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159 Cards in this Set

  • Front
  • Back
Percentage Growth of U.S. Population by Ethnicity:
1990 to 2000
Hispanics: 57.9
Asians: 52.4
Blacks: 16.2
American Indians: 15.3
Pacific Islanders: 8.5
Whites: 3.4
Projected Growth of Population by Ethnicity: 1990, 2000 and 2050
RACE: 1990, 2000, 2050

Hispanics: 9, 11.4, 24.5
Asians: 3, 4.1, 8.7
Blacks: 12.3, 12.9, 15.4
American Indians: .8, .9, 1.1
Whites: 75.7, 71.8, 52.8
Demographics
A. Increasing racial and ethnic diversity in the United States
B. Diversity is spreading geographically
C. How well has our science reflected the diversity in our nation?
Number and percentage of empirical articles on African Americans in 6 APA journals, across 4 publication periods
Total articles: 14, 542
Number on AAs: 526
Percentage: 3.6

Similarly, or worse, ratios found for other non-white races
Not White and Middle Class
“Academic psychology cannot maintain its integrity by continuing to allow ethnic minorities to remain marginalized in mainstream research. In contemporary society, most of the population is not White and middle class. Neither should the subject populations in the journals of our discipline continue to be so disproportionately defined.”
Graham (1992)
Mainstream Psychology
“…mainstream psychology has been faulted both politically and scientifically for its traditional exclusion of diverse groups from study and its claim to have discovered universal laws governing human behavior based on a limited sample of the world’s population.” (Veroff & Goldberger)
History
A. Persons of color have been poorly represented in psychological research.
B. But when they have been the focus of research, much prejudice and stereotypes directed towards these groups has been revealed (Thomas & Sillen, 1972)
1. drapetomania—mental disorder associated with runaway slaves
3. Mexican American and Anglo American symptom differences (Meadow & Stocker, 1965)
Drapetomania
The black man, it was repeatedly claimed, was uniquely fitted for bondage by his primitive psychological organization. For him, mental health was contentment with his subservient lot, while protest was an infallible symptom of derangement. Thus, a well-known physician of the ante-bellum South, Dr. Samuel Cartwright of Louisiana, had a psychiatric explanation for runaway slaves. He diagnosed their malady as drapetomania, literally the flight-from-home madness, “as much a disease of the mind as any other species of mental alienation.” (Thomas & Sillen ,1972)
Cultural differences in youth problems
Mexican American children > Anglo American children: frequency of impulsivity, indifferent attitude, passivity and truancy. (Matched for income)

“In Mexican American adult males the pattern of irresponsibility is seen in the more florid form of the “macho” pattern with its drinking, gambling, promiscuous behavior, and non-support of family. The pattern may result from the lack of goal direction and role expectation for the younger male child. Controls within the family are exceedingly strict but, because of the lack of direction over the behavior of the child outside family life, he is relatively free to express hostility. The Anglo American child differs because controls are more internalised and are therefore carried over into behavior outside of the home (Stoker & Meadow,1974)
Why are these studies prejudicial or stereotypical?
1. Fail to consider alternative hypotheses
a. social circumstances of runaway slaves.
b. assumes clear difference in intelligence based on race w/o considering social factors.
2. Fail to directly measure culture in Mexican American-Anglo American study
3. Good research rules out alternative hypotheses and measures directly culture

Ethnicity/race of psychology faculty and practitioners: Persons of color are poorly represented
Race/ethnicity of Faculty in U.S. Graduate Departments of Psychology (APA Research Office)
Averages:
93% White
4% Black
1% Hispanic
1% Asian
Changes are underway
a. books/journals
b. DSM-IV
c. Surgeon General’s report
DSM-IV
A. DSM-III—little mention of culture
1. Schizophrenia—delusions
2. Nothing for affective, personality disorders
B. DSM-IV—Much more attention
1. Sub-task force to address cultural issues.
2. Cultural considerations throughout DSM
3. Appendix I
a. Outline for cultural formulation of diagnosis
b. glossary of cultural bound syndromes
C. Glass half full or half empty?
Culture Counts
“The main message of this Supplement—that culture counts—should echo through the corridors and communities of this Nation. In today’s multicultural reality distinct cultures and their relationship to the broader society are not just important for mental health and the mental health system, but for the broader health care system as well.” (Surgeon General, 2001)
Challenges
A. Definition of culture
B. Towards a definition of culture
C. Exercise “Which of the following families are Mexican?” (shows photos)
Challenges
What is culture?
1. Does it equal Nationality? Ethnicity? Race?
2. If you rely on physiognomy to implicate culture might you be mistaken?
3. Limitations of categories used by researchers and laypersons.
4. We will be struggling with definitions throughout course, not unlike the field.
Other Challenges
1. Identify cultural, racial, ethnic influences w/o stereotyping—How do we avoid limitations of past research?
2. Extend knowledge beyond description to contribute to general knowledge base. Studying diverse populations can lead to broadening our understanding of human behavior, not just of specific groups.
First Lecture Conclusion...
A. Despite limited attention in psychology, culture, race and ethnicity matters
B. If we are going to discern its role in human behavior we need definitions and tools that reflect the complexity of culture in our every day lives.
Two views about the Study of Race/Ethnicity
CON: Should NOT be studied because of potential damage.
PRO: Should be studied to address health disparities (services and possible genetic susceptibility to disease)
Begone with Ethnicity
Ethnicity/Race Neutral Approach
“Begone with the entire notion of ethnicity, says I. Emphasizing multiethnicity only accelerates the perception of differences and fragments us into little groups who are fighting each other. There are more important survival-oriented matters to consider.”
Rudin 1997
Race/ethnicity is a social construct and too crude to measure to be of public health value.

