marsella & yamada 2010 culture and psychopathology

Journal of Pacific Rim Psychologyhttp://journals.cambridge.org/PRP

Additional services for Journal of Pacific Rim Psychology:

Email alerts: Click hereSubscriptions: Click hereCommercial reprints: Click hereTerms of use : Click here

Culture and Psychopathology: Foundations, Issues, Directions

Anthony J. Marsella and Ann Marie Yamada

Journal of Pacific Rim Psychology / Volume 4 / Issue 02 / December 2010, pp 103 115DOI: 10.1375/prp.4.2.103, Published online: 23 February 2012

Link to this article: http://journals.cambridge.org/abstract_S1834490900000465

How to cite this article:Anthony J. Marsella and Ann Marie Yamada (2010). Culture and Psychopathology: Foundations, Issues, Directions. Journal of Pacific Rim Psychology, 4, pp 103115 doi:10.1375/prp.4.2.103

Request Permissions : Click here

Downloaded from http://journals.cambridge.org/PRP, IP address: 111.68.97.27 on 23 Aug 2013

103JOURNAL OF PACIFIC RIM PSYCHOLOGY Volume 4, Issue 2 pp. 103 –115

Address for correspondence: Anthony J. Marsella, Professor Emeritus, Department of Psychology University of Hawaii, Honolulu, Hawaii 96822, USA.E-mail: [email protected]

FoundationsSome Historical Considerations

In 1904, Professor Emil Kraepelin (1856–1926), theacknowledged father of modern psychiatry, reportedthat his classification and diagnostic system, developedand refined in 19th century Europe (e.g., dementiapraecox, manic-depressive disorders), appeared to havelittle applicability to certain non-Western groups inSoutheast Asia and the Lakotah Indian tribes in theUnited States that he visited as part of a global lecturetour. This limitation posed a serious challenge to effortsto advance a psychiatric classification system thatwould be universally applicable. To his credit, Kraepelin(1904) recognised that the cultural background of thepatients needed to be considered in arriving at a validdiagnosis. He then proposed a new psychiatric specialty— Vergliechende Psychiatrie — Comparative Psychiatry.He wrote:

The characteristics of a people should find expression in thefrequency as well as the shaping of the manifestations ofmental illness in general; so that comparative psychiatryshall make it possible to gain valuable insights into thepsyche of nations and shall in turn also be able to contributeto the understanding of pathological psychic processes.(1904, p. 9)

Kraepelin’s brilliant insights and his proposal on the roleof cultural factors in the frequency and manifestation ofmental disorders were not unique, but reflected agrowing interest in the role of culture as a determinantof human behavior in previous centuries. For example,the writings of many 18th and 19th century philoso-phers and social commentators such as Jean JacquesRousseau (1704–1788), Karl Marx (1818–1883),Fredrich Engels (1820–1895), and Emile Durkheim(1858–1917), all pointed to the socio-cultural milieu asan important determinant of individual and collectivebehavior. The well-known words of Rousseau comereadily to mind when he asserted: ‘… Man is by nature

Culture and Psychopathology:Foundations, Issues, Directions

Anthony J. Marsella,1 and Ann Marie Yamada2

1 Department of Psychology, University of Hawaii, United States of America2 School of Social Work, University of Southern California, United States of America

The present article offers an overview of the historical influences, conceptual assumptions, andmajor findings and issues associated with the study of culture and psychopathology. The article

traces continuing reductionistic resistance to the incorporation of cultural considerations in the etiol-ogy, expression, and treatment of psychopathology to historical and contemporary forces. Theseforces include ‘cultural context’ of Western psychiatry and psychology, which choose to locate thedeterminants of behaviour in the human mind and brain. A definition of culture that acknowledges itsinternal and external representations is offered, and steps in the cultural construction of reality are pro-posed. Within this context, the risks of imposing Western cultural views universally are noted,especially attempts to homogenise classification and diagnostic systems across cultures. ‘Culture-bound’ disorders are used as example of Western bias via the assumption that they have ‘real’disorders, while the other cultures have disorders that are shaped by culture. Cultural considerationsin understanding the rate, etiology, and expression are presented, including recommended criteria forconducting epidemiological studies across cultural boundaries, especially ‘schizophrenic’ disordersas this problematic diagnostic category is subject to multiple cultural variations. The article closes withdiscussions of ‘cultural competence’ and ‘multilevel’ approaches to behaviour.

Keywords: culture, mental health, psychopathology, native Hawaiians, culture-bound disorders, diagnosis, healing

good, it is only our institutions that have made him bad’(Durant & Durant, 1967, p. 19). These words launchedthe Romanticist movement and raised questions aboutthe role of civilization and ‘madness’.

The thoughts of this group of social philosopherswere given new authority and relevance within psychia-try with the subsequent work of the founder ofpsychoanalysis, Sigmund Freud (1856–1939), whoindicted society as a major source of neuroses and otherpsychological dysfunctions in his definitive work,Civilization and Its Discontents (1930). When Freud jux-taposed human biological impulses (i.e., id/nature)against the constraints of conscience (i.e., super-ego/society), he captured the complex tensions ofcultural socialisation in the life experiences of individu-als. It is through a process of cultural socialisation viafamilial and community rewards/punishments, model-ling, and selective exposures to beliefs and practices, thatculture comes to construct our realities, and to helpdetermine and shape our behavior within our uniquetemperament and common anatomy.

Yet, in spite of the broad endorsement of the socio-cultural perspective across the decades, including bysupport from some of psychiatry’s most famous figures,the socio-cultural perspective was widely dismissed bymany others in psychiatry, who were committed toreductionistic approaches that located the causes, mani-festations, and cures of mental disorders in the brainand nervous system. Indeed, Freud’s own mentors, Ernstvon Brucke (1819–1892), and Emil Dubois Reymond(1818–1896), claimed that there are ‘No other forcesthan the common physical–chemical ones are activewithin the organism’ (Jones, 1953, p. 40).

As a result, many psychiatrists concluded that mentaldisorders were neuropsychiatric diseases, universal innature, and free of any substantive socio-cultural deter-minants. This was especially the case for 19th-centuryEurope, where the biological foundations of psychiatryhad gained a firm foothold via the teachings of theGermans psychiatrists Wilhelm Griesinger (1817–1868)and Emil Kraepelin (1856–1926) and others whosemedical approaches resisted the popular ‘psychody-namic’ approaches that took hold in the United Statesand remain to the present day.

Biological approaches would gain further support inpsychiatry in the United States with the development oftranquilizers and anti-depressant medications in the1960s and 1970s, and with the leadership of GeraldKlerman, professor of psychiatry at Harvard University,and former director of the National Institute of MentalHealth during this period. Klerman and his colleaguessought to break the hold of psychodynamic practitionersand psychologists by advancing what has been termed bysome as a ‘neo-Kraepelian’ conspiracy (e.g., Blashfield,1984). Klerman proposed that psychiatry needed to re-establish itself as a medical specialty and to focus upon

104 JOURNAL OF PACIFIC RIM PSYCHOLOGY

Anthony J. Marsella, and Ann Marie Yamada

the biological substrates of mental illness. But it is note-worthy that Klerman’s success in moving psychiatrytoward a ‘medical model’ of mental disorders reflects thevery role of disciplinary ‘cultures’ in shaping thoughtand practice via leader-based conceptual biases and pref-erences. This thought does not deny the fact that soundscientific research contributed to changes, but ratherthat ‘power’ in shaping thought and practice does oftenstem from individual biases.

