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Towards a Cultural–Clinical PsychologyAndrew G. Ryder1,2*, Lauren M. Ban1,2 and Yulia E. Chentsova-Dutton31 Concordia University2 Sir Mortimer B. Davis-Jewish General Hospital3 Georgetown UniversityAbstractFor decades, clinical psychologists have catalogued cultural group differences in symptom presentation, assessment, and treatment outcomes. We know that ‘culture matters’ in mental health – butdo we know how it matters, or why? Answers may be found in an integration of cultural andclinical psychology. Cultural psychology demands a move beyond description to explanation ofgroup 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 theseapproaches, opening up new lines of inquiry. The central assumption of this interdisciplinary fieldis that culture, mind, and brain constitute one another as a multi-level dynamic system in whichno level is primary, and that psychopathology is an emergent property of that system. We illustratecultural–clinical psychology research using our work on depression in Chinese populations andconclude 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 depressedmood. 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 andknowledge of North American practices, his business is in difficulty. He attributes business troublesto 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 Chinesetraditions; however, his daughters desire greater participation in North American society. He describeshis wife as much more traditional than he is, but to his surprise it is she who encourages the childrento participate in mainstream society. At the initial interview, Mr. Cho denies depressed mood butagrees 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 mentalhealth 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 tothink 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 inmainstream psychology. That ‘culture matters’ in clinical psychology is nothing new,although it bears frequent repetition in an era of biological reductionism. Rather, our claimis threefold: first, that there is relatively little cultural research in clinical psychology thataspires 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 clinicalSocial and Personality Psychology Compass 5/12 (2011): 960–975, 10.1111/j.1751-9004.2011.00404.xª 2011 Blackwell Publishing Ltdpsychology, to the benefit of both; and third, that the result is a new field. Cultural–clinicalpsychology has in some sense been around for a while, pursued by a small number ofresearchers. Nonetheless, it has not yet coalesced as an established field of study or as anapproach 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. Centralto this integration is the idea of mutual constitution – that culture, mind, and brain forma single system in which no level can be understood without the others. We then drawon our own research, pertaining to depression in Chinese populations, to provide someempirical examples. We conclude with a brief critique of these studies, considering waysin which they could be improved and interpreted in light of cultural–clinical psychology.Concrete suggestions to improve cultural–clinical psychology research are summarized inthe Appendix and referenced throughout.Cultural–Clinical Psychology: A Brief IntroductionCultural psychologyIn positioning cultural–clinical psychology, we begin by grounding the first term in the‘cultural psychology’ perspective (e.g., Markus & Kitayama, 1991; Shweder, 1990). Theword ‘culture’ has long been used in psychology to stand for ethnicity or nationality, andinvoked as a black-box explanation: groups differ because of ‘culture’, but the specificways in which this happens remain unclear. Cultural psychology represents a move awayfrom cataloguing differences to understanding culture and how it shapes psychologicalvariation (e.g., Betancourt & Lo´pez, 1993; Cohen, Nisbett, Bowdle, & Schwarz, 1996;Heine and Norenzayan, 2006; Kitayama, Markus, Matsumoto, & Norasakkunkit, 1997).Differentiating between culture and ‘cultural group’ emphasizes that individual groupmembers can partially adhere to or reject aspects of culture. For example, Mr. Cho andhis wife have different views about the acculturation of their children, and not in waysthat 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 intension 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 byobservers as meaningful. These acts are framed by the cultural meaning system and theirenactment 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 theAmerican South, reporting that southerners have more favorable attitudes towards violence in cases where honor is at stake. Moreover, they demonstrated experimentally thatsoutherners whose honor has been challenged are more physiologically reactive and takelonger 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 ofboth participant and confederate are understood as meaningful.The idea of cultural scripts can bridge these perspectives, as they both reflect meaningstructures in the head and guide behavioral practices in the world (DiMaggio, 1997).Scripts refer to organized units of knowledge that encode and propagate meanings