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Towards a Cultural–Clinical Psychology
Andrew G. Ryder1,2*, Lauren M. Ban1,2 and Yulia E. Chentsova-Dutton3
1
2
3
Concordia University
Sir Mortimer B. Davis-Jewish General Hospital
Georgetown University
Abstract
For decades, clinical psychologists have catalogued cultural group differences in symptom presentation, assessment, and treatment outcomes. We know that ‘culture matters’ in mental health – but
do we know how it matters, or why? Answers may be found in an integration of cultural and
clinical psychology. Cultural psychology demands a move beyond description to explanation of
group variation. For its part, clinical psychology insists on the importance of individual people,
while also extending the range of human variation. Cultural–clinical psychology integrates these
approaches, opening up new lines of inquiry. The central assumption of this interdisciplinary field
is that culture, mind, and brain constitute one another as a multi-level dynamic system in which
no level is primary, and that psychopathology is an emergent property of that system. We illustrate
cultural–clinical psychology research using our work on depression in Chinese populations and
conclude with a call for greater collaboration among researchers in this field.
Horace Cho1 is a 57-year-old businessman from Hong Kong who has resided in Vancouver for fifteen years, referred for insomnia, fatigue, loss of appetite, gastrointestinal distress, and depressed
mood. Mr. Cho was raised in Hong Kong, completed his MBA in California, and moved to Vancouver to join his wife’s family and start a new business. Despite Mr. Cho’s excellent English and
knowledge of North American practices, his business is in difficulty. He attributes business troubles
to the effects of his physical symptoms, rather than seeing these symptoms as resulting from psychosocial stress.
Mr. Cho lives in a majority Chinese suburb and encourages his children to stay close to Chinese
traditions; however, his daughters desire greater participation in North American society. He describes
his wife as much more traditional than he is, but to his surprise it is she who encourages the children
to participate in mainstream society. At the initial interview, Mr. Cho denies depressed mood but
agrees that symptoms, business difficulties, and values conflicts in his family are ‘upsetting sometimes’.
What is Mr. Cho’s ‘culture’, and is it the same as his wife’s? Does he have a mental
health problem and, if so, what is it? In what ways does culture shape the experience,
expression, and communication of his distress? Where can psychologists look for ways to
think about such questions?
Over the past few decades, scholars from several disciplines have examined the interrelation of culture and mental health. Many more have taken on cross-cultural comparisons in
mainstream psychology. That ‘culture matters’ in clinical psychology is nothing new,
although it bears frequent repetition in an era of biological reductionism. Rather, our claim
is threefold: first, that there is relatively little cultural research in clinical psychology that
aspires to explanation, to telling a culturally-framed story about what is observed; second,
that the means for achieving this can be found in greater integration of cultural and clinical
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psychology, to the benefit of both; and third, that the result is a new field. Cultural–clinical
psychology has in some sense been around for a while, pursued by a small number of
researchers. Nonetheless, it has not yet coalesced as an established field of study or as an
approach to culture and mental health research. This paper aims to promote these ends.
We start by locating ourselves with respect to ‘cultural psychology’ and ‘clinical psychology’, and then present some first steps toward a cultural–clinical psychology. Central
to this integration is the idea of mutual constitution – that culture, mind, and brain form
a single system in which no level can be understood without the others. We then draw
on our own research, pertaining to depression in Chinese populations, to provide some
empirical examples. We conclude with a brief critique of these studies, considering ways
in which they could be improved and interpreted in light of cultural–clinical psychology.
Concrete suggestions to improve cultural–clinical psychology research are summarized in
the Appendix and referenced throughout.
Cultural–Clinical Psychology: A Brief Introduction
Cultural psychology
In positioning cultural–clinical psychology, we begin by grounding the first term in the
‘cultural psychology’ perspective (e.g., Markus & Kitayama, 1991; Shweder, 1990). The
word ‘culture’ has long been used in psychology to stand for ethnicity or nationality, and
invoked as a black-box explanation: groups differ because of ‘culture’, but the specific
ways in which this happens remain unclear. Cultural psychology represents a move away
from cataloguing differences to understanding culture and how it shapes psychological
variation (e.g., Betancourt & López, 1993; Cohen, Nisbett, Bowdle, & Schwarz, 1996;
Heine and Norenzayan, 2006; Kitayama, Markus, Matsumoto, & Norasakkunkit, 1997).
Differentiating between culture and ‘cultural group’ emphasizes that individual group
members can partially adhere to or reject aspects of culture. For example, Mr. Cho and
his wife have different views about the acculturation of their children, and not in ways
that are obviously predictable from their own degree of traditionalism (Appendix: 1.1).
Is culture best understood as ‘in the head’ or ‘in the world’? These views are held in
tension and they sometimes conflict but, as with cognition and behavior in clinical psychology, neither is sufficient alone. People do not simply carry out behaviors. Rather,
they perform ‘acts of meaning’ (Bruner, 1990), intended by the actor and understood by
observers as meaningful. These acts are framed by the cultural meaning system and their
enactment contributes to shaping this system (Kashima, 2000). Nisbett and Cohen (1996),
for example, conducted an important series of studies on the ‘Culture of Honor’ in the
American South, reporting that southerners have more favorable attitudes towards violence in cases where honor is at stake. Moreover, they demonstrated experimentally that
southerners whose honor has been challenged are more physiologically reactive and take
longer to step out the way of a confederate walking toward them in a narrow corridor.
Cultural variation is captured here by both opinions and behaviors, and the behaviors of
both participant and confederate are understood as meaningful.
The idea of cultural scripts can bridge these perspectives, as they both reflect meaning
structures in the head and guide behavioral practices in the world (DiMaggio, 1997).
Scripts refer to organized units of knowledge that encode and propagate meanings and
practices. They serve as mechanisms that allow for rapid automatic retrieval and use of
information acquired from the world while shaping how that information is perceived.
Enacted as behavior, scripts are observable to others and become part of the cultural
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context, shaping assumptions about what others think and expectancies about how they
will behave (Chiu, Gelfand, Yamagishi, Shteynberg, & Wan, 2010). Moreover, people
can access multiple cultural scripts, primed by different contextual cues (Hong & Chiu,
2001). If while at home Mr. Cho scolds his children for pursuing a ‘Western lifestyle’, he
is accessing available scripts for cultural preservation while his actions and others’
responses contribute to shaping these scripts, and passing them to his children. In work
contexts, these same scripts may be primed rarely if at all. Mr. Cho’s wife can understand
him according to their shared meaning system even as she accesses a different available
cultural script – promoting her children’s well-being by ensuring they can function in a
new society (Appendix: 2.2).
Clinical psychology
In using the term ‘clinical’ in cultural–clinical psychology, we are thinking primarily of
researchers trained as scientists or scientist-practitioners in clinical psychology, health psychology, or experimental psychopathology. Although not all of these researchers are
directly engaged with both science and practice, there is an emphasis on moving between
theory and research about groups on the one hand, and the experiences and needs of
individual sufferers on the other. Clinical psychology is concerned both with describing
pathological phenomena and with using psychological principles to intervene with these
phenomena therapeutically.
As a health discipline, clinical psychology inevitably discusses ‘symptoms’ and ‘syndromes’ – specific pathological experiences and the ways in which they are grouped. Mr.