Some scientists suggest that there is insufficient evidence that race/ethnicity has biological or genetic significance and promote ignoring race/ethnicity.
Karter, 2003
Race/Ethnicity Should be Studied
“Observations of racial/ethnic differences in (health) outcomes, exposures, or processes in care must not be ignored, regardless of whether due to social differences in access of quality of care, health behaviors or genetic susceptibility.” Karter, 2003
Race/Ethnicity Should be Studied But…
Should contribute to our understanding of human behavior generally and contribute to improving the status of all human kind
Need the very best research possible.
No research is better than poor research.
Requires us to be critical consumers of available research
Conceptualization of Culture, Race, & Ethnicity
Social Categories in Everyday Life
In our every day life, how is race, culture, ethnicity used?
What is black, white, Asian, Armenian, Muslim, Jewish, Persian, Iranian, Vietnamese?
Are they races, cultures, ethnicities, nationalities, religious backgrounds?
What are you? Is that a race, culture, ethnic group?
Race, culture, and ethnicity in Science
Ethnopharmacology (Keh-Ming Lin)
a. Asian Americans metabolize certain medications more slowly than Whites. Even after controlling for body size, the differences remain.
b. Asian Americans may require lower dosages than Caucasians.
c. Is this difference a function of culture, race or ethnicity?
d. Asian Americans as a group are more likely to lack a specific enzyme that metabolizes specific drugs and may adhere to a different diet that affects metabolism.
e. Given enzyme or given diet, is metabolism difference a function of culture, race, or ethnicity?
Empirical observations—Prevalence rates of mental disorders
a. Mexican immigrants, as a group, have lower prevalence rates of mental disorders than U.S. born Mexican Americans.
b. Is this difference a function of culture, race or ethnicity?
c. Mexican immigrants with less than 13 years in the United States have lower prevalence rates than Mexican immigrants with 13 years or more in the United States.
d. Is this difference a function of culture, race, or ethnicity?
Lifetime Prevalence of CIDI Disorders in Fresno
and National Comorbidity Survey (NCS)
(Vega, Kolody, Aguilar-Gaxiola et al., 1998)
Group: [%]Affective Disorders, Anxiety Disorders, Any Substance/Abuse Dependence, Any Disorder

Immigrants: 8, 13, 10.5, 24.9
U.S.-Born Mexicans: 18.7, 23.2, 27.7, 48.1
NCS Total: 19.5, 25, 28.2, 48.6
To study culture, race and ethnicity, we need...
To study culture, race and ethnicity, we need clear definitions to guide our inquiry (Helms, 1977; Betancourt & Lopez, 1993)
Definitions and conceptualizations will determine what should be measured.
We also need to measure directly culture, race, or ethnicity’s association with specific functioning.
What is race? (views)
Biological or social?
Race as a biological (genetic) construct does not exist (Owens & King, 1999; Am Assoc of Anthro)
There is more genetic variability within a race than between races.
Even enzyme differences in groups are tied to adaptation to prior environment.
Karter (2003) offers competing view. Even though any 2 humans share 99.9% of their DNA, there is still that .1% difference.
In psychology, race is primarily viewed today as a social construct (Jones, 1991), although opposing views.
Experiences of discrimination (socio-race) & racial identity (psycho-race) are two specific race variables. (Helms, 1997)
What is race? (Jones 1991)
“Race, then, refers to a group of people who share biological features that come to signify group membership and the social meaning such membership has in the society at large. Race becomes the bases for expectations regarding social roles, performance levels, values, and norms and mores for group and nongroup members and ingroup members alike.”

Jones 1991
What is ethnicity?
Refers to groups that are characterized by nationality, culture, language (See Betancourt & Lopez, 1993
Ethnic identity and diet are examples of specific ethnic variables of interest.
Diet can influence drug metabolism for example.
What is culture? Old view
Values, beliefs and practices (Betancourt & Lopez, 1993)
Limitations
Largely resides in heads of individuals
Fails to acknowledge dynamic nature of culture
Assumes people are passive recipients of culture
Tied closely to ethnic groups
What is culture? Present
Based on Kleinman’s (1995) theoretical notion of experience.
Experience is viewed as “felt flow” of the intersubjective space between individuals (their minds & bodies) and their social world. In this theoretical space, the individual and social world are interconnected.
For practical purposes this intersubjective medium is what is at stake/what matters for individuals and groups.
“Preservation of life, aspiration, prestige, and the like” is relevant for all, however, it is that which is at stake in peoples’ daily lives that is tied closely to culture.
Cultural scientist’s central concern--to interpret what matters for specific individuals in specific situations. (Lopez & Weisman,2004)
Culture and immigration status and mental health
Suarez-Orozco argued that immigrants compare themselves to relatives in Mexico, and, as a result, view their current lives in positive terms.
Mexican Americans however compare themselves to “Anglos” and view their current lives more negatively.
What matters for immigrants then is to do well to help their family.
What matters for Mexican Americans is to fit in, to be accepted as American.
Note that culture is a process, not a specific factor
What’s at Stake in Daily Lives: Advantages/Limitations
Some Advantages
Grounded in observations of peoples’ lives/Not imposed by investigators/Not solely in people’s minds
Dynamic nature more easily represented (e.g., collectivism of Mexicans in Mexico City)
Investigator not tied to ethnicity to discern the social groups (gender, sexual orientation, political orientation)
Limitations
Abstract/vague set of notions
Reliability of observations/interpretations
Return to social categories
So what is white, black, African, Armenian, etc.?
Depends on how they are used
If there is the social construction of groups based on physical features than more likely race is used
If nationality, language, or identity is the focus then more likely person is referring to ethnicity
If emphasis is given to what is at stake in particular settings than likely culture.
Race and biology could be related but could also be tied to environment
Categories and use can overlap.
Every day use of terms (e.g., census categories) may not conform to academic definitions
Human Behavior: Culture-Specific or Universal?
What is your view about human behavior?