andpractices. They serve as mechanisms that allow for rapid automatic retrieval and use ofinformation acquired from the world while shaping how that information is perceived.Enacted as behavior, scripts are observable to others and become part of the culturalCultural–Clinical Psychology 961ª 2011 Blackwell Publishing Ltd Social and Personality Psychology Compass 5/12 (2011): 960–975, 10.1111/j.1751-9004.2011.00404.xcontext, shaping assumptions about what others think and expectancies about how theywill behave (Chiu, Gelfand, Yamagishi, Shteynberg, & Wan, 2010). Moreover, peoplecan 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’, heis accessing available scripts for cultural preservation while his actions and others’responses contribute to shaping these scripts, and passing them to his children. In workcontexts, these same scripts may be primed rarely if at all. Mr. Cho’s wife can understandhim according to their shared meaning system even as she accesses a different availablecultural script – promoting her children’s well-being by ensuring they can function in anew society (Appendix: 2.2).Clinical psychologyIn using the term ‘clinical’ in cultural–clinical psychology, we are thinking primarily ofresearchers trained as scientists or scientist-practitioners in clinical psychology, health psychology, or experimental psychopathology. Although not all of these researchers aredirectly engaged with both science and practice, there is an emphasis on moving betweentheory and research about groups on the one hand, and the experiences and needs ofindividual sufferers on the other. Clinical psychology is concerned both with describingpathological phenomena and with using psychological principles to intervene with thesephenomena 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 over300 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 ofpsychopathology, as diagnostic systems are themselves cultural products (Gone & Kirmayer, 2010; Lewis-Ferna´ndez & Kleinman, 1994). Moreover, Kleinman (1988) argues thatrigid application of a diagnostic system conceals cultural variation. He has shown howThe 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 variabilityacross the cultural groups (Appendix: 1.2).Cultural–clinical psychology: what’s new?In an era both of fragmentation and interdisciplinarity in psychology (Cacioppo, 2007) itis 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 culturalpsychology is altered by clinical questions, not simply given new content. Research incultural–clinical psychology should tell us something new about the cultural contextsunder study, not just the pathologies. Finally, we must demonstrate that new questionsand methods for addressing them emerge from this sub-discipline, or at least that thepotential is there (Appendix 2.1).962 Cultural–Clinical Psychologyª 2011 Blackwell Publishing Ltd Social and Personality Psychology Compass 5/12 (2011): 960–975, 10.1111/j.1751-9004.2011.00404.xClinical 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 correspondingmalfunction 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 indicatesthe failure of a biological system evolutionarily adapted for particular ends.While these approaches ostensibly give equal credit to culture and biology, uncriticalacceptance plays into biases of mainstream clinical psychology. Researchers can end upexemplifying 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 seedisorder as both biological and cultural, in a fundamentally inseparable way. Depressedmood has many biological and cultural constituents worthy of focused study for specificpurposes, but there is no depressed mood until these constituents come together and areexperienced by someone.Methodologically, clinical research has much to gain from incorporating the culturalpsychology perspective. Integration of findings on the cultural shaping of psychologicalfunctioning can allow clinical psychologists to develop a broader and more nuanced viewof normal human experience. Cultural psychology is well positioned to help clinical psychology move beyond conceptualizations of mental illnesses as products of solitary mindsto 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, includingboth patients and clinicians, incorporate contextual information in detecting, reportingand interpreting symptoms of mental illness (for examples of these cultural psychologyideas, not yet adapted for clinical questions, see Heine, Lehman, Markus, & Kitayama,1999; Hong, Morris, Chiu, & Benet-Martı ´nez, 2000; Masuda & Nisbett, 2001; Uchida,Norasakkunkit, & Kitayama, 2004. In Mr. Cho’s case, the institutional demands of amental health clinic may have tilted the emphasis toward symptoms and attributions andaway 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 isshaped by cultural context. Although by definition abnormality violates expectations ofwhat is normal, people nonetheless have scripts to help them make sense of pathology asbest they can. Confusing and frightening experiences, such as emerging psychopathology,have a particularly strong need for scripts (Philippot & Rime´, 1997; Taylor, 1983). Thelarge but finite number of ways