Cultures have different views of understanding psychological disorders and psychological maladjustment. For instance, some cultures may view psychological conditions resulting from a bio-medical condition such as a brain condition. Other cultures view psychological conditions deriving from psychosocial stressors from social causes. Still other cultures combine multiple explanations. For this reason, as a working professional, it will be important for you to understand how culture influences the way psychological conditions are treated.
For this Discussion, you will examine the influence of culture on psychological conditions or treatments.
Describe a psychological condition or treatment that was unfamiliar to you. Then, explain why you think this condition or treatment occurs in the culture you read about but not in others, that you know about.
Note: Be sure to support your postings and responses with specific references to the Learning Resources and identify current relevant literature to support your work.
Available online at www.sciencedirect.com
Clinical Psychology Review 28 (2008) 211–227
A conceptual paradigm for understanding culture’s impact on mental
health: The cultural influences on mental health (CIMH) model
Wei-Chin Hwang a,⁎, Hector F. Myers b, Jennifer Abe-Kim c, Julia Y. Ting d
a Department of Psychology, Claremont McKenna College, 850 Columbia Avenue, Claremont, CA, 91711 United States
b University of California, Los Angeles, United States
c Loyola Marymount University, United States
d University of Utah, United States
Received 14 February 2007; accepted 3 May 2007
Abstract
Understanding culture’s impact on mental health and its treatment is extremely important, especially in light of recent reports
highlighting the realities of health disparities and unequal treatment. This article provides a conceptual paradigm for under-
standing how culture influences six mental health domains, including (a) the prevalence of mental illness, (b) etiology of disease,
(c) phenomenology of distress, (d) diagnostic and assessment issues, (e) coping styles and help-seeking pathways, and (f) treatment
and intervention issues. Systematic interrelationships between each of these domains are highlighted and relevant literature is
reviewed. Although no one model can adequately capture the complex facets of culture’s influence on mental health, the Cultural
Influences on Mental Health (CIMH) model serves as an important framework for understanding the complexities of these
interrelationships. Implications for clinical research and practice are discussed.
© 2007 Elsevier Ltd. All rights reserved.
Contents
1. The CIMH model . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 213
1.1. Cultural issues in the development of illness . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 213
1.2. Culture and the expression of distress . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 215
1.3. Expression of distress, diagnostic accuracy, and the prevalence of illness . . . . . . . . . . . . . . . . . . . 217
1.4. Culture, expression of distress, and help-seeking . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 218
1.5. Help-seeking, diagnoses, and their relation to treatment . . . . . . . . . . . . . . . . . . . . . . . . . . . . 220
1.6. Meeting the needs of ethnic minority and immigrant communities: policy implications . . . . . . . . . . . . 222
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 223
Recently in the United States, the Surgeon General and the Institute of Medicine reported that racial and ethnic
health disparities exist, and that in general, ethnic minorities continue to be missing from the research from which
evidence-based treatments (EBTs) are drawn (Smedley, Smith, & Nelson, 2003; USDHHS, 2001). In addition, there is
⁎ Corresponding author.
E-mail address: [email protected] (W.-C. Hwang).
0272-7358/$ – see front matter © 2007 Elsevier Ltd. All rights reserved.
doi:10.1016/j.cpr.2007.05.001
mailto:[email protected]
http://dx.doi.org/10.1016/j.cpr.2007.05.001
212 W.-C. Hwang et al. / Clinical Psychology Review 28 (2008) 211–227
a growing body of European and other international literature supporting these findings and suggesting that immigrants
and ethnic minorities evidence a disproportionate burden of illness and unequal access to health care services
(Department of Health, 2003; Fernando, 2005). This accumulating body of evidence underscores the idea that extant
health care systems may not be adequately prepared to meet the needs of minority and immigrant populations. The
importance of incorporating issues of culture, race, and ethnicity into research, teaching, and clinical practice are sorely
needed. This task has proven to be quite complicated given the limited resources that have been invested towards
improving our understanding of cultural influences on mental health. Without guiding frameworks from which to work
from, the larger audience of mental health professionals will continue to acknowledge that culture is important, but
struggle in articulating how culture makes a difference and be unprepared in addressing growing world-wide health
disparities.
The goal of this article is to provide a conceptual framework, the Cultural Influences on Mental Health (CIMH)
model, to help bridge this gap and increase cultural understanding and awareness (see Fig. 1). In this article, we define
culture broadly as not only including the set of attitudes, values, beliefs, and behaviors shared by a group of people
(Barnouw, 1985), but also as inclusive of culture-related experiences such as those related to acculturation and being
an ethnic minority. The CIMH model argues that culture permeates and affects several core domains of the illness
process. Culture contributes to differences in (a) the prevalence of mental illness, (b) etiology and course of disease, (c)
phenomenology or expression of distress, (d) diagnostic and assessment issues, (e) coping styles and help-seeking
pathways, and (f) treatment and intervention issues. Because of the multitude of ways that culture can influence mental
health issues, these domains are not meant to be all-inclusive, but rather provide a starting point for understanding the
more visible ways that culture influences the development and treatment of psychopathology.
Cultural influences each of the above domains, which are also clearly and logically related. For example, cultural
differences in the expression of distress (e.g., emotional distress or physical symptoms) could influence diagnostic
accuracy in the assessment of depression, which in turn, impacts our ability to reliably estimate the prevalence of
depression. What one believes to be the causes of one’s problems (e.g., bodily problems causing depression or
depression causing physical health problems) also plays a role in where one seeks help (e.g., primary care or mental
health facility), and one’s confidence in the treatment provided (e.g., belief that talk therapy is effective versus feeling
like talking about problems makes one feel worse). Research conducted to examine how culture impacts each of these
domains as well as how they are systematically interrelated continues to be limited. Understanding these inter-
relationships is integral to understanding how culture influences the development, progression, and treatment of mental
illness.
The CIMH was initially developed to provide students and professionals with a broad and more sophisticated
understanding of culture’s dynamic influence on mental health. Specifically, in our teaching of culture and mental
health issues, professionals and students often developed a simplistic understanding that culture matters, but often had
difficulty understanding the dynamic and interactive nature of culture on interrelated mental health domains. The
Fig. 1. The Cultural Influences on Mental Health (CIMH) Model.
213W.-C. Hwang et al. / Clinical Psychology Review 28 (2008) 211–227
CIMHmodel serves as an illustrative roadmap to help students and professionals visualize the complexities involved in
understanding culture’s influence on mental health. We acknowledge that no single conceptual model can adequately
capture the complexities involved in understanding cultural influences on mental health, but hope that the CIMHmodel
will provide a solid foundation for those wanting and needing to improve their cultural awareness.
1. The CIMH model
1.1. Cultural issues in the development of illness
At a basic level, we understand that the cultural background and characteristics of the individual plays an important
role in the etiology of disease and the resulting psychological distress and mental illness as illustrated by Pathways A
and B in Fig. 1. For instance, we know that the day to day experiences of people from different backgrounds may be
very different. We also know that ethnic minorities are likely to be exposed to a disproportionate burden of unique
stressful experiences. A basic example would be that of the refugee experience. Many refugees immigrate to countries
around the world having experienced a variety of traumatic experiences, including war, genocide, violence, famine,
and political persecution (Gong-Guy, Cravens, & Patterson, 1991; Williams & Berry, 1991). Whether one escapes to
another country or not, those exposed to violent experience evidence increased risk for depression and post traumatic
stress disorder, as has been found among Southeast Asian, African, Bosnian, and Kurdistanian refugees (Chung &
Kagawa-Singer, 1993; Hirschowitz & Orkin, 1997; Kinzie et al., 1990; Kroll et al., 1989; Sundquist, Johansson,
DeMarinis, Johansson, and Sundquist, 2005; Wahlsten, Ahmad, Von Knorring, 2001). Traumatic experiences are
culture-universal in that anyone exposed to such stressors would likely be negatively affected. However, refugees are
much more likely than the general population to experience traumas (Gong-guy et al., 1991; Williams & Berry, 1991),
and as a result, their vulnerability to developing psychological problems increase with accumulated stress burden.
Refugee experiences can be very different from that of other ethnic minorities. For example, Native Americans who
have suffered from the cumulative impact of colonization and generations of oppression also suffer from higher rates of
lifetime trauma and violent victimization than other groups living in the U.S. (National Center for Injury Prevention
and Control, 2002; Walters & Simoni, 1999).
Regardless of refugee status, many immigrants also experience acculturative stresses while trying to adapt to a new
cultural environment that those in the majority population are unlikely to face (Hovey, 2000; Williams & Berry, 1991).
Acculturative stress, defined as the stress related to transitioning and adapting to a new environment (e.g., linguistic
difficulties, pressures to assimilate, separation from family, experiences with discrimination, and acculturation-related
intergenerational family conflicts) refers to adaptational stressors that can increase risk for mental health problems
(Berry, 1998; Berry & Sam, 1997). These stressors have been found to have a detrimental effect on immigrant health
and mental health, especially among recent immigrants (Berry, 1998; Goater et al., 1999; Hovey, 2000; Jarvis, 1998;
King et al., 2005; Myers, & Rodriguez, 2003; Oh, Koeske, & Sales, 2002; Organista, Organista, & Kurasaki, 2003;
Schrier,Van de Wtering, Mulder, and Selten, 2001; Vega & Rumbaut, 1991; Veling et al., 2006). The degree to which
acculturative stresses are likely to have a negative impact partially depends on a number of pre-post migration factors,
such as educational status, linguistic ability, refugee status, access to thriving ethnic neighborhoods in the host country,
and support networks available (Williams & Berry, 1991).
