text:
Comprehensive Clinical Psychology [PDF]
Authors: Bellack A.S. , Hersen M. (eds.)
Medicine , Clinical Medicine
Michel Hersen (Ph.D. State University of New York at Buffalo, 1966) is Professor and Dean, School of Professional Psychology, Pacific University, Forest Grove, Oregon. He is Past President of the Association for Advancement of Behavior Therapy. He has written 4 books, co-authored and co-edited 126 books, including the Handbook of Prescriptive Treatments for Adults and Single Case Experimental Designs. He has also published more than 220 scientific journal articles and is co-editor of several psychological journals, including Behavior Modification, Clinical Psychology Review, Journal of Anxiety Disorders, Journal of Family Violence, Journal of Developmental and Physical Disabilities, Journal of Clinical Geropsychology, and Aggression and Violent Behavior: A Review Journal. With Alan S. Bellack, he is co-editor of the recently published 11 volume work entitled Comprehensive Clinical Psychology. Dr. Hersen has been the recipient of numerous grants from the National Institute of Mental Health, the Department of Education, the National Institute of Disabilities and Rehabilitation Research, and the March of Dimes Birth Defects Foundation. He is a Diplomate of the American Board of Professional Psychology, Distinguished Practitioner and Member of the National Academy of Practice in Psychology, and recipient of the Distinguished Career Achievement Award in 1996 from the American Board of Medical Psychotherapists and Psychodiagnosticians. Dr. Hersen has written and edited numerous articles, chapters and books on clinical assessment.
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) 10.14 Perspectives from Lithuania, Pages 325-334, Danut Image Gailien 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 LetlakaRennert 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 349355, 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.
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.
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. file:///D|/1/CCP/10/00.htm (4 of 10)17.10.06 11:05:55
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.
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 file:///D|/1/CCP/10/00.htm (6 of 10)17.10.06 11:05:55
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 file:///D|/1/CCP/10/00.htm (7 of 10)17.10.06 11:05:55
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
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
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
10.01.2 DEFINITIONS
10.01.2.1 Culture 10.01.2.2 Cultural Syndromes 10.01.2.3 Identity 10.01.2.4 Acculturation 10.01.2.5 Ecology 10.01.2.6 Psychological Processes 10.01.2.7 Cultural Distance 10.01.2.8 Culture Shock 10.01.2.9 Ethnocentrism 10.01.2.10 Racism 10.01.2.11 Prejudice 10.01.2.12 Emic and Etic Aspects of Culture 10.01.2.13 An Integrative Example of These Definitions
2 3 3 3 4 4 4 4 4 4 5 5 5
10.01.3 WORLD VIEWS
10.01.3.1 Cultural Complexity 10.01.3.2 Tightness±Looseness 10.01.3.3 Collectivism 10.01.3.4 Individualism 10.01.3.5 Horizontality 10.01.3.6 Verticality 10.01.3.7 Active±Passive 10.01.3.8 Honor 10.01.3.9 Universalism±Particularism 10.01.3.10 Diffuseness±Specificity 10.01.3.11 Ascription±Achievement 10.01.3.12 Instrumental±Expressive 10.01.3.13 Value Orientations 10.01.3.14 Dionysian vs. Apollonian Cultures
10.01.4 METHODOLOGIES FOR THE STUDY OF WORLD VIEWS 10.01.4.1 Some General Strategies 10.01.4.2 Good Theory Can Eliminate Some Rival Hypotheses 10.01.4.3 Methods that Can Establish Measurement Equivalence Across Cultures 10.01.4.4 Emics and Etics in Cross-cultural Research 10.01.4.5 How to Use Emic Measurements of Etic Constructs 10.01.4.5.1 General recommendations 10.01.4.6 Examples of Multimethod Measurements 10.01.4.6.1 Ethnographic work 10.01.4.6.2 Establishing shared cognitions 10.01.4.6.3 Conclusions
9 11 12 12 12 14 15 15 15 16 17
Introduction to Diversity in Clinical Psychology 10.01.4.7 Translations 10.01.4.8 Ethics of Cross-cultural Studies 10.01.4.9 Ethnocentric and Androcentric Bias of Researchers 10.01.4.10 Summary of Criteria of Good Cross-cultural Research
10.01.5 ACCULTURATION
10.01.6 IDENTITIES OF AFRICAN- AND EUROPEAN-AMERICANS AS AN EXAMPLE OF THE IDENTITIES OF CLINICIANS AND CLIENTS
10.01.7 METHODS FOR THE DEVELOPMENT OF AN UNDERSTANDING OF THE CULTURE OF THE CLIENT
10.01.7.1 Methods of Culture Learning 10.01.7.1.1 Culture-general vs. culture-specific training 10.01.7.1.2 Self-insight 10.01.7.1.3 Experiential training 10.01.7.1.4 Exposure to many local cultures 10.01.7.1.5 Field trips 10.01.7.1.6 Culture assimilators or intercultural sensitizers 10.01.7.1.7 Behavior modification cross-cultural training 10.01.7.1.8 Some summary points about training
10.01.8 FUTURE DIRECTIONS
10.01.9 SUMMARY AND CONCLUSIONS
10.01.10 REFERENCES
10.01.1 INTRODUCTION Clinical psychologists deal with many kinds of diversity. While diversity due to culture may be the most imporant kind that affects their work, it is useful to remember that diversity in social class, sexual orientation, gender definitions, disabilities, political perspectives, esthetic preferences, religion, and the definition of what is ªtrueº may also affect their practice. Diversity may be defined as the condition of interacting with another person who is perceived to be ªdifferent.º It is a condition which is increasingly more frequent, since most societies are multicultural and a number of factors favor interactions among the cultures. In the US the clients of clinical psychologists are becoming more different from the white middle-class which was the usual clientele of these professionals a few years ago. It is impossible to deal with all the aspects of diversity in one chapter, so the focus will be on culture. However, some of the other kinds of diversity (e.g., in religion or social class) do interact with cultural differences, and some of the experience which clinicians have acquired in dealing with these other kinds of diversity may prove useful in dealing with cultural diversity. This chapter will begin with definitions of concepts such as culture, and the relevance of ethnocentrism, prejudice, and racism in making judgments about the behavior of other humans. It will also examine the terminology for dealing with what is culture-common (etic) and culturespecific (emic). Section 10.01.3 will describe some of the diversity of world views and values, and will examine methodologies which can
provide reliable information concerning such world views. The focus will be on helping clinicians discriminate reliable from unreliable cross-cultural studies, so that they can begin developing a body of knowledge about cultural differences. Then, the chapter will examine the relationship of acculturation to varieties of cultural identity (in both the majority and minority culture). Finally, it will describe methods and procedures that clinicians can use to develop more detailed understandings of other cultures, and to improve the effectiveness of their behavior when interacting with diverse clients. 10.01.2 DEFINITIONS 10.01.2.1 Culture Culture is to society what memory is to individuals (Kluckhohn, 1954, p. 967). It includes all the things which have ªworkedº in the history of an interacting group of humans, and have become unstated assumptions, standard operating procedures, standards of perceiving, judging, deciding, and acting. Cultural anthropologists (e.g., Kroeber & Kluckhohn, 1952) have developed more than 100 definitions of ªculture,º such as that culture is the humanmade part of the environment (Herskovits, 1955). Such a definition is too broad, but it does have the advantage that we can ask: Is this particular element human-made? For instance, is this belief human-made? Then it is an aspect of culture. The Herskovits' definition can become more useful if we distinguish material culture (tools, roads, houses) from subjective culture
Definitions (categorizations, beliefs, attitudes, self-definitions, role definitions, norms, values (Triandis, 1972). Most contemporary anthropologists (e.g., Shweder & Levine, 1984) agree that culture is a system of shared meanings. Hence my favorite definition: Culture is a set of human-made objective and subjective elements that in the past have increased the probability of survival and resulted in satisfactions for the participants in an ecological niche, and thus became shared among those who could communicate with each other because they had a common language and they lived in the same time period and place. (Triandis, 1994, p. 22)
Note that this definition, in addition to focusing on what is shared, specifies that a common language is important, and communication can take place because people live in the same time period and geographic region. Thus, in principle, people who live next door to each other but speak different languages (say, in Los Angeles, Hispanics and Thais), or during different time periods (say, in Los Angeles in 1950 and in 1996), or in different geographic regions (say, in Texas and New York) may have different cultures. Physicians have their own language in the hospital, and thus physicianson-the-job may constitute a culture, by this definition. According to this definition the number of cultures is enormous. Humans regardless of culture have many common attributes. All humans have language, food habits, art, myths, religious practices, family structures, economic systems, ªtruth,º government, war, kinship, shelter, training systems, hygiene, and incest taboos (Brown, 1991). However, note that these categories are extremely broad. Take an easy one to think about: food habits. What people eat, when, where, with whom, and to what effect are clearly diverse. If we are to pay attention to that level of detail, it is obvious that the diversity of cultures is enormous.
scale that measures an element of subjective culture, then that element is an aspect of the cultural syndrome. Another method (see Triandis, Bontempo, Leung, & Hui, 1990) is to form (say 50) triads of representatives of each culture, and ask them to reach a group agreement on an element of subjective culture, for example, ªDo you agree that widows should not eat chicken?º Agreement in less than 60 seconds, among say 90% of the triads, would indicate that the belief is widely shared, and thus it is an element of the culture syndrome. In sum, both the time to reach agreement and the percentage of triads which reach agreement can be used as criteria for determining the presence of an element of a cultural syndrome. When the cultural elements, identified by such procedures, which represent attitudes, beliefs, norms, roledefinitions, self-definitions, and values are interrelated, we have defined empirically the cultural syndrome. 10.01.2.3 Identity People make statements that include the words ªme,º ªmine,º ªmyself,º ªI,º and the like. All these statements taken together constitute the self. An important aspect of the self concerns statements about belonging to some group. For example ªI am a Koreanº specifies a Korean identity. ªI am a bridge-playerº is also an identity. Brewer (1991) has argued that each individual experiences forces toward differentiation from groups as well as assimilation to groups. These opposing forces are in equilibrium at the point of ªoptimal distinctivenessº which is characteristic of each person. This point is determined by cultural norms, individual socialization, and recent experiences with the group. For instance, in traditional cultures, which tend to be collectivist, the forces of assimilation are stronger than the forces of differentiation, and thus the optimal distinctiveness point is closer to the group than in modern cultures.
10.01.2.2 Cultural Syndromes
10.01.2.4 Acculturation
Shared patterns of beliefs, attitudes, selfdefinitions, norms, roles, and values are sometimes organized around a common theme. When they are and found among members of a culture, they constitute a cultural syndrome. The logic of shared elements of subjective culture allows us to identify such syndromes (Triandis, 1996). For example, we can examine the response distributions obtained from samples in a particular culture, and if an arbitrary 90% of the participants give a response on the same side of the neutral point, on a nine-point
Some individuals, especially in multicultural cities, are exposed to numerous cultures simultaneously. They may use more than one identity, for example, ªI am Mexicanº and ªI am American.º The more elements of one culture are attached to an identity (e.g., Since I am Mexican I speak Spanish most of the time), the more influential is that identity in determining behavior. An individual may be more or less bicultural, include elements from both cultures in an identity, assimilated, include mostly elements of another culture in an identity,
Introduction to Diversity in Clinical Psychology
separated, that is, even though the individual lives in an environment which includes many cultures the identity is separate and distinct and monocultural, or alienated, may reject all cultures. 10.01.2.5 Ecology Ecology refers to where people live. It consists of objects, resources, the geography of the environment, and the ways of making a living and surviving in that environment. Ecology provides schedules of reinforcement (Skinner, 1981), which shape both the elements of subjective culture and the behavior of those who live in these ecologies. Thus, culture emerges from the ecology. 10.01.2.6 Psychological Processes Clinicians are, of course, focusing on psychological processes, such as personality, behavior patterns, and the beliefs, attitudes, and values of their clients. It is obvious from the above definitions that culture influences many of these psychological processes. Poor clinical analyses occur when the clinician and the client come from different cultures, because the very same behavior may have different meanings in the two cultural systems and very frequently these meanings influence important judgments, such as diagnoses. Take one simple example: in collectivist cultures, such as those found in the Far East, communications that are unclear and indirect which save someone's face are expected and are very common. In individualistic cultures, such as in the West, people are expected to provide ªstraight talkº and not ªbeat around the bush.º Similarly, a lie is morally reprehensible in the West much more than in the East. Authenticity (Trilling, 1972) is valued in the West, and that includes ªtelling it as it isº and telling the truth. Thus, the same behavior can be interpreted differently in the two kinds of cultures. Indirect communications may be seen as ªtactful and politeº and a lie can be seen as saving face in the East, while the same behaviors may be seen as ªconfused and confusingº and reprehensible in the West. The interpretation is an aspect of an integrated conceptual system, and is often so compelling that it is difficult for either party to easily use the other's way of thinking. 10.01.2.7 Cultural Distance Cultural distance is an important concept in understanding diversity, and the way it affects human relationships. Cultural distance can reflect differences in (i) language (e.g., language families, such as the client speaks a tonal
language and the clinician an Indo-European language), (ii) family structure (say, monogamous vs. polygamous marriages can create distance), (iii) religions (e.g., animist and Christian religions), (iv) wealth and life style (e.g., the difference between a wealthy jetsetter and a member of a culture of hunters and gatherers), (v) values (e.g., the difference between conservative, very traditional values and self-actualizing, hedonistic values). 10.01.2.8 Culture Shock Triandis and Gelfand (1994) presented a model that links cultural distance and culture shock (Oberg, 1960). The larger the cultural distance the larger the culture shock. The model posits that cultural distance leads to low perceived similarity. When people perceive each other as dissimilar and are also in contact, the relationship is tense, and punishing, resulting in distortions such as extreme stereotypes, inaccurate attributions (e.g., clinician and client attribute different causes to the same behavior), which lower the sense of control (ability to act so as to obtain positive outcomes from relationships). A low sense of control results in culture shock. The model also includes other variables, which need not concern us here. 10.01.2.9 Ethnocentrism Most humans are ethnocentric (Brewer & Campbell, 1976; Campbell & Levine, 1968; Triandis, 1994). Ethnocentrism follows from the fact that most humans are only exposed to their own culture. Only humans who live in multicultural environments, or have traveled extensively, are moderately ethnocentric. The extent our culture influences our perceptions of the behavior of others is large and subtle. We are usually not aware of our ethnocentrism. Those who have been exposed to other cultures learn to appreciate aspects of these cultures which are not included in their own cultures, and thus become less ethnocentric. Clinicians must control their ethnocentrism by learning to appreciate other cultures. Yet that is especially difficult when the cultural distance between their culture and the client's culture is large. In that case it may be best to admit that they are not able to help the client, and it is desirable to find colleagues whose cultural distance is smaller and who might be able to help the client. 10.01.2.10 Racism Racism is a special case of ethnocentrism, where the standards of one's own racial group are used to judge other racial groups.
Definitions 10.01.2.11 Prejudice Prejudice is judgment of the attributes and behavior of members of another culture on the basis of negative preconceived ideas and inaccurate stereotypes. Such judgments are usually associated with negative emotional reactions toward members of the other culture, as well as with self-instructions to keep some social distance from the members of the other culture (rejection of positive and endorsement of negative behavioral intentions toward the members of the other culture). People who are very ethnocentric tend to be prejudiced. Even people who score as nonprejudiced on attitude scales, when responding to ethnic stimuli tachistoscopically, so that they do not have the opportunity to ªcontrolº their prejudice, show themselves to use unfavorable stereotypes. In short, the unprejudiced have learned to control their prejudice and not show it to researchers, but the negative stereotypes are nevertheless present in their cognitive system (Devine, 1989). 10.01.2.12 Emic and Etic Aspects of Culture Phonetics deals with sounds which occur in all languages. Phonemics deals with sounds which occur in only one language. This led the linguist Pike (1967) to coin the words etics and emics to refer to the culture-general and culturespecific elements of culture. Etics reflect constructs which apply to phenomena that occur in all cultures. Emics are constructs which occur in only one culture. For example, in all cultures ingroup members (family, tribe, co-workers, co-religionists) are treated better than outgroup members (enemies, strangers, outsiders). That is an etic. However, there are also emic patterns. For example, when Hispanics and non-Hispanics were presented with several hundred situations and asked if they expected people in such a situation to use positive (e.g., admire, respect, support) or negative (e.g., criticize, dominate, fight with) behaviors, there was a response pattern which was called the ªsimpatia cultural scriptº (Triandis, Marin, Lisansky, & Betancourt, 1984) that emerged when the Hispanic responses were compared to the non-Hispanic responses to the same situations. Specifically, Hispanics compared to non-Hispanics expected more positive behaviors and fewer negative behaviors in a wide range of situations. They expected people to try to be simpatico, that is, to be nice and pleasant, even in situations where non-Hispanics expected neutral or negative behaviors. This is similar, but not identical, to the greater importance of face in collectivist than in
individualistic cultures that has been discussed by East Asian social scientists (e.g., TingToomey, 1988). The simpatia cultural script is an emic. In other words, when dealing with ingroup members or even acquaintances, Hispanics tend to be more positive in their behaviors than nonHispanics. The practical significance of this pattern is that, relative to non-Hispanics, Hispanics will expect a clinician to be more positive in situations that ordinarily will be ambiguous or call for somewhat negative behaviors. For instance, criticism or other negative behaviors may be more upsetting to Hispanics than to non-Hispanics. For another example of an emic motif, consider the amae pattern found in Japan (Doi, 1986). Japanese often presume that they may depend on others, the way a child depends on a parent. Mutual dependence is an emic aspect of that culture. The significance of the emic and etic distinction is that it alerts us to which specific cultures may have idiosyncratic ways of cutting the pie of experience. If we use only etics, we miss some of that information and do not identify many cultural differences (Marin & Marin, 1991). There are ways to combine emics and etics (see Triandis, 1992), making our measurements culture-sensitive but also equivalent across cultures. These techniques will be discussed in Section 10.01.4.5. Many techniques specific to cultural studies have been identified (see Triandis & Berry, 1980). Some of these use methods (e.g., Szalay, 1970; Szalay & Deese, 1978) such as word association which are also used by some clinical psychologists. 10.01.2.13 An Integrative Example of These Definitions The ethnocentrism mentioned above is an etic. It is accentuated by two other phenomena, which are also probable etics: (i) we have a tendency toward naive realism which limits our capacity to appreciate the extent to which our construals are subjective (Robinson, Keltner, Ward, & Ross, 1995); and (ii) we have a tendency toward false consensus, which is to think that other humans agree with our positions more than is true, and disagree with our position less than is true (Krueger & Clement, 1994). In short, we tend to think that the way we see the world is both valid and universal. Our culture provides the ªlensesº for seeing the world in a particular way and that way of seeing is so obvious that it is not questioned. Consider this example. In Orissa, India, most of the population believes that widows must not
eat chicken (Shweder, Mahapatra, & Miller, 1990). When asked if this behavior should be 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 upon Americans, and explain this ªmoral deficiencyº by noting that America is a young country which has not yet reached the level of moral maturity found in India. Now, consider what happens when Illinois participants are asked whether widows must not 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 Orissa, India, strongly believe that widows must not eat chicken, they look down upon these Indians, and point out that they are not sufficiently developed to have ªcorrect views.º Do you see the ethnocentrism in both perspectives? The Indian view stems from the basic assumption that people are interdependent. Married individuals are supposed to be linked to each other for ever. For a widow to eat chicken is a sin because they believe that eating chicken makes one sexually aroused, and such arousal will result in the widow having sexual relations with someone, and thus breaking the eternal bond with her husband. Note that cultures often have sets of beliefs which are supportive of each other. Now consider the American view. The basic assumption is consistent with American individualism (Triandis, 1995) which assumes that people are autonomous entities. Widows can do their own thing. If Indians have an idea that is different from the American idea, it is because they are not sufficiently developed! Thus, both cultures conclude that their views are superior and the views of the other culture are inferior. Ethnocentrism leads to prejudice, and attempts to impose the subjective culture of one's own culture on other cultural groups. This is not the place to debate the merits of individualism and collectivism. Hofstede (1980) linked these concepts with many ecological variables. Triandis (1995) has suggested that individualism is associated with high levels of achievement, creativity, self-actualization, and democracy, but also with high levels of crime, divorce, and child abuse. Collectivism is associated with high levels of social support, cooperation, interpersonal sensitivity, and pleasantness in social relationships, but also with extreme conformity, low creativity, and ethnic cleansing. In short, both cultural patterns have both positive and negative elements, and it is natural for most people from all types of cultures to prefer their cultures. As scientists we can examine the links of ecology, culture, and social pathology, but
preferences for social pathology are matters of taste, not scientific judgment! 10.01.3 WORLD VIEWS Many cultural syndromes have been identified thus far. The exact number of syndromes is not known, but a guess is that a score may be sufficient to describe the most important cultural differences. Here we present some of the most important syndromes. 10.01.3.1 Cultural Complexity Simple cultures such as hunters and gatherers have few roles, simple social structures, few levels of social and political stratification, simple religious beliefs, simple understandings of the nature of the world, few domains of esthetic activity, and simple methods of economic exchange (e.g., barter). Specific simple cultures may be very complex in one domain, such as people may have an extensive knowledge of the history of their ancestors, as is found among Australian aborigines, but in most domains they are simple. Many attributes of culture are associated with cultural simplicity. For example, simple cultures are characterized by small communities (often bands of 50 individuals), the use of barter, walking as the only means of transportation, and so on. Complex cultures, such as information societies, have many roles, for example, a quarter of a million occupations in the Dictionary of Occupational Titles, complex social structures, for example, General Motors, complex social and political stratification (e.g., federal, state, and local governments), a multiplicity of religious beliefs, a complex understanding of the nature of the world, for example, modern science, multiple types of esthetic activities, and numerous methods of economic exchange, such as, money, bonds, stock, certificates of deposit, etc. They include mostly urban social patterns. Again, in one domain there might be considerable simplicity, such as a family structure that consists of only a mother and her children, but on the whole there is complexity in most domains. In complex cultures subjective cultures also tend to be more complex, for example, one finds large vocabularies (100 000+ terms in English) and complex ways of classifying experience, as well as complex beliefs. 10.01.3.2 Tightness±Looseness Some cultures have (i) many rules, norms, and detailed specifications about how one is to act,
World Views and (ii) members who react quite strongly (e.g., criticize or even kill those who deviate from the norms) to minor deviations from the rules, norms, and ªproper behaviorº (Triandis, 1989, 1994). Such cultures are called ªtight.º Other cultures are loose, that is, have few rules, norms, and do not specify how one is to behave in very many situations, and when a person deviates from these few rules, norms, or conceptions about proper behavior, people tolerate such deviations. Tight cultures provide criticism and severe sanctions (e.g., 50 lashes) for deviation; loose cultures criticize only major deviations and provide mild sanctions (e.g., a fine) for most deviations. Tightness and looseness are domain specific. For example, a culture may be very tight about the use of time, but be rather loose about the way one chooses friends. For example, the US, in 1996, is very tight about writing bad checks and rather loose about who one lives with. However, across domains, tight cultures tend to 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 is fairly loose. For example, one extreme incident that occurred in Japan in 1990 was that a teacher killed a student who was two minutes late for class. Japanese opinion was divided about this teacher, most arguing that he was ªderangedº even though they understood his efforts to impose discipline. However, some psychopathology is an extreme expression of a cultural norm (Draguns, 1990)! Rural Thailand is loose. An employee may come to work, or not come to work, and no explanations are offered (Phillips, 1965). After living in Thailand for several months, Phillips (1965) had difficulty understanding ªthe mystifying American capacity to conform to the expectations of othersº (p. 204). 10.01.3.3 Collectivism The collectivism syndrome has been studied more extensively than most of the other syndromes (Kim, Triandis, Choi, Kagitcibasi, & Yoon, 1994; Markus & Kitayama, 1991; Triandis, 1990, 1995). It has received a central position in most reviews of cultural differences in social behavior (e.g., M. Bond & Smith, 1996). Triandis (1994) has speculated that maximum collectivism occurs in simple tight cultures, such as theocracies. He also argued (Triandis, 1995) that in collectivist cultures individuals define themselves as aspects of groups (i.e., I am a member of . . . ), place the goals of their collectives ahead of their personal goals, behave under the influence of norms and
roles imposed by their groups, and relate to ingroup members by paying attention to the needs of others rather than to their own needs. Many East Asian societies are collectivist, as are many traditional societies in Africa and Latin America. In the US, Hispanics and Asians tend to be collectivists. 10.01.3.4 Individualism Triandis (1994) speculated that this pattern is maximal in complex, loose cultures, and is characterized (Triandis, 1995) by individualists perceiving themselves as autonomous from their groups, giving priority to their personal rather than to their ingroup's goals, behaving according to their attitudes and feelings of enjoyment, and dealing with members of their ingroups by paying attention to the ªprofitº and ªlossº incurred from the relationship, as specified by exchange theory (Thibaut & Kelley, 1959). Many Western societies are individualistic, especially the US, Australia, and Britain. 10.01.3.5 Horizontality Cultures that are egalitarian, such as the Eskimos, and tend to emphasize tit-for-tat, one person one vote and the like are horizontal. In such cultures, people do not share or distribute resources according to need, contributions (equity), or status, but equally. There is little social stratification; most people carry out most of the tasks of the society. 10.01.3.6 Verticality The cultural pattern of verticality emphasizes hierarchy. It is similar to Hofstede's (1980) ªpower distance,º a cultural pattern in which 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 status. There is much deference for those who have status. High levels of stratification are present. 10.01.3.7 Active±Passive This syndrome was described by DiazGuerrero (1979) when he compared US and Mexican data. Those who are active, such as Americans, thrive on competition, action, and emphasize self-fulfillment. They try to change the world, rather than change themselves to fit into the world. Those who are passive, are cooperative, emphasize the experience of being, and tend to change themselves to fit into situations.
10.01.3.8 Honor Honor is a narrow syndrome, found in environments in which property is mobile, and thus individuals develop attitudes, values, and behaviors that are designed to scare others, so as to ensure that their property is not taken away from them. For example, cattle are more easily stolen than agricultural property, so that people in cattle cultures are fierce, aggressive, hypersensitive to affronts, stress defense of one's honor, and socialize their children to react to challenges more than occurs in agricultural societies (Cohen & Nisbett, 1994; Nisbett & Cohen, 1996). Several kinds of studies support the view that the American South is high on this cultural syndrome. Cohen, Nisbett, Bowdle, and Schwartz (1996) reported three experiments where University of Michigan students from the North or South of the US were insulted by a confederate. They reported that Southerners were more likely to think that their masculine reputation was threatened, became more upset (as shown by the rise of cortisol levels), became more physiologically primed for aggression (as shown by testosterone levels), were more cognitively primed for aggression, and more likely to engage in aggressive and dominant behavior than students from the North. Cohen (1996) showed that this cultural syndrome was reflected in social policies. An analysis of laws relating to guns, defense of self and home, corporal punishment, capital punishment, and attitudes toward foreign policy issues showed greater approval of violence in the South than in the North. While the Nisbett and Cohen research focuses on the higher levels of honor found in the American South than the North, extreme emphasis on honor can be found also in most of the Mediterranean societies, for example, Corsica, the Serbs. Campbell's (1964) ethnography of a culture of Northern Greece (the Karakatzanoi) provides details of this syndrome. 10.01.3.9 Universalism±Particularism Parsons and Shils (1951) contrasted cultures where people categorize other people on the basis of universal criteria, and cultures in which people categorize other people by taking into account their particular characteristics and the unique situation within which they are interacting with them. 10.01.3.10 Diffuseness±Specificity Parsons and Shils (1951) contrasted cultures in which people respond in a diffuse, holistic manner (e.g., I do not like your report implies I
do not like you) with cultures where people respond with specificity. 10.01.3.11 Ascription±Achievement Parsons and Shils (1951) discussed cultures in which people judge others primarily on the basis of ascribed attributes (e.g., sex, race, family membership) with those which use achieved attributes (e.g., has received this award). 10.01.3.12 Instrumental±Expressive Parsons and Shils (1951) contrasted cultures in which most interaction has instrumental purposes (get task done) with cultures in which most interactions are expressive (friendship, enjoyment). 10.01.3.13 Value Orientations Kluckhohn and Strodtbeck (1961) identified several value orientations which may well be the bases of additional cultural syndromes. Specifically, they identified societies where innate human nature is assumed to be (i) evil, neutral, or good; (ii) mutable or immutable. When human nature is assumed to be evil, many rules are introduced to control people and make them behave appropriately; when it is assumed to be good there is a tendency towards minimal government; when it is assumed to be mutable institutions are created (e.g. educational systems) which can change them in the appropriate direction, but when they are assumed to be immutable there is little support for such institutions. (iii) Humans are assumed to be subjugated to nature, in harmony with nature, or allowed to master nature. In cultures which emphasize mastery over nature, beliefs, attitudes, values, and behaviors favor changes of the environment. Where harmony is emphasized, there is more concern about not changing the environment (e.g., the ªgreensº of the world). When subjugation is emphasized there are many beliefs, attitudes, and behavior showing reverence for nature (e.g., in many Native American cultures). (iv) Varieties of time orientation, such as emphases on the past, present, or future. Time orientation also differs because some societies use linear time (e.g., the West) and others use circular time (e.g. the ancient Mayans). Monochronic use of time (i.e., people can carry out only one conversation at a time) or polychronic use of time (i.e., people can carry out several conversations at the same time) are also important cultural differences in the use of time. (v) The emphasis is on doing, being (the experience), or becoming (growing, changing,
Methodologies for the Study of World Views improving). For example, in doing cultures, such as the US, a person's worth is measured by a record of accomplishments, income, previous actions. In cultures which emphasize experiences, a person's worth depends on the experiences that the person has had. In cultures which emphasize becoming, the focus is in how much and how fast the person is changing. 10.01.3.14 Dionysian vs. Apollonian Cultures Again this is a narrow syndrome focused on the way people are expected to deal with emotions. In Dionysian cultures they are taught to express emotions. Loud speech is expected. Beliefs that one should state a view by using extreme language are common (e.g., as found among some Arabs), and attitudes such as the positive evaluation of touching, kissing, close positioning of the bodies, looking into the eye, and other behaviors are often associated with this pattern. The Apollonian pattern requires people to control their emotions (e.g., East Asians), to stand far from others, not touch, not look into the eye. Corresponding beliefs, attitudes, and values support these behaviors. For example, it is impolite, and an indication of low social class, to speak loudly. Related to the above pattern is: high contact vs. low contact cultures, which reflects high or low level of voice, eye contact, frequency of gestures, touching, distance between the bodies. Interrelationships of the syndromes. Since the concept of cultural syndromes is relatively new, there has not been much research on their number or a clear indication of how many syndromes there are or how they are interrelated. In addition, there will be emic patterns, which will characterize each individual culture. To identify cultural syndromes it is necessary to do research, based on the fact that syndromes reflect shared psychological processes (see Triandis, 1996) to see exactly what cultural elements are to be included in each cultural syndrome. We need to develop reliable and valid methods for the measurement of cultural syndromes, and then correlate these measurements to discover how the syndromes are related to each other. 10.01.4 METHODOLOGIES FOR THE STUDY OF WORLD VIEWS The general perspective of this section is not to teach the reader how to do cross-cultural research, but how to tell the difference between a ªgoodº and a ªbadº study. I assume that clinicians read the literature, but the literature includes many ªbadº studies. The most com-
mon error is to take an instrument that has been developed with middle-class mainstream undergraduates and use it with some ethnic group that is quite different from the standardization sample, without any attempt to check the reliability and construct validity of the instrument in this new sample. Those wishing to do cross-cultural studies can consult a more advanced text. The most complete one is the volume by Triandis and Berry (1980). A shorter volume is by Lonner and Berry (1986). Special issues concerning the equivalence of cross-cultural measurement, and the unstated assumptions that are made by people who collect cross-cultural data are discussed in Hui and Triandis (1985). Good cross-cultural research is like ordinary social research, only more difficult because of the complexity of the issues of translation, equivalence of measurement, and the like. Those who want to do such research should become familiar with the writings of Campbell (1988), as well as the publications mentioned above. A central issue in cross-cultural research is whether we have a ªrealº cultural difference or an ªapparentº difference due to an artifact or a ªrival hypothesis.º For example, it may be that people in one culture respond to a particular method of data collection differently from the way people in another culture respond to it. In such a case we do not have a substantive finding but rather a finding that is best explained by the way people react to the method of data collection. Or, it may be that we have an apparent ªraceº effect, but careful examination would reveal that it is a ªsocial classº effect. To establish a ªrealº cultural difference we need to eliminate all plausible ªrival hypothesesº (Malpass & Poortinga, 1986) that may account for the observed difference. Consider the following specific case. We tested two samples and found a difference in their level of anxiety. What are some of the plausible rival hypotheses? (i) Anxiety may mean different things in the two cultures. The perceived antecedents of anxiety may be different. For example, in one culture it may be seen as caused by the prospect of lack of food and in the other by the possibility of downsizing the corporations most people work for. To eliminate this rival hypothesis one needs to study the meaning of constructs, in the relevant cultures, independently of their measurement. For example, one can ask samples of participants from the various cultures: What makes you anxious? When you are anxious, what happens after that? Content analyses of the responses to such questions obtained in the
relevant cultures can reveal both similarities and differences in the meaning of the construct. Associations of events with anxiety, semantic differential judgments involving the words ªFear,º ªAnxiety,º and their synonyms, can result in an understanding of the these similarities and differences in the meaning of the concept. More generally, when we compare two cultures we are comparing entities that differ in a myriad of ways. The conclusion that the difference reflects a particular variable (e.g., anxiety) requires that we ªcontrolº all the interactions of anxiety with other plausible variables. Furthermore, we need to sort out which aspect of culture is the relevant one. For example, in a comparison of African-Americans and White-Americans, we need to distinguish a difference due to race/color, per se, from differences due to nutrition, social class, neighborhood, historical influences, and so on. If all the observed differences are due to social class, it is scientifically irresponsible to report them as due to race. If both social class and race are relevant, one must report that fact also. Since any two cultures differ in many ways, it becomes apparent that a two-culture comparison will have almost no scientific value, since in science we want to find relationships among well-defined, clear, reliably measured variables. Suppose we want to check the relationship of nutrition to anxiety. Ideally (assuming we have the funds), we should try to include a large sample of cultures in our study that differ in measurable ways on the nutrition variable. Ideally, the cultures that we select should differ in many ways, except that they should be ranked on one clear variable, nutrition. Then the countless other variables will not be systematically associated with nutrition, and we will be able to say something reliable about the relationship of nutrition to anxiety (Leung, 1989). Campbell (1988) makes a valid point: the comparison of any two cultures is essentially useless (except for preliminary, hypothesesgenerating work). This point requires us to study many cultures (a minimum of two ªhighº and two ªlowº on the variable of interest). The more cultures we can include in our analyses, the better. Furthermore, we must select cultures which are similar on the variable of interest but very different on all other variables, because of the phenomenon of cultural diffusion. It is well known that cultural elements are copied in adjacent cultures. If there is a lot of diffusion we do not have two independent cases, but actually only one case. In addition, we must replicate the study with many different methods, since each method has
its own meaning in each culture, but it is unlikely that an unsound hypothesis will be supported with very different methods. It is especially important to replicate the study with both nonreactive (e.g., participant observations) and more reliable (but usually reactive) methods, such as tests or questionnaires. In sum, one must be skeptical about the equivalence of the meaning of concepts. For example, Diener (personal communication) asked samples in different parts of the world whether they were ªhappy.º One respondent in India said: ªI do not know; ask my husband.º In what follows I will identify some of the more obvious additional rival hypotheses which may produce an ªapparentº difference when a ªrealº difference is not present. (ii) The instructions may not be understood the same way. This is especially likely if the members of one culture have much less experience with a method or task than the members of the other. Related to this variable is the extent the two populations are familiar with the measurement method. For example, multiple choice tests are widely used in the US and a measure which uses such a format can give US subjects an advantage over a population from a country where such tests are not used. A special test which measures the ªunderstanding of the instructionsº should be used routinely to eliminate this rival hypothesis. Familiarity with the measurement format and content has to be equated. This can be done by using formats which are equally familiar (and contents which have been pretested to be equally familiar) in the two cultures. (iii) The level of motivation to respond to the particular method of the two samples may be different. Americans are likely to be motivated if an experimenter tells them that their ªanxietyº will be measured to give an accurate response. They may want to know ªtheir scoreº and how it compares to the scores of their peers. But in other cultures, where ªanxietyº is perceived as a private matter not to be revealed to outsiders, or where it is mandatory to lie to outsiders, or where anxiety is conceived as something shameful, there may be strong motivation to give an inaccurate answer. Independent measurements of the levels of motivation should be used to eliminate this rival hypothesis. (iv) The reactions to the experimenter may be different. For example, in some cultures it is against the norms to cooperate with ªoutsiders.º In some cultures it is mandatory to ªlieº to outsiders or trick them! In such cultures villagers compete among themselves in telling lies about their culture, and later discuss among themselves what lies they told and laugh at the
Methodologies for the Study of World Views researcher for having believed their lies. To overcome such difficulties it is necessary to use several researchers, some ªinsiders,º and some ªoutsidersº to obtain some estimate of the importance of this factor. (v) The meaning of the test situation is not always the same. For example, in some studies (Bond & Yang, 1982; Bond & Cheung, 1984; Yang & Bond, 1980) the language of the instructions influenced the results. When instructions were given to Hong Kong subjects in Mandarin, Cantonese, or English, the results differed. Apparently, the language of the instructions suggested to the subjects who was interested in the results of the studyÐthe Beijing authorities, the Hong Kong authorities, or the British colonial authorities. (vi) Response sets differ across cultures (Hui & Triandis, 1989; Triandis, 1972). For example, in some cultures if one is ªsincereº one gives a strong answer (e.g., ªI strongly agree.º), but if one is not sincere, one might use the middle of a Likert scale. In Japan it is arrogant to use an extreme response, and it is appropriate (modest, polite) to use the middle of the scale (ªperhaps I agree with itº). In some cultures people only answer the questions which they are absolutely sure of; in others, they answer all the questions. Marin, Gamba, and Marin (1992) found that Hispanics in the US, relative to non-Hispanics, are more likely to use extreme responses (e.g., I strongly agree) and to show acquiescence (agree with every question). The more acculturated (spent a lot of time in the US, are comfortable when using English) the Hispanics are to the US, the less they do that. In some cultures people are expected to agree when asked questions; in others they are expected to disagree when asked questions by ªoutsiders.º (vii) The samples, in the relevant cultures, may not have been strictly equivalent. For example, there might have been differences in social class, age, sex, religion, or some other demographic attributes which are the ªrealº cause of the difference, yet the difference is attributed to language/culture. One should analyze the data separately for each demographic category. Furthermore, the two populations under study may not be stable over time (e.g., sampling in 1960 and assuming that the results apply in 1999 may well be an error). When a population is heterogeneous, sampling in one area and hoping that the results are valid in another area (e.g., sampling in New York and assuming that the results apply to the whole of the US) may be misleading. For that reason, ideally, one should obtain samples in different parts of a country, and from different occupational, sex, and age groups, and check the consistency of the findings across these samples.
(viii) The ethical acceptability of the method may not have been the same in the various cultures. For example, in some cultures some samples (e.g., women) are not supposed to have an opinion, let alone an opinion which is different from their husband's. If one asks about that opinion, people can become embarrassed or angry because the experimenter ªdaredº to ask such a question. Pretests are needed in which samples are asked after the pretest ªwhat did you think about this method?º It is useful to use a set of scales (such as good vs. bad, active vs. passive, strong vs. weak) for the subjects to rate the test situation itself (was the test situation pleasant or unpleasant?) One of these scales could be moral vs. immoral. If the study appears moral in one culture and immoral in the other, it would be necessary to investigate the matter further, before collecting much data. It is clear from the above that there are many ways in which a difference may appear. A difference is easy to obtain across cultures, but the question is: Is the difference a substantive finding, or is the apparent difference due to something which is indirectly associated with the measurement? We can never be sure that we ªcontrolledº all rival hypotheses, so any conclusions about cultural differences must remain tentative. The discussion presented above does not mean that we must reject all forms of measurement. One can control statistically variables which are correlated with the dependent variable of interest. For example, if there is a response set, one way to control it is to ªstandardizeº the data statistically. One method is to standardize the data obtained from a single participant (within participant standardization), thus eliminating individual differences, but focusing of cultural differences. If one is interested in individual differences, the best strategy is to measure them within culture, not across cultures. 10.01.4.1 Some General Strategies When studying a phenomenon across cultures it is highly desirable to work with local social scientists who understand their culture. Such scientists are likely to insist that culturespecific aspects of the phenomenon be included in the study. Measurement can be made sensitive to the cultural context. Interpretation of the results can be much more sound when the perspectives of many cultures are used during data interpretations. In addition, it is necessary to use more than one method because each method has a different meaning in each culture. If the results of several
different methods converge, it is unlikely that the same bias accounts for all the results. One must also do separate ªconstruct validationsº within each culture. In a construct validation, one has a theory and tests the theory. If the data hang together the way the theory predicts, then both the theory and the measurements of the constructs must be valid. Suppose you have a theory which predicts that there are certain ªantecedentsº of anxiety in every environment and certain ªconsequences.º If you measure anxiety with different methods in each culture and you find that the correlations between your measures of anxiety and the several antecedents and consequences specified by your theory are approximately the same in all cultures, then you have validated your measures in those cultures. If the patterns of correlations are similar, and if certain statistical tests (discussed by Irvine & Carroll, 1980) indicate that the measures are equivalent, then you can compare the results across the cultures. 10.01.4.2 Good Theory Can Eliminate Some Rival Hypotheses If one has a well-developed theory that makes several predictions, and the theory is supported by the data, some of the rival hypotheses become less plausible (Malpass, 1977). Suppose my theory predicts that in a collectivist culture people will be low in anxiety when they are with members of their ingroups and higher in anxiety when they are far away from their ingroups. In an individualistic culture my theory predicts no difference when the individual is tested when with or away from members of the ingroup. Suppose I collected data in rural China and rural America and I found what I predicted. In that case many of the rival hypothesesÐ different definitions of the constructs, different levels of motivation, response setsÐbecome less plausible. This does not mean we should not worry about rival hypotheses when we have good theory. Clearly, if the theory and a rival hypothesis make the same predictions, we cannot use the theory to eliminate that rival hypothesis. But in many cases the theory and the rival hypothesis will make different predictions and then if the data support the theory that is reassuring. The main point to remember from this discussion is that cultural comparisons which indicate a cultural difference require a lot of work, checking, elimination of rival hypotheses, multimethod measurements, and the like, before the presence of cultural difference becomes plausible. As a sophisticated consumer of cross-cultural research, the reader should be
looking for evidence that this extra work, checking, and elimination of rival hypotheses was actually undertaken by the researcher. 10.01.4.3 Methods that Can Establish Measurement Equivalence Across Cultures Several methods may be used to establish cross-cultural equivalence. (i) Suppose one has measured several variables in each culture and submits the correlations among these variables to a factor analysis. If the same factor structure appears in each culture (e.g., Tucker coefficients of 0.90 + for each factor) that is one indication that the variables have the same meaning in the relevant cultures. (ii) Item response theory (Hulin, Drasgow, & Parsons, 1983) provides a statistical procedure which indicates if a particular item has the same meaning in two or more cultures. The procedure is based on the similarity in the way people respond to that item and to all the other items. (iii) Psychophysical methods allow some physical variable (e.g., distance between physical objects) to be linked to a psychological variable (how do you feel about social entities) (for an example, see Triandis, McCusker, & Hui, 1990). 10.01.4.4 Emics and Etics in Cross-cultural Research I introduced above the idea of etic (universal) and emic (culture specific) cultural elements. Here I will elaborate on the meaning of these constructs and explain how they might be used in the measurement of constructs. Emics, roughly speaking, are ideas, behaviors, items, and concepts, which are culturespecific. Etics, roughly speaking, are ideas, behaviors, items, and concepts which are culture-generalÐthat is, universal. Emic concepts are especially useful in communicating within a culture, where one word can sometimes be used to convey a very complex idea. For example, a geographer who has studied the inhabitants of the Tierra del Fuego in the Southern tip of South America, told me that they have a word, mamihlapinatapei, which means ªlooking at each other hoping that either one will offer to do something that both desire but are unwilling to be the first to do.º One can almost see the scenario when boy meets girl and they mamihlapinatapei! One learns quite a bit about that culture by knowing the definition of this word. Similarly, by learning particular words, we get to know more about a culture.
Methodologies for the Study of World Views Emic concepts are essential for understanding a culture. However, since they are unique to the particular culture, they are not useful for crosscultural comparisons. Let us consider an analogy, the comparison of apples and oranges. Apples and oranges have some common attributes, such as size, weight, price, and availability. They also have some unique attributes, such as unique flavor and aroma. Clearly, if we are going to understand what an orange is, we need to know about orange flavor. But we can not compare apples and oranges on orange flavor, except to say that apples do not have it. On the other hand, if we want to talk about price, we can compare apples and oranges. If we want to compare price to size or weight we can certainly do that, too. So, we can have a ªtheoryº of size±weight±price relationships and see if it holds as well for apples as it does for oranges, and we can even extend it to other fruits. Emics are like apple or orangeflavor; etics are like size, weight, and price. So, for certain purposes, such as comparisons, we must use etic concepts; for other purposes, such as getting a real ªtasteº of the culture, we must use emic concepts. More formally, emics are studied within the system in one culture, and their structure is discovered within the system. Etics are studied outside the system, in more than one culture, and their structure is theoretical. To develop ªscientificº generalizations about relationships among variables, we must use etics. However, if we are going to ªunderstandº a culture we must use emics. Many anthropologists work with emics and think that etics are silly. They would say: ªyou do not know about apples by just knowing about their price, weight, and size.º Psychologists want to make generalizations about people, so they do not want to get into the details of a single culture. Cross-cultural psychologists try to both understand and compare cultures. They work with both emics and etics. The important point is to find convergence between different methods of understanding reality. I do not agree with the view expounded by some ªdeconstructionº humanists, or even some who pretend to be scientists, who argue that nature is constructed, not discoveredÐthat truth is made, not found (e.g., Haraway, 1991). I think that this is an extreme position which is not science, since it cannot be discomfirmed. On the other hand, I do grant that our subjective responses to reality are often constructed. I am a realist, so I do not believe that women are less good as Chief Executive Officers (CEOs), just because that is the male-dominated ªconstructionº and conventional wisdom of current CEOs. But I would agree with this view if
someone showed me a convincing study, with hard criteria, which indicated that this view is correct. ªConstructionismº can result too easily in an image of reality which is found in only one person's mind. It might be good literature, but it is terrible science. The essence of science is a conversation between scientists and nature. It requires probing with multiple methods, to replicate important findings, and establish convergence between observations and measurements. If such convergence is broad, that is, includes humanistic ªfindingsº as well as findings obtained through scientific methods, we can be much more certain that we have identified an important phenomenon than if we have only one person's argument or a single set of findings obtained in one place, with only one method. An important distinction between the humanistic and the scientific method is the contrast between the subjective and the objective. If the humanistic insight is to be taken seriously it has to converge at some point with other evidence; it cannot remain entirely subjective. If we take a construct generated in our culture and use it in another culture, we may have a pseudoetic (false etic) construct. We must get empirical evidence that the construct operates the same way in the other culture, that is, it is a true etic, before we use it to compare the cultures. Remember the discussion about construct validity above? That is what needs to be done to establish a true etic. Then we have to make sure that this etic construct is measured in ways that are culturally sensitive. That often requires the use of local terms and ideas. In short, we must use both etic constructs and emic ways to measure them. That is why crosscultural psychologists advocate the use of both emics and etics (Berry, Poortinga, Segall, & Dasen, 1992; Triandis, 1972, 1992). One advantage of such a strategy is that one can obtain more sensitive information about the relevant cultures, which implies that one can obtain more cultural differences if one uses both emics and etics in the design of cross-cultural studies. In one study (Triandis & Marin, 1983), samples of Hispanics and non-Hispanics responded to either a questionnaire based on ideas generated in previous studies with American samples (pseudoetic) or a questionnaire which used ideas obtained from focus groups (informal discussion groups which generated items to be used in the questionnaire) of Hispanics and non-Hispanics. The latter questionnaire included both emic items which were spontaneously generated only by the Hispanic focus groups and etic items which were generated by both the Hispanic and non-Hispanic focus
groups. Since the questionnaires in that study had 600 questions, one could get six cultural differences by chance (at the 0.01 level of significance). The number obtained by the pseudoetic questionnaire was 14 and the number obtained by the emic plus etic questionnaire was 50. In other words, one can miss a lot of subtle information about the way cultures differ if one does not use emics. The importance of emics cannot be overestimated. There are emic concepts that are extremely difficult to understand by people who use an etic framework. Consider this example: What is a geisha? Most Westerners are likely to freely associate ªprostituteº with that concept, and as a result they will be quite wrong. A 500+ page ethnography about geishas (Dalby, 1983) shows that the closest association to ªgeishaº should be ªjester.º Just like the jester in a king's court had the function of diverting the king and his guests, so a geisha has as her chief function entertaining the clients of an establishment. Most geishas spend their time reciting poetry, singing, dancing, and serving their clients while they eat and drink. Furthermore, there are many kinds of geishas, and only a minority are actual prostitutes (yujo). Most do other things, including greeting people at the door or playing musical instruments. The most highly sought geishas are older, more experienced, and thus able to act more appropriately. President Ford, the first US President to visit post-war Japan, had dinner with several geishas as part of his touring experience. The most beautiful were placed next to him; but the ones who did most of the entertaining were the older, more experienced ones. Of course, without knowledge of Japanese, President Ford may not have been able to appreciate the entertainment. The contrast between ªgeishaº and ªwife,º in terms of the free associations of these words among Japanese males, is instructive. The former is seen as sexy, artistic, witty, and economically self-sufficient; the latter as sober, humdrum, serious, and economically dependent. The former is likely to be well read, know the latest poems and songs; the latter is likely to talk about the problems of the children. Now that you have a glimpse of the meaning of geisha, do you see that it is a culturally specific role, that corresponds to an emic Japanese term, and the Western view that she is a ªprostituteº is a pseudoetic, and becomes a true etic only when it uses the idea of ªjester?º The general point is that using our own emic terms to understand other cultures will generally result in misunderstandings. We need to obtain etic terms which correspond to the emics.
10.01.4.5 How to Use Emic Measurements of Etic Constructs Any theoretical construct of some generality in psychology is likely to have both etic and emic aspects. For example, the concept of ªsocial distanceº makes sense in every culture, and even among animals where territoriality is a wellestablished phenomenon. You allow some people to come close while you keep others away from you. The original concept, developed by Bogardus (1925), was operationalized by asking people if they would like to ªmarry,º ªlive in the same neighborhood,º ªexclude from the country,º etc. certain groups of people. It was found that Americans, in the 1920s, showed little social distance toward Western Europeans, especially those who came from the UK, and much social distance toward ªNegroes,º ªTurks,º and ªJews.º While the social distance concept is etic, the way it is operationalized can vary with culture. In India, the idea of ªritual pollutionº results in social distance, and while a person may not mind living in the same neighborhood with a member of the lower castes, especially if that person is a servant, one can mind very much if that person ªtouches my earthenware.º Thus, in India, social distance is indexed differently. Touching earthenware is an Indian emic; social distance is a theoretical concept, an etic. Let me give you an example of how to use emic items to measure etic constructs. In a study I did a long time ago (Triandis & Triandis, 1962) I asked focus groups to generate items which measure social distance in Athens, Greece, and in Champaign, Illinois. I obtained at least 100 ideas from each sample. I then subjected the items to Thurstone scaling, which eliminates items which are ambiguous in each culture, and provides scale values for each item on an equal interval scale. I found that some items were etic, for example, ªI would accept this person as an intimate friendº had a scale value of 11.1 in the US, and ªI would accept this person as a best friendº had a scale value of 13.5 in Greece. But ªI would accept this person as a roommateº was an American emic, with a scale value of 29.5. ªI would accept this person as a member of my pareaº was a Greek emic, with a scale value of 31.1. Parea means, roughly, regularly-meeting peer group. Thus, these two items mean more or less the same thing, but the American item does not make sense in Greece, and the Greek item does not make sense in the US. The method allows for culture-sensitive measurement, since Greeks rarely live in residential quarters in college, and thus rarely have roommates, while Americans are used to that concept. On the other hand, Greeks do have regular-meeting
Methodologies for the Study of World Views peers and a term for that. ªI would accept this person as my family's friendº had a scale value of 40.9 in the US and 24.0 in Greece, indicating that while that item makes sense in both cultures it implies much less social distance in Greece than in the US. It apparently was more 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) than in the US. Similarly, ªI would rent a room from this personº implied less social distance in Greece (42.8) than in the US (57.5). On the other hand, ªI would exclude this person from my countryº had about the same meaning (95 in US, 82.6 in Greece). Thurstone scaling uses judges to obtain the scale values of the items. The judges examine each item and place it on an 11-point scale, according to how much social distance is implied when a person agrees with that item. About 30 judges seem to be sufficient for each culture. The distributions of the 30 judgments concerning each item are examined. When these distributions are broad or bimodal, the item is rejected because it is ambiguous, or does not measure the quality of interest. These judgments are then treated statistically to obtain the scale values for each item. In this case the top and bottom of the scale were called 100 and zero for easy comprehension. When the actual people are studied, the items of the social distance scale are presented to them in a scrambled order. They are asked to pick three statements which best represent how they would act toward a particular stimulus person, for example, a ª50-year-old unskilled Chinese laborer.º The respondent's social distance is the average social distance value of the three items which were endorsed. One can generate stimuli systematically, by varying, for instance, the age, nationality, and occupation (or whatever one is interested in studying) of the stimulus person and then obtain the social distance each respondent feels toward that stimulus combination. This allows the researcher to do analyses of variance that show the relative importance of the attributes, such as age, nationality, and occupation, as determinants of the social distance judgments. Note that the data come from the scale values of the statements that have been generated and standardized in each culture separately. So, the fact that the statements have different scale values in different cultures does not produce a problem. They are emic values, but the construct is etic, allowing cross-cultural comparison. The same strategy can be used with most concepts and any attitude. Concepts may have a universal meaning that most researchers understand the same way, yet they must be
operationalized and measured differently in each culture, because behavior has different meanings in each culture (Triandis, Vassiliou, & Nassiakou, 1968). Those interested in a more detailed discussion of this approach may find Triandis (1992) useful. 10.01.4.5.1 General recommendations In summary, for good cross-cultural work we must start with the theoretical construct and discuss it with local informants to see how it is best operationalized. It is then useful to use ªfocus groups,º that is, small groups that do some brainstorming, and come up with around 100 ideas about how to measure the construct. While these ideas will probably be different in each culture, the chances are that some of them will be generated in both cultures. Next, we should take each of these 100 ideas and ªscale themº separately in each culture. This means local standardization of the items. The technique developed by Thurstone (1931) (see, Edwards, 1957, Chapter 5) seems most helpful, but other scaling strategies may also be useful. With this method a small set of 15 or so scaled items can be identified in each culture that have been locally standardized but link to the etic continuum under study. This method provides excellent locally standardized and equivalent equal-interval scales in the two cultures. Then the 15 items are scrambled and presented to the subjects under study in each culture with the instructions: ªPick three of the following 15 items which describe your most likely behaviors toward (the social category of interest).º 10.01.4.6 Examples of Multimethod Measurements We have already emphasized the desirability of using multimethod measurements in crosscultural studies. The following list of methods suggests the range of possibilities. 10.01.4.6.1 Ethnographic work This is based on observations, with some questioning of informants and occasionally an experiment or survey (see Goodenough, 1980, for details). In such work an anthropologist spends one or two years among a group of people as a participant observer. After learning the local language, the scientist becomes a member of the culture, and often assumes one of the existing roles within the culture (e.g., the chief's son). After that, observations can be
done informally or formally (see Longabaugh, 1980, for details) using video tapes or films which are later coded by several coders to establish inter-rater reliability.
10.01.4.6.2 Establishing shared cognitions This approach includes the measurement of a psychological construct with several methods in each culture, and checking if the measurements converge. However, it is important to be able to distinguish a psychological from a demographic or cultural construct. Culture consists of shared elements. When we measure a psychological construct we do not know if it is shared so it may or may not be part of culture. Triandis, Bontempo, Leung, and Hui (1990) have developed a method which allows a researcher to sort the personal, demographic, and cultural constructs. The basic idea is to have triads (three respondents) hear a question and answer it while the time it takes for them to agree on the answer is measured. Cultural elements do not require debate. For example, if you ask three Americans whether ªfairnessº is important or unimportant in everyday life, they are likely to supply a ªYesº in less than two seconds, and over 90% of the triads which are tested will agree. But if you ask: Is ªfameº important or unimportant, they engage in a debate. Being famous is not a widely shared element of American culture; some want to be famous and others do not. For those who want to be famous this is a personal construct. Using these two criteria (length of time to respond, percent of the triads who agree), the researchers can pick those elements of the culture which are widely shared. This study was done in Hong Kong and Illinois as a demonstration of what can be done to measure cultural elements. The same could be done with demographic elements (men vs. women, old vs. young, rich vs. poor) by assembling appropriate triads and measuring how much time it takes for them to agree on how to answer a question, and what percentages of the triads do agree. Also, this study was limited to ªvalues,º but it could be done with any element of subjective culture. Unfortunately, this method is participantintensive. To have 50 triads, which is not an especially large number for a somewhat heterogeneous culture, 150 people are needed in each culture. It is possible to compare the data of this method with the results obtained by questioning one person at a time with other methods. If the results are similar, one has evidence about the convergent validity of both methods. The Hong
Kong/Illinois study did that and convergent validity was obtained. Another strategy which takes seriously the 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 give the same answer, that is a cultural element. Clearly, the identification of cultural elements is important in studying cultures, but is of little interest when the focus is on individual differences. The two strategies are quite different. When studying individual differences we should do it within culture. Interviews and surveys are often used (Pareek & Rao, 1980). Some of these are informal and allow for questions to be asked as the interview proceeds, while others follow a rigid schedule. These interviews can be based on limited or representative samples of the culture. One might also use tests (Irvine & Carroll, 1980), attitude scales, personality scales, projective tests (Holtzman, 1980), and psychophysical tests. Experiments can be done in more than one culture, but they present special difficulties (see Brown & Secrest, 1980; Ciborowski, 1980). For example, it is extremely difficult to ensure that the same degree of manipulation of the independent variables has been used in each culture. However, some interesting results can be obtained when the same experimental procedure is used in each culture. Strodtbeck (1951) provides an interesting example. He examined whether culture is related to the probability that the wife or the husband will ªwinº an argument. He tested 10 husband-wife pairs in each of three cultures: Navajos (where the custom was for the husband to live with his wife's relatives, and hence one might expect husbands to have less power), Texans, and Mormons (where traditional male supremacy was used). The study began by asking each spouse a number of questions separately. The researcher noted on which questions the spouses disagreed. He then put them together and tape-recorded their interactions while they discussed their answers to the questions and attempted to reconcile their differences. If the couple finally agreed with the husband's original position, that indicated husband dominance; if the couple finally agreed with the wife's original position, it indicated wife dominance. The results were as follows: Number of decisions ªwonº by Husband Navajos 34 Texans 39 Mormons 42
Wife 46 33 29
Methodologies for the Study of World Views The hypothesis was supported. Culture predicts who wins, with the Navajo more likely to agree with the wife and the Mormons with the husband. Finally, I will mention two methods which can obtain data from texts or other kinds of published materials: (i) Content analyses (see Brislin, 1980) of children's stories, newspaper stories, myths, formal and informal communications, speeches, or movies produced in several cultures have been used to measure attitudes, motives, opinions, values, and other attributes. For example, one rates the materials on two variables and sees if the ratings are correlated. (ii) The human relations area files (Barry, 1980) is a very useful data set. It consists of photocopies of much of the world's ethnographic record classified alphabetically according to the content of each paragraph. Thus, for instance, a researcher who is interested in checking if the ªage of weaningº of a child is related to ªlevel of anxietyº in the culture's adult population would look in the files under ªweaningº and would find the ages of weaning which were reported by ethnographers who had studied several cultures. Similarly, this researcher would find some categories which might index the extent adults in the culture are high or low in anxiety. Then the researcher would either plot the data, or use correlations or chi-squares to check the relationship of age of weaning to anxiety. Of course, ethnographies do not include every type of information, so it may be that there is no information relevant to anxiety in a particular culture. The result is ªmissing data.º In these analyses the number of cultures is the number of observations on the basis of which the correlation is computed, or N cultures are classified as ªhighº or ªlowº on each of the variables to compute the chi-square test. In other words, one can establish an association between two variables, based on holocultural data (all cultures on which there is information; see, Naroll, Michik, & Naroll, 1980 for details). 10.01.4.6.3 Conclusions It is ideal to test a hypothesis with as many of these methods as feasible. Some of these methods are ªoperantº in the sense that the researcher provides a minimal stimulus and the subjects provide many responses (operate on the stimulus as they see fit when responding). For example, sentence completion or projective techniques, ethnographies and the human relations area files, observations, unobtrusive measures (see Bochner, 1980, for details), and
content analyses are operant techniques. In most cases the researcher does nothing to stimulate the production of the data. In some cases a minimal stimulus, such as ªPlease write 20 statements which begin with the words `I am,'º is provided. By contrast, experiments, surveys, and interviews are ªrespondentº methods; the subject is responding to stimuli presented by the researcher. Respondent methods are more obtrusive, and they are more likely to be distorted by reactivity. The respondents are more likely to distort their answers, so they will appear to be socially desirable people to the researcher, their peers, the authorities in their culture, or from the point of view of their culture's ideal. In short, respondent methods are more likely to result in cultural differences due to the method. However, it is easier to ªcontrolº artifacts, when using respondent methods because the study can be replicated under a variety of conditions. Operant methods are generally less reliable. Many observations or responses are obtained and it is not clear which ones are the most important. Operant methods also have a high ªdross rateº (irrelevant information is a high proportion of the total information obtained). Furthermore, the observer may be biased and only see or hear what is consistent with a hypothesis. Both kinds of methods should be used at different points in the research sequence. At the initial stages of the research, when one knows little about the culture, lacks good hypotheses, and is dealing with respondents who are not familiar with social science methodologies, it is best to use operant methods. Such methods are especially good when investigating complex relationships. These relationships can be kept in mind while making additional observations. However, since these methods are not sufficiently reliable, and are difficult to check for reliability and validity, one should not reach definitive conclusions by using only these 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 more is known about the culture, the hypotheses are more likely to be supported and then it might be possible to design experiments, questionnaires, and interview schedules which are appropriate for the problem. It also helps if the participants are familiar with the researcher's methods, since they may then be more likely to give the same meaning as the researcher to the testing situation. In other words, no method is perfect; each method has both advantages and disadvan-
tages. The sophisticated consumer of crosscultural research will give more weight to findings which have been supported by more than one method, particularly if the methods were very different. Separate tests of hypotheses within cultures and between cultures, and with more than one method, increase the confidence in any finding. However, we must not assume that a test at the between cultures level will necessarily give the same results as a test at the within cultures level. For example, consider the variable ªdegree of industrializationº and correlate it with the variable ªprobability that a worker will vote for the communist party.º In India and the US, there is a greater probability of a communist vote in a highly industrialized voting district than in a less industrial one. In other words, within countries there is a positive relationship between the variables of interest. But when we compare the two countries we see a negative relationship between these two variables. In the US there is a higher level of industrialization and also a low probability that anyone will vote for the communist party; in India, there is less industrialization, but a relatively high probability that a worker will vote for the communists. In short, there is a reversal of the sign of the relationship between the two variables when we study the phenomenon across vs. within cultures. This means that while we should do our analyses at both the between and within cultures levels, we need not become discouraged when these results are inconsistent. Of course, consistency boosts our confidence that the relationship is robust. There are examples (see Rohner, 1986; Schwartz, 1994) in which a hypothesis has been tested at both levels and was supported consistently. 10.01.4.7 Translations It is ideal to gather the data in each culture independently by using the same procedures but without translation of specific items. This view is supported by the realization that translation is at best approximate. There are some hilarious examples of poor translation that suggest how difficult it is to translate. For example, outside a Hong Kong tailor shop: ªLadies may have a fit upstairs.º In a Greek tailor shop: ªOrder your suits here; because of a big rush we will execute customers in strict rotation.º An Italian laundry: ªLadies, leave your clothes here and spend the afternoon having a good time.º In a Japanese hotel: ªYou are invited to take advantage of the chambermaid.º A Norwegian cocktail lounge: ªLadies
are requested not to have children in the bar.º At the office of an Italian physician: ªSpecialist in women and other diseases.º A Japanese hotel air conditioner: ªCools and Heats: If you want just condition of warm in your room, please control yourself.º In short, one can make the case that translation should be avoided. But that is not always practical, so a word about translation is necessary. Translation of single words is unwise. It is extremely difficult to establish exact equivalence in meaning for single words. Only if the study focuses on the meaning of single words and uses several methods to tap that meaning is translation of single words acceptable. The greater the context of a text, idea, or concept, the more likely it is that it can be translated properly. If one expresses an idea in more than one way, translation has a chance of reaching linguistic equivalence. Thus, it is helpful to introduce redundancy, synonyms, and context. Brislin (1980) provides many useful suggestions on how to maximize linguistic equivalence. A good approximation to the ideal translation uses the Werner and Campbell (1970) method of double translation with decentering. This method is based on the realization that there are many ways to say the same thing, and careful adjustments to the original language of the research project may not produce any difficulties for the research but may facilitate the translation. For example, the researcher starts with an English text (E), and asks a bilingual to translate it into Japanese (J). Then, he/she asks another bilingual to translate it back into English to obtain E'. A comparison of E and E' indicates where problems may exist. If the discrepancies of E and E' are significant, the researcher can ªdecenterº the text by producing a new text ([email protected] which is satisfactory for the purposes of the research, but is closer to E' than to E). Such a text is likely to translate into Japanese more easily, since E' was an English version of a Japanese text. The process of translation, backtranslation, and decentering continues until two English texts emerge that are more or less identical. Back translation seems like a good way to obtain linguistic equivalence but it has problems. First, many words in languages of the same language family (e.g., Indo-European languages cover a wide area from India to Europe to the Americas) have the same roots but different meanings. For example, in the Latin-based languages, the term sympatique or simpatico means ªpleasant or agreeable person.º In English sympathetic means ªsomeone
Methodologies for the Study of World Views who feels like the other person does.º Clearly, the meanings are not the same. Yet, bilinguals are apt to translate it and back-translate it into the original language when in fact the translation is not correct. Second, skilled bilinguals are good at imagining what the original text might have looked like. So, suppose a Japanese text is being translated, the interpreter may be able to guess what the original E or E' was and produce an [email protected] which is just like it. The researcher would be reassured, but the translation is imperfect. In short, while back-translation is desirable, it does not guarantee linguistic equivalence. One technique which is useful, continuing with our example of English and Japanese, is administration of both the English and Japanese version of a questionnaire to a sample of Japanese bilinguals. In such a case one can compare the responses of the same person when answering in the two languages. This can provide a check on the translation, since the same answer would indicate good translation. However, even this technique is problematic because bilinguals have a tendency to present themselves in a more socially desirable way to ªoutsidersº than to ªinsidersº (Marin, Triandis, Betancourt, & Kashima, 1983). Thus, it is likely that a Japanese bilingual will present a more favorable set of answers when answering in English than when answering in Japanese. In sum, to be safe do not translate. Basically, you can carry out the same data gathering operations in each culture, and the only text that needs to be translated is the instructions, which usually have a good deal of context. Then, standardization is done separately in each culture. Comparison of distributions, computation of Tucker coefficients of the factor structures that emerge from the correlations of the variables of the study, item response theory checks, etc. can be done to establish equivalence before any comparisons are made. Finally, studies which report a large number of cultural similarities, and show the cultural differences as being embedded in these similarities, are more dependable than studies which do not report similarities. If all the data from one culture is different from all the data from another, it is very likely that the tasks were not communicated adequately from one culture to another, and the cultural differences are due to some artifact.
ethical. Unfortunately, not all researchers carry out their work ethically. Some study what is easy to study, and as a result we know a lot more about the disadvantaged than the advantaged segments of most cultures. When two groups are in conflict and a researcher offers to study the conflict, the weak are more likely than the strong to accept the study. The powerful do not submit to research very easily; that means our picture of the powerful members of a culture may be distorted. Some researchers do not provide their subjects ªinformed consent.º Ethical research requires that the participants are able to avoid participation in studies they consider unethical or disadvantageous to them. But in many nonliterate societies the concept of ªresearchº is nonexistent, and it is impossible for the prospective participants to provide meaningful informed consent. With most operant methods the chances are that people will not be exposed to stress or risks. But with respondent methods some risks can be significant. If risks beyond those of ordinary life are involved in a research method it is essential that the risks be explained to the individuals, and they should have the opportunity to decline participation. This, of course, produces other problems, such as distorted samples consisting mostly of volunteers. Nevertheless, if risk is involved the subjects must be informed. Since risk is perceived differently in each culture, it is important to bring research collaborators into the decision-making process at the earliest points of a project. If a method which appears risk free in one culture is not risk free in another, the method may have to be changed. There are many ways to collect data, so it does not follow that because we changed the method we cannot test an important theory. There are special problems of research collaboration across cultures that are discussed in detail by Tapp, Kelman, Triandis, Wrightsman, and Coelho (1974). For example, research collaborators may be harmed by collaborating with someone from a culture that is politically taboo in their country. It is generally believed that researchers must leave something of value in the culture they studied to avoid ªintellectual colonialism.º What is of value will, of course, vary with culture but it can be information, procedures, material goods, or payments.
10.01.4.8 Ethics of Cross-cultural Studies
10.01.4.9 Ethnocentric and Androcentric Bias of Researchers
The sophisticated consumer of cross-cultural research will want to see that the research has been carried out ethically. Good research is
Most cross-cultural researchers are Western men; we all have difficulties in escaping our ethnocentric (my culture is the standard of
comparison) and androcentric (my gender offers the only valid perspective on an issue) biases. We can try to control such biases, but the choices of problems, theories, and methods are likely to reflect such biases. For example, we cannot be sure that we have controlled such biases when we evaluate whether or not gender inequalities are similar or different across cultures. Thus, when evaluating cross-cultural research it is wise to ask whether such biases may have colored the reported findings, interpretations, and conclusions. A useful way to overcome such biases is to collaborate with researchers from other cultures and the other sex. 10.01.4.10 Summary of Criteria of Good Cross-cultural Research (i) Does the study include many similarities across the cultures and are cultural differences embedded in the similarities? (ii) Did the study use multimethod procedures that converged (Fiske, 1986; Fiske & Shweder, 1986)? (iii) Did the study use tests both within (psychological level) and between (cultural level) cultures? Were the results consistent, or when inconsistent theoretically meaningful? (iv) Were rival hypotheses checked and eliminated? (v) Did the study use etic constructs measured emically, that is, with emic items generated in each culture to tap the etic constructs. Ideally, researchers should generate items from both men and women (Harding, 1987; Nielson, 1990; Reinharz, 1992), as well as from all important groups that make the culture heterogeneous (e.g., social class, religion, language, age, family structure). Were measurements standardized independently in each culture? (vi) Was the study conducted ethically? (vii) Did the researchers make an effort to control ethnocentric and androcentric biases? 10.01.5 ACCULTURATION The discussion above assumed that cultures are isolated entities. However, in fact, they are in constant interaction. Individuals are often influenced by many cultures. When two cultures come in contact with each other, individuals have the tendency to adopt some of the attributes of members of the other culture (accommodation), and sometimes they are so enthusiastic in adopting elements of the other culture that they overshoot. For example, individuals who come from a culture which uses time flexibly, for example, Mexico, may become
superpunctual in a culture where ªtime is money.º However, migrants who are rejected sometimes react to the culture contact by emphasizing their own culture (ethnic affirmation). For example, they may become even more flexible about their use of time, and advocate that one should not own a watch, or bother to be on time, because that reduces one's freedom and makes a person like an automaton. A complication is that in some domains people show accommodation or overshooting, and in other domains they show ethnic affirmation. Triandis, Kashima, Shimada, and Villareal (1986) hypothesized that if newcomers in the US are accepted they will show accommodation or overshooting, but if they are rejected they will show ethnic affirmation. In addition, accommodation and overshooting are more likely on visible traits, such as clothing, and ethnic affirmation is more likely on subjective traits, such as beliefs, stereotypes, or values. A socio-political issue of great importance, when two cultures meet, is whether individuals should adopt or reject the other culture, and also try to maintain or reject their own culture. Berry (1990) identified four outcomes of the acculturation process: he used the terminology integration for the situation when the individual adopts the other culture while maintaining his/ her own culture; assimilation for the situation when the individual adopts the other culture and rejects his/her own culture, separation for the situation where the individuals maintain their own culture and reject the other culture, and marginalization for the situation where both cultures are rejected. Given that in the US, integration, as used in the press, means something different from Berry's integration, it may be best to call that condition biculturalism. In any case, Berry, Kim, Power, Young, and Bujaki (1989) found that people who adopt the integration or biculturalism solution to the acculturation situation, and secondarily the assimilation pattern, are better adjusted, both physically and in terms of their mental health, than those who use the other two acculturation patterns. If we note that learning about another culture is similar to learning another language, we can see the advantages of knowing about more than one culture. Segalowitz (1980) identified many cognitive advantages associated with bilingualism, for example, cognitive flexibility, creativity. Similarly, a multicultural person has more than one way of interpreting reality. However, as Lambert (1992) has noted, bilingualism can be both negative and positive. It is negative when in the process of learning another language one
Identities of African- and European-Americans forgets one's own language; it is positive when one is actually comfortable in both languages. Similarly, Triandis (1976a) has argued that multiculturalism can be both negative (assimilation) and positive (biculturalism). Adjustment is likely to be superior when positive multiculturalism is present. Social identity (Tajfel, 1982) is strongly linked with the processes reflected in acculturation. An interesting example is provided by Rhee, Uleman, Lee, and Roman (1995). They asked Korean and American participants to complete 20 statements that started with ªI am . . . º They coded the responses into nine categories, one of which was ªpure traits.º Previous work (e.g., Triandis et al., 1990) had found that in collectivist cultures the content of the responses to the 20 statements is more social than in individualistic cultures. Clearly, pure traits is an individualistic category. European-Americans gave pure trait responses 29% of the time, Koreans did so only 12% of the time. Asian-Americans were classified according to whether when completing ªI am . . .º sentences they had identified their ethnicity ªnever,º ªonce,º or ªtwice.º Those who never mentioned their ethnicity gave 39% pure trait responsesÐa case of overshooting the European-American norm. They must have been the assimilated Asian-Americans. Those who identified their ethnicity once (e.g., I am Asian or I am KoreanAmerican) averaged 25%, almost the same as the European-Americans. Those who identified their ethnicity twice averaged 17%, which is very similar to the 12% of the Koreans in Korea. In short, those with a strong AsianAmerican identity responded like the Koreans. The implications for clinical work of the observation that biculturalism is best is that far from pressuring clients to discard their culture, clinicians should urge them to maintain parts of their culture as well as to acquire those aspects of the mainstream's culture which will help their economic advancement. That may at times seem difficult to achieve. However, there are opportunities for ªcultural synergyº (Adler, 1991). Adler argues that when one culture solves a problem one way and the other culture solves it in a different way, rather than become frozen in the opposing ways to solve the problem, one should seek creative solutions which are acceptable to both cultures. In short, rather than the parochial ªour way is the only way,º or the ethnocentric ªour way is the best way,º there should be the synergistic, that is, the ªcreative combinations of our way and their way may be the best wayº (p. 107). To achieve synergy one needs to understand the point of view of each culture first. Second, one needs to explore and understand the
cultural assumptions which underpin the particular beliefs. Then one can create new alternatives which are based on, but are not limited to, the cultures involved. For example, in the clash of collectivist and individualist perspectives, one might find a perspective which is compatible with both sets of assumptions. In our previous example about widows not eating chicken, one could serve a food which is not perceived as having the attributes of increasing sexual desire (as seen in Orissa) and is interesting and desirable (as seen in the US). The next step is to check if the solution fits the assumptions of both cultures. One must discuss the solution with members of each culture to make sure that the solution is acceptable. 10.01.6 IDENTITIES OF AFRICAN- AND EUROPEAN-AMERICANS AS AN EXAMPLE OF THE IDENTITIES OF CLINICIANS AND CLIENTS The US includes 125 ethnic groups with nontrivial numbers (Thernstrom, 1980). Thus, a clinical psychologist is likely to encounter clients from many ethnic groups. Of course, a lot will depend on location. There are more Albanians or Zairians in one city than another. Also, fortunately, there are similarities among cultures. Anthropologists identify ªcultural regionsº within which there is considerable cultural similarity. Generally speaking, Africa South of the Sahara is one region; the cultures around the Mediterranean, including most of Europe, have much in common; the cultures of East Asia, South Asia, and the Pacific Islands have similarities. Native Americans (of course, they include tribes in South, Central, as well as North America) are among the most diverse cultures. For example, according to the criterion of social structure, they belong to five cultural regions (Burton, Moore, Whiting, & Romney, 1996). Clearly, clinicians cannot be expected to know much about all 125 cultures, or even about most of the cultural regions. However, there are some ethnic groups which are sufficiently common to require such knowledge. African-Americans are by far the most important, both because of their numbers and the long history of cross-cultural contact between them and the European cultures. Each pair of cultures has a unique history of contact. For example, African- and EuropeanAmericans have had a history of contact which is not the same as the history of AsianAmericans with African-Americans. It is important to realize that the history of contact is an important factor in the kinds of identity which each group develops, and the kinds of ªcontact modelsº which each group generates.