To be sure, there were those within psychiatry throughthe early 20th century who continued to argue about theimportance of socio-cultural factors for our understand-ing of the etiology, manifestations, and treatment ofmental disorders. For example, Georges Devereux coinedthe terms ‘primitive psychiatry’, ‘ethnopsychiatry’, and‘psychiatric anthropology’ in a series of publicationsthroughout the 1940s and 1950s. Other pioneer figuresinclude Eric Wittkower, H.B.M. Murphy, and RaymondPrince at McGill University in Canada, Arie Kiev in NewYork, Alexander Leighton at Cornell and Harvard, andTsung-Li Lin at WHO. All of these figures made signifi-cant efforts to advance the socio-cultural perspective,especially through international studies that revealed vari-ations in rates and expressions of mental disorders. Theywere joined in their efforts by anthropologists of the eralike Ruth Benedict, Margaret Mead, and Ralph Linton,who called attention to the relativity of ‘normality’, and tothe power of culture in shaping normal and disorderedbehaviour.

However, it was not until the pioneering efforts ofArthur Kleinman at Harvard University and LaurenceKirmayer at McGill University that the psychiatric spe-cialties of ‘transcultural psychiatry’ and ‘culturalpsychiatry’ gained widespread acceptance, including thedevelopment of special residency training programs.There work was followed by major contributions from anumber of minority psychiatrists, including JuanMezzich and Horatio Fabrega, whose efforts facilitatedthe inclusion of the cultural criteria for diagnosis in theAmerican Psychiatric Association’s Diagnostic andStatistical Manuals (DSMs), after years in which psychia-try seemed to ignore socio-cultural factors. Two volumesby Arthur Kleinman (Kleinman, 1980; Kleinman &Good, 1996) crystallised much of the research and con-ceptual literature and helped establish the field. It isnoteworthy that Arthur Kleinman is both a psychiatristand anthropologist, and this combination of trainingenabled him to better articulate the role of culture.

Yet another important event in the shaping of thestudy of culture and psychopathology came via theUnited States Department of Health and HumanServices in its published report entitled Mental Health:Culture, Race, and Ethnicity (2001). In this report, theDHHS reached specific conclusions about the role ofculture and forcefully stated ‘Culture counts!’ The reportdetailed disparities in the provision of psychiatric ser-

vices to racial and ethnic minorities in the United Statesand called for renewed efforts to address these problems.The report states:

The main message of this supplement is that ‘culture counts’.The cultures that patients come from shape their mentalhealth and affect the types of mental health services theyuse. Likewise, the cultures of clinician and the service systemaffect diagnosis, treatment, and the organisation and financ-ing of services. Cultural and social influences are not theonly influences on mental health and service delivery, butthey have been historically underestimated — and they docount. Cultural differences must be accounted for to ensurethat minorities, like all Americans, receive mental healthcare tailored to their needs. (DHHS, 2001, p. 14)

Among the social and behavioral sciences, credit mustgiven to a number of early anthropologists whose entryinto the field brought credible theoretical and researchcontributions (e.g., William Caudill, Byron Good,William Lebra, Takie Lebra). Within psychology,advances in the field occurred via the work of JurisDraguns, Stanley Sue, and Anthony J. Marsella in clinicalpsychology, and Paul Pedersen, Alan Ivey, and DeraldSue in counseling psychology. Counselling psychology,in fact, was the discipline that made many contributionsto ethnic minority psychology. Key figures in variousethnic groups include Derald Sue and Fred Leong(Chinese), Teresa LaFramboise and Joseph Trimble(American Indian), Patricia Arredondo, Lillian ComasDiaz (Latino), and Anthony Franklin and ThomasParham (African American). The list of names could, ofcourse, be extended to include numerous others.However, these names help document the historicalprogress that has occurred as cultural factors assumed arecognised and acknowledged dimension of the mentalhealth professions and sciences.

Today, articles on the history of culture and psy-chopathology — the name now preferred by manybecause of its independence from a particular disciplineor profession — document the course of historicchanges in greater detail (e.g., Marsella, 1996; Fabrega,2001). Space constraints in the present article limit theextensive literature on culture and psychopathology thatnow exists. Readers are encouraged to see Draguns(2006), Lopez and Guarnaccia (2008), and Marsella andYamada (2002, 2007) for detailed reviews.

The Concept of Culture

Efforts to advance the socio-cultural perspective wereobviously contingent on an understanding of the term‘culture’. And like so many terms that were used widelyin both the ‘popular’ and ‘professional’ vernaculars,‘culture’ had many surplus meanings that interfered withtheory and research (e.g., see Kluckholm & Kroeber,1952, for a listing of 100 early definitions of culture).Although the term ‘culture’ continues to be used widelytoday to mean many different things from the arts (i.e.,music, dance, drama, paintings) to a quality of personal-

ity (‘She is cultured’), its meaning for the study ofhuman behavior is much more specific, and goes beyondthe popular vernacular to a more technical definition.For current purposes, we will define culture as the fol-lowing:

Culture is shared learned behavior and meanings that aresocially transmitted for purposes of adjustment and adapta-tion. Culture is represented externally in artificats (e.g.,food, clothing, music), roles (e.g., the social formation), andinstitutions (e.g., family, government). It is representedinternally (i.e., cognitively, emotionally) by values, attitudes,beliefs, epistemologies, cosmologies, consciousness patterns,and notions of personhood. Culture is coded in verbally,imagistically, proprioceptively, viscerally, and emotionallyresulting in different experiential structures and processes.

Thus, culture is the lens or template we use in construct-ing, defining, and interpreting reality. This definitionsuggests that people from different cultural contexts andtraditions will define and experience reality in very dif-ferent ways. Thus, even mental disorders must varyacross cultures because they cannot be separated fromcultural experience. Marsella (1982) stated:

We cannot separate our experience of an event from oursensory and linguistic mediation of it. If these differ, so mustthe experience differ across cultures. If we define who we arein different ways (i.e., self as object), if we process reality indifferent ways (i.e., self as process), if we define the verynature of what is real, and what is acceptable, and even whatis right and wrong, how can we then expect similarities insomething as complex as madness. (1982, p. 363)

It should also be noted that the very languages that weuse in mediating reality critically structure our realityand thus shape our behavior. For example, Marsella(1985) noted that languages vary in their reliance anduse on metaphorical terms and this results a differentsensory mediation of reality by presenting immediateimagistic and felt experiences rather than detachedabstractions:

In this respect, a metaphorical language provides a rich andimmediate sensory experience of the world which is notdiluted by being filtered through words which distantiate thecognitive understanding from the experience. In ametaphorical language system, the understanding and thelanguage are one. (Marsella, 1985, p. 292)

So how is it that our cultural constructions of reality arecreated? Our worldviews — our cultural templates fornegotiating reality — emerge from our inborn humaneffort to pursue meaning via the brain’s functions ofseeking, taking in, and organising information intocoherent units. The brain inherently and reflexively pro-vokes us to describe, understand, predict, and controlthe world about us through the ordering of stimuli intocomplex belief and meaning systems that negotiate ourperceptions and our milieu by guiding behavior. Ourbrain not only responds to stimuli from the earliestmoments following birth (indeed, also in utero), it alsoorganises, connects, and symbolises them, and in thisprocess, generates patterns of explicit and implicit

105JOURNAL OF PACIFIC RIM PSYCHOLOGY


meanings and purposes that serve to promote survival,growth, and development. This process occurs, as notedpreviously, through cultural socialisation. Thus, what is‘universal’ is the brain and its reflexive tendency toprocess information from its milieu. What is relative isthe social contexts in which we exist, and the contentand process that serves as the foundations for our con-structions of reality.

