Psychological Disorders

 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: wei-chin.hwang@claremontmckenna.edu (W.-C. Hwang).

0272-7358/$ – see front matter © 2007 Elsevier Ltd. All rights reserved.
doi:10.1016/j.cpr.2007.05.001

mailto:wei-chin.hwang@claremontmckenna.edu

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

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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 a spiritual possession type culture-bound syndrome have been reported
(Grisaru, Budowski, & Witztum, 1997). In Western Africa and different parts of Asia, similar but qualitatively distinct

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small-scale epidemics of genital shrinking distress have also been reported (Dzokoto & Adams, 2005). There is clearly
a link between culture and the development, expression, and definition of psychiatric disorders. Because of the link
between Westernization and increasing rates of eating disorders across the world, some have also begun to question
whether commonly accepted psychiatric disorders which were believed to be culture-universal, such as anorexia
nervosa and bulimia, are actually western culture-bound syndromes (Banks, 1992; Keel & Klump, 2003).

1.3. Expression of distress, diagnostic accuracy, and the prevalence of illness

The ability to accurately identify and classify illness is an essential part of providing quality health care (Corey,
Corey, & Callahan, 1993). Accurate diagnoses help practitioners properly identify the problem, prescribe an
appropriate treatment, and understand the etiology, course, and prognosis of the illness. Moreover, the ability to
accurately diagnose a problem helps us determine the prevalence of different illnesses and assess the public health
needs of different populations. Diagnostic and assessment practices can be especially challenging because of cultural
differences in the manifestation, presentation, and concealment of problems (Pathway I). As a result, current diagnostic
systems, which are based on Western conceptualizations of mental illness, may be less accurate in diagnosing those
from different cultural backgrounds. In fact, there is much literature documenting the fact that ethnic minorities are
more likely to be misdiagnosed than Whites (Fernando, 2005; Smedly et al., 2003; USDHHS, 2001).

Differences in expression influence diagnostic accuracy and ultimately impact our ability to assess the prevalence
and rate of psychiatric disorders across different groups as illustrated by Pathway L. Ability to differentially diagnose
patient problems is necessary for accurate referral and treatment. In order to develop accurate assessment instruments,
Marsella, Kaplan, & Suarez (2002) recommends the following considerations: (a) appropriate items and questions,
including the use of idioms of distress; (b) opportunities to index frequency, severity, and duration of symptoms since
groups vary in their reporting within certain modes; (c) establishment of culturally relevant baselines in symptom
parameters; (d) sensitivity to the mode and context of response (i.e., self-report, interview, translation issues);
(e) awareness of normal behavior patterns; and (f) symptom scales should be normed and factor-analyzed for specific
cultural groups. In addition to having accurate assessment instruments, clinicians need to be culturally competent and
aware so that diagnostic errors can be reduced.

Accurate clinical diagnoses are essential to providing appropriate and equitable services for all patients. Inaccurate
diagnosis severely impairs our ability to properly assess the prevalence of problems in different communities, which in
turn, impacts our understanding of the immediacy of the problem and our ability to respond with policy efforts
(Pathway K). For example, epidemiological studies assessing the rates of depression among Chinese and Chinese
Americans have found lower rates of depression than the general U.S. population (Chen et al., 1993; Hwu, Yeh, &
Chang, 1989; Takeuchi et al., 1998; Yeh, Hwu, & Lin, 1995). However, community-based studies of Asian Americans
have found higher rates of depressive symptoms among Asian Americans than White Americans (Abe & Zane, 1990;
Kuo, 1984; Okazaki, 1997; Sue & Sue, 1987a). Is this because Asians Americans are truly less depressed, or is it
because they exhibit a narrower range of symptoms, and consequently do not meet the five out of nine symptoms
required to qualify for a diagnosis? If they only meet three or four of the five symptoms required, but evidence similar
or greater severity in those symptoms or evidence equal or greater functional disability, should they not meet criteria for
depression? Is this discrepancy due to methodological and/or reporting biases where some ethnic minorities may be
less likely to reveal psychiatric difficulties to interviewers whom they do not personally know, but are willing to
endorse experiencing a problem on a symptom checklist? Should an individual who evidences additional other
symptoms be given a diagnosis of depression if these symptoms are not included in the DSM or ICD, but are indicative
of cultural manifestations of depression (e.g., somatic difficulties)? Should an individual be given a diagnosis of major
depression if they do not meet diagnostic criteria, but do meet criteria for a depressive culture-bound syndrome such as
neurasthenia? Because health care insurance does not pay for services unless a diagnosis is provided, should
individuals who evidence considerable illness burden but do not meet Western criteria for depression be excluded from
coverage? These and other culture-related questions need to be answered if we are to provide appropriate care. If left
unattended, biases in diagnostic practices may lead to inaccurate assumptions about how prevalent problems are in
minority communities, and inappropriately influences funding and policy decisions, resulting in deficiencies in the
type, quality, and amount of treatments provided (Pathways K and L).

When diagnosing those from different cultural backgrounds, practitioners must also be knowledgeable enough to
understand whether symptoms and behaviors are culturally normative. For example, Egeland, Hostetter, and Eshleman

218 W.-C. Hwang et al. / Clinical Psychology Review 28 (2008) 211–227

(1983) pointed out that an insufficient understanding of Amish cultural values and norms can easily lead to
misdiagnosis of bipolar illness. They pointed out examples of what would be considered to be normative behaviors by
mainstream White standards would meet manic criteria for grandiosity, excessive involvement, and reckless behavior
in Amish culture (e.g., driving a car, using machinery, dressing in nontraditional clothes, flirting with a married woman,
smoking, taking vacations off season, and excessive telephone usage).

In addition, it is also important to understand within-group differences in psychiatric risk. For example, Brown,
Ahmed, Gary, and Milburn (1995) found a significant within-group age effect indicating that African Americans
between the ages of 20–29 and over age 65 evidenced the highest risk for major depression than those in their middle
adulthood. In examining gender differences, the National Comorbidity Survey found that African American women
between the ages of 35 to 44 were at particularly high risk for becoming depressed (Blazer, Kessler, McGonagle, &
Swartz., 1994). Among Chinese Americans, elderly Chinese American women have been found to have the highest
rates of suicide when compared to other groups (Yamamoto et al., 1997; Yu, 1986). Unfortunately, some ethnic groups
such as Native Americans have been subject to the cumulative effects of devastating experiences, and as a result
evidence more illness burden as a whole than White Americans (Robins, Chester, & Goldman, 1996).

1.4. Culture, expression of distress, and help-seeking

In raising the issue of culture, illness, and care, Kleinman (1978) introduced the notion of the explanatory model of
illness. He proposed that how a patient understands and experiences an illness is embedded within a social context. As a
result, those from different cultural backgrounds may experience and interpret their illnesses differently, as well as affix
different labels to their sickness (Kleinman, 1978, 1988). These labels serve to prescribe a socially sanctioned sick role
that can potentially minimize the social consequence and the amount of stigma experienced by those who are ill.
Explanatory models may also impact the manner in which distress is expressed and experienced, and play a role in
identifying what types of expression are more culturally normative. When both the practitioner and client are from the
same cultural system, it is more likely that they will have matching explanatory models which reinforce socially
constituted “clinical realities” (Kleinman, 1978). However, when the patient and clinician’s explanatory models do not
match, the cultural and clinical realities of what is perceived to be wrong, what caused the problem, and what type of
treatment is most appropriate may conflict and lead to misdiagnosis, greater disbelief in the service provided, treatment
dissatisfaction, noncompliance, and less than optimal outcomes.

Cultural meanings of illness are likely to influence the manner in which distress is expressed (Pathway D). The
manner in which one experiences his/her illness and expresses his/her distress is embedded in a larger cultural milieu,
and ultimately affects the who, why, when, how, and if people seek help and cope with problems as illustrated in
Pathway E. Those who believe his/her problem is psychological might seek help from a psychologist, while those who
believe his/her problems are somatic, and because there is a large amount of stigma associated with mental illness in
many cultures, may choose to seek help from a primary care physician (Hwang et al., 2006). There is some research to
suggest that ethnic minorities may be more likely to seek psychiatric help from their primary care physician than mental
health practitioners, but that primary care doctors are at greater risk for not detecting mental health problems among
various ethnic minority groups (Borowsky et al., 2000).

For many ethnic minorities, an additional choice has to be made, whether to seek help from a formal source (e.g.,
psychiatrist or physician), or whether to explore more indigenous or informal sources of treatment that they may be
more familiar with, have greater access to, and have more confidence in (e.g., TCM, herbal treatment, or religious
prayer). Research examining alternative services have found that even though use of alternative therapies are popular
among U.S. citizens in general (Eisenberg et al., 1998), ethnic minority groups may be more likely to turn to indigenous
or complementary treatments for physical and mental health care (Barnes, Powell-Griner, McFann, & Nahin, 2004;
Becerra & Inlehart, 1995; Koss-Chioino, 2000).

The relation between cultural beliefs about the causes of illness and where one seeks helps also needs to be further
researched. There is a growing body of research confirming that non-White groups hold different beliefs about the
causes of their illness than Whites. For example when explaining why they developed schizophrenia, Bangladeshis and
African-Caribbeans living in the U.K. are more likely to cite supernatural causes than Whites who more frequently cite
biological reasons (McCabe & Priebe, 2004). Different beliefs about the causes of one’s illness may result in
differential usage of coping methods to deal with one’s problems. For example, depressed Chinese Americans seeking
health in primary care rarely reported depressed mood spontaneously and only 10% of patients labeled their illness as a

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psychiatric condition and 3.5% sought care from a mental health professional for their depression (Yeung, Chang,
Gresham, Nierenberg, & Fava, 2004). Most of the patients sought help from primary care, lay help, and used alternative
treatments.