Cho’s reported symptoms are insomnia, fatigue, loss of appetite, and gastrointestinal distress, with some evidence of depressed mood. A clinician trained in DSM-IV has over
300 syndromes to consider, but would most likely consider Major Depressive Disorder
(MDD). Clinical psychology has long had a certain willingness to critique diagnostic systems accompanied by a preference for evidence-based symptom dimensions (Achenbach
& Edelbrock, 1983; Krueger & Markon, 2006). This openness benefits cultural studies of
psychopathology, as diagnostic systems are themselves cultural products (Gone & Kirmayer, 2010; Lewis-Fernández & Kleinman, 1994). Moreover, Kleinman (1988) argues that
rigid application of a diagnostic system conceals cultural variation. He has shown how
The International Pilot Study of Schizophrenia reliably identified patients meeting diagnostic criteria for schizophrenia, but in doing so eliminated a large proportion of psychotic patients at each site – precisely those patients who showed the most variability
across the cultural groups (Appendix: 1.2).
Cultural–clinical psychology: what’s new?
In an era both of fragmentation and interdisciplinarity in psychology (Cacioppo, 2007) it
is easy to argue that two areas can benefit from collaboration on topics of shared concern.
We wish to make a stronger claim in this case: a new field emerges at their intersection.
For this to be plausible, we must first establish that clinical psychology is altered by consideration of cultural questions. More challenging, we must also establish that cultural
psychology is altered by clinical questions, not simply given new content. Research in
cultural–clinical psychology should tell us something new about the cultural contexts
under study, not just the pathologies. Finally, we must demonstrate that new questions
and methods for addressing them emerge from this sub-discipline, or at least that the
potential is there (Appendix 2.1).
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Clinical psychology encounters cultural psychology. A central issue for clinical psychology –
what is disorder? – cannot be fully understood without considering deep cultural influence. The oft-used distinction between illness and disease defines illness as the socially-situated experience of having a particular disorder and disease as the corresponding
malfunction in biological or psychological processes (Boorse, 1975; Kleinman, 1977).
Wakefield (1992) similarly defines disorder as harmful dysfunction, in which harm indicates that the disorder is problematic in a given cultural context and dysfunction indicates
the failure of a biological system evolutionarily adapted for particular ends.
While these approaches ostensibly give equal credit to culture and biology, uncritical
acceptance plays into biases of mainstream clinical psychology. Researchers can end up
exemplifying Geertz’s (1984, p. 269) characterization of the behavioral sciences, in which,
‘‘culture is icing, biology, cake...difference is shallow, likeness, deep’’. We prefer to see
disorder as both biological and cultural, in a fundamentally inseparable way. Depressed
mood has many biological and cultural constituents worthy of focused study for specific
purposes, but there is no depressed mood until these constituents come together and are
experienced by someone.
Methodologically, clinical research has much to gain from incorporating the cultural
psychology perspective. Integration of findings on the cultural shaping of psychological
functioning can allow clinical psychologists to develop a broader and more nuanced view
of normal human experience. Cultural psychology is well positioned to help clinical psychology move beyond conceptualizations of mental illnesses as products of solitary minds
to thinking of it as contextually embedded in networks of local meanings, norms, institutions, and cultural products (e.g., Adams, Salter, Pickett, Kurtis, & Phillips, 2010). Finally,
cultural psychology can inform our understanding of the ways in which people, including
both patients and clinicians, incorporate contextual information in detecting, reporting
and interpreting symptoms of mental illness (for examples of these cultural psychology
ideas, not yet adapted for clinical questions, see Heine, Lehman, Markus, & Kitayama,
1999; Hong, Morris, Chiu, & Benet-Martı́nez, 2000; Masuda & Nisbett, 2001; Uchida,
Norasakkunkit, & Kitayama, 2004. In Mr. Cho’s case, the institutional demands of a
mental health clinic may have tilted the emphasis toward symptoms and attributions and
away from the understandable suffering caused by business and family difficulties (Appendix: 2.3).
The idea of scripts can help us think about specific ways in which mental health is
shaped by cultural context. Although by definition abnormality violates expectations of
what is normal, people nonetheless have scripts to help them make sense of pathology as
best they can. Confusing and frightening experiences, such as emerging psychopathology,
have a particularly strong need for scripts (Philippot & Rimé, 1997; Taylor, 1983). The
large but finite number of ways to be physically or psychologically distressed is further
molded by cultural-historical context, so that specific disorders draw upon a pool of available symptoms (Shorter, 1992). Cultural scripts can then be seen as mapping the sufferer’s
experience to what is available in this ‘symptom pool’, focusing on and thereby amplifying those symptoms that best serve explanatory and communicative purposes. Denial of
depressed mood and acknowledgement that his problems are upsetting can be seen as
serving Mr. Cho’s communication goals in a particular health care setting.
Cultural psychology encounters clinical psychology. Beyond providing new content, potential
contributions of clinical psychology begin with two of cultural psychology’s core
concerns: heterogeneity of cultural groups and limited coherence of cultural contexts
(Kashima, 2000). These concerns do not necessarily require clinical psychology, but the
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study of mental disorder serves as an engine to generate many examples of each. Psychopathological phenomena also shed new light on culture; as with the lesion studies that
propelled neuroscience, we learn new things about cultural processes when the normal
cultural scripts no longer work (For a similar idea, not specific to psychopathology, see
Beckstead, Cabell, & Valsiner, 2009). North American studies of social phobia patients
highlight the central role fear of negative evaluation plays when healthy interpersonal functioning breaks down (see Hofmann & Barlow, 2002). These findings also reveal some of
the assumptions of normal social relationships in North America: one is to portray one’s
true self and have it be positively evaluated by others. Studies of socially anxious patients in
other cultural groups can serve the same function, showing for example how fear of causing discomfort to others – perhaps by inappropriately revealing one’s true self – is a central
concern for many socially anxious people in East Asian contexts (Rector, Kocovski, &
Ryder, 2006; Sasaki & Tanno, 2005; Zhang, Yu, Draguns, Zhang, & Tang, 2000).
Methodologically, clinical psychology has a rich tradition of modeling ways in which
abnormal behavior is shaped by constraints imparted by physiological and environmental
influences, and their interactions. For example, contemporary research on depression
spans multiple levels of analysis ranging from genes to hormones, brain anatomy and
function, attention, memory, emotional reactivity, personality, and interpersonal functioning (Hammen, 2003; for a thorough review, see chapters in Gotlib & Hammen, 2009).
Clinical psychology can also provide tools for theorizing about the ways in which psychological processes become functional or dysfunctional in a cultural context. For example, cultural innovation and propagation depends on specific abilities, such as harnessing
novel associations or conveying negative emotions (Chentsova-Dutton & Heath, 2007),
that are also associated with predisposition to certain forms of psychopathology.
Cultural–clinical psychology: mutual constitution of culture–mind–brain
The core claim of cultural psychology is not simply that groups differ or ‘culture matters’,
but rather that human culture and human psychology are each grounded in the other:
that culture and mind ‘make each other up’ (Shweder, 1991). Clinical psychology
research, in keeping with trends in psychological science and in psychiatry, tends to focus
more on the interrelation of mind and brain (Andreasen, 1997; Barrett, 2009; Ilardi &
Feldman, 2001). We argue that the best approach for cultural–clinical psychology emerges
from the joint concerns of the two fields, leading us to discuss mutual constitution of culture, mind, and brain. This approach follows recent trends in cultural psychiatry (Kirmayer, forthcoming) and cultural psychology (Chiao, 2009; Kitayama & Park, 2010;
Kitayama & Uskul, 2011), in which culture, mind, and brain are thought of as multiple
levels of a single system, here called the culture–mind–brain (Appendix: 3.1).
Culture and mind. The mutual constitution of culture and mind develops through processes that are an integral part of socialization, in that minds develop in cultural contexts
that are themselves composed of minds (Cole, 1996; Valsiner, 1989). We cannot understand human minds unless we understand them in cultural context, and we cannot understand human culture unless we understand minds. The goal is to find ways of thinking
and studying the psychological and the cultural so that neither is seen as the ultimate
source of the other (Markus & Hamedani, 2006; Shweder, 1995).