Western Psychiatry, Clinical Psychology and RelatedDisciplines Are Cultural Constructions: They Are Not Universal

Somewhere along the way, amid the ethnocentric blind-ness that is so reflexive in all cultures to the realities ofothers, it is essential we recognise that Western mentalhealth professions and sciences are ‘cultural construc-tions’. As such, they must be seen as relative to thehistorical, linguistic, and socio-political influence ofWestern cultural traditions, and as such, they should notbe considered ‘objective’, but rather representations ofcultural knowledge and practice (e.g., ontogenies, episte-mologies, praxiologies) rooted within Western culturaltraditions (e.g., Marsella, 2009). Unfortunately, the pow-erful political, economic, and cultural influences ofWestern nations promote the widespread acceptance ofWestern psychiatry fostering a pseudo global homogene-ity in psychiatry. This homogeneity is further supportedand promoted by leaders at institutions like the WorldHealth Organization, where officials — all of whom areeither Western or trained in Western medical traditions— the National Institute of Mental Health, and variousmedical and pharmaceutical scientific and commercialinterests whose biases limit their criteria for accuracy(e.g., Higginbotham & Marsella, 1988).

As a result, the indiscriminate application and impo-sition of Western psychiatry is subject to question andcriticism, and much of this growing criticism is beinggenerated by non-Western psychiatrists who are resistingWestern cultural hegemony. For example, consider thepowerful words of the Asian Indian psychiatristChakraborty (1991), who wrote:

Even where studies were sensitive, and the aim was to showrelative differences caused by culture, the ideas and toolswere still derived from a circumscribed area of Europeanthought. This difficulty still continues and, despite, modifi-cations, mainstream psychiatry remains rooted inKraepelin’s classic 19th century classification, the essence ofwhich is the description of the two major ‘mental diseases’seen in mental hospitals in his time — schizophrenia andmanic depression. Research is constrained by this view ofpsychiatry. A central pattern of (western) disorders is identi-fied and taken as the standard by which other (local)patterns are seen as minor variations. Such a constructimplies some inadequacy on the part of those patients whofail to reach ‘standard’. Though few people would agree withsuch statements, there is evidence of biased, value-based,and often racist undercurrents in psychiatry.… Psychiatristsin the developing world … have accepted a diagnosticframework developed by Western medicine, but which does

not seem to take into account the diversity of behavioralpatterns they encounter. (p. 1204)

This recognition of ethnocentric bias has, for obviousreasons, been the source of considerable argument anddebate. There is a reluctance to admit that one’s world-views are not universal, whether in religions, politics, ordaily values and practices. Thus, Western psychiatricassumptions and practices may be relevant and accuratewithin a Western cultural context, but this does not meanthey are relevant or accurate in other cultural contexts. Wemust not mistake ‘power’ and ‘dominance’ for accuracy.

Culture, Classification, and DiagnosisIssues in Classification and Diagnosis

Within psychology, the academic and disciplinary fieldsof cross-cultural psychology, cultural psychology, indige-nous psychology, and various ethnic minoritypsychologies have all provided extensive researchsupport to document the role of culture in shapinghuman behaviour. When added to the research in tran-scultural psychiatry, cultural psychiatry, psychiatricanthropology, and others, it is now widely accepted thatcontinued efforts that ignore cultural variations consti-tute erroneous and pernicious ethnocentric biases thatrisk serious mistakes in clinical practices and research(e.g., Marsella, 2009, Marsella & Yamada, 2007;Paniagua, 2001) ). Fortunately, even the DSM IV-TR(APA, 2000) now points out the risks of ignoring aperson’s culture:

A clinician who is unfamiliar with the nuances of an indi-vidual’s cultural frame of reference may judge incorrectlyjudge as psychopathology those normal variations in behav-ior, belief, and experience that are particular to theindividual’s culture … Applying [Certain diagnostic criteriaand categories] across cultural settings may be especially dif-ficult because of wide cultural variation in concepts of self,styles of communication, and coping mechanisms.(American Psychiatric Association, 2000, p. XXXIII)

Cultural Criteria for Formulating a Case

In an effort to increase sensitivity to cultural variations,the DSM further offers a series of criteria (albeit in itsvery last pages: pages 897–898 out of 943 pages) for thecultural formulation of a case and a listing of ‘culture-bound syndromes’. The criteria include determining the(1) cultural identity of the individual, (2) cultural expla-nations of the individual’s illness, (3) cultural factorsrelated to the psychosocial environment and levels offunctioning, (4) cultural elements of the relationshipbetween the individual and clinician, and (5) overall cul-tural assessment for diagnosis and care. Theoretically,these criteria should be used in each and every case sinceeach case is a ‘cultural’ encounter between the differentcultures of the patient and professional. This especiallytrue today as we now find patients from so many differ-ent ethnocultural groups (e.g., Chinese, Mexican,Nigerian, Vietnamese, WASP) seeking care from profes-



sionals from so many different ethnocultural groups(e.g., Filipino, Iranian, Israeli, Korean, WASP). Assessingsociocultural issues is one step in designing culturallyrelevant and empirically supported practices as it afoundation for examining the relevance of interventionsacross groups and also generates knowledge that can beused to develop culturally-tailored interventions(Yamada & Brekke, 2008).

Culture-Bound Disorders

One of the problematic topics for Western classificationand diagnosis is the issue of culture-bound disorders (e.g.,APA DSM IV TR, 2000; Marsella, 2000; Simon & Hughes,1989). Examples of these disorders are displayed in Table1. While some favouring universal views of psychiatricdisorders claim that these disorders are merely variants ofWestern disorders contextualised in non-Western cul-tures, here, the question must be asked: Why is it that thenon-Western disorders are contextualised in non-Westerncultures, but those identified and coded in the West inDSMs and ICDs are the real thing? Certainly, they are asmuch cultural products and are those from non-Westerncultures. Marsella (2000) summarises many of the argu-ments and issues regarding culture-bound disorders.

An Example from Native Hawaiian Culture and Behavior

The Native Hawaiian people (Kanaka Maoli) provide anexcellent example of an indigenous theory of maladjust-ment and dyfunction, and its relationship to cultural

worldviews and traditions (see Higginbotham et al,1987; Marsella, Oliviera, Plummer, & Crabbe, 1995;McCubbin & Marsella, 2009). The Native Hawaiianculture considers all of its people to be embedded withina complex ecology of relationships among gods, nature,and family, and person (see Figure 1). Harmony(Lokahi) across these elements occurs as long as a personmeets his/her individual, familial, environmental, andspiritual responsibilities. The cultural system is based onan ethos of preserving the social fabric of the groupthrough a well-developed series of beliefs about expectedbehaviors and about behaviors that interfere or harm thesocial fabric.

Within this framework, health and illness are consid-ered to be a function of those forces that serve to eitherpromote or to destroy harmony. Given the importanceof the complex social fabric for Native Hawaiians, manyof these forces reside in events and behaviors thatsupport or undermine social and spiritual relations. Forexample, things that destroy the social fabric include thefollowing behaviors:

• Hate (ina’ina)

• Jealousy (lili)

• Rudeness (ho’okano)

• Being nosy (niele)

• Bearing a grudge (ho’omauhala)

• Bragging (ha’anui)

• Showing off (ho’oi’o)



Table 1

Examples of Culture-Bound Disorders

Name Definition and cultural and geographical location

Amok Sudden outburst of explosive and assaultive violence preceded by period of social withdrawal and apathy (Southeast Asia,Philippines)

Ataque de Nervios Uncontrollable shouting and/or crying. Verbal and physical aggression. Heat in chest rising to head. Feeling of losing control.Occasional amnesia for experience (Caribbean Latinos and South American Latinos).