Religion may also act as a powerful coping resource for all groups (George, Larson, Koenig, McCullough, 2000),
there is some evidence to suggest that marginalized ethnic minorities such as African Americans may engage in more
religious coping to deal with adversity than White Americans (Conway, 1985), and that they report having greater
satisfaction with their religious coping efforts and feel more connected to God (McAuley, Pecchioni, Grant, 2000;
Myers & Hwang, 2004). Better integration of indigenous and alternative health care services (e.g., herbal medicine,
prayer, and TCM) may help facilitate the patient’s “buy-in” to therapy because it establishes a cultural bridge that links
the patient’s cultural beliefs to the treatment.

Currently, most people suffering from a mental illness do not receive treatment (USDHHS, 1999). Ethnic minorities
are also less likely to have access to and use mental health service than Whites, with many groups evidencing delayed
help-seeking (Cheung & Snowden, 1990; Robins & Regier, 1991; Snowden & Cheung, 1990; Swartz et al., 1998;
Sussman, Robin, Earls 1987). The underutilization of mental health services by minorities is likely the result of a
combination of culture-related and economic barriers, such as lack of insurance and greater poverty in many minority
communities (USDHHS, 2001). For example, African Americans, Native Americans, Latino Americans, and some
Asian American groups have a much higher rate of poverty and are less likely to be insured than White Americans
(Proctor & Dalaker, 2003; Brown, Ojeda, Wyn & Levan, 2000). Lack of insurance and financial barriers have been
found to be related to decreased help-seeking rates among ethnic minorities (Abe-Kim, Takeuchi, & Hwang, 2002;
Chin, Takeuchi, & Suh, 2000). However, even when health insurance plans do cover mental health services or when
sociodemographic and need variables are controlled, it does not seem to increase treatment seeking as much for ethnic
minorities as for Whites (Padgett, Struening, Andrew, Pittman, 1995; Swartz et al., 1998), indicating that financial
barriers are not sufficient explanations of why ethnic minorities utilize mental health services at a lower rate.

Not enough research has been conducted on stigma, which is one of the most formidable obstacles to making mental
health services available and accessible to the general public (USDHHS, 1999). Stigma towards mental illnesses is a
worldwide phenomenon and operates by motivating the general public to reject, avoid, fear, and discriminate against
those with mental illness (Corrigan, 2004). As a result, those with mental illness become ashamed, conceal their
problems, and delay or do not seek help due to fear of being stigmatized and negatively labeled. Unfortunately, there is
little comparative research examining the prevalence of mental illness stigma among different ethnic groups. However,
many people believe that stigma operates more severely among non-White communities, and has a more detrimental
impact on help-seeking behavior for a number of reasons, including ethnic communities being less educated about
mental health issues or where to seek treatment, cultural incongruity between cultural beliefs and Western psychiatric
services, decreased confidence in the treatments available, and collectivistic cultural orientation which places greater
importance on social appearances (Ng, 1997; Uba, 1994). For example, Ng (1997) pointed out that stigma is such a
powerful factor in Asian cultures that it not only reflects badly on the one who is ill, but it also diminishes the economic
and marriage value for that person as well as his/her family. Because strong stigma towards mental illness is often
equated with being “crazy” or “weak” in many ethnic minorities, community interventions that focus on public health
education and decreasing stigma in community and clinical populations are sorely needed.

The shortage of ethnic minority mental health professionals and the limited availability of services available in
various ethnic languages also act as a barrier to treatment. Some research suggests that ethnic minorities would prefer
an ethnic-matched provider, but that few ethnic minority providers are available (USDHHS, 2001). This issue becomes
even more salient because many ethnic minority groups have less than positive attitudes towards mental health
services. For example, because of historical experiences with racism and discrimination, African Americans may have
a greater fear and misunderstanding of mental health services than White Americans (Clark et al., 1999; Keating &
Robertson, 2004). Mistrust of mental health providers was cited as a major barrier to receiving mental health treatment
by ethnic minorities (USDHHS, 1999). Summative reports in the U.S. and England have also found that some ethnic
minorities lack confidence in the mental health care system and feel that they have been mistreated and discriminated
against by providers and the system (Smedley et al., 2003; USDHHS, 2001).

Reducing the impact of racism and addressing social inequalities that act as barriers to care needs to be properly
addressed if we are to improve care for ethnic minorities. In summarizing the apparent failure of England’s mental
health system in treating ethnic minorities over the past 20 years, Fernando (2005) notes that ethnic minorities are more
often than Whites to be diagnosed as schizophrenic, compulsorily detained in hospitals, admitted as offender patients,

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held by the police for observation for mental illness, transferred to locked wards from open wards when they are
patients in hospitals, given high doses of medication when they are hospital patients, and are less likely to be referred
for psychotherapy when suffering from a mental illness. Keating (2000) underscores that anti-racist perspectives and
proper staff training is critical in fighting provider racist ideas, institutional racism, and discriminatory practices. Until
these issues are adequately addressed, social inequalities, fear of discriminatory maltreatment, and dissatisfaction with
services will continue to act as barriers to care.

1.5. Help-seeking, diagnoses, and their relation to treatment

The from who, when, why, how, and if one seeks help is likely to affect treatment quality, availability, access, and
outcomes as illustrated by Pathway F, and also has important implications for treatment outcome if people are delaying
treatment and coming in only when their problems get intolerably worse. Practitioners from different help-seeking
sources such as primary care, mental health services, and indigenous medicines may also diagnose patients differently
(Pathway G), leading to different types of treatment given as well as potentially different outcomes (Pathway H).
Overall, the available research evidence indicates that ethnic minorities evidence higher levels of mental illness burden
and disability, and that they are less likely to have access to and receive quality health and mental health services
(Smedley et al., 2003; Sue & Chu, 2003; USDHHS, 2001). In addition, some ethnic minority groups are more likely to
drop out of treatment prematurely and evidence worse treatment outcomes (Smedley et al., 2003; USDHHS, 2001).
Given what we currently know about the relationship between culture and various mental health domains, there are a
number of strategies that we can use to improve services.

For example, if we believe that stigma plays a large role in why minorities do not seek care (Ng, 1997; Uba, 1994),
more efforts need to be placed on public health education and breaking down common stereotypes and misperceptions
of mental illness and its treatment. In addition, if we know that minorities are likely to seek other sources of support first
or to access alternative sources of care (Barnes et al., 2004; Becerra & Inlehart, 1995; Eisenberg et al., 1998; Koss-
Chioino, 2000), a stronger coordination of services could be established and educational brochures and resources could
be placed in strategic locales. If we know that some ethnic minorities may delay treatment seeking and as a result are
more likely to be severely ill at point of entry and be hospitalized into the health care system (Breaux and Ryujin, 1999;
Hu, Snowden, Jerrell, & Nguyen, 1991; Snowden and Cheung, 1990; Sue, 1977; Sue & Sue, 1987b), more effort
should be placed on ensuring that the initial contact is culturally sensitive and that a smooth transition is made in
referring clients to service centers that may be better able to serve their needs. In addition, greater emphasis on orienting
clients to mental health services should help decrease stigma, misperceptions, and comfort in treatment which will
hopefully reduce treatment outcomes. There is some evidence to suggest that treating patients in a more culturally
sensitive manner (i.e., providing client-therapist ethnic matching and being treated at ethnic-specific services) can
reduce premature treatment dropouts (Flaskerud & Liu, 1991; Sue, Fujino, Hu, Takeuchi, & Zane, 1991; Takeuchi,
Sue, & Yeh, 1995). Among English speaking Asian Americans, the beneficial effects of being treated at a culturally
sensitive treatment center seem to outweigh the positive effects of being matched with an ethnically similar therapist
(Takeuchi et al., 1995), indicating that training therapists to be culturally competent and developing culturally
congruent interventions can serve as a form of quality improvement, and should be a top priority in improving care.

Unfortunately, we still know little about the direct benefits of cultural competence in influencing outcomes for
minority groups. There continues to be a lack of empirical research examining this issue, and as a result, we have yet to
confirm the active mechanisms that might lead to more positive results. In order to improve cultural competency
trainings, an integration of theory, clinical insight, and empirical findings will be needed to better inform our efforts. It
is surprising that more resources have not been delegated to understand this very important issue. Other areas that need
more work include building a better recruitment and training pipeline to address the shortage of ethnic minority mental
health professionals.

Recently, the American Psychological Association (APA) published “Guidelines on Multicultural Education,
Training, Research, Practice, and Organizational Change for Psychologists (APA, 2003). Although these guidelines
reinforce the idea that culture and diversity need to be taken into account when treating diverse clientele, they have been
largely aspirational. Specifically, professionals who want and need to be culturally competent are left with the message
that culture matters, but continue to struggle with how to be a more culturally competent provider in concrete terms.

It is still unclear how discrepancies in the availability of effective treatments for ethnic minorities are being
addressed. There seems to be growing interest in understanding whether psychological treatments work in refugee

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populations. For example, a small body of outcome research indicates that various psychotherapies may be effective in
treating PTSD in adult and child refugees in Africa, Sweden, and other European countries (Lustig et al., 2004; Neuner,
Schauer, Klaschik, Karunakara, Elbert, 2004; Paunovic & Ost, 2001). However, there is little long-term outcome
research and there is some evidence to suggest that refugees may continue to suffer form the enduring effects of war and
trauma (Carlsson, Mortensen, Kastrup, 2005).

Recent reports indicate that ethnic minorities have for the most part been left out of the U.S. APA’s initiative to
establish, define, and validate empirically supported treatments. For example, the U.S. Surgeon General’s report
indicates that out of the 9266 participants involved in the efficacy studies forming the major treatment guidelines for
depression, bipolar disorder, schizophrenia, and ADHD, only 561 participants were African American, 99 were Latino,
11 were Asian Americans or Pacific Islanders, and none were Native Americans or Alaskan Natives. Other reviews
have also found that although there is a growing body of literature documenting that psychotherapeutic treatments work
with some minority groups, there continues to be a dearth of research examining how they respond to Empirically
Based Treatments (EBTs) (Miranda et al., 2005).

