The psychological investigation of culture and health has been pursued by scholars in various disciplines for decades, but Cultural-Clinical Psychology is just beginning to emerge as a coherent field of study. We have selected these readings with the beginner in mind — the student or researcher who is just beginning work in this area. Each identified author has made ongoing contributions to the study of culture and mental health; literature searches on their names would point to many additional papers on the topic.
Juris Draguns (The Pennsylvania State University) and Junko Tanaka-Matsumi (Kwansei Gakuin University) study clinical psychology issues from a cross-cultural psychology perspective. Here, they present an evidence-based review of cultural issues in the assessment of psychopathology. They advocate greater attention to cultural values in explaining group differences, and draw the reader’s attention to the potential impact of the diagnostician’s cultural context and of rapid social change.
Gordon Nagayama Hall (University of Oregon) integrates clinical/counselling and ethnic minority psychology perspectives. This paper explores the lack of firm evidence for Empirically Supported Therapies (ESTs) in ethnic minority groups, and the similar lack for specially-designed Culturally Sensitive Therapies (CSTs). The gap between these two goals is attributed to differences in theories and methods in the two research communities, and the lack of dialogue between them.
Laurence Kirmayer (McGill University) is a cultural psychiatrist and director of the Division of Social and Transcultural Psychiatry at McGill University (see section 3). This paper argues that psychotherapies are unique in that they involve explicit talk about the self, which is based on implicit self-concepts, which are shaped by culture. He describes several different culturally-shaped models of the self and discusses their psychological ramifications. These approaches to self are contrasted with the ‘idiocentric’ or individualist model grounding most ‘Western’ assumptions about psychotherapy.
Arthur Kleinman (Harvard University) is a psychiatrist with anthropological training who launched the modern field of cultural psychiatry with this paper. He uses the example of the somatization of depression in Taiwan to illustrate how culture shapes mental health. Moreover, he argues that it is this attention to shaping that should be the hallmark of the new field, rather than a focus on group differences. Over the ensuing decades, several authors have commented on the progress made with this endeavor.
Anna Lau (University of California, Los Angeles), Doris Chang (New School for Social Research), and Sumie Okazaki (New York University) are clinical psychologists who conduct research in East Asian and Asian American cultural settings. This paper reviews the challenges that face researchers attempting to conduct ethnoculturally diverse treatment outcome studies. They begin by considering the limitations of the Randomized Clinical Trial approach, and then propose several alternatives aimed at advancing culturally-focused treatment research.
Sing Lee (Chinese University of Hong Kong) is a psychiatrist with particular research and clinical interests in eating and somatoform disorders. This paper takes the perspective that psychiatric symptoms and syndromes are shaped by cultural context, a process that is evident in the construction of formal diagnostic systems. These systems both reflect and constrain the ways in which psychopathology is experienced, expressed, and communicated to others. The argument is made through a detailed consideration of the revised second edition of the Chinese psychiatric classification system.
Frederick Leong (Michigan State University) is the director of the Consortium for Multicultural Psychology Research, integrating a multicultural perspective with clinical and counselling psychology. In this paper he reviews Kluckhohn and Murray’s integrative approach to anthropology and personality (the universal, the group, and the individual) and then applies these ideas to the therapeutic encounter. He concludes by describing the ways in which a therapeutic relationship can be thought of as a complex adaptive system.
Roland Littlewood (University College, London) is trained as both a psychiatrist and anthropologist and applies ethnographic methods to the study of mental health, with a particular interest in religion. This paper critically examines the progress made in cultural psychiatry since Kleinman’s 1977 paper, in particular the move from labeled cultural categories to fluid cultural contexts.
Steven López (University of Southern California) and Peter Guarnaccia (Rutgers University) are, respectively, a clinical psychologist and a cultural anthropologist who both have a particular interest in Latino mental health. This review emphasizes developments in the field since Kleinman’s Rethinking Psychiatry from 1988, covering theoretical (defining culture, purposes of cultural research, culture in DSM) and empirical (anxiety, schizophrenia, childhood disorders) topics. The paper concludes by considering a few emerging trends for future research in the area.
Stanley Sue and Nolan Zane (both at University of California, Davis) are clinical psychologists with particular interests in Asian American mental health; Dr. Zane directs the Asian American Center on Disparities Research. Here, the authors critique the emphasis on cultural match and specific cultural knowledge, advocating instead for more general principles. They argue that these principles are grounded in good psychotherapy practice regardless of the cultural issues, but are especially important when engaging with clients across a cultural divide.
Fanny Cheung (Chinese University of Hong Kong) is a clinical psychologist who takes a cross-cultural psychology perspective on assessment of personality and psychopathology, especially in Chinese contexts. In this study, she describes with her co-authors the construction of a comprehensive assessment instrument based in the Chinese cultural context. They then validate the instrument in a large sample of Chinese clinical patients, showing expected differences between diagnostic groups and clinical vs. forensic vs. community samples. The study demonstrates how one can go from indigenous constructs to psychometrically valid clinical instruments.