Carter (1995) argues that people in the US develop a racial identity which affects their thoughts, feelings, and behaviors. Any valid psychotherapeutic process in this country must include race. He believes that this identity is important even in White±White interactions because so much of the content of social behavior in the US reflects inter-racial experiences in school, work, dating, neighborhood, or public policy. Carter (1995) also argues that each ethnic group (Native Americans, Asian-Americans, Hispanics, African-Americans) goes through a series of stages in developing an ethnic identity which is bound to enter into the clinician±client relationship. Ethnic identity reflects how the individuals think about their own group as well as how they view the relationship between their group and the other ethnic groups. Ethnic identity, of course, also reflects the kinds of acculturation patterns which are operating, as discussed above. Carter's (1995) discussion of Black racial identity specifies four stages, each of which includes two levels. I will only describe the four stages. Stage 1 is the pre-encounter stage during which there is dependency on White society for self-definition and approval. Racial identity attitudes towards Blackness are negative and White culture and society are seen as the ideal. There is an idealization of whites: much anxiety, low self-esteem, and a weak ego (in Loevinger's, 1976, 1979, sense). Most Blacks in this stage have higher than average incomes and do not report that they experience discrimination in the workplace. The client in this stage prefers a white counselor. Stage 2, the encounter stage, begins when the individual has a personal and challenging racial experience. It includes confusion, emotions which are bitter, hurt, angry; there is high anxiety, low psychological well-being, high depression, and preference for a Black counselor. Stage 3, the immersion stage, is characterized by positive feelings toward Blacks and idealization of Black culture, while having intense negative feelings toward Whites and White culture. The emotions include rage and depression. Individuals have low self-esteem and low self-actualization tendencies, are characterized by emotional dependence, but people in this stage have a strong ego in Loevinger's sense. This stage is most common among those of low education, who are separatists with Afro-centric values and anti-White/system attitudes. Stage 4 is internalization. Here individuals realize that both Blacks and Whites have both strengths and weaknesses. Black identity is experienced as positive, important, and a valued
aspect of the self. Individuals in this stage respect Whites and tolerate differences between Whites and Blacks. The emotions are selfconfidence and security. At the most developed level of this stage there is individual activity to promote the welfare of Black people. Carter (1995) describes five stages of White racial identity: stage 1, contact, includes persons who are unaware of others in racial terms, and deny the importance of race. However, they experience discomfort with unfamiliar people and situations. They are characterized by low anxiety, poor self-image, dependence, and are immature interpersonally. Such people have Euro-American values, but support organizations that promote equity. In Stage 2, disintegration, people become aware of social norms and pressures associated with cross-racial interactions, see negative reactions by Whites to inter-racial associations, and attempt to find some balance between human decency and external pressures to be negative toward Blacks. Typical emotions are anger and guilt. They are still interpersonally immature, prefer a White counselor, are confused by Blacks, have Euro-American values, and may have negative views of racial issues in the workplace. Stage 3 is reintegration. People at this stage are fearful, angry and hostile toward Blacks. They are anti-Black and pro-White, and see Blacks stereotypically. Individuals idealize Whiteness, devalue other races, and are antiBlack. Their emotions include fear and anger. They feel high anxiety and hold racist views; they have Euro-American values and negative views of the racial issues in the workplace. Stage 4 is called pseudo-independence. At this stage people understand that there are similarities and differences between the races and accept the differences. However, these people understand the differences only intellectually, and remain emotionally distant from Blacks. They may be interpersonally mature, may accept inter-racial dating, may be comfortable in cross-racial settings, but nevertheless prefer White company. Stage 5, autonomy, is the most accepting and flexible of the White racial identities. People at this stage accept race as a positive part of the self, are calm, secure, self-confident, mature interpersonally, self-actualized, inner-directed, support racial integration, have balanced views of inter-racial relations, and positive racial views of the workplace. Carter's theory is that if the therapist (Black or White) and client (Black or White) are at equivalent levels of racial identity development, there will be little improvement in the client's condition. Even worse, if the therapist is at a
Methods for the Development of an Understanding of the Culture of the Client lower stage than the client, there can be regression. Only when the therapist is at a higher stage than the client will there be progress in psychotherapy. Thus, he argues that racial identity is crucial in understanding the therapeutic relationship. In fact, it is not race as such but racial identity that is most important in understanding the course of psychotherapy. Therapists who are not aware of the proper way of understanding Black behavior may misinterpret as pathological behaviors which are normal in the other culture, or clients might feel anxious for not being what the dominant culture expects them to be. Thus, Carter (1995) advocates that racial identity must be incorporated in clinical training and practice and he criticizes models of intercultural training which do not explicitly deal with racial identity. The second part of his book reports empirical studies which support some of these arguments. This theory may have merit, but perhaps Carter (1995) overemphasizes the importance of race, and also does not seem to take seriously the importance of the situation. There is at least one study which suggests that identity may switch rather readily. Sussman and Rosenfeld (1982) asked Venezuelan and Japanese bilingual students to place their chairs anywhere in an empty room and chat for 10 minutes in either their own language or in English. The researchers measured the distance between the chairs. They found that when these students spoke in their own languages the Venezuelans placed their chairs close to each other and the Japanese placed them far from each other. But when these participants spoke in English there were no cultural differences. This study would suggest that the situation (speaking in own language or in English) determined the participants' identity and behavior. It would seem that any theory about the way racial identity influences behavior should take the situation into account. 10.01.7 METHODS FOR THE DEVELOPMENT OF AN UNDERSTANDING OF THE CULTURE OF THE CLIENT Analysis of the subjective culture of the clients (Triandis, 1972) requires examination of the way clients categorize experience, the meaning of key terms, associations, beliefs, evaluations, expectations, norms, role definitions, self-definitions, ideals, and values (see Triandis, 1994, Chapter 4). This is often done most easily by reading ethnographies about the client's culture, or empirical studies which have measured these cultural elements.
All 125 or so of the American ethnic groups (Thernstrom, 1980) are quite heterogeneous, so that any statement made about them must be used very carefully. For example, Hispanics are quite different depending on whether they have come from Cuba, Mexico, South America, or Puerto Rico. Social class differences, the relative influence of African or Native American cultures, the genetic mixture of Europeanand Native-American populations, and factors reflecting the history of the relationship between the ethnic group and the mainstream populations of the US, have influenced the kind of culture that has emerged. A major difference between Asian- and Hispanic-Americans, on the one hand, and European-Americans, on the other, is that the former are more collectivist than the latter. Many of the attributes of these two kinds of cultural patterns (see Triandis, 1995, for details) are reflected in the greater emphasis on politeness, being a nice person, saving face (TingToomey, 1988), and the like which are associated with collectivism and increasingly neglected among extreme individualists. Asian-Americans are also said to be less assertive than EuropeanAmericans (e.g., Zane, Sue, Hu, & Kwon, 1991). An excellent comparison of Chinese and Americans can be found in Hsu (1981). Hispanics have been found to be rather collectivist (Marin & Triandis, 1985), especially familist (see Triandis, 1994, p. 247 for references), concerned with smooth interpersonal relationships (Triandis et al., 1984), interpersonal connections, and personalistic relationships (dealing with each person differently). They are especially concerned with ªrespect,º ªdignity,º ªloyalty,º and ªcooperationº (Albert, 1996). African-Americans value expression in movement, sound, and the visual modalities more than European-Americans. Expression as personal style and movement, and the use of a ªcool poseº (Majors & Mancini-Billson, 1992), as well as different patterns of communication in both language (Landis, McGrew, Day, Savage, & Saral, 1976) and paralinguistically, require that for effective interaction with African-Americans, European-Americans must learn a good deal about the African-American subcultures. Some analysts have argued that AfricanAmericans when compared to European-Americans are more spiritual, higher in harmony with nature, more present oriented, use time more flexibly, emphasize oral expressions, movement, surprise, improvisation (see jazz), rejection of routine, have an identity that is defined by expression, style, and spontaneous activity, are more gregarious, flexible, easygoing, affectively driven, and high in affect (Boykin, 1983; Jones,1986, 1988).
The largest differences between Europeanand African-Americans have been found among those African-Americans who have never had a job (Triandis, 1976b). While those with jobs often have a very positive self-concept and a subjective culture that is not very different from the subjective culture of mainstream Americans, those who have never had a job often have neutral self-concepts; they accept the conditions of the ghettos (e.g., high crime rates) as natural, have strong antiestablishment attitudes, and see little connection between what one does and what one gets. They can be characterized as having ªecosystem distrust,º that is, they do not trust people in their environment, and see events in their environment as unpredictable. Some of these perceptions may reflect the realities of life in segregated ghettos. For example, if discrimination prevents people from getting a job, not seeing a link between finishing school and a job may actually be a veridical judgment rather than an aspect of ecosystem distrust. It may be the case that people in those environments are untrustworthy. What is striking, however, is that the great distrust is uncovered across the board, in the way they rate stimuli like mother, father, teachers, Black women, Black professionals, Black men, and so forth (Triandis, 1976b, p. 123). When clinicians interact with ethnics, such as those described above, they may well experience ªculture shockº (Oberg, 1960). Culture shock is a consequence of not having as much control (Langer, 1983) over the social environment as one is used to having. If the way clinicians usually approach their clients does not result in anticipated changes, the clinicians may feel that they have lost control of their clients. To regain control clinicians need to put themselves into the shoes of their clients (Brislin, 1993). That means learning to make ªisomorphic attributionsº (Triandis, 1975). That is, when they explain the behavior of their clients, they must use approximately the same causal attributions as their clients use to explain their own behavior. 10.01.7.1 Methods of Culture Learning There are numerous ways clinicians can learn about another culture: they can spend time with members of the other culture; they can read about them; they can ask people who have worked with members of the other culture to describe that culture. Each of these methods can be effective, but each has limitations. One of the major problems in culture learning is convincing the clinician that culture training is worthwhile. After all the clinician is busy, and culture learning is like learning another lan-
guage. Can the time it takes to learn about the other culture be justified? Also, most people are ethnocentric and feel that others must learn about their culture rather than they should learn about other cultures. After all, if clients are going to be successful in American culture they must learn how to negotiate situations within that culture, that is, learn the culture of the clinician. So why should the clinician bother to learn their culture? Many clinicians also feel that they already know enough. Thus, very little cross-cultural learning is likely to take place. However, if one is to do a good job with a client from another culture it is important to learn as much as possible about that culture. Changing a behavior which is central to the other culture can do more harm than good. For example, clients from collectivist cultures often appear to be too dependent on their families. A clinician may be tempted to make them more autonomous. Yet that is likely to upset many beliefs, feelings, and behavioral patterns if it is attempted too quickly and while the client is still young. Changing a client without understanding that behaviors which appear pathological are normal in the client's culture is extremely dangerous. Qureshi (1989) has written a whole book about misdiagnoses which are likely when the health provider and the client come from different cultures. For example, if the clinician does not know that in Pakistan it is inappropriate to say ªI do not know,º or in India it is rare that one says ªthank you,º major misunderstandings might occur. If the clinician does not know that in the Eastern Mediterranean there is often a culture of honor (Campbell, 1964), and many people show an ªOthelo syndromeº which consists of excessive concern about the chastity of spouse, jealousy, and delusions that the wife is unfaithful, he might interpret ªnormal behaviorº as abnormal. Differences in gestures, 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 interaction. Culture-linked diets can result in misinterpretations. Differences in what is normal social structure (e.g., equality or inequality of roles), conceptions of beauty (e.g., fat is beautiful in some cultures), taboos (what parts of the body can a clinician not touch), conceptions about what it means to be ªsickº and what one is supposed to do about it (e.g., go to a shaman or take a drink which contains mercury that is supposed to be a therapy for impotence), beliefs about the proper behavior after a birth, marriage, death, and bereavement can also result in misunderstandings.
Methods for the Development of an Understanding of the Culture of the Client Psychopathology often is an exaggeration or caricature of normal culture (Draguns, 1988). It may reflect culture-linked myths, religious beliefs, political views, esthetic standards, economic conditions which are unknown to the clinician, and result in misunderstandings. It often reflects the basic personality which is most frequent in the culture, social representations found in that culture, the inability to deal with specific environments, the values of the culture, specific forms of the self, methods of selfcontrol, and culture-linked lifestyles. Even highly educated samples may use indigenous methods of dealing with illness. For example, Cook (1994) asked university level samples of Chinese, Indian, and Anglo-Canadians about their beliefs. Three kinds of methods of dealing with 16 illnesses were provided: (i) biomedical (e.g., consult a physician), (ii) psychosocial (e.g., use a remedy recommended by the family), and (iii) indigenous (consult a religious leader). There were highly significant differences among the three cultural groups in the extent of endorsement of the indigenous and psychosocial beliefs, but their endorsement of the biomedical methods was equivalent. For example, the Chinese indicated that in many cases they would not go beyond the family for help. Issues of ªfaceº are linked with going for help outside the family in Chinese culture. There is also much more somatization of psychological problems in that culture. There are many forms of cross-cultural training. Here I will describe them briefly. Landis and Bhagat (1996) have provided a Handbook which discusses them in detail. 10.01.7.1.1 Culture-general vs. culture-specific training There are many topics relevant to understanding other cultures that are not specific to any culture. These include: (i) Know that we are all ethnocentric. Try to catch yourself when you are ethnocentric. (ii) Know that the attributions that clients will make about their own behavior are likely to be different from the attributions which you will make about their behavior. Look for discrepancies in these attributions. (iii) Learn to sort what is personal from what is ethnic. When clients react to you they are often seeing you as a ªrepresentativeº of your own ethnic group. They may be hostile, not because they do not like you, but because they do not like your ethnic group, which may have dominated their ethnic group. Also, people may be reacting to a cultural trait (e.g., they may not like professionals who wear white coats) rather than to a personal trait.
(iv) Learn that it is most difficult to act correctly in an environment where the situation looks just as it does in your own culture, but where the required behavior is very different. Most cross-cultural errors occur in such situations. You are in a situation called psychotherapy and have tendencies to behave as that situation specifies, not taking into account the special attributes of the client that may require some different behaviors. (v) Learn how to initiate conversations which will teach you about the client's culture. For instance, ask questions like these: What do you think has caused your problem? When did it start? Who is likely to be involved in causing your problem? Why do you think it started when it did? What do you think your problem is doing to you? How does it do that? How severe is your difficulty? Will it have a short or a long course? What kinds of treatment do you think you should receive? What are the most important results which you hope to receive from this treatment? What are the chief side effects which your difficulty has caused you? What do you fear most about your condition? From such questions the clinician can construct the client's ªcultural model of the problem.º Especially important is to obtain clear definitions of the meaning of terms, associations between terms and other terms, and the perceived antecedents and perceived consequences of the clients ªproblem.º For instance, one can ask ªIn your culture, most people experience what conditions which result in the kind of problem you are having?º ªIn your culture, people who have the condition you are having experience what kinds of consequences?º The cultural model that is identified may be quite different from any model encountered in the clinician's culture. To place it in context, it may be useful to inquire about religious beliefs, myths, norms, values, and the like which may have influenced the definition of the problem and the expected outcomes of the treatment. (vi) Learn to see a positive aspect in every one of the client's cultural traits. (vii) Learn to suspend judgment, to live with ambiguity, to categorize broadly (e.g., while the client's response is different from the typical response of most clients, it is not that different). (viii) Learn how people react when they are confronted by differences in attitudes and values: they are likely to (a) ignore the difference; (b) bolster their position (I am obviously correct and you are stupid; they are likely to find additional arguments to strengthen their own position, or get social support from others who agree with them); (c) differentiateÐ it is okay for people in the other culture to do it
that way, and for us to do it our way; and (d) transcendÐboth are correct under some conditions; our way is best under conditions X and their way is best under conditions Y. Once you know these four ways of reacting to what is different, try to suppress the first two and use the last one more frequently. 10.01.7.1.2 Self-insight The emphasis in this kind of training is the development of an understanding of how culture affects one's behavior. This technique uses an actor to behave in the opposite way from the way which is prescribed by the culture of the trainee. For example, in training Americans, the actor behaves like a ªcontrast-Americanº (Stewart, 1966). Topics include the American emphasis on material goals vs. stress on spiritual goals (e.g., as in India), the emphasis on achievement vs. ascribed status based on family prestige; Americans see competition as desirable, whereas in many cultures it is undesirable; Westerners in general emphasize planning, while traditional cultures emphasize fate; Westerners also place reliance on self, while in high power cultures reliance on superiors is more likely. Similarly, in low power distance cultures, the emphasis is on equality, while status differences are most important in high power distance cultures. Other contrasts: the belief that knowledge through observation is superior to knowledge received from authorities; the belief that thoughts cannot influence events vs. the belief that they can do so. The actor interacts with the trainee and the session is videotaped. The trainer then spends time with the trainee going over the tape and explaining how the trainee's behavior is determined by culture. This method is good because the trainee learns about his/her own culture. However, the trainee does not learn anything specific about another particular culture. 10.01.7.1.3 Experiential training Experiential training involves bringing the trainees into contact with members of the host culture in situations where they can make mistakes which will not hurt long-term relationships. For example, in the early 1960s, the Peace Corps used an exact replica of a South Pacific village (no electricity, no movies, no running water, etc.) in a valley on the Big Island of Hawaii (Brislin, 1993). Trainees spent several weeks learning the languages and customs of such villages while interacting with trainers
from South Pacific cultures. Many trainees exposed to the rigors of that environment decided to drop out, saving the Peace Corps the expense of early repatriation and the embarrassment of failure on the job. This method, however, is expensive, and depends on trial and error learning, which is slow. Nevertheless, it produces results if the training organization can spend the money and the trainees have the time. 10.01.7.1.4 Exposure to many local cultures It is assumed that the more experience trainees have had in entering, learning about, and leaving cultures, the better equipped they will be to deal with new cultures. This type of training was developed by the late psychiatrist Wedge. It encourages the trainees to join different urban subcultures, such as the police, the fire department, unions, top management of corporations, school boards, religious groups, political groups, pickpockets, prostitutes, and so on. Each of these groups has a unique culture, and the skills required to join it should be valuable. One has to learn how to scout, enter, explore, terminate, evaluate the new skills and transfer them to the next culture. The trainer helps the trainee get in and out of each subculture, and discusses the experiences of the trainees once a week in review sessions where each trainee's problems in getting in and out of each culture are examined. This method has a number of practical difficulties. It is difficult for a trainee to get into some of these groups (e.g., in one case, when a trainee wanted to join some stevedores they attacked him with a knife), and while there is much to be said for the process skills which one acquires, trainees do not learn much content about the host culture. 10.01.7.1.5 Field trips The clinician may visit the culture of the client for some weeks to become familiar with the environment. This method teaches very little in depth about the local culture. 10.01.7.1.6 Culture assimilators or intercultural sensitizers The introduction to this section mentioned the importance of learning to make isomorphic attributions (Triandis, 1975). In order to train people to make isomorphic attributions this technique was developed and validated (e.g., Fiedler, Mitchell, & Triandis, 1971) and found to work. It is the only cross-cultural training method that has been evaluated so far, with
Methods for the Development of an Understanding of the Culture of the Client random assignment of trainees to experimental and control groups and has been shown to be effective (Albert, 1983). This does not mean that the other methods do not work; it only means that rigorous studies have not yet been reported. The culture assimilator is a programmed learning approach to cultural training. It consists of a set of 100±200 critical incidents, that is, scenarios where people from two cultures interact. Each episode is followed by four or five explanations of why the member of the other culture has acted in a specific way. The trainee selects one of the explanations and is asked to turn to another page (or computer screen) where feedback is provided concerning the chosen explanation. Let us look at a simple example. Suppose you are teaching a clinical psychologist to understand the behavior of a lower class Hispanic. If the psychologist understands the Hispanic's viewpoint, this is considered successful training. Episode: A Hispanic lower class client looks down when spoken to. Question: Why did the client look down? Attributions: (i) He was distracted. Turn to page 50. (ii) He was fearful. Turn to page 51. (iii) He was respectful. Turn to page 52. (iv) He was hostile. Turn to page 53. When trainees turn to pages 50, 51, or 53, they find negative feedback, along lines such as these: ªNo, this is incorrect; try another explanation.º When the trainees turn to page 52, they get feedback such as: ªExcellent! That is correct. When we presented this question to a sample of 80 Hispanics and 95 non-Hispanics, 85% of the Hispanics considered this answer to be the correct one, and only 36% of the nonHispanic thought that this was correct.º Note that the construction of assimilator training is culture-specific. It requires the use of samples of people from the two cultures who study the episode and the attributions and select the attribution they consider to be correct. Thus, the training is validated as it is being constructed. In addition, the feedback gives the percentages of samples who agree or disagree with each answer. This avoids teaching stereotypes. Instead, one learns that judgments about why people acted in a given way are probabilistic, and the probabilities differ across cultures. Of course, in constructing assimilators it is necessary to have many more episodes than will be used in the final training, because some will not discriminate the two samples of subjects, and thus must be discarded. Construction of the episodes is based on interviews with people who have wide experience in the two relevant cultures, or on research
which has identified differences in the subjective culture of the two relevant samples. Any item of cultural difference can be included. For example, if the trainer wants to teach what it means to be simpatico she would have one correct option and several incorrect ones and let the trainee pick options and get feedback. In training persons from an individualistic culture such as the US to go to a collectivist culture such as the Far East, one might include a variety of items such as: (i) Differences in norms, such as do not bring a present of a certain color. (ii) Differences in roles, such as the almost sacred parent±child role in some collectivist cultures (so that if one's spouse disagrees with one's parents, it is obligatory to take the side of one's parents in such a dispute). (iii) Differences in the way behaviors can express intentions, so that ªnoº must be expressed most indirectly, and in a very subtle way, for instance during a visit by serving two substances (e.g., tea and bananas) which are usually not served together. (iv) Differences in self-concepts, for example, collectivist selves are more likely to be appendages of groups than to be autonomous. (v) Differences in what behaviors are valued, for example, that in collectivist cultures people use a modest introduction of their lecture, such as ªwhat I have to tell you is not very important;º or they may say ªI thank you for spending your valuable time with me.º In individualist cultures they are more likely to present a self-assured front. (vi) Differences in the kinds of associations which people make, for instance, in collectivist cultures people are more likely to associate the word ªprogressº with national rather than with personal progress. (vii) Differences in the kinds of differentiations (sensitivity to hierarchies based on minor cues) which people typically make, for example, in collectivist cultures there will be more differentiations on the vertical axes than on the horizontal axes of social relationships. (viii) Differences in the important determinants of behaviorÐin collectivist cultures behavior is more likely to reflect norms than attitudes. (ix) Differences in the kinds of reinforcements which people expect for particular behaviors in particular situationsÐin collectivist cultures one is supposed to give a gift in many situations in which in individualist cultures one would pay. Triandis, Brislin, and Hui (1988) advised individualists to pay attention to group attributes more than they do in their own culture, to learn more about the ingroups and outgroups of
collectivists and to expect sharp differences in behavior when the collectivist interacts with members of such groups, to expect more harmony within the ingroup, for example, no criticism of high status people, than is typical of their own culture. They also suggested that trainees should cultivate long-term relationships, be modest when presenting a lecture, stress equality and need when distributing resources, and give more gifts than is customary in their own culture. Construction of a typical assimilator begins with 200 or so episodes extracted from discussions with people who know both cultures, or by analyzing relevant ethnographies to identify a set of four or five attributions for each episode. Then the episodes and the attributions are presented to samples from the trainee's and the host's culture, and differences in the response patterns are examined. Those episodes which do not produce significant chi-squares are discarded. Then the assimilator is printed in a book or placed in a computer. Administration can be done with each trainee working through the book or computer program alone, or the trainer may select some of the more interesting episodes and present them for discussion. Trainees may also role play the content of some of the episodes. In principle, this method can be expanded for use with an interactive disk technology, so that trainees see videotaped actors performing the episode and participate by pushing buttons that indicate what responses they think are appropriate. Feedback from the computer in the form of praise or criticism can make this task most interesting. In evaluations of this kind of training, trainees were assigned randomly to two groups: they received or did not receive the training (e.g., Weldon, Carlston, Rissman, Slobobin, and Triandis, 1975). Such studies have shown that trained people learn to make isomorphic attributions, they expand the range of explanations they give for specific behaviors, they become less ethnocentric, and develop more accurate expectations concerning appropriate behavior. Assimilator training increases cognitive complexity. Cognitive complexity makes it possible to consider the subjective culture of the other cultural group as ªvalidº and thus lessens prejudice (Gardiner, 1972). However, culture assimilator training does not strongly increase liking for the other group or reduce social distance toward it. Liking depends on the number of pleasant experiences one has shared with the other group. Just knowing how the other group thinks does not change emotions.
Stephan and Stephan (1984) used a culture assimilator to increase ªknowledge of Chicano cultureº among Anglo students in New Mexico. This study indicated that Anglo students' attitudes toward Chicanos in the Southwest of the US are related to three factors: (i) how much they know about Chicano culture, (ii) how much contact they have with Chicanos, and (iii) their parents' attitudes toward Chicanos. Contact with Chicanos was determined by the attitudes of their friends toward Chicanos. Finally, contact increased knowledge of Chicano culture, and the assimilator training boosted that knowledge a bit more, so that those who were trained had more positive attitudes than those who were not. The Stephans concluded their study as follows: Simple intergroup contact, such as the contact that typically occurs in desegregated schools, is not likely to improve intergroup relations. However, specially designed educational programs, designed to reduce ignorance of the outgroup, do appear to improve intergroup relations. (p. 249)
Social distance often depends on the norms of our own group. If our own group urges us to get along with the other group, we are more likely to do so than if it opposes such friendliness. As in the Stephans' study, when the friends favor contact, there is likely to be an improvement in relationships. For these reasons culture assimilator training is only one component of cross-cultural training. It is not sufficient by itself. It needs to be supplemented with other methods, such as the self-insight method which is likely to increase the motivation of the trainees to learn about the other culture, and experiential training which can change emotions. Also, the norms of social interaction between the two cultures need to be changed to modify social distance. Another limitation of assimilator training is that it does not change behavior. It is one thing to know how one is supposed to behave, and quite another to behave correctly. To achieve the latter goal one needs to have behavior modification training. The development of assimilators is timeconsuming. It is obvious that any one clinician cannot afford to develop an assimilator for particular clients. However, a group of clinicians, such as the APA's Division 12, could undertake the development of relevant assimilators. In addition to assimilators which focus on a specific culture, there is a general assimilator (Brislin, Cushner, Cherrie, & Yong, 1986). It deals with the fact that it is natural and to be
Methods for the Development of an Understanding of the Culture of the Client expected to: (i) feel anxious abroad, (ii) experience disconfirmed expectancies, (iii) be unable to feel that one belongs to the local culture, (iv) experience ambiguity about what one should do, and (v) be exposed to local prejudices. It teaches that one must learn to control one's own prejudices. The general assimilator also teaches trainees to expect differences in the way people view: (i) work, (ii) the relationship of work and social interaction, (iii) time, (iv) space, (v) language, (vi) roles, (vii) groups, (viii) rituals, (ix) hierarchies, and (x) values. It also helps the trainees to understand differences in: (i) categorization, (ii) differentiation (e.g., some people know more about some subjects than you do), (iii) the importance of the ingroup±outgroup distinction (e.g., between collectivists and individualists), (iv) learning styles (not everyone learns best the same way), and (v) attributions (how to make isomorphic attributions). The general assimilator has been successfully evaluated (Cushner, 1989). Twenty-eight trained adolescents from the Pacific Rim visiting New Zealand were better adjusted than 22 control adolescents hosted by New Zealanders. The trained adolescents completed a number of tasks measuring cross-cultural sensitivity better than the control subjects. A final point about assimilators: clinicians who have been warned that there will be problems when interacting with members of a specific culture are more likely to be able to deal with these problems than naive clinicians. This phenomenon is parallel to findings with hospital preoperative patients: those who were told that they will feel quite uncomfortable after an operation dealt better with the postoperative pain than those who had been told nothing. In general, the more the training creates realistic expectations about events, the better. 10.01.7.1.7 Behavior modification cross-cultural training Behavior modification techniques require that people be rewarded for desirable behaviors and be made to do an incompatible behavior whenever they have the urge or tendency to do an undesirable behavior. For example, in Latin America it is customary among friends to give an abrazo, a kind of embrace with the arms. Also, holding hands, touching, and other behaviors between good friends of the same sex are common. Yet North Americans have to be trained to carry out such behaviors. If they behave as is expected by the Latinos they will be liked better when interacting with Latinos than
if they behave as they do at home. If they do not behave as expected the locals will think of them as cold and undemonstrative ªGringos.º But North Americans who behave this way without proper training will feel that they are behaving inappropriately. Conversely, some behaviors have to be eliminated. For example, in some cultures (e.g., Greece), to show the palm of your open hand is an insult. It is called a ªmoutzaº and reflects utmost contempt. However, many people are in the habit of greeting others by waving an open hand. For these people to stop doing this requires some training. Most people wave without thinking. A trainer must catch them in the act, and tell them not to open their hand. Self-correction after such acts can change the habit, so that the person waves with the palm closed and turned toward themself. Especially difficult is to change habits such as nodding to say ªnoº and shaking the head to say ªyesº (Bulgaria, Southern India). Here one needs a lot of practice to get over wellestablished habits. 10.01.7.1.8 Some summary points about training Cross-cultural training can be effective. Black and Mendelhall (1990) reviewed 29 studies that measured effectiveness. They found that all the studies that measured how people felt about the training had positive results, all the studies which measured effective interpersonal relationships found improvements, all the studies which measured changes in perception found them, and all research which tried to reduce culture shock succeeded in doing so. Two-thirds of the studies which measured performance obtained improved performance. In general these effects were found in field studies but not in laboratory studies. This may be due to the limited time one can use in the laboratory. A few hours of training are not enough to produce major changes. Furthermore, field studies involve volunteers who are motivated to succeed. If we tried to train the general public perhaps we would not have positive results. No matter how good the training or the trainer, if the trainees do not wish to change, they will not. Nevertheless, the studies with control groups and longitudinal designs reviewed by Black and Mendelhall (1990) show some impressive results which should encourage more cross-cultural training. A meta-analysis which statistically combines the results from many studies has also found that cross-cultural training is effective (Deshpande & Viswesvaran, 1992). The scientific understanding of how culture affects social behavior and the use of this
understanding to improve relationships across cultures has just begun, but it is a promising area of activity. 10.01.8 FUTURE DIRECTIONS Future research should determine how many cultural syndromes are needed for an adequate understanding of cultural differences. Learning about these cultural syndromes should allow clinicians to improve their understanding of the cultures of their clients. 10.01.9 SUMMARY AND CONCLUSIONS Culture penetrates our judgments and behaviors in subtle often uncontrollable ways. Becoming familiar with the extent culture shapes our perceptions, standards, and standard operating procedures can be useful. The aim of this chapter was to increase the sensitivity of the readers to the concepts which may help clinicians control the cultural dimensions of their interaction with their clients. It examined the major ways in which cultures differ and explored the attributes of methodologically sound studies which can determine precisely how cultures differ. It then reviewed ways in which clinicians can learn about the culture of their clients. 10.01.10 REFERENCES Adler, N. (1991). International dimensions of organizational behavior. Boston: PWS-Kent Publishing. Albert, R. D. (1983) The intercultural sensitizer or culture assimilator: A cognitive approach. In D. Landis & R. W. Brislin (Eds.), Handbook of intercultural training (Vol. 2, pp. 186±217). New York: Pergamon. Albert, R. D. (1996). A framework and model for understanding Latin American and Latino/Hispanic cultural patterns. In D. Landis & R. S. Bhagat (Eds.), Handbook of intercultural training (2nd ed., pp. 327±348). Thousand Oaks, CA: Sage. Barry, H. (1980). Description and uses of the Human Relations Area Files. In H. C. Triandis & J. W. Berry (Eds.), Handbook of cross-cultural psychology (Vol. 2, pp. 445±478). Boston: Allyn and Bacon. Berry, J. W. (1990). The psychology of acculturation. In Nebraska Symposium on Motivation, 1989 (pp. 201±234). Lincoln, NE: University of Nebraska Press. Berry, J. W., Kim, U., Power, S., Young, M., & Bujaki, M. (1989). Acculturation attitudes in plural societies. Applied Psychology, 38, 185±206. Berry, J. W., Poortinga, Y., Segall, M., & Dasen, P. (1992). Cross-cultural psychology. New York: Cambridge University Press. Black, J. S., & Mendenhall, M. (1990). Cross-cultural training effectiveness: A review and theoretical framework for future research. Academy of Management Review, 15, 113±136. Bochner, S. (1980). Unobtrusive methods in cross-cultural experimentation. In H. C. Triandis & J. W. Berry (Eds.), Handbook of cross-cultural psychology (Vol. 2, pp. 319±388). Boston: Allyn and Bacon..
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Jones, J. M. (1986). Racism: A cultural analysis. In J. F. Dovidio & S. L. Gaertner (Eds.), Prejudice, discrimination and racism. Orlando, FL: Academic Press. Jones, J. M. (1988). Racism in black and white. In P. A. Katz & D. A. Taylor (Eds.), Eliminating racism (pp. 117±135). New York: Plenum. Kim, U., Triandis, H. C., Choi, S. Kagitcibasi, C., & Yoon, G. (1994). Individualism and collectivism: Theory, method and applications. Thousand Oaks, CA: Sage. Kluckhohn, C. (1954). Culture and behavior. In G. Lindzey (Ed.), Handbook of social psychology (Vol. 2, pp. 921±976). Cambridge, MA: Addison-Wesley. Kluckhohn, F., & Strodtbeck, F. (1961). Variations in value orientations. Evanston, IL: Row Peterson. Kroeber, A. L., & Kluckhohn, C. (1952). Culture: A critical review of concepts and definitions (Vol. 147, No. 1). Cambridge, MA: Peabody Museum. Kruger, J., & Clement, R. W. (1994). The truly false consensus effect: An ineradicable egocentric bias in social perception. Journal of Personality and Social Psychology, 67, 596±610. Lambert, W. E. (1992). Challenging established views on social issues: The power and limitations of research. American Psychologist, 47, 533±542. Landis, D., & Brislin, R. (1983). Handbook of intercultural training (in 3 vols). New York: Pergamon. Landis, D., & Bhagat, R. S. (1996). Handbook of intercultural training (2nd ed.). Thousand Oaks, CA: Sage. Landis, D., McGrew, P., Day, H., Savage, J., & Saral, T. (1976). Word meaning in black and white. In H. C. Triandis (Ed.), Variations in black and white perceptions of the social environment (pp. 45±80). Urbana, IL: University of Illinois Press. Langer, E. J. (1983). The psychology of control. Beverly Hills, CA: Sage. Leung, K. (1989). Cross-cultural differences: Individuallevel vs. cultural level analysis. International Journal of Psychology, 24, 703±719. Loevinger, J. (1976). Ego development. San Francisco: Jossey-Bass. Loevinger, J. (1979). The idea of the ego. Counseling Psychologist, 8, 3±5. Longabaugh, R. (1980). The systematic observation of behavior in naturalistic settings. In H. C. Triandis & J. W. Berry (Eds.), Handbook of cross-cultural psychology (Vol. 2, pp. 57±126). Boston: Allyn & Bacon. Lonher, W., & Berry, J. (1986). Field methods in crosscultural research. Beverly Hills, CA: Sage. Malpass, R. S. (1977). Theory and method in cross-cultural psychology. American Psychologist, 32, 1069±1079. Malpass, R. S., & Poortinga, Y. H. (1986). Strategies for design and analysis. In W. J. Lonner & J. W. Berry (Eds.), Field methods in cross-cultural research (pp. 47±84). Beverly Hills, CA: Sage. Majors, R., & Mancini-Billson, J. (1992). Cool pose. New York: Lexington Books. Marin, G., & Marin, B. V. (1991). Research with Hispanic populations. Newbury Park, CA: Sage. Marin, G., Gamba, R. J., & Marin, B. V. (1992). Extreme response style and acquiescence among Hispanics. Journal of Cross-Cultural Psychology, 23, 498±509. Marin, G., & Triandis, H. C. (1985). Allocentrism as an important characteristic of the behavior of Latin Americans and Hispanics. In R. Diaz-Guerrero (Ed.), Cross-cultural and national studies in social psychology (pp. 85±104). Amsterdam: North-Holland. Marin, G., Triandis, H. C., Betancourt, H., & Kashima, Y. (1983). Ethnic affirmation versus social desirability: Explaining discrepancies in bilinguals' responses to a questionnaire. Journal of Cross-Cultural Psychology, 14, 173±186. Markus, H., & Kitayama, S. (1991). Culture and self:
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10.02 Cross-cultural Psychopathology FANNY M. CHEUNG The Chinese University of Hong Kong, Hong Kong 10.02.1 INTRODUCTION
10.02.2 ETHNOCENTRIC APPROACH OF CLINCIAL PSYCHOLOGY
10.02.3 CULTURE-BOUND SYNDROMES
10.02.4 KORO
10.02.5 ALTERNATIVE VIEWS ON CBS
10.02.6 TRANSFORMATION OF NEURASTHENIA
10.02.7 ILLNESS EXPERIENCE
10.02.8 SOMATIZATION AS A CATEGORY FALLACY
10.02.9 SOMATIZATION AS ILLNESS EXPERIENCE
10.02.10 CULTURE AND PSYCHOPATHOLOGY
10.02.10.1 Role of Culture in Psychopathology 10.02.10.1.1 Culture-produced stress 10.02.10.1.2 Culture-related problems 10.02.10.1.3 Culture-inherited vulnerability 10.02.10.1.4 Cultural contribution to choice of psychopathology 10.02.10.2 Cultural Explanations 10.02.11 CROSS-CULTURAL PSYCHOPATHOLOGY
10.02.11.1 Universalist vs. Relativist Approaches 10.02.11.2 Recent Research on Cross-cultural Psychopathology 10.02.11.3 Future Directions
10.02.12 SUMMARY
10.02.1 INTRODUCTION
peripheral curiosities about bizarre phenomena in exotic cultures. Because of their peripheral status, culture-bound syndromes were identified without much systematic research into the cultural dynamics of these syndromes. While they may have clinical meaning to the specific cultures, there is little relevance to the mainline theories. In this chapter, some of the culturebound syndromes are demystified. The roles played by cultural factors in the presentation and interpretation of psychopathology are examined. Recent research is incorporating
While psychopathology is embedded in the wider cultural context, theories of clinical psychology have generally been ethnocentric in nature. Cross-cultural studies in psychopathology often started with the assumption of the universality of these theories and attempted to compare the similarities and differences between cultural groups on aspects of these theories. Earlier interests in culture-specific aspects of psychopathology were related to 35
Cross-cultural Psychopathology
the universalist and relativist approaches of cross-cultural psychology and bringing cultural dimensions of psychopathology into the mainstream. 10.02.2 ETHNOCENTRIC APPROACH OF CLINCIAL PSYCHOLOGY Clinical psychology has always considered itself to be a scientific field and has placed a strong emphasis on research (Routh, 1994). The major content areas of research include psychopathology, assessment, and intervention. Despite the empirical orientation of psychology, a major deficiency in the prominent models of psychopathology is the lack of cross-cultural awareness in both theory and research. The ethnocentric approach in Anglo-American clinical psychology may be reflected in the emphasis on the individual or the intrapsychic self, be it the biological paradigm, the psychoanalytic paradigm, the learning paradigm, the cognitive paradigm, or the phenomenological paradigm. In none of these models is the wider cultural context considered to be an important factor in understanding the cause, course, and consequences of psychopathology. Lewis-Fernandez and Kleinman (1994) pointed out three culture-bound assumptions which biased the professional concepts of mental health and illness in North America. The first is the ªegocentricity of the selfº which is seen as ªa self-contained, autonomous entity, characterized by a unique configuration of internal attributes that determine behaviorº (p. 67). The focus on the self, individual experience, and internal attributes of personality in understanding psychopathology misses the sociocentric ideology and interpersonal contexts which most of the rest of the world espouses. The second culture-bound assumption is the philosophical roots of mind±body dualism, which leads to the division of psychopathology into the organic disorders and psychological problems. This dualistic professional model would misinterpret the cultural expressions of patients in most parts of the world who experience human suffering as simultaneous mind and body distress. The integrated somatopsychological idioms of expressions are often viewed as a reflection of a lack of introspection or psychological-mindedness. The third culture-bound assumption that biases professional concepts is the view that culture is ªan arbitrary superimposition on a knowable biological realityº (p. 67). This assumption views culture as ªepiphenomenal.º Cultural beliefs about disease categories, illness
experiences, and healing practices of people in other cultures are reduced to the status of misinformed or superstitious obstacles in the diagnosis, treatment, and outcome of real diseases which are based on an invariant reality of biology. These culture-bound assumptions result in an ethnocentric psychology based on ªculturally specific ways of viewing individuals and their personality development,º ªdiagnostic categories of personality disorder that ignore the fundamental influence of social context and cultural norms on human behavior,º and ªa psychiatric nosology that claims to be universal but does not take seriously the great crosscultural diversity of somatic and psychological symptomsº (Lewis-Fernandez & Kleinman, 1994, p. 67). The lack of a cross-cultural perspective in clinical psychology cannot be explained purely on the grounds of the limited diversity of the ethnic backgrounds of trained clinical psychologists. The ethnic backgrounds of clinical psychologists in the USA have diversified in the past two decades and the population of clinical psychologists in different parts of the world has vastly expanded. The little research found in cross-cultural clinical psychology has focused mainly on applicability of Western or Caucasian middle-class models of treatment or assessment procedures. In contrast, since the 1960s the field of psychiatry has developed a substantial, albeit peripheral, interest in cultural psychiatry, raising sensitivity to cultural aspects of psychopathology and treatment. It has been pointed out that modern psychiatry was ªmoulded by specifically Western philosophical and scientific traditionsº and should overcome the ªinertia of ethnocentricismº (Lin, 1982, p. 235). Largescale international collaborative research in psychopathology and diagnosis is evident in the activities of international psychiatric organizations and publications of cultural psychiatry. For example, a sociocultural lexicon for psychiatry (Mental Health Division, WHO, in press) will be published to accompany the tenth revision of the International Classification of Diseases (ICD-10; World Health Organization, 1992). Global collaborative research projects have been set up to compare the etiology, symptomatology and treatment of specific psychiatric disorders such as schizophrenia (World Health Organization, 1973, 1975, 1979, 1991). Within American psychiatry, there are attempts to make the role of cultural analysis more of a mainstream than a secondary activity. Where the Diagnostic and statistical manual of mental disorder (3rd ed.) (DSM-III American
Culture-bound Syndromes Psychiatric Association, 1980) has been criticized for ignoring cultural diversity, efforts have been made to represent cultural concerns in DSM-IV (American Psychiatric Association, 1994; Good, 1996). A Group on Culture and Diagnosis consisting of anthropologists and cross-cultural psychiatrists was formed to advise the DSM-IV Task Force on how to make culture more central to DSM-IV. One of the specific aims of the Group was ªto devise a mechanism that would facilitate the application of a cultural perspective to the process of clinical interviewing and diagnostic formulation in psychiatryº (Lewis-Fernandez, 1996, p. 133). The Group on Culture and Diagnosis proposed an outline for cultural formulation to supplement multiaxial diagnostic assessment in a multicultural environment. As summarized by Lewis-Fernandez: the cultural formulation provides a systematic review of the individual's cultural background, the role of the cultural context in the expression and evaluation of symptoms and dysfunction, and the effect that cultural differences may have on the relationship between the individual and the clinician. (p. 137)
Eventually, however, only an edited and shortened version of this outline was included as an appendix instead of the central text of DSM-IV. Nevertheless, compared with previous editions, cultural concerns are represented in a much more significant manner in the text of DSM-IV and are included in the introduction, in the context of particular categories, as well as in a glossary of cultural terms (Good, 1996). No such systematic approach to mainstream cultural analysis is found in the field of clinical psychology. Therefore, reference to the knowledge base developed in cultural psychiatry is needed to review research in cross-cultural psychopathology and culturebound syndromes. 10.02.3 CULTURE-BOUND SYNDROMES The interest in culture-bound syndromes (CBS) in cultural psychiatry in itself illustrates a process of transformation in the approach to cultural dimensions of psychopathology. Fascination with CBS has its sources in the ªbizarre characteristics of the behavior displayedº (Hughes, 1985). Originating from the voyeuristic interest on folk illnesses in ªexoticº cultures, CBS are now included in the glossary of cultural terms in DSM-IV. The study of culture-bound syndromes has gained respectability from the scholarly works of pioneers such as Yap who alleged that:
It has long been known that there are, in certain cultural groups, peculiar aberrations of behavior which are regarded by themselves as abnormal. Over the years a number of terms taken from indigenous languages have crept into the psychiatric literature to denote these conditions, but many of them do not point to novel or distinct forms of disorder unknown elsewhere. Some are simply generic terms for ªmental disordersº without definite meaning, others refer only to healing rituals, and still others to supernatural notions of disease causation. . . . To avoid stagnation in this field, it is essential to apply the concepts of clinical psychopathology to the analysis of these disorders, to integrate them into recognized classifications of disease if possible, or to broaden the classification if necessary. (1974, p. 86)
Initial interests in CBS have given rise to a host of ªfolkº taxonomies from different cultures (Simons & Hughes, 1985). More common CBS include the following: (i) Latah. Originating from Malaysia and Indonesia, Latah refers to the exaggerated startle response followed by odd behaviors. The afflicted person typically responds to a frightening stimulus with an exaggerated startle or jump, sometimes throwing or dropping a held object, uttering some improper word, or matching the words or movements of people nearby (Simons, 1985, p. 43). The pattern is a highly stereotypic, culturally labeled state which, though contravening the social norm, is differentiated from insanity. (ii) Amok. Amok refers to the sudden mass assault taxon indigenous to Malayo-Indonesians, but may find parallel instances of indiscriminate homicide in other parts of the world. It is defined as ªan acute outburst of unrestrained violence associated with homicidal attack, preceded by a period of brooding, and ending with exhaustion and amnesiaº (Carr, 1985, p. 199). It is believed to have originated from the cultural training for warfare of the early Javanese and Malays which was intended to terrify the enemy into believing that they could expect no mercy and could save themselves only by flight. (iii) Pibloktoq. The term is also labeled as arctic hysteria, polar hysteria, or transitional madness, referring to a group of hysterical symptoms among the Polar Eskimo of Greenland brought on by the depressing or monotonous effects of the Arctic's winter climate. The syndrome is composed of a series of reactive patterns with different combinations of the features in different cases. Disturbance of consciousness during the seizure and amnesia for the attack are the central clinical features. Some frequent behavioral symptoms are tearing off of clothing resulting in nudity, glossolalia,
fleeing, and running across or rolling in snow. Gussow (1985) suggested that Pibloktoq is a reaction of ªthe basic Eskimo personalityº to ªsituations of unusually intense, but culturally typical stressº (p. 282). (iv) Susto. Illness arising from spirit separating from the body due to fright is widespread in one form or another in Latin America. The folk interpretation of Susto is based on the belief that a person comprises spiritual and organic elements. The spiritual element may be detachable from the host organism under unsettling experiences that disturb the equilibrium or when the unsettled spiritual element is seized and controlled by the spirits of the natural environment. The situation results in loss of appetite, weight, and strength; restlessness in sleep; listlessness when awake; and depression and introversion. ªFor recovery, the captured spirit must be retrieved from its captor, ransomed in the folk treatment process, and `led back' to be reincorporated into the victim's bodyº (Rubel, O'Nell, & Collado, 1985, p. 334). Most of the initial interest in CBS has surrounded the description of these phenomena. According to Prince and Tcheng-Laroche's (1987) definition of CBS, the culturally distinct meaning of the illness for individuals and cultures affects the occurrence of signs and symptoms of diseases in some cultures but not in others. The difference in occurrence depends on the psychosocial features of those cultures. CBSs have also been called culture-reactive syndromes, which suggests that the psychopathology is deemed to be rooted in social environmental forces and/or situations. The signs and symptoms reflect an attempt by the patients to adapt to major problems in their lives. In the following section, one of the more popular syndromes in the literature, Koro, will be discussed in greater detail to illustrate how the cultural context of CBS affects their manifestation. 10.02.4 KORO Koro arises from the belief about the retraction of the sexual organs (including penis, breast, nipples) into the body which leads to eventual death. Koro was believed to originate from the Malay word koro which means ªshrink.º An alternative source is from the 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 (Edwards, 1985). A similar condition is also found among Chinese under the name of Suoyang, another native terminology for genital
retraction complaints. The syndrome was considered an emic or locally defined construct unique to these cultures with culture-specific etiologies. Cultural meanings have been offered to explain individual and mass episodes of Koro. For example, Bartholomew (1994) argued that Koro is ªa rational attempt at problem-solving that involves conformity dynamics, perceptual fallibility, and the local acceptance of koroassociated folk realitiesº (p. 46). Gwee (1985) offers the interpretation that Koro is an ªacute hysterical panic reaction, brought on by auto- or hetero-suggestion and conditioning by the cultural backgroundº (p. 159). The indigenous ethnographic literature describes Koro attacks as ªunpredictable, but [they] usually appear after a shock which made the patient anxious or frightened, after performing strenuous manual labor or no labor at all, or as a result of immoderate nocturnal partyingº (Edwards, 1985, p. 171). The etiology is attributed to nonconformity with community norms in the cultural context of competitiveness. In Chinese societies, these fears are associated with beliefs about sexual activities. Suoyang appears as ªa product of intra- and inter-personal violations of medico-sexual regulationsº (Edwards, p. 183). Originally believed to be indigenous to Southeast Asia, Koro has also been detected in Africa, South Asia, and North America since the late 1970s (Chowdhury, 1996; Fishbain, Barsky, & Goldberg, 1989; Holden, 1987). Attempts have been made to fit Koro into the etic or externally defined psychiatric nosology, including acute hysterical panic reaction, anxiety states, depersonalization, conversion disorder, or atypical somatoform disorder (Simons & Hughes, 1985). Hughes (1985) justified the application of conventional diagnostic concepts to culture-bound phenomena in that they provided ªthe basis for more informed judgment regarding the ontological status and (eventually) etiology of the culture-bound syndromesº (p. 21). He went on to point out that a culturally informed use of the conventional diagnostic categories required knowing the culture of the person being evaluated to make a valid assessment of the behaviors, as well as being skeptical of the implicit values and assumptions underlying these categories. He warned that these categories should be tested against the observed primary behavior patterns and not be taken for granted. 10.02.5 ALTERNATIVE VIEWS ON CBS In a reversed direction in the search for culture-bound syndromes, some Western-based
Transformation of Neurasthenia syndromes such as anorexia nervosa, obesity, or even adolescence have been postulated as Western cases of CBS (Hill & Fortenberry, 1992; Prince, 1985; Ritenbaugh, 1982; Swartz, 1985). It was argued that anorexia nervosa fits the criteria of CBS, namely, that ªthe syndrome cannot be understood apart from its specific cultural or subcultural context,º that ªthe etiology summarizes and symbolizes core meanings and behavioral norms of that culture,º that ªdiagnosis relies on culture-specific technology as well as ideology,º and that ªsuccessful treatment is accomplished only by participants in that cultureº (Swartz, p. 725). Notwithstanding the need for empirical evidence to demonstrate that anorexia nervosa is indeed restricted to Western cultures, such an encapsulated direction to search for CBS misses the conceptual advances provided by CBS research in understanding the contextual nature of all forms of psychopathology. Prince and Tcheng-Laroche 1987) justifiably pointed out that Western diagnostic classification systems, including both ICD and DSM, are based on psychiatric conceptualization of Western medical science. Western medical models are based on universal theories of disease. CBS, on the other hand, do not fit well into these universal models. According to Prince and Tcheng-Laroche, the inherent emic± etic diversity and semantic specificities of the CBS hinder their incorporation into prototype approaches. Instead, they suggested that the descriptive classification consisting of inventories of signs and symptoms based on the meaning of illness both for individuals and for cultures rather than the etiological classification would be more practical for clinical use. ªCulture-boundº syndromes are now generally viewed as ªculture-relatedº syndromes (Mental Health Division, WHO, in press). While these syndromes have been found with differing incidence or prevalence rates across societies, they are considered to be more ªoverdeterminedº or ªrelatedº to certain cultures than they are ªboundº to those cultures. These culture-related syndromes serve to illustrate both the ªcore elementsº of a psychiatric disorder, as well as ªthose elements that can be modified by individual psychology, social context, and culture.º By examining how cultural contexts affect the conceptualization and manifestation of these syndromes, we not only expand our knowledge of aberrant phenomena unfamiliar to Western models of psychopathology, but also gain a better understanding of the cultural contexts of the conventional models of psychopathology themselves. For example, neurasthenia, once classified as a form of neurosis in Western psychiatric
nosology, has assumed the identity of a culturerelated syndrome in Chinese societies. The transplantation and transformation of neurasthenia as a disease entity outside Western societies provides an apt illustration of the pathoplasticity of culture-related syndromes. 10.02.6 TRANSFORMATION OF NEURASTHENIA Neurasthenia as a diagnostic category has a vicissitudinary career in Western psychiatry. Coined by the American neurologist George Beard (1869) to describe the exhaustion of the nervous system, it was found to be common among patients attending general practitioners in the early 1990s. It was, however, ignored as a diagnostic category until being classified among the neuroses in DSM-II (American Psychiatric Association, 1968) as a condition characterized by weakness, fatigue, lack of stamina, and exhaustion, as distinguished from hysterical neurosis, anxiety neurosis, and depressive neurosis. Literally, it connotes a condition of ªweak nervesº in which the sufferer is ªthought to be easily overwhelmed by the ordinary stresses of life, with resultant symptoms of somatization, anxiety, and depressionº (Mental Health Division, WHO, in press). It was subsequently dropped from the later revisions of the DSM but is still retained in ICD-10 (World Health Organization, 1992). Because of the somatic focus of the symptoms, it is common for patients complaining of neurasthenia to be diagnosed by physicians for some physical dysfunctions. The vagueness of the nosology, however, does not fit in with the increasing emphasis on objectivity and functionality in the American classification system. Despite its American origin, neurasthenia has become a nondisease in America (Kleinman, 1982). On the other hand, neurasthenia is now the most widely utilized psychiatric diagnosis in China (Mental Health Division, WHO, in press), and is a popular folk nomenclature in Chinese societies and Japan (Lin, 1989). Literally translated as shenjing shuairuo (weakness of the nervous system), this Western term was believed to be ªimportedº into China via Japan in the early 1990s (Lin). Popular books on Chinese folk medicine published in the past few decades have included neurasthenia as a condition that could benefit from traditional medical treatment, as if it were an indigenous form of disorder. The term is also commonly used among traditional doctors, physicians, psychiatrists, and lay persons to refer to a range of neurotic, psychosomatic, and psychotic
disorders (Cheung, 1989; Lee & Wong, 1995). Etiology and treatment of neurasthenia are also elaborated using lay concepts of mental health and Chinese folk medicine. Cheung (1989) suggested that the term's ambiguity as well as the overlap with other psychoneurotic disorders may be reasons leading to the rare use of this diagnosis in Western psychiatry . . . [but] due to its popularity among the lay public that new life has been injected into this imported medical term. Neurasthenia has been incorporated into Chinese folk medicine, and a set of beliefs has grown up around the original definitions of the disease outlined by George Beard in 1880. (pp. 235±236)
Cheung proposed two possible reasons to explain the popularity of neurasthenia as a diagnostic term among the Chinese. First, neurasthenia provides an acceptable paradigm of health and medicine. From its original Western definitions, neurasthenia has been ªindigenizedº and incorporated into the paradigm of traditional Chinese folk medicine which is based on a holistic concept of health and illness. Neurasthenia as a multidimensional illness provides a conceptualization in terms of both psychological and somatic symptoms and contexts. Among Chinese patients, somatic symptoms form an important part of the phenomenology of psychiatric illness. The illness experience of neurasthenia in the form of what Kleinman (1982) described as a ªsocially and culturally shaped type of somatizationº may be affected by the patientsº course of helpseeking. The somatic symptoms legitimize the sick role whereby the patient can get sympathy and attention from medical professionals and yet not be rejected or stigmatized. The second reason is the use of the term neurasthenia as a euphemism by psychiatrists and the lay public alike to destigmatize psychiatric disorders. As many as 30% of Chinese psychiatric patients describe themselves as suffering from neurasthenia when presenting themselves to psychiatric clinics (Kleinman, 1982; Wong & Chan, 1984). The distinction between neurasthenia and other forms of psychiatric disorders may stem from its detachment from the notion of insanity and the stigma of madness. Neurasthenia is attributed to somatic depletion, overwork, irregular lifestyle, and extended intellectual activities. It is an acceptable pretext for seeking help for a variety of conditions including psychological symptoms such as overworry, irritability, and memory difficulties, which when presented on their own accord, may be considered inappropriate or insufficient cause for medical consultation.
Even during the early days of the Great Leap Forward and the Cultural Revolution in the People's Republic of China between the 1950s and 1960s, the problem of neurasthenia as a form of mental illness was readily accepted, whereas other Western theories of psychopathology were deemed mentalistic and therefore inconsistent with the communist ideology. The concept of neurasthenia in the People's Republic of China was originally based on the Pavlovian theory of neurophysiology (Chin & Chin, 1969) during the era of Sino-Soviet cooperation when Soviet neuropsychology had a strong influence on Chinese psychology. Neurasthenia is attributed to ªtension in the higher nervous system in excess of its capacity, thus causing a weakening in the functioning capacity of the brain tissues and a lack of balance or confusion in nervous activityº (p. 70). Serious disturbances occur in the activity of the nervous system relating to work, study, society, and family. Its ªpolitically correctº etiology and manifestation allowed the disease entity to survive the Cultural Revolution during which other forms of Western diagnoses tended to be denied (Cheung, 1989). Cadres and professionals were spontaneous in their admission of the high prevalence of neurasthenia especially among their peers since they regarded neurasthenia as the outcome of overwork and not as a form of mental illness. The manifestation of neurasthenia as an illness has also undergone changes within Chinese societies. Earlier studies in China and Hong Kong (Kleinman, 1982; Wong & Chan, 1984) showed that the presenting complaints of neurasthenic patients were predominantly somatic, especially weakness, fatigue, insufficiency of qi (vital energy), poor appetite, backache, and weak limbs. A more recent study with young university students (Lee & Wong, 1995) found a more psychological construal of neurasthenia. Moreover, there is a disparity between lay and professional definitions of neurasthenia. According to Beard's (1869) or the ICD-10's (World Health Organization, 1992) definition, fatigue is considered a core symptom of neurasthenia but is infrequently reported in Taiwan or Hong Kong (Lee & Wong, 1995; Rin & Huang, 1989). The de-emphasis on fatigue distinguishes the Chinese experience from the Western condition of chronic fatigue syndrome which may be considered as a contemporary form of ªrevivedº neurasthenia in the West (Abbey & Garfinkel, 1991). Such a disparity points to the importance of examining crosscultural differences not only in disease entities, but also in the conceptualization of the illness experience.
Somatization as a Category Fallacy 10.02.7 ILLNESS EXPERIENCE Medical sociologists and cultural psychiatrists have distinguished between illness and disease (Mechanic, 1982). Kleinman (1988a) makes the distinction succinctly by referring to illness as ªthe patient's perception, experience, expression, and pattern of coping with symptomsº and to disease as ªthe way practitioners recast illness in terms of their theoretical models of pathologyº (p. 7). The illness experience is a culturally shaped phenomenon that is interpreted by the patients and their families resulting in a particular course of action. These interpretations are mediated by language, illness beliefs, personal significance of suffering, and learned illness behavior. The experiences of distress are multifaceted. The distressed persons choose their form of expression according to their own sensitivity to those facets that make sense to them or that conform to their understanding. Folk understanding of psychological distress seldom conforms to the professional classification of disorders, especially in cultures where formalized mental health services are not popular or are inaccessible. Thus, these expressions are necessarily selective, being bound by the personal and cultural repertoire of distress idioms. The repertoire of coping and illness behavior is similarly acquired in the sociocultural context. The illness experience encompasses not only the phenomenology of the individual which focuses on the intrapsychic dimension, but also on the interaction of the person with significant members and aspects of the environment. These social and cultural dimensions form an integral part of the dynamics involved in the process of illness. A psychiatric diagnosis, on the other hand, is a professional's interpretation of the person's experience which becomes formalized as signs of particular disease states in a static medical model. These diagnostic categories are often reified as real entities by the professionals who try to fit the reported experiences into one of the categories. Through exposure, patients learn to report what the professionals expect of them. However, when the diagnostic categories developed in one culture are projected onto patients in another culture, their validity needs to be established. Mental health professionals who are mostly trained in Western medical models have often imposed these categories in nonWestern cultures even when they lack folk coherence. Some of these categories may be more valid or relevant than others, whereas there is strong evidence that psychiatric diagnoses such as organic brain disorders and schizophrenia are valid worldwide (Kleinman,
1988a; World Health Organization, 1973, 1979), other diagnoses such as dysthymic disorder or anorexia nervosa are questioned as examples of ªcategory fallacyº which lack cross-cultural validity. When the culturally imposed categories are found to differ from the illness experience found within the culture, ethnocentric professionals tend to interpret the discrepancy as a problem of the individual or the culture, instead of questioning the relevance of the category itself. 10.02.8 SOMATIZATION AS A CATEGORY FALLACY The problem of category fallacy can be illustrated by the way in which mental health professionals from Western cultures initially interpreted the tendency among Chinese psychiatric patients to somatize their psychological distress. In the wake of early interest in cultural psychiatry, a number of studies on the patterns of symptom presentation among Chinese psychiatric patients noted that these patients tend to somatize their problems and delay psychiatric treatment (Kleinman, 1977; Lin, 1982; Lin, Tardiff, Donetz, & Goresky, 1978; Marsella, Kinzie, & Gorson, 1973; Tseng, 1975). Somatization has been emphasized as the cultural feature of neurotic disorders, especially depression, among the Chinese. Various aspects of the Chinese culture were then put forth to explain the somatization tendency (Cheung, 1982, 1985, 1995; Cheung & Lau, 1982). One group of cultural explanations attributes the somatization tendency to denial, suppression, or repression of emotions. The typical Chinese is described as being reserved in expressing feelings and prone to avoiding open display of emotions, especially negative ones. Another group of explanations argues that the use of concrete physical terms in expressing one's distress demonstrates that the Chinese language lacks an adequate vocabulary to express emotions explicitly. So physical metaphors or terms related to body organs are used to represent affective states. The third group of explanations is based on the assumption of mind±body dualism as the standard of epistemology, so that the lack of distinction between psychological and somatic systems among the Chinese was likened to the simple, undifferentiated, and concrete level of thinking among primitive cultures. These cultural assumptions have been challenged both on the grounds of cultural specificity as well as interpretation. It has been questioned whether somatization is indeed
specific to the Chinese as originally claimed. Even so, the explanations for this culturally related observation need further scrutiny. Cheung (1982, 1985) criticized these cultural attributions as post hoc explanations based on cultural generalizations without empirical verification. In an extensive review of the literature, Singer (1975) argued that in the first place, the phenomenon of somatization is not exclusive to Chinese patients, but is also commonly found among less educated and lower social-class patients in Western countries. Kleinman (1986) later reckoned that somatization is also very common in the West although the fact may be ignored or de-emphasized there. Cheng (1989) compared survey results on the symptomatology of minor psychiatric morbidity in Taiwan and in Britain and found the rates of somatic symptoms for both countries to be comparable. There is also evidence to show that although somatic complaints are the dominant features in Chinese patients' symptom presentation, psychological symptoms are by no means suppressed or repressed. Cheung, Lau, and Waldmann (1980±81) found that while depressed patients reported mostly somatic complaints to the medical doctor in general practice, they were very ready to admit to having a range of psychological and emotional symptoms when directly asked by the practitioner. Subsequent studies with psychiatric patients attending psychiatric services for the first time also revealed that psychological symptoms were frequently reported along with somatic complaints (Cheung, Lau, & Wong, 1984). Studies with the general population and with university students in Hong Kong also confirm that psychological problems were commonly reported (Cheung, 1982; Cheung, Lee, & Chan, 1983). However, psychological problems may not be readily reported to the medical practitioner. Instead, the Chinese would turn to their friends and family members for help if they perceive their problems to be psychological in nature. One of the problems of these early discussions on the somatization tendency suffered from variations in the definitions of the term used. Somatization may be referred to as a psychiatric disorder, various patterns of illness behavior, forms of help-seeking related to bodily symptoms, or a combination of these concepts. Based on the formistic and mechanistic model of biomedicine (Schwartz, 1982), somatic presentation of distress is assumed to be due to an underlying psychological problem masked by the somatic presentation of symptoms often equated with somatization. Somatization, thus, is presumed to be pathological with maladaptive consequences. In the formistic world view, a
person is categorized as either sick or well. In the mechanistic world view, a specific cause is linked to a single effect. These approaches ignore the contextual nature of illness involving both the organism and the environment, in which there may be interaction among multiple causes in the organism and the environment. The focus on somatization as a pathological disorder misses the opportunity to understand in a systemic way the various patterns of illness behavior among Chinese patients, including their subjective experience, problem presentation, communication, and form of help-seeking. 10.02.9 SOMATIZATION AS ILLNESS EXPERIENCE While studies of Chinese patients in Chinese societies have consistently found that somatic complaints are the dominant features in their descriptions of discomfort, it is also noted that psychological symptoms are readily reported by both clinical and nonclinical samples, especially if directly asked (Cheng, 1988, 1995; Cheung, 1982, 1987; Cheung et al., 1980±81, 1984). An attempt to understand the phenomenon of somatization among the Chinese should take into account the phenomenology of discomfort and suffering, the process of communication, ways of coping and help-seeking, and the patient±doctor relationship. In his recent works, Kleinman (1986, 1988b) has provided an insightful perspective to understand somatization as human suffering contextualized in the personal, interpersonal, and cultural meanings of illness. He proposed that a ªdialectical relationship exists between symptoms and societyº (p. 2). The examination of how social factors produce the connection between neurasthenia-depression and pain which may be perceived as the cause of disease provides the illustration as to the way ªculture shapes the strategic interpretation and negotiated experience of illnessº (p. 2). As an idiom of distress, somatization is an illustration of the ethnography of the suffering experience. While the narrative of human suffering is not confined to bodily sensations, this mode of expression is highlighted in the medical context especially in non-Western cultures. The meaning of bodily symptoms for the Chinese has been examined in terms of the Chinese language and traditional Chinese medical practice (Cheng, 1989; Ots, 1990; Tung, 1994). In traditional Chinese medicine, emotional problems are associated with different body organs. Dysharmonic emotions are pathogenic etiological factors which produce somatic dysfunctions, which, in turn, should be treated
Somatization as Illness Experience by harmonizing bodily functions (Ots, 1990). Tung also illustrated that the Chinese use bodyrelated verbal expressions in an all-embracing fashion to express personal and social aspects of human concerns. Body-related words form expressions that are idioms of human conditions. These forms of expression are indigenous and often expressed in local dialects that escape the attention of Western-trained psychiatrists (Cheng, 1989). On the other hand, psychiatrists who try to fit the patientsº expressions into their professional taxonomy would miss the rich information that accompanies the patients' expressions. As illustrated earlier, the use of the term neurasthenia provides culturally legitimized somatic idioms to sidestep the Western framework of mental diseases which are highly stigmatized. However, somatic idioms are more than just euphemistic substitutes for Western diagnostic labels. They encompass schema to make sense of life problems and to direct courses of action. Illness meanings are physiological as well as social. According to Kleinman (1986), ªthe lived experience of social reality mediated by the body . . . is the symbolic bridge, the socio-somatic reticulum that ties failure to headaches, anger to dizziness, loss and demoralization to fatigueº (p. 146). Zheng, Xu, and Shen 1986) analyzed the styles of verbal expression of emotional and physical experiences of depressed patients and normal controls in China. Both emotional and physical expressions are used as narratives of human suffering, depending on the nature of the experience. For example, a purely psychological verbal style with words such as ªunhappyº and ªworriedº was used to describe abstract emotional states such as indecisiveness, self-pity, guilt, or helplessness. Purely somatic expressions such as ªheart beatingº would be used for the concrete emotional state of fear. The neutral mode including both psychological and somatic features (e.g., ªuncomfortable inside the heartº or ªcannot use my brainº) was used to express anxiety. For depression, both the somatic and the neutral modes were frequently used. In the expression of suicidal ideation, however, the person was often unable or unwilling to choose an expression, which the authors labeled as the deficient expressive style. The somatic style in expressing emotions among the Chinese patients in this study, however, was not related to symptom manifestation as reported on a symptom checklist. Cheung (1995) pointed out that ªsomatization as an idiom of distress is contextualized in a process of communicationº (p. 163). This process includes both the discourse between Chinese patients and doctors as well as other
interpersonal interactions. Cheung and Lau (1982) showed that situational variations elicited different expectations and behaviors from patients who behave according to what they believe is expected of them in the situation. When Chinese psychiatric patients perceived their consultation to be medical in nature, such as attending a psychiatric clinic, they reported their physical as well as psychological symptoms. On the other hand, when they perceived their consultation to be related to a judicial nature, such as being referred to the psychiatrist at the correctional services by the judge, prisoners would recount the events leading to their arrest instead of presenting their symptoms. Studies based on experiences of psychiatric patients may be biased by the self-selection of people who have chosen to consult psychiatric services, leading to the conclusion that Chinese patients tend to somatize their psychological problems. To understand the illness experience of the Chinese people, their coping approaches and the course of help-seeking prior to the psychological consultation need to be included. Studies of the patterns of help-seeking among different ethnic groups have shown that nonCaucasian patients generally delay seeking psychiatric treatment and approach other indigenous resources instead, at least initially (Cheung, 1987; Cheung et al., 1984; Lin et al., 1978). In Hong Kong, psychiatric consultation may be delayed by as long as 30 years after the initial onset of symptoms if they were perceived to be purely psychological in nature (Cheung, 1987). The Chinese prefer to endure their suffering, rely on themselves, or seek help from their friends or family for psychological problems. They would be more likely to seek medical attention for physical symptoms which would be perceived as illness needing medical attention (Cheung et al., 1983, 1984). The first medical consultation is predominantly with the general practitioner. Owing to the unfamiliarity with mental health services, the patients generally do not make a distinction among medical and mental health specialties which are more demarcations defined by the professionals. The dominant role played by the general practitioner in directing psychiatric patients to mental health services has been highlighted by Goldberg and Huxley (1980). They showed that even in developed countries, only a small minority of psychologically disturbed persons reached psychiatric services. Many psychiatric illnesses passed unrecognized by general practitioners who prolonged medical attention on the physical complaints. Cheung (1991) likened the function of the general practitioner to that of ªa roundabout where routes may converge and be redirected. When most travelers were
unfamiliar with the direct route to recovery, the roundabout was the hub they would return to before embarking on alternative treatment pathsº (p. 67). The patients' initial conceptualization of the causes and severity of their illness would direct their coping and help-seeking behavior. They would only seek medical attention if the problem is perceived to be somatic and serious. Once they embark on the medical course, the experience of medical consultation, in turn, would have shaped the patients' interpretation of their suffering. Patients who finally arrived at the psychiatric clinic are likely to have traveled through detours of medical consultation which focus their attention on their somatic complaints. They would be likely to present to the mental health professional, to them another medical doctor, that which they deemed as expected and appropriate (Cheung, 1987). The reconceptualization of somatization in terms of the individual's culturally embedded illness experience and narratives of suffering advances the theoretical understanding from that of a category fallacy to a useful framework to interpret the phenomena. Psychopathology is after all a scientific attempt to organize and explain the observed phenomena systematically. Recognition of cross-cultural diversities poses new challenges to the traditional ethnocentric ideologies that have encapsulated Western theories of psychopathology and approaches to clinical psychology. 10.02.10 CULTURE AND PSYCHOPATHOLOGY The role of culture in counseling and psychotherapy has received more attention from psychologists than the role of culture in the area of psychopathology (Leong, 1986; Pedersen, 1983, 1987, 1990, 1991; Pederson & Marsella, 1982; Pedersen, Draguns, Lonner, & Trimble, 1981; Sue, D. W., 1977, 1978, 1989, 1990, 1991; Sue, Arredondo, & McDavis, 1992; Sue & Kirk, 1975; Sue & Sue, 1977, 1990; Sue & Zane, 1987; Vontress, 1974). Culture has gained the status of a generic theory to explain counseling relationships in general, and not just for understanding exotic people. Pedersen (1991) proposed multiculturalism as a ªfourth forceº in counseling, complementary to psychodynamic, behavioral, and humanistic explanations of human behavior. The multicultural perspective ªcombines the extremes of universalism and relativism by explaining behavior both in terms of those culturally learned perspectives that are unique to a particular culture and in the search for common-ground universals that are shared
across culturesº (p. 6). While acknowledging the pervasive nature of multiculturalism in complex modern society, Pedersen's theory is focused only on counseling approaches. A few attempts have been made to apply specific psychological theories to mental health issues among ethnic subgroups in the USA. For example, S. Sue (1977) and Zane, Sue, Hu, and Kwon (1991) examined cultural differences in learned helplessness and assertion among Asian-Americans using a social learning analysis. Specific interest has been directed to the identity development of ethnic minority groups and how minority identity development may affect mental health problems (Sue, 1989). These efforts result in better understanding of the cultural diversities and cultural differences among specific ethnic groups. There is much less written on the general role of culture in psychopathology or abnormal psychology. 10.02.10.1 Role of Culture in Psychopathology Tseng and McDermott (1981) gave a more comprehensive introduction to the role of culture in psychiatry. Culture affects psychopathology in many ways, including producing stress, creating specific problems, predisposing vulnerability, and contributing to the choice of psychopathology (pp. 14±24). 10.02.10.1.1 Culture-produced stress Stress may be created by culturally formed anxiety or culturally demanding performance. Cultural attitudes and beliefs prescribe expectations and standards which if not met would produce mental and emotional stresses. Many societies have established taboos, rules, or rites which, if contravened, would create anxieties. Individuals living in cultures that believe spells can cause death would become ill or even die if they think that they are under a spell. Similarly, cultural demands of individuals cause stress to those who are unable to meet those demands. For example, many cultures demand that a woman produce a male child. The woman would be blamed and would feel guilty if she continued to produce only girls. She would face a loss of status or the threat of replacement by another woman. These demands produce fear, anxiety, and shame. 10.02.10.1.2 Culture-related problems Specific problems may be created by a culturally determined limitation in behavior range, cultural changes, changing roles, and loss of source of support, as well as sociocultural discrimination. Within a cultural setting where
Cross-cultural Psychopathology rules are excessive, but the behavior range allowed is very limited, individuals who are not prepared for these restrictions would encounter problems. Similarly, rapid cultural changes may result in a confused value system to individuals who are used to a stable and traditional culture. Changing roles for women, for example, while improving women's social status and sense of independence, may also render them more vulnerable to loneliness and depression when the protection and support women previously obtained from their families have diminished. Sociocultural groups who face discrimination within a society suffer scorn, isolation, and disadvantage, resulting in stress and deficits. 10.02.10.1.3 Culture-inherited vulnerability Vulnerability to stress may be predisposed by culturally prescribed child-rearing practices which influence the child's personality. In some cultures, parents emphasize independence and early decision making. This push toward independence may put undue pressure on the young person who needs a longer period of dependency. In other cultures, intimate dependency on mothers is extended for a much longer time. This dependency is extended into adult relationships as well which may lead to later problems in socialization with others. 10.02.10.1.4 Cultural contribution to choice of psychopathology Culture plays a part in how its vulnerabilities find expression by influencing model solutions to problems that may themselves be pathological. The form of psychopathology found in a culture tends to be linked with the stresses within that culture. For example, excessive selfdepreciation, a result of compliance to strong external control, may become a cause for depression. There is also a suggestion that low social cohesion in a community is related to the frequency of depression. 10.02.10.2 Cultural Explanations Once psychological disorders are detected, culture also plays a role in labeling these disorders based on its concepts of mental illness. These labels describe the observed behavior, attribute causes, provide explanations, and convey social acceptance or rejection of the afflicted. Explanations of the nature and cause of mentally disturbed behaviors are grouped into four categories by Tseng and McDermott (1981, pp. 29±33): (i) Supernatural explanations. The disturbance is explained as resulting from spirit
possession, soul loss, divine wrath, sorcery, or violation of taboo. (ii) Natural explanations. Illness, misfortune, and unhappiness are related to the underlying principles of the universe which govern all nature. Disharmony of the natural elements within the human body, incompatibility with natural principles in the environment, and noxious factors in the environment upset the natural principles and cause physical and mental disturbance. (iii) Physical-medical explanations. The reasons for illness are viewed as physical or physiological originating from the individual. The causes may be physical-physiognomy problems (such as facial features, body build), physiological imbalance or insufficiency (such as badly balanced diet, excessive sexual activity), or disease. (iv) Sociopsychological explanations. Mental disorder is seen as a psychological reaction to the stress of internal or external maladjustment. Tseng and McDermott, however, did not make any distinction between the professional or ªauthoritativeº explanations of abnormal behaviors and the folk conceptualizations and attributions of the experience of distress in these categories. In non-Western cultures that have not adopted Western models of medicine and psychology, explanatory models are often based on folk concepts. In cross-cultural comparisons of explanatory models, there may be biases when Western professional models of psychiatric classification are compared with local folk concepts of distress. 10.02.11 CROSS-CULTURAL PSYCHOPATHOLOGY 10.02.11.1 Universalist vs. Relativist Approaches Cross-cultural psychopathology is premised on two competing orientations. The biological approach assumes that the cultural invariance of mental disorders, that is, the same disorders are prevalent in all cultures (Fernando, 1988, p. 60). In this approach, the ªuniversalistº would use the psychiatric classification system developed in the West as a basis of identifying disorders in other parts of the world. The social-anthropological approach, on the other hand, emphasizes the cultural relativity of psychopathology, with each culture having its own disorders. Culture plays an important role in determining the behavior, thinking, and emotions of the individuals resulting in different forms of mental disorders. The ªrelativistº looks at illness as a part of the total cultural context deriving its meaning from the specific culture.