100%-------75%-------------50%-------------25%---------- 0%
Risks in the Cultural Assumptions
Emphasize universals, risk overlooking culture-specifics
Emphasize culture-specifics, risk overlooking universals
Tension exists
Ascribing Meaning: Shifting Cultural Lenses
Part of studying culture is learning that there are alternative meanings to daily lives that we may not have access to.
How do we access these alternative meanings in a way that does not stereotype and that respects the dynamic, social nature of culture?
Metaphor—turn signals on Mexican highways have alternative meanings
Shifting Cultural Lenses
The ethnographer’s focus moves back and forth. The task is to interpret patterns of meaning within situations understood in experience-near categories; yet ethnographers also bring with them a liberating distance that comes from their own experience-near categories and their existential appreciation of shared human conditions.
Lecture 2 Part 1 Conclusion
Culture, race and ethnicity are complex phenomena.
The focus of researchers will tell us as to whether they are studying culture, race or ethnicity.
Cultural psychologists are interested in culture-specific and culture-general processes.
Cultural psychologists recognize that a given phenomenon can have multiple meanings and they try to elicit the meanings from others.
Methods: Cross-Cultural Approach
A. Quantitative approach
1. Count phenomena (e.g., values, behavior)
2. Apply established measures, concerned about equivalence in new cultural setting.
B. Comparative--test for group differences
1. Between groups: ethnicity, nationality
2. Within group (apply cultural value measure, e.g., individualism/ collectivism)
U.S. and Thai youth behavior problems (Weisz et al., 1987)
Culture and types of behavior problems
Overcontrolling (internalizing, e.g., sadness)
Undercontrolling (externalizing, e.g., fighting)
Measurement tool (Childhood Behavior Checklist)
specific behavior problems of youth referred to mental health clinics U.S. and Thailand
behavior problems extracted from clinical records.
Theoretical notion tested
problem suppression-facilitation model
adult distress threshold model
Depiction of Thai culture—refers to Buddhism
respect for others
self control
Two Most Common Referral Problems in Thailand and in the U. S. (Weisz et al. 1987)
US
Disobedient at home: US%19.3, Thai%6.1
Gets into fights: US%14.3, Thai%0.8
Thailand
Fearful or anxious: US%3.4, Thai%12.8
Sleep problems: US%1.0, Thai%11.7
U.S. and Thai youth behavior problems--Interpretation and Evaluation
Is culture related to findings? How do you know?
only suggestive given differences in nationality
culture was not directly measured
How would you go about testing whether culture plays a role?
measure culture by reducing culture to domains & dimensions
see if they account for group differences (Betancourt & Lopez)
Strengths
Widely used measure; findings can be compared with other studies
Raises possibility of cultural influences in behavior problems
Weaknesses
does not measure culture directly
does not examine how behavior problems are defined by community under study; largely imposes definitions of behavior problems
Methods: Cultural Approach
A. Qualitative approach
1. field work: observations & interviews
2. research direction open to phenomena observed at site.
3. context rich—history and social setting
4. fine grained analysis
B. Process oriented (can be comparative)
1. how daily lives are understood
2. connections between social world and psychology/behavior
Diabetes Narratives among Anishinaabe (Garro, 2000)
Methods
Open to study what matters to community (p. 75)
Conducted interviews that elicit narratives about illness
qualitative, no numbers reported
Theoretical notion examined
how cultural knowledge is applied in individuals’ daily lives with reference to illness and illness management
Central Findings: Diabetes Narratives
Shared cultural knowledge about diabetes
sweet sickness—linked to consumption of sugar (food or alcohol)
White man’s sickness—came after white man’s arrival, reliance on store bought foods instead of natural foods
Alternative explanatory models
stress and high blood pressure (Mrs. Green)
Anishinaabe sickness (Mrs. Stevenson, due to broken pledge)
Importance of individual experience
Mrs. Spence remembers how mother cooked
Mrs. Green draws on physician’s model
Mrs. Stevenson’s daughter arranges for healer visit
Diabetes Narratives: Main Conclusion
With reference to understandings about diabetes, the culturally available explanatory frameworks do not shape the construction of illness experience in a deterministic fashion but are flexible and provide relatively wide latitude for constructing a narrative that is both plausible and consistent with individual experience. Attending to the “known” and the “remembered” illuminates how culturally available knowledge serves as a resource in assigning meaning and in responding to illness (Garro, 2000)
Diabetes Narratives: Interpretation and Evaluation
What is “cultural” about the findings?
how the (shared) social world relates to explanations and actions
Is it Anishinaabe, Indian, North American or South Beach Diet culture?
Focuses on cultural processes rather than cultural groups
Strengths
Fine grained analysis points out heterogeneity of explanatory models
Depicts culture as available knowledge that people draw from; not fixed set of knowledge
Tests theoretical notions
Weaknesses
limited sample size and limited generalizability
reliance on narratives only; doesn’t include observations of behavior
Which Approach Is Best to Study Culture?
Cross-cultural approach?
Cultural approach?
Why?
Experience-Near
A concept “which someone--a patient, a subject, in our case an informant--might himself naturally and effortlessly use to define what he or his fellows see, feel, think, imagine, and so on, and which he would readily understand when similarly applied by others.” (Geertz, 1975)
Experience-distant
A concept “which specialists of one sort or another--
an analyst, an experimenter, an ethnographer, even
a priest or an ideologist--employ to forward their
scientific, philosophical, or practical aims.”

‘Love’ is an experience near concept, ‘object cathexis’
is an experience distant one. ‘Social stratification’, or
…‘religion’ are experience distant; ‘caste’ or ‘nirvana’are experience-near, at least for Hindus and Buddhists. (Geertz, 1975)
Cultural lenses returns
To grasp concepts “which, for another people, are exper-
ience-near, and to do so well enough to place them in
illuminating connection with experience distant concepts
theorists have fashioned to capture the general features
of social life, is clearly a task at least as delicate… The
trick is to figure out what the devil they think they are up
to.”

“…namely a continuous dialectical tacking between the
most local of local detail and the most global of global
structure in such a way as to bring them into simultaneous
view.” (Geertz, 1975)
Conclusions lecture 2 part 2
Conclusions
A. Both methods are needed
B. Knowledge is gained over many studies with multiple methodologies.
C. Each method has their relative strength and weakness
D. But our work should be guided by critical thinking about culture
Discuss the definitions of:
Culture
Race
Ethnicity
Culture
-shared values and beliefs
Race
-phenotype(the observable properties of an organism that are produced by the interaction of the genotype and the environment)
Ethnicity
-Nationality and Language (part of culture)
Does Culture Race and Ethnicity Matter?
Prevalence rates are similar for many disorders across races and throughout the world
-Schizophrenia, bipolar
Are disorders that are more biologically determined, as assessed by heritability, culture free?
-attributes, meaning attributed, etc. differ by culture
What does Culture Race and Ethnicity affect?
CRE can affect many aspects of mental health
CRE Risk Factors
Diagnosis and Assessment
Symptom presentation
Access to Care
Treatment
CRE Risk Factors
Racism/ Discrimination
-stressful event (can be chronic)
Physical Health Status
-Low physical health has a high correlation with low mental health
Socioeconomic Status
-Stressful environment
--Low SES -> high crime, unemployment, subtance abuse
-Mental disorders can lead to poverty
--jobless, socially defunct
---need great support systems
Risk Factors definition
Something in the world that predisposes you to some adverse effect
Dict: something that increases risk or susceptibility
Lick? and Mays
AA vs, EA : (1990) AA live to 65 same as a man living in Bangladesh (poor country)
-Lifestyle differences, social opportunity
-experience of racism -> chronic stress response -> mental health problems
-Internalized racism leads to alcoholism
Diagnosis and Assessment
Language
Clinician Stereotyping
Flexible vs Structured Interview
Unfamiliarity with norms of behavior
Neighbors et al. 2003
Diagnosis and Assessment: Language
Speaking, pencil and paper
1) Ask questions
2) Determine problem from answers
--Normed using English speakers
Diagnosis and Assessment: Clinician Stereotyping
Clinicians typically white men who are not aware of their biases