This critical lacuna in our knowledge along with our under-preparedness to effectively treat ethnic minorities
suffering from mental illness is becoming more apparent. Mental health providers are faced with the dilemma of either
(1) implementing an “as-is approach” to disseminating Empirically Based Treatments (EBTs) to ethnic groups who are
culturally different, (2) adapting EBTs to be more culturally congruent in order to better fit the needs of ethnic clientele,
or (3) developing new, culture-specific EBTs for each ethnic group (Hwang, 2006b). Implementing an “as is approach”
or culturally unmodified EBT is likely to improve quality of care because ethnic minorities currently seldom receive
EBTs. However, this may not fully address the discrepancy in treatment outcomes between ethnic minority and White
patients, and we still do not know whether EBTs are ecologically valid or will be effective in treating ethnic minorities.
Developing new ethnic-specific treatments may be prohibitively costly and not yet fully justified. Again, given the
importance of these issues, it is surprising that so little treatment research has been conducted on ethnic minorities.

In trying to address this dilemma, some effort has been put forth to increase cultural competence, develop ethnic-
specific approaches (Costantino, Malgady, & Rogler, 1986; Morita, Kondo, & LeVine, 1998), and adapt EBTs to better
meet the needs of immigrant communities (Malgady, Rogler, & Costantino, 1990). Sue (1998) brought to the attention
the issue of “dynamic sizing” or the skill of knowing when to generalize our cultural knowledge and when to flexibly
individualize treatments. Awareness of dynamic sizing helps prevent the development of rigid overgeneralizations and
stereotypes that may work to decrease the cultural effectiveness of those learning to be culturally competent. Hays
(2001) also provided the “ADDRESSING” framework to help clinicians understand and respond to cultural
complexities. Specifically, minorities possess many aspects of identity that may be even more salient than ethnicity and
that should be included in the conceptualization of how best to treat the client, such as their (A) age and generation-
al influences, (D) developmental or acquired disabilities (D), (R) religion and spiritual orientation, (E) ethnicity,
(S) socioeconomic status, (S) sexual orientation, (I) indigenous heritage, (N) national origin, and (G) gender. For
example, a client is not just Vietnamese American. Adapting therapy to be more culturally responsive can be incredibly
difficult because culture can have both proximal and distal effects on the various domains of mental health, as
illustrated by the CIMHmodel. This can be especially problematic when providers attempt to apply cultural knowledge
to the therapeutic process because such knowledge is quite distal to therapeutic outcomes and practitioners have
difficulty operationalizing this information (Sue & Zane, 1987).

In trying to bridge the gap between cultural understanding and helping practitioners think systematically about
improving treatment efforts, Hwang (2006b) developed the Psychotherapy Adaptation and Modification Framework
(PAMF) to help facilitate adaptation of psychotherapy for use with ethnic minorities. The PAMF framework consists of
a three tiered framework consisting of 6 broad domains, 25 adaptable therapeutic principles, and corresponding
rationales. Domains targeted for adaptation include: (a) dynamic issues and cultural complexities, (b) orienting clients
to psychotherapy and increasing mental health awareness, (c) understanding cultural beliefs about mental illness, its
causes, and what constitutes appropriate treatment, (d) improving the client-therapist relationship, (e) understanding
cultural differences in the expression and communication of distress, and (f) addressing cultural issues specific to the
population. This three-tiered approach to presenting cultural adaptations to therapy was developed in order to make the
PAMF more accessible, user-friendly, and adaptable for use with other diverse populations.

Because many mental health professionals need and want to be more culturally competent, research and trainings
that help practitioners conceptualize and actualize these hard to render and needed skills are sorely needed. Adaptation
of treatments is especially important since the concept of therapy and the rationale behind therapeutic treatment may be

222 W.-C. Hwang et al. / Clinical Psychology Review 28 (2008) 211–227

culturally unfamiliar or foreign to those who have had little exposure or experience with mental illness, and to cultures
where mental illness can be especially stigmatizing (Hwang, 2006; Hwang et al., 2006). Although the core healing
elements of many therapies may generalize across cultures, packaging treatments to better fit with a patient’s needs is
integral to improving patient satisfaction, improving treatment involvement, compliance, outcomes, and reducing
premature dropout. It is the responsibility of treatment providers to deliver culturally sensitive care that is easily
translatable and understood by consumers, not the responsibility of patients to adjust to the requirements of treatment
approaches that may be culturally dystonic. Because health disparities are very real, cultural sensitivity and
modifications that make health care services more accessible to consumers are a necessity rather than a luxury.

1.6. Meeting the needs of ethnic minority and immigrant communities: policy implications

Given that many ethnic minorities and immigrants are culturally different from White Americans and Europeans,
current health care systems may not be prepared to meet the needs of rapidly diversifying countries. This has become
increasingly evident as recent reports reaffirm that racial and ethnic health disparities do exist, and that there may be
biases in the health care system that influence whether people of differing backgrounds receive equitable services
(Smedley, 2003; USDHHS, 2001). Concrete plans for preventing health disparities at all levels need to be
implemented. These plans need to be global and international in nature. Recently, the World Health Organization
(WHO) reported that mental illness accounts for five of the top ten leading causes of disability around the world and
accounts for between 12–15% of the disease burden in the world (Murray & Lopez, 1996).

Yet few national and international policies have been developed to address this global problem. For example, when
reviewing existing international policies across the world for child and adolescent mental health care, Shatkin and
Belfer (2004) found that only 18% of countries worldwide had an identifiable mental health policy. This is especially
problematic for developing countries where access to quality health and mental health care is less available. Patel,
Saraceno, and Kleinman (2006) note that policies that help address international access to services need to be
established and that it is unethical to deny effective and affordable care to those suffering from mental illness. For
example, international property rights agreements deny developing countries the right to produce generic versions of
drugs, resulting in unaffordable prices set by pharmaceutical companies. Civil rights abuses, including denial of basic
rights, forced long-term residential treatment, treatment with older drugs with severe side effects, unsanitary
conditions, and forced lockdowns of those who are mentally ill, also occur throughout the world. In addition to
improving training and educational programs, policies that establish incentives for returning to one’s country and
reducing the brain drain among developing countries to more affluent countries need to be developed.

In the U.S., the President’s New Freedom Commission (2003) and the Institute of Medicine (IOM, 2001)
recommend that transformations in mental health delivery systems target 6 goals for improvement, including ensuring
that people understand that mental health is essential to general health, mental health care is consumer and family
driven, disparities in mental health services are eliminated, early screening, assessment, and referral services are
established, quality mental health care is delivered and research is accelerated, and technology be used to access mental
health care and information. These recommendations are surprisingly similar to targeted improvements in England
(Beinecke, 2005), and could be applied to international services and a Global Alliance for Mental Health under the
umbrella of the World Health Organization (Patel & Kleinman, 2006). When actualizing these goals, particular
attention needs to be made to fulfilling these obligations to ethnic minority and immigrant populations.

Fernando (2005) notes that some of the more successful multicultural services in the UK tend to employ a number of
“good practices,” including the use of multicultural multidisciplinary teams, specific cultural sensitivity and anti-racist
practice trainings, anti-oppressive practices in establishing collaborative ties with communities and helping clients
deal with racism, increasing the number of ethnic minority staff and improving the educational pipeline, linking
psychological support to housing, providing advocacy to help clients deal with statutory services, integrating cultural
spirituality and alternative treatments to psychotherapeutic services, and culturally adapting psychotherapy for
clientele. For developing countries, these goals may only be aspirational and critical economic and social problems
may need to be addressed more immediately.

There is much that we can do as mental health researchers, practitioners, and teachers to improve our cultural
awareness and competence. However, mental health providers need to develop a more sophisticated understanding of
how culture systematically affects several interrelated mental health domains. The CIMH conceptual framework was
developed to help providers move beyond simplistic dyadic conceptualizations of cultural influences and to better

223W.-C. Hwang et al. / Clinical Psychology Review 28 (2008) 211–227

understand the complexities involved in providing culturally competent and sensitive care. Although we acknowledge
that this paradigm is far from comprehensive, we offer it as a basic framework for understanding systematic and
interrelated cultural issues and their impact on mental health. We hope that the CIMH model can be used to help
improve the teaching of psychological research and practice.

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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

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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

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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

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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

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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

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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 boy, acting out during the day
and wetting his tiny mat at night; a teenage girl cannot sleep more than two hours
without waking up afraid, at times screaming from nightmares; another young lady
cannot hide the hurt and shame of being sexually assaulted and raped during a militia
invasion, yet she tries to help a boy whose body is full of shrapnel after a nearby
explosion; a young man cannot erase bloody images of his best friend and cousin who
went into pieces in front of his eyes, due to a shell bomb hitting their small street; an
older man refuses to eat much, or mix with others, after witnessing his own building
collapse and kill all his family members; a young woman, who was a schoolteacher,
now shares a tent with relatives, and deeply grieves the loss of many family members
and students as she saw her own school hit repeatedly, destroyed, and burned with fire;
a child, when still under siege and bombardment, kept seeing a dream of a fountain
running of fresh water and a basket of fresh fruits; and an older lady kept wondering
whether she would ever again see and smell a fresh rose, before she dies.

