Cross-Cultural Assessment of Abnorm

Cross-Cultural Assessment of Abnormal Behavior
Not only is it important to have a reliable and valid system of classification of abnormal behaviors; it is also important to have a set of tools that can reliably and validly measure behaviors, feelings, and other psychological parameters related to mental illness. Those tools may include questionnaires, interview protocols, or standardized tasks that require some sort of behavior on the part of the test taker.
Needless to say, many of the issues that concern the valid and reliable measurement of any psychological variable cross-culturally for research purposes are also relevant to discussions of measurement tools for abnormality. For in- stance, it may be difficult to adequately transfer and use a psychological assessment that has been developed in one culture to another because of cultural- specific expressions of distress. Kleinman (1995) points out that many items of an assessment instrument may use wordings that are so culture-specific (for example, “feeling blue”) that directly translating them to another culture would be nonsensical. Draguns (1997) recently reviewed a number of issues in this area of psychological measurement, including stimulus equivalence, sample characteristics, comparability of constructs, structured self-reports, personal interviews, experimental apparatuses, and the impact of the examiner. These is- sues, and others, make valid and reliable measurement of pathology across cultures very difficult and complex.
A critical examination of how the tools in use fare across cultures provides a stark glimpse of reality. Traditional tools of clinical assessment in psychology are generally based on a standard definition of abnormality and use a standard set of classification criteria for evaluating problematic behavior. Therefore, the tools may have little meaning in cultures with varying definitions, however well translated into the native language; and they may mask or fail to capture culturally specific expressions of disorder (Marsella, 1979). The assessment problems encountered in studying schizophrenia and depression across cultures illustrate the limitations of traditional assessment methods.
The WHO studies described earlier, for example, used the Present State Ex- amination (PSE) to diagnose schizophrenia. Leff (1986) has commented on the ethnocentric bias of procedures such as the PSE and the Cornell Medical Index. In a psychiatric survey of the Yoruba in Nigeria, investigators had to supplement the PSE to include culture-specific complaints such as feeling “an expanded head and goose flesh.”

Standard diagnostic instruments to measure depressive disorder may also miss important cultural expressions of the disorder in Africans (Beiser, 1985) and Native Americans (Manson, Shore, & Bloom, 1985). In an extensive study of depression among Native Americans (Manson & Shore, 1981; Manson et al., 1985), the American Indian Depression Schedule (AIDS) was developed to assess and diagnose depressive illness. The investigators found that depression among the Hopi includes symptoms not measured by standard measures of depression such as the Diagnostic Interview Schedule (DIS) and the Schedule for Affective Disorders and Schizophrenia (SADS). These measures, based on di- agnostic criteria found in the DSM-III (American Psychiatric Association, 1987), failed to capture the short but acute dysphoric moods sometimes reported by the Hopi (Manson et al., 1985).
Concerning children, the Child Behavior Checklist (CBCL; Achenbach, 2001) has been used to assess emotional and behavioral problems of children in various parts of the world, including Thailand, Kenya, and the United States (Weisz, Sigman, Weiss, & Mosk, 1993; Weisz et al., 1988); China (Su, Yang, Wan, Luo, & Li, 1999); Israel and Palestine (Auerbach, Yirmiya, & Kamel, 1996); and Australia, Jamaica, Greece, and nine other countries (Crijnen, Achenbach, & Verhulst, 1999). Generally, studies have found that U.S. children tend to exhibit higher levels of undercontrolled behaviors (“externalizing behaviors” such as acting out and aggression) and lower levels of overcontrolled behaviors (“internalizing” behaviors such as fearfulness and somaticizing) compared to children of other, particularly collectivistic, cultures. Thus, the CBCL (sometimes slightly modified) has been widely used in many cultures to assess problematic behaviors. However, a study that recruited American Indian (Dakota/Lakotan) parents to assess the acceptability and appropriateness of using the CBCL in their culture found that some questions were difficult for the parents to answer because the questions did not take into account Dakotan/ Lakotan cultural values or traditions, and because the parents believed their responses would be misinterpreted by members of the dominant culture who did not have a good understanding of the Dakotan/Lakotan culture (Oesterheld, 1997). This underscores again the importance of critically examining assessment tools for use cross-culturally.