Mind and brain. It is increasingly untenable to propose models of mental health that have
no room for the brain, as shaped by the genome and in turn by evolutionary processes.
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While we agree wholeheartedly with Geertz (1973) that, ‘‘it is culture all the way
down’’, we also simultaneously make the opposite claim: it is biology all the way up.
Both must be true for mutual constitution to have any meaning. Rather than seeing mind
as the subjective epiphenomenon of brain, however, we prefer a view of mind as fundamentally social and tool-using, even as extended beyond the brain (Clark & Chalmers,
1998; Hutchins, 1995; Kirmayer, forthcoming; Vygotsky, 1978). Habitually used tools
and close others are partially incorporated into one’s mind: the online calendar can
become part of the mind’s memory system; the close friend can become part of the mind’s
emotion regulation system.
Culture and brain. It does not necessarily follow from a tripartite model of culture, mind,
and brain in this way that mind mediates all culture-brain links. The human brain is
adapted to acquire culture and responds to cultural inputs with marked plasticity, especially early in development (Wexler, 2006). Indeed, the emergence of a recognizable
human mind may require these transactions between culture and brain. At the same time,
biology constrains culture. There are a large number of possible ways in which culture
can be configured, yet the number of impossible configurations is practically infinite (Gilbert, 2002; Mealey, 2005; Öhman & Mineka, 2001). That this is true does not compromise the equally important observation that human possibilities are many, diverse, and
deeply shaped by culture (Marsella & Yamada, 2010; Tseng, 2006).
The ecology of culture–mind–brain. Describing the interrelations of culture, mind, and brain
as a triangle of linked associations might imply three interrelated systems. We prefer to
think of culture–mind–brain as one dynamic multilevel system, an information network
instantiated in neuronal pathways, cognitive schemata, human relationships, culturallymediated tools, global telecommunications, corporations, political actors, health care systems, and so on. Cultures, minds, and brains cannot be understood in isolation from one
another. As yet, there is little research that engages with all three levels simultaneously,
although a promising avenue has been opened by Kim, Sherman, Taylor, et al. (2010a).
These researchers showed that cultural context and variations in certain serotonin receptor genes interact to predict locus of attention. Specifically, one of the variants predicts a
tendency to attend to context in Korean participants, and the same variant predicts an
especially strong tendency to attend to the focal object in Euro-American participants.
Psychopathology is an emergent property of culture–mind–brain, with no ultimate
cause at any one level. While changes at one level affect all levels, it does not follow that
disorder at one level means disorder at other levels, let alone that disorder at a higher
level must be caused by disorder at a lower level. A disordered brain circuit does not
require malfunctioning neurons, nor does a disordered neuron require malfunctioning
molecules, although neither makes sense in the absence of neurons or molecules. Pathology can emerge from problematic feedback loops in which the response to a problem
exacerbates the problem, even when all components of the loop are working normally
(Hacking, 1995; Kirmayer, forthcoming). A conditioned fear that goes on to cause problems in living is a disorder, it involves the brain, but it does not require a disordered
brain. Values conflict between Mr. Cho and his wife can create a stressful environment
for their children, but not because a lower-level disorder leads them to adhere to pathological values.
Disorder at higher levels can also lead to disorder at lower levels. Cultural norms, economic conditions, and political response might interact to produce violent conflict, with
consequences that include damage to brains from traumatic stress. It is incomplete at best
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to claim that psychological consequences of that damage are caused by the brain without
acknowledging political or economic causes. Similarly, Mr. Cho’s depression might make
sense as psychosocial stress coupled with preexisting vulnerability, but the depression has
lasting consequences for the brain (Kendler, Thornton, & Gardner, 2000). A mind-level
intervention such as Cognitive-Behavior Therapy (CBT), moreover, impacts on the brain
(DeRubeis, Siegle, & Hollon, 2008) – unsurprising, as culture–mind–brain is a single
system (Appendix: 3.2).
Before considering an example of three recent cultural–clinical psychology lines of
research focused on an interrelated set of questions, let us briefly return to the case of
Mr. Cho.
After the initial assessment, Mr. Cho began a 16-week course of CBT for depression. The
case at first appeared to be a textbook case of ‘Chinese somatization’; somatic symptoms were
discussed almost exclusively, unlinked to psychosocial stressors. Sustained discussion of these
stressors would sometimes lead to marked tearfulness and inability to maintain emotional composure. Once rapport was established, depressed mood was acknowledged fairly quickly, along with
guilt and pessimism, primarily described as reactions to how the physical symptoms had impacted
his business and family life.
Mr. Cho asked several times how CBT could help him with his primary concern – the somatic
symptoms – and as treatment turned to depressed mood, guilt, and pessimism, he began to miss sessions. We reframed treatment in line with CBT approaches to Chronic Fatigue Syndrome – emphasizing holism of mind and body, talking more openly about somatic symptoms, and incorporating
some somatic approaches such as sleep hygiene and diet regulation. Psychological and physical causes,
psychological and physical symptoms, all became legitimate topics for discussion.
Cultural–Clinical Psychology: Empirical Examples
We are each involved in independently developed lines of research taking a cultural psychology approach to clinically-relevant questions about Chinese-origin participants and
depression. To illustrate the potential of cultural–clinical psychology, we turn to a more
sustained discussion of this work.
Cultural psychology research on depression
Somatic and psychological symptoms. In a now classic study, Kleinman (1982) argued that
Chinese psychiatric patients tend to emphasize somatic symptoms relative to ‘Western’
norms (see also Parker, Cheah, & Roy, 2001). Ryder et al. (2008) used multiple assessment methods with Han Chinese and Euro-Canadian psychiatric outpatients. Results
generally showed greater somatic symptom reporting in the Chinese group and greater
psychological symptom reporting in the Euro-Canadian group. The tendency to devalue
the importance of one’s emotional life was also higher in the Chinese group and mediated the relation between cultural group and symptom presentation.
Devaluation of one’s emotional life does not fit well with readily accessible cultural
scripts in North America. This tendency was measured using a tool designed to measure pathology, the Externally-Oriented Thinking (EOT) subscale of the Twenty-item
Toronto Alexithymia Scale (TAS-20; Bagby, Parker, & Taylor, 1994). Whereas EOT
might capture pathological beliefs in a cultural context that fosters ideals of healthy
emotional expression, it may simply represent adherence to an accessible cultural
script in Chinese contexts (see Dion, 1996; Kirmayer, 1987). In a comparison of
Chinese- and Euro-Canadians, group difference in EOT was mediated by adherence to
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‘Western’ values (Dere, Falk, & Ryder, forthcoming). People vary in accessibility of
cultural scripts about emotional expression, and cultural contexts vary in terms of how
normal these scripts are perceived to be. Mr. Cho had access to multiple scripts but
the Chinese somatic script predominated – he emphasized somatic symptoms while
increasingly considering psychological symptoms, and tended to see the latter as consequences of somatic symptoms.
Emotional expression. Studies comparing depressed Euro-Americans and Asian-Americans
to their non-depressed counterparts show that depression is associated with culturally-specific patterns of emotional reactivity. For Euro-Americans, depression is characterized by
dampened emotional reactivity in response to positive and negative emotional films (see
Bylsma, Morris, & Rottenberg, 2008). Chentsova-Dutton et al. (2007) replicated this
pattern with negative films in Euro-Americans using self-report, facial coding, and
physiological measures, but failed to find it – and at times, found the inverse – in AsianAmericans (primarily Chinese-Americans). More surprisingly, Chentsova-Dutton, Tsai,
and Gotlib (2010) replicated the pattern using positive films, so that on certain measures
such as cardiac reactivity, depressed Asian-Americans were actually more reactive than
non-depressed Asian-Americans.