Psychosocial Effect and Adjustment

In the aftermath of any natural disaster, major tragedy, or war violence, survivors

often experience a wide range of mental-emotional disturbances. Besides the horror of
wars, people carry the scars of loss and grief, memories of shattered communities, and
the lack of stability and security. The pressures of uprooting and escaping, and then
squeezing everybody in tiny living places so as to share the quarters with other families
(e.g., kitchenette, one entrance, small bathroom, a drinking tab), have created
tremendous mental stressors and relational tensions among the people involved. Six
years of intense wars have torn the country apart. Young families, along with children
and elderly, have borne the weight and disastrous consequences of this conflict.
Helpers from humanitarian, media, religious, and volunteer organizations working in
Aleppo, reported that the situation there was the direst ever seen, and the victims of that
urban war have endured hardships that would last for several lifetimes (Ward, 2017;
World Vision, 2017). Those who were less exposed to war traumas and atrocities still
suffer from significant anxieties, apprehensions, mourning, and existential questioning.

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Many Syrians feel they have lost their social identity, life savings, sense of belonging,
communal lifestyle, unique heritage, and national pride. When everything seems
collapsing, people are forced to redefine their lives and outlook on existence. Some find
new meaning and purpose, others fall into despair and apathy, yet others mobilize their
spare energy and passion to help those less fortunate, and with that they help
themselves in return. That is the resilient art of meaning making (cf. Wong, 2013).
Unlike medical and humanitarian aid, psychological caregiving and mental health
services are not as prominent, available, or urgent as the physical and medical needs.
Limited psycho-emotional care started very late in the process, well after the war events
unfolded and intensified. Assessment and therapeutic interventions were scarcely
offered or even accessible to Syrians, both inside and outside Syria. There is still a
major shortage of trained personnel, social workers, and therapy counselors. Some
serious mental health problems were actually discovered by default or chance, while
other health care providers and volunteers attended to pressing needs of the affected
and displaced. In the last couple of years, psychiatric/psychological caregiving and
trauma counseling have been more available to some of the needy, who have
responded very well. They show enthusiasm and gratitude to any therapeutic activities,
clinical intervention, educational programs, or pastoral care, especially among the
children and young generation (cf. Abi-Hashem, in press; Mercy Corps, 2016, 2017;
News, 2016). The multiple concerns and agonies of Syrians include their ongoing grief
over the collapse of their country along with excessive worry over their safety and
means of survival. The unknown destiny of their properties and fate of family members,
the uncertainties of having enough income, and a lack of information about their own
future all add to their marked disorientation and acute anxiety. They are constantly
facing challenges, like adapting to new environments and tight living surroundings,
receiving mixed messages from the hosting societies, trying to manage their cultural
shock, and binding their wounds while relearning to survive again (UNHCR, 2015a,
2015b). Intercultural adjustment and cross-cultural adaptation place extra pressure on
any displaced people or refugees. In a new setting, some remain isolated and aloof
(alienation), others mingle and melt within the setting (fusion), while others assimilate
well and achieve a healthy adaptation (integration). Therefore, acculturation stress can
be a significant burden for those vulnerable, drained, distressed, and demoralized (Abi-
Hashem & Brown, 2013; Chan, Young, & Sharif, 2016; Mitschke et al., 2017; Wong &
Wong, 2006).

Mutual Impact on the Countries of Lebanon and Syria

Lebanon has the largest refugee population in the world compared to its size and
population (Caryl, 2016; Karam, 2015; Marsi, 2015; Refaat & Mohanna, 2013;
Sobelman, 2015). It is roughly the size of Rhode Island in the United States or the
Island of Cyprus in the Mediterranean Sea. Although Lebanon was caught by surprise

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with the magnitude of the Syrian turmoil and displacement, it has done great favors to
host far more Syrians per capita than any other country in the world. There are no
sanctioned camps or refugee concentrations in Lebanon (except a few with loose
security apparatus), unlike in Jordan and Turkey, where guards closely check the camp
entrances and activities. At first, the Lebanese accommodated the Syrians realizing this
may be just for a short time before they return home, once the troubles subside.
Instead, the Syrian troubles escalated further and spread wider, making Lebanon one of
the easiest and best choices for escape and resettlement. In the last couple of years the
Lebanese authorities woke up to the fact that this may be a long and chronic crisis and
began to put requirements and restrictions on Syrians in order to regulate their influx
and intense presence (e.g., criteria for entrance into the country, need to have a
Lebanese sponsor in order to work, and short but renewable residence).

Evidently, the majority of Syrians coming to Lebanon have experienced immense
hardships, yet they are decent, hard-working, law abiding, and god-fearing people. They
qualify to be labeled as refugees. Those able to work are quite willing to provide cheap
labor, which eventually helps the Lebanese economy. However, other Syrian civilians,
not directly affected by the war and who do not consider themselves as refugees, are
also drawn to Lebanon due to its open policy, safety, and opportunities for livelihood.
These come in and go out as they wish (no visa required, just minimal paper work), get
benefits similar to the refugees, compete with the Lebanese for jobs, and take the
money back home, yet are only considered regular workers or visitors. This has been
confusing as to “who is who?” A tiny Syrian elite came to Beirut from Damascus and
Aleppo early on, and brought their wealth; but a vast majority of Syrian evacuees are
now extremely poor and depending on Lebanese welfare, menial jobs, and private
donations. The sudden migration from Syria and constant influx through the wide
borders into Lebanon has absolutely overwhelmed this tiny country’s infrastructure and
limited resources.

Due to previous friendly agreements between the two countries, people could move
easily between them. Therefore, it is difficult to know exactly how many Syrians are in
Lebanon as they have literally infiltrated almost every street, corner, and town in
Lebanon, from up the mountains to the seashores. Many Lebanese are apprehensive
about such migrant density and even begin to feel as strangers in their own land (Geha,
2016; Marsi, 2015; Refaat & Mohanna, 2013).

According to several analyses and reports (Aljazeera, 2017; Geha, 2016; UNHCR,
2015a, 2015b), Lebanon has been drained and devastated for paying such a high price
and is currently at risk. The refugees’ presence has created a number of social
dilemmas, including housing shortages, serious competition for jobs, an educational and
medical crisis, an unprecedented street children problem, major safety and security
concerns, higher unemployment, and ethno-demographic shift. There are plenty of
mixed marriages and unwanted out-of-wedlock children. The childbirth rate among the

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Syrians in Lebanon is double that of the Lebanese themselves (Aljazeera, 2017; Geha,
2016; Marsi, 2015; Refaat & Mohanna, 2013; UNHCR, 2015a, 2015b).

In addition, there has been an increase in using or abusing public services and private
donations, drug dealing, money laundering, prostitution, child exploitation and
trafficking, gang and crime activity, secret arms selling, and black market activities.
Lebanese observers fear that some fighters, criminals, and radical militants, freely
roaming in Syria, may have already infiltrated the border into Lebanon and may create
dangerous cells and draw followers. The Lebanese security forces are strong and alert
but the task of keeping up security is enormous and is stretching their capabilities. Thus,
there are some serious threats to the cohesiveness, survival, and integrity of the
Lebanese themselves. Such negative consequences and social disorders normally
follow any major armed conflict, population displacement, and forced migration.

In spite of all the disadvantages and tangible or existential threats, Lebanon has so far
shown extreme resiliency, containment, and adaptability as a tiny nation, which already
has its share of problems. Lebanon continues to mobilize its limited resources and
highly motivated service personnel to help and accommodate the huge social demands
of Syrian refugees, visitors, and migrants. The market place, housing, schools,
factories, shops, labor forces, construction sites, homes, etc., still are welcoming
Syrians openly. This was unexpected, due to the negative way the Syrian regime and its
army treated the Lebanese in the past, when they ruled Lebanon with an iron fist for
almost 20 years (Akoury-Dirani et al., 2015; Aljazeera, 2017; Geha, 2016; UNHCR,
2015a, 2015b).

According to Karam (2015), Lebanon has been the recipient of more than a million
Syrian evacuees and migrants (those registered back then prior to 2015), even without
having a major say in the matter. Although struggling and overwhelmed, Lebanon as a
hosting country is surviving and helping the Syrians to survive as well. With that, it is
setting an example for the international community, especially Europe, that
accommodating refugees is possible and doable, of course with a price but also with an
advantage of having industrious people on its land—very hard working and highly
family-community oriented (see also Caryl, 2015; Sobelman, 2015).

A few hundred thousand Syrians used Lebanon temporarily as a stepping-stone to
apply, via the local United Nations offices, for political asylum or full immigration to a
Western nation of their choice. The rest have settled in and built their lives locally, until
further notice. Some of them express a strong desire to return home to their beloved
country. Others seem very happy in Lebanon and have no intention of leaving again
(Caryl, 2016; Karam, 2015; Marsi, 2015; Refaat & Mohanna, 2013; Sobelman, 2015).

The very fact that Lebanon does not require that Syrian refugees and war victims be
grouped in reservation camps, is by itself an empowering fact that offers a major
psychological boost to their morale. Syrians love Lebanon due to its open policy and
freedom of moving, working, living, mingling, and enjoying its diversity, leisure, and
beauty (with no need to learn a new language). These aspects and ample commodities
and the availability of social services are greatly contributing to the Syrian refugees’

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sense of personal dignity, restoration of some stability, emotional recovery, and general
empowerment. However, as with every sudden population influx and relocation, such
huge numbers coming from Syria, a neighboring and sister country, has created serious
implications on this hosting society of Lebanon. Therefore, anxiety, fear, and
resentment are rising among locals and nationals. The Lebanese government, social
institutions, and private sectors were never ready for this demographic flooding, so they
became at loss what to do and how to handle this unplanned migration. After a year or
so, when it became evident that there was no solution in sight, and the flood of Syrians
into Lebanon continued, reports of discrimination cases, refusal of service, and
tightening of privileges and freedoms increased. Still, the Lebanese in general are
accommodating, employing, facilitating life, and providing for the Syrians, young and
old, with generous hospitality, trust, and solidarity. Thus, what was a Syrian struggle for
survival and recovery has now become a duel Lebanese-Syrian struggle for survival,
recovery, and resiliency (Akoury-Dirani et al., 2015; Carta, Moro, & Bass, 2015; Caryl,
2016; Karam, 2015; Marsi, 2015; Refaat & Mohanna, 2013; Sobelman, 2015).