to be physically or psychologically distressed is furthermolded 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’sexperience to what is available in this ‘symptom pool’, focusing on and thereby amplifying those symptoms that best serve explanatory and communicative purposes. Denial ofdepressed mood and acknowledgement that his problems are upsetting can be seen asserving Mr. Cho’s communication goals in a particular health care setting.Cultural psychology encounters clinical psychology. Beyond providing new content, potentialcontributions of clinical psychology begin with two of cultural psychology’s coreconcerns: heterogeneity of cultural groups and limited coherence of cultural contexts(Kashima, 2000). These concerns do not necessarily require clinical psychology, but theCultural–Clinical Psychology 963ª 2011 Blackwell Publishing Ltd Social and Personality Psychology Compass 5/12 (2011): 960–975, 10.1111/j.1751-9004.2011.00404.xstudy 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 thatpropelled neuroscience, we learn new things about cultural processes when the normalcultural scripts no longer work (For a similar idea, not specific to psychopathology, seeBeckstead, Cabell, & Valsiner, 2009). North American studies of social phobia patientshighlight the central role fear of negative evaluation plays when healthy interpersonal functioning breaks down (see Hofmann & Barlow, 2002). These findings also reveal some ofthe assumptions of normal social relationships in North America: one is to portray one’strue self and have it be positively evaluated by others. Studies of socially anxious patients inother 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 centralconcern 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 whichabnormal behavior is shaped by constraints imparted by physiological and environmentalinfluences, and their interactions. For example, contemporary research on depressionspans multiple levels of analysis ranging from genes to hormones, brain anatomy andfunction, 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 harnessingnovel 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–brainThe 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 psychologyresearch, in keeping with trends in psychological science and in psychiatry, tends to focusmore on the interrelation of mind and brain (Andreasen, 1997; Barrett, 2009; Ilardi &Feldman, 2001). We argue that the best approach for cultural–clinical psychology emergesfrom 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 multiplelevels 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 contextsthat 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 thinkingand studying the psychological and the cultural so that neither is seen as the ultimatesource of the other (Markus & Hamedani, 2006; Shweder, 1995).Mind and brain. It is increasingly untenable to propose models of mental health that haveno room for the brain, as shaped by the genome and in turn by evolutionary processes.964 Cultural–Clinical Psychologyª 2011 Blackwell Publishing Ltd Social and Personality Psychology Compass 5/12 (2011): 960–975, 10.1111/j.1751-9004.2011.00404.xWhile we agree wholeheartedly with Geertz (1973) that, ‘‘it is culture all the waydown’’, 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 mindas 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 toolsand close others are partially incorporated into one’s mind: the online calendar canbecome part of the mind’s memory system; the close friend can become part of the mind’semotion 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 isadapted to acquire culture and responds to cultural inputs with marked plasticity, especially early in development (Wexler, 2006). Indeed, the emergence of a recognizablehuman 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 culturecan be configured, yet the number of impossible configurations is practically infinite (Gilbert, 2002; Mealey, 2005; O¨ hman & Mineka, 2001). That this is true does not compromise the equally important observation that human possibilities are many, diverse, anddeeply shaped by culture (Marsella & Yamada, 2010; Tseng, 2006).The ecology of culture–mind–brain. Describing the interrelations of culture, mind, and brainas a triangle of linked associations might imply three interrelated systems. We prefer tothink of culture–mind–brain as one dynamic multilevel system, an information networkinstantiated 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 oneanother. 