Several researchers (Higginbotham, 1979; Lonner & Ibrahim, 1989; Marsella, 1979) have offered guidelines for developing measures to use in cross-cultural assessment of abnormal behavior. They suggest that sensitive assessment methods examine sociocultural norms of healthy adjustment as well as culturally based definitions of abnormality. Higginbotham also suggests the importance of examining culturally sanctioned systems of healing and their influence on abnormal behavior. There is evidence that people whose problems match cultural categories of abnormality are more likely to seek folk healers (Leff, 1986). Failure to examine indigenous healing systems thus overlooks some expressions of disorder. Assessment of culturally sanctioned systems of cure should also enhance planning for treatment strategies, one of the primary goals of traditional assessment (Carson et al., 1988).

Other research has found that the cultural backgrounds of therapist and client may contribute to the perception and assessment of mental health. For instance, Li-Repac (1980) conducted a study to evaluate the role of culture in the diagnostic approach of therapists. In this study, Chinese American and European American male clients were interviewed and videotaped, then rated by Chinese American and European American male therapists on their level of psychological functioning. The results showed an interaction effect between the cultural backgrounds of therapist and client on the therapists’ judgment of the clients. The Chinese American clients were rated as awkward, confused, and nervous by the European American therapists, but the same clients were rated as adaptable, honest, and friendly by the Chinese American therapists. In contrast, European American clients were rated as sincere and easygoing by European American therapists, but aggressive and rebellious by the Chinese American therapists. Furthermore, Chinese American clients were judged to be more depressed and less socially capable by the European American therapists, and European American clients were judged to be more severely disturbed by the Chinese American therapists. These findings illustrate how judgments of appropriate, healthy psychological functioning may differ depending on the cultural background and notions of normality of the person making the assessment.
Lopez (1989) has described two types of errors in making clinical assessments: overpathologizing and underpathologizing. Overpathologizing may occur when the clinician, unfamiliar with the client’s cultural background, incorrectly judges the client’s behavior as pathological when in fact the behaviors are normal variations to that individual’s culture. For instance, in some cultures, hearing voices from a deceased relative is considered normal. A clinician unaware of this feature of his or her client’s culture may overpathologize and mistakenly attribute this behavior to a manifestation of a psychotic disorder. Underpathologizing may occur when a clinician indiscriminantly explains the client’s behaviors as cultural—for example, attributing a withdrawn and flat emotional expression to a normal cultural communication style when in fact this behavior may be a symptom of depression.
Finally, one interesting topic in recent literature concerns language issues in psychological testing. In more and more cases today, test takers (such as patients or clients) have a first language and culture that differ from the diagnostician’s or clinician’s. Some writers (for example, Oquendo, 1996a, 1996b) have sug- gested that evaluation of such bilingual patients should really be done in both languages, preferably by a bilingual clinician or with the help of an interpreter trained in mental health issues. The reason, as was discussed in Chapter 10, is that cultural nuances may be encoded in language in ways that are not readily conveyed in translation. That is, translations of key psychological phrases and constructs from one language to another may give the closest semantic equivalent, but may not have exactly the same nuances, contextualized meanings, and associations. Also, Oquendo (1996a) suggests that patients may use their second language as a form of resistance to avoid intense emotions. Administration of tests and therapy bilingually may help to bridge this gap.