Thus, in many ways, the country of Lebanon and its people can be presently
considered as co-partners in the coping process of the Syrian crisis and as co-survivors
alongside the Syrian people in enduring and thriving toward better tenacity, mastery,
and resiliency, all in the face of an unprecedented communal, national, and regional war
disaster and adversity of such magnitude.

Healthy and Unhealthy Coping Styles

As in any major crisis and disaster, people, often labeled as victims or survivors, try to
find ways to soothe the pain and cope with the anxieties and acute stresses. They
usually develop coping strategies that range from the healthy-constructive to the
unhealthy-destructive ones.

Some of the unhealthy, risky, and damaging modes of coping include withdrawing,
isolating, becoming cynical, falling into apathy and pessimism, perpetually moving and
relocating, acting out behaviors, resorting to aggression and domestic violence,
engaging in addictions, resorting to occult/black magic practices, gambling and
overspending, using/abusing drugs and alcohol, overworking, oversexualizing, etc.
However, in terms of healthy coping strategies, the following are a sample of those that
survivors usually employ during and after tragedies. Syrians are displaying many of
these skills and others as well, reflecting their unique ways and subcultures in handling
stress and striving toward restoration (cf. Abi-Hashem, 2006, 2008b, 2011b, 2013,
2014b, 2016a; Chan, Young, & Sharif, 2016; Clinic Psychology, 2016; Hassan et al.,
2016; Mercy Corps, 2016, 2017; Mitschke et al., 2017): Syrians are bonding and
adopting each other as friends and relatives, especially those who lost family members.
They are becoming creative in finding innovative ways to work and survive financially.

119

Even young children and teenagers are becoming little entrepreneurs and market smart
(unfortunately at times in black markets) as many are cleaning cars, working as bag
boys in grocery stores, trading in vegetables, collecting any good items for recycling
from stores, garbage, or trash, are willing to work in anything and with any capacity,
even selling items on the streets and among cars or begging there for long hours, just to
raise small funds to help mother or grandmother or siblings with food and rent and the
basics. They are bravely enduring the hardships of street life—the hot sun, dust, dirt,
and harassment by others, young and old, even competition among themselves, just to
make enough at the end of day, if at all possible.

Traditionally, Syrians tend to socialize with each other closely and celebrate all social
events and feasts together, with hosting families or communities around them. Often
that includes having music and singing and, at times, folk dancing. This proves to be
therapeutic in many ways, which provides beautiful communal strength and restoration.
Often, they gather in small circles, ladies for morning coffee, and older men in the
afternoon for playing cards or table games, smoking water pipes, and discussing current
worries, events, and politics. Children are found playing ball in the tiny corner of their
street or shelter building. All of these have become very healing activities. When
gathering around food, which is an engrained habit in the Middle East psyche since
ancient times, normally people have a great opportunity to nurture and support each
other, bond closer, and show solidarity with each other. Many Syrians are becoming
spiritually more active and finding strength in faith. Although the majority of people in the
Middle East are religious by affiliation, if not by practice (religious affiliation/celebrations
are part of social identity and culture), many are now seeking genuine faith and new
spiritual experiences for deeper meaning, comfort, commitment, camaraderie, and
contentment.

Others are volunteering to help fellow refugees and evacuees who are less fortunate
than themselves, both in Lebanon and back home in Syria. Many are cultivating
passions and future inspirations even among children who are begging on the streets of
Beirut. I usually stop and talk with many of them. They gather around me eagerly and
love the attention. I get to meet them by name and inquire about their lives. Where do
they come from? Are they alone or with any family members? How long have they been
begging on the streets? When did they eat last? Were they ever at any school in their
lifetime? In response, I hear sad stories. But when asking what would they like to
become when growing up and why, without hesitation, and with a spark in their eyes,
they answer: nurse, to help treat my sick family and all victims of this ugly war; teacher,
to educate children so they will not miss school like us; farmer, to help my aging father
work in our good land; etc. Unfortunately, many children have lost their childhood and
have not played, studied, or laughed much, yet they have not lost their ability to dream
and set worthy and bright goals for the future.

120

Promoting Further Resiliency and Strength

Resiliency refers to the human individual potential and the collective communal spirit to
effectively and positively face adversity, tolerate ambiguity, handle pressure, cope with
crises, and recover from disaster or tragedy (Abi-Hashem, 2011a, 2016b; Ungar, 2008,
2013). Nevertheless, surviving usually comes with a price tag. People normally bounce
back but not without a scar, a stress, a residual, or a heaviness.

Resiliency focuses on the hopeful side of life and mobilizes the positive strength in
human nature. Other words are used to describe resiliency: Flexibility, hardiness,
elasticity, resourcefulness, tenacity, robustness, and mastery. There are several
psychological dynamics, cultural mediators, and spiritual factors at work in every aspect
of surviving, coping, and thriving. However, enduring suffering constructively somehow
adds to the emotional maturity and spiritual depth of people. For the sake of our
discussion, resiliencythen is more than an isolated individual construct. It can be best
described as a cultural competency in action and as a fluid concept that is a function of
the emotional resources, social identity, religious values, and cultural capitals of the
group or the community (Abi-Hashem, 2011a, 2016b; Chan, Young, & Sharif, 2016;
Ungar, 2008, 2013).

Syrians Respond Well to Lebanese Outreach

Government agencies, NGOs, community groups, schools, churches, mosques, and
other local societies and organizations are doing all they can to help, accommodate,
and empower the refugees of all walks and ages, especially the women and children.
Foreign agencies often work with national Lebanese teams in joint efforts. Together,
they are providing health care, social work, and medical clinics, in fixed or mobile
locations. Most hospitals treat Syrians free or with minimal fees. The ministry of
education established after-school tracks across Lebanon for refugee children, as the
Syrian curriculum is somehow different and less rigorous than the Lebanese (still many
cannot enroll because they have to work). Also, women are being trained in basic
reading, writing, and entrepreneurial skills to help them start small businesses or sell
products. In addition, services provide for emotional recovery, personal training,
pastoral ministry, and spiritual care to help the displaced find more healing, solace,
restoration, and existential hope. Sociocultural coaching helps those feeling intimidated
and lost in transition.

Syrian refugees are responding amazingly well to all these initiatives and services and
are asking for more. Although the majority of Lebanese caregivers are exhausted and
depleted, they keep on giving enthusiastically, realizing the rewarding outcomes and
sense of fulfillment. Countless Syrians are bouncing back, flourishing, and doing much
better under unfavorable circumstances. They are deeply grateful to all the attention,

121

help, and care. Many have lost almost everything to the ugly war, but maintain their
imagination, resolve, affection, and hopefulness (Clinic Psychology, 2016; Geha, 2016;
Mercy Corps, 2016; UNHCR, 2015a, 2015b).

Implications for Mental Health Care and Counseling

The following are hints for intervention, and practical guidelines for health care providers
and mental health professionals, including key questions to ask the survivors during
almost any therapeutic encounter and counseling service (cf. Abi-Hashem, 1999b,
2008b, 2011b, 2013, 2014a, 2014b, in press; Almoshmosh, 2015; Chan, Young, &
Sharif, 2016; Clinic Psychology, 2016; Hassan et al., 2016; James et al., 2014; Lee,
2010; Mitschke et al., 2017; News, 2016; UNHCR, 2015a, 2015b; WHO, 2017):

• Establish a welcoming atmosphere and a warm relationship for the distressed
people, so they would feel comfortable and safe (could be on a walk or over a meal).

• Gently ask about general details of what happened to them without pressing them
with questions. Avoid sounding like you are interrogating them.

• Show basic empathy and provide much needed comforting statements.
• Educate the sufferers about the nature of common emotional disturbances that

usually follow tragedies.
• Insure the safety and survival of each person with whom you are working by

providing solidarity, reassurance, and physical provision (if needed and possible).
• In case of multiple traumas and victimizations, start with the most urgent one and

gradually move to the others.
• Teach people basic ways how to reduce their anxiety, stress, and interpersonal

tension.
• Help people discover the unhealthy reactions they use to protect themselves, their

loved ones, or their fragile emotions.
• Introduce desensitization and encourage them to reverse any unhealthy coping

modes in a gentle, yet effective manner.
• For those struggling with acute traumatic stress, teach them to reframe their thinking

and responses, so their fears and calamities will not become exaggerated.
• Be careful when uncovering tragic memories, because some aspects of any

recollection could expand unconsciously to become vague, and the real becomes
mixed with the unreal.

• Ask them what they miss most about their previous lives before becoming refugees.
Help them process and treasure good memories.

• Remember that the experience of grief, loss, trauma, and tragedy is not separate
from people’s mentality, worldview, culture, and spirituality. These always interact
and overlap.

122

• Make sure to conduct grief counseling simultaneously with trauma therapy in order
to facilitate the mourning process of complicated bereavement and the mastery of
traumatic reactions.

• Refer severe cases to medical and psychiatric evaluation/treatment as needed.
• Investigate the challenges of social adjustment and cultural integration they are

facing. “What are the most difficult aspects of you being a refugee right now?”
• Acknowledge the hardship and possible discrimination they may be facing.
• Commend them on any positive step and degree of strength they are utilizing,

gaining, and demonstrating.
• Help them to constantly shift their mental focus from being victims to being survivors.
• Network with other caregivers to find out what supportive resources are available in

nearby cultural centers, communities of faith, and society at large.
• Introduce experiential activities alongside talk therapy. Give them homework to do,

even simple activities, and discuss the next steps of recovery to avoid any future
lapses.

• Guide them to establish new relationships, set new goals, develop realistic
expectations, and discover new inner potentials and aspirations.