Flexible vs Structured Interview
-AA: Flexible=schizo; Structured (go through every symptom)=Bipolar
-EA: mostly bipolar
-Symptom attribution - delusions - way expressed determine diagnosis
Unfamiliarity with norms of behavior
-Useful to know what is a "disorder"; e.g., ADHD)
Neighbors et al. 20003
Symptom presentation Disorder Prevalence
Cultural differences on symptom description, presentation, what they report, and attribution
Culture-bound syndromes
Cultural Norms
Culture-bound syndromes
Sets of symptoms that occur in certain parts of the world

Latin disorder: screaming, suicidal attempts, panic disorder similar but absent of fear and occurs after a specific event (a death), so culture dependent (bound).
Cultural Norms
Normative behavior determines what is or is not a disorder

Amish: small gene pool, large families, restrained culture, good geneologies
-Manic to Amish is racing your buggy, driving a car, etc.
--exceeds the norms of the Amish culture
Cultural differences on symptom description, presentation, what they report, and attribution
Asians attitudes on depression

Asian Americans same as EA in reporting symptoms in L.A. (in difference to study that found native Chinese prmarily reporting physical symptoms only)
-religion, clinician differences, surveys or indepth interviews, socialization, chinese in China vs. "Asians" in Los Angeles
Access to Care
Economics: yours and level of neighborhood

Availability of Appropriate Services:
-Language

Mistrust and Stigma
-Tuskegee Syphilis experiments
-AA prefer to go to church(!)
-Young adults less likely to seek treatment
-high education, ses more likely
Concentration of mental disorders
Mental disorders are concentrated in low SES neighborhoods -> high minorities and no proper preventive care; so, they use the emergency room when the problems can no longer be ignored, but by this time the affliction is hard to treat.
Treatment
Culturally Competent Services
“The delivery of services responsive to the cultural concerns of racial and ethnic minority groups, including their languages, histories, traditions, beliefs, and values.”
-Comfort, trust, understanding
If you were a clinician how would you ensure you were delivering culturally competent services?
Why are culturally competent services important?
Ethnic Match
Genetics
Evidence Based Treatment
Treatment: Ethnic Match
AA want AA clinician
-More comfortable at church
Treatment: Genetics
Metabolism

Asians, for example, may ned a lower dosage of a medication in comparison to AAs or EAs
Treatment: Evidence Based Treatment
Empirically supported research (good quality)

BUT, currently, majority of research done on middle class, white college students
Surgeon General Report
Bottom Line
“Many studies report the ethnic or racial background of study participants as a shorthand for their culture, without systematically examining more specific information about their living circumstances, social class, attitudes, beliefs, and behavior.”

Blanket clasifications can hide differences of individuals
Study of Problem Behaviors among U.S. and Thai youth (Weisz et al.)--Critiqued
Relationship between Nationality and Specific Youth Problem Behavior- clear correlation.
-Weisz claims culture...

Hypothetical Relationship between Nationality
and Specific Cultural Value
-Did not measure this

Hypothetical Relationship: Cultural Value Explains Relationship between Nationality and Problem Behavior
-Might be a third value
Main Methodological Point
1. Can not assume cultural factors explain group difference
--CRITICAL POINT OF CLASS
2. Groups could differ in other ways besides culture or groups may not differ on presumed cultural dimension.
3. Need to test directly cultural explanation.
4. Directly testing cultural hypothesis applies to class journals as well
Cultural Approach
1. Qualitative approach
A. field work: observations & interviews
-could have supplemented Thai study by observing some number of families for a few weeks
B. research direction open to phenomena observed at site (Garro, p. 75)
C. context rich—history and social setting
D. fine grained analysis—level of analysis focuses on individuals not groups
2. Process oriented (can be comparative)
A. how cultural knowledge is applied in individuals’ daily lives with reference to illness and illness management
B. Not focused on group differences
Conclusion Methodology:
Shifting Cultural lenses
To grasp concepts “which, for another people, are experience- near, and to do so well enough to place them in illuminating connection with experience-distant concepts theorists have fashioned to capture the general features of social life, is clearly a task at least as delicate… The trick is to figure out what the devil they think they are up to.”

“…namely a continuous dialectical tacking between the
most local of local detail and the most global of global
structure in such a way as to bring them into simultaneous
view.” (Geertz, 1975)
Psychopathology--Cultural Categories of Disorders and Conditions
A. Levels of meaning
1. Art depictions of mental disorders
2. La loca (the crazy woman)-anguish
3. Los locos (the crazy men)- innocent
4. La borracha (the drunkard)-shame
5. One could apply DSM-IV criteria and consider schizophrenia, mental retardation or alcohol abuse (experience-distant)
6. One could also apply lay meanings (experience-near understandings)
7. Both apply
DSM-IV
Based on research from biomedical tradition.
American Psychiatric Association Committee decided what symptoms comprise syndrome.
Assumes little group differences
Although makes reference to cultural differences and cultural syndromes largely assumes universality of disorders
Nevertheless, the disorders represent cultural categories
12-Month Prevalence Rates by Race in ECA
and National Comorbidity Survey (NCS)
(Zhang & Snowden, 1999)
St. Louis had largest difference between AA and EA

Used DSM categories in NCS
-not much difference between races, but not finding differences developed for a certain race (close-minded filtering through a single screen that does not discriminate properly for non-whites)
Cultural Influences in Expression of Disorders
U.S. Thai differences in youth problem behaviors.
Amish and manic depressive disorder—objective was to study genetic basis of disorder (Egeland et al., 1984)
Main point is that culture can influence expression of presumed universal disorders.
Misdiagnosis of Bipolar Disorder: Amish
79% were previously diagnosed with schizophrenia
Failure to consider cultural expression
Research Diagnostic Classification (social actions w/negative consequences--e.g., speeding; but Amish don't drive cars)
Actual clinical presentation
Cultural misinterpretation
Silly, giddy behavior
Suspiciousness
(Egeland et al., 1984)