Cultural assimilation, or the process of gradually taking on the characteristics of a new environment, can also
increase risk for health problems as immigrants acculturate, possibly due to a regression to the normative prevalence
rates of illness in the general population (Berry, 1998). For example, there is a growing body of research indicating that
U.S. born Latinos evidence higher rates of a variety of mental and physical health problems than foreign-born Latinos
(Escobar, Nervi, and Gara, 2000; Ortega, Rosenheck, Alegria, and Desai, 2000). Chinese Americans also evidence this
cultural assimilation effect in relation to major depression (Hwang, Chun, Takeuchi, Myers, & Siddarth, 2005). A
similar problem is also developing in European countries. For example, several studies have found that the rate
of schizophrenia was approximately 2–3 times higher for African immigrants, Afro-Caribbeans, Asian, Surinam,
Netherland Antilles, Moroccan, and other immigrants than Whites in Great Britain and the Netherlands (Goater et al.,
1999; Jarvis, 1998; King et al., 2005; Schrier et al., 2001; Veling et al., 2006). There is little empirical evidence that
explains why this is happening, however, some believe that it may be due to a combination of accumulated stress
burden, increased exposure to culturally unfamiliar environmental and psychosocial experiences, racism and dis-
crimination, and the loss and attenuation of culturally protective factors.
214 W.-C. Hwang et al. / Clinical Psychology Review 28 (2008) 211–227
Immigrant issues aside, ethnic minorities are likely to be exposed to a number of other stressors that are unique to
their minority status. For example, many minorities report negative experiences with racism and discrimination (Clark,
Anderson, Clark, & Williams, 1999; Kessler, Mickelson, & Williams, 1999; Williams, 1996). Racial discrimination
(whether overt, covert, or perceived) is likely to have a negative impact on health and mental health, and often leaves
people with feelings of anger, disempowerment, fear, loss of control, and helplessness (Clark et al., 1999; Krieger,
Sidney, & Coakley, 1999). Persistent ethnic and racial discrimination continues to be highly prevalent around the world
with many citizens holding disparaging and negative stereotypes of ethnic minorities being dangerous, lazy, less
intelligent, and so forth (Davis & Smith, 1990). Recent reports also indicate that ethnic and racial discrimination not
only results in economic disadvantages for many ethnic minorities, but also persist in health care systems and
exacerbate health disparities (Smedley et al., 2003).
In addition to being the target of racism, ethnic minorities are less likely to benefit from a number of privileges
available to Whites (McIntosh, 1989; Rothenberg, 2005). In discussing White privilege, McIntosh (1989) notes, “I was
taught to see racism only in individual acts of meanness, not in invisible systems conferring dominance in my group”
(pp. 31). White privilege acts to confer a number of advantages to White people that ethnic minorities do not have. In
the U.S., for example, Chin, Cho, Kang, and Wu (1999) note that:
For many people of color, racism has decreased the amount and value of economic, social, and cultural capital
inherited from our ancestors. Not only did we receive less material wealth, we also received less “insider
knowledge” and fewer social contacts so instrumental to one’s educational and professional advancement. The fact
that runners today might compete on more equal “footing” does nothing to change this fact…even if you are
individually innocent of any racial discrimination, do you still enjoy its illicit fruits? After all, discrimination (by
others) has shrunk your pool of competitors for admissions, public contracting, and jobs. (pp. 3, 5)
Because of this, White privilege not only reduces the amount of stressful experiences that White Americans face, but
also serves as a protective factor and increases their resources for anticipating and coping with adversity relative to
persons of color.
Some ethnic minorities are exposed to a different set of stressful experiences that White Americans are less likely to
face. In addition, these experiences may affect different groups differently, and as a result, bias research findings. For
example, African Americans, Latino Americans, Native Americans, and some Asian American groups evidence a
higher burden of poverty in the U.S. (Proctor & Dalaker, 2003). Given the high rates of poverty and the cumulative and
current exposure to racism and discrimination experienced by many of these groups, it is surprising that ethnic
minorities do not evidence even higher disproportionate rates of mental dysfunction than White Americans (Chernoff,
2002). Chernoff (2002) noted that while positive coping resources (e.g., kinship, spirituality, ethnic pride, collective
unity) may help to preserve the mental health of minority communities, the disproportionate risk burden they carry still
takes its toll as evidenced by the disproportionate burden of medical morbidity in many of these groups.
Betancourt and Lopez (1993) caution that understanding the relationship between race and socioeconomic status
(SES) is a complex process and vulnerable to methodological and statistical bias. For example, they note that the
prevalence of depressive symptoms was found to be higher among Latinos than White Americans in a study conducted
by Frerichs, Aneshensel, and Clark (1981), which provided evidence of an ethnic difference. However, this effect may
be overestimated because when SES is controlled, the ethnic effect disappeared and SES became the significant
predictor of depression. Because SES and ethnicity can be highly overlapped in some minority groups, both variables
need to be included in statistical analyses. However, this overlap also effectively limits our ability to disaggregate
shared variability. In order to properly understand these relations, they caution that a sufficient representation of ethnic
groups in multiple SES stratum is required (Betancourt & Lopez, 1993).
Social factors such as familial relationships serve as an important risk and protective factor for all people, but may
also affect ethnic minorities differently. For example, research examining expressed emotions found that while family
interactions involving criticism was more predictive of relapse for White Americans returning home after hos-
pitalization for schizophrenia, emotional distance and lack of warmth played a stronger role than emotionally negative
interactions in predicting relapse for Mexican American families (Lopez et al., 2004). Chao (1994) also challenged
what were believed to be culture-universal relationships between parenting styles and child outcomes by noting that
Chinese American parents tended to be more “authoritarian” but that Chinese American children still performed well in
school. She introduced the notion of a Chinese parenting style called “Xiao xun” or “child training,” and believes that
this culture-specific parenting style, based on Chinese notions of filial piety, may better explain child-parent relations
215W.-C. Hwang et al. / Clinical Psychology Review 28 (2008) 211–227
than predominant Western conceptualizations. More research needs to be done to examine operational differences in
how family and social relations preserve or exacerbate mental health outcomes. In addition, more research needs to be
conducted to examine how acculturation impacts family relations. Recently, Hwang (2006a) proposed a theory of
Acculturative Family Distancing (AFD), noting how growing acculturative gaps place immigrant families at risk
for developing AFD along two dimensions, a breakdown of communication and an increase of incongruent cultural
values, both of which negatively impact family relations and increase risk for psychological distress and functional
impairment.
1.2. Culture and the expression of distress
The cultural background of the individual not only influences the etiology and development of disease, but also
plays a role in the definition and sociocultural meanings of illness. The sociocultural meanings in turn are shaped by
cultural norms and beliefs, and ultimately serve as a filter to shape the manner in which distress is expressed as
illustrated by Pathways C and D. People from all around the world experience mental illness, and for the most part,
symptom profiles for the major disorders are similar (USDHHS, 2001). However, the manifestation of such difficulties
(e.g., how they are communicated, experienced, whether they are expressed, and the social meanings of different
symptom clusters) can vary by age, gender, and cultural background (Kleinman, 1978). For example, although there
may be core symptoms of depression that are similar across cultures, there may also be differences in emphases placed
on certain types of symptoms (e.g., differences in the loading of affective, cognitive, and somatic complaints) and/or
symptoms associated with depression (e.g., headaches and stomachaches) that are not currently included in the U.S.
Diagnostic Statistical Manual (DSM) or the International Classification of Disease (ICD) (APA,1994; WHO, 1992).
The sociocultural environment may act as a contextual backdrop and influence cultural conceptions of illness (e.g.,
what an illness is), symptom recognition and tolerance, the manner in which it is expressed, social meanings associated
with it, and the manner in which it is communicated (e.g., directly, indirectly, or not at all) (Marsella, 1980).
When considering cultural differences in the expression of distress, etic (culture-universal phenomena) and emic
(culture-specific phenomena) distinctions are also important to make (Fischer, Jome, & Atkinson, 1998; Sue, 1983).
Using depression as an illustrative example, the etic perspective assumes that all people express depression in similar
ways and that our diagnostic criteria can be applied to people from all backgrounds without significant cultural bias. On
the other hand, an emic perspective would argue that there are likely to be both universal forms of depressive symptoms
(i.e. criterial symptoms), as well as cultural variability in symptom expression (Fischer et al., 1998; Sue, 1983).