Cultural contexts provide people with shared scripts for how to feel and express emotions. Failure to enact culturally normative emotional scripts may contribute to depressed
mood, and may also be exacerbated by such mood. The Euro-American pattern of dampened reactivity when depressed may reflect failure to enact accessible cultural scripts for
open and prominently displayed emotional responses (Bellah, Sullivan, Tipton, Swidler,
& Madsen, 1985). The Chinese-American pattern of heightened reactivity when
depressed may reflect failure to enact readily available cultural scripts of moderated experience and expression of one’s emotions (Russell & Yik, 1996). Exemplifying the latter,
Mr. Cho was at times strikingly expressive discussing difficult topics despite retrospectively denying depressed mood.
Explanatory models. It is normative in ‘Western’ cultural settings to not just emphasize
psychological symptoms but also to link distress to psychological causes. Ban, Kashima,
and Haslam (2010) explored the extent to which behavior is deemed pathological if it
violates this cultural script. A vignette describing someone with depression, including or
not including a psychological cause, was presented to Euro-Australian and Chinese-Singaporean university students. Euro-Australian students were more likely to perceive
depression as ‘normal’ when their vignette included a psychological explanation. For
Chinese-Singaporean students, psychological explanations made the depression seem less
normal, and they preferred moral to psychological explanations on a questionnaire.
For Euro-Australians, living in a cultural context with a readily accessible script equating abnormality with irrational psychological functioning, psychological explanations help
restore a sense of order. Chinese-Singaporeans, by contrast, live in a cultural context
where the predominant script equates emotional maturity with adjustment of behavior to
situational demands (Kirmayer, 2007). Indeed, Chinese-Singaporean moral explanations
centered on failed social obligations. These modes of explanation represent scripts that are
available, to varying extents, in different cultural contexts. Mr. Cho initially presented
along the lines of a medicalizing script, which soon gave way to a moralizing script about
failing his family. Eventually, he was willing to consider a psychologizing script without
fully endorsing it.
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Reinterpreting the research
How can we understand these findings in light of culture–mind–brain? Before depression
emerges, people have access to culturally shaped scripts about what depression is and
assume others have access to these scripts as well (Ban et al., 2010). Once depression
emerges, its implications cascade rapidly through all levels of culture–mind–brain, motivating people to make sense of what is happening to them (Philippot & Rimé, 1997).
Scripts focus attention on certain symptoms, magnifying some experiences and minimizing others. A looping effect takes place – experiences that best draw upon the cultural
symptom pool in ways that fit available scripts about depression are focused upon, further
contributing to their severity (Shorter, 1992). Multiple cultural scripts can coexist and
draw upon this pool, so that patients in a single cultural context can nonetheless present
many different kinds of symptoms (Ryder et al., 2008).
In keeping with the idea of mind as social, we have real and imagined audiences for
this process: what do we tell other people; what are they going to notice; how are they
going to react? (Chiu et al., 2010) These others are specific others, with their own experiences, relationships with the sufferer, social roles, and functions within societal institutions. The real and imagined presence of specific others shapes the explanations chosen,
the emotions expressed, and the symptoms emphasized (Chentsova-Dutton & Tsai, 2010;
Jakobs, Manstead, & Fisher, 1996; Lam, Marra, & Salzinger, 2005; Matsumoto, Takeuchi,
Andayani, Kouznetsova, & Krupp, 1998). Sufferers generate additional stressors as others
react to evident and unusual signs. It is not simply that depression is associated with nonnormal emotional expressions (Chentsova-Dutton et al., 2007, 2010), but that another
loop is generated where reactions of others to these expressions lead to censure and withdrawal, hence to rejection and further depression.
As per the cultural dynamical approach (Kashima, 2000), we should expect actual
experiences of depression – what is experienced, expressed, talked about, witnessed,
shared with mental health professionals, discussed in the local community – to shape cultural scripts pertaining to depression. There is emerging evidence in China that rapid
social change is shifting public understanding of depression, altering cultural scripts, and
in turn shaping symptoms presented by successive cohorts. In consequence, exposure to
modernization and Westernization values is lessening the tendency for Chinese patients to
emphasize somatic symptoms of depression (Ryder et al., forthcoming).
Contributions and limitations
These studies represent three independent attempts to bring together cultural and clinical
psychology to investigate a particular clinical phenomenon in a particular cultural group,
drawing on both fields for theory, methodology, and interpretation. These studies go
beyond cataloguing group differences, examining how various aspects of Chinese – and
‘Western’ – cultural contexts, including scripts, values, cognitive styles, norms, and attributions, shape depression. They are methodologically varied, including self-report questionnaires but also interviews, open-ended response coding, psychophysiology, facial
coding, vignettes, mediation analysis, and experimental designs.
Our studies have limitations, notably including failures to adhere to some of the recommendations summarized in the Appendix. Cultural and diagnostic groups, for example,
could be more clearly defined. The studies are compatible with a dynamic view of
culture but do not go very far in advancing that agenda. Culture is not assessed in a
multi-method way. More fundamentally, however, what is missing so far is the brain,
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and thus the potential synthesis implied by culture–mind–brain. Somatic and emotional
experiences are connected in the brain (Craig, 2008) and may be emphasized or deemphasized in the mind based on cultural scripts (Wiens, 2005). Kim, Sherman, Sasaki, et al.
(2010b) have shown that variations in oxytocin receptor genes interact with cultural context and level of subjective distress to predict help-seeking, a rare example of how levels
of culture–mind–brain can be included in a single study.
Even with improvements in conception, sampling, methods, and interpretation, we do
not expect that any given study, or even research program, would cover everything discussed here. Cultural–clinical psychology already exists in a sense, including researchers
who have been making important contributions for years. At the same time, there is as
yet little sense of a shared enterprise, let alone of the institutional markers of such. What
is needed is a greater degree of coherence and integration, where individual research
groups approach different pieces of the overall puzzle, but with a shared framework and
an ongoing commitment to putting this puzzle together.
Conclusion
There is much to be gained from greater connection between cultural and clinical psychology, with a core of researchers at the intersection. Cultural psychology can benefit
from testing the limits of cultural influence across the full range of psychological functioning, including psychopathological extremes and difficult environmental conditions.
Likewise, clinical psychology can consider a wider range of sociocultural phenomena that
may affect mental illness. The two fields together point to a dynamic model of culture–
mind–brain that can serve as a central pillar of this interdisciplinary field. Cultural–clinical
psychology advances attempts to conceptualize mental health phenomena as dynamic and
context-dependent, rather than fully reducible to physiological deficits or environmental
stressors. We emphasize ‘cultural’ aspects because we believe that explanations at this level
are often neglected in mental health research, but hope that ultimately no discussion of
mental health will seem complete without consideration of all levels.
The case of Mr. Cho illustrates how knowledge of cultural context and its accessible
symptom scripts help us to better assess clients and modify treatment approaches to better
adapt to these scripts. We observe how the clinical encounter becomes a space in which
cultural scripts are negotiated, influencing both participants and shifting over the course of
treatment. Training programs, internship sites, and licensing bodies increasingly insist on
training in diversity and cultural competence without a clear vision of how to proceed or
what evidence to use. Cultural competence is more than simply using good clinical skills
with ethnic minority patients; cultural–clinical psychology can aspire to provide an evidence
base (Ryder & Dere, 2010). At the same time, cultural competence includes questioning
that evidence, considering dangers of reducing people to cultural categories (Kleinman &
Benson, 2006). As we conclude our case history, we catch a glimpse of how seeing a
patient’s symptoms only through the lens of cultural explanations can yield surprises.