• Inspire them to possibly get involved in helping other people who are struggling with
similar agonies, so by helping others they will eventually help themselves.

• Encourage them to cultivate healthy soul care and spiritual vitality. To do that, first
find out whether faith has become a part of the solution or the problem in their lives.
“How can your faith and religious values inspire you at this time of life?”

• “Are there any elders, mentors, or sages in your life circle that you can seek to guide
and nurture you?”

• “How would your grandparents handle and cope with a similar situation? What
common sense, insight, and generational wisdom from your heritage can you use
and employ?”

• “If you are a role model, what can others, young or old, see and observe in you? And
learn from you?”

• Encourage them to use resources from the new environment and also make
contributions into it.

• Help them navigate the challenges of adjustment and integrate well in the hosting
society, without losing much of their social identity or cultural heritage, yet without
isolating and becoming socially rigid, in order to blend well and function best.

• Encourage them to practice basic meditation and mindfulness.
• Promote resiliency and survival. Hopefully, these people will begin to transfer their

pain into purpose, their crippling into creativity, their misery into mission, and their
tragedies into treasures.

• Finally, remain available for continual support, guidance, accountability, nurture, and
encouragement.

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CONCLUSION

In this chapter we have discussed the agony and perseverance of the Syrian people
who have been directly affected by the ongoing armed conflict and large-scale war
since 2011. We have described the background of their ordeal and focused on the
dynamics of their coping skills and survival abilities. We have presented an overview of
the circumstances preceding the massive troubles and tribulations that hit most of their
homeland along with a general profile of the country and its population, subcultures,
social norms, and religious faiths, so to help us better understand the scope and
seriousness of the current situation and put its acute humanitarian crisis in the right
social framework and psychological perspective.

As the armed conflict and fighting continue and, at times, spread or switch from one
regional area to another, scores of Syrians continue to suffer greatly. Besides their
tangible losses, actual military sieges of their communities, and destruction of their
homes and neighborhoods, they had to endure severe emotional horrors, multiple
physical displacements, bodily injuries, and often death of a family member or loved
one, and obviously accumulated levels of traumatic stress.

Some of them became refugees in their own country. Others became refugees in a
nearby country across the border, like Jordan, Lebanon, Turkey, and Iraq. A few of
them, relatively speaking to the millions displaced, made their way to North Africa, the
Gulf region, or to the European continent. However, the majority of them settled in
residential communities or large established camps near the Syrian border, indefinitely
waiting and desperately hoping to return home perhaps someday.

We have found that, under the right circumstances, and with the intentional help, care,
and hospitality of the hosting country or community, even the most traumatized and
victimized Syrian refugees have been able to slowly (but surely) readjust, gain strength,
persevere, recover, and build a new life in exile. Those who were able to return to their
relatively safe towns and villages have started cleaning, repairing, and reestablishing
their neighborhood again. Survival and resiliency are manifested by their ability to utilize
well the resources available to them, respond well to the coaching and training provided
to them, engage in the guidance and counseling given to them, and be indigenous and
creative in finding solutions and new innovative ways around the many obstacles facing
their restoration.

We have also seen that the welfare and survival of Syrian refugees has not been
without negative consequences on the hosting communities, societies, or countries. In
this chapter, I have included a Lebanese perspective about that difficult aspect and
how, since the very beginning of the Syrian war, the tiny nation of Lebanon has been
extremely strained, and still, as a full resolution of the crisis appears unattainable.
Lebanon is now considered having the largest refugee population in the world per
capita. However, and in spite of this sobering reality, the Lebanese government and

124

people, regardless of their socioeconomic background, political persuasion, religion, or
education rally behind accommodating Syrian evacuees and migrants in all areas and
on all levels. Thus, the Lebanese have become partners with the Syrians in enduring
their crisis and paying the heavy price of their displacement. The Lebanese people also
have shown tremendous resiliency, practiced great absorption, and exhibited
remarkable solidarity. And together they have displayed a great model of containing the
aftermath of an ugly war and a catastrophic tragedy, which have caused a national
misery, an unbelievable regional dilemma, and an unprecedented humanitarian crisis.

As the author of this chapter, I have shared many personal insights, observations, and
conclusions based on my social interactions, clinical interventions, private interviews, in-
depth readings, and cross-cultural works. A glimpse of what the helpers, providers, and
volunteers, who are working with Syrian refugees, are facing and experiencing is also
included. This perspective is to complete the psychosocial picture and provide a global
view of the impact of such a war disaster on both the caregivers and care-receivers
alike.

In conclusion, the whole account may serve as a testimony to the resilient human
spirit which, on one hand, can endure adversities, experience various traumas, and be
moved deeply by multiple calamities and, yet, on the other hand, can begin to restore
the many losses, heal the profound emotional wounds, recover from the painful
agonies, and chart a new path toward a future filled with hope, confidence, patience,
striving, and survival.

• Structure Bookmarks

• Establish a welcoming atmosphere and a warm relationship for the distressed people, so they would feel comfortable and safe (could be on a walk or over a meal).

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: jgd1@psu.edu (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

763J.G. Draguns, J. Tanaka-Matsumi / Behaviour Research and Therapy 41 (2003) 755–776

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 regarded as problems that would justify seeking help
from health professionals (Cheung, 1989). Indeed, a culturally sanctioned code for couching spe-
cific psychological experiences in organ related terms survives to this day (Ots, 1990).

Seiden (1999) presented both Chinese and European–American clinicians with videotaped inter-
views of four Chinese immigrant patients with neurasthenic complaints in the United States. There
was consensus on the symptoms presented and the interventions indicated. However, cultural
differences appeared in the relative importance assigned to somatic experiences versus cogni-
tive problems.

In addition to China, prominence of somatic complaints has been reported in Japan, India, Latin

764 J.G. Draguns, J. Tanaka-Matsumi / Behaviour Research and Therapy 41 (2003) 755–776

America, and Africa (Kirmayer, 1984). Indeed, their relative neglect by clinicians in North Amer-
ica and Western Europe may itself be a cultural phenomenon as is the Cartesian dichotomization
of soma and psyche. Around the world and across epochs, fusion of bodily and mental experience
is a lot more prevalent (Draguns, 1975). The challenge is to incorporate this recognition into a
comprehensive system of worldwide assessment of psychopathology.

3.3. Schizophrenia

The most ambitious project of investigating schizophrenia across nations was initiated by the
WHO. In the initial phase of this continuing research program, patients experiencing their first
episode of schizophrenia in nine countries were interviewed, observed, and diagnosed by means
of a standardized Present Status Examination (WHO, 1973). A pattern of core symptoms presented
by the great majority of schizophrenic patients at all centers was ascertained, consisting of lack
of insight, flat affect, delusional mood, ideas of reference, perplexity, auditory hallucinations, and
experience of control (see also Tseng, 2001). Two years later, WHO (1980) conducted a follow-
up study on the course and outcome of schizophrenia. Most positive symptoms such as halluci-
nations had disappeared. However, negative symptoms exemplified by lack of insight and flatness
of affect persisted in a substantial proportion of cases. Somewhat surprisingly, prognosis was
more favorable in the three developing countries (Colombia, Nigeria, and India) than in developed
countries (United States, Great Britain, and Denmark). Also unexpectedly, high educational level
was associated with chronicity in developing countries. On a more general plane, Jablensky and
Sartorius (1988) summarized the results of the WHO research as follows: “ (I) Syndromes of
schizophrenia occur in all cultures and geographical areas investigated; (II) their rate of incidence
is very similar in the different populations; (III) the course and prognosis of schizophrenia is
extremely variable, but outcome is significantly better in the developing countries (p. 65).”

In the most recent and ambitious phase of the WHO series of investigation, Jablensky et al.,
1992) set out to compare the true prevalence of schizophrenia across cultures at 12 centers in ten
countries. All persons who sought their first contact with a helping agency within the catchment
area of a participating center were identified. They were then screened for schizophrenic symp-
toms. There were no major differences between individual centers, and the incidence rates in
developing and developed countries were comparable. Acute onset of schizophrenia was more
frequently encountered in the developing countries.

This case finding procedure was also employed to investigate the impact of stressful events
within two to three weeks prior to the onset of schizophrenia. Day et al. (1987) reported similarity
in the mean number of stressful events among six of the nine participating centers. Two centers
in India and one in Nigeria reported lower rates of such events. It is not clear whether these
findings reflect a true difference or whether the experience of stress at these locations was not
adequately represented among the measures of this study.

The results of the WHO research provide impressive corroboration of similarities of rates of
schizophrenia across cultures. At the same time, some differences have also been identified. In
pursuit of such variations, Murphy (1982) identified faulty information processing as a potential
risk factor in developing schizophrenia. Murphy’s formulation is akin to the double bind hypoth-
esis by Bateson, Jackson, Haley and Wheatland (1956). It is, however, extended beyond messages
from the mother to the child. Rather, the community (and, by extension, the culture) is regarded

765J.G. Draguns, J. Tanaka-Matsumi / Behaviour Research and Therapy 41 (2003) 755–776

as the putative source of unclear, complex, and contradictory messages, which are difficult to
ignore or to disregard. Work on these intriguing possibilities, however, does not appear to be
pursued by any current investigators.

The WHO finding of a better prognosis in developing countries is somewhat counterintuitive,
and it has not gone unchallenged. Cohen (1992) has offered an alternative explanation on the
basis of availability of hospital contact rather than the actual course of schizophrenia. Waxler-
Morrison (1992), however, has challenged this reinterpretation and has corroborated positive out-
comes in a five-year study of hospitalized schizophrenics in Sri Lanka. Kurihara, Kato and Yagi
(2000) compared prognosis of schizophrenic patients in Japan and Bali. Consistent with the WHO
finding, five-year prognosis was better for patients in Bali in terms of length of hospital stay,
social participation, and percent of follow-up patients on drug treatment. A significantly higher
proportion of Bali patients were married, lived with extended families, and were less educated
than Japanese patients. Jablensky and Sartorius (1988) asserted that the culturally relativistic pos-
ition that schizophrenia is labeled and identified differently across cultures has received little
support from the findings of the WHO series of studies.