Somatization, or the degree to which people express their distress through physical symptoms can vary across
cultural groups, affect different parts of the body, and carry different social meanings. For example, in Asian cultures,
research suggests that somatic expression of distress is very common place; whereas, in Western cultures, there is a
greater emphasis on talking about problems and expressing oneself verbally and emotionally (Chun, Enomoto, &
Sue, 1996). When comparing Chinese and American psychiatric patients with depressive syndromes, Kleinman (1977)
found that 88% of Chinese patients compared to 20% of U.S. patients did not present affective complaints and reported
only somatic complaints. In Taiwan, nearly 70% of psychiatric outpatients presented with predominantly somatic
complaints at their first visit (Tseng, 1975). Chun et al., (1996) note that somatization may be more prevalent among
Asians because open displays of emotional distress is discouraged, possibly because of differences in value orientation
and strong stigma associated with mental illness. Displays of psychological symptoms of depression may be perceived
as characteristic of personal or emotional weakness. As a result, Asians may deny, suppress, or repress the experience
and expression of emotions. This is not to say that Asians and Asian Americans do not experience psychologically
related depressive emotions per se. Instead, there may be cultural differences in selective attention (e.g., amount of focus
on the mind vs. body), ordering of such foci (e.g., focusing on somatic symptoms first because this is more culturally
acceptable and less stigmatized than acknowledging cognitive and emotional symptoms), and/or willingness to express
distress based on what’s culturally appropriate or accepted (e.g., greater stigma associated with mental illness and/or
differences in divulging problems to people outside of the family). In some Latino groups for example, somatic
disturbances take the form of chest pains, heart palpitations, and gas (Escobar, Burnam, Karno, Forsythe, & Golding,
1987); whereas, in some African and South Asians groups it is sometimes expressed through burning of the hands
and feet and the experience of worms in the head or the crawling of ants under the skin (APA, 1994; USDHHS, 2001).
There may even be linguistic differences in the language available to describe, interpret, and communicate one’s
problems. For example, in Native American culture, words for many Western conceptualizations of illness such as
216 W.-C. Hwang et al. / Clinical Psychology Review 28 (2008) 211–227
depression and anxiety do not exist (Manson, Shore, & Bloom, 1985). In examining ethnic differences in the clinical
presentation of depression, Myers et al. (2002) found that even after controlling for SES and severity of distress,
African American and Latina women who were depressed reported more somatic complaints than White American
women. Greater somatic manifestations among many ethnic groups may be associated with philosophical or cultural
underpinnings that emphasize an integrated or holistic mind-body-spirit experience (Hwang, Wood, Lin, Cheung, &
Wood, 2006). This can be seen in Traditional Chinese Medicine (TCM) where the mind and body are treated as one,
inseparable, and a balance of yin (negative) and yang (positive) energies.
How psychological or emotional distress is initially expressed can also be culturally incongruent and open the door
for social or self-criticism (Chun et al., 1996). In some cultures, extreme emotional reactions may elicit negative social
responses (e.g., other perceiving this person as crazy, weak, or lazy); whereas, somatic expression of distress may elicit
empathy and help rally support from social networks (e.g., the belief that this person has a real medical problem and
needs help). Illnesses are dynamic in that they represent complex social constructs that are influenced by social norms
and complex social feedback interactions between the person and their social environment (Chun et al., 1996). In some
cultures, attribution of interpersonal distress to physical causes may also initially protect patients from feeling negative
emotions and worry, and reduce feelings of shame, weakness, and loss of control.
Although Chinese patients may initially report more somatic symptoms and suppress or ignore emotional
symptoms, this does not mean that they do not experience emotional and cognitive symptoms (Cheung, 1982; Cheung
& Lau, 1982). In fact, clinical experience tells us that after developing a good therapeutic relationship, Chinese patients
begin to feel more comfortable expressing more cognitive and affective symptoms. In addition, studies have found that
although some patients were more likely to focus on physical complaints when they initially came into treatment, they
were fully aware of and capable of expressing feelings and talking about the social problems that had brought them into
treatment after a strong patient-therapist relationship developed (Cheung, 1982; Cheung & Lau, 1982).
Culture-bound syndromes, defined as culture-specific idioms of distress that form recognized symptom patterns and
have distinct clinical characteristics, symptom constellations, and social meanings, have been documented in many
cultures (APA, 1994; Levine & Gaw, 1995). Two of the most researched include ataque de nervios and neurasthenia.
Ataque de nervios, often characterized as a form of panic attack among Latinos, is associated with feelings of being out
of control due to stressful events relating to family difficulties (APA, 1994). Unlike traditional panic attack, it is
not associated with the hallmark symptoms of acute fear or apprehension. Other symptoms include trembling,
uncontrollable shouting or crying, somatic feelings of heat rising through the chest to the head, dissociative
experiences, seizure-like fainting episodes, and aggressive behavior (APA, 1994). Recent evidence suggests that
although a portion of those diagnosed with ataque de nervious also meet criteria for panic disorder, the majority of
subjects with ataque de nervios do not, suggesting that ataque de nervios is a more inclusive construct (Lewis-
Fernandez et al., 2002). Key features that distinguish ataque de nervious from panic include a more rapid onset of
attack, being preceded by an upsetting event in one’s life, and greater fears of losing control, going crazy,
depersonalization, sweating, and dizziness (Lewis-Fernandez et al., 2002; Liebowitz et al., 1994).
Neurasthenia (NT) or shenjing shuairuo in Mandarin Chinese, commonly referred to as a Chinese form of
depression, is characterized by two highly overlapping symptom domains including increased fatigue after mental
effort (e.g., poor concentration, increased distractibility, inefficient thinking) or physical weakness or exhaustion that is
accompanied by physical pains and inability to relax (e.g., headaches, dizziness, sleep difficulties, gastrointestinal
problems, anhedonia, and bodily pain) (WHO, 1992). This diagnosis continues to be used in China and is included in
the Chinese Classification of Mental Disorders, Second Edition (Neuropsychiatry Branch of the Chinese Medical
Association, 1989). There continues to be controversy about whether neurasthenia is merely major depression with a
cultural label or whether it is a distinct diagnostic entity. For example, Kleinman (1982) found that 87% of psychiatric
patients diagnosed with NT in a Chinese clinic could be rediagnosed with major depression. In contrast, a recent
epidemiological study of Chinese Americans in Los Angeles found that 78% of those diagnosed with neurasthenia did
not meet criteria for major depression or an anxiety disorder, yielding a neurasthenia prevalence rate that was as high as
that of major depression (Zheng et al., 1997).
Many other culture-bound syndromes have also been documented (Levine & Gaw, 1995). Unfortunately, there is
less empirical research to help us understand these syndromes which affect people from all around the world. For
example, many cultures believe in magical powers, spiritual possessions, and witchcraft or juju. In Northern Africa and
parts of the Middle East, cases of “Zar” or …
105
Chapter 7
Trauma, Coping, and Resiliency among Syrian Refugees in Lebanon and Beyond
A Profile of the Syrian Nation at War
Naji Abi-Hashem
INTRODUCTION
How are the Syrian refugees coping and surviving? And how are they handling the
many losses, displacements, traumas, psycho-emotional struggles and sociocultural
obstacles? What motivates them to keep facing hardships and to thrive in the face of
adversities in constructive ways? This chapter will attempt to highlight the abilities of
many deeply affected Syrians to transform their tragedy and misery into a trajectory of
purpose, a mission of survival, and a path toward resiliency. They are willing to work
extremely hard, live in tight places or on tiny budgets, and keep a grateful attitude in
order to preserve their dignity, basic survival, and safety of their loved ones. Syrian
refugees are proving to be quite industrious and able to utilize any available resource,
opportunity, facility, and support to their benefit and family welfare. All the while they
carry with them many scars of war, torn memories, and strong longings for home, from
where they were suddenly uprooted and unwillingly left behind. In spite of all their
misfortunes, they seem to keep the hope alive.
As the author of this chapter, and a Lebanese-American clinical and cultural
psychologist, I have been living and functioning in two geographic regions, the United
States in North America and the Middle East, almost dividing my time between the two.
In both places, I am involved in teaching, counseling, training, lecturing, networking,
writing, and cross cultural service. While in Lebanon, I normally spend time consulting
with health care providers, counselors, educators, pastors, and community leaders. One
of my passions is to care for the caregivers, especially those who are working
under stress, serving underprivileged populations, or operating in danger and on the
front lines. Often I am called upon to conduct training seminars or debriefing sessions
for those teachers, caregivers, and volunteers who are helping some of the multitude of
refugees in their area. Therefore, I have observed firsthand the related struggles, stress,
agonies, and persisting symptoms. Also, I had the opportunity to work with hundreds of
Syrians from all walks of life and social backgrounds, formally and informally, as we see
them and interact with them on a daily basis everywhere we go in town.
Personally, I grew up in a mountain town in Lebanon called Aley, went to a Catholic
school there, and initially pursued technical college in Beirut for training in Electronics.
My first job was at the American University Hospital. So, I lived in Beirut in late 1970s
and early 1980s, during what known as the civil armed conflicts and other people’s wars
on our land. While enduring the long bloody troubles and trying to help others through
their dark times, I continued my education in the general area of liberal arts, covering
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social and cultural studies, psychology, pastoral care, philosophy, counseling, and
theology. At age 30, I traveled to the United States in 1984, to focus more on graduate
studies in pastoral counseling and clinical psychology, respectively earning an MDiv, an
MA, and a PhD in these fields. Then, I became fully licensed as a psychologist in the
State of Washington in 1995. While in the States I served as a consultant to a number
of agencies that deal with Arab Americans and with Middle Eastern congregations. So, I
have had a long educational journey and community service heritage both in Lebanon
and the United States. In terms of my spiritual practice and religious preference,
although it is within the Protestant tradition, I really consider myself as
interdenominational, relating to all churches and faith traditions. I have been involved in
many interfaith conferences and been part of several ongoing in-depth Christian-Muslim
dialogues, especially in Beirut, Lebanon.