By the end of treatment, Mr. Cho was still struggling but wanted to try implementing some
changes by himself. He continued to prioritize somatic symptoms, but agreed that psychological
symptoms were part of his experience. At six-month follow-up, Mr. Cho reported ongoing appetite
and gastrointestinal problems, but much better sleep, energy level, and mood. He mentioned that he
was now working with a specialist, who was finding that the ongoing gastrointestinal and appetite
problems might be related to a specific medical issue. The possibility of this separate issue may have
been lost in the context of the other symptoms.
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970 Cultural–Clinical Psychology
Acknowledgment
Preparation of this manuscript was supported by a New Investigator Award from the
Canadian Institutes of Health Research to AGR. The authors gratefully acknowledge the
comments provided by Emily Butler, Jessica Dere, Marina Doucerain, Alan Fiske,
MarYam Hamedani, Nick Haslam, Steve Heine, Tomas Jurcik, Yoshi Kashima, Laurence
Kirmayer, Michael Lorber, Andrea McCarthy, Vinai Norasakkunkit, Nicole Stephens,
and Romin Tafarodi on earlier versions of this manuscript.
Short Biographies
Andrew G. Ryder received his doctorate in psychology (clinical) from the University of
British Columbia and currently directs the Culture, Health, and Personality Lab in the
Department of Psychology at Concordia University, where he holds the position of Associate Professor. He is also an adjunct faculty member in the Culture and Mental Health
Research Unit at the Sir Mortimer B. Davis–Jewish General Hospital in Montreal. Dr.
Ryder’s research lies at the intersection of cultural, clinical, and personality psychology.
Most of his published work combines at least two of these areas, including papers in Journal of Abnormal Psychology, Harvard Review of Psychiatry, Journal of Affective Disorders, Journal
of Personality and Social Psychology, and Journal of Personality Disorders. Current research
focuses on: (a) the intersection of cultural and personality variables in shaping depressive
symptom presentation in China and South Korea; and (b) acculturation and adaptation in
complex multicultural societies. His work is supported by a New Investigator Award
from the Canadian Institutes for Health Research (CIHR) and grants from CIHR and the
Fonds de la recherche en santé du Québec.
Lauren M. Ban received her doctoral degree in psychology (social) from the University
of Melbourne. At time of writing she was a postdoctoral fellow in the Department of Psychology at Concordia University and the Culture and Mental Health Research Unit at the Sir
Mortimer B. Davis–Jewish General Hospital in Montreal, under the supervision of Dr.
Ryder and Dr. Laurence Kirmayer. Her dissertation research explored folk perceptions of
mental disorder comparing people with East Asian (primarily Chinese–Singaporean) and
European–Australian cultural backgrounds, and a study from this work has been published
in the Journal of Cross-Cultural Psychology. Current research takes a cultural psychology perspective on self-construals, explanatory models of mental illness and internalized stigma.
Yulia E. Chentsova-Dutton received her master’s degree (clinical science and psychopathology) from the University of Minnesota and her doctoral degree (affective science)
from Stanford University. She holds the position of assistant professor in the Department
of Psychology at Georgetown University in Washington, D.C., where she directs the
Culture and Emotion Lab. Her research spans cultural psychology, emotions, and mental
health, and her publications include papers in the Journal of Abnormal Psychology, Journal of
Personality and Social Psychology, and Cultural Diversity and Ethnic Minority Psychology. Her
specific research interests include the cultural shaping of: (a) emotions, including conceptions and functions of emotions, emotional reactivity, and interoception); and (b) social
support, including advice-giving and support networks. Her work is supported by the
Social Psychology Program of the National Science Foundation.
Endnotes
* Correspondence address: PY153-2, 7141 Sherbrooke St. W., Montreal, Quebec, H4B 1R6, Canada. Email:
andrew.ryder@concordia.ca
1
Horace Cho is based on a composite of two cases. Identifying information has been fictionalized.
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Appendix: Practical recommendations for conducting cultural–clinical
psychology research
1. Defining cultural and diagnostic categories. When we use categories, we have
a tendency to assume that these categories are clearly separated from one another and
capture fundamental differences. We essentialize groups when we assume that all people
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from a certain cultural background or carrying a certain diagnosis are the same as one
another, and different from people in other groups. At the same time, however, it is very
difficult to conduct research without relying on groupings of individual people. Researchers should therefore adopt a pragmatic rather than essentialized approach to describing cultural groups
and diagnostic categories:
1.1. For cultural groups, specify on a study-by-study basis how each group is defined
and for what purposes, and interpret results in light of a more nuanced and dynamic view
of culture. Doing so not only means more accurate reporting of methods, but also serves
as a reminder that group membership is not self-evident, especially around the edges of a
given category.
1.2. For diagnostic categories, consider a ‘lumping’ approach for syndromes and a
‘splitting’ approach for symptoms – very few broad categories for communication and
comparison purposes (e.g., emotional disorders, psychotic disorders) followed by a
fine-grained approach to individual symptoms. We might define the problem being
compared across groups very broadly – for example, how do people in different context
cope with loss? – and then seek to answer that question in part by looking at differences
in how individual symptoms are presented.
2. Understanding and measuring culture. Culture is complex, deeply interconnected with all aspects of human life, often implicit, rarely straightforward, and can shape
different people in different ways. It is therefore difficult to study, and it is hard to
conduct good research without already knowing a lot about the context being studied –
much as mainstream psychology researchers have a lot of tacit and unexamined
knowledge about their own contexts. Researchers should therefore know the cultural context
well, aided by personal immersion in the context, selected cultural informants, and ⁄ or multicultural
research teams:
2.1. Tell a cultural story about the phenomena under study, aiming to explain ways in
which culture shapes mental health rather than cataloguing group differences. At the start
of a line of inquiry, that should involve using knowledge of the cultural context to
propose potential explanations. Later on, studies should incorporate these potential
explanations into the research design; for example, by testing the extent to which they
can mediate group difference effects, or by manipulating them experimentally.
2.2. Pay attention to and assess contradictory cultural scripts, rather than assuming that
cultural contexts foster a single script for a particular domain. Doing so helps move away
from cultural determinism and helps counteract the tendency to essentialize culture, serving as a reminder that culture is complex and can influence different people in different
ways.
2.3. Aim to measure culture in a multi-method way, as it exists in the head (e.g., via
self-report or implicit cognitive tasks) and in the world (e.g., via behavioral observation
or examination of cultural products). While not always possible within a single study, use
of different methods strengthens a line of research and captures some of the complexity
of culture. Indeed, it is not always the case that these different methods will agree; points
of contradiction may be important.
3. Situating research within the culture-mind-brain system. We have described
culture, mind, and brain as a deeply interactive and non-reductive multilevel system. It is
not possible to capture such a system within a single study, or even in a line of research.
What is possible, however, is to focus on aspects that are important to the research
question and compatible with one’s training and resources. These aspects should be idenª 2011 Blackwell Publishing Ltd
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tified and studied carefully while we remain mindful that our work is embedded within a
broader system. Researchers should therefore remember that a complex and dynamic system requires
one to enter at a certain point, chosen for reasons of practicality or training:
3.1. Use culture–mind–brain as the overarching framework, clearly delineating a certain part of the system within a study for pragmatic research purposes. A more narrowlydefined study (e.g., described by the methods and results) can be framed within a broader
conceptual argument (e.g., described by the introduction and discussion). A series of
more specific empirical papers can be supported by a more general theoretical review.
3.2. Given that one is focusing on part of the system, frame causal arguments as proximal rather than ultimate. It is unlikely that one has identified a causal explanation for
anything that itself has no need of explanation. This does not take away from the possibility that we might have identified a crucial link in the causal chain, or the importance
of doing so.
