. This introduction of complex-
languages in Malawi, Africa. They discovered ity into the interview has been deemed to have a
that some words lacked accurate English positive impact on meaningful communication
equivalents. (Pedersen, 1991c, 1994). Rogler (1993) has
Acosta, Yamamoto, and Evans (1982) have examined the impact of bilingualism on the
called for non-Spanish-speaking therapists to development of diagnostic errors with culturally
use trained interpreters when conducting inter- diverse clients. He proposed a research frame-
views with Spanish-speaking clients to ensure work designed to facilitate a culturally sensitive
accuracy of communication. Trained bilingual diagnostic interview that encompasses the
interpreters have been used with success in assessment of symptoms from a culturally
community clinics in the USA (Acosta & appropriate viewpoint.
Cristo, 1981). Baker (1981) advocated the use Salzma (1995) discovered that cross-cultural
of interpreters with culturally diverse clients. He interactions were replete with attributional
worked with south Asian refugees and recom- discrepancies, partially based on linguistic fac-
mended the creation of a group of interpreters tors. He studied Navajo and Athabascan Native
who understood psychological and social Americans and discovered many assessment
processes. Additionally, Owan (1985) exten- errors occurred during diagnostic interviews.
sively discussed the successful use of interpreters These errors were due to linguistically based
when interviewing south east Asian clients. attribution biases which occurred because of
Freed (1988) found that interpreters who had differences between client and therapist. These
backgrounds in social work and psychology differences included social distance, taciturnity,
were effective largely due to the fact they could length of pause, and initiation of speech.
facilitate a therapeutic alliance with the thera- Ho (1987, 1992) calls for care in the
pist. She listed a series of translator considera- assessment of a client's fluency in English and
tions deemed important for the establishment of their dominant language when choosing a
accurate and meaningful communication. These treatment modality. He delineated guidelines
factors included role definition, assurance of in this area for working with Asian-American
confidentiality, cultural differences, and the families. Similarly, Nguyen (1992) examined
individual characteristics of the translator. Asian-American communication patterns and
While skillful translators appear to be desir- called for therapists to consider the metaphoric
able, evidence suggests that low socioeconomic nature of Japanese, Chinese, and Vietnamese
clients use nonstandardized English which can languages.
create difficulties for middle-class formal lan-
guage users. Forrest, Ryan, and Lazar (1978)
showed that foreign medical graduates were 10.04.4 THERAPIST±CLIENT MATCH
more deficient in slang than in standard English.
This factor caused them difficulty when com- There has been a long-standing debate over
municating with clients. This prompted the the issue of whether a client should be given
 Therapist±Client Match 105

therapy by a culturally similar therapist or one 1989). They discovered that clients perceive
who is not of the same cultural background. ethnically/racially similar counselors as posses-
Atkinson 1983, 1985) provided comprehensive sing greater clinical judgment skills than
reviews of the studies that occurred in the 1970s nonsimilar counselors.
and early 1980s. Atkinson and Lowe (1995) In the 1990s, the majority of studies have
updated the earlier reviews with a more tended to support the notion that ethnically/
contemporary discussion of preference for racially diverse clients prefer ethnically/racially
counselor ethnicity. They stated that early similar therapists (Coleman, Wampold, &
research on client±therapist match focused on Casali, 1995). The following three studies,
the preferences of African-American clients. however, have failed to support this notion.
Most studies (e.g., Bernstein, Wade, & Hof- Steward, Gimenez, and Jackson (1995) studied
mann, 1987; Greene, 1982; Harrison, 1975; the preferences of academically successful,
Sattler, 1977) revealed that African-American culturally diverse students and concluded that
clients preferred African-American counselors ethnic match was not a well-defined preference
and that Asian-Americans preferred Asian- among this group. Sue, Fujino, Hu, Takeuchi,
American therapists over white therapists. and Zane (1991) failed to show any treatment
These studies were predicated on the work of effects when counselors were matched for
Carkhuff and Pierce (1967), LeVine and Camp- ethnicity. Gottheil, Sterling, Weinstein, and
bell (1972), Mitchell (1970), and Stanges and Kurtz (1994) matched therapists and patients
Riccio (1970) which indicated that clients prefer with respect to gender and race. The matching
counselors who are culturally similar to them. did not increase the proportion of cocaine-
Higginbotham (1977) and Higginbotham, dependent patients that returned for a second
West, and Forsyth (1988) provided an alter- session.
native point of view by concluding that race or The following studies, however, have exam-
ethnicity may not be the most important ined client preferences, and results support the
variable in cross-cultural counseling. They notion that clients prefer same-race/ethnic
believed that situational, rather than cultural, counselors. These studies focus on Asian-
variables could evoke client outcome expectan- American, Hispanic-American, African-Amer-
cies. In addition, Atkinson (1983) concluded ican, and Native American subjects.
that, even though African-American clients Yeh, Eastman, and Cheung (1994) investi-
showed a preference for racially similar coun- gated the effects of language and ethnic match
selors, other ethnic groups showed no such with Asian-American clients and therapists.
preference. Instead, these studies have stressed Ethnic match was a significant predictor of the
that other variables of counselor effectiveness dropout rate after the first session, while
have a greater impact with ethnically diverse language match failed to predict early termina-
clients. Parloff, Waskow, and Wolfe (1978) have tion of counseling. Takeuchi, Mokuau, and
pointed out the need to include the sex, Chun (1992) investigated the counselor match-
socioeconomic status, and attitude of the ing among Asian-American and Pacific islander
counselor in client preference studies. Some clients. They discovered that ethnic matching
studies have concluded that clients actually significantly reduced premature termination of
prefer ethnically dissimilar counselors (Gam- therapy. In fact, when clients were matched with
boa, Tosi, & Riccio, 1976). In addition, ethnically similar therapists they were five times
Flaskerud (1990) reviewed the literature on less likely to prematurely leave therapy than
client match from 1970 to 1990 and concluded clients matched with an ethnically similar
that there was no strong support for the notion therapist. They found, however, no subject
that client±therapist match in ethnicity, lan- differences in global functioning, an outcome
guage, and gender had positive effects on the measure of psychological, social, and occupa-
process or outcome of therapy. tional functioning as determined by the Global
Many studies in the 1980s focused on the Assessment Scale.
impact of racial identification on preference Yeh, Takeuchi, and Sue (1994) discovered
for counselors (Parham & Helms, 1981, 1985; that Asian-American children and adolescents
Sanchez & Atkinson, 1983). These studies who received treatment at facilities with ethni-
concluded that the more one identified with cally similar therapists were more likely to
one's own cultural group, the greater likelihood remain in therapy and achieve higher function-
of preference for an ethnically/racially similar ing upon termination than those at facilities with
therapist. In addition, some researchers have mainstream professionals. Flaskerud and Liu
focused on the issue of clinical judgment as it is (1991) discovered that ethnicity match with
related to the ethnicity of the therapist (Lopez Asian clients and therapists significantly re-
& Hernandez, 1987; Malgady, Rogler & duced the early termination rate but did not
Constantino, 1987; Pakov, Lewis & Lyons, affect global functioning scores. The researchers
106 Cross-cultural Clinical Interventions

also examined the effect of counselor language tion to perceived counselor competence. They
and ethnicity on the outcome of therapy with concluded that cultural competence was related
southeast Asian clients (Flaskerud & Liu, 1990). to perceived cultural responsiveness, regardless
Ethnicity match and language match signifi- of counselor ethnicity or client acculturation.
cantly increased the number of client sessions Hess and Street (1991) studied Mexican-Amer-
but not the overall global functioning upon ican high school students with respect to the
discharge. Flaskerud and Hu (1994) further effects of counselor ethnicity. No significant
studied the process of therapy for Asian- differences were found in the ratings of
Americans suffering from major depression. effectiveness in relation to ethnicity. Yeh et al.
They concluded that treatment by an ethnically (1994) reported a lower therapy dropout rate
similar therapist within an ethnically matched when Mexican-American clients were matched
facility was related to the duration of treatment, with ethnically similar therapists. Sue et al.
not to the clients's global functioning upon (1991) showed that ethnic match between
termination of therapy. Fujino, Okazaki, and Mexican clients and therapists increased the
Young (1994) examined therapist±client match length of treatment and improved the effective-
with Asian-American female clients. They ness of therapy.
concluded that ethnic match was significantly While most research indicates problems with
related to lowered premature termination, matching of black clients with white therapists
increased treatment duration, and higher func- (Krause & Miller, 1995), problems associated
tioning upon termination. with black therapists working with black clients
Tedeschi and Willis (1993) examined the have been observed (Montalvo & Gutierrez,
attitudes of Asian international students toward 1988; Thomas, 1995). These matching studies
counseling. Asian subjects were found to prefer have focused on the attractiveness and cred-
an older counselor of similar ethnicity. Gim et ibility of the therapist.
al. (1991) examined the effects of counselor Tomlinson-Clarke and Cheatham (1993)
ethnicity on clients' perceptions of counselors matched ethnically/racially similar counselors
credibility and efficacy. Asian-Americans were with black and white clients. They discovered no
shown to attribute greater effectiveness and significant differences in counselor judgments
credibility to Asian counselors. (i.e., clinical disposition, severity of diagnostic
Atkinson and Matsushita (1991) discovered rating, need for psychological treatment, and
that Japanese-Americans were most apt to seek predicted number of sessions) upon intake when
counseling from a directive Japanese-American clients were matched with similar counselors.
counselor. Ngugen (1992) discovered that Goldberg and Tidwell (1990) investigated
Asian-American patients extended therapy with perceived counselor±client similarity and its
Asian-American therapists. Several disadvan- relationship to the clients' perceptions of
tages were noted in the study with therapist attractiveness and the satisfaction derived from
matching. Some Vietnamese-American and therapy. They investigated both gender and race
Chinese-American clients preferred Western with black and white counselors and students.
therapists, because of a fear of encountering They concluded that racial and gender differ-
breaches of confidentiality with Asian-Amer- ences appeared not to function as barriers to
ican therapists, a concept apparently not totally effective communication. They suggested in-
adhered to in Asian-to-Asian encounters. stead that other counselor variables such as
Lopez, Lopez, and Fong (1991) reviewed attitudes and personality were more important
client preference among Mexican-Americans. characteristics for perceived competence.
They discovered that all studies supported the Redfern, Dancey, and Dryde (1993) exam-
notion that Mexican-American clients prefer ined the role of counselor ethnicity with English
ethnically similar counselors. The authors black and white undergraduate students. Black
stated they had conducted two studies of their counselors were rated higher than white
own confirming this preference. A third study counselors on scales of attractiveness, compe-
showed that medium and highly acculturated tency, and trustworthiness. Tomlinson and
Mexican-Americans indicated greater prefer- Cheatham (1989) examined the effects of
ence for same-ethnicity counselors than ethnicity match on intake interviews with black
Mexican-Americans with low acculturation. clients. They concluded that the race of the
Atkinson and Wampold (1993) critiqued the therapist affected the clinical judgments at the
methodology used to obtain these conclusions. time of client intake.
They called for the avoidance of simple choice Race and ethnicity have been studied within
methods to assess preference for counselors with the psychoanalytic relationship (Leary, 1995).
Mexican-Americans. Further, Atkinson, Casas, Three patients were paired with an African-
and Abreu (1992) examined low-, medium-, and American therapist. Qualitative descriptions
high-acculturated Mexican-Americans in rela- showed the importance of client±therapist
 Treatment Outcome 107

negotiation when racial characteristics differ. In of personality before and after treatment and
addition, White (1994) investigated the impact noting the nature and extent of the resulting
of race and ethnicity on transference and changesº (p. 4). Sue and Zane (1987) have stated
countertransference in interracial group psy- that therapeutic outcome is ªthe cumulative
chotherapy and discovered differential trans- product of many discrete dynamics between
ference issues related to the race or ethnicity of client and therapistº (p. 44). Orlinski, Grawe,
the therapist. and Parks (1994) have asserted that the term
Bennett and Bigfoot-Sipes (1991) examined ªtreatment outcomeº has had a history of
Native American and white college student divergent meanings that have ranged from
preferences for counselor ethnicity. They con- observational perspective to analysis levels.
cluded that both American Indian and white The authors pointed out that the definition
students preferred counselors to have similar and criteria for outcomes differ depending on
values, but Native Americans showed greater who is completing the assessments before and
preferences for ethnically similar counselors, after treatment is received. That is, differences
while white students showed no such preference. are present if the assessment is completed by
In addition, Johnson and Lashley (1989) therapists, clients, nonparticipant observers, or
examined the counselor preferences of Native nonprofessionals. They indicated that level of
American undergraduate students. They dis- analysis also had critical issues in need of
covered that clients with a strong cultural clarification. These issues included the out-
commitment to Native American values placed comes occurring within, and external to, the
great importance on the ethnicity of the therapy sessions and the use of evaluative or
counselor by preferring counselors with similar descriptive assessment instruments. The
ethnic backgrounds. authors concluded that ªtreatment outcome
Comas-Diaz and Jacobsen (1987) proposed should refer to changes in condition (psycho-
that a client's ethnocultural identity be assessed logical, somatic, physical, social, and cultural)
as an auxiliary therapeutic tool. One aspect of reflecting favorable or adverse effects on the
their identity assessment focuses on the back- patients well beingº (p. 284).
ground of the therapist relative to that of the
client. This assessment then aids in matching
client and counselor. Hall and Maloney (1983) 10.04.5.2 Cross-cultural Outcome Research
suggested that highly ethnoculturally dominant
therapists should be matched with same- VandenBos (1996) presented a succinct
ethnicity clients while less ethnoculturally history of outcome research beginning in the
dominant therapists be matched with culturally 1950s. He pointed out that most contemporary
different clients. Coleman et al. (1995) con- treatment outcome research has focused on the
ducted a meta-analysis of studies that investi- effectiveness of comparative treatment inter-
gated perceptions and preferences of ethnically ventions and/or has focused on specific treat-
diverse clients. They concluded that ethnic ment methods targeting specific clinical
minorities tended to prefer ethnically similar problems. Goldfried and Wolfe (1996) exam-
therapists and rated these therapists as more ined the difficult relationship between psy-
competent than European-American therapists. chotherapy practice and research. They called
The client±therapist match literature in the for a new outcome research paradigm that seeks
1990s, therefore, has focused on the preferences to increase clinician and researcher collabora-
for counselors of Asian-Americans, Hispanic- tion. Other recent studies have examined many
Americans, African-Americans, and Native issues surrounding the outcome assessment of
Americans. Various topics in relation to client psychotherapy, pointing to methodological and
preference have been investigated, most nota- conceptual problems (Barlow 1996; Hollon,
bly: racial/ethnic identification, acculturation, 1996; Howard, Moras, Brill, Martinovich, &
counselor credibility, early termination from Lutz 1996; Jacobson & Christensen, 1996;
therapy, and outcome measures of global Newman & Tejeda, 1996; Sechrest, McKnight,
functioning. Investigation of these and other & McKnight 1996; Seligman 1996; Strupp,
variables will continue into the next decade. 1996).
While these studies examined many of the
contemporary issues surrounding treatment
10.04.5 TREATMENT OUTCOME outcome research, they conspicuously omitted
10.04.5.1 Definition any mention of ethnic or racial factors that
contribute to the efficacy of treatment. Sue et al.
Treatment outcome research was defined by (1994) have comprehensively analyzed the
Mowrer (1953) as a situation whereby the research on American minority clients. Speci-
ªemphasis is upon measuring significant aspects fically, they reviewed the outcome research
108 Cross-cultural Clinical Interventions

using African-American, Asian-American, Na- using more direct measures have been scarce in
tive American, and Latino clients. The authors the literature. However, discussion on culturally
addressed the question: Is there any research appropriate modes of therapy and the effective-
evidence that reveals the efficacy of treatment ness of therapies tailored for Latino/Hispanic
with minority clients? Specifically, their paper clients have been studied (Sue et al., 1994;
addressed whether minority clients demon- Szapocznik et al., 1989). Cuento therapy,
strated differences in pre- and post-therapy utilizing Puerto Rican folktales, was examined
assessment. It also investigated whether ethnic by Constantino, Malgady, and Rogler (1986),
minority treatment outcomes differed from and results from this study confirmed that
outcomes seen in majority clients, and whether culturally sensitive forms of therapy can reduce
various ethnic groups had differential treatment trait anxiety scores. Malgady, Rogler, & Con-
outcomes. They pointed out that research in stantino (1990) discovered that using culturally
these areas has historically been lacking and has appropriate modeling therapy in conjunction
not specifically addressed the outcome of with Cuento (folktales) therapy reduced anxiety
psychotherapy. Sue et al. asserted that the symptoms and aggression in Puerto Rican
relationship between ethnic/cultural/racial vari- children. Rey-Perez (1996), using a qualitative
ables and psychotherapy outcome has not been approach with five Hispanic families, con-
determined with empirical evidence. structed a comprehensive, culturally sensitive
Zane and Sue (1991) stated that ethnic treatment program for Hispanic children and
differences involve group membership, while their families. Therapeutic gains were noted in
cultural differences ªconstitute a host of each child; the subjects were Cuban, Puerto
cognitive variables which are limited to different Rican, Nicaraguan, and Peruvian.
cultural lifestyles and perspectivesº (p. 32). They There have been a limited number of outcome
stated that these cognitive variables, rather than studies using Asian-American subjects. Many
ethnic membership, have been responsible for studies have not studied specific groups of
the lack of conclusive psychotherapy outcome Asian-Americans (e.g., Vietnamese, Chinese,
studies. Japanese); rather they have viewed Asians as
Sue et al. (1994) identified the reasons why monolithic. Kinzie and Leung (1989), Mollica,
outcome studies in cross-cultural psychology Wyshak, Lavelle, Truong, Tor, and Yang
have been problematic. They pointed to four (1990), and Snodgrass et al. (1993) found
areas of concern: (i) the use of analogue studies, outcome gains in Vietnamese, Laotian, and
(ii) the heterogeneity of the sample, (iii) the Cambodian patients. Comparative studies with
insensitive or inappropriate use of dependent Asian and non-Asian clients have revealed few
measures, and (iv) the lack of within-group differences (Sue et al. 1994).
design strategies. These methodological defi- The authors stated that:
ciencies have caused both researchers and
clinicians to dismiss outcome research as being any conclusions about the effectiveness of treat-
of limited practical value. With these limitations ment for Asians would be premature given the
in mind, researchers have most often focused on limited data (four outcome studies), but that
treatment outcomes of African-Americans, several empirical trends should be noted. First,
Asian-Americans, Latino-Americans, and Na- some evidence suggests that certain Asian groups
tive Americans. Research studies with these four improve with psychotherapy and/or adjunct treat-
ments. Second, with respect to differential out-
groups will now be examined. come, divergent trends are found and these are
With regard to studies conducted with associated with the type of outcome measure
African-American subjects, Sue et al. (1994) used. . . .In summary, Asian clients appear to be
state that, generally, ªin no studies have deriving less positive experiences from therapy
African-Americans been found to exceed white than whites but it is unclear if this difference in
Americans in terms of favorable treatment client satisfaction actually reflects ethnic differ-
outcomes. Some investigators have revealed ences in actual treatment outcomes (i.e., symptom
no ethnic differences and some studies have reduction). (p. 798)
supported the notion that outcomes are less
beneficial for African Americansº (p. 788). Native American populations, while culturally
These conclusions were based on studies heterogenous, have been generally studied as an
conducted in the 1970s and 1980s (Brown, aggregate population. The number of outcome
Joe, & Thompson, 1985; Griffith & Jones, 1978; studies is limited in this area, and Manson,
Jones, 1978, 1982; Lerner, 1972; Parloff et al., Shore, and Bloom (1985) and Neligh (1988)
1978; Sattler; 1977). have reported that no research has been con-
Latino/Hispanic-American studies have often ducted to compare the efficacy of various
been evaluated in terms of the utilization and treatment modalities with this population. Most
retention rate of patients in therapy. Studies outcome studies have focused on alcohol and
 Methodological Considerations 109

drug use reduction and prevention (Bobo, (vi) reliance on culturally encapsulated psy-
Gilchrist, Cvetkovich, Trimble, & Schinke, chometric instrumentation;
1988; Manson, 1982; Query, 1985; Schinke (vii) failure adequately to describe one's
et al., 1988). Sue et al. (1994) have concluded sample in terms of socioeconomic status;
that ªit is apparent that research on interven- (viii) failure to delineate the study's limita-
tion (i.e., treatment and prevention) has pro- tions;
ceded very slowly, and it would be premature to (ix) lack of adequate sample sizes; and
try to address the question of the efficacy of (x) overreliance on paper and pencil out-
mental health interventions with American come measures.
Indians at this timeº (p. 795). In addition to the identification of the
The paucity of outcome studies in the methodological weaknesses in ethnic/social
literature suggest that more ethnically/racially research, the authors reviewed articles from
specific studies on the efficacy of treatment are the five journals that most often publish
needed. In addition, methodological weak- research in this area. They discovered that only
nesses need to be examined and corrected by about one-third of the studies had an adequate
future researchers. These methodological issues conceptual foundation. With regard to the
are explored in the next section. second criticism, the authors discovered that,
although many variables were investigated, key
areas lacked systematic attention. Those areas
10.04.6 METHODOLOGICAL
included communication styles, socializing
CONSIDERATIONS
practices, learning styles, effects of poverty
10.04.6.1 Reliability and Validity in Cross- and discrimination, and acculturation. With
cultural Research respect to the third criticism, it was discovered
that survey research was used in 72.5% of the
The last decade has seen a focus on racial/ studies, while analog research accounted for
ethnic research issues as they relate to shedding 12.5%, true experimental designs 8.8%, and
light on effective clinical interventions. Much of archival designs 6.3% (p. 89). The authors
the literature has centered on the validity and concluded that researchers, rather than relying
usefulness of research studies that investigate on analog studies, have overutilized a survey
racial and ethnic variables. The APA (1993) has methodology.
outlined six areas that have been the focus of The authors found overwhelming evidence to
mental health research: justify the veracity of their claim in the fourth
criticism. They discovered that two-thirds of the
(a) the impact of ethnic/racial similarity in the literature did not include within-group designs
counseling process, (b) minority underutilization
of mental health services, (c) relative effectiveness
or intracultural comparisons. The fifth criticism
of directed versus nondirected styles of therapy, (d) was justified, as it was discovered that over one-
the role of cultural values in therapy, (e) appro- half of the studies used college and high-school
priate counseling and therapy models, and (e) student samples. The sixth criticism was also
competency in skills for working with specific supported, as the authors discovered that only
ethnic populations. (p. 45). one-third of the studies used instruments that
were designed for minority populations. The
Research designs using cross-cultural vari- authors concluded this to be one of the most
ables, as with all research designs, are expected justified criticisms in ethnic/racial research
to have adequate reliability and validity. studies.
Ponterotto and Casas (1991) have carefully Criticism (vii) was justified, as two-thirds of
delineated the major criticisms leveled at racial/ the studies failed to report social economic
ethnic minority research. They have listed variables. The eighth criticism was not wholly
(pp. 78±79) the top 10 criticisms as: justified, as 60% of the studies listed their
(i) lack of conceptual/theoretical frame- limitations. Criticism (ix) was not justified, as
works to guide research; sample size depends on many factors, including
(ii) overemphasis on simplistic counselor/ type of design and sampling characteristics.
client process variables and a disregard for im- Finally, the tenth criticism was fully justified, as
portant psychosocial variables, within and out- 90% of the studies utilized outcome measures
side the culture, that might impact counseling; that were paper-and-pencil instruments.
(iii) overreliance on experimental analog The authors concluded, therefore, that criti-
research; cisms (i), (iv), (v), (vi), (vii) and (x) are justified;
(iv) disregard for within-group or intracul- criticisms (ii) and (ix) partially justified; and
tural differences; criticisms (iii) and (viii) unjustified.
(v) the use of easily accessible college student Stanfield (1993) has criticized cross-cultural
populations; research methods from an epistomological
110 Cross-cultural Clinical Interventions

perspective. He examined the fallacies of empirical research study are the design and the
homogeneity and monolithic identity, and the analysis of results. The authors indicated that
presumptions that underlie research ethics. He results from studies which focus on racially
believed that the failure of researchers ade- diverse subjects are more difficult to interpret
quately to clarify these issues has led to validly than studies in which race and ethnicity
exploitative research with ethnically and racially are not considered as variables. They delineated
diverse subjects. four measures for accepting alternative hypoth-
eses indicated by the data.
10.04.6.2 Recommendations One method for increasing confidence is by
selecting subjects on the basis of the variables
The comprehensiveness of Ponterotto and race, ethnicity, and culture. Groups need to be
Casas's (1991) work can be seen in the included in a study based on their ethnic group
methodological recommendations that they inclusion. The authors point out that many
offer. These suggestions cover five areas of studies involving ethnically/culturally diverse
concern. First, because culture is complex subjects have problems during the selection
(Pedersen 1991c), a variety of research methods phase of the study. Differences between the
need to be used. In particular, the authors called groups can be due to factors that are present in
for researchers to ªembrace qualitative methods the majority culture, the minority culture, or an
that have been effectively employed in the interaction of factors between the two cultures.
related disciplines of ethnology, cultural anthro- Second, Berry et al. (1992) recommend the
pology, and sociologyº (p. 96). Second, the dependent variable be ªexpressed as a function
authors suggest that studies focus on within- of two or more separate scores. An example is
group differences rather than between-group the score that can be obtained by taking the
differences. In so doing, research could avoid difference betwween scores on two measure-
comparing racially and ethnically different mentsº (p. 223); this strategy can help to
clients to white or mainstream clients, a eliminate rival hypotheses.
situation that usually implies majority behavior Third, they advocate the minimization of the
to be normal and minority behavior to be effect of extraneous variables through statistical
abnormal. Third, the authors suggest research methods such as analyses of covariance and
that focuses on variables that ªtranscend multiple regression analysis. Finally, they
cultureº (p. 99). Those variables could include advocate that more than one dependent mea-
some of the universals of human experience such sure be used, through methods that include self-
as economic deprivation, family loss, serious report measures, interviews, and archival in-
medical and psychological illness, and change in formation. This method increases the amount of
environmental conditions. Fourth, culture-spe- data one has to use in the formulation of
cific instrumentation is recommended, espe- conclusions and interpretations.
cially for such psychological constructs as Like Ponterotto and Casas (1991), Berry et al.
depression, self-concept, and assertiveness. (1992) show concern about the instrumentation
Finally, the authors believe that more studies utilized in cross-cultural studies. ªEmicº ap-
need to focus on the strengths of ethnically/ proaches study behaviors of one culture from
racially different clients, rather than on their within the subjects' cultural system and use
weaknesses. This suggestion also includes a criteria that are related to the internal char-
focus on the positive aspects of biraciality and acteristics of that culture. ªEticº approaches
biculturality. study behaviors from outside of the culture, by
Mio and Iwamasa (1993) vociferously at- comparing one or more cultures, using depen-
tacked the methodologies used in conducting dent measures that are considered universally
ethnic minority research. They posed the applicable. The authors indicate that one must
question of whether or not researchers from a consider the emic±etic distinction when design-
majority culture could and should conduct ing and interpreting research studies. Berry
research with minority clients. Reactions to this (1969), based on the work of Pike (1967), argued
position can be found in Atkinson (1993), that researchers need to distinguish between
Ponterotto (1993), Casas and San Miguel culturally specific variables (emic variables) and
(1993), Helms (1993), Ivey (1993), Parham culture-general, universal variables (etic vari-
(1993), Pedersen (1993), and Sue (1993). These ables). The authors advocate emic approaches
reactions suggested ways to improve the quality to research. These recommendations reflect
of ethnic/racial minority research. Ponterotto and Casas's suggestions that cultu-
Berry, Poortinga, Segall, and Dasen (1992) rally relevant instruments be used for measuring
also explored methodological issues in cross- variables in a study.
cultural psychology. They indicated that the Berry et al. (1992), Hui and Triandis (1985),
two major methodological concerns in any and Triandis (1978) have advocated a combined
 Future Directions 111

emic and etic approach to research. This would be an increasing focus on individualism
approach identifies an etic construct to study, and collectivism, on indigenous psychothera-
then operationalizes that construct through the pies, and on the search for behaviors and values
development of emic instrumentation which common to every culture (cultural universals).
evolves out of the culture studied. Bond and In 1996, Bond and Smith concluded that three
Smith (1996) have concluded that if future trends have emerged during the 1990s in cross-
research is to proceed in a useful manner the cultural psychology. They suggested individu-
ªmethodological problems stemming from the alism and collectivism have been studied
etic±emic dilemma must be more clearly extensively but the other two areas have been
addressedº (p. 226). Berry (1989) has suggested plagued by methodological problems. They
that research should proceed by investigating state that the emic±etic (i.e., culture-specific±
indigenously two or more cultures in order to universal) dilemma must be more clearly
arrive at a universally derived etic. This delineated. This clarification could provide
approach is in stark contrast to the more typical new frameworks for research with culturally
approach in cross-cultural psychology that uses diverse subjects.
etic measures from Western countries. In addition, psychologists will have to focus
Mrinal, Mrinal, and Takooshian (1994) have on resolving issues of terminology and defini-
outlined the various research methods that have tion, clarifying professional and ethical con-
historically been utilized by cross-cultural cerns, addressing methodological weaknesses in
researchers. They discuss the use of experimen- research, and generating new topics for study.
tation, observation, sampling, and assessment. These areas of concern will be examined in this
In particular they analyze the use of dependent section of the chapter.
measures by comparing various assessment
methods and instruments. They call for flex- 10.04.7.1 Terminology
ibility and adaptation to be used when
conducting research cross-culturally. The terms ªethnicity,º ªrace,º and ªcultureº
Stanfield (1993) has questioned the episto- have had a long history of clarification
mological and methodological perspectives in (Jackson, 1995; Jones, 1991). This history has
contemporary cross-cultural studies. He be- been fraught with confusion and misunder-
lieves that researchers have been pursuing the standing (Phinney, 1996). Ridley et al. (1994)
wrong question, or have answered incomplete and Westbrook and Sedlacek (1991) have
questions concerning ethnically and racially criticized the inconsistent usage of terminology
diverse topics. He advocates a reorientation and pointed to the negative effects of labeling
among researchers to re-evaluate and improve and stereotyping. LaFromboise, Foster, and
qualitative, quantitative, and comparative/his- James (1996) have suggested that the term
torical research methods. ªraceº may be eliminated from future research
Qualitative researchers have advocated the studies, based on the conclusions of Yee,
improvement of cross-cultural research by Fairchild, Weizmann, and Wyatt (1993), who
focusing on class, race, or gender relations indicated the lack of uniform use of the terms
from within the culture (Andersen, 1993), ªraceº and ªethnicity.º
participant observation (Dennis, 1993), ethno- Alvidrez, Azocar, and Miranda (1996) have
graphic methods (Facio, 1993; Spradley, 1979; suggested methods to conceptualize, measure,
Williams, 1993), discourse analysis (Van Dijk, and interpret ethnic or racial variables in studies
1993), and personal narrative approaches of clinical interventions. The recommendations
(Jordan, 1995; Madrid, 1995; Moraga 1995). were that researchers should identify their
Quantitative suggestions range from re-evalu- definitions of race and ethnicity, provide more
ating demographic statistics (Marks 1993), to comprehensive information about subjects
new ways of measuring and detecting discrimi- other than ethnicity or race (e.g., demographic
nation (Myers 1993), to the assessment of information and language), identify social class
outcomes (Patton 1993; Sue et al., 1994), and to variables, and indicate occupation level. The
survey research (Smith 1993). Comparative/ recognition that ethnicity is multifaceted has led
historical methods have been suggested and to a re-examination of the terminology. Ragin
outlined by Champagne (1993), Ragin and Hein and Hein (1993) have described the term
(1993), and Stanfield (1993). ªethnicityº as interactive and contextual. Eth-
nicity and race have recently been viewed as
dimensions rather than categories (Goodchilds,
10.04.7 FUTURE DIRECTIONS 1991). Phinney (1996) has suggested these
dimensions ªclearly cluster together in ways
In 1989 three trends were predicted by that make ethnicity a highly salient and mean-
Kagitcibasi and Berry. They predicted there ingful constructº (p. 925).
112 Cross-cultural Clinical Interventions

Additionally, Phinney (1996) has also sug- therapeutic interventions, arising from stereo-
gested that if psychologists wish to generate typing or discrimination. The ACA ethical
adequate explanations about treatment out- principles indicate the need to respect the
comes when ethnicity is a factor, they need to client's individuality and dignity with regard
investigate three dimensions within and across to cultural difference. In addition, guidelines
ethnic groups. These are: significant cultural have been provided for clinical interventions
norms and attitudes, factors involved with a with ethnically, culturally, and linguistically
client's ethnic identification, and individual different clients (APA, 1993).
minority client experiences of decreased status Several future trends seem imminent in the
and power. area of ethics. Ethical principles are being
Pedersen (1995) advocates the future use of revised and more specifically delineated. The
the term ªcultureº as formulated by Betancourt ethics of caring and responsibility are beginning
and Lopez (1993). These authors have described to receive more attention in the cross-cultural
culture as a learned, socially shared set of literature (Pedersen, 1995). Ethics in the area of
variables, incorporating individual, family, and multiculturalism will be expanded to delineate
societal variables. Fernando (1995) has exam- more fully the impact of psychotherapeutic
ined the issue from the perspective of ethnic training models on a counselor's multicultural
groups in Great Britain and has argued for a competence (Sue et al., 1996). In addition,
more dynamic conception of culture to be ethical issues concerning the types of, and
formulated in cross-cultural psychology. Ped- approaches to, research with diverse popula-
ersen and Ivey (1993) have outlined the tions will be elaborated in greater detail
complexity and dynamic nature of culture and (Pedersen, 1995).
have focused on the need to identify salient The issue of white American researchers
ethnic, racial, and cultural variables. The conducting the majority of the research with
importance of these variables varies from minority clients is an area that will be examined
moment to moment, and they include ªethno- with greater focus (Mio & Iwamasa, 1993). This
graphic, demographic, status, and affiliation issue will be expanded to incorporate the
characteristics . . . particularly gender, ethnicity, recruitment and retention of minorities in
life-style or other affiliationsº (p. 188). psychotherapy research, as there has been an
The consideration of these variables will under-representation of minorities in clinical
allow researchers and practitioners to dissolve research (Miranda, 1996). This under-represen-
stereotypes of client behaviors based only on tation has led to the formation of guidelines
ethnic, cultural, and racial group membership. from the National Institutes of Health (NIH) in
Pedersen and Ivey (1993) concluded that one the USA concerning the inclusion of minorities
needs to address the dynamics of culture by and women in psychology research (NIH,
focusing on the salience and complexity of 1994). These new NIH guidelines for the
culture. This new focus will have greater inclusion of minorities in clinical research will
relevance in future individual counseling dis- be evaluated and studied in greater depth
cussions and is a foundation for an examination (Hohmann, & Parron, 1996). The focus on
of ethical considerations in cross-cultural coun- recruitment and retention has centered on
seling (LaFromboise et al., 1996; Pedersen, Native Americans (Norton & Manson, 1996),
1995). African-Americans (Thompson, Neighbors,
Munday, & Jackson, 1996), Latinos (Miranda,
Azocar, Organista, Munoz, & Lieberman,
10.04.7.2 Ethical and Professional Issues 1996), and elderly ethnic clients (Arean &
Gallagher-Thompson, 1996). It is believed that
A 20 year historical analysis of cross-cultural the NIH guidelines will help encourage colla-
counseling ethics, beginning with the 1973 Vail borative efforts between practitioners and
Conference, has been completed by Pedersen researchers (Miranda, 1996). Specific recom-
(1994). He traced the formulation of ethical mendations will need to be formulated for
principles in the professional associations of recruiting and retaining other specific, racially,
psychology. Ethical principles for conducting ethnically, and culturally diverse research
cross-cultural research were adopted in the subjects.
1970s by the International Association of Cross-
Cultural Psychology (Tapp, Kelman, Triandis,
Wrightsman, & Coelho, 1974). Ethical princi- 10.04.7.3 Future Research
ples have also been formulated by the APA
(1992) and the ACA (1988). The APA principles Future cross-cultural research will address
address the issues of race, ethnicity, and culture methodological, theoretical, and content issues.
in an effort to minimize and dispel bias in In particular, an examination of research
 Future Directions 113

agendas, assessment methods, multicultural (x) Within-group differences on variables

counseling and therapy theory, and specific such as acculturation and stage of racial identity
research topics, appear to be areas of future may influence receptivity to counseling.
concern. (xi) Credibility can be enhanced through
acknowledgment of cross-cultural factors in
cross-cultural encounters.
(xii) In general, women respond more posi-
10.04.7.3.1 Research agenda
tively than men to Western-style counseling.
Sue and Sundberg (1996) have proposed 15 (xiii) ªThe person who acts with intention-
specific hypotheses to be tested in future ality has a sense of capability. She or he can
research on individual counseling. These hy- generate alternative behaviors in a given situa-
potheses are based on questions that range from tion and approach a problem from different
client±counselor similarity, to worldview differ- vantage points. The intentional, functioning
ences, to emic±etic issues. They are as follows individual is not bound to one course of action
(pp. 329±343). but can respond in the moment to changing life
(i) Entry into the counseling system will be situationsº (cited from Ivey, Ivey, & Simek-
affected by cultural conceptualization of mental Morgan, 1993, p. 8).
disorders and socialization towards seeking (xiv) Identity-related characteristics of white
help. counselors can influence their reaction to ethnic
(ii) The more similar the expectations of the minority clients.
intercultural client to the goals and process of (xv) Despite great differences in cultural
counseling the more effective the counseling will contexts, in language, and in the implicit theory
be. of the counseling process, a majority of the
(iii) Of special importance in intercultural important elements of intercultural counseling
effectiveness is the degree of congruence be- are common across cultures and clients.
tween the counselor and client in their orienta- The authors have labeled their 15 hypotheses
tions in philosophical values and views towards as protohypotheses because they acknowledge
dependency, authority, power, openness of that the constructs and propositions need to be
communication, and other special relationships more fully sharpened, focused, and developed
inherent in counseling. before effective research can be started. Their
(iv) The more the aims and desires of the hope is to stimulate further thinking in this area.
client can be appropriately simplified and The testing of their hypotheses is proposed by
formulated as objective behavior or informa- the authors as an agenda for future research in
tion (such as university course requirements or the area of cross-cultural counseling and psy-
specific tasks), the more effective the intercul- chotherapy. Sue and Sundberg (1996) also have
tural counseling will be. suggested that future research should broaden
(v) Cross-cultural empathy and rapport are the criteria for inclusion into a study by using
important in establishing a working alliance marginal and at-risk clients. They also advocate
between the counselor and the culturally dif- a detailed examination of the emic±etic con-
ferent client. troversy.
(vi) Effectiveness will be enhanced by the Ponterotto and Casas (1991) have identified
counselor's general sensitivity to communica- areas of research that should constitute the
tions, both verbal and nonverbal. The more agenda for the 1990s and beyond. The areas
personal and emotionally laden the counseling include: accurate epidemiological studies of
becomes, the more the client will rely on words psychological problems with various ethnic and
and concepts learned early in life, and the more racial identities, impact of Eurocentric political
helpful it will be for the counselor to be and social systems on clients, systemic racism, a
knowledgeable about socialization and com- focus on the strengths present in low socio-
munication styles in the client's culture. economic groups, biracial identity develop-
(vii) The less familiar the client is with the ment, ethnic minority youth research, primary
counseling process, the more the counselor or prevention, assessment, and combination emic±
the counseling program will need to instruct the etic studies.
client in what counseling is and in the role of the Berry et al. (1992) predict a future focus on
client. examining emic±etic issues. They envisage
(viii) Culture-specific modes of counseling cross-cultural research that examines psycho-
will be found that will work more effectively pathology from various perspectives. These
with certain cultural ethnic groups than others. perspectives are: invariate or present in all
(ix) Ethnic similarity between counselor and cultures (absolute); present in all cultures, but
client increases the probability of a positive culturally determined (universal); and unique to
outcome. specific cultures and emically definable (cultu-
114 Cross-cultural Clinical Interventions

rally relative). Helms (1994) has argued that the The authors have advocated a future agenda
new focus on multiculturalism and pluralism that has researchers: (i) conduct a metareview of
has resulted in a neglect of racial factors that historical and current studies from a MCT
contribute to psychotherapy interventions. She perspective, (ii) examine the shift from a focus
has called for a greater focus on racial factors on the individual to a study of the individual
for the future. within a context or in relation to others, and (iii)
examine the positive attributes of individuals
and cultures, rather than focusing on stereo-
10.04.7.3.2 Assessment techniques
typed behaviors and pathologies. Additionally,
Future research will inevitably include the they have advocated the investigation of
development and validation of assessment traditional research methods that generate
techniques that are culturally appropriate. epistemological assumptions that may not be
The use of traditional assessment techniques universal. This future focus could incorporate a
has been criticized extensively in the literature detailed examination of differing worldviews
(APA, 1993; Dana, 1993; Lonner, 1990; Pania- and how these differences impact on cross-
gua, 1994; Ponterotto & Casas, 1990; Samuda, cultural interventions. Finally, the authors
1975; Samuda, Kong, Cummins, Pascual- recommend the use of qualitative research
Leone, & Lewis, 1991; Sodowski & Impara, methodologies when working with a culturally
1996). The issues of cross-cultural assessment diverse population. This approach, as well as
and appraisal have most recently been examined quantitative methods, will need to be used
by Lonner and Ibrahim (1996). The authors effectively to ªexplore new methods that are
present a general overview of the issues involved culture centered rather than consider culture as
when assessing culturally diverse clients by peripheralº (p. 36).
focusing on the impact of response sets and The reactions to MCT theory (Arredondo,
emic±etic issues. They have examined the use of 1996; Ballou, 1996; Casas & Mann, 1996; Corey,
cognitive ability tests and personality measures. 1996; Daniels, & D'Andrea, 1996; Highlen,
In addition, they have provided a historical 1996; LaFromboise & Jackson, 1996; Lee, 1996;
analysis of the assessment of the therapeutic Leong, 1996; Parham, 1996; Pope-Davis &
process and the assessment of refugees. Sub- Constantine, 1996; Vasquez-Nuttal, Webber, &
sequent to their extensive review they concluded Sanchez, 1996) and the counter-reactions (Sue
that these areas need to have a greater focus in et al., 1996) indicate that the dialogue will
the future. continue into the twenty-first century, with a
In addition to the investigation of traditional refinement of the theory and an empirical
standardized cognitive and personality mea- validation of the underlying constructs.
sures, researchers will need to develop future
instruments, in various areas of concern, from
10.04.7.3.4 Specific research topics
an emic perspective (e.g., biracial identity and
worldview). These instruments will need to be The methodological issues previously out-
validated and thoroughly researched. Process- lined and the research suggestions offered
oriented techniques of assessment, such as those (APA, 1992; Berry et al., 1992; Ponterotto &
in the dynamic assessment movement (Feuer- Casas, 1990; Sue et al., 1996; Sue & Sundberg,
stein, 1979), will need to be considered for cross- 1996) provide a foundation for specific topic
cultural utility and feasibility (Samuda & Lewis, areas that appear to be receiving attention in the
1992). The area of assessment constitutes one of literature. Topics such as underserved popula-
the most significant methodologic weaknesses tions, biraciality, the vocational behavior of
(Ponterotto & Casas, 1991) and will, therefore, diverse clients, and indigenous therapy, need
continue to occupy psychologists in the next more examination in the future. These four
decade. potential topics are now examined in greater
detail.
In the 1990s, there has been a move to focus
10.04.7.3.3 Theory of multicultural counseling
on specific ethnic/cultural/racial groups, rather
and therapy
than the more commonly studied four groups, in
Future research will focus on the theory of the USA: African-American, Asian-Americans,
multicultural counseling and therapy (MCT). Latino-Americans, and Native Americans (Sue
This new framework for delivery of psychother- et al., 1994). This new focus on specific under-
apeutic services to culturally diverse clients, served populations and within-group popula-
proposed by Sue et al. (1996), has six major tions could be a major focus in the next decade.
propositions and 47 corollary suppositions. In particular, the treatment of specific popula-
Research will undoubtedly focus on the specifics tions has begun to appear in the literature:
proposed by these authors. traditional Arabic clients (Dwairy & Van Sickle,
 Future Directions 115

1996), Puerto Ricans (Malgady, Rogler, & tions will elucidate and attempt to validate this
Rogler, & Constantino, 1990), Haitians (Gies, theory.
1990), Guatemalan Mayans (Alger, 1996), Another area of concern is the role of
Vietnamese (Snodgrass et al., 1993), Cambo- indigenous therapies. In many countries there
dians (Bemak & Greenberg, 1994), and Vene- is an acceptance of both standard, formal
zuelans (Villegas-Reimers, 1996). These authors psychotherapeutic intervention methods and
have concluded that researchers need to go traditional healing methods. The role of tradi-
beyond the traditional ethnic/racial group tional, or indigenous, healing practices has been
categories to focus on the heterogeneity that examined by Lefley (1994) and Hiegel (1994). A
exists within each ethnic/racial group. Future comprehensive treatment of the subject is
studies that examine these and other minority available in Kim & Berry (1993). This area of
groups need to focus on both between- and psychotherapy will inevitably continue to grow
within-group comparisons. Such a focus will as emic approaches become more acceptable in
provide an evaluation of the impact of the both Western and non-Western cultures. In-
culture-specific versus universal variables on digenous methods for investigation could
counseling and psychotherapy. include Morita, Naikan, Voodoo, Santoria,
The focus on heterogeneity has revealed the and Espiritismo therapy. Bemak, Chung, and
presence of biracial/biethnic and multiracial/ Bornemann (1996) have proposed a multilevel
multiethnic variables. As the demographics model for counseling refugees that integrates
change in countries, so do the number of Western therapies and indigenous methods of
intercultural and interracial marriages. Inter- intervention. This integration of approaches has
racial, interethnic, and biracial families have resulted in more effective psychotherapy out-
become a reality in the 1990s and have received comes (World Health Organization, 1992) and
increasing attention in the psychological litera- is a harbinger of future work in cross-cultural
ture (Root, 1992). The term ªbiracialityº has psychology.
been used to describe the children of racially
different parents and is akin to biculturality and 10.04.7.4 Global Psychology
bilingualism (Kerwin & Ponterotto, 1995).
This area has evolved from early research on It has been suggested by Moghaddam (1987),
the biracial identity models as outlined by that three worlds of psychology exist: the body
Kerwin and Ponterotto. The authors have of research derived from American research
suggested five research areas for future study: studies in the USA, research generated in other
(i) effects of peer pressure on adolescent identity industrialized countries, and a third body of
development, (ii) impact of cultural focus on knowledge that has emerged from developing
identity development, (iii) dichotomous choices countries. Mays, Rubin, Sabourin, and Walker
of identifying as multiracial/multicultural (1996) have stated: ªWithin this triumvirate, US
rather than choosing one racial/ethnic categor- psychology has been imported and serves as an
ization, (iv) development of bicultural compe- important source of influence for a number of
tence for biracial adolescents and adults, and (v) developed nationsÐthe European commu-
role of parents and educators in developing an nities, in particularÐas well as the developing
adequate sense of identity in biracial children. nationsº (p. 485). Pawlik and d'Ydewalle (1996)
This complex area of concern will receive have predicted the rise of international coop-
greater study in the future. eration and exchange in psychology, occurring
During the 1980s and 1990s there has been an through international organizations, confer-
increasing focus on the vocational concerns of ences, and publications. Gergen, Gulerce, Lock,
racial and ethnic minorities (Leong, 1995). This and Misra (1996) have examined the global
focus on career development of the culturally context of psychological practice. They deli-
diverse has led to an exploration of the issues neated various indigenous issues present in
with African-Americans (Bowman, 1995; India, New Zealand, and Turkey. They argue
Brown, 1995), Hispanic-Americans (Arbona, for a multicultural psychology that down plays
1995; Fouad, 1995), Asian-Americans (Leong & the dominant influence of Western psychologi-
Gim-Chung, 1995; Leong & Serafica, 1995), cal models of theory and practice. Lunt and
and Native Americans (Johnson, Swartz, & Poortinga (1996) have advocated the increase in
Martin, 1995). This examination of career European psychology studies that are based on
behavior has promulgated a multicultural the multicultural diversity present in European
theory of career development (Osipow & countries. The trend towards internationalizing
Littlejohn, 1995) and recommendations for psychology, therefore, appears to be one which
vocational assessment and career counseling will receive greater attention in the future and
(Betz & Fitzgerald, 1995). Future literature on may have an impact on the area of cross-cultural
cross-cultural vocational counseling interven- intervention research.
116 Cross-cultural Clinical Interventions

10.04.8 SUMMARY utilization intent of counseling among Chinese and

White students: A test of the proximal±distal model.
Multicultural counseling has been hailed as Journal of Counseling Psychology, 37(4), 445±452.
the fourth force in psychology (Pedersen, 1990). Alger, M. (1996). Counseling Guatemalan Mayans in South
Florida. Unpublished manuscript, Boca Raton, FL:
The area of cross-cultural interventions has Florida Atlantic University.
evolved into a multidimensional field that Altman, I. (1975). The environment and social behavior.
encompasses several specific interest areas. Monterey, CA: Brooks/Cole.
First, the impact of proximal and distal Altman, A., & Chemers, M. M. (1980). Culture and
environment. Monterey, CA: Brooks/Cole.
variables upon behavior has been examined. Alvidrez, J., Azocar, F., & Miranda, J. (1996). Demystify-
This area has provided evidence that a therapist ing the concept of ethnicity for psychotherapy research-
needs to understand both universal and culture- ers. Journal of Consulting and Clinical Psychology, 64(5),
specific aspects of a client's functioning. Second, 903±908.
research on cross-cultural intervention pro- American Counseling Association (1988). Ethical stan-
dards. Alexandria, VA: Author.
cesses has been reviewed. These processes American Counseling Association (1990). Counseling the
include topics as diverse as counselor compe- Black/African American client; Counseling the Mexican
tence and sensitivity, communication style, and client; Counseling the Native American client; Counseling
verbal and nonverbal communication. The the Vietnamese client [videocassettes]. (Available from
the American Counseling Association, Alexandria, VA).
research suggests that cross-cultural interven- American Psychological Association (1992). Ethical prin-
tions can be facilitated and improved by a ciples of psychologists and code of conduct. American
therapist having an understanding of the racial/ Psychologist, 47(12), 1597±1611.
ethnic/cultural differences that exist between the American Psychological Association (1993). Guidelines for
client and therapist. Third, the research on providers of psychological services to ethnic, and
culturally diverse populations. American Psychologist,
therapist±client match was examined. The 48, 45±48.
majority of studies suggest that clients prefer American Psychological Association (1994). Ethnocultural
ethnically/racially/culturally similar therapists psychotherapy: Comas-Diaz [videocassette]. (Available
and judge these therapists as more competent from the American Psychological Association, Washing-
than dissimilar therapists. Other research, ton, DC)
Andersen, M. (1993). Studying across difference: Race,
however, repudiates these notions, pointing to class, and gender in qualitative research. In J. Stanfield II
other therapist variables (e.g., sensitivity) as & R. Dennis (Eds.), Race and ethnicity in research
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research has been examined. It was discovered Apple, W., Streeter, L., & Krauss, R. (1979). Effects of
pitch and speech rate on personal attribution. Journal of
that few methodologically sound studies exist in Personality and Social Psychology, 37, 715±727.
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focused on minority groups in the USA. Fifth, ethnic minorities: Hispanic Americans. In F. Leong
methodological research concerns were ex- (Ed.), Career development and vocational behavior of
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Erlbaum.
were examined, and recommendations for Arean, P., & Gallagher-Thompson, D. (1996). Issues and
future research were reviewed. Finally, this recommendations for the recruitment and retention of
chapter has looked to future trends in cross- older ethnic minority adults into clinical research.
cultural intervention research. It predicted that Journal of Consulting and Clinical Psychology, 64(5),
875±880.
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 Copyright © 1998 Elsevier Science Ltd. All rights reserved.

10.05
Cultural Competence Training in
Clinical Psychology: Assessment,
Clinical Intervention, and
Research
FELIPE G. CASTRO
Arizona State University, Tempe, AZ, USA

10.05.1 INTRODUCTION 127

10.05.2 DEFINITIONS AND KEY CONCEPTS 128
10.05.2.1 Why the Need for Cultural Competence Training? 128
10.05.2.2 Cultural Competence as Good Science and Practice 128
10.05.2.3 Key Aspects of Cultural Competence 129
10.05.2.4 The Concept of Culture 130
10.05.2.5 Levels of Cultural Capacity 131
10.05.3 EVALUATING LEVELS OF CULTURAL CAPACITY 133
10.05.3.1 Evaluation Relevant to a Reference Group 133
10.05.3.2 Cultural Capacity in Assessment 135
10.05.3.3 Cultural Capacity in Clinical Intervention 136
10.05.3.4 Cultural Capacity in Research 137
10.05.3.5 A Life-long Professional Odyssey 138
10.05.4 FUTURE DIRECTIONS 139
10.05.5 SUMMARY 139
10.05.6 REFERENCES 139

10.05.1 INTRODUCTION health professionals aims to enhance quality in

the health services and research that is delivered
This chapter presents a three-factor model for to members of various ethnic minority groups,
describing and rating the capacity of a clinical including African-Americans, Latinos/Hispa-
psychologist or other health professional to nics, Asian-Americans and Pacific Islanders,
conduct culturally effective assessments, clinical and Native Americans.
interventions, and research with members of This training model introduces a distinct
ethnic minority populations. The overall aim of minority perspective based on at least five
this model is to provide a specific and clinically assumptions. First, the model assumes that
useful system that guides skills training towards ªcultureº cannot be ignored, and that it must be
the development of cultural competence. Devel- well understood in order for a clinical psychol-
oping cultural competence in a new cohort of ogist or for a health program to work effectively

127
128 Cultural Competence Training in Clinical Psychology

with members of ethnic/racial populations. Health and Human Services, 1985). Moreover, a
Second, this model assumes that the clinical social process involving several interrelated
psychologist must examine sociocultural factors behavioral, sociocultural, environmental, and
in order to conduct effective assessments, economic factors has contributed to this
treatments, and research with ethnic minority disparity (Anderson, 1995). Thus, clinical
clients and communities. Third, it assumes that psychologists and other providers of health
attaining the highest level of cultural capacity, services must comprehend the manner in which
which is cultural proficiency, requires the these various sociocultural factors have oper-
clinical psychologist to decenter himself or ated to influence the health status of these
herself culturally, meaning that he or she must minority populations. Clearly then, clinical
learn empathically to adopt the client's emic psychologists must acknowledge and under-
(cultural insider's) world view. A fourth assump- stand the detrimental effects of certain socio-
tion is that cultural proficiency in research and in cultural factors when conducting assessments,
community-based health service programs re- when developing clinical interventions, and
quires a social action research approach, an when designing and conducting research that
approach which invites the participation of involves ethnic minority individuals, families, or
ethnic minority community folks in the devel- communities. Within this context and at the level
opment and implementation of any intervention of the individual client, it is clear that ethnic
that is conducted within that ethnic minority minority clients have complex, and at times
community (Flores, Castro, & Fernandez- unique, needs that must be well understood
Esquer, 1995). Finally, within this perspective, within a cultural context in order to engage them
a fifth assumption is that the culturally successfully in treatment and/or research. This
proficient clinical psychologist should exercise emerging recognition of the effects of socio-
leadership by way of mentorship and an active cultural factors on physical and mental health
involvement in advancing minority issues. underscores the need for cultural competence
training, in order to improve the clinical
psychologist's capacity to work effectively with
10.05.2 DEFINITIONS AND KEY members of these minority populations.
CONCEPTS Third, the current need to develop cultural
competence in clinical psychologists has also
10.05.2.1 Why the Need for Cultural emerged as a result of the ªpipeline issue.º
Competence Training? Trends regarding the educational progress of
students of ethnic/racial backgrounds reveal
Today, the concept of cultural competence low numbers of ethnic minority graduates who
has emerged as the result of several converging will be able to provide culturally relevant health
social trends. First, the demographic face of the services to members of their ethnic/racial group.
USA has changed since the early 1970s as Only a limited number of these minority
several ethnic/racial populations have grown in graduates will enter the professional arena in
size and significance. Several of the major order to address the large and growing need for
ethnic/racial populations in the USA have services offered by minority professionals who
shown growth rates that surpass the growth understand the needs of ethnic/racial minority
rate of the mainstream USA population. As clients. Given this trend, and the growing need
these trends continue, for the year 2000, the for culturally relevant health services, a more
projected sizes of the major ethnic racial viable solution is to train and educate main-
populations of the USA in terms of size and stream service providers, administrators, and
percentage are: African-Americans, about 33.7 researchers on essential aspects of the culture
million (about 12.2%); Latinos/Hispanics, and health needs of clients from various ethnic/
about 31.1 million (about 11.3%); Asian- racial populations.
Americans and Pacific Islanders, about 11.4
million (about 4.1%); and Native Americans/
American-Indians, about 2.2 million (about 10.05.2.2 Cultural Competence as Good Science
0.7%) (Department of Commerce, 1994). and Practice
As a second factor, the 1985 Secretary's Task
Force Report on Black and Minority Health Developing cultural competence in clinical
highlighted in greater detail what was known psychologists of all backgrounds should not be
previously, which is that within the USA there seen as a ªpolitically correctº gesture to
exists a major gap in health status between the demonstrate token responsiveness to a con-
white mainstream (primarily middle class) temporary social concern. On the contrary,
population and the ethnic/racial minority and developing the cultural competence of clinical
mostly lower class populations (Department of psychologists should be seen as an important
 Definitions and Key Concepts 129

training goal that offers them a broader range alization among members of their staff who see
of capabilities for working more effectively the need for cultural competence in services that
clinically and in research with a broader and would be delivered to minority clients.
more diverse group of clients and research Finally, cultural competence training is also
participants. Moreover, the American Psycho- relevant to the conduct of good research and
logical Association's Ethical Principles of good science. In March 1994, the National
Psychologists and Code of Conduct indicates Institutes of Health (NIH) published new
that psychologists should ªprovide services, guidelines for the inclusion of women and
teach, and conduct research only within the minorities in clinical research, guidelines which
boundaries of their competence, based on their reflected the requirements of the NIH Revita-
education, training, supervised experience, or lization Act 1993 (Public Law 103-43) (National
appropriate professional experienceº (Ameri- Institutes of Health, 1994). The release of these
can Psychological Association, 1992, p. 1600; guidelines gave formal recognition to the
Standard 1.04ÐBoundaries of Competence). importance of gender and ethnic cultural factors
In addition, these guidelines indicate that, in scientific clinical research (Hohmann &
Parron, 1996). These guidelines indicate that
in those emerging areas in which generally recog- studies of outstanding scientific merit cannot be
nized standards for preparatory training do not yet conducted if such studies systematically or
exist, psychologists [should] nevertheless take arbitrarily exclude a large and diverse sector
reasonable steps to ensure the competence of their of the population from their operating plans.
work and to protect patients/clients, students, Such studies are flawed if, without a sound
research participants, and others from harm. rationale, they exclude women and/or mino-
rities from their theoretical framework, their
Clearly, in the late 1990s and in the early sampling design, their methodology, and thus
years of the twenty-first century, the guidelines from their findings and their conclusions. Here,
that define cultural competence in clinical cultural competence in research is demonstrated
interventions with ethnic/racial populations by an investigator who understands and can
are still evolving. Thus, in response to the conceptualize the hypothesized effects of spe-
American Psychological Association's Ethical cific sociocultural factors on health outcomes,
Principles, all psychologists who work with and who can design and implement studies that
clients from ethnic/racial backgrounds or who effectively recruit and retain women and
anticipate working with these clients should minority participants (AreaÂn & Gallagher-
continually seek ways to enhance their cultural Thompson, 1996; Miranda, Azocar, Organista,
competence in order to conduct effective assess- MunÄoz, & Lieberman, 1996; Thompson, Neigh-
ments, interventions, and/or research with these bors, Munday, & Jackson, 1996).
minority clients.
Moreover, from an organizational perspec-
tive, it can be noted that practically all 10.05.2.3 Key Aspects of Cultural Competence
organizations have a ªculture,º which consists
of organizational operating characteristics. Generally, cultural competence may be
Based on these operating characteristics, some conceptualized as a capacity to work effectively
organizations can be described as having a with individuals from special populations,
healthy, accepting, collegial, supportive, com- including clients from ethnic/racial commu-
fortable, consumer-friendly, and culturally nities. Cultural competence is expressed by
competent culture. By contrast, other organiza- communicating acceptance, deep understand-
tions can be described as having a paranoid, ing, and responsiveness to the needs and
judgmental, patriarchal, controlling, stressful, concerns of members of special populations.
consumer-unfriendly, and culturally incompe- Cultural competence may also be conceptua-
tent culture. The operating characteristics that lized as a capacity level that supersedes cultural
govern a particular organization's culture affect sensitivity, given that cultural competence
the way that consumers will react to the services involves a level of understanding and skills
that the organization delivers, and this is that moves beyond a basic awareness of the
especially true for the ethnic minority consu- needs and concerns of members from a special
mers who seek services within that organization. population.
Human service organizations that have institu- Cultural competence has been defined in
tional policies, procedures, and structures that various ways, although several definitions
discount or devalue the importance of cultural reveal certain common themes. For example,
competence are not likely to deliver culturally the Arizona Department of Health Services has
competent services to their minority clients, and defined cultural competence at the institutional
they are likely to induce tension and demor- level as
130 Cultural Competence Training in Clinical Psychology

knowledge, attitudes, and policies within an care environment, the culturally competent
agency which allows individuals to work effec- clinical psychologist is capable of delivering
tively in cross cultural situations. This requires the culturally responsive interventions that surpass
willingness and ability to utilize community-based the effectiveness of conventional interventions
values, traditions, and practices in developing and
(The National Latino Behavioral Health Work-
evaluating interventions, communication, and
other activities. (Arizona Department of Health shop, 1996);
Services, 1995) (ii) that level of cultural competence is spe-
cific to a given cultural reference group, where,
based on training and experience, a given clinical
A definition that applies at the individual and
psychologist may exhibit cultural competence in
institutional levels was developed by a beha-
working with one cultural group, for example
vioral health workgroup. This definition indi-
with inner city African-American adolescents,
cates that cultural competence
but may only exhibit cultural sensitivity in
addressing the needs of a different cultural
includes the attainment of knowledge, skills, and group, such as elderly rural Mexican Americans;
attitudes to enable practitioners and systems of
(iii) that the concepts of culture and sub-
care to provide care for diverse populations, i.e., to
work within the person's reality conditions, in culture are not synonymous with demographic
particular minority populations, acknowledges ethnic labels (e.g., Hispanic), where cultural
and incorporates variance in normative acceptable competence in program planning requires a
behaviors, beliefs, and values in determining an segmentation of the targeted ethnic population
individual's mental wellness/illness and incorpo- into subcultural groups (Balcazar, Castro, &
rates those variables into assessment and treat- Krull, 1995), the members of which have
ment. (The National Latino Behavioral Health distinct lifestyles, needs, and problems (e.g.,
Workshop, 1996) Chicano gang adolescents from East Los An-
geles vs. Navajo elderly who live on the
A few common themes have been stated or reservation);
implied in these and other definitions of cultural (iv) that culturally responsive interventions
competence as defined at both the macro should be guided by culturally relevant inter-
institutional level, and the micro individual vention models and defining criteria, and by a
levels. These themes include the notions that management information system that gathers
cultural competence: local data and that uses culturally relevant
(i) consists of a complex set of knowledge, variables; and
attitudes, and skills; (v) that truly effective training to develop
(ii) is characterized by an empathic and cultural competence requires continuing educa-
culturally relevant understanding of the client, tion that systematically upgrades skills across
using an insider's view of the client's presenting levels of the cultural capacity continuum to-
problem; wards the ultimate goal of cultural proficiency
(iii) requires that the clinical psychologist or (Bernal & Castro, 1994).
program exhibit cultural responsiveness, that is,
a commitment towards understanding the client
within the context of the client's own culture; 10.05.2.4 The Concept of Culture
(iv) requires the use of culture-based insights
in planning an intervention (individual/family The concept of ªcultureº is often difficult to
therapy, or a program) that is culturally rele- grasp operationally, because, as a concept,
vant and effective in alleviating the client's culture is a rich, complex, and multidimensional
problem; and concept. Indeed, one metaphor of culture as it
(v) requires careful attention to the process relates to the heart and soul of ethnic minority
of intervention, which is as important as the peoples is the concept of ªhumidityº as it relates
outcome, because in minority cultures expres- to the weather. You cannot see humidity, but
sions of respect and acceptance are indispen- you can definitely feel it when it is there. The
sable aspects of the client±therapist relationship same is true for culture. Given its rich complex-
and will greatly influence client participation ity, well over 100 definitions of ªcultureº have
and treatment outcomes. been proposed (Murphy, 1986, cited in Baldwin
In addition, there are other aspects of cultural & Lindsley, 1994). Indeed, culture has been
competence, primarily at the micro clinical defined broadly as
level, that are less salient in the literature, but
that are important in cultural competence the total body of tradition borne by a society and
training for clinical psychologists. These are: transmitted from generation to generation. It thus
(i) that cultural competence is a value-added refers to norms, values, and standards by which
capability where, under the current managed people act, and it includes the ways distinctive in
 Definitions and Key Concepts 131

each society of ordering the world and rendering it has been proposed previously by various
intelligible. (Baldwin & Lindsley, 1994; Murphy, scholars (Cross, Bazron, Dennis, & Isaacs,
1986). 1989; Kim, McLeod, & Shantis, 1992; Orlandi,
1992). In our current model, we are taking this
Across various definitions of culture, certain concept of a cultural capacity continuum and
common themes have emerged. These are: are modifying and expanding it.
(i) that culture consists of the totality of On this cultural capacity continuum, the
learned behaviors of a people; lowest level is ªcultural destructivenessº (7 3),
(ii) that it is transmitted from generation to which consists of an ethnocentric orientation
generation, that is, from elders to children; that harbors openly negative destructive atti-
(iii) that people construct their own culture in tudes that emphasize the superiority of one's
order to give meaning to life by creating a world own culture and the inferiority of other cultures.
view that helps to explain their own reality; Attitude has been previously defined as a
(iv) that it consists of a people's shared ªreadiness to respond,º a learned ªpredisposi-
beliefs, values, ways of making things, customs, tion to respond in a particular way to a specific
behaviors, traditions, and lifestyles; attitude objectº (Oskamp, 1991). Within a
(v) that it offers a community of people with health service organization, a given staff
a set of social norms and moral values on how member's condescending attitude can serve as
life should be lived; an expression of cultural destructiveness, and
(vi) that, via a culture's art, music, folklore, this attitude will destroy the client±provider
and other forms of creative expression, culture relationship. Similarly, at the institutional level,
captures the soul, character, and essence of a an agency's policies or practices that promote
people; and stereotypes and a discrimination of lower class
(vii) that culture is important to a group of clients is an expression of institutional cultural
people because it promotes a sense of kinship, destructiveness. Here a stereotype refers to a
belonging, and group identity. mental image or a set of beliefs about a group of
Given the breadth and richness of the concept people, beliefs that are highly simplistic (and
of culture, for cultural competence training a often inaccurate), highly evaluative (often
more narrow concept and definition is needed as derogatory), and rigidly resistant to change
a reference point for the operationalization of (and thus not modified by corrective informa-
levels of cultural capacity (cultural sensitivity, tion) (Oskamp, 1991). Ironically, in contem-
cultural competence, and cultural proficiency). porary American society, culturally destructive
The approach that we will use is to begin by attitudes in individuals and culturally destruc-
identifying a specific targeted reference group, tive policies within institutions still exist.
which is the group of clients that is targeted for a ªCultural incapacityº(72) refers to a pro-
given intervention or program. This targeted fessional's or an organization's orientation that
group may be defined either broadly (e.g., emphasizes separate but equal treatment. While
African-Americans, Asian-Americans) or more this may seem to be a viable and fair approach,
narrowly (e.g., African-American elderly aged in reality it often results in an institutional
65 years and older, low-acculturated Chinese incapacity to provide equal and effective
adolescents). The more broadly defined groups treatment of those clients who are culturally
are typically populations that share a common different. Similarly, at the next level, an
culture. By contrast, the more narrowly defined orientation describable as ªcultural blindnessº
groups are typically subpopulations and sub- (71) emphasizes that all cultures and people are
cultures that share a culture with the parent alike and equal. While this orientation appears
group, but that are also governed by additional unbiased and accepting, its subtle yet injurious
and perhaps unique norms, values, and other effect on members of special populations is that
local sociocultural conditions. Thus, a clinical this approach discounts the importance of
psychologist's cultural capacity level can be culture and the need to consider multicultural
defined more accurately, by describing specific perspectives. Indeed, in a well-meaning but
capacity levels in the areas of assessment, culturally insensitive effort to be fair and to treat
clinical intervention, or research that are everyone the same, an administrator may use
defined in relation to the culture of a specific this orientation to discount or discredit pro-
targeted reference group. grammatic efforts that aim to respond affirma-
tively and in a culturally sensitive manner to the
10.05.2.5 Levels of Cultural Capacity unique needs of clients from special popula-
tions.
Figure 1 shows that the capacity for cultural The first level of a positive cultural capacity is
competence varies along a graded continuum. ªcultural sensitivityº (+1). Cultural sensitivity
This concept of a cultural capacity continuum is characterized by the presence of a basic
132 Cultural Competence Training in Clinical Psychology

–3 1. Cultural Destructiveness
Superiority of dominant culture and inferiority of
other cultures
–2 2. Cultural Incapacity
Separate but equal treatment

–1 3. Cultural Blindness
All cultures and people as alike and equal

+1 4. Cultural Openness (Sensitivity)

Basic understanding and appreciation of importance of
sociocultural factors in work with minority populations
+2 5. Cultural Competence
Capacity to work with more complex issues and cultural
nuances
+3 6. Cultural Proficiency
Highest capacity for work with minority populations; a
commitment to excellence and proactive effort

Figure 1 Levels of cultural capacity. Adapted from Kim et al. (1992).

understanding and appreciation of the impor- that allows the clinical psychologist to under-
tance of sociocultural factors as these affect the stand and work effectively with cultural
client and the most viable treatment that may be nuances. By understanding cultural nuances,
offered. For example, in a health promotion the clinical psychologist is able to detect the
program for Latinos, cultural sensitivity is ethnic client's subtle communications, to
reflected by the program's attention to the role interpret their meanings, and to do so within
of linguistic factors, interpersonal factors (per- the client's specific cultural context. Based on
sonalismo, respeto, confianza), and of familal this deeper level of understanding, the clinical
factors (traditionalism, familism), as these affect psychologist is thus more capable of planning
the health-related behaviors of various Latinos. culturally potent interventions. Such interven-
Cultural sensitivity is also characterized by tions would appeal to the ethnic client, elicit
the presence of an elementary, but nonetheless the client's participation, and motivate sus-
critical, appreciation of the within-group varia- tained participation.
bility, that is, of the diversity that exists within a Similarly, in a community-based health
given ethnic minority population. For example, promotion program, the cultural competence
among Latinos, scholars have regularly asserted of the program's staff is characterized by their
that Hispanics/Latinos are a heterogeneous capacity to work actively with members of a
population characterized by large variability community. This capacity includes an under-
among its members in terms of racial back- standing of the cultural and political nuances
ground, educational attainment, household that helps these staff members to develop trust
income, family size and composition, and even and credibility with members of the local
in the level of ethnic pride evident among its community, and to elicit their support and
members (Montgomery, 1994). participation in the design and implementation
ªCultural competenceº (+2) represents a of a health promotion program. Here also,
higher level of capacity to work with members cultural competence is characterized by the
of a special population. Relative to cultural clinical psychologist's knowledge of the motiva-
sensitivity, cultural competence is character- tional dynamics that prevail within subgroups
ized by a greater depth of skills and experience of a given population, as these motivational
 Evaluating Levels of Cultural Capacity 133

dynamics may be mediated by age, gender, where these descriptive statements serve as
cultural orientation, and other aspects of the guideposts for conceptualization and evalua-
group's subculture. tion when conducting cultural capacity training
ªCultural proficiencyº (+3) is the highest in the areas of assessment, clinical intervention,
expression of cultural capacity. It serves as an and research. When using Table 1, cultural
ideal, rather than necessarily as a state that is capacity should be evaluated in relation to a
attainable by all clinical psychologists. Cultural specific reference group, that is a specific and
proficiency consists of a state of high mastery, a targeted cultural group or subgroup.
commitment to excellence, and a proactive
attitude that facilitates the design and delivery
of therapeutic services for members of a specific 10.05.3.1 Evaluation Relevant to a Reference
population. Here it is recognized that a given Group
clinical psychologist or health program may
exhibit cultural proficiency in service delivery to One major problem in prior conceptualiza-
members of one targeted population (e.g., tions of cultural competence is that previous
Latinos), but may only exhibit cultural sensi- approaches have defined it in global and
tivity in service delivery to members of a nonspecific terms. As a result, for the purpose
different population. Thus, complete cultural of clinical training, cultural competence has
proficiency with all special populations would remained a vague, unintelligible concept that is
be a rare accomplishment for many clinical disassociated from critical clinical and organi-
psychologists, health programs, or human zational referents. Thus, as used previously, the
service agencies. Nonetheless, constantly striv- concept of cultural competence has had limited
ing to develop cultural proficiency in work with practical usefulness to clinicians and to program
one or more special population is a laudable planners. Missing is a conceptualization that
goal for any clinical psychologist, health defines cultural competence more accurately, as
program, or agency, although this calls for a it is linked to a specific reference group. The
commitment to life-long learning with the present model aims to add greater precision and
ultimate aim of developing depth and breadth specificity to the conceptualization and mea-
in skills for working with members of one or surement of cultural competence.
more special population. To operate as a construct that has practical
applicability in the clinical, organizational, and
community settings, cultural competence must
10.05.3 EVALUATING LEVELS OF therefore be defined in terms of skills for service
CULTURAL CAPACITY delivery to members of a specific reference
group. For example, through training and
This section presents a more detailed discus- experience, a clinical psychologist may acquire
sion of key aspects of cultural capacity relevant the knowledge, attitudes, and skills that afford
to the training of clinical psychologists. Table 1 him or her the capacity to conduct effective
lists the specific knowledge, attitudes, and skills therapeutic work with various African-Amer-
that serve as indicators of varying levels of ican clients. Thus, this clinical psychologist
cultural capacity in the areas of assessment, could be rated as being culturally competent in
clinical intervention, and research. The table the area of clinical interventions with African-
presents a progressive increase in the knowl- American clients. By contrast, this same clinical
edge, attitude, and skills that serve as specific psychologist may have never worked with a
operational criteria to help gauge a clinical Asian-American client, and thus would not be
psychologist's progression across levels of culturally competent in service delivery with
cultural capacity from cultural sensitivity, to Asian-American clients. However, that clinical
cultural competence, to cultural proficiency. psychologist's knowledge about aspects of
The criteria in Table 1 that describe levels of Asian-American cultural norms and values,
cultural capacity are presented as illustrative his or her accepting attitude towards Asian-
descriptors. They have not been validated Americans and their culture, and his or her
empirically, although they are derived from assessment skills for differential interpretation
the contemporary literature on cultural compe- of tests conducted with various Asian
tence and from clinical and research experience American subgroups, including a familiarity
(Allison, Crawford, Echemendia, Robinson, & with scales of acculturation, could garner for
Knepp, 1994; American Psychiatric Associa- this clinical psychologist a rating of cultural
tion, 1994; Dillard et al., 1992; La Fromboise & sensitivity for work with Asian-American
Foster, 1992; Szapocznik & Kurtines, 1993). clients in the area of assessment.
Accordingly, these statements offer a viable Based on these considerations, cultural
system to evaluate levels of cultural capacity capacity can be defined more accurately by
134 Cultural Competence Training in Clinical Psychology

Table 1 General guidelines for evaluating levels of cultural capacity in assessment, clinical intervention, and
research.

Assessment
Sensitivity (+1)
Is familiar with major cultural characteristics found among members of one or more cultural group, and
understands basic aspects of the within-group variability that exists for a given cultural group
Is accepting of the concept of diversity, and is aware of the need to decenter oneself culturally in order to
understand the world view of people from other cultures
Is capable of administering and interpreting tests and assessment instruments with a consideration of sources
of bias or adjustment needed in order to interpret test results in a fair manner. Can formulate culturally
relevant treatment recommendations
Competence (+2)
Is knowledgeable of and can understand apparent paradoxes and cultural nuances in the thoughts and
behaviors of members of the cultural group
Has an affective attachment to the culture and a deeper understanding of issues within that culture.
Has the capacity for empathic decentering
Is capable of understanding and working with nuances and apparent paradoxes in assessing, diagnosing, and
interpreting more complex cultural aspects of thought and behavior. Can design a comprehensive
treatment plan
Proficiency (+3)
Has developed a deep, integrated knowledge of a culture based on years of experience
Feels a deep attachment and appreciation for that culture
Is capable of understanding nuances and apparent paradoxes. Can distil deeper cultural meaning to obtain a
deep understanding of cultural thoughts and behaviors in assessing or diagnosing a problem. Can plan an
optimally effective treatment plan
Clinical intervention
Sensitivity (+1)
Is familiar with basic aspects of a culture and with the within-group variability in social norms that govern
interpersonal relationships and the accepted manner in which various people communicate with one
another
Is accepting of these social norms
Has developed ease and comfort in engaging persons from that culture in a culturally appropriate manner. Is
able to decenter empathically and thus to gain an awareness of the world view of persons from the cultural
reference group
Competence (+2)
Has greater knowledge of complex aspects of social norms and patterns of communication within the culture,
and is able to understand nuances present in that communication
Has an affective bond with the culture and has a finer appreciation and acceptance of nuances and of apparent
paradoxes. Is able to engage in advanced empathic decentering by understanding his or her own prejudices,
as well as by being able to understand the reference culture from the ªworld viewº perspective of members
of that culture
Is able to conceptualize the client's problem using the most relevant therapeutic mode
Proficiency (+3)
Has deep, rich, culturally relevant knowledge of the culture and about the rich complexity that governs that
culture
Feels a strong affective bond with the culture and expresses this in appreciation and respect for that culture
and its people
Has the capacity to detect and to work with clinical nuances and to implement one of various therapeutic
approaches as is most relevant to a client's central problem. In doing so, knows clearly where the case is
going and can intervene efficiently and effectively. Is able to conduct potent culturally relevant
interventions and/or design potent culturally relevant programs
Research
Sensitivity (+1)
Is familiar with variables such as race and ethnicity as important sociocultural factors in research design and
methodology. Attends to issues involved in approaching and informing individuals and communities in a
manner that protects their rights and fosters trust, respect, and mutual collaboration
Has an attitude of respect for the rights and sovereignty of individuals or communities from the culture who
may participate in a proposed study
Is able to engage individuals or communities in an ongoing dialogue that promotes a partnership in research
 Evaluating Levels of Cultural Capacity 135
Table 1 (continued).

Competence (+2)
Has a knowledge of the complexities of race, ethnicity, acculturation, and other sociocultural factors as these
must be conceptualized and at times reconceptualized, in order to understand the more complex aspects of
a culture. Can engage in theoretical decentering by evaluating the fit or lack of fit of Eurocentric models as
applied to a cultural reference group
Has a commitment to establishing a partnership with individuals or communities from a culture in a manner
that offers them a voice and active ownership of the research that is to be conducted
Is capable of working actively with individuals or communities from the culture in order to ensure their
participation and active ownership of the study. Develops social action research
Proficiency (+3)
Has a deep and rich knowledge of the complexities and apparent paradoxes that exist and may emerge within
a culture
Has a strong affection for the core values and traditions of a culture and has a strong commitment to ensuring
that these values and traditions are acknowledged and respected in the design of proposed research. This
respect includes ensuring that members of the culture have a voice and active ownership of the study
Is capable of establishing a strong and enduring collaboration with individuals or communities from the
culture based on earned respect and trust. This strong research bond is also used to design research that has
social action value, social action research, such that its findings or discoveries can be used to benefit the
individuals or communities that have participated in that research. Also, takes a leadership role in offering
scholarly critique on various minority issues and in serving as a role model and mentor for junior faculty
and graduate students

conceptualizing it according to three dimen- cents, but may only be rated as having attained
sions: (i) capacity level (none, sensitivity, cultural sensitivity in conducting clinical inter-
competence, proficiency; (ii) in a specialty area ventions with African-American elderly.
(assessment, clinical intervention, research); Similarly, this three-factor model can be
and (iii) in relation to a specific cultural applied at the organizational level, where an
reference group (African-Americans, Latinos, intervention program can be rated for its
Asian-Americans, Native Americans). Thus, in capacity to deliver culturally relevant services.
assessing training-related cultural capacity, a Based on the service components of an inter-
clinical psychologist may be described as having vention program, the skills of its providers, its
attained cultural competence (capacity level) in institutional policies, and its clinical environ-
the area of clinical intervention (specialty area) ment, a program may be rated in terms of
for work with African-Americans (reference cultural capacity (none, sensitivity, competence,
group). This three-factor descriptive model proficiency), in a specialty area (assessment,
provides a specific and meaningful approach clinical intervention, research, or other), with a
to guide clinical training and professional given reference group (e.g., Native American
communications about the relevant cultural elderly).
capacity of a given clinical psychologist as he or
she proceeds through a training program.
10.05.3.2 Cultural Capacity in Assessment
Regarding the dimension of reference group,
a targeted reference group can be defined more Assessment refers to the use of standardized
generally, as a primary reference group, such as tests, interview approaches, and other diagnos-
for example an entire ethnic/racial population tic methods for systematically learning about
that has a definable culture such as African- the client (Dana, 1993). A clinical psychologist's
Americans or Latinos. Alternatively, this re- progressive increase in knowledge, attitudes,
ference group may be defined more specifically and skills characterizes his or her increased
as a secondary reference group, that is a smaller levels of cultural capacity in the area of
more specific subgroupÐa subpopulation, such assessment.
as African-American adolescents or Latino At the lowest capacity level, cultural sensi-
elderly. Referring to a more specific reference tivity in assessment, the clinical psychologist
group may influence the level of cultural should demonstrate an elementary knowledge
capacity that can be rated. As indicated earlier, of major cultural issues that affect the life
a clinical psychologist may have attained experiences of members of a special population,
cultural proficiency in conducting clinical such as members of one of the major ethnic/
interventions with African-American adoles- racial groups (African-Americans, Latinos,
136 Cultural Competence Training in Clinical Psychology

Asian-Americans, Native Americans). The the area of assessment. The clinical psycholo-
clinical psychologist should also be familiar gist's affective attachment to the reference
with the need to decenter himself or herself from group's culture would enhance his or her skills
a solely Eurocentric world view in order to for working with cultural conflicts and with
adopt an insider's emic view (i.e., one that takes more subtle issues. Having advanced skills for
the perspective of the indigenous client). This interpreting manifest and more latent content,
decentering allows the exploration of culturally for organizing content, and for processing
specific concepts; these are concepts that may be information would help the clinical psychologist
unique to the indigenous culture, or concepts to design an insightful and comprehensive
that are defined differently in the indigenous treatment plan or intervention program.
culture relative to how they are defined within As compared with cultural competence, at the
the mainstream culture. level of cultural proficiency in assessment, the
At the level of cultural sensitivity in assess- clinical psychologist would exhibit a deep and
ment, the clinical psychologist should have an integrative knowledge of the client's culture.
elementary knowledge of the within-group This knowledge would be coupled by a deep
variability that exists within a given reference appreciation and bonding with that culture,
group, and should know about the moderator based on having a deep personal involvement
variables, such as the level of acculturation, that and years of experience. The culturally profi-
describe this within-group variability (Dana, cient clinical psychologist would have masterful
1993). This basic knowledge ideally facilitates skills for detecting and understanding subtle
an accepting attitude towards variability in and complex cultural communications and for
culture, where variability is conceptualized as interpreting these accurately and in culturally
consisting of differences and not as deficits. appropriate ways. Such deep insight would
Furthermore, this orientation should aid in allow the clinical psychologist to plan an
reducing biased and stereotypical thinking optimally effective treatment plan or interven-
(Oskamp, 1991), thus facilitating a more tion program.
accurate assessment of clinical issues which
are examined within the context of the client's
cultural background. 10.05.3.3 Cultural Capacity in Clinical
In addition, this sensitivity in orientation Intervention
should contribute to overall skills for conduct-
ing a basic assessment of the client's needs and In a manner parallel with assessment, a level
clinical problems. This assessment should take of cultural sensitivity in clinical intervention is
into account the influence of cultural and social characterized by a clinical psychologist's de-
factors in drawing valid conclusions about the monstrated knowledge about the prevailing
client's strengths and weaknesses, while also social norms and patterns of interpersonal
observing conflicts, relative skills deficits, and communication for a given cultural reference
psychopathology if these are present. Attaining group. This includes having a basic under-
cultural sensitivity in assessment should en- standing of the within-group variability that
hance the clinical psychologist's capabilities for exists in that group. This knowledge would be
developing preliminary treatment recommenda- supplemented by the clinical psychologist's
tions that take into account the client's social, accepting attitude towards the group's culture
familial, and personal resources and barriers, as and values. This positive orientation towards
these may facilitate or impede participation in a that cultural group would also facilitate the
treatment or intervention program. clinical psychologist's ease and comfort in
As compared with cultural sensitivity, cultur- conducting therapeutic work with persons from
al competence in assessment constitutes a higher that cultural reference group. The clinical
level of skills development. As contrasted with psychologist's basic capacity for empathic
cultural sensitivity, attaining cultural compe- decentering would also help in understanding
tence in assessment requires a higher knowledge the ethnic experience of members of that
level, wherein the clinical psychologist under- cultural reference group.
stands more complex interactions and nuances Cultural competence in clinical intervention
as observed within the context of the client's would be characterized by the clinical psycho-
culture. Apparent paradoxes when observed logist's greater depth of knowledge about
from a Eurocentric perspective may not neces- complex aspects of a culture's social norms,
sarily appear as paradoxical or as psychopathol- forms of communication, and types of inter-
ogy when observed from an indigenous cultural personal behavior, thus fostering the capacity to
perspective. This capacity for empathic decen- understand nuances and apparent cultural
tering when interpreting complex cultural contradictions. Moreover, developing an affec-
meanings characterizes cultural competence in tive bond and an appreciation for the reference
 Evaluating Levels of Cultural Capacity 137

culture and its people would foster the caring for the protection of potential research parti-
attitude that characterizes cultural competence cipants that would be recruited from that
in the clinical setting. This advanced level of reference group. An attitude of respect for
knowledge and a caring attitude would enhance members of that culture and an awareness of
the clinical psychologist's understanding of the their special linguistic and other needs would
life conditions and the major ways of coping enhance the clinical psychologist's ability to
found among members of the reference group, safeguard the rights of these potential partici-
and would aid in relating effectively to the pants. In addition, cultural sensitivity would be
client. Moreover, the clinician's ability to reflected in the clinical psychologist's basic
understand his or her own prejudices as one capacity to engage individuals or communities
aspect of advanced empathic decentering would from the reference group with respect, and in his
further enhance his or her cultural competence or her ability to develop a research partnership
for conducting clinical interventions. This with members of that reference group.
enhanced capacity to understand self and client As a more advanced stage of research
as a dyad would also facilitate the clinical capacity, cultural competence in research would
psychologist's capacity to conceptualize the be characterized by the clinical psychologist's
client's problem using the most relevant greater knowledge of cultural interactions and
therapeutic model, as it may apply within the of complex sociocultural processes, such as the
client's life context. In addition, the culturally process of acculturation, as these affect various
competent clinical psychologist would be able members of the cultural reference group. This
to plan and implement insightful and effective includes the clinical psychologist's capacity for
interventions or programs that address the theoretical decentering, which involves taking a
ethnic client's most pressing needs. critical examination of current Eurocentric
As an even more advanced stage of clinical models and their fit, or lack of fit, when applied
capability, cultural proficiency in clinical inter- with members of the cultural reference group. In
vention would be characterized by a clinical cases in which model fit is poor, the culturally
psychologist's deep and rich knowledge of the competent clinical psychologist is able to
reference group's culture and of the complex consider alternate constructivist models that
norms, values, and other factors that govern feature an emic, insider's view of the ethnic
behavior within that culture. At this stage, the person's life experiences and of the experience of
clinical psychologist would develop a strong being a minority person.
affective bond with the reference group and its Moreover, the clinical psychologist's com-
culture and would have a deep respect for its mitment to establishing a research partnership
people. This combination of rich knowledge with individuals and communities in a manner
and a strong positive attitude would facilitate that offers them a voice in the design and
the clinical psychologist's capacity to compre- conduct of the proposed research would also
hend the life situation of various clients from characterize cultural competence in research
that reference group, to conceptualize a given (Flores et al., 1995; Norton & Manson, 1996).
client's problem from various theoretical per- This in-depth knowledge and a proactive
spectives, and to visualize clearly where the case attitude that favors research partnerships and
is going. Thus, the culturally proficient clinician social action research would facilitate the
would also have the capacity to plan and clinical psychologist's capacity to work actively
implement potent clinical interventions and/or with individuals and communities from the
to design and implement culturally effective cultural reference group in the design and
treatment programs. implementation of social action research.
Beyond cultural competence, the more
advanced level defined as cultural proficiency
10.05.3.4 Cultural Capacity in Research in research would involve advanced knowledge
about the cultural reference group. This
In parallel with the knowledge, attitudes, and proficiency would be demonstrated by the
skills that serve as indicators of cultural capacity clinical psychologist's deep and rich knowledge
in a given specialty area, a clinical psychologist's about the complexities and apparent paradoxes
cultural sensitivity in research would be char- observed within the cultural reference group.
acterized by his or her basic familiarity with This depth of knowledge would yield insights
sociocultural variables, including moderator that facilitate the clinical psychologist's capa-
variables, that must be incorporated into the city to design significant new research. In
research design and methodology of studies principle, such research would be insightful and
conducted with participants from a given integrative, and would propose new culturally
cultural group. This knowledge-based sensitiv- relevant models that could be adequately
ity would include an awareness of procedures defined and tested. These models would include
138 Cultural Competence Training in Clinical Psychology

sociocultural variables, including moderator particular social situation (Oskamp, 1991), it is

and culturally specific variables that capture, the clinical psychologist's positive attitude, an
describe, and explain various sociocultural open-mindedness and willingness to learn about
processes that affect the health of clients from new cultures and people which characterizes
the given cultural reference group. that clinical psychologist's preparedness to
In addition, cultural proficiency in research embark on the journey towards cultural
would be characterized by the clinical psycho- proficiency. Thus, instilling an attitude of
logist's strong appreciation for the core values openness in those who do not already have it
and traditions of the cultural reference group is the first task in cultural competence training.
and by a deep and abiding respect for these In addition, ethical practice in work with
values and traditions. These proactive attitudes diverse populations requires a commitment on
would be reflected in the clinical psychologist's the part of the clinical psychologist continually
strong commitment to safeguard the rights of to upgrade his or her cultural capabilities. To
prospective participants that are recruited from meet this need, clinical training programs
the cultural reference group. should be proactive in developing curricula
The culturally proficient researcher would and resources that help clinical psychology
also exhibit research leadership in conceptualiz- trainees to develop their cultural competence.
ing, designing, and implementing innovative Here, Standard 6.01 of the Ethical Principles of
research that examines critical issues of concern Psychologists and Code of Conduct asserts that
to members of the reference community. In
conducting social action research, the culturally psychologists who are responsible for education
proficient researcher would pursue active solu- and training [should] seek to ensure that the
tions to contemporary social problems that programs are competently designed to provide
affect the reference community. In such re- the proper experiences, and meet the requirements
search, the investigator would exert leadership for licensure, certification, or other goals for which
in building community partnerships and in claims are made by the program. (American
building a research team that includes members Psychological Association, 1992, Standard 6.01,
of the targeted community in positions that Design of Education and Training Programs)
contribute to the planning, design, and im-
plementation of that social action research Relevant to this point, a study of 104 clinical
project. training programs that examined changes in
Finally, the culturally proficient researcher service and research with ethnic/racial popula-
would serve as a role model and as a mentor to tions across a 10-year period found some
junior faculty and graduate students, thus improvements among many of the 104 clinical
contributing to the training of future culturally training programs surveyed (Bernal & Castro,
competent investigators and teachers. The 1994). However, these improvements consisted
culturally proficient researcher would also primarily of introductory-level capabilities
adopt a leadership role in conducting critical training, and did not offer the depth in training
yet helpful reviews of publication manuscripts needed to develop cultural competence among
and research proposals. This criticism would program trainees. Bernal and Castro noted
not only address issues of scientific merit, but that, despite the tangible improvements in
would also address ethnic/racial issues, as well minority training in clinical psychology that
as issues of social inequality and scientific have occurred since the mid-1980s relevant
inaccuracy in manuscripts that examine ethnic structural shifts have not taken place. These
minority communities and members of other structural shifts refer to institutionalized pro-
special populations. In short, the culturally grammatic changes that involve concerted
proficient researcher would take a proactive and plans to integrate key aspects of minority
leadership role in advancing a variety of training across the clinical training curriculum,
minority research and training issues in the coupled with a commitment of resources to
fields of clinical psychology, minority mental implement these plans. Indeed, only four of the
health, minority health, health promotion, and 104 programs surveyed, all at professional
other related fields. schools, exhibited training program profiles
for an integrated curriculum that would foster
cultural proficiency among its trainees.
10.05.3.5 A Life-long Professional Odyssey Whereas many programs may express an in-
principle endorsement of the importance of
The road to cultural proficiency begins not multicultural training, few have developed the
with knowledge or skills, but with attitude. infrastructure (coursework, minority faculty
Given that ªattitudeº is defined as a predis- recruitment and retention, community links)
position to respond in a particular manner to a for promoting cultural competence in clinical
 References 139

training. Given that departments and clinical training program; that is, to rate the current
training programs can also be rated on levels of capacity of the program to train culturally
cultural capacity, most programs nationally proficient clinical psychologists.
would fare no higher than being culturally
sensitive. Clearly, based on the findings of the
Bernal and Castro study, it can be concluded 10.05.5 SUMMARY
that most clinical psychology training pro- In this chapter a three-factor model has been
grams in the USA can and should do more
presented that aims to define operationally the
in order to develop their future capacity to
various levels of cultural capacity (sensitivity,
promote cultural competence within their own
competence, proficiency) as related to three
clinical training program.
specialty areas (assessment, clinical interven-
Within the context of our previous state-
tion, research), and as related to a specific
ments, we also recognize that not all clinical
cultural reference group. It is recognized that
psychologists or students are necessarily inter-
attaining true cultural competence in the areas
ested in or prepared to participate in cultural
of assessment, intervention, and research for
competence training. Similarly, not all clinical
each of several ethnic/racial populations is a
training programs give sufficient value to
high ideal that will be achieved by only a few
cultural competence training, or do not seek
clinical psychologists in a lifetime of profes-
to offer their students training in cultural
sional practice. However, this chapter has also
competence as compared with other important
identified and defined graded steps towards this
clinical training needs. Unfortunately, those
ideal, and encourages the clinical psychologist
who could benefit most from cultural compe-
to commit a sustained effort towards enhancing
tence training are often those who are least
his or her level of cultural capacity. Here also,
interested in it. However, for those who do value
clinical training programs have a professional
learning about other cultures, and for those who
obligation to upgrade their training program by
can be convinced to try it, developing the
adding depth of content and activities in order
cultural capacity to work with persons from
to enhance their programmatic capacity to offer
various cultures is an odyssey of a professional
true depth in cultural competence training. It is
lifetime that offers intellectual, affective, social,
recognized that the present three-factor model
and spiritual rewards. The invitation to under- constitutes only an early step in the task of
take this journey is there for those who are
further articulating the characteristics of var-
willing to take it.
ious levels of cultural capacity, as this articula-
tion aids in clarifying further what it means to
become culturally competent.
10.05.4 FUTURE DIRECTIONS
The overview of the levels of cultural capacity 10.05.6 REFERENCES
that has been presented offers specific guidelines
to help define cultural sensitivity, culture Allison, K. W., Crawford, I., Echemendia, R., Robinson,
L. V., & Knepp, D. (1994). Human diversity and
competence, and culture proficiency in the professional competence: Training in clinical and coun-
areas of assessment, clinical intervention, and seling psychology revisited. American Psychologist, 49,
research. However, in many ways, the present 792±796.
model only constitutes an early step towards a American Psychiatric Association (1994). Diagnostic and
statistical manual of mental disorders (4th ed.). Washing-
more detailed articulation of levels of cultural ton, DC: Author.
capacity. Additional work can and should be American Psychological Association. (1992). Ethical prin-
conducted to relate the guidelines presented ciples of psychologists and code of conduct. American
here to a variety of specific cases with the aim of Psychologist, 47, 1597±1611.
enhancing quality in assessment, treatment, and Anderson, N. B. (1995). Behavioral and sociocultural
perspectives on ethnicity and health: Introduction to
research with a diverse group of ethnic/racial the special issue. Health Psychology, 14, 589±591.
clients. AreaÂn, P. A. & Gallagher-Thompson, D. (1996). Issues and
Moreover, clinical training programs can and recommendations for the recruitment and retention of
must do more to add depth of content and older ethnic minority adults into clinical research.
Journal of Consulting and Clinical Psychology, 64,
diversity in their clinical training activities, as 875±880.
these additions facilitate greater competence in Arizona Department of Health Services (1995). Cultural
assessment, clinical intervention, and research competency in the administration and delivery of beha-
with members of ethnic/racial populations. One vioral health services. Phoenix, AZ: Author.
potential outcome of presenting the current Balcazar, H., Castro, F. G., & Krull, J. L. (1995). Cancer
risk reduction in Mexican American women: The role of
three-factor model and its guidelines is that it acculturation, education, and health risk factors. Health
may serve as a template from which to rate the Education Quarterly, 22, 61±84.
level of cultural capacity of given clinical Baldwin, J. R., & Lindsley, S. L. (1994). Conceptualizations
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of culture. Tempe, AZ: Urban Studies Center. Counseling Psychologist, 20, 472±489.
Bernal, M., & Castro, F. G. (1994). Are health profes- Miranda, J., Azocar, F., Organista, K. C., MunÄoz, R. F.,
sionals prepared for service and research with ethnic & Lieberman, A. (1996). Recruiting and retaining
minorities? Report of a decade of progress. American low-income Latinos in psychotherapy research.
Psychologist, 49, 797±805. Journal of Consulting and Clinical Psychology, 64,
Cross, T. L., Bazron, B. J., Dennis, K. W., & Isaacs, M. R. 868±874.
(1989). Toward a culturally competent system of care. Montgomery, P. A. (1994). The Hispanic population in the
Washington, DC: Georgetown University Child Devel- United States: March 1993. Current Population
opment Center. ReportsÐPopulation Characteristics (Series P20-475).
Dana, R. H. (1993). Multicultural assessment perspectives Washington, DC: US Government Printing Office.
for professional psychology. Boston: Allyn and Bacon. Murphy, R. F. (1986). Cultural and social anthropology: An
Department of Commerce (1994). Statistical abstract of the overture. Englewood Cliffs, NJ: Prentice-Hall.
United States: 1994 (114th ed.). Washington, DC: US National Institutes of Health. (1994). Outreach notebook
Government Printing Office. for the NIH guidelines on inclusion of women and
Department of Health and Human Services (1985). Report minorities as subjects in clinical research. Bethesda,
of the Secretary's Task Force on Black and Minority MD: Author.
Health. Washington, DC: US Government Printing Norton, I. M., & Manson, S. M. (1996). Research in
Office. American Indian and Alaska Native communities:
Dillard, M., Andonian, L., Flores, O., Lai, L., MacRae, A., Navigating the cultural universe of value process.
& Shakir, M. (1992). Culturally competent occupational Journal of Consulting and Clinical Psychology, 64,
therapy in a diversely populated mental health setting. 856±860.
The American Journal of Occupational Therapy, 46, Orlandi, M. A. (1992). Defining cultural competence: an
721±726. organizing framework. In M. A. Orlandi, R. Weston, &
Flores, E. T., Castro, F. G., & Fernandez-Esquer, M. L. G. Epstein (Eds.), Cultural competence for evaluators
(1995). Social theory, social action, and intervention (pp. 293±299). Rockville, MD: Center for Substance
research: Implications for cancer prevention among Abuse Prevention.
Latinos. Journal of the National Cancer Institute Mono- Oskamp, S. (1991). Attitudes and opinions (2nd ed.).
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Hohmann, A. A., & Parron, D. L. (1996). How the new Szapocznik, J., & Kurtines, M. (1993). Family psychology
NIH guidelines on inclusion of women and minorities and cultural diversity: opportunities for theory, research
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Journal of Consulting and Clinical Psychology, 64, The National Latino Behavioral Health Workshop (1996).
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communities: Some practical considerations. In M. A. Thompson, E. E., Neighbors, H. W., Munday, C., &
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competence for evaluators (pp. 203±260). Rockville, MD: African American patients for clinical research: An
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 Copyright © 1998 Elsevier Science Ltd. All rights reserved.