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 atendency to attend to context in Korean participants, and the same variant predicts anespecially strong tendency to attend to the focal object in Euro-American participants.Psychopathology is an emergent property of culture–mind–brain, with no ultimatecause at any one level. While changes at one level affect all levels, it does not follow thatdisorder at one level means disorder at other levels, let alone that disorder at a higherlevel must be caused by disorder at a lower level. A disordered brain circuit does notrequire malfunctioning neurons, nor does a disordered neuron require malfunctioningmolecules, although neither makes sense in the absence of neurons or molecules. Pathology can emerge from problematic feedback loops in which the response to a problemexacerbates 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 disorderedbrain. Values conflict between Mr. Cho and his wife can create a stressful environmentfor 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, withconsequences that include damage to brains from traumatic stress. It is incomplete at bestCultural–Clinical Psychology 965ª 2011 Blackwell Publishing Ltd Social and Personality Psychology Compass 5/12 (2011): 960–975, 10.1111/j.1751-9004.2011.00404.xto claim that psychological consequences of that damage are caused by the brain withoutacknowledging political or economic causes. Similarly, Mr. Cho’s depression might makesense as psychosocial stress coupled with preexisting vulnerability, but the depression haslasting consequences for the brain (Kendler, Thornton, & Gardner, 2000). A mind-levelintervention such as Cognitive-Behavior Therapy (CBT), moreover, impacts on the brain(DeRubeis, Siegle, & Hollon, 2008) – unsurprising, as culture–mind–brain is a singlesystem (Appendix: 3.2).Before considering an example of three recent cultural–clinical psychology lines ofresearch focused on an interrelated set of questions, let us briefly return to the case ofMr. Cho.After the initial assessment, Mr. Cho began a 16-week course of CBT for depression. Thecase at first appeared to be a textbook case of ‘Chinese somatization’; somatic symptoms werediscussed almost exclusively, unlinked to psychosocial stressors. Sustained discussion of thesestressors would sometimes lead to marked tearfulness and inability to maintain emotional composure. Once rapport was established, depressed mood was acknowledged fairly quickly, along withguilt and pessimism, primarily described as reactions to how the physical symptoms had impactedhis business and family life.Mr. Cho asked several times how CBT could help him with his primary concern – the somaticsymptoms – 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 incorporatingsome 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 ExamplesWe are each involved in independently developed lines of research taking a cultural psychology approach to clinically-relevant questions about Chinese-origin participants anddepression. To illustrate the potential of cultural–clinical psychology, we turn to a moresustained discussion of this work.Cultural psychology research on depressionSomatic and psychological symptoms. In a now classic study, Kleinman (1982) argued thatChinese 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. Resultsgenerally showed greater somatic symptom reporting in the Chinese group and greaterpsychological symptom reporting in the Euro-Canadian group. The tendency to devaluethe 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 culturalscripts in North America. This tendency was measured using a tool designed to measure pathology, the Externally-Oriented Thinking (EOT) subscale of the Twenty-itemToronto Alexithymia Scale (TAS-20; Bagby, Parker, & Taylor, 1994). Whereas EOTmight capture pathological beliefs in a cultural context that fosters ideals of healthyemotional expression, it may simply represent adherence to an accessible culturalscript in Chinese contexts (see Dion, 1996; Kirmayer, 1987). In a comparison ofChinese- and Euro-Canadians, group difference in EOT was mediated by adherence to966 Cultural–Clinical Psychologyª 2011 Blackwell Publishing Ltd Social and Personality Psychology Compass 5/12 (2011): 960–975, 10.1111/j.1751-9004.2011.00404.x‘Western’ values (Dere, Falk, & Ryder, forthcoming). People vary in accessibility ofcultural scripts about emotional expression, and cultural contexts vary in terms of hownormal these scripts are perceived to be. Mr. Cho had access to multiple scripts butthe Chinese somatic script predominated – he emphasized somatic symptoms whileincreasingly considering psychological symptoms, and tended to see the latter as consequences of somatic symptoms.Emotional expression. Studies comparing depressed Euro-Americans and Asian-Americansto their non-depressed counterparts show that depression is associated with culturally-specific patterns of emotional reactivity. For Euro-Americans, depression is characterized bydampened emotional reactivity in response to positive and negative emotional films (seeBylsma, Morris, & Rottenberg, 2008). Chentsova-Dutton et al. (2007) replicated thispattern with negative films in Euro-Americans using self-report, facial coding, andphysiological 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 measuressuch as cardiac reactivity, depressed Asian-Americans were actually more reactive thannon-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 depressedmood, 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 foropen and prominently displayed emotional responses (Bellah, Sullivan, Tipton, Swidler,& Madsen, 1985). The Chinese-American pattern of heightened reactivity whendepressed 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 emphasizepsychological symptoms but also to link