The two orientations have led to different research directions in cross-cultural psychopathology. The universalist or etic orientation has focused on cross-cultural comparisons in the rates of major psychiatric disorders, based on classification systems developed in the West. These studies have made use of population surveys with results showing a range of rates of major mental disorders in different countries (cf. Kleinman, 1988a, pp. 34±41, or Draguns, 1985, 1986, 1989 for a review of the findings). However, it has been noted that a narrower range of rates is found when diagnostic criteria are standardized and more homogenous samples of cases are used. International studies have been carried out to compare the prevalence and symptomatology of common psychiatric diseases such as schizophrenia (Sartorius et al., 1986; World Health Organization, 1973, 1979) or depression (Jablensky, Sartorius, Gulbinat, & Ernberg, 1981; World Health Organization, 1983). These studies identified core syndromes of the disorders. For example, across the nine research sites which represented both developed and developing countries, the core syndrome of schizophrenia included ªrestricted affect, poor insight, thinking aloud, poor rapport, incoherent speech, unrealistic information, and bizarre and/or nihilistic delusionsº (Draguns, 1989, p. 242). The more modest project on depression involving four countries (World Health Organization, 1983) also identified a small number of symptoms such as vegetative symptoms which were present in most of the countries. On the other hand, the experience of guilt is much less universal in the symptomatology of depression. Similar to psychiatric epidemiological studies comparing specific disorders, cross-cultural assessment studies have applied the major assessment instruments developed in the West to other cultures and identified cross-cultural similarities and differences. For example, one personality test that has been translated and tried out in the most number of countries is the Minnesota Multiphasic Personality Inventory (MMPI; Butcher & Clark, 1979; Butcher & Pancheri, 1976; Butcher & Spielberger; 1985, Hathaway & McKinley, 1967). These studies confirmed the clinical utility of the MMPI in other countries although cultural differences are identified and cultural adaptations may have to be made (e.g., Cheung & Song, 1989; Cheung, Song, & Butcher, 1991; Cheung, Song, & Zhang, 1996; Cheung, Zhao, & Wu, 1992). The relativist or emic orientation has focused on culture-specific phenomena, such as culturebound syndromes discussed in an earlier section. Research based on in-depth studies
within a single culture provides a rich source of information about the phenomena. However, as pointed out earlier, attributions to cultural phenomena were often based on post hoc and generalized assumptions about the culture involved without elaboration on the functional relationship between cultural processes and psychopathology. The shortcoming of the universalist approach lies in its ethnocentricism which assumes that the Western culture is more developed and superior. Cross-cultural differences are interpreted as a reflection of cultural underdevelopment, as in the early days of psychiatry when non-Western cultures were often referred to as ªprimitiveº and ªsavagesº (Fernando, 1988, p. 60). It is assumed that diagnostic categories developed in a Western cultural setting are applicable universally. Standardized research methods are developed to establish reliable diagnoses across cultures in Western terms. However, the crosscultural validity of the disease as an illness or a phenomenon in those other cultures may not be established (Fernando). Similarly, the universalist approach to assessment may lead to misleading clinical interpretations. For example, in the application of the MMPI to the Chinese people, several clinical scales, including the Depression scale and the Schizophrenia scale, were found to be consistently elevated even among normal samples when the American norms were used (Cheung, 1995; Cheung, Song, & Zhang, 1996). Both in Hong Kong and the People's Republic of China, the mean T-scores for normal adults on these two scales usually approach the clinical cut-off point used in the USA, although the mean scores for clinical samples are even higher. If cultural universality is assumed, there would be a danger of overinterpreting clinical pathology in the normal Chinese population. The relativist approach, on the other hand, may not get beyond describing culture-bound syndromes and constructing intracultural explanations, thereby not contributing much to cross-cultural psychopathology. By assuming cultural specificity, no comparison can be made between cultural units. Without a cross-cultural framework, the notion of culture, however, becomes irrelevant. The determination of the cultural unit itself is also a subject of controversy. Cultural groups are usually operationally defined in terms of race, ethnicity, geographic location, or religion, assuming cultural similarity among members of the same groups. Subcultural groups further complicate the assumption of cultural similarity. An alternative approach to get out of the impasse created by these two extreme positions is to reconstruct cross-cultural psychopathology
Cross-cultural Psychopathology from the basic units of clinical psychology: observation of the phenomenological experience of individuals from their cultural contexts, description of these expressions and manifestations on the basis of the individuals' perspectives, prescription of labels which are culturally relevant or meaningful based on indigenous and cross-cultural studies, selection of appropriate treatment alternatives, and prediction of outcome. While the world is becoming more multicultural, this contextualized analysis may become a ªuniversalº approach. 10.02.11.2 Recent Research on Cross-cultural Psychopathology Recent research on cross-cultural differences in psychopathology has attempted to explain the similarities and differences in terms of the cultural contexts. For example, while a pancultural nucleus of symptoms was found for schizophrenia and depression, a variety of cultural transformations was also identified. Draguns (1989) proposed a range of possible relations between culture and the manifestations of the disorders. These include: (i) magnification or exaggerationÐa culturally characteristic behavior being caricatured and reduced to absurdity; (ii) violation of cultural normsÐdoing what is not culturally permissible; (iii) cultural differences in values affecting the characteristic modes of expressing psychopathologyÐsymptom choice and expression being conceptualized as social transactions. However, there are few studies that examine the functional relationship between cultural characteristics and cross-cultural differences in psychopathology. Draguns (1989) attempted to apply Hofstede's (1980) worldwide study of work-related values to manifestations of abnormal behavior across cultures. In Hofstede's original study, which involved employees from over 40 nationalities, four cultural dimensions were found to be capable of accounting for most of the cultural differences. These four dimensions were individualism/collectivism, uncertainty avoidance, power distance, and masculinity/femininity. Hofstede (1983) had linked the dimension of individualism/collectivism to the distinction made earlier by Benedict (1946) between ªguiltº (individualist) and ªshameº (collectivist) cultures. However, the relationship between this value dimension and psychopathology involves a more subtle process. Rather than assuming that patients from some Asian cultures do not experience guilt, cultural differences may be found more in the way that guilt is expressed. In individualistic
cultures, guilt may be expressed in absolute and abstract terms involving self-accusation and condemnation. In collectivistic cultures, guilt may be expressed in more concrete and interpersonal modes. To date, there are few studies on crosscultural psychopathology using the other three dimensions from Hofstede's study. Draguns (1989) further noted that psychopathology varied across cultures even when there was no substantial difference on Hofstede's four dimensions. He pointed to the need for more multicultural studies involving both normal and abnormal samples in order to formulate the functional relationship between cultural characteristics and psychopathology. The series of studies on somatization among the Chinese described in earlier sections also illustrates how cross-cultural differences in the expression of symptomatology could be understood in terms of the culturally relevant cognitive schema and interpersonal contexts. Through these cultural studies, important dimensions that have not been examined in North American and Western European theories could be incorporated to increase the cultural sensitivity of these theories. This cultural sensitivity is becoming more important not only because ethnic and cultural pluralism is becoming more prevalent in many societies. What are thought to be indigenous categories can in fact be extended to explain the complexity of human personality and psychopathology within and across cultures. One example of this combined emic-etic approach is the development of the Chinese Personality Assessment Inventory (CPAI; Cheung, Leung, Fan, et al., 1996) which integrated Western methods of personality assessment with folk concepts of personality in the Chinese culture. In addition to etic personality constructs, emic constructs which were not covered in translated personality inventories were included in the CPAI. Scales were developed for personality characteristics such as harmony, relationship orientation, face, modernization, and thrift, which are salient constructs for person descriptions among the Chinese. These scales were loaded on a factor labeled Chinese Tradition. The Chinese Tradition factor was found to be a relevant predictor of mental health measures especially for Chinese males. It enhanced life satisfaction and prevented the acting out of antisocial behavior particularly when the stress level was high (Cheung & Gan, 1996). The Chinese Tradition factor was also found to be culturally distinct from the five-factor structure of personality which is currently accepted as a universal model of personality (Cheung, Leung,
Law, & Zhang, 1996). These emic constructs may introduce new dimensions of the personality structure to Western models of personality and psychopathology. 10.02.11.3 Future Directions As Lewis-Fernandez and Kleinman (1994) concluded, ªwe might very well come across local indigenous categories, such as face and favor, that can be used to reformulate our leading models of personality formation and their relationship to psychopathologyº (p. 70). The study of cross-cultural psychopathology is expanding beyond the exotic frontier into the mainstream of psychology. Research in cross-cultural psychopathology, as in other fields of cross-cultural psychology, is incorporating the combined emic±etic approach. There is an increasing recognition that ªculture-boundº syndromes may not be unique to a specific culture. Instead, culture-related phenomena such as neurasthenia and somatization help to illustrate the dynamics of cultural forces affecting illness behavior in different societies. Psychopathology is manifested in a cultural context, and should be interpreted via a contextualized analysis. Cross-cultural psychopathology research can help to identify convergent and divergent dimensions in explaining normal and abnormal behaviors across cultures, enhancing our awareness as researchers and practitioners of the cultural context of our analyses. As our global community becomes more multicultural, the dialectic process of synthesizing new observations and constructs from other cultural contexts poses a challenge to clinical psychologists to recognize culture as an integral part of their theoretical framework. 10.02.12 SUMMARY Clinical psychology has suffered from an ethnocentric approach blinded by culturebound assumptions. Early research in crosscultural psychopathology was borrowed from cultural psychiatry which has focused its interest on the identification of culture-bound syndromes. In this chapter, an alternative approach to study the interplay of cultural dynamics in the manifestation of these ªculture-bound syndromesº is illustrated through the discussion of Koro, neurasthenia, and somatization. The transplantation and transformation of neurasthenia from a Western diagnostic category to a culture-related syndrome in Chinese societies demonstrate the fluidity of diagnostic labels in incorporating cultural meanings. By reexamin-
ing somatization as an illness experience and narratives of suffering, a more useful framework for studying the relationship between culture and psychopathology is also identified. Culture affects psychopathology by producing stress, creating specific problems, predisposing vulnerability, and selecting the form of psychopathology. It also provides folk explanations of the nature and cause of aberrant behavior. Earlier research methods have adopted either the emic or the etic approach. The emic approach focused on the relativistic aspects of culture such as culture-bound syndromes. The etic approach, on the other hand, assumes that Western-based constructs are applicable in other cultures and attempts to replicate these constructs in cross-cultural studies. Recent studies attempt to incorporate the emic±etic approaches. For example, the development of an emic±etic instrument such as the CPAI has introduced new dimensions of the personality structure to Western models of psychopathology. Other work such as that by Draguns (1989) are uses multicultural studies to formulate functional relationships between cultural characteristics and psychopathology. These new developments have pointed to the importance of the interpersonal dimension in psychopathology which has often been neglected in Western models of psychopathology. Future directions for study in cross-cultural psychopathology need to bring culture from its marginal status into the mainstream of clinical psychology. 10.02.13 REFERENCES Abbey, S. E., & Garfinkel, P. E. (1991). Neurasthenia and chronic fatigue syndrome: The role of culture in the making of a diagnosis. American Journal of Psychiatry, 148, 1638±1646. American Psychiatric Association (1968). Diagnostic and statistical manual of disorders (2nd ed.). Washington, DC: Author. American Psychiatric Association (1980). Diagnostic and statistical manual of mental disorders (3rd ed.). Washington, DC: Author. American Psychiatric Association (1994) Diagnostic and statistical manual of mental disorders (4th ed.). Washington, DC: Author. Bartholomew, R. E. (1994). The social psychology of ªepidemicº koro. International Journal of Social Psychiatry, 40, 46±60. Beard, G. M. (1869). Neurasthenia, or nervous exhaustion. Boston Medical and Surgical Journal, 3, 217±221. Benedict, R. (1946). The chrysanthemum and the sword. Boston: Houghton Mifflin. Butcher, J. N., & Clark, L. A. (1979). Recent trends in cross-cultural MMPI research and application. In J. N. Butcher (Ed.), New developments in the use of the MMPI (pp. 69±111). Minneapolis, MN: University of Minnesota Press. Butcher, J. N., & Pancheri, P. (1976). A handbook of crossnational MMPI research. Minneapolis, MN: University of Minnesota Press.
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Prince, R. (1985). The concept of culture-bound syndromes: Anorexia nervosa and brain-fag. Social Science and Medicine, 21, 197±203. Prince, R., & Tcheng-Laroche, F. (1987). Culture-bound syndromes and international disease classification. Culture, Medicine, and Psychiatry, 11, 3±20. Rin, H., & Huang, M. G. (1989). Neurasthenia as nosological dilemma. Culture, Medicine, and Psychiatry, 13, 215±226. Ritenbaugh, C. (1982). Obesity as a culture-bound syndrome. Culture, Medicine, and Psychiatry, 6, 347±361. Routh, D. K. (1994). Clinical psychology since 1917: Science, practice, and organization. New York: Plenum. Rubel, A. J., O'Nell, C. W., & Collado, R. (1985). The folk illness called Susto. In R. C. Simons & C. C. Hughes (Eds.), The culture-bound syndromes: Folk illnesses of psychiatric and anthropological interest (pp. 33±350). Dordrecht, The Netherlands: Reidel. Sartorius, N., Jablensky, A., Korten, A., Ernberg, G., Anker, M., Cooper, J. E., & Day, R. (1986). Early manifestation and first contact incidence of schizophrenia: A preliminary report on the initial evaluation phase of the WHO Collaborative Study on Determinants of Outcome of Severe Mental Disorders. Psychological Medicine, 16, 909±928. Schwartz, G. E. (1982). Testing the biopsychosocial model: The ultimate challenge facing behavioral medicine? Journal of Consulting and Clinical Psychology, 50, 1040±1053. Simons, R. C. (1985). The resolution of the Latah paradox. In R. C. Simons & C. C. Hughes (Eds.), The culturebound syndromes: Folk illnesses of psychiatric and anthropological interest (pp. 43±62). Dordrecht, The Netherlands: Reidel. Simons, R. C. & Hughes, C. C. (Eds.) (1985). The culturebound syndromes: Folk illnesses of psychiatric and anthropological interest. Dordrecht, The Netherlands: Reidel. Singer, K. (1975). Depressive disorders from a transcultural perspective. Social Science and Medicine, 9, 289±301. Sue, D. W. (1977). Counseling the culturally different: A conceptual analysis. Personnel and Guidance Journal, 55, 422±425. Sue, D. W. (1978). Eliminating cultural oppression in counseling: Toward a general theory. Journal of Counseling Psychology, 25, 419±428. Sue, D. W. (1989). Racial/cultural identity development among Asian-Americans: Counseling theory implications. Asian-American Psychological Association Journal, 13, 80±86. Sue, D. W. (1990). Culture-specific strategies in counseling: A conceptual framework. Professional Psychology: Research and Practice, 21, 424±433. Sue, D. W. (1991). A model for cultural diversity training. Journal of Counseling and Development, 70, 99±105. Sue, D. W., Arredondo, P., & McDavis, R. J. (1992). Multicultural counseling competencies and standards: A call to the profession. Journal of Multicultural Counseling and Development, 20, 64±88. Sue, D. W., & Kirk, B. A. (1975). Asian-Americans: Use of counseling and psychiatric services on a college campus. Journal of Counseling Psychology, 22, 84±86. Sue, D. W., & Sue, D. (1977). Barriers to effective crosscultural counseling. Journal of Counseling Psychology, 24, 420±429. Sue, D. W., & Sue, D. (1990). Counseling the culturally different: Theory and practice (2nd ed.). New York: Wiley. Sue, S. (1977). Psychological theory and implications for Asian Americans. Personnel and Guidance Journal, 55, 381±389. Sue, S., & Zane, N. (1987). The role of culture and cultural techniques in psychotherapy: A critique and reformula-
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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
10.03.2 THE CONTROVERSY OVER BIAS IN PSYCHOLOGICAL TESTING: WHAT IT IS AND WHAT IT IS NOT
10.03.3 THE NATURE OF PSYCHOLOGICAL TESTING ADDS TO THE CONTROVERSY
10.03.4 WHAT ARE POSSIBLE SOURCES OF BIAS?
10.03.5 MEAN SCORE DIFFERENCES AS TEST BIAS
10.03.5.1 Culture-free Tests, Culture Loading, and Culture Bias 10.03.5.2 The Question of Labeling Effects
10.03.6 THE PROBLEM OF DEFINITION
10.03.7 RESEARCH STRATEGIES AND RESULTS
10.03.7.1 Bias in Content Validity 10.03.7.2 Bias in Construct Validity 10.03.7.3 Bias in Predictive or Criterion-related Validity
10.03.8 CROSS-CULTURAL TESTING WHEN TRANSLATION IS REQUIRED
10.03.9 SUMMARY AND FUTURE DIRECTIONS
have not been exposed to the cultural and environmental circumstances and values of the so-called White middle class. Intertwined within the general issue of bias in tests has been the more specific question of whether intelligence tests should be used for educational purposes. Although scientific and societal discussion pertaining to differences among groups on measures of cognitive or intellectual functioning in no way fully encompasses the broader topic of bias in mental measurement, there is little doubt that the so-called ªIQ controversyº has received the lion's share of public scrutiny over the years. It has been the subject of numerous publications in the more popular press (see Gould, 1981;
The issues of bias in psychological testing have been a source of intense and recurring social controversy throughout the history of mental measurement. In England, the issue was raised by Burt (1921) early in the twentieth century. The first investigations into cultural bias, however, can be traced to Binet, originating around 1910 in France (Binet & Simon, 1916) and to Stern (1914) shortly therafter. In the USA, discussions pertaining to test bias are frequently accompanied by emotionally laden polemics decrying the use of mental tests with any minority group member, since ethnic minorities 53
Cultural Bias in Testing of Intelligence and Personality
Herrnstein & Murray, 1994; or Jensen, 1980, chap. 1), and court actions and legislation have addressed the use of IQ tests within schools and industry. From Binet to Jensen, many professionals have addressed the problem, with varying and inconsistent outcomes. Unlike the pervasive and polemical nature±nuture argument, the bias issue was until the 1970s largely restricted to the professional literature, except for a few early discussions in the popular press (e.g., Freeman, 1923; Lippmann, 1923a, 1923b). Of some interest is the fact that one of the psychologists who initially raised the question was the thenyoung Cyril Burt (1921), who even in the 1920s was concerned about the extent to which environmental and motivational factors affected performance on intelligence tests. Within the last 30 years, however, the questions of cultural test bias have burst forth as major contemporary problems far beyond the bounds of scholarly academic debate in psychology. The debate over bias has raged in both the professional and the popular press for multiple decades (e.g., Fine, 1975). Entangled in the larger issues of individual liberties, civil rights, and social justice, the bias issue has become a focal point for psychologists, sociologists, politicians, and the public. Increasingly, the issues have become political and legal ones, as reflected in numerous court cases and passage in the state of New York and consideration elsewhere of what is popularly known as ªtruth-in-testingº legislation. The magnitudeÐand the uncertaintyÐof the controversy and its outcome is shown in two highly publicized US Federal district court cases. The judiciary's answer to the question ªAre the tests used for pupil assignment to classes for the educably mentally retarded biased against cultural and ethnic minorities?º initially was ªYesº in California (Larry P. et al. v. Wilson Riles et al., 1979) and ªNoº in Illinois (PASE v. Hannon et al., 1980), although the Larry P. finding has now been overturned, giving a consistent nature to court findings in the USA. Unfortunately, we are all prisoners of our language. The word bias has several meanings, not all of which are kept distinct. In relation to the present issue, bias as ªpartiality towards a point of view or prejudiceº and bias as ªa statistical term referring to a constant error of a measure in one specific direction as opposed to random errorº frequently become coalesced. If the latter meaning did not drag along the excess baggage of the former, the issue of bias in mental testing would be far less controversial and emotional than it is. However, as indicated in the Oxford English Dictionary, bias as partiality or prejudice can be traced at least to the sixteenth century and clearly antedates the statistical
meaning. Nevertheless, the discussion of bias in psychological testing as a scientific issue should concern only the statistical meaning, whether or not there is systematic error in the measurement of a psychological attribute as a function of membership in one or another cultural or racial subgroup (Reynolds, 1982b). This definition, defined more technically as required later, will be followed throughout this chapter. 10.03.2 THE CONTROVERSY OVER BIAS IN PSYCHOLOGICAL TESTING: WHAT IT IS AND WHAT IT IS NOT Systematic group differences on standardized intelligence and aptitude tests occur as a function of socioeconomic level, race or ethnic background, and other demographic variables throughout the various countries of the world. Black±White differences on IQ measures in the USA have received extensive investigation since the 1930s. The preponderance of these studies have been reviewed by Shuey (1966), Tyler (1965), Jensen (1980), and Willerman (1979). Results have not changed fundamentally in the last century. Although the results occasionally differ slightly, depending on the age groups under consideration, random samples of Blacks and Whites in the USA show a mean score difference of about one standard deviation, with the mean score of the Whites consistently exceeding that of the Black groups. The differences have persisted at relatively constant levels for quite some time and under a variety of methods of investigation. The exception to this is the reduction of the Black±White IQ difference on the Kaufman Assessment Battery for Children (K-ABC; Kaufman & Kaufman, 1983) to about 0.5 standard deviations on the intelligence portion of the scale, a controversial and poorly understood finding (see Kamphaus & Reynolds, 1987, for a discussion). These findings are consistent only for the US Black population, however, and other, quite diverse findings appear for African and other Black populations (e.g., see Jensen, 1980). When a number of demographic variables are taken into account (most notably socioeconomic status), the size of the mean Black±White difference in the USA reduces to 0.5±0.7 standard deviations (e.g. Jensen, 1980; Kaufman, 1973; Kaufman & Kaufman, 1973; Reynolds & Gutkin, 1981), but remains robust in its appearance. All studies of racial and ethnic group differences on ability tests do not show higher levels of performance by Whites. Although not nearly as thoroughly researched as Black±White groups, Oriental groups have been shown to perform consistently as well as, or
The Controversy Over Bias in Psychological Testing better than, White groups (Pintner, 1931; Tyler, 1965; Willerman, 1979). Depending on the specific aspect of intelligence under investigation, other racial and ethnic groups show performance at or above the performance level of White groups. There has been argument over whether any racial differences in intelligence are real or even researchable (e.g., Schoenfeld, 1974), but the reliability across studies is very high, and the existence of the differences is now generally accepted. It should always be kept in mind, however, that the overlap among the distributions of intelligence test scores for the different races is much greater than the degree of differences among the various groups. There is always more within-group variability than between-group variability in performance on psychological tests. The differences are nevertheless real ones and are unquestionably complex (e.g., Reynolds & Jensen, 1983). The issue at hand is the explanation of those group differences. It should be emphasized that both the lower scores of some groups and the higher scores of others need to be explained, although not necessarily, of course, in the same way. The problem was clearly stated by Eells in his classic study of cultural differences: Do the higher test scores of the children from high socioeconomic backgrounds reflect genuine superiority in inherited, or genetic, equipment? Or do the high scores result from a superior environment which has brought about real superiority of the child's ªintelligence'? Or do they reflect a bias in the test materials and not any important differences in the children at all? (Eells, Davis, Havighurst, Herrick, & Tyler, 1951, p. 4).
Eells et al. also concisely summarized the cultural-test-bias hypothesis as it applied to differences in socioeconomic status (SES): If (a) the children from different social-status levels have different kinds of experiences and have experiences with different types of material, and if (b) the intelligence tests contain a disproportionate amount of material drawn from the cultural experiences with which pupils from the higher social-status levels are more familiar, one would expect (c) that children from the higher social-status levels are more familiar, one would expect (d) that children from the higher socialstatus levels would show higher IQs than those from the lower levels. This argument tends to conclude that the observed differences in pupil IQs are artifacts dependent upon the specific content of the test items and do not reflect accurately any important underlying ability in the pupils. (Eells et al., 1951 p. 4)
Eells was aware that his descriptions were oversimplifications and that it was unlikely that
all of the observed group differences could be explained by any one of the three factors alone. Loehlin, Lindzey, and Spuhler (1975) concluded that all three factors were probably involved in racial differences in intelligence as have a myriad of other researchers (e.g., Bouchard & Segal, 1985; Flynn, 1991). In its present, more complex form, the cultural test bias hypothesis considers other factors than culture-loaded items, as will be seen below. But the basics of Eell's summary of the cultural-testbias hypothesis still hold: group differences stem from characteristics of the test or from aspects of test administration. Because mental tests are based largely on middle-class White values and knowledge, they are more valid for those groups and are biased against other groups to the extent that these groups deviate from those values and knowledge bases. This position has been reframed slightly over the years, principally by Mercer (e.g., 1979) and reinforced by Helms (1994), who argue the lower scores of ethnic minorities on aptitude measures can be traced to the Anglocentrism (degree of adherence to White, middle-class value systems of USA families) of aptitude measures. Mercer (1979) developed an entire system of assessments designed to provide complex demographic corrections to IQs obtained by ethnic minorities that had the effect of equating these groups on mean scores. (This system, known as the SOMPA, had quite a bit of popularity for several years but is rarely used today because of its conceptual and psychometric inadequacies.) Lonner (1985) discusses similar issues under the rubric of cultural isomorphism in testing and assessment. Helms (1994) makes similar criticisms of ability tests, rejects most psychometric research on these issues, and posits (quite similar to Mercer's position) it is the Eurocentric nature of aptitude tests that produces artifactual differences in mean levels of performance across ethnic lines, focusing especially on the performance of Black Americans. In all of those conceptual models, which are essentially contemporaneous even with arguments of Burt as early as 1921, ethnic and other group differences in mean levels of performance on aptitude measures are seen to result from flawed psychometric methodology and not from actual differences in aptitude (see also Harrington, 1975, 1976). As described below, this hypothesis reduces to one of differential validity, the hypothesis of differential validity for mental tests being that tests measure intelligence more accurately, and make valid predictions about the level of intellectual functioning for individuals from the groups on which the tests are mainly based than for those from other groups. Artifactually low scores on
an aptitude test could lead to denial of employment or in schools to pupil misassignment to educational programs and unfair denial of admission to college, graduate school, or other programs or occupations in which such test scores are an important decision-making component. This is the issue over which most legal cases have been fought in the USA. Further, there would be dramatic implications for whole areas of psychological research and practice if the cultural-test-bias hypothesis is correct. The principal research of the twentieth century in the psychology of human differences would have to be dismissed as confounded and largely artifactual because much of the work is based on standard psychometric theory and testing technology. The result would be major upheavals in the practice of applied psychology, as the foundations of clinical, school, counseling, and industrial psychology are strongly tied to the basic academic field of individual differences. The issue, then, is crucial not only to the science of psychology but to practice (Lonner, 1985; Reynolds, 1980c). On the other hand, if the cultural-test-bias hypothesis is incorrect, then group differences are not attributable to the tests and must be due to one of the other factors mentioned by Eells et al. (1951) or to some combination of them. That group differences in test scores reflect real group differences in ability should be admitted as a possibility, and one that calls for scientific study. The controversy over test bias should not be confused with that over the etiology of any obtained group differences in test scores (see Reynolds & Kaiser, 1990, for a review) other than to rule bias in or out as an explanation. Unfortunately, it has often been inferred that measured differences themselves indicate genetic differences, and therefore the genetically based intellectual inferiority of some groups. Jensen has himself consistently argued since 1969 that mental tests measure, to a greater or lesser extent, the intellectual factor g which has a large genetic component, and that group differences in mental test scores may then reflect group differences in g. Unless one reads Jensen's statements carefully, it is easy to overlook the many qualifications that he makes regarding these differences and conclusions. But, in fact, Jensen's or anyone else's position on the genetic basis of actual group differences should be seen as irrelevant to the issue of test bias. However controversial, etiology is a separate issue. It would be tragic to accept the cultual test bias hypothesis as true if it is, in fact, false. In that case, measured differences would be seen as not real, and children, for example, might be denied access to the educational
environment best suited to them, and job applicants may end up in occupations for which they are ill-suited or for which others are more qualified. Further, research on the basis of any group differences would be stifled, as would the implementation of programs designed to remediate any deficiencies. The most advantageous position for the true White racist and bigot would be to favour the test bias hypothesis! Acceptance of that hypothesis inappropriately would eventually result in inappropriate pupil assignment, less adaptive education for some groups, and less implementation of long-range programs to raise intellectual performance. Inappropriate confirmation of the test bias hypothesis would appear to maintain, not break down, the poverty cycle (Birch & Gussow, 1970). The controversy is also not over the blatantly inappropriate administration and use of mental tests. The administration of a test developed and published in English to an individual for whom English is a second language and whose English language skills are poor is inexcusable, regardless of any bias in the tests themselves. It is just as inexcusable to translate the test into the examinee's first or dominant language and assume the validity of the results. Translating a test from its original language is a wholly inadequate process and creates many problems of reliability and validity. Instead, a test must be redeveloped, preferably following the steps outlined and discussed by Hambleton and Kanjee (1995). It is of obvious importance that tests be administered by skilled and sensitive professionals who are aware of the factors that may artifactually lower an individual's test scores. Considering the use of tests to assign pupils to special education classes or other programs, a question needs to be asked: What would one use instead? Teacher recommendations are notoriously less reliable and less valid than standardized test scores, which increases the probability of bias occurring. For college admissions, this question was asked long ago and the use of grades and subjective letters of recommendation and interviews found to be unreliable and biased. This research in the early 1900s led to the formation of the College Entrance Examination Board and the Scholastic Achievement Test (SAT). The controversy over the use of mental tests is further complicated by the fact that resolution of the cultural test bias question in either direction will not resolve the problem of the role of nonintellective factors that may influence the test scores of individuals from any ethnic group. Regardless of any group differences, it is individuals who are tested and whose scores may or may not be accurate. Similarly, it is individuals who are assigned to classes, chosen
The Nature of Psychological Testing Adds to the Controversy for universities, placed in jobs or vocations, and who are accepted or rejected. As indicated by Wechsler (1975) and others, nonintellective factors, informational content, and emotional± motivational conditions may be reflected in performance on mental tests. The extent to which these factors influence individual as opposed to group performance is difficult to determine. Perhaps with more sophisticated multivariate designs, we will be better able to identify individuals with characteristics that are likely to have an adverse effect on their performance on mental tests. Basically, outside the major thrust of the issue of bias against groups, potential bias against individuals is a serious problem itself, and merits research and analysis. Sternberg (1980), also concerned about individual performance, observed a still true matter: research on bias has concentrated on status variables such as ethnicity rather than on functional variables such as cognitive styles and motivations. 10.03.3 THE NATURE OF PSYCHOLOGICAL TESTING ADDS TO THE CONTROVERSY The question of bias in mental testing arises largely because of the nature of psychological processes and the measurement of those processes (Reynolds & Brown, 1984). Psychological processes, by definition internal and not directly subject to observation or measurement, must be inferred from behavior. Theoretically, in the classic discussion by MacCorquodale and Meehl (1948), a psychological process has the status of an ªintervening variableº if it is used only as a component of a system that has no properties beyond those that operationally define it, but it has the status of a ªhypothetical constructº if it is thought actually to exist with properties beyond the defining ones. A historical example of a hypothetical construct is gene, which had meaning beyond its use to describe the cross-generational transmission of characteristics. Intelligence, from its treatment in the professional literature, has the status of a hypothetical construct as does personality. As even beginning psychology students know, it is difficult to determine one-to-one relationships between observable events in the environment, the behavior of an organism, and hypothesized underlying mediational processes. Many classic controversies over theories of learning have revolved around constructs such as expectancy, habit, and inhibition (e.g., Goldstein, Krantz, & Rains, 1965; Hilgard & Bower, 1975; Kimble, 1961). Disputes among different camps in learning have been polemical
and of long duration. Indeed, there are still disputes about the nature and the number of processes such as emotion and motivation (e.g., Bolles, 1975; Mandler, 1975). One of the major areas of disagreement has been over the measurement of psychological processes. It should be expected that intelligence, as one of the most complex of psychological processes, involves definitional and measurement disputes that prove difficult to resolve. Assessment of intelligence and personality, like that of many other psychological processes in humans, is accomplished by standard psychometric procedures that are the focus of the bias issue. These procedures, described in detail in general assessment texts (e.g., Anastasi, 1982; Linn, 1989), are only briefly summarized here in relation to the issue of bias. Problems specific to validity are discussed in Section 10.03.7. Similar procedures are used in the development of any standardized psychological test. First, a large number of items are developed that for theoretical or practical reasons are thought to measure the construct of interest. Through a series of statistical steps, those items that best measure the construct in a unitary manner are selected for inclusion in the final test battery. The test is then administered to a sample, which should be chosen to represent all aspects of the population on whom the test will be used. Normative scales based on the scores of the standardization sample then serve as the reference for the interpretation of scores of individuals tested thereafter. Thus, as has been pointed out numerous times, an individual's score is meaningful only relative to this normative base and is a relative, not an absolute, measure. Charges of bias frequently arise from the position that the test is more appropriate for the groups heavily represented in the standardization sample. Whether bias does, in fact, result from this procedure is a specific question to be addressed empirically. As has also been frequently pointed out, there are few charges of bias of any kind relating to physical measures that are on absolute scales, whether interval or ratio. Group differences in height, as an extreme example, are not attributed by anyone we know of to any kind of cultural test bias or specific methods of measuring height. There is no question concerning the validity of measures of the height or weight of anyone in any culture. Nor is there any question about one's ability to make crosscultural comparisons of these absolute measures (which variables, such as height, are clearly subject to genetic by environmental interactions). The whole issue of cultural bias arises because of the procedures involved in psychological
testing. Psychological tests measure traits that are not directly observable, that are subject to differences in definition, and that are measurable only on a relative scale. From this perspective, the question of cultural bias in mental testing is a subsetÐobviously of major importanceÐof the problems of uncertainty and of possible bias in psychological testing generally. Bias may exist not only in mental tests but in other types of psychological test, including personality, vocational, and psychopathological tests. Making the problem of bias in mental testing even more complex is the fact that not all mental tests are of the same quality. Like Orwell's pigs, some may be more equal than others. There is a tendency for critics and defenders alike to overgeneralize across tests, lumping virtually all tests together under the heading ªmental testsº or ªintelligence tests.º As reflected in the Mental measurements yearbook (e.g., Buros, 1978), professional opinions of mental tests vary considerably, and some of the most used tests are not well respected by psychometricians. Thus, unfortunately, the question of bias must eventually be answered on a virtually test-by-test basis. In 1969, the Association of Black Psychologists (ABP), a USA-based professional association, adopted the following official policy on educational and psychological testing: The Association of Black Psychologists fully supports those parents who have chosen to defend their rights by refusing to allow their children and themselves to be subjected to achievement, intelligence, aptitude and performance tests which have been and are being used to A. Label Black people as uneducable. B. Place Black children in ªspecialº classes and schools. C. Perpetuate inferior education in Blacks. D. Assign Black children to educational tracts. E. Deny Black students higher educational opportunities. F. Destroy positive growth and development of Black people. (quoted in Reynolds, 1982a, p. 179)
Since 1968, the ABP has sought continuously a moratorium on the use of all psychological and educational tests with the culturally different (Samuda, 1975, and Williams, Dotson, Dow, & Williams, 1980, have provided a more detailed history of these efforts). The ABP, an organizational leader in protesting test bias for all ethnic groups, carried its call for a moratorium to other professional organizations in psychology and education. In direct response to the ABP call, the Board of Directors of the American Psychological Association (APA) requested its Board of Scientific Affairs to appoint a group to study the use of psychological and educational tests with disadvantaged students. The committee report (Cleary, Humphreys, Kendrick, &
Wesman, 1975) was subsequently published in the official journal of the APA, American Psychologist. Subsequent to the ABP's policy statement, other groups adopted policy statements on testing. These groups included the National Association for the Advancement of Colored People (NAACP), the National Education Association (NEA), the National Association of Elementary School Principals (NAESP), the American Personnel and Guidance Association (APGA), and others (Committee on Testing, 1974; Williams et al., 1980). The APGA called for the Association for Measurement and Evaluation in Guidance (AMEG), a sister organization, to develop and disseminate a position paper stating the limitations of group intelligence tests particularly and generally of standardized psychological, educational, and employment testing for low socioeconomic and underprivileged and non-White individuals in educational, business, and industrial environments. The APGA also resolved that, if no progress was made in clarifying and correcting the current testing of minorities, it would also call for a moratorium, but only on the use of group intelligence tests with these groups. The NAACP adopted a more detailed resolution and joined in the call for a moratorium on standardized testing of minority groups at its annual meeting in 1974. The text of the NAACP resolution was: Whereas a disproportionately large number of Black students are being misplaced in special education classes and denied admissions to higher educational opportunities, Whereas students who fail to show a high verbal or numerical ability, score low on the Scholastic Achievement Test (SAT), the Law School Admissions Test (LSAT), the Graduate Record Examination (GRE), etc., and are routinely excluded from college and graduate or professional education, Be it resolved that the NAACP demands a moratorium on standardized testing whenever such tests have not been corrected for cultural bias and directs its units to use all administrative and legal remedies to prevent the violation of studentsº constitutional rights through the misuse of tests, and Be it further resolved that the NAACP calls upon the Association of Black Psychologists to assert leadership in aiding the College Entrance Examination Board to develop standardized tests which have been corrected for cultural bias and which fairly measure the amount of knowledge retained by students regardless of his or her individual background. Be it finally resolved that the NAACP directs its units to use all administrative remedies in the event of violation of students' constitutional rights
What are Possible Sources of Bias? through the misuse of tests and directs National Office staff to use its influence to bring the CEEB and ABP together to revise such tests.
Also in 1974, the Committee on Testing of the ABP issued a position paper on the testing of Blacks that described their intent as well as their position: (1) To encourage, support and to bring action against all institutions, organizations and agencies who continue to use present psychometric instruments in the psychological assessment of Black people; (2) To continue efforts to bring about a cessation of the use of standard psychometric instruments on Black people until culturally specific tests are made available; (3) To establish a national policy that in effect gives Black folk and other minorities the right to demand that psychological assessment be administered, interpreted, and supervised by competent psychological assessors of their own ethnic background; (4) To work toward and encourage efforts to remove from the records of all Black students and Black employees that data obtained from performance on past and currently used standard psychometric, achievement, employment, general aptitude and mental ability tests; (5) To establish a national policy that demands the appropriate proportional representation of competent Black psychologists on all committees and agencies responsible for the evaluation and selection of tests used in the assessment of Black folk; (6) To establish a national policy that demands that all persons engaged in the evaluation, selection and placement of Black folks undergo extensive training so they may better relate to the Black experience; (7) To demand that all Black students improperly diagnosed and placed into special education classes be returned to regular class programs; (8) To encourage and support all suits against any public or private agency for the exclusion, improper classification and the denial of advancement opportunities to Black people based on performance tests.
It should be noted that the statements by these organizations have assumed that present tests are biased, and that what is needed is the removal of that assumed bias. These assumptions continue in the work of Helms (e.g., 1992), Mercer (1979), Padilla and Medina (1996), and others (e.g., Guilford Press, 1997). 10.03.4 WHAT ARE POSSIBLE SOURCES OF BIAS? Many potentially legitimate objections to the use of educational and psychological tests with
minorities have been raised by Black and other minority psychologists. Unfortunately, these objections are frequently stated as facts on rational rather than empirical grounds (e.g., Council for Exceptional Children, 1978; Chambers, Barron, & Sprecher, 1980; Dana, 1996; Helms, 1992; Hilliard, 1979). The most frequently stated problems fall into one of the following categories: (i) Inappropriate content. Black and other minorities have not been exposed to the material involved in the test questions or other stimulus materials. The tests are geared primarily toward the majority class homes, vocabulary, and values. Different value systems among cultures may lead to cognitively equivalent answers scored as incorrect based on prejudicial value judgments, not on differences in ability. (ii) Inappropriate standardization samples. Ethnic minorities are underrepresented in standardization samples used in the collection of normative reference data. Population proportionate sampling with stratification by ethnicity is the herald for standardization samples for tests and is done to enhance the accuracy of parameter estimation for scaling purposes. As such, although presented proportionately, ethnic minorities may appear in test standardization samples in small absolute numbers. This may bias item selection (e.g., Harrington, 1975, 1976) and fails to have any impact of significance on the tests themselves from these ethnic groups. In earlier years, it was not unusual for standardization samples to be all White (e.g., the 1937 Binet and 1949 WISC). (iii) Examiner and language bias. Since most psychologists in the USA are White and speak only standard English, they may intimidate Black and other ethnic minorities. They are also unable accurately to communicate with minority childrenÐto the point of being insensitive to ethnic pronunciation of words on the test. Lower test scores for minorities, then, may reflect only this intimidation and difficulty in the communication process or motivational differences (Zigler & Butterfield, 1967), not lower ability. In other countries, professionals such as psychologists tend to be from the dominant culture and similar issues appear. (iv) Inequitable social consequences. As a result of bias in educational and psychological tests, minority group members, already at a disadvantage in the educational and vocational markets because of past discrimination and thought unable to learn, are disproportionately relegated to dead-end educational tracks. Labeling effects also fall under this category. (v) Measurement of different constructs. Related to (i), this position asserts that the tests measure different attributes when used with
children from other than the majority culture of a country, the culture on which the tests are largely based, and thus do not measure minority intelligence or personality validly. (vi) Differential predictive validity. Although tests may accurately predict a variety of outcomes for members of a majority culture within a population, they do not predict successfully any relevant behavior for cultural minority group members Further, there are objections to use of the standard criteria against which tests are validated with minority cultural groups. For example, in the USA, scholastic or academic attainment levels in White middle-class schools are themselves considered by a variety of Black psychologists to be biased as criteria (e.g., see discussion in Reynolds, 1982a, pp. 179±180). (vii) Minority and majority aptitude and personality are qualitatively distinct. Championed by Helms (e.g., 1992), this position would lead to the conclusion that ethnic minorities and the majority culture are so different as to require different conceptualizations of ability and personality. Helms (1982), for example, argues the potential existence of a ªWhite gº factor that is separate from an ªAfrican gº factor (p. 1090) that would necessitate separate tests for these groups. Contrary to the situation of the late 1960s and 1970s, when the current controversies resurfaced after some decades of simmering, research now exists that examines the above areas of potential bias in assessment. Except for the still unresolved issue of labeling effects, the least amount of research is available on the long-term social consequences of testing, although some limited data are available (e.g., Lambert, 1979). Both of these problems are aspects of testing in general and are not limited to minorities. The problem of the social consequences of educational tracking is frequently lumped with the issue of test bias. Those issues, however, are separate. Educational tracking and special education should be treated as problems of education, not assessment. These are going to become more heavily contested areas for psychologists in the future, however, as the revision of the Joint Technical Standards for Educational and Psychological Tests and Manuals now underway is likely to add the issue of consequential validity to considerations in test use, reflecting concerns by minority groups within the USA over the consequences of test use with ethnic minorities. Educational tracking as a result of test performance is a prominent problem for ethnic minorities in many countries applying such competitive schooling practices. The call by Helms (1992) and earlier by Williams (1974) for separate tests for minority
groups within the USA deserves comment and raises an interesting set of legal and conceptual issues. The concept of separate but equal programs, facilities, and the like was protested vehemently by minorities for many years and ultimately rejected by the US Supreme Court. It is of interest that some minority scholars would now seek ªseparate but equalº tests. This could lead to arguments that if the cognitive structures of various ethnic groups are so different as to require distinct tests of intelligence and personality for accurate assessment, then schooling, job training, mental health interventions, and the like might also need to be differentÐan argument long attacked and rejected by many minority scholars and spokespersons. 10.03.5 MEAN SCORE DIFFERENCES AS TEST BIAS A popular lay view, and one promoted in the popular media, has been that differences in mean levels of scoring on cognitive, achievement, or personality tests among groups constitute bias in tests; however, such differences alone clearly are not evidence of test bias. A number of writers in the professional literature have taken this position as well (e.g., Adebimpe, Gigandet, & Harris, 1979; Alley & Foster, 1978; Chinn, 1979; Guilford Press, 1997; Hillard, 1979; Jackson, 1975; Mercer, 1976; Padilla, 1988; Williams, 1974; Wright & Isenstein, 1977). Those who support this definition of test bias correctly state there is no valid a priori scientific reason to believe that intellectual or other cognitive performance levels should differ across race. It is the inference that tests demonstrating such differences are inherently biased because there can in reality be no differences that is fallacious. Just as there is no a priori basis for deciding that differences exist, there is no a priori basis for deciding that differences do not exist. From the standpoint of the objective methods of science, a priori or premature acceptance of either hypothesis (`differences existº vs. ªdifferences do not existº) is untenable. As stated by Thorndike (1971), ªThe presence (or absence) of differences in mean score between groups, or of differences in variability, tells us nothing directly about fairnessº (p. 64). Some adherents to the ªmean score differences as biasº viewpoint also require that the distribution of test scores in each population or subgroup be identical before one can assume that the test is fair: ªRegardless of the purpose of a test or its validity for that purpose, a test should result in distributions that are statistically equivalent across the groups tested in order for it to be considered nondiscriminatory for those groupsº (Alley & Foster, 1978,
Mean Score Differences as Test Bias p. 2). Portraying a test as biased regardless of its purpose or validy is psychometrically naive. Mean score differences and unequivalent distributions have been the most uniformly rejected of all criteria examined by sophisticated psychometricians involved in investigating the problems of bias in assessment. Ethnic group differences in mental test scores are among the best-documented phenomena in psychology, and they have persisted over time at relatively constant levels (Reynolds & Gutkin, 1980a, 1981). Jensen (1980) has discussed the ªmean score differences as biasº position in terms of the egalitarian fallacy. The egalitarian fallacy contends that all human populations are in fact identical on all mental traits or abilities. Any differences with regard to any aspect of the distribution of mental test scores indicates that something is wrong with the test itself. Such an assumption is totally scientifically unwarranted. There are simply too many examples of specific abilities and even sensory capacities that have been shown to differ unmistakably across human populations. The result of the egalitarian assumption, then, is to remove the investigation of population differences in ability from the realm of scientific inquiry. Logically followed, this fallacy leads to other untenable conclusions as well. Torrance (1980), an adherent of the cultural bias hypothesis, pointed out that disadvantaged Black children in the USA occasionally earn higher scores on creativity testsÐand therefore, have more creative abilityÐthan many White children because their environment has forced them to learn to ªmake doº with less and with simpler objects. The egalitarian assumption would hold that this is not true, but rather that the content of creativity tests is biased against White or high SES children. The attachment of minorities to the ªmean score differences as biasº definition is probably related to the nature±nurture controversy at some level, and has been difficult for even databased, minority research scientists to abandon (e.g., Dana, 1993). Certainly data reflecting racial differences on various aptitude measures have been interpreted to indicate support for a hypothesis of genetic differences in intelligence and to imply that one race is superior to another. However, as discussed previously, the so-called nature±nurture issue is not an inextricable component of bias investigation. Assertions as to the relative impact of genetic factors on group ability levels step into a new arena of scientific inquiry, with differing bodies of knowledge and methods of research. Suffice it to say that in the arena of bias investigation, mean differences on aptitude,
achievement, or personality measures among selected groups are not evidence per se that the measures are biased. 10.03.5.1 Culture-free Tests, Culture Loading, and Culture Bias A third area of bias investigation that has been confusing in both the professional (e.g., Alley & Foster, 1978; Chinn, 1979) and the lay literature has been the interpretation of culture loading and culture bias. A test can be culture loaded without being culturally biased. Culture loading refers to the degree of cultural specificity present in the test or individual items of the test. Certainly, the greater the cultural specificity of a test item, the greater the likelihood of the item being biased when it is used with individuals from other cultures. The test item ªWho was the first president of the United States?º is a culture-loaded item. However, the item is general enough to be considered useful with school-aged children attending school since first grade in the USA. The cultural specificity of the item is too great, however, to allow the item to be used on an aptitude measure of 10-year-old children from other countries. Virtually all tests in current use are bound in some way by their cultural specificity. Culture loading must be viewed on a continuum from general (defining a culture in a broad, liberal sense) to specific (defining a culture in narrow, highly distinctive terms). A variety of attempts have been made to develop a ªculture-freeº (sometimes referred to as ªculture-fairº) intelligence test (e.g., Cattell, 1979). However, the reliability and validity of these tests are uniformly inadequate from a psychometric perspective (Anastasi, 1982; Ebel, 1979). The difficulty in developing a culture-free measure of intelligence lies in the test being irrelevant to intellectual behavior within the culture under study. Intelligent behavior is defined within human society in large part on the basis of behavior judged to be of value to the survival and improvement of the culture and the individuals within the culture. A test that is ªculture-blind,º then, cannot be expected to predict intelligent behavior within a variety of cultural settings. Once a test has been developed within a culture (a culture-loaded test), its generalizability to other cultures or subcultures within the dominant societal framework becomes a matter for empirical investigation, and tests should not be used cross-culturally without demonstrative evidence for the validity of inferences to be drawn from such tests. The same holds true for personality tests and other techniques designed to assess affective disorders.
Although there exists a universality to certain psychopathological disorders (e.g., schizophrenia, bipolar disorder) in both taxonomy and manifestation, the existence of certain disorders independent of a cultural context can be questioned readily (e.g., dependent personality disorder) and the symptoms or manifestations of other disorders may well vary across cultures as they do across age (e.g., depression, anxiety disorders). Jensen (1980) admonishes that when one is investigating the psychometric properties of culture-loaded tests across differing societies or cultures, one cannot assume that simple inspection of the content will determine which tests or items are biased against those cultures or societies not represented in the tests or item content. Tests or items that exhibit characteristics of being culturally loaded cannot be determined to be biased with any degree of certainty unless objective statistical inspection is completed. Jensen refers to the mistaken notion that anyone can judge tests and/or items as being ªculturally unfairº on superficial inspection as the ªculture-bound fallacy.º The issue of item bias is revisited in some detail in Section 10.03.7.1. 10.03.5.2 The Question of Labeling Effects The relative impact of placing a label on a person's behavior or developmental status has also been a hotly discussed issue within the field of psychometrics in general and bias investigation in particular. The issue undoubtedly has been a by-product of the practice of using intellectual measures for the determination of mental retardation. Although the question of labeling effects is a viable and important one, it requires consideration in bias research only in much the same way as does the ongoing debate surrounding the nature±nurture question. As the concept of consequential validity grows, this issue will likewise grow in importance. However, there are some important considerations regarding bias in referral for services, diagnosis, and labeling, which no interested student of the diagnostic process in psychology can afford to ignore. Rosenthal is the researcher most closely associated with the influence of labeling upon teachers' and parents' perceptions of a child's ability and potential. Even though his early studies had many methodological and statistical difficulties, labeling effects have been shown in some subsequent experimental studies (e.g., Critchley, 1979; Foster & Ysseldyke, 1976; Jacobs, 1978), but not in others (e.g., MacMillan, Jones, & Aloia, 1974; McCoy, 1976).
However, these studies have generally been of a short-term nature, and have usually been conducted under quite artificial circumstances. Typically, participants are asked to rate the behavior or degree of pathology of a child seen on videotape. Categorical labels for the child are systematically varied while the observed behaviors remain constant. The demand characteristics of such a design are substantial. Long-term effects of labeling and diagnoses resulting in special education placement or mental health treatment in real-life situations have been examined less vigorously. For example, comparisons of the effects of formal diagnostic labels with the informal, often cursory, personal labeling process that occurs between teachers and children over the course of a school year, and that is subsequently passed on to the next grade via the teachers' lounge (Dworkin & Dworkin, 1979), need to be made. Although Reynolds (1982b) called for this research in past decades, this important question has not been addressed. The strict behaviorist position (Ross, 1974, 1976) also contends that formal diagnostic procedures are unnecessary and potentially harmful because of labeling effects. However, 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 monumental effort to address these important questions throughout the USA in the mid-1970s (Hobbs, 1975). Even without the application of formal, codified labels by psychologists or psychiatrists, the mental labeling, classification, and appraisal of individuals by people with whom they come into contact are common, constant occurrences (Reynolds, 1979a). Auerbach (1971) found that adults often interpret early learning difficulties of children as primarily emotional disturbances, unrelated to learning problems. According to Bower (1974), children who start the first grade below the mean age of their classmates and are below average in the development of school readiness skills or have behaviour problems are more likely to be regarded as emotionally disturbed by school staff and are more likely to be referred to residential placement than their peers. The American Psychological Association (1970) acknowledges that such constant appraisal of individuals occurs at the informal level, and in an official position statement takes the stance that specialized, standardized psychological techniques have been developed to supersede our informal, often casual approach to the appraisal of others. The specialized psychological techniques available to the trained examiner add validity and utility to the results of such appraisals. The quantification of behaviour permits systematic comparisons of individuals'
Mean Score Differences as Test Bias characteristics with those of a selected reference or norm group. It is not unreasonable to anticipate that the informal labeling of children so often indulged in by teachers and parents is substantially more harmful than accurate psychoeducational diagnostics intended to accrue beneficial activity toward the child. Should noncategorical funding for services to exceptional children become a reality (Gutkin & Tieger, 1979), or should the use of normative assessment ultimately be banned, the informal labeling process will continue and in all likelihood will exacerbate children's problems. From the standpoint of cultural test bias issues, the question of labeling persons or not labeling persons is moot. Cultural test bias is concerned with the accuracy of such labels across some nominal grouping system (typically, race, sex, and SES have been the variables of interest). It is a question of whether race, sex, or any other demographic variable of interest influences the diagnostic process or the placement of an individual in special treatment programs, independent of the individual's cognitive, emotional, and behavioral status. Several well-designed studies have investigated the influences of race and SES on diagnosis and the placement recommendations of school psychologists (i.e., bias in test interpretation). One of the studies investigated teacher bias as well. Frame (1979) investigated the accuracy of school psychologists' diagnoses and consistency of treatment plans within the USA, with regard to bias effects associated specifically with race and SES. In Frame's study, 24 school psychologists from a number of school districts diagnostically rated and provided treatment plans for hypothetical cases in which all information except race, SES, and the achievement level of the child's school was held constant. No differences in the accuracy of diagnosis (as defined by interrater reliability) occurred as a function of race or SES. Differences did occur with regard to treatment recommendations, however. With all other data held constant, lower SES Black children were less likely to be recommended for special education placement than their White counterparts or higher SES Black children. A more general trend was for higher SES children to be recommended for special class placement more often than children of lower SES. In a similar vein, Matuszek and Oakland (1979) asked whether SES and race influenced teacher or psychologist placement recommendations, independent of other characteristics such as adaptive behavior, IQ, and classroom achievement levels. Matuszek and Oakland concluded that ªThe data from this study
clearly indicate that they [psychologists] did not make different recomendations on the basis of race.º Consistent with the results of Frame (1979), psychologists were more likely to recommend special class placement for high SES status children than for low SES children when other varibles were held constant. Teachers showed no bias in regard to special education placement recommendations on the basis of race or SES. Upon investigating special education placement recommendations as a function of minority group status (Black, native American, or Oriental), Tomlinson, Acker, Canter, and Lindborg (1977) reported that psychologists recommended special education resource services more frequently for minority than for White children. Placement in a special education class, however, was recommended more frequently for White than minority children. A rather extensive study of placement in classes for the educable mentally retarded (EMR) in California also failed to find any racist intent in the placement of minority children in special classes (Meyers, MacMillan, & Yoshida, 1978). In fact, the tendency was not to place Black children in special education classes, even though they might be failing in the regular classroom. An even earlier study by Mercer (1971), one of the major critics of IQ testing with minorities, reached the same conclusion. The general tendency not to label Black children also extends to community mental health settings. Lewis, Balla, and Shanok (1979) reported that when Black adolescents were seen in mental health settings, behaviors symptomatic of schizophrenia, paranoia, and a variety of psychoneurotic disorders were frequently dismissed as only ªcultural aberrationsº appropriate to coping with the frustrations created by the antagonistic White culture. Lewis et al. (1979) further noted that White adolescents exhibiting similar behaviours were given psychiatric diagnoses and referred for therapy and/ or residential placement. Lewis et al. contended that this failure to diagnose mental illness in the Black population acts as bias in the denial of appropriate services. A tendency for psychologists to reward depressed performance on cognitive tasks by Blacks and low SES groups as a ªcultural aberrationº has also been shown. An early empirical study by Nalven, Hofmann, and Bierbryer (1969) demonstrated that psychologists generally rated the ªtrue intelligenceº of Black and lower SES children higher than that of White and middle-class children with the same Wechsler Intelligence Scale for Children (WISC) IQ. This tendency to ªoverrateº the intellectual potential of Black and low SES children probably accounts, at least in part, for
psychologists' reluctance to recommend special education placement for these children; it could also be viewed as a discriminatory denial of services, depending on whether the provision of services is considered beneficial or harmful to the individual. Despite the outcome of these and other studies, it is common to read that psychologists overdiagnose psychopathology in cultural groups outside the mainstream culture (e.g. Dana, 1993). Bias by ethnicity in diagnosis of specific forms of affective disturbance has been the subject of fewer examinations in the literature. However, there is little evidence to suggest that ethnicity or SES independently influence clinical diagnoses such as autistic disorders or attention-deficit hyperactivity disorder (e.g., Cuccaro, Wright, Rhownd, & Abramson, 1996). These studies clearly indicate that the demographic variables of race and SES do not, independent of other pupil characteristics, influence or bias psychologists' diagnostic or placement behavior in a manner that would cause Blacks or lower SES children to be labeled inaccurately or placed inappropriately or in disproportionate numbers in special education programs. The empirical evidence, rather, argues in the opposite direction: in the USA, Black and low SES children are less likely to be diagnosed as having a form of psychopathology than their White or higher SES peers with similar cognitive, behavioral, and emotional characteristics. The data simply do not support William's (1970) and others (e.g., Dana, 1993; Guilford Press, 1997; Padilla, 1988) charges that ethnic minorities are more likely to be overly diagnosed with a variety of psychopathological disorders. 10.03.6 THE PROBLEM OF DEFINITION The definition of test bias has produced considerable continuing debate among measurement and assessment experts (Angoff, 1976; Bass, 1976; Bernal, 1975; Bond, 1981; Cleary et al., 1975; Cole & Moss, 1989; Cronbach, 1976; Dana, 1993; Darlington, 1978; Einhorn & Bass, 1970; Flaugher, 1978; Gordon, 1984; Gross & Su, 1975; Helms, 1992; Humphreys, 1973; Hunter & Schmidt, 1976, 1978; Jackson, 1980; Linn, 1976; McNemar, 1975; Moreland, 1996; Novick & Petersen, 1976; Padilla, 1988; Petersen & Novick, 1976; Reschly, 1980; Reynolds, 1978; 1982b, 1995; Reynolds & Brown, 1984; Sawyer, Cole, & Cole, 1976; Schmidt & Hunter, 1974; Thorndike, 1971). Although the resulting debate has generated a number of selection models with which to examine bias, selection models focus on the
decision-making system and not on the test itself. The various selection models are discussed at some length in Hunter and Schmidt (1974), Hunter, Schmidt, and Rauschenberger (1984), Jensen (1980), Peterson and Novick (1976), and Ramsay (1979). The choice of a decision-making system (especially a system for educational decision-making) must ultimately be a societal one; as such, it will depend to a large extent on the value system and goals of the society. Thus, before a model for test use in selection (whether ultimately selection is for a treatment program, a job, a college, etc.) can be chosen, it must be decided whether the ultimate goal of selection is equality of opportunity, equality of outcome, or representative equality (these concepts are discussed in more detail in Nichols, 1978). ªEquality of opportunityº is a competitive model wherein selection is based on ability. As more eloquently stated by Lewontin (1970), under equality of opportunity, ªtrue merit . . . will be the criterion of men's earthly rewardº (p. 92). ªEquality of outcomeº is a selection model based on ability deficits. Schooling provides a good model to illustrate these concepts that are also applicable to mental health. Compensatory and remedial programs are typically constructed on the basis of the equality-of-outcome model. Children of low ability or children believed to be a high risk for academic failure are selected for remedial, compensatory, or other special educational programs. Adults vying for jobs may be placed in specialized job training programs. In a strictly predictive sense, tests are used in a similar manner under both of these models. However, under equality of opportunity, selection is based on the prediction of a high level of criterion performance; under equality of outcome, selection is determined by the prediction of ªfailureº or a preselected low level of criterion performance. Interestingly, it is the failure of compensatory and remedial education programs to bring the disadvantaged learner to ªaverageº levels of performance that resulted in the charges of test bias now in vogue. The model of ªrepresentative equalityº also relies on selection, but selection that is proportionate to numerical representation of subgroups in the population under consideration. Representative equality is typically thought to be independent of the level of ability within each group; however, models can be constructed that select from each subgroup the desired proportion of individuals (i) according to relative ability level of the group, (ii) independent of group ability, or (iii) according to some decision rule between these two positions. Even under the conditions of representative equality, it is
Research Strategies and Results
imperative to employ a selection device (test) that will rank order individuals within groups in a reliable and valid manner. The best way to ensure fair selection under any of these models is to employ tests whose scores are equally reliable and equally valid for all groups concerned. The tests employed should also yield the most reliable and most valid scores for all groups under consideration. The question of test bias per se then becomes a question of test validity. Test use (i.e., fairness) may be defined as biased or nonbiased only by the societal value system; at present, this value system within the USA is leaning strongly toward some variant of the representative-equality selection model. In other sociopolitical structures, other models may be more appropriate. As noted above, all models are facilitated by the use of a nonbiased test. That is, the use of a test with equivalent cross-group validities makes for the most parsimonious selection model, greatly simplifying the creation and application of the selection model that has been chosen. This leads to the essential definitional component of test bias. ªTest biasº refers in a global sense to systematic error in the estimation of some ªtrueº value for a group of individuals. The key word here is ªsystematicº; all measures contain error and in all cultural settings, but this error is assumed to be random unless shown to be otherwise. Bias investigation is a statistical inquiry that does not concern itself with culture loading, labeling effects, or test use/test fairness. Concerning the last of these, Jensen (1980) comments,
valid for one group but not another. Differential validity refers to a condition where an interpretation is valid for all groups concerned, but the degree of validity varies as a function of group membership. Although these terms have been most often applied to predictive or criterion-related validity (validity coefficients are then examined for significance and compared across groups), the concepts of singlegroup and differential validity are equally applicable to content and construct validity.
[U]nbiased tests can be used unfairly and biased tests can be used fairly. Therefore, the concepts of bias and unfairness should be kept distinct . . . [A] number of different, and often mutually contradictory, criteria for fairness have been proposed, and no amount of statistical or psychometric reasoning per se can possible settle any arguments as to which is best. (pp. 375±376)
Bias in the item content of intelligence tests is one of the favorite topics of those who decry the use of standardized tests with minorities (e.g., Hilliard, 1979; Jackson, 1975; Williams, 1972; Wright & Isenstein, 1977). The earliest work in cultural test bias centered around content. Typically, critics review the items of a test and select specific items as being biased because: (i) the items ask for information that ethnic minority or disadvantaged persons have not had equal opportunity to learn; and/or (ii) the scoring of the items is improper, since the test author has arbitrarily decided on the only correct answer and ethnic minorities are inappropriately penalized for giving answers that would be correct in their own culture but not that of the test maker; and/or (iii) the wording of the questions is unfamiliar, and an ethnic minority person who may ªknowº the correct answer may not be able to respond because he or she does not understand the question. Each of these and related criticisms, when accurate, has the same basic empirical result: the item becomes relatively more difficult
There are three types of validity as traditionally conceived: content, construct, and predictive (or criterion-related). Test bias may exist under any or all of these categories of validity. Though no category of validity is completely independent of any other category, each is discussed separately here for the purposes of clarity and convenience. (All true evidence of validity is as likely as not to be construct validity, and other, more detailed divisions including this one are for convenience of discussion.) Frequently encountered in bias research are the terms ªsingle-group validityº and ªdifferential validity.º Single-group validity refers to the phenomenon of a score interpretation being
10.03.7 RESEARCH STRATEGIES AND RESULTS The methodologies available for research into bias in mental tests have grown rapidly in number and sophistication since the 1970s. Extensive reviews of the questions to be addressed in such research and their corresponding methodologies are available in Berk (1982), Camilli and Shepard (1994), Jensen (1980), Reynolds (1982b, 1995), and Reynolds and Brown (1984). The most popular methods are reviewed below, along with a summary of findings from each area of inquiry (these summaries are based almost entirely on research with ethnic subcultures within the USA). The sections are organized primarily by methodology within each content area of research (i.e., research into content, construct, and predictive validity). 10.03.7.1 Bias in Content Validity
for ethnic minority group members than for the majority population, for example, an ethnic minority and a member of the majority culture with the same standing on the construct in question will respond differently to such biased items. This leads directly to a definition of content bias for aptitude tests that allows empirical assessment of the phenomenon. An item or subscale of a test is considered to be biased in content when it is demonstrated to be relatively more difficult for members of one group than for members of another when the general ability level of the groups being compared is held constant and no reasonable theoretical rationale exists to explain group differences on the item (or subscale) in question. With regard to achievement tests, the issue of content bias is considerably more complex. Exposure to instruction, general ability level of the group, and the accuracy and specificity of the sampling of the domain of items are all important variables in determining whether the content of an achievement test is biased (see Schmidt, 1983). Research into item (or content) bias with achievement tests has typically, and perhaps mistakenly, relied on methodology appropriate for determining item bias in aptitude tests. Nevertheless, research examining both types of instruments for content bias has yielded quite comparable results. Items on personality tests may be perceived differently across cultures as well or appropriate responses may vary dramatically and quite properly deserve different interpretations cross-culturally. If so, the items will behave differently across groups for individuals with the same relative standing. This too is detectable through analyses of item response data across groups. One method of locating ªsuspiciousº test items requires that item difficulties be determined separately for each group under consideration. If any individual item or series of items appears to be exceptionally difficult for the members of any group, relative to other items in the test, the item is considered potentially biased and removed from the test. An early, widespread approach to identifying biased items involved analysis of variance (ANOVA) and several closely related procedures wherein the group X item interaction term is of interest (e.g., Angoff & Ford, 1973; Cardall & Coffman, 1964; Cleary & Hilton, 1968; Plake & Hoover, 1979; Potthoff, 1966; Stanley, 1969). The definition of content bias set forth above actually requires that the differences between groups be the same for every item on the test. Thus, in the ANOVA procedure, the group X item interaction should not yield a significant result. Whenever the differences in items are not uniform (a significant group X item interaction
does exist), one may contend that biased items exist. Earlier in this area of research, it was hoped that the empirical analysis of tests at the item level would result in the identification of a category of items having similar biased, and that such items could then be avoided in future test development (Flaugher, 1978). Very little similarity among items determined to be biased has been found. No one has been able to identify those characteristics of an item that cause the item to be biased. It does seem that poorly written, sloppy, and ambiguous items tend to be identified as biased with greater frequency than those items typically encountered in a wellconstructed standardized instrument. The variable at issue then may be the item reliability. Item reliabilities are typically not large, and poorly written or ambiguous test items can easily have reliabilities approaching zero. Decreases in reliability are known to increase the probability of the occurrence of bias (Linn & Werts, 1971). Informal inventories and locally derived tests are much more likely to be biased than professionally written standardized tests that have been scrutinized for bias in the items and whose item characteristics are known. Once items have been identified as biased under the procedures described above, attempts have been made to eliminate ªtest biasº by eliminating the offending items and rescoring the tests. As pointed out by Flaugher (1978) and Flaugher and Schrader (1978), however, little is gained by this tactic. Mean differences in performance between groups are affected only slightly, and aptitude and achievement tests become more difficult for everyone involved, since the eliminated items typically have moderate to low difficulty. When race X item interactions have been found, the interaction typically accounts for a very small proportion of variance. For example, in analyzing items on the WISC-R, Jensen (1976), Sandoval (1979), and Mille (1979) found the group X item interaction to account for only 2±5% of the variance in performance. Using a similar technique with the Wonderlic Personnel Test, Jensen (1977) found the race X item interaction to account for only about 5% of the test score variance. Thus, elimination of the offending items can be expected to have little, if any, significant effect. These analyses have been of a post hoc nature (i.e., after the tests have been standardized), however, and use of empirical methods for determining item bias during the test development phase (as with tests like the K-ABC and the TOMAL) is to be encouraged. The ANOVA methodology is appealing conceptually but has some significant problems, even though it was the dominant methodological approach to the issue of item bias through the
Research Strategies and Results 1980s. Camilli and Shepard (1987) have provided convincing examples, albeit using contrived data, that ANOVA methods often miss biased items, in both directions, and identify some items as biased which are not. An algebraic demonstration of the reasons for this is provided in Camilli and Shepard (1994) who conclude that ANOVA should no longer be used. Based upon their thorough and compelling analysis of methods for detecting biased items, Camilli and Shepard (1994) recommend methods derived from item response theory (IRT) to detect what has come to be known as differential item functioning (DIF). IRT models are conceptually similar to what other models such as ANOVA attempt. IRT is concerned principally with the probability of a particular response to a test item as a function of the examinee's relative position on the latent trait assessed by the scale to which the item belongs. IRT models to detect DIF are primarily superior to prior methods because they are less sample dependent and they allow one to estimate multiple item statistics more precisely than a technique such as ANOVA. Using item characteristic curves, DIF is more accurately and readily detected when the probability of a particular response changes as a function of some nominal variable (e.g., ethnicity or gender) for individuals with the same relative standing on the latent trait being assessed. Early studies using other approaches for the detection of DIF using a partial correlation procedure developed independently by Stricker (1982) and Reynolds, Willson, and Chatman (1984) have found no systematic bias against American Blacks or against women on measures of English vocabulary. Willson, Nolan, Reynolds, and Kamphaus (1989), using the same partialling methodology, examined DIF of the mental processing scales of the Kaufman Assessment Battery for Children, concluding ª . . . there appears to be little evidence of systematic race or gender bias . . . º (p. 289). With multiple-choice tests, another level of complexity is added to the examination of content bias. With a multiple-choice question, three or four distractors are typically given in addition to the correct response. Distractors may be examined for their attractiveness (the relative frequency with which they are chosen) across groups. When distractors are found to be disproportionately attractive for members of any particular group, the item may be defined as biased. When items are constructed to have an equal distribution of responses to each distractor for the total test population, then chisquare can be used to examine the distribution of choices for each distractor for each group (e.g., Burrill, 1975).