Hwa-Byung Acute panic, fear of death, fatigue, anorexia, dyspnea, palpitations, lump in upper stomach (Korea).

Latah Startle reaction followed by echolalia and echopraxia, and sometimes coprolalia and altered consciousness (Malaysia andIndonesia).

Koro (Shook yong) Intense fear following perception that one’s genitalia (men/women) or breasts (women) are withdrawing into one’s body.Shame may also be present if perception is associated in time with immoral sexual activity (Chinese populations in Hong Kongand Southeast Asia).

Phii Pob Believes one is possessed by a spirit. Numbness of limbs, shouting, weeping, confused speech, shyness (Thailand).

Pissu Burning sensations in stomach, coldness in body, hallucinations, dissociation (Ceylon).

Suchi-bai Excessive concerns for cleanliness (changes street clothes, washes money, hops while walking to avoid dirt, washesfurniture, remains immersed in holy river (Bengal, India - especially Hindu widows).

Susto (Espanto) Strong sense of fear that one has lost their soul. Accompanied by anorexia, weight loss, skin pallor, fatigue, lethargy,extensive thirst, untidiness, tachycardia, and withdrawal (Latinos in South and Central America, Mexico, and Latinomigrants to North America).

Taijin Kyofusho Intense fear of interpersonal relations. Belief that parts of body give off offensive odors or displease others (Japan).

Tawatl Ye Sni Total discouragement. Preoccupation with death, ghosts, spirits. Excessive drinking, suicide thoughts and attempts(Sioux Indians).

Uquamairineq Hypnotic states, disturbed sleep, sleep paralysis, dissociative episodes and occasional hallucinations (Native Alaskans: Inuit,Yuit).

Source: Marsella, 2000, p. 408.

• Breaking promises (hua Olelo)

• Speaking bitter thoughts (waha ‘awa)

• Stealing, fighting, and hostile (huhu) behaviour.

Destruction of the spiritual fabric occurs as forces comeinto play when an individual or a family violates certaintaboos or restrictions, thus opening the door for super-natural forces seeking propitiation or mollification toenter their lives. These forces are:

• Offended ghosts (lapu)

• Natural spirits (kupua)

• Spirit guardians (aumakua)

• Ancestor/elders (kupuna)

• Black magic or sorcery (ana’ana)

• Curse (anai).

The resolution of both social and supernatural conflictscan occur by using prosocial behaviors and certain ritualsthat can restore and promote lokahi. Prosocial behaviorsinclude adopting the behaviors of a Kanaka Makua (agood person); these behaviors include the following:

• Humility and modesty (ha’aha’a)

• Politeness and kindness (‘olu’olu)

• Helpfulness (kokua)

• Acceptance, hospitality, and love (aloha).

Ritualistic behaviors that can restore and promoteharmony include the following Native Hawaiianhealing arts:

• Herbal treatments (la’au kahea)

• Purification baths (kapu kai)

• Massage (lomi lomi)

• Special diets and fasting

• Confession and apology (mihi)

• Dream interpretation (moe ‘uhane)

• Clairvoyance (hihi’o)

• Prayer (pule ho’onoa)

• Transfer of thought (Ho ‘olulu ia)

• Possession (noho)

• Water blessings ( pi kai)

• Spirit mediumship (haka).



Mana = Life Energy Lokahi = Harmony

Vulnerable

Person

FAMILY

OHANA

NATURE

MAKANI AINA WAI

GODS & SPIRITS

AKUA & AMAKUA

PERSON

Dislocated

Unconnected

Figure 1:

Traditional Native Hawaiian Conception of Psyche: Person, Family, Nature, and Spiritual World.Note: A person dislocated from the spiritual, nature, and social environmental, social, context becomes vulnerable to different patterns of maladjustment and deviancy. Healing involves

restoring the person to the context and recovering mana and lokahi.

Source: McCubbin & Marsella , 2009.

Thus, the Native Hawaiian worldview encompasses acomplex system that is rooted in the interaction of body,mind, and spirit. It is directly tied to prosocial humanrelations and prospiritual relations. The restoration ofhealth and wellbeing requires the adoption of prosocialbehaviors and engagement in the healing arts and proto-cols that can reestablish interpersonal and psychologicalharmony. If violations occur, there are a number of dys-functions or disorders that can occur including (seeMarsella — E Ola Mau Mental Health Task Force Report,1985):

• ’a ’a: Panic stricken. Made dumb byanger and fury

• ’a aia: Demented

• ’a ala’ioa: Wild, uncontrolled

• hehena: Insane, lunatic, crazy

• ho’ohewahewa: Deranged (not as strong as hehena or pupule)

• kaumaha: Sad, heavily burdened

• kuloloa: Idiotic

• loha: Sullen, spiritlessness

• lu’ulu’u: Heavily burdened, sorrowful,troubled

• ma’ina loko: Sickness from within (caused by misdeeds, family troubles)

• ma’ina waho: Sickness from outside (evil forces,external cause)

• ohewa: Delirious, incoherent, drunk

• opulepule: Moronic, imbecilic

• pupule: Crazy, insane, wild, uncontrolled

• uluahewa: Crazy, sometimes due to evil spirit

• uluhia: Possessed by evil spirits

• uluhua: Irritated, vexed, annoyed

• uluku: Disturbed, agitated, nervous

• ’uhane noho: Possessed by a spirit

• wela: Angry (hot)

All of these outcomes are related to a person becomingdislocated or disconnected from the spiritual and socialsocietal fabric as a result of violations. The healing thenseeks to reconnect the person. Thus, the Native Hawaiianculture offers an excellent example of a non-Westernapproach to health and disorder and to the pathways tohealing. It is, in our opinion, more sophisticated and sub-stantive in its premises, assumptions, and terminologythan Western psychiatric views that focus on reductionis-tic views locating problems within the individual brain.

Cultural Considerations in Psychopathology

Evidence points to the fact that cultural factors are criti-cal determinants of the etiology (e.g., Leighton &Murphy, 1961; Marsella, 1982). For example, consider

the following cultural processes in the etiology of psy-chopathology: Culture determines: (1) the patternsphysical and psychosocial stressors, (2) the types andparameters of coping mechanisms and resources used tomediate stressors, (3) basic personality patterns includ-ing, but not limited to, self-structure, self-concept, andneed/motivational systems, (4) the language system ofan individual, especially as this mediates the perception,classification, and organisation of responses to reality,(5) standards of normality, deviance, and health, (6)treatment orientations and practices, (7) classificationpatterns for various disorders and diseases, (8) patternsof experience and expression of psychopathology,including such factors as onset, manifestation, course,and outcome.

While psychiatry and psychology continue to localisepsychopathology in the brain, there is a failure to recog-nise that the context in which we live shapes theelectrochemical forces that occur at the synaptic levels.Can anyone deny that events that occur macro-levelssuch as urbanisation, social change, violence and warleave no imprint on the brain or that the various stressesassociated with family life, work, school, and neighbor-hood have no impact. Consider Figure 1, in whichmassive life-change events eventually impact the synapseresulting in various forms of psychopathology.Understanding the process by which events at higherlevels shape events at lower levels (e.g., hierarchicalsystems) remains for greater study, but the impact isquestionable.