Therefore, my academic background and outlook on human service are varied, broad,
intercultural, and interdisciplinary in nature. Often, I am invited to speak in public, teach
an intense course, or present at conventions on subjects related to the Middle East,
cross-cultural counseling, migration and refugees, Arab Americans, the impact of
globalization, psychology of religion and spirituality, fundamentalism and radicalism,
tragic loss and grief, and war stress and coping. Now, that personal background
overview will lead us to explore the topics and themes of this particular chapter.
As of today, it is estimated that the Syrian crisis is one of the worst humanitarian
disasters in our modern times. The armed conflicts in Syria are still raging, and it seems
that there is no end in sight for its calamities. These intense wars and fighting have
been going on nonstop since 2011, tearing apart the land and its people. The reality is
that nobody knows exactly how many people have escaped, relocated, or been forced
out; how many have been hurt and injured; and how many have totally disappeared or
tragically lost their lives (Almoshmosh, 2015; James et al., 2014; Quosh, Eloul, & Ajlani,
2013).
Many political observers and social analysts are truly concerned about such a crisis of
such a magnitude (Carpenter, 2013; Geha, 2016; Laub & Masters, 2013; OCHA, 2017).
It has the potential to heavily burden and destabilize, not only neighboring countries,
which is already happening, but also faraway societies, countries, and governments. It
is affecting political establishments, geographical borders, the global economy, and
world powers. Iraq came first and now Syria. The combined effects of both misfortunes
are causing a substantial increase in negative discourses, hostile sentiments, religious
fundamentalism, and political radicalism in the Near East and beyond.
Since 2011, it is estimated that the death toll of Syrian people has reached about
500,000 of all ages and backgrounds. Some reports predicted that about 400,000
victims died as a direct result of the bombing and fighting, and about 100,000 died as a
result of the military sieges, lack of basic living necessities and care, and break down of
the infrastructure. In addition, five to six million have become refugees outside Syria and
107
six to seven million have been displaced within Syria. Between 50,000 and 100,000 are
reported detainees or missing. Millions are injured, and thousands have been drafted,
persecuted, starved, or tortured. Presently, between 13 and 14 million are in need of
essential humanitarian aid and improved basic living conditions (Boghani, 2016; Mercy
Corps, 2017; OCHA, 2017; UNICEF, n.d.; World Vision, 2017).
Background and National Profile
The country of Syria is located on the eastern side of the Mediterranean Sea in
southwestern Asia, with a population of approximately 22 million. It is surrounded by
Iraq to the east, Lebanon and seashore to the west, Turkey to the north, and Jordan to
the south. In addition, Syria has a small section border with Israel/Palestine, mainly the
Golan Heights, which is located in the southwest. Syria is about 71,500 square miles
and most of it is positioned at the western end of a rich farmland, called the Fertile
Crescent.
The nation is officially known as “The Syrian Arab Republic” or “The Arab Republic of
Syria” (In Arabic, Al-Jamhooriyyah el-Arabia Assouriyah). Its landscape consists of
many fertile plains, a few mountain ranges, and widespread deserts. Its borders do not
match with Ancient Syria and Damascus Land (Souriyyah al-Koubra wa bilaad el-
Shaam). The country has been the home to many diverse ethnic, sociocultural, and
religious populations. Lifestyles are mixed, reflecting the urban, complex, and modern
styles and the rural, simple, and traditional styles. The majority population is Arab
Muslim of the Sunni branch. Other minority groups include the Kurds, the Armenians,
the Assyrians, the Alawites, the Shiites, the Arab Christians, and the Arab Druze (cf.
Abi-Hashem, 2003, 2008a; Hourani et al., 2016; Lawson, 1992; Nation Master, 2013).
Syria is an extremely ancient country, and has a rich cultural heritage. Many old
civilizations have passed through, invaded, and ruled the whole area, leaving clear and
deep marks. Once, Greater Syria was the hub for the ethnic Arab Kingdoms, long
before the Arab-Muslims came to the scene. Later, Greater Syria became a center for
the Islamic Empire. Thus, it has a history of being the guardian of Arab Nationalism and,
at some point, of the Muslim heritage, thought, and culture.
In 1946, Syria became a fully independent nation, ceding from the French Mandate.
Prior to that, it was part of the Ottoman Empire, similar to the fate of many nearby
countries. Since then, Syria has been a member of the Arab League, the United
Nations, and the Organization of the Islamic Conference (OIC), as well as many other
global organizations. Modern Syria has also a history of political unrest and coups. One
of these coups brought Havez el-Assad to power, the father of the current president,
Bashar el-Assad. Since then, Syria has been a very stable and cohesive society,
because Assad established a one-party rule, a secular ideology (with a thin cover of
religion), and an authoritarian regime in the style of a police state. The 1973 constitution
gave the president major executive powers, including the commander in chief of the
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armed forces and the secretary general of the ruling party, which is known as El-Baath
Party (Hourani, et al., 2016).
Along with other concentration areas of cultures in the Near East, like Mesopotamia,
Egypt, and Phoenicia, Ancient Syria was also part of the cradle of civilizations, where
some of the greatest human achievements were established. Language, philosophy,
astronomy, religious thought, human trade, systems of agriculture, governing models,
cultural exchanges and other fields of inquiry had their roots there. Damascus has been
the longtime capital and is the largest city in Syria. Damascus, along with Aleppo and
Hama, pride themselves on being among the oldest continuously inhabited cities in the
world (Abi-Hashem, 2003, 2008a; Abul-Fadil, 1998; Haddad, 1994).
Rural Syria is extremely traditional. Nomadic and seminomadic tribes are still roaming
the countryside. There are also several racial-ethnic people-groups who settled there
through the generations, and some of them are integrated within their region.
Historically, the location of villages was usually determined by the availability of water,
fertile land, and safe fortification. Community living is in very close proximity, and streets
are very narrow. A mosque, a shrine, or a church normally stands in the middle of the
community, or built on higher grounds nearby, so that it can be seen from afar and
provide a landmark for the surroundings. Even within cities, several families (usually
related) live in one large dwelling place, around an enclosed major entrance, with a
garden and a water fountain inside the compound. The families often gather there daily
to eat, visit, stay abreast of current events, and discuss important social affairs.
However, this type of high-density living proved to have both advantages and
disadvantages on the structure of Syrian marriages, families, and communities. Life is
normally characterized by a strong sense of collectivism and social bonding, but leaves
little space for personal maneuver and privacy (Hourani, et al., 2016; Mulaika, 1979;
Sfeir, 2000).
Because work is seasonal and opportunities are very limited in rural-desert areas,
many families and younger generations have been migrating to larger towns and cities,
thus facing extra challenges for mental and sociocultural adjustments and placing extra
demands and pressures on the limited social institutions. The country’s rich natural
resources and agriculture supplies have been subject to internal feuds and commercial
exploitations. The industrialization of many areas has caused pollution of already-
overstretched water resources. Inefficient irrigation methods and misuse of fertilizers
have compounded this phenomenon creating further competition and wider gaps
between the haves and the have nots. Many observers see these trends as the genesis
of the current unrest and popular uprising, which has triggered civil turmoil, and
therefore dragging the country into localized fighting, open borders, and multiple battles
and leading it into deeper divisions and widespread wars.
Syrians, like other Middle Easterners, are a very hospitable people and easily
welcome friends and strangers into their homes. Aleppo is the second largest city and
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the economic-industrial center of the country. It is also the home of the Armenian
population, about 400,000 people, who became well integrated and prosperous in that
region. The Arabic language is strongly emphasized in Syria, at the expense of other
foreign languages. All school and university curricula are transliterated and taught in
Arabic. Syria has prided itself as the protector of Arabism.
The following facts reflect some vital statistics about the country (cf. Hourani, et al.
2016; Lawson, 1992; Nation Master, 2013; UN Data, 2017; UNHCR, 2015a, 2015b):
The gender distribution in Syria is 51.3 percent for males and 48.7 percent for females.
The distribution of population is 54 percent urban and 46 percent rural. The literacy rate
in Syria for those 15 years of age and over in 1995 was 75 percent as the government
requires six years of compulsory primary education for all. The average life expectancy
in 2012 was 75 years. The annual growth rate was 6.2 in 2005, 3.4 in 2010, and 0.4 in
2014. The ethnicity of Syria is composed of: Arabs, 75 percent; Bedouins Arab, 7.5
percent; Kurds, 7.3 percent; Palestinians, 4 percent; Armenians, 2.8 percent; and
Others 3.4 percent. The distribution of religious affiliations as of 1992 was: Muslim
Sunni, 74 percent; Alawites and Shiites, 11 percent; Christians, 10 percent; Druze, 3.0
percent; and Others (like Yezidis), 2.0 percent. Before the current extended conflict,
Syria hosted a number of refugees and asylum seekers from Iraq, Sudan, Somalia, and
Afghanistan in addition to the Palestinian refugees settlers, who have been in Syria
since 1948. Many of those had to flee and relocate multiple times in recent years, both
inside and outside Syria.
Trauma Through Cultural Lenses
What is considered tragic or traumatic in one place is not exactly considered the same
everywhere. The concept of trauma is very broad and has many layers and dimensions.