Jensen (1976) investigated the distribution of wrong responses for two multiple-choice intelligence tests, the Peabody Picture Vocabulary Test (PPVT) and Raven's Progressive Matrices (the Raven). Each of these tests was individually administered to 600 White and 400 Black children between the ages of six and 12. The analysis of incorrect responses for the PPVT indicated that the errors were distributed in a nonrandom fashion over the distractors for a large number of items. However, no racial bias in response patterns occurred, since the disproportionate choice of distractors followed the same pattern for Blacks and Whites. On the Raven, Blacks make different types of errors than Whites, but only on a small number of items. Jensen followed up these items and compared the Black response pattern to the response pattern of White children at a variety of age levels. For every item showing differences in Black±White response patterns, the Black response could be duplicated by the response patterns of Whites approximately two years younger than Blacks. Veale and Foreman (1983) have advocated inspecting multiple-choice tests for bias in distractor or ªfoilº response distributions as a means of refining tests before they are finalized for the marketplace. They note that there are many instances whereby unbiased external criteria (such as achievement or ability) or culturally valid tests are not readily accessible for detecting bias in the measure under study. Veale and Foreman add that inspection of incorrect responses to distractor items can often lead to greater insight concerning cultural bias in any given question than would inspection of percentage of correct responses across groups. Veale and Foreman (1983) provide the statistical analyses for their ªoverpull probability modelº along with the procedures for measuring cultural variation and diagraming the source of bias within any given item. Investigation of item potential sources of bias during test development is certainly not restricted to multiple-choice items and methods such as those outlined by Veale and Foreman (1983). The possibilities are numerous (see Camilli & Shepard, 1994; Jensen, 1980, chap. 9). For example, Scheuneman (1987) has used the results of linear methods on Graduate Record Examination (GRE) item data to show interesting influences on Black± White performance when specific item characteristics (e.g., vocabulary content, one true or one false answer to be selected, diagrams to be used or not used, use of antonym items, etc.) are uniformly investigated. Although Scheuneman indicates that future research of this type should reduce the number of variables to address (there
are 16 hypotheses therein), the results nonetheless suggest that bias methodology is a viable way in which to determine whether differential effects can ªbe demonstrated through the manipulation of relatively stable characteristics of test itemsº (p. 116). Scheuneman presented pairs of items, with the designated characteristic of a question format under study present in one item and absent or modified in the other. Paired experimental items were administered in the experimental section of the GRE General Test, given in December 1982. Results indicated that certain ªitem elements'Ðcommon in general form to a variety of questionsÐappeared to have a differential impact on Black and White performance. For example, significant group version interactions were seen for one correct true vs. one correct false response and for adding/modifying prefixes/suffixes to the stimulus word in antonym items. The question is thus raised as to whether the items showing differential impact are measuring the content domain (e.g., veral, quantitative, or analytial thinking) as opposed to an aspect of ªelementº within the presentation to some degree. Another approach to the identification of biased items has been pursued by Jensen (1976). According to Jensen, if a test contains items that are disproportionately difficult for one group of examinees as compared to another, the correlation of P decrements between adjacent items will be low for the two groups. (ªP decrementº refers to the difference in the difficulty index, P, from one item of a test to the next least or most item. Typically, ability test items are arranged in ascending order of difficulty.) Jensen (1974, 1976) also contends that if a test contains biased items, the correlation between the rank order of item difficulties for one race with another will also be low. Jensen (1974, 1976, 1977) calculated cross-racial correlations of item difficulties for large samples of Black and White children on five major intelligence tests: the PPVT, the Raven, the Revised Stanford±Binet Intelligence Scale Form L-M, the WISC-R, and the Wonderlic Personnel Test. Cross-racial correlations of P decrements were reported for several of the scales. Jensen's results are summarized in Table 1, along with the results of several other investigators also employing Jensen's methodology. As is readily apparent in Table 1, little evidence to support any consistent content bias within any of the scales investigated was found. The consistently large magnitude of the crossracial correlations of P decrements is impressive and indicates a general lack of content bias in the instuments as a whole. As previously noted, however, some individual items were identified
as biased, yet they collectively accounted for only 2±5% of the variance in performance differences and showed no detectable pattern in item content. This method has proved popular with some test publishers who desire to look at the items on a test as a group, despite the fact this approach may be overly sensitive due to the instability of estimates of P values (which would cause the correlation to be spuriously low). Using the most recent version of the Detroit Tests of Learning Aptitude (DTLA-3; Hammill, 1991), Hammill reported correlations of P decrements exceeding 0.90 for all subtests with most exceeding 0.95. Similar results have been reported for other aptitude measures. On the 14 subtests of the Test of Memory and Learning (TOMAL; Reynolds & Bigler, 1994), Reynolds and Bigler report correlations across P decrements by gender and ethnicity that all exceed 0.90 with most again above 0.95. Another approach to this question is to use the partial correlation between a demographic or other nominal variable and item score, where the correlation between total test score and the variable of interest has been removed from the relationship. If a significant partial correlation exists, say, between race and an item score after the race±total test score relationship has been partialed, then the item is performing differentially across race within ability level. Bias has been demonstrated at this point under the definition offered above. Use of the partial correlation (typically a partial point-biserial r) is a simple yet powerful item bias detection approach, but its development is relatively recent and its use not yet common. The partial correlation approach also does not have the problems of ANOVA methods. An example of its application may be found in Reynolds, Willson, and Chatman (1984). A common practice has been a return to including expert judgment by professionals and members of minority groups in the item selection for new psychological and educational tests. This approach was used in development of the K-ABC, the revision of the Wechsler Preschool and Primary Scale of Intelligence (WPPSI-R), the PPVT-R, PPVT-III, and a number of other contemporary tests. The practice typically asks for an ªarmchairº inspection of individual items as a means of locating and purging biased items in the measure under development. Since, as previously noted, no detectable pattern or common characteristic of content of individual items statistically shown to be biased has been observed (given reasonable care in the itemwriting stage), it seems reasonable to question the ªarmchairº approach to determining biased
Table 1 Cross-racial analysis of content bias for five major intelligence scales. Cross-racial correlation of rank order of item difficultiesa Scale Peabody Picture Vocabulary Test (Jensen, 1974) Raven's Progressive Matrices (Jensen, 1974) Stanford-Binet Intelligence Scale (Jensen, 1976) Wechsler Intelligence Scale for Children-Revised (Jensen, 1976) (Sandoval, 1979)c (Mille, 1979) (1949 WISC) Wonderlic Personnel Test (Jensen, 1977)
Black±White correlationsb
White±Mexican±American correlationsb
0.99 (0.79), 0.98 (0.65) 0.99 (0.98), 0.99 (0.96) 0.96
0.98 (0.78), 0.98 (0.66)
0.95 0.98 (0.87) 0.96, 0.95 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 pioneering work of McGurk (1951) has not supported the position that anyone canÐupon surface inspectionÐdetect the degree to which any given item will function differentially across groups (Shepard, 1982). Several researchers since McGurk's time have identified items as being disproportionately more difficult for minority group members than for members of the majority culture and have subsequently compared their results with a panel of expert judges. The data have provided some interesting results. Although examples of the failure of judges to identify biased items now abound (Camilli & Shepard, 1994) and show that judges are right about an item about as often as they are wrong, two studies demonstrate this failure most clearly. After identifying the eight least racially discriminating items on the Wonderlic Personnel Test, Jensen (1976) asked panels of five Black psychologists and five White psychologists to sort out the eight most and eight least discriminating items when only these 16 items were presented to them. The judges sorted the items at a level no better than chance. Sandoval and Mille (1980) conducted a somewhat more extensive analysis, using items from the WISCR. These two researchers had 38 Black, 22 Mexican-American, and 40 White university students from Spanish, history, and education classes identify items from the WISC-R that would be more difficult for a minority child than a White child and items that would be equally difficult for each group. A total of 45 WISC-R items were presented to each judge; these items included the 15 most difficult items for Blacks as compared to Whites, the 15 most difficult items
for Mexican-Americans as compared to Whites, and the 15 items showing the most nearly identical difficulty indices for minority and White children. The judges were asked to read each question and determine whether they thought the item was: (i) easier for minority than for White children, (ii) easier for White than for minority children, or (iii) of equal difficulty for White and minority children. Sandoval and Mille's (1980) results indicated that the judges were not able to differentiate accurately between items that were more difficult for minorities and items that were of equal difficulty across groups. The effects of the judges' ethnic background on the accuracy of item bias judgments were also considered. Minority and nonminority judges did not differ in their ability to identify accurately biased items, nor did they differ with regard to the type of incorrect identification they tended to make. Sandoval and Mille's (1980) two major conclusions were that ª(1) judges are not able to detect items which are more difficult for a minority child than an Anglo child, and (2) the ethnic background of the judge makes no difference in accuracy of item selection for minority childrenº (p. 6). In each of these studies, the most extreme items were used, which should have given the judges an advantage. Anecdotal evidence is also available to refute the assumption that armchair analyses of test bias in item content are accurate. The most widely cited example of a biased intelligence test item is item 6 of the WISC-R Comprehension subtest: ªWhat is the thing to do if a boy (girl) much smaller than yourself starts to fight with you?º This item is generally considered to be biased against US Black children in particular,
because of the scoring criteria. According to the item's critics, the most logical response for a Black child is to ªfight back,º yet this is a 0point response. The correct (2-point) response is to walk away and avoid fighting with the childÐa response that critics claim invites disaster in the Black culture, where children are taught to fight back and would not ªknowº the ªcorrect White response.º Black responses to this item have been investigated empirically in several studies, with the same basic results: the item is relatively easier for Black children than for White children. When all items on the WISC-R are ranked separately according to difficulty level for Blacks and Whites, this item is the 42nd least difficult item (where 1 represents the easiest item) for Black children and the 47th least difficult for White children (Jensen, 1976). Mille (1979), in a large N study of bias, reached a similar conclusion, stating that this item ªis relatively easier for Blacks than it is for Whitesº (p. 163). The results of these empirical studies with large samples of Black and White children in the USA are unequivocal: when matched for overall general intellectual skill, more Black than White children will get this item correctÐthe very item most often singled out as a blatant example of the inherent bias of intelligence test against Blacks, but so selected using anecdotal impressions and sterotypical views of Black cultural even by Black judges (see also Reynolds & Brown, 1984). Even without empirical support for its accuracy, a number of prestigious writers support the continued use of the ªface validityº approach of using a panel of minority judges to identify ªbiasedº test items (Anastasi, 1986; Kaufman, 1979; Sandoval & Mille, 1979). Those who support the continued use of this technique see it as a method of gaining greater rapport with the public. As pointed out by Sandoval and Mille (1979), ªPublic opinion, whether it is supported by empirical findings, or based on emotion, can serve as an obstacle to the use of a measurement instrumentº (p. 7). The elimination of items that are offensive or otherwise objectionable to any substantive segment of the population for whom the test is intended seems an appropriate action that may aid in the public's acceptance of new and better psychological asessment tools. However, the subjective-judgment approach should not be allowed to supplant the use of more sophisticated analyses in the determination of biased items. The subjective approach should serve as a supplemental procedure, and items identified through this method (provided that some interrater agreement can be obtainedÐan aspect of the subjective method yet to be demonstrated) as objectionable can be eliminated when a
psychometrically equivalent (or better) item can be obtained as a replacement and the intent of the item is kept intact (e.g., with a criterionreferenced measure, the new item must be designed to measure the same objective). Researchers such as Tittle (1982) have stressed that the possibility of and need for cooperation between those advocating statistical validity and those advocating face validity in nonbiased test construction is greater than one might think, given the above-cited research. Judgmental analysis allows for the perception of fairness in items, tests, and evaluations, and this perception should not be taken lightly. Tittle (1982) argues that ªjudgmental methods arise from a different, nonstatistical ground. In examining fairness or bias primarily on statistical grounds, we may again be witnessing a technical solution to a problem that is broader than the technical issuesº (p. 34). Cronbach (1980) does not find the issue of fairness as determined by subjective judgment to be outside the realm of test validation. Cronbach states, ªThe politicization of testing ought not [to] be surprising. Test data influence the fortunes of individuals and the support given to human service programsº (p. 100). Tittle (1975, 1982) argues that the general field of test development requires greater consensus regarding specific, multidimensional steps taken in formulating ªfairº measures, because ªfairnessº in testing will never be realistically viewed by the public from a unidimensional statistical standpoint. Considerably less work has been conducted in all areas of bias relative to personality testing, where there would appear to be greater opportunity for cultural, social, and ethnic factors to act to produce bias. Research on item bias of personality measures, though less extensive than with aptitude measures, has produced results similar to those with aptitude measures (see especially Moran, 1990; Reynolds, in press; Reynolds & Harding, 1983). Research evaluating behavior rating scales is also meager but at present supports the use of parent ratings in the diagnosis of childhood psychopathology independent of the child's ethnic background (e.g., see Mayfield & Reynolds, in press). A common set of items seems to measure consistently a variety of personality and behavioral traits for Whites, Blacks, and various Hispanic and Latin population residing in the USA (James, 1995; Mayfield & Reynolds, in press; Reynolds & Kamphaus, 1992). Thus far, this section has focused on the identification of biased items. Several studies evaluating other hypotheses have provided data that are relevant to the issue of content bias of psychological tests, specifically the WISC-R
Research Strategies and Results (although now largely superseded in practice by WISC-III, little data regarding bias are available specifically on this new scale). Jensen and Figueroa (1975) investigated Black±White differences in mental test scores as a function of differences in Level I (rote learning and memory) and Level II (complex cognitive processing) abilities. These researchers tested a large number of Blacks and Whites on the WISC-R Digit Span subtest and then analyzed the data separately for digits forward and digits backward. The content of the digits forward and digits backward procedures is the same. Thus, if score differences are due only to bias in content of the item validity, score differences across race should remain constant for the two tasks. On the other hand, since the information-processing demands of the two tasks are quite different (Reynolds, 1997b), the relative level of performance on the two tasks should not be the same, as Blacks and Whites differ in their ability to process information according to the demands of the two tasks. Jensen and Figueroa (1975) found the latter to be the case. The Black±White score difference on digits backward was more than twice the magnitude of the difference for digits forward. Granted, this methodology can provide only indirect evidence regarding the content validity of an instrument; however, its importance is in providing a different view of the issues and an alternative research strategy. Since the Jensen and Figueroa results do not indicate any content bias in the Digit Span subtest, they add to a growing body of literature that strongly suggests the lack of cultural bias in wellconstructed, standardized tests, and their generalization within a common language and with some cultural diversity, at least for Black and for White US cultures. Another study (Reynolds & Jensen, 1983) examined each of the 12 WISC-R subtests for cultural bias against Blacks using a variation of the group X item ANOVA methodology discussed earlier. Reynolds and Jensen matched 270 Black children with 270 White children from the WISC-R standardization sample on the basis of gender and WISC-R Full Scale IQ. Matching the two groups of children on the bases of the Full Scale IQ essentially equated the two groups for g. Therefore, examining Black± White differences in performance on each subtest of the WISC-R made it possible to determine which, if any, of the subtests were disproportionately difficult for Blacks or Whites. A summary of the Reynolds and Jensen (1983) results is presented in Table 2. Blacks exceeded Whites in performance on two subtests: Digit Span and Coding. Whites exceeded Blacks in performance on three
subtests: Comprehension, Object Assembly, and Mazes. A trend was apparent for Blacks to perform at a higher level on the Arithmetic subtest, while Whites tended to exceed Blacks on the Picture Arrangement subtest. Although these results can be interpreted to indicate bias in several of the WISC-R subtests, the actual differences were very small (typically of the order of 0.10±0.15 standard deviation), and the amount of variance in performance associated with ethnic group membership was less than 5% in each case. The results are also reasonably consistent with Jensen's theory on mental test score differences and their relationship to Level I and Level II abilities. The Digit Span and Coding subtests are clearly the best measures of Level I abilities on the WISC-R, while Comprehension, Object Assembly, and Mazes are more closely associated with Level II abilities. Digit Span and Coding are also tasks adversely affected by increases in an examinee's anxiety level. The relatively higher level of performance by the Black children on these tasks is also inconsistent with arguments that the testing circumstance is more unfamiliar and more anxiety provoking to minority children relative to their White counterparts. From a large number of studies employing a wide range of methodologies, a relatively clear picture emerges: content bias in well-prepared standardized tests is irregular in its occurrence, and no common characteristics of items that are found to be biased can be ascertained by expert judges (minority or nonminority). The variance in group score differences on mental tests associated with ethnic group membership when content bias has been found is relatively small (typically ranging from 2% to 5%). Even this small amount of bias has been seriously questioned, as Hunter (1975) describes such findings basically as methodological artifacts. Harrington (1975, 1976) argued that traditional statistical methods would not detect DIF and that tests are designed in a psychometrically flawed manner so as to always favor the numerically superior group in a population. Although Harrington's research and logic are impressive, his results have not held and the Harrington Effect is not seen in a variety of works (e.g., Bayley, 1969; Beauchamp, Sammuels, & Griffore, 1974; Hickman & Reynolds, 1986; James, 1995). Although the search for common ªbiasedº item characteristics will continue, and psychologists must pursue the public relations issues of face validity, ªarmchairº claims of cultural bias in aptitude tests have found no empirical support in a large number of actuarial studies contrasting the performance of a variety of racial groups on items and subscales of the most
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
WISC-R variable Information Similarities Arithmetic Vocabulary Comprehension Digit Span Picture Completion Picture Arrangement Block Design Object Assembly Coding Mazes Verbal IQ Performance IQ Full Scale IQ NS, not significant. ± ± a White X ±Black X difference.
8.40 8.24 8.98 8.21 8.14 9.51 8.49 8.45 8.06 8.17 9.14 8.69 89.63 89.29 88.61
70.16 70.11 70.36 +0.06 +0.44 +0.62 +0.11 +0.34 +0.27 +0.51 70.49 +0.50 70.02 +0.87 +0.35
0.54 0.22 2.52 0.06 4.27 6.03 0.18 1.78 1.36 4.41 4.30 3.60 0.04 0.72 0.13
NS NS 0.10 NS 0.05 0.01 NS 0.01 NS 0.05 0.05 0.05 NS NS NS
Degrees of freedom = 1538.
widely employed intelligence and achievement scales in the USA; neither differential for singlegroup validity has been demonstrated. However, these results apply only to groups where a common language exists among examinees. Personality and interest measures fare likewise but there is less good research available for such tests. Test translations are a different issue and required a different line of study altogether. 10.03.7.2 Bias in Construct Validity There is no single method for the accurate determination of the construct validity of educational and psychological tests. Defining bias in construct validity thus requires a general statement that can be researched from a variety of viewpoints with a broad range of methodologies. The following rather parsimonious definition is proffered: bias exists in regard to construct validity when a test is shown to measure different hypothetical traits (psychological constructs) for one group than for another; that is differing interpretations of a common performance are shown to be appropriate as a function of ethnicity, gender, or another variable of interest, one typically but not necessarily nominal. As befits the concept of construct validity, many different methods have been employed to examine existing tests for potential bias in construct validity. One of the most popular and necessary empirical approaches to investigating construct validity is factor analysis (Anastasi,
1982; Cronbach, 1970). Factor analysis as a procedure identifies clusters of test items or clusters of subtests of psychological or educational tests that correlate highly with one another, and less so or not at all with other subtests or items. It thus allows one to determine patterns of interrelationships of performance among groups of individuals. For example, if several subtests of an intelligence scale load highly on (are members of) the same factor, then if a group of individuals score high on one of these subtests, they would be expected to score at a high level on other subtests that load highly on that factor. Psychologists attempt to determine, through a review of the test content and correlates of performance on the factor in question, what psychological trait underlies performance; or, in a more hypothesis-testing approach, they will make predictions concerning the pattern of factor loadings. Dana (1993) notes that factor analysis across various cultural groups can be a useful means of examining the cross-cultural validity of tests of personality, behavior, or cognitive skill. Dana argues that when ª . . . the factor dimensions resulting from different factor analytic methods are stable, and therefore present an invariant structure across cultures, then cross-cultural validity may be inferredº (1993, p. 101). Reynolds (1982a, 1982b) has made similar albeit more detailed arguments as have others in specific domains such as intelligence. Hilliard (1979), one of the more vocal critics of IQ tests on the basis of cultural bias, has pointed out one of the
Research Strategies and Results potential areas of bias in comparisons of the factor-analytic results of tests across races: If the IQ test is a valid and reliable test of ªinnateº ability or abilities, then the factors which emerge on a given test should be the same from one population to another, since ªintelligenceº is asserted to be a set of mental processes. Therefore, while the configuration of scores of a particular group on the factor profile would be expected to differ, logic would dictate that the factors themselves would remain the same. (p. 53)
Although researchers do not necessarily agree that identical factor analytic results across groups speak to the innateness of the traits being measured, consistent factor-analytic results across populations do provide strong evidence that whatever is being measured by the instrument is being measured in the same manner and is, in fact, the same latent construct within each group. The information derived from comparative factor analysis across populations is directly relevant to the use of educational and psychological tests in diagnosis and other decision-making functions. Psychologists, in order to make consistent interpretations of test score data, must be certain that a test measures the same variable across populations. Two basic approaches, each with a number of variations have been employed to compare factor-analytic results across populations. The first and more popular approach asks how similar the results are for each group; the second and less popular approach asks whether the results show a statistically significant difference between groups. The most sophisticated approach to the latter question has been the foundational work of JoÈreskog (1969, 1971) in simultaneous factor analysis in several populations and now basically represented in the LISREL series of computer programs. However, little has been done with the latter approach within the context of test bias research. Mille (1979) has demonstrated the use of a simpler method (actually developed by Jensen and presented in detail in Jensen, 1980) for testing the significance of the difference between factors for two populations. A number of techniques have been developed to measure the similarity of factors across groups. The two most common methods of determining factorial similarity or factorial invariance involve the direct comparison of factor loadings across groups. The two primary techniques for this comparison are (i) the calculation of a coefficient of congruence (Harman, 1976) between the loadings of corresponding factors for two groups, and (ii) the simple calculation of a Pearson product-moment
coefficient of correlation between the factor loadings of the corresponding factors. The latter technique, though used with some frequency, is less satisfactory than the use of the coefficient of congruence, since in the comparison of factor loadings certain of the assumptions underlying the Pearson r may be violated. When one is determining the degree of similarity of factors, a value of 0.90 or greater is typically, though arbitrarily, taken to indicate equivalent factors (factorial invariance). However, the most popular methods of calculating factorial similarity produce quite similar results (Reynolds & Harding, 1983), at least in large n studies. In contrast to Hilliard's (1979) strong statement that studies of factorial similarity across race have not been reported in the technical literature on IQ, a number of such studies have appeared dealing with a number of different tests. The focus here is primarily on studies comparing factor-analytic results across ethnic groups in the USA for aptitude tests, since these are the most controversial of tests. Because the WISC (Wechsler, 1949) and its successor, the WISC-R (Wechsler, 1974; now superseded by the WISC-III, but as yet no such bias research is available on the latter scale), have been the most widely employed individual intelligence tests with school-age children in much of the world, it is appropriate that the cross-race structure of these two instruments has received extensive investigation for both normal and referral populations of children. Using a large, random sample, Reschly (1978) compared the factor structure of the WISC-R across four racially identifiable groups: Whites, Blacks, Mexican-Americans, and native American Papagos, all from the southwestern USA. Consistent with the findings of previous researchers with the 1949 WISC (Lindsey, 1967; Silverstein, 1973), Reschly (1978) reported substantial congruency of factors across races when the two-factor solutions were compared (the twofactor solution typically reiterated Wechsler's a priori grouping of the subtests on to a Verbal and a Performance, or nonverbal, scale). The 12 coefficients of congruence for comparisons of the two-factor solution across all combinations of racial groupings ranged only from 0.97 to 0.99, denoting factorial equivalence of this solution across groups. Reschly also compared three-factor solutions (three-factor solutions typically include Verbal Comprehension, Perceptual Organization, and Freedom from Distractibility factors), finding congruence only between Whites and Mexican-Americans. These findings are also consistent with previous research with the WISC (Mille, 1979; Semler & Iscoe, 1966), an intelligence scale originally developed and normed on an all-White sample.
The g factor present in the WISC-R was shown to be congruent across race, as was also demonstrated by Mille (1979) for the WISC. Reschly (1978) concluded that the usual interpretation of the WISC-R Full Scale IQ as a measure of overall intellectual ability appears to be equally appropriate for Whites, Blacks, Mexican-Americans, and Native American Papagos. Jensen (1985) has presented compelling data indicating that the Black-White discrepancy seen in major tests of aptitude reflects primarily the g factor. Reschly also concluded that the Verbal-Performance scale distinction on the WISC-R is equally appropriate across race and that there is strong evidence for the integrity of the WISC-R's construct validity as a measure of intelligence for a variety of populations. Support for Reschly's (1978) conclusions is available from a variety of other studies of the WISC and WISC-R. Applying a hierarchical factor-analytic method developed by Wherry and Wherry (1969), Vance and Wallbrown (1978) factor analyzed the intercorrelation matrix of the WISC-R subtests for 150 referred Blacks from the Appalachian region of the USA. The two-factor hierarchical solution determined for Vance and Wallbrown's (1978) Blacks was highly similar to hierarchical factor solutions determined for the standardization samples of the Wechsler scales generally (Blaha, Wallbrown, & Wherry, 1975; Wallbrown, Blaha, & Wherry, 1973). Vance and Wallbrown's (1978) results with the WISC-R are also consistent with a previous hierarchical factor analysis with the 1949 WISC for a group of disadvantaged Blacks and Whites (Vance, Huelsman, & Wherry, 1976). Several studies comparing the WISC-R factor structure across races for normal and referral populations of children have also provided increased support for the generality of Reschly's (1978) conclusions and the results of the other investigators cited above. Oakland and Feigenbaum (1979) factor analyzed the 12 WISC-R subtests' intercorrelations separately for stratified (race, age, sex, SES) random samples of normal White, Black, and Mexican-American children from an urban school district of the northwestern USA. Pearson r's were calculated between corresponding factors for each group. For the g factor, the Black±White correlation between factor loadings was 0.95, the MexicanAmerican White correlation was 0.97, and the Black Mexican-American correlation was 0.96. Similar comparisons across all WISC-R variables produced correlations ranging only from 0.94 to 0.99. Oakland and Feigenbaum concluded that the results of their factor analyses ªdo not reflect bias with respect to construct
validity for these three racial-ethnic . . . groupsº (1979, p.973). Gutkin and Reynolds (1981) determined the factorial similarity of the WISC-R for groups of Black and White children from the WISC-R standardization sample. This study is particularly important to examine in determining the construct validity of the WISC-R across races, because of the sample employed in the investigation. The sample included 1868 White and 305 Black children obtained in a stratified random sampling procedure designed to mimic the 1970 US census data on the basis of age, sex, race, SES, geographic region of residence, and community size. Similarity of the WISC-R factor structure across race was investigated by comparing the Black and White groups for the two- and three-factor solutions on (i) the magnitude of unique variances, (ii) the pattern of subtest loadings on each factor, (iii) the portion of total variance accounted for by common factor variance, and (iv) the percentage of common factor variance accounted for by each factor. Coefficients of congruence comparing the unique variances, the g factor, the two-factor solutions, and the three-factor solutions across races all achieved a value of 0.99. The portion of total variance accounted for by each factor was the same in both the twoand three-factor racial groups. Gutkin and Reynolds (1981) concluded that for White and Black children the WISC-R factor structure was essentially invariant, and that no evidence of single-group or differential construct validity could be found. Subsequent studies comparing the WISC-R factor structure for referral populations of White and Mexican-American children have also strongly supported the construct validity of the WISC-R across races (e.g., Dean, 1979b; Gutkin & Reynolds, 1980). DeFries et al. (1974) administered 15 mental tests to large samples of Americans of Japanese and Chinese ancestry. After examining the pattern of intercorrelations among the 15 tests for each of these two ethnic groups, DeFries et al. concluded that the cognitive organization of the two groups was virtually identical. In reviewing this study, Willerman (1979) concluded that ªThe similarity in factorial structure [between the two groups] suggests that the manner in which the tests are constructed by the subjects is similar regardless of ethnicity and that the tests are measuring the same mental abilities in the two groupsº (p. 468). At the adult level, Kaiser (1986) and Scholwinski (1985) have analyzed the Wechsler Adult Intelligence ScaleRevised (WAIS-R; Wechsler, 1981) and reported substantial similarity between factor structures for Black and White samples obtained from the WAIS-R standardization data.
Research Strategies and Results At the preschool level, factor-analytic results also tend to show consistency of construct validity across races, though the results are less clear-cut. In a comparison of separate factor analyses of the McCarthy Scales of Children's Abilities (McCarthy, 1972) for groups of Black and White children, Kaufman and DiCuio (1975) concluded that the McCarthy Scales showed a high degree of factorial similarity between the two races. The conclusion was not straightforward, however. Four factors were found for the Blacks and three for the Whites. Kaufman and DiCuio based their conclusion on factorial similarity on the finding that each ªWhiteº factor had a coefficient of congruence of 0.85±0.93 with one ªBlackº factor. One Black factor on the McCarthy Scales had no White counterpart with a coefficient of congruence beyond 0.74 (the Memory factor), and the Black and White Motor factors showed a coefficient of congruence of only 0.85. When investigating the factor structure of the WPPSI across race, Kaufman and Hollenbeck (1974) found much ªcleanerº factors for Blacks and Whites than with the McCarthy Scales. The two factors, essentially mirroring Wechsler's Verbal and Performance scales, were virtually identical between the races. Both factors also appear closely related to the hierarchical factor solution presented by Wallbrown at al. (1973) for Blacks and Whites on the WPPSI. When comparing factor analyses of the Goodenough± Harris Human Figure Drawing Test scoring item, Merz (1970) found highly similar factor structures for Blacks, Whites, Mexican-Americans, and native Americans. Other investigators have found differences across races in the factor structures of several tests designed for preschool and primary-grade children. Goolsby and Frary (1970) factoranalyzed the Metropolitan Readiness Test (MRT) together for separate groups of Blacks and Whites, finding differences in the factor structure of this grouping of tests across races. When evaluating the experimental edition of the Illinois Test of Psycholinguistic Abilities, Leventhal and Stedman (1970) noted differences in the factor structure of this battery for Blacks and Whites. Two more studies have clarified somewhat the issue of differential construct validity of preschool tests across race. The MRT (Hildreth, Griffith, & McGauvran, 1969) is one of the most widely employed of all preschool screening measures in the USA, and its 1969 version is composed of six subtests: Word Meaning, Listening, Matching, Letter Naming, Numbers, and Copying. Reynolds (1979b) had previously shown this to be essentially a one-factor (general Readiness) instrument. In a subsequent study, Reynolds
(1979c) compared the general factor making up the MRT across races (Blacks and Whites) and genders. Substantial congruence was noted: coefficients of congruence across each pair of race±sex groupings ranged only from 0.92 to 0.99, with the lowest coefficient derived from the intraracial comparison for White females and White males. Eigenvalues, and subsequently the proportion of variance accounted for by the factor, were also highly similar for the race±sex groupings. The lack of differential or single-group construct validity across sex has also been demonstrated with aptitude tests for school-age children (Reynolds & Gutkin, 1980c). In a more comprehensive study employing seven major preschool tests (the McCarthy Draw-a-Design and Draw-a-Child subtests, the Lee-Clark Reading Readiness tests, The Tests of Basic Experiences Language and Mathematics subtests, the Preschool InventoryRevised Edition, and the MRT), Reynolds (1980a) reached a similar conclusion. A twofactor solution was determined with this battery for each of the four race±sex groups as above. Coefficients of congruence ranged only from 0.95 to 0.99 for the two factors, and the average degree of intercorrelation was essentially the same for all groups, as were eigenvalues and the percentage of variance accounted for by the factors. Reynolds (1980a) again concluded that the abilities being measured were invariant across race and that there was no evidence of differential or single-group construct validity of preschool tests across races or genders. The clear trend in studies of preschool tests' construct validity across race (and sex) is to uphold validity across groups. Such findings add support to the use of existing preschool screening measures with Black and White children of both sexes in the very necessary process of early identification (Reynolds, 1979a) of potential learning and behavior problems. Taken individually but especially as a whole, these various cross-group factor analytic studies contradict sharply Helms' (1992) assertion that Black and White groups within the USA have significantly different latent cognitive structures. These results argue in favor of a common human organization of abilities and neuropsychological processes among the many ethnic groups studied thus far. Although majority± minority culturally related differences in level of performance differ in various ways across many ethnic groups, a common organization of latent ability structures seems clearly evident at this time. As is appropriate for studies of construct validity, comparative factor analysis has not been the only method of determining whether
single-group or differential validity exists. Another method of investigation involves comparing internal-consistency reliability estimates across groups. Internal-consistency reliability is determined by the degree to which the items are all measuring a similar construct. To be unbiased with regard to construct validity, internal-consistency estimates should be approximately equal across races. This characteristic of tests has been investigated with Blacks, Whites, and Mexican-Americans for a number of popular aptitude tests within the US population. With groups of Black and White adults, Jensen (1977) calculated internal-consistency estimates (using the Kuder±Richardson 21 formula) for the Wonderlic Personnel Test (a frequently used employment/aptitude test). Kuder±Richardson 21 values of 0.86 and 0.88 were found, respectively, for Blacks and Whites. Using Hoyt's formula, Jensen (1974) determined internal-consistency estimates of 0.96 on the PPVT for each of three groups of children: Blacks, Whites, and Mexican-Americans. When children were categorized by gender within each racial grouping, the values ranged only from 0.95 to 0.97. On Raven's Progressive Matrices (colored), internal-consistency estimates were also quite similar across race and sex, ranging only from 0.86 to 0.91 for the six race±sex groupings. Thus, Jensen's (1974, 1977) research with three popular aptitude tests shows no signs of differential or single-group validity with regard to homogeneity of test content or consistency of measurement across groups. Sandoval (1979) and Oakland and Feigenbaum (1979) have extensively investigated internal consistency of the various WISC-R subtests (excluding Digit Span and Coding, for which internal-consistency analysis is inappropriate) for Whites, Blacks, and MexicanAmericans. Both of these studies included large samples of children, with Sandoval's (1979) including over 1000. Sandoval found internalconsistency estimates to be within 0.04 of one another for all subtests except Object Assembly. This subtest was most reliable for Blacks (0.95), while being about equally reliable for Whites (0.79) and Mexican-Americans (0.75). Oakland and Feigenbaum (1979) reported internal-consistency estimates that never differed by more than 0.06 among the three groups, again with the exception of Object Assembly. In this instance, Object Assembly was most reliable for Whites (0.76), with about equal reliabilities for Blacks (0.64) and Mexican-Americans (0.67). Oakland and Feigenbaum also compared reliabilities across sex, finding highly similar values for males and females. Dean (1977) examined the internal consistency of the
WISC-R for Mexican-American children tested by White examiners. He reported internalconsistency reliability estimates consistent with, although slightly exceeding, values reported by Wechsler (1974) for the predominantly White standardization sample. The Bender±Gestalt Test has also been reported to have similar internal-consistency estimates for Whites (0.84), Blacks (0.81), and Mexican-Americans (0.72), and for males (0.81) and females (0.80) (Oakland & Feigenbaum, 1979). Several other methods have also been used to determine the construct validity of popular psychometric instruments across races. Since intelligence is considered a developmental phenomenon, the correlation of raw scores with age has been viewed as one measure of constrict validity for intelligence tests. Jensen (1976) reported that the correlations between raw scores on the PPVT and age were 0.79 for Whites, 0.73 for Blacks, and 0.67 for MexicanAmericans. For Raven's Progressive Matrices (colored), correlations for raw scores with age were 0.72 for Whites, 0.66 for Blacks, and 0.70 for Mexican-Americans. Similar results are apparent for the K-ABC (Kamphaus & Reynolds, 1987) and the Test of Memory and Learning (Reynolds & Bigler, 1994). Thus, in regard to increase in scores with age, the tests behave in a highly similar manner for Whites, Blacks, and Mexican-Americans. Similar findings occur in male±female comparisons. In the review work of Moran (1990) and in a search for more recent work, it is apparent that only a few studies of the differential construct validity of personality tests have been undertaken, despite large mean differences across ethnicity and gender on such popular measures as the stalwart MMPI. Dana (1993) sharply criticizes even the meager work to date on the MMPI, stating that ª[C]omparative MMPI research studies of Anglo-American and other cultural groups have typically not only used inappropriate statistics but also failed to equate groups adequately on socioeconomic criteria or even to define ethnicityº (p. 98). The lack of extensive research using method designed to detect test bias for such widely used scales as the MMPI is nothing short of appalling. A look at the newer MMPI-2 Manual suggests gender differs in construct validity but provides no real evidence either way. A few studies of factorial similarity of instruments such as the Revised Children's Manifest Anxiety Scale show little bias and high degrees of similarity by ethnicity and gender (Moran, 1990; Reynolds & Paget, 1981). Constuct validity of a large number of popular psychometric assessment instruments has been investigated across races and genders
Research Strategies and Results with a variety of populations of minority and White children and with a divergent set of methodologies (see Reynolds, 1982b, for a review of methodologies). All roads have led to Rome: no consistent evidence of bias in construct validity has been found with any of the many tests investigated. This leads to the conclusion that psychological tests (especially aptitude tests) function in essentially the same manner, that test materials are perceived and reacted to in a similar manner, and that tests measure the same construct with equivalent accuracy for Blacks, Whites, Mexican-Americans, and other American minorities of both sexes and at all levels of SES. Single-group validity and differential validity have not been found and probably do not exist with regard to well-constructed and well-standardized psychological and educational tests of intellect, personality, or behavior although data are not as thorough for the latter two categories and much work is needed here. 10.03.7.3 Bias in Predictive or Criterion-related Validity Evaluating bias in predictive validity of educational and psychological tests is less closely related to the evaluation of group mental test score differences than to the evaluation of individual test scores in a more absolute sense. This is especially true for aptitude (as opposed to personality or diagnostic) tests, where the primary purpose of administration is the prediction of some specific future outcome or behavior. Internal analyses of bias (such as in content and construct validity) are less confounded than analyses of bias in predictive validity, however, because of the potential problems of bias in the criterion measure. Predictive validity is strongly influenced by the reliability of criterion measures, which frequently is poor. The degree of relationship between a predictor and a criterion is restricted as a function of the square root of the product of the reliabilities of the two variables. Arriving at a consensual definition of bias in predictive validity is also a difficult task, as previously discussed. Yet, from the standpoint of the practical applications of aptitude and intelligence tests, predictive validity is the most crucial form of validity in relation to test bias. Much of the discussion in professional journals concerning bias in predictive validity has centered around models of selection. These issues have been discussed in Section 10.03.6. Since this section is concerned with bias in respect to the test itself and not the social or political justification of any one particular
selection model, the Cleary at al. (1975) definition, slightly rephrased here, provides a clear and direct statement of test bias with regard to predictive validity: a test is considered biased with respect to predictive validity if the inference drawn from the test score is not made with the smallest feasible random error or if there is constant error in an inference or prediction as a function of membership in a particular group. This definition is a restatement of previous definitions by Cardall and Coffman (1964), Cleary (1968), and Potthoff (1966), and has been widely accepted (though certainly not without criticism; e.g., Bernal, 1975; Linn & Werts, 1971; Schmidt & Hunter, 1974; Thorndike, 1971). Oakland and Matuszek (1977) examined procedures for placement in special education classes under a variety of models of bias in prediction, and demonstrated that the smallest number of children are misplaced when the Cleary et al (1975) conditions of fairness are met. (However, under ªquotaº system requirements, Oakland and Matuszek favor the Thorndike, 1971 conditions of selection.) The Cleary et al. definition is also apparently the definition espoused in US government guidelines on testing and has been held in at least one court decision (Cortez v. Rosen, 1975) to be the only historically, legally, and logically required condition of test fairness (Ramsay, 1979), although apparently the judge in the Larry P. v. Riles (1979) decision (but overturned on appeal) in the US Federal court system adopted the ªmean score differences as biasº approach. A variety of educational and psychological personnel long have adopted the Cleary et al. regression approach to bias, including: (i) noted psychological authorities on testing (Anastasi, 1986; Cronbach, 1970; Humphreys, 1973); (ii) educational and psychological researchers (Brossard, Reynolds, & Gutkin, 1980; Kallingal, 1971; Pfeifer & Sedlacek, 1971; Reynolds & Hartlage, 1978, 1979; Stanley & Porter, 1967; Wilson, 1969); (iii) industrial/organizational psychologists (Barlett & O'Leary, 1969; Einhorn & Bass, 1970; Gael & Grant, 1972; Grant & Bray, 1970; Ramsay, 1979; Tenopyr, 1967); and (iv) even critics of educational and psychological testing (Goldman & Hartig, 1976; Kirkpatrick, 1970; Kirkpatrick, Ewen, Barrett, & Katzell, 1968). The evaluation of bias in prediction under the Cleary et al. (1975) definition (the regression definition) is quite straightforward. With simple regression, predictions take the form of YÃi = aXi + b, where a is the regression coefficient and b is a constant. When this equation is graphed (forming a regression line), a represents the slope of the regression line and b the Y intercept. Since
our definition of fairness in predictive validity requires errors in prediction to be independent of group membership, the regression line formed for any pair of variables must be the same for each group for whom predictions are made. Whenever the slope or the intercept differs significantly across groups, there is bias in prediction if one attempts to use a common equation for all groups. However, if the regression equations for two (or more) groups are equivalent, prediction is the same for all groups. This condition is referred to variously as ªhomogeneity of regression across groups,º ªsimultaneous regression,º or ªfairness in prediction.º Homogeneity of regression across groups is illustrated in Figure 1. In this case, the single regression equation is appropriate with all groups, any errors in prediction being random with respect to group membership (i.e., residuals uncorrelated with group membership). When homogeneity of regression does not occur, for ªfairness in predictionº to occur, separate regression equations must be used for each group. In actual clinical practice, regression equations are seldom generated for the prediction of future performance. Instead, some arbitrary or perhaps statistically derived cutoff score is determined, below which ªfailureº is predicted. For school performance, IQs two or more standard deviations below the test mean are used to infer a high probability of failure in the regular classroom if special assistance is not provided for the student in question. Essentially, then, clinicians are establishing mental prediction equations that are assumed to be equivalent across ethnicity, gender, and so on. Although these mental equations cannot be tested readily across groups, the actual form of criterion prediction can be compared across groups in several ways. Errors in prediction must be independent of group membership. If regression equations are equal, this condition is met. To test the hypothesis of simultaneous regression, slopes and intercepts must both be compared. An alternative method is the direct examination of residuals through ANOVA or a similar design (Reynolds, 1980b). In the evaluation of slope and intercept values, two basic techniques most often have been employed in the research literature. Gulliksen and Wilks (1965) and Kerlinger (1973) describe methods for separately testing regression coefficients and intercepts for significant differences across groups. Using separate, independent tests for these two values considerably increases the probability of a decision error and unnecessarily complicates the decision-making process. Potthoff (1966) has described a useful technique that allows one
to test simultaneously the equivalence of regression coefficients and intercepts across K independent groups with a single F ratio (the Potthoff equations may be found also in Reynolds, 1982b). If a significant F results, the researcher may then test the slopes and intercepts separately if information concerning which value differs is desired. When homogeneity of regression does not occur, there are three basic conditions that can result: (i) intercept constants differ, (ii) regression coefficients (slopes) differ, or (iii) slopes and intercepts differ. These conditions are depicted pictorially in Figures 2, 3, and 4, respectively. The regression coefficient is related to the correlation coefficient between the two variables and is one measure of the strength of the relationship between two variables. When intercepts differ and regression coefficients do not, a situation such as that shown in Figure 2 results. Relative accuracy of prediction is the same for the two groups (a and b), the use of a regression equation derived by combining the two groups results in bias that works against the group with the higher mean criterion score. Since the slope of the regression line is the same for all groups, the degree of error in prediction remains constant and does not fluctuate as a function of an individual's score on the independent variable. That is, regardless of group member bs score on the predictor, the degree of underprediction in performance on the criterion is the same. As illustrated in Figure 2, the use of the common score of Yc for a score of X overestimates how well members of group a will perform and underestimates the criterion performance of members of group b. In Figure 3, nonparallel regression lines illustrate the case where intercepts are constant across groups but the slope of the line is different for each group. Here, too, the performance of the group with the higher mean criterion score is typically underpredicted when a common regression equation is applied. The amount of bias in prediction that results from using the common regression line is the distance of the score from the mean. The most difficult, complex case of bias is represented in Figure 4 where the result of significant differences in slopes and intercepts is shown. Not only does the amount of bias vary but even the direction can reverse, depending on the location of the individual's score in the distribution of the independent variable. Only in the case of Figure 4 do members of the group with the lower mean criterion score run the risk of having their performance on the criterion variable underpredicted by the application of a common regression equation. A considerable body of literature has developed regarding the differential predictive
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 employment selection and college admissions. However, virtually nothing appears in this regard with reference to personality tests (Dana, 1993; Moran, 1990) and this is a major weakness in the literature. In a review of 866 Black±White test validity comparisons from 39 studies of test bias in personnel selection, Hunter, Schmidt, and Hunter (1979) concluded that there was no evidence to substantiate hypotheses of differential or single-group validity with regard to the prediction of job performance across races for Blacks and Whites. A similar conclusion was reached by Jensen (1980), O'Conner, Wexley, and Alexander (1975), and Reynolds (1982a, 1995) among others. A number of studies have also focused on differential validity of the Scholastic Aptitude Test (SAT) in the prediction of college performance (typically measured
by grade point average, GPA). In general, these studies have found either no differences in the prediction of criterion performance for Blacks and Whites or a bias (underprediction of the criterion) against Whites (Cleary, 1968; Cleary et al., 1975; Goldman & Hewitt, 1976; Kallingal, 1971; Pfeifer & Sedlacek, 1971; Stanley, 1971; Stanley & Porter, 1967; Temp, 1971). When bias against Whites has been found, the differences between actual and predicted criterion scores, although statistically significant, have been quite small. Reschly and Sabers (1979) evaluated the validity of WISC-R IQs in the prediction of Metropolitan Achievement Tests (MAT) performance (Reading and Math subtests) for Whites, Blacks, Mexican-Americans, and native American Papagos. The choice of the MAT as a criterion measure in studies of predictive bias is particularly appropriate, since item analysis
Regression line group b
Common regression line c
Regression line group a
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) to eliminate racial bias in item content during the test construction phase. Anastasi (1986) has described the MAT as an excellent model of an achievement test designed to reduce or eliminate cultural bias. Reschly and Saber's (1979) comparison of regression systems indicated bias in the prediction of the various achievement scores. Again, however, the bias produced generally significant underprediction of White performance when a common regression equation was applied. Achievement test performance of the native American Papago group showed the greatest amount of overprediction of all non-White groups. Using similar techniques, but including teacher ratings, Reschly and Reschly (1979) also investigated the predictive validity of WISC-R factor scores with the samples of White, Black, Mexican-American,
and native American Papago children. A significant relationship occurred between the three WISC-R factors first delineated by Kaufman (1975) and measures of achievement for the White and non-White groups, with the exception of the Papagos. Significant correlations occurred between the WISC-R Freedom from Distractibility factor (Kaufman, 1975) and teacher ratings of attention for all four groups. Reschly and Reschly concluded that ªThese data also again confirm the relatively strong relationship of WISC-R scores to achievement for most non-Anglo as well as Anglo groupsº (1979, p. 239). Reynolds and Hartlage (1979) investigated the differential validity of Full Scale IQs from the WISC-R and its 1949 predecessor, the WISC, in predicting reading and arithmetic achievement for Black and White children who had been referred by their
a Yc
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 Southern school district. Comparisons of correlations and a Potthoff (1966) analysis to test for identity of regression lines revealed no significant differences in the ability or function of the WISC and WISC-R to predict achievement for these two groups. Reynolds and Gutkin (1980b) replicated this study for the WISC-R with large groups of White and Mexican-American children from the Southwest. Reynolds and Gutkin contrasted regression systems between WISC-R Verbal, Performance, and Full Scale IQs and the ªacademic basicsº of reading, spelling, and arithmetic. Only the regression equation between the WISC-R Performance IQ and arithmetic achievement differed for the two groups. The difference in the two equations was due to an intercept bias that resulted in the
overprediction of achievement for the MexicanAmerican children. Reynolds, Gutkin, Dappen, and Wright (1979) also failed to find differential validity in the prediction of achievement for males and females with the WISC-R. In a related study, Hartlage, Lucas, and Godwin (1976) compared the predictive validity of what they considered to be a relatively culture-free test (Raven's Progressive Matrices) with a more culture-loaded test (the 1949 WISC, a test developed and standardized on all White sample) for a group of low-SES, disadvantaged rural children. Hartlage et al. (1976) found that the WISC had consistently larger correlations with measures of reading, spelling, and arithmetic than Raven's Matrices. Although it did not make the comparison with other groups that is necessary for the drawing of firm conclusions, the study does support the validity of the WISC,
b c Yb a
Ya Yc Yb
Xi Predictor
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 of bias in the prediction of achievement for lowSES, disadvantaged rural children. Henderson, Butler, and Goffeney (1969) also reported that the WISC and the Bender±Gestalt Test were equally effective in the prediction of reading and arithmetic achievement for White and nonWhite groups, though their study had a number of methodological difficulties, including heterogeneity of the non-White comparison group. Reynolds, Willson, and Chatman (1985) evaluated the predictive validity of the K-ABC for Blacks and Whites. Occasional evidence of bias was found in each direction, but mostly in the direction of overprediction of the academic attainment levels of Blacks. Bossard et al. (1980) published a regression analysis of test bias on the 1972 Stanford±Binet Intelligence Scale for separate groups of Black
and White children. Neither regression systems nor correlations differed at p 5 0.05 for the prediction of the basic academic skills of reading, spelling, and arithmetic achievement for these two groups of referred children. An earlier study by Sewell (1979), a Black opponent of testing, did not compare regression systems, but also found no significant differences in validity coefficients for Stanford±Binet IQs predicting California Achievement Test (CAT) scores for Black and White first-grade children. A series of studies comparing the predictive validity of group IQ measures across races has been reviewed by Jensen (1980) and Sattler (1974). Typically, regression systems have not been compared in these studies: instead, researchers have compared only the validity coefficients across racesÐa practice that tells
Research Strategies and Results only whether the test is potentially nonbiased. The comparison of validity coefficients is nevertheless relevant, since equivalence in predictive validities is a first step in evaluating differential validity. That is, if predictive validities differ, then regression systems must differ; the reverse is not necessarily true, however, since the correlation between two variables is a measure of the strength or magnitude of a relationship and does not dictate the form of a relationship. Although the number of studies evaluating group IQ tests across ethnicity is small, they have typically employed extremely large samples. The Lorge± Thorndike verbal and nonverbal IQs have been most often investigated. Jensen (1980) and Sattler (1974) concluded that the few available studies suggest that standard IQ tests in current use have comparable validities for Black and White children at the elementary school level. Guterman (1979) reported on an extensive analysis of the predictive validity of the Ammons and Ammons Quick Test (QT; a measure of verbal IQ) for adolescents of different social classes. Social class was determined by a weighted combination of Duncan's SES index and the number of years of education of each parent. Three basic measures: (i) the Vocabulary subtest of the General Aptitude Test Battery (GATB); (ii) the test of Reading Comprehension from the Gates Reading Survey; and (iii) the Arithmetic subtest of the GATB were used. School grades in academic subjects for 9th, 10th, and 12th grades were also used to examine for bias in prediction. Guterman reached similar conclusions with regard to all criterion measures across all social classes: slopes and intercepts of regression lines did not differ across social class for the prediction of any of the criterion measures by the IQ derived from the QT. Several other social knowledge criterion measures were also examined. Again, slopes were constant across social class, and, with the exception of sexual knowledge, intercepts were also constant. Guterman concluded that his data provided strong support for equivalent validity of IQ measures across social class. In reanalyzing the Guterman (1979) study, Gordon and Rudert (1979) reached even stronger conclusions. Certainly with school-age children and adults, there is compelling evidence that differential and single-group predictive validity hypotheses must be rejected. As with constrict validity, at the preschool level the evidence is less clear and convincing but points toward a lack of bias against minorities. Because of doubts expressed about the usefulness of customary readiness tests with students of certain racial and ethnic backgrounds and with low-SES children, Mitchell (1967) inves-
tigated the predictive validity of two preschool readiness tests used in the US Office of Education (Cooperative First-Grade Reading Study, 1964±1965 revision) and the Murphy± Durell Reading Readiness Analysis (1964 revision). Mitchell concluded that the two readiness tests performed their functions as well with Black as with White children and that the general level of predictive validity was similar. This overstates the case somewhat, since only validity coefficients and not regression systems were compared, but Mitchell's (1967) study does support the predictive validity of these readiness tests across race. Oakland (1978) assessed the differential predictive validity of four readiness tests (the MRT, the Tests of Basic Experiences battery, the Slosson Intelligence Test, and the Slosson Oral Reading Test) across races (Black, White, and Mexican-American) for middle- and lowerSES children. The MAT, the CAT, and the California Test of Mental Maturity (CTMM) served as criterion variables. Since the CTMM is an IQ test, prediction of CTMM scores by the various readiness tests is excluded from the following discussion. Although Oakland (1978) did not use any test of statistical significance to compare the correlations between the independent and dependent variable pairs across ethnicity and SES, a clear pattern was found, showing higher levels of prediction for White as opposed to non-White groups. Oakland also did not compare regression systems, limiting his study to the report of the various validity coefficients for each race±SES grouping. Oakland's (1978) results clearly indicate potential bias in the prediction of early school achievement by individual readiness or screening tests. The lower correlations for non-White groups, however, given their lower mean criterion scores, led to anticipation of bias favoring non-Whites in the prediction of early school achievement. To investigate this possibility, Reynolds (1978) conducted an extensive analysis of predictive bias for seven major preschool tests (the Draw-a-Design and Draw-a-Child subtests of the McCarthy Scales; the Mathematics and Language subtests of the Tests of Basic Experiences; the Preschool Inventory-Revised Edition; and the Lee±Clark Reading Readiness Test) across race and gender for large groups of Blacks and Whites. For each preschool test, validity coefficients, slopes, and intercepts were compared, with prediction of performance on four subtests of the MAT (Word Knowledge, Word Discrimination, Reading, and Arithmetic) as the criterion measures. The general advantage of the MAT as a criterion in external studies of bias has previously been pointed out.
In the Reynolds (1978) study, the MAT had the added advantage of being chosen by the teachers in the district: data were gathered on a large number of early achievement tests, and the teachers selected the MAT as the battery most closely measuring what was taught in their classrooms. Regression systems and validity coefficients were compared for each independent±dependent variable pair for White females (WF) vs. White males (WM), Black females (BF) vs. Black males (BM), WF vs. BF, and WM vs. BM, resulting in 112 comparisons of validity coefficients and 112 comparisons of regression systems. Although the mean correlations were slightly lower for Blacks, the 112 comparisons of pairs of correlations revealed only three significant differences, a less-thanchance occurrence with this number of comparisons. Using the Potthoff (1966) technique for comparing regression lines produced quite different results. Of the 112 comparisons of regression lines, 43 (38.4%) showed differences. For comparisons with race as the major variable (and gender controlled), 31 (55.2%) of the 56 comparisons showed significantly different regression lives. Clearly, racial bias was significantly more prevalent than gender bias (p 5 0.01) in prediction. In comparing the various pretests, bias occurred most often with the Preschool Inventory and the Lee±Clark, whereas none of the comparisons involving the MRT showed bias. Though race clearly influenced homogeneity of regression across groups, the bias in each case acted to overpredict performance of lower-scoring groups; thus the bias acted against Whites and females and in favor of Blacks and males. A follow-up study (Reynolds, 1980b) has indicated one potential method for avoiding bias in the prediction of early school achievement with readiness or screening measures. Brief screening measures, especially at the preschool level, typically do not have the high level of reliability obtained by such instruments as the WISC-R or the Stanford±Binet. Linn and Werts (1971) have demonstrated convincingly that poor reliability can lead to bias in prediction. Early screening measures, as a rule, also assess a very limited area of functioning, rather than allowing the child to demonstrate its skills in a variety of areas of cognitive functioning. The one well-researched, reliable, broad-based readiness test, the MRT, has failed to show bias with regard to internal or external criteria. Comprehensive and reliable individual preschool instruments such as the WPPSI and the McCarthy Scales, while showing no internal evidence of test bias, have not been researched with regard to predictive bias across race. Reynolds (1980b) examined the predictive
validity of the seven preschool measures described previously when these were combined into a larger battery, thus increasing the scope and reliability of the assessment. Since the definition of predictive bias noted earlier requires that errors in prediction be independent of group membership, Reynolds (1980b) directly examined residuals (a ªresidual termº is the remainder when the predicted score for an individual is subtracted from the individual's obtained score) across race and gender when the seven-test battery was used to predict MAT scores in a multiple-regression formula. Subtests of the seven-test battery were also examined. Results of a race X sex ANOVA of residuals for each of the MAT subtests when the seven-test battery was employed revealed no significant differences in residuals across races and genders, and no significant interactions occurred. When a subset of the larger battery was submitted to the same analysis, racial bias in prediction did not occur; however, a significant F resulted for gender effects in the prediction of two of the four MAT subscores (Word Discrimination and Word Knowledge). Examination of the residuals for each group showed that the bias in prediction was again against the group with the higher mean criterion scores: there was a consistent underprediction of performance for females. The magnitude of the effect was small, however, being of the order of 0.13±0.16 standard deviations. Thus, at the preschool level, the only convincing evidence of bias in predictive validity is a gender effect, not a race effect. Kamphaus and Reynolds (1987) reviewed the available literature on predictive bias with the K-ABC and concluded that overprediction of Black children's performance in school is more common with the K-ABC, particularly the KABC Sequential Processing scale, than with other tests. The effects are small, however, and are mitigated in large part by using the K-ABC Mental Processing Composite. Some bias also occurs against Blacks, but when the extensive nature of the bias research with the K-ABC is considered, results with the K-ABC are not substantially different from the results with the WISC-R (with the exception of overprediction of Black academic performance by the K-ABC Sequential Processing scale). Keith and Reynolds (1990) have suggested the use of path analysis as an alternative model for assessing bias is predictive validity. In such a path model, ability would be proposed to predict achievement, and group membership would be assessed as a moderator variable. A diagrammatic representation of a biased and an unbiased model is shown in Keith and Reynolds (1990). Bias in prediction would exist in such a
Summary and Future Directions model when group membership affects measured ability independent of true ability, that is, errors of measurement in testing of ability would be correlated with group membership. With regard to bias in predictive validity, the empirical evidence suggests conclusions similar to those regarding bias in content and construct validity. There is no strong evidence to support contentions of differential single-group validity. Bias occurs infrequently and with no apparently observable pattern, except when instruments of poor reliability and high specificity of test content are examined. When bias occurs, it is most often in the direction of favoring low-SES, disadvantaged ethnic minority children, or other low-scoring groups. 10.03.8 CROSS-CULTURAL TESTING WHEN TRANSLATION IS REQUIRED When a test is translated from one language to another, the research findings discussed thus far do not hold. It is inappropriate simply to translate a test and apply it in a different linguistic culture. A test must be redeveloped from scratch (although constructs may be retained) basically before any such application would be appropriate. New items, new normative data, and new scaling would all be required. This has been known since the early days of psychological assessment and testing. In the early 1900s, when the Binet±Simon tests were brought to the USA from France, approximately 30 different versions of the test were developed in the USA by various researchers. However, most of these were mere translations or contained minor modifications to adapt to American culture. The Stanford±Binet Intelligence Scale, in its various incarnations, however, became the standard bearer for measurement of intelligence for nearly 60 years and was even more popular in France at one time than the original French Binet±Simon scales. The reason for the domination of the Stanford±Binet series was Lewis Terman's insight and tenacity in redeveloping the test in the USA. After determining that Binet's theory of intelligence applied, new items were written, tried out, and a new scale devised for norming that was conceptually consistent with the Binet±Simon scales but in its practical application was a new and different test. The problems in translating verbal and nonverbal concepts across linguistic cultures are difficult but in any event the redevelopment of tests in such circumstances seems required. Cronbach and Drenth (1972) provide a book length treatment of these problems and various
experiences with proposed solutions to crosscultural adaptation of psychological tests stemming from some 30 nations from throughout the world. The various contributors describe both the strengths and limitations of adapting tests cross-culturally from one country to another, providing perspectives from such diverse discipline psychometrics, cognitive development, psychology, and anthropology. More recent guidelines and reviews of the issues involved in cross-cultural adaptation of psychological and educational tests can be found in Hambleton (1994), Hambleton and Kanjee (1995), and Van de Vijver and Hambleton (1996). 10.03.9 SUMMARY AND FUTURE DIRECTIONS There is little question that the issue of bias in mental testing is an important one with strong historical precedence in the social sciences and, ultimately, formidable social consequences. Because the history of mental measurement has been closely wed from the outset to societal needs and expectations, testing in all forms has remained in the limelight, subjected to the crucible of social inspection, review, and (at times) condemnation in various cultures throughout the world. However, the fact that tests and measures of human aptitude and achievement continue to be employed in most modern cultures indicates strongly that the practice has value, despite the recurring storms of criticism over the years. The ongoing controversy related to test bias and the ªfairº use of measures will undoubtedly remain with the social sciences for at least as long as we intertwine the nature±nuture question with these issues and affirm differences between± among groups in mean performance on standardized tests. Numerous scholars in the field of psychometrics have been attempting to separate the nature±nurture issue and data on mean score differences from the more orderly, empirically-driven specialty of bias investigation, but the separation will undoubtedly not be a clean one. A sharp distinction has developed between the popular press and scientific literature with regard to the interpretation of mental measurement research. The former all too often engenders beliefs that biased measures are put into use for socially pernicious purposes and psychology and education are often accused of courting political, social, and professional ideologies. The former appears to have created confusion in public opinion concerning the possibility of ªfairº testing, to say the least. The latterÐreported in this chapterÐhas been demonstrating through a rather sizable body
of data that the hypothesis of cultural bias in tests is not a particularly strong one at present, at least in cultures with a common language and some degree (the extent or qualitative features of which are as yet indeterminant) of common experience. In any event, societal scrutiny and ongoing sentiment about testing have without question served to force the psychometric community to refine its definitions of bias further, to inspect practices in the construction of nonbiased measures, and to develop statistical procedures to detect bias when it is occurring. We can argue whether the social sciences have from the outset overstepped their bounds in implementing testing for social purposes before adequate data and methods were developed, but the resulting advancements made in bias technology in response to ongoing public inspection are undeniable. Data from the empirical end of bias investigation do suggest several guidelines to follow in order to ensure equitable assessment. Points to consider include: (i) investigation of possible referral source bias, as there is evidence that persons are not always referred for mental health or special eductional services on the basis of impartial, objective rationales; (ii) inspection of test developers' data for evidence that sound statistical analyses for bias across groups to be evaluated with the measure have been completed; (iii) assessment with the most reliable measures available; and (iv) assessment of multiple abilities with multiple methods. In other words, psychologists need to view multiple sources of accurately derived data prior to making decisions concerning individuals. We may hope that this is not too far afield from what has actually been occurring in the practice on psychological assessment, though one continues to hear isolated stories of grossly incompetent diagnostic decisions being made (e.g., Mason, 1979). This does not mean that psychologists should be blind to a person's environmental background. Information concerning the home, community, and other environmental circumstances must all be evaluated in the individualized decision-making process. Exactly how this may be done is addressed in all other chapters and volumes of this work. Neither, however, can the psychologist ignore the fact that ethnic minority group members who score at levels indicative of psychopathology are just as likely to have problems and need intervention as are majority-class individuals. Indeed, it is the purpose of the assessment process to beat the predictionÐto provide insight into hypotheses for environmental and biological interventions that will prevent the identified pathology from continuity to exert a negative influence on the person's life.
A philosophical perspective is emerging in the bias literature that is requiring test developers not only to demonstrate whether their measures demonstrate differential content, construct, and predictive validity across groups prior to publication, but also to incorporate in some form content analyses by interested groups to ensure that offensive materials are omitted. Although there are no sound empirical data to suggest that persons can determine bias upon surface inspection, the synergistic relationship between test use and pure psychometrics must be acknowledged and accommodated in an orderly fashion before tests gain greater acceptance within society. Ideally, a clear consensus on ªfairnessº (and steps taken to reach this end) is needed between those persons with more subjective concerns and those interested in gathering objective bias data during and after test construction. Accommodation along this line will ultimately ensure that all parties interested in any given test believe that the measure in question is nonbiased and that the steps taken to achieve ªfairnessº can be held up to public scrutiny without reservation. Given the significant and reliable methods developed over the last several decades in bias research, it is untenable at this point to abandon statistical analyses in favor of ªarmchairº determinations of bias. Test authors and publishers need to demonstrate factorial invariance across all groups for whom the test is designed in order to make the instrument more readily interpretable. Comparisons of predictive validity across races and genders during the test development phase are also needed. With the exception of some recent achievement tests, this has not been common practice, yet it is at this stage that tests can be altered through a variety of item analysis procedures to eliminate any apparent racial and sexual bias. As scientists, we must also inform the media of our results, whatever they may be. Bias research in the area of personality testing must be expanded. Little has been done and this represents a major weakness in the literature. Only recently (e.g., Reynolds & Kamphaus, 1992) have publishers begun to give appropriate attention to this problem. Researchers in personality and psychodiagnostics must move ahead in this area of concern. Similar problems exist in the growing area of neuropsychological testing (e.g., Reynolds, 1997a). 10.03.10 REFERENCES Abebimpe, V. R., Gigandet, J., & Harris, E. (1979). MMPI diagnosis of Black psychiatric patients. American Journal of Psychiatry, 136, 85±87. Alley, G., & Foster, C. (1978). Nondiscriminatory testing
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10.04 Cross-cultural Clinical Interventions JOHN E. LEWIS Nova Southeastern University, Fort Lauderdale, FL, USA 10.04.1 INTRODUCTION
10.04.2 PROXIMAL VS. DISTAL VARIABLES
10.04.2.1 Proximal Variables 10.04.2.2 Distal Variables
10.04.3 CLINICAL INTERVENTION PROCESSES
10.04.3.1 Cross-cultural Competence and Sensitivity 10.04.3.2 Intercultural Communication Style 10.04.3.3 Cross-cultural Verbal Communication 10.04.3.4 Nonverbal Communication 10.04.3.4.1 Proxemics 10.04.3.4.2 Kinesics 10.04.3.4.3 Paralinguistics 10.04.3.5 Use of Translators
97 98 100 100 100 101 103 103
10.04.4 THERAPIST±CLIENT MATCH
10.04.5 TREATMENT OUTCOME
10.04.5.1 Definition 10.04.5.2 Cross-cultural Outcome Research
10.04.6 METHODOLOGICAL CONSIDERATIONS
10.04.6.1 Reliability and Validity in Cross-cultural Research 10.04.6.2 Recommendations 10.04.7 FUTURE DIRECTIONS
10.04.7.1 Terminology 10.04.7.2 Ethical and Professional Issues 10.04.7.3 Future Research 10.04.7.3.1 Research agenda 10.04.7.3.2 Assessment techniques 10.04.7.3.3 Theory of multicultural counseling and therapy 10.04.7.3.4 Specific research topics 10.04.7.4 Global Psychology
10.04.8 SUMMARY
10.04.9 REFERENCES
Cross-cultural Clinical Interventions
10.04.1 INTRODUCTION While attempts have been made to trace the evolution of multicultural counseling from ancient civilizations to the present day (Thompson, 1989), current thinking supports the notion that multicultural counseling is only several decades old. This is evidenced by the increased intercultural focus in publications from 1960 to 1995 (Jackson, 1995). Early in the 1990s multicultural counseling and therapy (MCT) was hailed as the fourth force in psychology (Pedersen, 1990, 1991b, 1994; Pedersen & Ivey, 1993). As a result, the movement has been to formulate a framework for MCT in an attempt to describe and explain the impact of cultural diversity on psychotherapeutic interventions. This movement spawned a definitive explication of MCT theory in a conceptual treatise (Sue, Ivey, & Pedersen, 1996). The work provides a metatheory for cross-cultural interventions that espouses six basic propositions, encompassing 47 corollary suppositions. The propositions and corollaries were originally proposed by Sue (1995), but were refined by Sue et al. (1996) to help psychologists move from a culture-bound theory of intervention to a theory that could encompass a variety of existing world views. The propositions and corollaries acknowledge that (i) both therapist and client identities are formed and embedded within a complex set of experiences that have a fluid dimension and a contextual salience, (ii) the development of one's cultural identity encompasses attitudes to one's own culture and other cultures; (iii) psychotherapeutic outcomes are more successful when goals and therapy modalities are consistent with a client's values, goals, and cultural experiences; and (iv) individual counseling may need to be balanced with models that incorporate family and societal units. This new framework spawned critical debate (Casas & Mann, 1996; Corey, 1996) centered on the lack of adequate definitions within the field of MCT. The terms ªrace,º ªethnicity,º ªminority,º and ªcultureº have not been clarified and, thus, are constantly confused by professionals (Atkinson, Morten, & Sue, 1993). In 1994, Pedersen defined these terms. He stated that race is a classification based on genetic or biological differences and includes a shared genetic history and/or physical characteristics such as skin color; ethnicity refers to a common sociocultural history that can include political history, similar genealogy, and religion; minority is used to identify a group that has been treated unfairly or has suffered from collective discriminating practices due to the minorities'
lack of power in the dominant culture; finally, culture has taken on broader implications in the literature of the 1990s to include demographic variables (e.g., age, gender, and region), status variables, affiliation variables, and the traditional variables of race and ethnicity. This view of culture focuses on its nonstatic nature, as culture also denotes patterns of behavior, family life, and beliefs (Fernando, 1995). Poortinga (1992) has argued that culture constitutes a set of shared constraints that limit individual members of groups in terms of their behavioral responses. Goodchilds (1991) described race and ethnicity as dimensions not categories. Phinney (1996) argued that one needs to explore three dimensions that differ between and within ethnic groups: ªFirst, cultural norms and attitudes that may be influential in psychological processes. . . . Second, the strength, salience, and meaning of individuals' ethnic identities. . . . Third, individuals' experiences as a member of a minority group with lower status and powerº (p. 925). Readers are diverted to more complete explanations of the terminology concerning culture, race, and ethnicity (Gaw, 1993; Jackson, 1995; Marsella & Pedersen, 1981; Marsella & White, 1982; Pedersen, 1991b; Phinney, 1996). This new emphasis has spawned concern about the terminology and definitions used by researchers and practitioners alike. In particular, current terms such as ªmulticultural counseling,º ªculture-centered counseling,º cross-cultural intervention,º ªcross-cultural communication,º ªminority counseling,º and ªpluralismº have tended to obfuscate an already complex area of interest. Pedersen (1991b) has suggested that psychologists use a broad definition of culture that includes demographic variables such as economics and education as well as informal and formal affiliation variables to supplement the traditional cultural variables of ethnicity, race, nationality, religion, and linguistic group. This wide view of culture seeks to balance culturespecific with universal perspectives that underlie a client's behavior, cognition, and affect. Pedersen (1991a) has also called for the term ªmulticultural counseling and therapyº to be used since it ªimplies a wide range of multiple groups without grading, comparing, or ranking them as better or worse than one another and without denying the very distinct and complementary perspective that each group brings with itº (p. 4). Keeping in the forefront the concepts and definitions integral to MCT, this chapter will focus on issues pertaining to cross-cultural interventions. First, proximal and distal factors
Proximal vs. Distal Variables will be described. Second, interviewing and clinical interventions will be examined, by summarizing the research on effective intercultural communication, and verbal/nonverbal language factors in counseling and psychotherapy. Third, the issue of client and therapist match will be explored. This discussion will evaluate the notion that therapists and clients from similar backgrounds have more accurate communication and greater potential for successful therapeutic outcomes. Fourth, the treatment outcome literature will be examined with a view to evaluating the efficacy of particular intervention strategies with culturally different clients. Fifth, present and future methodological issues that relate to the clinical interventions with a culturally diverse clientele will be examined. Finally, future issues in this area will be discussed. 10.04.2 PROXIMAL VS. DISTAL VARIABLES Two prerequisites of culturally responsive behavior are attitudes and beliefs (Ridley, Mendoza, Kanitz, Angermeier, & Zenk, 1994). These two constructs can be discussed by using Poortinga's (1992) notion that behavioral responses are dependent upon internal and external constraints which are governed by a person's sociocultural history. These constraints have been delineated into two variables: internal±proximal and external±distal. Proximal variables, also called proximal levels, include aspects of the immediate setting and behavior of the client, and the ªrelated flux of affect and cognition during a particular interactionº (Fletcher & Fitness, 1990, p. 464). Distal variables, or levels, are generally ªstable dispositional variables that predate the immediate proximal contextº (Fletcher & Fitness, 1990, p. 464). Distal variables include personality characteristics, levels of effect, and client expectations. They also include ethnicity and race (Sue, Zane, & Young, 1994). 10.04.2.1 Proximal Variables The effect of proximal variables on relationships and communication processes has emerged in studies originating in the field of social cognition (Bradbury & Fincham, 1988; Fletcher & Fitness, 1990; Kelly et al., 1983). The social cognition notion of proximal level can be expanded into cross-cultural interactions. The therapist must identify the thoughts and feelings experienced by the client immediately preceding a therapy session, especially values and beliefs (Bond & Smith, 1996).
The study of values within a cross-cultural framework is best exemplified in the work of Kluckhohn and Strodtbeck (1961). This model recognized that cultures differ in their perception of time, attitudes towards activity, their lineal versus collateral relationships, and their notion of the nature of people. These value orientations have been modified and expanded by Ibrahim, (1985) and Kohls (1979) to provide social/cultural interpretations and examples. Carter (1991) reviewed the research on the Kluckhohn±Strodtbeck model and concluded that a counselor needed to understand a culture's value structure if he or she hoped to understand both the unique and universal attributes of that culture. Schwartz (1992, 1994) has examined the universal content and structure of values. He identified, through the results of a self-report values instrument, 10 universal value domains at the individual level and seven at the global cultural level. Scores were obtained for 38 different cultural groups (Schwartz, 1994). These culture-level scores have been compared to the results obtained in Hofstede's studies. Hofstede (1980, 1991) described a pattern of universal and culture-specific variables in 55 countries. He identified measures that related to thinking, feeling, and behaving and claimed that these patterns, or mental programs, were constructed differently by different cultures at different times. In addition, he described four dimensions that varied among the countries: small/large power distance, collectivism vs. individualism, femininity vs. masculinity, and weak/strong uncertainty avoidances. More recently, researchers (Kim, Triandis, Kagitcibasi, Choi, & Yoon, 1994; Smith, Peterson, Akande, Callan, & Cho, 1995) have examined specific value orientations in different countries and have illustrated clear patterns of cultural difference with respect to external±internal control and collectivism, respectively. Whereas values exemplify what a culture or individual holds as important, beliefs encompass an individual's or culture's sense of how the world is construed. The most often studied variable in this area is locus of control. This concept was formulated by Rotter (1966) and incorporated the notion that people have differential beliefs about how outcomes are obtained in relation to personal power. Rotter described two dimensions, internal control and external control. Internal control referred to the idea that people can control their own outcomes. External control referred to the notion that outcomes are more determined by chance environmental circumstances rather than personal power. Through the socialization process, people learn one of these two views. These
locus-of-control beliefs of clients are related to how a client experiences ªcontrol harmony, and submission with respect to the environmentº (Bond & Smith, 1996, p. 211). Locus of responsibility is closely related to locus of control. This belief, which has emerged largely from attribution theories in social cognition (Fiske & Taylor, 1991), is concerned with how much blame is placed on individuals or systems. Sue and Sue (1990) have described these emphases as important for a client's life orientation development. They believe that a person-oriented, person-blame individual tends to focus on individual responsibility attributes. He or she tends to focus on a person's motivations, values, feelings, and goals and tends to attribute successful or unsuccessful outcomes to a person's strengths and weaknesses. These individuals see a strong relationship between individual effort and success. This stance allows some members of the dominant culture to view minorities as totally responsible for their behavior and ignore contextually relevant information that may contribute to or cause a person's behavior. Some clients, on the other hand, tend to be situation-blaming. They tend to attribute successful and unsuccessful outcomes to variables outside of themselves, in the sociocultural environment. Sue and Sue believe that therapists need to view the individual±system blame continuum in an effort to understand their clients and to see the culturally relevant factors that may impact on a person's situation. Other beliefs that are not universal, but culturally specific, have been suggested. They include the notion of justice (Furnham, 1993), global cooperation (Der-Kerabetian, 1992), and beliefs and attitudes about the work ethic (Furnham, Bond, Heaven, Hilton, & Lobel, 1993). Further research is needed to clarify and verify these variables. 10.04.2.2 Distal Variables There has been a notable lack of empirical studies that have focused on external±distal factors. Bond and Smith (1996) have concluded that ªalmost all current models of cultural difference are thus proximal rather than distalº (p. 211). Sue and Zane (1987) discussed the proximal±distal issue by evaluating whether cultural knowledge or culture-specific techniques were linked to psychotherapeutic success. They formulated a proximal±distal model that suggested cultural knowledge and techniqueoriented methods in therapy are of a distal nature and, therefore, may not contribute significantly to effective counseling and psy-
chotherapy. Rather, they believe that ªit may be wiser to focus on the proximal process of therapist credibilityº (p. 39). This credibility involves a therapist's ability to conceptualize the client's problem, sensitivity to culturally appropriate means of problem resolution, and client± therapist goal compatibility. In other words, high achieved and ascribed credibility is likely to produce an effective therapeutic process, whereas low ascribed and achieved credibility will result in early termination of therapy. Akutsu, Lin, and Zane (1990) stated that the proximal±distal model predicts that counselor credibility is related to continued involvement in treatment, whereas the distal variables, cultural knowledge, and techniques are mediated through the credibility that exists in the therapeutic relationship. They tested the proximal± distal model with Chinese students and concluded that counselor credibility was related to the client's intention to utilize therapy and that relationship variables and therapist style were mediated through the subject's evaluation of the counselor's credibility. Proximal factors, therefore, were seen as essential for continued intentions for therapy by culturally diverse clients. Berry (1990) has studied distal factors with respect to ethnic group relationships. He identified a map of relationships that included three sociocultural factors: collective stereotypes, history±economics±politics, and collective behaviors. These categories influenced various psychological variables, including perception, attribution, attitudes, and behavior. Fiske (1992) has described sociocultural factors by proposing a four-component model, stating that social relationships in cultures include communal sharing, authority, ranking, equality matching, and market pricing. Berry (1990) and Triandis (1994) have called for more studies that are sensitive to external, distal ethnic variables. The preceding discussion has encompassed the notion that universal and culture-specific thoughts, feelings, and behaviors affect client± therapist interaction. It was Frank (1961) that stated a ªpsychotherapist in any culture works to assist in the definition of subtle gradations of implicit rules governing behavior which derive from a vast array of norms, value systems, and ideologies present in the shared assumptive worlds of the patient and therapistº (p. 28). Therapists with culturally diverse clients are required to decode implicit rules that are culturally determined and to make them more situationally appropriate in therapy. It necessitates a therapist's close attention to what individual and sociocultural variables are salient at any given moment during the crosscultural interaction. Failure to do so will result
Clinical Intervention Processes in cultural encapsulation, ineffective client± therapist relationships, and possible ineffective treatment outcomes. The issues involved with distal and proximal variables are at the core of interviewing skills and clinical interventions. The act of interviewing and therapy involves the formation of a close relationship between client and therapist. This relationship, inevitably, exposes the proximal and distal factors present in the lives of both participants. Sensitivity to proximal and distal factors, as well as culture-specific and universal expressions of behavior from a client, are fundamental concerns in clinical interventions.
10.04.3 CLINICAL INTERVENTION PROCESSES The area of clinical intervention process encompasses topics as diverse as cross-cultural sensitivity and competence, intercultural communication style, cross-cultural verbal communication, nonverbal communication, and the role of translators during therapy. 10.04.3.1 Cross-cultural Competence and Sensitivity Cross-cultural counseling has been defined as ªany counseling relationship in which two or more participants differ in cultural background, values, and lifestyleº (Sue et al., 1982, p. 47). This definition has led many counselors and therapists to the conclusion that all counseling could be considered to have a multicultural dimension (Pedersen, 1994; Speight, Myers, Cox, & Highlen, 1991; Sue, Ivey, & Pedersen, 1996). In fact, it is argued that within-group differences have at least equal impact as between-group differences on the clarification of cultural issues (Speight et al., 1991). These definitions and statements have demanded the attention of organizations and policy makers concerned with the provision of psychological services. In 1992, the Association for Multicultural Counseling and Development (AMCD), a branch of the American Counseling Association (ACA), published a document that outlined multicultural counseling competencies and standards for inclusion in psychological service provider programs. This document espoused a three-by-three matrix for organizing and developing cross-cultural competencies. This matrix identified three areas of concern: (i) beliefs and attitudes, (ii) knowledge, and (iii) skills in relation to counselor self-awareness,
counselor understanding of client's world view, and the development of culturally appropriate intervention strategies and techniques. Of particular relevance were the recommendations for interventions, which included the need for more accurate verbal communication, increased understanding of nonverbal communication, greater proficiency in dealing with clients' diverse behavioral and affective response styles, and increased understanding of the role of societal and familial issues in therapy. In 1993, the American Psychological Association (APA) established guidelines for the provision of services to ethnic, linguistic, and culturally diverse populations. These guidelines stated: ªPsychologists need a sociocultural framework to consider diversity of values, interactional styles, and cultural expectations in a systematic fashionº (p. 45). In response to this need for frameworks for effective cross-cultural interactions, psychologists have examined cultural differences and universal expressions of client behavior (Sue & Sue, 1990). Culture tends to have a limiting or restructuring effect on universal expression. These cultural differences create stress on the therapeutic relationship. Problems can occur when the therapist becomes too enamored of his or her own cultural values. Wrenn (1962, 1985) created the term ªcultural encapsulationº to describe the notion that some therapists: (i) substitute stereotypes for the real world, (ii) ignore cultural variations across cultures, and (iii) adhere to a technique-oriented, static notion of the therapeutic process. The result of cultural encapsulation is that the therapist's role becomes rigidly defined with an ensuing universal notion of health, normality, and pathology. This notion of cultural encapsulation led Sue and Sue (1990) to outline the characteristics of the culturally skilled counselor and therapist. These characteristics involve the development of attitudes and beliefs that have understanding of the self and the client's world view at their core. The culturally skilled counselor (pp. 167±169): (i) has moved from being culturally unaware to being aware and sensitive to his or her own cultural heritage and to valuing and respecting differences; (ii) is aware of his or her own values and biases and how they might affect minority clients; (iii) is comfortable with differences that exist between themselves and their clients in terms of race and beliefs; (iv) is sensitive to circumstances (personal biases, stage of ethnic identity, sociopolitical influences, etc.) that may dictate referral of a
minority client to a member of his or her own race or culture or to another counselor in general; (v) is aware of his or her own racial attitudes, beliefs, and feelings; (vi) must possess specific knowledge and information about the particular group he or she is working with; (vii) must have a good understanding of the sociopolitical systems' operation with respect to its treatment of minorities; (viii) has clear and explicit knowledge of the generic characteristics of counseling and therapy; (ix) is aware of the institutional barriers that prevent minorities from using mental health services. These attributes of the skilled multicultural therapist have been discussed more elaborately in the cross-cultural competencies and standards outlined by Sue, Arredondo, and McDavis (1992). Attempts to measure these competencies have been made with two rating scales: the Cross-cultural Competence Inventory (Hernandez & LaFromboise, 1985) and the Cross-cultural Competence Inventory±Revised (LaFromboise, Coleman, & Hernandez, 1991) and three self-report measures: the Multicultural Awareness±Knowledge±Skills Survey (D'Andrea, Daniels, & Heck, 1991), the Multicultural Counseling Awareness Scale (Ponterotto, Sanchez, & Magids, 1991), and the Multicultural Counseling Inventory (Sodowski, Taffe, Gutkin, & Wise, 1994). Cultural sensitivity has been defined in various ways: cross-cultural competence, crosscultural expertise, cross-cultural effectiveness, culture responsiveness, cultural awareness, and cultural skill. This has led to confusion in the vast literature surrounding cultural sensitivity (Ridley, 1984; Ridley et al., 1994) as authors have tended to use the terms interchangeably. Speigal and Papajohn (1986) have accordingly questioned how one can operationalize the terminology in order to construct treatment models. Ridley et al. (1994) have called for cultural sensitivity that is linked to culturally responsive interventions. They formulated a model that proposed that cultural sensitivity can be viewed as being measured on a continuum which has underlying prerequisite behaviors, culturally responsive behavior, and the effects of this culturally responsive behavior. The assumptions that underlie this model are fivefold. First, the authors believe that cultural sensitivity depends on the personal meaning that a client has about events that depend on the broad spectrum of cultural attitudes available to the client (Pedersen, 1994). Second, therapists need
to adopt a ªnaiveº posture in processing information (p. 129). Third, cultural sensitivity is a prerequisite for interventions that are culturally responsive. Fourth, cultural differences that exist between client and therapist may interfere with a therapist's information processing. Fifth, cultural sensitivity is grounded in the information processing theory of perceptual schemata; mental schemata develop likely as a natural process during client and therapist interactions. The authors have called for empirical studies that can verify or expand this model. Culturally sensitive counselors, therefore, are seen as implicitly facilitating therapy that has more effective outcomes for diverse clients, while culturally insensitive counselors are seen as ineffective change agents. Culturally insensitive counselors have been viewed as a main contributor to problems of ethnocentrism, lack of empathy, misdiagnosis, and treatment selection errors (Gim, Atkinson, & Kim, 1991). In addition, the underutilization of mental health services and early termination by minorities have been attributed to the lack of sensitive therapy services (Romeo, 1985; Sue & Sue, 1990). Pedersen and Lefley (1986), Sue and Sue (1990), and Sue et al. (1992) state that, for effective counseling to occur, the counselor and the client must also be able to appropriately and accurately send and receive both verbal and nonverbal messages. The next section of this chapter looks at the various factors that lead to effective interviewing and counseling. In order to understand effective interviewing and counseling strategies, however, one must first examine the elements of effective intercultural communication and the barriers present in noneffective communication. This necessitates a discussion of how communication styles differ between client and therapist. 10.04.3.2 Intercultural Communication Style Communication style refers to those aspects that go beyond the literal content presented in verbal interactions. It includes the cadence of speech, inflection, tone, syntactical structure, fluidity, and depth. Communication styles are strongly correlated with race, ethnicity, and culture (Sue & Sue, 1990). For example, Yum (1991) has suggested that Confucianism has strongly impacted on communication styles with Asians; the main function of communication is to initiate, foster, and maintain social relationships. Communication, therefore, encourages these relationships and sets the framework for an infinite interpretation (Cheng, 1987).