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• Rejoinder
Walking the Talk:
Implementing the Prevention Guidelines and
Transforming the Profession of Psychology
Sally M. Hage
Teachers College, Columbia University
John L. Romano
University of Minnesota, Twin Cities
Robert K. Conyne
University of Cincinnati
Maureen Kenny
Boston College
Jonathan P. Schwartz
University of Houston
Michael Waldo
New Mexico State University
The Major Contribution aimed at strengthening a prevention focus in psychology, so as to
more effectively and equitably promote the well-being of all members of psychology communities. The 3 reactions (L. A. Bond & A. Carmola Hauf, 2007 [this issue]; L. Reese,
2007 [this issue]; E. Rivera-Mosquera, E. T. Dowd, & M. Mitchell-Blanks 2007 [this
issue]) give strong support for the best practice prevention guidelines, while providing
new insights for their implementation in the field of psychology. In this rejoinder, the
authors make an effort to build upon their colleagues’ ideas, by addressing the topics of
community-based collaboration, prevention across the life span, and implementation of
the best practice guidelines. The authors urge further interdisciplinary collaboration by
members of the American Psychological Association, and others interested in prevention,
and invite genuine action to expand prevention efforts.
Undoubtedly, the expression—“You can talk the talk, but can you walk
the walk?”—is familiar to many people. A shortened variation of the original phrase, “Walk the talk,” may be less well known but can be found in
the Encarta World English Online Dictionary (2006), and is defined as “to
act on what you profess to believe in or value.” The words suggest that real
After the first two authors listed above, the remaining authors of this article are listed in alphabetical order. Correspondence concerning this article should addressed to Sally M. Hage,
Teachers College, Columbia University, Counseling and Clinical Psychology Department,
Box 102, 426A Horace Mann, New York, NY 10027; e-mail: hage@tc.columbia.edu.
THE COUNSELING PSYCHOLOGIST, Vol. 35, No. 4, July 2007 594-604
DOI: 10.1177/0011000006297158
© 2007 by the Division of Counseling Psychology
594
Hage et al. / WALKING THE TALK
595
change happens when leaders not only say they want change and advancement but also match their words with actions. We are grateful to the authors
who provided reactions to our article (Bond & Carmola Hauf, 2007 [this
issue]; Reese, 2007 [this issue]; Rivera-Mosquera, Dowd, & Mitchell-Blanks,
2007 [this issue]). Their thoughtful commentary and suggestions highlight
the importance of moving these Prevention Guidelines (Hage et al., 2007
[this issue]) from a publication in a scholarly journal to genuine actions for
change in the field of psychology. We are also grateful to The Counseling
Psychologist (TCP) Editor Robert T. Carter who gave us the opportunity to
develop the article into a Major Contribution manuscript, and to receive
reactions to these guidelines by eminent scholars in the field.
The reaction articles in this Major Contribution include authors from
specialties in social work, clinical psychology, and counseling psychology.
In addition, they represent work settings as diverse as university psychology departments, a government mental health department, a community
advocacy agency, and a medical school. The work of prevention is multidisciplinary, and it is critically important that researchers, practitioners, and
policy makers from across the professional landscape collaborate and form
partnerships to advance a prevention agenda. We are extremely pleased and
honored that these scholars, from different specialties and professional
work environments, have given their reactions to the guidelines. In the limited space in this rejoinder, we will address several of the issues presented
by the reaction articles.
COMMUNITY-BASED COLLABORATION
Bond and Carmola Hauf (2007), Reese (2007), and Rivera-Mosquera
et al. (2007) all identified the importance of collaboration as a central component of best practices in prevention. Although our guidelines did not
explicitly address collaboration, our third practice guideline emphasizes
the importance of including “clients and other relevant stakeholders in all
aspects of prevention planning and programming” and thus recognizes the
necessity of forming community partnerships in prevention work (p. 508).
That being said, the reactants did a service by further emphasizing the
importance of collaboration as an integral component of best practices at
several levels. All three reaction articles note that the perspectives and
knowledge base of any single profession are limited in informing and
guiding the practice of prevention. Indeed, these authors collectively
describe why collaboration should occur at the local community level,
with other helping professionals, and with scholars and researchers from
other disciplines.
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Bond and Carmola Hauf (2007) maintain that interdisciplinary scholarship should provide the theory and research base for effective prevention.
They effectively explain how community collaboration is critical to the
development of comprehensive and multisystemic interventions. In addition, Rivera-Mosquera et al. (2007) advocate for collaboration across the
health and mental health professions, including counseling and clinical psychologists, social workers, nurses, and public health workers. Reese (2007)
similarly notes that the knowledge base of multiple disciplines, such as epidemiology, health, economics, and sociology, are integral to public health
practice and prevention. By insulating ourselves from other disciplines and
professions, we are likely to miss important research knowledge. Similarly,
by cutting ourselves off from the communities we serve, we may miss an
understanding of local needs and knowledge. Furthermore, from a training
perspective, learning the art of collaboration represents an example of an
area where even more “how to” guidance is needed. Some authors (e.g.,
Kenny, Sparks, & Jackson, in press) are documenting their work in collaboration in efforts to identify lessons to further guide training and practice in
interprofessional collaboration. Developing and sustaining effective collaborations with multiple stakeholders and then negotiating and reconciling
the competing needs represented by varied perspectives are challenging
tasks.
Similarly, as Bond and Carmola Hauf (2007) suggest, community-based
collaboration enables more accurate and relevant prevention research. One
potential function of Waldo and Schwartz’s (2003) prevention research
matrix presented in this issue is to point out how diverse sources of expertise available through community and interdisciplinary collaboration can be
integrated to conduct comprehensive prevention research. For example,
community members can provide unique information on the epidemiology
of problems within their community; they can inform the design of preventive interventions, ensuring they are targeted on the most salient variables
and are sensitive to community norms; and they can identify the systems
and resources within a community that will allow wide and sustained delivery of prevention services.
The expertise of different disciplines may also make unique contributions in each of these service areas. For example, the field of public health
is especially suited to clarifying epidemiology, clinical psychology is
strong in the design and evaluation of interventions, and the social work
profession is adept at creation and assessment of service delivery systems.
Rivera-Moquera et al. (2007) eloquently state that “each of us brings a
unique experience and set of skills that are needed to begin to address the
serious societal problems facing our country and our world” (p. 590).
Hence, the diverse communities and professional disciplines must work
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together in “sharing our skill sets, lessons learned, and methodology to
bring about real social change” (Rivera-Mosquera et al., 2007, p. 590).
Nevertheless, in spite of our strong agreement with all three of the reactants that collaborative community partnerships are critically important to
the work of prevention specialists, we are reluctant to identify the forming
of such partnerships as the “overarching best practice” of prevention. The
major reason for our hesitation to adopt this perspective, as argued by Bond
and Carmola Hauf (2007), is that “community” is too often interpreted narrowly. A framework of “community” may not give sufficient visibility to
educational training of psychologists or political advocacy for prevention.
As Rivera-Mosquera et al. (2007) comment, the four conceptual areas of
the guidelines, which include practice, research, training, and social advocacy, provide a necessary conceptual framework. In addition, a community
is not a single voice and may, for example, include parents, teachers, businesses, workers, social services agency leaders, clergy, and youths. In addition to a divergence in voices emanating from the field, these voices may
not be congruent with those from multiple professions and scholarly disciplines. Thus, although better practice may eventually emerge, the processes
through which this happens are not always clear. Indeed, Bond and
Carmola Hauf (2007) recognize the tensions that often exist when preventionists attempt to apply prevention interventions across diverse groups of
people.