Hasil (Bahasa Indonesia) 1:

Penilaian Antarbudaya kelakuan AbnormalTidak hanya itu penting untuk memiliki sistem yang dapat diandalkan dan berlaku klasifikasi perilaku abnormal; Hal ini juga penting untuk memiliki satu set alat yang dapat diandalkan dan sah mengukur perilaku, perasaan, dan parameter lain psikologis yang berkaitan dengan penyakit mental. Alat tersebut dapat mencakup kuesioner, wawancara protokol, atau standar tugas-tugas yang membutuhkan semacam perilaku dari pengambil tes.Tak perlu dikatakan, banyak masalah yang menyangkut sah dan handal pengukuran variabel manapun psikologis lintas-budaya untuk tujuan penelitian juga relevan dengan diskusi alat pengukuran untuk kelainan. Untuk di sikap, mungkin sulit untuk secara memadai mentransfer dan menggunakan asesmen psikologis yang telah dikembangkan dalam satu kebudayaan lain karena ekspresi budaya-spesifik tertekan. Kleinman (1995) menunjukkan bahwa banyak item instrumen penilaian dapat menggunakan pengkalimatan yang jadi budaya tertentu (misalnya, "merasa biru") yang langsung menerjemahkan mereka ke budaya lain akan masuk akal. Draguns (1997) baru saja memeriksa sejumlah isu dalam bidang pengukuran psikologis, termasuk stimulus kesetaraan, karakteristik sampel, keterbandingan konstruksi, terstruktur diri laporan, wawancara pribadi, aparat eksperimental dan dampak pemeriksa. Ini adalah - menggugat, dan lain-lain, membuat sah dan handal pengukuran patologi kebudayaan sangat sulit dan kompleks.Pemeriksaan penting bagaimana alat-alat dalam menggunakan tarif di seluruh budaya menyediakan sekilas mencolok realitas. Alat-alat tradisional penilaian klinis dalam psikologi umumnya didasarkan pada definisi standar kelainan dan menggunakan seperangkat standar klasifikasi kriteria untuk mengevaluasi perilaku bermasalah. Oleh karena itu, alat-alat mungkin memiliki sedikit makna dalam budaya dengan definisi yang berbeda-beda, namun juga diterjemahkan ke dalam bahasa asli; dan mereka mungkin topeng atau gagal untuk menangkap ungkapan-ungkapan yang spesifik secara budaya gangguan (Marsella, 1979). Masalah penilaian yang dihadapi dalam mempelajari skizofrenia dan depresi di seluruh budaya menggambarkan keterbatasan metode penilaian tradisional.Studi WHO yang dijelaskan sebelumnya, misalnya, digunakan saat negara Ex - amination (PSE) untuk mendiagnosa skizofrenia. LEFF (1986) telah berkomentar pada bias Serikat etnosentris prosedur seperti PSE dan indeks medis Cornell. Dalam sebuah survei psikiatri Yoruba di Nigeria, peneliti harus melengkapi PSE untuk memasukkan keluhan budaya-spesifik seperti perasaan "kepala diperluas dan angsa daging." Standard diagnostic instruments to measure depressive disorder may also miss important cultural expressions of the disorder in Africans (Beiser, 1985) and Native Americans (Manson, Shore, & Bloom, 1985). In an extensive study of depression among Native Americans (Manson & Shore, 1981; Manson et al., 1985), the American Indian Depression Schedule (AIDS) was developed to assess and diagnose depressive illness. The investigators found that depression among the Hopi includes symptoms not measured by standard measures of depression such as the Diagnostic Interview Schedule (DIS) and the Schedule for Affective Disorders and Schizophrenia (SADS). These measures, based on di- agnostic criteria found in the DSM-III (American Psychiatric Association, 1987), failed to capture the short but acute dysphoric moods sometimes reported by the Hopi (Manson et al., 1985).Concerning children, the Child Behavior Checklist (CBCL; Achenbach, 2001) has been used to assess emotional and behavioral problems of children in various parts of the world, including Thailand, Kenya, and the United States (Weisz, Sigman, Weiss, & Mosk, 1993; Weisz et al., 1988); China (Su, Yang, Wan, Luo, & Li, 1999); Israel and Palestine (Auerbach, Yirmiya, & Kamel, 1996); and Australia, Jamaica, Greece, and nine other countries (Crijnen, Achenbach, & Verhulst, 1999). Generally, studies have found that U.S. children tend to exhibit higher levels of undercontrolled behaviors (“externalizing behaviors” such as acting out and aggression) and lower levels of overcontrolled behaviors (“internalizing” behaviors such as fearfulness and somaticizing) compared to children of other, particularly collectivistic, cultures. Thus, the CBCL (sometimes slightly modified) has been widely used in many cultures to assess problematic behaviors. However, a study that recruited American Indian (Dakota/Lakotan) parents to assess the acceptability and appropriateness of using the CBCL in their culture found that some questions were difficult for the parents to answer because the questions did not