Clinical Intervention Processes In a multicultural setting the therapist usually conducts therapy without the familiar cultural guidelines that are normally present in counseling sessions with mainstream clients (Pedersen, 1994). Garza, (1981) focused on issues that emerge during initial diagnostic interviews with minorities. He discussed the notion that therapists, when confronted with a culturally different client, depart from their usual ways of interviewing. These departures include the use of cultural stereotypes as a distancing device. The therapist also tends to use generalizations which produce dehumanizing consequences. Furthermore, therapists are guilty of simplifying the task of diagnosis by overinterpreting, Garza stated: Overdiagnosing issues around cultural difference, precise and accurate as it may be, can at times serve the purpose not so much of enhancing the diagnostic process through the lens of a bicultural perspective, but of avoiding the task of really getting into the complexities of another's individual life. (p. 15)
Sue and Sue (1990) have delineated generic characteristics in Western counseling and psychotherapy. These characteristics incorporate culture, class, and language issues. Specifically, these generic characteristic include standard English, verbal communication, individual-centered therapy, verbal/behavioral/emotional expressiveness, openness, cause and effect attributions, and clear mental±physical dimensions. In addition, counseling models and techniques have traditional middle-class use of language, verbal communication, rigid time frames, long-range goals, and ambiguity. Sue and Sue (1990) describe these variables as being largely used in Western models of counseling and therapy. Non-Western cultures, on the other hand, have different modes of expressing affect, using silence, different language usage, differing time perspectives, nonstandard English, and a focus on individualism versus collectivism. Sue (1977, 1981) has outlined in detail the barriers to effective cross-cultural counseling that have evolved as a natural consequence of utilizing generic modes of counseling with culturally diverse clients. Culture-bound values encompass several areas of concern. First, most forms of therapy are individually focused, emphasizing the importance of the client± counselor relationship. Some Western cultures, such as are found in the USA, have been identified as cultures that are based on individualism and competition between members. Individualism and competitiveness are seen as virtues within the culture. Not all
cultures are based on this notion of individualism. Many cultures are socialized in a system of communality and codependence. The values in non-Western cultures differ markedly in that some might view individualism as an impediment to true mental health. Thus, counselors who do not deal with individualism versus group orientation will potentially create problems in the interview. An extensive review of cooperation and individualism in various cultures has provided support for this viewpoint (McGoldrick, Pearce, & Giordano, 1982). Second, many therapists create an atmosphere within an interview that promotes verbal, emotional, and behavioral expressiveness. It is felt that such openness will allow a more accurate exploration of the problem and concomitant issues. Also, that it will provide a more focused emphasis on intrapsychic issues. This belief is especially important since it can lead to misperceptions and labeling of the client's reactions during the interview. Clients are in danger of being labeled as apathetic, repressed, or resistant if they do not exhibit expressiveness and openness. An open, expressive communication style is not predominant in Hispanic, Asian, or Aboriginal cultures (Sue & Sue, 1990). Studies have shown, for instance, that Chinese and Japanese cultures value restraint of feeling and circumspectual approaches when communicating (Samovar & Porter, 1991). Additionally, openness and expressiveness are antithetical to Native American communication styles (Dignes, Trimble, Manson, & Pasquale, 1981; Thomason, 1991). Many interviews and psychotherapeutic interventions encourage and foster self-disclosure from the client. The problem with this approach is that self-disclosure has been determined to be a negative value trait among many cultures ( Sue & Sue, 1990). Self-disclosure is a Western psychotherapeutic value. It has been called the sine qua non of most approaches to therapy (Poston, Craine, & Atkinson, 1991). Therapists may misinterpret a client's nondisclosure, as different cultures teach and validate different levels of self-disclosure (Pedersen, 1994). Another culture-bound barrier involves the notion of ªinsightº in psychotherapy. Client insight is generally assumed to have positive or beneficial consequences, but clients from different cultures may place lower value on insight (Sue & Sue, 1990). This dichotomy can impede accurate communication. In addition, Sue and Sue described counseling and therapy within a Western context as linear and analytic with an emphasis on cause-and-effect explanations of healthy psychological functioning and psychological maladjustment. This reliance on scientific method and rationalism has contributed to
client±counselor barriers in therapy, since different attributions about the etiology of psychological problems may exist between client and therapist. Finally, the culture-bound barrier of ambiguity is concerned with the level of structure that is present in an interview or counseling session. Sue and Sue (1990) state that lack of definitive structure may be confusing to clients from Hispanic backgrounds and may impede the communication process. They go on to state that the patterns of communication among culturally diverse clients are dependent upon one's cultural upbringing. The focus on differing communication styles has led to an ever-increasing list of models, prescriptives, and resources for effective interviewing and counseling with specific populations (ACA, 1990; APA, 1994; Eisenbruch, 1990; Fiksdal, 1990; Gonzalez-Lee & Simon, 1990; Hollingsworth, 1987; Pedersen & Ivey, 1993; Song & Parker, 1995; University of Wisconsin, 1991). In particular, these differences in communication styles have led to a detailed examination of language issues that encompass verbal and nonverbal aspects of communication. 10.04.3.3 Cross-cultural Verbal Communication Language issues constitute one of the most important differences and one of the greatest barriers to effective communication between cultures (Argyle, 1991). Labov and Fanshel (1977) state that the most important data during the counseling session are the words spoken by the client and counselor and, thus, whatever is construed from these words. Further, Ivey (1981) has stated that any person-to-person encounter must consider the language of helping. This is especially crucial in multicultural counseling since different cultures use different words, syntax, and constructs to convey meaning. Ivey called for an examination of language patterns as central to effective cross-cultural interviewing and therapy. Language in therapy can be idiosyncratic and misunderstood by therapists who are not familiar with a particular culture (Draguns, 1981). Meaning is lost in therapy when the counselor is not attuned to the subtleties of specific cultural uses of affect, diagnosis, and treatment (Vontress, 1981; Yamamoto, Silva, Justice, Chang, & Leong, 1993). Yum (1991) has indicated that east Asian communication patterns differ from those in North America. East Asian languages are very complex and there are honorific linguistic
systems present in Asia which differentiate the use of words based on formality or informality of context (Ogino, Misono, & Fukushima, 1985). Dillard (1983) and McWhirter and Ryan (1991) have described the enormous number of dialects and language systems in North American native clients. Cross (1995), Dillard (1983), Pennington (1979), and Sue and Sue (1990) have described the language characteristics of African-Americans and their impact on therapy. Language plays a critical role in psychotherapy, especially when the therapist and client do not share a common language. Westermeyer (1993) has stated that most cultures have a lingua franca or single major language. ComasDiaz and Griffith (1988) have described the differential impact of a client using nonstandard English. They claimed that clients are diagnosed and assessed primarily on the basis of their ability to use standard English. They stressed the importance of accurate and meaningful client±therapist communication. 10.04.3.4 Nonverbal 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 (Wolfgang, 1985). The study of nonverbal behavior has been divided into three areas: proxemics, kinesics, and paralinguistics. Overviews of the early work done in nonverbal communication can be found in Harper, Wiens, & Matarazzo (1978), Henley (1977), and LaFrance and Mayo (1978), and a comprehensive bibliography of the nonverbal literature from 1859 to 1983 has been compiled by Wolfgang and Bhardwaj (1984). 10.04.3.4.1 Proxemics Hall (1959) initiated the study of proxemics. He demonstrated the impact of ethnicity and culture on various nonverbal behaviors such as eye contact, gestures, and personal space. The term ªpersonal spaceº was introduced by Sommer (1959) to denote the area that separates ourself from others. The size of this area varies with situations and contexts. Hall (1969) delineated four zones of interpersonal distance that characterize Western culture: intimate (up to 18 inches), personal (18±48 inches), social (48 inches to 12 feet), and public (greater than 12 feet). Extensive research into proxemics has revealed that conversational distances vary cross-culturally and that these differences have an impact on formal and informal counseling interactions (Wolfgang, 1985).
Clinical Intervention Processes Ramsay (1979) examined the studies that evolved from the proxemic inventory described by Hall (1959). These studies examined Arabs, Latin Americans, southern Europeans, northern Europeans, Indians, Pakistanis, east Asians, and Puerto Ricans. This body of literature served to illustrate that different cultures have different culturally determined ideas of appropriate social distance. Hanna (1984) studied the interactional distances between blacks and whites in the USA and discovered substantial variation in conversational distance. Jensen (1985) discovered smaller acceptable conversational distances for Latin-Americans, Africans, African-Americans, Indonesians, Arabs, and South Americans than Anglos. Some studies have extended the investigation to include cultural attitudes toward crowding and its resultant effect on intimacy (Altman, 1975; Altman & Chemers, 1980; Pandey, 1978, 1990, 1996; Worchel & Teddlie, 1976). These studies illustrate that attitudes towards crowding differ around the world with respect to individual comfort level, as every culture has different tolerance levels for personal space. Further research is needed to clarify the relationship of these findings to the dynamics of interviewing. 10.04.3.4.2 Kinesics The study of kinesics was originally described by Birdwhistell (1970) and focused on body movements. Kinesics include facial expressions, gestures, eye behavior, and posture. Kinesics are influenced strongly by the norms of one's culture (Smith, 1984). Rosenthal, Hall, Archer, Dimatteo, and Rogers (1979) discovered that subjects from outside of the USA, in countries that were culturally and/or linguistically similar (e.g., Canada, New Zealand, and the UK), scored higher than other nations on tests measuring the nonverbal accuracy of meaning. In other words, the subjects were able to interpret the body movements and gestures accurately. American subjects received the highest accuracy scores, indicating that culturally specific cues are present in a person's body language. Key (1975) described nonverbal acts within an overall structure that related kinesic qualities to communication channel, time, distance relationship, cultural affiliation, environmental considerations, and individual differences. She believed the preceding determinants of nonverbal language should be considered as interactional in nature. Sue and Sue (1990) state that eye contact is ªperhaps the non-verbal behavior most likely to be addressed by mental health providers . . . counselors attribute negative traits to the
avoidance of eye contact: shy, unassertive, sneaky, or depressedº (p. 55). Studies have illustrated that higher levels of gaze and eye contact invite more positive reciprocal nonverbal behavior (Smith, 1984). Studies on gaze behavior in Europe have been analyzed and summarized by Ellgring (1984); these studies showed cross-national differences among subjects. Ramsey (1984) discovered differences between Eastern and Western cultures in eye gazing behavior largely through an analysis of studies conducted in Japan. Graham (1985) discovered differences in gazing behavior among Brazilian, Japanese, and American negotiators. Researchers have investigated the role of gaze-directed behavior and reciprocal interactions (Argyle & Cook, 1976; Argyle & Dean, 1965; Exline, Gray, & Schuette, 1985). Johnson (1972) discovered differences between black and white clients with respect to eye movements and discovered eye-rolling behavior in black American speakers. These eye movements were used to convey disapproval, impudence, and hostility. Ivey (1994) identified the dimensions of attending. The first dimension concerned the 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 behavior had the universal characteristic of being used to convey meaning. Ivey concluded that eye contact should be modeled by the counselor as early in the relationship as possible. Pedersen and Ivey (1993) offer practical suggestions on improving one's eye contact and other attending skills for use in cross-cultural counseling and therapy. Gestures refer to the types of hand movements that people make. Although there has been a great deal of disagreement as to what constitutes a gesture (Krauss, Chen, & Chawla, 1996), a typology of gestures has been proposed by Kendon (1983). This classification system describes symbolic, conversational, and adaptational gestures. The differentiation of gestures grew largely out of early anthropological studies with Darwin and included the work of Kleinberg and LaBarre (Efron, 1972; Ramsey, 1979). Morris, Collette, Marsh, and O'Shaughnessy (1979) studied the meaning given to various hand movements in British, Greek, Spanish, Turkish, and Italian subjects. They studied 20 forms of gestures and discovered that only two had universal use, and five had widespread use. The occurrences of the remaining gestures were found to be culturally specific. They concluded that people from various regions in Europe use substantively different gestures when communicating.
The most often studied area in cross-cultural interaction is conversational gestures, which are hand movements that accompany speech and seem to be related to the meaning of that speech. LaBarre (1985) documented the different gestures of politeness in south Asian, African, European, Pacific islander, east Asian, and American cultures. He also identified crosscultural differences in gestures of contempt, beckoning behavior, kissing, and sticking out of one's tongue. These culturally determined nonverbals have been analyzed extensively by Krauss, Chen, and Chawla (1996). They have indicated that gestures contribute to comprehension and communicative intent in conversations and interviews. Touching another person has been studied from a cross-cultural perspective. It has been claimed that touching holds special significance in Anglo cultures because of its infrequency of occurrence (Henley & LaFrance, 1984). Touching behavior studies, even though generally focused on gender issues, have been reviewed by Knapp (1984). Eakins and Eakins (1985) have gone beyond looking at hand movements to an examination of head movements. Jensen (1985) has illustrated that cultural differences exist in the meaning attached to head movements. A most detailed focus on head movements can be found in Erickson and Schultz (1982). The authors used a microethnographic approach to study social interactions. Head-nodding behavior was analyzed within a cultural context. It was discovered that head nodding was part of a conversational rhythm that contained culturally specific patterns. They described the impact of cultural organization or shared standards and communication traditions on nonverbal social interactions. They stated that ªboth the ends and means of communication are culturally defined as appropriate, effective, and intelligible. When persons meet who have learned different communicative traditions regarding intelligibility, effectiveness, and appropriateness, troubles can result in the social organization of their interactionº (p. 100). Pearson (1985) believed counseling interpretations can be based on the facial expressions of a client. Early studies of facial expression focused on the universality of expressions and the culturally specific interpretations of facial movement (Ekman & Friesen, 1975; Izard, 1971). Ekman (1993) claimed that such psychological luminaries as Allport, Brunswik, Hull, Maslow, and Titchner all studied facial expressions early in their careers, each focusing on the dilemma of whether or not facial expressions are universal or culture-specific. Ekman concluded after considering the history of kinesics, ªI found more than one answer. Different aspects
of expression are both universal and culturespecificº (p. 391). In particular he studied facially active vs. facially inactive subjects. The first issue of concern was specificity. This refers to any differences that exist in the manifestation of emotions. Are clients facially active with some emotions, yet facially inactive with others? Ekman (1993) concluded that individual differences are present with respect to specificity and that future research on these differences may shed light on the issue of universality. Yamamoto and Kubota (1983) described the differences in facial expressions between Asian and European clients. In particular, restraint of facial expressions was valued in Asian culture. The second issue is threshold. Do individuals have a lower threshold for emotional experience than facial expression? Are clients able to experience psychological distress without showing physical signs? Izard and Izard (1980) theorized there was a cultural universality of emotion that was strongest in the area of primary emotions such as fear, sadness, and happiness. He argued the further one was removed from these basic primary emotions, the more cultural specificity occurred in the expression of emotion. Ekman (1993) has suggested further research is needed in this area. Choosing one postural stance from the many options that are available appears to be culturally determined (Hewes, 1955; Ramsey, 1979). Mehrabian (1972) described posture as having two dimensions. These dimensions, immediacy and relaxation, were found to be related to how one communicates one's attitudes. Leaning forward increases immediacy of contact and communicates acceptance and liking. Leaning backwards tends to indicate relaxation and sometimes disinterest. These dimensions have been studied by Bond and Shirashi (1974) with Japanese subjects. They discovered preferences for counselors to lean forward, since flexibility and politeness were attributed to this postural movement. Scheflen (1964) linked the notion of posture congruence to successful psychotherapy. He claimed that if a therapist wished to communicate congruent feelings, he or she needed to have a relaxed posture that was reflective of his or her state of mind. From the field of neurolinguistic programming there have begun to emerge studies on posture that are cross-cultural in scope. Sandhu (1984) found that therapists' mirroring of Choctaw adolescents in the USA increased adolescents' perceptions of empathy present in the therapists. Sandhu, Reeves, and Portes (1993) further studied the effects of mirroring on empathy with Native Americans. They
Clinical Intervention Processes concluded that postural mirroring may significantly aid in the building of rapport with culturally different clients.
10.04.3.4.3 Paralinguistics Paralinguistics is the study of vocal cues that clients use to communicate meaning. Poyatos (1984) defined paralanguage as ªthe ever present co-occurrent voice modifications or alternating independent sounds of perfectly lexical valueº (p. 433). These aspects of language include the higher volume used in conversation with Latins and Arabs, highpitched or breathy intonations of some clients, tongue clicking as seen in South Africa, and sighing. It includes the use of silence, hesitations or pauses, rate of speech, inflections, and expressiveness (Sue & Sue, 1990). Lass, Mertz, and Kimmel (1978), Mehrabian and Ferris (1976), and Poyatos (1976, 1984) concluded that paralanguage is culture specific. Wolfgang (1985) has described the use of extraverbal elements associated with speech, from a cross-culture perspective. He has described these elements as operating at the unconscious level in clients. Weitz (1972) outlined the effects of paralanguage in black American and white American communications. Crystal (1975) has looked at the various cultural uses of paralanguage. Apple, Streeter, and Krauss (1979) indicated that pitch and speech rate can significantly affect a person's attributions. Erickson and Shultz (1982) provided a detailed exploration of interactional rhythmic styles in social interactions. They explored cultural differences with regard to pauses, hesitation, and silences. The authors concluded ªbehavioral regularity, especially rhythmic regularity, may be prima facie evidence of shared interpretative frameworks among those engaged in interactionº (p. 143). Nonmembers of the culture may display interactional arrhythmia and fail to engage a client in a smooth conversation or verbal interaction. Erickson and Shultz (1982) have claimed that when counseling occurs with ethnically and racially diverse clients, interactional arrhythmia occurs which causes discomfort in the one-on-one interview. These interactional differences may cause counselors who are unaccustomed to the interactional rhythm to be ªout of sync in communicatingº (Kim, 1988, p. 91) with different language proficient clients. In addition, Kim (1988) indicated that stuttering, accents, and other paralinguistic patterns which differ from the language used in therapy could also stifle the communication process.
Thomas (1995) has stated that, in Great Britain, English is the predominant language 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. These paralinguistic patterns also include the notion of monochronic and polychronic time systems (Hall, 1976). Hall stated that monchronic time patterns are prevalent in the USA, where punctuality is valued, and the pace of the conversation differs from the polychronic time orientation found in Mexico and other Latin American countries. Kim (1988) stated that these vocal patterns help to establish the emotional and attitudinal foundations of social interaction and clarify the relationship between client and therapist. 10.04.3.5 Use of Translators Translation has been described as ªthe exchange of the demonstrative meaning of a word, phrase, or sentence in one language for the same meaning in another languageº (Westermeyer, 1993, p. 129). Some therapists call for literal translations when working with linguistically different clients; however, many therapists move beyond literalism to the interpretation of a client's words through the discovery of connotative meanings. The latter is attempted in order to achieve accuracy of meaning. De Figueiredo (1976) and de Figueiredo and Lemkau (1980) stressed the need for accurate translation when interviewing in Portuguese and Knokani in Goa, India. Kline, Acosta, Austin, and Johnson (1980) interviewed Spanish-speaking patients with the aid of an interpreter. They discovered increased patient satisfaction and greater client understanding. Therapy with the use of translators has been shown to be time-consuming, inaccurate, and difficult (Carillo, 1982). Marcos (1976) has studied bilingual therapists and patients and discovered that language switching can be used by the patient to distance themselves from emotional issues in therapy. This process, labeled ªcode switchingº (Pitta, Marcos, & Alpert, 1978), has been shown to occur in Hispanic clients (Price & Cuellar, 1981; RivasVazquez, 1989). Russell (1988) determined that code switching during an interview or therapy session is a clear signal from the client that clinicians should ignore; it will have impact on the credibility of the therapist. In cultures where bilingualism is present, code switching can occur. The result is that communication accuracy is minimized (Berkanovic, 1980; Kline et al., 1980). Moreover, when bilingual clients
switch to their mother tongue, an increase in emotional response has been observed (Marcos, Urcuyo, Kesselman, & Alpert, 1973). SantiagoRivera (1995) has concluded that therapists need to assess a client's language dominance and preference prior to assessing their psychological and physical health. Difficulties in translating mental health concepts into different languages occur when attempting to apply Western methods of therapy in other parts of the world. Westermeyer (1993) illustrated these issues with ThaiLao language translators. Nichter (1981) discovered similar issues when working in south India where undesirable connotations occurred with translated terminology. Edgerton and Karno (1971) discovered differences between Mexican-American English speakers and Mexican-American Spanish speakers with respect to describing symptomatology. Jackson and Moto (1996) translated various forms of psychopathology and therapy terms from English into Chichewa, one of the main languages in Malawi, Africa. They discovered that some words lacked accurate English equivalents. Acosta, Yamamoto, and Evans (1982) have called for non-Spanish-speaking therapists to use trained interpreters when conducting interviews with Spanish-speaking clients to ensure accuracy of communication. Trained bilingual interpreters have been used with success in community clinics in the USA (Acosta & Cristo, 1981). Baker (1981) advocated the use of interpreters with culturally diverse clients. He worked with south Asian refugees and recommended the creation of a group of interpreters who understood psychological and social processes. Additionally, Owan (1985) extensively discussed the successful use of interpreters when interviewing south east Asian clients. Freed (1988) found that interpreters who had backgrounds in social work and psychology were effective largely due to the fact they could facilitate a therapeutic alliance with the therapist. She listed a series of translator considerations deemed important for the establishment of accurate and meaningful communication. These factors included role definition, assurance of confidentiality, cultural differences, and the individual characteristics of the translator. While skillful translators appear to be desirable, evidence suggests that low socioeconomic clients use nonstandardized English which can create difficulties for middle-class formal language users. Forrest, Ryan, and Lazar (1978) showed that foreign medical graduates were more deficient in slang than in standard English. This factor caused them difficulty when communicating with clients. This prompted the
creation of a course ªAmerican for Foreign Medical Graduate Psychiatric Residentsº designed to equip therapists with slang, colloquial language, and subtleties of humor. Follow-up indicated that greater communication skills were present in the trained experimental group than in those in a nontrained control group. The use of bilingual or bicultural counseling has received attention in the literature. Ruiz and Casas (1981) indicated that bicultural counseling can be considered as a blending of majority and minority approaches to communication. There is evidence that bicultural/bilingual therapists have increased flexibility, greater tolerance for ambiguity, and serve well as cultural mediators (Szapocznik, Rio, PerezVidal, Kurtines, & Sanisteban, 1986). Song and Parker (1995) focused on bicultural Chinese-English and Korean-American young adults. They discovered their interviews were filled with shifting multiple positions as well as identifications rather than a single unitary focus on identification. This introduction of complexity into the interview has been deemed to have a positive impact on meaningful communication (Pedersen, 1991c, 1994). Rogler (1993) has examined the impact of bilingualism on the development of diagnostic errors with culturally diverse clients. He proposed a research framework designed to facilitate a culturally sensitive diagnostic interview that encompasses the assessment of symptoms from a culturally appropriate viewpoint. Salzma (1995) discovered that cross-cultural interactions were replete with attributional discrepancies, partially based on linguistic factors. He studied Navajo and Athabascan Native Americans and discovered many assessment errors occurred during diagnostic interviews. These errors were due to linguistically based attribution biases which occurred because of differences between client and therapist. These differences included social distance, taciturnity, length of pause, and initiation of speech. Ho (1987, 1992) calls for care in the assessment of a client's fluency in English and their dominant language when choosing a treatment modality. He delineated guidelines in this area for working with Asian-American families. Similarly, Nguyen (1992) examined Asian-American communication patterns and called for therapists to consider the metaphoric nature of Japanese, Chinese, and Vietnamese languages. 10.04.4 THERAPIST±CLIENT MATCH There has been a long-standing debate over the issue of whether a client should be given
Therapist±Client Match therapy by a culturally similar therapist or one who is not of the same cultural background. Atkinson 1983, 1985) provided comprehensive reviews of the studies that occurred in the 1970s and early 1980s. Atkinson and Lowe (1995) updated the earlier reviews with a more contemporary discussion of preference for counselor ethnicity. They stated that early research on client±therapist match focused on the preferences of African-American clients. Most studies (e.g., Bernstein, Wade, & Hofmann, 1987; Greene, 1982; Harrison, 1975; Sattler, 1977) revealed that African-American clients preferred African-American counselors and that Asian-Americans preferred AsianAmerican therapists over white therapists. These studies were predicated on the work of Carkhuff and Pierce (1967), LeVine and Campbell (1972), Mitchell (1970), and Stanges and Riccio (1970) which indicated that clients prefer counselors who are culturally similar to them. Higginbotham (1977) and Higginbotham, West, and Forsyth (1988) provided an alternative point of view by concluding that race or ethnicity may not be the most important variable in cross-cultural counseling. They believed that situational, rather than cultural, variables could evoke client outcome expectancies. In addition, Atkinson (1983) concluded that, even though African-American clients showed a preference for racially similar counselors, other ethnic groups showed no such preference. Instead, these studies have stressed that other variables of counselor effectiveness have a greater impact with ethnically diverse clients. Parloff, Waskow, and Wolfe (1978) have pointed out the need to include the sex, socioeconomic status, and attitude of the counselor in client preference studies. Some studies have concluded that clients actually prefer ethnically dissimilar counselors (Gamboa, Tosi, & Riccio, 1976). In addition, Flaskerud (1990) reviewed the literature on client match from 1970 to 1990 and concluded that there was no strong support for the notion that client±therapist match in ethnicity, language, and gender had positive effects on the process or outcome of therapy. Many studies in the 1980s focused on the impact of racial identification on preference for counselors (Parham & Helms, 1981, 1985; Sanchez & Atkinson, 1983). These studies concluded that the more one identified with one's own cultural group, the greater likelihood of preference for an ethnically/racially similar therapist. In addition, some researchers have focused on the issue of clinical judgment as it is related to the ethnicity of the therapist (Lopez & Hernandez, 1987; Malgady, Rogler & Constantino, 1987; Pakov, Lewis & Lyons,
1989). They discovered that clients perceive ethnically/racially similar counselors as possessing greater clinical judgment skills than nonsimilar counselors. In the 1990s, the majority of studies have tended to support the notion that ethnically/ racially diverse clients prefer ethnically/racially similar therapists (Coleman, Wampold, & Casali, 1995). The following three studies, however, have failed to support this notion. Steward, Gimenez, and Jackson (1995) studied the preferences of academically successful, culturally diverse students and concluded that ethnic match was not a well-defined preference among this group. Sue, Fujino, Hu, Takeuchi, and Zane (1991) failed to show any treatment effects when counselors were matched for ethnicity. Gottheil, Sterling, Weinstein, and Kurtz (1994) matched therapists and patients with respect to gender and race. The matching did not increase the proportion of cocainedependent patients that returned for a second session. The following studies, however, have examined client preferences, and results support the notion that clients prefer same-race/ethnic counselors. These studies focus on AsianAmerican, Hispanic-American, African-American, and Native American subjects. Yeh, Eastman, and Cheung (1994) investigated the effects of language and ethnic match with Asian-American clients and therapists. Ethnic match was a significant predictor of the dropout rate after the first session, while language match failed to predict early termination of counseling. Takeuchi, Mokuau, and Chun (1992) investigated the counselor matching among Asian-American and Pacific islander clients. They discovered that ethnic matching significantly reduced premature termination of therapy. In fact, when clients were matched with ethnically similar therapists they were five times less likely to prematurely leave therapy than clients matched with an ethnically similar therapist. They found, however, no subject differences in global functioning, an outcome measure of psychological, social, and occupational functioning as determined by the Global Assessment Scale. Yeh, Takeuchi, and Sue (1994) discovered that Asian-American children and adolescents who received treatment at facilities with ethnically similar therapists were more likely to remain in therapy and achieve higher functioning upon termination than those at facilities with mainstream professionals. Flaskerud and Liu (1991) discovered that ethnicity match with Asian clients and therapists significantly reduced the early termination rate but did not affect global functioning scores. The researchers
also examined the effect of counselor language and ethnicity on the outcome of therapy with southeast Asian clients (Flaskerud & Liu, 1990). Ethnicity match and language match significantly increased the number of client sessions but not the overall global functioning upon discharge. Flaskerud and Hu (1994) further studied the process of therapy for AsianAmericans suffering from major depression. They concluded that treatment by an ethnically similar therapist within an ethnically matched facility was related to the duration of treatment, not to the clients's global functioning upon termination of therapy. Fujino, Okazaki, and Young (1994) examined therapist±client match with Asian-American female clients. They concluded that ethnic match was significantly related to lowered premature termination, increased treatment duration, and higher functioning upon termination. Tedeschi and Willis (1993) examined the attitudes of Asian international students toward counseling. Asian subjects were found to prefer an older counselor of similar ethnicity. Gim et al. (1991) examined the effects of counselor ethnicity on clients' perceptions of counselors credibility and efficacy. Asian-Americans were shown to attribute greater effectiveness and credibility to Asian counselors. Atkinson and Matsushita (1991) discovered that Japanese-Americans were most apt to seek counseling from a directive Japanese-American counselor. Ngugen (1992) discovered that Asian-American patients extended therapy with Asian-American therapists. Several disadvantages were noted in the study with therapist matching. Some Vietnamese-American and Chinese-American clients preferred Western therapists, because of a fear of encountering breaches of confidentiality with Asian-American therapists, a concept apparently not totally adhered to in Asian-to-Asian encounters. Lopez, Lopez, and Fong (1991) reviewed client preference among Mexican-Americans. They discovered that all studies supported the notion that Mexican-American clients prefer ethnically similar counselors. The authors stated they had conducted two studies of their own confirming this preference. A third study showed that medium and highly acculturated Mexican-Americans indicated greater preference for same-ethnicity counselors than Mexican-Americans with low acculturation. Atkinson and Wampold (1993) critiqued the methodology used to obtain these conclusions. They called for the avoidance of simple choice methods to assess preference for counselors with Mexican-Americans. Further, Atkinson, Casas, and Abreu (1992) examined low-, medium-, and high-acculturated Mexican-Americans in rela-
tion to perceived counselor competence. They concluded that cultural competence was related to perceived cultural responsiveness, regardless of counselor ethnicity or client acculturation. Hess and Street (1991) studied Mexican-American high school students with respect to the effects of counselor ethnicity. No significant differences were found in the ratings of effectiveness in relation to ethnicity. Yeh et al. (1994) reported a lower therapy dropout rate when Mexican-American clients were matched with ethnically similar therapists. Sue et al. (1991) showed that ethnic match between Mexican clients and therapists increased the length of treatment and improved the effectiveness of therapy. While most research indicates problems with matching of black clients with white therapists (Krause & Miller, 1995), problems associated with black therapists working with black clients have been observed (Montalvo & Gutierrez, 1988; Thomas, 1995). These matching studies have focused on the attractiveness and credibility of the therapist. Tomlinson-Clarke and Cheatham (1993) matched ethnically/racially similar counselors with black and white clients. They discovered no significant differences in counselor judgments (i.e., clinical disposition, severity of diagnostic rating, need for psychological treatment, and predicted number of sessions) upon intake when clients were matched with similar counselors. Goldberg and Tidwell (1990) investigated perceived counselor±client similarity and its relationship to the clients' perceptions of attractiveness and the satisfaction derived from therapy. They investigated both gender and race with black and white counselors and students. They concluded that racial and gender differences appeared not to function as barriers to effective communication. They suggested instead that other counselor variables such as attitudes and personality were more important characteristics for perceived competence. Redfern, Dancey, and Dryde (1993) examined the role of counselor ethnicity with English black and white undergraduate students. Black counselors were rated higher than white counselors on scales of attractiveness, competency, and trustworthiness. Tomlinson and Cheatham (1989) examined the effects of ethnicity match on intake interviews with black clients. They concluded that the race of the therapist affected the clinical judgments at the time of client intake. Race and ethnicity have been studied within the psychoanalytic relationship (Leary, 1995). Three patients were paired with an AfricanAmerican therapist. Qualitative descriptions showed the importance of client±therapist
Treatment Outcome negotiation when racial characteristics differ. In addition, White (1994) investigated the impact of race and ethnicity on transference and countertransference in interracial group psychotherapy and discovered differential transference issues related to the race or ethnicity of the therapist. Bennett and Bigfoot-Sipes (1991) examined Native American and white college student preferences for counselor ethnicity. They concluded that both American Indian and white students preferred counselors to have similar values, but Native Americans showed greater preferences for ethnically similar counselors, while white students showed no such preference. In addition, Johnson and Lashley (1989) examined the counselor preferences of Native American undergraduate students. They discovered that clients with a strong cultural commitment to Native American values placed great importance on the ethnicity of the counselor by preferring counselors with similar ethnic backgrounds. Comas-Diaz and Jacobsen (1987) proposed that a client's ethnocultural identity be assessed as an auxiliary therapeutic tool. One aspect of their identity assessment focuses on the background of the therapist relative to that of the client. This assessment then aids in matching client and counselor. Hall and Maloney (1983) suggested that highly ethnoculturally dominant therapists should be matched with sameethnicity clients while less ethnoculturally dominant therapists be matched with culturally different clients. Coleman et al. (1995) conducted a meta-analysis of studies that investigated perceptions and preferences of ethnically diverse clients. They concluded that ethnic minorities tended to prefer ethnically similar therapists and rated these therapists as more competent than European-American therapists. The client±therapist match literature in the 1990s, therefore, has focused on the preferences for counselors of Asian-Americans, HispanicAmericans, African-Americans, and Native Americans. Various topics in relation to client preference have been investigated, most notably: racial/ethnic identification, acculturation, counselor credibility, early termination from therapy, and outcome measures of global functioning. Investigation of these and other variables will continue into the next decade. 10.04.5 TREATMENT OUTCOME 10.04.5.1 Definition Treatment outcome research was defined by Mowrer (1953) as a situation whereby the ªemphasis is upon measuring significant aspects
of personality before and after treatment and noting the nature and extent of the resulting changesº (p. 4). Sue and Zane (1987) have stated that therapeutic outcome is ªthe cumulative product of many discrete dynamics between client and therapistº (p. 44). Orlinski, Grawe, and Parks (1994) have asserted that the term ªtreatment outcomeº has had a history of divergent meanings that have ranged from observational perspective to analysis levels. The authors pointed out that the definition and criteria for outcomes differ depending on who is completing the assessments before and after treatment is received. That is, differences are present if the assessment is completed by therapists, clients, nonparticipant observers, or nonprofessionals. They indicated that level of analysis also had critical issues in need of clarification. These issues included the outcomes occurring within, and external to, the therapy sessions and the use of evaluative or descriptive assessment instruments. The authors concluded that ªtreatment outcome should refer to changes in condition (psychological, somatic, physical, social, and cultural) reflecting favorable or adverse effects on the patients well beingº (p. 284). 10.04.5.2 Cross-cultural Outcome Research VandenBos (1996) presented a succinct history of outcome research beginning in the 1950s. He pointed out that most contemporary treatment outcome research has focused on the effectiveness of comparative treatment interventions and/or has focused on specific treatment methods targeting specific clinical problems. Goldfried and Wolfe (1996) examined the difficult relationship between psychotherapy practice and research. They called for a new outcome research paradigm that seeks to increase clinician and researcher collaboration. Other recent studies have examined many issues surrounding the outcome assessment of psychotherapy, pointing to methodological and conceptual problems (Barlow 1996; Hollon, 1996; Howard, Moras, Brill, Martinovich, & Lutz 1996; Jacobson & Christensen, 1996; Newman & Tejeda, 1996; Sechrest, McKnight, & McKnight 1996; Seligman 1996; Strupp, 1996). While these studies examined many of the contemporary issues surrounding treatment outcome research, they conspicuously omitted any mention of ethnic or racial factors that contribute to the efficacy of treatment. Sue et al. (1994) have comprehensively analyzed the research on American minority clients. Specifically, they reviewed the outcome research
using African-American, Asian-American, Native American, and Latino clients. The authors addressed the question: Is there any research evidence that reveals the efficacy of treatment with minority clients? Specifically, their paper addressed whether minority clients demonstrated differences in pre- and post-therapy assessment. It also investigated whether ethnic minority treatment outcomes differed from outcomes seen in majority clients, and whether various ethnic groups had differential treatment outcomes. They pointed out that research in these areas has historically been lacking and has not specifically addressed the outcome of psychotherapy. Sue et al. asserted that the relationship between ethnic/cultural/racial variables and psychotherapy outcome has not been determined with empirical evidence. Zane and Sue (1991) stated that ethnic differences involve group membership, while cultural differences ªconstitute a host of cognitive variables which are limited to different cultural lifestyles and perspectivesº (p. 32). They stated that these cognitive variables, rather than ethnic membership, have been responsible for the lack of conclusive psychotherapy outcome studies. Sue et al. (1994) identified the reasons why outcome studies in cross-cultural psychology have been problematic. They pointed to four areas of concern: (i) the use of analogue studies, (ii) the heterogeneity of the sample, (iii) the insensitive or inappropriate use of dependent measures, and (iv) the lack of within-group design strategies. These methodological deficiencies have caused both researchers and clinicians to dismiss outcome research as being of limited practical value. With these limitations in mind, researchers have most often focused on treatment outcomes of African-Americans, Asian-Americans, Latino-Americans, and Native Americans. Research studies with these four groups will now be examined. With regard to studies conducted with African-American subjects, Sue et al. (1994) state that, generally, ªin no studies have African-Americans been found to exceed white Americans in terms of favorable treatment outcomes. Some investigators have revealed no ethnic differences and some studies have supported the notion that outcomes are less beneficial for African Americansº (p. 788). These conclusions were based on studies conducted in the 1970s and 1980s (Brown, Joe, & Thompson, 1985; Griffith & Jones, 1978; Jones, 1978, 1982; Lerner, 1972; Parloff et al., 1978; Sattler; 1977). Latino/Hispanic-American studies have often been evaluated in terms of the utilization and retention rate of patients in therapy. Studies
using more direct measures have been scarce in the literature. However, discussion on culturally appropriate modes of therapy and the effectiveness of therapies tailored for Latino/Hispanic clients have been studied (Sue et al., 1994; Szapocznik et al., 1989). Cuento therapy, utilizing Puerto Rican folktales, was examined by Constantino, Malgady, and Rogler (1986), and results from this study confirmed that culturally sensitive forms of therapy can reduce trait anxiety scores. Malgady, Rogler, & Constantino (1990) discovered that using culturally appropriate modeling therapy in conjunction with Cuento (folktales) therapy reduced anxiety symptoms and aggression in Puerto Rican children. Rey-Perez (1996), using a qualitative approach with five Hispanic families, constructed a comprehensive, culturally sensitive treatment program for Hispanic children and their families. Therapeutic gains were noted in each child; the subjects were Cuban, Puerto Rican, Nicaraguan, and Peruvian. There have been a limited number of outcome studies using Asian-American subjects. Many studies have not studied specific groups of Asian-Americans (e.g., Vietnamese, Chinese, Japanese); rather they have viewed Asians as monolithic. Kinzie and Leung (1989), Mollica, Wyshak, Lavelle, Truong, Tor, and Yang (1990), and Snodgrass et al. (1993) found outcome gains in Vietnamese, Laotian, and Cambodian patients. Comparative studies with Asian and non-Asian clients have revealed few differences (Sue et al. 1994). The authors stated that: any conclusions about the effectiveness of treatment for Asians would be premature given the limited data (four outcome studies), but that several empirical trends should be noted. First, some evidence suggests that certain Asian groups improve with psychotherapy and/or adjunct treatments. Second, with respect to differential outcome, divergent trends are found and these are associated with the type of outcome measure used. . . .In summary, Asian clients appear to be deriving less positive experiences from therapy than whites but it is unclear if this difference in client satisfaction actually reflects ethnic differences in actual treatment outcomes (i.e., symptom reduction). (p. 798)
Native American populations, while culturally heterogenous, have been generally studied as an aggregate population. The number of outcome studies is limited in this area, and Manson, Shore, and Bloom (1985) and Neligh (1988) have reported that no research has been conducted to compare the efficacy of various treatment modalities with this population. Most outcome studies have focused on alcohol and
Methodological Considerations drug use reduction and prevention (Bobo, Gilchrist, Cvetkovich, Trimble, & Schinke, 1988; Manson, 1982; Query, 1985; Schinke et al., 1988). Sue et al. (1994) have concluded that ªit is apparent that research on intervention (i.e., treatment and prevention) has proceded very slowly, and it would be premature to try to address the question of the efficacy of mental health interventions with American Indians at this timeº (p. 795). The paucity of outcome studies in the literature suggest that more ethnically/racially specific studies on the efficacy of treatment are needed. In addition, methodological weaknesses need to be examined and corrected by future researchers. These methodological issues are explored in the next section. 10.04.6 METHODOLOGICAL CONSIDERATIONS 10.04.6.1 Reliability and Validity in Crosscultural Research The last decade has seen a focus on racial/ ethnic research issues as they relate to shedding light on effective clinical interventions. Much of the literature has centered on the validity and usefulness of research studies that investigate racial and ethnic variables. The APA (1993) has outlined six areas that have been the focus of mental health research: (a) the impact of ethnic/racial similarity in the counseling process, (b) minority underutilization of mental health services, (c) relative effectiveness of directed versus nondirected styles of therapy, (d) the role of cultural values in therapy, (e) appropriate counseling and therapy models, and (e) competency in skills for working with specific ethnic populations. (p. 45).
Research designs using cross-cultural variables, as with all research designs, are expected to have adequate reliability and validity. Ponterotto and Casas (1991) have carefully delineated the major criticisms leveled at racial/ ethnic minority research. They have listed (pp. 78±79) the top 10 criticisms as: (i) lack of conceptual/theoretical frameworks to guide research; (ii) overemphasis on simplistic counselor/ client process variables and a disregard for important psychosocial variables, within and outside the culture, that might impact counseling; (iii) overreliance on experimental analog research; (iv) disregard for within-group or intracultural differences; (v) the use of easily accessible college student populations;
(vi) reliance on culturally encapsulated psychometric instrumentation; (vii) failure adequately to describe one's sample in terms of socioeconomic status; (viii) failure to delineate the study's limitations; (ix) lack of adequate sample sizes; and (x) overreliance on paper and pencil outcome measures. In addition to the identification of the methodological weaknesses in ethnic/social research, the authors reviewed articles from the five journals that most often publish research in this area. They discovered that only about one-third of the studies had an adequate conceptual foundation. With regard to the second criticism, the authors discovered that, although many variables were investigated, key areas lacked systematic attention. Those areas included communication styles, socializing practices, learning styles, effects of poverty and discrimination, and acculturation. With respect to the third criticism, it was discovered that survey research was used in 72.5% of the studies, while analog research accounted for 12.5%, true experimental designs 8.8%, and archival designs 6.3% (p. 89). The authors concluded that researchers, rather than relying on analog studies, have overutilized a survey methodology. The authors found overwhelming evidence to justify the veracity of their claim in the fourth criticism. They discovered that two-thirds of the literature did not include within-group designs or intracultural comparisons. The fifth criticism was justified, as it was discovered that over onehalf of the studies used college and high-school student samples. The sixth criticism was also supported, as the authors discovered that only one-third of the studies used instruments that were designed for minority populations. The authors concluded this to be one of the most justified criticisms in ethnic/racial research studies. Criticism (vii) was justified, as two-thirds of the studies failed to report social economic variables. The eighth criticism was not wholly justified, as 60% of the studies listed their limitations. Criticism (ix) was not justified, as sample size depends on many factors, including type of design and sampling characteristics. Finally, the tenth criticism was fully justified, as 90% of the studies utilized outcome measures that were paper-and-pencil instruments. The authors concluded, therefore, that criticisms (i), (iv), (v), (vi), (vii) and (x) are justified; criticisms (ii) and (ix) partially justified; and criticisms (iii) and (viii) unjustified. Stanfield (1993) has criticized cross-cultural research methods from an epistomological
perspective. He examined the fallacies of homogeneity and monolithic identity, and the presumptions that underlie research ethics. He believed that the failure of researchers adequately to clarify these issues has led to exploitative research with ethnically and racially diverse subjects. 10.04.6.2 Recommendations The comprehensiveness of Ponterotto and Casas's (1991) work can be seen in the methodological recommendations that they offer. These suggestions cover five areas of concern. First, because culture is complex (Pedersen 1991c), a variety of research methods need to be used. In particular, the authors called for researchers to ªembrace qualitative methods that have been effectively employed in the related disciplines of ethnology, cultural anthropology, and sociologyº (p. 96). Second, the authors suggest that studies focus on withingroup differences rather than between-group differences. In so doing, research could avoid comparing racially and ethnically different clients to white or mainstream clients, a situation that usually implies majority behavior to be normal and minority behavior to be abnormal. Third, the authors suggest research that focuses on variables that ªtranscend cultureº (p. 99). Those variables could include some of the universals of human experience such as economic deprivation, family loss, serious medical and psychological illness, and change in environmental conditions. Fourth, culture-specific instrumentation is recommended, especially for such psychological constructs as depression, self-concept, and assertiveness. Finally, the authors believe that more studies need to focus on the strengths of ethnically/ racially different clients, rather than on their weaknesses. This suggestion also includes a focus on the positive aspects of biraciality and biculturality. Mio and Iwamasa (1993) vociferously attacked the methodologies used in conducting ethnic minority research. They posed the question of whether or not researchers from a majority culture could and should conduct research with minority clients. Reactions to this position can be found in Atkinson (1993), Ponterotto (1993), Casas and San Miguel (1993), Helms (1993), Ivey (1993), Parham (1993), Pedersen (1993), and Sue (1993). These reactions suggested ways to improve the quality of ethnic/racial minority research. Berry, Poortinga, Segall, and Dasen (1992) also explored methodological issues in crosscultural psychology. They indicated that the two major methodological concerns in any
empirical research study are the design and the analysis of results. The authors indicated that results from studies which focus on racially diverse subjects are more difficult to interpret validly than studies in which race and ethnicity are not considered as variables. They delineated four measures for accepting alternative hypotheses indicated by the data. One method for increasing confidence is by selecting subjects on the basis of the variables race, ethnicity, and culture. Groups need to be included in a study based on their ethnic group inclusion. The authors point out that many studies involving ethnically/culturally diverse subjects have problems during the selection phase of the study. Differences between the groups can be due to factors that are present in the majority culture, the minority culture, or an interaction of factors between the two cultures. Second, Berry et al. (1992) recommend the dependent variable be ªexpressed as a function of two or more separate scores. An example is the score that can be obtained by taking the difference betwween scores on two measurementsº (p. 223); this strategy can help to eliminate rival hypotheses. Third, they advocate the minimization of the effect of extraneous variables through statistical methods such as analyses of covariance and multiple regression analysis. Finally, they advocate that more than one dependent measure be used, through methods that include selfreport measures, interviews, and archival information. This method increases the amount of data one has to use in the formulation of conclusions and interpretations. Like Ponterotto and Casas (1991), Berry et al. (1992) show concern about the instrumentation utilized in cross-cultural studies. ªEmicº approaches study behaviors of one culture from within the subjects' cultural system and use criteria that are related to the internal characteristics of that culture. ªEticº approaches study behaviors from outside of the culture, by comparing one or more cultures, using dependent measures that are considered universally applicable. The authors indicate that one must consider the emic±etic distinction when designing and interpreting research studies. Berry (1969), based on the work of Pike (1967), argued that researchers need to distinguish between culturally specific variables (emic variables) and culture-general, universal variables (etic variables). The authors advocate emic approaches to research. These recommendations reflect Ponterotto and Casas's suggestions that culturally relevant instruments be used for measuring variables in a study. Berry et al. (1992), Hui and Triandis (1985), and Triandis (1978) have advocated a combined
Future Directions emic and etic approach to research. This approach identifies an etic construct to study, then operationalizes that construct through the development of emic instrumentation which evolves out of the culture studied. Bond and Smith (1996) have concluded that if future research is to proceed in a useful manner the ªmethodological problems stemming from the etic±emic dilemma must be more clearly addressedº (p. 226). Berry (1989) has suggested that research should proceed by investigating indigenously two or more cultures in order to arrive at a universally derived etic. This approach is in stark contrast to the more typical approach in cross-cultural psychology that uses etic measures from Western countries. Mrinal, Mrinal, and Takooshian (1994) have outlined the various research methods that have historically been utilized by cross-cultural researchers. They discuss the use of experimentation, observation, sampling, and assessment. In particular they analyze the use of dependent measures by comparing various assessment methods and instruments. They call for flexibility and adaptation to be used when conducting research cross-culturally. Stanfield (1993) has questioned the epistomological and methodological perspectives in contemporary cross-cultural studies. He believes that researchers have been pursuing the wrong question, or have answered incomplete questions concerning ethnically and racially diverse topics. He advocates a reorientation among researchers to re-evaluate and improve qualitative, quantitative, and comparative/historical research methods. Qualitative researchers have advocated the improvement of cross-cultural research by focusing on class, race, or gender relations from within the culture (Andersen, 1993), participant observation (Dennis, 1993), ethnographic methods (Facio, 1993; Spradley, 1979; Williams, 1993), discourse analysis (Van Dijk, 1993), and personal narrative approaches (Jordan, 1995; Madrid, 1995; Moraga 1995). Quantitative suggestions range from re-evaluating demographic statistics (Marks 1993), to new ways of measuring and detecting discrimination (Myers 1993), to the assessment of outcomes (Patton 1993; Sue et al., 1994), and to survey research (Smith 1993). Comparative/ historical methods have been suggested and outlined by Champagne (1993), Ragin and Hein (1993), and Stanfield (1993). 10.04.7 FUTURE DIRECTIONS In 1989 three trends were predicted by Kagitcibasi and Berry. They predicted there
would be an increasing focus on individualism and collectivism, on indigenous psychotherapies, and on the search for behaviors and values common to every culture (cultural universals). In 1996, Bond and Smith concluded that three trends have emerged during the 1990s in crosscultural psychology. They suggested individualism and collectivism have been studied extensively but the other two areas have been plagued by methodological problems. They state that the emic±etic (i.e., culture-specific± universal) dilemma must be more clearly delineated. This clarification could provide new frameworks for research with culturally diverse subjects. In addition, psychologists will have to focus on resolving issues of terminology and definition, clarifying professional and ethical concerns, addressing methodological weaknesses in research, and generating new topics for study. These areas of concern will be examined in this section of the chapter. 10.04.7.1 Terminology The terms ªethnicity,º ªrace,º and ªcultureº have had a long history of clarification (Jackson, 1995; Jones, 1991). This history has been fraught with confusion and misunderstanding (Phinney, 1996). Ridley et al. (1994) and Westbrook and Sedlacek (1991) have criticized the inconsistent usage of terminology and pointed to the negative effects of labeling and stereotyping. LaFromboise, Foster, and James (1996) have suggested that the term ªraceº may be eliminated from future research studies, based on the conclusions of Yee, Fairchild, Weizmann, and Wyatt (1993), who indicated the lack of uniform use of the terms ªraceº and ªethnicity.º Alvidrez, Azocar, and Miranda (1996) have suggested methods to conceptualize, measure, and interpret ethnic or racial variables in studies of clinical interventions. The recommendations were that researchers should identify their definitions of race and ethnicity, provide more comprehensive information about subjects other than ethnicity or race (e.g., demographic information and language), identify social class variables, and indicate occupation level. The recognition that ethnicity is multifaceted has led to a re-examination of the terminology. Ragin and Hein (1993) have described the term ªethnicityº as interactive and contextual. Ethnicity and race have recently been viewed as dimensions rather than categories (Goodchilds, 1991). Phinney (1996) has suggested these dimensions ªclearly cluster together in ways that make ethnicity a highly salient and meaningful constructº (p. 925).
Additionally, Phinney (1996) has also suggested that if psychologists wish to generate adequate explanations about treatment outcomes when ethnicity is a factor, they need to investigate three dimensions within and across ethnic groups. These are: significant cultural norms and attitudes, factors involved with a client's ethnic identification, and individual minority client experiences of decreased status and power. Pedersen (1995) advocates the future use of the term ªcultureº as formulated by Betancourt and Lopez (1993). These authors have described culture as a learned, socially shared set of variables, incorporating individual, family, and societal variables. Fernando (1995) has examined the issue from the perspective of ethnic groups in Great Britain and has argued for a more dynamic conception of culture to be formulated in cross-cultural psychology. Pedersen and Ivey (1993) have outlined the complexity and dynamic nature of culture and have focused on the need to identify salient ethnic, racial, and cultural variables. The importance of these variables varies from moment to moment, and they include ªethnographic, demographic, status, and affiliation characteristics . . . particularly gender, ethnicity, life-style or other affiliationsº (p. 188). The consideration of these variables will allow researchers and practitioners to dissolve stereotypes of client behaviors based only on ethnic, cultural, and racial group membership. Pedersen and Ivey (1993) concluded that one needs to address the dynamics of culture by focusing on the salience and complexity of culture. This new focus will have greater relevance in future individual counseling discussions and is a foundation for an examination of ethical considerations in cross-cultural counseling (LaFromboise et al., 1996; Pedersen, 1995). 10.04.7.2 Ethical and Professional Issues A 20 year historical analysis of cross-cultural counseling ethics, beginning with the 1973 Vail Conference, has been completed by Pedersen (1994). He traced the formulation of ethical principles in the professional associations of psychology. Ethical principles for conducting cross-cultural research were adopted in the 1970s by the International Association of CrossCultural Psychology (Tapp, Kelman, Triandis, Wrightsman, & Coelho, 1974). Ethical principles have also been formulated by the APA (1992) and the ACA (1988). The APA principles address the issues of race, ethnicity, and culture in an effort to minimize and dispel bias in
therapeutic interventions, arising from stereotyping or discrimination. The ACA ethical principles indicate the need to respect the client's individuality and dignity with regard to cultural difference. In addition, guidelines have been provided for clinical interventions with ethnically, culturally, and linguistically different clients (APA, 1993). Several future trends seem imminent in the area of ethics. Ethical principles are being revised and more specifically delineated. The ethics of caring and responsibility are beginning to receive more attention in the cross-cultural literature (Pedersen, 1995). Ethics in the area of multiculturalism will be expanded to delineate more fully the impact of psychotherapeutic training models on a counselor's multicultural competence (Sue et al., 1996). In addition, ethical issues concerning the types of, and approaches to, research with diverse populations will be elaborated in greater detail (Pedersen, 1995). The issue of white American researchers conducting the majority of the research with minority clients is an area that will be examined with greater focus (Mio & Iwamasa, 1993). This issue will be expanded to incorporate the recruitment and retention of minorities in psychotherapy research, as there has been an under-representation of minorities in clinical research (Miranda, 1996). This under-representation has led to the formation of guidelines from the National Institutes of Health (NIH) in the USA concerning the inclusion of minorities and women in psychology research (NIH, 1994). These new NIH guidelines for the inclusion of minorities in clinical research will be evaluated and studied in greater depth (Hohmann, & Parron, 1996). The focus on recruitment and retention has centered on Native Americans (Norton & Manson, 1996), African-Americans (Thompson, Neighbors, Munday, & Jackson, 1996), Latinos (Miranda, Azocar, Organista, Munoz, & Lieberman, 1996), and elderly ethnic clients (Arean & Gallagher-Thompson, 1996). It is believed that the NIH guidelines will help encourage collaborative efforts between practitioners and researchers (Miranda, 1996). Specific recommendations will need to be formulated for recruiting and retaining other specific, racially, ethnically, and culturally diverse research subjects. 10.04.7.3 Future Research Future cross-cultural research will address methodological, theoretical, and content issues. In particular, an examination of research
Future Directions agendas, assessment methods, multicultural counseling and therapy theory, and specific research topics, appear to be areas of future concern.
10.04.7.3.1 Research agenda Sue and Sundberg (1996) have proposed 15 specific hypotheses to be tested in future research on individual counseling. These hypotheses are based on questions that range from client±counselor similarity, to worldview differences, to emic±etic issues. They are as follows (pp. 329±343). (i) Entry into the counseling system will be affected by cultural conceptualization of mental disorders and socialization towards seeking help. (ii) The more similar the expectations of the intercultural client to the goals and process of counseling the more effective the counseling will be. (iii) Of special importance in intercultural effectiveness is the degree of congruence between the counselor and client in their orientations in philosophical values and views towards dependency, authority, power, openness of communication, and other special relationships inherent in counseling. (iv) The more the aims and desires of the client can be appropriately simplified and formulated as objective behavior or information (such as university course requirements or specific tasks), the more effective the intercultural counseling will be. (v) Cross-cultural empathy and rapport are important in establishing a working alliance between the counselor and the culturally different client. (vi) Effectiveness will be enhanced by the counselor's general sensitivity to communications, both verbal and nonverbal. The more personal and emotionally laden the counseling becomes, the more the client will rely on words and concepts learned early in life, and the more helpful it will be for the counselor to be knowledgeable about socialization and communication styles in the client's culture. (vii) The less familiar the client is with the counseling process, the more the counselor or the counseling program will need to instruct the client in what counseling is and in the role of the client. (viii) Culture-specific modes of counseling will be found that will work more effectively with certain cultural ethnic groups than others. (ix) Ethnic similarity between counselor and client increases the probability of a positive outcome.
(x) Within-group differences on variables such as acculturation and stage of racial identity may influence receptivity to counseling. (xi) Credibility can be enhanced through acknowledgment of cross-cultural factors in cross-cultural encounters. (xii) In general, women respond more positively than men to Western-style counseling. (xiii) ªThe person who acts with intentionality has a sense of capability. She or he can generate alternative behaviors in a given situation and approach a problem from different vantage points. The intentional, functioning individual is not bound to one course of action but can respond in the moment to changing life situationsº (cited from Ivey, Ivey, & SimekMorgan, 1993, p. 8). (xiv) Identity-related characteristics of white counselors can influence their reaction to ethnic minority clients. (xv) Despite great differences in cultural contexts, in language, and in the implicit theory of the counseling process, a majority of the important elements of intercultural counseling are common across cultures and clients. The authors have labeled their 15 hypotheses as protohypotheses because they acknowledge that the constructs and propositions need to be more fully sharpened, focused, and developed before effective research can be started. Their hope is to stimulate further thinking in this area. The testing of their hypotheses is proposed by the authors as an agenda for future research in the area of cross-cultural counseling and psychotherapy. Sue and Sundberg (1996) also have suggested that future research should broaden the criteria for inclusion into a study by using marginal and at-risk clients. They also advocate a detailed examination of the emic±etic controversy. Ponterotto and Casas (1991) have identified areas of research that should constitute the agenda for the 1990s and beyond. The areas include: accurate epidemiological studies of psychological problems with various ethnic and racial identities, impact of Eurocentric political and social systems on clients, systemic racism, a focus on the strengths present in low socioeconomic groups, biracial identity development, ethnic minority youth research, primary prevention, assessment, and combination emic± etic studies. Berry et al. (1992) predict a future focus on examining emic±etic issues. They envisage cross-cultural research that examines psychopathology from various perspectives. These perspectives are: invariate or present in all cultures (absolute); present in all cultures, but culturally determined (universal); and unique to specific cultures and emically definable (cultu-
rally relative). Helms (1994) has argued that the new focus on multiculturalism and pluralism has resulted in a neglect of racial factors that contribute to psychotherapy interventions. She has called for a greater focus on racial factors for the future. 10.04.7.3.2 Assessment techniques Future research will inevitably include the development and validation of assessment techniques that are culturally appropriate. The use of traditional assessment techniques has been criticized extensively in the literature (APA, 1993; Dana, 1993; Lonner, 1990; Paniagua, 1994; Ponterotto & Casas, 1990; Samuda, 1975; Samuda, Kong, Cummins, PascualLeone, & Lewis, 1991; Sodowski & Impara, 1996). The issues of cross-cultural assessment and appraisal have most recently been examined by Lonner and Ibrahim (1996). The authors present a general overview of the issues involved when assessing culturally diverse clients by focusing on the impact of response sets and emic±etic issues. They have examined the use of cognitive ability tests and personality measures. In addition, they have provided a historical analysis of the assessment of the therapeutic process and the assessment of refugees. Subsequent to their extensive review they concluded that these areas need to have a greater focus in the future. In addition to the investigation of traditional standardized cognitive and personality measures, researchers will need to develop future instruments, in various areas of concern, from an emic perspective (e.g., biracial identity and worldview). These instruments will need to be validated and thoroughly researched. Processoriented techniques of assessment, such as those in the dynamic assessment movement (Feuerstein, 1979), will need to be considered for crosscultural utility and feasibility (Samuda & Lewis, 1992). The area of assessment constitutes one of the most significant methodologic weaknesses (Ponterotto & Casas, 1991) and will, therefore, continue to occupy psychologists in the next decade. 10.04.7.3.3 Theory of multicultural counseling and therapy Future research will focus on the theory of multicultural counseling and therapy (MCT). This new framework for delivery of psychotherapeutic services to culturally diverse clients, proposed by Sue et al. (1996), has six major propositions and 47 corollary suppositions. Research will undoubtedly focus on the specifics proposed by these authors.
The authors have advocated a future agenda that has researchers: (i) conduct a metareview of historical and current studies from a MCT perspective, (ii) examine the shift from a focus on the individual to a study of the individual within a context or in relation to others, and (iii) examine the positive attributes of individuals and cultures, rather than focusing on stereotyped behaviors and pathologies. Additionally, they have advocated the investigation of traditional research methods that generate epistemological assumptions that may not be universal. This future focus could incorporate a detailed examination of differing worldviews and how these differences impact on crosscultural interventions. Finally, the authors recommend the use of qualitative research methodologies when working with a culturally diverse population. This approach, as well as quantitative methods, will need to be used effectively to ªexplore new methods that are culture centered rather than consider culture as peripheralº (p. 36). The reactions to MCT theory (Arredondo, 1996; Ballou, 1996; Casas & Mann, 1996; Corey, 1996; Daniels, & D'Andrea, 1996; Highlen, 1996; LaFromboise & Jackson, 1996; Lee, 1996; Leong, 1996; Parham, 1996; Pope-Davis & Constantine, 1996; Vasquez-Nuttal, Webber, & Sanchez, 1996) and the counter-reactions (Sue et al., 1996) indicate that the dialogue will continue into the twenty-first century, with a refinement of the theory and an empirical validation of the underlying constructs. 10.04.7.3.4 Specific research topics The methodological issues previously outlined and the research suggestions offered (APA, 1992; Berry et al., 1992; Ponterotto & Casas, 1990; Sue et al., 1996; Sue & Sundberg, 1996) provide a foundation for specific topic areas that appear to be receiving attention in the literature. Topics such as underserved populations, biraciality, the vocational behavior of diverse clients, and indigenous therapy, need more examination in the future. These four potential topics are now examined in greater detail. In the 1990s, there has been a move to focus on specific ethnic/cultural/racial groups, rather than the more commonly studied four groups, in the USA: African-American, Asian-Americans, Latino-Americans, and Native Americans (Sue et al., 1994). This new focus on specific underserved populations and within-group populations could be a major focus in the next decade. In particular, the treatment of specific populations has begun to appear in the literature: traditional Arabic clients (Dwairy & Van Sickle,
Future Directions 1996), Puerto Ricans (Malgady, Rogler, & Rogler, & Constantino, 1990), Haitians (Gies, 1990), Guatemalan Mayans (Alger, 1996), Vietnamese (Snodgrass et al., 1993), Cambodians (Bemak & Greenberg, 1994), and Venezuelans (Villegas-Reimers, 1996). These authors have concluded that researchers need to go beyond the traditional ethnic/racial group categories to focus on the heterogeneity that exists within each ethnic/racial group. Future studies that examine these and other minority groups need to focus on both between- and within-group comparisons. Such a focus will provide an evaluation of the impact of the culture-specific versus universal variables on counseling and psychotherapy. The focus on heterogeneity has revealed the presence of biracial/biethnic and multiracial/ multiethnic variables. As the demographics change in countries, so do the number of intercultural and interracial marriages. Interracial, interethnic, and biracial families have become a reality in the 1990s and have received increasing attention in the psychological literature (Root, 1992). The term ªbiracialityº has been used to describe the children of racially different parents and is akin to biculturality and bilingualism (Kerwin & Ponterotto, 1995). This area has evolved from early research on the biracial identity models as outlined by Kerwin and Ponterotto. The authors have suggested five research areas for future study: (i) effects of peer pressure on adolescent identity development, (ii) impact of cultural focus on identity development, (iii) dichotomous choices of identifying as multiracial/multicultural rather than choosing one racial/ethnic categorization, (iv) development of bicultural competence for biracial adolescents and adults, and (v) role of parents and educators in developing an adequate sense of identity in biracial children. This complex area of concern will receive greater study in the future. During the 1980s and 1990s there has been an increasing focus on the vocational concerns of racial and ethnic minorities (Leong, 1995). This focus on career development of the culturally diverse has led to an exploration of the issues with African-Americans (Bowman, 1995; Brown, 1995), Hispanic-Americans (Arbona, 1995; Fouad, 1995), Asian-Americans (Leong & Gim-Chung, 1995; Leong & Serafica, 1995), and Native Americans (Johnson, Swartz, & Martin, 1995). This examination of career behavior has promulgated a multicultural theory of career development (Osipow & Littlejohn, 1995) and recommendations for vocational assessment and career counseling (Betz & Fitzgerald, 1995). Future literature on cross-cultural vocational counseling interven-
tions will elucidate and attempt to validate this theory. Another area of concern is the role of indigenous therapies. In many countries there is an acceptance of both standard, formal psychotherapeutic intervention methods and traditional healing methods. The role of traditional, or indigenous, healing practices has been examined by Lefley (1994) and Hiegel (1994). A comprehensive treatment of the subject is available in Kim & Berry (1993). This area of psychotherapy will inevitably continue to grow as emic approaches become more acceptable in both Western and non-Western cultures. Indigenous methods for investigation could include Morita, Naikan, Voodoo, Santoria, and Espiritismo therapy. Bemak, Chung, and Bornemann (1996) have proposed a multilevel model for counseling refugees that integrates Western therapies and indigenous methods of intervention. This integration of approaches has resulted in more effective psychotherapy outcomes (World Health Organization, 1992) and is a harbinger of future work in cross-cultural psychology. 10.04.7.4 Global Psychology It has been suggested by Moghaddam (1987), that three worlds of psychology exist: the body of research derived from American research studies in the USA, research generated in other industrialized countries, and a third body of knowledge that has emerged from developing countries. Mays, Rubin, Sabourin, and Walker (1996) have stated: ªWithin this triumvirate, US psychology has been imported and serves as an important source of influence for a number of developed nationsÐthe European communities, in particularÐas well as the developing nationsº (p. 485). Pawlik and d'Ydewalle (1996) have predicted the rise of international cooperation and exchange in psychology, occurring through international organizations, conferences, and publications. Gergen, Gulerce, Lock, and Misra (1996) have examined the global context of psychological practice. They delineated various indigenous issues present in India, New Zealand, and Turkey. They argue for a multicultural psychology that down plays the dominant influence of Western psychological models of theory and practice. Lunt and Poortinga (1996) have advocated the increase in European psychology studies that are based on the multicultural diversity present in European countries. The trend towards internationalizing psychology, therefore, appears to be one which will receive greater attention in the future and may have an impact on the area of cross-cultural intervention research.
10.04.8 SUMMARY Multicultural counseling has been hailed as the fourth force in psychology (Pedersen, 1990). The area of cross-cultural interventions has evolved into a multidimensional field that encompasses several specific interest areas. First, the impact of proximal and distal variables upon behavior has been examined. This area has provided evidence that a therapist needs to understand both universal and culturespecific aspects of a client's functioning. Second, research on cross-cultural intervention processes has been reviewed. These processes include topics as diverse as counselor competence and sensitivity, communication style, and verbal and nonverbal communication. The research suggests that cross-cultural interventions can be facilitated and improved by a therapist having an understanding of the racial/ ethnic/cultural differences that exist between the client and therapist. Third, the research on therapist±client match was examined. The majority of studies suggest that clients prefer ethnically/racially/culturally similar therapists and judge these therapists as more competent than dissimilar therapists. Other research, however, repudiates these notions, pointing to other therapist variables (e.g., sensitivity) as important. Fourth, the treatment outcome research has been examined. It was discovered that few methodologically sound studies exist in the literature and, also, that most studies have focused on minority groups in the USA. Fifth, methodological research concerns were explored. The weaknesses of cross-cultural studies were examined, and recommendations for future research were reviewed. Finally, this chapter has looked to future trends in crosscultural intervention research. It predicted that terminology and ethical considerations will be more clearly delineated. In addition, future trends include the elucidation and validation of the theory of multicultural counseling and therapy, refinement and construction of culturally appropriate assessment and outcome measures, and a focus on specific within-group research topics. It is suggested that greater emphasis on global issues in psychology, and an increase in international research, will further the study of cross-cultural clinical interventions. 10.04.9 REFERENCES Acosta, K., & Cristo, M. (1981). Development of a bilingual interpreter: An alternative model for Spanishspeaking services. Professional Psychology, 12, 474±482. Acosta, K., Yamamoto, J., & Evans, L. (1982). Effective psychotherapy for low-income and minority patients. New York: Plenum. Akutsu, P., Lin, C., & Zane, N. (1990). Predictors of
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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
10.05.2 DEFINITIONS AND KEY CONCEPTS
10.05.2.1 10.05.2.2 10.05.2.3 10.05.2.4 10.05.2.5
Why the Need for Cultural Competence Training? Cultural Competence as Good Science and Practice Key Aspects of Cultural Competence The Concept of Culture Levels of Cultural Capacity
10.05.3 EVALUATING LEVELS OF CULTURAL CAPACITY 10.05.3.1 10.05.3.2 10.05.3.3 10.05.3.4 10.05.3.5
Evaluation Relevant to a Reference Group Cultural Capacity in Assessment Cultural Capacity in Clinical Intervention Cultural Capacity in Research A Life-long Professional Odyssey
health professionals aims to enhance quality in the health services and research that is delivered to members of various ethnic minority groups, including African-Americans, Latinos/Hispanics, Asian-Americans and Pacific Islanders, and Native Americans. This training model introduces a distinct minority perspective based on at least five assumptions. First, the model assumes that ªcultureº cannot be ignored, and that it must be well understood in order for a clinical psychologist or for a health program to work effectively
This chapter presents a three-factor model for describing and rating the capacity of a clinical psychologist or other health professional to conduct culturally effective assessments, clinical interventions, and research with members of ethnic minority populations. The overall aim of this model is to provide a specific and clinically useful system that guides skills training towards the development of cultural competence. Developing cultural competence in a new cohort of 127
Cultural Competence Training in Clinical Psychology
with members of ethnic/racial populations. Second, this model assumes that the clinical psychologist must examine sociocultural factors in order to conduct effective assessments, treatments, and research with ethnic minority clients and communities. Third, it assumes that attaining the highest level of cultural capacity, which is cultural proficiency, requires the clinical psychologist to decenter himself or herself culturally, meaning that he or she must learn empathically to adopt the client's emic (cultural insider's) world view. A fourth assumption is that cultural proficiency in research and in community-based health service programs requires a social action research approach, an approach which invites the participation of ethnic minority community folks in the development and implementation of any intervention that is conducted within that ethnic minority community (Flores, Castro, & FernandezEsquer, 1995). Finally, within this perspective, a fifth assumption is that the culturally proficient clinical psychologist should exercise leadership by way of mentorship and an active involvement in advancing minority issues.
10.05.2 DEFINITIONS AND KEY CONCEPTS 10.05.2.1 Why the Need for Cultural Competence Training? Today, the concept of cultural competence has emerged as the result of several converging social trends. First, the demographic face of the USA has changed since the early 1970s as several ethnic/racial populations have grown in size and significance. Several of the major ethnic/racial populations in the USA have shown growth rates that surpass the growth rate of the mainstream USA population. As these trends continue, for the year 2000, the projected sizes of the major ethnic racial populations of the USA in terms of size and percentage are: African-Americans, about 33.7 million (about 12.2%); Latinos/Hispanics, about 31.1 million (about 11.3%); AsianAmericans and Pacific Islanders, about 11.4 million (about 4.1%); and Native Americans/ American-Indians, about 2.2 million (about 0.7%) (Department of Commerce, 1994). As a second factor, the 1985 Secretary's Task Force Report on Black and Minority Health highlighted in greater detail what was known previously, which is that within the USA there exists a major gap in health status between the white mainstream (primarily middle class) population and the ethnic/racial minority and mostly lower class populations (Department of
Health and Human Services, 1985). Moreover, a social process involving several interrelated behavioral, sociocultural, environmental, and economic factors has contributed to this disparity (Anderson, 1995). Thus, clinical psychologists and other providers of health services must comprehend the manner in which these various sociocultural factors have operated to influence the health status of these minority populations. Clearly then, clinical psychologists must acknowledge and understand the detrimental effects of certain sociocultural factors when conducting assessments, when developing clinical interventions, and when designing and conducting research that involves ethnic minority individuals, families, or communities. Within this context and at the level of the individual client, it is clear that ethnic minority clients have complex, and at times unique, needs that must be well understood within a cultural context in order to engage them successfully in treatment and/or research. This emerging recognition of the effects of sociocultural factors on physical and mental health underscores the need for cultural competence training, in order to improve the clinical psychologist's capacity to work effectively with members of these minority populations. Third, the current need to develop cultural competence in clinical psychologists has also emerged as a result of the ªpipeline issue.º Trends regarding the educational progress of students of ethnic/racial backgrounds reveal low numbers of ethnic minority graduates who will be able to provide culturally relevant health services to members of their ethnic/racial group. Only a limited number of these minority graduates will enter the professional arena in order to address the large and growing need for services offered by minority professionals who understand the needs of ethnic/racial minority clients. Given this trend, and the growing need for culturally relevant health services, a more viable solution is to train and educate mainstream service providers, administrators, and researchers on essential aspects of the culture and health needs of clients from various ethnic/ racial populations. 10.05.2.2 Cultural Competence as Good Science and Practice Developing cultural competence in clinical psychologists of all backgrounds should not be seen as a ªpolitically correctº gesture to demonstrate token responsiveness to a contemporary social concern. On the contrary, developing the cultural competence of clinical psychologists should be seen as an important
Definitions and Key Concepts training goal that offers them a broader range of capabilities for working more effectively clinically and in research with a broader and more diverse group of clients and research participants. Moreover, the American Psychological Association's Ethical Principles of Psychologists and Code of Conduct indicates that psychologists should ªprovide services, teach, and conduct research only within the boundaries of their competence, based on their education, training, supervised experience, or appropriate professional experienceº (American Psychological Association, 1992, p. 1600; Standard 1.04ÐBoundaries of Competence). In addition, these guidelines indicate that, in those emerging areas in which generally recognized standards for preparatory training do not yet exist, psychologists [should] nevertheless take reasonable steps to ensure the competence of their work and to protect patients/clients, students, research participants, and others from harm.
Clearly, in the late 1990s and in the early years of the twenty-first century, the guidelines that define cultural competence in clinical interventions with ethnic/racial populations are still evolving. Thus, in response to the American Psychological Association's Ethical Principles, all psychologists who work with clients from ethnic/racial backgrounds or who anticipate working with these clients should continually seek ways to enhance their cultural competence in order to conduct effective assessments, interventions, and/or research with these minority clients. Moreover, from an organizational perspective, it can be noted that practically all organizations have a ªculture,º which consists of organizational operating characteristics. Based on these operating characteristics, some organizations can be described as having a healthy, accepting, collegial, supportive, comfortable, consumer-friendly, and culturally competent culture. By contrast, other organizations can be described as having a paranoid, judgmental, patriarchal, controlling, stressful, consumer-unfriendly, and culturally incompetent culture. The operating characteristics that govern a particular organization's culture affect the way that consumers will react to the services that the organization delivers, and this is especially true for the ethnic minority consumers who seek services within that organization. Human service organizations that have institutional policies, procedures, and structures that discount or devalue the importance of cultural competence are not likely to deliver culturally competent services to their minority clients, and they are likely to induce tension and demor-
alization among members of their staff who see the need for cultural competence in services that would be delivered to minority clients. Finally, cultural competence training is also relevant to the conduct of good research and good science. In March 1994, the National Institutes of Health (NIH) published new guidelines for the inclusion of women and minorities in clinical research, guidelines which reflected the requirements of the NIH Revitalization Act 1993 (Public Law 103-43) (National Institutes of Health, 1994). The release of these guidelines gave formal recognition to the importance of gender and ethnic cultural factors in scientific clinical research (Hohmann & Parron, 1996). These guidelines indicate that studies of outstanding scientific merit cannot be conducted if such studies systematically or arbitrarily exclude a large and diverse sector of the population from their operating plans. Such studies are flawed if, without a sound rationale, they exclude women and/or minorities from their theoretical framework, their sampling design, their methodology, and thus from their findings and their conclusions. Here, cultural competence in research is demonstrated by an investigator who understands and can conceptualize the hypothesized effects of specific sociocultural factors on health outcomes, and who can design and implement studies that effectively recruit and retain women and minority participants (AreaÂn & GallagherThompson, 1996; Miranda, Azocar, Organista, MunÄoz, & Lieberman, 1996; Thompson, Neighbors, Munday, & Jackson, 1996). 10.05.2.3 Key Aspects of Cultural Competence Generally, cultural competence may be conceptualized as a capacity to work effectively with individuals from special populations, including clients from ethnic/racial communities. Cultural competence is expressed by communicating acceptance, deep understanding, and responsiveness to the needs and concerns of members of special populations. Cultural competence may also be conceptualized as a capacity level that supersedes cultural sensitivity, given that cultural competence involves a level of understanding and skills that moves beyond a basic awareness of the needs and concerns of members from a special population. Cultural competence has been defined in various ways, although several definitions reveal certain common themes. For example, the Arizona Department of Health Services has defined cultural competence at the institutional level as
knowledge, attitudes, and policies within an agency which allows individuals to work effectively in cross cultural situations. This requires the willingness and ability to utilize community-based values, traditions, and practices in developing and evaluating interventions, communication, and other activities. (Arizona Department of Health Services, 1995)
A definition that applies at the individual and institutional levels was developed by a behavioral health workgroup. This definition indicates that cultural competence includes the attainment of knowledge, skills, and attitudes to enable practitioners and systems of care to provide care for diverse populations, i.e., to work within the person's reality conditions, in particular minority populations, acknowledges and incorporates variance in normative acceptable behaviors, beliefs, and values in determining an individual's mental wellness/illness and incorporates those variables into assessment and treatment. (The National Latino Behavioral Health Workshop, 1996)
A few common themes have been stated or implied in these and other definitions of cultural competence as defined at both the macro institutional level, and the micro individual levels. These themes include the notions that cultural competence: (i) consists of a complex set of knowledge, attitudes, and skills; (ii) is characterized by an empathic and culturally relevant understanding of the client, using an insider's view of the client's presenting problem; (iii) requires that the clinical psychologist or program exhibit cultural responsiveness, that is, a commitment towards understanding the client within the context of the client's own culture; (iv) requires the use of culture-based insights in planning an intervention (individual/family therapy, or a program) that is culturally relevant and effective in alleviating the client's problem; and (v) requires careful attention to the process of intervention, which is as important as the outcome, because in minority cultures expressions of respect and acceptance are indispensable aspects of the client±therapist relationship and will greatly influence client participation and treatment outcomes. In addition, there are other aspects of cultural competence, primarily at the micro clinical level, that are less salient in the literature, but that are important in cultural competence training for clinical psychologists. These are: (i) that cultural competence is a value-added capability where, under the current managed
care environment, the culturally competent clinical psychologist is capable of delivering culturally responsive interventions that surpass the effectiveness of conventional interventions (The National Latino Behavioral Health Workshop, 1996); (ii) that level of cultural competence is specific to a given cultural reference group, where, based on training and experience, a given clinical psychologist may exhibit cultural competence in working with one cultural group, for example with inner city African-American adolescents, but may only exhibit cultural sensitivity in addressing the needs of a different cultural group, such as elderly rural Mexican Americans; (iii) that the concepts of culture and subculture are not synonymous with demographic ethnic labels (e.g., Hispanic), where cultural competence in program planning requires a segmentation of the targeted ethnic population into subcultural groups (Balcazar, Castro, & Krull, 1995), the members of which have distinct lifestyles, needs, and problems (e.g., Chicano gang adolescents from East Los Angeles vs. Navajo elderly who live on the reservation); (iv) that culturally responsive interventions should be guided by culturally relevant intervention models and defining criteria, and by a management information system that gathers local data and that uses culturally relevant variables; and (v) that truly effective training to develop cultural competence requires continuing education that systematically upgrades skills across levels of the cultural capacity continuum towards the ultimate goal of cultural proficiency (Bernal & Castro, 1994). 10.05.2.4 The Concept of Culture The concept of ªcultureº is often difficult to grasp operationally, because, as a concept, culture is a rich, complex, and multidimensional concept. Indeed, one metaphor of culture as it relates to the heart and soul of ethnic minority peoples is the concept of ªhumidityº as it relates to the weather. You cannot see humidity, but you can definitely feel it when it is there. The same is true for culture. Given its rich complexity, well over 100 definitions of ªcultureº have been proposed (Murphy, 1986, cited in Baldwin & Lindsley, 1994). Indeed, culture has been defined broadly as the total body of tradition borne by a society and transmitted from generation to generation. It thus refers to norms, values, and standards by which people act, and it includes the ways distinctive in
Definitions and Key Concepts each society of ordering the world and rendering it intelligible. (Baldwin & Lindsley, 1994; Murphy, 1986).