Joseph Gone (University of Michigan) is a clinical psychologist who focuses on the mental health of indigenous peoples. This study takes a mixed-methods approach, combing qualitative and quantitative techniques. Specifically, it demonstrates how semi-structured interviews combined with thematic content analysis can be used to generate rich data about a culturally-specific treatment setting. In addition to presenting specific results, the paper presents a vision of how the gap between evidence-based treatment and culturally sensitive therapies might be bridged.
Hinton, D. E., Chhean, D., Pich, V., Um, K., Fama, J. M., & Pollack, M. H. (2006). Neck-focused panic attacks among Cambodian refugees: A logistic and linear regression analysis. Journal of Anxiety Disorders, 20, 119-138.
Devon Hinton (Harvard University) is a cultural psychiatrist interested in how culture shapes anxiety disorders, especially panic disorder and PTSD. His research has demonstrated how just as American cultural beliefs surrounding heart attacks contribute to the catastrophic misinterpretation of chest pain, and hence to a loop that culminates in a panic attack, a similar pattern can be observed for Cambodians with neck pain. This study uses regression methods to study the influence of mind-level factors on a culturally-shaped symptom presentation and also uses mediation and moderation to help explain differences between patients with and without neck-focused panic attacks.
Janis Jenkins (University of California, San Diego) is an anthropologist interested in the subjective experiences of patients with different psychiatric disorders, living in different cultural contexts. This study used structured and semi-structured interview methods to yield both qualitative and quantitative data. Strikingly, nearly half the overall sample did not mention the illness when describing their life situation in detail – their scripts for describing distress focused much more on whether or not one was living a good and desirable life rather than incorporating psychiatric labels. This study demonstrates how mixed methods can be used to uncover cultural scripts.
Kim, H. S., Sherman, D. K., Sasaki, J. Y., Xu, J., Chu, T. Q., Ryu, C., Suh, E. M., Graham, K., & Taylor, S. E. (2010). Culture, distress, and oxytocin receptor polymorphism (OXTR) interact to influence emotional support seeking. Proceedings of the National Academy of Sciences, 107, 15717-15721.
Heejung Kim (University of California, Santa Barbara) is a cultural psychologist interested in how culture shapes basic psychological processes. This collaborative interdisciplinary study is one of the few to integrate culture, mind, and brain in the same design. Here, brain is represented by a genetic polymorphism that affects oxytocin receptors. The research team found that neither genetic/brain variation nor cultural variation is sufficient to explain a clinically important phenomenon at the mind-level; namely, emotional support seeking from important others.
Brandon Kohrt (George Washington University) has doctoral degrees in medicine and anthropology from Emory University and is currently a psychiatry resident at GWU. He conducts research in Nepal using both qualitative and quantitative methods, including ethnography, medical examinations, psychophysiological measurement, and subjective self-report. In this study, he shows that Nepalese patients with symptoms consistent with ‘somatization’ are also much more likely to have physical conditions that could account for these somatic symptoms. The study highlights the importance of considering both physical and psychological causation.
Mauss, I. B., Butler, E. A., Roberts, N. A., & Chu, A. (2010). Emotion control values and responding to an anger provocation in Asian-American and European-American individuals. Cognition & Emotion, 24, 1026-1043.
Iris Mauss (University of California, Berkeley), Emily Butler (University of Arizona), and Nicole Roberts (Arizona State University) are research psychologists in affective science with interests in how culture shapes emotional responding. This paper shows how an in vivo lab experience can be used to study anger response, as measured by physiology, behavioral observation, and subjective self-report. Importantly, patterns of cultural variation depended on the assessment method used; observed differences were partially mediated by the extent to which participants valued emotional control.
Jeanne Tsai (Stanford University) is a clinical psychologist and affective scientist who takes a cultural psychology perspective on emotions and emotional disorders. In this study, cultural contexts are extended to their religious manifestations. Importantly, culture is considered both as ‘in the head’ and ‘in the world’, with one study based on subjective self-report and the second and third based on analysis of sacred texts and contemporary religious texts, respectively. This paper demonstrates how a single line of research can assess culture in multiple ways.
Weisz, J. R., Weiss, B., Suwanlert, S., & Chaiyasit, W. (2006). Culture and youth psychopathology: Testing the syndromal sensitivity model in Thai and American adolescents. Journal of Consulting and Clinical Psychology, 74, 1098-1107.
John Weisz (Harvard Unviersity) is a clinical psychologist whose extensive research on child and adolescent psychopathology includes several cultural studies. Bahr Weiss (Vanderbilt University) is a clinical psychologist interested in how culture shapes symptom expression in children. This study tests the Syndromal Sensitivity Model, which posits three processes linking culture and symptom presentation, in Thai and American youth samples. Results confirmed previously identified Thai-specific syndromes, demonstrating how cultural processes shape them in predictable ways.