-Culture can influence the expression of the disorder
Popular/Lay Categories of Illness-- Idioms of Distress
What are terms of conditions used in everyday life?
Isolated sleep paralysis
Nervios versus mental illness
Lay categories can apply to people with DSM-IV disorders or people without DSM-IV disorders
Isolated Sleep Paralysis
Identified in many groups particularly African Americans
Altered state of consciousness experienced while falling asleep or awakening
Experience an inability to move for a few seconds or minutes
Experience feelings of anxiety or apprehension
When episode ends persons report panic-like symptoms, e.g., fear, hyperventila

"Witch is riding you"
Isolated Sleep Paralysis by Race and Presence of Anxiety Disorder (Paradis et al, 1997)
With Panic Disorer: AA 60%, EA 8%

With other Anxiety Disorder: AA 11%, EA 0%

No Axis I Disorder: AA 23%, 6%

-Race/cultural difference in the ways distress is expressed
-not in DSM
Conceptions of Schizophrenia
MA vs EA
RACE: Nerves, Mental Illness

MA: 67%, 26%
EA: 11%, 74%
Nervios
Culturally-specific illness condition that prevails in Latin American countries. In the Mexican rural context, Nervios is more prevalent among women and has somatic and psychological components that are manifested through a variety of symptoms. The manifestation of this condition does not differentiate the body-mind duality that prevails in biomedicine.
Symptoms of Nervios
Examples of physical discomfort:

headaches nausea
trembling diarrhea
lack of appetite and sleep dizziness
fatigue blurred vision

Examples of psychological distress:

irritability overwhelming concerns
anger mental confusion
sadness erratic behavior
fears crying spells
Ataque de Nervios in Puerto Rican Island Adults (Guarnaccia et al., 1993)
Total Sample 912 100%
Ataque de nervios 145 16%

Without DIS disorder 54 37%
With DIS disorder 91 63% (had real (i.e., DSM) disorder)

Anxiety disorder 58 40%
Affect disorder 30 43%
Alcoholism 23 16%

-The way they understand the illness & what they include in their term (different from DSM)
Sociocultural Processes: Family
Factors & Course of Schizophrenia
Less concerned about disorders, more concerned about how cultural processes shape course of illness

EXPRESSED EMOTION -> RELAPSE
Criticism
Hostility
Emotional Overinvolvement
(Warmth)
(Positive Remarks) These two positive aspects ignored by the early research
Sociocultural Processes: Family
Factors & Course of Schizophrenia--Aggregate Analysis (Bebbington & Kuipers, 1994)
High EE: relapse and no relapse numbers equal

Low EE: NO relapse far higher than relapse

Not enough positive psychology
-What are the Low EE people doing to fight relapse?
Importance of Research
Points out relevance of psychosocial factors in the context of a largely biologically based disorder
Has led to the development of family interventions that largely attempt to reduce conflict and stress in families
-schizo, bipolar, etc.
Three Major Limitations
Limited attention to positive family factors (Bebbington & Kuipers, 1994)
Describes more than it explains
Limited attention to culture (Jenkins & Karno, 1992)
Warmth is a “complex variable”
“Warmth, which was formerly considered to be a component (of expressed emotion), is now seen to be a complex variable. A high rating of warmth is often accompanied by a high rating on emotional over-involvement, while a low rating on warmth usually implies a high level of critical comments. Patients whose relatives showed marked warmth without also expressing criticism or over-involvement had a significantly better outcome. Warmth was consequently not included in the index of expressed emotion. ‘Expressed emotion’, therefore, has a mainly negative connotation. (Brown et al., 1972)
Warmth Assessed in Family Interview
Instances of definite and clear cut tonal warmth, enthusiasm, interest in and enjoyment of the person (4 or 5)

Instances in which there are definite, understanding, sympathy and concern, but only limited warmth of tone (2 or 3)

Only slight understanding, sympathy and concern, or enthusiasm about or interest in the person (1); absence of warmth (0)
(Leff & Vaughn, 1985)
Towards an Attributional Model of Relapse
Attributions(Outside of John control; lazy, but looking job)
v v
positive affect negative affect
(Low control over prob) (high control)
Sympathy Criticism
v v
less more
Relapse
She has to put out...
“I think Mary is unable to cope with problems that arise every day. I think that it is up to each individual to adjust themselves to cope with these problems. It is more difficult for one person to do it than it is for another one to do it. I think that therefore Mary has to put out and has to accept the fact that she has to put out and overcome this problem.” Mary’s father
Percentage of High EE by Cultural Groups
AA 70
Montreal 60
British 47
Mexican Americans 38
East Indians 20

-Suggestive of a role played by culture
Patient Clinical & Social Background by Ethnicity
Background Mexican American Anglo American
N M N M t-value
Years since onset 44 4.21 54 4.60 -0.48
Number admissions 44 3.16 51 2.98 0.35
Age 45 25.33 54 26.06 -0.51
N % N % χ2
Relapse 45 .38 54 .43 1.37
Regular Medication 44 .55 53 .34 4.15*
Street Drug Use 44 .39 54 .44 0.34
High Family Contact 45 .71 53 .42 8.62**
Women 45 .44 54 .24 4.58*
Married 45 .11 52 .08 0.33
Low SES 44 .93 51 .51 20.24***
*p < .05; **p < .01; ***p < .001.
Mexican American Key Relatives and Patient Acculturation
Key Relatives Patients

Acculturation M = 1.64 M = 2.35
Score (1 lo to 5 hi)

Mexican-born 71% 63%

Monolingual 65% 43%
Spanish
Family Criticism & Probability of Relapse by Ethnicity
Prob of relapse increases with increased criticism in EAs

Prob of relapse stays relatively the same, with a slight increase to the right, regardless of criticism in MAs
Family Warmth and Probability of Relapse by Ethnicity
EA: probability of relapse increases with increased warmth

MA: probability of relapse decreases with increased warmth
Implications of Curvilinear Analyses (Family Warmth and Probability of Relapse)
Points out possible two-edged sword of family closeness
A moderate degree of involvement and a high degree of warmth are both associated with less relapse
Too much closeness is associated with more relapse
Unlike past EE research which focuses on family negativity, what matters with the Mexican American sample is family connection, its presence or its overabundance
What About Warmth Matters?
Previous findings based largely on finding ethnic differences and attributing differences to culture.
As a first step in unpacking ethnicity, we are carrying out qualitative research
Examining what about social world may promote warmth or may impede warmth
Two illustrative cases
One with moderate degree of warmth
One with low degree of warmth
“We’re a close knit family”:
Social world facilitates warmth?
Mrs. Gutierrez is a bilingual Mexican American widow and the primary caretaker for Richard, a 44 year-old single man with schizophrenia.
They live in a modest home in El Paso with Richard’s older brother, a construction worker.
Nearby, in the same neighborhood, lives Dolores, Richard’s older sister, and her husband and children.
What is at stake for Mrs. Gutierrez is maintaining the close family connections.