Across various definitions of culture, certain common themes have emerged. These are: (i) that culture consists of the totality of learned behaviors of a people; (ii) that it is transmitted from generation to generation, that is, from elders to children; (iii) that people construct their own culture in order to give meaning to life by creating a world view that helps to explain their own reality; (iv) that it consists of a people's shared beliefs, values, ways of making things, customs, behaviors, traditions, and lifestyles; (v) that it offers a community of people with a set of social norms and moral values on how life should be lived; (vi) that, via a culture's art, music, folklore, and other forms of creative expression, culture captures the soul, character, and essence of a people; and (vii) that culture is important to a group of people because it promotes a sense of kinship, belonging, and group identity. Given the breadth and richness of the concept of culture, for cultural competence training a more narrow concept and definition is needed as a reference point for the operationalization of levels of cultural capacity (cultural sensitivity, cultural competence, and cultural proficiency). The approach that we will use is to begin by identifying a specific targeted reference group, which is the group of clients that is targeted for a given intervention or program. This targeted group may be defined either broadly (e.g., African-Americans, Asian-Americans) or more narrowly (e.g., African-American elderly aged 65 years and older, low-acculturated Chinese adolescents). The more broadly defined groups are typically populations that share a common culture. By contrast, the more narrowly defined groups are typically subpopulations and subcultures that share a culture with the parent group, but that are also governed by additional and perhaps unique norms, values, and other local sociocultural conditions. Thus, a clinical psychologist's cultural capacity level can be defined more accurately, by describing specific capacity levels in the areas of assessment, clinical intervention, or research that are defined in relation to the culture of a specific targeted reference group. 10.05.2.5 Levels of Cultural Capacity Figure 1 shows that the capacity for cultural competence varies along a graded continuum. This concept of a cultural capacity continuum
has been proposed previously by various scholars (Cross, Bazron, Dennis, & Isaacs, 1989; Kim, McLeod, & Shantis, 1992; Orlandi, 1992). In our current model, we are taking this concept of a cultural capacity continuum and are modifying and expanding it. On this cultural capacity continuum, the lowest level is ªcultural destructivenessº (7 3), which consists of an ethnocentric orientation that harbors openly negative destructive attitudes that emphasize the superiority of one's own culture and the inferiority of other cultures. Attitude has been previously defined as a ªreadiness to respond,º a learned ªpredisposition to respond in a particular way to a specific attitude objectº (Oskamp, 1991). Within a health service organization, a given staff member's condescending attitude can serve as an expression of cultural destructiveness, and this attitude will destroy the client±provider relationship. Similarly, at the institutional level, an agency's policies or practices that promote stereotypes and a discrimination of lower class clients is an expression of institutional cultural destructiveness. Here a stereotype refers to a mental image or a set of beliefs about a group of people, beliefs that are highly simplistic (and often inaccurate), highly evaluative (often derogatory), and rigidly resistant to change (and thus not modified by corrective information) (Oskamp, 1991). Ironically, in contemporary American society, culturally destructive attitudes in individuals and culturally destructive policies within institutions still exist. ªCultural incapacityº(72) refers to a professional's or an organization's orientation that emphasizes separate but equal treatment. While this may seem to be a viable and fair approach, in reality it often results in an institutional incapacity to provide equal and effective treatment of those clients who are culturally different. Similarly, at the next level, an orientation describable as ªcultural blindnessº (71) emphasizes that all cultures and people are alike and equal. While this orientation appears unbiased and accepting, its subtle yet injurious effect on members of special populations is that this approach discounts the importance of culture and the need to consider multicultural perspectives. Indeed, in a well-meaning but culturally insensitive effort to be fair and to treat everyone the same, an administrator may use this orientation to discount or discredit programmatic efforts that aim to respond affirmatively and in a culturally sensitive manner to the unique needs of clients from special populations. The first level of a positive cultural capacity is ªcultural sensitivityº (+1). Cultural sensitivity is characterized by the presence of a basic
1. Cultural Destructiveness Superiority of dominant culture and inferiority of other cultures
2. Cultural Incapacity Separate but equal treatment
3. Cultural Blindness All cultures and people as alike and equal
4. Cultural Openness (Sensitivity) Basic understanding and appreciation of importance of sociocultural factors in work with minority populations
5. Cultural Competence Capacity to work with more complex issues and cultural nuances
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 importance of sociocultural factors as these affect the client and the most viable treatment that may be offered. For example, in a health promotion program for Latinos, cultural sensitivity is reflected by the program's attention to the role of linguistic factors, interpersonal factors (personalismo, respeto, confianza), and of familal factors (traditionalism, familism), as these affect the health-related behaviors of various Latinos. Cultural sensitivity is also characterized by the presence of an elementary, but nonetheless critical, appreciation of the within-group variability, that is, of the diversity that exists within a given ethnic minority population. For example, among Latinos, scholars have regularly asserted that Hispanics/Latinos are a heterogeneous population characterized by large variability among its members in terms of racial background, educational attainment, household income, family size and composition, and even in the level of ethnic pride evident among its members (Montgomery, 1994). ªCultural competenceº (+2) represents a higher level of capacity to work with members of a special population. Relative to cultural sensitivity, cultural competence is characterized by a greater depth of skills and experience
that allows the clinical psychologist to understand and work effectively with cultural nuances. By understanding cultural nuances, the clinical psychologist is able to detect the ethnic client's subtle communications, to interpret their meanings, and to do so within the client's specific cultural context. Based on this deeper level of understanding, the clinical psychologist is thus more capable of planning culturally potent interventions. Such interventions would appeal to the ethnic client, elicit the client's participation, and motivate sustained participation. Similarly, in a community-based health promotion program, the cultural competence of the program's staff is characterized by their capacity to work actively with members of a community. This capacity includes an understanding of the cultural and political nuances that helps these staff members to develop trust and credibility with members of the local community, and to elicit their support and participation in the design and implementation of a health promotion program. Here also, cultural competence is characterized by the clinical psychologist's knowledge of the motivational dynamics that prevail within subgroups of a given population, as these motivational
Evaluating Levels of Cultural Capacity dynamics may be mediated by age, gender, cultural orientation, and other aspects of the group's subculture. ªCultural proficiencyº (+3) is the highest expression of cultural capacity. It serves as an ideal, rather than necessarily as a state that is attainable by all clinical psychologists. Cultural proficiency consists of a state of high mastery, a commitment to excellence, and a proactive attitude that facilitates the design and delivery of therapeutic services for members of a specific population. Here it is recognized that a given clinical psychologist or health program may exhibit cultural proficiency in service delivery to members of one targeted population (e.g., Latinos), but may only exhibit cultural sensitivity in service delivery to members of a different population. Thus, complete cultural proficiency with all special populations would be a rare accomplishment for many clinical psychologists, health programs, or human service agencies. Nonetheless, constantly striving to develop cultural proficiency in work with one or more special population is a laudable goal for any clinical psychologist, health program, or agency, although this calls for a commitment to life-long learning with the ultimate aim of developing depth and breadth in skills for working with members of one or more special population. 10.05.3 EVALUATING LEVELS OF CULTURAL CAPACITY This section presents a more detailed discussion of key aspects of cultural capacity relevant to the training of clinical psychologists. Table 1 lists the specific knowledge, attitudes, and skills that serve as indicators of varying levels of cultural capacity in the areas of assessment, clinical intervention, and research. The table presents a progressive increase in the knowledge, attitude, and skills that serve as specific operational criteria to help gauge a clinical psychologist's progression across levels of cultural capacity from cultural sensitivity, to cultural competence, to cultural proficiency. The criteria in Table 1 that describe levels of cultural capacity are presented as illustrative descriptors. They have not been validated empirically, although they are derived from the contemporary literature on cultural competence and from clinical and research experience (Allison, Crawford, Echemendia, Robinson, & Knepp, 1994; American Psychiatric Association, 1994; Dillard et al., 1992; La Fromboise & Foster, 1992; Szapocznik & Kurtines, 1993). Accordingly, these statements offer a viable system to evaluate levels of cultural capacity
where these descriptive statements serve as guideposts for conceptualization and evaluation when conducting cultural capacity training in the areas of assessment, clinical intervention, and research. When using Table 1, cultural capacity should be evaluated in relation to a specific reference group, that is a specific and targeted cultural group or subgroup. 10.05.3.1 Evaluation Relevant to a Reference Group One major problem in prior conceptualizations of cultural competence is that previous approaches have defined it in global and nonspecific terms. As a result, for the purpose of clinical training, cultural competence has remained a vague, unintelligible concept that is disassociated from critical clinical and organizational referents. Thus, as used previously, the concept of cultural competence has had limited practical usefulness to clinicians and to program planners. Missing is a conceptualization that defines cultural competence more accurately, as it is linked to a specific reference group. The present model aims to add greater precision and specificity to the conceptualization and measurement of cultural competence. To operate as a construct that has practical applicability in the clinical, organizational, and community settings, cultural competence must therefore be defined in terms of skills for service delivery to members of a specific reference group. For example, through training and experience, a clinical psychologist may acquire the knowledge, attitudes, and skills that afford him or her the capacity to conduct effective therapeutic work with various African-American clients. Thus, this clinical psychologist could be rated as being culturally competent in the area of clinical interventions with AfricanAmerican clients. By contrast, this same clinical psychologist may have never worked with a Asian-American client, and thus would not be culturally competent in service delivery with Asian-American clients. However, that clinical psychologist's knowledge about aspects of Asian-American cultural norms and values, his or her accepting attitude towards AsianAmericans and their culture, and his or her assessment skills for differential interpretation of tests conducted with various Asian American subgroups, including a familiarity with scales of acculturation, could garner for this clinical psychologist a rating of cultural sensitivity for work with Asian-American clients in the area of assessment. Based on these considerations, cultural capacity can be defined more accurately by
134 Table 1
Cultural Competence Training in Clinical Psychology 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
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 dimensions: (i) capacity level (none, sensitivity, competence, proficiency; (ii) in a specialty area (assessment, clinical intervention, research); and (iii) in relation to a specific cultural reference group (African-Americans, Latinos, Asian-Americans, Native Americans). Thus, in assessing training-related cultural capacity, a clinical psychologist may be described as having attained cultural competence (capacity level) in the area of clinical intervention (specialty area) for work with African-Americans (reference group). This three-factor descriptive model provides a specific and meaningful approach to guide clinical training and professional communications about the relevant cultural capacity of a given clinical psychologist as he or she proceeds through a training program. Regarding the dimension of reference group, a targeted reference group can be defined more generally, as a primary reference group, such as for example an entire ethnic/racial population that has a definable culture such as AfricanAmericans or Latinos. Alternatively, this reference group may be defined more specifically as a secondary reference group, that is a smaller more specific subgroupÐa subpopulation, such as African-American adolescents or Latino elderly. Referring to a more specific reference group may influence the level of cultural capacity that can be rated. As indicated earlier, a clinical psychologist may have attained cultural proficiency in conducting clinical interventions with African-American adoles-
cents, but may only be rated as having attained cultural sensitivity in conducting clinical interventions with African-American elderly. Similarly, this three-factor model can be applied at the organizational level, where an intervention program can be rated for its capacity to deliver culturally relevant services. Based on the service components of an intervention program, the skills of its providers, its institutional policies, and its clinical environment, a program may be rated in terms of cultural capacity (none, sensitivity, competence, proficiency), in a specialty area (assessment, clinical intervention, research, or other), with a given reference group (e.g., Native American elderly). 10.05.3.2 Cultural Capacity in Assessment Assessment refers to the use of standardized tests, interview approaches, and other diagnostic methods for systematically learning about the client (Dana, 1993). A clinical psychologist's progressive increase in knowledge, attitudes, and skills characterizes his or her increased levels of cultural capacity in the area of assessment. At the lowest capacity level, cultural sensitivity in assessment, the clinical psychologist should demonstrate an elementary knowledge of major cultural issues that affect the life experiences of members of a special population, such as members of one of the major ethnic/ racial groups (African-Americans, Latinos,
Asian-Americans, Native Americans). The clinical psychologist should also be familiar with the need to decenter himself or herself from a solely Eurocentric world view in order to adopt an insider's emic view (i.e., one that takes the perspective of the indigenous client). This decentering allows the exploration of culturally specific concepts; these are concepts that may be unique to the indigenous culture, or concepts that are defined differently in the indigenous culture relative to how they are defined within the mainstream culture. At the level of cultural sensitivity in assessment, the clinical psychologist should have an elementary knowledge of the within-group variability that exists within a given reference group, and should know about the moderator variables, such as the level of acculturation, that describe this within-group variability (Dana, 1993). This basic knowledge ideally facilitates an accepting attitude towards variability in culture, where variability is conceptualized as consisting of differences and not as deficits. Furthermore, this orientation should aid in reducing biased and stereotypical thinking (Oskamp, 1991), thus facilitating a more accurate assessment of clinical issues which are examined within the context of the client's cultural background. In addition, this sensitivity in orientation should contribute to overall skills for conducting a basic assessment of the client's needs and clinical problems. This assessment should take into account the influence of cultural and social factors in drawing valid conclusions about the client's strengths and weaknesses, while also observing conflicts, relative skills deficits, and psychopathology if these are present. Attaining cultural sensitivity in assessment should enhance the clinical psychologist's capabilities for developing preliminary treatment recommendations that take into account the client's social, familial, and personal resources and barriers, as these may facilitate or impede participation in a treatment or intervention program. As compared with cultural sensitivity, cultural competence in assessment constitutes a higher level of skills development. As contrasted with cultural sensitivity, attaining cultural competence in assessment requires a higher knowledge level, wherein the clinical psychologist understands more complex interactions and nuances as observed within the context of the client's culture. Apparent paradoxes when observed from a Eurocentric perspective may not necessarily appear as paradoxical or as psychopathology when observed from an indigenous cultural perspective. This capacity for empathic decentering when interpreting complex cultural meanings characterizes cultural competence in
the area of assessment. The clinical psychologist's affective attachment to the reference group's culture would enhance his or her skills for working with cultural conflicts and with more subtle issues. Having advanced skills for interpreting manifest and more latent content, for organizing content, and for processing information would help the clinical psychologist to design an insightful and comprehensive treatment plan or intervention program. As compared with cultural competence, at the level of cultural proficiency in assessment, the clinical psychologist would exhibit a deep and integrative knowledge of the client's culture. This knowledge would be coupled by a deep appreciation and bonding with that culture, based on having a deep personal involvement and years of experience. The culturally proficient clinical psychologist would have masterful skills for detecting and understanding subtle and complex cultural communications and for interpreting these accurately and in culturally appropriate ways. Such deep insight would allow the clinical psychologist to plan an optimally effective treatment plan or intervention program. 10.05.3.3 Cultural Capacity in Clinical Intervention In a manner parallel with assessment, a level of cultural sensitivity in clinical intervention is characterized by a clinical psychologist's demonstrated knowledge about the prevailing social norms and patterns of interpersonal communication for a given cultural reference group. This includes having a basic understanding of the within-group variability that exists in that group. This knowledge would be supplemented by the clinical psychologist's accepting attitude towards the group's culture and values. This positive orientation towards that cultural group would also facilitate the clinical psychologist's ease and comfort in conducting therapeutic work with persons from that cultural reference group. The clinical psychologist's basic capacity for empathic decentering would also help in understanding the ethnic experience of members of that cultural reference group. Cultural competence in clinical intervention would be characterized by the clinical psychologist's greater depth of knowledge about complex aspects of a culture's social norms, forms of communication, and types of interpersonal behavior, thus fostering the capacity to understand nuances and apparent cultural contradictions. Moreover, developing an affective bond and an appreciation for the reference
Evaluating Levels of Cultural Capacity culture and its people would foster the caring attitude that characterizes cultural competence in the clinical setting. This advanced level of knowledge and a caring attitude would enhance the clinical psychologist's understanding of the life conditions and the major ways of coping found among members of the reference group, and would aid in relating effectively to the client. Moreover, the clinician's ability to understand his or her own prejudices as one aspect of advanced empathic decentering would further enhance his or her cultural competence for conducting clinical interventions. This enhanced capacity to understand self and client as a dyad would also facilitate the clinical psychologist's capacity to conceptualize the client's problem using the most relevant therapeutic model, as it may apply within the client's life context. In addition, the culturally competent clinical psychologist would be able to plan and implement insightful and effective interventions or programs that address the ethnic client's most pressing needs. As an even more advanced stage of clinical capability, cultural proficiency in clinical intervention would be characterized by a clinical psychologist's deep and rich knowledge of the reference group's culture and of the complex norms, values, and other factors that govern behavior within that culture. At this stage, the clinical psychologist would develop a strong affective bond with the reference group and its culture and would have a deep respect for its people. This combination of rich knowledge and a strong positive attitude would facilitate the clinical psychologist's capacity to comprehend the life situation of various clients from that reference group, to conceptualize a given client's problem from various theoretical perspectives, and to visualize clearly where the case is going. Thus, the culturally proficient clinician would also have the capacity to plan and implement potent clinical interventions and/or to design and implement culturally effective treatment programs. 10.05.3.4 Cultural Capacity in Research In parallel with the knowledge, attitudes, and skills that serve as indicators of cultural capacity in a given specialty area, a clinical psychologist's cultural sensitivity in research would be characterized by his or her basic familiarity with sociocultural variables, including moderator variables, that must be incorporated into the research design and methodology of studies conducted with participants from a given cultural group. This knowledge-based sensitivity would include an awareness of procedures
for the protection of potential research participants that would be recruited from that reference group. An attitude of respect for members of that culture and an awareness of their special linguistic and other needs would enhance the clinical psychologist's ability to safeguard the rights of these potential participants. In addition, cultural sensitivity would be reflected in the clinical psychologist's basic capacity to engage individuals or communities from the reference group with respect, and in his or her ability to develop a research partnership with members of that reference group. As a more advanced stage of research capacity, cultural competence in research would be characterized by the clinical psychologist's greater knowledge of cultural interactions and of complex sociocultural processes, such as the process of acculturation, as these affect various members of the cultural reference group. This includes the clinical psychologist's capacity for theoretical decentering, which involves taking a critical examination of current Eurocentric models and their fit, or lack of fit, when applied with members of the cultural reference group. In cases in which model fit is poor, the culturally competent clinical psychologist is able to consider alternate constructivist models that feature an emic, insider's view of the ethnic person's life experiences and of the experience of being a minority person. Moreover, the clinical psychologist's commitment to establishing a research partnership with individuals and communities in a manner that offers them a voice in the design and conduct of the proposed research would also characterize cultural competence in research (Flores et al., 1995; Norton & Manson, 1996). This in-depth knowledge and a proactive attitude that favors research partnerships and social action research would facilitate the clinical psychologist's capacity to work actively with individuals and communities from the cultural reference group in the design and implementation of social action research. Beyond cultural competence, the more advanced level defined as cultural proficiency in research would involve advanced knowledge about the cultural reference group. This proficiency would be demonstrated by the clinical psychologist's deep and rich knowledge about the complexities and apparent paradoxes observed within the cultural reference group. This depth of knowledge would yield insights that facilitate the clinical psychologist's capacity to design significant new research. In principle, such research would be insightful and integrative, and would propose new culturally relevant models that could be adequately defined and tested. These models would include
sociocultural variables, including moderator and culturally specific variables that capture, describe, and explain various sociocultural processes that affect the health of clients from the given cultural reference group. In addition, cultural proficiency in research would be characterized by the clinical psychologist's strong appreciation for the core values and traditions of the cultural reference group and by a deep and abiding respect for these values and traditions. These proactive attitudes would be reflected in the clinical psychologist's strong commitment to safeguard the rights of prospective participants that are recruited from the cultural reference group. The culturally proficient researcher would also exhibit research leadership in conceptualizing, designing, and implementing innovative research that examines critical issues of concern to members of the reference community. In conducting social action research, the culturally proficient researcher would pursue active solutions to contemporary social problems that affect the reference community. In such research, the investigator would exert leadership in building community partnerships and in building a research team that includes members of the targeted community in positions that contribute to the planning, design, and implementation of that social action research project. Finally, the culturally proficient researcher would serve as a role model and as a mentor to junior faculty and graduate students, thus contributing to the training of future culturally competent investigators and teachers. The culturally proficient researcher would also adopt a leadership role in conducting critical yet helpful reviews of publication manuscripts and research proposals. This criticism would not only address issues of scientific merit, but would also address ethnic/racial issues, as well as issues of social inequality and scientific inaccuracy in manuscripts that examine ethnic minority communities and members of other special populations. In short, the culturally proficient researcher would take a proactive and leadership role in advancing a variety of minority research and training issues in the fields of clinical psychology, minority mental health, minority health, health promotion, and other related fields. 10.05.3.5 A Life-long Professional Odyssey The road to cultural proficiency begins not with knowledge or skills, but with attitude. Given that ªattitudeº is defined as a predisposition to respond in a particular manner to a
particular social situation (Oskamp, 1991), it is the clinical psychologist's positive attitude, an open-mindedness and willingness to learn about new cultures and people which characterizes that clinical psychologist's preparedness to embark on the journey towards cultural proficiency. Thus, instilling an attitude of openness in those who do not already have it is the first task in cultural competence training. In addition, ethical practice in work with diverse populations requires a commitment on the part of the clinical psychologist continually to upgrade his or her cultural capabilities. To meet this need, clinical training programs should be proactive in developing curricula and resources that help clinical psychology trainees to develop their cultural competence. Here, Standard 6.01 of the Ethical Principles of Psychologists and Code of Conduct asserts that psychologists who are responsible for education and training [should] seek to ensure that the programs are competently designed to provide the proper experiences, and meet the requirements for licensure, certification, or other goals for which claims are made by the program. (American Psychological Association, 1992, Standard 6.01, Design of Education and Training Programs)
Relevant to this point, a study of 104 clinical training programs that examined changes in service and research with ethnic/racial populations across a 10-year period found some improvements among many of the 104 clinical training programs surveyed (Bernal & Castro, 1994). However, these improvements consisted primarily of introductory-level capabilities training, and did not offer the depth in training needed to develop cultural competence among program trainees. Bernal and Castro noted that, despite the tangible improvements in minority training in clinical psychology that have occurred since the mid-1980s relevant structural shifts have not taken place. These structural shifts refer to institutionalized programmatic changes that involve concerted plans to integrate key aspects of minority training across the clinical training curriculum, coupled with a commitment of resources to implement these plans. Indeed, only four of the 104 programs surveyed, all at professional schools, exhibited training program profiles for an integrated curriculum that would foster cultural proficiency among its trainees. Whereas many programs may express an inprinciple endorsement of the importance of multicultural training, few have developed the infrastructure (coursework, minority faculty recruitment and retention, community links) for promoting cultural competence in clinical
References training. Given that departments and clinical training programs can also be rated on levels of cultural capacity, most programs nationally would fare no higher than being culturally sensitive. Clearly, based on the findings of the Bernal and Castro study, it can be concluded that most clinical psychology training programs in the USA can and should do more in order to develop their future capacity to promote cultural competence within their own clinical training program. Within the context of our previous statements, we also recognize that not all clinical psychologists or students are necessarily interested in or prepared to participate in cultural competence training. Similarly, not all clinical training programs give sufficient value to cultural competence training, or do not seek to offer their students training in cultural competence as compared with other important clinical training needs. Unfortunately, those who could benefit most from cultural competence training are often those who are least interested in it. However, for those who do value learning about other cultures, and for those who can be convinced to try it, developing the cultural capacity to work with persons from various cultures is an odyssey of a professional lifetime that offers intellectual, affective, social, and spiritual rewards. The invitation to undertake this journey is there for those who are willing to take it. 10.05.4 FUTURE DIRECTIONS The overview of the levels of cultural capacity that has been presented offers specific guidelines to help define cultural sensitivity, culture competence, and culture proficiency in the areas of assessment, clinical intervention, and research. However, in many ways, the present model only constitutes an early step towards a more detailed articulation of levels of cultural capacity. Additional work can and should be conducted to relate the guidelines presented here to a variety of specific cases with the aim of enhancing quality in assessment, treatment, and research with a diverse group of ethnic/racial clients. Moreover, clinical training programs can and must do more to add depth of content and diversity in their clinical training activities, as these additions facilitate greater competence in assessment, clinical intervention, and research with members of ethnic/racial populations. One potential outcome of presenting the current three-factor model and its guidelines is that it may serve as a template from which to rate the level of cultural capacity of given clinical
training program; that is, to rate the current capacity of the program to train culturally proficient clinical psychologists. 10.05.5 SUMMARY In this chapter a three-factor model has been presented that aims to define operationally the various levels of cultural capacity (sensitivity, competence, proficiency) as related to three specialty areas (assessment, clinical intervention, research), and as related to a specific cultural reference group. It is recognized that attaining true cultural competence in the areas of assessment, intervention, and research for each of several ethnic/racial populations is a high ideal that will be achieved by only a few clinical psychologists in a lifetime of professional practice. However, this chapter has also identified and defined graded steps towards this ideal, and encourages the clinical psychologist to commit a sustained effort towards enhancing his or her level of cultural capacity. Here also, clinical training programs have a professional obligation to upgrade their training program by adding depth of content and activities in order to enhance their programmatic capacity to offer true depth in cultural competence training. It is recognized that the present three-factor model constitutes only an early step in the task of further articulating the characteristics of various levels of cultural capacity, as this articulation aids in clarifying further what it means to become culturally competent. 10.05.6 REFERENCES Allison, K. W., Crawford, I., Echemendia, R., Robinson, L. V., & Knepp, D. (1994). Human diversity and professional competence: Training in clinical and counseling psychology revisited. American Psychologist, 49, 792±796. American Psychiatric Association (1994). Diagnostic and statistical manual of mental disorders (4th ed.). Washington, DC: Author. American Psychological Association. (1992). Ethical principles of psychologists and code of conduct. American Psychologist, 47, 1597±1611. Anderson, N. B. (1995). Behavioral and sociocultural perspectives on ethnicity and health: Introduction to the special issue. Health Psychology, 14, 589±591. AreaÂn, P. A. & Gallagher-Thompson, D. (1996). Issues and recommendations for the recruitment and retention of older ethnic minority adults into clinical research. Journal of Consulting and Clinical Psychology, 64, 875±880. Arizona Department of Health Services (1995). Cultural competency in the administration and delivery of behavioral health services. Phoenix, AZ: Author. Balcazar, H., Castro, F. G., & Krull, J. L. (1995). Cancer risk reduction in Mexican American women: The role of acculturation, education, and health risk factors. Health Education Quarterly, 22, 61±84. Baldwin, J. R., & Lindsley, S. L. (1994). Conceptualizations
of culture. Tempe, AZ: Urban Studies Center. Bernal, M., & Castro, F. G. (1994). Are health professionals prepared for service and research with ethnic minorities? Report of a decade of progress. American Psychologist, 49, 797±805. Cross, T. L., Bazron, B. J., Dennis, K. W., & Isaacs, M. R. (1989). Toward a culturally competent system of care. Washington, DC: Georgetown University Child Development Center. Dana, R. H. (1993). Multicultural assessment perspectives for professional psychology. Boston: Allyn and Bacon. Department of Commerce (1994). Statistical abstract of the United States: 1994 (114th ed.). Washington, DC: US Government Printing Office. Department of Health and Human Services (1985). Report of the Secretary's Task Force on Black and Minority Health. Washington, DC: US Government Printing Office. Dillard, M., Andonian, L., Flores, O., Lai, L., MacRae, A., & Shakir, M. (1992). Culturally competent occupational therapy in a diversely populated mental health setting. The American Journal of Occupational Therapy, 46, 721±726. Flores, E. T., Castro, F. G., & Fernandez-Esquer, M. (1995). Social theory, social action, and intervention research: Implications for cancer prevention among Latinos. Journal of the National Cancer Institute Monographs, 18, 101±108. Hohmann, A. A., & Parron, D. L. (1996). How the new NIH guidelines on inclusion of women and minorities apply: Efficacy trials, effectiveness trials, and validity. Journal of Consulting and Clinical Psychology, 64, 851±855. Kim, S., McLeod, J. H., & Shantis, C. (1992). Cultural competence for evaluators working with Asian American communities: Some practical considerations. In M. A. Orlandi, R. Weston, & L. G. Epstein (Eds.), Cultural competence for evaluators (pp. 203±260). Rockville, MD: Office of Substance Abuse Prevention. La Fromboise, T. D. & Foster, S. L. (1992). Cross-cultural training: scientist±practitioner model and methods. The
Counseling Psychologist, 20, 472±489. Miranda, J., Azocar, F., Organista, K. C., MunÄoz, R. F., & Lieberman, A. (1996). Recruiting and retaining low-income Latinos in psychotherapy research. Journal of Consulting and Clinical Psychology, 64, 868±874. Montgomery, P. A. (1994). The Hispanic population in the United States: March 1993. Current Population ReportsÐPopulation Characteristics (Series P20-475). Washington, DC: US Government Printing Office. Murphy, R. F. (1986). Cultural and social anthropology: An overture. Englewood Cliffs, NJ: Prentice-Hall. National Institutes of Health. (1994). Outreach notebook for the NIH guidelines on inclusion of women and minorities as subjects in clinical research. Bethesda, MD: Author. Norton, I. M., & Manson, S. M. (1996). Research in American Indian and Alaska Native communities: Navigating the cultural universe of value process. Journal of Consulting and Clinical Psychology, 64, 856±860. Orlandi, M. A. (1992). Defining cultural competence: an organizing framework. In M. A. Orlandi, R. Weston, & L. G. Epstein (Eds.), Cultural competence for evaluators (pp. 293±299). Rockville, MD: Center for Substance Abuse Prevention. Oskamp, S. (1991). Attitudes and opinions (2nd ed.). Englewood Cliffs, NJ: Prentice-Hall. Szapocznik, J., & Kurtines, M. (1993). Family psychology and cultural diversity: opportunities for theory, research and application. American Psychologist, 48, 400±407. The National Latino Behavioral Health Workshop (1996). Cultural competence standards in managed care mental health services for Latino populations. Phoenix, AZ: Author. Thompson, E. E., Neighbors, H. W., Munday, C., & Jackson, J. S. (1996). Recruitment and retention of African American patients for clinical research: An exploration of response rates in the urban psychiatric hospital. Journal of Consulting and Clinical Psychology, 64, 861±867.
10.06 Reconstructing Race, Rethinking Ethnicity MARIA P. P. ROOT University of Washington, Seattle, WA, USA 10.06.1 INTRODUCTION
10.06.1.1 Race and Ethnicity 10.06.1.2 Racial Identity Development as Racial Healing
10.06.2 PROCESS OF IDENTITY CONSTRUCTION
10.06.2.1 Process of Differentiation
10.06.3 RACIAL IDENTITY THEORIES
10.06.3.1 Nigrescence and Minority Racial Identity Stage Model Theories 10.06.3.2 White Racial Identity 10.06.4 ETHNIC IDENTITY MODELS
10.06.4.1 Comparison and Critique of Racial and Ethnic Identity Models
10.06.5 RETHINKING RACE AND ETHNICITY
10.06.6 CONTEMPORARY MODELS FOR RETHINKING THE RELATIONSHIP BETWEEN RACE AND ETHNICITY
10.06.6.1 Ecological Model of Race and Ethnicity
10.06.7 CLINICAL IMPLICATIONS
10.06.8 FUTURE DIRECTIONS: RETHINKING RACE AND ETHNICITY
forbidding and penalizing interracial marriage. Since this period of time the percentage of interracial marriages has approximately doubled with each subsequent decade. Correlated with this increase in legalized interracial unions has been a significant increase in the number of biracial and multiracial children and young adults, particularly in large cities of the USA (Root, 1992, 1996b)). These constructs seemingly collide when we consider the identities of people who claim multiple group memberships. This chapter uses the presence and experience of a growing presence of racially
Ethnicity and race in the USA have become synonymous concepts in everyday language although they signify different experience. This chapter, which considers identity development in persons of mixed racial heritage, necessitates we differentiate these concepts. Increasingly, ambiguous phenotypes, proliferating since the biracial baby boom post-1967, defy instantaneous recognition or accurate assignment of ethnic group belonging (1967 marked the repeal of the last antimiscegenation laws in the USA 141
Reconstructing Race, Rethinking Ethnicity
mixed people in the USA whose simultaneous, dynamic, and multiple identies require reexamination of assumptions about race and ethnicity. How are racial and ethnic identity different? This has become an increasingly difficult differentiation as racial logic is somewhat circular and the distinctions between their historical constructions are suppressed (Gordon, 1995). Both exist because diversity in race and ethnicity have a social significance used to stratify society (Phinney, 1990). Much of the work on ethnic and racial identity stems from notions of the effects of marginality (Oetting & Beauvais, 1990±1991) and the observations and hypothesizing about the hybrids of race and culture (Park, 1931; Stonequist, 1964; Young, 1995). Race and ethnicity become significant statuses relevant to experience of self and others when they are differentiated within a society. In his classic work on the roots of discrimination, Allport (1994, p. 221) lists 10 conditions which when present are accompanied by an increase in prejudiced personalities: Where the social structure is marked by heterogeneity Where vertical mobility is permitted Where rapid social change is in progress Where there are ignorance and barriers to communication Where the size of a minority group is large or increasing Where direct competition and realistic threats exist Where exploitation sustains important interests in the community Where customs regulating aggression are favorable to bigotry Where traditional justifications for ethnocentrism are available Where neither assimilation nor cultural pluralism is favored.
If one carries a visible status such as race, its socially constructed meaning results in a labeling process. Visible identities, whether they connote positive meaning or stigmatized status, effect the opportunities we encounter (Goffman, 1963). The process of incorporating a stigmatic status requires a personal understanding of human competition, oppression, and resilience. When these identities carry stigmatic statuses, the process by which they are incorporated into a positive aspect of self requires ego strength, resilience, and a repertoire of coping. Thus, identity is a very central concept for clinical, developmental, and social psychology. The construction of race in the USA is not unique. Several scholars have elucidated the construction of racial and ethnic others as a
colonial strategy (whether it be the Spanish, Dutch, Japanese, British, American, etc.) for justifying maltreatment of people (Foucault, 1978; Young, 1995). The construction of the racial or ethnic other sets the stage for justifying genocide whether it be in Bosnia, World War II Germany, the USA, or Africa at various points in history. Because the mechanics of oppression have universal methods, the example of US history of race relations to examine current theories of racial identity development is used. In doing so, it becomes clear that our psychology exists within a political tangle of propaganda and oppressionÐpast and present. The effects of our history of racial and ethnic oppression becomes evident in the critical examination of current racial identity theories from the experience of a growing minority in this country, persons of multiracial origin, who declare a biracial or multiracial heritage. DuBois (1903) noted that the affirmation of a devalued self can create a depth of conscious awareness that possibly expands one's humanity. Almost three-quarters of a century later, the development of ethnic and racial identity theories elucidate the phenomenological process largely affected by a political history (Ramirez, 1983, 1997; Root, in press). Allport's (1954) conditions of almost a half century ago work well in understanding how sociology, politics, and psyche are interdependent. The 10 conditions he outlines shape the social intercourse of identity. Identity development will be necessarily a conscious and more complex status for racial and ethnic others. In this chapter, the biracial or multiracial person who chooses not to adhere to centuries-old rules of racial classification and insists upon simultaneous or blended identities is chosen as the example with which to explore race and ethnicity. Differentiating between race and ethnicity becomes more important at this moment in history because of the trend in increasing miscegenation and the subsequent, significant biracial baby boom. This young, visible cohort, contests the virulent antimiscegenistic foundation upon which racial rules for belonging and identification derived and even Stonequist's hypothesized marginality (1964). Furthermore, recent research using multiracially identified individuals suggests that race is neither a necessary nor sufficient condition for establishing ethnic identity (Hall 1980, 1992; Stephan, 1992). The psychological models guiding and capturing racial identity are now dated and limited. Current and future directions must be plotted against the backdrop of a post-civil rights era that has spawned a biracial baby boom.
Introduction 10.06.1.1 Race and Ethnicity Some scholars suggest that the racially mixed person embodies one of the most tangible threats to the current racial order. In order to understand this threat, an historical understanding of the derivation of race is necessary. Without this examination, culture and ethnicity are misleading euphemisms for a construct laden with centuries of harm. Colonists striving for an economic and political stronghold in new lands needed to create a system with which to distinguish themselves from the indigenous people. The construction of race was intrically aligned with economic systems of expansion. This system racialized gender and engendered race (Foucault, 1978; Stoler, 1995; Zack, 1997b). Whether this be through Dutch, Spanish, British, Japanese, or US colonization, the mechanisms have manufactured similar oppressions. Ethnocentric interpretations of differences in cultural practices are coded through the colonized group's bodies (Fanon, 1967; Foucault, 1978; Stoler, 1995; Young, 1995; Zack, 1997a). Subsequently, notions of group distinctions on moral and behavioral bases are attributed to lineage which eventually becomes accepted scientific folklore as biological heritability. A mythology and rationale for oppressive treatment of the colonized completes an irrational circle of logic to ensure that the physical demarcations provide clear markers of insider and outsider (Spickard, 1992). Utilizing paternalistic attitudes coupled with the belief in biological heritability of morality, intelligence, and civility (Young, 1995), the colonized group is considered helpless to change its outlook or status, which justifies paternalistic and missionary interventions introduced with imperial expansion. Whereas racial classification systems are determined by those in power, those subjects disenfranchised by this system often unwittingly internalize it; subsequently, groups agree upon assignments between the colonizer and the colonized. For example, in the USA, hypodescent, a system by which a mixed race person is assigned to the group with the lowest social value, is now an agreed upon system. Using an extreme example, many black people will insist a person is black even if they grow up with a single white parent in a predominantly white neighborhood with little African-American ethnic group knowledge or shared customs, behaviors, or attitudes. Weinreich (1986) suggests that ethnicity requires internal recognition and affiliation with the ethnic reference group. Mutual agreement between participant and group regarding
group membership is based upon behavioral practices, rituals, customs, and values. However, because we are such an ethnically diverse society, and ethnicity is centrally defined by the previous variables and not defined phenotypically, ethnic ambiguity is reduced through using racialized bodies as signifiers of ethnic group membership. Whereas the enactment of ethnicity is dynamic over time and generation, race is repeatedly enacted within the constricture of laws of hypodescent and, until recently, laws against miscegenation. Among other purposes, these latter laws kept phenotypical signifiers of group belonging more visible. Given our country's history of racial tragedy, dialogue about race is avoided through the use of terms as ethnicity and culture that have come to be used interchangeably for race despite their essential difference. Both ethnicity (Tajfel, 1981) and race (Cross, 1971; Helms, 1990) are salient identities of the self that provide a basis for interpreting the actions of others and one's internal experiences. Their similarities are perhaps bound both by the sense of reference group or belonging that one psychologically internalizes. One might construct their difference by viewing race as constructed by negative forces which subsequently require connectivity between members of a disenfranchised group for survival. In contrast, the connectivity between people derived from ethnicity includes positive experiences of sharing rituals and customs and language on daily basis. When negative forces drive definitions of ethnicity from outside the group, such as in anti-semitism, Jewishness is also constructed in racial rather than only ethnic terms, and the negative connectivity resulting from race also binds this ethnic group for survival. Ironically, colonization and physical proximity between different populations inevitably leads to miscegenation of populations (Spickard, 1989; Stoler, 1995; Young, 1995). Initially the offspring may have the privileges, but when a critical mass starts to develop, these bodies may become viewed as the enemy within (Stoler, 1995), and this new group is relegated to another position. This system is challenged and breaks down when a critical mass of people refuse to collude with the system. This is the case with a portion of the contemporary generation of mixed racial heritage. The numbers of people born out of a biracial baby boom who do not wish to participate in conventional societal racial antagonisms has reached a critical mass. In summary, race is based upon a delusional system of hierarchical difference marked by phenotypical differences. Systemically, race is not initially an agreed upon system. Assigned by
those in power, group acceptance and belonging is based upon recognition and acceptance by the disenfranchised group. Whereas white society and groups of color are congruent in their assignments and acceptance of racial group membership, this system breaks down contemporarily with the refusal of many people of mixed heritage to agree to participate according to the rules of the system. We must reexamine the assumptions upon which racial identity has been based as we reach the centennial anniversary of DuBois' observation that the color line would be one of the most significant issues of the twentieth century. We must shift our concern at the end of this millennium to the microcosm of this American dilemmaÐthe individual who embodies multiple heritages and affirms multiple allegiances. What are the psychological implications of this for us as a nation and for individual identity development (Root, 1996b)? Current data suggest that the biracial baby boom is accelerating an unraveling of race as it has been practiced in the USA for centuries. These changes have implications for psychological constructions of race and racial identity through the dilemas posed by demographic changes. 10.06.1.2 Racial Identity Development as Racial Healing Racial identity is necessarily defined in terms of a psychological process of healing from the insidious wounds of racism. In the broadest sense, the damage caused by justifying racial inferiority of nonwhite people has similar dynamics to hostage-taking during war. Interestingly, Banks' (1988) ethnic identity development theory posits the first stage as ªethnic psychological captivity.º The tactics of isolation of the individual or group, deprivation, monopolizing of perceptions, and brainwashing result in a dependence on the captor, a belief in one's inferiority, and an aspiration to be more like the captor in hopes of survival, or even better treatment. Furthermore, contemporary literature makes the case that race and gender are co-constructed (Zack, 1997a). Lerner (1986) suggest that men of color are constructed in the female gender. Historically, she makes the case for observing that desirable women have been constructed in the image of children. Paternalistic models of racism also construct people of color and indigenous people in images and caricatures of children. Similarly, the dynamics of race relations have shared similar aspects to the chronic abuse of children or women in domestic households. In
these positions women and children are often held hostage economically, materially, and psychologically. Their survival and welfare depends on developing a keen sensitivity to the whims and wishes of the captor or head of household. Feelings of inferiority, wishes to be other than female, and devaluing other women may follow (Griffin, 1992). With the metaphors of war and the insidious psychological violence wreaked by the abuse of dominance, a healing process is required to establish a constructive sense of self which affirms the possibility of a positive racial and ethnic identity. In the meantime, however, what is the cost to individuals? Rates of depression, schizophrenia, and stress reactions have been associated with race and social class which are confounded in this society (Dowrenhend & Dowrenhend, 1974). Although depression and schizophrenia exist across cultures, their rates vary across countries suggesting mediation by environmental influences. The US literature points to the stress caused by self-devaluation by racial system in terms of obstacles to economic advancement through glass ceilings and limited employment opportunities, and stress caused by living in unsafe neighborhoods that are also associated with impoverished levels of income, joblessness, and disillusionment by young people (Wilson, 1987). Recent literature investigates the relationship of stress caused by racial position and impact on mental health such that seeming personality disorders must be viewed in cultural contexts (Alarcon & Foulks, 1995). Unfortunately, the standard reference group unchallenged until more recent times has been similar to the researchers: white, male, and middle to upper middle class. Clients or students whose behaviors or psychological profile differed significantly tended to be pathologized or problematized. For example, a significant body of literature exists on the personality problems of the person of African-American heritage, particularly in the use of the Minnesota Multiphasic Personality Inventory. A debate over the intelligence of minority group children, particularly those of African heritage or of bilingual backgrounds, resurfaces every 15±20 years (Hilliard, 1996). The civil rights movement, and legislation that accompanied it to extend equal rights guaranteed by the US constitution to all people, beginning in the 1950s and extending two more decades, might best mark the beginning of public awareness of the healing oppressed persons continued despite prevailing conditions in which prejudices thrived. Legislation attempted to correct previous misapplications of the US constitution and the Bill of Rights
Process of Identity Construction through formal desegregation of schools, workplaces, and neighborhoods. In time, a new body of literature emerged on ethnic and racial identity, produced primarily by people of color who were now part of a small and growing cohort of scholars. It was no coincidence that the primary originators of racial identity theories were people who were deeply influenced by the racial pride movements of the 1960s and 1970s, which occurred during their young adult years. During this period in history, ethnicity and race essentially became the same; ethnic solidarity meant racial solidarity (Omi & Winant, 1986). Ironically, notions of ethnic/ racial solidarity invoked an inside±outsider politic akin to the process outlined for individuals in racial identity theories; the oppressed person, in an attempt to selvage their racial selfesteem, separates themselves from the majority to seek refuge and absorb the positive aspects of identifying as a person of color. This period of refuge may also reflect a hatred of what is white and dominant, accompanied by an uncritical acceptance of racial group signifiers that one idealistically reveres. Phenotypic identification by styles of dress and physical appearance take on significant meaning as ethnic markers and symbols of racial pride and solidarity. Thus, a literature emerged on racial identity that was virtually synonymous with African heritage and ethnicity (Cross, 1971). Simultaneously, within the ethnic pride movements of the American Indian Movement (AIM), the Chicano Movement (La Raza), and the Asian American Movement, other theorists emerged who focused on the meaning and importance of biculturality (Ramirez, 1983). 10.06.2 PROCESS OF IDENTITY CONSTRUCTION Human nature observes difference and leads us to differentiate ourselves at a basic level from ªthe other,º someone different from us on a dimension that has meaning. Thus, part of building self-definition is through contrasting ourselves with the other (Sartre, 1976). This process of differentiation is initially primitive rather than complex, casting difference in binary, oppositional terms establishing poles of privilege and disenfranchisement (Zack, 1993): male, female; white, not-white; able bodied, disabled; same sex orientation, different sex orientation. Gordon (1995) outlines the logic of this transformation as it has been applied to race. A superior group is boundless from constraints and derives its justification from the proof of the inferior. In turn, the
inferior is treated and constructed in less than human form. This oppressive process is the process of colonization of a people and colonization of the mind. The body of the individual, through assigned social meaning, is stigmatized (Goffman, 1963; Young, 1995). In more recent work, Gordon (1997) uses a philosophical perspective to suggest that to have a race, in an antiblack world, is to be assigned the pole of raced, that is, black. To be white is raceless. A similar physical marker is assigned to gender. To have a gender is to be female; male is genderless. In contrast, Zack (1993) suggests that the polar opposites on race are to have a race (black, white, etc.) and its opposite is hybridity. Thus, racial mixing derived from either system of logic has the negative valence and has the most significant meaning attached to its embodiment. Racial mixing also brings in the topic of control of sexuality through privileged positions of bodies, both raced, and gendered. In patriarchal societies the ideal self is referenced as male, white, able-bodied, and heterosexual. Sociological theories of anomy (Durkheim, 1966) and marginality (Stonequist, 1964) conclude that to possess other than the ideal and privileged position is to be inherently less powerful and more likely to be marginal. Activists and scholars concerned with the impact of colonialism make similar conclusions (Fanon, 1967; Friere, 1970). To function in the other position is to have more obstacles to overcome and to have to fight harder to derive a positive self-identity. Erikson's (1968) theory on the importance of identity and conscious identity process suggests that to be defined as 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 representative of the times in which he was produced; gender identity development receives relatively little attention (Burman, 1994).) The ethnic and racial identity theories that developed in the 1970s and 1980s are very much a consequence of this arduous task. 10.06.2.1 Process of Differentiation Deriving a sense of self from contrast with the other begins a process of differentiation (Allport, 1954). Much contemporary literature has focused on the social construction of race and virtually little on the process of differentiation that gives rise to meanings assigned to differences. This process has different paths it can take. Root (in press) notes that the process of differentiation can be constructive or destructive, which promotes very different cognitive schemas around differences.
Tolerance for ambiguity of meaning and ability to operate fearlessly in the face of difference allows one to engage in the process of constructive differentiation. Tolerance for ambiguity allows the individual to suspend stereotyping and to refrain from applying conceptual frameworks that do not fit the situation. Differences may be observed, but neither a binary schema nor a valence is assigned. Thus, the other is observed side by side with the self rather than in competition or opposition. The other does not have to be inferior. Constructive differentiation observes difference outside of a hierarchical schema and allows one to expand one's world view, and even possibly find oneself in this difference. The ability to do this, particularly in light of observable physical differences, such as by color, by gender, or by height, is stifled early on by external inputs that impart hierarchical, competitive schemas and schemas of opposition. Categorization seems to be an important part of the cognitive process that allows the world to be made simpler. However, categorization is not necessarily synonymous with hierarchical stratification. It is the step from categorization to hierarchicalization which may shift the process of understanding difference into destructive differentiation. Unfortunately, by the age of seven or eight, the process of destructive differentiation around race is well assimilated. Remember the song in the 1950s musical, South Pacific set during World War II: ªyou've got to be taught/before it's too late/before you are six, or seven, or eight/ to hate all the people your relatives hate.º Underlying such a process is a tendency to interpret the other as threatening and to subsequently counter anxiety or threat with negative evaluation. Through a process of negative stereotyping, threatening differences are stratified (Berger, Cohen, & Zelditch, 1966) and stigmatized (Goffman, 1963). Negative differentiation employs parsimonious, reductionistic strategies too early. Subsequently, this process yields primitive rather than complex understanding, though, complex and convoluted rationalization may develop to sustain these reductionistic schemas, as has been the case in using race as a reductionistic scheme. Racial epithets are an extreme example of destructive differentiation. With a few words, an overtly hostile act of differentiation relegates the target person to a less desirable position. In this act, the instigator defines themselves as superior in contrast to their target. Ultimately, negative differentiation results in self-definition by what one is notÐa distancing from feared association with the other. For example, a person may have ideas that they are
not like Filipinos, not like Africans, but still not have a constructively defined notion of a racial self as a white person, that is, whiteness as the privileged position is inherently defined as raceless or without stigma. (In the USA, many white persons no longer have an ethnic affiliation, so that the primary identity is through white racial status rather than through an ethnic identity). Many researchers note that, unlike the identity process that persons who have been defined as other experience in this country, white persons do not have to think about themselves on a daily basis in terms of their race or ethnic belonging (Frankenburg, 1993; Helms & Carter, 1990). Destructive differentiation leaves little room for exploration on the very dimension one might use to expand one's world view. The mixed heritage person, socially located as other, and invisible, but feared and mistrusted, must struggle to create positive selfdefinition in the face of few positively valued reference groups or role models. Destructive differentiation produces an identity that is inherently fragile, dependent upon maintaining distance from the other, and believing in the inferiority of the other in order to maintain a sense of self. Its unresolved conflicts regenerate itself; the oppressed may become the oppressor (identifying with the captor) as a survival strategy, yielding again, a fragile sense of identity. For example, given that this country's racial system is predicated on pure race, mixed-race people experience gatekeeping around racial belonging. Acceptance requires a singular belonging. Thus, persons who declare a biracial identity are often put to racial authenticity tests by other people of color. If they are also of white European origin, centuries-old rules of hypodescent automatically fail them in white authenticity. Multiple allegiances and affiliations of multiracial or multiethnic people may be vilified through the process of negative differentiation. On another level, women may be more oppressed than dictated by cultural rules as a means for men who feel oppressed to achieve a position of superiority. Unfortunately, this yields a fragile self construction. This juxtaposition of the inferiorizing of racial and gendered identity can provide the basis for some racial antagonisms between parents and mixed heritage children in some families (Kich, 1992). Ironically, political consciousness pertaining to racial and ethnic identity is a response to negative differentiation in which being the other has simultaneous negative meaning and invisibility (Freire, 1970). Hurtado and Gurin (1995) discuss three interrelated aspects of racial and ethnic identity that originate out of a process of negative differentiation for individuals of
Racial Identity Theories Mexican heritage. These issues are also relevant to other groups of people who may locate themselves in a multiracial and/or multiethnic context. First, the group is indignant over the lack of power; for example they might protest over lower wages than other ethnic groups in the same work environment performing the same work. Second, the group demonstrates that this social location and lack of power results in suffering healthwise, economically, and/or educationally. Third, collective action is necessary to improve the social standing of the group, such as strike action by groups of persons who occupy niches of wage work that capitalize on their lower status, but are necessary for the profit of a capitalist society. All three aspects of this increased political consciousness are directly implicated in the process of racial awareness and the personal meaning of racial identification. Diminishing denigrating defensive strategies is difficult in a society that has colluded and condoned negative stereotyping such as that based on colorism, race, body size, gender, and so on. Bennett (1995, p. 36) suggests that confrontation of negative stereotyping or denigrating tactics may result in more overt protests that are denial defenses. In contrast to Bennett's suggestion that superiority or grandiosity is a defense that does not require overt denigration of the group constructed as other, it is a stratification defense against fragility. This defense, too, is a form of destructive differentiation through stratification driven by anxiety and primitive threat. 10.06.3 RACIAL IDENTITY THEORIES 10.06.3.1 Nigrescence and Minority Racial Identity Stage Model Theories Numerous theories blend racial and ethnic identity. The most numerous models are found in the nigrescence models of racial identity offered by African-American researchers (Banks, 1988; Cross, 1971; Gay, 1984; Jackson, 1975; Milliones, 1980; Parham, 1989; Thomas, 1971; Vontress, 1971). Most of these models emerged in the context of working with clients of African-American heritage in counseling or educational settings. In both settings, the standard for behavior and mental health used a middle-class, white, male reference group similar to the majority of researchers. African-American researchers started depathologizing and renorming behavior in the social and historical context of healing from the wounds of racism. Significant reviews of this literature have been provided over the course of its development (Carter, 1995; Cross, 1978; Helms, 1990).
Although all these models imply some process that responds to racial traumatization, some might best be described as typology models and others as stage models. Helms (1990) summarizes the stages or categories proposed by each model in the early body of identity models. The models that have had most impact on contemporary thinking about racial identity are the stage models. These models, particularly the early ones, were developed with little influence from each other. Thus, it is all the more remarkable how similar they are in process, varying in the number of stages from four to six. The assumption is that an individual proceeds linearly through the stages with the final stage synonymous with optimum mental health. Crises, which may be personally defined, are the catalysts to rethink one's experience and assumptions about race and how they fit into that schema. First stages of these models typically suggest that the individual is hostage to the prevailing racial system. Both a racial and ethnic identity model, Banks' (1988) first stage is labeled ªethnic psychological captivity,º connotating the culmination of destructive differentiation. In the first stage of these models, the individual holds the prevailing stereotypes which denigrate the group to which one is assigned. As a result, one may blame the self for plights and difficulties, ignoring systemic obstacles and barriers to success. They may insist that history has changed so that opportunities for equitable 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 that right behavior is rewarded and the individual is valued (Janoff-Bulman, 1992). When one encounters a significant challenge to this perception of the world, their assumptions are shattered and they must recreate a new understanding of how the world works. A typical second stage in these models suggests that the individual withdraws into the black culture to reconstruct their world; simultaneously, they may employ negative differentiation by relabeling the binary poles of opposition. That which is associated with the dominant culture is worthless and reprehensible. The default racial label for dominance is white and engendered as male. Labels such as ªencounter,º ªimmersion,º ªseparation,º and ªconfrontationº characterize the process at work in this stage. Typical of the process of quick change which swings to an opposite pole, this stage might be characterized by overidealization of the new world view, at times exaggeration of the evils of the dominant world view, and exaggeration of the flawlessness of
one's racial/ethnic group. The racial pride movements of the 1960s and 1970s typified this stage of ethnic identity. Everything black, Chicano, Indian, or Asian was idealized by the respective groups. Those aspects of the culture that may not be positive may be ignored. Theorists reflected what they observed in the process of clients and peers. In order to counter the abundant negative messages one must denigrate the practices and identities associated with dominance. Out of this stage emerges a new basis for an identity that rebuffs the negative images of self. What has received little attention is that the default gender is black male, or male of color. Female gender and the co-constructed process of identity is not addressed. With labels such as ªinternalization,º ªpostencounter,º and ªaffirmation mode,º the next stage suggests that one works to be able to internalize positive images of blackness that are not necessarily at the expense of denigrating whiteness or any other group. Thus, negative differentiation is less prevalent as an organizing strategy. One continues to build pride in one's self associated with ethnic and racial heritage. Some models originally offered a stage that suggested it was possible to move towards a multicultural position and appreciation of diversity (Banks, 1988; Cross, 1971, 1991; Milliones, 1980; Thomas, 1971). Labeled as ªintegration,º ªinternalization±commitment,º or ªglobal competency,º individuals in this stage attempt to use experience and knowledge to fight oppression around them. Solidarity is defined less stereotypically as behaviors; symbols are not used for quick judgments or categorizations of other people. Constructive differentiation is an organizing schema. This stage implies a level of healing of rage and anger that requires life experience and some luck of positive encounters. In more recent work and reworking of these models, a last stage seems to be informed by the life stage of the researchers. This stage is one in which there seems to be a transcendence of the constrictions of race, while maintaining an awareness that race does make a difference (Atkinson, Morten, & Sue, 1979; Carter, 1995; Cross, 1985, 1991). Most of these models exist within a dichotomous racial framework of white and not white, thus, capturing the prevalent racial paradigm and the prevailing racial politics of the time in which they emerged. They assume that the two major operating rules of race (pure race and hypodescent) abound so that there is a racial hierarchy and the races are separate. Atkinson et al. (1979) developed a minority identity model to reflect similar process in ethnic identity and racial identity development across groups.
However, this model as the other racial identity models, does not explain the process of identity development when a multiracial paradigm exists and other aspects of identity coconstruct identity. 10.06.3.2 White Racial Identity Starting in the late 1970s through the 1980s researchers conceptualized white identity stage models (Carney & Kahn, 1984; Ganter, 1977; Helms, 1984). Again, Helms (1990) provides a summary of these models. An identifiable process of white racial identity formation has been offered, that is, moving from assuming a raceless position to acknowledging that whiteness comes with inherent privileges and power. These models suggests that a white person's linear movement through the stages progresses towards establishing egalitarian relationships with persons different from oneself. Such an accomplishment would again require an active use of constructive differentiation to interpret differences. These models vary between offering three to six stages. These descriptions of the process through which an individual moves are not as uniform as the black identity models. The labels are less descriptive in these models, some preferring to refer to stages as phase or stage 1, 2, 3, and so on. Although it is hard to typify the stages across models, the first and last stages bear similarities across models. The first stage typically captures the acceptance of the white dominant position in society with an obliviousness to this being a racial identity. Without acknowledgment of white racial identity at work, an individual can protest the notion that the status quo associated with white domination economically and politically promotes racismÐor that these white individuals serve as pawns in the racial machinery governing the social structure of this country. In the last stage of the models, the individual acknowledges the significance of white racial identity and accepts responsibility for the losses associated with white superiority and domination. The individual moves to broaden their standards and values of reference beyond their own. Unlike the nigrescence or minority models, none of the models reviewed by Helms (1990) suggest that fighting oppression is inherent to transcending the constrictures of race as constructed in this country. The racial identity models, that developed out of the counseling and educational contexts, have been conceptually linked to mental health: wellbeing, beliefs, and behaviors. However, the empirical testing is just beginning. No conclusive data is available.
Ethnic Identity Models 10.06.4 ETHNIC IDENTITY MODELS Outside the bipolar black±white racial framework, multiracial populations exist which are primarily defined by ethnicity (e.g., Mexican, Latino, Puerto Rican, Native Hawaiian, Native American, and Filipino) rather than race (e.g., black, white). Although the embodiment of this ethnicity may be physically blended with nonEuropean features, these groups fall outside of the most contrasted borders of black±white. Examination of the process of identity that occurs for these groups of people is important when considering the question of how race and ethnicity might be different despite phenotypic variation within a population (Ramirez, 1983, 1997). The ethnic identity models do not contend with race directly as much as they do with cultural difference and shared cultural elements that define an ethnic community. Sociological theories suggest that several interactional factors affect ethnic identity: the individual, the society, and the group to which an immigrant is assigned reactions, positive or negative, and the interaction of these three social locations (Mittelberg & Waters, 1992). The symbolic interactionist theories highlight the interaction between the individual or collective and the environment from the actor's point of view (Lal, 1995). These models become precursors for multidimensional psychological models which emphasize the ecology of the environment within which the individual acts. Furthermore, many sociological concepts of ethnicity explore which factors influence the boundaries of ethnic identity. Within this framework, certain visible characteristics of an individual restrict options for ethnic identification, such as race and language facility (Mittelberg & Waters, 1992; Waters, 1990). Psychological models of ethnic identification introduce concepts of acculturation and assimilation as source of stress, directing the outcome of attempts to integrate a bicultural world view (Olmedo, 1979; Padilla, 1980; Ramirez, 1983, 1997). Much of this work emerges from research with youth (Oetting & Beauvais, 1990±1991; Padilla, 1980; Phinney, 1989; Ramirez, 1983; Trimble, 1996, in press). Gurin, Hurtado, and Peng (1994) concluded the macrosocial conditions, such as language dominance, length of residence, geographic dispersal, and the diversity of work settings, that influenced the opportunities for group contact which in turn influence the formation of social ethnic identities in Chicanos and Mexicanos in the Southwest and Chicago. Ramirez (1983, 1997) uses the term mestizo(a) as a world view perspective rather than a racial term for bicultural individuals who are capable of blending distinct
cultural influences. More recently, Huang (1994) provides a model for identity formation for Asian Americans. Acknowledging the interplay between internal and external identities, she notes that an important aspect of ethnic identity is the degree to which the individual perceives it to have salience in life and the degree to which the person's external identity is mediated by the congruence or conflict between their acceptance and belonging to an in group and out group. The centrality of a salience hierarchy, and the flexibility posed by separating internal from external identities, provides for a host of profiles of identity which can accommodate the range of ethnic identity outcomes discussed in the literature. Thus, her model moves towards a newer wave of multidimensional models. Oetting and Beauvais (1990±1991) suggest that the precursors to ethnic or cultural identification models stem from Park's (1931) and his student's, Stonequist's (1964), seminal work on hybridity and marginality, respectively. Similar to the racial identity models, these ethnic or cultural identification models emerge out of attempts to explain problematic behavior in persons who are culturally different to the dominant reference group, deemed American. They provide a summary of models that have prevailed from the linear continuum models to more complex multidimensional models. Finally, they propose the orthogonal cultural identification theory. The dominant majority models suggest movement away from the culture of origin to the new. Furthermore, Anglo culture is good and to be emulated. Simple transitional models suggest that, in the process of movement there is inherent stress that is always difficult and may result in problematic behaviors such as drinking. Another form of transitional model, the alienation model, suggests that in the transition there may be a good or a bad outcome, depending on coping. Good coping results in movement towards the adoption of Anglo ways, whereas failed coping results in alienation. To some degree these models are invoked at various times in the research literature or in everyday life explanations for the success and failure of people who are originally culturally different from the dominant, European-derived culture. Three multidimensional models are also summarized, including their own. Multidimensional models allow multiple values to co-exist at different points along the continuum from culture of origin to European derived culture. Bicultural models are the first models to suggest that an individual can be simultaneously identified with two cultures. Although they explain and predict that people who are adept
and involved in both cultures become more flexible, these models do not generally have explanatory power for the individual who is marginal to both cultures, who demonstrates low involvement or identification with both cultures. Lastly, the orthogonal identification model suggests that identification with one culture is independent of another. Thus, unlike other models, this one allows for any and all combinations of identifications. It is important with the multidimensional models not to believe that the bicultural models are inferior to the orthogonal models, but to examine which model fits which contexts best. Ramirez (1983) offers a bicultural model born out by research which strongly suggests that biculturality does seem to increase some cognitive flexibility. In educational settings, this model may be advantageous (Banks, 1988). With increasing trends for some populations to live in two countries, the notions of biculturality will continue to be reinforced and be a reality for many populations of Latino and Asian origin. On a process level, Bennett (1995) suggests that the defenses of denial, minimization, acceptance, adaptation, and integration are employed as people move through a process of interethnic and intercultural valuation related to identity. This model is unique in that process is discussed in terms of developmental strategies with an emphasis on the role of intrapsychic defenses against inferior status. 10.06.4.1 Comparison and Critique of Racial and Ethnic Identity Models The ethnic identity models have grappled with reference group orientation multiple alliances, and more recently with the transnational identities. Often referred to as a process of ethnogenesis, immigrants reformulate their identity after entering the USA. This reformulation often requires accomodating a new definition of race and being relegated to a minority status. This process is impacted by the way in which bodies are racially assigned meaning. The destructive differentiation based on race in the process of ethnogenesis is illustrated succinctly in a recent study by Mittelberg and Waters (1992) of identity formation in two immigrant groups: middle-class Haitians and secular kibbutz-born Israelis. The authors observe, unsurprisingly, that the Israelis have fewer constraints in reformulating their identities than do Haitians, because of the primacy of the meaning of blackness as a race in this country. The racial identity models seem the more limited in contemporary context because they are still embedded in an undimensional model of
racial belonging, as centuries-old rules remain unquestioned. The linear nature of the models of nigrescence and minority racial identity development assume that an individual will retreat from white society's denigration and refuge in the community of color. However, biracial people, particularly of European heritage, do not have a guaranteed refuge because of their marginalized status by multiple groups. With other people in this stage of development, such as high school and college age peers, they may not be viewed as authentic members due to their biracial status, particularly if they are not willing to denigrate and denounce in an exaggerated way that which is white. To do this is to potentially denounce part of one's heritage and people one loves (Root, 1990). Thus, the biracial person may be subjected to racial or ethnic authenticity tests which are charicatures of socially constructed race and ethnicity. Many biracial persons find this neither a natural nor only process for achieving a positive racial and ethnic identity (Root, 1992a, 1996b). Many young adults enact multidimensional models of race which are more similar to models of ethnicity. Identities can be dynamic fluctuating in salience contextually and be orthogonal (Duffy, 1978; Hall, 1980, 1992; Stephan, 1992; Williams, 1992). Contextually, the salient identity of someone of black and Asian heritage may sometimes be black, at other times Asian. An orthogonal experience of identity would be manifested in the declaration of being both black and Asian. However, despite some of the strengths of applicability of multidimensional models of ethnicity to mixed heritage individuals, neither the racial nor ethnic identity development models consider other simultaneous influences of other salient statuses integral to identity, such as gender or sexual orientation. Huang's (1994) model can acccomodate this through the identity salience hierarchy and the consideration that other identities interact and inform personal internal identity. Even the diversity of social economic class orientation, often erroneously assumed homogeneous within ethnic and racial groups, may be critical to the construction of identity. For example, Singelis, Triandis, Bhawuk, and Gelfand (1995) observe that individualism and collectivism vary crossculturally within a culture according to class: wealthy and impoverished classes are much more individualistic than middle classes. Thus, class location may affect value systems as much or more man race; class and race are often confounded. Stage models of racial identity do not explain the fluidity of exchange of different aspects of identity between background and foreground,
Rethinking Race and Ethnicity such as gender and race, race and class and gender, sexual orientation and race. These models assume to some degree that either gender has negligible effect orÐconsistent with much research of the timeÐdid not critically assess how gender informs and shapes life experience and worldview. Notably, most of these researchers being male did not have access to the gendered experience of femaleness and its secondary status within their ethnic and racial groups. Also with a more privileged gendered status, they were not as compelled to consider simultaneously the role of female experience as a female researcher might be. It is also very likely that the models which prevail have been implicity generation specific; it was no coincidence that early racial and ethnic identity models emerged out of the movements of the 1960s and 1970s. However, the contemporary generation of teenagers and adults have inherited many of the benefits of the civil rights movement of the third quarter of this century. Subsequently, they have not experienced the extremes of racial injustice experienced by persons a generation or more before them. There is also a large segment of the Asian American community who is adjusting to the social construction of race in the USA, having moved from racially homogenous cultures to a racially diverse society that stratifies according to race. Many of these immigrants are learning to identify the racism that blocks their opportunities or explains the differential treatment they receive. When primary identities are without significant ties and markers specific to ethnicity, more fragile identities are constructed through race For example, consider the genre of US movies and trade books that describe someone who is white discovering they have a black ancestor and consider the deep emotional reaction someone has to this revelation. Why should this be such an unravelling experience if one already knows who one is? Such reactions suggest that the primary identity occurs through race and whiteness rather than through ethnicity. 10.06.5 RETHINKING RACE AND ETHNICITY Both race and ethnicity are socially constructed. Thus, they are dynamic and influenced by many factors including history, gender, and other aspects of identity that are socially salient and specific to the macro- and microsocial compositions of regions or neighborhoods and ethnic group histories. With the legacy of civil rights legislation in the third quarter of this century, many young people grow up with more
latitude to cross racial boundaries in friendship and intimacy. Technological advances in transportation and communication have increased the numbers of persons involved in international and cross-cultural marriages. Again, we can expect that the products of these unions will have the options to be multiethnically, multiracially, and even multinationally identified. This forecast necessitates that we rethink the meaning of race and ethnicity and their relationship. Consider these demographic trends (Root, 1996b). Since the repeal of antimiscegenation laws in 1967, the rates of racial intermarriage have almost doubled with each subsequent decade. The number of babies of mixed racial heritage has boomed since the late 1980s. Also, the number of persons writing in racial identifiers to elaborate on the other choice has caused the US Bureau of the Census enough concern to entertain a multiracial way of identifying for the year 2000 census. In July 1997, the Office of Management and Budget which oversees the Bureau of the Census decided after much research that the year 2000 decennial census will allow people to mark more than one box in response to the race question. This is an historical change in the accounting of population in the USA. Whereas the folklore sustaining racial boundaries has purported that racially mixed people will be marginally located and accepted in society, this marginality is being explored and challenged in the academic literature (Anzaldua, 1987; Root, 1992, 1996a; Zack, 1993; 1995), literary essays (Funderburg, 1994; Jones, 1994), novels, and mainstream cinema. The social location of an increasing number of multiracially and multiethnically identified people is often positively constructed, in contemporary time and particular on the west coast of the USA. More than ever, current research on ethnicity and race suggests that we must attempt to disengage these constructs so that, although at times they admittedly remain confounded, they are not synonymous. For example, Stephan's (1992) research in Hawaii and New Mexico points out geographic differences in how race and parents' ethnicity effects the identification of multiracial Asians and multiracial Mexican American young adults. Her conclusion is that race is neither a necessary nor sufficient condition for making an assumption about ethnic identification. She found that when offered an open ended response option to ethnicity in different situations, few respondents identified themselves consistently across all situations. The conclusion was that identity has contextually constructed Hall (1980) found
that neither self-assessed phenotypical resemblance to either black or Japanese reference groups or language facility predicted ethnic identity in her black Japanese sample. The person of mixed heritage experiences many of the psychological assaults and injuries that their generation cohort of people of color experience. Furthermore, many assaults and insults stem from and are specifically directed to their racial ambiguity. These assaults come from groups of people with whom the biracial person shares heritage and identifies. Table 1 provides a summary of 40 racial experiences commonly experienced by many persons whose racial classification is ambiguous or interpreted by others as mixed. Experienced repeatedly throughout a lifetime, these items potentially influence one's understanding of race relations, race rules, and racial identity. Inherent to this inventory is the negative stereotyping of mixed race, boundary policing of authentic racial behavior, physical objectification of phenotype, and denigration of whiteness. Therapists, teachers, and school counselors might use such a list to provoke discussion. Therapists might further use such an inventory to generate discussion about coping, identity formation, and psychological defenses against exclusion, authenticity testing, denigration, and idealizing that the person of mixed heritage may experience. 10.06.6 CONTEMPORARY MODELS FOR RETHINKING THE RELATIONSHIP BETWEEN RACE AND ETHNICITY Current trends to reformulate racial formation or ethnogenesis should not ignore the conceptual and empirical information gleaned from earlier research. However, current trends necessitate that we move beyond bipolar conceptualizations of race, reexamine assumptions about racial identity formation, and differentiate race and ethnicity. Contextual spheres of influence from large macrodimensions of geographic region to microdimensions of family interaction and personality must be considered in identity formation. 10.06.6.1 Ecological Model of Race and Ethnicity Figure 1 represents an ecological identity model of influences on identity development. It evolved out of observing the identity process and differential outcomes for persons of multiracial ancestry, often of multiethnic background, in both clinical and nonclinical settings. The model can accommodate several
different outcomes of identity for both monoracially and multiracially identified people from very fragile identities to well-grounded and stable identities. It also accomodates some previous work which states that identity is indeed dynamic and can change over a lifetime due to changing contexts and developmental issues over the lifespan (Root, 1990, in press). However, unlike the stage models which may reflect an underlying linear process, this change of identity does not necessarily invoke a linear movement. Social identities are informed by the interaction of micro and macro influences on identity. This model breaks away from the longstanding constraints of bipolar racial frameworks and assumed rules of hypodescent. In line with the symbolic interactionist theories and models, this one proposes reflexive interaction between variables. In the proposed model, all boxes are lenses and are present to some degree. The drawing serves as a conceptual organizing tool with which to consider influences in identity. The lenses recognize individual factors, familial factors, community influencesÐboth imagined and factual such as historical influence and experience that transcends generations. Through these lenses, the inherited influences, traits, and social interactions with community determine identity development. The inherited influences include biological and environmental inheritance. Biological inheritance, such as sexual orientation and phenotype, significantly influence life. The other inherited influential lenses are environmental: languages spoken at home; parent's identification ethnically, racially, and nationally; nativity; presence and socialization influence of extended family; given names and nicknames; and home values. All of these variables have been documented in different literatures as having influence on identity. All the environmental influences provide cultural markers to a lesser or greater degree of distinctiveness. The lenses with inherited influences interact with one another. These inherited influences interact with traits: temperament, social skills, talents, and coping skills. These influences may have both elements of nature and nurture. The traits are some of those aspects of the individual that together are often summarized as personality. The traits are differentiated from inherited influences through what the individual has control over. This model assumes the individual has little control over their inherited influences, whether they be biological or environmental. In contrast, the traits, are deemed to be majorly subject to social influence and learning, even when there may be different degrees of natural talents, coping, sociability and its skills, and even temperament.
Contemporary Models for Rethinking the Relationship between Race and Ethnicity
Table 1 Items from the racial experiences questionnaire. 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. 16. 17. 18. 19. 20. 21. 22. 23. 24. 25. 26. 27. 28. 29. 30. 31. 32. 33. 34. 35. 36. 37. 38. 39. 40.