10.06
Reconstructing Race, Rethinking
Ethnicity
MARIA P. P. ROOT
University of Washington, Seattle, WA, USA

10.06.1 INTRODUCTION 141

10.06.1.1 Race and Ethnicity 143
10.06.1.2 Racial Identity Development as Racial Healing 144
10.06.2 PROCESS OF IDENTITY CONSTRUCTION 145
10.06.2.1 Process of Differentiation 145
10.06.3 RACIAL IDENTITY THEORIES 147
10.06.3.1 Nigrescence and Minority Racial Identity Stage Model Theories 147
10.06.3.2 White Racial Identity 148
10.06.4 ETHNIC IDENTITY MODELS 149
10.06.4.1 Comparison and Critique of Racial and Ethnic Identity Models 150
10.06.5 RETHINKING RACE AND ETHNICITY 151
10.06.6 CONTEMPORARY MODELS FOR RETHINKING THE RELATIONSHIP BETWEEN RACE
AND ETHNICITY 152
10.06.6.1 Ecological Model of Race and Ethnicity 152
10.06.7 CLINICAL IMPLICATIONS 155
10.06.8 FUTURE DIRECTIONS: RETHINKING RACE AND ETHNICITY 157
10.06.9 SUMMARY 157
10.06.10 REFERENCES 158

10.06.1 INTRODUCTION forbidding and penalizing interracial marriage.

Since this period of time the percentage of
Ethnicity and race in the USA have become interracial marriages has approximately
synonymous concepts in everyday language doubled with each subsequent decade. Corre-
although they signify different experience. This lated with this increase in legalized interracial
chapter, which considers identity development unions has been a significant increase in the
in persons of mixed racial heritage, necessitates number of biracial and multiracial children and
we differentiate these concepts. Increasingly, young adults, particularly in large cities of the
ambiguous phenotypes, proliferating since the USA (Root, 1992, 1996b)). These constructs
biracial baby boom post-1967, defy instanta- seemingly collide when we consider the iden-
neous recognition or accurate assignment of tities of people who claim multiple group
ethnic group belonging (1967 marked the repeal memberships. This chapter uses the presence
of the last antimiscegenation laws in the USA and experience of a growing presence of racially

141
142 Reconstructing Race, Rethinking Ethnicity

mixed people in the USA whose simultaneous, colonial strategy (whether it be the Spanish,
dynamic, and multiple identies require reex- Dutch, Japanese, British, American, etc.) for
amination of assumptions about race and justifying maltreatment of people (Foucault,
ethnicity. 1978; Young, 1995). The construction of the
How are racial and ethnic identity different? racial or ethnic other sets the stage for justifying
This has become an increasingly difficult genocide whether it be in Bosnia, World War II
differentiation as racial logic is somewhat Germany, the USA, or Africa at various points
circular and the distinctions between their in history.
historical constructions are suppressed (Gor- Because the mechanics of oppression have
don, 1995). Both exist because diversity in race universal methods, the example of US history of
and ethnicity have a social significance used to race relations to examine current theories of
stratify society (Phinney, 1990). Much of the racial identity development is used. In doing so,
work on ethnic and racial identity stems from it becomes clear that our psychology exists
notions of the effects of marginality (Oetting & within a political tangle of propaganda and
Beauvais, 1990±1991) and the observations and oppressionÐpast and present. The effects of
hypothesizing about the hybrids of race and our history of racial and ethnic oppression
culture (Park, 1931; Stonequist, 1964; Young, becomes evident in the critical examination of
1995). current racial identity theories from the experi-
Race and ethnicity become significant sta- ence of a growing minority in this country,
tuses relevant to experience of self and others persons of multiracial origin, who declare a
when they are differentiated within a society. In biracial or multiracial heritage.
his classic work on the roots of discrimination, DuBois (1903) noted that the affirmation of a
Allport (1994, p. 221) lists 10 conditions which devalued self can create a depth of conscious
when present are accompanied by an increase in awareness that possibly expands one's human-
prejudiced personalities: ity. Almost three-quarters of a century later, the
development of ethnic and racial identity
Where the social structure is marked by hetero- theories elucidate the phenomenological process
geneity largely affected by a political history (Ramirez,
Where vertical mobility is permitted 1983, 1997; Root, in press). Allport's (1954)
Where rapid social change is in progress conditions of almost a half century ago work
Where there are ignorance and barriers to com- well in understanding how sociology, politics,
munication and psyche are interdependent. The 10 condi-
Where the size of a minority group is large or tions he outlines shape the social intercourse of
increasing
Where direct competition and realistic threats exist
identity. Identity development will be necessa-
Where exploitation sustains important interests in rily a conscious and more complex status for
the community racial and ethnic others. In this chapter, the
Where customs regulating aggression are favor- biracial or multiracial person who chooses not
able to bigotry to adhere to centuries-old rules of racial
Where traditional justifications for ethnocentrism classification and insists upon simultaneous or
are available blended identities is chosen as the example with
Where neither assimilation nor cultural pluralism which to explore race and ethnicity.
is favored. Differentiating between race and ethnicity
becomes more important at this moment in
If one carries a visible status such as race, its history because of the trend in increasing
socially constructed meaning results in a label- miscegenation and the subsequent, significant
ing process. Visible identities, whether they biracial baby boom. This young, visible cohort,
connote positive meaning or stigmatized status, contests the virulent antimiscegenistic founda-
effect the opportunities we encounter (Goff- tion upon which racial rules for belonging and
man, 1963). The process of incorporating a identification derived and even Stonequist's
stigmatic status requires a personal understand- hypothesized marginality (1964). Furthermore,
ing of human competition, oppression, and recent research using multiracially identified
resilience. When these identities carry stigmatic individuals suggests that race is neither a
statuses, the process by which they are incor- necessary nor sufficient condition for establish-
porated into a positive aspect of self requires ego ing ethnic identity (Hall 1980, 1992; Stephan,
strength, resilience, and a repertoire of coping. 1992). The psychological models guiding and
Thus, identity is a very central concept for capturing racial identity are now dated and
clinical, developmental, and social psychology. limited. Current and future directions must be
The construction of race in the USA is not plotted against the backdrop of a post-civil
unique. Several scholars have elucidated the rights era that has spawned a biracial baby
construction of racial and ethnic others as a boom.
 Introduction 143

10.06.1.1 Race and Ethnicity group membership is based upon behavioral

practices, rituals, customs, and values. How-
Some scholars suggest that the racially mixed ever, because we are such an ethnically diverse
person embodies one of the most tangible society, and ethnicity is centrally defined by the
threats to the current racial order. In order to previous variables and not defined phenotypi-
understand this threat, an historical under- cally, ethnic ambiguity is reduced through using
standing of the derivation of race is necessary. racialized bodies as signifiers of ethnic group
Without this examination, culture and ethnicity membership. Whereas the enactment of ethni-
are misleading euphemisms for a construct city is dynamic over time and generation, race is
laden with centuries of harm. repeatedly enacted within the constricture of
Colonists striving for an economic and laws of hypodescent and, until recently, laws
political stronghold in new lands needed to against miscegenation. Among other purposes,
create a system with which to distinguish these latter laws kept phenotypical signifiers of
themselves from the indigenous people. The group belonging more visible. Given our
construction of race was intrically aligned with country's history of racial tragedy, dialogue
economic systems of expansion. This system about race is avoided through the use of terms
racialized gender and engendered race (Fou- as ethnicity and culture that have come to be
cault, 1978; Stoler, 1995; Zack, 1997b). Whether used interchangeably for race despite their
this be through Dutch, Spanish, British, essential difference.
Japanese, or US colonization, the mechanisms Both ethnicity (Tajfel, 1981) and race (Cross,
have manufactured similar oppressions. Ethno- 1971; Helms, 1990) are salient identities of the
centric interpretations of differences in cultural self that provide a basis for interpreting the
practices are coded through the colonized actions of others and one's internal experiences.
group's bodies (Fanon, 1967; Foucault, 1978; Their similarities are perhaps bound both by the
Stoler, 1995; Young, 1995; Zack, 1997a). sense of reference group or belonging that one
Subsequently, notions of group distinctions psychologically internalizes. One might con-
on moral and behavioral bases are attributed to struct their difference by viewing race as
lineage which eventually becomes accepted constructed by negative forces which subse-
scientific folklore as biological heritability. A quently require connectivity between members
mythology and rationale for oppressive treat- of a disenfranchised group for survival. In
ment of the colonized completes an irrational contrast, the connectivity between people
circle of logic to ensure that the physical derived from ethnicity includes positive experi-
demarcations provide clear markers of insider ences of sharing rituals and customs and
and outsider (Spickard, 1992). Utilizing pater- language on daily basis. When negative forces
nalistic attitudes coupled with the belief in drive definitions of ethnicity from outside the
biological heritability of morality, intelligence, group, such as in anti-semitism, Jewishness is
and civility (Young, 1995), the colonized group also constructed in racial rather than only ethnic
is considered helpless to change its outlook or terms, and the negative connectivity resulting
status, which justifies paternalistic and mis- from race also binds this ethnic group for
sionary interventions introduced with imperial survival.
expansion. Ironically, colonization and physical proxi-
Whereas racial classification systems are mity between different populations inevitably
determined by those in power, those subjects leads to miscegenation of populations (Spick-
disenfranchised by this system often unwittingly ard, 1989; Stoler, 1995; Young, 1995). Initially
internalize it; subsequently, groups agree upon the offspring may have the privileges, but when
assignments between the colonizer and the a critical mass starts to develop, these bodies
colonized. For example, in the USA, hypodes- may become viewed as the enemy within (Stoler,
cent, a system by which a mixed race person is 1995), and this new group is relegated to
assigned to the group with the lowest social another position. This system is challenged
value, is now an agreed upon system. Using an and breaks down when a critical mass of people
extreme example, many black people will insist a refuse to collude with the system. This is the case
person is black even if they grow up with a single with a portion of the contemporary generation
white parent in a predominantly white neigh- of mixed racial heritage. The numbers of people
borhood with little African-American ethnic born out of a biracial baby boom who do not
group knowledge or shared customs, behaviors, wish to participate in conventional societal
or attitudes. racial antagonisms has reached a critical mass.
Weinreich (1986) suggests that ethnicity In summary, race is based upon a delusional
requires internal recognition and affiliation system of hierarchical difference marked by
with the ethnic reference group. Mutual agree- phenotypical differences. Systemically, race is
ment between participant and group regarding not initially an agreed upon system. Assigned by
144 Reconstructing Race, Rethinking Ethnicity

those in power, group acceptance and belonging these positions women and children are often
is based upon recognition and acceptance by the held hostage economically, materially, and
disenfranchised group. Whereas white society psychologically. Their survival and welfare
and groups of color are congruent in their depends on developing a keen sensitivity to
assignments and acceptance of racial group the whims and wishes of the captor or head of
membership, this system breaks down contem- household. Feelings of inferiority, wishes to be
porarily with the refusal of many people of other than female, and devaluing other women
mixed heritage to agree to participate according may follow (Griffin, 1992).
to the rules of the system. With the metaphors of war and the insidious
We must reexamine the assumptions upon psychological violence wreaked by the abuse of
which racial identity has been based as we reach dominance, a healing process is required to
the centennial anniversary of DuBois' observa- establish a constructive sense of self which
tion that the color line would be one of the most affirms the possibility of a positive racial and
significant issues of the twentieth century. We ethnic identity. In the meantime, however, what
must shift our concern at the end of this is the cost to individuals?
millennium to the microcosm of this American Rates of depression, schizophrenia, and stress
dilemmaÐthe individual who embodies multi- reactions have been associated with race and
ple heritages and affirms multiple allegiances. social class which are confounded in this society
What are the psychological implications of this (Dowrenhend & Dowrenhend, 1974). Although
for us as a nation and for individual identity depression and schizophrenia exist across
development (Root, 1996b)? Current data cultures, their rates vary across countries
suggest that the biracial baby boom is accel- suggesting mediation by environmental influ-
erating an unraveling of race as it has been ences. The US literature points to the stress
practiced in the USA for centuries. These caused by self-devaluation by racial system in
changes have implications for psychological terms of obstacles to economic advancement
constructions of race and racial identity through through glass ceilings and limited employment
the dilemas posed by demographic changes. opportunities, and stress caused by living in
unsafe neighborhoods that are also associated
with impoverished levels of income, joblessness,
10.06.1.2 Racial Identity Development as Racial and disillusionment by young people (Wilson,
Healing 1987). Recent literature investigates the rela-
tionship of stress caused by racial position and
Racial identity is necessarily defined in terms impact on mental health such that seeming
of a psychological process of healing from the personality disorders must be viewed in cultural
insidious wounds of racism. In the broadest contexts (Alarcon & Foulks, 1995). Unfortu-
sense, the damage caused by justifying racial nately, the standard reference group unchal-
inferiority of nonwhite people has similar lenged until more recent times has been similar
dynamics to hostage-taking during war. Inter- to the researchers: white, male, and middle to
estingly, Banks' (1988) ethnic identity develop- upper middle class. Clients or students whose
ment theory posits the first stage as ªethnic behaviors or psychological profile differed
psychological captivity.º The tactics of isolation significantly tended to be pathologized or
of the individual or group, deprivation, mono- problematized. For example, a significant body
polizing of perceptions, and brainwashing result of literature exists on the personality problems
in a dependence on the captor, a belief in one's of the person of African-American heritage,
inferiority, and an aspiration to be more like the particularly in the use of the Minnesota Multi-
captor in hopes of survival, or even better phasic Personality Inventory. A debate over the
treatment. intelligence of minority group children, parti-
Furthermore, contemporary literature makes cularly those of African heritage or of bilingual
the case that race and gender are co-constructed backgrounds, resurfaces every 15±20 years
(Zack, 1997a). Lerner (1986) suggest that men of (Hilliard, 1996).
color are constructed in the female gender. The civil rights movement, and legislation
Historically, she makes the case for observing that accompanied it to extend equal rights
that desirable women have been constructed in guaranteed by the US constitution to all people,
the image of children. Paternalistic models of beginning in the 1950s and extending two more
racism also construct people of color and decades, might best mark the beginning of
indigenous people in images and caricatures public awareness of the healing oppressed
of children. persons continued despite prevailing conditions
Similarly, the dynamics of race relations have in which prejudices thrived. Legislation at-
shared similar aspects to the chronic abuse of tempted to correct previous misapplications of
children or women in domestic households. In the US constitution and the Bill of Rights
 Process of Identity Construction 145

through formal desegregation of schools, work- inferior is treated and constructed in less than
places, and neighborhoods. In time, a new body human form. This oppressive process is the
of literature emerged on ethnic and racial process of colonization of a people and
identity, produced primarily by people of color colonization of the mind.
who were now part of a small and growing The body of the individual, through assigned
cohort of scholars. It was no coincidence that social meaning, is stigmatized (Goffman, 1963;
the primary originators of racial identity Young, 1995). In more recent work, Gordon
theories were people who were deeply influ- (1997) uses a philosophical perspective to
enced by the racial pride movements of the suggest that to have a race, in an antiblack
1960s and 1970s, which occurred during their world, is to be assigned the pole of raced, that is,
young adult years. black. To be white is raceless. A similar physical
During this period in history, ethnicity and marker is assigned to gender. To have a gender
race essentially became the same; ethnic is to be female; male is genderless. In contrast,
solidarity meant racial solidarity (Omi & Zack (1993) suggests that the polar opposites on
Winant, 1986). Ironically, notions of ethnic/ race are to have a race (black, white, etc.) and its
racial solidarity invoked an inside±outsider opposite is hybridity. Thus, racial mixing
politic akin to the process outlined for indivi- derived from either system of logic has the
duals in racial identity theories; the oppressed negative valence and has the most significant
person, in an attempt to selvage their racial self- meaning attached to its embodiment. Racial
esteem, separates themselves from the majority mixing also brings in the topic of control of
to seek refuge and absorb the positive aspects of sexuality through privileged positions of bodies,
identifying as a person of color. This period of both raced, and gendered.
refuge may also reflect a hatred of what is white In patriarchal societies the ideal self is
and dominant, accompanied by an uncritical referenced as male, white, able-bodied, and
acceptance of racial group signifiers that one heterosexual. Sociological theories of anomy
idealistically reveres. Phenotypic identification (Durkheim, 1966) and marginality (Stonequist,
by styles of dress and physical appearance take 1964) conclude that to possess other than the
on significant meaning as ethnic markers and ideal and privileged position is to be inherently
symbols of racial pride and solidarity. Thus, a less powerful and more likely to be marginal.
literature emerged on racial identity that was Activists and scholars concerned with the
virtually synonymous with African heritage and impact of colonialism make similar conclusions
ethnicity (Cross, 1971). Simultaneously, within (Fanon, 1967; Friere, 1970). To function in the
the ethnic pride movements of the American other position is to have more obstacles to
Indian Movement (AIM), the Chicano Move- overcome and to have to fight harder to derive a
ment (La Raza), and the Asian American positive self-identity. Erikson's (1968) theory on
Movement, other theorists emerged who fo- the importance of identity and conscious
cused on the meaning and importance of identity process suggests that to be defined as
biculturality (Ramirez, 1983). other will predict at the least a more arduous
task of positive self-identification. (Whereas he
tackles the topic of race he does it also as a
10.06.2 PROCESS OF IDENTITY representative of the times in which he was
CONSTRUCTION produced; gender identity development receives
relatively little attention (Burman, 1994).) The
Human nature observes difference and leads ethnic and racial identity theories that devel-
us to differentiate ourselves at a basic level from oped in the 1970s and 1980s are very much a
ªthe other,º someone different from us on a consequence of this arduous task.
dimension that has meaning. Thus, part of
building self-definition is through contrasting 10.06.2.1 Process of Differentiation
ourselves with the other (Sartre, 1976). This
process of differentiation is initially primitive Deriving a sense of self from contrast with the
rather than complex, casting difference in other begins a process of differentiation (All-
binary, oppositional terms establishing poles port, 1954). Much contemporary literature has
of privilege and disenfranchisement (Zack, focused on the social construction of race and
1993): male, female; white, not-white; able virtually little on the process of differentiation
bodied, disabled; same sex orientation, different that gives rise to meanings assigned to differ-
sex orientation. Gordon (1995) outlines the ences. This process has different paths it can
logic of this transformation as it has been take. Root (in press) notes that the process of
applied to race. A superior group is boundless differentiation can be constructive or destruc-
from constraints and derives its justification tive, which promotes very different cognitive
from the proof of the inferior. In turn, the schemas around differences.
146 Reconstructing Race, Rethinking Ethnicity

Tolerance for ambiguity of meaning and not like Filipinos, not like Africans, but still not
ability to operate fearlessly in the face of have a constructively defined notion of a racial
difference allows one to engage in the process self as a white person, that is, whiteness as the
of constructive differentiation. Tolerance for privileged position is inherently defined as
ambiguity allows the individual to suspend raceless or without stigma. (In the USA, many
stereotyping and to refrain from applying white persons no longer have an ethnic affilia-
conceptual frameworks that do not fit the tion, so that the primary identity is through
situation. Differences may be observed, but white racial status rather than through an ethnic
neither a binary schema nor a valence is identity). Many researchers note that, unlike the
assigned. Thus, the other is observed side by identity process that persons who have been
side with the self rather than in competition or defined as other experience in this country,
opposition. The other does not have to be white persons do not have to think about
inferior. Constructive differentiation observes themselves on a daily basis in terms of their race
difference outside of a hierarchical schema and or ethnic belonging (Frankenburg, 1993; Helms
allows one to expand one's world view, and even & Carter, 1990). Destructive differentiation
possibly find oneself in this difference. The leaves little room for exploration on the very
ability to do this, particularly in light of dimension one might use to expand one's world
observable physical differences, such as by view. The mixed heritage person, socially
color, by gender, or by height, is stifled early located as other, and invisible, but feared and
on by external inputs that impart hierarchical, mistrusted, must struggle to create positive self-
competitive schemas and schemas of opposi- definition in the face of few positively valued
tion. Categorization seems to be an important reference groups or role models.
part of the cognitive process that allows the Destructive differentiation produces an iden-
world to be made simpler. However, categor- tity that is inherently fragile, dependent upon
ization is not necessarily synonymous with maintaining distance from the other, and
hierarchical stratification. It is the step from believing in the inferiority of the other in order
categorization to hierarchicalization which may to maintain a sense of self. Its unresolved
shift the process of understanding difference conflicts regenerate itself; the oppressed may
into destructive differentiation. become the oppressor (identifying with the
Unfortunately, by the age of seven or eight, captor) as a survival strategy, yielding again, a
the process of destructive differentiation around fragile sense of identity. For example, given that
race is well assimilated. Remember the song in this country's racial system is predicated on pure
the 1950s musical, South Pacific set during race, mixed-race people experience gatekeeping
World War II: ªyou've got to be taught/before around racial belonging. Acceptance requires a
it's too late/before you are six, or seven, or eight/ singular belonging. Thus, persons who declare a
to hate all the people your relatives hate.º biracial identity are often put to racial authen-
Underlying such a process is a tendency to ticity tests by other people of color. If they are
interpret the other as threatening and to also of white European origin, centuries-old
subsequently counter anxiety or threat with rules of hypodescent automatically fail them in
negative evaluation. Through a process of white authenticity. Multiple allegiances and
negative stereotyping, threatening differences affiliations of multiracial or multiethnic people
are stratified (Berger, Cohen, & Zelditch, 1966) may be vilified through the process of negative
and stigmatized (Goffman, 1963). differentiation. On another level, women may
Negative differentiation employs parsimo- be more oppressed than dictated by cultural
nious, reductionistic strategies too early. Sub- rules as a means for men who feel oppressed to
sequently, this process yields primitive rather achieve a position of superiority. Unfortu-
than complex understanding, though, complex nately, this yields a fragile self construction.
and convoluted rationalization may develop to This juxtaposition of the inferiorizing of racial
sustain these reductionistic schemas, as has been and gendered identity can provide the basis for
the case in using race as a reductionistic scheme. some racial antagonisms between parents and
Racial epithets are an extreme example of mixed heritage children in some families (Kich,
destructive differentiation. With a few words, an 1992).
overtly hostile act of differentiation relegates the Ironically, political consciousness pertaining
target person to a less desirable position. In this to racial and ethnic identity is a response to
act, the instigator defines themselves as superior negative differentiation in which being the other
in contrast to their target. has simultaneous negative meaning and invisi-
Ultimately, negative differentiation results in bility (Freire, 1970). Hurtado and Gurin (1995)
self-definition by what one is notÐa distancing discuss three interrelated aspects of racial and
from feared association with the other. For ethnic identity that originate out of a process of
example, a person may have ideas that they are negative differentiation for individuals of
 Racial Identity Theories 147

Mexican heritage. These issues are also relevant Although all these models imply some
to other groups of people who may locate process that responds to racial traumatization,
themselves in a multiracial and/or multiethnic some might best be described as typology
context. First, the group is indignant over the models and others as stage models. Helms
lack of power; for example they might protest (1990) summarizes the stages or categories
over lower wages than other ethnic groups in the proposed by each model in the early body of
same work environment performing the same identity models. The models that have had most
work. Second, the group demonstrates that this impact on contemporary thinking about racial
social location and lack of power results in identity are the stage models.
suffering healthwise, economically, and/or edu- These models, particularly the early ones,
cationally. Third, collective action is necessary were developed with little influence from each
to improve the social standing of the group, other. Thus, it is all the more remarkable how
such as strike action by groups of persons who similar they are in process, varying in the
occupy niches of wage work that capitalize on number of stages from four to six. The
their lower status, but are necessary for the assumption is that an individual proceeds
profit of a capitalist society. All three aspects of linearly through the stages with the final stage
this increased political consciousness are di- synonymous with optimum mental health.
rectly implicated in the process of racial Crises, which may be personally defined, are
awareness and the personal meaning of racial the catalysts to rethink one's experience and
identification. assumptions about race and how they fit into
Diminishing denigrating defensive strategies that schema.
is difficult in a society that has colluded and First stages of these models typically suggest
condoned negative stereotyping such as that that the individual is hostage to the prevailing
based on colorism, race, body size, gender, and racial system. Both a racial and ethnic identity
so on. Bennett (1995, p. 36) suggests that model, Banks' (1988) first stage is labeled
confrontation of negative stereotyping or ªethnic psychological captivity,º connotating
denigrating tactics may result in more overt the culmination of destructive differentiation.
protests that are denial defenses. In contrast to In the first stage of these models, the individual
Bennett's suggestion that superiority or grandi- holds the prevailing stereotypes which denigrate
osity is a defense that does not require overt the group to which one is assigned. As a result,
denigration of the group constructed as other, it one may blame the self for plights and
is a stratification defense against fragility. This difficulties, ignoring systemic obstacles and
defense, too, is a form of destructive differ- barriers to success. They may insist that history
entiation through stratification driven by has changed so that opportunities for equitable
anxiety and primitive threat. treatment exist. Thus, they are able to hold a just
world hypotheses view of the world regarding
race: People basically get what they deserve and
10.06.3 RACIAL IDENTITY THEORIES that right behavior is rewarded and the
10.06.3.1 Nigrescence and Minority Racial individual is valued (Janoff-Bulman, 1992).
Identity Stage Model Theories When one encounters a significant challenge
to this perception of the world, their assump-
Numerous theories blend racial and ethnic tions are shattered and they must recreate a new
identity. The most numerous models are found understanding of how the world works.
in the nigrescence models of racial identity A typical second stage in these models
offered by African-American researchers suggests that the individual withdraws into
(Banks, 1988; Cross, 1971; Gay, 1984; Jackson, the black culture to reconstruct their world;
1975; Milliones, 1980; Parham, 1989; Thomas, simultaneously, they may employ negative
1971; Vontress, 1971). Most of these models differentiation by relabeling the binary poles
emerged in the context of working with clients of of opposition. That which is associated with the
African-American heritage in counseling or dominant culture is worthless and reprehensi-
educational settings. In both settings, the stan- ble. The default racial label for dominance is
dard for behavior and mental health used a white and engendered as male. Labels such as
middle-class, white, male reference group similar ªencounter,º ªimmersion,º ªseparation,º and
to the majority of researchers. African-Amer- ªconfrontationº characterize the process at
ican researchers started depathologizing and work in this stage. Typical of the process of
renorming behavior in the social and historical quick change which swings to an opposite pole,
context of healing from the wounds of racism. this stage might be characterized by over-
Significant reviews of this literature have been idealization of the new world view, at times
provided over the course of its development exaggeration of the evils of the dominant world
(Carter, 1995; Cross, 1978; Helms, 1990). view, and exaggeration of the flawlessness of
148 Reconstructing Race, Rethinking Ethnicity

one's racial/ethnic group. The racial pride However, this model as the other racial identity
movements of the 1960s and 1970s typified this models, does not explain the process of identity
stage of ethnic identity. Everything black, development when a multiracial paradigm exists
Chicano, Indian, or Asian was idealized by and other aspects of identity coconstruct
the respective groups. Those aspects of the identity.
culture that may not be positive may be ignored.
Theorists reflected what they observed in the 10.06.3.2 White Racial Identity
process of clients and peers. In order to counter
the abundant negative messages one must Starting in the late 1970s through the 1980s
denigrate the practices and identities associated researchers conceptualized white identity stage
with dominance. Out of this stage emerges a new models (Carney & Kahn, 1984; Ganter, 1977;
basis for an identity that rebuffs the negative Helms, 1984). Again, Helms (1990) provides a
images of self. What has received little attention summary of these models. An identifiable
is that the default gender is black male, or male process of white racial identity formation has
of color. Female gender and the co-constructed been offered, that is, moving from assuming a
process of identity is not addressed. raceless position to acknowledging that white-
With labels such as ªinternalization,º ªpost- ness comes with inherent privileges and power.
encounter,º and ªaffirmation mode,º the next These models suggests that a white person's
stage suggests that one works to be able to linear movement through the stages progresses
internalize positive images of blackness that are towards establishing egalitarian relationships
not necessarily at the expense of denigrating with persons different from oneself. Such an
whiteness or any other group. Thus, negative accomplishment would again require an active
differentiation is less prevalent as an organizing use of constructive differentiation to interpret
strategy. One continues to build pride in one's differences. These models vary between offering
self associated with ethnic and racial heritage. three to six stages. These descriptions of the
Some models originally offered a stage that process through which an individual moves are
suggested it was possible to move towards a not as uniform as the black identity models. The
multicultural position and appreciation of labels are less descriptive in these models, some
diversity (Banks, 1988; Cross, 1971, 1991; preferring to refer to stages as phase or stage 1,
Milliones, 1980; Thomas, 1971). Labeled as 2, 3, and so on.
ªintegration,º ªinternalization±commitment,º Although it is hard to typify the stages across
or ªglobal competency,º individuals in this models, the first and last stages bear similarities
stage attempt to use experience and knowledge across models. The first stage typically captures
to fight oppression around them. Solidarity is the acceptance of the white dominant position in
defined less stereotypically as behaviors; sym- society with an obliviousness to this being a
bols are not used for quick judgments or racial identity. Without acknowledgment of
categorizations of other people. Constructive white racial identity at work, an individual can
differentiation is an organizing schema. This protest the notion that the status quo associated
stage implies a level of healing of rage and anger with white domination economically and poli-
that requires life experience and some luck of tically promotes racismÐor that these white
positive encounters. individuals serve as pawns in the racial
In more recent work and reworking of these machinery governing the social structure of this
models, a last stage seems to be informed by the country.
life stage of the researchers. This stage is one in In the last stage of the models, the individual
which there seems to be a transcendence of the acknowledges the significance of white racial
constrictions of race, while maintaining an identity and accepts responsibility for the losses
awareness that race does make a difference associated with white superiority and domina-
(Atkinson, Morten, & Sue, 1979; Carter, 1995; tion. The individual moves to broaden their
Cross, 1985, 1991). standards and values of reference beyond their
Most of these models exist within a dichot- own. Unlike the nigrescence or minority models,
omous racial framework of white and not white, none of the models reviewed by Helms (1990)
thus, capturing the prevalent racial paradigm suggest that fighting oppression is inherent to
and the prevailing racial politics of the time in transcending the constrictures of race as con-
which they emerged. They assume that the two structed in this country.
major operating rules of race (pure race and The racial identity models, that developed out
hypodescent) abound so that there is a racial of the counseling and educational contexts, have
hierarchy and the races are separate. Atkinson been conceptually linked to mental health: well-
et al. (1979) developed a minority identity model being, beliefs, and behaviors. However, the
to reflect similar process in ethnic identity and empirical testing is just beginning. No con-
racial identity development across groups. clusive data is available.
 Ethnic Identity Models 149

10.06.4 ETHNIC IDENTITY MODELS cultural influences. More recently, Huang

(1994) provides a model for identity formation
Outside the bipolar black±white racial frame- for Asian Americans. Acknowledging the inter-
work, multiracial populations exist which are play between internal and external identities,
primarily defined by ethnicity (e.g., Mexican, she notes that an important aspect of ethnic
Latino, Puerto Rican, Native Hawaiian, Native identity is the degree to which the individual
American, and Filipino) rather than race (e.g., perceives it to have salience in life and the degree
black, white). Although the embodiment of this to which the person's external identity is
ethnicity may be physically blended with non- mediated by the congruence or conflict between
European features, these groups fall outside of their acceptance and belonging to an in group
the most contrasted borders of black±white. and out group. The centrality of a salience
Examination of the process of identity that hierarchy, and the flexibility posed by separat-
occurs for these groups of people is important ing internal from external identities, provides
when considering the question of how race and for a host of profiles of identity which can
ethnicity might be different despite phenotypic accommodate the range of ethnic identity
variation within a population (Ramirez, 1983, outcomes discussed in the literature. Thus,
1997). The ethnic identity models do not her model moves towards a newer wave of
contend with race directly as much as they do multidimensional models.
with cultural difference and shared cultural Oetting and Beauvais (1990±1991) suggest
elements that define an ethnic community. that the precursors to ethnic or cultural
Sociological theories suggest that several identification models stem from Park's (1931)
interactional factors affect ethnic identity: the and his student's, Stonequist's (1964), seminal
individual, the society, and the group to which work on hybridity and marginality, respec-
an immigrant is assigned reactions, positive or tively. Similar to the racial identity models,
negative, and the interaction of these three these ethnic or cultural identification models
social locations (Mittelberg & Waters, 1992). emerge out of attempts to explain problematic
The symbolic interactionist theories highlight behavior in persons who are culturally different
the interaction between the individual or to the dominant reference group, deemed
collective and the environment from the actor's American. They provide a summary of models
point of view (Lal, 1995). These models become that have prevailed from the linear continuum
precursors for multidimensional psychological models to more complex multidimensional
models which emphasize the ecology of the models. Finally, they propose the orthogonal
environment within which the individual acts. cultural identification theory. The dominant
Furthermore, many sociological concepts of majority models suggest movement away from
ethnicity explore which factors influence the the culture of origin to the new. Furthermore,
boundaries of ethnic identity. Within this Anglo culture is good and to be emulated.
framework, certain visible characteristics of Simple transitional models suggest that, in the
an individual restrict options for ethnic identi- process of movement there is inherent stress that
fication, such as race and language facility is always difficult and may result in problematic
(Mittelberg & Waters, 1992; Waters, 1990). behaviors such as drinking. Another form of
Psychological models of ethnic identification transitional model, the alienation model, sug-
introduce concepts of acculturation and assim- gests that in the transition there may be a good
ilation as source of stress, directing the outcome or a bad outcome, depending on coping. Good
of attempts to integrate a bicultural world view coping results in movement towards the adop-
(Olmedo, 1979; Padilla, 1980; Ramirez, 1983, tion of Anglo ways, whereas failed coping
1997). Much of this work emerges from research results in alienation. To some degree these
with youth (Oetting & Beauvais, 1990±1991; models are invoked at various times in the
Padilla, 1980; Phinney, 1989; Ramirez, 1983; research literature or in everyday life explana-
Trimble, 1996, in press). Gurin, Hurtado, and tions for the success and failure of people who
Peng (1994) concluded the macrosocial condi- are originally culturally different from the
tions, such as language dominance, length of dominant, European-derived culture.
residence, geographic dispersal, and the diver- Three multidimensional models are also
sity of work settings, that influenced the summarized, including their own. Multidimen-
opportunities for group contact which in turn sional models allow multiple values to co-exist
influence the formation of social ethnic iden- at different points along the continuum from
tities in Chicanos and Mexicanos in the South- culture of origin to European derived culture.
west and Chicago. Ramirez (1983, 1997) uses Bicultural models are the first models to suggest
the term mestizo(a) as a world view perspective that an individual can be simultaneously
rather than a racial term for bicultural identified with two cultures. Although they
individuals who are capable of blending distinct explain and predict that people who are adept
150 Reconstructing Race, Rethinking Ethnicity

and involved in both cultures become more racial belonging, as centuries-old rules remain
flexible, these models do not generally have unquestioned. The linear nature of the models
explanatory power for the individual who is of nigrescence and minority racial identity
marginal to both cultures, who demonstrates development assume that an individual will
low involvement or identification with both retreat from white society's denigration and
cultures. Lastly, the orthogonal identification refuge in the community of color. However,
model suggests that identification with one biracial people, particularly of European heri-
culture is independent of another. Thus, unlike tage, do not have a guaranteed refuge because of
other models, this one allows for any and all their marginalized status by multiple groups.
combinations of identifications. With other people in this stage of development,
It is important with the multidimensional such as high school and college age peers, they
models not to believe that the bicultural models may not be viewed as authentic members due to
are inferior to the orthogonal models, but to their biracial status, particularly if they are not
examine which model fits which contexts best. willing to denigrate and denounce in an
Ramirez (1983) offers a bicultural model born exaggerated way that which is white. To do
out by research which strongly suggests that this is to potentially denounce part of one's
biculturality does seem to increase some heritage and people one loves (Root, 1990).
cognitive flexibility. In educational settings, Thus, the biracial person may be subjected to
this model may be advantageous (Banks, 1988). racial or ethnic authenticity tests which are
With increasing trends for some populations to charicatures of socially constructed race and
live in two countries, the notions of biculturality ethnicity. Many biracial persons find this
will continue to be reinforced and be a reality for neither a natural nor only process for achieving
many populations of Latino and Asian origin. a positive racial and ethnic identity (Root,
On a process level, Bennett (1995) suggests 1992a, 1996b). Many young adults enact
that the defenses of denial, minimization, multidimensional models of race which are
acceptance, adaptation, and integration are more similar to models of ethnicity. Identities
employed as people move through a process can be dynamic fluctuating in salience contex-
of interethnic and intercultural valuation re- tually and be orthogonal (Duffy, 1978; Hall,
lated to identity. This model is unique in that 1980, 1992; Stephan, 1992; Williams, 1992).
process is discussed in terms of developmental Contextually, the salient identity of someone of
strategies with an emphasis on the role of black and Asian heritage may sometimes be
intrapsychic defenses against inferior status. black, at other times Asian. An orthogonal
experience of identity would be manifested in
the declaration of being both black and Asian.
10.06.4.1 Comparison and Critique of Racial However, despite some of the strengths of
and Ethnic Identity Models applicability of multidimensional models of
ethnicity to mixed heritage individuals, neither
The ethnic identity models have grappled the racial nor ethnic identity development
with reference group orientation multiple models consider other simultaneous influences
alliances, and more recently with the transna- of other salient statuses integral to identity, such
tional identities. Often referred to as a process of as gender or sexual orientation. Huang's (1994)
ethnogenesis, immigrants reformulate their model can acccomodate this through the
identity after entering the USA. This reformula- identity salience hierarchy and the considera-
tion often requires accomodating a new defini- tion that other identities interact and inform
tion of race and being relegated to a minority personal internal identity. Even the diversity of
status. This process is impacted by the way in social economic class orientation, often erro-
which bodies are racially assigned meaning. The neously assumed homogeneous within ethnic
destructive differentiation based on race in the and racial groups, may be critical to the
process of ethnogenesis is illustrated succinctly construction of identity. For example, Singelis,
in a recent study by Mittelberg and Waters Triandis, Bhawuk, and Gelfand (1995) observe
(1992) of identity formation in two immigrant that individualism and collectivism vary cross-
groups: middle-class Haitians and secular culturally within a culture according to class:
kibbutz-born Israelis. The authors observe, wealthy and impoverished classes are much
unsurprisingly, that the Israelis have fewer more individualistic than middle classes. Thus,
constraints in reformulating their identities than class location may affect value systems as much
do Haitians, because of the primacy of the or more man race; class and race are often
meaning of blackness as a race in this country. confounded.
The racial identity models seem the more Stage models of racial identity do not explain
limited in contemporary context because they the fluidity of exchange of different aspects of
are still embedded in an undimensional model of identity between background and foreground,
 Rethinking Race and Ethnicity 151

such as gender and race, race and class and latitude to cross racial boundaries in friendship
gender, sexual orientation and race. These and intimacy. Technological advances in trans-
models assume to some degree that either portation and communication have increased
gender has negligible effect orÐconsistent with the numbers of persons involved in interna-
much research of the timeÐdid not critically tional and cross-cultural marriages. Again, we
assess how gender informs and shapes life can expect that the products of these unions will
experience and worldview. Notably, most of have the options to be multiethnically, multi-
these researchers being male did not have access racially, and even multinationally identified.
to the gendered experience of femaleness and its This forecast necessitates that we rethink the
secondary status within their ethnic and racial meaning of race and ethnicity and their
groups. Also with a more privileged gendered relationship.
status, they were not as compelled to consider Consider these demographic trends (Root,
simultaneously the role of female experience as 1996b). Since the repeal of antimiscegenation
a female researcher might be. laws in 1967, the rates of racial intermarriage
It is also very likely that the models which have almost doubled with each subsequent
prevail have been implicity generation specific; decade. The number of babies of mixed racial
it was no coincidence that early racial and ethnic heritage has boomed since the late 1980s. Also,
identity models emerged out of the movements the number of persons writing in racial
of the 1960s and 1970s. However, the con- identifiers to elaborate on the other choice
temporary generation of teenagers and adults has caused the US Bureau of the Census enough
have inherited many of the benefits of the civil concern to entertain a multiracial way of
rights movement of the third quarter of this identifying for the year 2000 census. In July
century. Subsequently, they have not experi- 1997, the Office of Management and Budget
enced the extremes of racial injustice experi- which oversees the Bureau of the Census
enced by persons a generation or more before decided after much research that the year
them. There is also a large segment of the Asian 2000 decennial census will allow people to mark
American community who is adjusting to the more than one box in response to the race
social construction of race in the USA, having question. This is an historical change in the
moved from racially homogenous cultures to a accounting of population in the USA.
racially diverse society that stratifies according Whereas the folklore sustaining racial bound-
to race. Many of these immigrants are learning aries has purported that racially mixed people
to identify the racism that blocks their oppor- will be marginally located and accepted in
tunities or explains the differential treatment society, this marginality is being explored and
they receive. challenged in the academic literature (Anzal-
When primary identities are without signifi- dua, 1987; Root, 1992, 1996a; Zack, 1993;
cant ties and markers specific to ethnicity, more 1995), literary essays (Funderburg, 1994; Jones,
fragile identities are constructed through race 1994), novels, and mainstream cinema. The
For example, consider the genre of US movies social location of an increasing number of
and trade books that describe someone who is multiracially and multiethnically identified
white discovering they have a black ancestor and people is often positively constructed, in
consider the deep emotional reaction someone contemporary time and particular on the west
has to this revelation. Why should this be such coast of the USA.
an unravelling experience if one already knows More than ever, current research on ethnicity
who one is? Such reactions suggest that the and race suggests that we must attempt to
primary identity occurs through race and disengage these constructs so that, although at
whiteness rather than through ethnicity. times they admittedly remain confounded, they
are not synonymous. For example, Stephan's
(1992) research in Hawaii and New Mexico
10.06.5 RETHINKING RACE AND points out geographic differences in how race
ETHNICITY and parents' ethnicity effects the identification
of multiracial Asians and multiracial Mexican
Both race and ethnicity are socially con- American young adults. Her conclusion is that
structed. Thus, they are dynamic and influenced race is neither a necessary nor sufficient
by many factors including history, gender, and condition for making an assumption about
other aspects of identity that are socially salient ethnic identification. She found that when
and specific to the macro- and microsocial offered an open ended response option to
compositions of regions or neighborhoods and ethnicity in different situations, few respondents
ethnic group histories. With the legacy of civil identified themselves consistently across all
rights legislation in the third quarter of this situations. The conclusion was that identity
century, many young people grow up with more has contextually constructed Hall (1980) found
152 Reconstructing Race, Rethinking Ethnicity

that neither self-assessed phenotypical resem- different outcomes of identity for both mono-
blance to either black or Japanese reference racially and multiracially identified people from
groups or language facility predicted ethnic very fragile identities to well-grounded and
identity in her black Japanese sample. stable identities. It also accomodates some
The person of mixed heritage experiences previous work which states that identity is
many of the psychological assaults and injuries indeed dynamic and can change over a lifetime
that their generation cohort of people of color due to changing contexts and developmental
experience. Furthermore, many assaults and issues over the lifespan (Root, 1990, in press).
insults stem from and are specifically directed to However, unlike the stage models which may
their racial ambiguity. These assaults come from reflect an underlying linear process, this change
groups of people with whom the biracial person of identity does not necessarily invoke a linear
shares heritage and identifies. Table 1 provides a movement. Social identities are informed by the
summary of 40 racial experiences commonly interaction of micro and macro influences on
experienced by many persons whose racial identity. This model breaks away from the long-
classification is ambiguous or interpreted by standing constraints of bipolar racial frame-
others as mixed. Experienced repeatedly works and assumed rules of hypodescent. In line
throughout a lifetime, these items potentially with the symbolic interactionist theories and
influence one's understanding of race relations, models, this one proposes reflexive interaction
race rules, and racial identity. Inherent to this between variables.
inventory is the negative stereotyping of mixed In the proposed model, all boxes are lenses
race, boundary policing of authentic racial and are present to some degree. The drawing
behavior, physical objectification of phenotype, serves as a conceptual organizing tool with
and denigration of whiteness. Therapists, tea- which to consider influences in identity. The
chers, and school counselors might use such a list lenses recognize individual factors, familial
to provoke discussion. Therapists might further factors, community influencesÐboth imagined
use such an inventory to generate discussion and factual such as historical influence and
about coping, identity formation, and psycho- experience that transcends generations.
logical defenses against exclusion, authenticity Through these lenses, the inherited influences,
testing, denigration, and idealizing that the traits, and social interactions with community
person of mixed heritage may experience. determine identity development. The inherited
influences include biological and environmental
inheritance. Biological inheritance, such as
10.06.6 CONTEMPORARY MODELS FOR sexual orientation and phenotype, significantly
RETHINKING THE influence life. The other inherited influential
RELATIONSHIP BETWEEN RACE lenses are environmental: languages spoken at
AND ETHNICITY home; parent's identification ethnically, ra-
cially, and nationally; nativity; presence and
Current trends to reformulate racial forma-
socialization influence of extended family; given
tion or ethnogenesis should not ignore the
names and nicknames; and home values. All of
conceptual and empirical information gleaned
these variables have been documented in
from earlier research. However, current trends
different literatures as having influence on
necessitate that we move beyond bipolar
identity. All the environmental influences
conceptualizations of race, reexamine assump-
provide cultural markers to a lesser or greater
tions about racial identity formation, and
degree of distinctiveness. The lenses with
differentiate race and ethnicity. Contextual
inherited influences interact with one another.
spheres of influence from large macrodimen-
These inherited influences interact with traits:
sions of geographic region to microdimensions
temperament, social skills, talents, and coping
of family interaction and personality must be
skills. These influences may have both elements
considered in identity formation.
of nature and nurture. The traits are some of
those aspects of the individual that together are
10.06.6.1 Ecological Model of Race and often summarized as personality. The traits are
Ethnicity differentiated from inherited influences through
what the individual has control over. This model
Figure 1 represents an ecological identity assumes the individual has little control over
model of influences on identity development. It their inherited influences, whether they be
evolved out of observing the identity process biological or environmental. In contrast, the
and differential outcomes for persons of multi- traits, are deemed to be majorly subject to social
racial ancestry, often of multiethnic back- influence and learning, even when there may be
ground, in both clinical and nonclinical different degrees of natural talents, coping,
settings. The model can accommodate several sociability and its skills, and even temperament.
 Contemporary Models for Rethinking the Relationship between Race and Ethnicity 153

Table 1 Items from the racial experiences questionnaire.

1. Told, ªYou have to choose; you can't be bothº

2. Your ethnicity misidentified
3. People assume your race to be different by phone and in person
4. Accused of not acting or wanting to be . . . (Latino, black, Asian, etc.)
5. Told, ªMixed race people are so beautiful/handsomeº
6. Strangers look between you and your parent(s) to figure out if you are related
7. Told, ªYou don't look . . . (Asian, black, native, etc.)º
8. Asked, ªWhat are you?º
9. People might not say certain things in front of you if they knew how you think about race
10. Asked, ªWhere are you from?º
11. Stared or looked at by strangers
12. Told, ªYou look exoticº
13. Your choice of friends is interpreted as your selling out or not being authentic
14. Accused of acting or wanting to be white
15. Judgments of your racial authenticity are based upon your partner's race
16. Comments are made about your physical attributes (hair/hairstyle, skin color, eyes, shape,
etc.)
17. You are subjected to jokes about people of mixed heritage
18. Told, ªYou think you're too good for your own kindº
19. Grandparent(s) or relatives don't accept you because of your parents' interracial relationship
20. Your parents/relatives compete to claim you for their own racial or ethnic group
21. Told, ªYou have the best of both worldsº
22. Asked about your racial heritage
23. Upon meeting you, people seem confused by your name(s)
24. People assume you are confused about your racial identity
25. People speak to you in foreign languages because of how they intepret your physical
appearance
26. Told, ªSociety doesn't recognize mixed raceº
27. Told, ªyou aren't really . . . (Asian, black, Hispanic/Latino, native, etc.)º
28. Mistaken for another person of mixed heritage who does not resemble you
29. Told you must be full of self-loathing or hatred because of how you racially identify yourself
30. Told, ªYou are a mistakeº
31. People's racial identification of you varies and is colored by the race of the people you are with
32. The race people assume you are varies in different parts of the USA
33. You have difficulty filling out forms requiring you to check one race only
34. You identify your race differently to how others identify your race
35. Told, ªYou aren't like other . . . (blacks, Latinos, native Americans, Asians, etc.)º
36. Your siblings identify their race differently than you identify yours
37. Called racial slurs of groups who aren't part of your heritage
38. When friends suggest dating partners for you, they stick within a single racial or ethnic group
39. Your parents identify your race differently than you identify yourself
40. Told, ªYou aren't . . . (native, Asian, black, Latino, etc.) enoughº

These interactions takes place in contexts. multiracially or multiethnically identified, a

Such interpersonal contexts allow for the community to which they are a stranger may
communications about rules of belonging provide them with feedback that affects how
whether it be to the outgroup or ingroup. they experience themselves in relationship to
Reflections of who we are outside of our othersÐand it may be different to what they are
families serves as frame for further reconciling used to. The most dramatic stories emerge from
the private and public experience of identity. recent biographical stories of persons raised
For most of us, five social contexts encapsulate white who change living situation or state and
most of our social interactions: home; school then, though phenotypically white, must as-
and/or work; community groups; friendships, sume the life of a black person (Williams, 1995).
and communities in which we are strangers. Lastly, the summation of this interactive life
This last social context is important because it experience filtered through the interaction of
may challenge an individual's construction of the different lenses posed by inherited influ-
self when community environments differ from ences, traits, and social contexts helps us
one another or a person's identity is in some way understand identityÐboth ethnic and racial
ambiguous. In the case of phenotypically identity in the context of history and gender.
ambiguous people, whether or not they are These identities, in turn, provide a lens through
154 Reconstructing Race, Rethinking Ethnicity

Gender

Regional history of race relations

Class

Generation

Social
interactions
Inherited with
influences Traits community

Languages Tempera-
Home
at home ment

Parent’s Social School/

Identity
identity skills work

Nativity Talents Community Racial

Extended Coping
Friends Ethnic
family skills

Outside your
Names
community

Home
values

Sexual
orientation

Phenotype

Figure 1 Ecological identity model; all boxes are interactive.

 Clinical Implications 155

which life is experienced. As one moves through race based on attitudes (Root, 1996b). There
milestones in one's life course, racial and ethnic will be points at which the experiences of each of
identity can influence what is passed on as these groups will overlap. However, if the
inherited influences to the next generation. gender lens is more prominent, an African-
This model suggests that the sociohistorical American woman may share more in common
construction of gender and race are lenses in a given context with a Chicana than with an
through which most of our life experiences are African-American man. For example, the threat
filtered. However, the construction and con- to one's body through sexual violence is an
notations of race and gender are also informed experience shared by women and much less so
by geographical regional context and the by men. The lense of historical race relations
historical generational cohort. These additional suggest that women of color have been less
filters allow us to understand how race and protected by the legal system in matters of
gender have been constructed through para- violations of their body, whether it be child
digms of domination and submission (Lerner, abuse, domestic violence, or rape.
1986; Stoler, 1995; Zack, 1997b). Patriarchal This model can accommodate the process
and imperialistically driven cultures construct described in racial identity development models
racial and ethnic hierarchies with imperialist or described earlier in this chapter. However, it
the colonial schemes (Freire, 1970; Stoler, 1995; does not predict or require that an individual
Young, 1995). Therefore, in this model gender will go through the first stage of negative
and ultimately racial identity are viewed as feelings about their minority racial or ethnic
lenses that are layered upon one another. These group; it can accomodate such a process,
two lenses interact dynamically, exchanging though. This is important because in contem-
salience in relationship to one another as porary times, perhaps due to some of the
foreground or background filters. This con- benefits of the civil right movement, many
ceptual relationship also explains why some young people do not feel badly about their
persons assert that gender is the primary ethnic or racial reference group which society
organizing factor in life experience, whereas ascribes to them.
others assert that race is the primary organizing The ecological identity model also accom-
factor in life. However, at all times there is an modates typology models. It evolved from an
interaction as described above that makes it earlier work (Root, 1990) in which types of
certain that the social address of men and identity were proposed for multiracial people.
women differ when we filter their location The process by which people might get to those
through the lenses of gender and race. identities is subsumed in this model. Thus, it is
Other secondary statuses are significant possible to change identity over time, and
dimensions or lenses through which life is sometimes this move is simply precipitated by a
experienced, for example, class and sexual geographic move, such as from mainland USA
orientation. Both of these locations may be to Hawaii where a multiracial and multiethnic
accompanied by denigrating and oppressive or identity is the norm. It also provides an
affirming reflections of self. Again, psycholo- increased number of variables with explanatory
gical defenses and coping skills are necessary to power for differences in identity absent in other
be able to incorporate these aspects of experi- racial identity models.
ence, and ultimately identity into the larger
concept of self.
Likewise, racial and ethnic experience in this 10.06.7 CLINICAL IMPLICATIONS
country, by region, yield different experiences
between two individuals despite the similarity of The ecological identity model may be useful in
a host of other life variables. For example, the clinical settings. It acknowledges trauma which
rates of intermarriage between whites and in fact determines some of the salient lenses
blacks is very different in the south compared through which one experiences life (Root, 1992).
to the west. The histories of these regions are If a patient has been sexually violated because
also very different. The prominence of lynchings she is female, and links her suffering to this
of black men who dared to interact or even look status, the lens of gender will be prominent. If life
at white women is well documented in the south, chances have been compromised by skin color,
particularly prior to this century. Through the and this link has been made, the lens of race will
lens of race, the socially constructed groups in operate prominently. But both lenses will
the USA are Asian and Pacific Islander interact. Therapists and counselors can under-
American, American Indian, African-Ameri- stand the possibility and impact of transgenera-
can, and white. Whereas persons of Hispanic tional trauma as part of inherited influence:
origin may be any race, this country's history of stories of genocide, slavery, incarceration,
race relations has constituted this category as a colonization, and domination imparted from
156 Reconstructing Race, Rethinking Ethnicity

an early age are part of a parent's or relative's Rejection is captured by items such as, ªYou
identity. The stories may be passed on in the are a mistake,º ªGrandparents or relatives don't
inherited influences of names and family inter- accept you because of your parents' interracial
actions within the community. Parenting is relationship,º and ªTold society doesn't recog-
extremely important in the passing on of both nize mixed race.º It also encompasses the
coping with a secondary status and the forma- accusations of passing into a dominant desired
tion and interpretation of both racial and ethnic group with statements such as ªYou think
identity. you're to good for your own kind,º ªEthnicity
Kich (1992) provides one of the best clinical misidentified,º or ªAccused of acting white.º
explanations of the processes and outcomes that Ironically, because of the past history of racially
the biracial person may experience through his mixed people passing into a desired group group
three stages. One of his most significant because their phenotype allowed this, many
contributions is that his model provides for racially mixed persons are struggling for
an understanding of how internal family acceptance from an ethnic group or racial
dynamics may interact with lessons around group of their heritage because their phenotype
race and ethnicity. Given that society stratifies creates suspicion about their intent to belong
race, this hierarchy may be replicated in family and their trustworthiness.
dynamics. A child may develop a distance and Marginalization relates to rejection through
ambivalent relationship with the parent of color authenticity tests and applications of rigid
if emotional denigration or the process of boundaries. Cues for this experience may occur
destructive differentiation occurs around cul- with statements such as, ªYou have to choose,
tural differences. you can't be bothº or ªTold you must be full of
The model has implications for different self-loathing or hatred because of how you
developmental periods that can be further racially identifyº or ªYour racial authenticity is
elucidated by the ecological framework sug- based upon your partner's race.º
gested in this chapter. For example, if the parent Much societal anxiety about race is projected
with higher racial or ethnic status denigrates the onto the mixed race person who refuses to
other parent, a child may feel simultaneously comply with the implicit rules of race which
victimized or denigrated. Simultaneously, if this guide daily interactions. This anxiety manifests
child feels helpless to help, she or he may in questions and statements such as, ªAsked
develop an acute awareness of self which is akin about your racial heritage,º ªAsked what are
to the vigilance typical of post-traumatic you?º and ªAccused of not wanting to be
responding. Several aspects of his or her Latino/black/Asian, etc.º
existence may serve as subsequent environmen- Objectification encompasses the deindividua-
tal cues which trigger vigilance in certain lization and sexualization projected onto race
settings. For those children who have been and gender and their interaction. Such a process
raised in psychologically or emotionally deni- sets the stage for cruel treatment and relegating
grating households, the statements, questions, persons of mixed heritage to otherwise invisi-
and experiences in Table 1 may all serve as cues bility. Experiences such as being ªtold you look
leading to experiences of marginalization and exoticº and ªstared or looked at by strangersº
rejection. signal this process.
Therapists and clinicians may want to explore In increasing attempts at individuation,
how these experiences have had impact on a particularly during adolescence in western
person at different stages in their life, and how cultures, anger at the parent with perceived
their coping deflects or defends against society's lower status may be a dysfunctional attempt to
unresolved anger stemming from the conse- attempt to avoid taking on the denigrated
quences of the racial system. In this system status. Also of this racial group, the adolescent
anger and anxiety is projected onto the body of is caught in a cycle of anger or even hate that
the mixed-race person and subsequently creates precludes them from realistic affirmation of
a gestalt of experience unique to the mixed-race their whole self. Whereas adolescence in the
individual's experience. Major themes are USA is replete with anger, racial dynamics and
rejection, marginalization, societal anxiety, gender dynamics may become entwined in a
and objectification as represented by the items way that makes it very difficult for a child to
of Table 1. These experiences may be specific to cope and determine psychologically adaptive
certain social environments which feed into ways of responding that may serve them into
definition of self through acceptance and adulthood. For example, if a white father
rejection experiences which also seem critical repeatedly denigrates an Asian mother, not
to ethnic identity of racially mixed people (Hall, only does this set up the possible dynamics
1992; Root, 1990; Stephan, 1992). Each of these above, it may perpetuate misogyny and
themes is explained below. denigration of female status, particularly
 Summary 157

women of color, and set up an idealization of 10.06.8 FUTURE DIRECTIONS:

white women. RETHINKING RACE AND
The status of parents' relationship to one ETHNICITY
another and society may also be formative in
identity. Stephan (1992) discusses the possible There are several factors driving the need for
influence of the gender of parents in patriarch- a reexamination of how we think about race and
ally organized societies as it may differentially ethnicity. Unless we rethink race, the process of
influence identity formation in Hawaii versus differentiation between ourselves and those who
New Mexico. Results from her study suggest look different from us will often times be a
that for persons of mixed heritage, having an destructive process of differentiation driven by
Hispanic father in New Mexico may be more of unresolved conflicts and fraught with stigmatiz-
a determining factor in New Mexico, where ing of bodies we have inherited from this
such status is lower than having a Japanese country's history of race relations. Unless we
American father in Hawaii, where Japanese reopen the dialogueÐand a new one that
Americans have relatively high social status. considers a contemporary meaning for mixed
Kich (1982, 1992) further suggests that the raceÐwe may not be able to understand
absence of a parent and how that absence occurs contemporary ethnicity in America. Without
and is explained may be very critical to how race separating the concepts of ethnicity and race,
is interpreted in the family. More recently, with dialogues will remain confused as discomfort
high rates of divorce, increasing attention is with the construct of race, can be evaded by
paid to white single parenting of mixed heritage changing the dialogue to one that shifts
children so that they can defend themselves in a emphasis to the other construct of ethnicity,
society that has been antimiscegenistic and despite the negative differentiating driving the
anxious about their existence. Similarly, chil- construct.
dren of single parents of color must also be Likely the racial identity models of the 1970s
aware of the intense discrimination towards and 1980s were necessary to understand and be
racially mixed people that may occur in some able to educate people oppressed by the racial
closed communities of color. McRoy and Hall's system in a way that promoted healing. We are
(1996) clinical work on transracial adoption is now challenged to see if we can undertake a next
applicable here. They essentially point out that step in healing. Can we develop models that
basic needs of a child must be met even before allows us to explore the fluidity of identity in the
the tasks of racial defense are relevant, that is, a social contexts of current and past historical
child must feel loved and secure. moments?
Root (1994) identifies the issues in therapy for
mixed race women, although most of the issues
are applicable to men. Whereas few people enter 10.06.9 SUMMARY
therapy to work on their mixed racial heritage,
the experiences society has dealt around this A biracial baby boom became possible with
status can manifest in issues around self- the repeal of the last antimiscegenation laws in
definition, acceptance and belonging, interpre- the USA in 1967, changes in immigration laws,
tations of power, sources of self-esteem, and and global mobility of people and populations.
independence. Changes in the psychology of race and ethnicity
Gibbs and Hines (1992) suggest that adoles- in this last part of the century are integrally
cent biracial identity resolution revolves around linked to these demographic changes. Never-
several developmental questions: Who am I? theless, the 10 conditions Allport (1954)
Where do I fit? What is my social role? Who is in hypothesized correlate with prejudicial attitudes
charge of my life? Where am I going? These still exist. A more critical understanding of how
questions are windows into several areas of racial politics derive from a process of negative
developmental conflicts including, racial/ethnic rather than constructive differentiation is high-
identity, social marginality, sexuality, autono- lighted by examining the current experience,
my and independence, and education and career identity process, and social location of the
aspirations. Bradshaw (1992) cautions thera- person of mixed racial heritage. An ecological
pists to take the time to understand the framework for thinking about the different
contemporary multiracial experience to con- outcomes of racial identity is presented. Gender,
textualize the acute and at times everpresent geographical history, class, and generation are
self-consciousness present in people's lives. significant, dynamic lenses which filter many life
Lastly, Root (1994) cautions therapists not to experiences which have not been put forth in
assume that being of mixed heritage is an previous racial identity models. The ecological
unresolved issue for persons coming into identity model can accomodate the processes
therapy. proposed by past identity models. However, it
158 Reconstructing Race, Rethinking Ethnicity

accomodates increasingly more common iden- and cultural influences on psychopathology. Annual
tity development processes that do not involve Review of Psychology, 25, 417±452.
DuBois, W. E. B. (1903, 1989). The souls of Black folks.
traumagenic experiences despite prevailing New York: Bantam.
conditions towards prejudicial attitudes. Psy- Duffy, L. K. (1978). The interracial individuals: Self-
chological processes in resolution and integra- concept, parental interaction, and ethnic identity.
tion of a multiracial location and identity are Unpublished master's thesis, University of Hawaii,
Honolulu.
discussed in this chapter with cautions that Durkheim, E. (1966, c1951). Suicide: A study in sociology.
therapists should not assume that a multiracial (Translated by John A. Spaulding and George Simpson.)
identity is inherently problematic. For many New York: Free Press.
young people, the work of the generation before Erikson, E. (1968). Race and the wider identity. In E. H.
has allowed them to open a different dialogue on Erikson, Identity, youth and crisis. New York: Norton.
Fanon, F. (1967). Black skin: White masks. New York:
race. This is a challenge to society and to Grove Press.
therapists trying to understand the process by Foucault, M. (1978). The history of sexuality: An introduc-
which these people negotiate their daily lives. tion. New York: Random House.
Frankenberg, R. (1993). The social construction of white-
ness: White women, race matters. Minneapolis, MN:
University of Minnesota Press.
Friere, P. (1970). Pedagogy of the oppressed. New York:
10.06.10 REFERENCES Seabury.
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Diversity and Mental Health, 1, 3±17. William Morrow.
Allport, G. W. (1954). The nature of prejudice. Reading, Ganter, G. (1977). The socio-conditions of the White
MA: Addison-Wesley. practitioner: New perspectives. Journal of Contemporary
Anzaldua, G. (1987). Borderlands/La Frontera: The New Psychotherapy, 9(1), 26±32.
Mestiza. San Francisco: Spinsters/Aunt Lute. Gay, G. (1984). Implications of selected models of ethnic
Atkinson, D. R., Morten, G., & Sue, D. W. (Eds.) (1979). identity development for educators. The Journal of Negro
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Banks, J. A. (1988). The stages of ethnicity: Implications identity: Issues for black±white biracial adolescents. In
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Allyn & Bacon. Goffman, E. (1963). Stigma: Notes on the management of
Bennett, M. J. (1995). A developmental model of inter- spoiled identity. Englewood Cliffs, NJ: Prentice-Hall.
cultural sensitivity. In R. M. Paige (Ed.), Education for Gordon, L. R. (1995). Critical ªMixed Raceº? Social
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DC: Intercultural Press. Gordon. L. R. (1997). Race, sex, and matrices of desire in
Berger, J., Cohen, B. P., & Zelditch, M. J. (1966). Status an antiblack world: An essay in phenomenology and
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Bradshaw, C. K. (1992). Beauty and the beast: On racial Griffin, S. (1992). A chorus of stones: The private life of war.
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people in America (pp. 77±90). Thousand Oaks, CA: Gurin, P., Hurtado, A., & Peng, T. (1994). Group contacts
Sage. and ethnicity in the social identities of Mexicanos and
Burman, E. (1994). Deconstructing developmental psychol- Chicanos. Personality and Social Psychology Bulletin,
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Carney, C. G., & Kahn, K. B. (1984). Building compe- Hall, C. C. I. (1980). The ethnic of racially mixed people: A
tencies for effective cross-cultural counseling: A devel- study of Black-Japanese. Unpublished doctoral disserta-
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111±119. Hall, C. C. I. (1992). Please choose one: Ethnic identity
Carter, R. T. (1995). The influence of race and racial identity choices for biracial individuals. In M. P. P. Root (Ed.),
in psychotherapy: Toward a racially inclusive model. New Racially mixed people in America (pp. 250±264). Thou-
York: Wiley. sand Oaks, CA: Sage.
Cross, W. E., Jr. (1971). The Negro-to-Black conversion Helms, J. E. (1984). Toward a theoretical explanation of
experience: Toward a psychology of Black liberation. the effects of race on counseling: A black and white
Black World, 20 (9), 13±27. model. The Counseling Psychologist, 12(4), 153±165.
Cross, W. E., Jr. (1978). Models of psychological nigres- Helms, J. E. (1990). An overview of Black racial identity
cence: A literature review. Journal of Black Psychology, theory. In J. E. Helms (Ed.), Black and White racial
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Cross, W. E., Jr. (1985). Black identity: Rediscovering the York: Greenwood Press.
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group orientation. In M. Spencer, G. Brookins, & W. White Racial Identity Inventory. In J. E. Helms (Ed.),
Allen (Eds.), Beginnings: The social and affective devel- Black and White racial identity: Theory, research, and
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Erlbaum. Hilliard, A. G., III (1996). Either a paradigm shift or no
Cross, W. E., Jr. (1991). Shades of black: Diversity in mental measurement: The nonscience and the nonsense
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 Copyright © 1998 Elsevier Science Ltd. All rights reserved.

10.07
The Psychology of Gender and
Health
RICHARD M. EISLER
Virginia Polytechnic Institute and State University, Blacksburg,
VA, USA

10.07.1 INTRODUCTION 161

10.07.2 GENDER AND EPIDEMIOLOGY OF HEALTH PROBLEMS 162
10.07.3 HISTORICAL PERSPECTIVE ON GENDER DIFFERENCES 163
10.07.4 THEORETICAL OVERVIEW OF GENDER DIFFERENCES 164
10.07.4.1 Biological Perspective 164
10.07.4.2 Social Psychological Perspective 165
10.07.4.3 Cross-cultural Perspective 165
10.07.4.4 Summary of Gender and Health Perspectives 166
10.07.5 THE ROLE OF PSYCHOLOGICAL STRESS IN WOMENS' AND MENS' HEALTH 166
10.07.5.1 Gender and Biological Vulnerability to Stress 166
10.07.5.2 Gender and Cognitive Vulnerability to Stress 167
10.07.5.3 Gender Role Stress 167
10.07.5.4 Gender Roles and Coping with Stress 168
10.07.6 GENDER DIFFERENCES IN SELF-DISCLOSURE AND HELP SEEKING 168
10.07.6.1 Gender and Emotional Expression 169
10.07.6.2 Gender and Social Support 169
10.07.6.3 Gender and Help Seeking 170
10.07.7 FUTURE DIRECTIONS 170
10.07.8 SUMMARY 171
10.07.9 REFERENCES 171

10.07.1 INTRODUCTION model biochemical problems caused by faulty

organs or infectious agents resulted in illness.
Why is it important for a discourse on the The biomedical model served us well 100 years
psychology of health to focus on gender issues? ago, when the leading causes of death were
Most importantly, there has been a shift in the tuberculosis, pneumonia, and influenza. The
conception of healthcare practices over the past leading causes of death today, however, such as
few decades from the biomedical model to the cardiovascular disease and lung cancer, have
biopsychosocial model. The biomedical model psychosocial etiologies that may be more
had limited the assessment and treatment of comprehensively evaluated and treated by
disease to the biological components of organs, understanding cultural risk factors, including
biochemicals, and infectious agents. In this gender determinants.

161
162 The Psychology of Gender and Health

In the current biopsychosocial model of with diseases that they consider to be most
health, biological disease processes are ac- prevalent in men, such as heart disease.
knowledged, but psychosocial factors that Thus, we may conclude that there are very
predispose one to illness are strongly empha- significant reasons for including gender in
sized. The psychosocial components encompass studying the psychology of health. More than
engaging in high-risk behaviors, appraising and half of the mortality from the 10 leading causes
coping with stress, utilizing social support of death may be traced to lifestyle risk factors on
systems, and the seeking of appropriate help which women and men differ significantly
from the healthcare system. In all the afore- (Verbrugge, 1989). Divergent gender roles
mentioned psychosocial areas, recent research produce large variations in exposure to and
has shown that there are important sex or coping with stress, which result in different
gender distinctions, the evaluation of which is vulnerabilities to various disorders. Also, men
crucial for the prevention of illness and the and women have different values regarding the
maintenance of health. These psychosocial importance of social support and preventive
issues are the focus of this chapter. healthcare practices. Finally, existing research
It has been evident that many health protocols have primarily been designed to assess
problems occur with different frequencies the causes of health problems in white males. It
among men and women. Paradoxically, while is clear that this is inadequate for understanding
women are more likely than men to have most of treatment issues for women and other cultural
the nonfatal chronic illnesses and acute medical groups.
conditions, more men than women die of each of It is instructive to note here that the current
the 12 leading causes of death (Wingard, 1984). convention is to use the term ªsexº when
There are also important differences in the types referring to reliable biological distinctions
of stress to which each gender is subjected. For between males and females. Sex refers to
example, research has shown that working biological characteristics including chromo-
women have greater gender role stresses than some pattern, and genital structure. However,
working men, in that they have to manage both ªgenderº is the term preferred by psychologists
family and work roles (Frankenhaeuser, Lund- to denote the idea that men and women are
berg, & Chesney, 1991). Further, it appears that socialized to display ªmasculineº and ªfemi-
marriage itself contributes differentially to the nineº characteristics and behavior patterns. The
health of women as contrasted to men. Married term sex will be used henceforth to denote the
men report lower rates of mental and physical biological aspects of individuals, and gender will
health problems than single men. Married be used to refer to the socially constructed roles
women, on the other hand, report higher rates deemed socially appropriate for either men or
of mental health problems than single women. women.
Finally, women are far more vulnerable to
sexual and physical abuse than men in their
intimate relationships (Koss et al., 1994). 10.07.2 GENDER AND EPIDEMIOLOGY
Another gender-related health issue is the OF HEALTH PROBLEMS
frequency and quality of each sex's interaction
with the professional healthcare system. Across Recent epidemiological data on the associa-
most age categories men have a lower frequency tion between gender and health have documen-
of physician office visits than women, and less ted gender differences in ªpremature mortalityº
than a third as many visits to a mental health based on more hazardous lifestyles and beha-
professional. Pennebaker (1982) theorized that vior patterns engaged in by men compared to
underutilization of the healthcare system by women (Harrison, Chin, & Ficarrotto, 1989). In
men compared to women may be the result of the USA, women live, on average, about seven
men's tendency to disregard the importance of years longer than men. The death rate for men is
their symptoms. Another possibility could be higher than for women at all ages and for all
that men are reluctant to visit caregivers because leading causes of death (Verbrugge, 1985). Men
it conflicts with masculine gender role impera- have twice the rate of premature death from
tives to appear strong and tolerate pain (Eisler & coronary artery disease, and they are three times
Blalock, 1991). Not only do women and men more likely to die in motor vehicle accidents
utilize healthcare systems differently, but than are women. In addition, Waldron and
healthcare systems may also respond differently Johnson (1976) have noted that mens' death
to each gender. If similar kinds of symptoms are rates from lung cancer have been nearly six
reported by each sex, women are more likely times that of women, and twice as high from
than men to be diagnosed with a mental or cirrhosis of the liver.
nervous condition (Travis, 1988). In addition, In terms of psychological dysfunction, men
physicians may be less likely to diagnose women are much more prone to a higher incidence of
 Historical Perspective on Gender Differences 163

personality and behavior disorders. In a review handles and expresses emotional distress. In
of epidemiological studies, Cleary (1987) noted addition, we discuss how each gender seeks help
that men have been three times more likely to be for their psychological problems through in-
problem drinkers and four times as likely to be formal support systems and professional coun-
diagnosed with alcoholism than are women. It seling. Finally, we explore how these
was also evident in this review that men were perspectives may influence the future directions
more likely than women to abuse drugs and to of the investigations concerned with gender and
be diagnosed with antisocial personality dis- health.
order. In addition, a review by Widom (1984)
cited evidence that men, far more than women,
are involved in violent crime, including armed 10.07.3 HISTORICAL PERSPECTIVE ON
robbery and homicide. Widom also noted that GENDER DIFFERENCES
men are much more likely than women to be
involved in sexual deviance and more frequently While philosophers and social scientists have
are perpetrators of child and spouse abuse. deliberated for ages about the essential qualities
Taken together, these statistics suggest that men of women compared to men, the first systematic
more than women tend to employ antisocial and attempt by psychologists to synthesize a large
aggressive means in dealing with conflicts and body of research data about the psychological
personal problems. This is consistent with the differences between the sexes may be traced to
evidence reported by Huselid and Cooper Maccoby and Jacklin's classic work The
(1994) that men are more inclined than women Psychology of sex differences published in
to ªexternalizeº their distress through aggres- 1974. Maccoby and Jacklin's volume reviewed
sive and hazardous coping strategies. over 1400 of the available psychological studies
On the other hand, there is convincing which conducted statistical comparisons of the
evidence that women may suffer from more sexes on their intellectual abilities and social
ªinternalizedº psychological distress than men behavior. Their purpose, as stated in the
(Huselid & Cooper, 1994). Women's stereotypic introduction, was to ªsift the evidenceº to
gender roles associated with passivity and self- determine which of the many (stereotypic)
blame may be responsible for their greater beliefs about presumed differences between
vulnerability to internalizing disorders such as the sexes had a solid basis in fact and which
anxiety and depression. In an early study, did not. Overall, they concluded from the data
Weissman and Klerman (1977) reviewed 40 that the sexes differed much less than commonly
studies in over 30 countries before concluding held cultural stereotypes had indicated. Based
that women were two to three times more likely on the evidence, the authors found sex
than men to suffer from depression. The greater differences in a few intellectual abilities: verbal,
incidence of depression in women has been quantitative, and spatial skills. However, Mac-
confirmed in a large-scale community study of coby and Jacklin argued that the evidence was
the mental health of over 20 000 residents in negative or inconclusive with regard to differ-
different US cities (Robins et al., 1984). With ences in social behavior, with the notable
respect to the anxiety disorders, Robins et al. exception that boys tended to display more
showed that women had higher prevalence rates aggression than girls. Finally, they drew atten-
of agoraphobia, panic disorder, and obsessive- tion to the fact that differences among indivi-
compulsive disorders than men. In an extensive duals within each gender were often as great as
review, Attie and Brooks-Gunn (1987) de- the average differences between genders. Once
scribed weight concerns and chronic dieting again, the point was made that the ability of the
as the focus of constant stress in women as being individual, not the individual's gender, was
directly responsible for the extraordinarily high most important.
ratio of eating disorders (anorexia and bulimia) With respect to the potential sources of
in women compared to men. verified sex differences, such as aggression,
From the above discussion, we may conclude Maccoby and Jacklin acknowledged that bio-
that there have been significant gender differ- logical predispositions based on sex could
ences in incidence of different disorders, interact with psychosocial experiences to deter-
including psychological dysfunction. It is also mine the psychological and social characteristics
apparent that gender roles mediate male vs. of the person. However, the authors indicated
female differences in expressions of psycho- that the biological bases for these psychological
pathology in response to stress. In the remaining characteristics of women and men could not be
sections of this chapter, we will be concerned specified with any degree of certainty.
with the historical and theoretical studies of Interestingly, and probably not coincidently,
gender differences, gender roles and one's the publication of Maccoby and Jacklin's (1974)
vulnerability to stress, and how each gender volume coincided with the early phases of the
164 The Psychology of Gender and Health

feminist movement in the USA. At that time disorders? To what extent are the sources of
feminist theory had a political as well as a these distinctions biological, environmental, or
scientific stake in gender research (Eagly, 1995). an interaction between both?,Furthermore, how
Two of the major feminist political agendas does the health of the individual depend on her
were to discover scientific data to show that: (i) or his social roles and abilities? Shifting from the
women were intellectually just as capable as question of whether gender differences exist to
men, and (ii) gender stereotypes that depicted explaining why males and females are predis-
women socially or emotionally at a disadvan- posed to different health problems requires
tage compared to men were false. This agenda testable theories about how gender differences
required an interpretation of the data that come about and what biopsychosocial forces
showed there were no meaningful differences maintain them.
between the basic abilities of men and women, Most modern theories about the origin of
which would then give women equal opportu- gender difference adopt an ªinteractionalº
nity with men to succeed in society. While perspective, whereby the biological features of
feminist ideology may have biased gender each sex interact with the social environment to
research of the 1970s toward the conclusion produce the observed gendered behavior of men
that there was little evidence of sex differences, and women. On the one hand, however, it is fair
research in the mid-1980s and 1990s returned to to say that theories that give prominence to
more refined theoretical questions about the ªbiologicalº features treat gendered behavior as
origin and health implications of gender arising primarily from characteristics that are
similarities and differences. built into the person prior to social experience.
A thorough critique of Maccoby and Jack- On the other hand, social psychological theories
lin's (1974) synthesis regarding the evidence of regard gendered behavior as primarily arising
significant gender differences in intellectual and out of the interaction between the person and his
social abilities is beyond the scope of this or her social environment.
chapter. Suffice it to say that subsequent to their
review, more sophisticated quantitative ana-
lyses comparing gender differences in a variety 10.07.4.1 Biological Perspective
of skills and social behavior have followed.
These have included meta-analytic studies of Few modern theories attempt to explain the
gender differences in decoding nonverbal cues differences in the behavior of men and women
(Hall, 1978), conformity and influenceability solely in terms of biological forces. Recently,
(Becker, 1986), and helping and aggressive Buss and Schmitt (1993) and Kenrick (1994)
behaviors (Eagly & Crowley, 1986), to name have advocated what has been termed ªevolu-
just a few. While the significance of these newer tionary psychological theoryº to account for
findings is hotly debated, the conclusions some different features in the behavior of the
reached by more recent work have been that sexes. Evolutionary psychology, which was first
there are in fact functional gender distinctions in applied to nonhuman species, is based on the
such areas as empathy (Eisenberg & Lennon, premise that biologically based sex differences
1983), leadership (Eagly & Karau, 1992), and have evolved over time, employing the Darwin-
the incidence of psychological disorders such as ian notion of sexual selection (Buss, 1995).
depression (Nolen-Hocksema, 1987). In addi- These biologically oriented psychologists have
tion, nontrivial gender differences in important postulated that there are sex differences in
social behaviors have been reviewed and genetic make-up or differences in the structural
discussed by gender researchers (Daly & features of females' and males' brains. Pre-
Wilson, 1988; Deaux & Major, 1987; Eagly & sumably, these biological distinctions have
Wood, 1991). evolved over time to produce functionally useful
aspects of masculine behavior for men, and
feminine behavior for women. Evolutionary
10.07.4 THEORETICAL OVERVIEW OF psychology predicts that males and females will
GENDER DIFFERENCES be similar in those domains in which the sexes
have faced similar adaptive problems. For
Having established that gender differences example, both sexes have similar preferences
exist in certain psychological and behavioral for fats, sugars, and salt because both sexes have
domains, we can turn to questions more faced similar food consumption problems.
pertinent to the present chapter on the relation- However, in some domains the sexes will have
ship between gender and health psychology. For faced different problems. For instance, men
instance, why do males and females sometimes have evolved to have greater skills in spatial
differ considerably, moderately, or not at all in visualization than women, because men have
their vulnerability to physical and psychological had a greater need to develop these skills for
 Theoretical Overview of Gender Differences 165

hunting. Women, on the other hand, have faced one's emotional vulnerability. ªNever let them
the adaptive challenge of securing sufficient see you sweatº was an often quoted line from a
food to carry them through pregnancy and men's deodorant commercial. Indeed, an in-
lactation; therefore, evolution might have dividual's own behavior is constantly being
favored selection of women who developed scrutinized by his or her own cognitive
the ability and features to attract mates to help commitments to being in conformity with
them through this period. Thus, evolutionary masculine or feminine ideology.
psychology predicts distinctive male and female In addition to what we as women or men
behavior in areas where sexual selection has consider is acceptable behavior for our gender,
favored the development of the physically and social psychological research has shown that a
psychologically different adaptive characteris- great deal of our behavior is based on what
tics for men and women. Presently, the evolu- others expect from us solely on the basis of our
tionary account of sex differences is regarded by being male or female. Geiss (1993) and
many gender researchers as highly speculative. Maccoby (1990) have reviewed research which
However, this perspective has presumably showed that our sex-typed expectations of each
generated testable hypotheses (Eagly, 1995). sex tends to generate ªself-fulfilling propheciesº
in producing the behavior expected of our
gender. For example, if we expect a woman to be
10.07.4.2 Social Psychological Perspective submissive in the presence of a dominant male
colleague, she may well conform to this
Over the past several decades, a diverse group ªfeminineº expectation in his presence. How-
of scientists has contributed to the social ever, she might not act submissively with her
psychology of gender, which in its simplest husband who does not expect her to act in a
description investigates how gendered behavior stereotypically feminine way. Because we expect
is defined, created, and maintained for each sex males not to show their pain, we might see a
through social norms and social interaction. little leaguer get up smiling defiantly after being
Social psychological theories that feature dis- knocked down by a fast ball at the plate.
cussions about the acquisition of disparate Moreover, it is evident that our own beliefs
gender roles and how ªsex-typedº gender roles about how each gender should think and act, as
create stress-related problems for men com- well as others' expectations about how we as
pared to women have generated much of the women or men should think and act are major
recent data on gender and behavior for clinical determinants of our behavior. The notion that
health psychologists. For example, the mascu- gendered behavior is socially constructed and
line gender imperative for men always to appear enforced by society to provide distinctive roles
invulnerable may be related to their reluctance and behaviors for men and women has
to seek medical or psychological care. Similarly, important implications for people who live in
the feminine gender imperative for women to be diverse cultures. If the behavior of women is
ever youthful and attractive may contribute to largely the result of cultural imperatives, we
excessive dieting among women, which may in would expect the behavior of women to differ
turn render women especially vulnerable to depending on the culture in which they live.
eating disorders.
The following are a few examples of the
contributions of social psychologists that view 10.07.4.3 Cross-cultural Perspective
gender distinctions more as a social construc-
tion than a biological reality. Bem (1981, 1982) Cross-cultural research on gender has been
contributed to gender role theory by supposing concerned with the degree to which each
that children develop cognitive schema to gender's attitudes and behaviors are either
organize information about the world and invariant across cultures or may be different
themselves in terms of socially desirable mascu- depending on the distinctive features of one's
line or feminine traits. That is, at an early age, cultural environment. Let us frame the question
boys and girls learn to judge their adequacy as in another way. Are men less expressive of
people based on whether their thoughts and tender emotions than women in all cultures? If
behavior are in conformity with social norms the answer to this question is yes, it would mean
for their gender. For example, women may be that inexpressiveness is intrinsic to all indivi-
reluctant to be assertive about their needs duals who are biologically male, no matter what
because it conflicts with their gender schema their social environment. On the other hand, if a
about appearing appropriately conciliatory. A man's emotional expressiveness depends on the
man's gender schema might direct him not to particular culture in which he is found, then we
express his true worries and concerns because it would have evidence that expressiveness in men
is inconsistent with masculine values to show is largely determined by cultural forces.
166 The Psychology of Gender and Health

While the study of cultural differences in which each may be exposed. This is crucial in
gendered behavior is still in its infancy, Williams our understanding of the nature of the relation-
and Best (1990) have collected some interesting ship between gender and vulnerability to
data on sex role ideology, sexual stereotypes, specific health problems. We begin with an
and work values in 14 different countries. Their orientation to the biological and psychological
results showed a high degree of agreement features of stress and coping as they relate to
between men and women living within a given health.
country about expected gender roles. However,
there were important differences in social
expectations about distinctive gender roles 10.07.5.1 Gender and Biological Vulnerability
across different cultures. For example, within to Stress
developed Protestant countries, both genders
emphasized the importance of men behaving Modern theories of how stressful situations
assertively and having power and possessions to produce health problems for each sex are based
a greater extent than women and men in the less on the notion that psychological responses to
economically developed countries. Also, men stress produce aberrant physiological or cogni-
and women were seen as necessarily more tive responses that may be different for women
distinctive in their gender roles by people in and men. For example, it has been demon-
developed countries, while people from less strated that men produce larger increases in
developed countries tended to see the gender blood pressure in response to some forms of
roles of males and females as more similar. stress than women (Stoney, Davis, & Matthews,
Williams and Best (1990) concluded that the 1987). The question of how differences in the sex
effect of culture was greater than the effect of hormones estrogen, progesterone, and testos-
biological sex in determining the expected terone affect gender differences in health has
behavior of women compared with men. also been a novel area of study. There has been
some evidence that the female hormone estro-
gen is protective against atherosclerosis for
10.07.4.4 Summary of Gender and Health women, whereas testosterone may enhance the
Perspectives risk of this disease for men (Polefrone &
Manuck, 1987). In addition, there appear to
Taken as a whole, research examining the
be consistent differences between women and
basis for gendered behavior seems to demon-
men in healthy immune function, which is
strate that biological differences between the
suppressed by gender related stresses (Kiecolt-
sexes may establish predispositions for certain
Glaser & Glaser, 1987). Women, for example,
kinds of health problems. Female hormones
exhibit higher immunoglobulin levels than men,
have been found to offer protection from heart
and produce larger antibody response to
disease prior to women's menopause. Greater
infection than do men (Michaels & Rogers,
cardiovascular reactivity in men may predispose
1971).
males to coronary artery disease. However,
Psychologists and other scientists who have
most researchers would agree that sociocultural
accumulated large quantities of data over the
forces appear to have the most profound effect
years about stress have concluded that stress is
on predisposing each gender to different health
prominently involved in the production of a
risks. In the following sections we hope to show
myriad of physical and psychological disorders
that the mechanisms linking gender to health
(see Goldberger & Breznitz, 1982; Neufield,
involves, to a great extent, gender differences in
1989). During the latter part of the twentieth
beliefs about health, exposure to certain health
century, conceptions of stress have evolved and
risks, gender determined roles, and gender
have repeatedly shown that biological responses
relevant stresses and coping styles.
and the psychological make-up of a person
interact with environmental pressures to pro-
10.07.5 THE ROLE OF PSYCHOLOGICAL duce deleterious somatic and mental health
STRESS IN WOMENS' AND MENS' problems. Psychological stress has been ac-
HEALTH knowledged to pose health risks for both
medical and psychological types of disorders
At this point we have some theoretical (Goldberger & Breznitz, 1982; Neufield, 1989).
perspectives about the acquisition and main- The fact that psychological stressors may be the
tenance of socially constructed gender roles origin of either mental or somatic health
related to socially accepted behavior for women problems, and the fact that biological and
as distinct from acceptable behavior for men. psychological systems have been shown to
We now move to a discussion about how each interact have tended to blur earlier distinctions
gender evaluates and copes with the stressors to between the two categories of health problems.
 The Role of Psychological Stress in Womens' and Mens' Health 167

Currently, sophisticated views about stress Grunberg, 1991; Collins & Frankenhaeuser,
describe an interaction between biological and 1978). Building on the previous cognitive
psychosocial factors. First, there are gender conceptualizations of stress, the present author
differences in the probability that each gender and his colleagues have developed a paradigm
will be exposed to a particular stressful describing gender role stress to explain how
situation. For example, women are more likely one's commitment to gender role ideology
to be exposed to the stress of sexual harassment produces stress that may lead to gender-related
and rape than men. Divorced women compared health problems.
to divorced men are more likely to be exposed to Incorporating Pleck's (1981) initial notions
the dual stresses of having to earn a living and about the stress imposed by gender roles, we
manage a family. However, men may be more have developed a model that independently
stressed than women at some work sites because evaluates masculine gender role stress (MGRS)
men have been expected to deal with physically for men and feminine gender role stress (FGRS)
hazardous situations (e.g., working in a coal for women. This gender role stress model
mine) to a greater extent than women. In reflects our attempt to account for some of
addition to the nature of the environmental the vulnerability of women and men to
events, modern views about stress focus on the contrasting health problems (Eisler, 1995; Eisler
individual's cognitive appraisal of the threat & Blalock, 1991; Eisler & Skidmore, 1987;
and her or his psychological coping strategies. Eisler, Skidmore, & Ward, 1988; Gillespie &
Eisler, 1992; Lash, Eisler, & Schulman, 1990;
Lash, Gillespie, Eisler, & Southard, 1991;
10.07.5.2 Gender and Cognitive Vulnerability Martz, Handley, & Eisler, 1995; Watkins,
to Stress Eisler, Carpenter, Schectman, & Fisher, 1991).
The gender role stress paradigm includes
Mediating the relationship between trau-
several major components. The first of these is
matic events and physiological stress arousal
the development of gender schema through
are cognitive processes that assess the nature of
social learning environments, which tend to
the threat (Lazarus & Folkman, 1984; Neufield,
reward the development of masculine concep-
1989). According to Lazarus and Folkman
tions of self for boys and feminine conceptions
(1984), psychological stress involves the rela-
of self for girls. Opposite gender conceptions of
tionship between the person and the environ-
self tend to be strongly discouraged. For
ment that is appraised by the person as taxing or
example, boys are rewarded for acting tough
exceeding his or her coping resources and
and girls for being nice. Boys are punished for
endangering his or her well-being. Thus, the
acting feminine (sissy) and girls for acting
interaction between our cognitive evaluations of
aggressively (bitchy). These gender schema are
particular situations and our assessment of our
then utilized to evaluate whether or not a
abilities to manage those problems physically
particular situation may be threatening. Ex-
and psychologically defines the stress process
pressing feelings of vulnerability tends to be far
for us as individuals.
more stressful for men than women. On the
Furthermore, according to Lazarus and
other hand, many women are much more
Folkman, the strength of one's commitment
concerned about their looks than men so that
to a particular outcome increases vulnerability
a substantial weight gain is more stressful to
to stress. Therefore, should a woman become
women. Finally, one's gender schema guide
extremely committed to losing weight, her
each person's choice of coping responses. A
vulnerability to stress will be proportional to
man whose masculine gender schema promotes
the strength of her commitment to weight loss.
highly vigorous means of coping with stress may
These concepts about stress have been adopted
rely extensively on aggression to cope with
by most clinical health psychologists, whether
stress, whereas a woman might feel that
they work with psychological disorders such as
aggressive displays were inconsistent with her
anxiety and depression, or with the effects of
feminine gender schema of how women should
stress on biological systems, such as in the cases
act.
of gastric ulcers and coronary heart disease.
According to this paradigm, gender role
stress may result from faulty gender determined
10.07.5.3 Gender Role Stress appraisals of the situation, in that a man's
expression of fear (feminine) need not lead to
A fair amount of evidence has linked sex environmental stress for him, whereas acting in
differences in the incidence of various health a forceful (masculine) manner might reduce the
problems to gender differences in appraisal of environmental pressures felt by a woman.
stress and utilization of coping responses (see Alternatively, gender role stress may result
Barnett, Biener, & Baruch, 1987; Baum & from excessive reliance on socially approved
168 The Psychology of Gender and Health

masculine or feminine coping styles. For disorders. However, the possibilities are intri-
example, a man's reliance on a hostile or guing, and we have conducted a number of
combative style of coping with stress may be preliminary studies to evaluate the possible
dysfunctional in that it produces chronic association between gender role stress and
physiological arousal leading to a heart attack. coping and potentially adverse health effects.
A woman who copes with stresses by the Utilizing the MGRS scale (Eisler and Skid-
continual expression of dysphoric emotions and more, 1987), we found that there were sig-
rumination about her difficulties could end up nificant associations between the MGRS scale
feeling helpless and depressed. Consequently, measure and self-reported anger, anxiety, anger,
gender role norms have helped create gender and poor health habits in men (Eisler &
role coping strategies for an individual based Skidmore, 1987; Eisler, Skidmore, & Ward,
purely on his or her gender. Living up to these 1988). In addition, Lash, Eisler, and
culturally defined masculine or feminine ex- Schulman (1990) showed that men with a high
pectations may, in itself, be difficult for each score on the MGRS scale, compared to men
gender, and produce stress or dysfunctional with a low score, were subject to greater
appraisal and coping behavior. increases in blood pressure when the stressor
dealt with masculine relevant tasks in which
men were expected to perform well. No
10.07.5.4 Gender Roles and Coping with Stress differences between men with high and low
MGRS scale scores were noted when the task
A major issue linking gender role stress and was concerned with feminine behaviors or tasks
health has involved gender differences in coping not particularly relevant to expected male
with stress. As we alluded to earlier, consistent gender roles. Additional studies by Lash et al.
with their gender roles, men are more likely to (1991) showed that women had greater increases
externalize and women internalize their stress in their blood pressure responses than men if the
(Huselid & Cooper, 1994). Therefore, masculine stress threatened areas that were inherent in the
ideology specifies different kinds of coping female gender role, including nurturance and
behavior for men than feminine ideology does child rearing. Watkins et al. (1991) showed that
for women. Because of social norms, men are high gender role stress was associated with
more likely to utilize instrumental aggressive coronary-prone type A behavior and elevated
behaviors and displays of dominance to cope blood pressure in both men and women. Martz
with their problems than women. However, et al. (1995) found that FGRS scores could
women may be more likely to ruminate and distinguish women who had eating disorders
engage in self-blame in response to crises in their from women who had other psychiatric condi-
lives because this behavior is more consistent tions. Gillespie and Eisler (1992) showed that
with feminine gender role expectations. women who had high scores on the FGRS scale
When we look at gender-related coping styles, reported more depression than did women low
we can see that some health problems may result in feminine role stress.
from dysfunctional coping styles associated As a whole, these studies have demonstrated
with one's gender role. For example, most that responses to stress have gender components
psychological disorders involving antisocial and in that women are more likely than men to be
abusive behavior reflect exaggerated aggressive stressed by events that the culture has specified
coping styles typically used by men. This might as especially important to women's gender roles.
explain why there is a strikingly high incidence Similarly, men are more subject to stress when
of men compared to women who commit crimes the situation requires expected masculine beha-
of violence (Widom, 1984). Also, women make viors. These studies have also tended to indicate
more suicide attempts than men, yet men are that gender differences in favored coping styles
more likely to succeed in killing themselves. may be predictive of the types of disorder that
Psychological disorders utilizing passive, stereo- men compared with women are prone to
typical feminine coping styles are disorders that develop.
show higher prevalence rates for women, such as
anxiety disorders and obsessive-compulsive
disorders. Learned helplessness (Seligman, 10.07.6 GENDER DIFFERENCES IN SELF-
1975), a major cognitive theory of depression, DISCLOSURE AND HELP
is more consistent with enacting the feminine SEEKING
rather than the masculine role. Admittedly,
much research remains to be done to demon- In this section we consider gender issues in the
strate that there are direct relationships between expression of emotion, the ability to elicit or
masculine or feminine gender roles and gender utilize social support, and the inclination to seek
role coping strategies responsible for particular help for personal problems. These are gender
 Gender Differences in Self-disclosure and Help Seeking 169

differences that may have profound implica- men. Eisler and Blalock (1991) proposed an
tions for the health of women compared to men. alternative possibility: that expressing feelings
The majority of verbal psychological therapies other than anger is perceived by men as
used in Western countries rely on the assump- ªfeminineº behavior, which is contrary to their
tion that expressing one's feelings about past masculine role. Finally, while developing a
traumatic or painful events has a healing effect. measure of MGRS, Eisler and Skidmore (1987)
Pennebaker (1995) has been foremost among found that men found it significantly more
researchers attempting to understand the ben- stressful than women to express feelings of
eficial effects of emotional disclosure on affection or fear. However, this might not be
psychological and physical health. In the true for men in other cultures.
introductory chapter of his book Emotion,
disclosure, and health, Pennebaker (1995) has
reviewed the evidence that full expression of 10.07.6.2 Gender and Social Support
emotion reduces rumination and worry and
promotes cognitive resolution of disturbing The evaluation of social support in psychol-
events. He also cites laboratory studies which ogy has been hampered by a lack of agreement
show that disclosure of upsetting events has on a single definition of support and a broad
produced reductions in sympathetic nervous range of measures. However, most researchers
system arousal, including blood pressure and agree that the functions of social support
muscle tension. Other studies have shown that include providing assistance in obtaining re-
improvement in immune function is another sources, problem solving, and bolstering self-
benefit of self-disclosure (Petrie, Booth, & worth (Belle, 1987). Research has shown that
Davison, 1995). In reviewing the research other mechanisms by which social support is
detailed in chapters in Pennebaker's book by associated with health are: (i) decreasing the
experts on psychopathology, psychophysiol- supported persons's feelings of isolation and
ogy, and counseling, one is struck by the loss of self-esteem; (ii) attenuating the percep-
evidence that the tendency to share emotional tion of certain events as highly threatening; and
experiences has great power in increasing (iii) reducing physiological reactivity to stress
interpersonal intimacy, which in turn tends to (Shumaker & Hill, 1991).
buffer stress for the individual. Throughout the lifespan, evidence indicates
How do the genders compare on the tendency that females are more likely to have supportive
to express emotion and create social support confidants than men. While the relative size of
networks to buffer stress? Is the ability to womens' and mens' support networks varies,
express innermost feelings related to an in- womens' investment in supportive disclosing
dividual's tendency to seek help for emotional relationships consistently tends to exceed those
turmoil? These questions about emotional of men (Belle, 1987). While mens' supportive
expression, social support, and the willingness relationships center around shared activities
to seek help for psychological and other health and experiences, womens' relationships empha-
problems are very much interrelated issues. size shared emotional intimacy. Females are
Hence we now turn to a discussion of gender more likely both to seek and to receive social
differences in emotional expression, gender support in times of stress than men (Wolchik,
distinctions in the ability to develop social Sandler, & Braver, 1984). Women are also more
support networks, and the tendency for women likely than men to be supportive as friends.
as contrasted to men to seek professional help Finally, the evidence indicates that men have
for health problems. much more restricted social networks than
women. In fact, married men tend to rely almost
exclusively on their spouses for support,
10.07.6.1 Gender and Emotional Expression whereas married women utilize other relatives
and friends for support (Belle, 1987). The
In a review of literature on gender differences potential downside of this for women is that
in emotional expression Sauer and Eisler (1990) large social networks may be emotionally
found that, almost without exception, women stressful as well as being supportive.
were more self-disclosing than men. However, it The impact of social support on the overall
did appear that men self-disclosed more to health of women compared to men is far from
women than to other men. Eagly and Wood clear. We do know from the above data that
(1991) explained these gender differences in women are more likely than men to participate
terms of the widespread belief in our culture that in stress-buffering social networks and are more
women are more emotionally sensitive, more able to mobilize social support in times of stress.
socially skilled, and more concerned with Women also provide more frequent and more
maintaining personal relationships than are effective support to others of both sexes.
170 The Psychology of Gender and Health

Schumaker and Hill (1991) have concluded that of this is that men typically perceive going for
the role of social support in womens' and mens' help with personal problems as an intolerable
health awaits greater numbers of women to add loss of personal control and power. Psy-
power to the comparative health studies and chotherapists perceive the behavior of most of
more sophisticated measures of social support. their male clients as defensive, emotionally
We now turn to some data from the counseling constricted, and insensitive because the male
literature on the relationship between gender role of ªinvincibilityº appears inconsistent with
and the tendency to seek help for health seeking help. We must conclude that, for many
problems. men, entrenched masculine values continue to
be an important obstacle to seeking and
10.07.6.3 Gender and Help Seeking receiving help for health problems.

A crucial determinant of preventing disorder

and maintaining health involves the desire and 10.07.7 FUTURE DIRECTIONS
ability to seek help for problems at an early
stage of difficulty. Nearly 70% of all clients Expanding our understanding of health from
seeking psychological help are female. Further- a biomedical enterprise to a biopsychosocial
more, one in three women, as compared to one paradigm requires a greater understanding of
in seven men, has sought help from a mental health beyond assessment and treatment of
health professional at some point during her life disease processes and infectious agents. More
(Collier, 1982). Psychologists concerned with comprehensive views of health require an
gender issues have written extensively about a understanding of psychological and sociocul-
strong association between the masculine tural factors. An individual's beliefs and
gender role and the comparative reluctance of attitudes, and his or her perception of and
men to seek help for psychological problems exposure to stress that differentially affect the
(Eisler, 1990; Good, Dell, & Mintz, 1990; Scher, risk of illness have been shown to have
1990). Until recently, most forms of psychother- important gender and cultural components.
apy were developed by men to be practiced on How these psychosocial components interact
women by male psychotherapists. This unfor- with biological systems continues to be a
tunate evolution of the provider±client relation- fascinating area for further theory and research.
ship has created problems in the delivery of Research on health should endeavor to employ
health services to both women and men. a more equal distribution of women and men, as
In order to understand why men seek well as to sample more individuals from
psychological and other health services as a different ethnic groups.
last resort, we need to appreciate the demands of Many of the health problems of the twenty-
the masculine gender role and the fact that most first century that are reflected in premature
forms of counseling have required behavior that mortality and morbidity will be preventable by
may be regarded as feminine. Writers on mens' attention to changes in lifestyle risk factors and
issues have theorized that client characteristics creation of lower stress environments for people
required by most forms of counseling and of different gender and cultural backgrounds.
psychotherapy are completely antithetical to the For example, preliminary research has shown
masculine gender role (Eisler, 1990; Eisler & that cultural and gender differences in dietary
Blalock, 1991; Scher, 1990). Conventional patterns, smoking, alcohol consumption, and
wisdom is that, for counseling to be successful, high-risk sexual and aggressive behaviors are
the client must acknowledge personal problems, significantly related to differential risks of
be willing to self-disclose, tolerate feelings of mortality and morbidity in different cultural
interpersonal vulnerability, and be willing to groups (Anderson, 1995).
submit control of the central issues in one's life More research is needed to understand the
to an outsider. All these therapeutic expecta- different kinds of stress factors to which women
tions are completely contrary to what males and men and people from different cultural
have been taught is essential to perform groups are exposed. Clearly, racism, sexism, and
adequately as a man. economic hardship variously constitute major
Men are raised to see their world as an stress and health risks for different groups.
adversarial place where a man must attain Presently, health research has focused on
mastery of the world by being independent and specific health problems such as heart disease,
cope with stress by wielding power and not by the effectiveness of smoking cessation pro-
revealing his vulnerabilities. Men perceive a grams, cancer screening tests, and blood
basic incongruity between what is expected from pressure monitoring programs. Perhaps this
them as men in society and what is expected of should be supplemented by comprehensive
them as consumers of health services. The result studies examining the health risks to which
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 Copyright © 1998 Elsevier Science Ltd. All rights reserved.