We’re a close knit family. My grandkids go after school. Mostly every day. “How are you doing Richard?” You know…(they) stay there a little while and then leave. And they notice when he’s not well. So they don’t even talk to him cuz he yells sometimes. So they…”We’re leaving grandma.” “Okay.”

That’s when he would get abusive…not about hitting…abusive with…verbally abusive and we just have to cut it out of him. “You don’t speak like that in front of the little kids” because I have small grandkids. “Well it’s my house I can…” “No. No it’s not your house. It’s my house. So you do not talk like that in here.” “Okay, then I’ll go outside.” “Outside either. There’s neighbors and they don’t like to hear noise and stuff like that. Oh if you wanna go outside, go ahead. Go outside and yell. When you had your good yell then you can come back inside.”
“No Espanish Mami!”: Social World Limits Warmth?
Emilio is an 18-year old male born in the United States to Mexican born parents.
His father received a diagnosis of schizophrenia and is being treated.
The father has recently been laid off from his work in a factory.
The mother contributes to the family income by occasionally cleaning apartments, in addition to managing their household of four children.
What’s at stake for parents is surviving economically.
What’s at stake for Emilio is “making it” in an English language world
Implications of Cases (warmth related)
Suggests aspects of the social world may be related to warmth
Organization of family/friends
Language barrier between parents and son
Need to carry out more systematic analysis to further explore role of social world
Need to carry out similar analysis for emotional overinvolvement
Implications for Expressed Emotion Research
Regardless of cultural perspective
Findings add to established paradigm that emphasizes that family criticism predicts relapse.
Findings point out that families can also serve as protective factors in course of illness

Treatment Implications
Reconsider sole focus on decreasing negativity
Consider adding strategies to augment prosocial factors without excessive involvement
Methods Revisted (warmth)
Cross cultural approach
Two ethnic groups
Value of diversity in sample—uncover new processes
Draw on existing research methods and theory
Limitation: culture not directly measured
Added cultural process interpretation—what’s at stake with focus on social world of immigrants.
Cultural approach
Case studies of key family members
What’s at stake for a given family member and how that may relate to family interactions
Conclusion—Both methods help advance cultural psychopathology

Final Conclusion
Culture influences psychopathology in many ways.
Expression of disorders
Development of culture-specific disorders
Processes associated with course
Shifting Cultural lenses –experience-near and experience-distant will help us best identify culture’s role.
Test Taking Tips
Get right to the point and answer the question
Don’t waste valuable time restating facts noted in the question.
Sometimes full sentences are not needed.
Brief examples of key points are helpful to show that you understand a concept
Clarity helps
take a minute to organize your thoughts
illegible handwriting can cost you points
Budget your time wisely
Don’t spend a lot of time on a overly thorough answer for one question that leaves little time for others
There will be separate graders for each question.
In answering one question do not refer to your answer to another
Valid Discriminatory test
What position would you take?
Maintain 6 foot wall, thus decreasing women’s access to law enforcement positions?
Make alteration in test, thus increasing women’s access to law enforcement positions?
Why?
Values and Assessment
“The measurement of such (human)
characteristics entails value judgments—at all
levels of test construction, analysis,
interpretation, and use—and this raises
questions both of whose values are the
standard and of what should be the
consequences of negative valuation.”(p.1013).
Messick (1980)
True Differences or Biased Tests?
Difference of 10-15 points on verbal intelligence tests between Whites and Blacks, somewhat less for Latinos.
1. Defenders of test argue that differences reflect true differences. No evidence of bias. Some point out that Asian Americans do better than whites which supports view of no bias.
2. Reformers argue that the tests are biased. We need to change or eliminate tests.
Mean WISC-R Subtest Scores for Black and White Children in the Standardization Sample
Subtest White (1868) Black (305)
Information 10.4 8.1
Similarities 10.3 7.9
Arithmetic 10.4 8.6
Vocabulary 10.4 7.9
Comprehension 10.4 7.8
Digit Span 10.1 9.2
Picture Completion 10.4 8.1
Adapted from Gutkin & Reynolds (1981)
Actual Differences (Defenders) or Biased Tests (Reformers)?
“…many researchers in the test bias area can be roughly characterized as belonging to one of the two groups: The defenders or the reformers. The defenders expected to find no bias and to contribute to the solution of several social issues by eliminating the specter of bias from the public debates. The reformers expected to find bias and to contribute to the solution of the same issues by forcing reforms to correct bias. However, neither group has found perfect satisfaction in its quest” (Cole, 1981, p. 1074).
Evidence to Support Defenders’ Position (IQ)
Little evidence of biased test items
a. Internal validity
1) item scale correlations
2) factor structure
b. External validity
1) association with other abilities e.g., achievement tests.
Median Correlations (r) of IQ tests and Achievement Tests for Three Groups
READING ARITHMETIC
# of Mdn r # of Mdn r
studies studies
Anglo-Am 14 .52 12 .54
Black-Am 17 .60 11 .58
Hispanic-Am 7 .51 7 .53
Adapted from Sattler (2004)
Exercise: Find the more difficult WISC-R Items for Black than White Children
Equally More
INFORMATION Difficult Difficult
5. How many pennies make a nickel? ED MD 4
6. What do we call a baby cow? ED MD 5
7. How many days make a week? ED MD 9
8. Name the month that comes next after ED MD 6
March?