There is a variety of terminology to describe any traumatic event, like tragedy, disaster,
adversity, calamity, destruction, catastrophe, terrifying event, severe crisis, devastating
loss, threatening danger, horrific violence, etc. Although there are some technical
differences among some of these terms, they have often been used interchangeably in
the literature as well as in the mass media, due to their perceived similarities and impact
on human nature. There are many aspects to the notion and experience of trauma;
among them are the mental-emotional, interpersonal-behavioral, physical-physiological,
tribal-communal, religious-spiritual, social-national, existential-philosophical, and
traditional-cultural.
How people perceive, label, experience, or express trauma, or any other event,
concept, notion, or feeling for that matter, is quite different. All depends on many vital
aspects and wide influences. These include ethnic, social, emotional, religious, cultural,
psychological, and existential factors. Experiences of acute stress and tragic
occurrences affect people regardless of age, location, mentality, or status, yet each in
their own way. Traumatic experiences can have equally deep influences on both the
110
personal-individual and the collective-communal levels. Cultural background, emotional
capital, life wisdom, psychological awareness, communal cohesiveness, mental outlook,
social support, and religious faith all are essential dynamics in responding to crises and
tragedies. Interestingly, communities, societies, and nations tend to react, process,
struggle, and cope with adversities and disasters in a similar way to an individual person
or a private self (Abi-Hashem, 2011a, 2012, 2014b, in press; Ellis & Abdi, 2017; Kleber,
Figley, & Gersons, 1995; Mitschke et al., 2017; UNHCR, 2015a, 2015b).
In contrast to most Western views and models, life experiences, in general, and
traumatic stressors, in particular, extend beyond the individual person or one human
soul. They reach a broader level and scope to the large social context. People’s
understanding and reactions to life’s events are significantly informed by their
worldview, subcultures, and values, and are guided by their collective bonds and family
sustenance, which typically are provided generously within their group, tribe, or
community. In most poor, low-income, and developing countries, people expect
hardships in life and seem to have a higher tolerance to pain. According to Kleber,
Figley, and Gersons (1995), trauma does not occur to us in a vacuum; rather, it is
shaped and approved by our surroundings, our value system, and our cultural heritage.
Societal and cultural dimensions of traumatic stress are organic and fundamental. Thus,
trauma is not only an individual matter but also a collective and communal matter, and
that fact should necessitate a careful approach to all labeling and clinical diagnosing,
like the posttraumatic stress disorder (PTSD), acute stress disorder (ASD), and
related Diagnostic and Statistical Manual of Mental Disorders (DSM) classifications.
Many international educators and clinical caregivers believe that mental health criteria
cannot be applied everywhere in the world equally or blindly. In addition, some of these
experts observed that certain diagnoses, like the PTSD, have been overly used and
mechanically applied, not only in the general West, but also elsewhere across the world
(Abi-Hashem, 2008b, 2014a, 2015, 2016a; Arkowitz & Lilienfeld, 2009; Kleber, Figley, &
Gersons, 1995; Marsella, 1982).
For typical Syrian evacuees and refugees, losing their sense of stability, basic life
functions, rootedness in the land, most of their physical possessions, and sense of
national pride are considered major and significant losses. Moreover, experiencing
suddenly and for the first time intense fighting, the outbreak of war, and severe
destruction, accompanied with blood, death, horrific images, and disabling fear were too
tragic and traumatic for them to bear. Most Syrians have expressed that after growing
up in an extremely safe, secure, and controlled environment (as in a police state) along
with plenty of almost free services, like education and medical care, (provided by the
government), now trying to settle in a totally new location, learn new ways of life, and
dealing with a new set of rules and authorities made them go through a serious mental
shock and stressful reorientation process (adjustment disorders), some of which have
been traumatic in nature, since many relocated from rural areas into dense urban
111
settings. Although they stated that they were not easily shaken by mini-traumas and
regular hardships of life, at the same time they described the tearing apart of their
tightknit families and community bonds, the total disappearance of close friends and
relatives, and the disturbing sounds and smells of heavy fighting hitting home as a real
tragedy (ma’saat) and a deep trauma (fajiaah) (Abi-Hashem, 1999a; Almoshmosh,
2015; Arkowitz & Lilienfeld, 2009; Clinic Psychology, 2016; Hassan et al., 2016; James
et al., 2014; Mitschke et al., 2017; Quosh, Eloul, & Ajlani, 2013).
The Syrian Crisis
Syria was once a very stable country and its people were nicely settled in their
communities, rooted in their land, embedded in their routines, and tranquil in their
generational living. Suddenly, they were caught up in a devastating war, totally
unprepared and terribly unequipped to face such a calamity of such magnitude. Like the
Iraqis before them, Syrians quickly became destabilized, traumatized, and victimized,
with no time to process their disorientation, bind their wounds, sort their options, or say
goodbye to their homes, community, and way of life. Many had to flee with minimum
belongings (if any) and with no sense of awareness or direction as where to go or what
to do next. They were caught off guard, were ill prepared, and quickly began to manage
serious disillusionments and endure multiple losses, injuries, and huge uncertainties.
Some decided to stay “home” regardless of the dire situation, choosing the known for
the unknown.
In the Middle East, home is precious, and symbolic of a family’s heritage. Also, such
decisions depend on the circumstances of the violence, on the windows of cease-fire,
and on the mental-physical ability of the survivors. Not everyone could pack a few
things and run. So, many anxious people stayed behind not knowing what would
happen to them or their neighborhood. Those who remained soon came under siege of
brutal militias or military, enduring heavy bombardment and trying to survive among the
rubble. In other developed countries, immediately following any major accident, tragedy,
crime, mass shooting, or natural disaster, scores of first responders, counselors, social
workers, pastors, volunteers, etc., hurry to the scene to offer their therapeutic attention
and service. Then, the survivors would continue to receive guidance, treatment, and
supportive care. In contrast, Syrian victims have been largely left alone to help each
other and, at times, to suffer in silence and obscurity. They lean on and uplift each
other. When one falls or collapses emotionally, the others rally around him or her to
support and encourage. They take turn in containing the pressures, intervening when
needs are urgent, and morally elevating each other in dark times. Obviously, the most
difficult aspect of any crisis or tragedy is its consistency and unpredictability. In times of
war, when the agony keeps unfolding, the uncertainty is prolonged, the stress becomes
chronic with no end in sight, and the ability to survive and the tolerance to endure all
112
drop down significantly (Abi-Hashem, 2006, 2011a, 2014b; Hobfoll et al., 1991; OCHA,
2017; Wong & Wong, 2006).
In 2011, what appeared to be a regular uprising and police confrontation, in one small
corner of Syria, developed quickly into a widespread armed conflict that engulfed
various regions. The Syrian crisis became so complex that no analyst is able to
understand it completely. It grew rather fast, shifted numerous times, ignited so many
fronts, involved many inner and outer players, penetrated into all the sociopolitical
layers, and put the nation on a serious downhill spiral. What used to be a very stable
land, ruled by a strict regime with heavy security apparatus, quickly slipped into major
disorder and dangerous turmoil. Mini wars and social chaos became the norms. Cities
were divided and militias ruled the streets. Black markets, arms dealing, and trafficking
youngsters flourished overnight. “Green lines” (a term used to describe the dividing line
or limit between two warring factions in urban civil wars) were formed on the ground,
and many cities and towns were transformed into mini battlefields. Fierce fighting raged
heavily with the use of conventional weapons and war machines to inflict unbelievable
physical destruction and mental-emotional pain and horror.
Of course, there are some regions and city areas that are still intact within Syria and
life is going on naturally there. Other areas are restricted and require passes and
maneuvers to go around (with plenty of check points). But there are way too many other
areas and places that are highly dangerous, utterly devastated, and completely
destroyed. Even seasoned caregivers and reporters, at times, don’t have words to
describe the scenes they are observing. A reporter described a town, which was once a
hub of activities and livelihood, as a ghost city (Masters & Kourdi, 2016). Another, a
veteran of war coverage, shares her intense eerie feeling, when walking through some
of the neighborhoods in Aleppo and sensing the deafening silence and the dark
shadows of death. Another said, “This is Hell!” Others declared that there would be no
real winners in these compound wars, only and certainly losers (Ward, 2016). Although
the news media still relay powerful images, five years into the troubles, unfortunately
most of the viewers around the world have become numb to the realities of war,
distancing themselves from that agony, to protect themselves consciously or
unconsciously, or justifying their passive attitude by considering the tragedy as a Syrian
problem and part of the Middle East’s chronic troubles. However, scores of volunteers,
caregivers, and humanitarian aid workers are still working tirelessly on the ground in
refugee centers, neighborhoods, and camps. They are bringing much needed help,
hope, and healing and a new zest for life to the desperate and destitute (Abi-Hashem,
2004, 2016a, in press; Boghani, 2016; Ko-Din, 2017; Uechi, 2016; Ward, 2016; World
Vision, 2017).