10.08
A Cultural Perspective on Families
Across the Life Cycle: Patterns,
Assessment, and Intervention
Outline
NADINE J. KASLOW and KEITH A. WOOD
Emory University School of Medicine, Atlanta, GA, USA
and
MONICA R. LOUNDY
Georgia State University, Atlanta, GA, USA

10.08.1 INTRODUCTION 174

10.08.2 DEFINITION OF TERMS AND CONCEPTS 175
10.08.2.1 Culture 175
10.08.2.2 Family 175
10.08.2.2.1 Normal and dysfunctional family processes 176
10.08.3 CULTURE AND THE FAMILY LIFE CYCLE 177
10.08.3.1 Family Life Cycle 177
10.08.3.2 Significance of Family Life Transitions Across Cultures 177
10.08.3.3 Rituals Denoting Family Transitions Across Cultures 177
10.08.3.4 Migration: A Life Cycle Transition Unique to Immigrant Families 178
10.08.4 FAMILY LIFE CYCLE STAGES: A CULTURAL PERSPECTIVE 179
10.08.4.1 The Joining of Families Through Marriage: The New Couple 179
10.08.4.1.1 Marriage: a life cycle transition 179
10.08.4.1.2 Intermarriage 181
10.08.4.2 Becoming Parents: Families with Young Children 181
10.08.4.2.1 Childbirth 181
10.08.4.2.2 Childrearing 181
10.08.4.2.3 Attachment 182
10.08.4.2.4 Developing a personal identity 182
10.08.4.2.5 Developing an ethnic identity 183
10.08.4.2.6 Developing effective coping strategies 184
10.08.4.3 Families of Adolescents 184
10.08.4.3.1 Separation-individuation 185
10.08.4.3.2 Ethnic identity development 185
10.08.4.3.3 Achievement 186
10.08.4.3.4 Dating and sexuality 186
10.08.4.4 Launching Children, Single Young Adults Leaving Home, and the Middle Generation Moving On 187
10.08.4.4.1 Cultural values and norms on launching 188

173
174 A Cultural Perspective on Families Across the Life Cycle

10.08.4.4.2 Leaving home: single young adults 188

10.08.4.4.3 Conflicts experienced by the middle generation 189
10.08.4.4.4 Dealing with parental illness and death 189
10.08.4.5 Families in Later Life 189
10.08.4.5.1 Definition of the elderly 190
10.08.4.5.2 Issues confronting the elderly 190
10.08.4.5.3 Immigrant elderly 190
10.08.4.5.4 Ethnic identity 191
10.08.5 CULTURALLY SENSITIVE FAMILY ASSESSMENT AND INTERVENTION 191
10.08.5.1 Values 191
10.08.5.2 Help-seeking Patterns 192
10.08.5.3 Adherence 193
10.08.5.4 Culturally Sensitive Techniques 193
10.08.5.4.1 Stance of the therapist 193
10.08.5.4.2 Development of the working alliance 194
10.08.5.4.3 Assessment process 194
10.08.5.4.4 Intervention process 195
10.08.5.5 Culturally Sensitive Techniques Across the Life Cycle 197
10.08.5.5.1 The joining of families: culturally sensitive assessment and intervention 197
10.08.5.5.2 Families with young children: culturally sensitive assessment and intervention 198
10.08.5.5.3 Families with adolescents: culturally sensitive assessment and intervention 199
10.08.5.5.4 Launching children, single young adults leaving home, and the middle generation moving on:
culturally sensitive assessment and intervention 200
10.08.5.5.5 Families in later life: culturally sensitive assessment and intervention 200
10.08.6 FUTURE DIRECTIONS 201
10.08.7 SUMMARY 202
10.08.8 REFERENCES 202

10.08.1 INTRODUCTION After defining terms and concepts (e.g.,

culture, family) central to a discussion of a
Family theory and therapy and the multi- cultural perspective on families across the life
cultural perspective offer complementary views cycle, a detailed presentation of cultural
on assessment and intervention (Gushue & characteristics of families across the family life
Sciarra, 1995). Both approaches share the cycle is offered. Adapting the work of Carter
assumption that the individuals must be under- and McGoldrick (1989), information is pro-
stood within their larger familial and socio- vided on cultural group differences across the
cultural context (Gushue & Sciarra, 1995). Thus, major family life cycle stages. The aforemen-
a comprehensive assessment and intervention tioned sections lay the groundwork for a
should attend to the complex interactions discussion of culturally sensitive family assess-
among the individual, the family, and the culture ment and intervention across the family life
across the family life cycle (Carter & McGol- cycle. The theoretical underpinnings of family
drick, 1989; Szapocznik & Kurtines, 1993). therapy from a culturally informed perspective
Family theorists and therapists increasingly are reviewed and culturally sensitive family
have underscored the importance of the cultural assessment and intervention approaches in the
context in which family therapy is conducted United States are delineated. Hopefully, the
(e.g., Falicov, 1983; Ho, 1987; McGoldrick, information provided will inform psychologists
Giordano, & Pearce, 1996; McGoldrick, Pearce, about ways to adapt and modify current
& Giordano, 1982). They have come to practices to enhance the cultural fit between
appreciate therapeutic models as reflecting the the assessment and intervention approach and
culture within which they are developed and the family. Additionally, given the considerable
practiced. Family theorists have become at- intra- and intercultural variation in family
tuned to the role of culture and values in the patterns, it is our goal to present information
conceptualization of interactive processes. Con- that will help psychologists better treat families
sistent with this, family therapists have become with whom they share a common cultural
more cognizant of the impact of culture, values, heritage and families from a different cultural
and theoretical stance on the assessment and background than their own.
intervention process and outcome. These We hope the reader will bear in mind the
changes in perspective have led more family following caveats regarding our presentation.
theorists and therapists to view each individual First, there is a lack of clarity in the literature
as a member of a family system that exists within regarding the distinction between culture and
a context of cultural diversity (Szapocznik & ethnicity. We use the term culture to refer
Kurtines, 1993). broadly to values, attitudes, and behaviors that
 Definition of Terms and Concepts 175

characterize groupings of people who are transmitted by families from one generation to
influenced by their culture of origin, religion, the next (Bullrich, 1989). Cultural patterns are
race, and socioeconomic status (SES). Second, influenced by multiple factors, including ethni-
the cultural characterizations presented are not city, race, SES, education, gender roles, sexual
meant as stereotypes of specific groups. Instead, orientation, country of origin, current resi-
the depictions reflect generalizations regarding dence, migration, religious and political affilia-
common family patterns associated with a given tions, and family life cycle stage. Cultural norms
cultural group (Falicov, 1983). These general- and values inform family members' roles and
izations require validation at the level of the rules regarding family membership and struc-
individual family. Third, and in a related vein, ture, rituals, help seeking behavior, problem
this chapter incorporates an intercultural per- definition and resolution, communication
spective in which the definitions of what is styles, expression of affect, and feelings about
appropriate or normal family structure, values, life, death, and illness (Carter & McGoldrick,
communication patterns, and interactional 1996). In sum, culture is a dynamic and evolving
processes are seen as varying across different process reflecting the interaction between a
cultures. Although this chapter does not attend family's and a group's collective history and
to individual differences between families within ongoing experiences in a particular context.
a given culture (intracultural perspective), we
want to underscore the importance of attending
to the unique characteristics of each family, 10.08.2.2 Family
which are often affected by such variables as the
phase of acculturation, the stage of ethnic Historically, the dominant American defini-
identity, and each members' choice of a primary tion of family has focused on the intact, nuclear,
language(s) both within the family system and in heterosexual family unit, connected by blood or
the larger community (Gushue & Sciarra, 1995). legal bonds, the members of which typically
Fourth, due to space considerations, only a reside in one domicile. During the past few
limited number of examples of some family decades, the definition of the American family
cultures are provided. For in-depth reviews of has expanded to include myriad constellations
families from specific cultures, and for coverage of emotional subsystems, such as step and
of a greater breadth of families, the reader is remarried families, foster and adopted families,
referred to McGoldrick, Pearce, and Giordano and cohabitating heterosexual, lesbian, gay, and
(1982) and McGoldrick, Giordano, and Pearce bisexual couples.
(1996). Fifth, it is not our intention to suggest With the multifaceted complexion of Amer-
that culture is the only or primary factor that ica, the definition of ªfamilyº varies among
impacts the family life cycle. Culture is one cultural groups (McGoldrick et al., 1996). For
variable that interacts with multiple factors in example, African-Americans' definition of fa-
influencing a family's presentation and effective mily often refers to a wide network of kin and
assessment and intervention approaches. The community and extended family members (e.g.,
salience of cultural issues differs across families, grandparents, aunts, uncles, cousins) and non-
as does the significance of cultural factors in family members (e.g., very close neighbors and
assessment and intervention. Thus, it behoves friends, church leaders, boyfriends) who func-
clinicians and researchers to incorporate culture tion as part of one's psychological family. It is
as a key, albeit not sole, element in their work understood that all members of this family will
with families. provide assistance and guidance in various
aspects of family life including child rearing,
caring for the elderly, providing material
10.08.2 DEFINITION OF TERMS AND resources, and offering support during crises
CONCEPTS and transitions (Billingsley, 1992; Boyd-Frank-
lin, 1989).
To set the stage for a discussion of culture and
In the Latino community, the term family
the family life cycle and culturally sensitive
frequently connotes a close network of blood
assessment and intervention, a number of terms
relatives that spans three or four generations.
warrant definition.
This network often includes nonblood members
(e.g., godparents, legally adopted children
10.08.2.1 Culture whose adoptions have not been formalized).
The traditional concept of the nuclear family
For this chapter, culture is defined as the has little meaning or applicability in the Latino
totality of tacit behaviors, ideas and knowledge, subculture (Garcia-Preto, 1996).
attitudes, values, beliefs, customs, language, Historically, the definition of family in
and technology shared by a group of people and certain Asian cultures (e.g., Chinese) included
176 A Cultural Perspective on Families Across the Life Cycle

ancestors and descendants as well as living to which triangulation (two opposing family
nuclear and extended family members. These members demand that a third person support
families were patriarchal in structure. However, him or her against the opposing party) within
the Chinese-American family has evolved such the family should be interpreted as reflecting
that the contemporary family consists primarily maladaptive family patterns depends on the
of members of the nuclear family in which there cultural context. In nuclear family structures
is a more egalitarian sharing of roles across common to EuroAmericans, triangulation re-
gender lines. This shift in family structure may flects family pathology and thus may destabilize
reflect an accommodation to the dominant the family unit. In extended family structures
culture, the reality that only certain family common to many African-American, Asian,
subgroups immigrated to the US, and an and Latino families, in which cross-generational
increased emphasis on functional relationships executive subsystems (e.g., mother and grand-
(Lee, 1996). mother) are normative, triangulating a child is
In some Native American cultures, the less likely to affect the marital dyad negatively
primary parental functions are played by the because authority lines are clear and the
grandparents and thus the key bond is between exclusion of one parent is not perceived as
the children and the grandparents. The term rejection (Falicov, 1983).
grandparent in these families may refer to These examples highlight the fact that the
grandparents by blood, godparents, maternal or cultural validity of various family theories and
paternal great aunts, and so on. In many Native theoretical constructs (e.g., kinship, division of
American families, no distinctions are made labor, proximity and hierarchy, triangulation,
between one's family of origin and in-law parentification) require empirical examination
family; these families are blended, rather than prior to making claims about universal v.
joined by marriage (Sutton & Nose, 1996). culturally specific models of family normality
and dysfunction (Boyd-Franklin, 1989; Fisek,
1991; Tseng, 1985). In addition, differences in
10.08.2.2.1 Normal and dysfunctional family
family interactions between cultural groups
processes
(e.g., Japanese-American vs. Caucasian fa-
Historically, family theories (for review, see milies in Hawaii) may be attributed to cultural
N. J. Kaslow, Celano, & Dreelin, 1995) have factors, thus, it is essential that culture-specific
portrayed the family as structured according to profiles of healthy family functioning be
clearly defined, static, gender-based roles and devised (Hsu et al., 1985). If distinct, culture-
family composition and have viewed the specific portrayals of normal family function-
stability of the family household as the major ing are not developed and validated empiri-
family unit (Wamboldt & Reiss, 1991). These cally, normal interactions among family
models also delineated the primary tasks to be members that are disparate from those ob-
accomplished by the typical family (Wamboldt served in the majority culture may be mis-
& Reiss, 1991). For the most part, however, until construed as pathological (Hsu et al.).
recently, when detailing normal family structure Theories on normal and abnormal family
and processes, these models failed to consider functioning are socially constructed and shaped
the effects of gender, social class, ethnicity, race, by the evolving cultural context (Walsh, 1993).
and sexual orientation (N. J. Kaslow et al.). This Even the value placed on distinguishing between
is unfortunate given that a Eurocentric model functional (i.e., normal) and dysfunctional
of normalcy is not applicable across cultures family processes varies across cultures. While
(e.g., Jamaican-Americans, Japanese-Ameri- such a distinction has been of paramount
cans, African-Americans) (e.g., Boyd-Franklin, importance in mainstream American culture,
1989; Dechesnay, 1986; Hsu, Tseng, Ashton, the conceptual dichotomy associated with the
McDermott, & Char, 1985). distinct categories of normal and abnormal is
For instance, while the role of the parental antithetical to the underlying assumptions of
child is often viewed as indicative of dysfunction human behavior characteristic of many non-
in the family structure, in many low-income western societies (Foulks, 1991). Given that
African-American families, parentification of definitions of normal behavior vary across
children may reflect a family's adaptive re- cultural groups, and the utility of the construct
sponse to their economic conditions (Boyd- of normality differs between Western and non-
Franklin, 1989). In these families, the presence Western societies, it behoves therapists to
of a parentified child is dysfunctional only when refrain from classifying certain family patterns
these young people are inundated with abdi- as dysfunctional solely because they deviate
cated, rather than delegated, responsibilities from the norms of the dominant culture (Walsh,
at the expense of their development (Boyd- 1993). Rather, only families who manifest
Franklin, 1989). As another example, the extent interactional processes discordant with the
 Culture and the Family Life Cycle 177

cultural context in which they are embedded processes identified with each stage, as well as
and/or are associated with elevated levels of with the requisite second-order changes in
distress or problems establishing relationships family status that accompany each family life
with other cultural group members, require cycle stage. Thus, families often seek or require
intervention (Foulks, 1991; Wamboldt & Reiss, mental health services during key transition
1991). For example, a person raised in a South- points.
ern African-American family affiliated with a
Pentecostal Church who believes that their
symptoms can be attributed to rootwork (a 10.08.3.2 Significance of Family Life
malevolent form of magic) may not be Transitions Across Cultures
psychotic, particularly if these beliefs are shared
Cultural factors impact families' definitions
by the family (Hillard, 1982). Although mental
of the nature, timing, tasks, and rituals of life
health services may be required, the patient and
cycle transitions, as well as the significance the
family may benefit from the assistance of a
family attaches to each transition (Carter &
rootdoctor, who can remove a hex from the
McGoldrick, 1989). For example, in Amish-
patient (Hillard, 1982). This example highlights
American families, births are understood as
that it is a challenge for therapists both to
gifts from God and associated with increased
refrain from falsely ascribing dysfunction to a
standing in the community; thus, births repre-
culturally normative pattern or exaggerating the
sent a transition of particular importance in the
significance of culture at the cost of failing to
Amish community (Emery, 1996). Births are
identify dysfunctional patterns (Falicov, 1983).
major events in many other groups, including
most Latino cultures.
10.08.3 CULTURE AND THE FAMILY The shift from adolescence to adulthood,
LIFE CYCLE marked by the ritual of the Bar or Bar Mitzvah,
is the most salient transition in Jewish-Amer-
To present coherently the wealth of material ican tradition (Davis, 1988). The transition to
on cultural characteristics of families across the adulthood is also one of importance in the
life span, we organize our discussion using a Amish culture, denoted by the individual's
family life cycle framework (Carter & McGol- decision to join the church and marriage
drick, 1989), which provides a breadth and (Emery, 1996). In many Latino cultures,
depth of insight into family functioning in all quinceaneras (at 15, girls are given a party in
stages of development. This rubric is applicable honor of their coming of age) mark the
to families from myriad cultures. adolescence to adulthood transition. Depend-
ing on the country of origin and the social class,
the elaborateness of these festivities and the
10.08.3.1 Family Life Cycle associated religious ceremonies vary.
Marriage is a highly valued family life cycle
The family life cycle, a circular model of
stage that carries considerable status in many
normal family development, identifies key
cultural groups (e.g., Italian-American, Puerto
transitional stages of the family. First applied
Rican, West Indian). Finally, in some cultures,
to intact, middle class, mainstream Euro-
death is the most significant transition. This is
American families, this model divides the life
the case for Irish-American families who
span into six stages reflecting significant events
emphasize rituals associated with mourning
in the lives of family members: unattached
(e.g., wake).
young adulthood, young couples, transition to
parenthood, families with adolescents, launch-
ing, and families in later life (Carter & 10.08.3.3 Rituals Denoting Family Transitions
McGoldrick, 1989). As the composition of Across Cultures
family units has evolved, the model has been
revised to incorporate additional life cycle Cultures also differ in the rituals used to
stages observed in families who experience connote major life events (Carter & McGol-
divorce, single parenthood, and remarriage drick, 1989). For example, there are notable
(Carter & McGoldrick, 1989). An additional differences in the rituals associated with a
life cycle transition pertinent to immigrant child's birth. In the Jewish-American tradition,
families, and thus relevant to this chapter, is the birth of a son includes a celebration (bris)
that of migration. when the circumcision takes place. In response
Significant intra- and extrafamilial stress are to the increased value placed upon females in
evidenced by many families during family life the Jewish culture, baby naming ceremonies and
cycle transitions. Elevated stress levels are parties have become more common for girls. In
associated with disruption in the emotional the Roman Catholic community, birth is
178 A Cultural Perspective on Families Across the Life Cycle

marked by the baptism. In some Latino lesbian and gay couples in making public their
Catholic subcultures, baptism is accompanied commitment to one another, and acknowl-
by parties marking the beginning of a life long edging divorce (Imber-Black, Roberts, & Whit-
relationship among the child, parents, and ing, 1988; F.W. Kaslow, 1993; Scrivner &
godparents. Eldridge, 1995). Although historically, certain
Marriage and wedding rituals are strikingly cultures (e.g., Orthodox Jews) have had divorce
different across ethnic groups. An African ceremonies for the purpose of freeing each
tradition, adopted by many African-Americans, partner to remarry and for acknowledging the
is jumping the broom, in which the couple jump legitimate birth of subsequent children, only
together over a broom to mark their union. The recently has such a ritual been recommended for
broom signifies the beginning of homemaking individuals across cultures. F. W. Kaslow (1993)
for the couple. Consistent with ancient Chinese presents a framework for conducting a divorce
tradition, Chinese-American women may wear ceremony to help each partner heal from the
red wedding gowns. Red symbolizes prosperity, pain of the termination of a failed union. In this
fertility, and good luck. In addition, before the ceremony, each partner affirms the positive
wedding, the groom and bride give tea to elder aspects of the relationship and acknowledges
family members as a token of appreciation for that the children represent an important
having been nurtured. Family members bless product of their union. The children are
them with red packets of money that represent encouraged to process the impact of the divorce
support for having a good life. In the Iranian and to articulate expectations regarding future
community, the wedding is a spontaneous involvements with each parent.
occasion, held at the bride's family's home in
the presence of close relatives. Family members
stand and clap during the ceremony, and the 10.08.3.4 Migration: A Life Cycle Transition
bride and groom are seated as they take their Unique to Immigrant Families
marriage vows.
Family and community behaviors that mark Migration, a unique life cycle transition of
death differ significantly (McGoldrick, Hines, immigrant families, reflects a developmental
Lee, & Preto, 1986). For example, for Irish- process of family adjustment with impact across
American families, funerals are times of drinking multiple generations. The process of the
and story and joke telling. In the African- immigrant family's transition to a new culture
American community, funerals are marked by a occurs on a continuum, and includes a number
public expression of grief and moving spirituals. of specific stages: preparatory, active migration,
The funerals of Puerto Rican families are overcompensation, decompensation, and trans-
characterized by crying, screaming, and ataques generational phenomena (Sluzki, 1979). Suc-
(i.e., hysterical, convulsive reactions). In cessful immigration is associated with both
Chinese-American families, survivors are ex- maintenance of the family's cultural identity
pected to cry without inhibition at the wake and and integration into the new culture; both tasks
funeral. To facilitate the deceased person's require reorganization of the family unit and the
transition to the afterlife, and to insure that development of complex elaborations of family
the next life is a good one, loved ones burn paper structure and processes (Bullrich, 1989).
money and clothing and present elaborate Although the migration process varies across
spreads of food. Other dealth-related rituals cultures and is affected by the family's stage of
that differ across cultural groups relate to the development, cultural patterns, and the char-
timing of the funeral (e.g., African-American acteristics of the new culture, there are simila-
Muslims and Jews bury the dead person quickly, rities in family patterns associated with the
whereas Hindus in America allow many days to migratory process across cultures (Carter &
elapse between one's death and burial) (McGol- McGoldrick, 1989; Sluzki, 1979).
drick et al., 1996) and the preparation of the Many refugee families seek mental health
deceased for the burial (e.g., in the African- services in response to the stress associated with
American Muslim and Orthodox Jewish com- immigration and acculturation, in addition to
munities, often the deceased person's corpse is the traumas experienced in their country of
cleansed by individuals of the same sex as the origin. Typical presenting complaints relate to
deceased and given a ritual ablution) (McGol- intergenerational conflicts, marital discord,
drick et al., 1996). guilt and anxiety mixed with anger secondary
Consistent with the evolving nature of the to the tensions experienced between family
American family, rituals have been designed to members and relatives left behind, and conflicts
mark transitions in a broader array of family with the sponsor/sponsor organization (McGol-
constellations, such as welcoming adopted drick et al., 1996). Often, a family assessment
members, addressing remarriage, supporting reveals that intergenerational difficulties are a
 Family Life Cycle Stages: A Cultural Perspective 179

screen for a more fundamental problem, namely Historically, in the majority of cultures, the
a clash between the family's culture of origin ritual of marriage was the primary marker of the
and the host culture. In such cases, it is transition to adulthood. The significance and
recommended that the therapist reframe the universality of this life cycle stage have shifted
subsystem conflicts as culture conflicts, which with changes in the onset of sexual involvements
ameliorates the fixed subsystem±culture alli- (earlier), increased incidence of cohabitation
ances (Szapocznik, Santisteban, Kurtines, among nonmarried partners, increased reliance
Perez-Vidal, & Hervi, 1984). on nontraditional marital arrangements (e.g.,
same-sex couples, couples who cohabitate for
long periods without having a legal ceremony
10.08.4 FAMILY LIFE CYCLE STAGES: A marking their commitment), greater acceptance
CULTURAL PERSPECTIVE of people's choices to remain single or divorce or
remarry, and later onset of marriages due to
The following sections address cultural
changes in educational and career paths. Also,
influences on each major family life cycle stage.
although many groups prohibit intermarriages,
Due to space considerations, only key stages are
there has been a significant rise in intermarriage
detailed. (i) The joining of families through
rates since the mid-1970s.
marriage: The new couple. (ii) Families with
young children. (iii) Families with adolescents.
(iv) Launching children, single young adults 10.08.4.1.1 Marriage: a life cycle transition
leaving home and the middle generation moving
Virtually every cultural group has traditions
on. (v) Families in later life. We deviate some
and rituals associated with one's choice of a
from the family life cycle sequence provided by
partner and the marital process. Between-group
Carter and McGoldrick (1989), since the family
differences are noted on such factors as: process
life cycle is a circular process that can be
of mate selection, age at time of marriage,
conceptualized as begining at any stage. One of
presence of a formal marital contract, meaning
our modifications reflects our decision to
of marriage, marital roles and responsibilities,
initiate the family life cycle with the marriage
and expectations regarding monogamy and
of the young couple, which is the begining of a
marital fidelity.
new family unit. Our second modification is our
In the past, many cultures advocated ar-
decision to combine two stages, launching
ranged marriages. In some groups, arranged
children and moving on (Stage 5 in the Carter
marriages are still common (Iranians, Greeks).
and McGoldrick model) with the leaving home:
In many Islamic Arab-American families,
single young adult phase (Stage 1 in the Carter
marriage is a family matter, in which partners
and McGoldrick model) because these pro-
are chosen by one's family and not on the basis
cesses often occur simultaneously in the young-
of romantic love, as is the norm in most Western
er and middle generations. Although cultural
cultures (McGoldrick et al., 1996). In other
variations in patterns and belief systems across
communities (Chinese-American), arranged
the family life cycle have been delineated, there
marriages of two young adults residing in their
is a dearth of empirical data on this topic (N. J.
parents' homes used to be the norm. However,
Kaslow et al., 1995). Relevant empirical data
cultural shifts have resulted in many more
will be cited when available.
marriages occurring after the adult children
leave the family home and form a romantic
10.08.4.1 The Joining of Families Through attachment with a partner (McGoldrick et al.,
Marriage: The New Couple 1996).
In terms of age at time of marriage, in some
The decision to marry represents a commit- cultures (e.g., Amish) it is expected that
ment to a new family unit and a marital individuals marry young (late adolescence or
subsystem. This entails maintaining an intense young adulthood), whereas in other cultures
attachment to someone outside of one's family (e.g., Jewish), people tend to marry at an older
of origin and renegotiating one's family of age. Further, sex differences exist within
origin and peer group relationships. Such cultures regarding the expected age of marriage.
renegotiation includes redefining the structure For instance, among Iranian-Americans, fe-
and process of the relationships in order to males typically marry during adolescence or
incorporate a new member, and a change in the young adulthood, whereas males tend to be
family member's identity. Forming a new family 10±15 years older than their partners (McGol-
(family of creation, family of choice) also drick et al., 1982). In addition, the expectations
requires that the couple make decisions regard- regarding one's financial status often influence
ing routines and rituals, and customs and the typical age at the time of marriage. As an
traditions. example, Jamaican males often marry 10 years
180 A Cultural Perspective on Families Across the Life Cycle

after their Euro-American male counterparts, and sheltering of his partner. Normative
due to the expectation that they be financially behavior of married women within Mexican-
secure prior to marriage (Comas-Diaz & American homes is consistent with submission
Greene, 1994). and humility. However, despite these gender
In the majority of cultural groups, hetero- role based social presentations, within the
sexual couples have a formal legal marital home, the domineering and patriarchal male
agreement. However, this is not true for couples member of the marital dyad often depends on
of all socioeconomic levels in a given cultural his female partner for major family-related
group. As an example, formalized marriages are decisions (Falicov, 1996). In the Puerto Rican
the norm among middle and upper class community and in many Dutch families, women
Haitians, but the equivalent of common-law have the primary responsibility for home and
marriages (i.e., placage) are common among family, whereas men are responsible for pro-
low-income Haitian couples (McGoldrick et al., tecting and providing for the family (Garcia-
1996). In the West Indian culture, although legal Preto, 1996). However, among Dutch partners,
marriages are valued, many couples cohabit for the husband often solicits his wife's input on
lengthy periods of time to test their compat- business, career, and family financial matters. A
ibility and they often procreate during this reverse pattern of gender roles in marriage is
period (McGoldrick et al., 1982). Among some observed among many Hungarian families
cultural groups, two types of formal marital (Smith, 1996). Hungarian women often are
contracts are obtained. Many Jews have a powerful in politics, business, and community
Jewish marriage certificate (ketubah) and a affairs, yet have a clearly delineated role in the
state-approved marriage certificate, with sepa- family typically confined to childrearing deci-
rate rituals associated with the receipt of each sions and domestic tasks. In these families, the
document. husband has ultimate power regarding domestic
There are myriad ways in which the meaning decisions. Among Amish-Americans, marriage
of the marital bond differs across cultural is viewed as a practical matter and thus partners
groups. For some groups, the formation of a are expected to cooperate and be respectful of
marital unit indicates the creation of a new one another, but there is no expectation of
family designed to enable individuals to meet romantic love or physical affection (Emery,
individual needs (e.g., Anglo-American); for 1996).
others, it marks a continuation of the man's There are also within-culture variations
family line (e.g., Asian-American), and for still regarding marital roles that often reflect the
others it represents an alliance between two era of one's birth. As an example, Japanese-
extended families (e.g., Nigerian, Puerto Rican) American couples in which both partners were
(McGoldrick et al., 1982, 1996). In some born prior to 1935 tend to exhibit traditional,
communities, getting married is a sign of status. patriarchal, and hierarchical family structures
Within the West Indian culture, a man only in which the overt expression of affection and
marries once he is capable of providing his love is minimal, whereas couples with members
spouse with economic security and material born subsequent to 1935 more often assume an
goods (e.g., house). In other cultures, getting egalitarian relationship in which physical dis-
married is an expectation and is not associated plays of affection are normative. Although
with status (Anglo-Americans). Finally, in some these younger couples appear to have mar-
communities, marriage is conceived of as a riages more similar to that observed in many
symbolic rite of passage into adulthood (e.g., Euro-American families, they typically retain
Amish), whereas other nodal events mark the their cultural heritage by continuing to hold
transition from adolescence to adulthood in traditional Japanese attitudes, values, and
other communities. beliefs (Matsui, 1996). Similar generational
With regard to marital roles and responsi- differences are exhibited among other cultural
bilities, significant intercultural variations, of- groups (e.g., Korean-Americans).
ten reflecting differences in gender roles, have Fidelity is a value shared by members of
been noted. In many cultural groups, the virtually all cultural groups. However, the
traditional marriage is one in which the male consequences of infidelity differ significantly.
is the dominant member who has key roles Among West Indians, adultery is an acceptable
outside the family system, whereas the women's reason to divorce. In Vietnamese families,
major role is at home and with the family. divorce is only an option if adultery is
Within many Mexican-American families, the committed by the women. Although polygamy
ideal of machismo is expected from the is illegal in America and thus is illegal for
husband; that is, the male member of the Vietnamese individuals residing in the US, the
marital dyad is expected to have considerable practice of men having female sexual partners in
sexual experience, and to be brave, pugnacious, addition to their wives is somewhat acceptable
 Family Life Cycle Stages: A Cultural Perspective 181

and overlooked by the wife if her position in her and parenting (Carter & McGoldrick, 1989).
extended family is secure and her children Young children in families form attachments,
receive adequate provisions (McGoldrick et al., develop increased competencies, and begin to
1996). In the Jamaican community, although develop a sense of self and an ethnic identity.
monogamy is supported, many Jamaican men This section reviews the major tasks for the
maintain a mistress and their mutual children in adults associated with this family life cycle
a separate household (practice of ªtwin house- phase, including childbirth and childrearing.
holdsº) (Comas-Diaz & Greene, 1994). Then, attention is paid to issues focal in the
child's development: attachment, developing a
10.08.4.1.2 Intermarriage personal identity, developing an ethnic identity,
and learning effective coping strategies.
More than 50 % of people in the US marry
someone who is not a member of the same 10.08.4.2.1 Childbirth
cultural group and 33 million adults reside in
homes in which at least one other adult has a Variations are noted in birth practices across
different religious background (Mayer & Kos- cultures. In the US, the birth process has been
min, 1994). In 1990, 1.5 million children lived in considered a medical event, one that usually
families in which one caregiver was Caucasian occurs in the hospital. With the influence of
American and another caregiver was of African, other cultures on American customs, more
Asian, or Native American descent. The rates of American families choose naturalistic ap-
African-American±Caucasian marriages have proaches (e.g., home births, midwives, involve-
tripled since the mid-1960s, even though the ment of multiple family members) (McGoldrick
actual numbers of such marriages remain et al., 1996).
relatively low (Wright, 1995). Within the
Asian-American community, inter-racial mar- 10.08.4.2.2 Childrearing
riages constitute 10±15 % of marriages, with Cultural differences in childrearing, parent-
such marital unions being most common among ing styles, and socialization practices are
Japanese-Americans and least evidenced by significant and often reflect the conditions
Korean-Americans (Karnow & Yoshihara, (e.g., economics, work demands) and values
1992). The increasing rates of intimate partner- (e.g., independence vs. dependence) of the
ships between individuals of different ethnic, culture in which they are formed (Matsumoto,
religious, and racial backgrounds suggest that 1994). For example, Mexican-American and
American society is becoming more tolerant of Puerto Rican parents value family closeness and
differences. However, couples from intercultur- thus often socialize their children to be obedient
al marriages often need therapy to address their and respectful and to prefer familial support
cultural differences. over self-reliance (e.g., Zayas & Solari, 1994).
Inter-racial marriage complicates the success- As another example, Caucasian American
ful negotiation of this family life cycle phase. mothers are more likely than African-American
Conflicts regarding values, religious beliefs and or Haitian mothers to use modeling and
practices, communication styles, childrearing, reassurance to help their children cope with
and relations with in-laws are common (McGol- fearful situations; Haitian mothers are more
drick et al., 1996). The more salient the cultural likely than either Caucasian American or
differences between the partners, the more African-American mothers to use force when
difficulty they are likely to experience in their children confront anxiety-producing sti-
accommodating to married life (McGoldrick muli (Reyes, Routh, Jean-Gilles, Sanfilippo, &
et al., 1996). It has been hypothesized that ethnic Fawcett, 1991). These differential parenting
intermarriages reflect an effort on the part of patterns could be construed as mothers using
each partner to redefine the most important parenting styles that encourage adaptive survi-
ethnic characteristics and to abandon those val in their home country.
ethnic traits that are valued least (McGoldrick The structure of the family affects child-
et al., 1996). rearing and caregiving practices. In Euroamer-
ican culture, the primary responsibility for
10.08.4.2 Becoming Parents: Families with childrearing has been the purview of the mother,
Young Children and more recently the parental dyad, while in
many non-Anglo-American cultures, children
Within the Euroamerican culture, the transi- have been raised by extended family members
tion to this life cycle stage requires that the new (e.g., grandparents, aunts, and uncles) older
parents develop a primary identity as caretakers siblings, nannies, wet nurses, or in group
for the next generation. Typical issues addressed settings (e.g., kibbutz) (Matsumoto, 1994;
are associated with childbearing, childrearing, McGoldrick et al., 1996). For example, African-
182 A Cultural Perspective on Families Across the Life Cycle

American children living in poverty are often 10.08.4.2.3 Attachment

raised in multigenerational families in which
Cultural values in childrearing practices
maternal grandmothers are the primary care-
impact upon the nature and perception of the
givers. Frequently, these grandmothers coreside
parent±child attachment bond. While many
with their daughter and her children, often with
attachment behaviors are found across cultures,
no adult male in the home (Harrison, Wilson,
the selection, shaping, and interpretation of
Pine, Chan, & Buriel, 1990). Although this
these attachment behaviors are culturally
family constellation differs from what has been
determined (IJzendoorn, 1990). Empirical in-
considered the typical American family (i.e.,
vestigations reveal frequency differences of the
heterosexual, married parents, who coreside
major forms of attachment (anxious avoidant,
with their biological children), it is often
anxious resistant, securely attached, disorga-
associated with healthy African-American child
nized/disoriented) between and within cultures
and family development (Canino & Spurlock,
(across regional and socioeconomic groups)
1994; Wilson, 1989). In addition, a significant
(Bretherton & Waters, 1985; IJzendoorn, 1990).
percentage of minority single-parent families
These data underscore the importance of
are successful (Lindblad-Goldberg, 1989). As
ascertaining the contextual meanings of attach-
another example, in a number of cultures (e.g.,
ment behavior, as well as whether or not
Latino, Filipino), godparents serve as important
attachment patterns are differentially adaptive
models for young children and as sources of
across cultures (Harwood, Miller, & Irizarry,
support for the young child's parents (Matsu-
1995).
moto, 1994). Although the composition of the
Studies examining attachment behavior in
extended family varies across groups, extended
Anglo vs. Puerto Rican mother±infant dyads
family networks are all characterized by a
indicate that Anglo-American mothers value
sharing of resources, emotional support, and
child qualities associated with individualism
caregiving responsibilities (Matsumoto, 1994).
(e.g., autonomy, self-control, activity), whereas
In addition to cross-cultural differences in the
Puerto Rican mothers prefer child factors
identity of the primary caretaker(s), there are
consistent with interpersonal relatedness (e.g.,
variations between cultures in terms of how
affection, dignity, respectfulness, responsive-
caretaking occurs and the values communicated
ness to others, proximity seeking) (Harwood,
to young children within the family. These
1992; Harwood & Miller, 1991). These prefer-
variations reflect differences in both beliefs
ences mirror the differences in values within the
regarding childrearing and in standards of living
two cultures as individuation is promoted in
(e.g., family economic status, country of origin).
Anglo-American culture, whereas relatedness is
In many Western European cultures, teaching
considered optimal in Puerto Rican culture.
some independence early is emphasized. Tod-
Despite these differences in valued child
dlers are raised in their own rooms, some crying
characteristics, both Anglo-American and Puer-
is tolerated so the child learns not to cry
to Rican mothers rate the securely attached
manipulatively, strong verbal feedback during
child as more positive than the insecurely
childhood is accepted, and the reward±
attached child. However, the basis for this
punishment system emphasizes the gain or loss
preference differs between the two groups of
of possessions or privileges (Matsumoto, 1994).
women. Anglo mothers note the confidence and
In many other cultures (e.g., Asian-American,
independence of the securely attached child;
African-American, Native-American) commu-
Puerto Rican mothers find the child's demea-
nicating a value on dependence and interde-
nor, obedience, and relatedness most appealing
pendence is emphasized (Matsumoto, 1994).
(Harwood & Miller, 1991).
For some, the young child may sleep in the
parents' bed for several years and may be breast
10.08.4.2.4 Developing a personal identity
fed until age three or four. Often in cultures in
which dependence and interdependence are The challenge for young children is learning,
emphasized, crying is not tolerated and thus through interactions with key attachment
may result in positive (e.g., picking up, figures, the adaptive patterns of their social
cuddling) or negative (e.g., spanking) attention, group (Canino & Spurlock, 1994). Early in life,
disrespect in the form of talking back to elders a child begins negotiating different affiliation
(parental figures) is unacceptable, and the styles, communication strategies, coping pat-
reward±punishment system frequently means terns, and family hierarchy and approaches to
the presence or absence of corporal conse- discipline. As the young children struggle with
quences (e.g., Greek-American, Puerto Rican). these issues and conflicts, they begin to form a
These differential rearing and parenting prac- personal identity.
tices prepare youth to live in the cultural context The development of a personal identity is
in which they are embedded. complicated when the child has to adapt to
 Family Life Cycle Stages: A Cultural Perspective 183

various, changing, and/or conflicting social rules Helms, 1981). This is a challenging task,
and expectations. This is particularly true when especially when the socialization process (adult
the child must meet the demands of different guided) is not clear on such issues. Older siblings
cultures or adapt to a culture in rapid transition. and caretakers must model for younger children
Understandably, the child may have difficulty the internalization phase and help them negoti-
finding that adaptive skills in one culture may be ate earlier phases to facilitate their attainment of
a liability in another. For example, the openness a more mature ethnic identity.
valued in the Euro-American culture may be The best known empirical studies on ethnic
shamed in the Asian-American family context, identity in youth focus on minority children's
and the gender-associated aggresiveness praised preference for stimuli associated with Cauca-
in the Latino culture may be punished in the sian culture (e.g., white dolls) vs. their own
Euroamerican culture. Many first-generation culture (e.g., Banks, 1976; Clark & Clark, 1940).
immigrant children become confused and over- These findings initially were interpreted as
whelmed by the need for their family to adapt to indicating low self-esteem and a preference
the dominant cultural demands. They may feel for the dominant culture vs. one's own culture.
rejected by their peer group when their family Many researchers criticized these early studies
engages in behaviors consistent with their on methodological grounds (Banks, 1976).
culture of origin (e.g., afternoon siesta) and Also, the findings are dated and with the
rejected by their family if they fail to conform increased Afrocentric pride evidenced in most
with culturally normative rituals. In addition, African-American families (Mahon, 1976) and
these children often receive contradictory mes- the greater availability of black dolls in stores,
sages from their family as the family tries to meet African-American children are more likely to
the demands of the American culture (e.g., prefer black dolls. The other well-researched
forego the afternoon siesta). topic relates to children's self-identification, or
self-definition, and capacity to correctly label
their own ethnic identity (Aboud, 1987). Some
suggest that incorrect self-definition vis-aÁ-vis
10.08.4.2.5 Developing an ethnic identity
one's ethnicity indicates a negative self-concept,
As part of a personal identity, each child and thus may merit attention.
develops an ethnic identity, that is, a sense of Much of ethnic identity is developed in the
belonging to an ethnic group with shared values, communication style in which the child is
attitudes, language, behavior, perceptions, and surrounded. For example, in many African-
social interaction patterns (Phinney, 1990a). American social groups, the meaning of a
The relevance of ethnic identity and awareness message may be more in how (rhythm, tonal
of this aspect of a person's identity are range) something is said than what is said. Part
particularly important when children realize of the identity of the Italian language is the use
that their personal ethnic or cultural identity of hand motions which are absent in Asian
differs from the culture in power (Erikson, cultures. For certain African groups, much of
1958). Therefore, being a ªminorityº or a the meaning of a message is in the nonword
member of a nondominant culture automati- sounds that accompany the language, whereas
cally predisposes a child to different identity for some Native Americans certain sounds are
development contingencies. For example, the their words.
dark, slanted eyes common in Asian-American Cultures take possession of their unique
children are not dark or slanted (they are ways of communication and generally are
normal) when everyone else's eyes are that way; intolerant of deviations. In each culture, there
but when a child realizes that beautiful and are idiosyncratic words, phrases, grammar
normal equals bluer and rounded eyes, that patterns, accents, and nonverbal behaviors
child has to deal with different identity-related that are understood by group members. For
issues than blue, round-eyed children. How this example, Jewish phrases help identify one's
difference impacts identity is significant, and the Jewishness. Children learn these language
family's role in helping the child develop a patterns and are reinforced for using these
positive identity is crucial. words in their family and with their Jewish
Accepting differences in personal character- peers, but may be teased if they incorporate
istics is a developmental process. Children these phrases into their communication with
proceed from wanting to be something other their non-Jewish peers. Black children sound-
than who they are (pre-encounter phase) to only ing White to sound intellectual in the school
wanting to be with and trusting others who are environment may be perceived as rejecting their
like themself (encounter and immersion± cultural communication identity, which could
emersion stages), to accepting and appreciating result in them having to deal with derogatory
variety (internalization stage) (Parham & perceptions and comments from peers and
184 A Cultural Perspective on Families Across the Life Cycle

family members. Cultural communication is 10.08.4.2.6 Developing effective coping

also developed in musical types and unique strategies
sounds are associated with each culture.
A major challenge of childhood is developing
Learning these patterns of communication is
a coping style for handling the obstacles further
a crucial aspect of children developing their
developmental stages present. If the child looks
ethnic identity.
or sounds different from the majority of
Communication conflicts occur when one
Americans, strategies must be formed for
group defines the ªrightº way to speak and
coping with being a minority and facing
views certain cultural subtypes as ªwrongº or
discrimination. Effective use of such tactics
inferior. Children struggle with their language
enables the child to establish a healthy self-view
identity when they learn different rules at
and a respect for others. While myriad coping
school and at home. For some immigrant
strategies are potentially efficacious, it is the
families, attempting to fit in with the major
child's capacity to use a range of tactics flexibly
culture's language style has been critical and, as
that determines the overall coping ability. It is
a result, their native language or dialects are not
helpful to the child if these strategies are taught
taught to their children. As an example, many
by elders. For example, African-American
Japanese families who were in internment
children can learn to cope with racism if their
camps during World War II discourage the
caretakers share African cultural values and
use of Japanese by their children and grand-
practices and instil in them a sense of pride in
children. This is in an effort to reduce their own
their racial background (Vargas & Koss-
pain and to be more ªAmerican,º but may also
Chioino, 1992).
function to hinder the development of a
When developing strategies for handling
positive ethnic identity as a Japanese-American
discrimination, it is often a challenge for
in their children or grandchildren (Vargas &
children to find an approach that is respected
Koss-Chiono, 1992).
in their own culture and the dominant culture.
Issues around appearance are another do-
Withdrawing from or attacking the majority
main of ethnic socialization often associated
culture may be praised by one's own culture, but
with parent±child tensions. The young female
may result in rejection from the majority
whose family is from East India who wants to
culture. Thus, this approach is inconsistent
cut her hair in a stylish fashion (rather than
with developing bicultural competence.
never to cut it as is the cultural custom) like her
The child must also form strategies for
friends poses issues for herself (identity forma-
negotiating differences between the family's
tion), and is likely to meet with resistance from
culture and the majority culture. Applying
her parents who may feel distressed that their
traditions associated with the environmental,
ability to control her ethnic identity is threa-
social, or economic demands of a non-American
tened. The Native American boy who only
country may have limited applicability to
wants to perform the ªinº (i.e., Macarena) is
successful matriculation the US. One common
engaging in behavior that is likely to conflict
coping strategy for maintaining important
with the traditional cultural patterns being
elements from one's culture of origin, while
enforced at home. What could be interpreted as
accommodating to one's culture of choice, is
ªrebelliousº may more appropriately be framed
culture blending. This involves the American-
as the child's efforts to fit in.
ization of traditional practices, thoughts, and
Children must learn the subtleties of how to
perceptions. Culture blending is noted through-
act appropriately within each unique cultural
out the US, including among the Creole
context. Much of this learning is acquired
population in New Orleans (French and Amer-
through parental modeling. Mothers and
ican) and the Gullah population on the coast of
fathers struggling to negotiate their cultural
South Carolina and Georgia (African and
practices in an environment intolerant of certain
American). Culture blending is often manifested
customs (corporal punishment is encouraged in
in the use of amalgamated language forms, such
some cultures, but is illegal in America) often
as Patwah (Caribbean dialect and English),
send confusing messages to their children. This
Gullah (African dialect and English), and
learning process is complicated further by
Spanglish (Spanish and English).
possible cultural clashes at school, where
appropriate behavior, modeled and reinforced
by teachers and students, can be drastically 10.08.4.3 Families of Adolescents
different from the home environment (e.g.,
asking questions and challenging authority The transition to this stage in the family life
may be the norm in school, whereas deference cycle often brings marked changes in the roles
to authority is expected in Asian-American that adults and children take in the family. In
families). Euroamerican culture, this stage is marked by
 Family Life Cycle Stages: A Cultural Perspective 185

the establishment of boundaries between ado- controlling. If the therapist holds the dominant
lescents and younger children, as well as parents value orientation, valuing autonomy more than
relinquishing complete authority over the responsibility to a collectivity (Papajohn &
adolescent (Carter & McGoldrick, 1989). In Spiegel, 1975), the cultural basis of the conflict,
addition, the married couple begin to address may not be acknowledged. As a result, the
midlife marital and career issues and start to therapist will have problems supporting the
care for the older generation. This section family's negotiation of a mutually acceptable
focuses on cultural differences in negotiating the solution.
major issues of adolescence, separation-indivi- During this family life cycle stage, adolescents
duation, ethnic identity development, achieve- often fight to spend more time away from the
ment, and dating and sexuality. family as peer relations become paramount.
Similarly, as adolescents seek to fine tune their
personal identity, they will often bring friends
10.08.4.3.1 Separation-individuation
home who may expose the family to new values
Families who experience problems in this and ideas. While including nonblood relatives is
stage often have difficulty negotiating flexible welcomed in some cultures (e.g., Irish-Amer-
boundaries in which the adolescent is encour- icans) it may be frowned upon as an intrusion in
aged to be both independent and dependent. other cultures (e.g., Italian-Americans).
The shift in parenting patterns from childhood
to adolescence is often problematic. As an
10.08.4.3.2 Ethnic identity development
example, some Irish-American families move
from a structured, controlling parenting style in Given the centrality of identity development
childhood to a permissive, laissez-faire style in concerns during adolescence, ethnic identity is
adolescence, a shift often associated with of great importance during this developmental
increased behavior problems in the teenager stage (Phinney, 1990a). Whereas the primary
(Carter & McGoldrick, 1989). Parents may be question for young children regarding ethnic
confused about how much autonomy is appro- identity relates to the accuracy of self-definition,
priate and norms on the balance between during adolescence the major issues relate to the
dependence and independence vary across labels one chooses to use to define oneself, the
cultural groups. In Arab-American families, degree to which one examines one's ethnic
adolescents are not expected to challenge identity, and the degree and nature of group
parental authority, to engage in behaviors that identification (Phinney, 1990a). In terms of
conflict with parental expectations, or to place labels, do adolescents whose parents migrated
individual concerns over family interests (Ti- from Cuba refer to themselves as Cuban,
mimi, 1995). Those Arab-American adolescents Cuban-American, Hispanic, or Latino? Do
who rebel to attain increased autonomy are adolescents whose parents grew up in Poland
engaging in culturally unacceptable behavior and moved to the US prior to their birth refer to
and are likely to meet with intense parental themselves as Polish-American or simply Amer-
resistance (Timimi, 1995). In a related vein, ican? Such decisions are complex for an
whereas Euroamerican families believe that adolescent, particularly if the parents are of
healthy development in adolescence is asso- different heritages, as parental heritage may not
ciated with the young people's capacity to both be consistent with the adolescent's ethnic self-
love and leave their parents, in Japanese identification (Phinney, 1990a). Further, each
American families, the value is on family ethnic label has a different connotation regard-
cohesion and support; leaving home is not ing the adolescent's ethnic identity and group
viewed as an important aspect of adolescent identification.
development (McGoldrick et al., 1996). Research reveals that adolescents with a well-
In the most cultures, adolescent males are defined ethnic identity manifest more positive
afforded more latitude to exert independence psychological adjustment than their counter-
than their female counterparts, who often parts with limited ethnic self-identification. In a
experience rigid and restricted rules. For group of African-American, Asian-American,
example, an Italian-American family presents and Mexican-American high school students,
for help because their 16-year old daughter is those who revealed more mature stages of ethnic
ªdisrespectful, rejecting, and unappreciative.º identity during an interview had higher self-
They report that she asserts her plan to stay out esteem, a greater sense of mastery, and more
after midnight following her prom, intends to positive relationships than their peers who
apply to and attend an out-of-state college, and endorsed lower levels of ethnic identity (Phin-
prefers to buy her own clothes rather than wear ney, 1989).
clothes made by her mother. The 16-year-old The degree and nature of group identification
claims her parents are old-fashioned and can often be inferred from the degree to which
186 A Cultural Perspective on Families Across the Life Cycle

individual adolescents manifest positive vs. peers (Sue & Okazaki, 1990). Environmental
negative attitudes toward their ethnic group, factors proposed to explain the impact of
and their involvement in the social activities and culture on adolescents' school performance
cultural practices of their ethnic group. The focus on parenting practices, familial values
adolescent's involvement in such activities is regarding education, and beliefs communicated
evident via language choice, friends' ethnic within the family regarding the benefits of
background, religious practices, and participa- education. The data on each of these variables
tion in structured ethnic social groups (Phinney, are complex and do not provide a clear picture
1990a). It is interesting to note that there are sex (Steinberg et al., 1992). Evidence suggests,
differences in adolescents' ethnic group identi- however, that although the authoritarian par-
fication; research suggests that females are more enting patterns often found in Asian-American
involved with their ethnic heritage and manifest families may not be optimal for superior
more mature levels of ethnic identity than males academic performance, these parenting styles
(Phinney, 1990a; Plummer, 1995). are typically counterbalanced by high levels of
One important aspect of personal and ethnic peer support for superior academic perfor-
identity is the expression of gender role, which is mance. Caucasian adolescents tend to have
influenced by cultural factors. For Latino optimal academic performance when their
males, becoming a man often involves learning parents use an authoritative parenting style
to physically fight, and taking a dominant role and they receive support from their peer group
with females. These behaviors could be con- regarding academic achievement. In addition,
sidered chauvinistic and threatening to those difficulties in academic success among both
from a Euro-American culture that takes a more African-American and Latino youth may be
egalitarian view regarding gender differences. attributed to low levels of peer support for
Traditional Chicano ways by a Mexican-Amer- academic excellence. This low level of peer
ican adolescent male toward a White girl could support is often accompanied by authoritarian
be interpreted as rude or discriminatory and parenting practices in the homes of Latino
result in a very negative social interaction, youth, a combination of factors that often
despite the fact that the behaviors reflect interferes with academic success. These data
cultural differences in communication between underscore the importance of focusing on
the sexes. cultural values and expectations, as well as
family and peer relations, in assessing academic
difficulties and devising intervention programs.
10.08.4.3.3 Achievement
The development and implementation of such
The arenas in which achievement is valued preventive intervention programs must be
differ across cultural groups (Gibbs & Huang, sensitive to the child's economic conditions.
1989). Native American youth may become
estranged from their community if they receive
10.08.4.3.4 Dating and sexuality
recognition for their academic successes, parti-
cularly if they choose education over tribal Another important task of adolescence is
activities. For many Asian-American families, managing dating and sexuality. The major
strong academic success is the focus of the issues that differ across cultures regarding
family and the source of praise and attention. dating relate to the presence of a chaperon
Excellence in sports, for example, is less valued and who chooses who the adolescent will date
among many Asian-American families com- (and ultimately marry). The tradition in many
pared to African-American families. Cuban-American families continues in which
One aspect of achievement that has received chaperons accompany the dating couple
considerable attention is academic achievement. (McGoldrick et al., 1982). The chaperon's
A burgeoning body of research underscores presence may be a major source of parent±
ethnic differences in school performance among adolescent conflict for adolescents who are
children and adolescents (Slaughter-Defoe, more acculturated than their parents. The
Nakagawa, Takanishi, & Johnson, 1990; Stein- custom of parental mate selection persists in a
berg, Dornbusch, & Brown, 1992). Data number of cultures outside the US. Families
indicate that African-American and Latino from some of these cultures continue this
youth perform more poorly in academic settings practice upon immigrating to America (e.g.,
than their Caucasian counterparts in terms of Arab-Americans, East Indians). Again, this
grades obtained and amount of education practice may cause disagreement between
completed (e.g., Mickelson, 1990). Conversely, acculturated adolescents and their families. A
there is evidence that the academic performance major issue among many cultural groups relates
of Asian-American students surpasses that of to parental and extended family concerns
their Caucasian, African-American, and Latino regarding the adolescent's decision to date
 Family Life Cycle Stages: A Cultural Perspective 187

someone outside the family's culture, race, or use contraception or to get abortions (Franklin,
religion. Interethnic, interracial, and interfaith 1987). Further, there is increased tolerance of
dating on the part of the adolescent is often a teenage pregnancy in many low-income
controversial family matter. African-American families and communities
Many immigrant populations (e.g., Portu- and such a pattern has a long history (Boyd-
guese, Amish) have strong beliefs that sex is Franklin, 1989). In addition, extended family
reserved for marriage. However, other cultural members are more likely to assist in raising
groups are permissive of sexual experiences children of teen mothers in the African-
prior to marriage. Italian-American families American community than in the Caucasian
often encourage and expect their adolescent community (Boyd-Franklin, 1989).
sons (not daughters) to become sexually
proficient as a sign of masculinity and mastery 10.08.4.4 Launching Children, Single Young
of interpersonal relations. Given that premar- Adults Leaving Home, and the Middle
ital sex is the norm in present day American Generation Moving On
culture, it is common for a family whose
heritage views premarital sex as unacceptable We have modified Carter and McGoldrick's
and deserving of punishment to seek mental (1989) family life cycle stages by combining the
health services for the adolescent engaged in ªLaunching Children and Moving Onº and the
sexual relations. With this presenting problem, ªLeaving Home: Single Young Adultsº phases;
a family intervention rather than individual these typically occur simultaneously in the
therapy for the adolescent is warranted. The family's life. This family life cycle stage for
goal of the family intervention is to help all EuroAmericans refers to family functioning
members address the conflicting norms and once children become of age and begin to leave
understand one another's behavior and atti- the home.
tudes within the larger sociocultural context. In For the middle generation, the major tasks of
families such as Chinese-American families in this transition are the negotiation and accep-
which sexuality is a taboo subject, the therapist tance of adult children leaving the family unit
must form a strong working alliance with the and welcoming their partners and children into
family prior to addressing issues of sexuality the extended family system (Carter & McGol-
(Gibbs & Huang, 1989). drick, 1989). The launching of adult children
One possible consequence of sexual behavior facilitates restructuring of the parent subsystem
is pregnancy. The rates of pregnancy and back to the marital dyad. In addition, it is likely
teenage parenthood differ significantly across that the couple will have to endure the disability
cultural groups. For example, adolescent child- and death of their parents. Families at this stage
bearing and parenthood are more likely to occur often present for therapy when parents, parti-
in low-income African-American samples than cularly mothers who worked as homemakers,
in demographically matched Caucasian samples experience depression and the ªempty nest
or middle-income African-American groups syndromeº at the loss of the family unit as
(Franklin, 1987). Also, the rates of teenage defined since the mid-1970s. The couple's role as
pregnancy in the US are increasing, most parents is no longer paramount and, as such,
notably among African-Americans and Latinas they may experience difficulties finding mean-
(Jacobs, 1994). Multiple psychosocial factors ingful new life activities. This period may be the
have been proposed to explain differential first time the couple has lived alone since their
pregnancy rates among adolescents from dif- early marriage, and thus, they may need to
ferent ethnic groups. It has been suggested that become reacquainted as husband and wife. This
African-American teenagers from low-income may be a period of reinvestment in the
or single-parent homes become more active relationship or a time when the couple move
sexually than their Caucasian peers and at a toward dissolving the marriage. For those who
younger age. Their increased exposure to sexual renew their marital commitment, this phase of
behavior in the overcrowded environments in the family life cycle often brings greater
which they reside, the greater level of peer financial freedom, allowing the couple to
socialization associated with an enhanced engage in activities that may have been
awareness of sexuality at an early age, and postponed earlier in the relationship (e.g.,
the higher levels of involvement in adult vacations, new careers, relocation).
responsibilities including sexual roles are hy- For the younger generation of young adults
pothesized as factors to explain this discrepancy from Euroamerican backgrounds, during the
(Staples & Johnson, 1993). In addition to higher leaving home phase, the major emotional tasks
rates of sexual activity, low-income African- are that of accepting responsibility (emotional,
American adolescents are less likely than their financial) for themselves, differentiating as an
demographically matched Caucasian peers to adult from their family of origin, developing
188 A Cultural Perspective on Families Across the Life Cycle

intimate relationships, and gaining increased ethnic identity, processes begun earlier in life.
academic and/or occupational self-definition The recently ªlaunchedº young adults must
(Carter & McGoldrick, 1989). The individua- grapple with the degree and nature of contact
tion characteristic of this phase of development with their family of origin. Young adults from
entails clear articulation of personal and ethnic certain ethnic backgrounds (e.g., Jewish, Greek)
identities (Phinney, 1990a). maintain frequent contact (telephone, letters,
email, visits) with their family of origin, yet
10.08.4.4.1 Cultural values and norms on attain a significant degree of autonomy to
launching pursue success in their chosen endeavors. When
they fail to attain such success, increased family
There is a continuum of normative launching
involvement occurs (Carter & McGoldrick,
behavior across cultural groups, ranging from
1989). Conversely, young adults from ethnic
no expectation of launching to a high degree of
backgrounds that value independence begin-
expectation regarding launching at an early age
ning in older adolescence or young adulthood
and to a significant extent (Carter & McGol-
(White Anglo Saxon Protestants, Germans,
drick, 1989). For example, in many Italian-
Scandinavians) may be rejected by their family
American families, older adolescent and young
of origin if they cannot function autonomously
adult children are not launched but are expected
due to personal limitations (e.g., disabilities) or
to remain in the family home or neighborhood,
need for continued financial support to pursue
and the family integrates their partners and
life goals (e.g., advanced training and educa-
children into the family. In these families,
tion) (Carter & McGoldrick, 1989). Young
interdependence is valued and autonomy striv-
adults often need to find a way to negotiate their
ings are experienced as disloyalty to the family
personal desires for autonomy, their family's
unit. In some cultural groups (Iranian-Amer-
and culture's expectations about independent
ican), the middle generation consider their adult
functioning, and the majority population's
children, even those who are married with
values on age-appropriate adult behavior. This
offspring, to be children (McGoldrick et al.,
negotiation is quite complex for young adults
1996). Further, in many refugee families,
who leave their ethnic community and engage
especially those who were traumatized in their
actively in mainstream culture.
homeland (e.g., Cambodian), the launching
Young adults' ethnic involvement during this
phase of the family cycle is threatening. The
phase is manifested in their choice of friends and
middle generation feels isolated and abandoned
partners, religious practices, structured ethnic
when the younger generation attempts to
social groups, political ideology and activity,
separate, particularly if their extended kin and
area of residence, and career path (Phinney,
social support network have remained in their
1990a). Studies examining ethnic identity
homeland (McGoldrick et al., 1996).
among college students fail to yield consistent
Conversely, in many White Anglo Saxon
results regarding the association between posi-
Protestant families, value is placed on launching
tive or negative feelings about individual's
older adolescents and young adults and in their
ethnic identity, self-esteem, and psychological
assuming significant independence. In such
adjustment (Phinney, 1990a). However, re-
families, an 18-year-olds' inability or unwill-
search on the stage model of ethnic identity
ingness to leave the family home and function
reveals an association between college students'
with limited family support is perceived as
achieved level of ethnic identity and self-esteem
pathological. Many cultural groups fall in the
(Parham & Helms, 1985a, 1985b; Phinney &
middle of this continuum, although the specific
Alipuria, 1990). This relation is particularly
characteristics of this middle group vary. As an
evident in African-American, Asian-American,
example, many Jewish-American families give
and Mexican-American young adults, and less
mixed messages about separation during this
obvious in Caucasian American college students
family life cycle phase. Increased autonomy and
(Phinney & Alipuria, 1990). Data also indicate
success is valued highly on the one hand, but
that college students' stage of ethnic or racial
high levels of contact and intimate sharing
identity is associated with their preferences
continue to be expected on the other. These
regarding the race or ethnicity of their therapist
conflictual messages are often associated with
(Parham & Helms, 1981). Specifically, older
guilty distancing or ambivalent closeness (Car-
African-American adolescents and young
ter & McGoldrick, 1989).
adults who endorse early stages of racial identity
(i.e., pre-encounter) often prefer Caucasian
10.08.4.4.2 Leaving home: single young adults
therapists and are nonaccepting of African-
For single young adults, this stage of American counselors, whereas African-Amer-
development includes continued separation± ican adolescents and young adults who exhibit
individuation, self-definition, and definition of higher levels of racial identity (i.e., encounter,
 Family Life Cycle Stages: A Cultural Perspective 189

immersion±emersion, internalization) manifest deal with the illness and death of their parents
varying degrees of both preference for same- are influenced by the middle generation's
race therapists and lack of interest in working culture of origin. Sex roles, an aspect of one's
with Caucasian counselors (Parham & Helms, culture of origin, impact the negotiation of these
1981). These data suggest an association family life cycle tasks (Carter & McGoldrick,
between identity formation and self-esteem; 1989). For families whose cultural traditions
the more young adults accept their ethnicity, the emphasize the primacy of the woman's role as
more positive they feel about themselves. These mother and wife (e.g., Italian-American, Puerto
data also underscore the need to consider the Rican), the launching phase may be associated
young adults' level of ethnic identity in making with a crisis in the marriage if the woman
decisions regarding therapist assignments. becomes involved in activities outside the home.
A major foci of the young adults' develop- Conversely, in communities in which the
ment relates to their choice of friends and woman's role outside the home is valued or
intimate partners, and decisions about whether accepted (e.g., Irish-American, African-Amer-
to be involved in a relationship or remain single. ican, White Anglo Saxon Protestant), the
Once older adolescents and young adults leave likelihood of this type of marital crisis at this
the family home, they often feel an increased stage is minimal. This is particularly true for
sense of personal choice regarding the ethnicity those cultural groups in which limited emphasis
of their friends and partners and their sexual is placed on intimacy within the marital dyad
orientation. While this may be a relief for young (e.g., Irish-American) or in which parent±child
adults, it often forces them to become more connectedness is valued more highly than the
clear about their preferences and values regard- husband±wife bond (e.g., Mexican-Americans)
ing interpersonal relationships as distinct from (McGoldrick et al., 1996).
those held by the family. Should young adults
choose to engage in relationships not acceptable 10.08.4.4.4 Dealing with parental illness and
to their family's cultural norms and expecta- death
tions (e.g., interracial, interfaith, or interethnic
dating; same-sex relationships), the risk of being There are differences among ethnic groups
ostracized or criticized by the family of origin about the responsibility the middle generation
may be considerable and certainly depends to experiences regarding caring for their aging and
some extent on the family's ethnic heritage. For dying parents (Carter & McGoldrick, 1989). In
instance, since the African-American family some ethnic groups (e.g., Greeks, Italians,
often buffers its members from racism, these Chinese, African-Americans), the middle gen-
families are unlikely to reject a lesbian young eration expects to be the primary caretakers for
adult family member, despite the fact that a their elderly parents and placing a loved one in a
lesbian life style may be considered unaccep- nursing home is rarely considered an option.
table (Comas-Diaz & Greene, 1994). This stance Among certain groups (e.g., Germans, Scandi-
does not imply acceptance of the young adult's navians, Jews), the decision to place an elderly
sexual orientation but rather reflects tolerance parent in a nursing home is commonly accepted.
and a desire to protect the young person from For some of these families, it is considered
additional discrimination. This stance of toler- essential to provide aging parents with a
ance, however, is often relinquished should the familiar cultural environment (e.g., Jewish
lesbian young adult openly define herself as a nursing home) in which familiar ethnic rituals
lesbian (Comas-Diaz & Greene, 1994). In the and customs are practiced.
Native American community, young adult
women who choose a lesbian life style are most 10.08.4.5 Families in Later Life
often accepted in the lesbian community within
the mainstream culture and rejected by their The elderly face many pressing challenges in
family and community on the reservation the US, and as such the role of culture has
(Comas-Diaz & Greene, 1994). As a result, often been overlooked by clinicians, research-
these young women often experience a loss of ers, and, at times, the elderly. As individuals
support if they explore a nontraditional sexual get older, there is a greater emphasis on
orientation. changing roles in the intergenerational family,
the ªculture of poverty,º age discrimination,
victimization, retirement, meaningfulness of
10.08.4.4.3 Conflicts experienced by the middle
life, health and vitality, loss of significant
generation
relationships and death of loved ones, and
Realignment of the marital subsystem in preparation for their own death. Such issues
response to the launching of young adult entail life review and integration. Families with
children and the manner in which marital dyads elderly loved ones generally function best when
190 A Cultural Perspective on Families Across the Life Cycle

they acknowledge and experience the wisdom it is most common for the elderly to wear
of the elderly and support the older generation traditional dress, many elderly Asian-Indian
without overfunctioning for them (Carter & women are ridiculed if they don a sari. Elderly
McGoldrick, 1989). The multitude of issues people who retain their culture's traditions may
experienced by the elderly and their family feel particularly ostracized if their younger
often obscure the importance of culture in this family members criticize their choices to retain
period. This section begins by defining the term their language and/or dress of origin.
elderly. This is followed by a review of issues The maintenance of beliefs from the home-
confronting the elderly, with specific attention land may also increase the elderly's vulnerability
paid to the immigrant elderly. Then, ethnic to oppression. The Chinese-American value
identity in the elderly is examined. It should be placed on stoicism often conflicts with the
noted that cultural information regarding the American medical system, as well as the family
elderly is minimal and the data are limited to a system (Sakauye & Chacko, 1994). Medical
few subcultures (American Psychiatric Asso- personnel and younger family members often
ciation, 1994a). express frustration and confusion regarding the
severity of an elderly Chinese-American's pain
given their tendency to refrain from articulating
10.08.4.5.1 Definition of the elderly the seriousness of their problems.
Many minority elderly face a sense of
In general, old is defined as 65±84, whereas
isolation and alienation due to their memories
old-old refers to age 85 and above. However, in
of traumatic experiences in the US and/or their
some groups, being elderly starts at 55. In the
country of origin. Elderly African-Americans
US, some benefits associated with age begin at
who talk about slavery, elderly European Jews
55, others begin at 65 or 70. These numbers have
who reflect upon the Holocaust, and elderly
changed over the years, partially due to the fact
Japanese-Americans who discuss the intern-
that the average life span has increased.
ment camp experiences of World War II may
The onset of old age varies among cultures, in
feel that their pain is discounted by younger
part because individuals of various cultures die
family members who fail to appreciate the
at different ages (American Psychiatric Asso-
ongoing significance of such traumatic times.
ciation, 1994a). The definition of old age is
This sense of rejection by family members, who
complicated further by the within-group varia-
are unlikely to ever encounter such tragedies,
bility in typical age of death. For instance,
further compounds the suspiciousness often
African-Americans tend to die younger than
associated with postslavery, the Holocaust, or
Euro-Americans. However, African-American
internment camp experiences.
individuals who survive past 75 have a longer
Some elderly people struggle to maintain a
life expectancy than Caucasian persons of the
sense of autonomy and independence, despite
same age (Baker, 1994). Differences in life
increased family dependence due to economic
expectancies and health status raise questions
limitations or physical or mental deterioration.
about when a family and cultural group views
This conflict is most pronounced in cultural
an older loved one as elderly.
groups in which caretaking of parents is not the
norm (e.g., Germans, Scandinavians, Jews).
Conversely, for those groups (e.g., African-
10.08.4.5.2 Issues confronting the elderly
Americans, Latinos, Native Americans, Asian-
The elderly confront myriad issues during the Americans) in which it is common for older
stage referred to as ªFamilies in Later Life.º family members to reside with, and be cared for
First, non-Euro-American elderly individuals by, younger members, independence±
often experience discrimination, based on their dependence struggles may be less central.
age and cultural background. Latino elders
often are the object of prejudice because of their
Spanish surnames and inability to speak English
10.08.4.5.3 Immigrant elderly
(Jimenez & de Figueiredo, 1994). Due to their
limited command of English, combined with the From a cultural perspective, the immigrant
fact that interpreters often fail to capture elderly deserve specific attention. With the
accurately the perspective of the elderly, Latino exception of African-Americans, Native Amer-
elderly are often unable to defend themselves icans, Alaskan, and Hawaiian Natives, and
against discrimination and their behaviors and those from cultures whose families immigrated
attitudes are often misinterpreted. to the US hundreds of years ago (e.g., White
Appearance (e.g., clothing, accessories) and Anglo Saxon Protestants), many minority elders
diet are variables associated with discrimination are relatively new immigrants to the country
against minority elderly. For instance, because (e.g., Soviet Jews) (American Psychiatric
 Culturally Sensitive Family Assessment and Intervention 191

Association, 1994a). These elderly immigrants According to Zayas et al. (1996) and Dana
must adapt to a novel environment with new (1993), therapists transverse a number of stages
expectation while losing much of their accu- in becoming culturally sensitive practitioners:
mulated experience from their culture of origin. (i) unawareness and/or denial, defensiveness
As a consequence, they may lose much of their and minimization of the importance of cultural
value within the family. Superimposed on this issues;
are the other issues surrounding getting older, (ii) heightened awareness and acceptance of
resulting in the immigrant elderly feeling culture;
extremely challenged and overwhelmed. The (iii) burden of considering culture and doing
intensity of these struggles appears correlated therapy and adapting behavior and thinking
with the recency of immigration, with less recent accordingly; and
immigrants manifesting fewer problems (Amer- (iv) integration and synthesis of culture into
ican Psychiatric Association, 1994a). In spite of the assessment and intervention process.
the aforementioned challenges, the elderly, Psychologists who engage in culturally in-
particularly those who are immigrants, tend formed assessments and interventions consider
to be survivors who are resilient and exhibit a myriad variables, including the family's group
pleasure in life that is not quelled by age, identity, the family's identity as a subsystem,
suffering, or loss (Myerhoff, 1979). and the identity of each individual member.
Also, the clinician focuses on the beliefs, values,
and language of each family member and the
10.08.4.5.4 Ethnic identity family unit as a whole (Dana, 1993).
The following section reviews the conceptual
Elders often assume the role of maintaining issues and assumptions that guide family
their own and their family's ethnic identity assessment and intervention in a culturally
despite the family's assimilation into main- informed manner (Kaslow et al., 1995; Odell,
stream culture and associated loss of cultural Shelling, Young, Hewitt, & L'Abate, 1994). The
knowledge, language, and traditional values topics covered include values, help-seeking
and beliefs (American Psychiatric Association, behavior, and adherence issues. These issues
1994a). In the Native American community, are of paramount importance given the con-
this may be particularly problematic given that siderable variation in the presenting problem,
much of the tradition is maintained through nature and rate of help-seeking, views of mental
oral history. A second aspect of ethnic identity health services, and the nature and rate of
of concern to many minority elderly is that they premature termination among diverse cultural
are no longer being as honored because of their groups (Kazdin, Stolar, & Marciano, 1995).
strong ethnic identification (Thompson, 1994). Next, techniques for assessment and interven-
Again, in some Native American families, as the tion appropriate across cultural groups and
younger generations become more American- family life cycle stages are described. This
ized, the elderly are less valued despite their information provides the background for the
wealth of experience. A similar process is later section on culturally sensitive assessment
evident in other groups (e.g., Asian-Americans). and intervention across each specific phase of
the family life cycle.

10.08.5 CULTURALLY SENSITIVE

FAMILY ASSESSMENT AND 10.08.5.1 Values
INTERVENTION
To conduct culturally sensitive assessments
The conduct of culturally sensitive assess- and interventions, psychologists must be cog-
ments and interventions is predicated on the nizant of their own biases and prejudicial
incorporation of a conceptual model that reactions regarding various cultural groups,
emphasizes the behaviors, perceptions, beliefs, their personal and culturally based values, and
and values of different groupings of individuals. the cultural values of the family with whom they
Clinicians and service delivery systems must be are working. Since families often seek help when
knowledgeable about, and attentive to, their their norms are disparate from the cultural
own cultural backgrounds and those of the values represented by other family members
client and their family. Awareness of these and/or the community, values play a central role
cultural factors must inform the assessment and in family work.
intervention process with families from all If the clinician and family differ in their
cultural groups (i.e., cultural competence) values about the presenting problem, but these
(Dana, 1993; Zayas, Torres, Malcolm, & differences do not reflect significant conflict or
DesRosiers, 1996). indicate pathological functioning in the family's
192 A Cultural Perspective on Families Across the Life Cycle

cultural context, it is recommended that the Classes among family members and/or gen-
therapist incorporates the family's cultural erations regarding values are a necessary
framework throughout the assessment and consideration in the assessment and treatment
intervention. This recommendation assumes of minority families (Gibbs & Huang, 1989).
that the therapist's and family's values are Failure to attend to the processes of value
equally valid. Another possible stance is for the orientation and value clashes may result in an
therapist and family to acknowledge their overemphasis on intrapsychic or family dy-
differences of opinion and the acceptability of namics, and may limit the treatment efficacy.
such differences. Thus, an ecologically oriented approach, that
If during evaluation or treatment the practi- attends to contextual issues as these influence
tioner discovers that the family's value system the values of each family member, must be
leads them to engage in behaviors considered incorporated in all assessment and intervention
illegal or unethical in the relevant jurisdiction, endeavors with families from nondominant
the clinician must inform the family and take cultural groups.
appropriate steps. Harsh physical punishment
of children may be normative in certain cultural
groups (e.g., Jamaican families), but such 10.08.5.2 Help-seeking Patterns
behavior is illegal in the US and thus requires
that the therapist report the family to the The family's cultural background often
appropriate authorities (e.g., Gibbs & Huang, influences the type of help the family seeks
1989). In such instances, the therapist needs to for a loved one's problems. Many families from
work with the family to help them modify their minority cultures prefer to receive help from
disciplinary practices in accordance with the both trained and not formally trained members
law. This needs to be done sensitively, without of their own community. This preference often
the therapist invalidating the family's cultural results in their being less likely to seek medical
practices. or mental health services from qualified profes-
If the behaviors associated with the family's sionals, given the relative dearth of well-trained
values are contrary to normative practices for minority providers and culturally sensitive
the relevant cultural groups in the current service programs. For example, African-Amer-
ecological context, but the behaviors are not ican and Latino families are less likely than
illegal or unethical, the therapy helps the Euroamerican families to seek support from
family modify these values and associated agencies and professionals in the initial stages of
behaviors in an effort to foster healthy responding to the a family members' difficulties.
development and enhance family functioning. (McMiller & Weisz, 1996). Different help-
To accomplish this goal, the psychologist must seeking patterns appear to reflect more negative
help the family examine the cultural origins of views toward professionals by majority families
these values, ascertain the positive and and the increased availability of alternative
negative consequences of engaging in beha- social networks (e.g., extended family, clergy) in
viors associated with the values, and learn many minority communities as compared to
culturally sanctioned alternative practices. It is Euroamerican communities. In a related vein, in
helpful if the therapist underscores that the many minority communities there is consider-
family's cultural values may lead to problems able stigma associated with revealing personal
in some contexts and be beneficial in others, and/or cultural values and beliefs to someone
and that values developed in one historical outside the family unit, particularly to someone
context may be maladaptive in a new socio- outside the culture.
cultural context. These differential help-seeking patterns must
When there are conflicts among family be considered when forming an alliance with
members regarding key values, and the therapist minority group families, assessing the index
shares the values of only some family members, person's and family's problems, and designing,
the therapeutic process becomes complicated. implementing, and evaluating culturally based
Often, the therapist will be most aligned with community outreach programs (McMiller &
those family members who have the most Weisz, 1996). Specifically, during the initial
similar acculturation status and/or cultural stages of the evaluation process with African-
identity to the therapist. It is common for the American and Latino families, the psychologist
therapist working with immigrant or refugee must address the family's concerns and reluc-
families to conflict with the grandparent tance about mental health services and educate
generation regarding gender roles in the family the family about mental health services. Only by
system and to support the gender roles desired doing so will the clinician earn the family's trust
by the adult children who are likely to have sufficiently to conduct a thorough, accurate
acculturated more rapidly. assessment (McMiller & Weisz, 1996).
 Culturally Sensitive Family Assessment and Intervention 193

10.08.5.3 Adherence consider the unique aspects of each family to

distinguish culturally based and idiosyncratic
Given the data on minority families' reluc- family relational patterns (Goldenberg &
tance to use professional mental health services Goldenberg, 1994).
and the high rates of attrition among culturally
diverse groups, it behoves the therapist to
become familiar with risk factors associated
with dropping out of treatment. While several 10.08.5.4.1 Stance of the therapist
factors of premature termination (e.g., parental Nonspecific therapist characteristics asso-
stress, antisocial behavior of the parent and/or ciated with the conduct of competent assess-
child, adverse parenting styles, low SES) are ments and interventions (e.g., empathy,
common among most families, specific differ- warmth, genuineness, acceptance, respect) are
ences among ethnic groups in the rate and necessary but not sufficient to assess adequately
nature of intervention drop out have been found cultural issues (Sue & Sue, 1990). Culturally
(Kazdin et al., 1995). As an example, African- informed clinicians must also: (i) be knowl-
American families leave treatment more fre- edgeable about their own cultural background
quently and earlier than their Caucasian and its influence on clinical practice; (ii)
counterparts (Kazdin et al.). Predictors of comprehend the impact of culture on the lives
African-American drop out also differed, with of the families with whom they work; (iii) be
compliance often predicated on child academic cognizant of the variability of normative family
functioning. structures and functioning across and within
There are a number of techniques that may cultural groups to avoid stereotyping; (iv) be
reduce attrition rates, however, many of these attuned to subtle cultural variations in lan-
strategies are ineffective with families from guage, nonverbal behavior, and expressions of
culturally diverse groups (Paniagua, 1994). distress; (v) adjust their style to be compatible
To effectively prevent premature termination with the family's culturally influenced patterns
of family therapy, the psychologist's inter- of relating to one another and to outsiders in
ventions must attend to the family's culture authority; (vi) modify the therapeutic strategies
and the impact of the family's culture on used to facilitate behavior change in a manner
attrition. Separate guidelines have been consistent with the family's cultural values; (vii)
proposed to prevent attrition in African- recognize and use the family's natural support
American, Latino, Asian-American, and Na- systems in the community; and (viii) be willing
tive American families. For example, when to incorporate other culturally acceptable
working with African-American families, it is clinicians from multiple disciplines into the
suggested that racial differences be addressed, assessment and intervention process (London &
mental health problems not be linked to Devore, 1988; Odell et al., 1994; Sue & Sue,
parental behaviors, medication not be re- 1990).
commended as the initial treatment of choice, The American Psychological Association's
and the psychologist ªnot give the impression guidelines for ethical practice for the provision
that he or she is the protector of the race of psychological services to ethnic, linguistic,
when discussing racial issuesº (Paniagua, and culturally diverse populations (American
1994, p. 93). To minimize the likelihood of Psychological Association, 1993) maintain that
attrition when working with Native American it is only ethical to assess and intervene with
families, the psychologist should emphasize individuals and families from the nondominant
listening and collaboration rather than talk- culture if the professional is trained in multi-
ing and authority, de-emphasize the issue of cultural assessment and intervention. Accord-
time, discuss the administration rather than ing to these guidelines, the therapist's stance
the control of the problem, and avoid must reflect their recognition of cultural
personalism. diversity, understanding of the role that
culture, ethnicity, and race play in psychosocial
development, awareness that economic and
10.08.5.4 Culturally Sensitive Techniques political factors influence psychosocial devel-
opment, and knowledge of the impact of
Cultural issues influence the therapeutic culture, gender, and sexual orientation on
stance, the development of the working behavior. Psychologists working with cultu-
alliance, and the assessment and intervention rally diverse families must communicate a
process (Sue & Zane, 1987). In addition to value on helping families understand, main-
attending to cultural factors as these influence tain, and resolve their own sociocultural
family dynamics, the psychologist conducting identification (American Psychological Asso-
the family assessment and intervention must ciation, 1993).
194 A Cultural Perspective on Families Across the Life Cycle

10.08.5.4.2 Development of the working alliance patterns must be considered (Zayas et al., 1996).
Evaluators must be mindful of the ways in
Joining, a key component of forming a
which their own culture may affect the assess-
working alliance between the therapist, each
ment process. In addition to cultural biases
family member, and the family system as a
influencing the assessment of intellectual,
whole, is crucial to the conduct of effective
psychiatric, and behavioral functioning, these
assessment and intervention. This process is
biases may impact upon the evaluator's percep-
facilitated when the therapist's space (office,
tion and evaluation of family functioning
agency) includes culturally familiar objects and
(Canino & Spurlock, 1994; Dana, 1993). Given
symbols to the family (Vasquez-Nuttall, Avila-
the growing literature on cultural considera-
Vivas, & Morales-Barreto, 1984). Through the
tions in assessing psychological symptoms and
joining process, a trusting relationship is forged
psychiatric conditions in people across the life
between the therapist and the family.
span (e.g., Alarcon, 1995; American Psychiatric
Through the process of joining, the clinician
Association, 1994a; Canino & Spurlock, 1994;
becomes cognizant of the culturally influenced
Gaw, 1993), and in diagnosing psychiatric
rules, roles, structure, communication and
disorders in the recent Diagnostic and statistical
problem-solving patterns, and traditional
manual of mental disorders (4th ed.; DSM-IV)
sources of help that impact on family interac-
(American Psychiatric Association, 1994b), our
tional processes. To enhance the working
comments on assessment only address consid-
alliance with a family from a cultural group
erations pertinent to families.
unfamiliar to the psychologist, or when the
During the evaluation, the clinician must
family engages in culturally driven family
gather information about the ethnic, racial, and
patterns to which the therapist is unaccustomed,
religious background of the family and data
it is suggested that the therapist assume a
about the historical and current political, social,
position of humility coupled with benign
and economic conditions of the family's cultural
curiosity (Odell et al., 1994). Such a stance
group. The construct of a genogram may be
can be assumed most readily if the clinician
useful (McGoldrick & Gerson, 1985). Geno-
requests the family's aid in learning relevant
grams, which graphically provide personal data
cultural norms and patterns. If the family is
regarding individual members (e.g., ethnicity,
unable to provide adequate information to
religion, current residence), and information
insure an empathic awareness of the family's
about family structure, relationships, and
interactions within their cultural context, the
patterns, enable the psychologist and family
therapist must glean such data from others
to develop systemic hypotheses about family
knowledgeable about the particular family's
functioning and its connection to the larger
culture.
family and sociocultural context.
Credibility is associated with effective joining
Some therapists question the appropriate
(Sue & Zane, 1987). Professionals' credibility, a
timing and nature of genogram construction
reflection of their status, may be determined by
with families from certain cultural groups.
the position assigned by the family (ascribed
Boyd-Franklin (1989) asserted that with
credibility) or by their competencies (achieved
African-American families, genogram work
credibility). When therapists exhibit culturally
may be most meaningful later in the treatment
consistent assessment and intervention strate-
after trust has been established, rather than
gies, they may be considered credible by a given
during the evaluation. Similarly, Odell et al.
family system. The lack of ascribed credibility of
(1994) have noted that since constructing a
formalized mental health services may account
genogram may elicit painful memories for many
for low utilization rates among certain cultural
immigrant and refugee families, this technique
groups, and the lack of achieved credibility may
may sabotage the development of the initial
contribute to explanations of nonadherence.
working alliance and thus may best be intro-
duced during the intervention. For many
families who have lost a loved one due to
10.08.5.4.3 Assessment process
sociopolitical conditions (e.g., Holocaust survi-
Once psychologists have begun to form a vors, Bosnian refugees), projective genogram-
working alliance with the family, the assessment ming elicits effectively distressing) yet important
may begin. The psychologist who gathers family information and feelings (F. W. Kaslow, 1995).
assessment data in a culturally sensitive manner Thus, while genograms may be an important
communicates a respect of the cultural diversity assessment tool with families from most cultural
of families (Hanson, Lynch, & Wayman, 1990). groups, the family's cultural background should
In conducting a family evaluation, the ways inform the timing of this task.
in which the family's culture impacts on An assessment strategy related to the geno-
their symptom presentation and interactional gram, but devised for work with diverse family
 Culturally Sensitive Family Assessment and Intervention 195

groups, is the culturagram (Congress, 1994). matters. Asian-American families prefer the
With the culturagram, psychologists glean therapist to be confident and active in the goal-
information from the family regarding: reasons setting process, while simultaneously commu-
for immigration, length of time in the commu- nicating respect for the family (Ho, 1987). With
nity, citizenship status, language spoken at Native American families, goal-setting should
home and in the community, health beliefs, be collaborative. Given the value on interde-
major holidays, and values on family, educa- pendence in the Native American community,
tion, work, gender roles, religion, and money. all relevant nuclear and extended family
Constructing a culturagram enables clinicians members should be included in setting inter-
to ascertain the effects of culture on the family vention goals (Ho, 1987). When setting goals
system and to individualize ethnically similar with low-income, African-American families, a
families. As a result, clinicians are more mutual process should be assumed, with a focus
culturally empathic and more able to empower on survival needs and the incorporation of an
the families with whom they work. ecostructural framework (Ho, 1987).
Enumerable tools and methodologies have In addition to setting goals specific to the
been devised to assess multiple aspects of family given family, many culturally competent practi-
functioning. These include self-report scales, tioners recommend that cultural intentionality
micro- and macroanalytic coding schemas to and bicultural competence be defined as
code interactional patterns, and projective therapeutic goals for families across cultural
techniques (for review, see Fredman & Sher- groups who seek mental health services (Boyd-
man, 1987; Jacob, 1987; L'Abate & Bagarozzi, Franklin, 1989; Ivey, Ivey, & Simek-Morgah,
1993). Unfortunately, few of these measures or 1993; Szapocznik et al., 1984). Cultural in-
coding schemas have been developed, normed, tentionality refers to the ability to communicate
or empirically tested for specific cultural groups, competently with others within the cultural
and thus their utility across groups remains group and with individuals from multiple
questionable (Dana, 1993). In addition, general- cultural backgrounds. Bicultural competence
izations about findings gleaned from using connotes the simultaneous processes of accom-
standard assessment protocols must be limited modating to the host culture and retaining
and made with caution. Given the scarcity of aspects of the culture of origin.
culture-free assessment strategies, the assessor
must take the family's cultural context into
10.08.5.4.4 Intervention process
account when interpreting findings from assess-
ment protocols not standardized with the Throughout the intervention phase, the
family's cultural group. This requires including psychologist is a cultural interpreter or culture
an evaluation of culturally valid constructs (e.g., broker, helping the family recognize and resolve
racial or ethnic identity, level of acculturation, conflicts between the demands and values of the
belief systems, culture-specific syndromes) minority and majority cultures (Canino &
(Lasry & Sayegh, 1992; Phinney, 1990b). For Spurlock, 1994; Glordano & Giordano, 1995).
example, the psychologist may use Gushue's Issues that may require interpretation include:
(1993) recent adaptation of Parham and Helms kinship relations, respect for roles and family
(1985b) Black and White interaction model for hierarchy, personalization in the therapeutic
assessing and working with families. This relationship, and the need to involve additional
assessment strategy enables the clinician to people from the family's community (e.g.,
incorporate cultural identity data in making an clergy). To assume the role of cultural inter-
initial family assessment. preter, the therapist may incorporate Boyntons
The final phase of the assessment process is (1987) ESCAPE model, according to which the
problem definition and goal-setting. Cultural therapist, as cultural interpreter, must: Engage
variables that may impact this phase include the the family within its context; be sensitive to the
role of authority, preferred decision-making family's culture; communicate an awareness of
strategies, the view of psychological problems the culture's potential and positives; and know
and potential solutions, and culturally based the environment in which culture clashes are
values. Thus, with Latino families, the goals likely to occur.
should address immediate and concrete con- When intervening with families from either
cerns (Ho, 1987). These families prefer to focus the same or a different cultural background as
on goals that affect family subsystems, parti- themselves, therapists must be mindful that
cularly the parent±child subsystem, rather than interpersonal behaviors may be interpreted
individual family members or the marital dyad. differently. For example, whereas listening
When working with many Asian-American may be experienced by some as reflecting
families, it is recommended that the goals be empathy and concern, families from certain
well-defined, objective, and address practical cultural backgrounds are likely to perceive
196 A Cultural Perspective on Families Across the Life Cycle

listening as not caring. Thus, it is crucial that interventions must take into account the
the family and the therapist discuss their family's specific ethnic background and level
differing perceptions and experiences through- of acculturation (Gaw, 1993). When working
out the course of the family work. Awareness of with Asian-American families, it is suggested
these differences should inform subsequent that the intervention approach be relatively
interventions. formal and structured, and focus on pragmatic
A major focus of family interventions is the concerns rather than underlying affects. The
introduction and utilization of adaptive therapist must balance showing respect for
problem-resolution tactics. Problem-resolution parental authority and the family's culture of
strategies are most effective when system and origin with the assumption of an authoritative
cultural variables are taken into account. Since stance. Family members should be encouraged
culturally specific intervention approaches for to communicate verbally and the value of
problem resolution have been offered to families democratic communication should be high-
from multiple cultural groups (for detailed lighted (Gaw, 1993). Since many Asian-Amer-
discussions, see Boyd-Franklin, 1989; Falicov, ican families prefer negotiation of differences
1983; Ho, 1987; McGoldrick et al., 1982, 1996; rather than direct conflict, it may help to hold
Paniagua, 1994), this section reviews, briefly, separate sessions with individual members prior
techniques for problem resolution with families to addressing family conflict directly (Berg &
from the most often encountered cultural Jaya, 1993; Ho, 1987).
groups in the US. The mental health services literature on work
The optimal family intervention approach for with Latino populations has focused on im-
African-American families, regardless of SES, is proving the accessibility of mental health
time-limited, problem-focused, and present- services, choosing interventions according to
oriented with all significant family members the cultural characteristics of Latinos, and
and members of the kinship and caregiving modifying traditional intervention approaches
networks included (Boyd-Franklin, 1989; Ho, based on a familiarity and evaluation of ethnic
1987; McGoldrick et al., 1996). The psycholo- characteristics or creatively deriving the inter-
gist, who needs to assume an active stance, vention program in response to the cultural
should inform the family about the goals, milieu (Rogler, Malgady, Constantino, & Blu-
process, structure, and limits of family therapy, menthal, 1987). For example, home visits may be
and serve as a role model, educator, and an essential component of family interventions
advocate. Effective family therapy underscores with Latino families (Ho, 1987). In addition, or
and utilizes family strengths and resources to when home visits are not possible, the psychol-
empower the family to solve its own problems, ogist should become acquainted with extended
exert more control over the environment, cope family members and assimilated into the family's
constructively with racism and oppression, and power hierarchy in order to exert the influence
extricate itself from the victim system (Boyd- necessary to help the family change. The
Franklin, 1989; Pinderhughes, 1989). Psycho- therapist must appreciate the positive aspects
education and skills training, role clarification, of roles within Latino families that may have
and boundary setting are useful strategies. The negative connotations within middle class,
unique power and value conflicts of middle- Anglo American culture (e.g., machismo in the
class African-American families may require father figure). It is essential that the therapist
additional treatment modifications, such as the function as cultural translator, mediator, and
therapist relabeling behaviors that appear role model to facilitate the family's active
maladaptive as manifestations of the family's engagement in the community.
determination to negotiate effectively between It is often the case that Native American
cultures with competing demands (Corner- families' explanation of a family problem (e.g.,
Edwards & Spurlock, 1988). marital discord, parent±child conflict) is that the
When intervening with Asian-American problem is a response to the family's inability to
families, the psychologist must respect key provide for essential needs (e.g., food, shelter)
values in the community (e.g., the central role (Ho, 1987). As such, the early stages of a family
of family solidarity, the emphasis on connect- intervention must address these basic needs and
edness and integration rather than separation the psychologist should provide advice and
and individuation) and must be sensitive to the information to enhance the family's capacity to
families' culturally sanctioned reluctance to fulfill these basic needs. Such a stance commu-
expose conflict to outsiders because it reflects nicates the therapist's sensitivity to the family's
disloyalty (Gaw, 1993; Tamura & Lau, 1992). basic needs and willingness to provide immedi-
Although these family values and patterns of ate services (Panigua, 1994). Such a stance is
relating characterize Asian-American families likely to foster the development of a working
from multiple countries of origin, effective alliance with the family. When undertaking the
 Culturally Sensitive Family Assessment and Intervention 197

problem-resolution phase of family interven- specific questions to elicit all relevant informa-
tions with Native American families, the tion, maintain a friendly distance, and avoid
therapist should emphasize group decision- exploration of painful effects and embarrassing
making by including nuclear and extended topics (Jalali, 1988; McGoldrick, 1996). Thus, a
family members and key community members structured approach, focusing on the presenting
(medicine man or woman, tribal leaders) (Ho, problem, is suggested (McGoldrick, 1996).
1987), and must be mindful of this culture's The family is of prime importance in Italian-
holistic, interdependent world view and the fact American communities. Families in these com-
that relationships with kin are of prime munities are often reluctant to support mem-
significance (Ho, 1987). Suggestions must be bers' differentiation. In addition, many Italian-
delivered to the family in a thoughtful, prag- American families attempt to resolve conflicts
matic, and calm manner (Ho, 1987; Panigua, within the nuclear and extended family. The
1994). One of the major goals of family therapist, therefore, must respect the family as a
interventions with Native American families is cohesive unit. Attempts to decrease family
the promotion of interdependence. This can be closeness by strengthening internal and weak-
achieved most readily when the therapist ening external boundaries are likely to be
functions as a role model, committed to resisted and met with the family's refusal to
engaging all relevant parties in problem assess- let the therapist enter the family system. This
ment and resolution. Involving all family impedes the family work, which can only be
members in the intervention process typically effective when the therapist is treated as a
entails allowing the family to determine the member, albeit distant, of the family. Because
issues to be addressed (Ho, 1987; Panigua, these families often seek therapy during life
1994). The use of structural and strategic cycle transitions associated with separation, it
interventions such as reframing and relabeling may be difficult for the therapist to refrain from
are likely to be particularly effective. Strategies challenging the family's strong emotional ties.
experienced by the family as indicating the Thus, family therapists can help most by
family's causal role in the identified patient's coaching individuals to remain close to the
symptoms are likely to meet with considerable family, without becoming engulfed (Giordano
opposition. & McGoldrick, 1996). Given the Italians'
Given the consistency between Jewish family penchant for ªhistrionics,º the therapist must
values (family membership and loyalty, egali- ascertain the actual severity of the problem
tarianism with regard to roles, intellectual (Jalali, 1988). Despite their emotionally expres-
achievement, verbal expression of feelings) sive presentation, they frequently deny family
and those of psychotherapy, Jewish families conflicts and secrets until they trust the
often appear to engage readily in family therapist. It is important, therefore, to provide
therapy (Rosen & Weltman, 1996). However, timely advice regarding the chief complaint,
the culture's pride in suffering and emphasis on while patiently waiting for the family to examine
insight over behavior change may complicate underlying patterns (Giordano & McGoldrick,
the family therapy process. Jewish families 1996).
often seek services when there is a conflict
within the system regarding the degree of
closeness vs. separateness. When working with
these families, the psychologist must commu- 10.08.5.5 Culturally Sensitive Techniques
nicate to the family a respect for their value on Across the Life Cycle
family cohesion, while simultaneously addres-
10.08.5.5.1 The joining of families: culturally
sing the ways in which closeness in the family
sensitive assessment and intervention
system may interfere with the development and
maintenance of family members' personal Given the significant cultural variations in the
boundaries and age-appropriate separation± nature of marital relationships among diverse
individuation. families, an assessment of a couple must include
Irish-Americans tend to minimize problems, attention to those cultural variables most likely
have difficulty articulating their feelings, and to impact upon the functioning of the dyad. In
use humor and alcohol to manage stress addition, when conducting an assessment, the
(McGoldrick, 1996). These coping strategies psychologist must be mindful of accepted
are often associated with a reluctance to seek cultural practices, many of which may be
psychological services. When Irish-American unfamiliar to the clinician (e.g., arranged
families do enter therapy, the psychologist is marriages, lack of emphasis placed on love).
likely to encounter guilt, resentment, and self- When assessing newly formed couples, whether
reproach. To intervene effectively with Irish- or not they are married, the psychologist must
American families, family clinicians should ask examine each person's perspective on the
198 A Cultural Perspective on Families Across the Life Cycle

meaning of an intimate partnership (values on perspective (Canino & Spurlock, 1994). This
intimacy, fidelity, divorce), appropriate gender involves using and producing culturally and
roles within a couple, and the degree of developmentally sensitive instruments, techni-
autonomy vs. interdependence expected by each ques, and explanations. Direct observation of
partner both within the dyad and between the children playing, drawing, and interacting with
dyad and the extended family. Attention must their family can provide metaphors for the
be paid to each person's notions regarding the child's thoughts and feelings (Grizenko,
degree to which each party has an equal role and Sayeghm, & Migneault, 1991). Such metaphors
value in the partnership and the responsibilities are particularly helpful when language differ-
to be assumed by each person. It is also crucial ences complicate the assessment process. The
that the psychologist investigates physical abuse psychologist must guard against any personal
in all couples, regardless of their ethnic heritage, biases and shed cultural stereotypes when
as domestic violence is prevalent in all cultures conducting and interpreting a family assessment
(Levinson, 1989). Finally, given the increasing of a young child (Grizenko et al., 1991). When
rates of intermarriage and the fact that intimate evaluating a child's presenting problem, the
relationships between people of different ethnic, psychologist must ascertain the meaning of the
religious, and racial backgrounds compound symptoms in the child's culture and the degree
the issues faced by couples from a single ethnic to which the symptoms are viewed as patholo-
group, similarities and differences between gical in the child's culture (Grizenko et al.). An
partners based upon their cultural heritage assessment of a young child, individually as well
must be examined. as in the context of the family, must consider the
The joining of two families through marriage cultural context of the child's socialization. For
requires that the two individuals choosing to example, deferential behavior may raise ques-
marry renegotiate with one another about areas tions about the Caucasian child's self-confi-
of concern. Difficulties in negotiating and dence and or a rigid family structure; such
compromising on such issues as core values, behavior is expected in many Latino cultures
the role of the family, communication styles, and thus is most appropriately understood as
roles and responsibilities, level of intimacy, reflecting the child's efforts to conform to
religion, and politics often lead couples to seek cultural expectations.
couples' therapy (Carter & McGoldrick, 1989). When intervening with families with young
When intervening with newly formed couples, children, the therapist must consider the
the psychologist must first help each partner to family's cultural values on various aspects of
feel comfortable in sharing their perceptions, childrearing and socialization. For example,
opinions, and wishes regarding various areas of when working with many traditional Latino
disagreement (e.g., Falicov, 1983). One way in families, it may be inappropriate for the
which a nonjudgemental context can be created therapist to emphasize the need for the child
to facilitate this sharing is by the therapist to be behaviorally and verbally assertive, as such
encouraging both members of the dyad to a recommendation may be perceived by the
examine how their views are influenced by their family as undermining of the parents' role
cultural background. During this process of (Zayas & Solari, 1994). The therapist must join
disclosure, it behoves the therapist to validate such family systems by acknowledging, not
for the couple the complexities of negotiating challenging, the parents' authority. Gradually,
different life styles and different cultural this will enable the family to trust the therapist,
stereotypes. The couple also needs help in which in turn will facilitate the family's
realizing the importance of integrating their increased comfort with the expression of a full
differences, rather than choosing between polar range of emotions from the children (Zayas &
opposites. The process of working through Solari, 1994).
similarities and differences enables the couple to One complicated dilemma that may be
form their own identification as a new family encountered when working with families with
unit, both related to and separate from their young children occurs when the child is the only
respective families of origin. family member fluent in English (Vasquez-
Nuttall et al., 1984). For example, for a Cuban-
American family in which Spanish is the sole
10.08.5.5.2 Families with young children:
language of the adults, a Spanish speaking
culturally sensitive assessment and
therapist may be optimal. If such a therapist is
intervention
unavailable or if the family prefers an English
In working with culturally diverse families speaking therapist who can introduce them to
with young children, psychologists need to the majority culture, a translator may be an
choose and administer assessment devices and option. Unfortunately, however, translations
interpret the results from a culturally informed often misrepresent the actual meaning and
 Culturally Sensitive Family Assessment and Intervention 199

cultural significance of family expressions and Among immigrant families from such diverse
fail to consider implications of nonverbal cultures as Mexico, Nigeria, and Kuwait,
behaviors. While some families prefer using adolescents are expected to seek, respect, and
the young child as an interpreter, this is obey their parents' guidance (Baptiste, 1993).
problematic in families from cultural groups After living in the US, adolescents from these
in which respect for parental authority is of families often begin to behave in a more
utmost importance. In such instances, the child individualistic fashion, place a greater value
as interpreter may be perceived as being on autonomy than is accepted in their family
insubordinate, disrespectful, and intruding on and culture of origin, and seek advice from
adult concerns. nonfamily members. Such actions are perceived
One particular form of intervention that by older family members as a reflection of the
impacts significantly on the family of a young family's inability to cope effectively with
child is that of early interventions (Hanson et immigration and are experienced as threatening
al., 1990). Because early interventions focus on and disrespectful. As a consequence, a rigidi-
the young child with a disability, these programs fication of family rules is common. If such a
interact with cultural views and values. Early response fails to reduce the adolescent's auton-
interventionists often work with the young child omy strivings, the family may seek a mental
with a disability in the family's home. This health evaluation. It is incumbent upon the
experience offers an inside view of family psychologist evaluating such families to bear in
rituals, communication, and caretaking pat- mind the conflictual values regarding family
terns, and a perspective on children and child- hierarchy and dependence vs. independence
rearing, and family and family roles. In manifested by members of different genera-
addition, it typically is sanctioned for early tions. Feedback from such an assessment must
interventionists to consult with the family incorporate the therapist's evaluation of the
regarding health and mental health care. Such extent to which the adolescent's behaviors and
involvements with the family heighten the early attitudes are consistent with, or discrepant
interventionist's awareness of different cultural from, the different cultures in which the
perspectives and the need to respect the family's adolescent embedded. If based on this feedback,
boundaries while simultaneously imparting the the therapist recommends treatment and the
views of the larger culture so that they can family concurs, the therapist should serve as a
receive optimal care for their young child family intermediary, whose primary function is
(Hanson et al., 1990). to translate cultural behavior in a develop-
mental perspective. In working with some
families (e.g., Mexican-Americans), this may
10.08.5.5.3 Families with adolescents: culturally
entail conducting separate sibling and parent
sensitive assessment and intervention
sessions to discuss sexual matters, prior to
Defining deviant adolescent behavior in the holding sessions with all family members
context of culturally diverse families is present (Falicov, 1996). Such an approach
complicated. The degree to which rebellion, demonstrates the therapist's respect for the
deviance, and separation±individuation striv- parents' view that discussion of intimate matters
ings are tolerated varies with different ethnic with their children is inappropriate and under-
and cultural groups. For example, the Latino mining of their authority (Garcia-Preto, 1996).
family's awareness that their adolescent There is a burgeoning body of research on
daughter is sexually active with her boyfriend racial and ethnic similarities and differences in
may lead to their seeking services for their adolescent substance abuse patterns and risk
child. Once the psychologist is familiar with factors (e.g., Gottfredson & Koper, 1996). Data
the family's cultural norm that premarital sex from these studies have been used to guide the
among adolescent females is unacceptable, the development and implementation of culturally
therapist must assess the adolescent's sexual informed preventive intervention programs,
activity (solely with significant other vs. with such as the State-wide Indian Drug Prevention
multiple partners, safe sex practices) and other Program (IDPP) (Bobo, Gilchrist, Cvetkovich,
potentially maladaptive or self-destructive Trimble, & Schinke, 1988). In addition, these
behaviors. Based on these data, the psychol- data have laid the foundation for treatment
ogist can ascertain if the adolescent's behavior outcome studies. For example, an excellent
is inconsistent with her family's cultural norms example of culturally sensitive treatment out-
but in keeping with the practices of the come research has been conducted with the
majority culture, or deviant from the expecta- families of Cuban-American adolescents with
tions of both cultures. This information substance abuse problems (e.g., Kurtines &
should be shared with the family during the Szapocznik, 1996; Szapocznik et al., 1984;
assessment. 1986). Bicultural effectiveness training (BET),
200 A Cultural Perspective on Families Across the Life Cycle

a brief family intervention model that incorpo- emancipation process and in renegotiating
rates culture as a key content area upon which to family relationships in order to develop a
base family interventions, has been found to be healthier balance between autonomy and at-
equally effective in improving family function- tachment that meets the needs of both the
ing as structural family therapy, a standard individual and the family, and that takes
family approach that is not necessarily cultu- cultural considerations into account. The
rally based. These findings support the use of a coaching process must address cultural norms
culturally informed family intervention for when focusing on the reduction of extreme
enhancing the functioning of adolescents with enmeshment, radical disengagement, and the
substance abuse problems from families that active use of triangulation. Specific strategies
experience conflicts associated with cultural and that may facilitate this process include: detrian-
generational differences (Szapocznik et al., gling, person-to-person contact, reversals, and
1986). reconnecting (Carter & McGoldrick, 1989).
These strategies enable the family system to
alter patterns of relating that are dysfunctional
10.08.5.5.4 Launching children, single young
given the family's current cultural context and
adults leaving home, and the middle
foster mature communication among family
generation moving on: culturally
members.
sensitive assessment and intervention
When couples seek mental health services
Given cultural variations in what is consid- during this family life cycle stage, culturally
ered normative behavior during the launching sensitive interventions must take at least a three-
stage of the family life cycle, it is crucial that the generation perspective. A multigenerational
psychologist takes cultural norms into account view allows the psychologist to help the couple
when ascertaining whether or not family deal with their independence from their off-
conflicts during this time reflect significant spring and their increased commitment to the
individual or family dysfunction, differences in older generation. In addition, they may need
values across generations about independence v. help in dealing with the separation and loss
interdependence, differences in perspectives on associated with the death of older family
healthy behavior during this phase between the members who often serve as culture bearers.
family's cultural group and the majority culture, The negotiation of new relationships with
or simply normal family processes. It is useful to children and parents is often complicated by
learn if previous generations of the family the need to renegotiate the marital dyad. Thus,
migrated during this phase, as these family of family interventions must address all relevant
origin experiences would intensify the signifi- relationships, with particular attention to the
cance of this period (Carter & McGoldrick, ways in which the cultural values of individuals
1989). When assessing the single young adult across the generations impact on the interper-
leaving home, it is recommended that informa- sonal difficulties that emerge. Further, for
tion be gleaned regarding how the person's individuals from many cultural groups, this
parents managed this phase of their own may be the first family life cycle stage in which
development. Questions should be asked about their own individual development is paramount.
the young adult's internal struggles and conflicts Thus, personal difficulties camouflaged by the
with cultural norms regarding separation and demands of family life at other stages in the
individuation. Also, data should be gathered family life cycle may come to the fore, and may
regarding the individual's view of acceptable require individual attention.
gender roles vs. those held by the family and
cultural group (e.g., views on remaining single
10.08.5.5.5 Families in later life: culturally
as a woman). Finally, given that this process
sensitive assessment and intervention
requires a restructuring of the marital relation-
ship, the parent's marital history and current For psychologists to assess accurately the
marital status deserve attention. functioning among culturally diverse families
It is often recommended that family work with elderly members, they must first build a
with single young adults or with young adults in therapeutic relationship with all family mem-
the launching phase be conducted primarily bers. This may be complicated when working
with the young adult, using a family of origin with elderly family members, as these indivi-
approach (Bowen, 1978). It is useful for the duals from different cultural groups are often
psychologist to help young adults examine the suspicious of professionals who they perceive as
relation between multigenerational patterns of having little in common with them. They suspect
relating and their own personal development. that mental health and health care professionals
To facilitate this awareness, the psychologist may have biases against their age, race, sex, and
can ªcoachº or guide young adults in both the culture.
 Future Directions 201

Hays' (1996) framework for the conduct of such instruments or processes are used with
culturally responsive assessments underscores elderly ethnic minority individuals, misdiag-
the importance of attending to a number of noses, confusion, and inappropriate interven-
influences that impact on the functioning of tions can occur (Hilliard, 1992). The likelihood
diverse older adults. She uses the acronym of misdiagnosis can be minimized if the
ADRESSING (albeit incorrectly spelled) to psychologist takes the time to use observations
organize the key influences to be taken into and interviews, and to look for ªintrapersonal
account when assessing elderly family members: strengths related to specific cultural identities as
age, disability, religion, ethnicity, social status, well as interpersonal or social supports related
sexual orientation, indigenous heritage, na- to minority group membershipº (Hays, 1996,
tional origin, and gender. Attention to these p. 192).
variables facilitates the building of rapport, There is a dearth of information on clinical
enhances the psychologist's understanding of interventions with the ethnic minority elderly
the elderly family member's cultural identity and their families (American Psychiatric Asso-
and heritage, and improves the psychologist's ciation, 1994a). Little data exist regarding
awareness of elderly family members' cultural whether or not efficacious interventions for
environment, needs, and strengths (Hays, 1996). nonminority elderly will be effective for min-
When assessing elderly clients in a family ority elderly. The extant literature underscores
context, it behoves the psychologist to use the importance of engaging as many extended
strategies that enhance rapport and commu- family members as possible in the care of older
nication. Possible techniques that may facilitate family members. Unfortunately, however, for
positive interactions include sitting closer and many immigrants, family support may be
speaking clearly, talking to ªthe good ear,º inadequate or absent and family relations are
using titles (Mr, Mrs, Dr, etc.) before names, often marked by significant intergenerational
using respectful and culturally sensitive inter- conflicts (Goldstein, 1989). Thus, adequate
preters when language differences exist, being mental health services must include outreach
equipped with conveniences for physical dis- efforts and the availability of mental health
abilities, and having culturally diverse artifacts resources in conjunction with medical care
in the office (Hays, 1996). When gathering a (Sakauye, 1989).
history from elderly family members, the Family interventions with diverse older
psychologist should be cognizant of the im- adults should be primarily directive (Paniagua,
portance of gathering extensive background 1994) and include the provision of education to
information and encouraging the older family the patient and family. The psychologist should
members to tell their life stories. During the assume an active stance and incorporate a
assessment process, it is recommended that problem focus. All interventions should com-
some time be spent with all family members municate respect for the elderly and an
present and some time should be devoted to appreciation of the elderly's perspective on
separate meetings with the older people. the role of the therapist. For example, Native
During the multigenerational meetings, the American elderly typically view the therapist as
psychologist can communicate respect for the akin to the medicine man, whereas Latino
elderly by encouraging the eldest family mem- elderly often perceive the therapist as a folk
ber to speak first and by valuing the input healer (Paniagua, 1994). Further, family inter-
offered by elderly family members (Kim, 1985). ventions should be geared toward the accep-
When conducting diagnostic interviews with the tance of intergenerational differences and the
elderly or administering and interpreting test resolution of associated conflicts.
results, the psychologist must bear in mind the
pernicious problem of misdiagnosis of psychia-
tric disorders in minority older adults (Amer- 10.08.6 FUTURE DIRECTIONS
ican Psychiatric Association, 1994a). Elderly
clients are likely to view testing as humiliating, Given the relative dearth of empirical
confusing, too time-consuming; and not rele- literature from a culturally sensitive perspective
vant to them, and thus may respond with regarding family patterns, family-oriented as-
excessive anxiety and a lack of focus and effort sessment, and family interventions, it is incum-
to the process. Frequently, the instruments used bent upon psychologists to conduct research on
and the process of assessing intelligence or all of these topics. One specific area that
personality have been created and indexed deserves immediate attention is the delineation,
around younger, Euroamerican cultural values based on research findings, of family patterns
and constructs (Berry, Poortinga, Segall, & among different ethnic groups across the
Dasen, 1992), and thus may not be valid or various family life cycle stages. A second
reliable for use with diverse older adults. When research topic that merits further investigation
202 A Cultural Perspective on Families Across the Life Cycle

is the development and collection of normative families across the life cycle and implications for
data on culturally sensitive assessment tools the conduct of culturally sensitive assessment
(e.g., questionnaires, observational coding sche- and intervention. While conceptualizations of
mas, semistructured interviews) for various culture often include ethnicity, race, SES,
aspects of family functioning across a multitude gender, sexual orientation, country of origin,
of cultural settings. The need for assessment and religious and political affiliations, we have
methodologies specific to each given culture chosen to concentrate on cultural issues relevant
requires special attention. A third avenue for to ethnic groups living in the US. A thorough
research exploration relates to the development, review of the literature suggests that effective
implementation, and evaluation of family family assessment and intervention is charac-
interventions designed to be culturally and terized by:
developmentally sensitive. The conduct of (i) the therapists' acknowledgement of their
assessment and intervention research must own cultural origins and the impact of this
include a focus on the validity, reliability, and background on the assessment and intervention
efficacy of various techniques based upon the process;
culture of the therapist and the family. (ii) a sensitivity to the family's cultural back-
Due to the rapidly changing nature of the ground;
family in America and throughout the world, as (iii) an appreciation of the unique interac-
well as increased levels of multiculturalism, tional patterns, attitudes, feelings, and beha-
clinicians and researchers must devote efforts to viors of each family;
understanding more about families embedded (iv) a recognition of the family's location in
in cultures in transition. This will require more the family life cycle;
attention to such issues as cultures within (v) validation and strengthening of the ethnic
cultures (e.g., a lesbian couple in which one identity of each family member and the family
member is Latino and her partner is Asian- unit as a whole; and
American), and intergenerational conflicts (vi) an incorporation of relevant support
within families associated with levels of accul- systems (Giordano & Giordano, 1995; N.J.
turation and/or sense of connection to the Kaslow et al., 1995).
culture of origin. To provide culturally sensitive family assess-
Fortunately, diversity training for clinicians ments and interventions, the clinician must
and researchers has advanced significantly. strive to overcome cultural barriers while de-
However, it is incumbent upon us as psychol- monstrating respect for the cultural identity and
ogists to insure that cultural considerations be integrity of each family member, the family
given paramount importance in coursework, system, and the therapist (Tyler, Brome, &
supervision, and continuing education pro- Williams, 1991). As the dramatic increase in
grams related to family assessment and inter- cultural diversity in the US is expected to
vention. This entails the utilization of a cultural continue into the twenty-first century, there is
formulation for family case conceptualization, a strong need for empirically validated multi-
increased and ongoing discussion of the family's cultural and culture specific family theories and
cultural context as it impacts on family relation- therapies. However, until such theories and
ships, and enhanced sensitivity to cultural issues therapies are available, psychologists are
in all aspects of the family assessment and charged with helping families negotiate the
intervention process. Such a shift in our reconnection with their cultural heritage in
orientation as psychologists and family thera- order to establish or preserve a sense of
pists will result in the delivery of more ethical belonging and cultural identity, while concur-
and effective interventions. rently adapting to an evolving cultural context
(N.J. Kaslow et al., 1995).