PICTURE COMPLETION
10. dresser ED MD 3
11. belt ED MD 10
16. coat ED MD 2
17. man ED MD 12
22. thermometer ED MD 7
24. telephone ED MD 8

Source: Sandoval & Miille, 1980
Summary of Defenders’ Position (IQ)
“…the biggest contribution personnel psychologists can make in the long run may be to insist collectively and candidly that their measurement tools are neither the cause of nor the cure for racial differences in job skills and consequent inequalities in employment” (Gottfredson, 1994, p. 963)
Evidence to Support Reformers’ Position (IQ)
Existence of group differences reflect biased tests.
a. Court cases
1) Larry P vs Wilson Riles
2) Data to support bias
3) ruling
4) consequence

2. Negative social consequences (Suzuki & Valencia)
a. Minorities overrepresented in special education
b. Minorities less likely to get vocational placement
Stereotype threat
Asked to IQ background before taking test

Women and AAs=poorer performance
Larry P vs Wilson Riles
Several major issues were raised against intelligence testing by the plaintiffs in Larry P. versus Wilson Riles. It was argued that since California used intelligence tests to ascertain who should be placed in programs for the educable mentally retarded (EMR), and since blacks performed less well on the tests than whites, it was the tests which caused too many blacks to be assigned to EMR classes. Blacks' poor performance on intelligence tests--particularly the Wechsler Intelligence Scale for Children and the Stanford-Binet Intelligence Scale--was claimed to be due to test bias. The criteria for test bias included the following: items were drawn from the white middle class culture; whites had much more prior experience playing with toys; the language of black children may not have been compatible with that of the test; the race of the examiner may have motivation and affected performance; and the test's standardization sample was basically white. The final objection to the continued use of intelligence tests was that such tests keep the schools from educating black children.
Representation of Black Students in Nation’s Schools and Special Education Classes: 1991
AA higher than %of school population they make up in educable and trainable Mentally retarded, Lower in gifted, same in learning disabled
Further Support of Reformers’ Position
Janet Helms View
a. Current tests are Eurocentric
b. Should include content relevant for low income and minority youth and adults.
c. Some comments regarding Picture Completion
Socioeconomic concerns—One is accustomed to making do with imperfect things and has little exposure to others. So a doorknob or buckle tongue may not be perceived as missing.
Culture—Some things are either common or infrequent and therefore are not missing.
Race—Task may be perceived as irrelevant because no visible racial or ethnic group minority individuals or circumstances are portrayed. (Helms, 1997)
Reformers
“…the conclusion that whatever construct is measured by standardized cognitive ability tests constitutes universal intelligence or general cognitive ability for all racial and ethnic groups in this country is dubious at best” (Helms, 1992, p. 1090)
Risks in Psychological Assessment
1. Tests are imperfect tools to measure a given construct—intelligence, vocational ability, or personality. There is noise in any given test. Particularly for individuals or groups who may not be well represented in normative samples.
2. If you take defenders’ position that the differences are valid then you may be at risk to judge some people from a given group as low functioning when they are not, at least relative to others from their background (overpathologize)
3. If you take reformers’ position that tests are biased then you may be at risk to judge someone as average functioning when they are low functioning even compared to similar others (underpathologize)
Problems with Test Bias Research
1. A reasonable conclusion is that there is little evidence of test bias.
2. Have examined test bias in samples for which there is less likelihood of finding bias (English-speaking Blacks and Latinos).
3. Researchers should consider samples for whom bias is most likely to occur—limited English speaking children and adults
4. Following research begins to move in that direction.
Clinical Considerations: Assessment of Spanish speaking Persons
A. Group Differences in Spanish language versus English language
1. Children
2. Adults

B. Socioeconomic background, test norms, or language?
1. Syllables in Spanish/English
2. Time to pronounce
Digit Span and age
Shows rise from 6yo to around 16yo
Digit Span: EIWA vs WAIS
Ave 7 in EIWA while only 4 in WAIS

So when choosing the average score for Puerto Rico, which score do you use?
Digit Span: Why differences?
1. Socioeconomic Differences
a. Educational background: US > PR
b. Occupational background: US>PR
2. Cognitive load of language in memory
1. No. of syllables: Spanish>English
2. Time to pronounce: Span > Eng
3. Data from Chinese-speaking students
Digit Span: DIGITS AND SYLLABLES
English Spanish Chinese
one 1 uno 2 yi 1
two 1 dos 1 èr 1
three 1 tres 1 san 1
four 1 cuatro2 sì 1
five 1 cinco 2 wǔ 1
six 1 sies 1 ltu 1
seven 2 siete 2 qi 1
eight 1 ocho 2 ba 1
nine 1 nueve 2 jtu 1
ten 1 diez 2 shi 1
TOTAL 10 17 10
Mean 1.1 1.7 1.0 (Best recall; less sound and low syllables)
Distribution of Digit Span Scores for Chinese and American University Students
English M=7.2
Chinese M=9.2
Clinical Assessment: Which norms to use in case of Julio
1. Background
23 year old Mexican male, born in Mexico City
Came to U.S. at age of 13
Parents have no education
Birth trauma, subsequently diagnosed with cerebral palsy spastic diplegia
Spanish is dominant language
Attends community college
Tested at 14 years of age: Borderline cognitive-intellectual functioning and moderately retarded social functioning.
Do you use Spanish or English language norms?

Conclusion: borderline cognitive-intellectual functioning and moderately retarded social functioning
Julio’s Recent Testing (23 years old)
English Spanish
Cognitive Intellectual
PPVT 60 111
WAIS-R Verbal 74
Information 3 11
Digit Span 4 6
WAIS-R Performance 63
Object Assembly 5 11
Digit Symbol 2 7
WAIS-R Full Scale 68
Social Functioning (Vineland)
Communication 97
Socialization 98
Daily Living 63

Conclusion: borderline to mild mental retardation in English; within average range in Spanish; no diagnosis of mental retardation
Summary of Findings in case of Julio
1. English Norms: Borderline intellectual functioning. Possibility of services
2. Spanish Norms: Average functioning. No services.