distress to psychological causes. Ban, Kashima,and Haslam (2010) explored the extent to which behavior is deemed pathological if itviolates this cultural script. A vignette describing someone with depression, including ornot including a psychological cause, was presented to Euro-Australian and Chinese-Singaporean university students. Euro-Australian students were more likely to perceivedepression as ‘normal’ when their vignette included a psychological explanation. ForChinese-Singaporean students, psychological explanations made the depression seem lessnormal, 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 helprestore a sense of order. Chinese-Singaporeans, by contrast, live in a cultural contextwhere the predominant script equates emotional maturity with adjustment of behavior tosituational demands (Kirmayer, 2007). Indeed, Chinese-Singaporean moral explanationscentered on failed social obligations. These modes of explanation represent scripts that areavailable, to varying extents, in different cultural contexts. Mr. Cho initially presentedalong the lines of a medicalizing script, which soon gave way to a moralizing script aboutfailing his family. Eventually, he was willing to consider a psychologizing script withoutfully endorsing it.Cultural–Clinical Psychology 967ª 2011 Blackwell Publishing Ltd Social and Personality Psychology Compass 5/12 (2011): 960–975, 10.1111/j.1751-9004.2011.00404.xReinterpreting the researchHow can we understand these findings in light of culture–mind–brain? Before depressionemerges, people have access to culturally shaped scripts about what depression is andassume others have access to these scripts as well (Ban et al., 2010). Once depressionemerges, its implications cascade rapidly through all levels of culture–mind–brain, motivating people to make sense of what is happening to them (Philippot & Rime´, 1997).Scripts focus attention on certain symptoms, magnifying some experiences and minimizing others. A looping effect takes place – experiences that best draw upon the culturalsymptom pool in ways that fit available scripts about depression are focused upon, furthercontributing to their severity (Shorter, 1992). Multiple cultural scripts can coexist anddraw upon this pool, so that patients in a single cultural context can nonetheless presentmany different kinds of symptoms (Ryder et al., 2008).In keeping with the idea of mind as social, we have real and imagined audiences forthis process: what do we tell other people; what are they going to notice; how are theygoing 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 othersreact 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 anotherloop 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 actualexperiences 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 rapidsocial change is shifting public understanding of depression, altering cultural scripts, andin turn shaping symptoms presented by successive cohorts. In consequence, exposure tomodernization and Westernization values is lessening the tendency for Chinese patients toemphasize somatic symptoms of depression (Ryder et al., forthcoming).Contributions and limitationsThese studies represent three independent attempts to bring together cultural and clinicalpsychology to investigate a particular clinical phenomenon in a particular cultural group,drawing on both fields for theory, methodology, and interpretation. These studies gobeyond 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, facialcoding, 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 ofculture but do not go very far in advancing that agenda. Culture is not assessed in amulti-method way. More fundamentally, however, what is missing so far is the brain,968 Cultural–Clinical Psychologyª 2011 Blackwell Publishing Ltd Social and Personality Psychology Compass 5/12 (2011): 960–975, 10.1111/j.1751-9004.2011.00404.xand thus the potential synthesis implied by culture–mind–brain. Somatic and emotionalexperiences 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 levelsof culture–mind–brain can be included in a single study.Even with improvements in conception, sampling, methods, and interpretation, we donot expect that any given study, or even research program, would cover everything discussed here. Cultural–clinical psychology already exists in a sense, including researcherswho have been making important contributions for years. At the same time, there is asyet little sense of a shared enterprise, let alone of the institutional markers of such. Whatis needed is a greater degree of coherence and integration, where individual researchgroups approach different pieces of the overall puzzle, but with a shared framework andan ongoing commitment to putting this puzzle together.ConclusionThere is much to be gained from greater connection between cultural and clinical psychology, with a core of researchers at the intersection. Cultural psychology can benefitfrom 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 thatmay 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–clinicalpsychology advances attempts to conceptualize mental health phenomena as dynamic andcontext-dependent, rather