10.08.7 SUMMARY
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 Copyright © 1998 Elsevier Science Ltd. All rights reserved.

10.09
Sexual Orientation
BEVERLY GREENE
St. John's University, Jamaica, NY, USA

10.09.1 INTRODUCTION 207

10.09.2 DEFINING AND CONCEPTUALIZING SEXUAL ORIENTATION: CHALLENGES 209
10.09.3 DEMOGRAPHICS 210
10.09.3.1 Etiology Theories 213
10.09.4 UNIQUE PSYCHOLOGICAL AND DEVELOPMENTAL TASKS CHALLENGING LGB PERSONS 215
10.09.4.1 Identity Development 216
10.09.4.2 Resilience in LGB People 217
10.09.5 UTILIZATION OF PSYCHOLOGICAL SERVICES 218
10.09.5.1 Psychotherapy with LGB Persons 219
10.09.6 LGB PERSONS AND FAMILY ISSUES 222
10.09.6.1 Gay and Lesbian Couples 223
10.09.6.2 Gay and Lesbian Parents 224
10.09.6.3 Gay and Lesbian Youth 225
10.09.7 TRAINING 226
10.09.7.1 Hetrosexist Bias in the Delivery of Psychological Services 226
10.09.8 FUTURE DIRECTIONS 228
10.09.9 SUMMARY 229
10.09.10 REFERENCES 229

10.09.1 INTRODUCTION with lesbian, gay, and bisexual (LGB) sexual

orientations. Heterosexuality traditionally has
Sexual orientation is generally defined by the been considered normative and because of this it
sex of the person that an individual is sexually has not been the object of study or the focus of
and emotionally attracted to (Bohan, 1996) and the kinds of questions that LGB sexual orienta-
includes heterosexual, lesbian, gay, and bisexual tions are subject to. The presumption of hetero-
orientations. The meaning of sexual orientation sexuality as the only form of sexual orientation
and what it represents, like other aspects of that is psychologically normal and legitimate,
sexuality, is contextual. The context in which and the subsequent depiction of other sexual
sexual orientation is defined and a brief history orientations as deviant or pathological, is refer-
of its conceptualization is required to assess its red to as heterosexism (Bohan, 1996; Gonsiorek
meaning appropriately both in our society and & Weinrich, 1991; McWhirter, 1990).
as an aspect of human identity. The failure of psychological research to ask
Despite the fact that sexual orientation relevant questions about the origins and
conceptually encompasses all orientations, the determinants of all sexual orientations, rather
study of sexual orientation in American psy- than selective, nontraditional orientations, ob-
chology has focused generally on individuals scures information about all of them and leads

173
228 Sexual Orientation

to a range of erroneous assumptions about sexual orientation would not at different stages
sexual orientation in general. Traditionally, of their sexual identity development manifest
nontraditional sexual orientations have been levels of ego dystonia or distress. In a climate that
assumed to represent the presence or manifesta- is hostile to LGB, persons, it would be likely that
tion of a psychological disturbance or patho- some would wish to be heterosexual or express
logical developmental arrest. distress about their sexual orientation. Bohan
Hooker (1957) was among the first empirical (1996) and Haldeman (1994, 1999) argue that a
studies in psychology to broadly contradict the period of ego dystonia does not represent the
pathology model of homosexuality in mental individual's distress with their sexual orientation
health (McWhirter, 1990). Hooker adminis- per se, but with the attitudes of a society that
tered batteries of projective tests to 30 homo- stigmatize that orientation and make its adop-
sexual male and 30 heterosexual male subjects. tion painful. Acknowledging an LGB sexual
Results were reviewed by experts who could not orientation means not only the loss of hetero-
distinguish homosexual and heterosexual sub- sexual privilege but also carries the realistic
jects on the basis of their test results. Gonsiorek danger of becoming the target of hostility,
(1977, 1991), Meredith and Reister (1980), and derision, potential rejection from loved ones,
Reiss (1980) provide detailed reviews of psycho- loss of employment, loss of child custody, and
metric studies on homosexuality. These studies even violence (Herek, 1989). The ego dystonia
generally conclude that homosexuality per se is observed should be regarded as a predictable and
not pathological, nor is it related to psycholo- understandable part of the evolution of an LGB
gical adjustment. The presence of such evidence, identity and a ªnormal aspect of the process of
however, has not led to a complete abandon- managing denigrating attitudesº associated with
ment of the pathology model in mental health those identities rather than as a condition that
practice. warrants attempts at conversion to heterosexual
An intense period of political activism and sexual orientation (Bohan, 1996, p. 19). The
advocacy for social justice for lesbians and gay diagnostic entity, ego dystonic homosexuality,
men, and the efforts of lesbian and gay mental was removed from the DSM in 1988.
health professionals, led to formal challenges to In 1975, the American Psychological Associa-
pathological views and subsequent changes in tion (APA) adopted an official policy statement
the diagnostic nomenclature. The details of that that: homosexuality per se implies no impair-
struggle are beyond the scope of this chapter, ment in judgment, stability, reliability, or
however, the reader is referred to Greene general social and vocational capabilities (Com-
(1994b) and Giusti and Katz (1992) for a more mittee on Lesbian and Gay Concerns [CLGC],
detailed description of them. 1986; Morin & Rothblum, 1991). At that time,
In 1973, the American Psychiatric Association APA urged all mental health professionals to
(APA) removed the diagnosis homosexuality take the lead in removing the stigma of mental
from the Diagnostic and statistical manual of illness that was associated historically with
mental disorders (DSM), replacing it with the lesbian and gay sexual orientations in Western
diagnosis of ªego dystonic homosexualityº psychology. After years of lobbying efforts, in
(Haldeman, 1991, 1999). This diagnosis was 1980 the CLGC was approved as a standing
used to describe individuals who were unhappy committee and an official part of APA's govern-
with their lesbian or gay sexual orientation and ance. The Committee, whose name has been
who wanted therapy to make them heterosexual. recently changed to include Bisexual concerns,
The absence of a diagnostic category for people (CLGBC), was charged with establishing stan-
who were dissatisfied with their heterosexuality dards for eliminating heterosexist bias in
was another manifestation of the presumed psychological research and practice with LGB
normative nature of heterosexuality. Opponents persons, as well as developing policy statements
to the use of ego dystonic homosexuality as a on lesbian and gay issues for the Association.
diagnostic entity argued that it continued to Since its adoption, the committee has developed
pathologize homosexuality, albeit indirectly a range of guidelines for affirmative practice and
(Bohan, 1996; Gonsiorek, 1991; Haldeman, research with LGB persons. Prior to the
1991, 1994, 1999). Diagnosing this predictable adoption of this policy, however, reproductive
response to society's intolerance as if it were a sexuality was legitimized as the only form of
condition that required repair fails to address the sexual orientation that was psychologically
pathology of homophobia (Weinberg, 1972), normal and morally correct. This assumption
heterosexism, and the unfair treatment of widely pervaded research, training, and practice
lesbians and gay men. Rather, it unfairly in psychology. Some would argue that despite
stigmatized the victims of unfair treatment. many changes, the association between pathol-
Furthermore, it is unlikely that individuals who ogy and LGB sexual orientations still lingers
face hostility and stigma as a result of an LGB broadly in various corners of this discipline.
 Defining and Conceptualizing Sexual Orientation: Challenges 175

In the 23 years since the introduction of APA and women. In the 1990s, LGB sexual orienta-
policy changes regarding LGB sexual orienta- tions or lesbian, gay man, and bisexual man and
tions, LGB persons assume a higher level of woman are the terms preferred by APA reflected
visibility among those who seek professional in their 1994 publication standards (APA, 1994).
psychological services (Liddle, 1997). However, Lesbian and gay sexual orientation is defined
despite major changes in the diagnostic nomen- as an erotic and or affectional disposition to the
clature aimed at removing the stigma of same sex (Bohan, 1996; Gonsiorek & Weinrich,
psychopathology from gay and lesbian sexual 1991). Bisexuality is defined as an affectional
orientations, negative bias and misinformation and/or erotic attraction to members of both
about lesbians and gay men continues and is still sexes, serially or simultaneously (Bohan, 1996).
observed in clinical practice, research, and While distinctions are made between members of
training efforts (Brown, 1996; CLGC, 1990; these groups for the sake of descriptive clarity,
Garnets, Hancock, Cochran, Goodchilds, & human sexuality exists along a continuum in
Peplau, 1991; Garnets & Kimmel, 1991; Mar- most persons, rather than as dichotomous and
kowitz, 1991; Rothblum, 1993). discrete categories. Any form of sexual orienta-
In 1986, the CLGC conducted a survey tion represents an interaction of biological,
investigating bias in psychotherapy with les- cultural, historical, and psychosocial influences
bians and gay men. Two thousand five hundred (Bohan, 1996; Garnets & Kimmel, 1991;
and forty-four psychologists were surveyed to McWhirter, 1990).
elicit themes suggestive of biased and sensitive The definition of sexual orientation in
practice. The results suggested the presence of a Western cultures is based explicitly on the
wide range of variance in the degree to which biological sex of the person an individual is
psychologists conform to unbiased practice sexually and emotionally attracted to (Ames,
standards with lesbian and gay clients (CLGC, 1996; Bohan, 1996). In this context, there is an
1990; Garnets et al., 1991). Data from this study inextricable link between the sociopolitical
and other research (DeCrescenzo, 1985; Ru- meanings of gender and sexual orientation in
dolph, 1988) suggests that practice does not Western culture (Ames, 1996; Bohan, 1996;
conform to APA policy standards. This suggests Greene, 1994a, 1996a, 1999; Kaschak, 1992;
that despite major strides in depathologizing Kitzinger, 1987). Sexual attraction to members
lesbian and gay sexual orientations per se, there of the other gender is a central part of the way
is still much to be done with respect to educating that being a normal man or woman has always
psychologists about sexual orientation and that been defined in American society (Ames, 1996;
attitudes within organized psychology toward Bem, 1993; Bohan, 1996; Greene, 1994a, 1994b,
sexual orientation remain ambivalent (CLGC, 1994c, 1999). It is not surprising that in this
1990; Garnet et al., 1991; Rothblum, 1993). context, lesbians and gay men are presumed to
want to be members of the other sex or are
10.09.2 DEFINING AND viewed as defective examples of their own sex.
CONCEPTUALIZING SEXUAL Bohan (1996) discusses the extent to which
ORIENTATION: CHALLENGES certain questionable assumptions about sexual
orientation are embedded in psychological
ªHomosexualº was the traditional, clinical theories and paradigms that are also a function
term used to refer to people whose erotic, sexual, of societal gender and sex roles. Lesbian or gay
and affectional attractions were to individuals of sexual orientation is assumed to entail cross-
the same sex. Many objections to the use of this gender behavior, with the assumption that
term came from lesbians and gay men themselves gender roles are and should be inextricably
as it was originally used to describe a form of linked to and defined by a person's biological
psychiatric disorder or psychopathology. Other sex. Bohan (1996) reviews a range of studies and
objections focused on the term's perceived scales in the psychological literature that serve as
emphasis on the sexual component of lesbian illustrations of these assumptions. The first
and gay men's experiences in isolation from psychological scale designed to measure mascu-
other complex and integral aspects of their linity and femininity assumed that lesbians and
identities. Still other objections focused on the gay men would have M±F scores that differed
gender neutrality of the term and its masking of from their biological sex. M±F scores measure
the differences between lesbians' and gay men's the degree to which a person's behavior is
experiences and issues based on gender (Bohan, consistent with that of male vs. female gender
1996; Gonsiorek, 1991). Since most early roles. The assumption is that a person's behavior
psychological and medical studies on sexual and therefore their score should be consistent
orientation focused on males, the continued use with their biological sex. Therefore, a basic
of the term homosexual was deemed methodo- assumption of the scale was that adherence to sex
logically imprecise in its application to both men role stereotypes defined heterosexual sexual
230 Sexual Orientation

orientation. Departures from those stereotypes enduring traits of people whose determinants
marked a person lesbian or gay. These kinds of could be discovered, quantified, and measured
assumptions are prevalent among lay persons as objectively and understood. The social con-
well as mental-health professionals. They are structionist perspective views sexual orientation
more of a reflection of what society values and as a construct that varies over time and place
wants people to be rather than an accurate and has meaning only in the context of a
reflection or measure of who they are. In other particular culture, in a specific point in time.
studies, when animal or human behavior was not Sexual orientation from this perspective is
consistent with traditional gender role stereo- viewed as contextual. It is a category that has
typed behavior, the presence of homosexuality meaning only because in Western culture we
or the potential for its development was choose to imbue it with specific meaning. This
presumed (Bohan, 1996; Haumann, 1995; meaning of sexual orientation is created out of
Parker & DeCecco, 1995). The latter is reflected the importance we give to the sex of a person
in the assumption that children who behave in that an individual is romantically attracted to.
gender atypical ways will become lesbian or gay. As previously discussed, that meaning is also a
There is some evidence to suggest a link between function of the meaning we give to gender and
extreme gender atypical behavior and later gay sex roles. In the absence of such ªconstructs,º
sexual orientation in boys. It does not, however, sexual orientation per se has no special meaning.
explain the development of lesbian sexual In cultures where gender and sexuality have
orientation in women, nor does it explain the different meanings, sexual orientation may not
presence of heterosexual sexual orientations in even exist as an entity to be studied or deemed
adults who were gender atypical children important enough to label (Tafoya, 1997).
(Bohan, 1996). Another assumption related to
the latter is expressed in the belief that if you are 10.09.3 DEMOGRAPHICS
able to inhibit gender atypical behavior in
children you will prevent them from becoming Gonsiorek and Weinrich (1991) estimate that
lesbian or gay. Of course there is no evidence to the number of lesbians and gay men in the USA
support this belief. All of these assumptions ranges from 4 to 17% of the general population
highlight the contextual nature of sexual depending on the sampling methods and sources
orientation as a concept. Gender and sex role used. These estimates may be deceptive, how-
behaviors and expectations differ across cultures ever, given the imprecision of the definitions
and differ over time within the same culture. used and the hidden nature of this population.
Because of these variations, the concept of sexual Both of these problems make obtaining repre-
orientation would vary as well. However, the sentative samples a major challenge in conduct-
ethnocentric nature of American psychological ing empirical research.
research has obscured important differences in Kirk and Madsen (1996) observe that one of
gender and sex role expectations across cultures the seven myths that straight Americans believe
and in doing this has also obscured the effect of is that all LGB persons can be easily identified by
those differences on the psychological concep- their outward appearance. This is based in part
tualization of human sexual orientation. on gendered definitions of heterosexual and
Gonsiorek (1991) goes on to discuss the LGB orientations. Despite these beliefs, for the
problems defining lesbian or gay sexual orienta- most part, LGB persons are invisible. They may
tions that contribute to methodological chal- not be identified solely on the basis of observa-
lenges and flaws in empirical research. Problems tion as they are a part of every social group in
establishing precise definitions of sexual orien- society. Unlike people with physical distinctions
tation also affect the degree to which even our or challenges that readily identify them, LGB
estimates of the number of LGB persons and persons who are subjects in research are deemed
heterosexual persons in the general population to be LGB because they self-identify or say that
can be considered accurate. The concept of they are. Just as we regard individuals in research
sexual orientation may be viewed from essenti- studies to be LGB because they say they are, we
alist or social constructionist perspectives. do not assume that someone is LGB unless they
Essentialist perspectives view sexual orientation actually tell us so. Therefore, we cannot be
as an intrinsic characteristic of a person, that certain about the numbers of heterosexual or
endures over time, whether it can be observed by LGB participants in such studies. Unfortu-
the individual possessing it, by others, or not. nately, for a variety of reasons this problem is not
From this perspective, sexual orientation is an completely resolved by simply asking subjects to
element of identity that has always existed in identify their sexual orientation.
every person, in every culture, and in every point Gonsiorek (1991), Bohan (1996), and
in time. For the most part, psychology has McWhirter (1990) assert that problems defining
studied LGB sexual orientations as if they were LGB orientations make it difficult to derive
 Demographics 177

accurate population estimates and to obtain as the family member does not label themselves
appropriate samples. Attempts to define sexual lesbian or gay, and as long as they do not attempt
orientation based on sexual behavior are less to discuss their sexual orientation openly. The
than reliable. Bohan (1996) observes that a failure to make such statements about LGB
person may experience themselves as or may be sexual orientation to family members must be
appropriately labeled lesbian or gay before they understood in the context of the ethnic group the
have ever had sexual relationships. Other person belongs to, the level of tolerance within
individuals may have both male and female that group, and traditional ways of managing
sexual partners and/or relationships. Some of members who deviate from family norms with-
these individuals would consider themselves out causing family strife (Chan, 1990; Croom, in
LGB while others would not self-label in this press; Fygetakis, 1997; Greene, 1994a, 1994b,
way. Still other people may have sexual partners 1999; Liu & Chan, 1996; Morales, 1992).
that are not consistent with the content of their Fygetakis (1997) observes that many white
fantasies. As observed in the previous example, lesbians and gay men who belong to ethnic or
some would self-label as LGB while others religious groups that are intolerant of LGB
would not. sexual orientations may not be ªoutº to their
Gonsiorek (1991) observes that defining and families or in their ethnic/religious communities
obtaining a representative sample of LGB for reasons that are similar to those expressed by
persons is the largest methodological problem lesbians and gay men of color. She warns that it is
in the scientific study of LGB sexual orientation. inappropriate to use Western models of being
If subjects are considered LGB because they say out (particularly to family) as a measure of LGB
that they are, it is important that the individual self-acceptance or well-being for all LGB
subjectively identifies themselves as having an persons (Fygetakis, 1997). Accordingly, such
LGB orientation if they are LGB. It is equally individuals may not openly acknowledge their
important that they do not identify themselves as LGB orientation as research subjects, despite
such if they are not. This approach cannot assurances of confidentiality.
account, however, for persons who do not yet Studies of LGB sexual orientations based on
acknowledge an LGB orientation, or those who samples of psychiatric patients, prison inmates,
are in an ego dystonic period. It also fails to psychoanalytic patients, and patients seeking
account for individuals who maintain intimate aversion therapy, the primary subject pool for
relationships with members of the same sex but early studies, are not considered representative
do not consider themselves or conceptualize of LGB persons and therefore are not general-
their relationships (for cultural and other izable to them (Gonsiorek, 1991). Their con-
reasons) as lesbian or gay (Tafoya, 1997). There tinued use in making such generalizations is
are other problems as well. Acknowledging an considered methodologically inappropriate. In
LGB sexual orientation is often associated with early studies of sexual orientation, the use of
negative consequences. As such, many indivi- psychiatric patients, patients in psychotherapy,
duals who may be LGB may not openly and psychoanalysis was widespread. Many of
acknowledge that they are. Class, ethnic, and these studies compared nonpatient heterosexual
other distinctions may also compound the controls to homosexual patients. Individuals
consequences of disclosure and affect the degree drawn from clinical populations by virtue of
to which many people will or will not take those their status as patients are not representative of
risks. On the one hand, many people who are nonpatient LGB samples (Bohan, 1996; Gon-
successful professionally but who are not out will siorek, 1991). Even if this population were
not risk the embarrassment or loss of stature that representative, comparisons to nonpatient het-
may be associated with disclosure (Gonsiorek, erosexual controls lack validity. Gonsiorek
1991). On the other hand, many LGB persons (1991) observes that samples drawn from
who are economically marginal may be unable, individuals in psychoanalysis are atypical of
for example, to risk the loss of their jobs, child the general population of LGB persons and may
custody, or visitation rights if their sexual be atypical of psychotherapy patients as well.
orientation is discovered (Bradford, Ryan, & On average they are better educated and must be
Rothblum, 1994; Fassinger, 1991; Greene highly motivated to engage in a form of therapy
1994a, 1999). Many members of ethnic minority that requires frequent visits over a protracted
groups may conceal their LGB orientation from period of time and as such is expensive to
their families and ethnic communities to a maintain. Samples drawn from the armed
greater degree than their white counterparts forces, prison, or other law enforcement sources
(Chan, 1992; Greene, 1990, 1994b, 1996a, 1997; are also dubious. The presence of the same sex
Morales, 1992). In fact, in many families of sexual behavior in prison or in places where
people of color, a lover or life partner may be heterosexual behavior is not available does not
accepted as long as they are not labeled, as long mean that its participants are LGB persons.
232 Sexual Orientation

Gonsiorek (1991) also warns that individuals ic, social, age, geographic locale, and other lines.
whose sexual behavior has come to the attention There is little research on or about LGB realities
of law enforcement officials may include a outside of the USA. Brown (1989) suggests that
higher proportion of individuals whose reality there is no unitary lesbian or gay reality; rather,
testing, impulse control, and capacity for good there are multiple realities as diverse as lesbians
judgement are impaired. Often, such individuals and gay men themselves (Bell & Weinberg,
may have been involved in sexual activity that 1978). While generalizations are made about a
was not conducted in private, was not consent- range of psychological realities for LGB
ing, was not with another adult, or was the persons, they are always embedded in other
specific result of entrapment (Gonsiorek, 1991). aspects of human experience and cannot be
Still, there are problems with other samples as understood realistically when examined in
well. Gonsiorek (1991) observes that studies isolation. LGB persons with multiple identities
whose samples are drawn from LGB bars and may experience their sexual orientation and
clubs are skewed toward people who drink heterosexism very differently than those who do
alcohol, are young, able-bodied, extroverted, not have multiple identities (Croom, in press;
urban, lack a consistent sexual partner, and who Greene, 1994b; 1999; Potgieter, 1997).
can economically afford to socialize in those For the most part, American psychology as
venues (Bradford et al., 1994; Croom, in press; well as LGB psychology has understood human
Greene, 1999). Other samples drawn from LGB behavior from decidedly Western cultural
organizations will over-represent people who perspectives. It is important to view LGB
are out and who do not fear disclosure of their psychology from diverse perspectives within
LGB orientation. Those samples obtained via and outside of the USA. There is often a glaring
social, friendship networks, experimenter con- absence of international perspectives on LGB
tacts, and the like tend to be biased in their persons' lives. Assumptions about what is
homogeneity (Gonsiorek, 1991). helpful or healthy in one context may not have
Generally, samples of LGB persons are the same meaning or implications in another.
sought in venues that tend to be labeled as For example, in American LGB psychology, the
such, an approach that would seem to make demise of pathology models of LGB sexual
sense. However, the diversity of LGB persons orientation is viewed as a major step toward
warrants understanding that many of them will affirming LGB sexual orientations as equal in
not be found in such venues for a variety of status to heterosexual sexual orientations. It is
reasons, some of which have been addressed difficult to consider that this would not be the
here. Whether or not they would respond to case for LGB men and women around the
requests for participation in such research is world, however, this may not be as simple as it
questionable. We know that there are many appears. Potgieter (1997) interviewed a sample
persons who would never be asked to participate of 30 Black South African lesbians from rural
by virtue of their absence in the kinds of venues and urban settings and from a wide range of
targeted for obtaining samples. Hence, they are class and educational backgrounds in South
invisible to us. Largely, research is based on Africa. Many of the women she interviewed had
samples that are predominantly white, middle- never even spoken to another lesbian. Potgie-
class, able-bodied, North American, English ter's (1997) study documents, with the exception
speaking, and well educated (Bradford et al., of dissertations, the absence of a single
1994; Croom, in press; Gonsiorek, 1991; published article on homosexuality by any
Greene, 1999). Because of these limitations, South African psychology journal, as well as
results of LGB research should be approached the prominent role of South African psychol-
with caution as its generalizability is often ogists in supporting the entrenchment of apart-
limited to very specific subgroups. Similarly, heid, and the view that homosexuality is both a
suspicion is warranted when evaluating popula- sickness (that can be cured) and a sin (that the
tion estimates of LGB persons. It is likely that individual is responsible for) that warrants
those estimates are an under-representation of criminalization.
the total population of LGB persons in the USA It would seem on the face of things that the
(Bohan, 1996). It is wise to ask how we know eradication of the pathology model would
what we propose to know about the group in benefit South African lesbians and gay men
question, how that information was acquired, of all ethnicities. Potgieter (1997), however,
and who would have been omitted by virtue of points out that among Black South Africans,
the sampling methods chosen. families are required to maintain contact with
LGB persons are often presumed to be a part and provide family support for any member
of a monolithic community. This obscures the who is deemed ill. Despite the fact that lesbian
wide range of diversity within them as a group or gay sexual orientation is viewed as both
that crosses all cultural, ethnic, racial, econom- pathological and sinful and is disapproved of,
 Demographics 179

the LGB family member is explicitly entitled to stigma will make a child or adult's life easier.
support and is not evicted to the degree that LGB sexual orientations, in this context, are still
LGB persons in Western culture might be deemed the cause of the problem. Alter it and
treated by disapproving family members. Pot- the problem goes away.
gieter (1997) asserts that we must consider what Bohan (1996) points out another way that the
would happen, in Black South African culture, pathology model continues to inform the way
if the lesbian or gay family member were not that LGB persons are understood. She writes
viewed as sick, but simply sinful, particularly in that when explanations for LGB orientations
a country where the gay and lesbian rights are sought, it is with the assumption that
movement per se is fledgling at best. The entire whatever markers are used or traits that are
basis of an entitlement to family support could found will be, by definition, abnormal in LGB
be questioned. Hence, the impact of rejecting persons. Conversely, whatever is found in
the pathology model poses different conse- heterosexual persons will be considered normal.
quences for LGB persons in different cultures. For example, she observes that the research
This highlights the importance of viewing LGB sought to find hormonal imbalances in LGB
psychologies and imperatives from a wide range samples to explain the presence of their
of perspectives. orientation. This approach, however, presumed
that whatever levels were measured in hetero-
10.09.3.1 Etiology Theories sexuals were normal. Bohan (1996) suggests
that the presence of bisexuality in different
The ªcauseº of LGB sexual orientations has societies in different historical times gives
long been a focus of interest in psychological credence to the bisexual potential in all persons
and medical research in the USA. However, the and suggests that legitimizing only one sexual
very question suggests that we know the origins orientation is arbitrary.
of heterosexuality. The reality is that we Explanations for LGB sexual orientations
presume to know because it is a preferred range from one extreme in which biological
orientation and whatever is believed to be underpinnings are presumed to totally account
characteristic of it is deemed normative. When for them, and at the other, that environmental
the question of causation of LGB sexual determinants are deemed causative. There is
orientations arises, it prompts us to ask why also a range of approaches that postulate the
its origins are important, particularly since presence of combinations of determinants that
similar questions are not raised about hetero- fall between the polarities of these extremes and
sexual sexual orientation. The latter is presumed contain elements from both of them. These
to be an evolutionary and adaptive means of theories fall roughly into three categories.
continuing the species. This assumption prevails Explanations based on psychodynamic the-
despite what we know about the complexity of ory are well known and longstanding. Overall
human sexuality and relationships that goes far traditional psychoanalytic explanations of LGB
beyond propagation. sexual orientation view them as a symptom of a
The importance of determining a cause for developmental conflict and early fixation (Isay,
LGB orientations assumes that if a cause is 1990). Isay (1990) observes that traditional
identified, interventions may be designed to analysts believe that homosexuality represents
prevent the development of LGB orientations. an unfavorable unconscious solution to a
This is consistent with the prevalence of the developmental conflict and that the entire
disease and pathology models of homosexu- personal life of the individual reflects the effects
ality, although some proponents of conversion of the early fixation. While this view is based on
would say that their position does not rest on Freud's (1922/1959) early models, Isay (1990)
the presumption of pathology. This group of notes that post-Freudian analysts ignore the
advocates of conversion would suggest that ambiguities in his theory of object choice. Freud
LGB sexual orientation is problematic for suggested that all human beings were innately
individuals because it is stigmatized and because bisexual, and supported decriminalizing and
it results in the LGB person being disadvan- depathologizing homosexuality (Bohan, 1996;
taged. The logic is that it is kinder to convert the Freud, 1922/1959; Isay, 1990; Jones, 1965).
individual to something that society will more Despite this, American psychoanalysts viewed
readily accept. Despite the formal changes in the LGB sexual orientations as illnesses in need of a
diagnostic nomenclature, inquiries about cau- cure. A range of explanations developed that
sation are embedded in the need to justify posit the presence of dysfunctional relationships
conversion. Altering LGB sexual orientations, between parents and children accounting for the
in this context, is couched in what appears to be development of LGB orientations. Their com-
a benign assumption. If being a member of a mon themes are based on the assumption that a
stigmatized group is difficult, removing the key task in psychosexual development is to
234 Sexual Orientation

identify with a parent of the same sex and However, making the leap to encompass the
transform oneself psychologically into that complexity of an LGB orientation is question-
parent. Based primarily on studies with psycho- able. Gendered assumptions about LGB or-
analytic patients as subjects, psychoanalytic ientations are evident in these approaches. It is
research alleged that the fathers of gay men were presumed that brain development is influenced
aloof, distant, and uninvolved with them, while by the presence of prenatal hormones and that
their mothers were smothering and overprotec- sex-typical behaviors are a reflection of brain
tive (Isay, 1990). Lesbianism was deemed a organization rather than cultural influences.
manifestation of incest fears, an expression of a Lesbians are presumed to have brain organiza-
wish to adopt a masculine role, or ªa girl's anger tions similar to those of heterosexual men, and
at her father for rejecting her causing her to hate gay men are presumed to have brain organiza-
menº (Bohan, 1996, p. 76). Critiques of these tions similar to those of heterosexual women. A
explanations cite their reliance on patient familiar problem in this schema is that gendered
samples and the presence of other methodolo- behaviors may have specific meaning in Western
gical problems. There is also too much variation culture that they do not have in other cultures.
in the families and family dynamics of lesbians The most recent study conducted by LeVay
and gay men to make such generalizations (1991) is based on autopsied brains of hetero-
(Bohan, 1996; Isay, 1990). Furthermore, the sexual and gay men. LeVay (1991) hypothesized
same kinds of dynamics ascribed to the families that a forward region of the hypothalamus
of lesbians and gay men may be found among would be smaller in the brains of gay men (as it
heterosexual men and women. There are no would in heterosexual women) than in hetero-
adequate explanations in these paradigms for sexual men. These findings were confirmed.
why heterosexual men and women with like Despite this, the meaning of these findings is
family dynamics do not become lesbian or gay. unclear. LeVay's (1991) sample was small and
Biological explanations enjoy great popular- involved the use of subjects who died as a result
ity in the 1990s and tend to look for genetic and/ of complications from AIDS. Furthermore,
or hormonal markers of lesbian or gay sexual there was no evidence that the differences in size
orientation. There is some evidence that there of these brain structures were prenatal. Overall,
may be a genetic element in the development of the results of these studies are intriguing but far
LGB orientations for some individuals, but it is from definitive. Bohan (1996) and McWhirter
far from conclusive (Bohan, 1996; Diamond, (1990) observe that research in the biology of
1993; McGuire, 1995). Bohan (1996) provides a sexual orientation has failed to produce any
detailed review of concordance studies that are conclusive findings.
summarized briefly. Concordance studies seek Another group of explanations are based on
to determine the degree to which there is social learning or learning theories. These
agreement between two individuals on a theories suggest that sexual orientation is a
particular trait. In this case, the trait would constellation of complex, learned behavior
be LGB sexual orientations. We would expect, if based on prior experiences that have been
sexual orientation were 100% genetically de- reinforced. One example posits the existence of
termined, to find a near 100% concordance rate previous heterosexual encounters that are
between monozygotic twins, and a 50% rate on unpleasant or traumatic, or same-sex sexual
measures between fraternal siblings. Studies in encounters early in life that are seductive in
this area (Bailey & Pillard, 1991) produce results nature. Still others suggest that ªgender de-
that show higher concordance rates for identical viance,º particularly in boys, goes unpunished
twin brothers than for fraternal siblings, and evolves into an LGB orientation. Bohan
however, not at the levels we would expect to (1996) explains that it is possible that some
find to demonstrate 100% genetic determina- children may cope with their gender atypical
tion. Similar findings for women are not identity by internalizing the identity that the
reported. Other biological theories analyze the culture provides them with to explain their
role of hormones in prenatal development difference, therefore defining themselves as
(Bailey, 1995; Hamer, Hu, Magnusson, Hu, & lesbian, gay, or bisexual. These are the labels
Pattatucci, 1993 Meyer-Bahlberg, 1995) and sex they are given to choose from. There is little to
differences in brain organization. In the former support perspectives based solely on social
theories, sex differences in behavior are attrib- learning models. This is particularly so given
uted to hormonally related brain organization. the degree to which LGB persons often identify
Despite contradictory findings in studies at- themselves as such long before they have any
tempting to replicate this work (Byne, 1995), same-sex or heterosexual contact. There is also
these models seem to have some measure of evidence that individuals who engage in same-
validity (when sexual behavior is the variable sex sexual behavior do not necessarily adopt an
measured) in research with lower animals. LGB orientation. Furthermore, same-sex sexual
 Unique Psychological and Developmental Tasks Challenging LGB Persons 181

contact is more likely to be delayed because of their orientation initially. Sexual orientation
the stigma associated with LGB orientations. appears to be a stable characteristic over the life
The notion that there is reinforcement for them span for some individuals; for others, one
seems questionable. Clinicians observe clients orientation may be adopted after lengthy
who want nothing more than to avoid the experience with the other as an adult. Money
societal rejection that accompanies the adop- (1988) refers to the latter as sequential bisexu-
tion of an LGB identity. ality (Bohan, 1996; Garnets & Kimmel, 1991;
In a shift toward a more interactionist Golden, 1996).
approach, Bem (1996) proposes that biological Because LGB individuals are not readily
determinants predispose temperaments and identifiable on the basis of physical character-
that it is temperaments that predispose behavior istics, they are often presumed to be and treated
which is sex-typical or atypical. Bem's theory as if they were heterosexual. Such treatment
asserts that a child who is sex-atypical will feel forces LGB persons to make conscious deci-
different from his or her same-sex peers and may sions about whether or not to reveal their sexual
be rejected by them. Children whose tempera- orientation routinely. This raises one of the core
ment predisposes them to be sex-typical experi- psychological tasks confronting LGB persons,
ence themselves as different from peers of the ªcoming out.º
other sex. The rejection from peers and a sense
of difference from them is presumed to create 10.09.4 UNIQUE PSYCHOLOGICAL AND
anxiety and discomfort which then triggers DEVELOPMENTAL TASKS
physiological arousal. He proposes that this is CHALLENGING LGB PERSONS
the crucible in which an association between
same-sex peers and physiological arousal leads Coming out has been defined at its simplest as
to erotocizing those peers. Bohan (1996) the realization or conscious acknowledgment of
suggests that this theory fails to explain why one's LGB sexual orientation and the subse-
in this situation anxiety becomes eroticized quent disclosure of that orientation to others
rather than leading to avoidance of same-sex (Bohan, 1996; Dworkin & Gutierrez, 1992;
peers. Garnets & Kimmel, 1991; Isay, 1990). While
The question of causality in LGB sexual this definition describes the salient features of
orientation research is intriguing but leaves us coming out as a developmental event, it is a
with no definitive conclusions. McWhirter deceptively simplistic depiction of an extremely
(1990) observes that there does not seem to be complex lifelong task. Because of the presump-
a single cause or a simple developmental path tion of heterosexuality in our society, most LGB
that determines sexual orientation of any type. persons will be presumed to be heterosexual
Bell and Weinberg (1978) suggest that our unless they say otherwise. For members of many
understanding of sexual orientation would be ethnic minority groups, skin color and other
greatly enhanced by recognizing and consider- features make their group membership visible
ing that there is great diversity among LGB and a given that is beyond their control. Unlike
persons, just as there is among heterosexual men visible minority group members, LGB persons
and women; that there may be many homo- must consciously decide whether or not to
sexualities as well as many multiple paths to any disclose their sexual orientation to others. This
single form of sexual orientation (Garnets & also means that to some extent, they have some
Kimmel, 1991). degree of control over who has information
Sexual orientation is likely established by about their orientation and who does not,
adolescence, usually before sexual activity affording a measure of safety under certain
begins, often preceded by a subjective awareness circumstances. This control, however, has
of same gender attraction (Bell, Weinberg, & benefits as well as disadvantages. The need to
Hammersmith, 1981; Garnets & Kimmel, 1991; make decisions about coming out surfaces
Gonsiorek & Weinrich, 1991). Still other LGB whenever the individual is in a new situation
persons may not be aware of same-sex attrac- such as a new job with new colleagues, and is
tions until later in life. It is difficult to determine usually stressful. Whether or not to disclose, to
how, at what stage of development, or chron- whom, at what point in time, and weighing the
ological age LGB sexual orientation would risks vs. benefits, is a lifelong task for most LGB
emerge were it not for the pervasive societal persons.
messages condemning it. Many individuals who Perhaps the most anxiety provoking stage of
have same-sex attractions may suppress or coming out is the initial stage of self-awareness.
repress an awareness of them because of the Bell, Weinberg, and Hammersmith (1981)
ways that LGB identity is stigmatizing. This is report that 70% of lesbians and gay men in
reflected in the tendency among many LGB their sample reported having a vague sense of
persons to reject or experience confusion about feeling different from same-sex peers as young
236 Sexual Orientation

as age four or five and that the vague feeling of confront fears of the unknown, an avoidance of
difference had or developed a sexual compo- rejection, or harassment or abuse by society
nent. Savin-Williams (1996) reports that LGB and/or loved and trusted figures in the indivi-
youth move from the stage of awareness to that dual's life (Savin-Williams, 1996). Some indivi-
of attempting to name or define the sense of duals structure their lives around two
difference that they experience. This period of completely separate worlds, their LGB friends
self-definition, that for some but not all LGB and acquaintances with whom they can be out,
people begins in early childhood, is usually and their co-workers, families, friends, or other
resolved by early adolescence or young adult- persons with whom they are closeted.
hood. The resolution of self-definition, how- It is important to remember that coming out
ever, may be postponed from several years to is a contextual process, and that it will be
decades depending on the degree to which experienced, timed, and understood by the
negative attitudes toward LGB people are individual in concert with that person's gender,
internalized (Savin-Williams, 1996). ethnicity, socioeconomic class, age, and other
Following the period of self-awareness, an- distinctions. For example, there may be differ-
other anxiety-provoking period may be marked ences in the process that are a function of gender
by the desire to come out to family members, that make it different for gay men and lesbians.
about not wanting to do so, or the uncertainty of Gonsiorek (1988) suggests that coming out may
which course to take. Many individuals, how- be more abrupt for males who come out during
ever, endure constant concern about being the adolescent period than for females, and that
ªoutedº before they have chosen to personally men may tend to act on their sexual feelings at
disclose their sexual orientation to someone. an earlier stage than women. Women in Western
Individuals who do not disclose their sexual cultures are permitted to display a broader
orientation are considered closeted (Bohan, range of emotions and behaviors with other
1996). However, being closeted, like being out, women that do not violate their traditional
is not a dichotomous, either/or state. Most LGB gender role expectations. Physical contact and
persons are out to some people in their lives and physical displays of affection between women
closeted to others. are not necessarily presumed to mean that such
Coming out is a major source of stress for contact is sexual or that they are lesbians. Their
LGB persons and is frequently cited as a major male counterparts do not enjoy the same
source of anxiety among LGB clients entering latitude of behaviors and in the expression of
psychotherapy (Bell & Weinberg, 1978; Brad- emotions. Men engaging in physical displays of
ford & Ryan, 1988). Coming out is, in reality, a affection with other men would be deemed
process that incorporates an important element suspicious as such conduct is not in keeping with
of a person's identity, an element that the the Western male stereotype of masculinity.
individual may not have always been aware of. However, there are subcultural differences in
The LGB individual is required to incorporate the latitude men are allowed for such conduct.
this perhaps newly discovered aspect of them- For example, African-American males who
selves, in affirmative ways, in the midst of a have close emotional or familial ties are very
culture which is anything but affirming. This is likely to hug one another or exchange unique
reflected in its legitimized intense, negative handshakes or other displays on greeting one
reactions to LGB persons (Bohan, 1996; another. This can be understood as a means of
Garnets & Kimmel, 1991; Gonsiorek, 1991; displaying solidarity as well as affection (Boyd-
Isay, 1990). Franklin, 1990). In the context of African-
There is research that documents the benefits American and Latino communities, such beha-
of coming out. Decreased feelings of loneliness vior is not presumed to represent suspicious
and guilt, identity synthesis, integration, and conduct, but rather may represent a more
commitment (Cass, 1979; Coleman, 1981/1982), culturally syntonic value of touch. This under-
healthy psychological adjustment and positive scores the importance of understanding the
self-esteem (Savin-Williams, 1990), positive gay cultural reference point of the person as it will
identity, a greater sense of freedom to be oneself, play a significant role in that person's response
of not living a lie, and experiencing genuine to their own as well as other's behaviors.
acceptance were reported as benefits of dis-
closure (Savin-Williams, 1996). Despite the 10.09.4.1 Identity Development
benefits of disclosure, for some LGB persons
negative reprisals may outweigh benefits de- Theories of sequential stages in identity
pending on the unique aspects of an individual's development in LGB persons are similar in
life, that may change over time and in different structure to those for ethnic group members
situations. For some LGB persons, reluctance (Bohan, 1996; Cass, 1984; Coleman, 1981/1982;
to come out may be attributed to a reluctance to Fassinger, 1991; Weinberg, 1983). However,
 Unique Psychological and Developmental Tasks Challenging LGB Persons 183

smooth transitions through the stages of any of coping strategies required for them to negotiate
these models will be complicated by the developmental tasks successfully in an antag-
pervasive presence of negative attitudes toward onistic environment. Such an approach, he
and discrimination against group members. suggests, will be more likely to yield important
Members of ethnic minority groups, who come information about adaptive and perhaps even
from healthy families and affirming commu- exceptional strategies that might otherwise be
nities, usually receive positive cultural mirroring overlooked. The concept of resilience in LGB
during the course of their development that persons is rarely explored. Jones (1997) at-
LGB people do not receive. That is, ethnic tempts to analyze the components of resilience
minority individuals are often socialized to by examining the paradoxical life of jazz
actively challenge rather than accept the composer Billy Strayhorn. Strayhorn, an
dominant culture's assertions about them from African-American gay man in a viciously racist
their families and community. LGB persons, and homophobic climate, was also the victim of
however, learn a range of negative stereotypes childhood physical abuse and other troubled
and attitudes about LGB persons, not simply family dynamics. Despite those obstacles, he
from the dominant culture but from loved and came to be known as a major figure in American
trusted figures (Greene, 1994a, 1994b; Greene & jazz music idioms, and developed what ap-
Boyd-Franklin, 1996). To complicate matters, peared to be satisfying adult relationships of all
they are likely exposed to such attitudes long types. His adult life was not entirely free of the
before they are aware of their own sexual residual psychological effects of his childhood
orientation. When LGB persons have uncriti- struggles with adversity. In many ways the
cally accepted such values and attitudes, more- effects of those struggles were compounded by
over, when they have internalized them, the the double layers of societal discrimination that
process of self-acceptance becomes complicated were routine features of American society at
and often fraught with ambivalence. It is not that time. Jones (1997) identifies a range of key
uncommon during this period to observe what ingredients in the psychological resilience found
has been previously described as ego dystonic in members of many groups, including sexual
feelings about one's LGB orientation. The minorities, who have been forced to endure
internalization of hateful and denigrating ªpatterned injusticeº (p. 13). Among those
attitudes toward LGB persons has been defined ingredients, Jones (1997) observes that carefully
as internalized homophobia (Bohan, 1996; constructed, segregated communities can facil-
Gonsiorek, 1982; Shidlo, 1994; Weinberg, itate the development of self-constructed psy-
1972). Internalized homophobia may be man- chological realities and a form of psychological
ifested in a hatred or contempt for any quality independence observable in members of dis-
or characteristic attributed to LGB persons. It advantaged groups. People who move within
may also be manifested in depression, suicidal those communities can develop a high level of
ideation or attempts, verbal or physical aggres- resilience in part because these communities
sion toward other LGB persons, substance provide them with the opportunity to engage in
abuse, and other self-destructive behaviors. a process of independent self-construction.
Addressing internalized homophobia and elim- LGB subcultures have always existed. They
inating it is an important aspect of psychother- have offered LGB persons the opportunity to
apy with LGB persons whenever it is present. have small corners of the world in which they
Successfully moving through the different may safely be themselves and experience other
stages of any model may take years or, for some people who are like them directly. Despite their
individuals, a lifetime to accomplish. The often secretive nature, these subcultures never-
precise length of time required, however, will theless provide members with the important
also vary from person to person depending on opportunity to develop the alternative self-
other circumstances and other psychological images needed to challenge the negative labels
tasks they must perform. There is frequently a applied to them from members of the dominant
delay in time between the discovery of an LGB group (Greene, 1999; Greene & Boyd-Franklin,
sexual orientation and its acceptance as a 1996; Jones, 1997). The opportunity to engage
healthy and acceptable part of an individual's in a process that allows group members to
identity (Bohan, 1996; Garnets & Kimmel, define themselves rather than accept negative
1991; Gonsiorek, 1991). definitions of them is a salient ingredient in their
mental health.
10.09.4.2 Resilience in LGB People The process of coming out is further
complicated by the frequent absence of routi-
D'Augelli (1994) suggests that development nely available and explicit role models that
in LGB persons should be approached from the socially affirm LGB identities. Media images of
perspective of exceptionality given the superior LGB persons, with rare exceptions, routinely
238 Sexual Orientation

depict them as seriously flawed, tragic, or are members of ethnic minority or other
comedic characters, when they are visible at societally disadvantaged groups as they must
all. Such depictions leave many persons strug- manage multiple levels of discrimination (Chan,
gling with their new found identity, reluctant to 1989; Greene, 1999; Greene & Boyd-Franklin,
identify with a group which is perceived to have 1996). Liddle (1997) observes that LGB clients
many negative features that are deemed to tend to choose LGB therapists 41% of the time;
characterize them. As a result, many individuals gay men tend to choose gay or bisexual male
must develop their own personal framework for therapists; lesbians tend to choose lesbian or
identity and for maintaining self-esteem (Gar- bisexual female therapists (Modrcin & Wyers,
nets & Kimmel, 1991; Peplau, 1991). 1990). When the sexual orientation of the
therapist is unknown, lesbians are more likely
to see female therapists, with 89% of Liddle's
10.09.5 UTILIZATION OF (1997) lesbian sample choosing female thera-
PSYCHOLOGICAL SERVICES pists (Modrcin & Wyers, 1990). Morgan (1992)
finds that lesbians hold unusually positive
Lesbians and gay men are more likely to see a attitudes about seeking professional help.
therapist or seek psychological services than However, this is consistent with the demo-
their heterosexual counterparts (Bell & Wein- graphics of lesbians that tend to be sampled.
berg, 1978; Bradford et al., 1994; Morgan, 1992; Members of groups sampled tended to be
Morgan & Eliason, 1992). This is not surprising young, White, and better educated than their
as group members are vulnerable to oppression heterosexual counterparts (Morgan, 1992; Trip-
and discrimination, the denial of many basic pet, 1994). Higher levels of education are
legal rights, as well as exposure to the same life associated with positive attitudes toward seek-
stressors that their counterparts must negotiate ing professional help.
(Fassinger, 1991; Greene, 1999). Some seek Presenting mental health concerns in therapy
therapy to have a place where they can safely include homophobia and stress (Niesen, 1990),
discuss their feelings about their sexual orienta- depression (Rothblum, 1990), relationship is-
tion, where their ªsecretº cannot be divulged to sues (not being out or coming out to family
anyone else without their permission. Over 50% members, limited support for or disparaging
of lesbians in a national sample reported being attitudes toward relationships), and conflicts
the target of verbal attacks, 13% reported losing about being closeted or out (e.g., being closeted
their jobs, and others reported discrimination at work and out socially; whether or not to come
against or being stereotyped by mental health out and to whom). Bradford et al. (1994) found
professionals because of their sexual orientation depression present in half of their sample, in fact
(Bradford et al., 1994). This kind of treatment depression was often the factor precipitating a
often results in fears of disclosure even to mental referral. They also determined that the degree to
health professionals. Such fears of disclosure which a subject was out affected their mental
may represent another factor that indirectly health. In a national survey of lesbian health
affects our estimates of the numbers of LGB care and mental health concerns, Bradford et al.
persons receiving mental health services, as found that relationships were a major focus of
some remain invisible to us, even in the therapy attention in therapy. Problems with lovers were
hour. Bradford et al. report that three-quarters reported as a major focus by 44% of partici-
of their sample reported seeking mental health pants, with family (34%), and with friends
services at some time, the majority reported (10%), respectively. Loneliness was also a
finding it helpful. significant focus of attention (21%). In the
Most LGB persons seek psychological ser- Bradford et al. sample, 68% of respondents
vices for many of the same reasons that other reported experiencing a range of mental health
people do, normal life transitions as well as problems in the past. Those problems included
unexpected trauma. However, they must man- long-term depression and sadness, constant
age those stressors in the context of an anxiety and fear, as well as other mental health
environment that is hostile to them. They also concerns. However, only 23% of that group
tend to see therapists for longer periods than reported being in therapy prior to the present
their heterosexual counterparts (Liddle, 1997; time. 49% of that group, however, reported
Morgan, 1992). Many of their presenting having been in therapy for one year or less.
problems, however, focus on or are related to These patterns suggest the presence of coping
the presence of societal and internalized homo- and survival skills, reliance on friends, and the
phobia, issues that heterosexual persons do not presence of social supports as alternatives to
have to manage, often exposing them to chronic, therapy (Bradford et al., 1994; Fassinger, 1991).
high levels of stress (Morgan, 1992). These Concerns about money and financial well-
issues are compounded for LGB persons who being were reported by 57% of the Bradford
 Utilization of Psychological Services 185

et al. (1994) sample. The percentages of African- Homosexuality (NARTH), founded by Charles
American lesbians and lesbians aged 54 and Socarides and Joseph Nicolosi, is committed to
younger were somewhat higher in the group the pathology model of LGB sexual orientation.
reporting financial concerns. While most re- Its members believe that the removal of
spondents reported a preference for private homosexuality as a diagnostic entity from the
therapy, the lack of third-party payments and DSM was the result of the power of gay rights
insufficient personal resources impinged on lobbyists and reject any scientific studies
those preferences. One-third of the sample challenging the pathology model. Group mem-
reported seeking professional services for bers are committed to the pathology model and
ªpersonal growth,º however, this was less use of reparative therapies to change LGB
frequently cited as a reason for referral among sexual orientations to heterosexual orienta-
African-American and Latin, lesbians. Rates of tions. Generally, the use of conversion therapies
eating disorders and sexual abuse among the rests on the assumption that LGB sexual
respondents in this group were similar to those orientations are expressions of psychopathol-
of their heterosexual counterparts. Higher ogy. Gonsiorek (1991) and Haldeman (1994,
percentages of suicidal ideation and attempts 1999) provide comprehensive discussions of the
were reported, however, among the younger weaknesses of the pathology models. Briefly
aged groups, suggesting that the potential for summarized, these studies suffer from a range of
suicide among LGB adolescents warrants methodological problems. Among them, it is
serious attention (Bradford & Ryan, 1989; not clear if the subjects who are labeled
Bradford et al., 1994). Researchers caution that homosexual in fact are homosexual, as opposed
the samples in the research studies cited tended to bisexual or even heterosexual. As previously
to be young, White, better educated, and discussed, they often compare lesbian or gay
accessible to major cities. Older, non-White, subjects drawn from patient populations to
financially less well off LGB persons in rural or nonpatient heterosexual controls, and fre-
isolated communities are not well represented. quently use outcome measures of questionable
In isolated settings, people may be at even validity. Furthermore, there is data to support
higher risk for distress and the development of the contention that there is no difference
mental disorders, however, they may be more between LGB persons and their heterosexual
likely to be cut off from a supportive and counterparts on instruments measuring psy-
sympathetic community when they are in chological adjustment. Haldeman (1999)
greatest need of one. further documents the methodological weak-
nesses in studies that purport to demonstrate
that sexual orientation can be altered. Selection
10.09.5.1 Psychotherapy with LGB Persons criteria, subject classification, and outcome
measures are cited as major flaws (Haldeman,
Prior to changes in the diagnostic nomen- 1991, 1994, 1999).
clature, most psychotherapy with lesbian and As previously examined in the discussion of
gay clients focused on changing their sexual ego dystonic homosexuality, there are serious
orientation. Despite changes in the nomencla- questions about the origins of requests from
ture and organized mental health's rejection of LGB clients to alter their sexual orientation. In
pathology theories, efforts to change the sexual this context, Haldeman (1999) raises an even
orientation of gay and lesbian clients have more important question. Whether or not LGB
persisted and are referred to as conversion sexual orientations can be changed, should they
therapies (Haldeman, 1991, 1994; 1999; be? In a climate of hostility and derision, where
McWhirter, 1990). There is no credible empiri- acknowledging an LGB sexual orientation
cal evidence to warrant the assumption that results in a loss of societal privilege, at the very
therapies aimed at altering sexual orientation least, the offer of ªtreatmentº or ªconversionº
are successful. Haldeman (1999) documents may serve to reinforce negative societal atti-
psychology's evolution from this position to its tudes. It would be difficult to conduct such
current policy and offers guidance to clinicians treatment without supporting the idea that
who deliver services to clients who may be something is wrong with the LGB person that
distressed by their LGB sexual orientation. warrants correction, and in doing so, reinfor-
Groups under the auspices of fundamentalist cing heterosexist bias. The LGB person be-
Christian denominations touting the sanctity of comes the focus of change, rather than the
literal biblical interpretations as superior to pathology of heterosexism and homophobia
scientific studies on LGB sexual orientations are and its advocates. Furthermore, Haldeman
the ªmain purveyorsº of conversion therapies. (1994, 1999) argues that such treatments are
In addition to these groups, the National not benign. In some studies, patients complain
Association for Research and Therapy of of significant discomfort following attempts to
240 Sexual Orientation

convert their sexual orientation. Such reactions The relative invisibility of gay men and
include chronic depression, anxiety, intimacy lesbians allows them to ªpassº as heterosexual.
avoidance, and sexual dysfunction. Passing in the LGB community is also referred
APA, in an attempt to address ethical ques- to as being closeted. Both ªpassingº and being
tions raised by the use of conversion therapies, ªoutº have their own distinct negative and
approved (in a near unanimous vote) a resolu- positive consequences. Passing may conceal
tion, ªAppropriate Therapeutic Responses to group members from other LGB persons. Both
Sexual Orientationº at its 105th Annual Con- passing and being out are accompanied by
vention in August 1997. The resolution holds varying types and degrees of psychological
clinicians responsible for rejecting depictions of demands and the stress that is a result of those
LGB persons as mentally ill and acknowledges demands. Gay men and lesbians pass or are
the role of societal prejudice in prompting many closeted when they do not challenge the
LGB persons to seek conversion therapies assumption that they are heterosexual or when
(Haldeman, 1999). Another aspect of the resolu- they actively conceal their sexual orientation.
tion requires clinicians to disclose the theoretical Passing can be an adaptive coping strategy
underpinnings and scientific basis for their inter- when used strategically. It has been used
ventions. As conversion therapies do not enjoy historically by ethnic minorities in threatening
the support of empirical evidence, it would make situations and can be an adaptive survival tool.
it more difficult to ethically offer them as suitable It was often effective in helping its users avoid or
responses to an LGB client's distress about their escape imminent harm or to obtain goods,
sexual orientation. APA commentary on con- services, or jobs which would be otherwise
version therapies states, ªthese findings suggest inaccessible to them because of discrimination
that efforts to repair homosexuals are nothing (Greene, 1994a, 1994b, 1994c). When used as a
more than social prejudice garbed in psycholo- long-term survival tool, however, it deprives its
gical accoutrementsº (Welch, 1990, in Halde- user of the spontaneity required for authenticity
man, 1991, p. 160). in interpersonal relationships. Individuals live
Different stages of the coming out process may with a consistent pressure to conceal major
be extremely anxiety provoking. The discovery aspects of their lives and may often live with the
or confirmation of a lesbian or gay sexual constant dread of being discovered (Bradford
orientation may be experienced as frightening, et al., 1994; Greene, 1992). When passing is
ego alien, and/or a source of great subjective accompanied by the belief that being gay or
distress (Gonsiorek, 1982, 1988). It is also a lesbian is a sign of inferiority or pathology, it
frequently cited reason LGB persons give for represents an expression of internalized homo-
seeking psychological services. As such, it may phobia. Lesbians and gay men who pass or are
lead to the expression of behaviors or feelings forced to remain closeted, particularly when it is
which resemble symptoms of severe psycho- dangerous not to do so, are confronted with a
pathology. However, the presence of this beha- chronic stressor which can leave them at risk for
vior, particularly under these circumstances, negative psychological outcomes (Bradford
does not warrant the immediate assumption that et al., 1994; Fassinger, 1991; Trippet, 1994).
an underlying psychiatric disorder is present Not only are lesbians and gay men unpro-
(Gonsiorek, 1982). For many clients, the clini- tected by legislation which prohibits discrimina-
cian is observing the individual's difficult strug- tion based on group membership, some
gle confronting the real nature of their sexual legislation exists which actually requires dis-
orientation, perhaps for the first time. For other crimination against them, for example, military
clients, however, the intense stress inherent in regulations.
this process may, like any other stressor, precipi- Bisexual persons are frequently the objects of
tate the expression of serious underlying psy- hostility from gay men, lesbians, and hetero-
chiatric disorders. In either case, a person is sexuals as well. Bohan (1996) uses the term
required to manage this realistically stressful life biphobia to describe the discomfort people
event. Clients who have underlying psycho- experience about bisexuality. The negative treat-
pathology must do this with fewer emotional ment bisexual men and women receive from the
resources. Another diagnostic variation is ob- lesbian and gay community can include their
served in the client who is consumed with great exclusion from LGB social events, as well as a
anxiety or fears of delusional proportions that denial of the legitimacy of bisexual identity. They
they may be gay or lesbian despite the absence of may be perceived by members of the gay and
any rational foundation for such beliefs. It is lesbian community as persons who are really gay
important to attend to diagnostic distinctions in or lesbian, but who conceal or deny their true
these situations. A comprehensive discussion of identity to avoid the stigma of being gay, and to
differential diagnostic issues can be found in allow them to benefit from heterosexual privi-
Gonsiorek (1982). lege (Bohan, 1996; Garnets & Kimmel, 1991).
 Utilization of Psychological Services 187

Their bisexuality may also be perceived as an strom, 1991). On the other hand, the therapist
expression of their internalized homophobia. may tend to focus on the client's lesbian or gay
Bohan (1996) argues that many lesbians and gay sexual orientation as pathological and the
men consider the presence of a singular commit- source of all of the client's problems, ignoring
ment to one's own sex as a statement of loyalty to matters that are more troubling to the client
lesbians and gay men, the absence of such a (Garnets et al., Markowitz, 1991). Similarly,
commitment as disloyal, and perhaps the fear therapists may focus on the client's sexual
that such a person will ultimately reject their orientation in a voyeuristic manner, wishing to
lesbian or gay sexual orientation if it is hear unnecessary details about the client's
opportune to do so. Conversely, they may be sexual practices for the therapist's own titilla-
viewed by heterosexuals as less normal or tion, neglecting other areas of inquiry important
inferior to persons who are exclusively hetero- to the client's treatment (Dworkin & Gutierrez,
sexual (Garnets & Kimmel, 1991). 1992; Garnets & Kimmel, 1991; Gonsiorek &
Heterosexism and its concomitant negative Weinrich, 1991; Markowitz, 1991).
stereotypes of gay men and lesbians has been so Many clients report finding that when they
much a part of the definition of psychological raise questions or attempt to explore their
normalcy that it predisposes practitioners to confusion about their sexual orientation, they
make a range of erroneous assumptions about find themselves confronted with the therapist's
LGB clients. Many of these assumptions anxiety about the topic. This anxiety may take
represent ideas of questionable validity, which the form of the therapist's failure to ask
they have not been sensitized to recognize questions or assist the client in explorations of
during their training (Brown, 1996; CLGC, these issues. Other clients report the therapist's
1990, 1991; Garnets et al., 1991; Glassgold, outright denial that the client could be gay. This
1992; Gonsiorek, 1991; Liddle, 1997; Marko- may be accompanied by the therapist actively
witz, 1991; Morin, 1977). discouraging the client from having or adopting
One example of such errors is the presump- a gay or lesbian sexual orientation (Brown, 1996;
tion that clients are heterosexual until proven Garnets et al., 1991; Youngstrom, 1991) or
otherwise. This can be particularly problematic selectively encouraging heterosexual relation-
for individuals who are in the early stages of ships. On these occasions, many clients simply
coming out, who lack a sense of clarity about drop the issue. Others move on to another
their sexual orientation, who are distressed by therapist. Still others leave therapy, sometimes
the possibility that they may have an LGB the worse for the experience.
sexual orientation, or who have internalized the Generally, therapists who work with LGB
dominant culture's heterosexist bias. The client persons must appreciate the individual client's
may not necessarily disclose their LGB orienta- dilemma in the context of real and not
tion to the therapist at all or they may do so at fantasised prejudice and discrimination. Het-
any point in treatment (Bradford et al., 1994; erosexism often assumes the form of physical
Fassinger, 1991; Garnets & Kimmel, 1991; violence directed at LGB persons (Fassinger,
Greene, 1994b; Markowitz, 1991; Liddle, 1997; 1991; Herek & Berrill, 1992). Data on bias
Youngstrom, 1991). Like other factors which crimes suggest that 92% of lesbians and gay
vary from person to person, sexual orientation men report being targets of antigay verbal abuse
may be centrally or distantly related to the or threats, and that 24% report physical
presenting problem. Many individuals, how- attacks, of which some result in death (Herek,
ever, may depend on the therapy process and the 1989). Gay men and lesbians face the routine
therapist's acceptance to help them navigate this tasks of assessing realistic dangers associated
uncharted and frequently anxiety-ridden course with divulging the nature of their sexual
to self-acceptance (Greene, 1994b). orientation. Many endure painful isolation
A former therapy client recounted: ªnot one from families of origin who do not accept their
of them (therapists) was prepared or brave identity, as well as the painful process of
enough to ask me the one question that might rejection which often precedes it. They are
have saved me and two ex-wives a lot of pain . . . challenged by their own internalized homo-
Do you think you might be gay?º (Woolley, phobia, which can negatively affect their
1991, p. 30). psychological adjustment (Fassinger, 1991;
Errors in treatment can occur at either of two Trippet, 1994; Weinberg, 1972).
extremes and, of course, at any point along the Those who are out face the formidable task of
continuum between those extremes. On the one negotiating nontraditional relationships and
hand, the therapist may minimize the impor- family structures with few models and little
tance of the client's sexual orientation and the support for doing so in a ubiquitously hostile
negative impact of heterosexism on the client's environment. In such a climate, many people
life (Garnets et al., 1991; Greene, 1994b; Young- who would consider expressions of racism or
242 Sexual Orientation

ethnic bigotry wholly inappropriate are quite or lesbian sexual orientation before the client is
comfortable expressing heterosexist bigotry and psychologically prepared to manage it. Rather,
find support for doing so. These issues are the therapist must be affirming and supportive
further complicated for gay men and lesbians of the client, regardless of the client's choice
who are members of ethnic minority or other about their sexual orientation or the manage-
marginalized groups (Chan, 1992; Greene, ment of challenges associated with adopting
1994a, 1994b, 1994c, 1996a, 1996b, 1999; LGB orientations. Furthermore, therapy with
Morales, 1992). members of oppressed groups must address the
Therapists must begin to assess the impact of pathology of the oppressive behavior rather
a legacy of negative stereotypes about LGB than exclusively focusing on victims' responses
persons on their own thinking, and they must do to oppressive behavior. In this context, helping
so before a client ever appears before them. the client understand negative responses to LGB
Markowitz (1991) warns that therapists must persons (heterosexist bias) as an example of
acknowledge and understand the extent to societal pathology, and not the client's flaw or
which they have internalized society's negative defect, must be an explicit part of the
depictions of gay men and lesbians. It is not therapeutic work (Brown, 1996; Dahlheimer
sufficient to simply not believe the stereotypes & Feigal, 1991; Greene, 1994b).
and to be unbiased without an inquiry into their Just as the authentic inclusion of any
personal effects on deeper levels (Brown, 1996; previously excluded minority group forces the
Liddle, 1997; Markowitz, 1991). larger group to transform itself into a realistic
Unexamined fears in the therapist may be reflection of the diversity of its members, the
triggered by a range of interactions with LGB visible presence of LGB persons who seek
clients. The client may, if angry, accuse the psychological services forces us to rethink our
therapist of being homophobic. Conversely, if traditional notions about personality develop-
the therapist is supportive and understanding, ment, developmental tasks and stressors, and
some LGB clients may assume that they share about what kinds of constellations of persons
sexual orientations. The therapist may assume a constitute a couple, a marriage, or a family
defensive posture, rather than exploring the (Greene, 1994b).
client's feelings in an uncritical manner. The
therapist may respond to the client's accusation 10.09.6 LGB PERSONS AND FAMILY
that the therapist is homophobic by failing to set ISSUES
or maintain appropriate limits, as if this
disproves the client's assumptions. Such beha- LGB persons come from diverse family
vior on the therapist's part is not done with the constellations as do their heterosexual counter-
client's interests in mind, rather it is often the parts. They also require the same tangible and
therapist's response to their own feelings of guilt emotional support that all people need, usually
or discomfort (Greene, 1994a, 1994b, 1994c). provided for by family members. It may be said
This does not mean that whenever a client that strong family ties are even more crucial to
perceives homophobia in the therapist, it must LGB persons given the hostility and rejection
be a distortion on the client's part. It means that they routinely confront in the outside world.
it is always the clinician's responsibility to be They may not, however, presume the support
familiar with their own personal feelings and that heterosexual family members facing any
attitudes toward LGB persons and the ways challenge might take for granted. Therapists
they may be manifested in the therapy process. should be attuned to the possibility that the
The therapist must then assess the client's absence of such support has more negative
complaint in this context, while simultaneously consequences for LGB persons than for their
exploring the range of conscious and uncon- heterosexual counterparts. Some research sug-
scious purposes which may be served by the gests that White lesbians report that they are as
client's beliefs about the therapist (Brown, 1996; much as three times more likely to depend on
Greene, 1994b, 1999; Liddle, 1997). friends for support over family members (Brad-
The issue of therapist neutrality, common in ford et al., 1994; Kurdek & Schmidt, 1987;
psychodynamic therapies, must be managed Morgan, 1992). Other research suggests that
delicately. Because LGB persons are frequently ethnicity may play a role in the extent to which
the objects of intense disapproval from both family or friends are more salient sources of
loved ones and society, a client may read a support. Mays and Cochran (1986; 1988) report
therapist's neutrality as disapproval. The thera- that African-American lesbians tend to depend
pist in these situations must also be careful not on family members for tangible and emotional
to advance their own agenda for the client, no support to a greater degree than their White
matter how well intentioned. It is inappropriate counterparts. This may contribute to making
to push the client toward acknowledging a gay African-American lesbians more reluctant to
 LGB Persons and Family Issues 189

come out to family members than their White families where their parents were heterosexual
counterparts. and where they had few useful role models for
Many lesbian and gay clients struggle at some understanding what normal transitions and
point in their lives with crises related to developmental periods in gay and lesbian
maintaining secrecy about their sexual orienta- relationships would be like (Garnets & Kimmel,
tion, the true nature of their relationships, and 1991). For some couples, there may be a
the ongoing problems that are a consequence of tendency to idealize relationships with members
that decision. An expected developmental issue of the same gender. This belief may have some of
involves the decision to come out to family its origins in the assumption that their gender
members, and the consequences of that deci- similarity makes them the same, and that
sion. Many clients may feel very conflicted sameness presumes an ease in relating. While
about what they want to do and will express this may be true for some couples, it is certainly
great confusion in making this decision. Some not generalizable to all of them. Gender
may even feel guilty about their disclosure if it similarity does not preclude conflicts, disagree-
upsets family members. The therapist in these ments, or dysfunction in relationships and in
situations must be careful not to reinforce the some cases may even intensify it. Hence, many
client's guilt by discouraging disclosure when it gay and lesbian couples are surprised and
is appropriate or by suggesting that the family's disappointed when they encounter problems
rejection is justified. or conflicts within their relationships, even when
While it may be expected that a family they are representative of the normal range of
member's disclosure may upset some family challenges for all couples. They may harbor the
members or disrupt family functioning, there is notion that they are the exception to their
no uniform way in which families respond. Each idealized image of lesbian or gay relationships,
client's family is different and the range and or conversely that all lesbian or gay relationships
intensity of their responses will vary from are doomed to fail. For example, some women
acceptance, or perhaps disappointment, to believe that battering does not occur in lesbian
outrage and outright rejection. Ethnicity, socio- relationships. They believe that women, unlike
economic class, religious belief, age at the time men, are not physically abusive. Hence, lesbians
of coming out, and other variables will affect the in battering relationships may be confused and
responses of family members as well as the unable to appropriately label such behavior out
consequences of those responses to the LGB of the belief that it does not occur between
person. Previous family dynamics, rivalries, women, despite the fact that it is happening to
close ties, and strengths will also affect the them. Renzetti (1992) documents the problem of
process differentially. Over time, some families partner abuse in lesbian relationships and offers
will come to accept the lesbian or gay member's a helpful analysis. Kanuha (1990) offers special
sexual orientation to varying degrees and others insights into this problem as it occurs in lesbian
will not. Responses of families will be as diverse women of color.
as the racial, ethnic, and class groups they If lesbian and gay couples are out, their
represent. Clients may need to be reminded of relationship may be constantly minimized and
the often lengthy and difficult process of coming challenged. If they are not out the invisibility of
out that they have previously negotiated. This their relationship can be just as problematic.
process required that they reevaluate their The invisible relationship goes unnoticed. While
previously accepted attitudes about LGB this is in part the idea, it means that the
persons and come to accept and embrace their legitimate status accorded relationships and the
identity over time. Just as they required time social and economic privileges that accompany
and understanding to do so, as painful or them are lost. The special pressures and
infuriating as the process may be for them stressors that accompany them remain unac-
personally, their family members will require knowledged as well. Family members who
time as well. Strommen (1989), Liu and Chan perceive a relative to be single, or without the
(1996), Greene and Boyd-Franklin (1996), and responsibility of a family of their own, may be
Brown (1988) provide a detailed discussion of more demanding of a relative's time or
the complexities inherent in the coming out resources. They may fail to understand the
processes for diverse LGB persons and their responsibility to a partner or relationship which
families of origin they do not see or one which they choose not to
recognize. On this informal level, when the
10.09.6.1 Gay and Lesbian Couples couple has a relationship problem, loss or
termination of the relationship, responses to
LGB persons seek, form, and sustain relation- such problems from heterosexual peers or
ships in a context where there is little support for family members may be inconsistent with the
them. Most lesbians and gay men grew up in realistic magnitude and significance of the loss,
244 Sexual Orientation

or with the attentiveness that would be given to couples which may be particularly helpful to the
a marital partner in a heterosexual relationship. therapist with no experience or training in this
Thus, members of couples may not derive area. Kurdek (1994), Kurdek and Schmidt
appropriate support during critical times from (1987), Peplau (1991), Peplau and Cochran
resources commonly available to heterosexual (1990), and Modrcin and Wyers (1990) report
couples. Lack of legal status for gay and lesbian on extensive studies of cohabiting gay, lesbian,
relationships in most cities in the USA has direct and heterosexual couples. Findings suggest that
economic consequences reflected in part in the lesbian and gay couples are no more prone to
loss of employee benefits that would normally relationship dissatisfaction or problems than
be extended to a marital partner. their heterosexual counterparts. While they may
Therapists who are unfamiliar with gay and have special problems and challenges, they are
lesbian couples, and some couples themselves, no more likely to have marital problems or
may attempt to impose male±female models on impoverished social support networks than
them, as there are no similar models for same- their heterosexual counterparts and generally
sex couples (Markowitz, 1991). The myth that in report satisfaction in their relationships.
lesbian and gay couples gender roles are
reversed is not supported, rather it is contra- 10.09.6.2 Gay and Lesbian Parents
dicted by empirical research on couples. Peplau
(1991) and Peplau and Cochran (1990) find that It has been traditionally, albeit incorrectly,
in most lesbian and gay relationships surveyed presumed that gay men and lesbians do not wish
participants actively reject traditional gender to have children and that they do not make
roles as models. Appropriate models would appropriate parents (Greene, 1990, 1994b).
need to take into account differences between Nonetheless, gay men and lesbians become
male and female socialization and its effects on parents in many different ways, as do hetero-
relationships in which both persons received the sexual parents. However, they do so amidst the
same gender socialization (Markowitz, 1991; pervasive assumption that their sexual orienta-
Schreurs, 1993). tion makes them inappropriate parenting
Peplau (1991) discusses a range of commonly figures. This assumption is often based on the
believed stereotypes about gay and lesbian false belief that they will increase the likelihood
couples. Among them, gay men and lesbians that their child will be gay, lesbian, or
neither wish to have, nor are they capable of psychologically defective. Research on children
forming, enduring relationships, most lesbians of LGB parents does not support these conten-
and gay men grow old unhappy and alone, their tions (Bigner & Bozett, 1989; Patterson, 1994,
relationships are inferior imitations of hetero- 1996). Patterson (1994) provides a systematic
sexual relationships, or that traditional husband study of the behavioral adjustment, self con-
and wife and other traditional gender roles are cepts, and sex role identity of children of the
reversed. Such stereotypes are still believed by lesbian baby boom.
many therapists despite the absence of any Many LGB persons choose to limit their
credible evidence to support them and in the social world to other LGB people whenever
presence of a growing body of evidence which possible. Those who have children, however, are
disputes such contentions. Bell and Weinberg forced to both interact with and negotiate
(1978) report that 40±60% of the participants in systems, for example, schools, that they might
their research were in steady relationships. otherwise choose to avoid. They find themselves
Peplau and Cochran (1990) suggest that the presented with the dilemma of how to present
invisibility of long-term couples in research can their unique family constellation in ways that
be attributed in part to sampling bias. LGB maintain its integrity, protect its privacy, and
research subjects are often recruited in venues are sensitive to the child's needs as well. Those
that over-represent young, White, urban parti- who are involved in shared custody arrange-
cipants, often in bars. They suggest that couples, ments with a former heterosexual spouse often
particularly long-term partners, do not frequent face the realistic danger of having the courts
bars as often as their younger, single counter- remove their children from their custody if the
parts. If older LGB people are not sufficiently true nature of their relationship is exposed. The
sampled, we would not expect to see longer problem of maintaining secrecy in families
relationships among young subjects. The fact where a gay or lesbian parent is not out is
that LGB persons cannot legally marry also complex. Care must be taken to determine how
means that there are no marriage records that to create the privacy or secrecy the family needs
would document the existence of long-term without leaving children feeling so fearful or
partnerships rendering them less visible (Peplau burdened that it interferes with their own
& Cochran, 1990). Clunis and Green (1988) emotional needs and development (Greene,
provide a detailed review of issues facing lesbian 1994b).
 LGB Persons and Family Issues 191

Disclosure of lesbian or gay sexual orienta- selves (Savin-Williams, 1996). Men, on the
tion to children is an anxiety-laden process for other hand, are more likely to disclose earlier
the parent and child. Many of the dynamics and to use external social and sexual activity to
discussed in Strommen (1989) and Brown develop a sense of self-acceptance, a more
(1988) can be applied to an understanding of external process (Savin-Williams, 1990, 1996).
problems which may arise in such disclosures to Many adolescents do not reveal their con-
children. Bigner and Bozett (1987), Crawford cerns about their sexual orientation to their
(1987), Falk (1989), and Green and Bozett families or other people who are close to them
(1991) provide detailed reviews of the issues out of realistic fears of rejection as well as
faced by gay and lesbian parents relevant to punishment (Hersch, 1991). When they do,
disclosure, family dynamics, clinical strategies, Savin-Williams (1996) observes that they are
and pertinent research. likely to tell a close friend first rather than a
family member. They may tell family members
10.09.6.3 Gay and Lesbian Youth as much as decades later or for some LGB
persons, never. Some may often withdraw at a
Gay and lesbian youth force us to take a time when they are in critical need of support.
second look at traditional assumptions about The high rate of suicide among adolescents
developmental tasks and tensions during the believed to be gay and lesbian underscores the
adolescent period. Despite the highly sexualized dire implications of this problem and warrants
nature of popular culture in the USA, most the serious attention of mental health practi-
adolescents have little accurate information tioners. Support groups, accessible health and
about sexuality at a time when they may be in social services, the availability of healthy role
greatest need of it. They have even less knowl- models, advocacy and education, and education
edge about gay and lesbian sexual orientation with respect to sexually transmitted diseases,
which is not pejorative. particularly AIDS, are suggested as needed
Gonsiorek (1988), Herdt (1989), Savin-Wil- services for gay and lesbian adolescents, a
liams (1989, 1990, 1996) describe a range of vulnerable population (Gonsiorek, 1988;
intense social and personal pressures facing gay Hersch, 1991).
and lesbian adolescents. All are complicated by The visibility of LGB persons as consumers of
the normative rigidity and intolerance of psychological services requires practitioners to
differences adolescents maintain toward them- rethink traditional definitions of family con-
selves and others. Adolescents who disclose stellations. Practitioners in the 1990s may find
their concerns about their sexual orientation are themselves confronted by the family in crisis
almost sure to find themselves in the midst of after an adolescent member has disclosed that
conflict with other family members and peers as they are lesbian or gay, or by the adolescent who
well. The negative stereotypes associated with is in the throes of deciding whether or not, or
gay and lesbian sexual orientations and the who, to tell. Similarly, they may be consulted by
dominant culture's denials of sexuality during the wife or husband who has chosen or struggles
this developmental period intensify this conflict. with the decision about whether or not to leave a
This denial is manifested in a conspicuous heterosexual marriage to come out. They may
absence of institutional support for these also be consulted by the confused and angry
youngsters. Coping strategies may also include heterosexual spouse.
withdrawal from social activities, denial, over- Practitioners may also be confronted with
compensation, emotional constriction, and self- family and couple constellations with which
destructive behavior (Gonsiorek, 1988; Savin- they are totally unfamiliar. Aside from issues of
Williams, 1989, 1990, 1996). custody and marital conflict in parents, it is not
Savin-Williams (1990, 1996) and Golden uncommon to be asked to treat a child or
(1996) caution that there are important gender children, in both the public and private sectors,
differences in the process of self-awareness and who must in these arrangements acknowledge
disclosure of LGB orientation. Golden (1996) this previously feared or unknown aspect of
tells us that self-labeling is more fluid in women their parent's life. This may occur in conjunc-
over the lifespan than men and that the concept tion with the sudden upheaval and breakup of
of sexual orientation may not be as stable for their family unit. As gay men and lesbians
women as it seems to be for their male actively embrace their lifestyles and choose to
counterparts. Women are more likely to initially form their own families, therapists are fre-
disclose their awareness of a lesbian sexual quently consulted to assist them in addressing
orientation in the context of an emotional and difficulties in their own relationships, as well as
affectionate relationship with another woman, making decisions to have and raise children in
and are less likely to disclose prior to coming to nontraditional situations. It is incumbent on
a more personal, internal resolution for them- therapists in these scenarios to be aware of the
246 Sexual Orientation

unwarranted but realistic level of prejudice and that current research and findings on lesbians
discrimination, particularly in custody hearings and gay men should be discussed in graduate
and court proceedings, against gay and lesbian programs, continuing education and inservice
parents that persists. training, as well as in undergraduate courses.
Liddle (1997) asserts that being unbiased is not
sufficient to demonstrate competence or ex-
10.09.7 TRAINING pertise in clinical work with LGB persons.
10.09.7.1 Hetrosexist Bias in the Delivery of Since the late 1980s we have witnessed the
Psychological Services growth of a significant body of psychological
literature which appropriately addresses the
Educational institutions are not exempt from aforementioned concerns. It has not, however,
pervasive heterosexist bias in Western culture. found its way into the mainstream of clinical
In fact, they have often communicated and psychology training programs and curriculums.
legitimized that bias. Institutions responsible Browning and Kain (1999), Buhrke (1989b),
for the training of clinical psychologists are no Chan (1996), Greene and Croom (1999), King
exception. Practicing psychologists, therefore, (1988), and Simoni (1999) review a range of
are not immune to the effects of the pervasive resources and strategies (see also Dworkin &
themes of heterosexist bias in the dominant Gutierrez, 1989; Stone, 1991) which may be
culture. Such bias has often served as an integral useful in the design, implementation, and
part of the underpinnings of theoretical and supplementation of traditional graduate and
research paradigms. Hence, this bias insidiously undergraduate psychology courses, rendering
pervades research and practice despite the them more sensitive and relevant to LGB
intentions of many well-meaning research persons.
scientists and practitioners. For example, psy- LGB sexual orientations are topics which
choanalytic theories evolved out of traditional most persons socialized in the USA have intense
culturally-bound views of gender roles. Its feelings about. Hence, it is important that
theory of etiology of sexual orientation has its psychologists learn to explore and understand
origins in views which privilege reproductive these issues appropriately in both their clients
sexuality as the only healthy outcome of and themselves. Few topics, however, are more
psychosexual development. Simoni (1999) re- scrupulously avoided in the formal training of
ports on the review of 24 college-level textbooks clinical psychologists. Just as members of ethnic
in social, abnormal, and developmental psy- minority groups have been harmed by a legacy
chology. Overall her study reveals inadequate of racially stigmatizing psychological folklore,
coverage and segregated treatment of the topic gay and lesbian clients are also harmed by
of lesbian and gay sexual orientation. Notably, negative heterosexist bias and the misinforma-
there was little attention given to the systematic tion which pervades psychotherapy practice and
incorporation of lesbians and gay men in has similarly pervaded psychological research.
contexts other than sexual orientation or sexual Just as ethnic minority clients can be harmed by
behavior, such as commitment, parenting, and the unexamined racism in the therapist or
other routine aspects of human behavior and inherent in a research design, gay and lesbian
relationships. clients can be similarly harmed by unexamined
The work of Hooker (1957), Kinsey, Pomer- and untransformed heterosexist bias in those
oy and Martin (1948), Kinsey, Pomeroy, areas.
Martin, and Gebhard (1953) and others estab- As greater numbers of gay and lesbian
lished that lesbian and gay sexual orientations individuals and families seek counseling and
were not synonymous with poor psychological psychotherapy, many therapists find themselves
adjustment. Despite this, ignorance and hetero- ill-equipped to provide services sensitive to what
sexist bias, which formal training rarely ad- may be seen as a distinct cultural group. It is
dresses directly, continues to significantly important that therapists be aware of the ways
influence the delivery of psychological services in which routine life stressors may be intensified
to gay and lesbian clients, as well as research in for individuals who are actively discriminated
areas relevant to developing a better under- against by the dominant culture and who, unlike
standing of this group (Greene, 1994b). members of oppressed ethnic groups, may not
Buhrke's (1989a) findings suggest that stu- find mentoring, support from, or identification
dents receive little exposure to information with family members. Such identification and
relevant to the delivery of services to gay and sense of shared struggle with family members
lesbian clients during the course of their formal has been an important coping mechanism in the
training. Garnets et al. (1991), Graham, Rawl- adaptive ªbanding together against the outside
ings, Halpern, and Hermes (1984), Liddle oppressorº for many members of oppressed
(1997), and Youngstrom (1991) recommend ethnic groups. While family members of ethnic
 Training 193

minority group members often teach their orientation. The locus and levels of danger
children to actively challenge the dominant assume different forms.
culture's views of them, they are more likely to D'Augelli (1989) observes that LGB students
embrace heterosexist attitudes and join in the and faculty members continue to suffer from
dominant culture's rejection of LGB persons. discrimination in the workplace. Three-quarters
The ethnic minority LGB person depends on of the lesbians and gay men in his sample in
the protective armoring of their family and university environments reported experiences of
ethnic community more than their White verbal abuse, 26% reported being threatened
counterparts but may find themselves on the with violence, and 17% reported having their
outskirts of that protective buffer against personal property damaged. Kitzinger (1996)
racism. In addition to the dominant culture's reports that British studies have similar findings.
racism, LGB people of color are challenged by Tierney (1992), in a report from the University of
the additional stress of coping with the LGB Oregon, finds the university environment
community's racism, the dominant culture's neither consistently safe, tolerant, nor academi-
heterosexism, as well as the heterosexist bias of cally inclusive of LGB persons or of research
their own ethnic group. This results in a complex relevant to them. The study concurred with
inter-relationship of loyalties and estrangements D'Augelli (1989) and Kitzinger (1996) who
(Chan, 1992; Greene, 1994a, 1994b, 1994c, 1996; report higher incidences of verbal and physical
Greene & Boyd-Franklin, 1996; Morales, 1992). attacks on LGB students than on their hetero-
Clinicians in these encounters are confronted sexual counterparts. Kitzinger (1996) reports
with the difficult and challenging task of that the British Psychological Society has
disentangling characterological issues from refused on three occasions to consider the
the personal distress that results from the establishment of a specific forum or unit devoted
pressures of societal inequities and their effects to the psychological study of LGB issues.
on mental health. This cannot be accomplished For many LGB students in graduate pro-
without a realistic portrayal of the institutional grams, disclosing their sexual orientation before
barriers which regularly confront LGB people. their formal training is completed puts them at
This includes an understanding of the role of risk for discrimination that may be subtle but
heterosexist bias in many psychological treat- nonetheless can adversely affect their training
ment and research paradigms. Despite the status within their programs. The requirement
extreme hostility and discrimination that LGB to manage the heterosexism of faculty members,
people routinely encounter, they are not supervisors, and fellow students can leave LGB
inevitable psychological cripples. The resilience students with additional challenges that are
and unique skills which many out gay men and neither appropriate nor shared by their hetero-
lesbians develop, despite the hostility and sexual counterparts. It also deprives them of the
barriers they face, must be more fully explored opportunity to authentically explore their own
as well as the negative outcomes (Greene 1994b, feelings, ideas, and appropriate use of self as a
1999). While the realistic need for secrecy, and clinical instrument in their work with clients.
often justifiable suspicion LGB persons hold for Hence, there is a failure to appropriately explore
mental health practitioners and research scien- countertransference problems as well as issues
tists often complicates research endeavors, they which may arise when the therapist and client
are not impossible to negotiate. are both LGB persons (Greene, 1994b).
Garnets et al. (1991) suggest the continued Dahlheimer and Feigal (1991) suggest that
use of survey research as a means of reducing therapists may use a variety of techniques in
sampling bias found in many studies on lesbians conjunction with didactic training to develop
and gay men. Caution must exercised when greater sensitivities toward gay and lesbian
making generalizations from samples which are clients. They suggest the use of role-playing and
nonrepresentative and replication of results is the review of case material for insensitive
important (Gonsiorek, 1991). approaches. Case material may be used that
While APA has charged psychologists with requires students or supervisees to review data
the task of challenging heterosexist bias in both or client histories and determine how they might
research and practice, it has provided little in view the case if the heterosexual client were an
their formal training to assist them in making LGB person (Greene, 1994b).
the necessary shifts in practice as well as Another suggestion directs therapists as a
attitude. Just as clients are presumed to be part of their training to purchase a gay or
heterosexual, faculty members and psycholo- lesbian magazine (which is clearly labeled as
gists in training are similarly regarded. Hetero- such), to carry it visibly throughout the course
sexist bias in training programs continue to of their day, to monitor their feelings about
make it unsafe for some faculty members and doing so as well as their internal and overt
lesbian and gay students to divulge their sexual responses to the inquiries and responses of
248 Sexual Orientation

others, and to discuss these experiences in A new line of inquiry must include acknowl-
supervision. It is suggested that these exercises edgment, exploration, and understanding of the
be used to develop a subjective sense of the level role of heterosexist bias in psychological prac-
of self-consciousness, shame, fear, vulnerability, tice, research, and the development of theoretical
or anger that many of their clients must manage paradigms. It must also include international
routinely (Dahlheimer & Feigal, 1991). Partici- perspectives on assessments of the role of neg-
pation in such exercises does not mean that ative attitudes toward LGB sexual orientations
doing so will give a heterosexual therapist a on the development of identities in lesbians, gay
complete understanding of what life is like for men, bisexual, and heterosexual persons. LGB
their LGB client. Rather it is intended to research must develop the means of sampling a
provide the therapist with some realistic, albeit wider range of LGB persons if studies are to be
minimal, understanding of what their client more representative of the population of LGB
must manage on an ongoing basis without the persons. This information is critical to the
luxury of terminating the ªexerciseº when they establishment of a reliable database as well as
are uncomfortable or in danger (Greene, to the development of culturally and contex-
1994b). Browning and Kain (1999) present a tually sensitive methods of understanding the
range of exercises and other strategies that may complex issues that arise when treating a diverse
be useful in training. range of LGB clients (Croom, in press).
Practitioners who lack formal training in or It is essential that the treatment of LGB clients
experience working with LGB clients and their and research with this population be given
families are advised to use cogroup and cofamily formal and explicit attention in the training of
therapist arrangements; others may use peer clinical psychologists. Initially, the invisibility of
and/or other forms of supervision with practi- LGB issues that should be integrated in and
tioners who have this professional experience across disciplines must be addressed. This can
and training as an additional means of assume many different forms including the
augmenting their skills (Liddle, 1997). incorporation of required course work and
David Scasta, editor of the Journal of Gay and clinical supervision (Buhrke, 1989a; Greene,
Lesbian Psychotherapy (Markowitz, 1991), ob- 1994b; Liddle, 1997). The active recruitment of
serves that the treatment of gay men and psychologists with research, supervision, teach-
lesbians is a specialized field that requires a ing, and other forms of expertise and interest in
heightened level of self-awareness in the clin- this area and the inclusion of openly gay or
ician and a commitment to being educated lesbian faculty and staff members in academic
about gay and lesbian issues. It is important that and training institutions must also be accom-
all current and prospective therapists examine plished in order to meet the goals of competent
their conscious and unconscious levels of practice.
heterosexist bias to assure that they do not This may also be accomplished by support-
intrude into their client's therapy (Brown, 1996; ing the creation of LGB scholarship by
Liddle, 1997). rewarding (rather than punishing or failing to
prioritize) course development, providing tan-
gible resources, supporting the acquisition of
10.09.8 FUTURE DIRECTIONS state-of-the-art publications and collections in
university libraries, and providing support for
As we approach the twenty-first century, interdisciplinary LGB research and teaching
clinical psychology is confronted with the need that develops scholarship from diverse per-
to be more inclusive if it is to serve the needs of spectives (Chan, 1996; Simoni, 1999). Simoni
consumers of psychological services appropri- (1999) advocates the identification, definition,
ately. It is also challenged with the need to create and confrontation of heterosexism in psychol-
theoretical paradigms and develop research that ogy as the explicit responsibility of an effective
is a reflection of a wider range of human instructor in the academy.
behavior and realities. Accreditation teams must be serious in their
Chan (1996) asserts that academic institutions efforts to hold training institutions, practicum,
play a major role in perpetuating heterosexist externship, and internship sites accountable for
bias and can play a major role in eliminating it. upholding meaningful standards of compe-
Listing sexual orientation in the nondiscrimina- tence. Establishing requirements for demon-
tion policies of institutions and seriously strating proficiency as an integral requirement
implementing that policy is one step. The for graduate comprehensive examinations,
assumption of a proactive, rather than reactive, licensing, and certification should be under-
affirmative stance among the leadership of taken as well. This can be accomplished by
academic institutions is an important means of including relevant items on LGB issues on
establishing and implementing such policies. licensing, certification, and advanced practice
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 Copyright © 1998 Elsevier Science Ltd. All rights reserved.