Value of shifting cultural lenses—using both sets of norms.
1. English norms risks interpreting poor language skills and unfamiliarity with culture as low functioning.
2. Spanish norms risks overlooking difficulties in functioning in English.
Clinical Assessment: Considering Culture/Language with only one Set of Norms
Child custody case of 33 yr old Pilipina mother
“Speech was heavily laced with a Filipino accent. Vocabulary and verbal concepts were rudimentary and slowly articulated.”
Test results
WAIS-III: 72 V, 75 P, 71 FS
WRAT-R: 81 percentile, 8th grade
“…we are left with the realization that Z is an individual prone to poor understanding of the world around her, poor judgment, and poor problem solving.”
Recommendation—Sole custody for father
Clinical Assessment: Considering Culture/Language with only one Set of Norms--My Consultation
Assessment based only on English-speaking psychologist’s test administration and clinical interview: experience-distant.
Need to shift lenses to experience-near
How do family members’ view her functioning
Work functioning
A boot-strap set of culture-specific norms
Work supervisor reports that she is an excellent worker at nursing home—organized & responsible
Judge ruling--share custody
Culturally Competent Approach
1. Shifting cultural lenses
a. Apply two sets of language norms
b. Apply English language norm and nonverbal test.
c. Apply English language norm and boot- strap alternative norm
d. Another example is use of Mayo older African American normative sample (Lucas et al., 2005)
Multiple measures and multiple perspectives
Conclusion: Assessment lecture
A. Most challenging
1. Failure to consider culture can be problematic
2. Consideration of culture can be problematic
B. Your values will likely influence what position you take
C. By being a critical consumer of available evidence from multiple measures/perspectives you reduce error in assessment.
Why language matters
Census Data
Personal Experience With Health Delivery Systems
Health Service Data
Non-English Language Speakers in US-Census data
Persons 5 Years or Older in the United States who speak a non-English language at home:
1990 2000
31,844,979 49,526,400
13.8% 17.6%

Of those who spoke another language in 1990:
6% did not speak English at all
15% did not speak English well
Source:http://www.census.gov/prod/2003pubs/c2kbr-29.pdf
Linguistic isolation
Linguistic isolation: persons living in household in which no one over 14 speaks English “very well.”

High among Asian groups
Why Language Matters
How many of you know of someone having negative experiences with health care because they didn’t speak English well?
Linguistic difficulties and implications for health care
Barrier to use health care system
Decrease adherence with medication regimens and appointment attendance
Decrease satisfaction with services
One study found having physician who spoke Spanish resulted in patients’ higher ratings of physical and psychological well being and lower perceptions of pain (Perez-Stable et al., 1997)
Puts Him in Better Contact with Reality
“I believe that a foreign-born individual who thinks and dreams in his own language will--if he becomes psychotic--distort reality in his own native thoughts and language... A language not his own, in which he has to make an effort to understand and to respond, can act as a stimulus that shakes him up, makes him think, and puts him in better contact with reality.” Del Castillo (1970)
“More on guard”
“...the intellectual effort of expressing oneself in a foreign language in which one lacks fluency is equivalent... to certain stimuli that are apt to awaken a sleeping person and to arouse his unconscious toward exerting that type of vigilance that is either absent during sleep or other forms of mental relaxation... Or it may be that when speaking in a foreign language the speaker is simply more on guard.”(p. 160) Del Castillo (1970)
Some Interview Language Differences
Content Changes
Interviewer: Do you get tired easily?
English: Yes, yes, very tired, yes.
Spanish: No sir.

Infracontent Changes
Speech Disturbances (e.g., sentence correction, incompletion, stutter)/Number of spoken words
English = .132 Spanish = .041
Speech Rate (words per minute)
English = .582 Spanish = 1.025
Silent Pause (pause duration/answer duration)
English = .568 Spanish = .182
Marcos et al. 1973
-Interviewer sees lang. differences as indications for other problems
Limitations & Implications of Marcos et al. 1973 (lang. diff.)
Methodologies limited
10 patients; contrived setting
Case studies
Language difficulties did not account for differences in ratings
Other studies provide mixed set of findings
Implications
Demonstrates that language matters
Maybe language can affect judgments of underdetecting and overdetecting pathology
Research: Multiple mechanisms (psychosis versus more affective symptoms
Clinical: When in doubt, assess in both languages; don’t assume poor functioning is a language issue.
Interpreting
Personal experiences: How many of you have served as translators for relatives?
“I Love Lucy” episode
Three Way Role Play
Observations
Growing attention to linguistic services
Executive Order (President Clinton)
Institute of Medicine Report (Confronting Racial and Ethnic Disparities in Health Care)
Robert Wood Johnson
--Language contributes to noise in the assessment
Conclusion - Language section
All persons living in U.S. should learn and improve their English language skills; it is in their best interest
Large number of people residing in the U.S. and throughout the world who do not speak English well
They deserve quality mental health care
Language can complicate assessment and treatment.
Those of you who speak another language are in a wonderful position to contribute to this great need.
Those of you who do not can learn ways to improve communication (interpreters, careful communication)
Language matters
symptom
is one part of a syndrome
syndrome
set of symptoms (DISORDER)
CULTURE
o old definition: lecture #1 (10/6)
§ beliefs, values, norms
§ what one person believes is important to them
o new definition:
§ what is at stake
§ differences between beliefs, values, and norms
§ incorporates how person interacts with others, how they behave
§ individual in their context ( LOCAL SOCIAL WORLD)
RACE
o Genetically speaking- more similar within racial groups than between
o Sociocultural understanding --- INTERPERSONAL (with others)
§ Def: race related processes on interpersonal level
§ Race has impact how others respond to you, and how you respond to others
ú Categories that matters in terms of experiences
o Psychorace – INTRAPERSONAL (self)
§ Def: intrapsychodynamics- internal mind
ú Own racial identity (your own concept)
ú What it means to be a person of whatever race
ETHNICITY
o Defined the least
o Related to both race and culture
o ***def: refers to groups that are characterized by nationality, culture, and language
o cultural practices that are related to sub-groups of race
Larry p vs Wilson riles case (review)
· 1st time tests taken (white psych)
o found to be below average
o put in remedial courses
· 2nd time same tests taken—(black psych)
o average intelligence!~
· SHOWS BIAS
Mexico- signaling
§ indicates turning left/right
§ if flashing left on straight road
ú indicates that it’s okay to pass
§ one behavior- with multiple meanings
ú if there is nowhere to turn left, than probably means that they mean it’s okay to pass
experience near vs experience distant
o experience near
§ ask the person what does it mean when they turn left blinker
ú understanding of what a person’s is like by asking
§ ex/psych asking indiv of their values (bottom- up approach)
o experience distant
§ researcher uses own understanding of universalities and past experiences and applies to another culture to understand another’s own behavior and world
§ top-bottom approach, applies their own understanding