Marsella and Yamada (2000) stated:

Mental health is not only about biology and psychology, butalso about education, economics, social structure, religion,and politics. There can be no mental health where there ispowerlessness, because powerlessness breeds despair; there



Rapid and Destructive Social Changes

(e.g., cultural change, collapse, abuse, disintegration, confusion) Social Stress and Confusion (e.g., family, community, work, school, government problems) Psychosocial Stress and Confusion (e.g., marginalized, powerlessness, alienation, anomie) Identity Stress & Confusion (e.g., Who am I, what do I believe) Psychobiological Changes (e.g., anger, hopelessness, despair, fear) Behavioral Problems

(e.g., depression, suicide, psychosis alcohol, violence, substance abuse, delinquency)

Synaptic Changes (e.g., dopamine, serotonin,

epinephrine)

Figure 1

Sociocultural pathways to distress, deviance and disorder.

Source: Adapted from Marsella & Yamada, 2007.

can be no mental health where there is poverty, because

poverty breeds hopelessness; there can be no mental health

where there is inequality, because inequality breeds anger

and resentment; there can be no mental health where there

is racism, because racism breeds low self-esteem and self

denigration; and lastly, there can be no mental health where

there is cultural disintegration and destruction, because cul-

tural disintegration and destruction breed confusion and

conflict (Marsella & Yamada, 2000, p. 10).

Culture and Psychiatric EpidemiologyThe Issue of Methodology

It is an almost reflexive question in culture and psy-

chopathology studies to ask whether rates of ‘mental

illness’ differ across cultures. To be sure, there are many

national and international reports of epidemiological

studies of various disorders (e.g., DiGirolamo &

MacFarlane, 1996; Hopper, Harrison, Janca, & Sartorious,

2008). However, there are so many complex issues

involved in conducting psychiatric epidemiology studies

that it may well be more just and judicious to acknowl-

edge their requirements.

As we have pointed out, there are numerous issues

involved in the assessment and diagnosis of mental illness

across cultures. The issues make valid data collection a

difficult task. Marsella (1979) and Marsella, Sartorious,

Jablensky, and Fenton (1985) listed criteria that must be

met before data can be compared. They stated that the

comparative epidemiological studies must:

1. Use relevant ethnographic and anthropological data

in designing an epidemiological study, especially in

determining what constitutes a symptom or category

or a case.

2. Develop glossaries of terms and definitions for

symptoms and categories.

3. Derive symptom patterns and clusters using multi-

variate techniques rather than relying on simple

a priori clinical categories.

4. Use similar/comparable case identification and vali-

dation methods.

5. Use culturally appropriate measurement methods

that include a broad range of indigenous symptoms

and signs that can be reliably assessed.

6. Establish frequency, severity, and duration baselines

for Indigenous and medical symptoms for normal

and pathological populations.

7. (Added 2009): Conduct case identifications using

both Western and Indigenous conceptions and defin-

itions. This will permit a determination of rates

using Western, Indigenous, and overlaps

Whose Criteria Will Be Used: What is a Case?

These steps do not guarantee accuracy, but they do callattention to the complexities involved in conductingcomparative epidemiological studies of mental illness.Failure to consider them can lead to destructive conse-quences for cultures under study since they may eitheroverestimate or underestimate actual rates leading tofaulty policy decisions and misleading stereotypes.Although cultures and nations do vary in terms of thestresses they impose on their members and resourcesavailable for dealing with these stresses, comparison datamust meet stringent criteria or one group may be seen aspathological and another as salutogenic when the oppo-site may be the more accurate conclusion. Nevertheless,these considerations have not stopped researchers fromdoing both national and international epidemiologystudies using Western criteria, seemingly oblivious to allwe have suggested. Their results should be consideredwithin the limitations described above (e.g., Weiss, 2001).Alarcon et al. (2002) echo the above in their words.

A crucial feature of the cultural epidemiologic context in rela-tion to diagnosis is who decides on the values and prioritiesthat transform findings into authoritative evidence. The cul-tural representation of mental illness requires a categoricalidentification but also a narrative account and a full assess-ment of the social context in which illness occurs. (p. 234)

The ‘Schizophrenic Spectrum’ DisordersSchizophrenia: A Problematic Term and Disorder(s)

Of all the mental disorders, dysfunctions, and neuro-logical disease that constitute the purview of mentalhealth scientists and professionals, the schizophrenicdisorders are the most problematic with regard to theaccepted role of cultural influences. The debate andargumentation is extensive because of the strong posi-tion that schizophrenia is a universal disorder becauseof a biological etiology and there are few cultural influ-ences in either its causation or clinical parameters.However, while research on biological aspects of schiz-ophrenia continues to receive much, both financiallyand theoretically, the facts of the matter point to a verydifferent conclusion.

Research projects by staff and research affiliates ofthe Division of Mental Health of the World HealthOrganization were set up to investigate rates, symptompatterns, clinical parameters such as onset, course, andoutcome. Results form these studies all point to inter-national variations in these areas, bewildering as thismay be for many affiliated with the WHO projectsbecause of their professional beliefs in biological posi-tions and their support for DSM and ICD classificationsystems (e.g., Day, Nielsen, Korten, Ernberg, et al.,1987; Hooper, Harrison, Janca, & Sartorius, 2007; Katz,Marsella, Dube, Olatawura, et al., 1988).



The Fault is in The Term Itself

Literature reviews and commentaries on schizophreniatheory and research by the senior author of this articleand his research team (Marsella, 1988; Marsella, 1999a;Marsella, Suarez, Morse, Leland, et al., 2002) summarisehistorical, conceptual, and empirical studies thatdocument the fact that schizophrenic disorders varyconsiderably across cultural boundaries and that thesource of this may be both actual and may reside in thevery conceptualization of schizophrenia replete with allits excess definitions, meanings, patterns, and treatmentresponses. Should Table 2 presents a set of potentialsocio-cultural determinants of schizophrenia.

But perhaps what is even more relevant here is thefact that the study of schizophrenia continues to be bur-dened by numerous conceptual and methodologicalproblems that have not been solved in spite of the effortsto develop diagnostic criteria in the DSM and ICDmanuals. There are too many issues that interfere withaccurate diagnosis. Table 3 lists 14 continuing concep-tual issues that are relevant for cross-cultural andinternational research but also for research within theWestern nations who continue to support the use of the‘concept’ of schizophrenia.

Some Closing Concerns and IssuesThe Issue of Cultural Competence

Cultural competence has become a popular term in themental health fields as ethnic minority groups called forincreased knowledge and sensitivity of their culture inrendering various services. Competence, of course, refers

to the capacity to perform a particular task according tocertain expected high standards that ensure quality.Cultural competence means the capacity to renderquality services to different cultural groups because ofincreased knowledge of their culture’s history, knowl-edge, ways of life. Appendix A provides a checklist forassessing one’s cultural competence by replying to aseries of questions on various aspects of a cultureincluding history, language, food, and so on.