War Migrants and Sociocultural Adaptation
113
Since the beginning of the armed conflict and bloody war, the Syrian society has
plunged into dark living conditions and communal disasters. According to a number of
sources and statistics (cf. Mercy Corps, 2017; Norton, 2014; SCPR, 2015; UNHCR,
2015a, 2015b; WHO, 2017), almost half of the existing population in Syria (about 11
million) has shifted or relocated to another place or region, at least once; two-thirds of
the population is now considered living in low socioeconomic conditions, in tangible
scarcity, or in extreme poverty; life expectancy has decreased from 75.8 in 2010 to 55.6
years in 2014 and it continues to drop lower due to the significant impacts of the war;
the destruction has endangered all resources and infrastructures in the country affecting
family life, individual well-being, and social welfare; the unemployment rate has
increased from 15 percent in 2010 to 28 percent in 2014, and is expected to reach
about 50 percent at the end of this year; half of Syria’s children have dropped out of
school or never had any academic training at all, due to the collapse of the schools and
educational systems; 60 out of 90 public hospitals are damaged or malfunctioning and
about 40 hospitals are completely out of service; most people remaining inside Syria are
forced to live under some kind of security siege, social alienation, internal subordination,
or terrible estrangement; 90 percent of the displaced and refugees actually remain in
the Middle East (Lebanon, Turkey, Jordan, Iraq, Egypt, Iran, Gulf area, etc.), and 10
percent only are trying to migrate to other continents, mostly Western Europe. Finally,
Syrians now constitute the single largest migrant, displaced, or transplant population
and humanitarian crisis in the world. More than half of these refugees are children and
teenagers.
Mental-Emotional Agonies
Among Syrians today, few have escaped the effects of the tragic events or war
insecurities. Symptoms of acute stress and psychological disturbances are elevated
among survivors of all groups and ages, each one exhibiting psycho-emotional troubles
in their own way (Alpak et al., 2015; Hassan et al., 2016; James et al., 2014; Quosh,
Eloul, & Ajlani, 2013).
Unfortunately, the most difficult type of stress is the one that is inherently prolonged in
nature. Many sociopolitical observers predict that the Syrian armed conflict and multiple-
militia fighting will continue to drag on in the country for a long time (Carpenter, 2013;
Laub & Masters, 2013). Sadly, there is no global or regional political will to end the
disaster… and even if there is a clear resolve, there is no simple solution available at
the moment for this enormous crisis (Abi-Hashem, 2006, 2016a; Hobfoll et al., 1991;
WHO, 2017).
Besides the major disorientation and disillusionment many people experienced, those
who were directly exposed to war atrocities were affected the most. The more severe
the traumas, the more serious were the symptoms, at least at first. Thus, the degree of
114
impact depended on the degree of exposure. Most people neither had words to
describe their agonies nor were aware of their serious psychological conditions. Right
after evacuation, most individuals and families began to display symptoms and shared
their internal suffering. Here is a sample of such cases and statements (James et al.,
2014; News, 2016; Personal communication, 2016; UNHCR, 2015a, 2015b; Ward,
2016; WHO, 2017): a young girl looking weak and pale, keeps hiding, barely talking or
smiling, and is regularly withdrawn; a mother, exhausted and depressed, easily cries
with anguish every time there is a mention of her previous life and present refugee
status; an elderly man cannot stop thinking of his home, garden, and neighborhood,
memories that plunge him into unspeakable sadness; a …
Behaviour Research and Therapy 41 (2003) 755–776
www.elsevier.com/locate/brat
Assessment of psychopathology across and within cultures:
issues and findings
Juris G. Dragunsa,∗, Junko Tanaka-Matsumib
a Department of Psychology, The Pennsylvania State University, 410 Moore Building, University Park, PA 16802,
USA
b Department of Psychology, Kwansei Gakuin University, 1-155 Ichibancho, Uegahara, Nishinomiya-City, 662-8501
Japan
Accepted 30 November 2001
Abstract
Research based information on the impact of culture on psychopathology is reviewed, with particular
reference to depression, somatization, schizophrenia, anxiety, and dissociation. A number of worldwide
constants in the incidence and mode of expression of psychological disorders are identified, especially in
relation to schizophrenia and depression. The scope of variation of psychopathological manifestations across
cultures is impressive. Two tasks for future investigations involve the determination of the generic relation-
ship between psychological disturbance and culture and the specification of links between cultural character-
istics and psychopathology. To this end, hypotheses are advanced pertaining to the cultural dimensions
investigated by Hofstede and their possible reflection in psychiatric symptomatology. It is concluded that
the interrelationship of culture and psychopathology should be studied in context and that observer, insti-
tution, and community variables should be investigated together with the person’s experience of distress
and disability.
2003 Elsevier Science Ltd. All rights reserved.
Keywords: Psychopathology; Culture; Symptoms; Cross-cultural; Adaptation
1. Introduction
Over the last two decades, culture’s interplay with human behavior and experience has moved
from periphery toward the center among the concerns of contemporary psychology. Psychopath-
∗ Corresponding author. Tel.:+1-(814)-863-1735; fax:+1-(814)-863-7002.
E-mail address: [email protected] (J.G. Draguns).
0005-7967/03/$ – see front matter 2003 Elsevier Science Ltd. All rights reserved.
doi:10.1016/S0005-7967(02)00190-0
756 J.G. Draguns, J. Tanaka-Matsumi / Behaviour Research and Therapy 41 (2003) 755–776
ology has not been exempt from this trend. Against this background, we shall endeavor to provide
a concentrated survey of the current state of conceptualization and knowledge in this area of
inquiry. Cultural influences will be examined in their dual manifestations, across regions and
boundaries around the world and within the ethnoculturally diverse milieus of many contemporary
nation states. Accumulated findings will be reviewed, unsolved problems identified, and rec-
ommendations for future research and clinical practice formulated. To this end, we embark upon
a consideration of the contrasting perspectives that have served as points of departure for the
investigation of culture and abnormal behavior.
1.1. Culturalist and universalist orientations and their prospective integration
Herskovits (1949) equated culture with the part of the environment that was created by human
beings. Marsella (1988, pp. 8–9) provided a more elaborate, psychologically oriented, description
of the attributes of culture as follows:
Shared learned behavior which is transmitted from one generation to another for purposes of
individual and societal growth, adjustment, and adaptation: culture is represented externally as
artifacts, roles, and institutions, and it is represented internally as values, beliefs, attitudes,
epistemology, consciousness, and biological functioning.
This conception overlaps with that of subjective culture as formulated by Triandis (1972).
How culture impinges upon and penetrates manifestations of psychological disturbance has
been studied from two contrasting points of view. Universalists have focused upon differences in
degree and number in preexisting, presumably worldwide, dimensions and categories. Relativists
have been impressed with the scope of cultural variation and with the interpenetration of culture
and psychopathology. Consequently, they have emphasized the uniqueness of phenomena within
any given culture and the need to study them on their own terms.
Emil Kraepelin (1904) is usually considered the originator of the universalistic comparison of
psychological entities. Specifically, he initiated the observation of the manifestations and incidence
of depression in Java. Moreoever, in a remarkably perceptive and prescient statement he antici-
pated the major tasks and issues of cross-cultural or comparative study of psychopathology:
If the characteristics of a people are manifested in its religion and its customs, in its intellectual
artistic achievements, in its political acts and its historical development, then they will also
find expression in the frequency and clinical formation of its mental disorders, especially those
that emerge from internal conditions. Just as the knowledge of morbid psychic phenomena has
opened up for us deep insights into the working of our psychic life, so we may also hope that
the psychiatric characteristics of a people can further our understanding of its entire psychic
character. In this sense comparative psychiatry may be destined to one day become an important
auxiliary science to comparative ethnopsychology (Ṽölkerpsychologie), (as quoted by Jilek,
1995, p. 231).
A more outspoken, radically relativistic, point of view upon psychopathology has been pro-
pounded by Benedict (1934); Devereux (1961); Nathan (1994); and Nathan and Hounkpatin
757J.G. Draguns, J. Tanaka-Matsumi / Behaviour Research and Therapy 41 (2003) 755–776
(1998), among others. These researchers prefer to observe psychological disorders within their
respective cultural context and tend to eschew or de-emphasize comparative investigations,
especially those of isolated aspects of psychopathology torn out of the matrix of their occurrence.
They warn against purportedly universal explanations and are reluctant to impose imported exter-
nal frameworks.
The universalistic and relativistic positions show overlap with the etic and emic orientations,
which focus upon the origins of the concepts to be investigated. The emic point of view capitalizes
upon notions and labels derived from the experience within a culture. Etically oriented theor-
eticians and researchers concentrate their efforts upon the purportedly universal rubrics and conti-
nua of experience. Thus, the study of the consequences of parental rejection around the world
(Rohner, 1986) is an eminently etic undertaking while the description of the uniquely Japanese
pattern of lifelong dependence or amae (Doi, 1973) exemplifies an emic inquiry. An etic orien-
tation, however, can also be applied to disentangling relationships within a culture. In Japan, for
example, Kurabayashi (2001) has explored the culturally characteristic interplay of work related
stress, depression, and suicide—three variables that tend toward universality. Culture-bound or
emic disorders are typically studied at their respective cultural sites and are rarely subjected to
quantification. However, in Southern China Tseng, Mo, Hsu, Li, Ou, Chen and Jiang (1988)
conducted an epidemiological study during an outbreak of koro, an anxiety syndrome over imagin-
ary penis shrinkage. This project was followed up by the collection of biographical and psycho-
metric data, couched entirely in etic terms (Tseng, Mo, Hsu, Li, Chen, Ou, & Zheng, 1992). These
admittedly atypical and innovative studies illustrate the potential of combining emic concepts with
an etic modus operandi. Switching from one perspective to the other is not only possible but
salutary and enriching. Integrative sources on psychopathology across cultures (e.g., Pfeiffer,
1994; Tseng, 2001) blend and incorporate information from these seemingly opposed, but actually
complementary, outlooks. In an ongoing project in France and at four Francophone sites in the
Indian Ocean: Madagascar, Mauritius, Comorro Islands, and Reunion, Roelandt (2001) is simul-
taneously pursuing universalistic and relativistic objectives by investigating the cultural concep-
tions of depression, mental illness, and madness and by recording the prevalence of mental dis-
order. In Table 1, the characteristics of the emic and etic approaches are schematically presented
and then integrated within a more comprehensive framework in both gathering data on cultural
groups and in the assessment of individuals.