take into account Dakotan/ Lakotan cultural values or traditions, and because the parents believed their responses would be misinterpreted by members of the dominant culture who did not have a good understanding of the Dakotan/Lakotan culture (Oesterheld, 1997). This underscores again the importance of critically examining assessment tools for use cross-culturally.Several researchers (Higginbotham, 1979; Lonner & Ibrahim, 1989; Marsella, 1979) have offered guidelines for developing measures to use in cross-cultural assessment of abnormal behavior. They suggest that sensitive assessment methods examine sociocultural norms of healthy adjustment as well as culturally based definitions of abnormality. Higginbotham also suggests the importance of examining culturally sanctioned systems of healing and their influence on abnormal behavior. There is evidence that people whose problems match cultural categories of abnormality are more likely to seek folk healers (Leff, 1986). Failure to examine indigenous healing systems thus overlooks some expressions of disorder. Assessment of culturally sanctioned systems of cure should also enhance planning for treatment strategies, one of the primary goals of traditional assessment (Carson et al., 1988).Other research has found that the cultural backgrounds of therapist and client may contribute to the perception and assessment of mental health. For instance, Li-Repac (1980) conducted a study to evaluate the role of culture in the diagnostic approach of therapists. In this study, Chinese American and European American male clients were interviewed and videotaped, then rated by Chinese American and European American male therapists on their level of psychological functioning. The results showed an interaction effect between the cultural backgrounds of therapist and client on the therapists’ judgment of the clients. The Chinese American clients were rated as awkward, confused, and nervous by the European American therapists, but the same clients were rated as adaptable, honest, and friendly by the Chinese American therapists. In contrast, European American clients were rated as sincere and easygoing by European American therapists, but aggressive and rebellious by the Chinese American therapists. Furthermore, Chinese American clients were judged to be more depressed and less socially capable by the European American therapists, and European American clients were judged to be more severely disturbed by the Chinese American therapists. These findings illustrate how judgments of appropriate, healthy psychological functioning may differ depending on the cultural background and notions of normality of the person making the assessment.Lopez (1989) has described two types of errors in making clinical assessments: overpathologizing and underpathologizing. Overpathologizing may occur when the clinician, unfamiliar with the client’s cultural background, incorrectly judges the client’s behavior as pathological when in fact the behaviors are normal variations to that individual’s culture. For instance, in some cultures, hearing voices from a deceased relative is considered normal. A clinician unaware of this feature of his or her client’s culture may overpathologize and mistakenly attribute this behavior to a manifestation of a psychotic disorder. Underpathologizing may occur when a clinician indiscriminantly explains the client’s behaviors as cultural—for example, attributing a withdrawn and flat emotional expression to a normal cultural communication style when in fact this behavior may be a symptom of depression.
Finally, one interesting topic in recent literature concerns language issues in psychological testing. In more and more cases today, test takers (such as patients or clients) have a first language and culture that differ from the diagnostician’s or clinician’s. Some writers (for example, Oquendo, 1996a, 1996b) have sug- gested that evaluation of such bilingual patients should really be done in both languages, preferably by a bilingual clinician or with the help of an interpreter trained in mental health issues. The reason, as was discussed in Chapter 10, is that cultural nuances may be encoded in language in ways that are not readily conveyed in translation. That is, translations of key psychological phrases and constructs from one language to another may give the closest semantic equivalent, but may not have exactly the same nuances, contextualized meanings, and associations. Also, Oquendo (1996a) suggests that patients may use their second language as a form of resistance to avoid intense emotions. Administration of tests and therapy bilingually may help to bridge this gap.