Historically, concern for culture competence in theUnited States can be traced to 1950s when White domi-nance and its accompanying racism showed littlesupport for the rights of people of color, women, andLBGT groups. Segregation was still widely practised. The1954 Brown v Board of Education (Kansas) decision bythe Supreme Court led to national equal rights — every-one must be treated the same. But, this did little topromote ‘competence’ in working with our diverseethnic minority populations. It was the 1960s thatbrought the issue to the foreground as civil rightsprotests, ‘Black is Beautiful’ movements, the rise of femi-nism, cultural studies, and post-colonial wars (e.g.,Kenya) raised consciousness about the need to under-stand diversity. Between the 1970s and the present, issuesof ‘ethnocentricity’, ethnic identity, and various legalactions encouraged ‘cultural competence’ to emerge, notas a legal imposition within the mental health profes-sions, but as a requirement for effective services andpractices.

Madeleine Leininger (1978), a professor of transcul-tural nursing, was among the first to call for cultural



Table 2

Some Socio-Cultural Determinants of Schizophrenia

1. Cultural concepts of personhood, and the related implications of this for individuated versus unindividuated definitions of selfhood and reality.

2. Cultural concepts regarding the nature and causes of abnormality, discomfort, disorder, deviance, and disease, and those regarding the nature andcause of normality, health, and wellbeing.

3. Cultural concepts and practices regarding health and medical care and prevention; attitudes toward illness and disease.

4. Cultural concepts and practices regarding breeding patterns and lineages.

5. Cultural concepts regarding pre-natal care, birth practices, and postnatal care, especially in such areas as nutrition and disease exposure.

6. Cultural concepts and practices regarding socialisation, especially family, community, and religious institutions, structures and processes.

7. Cultural concepts and practices regarding medical and health care especially with regard to the number and types of healers, doctors, sick-rolestatus, and so on.

8. Cultural stressors such as rates of socio-technical change, socio-cultural disintegration, family disintegration, migration, economic development,industrialisation, and urbanisation.

9. Culturally related patterns of deviance and dysfunction, including trauma (PTSD), substance abuse, violence and crime, social isolation,alienation/anomie, and the creation of pathological and deviant subcultures.

10. Cultural stressors related to the clarity, conflicts, deprivations, denigrations, and discrepancies associated with particular needs, roles, values, statuses,and identities.

11. Cultural stressors related to socio-political factors such as racism, sexism, and ageism and the accompanying marginalisation, segmentalisation, andunderprivileging.

12. Cultural resources and coping patterns including institutional supports, social networks, social supports, and religious beliefs and practices.

13. Cultural exposure to various risk conditions such as communicable diseases (e.g., viruses), toxins, dietary practices, population density, poverty,homelessness.

Source: Marsella et al., 2002.

competence in her volume on transcultural nursing, inwhich she proposed new standards for working withethnically diverse groups. Pedersen and Marsella (1982)subsequently called for changes in the AmericanPsychological Association Code of Ethics because ofbiases and cultural insensitivities in the ethical guide-lines. Other publications by Cross, Bazron, Dennis, &Isaacs (1989) made explicit calls for culturally competenthealth care systems in working with children, and theOffice of Minority Health of the United StatesDepartment of Health and Human Services (DHHS)advanced guidelines on the provision of health care ser-vices to culturally and linguistically diverse groups. Danaand Allen’s (2008) volume, Cultural Competency Trainingin a Global Society, provides a comprehensive overviewof cultural competency and its importance for mentalhealth services in a global community.

The Multiple Determinants of Human Behavior

As scientists and practitioners, mental health professionalsmust seek the determinants of psychopathology in itsmany forms and manifestations among many differentsources of causality. No single cause has ever been suffi-cient to describe, explain, or predict psychopathologybe it biological, psychological, or social. In so many ways,the early words of Clyde Kluckholm & Henry Murray(1950) offer us important insights regarding this issue.Kluckholm was an anthropologist and Murray a physicianand psychologist, problem when they opened their classic

volume, Personality in Nature, Culture, and Society, withthe following words (Kluckholm & Murray, 1950).

We are like all other men (sic)

We are like some other men (sic)

We are like no other man (sic). (frontispiece)

Think about it! We are like ‘all’ other men (sic) invarious aspects of our biology including variousanatomical structures and physiological processes andtheir implications for adjustment and adaptation. We arelike ‘some’ other men with respect to various diversitymarkers, especially those related to ethnicity, gender,marital status, religion, and other cultural expressions.And we are like ‘no’ other men with regard to our uniqueand distinct genetic heritage and lived experience, whichcontributes to our unique temperament and personality.

Within the mental health sciences and professions,governed as they have been by psychiatry with its prefer-ences for biological and related reductionisticdeterminants, and by psychology, with its preferences forpersonality and cognitive determinants, the ‘cultural’ per-spective has had to struggle for recognition andacceptance. Today, interest and concern for the culturaldeterminants of psychopathology occupies a new positionof authority that challenges the biological and psychologi-cal perspectives to acknowledge has ‘cultural variations’ inrates, expressions, diagnosis/classification, course,outcome, and treatment of psychopathology. Failure to



Table 3

Fourteen Continuing Issues in the Conceptualisation of Schizophrenia

1. Are there different subtypes of schizophrenia which share a common cause? (Issue of Equifinality)

2. Are there different causes of schizophrenia that share a common expression? (Issue of Equipotentiality)

3. Are there different subtypes of schizophrenia, each of which have different causes and expressions? (Issue of Heterogeneity in Cause, Expression, &Classification)

4. Are there variations in the course of different ‘subtypes’ of schizophrenia? (Issue of Variation in Course)

5. Are there variations in the outcomes of different ‘subtypes’ of schizophrenia? (Issue of Variations in Outcome)

6. Can schizophrenia(s) be reliably diagnosed? (Issue of Diagnostic Consistency)

7. Should the manic-depressive psychosis/bipolar disorder be considered a separate psychosis from schizophrenia(s) or is this an artifact of Kraepelin? (Issue of Arbitrary Separation of Cognition and Affect Traceable to Kraepelin)

7. Is there a spectrum of schizophrenic disorders with varying genetic–environmental etiologic penetrations?

8. Is schizophrenia continuous or discontinuous with normal personality and behavior? (Issue of Distinct Categories or Continuums of Disorder)

9. What are the specific basic deficits in schizophrenia(s) — social, psychological, biological, or interactive? (Issue of Locus of Deficit)

10. Are clinically-based diagnostic and classification systems of schizophrenia useful for predicting therapeutic and preventive functions? (Issue of the Value of Diagnosis for Prediction and Prevention)

11. Is schizophrenia a universal or a culture-specific disorder? (Issue of Variations in the Sources of Behavioral Plasticity)

12. How can we best understand the contributions of formative, precipative, exacerbative, and maintenance causes in schizophrenia(s)? (Issue of Multiple and Multiplicative Causality)

13. Can a reliable and valid diagnosis of schizophrenia(s) be made on the basis of presenting symptomatology, clinical history, and other clinical parameters? (Issue of Necessary, Adequate and Sufficient Diagnostic Criteria)

14. Can any single theory (i.e., genetic, biochemical, anatomical, psychological) account for the extensive variations in onset, manifestation, course,outcome, and/or treatment responsivity (Issue of Variation in Etiology and Clinical Parameters).

15. Do rates of schizophrenia vary across nations, cultures and historical periods? (Issue of Epidemiological Distribution)

Source: Marsella, 1995; Marsella et al., 2002.

accept these unassailable facts increases the risks of erro-neous and potentially destructive clinical decisions.