One method to address specific needs across divergent groups or to assess
in-group differences is through a process called “elicitation research”
(Flores, Tschann, & Marin, 2002). This research process collects information during the development phase of a prevention intervention to better
understand relevant personal cognitions and social norms important to a
group or population receiving the intervention, thus strengthening the relevancy of the intervention for those receiving it. Conducting elicitation
research prior to finalizing a prevention intervention increases the chances
of a successful outcome for behavior change by addressing variables important to the group being served. Romano and Netland (in press) demonstrated
how elicitation research and the theory of reasoned action (Ajzen &
Fishbein, 1980; Albarracin, Fishbein, Johnson, & Muellerleile, 2001) can
address within-group differences in the development and implementation of
prevention interventions.
PREVENTION ACROSS THE LIFE SPAN
Reese (2007) notes that many of the examples of prevention interventions
provided in our set of Prevention Guidelines were drawn from practice with
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young people, despite the fact that prevention theory and practice cut across
the life span. We concur with Reese on his point and hope that our examples
of effective interventions with youths do not lead readers to think of prevention as an activity only for the early years. Prevention is not only for children and adolescents but also must be applied throughout the life cycle,
including the development of preventative interventions for diverse groups
of women and men at midlife and communities of older adults. Indeed,
developmental challenges, risks, and opportunities for positive development
occur across the life span, and these many stages of life represent significant
opportunities for prevention-minded psychologists to engage in active collaborative efforts across the disciplines. It is possible that many of our
examples emerge from youth work because schools and colleges have been
available settings for prevention interventions, and they also offer opportunities for funding of prevention research. As we move to increase the reality
of prevention across the life span, we will need to find mechanisms to fund
and house prevention activities for all phases of life.
There are indications that the field of psychology is increasing its attention to the unique needs of older adults. For example, interventions have
addressed the prevention of suicide and depression in older adults (Heisel
& Duberstein, 2005; Whyte & Rovner, 2006). In addition, the American
Psychological Association (APA) Public Interest Directorate has established an Office on Aging, which coordinates APA activities pertaining to
aging and geropsychology. The Office on Aging also supports the work of
the APA Committee on Aging, which has published a handbook on psychology and aging (American Psychological Association Committee on
Aging, 2006). This work recognizes that not only are people 65 years of age
and older the fastest growing segment of the U.S. population, with an
increasing number of these older adults of immigrant status or members of
ethnic or racial minority groups, but that more than 5 million older adults
have incomes below the poverty level or are classified as poor. Adulthood
is also a period of life where adults confront a variety of changes related to
families, interpersonal relationships, careers, health, and end-of-life issues.
Prevention has a role to play in helping adults manage and prevent the
adverse effects of these changes.
Hence, we welcome Reese’s (2007) reminder to “cast a broad net” in the
goal of expanding our prevention efforts. He insightfully challenges psychologists to more effectively address the interface of physical and mental health,
and reminds us of the imperative to decrease health disparities and improve the
quality of life of communities in the United States and abroad. His remarks
reflect the social justice orientation out of which the Prevention Guidelines
emerge. This perspective demands that we become aware of how the numerous systems that are part of U.S. society, including economic, governmental,
Hage et al. / WALKING THE TALK
599
and educational structures, define truth for the entire community (Dounce,
2004; Dworkin & Yi, 2003). Prevention work can and should begin within the
local context (e.g., to apply the social justice model in our own communities)
but also needs to be thoughtfully concerned with systemic practices and the
state of power and oppression around the globe. Our efforts must aim to
enhance personal and collective well-being and to create social and political
change aimed at improving environments where people live, learn, and work
(Hage, 2005).
Similarly, we endorse Bond and Carmola Hauf’s (2007) recognition of the
importance of moving beyond a focus on strengths and protective factors at
the individual level, to also address such strengths at multiple systemic levels
(e.g., microsystem, organizations and institutions, community, sociopolitical,
cultural–environmental). While strength-based models related to individuals
have received attention in the literature, there is much less focus on strengths
and protective factors of communities, organizations, and institutions. Hence,
it is important to consider the strengths, as well as the limitations, of institutions, such as schools, cultural centers, faith communities, and community
organizations, when planning and implementing prevention interventions.
IMPLEMENTATION OF THE PREVENTION GUIDELINES
In their reaction articles, Rivera-Mosquera et al. (2007) and Reese (2007)
recognize the significance of moving beyond the “ivory tower” and the level
of “rhetoric” to make the Best Practices Prevention Guidelines a reality.
Similarly, Bond and Carmola Hauf (2007) remind us that prevention review
articles of this nature have been presented in other professional journals, with
remarkably similar conclusions. We would like to recognize the validity
of these concerns, while also providing further explanation of the process of
development of these guidelines. Members of the Prevention Section of
Division 17 developed these Prevention Guidelines with the goal of eventually bringing them forth for adoption by APA and other professional organizations and government entities, as suggested by Reese (2007). Therefore,
the Prevention Guidelines were formulated in accordance with Criteria for
Practice Guideline Development and Evaluation, developed by APA in 1995
and later revised and approved by the APA Council of Representatives
(American Psychological Association, 2002). The APA criteria specify that
proposed guidelines, such as those presented in our article, need to focus on
educating and informing the practice of psychologists, as well as stimulating
debate and research. As such, the APA document specifies that guidelines
“must be reasonable, well researched, aspirational in language, and appropriate in goals” (Section 1.1). Hence, the specificity of these requirements meant
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that content related to the implementation of the Prevention Guidelines was
mostly left out of our article. However, despite this limitation, the Prevention
Guidelines are the first set of comprehensive prevention guidelines that
encompass the major areas of prevention work (i.e., practice, research, training, and social advocacy) that have been prepared for eventual adoption by
APA. Finally, as noted in our article, these guidelines are an “initial step” in
what we hope will be a broader collaboration of psychologists working
together to enhance and implement these recommendations for prevention
within the Society of Counseling Psychology, other appropriate APA divisions, as well as APA and other professional organizations.
We share the concern voiced by Rivera-Mosquera et al. (2007): If further
efforts beyond the publishing of these guidelines are not made, this work
may likely “fail to provide forceful guidance for significant change”
(p. 587). Hence, while the guidelines may be recognized, as Reese (2007)
notes, as a “next step” in stimulating counseling psychologists to engage in
prevention, they represent just one step, and further discourse on implementation and process is essential to move prevention more visibly from the
fringes of the field to center stage in the profession. Similar comments were
made by two past presidents of Division 17, Rosie Bingham and Derald
Wing Sue, at the 2006 APA Symposium addressing the implications of these
guidelines (Hage & Romano, 2006). In their presentations, Bingham and
Sue drew comparisons between the Prevention Guidelines and the
Guidelines on Multicultural Education, Training, Research, Practice, and
Organizational Change for Psychologists (American Psychological
Association, 2003) in terms of their movement from an academic article to
implementation and action. In summary, the challenge for prevention specialists as well as the larger community of scholars and practitioners is to
develop creative ways to advance a prevention agenda, and we hope that
these Guidelines provide guidance.
We appreciate the specific recommendations put forth by the reactants for
how best to advance the dissemination of the Prevention Guidelines, and
would like to highlight some of their suggestions. Education and training,
both at the pre- and the postdoctoral levels, was cited as one essential area for
implementation. We strongly concur with Rivera-Mosquera et al. (2007) and
with Reese (2007) in their recommendation that prevention theory, research,
and practice need to be included within counseling psychology curricula
at all levels. The challenge that demands further attention is how we move
forward to infuse prevention practice and research not only in counseling
psychology training but also throughout psychology education.