2. Psychiatric diagnoses in a global perspective: etic positions, emic critiques, and
integrative reformulations
2.1. US–UK diagnostic project
Although observations on psychopathology in various parts of the world had been gradually
accumulating beginning with Kraepelin’s (1904) seminal account, and even some systematic data
had been collected, the US–UK Diagnostic Project (Cooper et al., 1972) can be considered as a
harbinger of modern cross-cultural research on psychopathology. In the three phases of this inves-
tigation, Cooper et al. first confirmed the previously reported striking disparity in the distribution
of psychiatric diagnoses in London and New York. Specifically, schizophrenia was found to be
758 J.G. Draguns, J. Tanaka-Matsumi / Behaviour Research and Therapy 41 (2003) 755–776
Table 1
Culture research and assessment in psychopathology: Options and integration
Orientations
Emic: Etic:
Idiographic Nomothetic
Uniqueness and Sensitivity Objectivity and Comparability
Objective
Description Comparison
Types of Studies
Anthropological Descriptions Multicultural Comparisons, e.g. WHO Studies
Indigenous Concepts and Explanations Epidemiological Research
Culture-Bound Syndromes Archival Studies
Native Healers Bicultural Comparisons
Relationships Within Culture Traditional Transcultural
Case Studies Within a Cultural Framework Studies of Incidence and Expression of Schizophrenia, Depression, etc.
Phenomenological Studies Resulting Information and Knowledge
much more frequently diagnosed in New York than in London. Conversely, initial diagnoses of
depression were a lot more prevalent for patients in London than in New York. In the second
phase of the study, Cooper et al. discovered that these diagnostic differences disappeared when
patients were diagnosed on the basis of World Health Organization’s (WHO) standardized diag-
nostic system (ICD-8). In the final phase of the project, American and British psychiatrists were
found to apply different diagnostic criteria to videotaped interviews of psychiatric patients some
of whom were British and some American. Cross-national agreement was substantial for typical,
‘ textbook’ cases. In the more frequent instances where mixed symptom pictures were presented,
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Americans opted for schizophrenia and Britons, for affective disorder. These results conformed
to the then emerging model (Draguns, 1973) which recognized that not only patients, but mental
health professionals and community as well as institutional settings, may contribute to differences
across cultures. Westermeyer (1987) proposed that a complex socio-cultural process was involved
in identifying, describing, labeling, and intervening in cases of behavioral or mental deviance.
Kleinman, 1978, 1991) advocated a shift from an exclusive preoccupation with the patient’s symp-
toms and syndromes to a more comprehensive view of the context in which the disturbance
occurred. Such contexts include the family, the community, and the institution with their norms
and values (Tanaka-Matsumi & Higginbotham, 1996; Tanaka-Matsumi, Seiden, & Lam, 1996).
These developments sparked two divergent, etic and emic, trends. From the etic perspective,
validation of cross-culturally usable diagnostic scales was powerfully stimulated. At the same
time, from the emic point of view, the uniqueness of each culture was increasingly recognized
and the futility of cross-cultural comparisons conceded. By now, standardized diagnostic instru-
ments exist for every major psychiatric disorder (Sartorius & Janca, 1996). The advent of these
measures has brought new problems with it. In particular, culturally distinctive factors have often
gone unnoticed and culturally relevant hypotheses have not been formulated or tested
(Betancourt & López, 1993; Canino, Lewis-Fernandez, & Bravo, 1997). From a contextual per-
spective, Kleinman (1977, p.4) pointed out that the traditional diagnostic categories are embedded
in of the culturally bound Euro-American psychiatric conceptualization and practice. The cross-
cultural applicability of the current American diagnostic system (DSM-IV) remains to be tested
(Thakker & Ward, 1998). Draguns (1980) identified three complicating factors in specifying which
features of psychopathology were universal and which were particular to distinct cultures: (1) the
application of the Kraepelinian diagnostic categories throughout the world; (2) the construction
of psychiatric institutions in various regions imitating their Western prototypes, and (3) the imi-
tation, to an as yet unknown degree, of Western symptoms in cultures undergoing modernization.
In an attempt to divest themselves of the obtrusive features of the Western categories and the
framework within which they are embedded, proponents of the more relativistic “new transcultural
psychiatry” (e.g., Kleinman & Good, 1985a) have concentrated their research efforts on cultural
interpretations of depression, cultural idioms of distress, and contextual descriptions of culture-
bound disorders.
2.2. Assessment within and across cultures: the observer’s contribution
Regardless of the diagnostician’s or interviewer’s orientation, the process of gathering infor-
mation about another individual involves a transaction during which personal information is com-
municated through a variety of channels. Such communication is greatly complicated when it
occurs across cultural barriers and screens. In an early report, Cheetham and Griffiths (1981)
documented a high proportion of diagnostic errors that occurred in interviewing African and
Indian patients in South Africa, traceable to the misinterpretation of their presenting symptoms.
Thus, affect was judged to be inappropriate on the basis of cultural misunderstandings and cul-
turally shared and sanctioned beliefs were deemed diagnostically significant. Among the Amish
in Pennsylvania, American psychiatrists were found to exhibit a predilection for diagnosing
schizophrenia (Egeland, Hostetter, & Eshleman, 1983). Upon the institution of uniform and objec-
tive diagnostic procedure, most of these diagnoses were changed to bipolar mood disorder. These
760 J.G. Draguns, J. Tanaka-Matsumi / Behaviour Research and Therapy 41 (2003) 755–776
findings should alert diagnosticians to two dangers. The first of these involves equating deviance
with disturbance (American Psychiatric Association, 1994; Draguns, 1990). The second danger
is more complex and subtle. Draguns (1973, 1990, 1996) and Tanaka-Matsumi (1992) have pro-
posed an inverse relationship between cultural or social distance and empathy. The more a per-
son’s cultural background is unfamiliar and baffling, the more difficult it is to experience
empathically. In the absence of personal contact and factual information, stereotypes tend to be
invoked. As a result, quantitative differences tend to be converted into qualitative distinctions,
overlap between groups is disregarded, and the complexities of trait distribution within a group
are overlooked. Thus, stereotypes stand in the way of recognizing a person’s individuality and
of being able to share his or her perspective and affect. As Ridley (1989) has cautioned, stereotyp-
ing is not limited to prejudiced individuals. López (1989) concluded that errors in assessment
stem more typically from selective information processing than from prejudicial and rejecting
attitudes. Therefore, such errors should be more readily amenable to modification through cogni-
tive techniques. In López’s view, biases toward underdiagnosing or overdiagnosing a disorder in
a cultural group may reflect diagnosticians’ implicit baselines for psychopathological entities in
various populations. Moreover, as Adebimpe (1981) suggested, such baselines may be influenced
by the clinicians’ normative judgments. Standardized project diagnoses counteract such errors and
increase precision. However, as Kleinman (1988) has indicated, such procedures tend not to do
justice to diagnostically atypical cases, which may be especially revealing and indicative from
the cultural point of view.
2.3. Innovations and advances in epidemiological research
Epidemiology is a branch of medicine that studies the distribution of diseases in designated
populations and/or specified territories. Progress in epidemiological research on mental disorders
has been greatly facilitated by the standardization of diagnostic and other assessment procedures.
As a result, epidemiological information has been gathered on the incidence and prevalence of
psychopathological categories within the major ethnic components of the United States population.
Epidemiological data have also been collected and compared across nations.
The Epidemiological Catchment Area Study (ECA), conducted at five urban centers in the
United States, relied upon the Diagnostic Interview Schedule for case identification (Escobar,
Karno, Burnam, Hough, & Golding, 1988; Robins & Regier, 1991). In Los Angeles, there was
only a small number of diagnostic differences across ethnocultural lines. Among Mexican Amer-
icans, prevalence for most diagnostic categories was lower by comparison with the US born
segment of the population (Escobar, Karno, Burnam, Hough & Golding, 1988). These differences
shrank or disappeared when Mexican Americans who were born in the United States were com-
pared with “Anglos” (Robins & Regier, 1991). These findings highlight the complex and inter-
active nature of epidemiological differences, the extent of overlap between the ethnocultural
groups compared, and the vulnerabilities of specific segments of the American population defined
on the basis of gender, age, and ethnicity. They also suggest the variability of such differences
across settings and time. Thus, the complex pattern of the findings obtained in ECA is not identical
with the array of results from the more recent National Comorbidity Survey (Kessler et al., 1994).