There is nothing admirable about a rigid mindsetthat denies alternatives because of an intolerance ofambiguity. It isn’t even good science, since good scienceprogresses from doubt, not certainty (Marsella, 1999b).Even as we evidence preferences for particular theoreti-cal and conceptual viewpoints, it is incumbent that wedo so with tentativeness. The study of culture and psy-chopathology has revealed how our clinical knowledgeand practice is often shaped not by science, but by socialand political forces that are in a position to advance par-ticular views based on their ethnocentric or genderbiases. We are not free of this risk, but we are now muchmore aware of it now and thus capable of responding toit with corrective and preventive measures. For ethnicminorities in the United States, and for the entire inter-national community, the expanded consideration ofcultural factors in psychopathology research and serviceprovision has introduced new hope and opportunitiesthat diagnostic and treatment errors will be reducedleading to improvements in the accessibility, availability,and acceptability of care across cultural boundaries (seeMarsella & Yamada, 2007).

ReferencesAlarcon, R., Alegria, M., Bell, C., Boyce, C., Kirmayer, L., Lin,

K.M., et al. (2002). Beyond the funhouse mirrors: Researchagenda on culture and psychiatric diagnosis. In D. Kupfer,M. First & D. Regier (Eds.). A research agenda for DSM-V(pp. 219–282). Washington, DC: American Psychiatric Press

American Psychiatric Association. (1994). Diagnostic and sta-tistical manual. of mental disorders. Fourth edition.Washington, DC: American Psychiatric Press.

American Psychological Association. (1992). Guidelines forproviders of psychological services to ethnic, linguistic, andculturally diverse populations. American Psychologist, 48,45–48.

Blashfield, R. (1984). The classification of psychopathology: Neo-Kraepelinian and quantitative approaches. New York:Plenum Press.

Chakraborty, A. (1991). Culture, colonialism, and psychiatry.The Lancet, 337, 1204–1207.

Cross, T.L. Bazron, B., Dennis, K, & Isaacs, M. (1989). Towardsa culturally-competent system of care: A monograph ofeffectve services for minority children who are severely emo-tionally disturbed. Washington, DC: Georgetown UniversityChild Development Center.

Dana, R., & Allen, J. (2008). Cultural competence training in aglobal society. New York: Springer SBM Publications

Day, R., Nielsen, J., Korten, A., Ernberg, G., Dube, K., Gebhart,J., et al. (1987). Stressful life events preceding the acuteonset of schizophrenia: A cross-national study from theWorld Health Organization. Culture, Medicine, andPsychiatry, 11, 1–123.

Department of Health and Human Services (2001). Culture,race, and ethnicity. Washington, DC: Author.

DiGirolamo, G., & MacFarlane, A. (1996). The epidemiology ofPTSD: An international review of the literature. In A.J.Marsella, M. Friedman, E. Gerrity, & R. Scurfield (Eds.)Ethnocultural aspects of PTSD: Issues, research, and clinicalapplications (pp. 33–86). Washington, DC: AmericanPsychological Association Press.

Draguns, J. (2006). Culture in psychopathology — psy-chopathology in culture. In T. Plante (Ed.), Mentaldisorders of the new millennium: Public and social problems(Vol 2., pp. 215–233). Westport, CT: Praeger.

Durant, W., & Durant, A. (1967). Rousseau and revolution.Story of civilzation: Part X. New York: Simon & Schuster

Fabrega, H. (2001). Culture and history in psychiatric diagno-sis and practice. In J. Mezzich, J., & H. Fabrega, H. (Eds.),Cultural psychiatry: International perspectives (pp. 391–406). Philadelphia, PA: W.B. Saunders

Higginbotham, H., & Marsella, A.J. (1988). Internationalmental health consultation and the homogenization ofthird-world psychiatry. Social Science and Medicine, 27,553–561.

Higginbotham, H., Takeuchi, D., Marsella, A.J., Gomes, K.,Kwan, L., Ostrowski, B., et al. (1987). Native Hawaiianmental health. In Robillard and A.J. Marsella (Eds.),Contemporary issues in mental health research in The PacificIslands. Honolulu, HI: SSRI (University of Hawaii Press).

Hooper, K., Harrison, G., Janca, A., & Sartorious, N. (2007).Recovery from schizophrenia: An international perspective.New York: Oxford University Press.

Jones, E. (1953). The life and work of Sigmund Freud. New York:Basic Books.

Katz, M., Marsella, A., Dube, K., Olatawura, M., Takahashi, R.,Nakane, Y., et al. (1988). On the expression of psychosis indifferent cultures: Schizophrenia in an Indian and in aNigerian community. Culture, Medicine, and Psychiatry, 12,331–355.

Kleinman, A. (1980). Patients and healers in the context ofculture: An exploration of the borderland between anthropol-ogy, medicine, and psychiatry. Berkeley, CA: University ofCalifornia Press.

Kleinman, A., & Good, B. (1985). Culture and depression.Berkeley, CA: University of California Press.

Kluckholm, C., & Kroeber, A. (1952). Culture: A critical reviewof concepts and definitions. Cambridge, MA: PeabodyMuseum.

Kluckholm, C., & Murray, H. (1950). Personality in nature,culture, & society. New York: Basic Books.

Kraepelin, E. (1904). Vergleichende psychaitrie. Zentralblatt furNervenherlkande und Psychiatrie, 15, 433–437.

Leighton, A., & Hughes, J. (1961). Cultures as causative ofmental disorder. In Causes of mental disorders: A review ofepidemiological knowledge. New York: Milbank MemorialFund.

Leininger, M. (1978). Transcultural nursing: Concepts, theories,and practices. New York: John Wiley.

Leininger, M. (1983). In P. Pedersen, N. Sartorius & A.J.Marsella (Eds.), Mental health services. The cultural context(pp. 109–134). Beverly Hill, CA: Sage



López, S.R., & Guarnaccia, P.J. (2008). Cultural dimensions ofpsychopathology: The social world’s impact on mental dis-orders. In J. Maddux & B. Winstead (Eds.),Psychopathology: Foundations for a contemporary under-standing (2nd ed., pp. 19–38). New York: Routledge/Taylor& Francis Group.

Marsella, A.J. (1979). Thoughts on cross-cultural studies on theepidemiology of depression. Culture, Medicine, andPsychiatry, 2, 343–357.

Marsella, A.J. (1982). Culture and mental health: An overview.In A.J. Marsella & G. White (Eds.), Cultural conceptions ofmental health and therapy (pp. 359–388). Boston, MA: G.Reidel Press.

Marsella, A.J. (1985). Culture, self, and mental disorder. In A.J.Marsella, G. DeVos & F. Hsu (Eds.), Culture and self: Asianand Western perspectives (pp. 279–308). New York andLondon: Tavistock Publications.

Marsella, A.J. (1988). Cross-cultural research on severe mentaldisorders: Issues and findings. Acta PsychiatricaScandinavica, 78, 7–22.

Marsella, A.J. (1993). Sociocultural foundations of psy-chopathology: A pre-1970 historical overview.Transcultural Psychiatric Research and Review, 30, 97–142.

Marsella, A.J. (1997, February). The plight of the NativeHawaiians. Paper presented at the Native Hawaiian identityand acculturation. Union of Polynesian NationsConference, East-West Center, Honolulu, Hawaii.

Marsella, A.J., (1999a). Conceptual and methodological issuesin schizophrenia research and practice. In T. Hallstrom & S.Ekblad (Eds.), Progress in psychopathology: Festschriften furProfessor Bengt Jansson. Stockholm, Sweden: KarolinskaInstitute

Marsella, A.J. (1999b). In search of meaning: Some thoughtson belief, doubt, and well being. The International Journalof Transpersonal Studies, 18, 41–52.