10.10
Diversity Matters: Religion and the
Practice of Clinical Psychology
DONALD W. PREUSSLER, RICHARD E. BUTMAN,
and STANTON L. JONES
Wheaton College, IL, USA

10.10.1 INTRODUCTION 233

10.10.2 THE DIVERSITY OF THE WORLD'S RELIGIONS 236
10.10.2.1 Cognitive Dimension 237
10.10.2.2 Ritualistic and Symbolic Dimension 237
10.10.2.3 Moral Dimension 237
10.10.2.4 Institutional Dimension 238
10.10.2.5 Community and Lifestyle Dimension 238
10.10.2.6 Experiential Dimension 238
10.10.3 RELIGION AND/OR VS. SPIRITUALITY 239
10.10.4 PHILOSOPHICAL BASIS FOR APPRECIATING RELIGIOUS DIVERSITY IN CLINICAL CARE 239
10.10.4.1 The Philosophical Conflict Between Clinical Care and Religious Belief 240
10.10.4.2 A Philosophy of Clinical Practice that Appreciates Religious Belief 240
10.10.4.3 A Paradigm for Dialog on Religious Beliefs in Clinical Care 241
10.10.5 CLINICAL ASSESSMENT AND DIAGNOSIS: APPRECIATING RELIGIOUS DIVERSITY IN THE
PROCESS OF MEASUREMENT 243
10.10.6 THE EMPIRICAL BASIS FOR APPRECIATING RELIGIOUS DIVERSITY IN CLINICAL CARE 245
10.10.6.1 Religious Persons and Mental Health 245
10.10.6.2 Psychotherapy and Values 246
10.10.6.3 Religion in Psychotherapy 246
10.10.6.4 Religion and Clinical Judgment, Technique and Behavior 247
10.10.6.5 Religion and Clinical Research 248
10.10.7 THE RELIGIOUS COMMUNITY AS A RESOURCE FOR SUPPORT 248
10.10.8 TRAINING CLINICAL PSYCHOLOGISTS IN RELIGIOUS DIVERSITY 249
10.10.9 FUTURE DIRECTIONS 250
10.10.10 SUMMARY 252
10.10.11 REFERENCES 252

10.10.1 INTRODUCTION assessment, diagnosis, and treatment of clients

by mental health professionals, particularly
In this chapter, the aim is to promote the clinical psychologists. To do this, an attempt
inclusion of spirituality and religion as poten- will be made to lay the philosophical, empirical,
tially important and salient factors in the and clinical bases for such a treatise. The

233
234 Diversity Matters: Religion and the Practice of Clinical Psychology

chapter will conclude with thoughts about important influence in their life and large
future directions for the inclusion of spirituality numbers (approximately 42%) would embrace
and religion in clinical care. the label of being ªborn againº (as cited in
ªProbably nothing in human history has Larson, Lu, & Swyers, 1996, p. 1). There is also
sparked more controversy and debate than evidence that there is no difference between the
religionº (Paloutzian, 1996, p. 2). The etymol- religious beliefs and practices of mental health
ogy of the word religion is interesting. It comes patients and the general population (Larson
from the Latin word legare, which means that et al., 1996).
which binds or connects. As Paloutzian (1996) These religious believers often see their faith
suggests, religion is a process of rebinding or as relevant to their health and lifestyle concerns.
reconnection. In the psychology of religion, it is Studies (e.g., Matthews, 1997) have found that
less clear whether that binding or connecting is 77% of patients in hospitals wanted their
to ªGod, Nature, a state of mind, a cosmic force, physician to consider their spiritual needs and
each other as individuals or their communitiesº 64% wanted their physician to pray for them if
(Paloutzian, 1996, p. 7). they requested it. Larson et al. (1996) review
Historically, religion has not been a promi- studies suggesting that most patients view
nent diversity issue for the field of clinical spiritual health as relevant and important to
psychology. Most often the field of psychology their general health. Further, studies cited by
has embraced tolerance of diversity in the world Larson et al. suggest that religious coping is a
of ideas and experience, with the notable major asset to elderly patients with psychiatric
exception of religious ideas and spirituality and mental disorders, and that there is a
(Kauffmann, 1991). It is remarkable that an significant relationship between church atten-
issue of The Clinical Psychologist devoted to dance and lower rates of mental illness, as well
diversity (Comas-DõÂ az & Striker, 1993) did not as a beneficial relationship between religious
focus on, and barely mentioned, religion as a commitment and lower suicide rates.
diversity variable. Bergin (1991) has asserted Research documents the positive contribu-
that ªPsychologists' understanding and support tion of religion to mental health and quality of
of cultural diversity has been exemplary with life. A study of over 1000 university students
respect to race, gender, and ethnicity but the found that religious students had better overall
profession's tolerance and empathy has not health and fewer injuries as well as less frequent
adequately reached the religious client.º use of tobacco, drugs, and alcohol, leading the
There is historical precedent for the inclusion researchers to conclude that religion had a
of religion in the practice of clinical psychology. positive effect on healthy lifestyle and behavior-
The pioneering psychologist William James al choices (Matthews, 1997, p. 13). Worthing-
wrote in 1910 on the pragmatics of religious ton, Kurusu, McCullough, and Sandage (1996)
diversity in his essays on the philosophical concluded, after an exhaustive review of the
construct of pluralism (James, 1910/1963). In empirical literature, that religious clients cannot
his classic text on the psychology of religion, The reliably be labeled as having poor mental health.
varieties of religious experience, James wrote Many draw on their religion to cope with stress
that ªReligion is an essential organ of our life, and the challenges of everyday living, especially
performing a function which no other portion of when crisis strikes and options are limited
our nature can so successfully fulfill.º Beyond (Hood, Spilka, Hunsberger, & Gorsuch, 1996).
James, there is a long and established tradition Hood et al. (1996, p. 378) summarize the work
of studies in the psychology of religion that of Pargament and others saying, ªPeople do not
lends support to the notion of ªinterestº in the face stressful situations without resources. They
psychological study of religion. Unfortunately, rely on a system of beliefs, practices, and
the psychology of religion literature conceptua- relationships which affects how they deal with
lizes religion primarily as a psychosocial vari- difficult situations. In the coping process, this
able or examines the functional utility of orienting system is translated into concrete
religion and rarely speaks to the issue of religion situation-specific appraisals, activities, and
as a clinically relevant diversity variable that goals. Religion is part of this general orienting
may transcend a unidimensional psychological system. A person with a strong religious faith
or functional analysis. who suffers a disabling injury must find a way to
Clearly, religion and spirituality are impor- move from the generalities of belief to the
tant to most people served by health care specifics of dealing with that injury.º In
providers. Gallup polls in 1990 indicated that particular, prayer and social support may be
95% of Americans believe in God and 85% viewed as positive coping strategies (Kauff-
believe the Bible to be the word of God. Polls mann, 1991).
also suggest that approximately 75% of Amer- Worthington et al.'s (1996, p. 457) analysis of
icans view their religious faith to be the most empirical findings in the field from the last 10
 Introduction 235

years suggests that there are seven positive through a variety of avenues, opportunities for an
effects religion may have on mental health: (i) enhanced sense of power and control over what is
religion may produce a sense of meaning; (ii) taking place. The result of both these tendencies
religion may stimulate hope; (iii) religion may and of faith itself is buttressing of self-esteem.
Things no longer seem as bad as they once were,
give religious people a sense of control by a
and since the individuals now believe they are
beneficent God, which compensates for reduced doing the best that is possible, they can feel good
personal control; (iv) religion prescribes a about themselves. For the overwhelming majority
healthier lifestyle that yields positive health of North Americans, the message of the 46th
and mental health outcomes; (v) religion may Psalm thus holds: ªGod is our refuge and strength,
set positive social norms that elicit approval, a very present help in time of trouble. (p. 401)
nurturance, and acceptance from others; (vi)
religion may provide a social support network; Still, there can be no doubt that in certain
(vii) religion may give a person a sense of the expressions of psychopathology, there is overt
supernatural that is certainly a psychological religious content and symbolism. Whether the
boost but may also be a spiritual boost that connection is causal or consequential is far less
cannot be measured phenomenologically. clear (Paloutzian, 1996). Considering the fact
Further, Hood et al. (1996) suggest that that the concept of mental health itself is hard to
religion has the potential to meet the needs for pin down precisely, it is exceedingly difficult to
meaning, control, and self-esteem. No doubt draw sweeping conclusions in this vast and
there are some positive and proactive ways this rapidly growing literature. Hood et al. (1996)
can take place, while other efforts might best be note that the research has not been organized
understood as avoidant or self-defeating (Mal- along productive theoretical lines. Further, they
ony, 1991). But to view prayer and social assert that antireligious biases were especially
support as only means to control emotions evident in earlier studies, and that serious
seems potentially reductionistic and even pa- methodological flaws limit the generalizability
tronizing. Perhaps naturalistic assumptions of those tentative conclusions. They remark:
limit full appreciation of more adaptive
ªproblem-focusedº or ªemotion-focusedº pos- Personal religious expression may still reflect
sibilities? Even speculations of sociobiologists underlying mental disturbance, and for some,
would suggest that religion has the potential to institutional faith remains a danger to their mental
be a species-wide coping mechanism that has health. In most instances, however, faith buttresses
aided humans to cope successfully with life, and people's sense of control and self-esteem, offers
meanings that oppose anxiety, provides hope,
has enhanced their chances for physical survival sanctions social facilitating behavior, enhances
(Wright, 1994). personal well-being, and promotes social integra-
Hood et al. (1996) have also concluded that tion. All of these possibilities work to the benefit of
the research evidence would ªappear to be quite distressed persons; ideally, they will be increasingly
strong that religion, through offering a sense of employed by mental health professions, to the
meaning, control and self-esteem, does support advantage of those who seek their help. (p. 436)
an optimistic outlook. This in turn helps people
deal constructively with life, and seems to have Friedman and Benson (1997) suggest, ªMany
long-range beneficial effects.º Especially pro- spiritual and religious individuals believe that
nounced are the potential for coping with death the positive relationship that may exist between
and the stresses often associated with the spirituality, religion, and health involves more
natural aging process. This is not to say that than psychology and behaviorº (pp. 1±12).
religion, in and of itself, ªguaranteesº stress Unfortunatley, as a study by Bergin and Jensen
inoculation; however, religiously based coping (1990) points out, of all the providers of
strategies appear to be quite effective for large psychotherapy, clinical psychologists are the
numbers of persons in our society. Beliefs, least religious of the group (as measured by
rituals, prayer, and social support are important formal institutional involvement and invest-
resources in the coping and adjustment of many ment) and they may also therefore be the least
people; religion may actually change a person informed about religious behavior, particularly
since new interpretations are offered that might as it is represented in its institutional forms.
make problems less distressing and threatening. They also appear to be significantly less likely
As Hood et al. (1996) suggest, for those in- than the general population to view religion
dividuals whose religious orientation is intrinsic- as having an important role in their lives. It
committed rather than extrinsic-consensual: could therefore be argued that there is not only a
lack of religious diversity in the profession but
Religion probably helps because it provides in- there may also be a lack of personal under-
dividuals with personally useful meanings for standing and investment in the important
upsetting circumstances. Concurrently, it offers, religious concerns of our clients.
236 Diversity Matters: Religion and the Practice of Clinical Psychology

The American Psychiatric Association (cited any search for common ground. Therefore,
in Larson et al., 1996, pp. 5±6) issued ªGuide- religion, by its nature, at times precipitates a
lines Regarding Possible Conflict Between philosophical conflict between those who em-
Psychiatrists' Religious Commitments and Psy- brace exclusive religious systems and those who
chiatric Practiceº in which they stated explicitly anticipate reciprocity in the celebration of
that psychiatrists should not only ªmaintain diversity.
respect for their patient's beliefsº but also
ªobtain information on the religious or ideolo-
gical orientation and beliefs of their patients so 10.10.2 THE DIVERSITY OF THE
that they may properly attend to them in the WORLD'S RELIGIONS
course of treatment.º However, as Larson et al.
point out in their psychiatric residency curricu- A chapter on the proper appreciation of
lum, ªWhile well intended and vital as an religion as a powerful diversity variable ought to
important first step, these guidelines may prove contain a terse summary of the major religions
difficult for mental health professionals to and their major distinctives, but such a sum-
follow due to their lack of familiarity with mary would fill an entire chapter itself and do an
religious issues in the clinical environment.º injustice to the exquisitely complex realities of
These important guidelines are germane to the religious faiths. Instead an attempt will be
the practice of clinical psychology as well. The made to mention some of the most important
American Psychological Association's revision dimensions on which religions vary.
(1992) of its ªEthical Principles of Psychologists Several caveats are in order. First, it should be
and Code of Conductº includes religion in the noted that there is the need for humility in
list of other matters of diversity as an area that attempting to understand different religions;
may require special competence (Standard few people are experts in the world religions and
1.08). It is suggested that clinicians need to all their variants (for orienting surveys, see
not only respect but also increase competency Nielsen; 1993; Noss & Noss, 1993; Smart, 1989),
by being sensitive to this multicultural diversity and even less can people truly be appreciative
issue through awareness, knowledge, and skills supporters of all religions equally. There should
related to addressing religion as a diversity be a readiness to acknowledge the limits of
variable in treatment (cf. Brems, 1993, p. 74). A knowledge, and of the limited attitudinal flex-
lack of understanding and appreciation for the ibility which can be mustered in confronting
role that religion plays in the lives of clients may beliefs that are different. Of particular danger to
reduce the clinician's effectiveness in assessing psychologists is the temptation to confuse their
and aiding clients to change, and may sig- personal synthesis of religions, often via some
nificantly influence the ability to build rapport sort of psychological functional analysis, with a
and trust. At a minimum, clinicians need to avail genuine appreciation of all religions. Such a
themselves of opportunities to learn more about synthesis is necessarily a variant on religious
religious traditions different from their own. belief itself and hence in tension with other
It is also important to acknowledge that religious beliefs; for example, an analysis of all
religion has provided some unique challenges as religions as ªparticularistic cognitive renderings
clinicians have embraced diversity in all its of the universal human pursuit of transcendent
important expressions. A commitment to di- purpose, the ethical good, and of communityº is
versity is associated in the minds of most with a competing definition of, rather than an apt
the presumed notion that diversity should be summary of, any particular religion.
celebrated in a pluralistic spirit. By implication, Second, often there is greater diversity within
if I recognize and respect your religion as on par religious categorizations than across them. For
with mine, you should reciprocate, a notion not example, conservative Catholics and conserva-
necessarily endorsed by all religions (Kung, tive Protestants have, on many dimensions,
1985). Some of the world's religions do embrace more in common than liberal and conservative
diversity which in turn may even lead to Protestants. Hence, some very diverse religious
syncretism or universalism (respectively, the groups are able to build remarkable consensus
combination or reconciliation of two belief on certain foundational issues.
systems). However, some of the world's major There have been many attempts to do what
religious systems are ªintolerantº and ªauthor- amounts to a conceptual factor analysis of
itarian,º and are compelled to embrace their religion, with varying outcomes (there have
own notions a priori and reject, or at least been empirical attempts as well; see Gorsuch,
devalue, those of other religions (exclusivism). 1984). This chapter draws on the work of Glock
Indeed, the study of world religions would (1962), Smart (1989), and others and discusses
suggest that it is easier to internalize exclusive the multidimensionality of the religions in terms
claims to truth, a reality which can complicate of their cognitive dimension (religious beliefs),
 The Diversity of the World's Religions 237

ritualistic and symbolic dimension (religious rituals by which to appease or petition their
practice), moral dimension (religious action), gods, but have few broader implications. But a
institutional dimension (religious organization), religion can give broad definition to the world
community and lifestyle dimension (religious which its faithful inhabit. In essence, a religious
community), and experiential dimension (reli- faith can constitute the lenses (i.e., cognitive-
gious feelings). perceptual ªstyle,º world view, or control
beliefs) through which believers see the world,
10.10.2.1 Cognitive Dimension and those lenses are clearly different from those
through which the unfaithful peer. The central
Religions vary cognitively in a number of focus around which a religious world organizes
ways. Myths play a central role in most is the sacred or divine. This understanding of the
religions, where myth is understood not in the divine is so striking that it literally shapes how
general use of the term as a fantastic fictional an individual, indeed, how a community, under-
tale, but rather as a set of religious stories that stands the greater order of existence. For a
ªquiver with special or sacred meaningº (Smart, Christian this picture orients around a creative,
1983, p. 7). The importance of these are made redemptive, and present God. To Shinto bel-
clear in the care and honor given to the sacred ievers, the kami, a spirit or divinity, completes
texts that record them: the Christian Bible, the their understanding of holiness in this world.
Hebrew Torah, the Hindu Bhagavad-Gita, The Muslim believer finds certainty in existence
Islam's Koran. The abiding power (i.e., the in Allah's Five Pillars of Faith.
value of the narrative whether oral or written) of
such sacred stories vibrates in the communities
which have been transformed and sustained by 10.10.2.2 Ritualistic and Symbolic Dimension
such stories as the Jewish Exodus from Egypt or
Most obvious to an outside observer are the
the visions of Lao-tzu of the early Taoist
differing roles played by ritual in the world
movement. For some believers, the historicity of
religions. Common forms of religious ritual are
the founding myths is vital, while others regard
worship, singing, fasting, and prayer. In general
them as symbols pointing to meanings not tied
these are ªsome form of outer behavior
to specific events in history. Christians, for
coordinated to an inner intention to make con-
example, have traditionally insisted on the
tact with, or take part in, the invisible worldº
historical reality of the death and resurrection
(Smart, 1968, p. 6). Rituals can be daily prac-
of Jesus Christ (literalism); some continue that
tices such as the yoga of Hindus, the prayers of
tradition while others regard that story as a
the Shinto or the purity rituals of Orthodox
nonhistorical emblem of the ability to overcome
Judaism, weekly participation in services such
evil and adversity through the transforming
as Catholic mass or Jewish temple, or annual
power of God's love (symbolism). Recognition
celebrations such as Islam's Ramadan or the
of the literalism vs. symbolism hermeneutic
Hindu Divali. Each is a unique attempt to
typically reaches beyond just one dogma or
connect with, through discipline and remem-
belief of the group but often pervades into other
brance, the divine which provides an orientation
areas of interpretation within the group's
to self, others, and moral good.
religious belief system.
Religions vary according to the content of
their founding myths, and also according to the 10.10.2.3 Moral Dimension
place of doctrine in the religious community, its
sophistication, and degree of elaboration. Religions vary in the degree of elaboration of
Smart (1983, p. 8) defines religious doctrine their accompanying ethical systems, but such
as ªan attempt to give system, clarity and systems are connected vitally to religious faith
intellectual power to what is revealed through and the consequences of belief. At its most basic
the mythological and symbolic language of level, ethics is the way in which religious systems
religious faith and ritual.º In essence, doctrine is answer the challenge of evil in the world and
an attempt to systematize divine revelation and deal with the profane (Paden, 1988, p. 144).
render it applicable to everyday life. Some Inherent in religious ethics is a call to live in a
religious traditions have given rise to extensive manner which reflects one faith in an unbeliev-
systematized literatures (e.g., Christianity, Ju- ing world. Thus for a Muslim, love for Allah will
daism, Islam, and Hinduism), while others have be reflected in distributing wealth among those
not (e.g., Animism and Shintoism). in need, while for a Sikh it involves, but is not
Myth and doctrine together can contribute to exhausted by, wearing uncut hair, a dagger,
the formation of the world views of religious breeches, a comb, and iron bangle (Smart, 1989,
adherents. Some religions have limited general p. 98). Religious ethics systems vary according
application; some animistic faiths prescribe to their overt applicability to society; Islam and
238 Diversity Matters: Religion and the Practice of Clinical Psychology

ancient Judaism have ethical systems seemingly distinction as long as the term sect is understood
designed for implementation on a societal basis, in a nonpejorative sense. Such a distinction may
while New Testament Christianity articulated also be an important indicator of potential
an ethical code for members of a disenfran- individual differences in ego-strength or asser-
chised and powerless subculture. Religious tiveness between groups as well as relevant to
ethical systems typically have individual, inter- understanding counterculture tendencies and
personal, and communal implications. conformity pressures for individuals within the
sect.

10.10.2.4 Institutional Dimension

10.10.2.6 Experiential Dimension
The religions differ in terms of their for-
Religious experience is often regarded as the
malization as enduring human institutions. At
sine qua non of religious life and its goal.
one end of the continuum, imagine an auton-
Historically, such experience has often occurred
omous American who distills a set of idiosyn-
at the founding moments of a religious tradi-
cratic religious beliefs which can be embraced,
tion: the Koran tells of Mohammed's over-
and who then quietly, privately, and with dig-
whelming, painful experience of receiving
nity lives consistently with those beliefs without
revelation from Allah; Buddhistsº honor the
the formation of an organization at all. At the
light that filled Buddha's mind under the Bodhi
other extreme contemplate the Roman Catholic
tree, allowing him to see the antidote for the
Church with its high degree of institutionaliza-
suffering of this world; and Christians recall the
tion. While some degree of institutionalization
blinding, life altering vision the apostle Paul
is probably inevitable with growing size of the
received on the road to Damascus. Believers
adherent body, religions differ in terms of how
across the spectrum regularly celebrate and
readily they engender institutionalization.
search after the same. Thus, many Christians
refer to their entrance in the faith as being ªborn
10.10.2.5 Community and Lifestyle Dimension again,º Taoists search for inner illumination
that will lead to a ªmystic union,º and Hindu's
World understandings formed and framed by practice yoga to catch a glimpse of Nirvana.
religious belief serve social functions. They draw Such desires recognize the unique and holy place
boundaries which allow believers to understand of the divine in the world of a believer and may
themselves (the insider) in contrast to others (the in fact be one dimension that drives clients in
outsiders); thus, a Jew is able to clearly define psychotherapy.
themselves as distinct from a Muslim or a Psychology as a discipline has often at-
Buddhist, both in terms of differences and tempted to understand religious experience,
commonalties. A communal consensus on ªwho but in doing so has often imperialistically
we are,º common understandings of proper and presumed that only certain types of experiences
improper behavior and values, the power of are properly religious. Lash (1988), for example,
shared rituals, language and symbols, common argued against the account of religious experi-
engagement with religious institutions, and even ence of William James (articulated in his classic
an emphasis on the importance of community The varieties of religious experience) on the basis
itself all contribute to a sense of belonging to a that it is an exclusivist account of religious
religious community and a cohesive sense of experience, one which looked for a particular
lifestyle. Some religious believers have a diffuse and peculiar type of experience as qualifying as
sense of engagement with their religious com- religious experience and which ruled out as
munity, while others are deeply engaged with a ªtrueº religious experience on a priori grounds
highly visible and formalized community. any experience which was tightly connected to a
Williams notes that it has been common in particular religious tradition. Such an a priori
the sociology of religion to distinguish between definition misses the reality that there is no such
church and sect according to the degree of thing as generic and pure religious experience,
rejection of the dominant social environment, and that the forms of religious experience are
with members of sects disengaged from majority intimately connected with and vary according to
culture. ªCompared with members of churches, the faith systems in which they occur (Lash,
members of sects are poorer, less educated, 1988). A variety of religious experiences within
contribute more money to their religious ChristianityÐof shame and guilt for sin, of
organizations, attend more services, hold stron- repentance, of gratitude for God's mercyÐhave
ger and more distinctive religious beliefs, belong no direct parallel in other faiths such as
to smaller congregations, and have more of their Buddhism, a reality which may produce some
friends as members of their denominationº unique challenges for engagement of the two
(Williams, 1993, p. 127). This is a helpful religious systems.
 Philosophical Basis for Appreciating Religious Diversity in Clinical Care 239

In attempting to understand the religion of a things as ªauthoritarianism, religious ortho-

client and its impact upon their presenting doxy, intrinsic religiousness, parental religious
concerns, understanding these dimensions of attendance, self-righteousness, and frequency of
religionÐcognitive, ritual and symbol, moral, prayer,º while spirituality was more closely
institutional, community and lifestyle, and associated with ªmystical experiences, new age
experientialÐcan serve as a guide for explora- beliefs and practices, higher SES, and frequency
tion of a client's particular religious faith. of prayerº (p. 9). Whereas spirituality seemed to
Awareness of these factors can assist psychol- be more closely aligned with both personal and
ogists to catch a general glimpse of how faith experiential dimensions, religion seemed to
affects and is interwoven into the lives of clients, connect specifically with organizational or
and the unique differences between the many institutional beliefs as well.
faiths which will be encountered. On the other hand, they also concluded that
individuals tend to integrate both spirituality
10.10.3 RELIGION AND/OR VS. and religion into their lives. In particular, they
SPIRITUALITY found that for the majority of individuals,
spirituality and religion were irrevocably tied
Even a cursory reading of standard texts in together. Their third conclusion was that ªmost
the psychology of religion (Hood et al., 1996; believers approach the sacred through the
Kauffmann, 1991; Malony, 1991; Meadow & personal, subjective, and experiential path of
Kahoe, 1984; Paloutzian, 1996; Wulff, 1991) spirituality, but they differ in whether they also
would suggest that there is no consensus in the include organizational or institutional beliefs
field about the definition of either religion or and practicesº (p. 10). The researchers described
ªspirituality.º The use of the term ªspiritualityº their study as having particular importance for
is almost a ªhotº topic in clinical psychology mental health workers, who as a group tend not
although the term is being historically redefined to integrate their spirituality into religiousness.
in the psychology of religion literature. As Thus, mental health workers may have a
Worthington et al. (1996) have noted, the potential bias toward spirituality but against
fascination has more to do with an interest in religiousness when for the general population
mysticism and very private spiritualities rather they are typically linked. In light of the fact that
than with the more institutionalized, corporate, their study found most people to identify
and communal expressions of institutional themselves as both spiritual and religious,
worship, fellowship, and service. This focus mental health workers prone to defining
on spirituality, in deference to the more classical themselves as spiritual but not religious may
understandings of the psychology of religion, fail to be sensitive to this integration. They may
trivializes more well-defined constructs like fail to appreciate the religious side of the
intrinsic-committed or extrinsic-consensual re- majority of their clients.
ligiosity or the quest orientation as well as the Finally, it should be noted that formal and
major religious orientations derived from informal attempts have been made throughout
decades of research. Many clinicians who focus history to engage in acts of kindness and healing
strictly on the notion of spirituality lack under the auspices of spiritual direction. In
significant familiarity with institutionalized contrast, disciplines like clinical psychology
religion. This has a tendency to make it difficult have a relatively recent history of such work.
for the clinicians to fully appreciate the complex Unfortunately, only a minority of the mental
and subtle ways that persons of corporate and health providers are even remotely aware of the
institutionalized faith interact within their rich and centuries-old traditions of pastoral care
communities. and spiritual formation (Benner, 1988; Brown-
Zinnbauer, Pargament, Cowell, and Scott ing, 1987; Coles, 1990; Groeschel, 1992; Jones &
(1996), in a paper entitled ªReligion and Butman, 1991; Malony, 1991; Miller & Jackson,
Spirituality: Unfuzzying the Fuzzy,º recognized 1995; Shafranske, 1996; Worthington et al.,
the inherent definitional difficulty in attempting 1996). In many ways, psychotherapy is an heir
to study ªspiritualityº in contrast to ªreligion.º to a rich tradition of altruistic service and
They conducted a study to measure how compassion performed by spiritual directors.
individuals define religiousness and spirituality.
They were interested in how the individual's 10.10.4 PHILOSOPHICAL BASIS FOR
definition might be associated with different APPRECIATING RELIGIOUS
demographic, religio/spiritual, and psychoso- DIVERSITY IN CLINICAL CARE
cial variables. They concluded, first, that
religiousness and spirituality are probably It could be argued that religion and mental
different concepts. They found that religious- health care have much in common metaphysi-
ness was associated with higher levels of such cally. This is particularly true in the broad
240 Diversity Matters: Religion and the Practice of Clinical Psychology

philosophical areas of ultimate meaning and psychosocial resources in their life. These
morality. In fact, there are those in the field of resources are often a direct result of the
clinical psychology and mental health care who corporate and/or communal dimensions of
would argue that the constructs and application their religion. To fail to do so may force the
of psychological theory are ªreligiousº in nature client into a painful choice between accepting
and form a pragmatic basis for the replacement the control beliefs of the clinician and losing
of institutional and/or personal religion in the important psychosocial resources or rejecting
lives of ªbelieversº (Gross, 1978; Szasz, 1977; the control beliefs of the clinician and being
Zilbergeld, 1983). Perhaps no one has made the abandoned.
case more clearly than London (1986) in regard Another example might involve questions of
to the moral and religious nature of psychology, ultimate reality. The religious client who comes
particularly applied psychology, and the en- to the clinician family a number of stresses as
terprise of psychotherapy. In many ways it well as feelings of depression in the aftermath of
would appear that religion and psychotherapy the death of a spouse may find religious beliefs
are both activities that involve the search for a about an afterlife minimized or even patholo-
coherent world view and attempt to link beliefs gized. Confrontation might be faced over being
with behaviors. in ªdenial,º or a challenge made to express
suppressed anger toward religious deity, or to
10.10.4.1 The Philosophical Conflict Between abandon a fantasy about reincarnation or
Clinical Care and Religious Belief reunion with the spouse. Such interventions
by the clinician fail to appreciate the positive
There is a potential for philosophical conflict role that religion may be playing in the life of the
between clinical psychology, as a presupposi- client. In the worst cases, the clinician may also
tionally religious enterprise attempting to assume that in some way the religious control
answer broad questions of ultimate reality beliefs of the client are inferior to the psycho-
and morality, and the control beliefs of other logized control beliefs of the clinician. In these
religious systems. Thinking about clinical work cases, the clinician presupposes that the client's
as controlled by a belief system that influences religious beliefs are totally ineffective in helping
how humans view themselves and their world the client manage his life.
makes it particularly important to consider how
the cliniciansº view of religion impacts the 10.10.4.2 A Philosophy of Clinical Practice that
practice of clinical psychology. The clinician's Appreciates Religious Belief
control belief system clearly impacts the lives of
religious clients. A starting point for the dialog about clinical
For example, for the client who presents with practice and religious belief may be to think
marital difficulties and comes with a religious about clinical psychology as a postpositivistic
background that contains strict teachings about science that is not value free. Further, in the
gender roles within the family or community, practice of clinical care, it should also be noted
the control beliefs of the client based on the that the scientific enterprise involves metaphy-
teachings of their religion may come into sical presuppositions that reflect the world view
conflict with the control beliefs of the clinician and belief system of the scientist. Obviously, the
regarding gender roles. For the clinician, this potential exists for the clinician's control beliefs
difference may be based on the theoretical about ultimate reality and morality to be
orientation which forms their frame of refer- different from the presuppositional control
ence or world view. Hypothetically, the hier- beliefs of a client's religious system. It is further
archical view of gender roles embraced by the suggested (cf. Jones, 1994) that the relationship
clinician may come into direct conflict with the between religion and clinical work is in part an
client's own chosen response to the egalitarian issue of addressing the religious diversity that
control beliefs of their religion. In fact, for the may exist between the clinician and the client.
clinician, the client's religious beliefs about An explicit acknowledgment of control beliefs,
gender roles may in fact suggest presence of is recommended, on the part of both the client
psychopathology or at least unhealthy thinking. and clinician, as an important point of
The client is left with the dilemma of either dialogical contact.
embracing the control beliefs of the clinician Following the ªEthical Principles of Psychol-
(and getting ªwellº or becoming ªhealthyº in ogists and Code of Conductº (American
the process) or maintaining their own beliefs Psychological Association, 1992) with respect
and being ªsickº or ªunhealthy.º Further, it is to ªPrinciple A: Competenceº and ªPrinciple D:
important to recognize the religious context Respect for People's Rights and Dignityº
from which the client comes and the role of would, on a very practical level, seem to involve
their control beliefs in maintaining important the clinician acknowledging awareness (or lack
 Philosophical Basis for Appreciating Religious Diversity in Clinical Care 241

thereof) of the person's particular religion, even when their control beliefs are irreconcilable
articulating a level of knowledge in regard to the respecting the control beliefs of the other
control beliefs of the religion, and finally without abandoning one's own control beliefs.
describing any skills or previous experience in To Dell'Olio, (1996), limited reciprocity or
working with individuals with similar religious ªinclusivismº is the moral ªhigh groundº or
beliefs. It would also seem logical that such a what he refers to as the ªmorality of recogni-
discussion would involve an articulation of the tion.º In other words, the individual is free to
contrasting or similar control beliefs of the acknowledge the sincerity of another's perspec-
clinician as well as the clinician's theoretical tive even when they would sincerely disagree
orientation. Obviously, the role of religion in with some, much, or all of it.
clinical work may be very different depending Dell'Olio's (1996) conceptualization (moral-
on the clinician's theoretical orientation. ity of recognition) applied to the relationship
Further, the extent of the discussion regarding between religion and clinical psychology would
religious diversity may ebb and flow with the suggest that clinicians need to recognize with
importance of the issue in the presenting sincerity the client's perspective regarding
problem of the client as well. religious truth even if the clinician disagrees
with some, much, or all of it. This is particularly
10.10.4.3 A Paradigm for Dialog on Religious important when clinical work addresses the
Beliefs in Clinical Care broader questions of ultimate reality and
morality. However, the religious perspective
Dialogical contact between clinical psychol- of the client may not only be very important to
ogy and religion may be enhanced by an the client's understanding of ultimate reality
articulation of the nature of the dialog, and morality but also the client's sense of self.
particularly if it is understood and applied in Dell'Olio's (1996) notion of inclusivism holds
terms of multicultural notions of religious promise as a paradigm for the dialogical
diversity. In an article on religion and multi- relationship between religious beliefs and the
culturalism, Dell'Olio (1996) attempted to practice of clinical psychology. Inclusivism
address three philosophical constructs related allows the person to remain committed to their
to religious diversity: exclusivism, pluralism, religious beliefs while recognizing that religion
and inclusivism. If the control beliefs of the does not have exclusive claim to all ªtruth.º In
clinician, whether personal or based on her this way, the religious client can remain open to
theoretical orientation, are considered as over- the truth-claims of the clinician. On the other
lapping metaphysically (e.g., issues of ultimate hand, the clinician can remain committed to the
meaning, morality, etc.) with the religious religious dimensions of their truth-claims while
control beliefs of the client, Dell'Olio's (1996) recognizing that they do not have exclusive
proposal for the management of religious claim to all ªtruth.º Inclusivism allows the
diversity may contain merit for understanding religious person to appreciate the truth-claims
the relationship between the clinician's perspec- of the clinician and also be free to note where
tive on these overlapping metaphysical issues and when the truth-claims of the clinician are
and the client's religious control beliefs. inadequate in describing or appreciating their
Dell-Olio (1996) rejects the construct of religious experience. Inclusivism allows the
religious exclusivism on moral grounds. He clinician to appreciate the truth-claims of the
believes it is immoral to reject totally the beliefs client's religion as well as to note where and
of another simply because they are different or when the client's religion is inadequate in
ancillary to one's own. In addition, he rejects the describing or appreciating the nature of the
religious pluralism of John Hick, arguing that in client's problems or their clinical work.
his underlying assumptions Hick's ªperspective The morality of recognition principle in the
presumes to know more about what the care of clients means that the clinician is not
religions themselves know about what they obligated to embrace all of the religious control
know, and thus refuses to recognize the beliefs of the client in order to work with the
legitimacy of the other's perspective regarding client, nor is the client obligated to embrace all
religious truth.º Dell'Olio (1996) argues for of the control beliefs of the clinician in order to
ªinclusivismº which allows for limited recipro- benefit from therapy. Rather, it is the open
city on the basis of what he refers to as the acknowledgment on the part of both the client
multicultural mandate of the ªmorality of and clinician of control belief similarities and
recognition.º Limited reciprocity refers to a differences that may impact their work together,
process whereby individuals seek common particularly as it relates to the presenting
ground in regard to their individual control problem and the experience of the clinician.
beliefs and gain an understanding of the For example, a religiously liberal Christian
distinctives of each others control beliefs and, client being treated with cognitive therapy for
242 Diversity Matters: Religion and the Practice of Clinical Psychology

depression may have little difficulty with the text would be discounted because of the primary
morality of recognition principle when being authority given to the text. Conversely, teach-
cared for by a religiously liberal Jewish or ings of a sacred text are often discounted by
Muslim clinician or visa versa. In contrast, a ªscientificº findings. The lack of awareness and
conservative Christian being treated for a knowledge of both epistemologies will be a
generalized anxiety disorder who is prescribed deficit to the clinician who requires skill to
an Eastern meditation technique will likely have navigate these issues in therapy. The clinician
difficulty embracing the acceptableness of that needs to recognize how the client understands
approach in light of their religious teachings, the authority of religious truth and the role the
regardless of the clinician's beliefs or intent. The client ascribes to ªscientificº truth and work
clinician's awareness of such a conflict based on with the tensions that may arise in both the
knowledge of the religious beliefs of the client client and clinician as a result.
may cause the clinician to consider alternative Religion and clinical psychology share simi-
treatments in light of the morality of recognition larities in subject matter and are human
principle. However, in some cases, the client or enterprises (Jones, 1994), and in their pragmatic
clinician may feel that the clinician's awareness, forms both attempt to understand and interpret
knowledge, and skill related to the client's the behavior and experience of human beings.
religious diversity issues are inadequate for their They also share constructs such as cognition,
work to be as productive as it might be if the consciousness, emotion, motivation, and rela-
client was referred to another clinician more tion to name just a few (Tisdale, 1980). As
aware, knowledgeable, or skillful in the religious clinical psychology and religion attempt to
diversity issues of the client. In all three share the same constructs, their contrasting
situations, there is an expression of the morality differences are pronounced by the fact that they
of recognition principle. may come from different epistemological and
Paradigmatically, inclusivism avoids the im- methodological bases. The result may often lead
perialism of exclusivism but in contrast to the to different conclusions about the same matters.
pluralism, inclusivism ªrealizes that judgments This affects the practice of clinical psychology
must be made from a particular perspectiveº because it affects not only how the clinician and
and that neither the clinician nor the client needs client view the nature of the client's problem but
to ªgive up their particular (religious) perspec- also the resources that should be accessed in
tiveº when engaged in the process of clinical treatment of the problem and the validity and
care. Clinicians are not required to give up their reliability of the treatment outcome.
control beliefs in appreciating their own and the For example, many clinicians have wondered
client's experience of religion and spirituality. about the immediate positive effects of anti-
It is necessary for those who practice clinical depressant medicine in clients who have been
psychology to seek an understanding of religion suffering from depression. This is particularly
and spirituality in the context of an inclusive true when psychiatric colleagues explain the
diversity while appreciating the contribution of pharmacology of the drug. Many clinicians may
both psychology and religion to the welfare of have also wondered about the client who
the human family. While applied postpositivis- informed them that their depressed mood had
tic psychology (as relativistic ªscienceº) and lifted as a result of prayer or some other
religion (as absolutist ªdivine or naturalº law) prescribed spiritual discipline. In the first case,
may share very similar subject matter, they there is no pharmacological basis to adequately
come to the human family with very different explain the effect. However, in the second there
epistemological and methodological notions. is often a clearly defined religious control belief
The morality of recognition principle goes or teaching for the religious intervention effect.
beyond just the awareness and knowledge of Both situations could be potentially explained
different control beliefs and the skills to address psychologically as the classic ªplaceboº effect,
those differences. The morality of recognition is but it may be a lack of epistemic humility that
also an awareness and knowledge of different makes the latter is so hard to accept. In fact,
epistemologies and methods for arriving at even though there may be no pharmacological
those control beliefs. For the clinician this explanation for the immediate effect of the
involves the development of skills to navigate antidepressant in some clients, most clinicians
these different epistemological and methodolo- still refer severely depressed clients for medical
gical approaches. treatment. Is it any less appropriate to refer a
For example, for the client who endorses the religious client for a religious intervention that is
ªabsolute authorityº of a sacred text, anything consistent with the client's religious belief
the ªscienceº of psychology may conclude from system?
empirical investigation or theoretical develop- Clinical psychology and religion share similar
ment that would oppose or contradict the sacred concerns about outcomes. It could be argued
 Clinical Assessment and Diagnosis 243

that both disciplines are attempting to interpret sure religious variables have two principle
and manipulate human experience in mean- historical roots: Allport's intrinsic and extrinsic
ingful ways that will produce ªultimate good.º orientations and Batson's quest approach
Again, the disagreement often comes in the (Batson, Schoenrade, & Ventis, 1993). In the
epistemology and methodology used (e.g., broadest sense, an intrinsic person appears to
divine revelation vs. materialistic determinism; live the faith whereas an extrinsic person uses
Stevenson, 1987). In fact, what ultimately may the faith (see any of the above noted overviews
matter to both is what or who gets the credit for for more in-depth discussions). The assumption
any ªgoodº outcome. is that an extrinsic orientation is a less mature or
Clinicians have also witnessed the lack of developed orientation. The quest orientation is
efficacy of medical treatments for a number of one in which an individual adopts a critical but
mental disorders. Should the practice of open-ended approach to existential questions.
referring clients for medical treatment for that Other formulations tend to combine elements of
reason be abandoned totally? Why should it be the quest and intrinsic orientations. These are
any different for religious interventions? In fact, hardly ªpureº categorizations.
many religious systems have developed systems Researchers and theoreticians alike assert
for explaining the limited efficacy, or the that the overwhelming majority of people in the
conditions of efficacy, for their religious inter- Anglo-American context show elements of all
ventions. It is a lack of epistemic humility that three tendencies in the ebb and flow of everyday
keeps clinicians from taking full advantage of life. It has been noted that all three orientations
the religious interventions found in the religious stress ªprocessº more than ªcontent,º as do
beliefs of many clients. measures of moral, cognitive, and psychosocial
Even in light of these commonalties and development. Perhaps the most helpful for-
significant metaphysical differences, we have an mulation is to use an attributional perspective
obligation to do ªgoodº psychology, while that is respectful of the phenomena studied,
recognizing the important role that religious appreciates the potential contributions of the
presuppositions play in all of our lives. The intrinsic, extrinsic, and quest orientations, and
multicultural mandate of the morality of strives to find connections between motiva-
recognition principle is important as is the fact tional and cognitive patterns that are at the
that religion is an important multicultural heart of religious experience and behavior.
variable in the lives of both clinicians and their For decades, attempts have been made to
clients. measure aspects of the dimensions of religious
commitment. Hundreds of decent measures are
available. Gorsuch (1984) has argued that there
10.10.5 CLINICAL ASSESSMENT AND is a need to refine existing measures rather than
DIAGNOSIS: APPRECIATING create new ones. Hill, Butman, and Hood (1997)
RELIGIOUS DIVERSITY IN THE have published a collection of such measures;
PROCESS OF MEASUREMENT this should help address the fact that few
clinicians seem to be aware of the existence of
There is a rich tradition in psychology and such measures or where to find them. Famil-
sociology of measuring and assessing religion iarity with a range of assessment instruments
and religiosity in its many complexities. For an can enrich an understanding of the range of
introduction to this vast literature, the inter- religious experience. Further, not all of the
ested reader is urged to turn to Gorsuch (1984) assessment effort has been targeted at individual
and Williams (1993), or to one of the excellent differences; Pargament and his colleagues have
survey texts in the psychology of religion, such done innovative work in assessing the differing
as Hood et al. (1996), Paloutzian (1996), or organizational climates of religious congrega-
Wulff (1995). Additionally, MacDonald, Le- tions (Pargament, Silverman, Johnson, Eche-
Clair, Holland, Alter, and Friedman (1995) mendia, & Snyder, 1983; Pargament, Tyler, &
provide an analysis of instruments which Steele, 1979), finding that they differ on such
attempt to measure spiritual experience and dimensions as order and clarity, sense of
spirituality disconnected from traditional forms community, openness to change, social concern,
of institutionalized Western religion; for exam- autonomy, stability, activity, expressiveness,
ple, ªspiritual orientation,º mysticism and problem solving, and participation.
mystical experience, peak experiences, self- The utility of existing measures is, however,
transcendence, paranormal beliefs and experi- limited. There is little convincing data on their
ences, altered states of consciousness, holistic ªrelevanceº beyond the majority culture in the
living, and so forth. Anglo-American context. They tend to stress
Religious beliefs and behaviors are complex, behaviors (e.g., church attendance) more than
multidimensional variables. Attempts to mea- religious beliefs, or often contain a mixture of
244 Diversity Matters: Religion and the Practice of Clinical Psychology

questions about belief content, attitudes, values, As the assessment of religion and religious
morality, actions, and experiences which makes faith in considered for the sake of better
interpretation of the resulting scores difficult. understanding clients and the difficulties they
Gorsuch (1984) criticizes their heavy reliance on present, however, the limitations of question-
self-report and tendency to self-distorting bias naire assessment methods are confronted. In the
or impression management. They are usually area of sexuality, a variety of measures exist
confined to an objective format and, thus, do which are well suited for research but which
not allow for a more complete understanding of have little clinical utility and which can never
the motivational and cognitive patterns that duplicate the richness of data which can be
undergird so many of our decisions to act, generated by competent clinical assessment; so
qualities that perhaps can only be fully explored also in this area.
in a more open-ended interview format. Many As in all areas of clinical interview assess-
instruments tend only to measure broad ment, the clinician will only get useful informa-
dimensions of religious orientation; it would tion if religion is queried sensitively and with
be helpful if these measures could evaluate the respect for whatever answer may result. Clin-
more specific and concrete aspects of religiosity icians should be wary of the functional
for descriptive/prescriptive purposes. Finally, equivalent of the ªYou aren't still masturbating,
psychological measurement of religion appears are you?º question in the area of religion.
to often be contaminated by the theoretical Introductory questions can include: ªPeople in
commitments of the researcher; Gartner (1996, our community hold to a wide variety of
pp. 187±203) has noted that ªhard measuresº of religious faiths and beliefs, and sometimes a
health and well-being (such as death rate) person's religion is quite important to the issues
almost without exception show the positive and concerns being addressed in the counseling
health benefits of religion, while ªsoft mea- relationship. Where are you on the matter of
suresº of personality traits and other religion? Do you see your religious faith as being
theoretically-grounded psychological variables related to this problem in any way?º
often show negative outcomes to be associated In responding to client output, clinicians must
with religion, suggesting that the soft measures be prepared for religion to serve a complex array
are biased or contaminated in some way. of roles, none of which are mutually exclusive:
Drawing from this vast assessment literature, motivation for change (ªGod wants me to
it is suggested that intake questionnaires in overcome this problemº), cause (ªMy funda-
clinical practice be used to increase the mentalist upbringing is what made me sexually
clinician's awareness of religious variables and unresponsiveº), effect (ªThis problem has
issues in the life of the client. Profitably they brought my faith to life as I have realized
could include a few initial items regarding how much I need Godº or ªI gave up believing
religion to set the stage for further examination as I have suffered through this problem for years
of these issues if merited. Brief items querying and found no relief in my churchº), potential
how frequently the person attends religious obstacle to change (ªBut the people in my
services and functions, and how frequently the church would ostracize me if I were to be more
person engages in personal religious practices assertive with themº), coping strategy (ªWhen I
and activities such as prayer, meditation, or get stressed out, it helps to meditateº), potential
bible reading, can both be answered on a five- or resource for change (ªA number of men in the
seven-point scale from daily to never. The vast synagogue are very willing to serve to keep me
assessment literature indicates that the action or on target in this change planº), apparent locus
behavioral dimension of religion is important to of pathology (religious delusions and religious
assess, as there is a direct tie between what content to depressogenic cognitions), and
people do and their degree of commitment to others.
religion; participation in personal or institutio- It is best to look at the client's religious faith
nalized religious activities may be regarded as a developmentally and as a dynamic reality rather
proxy for religious commitment generally. than as a static one. The various religious or
Clients can be asked to rate how important or faith development theories are not regarded as
significant religious faith is to them, from normative in this area, though they can be
extremely important and at the center of life helpful. For example, Fowler's (1981) theory
to not important at all. Enquiries can be made suggests that faith development parallels cog-
about their current religious affiliation, and nitive and moral development as understood
what other important religious affiliations have from the work of Piaget and Kohlberg as the
had a major impact upon them in the past. The individual moves from highly concrete and
degree to which they believe their religious faith literalistic faith to a religion of universal
is relevant to their presenting concerns can be abstraction. Such an analysis, while engaging,
rated. may overestimate the role of rationality in
 The Empirical Basis for Appreciating Religious Diversity in Clinical Care 245

religious growth and may impose an inap- Witnesses) minorities. This should highlight
propriate normative model that psychologizes how important it is for the clinician to be
faith and obscures differences across religions. sensitive to all minority issues, particularly
A more open-ended querying of religious when the individual's life is diverse in many
change over the life span is suggested. If a ways from the life of the clinician. As in
client indicates or comes to understand that expressing empathy with affective responses of
their religious faith is relevant to the clinical clients, so also in the area of religion should
concerns, it may be fruitful to explore the major clinicians check their understandings of the
epochs in the religious life, asking for informa- client's experiences regularly and with a spirit of
tion about those periods when religious faith willingness to be instructed and corrected by our
was most central to the person, the major clients.
factors producing change in religious belief and Diagnostically, the Diagnostic and statistical
experience, and important formative persons manual of mental disorders, 4th ed. (1994)
and events in the life of faith. The clinician's devotes only a single paragraph to ªreligious
ability to show respect and empathy for the or spiritual problem.º This would hardly seem
client's journey will pay dividends in rich to demand the development or use of diagnostic
information which can inform intervention. assessment instruments measuring religious
The clinician's ability to empower the client to constructs. Even within the multiaxial system,
believe that it is acceptable to talk about there is little or no place to address religious or
religion/religious issues and even to probe the spiritual factors in formulation of the client's
clinician's religious perspectives is a very helpful ªclinical picture.º Considering the importance
way to build rapport and facilitate the assess- of the religious diversity for the majority of
ment process. persons, this relative neglect is striking.
Religion serves a variety of functions in the
lives of participants, and psychological inter-
pretation of those functions can enrich clinical
understanding. Interpretations, however, may 10.10.6 THE EMPIRICAL BASIS FOR
be distorted by prejudices and theoretical APPRECIATING RELIGIOUS
systems, and such a functional analysis can be DIVERSITY IN CLINICAL CARE
alien to the fundamental views and instincts of
the client. The shape of a functional analysis is Our brief and selective overview of empirical
driven by the basic theoretical assumptions research on religion and clinical care will be
which the clinician brings to the case, and so organized around the findings of the excellent
functional analysis from a classic psychoanalytic review by Worthington et al. (1996) of empirical
perspective will come up with a fundamentally research since the late 1980s.
different portrait of the dynamics of religious
faith than that from a behavioral or a cognitive 10.10.6.1 Religious Persons and Mental Health
perspective. Psychological analyses also usually
presume that there is no supernatural dimension Worthington et al. (1996, p. 451) recall that
to religious experience, a presumption which religion has been viewed by many (such as
goes well beyond what science can demonstrate. Albert Ellis) as associated with irrationality and
Religiously grounded guilt may mediate avoid- psychopathology. A large number of studies
ance of and restraint of unacceptable sexual have produced relatively consistent findings
impulses, or may represent the internalization of that religion per se does not negatively impact
interpersonal patterns of approval and disap- mental health in general, and that the mental
proval in the social environment, but it may also health of religious persons is often positively
be the natural outcome of doing something effected by their religiosity in a variety of ways
wrong and a sign of a supernatural presence as discussed earlier.
quickening one's need for repentance. Colla- A number of studies discussed in Worthing-
borative exploration of the variety of meanings ton et al. (1996, p. 451) have found superior
of religious phenomena with a client can mental health outcomes for intrinsically reli-
facilitate growth in awareness and understand- gious individuals; extrinsically oriented persons
ing in the client and the clinician. may even experience some negative impact from
It is important to remember that much of the their religiosity. Therefore, assessing the reli-
research on the psychology and sociology of gious orientation (intrinsic vs. extrinsic) of the
religion has been done on white middle-class client may provide some important data for the
populations, and may not tap dimensions of clinician as to the potential impact of religion on
relevance to minority populations, whether the mental health of the client in the process of
racial/ethnic (the experience of African-Amer- clinical care. Bergin (1991, cited in Worthington
icans) or religious (the experience of Jehovah's et al., p. 457) found that intrinsically oriented
246 Diversity Matters: Religion and the Practice of Clinical Psychology

religious persons, while they may tend to certainty, self-restraint and submission to super-
frustrate the clinician with their religious ior external verities inclines people to become
explanations for their behavior and experiences, more religious in general.º
are more likely to be open to therapeutic change Given that psychotherapists are dispropor-
than the extrinsically oriented person. Parga- tionately nonreligious compared to their clien-
ment (1987, cited in Worthington et al.) found tele, and that psychotherapy is a value-changing
that religiously conservative people may be relationship, such findings can be seen as
more open to therapeutic change than people justifying concerns about value influence for
who typically associate themselves with more religious clients; it becomes obvious that value
mainline religious groups. As in other matters of differences based on religiosity may signifi-
diversity, stereotypes (in this case the stereotype cantly impact the work of clinicians who are not
that highly religious individuals are defensive sensitive to the values reflected in the religious
and rigid) can be very dangerous. beliefs of their clients. It may be for this very
Intrinsically and extrinsically oriented people reason that the data suggests that the world
differ on other life dimensions as well. views of religious people may lead them to
Worthington et al. (1996, pp. 451, 457) cited prefer religious counselors (Worthington et al.,
the findings of Hood et al. (1996) that there are 1996). Highly religious persons appear to prefer
significant differences in how intrinsically therapists of very similar religious beliefs. They
religious students, extrinsically oriented stu- may also have clear expectations of religious
dents, and proreligious students (both intrinsi- counseling. Highly religious individuals may
cally and extrinsically oriented) describe tend to view the world with religious schema and
identical sensory experiences. Intrinsically or- may view psychotherapy differently as a result.
iented students give religious descriptions of Shafranske and Malony (1990) discovered in
their experience spontaneously, while extrinsi- their study of the nature of clinical psycholo-
cally oriented students do not use religious gistsº religiousness that, while their sample of
descriptions of their experience even when clinical psychologists appeared to value the role
prompted to do so, and proreligious students of religion in human experience in general
tend to only mention religion in their descrip- terms, they were also less likely to be involved
tions if prompted. Clinically understanding the with religious institutions. ªLess than one in five
different ways in which the religious orientation declared organized religion to be their primary
of the client may predispose the client's use of source of spirituality.º Approximately 25%
religious explanations in therapy could be of reported negative feelings regarding past re-
significant help in the clinical care of the client. ligious experiences. They also found support for
the findings of previous studies that personal
attitudes appear to play a more important role
10.10.6.2 Psychotherapy and Values than clinical training when it comes to ther-
apeutic interventions related to religion. In fact,
It is widely recognized that successful psy- they suggest that ªit may be that religious beliefs
chotherapy often entails a certain degree of function as a meta-theory that significantly
convergence in values, with the values of the influences psychotherapy in both implicit and
client moving to be more like those of the explicit ways.º As Jones (1994) points out, ª . . .
clinician. It appears that psychotherapy does not it seems that the concerns presented by clients
typically result in movement in basic religious often push the practitioner beyond the limits of
values of clients, but the close articulation of so what consensually validated scientific research
many values with religious faith makes this an has established. `Given that research supplies
area of concern for many religious persons only a small fraction of the information needed
seeking counseling and psychotherapy (Wor- to completely understand the psychotherapeutic
thington et al., 1996). Schwartz and Huismans process, we are often compelled to rely on our
(1995) report in their article on value priorities tacit, background metaphysical notions' º
and religiosity that there is a negative correlation (p. 191).
between religiosity and values such as univers-
alism (understanding, appreciation, tolerance,
and protection for the welfare of all people and 10.10.6.3 Religion in Psychotherapy
for nature), stimulation (excitement, novelty,
and challenge in life), and self-direction (in- Religion can be best viewed as a multi-
dependent thought and action; choosing, creat- dimensional variable that includes facets such as
ing, exploring). Their research also suggested what people believe, feel, do, know, and how
that ªvaluing openness to change and free self- they respond to their beliefs. Thinking in terms
expression inclines people to become less of the many important dimensions of religious
religious.º Conversely, they found that ªvaluing experience helps to avoid the possibility of
 The Empirical Basis for Appreciating Religious Diversity in Clinical Care 247

reductionistic thinking (e.g., their religion is They also found that religious orientation did
ªnothing but . . . º) and encourages more holistic not appear to influence the ability of clinicians
and integrated thinking, that is, the type of to discriminate between religious experiences
thinking that should characterize the psy- that were either real or fabricated as well as the
chotherapy process. pathological or responsible use of religion.
The ªbiasº among clinical psychologists However, more recent research does not appear
appears to be overwhelmingly functional. In to be as clear. According to Worthington et al.
other words, when they speak about the (1996), studies done since the mid-1980s have
religiosity of a client, they are most often refer- had more mixed results. In fact, they cite a
ring to the intersection of psychodynamics and particularly methodologically sound study by
faith, that is, how it operates in an individual's Gartner, Harmatz, Hohmann, and Larson
life (Groeschel, 1992). It is suspected that it is (1990) which found that clinician ratings were
exceedingly rare for most clinical psychologists affected by patient ideology. It seems that in
to be able to speak directly to religion as both a light of the ªEthical Principles of Psychologists
process and as a set of particular beliefs and Code of Conductº (APA, 1992), it would be
(Shafranske, 1996). Clearly, institutional iden- important for clinicians to be aware of this
tification with a particular religious tradition is potential bias.
not generally seen as a top priority of the Religious variables can affect the formation
majority of clinical psychologists (Worthington of a therapeutic relationship. Worthington et al.
et al., 1996). If the majority of clients are (1996) summarize the research by noting that
religious and if the majority of providers do not ªWhen counselors disclose their religious beliefs
identify with institutional religion or are unable or values, their disclosure will likely affect both
to think about religiosity beyond the functional, the client's behavior and expectations about the
there is a clear possibility that clinical psychol- counseling process and outcome. Disclosing a
ogists and their clients may find it difficult to counselor's religious beliefs and values can
connect on issues which give them focus and facilitate counseling if the counselor and client
meaning in their lives (see for further discussion are quite similar in beliefs and values and if the
Hood et al., 1996, Kauffmann, 1991; Palout- counseling does not focus mainly on religionº
zian, 1996). (p. 460). In the light of managed care and the
Worthington et al. (1996) summarize their concerns of the public about accountability in
findings by saying, ªhighly religious people may the practice of psychotherapy, it may be well for
prefer religious counselors and explicitly reli- us to be concerned about the values clients bring
gious counseling . . .. Despite preferring reli- to therapy and their dissonance with the
gious counselors, people do not want their clinician's.
counseling to focus mainly on religionº (p. 460). Research studies cited by Worthington et al.
While it may be a truism, it is difficult to (1996) have investigated the role religion plays
appreciate the impact of the experience of in other clinical behaviors. It appears that there
another human being upon themselves or upon is a positive correlation between clergy exposure
clinicians if they have no reference point with to mental health issues and training and the
which to compare or have no particular propensity of clergy to do counseling and to
knowledge with which to interpret that experi- refer. There would also appear to be a relation-
ence. Clearly, if clinical psychologists are going ship between the clinician's theoretical orienta-
to do therapy with religious persons, it would tion and the referral behaviors of clergy. It
seem logical that they should have some appears that mainline Protestant clergy are
reference point or knowledge of religious more likely to refer to humanistic or behavioral
experience. It is contended that the religious therapists and that clergy from more conserva-
knowledge and experience of the clinician plays tive fundamentalist or orthodox faiths are more
an important role in clinical work with religious reluctant to refer to therapists of a psychody-
persons even if the client is not in therapy to namic orientation. Interestingly, they also state
address religious or spiritual issues. that ªSecular professionals rarely refer to
clergy, even when difficult spiritual issues arise
in counselingº (p. 468). It would seem important
10.10.6.4 Religion and Clinical Judgment, for clinicians to give clergy the same referral
Technique and Behavior treatment we do other helping professionals.
Perhaps it is an imperialistic attitude or a lack
Worthington et al. (1996, p. 467) refer to of relationships that prevents such from
previous studies more than 10 years old which happening.
found that the religious orientation of the Holden et al. (cited in Worthington et al.,
clinician did not seem to influence the diagnosis 1996, p. 468) found that both counselors and
given to either religious or nonreligious clients. clergy demonstrated equally developed skills in
248 Diversity Matters: Religion and the Practice of Clinical Psychology

assessing the interpretation accuracy of Judeo- Simanton (1988, cited in Worthington et al.,
Christian principles in the religious ideation of a 1996) found progressive relaxation and Chris-
depressed client. Further, counselors were more tian meditation equal in their efficacy.
reluctant than clergy to challenge those religious Worthington et al. (1996) state, ªMost of what
beliefs. The question might be asked; if can be accomplished therapeutically with med-
clinicians are reluctant to challenge religious itation can be accomplished with relaxation
beliefs that they accurately perceive as distorted, training which is generally easier and avoids
why don't they refer the client to someone who religious associations of meditationº (p. 475).
may help the client by doing just that? This is an example of an exclusive religious
Some explicitly or implicitly religious techni- practice that has mental health benefits and can
ques are used regularly in psychotherapy. be used inclusively when modified to meet the
Worthington et al. (1996) state, ªThe use of religious diversity concerns of others.
religious techniques by explicitly religious
therapists stands in some contrast to the general
field of clinical psychologyº (p. 469). They cite 10.10.6.5 Religion and Clinical Research
an important study by Shafranske and Malony
Worthington et al. (1996) note that religion
(1990) in which they did a national survey of
has become an increasingly acceptable topic for
clinical psychologists. They reported that 59%
research in counseling and psychotherapy in
of the clinicians surveyed supported the use of
part due to the ªfourth forceº in psychology, i.e.
religious language in psychotherapy but 55%
multiculturalism. According to the authors,
opposed the use of scriptures. Further, only
religion and spirituality has moved into the
19% of the clinician found it acceptable to pray
mainstream of clinical care in many ways. This
with a client while 68% believed it inappropri-
has been demonstrated by the increase in
ate. However, as previously noted, the public
religiously oriented professional organizations
seems to feel prayer is important to their
in the field, the development of doctoral level
physical health and the majority would like
training programs that have a religious orienta-
their physician to pray for them. Clearly, the
tion, the number of conferences and workshops
issue of prayer in mental health care needs to be
presented in mainstream marketplaces such as
investigated further. Worthington et al. (1996)
the APA preconvention workshops, and the
state, ªPrayer appears to be the most common
publishing of a ªplethora of theoretical, po-
form of religious coping by most religious
lemic, and conceptual worksº (p. 448). They
people, and even nonreligious people often turn
suggest that there has been an improvement in
to prayer in the throes of sufferingº (p. 474).
the scientific study of counseling for the
Another religious behavior that has found its
religious and of religious counseling since the
way frequently into clinical work is forgiveness.
mid-1980s. They conclude that ªreligious coun-
Worthington et al. (1996, p. 475) note that
seling by religious counselors of religious clients
forgiveness has been almost as popular in the
has recently assumed an increased prominenceº
psychological literature as the religious jour-
(p. 449), and note that the changes occurring in
nals. Unfortunately, they make a similar
the mental health care marketplace will have a
assessment of research on forgiveness as other
continuing effect on how religious clients and
religious interventions. While forgiveness is
religious counselors experience mental health
used with self-reported efficacy in case studies,
care (p. 480).
little empirical attention has been given to its
potential efficacy in clinical populations. Also,
while forgiving may have efficacy as an 10.10.7 THE RELIGIOUS COMMUNITY
intervention, few studies have investigated the AS A RESOURCE FOR SUPPORT
potential effect of seeking forgiveness in clinical
populations. This may have particular interest It seems clear that there are many signals in
for those investigating personality disorders contemporary North American society that
such as antisocial personality disorder. persons are looking for the kind of social
A particularly problematic clinical interven- support that can only be found in a community
tion for clients of the Western religious (Kauffmann, 1991). This phenomenon appears
traditions has been the Eastern Hindu and to be particularly relevant to the Christian
Buddhist oriented meditation techniques. Be- church. When the church is at its best, there is
cause of their close connection with specific concern for the total welfare of its members
practices of a religious system, many highly and friends: ªBy prayer and petition for the
religious persons have objected to their use or Spirit's leading, by identifying the resources it
have been surprised, given their religious possesses, and by framing programs consistent
connections, at their acceptance by the clinical with the best empirical findings, congregations
community. A study by Carlson, Bacaseta, and can provide a much needed service to both
 Training Clinical Psychologists in Religious Diversity 249

believers and nonbelieversº (Kauffmann, 1991, pists have grown up in the tradition of medicine,
pp. 134±135). the nature of the ailments they deal with and the
Particularly in the era of decreased resources way they treat them, make them function much
due to managed care, it might be useful to think like clergy.
about a religious group as a potential ther-
apeutic community. Indeed, the data (Miller & The profession's concern about diversity in
Jackson, 1995) would support the observation all its form is to be applauded. It can be argued
that religious professionals, rather than mental that religious diversity is an important multi-
health or health care providers, are often the cultural factor that has not been treated
first persons contacted and sought out when equally with others in addressing the need
individuals or families are in a crisis. A failure to for training. Petersen (1988, cited in Brems,
recognize this pattern and to consider network- 1993, pp. 72±86) proposes a threefold approach
ing with local religious groups might be one way to increase multicultural sensitivity: awareness,
to guarantee that even the best effort in the knowledge, and skills. Petersen's model is
consulting room will not generalize or maintain developmental in that each of the areas builds
beyond the immediate professional involve- on the other and thereby assumes a process of
ment. Religious professionals and members of growth.
local religious communities should be viewed as Awareness would be the first step in becom-
resources and as potential collaborators. In- ing sensitive to the issue of religious diversity as
deed, professional isolation (Guy, 1987) may be a multicultural issue. Brems (1993, p. 74)
hazardous to cliniciansº well-being as well as describes seven characteristics of an aware
that of clients. clinician. First, an aware clinician would have
an awareness of their own cultural heritage. The
clinician could participate in this by self-
10.10.8 TRAINING CLINICAL reflection on their own religious or spiritual
PSYCHOLOGISTS IN RELIGIOUS journey and seek to share that story with a
DIVERSITY colleague. Second, Brems proposes that the
It is hard to find truly balanced and informed clinician be conscious and embracing of all the
treatments of creative and even curative diversity memberships in their life. This may
possibilities of the resources of faith and involve the clinician making an intentional
religious communities in theoretical and re- connection between ethnic heritage, gender
search literature, although there are some identification, and religious background and
encouraging trends in the field (Browning, how these issues in concert may impact her
1987; Hood et al., 1996; Jones & Butman, clinical work with others, particularly in light of
1991; Malony, 1995; McLemore, 1982; Meyer & the fact that they may not share all of the same
Deitsch, 1996; Miller & Jackson, 1995; Sha- diversity issues with the client. Third, the
franske, 1996; Worthington et al., 1996; Wulff, clinician should ªvalue and respectº the diver-
1991). The lack of epistemic humility when sity of others. This may involve the intentional
studying the traditions of others is a truly exposure to other religious groups, orientations,
disturbing characteristics of training programs and variety of religious experiences through
and clinical practice. attending institutional functions or reading
Shafranske and Malony (1990) concluded in popular literature or even dialoging with a
their study of the religiousness of clinical colleague or friend who has a religious
psychologists that only one-third of their experience very different from one's own.
subjects ªexpressed personal competenceº to Fourth, the clinician should become aware of
intervene in the religious aspects of their clientsº their own values and potential bias and the
lives. This was contrasted with the finding that potential effect they may have on therapy. This
the majority felt they had the knowledge and could come as a result of dialoging with a
ability to deal with religious issues. Further, colleague or being supervised by a colleague
85% reported the frequency of discussion with more knowledge and expertise about the
related to religious issues in their training particular religious affiliation of a client. This
experiences to be rare or never. Along with would hopefully enable the clinician to become
other past reviewers, they concluded that more aware of the salient differences and their
clinical psychologists should ªreceive limited potential impact on therapy.
training respective of religious and spiritual Fifth, Brems (1993) would suggest that the
issuesº and that: aware clinician should be careful not to ªover-
emphasizeº or ªunderemphasizeº the differ-
in light of the limited training opportunities, the ences from the client. This might be observed by
profession may have failed to heed the admonition the clinician or the client. The clinician might
of Perry London that while modern psychothera- consider seeking common religious ground with
250 Diversity Matters: Religion and the Practice of Clinical Psychology

the client by comparing and contrasting 10.10.9 FUTURE DIRECTIONS

religious ideas. They might ask about the
client's concern with regard to religious symbols According to The encyclopedia of American
in their office, for example, or might seek religions (1993), there are 1730 ªprimary
clarification of the religious language used by religious bodiesº in America alone (cited in
the client. Sixth, the clinician should seek to be Paloutzian, 1996, p. 7). Collectively, these
comfortable with and diversity that exists groups are described in the psychology of
between themself and their client. This might religion as churches, denominations, sects, or
be accomplished by the clinician asking to be cults. As Paloutzian (1996) has noted, if to this
ªeducatedº by the client with regard to the the full scope of world religions is added
client's religious background while expressing including varieties of Buddhism, Hinduism,
genuine interest in understanding the impact New Age religions, Spiritualist, Wisdom reli-
religion has for the client. The clinician might gions, and others, the numbers are staggering.
read about the client's religion independently Even a full-time student of domestic or world
and dialog about that with the client. Finally, religions would have to devote decades of
the clinician should seek to be sensitive to the serious study in order to fully appreciate the
need for referral should that be in the best complexities and subtleties of the ideological,
interest of the client and the diversity issues ritualistic, experiential, intellectual, and con-
present. sequential dimensions of all these religious
Brems (1993) also describes the further commitments. Certainly, this would be an
development of knowledge in the process of unrealistic task for even the most interested
becoming sensitive to multicultural issues in and committed clinician or clinician-in-training.
therapy. The development of knowledge in- It is not proposed that clinicians become
volves gaining accurate information about the experts in religion or spirituality any more than
client's religion. It also involves being sensitive it is expected that clinicians be experts in law
to the fact that, even within very structured (although some are experts in forensic psychol-
religious groups, individuals within the group ogy) or medicine (although some are very
may think, feel, and act differently than their knowledgeable about psychopharmacology).
cohorts as it relates to their religious expres- Even if limiting oneself to Anglo-American
sion. Accurate information should not be religions (assuming one is from an Anglo-
limited to just the writing of psychologists American religious and cultural heritage), it
but should also involve the writings of both would be an unnecessary and daunting task.
supporters and critics of the religion. First- What is being argued in this chapter is a need
hand experience can also be a powerful source for sensitivity, awareness, and acknowledgment
of imagery as it relates to understanding the of the religious diversity (or lack thereof) of
client's experience. Finally, the clinician should clinicians and of the religious diversity of
become aware of the past injustices and clients. Further, it has been the intention to
inadequacies of the mental health system to make the case for understanding the role of
adequately address the needs of the religious religion in the experience of clients not only
client. The clinician may need to rethink their from a psychosocial perspective but from a
conclusions about psychopathology when re- transcendent one as well.
ligious variables predominate. It is suggested that religion be treated with the
Brems (1993) describes the skills necessary to same respect and concern for competency as
successfully deal with multicultural issues in other areas of diversity and that clinicians
therapy. This includes the matching of com- recognize their abilities as well as lack of ability
munication and therapeutic orientation to meet to deal with religious issues in the assessment,
the client's specific diversity needs, being careful diagnosis, and treatment of their clients. A
not to stereotype or categorize, and remaining model is proposed for such clinical activity that
flexible in meeting the client's needs. This may is consistent with other models of competency
involve being an agent for social change by including forensic psychology, or even more
using language that is appropriate and not appropriately, psychopharmacology.
prejudicial. Most importantly for the religious What is required is an Assess±Treat±Refer
client, a therapist may need to have the contacts model of clinical care as it relates to cliniciansº
and relationships within the client's religious religious diversity and that of their clients. The
community to promote or participate in ªAssessº aspect of this model involves identify-
institutional interventions or referrals. This ing control beliefs, religious beliefs, and
process is no different to that of the establish- commitments, and the impact they may have
ment of referral relationships with other mental on the care of clients. The clinician should not
health care providers who intervene in ways keep this totally to themself, but rather in
unique to their discipline. keeping with ethical guidelines be explicit with
 Future Directions 251

the client about differences that may impact ary. This model of care is held out to be not only
clinical care. in the best interest of the client, but it also
The clinician might attempt to articulate recognizes that the clinician cannot provide all
spirituality/religiosity through a self-assessment of the beneficial care that a client deserves or
by reflecting on the dimensions of religion noted that may be available. While some clinicians
(cognitive, ritualistic and symbolic, moral, may be relative experts in a particular religious
institutional, community and lifestyle, and context or identify with particular religious
experiential). Further, the clinician may need systems, even then the benefits of accessing
to increase sensitivity to the limits of knowledge clergy or other religious professionals may be
and the limits of attitudinal flexibility. They more appropriate in meeting the client's
may also need to reflect on the implicit religious and/or spiritual needs as part of a
assumption that nobody can support all multidisciplinary approach to mental health
religions equally and assess the level of empathy care.
with different traditions. Finally, in the assess- Certainly, the competence to treat involves
ment of their own control beliefs about religion not just multicultural awareness, knowledge,
and spirituality the clinician should be careful and skills but will ultimately be decided on by
not to make personal synthesis of religion a effectiveness in dealing with a particular client
ªrealityº but rather recognize it as a variant of with a particular problem and in a particular
religious belief itself. context. With the increasing call for account-
Additionally, the assessment aspect of this ability and responsibility for clinical care, it
model would involve exploring the client's would appear to be important to focus on
religious background and control beliefs in an outcomes as a particular measure in the care of
attempt to not only understand the psychosocial the religiously diverse client. Outcome measures
aspects of their religious experience but also the should certainly have clinical utility (changes in
potential resource that religion might be in their symptoms, behaviors, mood, relationships, and
clinical care. The clinician should be careful not so on), but also need to measure consumer
to only make a functional analysis of the client's satisfaction. Broadly understood, this could
religious beliefs and behaviors (as helpful as that involve the client, significant others in the
can be), but rather consider the implications client's life, and, for the religiously diverse
that religion has for the client's interpretation of client, the religious community. A potentially
ultimate reality. important measure of the effectiveness in
While there are many instruments available treating the religiously diverse client may be
for measuring the religious aspects of a client's the evaluation by the religious community of the
experience, the assessment of religion/spiritual- impact of work on the client in the context of
ity as part of the regular clinical interview may their faith.
be the most helpful place to start. As previously Finally, the ªReferº aspect of the model
noted, the clinical interview should explore the would suggest the obvious. There are times
various dimensions of religious experience and when competencies are clearly limited in cases
behavior as well as serve as a helpful under- that involve religious issues. We should seek to
standing of the role of religion in the life of the network with religious professionals similar to
client. The assessment process should be networks we may have with other healers.
sensitive to bias that may be inherent in Clinicians should be open and clear with clients
soliciting such information. Clinicians should that deference in caring for them is not a
pay careful attention to and encourage the function of inability to morally recognize their
continuing explosion of research on clinical religious diversity but rather it is a matter of
processes and outcomes which includes careful limited competence and the specialized ability of
study of religion and spirituality and how they others to whom they can be referred.
interact with clinical variables. A case example may illustrate the model. An
The ªtreatº aspect of the model recognizes 18-year-old male was referred for psychological
that some clinicians may identify readily with a evaluation by his public school because of
particular religious tradition in ways that make ªaggressive and violent behaviorº towards peers
them uniquely qualified to care for particular and staff. The young man was a new immigrant
clients. These clients may present with religious from Bosnia. His primary language was
issues that are very significant, in not only Bosnian, and so there was a language barrier
formalizing their case, but also in treating them. that would require the assistance of a translator.
It is important to note that the standard of An initial hypothesis was that this ªlanguage
care has changed and continues to evolve in barrierº in other relationships and the resulting
mental health care. The focus on managed care isolation and frustration may have played a role
and utilization review has produced a system of in this young man's ªaggressive and violent
care that is multidisciplinary and interdisciplin- behavior.º
252 Diversity Matters: Religion and the Practice of Clinical Psychology

While the examiner was aware of a ªreligious can have on the process and outcome of
warº in the former Yugoslavia, the ªreligiousº psychological service delivery. They must also
aspect of the war was not well understood by the become more aware of their own biases and
clinician. In taking the clinical history of this limitations in dealing with such material, more
young man it was discovered that he had aware of the degree to which their own religious
immigrated to the US through the auspices of a assumptions color their theories and practices in
ªChristianº organization. Prior to that, he had clinical psychology, more tolerant of the wide
been held in a refugee camp which he described array of religious beliefs and practices which
as very undesirable. While at the camp, he was characterize the people they serve, more
identified as one who could immigrate because respectful of the resource which religious beliefs,
of his ªcircumstances,º those circumstances practices, communities, and institutions are to
being the murder of his entire family, in his many clients, and more cognizant of the
presence, by ªChristians.º They were killed, he extensive and growing research base on the
stated, because they were ªMuslims.º role of religion in human life generally and in
He was a Muslim. He stated that he would die psychological practice in particular. Contrary to
for Islam. He also stated that his chief end in life the prevailing mindset in psychological circles,
was to revenge the death of his family and that for most of the population, to be spiritual is to
this was dictated by his Muslim religion. Having be religious, and psychologists must avoid the
only a rudimentary understanding of Islam and tendency to ªreduceº the religious faith of those
noting that revenge was not one of the five they serve to either a bland, generic spirituality
pillars of faith, the clinician was compelled to or to a set of sociopsychological processes.
seek the assistance of a Muslim cleric who could
clarify the issues and counsel this young man
about this issue in particular. It seemed better to 10.10.11 REFERENCES
the client to discuss his religious beliefs with a
American Psychiatric Association (1994). Diagnostic and
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It became clear in conceptualizing the nature ton: American Psychiatric Association.
of the ªaggressive and violent behaviorº that American Psychiatric Association Task Force on Religion
this young man was very angry over the loss of and Psychiatry (1975). Psychiatrists viewpoints on religion
his family, had struggled to understand and be and their services to religious institutions and the ministry.
Washington, DC: American Psychiatric Association.
understood in a culture with a language very American Psychological Association (1992). Ethical prin-
different from his own, and that the client was ciples of psychologists and code of conduct. American
conflicted over his hatred for ªChristiansº and Psychologist, 47, 1597±1611.
their apparent goodwill toward himself. Ob- Batson, C. D., Schoenrade, P., & Ventis, W. L. (1993).
Religion and the individual: A social-psychological per-
viously, the assessment of this young man's spective, New York: Oxford University Press.
presenting problem hinged upon an under- Benner, D. G. (Ed.) (1988). Psychology and religion. Grand
standing of his religious and sociocultural Rapids, MI: Zondervan.
background. The treatment of his problem Bergin, A. E. (1991). Values and religious issues in
required the special expertise of a Muslim cleric psychotherapy and mental health. American Psycholo-
gist, 46, 394±403.
as well as a recognition of the therapist's Bergin, A. E., & Jensen, J. (1990). Religiosity of
identification as a ªChristianº Ultimately, his psychotherapists: A national survey. Psychotherapy, 27,
care involved the multidisciplinary involvement 3±7.
of a foreign language teacher, a Muslim cleric, Brems, C. (1993). A comprehensive guide to child psy-
chotherapy. Boston: Allyn & Bacon.
and a clinical psychologist. Browning, D. S. (1987). Religious thought and the modern
psychologies: A critical conversation in the theology of
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Coles, R. (1990). Harvard diary: Reflections on the sacred
10.10.10 SUMMARY and the secular. New York: Crossroad.
Comas-DõÂ az, L., & Striker, G. (1993). Special issue:
Clinical psychologists are nonrepresentative Diversity in clinical psychology. The Clinical Psycholo-
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of commitment to traditional religious faiths. Dell'Olio, A. (1996). Multiculturalism and religious diver-
Religious faith, like other vital diversity vari- sity: A Christian perspective. Christian Scholars Review,
25, 459±477.
ables such as race, gender, ethnicity, age, sexual Fowler, J. (1981). Stages of faith. San Francisco: Harper &
orientation, and others, shapes and contextua- Row.
lizes the clinical concerns of persons who Friedman, R., & Benson, H. (1997). Spirituality and
present for psychological assessment and treat- medicine. Mind/Body Medicine, 2(1), 1.
ment. Clinical psychologists have an ethical Gartner, J. (1996). Religious commitment, mental health,
and prosocial behavior: A review of the empirical
obligation to become more knowledgeable, literature. In E. P. Shafranske (Ed.), Religion and the
aware, and skilled in managing the impact clinical practice of psychology (pp. 187±214). Washing-
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clinical judgment. Counseling and Values, 35, 58±62. psychology for pastors (2nd ed.). Englewood Cliffs, NJ:
Glock, C. (1962). On the study of religious commitment: Prentice-Hall.
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Gorsuch, R. L. (1984). Measurement: The boon and bane religions (9th ed.). New York: Macmillan.
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228±236. study of religion. Boston: Beacon Press.
Groeschel, B. J. (1992). Spiritual passages: The psychology Paloutzian, R. G. (1996). Invitation to the psychology of
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Gross, M. L. (1978). The psychological society. New York: Pargament, K., Silverman, W., Johnson, S., Echemendia,
Random House. R., & Snyder, S. (1983). The psychosocial climate of
Guy, J. D. (1987). The personal life of the psychotherapist. religious congregations. American Journal of Community
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Hill, P. C., Butman, R. E., & Hood, R. W., Jr. (Eds.) Pargament, K., Tyler, F. B., & Steele, R. E. (1979). The
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 Copyright © 1998 Elsevier Science Ltd. All rights reserved.

10.11
Mental Health in Rural Society
MICHAEL MURRAY
Memorial University of Newfoundland, St. John's, NF, Canada
DAVID S. HARGROVE
University of Mississippi, MS, USA
and
MICHAEL BLANK
University of Virginia, Charlottesville, VA, USA

10.11.1 INTRODUCTION 256

10.11.2 STRUCTURE OF RURAL SOCIETY 256
10.11.2.1 Changing Demographics 256
10.11.2.2 Definitions of Rural 256
10.11.2.3 Diversity 257
10.11.2.4 Age and Education 257
10.11.2.5 Work 257
10.11.2.6 Income 258
10.11.2.7 Living Conditions 258
10.11.3 LIFE IN RURAL SOCIETY 258
10.11.3.1 Social Life 258
10.11.3.2 Women and Family Life 259
10.11.3.3 Working Life 259
10.11.3.4 Change in Rural Society 260
10.11.4 HEALTH ISSUES 261
10.11.4.1 Stress in Rural Society 261
10.11.4.2 Impact of Crisis 261
10.11.4.3 Social Cohesion 261
10.11.4.4 Mental Illness 262
10.11.5 MENTAL HEALTH SERVICES 263
10.11.5.1 Healthcare Utilization 263
10.11.5.2 Specialty Mental Health Services 263
10.11.5.3 Public Policy 264
10.11.5.4 Empirical and Theoretical Basis for Planning Services 264
10.11.5.5 Healthcare Reform 265
10.11.5.6 Primary Care 265
10.11.5.7 Telemedicine 266
10.11.6 PSYCHOLOGY AND RURAL MENTAL HEALTH 267
10.11.6.1 Historical Background 267
10.11.6.2 Roles of Psychologists in Rural Communities 267
10.11.6.3 Training Psychologists for Rural Practice 268

255
256 Mental Health in Rural Society

10.11.7 TYPES OF INTERVENTION 269

10.11.7.1 Fitting the Intervention to the Context 269
10.11.7.2 The Rural Psychologist as a Generalist 270
10.11.7.3 The Concept of Community and Psychological Intervention 270
10.11.7.4 Ethical Dilemmas in Rural Practice 271
10.11.8 FUTURE DIRECTIONS 272
10.11.9 SUMMARY 272
10.11.10 REFERENCES 273

10.11.1 INTRODUCTION This decline in population is due to a steady

increase in outmigration from those rural
The twentieth century has seen a dramatic regions that are experiencing economic difficul-
shift in the distribution of the population over ties. Part of the reason for the absolute increase
most parts of the globe, including North in the rural population is the movement of
America. Whereas in the early part of this urban residents to rural or semirural areas from
century the majority of the world's population which they commute to urban centres for
lived in small communities relatively isolated employment. These numbers are also supple-
from population centers, the world has now mented by those former urban residents who
become a predominantly urban society. Large retire to rural areas.
metropolitan centers have not only become the
location for an increasing proportion of the
world's population but also of service provison 10.11.2.2 Definitions of Rural
and, indeed, of human research interest.
This change has led to an orientation towards In attempting to describe the character of
understanding and providing for the needs of rural society one endemic problem is the actual
urban society and a lesser interest in the nature definition of rural. There has been ongoing
of rural society and of the various problems it debate about the term. The three most common
faces. The purpose of this chapter is to focus dimensions used in definitions are (see Bealer,
attention specifically on rural society in North Willis, & Kuvlesky, 1965):
America. It begins by outlining the demo- (i) Ecological. This concerns the spatial dis-
graphic structure of rural society, proceeds to tribution of the population. According to this
describe some of the problems rural society is definition a rural area is one where the popula-
currently experiencing, describes some of the tion is small, widely distributed, and remote
main mental health problems, and then con- from more urban settings.
siders the character of health service provision, (ii) Occupational. This suggests that rural
and the role of psychologists in rural mental refers to a limited number of occupations,
health care. specifically those that are involved with agri-
culture and, to a lesser extent, with fishing,
forestry, and mining.
10.11.2 STRUCTURE OF RURAL SOCIETY (iii) Sociocultural. This refers to the complex
10.11.2.1 Changing Demographics of values and behaviors that typify a particular
group of people. Stereotypically, rural people
According to the most generous estimates, are considered to be socially conservative,
approximately 25% of North Americans cur- provincial, and resistant to change.
rently live in rural areas. This proportion has Admittedly, most studies do not make use of
declined steadily throughout the twentieth all three dimensions (see Bosack & Perlman,
century. However, the absolute number of 1982). In compiling statistics it is important to
people living in rural settings has actually have a common definition. In the USA the
increased. Between 1930 and 1990 the rural favored definition is that developed by the
population in the USA increased by 7.9 million Bureau of Census. It defines urban areas as
(15%) to 53 million (22%), whereas in Canada it central cities of 50 000 or more and adjacent
increased from 4.4 million (51%) in 1921 to 6.4 territory of more than 2500 residents living
million (23%) in 1991 (45% increase) (Statistics outside the geopolitical boundary. From this
Canada, 1993). This increase in population definition, rural is then defined as the residual
confirms what Cordes (1990) describes as the category.
myth of a shrinking rural America. Statistics Canada (1993) uses a similar
Admittedly, these overall figures conceal a definition describing an urban area as having
decline in the population of certain rural areas. attained a population concentration of at least
 Structure of Rural Society 257

1000 and a population density of at least 400 per similar age (Miller et al., 1994). In certain
square kilometer at the previous census. All pockets, the median age can be much higher.
territory lying outside urban areas is considered The exodus of many young people in search of
rural. Recently a more sophisticated definition employment has led in certain areas to a graying
has been developed which classifies US Census of rural America. Johnson and Beale (1992)
returns according to both the population of the note that in many rural communities more than
locality and the proximity to urban centers. This one in four of the population is over 65 years.
scheme produces a 17 category continuum from These elderly people are a mixture of those
core counties with a population greater than one who have lived all or most of their lives in rural
million to nonmetropolitan nonadjacent coun- areas and urban seniors who have retired to a
ties with no community greater than 2500. This rural setting. The latter tend to be wealthier and
classification scheme has recently been used to to have fewer immediate family connections.
clarify the demographics of the USA (Miller, There is also evidence that elderly rural
Farmer, & Clarke, 1994). Admittedly, even residents will migrate to small towns to retire
when using a classification as sophisticated as (Li & MacLean, 1989).
this, there remains the problem of the sub- The general pattern of education is one with
stantial variations that exist between and within rural residents having poorer educational
regions. qualifications than urban residents. For exam-
ple, whereas only 6.2% of the population of the
10.11.2.3 Diversity fringe suburban counties in the USA had less
than nine years of schooling, the figure for the
An overall characteristic of rural society in most rural counties was 17.7% (Miller et al.,
North America is the broad sociocultural 1994). In Canada, while 26% of the general
diversity of its population. From Southern working population has a university education,
Blacks, Hispanics in the Southwest, through only 13% of farm opeators have that level of
American indians and Appalachian whites, to education (Statistics Canada, 1996).
Canadian natives and Innuit in the Arctic north,
the diversity of cultures, languages, and tradi- 10.11.2.5 Work
tions is extensive.
It is estimated that about 8.3% of the rural While the traditional image of rural work is
population in the USA is Black as opposed to that of farming, in fact farmers represent only a
11.8% in urban areas. Similarly, less than 2.5% small proportion of workers in rural areas.
of the rural population is Hispanic compared According to the 1990 US Census only 11% of
with over 7.5% in urban areas (Cordes, 1989). the workforce in rural areas was involved in
However, these minorities are concentrated in farming (Miller et al., 1994). Admittedly,
certain regions. Snipp (1996) argues that racial agriculture may form a central component of
segregation is as much a feature of rural as of the economy of certain rural regions as do the
urban America. Besides the enduring poverty of fishery, forestry, and mining industries in
rural society, these minorities also experience others. The central position of these industries
discrimination and the threat of physical harm. in local communities can result in substantial
While the overall level of poverty is higher in dislocation of the whole community if that
rural than in urban areas, it peaks among the industry is threatened. This has occurred in
ethnic minorities. According to Lichter (1989), many rural areas since the mid-1970s.
rural blacks ªremain among the most economic- With the decline in the relative importance of
ally disadvantaged groups in the United Statesº these natural resource-based industries, increas-
(p. 444). Although there was an improvement in ingly the largest proportion of the rural work-
the economic position of these minorities during force is now employed as private wage and
the 1960s and 1970s the evidence suggests that salary workers in service and manufacturing
there has been a deterioration since the 1980s industries. In addition, farmworkers will seek
(Jensen & Tienda, 1989). temporary nonfarm employment. For example,
Bollman and Smith (1988) report that between
10.11.2.4 Age and Education 1951 and 1981 the number of off-farm work
days reported annually by farm operators in
The ongoing economic difficulties facing Canada increased from 75 to 171. Also during
rural America have led to an outflow of young the period 1941 to 1981 the proportion of farm
adults and a consequent aging of the rural operators reporting working full-time off the
population. According to 1990 US figures, farm increased from 3% to 14%.
whereas 11.3% of the population of core urban Increasingly, residents of rural areas have
areas was 65 years and older, 16.2% of those become more dependent upon other sources of
resident in the most rural counties were of a income. According to Bender et al. (1985) only
258 Mental Health in Rural Society

29% of US nonmetropolitan counties are 10.11.2.7 Living Conditions

farming-dependent, 28% are manufacturing-
dependent, 21% are retirement-dependent, and In general, housing in rural areas is of a lower
8% are mining- and energy-dependent. Further, standard than in urban areas. According to
while the farming-dependent counties only White House (1979) figures, rural people in the
account for 13% of the rural population, the USA are three times more likely to live in
manufacturing-dependent counties account for substandard housing than those in urban areas.
40%. Indeed, as some large firms relocate to Similarly, the 1981 Canadian census found that
rural areas in search of cheaper rents and labor, while 1 in 15 homes overall required major
the proportion of rural jobs now attributed to repairs in order to meet basic accommodation
manufacture is similar to that in urban centers standards, the comparable figure for rural areas
(Bluestone & Daberkow, 1986). was less than 1 in 10. Further, while 90% of
The job crisis affecting urban America has its urban homes had central heating, the compar-
counterpart in rural America. It has been able figure for rural homes was 80% (Bolaria
estimated that approximately half the work- et al., 1991).
force in rural America either does not have a job Again, these figures conceal substantial
or has an inadequate one (DeLeon, Wakefield, variation within rural areas. The same 1981
Schultz, Williams, & VandenBos, 1989). Young Canadian Census found that 21% of native
people without jobs will move to urban centers people in rural areas lived in housing that
in search of employment, while older unem- required major repairs, 46% lived in housing
ployed workers will tend to remain in the small that lacked central heating, and 27% did not
communities. have a bathroom.

10.11.3 LIFE IN RURAL SOCIETY

10.11.2.6 Income
10.11.3.1 Social Life
The average income of rural areas is generally
There has been much discussion in the rural
lower than that in urban areas. Analysis across
sociology literature about the so-called duality
the 17 US census categories revealed that while
between rural and urban life (see Labao, 1996).
the median income in core urban areas was
The popular image of rural life is that of
$32 000 and in the more suburban fringe
pastoral tranquillity. Short (1991) summarized
counties it reached $38 000, it was only
the features of this image as follows:
$20 000 in the most rural counties (Miller et
al., 1994). In comparison with urban centers a a less-hurried lifestyle where people follow the
greater proportion of rural dwellers are classi- seasons rather than the stock market, where they
fied as poorÐ17% in rural areas compared with have more time for one another and exist in more
12% in urban areas (Cordes, 1989). organic community where people have a place and
Again, these figures conceal substantial an authentic role. The countryside has become the
variations even within a single area. For refuge from modernity. (p. 34)
example, in Canada it was estimated that
30% of rural households had an income less This bucolic image of rural life is often
than $20 000 but 25% had an income greater contrasted with the murder and mayhem that
than $45 000 (Bolaria, Dickinson, & Wother- is supposed to typify urban America. Srole
spoon, 1991). Similarly, a study of the Atlantic (1972) traced this distinction back to the Old
fishery (Task Force, 1993) found that while two- Testament with the city life of Sodom and
thirds of fishermen made less than $20 000 per Gomorrah being portrayed as an example of
annum and nearly one-quarter made less than evil. Herzlich (1974) in her study of contem-
$10 000, 11% had average incomes of over porary social representations (popular beliefs)
$35 000. Thus while rural areas are generally of health and illness found that lay people tend
poorer than urban areas, there also exist pockets to characterize urban life as the major source of
of relative affluence and of substantial poverty ill health.
within these areas. To investigate this image further, Melton and
Further, the evidence suggests that along with Hargrove (1987) asked a sample of American
the rest of America, rural America is experien- university students to write a short paragraph
cing increasing inequalities in the distribution of describing an urban scene, an urban person, a
wealth (Tolbert & Lyson, 1992). This increasing rural scene, and a rural person. Content
inequality has implications for the health of the analysis of their replies revealed that their
community over and above that due to the descriptions of a rural person were generally
adverse effects of the absolute level of poverty positive and frequently referred to warmth,
(Wilkinson, 1996). friendliness, and simplicity of lifestyle. Less
 Life in Rural Society 259

frequently mentioned were slowness of pace, of assisting with a wide range of farming tasks.
family centeredness, and conformity. These Despite these increased demands, rural women
findings led Melton and Hargrove to concur have fewer sources of support. For example,
with the following comment of Coward and Bushy (1993), in a study of the health needs of
Jackson (1983): rural women found that they were less likely
than urban women to identify a large network
there is little empirical support for this folklore [of of social support that could be of benefit during
a family immersed in a strong and pervasive social times of difficulty. The rate of female participa-
support network of kin, friends, and church. To tion in the labor force also tends to be lower in
the extent that kin, friends, and neighbors can rural areas (Swanson & Butler, 1987).
serve to support families during periods of stress,
the conclusion to be drawn from the research
literature is that rural families are not particularly 10.11.3.3 Working Life
advantaged. (p. 196)
Rural occupations are not confined to farm-
ing and related activities. Indeed, increasingly
In North America, the decline of the family
there is a widespread range of occupations in
farm, the rise of agribusiness, and the integra-
rural areas, although admittedly there are fewer
tion of rural areas into urban society has
professionals and white-collar workers than in
contributed to the undermining of the tradi-
urban centres. Despite this change, an image
tional communitarian culture (Cordes, 1990).
persists that working life in rural areas is gentle
Murray and Kupinsky (1982) found that now
and easygoing. Behind this image there exist
fewer rural Americans participate in commu-
quiet desperation and much hardship.
nity activities, such as granges, church func-
Farming would seem to be an inherently
tions, and civic groups, than in the past. They
stressful occupation (Keating, 1987). There are
suggest that changes in communication patterns
a variety of reasons for this. An important
and the geographic dispersal of extended fa-
factor is the very uncertainty of the job in terms
milies have led to strains on traditional sources
of the market and the weather. This lack of
of social support.
control would be expected to lead to feelings of
One seemingly enduring attribute of rural
unease (see Belyea & Labao, 1990). Another
societies is a high value placed on self-
factor is the multiple responsibilities a farmer
sufficiency and self-reliance (Dengerink &
has in terms of work on and off the farm and
Cross, 1982). A consequence of this can be a
with respect to the family. Finally, there is the
reduced demand for health care. Bigbee (1990)
changing rural scene which threatens the whole
found less evidence of health problems in a rural
farming way of life.
community and suggested that this was due to
Keating (1987) considered the level of stress
under-reporting by residents who wished to
among farming couples on Canadian grain
maintain a sense of self-reliance.
farms. She found that personal resources, which
was a measure of perceived mastery, was the
10.11.3.2 Women and Family Life best predictor of stress. In a comparable study
of Ohio farmers, Belyea and Labao (1990)
Women have traditionally played a central found that relatively young farmers with a large
role in rural society. Although there are number of children and a large proportion of
substantial variations, there is evidence that acreage in grain crops were most vulnerable
rural women are more likely than urban women economically as measured by the debt-to-asset
to be married, have more children, and live in ratio and the net family income. Further, those
larger families (Mansfield, Preston, & Craw- who were most vulnerable reported more
ford, 1988). The greater frequency of larger feelings of economic hardship and stress. In
extended families is due to a variety of social and turn, perceived hardship and stress were related
economic factors. Many young rural couples to depression.
initially establish their families in their original One factor that deters many rural residents
family homes and some single-parent mothers from leaving despite difficulties is the sense of
return to their home of origin. This living family and community history. Many of the
arrangement can be a source of social support at rural residents will come from families who have
times of difficulty, but can also be a source of lived in a specific community for generations.
conflict (Bushy, 1990). Their whole lives are defined by the character of
There is evidence that rural women more their work and their community and it is
frequently adopt traditional gender roles in difficult for them to imagine another way of
terms of family care and household responsi- living. Often, they will have been working on the
bilities (see Bushy, 1993). In addition, those who farm or in the family business before they left
are farmers' wives have the dual responsibilities school and expect to do so until retirement as
260 Mental Health in Rural Society

their parents did before them. Their work is not who are younger and well educated. These are
just a job but a way of life. It is integrated into the farmers who took advantage of loans in the
their daily lives. It is for this reason that a threat 1970s to expand their operations but found it
to their jobs becomes a threat to their whole way difficult to maintain their payments when the
of life (Schroeder, Fliegel, & VanEs, 1985). market changed in the 1980s.
Another feature of rural employment, at least A survey of Canadian prairie provinces by the
that which is based upon the exploitation of National Farmers' Union (1989) concluded that
natural resources, is its seasonal nature. This has ªover the past ten years . . . thousands of farm
given rise to large numbers of migrant workers families have been dispossessedº (p. 4). The
in both the USA and Canada. These workers are report further adds that:
largely drawn from ethnic and racial minorities
(Burawoy, 1976). For example, most farm- the corporate ownership of land means that an
workers in British Columbia are East Indians, increasing amount of the value of farm production
Chinese, native Indians, Francophones, and leaves the community in the form of payment to
migrant youth (Sharma, 1983). These workers corporate owners. This means less spending power
often work in atrocious conditions and are will remain with rural communities which, in turn,
clearly exploited by their employers. A 1973 will influence their future viability. (p. 8)
Canadian Task Force study of migrant farm-
workers found evidence of ªchild labor, sick, In view of these economic difficulties it is
pregnant, and otherwise unfit adults working perhaps not surprising that farmers generally
with only the head of the family being paidº view financial problems as the principal source
(Sanderson, 1974, p. 405). Hopefully, condi- of stress (Olson & Schellenberg, 1986).
tions have improved since then. Throughout the twentieth century there has
Finally, a large proportion of rural workers been a steady decline in the number of farms and
are without regular employment. These indivi- what has been described as the rise of a dualistic
duals would be expected to experience the system of agriculture (Albrecht & Murdock,
various deleterious effects of loss of employment 1988). On the one hand are the small family-run
(see Jahoda, 1972). Admittedly there is some farms which are increasingly economically
evidence that this impact may be ameliorated in nonviable and where the farmer often seeks
rural areas owing to the presence of social part-time employment off the farm in order to
support (Harding & Sewel, 1992; Murray & survive. On the other hand are the large
Dolomount, 1995). However, the apparent industrial-type farms owned by corporations.
decline of such support leaves these individuals These large farms are run as capitalist enter-
at increased risk of psychological distress. prises with more mechanized methods of
cultivation and lesser requirement for human
labor. In Canada the total number of farms has
10.11.3.4 Change in Rural Society dropped from a peak of 732 832 in 1941 to
280 043 in 1990 (Statistics Canada, 1996).
Rural communities have been adversely Currently 8% of Canadian farms account for
affected by both economic and natural pro- 43% of Canadian farmland.
blems over the past decade or so. One major The crisis hitting small farmers and fisher-
change has been the rapid decline of the men has an impact beyond the immediate
medium-sized family farm. There are various worker and threatens the survival of the
economic and political explanations for this but worker's family and of the local community.
the result has been that many small farmers have Hoyt, O'Donnell, and Mack (1995) note that
had their farms seized by the banks and large the farm crisis had two major impacts on the
lending institutions. According to the US immediate community. First, there is the direct
Department of Agriculture (1985) about one- economic impact which removes money from
third of American farmers with sales over the local economy, threatens small businesses,
$100 000 are at risk of losing their operations. reduces employment opportunites, and accel-
Between 1981 and 1986 650 000 farms in the erates the exodus of young people in search of
USA were foreclosed. About half a million rural alternative employment. Davidson (1989) com-
jobs were lost between 1981 and 1983 (Human & pared the effects of this rural upheaval to the
Wasem, 1991). According to the US Office of more visible degradation of urban ghettos.
Technology over a million farmers will leave the A second, more indirect, consequence of the
land by the year 2000 (Rosemann & Delworth, farm crisis is the decline of support resources.
1990). The decline in the population base is followed
It would seem that the farmers who have been by the loss or consolidation of formal support
most vulnerable to this economic threat have services such as hospitals, community organi-
been those with medium-sized farms and those zations, and churches. Thus, the remaining
 Health Issues 261

elderly population has more difficulty gaining ones who shoulder more of the problems that
access to these services. Human and Wasem affect rural families, including those experi-
(1991) describe this process as a vicious cycle: enced by male farmworkers.
ªwhen times are bad, the need for health
servicesÐparticularly mental health servicesÐ
is greater, but because times are bad, the ability 10.11.4.2 Impact of Crisis
to purchase services is lower, as is the ability of Several studies have examined the impact of
the communities to provide servicesº (p. 234). farm crises and foreclosure on the health of
It is not just the natural resource-based farming families. This research has shown that
industries that have been restructured but also economic hardship is followed by a rise in
the small rural-based service and manufacturing psychological distress (e.g., Armstrong & Schul-
industries (Fitchen, 1991). Brooks, Stucker, and man, 1990; Belyea & Labao, 1990).
Bailey (1986) argue that as the small farms One important longitudinal study was con-
disappear so, too, do the small shops, to be ducted in Nebraska (see Ortega, Johnson,
relaced by fewer and larger firms with a total of Beeson, & Craft, 1994). A sample of farm
fewer employees. Like the large farms, these families was followed throughout the 1980s and
large firms are often owned by nonrural it was found that the level of self-reported
corporations whose primary interest is extract- depression significantly increased following the
ing profit from their investment and not with the economic downturn but improved when there
economic maintenance of rural society. was a recovery in the economy. This would
These changes have had a widespread impact suggest that the negative mental health effects
on the character of traditional rural society. were short term.
Naples (1994) found that rural residents Hoyt et al. (1995) found greater evidence of
frequently report increasing dissatisfaction with psychological distress among residents living in
community life and fewer feelings of community small rural communities than among those
cohesiveness. These feelings would be expected living on farms or in larger towns. This distress
to contribute to feelings of social isolation and was particularly pronounced among those with
hopelessness and subsequent psychological low levels of social support. This would suggest
distress. that the effect of place on distress may be due to
the erosion of communal identity and decreas-
10.11.4 HEALTH ISSUES ing sense of collective concern.

10.11.4.1 Stress in Rural Society 10.11.4.3 Social Cohesion

As already mentioned, farm life has a variety One of the most important factors in under-
of associated stressors. Rosmann and Delworth standing mental health, and indeed physical
(1990) distinguished between social stressors health, in rural society is the degree of social
and more work-related stressors. The former cohesion. Traditionally this has been considered
are the range of social pressures from commer- a defining aspect of rural societies. Brody (1973)
cial and government agents that the farmer has argues that mutual aid is virtually a defining
to deal with on a regular basis. The work-related characteristic of small farming communities. He
pressures derive directly from the uncertainty of quotes the Russian anarchist Kropotkin (1939):
farm life. These concern the variability of prices
and production costs, the variability of the the mutual-aid tendency in man has so remote an
weather, and the variability of government and origin, and is so deeply interwoven with all the past
other regulations. evolution of the human race, that it has been
The psychological consequences of such maintained by mankind up to the present time,
economic uncertainty affects the whole farming notwithstanding all vicissitudes of history. (p. 180)
family and not just the farmer. Rosenblatt and
Keller (1983) studied a small sample of It is the undermining of this social solidarity
Minnesota farming couples. They found that that is possibly the greatest threat to the mental
economic vulnerability was related to percep- health of rural society.
tions of economic distress and also to evidence Social interdependence leads to substantial
of interpersonal conflict. social interaction as a requirement both for
Some research has explored gender differ- work and also for entertainment. This was so in
ences in the character of psychological distress traditional rural communities. It was based
experienced by farmworkers. The results of this upon the large degree of social equality that
work would suggest that women farmworkers existed within these communities. This meant
experience higher levels of stress (Walker & that people shared in times of need and
Walker, 1987). This may be because they are the celebrated together in times of plenty. The
262 Mental Health in Rural Society

breakdown of the family farm and small rural problems among children largely disappeared
businesses has meant the rise of a social after statistically adjusting for mobility and
hierarchy in rural communities that undermines cultural and economic differences.
this basis of social solidarity. A classic example The Epidemiological Catchment Area study
of this change is the case of Roseto, the small (ECA; Robins & Regier, 1991) and National
Italian community in Pennsylvania. The reason Co-morbidity Study ( NCS; Kessler et al., 1994)
for initial research interest in this community found only minor differences in prevalence rates
was the low death rates despite the presence of among some diagnostic categories of mental
the standard behavioral risk factors. It was illness among individuals living in rural and
noticed that Roseto was a very egalitarian and urban areas. Prevalence data for rural popula-
close-knit community. Bruhn and Wolf (1979) tions in general and particularly for rural
summarized the impact as follows: African-American and poor populations are
limited and have provoked some controversy.
The sense of common purpose and the camar- The NCS failed to find differences based on race
aderie precluded ostentation or embarrassment to or rurality for the disorders studied. It has been
the less affluent, and the concern for neighbors suggested that conclusions about psychiatric
ensured that no one was ever abandoned. This disorders in these populations are inaccurate
pattern of remarkable cohesion . . . provided
and related to the poor representation of the
security and cohesion against any catastrophe
[and] was associated with the striking absence of samples of rural populations included in them
myocardial infarction and sudden death. (p. 136) and in the ECA study, as well as the insensitivity
of measures used.
Sadly, the death rate in the community rose as There is some evidence for differences in the
the degree of social integration declined (Egolf, prevalence of certain mental illness among the
Lasker, Wolf, & Potvin, 1992; Wilkinson, 1996). rural elderly. General estimates for the pre-
The decline of social solidarity is, perhaps, valence of mental illness among the rural elderly
one of the most negative consequences of the range from 23±25% (Scheidt & Windle, 1982;
social changes in rural America. It has also been Rosen et al., 1981), compared with 15±25% in
argued that the change in the social composition the general elderly population (Weber, 1990).
of rural America away from an interdependent The suicide rate is also high among rural elderly;
society towards one that in many ways is more however, the prevalence of depression is the
comparable to mainstream America has intro- same if not lower than among urban elderly (US
duced more individualistic attitudes and values Congress, Office of Technology Assessment,
to the detriment of rural mental health (Zahner, 1990). The suicide rate among the general
Jacobs, Freeman, & Trainor, 1993). elderly population is 19.8 per 100 000, compared
with 12.6 for the general population. Little is
10.11.4.4 Mental Illness known about the dynamics of suicide among
rural elderly or the consistent rise in suicide
The results of studies comparing mental among African-American elderly.
illness in urban and rural communities are Many nursing and adult homes exist in rural
confusing. One problem with early work was areas. Between 60 and 90% of the residents of
that it was limited to rates of admission to these institutions have been diagnosed as having
mental institutions and did not control for a mental illness. Many of these homes are not
differences in the regional provision of such licensed, are poorly staffed, maintain inade-
facilities (see Cochrane, 1983, for commentary). quate records, and do not provide adequate
For example, Srole (1972) refers to the early programs for their residents.
work which suggested that black slaves in the Taken as a whole, these epidemiological
southern states had lower rates of admission to studies do not provide compelling evidence
mental hospital than freed slaves in the north. for major differences in the incidence and
These studies neglected to point out that there prevalence of mental disorders between urban
were no mental hospital beds for blacks in the and rural populations. Admittedly there are
south. specific social and cultural issues peculiar to
Another problem is that early studies ne- rural communities that must be taken into
glected to consider sociodemographic differ- consideration in the design of intervention
ences between urban and rural areas. More programs. A key question is how rural persons
recent work that attempted to control for such conceptualize their symptoms, and whether or
differences, for example, Neff (1983) and not they access services. How rural persons
Scheidt (1985), concluded that there were few interpret physical illness symptoms, seek con-
differences between urban and rural mental firmation of the presence and meaning of
health. Zahner et al. (1993) found that urban± symptoms, and make decisions about where
rural differences in emotional and behavioral to go for help is not well understood. Even less
 Mental Health Services 263

well understood is the experience and meaning health system. Inpatient, outpatient, and partial
of symptoms of psychiatric disorders among care services have declined in the public sector
rural minority and poor persons. To understand while the availability of private services has
help-seeking for mental health problems among increased dramatically. There has also been a
these individuals, issues surrounding availabil- parallel increase in the number of private
ity, accessibility, and acceptability of care must psychiatric hospitals and psychiatric units in
be examined (Blank, Fox, Hargrove, & Turner, general hospitals. The number of staff available
1995). to these facilities has also increased dramatically
(Redick et al., 1992). Unfortunately, these
changes have not substantially affected the
10.11.5 MENTAL HEALTH SERVICES mental health care of rural persons, since these
10.11.5.1 Healthcare Utilization facilities are most frequently located in urban
areas, or in close proximity to urban hubs.
Despite claims that the disparity between A major concern for healthcare planners is
rural and urban health service availability is the distribution of mental health services across
narrowing (Freeman et al., 1987) and that different regions of North America and speci-
differences in access to healthcare in rural and fically within rural areas. It has been estimated
urban areas are less, patterns of utilization still that 50% of rural persons with mental disorders
reflect tremendous inequity (Gesler & Ricketts, do not seek any help (Lee & Bowles, 1974). No
1992). Although rural residents are more likely doubt, numerous factors contribute to this
to suffer from chronic health problems and reluctance to seek assistance, but the fact is that
limited functional status, they are more likely to there are 1682 counties in the USA without any
be without a regular source of health care psychiatrists, psychologists, or social workers.
(Robert Wood Johnson Foundation, 1987). All of these counties are rural. Inpatient,
They are also less likely to see a physician, and outpatient, and partial hospitalization pro-
those without Medicaid or private insurance are grams are much less likely to be located in
the least likely to access health services. rural than urban areas. For example, only 13%
Inequities in health service utilization are of nonmetropolitan counties have psychiatric
further exacerbated among cultural and ethnic inpatient units (Wagenfeld et al., 1988). Many
minorities in rural areas. In the USA, rural poor rural residents do not qualify for Medicaid
African-Americans are twice as likely as Whites because they own land (the ªlanded poorº) and
to be without a regular source of healthcare they are more likely to be uninsured. It is
(Davis et al., 1987). Further, service access and unlikely that a market for private psychiatric
utilization for poor rural African-Americans in services will develop in rural communities in the
the south continue to lag even further behind near future. The evidence that rural persons are
service access in other geographical regions. more likely to be admitted to public mental
Some have suggested that lack of insurance and hospitals probably reflects the absence of
social isolation among these rural poor minor- alternative mental health services in rural areas.
ities contribute substantially to the absence of a In the USA, specialty mental health service
regular source of care (Lewin-Epstein, 1991). organizations have expanded rapidly since
Given these circumstances, it is even more 1980. Documented increases in service delivery
important to design interventions that take into would indicate that these agencies are providing
account the barriers to care, community important services to individuals with mental
residents' beliefs about illness, and help-seeking disorders. Unfortunately, rural areas most
patterns. frequently do not have access to adequate
mental health services or service providers.
10.11.5.2 Specialty Mental Health Services Therefore, rural individuals with mental dis-
orders are most likely to go without appropriate
In the USA most inpatient mental health care care. If they do access care, they do so later in
(43%) is provided by general hospitals, with the course of the illness, which results in
only 35% provided by state and county increased cost and length of treatment. Also,
hospitals (Narrow et al., 1993). Compared with because of the shortage of specialty mental
several decades ago, the total number of mental health providers in rural areas, they are more
health facilities has increased but the number of likely to access care provided by poorly trained
inpatient beds has decreased. Thus the average or more entry-level professionals. Further, rural
facility has downsized while the overall number residents are more likely to access care at a great
of facilities has increased. distance from their home community which can
Over the same period of time, downsizing and result in loss of work and a severing of
closing of state and county hospitals has been a community ties (National Association for Rural
well-documented change in the specialty mental Mental Health, 1993).
264 Mental Health in Rural Society

10.11.5.3 Public Policy lists, and voluntary services including self-help

groups, families, and friends.
Rural mental health is a field that has been Healthcare reform efforts have been directed
historically neglected both by researchers and toward extending access to health services for
policy makers, rendering the development of previously uninsured and undeserved persons
coordinated and empirically based services even while simultaneously controlling overall costs
more difficult (Fox, Blank, Kans, & Hargrove, for care. Rowland and Lyons (1989) demon-
1994). The economic realities of providing strated that a large number of rural, minority,
public rural mental health services also serves and poor persons are included in the under-
as an obstacle to implementing theory-driven served and uninsured population. In order for
service delivery systems. For example, despite public policy to change to improve efficacy and
frequent claims of the cost effectiveness of cost containment a better understanding of
model prevention and treatment programs, mental health needs, as well as current modes of
there are declining allocations for new research service access and utilization, are imperative.
in rural mental health. Further, most of the
funding of public services for community-
dwelling mentally ill persons currently flows 10.11.5.4 Empirical and Theoretical Basis for
from entitlement programs such as Medicaid Planning Services
which are administered at the state level. This
shift in the locus of authority from a federal to Rural mental health service delivery is
state operation of mental health services reduces frequently described as costly, inefficient, and/
the opportunities both for national initiatives as or ineffective (Aviram, 1990), although there is a
well as for more carefully tailored local efforts in paucity of data regarding cost, effectiveness, or
rural systems development (Hargrove & Mel- outcomes. There is no doubt that the ªboun-
ton, 1987). What is needed is an empirical base darylessnessº (Bachrach, 1983) of mental health
and the development of sound theoretical service delivery in rural areas care not only
models of health and illness in rural areas, requires management of psychiatric symptoms,
which can then develop into the deliberate but also frequently requires attention to
development and testing of interventions de- physical health and to long-term needs includ-
signed to fit within a rural social ecology. ing housing, transportation, and safety (Bige-
Continuing healthcare reform efforts have low, McFarland, & Olson, 1991).
emphasized a lack of health and mental health Presently, public care for rural mentally ill
services for rural poor and minority persons. consumers is unable to provide consistent and
This lack of services can be conceptualized as reliable service focused on the complex require-
including problems of availability, accessibility, ments of effective community care. The lack of
acceptability, and accountability (Blank et al., data regarding the distribution of providers and
1995). Service providers and health policy the characteristics, needs, and outcomes of rural
analysts are beginning to address how mental dwellers with regard to mental health services
healthcare needs are identified among rural makes planning for policy dependent on
poor and minority persons, and how healthcare idiosyncratic beliefs of powerful decision ma-
providers in existing rural healthcare sites kers. In rural areas, the increasing dependency
address these needs. The impact of inadequate upon local authority makes public mental
diagnosis and ineffective treatment of mental health policy even more dependent upon a
disorders on utilization patterns and costs of few individuals who may or may not be well
other types of healthcare for rural minority and informed (Blank et al., 1995). As a result, rural
poor persons needs further research. service delivery systems are more vulnerable to
Most rural persons with mental illness receive changing political forces (Fox et al., 1994).
services in the general medical sector of the In order to provide better service delivery
healthcare system and through other nonspeci- systems in rural areas and evaluate them, more
alty providers including social support networks consistent theoretical perspectives and more
rather than through formal mental health uniform standards of care are needed. Social
specialist services. This commonly existing loose isolation and greater geographic distances in
and fragmented collection of mental health rural environments contribute to the variability
services has been described as the ªde facto and inconsistency of service systems. Because of
mental health service system.º The de facto the lack of attention to rural areas by the
system includes specialty mental health services, scientific community as well as policy makers,
general medical services including primary care there is relatively little to guide practice in this
and nursing homes, other human service area. The emerging literature of rural mental
providers such as ministers and counselors health care is influenced by assumptions about
who are not principally mental health specia- the nature of human service delivery in rural
 Mental Health Services 265

contexts which are frequently contradictory and mutual help, congregations can perceive
(Murray & Keller, 1991). ownership of innovative programs which can
The importance of understanding the influ- reduce suspiciousness, fear, and stigma, and
ence of informal sources of care in rural areas increase participation.
cannot be overemphasized. Fox et al. (1994) Rural mental health services can also learn
have proposed a model for linkage of formal from work in developing countries. Susser,
and informal care-givers for mental health Schanzer, Varma, and Gittelman (1996) note
service provision among seriously mentally ill that in these countries the family often plays a
consumers in rural areas. This model is based on central role in the care of patients with mental
the Balance Theory of Coordination developed illness. It has been known that despite the lack
by Litwak and Meyer (1966) and is applied to of availability of hospital care, mental patients
service delivery systems in rural areas. Critical in developing countries have been found to
features of this model are the formation of suffer from less impairment and disability than
linkages between formal and informal care those in developed countries (Jablensky et al.,
providers which are characterized by neither too 1992). Susser et al. (1996) suggest that this
much social distance nor overly enmeshed apparent advantage is due to the involvement of
relationships, and the fit of task to structure. the family who are encouraged to understand
By testing the applicability of such a model to the mental health problem and to develop ways
rural case management services, it may be of coping with the patient's needs and demands.
possible to ascertain the factors necessary to With such a shortage of hospital care in rural
provide optimal care for seriously mentally ill areas, the potental involvement of the family in
persons who live in rural areas. patient care offers much promise.