If epidemiological research has not yet brought forth definitive results pertaining to ethnic differ-
ences in the major components of psychopathology, it has called into question premature and
761J.G. Draguns, J. Tanaka-Matsumi / Behaviour Research and Therapy 41 (2003) 755–776
hasty assertions about such findings. Thus, Neal and Turner (1991) found that the conclusions
about the allegedly elevated levels of anxiety disorders among African Americans were unwar-
ranted. Again, a more promising undertaking is to look for pertinent findings in specific portions
of the African American population which may be susceptible to certain anxiety related symptoms
or syndromes (cf. Draguns, 2000). In Taiwan, Rin and Lin (1962) conducted a comparison of
prevalence of various mental disorders among the majority Chinese and the minority Taiwan
aboriginals. Differences emerged, with organic psychoses, epilepsy and alcoholism being higher
among the aborigines and schizophrenia and neuroses, among the Chinese. These discrepancies,
however, were traced to economic conditions rather than to intrinsic cultural characteristics.
Until recently, the comparison of epidemiological data on psychopathology across nations
appeared utopian. With the advent of standardized instruments and procedures, this objective is
beginning to be realized. This advance is exemplified by Hwu and Comptom (1994) who com-
pared the results of major epidemiological surveys completed in mainland United States, Puerto
Rico, Canada, Korea, Taiwan, and New Zealand. They found lower lifetime prevalence rates for
most disorders in Taiwan and Korea than in Canada, Puerto Rico, and New Zealand. An even
more ambitious task was undertaken by Weissman et al. (1996) who investigated the rates of
various depressive disorders in ten nations. Rates of bipolar mood disorder were much less vari-
able across nations, and insomnia and lack of appetite were found to be prominent and prevalent
symptoms of depression at all research sites. There were also ample differences in rates of
depression some of which Weissman et al. found puzzling, such as major discrepancies between
seemingly similar urban centers in the United States and Canada and between Korea and Taiwan
while major depression was virtually unaffected by such prolonged and intense stresses as the
civil war in Lebanon. These findings suggest the magnitude of the as yet unmet challenges in
comparative epidemiological research, even with validated and appropriate interview schedules.
While epidemiological investigations beyond national borders constitute a methodological break-
through, obtaining interpretable, definitive, and stable data from such studies remains an
ambitious objective.
3. Specific mental disorders: the accumulated findings
3.1. Depression
Depression occurs in widely different cultural contexts, yet is exceedingly difficult to reduce
to its fundamental and presumably culturally invariant features. This state of affairs has hampered
cross-cultural investigation; thorny conceptual and definitional issues have not been resolved
(Fabrega, 1974; Marsella, 1980). Marsella (1980) concluded that no universal conception of
depression exists but added that “even among those cultures not having conceptually equivalent
terms, it is sometimes possible to find variants of depressive disorders similar to those found in
Western cultures.” (p. 274). In numerous languages, there is no adequate dictionary equivalent
for depression (Marsella, 1980). Even if there is a term for depression, a high proportion of the
population may be unfamiliar with it, as is the case in Madagascar (Roelandt, 2001). Moreover,
cultures have been found to be different in the connotative meaning evoked by depression-related
experiences and the labels for them (Tanaka-Matsumi & Marsella, 1976).
762 J.G. Draguns, J. Tanaka-Matsumi / Behaviour Research and Therapy 41 (2003) 755–776
Criteria of depression have also shifted with the changes in the historical and political context.
Thus, during the colonial era in Africa, reports abounded of the rarity of depressive manifestations
south of the Sahara. Prince (1968) addressed the issue of the changes in the picture of depressive
manifestations and syndromes upon the advent of independence and traced the substantial increase
in reported depression to the increased prestige assigned to depressive experiences, the inclusion
of indirect and masked depressive symptoms, the shift from the institutional to community settings
of observations, and the actual increase of incidence due to westernization. Going beyond Prince’s
cautious conclusions, it would appear that the broadening of conceptions of depression and
extending the search for cases outside of closed milieus are the most plausible factors in the short
run; the effect of prestige and modernization is worth investigating over a longer period of time.
Both national and international research on the epidemiology of depression has been stymied
by the difficulty of establishing stable and general diagnostic criteria (Marsella, Sartorius, Jablen-
sky & Fenton, 1985). Thus, the differences in lifetime prevalence rates between Seoul, Korea and
Christchurch, New Zealand, appear dramatic, even with the standardized Diagnostic Interview
Schedule (Hwu & Comptom, 1994). However, they are paralleled by such discrepancies within
the same country, such as those between the ECA study (Robins & Regier, 1991) and the National
Comorbodity Survey (Kessler et al., 1994) in the United States.
WHO (1983) sponsored a prototypically etic study on the symptomatology of depression in
Canada, Iran, Japan, and Switzerland by means of the Schedule for Standardized Assessment of
Depressive Disorders. More than 76% of depressed patients reported a common pattern of depress-
ive symptoms that included sadness, absence of joy or pleasure, lowered pleasure, reduced concen-
tration, lack of energy, and a sense of inadequacy. Suicidal ideation was acknowledged in 59%
of cases.
Beyond these widely shared components of depressive experience, sense of guilt has emerged
as a source of cultural variation. Reports from Africa (Sow, 1980), India (Rao, 1973), Indonesia
(Pfeiffer, 1994), Japan (Kimura, l995), and China (Yap, 1971) converge in suggesting that guilt
feelings are less prominently featured among the subjective symptoms of depression. Moreover,
when guilt is experienced it is conceptualized and communicated differently than in Europe or
America. Murphy (1978) traced the prominence of guilt feelings in depression to the advent of
individualism during the Renaissance, Reformation, and Enlightenment. In Japan, guilt feelings
are more likely to be triggered by having violated personal obligations than by having transgressed
against abstract and absolute principles (Kimura, 1995). Among African people, spontaneous
reports of guilt are rare as a result of attributions of exogenous persecution (Sow, 1980).
In addition to etic comparisons of depression in incidence or symptomatology, search for emic
conceptions of depression has been pursued. Manson, Shore and Bloom (1985) developed the
American Indian Depression Scale on the basis of indigenous words and concepts used to describe
depression. In this manner, five Hopi illness categories were identified that were labeled respect-
ively as worry sickness, unhappiness, heartbroken, drunken-like craziness, and disappointment.
Unhappiness was closely related to dysphoric mood in DSM while being heartbroken encom-
passed the core syndrome of depression exemplified by loss of sleep, motor retardation, fatigue,
decline of interest in sexuality, and various aspects of self-rejection.
According to Abe (1996, 2001), who compared depressed patients in Japan and Spain, cata-
strophic delusions overshadow delusions of guilt among Japanese depressives. The premorbid
personality of depressive patients shows similarity to the typus homo melancholicus, identified
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by Tellenbach (1976) in Germany. In Japan, as well as in Germany, depression prone individuals
tend to be scrupulous, orderly, thrifty, and hardworking. In Japan, this personality constellation
is imbued by Confucian values which emphasize maintenance of sameness, preservation of group
harmony, and an equilibrium between the person and society.
Räder, Krampen, and Sultan (1990) found that external locus of control was more prevalent
among depressed patients in Egypt than in Germany. Moreover, these findings paralleled differ-
ences between normal Germans and Egyptians. This finding was extended in a triple comparison
of Afghan, Egyptian, and German patients. It is worth noting that Afghan and Egyptian responses
were similar and stood in contrast to the German findings (Shakoor, 1992).
In Sweden Perris (1988) has reopened the issue of the recall of childhood rejection and depri-
vation as an antecedent of depression in adulthood. In a series of multinational studies, he has
been able to demonstrate the cross-cultural robustness of the relationship between depression and
current recollections of lack of parental warmth. Less clear is the pattern of any cross-cultural
differentiation in this respect, and the link between familial and more broadly cultural context
and susceptibility to depression remains a promising subject for future investigation.
3.2. Somatization in depression and in other disorders
Bodily distress in the form of general malaise, sometimes equated with neurasthenia, shows a
great deal of overlap with the experience of various depressive states. This is also true of the
more specific states of somatic dysfunction and discomfort limited to or focused upon an organ
or a system. Moreover, pain and distress may function as avenues of communicating and experi-
encing dysphoria in various cultures, and there may be cultural differences in the prominence
accorded to somatization.
Kleinman (1982) and Kleinman and Kleinman (1985) investigated neurasthenia or shenjing
shuaiuro in Hunan, China. With the Chinese language version of the Schedule of Affective Dis-
orders and Schizophrenia, Kleinman found that 87 out of 100 patients met the DSM-III criteria for
major depression and six more exhibited other depressive disorders. On specific inquiry, Chinese
neurasthenic patients acknowledged dysphoric mood, anhedonia, trouble concentrating, hope-
lessness, and low self esteem. However, more recent findings (e.g., Zhang, 1989; Lee & Wong,
1995) point to a mixture of anxiety related and depressive symptoms in shenjing shuaiuro and
hold open the possibility of a shift toward a more psychological construal of this syndrome in
younger and more urbanized samples. Moreover, the disparity between the somatic symptoms
reported spontaneously and the expressions of psychological distress elicited on inquiry opens the
possibility of distortion by means of imported scales and externally imposed criteria. Traditionally,
in China psychological symptoms were not …