If culture impinges upon the experience of schizophrenia, it may do so in a subtle manner. A
promising area of research is focused upon expressed emotion (EE). This variable has been dem-
onstrated to have a prognostic significance in Great Britain and North America (Leff & Vaughn,
1986) Specifically, emotional, negatively toned communications toward the patient by the mem-
bers of his or her family increase the likelihood of relapse. Across cultures, however, the pro-
portion of EE communications is highly variable, and its rate in India is found to be about half
of what it is in Britain (Wig et al., 1987). Could this be one of the reasons why the prognosis
for schizophrenia is better in India than in the United Kingdom?

Hallucinations are a prominent symptom of schizophrenia in many cultures. Al-Issa, 1977,
1995) has demonstrated that cultural concepts of reality are related to the attitudes toward halluci-
nation and their thresholds of acceptability. Moreover, hallucinations trigger different social
responses across cultures. The choice of sense modality, visual or auditory, is in part determined
by culture. Whether a hallucinatory experience is construed as supernatural or pathological is
again influenced by the prevailing cultural beliefs. Cultures do not simply differ in the frequency
of hallucinations. As any other symptom, they occur in a context. Therefore, it is important to
identify the antecedent and consequent events and to describe the setting in which hallucinations
have occurred. Like any other behavior, hallucinations become a symptom when they are so label-
ed.

Cross-cultural research has also been extended to varieties of delusions. In particular, Stompe
(2001) summarized research conducted over more than a century by saying that “ religious
delusions are most frequent in Catholic societies followed by Protestant and Islamic ones” (p.
17) while in Buddhist countries they are exceedingly rare. A recent comparison of religious
delusions in Austria and in Pakistan sheds more light on this issue. In line with the above rank
ordering of religious content of delusions, Austrians exceeded the Pakistanis in the frequency of
religious delusions. Secular delusions, however, were also found to be more frequent in Austria
than in Pakistan. Among Austrian patients negative delusions centered upon the patient’s person
were invariably associated with a sense of transgression and an attendant feeling of guilt in an
absolute ontological sense (Stompe & Strobl, 2000). These findings illustrate how the prevailing
values and beliefs shape the content of delusions rather than cause them or trigger their appear-
ance.

766 J.G. Draguns, J. Tanaka-Matsumi / Behaviour Research and Therapy 41 (2003) 755–776

3.4. Anxiety disorders

In their review of anxiety in culture, Good and Kleinman (1985) concluded that anxiety dis-
orders are present in all human societies, but that they differ in phenomenology, modes of
expression, communication, and societal structuring. In light of this recognition, it is somewhat
paradoxical that anxiety related phenomena across cultures have been studied less intensively and
extensively than depression or schizophrenia. Perhaps the ready availability of depressives and
schizophrenics in institutional settings has something to do with it. Patients with anxiety disorders,
on the other hand, tend to be ambulatory and more difficult to track down.

In Hwu and Compton’s (1994) comparison of epidemiological surveys in six countries, lifetime
prevalence rates of specific anxiety disorders based on DIS differed markedly both across diagnos-
tic categories and cultures. These findings are indicative of differences in thresholds for anxiety
related experiences and manifestations. On the basis of reviewing mostly anthropological evi-
dence, Pfeiffer (1994) concluded that traditional small-scale cultures are not immune to anxiety,
and that they tend to be expressed in the form of intense avoidance reactions and panic states.

In one of the few studies that included both normal and clinical samples, Tseng, Asai, Jieqiu,
Wibulwasd, Suryiani et al. (1990) investigated anxiety related symptomatology at five Asian sites,
in Thailand, Bali (Indonesia), Taiwan, Mainland China, and Japan. In conformity with earlier
predictions (Draguns, 1973, 1980), profiles of the patients in the five locations deviated from the
baseline toward a magnification of symptoms observed among normals. Moreover, Tseng et al.
found the greatest degree similarity between the Chinese participants on the mainland and Taiwan,
presumably reflective of their shared cultural heritage.

Diagnosticians’ practices also potentially contribute to the reported cross-cultural differences
in anxiety related symptoms, as demonstrated by the comparisons of psychiatrists in Beijing,
Tokyo, and Honolulu (Tseng, Xu, Ebata, Hsu, & Cui, 1986; Tseng, Asai, Kitanishi, McLaugh-
lin, & Kyomen, 1992). In particular, disagreements revolved around neurasthenia versus adjust-
ment disorder, and were particularly marked in the culturally shaped syndromes of social phobia
in the United States and anthropophobia or taijin kyofusho in Japan. These findings were obtained
on the basis of identical videotapes, with the diagnosticians abiding by their usual clinical prac-
tices. Presumably, discrepancies would have been reduced if a standardized international diagnos-
tic system were employed.

Many of the intensively studied culture bound syndromes (CBS) represent the culturally struc-
tured anxiety syndromes, as prominently exemplified by taijin kyofusho in Japan (Russell, 1989;
Tanaka-Matsumi, 1979), a similar anthropophobic disorder in China (Zhang, 1995), koro through-
out Southeast Asia (Tseng et al. (1992), and ataque de nervios in Latin America (Guaranaccia,
Rivera, Franco, & Neighbors, 1996). In addition to clinical, case-based description of CBS, recent
studies have investigated the epidemiology of koro (Jilek, 1986; Tseng et al., 1988), have provided
test based information about the patients of this disorder (Tseng, Mo et al., 1992), and have
compared anthropophobic Chinese with their neurasthenic and normal counterparts in symptoma-
tology, social relationships, and attitudes (Zhang, Yu, Draguns, Zhang, & Tang, 2000; Zhang,
Yu, Tang, & Draguns, 2001). Tseng (2001) has proposed a comprehensive classification of these
syndromes into culture-related beliefs, culture-patterned reactions for coping with stress, culturally
shaped variations of psychopathology, culturally elaborated behavioral reactions, culturally pro-
voked frequent occurrence of pathological conditions; and cultural interpretations of specific men-

767J.G. Draguns, J. Tanaka-Matsumi / Behaviour Research and Therapy 41 (2003) 755–776

tal conditions. Of the above examples, koro is based on a culturally shaped belief, and taijin
kyofusho, anthropophobia, and ataques de nervios represent culturally shaped variants of psycho-
pathology.

The Expanatory Model Interview Catalogue (EMIC) has been developed by Weiss et al. (1992)
as an alternative to standardized assessment for identifying culture specific idioms of distress. It
was applied by Guaranaccia et al. (1996) to investigate ataque de nervios in Puerto Rico in its
social context and subjective experiences. Guarnaccia et al. found that it was the second most
prevalent psychiatric disorder in Puerto Rico, barely behind generalized anxiety disorder.

3.5. Dissociative disorders and phenomena

CBS greatly overlap with dissociative conditions, “characterized by a loss of integration of
faculties or functions that are normally integrated in consciousness.” (Castillo, 1998, p. 223). An
example of dissociative disorder is provided by an intermittent trance-like state marked by epi-
sodes of extreme restlessness, thrashing about of arms and legs, attempts at self-injurious behavior,
inability to recognize members of one’s family, and emitting animal calls, e,g., dog’s bark. These
behaviors were observed in rural Tipura in India (Chowdhury, Nath, & Chakraborty, 1993).

Dissociative manifestations are very much shaped by culture and are subject to imitation and
epidemic spread. Cultural factors also determine the meaning that is attributed to these phenom-
ena, and spiritual, magical, biological, or interpersonal causes may be assigned to them. Culture
also affects the threshold beyond which dissociative manifestations may be regarded as symptoms
of a psychological disorder (Pakaslahti, 2001). As all of the above factors tend to vary simul-
taneously, it has been difficult to initiate comparative research and the available documentation
typically remains in the form of descriptive accounts (cf., Tseng, 2001).

Recently, however, the Dissociation Questionnaire has been developed by Vanderlinden, Van-
Dyck, Vanderdeycken, Vertommen and Verkes (1993) in The Netherlands. It has been applied
across several countries in Europe to investigate two plausible antecedents of dissociation: (1)
the experience of abuse in childhood; and (2) the experience of totalitarian rule together with the
subsequent split between public and private discourse (Sebre, 2000). Qualitative findings have
provided preliminary support for the above relationships (Sebre, 2000). In the process, a paradox
has been discovered in the form of relatively high rates of self-reported dissociative phenomena,
for example among the general population in Latvia, while psychiatric diagnoses of dissociative
disorders in the same country remain extremely rare and those of multiple personality are virtually
absent (Sebre, 2000).

4. From psychopathology across cultures to culture in psychopathology

Our survey has demonstrated that the impact of culture upon psychopathology is considerable.
It remains, however, to be ascertained what kinds of features or dimensions of culture are impli-
cated in generating the distinctive manifestations of disturbance of a given time and place. This
question can be posed emically and etically. Within an emic framework, symptoms have been
traced to culturally shared preoccupations and themes (e.g., Kimura, 1995). Within an etic orien-

768 J.G. Draguns, J. Tanaka-Matsumi / Behaviour Research and Therapy 41 (2003) 755–776

tation, antecedents, especially in the form of characteristic values and shared attitudes, are worth
exploring in relation to psychopathological manifestations across cultures.