than fully reducible to physiological deficits or environmentalstressors. We emphasize ‘cultural’ aspects because we believe that explanations at this levelare often neglected in mental health research, but hope that ultimately no discussion ofmental health will seem complete without consideration of all levels.The case of Mr. Cho illustrates how knowledge of cultural context and its accessiblesymptom scripts help us to better assess clients and modify treatment approaches to betteradapt to these scripts. We observe how the clinical encounter becomes a space in whichcultural scripts are negotiated, influencing both participants and shifting over the course oftreatment. Training programs, internship sites, and licensing bodies increasingly insist ontraining in diversity and cultural competence without a clear vision of how to proceed orwhat evidence to use. Cultural competence is more than simply using good clinical skillswith ethnic minority patients; cultural–clinical psychology can aspire to provide an evidencebase (Ryder & Dere, 2010). At the same time, cultural competence includes questioningthat 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 apatient’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 somechanges by himself. He continued to prioritize somatic symptoms, but agreed that psychologicalsymptoms were part of his experience. At six-month follow-up, Mr. Cho reported ongoing appetiteand gastrointestinal problems, but much better sleep, energy level, and mood. He mentioned that hewas now working with a specialist, who was finding that the ongoing gastrointestinal and appetiteproblems might be related to a specific medical issue. The possibility of this separate issue may havebeen lost in the context of the other symptoms.Cultural–Clinical Psychology 969ª 2011 Blackwell Publishing Ltd Social and Personality Psychology Compass 5/12 (2011): 960–975, 10.1111/j.1751-9004.2011.00404.xAcknowledgmentPreparation of this manuscript was supported by a New Investigator Award from theCanadian Institutes of Health Research to AGR. The authors gratefully acknowledge thecomments provided by Emily Butler, Jessica Dere, Marina Doucerain, Alan Fiske,MarYam Hamedani, Nick Haslam, Steve Heine, Tomas Jurcik, Yoshi Kashima, LaurenceKirmayer, Michael Lorber, Andrea McCarthy, Vinai Norasakkunkit, Nicole Stephens,and Romin Tafarodi on earlier versions of this manuscript.Short BiographiesAndrew G. Ryder received his doctorate in psychology (clinical) from the University ofBritish Columbia and currently directs the Culture, Health, and Personality Lab in theDepartment 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 HealthResearch 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, Journalof Personality and Social Psychology, and Journal of Personality Disorders. Current researchfocuses on: (a) the intersection of cultural and personality variables in shaping depressivesymptom presentation in China and South Korea; and (b) acculturation and adaptation incomplex multicultural societies. His work is supported by a New Investigator Awardfrom the Canadian Institutes for Health Research (CIHR) and grants from CIHR and theFonds de la recherche en sante´ du Que´bec.Lauren M. Ban received her doctoral degree in psychology (social) from the Universityof 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 SirMortimer B. Davis–Jewish General Hospital in Montreal, under the supervision of Dr.Ryder and Dr. Laurence Kirmayer. Her dissertation research explored folk perceptions ofmental disorder comparing people with East Asian (primarily Chinese–Singaporean) andEuropean–Australian cultural backgrounds, and a study from this work has been publishedin 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 Departmentof Psychology at Georgetown University in Washington, D.C., where she directs theCulture and Emotion Lab. Her research spans cultural psychology, emotions, and mentalhealth, and her publications include papers in the Journal of Abnormal Psychology, Journal ofPersonality and Social Psychology, and Cultural Diversity and Ethnic Minority Psychology. Herspecific research interests include the cultural shaping of: (a) emotions, including conceptions and functions of emotions, emotional reactivity, and interoception); and (b) socialsupport, including advice-giving and support networks. Her work is supported by theSocial Psychology Program of the National Science Foundation.Endnotes* Correspondence address: PY153-2, 7141 Sherbrooke St. W., Montreal, Quebec, H4B 1R6, Canada. Email:[email protected]1 Horace Cho is based on a composite of two cases. Identifying information has been fictionalized.970 Cultural–Clinical Psychologyª 2011 Blackwell Publishing Ltd Social and Personality Psychology Compass 5/12 (2011): 960–975, 10.1111/j.1751-9004.2011.00404.xReferencesAchenbach, T. M., & Edelbrock, C. S. (1983). Taxonomic issues in child psychopathology. In T. H. Ollendick &M. Hersen (Eds.), Handbook of Child Psychopathology (pp. 65–93). New York: Plenum Press.Adams, G., Salter, P. S., Pickett, K. M., Kurtis, T., & Phillips, N. L. (2010). Behavior as mind-in-context: A cultural psychology analysis of ‘‘paranoid’’ suspicion. In L. F. Barrett, B. Mesquita & E. Smith (Eds.), The Mind inContext (pp. 277–306). New York: Guilford.Andreasen, N. C. (1997). 