Marsella, A.J. (2000). Culture-bound disorders. In A. Kazdin(Ed.), The encyclopedia of psychology (pp. 407–410).Washington, DC: American Psychological AssociationPress/Oxford University Press.

Marsella, A.J. (2009). Abuses of psychology’s knowledge andpractices. Psychological Studies, 1, 10–15.

Marsella, A.J., Gomes, K., Kwan, L., Ostrowski, B., Rocha, B.,Wight, K. (1985). Native Hawaiian mental health. E OlaMau Task Force Report. Honolulu, HI: Alu Like

Marsella, A.J., & Yamada, A. (2000). Culture and mental health:An overview. In I. Cuellar & F. Paniagua (Eds.), Handbook

of multicultural mental health: Assessment and treatment ofdiverse populations (pp. 3–26). New York: Academic Press.

Marsella, A.J., Oliviera, J., Plummer, M., & Crabbe, K. (1995).Native Hawaiian culture, mind, and wellbeing. In H.McCubbin, E. Thompson, & A. Thompson (Eds.), Stressand resiliency in racial and minority families in America.(pp. 93–114). Madison, WI: University of Wisconsin Press.

Marsella, A.J., Sartorius, N., Jablensky, A., & Fenton F. (1986).Culture and depressive disorders. In A. Kleinman & B.Good (Eds.), Culture and depression (pp. 299-324).Berkeley, CA: University of California Press.

Marsella, A.J., & Yamada, A. (2007). Culture and psychopathol-ogy. In S. Kitayama, & D. Cohen, (Eds.) Handbook ofcultural psychology (pp. 3–26). New York: GuilfordPublications.

Marsella, A.J., Suarez, E., Morse, H., Leland, T., Scheuer, A., &Digman, B. (2002). Cross-cultural aspects of schizophrenicdisorders. In H. Bot, M. Braakman, L. Preijde, et al. (Eds.),Culturen op de vlucht [Cultures for those in transition] (pp.47–76). Amsterdam: Phoenix Press.

McCubbin, L., & Marsella, A.J. (2009). Native Hawaiian cultureand behavior: The cultural, historical, and situationalcontext of knowing and being. Cultural Diversity andEthnic Minority Psychology, 15, 374–387.

Murray, H., & Kluckholm, C. (1953): Personality in nature,culture, and society. New York: Basic Books.

Office of Minority Health (DHHS) (2000). National standardsfor culturally and linguistically appropriate services in healthcare. Final Report. Office of Minority Health United StatesDepartment of Health and Human Services (DHHS).Rockville, Maryland.

Paniagua, F. (2001). Diagnosis in a multicultural context.Thousand Oaks, CA: Sage.

Pedersen, P, & Marsella, A.J. (1982). The ethical crisis for cross-cultural counseling and therapy. Professional Psychology, 13,492–500.

Simons, R., & Hughes, C. (Eds.) (1985). The culture-bound syn-dromes. Boston, MA: G.Reidel/Kluwer Publications.

Weiss, M. (2001). Cultural epidemiology: An introduction andoverview. Anthropology and Medicine, 8, 5–29.

Yamada, A.-M., & Brekke, J. (2008). Addressing mental healthdisparities through clinical competence not just culturalcompetence: The need for assessment of socioculturalissues in the delivery of evidence-based psychosocial reha-bilitation services. Clinical Psychology Review, 28,1386–1399.





APP

END

IX A

Cultu

ral C

ompe

tenc

e Se

lf-Ev

alua

tion

Form

(Ccs

e)

Plea

se s

elec

t an

ethn

ocul

tura

l gro

up: _

____

____

____

____

____

__

Then

rate

you

rsel

f on

the

follo

win

g ite

ms

of th

is s

cale

:

Very

true

of m

eTr

ue o

f me

Som

ewha

t tru

e of

me

Not

true

of m

eU

nsur

e ab

out m

e4

32

1U

1.__

____

___

Know

ledg

e of

gro

up’s

hist

ory

2.__

____

___

Know

ledg

e of

gro

up’s

fam

ily s

truc

ture

s, ge

nder

role

s, dy

nam

ics

3.__

____

___

Know

ledg

e of

gro

up’s

resp

onse

to il

lnes

s (i.

e., a

war

enes

s, bi

ases

)

4.__

____

___

Know

ledg

e of

hel

p-se

ekin

g be

havi

or p

atte

rns

of g

roup

5.__

____

___

Abili

ty to

eva

luat

e yo

ur v

iew

and

gro

up v

iew

of i

llnes

s

6.__

____

___

Abili

ty to

feel

em

path

y an

d un

ders

tand

ing

tow

ard

grou

p

7.__

____

___

Abili

ty to

dev

elop

a c

ultu

rally

resp

onsi

ve tr

eatm

ent p

rogr

am

8.__

____

___

Abili

ty to

und

erst

and

grou

p’s

com

plia

nce

with

trea

tmen

t

9.__

____

___

Abili

ty to

dev

elop

cul

tura

lly re

spon

sive

pre

vent

ion

prog

ram

for g

roup

10.

____

____

_ Kn

owle

dge

of g

roup

’s “c

ultu

re-s

peci

fic”

diso

rder

s

11.

____

____

_ Kn

owle

dge

of g

roup

’s ex

plan

ator

y m

odel

s of

illn

ess

12.

____

____

_ Kn

owle

dge

of g

roup

’s in

dige

nous

hea

ling

met

hods

and

trad

ition

s

13.

____

____

_ Kn

owle

dge

of g

roup

’s in

dige

nous

hea

lers

and

thei

r con

tact

eas

e

14.

____

____

_ Kn

owle

dge

of c

omm

unic

atio

n pa

tter

ns a

nd s

tyle

s (e

.g.,

non-

verb

al)

15.

____

____

_ Kn

owle

dge

of g

roup

’s la

ngua

ge

16.

____

____

_ Kn

owle

dge

of g

roup

’s et

hnic

iden

tific

atio

n an

d ac

cultu

ratio

n si

tuat

ion

17.

____

____

_ Kn

owle

dge

of h

ow o

ne’s

own

heal

th p

ract

ices

are

root

ed in

cul

ture

18.

____

____

_ Kn

owle

dge

of im

pact

of g

roup

’s re

ligio

us b

elie

fs o

n he

alth

and

illn

ess

19.

____

____

_ De

sire

to le

arn

grou

p’s

cultu

re

20.

____

____

Des

ire to

trav

el to

gro

up’s

natio

nal l

ocat

ion,

nei

ghbo

rhoo

d

TOTA

L SC

ORE

: ___

____

_ 80

–65

= C

ompe

tent

; 65–

40 =

Nea

r Com

pete

nt; 4

0 Be

low

= In

com

pete

nt

TOTA

L #

of U

’s: _

____

____

(If t

his

num

ber i

s ab

ove

8, m

ore

self-

refle

ctio

n is

nee

d)

Not

e: C

opyr

ight

200

9 AJ

M, A

tlant

a, G

eorg

ia. U

se w

ith a

ckno

wle

dgem

ent a

nd c

itatio

n. B

ased

on

Mar

sella

& K

apla

n, 2

002;

Yam

ada,

Mar

sella

, & Y

amad

a, 1

998;

Yam

ada,

Mar

sella

, & A

tuel

, 200

2; H

anso

n, P

epito

ne, G

reen

(200

0).

marsella & yamada 2010 culture and psychopathology

Documents