10.11.5.5 Healthcare Reform 10.11.5.6 Primary Care

Rural persons are disadvantaged by services In both urban and rural settings most
that are almost exclusively conceptualized as individuals with mental health problems only
facility-based. Given the characteristics of rural receive care in the general medical care system.
populations and rural areas, the mental health The National Co-morbidity Survey reported
of rural communities may be better served by that of the 42% of people with psychiatric
outreach treatment modalities and the devel- problems who received professional help, only
opment of in-home services. That is, services 26% obtained help from mental health specia-
cannot and should not be limited to the confines lists (Rich, 1994). An overwhelming majority of
of a particular place, and need to utilize existing people with psychiatric problems are being
community structures better, and expand upon managed through the general health sector.
informal systems of care. Ironically, more Furthermore, persons with mental health
community-responsive models of service such problems make about twice as many visits to
as home-based services and smaller population- primary care providers as do primary care
specific clinics are emerging in urban areas patients without mental health problems
(clinics specifically for women, homosexuals, (Cleary, 1987). Approximately 22% of persons
minorities, etc.). However, perhaps owing to utilizing primary care suffer from a mental
more severe financial constraints in rural areas, health problem (Narrow et al., 1993). Despite
parallel specialty services are not being devel- considerable concern about the co-occurrence
oped in rural areas. In fact, Mermelstein and of mental illnesses or emotional dysfunction
Sundet (1988) found that rural community and physical illnesses in primary care popula-
mental health centers were less likely to create tions, there has been little consideration of the
new and innovative services during the rural impact of the separate health and mental
crisis in the 1980s. healthcare services for individuals accessing
Another important feature in planning rural primary care (Coulehan et al., 1990).
mental health service delivery systems is that Lack of integration of general medical and
frequently the entry points into the mental mental health services is an often cited barrier to
health system are existing rural organizations. more effective referral from primary care to
An increasingly frequent example of this is the mental health specialists (Kamerow, Pincus, &
use of churches in collaboration with mental MacDonald, 1986). Widespread concern has
health professionals in providing for their been expressed about primary care providers'
congregations (Pargament et al., 1991). lack of recognition, and treatment or referral of
Churches provide naturally occurring, conve- patients with mental disorders (Jones et al.,
nient gathering places for the surrounding 1987). Approximately one-third of primary care
community, and through true collaboration patients with psychiatric disorders remain
266 Mental Health in Rural Society

unidentified and untreated and almost 40% of Additionally, little is known about the delivery
persons receiving treatment for mental disor- of standard effective mental health treatments in
ders receive all their treatment through general different types of primary care sites or how these
medical services (Jones et al.). treatments are related to health outcomes. The
According to Morlock (1989), primary care absence of research on outcomes of mental
physicians record a primary or secondary health treatment in primary care contributes to
psychiatric diagnosis for only about 4.4% of general healthcare providers' reluctance to
patient visits despite a significantly higher incorporate mental health screening and treat-
prevalence of mental disorders in the primary ment more rigorously in primary care encoun-
care patient population. In a study of 1000 ters (Davenport, Goldberg, & Millar, 1987).
primary care patients, Spitzer et al. (1994) found In view of the greater availability of primary
that 26% of those primary care patients met full care physicians than specialists in rural areas
diagnostic criteria for mental disorder with an (Dor & Holahan, 1990), they have potentially
additional 13% meeting conditions for sub- an even more important role than their urban
threshold diagnosis. However, approximately counterparts to play in the care of patients with
half of those patients (48%) had not been mental health problems. Greater cooperation
recognized by their physicians as having a between psychologists and primary care physi-
diagnosis. It is alarming that despite healthcare cians will ensure a more accessible service for
reform efforts, no reports have been published people with mental health problems.
documenting the capacity of the general medical
sector to identify, treat, or refer minority or
poor persons for mental disorders. 10.11.5.7 Telemedicine
Limited attention to mental health training of
primary care providers, negative provider and Interest in telemedicine and communications
patient attitudes about mental illness, and technologies to improve health and mental
practice constraints have been highlighted as healthcare in rural areas has increased drama-
barriers to more effective mental health treat- tically since 1985. The introduction of tele-
ment and referral in primary care practice. medicine offers great potential to enable the
Numerous investigators and clinicians have patient/client to overcome the physical/geogra-
proposed that psychiatric diagnostic instru- phical barriers to accessing specialist healthcare
ments and psychiatric epidemiological research and to enable the health professional to
instruments (the American Psychiatric Associa- continue his or her education (Preston, Brown,
tion's Diagnostic and statistical manual of mental & Hartley, 1992).
disorders Diagnostic Interview Schedule) are Zelman (1995) has described a typology for
not appropriate for use in primary care sites and innovative technologies using POTS (Plain Old
there is a need for development of sensitive and Telephone Service) and PANS (Pretty Amazing
specific mental health screening instruments for New Stuff). The PANS consist of two-way
general healthcare sites (Spitzer et al., 1993). interactive televideo systems which typically
Other investigators highlight resistance of care utilize high-speed dedicated access (such as T1,
providers and patients in primary care sites to ISDN, or switched-56 lines), and are dependent
refer to or comply with recommended treatment upon sophisticated (and expensive) equipment.
of mental health problems identified through The US Office of Rural Health Policy has
screening. Little is known about which mental funded over a dozen demonstration projects for
health approaches may be more or less telemedicine since 1992, many of which include
culturally acceptable and thus promote com- mental health treatment as part of their goal. To
pliance in primary care patients needing mental date, there have been no mental health services
health services. research studies concerning the cost, effective-
There are few studies on the management of ness, or attitudes of consumers and providers
psychiatric conditions in primary care practices, toward innovative technologies. One study did
factors that influence care providers' decisions examine the reliability of assessments using this
about mental health interventions, and how and technology for persons with obsessive-compul-
why these decisions differ for patients of various sive disorder (OCD; Baer et al., 1995). These
cultural and ethnic backgrounds and geo- researchers concluded that standardized assess-
graphic regions. Service systems have histori- ments for OCD could be administered reliably
cally been resistant to providing integrated using interactive televideo systems.
health and mental health services. The stigma Mental health service delivery seems particu-
associated with mental illness and treatment of larly well suited for dissemination using two-
mental disorders has also been blamed for way interactive televideo systems. Unlike many
underdevelopment of mental health screening of the medical specialties, mental health services
and intervention in primary healthcare settings. need to be delivered in real time. Further, most
 Psychology and Rural Mental Health 267

assessments and treatments rely on the type of mental health center movement. The American
face-to-face interaction that is supported by Psychological Association (APA) demonstrated
these systems. Given that most of the diagnostic interest in the late 1980s with the appointment
information typically relied upon is visual and of a Rural Task Force to address the issues of
verbal, these systems hold great promise for psychologists practicing in rural communities.
extending our reach into underserved rural While psychologists had been involved in the
areas. rural mental health movement for a number of
There are several public policy pitfalls years, this was the first time that organized
awaiting telemedicine. Perhaps most obvious psychology devoted resources and gave recog-
is the question of whether services delivered nition to an important issue for many of its
through these media will be eligible for third members.
party reimbursement. It seems clear that health As one of the four core professions designated
services research will need to be conducted to by the National Institutes of Mental Health
determine the quality and effectiveness of (NIMH), psychologists were typically well
specific procedures such as diagnosis, other represented in the early mental health centers
assessment, and treatments delivered at a and continued until the system experienced
distance through new technologies. Another major structural changes in most states in the
difficult policy issue concerns licensure of health early 1980s. Prior to the development of these
professionals. Typically, licenses to practice are centers, mental health services were typically
issued by states, yet these televideo transmis- not available to rural residents, who had to rely
sions may frequently cross state lines. Recogni- on whatever types of assistance may have been
tion of state licensure in other jurisdictions available in communities from other agencies or
presents a number of legal and administrative professionals or travel to the nearest urban
problems. There are also concerns about centers.
practice liability and confidentiality of video
transmissions.
10.11.6.2 Roles of Psychologists in Rural
Communities
10.11.6 PSYCHOLOGY AND RURAL The roles of psychologists in rural mental
MENTAL HEALTH health programs have included provider of
clinical services, program and agency adminis-
10.11.6.1 Historical Background
trator, program evaluator, clinical supervisor,
The discipline and profession of psychology and program and service planner. From the
has played a variable role in the history of number and diversity of roles that psychologists
mental health services in the rural areas of the play in mental health agencies in rural settings,
North America. As a part of the community it is clear that psychologists must be able to
mental health centers movement in the USA in perform a wide range in a number of different
the early 1960s, psychology was by mandate aspects of the service delivery system. Berry and
integrally involved in the planning, develop- Davis (1978) pointed out that ªrural mental
ment, and implementation of services in the health workers must be a practitioner±
catchment areas. But a further, more refined generalist, able to handle a variety of problems
focus on rural services within that movement because the rural community cannot afford a
was left to various multidisciplinary groups and large selection of specialists or referral re-
psychology as a profession took little interest in sourcesº (p. 677).
rural communities or the rural context of the Keller and Prutsman (1982) argue that rural
practice of psychology. As Keller and Prutsman psychologists ªmust be flexible generalists who
(1982) pointed out: comfortably serve a wide range of human
needs.º They added:
Psychology has traditionally been an urban pro-
fession. Most psychologists are trained in, and In a time when much of psychology is becoming
subsequently remain in, large metropolitan areas highly specialized, the rural psychologists will need
or atypical university communities. Consequently, to fulfill a broad range of functions partially
psychologists have largely failed to consider the because there exists a lack of specialists and
special mental health needs of more than one- persons from other disciplines who are available
quarter of the nation's population. (p. 190) to meet unusual needs. (p. 1992)

Professional groups such as the Rural Social Hargrove and Howe (1981) identified the
Work Caucus and the National Association for generalist style as an objective of clinical
Rural Mental Health were active in the 1960s psychology training for rural service delivery.
and 1970s, typically as a part of the community Hargrove (1983) further refined the concept of
268 Mental Health in Rural Society

generalist for psychologists and identified the program for psychologists, social workers, and
various components of that style of practice in nurses working in rural mental health. The
the light of professional identity. development of the common curriculum (APA
When the role of generalist is interpreted Office of Rural Health, 1994) not only signaled
within the clinical domain of practice, the the increasing awareness of the need for training
psychologist must be able to call upon a broad materials for those working in this area but of
range of assessment and intervention strategies. the necessity for collaboration in training.
A doctoral-level psychologist may be required Unlike urban practitioners, rural health work-
to conduct assessments for school systems, ers in general find that there is less value in
courts, law enforcement agencies, social service maintaining strict lines of professional demar-
agencies, as well as for the mental health system. cation and more need for interprofessional
In addition to these uniquely psychological collaboration to overcome the inadequacy of
functions, the psychologist is also likely to be resources and the breadth of mental health
expected to do case management and other problems.
programmatic and clinical functions as needed. This common curriculum emphasized the
It has been noted that doctoral-level psychol- need for rural psychologists to consider: (i) the
ogists are likely to rise rapidly in the adminis- social, economic, political, and religious influ-
trative structure of programs and agencies. It ences affecting rural communities; (ii) the
was not infrequent in the early days of importance of ethnic and cultural influences
community mental health centers for doctoral- in rural communities and the importance of oral
level psychologists to become directors of tradition; and (iii) the uniqueness of each region
centers with responsibilities for recruitment, and community. This report also refers to the
personnel management, systems development, reluctance of rural residents to seek professional
fiscal operations, management information support, often turning instead to the clergy and
systems, contract negotiation, and board ad- family members in times of distress. Further, the
ministration in addition to the clinical and report reminds the psychologists to be reflexive
programmatic operations. in their practice and to recognize the impact of
The generalist concept, then, reached far their own culture on the delivery of care and on
beyond serving a broad range of clients with a their sensitivity to the client.
wide range of problems. It included involvement Several other issues are important for
in the internal administrative operations of the professional psychology's rural training agen-
agency, clinical and program management, and da. First is training for personal and family
community linkages. Few psychologists were adaptation to the rural environment. Fre-
trained to assume such a broad range of quently it is difficult to assist in the personal
responsibilities at such significant levels in the preparation of professional persons in academic
organizations. settings because of the limited scope of
traditional activities. Second is whether
doctoral-level psychologists are necessary for
10.11.6.3 Training Psychologists for Rural rural service delivery or whether persons with
Practice masters degrees are adequate for this work.
Jerrell and Herring (1983) studied psychologists
Psychology training has largely taken place in in 20 rural Pennsylvania counties and found
urban settings. The greatest contextual influ- that there was little difference in job function
ence on training, then, has been an urban one. between doctoral- and masters-level providers.
This created problems for psychologists who Doctoral persons were slightly more likely to
wished to work in rural settings because they did assume administrative roles. The entry-level
not have appropriate conceptual frameworks or credentials have been and continue to be a
experiences to successfully work there. controversial topic for organized professional
As this urban domination of training pro- psychology.
grams and models became known, the NIMH in Training for personal adaptation is a difficult
the 1980s began its focus on prioritized rural task under any circumstances; much less in an
populations, among others, for special attention academic context. Personal adaptation to the
in the funding of training programs in psychol- rural environment involves the individual and
ogy, psychiatry, social work, and nursing for intimate choices that are made by persons and
rural practice. Several university and free- families, including choices of living environ-
standing programs for psychological training ments, and the associations with friends. They
for rural practice developed in conjunction with also include the preferences and needs for
this initiative. certain types of resources. The unexpected
An important recent initiative has been taken characteristics and demands of the rural
by the APA to develop a common training environment, particularly when the new recruits
 Types of Intervention 269

are not accustomed to rural lifestyles, can be It has been argued, however, that since
devastating to individuals and families who are peoples' values determine how they interpret
not able to anticipate them. Even students who their experience, values also influence how they
have grown up in rural areas had difficulties define problems in mental health terms. This
assuming the role of a professional person while definition has an impact on their choice of
adapting to the lifestyle in the small community. whether and how individuals choose to seek
Personal and family adaptation to the rural help for problems (Wagenfeld & Wagenfeld,
community is essential if the psychologist is to 1981). Mazer (1976) adds that the values and
be successful. Training for this adaptation is definitions influence the expectations that
typically lacking in psychology training pro- people have when they seek assistance for
grams. Further, Murray (1990) recommends problems. The rural context is characterized by
that ªrural recruiters [should] seek people who certain attitudes that mitigate against seeking
really understand rural life and who value its assistance for psychological problems (Ba-
virtues and are not just intent on escaping urban chrach, 1977; Kenkel, 1986). An awareness of
irritantsº (p. 18). these characteristics and of the broader chan-
The second important training issue for ging social context within which people live and
psychologists is the level of training. Typically, work is essential for the effective delivery of
in North America, the doctoral degree is the psychological services.
entry credential. However, many states and The manner in which the intervention is
several Canadian provinces license persons with implemented also depends on the context in
masters degrees. Indeed, persons with masters which it occurs. Espousing the behavioral-
degrees in psychology have begun to demand ecological perspective, Jeger and Slotnick
parity with doctoral providers both in public (1982) point out that:
agency service as well as in independent
practice. Strong positions have been taken on individual-level community mental health inter-
both sides and the issue is far from settled. ventions should aim to provide learning opportu-
The importance for the rural area is that most nities to consumers that will increase their ability
human resource distribution studies show that to influence their environments (i.e., promote
doctoral providers are not practicing in rural competence). Behavioral training to facilitate
communities. Several investigators (e.g., Sladen coping with stress, developing social skills, and
improving general problem-solving capacities are
& Mozdzierz, 1989) have studied various compatible with this value. (p. 11)
aspects of the distribution of psychologists in
different parts of the country and typically
found a lack of doctoral providers. They document Rappaport's caution that:

competence should not become a substitute label

for psychotherapy, which maintains a hierarchical
10.11.7 TYPES OF INTERVENTION doctor±patient relation. Furthermore, experts
should not offer canned behavioral packages to
10.11.7.1 Fitting the Intervention to the Context teach specific skills under the guise of competence
training. Instead, the broader community context
The focus of the practice of psychology and within which competence training takes place must
other mental health professions in rural be considered, since the community provides the
communities has been on the alleviation of meaning system and values of what constitutes
the suffering of individuals and families who adaptive behavior.
live in relatively remote areas, removed from
the traditional resources associated with mental The person suffering from schizophrenia who
health services. Since no consistent types of has supportive family members in the immedi-
psychopathology have been reported to char- ate vicinity will be treated quite differently from
acterize rural people or rural environments, the transient person who appears in town from
there are also no consistently recommended unknown places. While the technology of the
types of interventions that are especially therapeutic intervention may not differ sub-
designed for people in rural settings. While stantially between rural and urban environ-
there have been attempts to identify ªrural- ments, the choices and application of
nessº as a trait of individuals who live in rural interventions are heavily influenced by the
environments (Flax, Wagenfeld, Ivens, & contexts in which they are applied. The rural
Weiss, 1979; Melton, 1983), and consistent psychologist must be aware of the changing
perceptions of the environment among rural family, social, and working life of rural com-
and urban people (Melton & Hargrove, 1987), munities and especially attuned to the impact of
no reliable support for such constructs has been ongoing social crises. The person who loses his
found. farm that has been in his family for generations
270 Mental Health in Rural Society

and that provides a livelihood for an extended 10.11.7.3 The Concept of Community and
family needs to be approached differently from Psychological Intervention
a person who loses his job in a context of
expanding urban opportunity. It has been suggested that the best psycho-
logical interventions are not in the clinic, but in
the community. The concept of ªcommunityº is
10.11.7.2 The Rural Psychologist as a deeply embedded in the sense of ruralness both
Generalist in definitional as well as experiential terms.
Psychologists, like most mental health work- Virtually all definitions of rural contain refer-
ers, must function as generalists within the rural ences to small communities of people that are
context (Hargrove, 1983, Keller & Prutsman, some distance from other people. The idea of
1982). The demand of the generalist role ruralness is not limited to the population base of
counters the tendency toward specialization small communities, but is applicable to the
that characterizes the training and development experience of small communities with their
of professional psychologists. Generalist prac- limited populations and greater knowledge of
tice requires the psychologist to be skillful in a each other's affairs (see Section 10.11.4.3).
broad range of psychological functions with an Bell and Newby's (1972) use of Tonnies'
even broader range of potential clients. concepts of Gemeinschaft and Gesellschaft
The mental health system in the rural context provides a model for a general understanding
is characterized by few professionally trained of the rural community. Gemeinschaft is
practitioners who are separated from one described in terms of the intimacy of relation-
another by either long distances or natural ships, kinship, and one's place in the social and
barriers, or both (Hargrove, 1982). There are community structure. The terms ªblood,º ªkin-
fewer potential clients in the community and ship,º and ªfriendshipº are used to characterize
they will probably reside and work at great this concept of community. Gesellschaft, on the
distances from the providers. In most cases, the other hand, represents large, depersonalized
public delivery system, whether an outpost of a communities in which relationships might best
larger community mental health program or a be categorized as contractual. Gemeinschaft is
specialized mental health unit of a health closer to the traditional rural community in
department, is responsible for the delivery of which the rural mental health worker may be
care. There are relatively few doctoral psychol- located.
ogists who practice privately in rural areas. Heyman (1982), noting the lack of models for
Furthermore, there are relatively few practi- rural service delivery and the dominance of
tioners in other mental health or mental health- urban models for training and service, suggested
related professions in rural areas. that there was some freedom in the lack of
The result of this scarcity is that those constraints of rural practice:
providers who are available in the rural
community must be able to respond to the Every rural worker must deal with the absence of a
ªgeneralº model by developing situation-specific
mental health needs that present themselves. models. There may be similarities in the imple-
Since there are no data to indicate that rural mentation of these models, but the dissimilarities,
environments are exempt from the broad range in response to the varying situations, are likely to
of mental disorders, it is reasonable to assume be critical to their actual functioning. The absence
that rural mental health providers will probably of a model provides a freedom and flexibility that
encounter most, if not all, of the major mental complements the unique nature of each commu-
disorders at one time or another. It is not likely, nity. (p. 36)
on the other hand, that they will encounter them
in great numbers. Heyman points out the opportunities for rural
This characteristic has several consequences. service that are grounded in the Gemeinschaft
First, the mental health providers in rural areas orientation to community. They include visibi-
must be prepared to respond to the broad range lity within the community and access to various
of mental disorders without a significant dimensions of the community, including those
amount of collateral professional resources in which power is embedded.
and support. Second, these providers must Psychological and social intervention are
respond to needs without the benefit of being conducted within these contexts of social
able to aggregate the clientele in either clinically intimacy and knowledge. They are also carried
or economically beneficial ways. Finally, pro- out within the context of a high level of visibility
viders must be at least familiar with a broad and access. Clearly, there are both positive and
range of mental, emotional, and behavioral negative consequences of these features. First,
disabilities to be responsive to the needs of the the results of one's work is available and known
population that they serve. throughout the community. Clinical failures as
 Types of Intervention 271

well as successes may well be common knowl- health needs of people in rural areas and small
edge and may be topics of discussion in both towns.
personal and professional circles. Second, the An example of an initiative in community
mental health worker may well have access to mental health service delivery was the Com-
people and resources to bring to bear healing munity Support Program (CSP) developed by
forces that otherwise may be unavailable. Third, the NIMH in the USA (Turner & TenHoor,
common knowledge of people, families, and 1978). The CSP, which has been successfully
groups within communities may be useful in applied in rural settings, has a number of
programmatic and clinical activities. components including building social support
While Heyman (1982) certainly advocates for the client. A similar program developed by
intense involvement of the rural mental health the New York State Office of Mental Health
worker in the community in which he or she (Baker & Intagliata, 1984) also placed emphasis
lives and/or practices, he acknowledges that this on developing opportunities for work and social
involvement must be a cautious one. He calls interaction, competency skills training, social
upon the participant±observer model as one clusters, evening, and outreach programs, and
that would be satisfactory. Precaution must be so on.
taken to be involved in a broad, flexible way, Comprehensive psychological intervention
active but not over involved and certainly not in requires going beyond the traditional clinical
a polarizing manner. treatment approach to consider prevention and
Psychologists and other mental health work- rehabilitation. In the rural context this requires
ers who work in rural settings do not have the that the psychologist not only be prepared for
luxury of limiting their perspectives of inter- crisis intervention in the face of both personal
vention to face-to-face contact between clients and social crises but also to intervene to prepare
and clinicians. Some of the characteristics of and enhance people's resources to deal with and
rural environments preclude reliance on clinical to combat such assaults on their way of life (see
service delivery as the only means of providing Trainor, Pope, & Pomeroy, 1997).
mental health care to the population. Distances,
for example, prevent people from being able to
meet at frequent intervals. The infrequency of 10.11.7.4 Ethical Dilemmas in Rural Practice
the occurrence of similar types of psychopathol-
ogy, sometimes the criterion for grouping When the expectations of professional help-
consumers into group-oriented treatment pro- ers encounter the intimacy and complexity of
grams, prevents the use of these types of relationships that customarily exist in a rural
intervention strategies. community, the fabric of professional practice
As a result of these characteristics, rural is strained. This is particularly true in the
mental health service providers, researchers, ethical guidelines that govern the conduct of
and administrators have utilized strategies of practice of most mental health providers. The
prevention and collaboration with other agen- emerging literature on ethical complexities in
cies and indigenous groups to enhance the rural mental health practice (Hargrove, 1986)
quality of care available in the rural environ- has identified three problematic areas. These
ments. D'Augelli and Vallance (1981) reported are dual relationships, limits of competence,
on the Community Helpers Project in which and confidentiality.
local residents were trained in basic helping Small communities have a finite number of
skills who, in turn, trained others to provide people and potential relationships. Further,
informal help to persons in crisis. Libertoff people relate to one another on various levels
(1980) presented a case study in which the and in various domains of the community. For
informal system of care of a small New England example, the physician may be an elder in the
community was utilized in developing youth church, on the school board, and a director on
and family services. Bergstrom (1982) summar- the local bank's board. This places the psychol-
ized the research and made recommendations ogist in a special relationship to other members
for collaboration with natural helpers for rural of the church, the minister and family, teachers
mental health service delivery. and administrators of the school system, and
A number of programs that utilize para- employees and customers of the bank. These
professionals have been described (e.g., Con- relationships give the character of the therapist±
nors & Gabel, 1983; D'Augelli, 1982; D'Augelli client relationship a special personal quality
& Vallance, 1981; Echterling, 1981; Heyman, that can potentially be compromised if con-
1982; Sundberg, 1986) These programs typically siderable caution is not taken.
involve mental health professionals training Many people play many roles in rural
paraprofessionals, collateral workers, and in- communities. Therefore many people are in-
digenous persons to be responsible to the mental volved with several, different aspects of each
272 Mental Health in Rural Society

others' lives. The prohibition against dual Three areas appear to characterize the
relationships contained in the ethical codes of immediate future in the profession and disci-
mental health professionals presents potentially pline of psychology as it might appear in rural
difficult constraints on the professional and America. First, the tendencies toward behavior-
personal lives of rural practitioners. al health and, in some venues, becoming a
The second problematic area consists of limits primary care provider have expanded the roles
of competence. The mental health professional of psychologists beyond that of mental health
is in a difficult situation when he or she is the provider. The development of the family
only practitioner in a community and does not psychology specialty and the harmonious
have requisite skills to handle certain clinical relationships with family physicians have given
problems. Many problems of course are so far psychologists new perspectives of research,
outside the practitioner's competence that there training, and practice.
is no question but that a referral must be made. Second, the development of collaborative
The need for neuropsychological assessment or relationships with other professionals and with
rehabilitation is clearly outside the competence nonprofessionals and indigenous workers char-
of the average, clinically trained psychologist. acterizes the work of psychologists in rural
But, as specialties develop and techniques are settings. Collaboration is a relative newcomer to
refined, it is frequently difficult for the general the psychology lexicon, but the complexity of
practitioner to know whether the practice is the contexts in which psychologists practice
within the limits of competence. requires functional reciprocity. Fox et al. (1994)
Third, confidentiality may be problematic have provided a theoretical framework for
because of the high level of visibility and coordinating rural mental health services based
intimacy that is characteristic of rural com- on Litwak's Balance Theory of Coordination
munities. Certain professional relationships and have provided guidelines for collaboration
may carry the expectation of information with at least one population of providers.
exchange regardless of whether releases of Finally, in the USA managed care is oozing
information have been executed. The physi- into rural areas at a slower pace than it has
cian, for example, who refers a patient to the flowed into urban and suburban. There appear
mental health center may expect a report from to be several reasons for this. First, there are
the center on the progress of the patient. The fewer providers in rural areas. Second, the
release of information, a necessary formality, market is considerably smaller. Third, provision
may not be important to this physician because of adequate health and mental health services is
of the history of practice and involvement with considerably more difficult in rural areas. It is
people in the community. If the release is not not clear how managed care companies will
signed and the mental health professional respond to the health and mental health
refuses to report to the physician, the political problems of rural environments.
and community consequences could be quite
problematic.
The high levels of visibility and access of 10.11.9 SUMMARY
mental health professionals in the rural com-
munity require certain precautions and pre- Rural society represents a large, although
ventive measures to avoid unnecessary ethical neglected, part of North American society. It is
conflicts. Typically, frank and open discussion extremely diverse in its makeup. However, one
with clients in the clinical setting about consistent pattern is poverty and aging. Ad-
boundaries and suggested courses of action if mittedly, there are certain pockets of wealth, but
and when awkward situations develop is overall rural society is deprived with reference to
sufficient to avoid difficult situations. urban society. The character of rural society is
changing from one of full employment based on
exploitation of natural resources to one of
10.11.8 FUTURE DIRECTIONS underemployment and greater employment in
service and manufacturing industries. As a
Rural America is changing, and for a large consequence, social and working life in rural
number of its residents the future is not bright. America is undergoing dramatic change. For-
There is an urgent need for the careful merly it was a cohesive and supportive society
development of mental health services to but now there is less evidence of social cohesion.
address the many problems faced by rural In view of the diversity and changing
people. The discipline of psychology is also character of rural society it is not surprising
changing, embracing a broader range of that it is difficult to identify some consistent
activities but also continuing toward increased patterns of health. However, it is apparent that
specialization. there is a considerably lower degree of provision
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lowered degree of availability is coupled with J., & Coyle, J. T. (1995). Pilot studies of telemedicine for
patients with obsessive-compulsive disorder. American
difficulties in accessibility. There have been Journal of Psychiatry, 152, 1383±1385.
some limited initiatives in community mental Baker, F., & Intagliata, J. (1984). Rural community
health services but there is a need not only for support services for the chronically mentally ill. Journal
more resources but also for careful planning and of Rural Community Psychology, 5, 3±14.
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 Copyright © 1998 Elsevier Science Ltd. All rights reserved.

10.12
Objective Personality
Assessment: Computer-based
Minnesota Multiphasic
Personality Inventory-2
Interpretation in International
Clinical Settings
JAMES N. BUTCHER
University of Minnesota, Minneapolis, MN, USA
ELLEN BERAH
Monash Medical Centre, Clayton, Vic, Australia
BJORN ELLERTSEN
University of Bergen, Norway
PATRICIA MIACH
Monash Medical Centre, Clayton, Vic, Australia
JEEYOUNG LIM
Samsung Group, Jeongdun-Maul, Sungnam-City, South Korea
ELAHE NEZAMI
USC/IPR, Los Angeles, CA, USA
PAOLO PANCHERI
5a Cattedra di Clinica Psichiatrica, Rome, Italy
JAN DERKSEN
University of Nijmegen, The Netherlands
and

277
278 Objective Personality Assessment

MOSHE ALMAGOR
University of Haifa, Israel

10.12.1 INTRODUCTION 278

10.12.1.1 Cultural Factors in Mental Health Assessment 279
10.12.1.2 Application of Psychological Tests Across Cultural Boundaries 279
10.12.1.3 Development of Automated Interpretive Strategies for Objective Personality Tests 280
10.12.2 EVALUATION OF COMPUTER-BASED MMPI-2 REPORTS IN INTERNATIONAL CONTEXTS:
RESULTS FROM AUSTRALIA, FRANCE, NORWAY, AND THE USA 280
10.12.2.1 The Research Protocol 280
10.12.2.2 General Testing Procedures 280
10.12.2.3 Clinical Rating Procedures 281
10.12.2.4 The Test Sites 281
10.12.2.4.1 Australian clinical sample 281
10.12.2.4.2 French clinical sample 281
10.12.2.4.3 Norwegian clinical sample 282
10.12.2.4.4 US clinical sample 282
10.12.2.5 Results of the Studies 282
10.12.2.5.1 Validity considerations 282
10.12.2.5.2 Symptomatic pattern 283
10.12.2.5.3 Interpersonal relations 283
10.12.2.5.4 Diagnostic considerations 288
10.12.2.5.5 Treatment considerations 288
10.12.2.5.6 Overall accuracy 289
10.12.2.6 Discussion of Overall Accuracy 289
10.12.2.7 Limitations of this Research 290
10.12.3 CASES 290
10.12.3.1 Nijmegen, The Netherlands: The Case of Susan 290
10.12.3.1.1 The Minnesota Report on Susan 292
10.12.3.1.2 Comment 294
10.12.3.1.3 DSM-IV classification 294
10.12.3.1.4 Treatment 294
10.12.3.2 Rome, Italy: The Case of Mario P. 294
10.12.3.2.1 The Minnesota Report on Mario P. 295
10.12.3.2.2 Comment 298
10.12.3.2.3 Treatment 298
10.12.3.3 Iran, United States: The Case of Ms. B. 298
10.12.3.3.1 The Minnesota Report on Ms. B. 300
10.12.3.3.2 Diagnostic impression 302
10.12.3.3.3 Treatment 302
10.12.3.4 Seoul, Korea: The Case of Kim 302
10.12.3.4.1 Family history 303
10.12.3.4.2 Behavioral observations 303
10.12.3.4.3 Symptomatic behavior 303
10.12.3.4.4 The Minnesota Report on Kim 303
10.12.3.4.5 Diagnosis 306
10.12.3.5 Haifa, Israel: The Case of Yuri Z. 306
10.12.3.5.1 The Minnesota Report on Yuri Z. 307
10.12.3.5.2 Treatment 310
10.12.3.6 Cross-national Generality of Psychopathology: What We Have Learned from the Cases 310
10.12.4 FUTURE DIRECTIONS 310
10.12.5 SUMMARY 311
10.12.6 REFERENCES 311

10.12.1 INTRODUCTION The rapidly increasing use of Western-derived

clinical tests results from several factors includ-
The use of psychological testing in clinical ing: the expansion of available mental health
assessment situations has been expanding from services in many countries since the mid-1980s,
its origins within Europe and the USA to the growth in the number of assessment-trained
numerous other countries around the world. psychologists in other countries, an increased
 Introduction 279

recognition that psychological assessment can course, and so forth, are relatively stable if not
provide valuable information in mental health universal across cultures.
contacts, and as a result of increased profes-
sional communication through international 10.12.1.2 Application of Psychological Tests
congresses. Many psychologists have become Across Cultural Boundaries
aware of the effectiveness of psychological tests
in countries like the USA and have adapted The use of clinical personality tests across
these procedures for use in their own countries. cultures has a history dating back to the 1920s.
Can psychological assessment and clinical There were several early studies devoted to
diagnostic procedures developed in one lan- exploring the generalizability of psychoanalytic
guage and culture be readily adapted and test constructs across cultures by administering
applied in another? Do stimuli employed in the Rorschach test to individuals from different
objective personality tests, such as the items in cultural backgrounds and comparing their
the most widely used clinical measure, the responses to those of Westerners (see Adcock
Minnesota Multiphasic Personality Inventory & Richie, 1958). The use of the Rorschach in
(MMPI-2), transcend the gulf of language and anthropological research was, however, replete
culture and apply effectively in different cultural with problems and this approach had pretty well
contexts? Do psychological tests that are run its course by the late 1950s. Lindzey (1958)
translated into other languages require special discussed the problems of the projective method
test development methods? Can norms from in cross-cultural research and summarized these
one culture be ªtransplantedº to another? These difficulties.
questions have been addressed extensively in the The overall use of psychological tests across
cross-cultural testing literature and are briefly cultural boundaries was, however, not de-
summarized below (Butcher, 1996; Kazarian & creased by any means. In fact, the practical
Evans, in press; Lonner & Berry, 1986). use of translated and adapted personality tests
was only beginning. The 1950s and 1960s
10.12.1.1 Cultural Factors in Mental Health witnessed a number of projects to translate
Assessment and adapt objective personality instruments
across cultures, not for the purposes of
Although language and customs, as reflected anthropological study, but for the emphatically
in familial and social practices, vary between practical aim of making clinical decisions in a
countries, there are also many common fea- more objective manner than was currently
tures. Psychological disorders appear to be available.
generally comparable across different cultures One of the most widely employed and
and, although there have reportedly been some internationally adapted personality inventories
ªexoticº or culture-specific conditions (Yap, used in clinical assessment has been the MMPI,
1951), many commonalities exist with similar which was subjected to a number of early
symptoms and common manifestations across translations, including Italian (Reda, (1948),
diverse groups. For example, schizophrenia Japanese (Abe, (1955), and German (Sundberg,
appears to occur in all known cultures and 1956). In the years that followed, over 150
societies through history (where records permit translations of the MMPI were developed and
comparison) although the symptoms may vary the inventory came to be widely employed in
somewhat and rates may differ (Butcher, over 46 countries (see Cheung & Song, 1989;
Narikiyo, & Bemis-Vitousek, 1992). Cheung, Song, & Butcher, 1991; Cheung, Zhao,
Commonalities across cultures in mental & Wu, 1992; Kim, 1988; Risetti, Himmel,
disorder have allowed for the development of Maltes, & Gonzalez, 1989; Strassberg, Clutton,
the international classification of mental dis- & Korboot, 1991; Strassberg, Tilley, Bristone,
orders (World Health Organization, 1992) & Tian, 1992; Zou & Zhao, 1992). In 1976,
referred to as ICD-10 (the most up-to-date Butcher and Pancheri published an interna-
version). The ICD-10 diagnostic system paral- tional handbook on using the MMPI across
lels the diagnostic system developed in the USA, cultures that described model translation pro-
the Diagnostic and statistical manual of mental jects, provided substantial psychometric
disorders (4th ed.); DSM-IV), which is also in equivalence data, and illustrated clinical valida-
wide use in several other countries. Many tion efforts in international contexts.
psychiatrists employ DSM-IV instead of ICD- With the redevelopment of the MMPI and
10. The very existence of a common language the publication of MMPI-2 in 1989, a new wave
for describing these psychological disorders and of test translation projects was initiated. A
their apparent relevance around the world number of recent studies have explored the use
suggests that the elements of mental disorders, of the MMPI-2 in other cultures and a broad
that is, the symptoms, features, established collection of clinical researchers, from several
280 Objective Personality Assessment

different countries, have described their trans- Association [APA] 1986; Butcher, 1987; Eyde,
lation and adaptation research efforts and Kowal, & Fishburne, 1991; Fowler, 1969;
highlighted clinical usage in a compendium of Ziskin, 1981).
papers (Butcher, 1996). This international With computerized test interpretation pro-
handbook includes three chapters on test grams for the MMPI/MMPI-2 becoming widely
translation methods and recommended proce- available for clinical use in the USA (Butcher,
dures for evaluating translation equivalence. 1995), psychologists in other countries also
Central to using the MMPI-2 in cross-national began to explore computer-derived personality
settings is the establishment of sound transla- assessments (Fowler & Butcher, 1987; Gillet
tion of the items into the target language and et al., 1996; Pancheri & Biondi, 1987; Pancheri,
culture and demonstration of test equivalence, Sirigatti, & Biondi, 1996). An early study of the
but the core of the volume is 56 contributions utility of a computer-based report (Roche
from psychologists and psychiatrists from Psychiatric Service Institute) on the original
around the world. version of the MMPI in Australia produced
promising results (Fowler, 1978). More re-
10.12.1.3 Development of Automated cently, research has confirmed that computer-
Interpretive Strategies for Objective based MMPI-2 reports provided accurate and
Personality Tests useful information when applied with Austra-
lian psychiatric patients (Berah et al., 1993;
Progress in civilization has often involved the Berah, Miach, & Butcher, 1995).
evolution of labor-saving techniques or inven- In this chapter we explore the objective use of
tions that free human beings from routine or psychological tests in cross-cultural settings in
laborious tasks. Assessment psychologists have two ways. We describe an empirical evaluation
long been interested in the use of automated or of the generalizability and accuracy of
mechanical methods for assisting in the routine computer-derived MMPI-2 reports describing
and often onerous task of scoring and proces- the symptoms and behavior of patients in four
sing responses to psychological tests. Mechan- countriesÐAustralia, France, Norway, and the
ical test-scoring devices have been employed in USA. This discussion will be followed by several
psychology since the 1940s, and in the 1950s, case examples from other countries.
mainframe computers were first used to process
large batches of test protocols quickly and 10.12.2 EVALUATION OF COMPUTER-
accurately. BASED MMPI-2 REPORTS IN
Paralleling this technical effort to develop INTERNATIONAL CONTEXTS:
more efficient data-processing techniques came RESULTS FROM AUSTRALIA,
conceptual progress into methods of making FRANCE, NORWAY, AND THE
clinical decisions more objective. With several USA
publications by Meehl (1954, 1956) and his
followers (Gilberstadt & Duker, 1965; Hal- 10.12.2.1 The Research Protocol
bower, 1955; Marks, Seeman, & Haller, 1974)
the automatic interpretation of one test, the The research design for this project was
MMPI by mechanically combining established similar in all four countries. Clinicians who were
test correlates, received broad attention. The evaluating their patients administered the
MMPI, being an instrument that was developed MMPI-2 to each client using a booklet format.
according to an empirical scale-validation The appropriate language version was used in
approach, had acquired by 1960 a very each country. A broad range of clients were
substantial research base supporting the inter- tested in a variety of settings: inpatient, out-
pretation of scales and combinations of scales patient, court-ordered, neuropsychological, and
(profile codetypes). In the 1960s psychologists gender reassignment assessment. No effort was
began to experiment with the actual interpreta- made to obtain homogeneous research groups
tion of psychological test scores using compu- but to simply evaluate any available patients
ters. The first of these approaches, an MMPI being assessed in an ongoing process, so that the
computer interpretation program developed at psychologist would have sufficient information
the Mayo Clinic in Rochester, Minnesota, about the patient to be able to rate the adequacy
demonstrated the effectiveness and accuracy of the computer-based report.
of objective interpretation with the computer
(Rome et al., 1962). Computer test interpreta- 10.12.2.2 General Testing Procedures
tion programs have evolved substantially over
the succeeding decades and have become an The MMPI-2 testing was conducted by
accepted strategy for interpreting psychological psychologists who were seeing the patients for
tests in the USA (American Psychological clinical evaluations or psychological treatment.
 Evaluation of Computer-based MMPI-2 Reports in International Contexts 281

Following an explanation to the patient of the accuracy of the narrative report in describing
reasons for the assessment, testing took place in the behavior and symptoms of the client and to
individual sessions using standardized test complete the Rating Form.
instructions. Softcover booklet format was
used, with patients completing the test at a 10.12.2.4 The Test Sites
private table under supervision in the psycho-
10.12.2.4.1 Australian clinical sample
logist's office. The MMPI-2 was usually
administered in one long session but, depending The Australian patients were clients in the
on the needs of the particular patients, it was Adult Psychiatry Service of Monash Medical
occasionally administered in two or three Centre, Melbourne, Australia, a 700-bed gen-
shorter sessions. When there was any doubt eral hospital affiliated to Monash University.
about a patient's reading ability, a test to help The Adult Psychiatry Service provides treat-
determine reading comprehension was usually ment for patients from its local and regional
first administered. The completed MMPI-2 communities, from other services of the hospital
answer sheets and relevant demographic in- and, for its specialist programs, from the wider
formation were sent to James Butcher in community. It has a 36-bed inpatient unit which
Minneapolis, Minnesota for scoring and data admits informal and involuntary patients,
processing. The item responses of each patient several community clinics, a mobile community
were key-entered or optically scanned to a treatment team, and extensive consultation±
computer disk and scored by personal compu- liaison services to the divisions of obstetrics and
ter. The Minnesota Report, a computer-based gynecology, medicine and surgery. Specialist
narrative interpretation program (Butcher, inpatient and outpatient assessment and treat-
1993), was generated by microcomputer. (It is ment programs are provided through the eating
important to note that the American norms disorders and the mothers and babies clinics. A
were used in all of the countries to compare the specialist gender dysphoria clinic, the only such
cases.) The computer report printout was sent clinic in Australia, accepts referrals from the
back to the test location for the next phase of the whole country for assessment of gender dys-
project: the ratings of report adequacy. phoria and admission to the program for sexual
reassignment surgery. The Adult Psychiatry
10.12.2.3 Clinical Rating Procedures Service works on a multidisciplinary basis with
a staff of 11 clinical psychologists.
Ratings were completed by the same psy- Patients were referred to the Adult Psychol-
chologists who were seeing the patients in the ogy Section by their consultant psychiatrist for
context of psychological evaluation or therapy psychological assessment to help in differential
at the time of the study. The Rating Form diagnosis and treatment planning in the early
required the following information on each stage of admission or outpatient presentation.
report: Patient Information (gender, age, edu- The two exceptions to this were patients from
cation, marital status, clinical setting, and the eating disorders and the gender dysphoria
clinician's hours spent with the patient); Rater clinics who are routinely administered the
Information (degree, profession, years of ex- MMPI-2. The patients (N = 167) included 67
perience); Report Rating (the validity consid- men and 100 women with an age range of 16 to
erations, symptomatic pattern, interpersonal 75; 94 were being evaluated as outpatients, 69
relations, diagnostic considerations, and treat- were inpatients, and four were from other
ment considerations sections of each report settings. The clinical diagnoses of the patients
were each rated as providing ªinsufficient,º covered a broad range of problems. The amount
ªsome,º ªadequate,º ªmore than adequateº or of time the clinician-raters spent with patients is
ªextensiveº information. Raters also indicated an important consideration in the study. Nearly
the percentage of statements in the report they all patients (97%) had been seen by the
considered to be accurate descriptions of the psychologist for three or more hours and half
patient, using the categories of less than 20, had been seen for five or more hours. The
20±39, 40±59, 60±79, or 80±100%). Finally, amount of contact between raters and patients,
open-ended questions were asked for sympto- in all likelihood, provided raters with sufficient
matic and diagnostic information, and for ways knowledge of the patients' problems and
in which the report could have been improved. symptoms to be an appropriate source of
The raters participating in the evaluation external information about the patients.
program were clinicians who were seeing the
patient in the professional diagnostic context or
10.12.2.4.2 French clinical sample
for therapy at the time of the study. Each rater
was given a copy of the computer report output The French clinical study involved testing 100
and asked to evaluate the adequacy and patients (54 inpatients and 46 outpatients) in
282 Objective Personality Assessment

two specialized psychiatric departments in from diverse clinical settings (including inde-
Paris: the Clinique des Maladies Mentales et pendent practice, mental health clinics, hospital
de l'EnceÂphale (CMMD), which is part of the practice, court setting, and so forth) were asked
HoÃpital Sainte Anne, and the HoÃpital Inter- to rate their patients on a number of personality
national de l'Universite de Paris (see Gillet and symptom variables. They were also pro-
et al., 1996). The test was administered using vided with a copy of the Minnesota Report
the French language MMPI-2 booklet. A total derived from the patient's responses to the
of 22 mental health specialists, all of them MMPI-2. The therapists had a broad range of
psychiatrists, evaluated the 100 computerized backgrounds, although the majority had PhDs
reports. Their clinical experience varied as (46%) or PsyDs (20.5%) or MAs (23%) in
follows: 33 reports were analyzed by five psychology; 50% of these were trained in
practitioners with 4±6 years of experience in clinical and 23% in counseling psychology,
psychiatry, 33 reports were analyzed by 10 and 2.3% were trained in social work. Finally,
practitioners with 7±10 years' experience, and 63.6% considered themselves cognitive-beha-
33 reports were analyzed by 10 practitioners vioral; 11.4% were behavioral; 31.8% were
with more than 10 years' experience. The time psychodynamic; and 6.5% were client-centered.
spent with each patient varied from two to six The mean number of years the therapists had
hours (or more). Demographic data for the been conducting a practice in psychotherapy
population studied include the following: four was 11.5 years.
patients were between the ages of 18 and 19
years; 71 patients were between the ages of 20
and 40 years; 22 patients were between the age 10.12.2.5 Results of the Studies
of 41 and 60 years; and three patients were
older than 60 years. The number of years of The results of the four projects will be
schooling for the sample was as follows: 21 reported for each section of the Minnesota
patients had less than 10 years; 26 patients had Report. For example, under the heading
between 10 and 12 years; 23 patients had ªValidity considerationsº the findings from
between 13 and 14 years; and 30 patients had 15 each country will be presented. In addition,
years or more. the results from the four countries will be shown
in graphic form to give the reader a visual
comparison of the summaries of the clinicians'
10.12.2.4.3 Norwegian clinical sample ratings in each country.
The Norwegian study involved 99 valid
patient protocols. Among these, 60 patients 10.12.2.5.1 Validity considerations
were in psychotherapy (outpatients), eight were
psychiatric inpatients, 10 were medical (neurol- (i) Australia
ogy) inpatients, nine were substance abuse Valid, interpretable profiles were produced
inpatients and 10 were in counseling settings. by 95% of the sample (N = 59). While the
A total of 10 clinicians with PhDs, situated in validity considerations sections of the compu-
different counties covering all parts of Norway, terized reports were provided and rated for all
evaluated the protocols. Nine of these clinicians patients, the remaining sections of the reports
evaluated 10 protocols whereas one evaluated were unavailable for patients with invalid
nine protocols. Among the clinicians, nine had profiles. Over 90% of the computer-based
more than four years of clinical experience reports were rated as providing adequate-to-
whereas one had three years. The time spent extensive information in their appraisal of
with the patients being evaluated was more than patients' approach to the testing (Figure 1);
six hours in 75% of the cases, five or six hours in fewer than 5% of the reports were considered to
10%, three or four hours in 8% and two hours in have insufficient information about protocol
7%. The clinical sample consisted of 56 males validity.
(mean age 35, range 10±62) and 43 females
(mean age 35, range 18±58).
(ii) France
Of the 100 MMPI-2s completed, only 17
10.12.2.4.4 US clinical sample
profiles were found to be invalid and were not
The patients included in the US study were included in the study. Of these 17 invalid
263 people who were being evaluated using the MMPI-2 inventories, 11 of the patients had been
Minnesota Report in the Minnesota Psy- diagnosed as psychotic, three had personality
chotherapy Project (Butcher, 1996). A total of disorders, one was suffering from an eating
44 psychotherapists from several states and disorder, another from an affective disorder,
 Evaluation of Computer-based MMPI-2 Reports in International Contexts 283

and the last from a mixed disorder (Axis I and (iv) USA
Axis II on the DSM-III-R). The raters evaluated
Only 1.5% of the Minnesota Reports were
83 profiles, from 25 males and 58 females. Only
considered to provide insufficient information
13.3% of the cases were thought to provide
on the symptomatic pattern section of the
insufficient information; 61.3% were viewed as
report. On the other hand, 89.5% of the
adequate, more than adequate, or as providing
Minnesota Reports were rated as having
extensive information (Gillet et al., 1996;
adequate (39.7%), more than adequate (31%)
Figure 2).
or extensive information (17.6%) (Figure 4).
These findings are consistent with the results
(iii) Norway of other studies of the generalizability of
MMPI-2 descriptors to patients in other coun-
All of the Norwegian sample produced valid,
tries (Butcher & Pancheri, 1976; Manos, 1984;
interpretable profiles. Clinicians evaluating the
Savasir & Erol, 1990) and provide support
assessment adequacy of the Minnesota Report
for the general clinical impression reported
validity in appraising their patient's approach to
by the raters that the MMPI-2 correlates can
the testing rated the reports as providing
be confidently applied to patients in other
adequate-to-extensive information (82.8%).
countries.
Only 4% of the reports rated were considered
to have insufficient information about the
patient (Figure 3).
10.12.2.5.3 Interpersonal relations
(iv) USA
(i) Australia
Fewer than 1% of the reports were considered
to provide insufficient information, and 92% of Of the reports, 78% were considered to
the reports were considered to provide adequate provide adequate, more than adequate, or
(50.2%), more than adequate (27.2%), or extensive information on patients' interpersonal
extensive information (14.8%) (Figure 4). relationships, while 6% were rated as providing
insufficient information (Figure 1).

10.12.2.5.2 Symptomatic pattern (ii) France

(i) Australia The clinicians' ratings of the interpersonal
The description of patients' symptom patterns relations section of the 83 patient reports were
provided by the computerized reports was favorable in 70% of the cases when the
considered by the clinician-raters to provide categories ªextensive,º ªadequate,º and ªmore
adequate, more than adequate, or extensive than adequateº information were pooled (Gillet
information in 77% of cases (Figure 1). et al. 1996) (Figure 2).
Information was rated as insufficient in 8% of
reports. (iii) Norway
The MMPI-2 report also provided substan-
(ii) France tial information about the interpersonal beha-
According to Gillet et al. (1996), the vior of clients, according to practitioner ratings.
clinicians' opinions of the quality of descrip- Only 4% of the reports were judged to provide
tions in the symptomatic pattern section were insufficient information on this variable; how-
favorable in 59% of the cases, if the categories ever, 76% of the narrative reports were
ªextensive,º ªadequate,º and ªmore than considered adequate, more than adequate, or
adequateº and more than sufficient information extensive in information provided (Figure 3)
were pooled (Figure 2). and 21% of the raters stated that the reports
provided some information.
(iii) Norway
(iv) USA
In terms of symptom pattern exhibited by the
patients in the Norwegian study, 78.9% of the In the US sample, only 2.7% of the patient
Minnesota Reports were rated as providing reports were considered to provide insufficient
adequate, more than adequate, or extensive information (Figure 4) while 85.4% were
information, and only 2.0% of the narrative considered to be adequate (39.2%), more than
reports were considered insufficient by the adequate (29.2%), or to provide extensive
judges (Figure 3). information (16.9%).
284 Objective Personality Assessment

60 validity considerations 60 symptomatic pattern

50 50

40 40 39
35
33
30 30
25
23
20 20
16
14
10 10 8
4 3
0 0
Some > Adequate Some > Adequate
Insufficient Adequate Extensive Insufficient Adequate Extensive

60 interpersonal relations 60 diagnostic considerations

50 50

40 40
35
33
30
30 30 27

20 20 19
16 17
12
10 7 10
4
0 0
Some > Adequate Some > Adequate
Insufficient Adequate Extensive Insufficient Adequate Extensive

70 % considered accurate 66

60 treatment considerations 60

50 50

40 40
35

30 29 30
25
21
20 20

10 8 10 9
4 3
2
0 0
Some > Adequate 20–39 60–79
Insufficient Adequate Extensive < 20 40–59 80–100
Figure 1 Evaluations of computer-based MMPI-2 reports: Australian sample.
 Evaluation of Computer-based MMPI-2 Reports in International Contexts 285

60 validity considerations 60 symptomatic pattern

50 50

40 40
36

30 30 28 27 27
25

20 18 20
13 13
10 7 10
6

0 0
Some > Adequate Some > Adequate
Insufficient Adequate Extensive Insufficient Adequate Extensive

60 interpersonal relations 60 diagnostic considerations

50 50
46

40 40

31
30 27 30

21
20 18 20 17
12 12 12
10 10
5

0 0
Some > Adequate Some > Adequate
Insufficient Adequate Extensive Insufficient Adequate Extensive

60 treatment considerations 60 % considered accurate

50 50

40 40

30 30
26 26
24
21 22 22
20 19 20
17
12
10 10
6

0 0
Some > Adequate 20–39 60–79
Insufficient Adequate Extensive < 20 40–59 80–100
Figure 2 Evaluations of computer-based MMPI-2 reports: French sample.
286 Objective Personality Assessment

validity considerations
70
70

60 60 symptomatic pattern

50 50

40 40 38 38

30 30

20 20
16
14
11
10 10
6
4
2 2
0 0
Some > Adequate Some > Adequate
Insufficient Adequate Extensive Insufficient Adequate Extensive

60 interpersonal relations 60 diagnostic considerations

50 50 49

40 38 40

30 27 30 27
21
20 20

11 11
10 10 9
4 4
0 0
Some > Adequate Some > Adequate
Insufficient Adequate Extensive Insufficient Adequate Extensive

60 treatment considerations 60 % considered accurate

50 50
43
40 40 38
35

30 29 30
25

20 20
14
10 8 10
4 5

0 0
Some > Adequate 20–39 60–79
Insufficient Adequate Extensive < 20 40–59 80–100

Figure 3 Evaluations of computer-based MMPI-2 reports: Norwegian sample.

 Evaluation of Computer-based MMPI-2 Reports in International Contexts 287
60 validity considerations 60 symptomatic pattern

50
50 50

40
40 40

31
30 27 30

20 20 18
15
10
10 8 10

0.4 2
0 0
Some > Adequate Some > Adequate
Insufficient Adequate Extensive Insufficient Adequate Extensive

60 interpersonal relations 60 diagnostic considerations

50 50
43
40 39 40

30 29 30

20
20 17 20 17 16
12
10 10
3 4
0 0
Some > Adequate Some > Adequate
Insufficient Adequate Extensive Insufficient Adequate Extensive

60 treatment considerations 60 % considered accurate

52
50 50

40 38 40

30
30 30
25

20 20
15 15
13
10 10
6
4
2
0 0
Some > Adequate 20–39 60–79
Insufficient Adequate Extensive < 20 40–59 80–100

Figure 4 Evaluations of computer-based MMPI-2 reports: US sample.

288 Objective Personality Assessment

Thus reports from all four countries were used in the USA, Australia, and Norway and
thought to provide substantial information the ICD-10 in France.
about, the interpersonal behavior, of patients. (iii) Another difference to consider in the
cross-cultural comparisons is that in France
10.12.2.5.4 Diagnostic considerations the ratings were completed by psychiatrists
and in the other countries psychologists were
(i) Australia the predominant professional performing the
This section of the computerized reports was ratings.
considered by raters to be less adequate than the The above differences aside, the majority of
above sections. Even here, however, over half raters in all four countries considered the
(55%) of the narrative reports were rated as reports to have adequate, more than adequate,
containing at least adequate information on or extensive information available for the task
diagnosis, while 18% were thought to provide of clinical diagnosis from the MMPI-2.
insufficient information (Figure 1).
10.12.2.5.5 Treatment considerations
(ii) France (i) Australia
According to Gillet et al. (1996), the clinicians' As with diagnosis, 8% of reports were deemed
views of the diagnostic considerations section of to provide insufficient information regarding
the 83 reports were favorable in 38% of the cases treatment planning. Two-thirds (68%) were
when the categories ªextensive,º ªadequate,º considered to provide adequate, more than
and ªmore than adequateº and more than adequate or extensive information (Figure 1).
sufficient information were pooled (Figure 2).
This finding of less relevant diagnostic informa-
(ii) France
tion in the ratings probably results from the
reliance upon a different diagnostic system in The clinicians' ratings of the treatment
France than in the USA. considerations section of the 83 reports were
favorable in 51% of the cases when the categories
ªextensive,º ªadequate,º and ªmore than ade-
(iii) Norway
quateº and more than sufficient information
The diagnostic sections of the computer were pooled (Figure 2). The lower agreement
report were considered by raters to be slightly found between the clinicians and the computer-
less comprehensive than other sections of the based reports, compared with other countries,
report (Figure 3). Nevertheless, over 60% of the probably resulted from different treatment
narrative reports were judged to contain orientations and practices in France.
adequate, more than adequate, or extensive
diagnostic information about their clients. Only
(iii) Norway
8.1% of the protocols were considered to
provide insufficient information in the area of Similarly to diagnosis, the treatment con-
clinical diagnosis. siderations section of the Minnesota Report was
rated as providing valuable information on
clients. Over 64% of the patient MMPI-2
(iv) USA
reports were considered to provide adequate-
The clinicians from the USA considered 4.2% to-extensive information for treatment planning
of the reports as providing insufficient diagnos- (Figure 3). Only 8% of the patient reports were
tic information. However, 78.9% of the reports thought to provide insufficient information for
were thought to contain adequate (42.5%), more treatment planning. The relatively high rate of
than adequate (20.1%) or extensive information positive evaluations of the treatment considera-
(16.2%) (Figure 4). tions section of the report suggests that
treatment planning in Norway and the USA
Several factors may account for the variation may rely upon similar types of clinical informa-
in results in the rating of clinical diagnosis: tion, much of which is available through the
(i) Clinical diagnosis is a task that usually MMPI-2.
requires more information than is available
through an objective self-report questionnaire.
(iv) USA
Practitioners usually need to obtain a detailed
history and behavioral descriptions in order to The therapists rating the American patients
obtain a clinical diagnosis. considered the reports to be helpful in treatment
(ii) The diagnostic procedures differed some- planning. Only 5.8% considered the reports to
what between countries with DSM-IV being provide insufficient information while 78.9%
 Evaluation of Computer-based MMPI-2 Reports in International Contexts 289

thought the reports provided adequate (38.1%), at describing patients. As shown in Figure 3, the
more than adequate (25.4%), or extensive clinician ratings provided strong support for
information (15.4%). using the MMPI-2 in clinical assessment in
In general, as with clinical diagnosis, thera- Norway. Overall, 92.9% of the reports were
pists like to have extensive information for rated in the adequate, more than adequate, or
treatment planning, and test-based information extensive information categories . Over 42.4%
is not the sole source of data required. However, of the patient reports were classified as being in
in all four countries the majority of the the 80±100% range of accuracy and 38.4% were
clinicians rated the reports as adequate or judged to possess between 60 and 79%
better in their evaluations. accuracy. Interestingly, only 5% of the narra-
tive reports were considered low in accuracy.
Overall, the accuracy at describing clinical
10.12.2.5.6 Overall accuracy behavior and symptoms in a diverse clinical
(i) Australia sample was considered to be high.
In addition to rating the adequacy of the
information provided in the narrative reports,
raters estimated the percentage of statements (iv) USA
they considered to be accurate descriptions of In terms of overall accuracy, the American
their patients (Figure 1). Two-thirds (66%) of clinicians rated the reports as being quite
reports on Australian patients were rated as accurate. Only 1.9% were considered to be
having 80±100% accuracy, while 87% were inaccurate while 81.6% were considered to be
rated as having more than 60% accuracy. Only over 60% accurate with over half (52.1%) being
2% were rated as having less than 20% rated in the highest category (Figure 4).
accuracy. As noted above, a large number of
patients in the study (46) were gender-dysphoric
clients undergoing evaluation for possible
gender reassignment surgery. It might be 10.12.2.6 Discussion of Overall Accuracy
hypothesized that their inclusion may have The results of these studies are generally
lowered the overall adequacy and accuracy consistent with the impressions of practitioners
ratings because of possible attempts by these using computerized reports in other countries,
patients to present themselves in an overly namely that the automated MMPI-2 interpreta-
positive manner. This was not the case. There tions generalize well to other locations and that
was no significant difference between the ratings the descriptors about patients apply well in
of gender-dysphoric and other patients on the countries other than the USA. These results
symptomatic pattern (t(157) = 70.53), the support the conclusion that computer-based
interpersonal relations (t(157) = 1.14), the di- reports of the MMPI-2 can be a valuable aid in
agnostic considerations (t(156) = 1.79) and the clinical assessment in other countries.
treatment considerations (t(154) = 0.46) sec- Although the overall acceptability of the
tions of the reports. With respect to the two Minnesota Report in France was good, the
other ratings, the reports on the gender- ratings provided by French mental health
dysphoric patients were actually rated more professionals on the utility of the reports were
positively than those of the other patients somewhat lower than those obtained by their
(validity considerations, t(165) = 72.84, p 5 counterparts in Australia (Berah et al., 1993),
0.01; overall accuracy, t for unequal variances Norway, and the USA. These findings might
(110) = 72.15, p 5 0.05). reflect differences in clinical practice in different
countries, different attitudes toward computers,
(ii) France or genuine personality differences between the
French and patients from other countries.
The overall relevance of the report to French Further research will be needed to clarify this
clinicians was considered high when categories finding.
D and E were met and 67.5% if we consider Relatively few of the practitioners in any of
categories C, D, and E. the four countries studied found the reports
inappropriate or inaccurate. The sections for
which most of the reports were considered as
(iii) Norway
valuable and to provide in-depth information
In addition to the question of the thorough- were the validity considerations, the sympto-
ness of the information provided by the matic patterns, and the interpersonal relations
narratives, the study addressed the accuracy sections and, to a lesser degree, the diagnostic
of computer-generated personality descriptions and the treatment considerations sections.
290 Objective Personality Assessment

10.12.2.7 Limitations of this Research treated, usually on a short-term basis. The

mental health facility is integrated into the
The limited information that was available on primary health care system and wide-ranging
each patient from the clinicians prevented a referrals are accepted. Patients usually come in
fuller exploration of the descriptive power of the for an assessment initially and treatment starts
MMPI-2. As with any field study conducted in immediately. The mean number of sessions
service-oriented clinics or hospitals, the amount (including assessment) is 16 and the complaints
of extra work that can be asked of clinicians is include: anxiety disorders, mood disorders,
limited. While more extensive ratings would somatoform disorders, adjustment disorders,
have been desirable, the cooperation of clin- family problems, and personality disorders. A
icians may well have been sacrificed if the task group of eight clinical psychologists and two
was seen as overly burdensome. psychological assistants staff the facility. The
Second, it should be kept in mind that the practice is in a rural area near two cities,
study employed US norms for the computer- Nijmegen and Arnhem, and we work closely
derived interpretations. It is possible that the use with 15 family practice physicians for referrals.
of country-specific norms, particularly in Every week about six new patients are referred
France, might have added a higher degree of to the clinic. The treatment orientation is
accuracy to the reports and greater congruence eclectic: we do behavioral therapy, rational
in the ratings. French norms are now available emotive therapy, family therapy, short-term
for the MMPI-2. Future research might be psychodynamic therapy, group therapy, and
developed with country-specific norms, which assertiveness training.
gives different results. The case described here is a 23-year-old
Finally, we were not able, in this study, to woman named Susan who came to our practice
provide an estimate of inter-rater reliability. It on referral from her physician. Initial impres-
would have been desirable to have had a number sions suggested an attractive young woman, a
of cases rated by at least two clinicians, so that bit shy, but pleasant in the interpersonal sphere.
interrater reliability could have been assessed. It Her chief complaints were obsessive rumina-
is not known whether use of a different group of tions and a feeling of uncertainty about what she
clinicians in completing the ratings would have wants to do and can do with her life. She
produced similar results leading to the present expressed feelings of depression and feelings of
conclusions. Future research might be directed inferiority which she connects with her negative
toward obtaining a broader base of information. self-image. A direct reason for asking for help
Because of these limitations the results of this could be found in her suicidal thoughts that
study can be taken as only suggestive; it is felt, made her panic and feel ashamed. She sleeps
nonetheless, that the data indicate that the well, has no weight loss, and does not complain
computer-based Minnesota Report can be a about fatigue. Besides the symptoms mentioned
useful aid to assessment in other countries to aid earlier, she has had an eating disorder and
clinicians in interpreting MMPI-2 results. Even problems with the acceptance of her body which
with these limitations, the results of the present she considers too fat. Although she is slightly
study were very informative and encouraging overweight at present, this is only to a minor
with respect to the use of computer-based degree.
MMPI-2 reports in other countries. Overall, the The initial assessment did not result in a
reports were considered to provide a consider- diagnosis of major depressive disorder and
able amount of valuable information. psychotic symptoms were lacking. She does
We turn next to illustrations of the use of the show elements of dysthymia. Her personality
computer-based report in clinical settings from organization, in terms of Kernberg criteria, is
several other countries. We provide clinical case neurotic.
material from several other countries along with Susan was born in the eastern part of The
the MMPI-2 computerized report to provide the Netherlands and about six months before she
reader with an example of the kinds of came for treatment she had moved to a rural
information available in the report and its area near the practice. This happened at the time
relevance for other countries. that her boyfriend took over his father's
business, a nursery for growing roses. Susan
and her boyfriend started living together at that
10.12.3 CASES
time and she began working in this family
10.12.3.1 Nijmegen, The Netherlands: The Case enterprise. Her chief complaints started when,
of Susan in summer, they had a lot of work to do and lots
of responsibilities; amongst other things she had
In our outpatient psychological practice, to manage the staff. Especially when alone, she
patients with many types of complaints are began to feel unhappy. She responded by trying
 Cases 291

to avoid these feelings as long as possible and course with him. Prior to this relationship her
then by binge eating. In addition she often had interest in boys was purely nonsexual and she
crying spells. She connected the binge eating was afraid that boys might take advantage of
with a need to pamper herself. her. The relationship with her first boyfriend
During the assessment phase her boyfriend ended because he felt that she could not express
was invited for a session and he explained that any feelings toward him. She always wanted to
Susan had chosen to live with him but was not be strong and tough but the end of the
eager to work in the rose nursery. He himself has relationship was difficult for her and she never
worked in this business since he was 16 years old really worked through her feelings about it.
and is aware that the work is demanding and After school Susan attended a lower profes-
stressful at times. He would like her to enjoy this sional school (training as a hospital orderly) but
work because he wants to share everything with stopped in the second year of her education
her. The possibility of Susan choosing a because she was unable to maintain good
different career path is felt by him as a threat. interpersonal contact with co-workers and the
Susan is the youngest in a family with two patients. During this period, when she was 19
daughters. She reports some positive early child- years old, she met her present boyfriend who is
hood memories. She experienced her family as also her employer. She characterizes him as also
very well attached; many family activities were being introverted. After he had known her for
shared together. Her mother was, like Susan, one-and-a-half months he asked her whether
rather introverted and also reports problems she would like to work in the rose nursery and
with accepting her body and difficulties with she accepted his offer. She believed that their
bodily contact. Susan never felt secure with her relationship would have ended if she had
mother. She described her father as a warm and rejected his offer. Their relationship started
sensitive but somewhat prudish man. He works very cautiously and the sexual part of it has been
for an insurance company and was always busy problematic from the beginning.
and stayed away from home a lot. Her father From the earliest days of their relationship
used to call Susan the ªsunshine in the house.º she did not stand up for her needs and wants. In
Her mother was responsible for the children's addition, because she was afraid of losing him,
upbringing and stopped working as a typist she demanded perfection from herself. She feels
when she gave birth to the oldest. It is striking that she must be steady and very adaptable to
that, in the interview, when Susan made a critical the demands of her boyfriend's family. She also
comment about her parents she immediately feels quite stressed over the great demands
covered it up with a positive one. placed on her by the work in the nursery. Part of
During puberty she had difficulties with the her difficulty comes from the dual relationship
development of female secondary sex charac- she has with her employer. Her boyfriend is also
teristics because she really wanted to be a boy. her boss and he often makes administrative
There were some precursors for this in the decisions about, for instance, when she can have
family because her father often treated her as a day off. She often becomes emotional when
though she was a boy. She was always quiet, this complex relationship is discussed and she
introverted, well-adapted, nice, and sensitive tends to protect him immediately indicating that
but she never knew what to do with her life. Her ªhe is so patient with her.º
sister, who is two years older, however, always Her binge eating usually becomes manifest
manifested herself in a rebellious manner, when she is alone. She often stores candies and
refused to accept societal and family norms then eats them all at once. She feels ashamed
and values, and was extreme in her dress, for over her behavior and was especially guilty
example she often dressed as a ªpunk.º Her when her boyfriend discovered her problem.
parents devoted a lot of attention to her older One major cause of hurt for her was when her
sister. Susan solved her problems herself and boyfriend once told her that he was not
asked little from her parents. primarily attracted to her body but rather her
During her adolescence, her mother criticized character. She told her mother, her best friend
her quite often because of her weight and her and her sister about her problems and was
tendency to be introverted. This criticism surprised that they were so supportive of her.
resulted in her developing some irritation and During the evaluation and also later in
resentment. Her mother thought she was stub- therapy she impressed the psychologist as
born if Susan did not do what she asked her to playing the role of a victim in the mixed
do. During adolescence Susan always felt relationships in which she was involved with her
inferior to her sister and thought that her boyfriend and her own family. Everyone seems
mother preferred her sister. When she was 16 to know what was best for her and she had
she had a brief relationship with her first borne these burdens but was feeling unhappy
boyfriend; however, she refused sexual inter- now. She seemed unable to assert herself with
292 Objective Personality Assessment

others and to express her own anger in a Profile validity

productive way. This is a valid MMPI profile. The client's
The following psychological tests were ad- attitude toward the testing was appropriate. She
ministered as well as the MMPI-2. On the responded to the items in a frank and open
Wechsler Adult Intelligence Scale she had a manner, freely admitting to some psychological
verbal IQ of 103 and a performance IQ of 104 problems, which are described below.
which is in agreement with her school education.
On the ªhouse±tree±personº test she drew a Symptomatic patterns
person with only a head. It seems as if her
The behavioral correlates included in the narra-
thinking is most important and she likes to tive report are likely to provide a good description
control things rationally. Several other projec- of the client's current personality functioning. The
tive techniques were administered, such as the clinical scale prototype used in the report, which
Thematic Apperception Test and the Sentence incorporates correlates of D and Pt, is based on
Completion Test. Themes that appeared pro- scores with high profile definition. The client's
minent were her sexual problems, hidden MMPI-2 clinical profile reflects much psycholo-
aggression in relation to her parents, idealized gical distress at this time. She has major problems
pictures of other people, not knowing where to with anxiety and depression. She tends to be high-
go in life, and a lack of perseverance. strung and insecure, and she may also be having
somatic problems. She is probably experiencing
loss of sleep and appetite and a slowness in
personal tempo.
10.12.3.1.1 The Minnesota Report on Susan Individuals with this profile often have high
standards and a strong need to achieve, but they
On the MMPI-2 she produced the profiles feel that they fall short of their expectations and
shown in Figures 5 and 6 and the following then blame themselves harshly. This client feels
interpretation. quite insecure and pessimistic about the future.

MMPI–2
120

110

100

90

80

70

60

50

40

30
L F K Hs D Hy Pd Mf Pa Pt Sc Ma Si
Raw score 5 9 15 7 30 29 21 39 14 28 20 21 34
K correction 8 8 15 15 3
T score 57 68 50 54 70 65 60 43 63 79 65 62 58
Figure 5 MMPI-2 profile of Susan (1).
 Cases 293

MMPI–2
120

110

100

90

80

70

60

50

40

30
ANX FRS OBS DEP HEA BIZ ANG CYN ASP TPA LSE SOD FAM WRK TRT
Raw score 14 3 11 14 8 3 6 8 5 4 14 5 3 16 10
T score 66 41 67 65 55 56 50 48 47 41 70 46 42 63 61

Figure 6 MMPI-2 profile of Susan (2).

She also feels quite inferior, has little self-con- client's MMPI-2 high-point clinical scale score (Pt)
fidence, and does not feel capable of solving her is found in only 5.1% of the MMPI-2 normative
problems. sample of women. Only 2.1% of the women have
In addition, the following description is sug- Pt as the peak score at or above a T score of 65, and
gested by the content of the client's item responses. less than 1% have well-defined Pt spikes. This high
She has endorsed a number of items suggesting MMPI-2 profile configuration (2±7/7±2) is very
that she is experiencing low morale and a de- rare in samples of normals, occurring in 1.2% of
pressed mood. She reports a preoccupation with the MMPI-2 normative sample of women.
feeling guilty and unworthy. She feels that she Her MMPI-2 high-point score is relatively
deserves to be punished for wrongs she has uncommon in various outpatient settings. In the
committed. She feels regretful and unhappy about National Computer Systems (NCS) outpatient
life, and she seems plagued by anxiety and worry sample, only 6.4% of the females have this
about the future. She feels hopelessness at times MMPI-2 high-point clinical scale score (Pt). More-
and feels that she is a condemned person. She over, only 5.3% of the female outpatients have the
views her physical health as failing and reports Pt scale spike at or above a T score of 65, and only
numerous somatic concerns. She feels that life is no 2.1% have well-defined Pt peaks. Her elevated
longer worthwhile and that she is losing control of MMPI-2 profile configuration (2±7/7±2) is found
her thought processes. in 7.4% of the women in the NCS outpatient
According to her response content, there is a sample. This is the second most frequent elevated
strong possibility that she has seriously contem- two-point code in the sample.
plated suicide. The client's recent thinking is likely
to be characterized by obsessiveness and indecision. Profile stability

Profile frequency The relative scale elevation of the highest scales

in her clinical profile reflects high profile defini-
It is usually valuable in MMPI-2 clinical profile tion. If she is retested at a later date, the peak
interpretation to consider the relative frequency of scores on this test are likely to retain their relative
a given profile pattern in various settings. The salience in her retest profile pattern. Her high-
294 Objective Personality Assessment

point score on Pt is likely to remain stable over 10.12.3.1.2 Comment

time. Short-term test±retest studies have shown a
correlation of 0.88 for this high-point score. Susan produced a valid profile. The higest
scale is scale 7 (79), followed by scale 2 (70), and
Interpersonal relations 3 (65). The profile is essentially a neurotic one;
she seems to be controlling feelings by way of
She appears to be quite passive and dependent in rationalizing and ruminating. Her subjective
interpersonal relationships and does not speak up suffering is clearly present (scale 2). Scale 7
for herself even when others take advantage of her. assesses abnormal fears, self-criticism, difficul-
She avoids confrontation and seeks nurturance ties in concentration and guilt feelings. Further,
from others, often at the price of her own the item content reflects a characterologic basis
independence. She forms deep emotional attach- for a wide variety of psychasthenic symptoms.
ments and tends to be quite vulnerable to being
hurt. She also tends to blame herself for inter-
Anxiety is a persistent trait. This seems in
personal problems. Individuals with this profile agreement with her complaints and attitudes.
are often experiencing psychological distress in On the content scales her highest scale score was
response to stressful events. The intense feelings on Low Self Esteem (70) and her second highest
may diminish over time or with treatment. was Obsessions (67) and then Anxiety (66).
Depression is 65 and Problems in Relation to
Diagnostic considerations Work 63.

Individuals with this profile tend to be consid-

ered neurotic and receive diagnoses such as 10.12.3.1.3 DSM-IV classification
Dysthymic Disorder or Anxiety Disorder. They
may also receive Axis II diagnosis of Dependent or This was as follows:
Compulsive Personality Disorder Axis I: 313.82 Identity Problem
307.50 Eating Disorder Not Other-
Treatment considerations wise Specified
Axis II: 301.60 Traits of the Dependent and
Individuals with this MMPI-2 pattern are usually Obsessive-Compulsive Personality Disorder.
feeling a great deal of discomfort and tend to want
help for their psychological problems. The client's
self-esteem is low and she tends to blame herself too 10.12.3.1.4 Treatment
much for her difficulties. Although she worries a
great deal about her problems, she seems to have Individual insight-oriented sessions were
little energy left over for action to resolve them. initiated with Susan to give her the opportunity
Symptomatic relief for her depression may be to explore her needs and wishes in relation to her
provided by antidepressant medication. Psy- work, study, sexual behavior, and partner
chotherapy, particularly cognitive behavioral choice. Although her intelligence is only
treatment, may also be beneficial. average, she is well motivated to work things
The passive, unassertive personality style that out for herself. An attempt has been made to
seems to underlie this disorder might be a focus of focus on her conflicts between dependency and
behavior change. Individuals with these problems autonomy. The aim is to facilitate the process of
may learn to deal with others more effectively
through assertiveness training.
individualization and to provide her with the
If psychological treatment is being considered, it opportunity to discover her feelings of anger
may be profitable for the therapist to explore the that she holds toward others close to her.
client's treatment motivation early in therapy. The Treatment progress has thus far been effec-
item content she endorsed includes some feelings tive. During the course of her treatment she has
and attitudes that could be unproductive in psy- gradually discovered better her own needs and
chological treatment and in implementing change. preferences. She has started to understand her
ambivalent feelings towards her parents and
Note. This MMPI-2 interpretation can serve as a also towards her boyfriend. At the present time
useful source of hypotheses about clients. This in therapy she is exploring her fantasies of
report is based on objectively derived scale indices leaving him and starting a different life. Her
and scale interpretations that have been developed characterologic basis for psychasthenic traits,
in diverse groups of patients. The personality indicated by the MMPI-2, has appeared very
descriptions, inferences, recommendations con-
strong and difficult to influence so far.
tained herein need to be verified by other sources
of clinical information because individual clients
may not fully match the prototype. The informa-
tion in this report should most appropriately be 10.12.3.2 Rome, Italy: The Case of Mario P.
used by a trained, qualified test interpreter. The
information contained in this report should be Mr. P. is a 36-year-old male from a low socio-
considered confidential. economic background and educational level. At
 Cases 295

the age of 21 he married an 18-year-old woman amount of virtue while also endorsing a great
and they now have two children aged 14 and six. number of psychological difficulties. This infre-
He was referred to our outpatient psychiatry quent response pattern reflects some unconven-
service by an otolaryngologist whom he con- tional and possibly bizarre beliefs.
Careful evaluation of the individual's response
sulted for a ªlump in his throatº when his
attitudes should be undertaken to explain this
physician could find no organic basis to his unusual validity scale pattern. The following
symptoms. He has a family history of depres- hypotheses might be explored. He may have
sion: his mother suffered from depression in the consciously distorted the test responses to create
past and one of his three sisters is presently a particular impression, or he may be generally
depressed. His wife, who recently left her job to unsophisticated. The resulting clinical pattern
dedicate herself to housekeeping, had suffered should be interpreted with caution.
in the past from what seems to be somatic The client's responses to items in the latter
complaints of depression. portion of the MMPI-2 were somewhat exagger-
Until recently the patient was working as a ated in comparison to his responses to earlier
items. There is some possibility that he became
manual laborer until 2.00 a.m. every night
more careless in responding to these later items,
because he held two jobs. However, he had to thereby raising questions about that portion of the
give up one of his jobs three months ago, just test. Although the standard validity and clinical
prior his first visit to the clinic, because he scales are scored from items in the first two-thirds
developed nervousness, apathy, tension, and of the test, caution should be taken in interpreting
irritability. At this visit he reported poor sleep the MMPI-2 Content Scales and supplementary
quality, reduced appetite, and excessive increase scales, which include items found throughout the
in cigarette smoking. He lacked a drive for entire pool.
living; he could not face life either at home or at
work and saw no ªway-out.º He felt guilty Symptomatic patterns
about not being able to care for his children, he This report was developed using the D, Pt, and
seemed discouraged and ªswitched-off.º His Sc scales as the prototype. A pattern of chronic
impulse control is poor; he reported several acts psychological maladjustment characterizes indivi-
of violence (having beaten his children). Fearing duals with this MMPI-2 clinical profile. The client
the consequences of his impulsive behavior and is overwhelmed by anxiety, tension, and depres-
being afraid of his lack of control over his acts, sion. He feels helpless and alone, inadequate and
he often leaves his home for hours, walking with insecure, and he believes that life is hopeless and
no precise destination, seeking isolation to that nothing is working out right. He attempts to
escape from difficulties. He was prescribed control his worries through intellectualization and
1.5 mg/die oral desmethyldiazepam and took unproductive self-analysis, but he has difficulty
concentrating and making decisions. This is a
this medication for some time but had to reduce rather chronic behavior pattern. Individuals with
it to 0.5 mg/die due to the development of this profile typically live a disorganized and
marked sedation that impaired his daytime pervasively unhappy existence. They may have
performance. episodes of more intense and disturbed behavior
During the interview, the patient spoke resulting from an elevated stress level.
spontaneously, with a monotonous, low voice. He is functioning at a lower level of efficiency.
Speech content and form were normal, how- He tends to overreact to even minor stress, and he
ever, and he expressed guilt, pessimism, and may show rapid behavioral deterioration. He also
inadequacy. He showed no evidence of free- tends to blame himself for his problems. His
floating anxiety. His mood was markedly lifestyle is chaotic and disorganized, and he has
a history of poor work and achievement. He may
depressed and he frequently sighed aloud. He be preoccupied with obscure religious ideas.
appeared to have good insight with respect to The client seems to have a rather limited range
his psychopathological problems and was will- of cultural interests and tends to prefer stereotyped
ing to accept treatment. masculine activities to literary and artistic pursuits
or introspective experiences. Interpersonally, he
may be somewhat intolerant and insensitive.
10.12.3.2.1 The Minnesota Report on Mario P.
Profile frequency
The patient completed the MMPI-2 at the
end of his first visit to the clinic producing the It is usually valuable in MMPI-2 clinical profile
profiles shown in Figures 7 and 8 and the interpretation to consider the relative frequency of
following narrative report. a given profile pattern in various settings. The
client's MMPI-2 high-point clinical scale score (Pt)
Profile validity is found in only 4.9% of the MMPI-2 normative
sample for men. Only 3.1% of the sample have Pt
The client responded to the MMPI-2 items in an as the peak score at or above a T score of 65, and
unusual manner. He claimed an unrealistic only 1.6% have well-defined Pt spikes. This
296 Objective Personality Assessment

MMPI–2
120

110

100

90

80

70

60

50

40

30
L F K Hs D Hy Pd Mf Pa Pt Sc Ma Si
Raw score 8 19 8 16 35 31 26 22 11 35 36 20 43
K correction 4 3 8 8 2
T score 70 95 35 68 83 74 64 42 53 85 81 53 71
Figure 7 MMPI-2 profile of Mario P. (1).

elevated MMPI-2 profile configuration (2±7/7±2) Profile stability

is very rare in samples of normals, occurring in less
than 1% of the MMPI-2 normative sample of men. The relative scale elevation of the highest scales
The relative frequency of this MMPI-2 high- in his clinical profile reflects high profile defini-
point score is informative. In the NCS outpatient tion. If he is retested at a later date, the peak scores
sample, 7.7% of the males have this MMPI-2 high- on this test are likely to retain their relative salience
point clinical scale score (Pt). Moreover, 6.5% of in his retest profile pattern. His high-point score
the male outpatients have the Pt scale spike at or on Pt is likely to show high stability over time.
above a T score of 65, and 3.3% have well-defined Short-term test±retest studies have shown a cor-
Pt spike scores in that range. His elevated MMPI-2 relation of 0.89 for this high-point score. Spiro,
profile configuration (2±7/7±2) is relatively com- Butcher, Levenson, Aldwin, and Bosse (1993)
mon in outpatient men. It occurs in 4.8% of the reported a test±retest stability index of 0.65 in a
men in the NCS outpatient sample. The 2±7 profile large study of normals over a five-year test±retest
code is the second most frequent two-point code in period.
outpatient men when both scales are at or above a
T score of 65. Interpersonal relations
He scored relatively high on MAC-R, suggesting
the possibility of a drug or alcohol abuse problem. Problematic personal relationships are also
The base rate data on his profile type among characteristic of such clients. He seems to lack
residents in alcohol and drug programs should also basic social skills and is behaviorally withdrawn.
be evaluated. His MMPI-2 profile code, including He may relate to others ambivalently, never fully
D and Pt, is the second most frequent two-point trusting or loving anyone. Many individuals with
code among men in alcohol- and drug-abusing this profile never establish lasting, intimate rela-
populations. Over 13% of the men in substance- tionships. His marital situation is likely to be
abuse programs have this pattern (McKenna & unrewarding and impoverished. He seems to feel
Butcher, 1987). inadequate and insecure in his marriage.
 Cases 297

MMPI–2
120

110

100

90

80

70

60

50

40

30
ANX FRS OBS DEP HEA BIZ ANG CYN ASP TPA LSE SOD FAM WRK TRT
Raw score 18 9 11 26 20 5 14 19 14 17 13 14 6 29 18
T score 80 67 70 88 81 60 78 71 65 81 72 63 52 90 84

Figure 8 MMPI-2 profile of Mario P. (2).

He is a very introverted person who has of substance use or abuse problems is strongly
difficulty meeting and interacting with other recommended.
people. He is shy and emotionally distant. He
tends to be very uneasy, rigid, and overcontrolled Treatment considerations
in social situations. His shyness is probably
symptomatic of a broader pattern of social with- Individuals with this MMPI-2 clinical profile
drawal. Personality characteristics related to social often receive psychotropic medications for their
introversion tend to be stable over time. His depressed mood or intense anxiety. Many indivi-
generally reclusive behavior, introverted lifestyle, duals with this profile seek and require psycholo-
and tendency toward interpersonal avoidance may gical treatment for their problems along with any
be prominent in any future test results. medication that is given. Because many of their
His very high score on the Marital Distress Scale problems tend to be chronic, an intensive ther-
suggests that his marital situation is quite proble- apeutic effort might be required in order to bring
matic. about any significant change. Patients with this
profile typically have many psychological and
Diagnostic considerations situational concerns; consequently, it is often
difficult to maintain a focus in treatment.
Individuals with this profile have a severe He probably needs a great deal of emotional
psychological disorder and would probably be support at this time. His low self-esteem and
diagnosed as severely neurotic with an Anxiety feelings of inadequacy make it difficult for him
Disorder or Dysthymic Disorder in a Schizoid to get energized toward therapeutic action. His
Personality. The possibility of a more severe expectation for positive change in therapy may be
psychotic disorder, such as Schizophrenic Disor- low. Instilling a positive, treatment-expectant
der, should also be considered, however. attitude is important for him if treatment is to
His extremely high scores on the addiction be successful.
proneness indicators suggest the possible develop- Individuals with this profile tend to be over-
ment of an addictive disorder. Further evaluation ideational and given to unproductive rumination.
298 Objective Personality Assessment

They tend not to do well in unstructured, insight- Sodium valproate, 1 mg/die, was added to
oriented therapy and may actually deteriorate in control impulsiveness. He reported outbursts
functioning if they are asked to be introspective. of aggression and impulsiveness, with mood
He might respond more to supportive treatment of swings during the day, but overall, he felt
a directive, goal-oriented type. Individuals with
slightly better. By the third visit, one month
this profile present a clear suicide risk; precautions
should be taken. after the beginning of drug treatment, the
patient started to report better control of his
Note. This MMPI-2 interpretation can serve as a impulses and satisfactory mood improvement.
useful source of hypotheses about clients. This He further improved with time, returning to
report is based on objectively derived scale indices work after three months of therapy. By this
and scale interpretations that have been developed time, the quality of sleep had improved and his
in diverse groups of patients. The personality appetite had increased, especially for carbohy-
descriptions, inferences, recommendations con- drates. Impulsiveness and dysthymic mood were
tained herein need to be verified by other sources no longer reported.
of clinical information because individual clients He developed a fine tremor that subsided the
may not fully match the prototype. The informa- next month. After four months of treatment, his
tion in this report should most appropriately be
mood was stabilized and the patient was more
used by a trained, qualified test interpreter. The
information contained in this report should be active. He returned to work but still felt the
considered confidential. presence of a lump in his throat, although only
occasionally. About this time he developed
hypersomnia. He tried to suspend treatment for
10.12.3.2.2 Comment a week or so, but his symptoms worsened. He
had his chlomipramine reduced to 112.5 mg/die
Mario P. obtained high scores on the D scale, and valproate to 500 mg. Improvement con-
compatible with a depressive state, high scores tinued and after seven months the patient seems
on the Pt and Sc scales, compatible with the to have completely recovered and is maintained
symptoms of irritability, anxiety, avoidance, on the above drug combination.
and tension, and marginally high social intro-
version that can explain his pursuit of isolation.
His scores on the Pd scale reflect his violent acts
and impulsiveness. Higher than average scores 10.12.3.3 Iran, United States: The Case of
on the Hs and Hy scales are consistent with the Ms. B.
presence of the lump in the patient's throat The patient is a 30-year-old female Iranian,
(globus hystericus) and with the tendency to use who is currently separated. She has an AA
bodily symptoms to resolve his conflicts. The degree in fine arts and is currently unemployed.
mood axis is oriented towards depression. The She was self-referred for therapy. Ms. B.'s initial
presence of an 8±7±2 codetype reflects his complaints included a wide range of psychoso-
pessimism, weakness and fatigue, lack of matic problems including headaches, dizziness,
initiative, perception of loneliness, poor de- weakness, sore throat, pressure in the chest
scription of his own emotional state, self-blame, cavity, and upset stomach. She added that she
worthlessness, and impulsiveness. The person- felt sad, anxious, and angry and worried that she
ality profile, with the T scores of all neurotic might lose her mind. Ms. B. indicated that no
scales being over 65, was compatible with the one understands or accepts her. This feeling
presence of a neurotic disorder, and the generates a tremendously high level of stress,
diagnosis was made of severe, single episode sadness, and anger. As a result of the lack of
major depression. understanding, she feels lonely and tries to
justify herself and goes through lengthy ex-
planations to prove that she really is a good
10.12.3.2.3 Treatment
woman and worthy of love. This urge to prove
The patient was started on oral chlomipra- her virtues is dated back to the time that her
mine, 100 mg/die, titrated upwards. This drug is family found out about her sexual intimacy with
marketed in Europe as an antidepressant; it is an older man when she was 16 years old. The
also used for obsessive-compulsive disorder and patient got herpes from this two-year relation-
other disorders of the obsessive-compulsive ship. Ms. B. considers herself a victim of rape in
spectrum, including those where impulsive this relationship and believes that the trauma
behavior predominates. The patient returned and the consequent problems continue to have
regularly every 2±4 weeks for his follow-up an impact on her present life.
visits. At the second visit, the patient was Ms. B. stated that her parents had a turbulent
switched to slow-release chlomipramine, marriage. According to the patient her mother
150 mg/die, titrated upwards to 187.5 mg/die. married her father because of coercion, not love.
 Cases 299

She added that her mother was depressed when The patient is an Iranian and the oldest of
she was pregnant with the patient. During her three children. One of her younger brothers has
childhood she witnessed family discord and been diagnosed with schizophrenia. The patient
conflicts with repeated discussions of divorce. denied any history of other psychiatric pro-
According to the patient her father used to beat blems in her family. She also denied any history
her mother. Consequently, the patient would of alcohol or substance abuse in her family.
stay home to provide some sort of protection for However, during therapy the presence of
her mother. Her parents were separated for a personality problems and antisocial character-
couple of years but never got divorced. Her istics among the family members was detected.
mother repeatedly told her that she did not get a As a child, she reported being emotionally
divorce because of her and blamed the patient abused. Her parents, especially her mother,
for her unhappiness. blamed her for their unhappy marriage and she
The patient's emotional status has deterio- witnessed repeated family fights as she was
rated following early separation after a short- growing up. Her mother repeatedly told her that
lived marriage a couple of months before the she was an unwanted child.
present testing session. Ms. B. has been The patient reported having sex with an older
experiencing more problems, including depres- man at age 16. She remained intimate with this
sion and frustration, following her separation. man for a couple of years. When her family
The patient denied a history of previous found out about her relationship they severely
psychiatric problems, but later mentioned that chastised her and told her that she was not
she had received short-term counseling in the suitable for marriage any longer. She has always
past. The patient has been diagnosed with had difficulty in maintaining relationships with
herpes since the age of 16. No other medical men, particularly when there was a hint that it
problems are indicated. Ms. B. denies a history might become serious. At age 29, the patient was
of substance abuse. married for a very short period of time. This

MMPI–2
120

110

100

90

80

70

60

50

40

30
L F K Hs D Hy Pd Mf Pa Pt Sc Ma Si
Raw score 4 12 13 16 39 32 29 41 18 37 33 18 43
K correction 7 5 13 13 3
T score 52 79 46 71 90 73 79 38 78 92 81 53 67
Figure 9 MMPI-2 profile of Ms. B. (1).
300 Objective Personality Assessment

MMPI–2
120

110

100

90

80

70

60

50

40

30
ANX FRS OBS DEP HEA BIZ ANG CYN ASP TPA LSE SOD FAM WRK TRT
Raw score 20 12 13 21 11 6 6 12 11 14 13 14 13 22 16
T score 81 65 75 77 61 64 50 54 63 73 68 63 68 76 77
Figure 10 MMPI-2 profile of Ms. B. (2).

short marriage was marked by mistrust, She endorsed the items at the end of the booklet
ambivalence, verbal abuse, and recurrent argu- in an extreme or exaggerated manner, producing a
ments, resulting in a separation. high score on F(B). This elevated score could result
The assessment was conducted in an out- from a number of conditions such as confusion,
exaggerated symptom checking, or consistently
patient setting. At the time of testing, Ms. B.
misrecording her responses on the answer sheet.
presented as well-groomed and fashionably The scores on the MMPI-2 Content Scales,
dressed. She was oriented and her speech was supplementary scales, and content component
fluent and intelligible. No suicidal or homicidal scales could be influenced by this tendency.
thoughts were indicated. She denied having any
hallucinations and no delusions were noted.
Remote memory and immediate memory for Symptomatic patterns
recall were intact. This report was developed using the D, Pt, and
Sc scales as the prototype. A pattern of chronic
psychological maladjustment characterizes indivi-
10.12.3.3.1 The Minnesota Report on Ms. B. duals with this MMPI-2 clinical profile. The client
is overwhelmed by anxiety, tension, and depres-
When the MMPI-2 was administered, Ms. B. sion. She feels helpless and alone, inadequate and
produced the profiles shown in Figures 9 and 10 insecure, and she believes that life is hopeless and
and the following narrative report. that nothing is working out right. She attempts to
control her worries through intellectualization and
Profile validity unproductive self-analysis, but she has difficulty
concentrating and making decisions. This is a
This client has endorsed a number of psycho- rather chronic behavioral pattern. Individuals with
logical problems, suggesting that she is experien- this profile typically live a disorganized and
cing a high degree of stress. Although the MMPI-2 pervasively unhappy existence. They may have
clinical scale profile is probably valid, it may show episodes of more intense and disturbed behavior
some exaggeration of symptoms. resulting from an elevated stress level.
 Cases 301

She is functioning at a very low level of (Pt). Moreover, only 5.3% of the female out-
efficiency. She tends to overreact to even minor patients have the Pt scale spike at or above a T
stress, and she may show rapid behavioral dete- score of 65, and only 2.1% have well-defined Pt
rioration. She also tends to blame herself for her peaks. Her elevated MMPI-2 profile configuration
problems. Her lifestyle is chaotic and disorganized, (2±7/7±2) is found in 7.4% of the women in the
and she has a history of poor work and achieve- NCS outpatient sample. This is the second most
ment. She may be preoccupied with obscure frequent elevated two-point code in the sample.
religious ideas.
The client does not report great concerns about Profile stability
her sex-role identity. However, the extent to which
her rather ªtraditionally feminineº feelings and The relative elevation of her clinical scale scores
attitudes are integrated into her life at this point suggests that her profile is not as well defined as
may need to be evaluated further. many other profiles. That is, her highest scale or
In addition, the following description is sug- scales are very close to her next scale score
gested by the content of the client's item responses. elevations. There could be some shifting of the
She has endorsed a number of items suggesting most prominent scale elevations in the profile code
that she is experiencing low morale and a de- if she is retested at a later date. The difference
pressed mood. She reports a preoccupation with between the profile type used to develop the
feeling guilty and unworthy. She feels that she present report and the next highest scale in the
deserves to be punished for wrongs she has profile code was 2 points. So, for example, if the
committed. She feels regretful and unhappy about client is tested at a later date, her profile might
life, and she seems plagued by anxiety and worry involve more behavioral elements related to eleva-
about the future. She feels hopeless at times and tions on Pd. If so, then on retesting, acting-out,
feels that she is a condemned person. She endorsed aggressive, and irresponsible behavior might be-
response content that reflects low self-esteem and come more pre-eminent.
long-standing beliefs about her inadequacy. She
views her physical health as failing and reports Interpersonal relationships
numerous somatic concerns. She feels that life is no Problematic personal relationships are also
longer worthwhile and that she is losing control of characteristic of such clients. She seems to lack
her thought processes. basic social skills and is behaviorally withdrawn.
According to her response content, there is a She may relate to others ambivalently, never fully
strong possibility that she has seriously contem- trusting or loving anyone. Many individuals with
plated suicide. The client's recent thinking is likely this profile never establish lasting, intimate rela-
to be characterized by obsessiveness and indeci- tionships.
sion. She feels somewhat self-alienated and ex- She is quite shy and inhibited in social situa-
presses some personal misgivings or a vague sense tions, and she may avoid others for fear of being
of remorse about past acts. She feels that life is hurt. She is emotionally alienated from others. She
unrewarding and dull, and she finds it hard to is likely to have very few friends and to be
settle down. She views the world as a threatening considered by others as distant and hard to get
place, sees herself as having been unjustly blamed to know. She is quiet and submissive and lacks self-
for others' problems, and feels that she is getting a confidence in dealing with other people. Indivi-
raw deal out of life. She is rather high-strung and duals with this passive and withdrawing lifestyle
believes that she feels things more, or more are unable to assert themselves appropriately and
intensely, than others do. She feels quite lonely are frequently taken advantage of by others.
and misunderstood at times. The client attests to Personality characteristics related to social intro-
having more fears than most people do. Her high version tend to be stable over time. Her generally
endorsement of general anxiety content is likely to reclusive behavior, introverted lifestyle, and ten-
be important to understanding her clinical picture. dency toward interpersonal avoidance may be
prominent in any future test results.
Profile frequency Her very high score on the Marital Distress
Scale suggests that her marital situation is quite
It is usually valuable in MMPI-2 clinical profile problematic at this time. She has reported a
interpretation to consider the relative frequency of number of problems with her marriage that are
a given profile pattern in various settings. The possibly important to understanding her current
client's MMPI-2 high-point clinical scale score (Pt) psychological symptoms.
is found in only 5.1% of the MMPI-2 normative
sample of women. Only 2.1% of the women have Diagnostic considerations
Pt as the peak score at or above a T score of 65, and
less than 1% have well-defined Pt spikes. This high Individuals with this profile have a severe
profile configuration (2±7/7±2) is very rare in psychological disorder and would probably be
samples of normals, occurring in 1.2% of the diagnosed as severely neurotic with an Anxiety
MMPI-2 normative sample of women. Disorder or Dysthymic Disorder in a Schizoid
Her MMPI-2 high-point score is relatively Personality. The possibility of a more severe
uncommon in various outpatient settings. In the psychotic disorder, such as Schizophrenic Dis-
NCS outpatient sample, only 6.4% of the females order, should also be considered, however. Her
have this MMPI-2 high-point clinical scale score self-reported tendency toward experiencing a
302 Objective Personality Assessment

depressed mood should be taken into considera- information contained in this report should be
tion in any diagnostic formulation. considered confidential.