A set of four major dimensions of national cultures were identified by Hofstede (2001) on the
basis of a worldwide multivariate investigation of work-related values, as follows: (1) individual-
ism-collectivism, which pertains to the degree to which the person experiences himself or herself
as an autonomous self-contained human being, as opposed to feeling inextricably integrated into
the family or the community; (2) power distance, which is based on the acceptance and tolerance
of inequality in status and income; (3) masculinity–femininity, which refers to the degree of
differentiation of gender roles and to the emphasis on success and achievement vs interpersonal
relationships and sympathy; and (4) uncertainty avoidance, defined on the basis of the degree of
discomfort experienced in unstructured or unclear situations. To these four factorially derived
dimensions, Hofstede (2001) added the axis of Confucian Dynamism, rooted in values dominant
in China and developed by means of a very different methodology (Chinese Culture Connection,
1987; Hofstede & Bond, 1988). This construct emphasizes individual striving, social stability,
and hierarchical or vertical human relationships. In Hofstede’s (2001) recent reformulation, its
gist boils down to long-term orientation in relation to values, goals, and rewards. The above five
dimensions were extended beyond their original industrial organizational context to the school
setting (Hofstede, 1986), the psychotherapy enterprise (Draguns, 1995, 1997), and the experience
of subjective well-being (Arrindell et al., 1997). Expectations appear to be justified that Hofstede’s
continua are also relevant to psychopathology.

The self has evolved into a key construct in cultural psychology (Markus & Kitayama, 1991;
Triandis, 1989). In particular, the contrast between self experience in individualistic and collectiv-
istic cultures has been highlighted. An individualistic self is described as being clearly delineated,
highly differentiated, and constant across situations and time. A collectivistic self is construed to
be malleable across situations and to lack a sharp boundary between the person and other people.
Rather, such a self is defined by the individual’s distinctive relationships with significant other
persons. Draguns (1985, 1987) has articulated the hypothetical attributes of the self to the other
four cultural dimensions. In schematic form, this information is contained in Table 2.

High power distance is expected to promote the development of an encapsulated self, dependent
for its worth on indices of status and prestige, while low power distance would foster a more
permeable self, more closely linked to friendship and popularity. Masculinity is hypothesized to
foster the development of a pragmatic self, crucially dependent on productivity, efficiency, and
achievement while a feminine self is expected to value care, altruism, relationship, and feelings.
Uncertainty avoidance would put a premium on consistency and articulation of self-experience
at the high end of the continuum; at the low end, an intuitive self would be valued, and unver-
balized aspects of self experience would be tolerated. Finally, Confucian dynamism or long-term
orientation would emphasize self-control and self-restraint; its Western contrast would thrive on
self-assertion and self-actualization.

These formulations are easily extended to symptomatology, which is also described in Table
2. In individualistic cultures, psychopathology is expected to be characterized by guilt, alienation,
and loneliness; distress and frustration in collectivistic cultures would be focused upon unre-
warding personal relationships, social rejection, and shame. Power distance may be associated
with a sense of inadequacy and failure for not meeting conventional standards of success. Mascu-
linity may breed a sense of guilt and self-blame while femininity would be associated with anxiety-

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Table 2
Hofstede’s five dimensions in relation to self and symptoms

Individualism–Collectivism
Individualism Collectivism

Self: Autonomous Contextual
Private, differentiated Public, less differentiated, “ fuzzy boundaries”

between self and others
Constant, slow to change Malleable, adaptable to situations

Symptoms and Issues: Guilt Shame
Loneliness Rejection
Alienation Social conflict and disharmony
Grandiosity Social phobia and self-consciousness
Narcissism

Power distance
Low High

Self: Permeable Encapsulated
Relationships important Status and wealth important

Symptoms and Issues: Internal conflict Sense of failure
Personal uncertainty & confusion Self-blame

Femininity/masculinity
Femininity Masculinity

Self: Altruistic Pragmatic
Care-oriented Performance-oriented
Sensitive Efficient

Symptoms and Issues: Anxiety Guilt
Feeling misunderstood Skill & performance deficits
Unsatisfied dependent needs Inadequate sense of control and compentence

Uncertainty avoidance
High Low

Self: Articulate, consistent Partially verbalized, somewhat inconsistent
Rational Intuitive

Symptoms and Issues: Well delineated, specific More amorphous, hard to verbalize
Intellectualization of distress and Spontaneous expression
discomfort
Constricted feelings Emotional liability
Tension anxiety Confusion, helplessness

Dynamism (orientation)
Western (Short-term) Confucian (Long-term)

Self: Self-expression Self-control
Self-assertion Self-effacement
Self-actualization Self-subordination

Symptoms and Issues: Psychological discomfort Bodily distress
Insensitivity to others Overaccommodation to others
Elaborate construals of own actions Limited self-understanding and insight
and behaviors, often faulty
Impulsivity under stress Passivity under stress

770 J.G. Draguns, J. Tanaka-Matsumi / Behaviour Research and Therapy 41 (2003) 755–776

related and dependent symptoms. Uncertainty avoidance may be linked to highly articulate and
well delineated symptoms. Long-term orientation would direct attention to bodily discomfort and
distress and would be associated with few psychological symptoms and with their minimal elabor-
ation. It would also favor excesses of self-control and self-abnegation, in contrast to short-term
orientation which would promote symptoms associated with grandiosity and narcissim. It should
be emphasized that all of the proposed relationships are inferential and conjectural at this point.
If corroborated by systematic research, they would open the possibilities of adjusting techniques
of intervention to culturally dominant values and expectations.

5. Conclusions

1. This review documents substantial advances in research on psychopathology and culture achi-
eved over the recent three decades. Both etic and emic approaches have been operationalized
and refined. The bulk of this information has been gathered in the course of cross-cultural
comparisons. Time is ripe for a partial shift toward a more emic orientation in conceptualiz-
ation and data gathering. Eventually, we expect convergence and integration of these two
approaches as etic research is informed by greater cultural sensitivity and emic studies become
more objective, quantified, and rigorous (Tanaka-Matsumi, 2001; Tanaka-Matsumi & Dra-
guns, 1997).

2. Cultural research on psychopathology starts with the development of scales and other instru-
ments of assessment. It culminates with their application across and within cultures. The past
several decades have seen a major spurt in the standardization, validation, and utilization of
such measures. These tools are proving their usefulness in the assessment of help seeking
individuals in their respective cultural milieus, as a prelude to more flexible, sensitive, and
effective intervention.

3. In epidemiological research, the development of standardized procedures has led to compari-
sons of data across cultures. In smaller scale cross-cultural studies, both normal and psycho-
pathological samples have been included in a few pioneering investigations. This development
has enabled researchers to put to the test two general hypotheses about the nature of the
relationship of abnormal behavior and culture. Thus, Marsella’s (1988) expectation that cul-
tural variability decreases as psychological disturbance becomes more severe was tentatively
confirmed in a comparison in Sweden and Nicaragua of normal, borderline, and schizophrenic
individuals (Sundbom, Jacobsson, Kullgren, & Penayo, 1998). Draguns (1973, 1980) antici-
pated exaggeration of cultural differences in psychopathology; this notion has received support
in one study (Tseng et al., 1990) while two investigations (Räder et al., 1990; Radford, 1989)
have yielded ambiguous results.

4. A substantial amount of findings has accumulated on the universal features of psychopath-
ology, especially in relation to schizophrenia and depression. These results invariably coexist
with substantial differences in symptomatology and other features across cultures. In line with
Marsella’s (1988) hypothesis, such differences appear to be more pronounced as the disorders
become less disabling.

5. An open question pertains to the extent and nature of the links between psychopathology and
cultural characteristics. Predictions have been advanced about the psychopathological reflec-
tions of Hofstede’s (2001) cultural dimensions, but they remain to be systematically tested.

771J.G. Draguns, J. Tanaka-Matsumi / Behaviour Research and Therapy 41 (2003) 755–776

6. Guilt and somatization have emerged as two prominent sources of variation across cultures.
Both of these variables, and many others, interact in a complex and shifting fashion with
a variety of social, contextual, and psychopathological variables which have not yet been
completely disentangled.

7. Culturally characteristic features of abnormal behavior are invariably expressed in the course
of an encounter between the patient and the observer(s) in a specified culturally distinctive
context. Yet, in most of the research reviewed, “culture of diagnosticians has been forgotten
and cultural context has received minimal research attention.” (Tanaka-Matsumi, 1999, p. 24).
The challenge remains to recognize the importance of the observer and the milieu and to
incorporate these variables into future studies.

8. It is often overlooked that the impact of culture upon psychological disturbance is recorded
at a specific point in both space and time. With the fast pace of social transformation and
increasing globalization, many of the findings recorded here may become obsolete. Abrupt
and unanticipated social change, such as the collapse of the Soviet regime in Russia, is likely
to enhance some symptoms and reduce others (cf. Korolenko & Dmitriyeva, 1999). The task
of culturally oriented investigators is to follow and document the trends that such events may
both shape and provoke, especially in relation to distress and disability.

9. The bulk of empirically ascertained knowledge in this area pertains to the effects of culture
upon the manner in which psychological disorder is experienced, expressed, and communi-
cated. As yet, very little is known about any cultural causation of psychopathology, which
remains an important if elusive field of investigation (Jilek, 1982; Tseng, 2001).

10. It should be emphasized that the findings we have reviewed pertain to trends rather than types.
Invariably, there is overlap between cultures. Moreover, cultural characteristics described in
this article stand in a complex relationship to individual differences with culture. For example,
there are many individualists in cultures deemed collectivistic, and vice versa. Taking note
of cultural features, we strongly caution against converting them into stereotypes.

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• Assessment of psychopathology across and within cultures: issues and findings

Introduction
Culturalist and universalist orientations and their prospective integration
Psychiatric diagnoses in a global perspective: etic positions, emic critiques, and integrative reformulations
US-UK diagnostic project
Assessment within and across cultures: the observer™s contribution
Innovations and advances in epidemiological research
Specific mental disorders: the accumulated findings
Depression
Somatization in depression and in other disorders
Schizophrenia
Anxiety disorders
Dissociative disorders and phenomena
From psychopathology across cultures to culture in psychopathology
Conclusions
References