Told, ªYou have to choose; you can't be bothº Your ethnicity misidentified People assume your race to be different by phone and in person Accused of not acting or wanting to be . . . (Latino, black, Asian, etc.) Told, ªMixed race people are so beautiful/handsomeº Strangers look between you and your parent(s) to figure out if you are related Told, ªYou don't look . . . (Asian, black, native, etc.)º Asked, ªWhat are you?º People might not say certain things in front of you if they knew how you think about race Asked, ªWhere are you from?º Stared or looked at by strangers Told, ªYou look exoticº Your choice of friends is interpreted as your selling out or not being authentic Accused of acting or wanting to be white Judgments of your racial authenticity are based upon your partner's race Comments are made about your physical attributes (hair/hairstyle, skin color, eyes, shape, etc.) You are subjected to jokes about people of mixed heritage Told, ªYou think you're too good for your own kindº Grandparent(s) or relatives don't accept you because of your parents' interracial relationship Your parents/relatives compete to claim you for their own racial or ethnic group Told, ªYou have the best of both worldsº Asked about your racial heritage Upon meeting you, people seem confused by your name(s) People assume you are confused about your racial identity People speak to you in foreign languages because of how they intepret your physical appearance Told, ªSociety doesn't recognize mixed raceº Told, ªyou aren't really . . . (Asian, black, Hispanic/Latino, native, etc.)º Mistaken for another person of mixed heritage who does not resemble you Told you must be full of self-loathing or hatred because of how you racially identify yourself Told, ªYou are a mistakeº People's racial identification of you varies and is colored by the race of the people you are with The race people assume you are varies in different parts of the USA You have difficulty filling out forms requiring you to check one race only You identify your race differently to how others identify your race Told, ªYou aren't like other . . . (blacks, Latinos, native Americans, Asians, etc.)º Your siblings identify their race differently than you identify yours Called racial slurs of groups who aren't part of your heritage When friends suggest dating partners for you, they stick within a single racial or ethnic group Your parents identify your race differently than you identify yourself Told, ªYou aren't . . . (native, Asian, black, Latino, etc.) enoughº
These interactions takes place in contexts. Such interpersonal contexts allow for the communications about rules of belonging whether it be to the outgroup or ingroup. Reflections of who we are outside of our families serves as frame for further reconciling the private and public experience of identity. For most of us, five social contexts encapsulate most of our social interactions: home; school and/or work; community groups; friendships, and communities in which we are strangers. This last social context is important because it may challenge an individual's construction of self when community environments differ from one another or a person's identity is in some way ambiguous. In the case of phenotypically ambiguous people, whether or not they are
multiracially or multiethnically identified, a community to which they are a stranger may provide them with feedback that affects how they experience themselves in relationship to othersÐand it may be different to what they are used to. The most dramatic stories emerge from recent biographical stories of persons raised white who change living situation or state and then, though phenotypically white, must assume the life of a black person (Williams, 1995). Lastly, the summation of this interactive life experience filtered through the interaction of the different lenses posed by inherited influences, traits, and social contexts helps us understand identityÐboth ethnic and racial identity in the context of history and gender. These identities, in turn, provide a lens through
Reconstructing Race, Rethinking Ethnicity Gender Regional history of race relations Class Generation Social interactions with community
Inherited influences
Languages at home
Parent's identity
School/ work
Outside your community
Figure 1 Ecological identity model; all boxes are interactive.
Clinical Implications which life is experienced. As one moves through milestones in one's life course, racial and ethnic identity can influence what is passed on as inherited influences to the next generation. This model suggests that the sociohistorical construction of gender and race are lenses through which most of our life experiences are filtered. However, the construction and connotations of race and gender are also informed by geographical regional context and the historical generational cohort. These additional filters allow us to understand how race and gender have been constructed through paradigms of domination and submission (Lerner, 1986; Stoler, 1995; Zack, 1997b). Patriarchal and imperialistically driven cultures construct racial and ethnic hierarchies with imperialist or the colonial schemes (Freire, 1970; Stoler, 1995; Young, 1995). Therefore, in this model gender and ultimately racial identity are viewed as lenses that are layered upon one another. These two lenses interact dynamically, exchanging salience in relationship to one another as foreground or background filters. This conceptual relationship also explains why some persons assert that gender is the primary organizing factor in life experience, whereas others assert that race is the primary organizing factor in life. However, at all times there is an interaction as described above that makes it certain that the social address of men and women differ when we filter their location through the lenses of gender and race. Other secondary statuses are significant dimensions or lenses through which life is experienced, for example, class and sexual orientation. Both of these locations may be accompanied by denigrating and oppressive or affirming reflections of self. Again, psychological defenses and coping skills are necessary to be able to incorporate these aspects of experience, and ultimately identity into the larger concept of self. Likewise, racial and ethnic experience in this country, by region, yield different experiences between two individuals despite the similarity of a host of other life variables. For example, the rates of intermarriage between whites and blacks is very different in the south compared to the west. The histories of these regions are also very different. The prominence of lynchings of black men who dared to interact or even look at white women is well documented in the south, particularly prior to this century. Through the lens of race, the socially constructed groups in the USA are Asian and Pacific Islander American, American Indian, African-American, and white. Whereas persons of Hispanic origin may be any race, this country's history of race relations has constituted this category as a
race based on attitudes (Root, 1996b). There will be points at which the experiences of each of these groups will overlap. However, if the gender lens is more prominent, an AfricanAmerican woman may share more in common in a given context with a Chicana than with an African-American man. For example, the threat to one's body through sexual violence is an experience shared by women and much less so by men. The lense of historical race relations suggest that women of color have been less protected by the legal system in matters of violations of their body, whether it be child abuse, domestic violence, or rape. This model can accommodate the process described in racial identity development models described earlier in this chapter. However, it does not predict or require that an individual will go through the first stage of negative feelings about their minority racial or ethnic group; it can accomodate such a process, though. This is important because in contemporary times, perhaps due to some of the benefits of the civil right movement, many young people do not feel badly about their ethnic or racial reference group which society ascribes to them. The ecological identity model also accommodates typology models. It evolved from an earlier work (Root, 1990) in which types of identity were proposed for multiracial people. The process by which people might get to those identities is subsumed in this model. Thus, it is possible to change identity over time, and sometimes this move is simply precipitated by a geographic move, such as from mainland USA to Hawaii where a multiracial and multiethnic identity is the norm. It also provides an increased number of variables with explanatory power for differences in identity absent in other racial identity models. 10.06.7 CLINICAL IMPLICATIONS The ecological identity model may be useful in clinical settings. It acknowledges trauma which in fact determines some of the salient lenses through which one experiences life (Root, 1992). If a patient has been sexually violated because she is female, and links her suffering to this status, the lens of gender will be prominent. If life chances have been compromised by skin color, and this link has been made, the lens of race will operate prominently. But both lenses will interact. Therapists and counselors can understand the possibility and impact of transgenerational trauma as part of inherited influence: stories of genocide, slavery, incarceration, colonization, and domination imparted from
an early age are part of a parent's or relative's identity. The stories may be passed on in the inherited influences of names and family interactions within the community. Parenting is extremely important in the passing on of both coping with a secondary status and the formation and interpretation of both racial and ethnic identity. Kich (1992) provides one of the best clinical explanations of the processes and outcomes that the biracial person may experience through his three stages. One of his most significant contributions is that his model provides for an understanding of how internal family dynamics may interact with lessons around race and ethnicity. Given that society stratifies race, this hierarchy may be replicated in family dynamics. A child may develop a distance and ambivalent relationship with the parent of color if emotional denigration or the process of destructive differentiation occurs around cultural differences. The model has implications for different developmental periods that can be further elucidated by the ecological framework suggested in this chapter. For example, if the parent with higher racial or ethnic status denigrates the other parent, a child may feel simultaneously victimized or denigrated. Simultaneously, if this child feels helpless to help, she or he may develop an acute awareness of self which is akin to the vigilance typical of post-traumatic responding. Several aspects of his or her existence may serve as subsequent environmental cues which trigger vigilance in certain settings. For those children who have been raised in psychologically or emotionally denigrating households, the statements, questions, and experiences in Table 1 may all serve as cues leading to experiences of marginalization and rejection. Therapists and clinicians may want to explore how these experiences have had impact on a person at different stages in their life, and how their coping deflects or defends against society's unresolved anger stemming from the consequences of the racial system. In this system anger and anxiety is projected onto the body of the mixed-race person and subsequently creates a gestalt of experience unique to the mixed-race individual's experience. Major themes are rejection, marginalization, societal anxiety, and objectification as represented by the items of Table 1. These experiences may be specific to certain social environments which feed into definition of self through acceptance and rejection experiences which also seem critical to ethnic identity of racially mixed people (Hall, 1992; Root, 1990; Stephan, 1992). Each of these themes is explained below.
Rejection is captured by items such as, ªYou are a mistake,º ªGrandparents or relatives don't accept you because of your parents' interracial relationship,º and ªTold society doesn't recognize mixed race.º It also encompasses the accusations of passing into a dominant desired group with statements such as ªYou think you're to good for your own kind,º ªEthnicity misidentified,º or ªAccused of acting white.º Ironically, because of the past history of racially mixed people passing into a desired group group because their phenotype allowed this, many racially mixed persons are struggling for acceptance from an ethnic group or racial group of their heritage because their phenotype creates suspicion about their intent to belong and their trustworthiness. Marginalization relates to rejection through authenticity tests and applications of rigid boundaries. Cues for this experience may occur with statements such as, ªYou have to choose, you can't be bothº or ªTold you must be full of self-loathing or hatred because of how you racially identifyº or ªYour racial authenticity is based upon your partner's race.º Much societal anxiety about race is projected onto the mixed race person who refuses to comply with the implicit rules of race which guide daily interactions. This anxiety manifests in questions and statements such as, ªAsked about your racial heritage,º ªAsked what are you?º and ªAccused of not wanting to be Latino/black/Asian, etc.º Objectification encompasses the deindividualization and sexualization projected onto race and gender and their interaction. Such a process sets the stage for cruel treatment and relegating persons of mixed heritage to otherwise invisibility. Experiences such as being ªtold you look exoticº and ªstared or looked at by strangersº signal this process. In increasing attempts at individuation, particularly during adolescence in western cultures, anger at the parent with perceived lower status may be a dysfunctional attempt to attempt to avoid taking on the denigrated status. Also of this racial group, the adolescent is caught in a cycle of anger or even hate that precludes them from realistic affirmation of their whole self. Whereas adolescence in the USA is replete with anger, racial dynamics and gender dynamics may become entwined in a way that makes it very difficult for a child to cope and determine psychologically adaptive ways of responding that may serve them into adulthood. For example, if a white father repeatedly denigrates an Asian mother, not only does this set up the possible dynamics above, it may perpetuate misogyny and denigration of female status, particularly
Summary women of color, and set up an idealization of white women. The status of parents' relationship to one another and society may also be formative in identity. Stephan (1992) discusses the possible influence of the gender of parents in patriarchally organized societies as it may differentially influence identity formation in Hawaii versus New Mexico. Results from her study suggest that for persons of mixed heritage, having an Hispanic father in New Mexico may be more of a determining factor in New Mexico, where such status is lower than having a Japanese American father in Hawaii, where Japanese Americans have relatively high social status. Kich (1982, 1992) further suggests that the absence of a parent and how that absence occurs and is explained may be very critical to how race is interpreted in the family. More recently, with high rates of divorce, increasing attention is paid to white single parenting of mixed heritage children so that they can defend themselves in a society that has been antimiscegenistic and anxious about their existence. Similarly, children of single parents of color must also be aware of the intense discrimination towards racially mixed people that may occur in some closed communities of color. McRoy and Hall's (1996) clinical work on transracial adoption is applicable here. They essentially point out that basic needs of a child must be met even before the tasks of racial defense are relevant, that is, a child must feel loved and secure. Root (1994) identifies the issues in therapy for mixed race women, although most of the issues are applicable to men. Whereas few people enter therapy to work on their mixed racial heritage, the experiences society has dealt around this status can manifest in issues around selfdefinition, acceptance and belonging, interpretations of power, sources of self-esteem, and independence. Gibbs and Hines (1992) suggest that adolescent biracial identity resolution revolves around several developmental questions: Who am I? Where do I fit? What is my social role? Who is in charge of my life? Where am I going? These questions are windows into several areas of developmental conflicts including, racial/ethnic identity, social marginality, sexuality, autonomy and independence, and education and career aspirations. Bradshaw (1992) cautions therapists to take the time to understand the contemporary multiracial experience to contextualize the acute and at times everpresent self-consciousness present in people's lives. Lastly, Root (1994) cautions therapists not to assume that being of mixed heritage is an unresolved issue for persons coming into therapy.
10.06.8 FUTURE DIRECTIONS: RETHINKING RACE AND ETHNICITY There are several factors driving the need for a reexamination of how we think about race and ethnicity. Unless we rethink race, the process of differentiation between ourselves and those who look different from us will often times be a destructive process of differentiation driven by unresolved conflicts and fraught with stigmatizing of bodies we have inherited from this country's history of race relations. Unless we reopen the dialogueÐand a new one that considers a contemporary meaning for mixed raceÐwe may not be able to understand contemporary ethnicity in America. Without separating the concepts of ethnicity and race, dialogues will remain confused as discomfort with the construct of race, can be evaded by changing the dialogue to one that shifts emphasis to the other construct of ethnicity, despite the negative differentiating driving the construct. Likely the racial identity models of the 1970s and 1980s were necessary to understand and be able to educate people oppressed by the racial system in a way that promoted healing. We are now challenged to see if we can undertake a next step in healing. Can we develop models that allows us to explore the fluidity of identity in the social contexts of current and past historical moments?
10.06.9 SUMMARY A biracial baby boom became possible with the repeal of the last antimiscegenation laws in the USA in 1967, changes in immigration laws, and global mobility of people and populations. Changes in the psychology of race and ethnicity in this last part of the century are integrally linked to these demographic changes. Nevertheless, the 10 conditions Allport (1954) hypothesized correlate with prejudicial attitudes still exist. A more critical understanding of how racial politics derive from a process of negative rather than constructive differentiation is highlighted by examining the current experience, identity process, and social location of the person of mixed racial heritage. An ecological framework for thinking about the different outcomes of racial identity is presented. Gender, geographical history, class, and generation are significant, dynamic lenses which filter many life experiences which have not been put forth in previous racial identity models. The ecological identity model can accomodate the processes proposed by past identity models. However, it
accomodates increasingly more common identity development processes that do not involve traumagenic experiences despite prevailing conditions towards prejudicial attitudes. Psychological processes in resolution and integration of a multiracial location and identity are discussed in this chapter with cautions that therapists should not assume that a multiracial identity is inherently problematic. For many young people, the work of the generation before has allowed them to open a different dialogue on race. This is a challenge to society and to therapists trying to understand the process by which these people negotiate their daily lives.
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10.07 The Psychology of Gender and Health RICHARD M. EISLER Virginia Polytechnic Institute and State University, Blacksburg, VA, USA 10.07.1 INTRODUCTION
10.07.2 GENDER AND EPIDEMIOLOGY OF HEALTH PROBLEMS
10.07.3 HISTORICAL PERSPECTIVE ON GENDER DIFFERENCES
10.07.4 THEORETICAL OVERVIEW OF GENDER DIFFERENCES
Biological Perspective Social Psychological Perspective Cross-cultural Perspective Summary of Gender and Health Perspectives
10.07.5 THE ROLE OF PSYCHOLOGICAL STRESS IN WOMENS' AND MENS' HEALTH 10.07.5.1 10.07.5.2 10.07.5.3 10.07.5.4
Gender Gender Gender Gender
and Biological Vulnerability to Stress and Cognitive Vulnerability to Stress Role Stress Roles and Coping with Stress
10.07.6 GENDER DIFFERENCES IN SELF-DISCLOSURE AND HELP SEEKING 10.07.6.1 Gender and Emotional Expression 10.07.6.2 Gender and Social Support 10.07.6.3 Gender and Help Seeking
model biochemical problems caused by faulty organs or infectious agents resulted in illness. The biomedical model served us well 100 years ago, when the leading causes of death were tuberculosis, pneumonia, and influenza. The leading causes of death today, however, such as cardiovascular disease and lung cancer, have psychosocial etiologies that may be more comprehensively evaluated and treated by understanding cultural risk factors, including gender determinants.
Why is it important for a discourse on the psychology of health to focus on gender issues? Most importantly, there has been a shift in the conception of healthcare practices over the past few decades from the biomedical model to the biopsychosocial model. The biomedical model had limited the assessment and treatment of disease to the biological components of organs, biochemicals, and infectious agents. In this 161
The Psychology of Gender and Health
In the current biopsychosocial model of health, biological disease processes are acknowledged, but psychosocial factors that predispose one to illness are strongly emphasized. The psychosocial components encompass engaging in high-risk behaviors, appraising and coping with stress, utilizing social support systems, and the seeking of appropriate help from the healthcare system. In all the aforementioned psychosocial areas, recent research has shown that there are important sex or gender distinctions, the evaluation of which is crucial for the prevention of illness and the maintenance of health. These psychosocial issues are the focus of this chapter. It has been evident that many health problems occur with different frequencies among men and women. Paradoxically, while women are more likely than men to have most of the nonfatal chronic illnesses and acute medical conditions, more men than women die of each of the 12 leading causes of death (Wingard, 1984). There are also important differences in the types of stress to which each gender is subjected. For example, research has shown that working women have greater gender role stresses than working men, in that they have to manage both family and work roles (Frankenhaeuser, Lundberg, & Chesney, 1991). Further, it appears that marriage itself contributes differentially to the health of women as contrasted to men. Married men report lower rates of mental and physical health problems than single men. Married women, on the other hand, report higher rates of mental health problems than single women. Finally, women are far more vulnerable to sexual and physical abuse than men in their intimate relationships (Koss et al., 1994). Another gender-related health issue is the frequency and quality of each sex's interaction with the professional healthcare system. Across most age categories men have a lower frequency of physician office visits than women, and less than a third as many visits to a mental health professional. Pennebaker (1982) theorized that underutilization of the healthcare system by men compared to women may be the result of men's tendency to disregard the importance of their symptoms. Another possibility could be that men are reluctant to visit caregivers because it conflicts with masculine gender role imperatives to appear strong and tolerate pain (Eisler & Blalock, 1991). Not only do women and men utilize healthcare systems differently, but healthcare systems may also respond differently to each gender. If similar kinds of symptoms are reported by each sex, women are more likely than men to be diagnosed with a mental or nervous condition (Travis, 1988). In addition, physicians may be less likely to diagnose women
with diseases that they consider to be most prevalent in men, such as heart disease. Thus, we may conclude that there are very significant reasons for including gender in studying the psychology of health. More than half of the mortality from the 10 leading causes of death may be traced to lifestyle risk factors on which women and men differ significantly (Verbrugge, 1989). Divergent gender roles produce large variations in exposure to and coping with stress, which result in different vulnerabilities to various disorders. Also, men and women have different values regarding the importance of social support and preventive healthcare practices. Finally, existing research protocols have primarily been designed to assess the causes of health problems in white males. It is clear that this is inadequate for understanding treatment issues for women and other cultural groups. It is instructive to note here that the current convention is to use the term ªsexº when referring to reliable biological distinctions between males and females. Sex refers to biological characteristics including chromosome pattern, and genital structure. However, ªgenderº is the term preferred by psychologists to denote the idea that men and women are socialized to display ªmasculineº and ªfeminineº characteristics and behavior patterns. The term sex will be used henceforth to denote the biological aspects of individuals, and gender will be used to refer to the socially constructed roles deemed socially appropriate for either men or women. 10.07.2 GENDER AND EPIDEMIOLOGY OF HEALTH PROBLEMS Recent epidemiological data on the association between gender and health have documented gender differences in ªpremature mortalityº based on more hazardous lifestyles and behavior patterns engaged in by men compared to women (Harrison, Chin, & Ficarrotto, 1989). In the USA, women live, on average, about seven years longer than men. The death rate for men is higher than for women at all ages and for all leading causes of death (Verbrugge, 1985). Men have twice the rate of premature death from coronary artery disease, and they are three times more likely to die in motor vehicle accidents than are women. In addition, Waldron and Johnson (1976) have noted that mens' death rates from lung cancer have been nearly six times that of women, and twice as high from cirrhosis of the liver. In terms of psychological dysfunction, men are much more prone to a higher incidence of
Historical Perspective on Gender Differences personality and behavior disorders. In a review of epidemiological studies, Cleary (1987) noted that men have been three times more likely to be problem drinkers and four times as likely to be diagnosed with alcoholism than are women. It was also evident in this review that men were more likely than women to abuse drugs and to be diagnosed with antisocial personality disorder. In addition, a review by Widom (1984) cited evidence that men, far more than women, are involved in violent crime, including armed robbery and homicide. Widom also noted that men are much more likely than women to be involved in sexual deviance and more frequently are perpetrators of child and spouse abuse. Taken together, these statistics suggest that men more than women tend to employ antisocial and aggressive means in dealing with conflicts and personal problems. This is consistent with the evidence reported by Huselid and Cooper (1994) that men are more inclined than women to ªexternalizeº their distress through aggressive and hazardous coping strategies. On the other hand, there is convincing evidence that women may suffer from more ªinternalizedº psychological distress than men (Huselid & Cooper, 1994). Women's stereotypic gender roles associated with passivity and selfblame may be responsible for their greater vulnerability to internalizing disorders such as anxiety and depression. In an early study, Weissman and Klerman (1977) reviewed 40 studies in over 30 countries before concluding that women were two to three times more likely than men to suffer from depression. The greater incidence of depression in women has been confirmed in a large-scale community study of the mental health of over 20 000 residents in different US cities (Robins et al., 1984). With respect to the anxiety disorders, Robins et al. showed that women had higher prevalence rates of agoraphobia, panic disorder, and obsessivecompulsive disorders than men. In an extensive review, Attie and Brooks-Gunn (1987) described weight concerns and chronic dieting as the focus of constant stress in women as being directly responsible for the extraordinarily high ratio of eating disorders (anorexia and bulimia) in women compared to men. From the above discussion, we may conclude that there have been significant gender differences in incidence of different disorders, including psychological dysfunction. It is also apparent that gender roles mediate male vs. female differences in expressions of psychopathology in response to stress. In the remaining sections of this chapter, we will be concerned with the historical and theoretical studies of gender differences, gender roles and one's vulnerability to stress, and how each gender
handles and expresses emotional distress. In addition, we discuss how each gender seeks help for their psychological problems through informal support systems and professional counseling. Finally, we explore how these perspectives may influence the future directions of the investigations concerned with gender and health. 10.07.3 HISTORICAL PERSPECTIVE ON GENDER DIFFERENCES While philosophers and social scientists have deliberated for ages about the essential qualities of women compared to men, the first systematic attempt by psychologists to synthesize a large body of research data about the psychological differences between the sexes may be traced to Maccoby and Jacklin's classic work The Psychology of sex differences published in 1974. Maccoby and Jacklin's volume reviewed over 1400 of the available psychological studies which conducted statistical comparisons of the sexes on their intellectual abilities and social behavior. Their purpose, as stated in the introduction, was to ªsift the evidenceº to determine which of the many (stereotypic) beliefs about presumed differences between the sexes had a solid basis in fact and which did not. Overall, they concluded from the data that the sexes differed much less than commonly held cultural stereotypes had indicated. Based on the evidence, the authors found sex differences in a few intellectual abilities: verbal, quantitative, and spatial skills. However, Maccoby and Jacklin argued that the evidence was negative or inconclusive with regard to differences in social behavior, with the notable exception that boys tended to display more aggression than girls. Finally, they drew attention to the fact that differences among individuals within each gender were often as great as the average differences between genders. Once again, the point was made that the ability of the individual, not the individual's gender, was most important. With respect to the potential sources of verified sex differences, such as aggression, Maccoby and Jacklin acknowledged that biological predispositions based on sex could interact with psychosocial experiences to determine the psychological and social characteristics of the person. However, the authors indicated that the biological bases for these psychological characteristics of women and men could not be specified with any degree of certainty. Interestingly, and probably not coincidently, the publication of Maccoby and Jacklin's (1974) volume coincided with the early phases of the
feminist movement in the USA. At that time feminist theory had a political as well as a scientific stake in gender research (Eagly, 1995). Two of the major feminist political agendas were to discover scientific data to show that: (i) women were intellectually just as capable as men, and (ii) gender stereotypes that depicted women socially or emotionally at a disadvantage compared to men were false. This agenda required an interpretation of the data that showed there were no meaningful differences between the basic abilities of men and women, which would then give women equal opportunity with men to succeed in society. While feminist ideology may have biased gender research of the 1970s toward the conclusion that there was little evidence of sex differences, research in the mid-1980s and 1990s returned to more refined theoretical questions about the origin and health implications of gender similarities and differences. A thorough critique of Maccoby and Jacklin's (1974) synthesis regarding the evidence of significant gender differences in intellectual and social abilities is beyond the scope of this chapter. Suffice it to say that subsequent to their review, more sophisticated quantitative analyses comparing gender differences in a variety of skills and social behavior have followed. These have included meta-analytic studies of gender differences in decoding nonverbal cues (Hall, 1978), conformity and influenceability (Becker, 1986), and helping and aggressive behaviors (Eagly & Crowley, 1986), to name just a few. While the significance of these newer findings is hotly debated, the conclusions reached by more recent work have been that there are in fact functional gender distinctions in such areas as empathy (Eisenberg & Lennon, 1983), leadership (Eagly & Karau, 1992), and the incidence of psychological disorders such as depression (Nolen-Hocksema, 1987). In addition, nontrivial gender differences in important social behaviors have been reviewed and discussed by gender researchers (Daly & Wilson, 1988; Deaux & Major, 1987; Eagly & Wood, 1991). 10.07.4 THEORETICAL OVERVIEW OF GENDER DIFFERENCES Having established that gender differences exist in certain psychological and behavioral domains, we can turn to questions more pertinent to the present chapter on the relationship between gender and health psychology. For instance, why do males and females sometimes differ considerably, moderately, or not at all in their vulnerability to physical and psychological
disorders? To what extent are the sources of these distinctions biological, environmental, or an interaction between both?,Furthermore, how does the health of the individual depend on her or his social roles and abilities? Shifting from the question of whether gender differences exist to explaining why males and females are predisposed to different health problems requires testable theories about how gender differences come about and what biopsychosocial forces maintain them. Most modern theories about the origin of gender difference adopt an ªinteractionalº perspective, whereby the biological features of each sex interact with the social environment to produce the observed gendered behavior of men and women. On the one hand, however, it is fair to say that theories that give prominence to ªbiologicalº features treat gendered behavior as arising primarily from characteristics that are built into the person prior to social experience. On the other hand, social psychological theories regard gendered behavior as primarily arising out of the interaction between the person and his or her social environment. 10.07.4.1 Biological Perspective Few modern theories attempt to explain the differences in the behavior of men and women solely in terms of biological forces. Recently, Buss and Schmitt (1993) and Kenrick (1994) have advocated what has been termed ªevolutionary psychological theoryº to account for some different features in the behavior of the sexes. Evolutionary psychology, which was first applied to nonhuman species, is based on the premise that biologically based sex differences have evolved over time, employing the Darwinian notion of sexual selection (Buss, 1995). These biologically oriented psychologists have postulated that there are sex differences in genetic make-up or differences in the structural features of females' and males' brains. Presumably, these biological distinctions have evolved over time to produce functionally useful aspects of masculine behavior for men, and feminine behavior for women. Evolutionary psychology predicts that males and females will be similar in those domains in which the sexes have faced similar adaptive problems. For example, both sexes have similar preferences for fats, sugars, and salt because both sexes have faced similar food consumption problems. However, in some domains the sexes will have faced different problems. For instance, men have evolved to have greater skills in spatial visualization than women, because men have had a greater need to develop these skills for
Theoretical Overview of Gender Differences hunting. Women, on the other hand, have faced the adaptive challenge of securing sufficient food to carry them through pregnancy and lactation; therefore, evolution might have favored selection of women who developed the ability and features to attract mates to help them through this period. Thus, evolutionary psychology predicts distinctive male and female behavior in areas where sexual selection has favored the development of the physically and psychologically different adaptive characteristics for men and women. Presently, the evolutionary account of sex differences is regarded by many gender researchers as highly speculative. However, this perspective has presumably generated testable hypotheses (Eagly, 1995). 10.07.4.2 Social Psychological Perspective Over the past several decades, a diverse group of scientists has contributed to the social psychology of gender, which in its simplest description investigates how gendered behavior is defined, created, and maintained for each sex through social norms and social interaction. Social psychological theories that feature discussions about the acquisition of disparate gender roles and how ªsex-typedº gender roles create stress-related problems for men compared to women have generated much of the recent data on gender and behavior for clinical health psychologists. For example, the masculine gender imperative for men always to appear invulnerable may be related to their reluctance to seek medical or psychological care. Similarly, the feminine gender imperative for women to be ever youthful and attractive may contribute to excessive dieting among women, which may in turn render women especially vulnerable to eating disorders. The following are a few examples of the contributions of social psychologists that view gender distinctions more as a social construction than a biological reality. Bem (1981, 1982) contributed to gender role theory by supposing that children develop cognitive schema to organize information about the world and themselves in terms of socially desirable masculine or feminine traits. That is, at an early age, boys and girls learn to judge their adequacy as people based on whether their thoughts and behavior are in conformity with social norms for their gender. For example, women may be reluctant to be assertive about their needs because it conflicts with their gender schema about appearing appropriately conciliatory. A man's gender schema might direct him not to express his true worries and concerns because it is inconsistent with masculine values to show
one's emotional vulnerability. ªNever let them see you sweatº was an often quoted line from a men's deodorant commercial. Indeed, an individual's own behavior is constantly being scrutinized by his or her own cognitive commitments to being in conformity with masculine or feminine ideology. In addition to what we as women or men consider is acceptable behavior for our gender, social psychological research has shown that a great deal of our behavior is based on what others expect from us solely on the basis of our being male or female. Geiss (1993) and Maccoby (1990) have reviewed research which showed that our sex-typed expectations of each sex tends to generate ªself-fulfilling propheciesº in producing the behavior expected of our gender. For example, if we expect a woman to be submissive in the presence of a dominant male colleague, she may well conform to this ªfeminineº expectation in his presence. However, she might not act submissively with her husband who does not expect her to act in a stereotypically feminine way. Because we expect males not to show their pain, we might see a little leaguer get up smiling defiantly after being knocked down by a fast ball at the plate. Moreover, it is evident that our own beliefs about how each gender should think and act, as well as others' expectations about how we as women or men should think and act are major determinants of our behavior. The notion that gendered behavior is socially constructed and enforced by society to provide distinctive roles and behaviors for men and women has important implications for people who live in diverse cultures. If the behavior of women is largely the result of cultural imperatives, we would expect the behavior of women to differ depending on the culture in which they live. 10.07.4.3 Cross-cultural Perspective Cross-cultural research on gender has been concerned with the degree to which each gender's attitudes and behaviors are either invariant across cultures or may be different depending on the distinctive features of one's cultural environment. Let us frame the question in another way. Are men less expressive of tender emotions than women in all cultures? If the answer to this question is yes, it would mean that inexpressiveness is intrinsic to all individuals who are biologically male, no matter what their social environment. On the other hand, if a man's emotional expressiveness depends on the particular culture in which he is found, then we would have evidence that expressiveness in men is largely determined by cultural forces.
While the study of cultural differences in gendered behavior is still in its infancy, Williams and Best (1990) have collected some interesting data on sex role ideology, sexual stereotypes, and work values in 14 different countries. Their results showed a high degree of agreement between men and women living within a given country about expected gender roles. However, there were important differences in social expectations about distinctive gender roles across different cultures. For example, within developed Protestant countries, both genders emphasized the importance of men behaving assertively and having power and possessions to a greater extent than women and men in the less economically developed countries. Also, men and women were seen as necessarily more distinctive in their gender roles by people in developed countries, while people from less developed countries tended to see the gender roles of males and females as more similar. Williams and Best (1990) concluded that the effect of culture was greater than the effect of biological sex in determining the expected behavior of women compared with men. 10.07.4.4 Summary of Gender and Health Perspectives Taken as a whole, research examining the basis for gendered behavior seems to demonstrate that biological differences between the sexes may establish predispositions for certain kinds of health problems. Female hormones have been found to offer protection from heart disease prior to women's menopause. Greater cardiovascular reactivity in men may predispose males to coronary artery disease. However, most researchers would agree that sociocultural forces appear to have the most profound effect on predisposing each gender to different health risks. In the following sections we hope to show that the mechanisms linking gender to health involves, to a great extent, gender differences in beliefs about health, exposure to certain health risks, gender determined roles, and gender relevant stresses and coping styles. 10.07.5 THE ROLE OF PSYCHOLOGICAL STRESS IN WOMENS' AND MENS' HEALTH At this point we have some theoretical perspectives about the acquisition and maintenance of socially constructed gender roles related to socially accepted behavior for women as distinct from acceptable behavior for men. We now move to a discussion about how each gender evaluates and copes with the stressors to
which each may be exposed. This is crucial in our understanding of the nature of the relationship between gender and vulnerability to specific health problems. We begin with an orientation to the biological and psychological features of stress and coping as they relate to health. 10.07.5.1 Gender and Biological Vulnerability to Stress Modern theories of how stressful situations produce health problems for each sex are based on the notion that psychological responses to stress produce aberrant physiological or cognitive responses that may be different for women and men. For example, it has been demonstrated that men produce larger increases in blood pressure in response to some forms of stress than women (Stoney, Davis, & Matthews, 1987). The question of how differences in the sex hormones estrogen, progesterone, and testosterone affect gender differences in health has also been a novel area of study. There has been some evidence that the female hormone estrogen is protective against atherosclerosis for women, whereas testosterone may enhance the risk of this disease for men (Polefrone & Manuck, 1987). In addition, there appear to be consistent differences between women and men in healthy immune function, which is suppressed by gender related stresses (KiecoltGlaser & Glaser, 1987). Women, for example, exhibit higher immunoglobulin levels than men, and produce larger antibody response to infection than do men (Michaels & Rogers, 1971). Psychologists and other scientists who have accumulated large quantities of data over the years about stress have concluded that stress is prominently involved in the production of a myriad of physical and psychological disorders (see Goldberger & Breznitz, 1982; Neufield, 1989). During the latter part of the twentieth century, conceptions of stress have evolved and have repeatedly shown that biological responses and the psychological make-up of a person interact with environmental pressures to produce deleterious somatic and mental health problems. Psychological stress has been acknowledged to pose health risks for both medical and psychological types of disorders (Goldberger & Breznitz, 1982; Neufield, 1989). The fact that psychological stressors may be the origin of either mental or somatic health problems, and the fact that biological and psychological systems have been shown to interact have tended to blur earlier distinctions between the two categories of health problems.
The Role of Psychological Stress in Womens' and Mens' Health Currently, sophisticated views about stress describe an interaction between biological and psychosocial factors. First, there are gender differences in the probability that each gender will be exposed to a particular stressful situation. For example, women are more likely to be exposed to the stress of sexual harassment and rape than men. Divorced women compared to divorced men are more likely to be exposed to the dual stresses of having to earn a living and manage a family. However, men may be more stressed than women at some work sites because men have been expected to deal with physically hazardous situations (e.g., working in a coal mine) to a greater extent than women. In addition to the nature of the environmental events, modern views about stress focus on the individual's cognitive appraisal of the threat and her or his psychological coping strategies. 10.07.5.2 Gender and Cognitive Vulnerability to Stress Mediating the relationship between traumatic events and physiological stress arousal are cognitive processes that assess the nature of the threat (Lazarus & Folkman, 1984; Neufield, 1989). According to Lazarus and Folkman (1984), psychological stress involves the relationship between the person and the environment that is appraised by the person as taxing or exceeding his or her coping resources and endangering his or her well-being. Thus, the interaction between our cognitive evaluations of particular situations and our assessment of our abilities to manage those problems physically and psychologically defines the stress process for us as individuals. Furthermore, according to Lazarus and Folkman, the strength of one's commitment to a particular outcome increases vulnerability to stress. Therefore, should a woman become extremely committed to losing weight, her vulnerability to stress will be proportional to the strength of her commitment to weight loss. These concepts about stress have been adopted by most clinical health psychologists, whether they work with psychological disorders such as anxiety and depression, or with the effects of stress on biological systems, such as in the cases of gastric ulcers and coronary heart disease. 10.07.5.3 Gender Role Stress A fair amount of evidence has linked sex differences in the incidence of various health problems to gender differences in appraisal of stress and utilization of coping responses (see Barnett, Biener, & Baruch, 1987; Baum &
Grunberg, 1991; Collins & Frankenhaeuser, 1978). Building on the previous cognitive conceptualizations of stress, the present author and his colleagues have developed a paradigm describing gender role stress to explain how one's commitment to gender role ideology produces stress that may lead to gender-related health problems. Incorporating Pleck's (1981) initial notions about the stress imposed by gender roles, we have developed a model that independently evaluates masculine gender role stress (MGRS) for men and feminine gender role stress (FGRS) for women. This gender role stress model reflects our attempt to account for some of the vulnerability of women and men to contrasting health problems (Eisler, 1995; Eisler & Blalock, 1991; Eisler & Skidmore, 1987; Eisler, Skidmore, & Ward, 1988; Gillespie & Eisler, 1992; Lash, Eisler, & Schulman, 1990; Lash, Gillespie, Eisler, & Southard, 1991; Martz, Handley, & Eisler, 1995; Watkins, Eisler, Carpenter, Schectman, & Fisher, 1991). The gender role stress paradigm includes several major components. The first of these is the development of gender schema through social learning environments, which tend to reward the development of masculine conceptions of self for boys and feminine conceptions of self for girls. Opposite gender conceptions of self tend to be strongly discouraged. For example, boys are rewarded for acting tough and girls for being nice. Boys are punished for acting feminine (sissy) and girls for acting aggressively (bitchy). These gender schema are then utilized to evaluate whether or not a particular situation may be threatening. Expressing feelings of vulnerability tends to be far more stressful for men than women. On the other hand, many women are much more concerned about their looks than men so that a substantial weight gain is more stressful to women. Finally, one's gender schema guide each person's choice of coping responses. A man whose masculine gender schema promotes highly vigorous means of coping with stress may rely extensively on aggression to cope with stress, whereas a woman might feel that aggressive displays were inconsistent with her feminine gender schema of how women should act. According to this paradigm, gender role stress may result from faulty gender determined appraisals of the situation, in that a man's expression of fear (feminine) need not lead to environmental stress for him, whereas acting in a forceful (masculine) manner might reduce the environmental pressures felt by a woman. Alternatively, gender role stress may result from excessive reliance on socially approved
masculine or feminine coping styles. For example, a man's reliance on a hostile or combative style of coping with stress may be dysfunctional in that it produces chronic physiological arousal leading to a heart attack. A woman who copes with stresses by the continual expression of dysphoric emotions and rumination about her difficulties could end up feeling helpless and depressed. Consequently, gender role norms have helped create gender role coping strategies for an individual based purely on his or her gender. Living up to these culturally defined masculine or feminine expectations may, in itself, be difficult for each gender, and produce stress or dysfunctional appraisal and coping behavior. 10.07.5.4 Gender Roles and Coping with Stress A major issue linking gender role stress and health has involved gender differences in coping with stress. As we alluded to earlier, consistent with their gender roles, men are more likely to externalize and women internalize their stress (Huselid & Cooper, 1994). Therefore, masculine ideology specifies different kinds of coping behavior for men than feminine ideology does for women. Because of social norms, men are more likely to utilize instrumental aggressive behaviors and displays of dominance to cope with their problems than women. However, women may be more likely to ruminate and engage in self-blame in response to crises in their lives because this behavior is more consistent with feminine gender role expectations. When we look at gender-related coping styles, we can see that some health problems may result from dysfunctional coping styles associated with one's gender role. For example, most psychological disorders involving antisocial and abusive behavior reflect exaggerated aggressive coping styles typically used by men. This might explain why there is a strikingly high incidence of men compared to women who commit crimes of violence (Widom, 1984). Also, women make more suicide attempts than men, yet men are more likely to succeed in killing themselves. Psychological disorders utilizing passive, stereotypical feminine coping styles are disorders that show higher prevalence rates for women, such as anxiety disorders and obsessive-compulsive disorders. Learned helplessness (Seligman, 1975), a major cognitive theory of depression, is more consistent with enacting the feminine rather than the masculine role. Admittedly, much research remains to be done to demonstrate that there are direct relationships between masculine or feminine gender roles and gender role coping strategies responsible for particular
disorders. However, the possibilities are intriguing, and we have conducted a number of preliminary studies to evaluate the possible association between gender role stress and coping and potentially adverse health effects. Utilizing the MGRS scale (Eisler and Skidmore, 1987), we found that there were significant associations between the MGRS scale measure and self-reported anger, anxiety, anger, and poor health habits in men (Eisler & Skidmore, 1987; Eisler, Skidmore, & Ward, 1988). In addition, Lash, Eisler, and Schulman (1990) showed that men with a high score on the MGRS scale, compared to men with a low score, were subject to greater increases in blood pressure when the stressor dealt with masculine relevant tasks in which men were expected to perform well. No differences between men with high and low MGRS scale scores were noted when the task was concerned with feminine behaviors or tasks not particularly relevant to expected male gender roles. Additional studies by Lash et al. (1991) showed that women had greater increases in their blood pressure responses than men if the stress threatened areas that were inherent in the female gender role, including nurturance and child rearing. Watkins et al. (1991) showed that high gender role stress was associated with coronary-prone type A behavior and elevated blood pressure in both men and women. Martz et al. (1995) found that FGRS scores could distinguish women who had eating disorders from women who had other psychiatric conditions. Gillespie and Eisler (1992) showed that women who had high scores on the FGRS scale reported more depression than did women low in feminine role stress. As a whole, these studies have demonstrated that responses to stress have gender components in that women are more likely than men to be stressed by events that the culture has specified as especially important to women's gender roles. Similarly, men are more subject to stress when the situation requires expected masculine behaviors. These studies have also tended to indicate that gender differences in favored coping styles may be predictive of the types of disorder that men compared with women are prone to develop. 10.07.6 GENDER DIFFERENCES IN SELFDISCLOSURE AND HELP SEEKING In this section we consider gender issues in the expression of emotion, the ability to elicit or utilize social support, and the inclination to seek help for personal problems. These are gender
Gender Differences in Self-disclosure and Help Seeking differences that may have profound implications for the health of women compared to men. The majority of verbal psychological therapies used in Western countries rely on the assumption that expressing one's feelings about past traumatic or painful events has a healing effect. Pennebaker (1995) has been foremost among researchers attempting to understand the beneficial effects of emotional disclosure on psychological and physical health. In the introductory chapter of his book Emotion, disclosure, and health, Pennebaker (1995) has reviewed the evidence that full expression of emotion reduces rumination and worry and promotes cognitive resolution of disturbing events. He also cites laboratory studies which show that disclosure of upsetting events has produced reductions in sympathetic nervous system arousal, including blood pressure and muscle tension. Other studies have shown that improvement in immune function is another benefit of self-disclosure (Petrie, Booth, & Davison, 1995). In reviewing the research detailed in chapters in Pennebaker's book by experts on psychopathology, psychophysiology, and counseling, one is struck by the evidence that the tendency to share emotional experiences has great power in increasing interpersonal intimacy, which in turn tends to buffer stress for the individual. How do the genders compare on the tendency to express emotion and create social support networks to buffer stress? Is the ability to express innermost feelings related to an individual's tendency to seek help for emotional turmoil? These questions about emotional expression, social support, and the willingness to seek help for psychological and other health problems are very much interrelated issues. Hence we now turn to a discussion of gender differences in emotional expression, gender distinctions in the ability to develop social support networks, and the tendency for women as contrasted to men to seek professional help for health problems. 10.07.6.1 Gender and Emotional Expression In a review of literature on gender differences in emotional expression Sauer and Eisler (1990) found that, almost without exception, women were more self-disclosing than men. However, it did appear that men self-disclosed more to women than to other men. Eagly and Wood (1991) explained these gender differences in terms of the widespread belief in our culture that women are more emotionally sensitive, more socially skilled, and more concerned with maintaining personal relationships than are
men. Eisler and Blalock (1991) proposed an alternative possibility: that expressing feelings other than anger is perceived by men as ªfeminineº behavior, which is contrary to their masculine role. Finally, while developing a measure of MGRS, Eisler and Skidmore (1987) found that men found it significantly more stressful than women to express feelings of affection or fear. However, this might not be true for men in other cultures. 10.07.6.2 Gender and Social Support The evaluation of social support in psychology has been hampered by a lack of agreement on a single definition of support and a broad range of measures. However, most researchers agree that the functions of social support include providing assistance in obtaining resources, problem solving, and bolstering selfworth (Belle, 1987). Research has shown that other mechanisms by which social support is associated with health are: (i) decreasing the supported persons's feelings of isolation and loss of self-esteem; (ii) attenuating the perception of certain events as highly threatening; and (iii) reducing physiological reactivity to stress (Shumaker & Hill, 1991). Throughout the lifespan, evidence indicates that females are more likely to have supportive confidants than men. While the relative size of womens' and mens' support networks varies, womens' investment in supportive disclosing relationships consistently tends to exceed those of men (Belle, 1987). While mens' supportive relationships center around shared activities and experiences, womens' relationships emphasize shared emotional intimacy. Females are more likely both to seek and to receive social support in times of stress than men (Wolchik, Sandler, & Braver, 1984). Women are also more likely than men to be supportive as friends. Finally, the evidence indicates that men have much more restricted social networks than women. In fact, married men tend to rely almost exclusively on their spouses for support, whereas married women utilize other relatives and friends for support (Belle, 1987). The potential downside of this for women is that large social networks may be emotionally stressful as well as being supportive. The impact of social support on the overall health of women compared to men is far from clear. We do know from the above data that women are more likely than men to participate in stress-buffering social networks and are more able to mobilize social support in times of stress. Women also provide more frequent and more effective support to others of both sexes.
Schumaker and Hill (1991) have concluded that the role of social support in womens' and mens' health awaits greater numbers of women to add power to the comparative health studies and more sophisticated measures of social support. We now turn to some data from the counseling literature on the relationship between gender and the tendency to seek help for health problems. 10.07.6.3 Gender and Help Seeking A crucial determinant of preventing disorder and maintaining health involves the desire and ability to seek help for problems at an early stage of difficulty. Nearly 70% of all clients seeking psychological help are female. Furthermore, one in three women, as compared to one in seven men, has sought help from a mental health professional at some point during her life (Collier, 1982). Psychologists concerned with gender issues have written extensively about a strong association between the masculine gender role and the comparative reluctance of men to seek help for psychological problems (Eisler, 1990; Good, Dell, & Mintz, 1990; Scher, 1990). Until recently, most forms of psychotherapy were developed by men to be practiced on women by male psychotherapists. This unfortunate evolution of the provider±client relationship has created problems in the delivery of health services to both women and men. In order to understand why men seek psychological and other health services as a last resort, we need to appreciate the demands of the masculine gender role and the fact that most forms of counseling have required behavior that may be regarded as feminine. Writers on mens' issues have theorized that client characteristics required by most forms of counseling and psychotherapy are completely antithetical to the masculine gender role (Eisler, 1990; Eisler & Blalock, 1991; Scher, 1990). Conventional wisdom is that, for counseling to be successful, the client must acknowledge personal problems, be willing to self-disclose, tolerate feelings of interpersonal vulnerability, and be willing to submit control of the central issues in one's life to an outsider. All these therapeutic expectations are completely contrary to what males have been taught is essential to perform adequately as a man. Men are raised to see their world as an adversarial place where a man must attain mastery of the world by being independent and cope with stress by wielding power and not by revealing his vulnerabilities. Men perceive a basic incongruity between what is expected from them as men in society and what is expected of them as consumers of health services. The result
of this is that men typically perceive going for help with personal problems as an intolerable loss of personal control and power. Psychotherapists perceive the behavior of most of their male clients as defensive, emotionally constricted, and insensitive because the male role of ªinvincibilityº appears inconsistent with seeking help. We must conclude that, for many men, entrenched masculine values continue to be an important obstacle to seeking and receiving help for health problems. 10.07.7 FUTURE DIRECTIONS Expanding our understanding of health from a biomedical enterprise to a biopsychosocial paradigm requires a greater understanding of health beyond assessment and treatment of disease processes and infectious agents. More comprehensive views of health require an understanding of psychological and sociocultural factors. An individual's beliefs and attitudes, and his or her perception of and exposure to stress that differentially affect the risk of illness have been shown to have important gender and cultural components. How these psychosocial components interact with biological systems continues to be a fascinating area for further theory and research. Research on health should endeavor to employ a more equal distribution of women and men, as well as to sample more individuals from different ethnic groups. Many of the health problems of the twentyfirst century that are reflected in premature mortality and morbidity will be preventable by attention to changes in lifestyle risk factors and creation of lower stress environments for people of different gender and cultural backgrounds. For example, preliminary research has shown that cultural and gender differences in dietary patterns, smoking, alcohol consumption, and high-risk sexual and aggressive behaviors are significantly related to differential risks of mortality and morbidity in different cultural groups (Anderson, 1995). More research is needed to understand the different kinds of stress factors to which women and men and people from different cultural groups are exposed. Clearly, racism, sexism, and economic hardship variously constitute major stress and health risks for different groups. Presently, health research has focused on specific health problems such as heart disease, the effectiveness of smoking cessation programs, cancer screening tests, and blood pressure monitoring programs. Perhaps this should be supplemented by comprehensive studies examining the health risks to which
References diverse populations are exposed. For example, how are the dietary patterns and smoking habits of diverse populations including Asian, Black, White, and Latino women and men related to different rates of acute and chronic illness? Based on these analyses, it appears that preventive health interventions are inadequately guided if they do not consider individuals as inseparable from their gender and cultural beliefs and roles. Men experience, appraise, and cope with stress differently than women, and these cognitions and behaviors undoubtedly vary for women and men belonging to different cultural groups as well. Therefore, to be successful in providing health interventions to diverse populations, we will need to address the social and cultural differences among these diverse groups of women and men. 10.07.8 SUMMARY As stated in the introduction, research and practice in healthcare delivery has recently focused our attention on psychosocial risk factors in addition to the traditional emphasis on biology. A major aspect of this shift has been to study gender and cultural variables that affect group differences in prevention practices, health maintenance, activities, and differences in outcome. Many of our conclusions have been based on differences in cultural responses to stress and studying lifestyle risk factors for different groups. It was apparent from our review that women and men experience different rates of both somatic and mental health problems, including anxiety disorders, excessive anger problems, certain types of cancer, and premature heart disease to cite just a few examples. Taken as a whole, the bases for differences in womens' and mens' health were found to be related to an interaction of biological differences with psychosocial risk factors or lifestyles. More specifically, gender differences in appraisal and coping with stress was discussed as a major factor accounting for a significant amount of variance in mens' and womens' health problems. For example, gender differences in expressing emotion and tendency to seek help from the healthcare system were shown to have major implications for gender variations in health outcome. Gender differences in social support were difficult to evaluate because of problems of definition for empirical research. We concluded that the improved health care of the twenty-first century will be more attuned to research on the psychosocial characteristics of individuals who have different risk profiles for different medical and psychological disorders throughout their lifespan.
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Nolen-Hocksema, S. (1987). Sex differences in unipolar depression: Evidence and theory. Psychological Bulletin, 101, 259±282. Pennebaker, J. W. (1982). The psychology of physical symptoms. New York: Springer. Pennebaker, J. W. (Ed.) (1995). Emotion, disclosure, & health. Washington, DC: American Psychological Association. Petrie, K. J., Booth, R. J., & Davison, K. P. (1995). Repression, disclosure, and immune functioning: Recent findings and methodological issues. In J. W. Pennebaker (Ed.), Emotion, disclosure, and health. New York: Springer. Pleck, J. (1981). The myth of masculinity. Cambridge, MA: MIT Press. Polefrone, J. M., & Manuck, S. B. (1987). Gender differences in cardiovascular and neuroendocrine response to stressors. In R. C. Barnett, L. Biener, & G. K. Baruch (Eds.), Gender and stress (pp. 13±38). New York: Free Press. Robins, L. N., Helzer, J. E., Weissman, M. M., Orvaschel, H., Gruenberg, E., Burke, J. D., & Regier, D. A. (1984). Lifetime prevalence of specific psychiatric disorders in three sites. Archives of General Psychiatry, 41, 949±958. Sauer, M. H., & Eisler, R. M. (1990). The role of masculine gender role stress in expressivity and social support network factors. Sex Roles, 23, 261±271. Seligman, M. E. (1975). Helplessness: On depression, development, and death. San Francisco: Freeman. Scher, M. (1990). Effect of gender role incongruities on men's experience as clients in psychotherapy. Psychotherapy, 27, 322±326. Shumaker, S. A., & Hill, D. R. (1991) Gender differences in social support and physical health. Health Psychology, 10(2), 102±111. Stoney, C. M., Davis, M. C., & Matthews, K. A. (1987). Sex differences in physiological responses to stress and in coronary heart disease: A causal link? Psychophysiology, 24, 127±131. Travis. C. (1988). Women and health psychology. Hillsdale, NJ: Erlbaum. Verbrugge, L. M. (1985). Gender and health: An update on hypothesis and evidence. Journal of Health and Social Behavior, 26, 156±182. Verbrugge, L. M. (1989). The twain meet: Empirical explanations of sex differences in health and mortality. Journal of Health and Social Behavior, 30, 282±304. Waldron, I., & Johnson, S. (1976). Why do women live longer than men? Journal of Human Stress, 2, 19±29. Watkins, P. L., Eisler, R. M., Carpenter, L., Schectman, K. B., & Fisher, E. B. (1991). Psychosocial and physiological correlates of male gender role stress among employed adults. Behavioral Medicine, 17, 86±90. Weissman, M., & Klerman, G. L. (1977). Sex differences in the epidemiology of depression. Archives of General Psychiatry, 34, 98±111. Widom, C. S. (Ed.) (1984). Sex roles and psychopathology. New York: Plenum. Williams, J. E., & Best, D. L. (1990). Measuring sex stereotypes: A thirty-nation study (Rev. ed.). Beverley Hills, CA: Sage. Wingard, D. (1984). The sex differential in morbidity, mortality, and lifestyle. Annual Review of Public Health, 5, 433±458. Wolchik, S. A., Sandler, I. N., & Braver, S. L. (1984). The social support networks of children of divorce. Paper presented at the American Psychological Association meeting, Toronto.
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
10.08.2 DEFINITION OF TERMS AND CONCEPTS
10.08.2.1 Culture 10.08.2.2 Family 10.08.2.2.1 Normal and dysfunctional family processes 10.08.3 CULTURE AND THE FAMILY LIFE CYCLE 10.08.3.1 10.08.3.2 10.08.3.3 10.08.3.4
Family Life Cycle Significance of Family Life Transitions Across Cultures Rituals Denoting Family Transitions Across Cultures Migration: A Life Cycle Transition Unique to Immigrant Families
10.08.4 FAMILY LIFE CYCLE STAGES: A CULTURAL PERSPECTIVE
10.08.4.1 The Joining of Families Through Marriage: The New Couple 10.08.4.1.1 Marriage: a life cycle transition 10.08.4.1.2 Intermarriage 10.08.4.2 Becoming Parents: Families with Young Children 10.08.4.2.1 Childbirth 10.08.4.2.2 Childrearing 10.08.4.2.3 Attachment 10.08.4.2.4 Developing a personal identity 10.08.4.2.5 Developing an ethnic identity 10.08.4.2.6 Developing effective coping strategies 10.08.4.3 Families of Adolescents 10.08.4.3.1 Separation-individuation 10.08.4.3.2 Ethnic identity development 10.08.4.3.3 Achievement 10.08.4.3.4 Dating and sexuality 10.08.4.4 Launching Children, Single Young Adults Leaving Home, and the Middle Generation Moving On 10.08.4.4.1 Cultural values and norms on launching
A Cultural Perspective on Families Across the Life Cycle
10.08.4.4.2 Leaving home: single young adults 10.08.4.4.3 Conflicts experienced by the middle generation 10.08.4.4.4 Dealing with parental illness and death 10.08.4.5 Families in Later Life 10.08.4.5.1 Definition of the elderly 10.08.4.5.2 Issues confronting the elderly 10.08.4.5.3 Immigrant elderly 10.08.4.5.4 Ethnic identity 10.08.5 CULTURALLY SENSITIVE FAMILY ASSESSMENT AND INTERVENTION 10.08.5.1 Values 10.08.5.2 Help-seeking Patterns 10.08.5.3 Adherence 10.08.5.4 Culturally Sensitive Techniques 10.08.5.4.1 Stance of the therapist 10.08.5.4.2 Development of the working alliance 10.08.5.4.3 Assessment process 10.08.5.4.4 Intervention process 10.08.5.5 Culturally Sensitive Techniques Across the Life Cycle 10.08.5.5.1 The joining of families: culturally sensitive assessment and intervention 10.08.5.5.2 Families with young children: culturally sensitive assessment and intervention 10.08.5.5.3 Families with adolescents: culturally sensitive assessment and intervention 10.08.5.5.4 Launching children, single young adults leaving home, and the middle generation moving on: culturally sensitive assessment and intervention 10.08.5.5.5 Families in later life: culturally sensitive assessment and intervention
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10.08.1 INTRODUCTION Family theory and therapy and the multicultural perspective offer complementary views on assessment and intervention (Gushue & Sciarra, 1995). Both approaches share the assumption that the individuals must be understood within their larger familial and sociocultural context (Gushue & Sciarra, 1995). Thus, a comprehensive assessment and intervention should attend to the complex interactions among the individual, the family, and the culture across the family life cycle (Carter & McGoldrick, 1989; Szapocznik & Kurtines, 1993). Family theorists and therapists increasingly have underscored the importance of the cultural context in which family therapy is conducted (e.g., Falicov, 1983; Ho, 1987; McGoldrick, Giordano, & Pearce, 1996; McGoldrick, Pearce, & Giordano, 1982). They have come to appreciate therapeutic models as reflecting the culture within which they are developed and practiced. Family theorists have become attuned to the role of culture and values in the conceptualization of interactive processes. Consistent with this, family therapists have become more cognizant of the impact of culture, values, and theoretical stance on the assessment and intervention process and outcome. These changes in perspective have led more family theorists and therapists to view each individual as a member of a family system that exists within a context of cultural diversity (Szapocznik & Kurtines, 1993).
After defining terms and concepts (e.g., culture, family) central to a discussion of a cultural perspective on families across the life cycle, a detailed presentation of cultural characteristics of families across the family life cycle is offered. Adapting the work of Carter and McGoldrick (1989), information is provided on cultural group differences across the major family life cycle stages. The aforementioned sections lay the groundwork for a discussion of culturally sensitive family assessment and intervention across the family life cycle. The theoretical underpinnings of family therapy from a culturally informed perspective are reviewed and culturally sensitive family assessment and intervention approaches in the United States are delineated. Hopefully, the information provided will inform psychologists about ways to adapt and modify current practices to enhance the cultural fit between the assessment and intervention approach and the family. Additionally, given the considerable intra- and intercultural variation in family patterns, it is our goal to present information that will help psychologists better treat families with whom they share a common cultural heritage and families from a different cultural background than their own. We hope the reader will bear in mind the following caveats regarding our presentation. First, there is a lack of clarity in the literature regarding the distinction between culture and ethnicity. We use the term culture to refer broadly to values, attitudes, and behaviors that
Definition of Terms and Concepts characterize groupings of people who are influenced by their culture of origin, religion, race, and socioeconomic status (SES). Second, the cultural characterizations presented are not meant as stereotypes of specific groups. Instead, the depictions reflect generalizations regarding common family patterns associated with a given cultural group (Falicov, 1983). These generalizations require validation at the level of the individual family. Third, and in a related vein, this chapter incorporates an intercultural perspective in which the definitions of what is appropriate or normal family structure, values, communication patterns, and interactional processes are seen as varying across different cultures. Although this chapter does not attend to individual differences between families within a given culture (intracultural perspective), we want to underscore the importance of attending to the unique characteristics of each family, which are often affected by such variables as the phase of acculturation, the stage of ethnic identity, and each members' choice of a primary language(s) both within the family system and in the larger community (Gushue & Sciarra, 1995). Fourth, due to space considerations, only a limited number of examples of some family cultures are provided. For in-depth reviews of families from specific cultures, and for coverage of a greater breadth of families, the reader is referred to McGoldrick, Pearce, and Giordano (1982) and McGoldrick, Giordano, and Pearce (1996). Fifth, it is not our intention to suggest that culture is the only or primary factor that impacts the family life cycle. Culture is one variable that interacts with multiple factors in influencing a family's presentation and effective assessment and intervention approaches. The salience of cultural issues differs across families, as does the significance of cultural factors in assessment and intervention. Thus, it behoves clinicians and researchers to incorporate culture as a key, albeit not sole, element in their work with families. 10.08.2 DEFINITION OF TERMS AND CONCEPTS To set the stage for a discussion of culture and the family life cycle and culturally sensitive assessment and intervention, a number of terms warrant definition. 10.08.2.1 Culture For this chapter, culture is defined as the totality of tacit behaviors, ideas and knowledge, attitudes, values, beliefs, customs, language, and technology shared by a group of people and
transmitted by families from one generation to the next (Bullrich, 1989). Cultural patterns are influenced by multiple factors, including ethnicity, race, SES, education, gender roles, sexual orientation, country of origin, current residence, migration, religious and political affiliations, and family life cycle stage. Cultural norms and values inform family members' roles and rules regarding family membership and structure, rituals, help seeking behavior, problem definition and resolution, communication styles, expression of affect, and feelings about life, death, and illness (Carter & McGoldrick, 1996). In sum, culture is a dynamic and evolving process reflecting the interaction between a family's and a group's collective history and ongoing experiences in a particular context. 10.08.2.2 Family Historically, the dominant American definition of family has focused on the intact, nuclear, heterosexual family unit, connected by blood or legal bonds, the members of which typically reside in one domicile. During the past few decades, the definition of the American family has expanded to include myriad constellations of emotional subsystems, such as step and remarried families, foster and adopted families, and cohabitating heterosexual, lesbian, gay, and bisexual couples. With the multifaceted complexion of America, the definition of ªfamilyº varies among cultural groups (McGoldrick et al., 1996). For example, African-Americans' definition of family often refers to a wide network of kin and community and extended family members (e.g., grandparents, aunts, uncles, cousins) and nonfamily members (e.g., very close neighbors and friends, church leaders, boyfriends) who function as part of one's psychological family. It is understood that all members of this family will provide assistance and guidance in various aspects of family life including child rearing, caring for the elderly, providing material resources, and offering support during crises and transitions (Billingsley, 1992; Boyd-Franklin, 1989). In the Latino community, the term family frequently connotes a close network of blood relatives that spans three or four generations. This network often includes nonblood members (e.g., godparents, legally adopted children whose adoptions have not been formalized). The traditional concept of the nuclear family has little meaning or applicability in the Latino subculture (Garcia-Preto, 1996). Historically, the definition of family in certain Asian cultures (e.g., Chinese) included
ancestors and descendants as well as living nuclear and extended family members. These families were patriarchal in structure. However, the Chinese-American family has evolved such that the contemporary family consists primarily of members of the nuclear family in which there is a more egalitarian sharing of roles across gender lines. This shift in family structure may reflect an accommodation to the dominant culture, the reality that only certain family subgroups immigrated to the US, and an increased emphasis on functional relationships (Lee, 1996). In some Native American cultures, the primary parental functions are played by the grandparents and thus the key bond is between the children and the grandparents. The term grandparent in these families may refer to grandparents by blood, godparents, maternal or paternal great aunts, and so on. In many Native American families, no distinctions are made between one's family of origin and in-law family; these families are blended, rather than joined by marriage (Sutton & Nose, 1996). 10.08.2.2.1 Normal and dysfunctional family processes Historically, family theories (for review, see N. J. Kaslow, Celano, & Dreelin, 1995) have portrayed the family as structured according to clearly defined, static, gender-based roles and family composition and have viewed the stability of the family household as the major family unit (Wamboldt & Reiss, 1991). These models also delineated the primary tasks to be accomplished by the typical family (Wamboldt & Reiss, 1991). For the most part, however, until recently, when detailing normal family structure and processes, these models failed to consider the effects of gender, social class, ethnicity, race, and sexual orientation (N. J. Kaslow et al.). This is unfortunate given that a Eurocentric model of normalcy is not applicable across cultures (e.g., Jamaican-Americans, Japanese-Americans, African-Americans) (e.g., Boyd-Franklin, 1989; Dechesnay, 1986; Hsu, Tseng, Ashton, McDermott, & Char, 1985). For instance, while the role of the parental child is often viewed as indicative of dysfunction in the family structure, in many low-income African-American families, parentification of children may reflect a family's adaptive response to their economic conditions (BoydFranklin, 1989). In these families, the presence of a parentified child is dysfunctional only when these young people are inundated with abdicated, rather than delegated, responsibilities at the expense of their development (BoydFranklin, 1989). As another example, the extent
to which triangulation (two opposing family members demand that a third person support him or her against the opposing party) within the family should be interpreted as reflecting maladaptive family patterns depends on the cultural context. In nuclear family structures common to EuroAmericans, triangulation reflects family pathology and thus may destabilize the family unit. In extended family structures common to many African-American, Asian, and Latino families, in which cross-generational executive subsystems (e.g., mother and grandmother) are normative, triangulating a child is less likely to affect the marital dyad negatively because authority lines are clear and the exclusion of one parent is not perceived as rejection (Falicov, 1983). These examples highlight the fact that the cultural validity of various family theories and theoretical constructs (e.g., kinship, division of labor, proximity and hierarchy, triangulation, parentification) require empirical examination prior to making claims about universal v. culturally specific models of family normality and dysfunction (Boyd-Franklin, 1989; Fisek, 1991; Tseng, 1985). In addition, differences in family interactions between cultural groups (e.g., Japanese-American vs. Caucasian families in Hawaii) may be attributed to cultural factors, thus, it is essential that culture-specific profiles of healthy family functioning be devised (Hsu et al., 1985). If distinct, culturespecific portrayals of normal family functioning are not developed and validated empirically, normal interactions among family members that are disparate from those observed in the majority culture may be misconstrued as pathological (Hsu et al.). Theories on normal and abnormal family functioning are socially constructed and shaped by the evolving cultural context (Walsh, 1993). Even the value placed on distinguishing between functional (i.e., normal) and dysfunctional family processes varies across cultures. While such a distinction has been of paramount importance in mainstream American culture, the conceptual dichotomy associated with the distinct categories of normal and abnormal is antithetical to the underlying assumptions of human behavior characteristic of many nonwestern societies (Foulks, 1991). Given that definitions of normal behavior vary across cultural groups, and the utility of the construct of normality differs between Western and nonWestern societies, it behoves therapists to refrain from classifying certain family patterns as dysfunctional solely because they deviate from the norms of the dominant culture (Walsh, 1993). Rather, only families who manifest interactional processes discordant with the
Culture and the Family Life Cycle cultural context in which they are embedded and/or are associated with elevated levels of distress or problems establishing relationships with other cultural group members, require intervention (Foulks, 1991; Wamboldt & Reiss, 1991). For example, a person raised in a Southern African-American family affiliated with a Pentecostal Church who believes that their symptoms can be attributed to rootwork (a malevolent form of magic) may not be psychotic, particularly if these beliefs are shared by the family (Hillard, 1982). Although mental health services may be required, the patient and family may benefit from the assistance of a rootdoctor, who can remove a hex from the patient (Hillard, 1982). This example highlights that it is a challenge for therapists both to refrain from falsely ascribing dysfunction to a culturally normative pattern or exaggerating the significance of culture at the cost of failing to identify dysfunctional patterns (Falicov, 1983). 10.08.3 CULTURE AND THE FAMILY LIFE CYCLE To present coherently the wealth of material on cultural characteristics of families across the life span, we organize our discussion using a family life cycle framework (Carter & McGoldrick, 1989), which provides a breadth and depth of insight into family functioning in all stages of development. This rubric is applicable to families from myriad cultures. 10.08.3.1 Family Life Cycle The family life cycle, a circular model of normal family development, identifies key transitional stages of the family. First applied to intact, middle class, mainstream EuroAmerican families, this model divides the life span into six stages reflecting significant events in the lives of family members: unattached young adulthood, young couples, transition to parenthood, families with adolescents, launching, and families in later life (Carter & McGoldrick, 1989). As the composition of family units has evolved, the model has been revised to incorporate additional life cycle stages observed in families who experience divorce, single parenthood, and remarriage (Carter & McGoldrick, 1989). An additional life cycle transition pertinent to immigrant families, and thus relevant to this chapter, is that of migration. Significant intra- and extrafamilial stress are evidenced by many families during family life cycle transitions. Elevated stress levels are associated with disruption in the emotional
processes identified with each stage, as well as with the requisite second-order changes in family status that accompany each family life cycle stage. Thus, families often seek or require mental health services during key transition points. 10.08.3.2 Significance of Family Life Transitions Across Cultures Cultural factors impact families' definitions of the nature, timing, tasks, and rituals of life cycle transitions, as well as the significance the family attaches to each transition (Carter & McGoldrick, 1989). For example, in AmishAmerican families, births are understood as gifts from God and associated with increased standing in the community; thus, births represent a transition of particular importance in the Amish community (Emery, 1996). Births are major events in many other groups, including most Latino cultures. The shift from adolescence to adulthood, marked by the ritual of the Bar or Bar Mitzvah, is the most salient transition in Jewish-American tradition (Davis, 1988). The transition to adulthood is also one of importance in the Amish culture, denoted by the individual's decision to join the church and marriage (Emery, 1996). In many Latino cultures, quinceaneras (at 15, girls are given a party in honor of their coming of age) mark the adolescence to adulthood transition. Depending on the country of origin and the social class, the elaborateness of these festivities and the associated religious ceremonies vary. Marriage is a highly valued family life cycle stage that carries considerable status in many cultural groups (e.g., Italian-American, Puerto Rican, West Indian). Finally, in some cultures, death is the most significant transition. This is the case for Irish-American families who emphasize rituals associated with mourning (e.g., wake). 10.08.3.3 Rituals Denoting Family Transitions Across Cultures Cultures also differ in the rituals used to connote major life events (Carter & McGoldrick, 1989). For example, there are notable differences in the rituals associated with a child's birth. In the Jewish-American tradition, the birth of a son includes a celebration (bris) when the circumcision takes place. In response to the increased value placed upon females in the Jewish culture, baby naming ceremonies and parties have become more common for girls. In the Roman Catholic community, birth is
marked by the baptism. In some Latino Catholic subcultures, baptism is accompanied by parties marking the beginning of a life long relationship among the child, parents, and godparents. Marriage and wedding rituals are strikingly different across ethnic groups. An African tradition, adopted by many African-Americans, is jumping the broom, in which the couple jump together over a broom to mark their union. The broom signifies the beginning of homemaking for the couple. Consistent with ancient Chinese tradition, Chinese-American women may wear red wedding gowns. Red symbolizes prosperity, fertility, and good luck. In addition, before the wedding, the groom and bride give tea to elder family members as a token of appreciation for having been nurtured. Family members bless them with red packets of money that represent support for having a good life. In the Iranian community, the wedding is a spontaneous 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 bride and groom are seated as they take their marriage vows. Family and community behaviors that mark death differ significantly (McGoldrick, Hines, Lee, & Preto, 1986). For example, for IrishAmerican families, funerals are times of drinking and story and joke telling. In the AfricanAmerican community, funerals are marked by a public expression of grief and moving spirituals. The funerals of Puerto Rican families are characterized by crying, screaming, and ataques (i.e., hysterical, convulsive reactions). In Chinese-American families, survivors are expected to cry without inhibition at the wake and funeral. To facilitate the deceased person's transition to the afterlife, and to insure that the next life is a good one, loved ones burn paper money and clothing and present elaborate spreads of food. Other dealth-related rituals that differ across cultural groups relate to the timing of the funeral (e.g., African-American Muslims and Jews bury the dead person quickly, whereas Hindus in America allow many days to elapse between one's death and burial) (McGoldrick et al., 1996) and the preparation of the deceased for the burial (e.g., in the AfricanAmerican Muslim and Orthodox Jewish communities, often the deceased person's corpse is cleansed by individuals of the same sex as the deceased and given a ritual ablution) (McGoldrick et al., 1996). Consistent with the evolving nature of the American family, rituals have been designed to mark transitions in a broader array of family constellations, such as welcoming adopted members, addressing remarriage, supporting
lesbian and gay couples in making public their commitment to one another, and acknowledging divorce (Imber-Black, Roberts, & Whiting, 1988; F.W. Kaslow, 1993; Scrivner & Eldridge, 1995). Although historically, certain cultures (e.g., Orthodox Jews) have had divorce ceremonies for the purpose of freeing each partner to remarry and for acknowledging the legitimate birth of subsequent children, only recently has such a ritual been recommended for individuals across cultures. F. W. Kaslow (1993) presents a framework for conducting a divorce ceremony to help each partner heal from the pain of the termination of a failed union. In this ceremony, each partner affirms the positive aspects of the relationship and acknowledges that the children represent an important product of their union. The children are encouraged to process the impact of the divorce and to articulate expectations regarding future involvements with each parent. 10.08.3.4 Migration: A Life Cycle Transition Unique to Immigrant Families Migration, a unique life cycle transition of immigrant families, reflects a developmental process of family adjustment with impact across multiple generations. The process of the immigrant family's transition to a new culture occurs on a continuum, and includes a number of specific stages: preparatory, active migration, overcompensation, decompensation, and transgenerational phenomena (Sluzki, 1979). Successful immigration is associated with both maintenance of the family's cultural identity and integration into the new culture; both tasks require reorganization of the family unit and the development of complex elaborations of family structure and processes (Bullrich, 1989). Although the migration process varies across cultures and is affected by the family's stage of development, cultural patterns, and the characteristics of the new culture, there are similarities in family patterns associated with the migratory process across cultures (Carter & McGoldrick, 1989; Sluzki, 1979). Many refugee families seek mental health services in response to the stress associated with immigration and acculturation, in addition to the traumas experienced in their country of origin. Typical presenting complaints relate to intergenerational conflicts, marital discord, guilt and anxiety mixed with anger secondary to the tensions experienced between family members and relatives left behind, and conflicts with the sponsor/sponsor organization (McGoldrick et al., 1996). Often, a family assessment reveals that intergenerational difficulties are a
Family Life Cycle Stages: A Cultural Perspective screen for a more fundamental problem, namely a clash between the family's culture of origin and the host culture. In such cases, it is recommended that the therapist reframe the subsystem conflicts as culture conflicts, which ameliorates the fixed subsystem±culture alliances (Szapocznik, Santisteban, Kurtines, Perez-Vidal, & Hervi, 1984). 10.08.4 FAMILY LIFE CYCLE STAGES: A CULTURAL PERSPECTIVE The following sections address cultural influences on each major family life cycle stage. Due to space considerations, only key stages are detailed. (i) The joining of families through marriage: The new couple. (ii) Families with young children. (iii) Families with adolescents. (iv) Launching children, single young adults leaving home and the middle generation moving on. (v) Families in later life. We deviate some from the family life cycle sequence provided by Carter and McGoldrick (1989), since the family life cycle is a circular process that can be conceptualized as begining at any stage. One of our modifications reflects our decision to initiate the family life cycle with the marriage of the young couple, which is the begining of a new family unit. Our second modification is our decision to combine two stages, launching children and moving on (Stage 5 in the Carter and McGoldrick model) with the leaving home: single young adult phase (Stage 1 in the Carter and McGoldrick model) because these processes often occur simultaneously in the younger and middle generations. Although cultural variations in patterns and belief systems across the family life cycle have been delineated, there is a dearth of empirical data on this topic (N. J. Kaslow et al., 1995). Relevant empirical data will be cited when available. 10.08.4.1 The Joining of Families Through Marriage: The New Couple The decision to marry represents a commitment to a new family unit and a marital subsystem. This entails maintaining an intense attachment to someone outside of one's family of origin and renegotiating one's family of origin and peer group relationships. Such renegotiation includes redefining the structure and process of the relationships in order to incorporate a new member, and a change in the family member's identity. Forming a new family (family of creation, family of choice) also requires that the couple make decisions regarding routines and rituals, and customs and traditions.