Reese’s (2007) suggestion that the Prevention Guidelines become part of
“any reading packet for courses on prevention” is well taken, as is the recommendation to include implementation of the Prevention Guidelines on the
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601
agenda for discussion at the annual meeting of the Council of Counseling
Psychology Training Programs. We would also suggest that the guidelines
be included in the training of doctoral students and be discussed by other
psychology training groups (e.g., Council of School Psychology Training
Programs). Reese also suggests partnerships with professional organizations
outside of psychology (e.g., public health), government entities (e.g., U.S.
Department of Health and Human Services), and stakeholders in the community. We would add other academic disciplines (e.g., social work, counseling) as well as accreditation bodies such as the APA’s Committee on
Accreditation, the Council for Accreditation of Counseling and Related
Educational Programs, and psychology as well as other mental health licensing boards to the list of disciplines and partnering organizations. Moreover,
Rivera-Mosquera et al. (2007) note the importance of addressing the ethics
of prevention. This need has begun to be addressed, although not as broadly
as we would like (e.g., Hage & Schwartz, 2006; Schwartz & Hage, in press).
Prevention practica are also urgently needed, as Reese (2007) suggests.
Finally, developing the equivalents of “preventive medical residency programs” for counseling psychologists, as well as pre- and postdoctoral internships in prevention research and practice, are excellent suggestions that
deserve careful consideration.
In addition, one of the most innovative ideas for dissemination of these
guidelines comes from Rivera-Mosquera et al. (2007), who point out that the
economics of prevention has been a major obstacle in furthering prevention
efforts. Their unique contribution is the suggestion that preventive services be
viewed as a type of therapeutic program. They argue that by conceptualizing
prevention as a “therapeutic intervention,” new avenues to support the work of
prevention (e.g., third-party reimbursement) may emerge. By extension, if
third-party reimbursement were to become possible for prevention, then the
place of prevention in psychology education and training programs will be
more fully secured. This perspective is an interesting one to consider and merits close attention and further discussion among scholars, practitioners, and policy makers. However, it may be more effective to develop financial models that
can prove the cost-effectiveness of prevention, rather than compromising the
conceptualization of prevention. For example, several recent studies have found
that teaching clients interventions based on cognitive–behavioral therapy is
cost-effective in preventing the onset of a full-blown depressive disorder
(Churchill et al., 2001; McCrone et al., 2004; Schulberg, Raue, & Rollman,
2002; Smit et al., 2006). The dissemination of more findings like these studies
on depression is critical in convincing policy makers and funding organizations
that prevention is cost-effective.
Reese (2007) issues a similar call for prevention research that is relevant,
disseminated, and utilized. We agree that too much good prevention research
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remains academic, and thus fails to realize its potential to improve lives,
particularly in communities disadvantaged by disparities in resources. We
believe that including a focus on service delivery systems as an integral component of programmatic prevention research has significant potential for correcting this deficit. For example, we recommend that investigators examine
the practical utility and economic feasibility of their research by utilizing the
prevention research matrix presented in this issue, and by examining how a
research project relates to the third category—Prevention Service Delivery
Systems. The prevention research matrix provides a tool to understand the
need for research and how the outcome of this research can inform the field.
Understanding this process will often lead to more open and informed communication with participating communities about the meaning and scope of
the prevention program at each step of the intervention.
CONCLUDING OBSERVATION
A final observation we would like to make is to underline the significance
of the reaction articles being intentionally authored by a clinical psychologist,
a counseling psychologist, and a social worker. This effort by TCP represents
an excellent attempt at reflecting an important reality about prevention: It is
an interdisciplinary science and practice that requires interdependent collaboration in order to be effective. We need more efforts like this one, including applications to education and training in prevention. In addition, Reese
(2007) provides a valuable perspective as a counseling psychologist who previously was employed by the Centers for Disease Control and Prevention,
and currently is in the Department of Community Health and Preventive
Medicine, Morehouse School of Medicine. He observes that psychology
must move prevention more forcefully from the margins of the field to the
heart of the profession, and that the Society of Counseling Psychology ought
to take the lead for all of psychology in making this transformation happen.
We whole-heartedly agree with this perspective, and we invite psychologists
and others interested in prevention to join this effort by becoming involved in
the Prevention Section (http://www.div17.org/preventionsection).
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Prevention Activities in Professional Psychology:
A Reaction to the Prevention Guidelines
Evelyn Rivera-Mosquera
Department of Mental Health, Columbus, Ohio
E. Thomas Dowd
Kent State University
Marsha Mitchell-Blanks
Cleveland State University
In this reaction article, the authors provide a historical context for prevention activities and their place in psychological practice. They then discuss the prevention guidelines in the Major Contribution authored by S. M. Hage et al. (2007 [this issue]) and
provide their critique. Finally, the authors offer ideas for the future specific applications of these general guidelines and illustrate with a case example.
Hage et al. (2007 [this issue]) are to be commended for their comprehensive, thorough, and thoughtful contribution. They have managed to pull
together the relevant literature regarding prevention efforts and its supporting research, as well as organize this work into a set of aspirational guidelines. The scope of their efforts is truly impressive—a scope that has its
own problems as well as its obvious successes. This response will first provide a brief historical context for prevention activities, and then provide a
general response to these guidelines. We will conclude with ideas of our
own for future applications of these guidelines and prevention in general.
HISTORICAL OVERVIEW OF PREVENTION
Hage et al. (2007) correctly state that prevention activities have historically been an important aspect of the practice of counseling psychology
(p. 497). This is consonant with counseling psychology’s developmental
approach to mental health as compared with the more remedial approach of
clinical psychology and the more case management approach of social work.
Community psychology as a professiponal psychological specialty was
Correspondence concerning this article should be addressed to Evelyn Rivera-Mosquera,
Minority Behavioral Health Group, 1293 Copley Road, Akron, OH 44320; e-mail: rivera-mosquera
@sbcglobal.net.
THE COUNSELING PSYCHOLOGIST, Vol. 35, No. 4, July 2007 586-593
DOI: 10.1177/0011000006296160
© 2007 by the Division of Counseling Psychology
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originally intended to focus more on prevention (and ironically consists primarily of clinical psychologists), but it has never had the impact its
founders envisioned. Although prevention has been an important part of
counseling psychology since its early years, the authors note the paradoxical finding that despite a growing interest in prevention, counseling psychologists’ actual prevention activities are quite limited (Hage et al., 2007,
p. 498). The reasons, we suspect, are largely economic. The field of mental
health, like that of physical health to which status it has consistently aspired,
is now and always has been remedial in orientation. There is little money to
be made in prevention, and during the 1970s and 1980s counseling psychology attempted to play “catch-up” to clinical psychology in obtaining
third-party reimbursements for its services to individuals. Third-party payers in both medicine and psychotherapy typically do not pay for prevention,
although in the long run it is cheaper than remediation. Therefore, advocating for preventive mental/physical health activities is likely to be a hard
sell indeed, especially given the comprehensive, multiple causal factors,
contexts, and domains to which Hage et al. argue we should devote our
efforts (p. 529).
REACTION TO THE GUIDELINES
Overall, the guidelines appear to be well grounded in research, and the
authors do a superb job of building their case for prevention. They demonstrate how the development of these guidelines evolved over time and were
based in sound research as well as systemically discussed by key stakeholders before they were promulgated. This process gives the guidelines
much more credence and potential for acceptance by the entire psychological community. The authors have taken a complex and convoluted area of
practice/research and narrowed it down to guidelines that can help psychologists conceptually organize how they might best begin to engage in
prevention work. While the guidelines are phrased in very cautious language that may make them more politically acceptable in some quarters,
they may also fail to provide forceful guidance for significant change in the
practice of psychology.
The authors’ categorization of the guidelines into four conceptual areas
(practice, r...
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