Treatment considerations Ms. B. presents with a long-lasting discontent

with her life accompanied by mild depression
Individuals with this MMPI-2 clinical profile
often receive psychotropic medications for their which has worsened following her separation.
depressed mood or intense anxiety. Many indivi- She reports numerous physical complaints
duals with this profile seek and require psycholo- which might indicate somatization in the face
gical treatment for their problems along with any of stress or health concerns in accordance with a
medication that is given. Because many of their high level of general anxiety and the belief that
problems tend to be chronic, an intensive ther- nothing is working for her. While depressed the
apeutic effort might be required in order to bring patient has low self-esteem and feels hopeless.
about any significant change. Patients with this According to the patient, she was emotionally
profile typically have many psychological and abused as a child and sexually abused at the age
situational concerns; consequently, it is often
of 16. She feels tremendous guilt and a need to
difficult to maintain a focus in treatment.
She probably needs a great deal of emotional explain the past. There is a strong need for
support at this time. Her low self-esteem and approval and unconditional love. She blames
feelings of inadequacy make it difficult for her to herself for her parents' unhappiness in addition
get energized toward therapeutic action. Her to bringing shame on her family. While blaming
expectation for positive change in therapy may herself for everything that has gone wrong in her
be low. Instilling a positive, treatment-expectant parents' life as well as her own, she feels helpless
attitude is important for her if treatment is to be and insecure in the face of any challenges or
successful. problems. Following her separation, she reports
Individuals with this profile tend to be over- that life is full of difficulties and devoid of any
ideational and given to unproductive rumination.
They tend not to do well in unstructured, insight-
happiness or reinforcers.
oriented therapy and may actually deteriorate in
functioning if they are asked to be introspective. 10.12.3.3.2 Diagnostic impression
She might respond more to supportive treatment
of a directive, goal-oriented type. Individuals with According to the psychiatrist, Ms. B.'s
this profile present a clear suicide risk; precautions clinical diagnosis, at least for insurance pur-
should be taken. poses, was considered to be major depression.
The client endorsed item content that seems to Axis I: Major Depression
indicate low potential for change. She may feel that Axis II: Mixed Personality (borderline, passive-
her problems are not addressable through therapy aggressive, narcissistic, antisocial, histrionic,
and that she is not likely to benefit much from
psychological treatment at this time. Her appar-
and dependent)
ently negative treatment attitudes may need to be Axis III: Herpes.
explored early in therapy if treatment is to be
successful. 10.12.3.3.3 Treatment
Her item content suggests some family conflicts
that are causing her considerable concern at this Ms. B. was in therapy for a total of three
time. She feels unhappy about her life and resents years. She was prescribed Prozac, 40 mg, which
having an unpleasant home life. Psychological was later reduced to 20 mg. Her treatment plan
intervention could profitably focus, in part, on consisted of weekly individual therapy sessions
clarifying her feelings about her family. to address current stress due to her separation
In any intervention or psychological evaluation
program involving occupational adjustment, her
and divorce proceedings. Supportive therapy in
negative work attitudes could become an impor- a safe environment was provided to allow her to
tant problem to overcome. She has a number of discuss issues related to her childhood trauma
attitudes and feelings that could interfere with and acceptance of the past. According to the
work adjustment. therapist, Ms. B. was always demanding and
never satisfied with anything including therapy.
Note. This MMPI-2 interpretation can serve as a
useful source of hypotheses about clients. This
report is based on objectively derived scale indices 10.12.3.4 Seoul, Korea: The Case of Kim
and scale interpretations that have been developed Kim is a 36-year-old unemployed, unmarried
in diverse groups of patients. The personality
descriptions, inferences, recommendations con-
Korean man with two years of college educa-
tained herein need to be verified by other sources tion. Kim has been obsessed with suicidal ideas
of clinical information because individual clients (disembowelment) since 1992. He feels extre-
may not fully match the prototype. The informa- mely guilty and depressed. Kim feels that he has
tion in this report should most appropriately be to die, but he doesn't know what to blame for his
used by a trained, qualified test interpreter. The problems.
 Cases 303

In 1987, at the age of 27, Kim went to girlfriend whom he married. He also has troubles
Australia for his college education. In 1990, he with his new wife. Kim's brother also had some
stopped taking regular courses because of psychiatric problems when he was a high school
language difficulties and came back to Korea. student. At that time, he was worried that he
In 1992, he went to Australia again to continue would die of lung cancer even though he had no
his studies, but had a lot of difficulty in getting health problems. He was also very afraid that the
along with people, because he felt that people roof might fall down. Since then, he has not had
didn't like him and spoke ill of him behind his any mental problems. Kim also has a second
back. Kim decided to go to a psychiatric clinic brother, age 33, who runs a construction
but tried to jump off the roof of the hospital company and who is very close to the patient.
because he felt that some racists had followed
him to the hospital to kill him. A month later (in
10.12.3.4.2 Behavioral observations
September, 1992), Kim came back to Korea and
was extremely anxious because he thought the Kim does not talk easily with people and
Mafia would kill him and his family. A few prefers to keep a distance from others. He
weeks later, Kim tried to cut his wrist and was always worries about what other people think of
brought to a psychiatric hospital in Korea. He him or are saying about him, and is afraid that
was hospitalized with the diagnosis of schizo- he might make a mistake in front of people. Kim
phrenia, and remained at the hospital until spends most of the time staring at the wall or
January, 1993. lying in his bed. At times, he can be heard
After being released from the hospital, he talking to himself in a very loud voice.
stayed home in a relatively isolated state,
receiving outpatient treatment for a year. Kim 10.12.3.4.3 Symptomatic behavior
moved from job to job until the summer of 1995.
In November, 1995, Kim's brother suggested to Kim's symptoms and behavior reflect severe
him that they start a small construction psychopathology as is shown below.
company together. Kim was supposed to do (i) Thought control. He feels as though his
the jobs after his brother had made the business thoughts are being controlled by others, and
arrangements. However, three days before that somebody is telling him to jump off a
starting work, Kim began to feel extremely mountain or a building. He feels as though
anxious about the new business and suddenly other people are controlling his thinking pro-
told his family that he would kill himself. Kim cesses through the television or through birds.
was then brought to the hospital by his family (ii) Thought broadcasting or leaking. Kim
and was hospitalized. feels that other people know what he thinks
even though he says nothing to them. He feels
that, in spite of precautions, what he thinks just
10.12.3.4.1 Family history leaks out and he can not control it.
Kim's father is 80 years of age and owns a lot (iii) Idea of reference and paranoid ideas. Kim
of land in the southern part of Korea. However, feels that someone overhears his talking on the
he is extremely stressed about money and exists phone, and he suspects people around him are
on only minimal living expenses. He had trying to do him harm. He thinks that all
considerable trouble with his wife and children Koreans know that he has committed grave
because he was very stubborn, mean with offenses and are backbiting him.
money, and did not listen to anybody. He does (iv) Feels guilty and depressed. He says that
not get along well with people around him and is he feels depressed whenever he thinks about all
very indifferent to his children. Kim's mother, of his faults. He also reported that he feels more
who died in 1994, had received only six years of depressed since he failed to kill himself. Kim is
elementary school education. She was very worried now about how to kill himself.
introverted and passive, and had much trouble
with her husband who was verbally and 10.12.3.4.4 The Minnesota Report on Kim
physically abusive toward her. She relied on
her children and often told them how her The problems of Kim's psychopathology are
husband abused her. Her children were always clearly described in the MMPI-2 profiles of
on their mother's side. Kim has one sister (age Figures 11 and 12 and the following narrative
54) who is a pharmacist who worked at this report.
occupation and helped support her siblings until
she got married. Kim has a brother who is a 47- Profile validity
year-old obstetrician. He got married when he This MMPI-2 profile should be interpreted with
was in medical school and has a daughter. He caution. There is some possibility that the clinical
was divorced after a few years, because he got a report is an exaggerated picture of the client's
304 Objective Personality Assessment

MMPI–2
120

110

100

90

80

70

60

50

40

30
L F K Hs D Hy Pd Mf Pa Pt Sc Ma Si
Raw score 5 17 16 6 36 29 28 24 21 29 30 11 46
K correction 8 6 16 16 3
T score 56 89 51 54 85 69 77 46 90 89 84 38 74

Figure 11 MMPI-2 profile of Kim (1).

present situation and problems. He is presenting scales are scored from items in the first two-thirds
an unusual number of psychological symptoms. of the test, caution should be taken in interpreting
This response set could result from poor reading the MMPI-2 Content Scales and supplementary
ability, confusion, disorientation, stress, or a need scales, which include items found throughout the
to seek a great deal of attention for his problems. entire item pool
His test-taking attitudes should be evaluated for
the possibility that he has produced an invalid Symptomatic patterns
profile. He may be showing a lack of cooperation
with the testing or he may be malingering by This report was developed using the Pa and Pt
attempting to present a false claim of mental scales as the prototype. The client's MMPI-2
illness. Determining the sources of his confusion, clinical profile suggests that he is experiencing
whether conscious distortion or personality dete- many psychological problems at this time. He
rioration, is important because immediate atten- appears to ruminate a great deal and may manifest
tion may be required. Clinical patients with this obsessional or compulsive behavior. He holds
validity profile are often confused and distractible beliefs that others are not likely to accept and
and have memory problems. Evidence of delusions tends to obsess about them to the point of
and thought disorder may be present. He may be alienating others. He appears to be quite intense,
exhibiting a high degree of distress and personality anxious, and distressed. Individuals with this
deterioration. profile may be overreacting to environmental
The client's responses to items in the latter situations with intense anxiety, suspicion, and
portion of the MMPI-2 were somewhat exagger- concern. He feels insecure and inadequate when
ated in comparison to his responses to earlier dealing with his problems. He may feel very angry
items. There is some possibility that he became with himself and others, and he may feel very guilty
more careless in responding to these later items, about his fantasies or beliefs. Often rather rigid, he
thereby raising questions about that portion of the may have problems controlling and directly ex-
test. Although the standard validity and clinical pressing his anger.
 Cases 305

MMPI–2
120

110

100

90

80

70

60

50

40

30
ANX FRS OBS DEP HEA BIZ ANG CYN ASP TPA LSE SOD FAM WRK TRT
Raw score 7 5 11 27 3 10 3 5 6 5 17 17 10 19 18
T score 53 54 70 90 44 77 43 43 46 43 83 71 63 72 84
Figure 12 MMPI-2 profile of Kim (2).

Profile frequency (Arbisi & Ben-Porath, 1993) produce this high-

point peak score with 10.1% frequency; 9.1% of
Profile interpretation can be greatly facilitated the cases have Pa elevated above a T score of 65,
by examining the relative frequency of clinical and 6.1% of the cases are well defined.
scale patterns in various settings. The client's high- This elevated MMPI-2 pattern (6±7/7±6) is
point clinical scale score (Pa) occurs in 9.6% of the found in less than 1% of the males in the Graham
MMPI-2 normative sample of men. However, only and Butcher (1988) sample, in 2.6% of the males in
3% of the sample have Pa as the peak score at or the NCS inpatient sample, and in 1.7% of the men
above a T score of 65, and only 2.2% have well- in a Veterans Administration inpatient sample
defined Pa spikes. This elevated MMPI-2 pattern (Arbisi & Ben-Porath, 1993).
(6±7/7±6) is very rare in samples of normals,
occurring in less than 1% of the MMPI-2 norma- Profile stability
tive sample of men.
The frequency of this MMPI-2 high-point Pa The relative scale elevation of his highest clinical
score is relatively high in various inpatient settings. scale scores suggests some lack of clarity in profile
In the Graham and Butcher (1988) sample of definition. Although his most elevated clinical
psychiatric inpatients, this profile peak is the scales are likely to be present in his profile pattern
second most frequent peak score (15.7%) for if he is retested at a later date, there could be some
males, with 12.6% of the cases scoring in the shifting of the most prominent scale elevations in
clinically significant range (8.2% are well defined). the profile code. The difference between the profile
In the large NCS inpatient sample, this high-point type used to develop the present report and the
clinical scale score (Pa) is the third most frequent next highest scale in the profile code was 4 points.
peak score, occurring in 14.3% of the men. More- So for example, if the client is tested at a later date,
over, 12.1% of the males in the inpatient sample his profile might involve more behavioral elements
have this high-point scale spike at over a T score of related to elevations on D. If so, then on retesting,
65, and 7.5% are well defined in that range. Male pronounced complaints of depressed mood and
inpatients in a Veterans Administration setting low morale might become more prominent.
306 Objective Personality Assessment

Interpersonal relations tion in this report should most appropriately be

used by a trained, qualified test interpreter. The
Individuals with this profile tend to be ex- information contained in this report should be
periencing some interpersonal distress. The client considered confidential.
seems somewhat shy and may have excessively
high moral standards by which he judges others.
His inflexibility in interpersonal situations may
place a great strain on close relationships be- 10.12.3.4.5 Diagnosis
cause he seems to test other people to reassure
himself. He appears to be rather touchy or hos-
Possibly schizophrenia or delusional disorder.
tile interpersonally, and he may brood over what Rule out depression with psychotic feature.
he imagines others have done to him. He tends
to feel insecure in personal relationships, is
hypersensitive to rejection, and may become 10.12.3.5 Haifa, Israel: The Case of Yuri Z.
jealous at times. He tends to need a great deal
of reassurance. The patient, Yuri Z., is a 30-year-old male who
He is a very introverted person who has was born in Israel of Polish immigrant parents.
difficulty meeting and interacting with other He is married and he and his wife are expecting
people. He is shy and emotionally distant. He their second child. He has completed 13 years of
tends to be very uneasy, rigid, and overcontrolled education and at present he is a student in a large
in social situations. His shyness is probably university and works part-time as a security
symptomatic of a broader pattern of social with- guard. He was referred by the student counseling
drawal. Personality characteristics related to social
introversion tend to be stable over time. His
center of the university for psychological
generally reclusive behavior, introverted lifestyle, evaluation and possible treatment.
and tendency toward interpersonal avoidance may Yuri came to the clinic following a brief
be prominent in any future test results. course of couple therapy where he and his wife
were treated for severe marital problems.
Diagnostic considerations Following this family therapy Yuri decided to
seek further individual therapy even though he
His excessive anxiety and obsessive behavior
should be taken into consideration in the final still sees that separation from his wife is a
diagnosis. In addition, the possibility of a Paranoid possibility because their problems, though
Disorder or Paranoid Personality should be eval- lessened, are still present.
uated. Yuri is the youngest child in a family of four
siblings. His older sister is doing her residency in
Treatment considerations psychiatry at Harvard. He initially described his
Inpatients with this MMPI-2 clinical profile
family home life as ªloving, encouraging, and
usually have severe psychological problems as wonderful' but later in the session changed this
well as physical health concerns. Psychiatric interpretation to more rigid, Spartan, encoura-
treatment should focus on the client's anxiety ging to ªhold on,º and generally a ªstruggleº
and self-doubts. The use of medication to relieve much of the time. Yuri's parents are Holocaust
his intense tension should be considered. The survivors and the father is described as saying
possibility that he has suspicious or paranoid that he is not a victim of the Holocaust but a
ideas should be kept in mind when considering victor of the Holocaust. The father has tried to
psychological treatment options. He may have cut himself and his children off from the terrible
difficulty forming a therapeutic relationship. He is family history. The daughter, unlike Yuri, felt
quite rigid and intellectualizes a great deal;
therapeutic progress is likely to be slow. Indivi-
that the father did not allow her to grow and
duals with this MMPI-2 Clinical profile tend to develop her own identity and she disconnected
have unrealistic expectations of themselves and from the father a long time ago. Yuri sees his
perfectionistic ideals that may require some father as emotional, kind, and highly protective.
challenging if their personal vulnerability is to He described his mother as a model mother, a
be diminished. A therapeutic approach such as wonderful person. His mother is a nurse who
rational-emotive therapy might enable him to works with babies and who has always devoted
acquire more self-acceptance. herself to helping others. Later in the session he
described his mother as distant, cold, and
Note: this MMPI-2 interpretation can serve as a ªfrozen.º
useful source of hypotheses about clients. This Yuri is a very bright person who had been an
report is based on objectively derived scale indices
and scale interpretations that have been developed
excellent student all through his earlier school
in diverse groups of patients. The personality years. However, he had school behavior
descriptions, inferences, recommendations con- problems all the time. Yuri considers himself
tained herein need to be verified by other sources to have been an undiagnosed and untreated
of clinical information because individual clients hyperactive child. Due to behavior problems he
may not fully match the prototype. The informa- was suspended from junior high school for a
 Cases 307

month (this was very unusual in the school he Symptomatic patterns

was attending). The reason for the suspension, This report was developed using the Pd and Sc
after several reprimands, was his unexcused scales as the prototype. A somewhat mixed
absences from school. After a period of time he symptom picture is reflected in this profile. In-
was allowed to return to school. However, he dividuals with this MMPI-2 clinical scale config-
lost his motivation to attend the regular school uration tend to show a pattern of chronic
system and he transferred to another school. psychological maladjustment. The client appears
But when he learned about the possibility of to be unconventional and nonconforming, tending
going to a new kibbutz, he was excited, and left to act impulsively without regard for the con-
home despite his parents' objections, especially sequences. Apparently he is emotionally troubled,
and his behavior is unpredictable. He may be aloof
those of his mother who was afraid he wouldn't and withdrawn. He may also appear hedonistic
complete school. Yuri describes his years at the and may engage in dangerous or deviant behavior
kibbutz as the best time in his life. He felt as for the thrill of it. He may have a history of
though he had gained freedom, and enjoyed the unreliable and irresponsible actions, for which he
open land and young peers. often blames others. He tends to have low self-
He enlisted in the army, in a unit that esteem, a history of underachievement, and pro-
consisted mainly of persons who wished to live blems with authority. Excessive alcohol or drug
on a kibbutz. He served in an elite unit in that use is often found among individuals with this
corps. His mother died the day that he enlisted clinical pattern.
in the army. He served in the army for five years In addition, the following description is sug-
gested by the content of the client's item responses.
in what was described as a rigorous and very He had endorsed a number of items suggesting
hard duty, mostly in the field and in the front that he is experiencing low morale and a depressed
line, because ªI had nothing waiting for me mood. Although he may be socially assertive and
outside the army.º He saw many of his friends may project a positive image to others, his
die or be wounded and he participated in several response content indicates a rather negative self-
killings of enemy terrorists. Images of scenes image. He reports some antisocial beliefs and
from that period still recur in his dreams. He attitudes, admits to rule violations, and acknowl-
was a superb soldier in the army, but even there edges antisocial behavior in the past.
he had disciplinary problems because of his
irresponsible behavior at times. His underlying Profile frequency
personality problems persisted. Profile interpretation can be greatly facilitated
by examining the relative frequency of clinical
scale patterns in various settings. The client's high-
10.12.3.5.1 The Minnesota Report on Yuri Z. point clinical scale score (Pd) occurs in 9.1% of the
MMPI-2 normative sample of men. However, only
Yuri Z's personality problems are illustrated 3.3% of the normative men have Pd as the peak
in the MMPI-2 profiles of Figures 13 and 14 and score equal to or greater than a T score of 65, and
the following narrative report. only 1.0% have well-defined Pd spikes. This
elevated MMPI-2 profile configuration (4±8/8±4)
Profile validity is very rare in samples of normals, occurring in less
than 1% of the MMPI-2 normative samples of
This MMPI-2 profile should be interpreted with men. A high-point Pd scale score occurs in 10.3%
caution. There is some possibility that the clinical of the sample of military men (Butcher, Jeffrey,
report is an exaggerated picture of the client's et al., 1990). However, only 3% of the sample have
present situation and problems. He is presenting Pd equal to or greater than a T score of 65. Only
an unusual number of psychological symptoms. 2% of these high-point peaks are well defined at
This response set could result from poor reading that level of elevation.
ability, confusion, disorientation, stress, or a need He scored relatively high on AAS, suggesting
to seek a great deal of attention for his problems. the possibility of a drug- or alcohol-abuse pro-
His test-taking attitudes should be evaluated for blem. The base rate data on his profile type among
the possibility that he has produced an invalid residents in alcohol and drug programs should also
profile. He may be showing a lack of cooperation be evaluated. This MMPI-2 profile configuration
with the testing or he may be malingering by contains the most frequent high point, the Pd
attempting to present a false claim of mental score, among alcohol- and drug-abusing popula-
illness. Determining the sources of his confusion, tions. Over 24% of the men in substance-abuse
whether conscious distortion or personality dete- treatment programs have this pattern (McKenna
rioration, is important because immediate atten- & Butcher, 1987).
tion may be required. Clinical patients with this
validity profile are often confused and distractible Profile stability
and have memory problems. Evidence of delusions
and thought disorder may be present. He may be The relative scale elevation of the highest scales
exhibiting a high degree of distress and personality in his clinical profile reflects high profile definition.
deterioration. If he is retested at a later date, the peak scores on
308 Objective Personality Assessment

MMPI–2
120

110

100

90

80

70

60

50

40

30
L F K Hs D Hy Pd Mf Pa Pt Sc Ma Si
Raw score 4 16 7 5 20 18 33 33 15 29 34 23 37
K correction 4 3 7 7 1
T score 52 85 33 39 54 43 82 64 68 70 75 59 64
Figure 13 MMPI-2 profile of Yuri Z. (1).

this test are likely to retain their relative salience in relationships and social situations, and he may
his retest profile pattern. His high-point score on have some difficulty expressing his feelings to-
Pd is likely to remain stable over time. Short-term wards others.
test±retest studies have shown a correlation of 0.81 His very high score on the Marital Distress Scale
for this high-point score. Spiro, Butcher, Leven- suggests that his marital situation is quite proble-
son, Aldwin, and Bosse (1993) reported a moder- matic at this time. He has reported a number of
ate test±retest stability index of 0.62 in a large problems with his marriage that are possibly
study of normals over a five-year test±retest important to understanding his current psycholo-
period. gical symptoms.
The content of this client's MMPI-2 responses
Interpersonal relations suggests the following additional information
concerning his interpersonal relations. He views
Although his behavior is frequently seen as his home situation as unpleasant and lacking in
manipulative, he apparently lacks social skills. love and understanding. He feels like leaving home
Often misunderstanding the motives of others and to escape a quarrelsome, critical situation and to be
overly sensitive to rejection, he may appear aloof free of family domination.
and feel insecure in close personal relationships.
He may also greatly distrust others. He is probably Diagnostic considerations
behaving in unpredictable and erratic ways that
may produce a great deal of marital strain. Many Individuals with this profile usually receive a
individuals with this profile have serious marital diagnosis of Personality Disorder. His response
problems that require marriage counseling. content is consistent with the antisocial features in
He is somewhat shy, with some social concerns his history. These factors should be taken into
and inhibitions. He is a bit hypersensitive about consideration in arriving at a clinical diagnosis.
what others think of him and is occasionally His self-reported tendency toward experiencing a
concerned about his relationships with others. depressed mood should be taken into considera-
He appears to be somewhat inhibited in personal tion in any diagnostic formulation.
 Cases 309

MMPI–2
120

110

100

90

80

70

60

50

40

30
ANX FRS OBS DEP HEA BIZ ANG CYN ASP TPA LSE SOD FAM WRK TRT
Raw score 13 8 9 21 4 6 9 12 15 13 14 16 18 14 14
T score 67 64 63 80 48 63 59 52 69 64 75 68 85 63 74

Figure 14 MMPI-2 profile of Yuri Z. (2).

He has a number of personality characteristics The client is so emotionally and socially alienated
that are associated with a substance-use or abuse that it would be difficult for a therapist to gain his
disorder. The client's scores on the addiction confidence. Such individuals also tend to act out
proneness indicators, along with the personality problems rather than attempting to understand
characteristics reflected in the profile, suggests that and solve them.
he resembles some individuals who develop ad- Behavioral treatment that focuses on life man-
dictive disorders. A substance-abuse evaluation agement may be of value in teaching them more
should explore this possibility through a careful adaptive social functioning. Regardless of the
review of his personality traits and typical beha- treatment programs offered, their behavior may
viors. In his responses to the MMPI-2, he has change quite slowly and there may be many crises
acknowledged some problems with excessive use during the course of therapy.
or abuse of addictive substances.
Note This MMPI-2 interpretation can serve as a
Treatment considerations useful source of hypotheses about clients. This
Individuals with this profile often live stressful report is based on objectively derived scale indices
and crisis-filled lives and may need psychological and scale interpretations that have been developed
treatment to enable them to structure their lives in diverse groups of patients. The personality
better. They typically have a number of reality- descriptions, inferences, recommendations con-
based problems that complicate treatment on an tained herein need to be verified by other sources
outpatient basis. Although they may seek tempor- of clinical information because individual clients
may not fully match the prototype. The informa-
ary symptom relief or may be referred for psy-
chological treatment by another person or agency, tion in this report should most appropriately be
their long-standing personality problems make it used by a trained, qualified test interpreter. The
unlikely that they would profit much from in- information contained in this report should be
considered confidential.
dividual, insight-oriented psychotherapy. They are
evidently not very reflective or introspective and
would also have difficulty establishing a treatment After his discharge from the army he felt very
relationship because they mistrust other people. empty and depressed. He locked himself in at
310 Objective Personality Assessment

home for three months and was using drugs irrelevant to the manifestation of psychopathol-
extensively at this time. Afterwards he was ogy. It has been shown that, for example, child-
admitted to a technical program at the uni- rearing patterns in Italy might result in a
versity. Later in that year his father died. A year ªdramatization of symptomsº (Butcher &
later he went on a trip, a ªroot searching' tour to Pancheri, 1976; Zola, 1966) that is not noted
Poland. He described his parents' death as the in other cultures. However, such differences do
beginning of his crisis. He feels that he has never not greatly alter the main symptoms of disorder,
really processed or coped with their deaths. thereby resulting in some commonality for
disorders across cultures.
These case studies also provide an important
10.12.3.5.2 Treatment example with respect to objective personality
Yuri was admitted to the clinic's outpatient assessment. The study on computer-based
program for individual psychodynamically assessment across Norway, France, Australia,
oriented therapy. He comes quite regularly to and the USA shows that the empirical descrip-
sessions and has been in therapy for the last tion of MMPI-2 patterns has broad general-
eight months. izability whether interpreted by clinicians or by
the computer.

10.12.3.6 Cross-national Generality of

Psychopathology: What We Have 10.12.4 FUTURE DIRECTIONS
Learned from the Cases
Each year more foreign language translations
The case studies presented in this chapter of the MMPI-2 become available, providing
illustrate clearly the generalizability of the clinicians and researchers in other countries the
MMPI-2 across diverse cultures. As one can means of assessing clients in ways comparable to
see by reading the personality descriptions and those in the USA. The availability of objective
problem situations described in the clinical cases parallel methods of assessing psychological
from different countries, the MMPI-2 variables problems make it possible for joint international
are what one would expect to find if the patients research programs to examine psychopathology
were American patients assessed in the USA. cross-culturally. The MMPI-2 has shown con-
Moreover, these MMPI-2 profiles appear to be siderable adaptability across international
close matches with the cases, in spite of the fact boundaries. When careful translation and
that the profiles were generated on US norms. In adaptation procedures are followed to develop
addition, the computer-derived narratives, a sound translation, the MMPI-2 can be usefully
which were developed on research conducted employed in clinical assessment in other
in the USA, show close matches when the languages and cultures. Moreover, the trans-
reports are applied in other countries. lated version of the MMPI-2 appears to have a
How can an instrument developed in one high degree of accuracy in characterizing
language and culture show such robustness personality and patient problems even with
when applied to patients in other cultures who clients being assessed in very diverse settings.
responded to translated versions of the items? What can one conclude from this body of
Several factors account for this correspondence research?
of patient description across cultures. Research The research reported here supporting the
in cross-cultural psychopathology has shown questionnaire approach to psychopathology
that mental disorders and diagnostic systems are should assure psychologists from other coun-
comprised of similar symptom patterns in tries about the transportability of the MMPI-2.
different culturesÐa schizophrenic is a schizo- The utility of the instrument in making clinical
phrenic regardless of culture. Many similar decisions has been amply demonstrated through
disorders show common patterns of symptoms several international projects, and MMPI-2
across cultural boundaries. profiles can add a salient dimension to clinical
Similarly, the MMPI-2 items sample a broad decision making in other countries. Psycholo-
range of symptoms and problems constituting gists and psychiatrists in other countries who are
the abnormal syndromes. Given a well trans- interested in studying psychopathology across
lated item set, resulting in an equivalent form, different cultures or national groups might
the symptoms are found to describe well the consider employing an objective measuring
disorders in each culture. Patients who are instrument, like the MMPI-2, to assess symp-
depressed, for example, tend to respond to the toms of disorder.
same types of items in the cultures studied here, The accuracy of automated test interpreta-
producing familiar personality profile patterns. tion has been demonstrated in the research
This is not to say that cultural factors are reported here, and should provide researchers
 References 311

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in psychopathology. When a computer-based Psychological Association guidelines for computer-based
tests and intepretations. Washington, DC: Author.
interpretation, developed on normals and Arbisi, P., & Ben-Porath, Y. S. (1993, March). Interpreting
patients in the USA, is applied in international the F scales of inpatients: Moving from art to science.
contexts, the resulting reports characterize well Paper presented at the 28th Annual symposium on
the patients in other countries. This finding has Recent Developments in the Use of MMPI/MMPI-2/
MMPI-A. St. Petersburg Beach, FI.
great implications for cross-cultural research on Berah, E., Butcher, J., Miach, P., Bolza, J., Colman, S. &
psychopathology in that subjectivity in inter- McAsey, P. (1993, October). Computer-based interpreta-
pretation in cross-cultural psychopathology tion of the MMPI-2: An Australian evaluation of the
comparisons can be substantially reduced. Minnesota Report. Poster presented at the 28th Annual
Conference of the Australian Psychological Association,
Gold Coast.
10.12.5 SUMMARY Berah, E., Miach, P., & Butcher, J. N. (1995, June). The
MMPI-2 downunder: Validation of computer-based inter-
Psychologists have explored the use of pretive reports in Australia. Paper given at the 15th
International Conference on Personality Assessment.,
computers to interpret psychological tests for Haifa, Israel.
many years. The first psychological test to be Butcher, J. N. (Ed.) (1987). Computerized psychological
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Since then a number of computer interpretation Butcher, J. N. (1995). How to use computer-based
systems have become available in the USA. personality test reports. In J. N. Butcher (Ed.), Clinical
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Butcher, J. N. (1996). International adaptations of the
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approach. This chapter describes an empirical lis, MN: University of Minnesota Press.
evaluation of computer-based MMPI-2 reports Butcher, J. N., Jeffrey, T., Cayton, T. G., Colligan, S.,
on Australian, French, Norwegian, and Amer- DeVore, J., & Minnegawa, R. (1990). A study of active
ican patients. The patients were administered duty military personnel with the MMPI-2. Military
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the MMPI-2 and computerized Minnesota Butcher, J. N., Narikiyo, T., & Bemis-Vitousek, K. (1992).
Reports were generated. Clinicians familiar Understanding abnormal behavior in cultural context. In
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MMPI in Australia. Unpublished manuscript.
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Adcock, C. J., & Richie, J. E. (1958). Intercultural use of France. In J. N. Butcher (Ed.) International adaptations
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applications (pp. 395±415). Minneapolis, MN University (1989). Estandarizacion del Inventario Multifasico de
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Graham, J. R. & Butcher, J. N. (1988, March) Differentiat- adulta Chilena [Standardization of the Minnesota Multi-
ing schizophrenic and major affective disorders with the phasic Personality Inventory (MMPI) in the adult
revised form of the MMPI. Paper presented at the 23rd Chilean population]. Revista Chilena de Psicologia, 10,
Annual Meeting of the Symposium on Recent Develop- 41±62.
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Doctoral dissertation, University of Minnesota. ality assessment. Proceedings of the Staff Meetings of the
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 Copyright © 1998 Elsevier Science Ltd. All rights reserved.

10.13
Mental Health in the Arab World
MARWAN DWAIRY
Nova Southeastern University, Oakland Park, FL, USA

10.13.1 INTRODUCTION 313

10.13.2 ARAB SOCIOCULTURAL HISTORY AND POPULATION 313
10.13.3 PSYCHOCULTURAL FEATURES OF ARABS 314
10.13.4 CLINICAL ASSESSMENT CONSIDERATIONS 315
10.13.4.1 Manifestations of Psychosocial Disorders 315
10.13.4.2 Psychometric Characteristics 316
10.13.5 HELP-SEEKING BEHAVIOR 316
10.13.5.1 Traditional Arab Theory of Psychotherapy 318
10.13.6 EPIDEMIOLOGY OF CLINICAL PROBLEMS 318
10.13.6.1 Psychiatric Morbidity 318
10.13.6.2 Distribution of the Disorders 319
10.13.7 HEALTH SERVICE DELIVERY SYSTEM 320
10.13.8 FUTURE DIRECTIONS 321
10.13.9 SUMMARY 322
10.13.10 REFERENCES 323

10.13.1 INTRODUCTION countries? These points are addressed in this

chapter, and suggestions are offered to psy-
Compared to most Western societies, Arab chotherapists for tailoring their therapies to the
societies are more collectivist and authoritarian, Arab client.
and Arab individuals thus adhere more closely
to social values and norms. The relationship of 10.13.2 ARAB SOCIOCULTURAL
the Arab individual to the family is character- HISTORY AND POPULATION
ized by interdependence, resulting in people
who are less individuated than the typical Arabs are currently living in 21 countries to
Westerner. How do these sociocultural factors the east and south of the Mediterranean sea, and
affect the Arabsº personality characteristics? in the Arabian peninsula. The vast majority are
How does the Arabic culture influence the Muslims; however, a minority of Christians
epidemiology and manifestations of psycholo- reside in Syria, Lebanon, Palestine, Jordan, and
gical disorders? How do Arabs perform on Egypt, and a minority of Druze in Syria,
psychological tests? Given the individualistic Lebanon, and Palestine. Despite the socio-
background of psychotherapy, how do Arabs cultural diversity among Arabs, all share a
regard psychotherapy, and how do they deal historical experience that has shaped certain
with their psychological disorders? What kind sociocultural features of contemporary Arab
of mental health system exists in Arabic life.

313
314 Mental Health in the Arab World

Before the birth of Islam in 622, Arabs had The second cultural dimension, ruler±ruled,
lived in the Arabian peninsula, Syria, and Iraq, helps to explain the hierarchy of authority in
in a tribal social system characterized by most Arabic societies, in which men and elders
collectivism and authoritarianism. From the have exerted power over women and children
beginning of Islam until the fifteenth century, (Budman, Lipson, & Meleis, 1992). Children are
Arabs experienced the glory period of the Arab- typically expected to obey the rules of the family
Islamic empire, in which they were the rulers of a and to modify their own desires for education, a
state that expanded from Iran in the east, job, and marriage, to meet family expectations.
through North Africa, to Spain in the west. In Females are expected to maintain the family's
this period, Arabs combined their tribal cultural honor by chaste behavior, marrying through the
heritage with the new values of Islam. Between family's arrangement or approval, and produ-
the sixteenth and nineteenth centuries there was cing male children (Budman et al., 1992). In
a stagnation period, in which they were many Arab families, boys are regarded as an
governed by other Muslim states such as the asset, whereas girls are a liability (Sharabi,
Mamlukes and Ottomans (Turks). In the last 1977).
two centuries, two important processes have Socioeconomic styles of life explain much of
taken place in the Arab world: a massive the variance within the two cultural dimensions.
exposure to the democratic, more individualistic Three major socioeconomic groups are found
values of the West, and the establishment of among Arabs: Bedouin (nomadic), rural, and
separate independent states (Fattal & Sokari, urban. There has been a tremendous urbaniza-
1988; Mansfield, 1991). tion process since the late 1980s. Although the
Four main historical periods can be identi- majority of Arabs have lived rural or Bedouin
fied, each noteworthy for a different collective lives for centuries, endorsing a collective life-
experience: tribal, rulers, ruled, and westerniza- style, by the end of the twentieth century, 70%
tion, successively. New periods added new of Arabs will live in cities. Although living in a
layers of values that interacted with the former city is generally associated with less dependence
ones, such that each period is represented in on the family and less social control, collecti-
contemporary Arab culture. In this way, the vistic values are still esteemed. In fact, most
contemporary values of the Arab-Muslim Arabic cities do not meet all of the basic human
people vary along two main dimensions: (i) needs; many urban citizens continue to work in
collectivism±individualism, the first stemming agriculture and to maintain cohesive family
from the tribal heritage and the second from relationships (Barakat, 1993; Fattal & Sokari,
exposure to the West; and (ii) ruler±ruled, the 1988). Thus, most urban, as well as rural and
first with roots in the Arab-Muslim empire and Bedouin families continue to endorse a tradi-
the second from the period of stagnation tional collectivistic way of living (Dwairy,
(Dwairy, 1997b, 1998). 1997b, 1998).
These two-dimensional value structures help
to explain the cultural diversity among Arabs
today. For example, the first cultural dimension 10.13.3 PSYCHOCULTURAL FEATURES
would show that the majority of Arabs have OF ARABS
adopted a traditional collectivistic way of life, in
which the family is the primary social unit. The Certain psychological features of Arabic
identity of the individual is derived from the culture are derived from the collectivistic and
family (Dwairy & Van Sickle, 1996; Meleis & La authoritarian structures in Arabic societies and
Fever, 1984), and family interests take priority are typified as follows:
over individual ones (Timimi, 1995). Family (i) External locus of control. As a result of the
affairs are kept within the family, away from actual helplessness of the individual who lives in
external intrusion (Meleis & La Fever, 1984). a collective authoritarian society, he or she
Familial affiliation is central for the majority of learns to believe that life events are determined
Arabs, as it meets the basic needs of the by external powersÐfamily, social leaders, or
individual in exchange for the individual's God. Religious people believe that their destiny
adherence to family values and norms is maktoob (written). Therefore, they do not feel
(Dwairy, 1997b, 1998). The development of responsible for their behavior or the events in
an independent identity is not encouraged which they have been involved (Al Khani,
(Gorkin, Masalha, & Yatziv, 1985; Timimi, Bebbington, Watson, & House, 1986; Bazzoui,
1995). In addition to the collectivistic majority, 1970).
there is a portion of Arabs that has to some (ii) Interpersonal rather than intrapsychic
degree assimilated into the Western individua- sources of distress. Arab individuals are condi-
listic culture, or has adopted a bicultural way of tioned through external threats of sanctions,
life (Dwairy, 1997b, 1998). making external controls more significant than
 Clinical Assessment Considerations 315

internal (superego) ones. Therefore, shame distress, in general, are expressed in somatic
rather than guilt dominates (Gorkin et al., terms (Dwairy, 1997c). This is the legitimate
1985; Sharabi, 1975, 1977), and interpersonal way of expressing personal problems (Budman
coping strategies become more effective than et al., 1992; Racy, 1980). Sometimes somatic
intrapsychic defense mechanisms (Dwairy & complaints are, indeed, the only expression of
Van Sickle, 1996). psychological distress.
(iii) Indirect expression of emotions. In Ara- Bazzoui (1970), for example, has identified
bic socities, people tend to avoid expressing certain characteristics of depression among
negative emotions such as anger and jealousy patients in Iraq that are different from what
towards family members (West, 1987). Indivi- is common in the West. Iraqi depressed patients
duals are expected to exhibit emotions congru- show milder (and sometimes an absence of)
ent to societal norms (mosaiara), and to hide mood changes. Mood changes were found in
authentic expressions. Other emotions are ex- only 34% of depressed cases, and only 37% of
pressed through acting out behaviors away manic cases displayed an elated mood. Feelings
from the attention of others (isligaba) or of guilt and worthlessness were almost absent
through body language (Dwairy, 1997b, 1998; among the depressed (only 13.8%). Suicidal
Sharabi, 1975). thoughts and attempts were rare. Physical
(iv) Unindividuated self. The psychological symptoms and hysterical behavior were the
autonomy and individuation that many Wes- most outstanding features of depression, found
tern psychosocial theories describe bear only in 65.5% of the cases. Fear of breaking the rules
limited relevance to the common pattern of or shaming themselves and their families was
psychosocial development in Arabic cultures much more dominant than feelings of individual
(Dwairy & Van Sickle, 1996; Gorkin et al., responsibility and guilt (Bazzoui, 1970). Similar
1985; Timimi, 1995). An Arab's identity is findings were reported for Sudanese depressed
derived from the family, self-concept is en- patients (Baasher, 1962).
meshed in the family concept, and an indivi- Paranoid ideation, projection of responsibil-
dual's needs, attitudes, and values stem from ity, aggression, and ªnoisinessº were prevalent
those of the family. (47.5%) among hypomanic cases, and less
common (27.6%) among depressed cases in
Iraq. Interestingly, about one-quarter of the
10.13.4 CLINICAL ASSESSMENT depressed population in the Iraqi study ex-
CONSIDERATIONS pressed a desire to run out of their homes into
the wilderness, but this impulse was acted upon
Unfamiliarity with the Arabic culture may
in only a few cases (Bazzoui, 1970). Bazzoui
cause the clinician to misinterpret or patholo-
attributes these differences to the lack of
gize certain cultural behaviors. Overdependence
individuated ego that is necessary to experience
on the family, overprotective parents, avoid-
worthlessness. She suggests, moreover, that
ance of touching the opposite sex, passivity,
clinicians can diagnose Arab patients with
ambivalence, reluctance to reveal family mat-
depression even without the presence of miser-
ters, hesitation in making personal decisions,
able feelings (a hallmark feature for depression
and time-related problems are culturally normal
in the West), and with mania even when elated
and should not be considered as signs of
mood is absent.
immaturity or resistance (Budman et al.,
According to Okasha and his colleagues, the
1992). An Arab male inpatient's reluctance to
obsessive-compulsive disorder (OCD) manifes-
make his bed or to clean his room is probably
tations in Egypt are colored by Islamic religious
not resistance or regression; rather, it may well
rituals and beliefs that make the differential
be his normal way of living (Meleis & La Fever,
diagnosis difficult. Interestingly and in contrast
1984).
to one of the DSM-IV criteria for OCD, most
OCD subjects in the Egyptian study did not
10.13.4.1 Manifestations of Psychosocial recognize the absurdity of their symptoms
Disorders (Okasha, Saad, Khalil, Seif El Dawla, &
Yehia, 1994).
Because of the sociocultural background of Okasha and his colleagues also studied the
Arabic patients, the manifestations of some manifestations of psychosis in Egypt. Delu-
psychological disorders may vary from those sions, depression, excitement, hallucinations,
described in the Diagnostic and statistical worrying, delayed sleep, and irritability were the
manual of mental disorders (4th ed.) (DSM- most common presenting symptoms of Egyp-
IV, American Psychiatric Association, 1994). tian psychotic patients. The onset of acute
Due to the holistic cultural attitude toward psychosis occurred within five days in 68% of
mind and body adopted by Arabs, conflicts and the cases. A stressor preceded the onset of
316 Mental Health in the Arab World

psychotic symptoms in 74% of the Egyptian and concern for socially sanctioned behavior
cases, and correlated positively with a favorable and social desirability were more important
prognosis at the one year follow-up. During this personality factors among Egyptians than the
same follow-up period, 64% of the cases had neuroticism, psychoticism, and extraversion
fully remitted. The social and clinical outcomes which are more common cultural features in
of the cases were not correlated with family the West (Ibrahim, 1982). The latter three
psychiatric history (Okasha, Seif El Dawla, factors do also apply in Arab societies, however
Khalil, & Saad, 1993). (Farrag, 1987).
The results of Okasha and colleagues agree Based on clinical experience and field re-
with other studies that show similar psychotic search, the present author has found the
syndromes among other non-Western cultures following psychometric characteristics of Pa-
(Cooper, Jablensky, & Sartorius, 1990), and lestiniansº performance on some well-known
validate the presence of a special psychotic (Western-developed) psychological tests:
diagnostic category. This kind of psychosis is (i) Wechsler Intelligence Scale for Children-
normally precipitated by stress, has an acute Revised (WISC-R). Compared to Jewish stu-
onset, and most patients recover rapidly. dents, Arab elementary school students in Israel
Associated symptoms are rather polymorphic, had significantly lower IQ scores. The most
and include schizophrenic, affective, and neu- common difficulties were in the similarities and
rotic symptoms. comprehension subtests. The only subtest on
El-Islam (1979) reported that Arab schizo- which Arab students outperformed Jewish
phrenics belonging to extended families had less students was information. These differences
malevolent manifestations, and were found to may be at least partially explained by the
be less prone to deterioration into affectively culturally alien test items given to Arab stu-
blunted and withdrawn states than nuclear dents. In addition, these scores reflect the
families. Arabic educational climate that encourages rote
Some delusional cultural beliefs, such as the learning and discourages analytical thinking
devil, Jinn, sorcery, and the evil eye, may and the decision-making process.
mislead the therapist who is not familiar with (ii) Bender-Gestalt and draw-a-person. In
these beliefs (El-Islam, 1982). Much bizarre both tests, performance of Arab students is
behavior which seems to be psychotic may similar to that of Americans until age seven,
occur: unacceptable wishes, feelings, and acts then the Arab scores show a comparative
are liable to be projected onto the devil and decline. At age 10±11, the performance of Arabs
appear as wiswas, or jinn possession. Wiswas is a is equivalent to eight-year-old American chil-
rumination involving aggressive or sexual dren. This lag may be explained by the lack of
impulses that are attributed to the devil, encouragement for graphic activity by Arab
enabling people to avoid responsibility and parents and educators.
guilty feelings. Jinn possession permits acting (iii) Rorschach. The performance of 50 Arab
out of forbidden drives, while claiming to be students, age 16, was compared to a similar age
unaware of and not responsible for these acts group of Westerners (reported by Levitt &
(El-Islam, 1982). Truumaa, 1972). Only slight differences were
Thin lines differentiate pathological delusions found. Arab students showed lower R (17.2 vs.
from cultural ones. Sometimes hallucinations 20.8), higher W (35% vs. 21.9%), lower P (4.5
may lose their perceptual quality and their vs. 5.3), and higher shading scores. All other
contents are regarded as devil-induced scores were equivalent.
thoughts. El-Islam (1982) noted that paranoid
delusions may become normalized into ideas
which are in keeping with beliefs about the evil 10.13.5 HELP-SEEKING BEHAVIOR
eye or sorcery.
Generally speaking, Arabs tolerate their
psychological distresses for a long time before
10.13.4.2 Psychometric Characteristics seeking help. Among the Palestinian clients who
sought help in the author's clinic in Nazareth,
Few studies have addressed psychometric Israel, 44.2% came to therapy after years of
aspects among Arabs. Ibrahim (1977, 1979, hesitating, and another 44.2% came after
1982) found some psychometric features among months. Only 11% of the clients came after a
Egyptians. He found Egyptian students to be couple of weeks, and 0.6% came without any
more dogmatic than Western students (Ibrahim, delay (Dwairy, 1997b, 1998).
1977), and less extraverted than Americans and Arabs consider engaging in psychotherapy to
British (Ibrahim, 1979). He found that cultural be an admission of being crazy. Therefore,
features such as oversensitiveness, superstition, distressed people avoid this stigma by avoiding
 Help-seeking Behavior 317

therapy. Furthermore, Arabs believe that be referred to hospitals more than men. The
physicians, native healers, religious figures, or ratio between women and men in Saudi
family members are the proper alleviators of psychiatric hospitals was 1.6:1 (Rufaie &
illnesses and distress. Seeing a psychiatrist or Mediny, 1991).
psychologist is a last resort (Okasha et al., 1994; Arab clients typically are unaware of their
Timimi, 1995). mood and emotions. Initially, they present very
Traditional and religious healers play a major supportive family relationships, and present
role in primary psychiatric care in Arab their complaints in somatic terms, using
countries. They use religious and group psy- metaphoric styles, such as ªmy heart feels like
chotherapies, and devices such as amulets and a dark room,º or ªmy heart is deadº (Bazzoui,
incantations. An estimated 60% of outpatients 1970; Timimi, 1995). Based on the belief that
at the university clinic of Cairo, which serves life, as well as the future, is ªin the hands of
patients of low socioeconomic levels, have Allah (God),º clients do not assume responsi-
sought treatment from traditional healers bility for their pathological actions (West,
before coming to a psychiatrist (Okasha, 1987). They place the responsibility for change
1993; Okasha, Kamel, & Hassan, 1968). on the therapist. They often appear silent,
Arab families discourage long-term hospita- expecting the therapist to do all of the work.
lization or institutionalization for their patients. Because they regard comprehensive assessment
They feel they have the right and responsibility as intrusive, they become uncommunicative
to be the caretakers of the unfortunate members when asked probing questions, and endeavor to
of their family. Okasha (1993) reported that absolve the family from responsibility for the
caring for an elderly demented person outside of illness. Their answers are often vague and
the family is considered shameful; Egyptians, unspecific because they question the relevance
therefore, prefer to assimilate chronic mental of this personal information to their health
patients. The parents of retarded or hyperactive (Meleis, 1981; Meleis & La Fever, 1984). The
children also feel a primary responsibility concept of working to improve the self is
towards them rather than relinquishing them generally nonexistent in Arab cultures (West,
to institutionalized care (Okasha, 1993). Similar 1987). All these culture-bound behaviors are
attitudes seem to exist in Qatar (El-Islam, 1982). frequently misinterpreted by Western clinicians
During hospitalization, Arab families do not as resistance or lack of maturity (Dwairy, 1997a,
discontinue their supportive role; on the con- 1998).
trary, family members and friends volunteer to Typically, Arab patients expect an instant
attend to the patient. Groups of them stay with cure and assume that medication by intrusive
the patient for hours in the hospital, comforting methods (injections rather than pills) is most
him or her, bringing food from home, and effective (Meleis & La Fever, 1984). They do not
offering their help. This cultural system of believe that talk therapy is worth paying for,
support seems unusual for the Western practi- unless it is direct advice. Long-term and non-
tioner and may be considered intrusive. Meleis directive therapy may confuse and frustrate the
and La Fever (1984) reported that nurses and patient (Dwairy & Van Sickle, 1996; Gorkin
doctors in the USA often label Arab family et al., 1985; West, 1987).
members ªanxiousº and ªintrusive,º consider Despite the above, psychotherapists are
Arab patients ªunpopularº or ªchronic,º and considered an authority in Arab societies.
give them less time and personalized attention. Influenced by sexist attitudes, however, Arab
Males are currently approaching psychother- clients prefer and respect male rather than
apy more than females. Among the clients of the female therapists. Female therapists experience
author's clinic, 65.3% were males. Similarly, greater difficulties. Racy (1980) reported that
more males than females were represented in even Saudi Arabian women preferred a male
outpatient clinics in Cairo (Okasha et al., 1994). therapist.
It seems that women may be more vulnerable to He also described in detail the behavior of
the stigma of psychotherapy. For example, the Saudi female patients. He reported that typi-
family does its best to hide, and manage at cally they would come to the clinic veiled and
home, psychological disorders of females. They accompanied by a male member or several
may even consider some disorders normalÐ members of the family. They would limp in,
such as anxiety and phobias. Males, on the other leaning on the arms of a male relative. Dropping
hand, are less vulnerable and could not be heavily into a chair, they may remain quiet and
hidden at home. They are therefore referred veiled until spoken to. Their demeanor reflects
more easily (El-Islam, 1969, 1982). It seems that passivity to an extreme. Initially, they may say
psychiatric assistance is expedited for women nothing and refer the question to the accom-
only in severe cases, when the decision is finally panying relative. Shoulders are frequently
made by the family. Therefore, women seem to shrugged and ªI don't knowº is a common
318 Mental Health in the Arab World

answer. They will answer only when pressed. To undo the effects of Jinn, sorcery, or the evil
Interpersonal and psychological difficulties are eye, some rituals may be performed. Examples
usually denied, and the therapist is assured that are antisorcery and antienvy rituals, including
all is well and everyone is happy. Anger is the use of amulets containing verses of the
transformed into sadness, disappointment, and/ Qura'an (Muslim holy book), fumigation with
or self-blame, particularly when the object of incense, visits to the tombs of religious sheikhs,
anger is present. The patient may express her and purification rituals that involve drinking or
problem in somatic terms that prevent her from washing in water that has been washed off
attending to her household duties and force her Qura'anic verses written on a plate (El-Islam,
to spend much time resting. She does not assume 1982).
responsibility for her illness nor does she accuse Another common ritual is the Zar cere-
anyone else. She expects to be examined and mony. In this ceremony, participants experi-
prescribed a medication. Injections and large, ence states of trance under the influence of
colored pills are preferred (Racy, 1980). drumming, chanting, and dancing, during
In other Arab countries, especially in urban which they express worries and wishes that
populations, the behavior of Arab clients may are otherwise socially prohibited. Each song is
be very different from that of the Saudi example. directed by the Zar healer to a particular spirit
Racy (1977) reported that among urbanized which, if present in the body of a member of
Arabs, the behavior of depressive patients is the audience, will speak through him. It is to
approaching that in the West. Among the the spirit that strange wishes are attributed.
Palestinian clients of the author's clinic, 29.6% Such wishes must be answered, for example,
came without informing their families, and by sacrifices to placate the spirit and to
12.9% came in spite of family opposition persuade it to leave the possessed body. Birds,
(Dwairy, 1997b, 1998). rams, and lambs are often slaughtered as
It is difficult to maintain professional relation- sacrifices, and parts of them are then eaten by
ships and boundaries with Arab clients. They the person to be exorcized. Blue beads or
often prefer to discuss problems in a social visit figures involving the number five, such as hand
to their homes rather than in a formal session at symbols, are frequently used to protect people
the clinic. They may come late to the session or from the evil eye, sorcery, and Jinn (El-Islam,
appear on the wrong date, or they may invite the 1982).
therapist to the family home, or to a meal with In adddition to the aforementioned treatment
the family. The therapist's negative response to types, marriage is often regarded as ªthe cureº
such behavior is likely to be seen as insulting. for Arab patients. Schizoid, retarded, and
Although many clinicians have reported the depressed individuals may be forced into
difficulties of Arab clients in long-term therapy, marriage by family elders on the assumption
no information has been reported about the that marriage will take them out of their
attrition rate. In the author's clinic, only 15% seclusion and improve their health, an assump-
remained in therapy for more than 10 sessions, tion which is often disproved when they
and 49% dropped out after they achieved initial experience psychotic episodes soon after mar-
relief during 5±10 sessions. The rest were riage (El-Islam & El-Deeb, 1968).
referred to other kinds of treatment (hospitals
or psychiatrists) after the intake session or after
reaching an impasse (Dwairy, 1997b, 1998). 10.13.6 EPIDEMIOLOGY OF CLINICAL
PROBLEMS
Epidemiological psychiatric studies are lim-
10.13.5.1 Traditional Arab Theory of ited or localized in Arab countries, which makes
Psychotherapy it difficult to reach comprehensive conclusions
without the risk of inappropriate generaliza-
Germ theory and the evil eye have long
tions. The main findings currently available are
provided explanations for illness (Meleis, 1981).
outlined below.
Traditional Arabic beliefs about the origin of
psychological problems frequently have linked
them to supernatural causes: God, sorcery, or 10.13.6.1 Psychiatric Morbidity
the evil eye. Many Arabs believe that evil
thoughts could be transferred to another person Based on Western measures, many studies
through witchcraft or directly through the eye. have reported higher psychiatric morbidity
The Arabic word for madness is Junoon, derived among Arabs than Westerners. Ibrahim and
from the word Jinn, meaning evil spirit (Timimi, Ibrahim (1993) reported higher neuroticism and
1995). ªBad nervesº or ªfailure to eatº are other lower extraversion scores among Egyptians
common explanations (Budman et al., 1992). compared to Americans and British. They also
 Epidemiology of Clinical Problems 319

reported higher social anxiety and shyness were represented among hospitalized patients in
among Libyan students than a comparable Saudi Arabia (Rufaie & Mediny, 1991), sug-
Western cultural group. The high level of gesting the existence of covert morbidity among
anxiety and the tendency to develop neurotic Saudi women. The unmarried, widowed, sepa-
disorders under stress were attributed to the rated, polygamously married, and childless
social constraints imposed on individuals in women were at high risk for psychiatric
Arabic societies (Ibrahim, 1979; Ibrahim & morbidity in Dubai (Ghobash et al., 1992),
Ibrahim, 1993). and for somatization disorder in Saudi Arabia
Based on the clinical interview schedule, the (El-Islam, 1982).
point prevalence rate of psychiatric morbidity It seems that in less traditional Arabic
among patients of a primary health care center societies than Saudi Arabia, men rather than
in the United Arab Emirates was 27.6% (El- women tend to express their complaints in
Rufaie & Absood, 1993). A high prevalence somatic terms. Among the Palestinian clients of
(26%) was also found in Saudi Arabia (El- the author's clinic, for example, men were more
Rufaie, Albar, & A-Dabar, 1988) and Dubai likely to express their distress by physical
(22.7%) (Ghobash & Bibbington, 1994; Gho- symptoms, whereas women tended to express
bash, Hamdi, & Bibbington, 1992). These rates their feelings of anxiety, fear, and depression
were higher than those found in four other directly. Expressions of anxiety, fear, and
developing countries (Colombia, India, Sudan depression are normally considered signs of
[an Arabic country], and the Philippines), in weakness in Arab societies. Therefore, it is more
which the prevalence was between 10.6 and accepted among females, but detracts from the
17.7% (average 13.9%) (Harding et al., 1980). manhood of the Arab male, so somatic
Some studies have indicated that the high complaints may be more legitimate and less
morbidity in Saudi Arabia and the Gulf states ªdamagingº for him (Dwairy, 1997b, 1998).
is associated with sociocultural changes (Ibra- Children are also a higher risk group.
him & Al-Nafie, 1990). Children represent 65% of outpatient visits in
In Dubai, psychiatric morbidity was found to Saudi Arabia; almost 35% of them showed
be increased among women when their attitude psychiatric disturbances that warranted inten-
and behavior departed considerably from each sive care (Ibrahim & Ibrahim, 1993; Tuma,
other. For example, psychiatric morbidity was 1989). Children in Sudanese nuclear families
particularly high for women harboring tradi- had more conduct, emotional, and sleep
tional beliefs but behaving less conventionally problems, and were more likely to be over-
(Ghobash & Bibbington, 1994; Ghobash et al., dependent than those living in extended families
1992). (Al-Awad & Sonuga-Barke, 1992).
Conflicts between the traditional collectivistic Many areas in the Middle East such as
authoritarian values and the individualistic Lebanon, Palestine, Iraq, Kuwait, and Sudan,
liberal ones contribute heavily to the distress have been fraught with extreme and continuous
of Arabs. According to El-Islam (1979, 1982), stressors in the last decade, because of war and
intergenerational conflicts precipitated 50% of occupation. Many studies have indicated a high
suicide attempts, 20% of neuroses, and 17% of prevalence of psychological disorders in those
schizophrenic illness among young Arab pa- areaÐespecially among children. Of Lebanese
tients. Among the clients of the author's clinic, children, 20±30% have exhibited at least one of
18.1% of them exhibited client±family conflict the following types of behavioral problem:
by bringing it into therapy at the beginning, and hyperactivity, overdependence, aggression, de-
47.6% brought it during the course of therapy. pression, or social misbehavior, and 58% have
Only in 34.3% of the cases had this familial exhibited psychosomatic problems (Chimienti
conflict not emerged at all in therapy (Dwairy, & Abu-Nasr, 1992±93; Nassar, 1991). A high
1997b, 1998). prevalence of psychological disorders has been
Women and children were found to be more reported in Palestine (Baker, 1990), Sudan, and
vulnerable to psychiatric illness than other Iraq (Raundalen & Melton, 1994).
social groups. Although men approached
clinical help easier than women, studies indicate
higher morbidity among women in the United 10.13.6.2 Distribution of the Disorders
Arab Emirates (31.9% female vs. 20.3% male)
(El-Rufaie & Absood, 1993). Women reported A significant number of studies have shown
more symptoms of anxiety and depression that somatization is the main form of psycho-
(Ibrahim, 1991), and neuroticism (Khalik & logical complaint, and therefore the most
Eysenck, 1983). Although the general morbidity common diagnosis, in Iraq (Al-Issa & Al-Issa,
in Saudi Arabia was higher among men than 1969), Egypt (Isaui, 1994), Kuwait (Parhad,
women (El-Rufaie et al., 1988), more women 1965), Palestine (Dwairy, 1997b, 1998; Gorkin
320 Mental Health in the Arab World

et al., 1985), and Saudi Arabia (El-Islam, 1982; since the late 1980s these disorders have seemed
Racy, 1980; West, 1987). to be on the increaseÐespecially among Arabs
The most common diagnoses encountered in in social transition. Nasser (1986) found that
the United Arab Emirates have been neurotic 12% of the female Arab undergraduate students
depression (55% of the cases), anxiety-depres- attending London universities were bulimic, but
sive disorders (13.3%), and anxiety disorders found no anorexia or bulimia cases in a similar
(11.7%). Anxiety-depressive disorders have female Arab student group in Cairo. The
been more common in females. Neurotic absence of anorexia may be related to the
depression and anxiety-depression disorders Arabic cultural attitude towards food. Arabs
were most prevalent in the middle-aged group also associate plumpness with attractiveness
(35±54 years), while anxiety disorders were most and health (Timimi, 1995).
common in the young age group (15±34 years) Sexual dysfunction has been rarely studied in
(El-Rufaie & Absood, 1993). Arabic societies. Okasha and Demerdash (1975)
Depressive and related symptoms were reported on 68 male Arabs (Kuwaitis, Palesti-
common among Saudi university students nians, and Egyptians) who had suffered erectile
(Ibrahim & Al-Nafie, 1991). Among these disorders and/or premature ejaculation. Of
symptoms were self-blame (64% of the stu- these, 45% reported a past history of homo-
dents), inability to concentrate well (54%), sexuality. When asked about their own evalua-
shyness (53%), shivering and shaking in tion of their disorder, most of these patients
response to interpersonal distress (42%), and attributed it to undersized or diseased genitalia.
academic problems (33%). A similar epidemio- Few of them blamed supernatural causes or
logical study in Dubai showed that the masturbation. Many of the patients had
prevalence of depression (13.7%) was higher accompanying somatic complaints, mostly
than anxiety (7%) or mania and psychotic backache.
disorders (1.9%). Depressed mood was present Among the clients of the author's clinic, 18%
in two-thirds of the anxiety cases, and auto- of the women, but only 7% of the men,
nomic anxiety was present in over half the cases complained of sex-related anxiety. This differ-
of depression (Ghobash & Bibbington, 1994; ence may be attributed to the sexual oppression
Ghobash et al., 1992). of Arab women or to the difficulties of the Arab
In Egypt, Okasha (1993) reviewed the man in admitting his sexual problems (Dwairy,
diagnoses given to 800 patients admitted to 1997b, 1998).
the psychiatric center in Ain Shams in 1991 and
revealed the following rates of disorders: mood 10.13.7 HEALTH SERVICE DELIVERY
disorders (18.3%); schizophrenia (16.1%); so- SYSTEM
matoform disorders (9.5%); substance-use dis-
orders (8.5%); disorders of infancy, childhood, The first mental hospitals in the world were
and adolescence (8.2%); and anxiety disorders built in Arab countries: first in Baghdad, Iraq, in
(7.9%) (Okasha, 1993). The most frequent 705 AD, followed by hospitals in Cairo (800
diagnosis among the psychotic Egyptian pa- AD) and Damascus (1270 AD) (Okasha, 1993).
tients was brief reactive psychosis, with poly- Although Arabs were the first to develop
morphic acute symptoms precipitated by stress, psychiatric institutions, their psychiatric pro-
and with rapid recovery (Okasha et al., 1993). blems today are often referred either to native
In contrast to the above, Bazzoui (1970) (usually religious) healers (Timimi, 1995), or to
reported low rates of depression (1.3% depres- medical doctors, due to the somatic manifesta-
sive and 2.9% manic patients) among 1120 tions of their distress. When they do reach
patients admitted to a psychiatric hospital in psychiatrists, they are provided with medica-
Iraq. These contradictory results may be tions or other medical treatments rather than
attributed to demographic differences in the psychotherapy (Gorkin et al., 1985; Ibrahim &
population, to the methodology, or to changes Ibrahim, 1993; West, 1987). Psychiatric treat-
that have occured since Bazzoui's 1970 report, ment then typically occurs in one of two settings:
when only severe cases were sent to psychiatric the traditional mental hospital or an outpatient
hospitals. Among the Palestinian clients of the setting. Private psychiatric clinics are also an
author's clinic, 60% complained of anxiety, option for some. A few private corporations,
phobias, somatoform disorders, and obsessive- universities, and religious organizations own
compulsive disorders, compared to 32.6% and operate some health services that also
complaining of depression (Dwairy, 1997b, provide psychiatric services (Ibrahim & Ibra-
1998). him, 1993); however, in most of these institu-
Eating disorders (anorexia and bulimia) in tions psychotherapy per se is not represented.
Arabic societies have been rare or absent in the Variations of counseling, behavior therapy, and
past (Al-Issa, 1966; El-Sarrag, 1968); however, family therapy are sometimes employed.
 Future Directions 321

Obviously, the mental health system in the Fortunately, some countries are witnessing
Arab world barely reaches a small portion of the the nascent growth and dissemination of
population that needs psychological attention. information bringing to the awareness of
Marital counseling, parent counseling, voca- practitioners the psychological and social con-
tional guidance, crisis intervention, crisis sup- tributors to illness. The psychiatric center in Ain
port groups, school psychology, and other Shams, for example, emphasizes a biopsycho-
mental health services are rare or absent in social approach to outpatient care. In addition,
most Arab countries. Psychologists who are they are encouraging intensive psychiatric out-
trained in any form of psychotherapy are rare, patient programs in all general hospitals
making the need for research on mental health (Okasha, 1993).
in general, and training programs in particular, The Palestinians in the Gaza strip and the
imperative (Ibrahim & Ibrahim, 1993). West Bank, as well as inside Israel, have made
In general, there has been a paucity of significant progress in developing mental health
information about mental health services in services during the last few years. In the Gaza
Arab countries. An exception is Okasha's (1993) strip (an area of 800 000 citizens), one psychia-
detailed report about the mental health system tric hospital and one community mental health
in Egypt, considered one of the most developed program direct three local clinics. Programs
Arab countries. According to this report, only utilize a multidisciplinary approach that em-
450 psychiatrists serve 57 000 000 citizens of ploys psychiatrists, psychologists, social work-
Egypt (1 per 127 000 citizens). There are about ers, nurses, and other specialists. In the West
8000 psychiatric beds (1 bed per 7000 people), Bank (1 500 000 citizens) there is one large
5750 of them in Cairo. Only 250 clinical psychiatric hospital (320 beds) and three related
psychologists were reported to be practicing local clinics. In 1995, the Palestinian authority
in Egypt, with hundreds of general psycholo- initiated professional development courses for
gists working in fields unrelated to mental physicians to increase their awareness of mental
health services. There are many social workers health issues. In addition, a mental health plan
practicing in psychiatric facilities, but they are was initiated to meet the needs of schools and
not trained in psychiatric social work (Okasha, families adversely affected by the 29 years of
1993). Israeli occupation (Palestinian Authority Re-
Out of 24 governorates of Egypt, 19 have port, 1994±1995). Among the Palestinians who
some kind of psychiatric clinic and outpatient live in Israel (800 000 citizens), there has been
unit, while five have no psychiatric services. significantly more progress in the psychological
Community care in the form of hostels, day services provided to schools. At least 24 centers
centers, and rehabilitation centers is available for psychological services are now providing
only in Egypt's big cities. In the rural areas, mental health services to the Palestinian Arab
community care is implemented without health schools in Israel (Israeli Ministry of Education
care workers. Chronic and mild psychiatric Report, 1997).
patients are ªrehabilitatedº through cultivating Despite limited mental health services and the
and planting the countryside, under the super- lack of information about psychotherapy
vision of family members. The programs for among Arab populations, the number of Arabs
community care in big cities take the form of seeking psychotherapy has been steadily in-
outpatient clinics, hostels for the elderly, creasing (Dwairy, 1997b, 1998; Gorkin et al.,
institutions for the mentally retarded, centers 1985; Okasha, 1993).
for drug abuse, and school and university
mental health. In Egypt, there are 13 medical 10.13.8 FUTURE DIRECTIONS
schools, that for 35 years have offered school
master's and doctoral programs in psychiatry Compared to most people living in more
(Okasha, 1993). individualistic, liberal, Western societies, Arabs
The denial of the role of emotions in physical are more dependent on their families, their
health is common not only among patients, but personalities are less individuated, and they do
among physicians, as well. That somatic not welcome autonomy or self-actualization.
symptoms could be of psychological origin is Therefore, an individual's repression is main-
beyond the imagination of the average Arab tained by external factors rather than intrap-
patient and beyond the knowledge of many sychic constructs such as an ego or superego.
medical practitioners. Both physicians and Implementing psychodynamic or other nondir-
patients are somatically oriented. When doctors ective therapies, which are designed to deal with
fail to locate disease in the body, they typically intrapsychic processes and to motivate the
make the diagnosis of ªgeneral physical weak- patient towards self-actualization, may result
nessº and prescribe vitamins and rest (El-Islam, in serious problems. First, they miss the main
1982). source of repression, which is external rather
322 Mental Health in the Arab World

than internal; and second, they activate re- Egalitarian family therapy that focuses on
pressed emotions that may not be allowed to be encouraging the direct expression of feeling is
expressed in the Arabic society, such as sexual frustrating, if not impossible, with traditional
drives or aggression towards family members. families. Such therapy may threaten the author-
Therefore, ªsuccessfulº treatment that makes itatian structure of the Arab family, and
the unconscious conscious converts the intra- terminate treatment. Promotion of separation
psychic conflict into a conflict between the client from the family is considered disrespectful
and his or her family, and may leave the client (Budman et al., 1992).
with an untreated wound (Dwairy, 1997a; Therapists should learn about the culture
Dwairy & Van Sickle, 1996). (values, norms, prohibitions, taboos, etc.) from
To avoid these problems, therapists are en- the client, without imposing his or her own
couraged to be flexible, tailoring the therapy to values on the client. Therapists may enlist parts
the client, rather than fitting the client into their of the Arabic culture to accomplish therapeutic
favorite treatment approach. Therapists need to changes (Dwairy, 1998; Dwairy & Van Sickle,
be able to alter their personal therapeutic style, 1996). West (1987) suggested cooperating with
and be open and willing to learn new approaches folk healers to broaden therapistsº repertoire of
to treatment (Budman et al., 1992). An under- treatment modalities that have been proven
standing of the client's cultural identity and effective in Arab societies.
family relationships is essential evaluative The therapist should find a way to help the
information in directing the therapist's choice client within the limitations and specifications
and trajectory of treatment. For Westernized of the client's culture. Their culture should be
Arabs, such as some of the more educated considered an immutable, but important, piece
peoples of major urban areas, a therapist may of the therapeutic process. Racy (1980) sug-
consider insight-oriented therapies, whereas for gested that the therapist avoid both of two
traditional Arabs, behavioral, directive, goal- extremes: the temptation to be so respectful of
oriented, and short-term therapies are recom- tradition that one becomes paralyzed, and the
mended. With traditional clients, psychotherapy tendency to become a social reformer. A
may include counseling and academic and career combination of warmth, authority, diplomacy,
assistance (West, 1987). The client's ego strength and verbal facility can go far toward establish-
is another important factor to evaluate. Before ing an effective alliance.
implementing any type of insight therapy that Based on the sociocultural background of
may evoke culturally forbidden needs and Arabs, characterized by the somatization of
emotions, the therapist should be reasonably psychosocial distresses, and person±family
sure that the client is strong enough to interdependence, the flexible implementation
participate meaningfully in the conflicts that of a biopsychosocial approach to treatment,
will emerge between the client and family. involving the client's family, may be promising
Because Arab patients have many misunder- for the majority of Arab clients (Dwairy,
standings about psychotherapy, West (1987) 1997c).
suggested that issues of trust, the therapist±
patient relationship, and status differentials
need to be discussed openly in the early stages of
therapy. Orientation to psychotherapeutic pro- 10.13.9 SUMMARY
cesses prior to commencing treatment may
facilitate the effectiveness of the treatment, as The Arabic culture is characterized by
well (Dwairy & Van Sickle, 1996). After careful authoritarian and collective values rather than
consideration of the above factors, a therapist liberal and individualistic ones. The interperso-
may begin treatment in a directive mode and nal relationship is both supportive and distres-
later shift gradually to a nondirective and sing. The locus of control is external, and the
insight-oriented made (Gorkin et al., 1985). expression of emotions is indirect. An indivi-
When a traditional Arab client is not dual's self and identity are enmeshed in the
individuated from his/her family, parental collective identity.
authority is never to be challenged or criticized Unfamiliarity with Arabic culture may lead to
(West, 1987). Joining the authority of the family misinterpreting and pathologizing the normal
and gaining its trust is crucial at the beginning, behavior of Arabs. The manifestation of
especially when the client is a woman (Dwairy & psychological disorders among Arabs is differ-
Van Sickle, 1996; Racy, 1980). Without the ent from that in the West. Depression is
collaboration of the family, therapy may well be characterized by somatic rather than mood
sabotaged. A supportive personal approach changes. Guilt feelings, worthlessness, and
that acknowledges cultural norms may enhance suicidal thoughts and attempts among Arab
the trust. depressive patients are rare or absent.
 References 323

Obsessive-compulsive symptoms are influenced 10.13.10 REFERENCES

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A few psychometric characteristics have been Psychiatry, 16, 15±22.
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Saudi Arabian study. British Journal of Psychiatry, 148,
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cultural consultant in mental health care: The case of an
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attribute their symptoms to supernatural Cooper, J. E., Jablensky, A., & Sartorius, N. (1990). WHO
powers, germs, or the lack of food or rest. collaborative studies on acute psychosis using the
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 Copyright © 1998 Elsevier Science Ltd. All rights reserved.

10.14
Perspectives from Lithuania
DANUTEÇ GAILIENEÇ
University of Vilnius, Lithuania

10.14.1 INTRODUCTION 325

10.14.2 THE BEGINNINGS OF PROFESSIONAL PSYCHOLOGY 326
10.14.3 THE SITUATION OF PSYCHOLOGY UNDER SOVIET OCCUPATION 327
10.14.4 THE BEGINNINGS OF CLINICAL PSYCHOLOGY 328
10.14.5 REGAINING INDEPENDENCE 331
10.14.6 PRESENT SITUATION AND PROBLEMS 332
10.14.7 REFERENCES 334

10.14.1 INTRODUCTION tance to different occupations, threatened

assimilation, and dissolution.
The situation and development of clinical Let us consider what was happening in
psychology in Lithuania is inextricably related Lithuania at the time when clinical psychology
to the sociopolitical situation of the country and appeared in the West, that is when Lightner
its rather dramatic history. This chapter is an Witmer founded a ªpsychological clinicº at
attempt to show that all the historical and Pennsylvania University, Emil Kraepelin began
political changes have directly influenced clin- experimental psychological study in a psychia-
ical psychology in Lithuania. tric clinic, and Sigmund Freud was working out
Lithuania is situated near the Baltic Sea; it his theory and practice of psychoanalysis. At
presently has a population of approximately 3.7 that time Lithuania constituted part of the
million. Around 3000 BC the first wave of Indo- Czarist Russian Empire. The only Lithuanian
Europeans appeared in these places, and the university, which was actually the oldest in
group of Baltic peoples formed. The Balts Eastern Europe, founded in 1579 (Bumblaus-
included Lithuanians, Latvians, and Prussians. kas, 1994), had been closed for almost a century.
The latter were destroyed by the German Order This had been the reaction of the Czarist
of the Knights of the Cross or assimilated by government to the uprising of 1831 against
them a few centuries ago. Lithuanians now live the imperial regime. After an even more
in the neighborhood of Finno-Ugrians (Esto- powerful Lithuanian and Polish uprising in
nians, Finns) and Slavs (Russians, Poles). 1863, the reaction was still grimmer: the
Lithuanians were the only Balt people to found Lithuanian press was prohibited, Lithuanian
a powerful state of their own in the middle ages, schools were closed, even the Latin characters
the Grand Duchy of Lithuania. This state used in Lithuanian writing were prohibited; only
survived up to the late eighteenth century. As it the Cyrillic (Russian) script was allowed.
grew weaker, it was annexed to the Czarist Hundreds of people were murdered or deported
Russian Empire. The following centuries de- to long years of exile in Siberia. The others
manded from Lithuanians a determined resis- resisted with determination the threatened

325
326 Perspectives from Lithuania

national annihilation, until the press ban was psychotherapy. They applied their efforts to
abolished in 1904. This was the period of the spreading and providing a critical evaluation of
ªbook-hawkers,º the smugglers who secretly the new ideas, theories, and methods of clinical
carried over the border Lithuanian periodicals psychology, as well as towards educating society
and books published in East Prussia or else- with regard to the prophylaxis of mental disease
where in the West. The so-called ªhardship and to nurturing general psychic health.
schoolsº appeared at this time, where country As early as 1921 BlazÏys, who was the first
women would secretly teach children to read and professor of psychiatry in Lithuania and the
write in Lithuanian. author of the first Lithuanian psychiatry text-
book (Introduction to psychiatry; BlazÏys, 1935),
10.14.2 THE BEGINNINGS OF published an article entitled ªPsychoanalysis
PROFESSIONAL PSYCHOLOGY and psychotherapyº in the journal Medicina
(BlazÏys, 1921). It was a conceptual, exhaustive
It was only after the First World War that study, appearing in the early stages of the
Lithuania was re-established as an independent development of the new Lithuanian state and its
state. The country witnessed a vivid develop- medicine. The author stressed the necessity of
ment in all spheres of life: economic, cultural, psychotherapy, presented in sufficient detail the
and scientific. Since the capital city, Vilnius, was psychoanalytic theory of Freud and his meth-
occupied by Poland in 1919, the University of ods, and maintained that ªthe time has passed
Lithuania was founded in the temporary capital for being content with mere bromides,º and that
of Kaunas. There had been no professional psychological theory and practice concerning
psychologists in Lithuania up to that time, only mental disorders are indispensable. Psycho-
students of psychology or representatives of analysis occupied the central place in the
other professions, such as physicians, biologists, treatment of neuroses, being a method based
and the clergy, who showed interest in the field upon the psychogenic theory of the origins of
(e.g., M. Reinys, J. SteponavicÏius, J. Vabalas neuroses and the principle of causality. Com-
Gudaitis, V. Lazersonas). The reason was that: paring psychoanalysis to other prominent
methods of psychotherapy, the author asserted
The Lithuanian intelligentsia were not able to get
jobs in Lithuania; most often they had to work in
that in psychoanalysis, as in the rational
Russia. Only priests and representatives of the free psychotherapy of Dubois, explaining their
professionsÐphysicians and lawyersÐcould stay situation to the patient is related to persuasion,
in Lithuania. Therefore Lithuanian intelligentsia and the therapeutic effect depends on the moral
would usually choose these professions. (SÏapoka, influence the doctor exerts upon the patient.
1989, p. 523) Even though BlazÏys was a representative of
biological psychiatry, in the Introduction to
The new university also had a department of psychiatry he presented not only the biological
pedagogy and psychology. Some specialists, for aspects of psychic diseases, but also the latest
example, one of the most prominent pioneers of tendencies of psychotherapy and clinical psy-
professional psychology in Lithuania, Alfonsas chology: he discussed Freud's psychoanalysis
GucÏas, having completed their studies here, and Adler's individual psychology, pointing out
went abroad to enrich their qualifications with that these developments had illuminated the
the leading specialists of the time. In this way hitherto unpenetrated ªsecretº depths of the
the first generation of professional psycholo- human mind. They had also demonstrated that
gists came into existence. They taught psychol- not only in psychopathological disorders, but
ogy and organized practical and research also in normal psychic life a very important role
institutions, created the system of teaching was played by the deeper psychic layers, and
psychology, started experimental studies, ac- human feelings and drives. The author also
tively participated in the press, and published introduced behaviorist views, at the same time
and translated books on psychology. There also pointing out their limitations: the analysis of
appeared what could be called the rudiments of psychopathology cannot ignore the subjective
clinical psychology. factors. As already mentioned, BlazÏys aligned
In 1931 the Lithuanian Society of Psycho- himself with the neurological trend; however, he
technics and Vocational Guidance was founded, criticized physicians for their ªmedical materi-
including a consulting department headed by alism,º and invited them to take a new look at
the psychiatrist, Juozas BlazÏys (GucÏas, 1937). man, to be aware of and seek new ideas, and also
Some psychiatrists were interested in psy- encouraged them to take up philanthropy.
chology and psychotherapy, and would apply Eventually, the same author published a book
methods of suggestion, hypnosis, and rational entitled Tolerance as a cultural principle (BlazÏys,
psychotherapy in their practice; they also took 1936), which was to be banned in Lithuania
an interest in the newest trends and theories of throughout the years of Soviet occupation for
 The Situation of Psychology under Soviet Occupation 327

its strictly negative evaluation of totalitarian All these factors were also important in
regimes, such as fascism and bolshevism. surviving another disaster that befell the
Other methods of psychotherapy were also country, that is the 50-year-long Soviet occupa-
discussed, both in the specialist and popular tion. But even under the conditions of occupa-
press: autogenic training, hypnosis, and rational tion, clinical psychology did gradually develop
psychotherapy, as well as Jung's system of in Lithuania.
psychotherapy. Most publications could be
characterized as adhering to the pragmatic view
that no single theory can explain all of 10.14.3 THE SITUATION OF
psychopathology, while each may be useful in PSYCHOLOGY UNDER SOVIET
a certain aspect. The questions widely discussed OCCUPATION
comprised the training of professional psy-
chotherapists, problems of pediatric psychol- The existence of the independent state was
ogy, and the task of prophylaxis of mental again interrupted by subsequent occupations,
disorder. first by the Soviets in 1940, then by the Nazis,
During the 20 years of independence the first and once again by the Soviets after the Second
professional psychologists were trained in World War.
Lithuania, and the period saw what could be This had detrimental effects for the state in
called the beginnings of clinical psychology. The every way, and certainly interfered with the
treatment of mental disorders did not comprise development of psychology; the humanities, as
only biological methods but included psy- compared to the sciences, were especially strictly
chotherapy as well; Lithuanian society was restrained. At the beginning of the Soviet
being informed and its psychological back- period, the specialty of psychology still existed
ground enriched. Psychological knowledge was at Vilnius University; there was a department of
spread by people of various vocationsÐ psychology, and later a joint department of
psychologists, medical specialists, Catholic pedagogics and psychology, but these were soon
priests and bishops. closed, and the specialty abolished. A course for
All these achievements were doubtless very teachers of psychology, logics, and the Lithua-
modest. But the span of time was also brief: 20 nian language still existed for a time at the
years is not very long in the life of a state, Vilnius Pedagogical Institute, but from 1956
especially one which has started from nothing. even this training was stopped.
However, the goal of building a state of their Soviet reality established itself firmly. A kind
own mobilized enormously the activity and of Orwellian world crystallized, of which one of
initiative of the people. With amazing determi- the strictest requirements was that of ideological
nation they sought knowledge, high culture, and purity and loyalty. All the humanitarian
a more profound education. Even though the disciplinesÐphilosophy, history, psychology,
economic situation was difficult, young people literary scholarshipÐhad to be based not upon
studied foreign languages and made efforts to ªidealist conceptions,º but upon the founda-
go to the best universities abroad, and upon tions of dialectic materialism, whereas the
returning they embarked on the task of creating ªdoctrines alien to our viewº had to be
a scholarship and culture of their own. abandoned. As in Orwell's world, a special
Obstacles and hardships would foster character language developed that for an outsider would
and a constant readiness to accomplish some- sometime be very difficult to grasp. ªBourgeois
thing which seemed impossible. Even though ideology and idealist conceptionsº were Wes-
short, the period of the independent state helped tern, non-Marxist creations; ªobsequiousness
an entire generation to cherish initiative, before the Westº and ªviews alien and unac-
feelings of their own value, and responsibility ceptable to usº were crimes that would not only
for the state. A rather interesting point was draw criticism but could also possibly lead to
made by the historian Danys in 1986. Writing imprisonment, Siberian exile, or even death.
about the emigrants from Eastern Europe Such a perspective also confronted psycholo-
escaping from the horrors of the Second World gists, and other specialists who contributed to
War, nazism, and communism, she notes that the psychological culture of the country. Some
Lithuanians and emigrants from other inde- perished, others were deported to Siberia, while
pendent states of the period differed greatly some had managed to emigrate to the West
from the Soviet people who had lived for the before the ªIron Curtainº closed. The psychol-
same span under totalitarian regimes. The ogists remaining in Lithuanian had to be
former generally had more initiative, and were extremely cautious, like all people working in
more responsible and braver people since, in the the humanities. Most often psychological work
author's view, they already possessed the would be restricted to comparatively ªinno-
experience of building their own state. centº topics, remote from ideology, such as
328 Perspectives from Lithuania

investigations of perception, psychophysiologi- author). The department's attitude was positive

cal measurements, and so on. Psychology was toward this, even though, as already mentioned,
impoverished. It was ªsovietized,º which means clinical psychology was not officially included
that it was affected by the bureaucratization, among the spheres of study. Since higher
ideologization and centralization of learning education was strictly centralized, that is, the
and teaching (Bagdonas, 1991). whole curriculum was compiled by the central
From the beginning of the 1950s, when Nikita Ministry of Higher Education in Moscow, to
Khrushchev became leader of the Soviet Union, which all Soviet institutions of higher education
a period of ªwarmingº began. First of all, this were subordinated, the department was not
meant a more or less freer cultural climate. allowed to introduce teaching courses or to plan
Thanks to the initiative of Professor Alfonsas studies on its own. The only liberty afforded the
GucÏas, a psychologist of the prewar period, the department was the ªspecial coursesº that
specialty of psychology was reopened at Vilnius constituted a very small part of the curriculum.
University, and the department of psychology The first course of psychotherapy for students
was refounded within the faculty of history. of psychology was introduced in the form of
Officially the department was expected to train such a special course. It was entitled ªMethods
specialists in ªengineering and work psychol- of psychocorrection,º since ªpsychotherapy,º
ogy.º It soon emerged that under the conditions that is, healing, was a prerogative of physicians
of a planned economy, the work of psycholo- alone, and the fact that this type of healing
gists in various enterprises was hardly possible meant ªtreatment by psychological meansº did
and altogether senseless. Where everything is not interest the term-jugglers. Generally, ac-
decided ªfrom aboveº; where ªsome pretend to cording to the principle of economy, it was often
be working while others pretend to be paying more worthwhile to evade obviously absurd
themº; where there is no place for practically requirements and prohibitions than to try to
any initiative; where the principle of equaliza- prove their absurdity.
tion is applied everywhere; when it is not so
much the quantity, quality, and realization of 10.14.4 THE BEGINNINGS OF CLINICAL
the produced goods that are important, but PSYCHOLOGY
rather prestated plans ªaccomplished and over-
fulfilledº in papers and reports, as well as the Those starting to work in the field of clinical
ªfreely adoptedº obligations of ªsocialist com- psychology had to make efforts to attain the
petitionº; where the universal and most im- appropriate education and at the same time to
portant aim of everyone's efforts is to cheat achieve professional recognition. Clinical psy-
Moscow and to ªdrawº from it as much as chology was taught and developed at two
possibleÐthen simple, sound common sense centers in the USSR, Moscow and Leningrad.
and cynical socialist resourcefulness is quite Incidentally, the term ªclinical psychologyº
enough. Professional psychologists have noth- was not accepted, for ideological reasons.
ing to do in these areas. Everything went under the title ªmedical
However, these matters were merely the usual psychology,º while in Moscow the term
obstacles and absurdities that one would ªpathopsychologyº was also used, defined as
constantly face. Undoubtedly, the re-establish- being the application of psychological skills in a
ment of the psychology department at Vilnius mental clinic.
University was of immense importance to
Lithuanian psychology and clinical psychology. The psychologist assists the psychiatrist in the
different stages of the investigation, treatment and
The head of the department, Professor GucÏas, examination of the patient, as well as participating
and its teachers, his former students, were in the preparation of sociopsychological recom-
anything but adepts of Marxist psychology and mendations for the integration of the patients into
ideology. A positive element was also the fact society. The main form of the pathopsychologist's
that Lithuania had been incorporated into the work is the experimental psychological examina-
Soviet Union considerably later than other tion of psychiatric patients. (p. 5)
countries. Being closer to the West and of a
more European orientation, the country resisted In thus such a complicated way was the
Soviet indoctrination more persistently. The psychologist's work defined in an instruction
department existed in a rather liberal atmo- published in Moscow in 1975, On the work of the
sphere. The teachers sought to present modern pathopsychologist in a mental clinic (Zuhar,
psychology and its history objectively, to foster RubinsÏ tein, PoperecÏnaja, & Portnov, 1975),
a critical view of all the trends and fashions in which was approved by the head of the Chief
psychology. Among the first graduates of the Coordinating Board for Research Institutes and
department, a few began to take an interest in Research, and which was addressed to ªthe
clinical psychology (including the present chief specialists of psychiatric institutions, in
 The Beginnings of Clinical Psychology 329

order to lead and coordinate the pathopsychol- Another possible way of developing skills was
ogists' work, and to psychologists as methodical through contacts with colleagues in East
instructions for practical work.º As can be Germany. In this country, otherwise most
observed from the quoted passage, these in- strictly socialist, the psychodynamic trend in
structions did not mention psychotherapy, since clinical psychology was not banned. At the end
the treatment of mental disorders was supposed of the 1970s Dr. Kurt HoÈck, a psychotherapist
to be the prerogative of the medical specialists, from East Berlin, began to organize yearly
and the latter in their turn would treat only by seminars in psychodynamic group psychother-
medication and other medical procedures. apy for East German psychologists and psy-
Incidentally, the ªexperimental psychological chotherapists. One small group in this seminar
examinationº mentioned here is a very char- was international and included German-speak-
acteristic example of the imprecise usage of ing colleagues from Poland, Hungary, Czecho-
terms. In this situation, empirical data is usually slovakia and other East European countries.
accumulated at the clinic by means of psycho- The two participants from Lithuania were the
diagnostic techniques, whereas the instruction present author and the psychotherapist A.
presents this process, quite inadequately, as AlekseicÏikas. Of course, these visits were only
ªexperimental,º attaching to it the title of an a private initiative, unsupported by any institu-
investigative strategy (RimkuteÇ , 1986). tions, at one's own expense and during one's
In Moscow the dominating approach was vacation. But once an invitation ªto visit
Pavlovian, and altogether unfavorable with acquaintancesº was received, it was relatively
regard to psychotherapy. At Moscow Univer- simple to get leave to attend.
sity, however, research was carried out con- Participation in this seminar offered not
cerning the cognitive aspects of mental diseases merely the possibility of learning group psy-
and the psychological aspects of various chotherapy; it was in a sense an aid to
somatic diseases. Lithuanian clinical psychology at large. The
The attitudes at Leningrad University and the international group comprised active and
Bekhterev Institute of Psychoneurology were creative people from the East European
rather more liberal; there, both psychodiagnos- countries. Even after the several years' seminar
tics and psychotherapy were developed. Psy- program had been completed, the group
chological tests and techniques of examination continued to meet in different countries: East
worked out in the West were also applied there. Germany, Poland, Lithuania, Hungary. All in
Thus, those Lithuanian psychologists who all, this communication continued for 15 years.
wished to work in the field of clinical psychol- It offered opportunities to learn and to
ogy used to go to the universities and institutes exchange experience, and the possibility of
of Leningrad or Moscow to continue their creating joint projects. We did our best to
studies or to do postgraduate work. On the communicate the knowledge and new skills
whole those who started to work as clinical acquired during these sessions to our Lithua-
psychologists would at the same time have to nian colleagues, as well as to mediate their new
work independently and to seek opportunities contacts with East European specialists.
to develop their skills. On the one hand, one had This was a very special experience which
to strive for professional recognition, to seek unified the East European psychologists and
good contacts with medical specialists, to prove psychotherapists, all deprived and isolated to a
that clinical psychology and psychotherapy greater or lesser degree, and exerting immense
offered much to medical practice. On the other efforts in order to achieve professional skills.
hand, the information and literature available The dramatic political events in East Europe
were insufficient, for Soviet literature, usually in were also experienced togetherÐstarting with
Russian, was as a rule one-sided, while new the Solidarity movement in Poland and the first
literature from the West was very hard to visit by Pope John Paul II there, the birth of the
obtain. Also there was no chance of breaking liberation movements in these countries, and
through the Iron Curtain and going abroad to finally, the destruction of the Berlin Wall.
study. Other ways and means had to be sought. This seminar program directly inspired the
Comparatively good psychological literature yearly seminars for psychotherapists, clinical
was available from neighboring Poland, where psychologists and psychiatrists which we began
the situation was more favorable than in to organize in the Vilnius Psychoneurological
Lithuania. Poland was not a Soviet republic, Hospital. The first seminar took place in spring
but only a satellite to the Soviet Union, and 1978. Soon the initiative was taken over by the
ideological restraints were not so severe there. section of Clinical Psychology, the most active
Numerous valuable books were translated into one in the Lithuanian branch of the Society of
Polish, and therefore quite easily obtainable; Psychologists of the USSR. (According to the
one had only to learn Polish. already mentioned principle of centralization,
330 Perspectives from Lithuania

the Soviet Republics had no right to form For his first stay in Lithuania, Vytautas
professional organizations of their own, only to Bieliauskas had received a scientist's exchange
have so-called branches of the central organiza- grant from the National Institutes of Health,
tions.) The seminars would include reports on and visited the USSR as a health service
urgent subjects, as well as practical sessions. representative. Thus he had an opportunity to
They were positively valued by most colleagues, also visit Leningrad and Moscow. He described
and soon became well known throughout the his impressions from this trip in the journal
whole of the Soviet Union as the ªVilnius spring American Psychologist (1977). Writing of the
seminars.º They used to attract specialists from situation of clinical psychology and psychother-
Estonia, Latvia, Georgia, the Ukraine, Russia, apy in the USSR and Lithuania, he pointed out
and even from Siberia and the Far East. The that these were young professions in those
time came when all those wishing to attend countries. People working in them were young,
could not possibly be received, so the partici- enthusiastic, and hopeful. However, ªevery-
pants had to be selected. On the whole, in the thing requires time and a great deal of patience
1980s, the practical clinical psychology and in the USSRº (p. 379). He also noted the
psychotherapy of Lithuania were considered to dominating centralization and ideologization of
be the most developed among Soviet republics. science and learning. ªMy audience,º wrote
Lithuanians were often invited to other repub- Professor Bieliauskas of his lectures in Vilnius,
lics to conduct various training courses. ªshowed a great deal of familiarity with our
These seminars took place yearly for more literature and with the literature of the West in
than a decade and constituted an important generalº (p. 378). He also stated that in
contribution to the professional skills and Lithuania a wide interest in research and new
consciousness of clinical psychologists and trends of healing could be encountered, and the
psychotherapists. Understandably, with time, local psychiatric service was a little more
the huge common undertaking began to fail to developed than in other Soviet republics.
answer the needs of evermore differentiated There were also occasions for learning from
professional interests and growing specializa- other prominent specialists. Carl Rogers visited
tions. It was necessary to look for other forms Moscow and led seminars there, as did the
also and various more specialized professional creator of logotherapy, Viktor Frankl. (It was
associations began to appear. then that we started investigations of the
The pioneers of clinical psychology also ªfeeling of purpose in lifeº in Lithuania, as
received considerable assistance from the clin- well as the adaptation of the Crumbaugh and
ical psychologists of the Lithuanian emigration. Maholic purpose in Life test.) Virginia Satir also
In 1976 Vytautas Bieliauskas, Professor of led family therapy seminars in Vilnius.
Clinical Psychology at Xavier University (Cin- The first Lithuanian clinical psychologists
cinnati, Ohio) came to Lithuania for the first began to work at state psychiatric hospitals
time. Since then he has been a frequent visitor (there was no other type at the time). Through-
and offers much help in training specialists in out the Soviet Union, psychology, and applied
clinical psychology and raising their qualifica- psychology in particular, was regarded rather
tions. In the 1990s his son Linas Bieliauskas, suspiciously and only mental hospitals were
Professor of Neuropsychology at the University allowed to introduce psychologists into their
of Michigan, has also established contacts with staff, but not other health institutions.
Lithuanian psychologists and offers real assis- In Lithuania there were already some more
tance. During his first visits, Vytautas Bieliaus- progressive psychiatrists who were interested in
kas delivered cycles of lectures on various psychology and psychotherapy, and applied
questions of clinical psychology, to local clinical psychotherapeutic techniques in their work.
psychologists, psychotherapists, psychiatrists, They included N. IndrasÏ ius, A. AlekseicÏikas, A.
and other medical specialists. This was of great Dembinskas, L. RadavicÏius, and A. VinksÏ na.
importance not only because of the valuable Some of them had already acquired degrees in
information content, but also because it helped medical psychology in Leningrad. They were
psychologists to spread psychological knowl- both the first teachers and our first colleagues.
edge in the sphere of medicine, and contributed AlekseicÏikas was perhaps the only psychiatrist in
to the professional establishment of clinical Lithuania specifically practicing psychotherapy.
psychologists. During further visits Vytautas The doctor of medical psychology GosÏ tautas
Bieliauskas also conducted special training had already founded, at Kaunas Cardiology
courses for psychologists and psychotherapists Institute, a laboratory of medical psychology
in the theory and practice of family therapy, as which carried out research and the adaptation of
well as in clinical psychodiagnostics, presenting psychodiagnostic methods. Dembinskas and
in detail the projective personality test of GosÏ tautas formed psychology and psychother-
house±tree±person drawings. apy sections for medical students in the frame of
 Regaining Independence 331

students' research societies, in Vilnius and history of illness (BieliauskaiteÇ ), the effective-
Kaunas respectively. Students of psychology ness of group psychotherapy with young
joined them later. In this way circles of people stuttering patients (PolukordieneÇ ), the possibi-
were formed who sought to extend psychiatric lities of youth group psychotherapy (ZÏelvys),
aid in Lithuania beyond the biological ap- the psychological problems of alcoholic patients
proach, and to make psychotherapy available (BulotaiteÇ ), and psychological problems in
for patients too. cardiology (RugevicÏius, PalujanskieneÇ ).
The pioneer clinical psychologists worked in Clinical psychologists and psychotherapists
the field of psychodiagnostics and to an even also took up teaching; they gave various courses
greater extent occupied themselves with psy- in clinical and medical psychology, clinical
chotherapeutic work. psychodiagnostics, and psychotherapy courses
One must say that clinical psychology for students of medicine and psychology, as well
developed rather successfully in Lithuania, as for physicians. They also wrote several
insofar as it was possible under the prevailing textbooks (Dembinskas et al., 1981; GailieneÇ ,
political conditions. Professional recognition 1989; SargautyteÇ & ZÏelvys, 1988).
was achieved in psychiatry. The mere fact that The work of popularizing psychology and
quite soon psychologists were working in all psychotherapy, and informing the public was
Lithuanian mental hospitals was proof of this also very important. Psychologists wrote pop-
(given that it was up to the hospitals to decide ular articles, spoke on radio and television and
whether they needed such specialists), and some gave public lectures. In this way the popularity
hospitals even developed departments of psy- and authority of psychology grew, and psycho-
chology, the so-called ªpsychology labora- logical help become available to ever wider
tories.º Even some psychiatrists, having taken circles of society.
special courses, started working in clinical
psychology (JuozaityteÇ , DembinskieneÇ , etc.).
In spite of various restrictions, the psychol- 10.14.5 REGAINING INDEPENDENCE
ogy graduates of Vilnius University made
efforts to progress in diverse spheres of clinical In the late 1980s perestroika emerged in the
psychology. This always required considerable Soviet Union, which meant the beginning of the
initiative, commitment, and dedication. Much crash of the totalitarian system. In Lithuania all
depended on the first specialist in a particular the ties of exaggerated dependence were rapidly
field. The prestige of psychology would be torn. Professional organizations were the first to
enhanced by personalities able to demonstrate free themselves from enforced centralization,
competence and the value of psychology, as well and psychologists were among the very first. In
as to establish good contacts and collaborate November 1988 the Lithuanian branch of the
with other professionals; they would prepare the Society of Psychologists of the USSR held a
way for other colleagues in that field. Some of conference which adopted the decision to close
these pioneers should be mentioned. Rasa the branch. The constituent conference of
BieliauskaiteÇ started the development of child January 1989 founded an independent organi-
clinical psychology in Lithuania; RuÅ ta Sargau- zation, the Lithuanian Union of Psychologists,
tyteÇ was the first psychologist in a psychoso- confirmed its statute, and elected its council and
matic clinic; GrazÏina GudaiteÇ , a pioneer in president. An address to the Society of
Lithuania of Jung's analytic psychology, Psychologists of the USSR was adopted which
headed a department of a large mental clinic; was subsequently read at the Eighth Conference
Kristina Ona PolukordieneÇ began work in the of the Society on January 30, 1989, which was
psychotherapy of adolescents, youth, and ªas usual, pervaded by chaos. We were only
patients with stutters; Rimantas KocÏiuÅ nas observers thereº (Bagdonas, 1991, p. 62). The
and Aleksandras KucÏinskas pioneered the newly formed Lithuanian Union of Psycholo-
humanist psychology and psychotherapy which gists included 410 members. Moreover, clinical
won great popularity in Lithuania; and Laima psychologists and psychotherapists made haste
BulotaiteÇ was the first to investigate the to enjoy the emerging opportunities and free-
psychological aspects of alcoholism and drug dom, and created specialized associations. Thus
addiction. the Lithuanian Association for Application of
Alongside practical work, most psychologists Psychoanalysis was founded, followed by the
took up research; they usually prepared and Lithuanian Association of Group Psychother-
presented their doctoral theses in the univer- apy, and the Lithuanian Association for
sities of Moscow and Leningrad. In their Humanistic Psychology, also uniting mainly
dissertations they analyzed the cognitive pecu- clinical psychologists, and so on. It was then
liarities of schizophrenic patients (GailieneÇ ), the that the first private psychotherapy consulta-
personal peculiarities of children with a long tions appeared.
332 Perspectives from Lithuania

The same year witnessed radical reforms at still hesitate too much before seeking the help of
Vilnius University. It was the first among the a psychologist.
Soviet universities to declare the so-called For clinical psychologists the present situa-
ideological ªsciencesº to be pseudosciences, tion opens up countless possibilities for learn-
and to dissolve the departments of scientific ing. Contacts with other countries have become
communism, scientific atheism, and history of easier; many new professional contacts are
the Communist Party. Other Soviet universities being made. Psychologists go to European
followed this example. The oldest faculty of countries and the USA to study and to gain
Vilnius University, the Faculty of philosophy, experience. Specialists in various trends come to
was re-established, including studies in philo- Lithuania with lectures and seminars at the
sophy, sociology, and psychology. Instead of invitation of professional organizations and
one department of psychology, two were universities.
createdÐthe department of clinical and social Vilnius University trains the clinical psychol-
psychology and that of general and pedagogical ogists of Lithuania. Psychologists who have a
psychology. master's degree in clinical psychology are
On March 11, Lithuania proclaimed its Act of allowed to practice and psychologists with a
Independence, which meant that Lithuania was doctorate may teach students.
to be freed from the Soviet empire and was to The postgraduate training of clinical psychol-
seek, by persistent peaceful means, de facto ogists and psychotherapists is mainly the
independence. In the summer of 1991, after the business of professional associations. In the
abortive putsch in Moscow, the independent mid-1990s there are over 10 professional
state of Lithuania was recognized by the world. psychologists' organizations in Lithuania, and
On June 12, 1990 the Supreme Council of almost all of them encompass clinical psychol-
Lithuania confirmed the new Statute of Vilnius ogists and psychotherapists. Most of these
University, establishing the autonomy of the organizations have already become members
university. The university re-established the of corresponding international organizations.
stages of study that had already been adopted The Lithuanian Psychotherapeutical Society
in 1579: the bachelorship, mastership and is a member of the International Federation for
doctorate. This had positive effects upon the Psychotherapy and the European Association
training of clinical psychologists. The depart- of Psychotherapy. Its aim is that our schemes of
ment of clinical and social psychology prepared teaching psychotherapy and our certification
master's and doctorate programs in clinical procedures should correspond to European
psychology. The first doctorate theses worked requirements.
on at Vilnius University and written in The Lithuanian Association for Application
Lithuanian have already been presented. (Dur- of Psychoanalysis maintains close contacts with
ing the Soviet period, particularly in the 1970s the psychoanalytic associations of other coun-
and 1980s, an anticonstitutional requirement tries. The Finnish Association organized full
had been passed that dissertations should be instruction for six colleagues from Lithuania. At
presented only in Russian.) The teachers of the present, in 1997, they have finished the course,
department have written textbooks to be used in received the status of associate members and are
these studies (GudaiteÇ , in press; KocÏiuÅ nas, beginning to get back to work in Lithuania.
1995). Other members of the Association are partici-
pating in long-term programs for teaching
10.14.6 PRESENT SITUATION AND psychoanalysis which have been worked out
PROBLEMS together with the Dutch and German psycho-
analytic societies.
On the one hand the present situation is The field of group analysis, the concern of the
characterized by numerous positive changes in Lithuanian Association of Group Psychother-
various ways. The public attitude towards apy also has long-term teaching programs. This
psychology has changed. It is no longer ªsome association is a member of the International
kind of strange and funny profession,º but an Association of Group Psychotherapy. It not
undoubtedly necessary and respected one. This only seeks study opportunities for its members
is proved by the number of applicants each year but also organizes training courses in which
to the specialties of psychology, the popularity colleagues both from Lithuania and neighbor-
of psychological literature, and the willingness ing countries willingly participate.
of people in other professions to cooperate with The Lithuanian Association for Humanistic
psychologists. Of course, these changes greatly Psychology also pays great attention to training,
facilitate the work of psychologists. On the and has gone so far as to found the Institute of
other hand, clinical psychologists maintain that Humanistic and Existential Psychology (headed
fear of stigmatization is still too strong; people by Dr. R. KocÏiuÅ nas). Training courses are also
 Present Situation and Problems 333

organized by the Lithuanian Association of invalids, and others needing social support
Hypnosis and the Lithuanian Society of Jungian receive free help. The prices are established by
Analytical Psychology. the Minister of Health, and are low.
Of the professional associations, the Lithua- Thanks to the work of Dr. K. O. Polukor-
nian Suicidological Association, which is a dieneÇ , the Youth Psychological Aid Center
member of the International Association for (YPAC) has been opened in Vilnius. This is a
Suicide Prevention, is probably the most nonprofit, nongovernmental organization
interdisciplinary, like suicidology itself. The which gives free psychological help to young
problem of suicides in Lithuania has grown people. Psychologists and psychotherapists
dramatically during the 1990s, and the specia- work there, as well as over one hundred
lists in this area are the first to be alarmed. They specially selected and trained volunteers. The
in their turn are trying to draw the attention of Center provides the ªYouth Line,º a voluntary
both society and of governmental institutions to anonymous phone help service from other
the problem, to inform the public, conduct young people; professional psychological and
investigations, and create suicide prevention psychotherapeutic aid; various clubs and
programs (GailieneÇ , 1996). groups (e.g., the Stuttering Problems Club), a
At present psychologists and psychothera- youth discussion club, an art studio, and so on.
pists work in all Lithuanian mental hospitals The YPAC is a member of the International
and in the psychiatric departments of various Federation of Telephonic Emergency Services
clinics and general hospitals. Both professions and maintains close cooperation with Befrien-
are practicing psychotherapy. Even though the ders International, the international volunteer
formal position of the hospitals has not organization of the UK. The Center also assists
changedÐthey are all state mental health all the new psychological help services being
hospitalsÐsome shifts have taken place in founded in Lithuania and employs both
attitudes to patients and their treatment. The professionals and volunteers.
inpatient departments of mental hospitals have As a result of the persistent efforts of the child
often introduced the principles of the thera- psychiatrist Dr. D. PuÅ ras, the University Center
peutic community, and have opened day- for Children with Developmental Disorders
patient departments. Treatment is mostly began in Vilnius in 1991. Children with
combined medication and psychotherapy. especially complicated psychosocial problems
Three mental hospitals already have inpatient were, for the first time, treated not only
psychotherapeutic departments where the main biologically and by means of medication, but
method of treatment is psychotherapy, while also by receiving far wider psychosocial help
medication is used to a minimal extent. Mental which was offered to them and their families by
hospitals most often apply group psychother- clinical psychologists, child psychiatrists, and
apy, client-centered psychotherapy, psychody- social workers working as a team. Students of
namic therapy, cognitive-behavioral therapy, medicine, psychology, and social work are also
and Gestalt therapy. trained at the Center, and, postgraduate courses
Certainly it would be an exaggeration to are offered to specialists in these fields. The
speak of an unproblematic integration of Center cooperates intensively with correspond-
psychiatry and clinical psychology. There are ing institutions in various foreign countries. The
problems and tensions enough, but there is also Center has created two models of service for
progress. children with developmental disorders which
The Clinical Psychotherapy Center has been are being introduced in all the municipalities.
opened in Vilnius, offering specifically psy- The first is early intervention for children up to
chotherapeutic help. The Center includes in- four years old with risk factors and for their
patient departments for adults and children, an families. It is carried out by physicians, clinical
outpatient department, a psychotherapy and psychologists, social workers, physiotherapists,
rehabilitation department for torture victims, and speech therapists working as a team. The
and a department for the prevention of mental second model is that of child psychiatric help
disorder in adolescents and young people. The which also first involves planning various
Center is subordinated to the health department psychosocial interventions.
of Vilnius municipality, but receives patients Help for alcoholic patients and those with
from the whole republic, for there are practi- addictive diseases has also broken out of the
cally no such institutions to be found in other narrow medical framework. Although the
cities. The financial situation of the center is number of institutions providing assistance to
rather typical of the present Lithuanian health these patients is far from sufficient, in those that
service which has not yet turned into a health already exist, psychotherapy and psychosocial
insurance-based system. Psychotherapeutic interventions are widely applied, and specialists
help here is paid for, but children, adolescents, of various professions cooperate.
334 Perspectives from Lithuania

Clinical psychologists also work in the field of 10.14.7 REFERENCES

health psychology: they investigate the risk fact-
Bagdonas, A. (1991). Lietuvos psichologijos raida [The
ors for different disorders, organize teaching, development of Lithuanian psychology]. Mokslas ir
write books (GaileneÇ , BulotaiteÇ , & SturlieneÇ , Lietuva [Science, arts and Lithuania], 2, 55±63. (In
1996; LepesÏ kieneÇ , 1996) and edit the magazine Lithuanian)
Psychology for You (Dr. G. Chomentauskas). Bieliauskas, V. J. (1977). Mental health care in the USSR.
However, qualified psychological and psy- American Psychologist, 5, 376±379.
BlazÏys, J. (1921). PsichoanalizeÇ ir psichoterapija [Psycho-
chotherapeutic help is only available to the analysis and psychotherapy]. Medicina, 2, 35±42. (In
population of the few largest cities so far. In Lithuanian)
smaller settlements it is still lacking. Psychology BlazÏys, J. (1935). IË vadas iË psichiatrijaË [Introduction to
has been introduced only to a small extent into psychiatry]. Kaunas, Lithuania: Vytauto DidzÏiojo uni-
other spheres of medicine beside psychiatry. versiteto Medicinos fakultetas. (In Lithuanian)
BlazÏys, J. (1936). Tolerancija kaip kultuÅ ros principas
This is conditioned by different factors. The [Tolerance as a cultural principle]. Kaunas, Lithuania:
economic situation of Lithuania is still rather Spaudos fondas. (In Lithuanian)
unsteady. In the health service system even the Bumblauskas, A. (1994). Vilniaus universitetas: politineÇ s ir
most elementary needs of the patients are istoriografineÇ s kolizijos [Vilnius University: political and
sometimes scarcely answered, so a more historiographical collisions]. In Vilniaus universiteto
istorija 1579±1994 [History of Vilnius University
sophisticated kind of help, such as psychological 1579±1994] (pp. 7±17). Vilnius, Lithuania: Valstybinis
aid, seems to be an unaffordable luxury. leidybos centras. (In Lithuanian)
Moreover, the reform of the health service is Danys, M. (1986). Lithuanian immigration to Canada after
proceeding very slowly. As already mentioned, the Second World War. Toronto, ON: Multicultural
there is no insurance-based medical system. History Society of Ontario.
Therefore as yet there is almost no private Dembinskas, A., AlekseicÏikas, A., GailieneÇ , D., GosÏ tautas,
A., Grizickas, A., PuÅ ras, A., & RadavicÏius, A. (1981).
psychotherapy practice, since in this situation Psichologija medicinoje [Psychology in medicine]. Vilnius,
each payable service means that the client pays a Lithuania: Mokslas. (In Lithuanian)
double fee: once with his obligatory state taxes, GailieneÇ , D. (1989). H. RorsÏacho metodika asmenybei tirti
and also when paying for the particular service. [The Rorschach method of personality diagnosis].
Other acute problems also arise from the Vilnius, Lithuania: Vilniaus universitetas. (In Lithua-
nian)
economic situation. For example, on account of GailieneÇ , D. (1996). SavizÏudybeÇ ? Ne! [Suicide? No!].
the extremely poor salaries paid to specialists Vilnius, Lithuania: ia Lietuvos suicidologijos asociacija.
doing research or academic work, some capable (In Lithuanian)
people, especially the young, have to abandon GailieneÇ , D., BulotaiteÇ , L., & SturlieneÇ , N. (1996). AsÏmyliu
these areas. kiekvienaË vaikaË. Apie vaikuË psichologinio atsparumo
ugdymaË [In love each child. On training children's
Bureaucratic reforms are also taking a long psychological resistance]. Vilnius, Luthiania: Valstybinis
time. The legal status of the specialty of leidybos centras. (In Lithuanian)
psychotherapy remains problematic. The certi- GucÏas, A. (1937). PasÏaukimas ir darbas [Vocation and
fying commission at the ministry decides upon work]. Kaunas, Lithuania: Lietuvos psichotechnikos ir
the qualifications of psychologists and psycho- profesineÇ s orientacijos draugija. (In Lithuanian)
GudaiteÇ , G. (in press). IËvadas iË analitineË psichologijaË
therapists, assigning qualification categories
[Introduction to analytical psychology]. (In Lithuanian)
according to which the salaries of these workers KocÏiuÅ nas, R. (1995). Psichologinis konsultavimas [Psycho-
at governmental institutions are established. logical counseling]. Vilnius, Lithuania: Lumen. (In
Previously this was a prerogative of the certifying Lithuanian)
commission for neurologists and psychiatrists LepesÏ kieneÇ , V. (1996). Humanistinis ugdymas mokykloje
which was far less competent, for that matter, [Humanistic training at school]. Vilnius, Lithuania:
Valstybinis leidybos centras. (In Lithuanian)
than the present one. But probably in the future RimkuteÇ , E. (1986). Psichologijos tyrimo metodai
the task of certification of specialists will be [Methods of psychological investigation]. In A. GucÏas
taken over by professional organizations. For (Ed.), Bendroji psichologija [General psychology]
example, a licensing commission has already (pp. 24±36). Vilnius, Lithuania: Mokslas. (In Lithua-
been formed at the Lithuanian Society of nian)
SÏapoka, A. (Ed.) (1989). Lietuvos istorija [History of
Psychologists which is working upon the licen- Lithuania]. Vilnius, Lithuania: Mokslas. (In Lithuanian)
sing regulations for practicing psychologists. SargautyteÇ , R., & ZÏelvys, R. (1988). MedicinineÇ s psicholo-
Briefly speaking, the present situation of gijos pagrindai [Elements of medical psychology]. Vil-
Lithuanian clinical psychology is more or less nius, Lithuania: Lietuvos TSR auksÏ tojo ir specialiojo
hopeful. One can expect that as the general vidurinio mokslo ministerija. (In Lithuanian)
Zuhar, V. P., RubinsÏ tein, S. J., PoperecÏnaja, L. N., &
situation of the country normalizes, the position Portnov, A. A. (1975). O rabote patopsichologa v
of clinical psychology will improve as well, since psichiatricÏeskoj bolnice [On the work of the pathopsy-
the need for psychological help in this society is chologist in a mental hospital]. Moscow: Ministerstvo
very great indeed. zdravoohranenija RSFSR. (In Russian)
 Copyright © 1998 Elsevier Science Ltd. All rights reserved.