Historically, in the majority of cultures, the ritual of marriage was the primary marker of the transition to adulthood. The significance and universality of this life cycle stage have shifted with changes in the onset of sexual involvements (earlier), increased incidence of cohabitation among nonmarried partners, increased reliance on nontraditional marital arrangements (e.g., same-sex couples, couples who cohabitate for long periods without having a legal ceremony marking their commitment), greater acceptance of people's choices to remain single or divorce or remarry, and later onset of marriages due to changes in educational and career paths. Also, although many groups prohibit intermarriages, there has been a significant rise in intermarriage rates since the mid-1970s. 10.08.4.1.1 Marriage: a life cycle transition Virtually every cultural group has traditions and rituals associated with one's choice of a partner and the marital process. Between-group differences are noted on such factors as: process of mate selection, age at time of marriage, presence of a formal marital contract, meaning of marriage, marital roles and responsibilities, and expectations regarding monogamy and marital fidelity. In the past, many cultures advocated arranged marriages. In some groups, arranged marriages are still common (Iranians, Greeks). In many Islamic Arab-American families, marriage is a family matter, in which partners are chosen by one's family and not on the basis of romantic love, as is the norm in most Western cultures (McGoldrick et al., 1996). In other communities (Chinese-American), arranged marriages of two young adults residing in their parents' homes used to be the norm. However, cultural shifts have resulted in many more marriages occurring after the adult children leave the family home and form a romantic attachment with a partner (McGoldrick et al., 1996). In terms of age at time of marriage, in some cultures (e.g., Amish) it is expected that individuals marry young (late adolescence or young adulthood), whereas in other cultures (e.g., Jewish), people tend to marry at an older age. Further, sex differences exist within cultures regarding the expected age of marriage. For instance, among Iranian-Americans, females typically marry during adolescence or young adulthood, whereas males tend to be 10±15 years older than their partners (McGoldrick et al., 1982). In addition, the expectations regarding one's financial status often influence the typical age at the time of marriage. As an example, Jamaican males often marry 10 years
after their Euro-American male counterparts, due to the expectation that they be financially secure prior to marriage (Comas-Diaz & Greene, 1994). In the majority of cultural groups, heterosexual couples have a formal legal marital agreement. However, this is not true for couples of all socioeconomic levels in a given cultural group. As an example, formalized marriages are the norm among middle and upper class Haitians, but the equivalent of common-law marriages (i.e., placage) are common among low-income Haitian couples (McGoldrick et al., 1996). In the West Indian culture, although legal marriages are valued, many couples cohabit for lengthy periods of time to test their compatibility and they often procreate during this period (McGoldrick et al., 1982). Among some cultural groups, two types of formal marital contracts are obtained. Many Jews have a Jewish marriage certificate (ketubah) and a state-approved marriage certificate, with separate rituals associated with the receipt of each document. There are myriad ways in which the meaning of the marital bond differs across cultural groups. For some groups, the formation of a marital unit indicates the creation of a new family designed to enable individuals to meet individual needs (e.g., Anglo-American); for others, it marks a continuation of the man's family line (e.g., Asian-American), and for still others it represents an alliance between two extended families (e.g., Nigerian, Puerto Rican) (McGoldrick et al., 1982, 1996). In some communities, getting married is a sign of status. Within the West Indian culture, a man only marries once he is capable of providing his spouse with economic security and material goods (e.g., house). In other cultures, getting married is an expectation and is not associated with status (Anglo-Americans). Finally, in some communities, marriage is conceived of as a symbolic rite of passage into adulthood (e.g., Amish), whereas other nodal events mark the transition from adolescence to adulthood in other communities. With regard to marital roles and responsibilities, significant intercultural variations, often reflecting differences in gender roles, have been noted. In many cultural groups, the traditional marriage is one in which the male is the dominant member who has key roles outside the family system, whereas the women's major role is at home and with the family. Within many Mexican-American families, the ideal of machismo is expected from the husband; that is, the male member of the marital dyad is expected to have considerable sexual experience, and to be brave, pugnacious,
and sheltering of his partner. Normative behavior of married women within MexicanAmerican homes is consistent with submission and humility. However, despite these gender role based social presentations, within the home, the domineering and patriarchal male member of the marital dyad often depends on his female partner for major family-related decisions (Falicov, 1996). In the Puerto Rican community and in many Dutch families, women have the primary responsibility for home and family, whereas men are responsible for protecting and providing for the family (GarciaPreto, 1996). However, among Dutch partners, the husband often solicits his wife's input on business, career, and family financial matters. A reverse pattern of gender roles in marriage is observed among many Hungarian families (Smith, 1996). Hungarian women often are powerful in politics, business, and community affairs, yet have a clearly delineated role in the family typically confined to childrearing decisions and domestic tasks. In these families, the husband has ultimate power regarding domestic decisions. Among Amish-Americans, marriage is viewed as a practical matter and thus partners are expected to cooperate and be respectful of one another, but there is no expectation of romantic love or physical affection (Emery, 1996). There are also within-culture variations regarding marital roles that often reflect the era of one's birth. As an example, JapaneseAmerican couples in which both partners were born prior to 1935 tend to exhibit traditional, patriarchal, and hierarchical family structures in which the overt expression of affection and love is minimal, whereas couples with members born subsequent to 1935 more often assume an egalitarian relationship in which physical displays of affection are normative. Although these younger couples appear to have marriages more similar to that observed in many Euro-American families, they typically retain their cultural heritage by continuing to hold traditional Japanese attitudes, values, and beliefs (Matsui, 1996). Similar generational differences are exhibited among other cultural groups (e.g., Korean-Americans). Fidelity is a value shared by members of virtually all cultural groups. However, the consequences of infidelity differ significantly. Among West Indians, adultery is an acceptable reason to divorce. In Vietnamese families, divorce is only an option if adultery is committed by the women. Although polygamy is illegal in America and thus is illegal for Vietnamese individuals residing in the US, the practice of men having female sexual partners in addition to their wives is somewhat acceptable
Family Life Cycle Stages: A Cultural Perspective and overlooked by the wife if her position in her extended family is secure and her children receive adequate provisions (McGoldrick et al., 1996). In the Jamaican community, although monogamy is supported, many Jamaican men maintain a mistress and their mutual children in a separate household (practice of ªtwin householdsº) (Comas-Diaz & Greene, 1994). 10.08.4.1.2 Intermarriage More than 50 % of people in the US marry someone who is not a member of the same cultural group and 33 million adults reside in homes in which at least one other adult has a different religious background (Mayer & Kosmin, 1994). In 1990, 1.5 million children lived in families in which one caregiver was Caucasian American and another caregiver was of African, Asian, or Native American descent. The rates of African-American±Caucasian marriages have tripled since the mid-1960s, even though the actual numbers of such marriages remain relatively low (Wright, 1995). Within the Asian-American community, inter-racial marriages constitute 10±15 % of marriages, with such marital unions being most common among Japanese-Americans and least evidenced by Korean-Americans (Karnow & Yoshihara, 1992). The increasing rates of intimate partnerships between individuals of different ethnic, religious, and racial backgrounds suggest that American society is becoming more tolerant of differences. However, couples from intercultural marriages often need therapy to address their cultural differences. Inter-racial marriage complicates the successful negotiation of this family life cycle phase. Conflicts regarding values, religious beliefs and practices, communication styles, childrearing, and relations with in-laws are common (McGoldrick et al., 1996). The more salient the cultural differences between the partners, the more difficulty they are likely to experience in accommodating to married life (McGoldrick et al., 1996). It has been hypothesized that ethnic intermarriages reflect an effort on the part of each partner to redefine the most important ethnic characteristics and to abandon those ethnic traits that are valued least (McGoldrick et al., 1996). 10.08.4.2 Becoming Parents: Families with Young Children Within the Euroamerican culture, the transition to this life cycle stage requires that the new parents develop a primary identity as caretakers for the next generation. Typical issues addressed are associated with childbearing, childrearing,
and parenting (Carter & McGoldrick, 1989). Young children in families form attachments, develop increased competencies, and begin to develop a sense of self and an ethnic identity. This section reviews the major tasks for the adults associated with this family life cycle phase, including childbirth and childrearing. Then, attention is paid to issues focal in the child's development: attachment, developing a personal identity, developing an ethnic identity, and learning effective coping strategies. 10.08.4.2.1 Childbirth Variations are noted in birth practices across cultures. In the US, the birth process has been considered a medical event, one that usually occurs in the hospital. With the influence of other cultures on American customs, more American families choose naturalistic approaches (e.g., home births, midwives, involvement of multiple family members) (McGoldrick et al., 1996). 10.08.4.2.2 Childrearing Cultural differences in childrearing, parenting styles, and socialization practices are significant and often reflect the conditions (e.g., economics, work demands) and values (e.g., independence vs. dependence) of the culture in which they are formed (Matsumoto, 1994). For example, Mexican-American and Puerto Rican parents value family closeness and thus often socialize their children to be obedient and respectful and to prefer familial support over self-reliance (e.g., Zayas & Solari, 1994). As another example, Caucasian American mothers are more likely than African-American or Haitian mothers to use modeling and reassurance to help their children cope with fearful situations; Haitian mothers are more likely than either Caucasian American or African-American mothers to use force when their children confront anxiety-producing stimuli (Reyes, Routh, Jean-Gilles, Sanfilippo, & Fawcett, 1991). These differential parenting patterns could be construed as mothers using parenting styles that encourage adaptive survival in their home country. The structure of the family affects childrearing and caregiving practices. In Euroamerican culture, the primary responsibility for childrearing has been the purview of the mother, and more recently the parental dyad, while in many non-Anglo-American cultures, children have been raised by extended family members (e.g., grandparents, aunts, and uncles) older siblings, nannies, wet nurses, or in group settings (e.g., kibbutz) (Matsumoto, 1994; McGoldrick et al., 1996). For example, African-
American children living in poverty are often raised in multigenerational families in which maternal grandmothers are the primary caregivers. Frequently, these grandmothers coreside with their daughter and her children, often with no adult male in the home (Harrison, Wilson, Pine, Chan, & Buriel, 1990). Although this family constellation differs from what has been considered the typical American family (i.e., heterosexual, married parents, who coreside with their biological children), it is often associated with healthy African-American child and family development (Canino & Spurlock, 1994; Wilson, 1989). In addition, a significant percentage of minority single-parent families are successful (Lindblad-Goldberg, 1989). As another example, in a number of cultures (e.g., Latino, Filipino), godparents serve as important models for young children and as sources of support for the young child's parents (Matsumoto, 1994). Although the composition of the extended family varies across groups, extended family networks are all characterized by a sharing of resources, emotional support, and caregiving responsibilities (Matsumoto, 1994). In addition to cross-cultural differences in the identity of the primary caretaker(s), there are variations between cultures in terms of how caretaking occurs and the values communicated to young children within the family. These variations reflect differences in both beliefs regarding childrearing and in standards of living (e.g., family economic status, country of origin). In many Western European cultures, teaching some independence early is emphasized. Toddlers are raised in their own rooms, some crying is tolerated so the child learns not to cry manipulatively, strong verbal feedback during childhood is accepted, and the reward± punishment system emphasizes the gain or loss of possessions or privileges (Matsumoto, 1994). In many other cultures (e.g., Asian-American, African-American, Native-American) communicating a value on dependence and interdependence is emphasized (Matsumoto, 1994). For some, the young child may sleep in the parents' bed for several years and may be breast fed until age three or four. Often in cultures in which dependence and interdependence are emphasized, crying is not tolerated and thus may result in positive (e.g., picking up, cuddling) or negative (e.g., spanking) attention, disrespect in the form of talking back to elders (parental figures) is unacceptable, and the reward±punishment system frequently means the presence or absence of corporal consequences (e.g., Greek-American, Puerto Rican). These differential rearing and parenting practices prepare youth to live in the cultural context in which they are embedded.
10.08.4.2.3 Attachment Cultural values in childrearing practices impact upon the nature and perception of the parent±child attachment bond. While many attachment behaviors are found across cultures, the selection, shaping, and interpretation of these attachment behaviors are culturally determined (IJzendoorn, 1990). Empirical investigations reveal frequency differences of the major forms of attachment (anxious avoidant, anxious resistant, securely attached, disorganized/disoriented) between and within cultures (across regional and socioeconomic groups) (Bretherton & Waters, 1985; IJzendoorn, 1990). These data underscore the importance of ascertaining the contextual meanings of attachment behavior, as well as whether or not attachment patterns are differentially adaptive across cultures (Harwood, Miller, & Irizarry, 1995). Studies examining attachment behavior in Anglo vs. Puerto Rican mother±infant dyads indicate that Anglo-American mothers value child qualities associated with individualism (e.g., autonomy, self-control, activity), whereas Puerto Rican mothers prefer child factors consistent with interpersonal relatedness (e.g., affection, dignity, respectfulness, responsiveness to others, proximity seeking) (Harwood, 1992; Harwood & Miller, 1991). These preferences mirror the differences in values within the two cultures as individuation is promoted in Anglo-American culture, whereas relatedness is considered optimal in Puerto Rican culture. Despite these differences in valued child characteristics, both Anglo-American and Puerto Rican mothers rate the securely attached child as more positive than the insecurely attached child. However, the basis for this preference differs between the two groups of women. Anglo mothers note the confidence and independence of the securely attached child; Puerto Rican mothers find the child's demeanor, obedience, and relatedness most appealing (Harwood & Miller, 1991). 10.08.4.2.4 Developing a personal identity The challenge for young children is learning, through interactions with key attachment figures, the adaptive patterns of their social group (Canino & Spurlock, 1994). Early in life, a child begins negotiating different affiliation styles, communication strategies, coping patterns, and family hierarchy and approaches to discipline. As the young children struggle with these issues and conflicts, they begin to form a personal identity. The development of a personal identity is complicated when the child has to adapt to
Family Life Cycle Stages: A Cultural Perspective various, changing, and/or conflicting social rules and expectations. This is particularly true when the child must meet the demands of different cultures or adapt to a culture in rapid transition. Understandably, the child may have difficulty finding that adaptive skills in one culture may be a liability in another. For example, the openness valued in the Euro-American culture may be shamed in the Asian-American family context, and the gender-associated aggresiveness praised in the Latino culture may be punished in the Euroamerican culture. Many first-generation immigrant children become confused and overwhelmed by the need for their family to adapt to the dominant cultural demands. They may feel rejected by their peer group when their family engages in behaviors consistent with their culture of origin (e.g., afternoon siesta) and rejected by their family if they fail to conform with culturally normative rituals. In addition, these children often receive contradictory messages from their family as the family tries to meet the demands of the American culture (e.g., forego the afternoon siesta).
10.08.4.2.5 Developing an ethnic identity As part of a personal identity, each child develops an ethnic identity, that is, a sense of belonging to an ethnic group with shared values, attitudes, language, behavior, perceptions, and social interaction patterns (Phinney, 1990a). The relevance of ethnic identity and awareness of this aspect of a person's identity are particularly important when children realize that their personal ethnic or cultural identity differs from the culture in power (Erikson, 1958). Therefore, being a ªminorityº or a member of a nondominant culture automatically predisposes a child to different identity development contingencies. For example, the dark, slanted eyes common in Asian-American children are not dark or slanted (they are normal) when everyone else's eyes are that way; but when a child realizes that beautiful and normal equals bluer and rounded eyes, that child has to deal with different identity-related issues than blue, round-eyed children. How this difference impacts identity is significant, and the family's role in helping the child develop a positive identity is crucial. Accepting differences in personal characteristics is a developmental process. Children proceed from wanting to be something other than who they are (pre-encounter phase) to only wanting to be with and trusting others who are like themself (encounter and immersion± emersion stages), to accepting and appreciating variety (internalization stage) (Parham &
Helms, 1981). This is a challenging task, especially when the socialization process (adult guided) is not clear on such issues. Older siblings and caretakers must model for younger children the internalization phase and help them negotiate earlier phases to facilitate their attainment of a more mature ethnic identity. The best known empirical studies on ethnic identity in youth focus on minority children's preference for stimuli associated with Caucasian culture (e.g., white dolls) vs. their own culture (e.g., Banks, 1976; Clark & Clark, 1940). These findings initially were interpreted as indicating low self-esteem and a preference for the dominant culture vs. one's own culture. Many researchers criticized these early studies on methodological grounds (Banks, 1976). Also, the findings are dated and with the increased Afrocentric pride evidenced in most African-American families (Mahon, 1976) and the greater availability of black dolls in stores, African-American children are more likely to prefer black dolls. The other well-researched 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 one's ethnicity indicates a negative self-concept, and thus may merit attention. Much of ethnic identity is developed in the communication style in which the child is surrounded. For example, in many AfricanAmerican social groups, the meaning of a message may be more in how (rhythm, tonal range) something is said than what is said. Part of the identity of the Italian language is the use of hand motions which are absent in Asian cultures. For certain African groups, much of the meaning of a message is in the nonword sounds that accompany the language, whereas for some Native Americans certain sounds are their words. Cultures take possession of their unique ways of communication and generally are intolerant of deviations. In each culture, there are idiosyncratic words, phrases, grammar patterns, accents, and nonverbal behaviors that are understood by group members. For example, Jewish phrases help identify one's Jewishness. Children learn these language patterns and are reinforced for using these words in their family and with their Jewish peers, but may be teased if they incorporate these phrases into their communication with their non-Jewish peers. Black children sounding White to sound intellectual in the school environment may be perceived as rejecting their cultural communication identity, which could result in them having to deal with derogatory perceptions and comments from peers and
family members. Cultural communication is also developed in musical types and unique sounds are associated with each culture. Learning these patterns of communication is a crucial aspect of children developing their ethnic identity. Communication conflicts occur when one group defines the ªrightº way to speak and views certain cultural subtypes as ªwrongº or inferior. Children struggle with their language identity when they learn different rules at school and at home. For some immigrant families, attempting to fit in with the major culture's language style has been critical and, as a result, their native language or dialects are not taught to their children. As an example, many Japanese families who were in internment camps during World War II discourage the use of Japanese by their children and grandchildren. This is in an effort to reduce their own pain and to be more ªAmerican,º but may also function to hinder the development of a positive ethnic identity as a Japanese-American in their children or grandchildren (Vargas & Koss-Chiono, 1992). Issues around appearance are another domain of ethnic socialization often associated with parent±child tensions. The young female whose family is from East India who wants to cut her hair in a stylish fashion (rather than never to cut it as is the cultural custom) like her friends poses issues for herself (identity formation), and is likely to meet with resistance from her parents who may feel distressed that their ability to control her ethnic identity is threatened. The Native American boy who only wants to perform the ªinº (i.e., Macarena) is engaging in behavior that is likely to conflict with the traditional cultural patterns being enforced at home. What could be interpreted as ªrebelliousº may more appropriately be framed as the child's efforts to fit in. Children must learn the subtleties of how to act appropriately within each unique cultural context. Much of this learning is acquired through parental modeling. Mothers and fathers struggling to negotiate their cultural practices in an environment intolerant of certain customs (corporal punishment is encouraged in some cultures, but is illegal in America) often send confusing messages to their children. This learning process is complicated further by possible cultural clashes at school, where appropriate behavior, modeled and reinforced by teachers and students, can be drastically different from the home environment (e.g., asking questions and challenging authority may be the norm in school, whereas deference to authority is expected in Asian-American families).
10.08.4.2.6 Developing effective coping strategies A major challenge of childhood is developing a coping style for handling the obstacles further developmental stages present. If the child looks or sounds different from the majority of Americans, strategies must be formed for coping with being a minority and facing discrimination. Effective use of such tactics enables the child to establish a healthy self-view and a respect for others. While myriad coping strategies are potentially efficacious, it is the child's capacity to use a range of tactics flexibly that determines the overall coping ability. It is helpful to the child if these strategies are taught by elders. For example, African-American children can learn to cope with racism if their caretakers share African cultural values and practices and instil in them a sense of pride in their racial background (Vargas & KossChioino, 1992). When developing strategies for handling discrimination, it is often a challenge for children to find an approach that is respected in their own culture and the dominant culture. Withdrawing from or attacking the majority culture may be praised by one's own culture, but may result in rejection from the majority culture. Thus, this approach is inconsistent with developing bicultural competence. The child must also form strategies for negotiating differences between the family's culture and the majority culture. Applying traditions associated with the environmental, social, or economic demands of a non-American country may have limited applicability to successful matriculation the US. One common coping strategy for maintaining important elements from one's culture of origin, while accommodating to one's culture of choice, is culture blending. This involves the Americanization of traditional practices, thoughts, and perceptions. Culture blending is noted throughout the US, including among the Creole population in New Orleans (French and American) and the Gullah population on the coast of South Carolina and Georgia (African and American). Culture blending is often manifested in the use of amalgamated language forms, such as Patwah (Caribbean dialect and English), Gullah (African dialect and English), and Spanglish (Spanish and English). 10.08.4.3 Families of Adolescents The transition to this stage in the family life cycle often brings marked changes in the roles that adults and children take in the family. In Euroamerican culture, this stage is marked by
Family Life Cycle Stages: A Cultural Perspective the establishment of boundaries between adolescents and younger children, as well as parents relinquishing complete authority over the adolescent (Carter & McGoldrick, 1989). In addition, the married couple begin to address midlife marital and career issues and start to care for the older generation. This section focuses on cultural differences in negotiating the major issues of adolescence, separation-individuation, ethnic identity development, achievement, and dating and sexuality. 10.08.4.3.1 Separation-individuation Families who experience problems in this stage often have difficulty negotiating flexible boundaries in which the adolescent is encouraged to be both independent and dependent. The shift in parenting patterns from childhood to adolescence is often problematic. As an example, some Irish-American families move from a structured, controlling parenting style in childhood to a permissive, laissez-faire style in adolescence, a shift often associated with increased behavior problems in the teenager (Carter & McGoldrick, 1989). Parents may be confused about how much autonomy is appropriate and norms on the balance between dependence and independence vary across cultural groups. In Arab-American families, adolescents are not expected to challenge parental authority, to engage in behaviors that conflict with parental expectations, or to place individual concerns over family interests (Timimi, 1995). Those Arab-American adolescents who rebel to attain increased autonomy are engaging in culturally unacceptable behavior and are likely to meet with intense parental resistance (Timimi, 1995). In a related vein, whereas Euroamerican families believe that healthy development in adolescence is associated with the young people's capacity to both love and leave their parents, in Japanese American families, the value is on family cohesion and support; leaving home is not viewed as an important aspect of adolescent development (McGoldrick et al., 1996). In the most cultures, adolescent males are afforded more latitude to exert independence than their female counterparts, who often experience rigid and restricted rules. For example, an Italian-American family presents for help because their 16-year old daughter is ªdisrespectful, rejecting, and unappreciative.º They report that she asserts her plan to stay out after midnight following her prom, intends to apply to and attend an out-of-state college, and prefers to buy her own clothes rather than wear clothes made by her mother. The 16-year-old claims her parents are old-fashioned and
controlling. If the therapist holds the dominant value orientation, valuing autonomy more than responsibility to a collectivity (Papajohn & Spiegel, 1975), the cultural basis of the conflict, may not be acknowledged. As a result, the therapist will have problems supporting the family's negotiation of a mutually acceptable solution. During this family life cycle stage, adolescents often fight to spend more time away from the family as peer relations become paramount. Similarly, as adolescents seek to fine tune their personal identity, they will often bring friends home who may expose the family to new values and ideas. While including nonblood relatives is welcomed in some cultures (e.g., Irish-Americans) it may be frowned upon as an intrusion in other cultures (e.g., Italian-Americans). 10.08.4.3.2 Ethnic identity development Given the centrality of identity development concerns during adolescence, ethnic identity is of great importance during this developmental stage (Phinney, 1990a). Whereas the primary question for young children regarding ethnic identity relates to the accuracy of self-definition, during adolescence the major issues relate to the labels one chooses to use to define oneself, the degree to which one examines one's ethnic identity, and the degree and nature of group identification (Phinney, 1990a). In terms of labels, do adolescents whose parents migrated from Cuba refer to themselves as Cuban, Cuban-American, Hispanic, or Latino? Do adolescents whose parents grew up in Poland and moved to the US prior to their birth refer to themselves as Polish-American or simply American? Such decisions are complex for an adolescent, particularly if the parents are of different heritages, as parental heritage may not be consistent with the adolescent's ethnic selfidentification (Phinney, 1990a). Further, each ethnic label has a different connotation regarding the adolescent's ethnic identity and group identification. Research reveals that adolescents with a welldefined ethnic identity manifest more positive psychological adjustment than their counterparts with limited ethnic self-identification. In a group of African-American, Asian-American, and Mexican-American high school students, those who revealed more mature stages of ethnic identity during an interview had higher selfesteem, a greater sense of mastery, and more positive relationships than their peers who endorsed lower levels of ethnic identity (Phinney, 1989). The degree and nature of group identification can often be inferred from the degree to which
individual adolescents manifest positive vs. negative attitudes toward their ethnic group, and their involvement in the social activities and cultural practices of their ethnic group. The adolescent's involvement in such activities is evident via language choice, friends' ethnic background, religious practices, and participation in structured ethnic social groups (Phinney, 1990a). It is interesting to note that there are sex differences in adolescents' ethnic group identification; research suggests that females are more involved with their ethnic heritage and manifest more mature levels of ethnic identity than males (Phinney, 1990a; Plummer, 1995). One important aspect of personal and ethnic identity is the expression of gender role, which is influenced by cultural factors. For Latino males, becoming a man often involves learning to physically fight, and taking a dominant role with females. These behaviors could be considered chauvinistic and threatening to those from a Euro-American culture that takes a more egalitarian view regarding gender differences. Traditional Chicano ways by a Mexican-American adolescent male toward a White girl could be interpreted as rude or discriminatory and result in a very negative social interaction, despite the fact that the behaviors reflect cultural differences in communication between the sexes. 10.08.4.3.3 Achievement The arenas in which achievement is valued differ across cultural groups (Gibbs & Huang, 1989). Native American youth may become estranged from their community if they receive recognition for their academic successes, particularly if they choose education over tribal activities. For many Asian-American families, strong academic success is the focus of the family and the source of praise and attention. Excellence in sports, for example, is less valued among many Asian-American families compared to African-American families. One aspect of achievement that has received considerable attention is academic achievement. A burgeoning body of research underscores ethnic differences in school performance among children and adolescents (Slaughter-Defoe, Nakagawa, Takanishi, & Johnson, 1990; Steinberg, Dornbusch, & Brown, 1992). Data indicate that African-American and Latino youth perform more poorly in academic settings than their Caucasian counterparts in terms of grades obtained and amount of education completed (e.g., Mickelson, 1990). Conversely, there is evidence that the academic performance of Asian-American students surpasses that of their Caucasian, African-American, and Latino
peers (Sue & Okazaki, 1990). Environmental factors proposed to explain the impact of culture on adolescents' school performance focus on parenting practices, familial values regarding education, and beliefs communicated within the family regarding the benefits of education. The data on each of these variables are complex and do not provide a clear picture (Steinberg et al., 1992). Evidence suggests, however, that although the authoritarian parenting patterns often found in Asian-American families may not be optimal for superior academic performance, these parenting styles are typically counterbalanced by high levels of peer support for superior academic performance. Caucasian adolescents tend to have optimal academic performance when their parents use an authoritative parenting style and they receive support from their peer group regarding academic achievement. In addition, difficulties in academic success among both African-American and Latino youth may be attributed to low levels of peer support for academic excellence. This low level of peer support is often accompanied by authoritarian parenting practices in the homes of Latino youth, a combination of factors that often interferes with academic success. These data underscore the importance of focusing on cultural values and expectations, as well as family and peer relations, in assessing academic difficulties and devising intervention programs. The development and implementation of such preventive intervention programs must be sensitive to the child's economic conditions. 10.08.4.3.4 Dating and sexuality Another important task of adolescence is managing dating and sexuality. The major issues that differ across cultures regarding dating relate to the presence of a chaperon and who chooses who the adolescent will date (and ultimately marry). The tradition in many Cuban-American families continues in which chaperons accompany the dating couple (McGoldrick et al., 1982). The chaperon's presence may be a major source of parent± adolescent conflict for adolescents who are more acculturated than their parents. The custom of parental mate selection persists in a number of cultures outside the US. Families from some of these cultures continue this practice upon immigrating to America (e.g., Arab-Americans, East Indians). Again, this practice may cause disagreement between acculturated adolescents and their families. A major issue among many cultural groups relates to parental and extended family concerns regarding the adolescent's decision to date
Family Life Cycle Stages: A Cultural Perspective someone outside the family's culture, race, or religion. Interethnic, interracial, and interfaith dating on the part of the adolescent is often a controversial family matter. Many immigrant populations (e.g., Portuguese, Amish) have strong beliefs that sex is reserved for marriage. However, other cultural groups are permissive of sexual experiences prior to marriage. Italian-American families often encourage and expect their adolescent sons (not daughters) to become sexually proficient as a sign of masculinity and mastery of interpersonal relations. Given that premarital sex is the norm in present day American culture, it is common for a family whose heritage views premarital sex as unacceptable and deserving of punishment to seek mental health services for the adolescent engaged in sexual relations. With this presenting problem, a family intervention rather than individual therapy for the adolescent is warranted. The goal of the family intervention is to help all members address the conflicting norms and understand one another's behavior and attitudes within the larger sociocultural context. In families such as Chinese-American families in which sexuality is a taboo subject, the therapist must form a strong working alliance with the family prior to addressing issues of sexuality (Gibbs & Huang, 1989). One possible consequence of sexual behavior is pregnancy. The rates of pregnancy and teenage parenthood differ significantly across cultural groups. For example, adolescent childbearing and parenthood are more likely to occur in low-income African-American samples than in demographically matched Caucasian samples or middle-income African-American groups (Franklin, 1987). Also, the rates of teenage pregnancy in the US are increasing, most notably among African-Americans and Latinas (Jacobs, 1994). Multiple psychosocial factors have been proposed to explain differential pregnancy rates among adolescents from different ethnic groups. It has been suggested that African-American teenagers from low-income or single-parent homes become more active sexually than their Caucasian peers and at a younger age. Their increased exposure to sexual behavior in the overcrowded environments in which they reside, the greater level of peer socialization associated with an enhanced awareness of sexuality at an early age, and the higher levels of involvement in adult responsibilities including sexual roles are hypothesized as factors to explain this discrepancy (Staples & Johnson, 1993). In addition to higher rates of sexual activity, low-income AfricanAmerican adolescents are less likely than their demographically matched Caucasian peers to
use contraception or to get abortions (Franklin, 1987). Further, there is increased tolerance of teenage pregnancy in many low-income African-American families and communities and such a pattern has a long history (BoydFranklin, 1989). In addition, extended family members are more likely to assist in raising children of teen mothers in the AfricanAmerican community than in the Caucasian community (Boyd-Franklin, 1989). 10.08.4.4 Launching Children, Single Young Adults Leaving Home, and the Middle Generation Moving On We have modified Carter and McGoldrick's (1989) family life cycle stages by combining the ªLaunching Children and Moving Onº and the ªLeaving Home: Single Young Adultsº phases; these typically occur simultaneously in the family's life. This family life cycle stage for EuroAmericans refers to family functioning once children become of age and begin to leave the home. For the middle generation, the major tasks of this transition are the negotiation and acceptance of adult children leaving the family unit and welcoming their partners and children into the extended family system (Carter & McGoldrick, 1989). The launching of adult children facilitates restructuring of the parent subsystem back to the marital dyad. In addition, it is likely that the couple will have to endure the disability and death of their parents. Families at this stage often present for therapy when parents, particularly mothers who worked as homemakers, experience depression and the ªempty nest syndromeº at the loss of the family unit as defined since the mid-1970s. The couple's role as parents is no longer paramount and, as such, they may experience difficulties finding meaningful new life activities. This period may be the first time the couple has lived alone since their early marriage, and thus, they may need to become reacquainted as husband and wife. This may be a period of reinvestment in the relationship or a time when the couple move toward dissolving the marriage. For those who renew their marital commitment, this phase of the family life cycle often brings greater financial freedom, allowing the couple to engage in activities that may have been postponed earlier in the relationship (e.g., vacations, new careers, relocation). For the younger generation of young adults from Euroamerican backgrounds, during the leaving home phase, the major emotional tasks are that of accepting responsibility (emotional, financial) for themselves, differentiating as an adult from their family of origin, developing
intimate relationships, and gaining increased academic and/or occupational self-definition (Carter & McGoldrick, 1989). The individuation characteristic of this phase of development entails clear articulation of personal and ethnic identities (Phinney, 1990a). 10.08.4.4.1 Cultural values and norms on launching There is a continuum of normative launching behavior across cultural groups, ranging from no expectation of launching to a high degree of expectation regarding launching at an early age and to a significant extent (Carter & McGoldrick, 1989). For example, in many ItalianAmerican families, older adolescent and young adult children are not launched but are expected to remain in the family home or neighborhood, and the family integrates their partners and children into the family. In these families, interdependence is valued and autonomy strivings are experienced as disloyalty to the family unit. In some cultural groups (Iranian-American), the middle generation consider their adult children, even those who are married with offspring, to be children (McGoldrick et al., 1996). Further, in many refugee families, especially those who were traumatized in their homeland (e.g., Cambodian), the launching phase of the family cycle is threatening. The middle generation feels isolated and abandoned when the younger generation attempts to separate, particularly if their extended kin and social support network have remained in their homeland (McGoldrick et al., 1996). Conversely, in many White Anglo Saxon Protestant families, value is placed on launching older adolescents and young adults and in their assuming significant independence. In such families, an 18-year-olds' inability or unwillingness to leave the family home and function with limited family support is perceived as pathological. Many cultural groups fall in the middle of this continuum, although the specific characteristics of this middle group vary. As an example, many Jewish-American families give mixed messages about separation during this family life cycle phase. Increased autonomy and success is valued highly on the one hand, but high levels of contact and intimate sharing continue to be expected on the other. These conflictual messages are often associated with guilty distancing or ambivalent closeness (Carter & McGoldrick, 1989). 10.08.4.4.2 Leaving home: single young adults For single young adults, this stage of development includes continued separation± individuation, self-definition, and definition of
ethnic identity, processes begun earlier in life. The recently ªlaunchedº young adults must grapple with the degree and nature of contact with their family of origin. Young adults from certain ethnic backgrounds (e.g., Jewish, Greek) maintain frequent contact (telephone, letters, email, visits) with their family of origin, yet attain a significant degree of autonomy to pursue success in their chosen endeavors. When they fail to attain such success, increased family involvement occurs (Carter & McGoldrick, 1989). Conversely, young adults from ethnic backgrounds that value independence beginning in older adolescence or young adulthood (White Anglo Saxon Protestants, Germans, Scandinavians) may be rejected by their family of origin if they cannot function autonomously due to personal limitations (e.g., disabilities) or need for continued financial support to pursue life goals (e.g., advanced training and education) (Carter & McGoldrick, 1989). Young adults often need to find a way to negotiate their personal desires for autonomy, their family's and culture's expectations about independent functioning, and the majority population's values on age-appropriate adult behavior. This negotiation is quite complex for young adults who leave their ethnic community and engage actively in mainstream culture. Young adults' ethnic involvement during this phase is manifested in their choice of friends and partners, religious practices, structured ethnic social groups, political ideology and activity, area of residence, and career path (Phinney, 1990a). Studies examining ethnic identity among college students fail to yield consistent results regarding the association between positive or negative feelings about individual's ethnic identity, self-esteem, and psychological adjustment (Phinney, 1990a). However, research on the stage model of ethnic identity reveals an association between college students' achieved level of ethnic identity and self-esteem (Parham & Helms, 1985a, 1985b; Phinney & Alipuria, 1990). This relation is particularly evident in African-American, Asian-American, and Mexican-American young adults, and less obvious in Caucasian American college students (Phinney & Alipuria, 1990). Data also indicate that college students' stage of ethnic or racial identity is associated with their preferences regarding the race or ethnicity of their therapist (Parham & Helms, 1981). Specifically, older African-American adolescents and young adults who endorse early stages of racial identity (i.e., pre-encounter) often prefer Caucasian therapists and are nonaccepting of AfricanAmerican counselors, whereas African-American adolescents and young adults who exhibit higher levels of racial identity (i.e., encounter,
Family Life Cycle Stages: A Cultural Perspective immersion±emersion, internalization) manifest varying degrees of both preference for samerace therapists and lack of interest in working with Caucasian counselors (Parham & Helms, 1981). These data suggest an association between identity formation and self-esteem; the more young adults accept their ethnicity, the more positive they feel about themselves. These data also underscore the need to consider the young adults' level of ethnic identity in making decisions regarding therapist assignments. A major foci of the young adults' development relates to their choice of friends and intimate partners, and decisions about whether to be involved in a relationship or remain single. Once older adolescents and young adults leave the family home, they often feel an increased sense of personal choice regarding the ethnicity of their friends and partners and their sexual orientation. While this may be a relief for young adults, it often forces them to become more clear about their preferences and values regarding interpersonal relationships as distinct from those held by the family. Should young adults choose to engage in relationships not acceptable to their family's cultural norms and expectations (e.g., interracial, interfaith, or interethnic dating; same-sex relationships), the risk of being ostracized or criticized by the family of origin may be considerable and certainly depends to some extent on the family's ethnic heritage. For instance, since the African-American family often buffers its members from racism, these families are unlikely to reject a lesbian young adult family member, despite the fact that a lesbian life style may be considered unacceptable (Comas-Diaz & Greene, 1994). This stance does not imply acceptance of the young adult's sexual orientation but rather reflects tolerance and a desire to protect the young person from additional discrimination. This stance of tolerance, however, is often relinquished should the lesbian young adult openly define herself as a lesbian (Comas-Diaz & Greene, 1994). In the Native American community, young adult women who choose a lesbian life style are most often accepted in the lesbian community within the mainstream culture and rejected by their family and community on the reservation (Comas-Diaz & Greene, 1994). As a result, these young women often experience a loss of support if they explore a nontraditional sexual orientation. 10.08.4.4.3 Conflicts experienced by the middle generation Realignment of the marital subsystem in response to the launching of young adult children and the manner in which marital dyads
deal with the illness and death of their parents are influenced by the middle generation's culture of origin. Sex roles, an aspect of one's culture of origin, impact the negotiation of these family life cycle tasks (Carter & McGoldrick, 1989). For families whose cultural traditions emphasize the primacy of the woman's role as mother and wife (e.g., Italian-American, Puerto Rican), the launching phase may be associated with a crisis in the marriage if the woman becomes involved in activities outside the home. Conversely, in communities in which the woman's role outside the home is valued or accepted (e.g., Irish-American, African-American, White Anglo Saxon Protestant), the likelihood of this type of marital crisis at this stage is minimal. This is particularly true for those cultural groups in which limited emphasis is placed on intimacy within the marital dyad (e.g., Irish-American) or in which parent±child connectedness is valued more highly than the husband±wife bond (e.g., Mexican-Americans) (McGoldrick et al., 1996). 10.08.4.4.4 Dealing with parental illness and death There are differences among ethnic groups about the responsibility the middle generation experiences regarding caring for their aging and dying parents (Carter & McGoldrick, 1989). In some ethnic groups (e.g., Greeks, Italians, Chinese, African-Americans), the middle generation expects to be the primary caretakers for their elderly parents and placing a loved one in a nursing home is rarely considered an option. Among certain groups (e.g., Germans, Scandinavians, Jews), the decision to place an elderly parent in a nursing home is commonly accepted. For some of these families, it is considered essential to provide aging parents with a familiar cultural environment (e.g., Jewish nursing home) in which familiar ethnic rituals and customs are practiced. 10.08.4.5 Families in Later Life The elderly face many pressing challenges in the US, and as such the role of culture has often been overlooked by clinicians, researchers, and, at times, the elderly. As individuals get older, there is a greater emphasis on changing roles in the intergenerational family, the ªculture of poverty,º age discrimination, victimization, retirement, meaningfulness of life, health and vitality, loss of significant relationships and death of loved ones, and preparation for their own death. Such issues entail life review and integration. Families with elderly loved ones generally function best when
they acknowledge and experience the wisdom of the elderly and support the older generation without overfunctioning for them (Carter & McGoldrick, 1989). The multitude of issues experienced by the elderly and their family often obscure the importance of culture in this period. This section begins by defining the term elderly. This is followed by a review of issues confronting the elderly, with specific attention paid to the immigrant elderly. Then, ethnic identity in the elderly is examined. It should be noted that cultural information regarding the elderly is minimal and the data are limited to a few subcultures (American Psychiatric Association, 1994a). 10.08.4.5.1 Definition of the elderly In general, old is defined as 65±84, whereas old-old refers to age 85 and above. However, in some groups, being elderly starts at 55. In the US, some benefits associated with age begin at 55, others begin at 65 or 70. These numbers have changed over the years, partially due to the fact that the average life span has increased. The onset of old age varies among cultures, in part because individuals of various cultures die at different ages (American Psychiatric Association, 1994a). The definition of old age is complicated further by the within-group variability in typical age of death. For instance, African-Americans tend to die younger than Euro-Americans. However, African-American individuals who survive past 75 have a longer life expectancy than Caucasian persons of the same age (Baker, 1994). Differences in life expectancies and health status raise questions about when a family and cultural group views an older loved one as elderly. 10.08.4.5.2 Issues confronting the elderly The elderly confront myriad issues during the stage referred to as ªFamilies in Later Life.º First, non-Euro-American elderly individuals often experience discrimination, based on their age and cultural background. Latino elders often are the object of prejudice because of their Spanish surnames and inability to speak English (Jimenez & de Figueiredo, 1994). Due to their limited command of English, combined with the fact that interpreters often fail to capture accurately the perspective of the elderly, Latino elderly are often unable to defend themselves against discrimination and their behaviors and attitudes are often misinterpreted. Appearance (e.g., clothing, accessories) and diet are variables associated with discrimination against minority elderly. For instance, because
it is most common for the elderly to wear traditional dress, many elderly Asian-Indian women are ridiculed if they don a sari. Elderly people who retain their culture's traditions may feel particularly ostracized if their younger family members criticize their choices to retain their language and/or dress of origin. The maintenance of beliefs from the homeland may also increase the elderly's vulnerability to oppression. The Chinese-American value placed on stoicism often conflicts with the American medical system, as well as the family system (Sakauye & Chacko, 1994). Medical personnel and younger family members often express frustration and confusion regarding the severity of an elderly Chinese-American's pain given their tendency to refrain from articulating the seriousness of their problems. Many minority elderly face a sense of isolation and alienation due to their memories of traumatic experiences in the US and/or their country of origin. Elderly African-Americans who talk about slavery, elderly European Jews who reflect upon the Holocaust, and elderly Japanese-Americans who discuss the internment camp experiences of World War II may feel that their pain is discounted by younger family members who fail to appreciate the ongoing significance of such traumatic times. This sense of rejection by family members, who are unlikely to ever encounter such tragedies, further compounds the suspiciousness often associated with postslavery, the Holocaust, or internment camp experiences. Some elderly people struggle to maintain a sense of autonomy and independence, despite increased family dependence due to economic limitations or physical or mental deterioration. This conflict is most pronounced in cultural groups in which caretaking of parents is not the norm (e.g., Germans, Scandinavians, Jews). Conversely, for those groups (e.g., AfricanAmericans, Latinos, Native Americans, AsianAmericans) in which it is common for older family members to reside with, and be cared for by, younger members, independence± dependence struggles may be less central.
10.08.4.5.3 Immigrant elderly From a cultural perspective, the immigrant elderly deserve specific attention. With the exception of African-Americans, Native Americans, Alaskan, and Hawaiian Natives, and those from cultures whose families immigrated to the US hundreds of years ago (e.g., White Anglo Saxon Protestants), many minority elders are relatively new immigrants to the country (e.g., Soviet Jews) (American Psychiatric
Culturally Sensitive Family Assessment and Intervention Association, 1994a). These elderly immigrants must adapt to a novel environment with new expectation while losing much of their accumulated experience from their culture of origin. As a consequence, they may lose much of their value within the family. Superimposed on this are the other issues surrounding getting older, resulting in the immigrant elderly feeling extremely challenged and overwhelmed. The intensity of these struggles appears correlated with the recency of immigration, with less recent immigrants manifesting fewer problems (American Psychiatric Association, 1994a). In spite of the aforementioned challenges, the elderly, particularly those who are immigrants, tend to be survivors who are resilient and exhibit a pleasure in life that is not quelled by age, suffering, or loss (Myerhoff, 1979). 10.08.4.5.4 Ethnic identity Elders often assume the role of maintaining their own and their family's ethnic identity despite the family's assimilation into mainstream culture and associated loss of cultural knowledge, language, and traditional values and beliefs (American Psychiatric Association, 1994a). In the Native American community, this may be particularly problematic given that much of the tradition is maintained through oral history. A second aspect of ethnic identity of concern to many minority elderly is that they are no longer being as honored because of their strong ethnic identification (Thompson, 1994). Again, in some Native American families, as the younger generations become more Americanized, the elderly are less valued despite their wealth of experience. A similar process is evident in other groups (e.g., Asian-Americans). 10.08.5 CULTURALLY SENSITIVE FAMILY ASSESSMENT AND INTERVENTION The conduct of culturally sensitive assessments and interventions is predicated on the incorporation of a conceptual model that emphasizes the behaviors, perceptions, beliefs, and values of different groupings of individuals. Clinicians and service delivery systems must be knowledgeable about, and attentive to, their own cultural backgrounds and those of the client and their family. Awareness of these cultural factors must inform the assessment and intervention process with families from all cultural groups (i.e., cultural competence) (Dana, 1993; Zayas, Torres, Malcolm, & DesRosiers, 1996).
According to Zayas et al. (1996) and Dana (1993), therapists transverse a number of stages in becoming culturally sensitive practitioners: (i) unawareness and/or denial, defensiveness and minimization of the importance of cultural issues; (ii) heightened awareness and acceptance of culture; (iii) burden of considering culture and doing therapy and adapting behavior and thinking accordingly; and (iv) integration and synthesis of culture into the assessment and intervention process. Psychologists who engage in culturally informed assessments and interventions consider myriad variables, including the family's group identity, the family's identity as a subsystem, and the identity of each individual member. Also, the clinician focuses on the beliefs, values, and language of each family member and the family unit as a whole (Dana, 1993). The following section reviews the conceptual issues and assumptions that guide family assessment and intervention in a culturally informed manner (Kaslow et al., 1995; Odell, Shelling, Young, Hewitt, & L'Abate, 1994). The topics covered include values, help-seeking behavior, and adherence issues. These issues are of paramount importance given the considerable variation in the presenting problem, nature and rate of help-seeking, views of mental health services, and the nature and rate of premature termination among diverse cultural groups (Kazdin, Stolar, & Marciano, 1995). Next, techniques for assessment and intervention appropriate across cultural groups and family life cycle stages are described. This information provides the background for the later section on culturally sensitive assessment and intervention across each specific phase of the family life cycle. 10.08.5.1 Values To conduct culturally sensitive assessments and interventions, psychologists must be cognizant of their own biases and prejudicial reactions regarding various cultural groups, their personal and culturally based values, and the cultural values of the family with whom they are working. Since families often seek help when their norms are disparate from the cultural values represented by other family members and/or the community, values play a central role in family work. If the clinician and family differ in their values about the presenting problem, but these differences do not reflect significant conflict or indicate pathological functioning in the family's
cultural context, it is recommended that the therapist incorporates the family's cultural framework throughout the assessment and intervention. This recommendation assumes that the therapist's and family's values are equally valid. Another possible stance is for the therapist and family to acknowledge their differences of opinion and the acceptability of such differences. If during evaluation or treatment the practitioner discovers that the family's value system leads them to engage in behaviors considered illegal or unethical in the relevant jurisdiction, the clinician must inform the family and take appropriate steps. Harsh physical punishment of children may be normative in certain cultural groups (e.g., Jamaican families), but such behavior is illegal in the US and thus requires that the therapist report the family to the appropriate authorities (e.g., Gibbs & Huang, 1989). In such instances, the therapist needs to work with the family to help them modify their disciplinary practices in accordance with the law. This needs to be done sensitively, without the therapist invalidating the family's cultural practices. If the behaviors associated with the family's values are contrary to normative practices for the relevant cultural groups in the current ecological context, but the behaviors are not illegal or unethical, the therapy helps the family modify these values and associated behaviors in an effort to foster healthy development and enhance family functioning. To accomplish this goal, the psychologist must help the family examine the cultural origins of these values, ascertain the positive and negative consequences of engaging in behaviors associated with the values, and learn culturally sanctioned alternative practices. It is helpful if the therapist underscores that the family's cultural values may lead to problems in some contexts and be beneficial in others, and that values developed in one historical context may be maladaptive in a new sociocultural context. When there are conflicts among family members regarding key values, and the therapist shares the values of only some family members, the therapeutic process becomes complicated. Often, the therapist will be most aligned with those family members who have the most similar acculturation status and/or cultural identity to the therapist. It is common for the therapist working with immigrant or refugee families to conflict with the grandparent generation regarding gender roles in the family system and to support the gender roles desired by the adult children who are likely to have acculturated more rapidly.
Classes among family members and/or generations regarding values are a necessary consideration in the assessment and treatment of minority families (Gibbs & Huang, 1989). Failure to attend to the processes of value orientation and value clashes may result in an overemphasis on intrapsychic or family dynamics, and may limit the treatment efficacy. Thus, an ecologically oriented approach, that attends to contextual issues as these influence the values of each family member, must be incorporated in all assessment and intervention endeavors with families from nondominant cultural groups. 10.08.5.2 Help-seeking Patterns The family's cultural background often influences the type of help the family seeks for a loved one's problems. Many families from minority cultures prefer to receive help from both trained and not formally trained members of their own community. This preference often results in their being less likely to seek medical or mental health services from qualified professionals, given the relative dearth of well-trained minority providers and culturally sensitive service programs. For example, African-American and Latino families are less likely than Euroamerican families to seek support from agencies and professionals in the initial stages of responding to the a family members' difficulties. (McMiller & Weisz, 1996). Different helpseeking patterns appear to reflect more negative views toward professionals by majority families and the increased availability of alternative social networks (e.g., extended family, clergy) in many minority communities as compared to Euroamerican communities. In a related vein, in many minority communities there is considerable stigma associated with revealing personal and/or cultural values and beliefs to someone outside the family unit, particularly to someone outside the culture. These differential help-seeking patterns must be considered when forming an alliance with minority group families, assessing the index person's and family's problems, and designing, implementing, and evaluating culturally based community outreach programs (McMiller & Weisz, 1996). Specifically, during the initial stages of the evaluation process with AfricanAmerican and Latino families, the psychologist must address the family's concerns and reluctance about mental health services and educate the family about mental health services. Only by doing so will the clinician earn the family's trust sufficiently to conduct a thorough, accurate assessment (McMiller & Weisz, 1996).
Culturally Sensitive Family Assessment and Intervention 10.08.5.3 Adherence Given the data on minority families' reluctance to use professional mental health services 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 factors of premature termination (e.g., parental stress, antisocial behavior of the parent and/or child, adverse parenting styles, low SES) are common among most families, specific differences among ethnic groups in the rate and nature of intervention drop out have been found (Kazdin et al., 1995). As an example, AfricanAmerican families leave treatment more frequently and earlier than their Caucasian counterparts (Kazdin et al.). Predictors of African-American drop out also differed, with compliance often predicated on child academic functioning. There are a number of techniques that may reduce attrition rates, however, many of these strategies are ineffective with families from culturally diverse groups (Paniagua, 1994). To effectively prevent premature termination of family therapy, the psychologist's interventions must attend to the family's culture and the impact of the family's culture on attrition. Separate guidelines have been proposed to prevent attrition in AfricanAmerican, Latino, Asian-American, and Native American families. For example, when working with African-American families, it is suggested that racial differences be addressed, mental health problems not be linked to parental behaviors, medication not be recommended as the initial treatment of choice, and the psychologist ªnot give the impression that he or she is the protector of the race when discussing racial issuesº (Paniagua, 1994, p. 93). To minimize the likelihood of attrition when working with Native American families, the psychologist should emphasize listening and collaboration rather than talking and authority, de-emphasize the issue of time, discuss the administration rather than the control of the problem, and avoid personalism.
10.08.5.4 Culturally Sensitive Techniques Cultural issues influence the therapeutic stance, the development of the working alliance, and the assessment and intervention process (Sue & Zane, 1987). In addition to attending to cultural factors as these influence family dynamics, the psychologist conducting the family assessment and intervention must
consider the unique aspects of each family to distinguish culturally based and idiosyncratic family relational patterns (Goldenberg & Goldenberg, 1994).
10.08.5.4.1 Stance of the therapist Nonspecific therapist characteristics associated with the conduct of competent assessments and interventions (e.g., empathy, warmth, genuineness, acceptance, respect) are necessary but not sufficient to assess adequately cultural issues (Sue & Sue, 1990). Culturally informed clinicians must also: (i) be knowledgeable about their own cultural background and its influence on clinical practice; (ii) comprehend the impact of culture on the lives of the families with whom they work; (iii) be cognizant of the variability of normative family structures and functioning across and within cultural groups to avoid stereotyping; (iv) be attuned to subtle cultural variations in language, nonverbal behavior, and expressions of distress; (v) adjust their style to be compatible with the family's culturally influenced patterns of relating to one another and to outsiders in authority; (vi) modify the therapeutic strategies used to facilitate behavior change in a manner consistent with the family's cultural values; (vii) recognize and use the family's natural support systems in the community; and (viii) be willing to incorporate other culturally acceptable clinicians from multiple disciplines into the assessment and intervention process (London & Devore, 1988; Odell et al., 1994; Sue & Sue, 1990). The American Psychological Association's guidelines for ethical practice for the provision of psychological services to ethnic, linguistic, and culturally diverse populations (American Psychological Association, 1993) maintain that it is only ethical to assess and intervene with individuals and families from the nondominant culture if the professional is trained in multicultural assessment and intervention. According to these guidelines, the therapist's stance must reflect their recognition of cultural diversity, understanding of the role that culture, ethnicity, and race play in psychosocial development, awareness that economic and political factors influence psychosocial development, and knowledge of the impact of culture, gender, and sexual orientation on behavior. Psychologists working with culturally diverse families must communicate a value on helping families understand, maintain, and resolve their own sociocultural identification (American Psychological Association, 1993).
10.08.5.4.2 Development of the working alliance Joining, a key component of forming a working alliance between the therapist, each family member, and the family system as a whole, is crucial to the conduct of effective assessment and intervention. This process is facilitated when the therapist's space (office, agency) includes culturally familiar objects and symbols to the family (Vasquez-Nuttall, AvilaVivas, & Morales-Barreto, 1984). Through the joining process, a trusting relationship is forged between the therapist and the family. Through the process of joining, the clinician becomes cognizant of the culturally influenced rules, roles, structure, communication and problem-solving patterns, and traditional sources of help that impact on family interactional processes. To enhance the working alliance with a family from a cultural group unfamiliar to the psychologist, or when the family engages in culturally driven family patterns to which the therapist is unaccustomed, it is suggested that the therapist assume a position of humility coupled with benign curiosity (Odell et al., 1994). Such a stance can be assumed most readily if the clinician requests the family's aid in learning relevant cultural norms and patterns. If the family is unable to provide adequate information to insure an empathic awareness of the family's interactions within their cultural context, the therapist must glean such data from others knowledgeable about the particular family's culture. Credibility is associated with effective joining (Sue & Zane, 1987). Professionals' credibility, a reflection of their status, may be determined by the position assigned by the family (ascribed credibility) or by their competencies (achieved credibility). When therapists exhibit culturally consistent assessment and intervention strategies, they may be considered credible by a given family system. The lack of ascribed credibility of formalized mental health services may account for low utilization rates among certain cultural groups, and the lack of achieved credibility may contribute to explanations of nonadherence. 10.08.5.4.3 Assessment process Once psychologists have begun to form a working alliance with the family, the assessment may begin. The psychologist who gathers family assessment data in a culturally sensitive manner communicates a respect of the cultural diversity of families (Hanson, Lynch, & Wayman, 1990). In conducting a family evaluation, the ways in which the family's culture impacts on their symptom presentation and interactional
patterns must be considered (Zayas et al., 1996). Evaluators must be mindful of the ways in which their own culture may affect the assessment process. In addition to cultural biases influencing the assessment of intellectual, psychiatric, and behavioral functioning, these biases may impact upon the evaluator's perception and evaluation of family functioning (Canino & Spurlock, 1994; Dana, 1993). Given the growing literature on cultural considerations in assessing psychological symptoms and psychiatric conditions in people across the life span (e.g., Alarcon, 1995; American Psychiatric Association, 1994a; Canino & Spurlock, 1994; Gaw, 1993), and in diagnosing psychiatric disorders in the recent Diagnostic and statistical manual of mental disorders (4th ed.; DSM-IV) (American Psychiatric Association, 1994b), our comments on assessment only address considerations pertinent to families. During the evaluation, the clinician must gather information about the ethnic, racial, and religious background of the family and data about the historical and current political, social, and economic conditions of the family's cultural group. The construct of a genogram may be useful (McGoldrick & Gerson, 1985). Genograms, which graphically provide personal data regarding individual members (e.g., ethnicity, religion, current residence), and information about family structure, relationships, and patterns, enable the psychologist and family to develop systemic hypotheses about family functioning and its connection to the larger family and sociocultural context. Some therapists question the appropriate timing and nature of genogram construction with families from certain cultural groups. Boyd-Franklin (1989) asserted that with African-American families, genogram work may be most meaningful later in the treatment after trust has been established, rather than during the evaluation. Similarly, Odell et al. (1994) have noted that since constructing a genogram may elicit painful memories for many immigrant and refugee families, this technique may sabotage the development of the initial working alliance and thus may best be introduced during the intervention. For many families who have lost a loved one due to sociopolitical conditions (e.g., Holocaust survivors, Bosnian refugees), projective genogramming elicits effectively distressing) yet important information and feelings (F. W. Kaslow, 1995). Thus, while genograms may be an important assessment tool with families from most cultural groups, the family's cultural background should inform the timing of this task. An assessment strategy related to the genogram, but devised for work with diverse family
Culturally Sensitive Family Assessment and Intervention groups, is the culturagram (Congress, 1994). With the culturagram, psychologists glean information from the family regarding: reasons for immigration, length of time in the community, citizenship status, language spoken at home and in the community, health beliefs, major holidays, and values on family, education, work, gender roles, religion, and money. Constructing a culturagram enables clinicians to ascertain the effects of culture on the family system and to individualize ethnically similar families. As a result, clinicians are more culturally empathic and more able to empower the families with whom they work. Enumerable tools and methodologies have been devised to assess multiple aspects of family functioning. These include self-report scales, micro- and macroanalytic coding schemas to code interactional patterns, and projective techniques (for review, see Fredman & Sherman, 1987; Jacob, 1987; L'Abate & Bagarozzi, 1993). Unfortunately, few of these measures or coding schemas have been developed, normed, or empirically tested for specific cultural groups, and thus their utility across groups remains questionable (Dana, 1993). In addition, generalizations about findings gleaned from using standard assessment protocols must be limited and made with caution. Given the scarcity of culture-free assessment strategies, the assessor must take the family's cultural context into account when interpreting findings from assessment protocols not standardized with the family's cultural group. This requires including an evaluation of culturally valid constructs (e.g., racial or ethnic identity, level of acculturation, belief systems, culture-specific syndromes) (Lasry & Sayegh, 1992; Phinney, 1990b). For example, the psychologist may use Gushue's (1993) recent adaptation of Parham and Helms (1985b) Black and White interaction model for assessing and working with families. This assessment strategy enables the clinician to incorporate cultural identity data in making an initial family assessment. The final phase of the assessment process is problem definition and goal-setting. Cultural variables that may impact this phase include the role of authority, preferred decision-making strategies, the view of psychological problems and potential solutions, and culturally based values. Thus, with Latino families, the goals should address immediate and concrete concerns (Ho, 1987). These families prefer to focus on goals that affect family subsystems, particularly the parent±child subsystem, rather than individual family members or the marital dyad. When working with many Asian-American families, it is recommended that the goals be well-defined, objective, and address practical
matters. Asian-American families prefer the therapist to be confident and active in the goalsetting process, while simultaneously communicating respect for the family (Ho, 1987). With Native American families, goal-setting should be collaborative. Given the value on interdependence in the Native American community, all relevant nuclear and extended family members should be included in setting intervention goals (Ho, 1987). When setting goals with low-income, African-American families, a mutual process should be assumed, with a focus on survival needs and the incorporation of an ecostructural framework (Ho, 1987). In addition to setting goals specific to the given family, many culturally competent practitioners recommend that cultural intentionality and bicultural competence be defined as therapeutic goals for families across cultural groups who seek mental health services (BoydFranklin, 1989; Ivey, Ivey, & Simek-Morgah, 1993; Szapocznik et al., 1984). Cultural intentionality refers to the ability to communicate competently with others within the cultural group and with individuals from multiple cultural backgrounds. Bicultural competence connotes the simultaneous processes of accommodating to the host culture and retaining aspects of the culture of origin. 10.08.5.4.4 Intervention process Throughout the intervention phase, the psychologist is a cultural interpreter or culture broker, helping the family recognize and resolve conflicts between the demands and values of the minority and majority cultures (Canino & Spurlock, 1994; Glordano & Giordano, 1995). Issues that may require interpretation include: kinship relations, respect for roles and family hierarchy, personalization in the therapeutic relationship, and the need to involve additional people from the family's community (e.g., clergy). To assume the role of cultural interpreter, the therapist may incorporate Boyntons (1987) ESCAPE model, according to which the therapist, as cultural interpreter, must: Engage the family within its context; be sensitive to the family's culture; communicate an awareness of the culture's potential and positives; and know the environment in which culture clashes are likely to occur. When intervening with families from either the same or a different cultural background as themselves, therapists must be mindful that interpersonal behaviors may be interpreted differently. For example, whereas listening may be experienced by some as reflecting empathy and concern, families from certain cultural backgrounds are likely to perceive
listening as not caring. Thus, it is crucial that the family and the therapist discuss their differing perceptions and experiences throughout the course of the family work. Awareness of these differences should inform subsequent interventions. A major focus of family interventions is the introduction and utilization of adaptive problem-resolution tactics. Problem-resolution strategies are most effective when system and cultural variables are taken into account. Since culturally specific intervention approaches for problem resolution have been offered to families from multiple cultural groups (for detailed discussions, see Boyd-Franklin, 1989; Falicov, 1983; Ho, 1987; McGoldrick et al., 1982, 1996; Paniagua, 1994), this section reviews, briefly, techniques for problem resolution with families from the most often encountered cultural groups in the US. The optimal family intervention approach for African-American families, regardless of SES, is time-limited, problem-focused, and presentoriented with all significant family members and members of the kinship and caregiving networks included (Boyd-Franklin, 1989; Ho, 1987; McGoldrick et al., 1996). The psychologist, who needs to assume an active stance, should inform the family about the goals, process, structure, and limits of family therapy, and serve as a role model, educator, and advocate. Effective family therapy underscores and utilizes family strengths and resources to empower the family to solve its own problems, exert more control over the environment, cope constructively with racism and oppression, and extricate itself from the victim system (BoydFranklin, 1989; Pinderhughes, 1989). Psychoeducation and skills training, role clarification, and boundary setting are useful strategies. The unique power and value conflicts of middleclass African-American families may require additional treatment modifications, such as the therapist relabeling behaviors that appear maladaptive as manifestations of the family's determination to negotiate effectively between cultures with competing demands (CornerEdwards & Spurlock, 1988). When intervening with Asian-American families, the psychologist must respect key values in the community (e.g., the central role of family solidarity, the emphasis on connectedness and integration rather than separation and individuation) and must be sensitive to the families' culturally sanctioned reluctance to expose conflict to outsiders because it reflects disloyalty (Gaw, 1993; Tamura & Lau, 1992). Although these family values and patterns of relating characterize Asian-American families from multiple countries of origin, effective
interventions must take into account the family's specific ethnic background and level of acculturation (Gaw, 1993). When working with Asian-American families, it is suggested that the intervention approach be relatively formal and structured, and focus on pragmatic concerns rather than underlying affects. The therapist must balance showing respect for parental authority and the family's culture of origin with the assumption of an authoritative stance. Family members should be encouraged to communicate verbally and the value of democratic communication should be highlighted (Gaw, 1993). Since many Asian-American families prefer negotiation of differences rather than direct conflict, it may help to hold separate sessions with individual members prior to addressing family conflict directly (Berg & Jaya, 1993; Ho, 1987). The mental health services literature on work with Latino populations has focused on improving the accessibility of mental health services, choosing interventions according to the cultural characteristics of Latinos, and modifying traditional intervention approaches based on a familiarity and evaluation of ethnic characteristics or creatively deriving the intervention program in response to the cultural milieu (Rogler, Malgady, Constantino, & Blumenthal, 1987). For example, home visits may be an essential component of family interventions with Latino families (Ho, 1987). In addition, or when home visits are not possible, the psychologist should become acquainted with extended family members and assimilated into the family's power hierarchy in order to exert the influence necessary to help the family change. The therapist must appreciate the positive aspects of roles within Latino families that may have negative connotations within middle class, Anglo American culture (e.g., machismo in the father figure). It is essential that the therapist function as cultural translator, mediator, and role model to facilitate the family's active engagement in the community. It is often the case that Native American families' explanation of a family problem (e.g., marital discord, parent±child conflict) is that the problem is a response to the family's inability to provide for essential needs (e.g., food, shelter) (Ho, 1987). As such, the early stages of a family intervention must address these basic needs and the psychologist should provide advice and information to enhance the family's capacity to fulfill these basic needs. Such a stance communicates the therapist's sensitivity to the family's basic needs and willingness to provide immediate services (Panigua, 1994). Such a stance is likely to foster the development of a working alliance with the family. When undertaking the
Culturally Sensitive Family Assessment and Intervention problem-resolution phase of family interventions with Native American families, the therapist should emphasize group decisionmaking by including nuclear and extended family members and key community members (medicine man or woman, tribal leaders) (Ho, 1987), and must be mindful of this culture's holistic, interdependent world view and the fact that relationships with kin are of prime significance (Ho, 1987). Suggestions must be delivered to the family in a thoughtful, pragmatic, and calm manner (Ho, 1987; Panigua, 1994). One of the major goals of family interventions with Native American families is the promotion of interdependence. This can be achieved most readily when the therapist functions as a role model, committed to engaging all relevant parties in problem assessment and resolution. Involving all family members in the intervention process typically entails allowing the family to determine the issues to be addressed (Ho, 1987; Panigua, 1994). The use of structural and strategic interventions such as reframing and relabeling are likely to be particularly effective. Strategies experienced by the family as indicating the family's causal role in the identified patient's symptoms are likely to meet with considerable opposition. Given the consistency between Jewish family values (family membership and loyalty, egalitarianism with regard to roles, intellectual achievement, verbal expression of feelings) and those of psychotherapy, Jewish families often appear to engage readily in family therapy (Rosen & Weltman, 1996). However, the culture's pride in suffering and emphasis on insight over behavior change may complicate the family therapy process. Jewish families 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 communicate to the family a respect for their value on family cohesion, while simultaneously addressing the ways in which closeness in the family system may interfere with the development and maintenance of family members' personal boundaries and age-appropriate separation± individuation. Irish-Americans tend to minimize problems, have difficulty articulating their feelings, and use humor and alcohol to manage stress (McGoldrick, 1996). These coping strategies are often associated with a reluctance to seek psychological services. When Irish-American families do enter therapy, the psychologist is likely to encounter guilt, resentment, and selfreproach. To intervene effectively with IrishAmerican families, family clinicians should ask
specific questions to elicit all relevant information, maintain a friendly distance, and avoid exploration of painful effects and embarrassing topics (Jalali, 1988; McGoldrick, 1996). Thus, a structured approach, focusing on the presenting problem, is suggested (McGoldrick, 1996). The family is of prime importance in ItalianAmerican communities. Families in these communities are often reluctant to support members' differentiation. In addition, many ItalianAmerican families attempt to resolve conflicts within the nuclear and extended family. The therapist, therefore, must respect the family as a cohesive unit. Attempts to decrease family closeness by strengthening internal and weakening external boundaries are likely to be resisted and met with the family's refusal to let the therapist enter the family system. This impedes the family work, which can only be effective when the therapist is treated as a member, albeit distant, of the family. Because these families often seek therapy during life cycle transitions associated with separation, it may be difficult for the therapist to refrain from challenging the family's strong emotional ties. Thus, family therapists can help most by coaching individuals to remain close to the family, without becoming engulfed (Giordano & McGoldrick, 1996). Given the Italians' penchant for ªhistrionics,º the therapist must ascertain the actual severity of the problem (Jalali, 1988). Despite their emotionally expressive presentation, they frequently deny family conflicts and secrets until they trust the therapist. It is important, therefore, to provide timely advice regarding the chief complaint, while patiently waiting for the family to examine underlying patterns (Giordano & McGoldrick, 1996).
10.08.5.5 Culturally Sensitive Techniques Across the Life Cycle 10.08.5.5.1 The joining of families: culturally sensitive assessment and intervention Given the significant cultural variations in the nature of marital relationships among diverse families, an assessment of a couple must include attention to those cultural variables most likely to impact upon the functioning of the dyad. In addition, when conducting an assessment, the psychologist must be mindful of accepted cultural practices, many of which may be unfamiliar to the clinician (e.g., arranged marriages, lack of emphasis placed on love). When assessing newly formed couples, whether or not they are married, the psychologist must examine each person's perspective on the
meaning of an intimate partnership (values on intimacy, fidelity, divorce), appropriate gender roles within a couple, and the degree of autonomy vs. interdependence expected by each partner both within the dyad and between the dyad and the extended family. Attention must be paid to each person's notions regarding the degree to which each party has an equal role and value in the partnership and the responsibilities to be assumed by each person. It is also crucial that the psychologist investigates physical abuse in all couples, regardless of their ethnic heritage, as domestic violence is prevalent in all cultures (Levinson, 1989). Finally, given the increasing rates of intermarriage and the fact that intimate relationships between people of different ethnic, religious, and racial backgrounds compound the issues faced by couples from a single ethnic group, similarities and differences between partners based upon their cultural heritage must be examined. The joining of two families through marriage requires that the two individuals choosing to marry renegotiate with one another about areas of concern. Difficulties in negotiating and compromising on such issues as core values, the role of the family, communication styles, roles and responsibilities, level of intimacy, religion, and politics often lead couples to seek couples' therapy (Carter & McGoldrick, 1989). When intervening with newly formed couples, the psychologist must first help each partner to feel comfortable in sharing their perceptions, opinions, and wishes regarding various areas of disagreement (e.g., Falicov, 1983). One way in which a nonjudgemental context can be created to facilitate this sharing is by the therapist encouraging both members of the dyad to examine how their views are influenced by their cultural background. During this process of disclosure, it behoves the therapist to validate for the couple the complexities of negotiating different life styles and different cultural stereotypes. The couple also needs help in realizing the importance of integrating their differences, rather than choosing between polar opposites. The process of working through similarities and differences enables the couple to form their own identification as a new family unit, both related to and separate from their respective families of origin. 10.08.5.5.2 Families with young children: culturally sensitive assessment and intervention In working with culturally diverse families with young children, psychologists need to choose and administer assessment devices and interpret the results from a culturally informed
perspective (Canino & Spurlock, 1994). This involves using and producing culturally and developmentally sensitive instruments, techniques, and explanations. Direct observation of children playing, drawing, and interacting with their family can provide metaphors for the child's thoughts and feelings (Grizenko, Sayeghm, & Migneault, 1991). Such metaphors are particularly helpful when language differences complicate the assessment process. The psychologist must guard against any personal biases and shed cultural stereotypes when conducting and interpreting a family assessment of a young child (Grizenko et al., 1991). When evaluating a child's presenting problem, the psychologist must ascertain the meaning of the symptoms in the child's culture and the degree to which the symptoms are viewed as pathological in the child's culture (Grizenko et al.). An assessment of a young child, individually as well as in the context of the family, must consider the cultural context of the child's socialization. For example, deferential behavior may raise questions about the Caucasian child's self-confidence and or a rigid family structure; such behavior is expected in many Latino cultures and thus is most appropriately understood as reflecting the child's efforts to conform to cultural expectations. When intervening with families with young children, the therapist must consider the family's cultural values on various aspects of childrearing and socialization. For example, when working with many traditional Latino families, it may be inappropriate for the therapist to emphasize the need for the child to be behaviorally and verbally assertive, as such a recommendation may be perceived by the family as undermining of the parents' role (Zayas & Solari, 1994). The therapist must join such family systems by acknowledging, not challenging, the parents' authority. Gradually, this will enable the family to trust the therapist, which in turn will facilitate the family's increased comfort with the expression of a full range of emotions from the children (Zayas & Solari, 1994). One complicated dilemma that may be encountered when working with families with young children occurs when the child is the only family member fluent in English (VasquezNuttall et al., 1984). For example, for a CubanAmerican family in which Spanish is the sole language of the adults, a Spanish speaking therapist may be optimal. If such a therapist is unavailable or if the family prefers an English speaking therapist who can introduce them to the majority culture, a translator may be an option. Unfortunately, however, translations often misrepresent the actual meaning and
Culturally Sensitive Family Assessment and Intervention cultural significance of family expressions and fail to consider implications of nonverbal behaviors. While some families prefer using the young child as an interpreter, this is problematic in families from cultural groups in which respect for parental authority is of utmost importance. In such instances, the child as interpreter may be perceived as being insubordinate, disrespectful, and intruding on adult concerns. One particular form of intervention that impacts significantly on the family of a young child is that of early interventions (Hanson et al., 1990). Because early interventions focus on the young child with a disability, these programs interact with cultural views and values. Early interventionists often work with the young child with a disability in the family's home. This experience offers an inside view of family rituals, communication, and caretaking patterns, and a perspective on children and childrearing, and family and family roles. In addition, it typically is sanctioned for early interventionists to consult with the family regarding health and mental health care. Such involvements with the family heighten the early interventionist's awareness of different cultural perspectives and the need to respect the family's boundaries while simultaneously imparting the views of the larger culture so that they can receive optimal care for their young child (Hanson et al., 1990). 10.08.5.5.3 Families with adolescents: culturally sensitive assessment and intervention Defining deviant adolescent behavior in the context of culturally diverse families is complicated. The degree to which rebellion, deviance, and separation±individuation strivings are tolerated varies with different ethnic and cultural groups. For example, the Latino family's awareness that their adolescent daughter is sexually active with her boyfriend may lead to their seeking services for their child. Once the psychologist is familiar with the family's cultural norm that premarital sex among adolescent females is unacceptable, the therapist must assess the adolescent's sexual activity (solely with significant other vs. with multiple partners, safe sex practices) and other potentially maladaptive or self-destructive behaviors. Based on these data, the psychologist can ascertain if the adolescent's behavior is inconsistent with her family's cultural norms but in keeping with the practices of the majority culture, or deviant from the expectations of both cultures. This information should be shared with the family during the assessment.
Among immigrant families from such diverse cultures as Mexico, Nigeria, and Kuwait, adolescents are expected to seek, respect, and obey their parents' guidance (Baptiste, 1993). After living in the US, adolescents from these families often begin to behave in a more individualistic fashion, place a greater value on autonomy than is accepted in their family and culture of origin, and seek advice from nonfamily members. Such actions are perceived by older family members as a reflection of the family's inability to cope effectively with immigration and are experienced as threatening and disrespectful. As a consequence, a rigidification of family rules is common. If such a response fails to reduce the adolescent's autonomy strivings, the family may seek a mental health evaluation. It is incumbent upon the psychologist evaluating such families to bear in mind the conflictual values regarding family hierarchy and dependence vs. independence manifested by members of different generations. Feedback from such an assessment must incorporate the therapist's evaluation of the extent to which the adolescent's behaviors and attitudes are consistent with, or discrepant from, the different cultures in which the adolescent embedded. If based on this feedback, the therapist recommends treatment and the family concurs, the therapist should serve as a family intermediary, whose primary function is to translate cultural behavior in a developmental perspective. In working with some families (e.g., Mexican-Americans), this may entail conducting separate sibling and parent sessions to discuss sexual matters, prior to holding sessions with all family members present (Falicov, 1996). Such an approach demonstrates the therapist's respect for the parents' view that discussion of intimate matters with their children is inappropriate and undermining of their authority (Garcia-Preto, 1996). There is a burgeoning body of research on racial and ethnic similarities and differences in adolescent substance abuse patterns and risk factors (e.g., Gottfredson & Koper, 1996). Data from these studies have been used to guide the development and implementation of culturally informed preventive intervention programs, such as the State-wide Indian Drug Prevention Program (IDPP) (Bobo, Gilchrist, Cvetkovich, Trimble, & Schinke, 1988). In addition, these data have laid the foundation for treatment outcome studies. For example, an excellent example of culturally sensitive treatment outcome research has been conducted with the families of Cuban-American adolescents with substance abuse problems (e.g., Kurtines & Szapocznik, 1996; Szapocznik et al., 1984; 1986). Bicultural effectiveness training (BET),
a brief family intervention model that incorporates culture as a key content area upon which to base family interventions, has been found to be equally effective in improving family functioning as structural family therapy, a standard family approach that is not necessarily culturally based. These findings support the use of a culturally informed family intervention for enhancing the functioning of adolescents with substance abuse problems from families that experience conflicts associated with cultural and generational differences (Szapocznik et al., 1986). 10.08.5.5.4 Launching children, single young adults leaving home, and the middle generation moving on: culturally sensitive assessment and intervention Given cultural variations in what is considered normative behavior during the launching stage of the family life cycle, it is crucial that the psychologist takes cultural norms into account when ascertaining whether or not family conflicts during this time reflect significant individual or family dysfunction, differences in values across generations about independence v. interdependence, differences in perspectives on healthy behavior during this phase between the family's cultural group and the majority culture, or simply normal family processes. It is useful to learn if previous generations of the family migrated during this phase, as these family of origin experiences would intensify the significance of this period (Carter & McGoldrick, 1989). When assessing the single young adult leaving home, it is recommended that information be gleaned regarding how the person's parents managed this phase of their own development. Questions should be asked about the young adult's internal struggles and conflicts with cultural norms regarding separation and individuation. Also, data should be gathered regarding the individual's view of acceptable gender roles vs. those held by the family and cultural group (e.g., views on remaining single as a woman). Finally, given that this process requires a restructuring of the marital relationship, the parent's marital history and current marital status deserve attention. It is often recommended that family work with single young adults or with young adults in the launching phase be conducted primarily with the young adult, using a family of origin approach (Bowen, 1978). It is useful for the psychologist to help young adults examine the relation between multigenerational patterns of relating and their own personal development. To facilitate this awareness, the psychologist can ªcoachº or guide young adults in both the
emancipation process and in renegotiating family relationships in order to develop a healthier balance between autonomy and attachment that meets the needs of both the individual and the family, and that takes cultural considerations into account. The coaching process must address cultural norms when focusing on the reduction of extreme enmeshment, radical disengagement, and the active use of triangulation. Specific strategies that may facilitate this process include: detriangling, person-to-person contact, reversals, and reconnecting (Carter & McGoldrick, 1989). These strategies enable the family system to alter patterns of relating that are dysfunctional given the family's current cultural context and foster mature communication among family members. When couples seek mental health services during this family life cycle stage, culturally sensitive interventions must take at least a threegeneration perspective. A multigenerational view allows the psychologist to help the couple deal with their independence from their offspring and their increased commitment to the older generation. In addition, they may need help in dealing with the separation and loss associated with the death of older family members who often serve as culture bearers. The negotiation of new relationships with children and parents is often complicated by the need to renegotiate the marital dyad. Thus, family interventions must address all relevant relationships, with particular attention to the ways in which the cultural values of individuals across the generations impact on the interpersonal difficulties that emerge. Further, for individuals from many cultural groups, this may be the first family life cycle stage in which their own individual development is paramount. Thus, personal difficulties camouflaged by the demands of family life at other stages in the family life cycle may come to the fore, and may require individual attention. 10.08.5.5.5 Families in later life: culturally sensitive assessment and intervention For psychologists to assess accurately the functioning among culturally diverse families with elderly members, they must first build a therapeutic relationship with all family members. This may be complicated when working with elderly family members, as these individuals from different cultural groups are often suspicious of professionals who they perceive as having little in common with them. They suspect that mental health and health care professionals may have biases against their age, race, sex, and culture.
Future Directions Hays' (1996) framework for the conduct of culturally responsive assessments underscores the importance of attending to a number of influences that impact on the functioning of diverse older adults. She uses the acronym ADRESSING (albeit incorrectly spelled) to organize the key influences to be taken into account when assessing elderly family members: age, disability, religion, ethnicity, social status, sexual orientation, indigenous heritage, national origin, and gender. Attention to these variables facilitates the building of rapport, enhances the psychologist's understanding of the elderly family member's cultural identity and heritage, and improves the psychologist's awareness of elderly family members' cultural environment, needs, and strengths (Hays, 1996). When assessing elderly clients in a family context, it behoves the psychologist to use strategies that enhance rapport and communication. Possible techniques that may facilitate positive interactions include sitting closer and speaking clearly, talking to ªthe good ear,º using titles (Mr, Mrs, Dr, etc.) before names, using respectful and culturally sensitive interpreters when language differences exist, being equipped with conveniences for physical disabilities, and having culturally diverse artifacts in the office (Hays, 1996). When gathering a history from elderly family members, the psychologist should be cognizant of the importance of gathering extensive background information and encouraging the older family members to tell their life stories. During the assessment process, it is recommended that some time be spent with all family members present and some time should be devoted to separate meetings with the older people. During the multigenerational meetings, the psychologist can communicate respect for the elderly by encouraging the eldest family member to speak