Charmaine Williams (University of Toronto) is a professor of Social Work who focuses on race, culture, and disability in psychiatric settings. This study starts with the International Pilot Study of Schizophrenia and its finding, well-known to cultural psychiatrists, that outcomes are significantly better in ‘the Third World’ as compared with ‘the Western World’. She uses a qualitative method, discourse analysis, to critically examine the literature that followed publication of these findings, demonstrating that much of the resulting discourse served to maintain assumptions of ‘Western’ superiority.
Focal Studies from the Social and Personality Psychology Compass Paper
Ban, L., Kashima, Y., & Haslam, N. (2012). Does understanding behaviour make it seem normal? Perceptions of abnormality among Euro-Australians and Chinese-Singaporeans. Journal of Cross-Cultural Psychology, 43, 286-298.
This study examines cultural variation in beliefs about mental illness; specifically, whether a clear causal explanation makes abnormal behavior appear more normal and acceptable. While psychological explanations made behavior seem more normal to Euro-Australian students, they actually made the same behavior seem less normal to Chinese-Singaporean students. Chinese-Singaporeans had a greater tendency to prefer moral explanations of abnormal behavior, a group difference partially mediated by a measure of ‘traditionalism’. The study highlights the potential influence of intersubjectively held beliefs about abnormal behavior and how group differences can be partially unpacked through cultural values.
Chentsova-Dutton, Y. E., Chu, J. P., Tsai, J. L., Rottenberg, J., Gross, J., & Gotlib, I. H. (2007). Depression and emotional reactivity: Variation among Asian Americans of East Asian descent and European Americans. Journal of Abnormal Psychology, 116, 776-785.
Chentsova-Dutton, Y. E., Tsai, J. L., & Gotlib, I. H. (2010). Further evidence for the cultural norm hypothesis: Positive emotion in depressed and control European Americans and Asian Americans. Cultural Diversity and Ethnic Minority Psychology, 16, 284-295.
These studies involve four-group quasi-experiment comparing depressed and non-depressed East Asian and European Americans. The researchers used a multi-method approach, with psychophysiological, facial coding, and subjective self-report measurements of emotional response to film clips. Results were consistent with the Cultural Norm Hypothesis, that depression involves a deviation from cultural norms regarding emotions. These studies demonstrate how well-known and putatively universal findings on mental health do not necessarily hold in other cultural contexts. At the same time, they demonstrate how more general hypotheses that incorporate cultural norms can help explain observed cross-group differences.
Ryder, A. G., Yang, J., Zhu, X., Yao, S., Yi, J., Heine, S. J., & Bagby, R. M. (2008). The cultural shaping of depression: Somatic symptoms in China, psychological symptoms in North America. Journal of Abnormal Psychology, 117, 300-313.
This study uses multiple clinical assessment approaches – clinical interview, structured interview, and questionnaire – to evaluate symptom differences in Chinese and Euro-Canadian depressed patients. This study outlines a method for cross-group comparisons that point to potential specific explanations. First, item and structural equivalence methods are used to establish that the same symptom measures can be used across contexts and languages. Then, once group differences are established, mediation analysis is used to show how group differences in somatic symptom presentation can be partially explained by a tendency to engage in ‘externally-oriented thinking.’
On the Bookshelf
Dinesh Bhugra (King’s College, University of London) and Kamaldeep Bhui (Queen Mary University of London) are cultural psychiatrists who collaborated on editing a textbook in this field. Chapters 1, 2, 8, and 10-12 are particularly useful for background theory, 15-25 for specific disorders, and 28, 31, and 32 for psychological treatment.
Steven Heine (University of British Columbia) is a cultural psychologist who has written the first textbook for this specific approach to culture and psychology. Aimed at senior undergraduates and beginning graduate students, it introduces readers to the full range of the field, including chapters 11 and 12 on physical and mental health.
Shinobu Kitayama (University of Michigan) and Dov Cohen (University of Illinois at Urbana-Champaign) are cultural psychologists who have edited the first comprehensive handbook from this perspective. Especially relevant are parts 1 and 2 for background theory, and part 6 on motivation and emotion. A chapter on psychopathology is provided by Anthony Marsella (University of Hawai’i at Manoa), a pioneer in integrating clinical and cross-cultural psychology.
Arthur Kleinman’s book-length introduction to cultural psychology remains essential after more than two decades. Chapters 1 to 4 are particularly useful for cultural-clinical psychology.
This volume brings together a selection of classic papers in cultural psychiatry and medical anthropology. It starts in 1880 with George Miller Beard on the ‘Jumping Frenchmen of Maine’, includes Emil Kraepelin, Ernest Jones, Marcel Mauss, Claude-Lévi Strauss, and George Devereux, among others, and concludes in 1971 with Henry Murphy on the evolution of Latah and Amok.
Wen-Shing Tseng (University of Hawai’i at Manoa) is a cultural psychiatrist who distilled his earlier textbook for the field into this guide written especially for clinicians. Chapters 1-4 are recommended for a general theoretical overview, while chapters 5-7 are practical guides to culturally competent practice.