10.15
From a Monocultural Identity to
Diversity Identity: A Psychological
Model for Diversity Management
in South African Organizations
KEDIBONE LETLAKA-RENNERT
Johannesburg, South Africa
and
WOLFGANG P. RENNERT
University of the Witwatersrand, Johannesburg, South Africa

10.15.1 INTRODUCTION 335

10.15.2 PSYCHOLOGY IN SOUTH AFRICA: A HISTORICAL PERSPECTIVE 336
10.15.3 INDIVIDUAL AND CHANGE 336
10.15.4 A SOUTH AFRICAN MODEL FOR ORGANIZATIONAL DIVERSITY 337
10.15.5 MONOCULTURAL IDENTITY 338
10.15.5.1 Maintaining Monocultural Identity Through Restrictive Affirmative Action 339
10.15.5.2 Moving Towards an Identity of Awareness Through Restorative Affirmative Action 339
10.15.5.2.1 Role of the organizational psychologist: constructive affirmative action 340
10.15.6 IDENTITY OF MULTICULTURAL AWARENESS 340
10.15.6.1 From the Identity of Awareness to Diversity Identity Through Diversity Management Training 340
10.15.7 DIVERSITY IDENTITY: OUTLOOK FOR THE FUTURE 341
10.15.8 SUMMARY AND CONCLUSION 342
10.15.9 REFERENCES 342

10.15.1 INTRODUCTION by weary looking men and women, sunburnt

from hours of standing outside, holding up signs
The urban traveler in the South Africa of asking for food or for any job. The emphasis is
today is frequently confronted with a sight on ªany.º The days of job preservation for
unknown to his counterpart from older days: whites are clearly over, and with a new political
white homelessness. Street corners are occupied era comes the pressure for individuals as well as

335
336 A Psychological Model for Diversity Management in South African Organizations

institutions and organizations to adapt to what will impose on him . . . there is no place for him in the
bishop Desmond Tutu has named the ªrainbow European community above the level of certain
nation.º forms of labour . . . What is the use of teaching a
Identification as a rainbow nation demon- Bantu child mathematics when it cannot use it in
practice? . . . That is absurd. (Harrison, 1981, p. 194)
strates South Africa's will to survive change.
Adopting the rainbow nation as a construct,
although political and economic in nature, is As late as 1986 South African psychologists
also understandable psychologically. It is an applauded the Carnegie Investigation for its
inclusive construct that provides space for ªusefulness in the solution of social problemsº
everybody to join a multicultural society. It (Louw, 1986). Many professionals stood on the
enables the forging of a new identity, as members sidelines of the struggle for liberation and
of a new nation. Simply stated, diversity has four claimed that their disciplines were apolitical in
components in South Africa. It is a unifying nature, forbidding them to examine scientifically
mechanism, it provides a preventative strategy, the consequences of racial and economic oppres-
it creates a basis for proactive intervention, and sion, while benefitting themselves materially and
lastly it is a compelling vision. If the nation's in the progression of their careers from that very
entrenched divisions were not to be permitted oppression (Biesheuvel, 1958). Few psycholo-
to run rampant and deepen, some sustainable gists dared to speak out for a politicization of
way forward had to be found. Healing had to psychology, and went as far as to suggest that
take place simultaneously with growing as a new apartheid policies and the dehumanization of
nation. To varying degrees both the private and the vast majority of the population might
the public sectors have reacted to the implica- actually be detrimental to the mental well-being
tions of the new dispensation. of the community (Dawes, 1985).
For a while, the struggle became the focus of
research for mostly white academic psycholo-
10.15.2 PSYCHOLOGY IN SOUTH gists, who saw the writing on the wall and tried to
AFRICA: A HISTORICAL jump ship before they might lose influence and
PERSPECTIVE privilege. Studies on torture, violence, and
colonialism filled the journals authored by
Psychologists have been involved in the psychologists, who did not dare to venture out
creation of apartheid from the outset and are into the townships where their subjects lived, and
becoming instrumental in overcoming it today. who kept black professionals out of their own
In 1928 a team of psychologists, sociologists, academic units (Letlaka-Rennert, 1991).
and educators were sent to South Africa by the Psychologists of color, often against the
Carnegie Commission to study the problems of resistance of their white colleagues, struggled
poor whiteism. Their extensive report (Wil- to create an academic discourse of diversity,
cocks, 1932) stated with great concern that the: introducing African writers and theorists into
the psychological mainstream (Bulhan, 1990;
Long continued economic equality of poor whites Manganyi & du Toit, 1990; Nicholas, 1993). It
and the great mass of non-Europeans and propin- became obvious that the real liberation from
quity of their dwellings tend to bring them to social apartheid required the transformation of the
equality. This impairs the tradition which counter-
whole society including all institutions, organi-
acts miscegenation, and the social colour divisions
are noticeably weakening. (p. 33) zations, and structures of political, social, and
economic life. Clinical psychologists understand
today that the transformation of the individual
Wilcocks continued to recommend the creation
has to be accompanied by the transformation of
of employment categories reserved for whites
institutions and organizations. It is here that
and called for ªlegislation which inflicts severe
psychologists contribute to the development of
penalties on sexual intercourse between the
a new society, a rainbow nation. Therefore, the
racesº (p. 33).
authors choose to use the field of organizational
Fellow psychologist and later prime minister
psychology and the area of organizational
H.F. Verwoerd used Wilcocks' recommenda-
transformation in their discussion of diversity
tions and combined them with his own ideas of
development and psychology in South Africa.
racial supremacy. Verwoerd became one of the
architects of apartheid and focused particularly
on ªBantu educationº as a means with which to 10.15.3 INDIVIDUAL AND CHANGE
deprive the indigenous African population of
any access to knowledge. He believed that: In South African organizational psychology
today, professionals are as much concerned with
The school must equip the Bantu to meet the the psychological well-being of individuals
demands which the economic life of South Africa within organizations as with the organizations
 A South African Model for Organizational Diversity 337

themselves. It is not surprising that clinical in particular. Typically, models and conceptua-
psychologists find themselves working in in- lizations borrowed from the USA are used to
stitutions and organizations and that there is a help understand what manifests here and
demand for clinical skills from organizational unfortunately, occurances are not sufficiently
psychologists. contextualized (Cross, Katz, Miller, & Sea-
What is at play when looking at the individual shore, 1994; Thomas, 1996).
and change, from a clinical perspective? In order This chapter explains why it is in South
to tackle resistance and assist people seeking African organizations' self-interest to become
personal transformation in the context of involved in diversity work, in its broadest sense,
diversity, one has to focus on the obstacles from merely promoting multiculturalism and
and problems related to change. It is one thing pluralism to direct behavioral and mental health
to consider the theoretical background of interventions. Thus, a model is presented for
societal transformation. It is another to examine diversity development that is reflective of the
the foreground of personal interactions and specific historic and economic texture of South
behaviors as it presents itself in workshops and Africa. It tries to provide a conceptualization of
training sessions with employees and staff a possible development from the monocultural
members. philosophy of racial exclusion and oppression,
The clinical psychologist working with diver- as it was prevalent in the apartheid years, to a
sity is confronted with reactions of people under multicultural philosophy that acknowledges
threat. As coping with conflict, vulnerability, and respects difference and can provide the
and exposure are called upon, issues of safety basis for the progression of the rainbow nation
come to the fore. There is a risk of possible (Steyn & Motshabi, 1996).
repercussions at the workplace connected to The model is psychological in nature and
making disclosure in diversity management explains how organizations reflect the cultural
workshops after the encouraging and support- state of the society in which they operate.
ing psychologists have long gone. We also Historically, working environments in the South
underestimate the resilience and power of Africa of the apartheid era were structured and
stereotypes working against disclosure. Whites organized to care exclusively for the needs of the
might fail to disclose because of their feeling that white minority. The organizational identity was
blacks are not good enough or sufficiently like monocultural. In many institutions and orga-
them to appreciate them, warts and all. nizations this identity still prevails and will have
Similarly, blacks fail to disclose because of their to be transformed and developed. Changes have
feeling that whites cannot be trusted to operate to be promoted and facilitated on a level of
on a basis of equality. Thus, when under pressure personal identity management for members of
and scrutiny, the defense mechanisms of one's the organization, as well as on a collective level
choice flare up (Duckitt, 1992). The challenge for the organization as a whole.
remains to enable individuals to disclose and to The initial process will be largely one of
promote self-confidence, such that people awareness building. In a society where, for
cannot only take the risks of change in the generations, a small minority has succeeded in
workshop, but have the courage to try what they keeping a large indigenous population under
have discovered outside in the real world. conditions of total deprivation, psychological
strategies of denial, rationalization, and dis-
placement are widely prevalent cognitive pro-
10.15.4 A SOUTH AFRICAN MODEL FOR cesses and learned behaviors. Interventions will
ORGANIZATIONAL DIVERSITY have to utilize internal measures of awareness
building, together with external measures of
Companies and institutions looking for help reinforcement and control in order to overcome
in facilitating a process of adaptation are still prejudice, ambivalence, and resistance. Once an
hindered by the resistance of established power organization and its members have reached a
structures, prejudice, and a culture of exclusion. level of awareness that provides the background
Psychologists and human resource strategists in for active diversity seeking, an identity of
South Africa have no indigenous models to help multicultural awareness will have been reached.
them conceptualize the state of an organiza- From here onwards diversity becomes an
tion's cultural identity and to meaningfully integral part of the organization's strategies.
assist in the implementation of strategies to External control measures will become redun-
facilitate collective and organizational identity dant and diversity will become organizational
development (Table 1). Although models have policy until a state of diversity identity has
been developed in the western world, none has been reached. Now that diversity is no longer
been derived from and designed for the specific an objective, it has become part of the
conditions of Africa in general and South Africa organization's fiber. The following sections
338 A Psychological Model for Diversity Management in South African Organizations

Table 1 Concepts of South African organizational identity.

Monocultural identity Multicultural identity Diversity identity

Restrictive affirmative action Restorative affirmative action Affirmed environment

External control measures Awakening internal control Internalized control measures
measures
External regulation Practicing internal regulation Internalized regulation, both
individual and organizational

Racial superiority Multicultural awareness Multicultural advancement and

Entitlement Appreciation of difference promotion
Power Sharing of power Equality

Defensiveness Curiosity Deriving benefits for all from

Fear Openness diversity management
Sense of doom Engagement Confidence

Prejudice Open-mindedness Integrationist orientation

Cultural ignorance Culture of exploration, both internal Culture of inclusion
and external
Employee composition white Employee composition in transition Employee composition diverse
Organization monocultural Introduction of different cultures, and integrated
multiculturalism

explain the stages of the diversity management assets and money offshore totalled billions of
model in more detail and make reference to the rands. On the outside, physical terror and abuse
specific South African context, from which it is were combined with a system of dehumaniza-
derived. tion, together with the slow implementation of a
slave mentality (Fanon, 1967).
10.15.5 MONOCULTURAL IDENTITY Organizations and institutions were a reflec-
tion of the minority rather than integrated into
In the South Africa of the 1940s to the 1980s the society as a whole. Group thinking
the institutional and industrial culture was dominated industrial and political strategies,
monocultural. In a country of 30 million people, and promotional efforts were limited to mem-
only 4 million of European decent mattered. bers of the white group. At one stage, the mining
The indigenous population and, to a lesser industry management, down to the levels of
degree, Asian immigrants and people of mixed foremen on the shaft floors, became so aloof
racial origin, were used as industrial cannon from the black labor force that a new
fodder in a process that was exclusively geared languageÐFunigaloÐwas invented, in order
to the promotion and development of the white to maintain a minimum of communication
minority (Davenport, 1987). between foremen and laborers.
This process required a maximum level of Today, one still finds organizational thinking
external regulation and control, and promoted stuck in the same paralyzing framework of
on the inside a mentality of racial and prejudice and cultural ignorance. A culture of
intellectual superiority, entitlement, and power, exclusion has been sustained for decades
but also one of defensiveness, fear, and a sense through schools, universities, families, and the
of doom. The most powerful army on the information industry. The basic fibre of orga-
African continent focused its patrols on the nizational thinking has had to be loosened and
townships rather than the borders. The enemy rewoven into a culture of inclusion. It was
was within the society, not outside it. White interesting to note that, after the first demo-
South Africans who had access to foreign cratic elections in 1994, conservative white
passports were in a permanent state of pre- circles immediately called for a white homeland,
paredness to leave, while reaping the benefits of a move destined to maintain on a small scale,
their privileged position as long as possible. what had to be given up on the whole, namely
White gun ownership far exceeded the statistics apartheid, or the maintenance of a culture of
published in the USA, commonly known as the exclusion. Somewhat more liberal elements,
ªarmed society,º and the illegal transfer of around the former president F. W. deKlerk,
 Monocultural Identity 339

called for the inclusion of minority rights into 10.15.5.2 Moving Towards an Identity of
the new constitution, and a white popular Awareness Through Restorative
movement rallied around the few Afrikaans Affirmative Action
language schools trying to preserve a pocket of
white cultural exclusivity. It was the enforced The predominant sentiment in the established
introduction of the same Afrikaans into the white institutional and business community
syllabus of black schools in 1976 that had led to today is one of fear and insecurity. Although the
township riots, scores of lost lives, and a whole new national leadership has made it very clear
generation of youngsters who refused to acquire that it intends to include all communities in the
even a minimal education. In the South Africa process of national unification, there is an
of today a culture of inclusivity rather than atmosphere of mistrust, partially because many
exclusivity has to be learned from scratch. whites fear the maintenance of cultural
dominationÐblack culture this timeÐand par-
tially because there may be deeply rooted
10.15.5.1 Maintaining Monocultural Identity feelings, that the acquired privileges were
Through Restrictive Affirmative achieved through oppression and violence and
Action are therefore undeserved. The predominant
discussion in the public domain today is about
The instrument with which to maintain an crime, about the redistribution of white wealth
institutional culture of exclusivity was what we through black criminals. The call for punish-
would call ªrestrictive affirmative action.º The ment ranges from castration to the reintroduc-
development of a minority was furthered by the tion of the death penalty, scrapped from the
restriction of the majority. Pass laws were legal instrumentarium by the current govern-
imposed on black laborers, controlling their ment of national unity (Duckitt, 1992).
influx into the industrial centres. Wages for At this stage, the main need is one of
blacks were kept at a level prohibitive to the awareness building, and the overcoming of
support of a family, in order to keep women in resistance. Many institutions and organizations
rural farm labor. Black children were subjected are hesitant, fearful, or simply ignorant about
to Bantu education, designed to restrict knowl- how to honestly and more fully open themselves
edge to the following of simple orders. Where, to the needs and challenges of a multicultural
despite institutional disadvancement, black society. Many companies lack diversity in their
labor met with white labor in a potentially employee composition and have still to discover
competitive situation, labor laws were designed large parts of the population as customers and
to preserve certain jobs and job categories for clients, struggling with the need to modify
whites. Mine workers handling explosives had products and designs to accommodate different
to be white, not in the least in order to prevent a tastes (Gordon, 1991; Lau & Shani, 1992).
potentially dangerous skill transfer. The postal Here, affirmative action of a different kind,
services and other government agencies became namely restorative affirmative action, is re-
a haven for whites who could not otherwise quired to facilitate the achievement of an
secure employment. Apartheid laws enforcing identity of awareness. Resistance and ambiva-
segregated residential areas (Group Areas Act) lence can only be overcome with the help of
and the prohibition of interracial relationships external control measures, this time however,
(Immorality Act, Mixed Marriages Act) ce- not with the intention of enforcing a system of
mented cultural exclusivity (Davenport, 1987; injustice, but rather with the aim of setting in
Mandela, 1994). motion a dynamic of learning that will render
It is interesting to observe today, that those the tool redundant in the end. Government
parts of society who have benefited from legislation as well as organizational and institu-
affirmative action then, are the most outspoken tional policies need to be set in place to provide
critics of affirmative action now. They fear more the basis for the opening of organizational
than anything the competition of well-educated culture. Enhanced education of disadvantaged
blacks who are competing for jobs that whites students through scholarships and improved
have been occupying simply because they were educational strategies in the townships should
white. Inevitably there will be a shift away from be combined with provisions for improved
employment on racial grounds only, towards an on-the-job training for employees of color.
employment strategy that aims at racial equality Labor laws are being revised to abolish job
on the grounds of equal qualification and preservation for whites and to guarantee equal
competency. More whites holding up signs opportunity employment and remuneration.
at street corners will bear witness to the fact Government tenders are becoming linked to
that being white alone no longer guarantees affirmative action goals within the companies
advancement. competing for the job (Jones, 1991; Witt, 1990).
340 A Psychological Model for Diversity Management in South African Organizations

The Truth and Reconciliation Commission is investigated and put into a societal context.
another unique South African initiative at- On a practical basis, intercultural communica-
tempting to combine awareness of past injustices tion skills are provided, dealing with stereotypes
with reconciliation and a positive outlook on and myths, and methods useful in the over-
future cooperation between diverse racial and coming of resistance are practiced. On a further
political groups. Despite being criticized by level, personal diversity skills are integrated into
whites for being vindictive and by blacks for an organizational diversity management frame-
letting perpetrators of racial oppression off the work. Teamwork, interpersonal understanding,
hook, the commission has already achieved, relationship building, empowerment, and orga-
long before its conclusion, the initiation of nizational commitment are introduced as com-
dialogue between the races and the creation of an petencies that comprise the pillars of diversity
atmosphere of reflection on the limitations of management.
monoculturalism. A member of the South African Zulu people
greets another with the word sawubona, (I see
you). The reply is sikhona (I am here).
10.15.5.2.1 Role of the organizational
Essentially, this greeting means ªI exist because
psychologist: constructive
you see me.º To see a person as what they are,
affirmative action
rather than as what one's preconceptions of
On an intraorganizational level, companies them are, is the aim of intervention programs at
are seeking help from organizational psychol- this stage. In addition, individuals finding out
ogists to further an atmosphere of awareness of about and treating colleagues in ways that are
difference and its advantages for obtaining meaningful to them, and not only in the way
business objectives. Companies are slowly prescribed by the old corporate culture, is
understanding that diverse perspectives will another fundamental objective of the program
provide greater flexibility, increased creativity (Letlaka-Rennert, 1996).
and improved problem-solving strategies. What
they lack is a system to facilitate communication 10.15.6 IDENTITY OF MULTICULTURAL
and to understand different perspectives. Here AWARENESS
South African human resource specialists such
as psychologists can provide indigenous systems The intermediate phase of organizational
that help to bridge the gap between different identity finds companies and institutions in a
cultural backgrounds. The aim is to acquire state of raised awareness and residual ambiva-
awareness of difference as something nonthrea- lence, but with a positive attitude towards
tening and potentially beneficial to the progres- change. Staff members that have joined the
sion of the organization. There is a shift from a company through affirmative action programs
more external restorative affirmative action to a become appreciated as valuable additions to the
more internally motivate constructive affirma- team. There is less fear of retribution and reverse
tive action (Trompenaars, 1993). racism, but ambivalence and prejudice may still
A program has been designed for institutions inhibit processes of further diversification.
and organizations to facilitate this process. A However, at this stage, institutional leaders
multitude of intervention programs, workshop and industrial managers will be able to set goals
designs, and strategies are marketed by various and create visions of complete diversity identity.
organizations and companies, none of which They will have understood that, for an institu-
take into consideration the specific conditions tion to thrive in a society, it has to become a
of the South African context. The legacy of reflection of that society, in its goals as well as in
the past and the demands of the future pose its composition (Trompenaars, 1993).
unique challenges and obstacles that require an
approach that is indigenous and sensitive to 10.15.6.1 From the Identity of Awareness to
the multicultural background of the rainbow Diversity Identity Through Diversity
nation. Management Training
The program has two modules, the first of
which is designed to facilitate the progression of Human resource strategies at this level will
an organizational identity from one of mono- rely much less on externally controlled affirma-
culturalism to one of cultural awareness. tive action programs. Now organizational
Exercises are introduced to value difference, psychologists will provide organizations with
to understand affirmative action, and to devel- the tools to internally develop their identity
op concepts for the management of diversity. towards diversity. Diversity management may
Personal attitudes, assumptions, prejudices, and affect marketing strategies, the expansion or
behaviors have to be analyzed and modified. alteration of product portfolios, the composi-
The predominant organizational culture is tion of management teams, modifications of
 Diversity Identity: Outlook for the Future 341

managerial and production styles, and commu- difference has to do with flexibility and conflict
nication styles within the company and between resolution, and capitalizing on it leads to market
the company and the society in general. responsiveness and general productivity. Em-
The second module of the diversity manage- ployees are appreciated for their job perfor-
ment program is designed to facilitate this mance and judged in relation to achievement
transition. Managers learn how to create rather than background. The difference now is
environments that allow diverse individuals the openness of corporate culture to different
within the organization to reach their full approaches used to achieve the greater company
potential in pursuit of corporate objectives. good. An organization with a strong diversity
The impact of multiculturalism on market identity does not try to become a melting pot in
forces, competition, customer composition, which all differences are amalgamated into a
recruiting, decision making, competency, per- new singular identity. It becomes, rather, a salad
formance management, and conflict resolution bowl in which differences are maintained and
within the company are discussed. Crisis appreciated but freed from discrimination.
management in relation to issues around Interaction is possible with all aspects of society
diversity is exercised, self-awareness is practiced as they are represented within all structures of
and different management styles are introduced the organization (Letlaka-Rennert, 1996).
and analyzed. The projection of positive self- Diversity identity is the end result of a
fulfilling prophecies is demonstrated. Recruit- progression from prejudice in monocultural
ing, hiring, and promoting staff is discussed in identity, through openmindedness in multi-
the diversity management context. Performance cultural identity to an integrationist orientation.
management, compensation and rewards, com- The culture has moved from one of exclusion
munication, training, and education are all and ignorance to one of exploration and
discussed as part of integrated and successful ultimately one of inclusion and integration.
diversity management. Finally, the process of Characteristics of the monocultural identity
diversity management itself is analyzed and consist of racial superiority, elitism, entitlement,
reviewed from planning to intervention, mon- dominance, defensiveness, fear, aggression, and
itoring, analysis, and evaluation (Boon, 1996). a siege mentality. Characteristics of the multi-
Management styles may change from a cultural identity are openness, curiosity, dis-
hierarchical form emphasizing individual power covery, engagement, and risk-taking.
within a set structure, to a communal form, Characteristics of the diversity identity are
emphasizing consent in decision-making pro- appreciation of others, self-respect, differentia-
cesses. African management styles premised on tion, innovation, maturity, clarifying interac-
the philosophy of ubuntu (ªpersonhoodº in the tions, and ongoing dialogue.
Xhosa language) are examined as an addition to Typically, in the South African monocultural
the available repertoire of management styles. context, the corporate or institutional employee
The Southern African principle of ubuntu sets composition was predominantly white. In the
the individual in their communal context. multicultural context of today, the employee
Ubuntu ngumuntu ngabantu means ªa person composition is being addressed or redressed.
is a person through other human beings.º Race and gender are at the forefront of the
Consensus building, cooperation, and mutual diversity drive, more so than sexual orientation
supportiveness form the basis for personal or age. Skill shortages and the need for training
management that brings all members of the and staff development are hindrances that have
organization together for the benefit of the to be addressed. Organized labor is demanding
whole organization. Once the individuals that to be included in the process. So far, diversity
shape the organization have been included into has not been achieved but it is becoming an
the process of moving the organization forward organizational goal. In the South Africa of
through mutual trust and cooperation, they will tomorrow, organizations will have a multi-
be able to share the vision of the organization cultural integrated work force representing
and contribute fruitfully (Boon, 1996). diversity in race, gender, sexual orientation,
disability, socioeconomic status, lifestyle, and
family composition.
10.15.7 DIVERSITY IDENTITY: Both individuals and organizations will have
OUTLOOK FOR THE FUTURE evolved from the awakening internal control
measures and their practice to a naturally
At a level of diversity identity the achieve- internalized regulation. Multiracial advance-
ment of diversity is no longer a managerial goal. ment and promotion will be optimized for
Diversity has become integral to the fiber of the gaining a competitive edge. Organizational
organization. Difference is appreciated as diversity will translate into organizational
enriching, and as furthering creativity. Valuing growth. President Nelson Mandela stated that
342 A Psychological Model for Diversity Management in South African Organizations

South Africa's greatest resource is its people. By Boon, M. (1996). The African way: The power of interactive
empowering them to know how to work leadership. Johannesburg, South Africa: Zebra Press.
Bulhan, H. A. (1990) Afro-centric psychology: Perspective
together in a conducive environment with an and practice. In L. J. Nicholas & S. Cooper (Eds.),
accommodating and permissive culture is the Psychology and apartheid (pp. 66±78). Johannesburg,
best reason to give diversity a chance. South Africa: Modiba Publications..
Cross, E. Y., Katz, J. H., Miller, F. A., & Seashore. E. W.
(1994). The promise of diversity. New York: Irvin.
10.15.8 SUMMARY AND CONCLUSION Davenport, T. R. H. (1987). South Africa: A modern
history. Johannesburg, South Africa: Macmillan.
The history of South Africa is one of racism, Dawes, A. (1985). Politics and mental health: The position
exploitation, and oppression. On every level of of clinical psychology in South Africa. South African
personal, organizational, and societal life in- Journal of Psychology, 15, 55±61.
Duckitt, J. (1992). The social psychology of prejudice.
dividuals and institutions are faced with over- Westport, CT: Praeger.
coming psychological and institutional barriers Fanon, F. (1967) The wretched of the earth. Harmonds-
against change. Clinical and organizational worth, UK: Penguin.
psychologists are asked to help in facilitating Gordon, J. R. (1991). Organizational behavior. Boston:
a process of societal transformation that allows Allyn and Bacon.
individuals as well as organizations and institu- Harrison, D. (1981). The white tribe of Africa. Los Angeles:
University of California Press.
tions to change their culture. Coming from a Jones, A. J. (1991). Affirmative talk, affirmative action: A
background of cultural exclusion, moving comparative study of the politics of affirmative action.
towards an awareness and appreciation of Westport, CT: Praeger.
difference requires disclosure, vulnerability, Lau, J. B., & Shani, A. B. (1992). Behavior in organizations:
and the tolerance of conflict. Prejudices and An experiential approach. Chicago: Irvin.
Letlaka-Rennert, K. T. (1991). Ambivalence. Agenda: A
stereotypes have to be overcome and ingrained Journal about Women and Gender, 9, 9±10.
power structures have to be questioned and Letlaka-Rennert, K. T. (1996). The relationships among
loosened. racial and gender identity models and locus of control and
In the South Africa of today we have a long self-efficacy with black South African university students.
way to go before our institutionsÐany of our Unpublished doctoral dissertation, George Washington
University, Washington, DC.
institutions and organizationsÐcan claim to Louw, J. (1986). White poverty and psychology in South
have reached the diversity identity state. We are Africa: The poor white investigation of the Carnegie
dealing with setbacks at every step of the way, Commission. Psychology in Society, 6, 47±62.
we are hindered by old prejudices as much as by Mandela, N. (1994). Long walk to freedom: The autobio-
a sense of entitlement within the new elites, some graphy of Nelson Mandela. Randburg, South Africa:
Macdonald Purnell.
of whom forget their constituencies once they Manganyi, C., & du Toit, A. (1990). Political violence and
have reached positions of influence and power. the struggle in South Africa. Halfway House, South
Corruption is a problem, as it is in every society Africa: Southern Book Publishers.
today. But who would have predicted in 1989 or Nicholas, L. J. (1993). Psychology and oppression: Critiques
1992 that a process of societal transformation and proposals. Johannesburg, South Africa: Skotavi.
Steyn, M. E., & Motshabi, K. (1996). Cultural synergy in
could be achieved peacefully and with the full South Africa: Weaving strands of Africa and Europe.
commitment of the vast majority of the people Randburg, South Africa: Knowledge Resources.
of this country. The road is still long, but South Thomas, R. R. Jr. (1996). Redefining diversity. New York:
Africans are on the way, and we are determined AMACOM.
to arrive togetherÐa rainbow nation. Trompenaars, F. (1993). Riding the waves of culture:
Understanding cultural diversity in business. London:
Ther Economist Books.
10.15.9 REFERENCES Wilcocks, R. W. (1932). The poor white problem in South
Africa: The report of the Carnegie Commission. Stellen-
Biesheuvel, S. (1958), Objectives and methods of South bosch, South Africa: Pro Ecclesia Drukkery.
African psychological research. Journal of Social Psy- Witt, S. L. (1990). The pursuit of race and gender equity in
chology, 47, 161±168. American academe. Westport, CT: Praeger.
 Copyright © 1998 Elsevier Science Ltd. All rights reserved.

10.16
Clinical Psychology in Asia: A
Taiwanese Perspective
SUE-HUEI CHEN
National Taiwan University, Taipei, Taiwan
and
EUGENE K. EMORY
Emory University, Atlanta, GA, USA

10.16.1 INTRODUCTION 343

10.16.2 MANIFESTATION OF PSYCHOPATHOLOGY 344
10.16.2.1 Social Orientation and Collectivism as a Potential Cause 344
10.16.2.2 Social Orientation and Collectivism as a Buffer 345
10.16.3 DEVELOPMENT OF THE PROFESSION OF CLINICAL PSYCHOLOGY IN TAIWAN 346
10.16.4 CHOICE OF TREATMENT FOR PSYCHOLOGICAL DISORDERS 346
10.16.4.1 Treatment Choices 346
10.16.4.2 Therapy Models 347
10.16.5 CONCLUSIONS 347
10.16.6 REFERENCES 348

10.16.1 INTRODUCTION Asian people from different parts of the world

are considered by most Westerners as a homo-
Contrary to some Western conceptions, genous group. This tendency to homogenize
Asian people, such as those of Chinese descent, distinctly heterogenous subcultures can lead to
comprise a very heterogeneous group. The flawed concepts about these people. For exam-
impact of Western culture on Chinese societies, ple, many Westerners assume that people who
in particular, Taiwanese people, may have live on the China mainland, in Hong Kong, and
positive and negative effects. One important in Taiwan represent one ethnic group. While
feature of Westernization in Taiwan is the role it there are some obvious cultural and anthro-
plays in the manifestation of psychological pologic similarities, including religious practices
disorders. Cultural factors are imminently and physical features, these groups have mark-
important in the identification and interpreta- edly different social customs. They include
tion of clinical symptoms, and in the efficacy of dietary, religious, and even language differen-
certain forms of therapy. The emergence of ces. People in Hong Kong, for example, speak
doctoral level training of Taiwanese, from Cantonese, whereas Taiwan uses Mandarin
abroad and in the country itself, will have a Chinese. These are quite different dialects to
profound influence on the future of clinical what is spoken in various parts of mainland
psychology in this Chinese island nation. China. Moreover, vastly different ideologies

343
344 Clinical Psychology in Asia: A Taiwanese Perspective

and governmental policies exist. Thus, while social structures in an established society where
similarities within Asian populations may ap- social collectivism and group identity attempts
pear obvious to outsiders, they are mostly to co-exist with increasing individualistic ideals.
superficial. Historical, geographic, and political The impact of this change can be measured in
segregation have made Chinese in Taiwan psychological terms. There is still not enough
different from Chinese in other parts of the empirical evidence to clarify these relationships.
world, such as mainland China. One outcome unfortunately may be a rise in the
The transformation of the political system in diagnosis of major psychological disorders. Our
Taiwan and the remarkably rapid economic understanding of these outcomes may shed light
changes and influences from the Western cult- on the universe of human psychopathology, not
ure have altered the beliefs, value systems, and just the depiction of psychopathology and the
lifestyle of Taiwanese people. Therefore, the emergence of clinical psychology in Taiwan.
main sociocultural theme in Taiwan is a mixture
of traditional Chinese culture and contempor-
ary Western ideology. To what extent can one 10.16.2 MANIFESTATION OF
apply a traditional ªChineseº or Western PSYCHOPATHOLOGY
psychological perspective to the people of
Traditionally familial rather than individual
Taiwan?
goals have been the measures of social success in
In a rapidly changing society, people may face
Taiwan. According to K. S. Yang, a leading
heightened social and political stress. Economic
theorist of indigenous social and personality
competition and the standard of living have
psychology, people in Taiwan have been influ-
increased, but political conflicts between Tai-
enced greatly by familial collectivism (Yang,
wan and mainland China are persistent and
1972, 1995). On that account, social-oriented
apparent. Taiwanese people are experiencing
cultural features in Taiwan may very likely be
higher levels of uncertainty about lifestyle and
seen as both a potential cause, as well as a
future well-being than they were in the past. In
buffer, of psychopathology. In fact, these
contrast, the traditional emphasis on family
concepts are not much different from the social
structure and collective social orientation is
dynamics that exist in the West.
weakening (Yang, 1985, 1993, 1995). In societies
where traditional norms and values change
rapidly, new and effective coping strategies are 10.16.2.1 Social Orientation and Collectivism as
needed. These sociopolitical conditions are a Potential Cause
associated with increasing psychopathology
(Wallace, 1956). The lifestyle in Taiwan exhibits Traditionally Taiwanese people have a stron-
pervasive Western influences that are at var- ger social±collective rather than individual
iance with traditional Chinese values. The social orientation. That is, the individual was inclined
impact appears to be a greater level of emotional to subordinate her or his personal goals and
distress. As a result, the manifestation of stress- choices for the sake of the family. More
related psychopathology represents itself in a specifically, while dealing with family affairs,
changing pattern unique to this island. Could one tended to be primarily influenced by
the pattern be depicted as a ªWesternizedº family's decision, regardless of one's indivi-
psychopathology? duality (Yang, 1972, 1995).
In addressing the research and professional Such social oriented or collectivist attributes
issues related to clinical psychology in Taiwan, it may be manifested in the symptoms of psycho-
is appropriate to examine similarities and differ- pathology. For example, concerns or problems
ences in the manifestation of psychopathology, about family conflicts outnumbered other
development of clinical psychology, and choices psychological problems concerning individual
of treatment for psychological disorders, in issues in a Taiwanese sample who sought local
comparison to those in mainstream European spiritual help or professional counseling (Yee,
and American society. There is a paucity of 1985). Another interesting example is found in
empirical and theoretical literature focusing on the delusional content of schizophrenics. Spirit
clinical psychology from a Taiwanese perspec- possession phenomena (SPP) was noted in
tive, due in no small part to the limited number of about 25% of first-onset schizophrenic patients.
Taiwanese clinical psychologists. Of the variety of symptoms, there was a
The goal of this chapter is to clarify a disproportionate number related to being pos-
Taiwanese perspective on clinical psychology sessed by ancestors or alive family members,
issues. It is hoped that the perspective from a rather than spiritual agents or demons (Wen,
rapidly changing societyÐTaiwanÐmay serve Lin, Chen, Chou, & Huang, 1992). Thus, as is
to provoke further discussions and deeper the case in other societies, the content of
understanding of how such changes can alter delusional thought may be culturally balanced.
 Manifestation of Psychopathology 345

10.16.2.2 Social Orientation and Collectivism as tions, especially the negative emotions, may
a Buffer cause more social consequences and conflicts in
the social milieu, thereby bringing more shame
Similar to the influence of social orientation and guilt feelings to oneself and one's family or
on the manifestations of psychopathology, a relatives. In reality these emotions may be more
family orientation may buffer individuals likely to result from an interpersonal conflict,
against psychological distress and thus decrease but expression of depression or negative affect is
the frequency and type of psychological dis- culturally discouraged (Lin, 1982; Tseng & Hsu,
order. The different prevalence rates of major 1969). Thus a more stoic demeanor is generally
depression in Taiwanese and Americans pa- adopted.
tients may also reflect different distributions of Within the social-oriented system, somatiza-
psychopathology under the influences of col- tion tends to have positive social consequences
lectivism or individualism, respectively. Several to the extent that both care-givers and receivers
studies of Chinese samples carried out in obtain affirmative evaluations in the helping
Taiwan (Cheng, 1989; Compton et al., 1991; process. Since psychological complaints did not
Lin, 1953; Lin, Rin, Yeh, Hsu, & Chu, 1969) and have the same social efficacy that somatization
in the US (Weissman et al., 1992; Yamamoto, had in generating support and care (Kleinman,
Yeh, Loya, Slawson, & Hurwicz, 1985) have 1982), it is thus more likely to find the somatic
found that the prevalence rate of major depres- expression of depression in Chinese society. In
sion is lower among Chinese patients in Taiwan the past, somatization had been commonly seen
than American patients, ranging from 0.07 to as an expression of psychological distress in
1.1% and from 5.2 to 17.1%, respectively. Western society until psychological experience
Furthermore, as reported in several studies, and its rationalization into discrete labels were
Chinese depressives manifest more somatic regarded as one index of modernization. Psy-
symptoms (e.g., Lin, 1982; Kleinman, 1982). chologization, rather than somatization, con-
This somatization tendency may thus contri- sequently may have become the way of
bute to the possibility of under-reporting or perceiving and expressing one's own distress
under diagnosing clinical depression in Chinese in modern Western society (Kleinman & Klein-
patients (Kleinman, 1982). What tends to be man, 1985). Could the declining trend of social
overlooked by these studies, however, is that orientation in Westernized human societies
somatization may play a role in the illness account for the fact that major depression rates
process. Maintaining the mixed anxiety-depres- are increasing both in Taiwan and in several
sive state may in turn prevent the less depressed Western countries?
patients from becoming the hopeless depressive Another factor that affects the manifestation
(Chen, 1995). of psychopathology may be the availability and
In Taiwan, the whole family tends to take acceptability of emotional expression. Taking
responsibility for a psychological problem in depression as an index, Taiwan is in a progres-
order to protect the individual from being sive Westernization mode, and its rate of major
singled out. This buffering and shared respon- depression is increasingly approaching statistics
sibility may affect the revelation of a psycho- in the West. However, there has been a dearth of
logical disorder in the Western context. adequate ªwordsº to express ªdepressionº in
Taiwanese tend to express personal or social Taiwan. In Chinese culture people were not
distress via somatization, which has been used to expressing depression literally or verb-
defined by Kleinman and Kleinman (1985) as ally in colloquial speech. Instead, it was much
the expression of personal and social distress in easier to somatize (Tseng & Hsu, 1969), or to
an idiom of physical complaints and medical refer to those specific psycholinguistic expres-
help-seeking behaviors. Somatization may also sions which have been shaped by the more
be considered a reflection of basic cultural traits somatic-toned culture (Cheng, 1989). Hence, it
that discern Chinese society with a predomi- is not surprising that an enormous number of
nantly oral-hypochondriacal quality (Lin, Chinese cases of depression have sought phy-
1982). In addition to this psychosomatic con- sical, rather than psychological and psychiatric,
ception of ªdisorder,º the social system shaped treatment for their illness (Sue & Sue, 1990).
by collectivism has played a role in the expres- Younger people, however, seem to be conflicted
sion of emotional distress. between traditional values and contemporary
Note that within the traditionally social- Westernized culture. Again along with the
oriented collectivist Chinese society, the indivi- declining trend of social orientation and col-
dual is not the unit of social structure. The lectivism among younger generations, one
individual's private emotions may be largely might associate this trend with the earlier onset
considered as a reflection of family matters. of major depression in younger cohorts, both in
Public expression and discussing one's emo- Taiwan and in several Western countries.
346 Clinical Psychology in Asia: A Taiwanese Perspective

10.16.3 DEVELOPMENT OF THE clinical psychologists may be available to serve

PROFESSION OF CLINICAL in both academic and clinical settings.
PSYCHOLOGY IN TAIWAN With regard to psychological assessment,
there obviously exists a dearth of adequate tests
As of 1996, the number of clinical psychol- during this beginning stage in the development
ogists remained very low in Taiwan. According of clinical psychology in Taiwan. Two attempts
to the author's own informal surveys, the can be employed to ªsoothe the pangº: to
estimated number is about 200. There are about develop culturally sensitive tests or to conduct
10 clinical psychologists who have a Ph.D. in cross-cultural translation of those well-estab-
clinical psychology. Among those doctorates, lished Western tests. It seems more feasible to
there are three US-trained clinical psychologists adopt and translate well-established clinical
(including the first author) and one US-trained tests during this burgeoning period. In fact,
clinical neuropsychologist. The remainder re- some research concerning cross-cultural trans-
ceived their degrees from the same local clinical lation of Western tests such as Beck Depression
psychology program, National Taiwan Univer- Inventory (BDI) and Children's Depression
sity. All of them currently hold a faculty Inventory (CDI) has been conducted. Several
position in clinical psychology programs at well-validated personality inventories have been
various universities and are carrying out part used in Taiwan, such as Ko's Mental Health
time clinical services at their affiliated medical Questionnaire (Ko, 1977, 1995) and the Health±
centers. In addition, about a quarter have Personality±Habit Scale (Ko, 1996).
obtained a master's degree. The remainder hold Efforts need to proceed with caution when
a bachelor degree in psychology. There is no conducting cross-cultural translation of Wes-
formal licensure for clinical psychologists in tern tests. It was reported that Asian-Americans
Taiwan. at UCLA tended to endorse more items on the
In terms of subspecialties within Taiwanese MMPI-2 than their American counterparts (Dr.
clinical psychology, there are various programs Hsieh, personal communication 1996). The
established over the years, as is the case in many authors shared similar observations while using
Western universities. At National Taiwan Uni- the English form of the MMPI-2 with Taiwa-
versity, for example, there are traditional nese students at Emory University. Those
clinical psychology and child clinical psychol- students may not have presented a clear picture
ogy, health psychology, and clinical neuropsy- of distress at the interview, whereas they
chology, which provide training associated with endorsed more items on some negative distress
the application in psychiatric settings, family scales. A question thus arises as to whether the
medicine settings, and neurology departments, validity of assessment will be biased by test
respectively. Consistent with the Western trend, formats, such as self-report scales or interper-
health psychology and neuropsychology have sonal interview, across various groups from
received more attention in recent decades. We different cultural backgrounds. Still, such ques-
note that there is only one health psychology tions need to be answered.
program to date, but it has quickly developed
and encountered less resistance in Taiwan,
thanks, we suspect, greatly to the somatic-toned 10.16.4 CHOICE OF TREATMENT FOR
culture. PSYCHOLOGICAL DISORDERS
Although the first clinical psychology pro-
The behavioral patterns of people with a
gram started about 25 years ago, the number of
collectivism or social orientation may vary
Taiwanese clinical psychologists grew very
greatly from those who possess more individual-
slowly. This small number is due solely to the
oriented characteristics. The same holds true in
fact that clinical psychology is a recently
the manifestation of symptoms and their attri-
developing profession in this transitional socie-
bution of causes for psychopathology, and in
ty, where psychological services were discour-
turn, affects their choices related to treatment.
aged by traditional values. Although subtle
Another factor affecting their choice of treat-
resistance for the development of clinical
ment models may be the limited number of
psychology existed, the number of students
clinical psychologists in the country.
now being trained is growing. Equally impor-
tant, the percentage of master or doctorate level
recipients has shown a rapid increase in recent 10.16.4.1 Treatment Choices
years. This increase may mean that more, albeit
still less than enough, research in Taiwanese We hypothesize that the choice of treatment
clinical psychology may be generated by local or for psychological disorders varies across social
international psychologists in the foreseeable and economic status in Taiwan. The severity
future, and more qualified and/or experienced and types of the disorders may also affect the
 Conclusions 347

choice (Tseng, 1972; Tseng & McDermott, very acceptability of formality and authoritar-
1975; Wen, Lin, & Chen, 1993; Yee, 1985). ian aspects of psychotherapy in Taiwanese is
Specifically, people with higher socioeconomic likely to be consistent with the cognitive-
status (SES) tend to seek professional help from behavioral approach. Unfortunately, there is
Western models of treatment including psy- a lack of empirical evidence making compar-
chiatric medicine and psychotherapy for their isons among various approaches applied to
mental illnesses and counseling for maladjust- Taiwanese patients and clients.
ment problems. People with median SES have To be sure, there are some commonalities
pluralistic help-seeking patterns. That is, they among Asian populations with respect to psy-
tend to utilize Western models for more severe chological services. Atkinson, Maruyama, and
mental disorders but Chinese medicine or folk Matsui (1978) revealed that, while treating
therapy for psychosomatic-like disorders, as Asian-Americans, the therapist may have to
well as problems related to daily life. However, be more directive and active than they might
people with lower SES seldom access the otherwise be, given the preference of many
services of Western treatment models. Rather, Asian-Americans for a structured approach
they tend to visit spirit mediums, fortune-tellers, over an unstructured one. As proposed earlier,
shaman, and so forth (Yee, 1985). To date, this the younger cohorts have been dropping their
may suggest both a lack of knowledge of social orientation and/or authoritarian attitude
possible causes as well as a scarcity of available and becoming Westernized. Accordingly, what
professional psychology services. One can see may be informative is whether or not the youn-
parallels in the utilization of psychological ger cohorts show an increase in their preference
services as it relates to SES in both Taiwanese for less-structured therapies. Much research
and American culture. remains to be done with respect to how clinical
psychology can be most appropriately applied
10.16.4.2 Therapy Models in non-Western, especially Asian, culture.

Given that the availability of psychological

services is limited in Taiwan, and the number of 10.16.5 CONCLUSIONS
clinical psychologists is small, it comes as no
surprise that theoretical orientation of clinical As stated previously, the goal of this chapter
psychologists in the country appears relatively is to provoke thought and further discussion on
homogenous. According to the authors' anec- the topic of clinical psychology in Taiwan, and
dotal surveys, the cognitive-behavioral ap- more generally, Asian cultures. Will the devel-
proach is the most popular model employed opment of clinical psychology in Taiwan have
by clinical psychologists in Taiwan in both similar trends to the US or other non-Western
research and clinical settings. The pheno- nations, or will its development be unique?
menological-humanistic approaches are second, Clinical psychology in Taiwan has developed
followed by psychodynamic or psychoanalytic from a circumstance in which scientific psy-
approaches. chology has already developed itself as a mature
Several factors presumably contribute to this science, whereas clinical psychology in Western
pattern of theoretical orientation. The primary countries, such as the US, seems to parallel the
ingredient has been the lack of programs, as entire history of psychology. In some ways the
stated earlier, that recruit and train enough development of clinical psychology in Taiwan
clinical psychologists to provide for varied seems to be a microcosm of the 100 years of
theoretical orientations. Moreover, most main- Western clinical psychology. However, there are
stream clinical psychologists in Taiwan rarely vast differences between the East and the West.
stray from their mentors' orientation. Second, It will be interesting and exciting to observe
the authoritarian orientation of Chinese culture whether the development of clinical psychology
contributes to the preference for a particular in Taiwan, and Asia more generally, will
orientation. Chinese tend to respect structure continue the trend towards the West, or branch
and formality in interpersonal relationships. off into an entirely new direction.
The same holds true in therapeutic relation- The following factors will affect the future
ships. Yang (1995) pointed out, ªas long as the development of clinical psychology in Taiwan:
Chinese see authorities as trustworthy and (i) diversity of training programs throughout
`almighty,' they will be completely dependent the country;
upon those authorities.º Respect for authority (ii) the number of clinical psychologists
may take the form of agreeing readily to what trained locally and abroad;
the therapist does and proposes. The cognitive- (iii) the amount of empirical research con-
behavioral approach offers relatively more ducted;
formality and authoritarianism. Perhaps the (iv) sociopolitical changes.
348 Clinical Psychology in Asia: A Taiwanese Perspective

These factors, and perhaps others not men- ogy from cultural response sets: Asians and MMPI-2
tioned here, will influence significantly the performance. Abstract presented at the Annual Meeting
of Chinese Psychological Association, Taipei, Taiwan.
course of clinical psychology in Taiwan. Pro- Sue, D. W., & Sue, D. (1990). Counseling Asian Amer-
ductive cross-cultural collaboration as well as icans. In D. W. Sue & D. Sue (Eds.), Counseling the
indigenous research will undoubtedly contri- culturally different: Theory and practices (pp. 189±208).
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Tseng, W. S. (1972). Psychiatric study of shamanism in
Taiwan. Archives of General Psychiatry, 26(6), 561±565.
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 Copyright © 1998 Elsevier Science Ltd. All rights reserved.

10.17
Clinical Psychology in Aotearoa/
New Zealand: Indigenous
Perspectives
TAIMA M. MOEKE-PICKERING, MAHALIA K. PAEWAI, AMELIA
TURANGI-JOSEPH, and AVERIL M. L. HERBERT
University of Waikato, Hamilton, New Zealand

10.17.1 INTRODUCTION 349

10.17.2 A BRIEF HISTORY 350
10.17.2.1 Maori Identity 350
10.17.2.2 The Treaty of Waitangi 350
10.17.3 PSYCHOLOGY IN AOTEAROA 350
10.17.3.1 Historical Context 350
10.17.3.2 The State of Maori Mental Health 351
10.17.4 DEVELOPING A BICULTURAL MODEL IN AOTEAROA 351
10.17.4.1 The Need for Change 351
10.17.4.2 A New Approach to Maori Mental Health 351
10.17.5 PSYCHOLOGY IN A BICULTURAL SETTING 351
10.17.5.1 The Changing Face of Psychology 351
10.17.5.2 Training in Psychology 352
10.17.5.3 National Standing Committee on Bicultural Issues 352
10.17.6 MAORI AND PSYCHOLOGY 352
10.17.6.1 Research, Training, and Teaching 352
10.17.6.2 Cultural Safety 353
10.17.6.3 Cultural Safety and Clinical Practice 353
10.17.6.4 Maori Psychological Initiatives 353
10.17.7 CONCLUSION 354
10.17.8 REFERENCES 354

10.17.1 INTRODUCTION as psychology has evolved from early British to

later American influences is the relevance of
This chapter provides an indigenous per- Western based psychological theory and prac-
spective of psychology in Aotearoa (the Maori tice. This raised questions about the need to
name for New Zealand) by examining bicultur- develop indigenous paradigms in Aotearoa.
al developments in the fields of teaching, The Treaty of Waitangi provided a unique basis
research, theory, and practice. The key issue for a bicultural model to be developed.
for Maori (the indigenous people of Aotearoa) Bicultural and Maori initiatives have played a

349
350 Clinical Psychology in Aotearoa/New Zealand: Indigenous Perspectives

significant role in psychology training pro- 1840 and marked the beginning of a new era for
grams. In particular, the development of Maori- Maori. The treaty prescribed a proposed
initiated psychological programs demonstrate constitutional relationship between the Crown
an increased acceptance of cultural dimensions and Maori that outlined the duties and obliga-
in psychology. tions of both parties. In delegating limited
authority to the Crown, the Treaty of Waitangi
guaranteed Maori sovereignty or chieftainship
10.17.2 A BRIEF HISTORY over their lands, their settlements, and all other
10.17.2.1 Maori Identity property (Jackson, 1988). Written in both the
Maori and English language, ambiguities in
To understand the development of psychol- interpretation between both texts have caused
ogy in Aotearoa as well as its responsiveness to much debate until the late 1990s (Jackson, 1988;
the needs of Maori, the historical and cultural Orange, 1987; Renwick, 1990).
context in which the discipline has developed In the intervening 156 years, the principles of
must be considered. The dominant ethnic group the Treaty of Waitangi have been breached
in Aotearoa are Pakeha (mainly New Zealan- repeatedly through Pakeha hegemony and the
ders of predominantly European±British des- ethnocentric attitudes that underpin it (Ballara,
cent). Like the experience of many indigenous 1986). Maori have faced the trauma of loss of
peoples from other settler colonies, Maori land, language, and dignity, as well as absolute
continue to strive for self-determination in an control over their ability to maintain a separate
environment of Pakeha dominance (Hamerton, culture and identity (Vasil, 1988). As a result
Nikora, Robertson, & Thomas, 1995; Jackson, they suffered cultural alienation, poverty, un-
1988; Walker, 1990). employment, and hardship which ultimately led
Prior to Pakeha contact, Maori identified to further entrenchment and subordination to
themselves primarily from the strata of their dominant Pakeha cultural ways (Awatere, 1984;
tribal structures, these being whanau (extended Lawson-Te Aho, 1984; Walker, 1990).
family), hapu (subtribe), iwi (tribe), and waka Clearly, both Maori and Pakeha ethnic
(ancestral canoe linking iwi and the peoples of identities have developed, out of a binary
the Pacific). Tribal structure and organization opposition between the two people with Pakeha
were based on descent from a common Maori becoming the dominant ethnic group (Walker,
ancestor (Buck, 1949). Identity was derived 1989). Today Maori people comprise 12% of
from kinship and learning within these tribal the population, control less than 5% of the land,
structures (Moeke-Pickering, 1996). and continue to struggle to maintain a positive
Cultural practices were based on a shared cultural identity.
system of understanding by a tribal group that
were deemed to be important and meaningful to
them (Moeke-Pickering, 1996). Language, cus- 10.17.3 PSYCHOLOGY IN AOTEAROA
toms, spirituality, respect for the land, kinship
obligations, and traditions were fundamental to 10.17.3.1 Historical Context
the socialization of Maori identities. In essence Psychology modeled on the British system
historical references, cultural practices, kinship developed as a discipline within Aotearoa
structures, and the land served as charters for (Hamerton et al., 1995). The introduction of
Maori identities (Ritchie, 1992). psychology was part of the imposition of a
colonial knowledge system that systematically
10.17.2.2 The Treaty of Waitangi undermined Maori ways of knowing in favor of
a Western world view. Evidence of this was clear
During the period of early contact with in the way that the Western psychological
Pakeha, the sovereign status of Maori was paradigm was hierarchically positioned over
internationally recognized in the Declaration of and above Maori epistemology. Psychology had
Independence in 1836. Maori were involved in a status as a scientific discipline at a time when
international trade and were both thriving and Maori knowledge was perceived as an inferior
flourishing economically. The lawlessness of theoretical framework (Lawson-Te Aho, 1984;
many early Pakeha settlers, however, was Stewart, 1995).
causing concern among Maori leaders. They At that time, the application of a psycholo-
resolved to enter into a constitutional arrange- gical paradigm foreign to Maori experiences
ment with the British Crown which would allow became accepted practice by psychologists and
the British to control the unruly behavior of its was deemed to be appropriate despite obvious
citizens resident in Aotearoa (Orange, 1987). ethnocentric biases inherent within this frame-
The vehicle for this was to be the Treaty of work. An example was the use of intelligence
Waitangi which was signed on the February 6, tests to stream Maori school children used in the
 Psychology in a Bicultural Setting 351

1950s and 1960s. Predictably, these tests were passing of the 1975 Act and the Treaty itself
demonstrated to be both culturally biased and gave impetus to claims by Maori that health
an unfair means of assessing the ability of Maori policies and initiatives should reflect their rights
due to the culturally bound nature of the to development and self-determination.
constructs used (Thomas, 1988).
10.17.4.2 A New Approach to Maori Mental
10.17.3.2 The State of Maori Mental Health Health
During the 1990s it became clear that By the 1980s, challenges to the discipline of
although Maori were becoming mentally ill at psychology to recognize the significance of
a similar rate to Pakeha, poorer outcomes were cultural issues further increased. A bicultural
being experienced by Maori during the post- approach which served the health needs of
admission phases of treatment (Bridgman, Maori needed to be developed based on
1993). Drug and alcohol related problems as increased recognition of cultural differences
well as other psychoses were the main categories between Maori and Pakeha. In practice,
underpinning Maori admissions. Although the biculturalism as an approach to Maori health
actual statistics need careful examination, the initially attempted to include a Maori perspec-
overall trend highlighted the fact that the fastest tive into existing health systems.
growth area in terms of hospitalization was the With the increasing awareness of a range of
readmission of Maori with serious psychotic culturally determined behaviors, some profes-
illness (Awatere, 1984; Bridgman, 1993). Bridg- sionals suggested that Maori were misdiagnosed
man (1993) also suggested that psychiatric as psychotic and inappropriately referred to
diagnoses for Maori presented a distorted psychiatric services. Of particular significance
picture with inaccurate assessments and in- within the health field were Maori assertions
effective hospitalization. Psychiatric statistics that a bicultural model should provide equi-
for Maori were less indicative of the levels of tably for both Treaty partners. Furthermore,
psychopathology in the population and more an provisions already existed in the articles of the
indication of the inability of health providers to Treaty of Waitangi to justify these claims. Durie
understand the social, educational, and eco- (1994) noted that by 1985 the Standing
nomic realities faced by many Maori. Further- Committee on Maori Health had recommended
more, attitudes in service agencies had failed to that the Treaty of Waitangi be regarded as the
recognize or accommodate cultural differences foundation for good health.
(Spoonley, 1988). In the mental health setting, the application
of a bicultural model in the 1980s relied upon
good faith and agreed-upon-goals rather than
10.17.4 DEVELOPING A BICULTURAL formal conventions (Durie, 1994). As a result,
MODEL IN AOTEAROA the parameters of the bicultural model were not
10.17.4.1 The Need for Change clearly defined and the rights and responsibil-
ities of Maori and Pakeha were poorly under-
The inability of the health sector to respond stood. Some programs gave recognition, but
appropriately to many Maori clients became little else, to the cultural traditions of Maori
increasingly obvious to many health profes- (Mulgan, 1989a) while others favored a redis-
sionals and community workers and led to an tribution of resources to Maori (Jackson, 1988).
examination of different approaches to Maori At one level there was an implied inclusion of
health (Durie, 1994). While Durie (1994) was Maori values in mainstream institutions, at
able to identify earlier Maori health profes- another the development of specific Maori
sionals who had established appropriate cultural institutions to provide for Maori needs (Sharp,
practices, there was no widespread recognition 1995). Regardless of these difficulties, the
for such contributions until the mid-1970s. bicultural model served as a framework for
At this time the government finally addressed other institutions, agencies, and social services
over a century of injustices with the passing to extend upon.
of the Treaty of Waitangi Act 1975. This
provided for the first time a recognized forum
for Maori to air grievances and to advocate 10.17.5 PSYCHOLOGY IN A BICULTURAL
Treaty obligations in a bicultural milieu (Ka- SETTING
wharu, 1989). This led to Maori people being 10.17.5.1 The Changing Face of Psychology
legally recognized as ªtangata whenuaº or
indigenous people of the land, with rights under Awatere (1981), a noted Maori psychologist,
the Treaty to their own language and cultural raised the notion that certain psychological
self-determination (Abbot & Durie, 1987). The techniques and practices used the privilege of
352 Clinical Psychology in Aotearoa/New Zealand: Indigenous Perspectives

power to further oppress Maori cultural pro- Maoriº into training programs and to develop a
cesses. She expanded on this by asserting that: Maori psychology as well as include Maori
psychology programs within mainstream edu-
My job as a psychologist is to facilitate the process cation. In this study of 163 clinical psychologists
of understanding, confronting and changing; to of whom only one was Maori, over 85% of the
use psychological techniques to help the powerless sample supported the notion that psychologists'
gain power instead of what psychologists have knowledge of Maori culture was an important
always done, which is to help maintain their power. factor in good psychotherapeutic outcomes with
(p. 202)
Maori clients. Interestingly, 75% of the sample
felt they had inadequate Maori knowledge to
Waldegrave (1985), in developing therapies for effectively work with Maori, while 85% believed
Maori and Samoan families, found that the that their psychological training had not
predominantly monocultural and monoclass equipped them sufficiently to effectively work
approach was inadequate due to the existence with Maori clients.
of broader social and political issues which
impacted on these cultural groups. He pointed
out that psychologists were not required to 10.17.5.3 National Standing Committee on
demonstrate any knowledge of Maori culture at Bicultural Issues
all, and that psychological knowledge, includ-
ing family therapy, was considered sufficient to The report of Abbot and Durie (1987)
address the problems of both Maori and Pakeha presented a damning critique of psychological
families. training. The report served as the catalyst for
change in psychological training and two years
later the National Standing Committee on
10.17.5.2 Training in Psychology Bicultural Issues (NSCBI) was established
under the auspices of the New Zealand
In the United States, Yutrzenka (1995) noted Psychological Society.
that until the 1970s there was little inclusion of The NSCBI was formed to monitor the
cross-cultural material, as well as limited development of bicultural activities, organize
diversity in the client populations with whom symposia, disseminate information on issues
trainees received their clinical service training. relevant to indigenous development, and to
Increasing awareness in the 1980s and 1990s saw develop and encourage policies and practices
a change towards including more cross-cultural that reflected New Zealand's cultural diversity
theory and practices in psychology training (Hamerton et al., 1995). The Committee's broad
programs. Many professional psychologists aims were to initiate social changes that
were aware of this need to prepare for a supported recognition and development of
multicultural, multiracial, and multiethnic en- Maori psychology, to assist the New Zealand
vironment, but as Yutrzenka (1995) commen- Psychological Society to honor its obligations
ted, the commitment and implementation of under the Treaty of Waitangi, and to assist
cross-cultural understanding was highly vari- psychologists to develop appropriate teaching,
able across these programs. research, and practice (NSCBI, 1994a). These
To some extent this overseas trend was also activities have been effective in instituting
being reflected in Aotearoa. For example, in cultural agendas at both the national and
1987, a survey of the nine postgraduate training regional levels.
programs in clinical, educational, and commu-
nity psychology in Aotearoa was completed
(Abbot & Durie, 1987). The findings of this 10.17.6 MAORI AND PSYCHOLOGY
survey confirmed that few programs incorpo- 10.17.6.1 Research, Training, and Teaching
rated ªtaha Maoriº (a Maori dimension). The
monocultural training of psychologists com- By 1996 most university psychology depart-
pared unfavorably with social work and medical ments and psychological service providers have
training. Both Abbot and Durie and later Brady either considered, or put in place, initiatives
(1992) questioned the credibility of the discipline aimed at supporting Maori students and
and challenged it to: (i) increase the number of practitioners. While bicultural initiatives in
trained Maori psychologists; (ii) develop an Aotearoa have served to increase acceptance
increased awareness of entrenched attitudes; of cultural issues in psychology, it had also
and (iii) invest more energy into making changes become apparent that there was a need to
at all levels of training including format, develop a body of research relevant to Maori
assessment methods, texts, and ethics. and psychology. There has been a considerable
In 1990, a study conducted by Sawrey (1990) amount of research and literature relating to
further illustrated the need to include ªtaha Maori and psychology which is now having
 Maori and Psychology 353

some impact on both professional training and cultural approaches within other disciplines
mental health services (Awatere, 1981; Durie, have assisted psychology training to provide
1994; Lawson-Te Aho, 1984; McFarlane- strategies to improve cultural care, meaning,
Nathan, 1996; NSCBI, 1994b, 1995; Paterson, and sensitivity when working with Maori. One
1992; Ritchie & Ritchie, 1978; Stewart, 1995; such approach is that of ªcultural safetyº which
Thomas & Nikora, 1992). In addition, the is described as
experiences of other colonized indigenous
people overseas have relevance for Maori by . . . actions which recognise, respect and nurture
serving to direct attention on similar issues the unique cultural identity of tangata whenua,
within the context of Aotearoa (McFarlane- and safely meet their needs, expectations and
Nathan, 1996). rights. A culturally unsafe practice is (are) any
actions which diminish, demean or disempower
There are two universities in Aotearoa that
the cultural identity and well-being of an indivi-
currently offer courses which focus on Maori dual. (Ramsden, 1991, pp. 7±8)
topics relating to psychology. In addition, two
other universities have made an explicit commit-
Cultural safety was initiated by Maori nurses
ment to developing course material and/or
and later developed by the New Zealand
structures relevant to Maori in psychology Council of Nursing (Ramsden, 1991). As an
(Stewart, 1995). These courses have had the
approach, cultural safety has increased under-
effect of increasing Maori participation in
standing of the different ways that helping
psychology. An increase in the number of Maori professions might develop working guidelines.
enrolling in psychology training programs The focus of these guidelines is to enhance good
coupled with increased retention of Maori both teaching practices and strategies when educat-
within the discipline and as practitioners have
ing health professionals. Cultural safety is now
resulted in a larger pool of Maori with relevant
generally accepted in professional practice and
research and practical expertise. With increasing
training programs, including psychology.
numbers both in practice and research, Maori
are better placed to develop more appropriate
theoretical frameworks. 10.17.6.3 Cultural Safety and Clinical Practice
The frameworks referred to above contribute
to a psychology that services the needs of Maori Cultural safety incorporates two principles
in a way that is relevant to their needs and inherent in the Treaty of Waitangi. First, active
consistent with their world view. It has been protection of Maori Treaty rights, and second,
necessary to develop a Maori resource base recognition of all cultures in Aotearoa. A study
from which an understanding and awareness of by Paewai (1996) described various cultural
cultural knowledge, skills, and competence can safety strategies being employed by six Maori
be drawn. Students are encouraged to read clinical psychologists working in Aotearoa. A
literature describing colonization, Maori his- significant finding in Paewai's study was that
tory, Maori traditions, as well as tribal and psychotherapeutic outcomes were improved if
cultural knowledge to gain background infor- the clinician acknowledged the cultural identity
mation pertaining to Maori people. Durie of the client in assessment and treatment
(1994), Ritchie (1992), and Walker (1990) procedures.
provide comprehensive information on bicul- To this end, some training programs are
turalism, the impact of colonization, the developing a curriculum that monitors, teaches,
development of bicultural policies, tribal devel- and evaluates cultural safety and competence.
opment and identity, and Maori health. For example, at Waikato University, courses in
Current research in the areas of cross-cultural cross-cultural psychology, community psychol-
psychology (Thomas, Nikora, & Moeke-Pick- ogy, and Maori development and psychology
ering, 1996), identity issues (Durie et al., 1995; highlight cultural safety concepts and ap-
Heperi, 1996; Hingston, 1993; Moecke-Picker- proaches. These programs have been developed
ing, 1996; Nikora, 1995b; Thomas & Nikora, to assist psychology students to increase their
1996), and cultural practice issues (Paewai, cultural analysis by providing informed con-
1996) have helped to shape alternative practices sideration of issues of culture, with the intent of
and strategies for working with Maori and avoiding ignorant rejection or violation of
provide insights into Maori conceptualizations. cultural norms (Nikora, 1995c).

10.17.6.4 Maori Psychological Initiatives

10.17.6.2 Cultural Safety
Three agency-based programs (one hospital-
While psychological literature contributes to based and two in the Justice Department)
a more informed trainee and practitioner, developed specifically for working with Maori
354 Clinical Psychology in Aotearoa/New Zealand: Indigenous Perspectives

are presented in this section. The support of deculturation. Cultural supervision of the
local tribes, Maori healers, and resource people clinician ensures that the necessary knowledge
have been essential (McFarlane-Nathan, 1996) base is being maintained to enable satisfactory
to the success of these programs. assessment of Maori clients. Clinicians require
Whaiora is a ward based at a psychiatric training which focuses on the cultural context
hospital at Tokanui in the central North Island. within which Maori operate (McFarlane-
It emerged from an increasing awareness among Nathan, 1994). They must also develop an
Maori nursing staff at Tokanui Hospital that awareness of their own limitations for dealing
the therapy strategies employed were culturally with Maori clients. At the initial assessment
biased. They often alienated Maori clients stage, the trained clinician is encouraged to
(Durie, 1994). The successful development of consider the possibility of deculturation and/or
a parallel Maori cultural therapy unit in 1986 acculturation stressors in the assessment of
was a direct attempt to redress the spiritual and etiology. The Bicultural Therapy Model recog-
psychological imbalance prevalent among nizes that cognitive behavior therapy as a
Maori clients by implementing a more appro- therapeutic approach provides a framework
priate, holistic approach to mental health for the culturally-competent clinician to inves-
(Rankin, 1986). This approach encompassed tigate the social and behavioral context of the
many elements critical to Maori health and client. The client's level of bicultural compe-
necessitated that a balance be maintained tence is also assessed to establish the ªdegree to
between each dimension for adequate well- which clients possess sufficient cultural re-
being. One of these approaches is the Maori sources to enable them to develop successfully
health model that incorporates the tinana as indigenous people in Western societyº
(physical body), hinengaro (thoughts and as- (McFarlane-Nathan, 1996).
pects of the mind), whatumanawa (feelings and
deep emotions), and whanau (extended family).
The model provides a framework that assists in 10.17.7 CONCLUSION
the understanding of Maori processes and Bicultural and Maori initiatives in psychol-
people. In addition, Whaiora seeks to restore ogy have contributed to an evolving under-
and enhance self-esteem, self-worth, and self- standing of cultural variables when working
confidence by encouraging and promoting a with Maori people. Contributions made by
sense of being and pride in the client's own Maori psychologists, Maori students, and
cultural heritage (Rankin, 1986). The unit places Maori-initiated programs have helped to refine
strong emphasis on whanau involvement and a resource base where theory, research, and
community support networks which are funda- skills relevant to Maori development and
mental to a smoother transition for Maori psychology can be developed. As Maori are
clients returning to the community and decreas- appointed to senior positions in health agencies
ing readmission rates. and universities, there will be increasing oppor-
Te Piriti Special Treatment Unit is a relapse tunities for Maori initiatives in research and the
prevention program for sex offenders based in development and application of indigenous
Auckland. The main goal of the program is to psychological paradigms as well as Maori
reduce sexual reoffending and assist offenders control of services for Maori.
and whanau/support people through the initial
rehabilitation process. This organization has a
Maori ªcultural consultantº who is involved at 10.17.8 REFERENCES
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Society and the Treaty of Waitangi: Proposed imple- and New Zealander: Ethnic and national identity among
mentation plan. New Zealand Psychological Society New Zealand students. Journal of Intercultural Studies,
Bulletin, 82, 13±17. 17, 29±40.
National Standing Committee on Bicultural Issues Thomas, D. R., Nikora, L. W. & Moeke-Pickering, T. M.
(NSCBI) (1994b). An interview with Linda Waimarie (1996). Readings in culture and ethnicity. Department of
Nikora, out-going convenor of the NSCBI. New Zealand Psychology, University of Waikato, Hamilton, New
Psychological Society Bulletin, 83, 6±8. Zealand.
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(NSCBI) (March). How does the Treaty of Waitangi called non-political family therapy. Australia and New
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 Copyright © 1998 Elsevier Science Ltd. All rights reserved.

10.18
Perspectives from Sub-Sahara
Africa
PIUS K. ESSANDOH
Jersey City State College, NJ, USA

10.18.1 MISCONCEPTIONS ABOUT AFRICA 357

10.18.2 SOCIOCULTURAL BELIEFS 358
10.18.2.1 Spirituality 358
10.18.2.2 Collective Responsibility and Cooperation 359
10.18.2.3 Kinship 359
10.18.2.4 Gender Roles 360
10.18.3 OTHER THEORETICAL ISSUES 360
10.18.4 TRADITIONAL COMMUNITIES AND PSYCHOPATHOLOGY 360
10.18.5 THE THERAPEUTIC PROCESS 362
10.18.5.1 Assessment/Diagnosis 362
10.18.5.2 Prognosis 362
10.18.5.3 Treatment/Cure 363
10.18.6 TRAINING IMPLICATIONS 363
10.18.7 CONCLUSION 363
10.18.8 REFERENCES 364

10.18.1 MISCONCEPTIONS ABOUT (Binitie, 1981; German, 1987; Leighton, Lam-

AFRICA bo, & Hughes, 1963), there has not been a
consistent body of research on the theory of
Despite its size and the role it has played in psychopathology and treatment issues.
both ancient and modern civilization, Africa The primary focus of this chapter is to
continues to be relatively unknown to the discuss the sociocultural factors in psychologi-
Western world. The little that has been written cal health in sub-Sahara Africa, bearing in
about Africa in general, and African psychology mind that any good definition of mental health
in particular, is full of myths and misconcep- and the delivery of mental health services in
tions. For example, it was widely believed that Africa must take these factors into account.
depression, suicide, and affective disorders were The chapter also discusses issues of diversity
either nonexistent or less prevalent in African (e.g., gender) as they affect the delivery of
communities and that in general, Africans psychological services. It should be pointed out
experienced fewer psychological problems than that psychological therapy, as practiced in the
peoples from other cultures. Although such West, is almost nonexistent in most parts of
myopic views have been challenged by several Africa and as such, for many people it is not an
authors, who point to as many psychological option for the resolution of interpersonal
disturbances in Africa as in other cultures conflicts and other psychological problems. It

357
358 Perspectives from Sub-Sahara Africa

is also important to point out that sub-Sahara 10.18.2 SOCIOCULTURAL BELIEFS

Africa is so massive in size and rich in cultural
diversity that to attempt to write about Africa African etiological theory of mental illness
as if it contained one homogeneous group and psychological disorders is still profoundly
would be the greatest act of disservice. Most of rooted in sociocultural and spiritual founda-
the generalizations made in this chapter about tions (Danquah, 1982; Essandoh, 1995; Wyllie,
Africans or Africa are more impressionistic 1983). Enemies use witchcraft and other magical
than empirical and are drawn primarily from means to afflict their victims with mental illness.
my own experiences as an African and my work Binitie (1991) has indicated that it is the belief of
with African college students in the USA, and some Africans that witches ªcan do harm from a
also from the works of other indigenous distance without being in physical contact with
African researchers. their victims . . . They terrorize the victims
A suggestion frequently made is that African through their capacity to cause illness, mis-
traditional life and culture are primarily fortune, childlessness, poverty, and deathº
variants of folk culture that existed throughout (p. 5); thus, presenting problems that traditional
the rest of the world in the preindustrial healers as well as clinical psychologists have to
revolution era and are therefore not relevant deal with. The gods and ancestors can afflict
for the postindustrial revolution era. This is in individuals with mental illness as well as provide
spite of the fact that most Western nations are cure and grant success and well-being. As agents
desperately seeking some aspects of traditional of healing power and knowledge, they influence
life and culture as vital to national and to a very large extent the moral development of
individual well-being and as needed additions individuals as well as the social changes that
to industrial and economic development. It is take place in the community. Binitie (1991) has
commendable that despite the fact that sub- pointed out further that witches are viewed as
Sahara Africa is witnessing major political and ªjudicial agentsº and also as ªagents of
economic changes typical of postindustrial socializationº who help ªto equilibrate society
revolution, most of the urban communities by preventing social greed and unscrupulous
remain traditional and they continue to have a behaviorº (p. 5). Individuals and communities
more stable and homogeneous cultural tradi- become aware of the possible social conse-
tion. Writing about traditional healing in Africa quences of their behavior and thus they show
and its implication for cross-cultural counsel- deep respect for customs and traditions and also
ing, Vontress (1991) pointed out that even when work on improving interpersonal, family, and
they are outside of their countries, most African social relationships, very critical components of
students in the USA retain their traditional good mental health. When there are any lapses
beliefs; this presumably slows down the process that lead to mental health or physical problems,
of acculturation. It is reasonable to suggest then traditional healers who serve as intermediaries
that when they are in Africa, urbanized between the spirit world and the physical world
Africans, in spite of some changes in their intercede with sacrifices and provide treatment.
world views, may continue to hold a culturally Traditional healers also serve as interpreters and
pluralistic view of mental health and psycholo- teachers of social values and beliefs.
gical well-being. Inherent in this cultural
pluralism is group identity, collective responsi-
bility, cooperation, interdependence, certain 10.18.2.1 Spirituality
values and beliefs about etiological causes of
mental illness, attribution of disturbances, and African traditional beliefs emphasize the
spirituality. These values are for the most part importance of spirituality and external super-
retained or revisited when individuals have to natural sources of help. There is a sense of
respond to some psychological symptoms of reliance and dependence on a supreme being
stress and alienation that industrialization and and on nature. People must either be subjugated
urbanization present. In most instances, urba- to nature or live in harmony with it and submit
nized Africans utilize both systems of careÐ to the authority of God or a deity to whom
traditional and WesternÐsequentially, if not everybody is accountable. Faith in the super-
simultaneously. They see these two systems not natural influences most, if not all, healing. Thus,
as contradictory but as reinforcing each other traditional healers and religious/spiritual hea-
(Onyioha, 1977). The implications for psycho- lers become particularly powerful, not only
logical development and services have probably because they share these same beliefs as their
only been inferred or assumed at this time but clients, but also because only they have the skills
clinical psychologists must understand some to lock up evil spirits as well as invoke the help of
aspects of these sociocultural beliefs before they good spirits through prayer, sacrifices, and
are able to work with clients from this culture. concoctions.
 Sociocultural Beliefs 359

There is also the belief in reincarnation. This Ghanaian proverb (Akan) which, when literally
is expressed in ceremonies concerning life and translated into the English language, states that
death. For example, a new-born child is named if you depend on people during infancy when
after a dead ancestor and is sometimes believed you are growing your teeth, you reciprocate this
to be this dead ancestor who has reincarnated. gesture by helping these individuals during old
The link between the metaphysical and the age when they lose their teeth. This kind of
physical must remain unbroken and the new- reciprocal expectation, when not properly
born is expected to develop such altruistic resolved, could lead to anxiety over one's
attributes of sharing and interdependence that inability to be a good provider for one's
characterized the life of the deceased relative. children or parents. For the African parent,
For living relatives, it is a great honor to have a this relationship could lead to good mental
new-born baby named after them. This is a health and respectability in the community, as
testimony of their moral character and the well as provide social security during old age.
respect enjoyed between the family and com- For the African child, failure to live up to this
munity. Young ones learn early in life that if filial obligation has very serious social and
they do good, they can reap the benefit in this mental health consequences.
current life or the life thereafter. Even on the international scene, African
leaders have often recognized the importance of
collateral relationships. For example, Nkrumah
10.18.2.2 Collective Responsibility and of Ghana articulated very strongly and clearly
Cooperation the notion that Ghana's independence (and by
extension, development) was meaningless unless
Traditional African families derive their it was tied to the total emancipation and
strength from cooperation and mutual help- development of all Africa. Nkrumah's new
fulness. Individual growth and development republic was not ready for competitive nation-
must be seen in the context of family growth alism. Instead, he was ready to cooperate in a
and development. This collateral relationship harmonious relationship with the rest of Africa
which emphasizes self as part of a group, and for its political as well as economic develop-
people as more important than possessions, is ment. Thus, the African value of interdepen-
different from other world views where in- dence and collective responsibility is clearly
dividualism and task productivity are more demonstrated not only at the individual/family
important than relationships. The African is level but also at community, national, and
brought up with values that encourage mutual continental levels.
support in times of good fortune as well as in
times of adversity, ill-health, and failure. The
only contribution in life which significantly
influences development is to cooperate with the 10.18.2.3 Kinship
family and group. Individual happiness means
interdependence (not independence); there is no One of the most distinctive features of
other means of meaningful life. Interdepen- traditional African communities is the impor-
dence is a life-long virtue and a yardstick for tance of kinship ties and communal style of
measuring the ªgood life.º Too much indepen- living. All activities of social lifeÐeconomic,
dence is interpreted as pride and a haughty political, and religiousÐare based on such
attitude, and one is often punished by the gods kinship relations. Such ties bring people
for this kind of attitude. Within this culturally together for very important family activities
defined belief system that exalts interdepen- like farming and harvesting (e.g., the Ndoboa
dence above independence, the development of system among the Akans of Ghana where
mental illness (and to some extent physical families help each other in cultivating the land
illness) depends on the disturbed person's and in harvesting the produce), the birth of a
interpersonal relationship; recognizing the im- child, puberty rites, and marriage and funeral
portance of interdependence can ensure good ceremonies. Feeling closely related to kin
psychological health, but not recognizing this offers security in all aspects of family lifeÐ
important aspect of human development can economic, social, and psychologicalÐand it
lead to poor psychological health. gives expression to the sense of interdependence
Collective responsibility and mutual coop- and cooperation. A strong social support
eration also demand that parents (including the network, very instrumental in preventing some
extended family of uncles, aunts, etc.) provide psychological problems (e.g., stress, depression,
for the welfare and security of children who in uncomplicated bereavement), develops. Practi-
turn will ensure the security of parents in their tioners must recognize and utilize this network
old age. This view is nicely summarized by a in the delivery of psychological services.
360 Perspectives from Sub-Sahara Africa

10.18.2.4 Gender Roles 1976) and they have pointed out that women, as
well as the culturally different way of knowing
A number of researchers have estimated that and developing, are somehow different from
the ratio of African males to females in terms of the stages proposed by these Euro-American
psychiatric hospitalization is two to one theories.
(Dawson, 1964; Lamptey, 1977; Orley, Most developmental theories in psychology
1972). Yet, despite this difference in the rate and education follow a stage-wise, linear,
of hospitalization, it appears that African predictable, and hierarchical progression. They
women present with higher incidence of measure development in stages across life-span
depression and other psychosomatic disorders and this life-span is divided into prenatal,
than their male counterparts. Kisekka (1990) infancy, early childhood, late childhood, ado-
has speculated that the low hospitalization rate lescence, young adulthood, middle age, old age,
among women may well be due to the fact that and death. To most Africans, life-span devel-
women use alternative forms of treatment (such opment has very few stagesÐprenatal, child-
as spiritual healing and traditional healing); or hood, adulthood, and old age. The kind of
that because men are over-represented in the identity confusion that faces Western children
formal employment sector, they have access to as they make the transition from late childhood
free medical care; and that men are over- to adolescence simply may not exist for the
represented in cases of mandated admission African child, who becomes an adult overnight
from law enforcement agencies, particularly the after certain rites of passage ceremonies have
police. Kisekka has further hypothesized that been performed. In a similar vein, using
gender-role stressful situations such as a Eurocentric theories to measure constructs like
ªbarrenness, failure to have the desired number self-esteem, self-actualization, autonomy,
and sex of children, unwanted pregnancies, doubt, initiative, and guilt do not make sense.
divorces, matrifocality, and early and forced Development from an African frame of refer-
marriagesº (p. 10) may impact women more ence, including even life-span, is cyclical, non-
significantly than they do men. The etiology linear, multigenerational, as well as
and nature of these emotional disturbances in transgenerational and it measures constructs
Africa seem to point to sociocultural factors such as collaboration, communal values, and
rather than intrapsychic factors. If this asser- spirituality. In Africa, development in any facet
tion is accurate, it will be imperative for must include character training (similar to
psychologists and other mental health profes- Kohlberg's moral development) and only this
sionals to consider sociocultural factors in is seen as beneficial to society. It is important to
psychopathology and treatment as an integral understand that if these theoretical constructs
part of competent professional practice. have different meaning for the African, then a
transcultural description of psychopathology
10.18.3 OTHER THEORETICAL ISSUES may not be possible after all and that the
development of a common psychological lan-
Although it is clear from the discussion of the guage for communication between sub-Saharan
sociocultural beliefs that differences exist be- African mental health professionals and their
tween sub-Sahara Africa and the Euro-Amer- Euro-American counterparts is a long way from
ican culture, it is important to point out that happening. This has important implications for
differences exist also in terms of the psycholo- training, research, and practice.
gical characteristics of individuals from these
different cultures. There is evidence of variation
in the definition of some psychological con- 10.18.4 TRADITIONAL COMMUNITIES
structs. Traditional psychological theories have AND PSYCHOPATHOLOGY
often defined development from a Eurocentric
world view. This world view is middle class, The suggestion that traditional African life
male, white, and with Protestant values in and culture are not relevant for the post-
orientation. Development is conceptualized in industrial revolution era raises a number of
terms of self-actualization, separation, differ- important questions. Should modernizationÐ
entiation, independence, respect for personal technological, industrial, and economicalÐ
boundaries, and self-development. All this takes always be at the expense of the social, spiritual,
precedence over group and community inter- and communal values that have sustained the
ests. But even in the West, feminist critics and African continent for hundreds of years? Does
multicultural experts have challenged such the African culture help lay a foundation for a
Eurocentric developmental theories (Asante, psychologically healthy personality strong en-
1987; Atkinson, Morten, & Sue, 1993; Cross, ough to withstand the pressures of industria-
1971; Gilligan, 1982; Jackson, 1975; Miller, lization and urbanization? Answers to these
 Traditional Communities and Psychopathology 361

questions may help explain how psychopathol- Kisekka (1990) notes the excessive stigma
ogy develops in the sub-Sahara African attached to barrenness and goes on to point
context. If one adopts the unipolar way of out that ªboth traditional and modern folklore,
thinking that folk culture is not relevant for literature and popular music are replete with
development in the postindustrial revolution depictions of barren women as lonely, mal-
era, one will fail to recognize that the modern icious, [and] cruel to childrenº (p. 6). It appears
world, when alienated from social, spiritual, that the feelings of isolation, loneliness, and
and communal values, experiences a break- even depression are the expressions of the
down in moral values that leads to the problems of living in this culture and are
disintegration of families in particular and culturally induced rather than being intrapsy-
society in general. The argument for the chically induced.
retention of traditional cultural beliefs and Although cultural factors could exacerbate
practices also presupposes that Africans will and even initiate psychopathology, urbanized
enjoy an improved psychological health if they Africans may experience psychopathology be-
retain these beliefs. The truth, however, is that cause of the degree of their alienation from these
there are many aspects of traditional life that traditional and cultural values. For example,
could either initiate psychological problems or Africans have become enslaved to the corrupt-
exacerbate them. ing influences of individualism (the ªme firstº
The role of sociocultural factors in the attitude), and they have made social and
development of psychopathology has not cultural adaptations from kin-bound societies
received any serious research consideration in and kinship ties that provided the much needed
sub-Sahara Africa. While cultural factors could solidarity for physical as well as mental growth.
be the source of cohesion, identity, and The extent to which these individuals want to
strength, and be instrumental in the develop- assimilate the West culture creates an identity
ment of good psychological health and the confusion. The Western culture is very different
prevention of some serious psychological from the African culture and as Taft (1977) has
disorders, in some instances these same factors suggested, when the size of the gap between a
could be the source of psychopathology. For familiar culture and an unfamiliar culture is
example, it is often believed that the extended very big, it is difficult for individuals to adjust
family/kinship system provides personal and and cope with the changes that they need to
social security. However, literature is often make. Thus, caught between retaining most of
silent on the fact that such deep commitment to the traditional African values and beliefs that
the extended family could lead to stress, anger, are incompatible with the values of a compe-
intergenerational conflict, feelings of betrayal titive, impersonal, and technologically oriented
and shame, marital problems, and a host of value system, and the desire to be accepted by
other problems. Writing about bereavement the West; the social, spiritual, and communal
and stress in career women in Nigeria. Kalu values of Africans become very adulterated and
(1990) has indicated that friends and relatives compromised. As Some (1993) has observed,
take over ªthe care of children, household the ªsweeping industrial imperialismº (p. 36)
chores, and errands connected with funeral brought on Africans puts the African in two
announcement and arrangementº (p. 79). This worlds: the traditional and the corporate. He
arrangement could prevent ªdepression and further argues that:
low morale as the result of major life eventsº
(p. 75). She also indicates, however, that the the corporate world dims the light of the tradi-
contemporary Nigerian widow ªis under stress tional world by exerting a powerful magnetic
not so much from the loss of the spouse but shadow-like pull on the psyche of the individual.
from the demands of a large and sometimes Thus the individual feels compelled to respond.
unwieldy group of significant others who But as he or she tries to respond, the individual
participate in the funeral processº (p. 81). Is begins to realize that the source of the pull is
the source of this strain, discordance, and strife elusive. (p. 36)
clinical or is it a conflict over the ways of
achieving social values? To maintain a sense of self, there is the need
Another area where cultural factors become a to remain somewhat linked to ªessential tradi-
source of stress, anxiety, and depression tionalismº (Some, 1993). If this does not
revolves around generativity and the expecta- happen, the development of a healthy person-
tion to have children to continue the cycle of life. ality is affected. The African becomes margin-
The African society is family focused and it alized and this creates some stressful conditions
values child bearing and child rearing. In most that may very well be misdiagnosed. When
instances, singleness and childlessness are not misdiagnosed these stressful conditions may not
options, especially for the African woman. respond to traditional treatment.
362 Perspectives from Sub-Sahara Africa

10.18.5 THE THERAPEUTIC PROCESS respects this world view, in which ancestral
spirits and supernatural powers play an im-
10.18.5.1 Assessment/Diagnosis portant role both in the origin and treatment of
diseases. Divination, religion, sorcery, and
The issue of lack of trained mental health witchcraft all serve very important psychologi-
professionals in sub-Sahara Africa has been well cal and metaphysical functions in this context.
documented (Danquah, 1982; Lamb, 1983; The divination system includes the use of beads,
Okpaku, 1991). Thus, the variety of assessment amulets, rings, and other paraphernalia needed
methods described here are ones used primarily for the ritual and magical treatment as well as to
by traditional healers. However, it is important provide protective charm for the client.
to recognize parallels between what traditional Other assessment techniques include beha-
healers do and what Western-trained mental vior observational techniques by the healer, who
health professionals do or should do when will either move in and live with the family or
working with sub-Sahara African clients. This ask the client and sometimes family members to
has implication for training since the use of any move in and live with them (Vontress, 1991).
assessment methods requires cultural knowl- Again, like the life-history approach, healers
edge on the part of practitioners. Recognizing have no specific behaviors to observe. Instead
parallels will also encourage cooperation be- they allow a more naturalistic observation to
tween the two systems of helping. proceed but as difficulties in interpersonal
Assessment in traditional healing often relationship or other conflicts unfold, healers
begins with the healer attempting to establish use this diagnostic information to their advan-
credibility and genuineness. Among some tage. Yalom (1995) describes most forms of
Nigerian tribes, for example, traditional healers psychopathology as difficulties in interpersonal
initiate the session by offering cola nuts. The relationships, and psychotherapy (especially
belief is that ªhe who brings cola, brings lifeº group psychotherapy) as an exercise to improve
and as Onyioha (1977) further explains, cola or repair interpersonal relationship. This is
suggests that ªone is bound to be faithful to a consistent with what most traditional healers do
man with whom one has eaten colaÐyou must when they use this naturalistic observation
not lie against him, you must not plan evil technique.
against himº (p. 214). Healers pledge to be
faithful and truthful and they expect forth-
rightness from their clients. When this mutual 10.18.5.2 Prognosis
pledge for truth and respect is established,
clients are asked in a life-history or autobio- Traditional healers may use any of the
graphical approach (biographical approach if a diagnostic assessment methods described above
client is not competent or capable of doing so) or several others to determine the prognosis for
to tell their story to the healer. Although the a client. In some instances they may use herbs or
African culture does not encourage self-dis- perform some initial rituals. If the disorder does
closure outside of the family, the client now is not respond to these treatments, there is a
ready to talk about everything that the healer is rediagnosis, and other assessment methods are
ready to listen to and the healer does not considered. Essandoh (1995) has described this
impose any constraint on what should be practice as similar to the use of decision trees
included in the story. The content of the story and differential diagnosis in clinical practice in
provides the data for diagnosis as well as for the West and has suggested that when tradi-
treatment planning. Traditional healers, there- tional healers rule in or rule out causes of
fore, listen very attentively asking very few disorders, there is the implication that some-
questions. Essandoh (1995) has suggested that thing else (often supernatural) is causing the
this life-history narrative sometimes includes disease. Danquah (1982) has suggested that
multigenerational historical accounts and he some disorders do not respond to initial
has compared this to the use of genogram by treatment because traditional healers give
family therapists in the West. It is amazing that instructions that are impossible to follow
with no recording devices, traditional healers leading to a high ªpatient relapse rateº (p. 8)
are able to remember many of the details of which benefits the healer. Rediagnosis, accord-
what clients disclose to them; evidence of their ing to Danquah; involves giving the client ªa few
effective listening skills. simple post-treatment instructions to enable
The use of divination in diagnosis and him to carry them out daily with success, and
treatment provides a link between therapeutic less anxietyº (p. 8). In most instances, significant
methods and the spiritual and ceremonial life of alleviation of symptoms happens, albeit tem-
the African culture. If culture is truly a shared porarily leading both the client and the healer to
world view, the healer's use of divination believe that the prognosis is good.
 Conclusion 363

10.18.5.3 Treatment/Cure One of the first implications is that sub-

Sahara Africa must develop its own graduate
Traditional healers use a variety of techniques programs in psychology and mental health to
that have been empirically proven effective in prevent its mental health professionals from
Western psychotherapy. One of their many receiving graduate training almost exclusively in
strengths is their ability to engender faith and Europe and North America. Training programs
hope in the therapeutic process (Frank, 1978; should incorporate traditional medicine and
Yalom, 1995). Especially for spiritual healing, it healing into their curriculum in order to be
is important for the client to have faith and hope responsive to the needs of a large segment of the
in the process. Doubt and the lack of faith do population that continues to retain the tradi-
not lead to significant therapeutic gains. In fact, tional culture. Courses should be organized
psychotherapy and medical treatment in all around themes that emphasize world views and
societies benefit from faith and hope long before the sociopolitical nature of differences in the
the other therapeutic factors kick in. Thus, the region. Students who choose to train in Europe
ability of traditional healers to mobilize their or North America must be encouraged to
clientsº hope becomes an important variable in consider practicum and internship experiences
the therapeutic process. in Africa supervised either by indigenous
Traditional healers are also holistic in their clinicians in Africa or culturally competent
approach. Treatment usually combines the and sensitive non-Africans. This will increase
physical, social, and spiritual in an effort to self-knowledge and understanding of other
restore harmony to the client. Herbal treatment sociocultural factors in mental health. Graduate
is employed where necessary and social and programs in Europe and North America where
spiritual interventions are made as appropriate. most African governments send their citizens to
Whenever necessary (although very infre- train must develop multicultural competencies
quently) referral is made to another healer. In that take traditional healing methods into
all instances, family and close neighbors account. More culture-specific strategies must
participate in the treatment, making it easy be taught to sub-Sahara African students who
for the healer to employ all available resources will go back to work within this cultural context.
for support and effective treatment. What is In terms of assessment measures, socio-
good for the client is decided by all of them cultural factors should influence their develop-
within the context of the plural medical systems; ment very significantly. Assessment should also
choosing to use the systems concurrently or look at the importance of sociodemograhpic
simultaneously. variables as they predict psychopathology. This
Treatment techniques also include traditional will help in classification systems that will
music and dancing, therapeutic rituals and facilitate communication between sub-Sahara
sacrifices, suggestions, hypnosis, and other African mental health professionals and their
techniques similar to cognitive-behavioral ap- counterparts overseas.
proaches. The important thing throughout all Both faculty and students must be encour-
counseling is the attention given to interperso- aged to consider research into traditional
nal relationships, significant others, and con- healing methods and also sociocultural factors
textual issues. and psychopathology. Such research should
utilize both the empirical and experiential
10.18.6 TRAINING IMPLICATIONS approaches in order to capture the totality of
the African reality.
The preceding paragraphs should have placed
issues in their proper perspective not only for
clinical recognition by psychologists and mental 10.18.7 CONCLUSION
health professionals in sub-Sahara Africa but
also for training and empirical research. The The influence of the world view on how
lack of mental health resourcesÐhuman and counseling is delivered and/or accepted in a
infrastructuralÐmakes access to Western-type given society cannot be overemphasized. If such
mental health services very limited. In spite of differences in the world view are important
industrialization and urbanization, sub-Sahara considerations in clinical psychology, then more
Africans seem to be on a journey to reinvent the empirical research is needed to define clearly
traditional African culture. Any training of what mental health means in sub-Sahara Africa.
mental health professionals should recognize A diversified society in which people hold
this journey by not assuming that mental health culturally pluralistic views requires a mental
problems associated with industrialization will health system that is pluralistic, not mono-
be manifested in sub-Sahara Africa the same cultural. This is a social reality, the recognition
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