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When we use categories, we havea tendency to assume that these categories are clearly separated from one another andcapture fundamental differences. We essentialize groups when we assume that all peopleCultural–Clinical Psychology 973ª 2011 Blackwell Publishing Ltd Social and Personality Psychology Compass 5/12 (2011): 960–975, 10.1111/j.1751-9004.2011.00404.xfrom a certain cultural background or carrying a certain diagnosis are the same as oneanother, and different from people in other groups. At the same time, however, it is verydifficult to conduct research without relying on groupings of individual people. Researchers should therefore adopt a pragmatic rather than essentialized approach to describing cultural groupsand diagnostic categories:1.1. For cultural groups, specify on a study-by-study basis how each group is definedand for what purposes, and interpret results in light of a more nuanced and dynamic viewof culture. Doing so not only means more accurate reporting of methods, but also servesas a reminder that group membership is not self-evident, especially around the edges of agiven category.1.2. For diagnostic categories, consider a ‘lumping’ approach for syndromes and a‘splitting’ approach for symptoms – very few broad categories for communication andcomparison purposes (e.g., emotional disorders, psychotic disorders) followed by afine-grained approach to individual symptoms. We might define the problem beingcompared across groups very broadly – for example, how do people in different contextcope with loss? – and then seek to answer that question in part by looking at differencesin 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 shapedifferent people in different ways. It is therefore difficult to study, and it is hard toconduct good research without already knowing a lot about the context being studied –much as mainstream psychology researchers have a lot of tacit and unexaminedknowledge about their own contexts. Researchers should therefore know the cultural contextwell, aided by personal immersion in the context, selected cultural informants, and⁄or multiculturalresearch teams:2.1. Tell a cultural story about the phenomena under study, aiming to explain ways inwhich culture shapes mental health rather than cataloguing group differences. At the startof a line of inquiry, that should involve using knowledge of the cultural context topropose potential explanations. Later on, studies should incorporate these potentialexplanations into the research design; for example, by testing the extent to which theycan mediate group difference effects, or by manipulating them experimentally.2.2. Pay attention to and assess contradictory cultural scripts, rather than assuming thatcultural contexts foster a single script for a particular domain. Doing so helps move awayfrom cultural determinism and helps counteract the tendency to essentialize culture, serving as a reminder that culture is complex and can influence different people in differentways.2.3. Aim to measure culture in a multi-method way, as it exists in the head (e.g., viaself-report or implicit cognitive tasks) and in the world (e.g., via behavioral observationor examination of cultural products). While not always possible within a single study, useof different methods strengthens a line of research and captures some of the complexityof culture. Indeed, it is not always the case that these different methods will agree; pointsof contradiction may be important.3. Situating research within the culture-mind-brain system. We have describedculture, mind, and brain as a deeply interactive and non-reductive multilevel system. It isnot 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 researchquestion and compatible with one’s training and resources. These aspects should be iden-974 Cultural–Clinical Psychologyª 2011 Blackwell Publishing Ltd Social and Personality Psychology Compass 5/12 (2011): 960–975, 10.1111/j.1751-9004.2011.00404.xtified and studied carefully while we remain mindful that our work is embedded within abroader system. Researchers should therefore remember that a complex and dynamic system requiresone 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 broaderconceptual argument (e.g., described by the introduction and discussion). A series ofmore 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 foranything 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 importanceof doing so.Cultural–Clinical Psychology 975ª 2011 Blackwell Publishing Ltd Social and Personality Psychology Compass 5/12 (2011): 960–975, 10.1111/j.1751-9004.2011.00404.xCopyright of Social & Personality Psychology Compass is the property of Wiley-Blackwell and its content maynot be copied or emailed to multiple sites or posted to a listserv without the copyright holder’s express writtenpermission. However, users may print, download, or email articles for individual use.

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